Perinatal loss (stillbirth or the death of a neonate) can result in considerable psycho-social disruption for mothers. As women grieve, they try to make meaning of the death of their baby. In contexts of social and economic deprivation, perinatal loss often occurs alongside other difficulties which may affect and limit women's ability to make meaning. A narrative approach was used to explore how meaning-making functions in such contexts. In-depth interviews were conducted with 15 women who had experienced perinatal loss while attending a state maternity hospital. Narratives which the mothers constructed of the event were examined in order to understand what meanings they derived from the loss, and how these were (or not) achieved. These narratives were often linked to other stories of pervasive life difficulties. Despite their difficult contexts, the bereaved mothers engaged in meaning-making in similar ways to those described in previous studies in more affluent settings: they attempted to integrate the loss with their identity and goals, they affirmed the baby as a real person to be mourned and they searched for reasons for the loss. The effect of their contexts on meaning-making was mediated by social support and personal agency. Where one or both of these were present, the bereaved mothers were able to find meaning in their loss; women who had neither seemed unable to do so. Those who portrayed themselves as agentic were able to reflect on their experience and make decisions to change their lives. Mothers with strong social support made meaning through conversations, social validation of the loss and social help which mitigated against the sense of helplessness engendered by their loss and circumstances. It is recommended that hospital and counselling services implement practices which help to build or consolidate personal agency and social support to facilitate successful meaning-making following perinatal loss.

Objetivo: Determinar si la edad materna está asociada a un aumento o disminución de riesgo de complicaciones obstétricas y perinatales, ajustándola por diversas variables confusoras. Métodos: Estudio de cohorte retrospectiva de 67 693 gestantes en Lima, entre enero del 2000 a diciembre del 2010, usando la base de datos del Sistema informático perinatal del Hospital Nacional María Auxiliadora. Las complicaciones fueron comparadas entre gestantes adolescentes (< 20 años) y gestantes adultas (20-35 años); el grupo adolescente se clasificó en adolescentes tardías (15-19 años) y adolescentes tempranas (< 15 años). Se obtuvieron los Odds Ratio ajustados con la regresión logística simple y múltiple. Resultados: Al ajustar las diversas variables, se encontró mayor riesgo de cesárea e infección puerperal en las adolescentes menores de 15 años, así como mayor riesgo de episiotomía en el grupo total de adolescentes. Asimismo, se identificó un menor riesgo del embarazo adolescente para preeclampsia, hemorragia de la 2da mitad del embarazo, ruptura prematura de membranas, amenaza de parto pretérmino y desgarro vaginal. Conclusiones: Se encontró al embarazo adolescente como factor de riesgo para complicaciones obstétricas. Por lo tanto, se recomienda un control prenatal multidisciplinario para éste grupo etario. / Objective: To determine whether maternal age is associated with increased or decreased risk of obstetric and perinatal outcomes, adjusting by several factors. Metods: Retrospective cohort study of 67 693 pregnant women in Lima, from January 2000 to December 2010, using the perinatal database computer system from the Hospital Nacional María Auxiliadora. Outcomes were compared among pregnant adolescents (< 20 years) and adults (20-35 years); in addition, the adolescent group was divided in late adolescents (15-20 years), and early adolescents (<15 years). Adjusted odds ratios were obtained through logistic regression analysis. Results: Adjusting by several factors, an increased risk of cesarean and puerperal infection in adolescents less than 15 years was found, as well as an increased risk of episiotomy in the total group of adolescents. In addition, this study identified a lower risk of preeclampsia, 2nd half-pregnancy bleeding, premature rupture of membranes, preterm labor and vaginal tearing among adolescent mothers. Conclusion: Teenage pregnancy was found as a risk factor for adverse obstetric outcomes; hence, a multidisciplinary prenatal care for this group of adolescent is recommended. Key Word: Adolescent pregnancy, obstetric outcomes, perinatal outcomes / Tesis

The importance of preceptorships, as a mechanism to transfer knowledge of evidence-based nursing practices and developing confidence in nurses, is well-known. However, the effectiveness of preceptorships to develop confidence in perinatal nurses who provide safe care to childbearing women is unknown. Guided by Kolb's model of experiential learning and using a narrative analysis approach, this study examined perinatal nurse residents' perceptions of experiences that enhanced learning and developed confidence during preceptorship. Twenty nurses who completed a perinatal nurse residency of 18 weeks or more in the past 12 months participated in audiotaped, structured interviews. Their answers were transcribed and data analysis software was used to organize the interview data. Words and sentences were analyzed for themes. The following 7 themes emerged as confidence-building elements in perinatal nurse residency programs: 'break larger tasks into smaller steps,' 'offer encouragement,' 'provide written instructions,' 'push me a little,' 'practice with drills and quizzes,' 'show me, then let me do it,' and 'debrief after the day'. Nurses' perceptions of incivility from health care providers and experienced staff nurses was an unexpected finding. Preceptors, educators, and facilities can use these themes to standardize and strengthen perinatal preceptorships. This study has implications for positive social change by ensuring that perinatal nurse residents benefit from preceptorships that focus on the best ways to teach, instill confidence, and subsequently, pregnant women will receive safe, evidence-based care from a confident perinatal nurse. Organizations can use the results to structure quality perinatal preceptorships, retain confident nurses at the bedside, and enhance patient satisfaction.

Examina tasas y factores de riesgo asociados a la muerte fetal en un hospital público materno infantil de Lima; y su tendencia 2000-2007 y 2008-2015. Se utiliza la base de datos del Sistema Informático Perinatal del Hospital San Bartolomé completado con las historias clínicas de los casos de muerte fetal 2000- 2015. Se emplea el Open-epi para cálculo de tasas, riesgo relativo con intervalo de confianza del 95% y medidas de asociación. Encuentra que la mortalidad fetal global fue de 7,3 (total de partos 109 376) entre 2000- 2015, sin variación significativa en las tasas entre los periodos 2000-2007 y 2008- 2015. Los principales factores de riesgo asociados a muerte fetal fueron: ausencia de controles prenatales y pequeño para la edad gestacional; la diabetes gestacional y la preeclampsia fueron cuatro veces más frecuentes en los casos. La condición más frecuente de muerte fue la categoría no determinada (36,3%) seguida en menor porcentaje por pequeño para la edad gestacional (24,8%). En más de las tres cuartas partes de las muertes fetales (76%) estuvieron implicados más de dos factores de riesgo. El 81% de las muertes fetales ocurrieron en el anteparto y el 26,2% fueron a término. Se observaron cambios en el perfil epidemiológico de las madres entre los dos periodos de estudio. Concluye que la tasa de muerte fetal corresponde a la de países de ingresos medios; sin embargo, la ausencia de controles prenatales y la multiplicidad de factores de riesgo llevan a plantear la existencia de determinantes sociales de la salud en la población peruana. / Tesis

Indiana University-Purdue University Indianapolis (IUPUI) / The smoking rate of low-income pregnant women is almost 4 times the rate for higher-income women. A better understanding of smoking within the low-income population is needed. The purpose of this dissertation was to study smoking and related factors for pregnant and postpartum women living in poverty. The first component used Rodger’s evolutionary concept analysis method and uncovered three attributes, four antecedents, and three consequences for smoking cessation. The second (N = 1,554) and third (N = 71,944) components were a secondary data analysis of first-pregnancy Medicaid-eligible women enrolled in the Nurse-Family Partnership program from 2011-2016. The second component explored patterns of smoking and depression and their associations. Eight distinct patterns of smoking and depression were found. Smokers were more likely than nonsmokers to have depressive symptoms at the end of pregnancy (OR = 1.37 [1.04, 1.81] and 12 months post-delivery (OR = 1.93 [1.47, 2.51]. The third component investigated covariates present during early pregnancy and their relationships with smoking status and sought to find best fitting predictive models. Multivariable logistic regression showed cigarette use in the 3 months prior to pregnancy and at program intake were significant predictors for smoking status at the end of pregnancy and 12 months post-delivery. Interactive Matrix Language, Structured Query Language, and iterations of logistic regression identified 5 covariates (high school education, cigarette use prior to pregnancy, smoking status at pregnancy baseline, depression, and self-mastery) for the best fitting model at the end of pregnancy and three additional covariates (post-secondary education, marital status, and race) for the 12 months post-delivery model. The area under the receiver operator characteristic curve was 0.9681 for the end of pregnancy model and 0.9269 for 12 months post-delivery model, indicating excellent prediction ability of the models. Results can be integrated in smoking prevention education, screening, and cessation intervention programs.

Objective: To characterize current diabetes screening practices in the first trimester of pregnancy in the United States, evaluate patient characteristics and risk factors associated with early diabetes screening, and compare perinatal outcomes by early diabetes screening. Methods: This was a retrospective cohort study of US medical claims data from patients diagnosed with a viable intrauterine pregnancy who presented for care before 14 weeks of gestation without pre-existing pre-gestational diabetes from the IBM MarketScan® database for the period of January 1, 2016, to December 31, 2018. Univariate and multivariate analyses were used to evaluate clinical factors and perinatal outcomes. Results: There were 400,588 pregnancies identified as eligible for inclusion, with 18.0% of women receiving early screening for diabetes. Of those with laboratory order claims, 53.1% had hemoglobin A1c, 30.0% fasting glucose, and 16.9% oral glucose tolerance tests. Compared to women who did not have early diabetes screening, those that did were more likely to be older, obese, have a history of gestational diabetes, chronic hypertension, polycystic ovarian syndrome, hyperlipidemia, and a family history of diabetes. In adjusted logistic regression, history of gestational diabetes (aOR 3.99, 95% CI 3.73-4.26) had the strongest association with early diabetes screening. Early diabetes screening irrespective of the screening result was also associated with adverse perinatal outcomes including a higher rate of cesarean delivery, preterm delivery, gestational hypertension, pre-eclampsia, and gestational diabetes. Conclusion: First trimester early diabetes screening was mostly commonly performed by hemoglobin A1c evaluation, and women that underwent early diabetes screening regardless of the result were more likely to experience adverse perinatal outcomes.

Individuals with chronic medical conditions are at an increased risk for adverse reproductive and perinatal outcomes. However, there is limited condition-specific information on the reproductive and perinatal implications of chronic conditions and their associated treatments. In this dissertation, we focus on thyroid disorders and migraines, two relatively common chronic conditions among females of reproductive age, and three distinct reproductive outcomes, spanning from preconception to delivery. In study one, we analyzed the association between thyroid disorders and fecundability, the per-cycle probability of conception among non-contracepting couples, using data from Pregnancy Study Online (PRESTO), a preconception cohort study of pregnancy planners in the United States and Canada. We did not find an association between a diagnosis of hypothyroid, hyperthyroid, thyroid autoimmunity, or thyroid nodules/thyroid cancer and fecundability. We also found no association between thyroid medication use or non-use among individuals with a thyroid disorder and fecundability. In the second study, we focused on migraines and spontaneous abortion (SAB), which is pregnancy loss before twenty weeks gestation, also using PRESTO data. We found that a history of migraines is not independently associated with SAB risk in females, but that routine use of medication for migraines during the preconception period may be associated with an increased risk of SAB. In the third study, we focused on the association between migraines and hypertensive disorders of pregnancy (HDOP), which include gestational hypertension and preeclampsia. We used data from the Clinical Practice Research Datalink Gold, a longitudinal database of de-identified patient records from hundreds of primary care practices in the United Kingdom. We found that while migraines overall are associated with a small increase in risk of HDOP, this increase is most substantial among those with pre-pregnancy migraines that persist in the first trimester of pregnancy. Overall, we observed that while a history of diagnosed thyroid disorder or migraines ascertained via self-report during the preconception period may not be associated with the reproductive and perinatal outcomes we studied, certain subgroups of individuals with migraines may be at increased risk of SAB or HDOP. Migraine severity and persistence in the first trimester are likely important factors in determining the magnitude of this increased risk. Nuanced research into chronic conditions with a disproportionate disease burden among females of reproductive age will guide and improve reproductive health care for individuals with chronic conditions. This dissertation aims to address these gaps in the literature by exploring the relationship between two chronic conditions and three reproductive and perinatal outcomes: thyroid disorders and fecundability, migraines and spontaneous abortion, and migraines and hypertensive disorders of pregnancy. / 2023-04-20T00:00:00Z

<p> Asphyxia (hypoxia, hypercapnia, and acidosis) sensing by neonatal adrenal chromaffin cells (AMC) plays a key role in the adaptation of the neonate to extrauterine environment. During birth, exposure of the neonate to episodes of acute asphyxia results in secretion of catecholamines from AMC, independent of neural inputs. This catecholamine (CAT) secretion promotes re-absorption of fluid and surfactant production in the lung, improved cardiac conductance, and assists in neonatal arousal. The asphyxia-sensing responses in AMC are lost postnatally during a time course that parallels splanchnic innervation. </p> </p> <p> The primary goal of this thesis was to uncover the mechanisms of asphyxia sensing in neonatal rat AMC, using primary and immortalized chromaffin cells, and to elucidate the potential role of innervation in the postnatal loss of these mechanisms. The experimental approaches relied on patch clamp techniques to record ionic currents and membrane potential, carbon fiber amperometry to monitor CAT secretion, chemiluminescence to measure reactive oxygen species (ROS) production and ATP secretion, and molecular techniques to examine protein and gene expression. </p> <p> In primary neonatal, but not juvenile AMC, hypoxia (PO₂ = 15 mmHg) caused a suppression of outward K⁺ current, membrane depolarization, and increased secretion. These effects were associated with a decrease in mitochondrial ROS production, were reversed by exogenous H₂O₂, and where mimicked by antioxidants. Of several mitochondrial electron transport chain (ETC) inhibitors tested, only rotenone, a complex I blocker, mimicked and occulded the effects of hypoxia. The immortalized chromaffin cell line (MAH cells) behaved similarly, and became hypoxia-insensitive when depleted of functional mitochondria (ρ0 MAH). Both neonatal AMC and immortalized MAH cells also responded to increased CO₂ (hypercapnia) with K⁺ current inhibition, membrane depolarized, increased intracellular Ca²⁺, and CAT secretion. However, these responses were independent of functional mitochondria and were associated with the expression of carbonic anhydrase II (CAII). </p> <p> Since the splanchnic nerve supplies both cholinergic and opioid peptidergic innervation to AMC, I tested the hypothesis that postsynaptic activation of the corresponding receptors might underlie the postnatal loss of asphyxia-sensing. First, to determine whether nicotinic acetylcholine receptor stimulation was involved, pregnant rats were exposed to nicotine (or saline) during gestation and AMC were examined in the offspring, soon after birth. Control AMC isolated from pups born to saline-treated dams displayed typical responses to hypoxia and hypercapnia, including inhibition of outward K⁺ current, membrane depolarization, increased cytosolic calcium, and CAT secretion. In contrast, AMC from pups born to nicotine-treated dams showed a dramatic loss of hypoxic sensitivity, though hypercapnic sensitivity and the expression of CO₂ markers (i.e. carbonic anhydrase I and II) appeared normal. This effect of chronic nicotine could be reproduced in cultured chromaffin cells in vitro and was mediated via activation of α7-nicotinic acetylcholine receptors (nAChR), leading to upregulation of ATP-dependent (K_ATP) K⁺ channels, which open during hypoxia and cause membrane hyperpolarization. The upregulation of K_ATP channels involved expression ofthe hypoxia inducible transcription factor (HIF 2α). Second, to determine whether opioid receptor stimulation was also involved, cultured chromaffin cells were chronically exposed to mu, delta, or kappa opioid agonists in vitro. Treatment with both mu and delta, but not kappa, agonists resulted in the loss of both hypoxia and hypercapnia sensing and a decrease in CAII expression. </p> <p> Taken together, these studies suggest that neonatal chromaffin cells sense hypoxia via a reduction in ROS generation located at or upstream of mitochondrial complex I. Chronic stimulation of nicotinic α7 ACh receptors leads to a selective loss of hypoxia sensing and this appears to be mediated via a HIF 2α-dependent upregulation of K_ATP channels. These channels open during hypoxia causing membrane hyperpolarization and reduced excitability. The result of this upregulation of K_ATP channels results in cells deficient in the ability to respond to hypoxia. </p> / Thesis / Doctor of Philosophy (PhD)

No description available.

Rationale & Background: Gaining excessive adiposity in pregnancy is associated with altered cardiometabolic profile and adverse pregnancy outcomes. Lifestyle interventions may reduce excess weight gain, but the effect on fat gain is unclear. Our study explored this question by 1) comparing measures of body fat (BF) by bioelectrical impedance analysis (BIA) and 4-site skinfold thickness (SFT); 2) assessing the impact of a nutrition+exercise intervention on adiposity changes; 3) elucidating associations between adiposity changes and cardiometabolic biomarkers and adverse pregnancy outcomes. Study Design: Participants randomized to receive a high dairy protein diet and exercise program (intervention) or standard care (control) in the Be Healthy in Pregnancy RCT (NCT 01689961) had adiposity measured at 12-17, 26-28, and 36-38 weeks gestation by BIA (%BF) and SFT (sum and %BF), and at 6 months postpartum also by DXA. Fasted blood samples collected at 12-17 and 36-38 weeks gestation were analyzed for glucose, lipid profile, insulin, leptin, adiponectin, and CRP. Pregnancy outcomes were abstracted from medical charts. Results: In 181 participants, BIA %BF and SFT %BF had good agreement in early pregnancy and postpartum, but low agreement in late pregnancy. Adiposity changes across pregnancy were similar between study arms but were greater in normal weight compared to overweight women. Insulin and leptin were negatively associated with change in SFT (sum and %BF). Triglycerides were negatively associated with change in BIA %BF, while HDL was positively associated. Neither caesarean section nor operative vaginal delivery were associated with adiposity change. Conclusion: Adiposity measured by sum of SFT and BIA %BF increased across pregnancy but was not influenced by the diet+exercise intervention. Associations of adiposity change with cardiometabolic biomarkers varied between measurement tools. The lack of adiposity measurement tools appropriate across pregnancy and in clinical settings presents a concern for assessing clinical responses to adiposity change across pregnancy. / Thesis / Master of Science (MSc) / Pregnancy is associated with a natural gain in body fat, but it can reach excessive amounts. Excess body fat is of clinical consequence as it is associated with poor cardiovascular health and abnormal pregnancy outcomes. Improving diet and physical activity habits may reduce excess weight gain, but little is known about how it influences fat gained during pregnancy. In our study body fat gain during pregnancy was similar between the lifestyle intervention and control groups. However, entering pregnancy with greater BMI was associated with less fat gain during pregnancy. Changes in body fat influenced cardiovascular blood markers, but results differed between body fat assessment tools. We also found that methods to measure body fat produce different results at different stages of pregnancy. Our findings provide insight on the factors that influence fat gain during pregnancy and highlight the need for better tools to measure body fat accurately in pregnancy.