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Contains fulltext : 200189.pdf (publisher's version ) (Open Access), Background In cases of life-threatening maternal conditions in the periviable period, professionals may consider immediate delivery with fetal demise as a consequence of the treatment. We sought the opinion of involved medical professionals on management, reporting, and auditing in these cases. Methods We performed an online survey amongst all registered maternal-fetal medicine (MFM) specialists and neonatologists in the Netherlands. The survey presented two hypothetical cases of severe early-onset pre-eclampsia at periviable gestational ages. Management consisted of immediate termination or expectant management directed towards newborn survival. Findings In the case managed by immediate termination, 62% percent answered that fetal demise resulting from induction of labor for maternal indications should be audited only within the medical profession. In the case of expectant management, 17% of the participants agreed with this management. Some answers revealed a significant difference in opinion between the medical specialists. Conclusion Perspective of MFM specialists and neonatologists differs with regard to counseling prospect parents in case of severe early onset pre-eclampsia. The majority of professionals is willing to report late termination (after 24 weeks' gestation) for severe maternal disease to medical experts for internal audits but not for legal auditing.

Item does not contain fulltext, Importance: Preeclampsia with an onset before 28 weeks' gestation poses dilemmas for the obstetrician with regard to the mode of delivery. Objective: The aim of this study was to analyze the success rate of attempted vaginal delivery and the maternal and neonatal outcome according to the mode of delivery in women with preeclampsia and an indicated delivery before 28 weeks' gestation. Evidence Acquisition: A comprehensive search was performed in the bibliographic databases PubMed, Embase.com, and Wiley Cochrane Library. The main outcome was success rate of attempted vaginal delivery. Secondary outcomes were maternal and neonatal outcomes. Results: Eight studies describing a total of 800 women were included. Success rates of vaginal delivery varied from 1.8% to 80%, and rates for cesarean delivery after induction of labor varied from 13% to 51%. The rates for planned cesarean delivery varied from 0% to 73%. Two studies (n = 53) described no statistical significant differences in maternal outcomes. Two other studies (n = 107) report no statistical difference in neonatal outcome. Conclusions: Studies that report the success rate of attempted vaginal delivery are limited in size. However, giving the available evidence in the reported studies a trial of labor is a considerable option in counseling women with a pregnancy complicated by preeclampsia before 28 weeks' gestation due to the similar maternal and neonatal outcome. No differences in maternal or neonatal outcome were attributed to the mode of delivery, however, numbers are small.

Contains fulltext : 190747.pdf (publisher's version ) (Closed access)

Item does not contain fulltext, OBJECTIVE: To describe the maternal and neonatal outcomes and prolongation of pregnancies with severe early onset pre-eclampsia before 26 weeks of gestation. DESIGN: Nationwide case series. SETTING: All Dutch tertiary perinatal care centres. POPULATION: All women diagnosed with severe pre-eclampsia who delivered between 22 and 26 weeks of gestation in a tertiary perinatal care centre in the Netherlands, between 2008 and 2014. METHODS: Women were identified through computerised hospital databases. Data were collected from medical records. MAIN OUTCOME MEASURES: Maternal complications [HELLP (haemolysis, elevated liver enzyme levels, and low platelet levels) syndrome, eclampsia, pulmonary oedema, cerebrovascular incidents, hepatic capsular rupture, placenta abruption, renal failure, and maternal death], neonatal survival and complications (intraventricular haemorrhage, retinopathy of prematurity, necrotising enterocolitis, bronchopulmonary dysplasia, and sepsis), and outcome of subsequent pregnancies (recurrent pre-eclampsia, premature delivery, and neonatal survival). RESULTS: We studied 133 women, delivering 140 children. Maternal complications occurred frequently (54%). Deterioration of HELLP syndrome during expectant care occurred in 48%, after 4 days. Median prolongation was 5 days (range: 0-25 days). Neonatal survival was poor (19%), and was worse (6.6%) if the mother was admitted before 24 weeks of gestation. Complications occurred frequently among survivors (84%). After active support, neonatal survival was comparable with the survival of spontaneous premature neonates (54%). Pre-eclampsia recurred in 31%, at a mean gestational age of 32 weeks and 6 days. CONCLUSIONS: Considering the limits of prolongation, women need to be counselled carefully, weighing the high risk for maternal complications versus limited neonatal survival and/or extreme prematurity and its sequelae. The positive prospects regarding maternal and neonatal outcome in future pregnancies can s

Contains fulltext : 171635.pdf (Publisher’s version ) (Open Access), OBJECTIVE: To investigate frequency and practise of termination of pregnancy for early-onset hypertensive disorders where the fetus is considered to be non-viable. STUDY DESIGN: Retrospective cohort study in all Dutch tertiary perinatal care centres (n=10), between January 2000 and January 2014. All women who underwent termination of pregnancy, without fetal surveillance or intention to intervene for fetal reasons, for early-onset hypertensive disorders in pregnancy, were analyzed. Women eligible for this study were identified in the local delivery databases. Medical records were used to collect relevant data. RESULTS: Between January 2000 and January 2014, 2,456,584 women delivered in The Netherlands, of which 238,448 (9.7%) in a tertiary care centre. A total of 161 pregnancy terminations (11-12 per year) for severe early-onset preeclampsia were identified, including 6 women with a twin pregnancy. Mean gestational age at termination was 172 days (GA 244/7)+/-9.4 days. In 70% of cases termination was performed at or shortly after 24 weeks' gestation. 74.5% of women developed HELLP syndrome (n=96), eclampsia (n=10) or needed admission to an ICU (n=14). Birth weight was below 500g in 64% of cases. In 69% of the cases the estimated fetal weight was within a 10% margin of the actual birth weight. CONCLUSION: Termination of pregnancy for early-onset hypertensive disorders without intervention for fetal indication occurs approximately 12 times per year in The Netherlands. More data are needed to investigate contemporary best practice regarding termination of pregnancy for early-onset hypertensive indications at the limits of fetal viability. Considering the frequency of maternal complications, termination of pregnancy and not expectant management should be considered for all women presenting with severe early onset hypertensive disorders at the limits of fetal viability.

Contains fulltext : 136935.pdf (publisher's version ) (Open Access), OBJECTIVE: Maternal morbidity, either pregnancy related or pre-existent, can become life threatening and of such severity as to warrant termination of pregnancy (TOP). In this situation, chances of fetal survival are usually poor, either because of low gestational age and/or because of the fetal effects of the maternal condition. Examples include severe growth restriction in pre-eclampsia and intrauterine infection due to the very early preterm prelabour rupture of membranes. There are very few reports on the prevalence of TOP for maternal indication at the limits of fetal viability. We investigated the prevalence of and indications for TOP on maternal indication in the 10 tertiary care centres in the Netherlands during the past decade. STUDY DESIGN: We conducted a retrospective review of the medical records of all women who underwent TOP for maternal indications between 22 and 27 completed weeks of gestation in all 10 tertiary care centres from 2000 to 2009. RESULTS: During the study period, there were 1 929 470 deliveries; 163 052 (8.4%) of these took place in one of the 10 tertiary care centres and 177 pregnancies were terminated for severe maternal disease, 131 for hypertensive disorders, 29 for intrauterine infection and 17 for other reasons. The mean gestational age at TOP was 171 days (24(3/7))+/-10 days. No maternal deaths were recorded. The overall perinatal mortality was 99.4%. CONCLUSIONS: Over a 10-year period, TOP for maternal indications was performed in 1 in 1000 deliveries in the 10 Dutch tertiary care centres. Hypertensive disorders comprised three-quarters of the cases.

The current Critical Level for ammonia (CLENH3) in Europe is set at 8 µg NH3 m-3 as an annual average concentration. Recent evidence has shown specific effects of ammonia (NH3) on plant community composition (a true ecological effect) at much smaller concentrations. The methods used in setting a CLENH3 are reviewed, and the available evidence collated, in proposing a new CLENH3 for different types of vegetation. For lichens and bryophytes, we propose a new CLENH3 of 1 µg NH3 m-3 as a long-term (several year) average concentration; for higher plants, there is less evidence, but we propose a CLENH3 of 3 ± 1 µg NH3 m-3 for herbaceous species. There is insufficient evidence to provide a separate CLENH3 for forest trees, but the value of 3 ± 1 µg NH3 m-3 is likely to exceed the empirical Critical Load for N deposition for most forest ecosystems.

RIVM rapport:In het Derde Nationaal Milieubeleidsplan 3 is een evaluatie van de verzuringsdoelstelling aangekondigd. In het rapport wordt een wetenschappelijke onderbouwing van de evaluatie gegeven. Er is een overzicht gemaakt van de ontwikkeling van de emissies vanaf 1980 met een doorkijk naar 2010. Daarnaast is de stand van de wetenschappelijke kennis op een rij gezet wat betreft: *) de verspreiding, transport en depositie van verzurende stoffen den vorming van ozon en fijn stof; *) de effecten van grootschalige luchtverontreiniging op de gezondheid van mensen en schade aan planten en materialen; *) de effecten op de soortensamenstelling van terrestische en aquatische natuur en op bodem- en grondwaterkwaliteit. De belangrijkste bevindingen zijn: *) de meest recente inzichten in de effecten leiden niet tot wezenlijk andere kritische niveaus dan toen de beleidsdoelstellingen werden geformuleerd; *) de NMP3 emissiedoelstellingen voor 2010, met name NOx en NH3, vergen zeer grote beleidsmatige inspanningen, hetzelfde geldt voor de depostitiedoelstelling; *) de vermindering van de emissies heeft geleid tot een relatief groter belang van een aantal onderwerpen die eerder grof benaderd konden worden., The Third National Environmental Policy Plan announced an evaluation of the acidification policy goals for The Netherlands. This reports presents the scientific building blocks for this evaluation. An overview is given of the emission trends and the environmental quality since 1980 with an outlook up to the year 2010. Besides an assessment has been made of the state of the art on: *) the transport and depostion of acidifying compounds and the formation of ozone and particulate matter (PM10); the effects of transboundary air pollution on the health of human and the damage to plants and materials; *) the effects on the composition of species within terrestrial and aquatic ecosystems and on soil and ground water quality. The main findings are: *) the most recent scientific findings do not differ significantly from the critical loads and levels as they were when the goals were defined; *) the NOx and NH3 emission goals for the year 2010 require very large efforts, as is also the case for the depositon goals for 2010; *) the emission reduction of the last decades has enlarged the importance of some aspects that until recently could be neglected.

RIVM rapport:The Third National Environmental Policy Plan announced an evaluation of the acidification policy goals for The Netherlands. This reports presents the scientific building blocks for this evaluation. An overview is given of the emission trends and the environmental quality since 1980 with an outlook up to the year 2010. Besides an assessment has been made of the state of the art on: *) the transport and depostion of acidifying compounds and the formation of ozone and particulate matter (PM10); the effects of transboundary air pollution on the health of human and the damage to plants and materials; *) the effects on the composition of species within terrestrial and aquatic ecosystems and on soil and ground water quality. The main findings are: *) the most recent scientific findings do not differ significantly from the critical loads and levels as they were when the goals were defined; *) the NOx and NH3 emission goals for the year 2010 require very large efforts, as is also the case for the depositon goals for 2010; *) the emission reduction of the last decades has enlarged the importance of some aspects that until recently could be neglected., In het Derde Nationaal Milieubeleidsplan 3 is een evaluatie van de verzuringsdoelstelling aangekondigd. In het rapport wordt een wetenschappelijke onderbouwing van de evaluatie gegeven. Er is een overzicht gemaakt van de ontwikkeling van de emissies vanaf 1980 met een doorkijk naar 2010. Daarnaast is de stand van de wetenschappelijke kennis op een rij gezet wat betreft: *) de verspreiding, transport en depositie van verzurende stoffen den vorming van ozon en fijn stof; *) de effecten van grootschalige luchtverontreiniging op de gezondheid van mensen en schade aan planten en materialen; *) de effecten op de soortensamenstelling van terrestische en aquatische natuur en op bodem- en grondwaterkwaliteit. De belangrijkste bevindingen zijn: *) de meest recente inzichten in de effecten leiden niet tot wezenlijk andere kritische niveaus dan toen de beleidsdoelstellingen werden geformuleerd; *) de NMP3 emissiedoelstellingen voor 2010, met name NOx en NH3, vergen zeer grote beleidsmatige inspanningen, hetzelfde geldt voor de depostitiedoelstelling; *) de vermindering van de emissies heeft geleid tot een relatief groter belang van een aantal onderwerpen die eerder grof benaderd konden worden.