Violence Exposed Nepalese Pregnant Women have an Accepting Attitude to Domestic Violence and Suffer from Emotional Distress.

Background Violence against women and girls is frequent, a third of all women is estimated to experience violence in their lifetime and mostly by an intimate partner. Women in Southeast Asia are most affected, and previous studies in Nepal found that one in five women had experiences of domestic violence, including being afraid of someone in the family. Objective To investigate women's attitudes to domestic violence and their emotional distress, in a specific group of pregnant women. Method Validated questions from the WHO multi-country study on women's health and experiences of domestic violence, and questions from the Hopkins Symptom Checklist (HSCL-5), measuring depression and anxiety, were used. Women could answer anonymously by hearing questions in a headset and touching a tablet screen, for 'yes' or 'no'. Result In total 1011 pregnant women participated in the research and 240 women admitted being exposed to domestic violence (23.7%). These women had a more accepting attitude to violence compared to non-violence exposed women. They agreed more that the husband had good reasons to hit his wife, if she does not complete the household work to his satisfaction, she disobeys or refuses to have sex with him. Violence exposed women also reported more emotional distress and subsequently reduced wellbeing. They admitted worrying too much, feelings of hopelessness, feeling blue, fearful, or nervous. Conclusion The present study found that the pregnant Nepali women having an accepting attitude to violence suffer from emotional distress.

Caesarean section performed by medical doctors and associate clinicians in Sierra Leone.

BACKGROUND: Many countries lack sufficient medical doctors to provide safe and affordable surgical and emergency obstetric care. Task-sharing with associate clinicians (ACs) has been suggested to fill this gap. The aim of this study was to assess maternal and neonatal outcomes of caesarean sections performed by ACs and doctors. METHODS: All nine hospitals in Sierra Leone where both ACs and doctors performed caesarean sections were included in this prospective observational multicentre non-inferiority study. Patients undergoing caesarean section were followed for 30 days. The primary outcome was maternal mortality, and secondary outcomes were perinatal events and maternal morbidity. RESULTS: Between October 2016 and May 2017, 1282 patients were enrolled in the study. In total, 1161 patients (90·6 per cent) were followed up with a home visit at 30 days. Data for 1274 caesarean sections were analysed, 443 performed by ACs and 831 by doctors. Twin pregnancies were more frequently treated by ACs, whereas doctors performed a higher proportion of operations outside office hours. There was one maternal death in the AC group and 15 in the doctor group (crude odds ratio (OR) 0·12, 90 per cent confidence interval 0·01 to 0·67). There were fewer stillbirths in the AC group (OR 0·74, 0·56 to 0·98), but patients were readmitted twice as often (OR 2·17, 1·08 to 4·42). CONCLUSION: Caesarean sections performed by ACs are not inferior to those undertaken by doctors. Task-sharing can be a safe strategy to improve access to emergency surgical care in areas where there is a shortage of doctors.

Induction of CYP2D6 in pregnancy.

Expression of the drug-metabolizing enzyme cytochrome P4502D6 (CYP2D6) is predominantly under genetic control, and enzyme-inducing drugs have little influence on its activity. We studied the activity of CYP2D6 during pregnancy. One hundred forty pregnant women were genotyped for CYP2D6. Seventeen of them (four poor metabolizers, seven heterozygous extensive metabolizers, and six extensive metabolizers) were phenotyped with dextromethorphan in late pregnancy and 7 to 11 weeks after parturition. During pregnancy the dextromethorphan/dextrorphan metabolic ratio was significantly reduced (p = 0.0015) among homozygous and heterozygous extensive metabolizers, indicating increased CYP2D6 activity. In contrast, poor metabolizers showed an increased metabolic ratio during pregnancy. These results are consistent with previous findings of a marked increase in metabolism of the CYP2D6 substrate metoprolol during pregnancy. Both studies indicate an increase in CYP2D6 activity during pregnancy, which may be caused by an induction of the CYP2D6 enzyme.

The prophylactic effect of doxycycline on postoperative infection rate after first-trimester abortion.

A prospective double-blind study was performed to evaluate the effect of prophylactic antibiotic treatment before induced abortion. Eight hundred consecutive women admitted for first-trimester abortion, without signs of genital infection or antibiotic use in the last three weeks, were included in the study. Doxycycline 400 mg or placebo was given as a single oral dose ten to 12 hours before vacuum aspiration. Ninety-one women (11.8%) returned to the hospital with suspected complications. Thirty-two of these women were diagnosed as having pelvic inflammatory disease, eight of whom (2.1%) had received doxycycline before the abortion and 24 of whom (6.2%) had received placebo, a statistically significant difference (P less than .01). A history of pelvic inflammatory disease increased the risk of developing it again after an abortion.

Effects on lipids and lipoproteins in women treated with oestradiol and progesterone.

Thirty women with climacteric symptoms were treated for 4 months with 2 mg 17 beta-oestradiol and different doses of progesterone (50, 100 or 200 mg). The concentrations of total and free cholesterol, phospholipids, triglycerides (TG), apoprotein A1 and apoprotein B were determined in high-density lipoprotein (HDL), low-density lipoprotein (LDL) and very-low-density lipoprotein (VLDL) fractions and in serum. HDL levels increased and LDL levels decreased, while TG levels in VLDL remained unchanged, which indicates that the lipoprotein pattern is oestrogen-induced and that progesterone exerts little or no influence.

Clinical and endometrial effects of oestradiol and progesterone in post-menopausal women.

This study reports the clinical effects in a group of post-menopausal women after 4 months of treatment with 2 mg micronized 17 beta-oestradiol (E2) in combination with different doses of micronized progesterone (50, 100 or 200 mg) for 25 days each month. The 30 participants were divided into three groups. All of the subjects tolerated the preparation well and obtained relief from their climacteric complaints. None dropped out because of side effects and no changes were observed in blood pressure, weight or Papanicolaou cytology. Breakthrough bleeding was noted in the first cycle, mainly in the group receiving the lowest dose of progesterone. Endometrial biopsies performed before and after 4 months of treatment showed an atrophic endometrium in most of the women who received 100 mg progesterone and in all of the women on 200 mg progesterone. The results showed that this new combination of 2 mg E2 and micronized progesterone in different doses was both effective and well accepted.

Very early discharge from hospital after normal deliveries.

The aim of the present study was to investigate, in a descriptive study, how healthy women experienced early discharge from hospital, 6-12 hours, after normal deliveries. Expecting couples were prepared for early discharge during pregnancy. The women delivered at the University Hospital in Uppsala. All infants had two obligatory medical examinations, one before leaving the hospital and one for metabolic screening after four or five days. Both mothers and infants received postpartum care at home by midwives. One hundred and three women participated and answered a questionnaire four to five days after delivery. Twenty of the women were additionally interviewed by telephone four months after delivery. The average length of stay at the hospital after delivery was 8 hours. The families had, on average, 1.9 visits at home. All women considered that they had received sufficient care and advice from the midwives, although 40 percent felt uncertainty about something in the postpartum period. Questions frequently raised concerned breast-feeding. Two infants were readmitted to hospital due to mild neonatal hyperbilirubinemia. All but three women wanted to repeat very early discharge after a future uncomplicated delivery. Ninety-five percent of the women were still breast-feeding after four months. We conclude, that antenatal preparation and a well-organised, adequate postpartum home-care is of the greatest importance, to establish safe early discharge after uncomplicated deliveries. This concept of early discharge from hospital, with midwifery home care provided, is safe and appreciated by the new parents.

Knowledge of cervical cancer and screening practices of nurses at a regional hospital in Tanzania.

BACKGROUND: Cervical cancer, the most common cancer among women in Tanzania is strongly linked to Human Papilloma Virus. Precancerous lesions can be detected by Papanicolau smear screening. Nurses, being the largest group of health workers, have an important role in promotion of cervical cancer screening. OBJECTIVES: To determine nurses' awareness of cervical cancer and their own screening practices at a hospital in Tanzania. METHODS: A descriptive cross sectional study using questionnaires on 137 nurses. Data analysis was made by descriptive statistics and chi square tests. RESULTS: Less than half of the nurses had adequate knowledge regarding cervical cancer. There was a significant association between knowledge levels of causes of cervical cancer and transmission of HPV and age. Knowledge was more adequate among the young nurses (p = 0.027) and knowledge differed significantly between cadres. Registered nurses had more adequate knowledge than enrolled nurses (p = 0.006). The majority did not know screening intervals and a few were aware of HPV vaccine. Most nurses (84.6%) had never had a Pap smear examination. CONCLUSION: These results reflect a need for continuing medical education, creation of cervical cancer prevention policies and strategies at all levels of the health sector.

Self-reported sexual behaviour among adolescent girls in Uganda: reliability of data debated.

OBJECTIVE: To compare self-reported information about sexual behaviour in a research interview to information retrieved during a clinical consultation. METHOD: 595 sexually experienced women below 20 years, were interviewed by a social worker about genital symptoms and sexual behaviour. A midwife interviewed, examined, and took vaginal samples for gonorrhoea and chlamydia. Four questions were embedded in both the social workers interviews and among midwife's questions. The women were asked if they perceived their latest /current partner to be faithful, if he had complained about any genital symptoms, if a condom was used at latest sexual intercourse and if the woman knew her HIV status. RESULTS: The prevalence of gonorrhoea and/or chlamydia was 7.1% but for women who reported that their partner had complained about genital symptoms it was significantly higher. Agreement between answers given in the research interview and to the midwife was good for HIV status but only fair or moderate for perceived faithfulness, partner's symptoms and recent condom use. CONCLUSION: Information about risk factors revealed in individual interviews and by the midwives taking a history was incongruent. Any approach for management of STIs, which is built on self-reported risk factors, needs careful assessment of reliability.

Vulnerability and risk factors for sexually transmitted infections and HIV among adolescents in Kampala, Uganda.

Three hundred and six sexually experienced adolescents participated in a study on sexually transmitted infection (STI) prevalence and associated risk factors. The prevalence of Neisseria gonorrhoea (NG), Chlamydia trachomatis (CT), Trichomonas vaginalis (TV) and syphilis was 4.5%, 9%, 8% and 4% for females and 4.7%, 5.7%, 0% and 2.8% for males. HIV-seropositivity was found in 15.2% of females and 5.8% of males. Structured face-to-face interviews were used to obtain information about social background, sexual experience and genital symptoms. Four focus-group discussions were used in order to validate the interview data. Females were more likely to be infected by the four treatable STIs and HIV, despite risky behavior being more common among males. Unemployment, little formal education, the presence of bacterial STIs and post-coital bleeding or a bad smell from the vagina was highly associated with the risk for HIV in females. The higher prevalence of STIs, including HIV, among adolescent girls cannot be explained by sexual behavior only, as boys reported more risk behavior and were still less affected by STIs. Biological and social factors are definitely of importance.

Insulin-like growth factor binding protein-1, a quick way to detect amniotic fluid.

BACKGROUND: The detection of premature rupture of membranes (PROM) is essential to the management of pregnancy. Various tests, all with different limitations, have been used to diagnose PROM. Insulin-like growth factor binding protein-1 (IGFBP-1) is present in an essentially higher concentration in amniotic fluid, than in serum, cervical mucous, urine and seminal plasma. A commercial kit, with monoclonal antibodies to IGFBP-1 attached to a stick, is available. The aim of this study was to investigate whether a rapid dipstick test could confirm or exclude the presence of amniotic fluid. METHODS: A multicenter study, involving six departments of obstetrics and gynecology in Sweden, was designed to evaluate the new dipstick technique of diagnosing the presence of amniotic fluid in the vagina. One hundred and seventy-four women were examined. Forty-six women with obvious PROM, 29 women without PROM and 99 women with suspected PROM. RESULTS: Forty-four out of forty-six women with obvious PROM had a positive PROM-TEST. Twenty-seven out of twenty-nine women without PROM had a negative PROM-TEST, giving a sensitivity of 95.7% and a specificity of 93.1%. Among the women with suspected rupture of membranes, the sensitivity was 70.8%, the specificity 88.2% and the positive predictive value (PPV) 92%. CONCLUSION: IGFBP is present in high concentration in amniotic fluid. The dipstick test with monoclonal antibodies to IGFBP-1 is rapid and has a high PPV, sensitivity and specificity. It is a useful complement to the existing arsenal of tests to detect PROM.

The Misgav Ladach method for cesarean section compared to the Pfannenstiel method.

OBJECTIVE: The aim of the study was to evaluate the outcome of two different methods of cesarean section (CS). DESIGN: The study was designed as a prospective, randomized, controlled trial. SETTING: All CS were performed at the University Hospital in Uppsala, Sweden. POPULATION: Fifty women admitted to hospital for a first elective CS were consecutively included in the study. They were randomly allocated to two groups. METHODS: One group was operated on by the Misgav Ladach method for CS and the other group by the Pfannenstiel method. All operations were performed by the same surgeon. MAIN OUTCOME MEASURES: Duration of operation, amount of bleeding, analgesics required, scar appearance and length of hospitalization. RESULTS: Operating time was significantly different between the two methods, with an average of 12.5 minutes with the Misgav Ladach method and 26 minutes with the Pfannenstiel method (p<0.001). The amount of blood loss differed significantly, with 448 ml and 608 ml respectively (p=0.017). Significantly less analgesic injections and tablets (p=0.004) were needed after the Misgav Ladach method. CONCLUSION: The Misgav Ladach method of CS has advantages over the Pfannenstiel method by being significantly quicker to perform, with a reduced amount of bleeding and diminished postoperative pain. The women were satisfied with the appearance of their scars. In this study no negative effects of the new operation technique were discovered.

Ultrasonographic blood flow measurement in the carotid arteries in postmenopausal women.

OBJECTIVES: The aim of the present study was to evaluate blood flow in postmenopausal women on hormone replacement therapy (HRT) compared to controls. Blood flow was ultrasonographically measured in the great arteries of the neck instead of in the vessels of the internal genital organs. METHODS: Fifty healthy women with climacteric complaints, at least 6 months postmenopausal, participated in the study. They were randomly divided into two groups. One group received 2 mg estradiol (E2) for 12 days, continued with 2 mg E2 and 1 mg norethisterone acetate for 10 days, followed by 1 mg E2 for 6 days, cyclically during 6 months. The other group received placebo tablets the first 3 months and the same HRT as the first group for the last 3 months. Blood flow was measured ultrasonographically by color flow pulsed Doppler in the common (CCA), internal (ICA) and external (ECA) carotid arteries, before the start of the study, after 3 and 6 months of therapy. RESULTS: CCA and ICA, both low resistance vessels, and ECA, a high resistance vessel, and their waveforms were identified. Pulsatility index did not decrease statistically significant (p > 0.05) in any of the great vessels during 6 months of HRT in this study. There were no differences in blood flow between the HRT-treated group compared to control group during 3 months of therapy, except for the right ECA (p = 0.04). CONCLUSION: The difference in blood flow and wave-forms of the major arteries of the neck were clearly shown, but HRT did not have any important impact on the blood flow in this study. No difference was shown concerning blood flow between the two groups of postmenopausal women, on active therapy or placebo.

Liver metabolism during treatment with estradiol and natural progesterone.

Serum concentrations of sex hormone-binding globulin (SHBG), corticosteroid binding globulin (CBG), ceruloplasmin, lipoprotein A and liver enzymes were measured in 30 postmenopausal women treated with 2 mg micronized 17 beta-estradiol daily and micronized progesterone orally in doses of 50, 100 and 200 mg daily, as progestogen supplementation. The treatment lasted for 4 months. The serum levels of SHBG and CBG increased during treatment and a weak association between progesterone dosage and CBG was observed. Levels of lipoprotein A and liver enzymes did not change. It is concluded that micronized natural progesterone is an attractive means of progesterone supplementation in postmenopausal hormone replacement therapy without any liver-related side-effects.

Ki-67 immunostaining of endometrial biopsies with special reference to hormone replacement therapy.

BACKGROUND: The purpose of this investigation was to evaluate the Ki-67 immunostaining method on formalin-fixed, paraffin-embedded endometrium and to use the method on endometrial biopsies from 30 postmenopausal women treated with 2 mg estradiol and different doses of natural micronized progesterone (50, 100 or 200 mg). METHODS: Two technicians prepared the immunostaining of slides from each of 12 endometrial specimens and 3 different observers estimated the Ki-67 immunostaining. One observer estimated all the slides 3 times on different occasions. The percentage of immunopositive nuclei in glandular epithelium was evaluated. RESULTS: The dominating component of variation for this method was between observers, with a median standard deviation of 20%. A total median variation including all components rendered a standard deviation of 23%. No significant effects of different technicians, preparations, or from the same observer on different occasions were found. In the major part of the biopsies from women on hormone replacement therapy (HRT), only 0-10% of the glandular epithelium was Ki-67 stained. CONCLUSION: Ki-67 immunostaining is an adequate technique to use when evaluating the effects of HRT on the endometrium. The main source of variation is between observers and not the technique of preparing the slides.