Long-term effectiveness of an online decision aid for female cancer patients regarding fertility preservation: Knowledge, attitude, and decisional regret.

INTRODUCTION: The decision, whether to undergo fertility preservation or not is highly demanding for cancer patients. Decision aids may act as an additional source of support. So far, only a limited number of decision aids regarding fertility preservation for female cancer patients exist and have been evaluated systematically. This paper presents the results of secondary analyses of the first randomized controlled trial evaluating an online decision aid for female cancer patients affected by different types of cancer. It focuses on fertility-related knowledge, attitude toward fertility preservation, and long-term effectiveness regarding decisional regret. MATERIAL AND METHODS: Young female cancer patients between 18 and 40 years of age were recruited after fertility counseling with a reproductive specialist. They were assigned to either the control group (counseling only) or the intervention group (counseling followed by the additional use of the decision aid). Both groups had to complete a questionnaire after counseling as well as 1 and 12 months later, covering topics such as fertility-related knowledge, attitude towards fertility preservation, decisional conflict and regret. Recruitment was ongoing during 18 months in eight fertility centers located in Switzerland and Germany. RESULTS: Mean age of participating women was 29.31 years (SD 4.57). Of the entire sample (n = 51) 53% were affected with breast cancer, 27.4% with lymphoma, and 19.6% with various other types of cancer. Knowledge regarding the most common fertility preservation methods was high and comparable in both groups. Positive attitude significantly exceeded negative attitude among all participants (p = 0.001). Although the altogether low scores for decisional regret were on a higher level in the control group (T2: mean = 19.00, SD = 13.24; T3: mean = 22.0, SD = 20.67) than in the intervention group (T2: mean = 14.12, SD = 11.07; T3: mean = 12.94, SD = 13.24), there were no statistically significant differences between and within both groups. There was a positive association between decisional conflict and decisional regret at T3 (p = 0.001, r = 0.510). CONCLUSIONS: This decision aid was suitable as an additional source of knowledge and may positively impact decisional regret in the long term. Results suggest that the provision of an online decision aid as a complement to fertility counseling may facilitate decision-making.

Adenosine, Via A2B Receptors, Inhibits Human (P-SMC) Progenitor Smooth Muscle Cell Growth.

c-Kit+ progenitor smooth muscle cells (P-SMCs) can develop into SMCs that contribute to injury-induced neointimal thickening. Here, we investigated whether adenosine reduces P-SMC migration and proliferation and whether this contributes to adenosine's inhibitory actions on neointima formation. In human P-SMCs, 2-chloroadenosine (stable adenosine analogue) and BAY60-6583 (A2B agonist) inhibited P-SMC proliferation and migration. Likewise, increasing endogenous adenosine by blocking adenosine metabolism with erythro-9-(2-hydroxy-3-nonyl) adenine (inhibits adenosine deaminase) and 5-iodotubercidin (inhibits adenosine kinase) attenuated P-SMC proliferation and migration. Neither N6-cyclopentyladenosine (A1 agonist), CGS21680 (A2A agonist), nor N6-(3-iodobenzyl)-adenosine-5'-N-methyluronamide (A3 agonist) affected P-SMC proliferation or migration. 2-Chloroadenosine increased cyclic AMP, reduced Akt phosphorylation (activates cyclin D expression), and reduced levels of cyclin D1 (promotes cell-cycle progression). Moreover, 2-chloroadenosine inhibited expression of Skp2 (promotes proteolysis of p27Kip1) and upregulated levels of p27Kip1 (negative cell-cycle regulator). A2B receptor knockdown prevented the effects of 2-chloroadenosine on cyclic AMP production and P-SMC proliferation and migration. Likewise, inhibition of adenylyl cyclase and protein kinase A rescued P-SMCs from the inhibitory effects of 2-chloroadenosine. The inhibitory effects of adenosine were similar in male and female P-SMCs. In vivo, peri-arterial (rat carotid artery) 2-chloroadenosine (20 µmol/L for 7 days) reduced neointimal hyperplasia by 64.5% (P<0.05; intima/media ratio: control, 1.4±0.02; treated, 0.53±0.012) and reduced neointimal c-Kit+ cells. Adenosine inhibits P-SMC migration and proliferation via the A2B receptor/cyclic AMP/protein kinase A axis, which reduces cyclin D1 expression and activity via inhibiting Akt phosphorylation and Skp2 expression and upregulating p27kip1 levels. Adenosine attenuates neointima formation in part by inhibiting infiltration and proliferation of c-Kit+ P-SMCs.

Randomized controlled trial on the effect of an online decision aid for young female cancer patients regarding fertility preservation.

STUDY QUESTION: Does the use of an online decision aid (DA) about fertility preservation (FP), in addition to standard counselling by a specialist in reproductive medicine, reduce decisional conflict compared to standard counselling alone? SUMMARY ANSWER: Female cancer patients who could make use of the online DA had a significantly lower short-term decisional conflict score. WHAT IS KNOWN ALREADY: Nowadays, female cancer patients have several options for preserving fertility, but having to decide whether to opt for FP within a short time frame after cancer diagnosis and before the start of treatment is challenging. According to previous studies focussing mainly on breast cancer patients, decisional conflict among these women is high, and they have expressed the need for additional support. STUDY DESIGN, SIZE, DURATION: The study was a randomized controlled trial including female cancer patients who were referred by their treating oncologist to a specialist in reproductive medicine for fertility counselling. Participants were randomly assigned to the control group (counselling only) or to the intervention group (counselling and additional use of the online DA immediately after counselling). Recruitment was ongoing from July 2016 to December 2017 at eight fertility centres in Switzerland and Germany. PARTICIPANTS/MATERIALS, SETTING, METHODS: The online DA was developed by an interdisciplinary team of specialists in reproductive medicine, gynaecologists, oncologists and psychologists. Of 79 recruited participants, 59 completed the first assessment and could therefore be enrolled in the study. They were asked to complete an online questionnaire at three time points: at T1, after counselling (control group, n = 27) or after counselling and the additional use of the DA (intervention group, n = 24); at T2, 1 month later (N = 41: control group, n = 23; intervention group, n = 18); and at T3, 12 months later (N = 37: control group, n = 20; intervention group, n = 17). The survey comprised questions about fertility-related knowledge, attitude towards FP, willingness to undergo FP and socio-demographic data, as well as the decisional conflict and decisional regret scales. MAIN RESULTS AND THE ROLE OF CHANCE: All participants showed low decisional conflict scores. Women who used the online DA in addition to counselling (intervention group) showed a significantly lower total score on the Decisional Conflict Scale (DCS) compared to the control group at T1 (P = 0.008; M = 12.15, SD = 4.38; 95% CI, 3.35-20.95) and at T2 (P = 0.043; M = 9.35, SD = 4.48; 95% CI, 0.31-18.38). At T3, the mean total score of the DCS was still lower in the intervention group compared to the control group; however, this group difference was no longer significant (P = 0.199, M = 6.86, SD = 5.24; 95% CI, -3.78 to 17.51). The majority of participants had already made a decision regarding FP (yes or no) at T1 (72.5%): 91.7% in the intervention group compared to 55.6% in the control group (P = 0.014). Those who had decided already at T1 showed significantly lower decisional conflict (P = 0.007; M = 13.69, SD = 4.89; 95% CI, 3.86-23.52). The average number of DA sessions per user was 2.23, and 80.8% of the participants completed the DA's value clarification exercises. Participants in the intervention group were satisfied with the DA and would recommend it to other patients. LIMITATIONS, REASONS FOR CAUTION: The recruitment of participants was challenging because of the emotionally difficult situation patients were in. This led to the limited sample size for final analysis. Education levels were high in two-thirds of the participants. It is difficult to say whether the DA would be equally effective in women with a lower educational background. WIDER IMPLICATIONS OF THE FINDINGS: There is evidence that the DA served as a helpful complement to the decision-making process for young female cancer patients qualifying for FP. This is, to our knowledge, the first randomized controlled trial evaluating a DA targeted at patients with several cancer types and in a language other than English (i.e. German). This study contributes to extending the range of the still limited number of DAs in the context of FP. STUDY FUNDING/COMPETING INTEREST(S): The study was supported by a research grant of the Swiss Cancer Research. The authors declare that no competing interests exist. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov, trial no. NCT02404883. TRIAL REGISTRATION DATE: 19 March 2015. DATE OF FIRST PATIENT'S ENROLMENT: 4 July 2016.

Preserving fertility in an unconscious patient with Goodpasture syndrome-medicolegal and ethical aspects.

BACKGROUND: Every day in the ICU, legal issues arise while treating sedated, unconscious, and legally incapacitated patients. Whenever a life-saving treatment cannot be discussed in a timely manner with an unconscious patient, doctors are required by law to act according to the substituted judgment standard. However, if it is not survival that is at stake, but conservation of reproduction and the potential side effects are significant, the decision-making process becomes much more difficult. Legal issues associated with possible harm to the patient on the one hand and ethical issues with presumable benefit of the intervention on the other hand give rise to difficult decisions. CASE PRESENTATION: We present the case of a 24-year-old patient with Goodpasture syndrome. Because of rapid aggravation of kidney function and alveolar hemorrhage-the latter requiring an urgent initiation of mechanical ventilation-therapy with steroids, plasmapheresis, and cyclophosphamide was immediately required. Knowledge of the negative impact on fertility brought up the question about sperm cryopreservation. According to the substituted judgment standard, together with the mother of the patient and based on interdisciplinary evaluation of the situation with specialists from the reproductive endocrinology and urology department, the decision for a testicular sperm extraction in the absence of the possibility to obtain the patient's informed consent was made. Immediate chemotherapy was initiated and continued after the procedure. The patient recovered from the acute illness and was informed retrospectively about the testicular sperm extraction, which he received extremely positively. CONCLUSION: Our aim is to highlight the legal objectives and ethical aspects of a non-lifesaving but fertility-preserving intervention in an unconscious patient. The need for decision-making in this kind of situation is rare and therefore challenging. The present case may serve to encourage and guide other doctors in similar situations.

Fertility Preservation in Young Female Cancer Patients: Development and Pilot Testing of an Online Decision Aid.

PURPOSE: Impairment of fertility is a common sequela of successful cancer treatment. Therefore, fertility preservation (FP) should be discussed with all young cancer patients. Decisions about FP are challenging. Patients wish more specific support and the first results concerning the helpfulness of decision aids (DA) were promising. Aside from describing the process of development and the content of an online DA in German, the objective of this study was to pilot test users' satisfaction with the DA and its effect on knowledge about FP and decisional conflict (DC). METHODS: In this prospective consecutive study, a control group (n = 20, fertility counseling) was followed by and compared with an intervention group (n = 20, counseling and additional use of the DA, developed by an interdisciplinary team) of recently diagnosed female cancer patients between 18 and 40 years. RESULTS: Nearly all participants who applied the DA considered it helpful for decision-making and recommendable. Knowledge about FP was high with regard to FP techniques women went for. DC was moderate according to the mean score (M = 27.92, standard deviation = 13.27) and only in 20%, the score was above the threshold for high DC. There was no difference between the control and intervention group for knowledge and DC. CONCLUSION: The DA seems to serve as additional and well-accepted support tool in decision-making for patients and professionals. Referral to a reproductive specialist is crucial to warrant comprehensive information. These results need to be confirmed with the current ongoing randomized controlled study.

Ovarian Hyperstimulation and Oocyte Harvesting Prior to Systemic Chemotherapy-A Possible Pitfall in 18F-FDG PET/CT Staging of Oncologic Patients.

A 33-year-old woman with Hodgkin disease Ann Arbor stage IIA underwent baseline F-FDG PET/CT scanning. The scan showed gross multicystic enlargement of both ovaries and a nodule at the edge of the right ovary with intense FDG uptake (SUVmax = 14.8). Differential diagnosis would include ovarian lymphoma manifestation, endometrioma, and ovarian or pelvic neoplasia. However, chart analysis revealed previous superstimulation with gonadotropins and gonadotropin release hormone antagonist, and transvaginal oocyte retrieval the day before FDG PET/CT. This led to the diagnosis of ovarian hyperstimulation syndrome, with the FDG-avid focus representing a hemorrhagic follicle after transvaginal oocyte retrieval procedure.

Evaluation of the use and handling of three different pen systems considered for in vitro fertilization treatment.

OBJECTIVE: The objective of this study was to assess and compare the features of the Bemfola, Gonal-f and Puregon injection pens. METHODS: Females who intended to undergo hormonal treatment received the three different pens in a randomized, consecutive sequence. For each of the pens, the potential patients completed an Injection Pen Assessment Questionnaire, as well as a questionnaire comparing the handling, convenience and preference among the three pens. RESULTS: The mean score on the visual analogue scale (VAS) for the Bemfola pen (BP) was 77.8 ± 14.0; for the Puregon pen (PP), 72.1 ± 12.4; and for the Gonal-f pen (GP), 68.6 ± 16.4. The BP was superior to both competitor devices in pen size, inconspicuousness, ease of use and dose changing; no significant differences to both competitor pens were observed in the way the pen looks, the way the pen feels and the ease of injection of the volume. The 'overall' assessment was significantly better for the BP when compared to the GP (p = 0.0019), while no significant difference was observed between the BP and the PP. CONCLUSIONS: This study demonstrated significantly higher ratings for pen size, inconspicuousness, ease of use and dose adjustment for the BP compared to other marketed pens.

The relevance of age in female human reproduction--current situation in Switzerland and pathophysiological background from a comparative perspective.

During recent years women tend to postpone childbirth to ages when fertility declines. Consequently, an increasing number of women experiences reproductive difficulties and seeks help by assisted reproductive techniques (ART). To investigate the dynamics of age-related fertility in Switzerland we evaluated data from the nationwide FIVNAT-CH statistics on ART as well as from a subsample receiving ART at the Division of Reproductive Endocrinology, University Hospital Zurich. Since 2000 the average age of women receiving ART increased from 34.9 to 36.3 years in Switzerland and since 2006 numbers of annual ART cycles augmented steadily. The percentage of women ≥40 increased from 17.2% in 2007 to 19.6% in 2011. In the Zurich cohort AMH, the number of oocytes retrieved, the number of fertilized oocytes with two pronuclei, the number of embryos with an adequate cell number, clinical pregnancy rates as well as life birth/ongoing pregnancy rates were lower in the age group ≥40 years, especially when compared to 33 year-old women. In the nationwide sample pregnancy rates decreased from about 45% at the age of 30 to less than 3% at the age of 45; delivery rates declined from about 38% to nearly 0%. In the Zurich cohort percentages of clinical pregnancies declined from 46% in women ≤34 years to 21% in women ≥40 years. In the national sample as well as in the Zurich cohort the percentage of miscarriages increased dramatically from 15.4% and 22% in women ≤34 years to 38.6% and 33% in women ≥40 years, respectively. Even in a country with high health standards such as Switzerland fertility is declining with age and ART does not succeed to improve reduced fertility. Rodent and primate models enrich our knowledge on the pathophysiological mechanisms underlying reproductive senescence. As non-infertility specialist physicians as well as the general public are not sufficiently aware of the dramatic reduction of chances for life births in women ≥40 years, medical counseling as well as schools and media should support the distribution of information future parents need for successful family planning.

Prenatal care in adult women exposed to childhood sexual abuse.

AIMS: Several case reports show a negative impact of childhood sexual abuse (CSA) on prenatal care. The study aimed to systematically investigate this association in a larger study group. METHODS: CSA was investigated by face-to-face interviews and by a modified questionnaire developed by Wyatt. All study participants completed a self-administered questionnaire designed to investigate the consequences of CSA on prenatal care during adulthood. Data from 85 women after CSA were compared to those of 170 matched women without such experiences. RESULTS: Women exposed to CSA had fewer than five prenatal consultations more often than unexposed women (26%/7%; P<0.0001). Of the 85 women with a positive history for CSA, 9.4% had been asked for such antecedents, 36.5% had intense memories on original abuse situations during pregnancy, 56.6% mentioned specific consequences of CSA on prenatal care and 61.2% were satisfied with obstetrical support. Exposed women (62.4%) felt significantly less prepared for labor than unexposed women (75.9%) (P<0.0001). CONCLUSIONS: CSA experiences are associated with impaired prenatal care. These results underscore the compelling need to improve prenatal care in women exposed to CSA through better education of obstetricians regarding the effects of CSA and in their ability to provide empathetic professional support.

Vitrification of human single pronuclear oocytes following two approaches to polar body biopsy.

The purpose of the present study was to investigate whether the size of the opening in the zona pellucida (ZP) of human single pronuclear (1PN) oocytes made by laser and partial zona dissection (PZD) techniques might interfere with the survival and subsequent development to blastocyst stage upon vitrification and warming. Moreover, the viability of these blastocysts was evaluated by comparing their total cell number (TCN) to the TCN of blastocysts developed from control non-vitrified zona-intact 1PN oocytes. Prior to vitrification, a total of 97 and 88 1PN oocytes were subjected to polar body biopsy using laser-assisted and PZD techniques, respectively. The size of ZP opening made by laser and PZD techniques did not interfere with survival (94.8% and 95.4%) or development to the blastocyst stage (27.8% and 26.1%). However, the TCN of laser-derived blastocysts was significantly lower than the TCN of blastocysts developed from non-vitrified control 1PN oocytes (48.7 ± 3.4 versus 70.8 ± 7.1, P < 0.028). The vitrification protocol used here is thus revealed to be an effective method for cryopreservation of 1PN oocytes following polar body biopsy. However, the viability of blastocysts developed from laser-treated 1PN oocytes seems to be negatively affected by this method of biopsy.

Pregnancy complications in women with childhood sexual abuse experiences.

OBJECTIVE: Childhood sexual abuse (CSA) has an estimated prevalence of 20% and has a constantly growing list of known long-term consequences on physical as well as psychological health which may also influence obstetrical care attributed to it. However, scientific data on the association of CSA and pregnancy are sparse. Therefore, the study investigated pregnancy complications in women exposed to CSA. METHODS: The study was designed as a cohort study comparing 85 women exposed to CSA with 170 matched unexposed women. CSA was identified by interview using modified questions from Wyatt [Child Abuse Negl 9 (1985) 507-519]. Data on pregnancy complications were collected by questionnaire and based on entries in a booklet (Mutterpass) in which all relevant data on pregnancy are documented at each prenatal consultation for any women attending prenatal care in Germany. Statistical analysis was performed with chi square, Fisher's Exact Test, and multiple logistic regression analysis to control the association between CSA and pregnancy complications for confounders significant in univariate analysis, i.e., physical abuse, other adverse experiences during childhood, abuse during pregnancy, substance abuse, and occupation. RESULTS: Women exposed to CSA were significantly more often hospitalized during pregnancy (41.2%/19.4%; OR 2.91, CI 1.64-5.17). They presented more often complications such as premature contractions (38.8%/20%; OR 2.54 CI 1.43-4.51), cervical insufficiency (25.9%/9.4%; OR 3.36, CI 1.65-6.82), and premature birth (18.8%/8.2%; OR 2.58, CI 1.19-5.59). CONCLUSION: Therefore, health care providers should adapt prenatal care to the specific needs of women exposed to CSA.

Estradiol stimulates capillary formation by human endothelial progenitor cells: role of estrogen receptor-{alpha}/{beta}, heme oxygenase 1, and tyrosine kinase.

Endothelial progenitor cells (EPCs) repair damaged endothelium and promote capillary formation, processes involving receptor tyrosine kinases (RTKs) and heme oxygenase 1 (HO-1). Because estradiol augments vascular repair, we hypothesize that estradiol increases EPC proliferation and capillary formation via RTK activation and induction of HO-1. Physiological concentrations of estradiol (10 nmol/L) increased EPC-induced capillary sprout and lumen formation in matrigel/fibrin/collagen systems. Propyl-pyrazole-triol (PPT; 100 nmol/L; estrogen receptor [ER]-alpha agonist), but not diarylpropionitrile (ER-beta agonist), mimicked the stimulatory effects of estradiol on capillary formation, and methyl-piperidino-pyrazole (ER-alpha antagonist) abolished the effects of estradiol and PPT. Three different RTK activators (vascular endothelial growth factor, hepatocyte growth factor, and stromal derived growth factor 1) mimicked the capillary-stimulating effects of estradiol and PPT. SU5416 (RTK inhibitor) blocked the stimulatory effects of estradiol and PPT on capillary formation. Estradiol increased HO-1 expression by 2- to 3-fold, an effect blocked by SU5416, and PPT mimicked the effects of estradiol on HO-1. The ability of estradiol to enhance capillary formation, increase expression of HO-1, and augment phosphorylation of extracellular signal-regulated kinase 1/2, Akt, and vascular endothelial growth factor receptor 2 was mimicked by its cell-impermeable analog BSA estradiol. Actinomycin (transcription inhibitor) did not alter the effects of estradiol on RTK activity or vascular endothelial growth factor secretion. We conclude that estradiol via ER-alpha promotes EPC-mediated capillary formation by a mechanism that involves nongenomic activation of RTKs and HO-1 activation. Estradiol in particular and ER-alpha agonists in general may promote healing of injured vascular beds by promoting EPC activity leading to more rapid endothelial recovery and capillary formation after injury.

Motivation for motherhood in women with hypertensive diseases in pregnancy.

OBJECTIVE: To investigate the motivation for motherhood in women with hypertensive diseases in pregnancy. METHODS: A questionnaire was sent to 2600 women with hypertensive diseases in pregnancy and 1233 controls. Diagnoses from medical records were differentiated according to the International Society for the Study of Hypertension in Pregnancy criteria. After matching, data from 739 patients and 623 controls were evaluated with Student's-t, Chi square tests and multiple logistic regression models. RESULTS: Women with hypertensive diseases in pregnancy longed more often for children (85.3%/70.3%, p < 0.0001), considered children more often as the sense of their life (33.6%/29.7%, p < 0.005) and used pregnancy more often to stop a disliked professional activity (9.7%/2.3%, p < 0.0001). Controls reported more often to give birth to avoid termination of pregnancy (5.3%/10.4%, p = 0.0005). CONCLUSIONS: Women with hypertensive diseases in pregnancy concentrate more extensively on motherhood in their life. If this attitude is already present before pregnancy it may augment the risk for disease and might be used for prophylaxis.

Psychosocial distress associated with treatment of hypertensive diseases in pregnancy.

BACKGROUND: Hypertensive diseases in pregnancy (HDP) are a great challenge for healthcare providers. OBJECTIVE: The study aimed to investigate the experience of women developing HDP with different stressors associated with healthcare after a diagnosis of HDP. METHOD: A self- administered questionnaire referring to stress associated with general aspects, hospital stay, and mode of delivery was given to a convenience sample of 738 women with one pregnancy complicated by HDP. RESULTS: The three main aspects causing stress after diagnosis of HDP were the duration of hospital stay for women having to stay at least 7 days in the hospital, the infant's prematurity, and uncertainty about the child's health. Most stress factors did not vary among women showing different types of HDP, but with infants' gestational age at delivery. CONCLUSION: The diagnosis of HDP leads to important stress during pregnancy. In addition to stressors caused by other obstetrical complications, women developing HDP have to deal with a sudden and dramatic change in fetal health risk as well as their own sometimes life-threatening situation. Because stress may have an unfavorable effect on the clinical course of the disease, these aspects should be considered when treating women with HDP.

High survival and developmental rates of vitrified mouse zygotes following polar body biopsy.

The effect of two different methods of polar body biopsy followed by vitrification on the survival and development to blastocyst stage of mouse zygotes was examined. Prior to vitrification, a total of 119 and 124 mouse zygotes were subjected to polar body biopsy using either laser-assisted or partial zona dissection (PZD) techniques, respectively. Vitrification was also applied to 122 zona-intact zygotes that served as a control group. Following vitrification, no differences in the rate of zygote survival (95.8%, 91.9% and 94.3%) or in the rate of development to expanded blastocyst stage (82.3%, 79.8% and 82.0%) were observed between the two groups of biopsied zygotes, or between the biopsied zygotes and control zygotes. The mean total number of cells comprising the blastocysts of controls (77.1 +/- 4.7) was comparable to the mean cell number recorded in the laser (66.4 +/- 4.7) and PZD (69.7 +/- 5.3) groups. Blastocysts developed from laser-treated zygotes hatched much earlier than blastocysts developed from the control and PZD groups of zygotes (P < 0.001). The data obtained in the present study demonstrate that, irrespective of the biopsy method used prior to vitrification, mouse zygotes survive and develop to blastocysts upon warming in proportions similar to those of non-biopsied zygotes.

Effect of childhood sexual abuse on gynecologic care as an adult.

The study sought to evaluate whether childhood sexual abuse (CSA) experiences significantly affect the gynecologic care received as an adult. A self-administered questionnaire including eight questions on CSA was completed by 85 women exposed to CSA and 170 matched-control women. Women exposed to CSA experienced gynecologic examinations as anxiety-provoking significantly more often and sought more treatment for acute gynecologic problems; 43.5% of these women experienced memories of the original abuse situation during gynecologic consultations. Gynecologic care is particularly distressing for women exposed to CSA.

Emotional stress and the risk to develop hypertensive diseases in pregnancy.

OBJECTIVE: Cardiovascular diseases are strongly influenced by stress and do share several risk factors with hypertensive diseases in pregnancy (HDP). The aim of the study is to investigate the correlation between emotional stress during pregnancy and the risk for HDP. METHODS: A self-administered questionnaire comprising obstetrical and psychosocial questions was completed by 725 patients and 880 controls matched for age, parity, nationality, and educational level. RESULTS: Emotional stress during pregnancy was associated with a 1.6-fold increased risk for HDP. CONCLUSION: Psychosocial interventions to reduce emotional stress during pregnancy may help to decrease the risk to develop HDP.

Consequences of childhood sexual abuse experiences on dental care.

OBJECTIVE: Around 20% of female patients seeking dental care may have experienced childhood sexual abuse (CSA). Several similarities between abuse situations and dental treatment lead to dental fear. Since dental fear hampers oral health, the long-term effects of CSA on dental care and the specific factors that lead to increased stress during dental treatment have been investigated in women exposed to CSA. METHODS: A self-administered questionnaire, which was developed to investigate the objectives of the study, was distributed to 111 women recruited from support centers for women with CSA experiences. CSA was explored with a modified version of the questionnaire developed by Wyatt. Data from 85 women with CSA experiences were used for comparison to the data of 170 matching control women recruited, who were mothers of children attending kindergarten. RESULTS: Compared to controls, women exposed to CSA exhibited several long-term effects on dental care in terms of major psychological strain during dental treatment (36.5%/18.8%; P<.005), a lower number of prophylactic controls (72.9%/89.4%; P<.005), and preference for a female dentist to a male dentist (29.4%/8.2%; P<.0001). Women with CSA experiences considered four of five defined stressors associated with dental treatment as more intense. Of these women, 28% suffered from memories of their original abuse situations during dental treatment, and 29.4% believed that the dentist should have known about their history of abuse. CONCLUSION: CSA experiences may increase psychological strain during dental treatment. To improve dental care for women exposed to CSA, dentists should adjust their treatment plans to the specific needs of these patients.

Protein Z in normal pregnancy.

Changes in the coagulation and fibrinolytic systems during pregnancy lead to a higher risk of thromboembolism. These changes include the increase of many clotting factors, as well as a significant fall in activity of fibrinolytic proteins, such as protein C. Protein Z is a vitamin-K-dependent plasma glycoprotein and inhibits the activation of factor X by serving as a cofactor to a plasma proteinase inhibitor. Protein Z deficiency has recently been reported in women with unexplained early fetal losses, and antibodies to protein Z can contribute to adverse pregnancy outcomes. The aim of this study was to determine the range of protein Z in normal pregnancies at different gestational weeks in a cross-sectional and a longitudinal setting. In the longitudinal study we found a 20% increase (p=0.006) of protein Z from first trimester to delivery and a 30% decrease (p<0.0001) 6 to 12 weeks after delivery. In the cross-sectional study these findings were reproducible. In summary, our data show a progressive increase in protein Z levels with gestational age in normal pregnancies and a return to normal levels around 6 to 12 weeks postpartum. The normal increase of protein Z during pregnancy may balance the increase of clotting factors to protect pregnant women from thrombosis.