Recovery from postpartum psychosis: a systematic review and metasynthesis of women's and families' experiences.

Postpartum psychosis is a serious disorder that can result in adverse consequences for the mother and baby. It is important that we understand the experiences of women, to develop effective interventions during this critical period. The aim of this systematic review was to conduct a metasynthesis of qualitative research exploring women's experiences of postpartum psychosis and factors involved in recovery from the perspective of women and family members. A comprehensive literature search of five databases was conducted and the findings were appraised and synthesised, following a thematic synthesis approach. Fifteen studies, capturing the views of 103 women and 42 family members, met the inclusion criteria. Four main themes incorporating 13 subthemes were identified following synthesis: (1) Experiencing the unspeakable, (2) Loss and disruption, (3) Realigning old self and new self and the integrative theme of (4) Social context. The findings offer new insight into the unique experience of postpartum psychosis and demonstrate that recovery does not follow a linear path. To improve clinical outcomes, a more integrative and individualised approach is needed which incorporates long-term psychological and psychosocial support, and considers the needs of the family. Further areas for staff training, service development and future research are highlighted.

A qualitative study exploring the factors that influence the uptake of pre-pregnancy care among women with Type 2 diabetes.

AIM: To elicit the views and experiences of women with Type 2 diabetes and healthcare professionals relating to the pregnancy and pre-pregnancy care they have received or provided. METHODS: A qualitative study using in-depth semi-structured interviews with women with Type 2 diabetes (n=30) and healthcare professionals (n=22) from primary and specialist care. Women were purposively sampled to include different experiences of pregnancy and pre-pregnancy care. Data were transcribed verbatim and analysed thematically using Framework Analysis. RESULTS: The median age of the women was 37 years, and most were obese (median BMI 34.9 kg/m2 ), of black or Asian ethnicity (n=24, 80%) and from areas of high deprivation (n=21, 70%). Participating healthcare professionals were from primary (n=14), intermediate (n=4) and secondary (n=4) care. Seven themes expressing factors that mediate reproductive behaviour and care in women with Type 2 diabetes were identified at the patient, professional and system levels. Type 2 diabetes was generally perceived negatively by the women and the healthcare professionals. There was a lack of awareness about the pre-pregnancy care needs for this population, and communication between both groups was unhelpful in eliciting the reproductive intentions of these women. The themes also reveal a lack of systemic processes to incorporate pre-pregnancy care into the care of women with Type 2 diabetes, and consequently, health professionals in primary care have limited capacity to provide such support. CONCLUSION: If the current high levels of unprepared pregnancies in women with Type 2 diabetes are to be reduced, the reproductive healthcare needs of this group need to be embedded into their mainstream diabetes management.

Psychological interventions for managing postpartum psychosis: a qualitative analysis of women's and family members' experiences and preferences.

BACKGROUND: Postpartum psychosis is a rare, yet severe disorder, in which early identification and immediate intervention are crucial. Despite recommendations for psychological input, little is known about the types of psychological intervention reported to be helpful. The aim of this study was to explore the experiences, needs and preferences for psychological intervention from the perspective of women with postpartum psychosis and from the perspective of family members. METHODS: Thirteen women and eight family members, including partners were interviewed. The data from these semi-structured interviews were audio-recorded, transcribed and inductively analysed using thematic analysis. RESULTS: Twelve subthemes were identified and then organised around three main themes: 1) Seeking safety and containment, 2) Recognising and responding to the psychological impact and 3) Planning for the future. These themes highlight the temporal element of recovery from postpartum psychosis, because women's psychological needs and preferences changed over time. Emphasis was initially placed on ensuring safety, followed by a need to connect, process and adjust to their experiences. Additional needs were reported by women and family when planning for the future, including managing the fear of relapse and help to reach a decision about future pregnancies. CONCLUSION: The results illustrate a range of areas in which psychological intervention could be delivered to facilitate and enhance recovery. Further research is needed to develop meaningful and effective psychological interventions and to investigate the most appropriate timing for this to be offered.

Pregnancy in Diabetes: challenges and opportunities for improving pregnancy outcomes.

Our aim was to review the data from the National Pregnancy in Diabetes (NPID) audit, and to identify the challenges and opportunities for improving pregnancy outcomes in women with diabetes. We reviewed three years of NPID data and relevant diabetes and obstetric literature, and found that there has been little change in pregnancy preparation or outcomes over the past 3 years, with substantial clinic-to clinic variations in care. Women with Type 2 diabetes remain less likely to take 5 mg preconception folic acid (22.8% vs. 41.8%; P < 0.05), and more likely to take potentially harmful medications (statin and/or ACE inhibitor 13.0% vs. 1.8%; P < 0.05) than women with Type 1 diabetes. However, women with Type 1 diabetes are less likely to achieve the recommended glucose control target of HbA1c < 48 mmol/mol (6.5%) (14.9% vs. 38.1%; P < 0.05). The following opportunities for improvement were identified. First, the need to integrate reproductive health into the diabetes care plans of all women with diabetes aged 15-50 years. Second, to develop more innovative approaches to improve uptake of pre-pregnancy care in women with Type 2 diabetes in primary care settings. Third, to integrate insulin pump, continuous glucose monitoring and automated insulin delivery technologies into the pre-pregnancy and antenatal care of women with Type 1 diabetes. Fourth, to improve postnatal care with personalized approaches targeting women with previous pregnancy loss, congenital anomaly and perinatal mortality. A nationwide commitment to delivering integrated reproductive and diabetes healthcare interventions is needed to improve the health outcomes of women with diabetes.

Are end-of-life practices in Norway in line with ethics and law?

BACKGROUND: End-of-life decisions, including limitation of life prolonging treatment, may be emotionally, ethically and legally challenging. Euthanasia and physician-assisted suicide (PAS) are illegal in Norway. A study from 2000 indicated that these practices occur infrequently in Norway. METHODS: In 2012, a postal questionnaire addressing experience with limitation of life-prolonging treatment for non-medical reasons was sent to a representative sample of 1792 members of the Norwegian Medical Association (7.7% of the total active doctor population of 22,500). The recipients were also asked whether they, during the last 12 months, had participated in euthanasia, PAS or the hastening of death of non-competent patients. RESULTS: Seventy-one per cent of the doctors responded. Forty-four per cent of the respondents reported that they had terminated treatment at the family's request not knowing the patient's own wish, doctors below 50 and anaesthesiologists more often. Anaesthesiologists more often reported to have terminated life-prolonging treatment because of resource considerations. Six doctors reported having hastened the death of a patient the last 12 months, one by euthanasia, one by PAS and four had hastened death without patient request. Male doctors and doctors below 50 more frequently reported having hastened the death of a patient. CONCLUSION: Forgoing life-prolonging treatment at the request of the family may be more frequent in Norway that the law permits. A very small minority of doctors has hastened the death of a patient, and most cases involved non-competent patients. Male doctors below 50 seem to have a more liberal end-of-life practice.

Postnatal piglet husbandry practices and well-being: the effects of alternative techniques delivered in combination.

After birth, piglets undergo procedures likely to cause stress. The aim of this study was to evaluate stress responses evoked by 2 combinations (More Stressful [all a] or Less Stressful [all a] or More Stressful [all b]) of alternative methods for performing the following processing procedures: 1) teeth resection (TR) ­ [a] clip vs. [b] grind; 2) identification (ID) ­ [a] ear tag vs. [b] ear notch; 3)iron administration (FE) ­ [a] inject vs. [b] oral; 4) castration (CA) ­ [a] cords cut vs. [b] cords torn; 5) taildocking (TD) ­ [a] cold clip vs. [b] hot clip [corrected]. Ten litters of eight 2- and 3-d-old piglets were assigned to each procedure. Within each litter 1 male and 1 female piglet was assigned to 1 of 4 possible procedures: the 2 combinations, sham procedures, and sham procedures plus blood sampling. Blood was collected before processing and at 45 min, 4 h, 48 h, 1 wk, and 2 wk afterward and assayed for cortisol and ß-endorphin concentrations. Procedures were videotaped and analyzed to evaluate the time taken to perform the procedure and the number of squeals, grunts, and escape attempts. Vocalizations were analyzed to determine mean and peak frequencies and duration. Piglets were weighed before the procedure and at 24 h, 48 h, 1 wk, and 2 wk afterward. Identification, tail docking, and castration lesions were scored on a 0 to 5 scale at 24 h, 1 wk, and 2 wk postprocedure. Both combinations of methods took longer to carry out than sham procedures and resulted in more squeals, grunts, and escape attempts during the procedures and higher peak frequencies of vocalizations compared with the control treatments (P < 0.05). Cortisol concentrations 45 min after processing were also higher in the 2 combination treatments than in the sham treatments (P < 0.05). Comparing between procedure treatments, the More Stressful combination of methods took longer to carry out, resulted in higher ß-endorphin concentrations at 1 wk, had higher peak frequency of vocalizations, and increased ear (P < 0.05) and tail wound (P < 0.1) lesion scores at 1 wk than the Less Stressful combination. Growth during d 2 to 7 postprocedure was lower in More Stressful piglets than control piglets (P < 0.05) but by 2 wk, growth was unaffected. Using measures of behavior, physiology, and productivity, the More Stressful combination of procedures decreased welfare relative to the Less Stressful combination; however, both combinations decreased welfare relative to controls. The time taken to carry out the procedure would appear to be an important factor in the strength of the stress response.

Pre-pregnancy care and pregnancy outcomes in type 1 diabetes mellitus: a comparison of continuous subcutaneous insulin infusion and multiple daily injection therapy.

BACKGROUND: Pre-pregnancy care improves pregnancy outcomes in type 1 diabetes mellitus (T1DM). Continuous subcutaneous insulin infusion (CSII) therapy and multiple daily injection (MDI) therapy can both be used to achieve glycaemic targets, but few data are available to compare their efficacy in pre-pregnancy care. AIM: To compare MDI and CSII in pre-pregnancy care in T1DM. METHODS: Retrospective database review of women with T1DM attending the Dublin Diabetes in Pregnancy Centre. RESULTS: 464 women with T1DM (40 treated with CSII) were included. Women attending for pre-pregnancy care had lower HbA1c levels at booking to antenatal services [52 ± 10 mmol/mol (6.9 ± 0.9 %) vs. 62 ± 16 mmol/mol (7.8 ± 1.5 %), p < 0.001], and booked at an earlier gestation (6 ± 2 vs. 8 ± 6 weeks, p < 0.001). In those who attended for pre-pregnancy care, the CSII group had lower HbA1c levels at booking than those using MDI [48 ± 8 mmol/mol (6.5 ± 0.7 %) vs. 53 ± 10 mmol/mol (7.0 ± 0.9 %), p = 0.03]. Gestational age at delivery and birth weight did not differ between groups. Caesarean section rates were associated with CSII use (p < 0.001), duration of diabetes (p = 0.002), and parity (p = 0.006). Nulliparous women using CSII with a longer history of diabetes were more likely to deliver by Caesarean section. There was no perinatal mortality. CONCLUSIONS: Pre-pregnancy care delivered by a specialist multi-disciplinary team effectively reduces HbA1c levels peri-conception. CSII use results in lower HbA1c levels in pre-pregnancy care in selected individuals and should be considered in women with T1DM planning pregnancy.