Risk and protective factors for pregnancy-related urinary incontinence until 1 year postpartum: A cohort study using patient-reported outcome measures in Italy.

OBJECTIVE: To investigate the epidemiology of pregnancy-related urinary incontinence (UI) and the related risk factors, focusing also on women's characteristics related to maternity pathway utilization. METHODS: In this prospective cohort study, we used patient-reported data obtained from the systematic survey on the maternity pathway that all pregnant women in Tuscany, Italy, can join. We selected 8410 women who completed-between March 2019 and November 2022-all five follow-up questionnaires from the first trimester until 12 months postpartum, each including a UI-specific patient-reported outcome measure. We performed panel regression models to explore the related risk factors. RESULTS: Prevalence of UI was 4.4% at the first trimester, 23.7% at the third trimester, and 15.6%, 12.6%, and 12.4% at 3, 6, and 12 months postpartum. UI occurrence and severity were higher in older, overweight/obese, and unemployed women. High-risk pregnancy and discomfort during pregnancy were risk factors. Receiving a cesarean section reduced the risk, while spontaneous tears, episiotomy, and high birth weight increased it. Women who experienced delays in pregnancy examinations because of long waiting times and women who had planned pregnancy had a higher risk, while performing during-pregnancy pelvic-floor-muscle training was protective. CONCLUSION: Besides confirming the classic risk and protective factors for UI, we also found novel determinants related to the proper maternity pathway utilization.

Do prenatal depressive symptoms developed by hospitalized women with high-risk pregnancy persist to post-partum?

This study aims to explore the level of depressive symptoms during pregnancy and after childbirth comparing women hospitalized due to high-risk pregnancy (clinical group) and women with low-risk pregnancy (control group). Seventy pregnant women (26 clinical group and 44 control group) filled in the Edinburgh Postnatal Depression Scale both during pregnancy and three months after childbirth. Results showed that the clinical group reported significant higher levels of prenatal depression than the control group, while no differences were found on postnatal depression. Data highlighted that hospitalization could represents a significant stressor that can exacerbate depression in women with high-risk pregnancy.

Pregnancy vaccination predictive factors and uptake profiles among Italian women: A cross-sectional survey study on a large population.

OBJECTIVES: To assess influenza and Tdap (tetanus, diphtheria, pertussis) vaccine coverage during pregnancy, explore key socioeconomic and maternity pathway-related predictors of vaccination, and detect specific patterns of vaccination uptake. METHODS: The authors cross-sectionally analyzed self-reported data obtained from the systematic survey on the maternity pathways of Tuscany. They selected all pregnant women that completed from March 2019 to June 2022 the third-trimester questionnaire (n = 25 160), which included two dichotomous items on influenza and Tdap vaccination, as well as socioeconomic and pathway-related questions. Multilevel logistic models were performed to assess vaccination predictors and cluster analysis to identify vaccination patterns. RESULTS: Vaccination coverage was higher for pertussis (56.5%) than for influenza (18.9%). The main predictors of vaccination were high socioeconomic status, attending private gynecologists, and receiving vaccine information. Three clusters were identified: cluster 1 included women receiving both Tdap and influenza vaccines; cluster 2 included women receiving no vaccinations; and cluster 3 included women receiving only the pertussis vaccine. Although women from cluster 3 were of middle to low education status, vaccine information was the main adherence determinant also in this group. CONCLUSIONS: Health workers and policymakers should focus on groups of pregnant women less prone to vaccination to promote vaccination information and encourage wider uptake and coverage.

Five actions for five people: emergency cesarean section protocol.

OBJECTIVE: The scope of this work is to evaluate an operative protocol for emergency C-section to improve teamwork and reduce surgical setup time. METHODS: Sixty-six health care operators working together in the delivery ward (gynecologists, midwives, anesthesiologists) simulated an emergency scenario applying a "five actions for each operator" protocol. For each simulation, the decision to delivery interval was considered and the perception of each operator as a team worker was analyzed with specific tests. RESULTS: The "five actions for five people" protocol significantly reduces the decision to delivery interval (p < 0.001) for emergency C-section. At the same time, a simple and codified scheme improves communication among team members, avoids overlapping roles. Indeed, all the operators become more aware of being helpful to the team (p < 0.001). CONCLUSION: The use of a standardized, simple, and immediately usable protocol improves the performance of the delivery room team in terms of the urgency and quality of the operator's participation in the event. Procedures of this type should be favored within emergency obstetric settings. TRIAL REGISTRATION NUMBER: CEAVNO 19-01-23. Local ethical Committee (COMITATO ETICO REGIONALE PER LA SPERIMENTAZIONE CLINICA - Sezione autonoma Area Vasta Nord Ovest -CEAVNO) approved this study as simulation training study. All the operators participated voluntary during their working time.

Robot-assisted pelvic floor reconstructive surgery: an international Delphi study of expert users.

BACKGROUND: Robotic surgery has gained popularity for the reconstruction of pelvic floor defects. Nonetheless, there is no evidence that robot-assisted reconstructive surgery is either appropriate or superior to standard laparoscopy for the performance of pelvic floor reconstructive procedures or that it is sustainable. The aim of this project was to address the proper role of robotic pelvic floor reconstructive procedures using expert opinion. METHODS: We set up an international, multidisciplinary group of 26 experts to participate in a Delphi process on robotics as applied to pelvic floor reconstructive surgery. The group comprised urogynecologists, urologists, and colorectal surgeons with long-term experience in the performance of pelvic floor reconstructive procedures and with the use of the robot, who were identified primarily based on peer-reviewed publications. Two rounds of the Delphi process were conducted. The first included 63 statements pertaining to surgeons' characteristics, general questions, indications, surgical technique, and future-oriented questions. A second round including 20 statements was used to reassess those statements where borderline agreement was obtained during the first round. The final step consisted of a face-to-face meeting with all participants to present and discuss the results of the analysis. RESULTS: The 26 experts agreed that robotics is a suitable indication for pelvic floor reconstructive surgery because of the significant technical advantages that it confers relative to standard laparoscopy. Experts considered these advantages particularly important for the execution of complex reconstructive procedures, although the benefits can be found also during less challenging cases. The experts considered the robot safe and effective for pelvic floor reconstruction and generally thought that the additional costs are offset by the increased surgical efficacy. CONCLUSION: Robotics is a suitable choice for pelvic reconstruction, but this Delphi initiative calls for more research to objectively assess the specific settings where robotic surgery would provide the most benefit.

Driving time drives the hospital choice: choice models for pelvic organ prolapse surgery in Italy.

OBJECTIVE: The Italian healthcare jurisdiction promotes patient mobility, which is a major determinant of practice variation, thus being related to the equity of access to health services. We aimed to explore how travel times, waiting times, and other efficiency- and quality-related hospital attributes influenced the hospital choice of women needing pelvic organ prolapse (POP) surgery in Tuscany, Italy. METHODS: We obtained the study population from Hospital Discharge Records. We duplicated individual observations (n = 2533) for the number of Tuscan hospitals that provided more than 30 POP interventions from 2017 to 2019 (n = 22) and merged them with the hospitals' list. We generated the dichotomous variable "hospital choice" assuming the value one when hospitals where patients underwent surgery coincided with one of the 22 hospitals. We performed mixed logit models to explore between-hospital patient choice, gradually adding the women's features as interactions. RESULTS: Patient choice was influenced by travel more than waiting times. A general preference for hospitals delivering higher volumes of interventions emerged. Interaction analyses showed that poorly educated women were less likely to choose distant hospitals and hospitals providing greater volumes of interventions compared to their counterpart. Women with multiple comorbidities more frequently chose hospitals with shorter average length of stay. CONCLUSION: Travel times were the main determinants of hospital choice. Other quality- and efficiency-related hospital attributes influenced hospital choice as well. However, the effect depended on the socioeconomic and clinical background of women. Managers and policymakers should consider these findings to understand how women behave in choosing providers and thus mitigate equity gaps.

The use of a novel sensorized simulation platform for real-time labor progression assessment.

OBJECTIVE: To prove the potentialities of an integrated and sensorized childbirth platform as an innovative simulator for education of inexperienced gynecological and obstetrical medical students. METHODS: A total of 152 inexperienced medical students were recruited to a simulation program on labor progression evaluation. After an introductory lecture on basic concepts of labor and birth given by an expert gynecologist, three different gynecologic scenarios were simulated using both a traditional obstetric simulator and the innovative proposed platform, for a total of six tests for each student. A score was assigned for each performed scenario, based on its correctness. Self-assessment questionnaires were compiled before and after the simulation program for additional subjective assessment. RESULTS: Median score of the simulations performed with our platform was significantly higher than that of the simulations performed with a traditional simulator, for all the three experimented scenarios (P < 0.001). CONCLUSIONS: The use of a sensorized platform for labor progression allowed for an accurate and faster diagnosis if compared with a traditional simulator even for inexperienced operators, supporting its use in clinical training, which could be realistically introduced into the clinical practice for medical student education.

Influence of the COVID-19 pandemic on self-reported urinary incontinence during pregnancy and postpartum: A prospective study.

OBJECTIVE: To explore how the COVID-19 pandemic influenced self-reported occurrence and severity of pregnancy-related urinary incontinence (UI) in the maternity pathways of Tuscany, Italy. METHODS: In this prospective pre-post cohort study, we selected a pre-pandemic (n = 1018) and a post-pandemic (n = 3911) cohorts of women that completed, from the first trimester until 3 months postpartum, three surveys including validated patient-reported outcome measures for UI. Data were obtained from systematic surveys on the maternity pathways of Tuscany from March 2019 to June 2021. We performed panel regression models to explore how UI risk differed between COVID-19 groups. RESULTS: UI occurred less frequently and less severely in post-pandemic patients-especially stress/mixed UI in women never performing pelvic floor muscle training (PFMT)-whereas no difference emerged in women performing during-pregnancy PFMT. During COVID-19, obese women had higher risk of UI, whereas women undergoing operative delivery had lower risk. The post-pandemic group reported more severe UI symptoms at the third trimester, but less severe UI postpartum in women suffering from UI during pregnancy. CONCLUSIONS: During the COVID-19 pandemic, women reported fewer UI symptoms because they might have lacked chances to identify UI symptoms as a result of pandemic-related sedentarism and inactivity. The risk in women performing during-pregnancy PFMT was not increased, but just six of 26 health districts organized remote PFMT sessions, thus revealing limited resilience to the pandemic in Tuscany.

Hysterectomy by transvaginal natural orifice transluminal endoscopic surgery: An Italian initial experience.

Background: The aim of this study is to evaluate the initial feasibility, safety, and outcomes of hysterectomy performed by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) at three institutions in Italy. Materials and methods: All women who underwent vNOTES hysterectomy ± salpingo-oophorectomy for benign indications at three tertiary referral medical centers between July 2019 and April 2021 were included in a retrospective analysis. All vNOTESs were performed with the use of Alexis® and Vpath Gel paths® (Applied Medical). Perioperative data were extracted from patient records. Patient satisfaction and dyspareunia were prospectively inquired about at 60 days and 6 months. Results: Forty-six patients underwent vNOTES in the study period. Indications for surgery included myomas ± metrorrhagia (52.2%), H-Sil/in situ cervical cancer (10.7%), adenomyosis ± metrorrhagia (8.7%), BRCA 1-2 mutations (6.5%), endometrial hyperplasia (6.5%), ovarian cyst + history of breast cancer (6.5%), metrorrhagia (6.5%), and hydatidiform mole (2.2%). The mean operation time was 91.1 (±32.6) minutes. The mean hemoglobin drop was 1.2 (±0.8). The mean visual analog scale at 24 h for post-operative pain was 3.3 (±1.8). Secondary to our limited experience with the surgical technique, we favor discharge only from day 1. The mean length of hospital stay was 2 (±1.4) days. Two conversions to conventional laparoscopy were reported (4.3%), due to an obliterated pouch of Douglas and a preoperative complication. Two post-operative complications were reported (4.3%). Overall, our data on peri- and post-operative outcomes are similar to those already published for vNOTES. Conclusion: Our initial experience suggests that introducing vNOTES as an alternative to conventional surgery is feasible and may offer some advantages in selected women.

Mood disorders and hormonal status across women's life: a narrative review.

Depressive disorders and anxiety states represent one of the most frequent psychiatric pathologies occurring transiently in vulnerable women throughout their life, from puberty to menopause. It is now known that sex hormones play a key role on the nervous system, interfering with neuronal plasticity and enhancing the processes of learning, memory, cognition, and mood. Numerous mechanisms are at the base of these processes, displaying interactions between estrogen and serotoninergic, dopaminergic, and GABAergic receptors at the central level. Therefore, given the sexual steroids fluctuations throughout the entire female lifespan, and considering the role played by sex hormones at the central level, it is not surprising to observe the onset of mood or neurodegenerative disorders over time. This is especially true for women in hormonal transition phase, such as puberty, postpartum and the menopausal transition. Moreover, all these conditions are characterized by hormone withdrawal, imbalance, or modifications due to menopausal hormone therapies or contraceptives which could prompt to a deterioration of mood and cognition impairment or to an improvement in the quality of life. More studies are needed to better understand the hormone-related effects on the nervous system, and the underlying pathways involved in transitional or chronic mood disorders, to promote new patient-specific therapeutic strategies more effective than the current ones and tailored according to the individual need and women's life period.

Music Modulates Autonomic Nervous System Activity in Human Fetuses.

Context: Fetal Autonomic Nervous sysTem Evaluation (FANTE) is a non-invasive tool that evaluates the autonomic nervous system activity in a fetus. Autonomic nervous system maturation and development during prenatal life are pivotal for the survival and neuropsychiatric development of the baby. Objective: Aim of the study is to evaluate the effect of music stimulation on fetal heart rate and specific parameters linked to ANS activity, in particular fetal heart rate variability. Methods: Thirty-two women between the 32nd and 38th week with a singleton uncomplicated pregnancy were recruited. All FANTE data collections were acquired using a 10-derivation electrocardiograph placed on the maternal abdomen. In each session (5 min basal, 10 min with music stimulus, and 5 min post-stimulus), FANTE was registered. The music stimulus was "Clair de lune" Debussy, played through headphones on the mother's abdomen (CTR: 31927). Results: Music does not change the mean value of fetal heart rate. However, indices of total fetal heart rate variability statistically increase (RRsd p = 0.037, ANNsd p = 0.039, SD2 p = 0.019) during music stimulation in comparison to the basal phase. Heart rate variability increase depends mainly on the activation of parasympathetic branches (CVI p = 0.013), meanwhile, no significant changes from basal to stimulation phase were observed for indices of sympathetic activity. All the parameters of heart rate variability and parasympathetic activity remained activated in the post-stimulus phase compared to the stimulus phase. In the post-stimulus phase, sympathetic activity resulted in a significant reduction (LFn p = 0.037). Conclusion: Music can influence the basal activity of the fetal autonomic nervous system, enhancing heart rate variability, without changing fetal heart rate mean value. Music is enabled to induce a relaxation state in a near-to-term fetus, mediated by parasympathetic activation and by a parallel sympathetic inhibition.

Molecular and endocrine mechanisms involved in preterm birth.

Preterm birth is a worldwide social problem. Incidence rates may vary from 5 to 18% of all deliveries, with important differences observed between developed and developing countries. Preterm birth has a negative impact on newborns and neonatal mortality and morbidity are high. Despite improvements in modern neonatal care, we know little of the mechanisms that determine the onset and development of preterm birth. Infections seem to be one the most important triggers, determining the activation of protective mechanisms aimed at ending the pregnancy and safeguarding the health of the woman. However, threatened preterm birth often occurs even in women who do not have any ongoing infectious process. Of these, which are the majority, the causes and the activation mechanisms remain unknown or unclear; however, there are several molecular and endocrine mechanisms that finally lead to preterm birth. In this review, we seek to shed light and summarize the molecular and endocrine mechanisms underlying the development of preterm birth. Their understanding could help us to understand the dynamics of premature birth but, above all, to allow an early diagnosis and primary prevention of the problem.

"To get the baby out off the hook": a prospective, longitudinal, multicenter, observational study about decision making in vacuum-assisted operative vaginal delivery.

BACKGROUND: Since operative vaginal delivery may be risky for women and might cause neonatal complications, the aim of this study is to assess appropriateness of the procedure. This is a prospective, longitudinal, multicenter, observational study and it was conducted in three Italian Obstetric Units (Pisa, Massa Carrara and Prato). All term pregnant women, either nulliparous and multiparous, with singleton pregnancy and a cephalic fetus, with spontaneous or induced labour, requiring vacuum-assisted delivery were enrolled. Indications to operative vaginal delivery were grouped as alterations of fetal cardiotocography (CTG) patterns, delay/arrest of second stage of labour or elective shortening of second stage of labour. A board consisting of five among authors evaluated appropriateness of the procedure. RESULTS: Overall, 466 women undergoing operative vaginal deliveries were included. Cardiotocography, classified as ACOG category 2 or 3 was the indication for vacuum assisted delivery in 253 patients (54.29%). Among these, 66 women (26.1%) had an operative vaginal delivery which was then considered to be inappropriate, while in 114 cases (45.1%) CTG traces resulted to be unreadable. CONCLUSION: Decision making process, which leads clinicians to go for operative vaginal delivery, is often influenced by shortness of time and complexity of the situation. Therefore, clinicians tend to intervene performing vacuum delivery without adopting critical analysis and without adequately considering the clinical situation. Operative vaginal delivery might be a risky procedure and should be performed only when clinically indicated and after adequate critical analysis.

Patient-reported outcome measures for pregnancy-related urinary and fecal incontinence: A prospective cohort study in a large Italian population.

OBJECTIVE: To investigate prevalence and risk factors of pregnancy-related urinary/fecal incontinence (UI/FI) in a large Italian population. METHODS: This is a prospective cohort study analyzing patient-reported outcome (PRO) measures obtained from the systematic longitudinal survey on the maternity pathway of Tuscany from March 2019 to April 2021. Four questionnaires were completed by 6023 women from the beginning of pregnancy until 6 months postpartum, each including two PRO measures-Wexner scale for FI and ICIQ-SF for UI-, and questions investigating sociodemographic/clinical factors. After assessing UI/FI prevalence at each time-point, we run panel regressions to explore the related risk factors. RESULTS: Women reporting UI and FI were, respectively, 24.3% and 6.2% in the third trimester, and 12.6% and 4.2% 6 months postpartum. UI occurrence and severity were higher in highly educated, aged >30, and overweight/obese women. Spontaneous tears or episiotomy were risk factors for postpartum UI, while receiving cesarean-section and performing pelvic-floor-muscle-training during pregnancy were protective, mainly in specific groups. Finally, higher FI prevalence and severity emerged in overweight, aged >40, highly educated, non-Italian women and in those undergoing tears. CONCLUSION: We employed PRO measures to investigate the epidemiology of pregnancy-related UI/FI and detect the main risk groups. Pelvic-floor-muscle-training may be recommended in women with peculiar sociodemographic/clinical features.

Technical features, perioperative and anatomical outcomes of a standardized suturing pattern for robotic sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: Several technical alternatives to repair mesh using laparoscopic sacrocolpopexy exist. We aim to describe the outcomes and surgical technique of robotic-assisted colpo-/cervicosacropexy using a standardized suturing scheme to repair the mesh. METHODS: We retrospectively reported data of 60 consecutive cases of robotic-assisted colpo-/cervicosacropexy for advanced multicompartmental prolapse using a standardized suturing design. We placed three non-absorbable stitches on the cervix or three absorbable stitches on the apex of the vaginal vault, six long-term absorbable stitches on the anterior vaginal wall deep to the basis of the vesical trigone, six similar posterior stitches with the deeper row of sutures down to the levator ani plane and three non-absorbable stitches on the sacral promontory as the cranial support for Y-shaped polypropylene mesh. RESULTS: Median operative time was 188 ± 43 min. All the procedures were successfully performed using a Da Vinci Si platform in a three-arm configuration, and no conversion to open or traditional laparoscopic surgery was needed. The length of hospital stay was 1.2 ± 1.7 days, and no readmission within 30 postoperative days was reported. At a follow-up of 12 and 24 months, no case of extrusion or exposure of the mesh occurred, and the retreatment rate was 6.7%. CONCLUSIONS: Our suturing technique is safe and effective, with negligible risk of complications and good medium-term results. It is plausible that robotic systems may facilitate precise, accurate and reproducible placement of the stitches, thereby favoring wider diffusion of minimally invasive treatment of advanced prolapse.

Simulation training program for vacuum application to improve technical skills in vacuum-assisted vaginal delivery.

OBJECTIVE: evaluation of technical skills of the operators during the obstetrical device application for operative vaginal delivery, named kiwi-cup in a simulation training program. METHODS: Thirty-five residents in obstetrics and gynecology of the University of Pisa, Italy were recruited and evaluated with an assessment scale on technical skills from 0 to 55 points. They performed various operative vaginal delivery simulations with kiwi-cup and were evaluated at time 0 by a tutor. After 8 weeks, simulation training was repeated and trainees were re-evaluated by the same tutor. RESULTS: after 8 weeks from the first simulation session, trainees have been shown to increase technical skills (46.27 ± 4.6 with p-value < 0.0001), the successful application rate (85.71% with p-value 0.0161).) and to reduce the time to complete the procedure (86.2 ± 29.9 s with p-value < 0.0001). CONCLUSION: simulation training on operational vaginal delivery significantly increases technical skills, improves successful rate, and reduces the time taken to complete the procedure. CLINICAL TRIAL REGISTRATION: Not applicable.

Perioperative outcomes of the first five cases of surgeries for endometrial endometrioid cancer using the new integrated table motion for da Vinci Xi®.

BACKGROUND: The aim of this study was to evaluate feasibility of integrated table motion (ITM), comparing perioperative outcomes of patients with diagnosed endometrial endometrioid cancer who underwent total robotic hysterectomies (TRHs) and case-related staging procedures with and without ITM. METHODS: Five patients underwent surgery with da Vinci Xi system and ITM technology. ITM feasibility, efficacy and safety was compared with a second group of 56 patients, reduced to 10 with propensity score method, who underwent same procedures with da Vinci Xi System without ITM system. RESULTS: We report safety of robotic surgery with new ITM even in a preliminary experience of oncologic procedures. No significance in any analysed data between groups TRH with ITM and TRH without ITM are described. CONCLUSION: This preliminary study demonstrated the feasibility of ITM in performing da Vinci Xi TRH even in the first cases of surgery for malignancy such as early stage endometrial endometrioid cancer.

Delivery Mode Shapes the Composition of the Lower Airways Microbiota in Newborns.

Radical alterations in the human microbiota composition are well-known to be associated with many pathological conditions. If these aberrations are established at the time of birth, the risk of developing correlated pathologies throughout life is significantly increased. For this reason, all newborns should begin their lives with a proper microbiota in each body district. The present study aimed at demonstrating a correlation between the mode of delivery and the development of a well-balanced microbiota in the lower airways of newborns. 44 pregnant women were enrolled in this study. Microbiological comparative analysis was carried out on tracheobronchial secretions of babies born through vaginal delivery (VD) or caesarean section (CS). All samples showed the presence of bacterial DNA, regardless of the mode of delivery. No viable cultivable bacteria were isolated from the CS samples. On the contrary, VD allowed colonization of the lower airways by alive cultivable bacteria. The identification of bacterial species revealed that Lactobacillus spp. and Bacteroides vulgatus were the most common microorganisms in the lower airways of vaginally-delivered newborns. Data obtained from quantitative PCRs showed a significantly higher total bacterial load, as well as Firmicutes and Lactobacillus spp. amount, in VD samples than CS ones, while no statistically significant difference was found in Torque Teno Virus (TTV) load between samples. Taken together, our findings confirm the hypothesis that passage through the maternal vaginal canal determines more beneficial colonization of the lower airways in newborns.

Pregnancy after miscarriage in primiparae and multiparae: implications for women's psychological well-being.

Introduction: Miscarriage is a stressful life event with negative consequences that can last into the subsequent gestation, increasing women's risk for psychological symptoms. Less clear in literature is whether having a living child may buffer the psychological impact of miscarriage on subsequent pregnancies.Objective: explore levels of depression, anxiety and fear of delivery in women with and without a previous miscarriage, taking into consideration the presence of a living child.Method: 208 women (M = 34.68) were recruited during the third trimester of gestation. The sample was composed of 159 women without a previous miscarriage (72.3% primiparae and 27.7% multiparae) and 49 women with a history of miscarriage (53.1% primiparae and 46.9% multiparae). Participants filled out a battery of questionnaires aimed at assessing anxiety, depression, and fear of delivery.Results: Primiparae reported higher levels of fear of childbirth than multiparae. Moreover, women without a history of previous perinatal loss showed lower levels of depression and fear of childbirth than women with a previous perinatal loss.Conclusions: Data highlight the importance of developing specific support groups, for primiparae, due to their great emotional vulnerability, and for women with past miscarriage, to help them cope in adaptive ways with a new pregnancy.