Anti-Ro/SSA autoantibody-positive women's experience of information given on the risk of congenital heart block.

OBJECTIVE: Congenital heart block (CHB) may develop in fetuses of women with anti-Ro/SSA autoantibodies, and carries substantial morbidity and mortality. The aim was to evaluate how information on CHB is imparted and identify areas of improvement. METHODS: A questionnaire was distributed to anti-Ro/SSA antibody-positive women who had either participated in a surveillance programme but whose expected child did not develop CHB (n = 100, denoted Doppler-Assessed Pregnancies (DAP) group) or given birth to a child with CHB (n = 88, denoted CHB-Affected Pregnancies (CAP) group). RESULTS: The response rate was 83% (157/188). Most women received the information on CHB when they were already pregnant (DAP group 60%, CAP group 83%). However, a majority of them would have wanted the information before pregnancy (DAP group 52%, CAP group 56%), and most stated that it would not have influenced their decision to have a child (DAP group 77%, CAP group 58%). The ability to both understand the information and to perceive the information as sufficient were significantly higher when someone trained in paediatric cardiology gave the information. CONCLUSIONS: Our findings indicate that information on CHB should be given to women before pregnancy. The data further highlight the importance of having specific knowledge for giving relevant and understandable, yet sufficient information.

Ro/SSA autoantibody-positive pregnancy: reactions to serial fetal Doppler echocardiographic surveillance.

OBJECTIVE: The risk for congenital heart block (CHB) associated with maternal Ro/SSA autoantibodies is low, but the possibility of treating early stages of disease has seen the introduction of Doppler echocardiographic surveillance programs with serial examinations during the CHB susceptibility weeks of pregnancy. The aim of the present study was to understand how Ro/SSA autoantibody-positive women having undergone Doppler echocardiographic surveillance programs and giving birth to children without CHB experienced their pregnancy and frequent ultrasound examinations. METHODS: A validated questionnaire based on data from an interview-study was distributed to Ro/SSA-positive women supervised with Doppler examinations during their pregnancy (n = 100). RESULTS: The response rate was 79%. The majority of the women (61%) reported that the increased number of ultrasound examinations influenced their pregnancy, but in a positive way, with qualified information and additional support from health care personnel in conjunction with the examinations. Further, the visits to the clinic provided opportunities to see the ultrasound picture of the expected infant. However, one-third of the women also reported stress in relation to the examinations. CONCLUSIONS: Fetal echocardiographic surveillance holds many and predominantly positive effects for Ro/SSA-positive women during pregnancy in addition to the medical advantages.

Associations between advanced maternal age and psychological distress in primiparous women, from early pregnancy to 18 months postpartum.

OBJECTIVE: To investigate if advanced maternal age at first birth increases the risk of psychological distress during pregnancy at 17 and 30 weeks of gestation and at 6 and 18 months after birth. DESIGN: National cohort study. SETTING: Norway. SAMPLE: A total of 19 291 nulliparous women recruited between 1999 and 2008 from hospitals and maternity units. METHODS: Questionnaire data were obtained from the longitudinal Norwegian Mother and Child Cohort Study, and register data from the national Medical Birth Register. Advanced maternal age was defined as ≥ 32 years and a reference group of women aged 25-31 years was used for comparisons. The distribution of psychological distress from 20 to ≥ 40 years was investigated, and the prevalence of psychological distress at the four time-points was estimated. Logistic regression analyses based on generalised estimation equations were used to investigate associations between advanced maternal age and psychological distress. MAIN OUTCOME MEASURES: Psychological distress measured by SCL-5. RESULTS: Women of advanced age had slightly higher scores of psychological distress over the period than the reference group, also after controlling for obstetric and infant variables. The youngest women had the highest scores. A history of depression increased the risk of distress in all women. With no history of depression, women of advanced age were not at higher risk. Changes over time were similar between groups and lowest at 6 months. CONCLUSION: Women of 32 years and beyond had slightly increased risk of psychological distress during pregnancy and the first 18 months of motherhood compared with women aged 25-31 years.

Patterns of emotional responses to pregnancy, experience of pregnancy and attitudes to parenthood among IVF couples: a longitudinal study.

The aim of this longitudinal study was to compare couples who had conceived by in-vitro fertilization (IVF) with couples who had conceived naturally, regarding patterns of emotional response to different stages of pregnancy and to compare their expectations of and attitudes to pregnancy, parenthood and children. Fifty-seven IVF women and 55 of their male partners, and a control group of 43 pregnant women and 39 of their male partners participated. They completed scales measuring emotional responses to pregnancy, attitudes to pregnancy, parenthood and children. The IVF couples were interviewed about their experience of pregnancy. The overall anxiety about losing the pregnancy was higher among the IVF couples from early to late pregnancy. The IVF women experienced the pregnancy in a more positive way and they were less concerned about the child's gender and loss of freedom in their future lives as parents compared to controls. The IVF men were more anxious about the baby being injured during birth. The interviews with the IVF couples confirmed the self-ratings. In conclusion, the results suggest that it is important for healthcare providers to pay attention to an elevated anxiety among IVF couples and to give them extra time to discuss emotions during pregnancy and their future life as parents.

The impact of frozen embryos on emotional reactions during in vitro fertilization.

BACKGROUND: Emotional reactions of couples were investigated during in vitro fertilization (IVF) at a private clinic in Sweden. The purpose was to compare such reactions between couples who obtained supernumerary embryos that could be cryopreserved and couples without such embryos. METHODS: Forty women and men undergoing IVF treatment monitored individually their emotional reactions daily for one complete treatment cycle from the first day of down-regulation until the outcome of treatment was known. Ratings were extracted and analyzed from two separate days; the very first day of treatment and the day of embryo transfer. RESULTS: The group of women (n=16; 40%) with supernumerary embryos suitable for cryopreservation reported a greater increase in optimism than the group (n=24; 60%) without such embryos (p=0.024). Correspondingly, women with supernumerary embryos reported less pessimism than women without such embryos (p=0.014). Among men there was no difference in optimism or pessimism between the groups. The women and men with supernumerary embryos did not differ in distress reactions compared to those women and men without such embryos. There was no correlation between optimism and distress on the day of embryo transfer in women; r=-0.167 and men; r=-0.135 respectively. CONCLUSION: The presence of frozen embryos increased optimistic and reduced pessimistic feelings about pregnancy among women undergoing IVF treatment. However, the couples' increased optimism on the day of embryo transfer did not seem to reduce their experience of distress.

Gender differences in psychological reactions to infertility among couples seeking IVF- and ICSI-treatment.

BACKGROUND: Gender differences and similarities in psychological reactions related to infertility, perception of social support, the effect of infertility on the marital relationship and coping-style were investigated among Swedish couples seeking in vitro fertilization -- or intracytoplasmic sperm injection - treatment. METHODS: Ninety-one couples entering treatment completed the Infertility Reaction Scale, a self-report questionnaire with structured and open-ended questions and the Miller Behavioral Style Scale. RESULTS: The women reacted more strongly to their infertility than the men as measured by the Infertility Reaction Scale (p<0.05). Factor analysis of the Infertility Reaction Scale produced three factors for men and women respectively. The first factor that emerged for the men was 'The male role and social pressure' and the second factor was 'The major focus of life'. For the women the two first factors were reversed compared to those of the men. The third factor 'Effect on sexual life' was similar for men and women. Significantly more men than women had not confided in anyone about their infertility problem (p<0.001). The information-seeking coping style was significantly correlated with infertility distress only among men (p

Psychological reactions during in-vitro fertilization: similar response pattern in husbands and wives.

The purpose of this study was to examine differences in daily emotional, physical and social reactions among husbands and wives during in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). Forty couples about to undergo ICSI or IVF at a private infertility clinic monitored their emotional, physical and social reactions daily for one complete treatment cycle from the first day of stimulation until the outcome of treatment was known (approximately 35 days). The results showed that men and women had a similar response pattern to oocyte retrieval, fertilization, embryo transfer and the pregnancy test. These stages were associated with the most significant changes in reactions for both spouses. The pattern of results suggested that the most important psychological determinant of reactions during IVF was the uncertainty of treatment procedures. Spouses appeared to be equally sensitive to this uncertainty and both appeared to respond to it with ambivalent feelings involving emotional distress and positive feelings of hope and intimacy.

Distress level in men undergoing intracytoplasmic sperm injection versus in-vitro fertilization.

The purpose of this study was to compare the psychological reactions of men undergoing intracytoplasmic sperm injection (ICSI) (n=18) or in-vitro fertilization (IVF) (n=22). Men monitored their psychological reactions daily for one complete treatment cycle from the first day of down-regulation until the outcome of treatment was known (approximately 52 days). The results showed that ICSI patients reported marginally more distress on the days prior to retrieval than the IVF patients. Other than this difference the pattern of results indicated that the psychological reactions of men undergoing ICSI or IVF were similar and that there was no need to manage these patients differently during treatment. However, ICSI patients may benefit from some reassuring comments on the days prior to retrieval when they showed more anticipatory anxiety.

Role of talocalcaneal osteotomy in clubfoot surgery: results in 31 surgically treated feet.

The most important deformities in clubfeet can be demonstrated by simultaneous arthrography of the talonavicular and talocrural joints. In patients with a severe talar deformity, wedge osteotomy through the talar neck and calcaneus has been performed as a prerequisite for correction. Our series consisted of 20 patients with 31 idiopathic clubfeet with pronounced talar deformity. The mean observation time after osteotomy was 11 years 3 months. The principles and aims are described, as are the indications for talocalcaneal osteotomy. Results were good in 19 feet (60%), fair in six (20%), and poor in six (20%).

Congenital dislocation of the knee.

Congenital dislocations of the knee (CDK) are rare, occurring 40-80 times more rarely than congenital dislocation of the hip (CDH). In a multicentric study of the European Paediatric Orthopaedic Society, 56 cases of CDK were found in 46 babies. Many other malformations associated with CDK were noticed, and muscular abnormality was always found at the knee. According to the classification of Leveuf, three grades have to be considered: grade 3, or complete dislocation, was the most frequent. At birth, treatment consisted of physiotherapy with rigid splint. Twenty-four patients with CDK have been treated only by the conservative technique. Operations were performed according to the abnormalities of the extensor apparatus: a progressive release and lengthening of the quadricipital tendon was necessary in all cases. In all forms of treatment, the range of the knee flexion was 120 degrees. Only two children had a bad result because of unstable knees. Results were always better with conservative treatment.

Congenital dislocation of the hip: a biomechanical study in autopsy specimens.

The role of mechanical factors in neonatal hip instability was studied in four experimental series of autopsy specimens. The induced hip deformation and dislocation were examined by serial cryosectioning and cryodissection. Loading of the hips at 45 degrees of flexion with moderate forces for 3 h resulted in deformation and dislocation similar to those found at autopsy in congenital dislocation of the hip. There was no macroscopic damage to the joints. Loading at 135 degrees of flexion--to simulate a breech position--also resulted in dislocation, but the cartilage deformation was less pronounced than after loading at 45 degrees of flexion. When the same hip was loaded first at 135 degrees of flexion for 3 h and then at 45 degrees of flexion for another 3 h, the findings were similar to those following loading at 45 degrees of flexion alone. Thus a redeformation of the hip had taken place during the second step of the experiment. After unloading of the deformed and dislocated hips, marked joint laxity was observed, and examination 3 h after unloading showed incomplete recovery of the deformation.

Fibrinolysis inhibition after a major standardized trauma.

The present investigation on 20 patients after total hip replacement surgery has confirmed that the posttraumatic increase of the fibrinolysis inhibition activity (FIA) in serum and plasminogen-depleted serum is due to the primary fibrinolysis inhibitor (PFI, alpha 2-antiplasmin). This protein exists in at least two forms and it was indicated that PFI alpha with affinity to immobilized plasminogen, is mainly responsible for the posttraumatic variations of the FIA in plasminogen-depleted serum. PFI beta, the major part of the PFI-related antigen, which has none or low such affinity, displayed weak FIA and relatively small increase after the surgical trauma. It was established that the posttraumatic increase of the FIA was not derived from the low molecular weight fraction in serum of those patients.

Comparative influences of epidural and general anaesthesia on deep venous thrombosis and pulmonary embolism after total hip replacement.

In an investigation on deep venous thrombosis and pulmonary embolism, where neither dextran nor antithrombotic drug prophylaxis were employed, 30 patients undergoing total hip replacement were randomly allotted to one of two groups receiving either epidural or general anaesthesia. The epidural group (n = 15) was given 0.5% bupivacaine with epinephrine (5 micrograms/ml) and this was prolonged into the postoperative period for pain relief. The general anaesthesia group (n = 15) was operated on under artificial ventilation with nitrous oxide/oxygen via an endotracheal tube and intravenously administered fentanyl and pancuronium bromide. In this group of patients narcotic analgesics (ketobemidone) were given intramuscularly on demand for pain relief postoperatively. The frequency of deep venous thrombosis involving the femoral veins, as observed at phlebography, was significantly lower in patients receiving continuous epidural block (3 of 15; 20%), than in those receiving general anaesthesia and parenteral analgesics postoperatively (11 of 15; 73%). Further, the frequency of pulmonary embolism, as determined by pulmonary perfusion lung scanning, was lower in patients receiving continuous epidural block (2 of 15) than in the general anaesthesia group (7 of 15). Possible explanations for these findings are discussed, including a hyperkinetic lower limb blood flow and lower fibrinolysis inhibition activity in patients given epidural block. Lower blood transfusion requirements in patients given epidural block might also play a role, as well as a "stabilizing" effect of local anaesthetics on platelets, leukocytes and endothelial cells.

Talo-calcaneal osteotomy and soft tissue procedures in the treatment of clubfeet. I. Indications, principles and technique.

By simultaneous arthrography of the talocrural and talonavicular joints it is possible to demonstrate and measure the most important skeletal deformities in clubfoot. In this way it has been possible to establish the indications for alternative forms of treatment with a greater degree of precision. Most of our refractory or recurrent clubfeet have been treated successfully by various soft tissue procedures. In cases with severe talar deformity, however, these procedures have been complemented by correction osteotomy through the talar neck and calcaneus. The aim is to create muscle balance by soft tissue procedures and to correct pronounced skeletal deformities by osteotomy. This treatment plan has been used in about 50 of our clubfoot cases. The principles, objectives and indications of the surgical therapy are discussed in this article. The operative technique, as it has been developed with increasing experience, is described, and if careful attention is paid to all details the risk of complications is small and the correction is generally satisfactory. It must be emphasized that correction osteotomy is only a part of an overall treatment plan and that this operation is only indicated in a minority of clubfoot cases.

Talo-calcaneal osteotomy and soft-tissue procedures in the treatment of clubfeet. II. Results in 36 surgically treated feet.

Thirty-six refractory or recurrent clubfeet were treated by correction osteotomy through the talar neck and calcaneus in combination with various soft tissue procedures. The aim of the osteotomies was to correct the pronounced deformities observed at simultaneous arthrography of the talocrural and talonavicular joints. The soft tissue procedures were carried out to facilitate the correction and to prevent recurrence by creating muscle balance. Twenty-four clubfeet were idiopathic and 12 were secondary to neurological or other diseases. The observation period since the osteotomies were performed was, at the time of writing, 1.5 to 5.5 years (median 3 years). A brief report of the indications and methods of operation is given. Good or fair results were achieved in 21 of the 24 idiopathic clubfeet, while the results were somewhat poorer in the secondary clubfeet. A correlation between the degree of arthrographically demonstrated talar deformity and the results of surgical treatment was found. The main reason for a poor result was incomplete correction of the most extreme talar deformity in combination with marked preoperative joint rigidity.

A case of Albright's syndrome treated with calcitonin.

A 23-year-old woman with Albright's syndrome (polyostotic fibrous dysplasia of bone, precocious puberty and irregular cutaneous pigmentations) had sustained multiple fractures and was grossly disabled. Evaluation disclosed markedly raised serum alkaline phosphatases and a high urinary excretion of hydroxyproline, suggesting an accelerated bone turnover, while calcium metabolism was virtually undisturbed. During 12 months therapy with calcitonin, however, no apparent benefit was recorded and there was no evidence of any significant metabolic effects of the treatment. Initial discomfort with nausea and vomiting disappeared after dose reduction whereas diffuse bone and muscle pain, which gradually increased after a few months treatment, did not subside until after cessation of the therapy.

Neonatal hip instability. Reason for failure of early abduction treatment.

A series of nine children with hip joint instability in 17 hips, diagnosed neonatally, is presented. Seven had bilateral idiopathic instability and two instability secondary to arthrogryposis, one of them bilateral. After reduction seven of the children (14 hips) were treated with abduction devices, which in all cases did not lead to stability in one or both hips. In these cases arthrography revealed that closed reduction was impossible due to narrowing of the joint capsule (hour-glass shape) and the interposition of a capsular fold including the acetabular labrum. The same types of changes were seen within 1 or 2 months after birth in three hips which had had no abduction treatment before arthrography. At open reduction of 11 hips it was found that the narrowing of the capsule was caused by the tendons of the iliopsoas and rectus femoris muscles. Excision of the capsular fold (labrum) was not necessary. The femoral head was deformed and anteverted. Failure of conservative treatment can be due either to incomplete reduction or to inadequate immobilization. Our analysis has shown that the most probable reason is incomplete reduction due to interposition. An obstacle to reduction should be suspected if abduction is restricted at birth, if primary reduction is difficult and the position difficult to maintain or if instability persists after 8 weeks of treatment. On the basis of our material the incidence of such an impediment to reduction was 0.08 per thousand births in the region studied during a 5-year period.