Search

Objective: To assess whether postpartum hemorrhage can be predicted in women with gestational hypertension or mild preeclampsia at term., Design: A cohort study in which we used data from our multicentre randomized controlled trial (HYPITAT trial)., Setting: The study was conducted in 38 hospitals in the Netherlands between 2005 and 2008., Population: Women with gestational hypertension or mild preeclampsia at term (n = 1132)., Methods: An antepartum model (model A) and an antepartum/intrapartum model (model B) were created using logistic regression. The predictive capacity of the models was assessed with receiver operating characteristic analysis and calibration., Main Outcome Measure: Postpartum hemorrhage, defined as blood loss >1000 mL within 24 h after delivery., Results: Postpartum hemorrhage occurred in 118 (10.4%) women. Maternal age (odds ratio 1.03), prepregnancy body mass index (odds ratio 0.96), and women with preeclampsia (odds ratio 1.5) were independent antepartum prognostic variables of postpartum hemorrhage. Intrapartum variables incorporated in the model were gestational age at delivery (odds ratio 1.2), duration of dilatation stage (odds ratio 1.1), and episiotomy (odds ratio 1.5). Model A and model B showed moderate discrimination, with areas under the receiver operating characteristic curve of 0.59 (95% confidence interval 0.53-0.64) and 0.64 (95% confidence interval 0.59-0.70), respectively. Calibration was moderate for model A (Hosmer-Lemeshow p = 0.26) but better for model B (Hosmer-Lemeshow p = 0.36). The rates of postpartum hemorrhage ranged from 4% (lowest 10%) to 22% (highest 10%)., Conclusion: In the assessment of performance of a prediction model, calibration is more important than discriminative capacity. Our prediction model shows that for women with gestational hypertension or mild preeclampsia at term, distinction between low and high risk of developing postpartum hemorrhage is possible when antepartum and intrapartum variables are combined., (© 2014 Nordic Federation of Societies of Obstetrics and Gynecology.)

Study Question: Is the actual care for recurrent miscarriage in clinical practice in accordance with 23 guideline-based quality indicators?, Summary Answer: The accordance of actual care with the guidelines was poor and there is evident room for improvement., What Is Known Already: Evidence-based guidelines are important instruments to improve quality of care, but implementation of guidelines is often problematic., Study Design, Size, Duration: A retrospective cohort study was performed within a 12-month period (2006) in nine departments of Obstetrics and Gynaecology in the Netherlands., Participants, Setting, Methods: Five hundred and thirty women with recurrent miscarriage were included. Actual care was assessed with 23 guideline-based quality indicators (covering diagnostics, therapy and counselling) by calculating per indicator the percentage of women for whom the indicator was followed. Thereafter we did multilevel analyses, to relate the adherence to the indicator to determinants of women, professionals and hospitals., Main Results and the Role of Chance: Homocysteine and antiphospholipid antibodies were determined in 39 and 47%, respectively. Thrombophilia screening (54%) and karyotyping (50%) were offered to women regardless of their underlying risk for inherited thrombophilia or chromosome abnormalities. Higher maternal age at the time of presentation and a lower number of preceding miscarriages were improperly used to decide on diagnostic tests and were both associated with lower guideline adherence by professionals. Professionals with a subspecialization in recurrent miscarriage performed better standard care, i.e. screening for antiphospholipid antibodies and homocysteine, but also showed overuse of diagnostics in women at low risk of inherited thrombophilia., Limitations, Reasons for Caution: Retrospective cohort study., Wider Implications of the Findings: Quality indicators used will enable measurement of quality of care., Study Funding: The study was funded by The Netherlands Organisation for Health Research and Development (ZonMw) (Grant no. 94517005). None of the authors has any conflict of interest to declare.

Background: Caesarean section (CS) rates are rising worldwide. In the Netherlands, the most significant rise is observed in healthy women with a singleton in vertex position between 37 and 42 weeks gestation, whereas it is doubtful whether an improved outcome for the mother or her child was obtained. It can be hypothesized that evidence-based guidelines on CS are not implemented sufficiently. Therefore, the present study has the following objectives: to develop quality indicators on the decision to perform a CS based on key recommendations from national and international guidelines; to use the quality indicators in order to gain insight into actual adherence of Dutch gynaecologists to guideline recommendations on the performance of a CS; to explore barriers and facilitators that have a direct effect on guideline application regarding CS; and to develop, execute, and evaluate a strategy in order to reduce the CS incidence for a similar neonatal outcome (based on the information gathered in the second and third objectives)., Methods: An independent expert panel of Dutch gynaecologists and midwives will develop a set of quality indicators on the decision to perform a CS. These indicators will be used to measure current care in 20 hospitals with a population of 1,000 women who delivered by CS, and a random selection of 1,000 women who delivered vaginally in the same period. Furthermore, by interviewing healthcare professionals and patients, the barriers and facilitators that may influence the decision to perform a CS will be measured. Based on the results, a tailor-made implementation strategy will be developed and tested in a controlled before-and-after study in 12 hospitals (six intervention, six control hospitals) with regard to effectiveness, experiences, and costs., Discussion: This study will offer insight into the current CS care and into the hindering and facilitating factors influencing obstetrical policy on CS. Furthermore, it will allow definition of patient categories or situations in which a tailor-made implementation strategy will most likely be meaningful and cost effective, without negatively affecting the outcome for mother and child., Trial Registration: http://www.clinicaltrials.gov: NCT01261676.

Purpose and Methods: We reviewed the existing literature on medical termination of pregnancy in cases of congenital uterine malformation. Is medical termination of pregnancy safe in the presence of a uterine anomaly? Can termination of pregnancy still be performed when information concerning the presence of congenital uterine malformation is not available?, Results: The risk of adverse outcome, i.e. uterine rupture, was high in class 2 uterine anomalies, whereas the risks in classes 3-6 were negligible. However, the very low incidence of class 2 anomalies in pregnant women results in a calculated risk of uterine rupture in medical termination of pregnancy on the basis of this anomaly of 1 in 300,000 pregnancies. Ultrasound scanning is of limited diagnostic value to diagnose congenital uterine malformations., Conclusions: The implications of uterine anomalies are not an argument in the discussion whether to use misoprostol for termination of pregnancy in developing countries with scarce diagnostics tools.

Objective: To evaluate primary repaired obstetric lesions of the anal sphincter complex on anal endo-ultrasound within a few days and 8 weeks after primary repair and to investigate in this way the influence of suboptimal woundhealing on the final anatomical result. Furthermore to investigate the relation between faecal incontinence and sphincter defects., Design: A prospective cohort study. Setting The obstetric clinic and coloproctology outpatient clinic of the Zaans Medical Centre in Zaandam, the Netherlands. Subjects A cohort of 32 consecutive women with primary surgically repaired 3B, 3C or 4th degree anal sphincter defect after vaginal delivery., Main Outcome Measures: Appearance of the anal sphincter complex on anal endo-ultrasound within a few days week and 8 weeks after primary surgical repair, i.e. first and second ultrasound, respectively. Evaluation of anal continence, using the Vaizey incontinence score, at second ultrasound., Results: No major wound breakdown was seen and four women had superficial, skin related wound problems. Twenty-eight women (87.5%) had a repaired external anal sphincter on the first and the second ultrasound. Of four external anal sphincter defects on first ultrasound one defect was not present on second ultrasound. The internal sphincter showed a defect on first ultrasound in 11 women and this was still present in 10 on second ultrasound. A total of 11 women had a persisting anal sphincter defect (external, internal or in combination). Mean Vaizey scores were significantly higher in women with a persisting sphincter defect (EAS, IAS or in combination) than in women with no sphincter defects, 2.3 and 0.4 respectively (95% CI 0.1-3.6, P = 0.04)., Conclusion: Anal endo-ultrasound may be used for early evaluation of surgical repair of anal sphincter lesions after vaginal delivery. Persisting defects in the anal sphincters, in this series not because of major wound breakdown, can be explained by inadequate surgical repair.

The incidence of multiple pregnancy has increased significantly in recent years as a result of assisted reproductive therapy. The most important complication of these pregnancies remains preterm delivery. We report an extraordinary case of delayed delivery after late abortion of the first twin. Tocolysis successfully prolonged the pregnancy for more than three months, and combined with antibiotics and corticosteroids resulted in a term delivery of a second healthy sibling. A total of 37 reports that describe 145 cases of intentional delayed delivery are available. Delay of delivery may offer significant improvement in survival and outcome for the remaining fetus. Delay of delivery beyond 37 weeks is uncommon with only eight reports. A protocol for the procedure of delayed delivery of the second twin is suggested.

Background: Patients with ectopic pregnancy (EP) and low serum hCG concentrations and women with a pregnancy of unknown location (PUL) and plateauing serum hCG levels are commonly treated with systemic methotrexate (MTX). However, there is no evidence that treatment in these particular subgroups of women is necessary as many of these early EPs may resolve spontaneously. The aim of this study is whether expectant management in women with EP or PUL and with low but plateauing serum hCG concentrations is an alternative to MTX treatment in terms of treatment success, future pregnancy, health related quality of life and costs., Methods/design: A multicentre randomised controlled trial in The Netherlands. Hemodynamically stable patients with an EP visible on transvaginal ultrasound and a plateauing serum hCG concentration < 1,500 IU/L or with a persisting PUL with plateauing serum hCG concentrations < 2,000 IU/L are eligible for the trial. Patients with a viable EP, signs of tubal rupture/abdominal bleeding, or a contra-indication for MTX will not be included. Expectant management is compared with systemic MTX in a single dose intramuscular regimen (1 mg/kg) in an outpatient setting. Serum hCG levels are monitored weekly; in case of inadequately declining, systemic MTX is installed or continued. In case of hemodynamic instability and/or signs of tubal rupture, surgery is performed. The primary outcome measure is an uneventful decline of serum hCG to an undetectable level by the initial intervention. Secondary outcomes are (re)interventions (additional systemic MTX injections and/or surgery), treatment complications, health related quality of life, financial costs, and future fertility. Analysis is performed according to the intention to treat principle. Quality of life is assessed by questionnaires before and at three time points after randomisation. Costs are expressed as direct costs with data on costs and used resources in the participating centres. Fertility is assessed by questionnaires after 6, 12, 18 and 24 months. Patients' preferences will be assessed using a discrete choice experiment., Discussion: This trial will provide guidance on the present management dilemmas in women with EPs and PULs with low and plateauing serum hCG concentrations., Trial Registration: Current Controlled Trials ISRCTN 48210491.

Using a computer-stored database, birthweights and related variables over 25,000 infants born in Amsterdam (The Netherlands) were analysed retrospectively. Only after allowing for maternal height, did the difference between mean birthweights of Dutch and Asian infants disappear, whereas Negroid and Mediterranean infants continued to show respectively lower and higher means than the others. These results confirm that the birthweight standards presently used are inappropriate for detection of deviant weight in non-Dutch groups.

All 13 hospitals in the municipality of Amsterdam cooperated in this study; labor ward records for the years 1981 and 1982 were personally searched for cases of perinatal death that corresponded with the World Health Organization definitions of perinatal mortality, presently applied in The Netherlands. The 360 cases that had apparently occurred in the Amsterdam hospitals were individually linked to the cases that had been entered into the national records at the Central Bureau of Statistics. The study established that the magnitude of underregistration of perinatal mortality is considerable (14.3%). Underregistration at the national level is due to underreporting by physicians and not due to errors in statistical bookkeeping. Underreporting is related to birth weight, that is, viability of the infant, and immigrant status of the mother. Recommendations are made to improve uniformity of notification criteria and reliability of perinatal mortality statistics.