Academic literature on the topic 'WP Gynecology ; RG Gynecology and obstetrics'

Objectives: The objectives of this study were to a) examine the distribution of chondrocalcinosis (CC), b) determine the risk factors of CC, and c) examine the radiographic phenotype of osteoarthritis (OA) associated with CC. Methods: Data from the Genetics of Osteoarthritis and Lifestyle (GOAL) study were used to describe the radiographic distribution of CC, and to conduct a case-control study in which cases with CC were compared with controls without CC. All participants had already completed a detailed questionnaire, been examined by a research metrologist, had radiographs of knees, hands, and pelvis, and had given urine and blood samples. All radiographs had been scored for structural radiographic changes of OA, and for the presence of CC. Frontal plane knee alignment was measured on all knee radiographs. The prevalence (95% confidence interval (CI)) of CC was calculated. The odds ratio (OR) and 95% CI were calculated for risk factors of CC, and for structural changes associated with CC in joints with OA. This was adjusted for age, gender, body mass index (BMI), and OA as appropriate, using logistic regression. Results: 3170 participants were included in this study. There were 431 cases with CC. The overall prevalence (95%CI) of CC in the GOAL population was 13.7% (12.5% - 14.9%). In the GOAL population, knee was the commonest site of CC. However, 42% of participants with CC did not have any knee involvement. There was evidence for a generalized predisposition to CC. For example, CC at one joint associated with CC at distant joints. Joints with CC clustered together more than would be expected by chance alone. At knees, wrists and hips, bilateral CC was more likely to associate with CC at distant joints than unilateral CC – also supporting the existence of a systemic predisposition to CC. After adjusting for confounding factors, there was an association between CC and increasing age, lower current BMI, and OA. The association between OA at one joint and CC at the same joint was present for all joints except for the hip. There was no association between CC and gender, diuretic intake, and selected single nucleotide polymorphisms in enzymes involved in pyrophosphate (PPi) metabolism. CC associated with peri-articular calcification, vascular calcification, low cortical bone mineral density (BMD) but not with low cancellous BMD. Self-reported arthroscopy, meniscectomy, knee injury, occupational knee joint loading and knee mal-alignment in the 3rd decade of life associated with knee CC. However, after adjusting for confounding factors including OA, there was no association between either self-reported or radiographically assessed current knee mal-alignment and knee CC. In joints with OA, the additional presence of CC at the same joint associated with a different radiographic phenotype of structural arthropathy. For example, in knees with OA, knee CC associated with attrition. In hips with OA, hip CC associated negatively with osteophytes, joint space narrowing, and sclerosis at the right hip but not at the left. Similarly, in wrists with OA, wrist CC associated with sclerosis in the right but not in the left wrist; in scapho-trapezioid joints (STJs) with OA wrist CC associated with sclerosis on both sides; in metacarpophalangeal joints with OA, wrist CC associated with cysts in the right but not in the left hand; and in 1st carpometacarpal joint with OA, wrist CC associated with cysts in the left but not in the right hand. In knees with OA, the additional presence of CC at distant joints associated with knee attrition. Those with knee CC + OA were excluded from this analysis to remove any local effects of CC. CC at distant joints did not associate with a distinct structural OA phenotype in other joints examined. Conclusion: These findings suggest that CC results form a systemic predisposition, and that it commonly occurs at other joints in the absence of knee involvement. Established risk factors of CC such as age, OA, and previous arthroscopy and/or meniscectomy were validated in this study. Several novel risk factors of CC e.g. low current BMI, low cortical BMD, and vascular calcification were identified. Several novel associations of knee CC i.e. early life knee malalignment, self-reported knee injury, and occupational knee loading were also recognised. There was convincing evidence to suggest that in joints with OA, the additional presence of CC modifies the OA phenotype, and that this varies from joint to joint.

PCOS is one of the leading causes of infertility worldwide affecting 1 in 10 women of a reproductive age. One of the fundamental abnormalities in women with PCOS can be seen within hormonal irregularities, which may include hyperandrogenemia hyperinsulinemia and hyper secretion of luteinising hormone (LH); and it is hypothesised that a defect in steroid secreting ovarian theca cells is involved due to their contribution in non-PCOS hormonal synthesis. Hyperinsulinemia has been associated with hyper-androgenemia through in vitro studies of cultured PCOS theca, where it has been suggested that insulin increases progesterone and androstenedione secretion when compared to normal theca cells. Furthermore the augmented effects of LH and insulin have been seen to increase ovarian androgen synthesis in non-PCOS theca cultures whilst also increasing the expression of steroidogenic enzymes specific to the PI3-K pathway. Many theories exist toward the etiology of hyper androgenemia within PCOS. Very few approaches however, consider dysfunction in multiple tissue types that may contribute to hormonal imbalances. It is well established that an association between obesity and PCOS exists and it is often the first therapeutic target for re-establishing reproductive function in obese PCOS patients. Furthermore PCOS patients tend to show distinct gynoid body fat distribution, which is reported to aggravate PCOS symptoms. It was therefore valid to examine the involvement in adipocyte function and its contribution to androgen levels within peos. This is further supported through the link between metabolic disorders such as insulin resistance and hyperinsulinemia, and their associations to obesity. Our study employed isolated preadipocyte and thecal cultures with close regulation of the influential factors LH and insulin. In doing so, we analysed androgen synthesis through activation and expression of steroidogenic enzymes CYP17 within both normal and polycystic ovaries. This allowed us to examine whether protein/hormonal concentrations vary across non-PCOS and peos cultures. This also allowed us to examine the possibility of a novel pathway leading to localised adipocyte synthesis as well as pinpointing whether dysfunction existed within the insulin-signalling pathway of thecal androgen steroidogenesis. The work in this thesis shows that adipocytes derived from non-PCOS and PCOS women, maintained in vitro differ on the basis of their morphology, rates of differentiation and proliferation. Furthermore, they reacted differently under conditions designed to mimic PCOS in vitro (increased insulin and LH), with reduced non-PCOS proliferation, and increased non-PCOS androgen secretion on insulin treatment. We also found increased steroidogenic CYP 17 expression in PCOS cultures under insulin stimulation. However PCOS adipocytes androstenedione secretion remained unaffected by insulin stimulation and secreted constant levels of androstenedione similar to that seen by insulin stimulated non-PCOS adipocytes. Our examination of non-PCOS and PCOS primary thecal cultures showed CYP17 expression is increased in pcas theca under basal conditions and that increases in insulin and LH leads to increases in in vitro theca proliferation. These conditions were also seen to lead to significant increases in androstenedione secretion over non-PCOS thecal cultures, and the results suggest it to be acting through the PI3-K pathway. These results therefore point to a specific area of dysfunction that should be further targeted for examination. Furthermore, they suggest that an adipocyte dysfunction exists within PCOS patients that may significantly contribute to hyperandrogenemia through localized synthesis of androgens.

Background: Postnatal Depression (PND) is experienced by around 13% of women, who suffer a range of disabling symptoms that can have a negative effect on the mother and infant relationship, with significant consequences in terms of the child's later mental health. Research has shown that providing support to mothers experiencing PND can help reduce their depressive symptoms and improve their coping strategies. This study aimed to evaluate the impact of telephone peer-support for women experiencing PND. Methods/Design: A pilot RCT was conducted in which women who screened positive for postnatal depression using the Edinburgh Postnatal Depression Scale (EPDS > =10) were randomised to receive telephone-based support from peers who had recovered from PND, or standard care. Primary outcome measures included depressive symptomatology measured post-intervention and at six-months using the EPDS, and parent-infant interaction using the CARE-Index. Secondary outcome measures included anxiety and depression, dyadic adjustment, parenting stress, and self-efficacy. Maternal perceptions of the telephone peer-support were being assessed using semi-structured interviews. Quantitative and qualitative data was also collected from the peer-supporters to assess the impact on them of delivering the intervention. Results: Participants: twenty-eight participants were recruited to the study, and there was a fifty-percent dropout rate (intervention group n=6, control group n=8). While there were no differences in EPDS scores between the two groups at post-intervention, the intervention group continued to improve at six-month follow-up, whereas the control group showed signs of relapse. The intervention had no impact on mother-infant interaction. In-depth interview data show that women valued the support that was provided. Peer-Supporters: nineteen peer-supporters were recruited, of whom five left before supporting a participant, and eight left after supporting only one participant. The quantitative results showed a significant non-clinical increase in anxiety at post intervention. The qualitative results indicated that the peer-supporters found the majority of calls challenging, and that delivering the intervention had had a deleterious impact on some peer-supporters. Conclusion: While these findings suggest a positive impact of telephone-based peer-support, further research into ways of improving mother-infant interaction are urgently required. Research is also required into providing effective support for the peer supporters.

Immune mediated mechanisms are thought to contribute to recurrent pregnancy losses. A number of treatment options with limited evidence are being used in clinical practice to treat women with recurrent miscarriages. The objectives of this thesis was a. To summarise the available evidence for granulocyte colony stimulating factor (G-CSF) in reproductive medicine. b. To perform a randomised controlled study (RCT) to evaluate the efficacy and safety of recombinant human granulocyte colony stimulating factor (rhG-CSF) in women with unexplained recurrent miscarriages. The main conclusions from this thesis are: a. The systematic narrative review found that available evidence is of poor quality, but suggestive of benefit with granulocyte colony stimulating factor in women with recurrent miscarriages. b. The RCT concluded that administration of rhG-CSF does not improve pregnancy outcomes among women with a history of unexplained recurrent miscarriages. RhG-CSF appears to be safe for both mothers and their offspring/s.

Differences in recovery from types of hysterectomy may be due to different advice, rather than different incisions alone. Aims: What are the beliefs and experiences of women who have a hysterectomy and the practices and beliefs of health care professionals? Explore the evidence for psychological preparation for surgery. Methods: .Retrospective structured questionnaires .Semi-structured interviews and validated quality of life questionnaires .Systematic review Results: No significant difference in return to work for type of employment and incapacity pay. Variation between the advice given for recovery by UK gynaecologists and nurses. Regardless of route of surgery, the expectations and fears of women are similar and rely on health care advice, with conflicting advice and varied recovery experiences. Women who had a vaginal hysterectomy had concerns around sitting, laparoscopic route had a lower length of stay and abdominal hysterectomy had higher anxiety scores (P 0.003). Mean quality of life scores by EQ5 were not different based on route of surgery (pre-surgery P 0.4446, 1 week P 0.447, 4 weeks P 0.876,12 weeks P 0.850). There was a reduced length of stay [P 0.03, 5.65 (-10 82 to -0.48)] and reduced trait anxiety intervention [P < 0.00001, mean difference 7.78 (7.19, 10.61)] for psychological interventions.

This doctoral thesis by prospective publication aims to provide pragmatic, evidence-based guidance for the development and evaluation of physiological breech skills and services within the context of contemporary maternity care. The research uses multiple methods to explore development of professional competence and expertise. While skill and experience are acknowledged in multiple national guidelines as important safety factors in vaginal breech birth, prior to this research no guidance existed about how skill and experience should be defined, developed and evaluated. The thesis begins with an integrative review of the efficacy of current breech training methods, highlighting a lack of evidence associating any training methods with improved outcomes for breech births. Following this are two papers reporting the results of a Delphi consensus technique study involving a panel of breech experienced obstetricians, midwives and service user representatives. The first outlines standards of competence, training components and volume of experience recommended to achieve competence and maintain proficiency in upright breech birth. The second outlines principles of practice for physiological breech birth, rooted in relationship and response, and divergent from medicalised practices based on prediction and control. Following this is a grounded theory paper exploring the deliberate acquisition of breech competence among midwives and obstetricians with moderate upright breech experience. The paper reports a theoretical model that can inform development of breech teams and training programmes. The final paper reports a mixed methods analysis of data from the Delphi and grounded theory studies concerning breech expertise. The results present a model of generative expertise, underpinned by affinity, flexibility and relationship, which may function to increase the availability and safety of vaginal breech birth. Each paper is followed by critical analysis and reflection. The thesis ends with a discussion of the implications for practice and research in light of the overall body of work.

Pre-eclampsia is an important and serious condition affecting 2-8% of pregnancies worldwide and carries with it significant associated risk of morbidity and mortality for both mother and child. It is characterised by new onset hypertension after the 20th week of gestation with accompanying proteinuria. Resolution of symptoms should occur following delivery. Several pathophysiological mechanisms are common to both pre-eclampsia and cardiovascular disease, and the link between pre-eclampsia and cardiovascular disease later in life has been established. While the underlying pathophysiological mechanisms of pre-eclampsia are complex, endothelial dysfunction is a key component. Increased arterial stiffness and hypertension have also been documented. Endothelial dysfunction has been shown to extend beyond childbirth, into the postpartum period. Studies evaluating endothelial dysfunction at even longer time-points following an affected pregnancy have produced conflicting results. Results from biomarker studies have supported the concept of endothelial dysfunction throughout pregnancy and the postpartum period, but as more time elapses between index pregnancy and biomarker sampling, these results also vary. Cardiac imaging and electrocardiographic studies have also contributed to knowledge about the normal physiology of pregnancy and changes which are associated with hypertensive disorders of pregnancy during pregnancy, the postpartum period and beyond. The main focus of this thesis was to investigate the possible mechanisms behind the link between pre-eclampsia and future cardiovascular disease. The aim was to investigate women who were free from cardiovascular disease for any evidence of subclinical vascular damage long-term following a pre-eclamptic pregnancy. Overall women recruited to this study would be older than women who participated in the majority of previously published studies on this theme. Before embarking on the investigation of subclinical vascular damage in women with a history of pre-eclampsia, a link was confirmed between a history of pre-eclampsia and cardiovascular disease up to 30 years from time of index pregnancy. This was accomplished using record-linkage in a large Scottish cohort; the Generation Scotland Family Health Study (GS:SFHS). Following on from this, ECGs available in women with and without a remote history of pre-eclampsia in the GS:SFHS cohort were assessed for any obvious differences. There was a more leftward shift in the QRS-axis in these women and a trend towards a longer corrected QT interval (QTc) which approached statistical significance, but after adjusting for other co-variates, pre-eclampsia did not independently predict QTc. Investigations for subclinical vascular damage were carried out by means of non-invasive vascular function studies in women recruited from three different cohorts (blood pressure clinics, GS:SFHS and the previous Proteomics in Pre-eclampsia (PIP) study of women during pregnancy). Time since index pregnancy varied between 1-30 years. Flow-mediated dilatation (FMD) was performed to assess for endothelial dysfunction, pulse wave analysis (PWA) and pulse wave velocity (PWV) assessed arterial stiffness, and carotid ultrasound was performed to establish whether there was any evidence of atherosclerosis. After adjusting for other co-variates, I was able to demonstrate the presence of endothelial dysfunction many years after pregnancy in women with a history of pre-eclampsia in comparison with those who experienced a normotensive pregnancy. There was also a significantly higher presence of carotid plaque in women with a history of pre-eclampsia. To investigate whether the findings from the vascular study translated to findings in biomarker studies of women with a history of pre-eclampsia in comparison with controls, samples from the vascular studies cohort and from the wider GS:SFHS cohort were used. Markers of inflammation, angiogenesis, cardiac damage and collagen turnover were studied. A significantly higher vascular endothelial growth factor (VEGF) was detected in women with a history of pre-eclampsia. Pre-eclampsia is associated with an increased risk of cardiovascular disease, and endothelial dysfunction is evident later on in life. Larger studies are required to further investigate the vascular and biomarker results, and studies including more thorough cardiac assessment (such as echocardiography) in this population should also be considered. The studies described found no evidence of one single component to explain the relationship between pre-eclampsia and cardiovascular disease later in life. This is not unexpected as pre-eclampsia is a complex condition with multiple contributing factors and it is likely that the increased cardiovascular risk later in life is likewise multifactorial in origin.

Communication, anxiety and satisfaction during pregnancy was examined. Ley (1977) presents a cognitive model to explain satisfaction and its links with understanding. Janis (1958, 1971) notes a curvilinear relationship between anxiety and post-operative coping and postulates that information, anxiety and cognitive preparation are the variables accounting for this. Kumar and Robson note that obstetric anxiety is related to concerns for maternal and infant well being rather than irrational anxiety. This study examined the experience of women, stressors, communication satisfaction, knowledge and information and looked at the extent to which these three theories could interrelate to provide a fuller explanation of the psychological experience of women. Five studies were undertaken. Initially a pilot study revealed many negative statements about communication when transcripts were analysed. Communication factors and anxiety laden instances were correlated. The next study was set up to examine knowledge levels as Ley predicts that these, together with misunderstandings could contribute to dissatisfaction. Desire for knowledge was high. Knowledge varied according to social class but not parity. Doctors felt parity would be a factor. Women had difficulty approaching their doctor for information yet still desired doctors as their primary information source. Doctors delegated much information imparting to classes. Study three examined anxiety, communications and satisfaction in labour with pain management (a noted stressor in study 1). Patients receiving Pethidine were dissatisfied. Their pain experience did not differ markedly,but their psychological preparation did. In study 4 anxiety and outcome was monitored, together with information gathering strategies. Linear, rather than curvilinear relationships were found (unlike those predicted by Janis). The course of anxiety was a useful measure and the impact of anxiety on caregivers in the cycle of communications and recovery were explored. The final study looked at the impact of intervention on anxiety and satisfaction in ante-natal care. Women were randomly allocated to groups receiving no intervention, information and information plus feedback. The latter group had significantly lower post-consultation anxiety and higher satisfaction than the other two. The role of knowledge and accuracy in relation to satisfaction was explored. Kumar and Robsons propositions about anxiety were supported in these studies. Ley's cognitive model contributed much to the understanding but limitations in this model are explored, especially in relation to process and interaction factors and the routes to understanding. Janis' curvilinear relationship was not upheld, but his theoretical explanations involving the use of information and worry needs further testing.

This thesis examines to what extent women were involved in their own healthcare and that of others, in the late medieval period. It starts from the observation that modem text editing practices often exclude from discussion other widely disseminated texts that formed the 'travelling companions' of a manuscript - in this case particularly the ensemble known as the Trotula. By focusing on one specific text within the manuscript compilations, the diverse and widespread dissemination of women's knowledge of healthcare and the use of vernacular texts have been marginalised. The thesis argues that the consideration of these 'travelling companions' can offer an alternative view of women's involvement in healthcare, despite the seeming female exclusion from the culture of book-learning and the development of professional licensing in the later Middle Ages. The corpus of manuscripts examined is taken from a range of vernacular compilations produced in England, Flanders and Italy, with some discussion of ownership and transmission of these into the Early Modem period. A number of transcriptions and close readings of the contents are used to identify the discrete characteristics of each copy and to track changes that took place during the transmission process. Detailed comparisons demonstrate that conscious, active choices were made in both the adaptation and interpretation of the material being copied. Analysis of these manipulations reveals that the production of vernacular texts enabled easier consultation and use. The manuscripts point to women's continuing engagement with both the texts and the practice of self-care and that, despite the increase in the number of professional male practitioners over the period, women continued to offer advice to others well into the sixteenth century.