Although mechanical alterations to pelvic floor ligaments, such as the cardinal and uterosacral ligaments, are one contributing factor to the development and progression of pelvic floor disorders, very little research has examined their mechanical properties. In this study, the first biaxial elastic and viscoelastic tests were performed on uterosacral and cardinal ligament complexes harvested from adult female swine. Biaxial elastic testing revealed that the ligaments undergo large strains and are anisotropic. The direction normal to the upper vagina was typically stiffer than the transverse direction. Stress relaxation tests showed that the relaxation was the same in both directions, and that more relaxation occurred when the tissue was stretched to lower initial strains. In order to describe the experimental findings, a three-dimensional constitutive model based on the Pipkin-Rogers integral series was formulated and the parameters of such model were determined by fitting the model to the experimental data. In formulating the model, it was assumed that the tissues consist of a ground substance with two embedded families of fibers oriented in two directions and that the ligaments are incompressible. The model accounts for finite strains, anisotropy, and strain-dependent stress relaxation behavior. This study provides information about the mechanical behavior of female pelvic floor ligaments, which should be considered in the development of new treatment methods for pelvic floor disorders. / Master of Science

Objectives Despite their growing prevalence, pelvic floor disorders (PFDs) remain undertreated and not well understood by patients, with treatment disparities noted in specific subgroups of women. The goal of the present study was to determine the basic understanding of PFDs of women in the southern Appalachian region of the United States, to determine factors that predict knowledge, and to explore the possible disparities in seeking access to care among women in this region who reported symptoms. Methods A survey of patient knowledge of PFDs, specifically urinary incontinence (UI) and pelvic organ prolapse (POP), was conducted in Johnson City, Tennessee, and involved 305 female patients from this city and the surrounding region. Results Almost half of the participants (43%) reported UI symptoms, with only 25% of these participants reporting treatment. A much smaller percentage (5%) reported POP symptoms, but 44% reported receiving treatment. Overall proficiency for UI knowledge was 54.4%, and 69.5% for POP knowledge. Higher UI knowledge was predicted (P < 0.05) by age younger than 60 years, annual income >$50,000, more than a high school education, and being married. UI knowledge was unrelated to the presence of UI symptoms, receipt of UI treatment, or having seen a urospecialist. Higher POP knowledge was predicted (P < 0.05) by annual income >$50,000, more than a high school education, and presence of POP symptoms. The only factor significantly predicting seeking treatment among women with UI symptoms was marital status. Conclusions Overall knowledge of both UI and POP was reasonably high in this population, suggesting appropriate self-education or education by providers in the region. The women most affected by UI, particularly those older than 60 years, were not well informed, and education by providers does not appear to specifically target women seeking treatment. We must continue to educate and further reduce the gap of knowledge and treatment regarding PFDs in southern Appalachia.

No description available.

Around 80% of women experience vaginal tears during labor when the diameter of the vagina must increase from ~2.5 cm to ~9.5 cm to allow the passage of a full-term baby. Vaginal tears vary from superficial cuts of the mucosal lining to tears propagating through the entire vaginal wall and into the surrounding tissues and organs. Complications associated with vaginal tears include postpartum hemorrhaging, fecal incontinence, urinary incontinence, and dyspareunia. Beyond the agonizing pain, these complications are emotionally and psychologically traumatic for women. Prevention, evaluation, and treatment of vaginal tears and subsequent conditions are limited due to the lack of studies examining the mechanical behavior of the pelvic floor tissues. Therefore, the mechanical response of healthy and torn vaginal tissue is investigated here to establish quantitative metrics for maternal healthcare. Toward this end, swine and rat vaginal tissue is subjected to biaxial loads until tearing to reveal its mechanical properties. The resulting large inhomogeneous deformations are measured by the digital image correlation optical method to calculate material strain. The influence of these strains near to and far from the immediate vicinity of the tears on the tearing behavior is studied. Coupling mechanisms of the mechanical properties in the circumferential and axial directions as well as their effect on the nature of tear resistance is studied. Collagen fibers, the component within tissue responsible for its strength under tension, are imaged using a multiphoton microscopy technique known as second-harmonic generation imaging to investigate the change in organization with mechanical loading. Furthermore, imaging is performed in the near-regions of tears to reveal the relationship between collagen fibers and tearing resistance. The data collected through these studies provide new knowledge on the nonlinear elastic behavior of vaginal tissue, the geometrical and micro-structural characteristics of tears, and the mechanisms that contribute to the formation and propagation of tears. The mechanical properties and tearing mechanisms of vaginal tissue will be crucial in developing new prevention and treatment methods for maternal trauma following childbirth. Episiotomy, late-term stretching, surgical treatment with graft materials and other protocols will all benefit from a mechanically-informed perspective. It is our hope that this work will raise awareness to the serious complexities of pelvic floor trauma and encourage a more refined and systematic approach to the inspection, imaging, and treatment of all vaginal tears following delivery. This work was supported in part by the National Science Foundation fund #1511603 and the Institute for Critical Technology and Sciences at Virginia Tech. / Doctor of Philosophy / Every year nearly three million women give birth vaginally with 80% experiencing vaginal tears. These injuries sustained during delivery vary with severity and are associated with several conditions, including pelvic floor disorders. These disorders are a set of long-term conditions of the pelvic region presently affecting one-fourth of adult women in the United States. Pelvic floor disorders are: pelvic organ prolapse - a pelvic organ such as the uterus "falls" from its natural position, urinary incontinence - difficulty controlling urination, and fecal incontinence - difficulty controlling bowel movements. Pelvic floor disorders lower the quality of life for women not only physically due to pain and daily discomfort, but also mentally as the disorders are generally perceived as an embarassing and private matter. The pelvic floor represents a complex system of muscles, organs, and support structures that work together to ensure everything stays in place and is functioning properly. Injury to any of these structures poses the risk of developing a disorder. As a central supporting organ, injuries to the vagina may be particularly worrisome. Surprisingly, little is known about the magnitude of forces and/or stretching that is placed on the pelvic floor during delivery, how much force and/or stretching is required for an injury, or how various injuries relate to future complications. The goal of this research is to describe how much the normal, healthy vagina stretches to various forces including forces that will result in injuries. The research further examines the stretching of injured vaginas to quantify any observable differences due to this injury. Finally, the relationships between the biological components of the vagina, such as collagen, and the forces placed on the vagina are examined. The result of this work will provide doctors and engineers with guidelines for understanding the conditions that produce vaginal injuries. The relationships examined between the tissue makeup and forces exerted onto the tissue may also aid in identifying any irregularities that would place a woman at risk for injury. Many of the medical procedures surrounding childbirth as well as surgical treatment for pelvic floor disorders will benefit from knowing how far the vagina can stretch before being injured. It is our hope that this work will raise awareness to the serious complexities of pelvic floor injuries and encourage a more refined and systematic approach to the inspection, imaging, and treatment of all vaginal tears following delivery. This work was supported in part by the National Science Foundation fund #1511603 and the Institute for Critical Technology and Sciences at Virginia Tech.

Bakgrund: Bäckenbotten utsätts för stor påfrestning under graviditet och förlossning. I samband med förlossning kan skador på bäckenbotten uppstå. Dessa skador kan leda till både kort- och långsiktiga besvär som i sin tur kan påverka kvinnors livskvalitet och dagliga liv. Syfte: Syftet med studien var att kartlägga vilka bäckenbottenbesvär kvinnor upplever 6-16 veckor efter vaginal förlossning samt att beskriva dess påverkan på livskvalitet och dagligt liv. Metod: Studien var en kvantitativ tvärsnittsstudie där datainsamling skedde via en webbenkät. Webbenkäten bestod av bakgrundsfrågor utformade av författarna samt två validerade enkäter, PFDI-20 och PFIQ-7. Insamlad data analyserades i statistikprogrammet SPSS. Totalt deltog 135 kvinnor i studien. Resultat: I kartläggningen framkom att en stor andel kvinnor drabbats av bäckenbottenbesvär efter förlossning. Trots det uppgav majoriteten av kvinnorna att de ej hade besvär från sin bäckenbotten som inverkade på deras livskvalitet eller dagliga liv. Bland de kvinnor som upplevde besvär var det främst förmågan att utföra dagliga hushållsarbeten, förmågan till fysisk aktivitet och påverkan på psykisk hälsa som påverkade livskvaliteten. Konklusion: Studiens resultat antyder på att en stor andel kvinnor drabbas av bäckenbottenbesvär efter vaginal förlossning. Det är viktigt att belysa denna problematik så att kvinnor kan få adekvat stöd och behandling vid besvär. Trots att majoriteten av respondenterna ej upplevde att bäckenbottenbesvären inverkade på deras livskvalitet eller dagliga liv är det viktigt att ej normalisera bäckenbottenbesvär eller att se dem som en naturlig följd av graviditet och förlossning. / Background: The pelvic floor is exposed to great stress during pregnancy and childbirth. In connection to childbirth, injuries to the pelvic floor can occur, so called birth injuries. These injuries can lead to both short- and long term problems for women. These problems can have an impact on womens quality of life and daily life. Aim: The purpose of the study was to chart which pelvic floor disorders women experience 6–16 weeks after vaginal delivery and describe its impact on quality of life and daily life. Method: The study was a quantitive cross-sectionalstudy where the data collection was done through a online questionnarie. The online questionnarie consisted of background questions designed by the authors and two validated questionnaries, PFDI-20 and PFIQ-7. Collected data was analyzed using the statistical program SPSS. A total of 135 women participated in the study. Result: In the survey of pelvic floor disorders, it was found that a large proportion of women suffered from pelvic floor disorders after childbirth. Despite this, the majority of women stated that they did not have problems from their pelvic floor that affected their quality of life or daily life. Among the women who experienced problems it was mainly the ability to perform household chores, the ability for physical activity and the impact on mental health that affected quality of life. Conclusion: The results of the study suggest that a large proportion of women suffer from pelvic floor disorders after vaginal delivery. It is important to shed light on this issue so that women can receive adequate support and treatment for their problems. Despite the fact that the majority of the respondents stated that their pelvic floor disorders did not affect quality of life or daily life, it is important to not normalize or see pelvic floor disorders as a natural consequence of pregnancy and childbirth.

INTRODUÇÃO: Disfunções do assoalho pélvico incluem uma variedade de condições interrelacionadas, tais como prolapso de órgãos pélvicos (POP) e distúrbios urinários e defecatórios. Comumente, tais afecções são concomitantes, o que pode causar incômodo de forma significativa. Inúmeros questionários com foco nessas disfunções têm sido desenvolvidos e estão sendo utilizados em pesquisas, fornecendo informações importantes; porém, como geralmente possuem múltiplos itens, são muito complexos para serem utilizados na prática clínica. O \"Pelvic Floor Bother Questionnaire\" (PFBQ) foi delineado de forma a simplificar a identificação e o grau de incômodo relacionados a problemas comuns do assoalho pélvico, podendo ser usado na prática diária e para fins de pesquisa. Trata-se de um questionário de nove itens que avalia sintomas relacionados à incontinência urinária, urgência e frequência urinárias, dificuldade miccional, prolapso de órgãos pélvicos, evacuação obstruída, incontinência fecal e dispareunia. OBJETIVOS: Os objetivos foram validar uma versão do PFBQ adaptada para o português, assim como adapta-lo culturalmente para a língua portuguesa brasileira, atualizá-lo, e avaliar suas propriedades: confiabilidade, validade e capacidade de detectar mudanças. MÉTODOS: O PFBQ foi traduzido para o português (\"Forward Translation\") por dois tradutores independentes (sendo um deles um tradutor juramentado). Após consenso, essa versão foi traduzida para o inglês (\"Backward Translation\") por um terceiro tradutor independente. O questionário foi então testado por profissionais da saúde e em uma amostragem de 10 pacientes. Após estas etapas, a versão final do questionário foi obtida. Testes de validade foram então aplicados: confiabilidade interna, confiabilidade teste-reteste, validade dos itens e capacidade de resposta às mudanças. O PFBQ foi correlacionado com dados obtidos durante a anamnese, diários miccional e defecatório e exame pélvico, incluindo o \"Pelvic Organ Prolapse Quantification\" (POP-Q). Para avaliar a confiabilidade teste-reteste, cada paciente respondeu o PFBQ dentro de 1 semana a 10 dias. A capacidade de resposta às mudanças foi avaliada nas pacientes que completaram o questionário antes e após o tratamento. RESULTADOS: Entre fevereiro de 2014 e agosto de 2015, foram incluídas no estudo 147 pacientes com média de idade de 60,49 anos. As principais queixas foram: 12,2% incontinência urinária de esforço, 19% incontinência urinária mista, 6,1% perda urinária por urgência, 26,5% incontinência fecal, 18,4% evacuação obstruída e 17,7% POP (estádio 3 ou 4). O PFBQ demonstrou boa confiabilidade ( = 0,625, ICC = 0,981). Cada item do questionário apresentou concordância quase perfeita entre as avaliações (k = 0,895-1,00). O PFBQ correlacionou-se com o estadiamento do prolapso (p < 0,01), número de episódios de incontinência urinária e fecal (? = 0,791, p < 0,001; p = 0,780, p < 0,001) e evacuação obstruída (p = 0,875, p < 0,001). CONCLUSÕES O \"Pelvic Floor Bother Questionnaire\" em português é uma ferramenta confiável e válida que pode ser utilizada para a identificação e avaliação da gravidade/incômodo de vários sintomas do assoalho pélvico / INTRODUCTION Pelvic floor disorders include a variety of interrelated conditions, such as pelvic organ prolapse (POP), and urinary and defecatory dysfunction. Commonly, patients have concomitant pelvic disorders, which can significantly cause distress. Numerous surveys focusing on pelvic floor abnormalities have been developed and are being used, mainly in research settings. These instruments are mostly multi-item, and despite providing a rich source of information, are thus difficult to use in a clinical setting. Shorter questionnaires have been also validated, although most of them are specific for each disorder. Pelvic Floor Bother Questionnaire (PFBQ) was designed to identify the presence and degree of bother related to common pelvic floor problems, and can be used in clinical practice and for research purposes. It is a nine-item questionnaire that includes symptoms and bother related to urinary incontinence, urinary urgency and frequency, dysuria, pelvic organ prolapse, obstructed defecation, fecal incontinence, and dyspareunia. OBJECTIVE We aimed to update and validate a cross-culturally adapted version of the PFBQ in Portuguese. METHODS Translation and validation of the PFBQ was performed as follows: After conceptual analysis of the original questionnaire in English, the PFBQ was translated into Portuguese (\"Forward Translation\") by two independent translators (one certified translator). After a consensus was obtained, this version of the questionnaire was translated back into English (\"Backward Translation\") by an independent translator. The questionnaire was pilot tested on health care professionals and on 10 patients who were questioned about form and clarity of the questions. The final version of the questionnaire was obtained. Validity tests were then applied and included internal reliability, test-retest reliability, validity of the items and responsiveness to change. PFBQ was correlated with a structured clinical interview, bladder and fecal diaries and pelvic exam, including \"Pelvic Organ Prolapse Quantification\" (POP-Q) examination. To assess test-retest reliability, each patient fulfilled a second copy of the PFBQ within 7 to 10 days. Responsiveness to change was accessed in patients who completed the questionnaire before and after treatment. RESULTS A total of 147 patients of a mean age 60,49 years were enrolled in the study between February 2014 and August 2015. Chief complains were as follows: 12,2% of patients had stress urinary incontinence, 19% mixed urinary incontinence, 6,1% detrusor instability, 26,5% fecal incontinence, 18,4% obstructed defecation and 17,7% had POP (stage 3 or 4). PFBQ demonstrated good reliability (alpha = 0,625; ICC = 0,981). There was a strong agreement beyond chance observed for each question (k = 0,895-1,00). PFBQ correlated with stage of prolapse (p < 0,01), number of urinary and fecal incontinence episodes ( = 0,791, p < 0,001; p = 0,780, p < 0,001), and obstructed defecation ( p =0,875, p < 0,001). CONCLUSIONS The PFBQ is a reliable and valid tool that can be easily used for the identification and severity/bother assessment of various pelvic floor symptoms

INTRODUÇÃO: Disfunções do assoalho pélvico incluem uma variedade de condições interrelacionadas, tais como prolapso de órgãos pélvicos (POP) e distúrbios urinários e defecatórios. Comumente, tais afecções são concomitantes, o que pode causar incômodo de forma significativa. Inúmeros questionários com foco nessas disfunções têm sido desenvolvidos e estão sendo utilizados em pesquisas, fornecendo informações importantes; porém, como geralmente possuem múltiplos itens, são muito complexos para serem utilizados na prática clínica. O \"Pelvic Floor Bother Questionnaire\" (PFBQ) foi delineado de forma a simplificar a identificação e o grau de incômodo relacionados a problemas comuns do assoalho pélvico, podendo ser usado na prática diária e para fins de pesquisa. Trata-se de um questionário de nove itens que avalia sintomas relacionados à incontinência urinária, urgência e frequência urinárias, dificuldade miccional, prolapso de órgãos pélvicos, evacuação obstruída, incontinência fecal e dispareunia. OBJETIVOS: Os objetivos foram validar uma versão do PFBQ adaptada para o português, assim como adapta-lo culturalmente para a língua portuguesa brasileira, atualizá-lo, e avaliar suas propriedades: confiabilidade, validade e capacidade de detectar mudanças. MÉTODOS: O PFBQ foi traduzido para o português (\"Forward Translation\") por dois tradutores independentes (sendo um deles um tradutor juramentado). Após consenso, essa versão foi traduzida para o inglês (\"Backward Translation\") por um terceiro tradutor independente. O questionário foi então testado por profissionais da saúde e em uma amostragem de 10 pacientes. Após estas etapas, a versão final do questionário foi obtida. Testes de validade foram então aplicados: confiabilidade interna, confiabilidade teste-reteste, validade dos itens e capacidade de resposta às mudanças. O PFBQ foi correlacionado com dados obtidos durante a anamnese, diários miccional e defecatório e exame pélvico, incluindo o \"Pelvic Organ Prolapse Quantification\" (POP-Q). Para avaliar a confiabilidade teste-reteste, cada paciente respondeu o PFBQ dentro de 1 semana a 10 dias. A capacidade de resposta às mudanças foi avaliada nas pacientes que completaram o questionário antes e após o tratamento. RESULTADOS: Entre fevereiro de 2014 e agosto de 2015, foram incluídas no estudo 147 pacientes com média de idade de 60,49 anos. As principais queixas foram: 12,2% incontinência urinária de esforço, 19% incontinência urinária mista, 6,1% perda urinária por urgência, 26,5% incontinência fecal, 18,4% evacuação obstruída e 17,7% POP (estádio 3 ou 4). O PFBQ demonstrou boa confiabilidade ( = 0,625, ICC = 0,981). Cada item do questionário apresentou concordância quase perfeita entre as avaliações (k = 0,895-1,00). O PFBQ correlacionou-se com o estadiamento do prolapso (p < 0,01), número de episódios de incontinência urinária e fecal (? = 0,791, p < 0,001; p = 0,780, p < 0,001) e evacuação obstruída (p = 0,875, p < 0,001). CONCLUSÕES O \"Pelvic Floor Bother Questionnaire\" em português é uma ferramenta confiável e válida que pode ser utilizada para a identificação e avaliação da gravidade/incômodo de vários sintomas do assoalho pélvico / INTRODUCTION Pelvic floor disorders include a variety of interrelated conditions, such as pelvic organ prolapse (POP), and urinary and defecatory dysfunction. Commonly, patients have concomitant pelvic disorders, which can significantly cause distress. Numerous surveys focusing on pelvic floor abnormalities have been developed and are being used, mainly in research settings. These instruments are mostly multi-item, and despite providing a rich source of information, are thus difficult to use in a clinical setting. Shorter questionnaires have been also validated, although most of them are specific for each disorder. Pelvic Floor Bother Questionnaire (PFBQ) was designed to identify the presence and degree of bother related to common pelvic floor problems, and can be used in clinical practice and for research purposes. It is a nine-item questionnaire that includes symptoms and bother related to urinary incontinence, urinary urgency and frequency, dysuria, pelvic organ prolapse, obstructed defecation, fecal incontinence, and dyspareunia. OBJECTIVE We aimed to update and validate a cross-culturally adapted version of the PFBQ in Portuguese. METHODS Translation and validation of the PFBQ was performed as follows: After conceptual analysis of the original questionnaire in English, the PFBQ was translated into Portuguese (\"Forward Translation\") by two independent translators (one certified translator). After a consensus was obtained, this version of the questionnaire was translated back into English (\"Backward Translation\") by an independent translator. The questionnaire was pilot tested on health care professionals and on 10 patients who were questioned about form and clarity of the questions. The final version of the questionnaire was obtained. Validity tests were then applied and included internal reliability, test-retest reliability, validity of the items and responsiveness to change. PFBQ was correlated with a structured clinical interview, bladder and fecal diaries and pelvic exam, including \"Pelvic Organ Prolapse Quantification\" (POP-Q) examination. To assess test-retest reliability, each patient fulfilled a second copy of the PFBQ within 7 to 10 days. Responsiveness to change was accessed in patients who completed the questionnaire before and after treatment. RESULTS A total of 147 patients of a mean age 60,49 years were enrolled in the study between February 2014 and August 2015. Chief complains were as follows: 12,2% of patients had stress urinary incontinence, 19% mixed urinary incontinence, 6,1% detrusor instability, 26,5% fecal incontinence, 18,4% obstructed defecation and 17,7% had POP (stage 3 or 4). PFBQ demonstrated good reliability (alpha = 0,625; ICC = 0,981). There was a strong agreement beyond chance observed for each question (k = 0,895-1,00). PFBQ correlated with stage of prolapse (p < 0,01), number of urinary and fecal incontinence episodes ( = 0,791, p < 0,001; p = 0,780, p < 0,001), and obstructed defecation ( p =0,875, p < 0,001). CONCLUSIONS The PFBQ is a reliable and valid tool that can be easily used for the identification and severity/bother assessment of various pelvic floor symptoms

Introducción: Al tener una disfunción del suelo pélvico aumentan las probabilidades de desarrollar incontinencia urinaria o prolapso genital. Estas condiciones, a su vez, podrían generar una infección del tracto urinario (ITU). En la población de mujeres embarazadas, la disfunción del suelo pélvico ocurre principalmente por la carga de peso del vientre, el cual podría ser una causa de la ITU. Objetivo: Determinar la asociación entre la disfunción del suelo pélvico y la ocurrencia de la ITU en gestantes. Métodos: Estudio observacional de tipo transversal analítico. La población fueron gestantes entre 18 a 35 años de 5 centros de salud en Lima. La disfunción del suelo pélvico se evaluó con el cuestionario The Pelvic Floor Inventories Leiden (PeLFIs) dividiéndose en 3 componentes: sensación de flacidez, patrón de orina e incontinencia urinaria. La ITU se midió incluyendo una sección en el cuestionario abarcando 3 preguntas. Las variables edad, actividad física, ocupación y peso fueron incluidas en la sección de preguntas generales dentro del cuestionario. Resultados: En total fueron 146 gestantes encuestadas que cumplieron criterios de selección. La prevalencia de ITU durante el embarazo fue de 42.5%. Las gestantes con ITU durante el embarazo tienen un puntaje mayor en los componentes de sensación de flacidez (p=0.036), patrón de orina (p=0.001) e incontinencia urinaria (p=0.011). Conclusión: Luego de ajustar las variables confusoras se determinó que existe asociación entre los 3 componentes de disfunción del suelo pélvico y la ITU, ya que la mayoría de las gestantes tuvieron tratamientos contra la ITU para no perjudicar su embarazo. / Introduction: Upon occurrence of a pelvic floor dysfunction, the chances of developing urinary incontinence or vaginal prolapse increase. Such conditions, in turn, may lead to a urinary tract infection (UTI). In pregnant women, the pelvic floor dysfunction mainly occurs due to the weight of the womb, which could be a cause of the UTI. Objective: To determine the association between the pelvic floor dysfunction and the occurrence of UTI in pregnant women. Methods: Observational research of analytical cross-sectional type. The population included pregnant women between 18 to 35 years old from 5 health centers of Lima. The pelvic floor dysfunction was assessed through the questionnaire “The Pelvic Floor Inventories Leiden” (PelFIs), and it was divided into three components: vaginal swelling, urination pattern, and urinary incontinence. The UTI was measured based on three questions in a section of the questionnaire. Variables such as age, physical activity, occupation, and weight were included in the section of general questions within the questionnaire. Results: A total of 146 pregnant women surveyed met the selection criteria. The prevalence of UTI during pregnancy was 42.5 %. The pregnant women suffering from UTI during the pregnancy period show a higher score in the components of vaginal swelling (p=0.036), urination pattern (p=0.001), and urinary incontinence (p=0.011). Conclusion: After adjusting the confounding variables, it was determined that there is no association between the three components of the pelvic floor dysfunction and the UTI since most of the pregnant women followed treatments against UTI to avoid any harm during pregnancy. / Tesis