Structured Teaching of Early Pregnancy Loss Counseling.

OBJECTIVE: To estimate whether a novel structured curriculum could significantly improve medical student performance in early pregnancy loss counseling. BACKGROUND: Medical students receive limited exposure to early pregnancy loss counseling through real-life observation of this important skill. METHODS: A pre-post control group design was used to examine early pregnancy loss counseling performance among medical students from two medical schools doing their obstetrics and gynecology rotations at the same community hospital. The study outcomes were: (1) pre-post differences in Standardized Patient Objective Structured Clinical Examination scores; (2) pre-post differences in student confidence levels; and (3) postdifferences in standardized patient empathy ratings. Both groups had similar demographics, academic parameters, and longitudinal curricula. The study group (N=39) received a curriculum of demonstration and role-playing for delivering bad news and a shared decision-making model for early pregnancy loss management. The control group (N=38) received traditional instruction. RESULTS: Standardized Patient Objective Structured Clinical Examination posttest scores were significantly higher for the study group compared with the control group (94.2% compared with 69.7%, P<.001) after starting with similar pretest scores (64.0% compared with 61.6%, P=.53). Posttest confidence levels (1=high, 5=low) were significantly higher for the study compared with the control group (1.57 compared with 3.62, P<.001) after starting at similar levels (4.27 compared with 4.23, P=.79). Standardized patient empathy ratings (1=high, 5=low) were significantly higher for the study compared with the control group (1.84 compared with 2.62, P=.002). CONCLUSION: A structured curriculum for teaching early pregnancy loss counseling improved student performance on standardized Objective Structured Clinical Examinations compared with traditional instruction. Providing these counseling tools improved their confidence and empathy ratings in caring for patients with early pregnancy loss.

Management Strategies Aiming to Improve Horse Welfare Reduce Embryonic Death Rates in Mares.

The objective of this retrospective study was to evaluate the effect of management strategies aiming to improve animal well-being on pregnancy and embryonic death (ED) rates. Breeding records of a cohort of 1206 Thoroughbred mares brought to a stallion station facility, to be bred with the stallions housed there, were evaluated during ten breeding seasons. Mares were blocked according to management strategies in two groups: Stress and Relax. Strategies used to improve animal well-being (Relax group) were as follows: stopping the teasing routine, reducing or eliminating stall confinement, reducing the number of mares per group and maintaining herd stability during the breeding season. In barren mares, the pregnancy rate was higher in the Relax group (91.8%) when compared to the observed in Stress group (84.7%). However, no difference in pregnancy rates were observed (Stress = 85.2% vs. Relax = 86.2) in foaling mares. ED rate was higher in barren and foaling mares of the Stress group mares (25.5% and 26.8%, respectively) compared with the Relax group (16.1% and 14.7%, respectively). No significant differences were observed on foal heat pregnancy rate between groups; yet, the embryo loss on foal heat was significant reduced in Relax mares (Relax = 8.7% vs Stress = 24.5%). In conclusion, management strategies aimed to reduce social stress can reduce early pregnancy losses and the average cycles per pregnancy, improving reproductive performance in mares.

Twins less frequent than expected among male births in risk averse populations.

Male twin gestations exhibit higher incidence of fetal morbidity and mortality than singleton gestations. From an evolutionary perspective, the relatively high rates of infant and child mortality among male twins born into threatening environments reduce the fitness of these gestations, making them more vulnerable to fetal loss. Women do not perceive choosing to spontaneously abort gestations although the outcome may result from estimates, made without awareness, of the risks of continuing a pregnancy. Here, we examine whether the non-conscious decisional biology of gestation can be linked to conscious risk aversion. We test this speculation by measuring the association between household surveys in Sweden that gauge financial risk aversion in the population and the frequency of twins among live male births. We used time-series regression methods to estimate our suspected associations and Box-Jenkins modeling to ensure that autocorrelation did not confound the estimation or reduce its efficiency. We found, consistent with theory, that financial risk aversion in the population correlates inversely with the odds of a twin among Swedish males born two months later. The odds of a twin among males fell by approximately 3.5% two months after unexpectedly great risk aversion in the population. This work implies that shocks that affect population risk aversion carry implications for fetal loss in vulnerable twin pregnancies.

Altered autonomic nervous system activity in women with unexplained recurrent pregnancy loss.

AIM: Autonomic nervous system activity was studied to evaluate the physical and mental state of women with unexplained recurrent pregnancy loss (RPL). METHODS: Heart rate variability (HRV) is a measure of beat-to-beat temporal changes in heart rate and provides indirect insight into autonomic nervous system tone and can be used to assess sympathetic and parasympathetic tone. We studied autonomic nervous system activity by measuring HRV in 100 women with unexplained RPL and 61 healthy female volunteers as controls. The degree of mental distress was assessed using the Kessler 6 (K6) scale. RESULTS: The K6 score in women with unexplained RPL was significantly higher than in control women. HRV evaluated on standard deviation of the normal-to-normal interval (SDNN) and total power was significantly lower in women with unexplained RPL compared with control women. These indices were further lower in women with unexplained RPL ≥4. On spectral analysis, high-frequency (HF) power, an index of parasympathetic nervous system activity, was significantly lower in women with unexplained RPL compared with control women, but there was no significant difference in the ratio of low-frequency (LF) power to HF power (LF/HF), an index of sympathetic nervous system activity, between the groups. CONCLUSIONS: The physical and mental state of women with unexplained RPL should be evaluated using HRV to offer mental support. Furthermore, study of HRV may elucidate the risk of cardiovascular diseases and the mechanisms underlying unexplained RPL.

Duelo perinatal: un secreto dentro de un misterio / Perinatal grief: a secret within a mistery

La muerte del feto durante el embarazo, en el parto o pocos días después del nacimiento constituye un tema delicado, condicionado por numerosos factores. Esta pérdida puede desencadenar reacciones de duelo en los progenitores y situaciones de difícil manejo para los profesionales sanitarios. Son duelos que reciben escasa consideración y que pueden complicarse dando lugar a trastornos psiquiátricos. Es necesario conocer el significado de la pérdida perinatal desde la perspectiva de los progenitores para no caer en posturas paternalistas o en protocolos dogmáticos que consideran iguales a todos los progenitores ante pérdidas a las que ellos atribuyen significados diferentes (AU)

Fetal death in pregnancy, during delivery or in the days after birth is a sensible topic, influenced by several factors. The loss can trigger grief reactions in parents as well as situations difficult to manage by health care workers. This grief, which receives scant consideration, can complicate and give rise to psychiatric disorders. It is necessary to know the significance of perinatal loss from the parents’ perspective not to make the mistake of displaying paternalist attitudes or relying on dogmatic guidelines that consider all parents equal in the face of losses to which they attach different meanings (AU)

Estudio de variables asociadas a la psicoterapia grupal en los procesos de duelo patológico / Study of variables associated to the group psychotherapy in the process of pathological grief

Se estudian variables asociadas al proceso terapéutico grupal (10 sesiones de 75 minutos) de 24 sujetos adultos (23 mujeres y 1 varón) distribuídos en cuatro grupos de terapia durante los años 2007-2010 con diagnóstico de duelo complicado (DC). El DC se evalúa a través de la Escala de Prigerson (punto de corte >24) (Prigerson, 1995, Traducción Española Olmeda y García, 2006). Los pacientes pertenecen al Equipo de Salud (ESM) de Vallecas Villa y acuden remitidos por el médico de Atención Primaria para evaluar y tratar síntomas compatibles con duelo complicado. En otros casos el DC se detecta en las primeras entrevistas de evaluación, o bien a lo largo del tratamiento psiquiátrico o psicoterapéutico por los profesionales del ESM. Una vez finalizado el tratamiento grupal (TG) se vuelve a pasar La Escala de Prigerson obteniendo como resultado diferencias significativas en las puntuaciones antes y después del tratamiento, indicador de que el duelo complicado mejora significativamente en los sujetos que han participado en el tratamiento grupal (AU)

This paper presents the study of variables associated to the group treatment (10 sessions of 75 minutes) of 24 adult subjects (23 females and 1 male) divided into four therapy groups during the years 2007-2009 with a diagnosis of complicated grief (DC), evaluated through Prigerson Scale (cutoff> 24) (Prigerson, 1995, Spanish Translation Olmeda and García, 2006), belonging to the Mental Health Team Vallecas Villa (ESM). The patients were sent by their primary care physician to assess and treat symptoms consistent with complicated grief; in other cases the DC was detected in the early evaluation interviews, or along the psychiatric or psychotherapeutic treatment by professionals from ESM. Once finalized the group treatment (TG) becomes to pass the Scale of Prigerson obtaining results statistically differents in the scores, indicated that complicated grief improvement significantly in the subjects that have received group psycotherapy (AU)

Terapia cognitivista-comportamental para perda gestacional: resultados da utilização de um protocolo terapêutico para luto / Cognitive-behavioral therapy to miscarriage: results from the use of a grief therapy protocol

INTRODUÇÃO: O processo de luto devido à perda gestacional apresenta várias particularidades que devem ser consideradas no atendimento clínico daqueles que passam por uma experiência de aborto. Pacientes enlutados apresentam maior procura por assistência médica e número de hospitalizações e são mais vulneráveis a problemas psicossomáticos que a população geral. OBJETIVO: Apresentar um caso de tratamento de luto, decorrente de perda gestacional, com protocolo cognitivista comportamental. MÉTODO: O processo terapêutico foi composto por 12 sessões e o protocolo envolvia desenvolvimento de estratégias para lidar com as principais queixas somáticas, aprendizagem de novas habilidades, trabalho das alterações emocionais e cognitivas e treinamento para manejo dos problemas comportamentais. Os resultados foram avaliados por meio das escalas: Inventário Beck de Depressão, Inventário Beck de Ansiedade, Escala Beck de Desesperança e Questionário de Saúde Geral de Goldberg (QSG). RESULTADOS: O paciente apresentou redução nos sintomas de depressão e ansiedade, assim como em desesperança. Todos os fatores do QSG apresentaram redução, com forte declínio em "desejabilidade de morte" e "desordens psicossomáticas". Também foi notada melhora na qualidade de sono. CONCLUSÃO: O tratamento se mostrou efetivo em relação aos fatores apresentados, além de colaborar para melhor qualidade de vida e facilitação da reinserção social do paciente.

BACKGROUND: The grieving process due to a fetal loss has several features which should be considered in the clinical care of patients going through a miscarriage experience. Bereaved patients present greater demands for medical assistance, number of hospitalizations and are more vulnerable to psychosomatic problems than the general population. OBJECTIVE: This paper aims to present a case report of miscarriage grief treated with a cognitive behavioral therapy protocol. METHOD: The therapy was composed by 12 sessions and the protocol involves the development of strategies to deal with the main somatic complaints, learning of new abilities, approach to cognitive and emotional alterations and training to handle behavioral problems. Results were evaluated by Beck Anxiety Inventory, Beck Depression Inventory, Beck Hopelessness Scale, and Goldberg's General Health Questionnnaire (GGHQ). RESULTS: Patient presented reduction in depressive and anxiety symptoms. Hopelessness also decreased. All the GGHQ factors presented reduction, with a marked decline in "desire of death" and "psychosomatic disorders". It was also noted an improvement in sleep quality. DISCUSSION: The treatment showed itself effective in relation to the factors presented, apart from collaborating for a better quality of life and facilitating the social reinsertion of the patient.