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Study Question: What factors influence the decision-making process of fathers regarding multifetal pregnancy reduction or maintaining a triplet pregnancy, and how do these decisions impact their psychological well-being?, Summary Answer: For fathers, the emotional impact of multifetal pregnancy reduction or caring for triplets is extensive and requires careful consideration., What Is Known Already: Multifetal pregnancy reduction is a medical procedure with the purpose to reduce the number of fetuses to improve chances of a healthy outcome for both the remaining fetus(es) and the mother, either for medical reasons or social considerations. Aspects of the decision whether to perform multifetal pregnancy reduction have been rarely investigated, and the impact on fathers is unknown., Study Design, Size, Duration: Qualitative study with semi-structured interviews between October 2021 and February 2023., Participants/materials, Setting, Methods: Fathers either after multifetal pregnancy reduction from triplet to twin or singleton pregnancy or ongoing triplet pregnancies 1-6 years after the decision were included. The interview schedule was designed to explore key aspects related to (i) the decision-making process whether to perform multifetal pregnancy reduction and (ii) the emotional aspects and psychological impact of the decision. Thematic analysis was used to identify patterns and trends in the father's data. The process involved familiarization with the data, defining and naming themes, and producing a final report. This study was a collaboration between a regional secondary hospital (OLVG) and a tertiary care hospital (Amsterdam University Medical Center, Amsterdam UMC), both situated in Amsterdam, The Netherlands., Main Results and the Role of Chance: Data saturation was achieved after 12 interviews. Five main themes were identified: (i) initial responses and emotional complexity, (ii) experiencing disparities in counselling quality and post-decision care, (iii) personal influences on the decision journey, (iv) navigating parenthood: choices, challenges, and emotional adaptation, and (v) shared wisdom and lessons. For fathers, the decision whether to maintain or reduce a triplet pregnancy is complex, in which medical, psychological but mainly social factors play an important role. In terms of psychological consequences after the decision, this study found that fathers after multifetal pregnancy reduction often struggled with difficult emotions towards the decision; some expressed feelings of doubt or regret and were still processing these emotions. Several fathers after an ongoing triplet had experienced a period of severe stress in the first years after the pregnancy, with major consequences for their mental health. Help in emotional processing was not offered to any of the fathers after the decision or birth., Limitation, Reasons for Caution: While our study focuses on the multifetal pregnancy reduction process in the Amsterdam region, we recognize the importance of further investigation into how this process may vary across different regions in The Netherlands and internationally. We acknowledge the potential of selection bias, as fathers with more positive experiences might have been more willing to participate. Caution is needed in interpreting the role of the mother in the recruitment process. Additionally, the time span of 1-6 years between the decision and the interviews may have influenced emotional processing and introduced potential reporting bias., Wider Implications of the Findings: The emotional impact of multifetal pregnancy reduction or caring for triplets is significant, emphasizing the need for awareness among caregivers regarding the emotional challenges faced by fathers. A guided trajectory might optimize the decision-making and primarily facilitate the provision of appropriate care thereafter to optimize outcomes around decisions with potential traumatic implications., Study Funding/competing Interest(s): This study received no funding. The authors have no conflicts of interest to declare., Trial Registration Number: N/A., (© The Author(s) 2024. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology.)

Background: Studies have identified adverse maternal and neonatal outcomes for women with psychiatric disorders. Additionally, psychiatric disorders may pose an increased risk for unintended pregnancies (UPs) which in turn may also impact negatively on outcomes. The present study aims to compare the incidence of UPs in women with versus without current/past psychiatric diagnoses and investigates whether psychiatric history modifies the relation between delivery outcomes in women with and without UPs., Methods: A retrospective cohort was compiled of women who gave birth in a large hospital in Amsterdam, the Netherlands. Women ≥18 years old with singleton pregnancies and birth registrations in the electronic patient file during January 1, 2015 to March 1, 2020 were included. Patient characteristics (including pregnancy intention and psychiatric history), maternal (gestational diabetes, mode of delivery) and neonatal outcomes (e.g., gestational age [GA], birthweight and Apgar scores) were registered by health care providers in hospital charts. Incidence of UPs was compared between women with versus without current/past psychiatric diagnoses. Maternal and neonatal outcomes were compared between women with versus without UPs with linear or logistic regression models adjusted for relevant confounders with an interaction term for UP with current/past psychiatric diagnoses., Results: We included 1219 women with and 1093 women without current/past psychiatric diagnoses. Current/past psychiatric diagnoses were significantly associated with UPs after adjustment for confounders (39.0% vs. 29.6%, OR 1.56, CI 1.23-2.00, p < 0.001). In sub-analyses, women with depressive (OR 1.67, CI 1.24-2.26, p = 0.001), personality (OR 2.64, CI 1.38-5.11, p = 0.004) and substance-related and addictive disorders (OR 4.29, CI 1.90-10.03, p = 0.001) had higher odds of UPs compared to women without current/past psychiatric diagnoses. Amongst women with UPs, current/past psychiatric diagnoses did not modify maternal or neonatal outcomes, except for GA at delivery as women with both UPs and current/past psychiatric diagnosis had a 2.21-day higher mean GA at delivery than women in the reference group (p-value interaction = 0.001)., Conclusions: Current/past psychiatric diagnoses are associated with a higher odd of UPs. In our sample, maternal and neonatal outcomes were comparable for women with and without UPs and these results were similar for women with and without current/past psychiatric diagnoses, except for GA at delivery. Although our study is limited by several factors, we found that women with current/past psychiatric diagnoses, irrespective of pregnancy planning status, do not have more adverse maternal or pregnancy outcomes. Increased efforts are needed to ensure that psychoeducation and conversations about pregnancy planning and UPs are available for women with current/past psychiatric diagnoses., (© 2023 The Authors. Acta Psychiatrica Scandinavica published by John Wiley & Sons Ltd.)

Introduction: Pregnant women with fear of childbirth display an elevated risk of a negative delivery experience, birth-related post-traumatic stress disorder, and adverse perinatal outcomes such as preterm birth, low birthweight, and postpartum depression. One of the therapies used to treat fear of childbirth is eye movement desensitization and reprocessing (EMDR) therapy. The purpose of the present study was to determine the obstetric safety and effectiveness of EMDR therapy applied to pregnant women with fear of childbirth., Material and Methods: A randomized controlled trial (the OptiMUM-study) was conducted in two teaching hospitals and five community midwifery practices in the Netherlands (www.trialregister.nl, NTR5122). Pregnant women (n = 141) with a gestational age between 8 and 20 weeks and suffering from fear of childbirth (i.e. sum score on the Wijma Delivery Expectations Questionnaire ≥85) were randomly allocated to either EMDR therapy (n = 70) or care-as-usual (CAU) (n = 71). Outcomes were maternal and neonatal outcomes and patient satisfaction with pregnancy and childbirth., Results: A high percentage of cesarean sections (37.2%) were performed, which did not differ between groups. However, women in the EMDR therapy group proved seven times less likely to request an induction of labor without medical indication than women in the CAU group. There were no other significant differences between the groups in maternal or neonatal outcomes, satisfaction, or childbirth experience., Conclusions: EMDR therapy during pregnancy does not adversely affect pregnancy or the fetus. Therefore, therapists should not be reluctant to treat pregnant women with fear of childbirth using EMDR therapy., (© 2023 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Background: Lithium is the preferred treatment for pregnant women with bipolar disorders (BD), as it is most effective in preventing postpartum relapse. Although it has been prescribed during pregnancy for decades, the safety for neonates and obstetric outcomes are a topic of ongoing scientific debate as previous research has yielded contradicting outcomes. Our study aims to compare (re)admission rates and reasons for admissions in neonates born to women with bipolar disorders (BD) with and without lithium exposure., Methods: A retrospective observational cohort study was conducted in a Dutch secondary hospital (two locations in Amsterdam). Women with BD who gave birth after a singleton pregnancy between January 2011 and March 2021 and their neonates were included. Outcomes were obtained by medical chart review of mothers and neonates and compared between neonates with and without lithium exposure. The primary outcome was admission to a neonatal ward with monitoring, preterm birth, small for gestational age (SGA), 5-minute Apgar scores, neonatal asphyxia, and readmission ≤ 28 days., Results: We included 93 women with BD, who gave birth to 117 live-born neonates: 42 (36%) exposed and 75 (64%) non-exposed to lithium. There were no significant differences in neonatal admission with monitoring (16.7 vs. 20.0%, p = 0.844). Additionally, preterm birth (7.1 vs. 5.3%), SGA (0.0 vs. 8.0%), 5-minute Apgar scores (means 9.50 vs. 9.51), neonatal asphyxia (4.8 vs. 2.7%) and readmission (4.8 vs. 5.3%) were comparable. Overall, 18.8% of BD offspring was admitted. Women with BD had high rates of caesarean section (29.1%), gestational diabetes (12.8%) and hypertensive disorders of pregnancy (8.5%)., Conclusions: In a sample of neonates all born to women with BD using various other psychotropic drugs, exposure to lithium was not associated with greater risk of neonatal admission to a ward with monitoring compared to non-exposure to lithium, questioning the necessity for special measures after lithium exposure. However, offspring of women with BD was admitted regularly and women with BD have high obstetric risk which require clinical and scientific attention., (© 2023. The Author(s).)

High rates of unintended pregnancies in patients with mental health problems reflect the unmet need for tailored family planning. This study aims to explore aspects of family planning that are especially challenging for patients experiencing health problems by obtaining the perspective of (former) patients and those with close relationships with the (former) patients. In August 2021, members of a Dutch national mental health panel, consisting of (former) patients and close ones, were invited to respond to a 34-question online survey that included questions on four domains: reproductive history, decision making, parenting, and sexuality. This study has revealed the severe and adverse impact of mental health problems across all of the four domains of reproductive health and family planning, which the questions specifically targeted. Based on these results, we recommend discussing family planning with all patients experiencing or at risk for mental health problems and their partners. These discussions should address a desire to have children, (involuntary) childlessness, uncertainties about parenting and sexuality, while remaining considerate of experienced taboos.

Pre-eclampsia (PE) affects 2-8% of pregnancies and is responsible for significant morbidity and mortality. The maternal clinical syndrome (defined by hypertension, proteinuria, and organ dysfunction) is the result of endothelial dysfunction. The endothelial response to increased levels of soluble FMS-like Tyrosine Kinase 1 (sFLT1) is thought to play a central role. sFLT1 is released from multiple tissues and binds VEGF with high affinity and antagonizes VEGF. Expression of soluble variants of sFLT1 is a result of alternative splicing; however, the mechanism is incompletely understood. We hypothesize that neuro-oncological ventral antigen 2 (NOVA2) contributes to this. NOVA2 was inhibited in human umbilical vein endothelial cells (HUVECs) and multiple cellular functions were assessed. NOVA2 and FLT1 expression in the placenta of PE, pregnancy-induced hypertension, and normotensive controls was measured by RT-qPCR. Loss of NOVA2 in HUVECs resulted in significantly increased levels of sFLT1, but did not affect expression of membrane-bound FLT1. NOVA2 protein was shown to directly interact with FLT1 mRNA. Loss of NOVA2 was also accompanied by impaired endothelial functions such as sprouting. We were able to restore sprouting capacity by exogenous VEGF. We did not observe statistically significant regulation of NOVA2 or sFLT1 in the placenta. However, we observed a negative correlation between sFLT1 and NOVA2 expression levels. In conclusion, NOVA2 was found to regulate FLT1 splicing in the endothelium. Loss of NOVA2 resulted in impaired endothelial function, at least partially dependent on VEGF. In PE patients, we observed a negative correlation between NOVA2 and sFLT1., (© 2022. The Author(s).)

Objectives: Determine whether the Fear of Birth Scale (FOBS) is a useful screening instrument for Fear of Childbirth (FoC) and examine the potential added value of screening by analyzing how often pregnant women discuss their FoC during consultation., Methods: This cross-sectional survey study included nulliparous pregnant women of all gestational ages, recruited via the internet, hospital and midwifery practices. The online questionnaires included the FOBS and Wijma Delivery Expectations Questionnaire version A (W-DEQ A). The latter was used as golden standard for assessing FoC (cutoff: ≥85)., Results: Of the 364 included women, 67 (18.4%) had FoC according to the W-DEQ A. Using the FOBS with a cutoff score of ≥49, the sensitivity was 82.1% and the specificity 81.1%, with 111 (30.5%) women identified as having FoC. Positive predictive value was 49.5% and negative predictive value 95.3%. Of the women with FoC (FOBS ≥49), 68 (61.3%) did not discuss FoC with their caregiver., Conclusion: The FOBS is a useful screening instrument for FoC. A positive score must be followed by further assessment, either by discussing it during consultation or additional evaluation with the W-DEQ A. The majority of pregnant women with FoC do not discuss their fears, underscoring the need for screening.

Objective: To evaluate the rate of implementation after adding vaginal disinfection to the cesarean section protocol and its effect on post cesarean infections and hospital readmissions., Study Design: This is an intervention study where two groups were compared. Women the year before (n = 1384) and one year following (n = 1246) the addition of vaginal disinfection, with povidone-iodine 1% prior to the cesarean section, to the protocol. Primary outcome was the rate of implementation. Secondary outcomes were the rates of endometritis, wound infection and postoperative fever. With the effect expressed in the number of hospital readmissions., Results: The implementation rate was 85.6%. Intention-to-treat analysis showed endometritis rates of 2.0% versus 1.1% (p = 0.07). For women with preoperative ruptured membranes there was a significant decrease in endometritis, from 3.4% to 1.3% (p = 0.02). Per-protocol analysis showed endometritis rates of 2.0% to 1.0% (p = 0.05). Women with ruptured membranes, 3.4% versus 1.3% (p = 0.02), and women who were in the second stage of labor, 4.7% versus 0.0% (p = 0.01), had a significant decrease in endometritis. For wound infection and postoperative fever rates were similar. The decrease of infections had a significant effect on hospital readmissions, 27 versus 10 (p = 0.04)., Conclusion: The implementation of this quality improvement measure shows to be adequate as the vast majority of women undergoing a cesarean received vaginal disinfection. Vaginal disinfection showed a declining trend of endometritis and postoperative fever and for women with broken membranes prior to cesarean section the decrease in endometritis was significant. These beneficial effects have led to a statistical and clinically relevant decrease in hospital readmissions and thus cost reduction., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Introduction: Fear of childbirth is a well-known problem during pregnancy and can have implications for childbirth, including prolonged labor, use of epidural analgesia, obstetric complications, presence of traumatic stress symptoms, or request for an elective cesarean section. The coronavirus disease 2019 (COVID-19) pandemic has affected mental health and therefore could have increased fear of childbirth during the pandemic. The aim of this study was to investigate fear of childbirth during the pandemic in the Netherlands compared with a reference group from before the pandemic., Material and Methods: We conducted a cross-sectional study to evaluate pregnant women during the first and second waves of COVID-19 compared with both each other and with pregnant women from before the pandemic. Participants were recruited through social media platforms, hospitals, and midwifery practices. Pregnant women aged ≥18 years who had mastered the Dutch language were eligible to participate. Fear of childbirth was measured with the Wijma Delivery Expectancy Questionnaire online using a cut-off score of ≥85 to indicate clinically relevant fear of childbirth. The primary outcome was the prevalence of fear of childbirth. We undertook additional analyses to specifically look at possible effect modification., Results: In total, 1102 pregnant women completed the questionnaire during the first wave of the pandemic, 731 during the second wave, and 364 before the pandemic. Fear of childbirth was present in 10.6%, 11.4%, and 18.4%, respectively. We considered possible effect modification, which indicated that age and parity had a significant influence. In participants during the first wave of COVID-19, nulliparous women had significantly lower odds (odds ratio [OR] 0.50; 95% confidence interval [CI] 0.34-0.73; p < 0.01) of having a fear of childbirth than did the reference group. Both younger participants in the first wave (OR 0.59; 95% CI 0.37-0.93; p < 0.05) and older participants in the first wave (OR 0.44; 95% CI 0.28-0.71; p < 0.01) and the second wave (OR 0.36; 95% CI 0.21-0.62; p < 0.01) of COVID-19 had lower odds of fear of childbirth than the reference group., Conclusions: Pregnant women during the first and second waves of COVID-19 had lower fear of childbirth scores than pregnant women before the pandemic, indicating less fear of childbirth during the pandemic. This could be explained by an increased level of information, more time to consume information, and better work-life balance with more people working at home during the pandemic., (© 2022 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

There is no consensus on the treatment of posttraumatic stress disorder (PTSD) during pregnancy, and therapists' views on the matter are largely unknown. This cross-sectional study aimed to explore therapist beliefs and experiences regarding PTSD treatment during pregnancy. Participants were therapists (N = 301) with experience treating PTSD who completed an online survey. The primary outcome measure was the percentage of therapists who were experienced in treating PTSD symptoms during pregnancy; secondary outcome measures assessed preferred treatments for the general and pregnant populations, perceived reluctance to treat PTSD in pregnancy, and perceived effects and adverse events attributed to treatment for pregnant women and fetuses. The majority of participants (n = 246, 81.7%) had experience with treating PTSD during pregnancy. Eye movement desensitization and reprocessing was the preferred treatment for both the general and the pregnant populations. Almost half of the sample (48.8%) reported hearing that PTSD treatment in pregnancy could be harmful; 30.5% of therapists were reluctant to treat pregnant women with PTSD. Most therapists observed a clinically relevant posttreatment reduction of PTSD symptoms in pregnant women. Perceived adverse maternal and fetal events attributed to treatment were reported by 8.4% and 1.4% of therapists, respectively. Despite reluctance, most therapists reported treating PTSD during pregnancy. The results show that although therapists often reported hearing that treating PTSD during pregnancy was harmful, only a small percentage reported perceived adverse events, and treatment was often viewed as effective. These findings implicate a more positive view on the treatment of PTSD in pregnancy., (© 2022 International Society for Traumatic Stress Studies.)

Purpose: The relation between fear of childbirth (FoC) and gestational age is inconclusive, and self-reported need for help regarding this fear has never been investigated. This study aimed to determine the prevalence and course of FoC according to gestational age, to identify risk factors for the development of FoC, the influence of this fear on preferred mode of delivery, and self-reported need for help., Methods: Nulliparous pregnant women of all gestational ages completed an online survey. The study consisted of a cross-sectional and a longitudinal analysis. Women who completed the survey in the first or second trimester (T 0 ) were approached again in their third trimester (T 1 ). The Wijma Delivery Expectancy Questionnaire Version A (W-DEQ A) was used with a cut-off score ≥ 85 to define presence of fear of childbirth. Questionnaires indexing social support, anxiety, symptoms of depression, preferred mode of delivery, and self-reported need for help were included., Results: In total, 364 women were enrolled at T 0 , and 118 out of 184 eligible women were included in the longitudinal analysis. Point prevalence of FoC at T 0 was 18.4% with no significant difference between trimesters. In the longitudinal sample, the prevalence of FoC decreased from 18.6% (T 0 ) to 11.0% (T 1 ), p  = 0.004. Although mean scores for FoC decreased significantly, p  < 0.001, scores increased in 41 (34.7%) women. The presence of FoC was associated with elevated anxiety, less family support, prenatal care of the obstetrician by choice, preference for a cesarean section, and for pain relief. Women with FoC were more likely to actively seek for help compared to women without FoC., Conclusion: While FoC is common in each trimester, prevalence decreases over the course of pregnancy. Women with FoC are often actively seeking for help, suggesting that this fear should be addressed better, and help should be offered accordingly., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Hendrix, Baas, Vanhommerig, de Jongh and Van Pampus.)

Fear of childbirth (FoC) occurs in 7. 5% of pregnant women and has been associated with adverse feto-maternal outcomes. Eye Movement Desensitization and Reprocessing (EMDR) therapy has proven to be effective in the treatment of posttraumatic stress disorder (PTSD) and anxiety; however, its effectiveness regarding FoC has not yet been established. The aim was to determine the safety and effectiveness of EMDR therapy for pregnant women with FoC. This single-blind RCT (the OptiMUM-study, www.trialregister.nl, NTR5122) was conducted in the Netherlands. FoC was defined as a score ≥85 on the Wijma Delivery Expectations Questionnaire (WDEQ-A). Pregnant women with FoC and a gestational age between 8 and 20 weeks were randomly assigned to EMDR therapy or care-as-usual (CAU). The severity of FoC was assessed using the WDEQ-A. Safety was indexed as worsening of FoC symptoms, dropout, serious adverse events, or increased suicide risk. We used linear mixed model analyses to compare groups. A total of 141 women were randomized (EMDR n = 70; CAU n = 71). No differences between groups were found regarding safety. Both groups showed a very large (EMDR d = 1.36) or large (CAU d = 0.89) reduction of FoC symptoms with a mean decrease of 25.6 (EMDR) and 17.4 (CAU) points in WDEQ-A sum score. No significant difference between both groups was found ( p = 0.83). At posttreatment, 72.4% (EMDR) vs. 59.6% (CAU) no longer met the criteria for FoC. In conclusion, the results are supportive of EMDR therapy as a safe and effective treatment of FoC during pregnancy, albeit without significant beneficial effects of EMDR therapy over and above those of CAU. Therefore, the current study results do not justify implementation of EMDR therapy as an additional treatment in this particular setting., Competing Interests: Author AdJ has been a board member of the Dutch EMDR Association and EMDR Europe Association, and receives fees for courses and books about trauma and EMDR. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Baas, van Pampus, Stramrood, Dijksman, Vanhommerig and de Jongh.)

Background: Preterm birth is the leading cause of neonatal morbidity and mortality. The recurrence rate of spontaneous preterm birth is high, and additional preventive measures are required. Our objective was to assess the effectiveness of low-dose aspirin compared to placebo in the prevention of preterm birth in women with a previous spontaneous preterm birth., Methods and Findings: We performed a parallel multicentre, randomised, double-blinded, placebo-controlled trial (the APRIL study). The study was performed in 8 tertiary and 26 secondary care hospitals in the Netherlands. We included women with a singleton pregnancy and a history of spontaneous preterm birth of a singleton between 22 and 37 weeks. Participants were randomly assigned to aspirin 80 mg daily or placebo initiated between 8 and 16 weeks of gestation and continued until 36 weeks or delivery. Randomisation was computer generated, with allocation concealment by using sequentially numbered medication containers. Participants, their healthcare providers, and researchers were blinded for treatment allocation. The primary outcome was preterm birth <37 weeks of gestation. Secondary outcomes included a composite of poor neonatal outcome (bronchopulmonary dysplasia, periventricular leukomalacia > grade 1, intraventricular hemorrhage > grade 2, necrotising enterocolitis > stage 1, retinopathy of prematurity, culture proven sepsis, or perinatal death). Analyses were performed by intention to treat. From May 31, 2016 to June 13, 2019, 406 women were randomised to aspirin (n = 204) or placebo (n = 202). A total of 387 women (81.1% of white ethnic origin, mean age 32.5 ± SD 3.8) were included in the final analysis: 194 women were allocated to aspirin and 193 to placebo. Preterm birth <37 weeks occurred in 41 (21.2%) women in the aspirin group and 49 (25.4%) in the placebo group (relative risk (RR) 0.83, 95% confidence interval (CI) 0.58 to 1.20, p = 0.32). In women with ≥80% medication adherence, preterm birth occurred in 24 (19.2%) versus 30 (24.8%) women (RR 0.77, 95% CI 0.48 to 1.25, p = 0.29). The rate of the composite of poor neonatal outcome was 4.6% (n = 9) versus 2.6% (n = 5) (RR 1.79, 95% CI 0.61 to 5.25, p = 0.29). Among all randomised women, serious adverse events occurred in 11 out of 204 (5.4%) women allocated to aspirin and 11 out of 202 (5.4%) women allocated to placebo. None of these serious adverse events was considered to be associated with treatment allocation. The main study limitation is the underpowered sample size due to the lower than expected preterm birth rates., Conclusions: In this study, we observed that low-dose aspirin did not significantly reduce the preterm birth rate in women with a previous spontaneous preterm birth. However, a modest reduction of preterm birth with aspirin cannot be ruled out. Further research is required to determine a possible beneficial effect of low-dose aspirin for women with a previous spontaneous preterm birth., Trial Registration: Dutch Trial Register (NL5553, NTR5675) https://www.trialregister.nl/trial/5553., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: BM reported an Investigator grant from the National Health and Medical Research Council (NHMRC; grant no. GNT1176437); receipt of research funding from Guerbet; and is a former advisory board member at ObsEva. All other authors do not report any relevant financial activities outside the submitted work.

Purpose: To evaluate whether severe postpartum hemorrhage (PPH) is a risk factor for posttraumatic stress disorder (PTSD). Severe PPH can be experienced as a traumatic event. PTSD leads to negative mental health effects. Knowing risk factors for PTSD during childbirth offers opportunities for early interventions, which may prevent the development of PTSD., Materials and Methods: In this prospective study, we compared two groups of participants; women with ≥2000 mL of blood loss (severe PPH, patients) and women with ≤500 mL of blood loss (controls). Participants were screened for PTSD using the PCL-5 four to six weeks after delivery. Positive screening was followed by the CAPS-5 to diagnose PTSD., Results: We included 187 PPH patients and 121 controls. Median PCL-5 scores were higher for PPH patients (5.0) than controls (4.0, p  = 0.005). Thirteen PPH patients (7.0%) and two controls (1.7%) scored ≥32 on the PCL-5, indicative of probable PTSD (OR 4.45, 95% CI 0.99-20.06, p  = 0.035). Significant more PPH patients than controls met criteria for a clinical diagnosis of PTSD on the CAPS-5 ( n  = 10, 5.6% vs n  = 0, 0.0%; p  = 0.007)., Conclusions: There is a significant and clinically relevant increased risk for developing PTSD after severe PPH. Gynecologists and midwives are advised to screen for PTSD at postpartum follow-up visits to prevent long-term negative mental health effects., Clinical Trial Registration: NL50273.100.14.

Background: Up to 33% of women develop symptoms of posttraumatic stress disorder (PTSD) after a traumatic birth experience. Negative and traumatic childbirth experiences can also lead to fear of childbirth, avoiding or negatively influencing a subsequent pregnancy, mother-infant bonding problems, problems with breastfeeding, depression and reduced quality of life. For PTSD in general, eye movement desensitization and reprocessing (EMDR) therapy has proven to be effective. However, little is known about the preventive effects of early intervention EMDR therapy in women after a traumatic birth experience. The purpose of this study is to determine the effectiveness of early intervention EMDR therapy in preventing PTSD and reducing PTSD symptoms in women with a traumatic birth experience., Methods: The PERCEIVE study is a randomized controlled trial. Women suffering from the consequences of a traumatic birth experience will be randomly allocated at maximum 14 days postpartum to either EMDR therapy or 'care-as-usual'. Patients in the EMDR group receive two sessions of therapy between 14 (T0) and 35 days postpartum. All participants will be assessed at T0 and at 9 weeks postpartum (T1). At T1, all participants will undergo a CAPS-5 interview about the presence and severity of PTSD symptoms. The primary outcome measure is the severity of PTSD symptoms, whereas the secondary outcomes pertain to fear of childbirth, mother-infant bonding, breastfeeding, depression and quality of life. The study will be conducted at a large city hospital and at multiple midwifery practices in Amsterdam, the Netherlands., Discussion: It is to be expected that the results of this study will provide more insight about the safety and effectiveness of early intervention EMDR therapy in the prevention and reduction of PTSD (symptoms) in women with a traumatic birth experience., Trial Registration: Netherlands Trial Register NL73231.000.20 . Registered on 21 August 2020., (© 2021. The Author(s).)

The large interferon-inducible anti-angiogenic pro-inflammatory GTPase Guanylate Binding Protein-1 (GBP-1) is produced and secreted by activated endothelial cells and is highly induced by inflammatory cytokines and inhibited by angiogenic growth factors. During pregnancy a generalized mild inflammatory response is observed. During preeclampsia this generalized inflammatory response is even further activated and activation of the endothelium occurs. We hypothesized that GBP-1 is increased in healthy pregnancy and will be even further increased during preeclampsia. In the first experiment, plasma and placentas were collected from healthy and preeclamptic pregnancies. Plasma was also collected from non-pregnant women. For the second experiment longitudinal blood samples from women with a healthy or preeclamptic pregnancy were collected from the end of the first trimester until birth and one sample postpartum. The plasma GBP-1 levels were measured by ELISA and GBP-1 mRNA and protein levels in the placenta were tested by qPCR and immunohistochemistry. During pregnancy higher plasma concentrations of GBP-1 compared with non-pregnant women were observed. Surprisingly, during preeclampsia, plasma GBP-1 levels were lower than in control pregnancies and similar to the level of non-pregnant controls. Placental GBP-1 mRNA levels were not different between healthy and preeclamptic pregnancies and GBP-1 protein was virtually undetectable in the trophoblast by immunohistochemistry in placental tissue. Evaluation of longitudinal samples showed that plasma GBP-1 concentrations increased towards the end of pregnancy in healthy pregnancies, but not in preeclampsia. In line with our hypothesis, we found higher GBP-1 plasma levels during healthy pregnancy. However, plasma GBP-1 did not further increase during preeclampsia, but was stable. Further studies are needed to evaluate why GBP-1 does not increase during preeclampsia., (Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: The field of obstetrics and gynecology requires complex decision-making and skills because of unexpected high-risk situations. These skills are influenced by alertness, reaction time, and concentration. Night shifts result in sleep deprivation, which might impair these functions, although it is still unclear to what extent., Objective: This study aimed to investigate whether a night shift routinely impairs the obstetrics and gynecology consultants' and residents' fitness to perform and whether this reaches a critical limit compared with relevant frames of reference., Study Design: Residents (n=33) and consultants (n=46) in obstetrics and gynecology conducted multiple measurements (n=415) at precall, postcall, and noncall moments with the fitness to perform self-test. The self-test consists of an adaptive pursuit tracking task that is able to objectively measure alertness, reaction time, concentration, and hand-eye coordination and Visual Analog Scale tests to subjectively score alertness. The test is validated with a sociolegal reference of a 0.06% ethanol blood concentration (the peak level after 2 units of alcohol, the legal driving limit). This equals -1.37% on the objective score and -8.17 points on subjective alertness. Linear mixed models were used to analyze the difference within subjects over a night shift, integrating repeated measures over time., Results: The overnight objective difference between postcall and precall measurements was -0.62 (P<.05) for residents and 0.28 (P=NS) for consultants, both not exceeding the sociolegal reference as a group. Objective impairment exceeded the reference for 31% of the residents and 28% of the consultants. Subjective alertness decreased in residents (-18.26; P<.001) and consultants (-10.85; P<.001), both exceeding the reference. No residents had to continue work postcall versus 7.8% of the consultants. None of the consultants that had to continue work were in an objective critically impaired state., Conclusion: This study provides insight and awareness of individual performance after night shifts with clear frames of reference. The performance of residents is negatively and significantly affected by night shifts; therefore, a scheduled day off after a night shift is justified. Consultants showed no overall impairment; however, a quarter did exceed the alcohol limit reference after their night shift. If not logistically feasible to schedule a protected day off after a night shift, our group recommends safe shift scheduling, including options to transfer care after a demanding night shift to prevent working in a compromised state., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: The coronavirus disease (COVID-19) pandemic has negatively affected many people's mental health with increased symptoms of stress, anxiety and depression in the general population. Anxiety and depression can have negative effects on pregnant women and result in poor neonatal outcomes. Therefore, we analyzed stress, anxiety and depression in pregnant women during the COVID-19 pandemic., Materials and Methods: Cohort study of pregnant women during COVID-19 compared to pregnant women before COVID-19. Pregnant women were recruited through social media platforms from 21 May 2020 to 22 June 2020. Pregnant women ≥ 18 years of age, who master the Dutch language were included. The Hospital Anxiety and Depression Scale (HADS) and the Perceived Stress Scale (PSS-10) were analyzed. Demographic features were summarized using descriptive statistics. Possible differences in demographic variables between groups were compared using Mann Whitney U test and Chi-squared test. Significant demographic differences between groups were controlled for using logistical regression analysis or an independent one-way analysis of covariance., Results: Thousand hundred and two pregnant women completed the questionnaires during COVID-19, and 364 pregnant women before COVID-19. We found no differences in clinically high levels of anxiety (HADS-A ≥ 8) and depression (HADS-D ≥ 8) in women during COVID-19 (19.5% and 13.2%, respectively) and women before COVID-19 (23.1% and 15.7%, respectively). A question was implemented whether participants related their stress level to COVID-19. Women who related their stress to the COVID-19 pandemic reported significantly higher overall stress levels on the PSS-10 compared to women with stress unrelated to COVID-19 (mean, 15.62; standard deviation [SD], 6.44 vs. mean, 10.28; SD, 5.48; p  < 0.001)., Conclusion: In contrast to previous studies, COVID-19 did not increase anxiety and depression levels in Dutch pregnant women. Women who related their perceived stress to the COVID-19 pandemic experienced higher stress levels than women who did not relate their stress to the COVID-19 pandemic, suggesting that interventions that specifically aim to reduce COVID-19 stress, may help to reduce overall stress levels in pregnant women during the pandemic.

Introduction: The age at which women give birth is rising steadily in the western world. Advanced maternal age has been associated with adverse pregnancy outcomes. We assessed the association between advanced maternal age and the risk of adverse maternal and perinatal outcome in primigravid and multigravid women., Material and Methods: The study was a population-based cohort study and included women giving birth between January 2000 and December 2018 using data from the Dutch perinatal registration of Perined. Women were divided into age groups. We compared outcomes between women of 40-44, 45-49, and over 50 years old (the study groups) with women of 25-29 years old (reference group), stratified for parity. We employed multivariable regression to correct for possible confounders including methods of conception, multiple pregnancies, ethnicity, and socio-economic status. Our primary outcomes were maternal and perinatal mortality. Secondary outcomes included common maternal and perinatal complications, as well as cesarean section rate., Results: A cohort of 3 700 326 women gave birth during the study period. Of these women, 3.2% were above 40 years of age. Maternal mortality was rare in all groups, but significantly higher in multigravid women over 50 years old. Perinatal mortality was significantly higher in all pregnancies of women over 40 years old, but not for primigravida over 50 years old. The most notable results with the steepest increase were in maternal complications. Both primigravida and multigravida over 40 years old were at a two times higher risk of perinatal mortality, cesarean section, gestational diabetes, hypertensive disorders, and a low Apgar score after 5 minutes. The risk for women over 45 was almost tripled for perinatal mortality and gestational diabetes and six times higher for cesarean section. Women over 50 years old had a seven times higher risk of cesarean section, a four times higher risk of gestational diabetes, postpartum hemorrhage, and neonatal intensive care unit admission, and a 10 times higher risk of hypertensive disorders., Conclusions: The risk of adverse maternal and perinatal outcomes for women over 40 years old surges as age increases. A novel aspect was the consistent increased risks not only for primigravid women but also for multigravida., (© 2021 Nordic Federation of Societies of Obstetrics and Gynecology.)

Lymphangioleiomyomatosis (LAM) is a progressive cystic lung disease which mostly affects premenopausal women and could be exacerbated by pregnancy. Therefore, it is thought that oestrogen plays an important role in LAM pathogenesis. Here, a case of LAM is described in which the first presentation of symptoms occurred during the third trimester of pregnancy. Symptoms included acute onset dyspnoea and chest pain at gestational age of 39 weeks and 2 days. A CT was performed which showed multiple thin-walled cysts and a small pneumothorax. Serum levels of vascular endothelial growth factor-D (VEGF-D) was 1200 pg/mL. The typical cystic lung changes on chest CT in combination with elevated VEGF-D is diagnostic for LAM. Given the risk of respiratory complications, the decision was made to deliver the baby at a gestational age of 39 weeks and 6 days by a planned caesarean section. Both mother and child were discharged home in good condition., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The disproportionate intrauterine growth intervention trial at term was an intention to treat analysis and compared labor induction with expectant monitoring in pregnancies complicated by fetal growth restriction at term and showed equivalence for neonatal outcomes., Objective: To evaluate trial participation bias and to examine the generalizability of the results of an obstetrical randomized trial., Study Design: We used data from participants and nonparticipants of a randomized controlled trial-the disproportionate intrauterine growth intervention trial at term (n=1116) -to perform a secondary analysis. This study compared induction of labor and expectant management in women with term growth restriction. Data were collected in the same manner for both groups. Baseline characteristics and neonatal and maternal outcomes were compared. The primary outcome was a composite measure of adverse neonatal outcome. Secondary outcomes were delivery by cesarean delivery and instrumental vaginal delivery; length of stay in the neonatal intensive care, neonatal ward, and the maternal hospital; and maternal morbidity., Results: Nonparticipants were older, had a lower body mass index, had a higher level of education, smoked less, and preferred expectant management. The time between study inclusion and labor onset was shorter in participants than in nonparticipants. Notably, 4 perinatal deaths occurred among nonparticipants and none among participants. Among nonparticipants, there were more children born with a birthweight below the third centile. The nonparticipants who had expectant management were monitored less frequently than the participants in both the intervention and the expectant arm., Conclusion: We found less favorable outcomes and more perinatal deaths in nonparticipants. Protocol-driven management, differences between participants and nonparticipants, or the fact that nonparticipants had a preference for expectant management might explain the findings., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To compare the prevalence of work-related potential traumatic events (PTEs), support protocols and mental health symptoms across Dutch gynaecologists, orthopaedic surgeons and paediatricians., Design: Cross-sectional study, supplementary analysis of combined data., Setting: Nationwide survey between 2014 and 2017., Participants: An online questionnaire was sent to all Dutch gynaecologists, orthopaedic surgeons and paediatricians, including resident physicians (4959 physicians). 1374 questionnaires were eligible for analysis, corresponding with a response rate of 27.7%., Outcome Measures: Primary outcome measures were the prevalence of work-related PTEs, depression, anxiety, psychological distress and traumatic stress, measured with validated screening instruments (Hospital Anxiety and Depression Scale, Trauma Screening Questionnaire). Secondary outcomes were the association of mental health and defensive practice to traumatic events and support protocols., Results: Of the respondents, 20.8% experienced a work-related PTE at least 4 weeks ago. Prevalence rates indicative of depression, anxiety or post-traumatic stress disorder (PTSD) were 6.4%, 13.6% and 1.5%, respectively. Depression (9.2% vs 5.2%, p=0.019), anxiety (18.2% vs 8.2%, p<0.001) and psychological distress (22.8% vs 12.5%, p<0.001) were significantly more prevalent in female compared with male attendings. The absence of a support protocol was significantly associated with more probable PTSD (p=0.022). Those who witnessed a PTE, reported more defensive work changes (28.0% vs 20.5%, p=0.007) and those with probable PTSD considered to quit medical work more often (60.0% vs 35.8%, p=0.032)., Conclusion: Physicians are frequently exposed to PTEs with high emotional impact over the course of their career. Lacking a support protocol after adverse events was associated with more post-traumatic stress. Adverse events were associated with considering to quit medical practice and a more defensive practice. More awareness must be created for the mental health of physicians as well as for the implementation of a well-organised support system after PTEs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Physicians are frequently exposed to adverse events on the work-floor, which puts them at risk for depression, anxiety- or posttraumatic stress disorder. This study aims to explore what events orthopaedic surgeons consider to have the highest emotional impact as well as support, coping strategies and mental health. A questionnaire was emailed to all members of the Dutch Society of Orthopaedic Surgeons which included resident, attending, non-practicing and retired orthopaedic surgeons. The questionnaire in- cluded questions about demographics, personal experiences and subsequent support and coping. Also the Hospital Anxiety and Depression Scale and the Trauma Screening Questionnaire were included, which are validated screening instruments for anxiety, depression and posttraumatic stress disorder (PTSD), respectively. A total of 292 questionnaires were eligible for analysis. Most common events considered a high emotional impact stressor were : missing a diagnosis (59.2%), when a patient becomes severely handicapped (36.6%) or doubting whether one is making the right decision (36.6%). The prevalence of depression was higher compared to the general population with a high income in the Netherland (4.8 vs. 3.0 %,) and for anxiety as well (8.3 vs. 6.0%). Fifty-seven (19.5%) participants expe- rienced an adverse event as traumatic. Prevalence of PTSD was 0.3% among the whole sample. Most common coping strategies after adverse events were support from colleagues (80.7%), support from friends and family (59.3%) or doing sports (26.6%). Orthopaedic surgeons are exposed to many adverse events over the course of their career, which may have a high emotional impact. The prevalence rate found for depression and anxiety were both higher compared to the general population, while the rate for PTSD was lower. Still, more awareness must be created for the mental health of physicians as well as the implementation of a well-organized support system.

Objective: Fear of childbirth (FoC) and postpartum posttraumatic stress disorder (PP-PTSD) are often less well recognized by healthcare professionals than other peripartum mental health disorders. This study aims to evaluate knowledge, management and attitudes of gynecologists and gynecology residents regarding women with FoC and PP-PTSD. Study design: A cross-sectional study was conducted among gynecologists and gynecology residents using an online questionnaire. An invitation was sent to all 1401 members of the Dutch Society of Obstetrics and Gynecology. Results: Two hundred forty-four respondents completed the online multiple-choice and open question survey. More respondents were able to answer the questions about risk factors, signs/symptoms and consequences of FoC in comparison with similar questions about PP-PTSD. When asked about performing a cesarean section on maternal request, 74% of respondents would grant this request if fear would persist despite adequate psychological treatment. During labor, providing good explanations and obtaining informed consent were most frequently named to reduce fear or the likelihood of a traumatic birth experience. Caregivers' attitudes towards women with FoC or suspected PP-PTSD were mainly positive. Conclusions: Further knowledge, in particular about PP-PTSD, is desirable for appropriate recognition of women with FoC and PP-PTSD. Gynecologists should be made more aware of how their communication is perceived by patients, given the discrepancy between patients' experiences and the attitudes gynecologists report themselves. For optimizing the organization of care, we would recommend the use of a clear (inter)national policy regarding maternal requests for cesarean section (CS). Brief rationale The objective of this study was to evaluate knowledge and awareness regarding fear of childbirth (FOC) and postpartum posttraumatic stress disorder (PP-PTSD) among gynecologists and gynecology residents, assessing their attitudes towards women suffering from these conditions, and evaluating organization of care.The main findings and recommendations of the study include that gynecologists should be better trained to appropriately recognize fear of childbirth and postpartum posttraumatic stress disorder, and they should be made more aware of how their communication is perceived by patients, given the discrepancy between patients' experiences and the attitudes gynecologists report themselves.

Background: PTSD in pregnant women is associated with adverse outcomes for mothers and their children. It is unknown whether pregnant women with PTSD, or symptoms of PTSD, can receive targeted treatment that is safe and effective., Objective: The purpose of the present paper was to assess the effectiveness and safety of treatment for (symptoms of) PTSD in pregnant women., Method: A systematic review was conducted in accordance with the PRISMA guidelines in Pubmed, Embase, PsychINFO, and Cochrane. In addition, a case is presented of a pregnant woman with PTSD who received eye-movement desensitization and reprocessing (EMDR) therapy aimed at processing the memories of a previous distressing childbirth., Results: In total, 13 studies were included, involving eight types of interventions (i.e. trauma-focused cognitive behavioural therapy, exposure therapy, EMDR therapy, interpersonal psychotherapy, explorative therapy, self-hypnosis and relaxation, Survivor Moms Companion, and Seeking Safety Intervention). In three studies, the traumatic event pertained to a previous childbirth. Five studies reported obstetrical outcomes. After requesting additional information, authors of five studies indicated an absence of serious adverse events. PTSD symptoms improved in 10 studies. However, most studies carried a high risk of bias. In our case study, a pregnant woman with a PTSD diagnosis based on DSM-5 no longer fulfilled the criteria of PTSD after three sessions of EMDR therapy. She had an uncomplicated pregnancy and delivery., Conclusion: Despite the fact that case studies as the one presented here report no adverse events, and treatment is likely safe, due to the poor methodological quality of most studies it is impossible to allow inferences on the effects of any particular treatment of PTSD (symptoms) during pregnancy. Yet, given the elevated maternal stress and cortisol levels in pregnant women with PTSD, and the fact that so far no adverse effects on the unborn child have been reported associated with the application of trauma-focused therapy, treatment of PTSD during pregnancy is most likely safe., Competing Interests: No potential conflict of interest was reported by the authors., (© 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Background: Partners of women are increasingly present during childbirth and may be exposed to a traumatic experience. Since parents' mental health issues (i.e. posttraumatic stress disorder) have been shown to increase the risk of problems in the child's development, it is important to identify these risk factors. Partners often describe severe postpartum haemorrhage as traumatic., Aim: Whether witnessing severe postpartum haemorrhage is a risk factor for developing posttraumatic stress disorder in partners., Methods: In this prospective cohort study, we compared partners of women with severe postpartum haemorrhage (≥2000 mL) and partners of women with ≤500 mL of blood loss (controls). Four weeks after birth partners were screened for posttraumatic stress disorder symptoms with a self-report questionnaire. Scores ≥11 were followed by a gold standard clinical interview to diagnose posttraumatic stress disorder., Findings: We included 123 severe postpartum haemorrhage partners and 62 control partners. Partners of women with severe postpartum haemorrhage reported higher scores than control partners (median 3.0 (0.0-7.0) vs 2.0 (0.0-4.0), p = 0.04) on symptoms of posttraumatic stress, but no significant difference in probable posttraumatic stress disorder diagnosis according to the self-report questionnaire was found. According to the clinical interview no partners were diagnosed with posttraumatic stress disorder. Severe postpartum haemorrhage was experienced as traumatic by the partners who felt excluded., Conclusion: None of the partners developed posttraumatic stress disorder, revealing the resilience of young fathers. Because some partners reported severe postpartum haemorrhage as traumatic, we recommend sufficient information and support is provided during childbirth., (Copyright © 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Birth experiences can be traumatic and may give rise to PTSD following childbirth (PTSD-FC). Peripartum neurobiological alterations in the oxytocinergic system are highly relevant for postpartum maternal behavioral and affective adaptions like bonding and lactation but are also implicated in the response to traumatic events. Animal models demonstrated that peripartum stress impairs beneficial maternal postpartum behavior. Early postpartum activation of the oxytocinergic system may, however, reverse these effects and thereby prevent adverse long-term consequences for both mother and infant. In this narrative review, we discuss the impact of trauma and PTSD-FC on normal endogenous oxytocinergic system fluctuations in the peripartum period. We also specifically focus on the potential of exogenous oxytocin (OT) to prevent and treat PTSD-FC. No trials of exogenous OT after traumatic childbirth and PTSD-FC were available. Evidence from non-obstetric PTSD samples and from postpartum healthy or depressed samples implies restorative functional neuroanatomic and psychological effects of exogenous OT such as improved PTSD symptoms and better mother-to-infant bonding, decreased limbic activation, and restored responsiveness in dopaminergic reward regions. Adverse effects of intranasal OT on mood and the increased fear processing and reduced top-down control over amygdala activation in women with acute trauma exposure or postpartum depression, however, warrant cautionary use of intranasal OT. Observational and experimental studies into the role of the endogenous and exogenous oxytocinergic system in PTSD-FC are needed and should explore individual and situational circumstances, including level of acute distress, intrapartum exogenous OT exposure, or history of childhood trauma.

Background: Preeclampsia is a hypertensive pregnancy disorder in which generalized systemic inflammation and maternal endothelial dysfunction are involved in the pathophysiology. MiRNAs are small noncoding RNAs responsible for post-transcriptional regulation of gene expression and involved in many physiological processes. They mainly downregulate translation of their target genes., Objective: We aimed to compare the plasma miRNA concentrations in preeclampsia, healthy pregnant women, and nonpregnant women. Furthermore, we aimed to evaluate the effect of 3 highly increased plasma miRNAs in preeclampsia on endothelial cell function in vitro., Study Design: We compared 3391 (precursor) miRNA concentrations in plasma samples from early-onset preeclamptic women, gestational age-matched healthy pregnant women, and nonpregnant women using miRNA 3.1. arrays (Affymetrix) and validated our findings by real-time quantitative polymerase chain reaction. Subsequently, endothelial cells (human umbilical vein endothelial cells) were transfected with microRNA mimics (we choose the 3 miRNAs with the greatest fold change and lowest false-discovery rate in preeclampsia vs healthy pregnancy). After transfection, functional assays were performed to evaluate whether overexpression of the microRNAs in endothelial cells affected endothelial cell function in vitro. Functional assays were the wound-healing assay (which measures cell migration and proliferation), the proliferation assay, and the tube-formation assay (which assesses formation of endothelial cell tubes during the angiogenic process). To determine whether the miRNAs are able to decrease gene expression of certain genes, RNA was isolated from transfected endothelial cells and gene expression (by measuring RNA expression) was evaluated by gene expression microarray (Genechip Human Gene 2.1 ST arrays; Life Technologies). For the microarray, we used pooled samples, but the differently expressed genes in the microarray were validated by real-time quantitative polymerase chain reaction in individual samples., Results: No significant differences (fold change <-1.2 or >1.2 with a false-discovery rate <0.05) were found in miRNA plasma concentrations between healthy pregnant and nonpregnant women. The plasma concentrations of 26 (precursor) miRNAs were different between preeclampsia and healthy pregnancy. The 3 miRNAs that were increased with the greatest fold change and lowest false-discovery rate in preeclampsia vs healthy pregnancy were miR-574-5p, miR-1972, and miR-4793-3p. Transfection of endothelial cells with these miRNAs in showed that miR-574-5p decreased (P<.05) the wound-healing capacity (ie, decreased endothelial cell migration and/or proliferation) and tended (P<.1) to decrease proliferation, miR-1972 decreased tube formation (P<.05), and also tended (P<.1) to decrease proliferation, and miR-4793-3p tended (P<.1) to decrease both the wound-healing capacity and tube formation in vitro. Gene expression analysis of transfected endothelial cells revealed that miR-574-5p tended (P<.1) to decrease the expression of the proliferation marker MKI67., Conclusion: We conclude that in the early-onset preeclampsia group in our study different concentrations of plasma miRNAs are present as compared with healthy pregnancy. Our results suggest that miR-574-5p and miR-1972 decrease the proliferation (probably via decreasing MKI67) and/or migration as well as the tube-formation capacity of endothelial cells. Therefore, these miRNAs may be antiangiogenic factors affecting endothelial cells in preeclampsia., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The clinical dilemma on the preferred mode of delivery for breech position still exists. Elective caesarean delivery (CD) could be safer for neonates, whereas vaginal breech delivery (VBD) remains a safe option when conducted by an experienced person. Besides successful VBD is beneficial for mothers and subsequent pregnancies., Objectives: To evaluate breech deliveries on mode of delivery, maternal and neonatal outcomes., Study Design: A single center, retrospective, cohort study was performed of women who delivered a singleton fetus in breech position from 32 weeks' gestation onwards from January 2011 to December 2017. Primary outcome measure was mode of delivery defined as an elective CD and planned VBD. Secondary outcome measures were neonatal and maternal outcome. For neonatal outcome, we used neonatal mortality and a composite measure neonatal morbidity. Maternal outcome included maternal mortality and maternal morbidity divided in severe and non-severe complications. We subcategorized for preterm (32 weeks to 37 weeks of gestation) and term pregnancies (from 37 weeks of gestation onwards)., Results: 1.774 women delivered a child in breech position, 73 % opted for an elective CD. Of the 484 women that had a planned VBD (preterm 38 % (n = 59), term 26 % (n = 425)) 71 % were successful. Neonatal mortality occurred twice in the VBD cohort. Preterm neonatal morbidity occurred in the elective CD and VBD cohort equally (both 66 %), at term significantly more in the VBD cohort (12 % v 4%, OR 3.2, 95 % CI 2.1-4.8). For the total cohort, severe maternal postpartum complications occurred more often in the elective CD compared to successful VBD (2% v 0.3 %, OR 6.0, 95 % CI 0.80-44.3)., Conclusion: A high rate of successful VBD after opting for a planned VBD was found in our center. Nevertheless, compromised neonatal outcome at term was more frequent in the planned VBD group compared to the elective CD group. Severe maternal postpartum complications were more frequent in the elective CD group compared to the VBD group. Future research should focus alternations in the management of breech presentation., Competing Interests: Declaration of Competing Interest The authors did not report any potential conflicts of interest., (Copyright © 2020. Published by Elsevier B.V.)

Background: Perinatal depression and anxiety are associated with unfavourable child outcomes., Aims: To assess among women with antenatal depression or anxiety the effectiveness of prenatally initiated cognitive-behavioural therapy (CBT) on mother and child compared with care as usual (CAU). Trial registration: Netherlands Trial Register number NTR2242., Method: Pregnant women (n = 282) who screened positive for symptoms of depression and/or anxiety were randomised to either CBT (n = 140) or CAU (n = 142). The primary outcome was child behavioural and emotional problems at age 18 months, assessed using the Child Behavior Checklist (CBCL). Secondary outcomes were maternal symptoms during and up to 18 months after pregnancy, neonatal outcomes, mother-infant bonding and child cognitive and motor development at age 18 months., Results: In total, 94 (67%) women in the CBT group and 98 (69%) in the CAU group completed the study. The mean CBCL Total Problems score was non-significantly higher in the CBT group than in the CAU group (mean difference: 1.38 (95% CI -1.82 to 4.57); t = 0.85, P = 0.399). No effects on secondary outcomes were observed except for depression and anxiety, which were higher in the CBT group than in the CAU group at mid-pregnancy. A post hoc analysis of the 98 women with anxiety disorders showed lower infant gestational age at delivery in the CBT than in the CAU group., Conclusions: Prenatally initiated CBT did not improve maternal symptoms or child outcomes among non-help-seeking women with antenatal depression or anxiety. Our findings are not in line with present recommendations for universal screening and treatment for antenatal depression or anxiety, and future work may include the relevance of baseline help-seeking.

Rationale, Aims, and Objectives: We strive to maximize outcomes that are relevant to the women who deliver in our hospital. We demonstrate a practical method of using value-based health care (VBHC) concepts to analyse how care can be improved., Method: Using International Consortium of Health Outcome Measurements (ICHOM) set, a practical outcome set was constructed for women who go into spontaneous labour at term of a singleton in cephalic presentation and used for benchmarking. We included data on interventions that are major drivers of outcomes. Data from two hospitals in Amsterdam and for The Netherlands for 2011 to 2015 were collected., Results: Benchmarking of readily available data helped identify a number of statistically significant and clinically relevant differences in obstetric outcomes. Caesarean section rate was significantly different at 13.7% in hospital 2 compared with 11.5% in hospital 1 with similar neonatal outcomes. Third and fourth degree tearing rates were significantly higher for hospital 1 at 5.5% compared with 3.6% for hospital 2 and the national average of 3.5%. On the basis of the guidelines, literature, and discussion, initiatives on how to improve these outcomes were then identified. These include caesarean section audit and guidelines regarding caesarean section decision making. In order to reduce the rate of third and fourth degree tearing, routine episiotomy on vaginal operative deliveries was introduced, and a training programme was set up to make care providers more aware of risk factors and potential preventive measures., Conclusion: Defining, measuring, and comparing relevant outcomes enable care providers to identify improvements. Collection and comparison of readily available data can provide insights in where care can be improved. Insights from literature and comparison of care practices and processes can lead to how care can be improved. Continuous monitoring of outcomes and expanding the set of outcomes that is readily available are key in the process towards value-based care provision., (© 2019 John Wiley & Sons, Ltd.)

Objective: We aimed to identify determinants that predict hyperemesis gravidarum (HG) disease course and severity., Study Design: For this study, we combined data of the Maternal and Offspring outcomes after Treatment of HyperEmesis by Refeeding (MOTHER) randomized controlled trial (RCT) and its associated observational cohort with non-randomised patients. Between October 2013 and March 2016, in 19 hospitals in the Netherlands, women hospitalised for HG were approached for study participation. In total, 215 pregnant women provided consent for participation. We excluded women enrolled during a readmission (n = 24). Determinants were defined as patient characteristics and clinical features, available to clinicians at first hospital admission. Patient characteristics included i.e. age, ethnicity, socio-economic status, history of mental health disease and HG and gravidity. Clinical features included weight loss compared to pre-pregnancy weight and symptom severity measured with Pregnancy Unique Quantification of Emesis (PUQE-24) questionnaire and the Nausea and Vomiting in Pregnancy specific Quality of Life questionnaire (NVPQoL). Outcome measures were measures of HG disease severity present at 1 week after hospital admission, including weight change, PUQE-24 and NVPQoL scores. Total days of admission hospital admission and readmission were also considered outcome measures., Results: We found that high PUQE-24 and NVPQoL scores at hospital admission were associated with those 1 week after hospital admission (difference (β) 0.36, 95 %CI 0.16 to 0.57 and 0.70,95 %CI 0.45-1.1). PUQE-24 and NVPQoL scores were not associated with other outcome measures. None of the patient characteristics were associated with any of the outcome measures., Conclusion: Our findings suggest that the PUQE-24 and NVPQoL questionnaires can identify women that maintain high symptom scores a week after admission, but that patient characteristics cannot be used as determinants of HG disease course and severity., Competing Interests: Declaration of Competing Interest None declared. Completed disclosure of interests form available to view online as supporting information., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Women suffering from fear of childbirth and postpartum posttraumatic stress disorder are often not recognised by health care professionals., Aim: To evaluate practices, knowledge and the attitudes of midwives towards women with fear of childbirth and postpartum posttraumatic stress disorder., Methods: A cross-sectional study was performed amongst midwives who work in community practices and hospitals in the Netherlands with the use of a questionnaire purposefully designed for this research aim., Findings: 257 midwives participated in the study, of whom 217 completed all items in the questionnaire. Midwives were better equipped to answer knowledge questions concerning fear of childbirth than posttraumatic stress disorder (regarding symptomatology, risk factors, consequences and treatment). When tending to women with fear of childbirth or (suspected) postpartum posttraumatic stress disorder, most midwives referred to another caregiver (e.g. psychologist). Most midwives expressed a positive and compassionate attitude towards women with fear of childbirth and postpartum posttraumatic stress disorder., Discussion: The majority of midwives are well informed with respect to fear of childbirth, but knowledge of important aspects of postpartum posttraumatic stress disorder is often lacking. Midwives report no crucial issues related to their attitudes towards women with fear of childbirth and posttraumatic stress disorder. Most midwives provide adequate organisation of care and support., Conclusion: Midwives should acquire more in depth knowledge of fear of childbirth and postpartum posttraumatic stress disorder. This can be achieved by including the two conditions in the program of midwifery education., (Copyright © 2018. Published by Elsevier Ltd.)

Objective: The Hypertension and Preeclampsia Intervention Trial At near Term-I (HYPITAT-I) randomized controlled trial showed that, in women with gestational hypertension or mild pre-eclampsia at term, induction of labor, compared with expectant management, was associated with improved maternal outcome without compromising neonatal outcome. The aim of the current study was to evaluate the impact of these findings on obstetric management and maternal and perinatal outcomes in The Netherlands., Methods: We retrieved data for the period 2000-2014 from the Dutch National Perinatal Registry, including 143 749 women with gestational hypertension or pre-eclampsia and a singleton fetus in cephalic presentation, delivered between 36 + 0 and 40 + 6 weeks of gestation (hypertensive disorder of pregnancy (HDP) group). Pregnant women without HDP were used as the reference group (n = 1 649 510). The HYPITAT-I trial was conducted between 2005 and 2008. To study the impact of HYPITAT-I, we compared rate of induction of labor, mode of delivery and maternal and perinatal outcomes in the periods before (2000-2005) and after (2008-2014) the trial. We also differentiated between hospitals that participated in HYPITAT-I and those that did not., Results: In the HDP group, the rate of induction of labor increased from 51.1% before the HYPITAT-I trial to 64.2% after it (relative risk (RR), 1.26; 95% CI, 1.24-1.27). Maternal mortality decreased from 0.022% before the trial to 0.004% after it (RR, 0.20; 95% CI, 0.06-0.70) and perinatal death decreased from 0.49% to 0.27% (RR, 0.54; 95% CI, 0.45-0.65), which was attributable mostly to a decrease in fetal death. Both the increase in induction rate and the reduction in hypertensive complications were more pronounced in hospitals that participated in the HYPITAT-I trial than in those that did not. Following HYPITAT-I, the rate of induction of labor also increased (by 4.6 percentage points) in the reference group; however, the relative increase in the HDP group (13.1 percentage points) was significantly greater (P < 0.001 for the interaction). The reduction in maternal and perinatal deaths did not differ significantly between the HDP and reference groups. There was a decreased incidence of placental abruption in both HDP and reference groups, which was significantly greater in the HDP than in the reference group (P < 0.001 for the interaction). There was also an increased incidence of emergency Cesarean section in both HDP and reference groups; however, this change was significantly greater in the reference than in the HDP group (P < 0.001 for the interaction)., Conclusion: Following the HYPITAT-I trial, there was a higher rate of induction of labor and improved obstetric outcome in term pregnancies complicated by HDP in The Netherlands. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd., (Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.)

Objectives: Research focused on Internet behavior by women attempting pregnancy and pregnant women is scarce. Some research has been done in other countries, however it cannot be assumed those results also apply to Dutch women., Study Design: A descriptive cross-sectional study was performed using an Internet-questionnaire among women attempting pregnancy and pregnant women., Main Outcome Measures: The aim of this study was to identify the Internet behavior of women attempting pregnancy and pregnant women in the Netherlands., Results: In total, 365 women completed the questionnaire. Of these, 95.6% used the Internet as an information source before or during their pregnancy. Most searched topics were fetal development, lifestyle and pregnancy as well as birth complications. Over 90% of the women thought the information found was reliable and based pregnancy related decisions on this information. However, only 50.1% of the women discussed the information found with their caregiver. Of the respondents, 76.2% thought a reliable website is needed provided by the caregivers., Conclusions: A vast majority of Dutch women attempting pregnancy and Dutch pregnant women use the Internet to search for information and to make decisions about their pregnancy, however they were not satisfied with the information available online. A reliable, informative, interactive and up-to-date website is deemed necessary., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Management of preterm hypertensive disorders remains a clinical dilemma. The maternal benefits of delivery need to be weighed against the adverse neonatal consequences of preterm birth. Long-term consequences of obstetric management in offspring of women with hypertensive disorders in preterm pregnancy are largely unknown. We report child neurodevelopmental and behavioral outcomes at 2 years after the Hypertension and Preeclampsia Intervention Trial at near Term (HYPITAT-II) trial, which compared immediate delivery versus expectant monitoring in mild late preterm hypertensive disorders of pregnancy., Objective: To compare effects of immediate delivery vs expectant monitoring on neurodevelopmental and behavioral outcomes at 2 years of age in offspring of women with mild late preterm hypertensive disorders., Materials and Methods: We studied children born in the HYPITAT-II trial, a study in which women (n = 704) with hypertensive disorders of pregnancy who were between 34 and 37 weeks' gestation were randomized to immediate delivery or expectant monitoring. Participating women were asked to complete the Ages and Stages Questionnaire for developmental outcome and the Child Behavior Checklist for behavioral problems when their toddlers were 2 years old., Results: We approached 545 of 704 randomized women (77%); 330 of 545 (61%) returned the questionnaires. In the immediate delivery group, 45 of 162 infants (28%) had an abnormal Ages and Stages Questionnaire score compared to 27 of 148 (18%) in the expectant monitoring group (risk difference, 9.6%; 95% CI, 0.3-18.0%); P = .045. In the pregnancies (n = 94) that delivered before reaching 36 weeks, 27% (n = 25) had an abnormal Ages and Stages Questionnaire score compared to 22% (n = 47) when delivered after 36 weeks (odds ratio, 0.77; confidence interval, 0.44-1.34). An abnormal Child Behavior Checklist outcome was found in 31 of 175 (18%) in the delivery group vs 24 of 166 (15%) in the expectant monitoring group (risk difference, 3.2%; 95% CI, -4.6% to 11.0%). After correction for maternal education, management strategy remained an independent predictor of abnormal Ages and Stages Questionnaire score (odds ratio, 0.48; confidence interval, 0.24 to -0.96, P = .03). In multivariable analyses, low birth weight, low maternal education, and immediate delivery policy were all significantly associated with an abnormal Ages and Stages Questionnaire score., Conclusion: In this study, we found that early delivery in women with late preterm hypertensive disorders is associated with poorer neurodevelopmental outcomes in their children at 2 years of age. These findings indicate an increased risk of developmental delay after early delivery compared to expectant monitoring. This follow-up study underlines the conclusion of the original HYPITAT-II study that, until the clinical situation deteriorates, expectant monitoring remains the most appropriate management strategy in the light of short- and long-term neonatal outcomes in women with preterm hypertensive disorders., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Traumatic events that occur in a clinical setting can have long-lasting adverse effects on persons who are affected, including health care providers. This study investigated the prevalence of work-related traumatic events, posttraumatic stress disorder (PTSD), anxiety, and depression among Dutch midwives. Additionally, differences between midwives working in primary care (independently assisting births at home and in birthing centers) and midwives working in secondary or tertiary care (hospital setting) were examined. Finally, this study investigated the support midwives would like to receive after experiencing a work-related adverse event., Methods: A descriptive, cross-sectional online survey of Dutch midwives was conducted. The respondents completed a questionnaire about demographic and work-related events, as well as the Trauma Screening Questionnaire and the Hospital Anxiety and Depression Scale., Results: The estimated response rate was 23%, with 691 questionnaires eligible for analysis. Thirteen percent of respondents reported having experienced at least one work-related traumatic event. Among these, 17% screened positive for PTSD, revealing an estimated PTSD prevalence of 2% among Dutch midwives. Clinically relevant anxiety symptoms were reported by 14% of the respondents, significantly more often among midwives working in primary care (P = .014). Depressive symptoms were reported by 7% of the respondents. The desired strategies to cope with an adverse event were peer support by direct colleagues (79%), professional support from a coach or psychologist (30%), multidisciplinary peer support (28%), and support from midwives who are not direct coworkers (17%)., Discussion: Dutch midwives are at risk of experiencing work-related stressful or traumatic events that might lead to PTSD, anxiety, or depression. Midwives working in primary care reported higher levels of anxiety compared with their colleagues working in a clinical setting (secondary or tertiary care). Most midwives preferred peer support with direct colleagues after an adverse event, and some could have profited from easier access to seeking professional help. It could be speculated that midwives would benefit from increased awareness about work-related traumatic events as well as implementation of standardized guidelines regarding support after a traumatic event., (© 2019 The Authors. The Journal of Midwifery and Women's Health published by Wiley Periodicals, Inc., on behalf of the American College of Nurse-Midwives.)

The objective of this study was to study mental health, coping, and support after work-related adverse events among pediatricians. Physicians are frequently exposed to adverse events. It makes them at risk for posttraumatic stress disorder (PTSD), depression, and anxiety disorders. Besides the personal impact, physicians could pose a threat towards patients, as mental health problems are associated with medical errors. A questionnaire was sent to all members of the Pediatric Association of The Netherlands in October 2016. The questionnaire focused on adverse events, coping, and support. The Hospital Anxiety and Depression Scale and the Trauma Screening Questionnaire were included for evaluation of anxiety, depression, and posttraumatic stress. Four hundred ten questionnaires (18.9%) were eligible for analysis. Seventy-nine % (n = 325) of the respondents experienced adverse events, with "missing a diagnosis" having the most emotional impact and "aggressive behavior" as the most common adverse event. Nine (2.2%) pediatricians scored above the cut-off value on the Trauma Screening Questionnaire, indicative of PTSD. In total, 7.3% (n = 30) and 14.1% (n = 58) scored above the cut-off values in the Hospital Anxiety and Depression Scale, indicative of depression and anxiety. Only 26.3% reported to have a peer support protocol available for emotional support following adverse events.Conclusion: Pediatricians experience a considerable amount of adverse and potentially traumatizing events associated with significantly higher mental health problems compared to the general high-income population. Aggression towards pediatricians seems to be a common problem. Protocolled (peer) support should be implemented. What is known: • Physicians are frequently exposed to adverse events. It makes physicians at risk for depression, anxiety, and posttraumatic stress. • Physicians who are affected by these events pose a threat towards patients, as mental health problems are associated with medical errors. What is new: • Pediatricians experience a considerable amount of adverse and potentially traumatizing events associated with significantly higher mental health problems. • It is advised that (peer) support after adverse events is protocolled and education on coping strategies is implemented, to improve mental well-being of pediatricians.

Objective: Hypertensive disorders affect 3-10% of pregnancies. Delayed delivery carries maternal risks, while early delivery increases fetal risk, so appropriate timing is important. The aim of this study was to compare immediate delivery with expectant management for prevention of adverse maternal and neonatal outcomes in women with hypertensive disease in pregnancy., Methods: CENTRAL, PubMed, MEDLINE and ClinicalTrials.gov were searched for randomized controlled trials comparing immediate delivery to expectant management in women presenting with gestational hypertension or pre-eclampsia without severe features from 34 weeks of gestation. The primary neonatal outcome was respiratory distress syndrome (RDS) and the primary maternal outcome was a composite of HELLP syndrome and eclampsia. The PRISMA-IPD guideline was followed and a two-stage meta-analysis approach was used. Relative risks (RR) and numbers needed to treat or harm (NNT/NNH) with 95% CI were calculated to evaluate the effect of the intervention., Results: Main outcomes were available for 1724 eligible women. Compared with expectant management, immediate delivery reduced the composite risk of HELLP syndrome and eclampsia in all women (0.8% vs 2.8%; RR, 0.33 (95% CI, 0.15-0.73); I 2  = 0%; NNT, 51 (95% CI, 31.1-139.3)) as well as in the pre-eclampsia subgroup (1.1% vs 3.5%; RR, 0.39 (95% CI, 0.15-0.98); I 2  = 0%). Immediate delivery increased RDS risk (3.4% vs 1.6%; RR, 1.94 (95% CI 1.05-3.6); I 2  = 24%; NNH, 58 (95% CI, 31.1-363.1)), but depended upon gestational age. Immediate delivery in the 35 th week of gestation increased RDS risk (5.1% vs 0.6%; RR, 5.5 (95% CI, 1.0-29.6); I 2  = 0%), but immediate delivery in the 36 th week did not (1.5% vs 0.4%; RR, 3.4 (95% CI, 0.4-30.3); I 2 not applicable)., Conclusion: In women with hypertension in pregnancy, immediate delivery reduces the risk of maternal complications, whilst the effect on the neonate depends on gestational age. Specifically, women with a-priori higher risk of progression to HELLP, such as those already presenting with pre-eclampsia instead of gestational hypertension, were shown to benefit from earlier delivery. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology., (© 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.)

We present a 22-year-old pregnant woman at 15 weeks of gestation, with abdominal pain and vomiting. We demonstrate that diagnosis and treatment of vomiting and abdominal pain in pregnancy can be difficult. Therefore, involvement of other medical specialists is important when common treatments fail. Cholesterolosis can cause symptoms similar to those caused by cholelithiasis. Controversial to gallstones, identification of cholesterolosis by ultrasound is hard. Cholecystectomy is the only effective treatment option for cholesterolosis and can be performed safely during pregnancy. Cholecystectomy in pregnancy should be considered if, despite atypical symptoms, gallbladder disease is suspected and other diagnoses are ruled out. This may reduce recurrent symptoms, hospital admissions, exposure to harmful drugs and obstetric complications., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Problem: Low socioeconomic status and prior negative life events are documented risk factors for antenatal anxiety and depression, preterm birth and birth weight. We aimed to asses whether the adverse effects of prior negative life events increase with lower socioeconomic status and which aspects of socioeconomic status are most relevant., Methods: We performed a population-based cohort study in the Netherlands including 5398 women in their first trimester of pregnancy. We assessed the number of negative life events prior to pregnancy, aspects of paternal and maternal socio-economic position and symptoms of anxiety and depression. Associations of the number of prior negative life events with anxiety, depression, low birth weight and gestational age were quantified., Findings: The number of prior negative life events, particularly when they had occurred in the two years before pregnancy and maternal aspects of low socioeconomic status (educational level, unemployment and income) were associated with antenatal anxiety and depression. Furthermore, low socioeconomic status increased the adverse effects of prior negative life events. Obstetric outcomes showed similar trends, although mostly not statistically significant., Discussion: Low socioeconomic status and prior negative life events both have an adverse effect on antenatal anxiety and depression. Furthermore, low socioeconomic status increases the adverse impact of prior negative life events on anxiety and depressive symptoms in pregnancy., Conclusion: Interventions for anxiety and depression during pregnancy should be targeted particularly to unemployed, less-educated or low-income women who recently experienced negative life events., (Copyright © 2018 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Objective: To analyze the predictive value of antepartum vulnerability factors, such as social support, coping, history of psychiatric disease, and fear of childbirth, and intrapartum events on the development of symptoms of postpartum posttraumatic stress disorder (PP-PTSD) in women with a traumatic childbirth experience. Materials and methods: Women with at least one self-reported traumatic childbirth experience in or after 2005 were invited to participate through various social media platforms in March 2016. They completed a 35-item questionnaire including validated screening instruments for PTSD (PTSD Symptom Checklist, PCL-5), social support (Oslo social support scale, OSS-3), and coping (Antonovsky's sense of coherence scale, SoC). Results: Of the 1,599 women who completed the questionnaire, 17.4% met the diagnostic criteria for current PTSD according to the DSM-5, and another 26.0% recognized the symptoms from a previous period, related to giving birth. Twenty-six percent of the participating women had received one or more psychiatric diagnoses at some point in their life, and five percent of all women had been diagnosed with PTSD prior to their traumatic childbirth experience. Women with poor (OR = 15.320, CI = 8.001-29.336), or moderate (OR = 3.208, CI = 1.625-6.333) coping skills were more likely to report PP-PTSD symptoms than women with good coping skills. Low social support was significantly predictive for current PP-PTSD symptoms compared to high social support (OR = 5.557, CI = 2.967-7.785). A predictive model which could differentiate between women fulfilling vs. not fulfilling the symptom criteria for PTSD had a sensitivity of 80.8% and specificity of 62.6% with an accuracy of 66.5%. Conclusions: Low social support, poor coping, experiencing "threatened death" and experiencing "actual or threatened injury to the baby" were the four significant factors in the predictive model for women with a traumatic childbirth experience to be at risk of developing PP-PTSD. Further research should investigate the effects of interventions aimed at the prevention of PP-PTSD by strengthening coping skills and increasing social support, especially in women at increased risk of unfavorable obstetrical outcomes.

In some cases childbirth leads to negative psychological responses such as posttraumatic stress disorder (PTSD). Postpartum hemorrhage (PPH) is a common and major complication of childbirth, which occasionally requires emergency hysterectomy in severe cases. Patients often describe these complications as a traumatic experience. It is unknown whether PPH is a risk factor for developing PTSD. In this systematic review we summarize the current knowledge about the association between PPH with or without emergency hysterectomy and posttraumatic stress symptoms or PTSD. If PPH is a risk factor for PTSD, this will allow adequate preventive measures with the aim to reduce the long-term effects and socioeconomic problems associated with PTSD. To conduct this review MEDLINE, EMBASE, Web of Science, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, Cochrane Library and PsycINFO databases were searched for publications between January 1986 and October 2017. Manuscripts evaluating the association between PPH and peripartum emergency hysterectomy and PTSD or posttraumatic stress symptoms were included. Fifty-two articles met the criteria for full-text review. Seven articles were included in this review. Five studies focused on the association between PPH and PTSD and two studies evaluated the association between emergency hysterectomy and PTSD. Three studies found no association between PPH and PTSD. Two studies reported a higher risk of developing PTSD or posttraumatic stress symptoms after PPH. Two studies reported a higher risk of developing PTSD after emergency hysterectomy. Meta-analysis was not possible due to the heterogeneity of these studies. Based on the results of these studies there may be an association between PPH and PTSD. Secondly, it seems likely that an association exists between emergency postpartum hysterectomy and PTSD, but the strength of this conclusion is limited by the small amount of studies included., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Introduction: Between 9 and 44% of women experience giving birth as traumatic, and 3% of women develop a post-traumatic stress disorder following childbirth. Knowledge on risk factors is abundant, but studies on treatment are limited. This study aimed to present an overview of means to prevent traumatic birth experiences and childbirth-related post-traumatic stress disorder., Material and Methods: Major databases [Cochrane; Embase; PsycINFO; PubMed (Medline)] were searched using combinations of the key words and their synonyms., Results: After screening titles and abstracts and reading 135 full-text articles, 13 studies were included. All evaluated secondary prevention, and none primary prevention. Interventions included debriefing, structured psychological interventions, expressive writing interventions, encouraging skin-to-skin contact with healthy newborns immediately postpartum and holding or seeing the newborn after stillbirth. The large heterogeneity of study characteristics precluded pooling of data. The writing interventions to express feelings appeared to be effective in prevention. A psychological intervention including elements of exposure and psycho-education seemed to lead to fewer post-traumatic stress disorder symptoms in women who delivered via emergency cesarean section., Conclusions: No research has been done on primary prevention of traumatic childbirth. Research on secondary prevention of traumatic childbirth and post-traumatic stress disorder following delivery provides insufficient evidence that the described interventions are effective in unselected groups of women. In certain subgroups, results are inhomogeneous., (© 2018 Nordic Federation of Societies of Obstetrics and Gynecology.)

Objective: We aimed to assess the levels of endothelial cell specific molecule 1 (ESM-1) during pregnancy and preeclampsia., Methods: Plasma and placental samples were collected from women with a control pregnancy, early- or late-onset preeclamptic women and non-pregnant women (experiment 1). Plasma samples were collected between weeks 12 and birth from pregnant women at high risk for developing preeclampsia (experiment 2). ESM-1 plasma levels were measured by ELISA and in the placenta mRNA and protein were detected by immunohistochemistry and qPCR., Results: In the first experiment we observed lower concentrations of ESM-1 in pregnant women as compared to non-pregnant women and higher concentrations during early- and late-onset preeclampsia as compared to control pregnancies of the same gestational age. Early- and late-onset preeclamptic pregnancies were not different from their subsequent controls in ESM-1 mRNA or protein levels in placental tissue. The second experiment showed that in women who had an control pregnancy, plasma ESM-1 levels were decreased as compared to non-pregnant women, from week 16 ± 2 until the end of pregnancy and returned to non-pregnant levels postpartum. In women who developed early- or late-onset preeclampsia, plasma ESM-1 was also decreased as compared to non-pregnant women from week 20 ± 2 until week 28 ± 2 of pregnancy. Then ESM-1 levels increased and were no longer different from levels in non-pregnant women on weeks 32 and 36., Conclusions: Plasma ESM-1 levels are decreased during pregnancy and increased in early- and late-onset preeclampsia. The source of ESM-1 is probably not the placenta, but most likely maternal endothelial cells., (Copyright © 2018 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved.)

Background: Health care professionals who are frequently coping with traumatic events have an increased risk of developing a posttraumatic stress disorder. Research among physicians is scarce, and obstetrician-gynecologists may have a higher risk. Work-related traumatic events and posttraumatic stress disorder among obstetricians-gynecologists and the (desired) type of support were studied., Methods: A questionnaire was emailed to all members of the Dutch Society of Obstetrics and Gynaecology, which included residents, attending, retired and non-practicing obstetricians-gynecologists. The questionnaire included questions about personal experiences and opinions concerning support after work-related events, and a validated questionnaire for posttraumatic stress disorder., Results: The response rate was 42.8% with 683 questionnaires eligible for analysis. 12.6% of the respondents have experienced a work-related traumatic event, of which 11.8% met the criteria for current posttraumatic stress disorder. This revealed an estimated prevalence of 1.5% obstetricians-gynecologists with current posttraumatic stress disorder. 12% reported to have a support protocol or strategy in their hospital after adverse events. The most common strategies to cope with emotional events were: to seek support from colleagues, to seek support from family or friends, to discuss the case in a complication meeting or audit and to find distraction. 82% would prefer peer-support with direct colleagues after an adverse event., Conclusions: This survey implies that work-related events can be traumatic and subsequently can lead to posttraumatic stress disorder. There is a high prevalence rate of current posttraumatic stress disorder among obstetricians-gynecologists. Often there is no standardized support after adverse events. Most obstetrician-gynecologists prefer peer-support with direct colleagues after an adverse event. More awareness must be created during medical training and organized support must be implemented.

Introduction: The association between hypertensive pregnancy disorders and cardiovascular disease later in life is well described. In this study we aim to develop a prognostic model from patients characteristics known before, early in, during and after pregnancy to identify women at increased risk of cardiovascular disease e.g. chronic hypertension years after pregnancy complicated by hypertension at term., Methods: We included women with a history of singleton pregnancy complicated by hypertension at term. Women using antihypertensive medication before pregnancy were excluded. We measured hypertension in these women more than 2years postpartum. Different patients characteristics before, early in, during and after pregnancy were considered to develop a prognostic model of chronic hypertension at 2-years. These included amongst others maternal age, blood pressure at pregnancy intake and blood pressure six weeks post-partum. Univariable analyses followed by a multivariable logistic regression analysis was performed to determine which combination of predictors best predicted chronic hypertension. Model performance was assessed by calibration (graphical plot) and discrimination (area under the receiver operating characteristic (AUC))., Results: Of the 305 women in who blood pressure 2.5years after pregnancy was assessed, 105 women (34%) had chronic hypertension. The following patient characteristics were significant associated with chronic hypertension: higher maternal age, lower education, negative family history on hypertensive pregnancy disorders, higher BMI at booking, higher diastolic blood pressure at pregnancy intake, higher systolic blood pressure during pregnancy and higher diastolic blood pressure at six weeks post-partum. These characteristics were included in the prognostic model for chronic hypertension. Model performance was good as indicated by good calibration and good discrimination (AUC; 0.83 (95% CI 0.75 - 0.92)., Conclusion: Chronic hypertension can be expected from patient characteristics before, early in, during and after pregnancy. These data underline the importance and awareness of detectable risk factors both for increased risk of complicated pregnancy as well as increased risk of cardiovascular disease later in life., (Copyright © 2017 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved.)