Giving birth in Switzerland: a qualitative study exploring migrant women's experiences during pregnancy and childbirth in Geneva and Zurich using focus groups.

BACKGROUND: Migrant mothers in high-income countries often encounter more complications during pregnancy, delivery, and the postpartum period. To enlighten health care providers concerning potential barriers, the objective of this study was to explore positive and negative experiences with maternal health services in the University Hospitals of Geneva and Zurich and to describe barriers to maternity services from a qualitative perspective. METHODS: In this qualitative study, six focus groups (FGs) were conducted involving 33 women aged 21 to 40 years. All FG discussions were audio-recorded and later transcribed. Data were analysed using a thematic analysis approach assisted by the Atlas.ti qualitative data management software. RESULTS: Positive experiences included not only the availability of maternity services, especially during emergency situations and the postpartum period, but also the availability of specific maternity services for undocumented migrants in Geneva. Negative experiences were classified into either personal or structural barriers. On the personal level, the main barriers were a lack of social support and a lack of health literacy, whereas the main themes on the structural level were language barriers and a lack of information. CONCLUSION: Structural adaptation is necessary to meet the needs of the extremely diverse population. The needs include (1) the provision of specific information for migrant women in multiple languages, (2) the availability of trained interpreters who are easily accessible to health care providers, (3) specifically trained nurses or social assistance providers to guide migrants through the health system, and (4) a cultural competence-training programme for health care providers.

Barriers to reproductive health care for migrant women in Geneva: a qualitative study.

BACKGROUND: Migrant mothers in developed countries often experience more complicated pregnancy outcomes and less fewer women access preventive gynecology services. To enlighten health care providers to potential barriers, the objective of this paper is to explore barriers to reproductive health services in Geneva described by migrant women from a qualitative perspective. METHODS: In this qualitative study, thirteen focus groups (FG) involving 78 women aged 18 to 66 years were conducted in seven languages. All the FG discussions were audio-recorded and later transcribed. The data was classified, after which the main themes and sub-themes were manually extracted and analyzed. RESULTS: Barriers were classified either into structural or personal barriers aiming to describe factors influencing the accessibility of reproductive health services vs. those influencing client satisfaction. The five main themes that emerged were financial accessibility, language barriers, real or perceived discrimination, lack of information and embarrassment. CONCLUSION: Structural improvements which might meet the needs of the emergent extremely diverse population are the (1) provision of informative material that is easy to understand and available in multiple languages, (2) provision of sensitive cultural training including competence skill for all health professionals, (3) provision of specifically trained nurses or social assistance to guide migrants through the health system and (4) inclusion of monitoring and evaluation programs for the prevention of personal and systemic discrimination.

Post-traumatic stress disorder in parturients delivering by caesarean section and the implication of anaesthesia: a prospective cohort study.

BACKGROUND: Post-traumatic stress disorder (PTSD) occurs in 1-7% of women following childbirth. While having a caesarean section (C-section) is known to be a significant risk factor for postpartum PTSD, it is currently unknown whether coexisting anaesthesia-related factors are also associated to the disorder. The aim of this study was to assess anaesthesia-linked factors in the development of acute postpartum PTSD. METHODS: We performed a prospective cohort study on women having a C-section in a tertiary hospital in Switzerland. Patients were followed up six weeks postpartum. Patient and procedure characteristics, past morbidity or traumatic events, psychosocial status and stressful perinatal events were measured. Outcome was divided into two categories: full PTSD disease and PTSD profile. This was based on the number of DSM-IV criteria of the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV) present. The PTSD Checklist Scale and the Clinician Administered PTSD Scale were used for measurement. RESULTS: Of the 280 patients included, 217 (77.5%) answered the questionnaires and 175 (62.5%) answered to an additional phone interview. Twenty (9.2%) had a PTSD profile and six (2.7%) a PTSD. When a full predictive model of risk factors for PTSD profile was built using logistic regression, maternal prepartum and intrapartum complications, anaesthetic complications and dissociative experiences during C-section were found to be the significant predictors for PTSD profile. CONCLUSION: This is the first study to show in parturients having a C-section that an anaesthesia complication is an independent risk factor for postpartum PTSD and PTSD profile development, in addition to known perinatal and maternal risk factors.

[The Geneva prenatal interview: to prepare to parenthood and detect emotional troubles]. / Entretien prénatal genevois: préparer à la parentalité et dépister les troubles émotionnels.

Emotional disorders are common during the perinatal period and can have negative consequences on the woman's physical and mental health, as well as on the mother-child relationship. Screening for these difficulties is complicated because of a lack of knowledge and a lack of simple and validated tools that can be used on a large scale. A Geneva multidisciplinary team has developed a prenatal interview model, provided by specifically trained midwives. It aims to sensitize pregnant women, offer them a personalized space of listening, detect psychological weakness, develop resources and orient patients in need to specific care centers. This paper describes this interview and its main implications for clinical practice.

[Multidisciplinary care during peripartum: mother-baby dyad in the center of the relational constellations]. / Prise en charge multidisciplinaire du péripartum: le lien mère-bébé au centre des constellations relationnelles.

Pregnancy and new motherhood may be crisis and vulnerability periods and therefore increase the risk of psychiatric disorders. Liaison psychiatry plays a major role in the first psychiatric evaluation of mothers in order to specify a diagnosis and to initiate a treatment when necessary. This article describes the care of mothers suffering from peripartum psychiatric disorders by the liaison psychiatry in the maternity ward, an outpatient practice, as well as an in-patient care unit where mother and baby can stay together. The multidisciplinary approach and its constellation around the mother-baby dyad are detailed and two clinical cases are reported.

Overexpression of GRP78 in complete hydatidiform moles.

OBJECTIVE: Hydatidiform moles, subdivided into partial moles (PM) and complete moles (CM), are abnormal pregnancies with a disturbed invasive behavior. We had previously shown that MMP-2 and p53 proteins are overexpressed in CM versus PM, and that in primary cytotrophoblasts p53 protein is stabilized by complexing to the 78kDa glucose-regulated protein (GRP78) which is involved in cytotrophoblasts invasion process. The present study aims to compare the transcript expression profile of p53, MMP-2 and GRP78 in hydatidiform moles. METHODS: A retrospective study was performed by RT-qPCR and immunostaining on paraffin-embedded tissues of 19 PM, 16 CM and 16 control (CTRL) samples of gestational age 8-12 weeks. RESULTS: Expression of MMP-2 transcript was significantly overexpressed in CM compared to CTRL samples (p=0.031). In contrast, expression of p53 transcript was similar among the samples. This suggests a regulation of p53 in CM at the protein level. GRP78 cDNA was significantly overexpressed in CM compared to CTRL (p=0.021) and to PM (p=0.011). At the protein level, immunostaining of GRP78 was on average stronger in CM than PM samples. CONCLUSIONS: Collectively, present data suggest that in CM, p53 is normally expressed at the mRNA level but probably complexes at the protein level with the overexpressed GRP78, leading to accumulation of p53 protein. Moreover, since GRP78 and MMP-2 are increased in CM and known to play key roles in invasion, our results suggest that GRP78 and MMP-2 should be investigated as prognostic markers of hydatidiform moles.

Comparative analysis of secreted proteins from normal and preeclamptic trophoblastic cells using proteomic approaches.

Preeclampsia (PE) is a pathology of pregnancy which represents the main cause of maternal and perinatal morbidity and mortality. Defective placentation is the first event of this pathology. The purpose of this study was to identify the proteins secreted by cytotrophoblastic cells (CTB) using proteomic approach that are associated with PE. Comparison of secreted proteins by mass spectrometry allowed us to identify 21 proteins which were significantly differentially secreted by control and PE CTB. One protein has been detected exclusively in supernatant of control CTB and was identified as factor XIII chain A. To determine if this observation is due to a difference of protein secretion or gene expression, its mRNA was quantified in all CTB. We found that it was significantly decreased in PE CTB compared to control. Collectively, these data suggest that decrease of factor XIII chain A might be associated with development of PE.

[Psychosocial risk factors and preterm delivery]. / Facteurs de risque psychosociaux et accouchement avant terme.

Delivery before term (at less than 37 weeks of gestation) represents 5 to 10% of the deliveries and is an important cause of perinatal mortality and morbidity. Few improvements in prevention have been made. Difficulties include the multiplicity of medical risk factors, the absence of reliable diagnostic tests and the limited effectiveness of medical treatment. Several studies have shown that psychosocial risk factors are associated with preterm labour. The identification and management of these risk factors and of unfavorable social environment may potentially reduce the risk of preterm delivery. We describe and discuss the studies evaluating psychosocial interventions aiming at reducing the risk of prematurity.

Stressful events, social support and coping strategies of primiparous women during the postpartum period: a qualitative study.

OBJECTIVE: to identify problems and events perceived as stressful by primiparous mothers during the postpartum period, and to explore the social support and coping strategies they used to face these situations. DESIGN: a qualitative study. Data were collected via semi-structured interviews and analysed using a content-analysis method. SETTING: Geneva University Hospitals, Geneva, Switzerland from October 2006 to March 2007. PARTICIPANTS: 60 women interviewed six weeks after the birth at term of their first child. FINDINGS: during the early postpartum period, interaction with caregivers was an important source of perceived stress. Upon returning home, the partner was considered as the primary source of social support, but the first need expressed was for material support. Breast feeding was perceived negatively by the new mothers, and this may be due to the difference between the actual problems encountered and the idealised expectations conveyed by prenatal information. Educational information dispensed by medical staff during the prenatal period was not put into practice during the postpartum period. Mothers expressed the need to be accompanied and counselled when problems arose and regretted the lack of long-term postpartum support. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: both the prenatal education and postpartum social support seem to mismatch women's needs and expectations. Concerted efforts are required by health professionals at the maternity unit and in the community to provide mothers with more adequate postpartum assistance.

First-trimester prenatal diagnosis performed on pregnant women with fetal ultrasound abnormalities: the reliability of interphase fluorescence in situ hybridization (FISH) on mesenchymal core for the main aneuploidies.

OBJECTIVES: To examine the reliability of interphase FISH analysis of the main aneuploidies performed on mesenchymal core when prenatal diagnosis was performed on pregnant women with first-trimester fetal abnormalities on ultrasound. STUDY DESIGN: 386 first-trimester prenatal examinations were investigated from chorionic villus samplings for increased nuchal translucencies or other fetal ultrasound abnormalities. Interphase fluorescence in situ hybridization (FISH) for the main aneuploidies (trisomies 13, 18, 21 and gonosomal aneuploidies) was performed on the mesenchymal core of villi. Molecular cytogenetic results were always complemented by conventional cytogenetic results on long-term cultured villi (LTC-villi). Short-term cultured villi (STC-villi) preparations were retrospectively performed only when a chromosomal abnormality was observed with interphase FISH and/or LTC-villi. RESULTS: 88 chromosomal abnormalities (88/386=22.8% of first-trimester diagnoses) which could discuss subsequent abortions were observed after LTC-villi preparations. All cases possibly detectable by interphase FISH were detected. Thus, 85 aneuploidies (85/386=22.0% of first-trimester diagnoses; 85/88=96.6% of chromosomal abnormalities) were detected by interphase FISH, allowing early abortion by curettage before week 14 amenorrhea. No discrepancy occurred between interphase FISH and LTC-villi results for the aneuploidies studied. Three false-negative results (3/386=0.77% of first-trimester diagnoses; 3/88=3.41% of chromosomal abnormalities) were observed with STC-villi. CONCLUSION: We observed a high rate of false-negative results on cytotrophoblast cells. Conversely, interphase FISH of the main aneuploidies on the mesenchymal core provided rapid and reliable results, and therefore should be preferred to STC-villi in first-trimester prenatal diagnosis performed on pregnant women with fetal abnormalities on ultrasound.

[Interprofessional collaboration in perinatality: an obstetrical goal]. / Travailler sur les articulations interprofessionnelles en périnatalité: un objectif obstétrical.

In the field of perinatality, development of prenatal diagnosis and neonatal management have been impressive. But these were also associated with the emergence of the increasingly important emotional dimension for parents and professionals. Obstetricians dealing with the difficult breaking of bad news, the uncertainties of prenatal diagnosis and the complex somatic, psychological and social follow-up have to work in a multidisciplinary approach. The securing role of a coherent teamwork is recognised by parents as well as health care providers This article discusses interprofessional relationship as an obstetrical goal and give some landmarks in order to improve the management and the collaboration with parents.

[Changes in D-dimer levels during pregnancy and the postpartum period: results of two studies]. / Evolution des D-dimères durant la grossesse et le post-partum: résultats de deux études.

In outpatients D-dimer (DD) measurement is included in most algorithms to exclude venous thromboembolism (VTE). We have recently performed two studies to evaluate the evolution of DD during pregnancy and the postpartum. During pregnancy, DD increase progressively and are of poor value to exclude VTE after 20 weeks of gestation. During labour, DD are usually very high and decrease quickly during the first 3 days post-delivery. Many weeks are necessary to obtain their normalisation and therefore their utility to rule out VTE is very limited until 4 weeks postpartum. This increase of DD values until 4 to 6 weeks after delivery correlates with the length of antithrombotic prophylaxis recommended for women at high risk of VTE.

D-dimer levels during delivery and the postpartum.

BACKGROUND: D-dimer (DD) measurement has proved to be very useful to exclude venous thromboembolism (VTE) in outpatients. However, during pregnancy, the progressive increase as well as the interindividual variations of DD means that in this instance they are of poor value to rule out VTE. Only a few studies have reported measurements of DD levels in the postpartum. OBJECTIVES: To measure DD sequentially in the puerperium in order to determine when DD levels return to values obtained in non-pregnant women and can again be used in the exclusion of VTE. PATIENTS AND METHODS: After uncomplicated pregnancies, 150 women delivering at term either vaginally (n = 100) or by cesarean section (n = 50) were included. DD levels were measured immediately following delivery and next at days 1, 3, 10, 30 and 45. RESULTS: There was a marked elevation of DD at delivery, especially when instrumental. All DD measurements were above 500 ng mL(-1) at delivery, at day 1 and at day 3 postpartum. A sharp decrease in DD was observed between day 1 and day 3, followed by a slight increase at day 10. At day 30 and day 45, respectively, 79% and 93% of women in the vaginal delivery group and 70% and 83% in the cesarean group had levels below 500 ng mL(-1). Bleeding, breastfeeding and heparin prophylaxis did not modify DD levels significantly. CONCLUSION: Using the Vidas DD new assay, our study provides reference intervals for DD in the postpartum period. Using a cut-off at 500 ng mL(-1), DD measurement for ruling out VTE was found to be useful again 4 weeks after delivery.

"White dots on the placenta and red dots on the baby": congential cutaneous candidiasis--a rare disease of the neonate.

Cutaneous congenital candidiasis (CCC) is a very rare disease of the term or premature infant consisting of a generalized rash at or shortly after birth usually without other signs or symptoms. The presence of white microabscesses on the placenta and umbilical cord of an infant with such a rash must suggest the diagnosis of CCC, which is always secondary to Candida chorioamnionitis but may pass unrecognized. Despite the high prevalence of vulvo-vaginitis in pregnant women, Candida chorioamnionitis is rare and CCC remains apparently extremely rare with just some hundred cases described. However, as the condition is essentially benign and self-limited, underdiagnosis is likely. As occasional systemic spread of Candida infection is described and maternal complications may arise, diagnosis and a close follow-up or treatment is of importance. We present two cases of CCC, stressing the importance of sharing clinical findings between obstetrician and neonatologist for the diagnosis and subsequent management.

Intraobserver and interobserver agreement in the diagnosis of anal sphincter tears by postpartum endosonography.

OBJECTIVE: To evaluate intraobserver and interobserver agreement in the diagnosis of anal sphincter tears by endosonography when performed immediately postpartum by resident obstetricians. METHODS: Fifty-four primiparous women who delivered vaginally and had no anal sphincter tears (third- or fourth-degree perineal tears) diagnosed clinically were recruited. Four observers assessed photographic prints and video recordings of anal endosonography performed before the suture of the perineum. We calculated the intra- and interobserver agreement and the kappa coefficient to quantify the reliability of the diagnosis of clinically occult sphincter tears. RESULTS: The observers described sphincter tears in 13-28% of the prints, and in 7-32% of the video recordings. Intraobserver agreement was rated as substantial for prints (kappa, 0.63), and moderate for video recordings (kappa, 0.48). The interobserver agreement was fair for prints (kappa, 0.34) and moderate for video recordings (kappa, 0.42). CONCLUSION: Endosonography performed immediately postpartum to diagnose anal sphincter tears is of moderate reliability.

Contractility of the nonpregnant uterus: the follicular phase.

Recent renewed interest in uterine contractility stems from the possibility of directly visualizing uterine contractility on images generated by high-resolution ultrasound probes. During the menstrual cycle, three typical patterns of uterine contractility have been recognized. During the luteofollicular transition and early follicular phase (menses), the contractile event involves all layers of the myometrium and exerts antegrade (from fundus to cervix) expulsive forces. Characteristically, uterine contractions are often perceived by women at the time of menses, sometimes reaching the level of painful cramps (dysmenorrhea). In the late follicular phase, uterine contractility involves only the subendometrial layers of the myometrium and is never perceived by women. The primary function of uterine contractility in the late follicular phase is to facilitate the retrograde (cervix to fundus) transport of sperm towards the distal end of the fallopian tubes where fertilization normally takes place. Finally, the uterus reaches a stage of quiescence after ovulation (under the influence of progesterone) that characterizes the major part of the luteal phase. The present review summarizes our understanding of the physiological role of uterine contractility during the follicular phase and the possible implications in pathological circumstances such as endometriosis and dysmenorrhea.

CA125 production by the peritoneum: in-vitro and in-vivo studies.

The source of CA125 synthesis is still debated. Endometrial, peritoneal, ovarian and amniotic cells have been demonstrated to produce and secrete CA125. Different studies show that the peritoneum is a source of CA125. The present study aimed at investigating in vivo and in vitro the peritoneal contribution to circulating CA125. Cultures of uterine peritoneum, abdominal peritoneum and myometrium explants were performed and CA125 measured in the culture medium. To modulate the potential production of CA125, the explants were cultured with or without cycloheximide, bacterial lipopolysaccharide (LPS) or ascitic fluid. In a prospective study, we compared a group of patients after abdominal surgery (n = 19; nine men, 10 women) with a group after extra-abdominal surgery (n = 21; 11 men, 10 women), in order to detect a postoperative increase of serum CA125. De-novo synthesis of CA125 could not be demonstrated in the cultures of uterine and abdominal peritoneum and in myometrium, but CA125 concentrations were detectable in the culture medium without being modulated by cycloheximide, LPS or ascitic fluid. After peritoneal surgery, the proportion of patients with increased serum CA125 was significantly higher (P < 0.03) after abdominal surgery as compared with extra-abdominal surgery. This is considered as indirect evidence for in-vivo production of CA125 by the peritoneum.