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Wind M, Dekker L, van den Akker-van Marle ME, Ballieux BEPB, Cobbaert CM, Rabelink TJ, van Lith JMM, Teng YKO, Sueters M. The addition of the sFlt-1/PlGF ratio to the protein/creatinine ratio in multiple pregnancy: Post-hoc analysis of the PREPARE cohort study. Pregnancy Hypertens 2024; 36:101111. [PMID: 38387424 DOI: 10.1016/j.preghy.2024.101111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/14/2024] [Accepted: 02/11/2024] [Indexed: 02/24/2024]
Abstract
OBJECTIVE To assess the predictive accuracy of the sFlt-1/PlGF ratio cut-off 38 in addition to the standard-of-care spot urine protein/creatinine ratio (PCr) for multiple pregnancies in women with suspected pre-eclampsia. STUDY DESIGN Post-hoc analysis of a prospective cohort study. MAIN OUTCOME MEASURES Primary outcome was the occurrence of pre-eclampsia in one and four weeks after presentation with suspected pre-eclampsia. Test characteristics with 95% confidence intervals (CI) were calculated on pre-eclampsia development in one and four weeks. RESULTS Twenty-three multiple pregnancies with suspected pre-eclampsia between 20 and 37 weeks gestation were included for analysis. Women who eventually developed pre-eclampsia had a significantly higher PCr (34.0 vs. 16.5, p = 0.015), sFlt-1 (17033 vs. 5270 pg/ml, p = 0.047) and sFlt-1/PlGF ratio (99 vs. 25, p = 0.033) at baseline. Furthermore, PCr ≥ 30 and sFlt-1/PlGF ratio > 38 was respectively seen in 1/16 (6.3 %) and 3/16 (18.8 %) of the women who did not develop pre-eclampsia. For predicting pre-eclampsia within one week the sFlt-1/PlGF ratio sensitivity was 75.0 % [95 % CI 19.4-99.4] and the negative predictive value 93.8 % [73.0-98.8], while no pre-eclampsia developed when PCr was < 30. Consequently, the combination of these tests did not lead to an improvement in test characteristics, with non-significant differences in positive predictive value (50.0 % [29.5-70.5] versus 80.0 % [37.3-96.4]) compared to PCr alone for pre-eclampsia development in one week. CONCLUSIONS In addition to standard-of-care spot urine PCr measurements, this study has not been able to demonstrate that the sFlt-1/PlGF ratio cut-off 38 is of added value in the prediction of pre-eclampsia in multiple pregnancy. TRIAL REGISTRATION Netherlands Trial Register (NL8308).
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Affiliation(s)
- M Wind
- Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands.
| | - L Dekker
- Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - B E P B Ballieux
- Department of Clinical Chemistry, Leiden University Medical Centre, Leiden, the Netherlands
| | - C M Cobbaert
- Department of Clinical Chemistry, Leiden University Medical Centre, Leiden, the Netherlands
| | - T J Rabelink
- Department of Nephrology, Leiden University Medical Centre, Leiden, the Netherlands
| | - J M M van Lith
- Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Y K O Teng
- Department of Nephrology, Leiden University Medical Centre, Leiden, the Netherlands
| | - M Sueters
- Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
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Rennert KN, Breuking SH, Schuit E, Bekker MN, Woiski M, de Boer MA, Sueters M, Scheepers HCJ, Franssen MTM, Pajkrt E, Mol BWJ, Kok M, Hermans FJR. Change in cervical length after arrested preterm labor and risk of preterm birth. Ultrasound Obstet Gynecol 2021; 58:750-756. [PMID: 33860985 PMCID: PMC8596619 DOI: 10.1002/uog.23653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/09/2021] [Accepted: 03/26/2021] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To assess the association between preterm birth and cervical length after arrested preterm labor in high-risk pregnant women. METHODS In this post-hoc analysis of a randomized clinical trial, transvaginal cervical length was measured in women whose contractions had ceased 48 h after admission for threatened preterm labor. At admission, women were defined as having a high risk of preterm birth based on a cervical length of < 15 mm or a cervical length of 15-30 mm with a positive fetal fibronectin test. Logistic regression analysis was used to investigate the association of cervical length measured at least 48 h after admission and of the change in cervical length between admission and at least 48 h later, with preterm birth before 34 weeks' gestation and delivery within 7 days after admission. RESULTS A total of 164 women were included in the analysis. Women whose cervical length increased between admission for threatened preterm labor and 48 h later (32%; n = 53) were found to have a lower risk of preterm birth before 34 weeks compared with women whose cervical length did not change (adjusted odds ratio (aOR), 0.24 (95% CI, 0.09-0.69)). The risk in women with a decrease in cervical length between the two timepoints was not different from that in women with no change in cervical length (aOR, 1.45 (95% CI, 0.62-3.41)). Moreover, greater absolute cervical length after 48 h was associated with a lower risk of preterm birth before 34 weeks (aOR, 0.90 (95% CI, 0.84-0.96)) and delivery within 7 days after admission (aOR, 0.91 (95% CI, 0.82-1.02)). Sensitivity analysis in women randomized to receive no intervention showed comparable results. CONCLUSION Our study suggests that the risk of preterm birth before 34 weeks is lower in women whose cervical length increases between admission for threatened preterm labor and at least 48 h later when contractions had ceased compared with women in whom cervical length does not change or decreases. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- K. N. Rennert
- Faculty of Medicine, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - S. H. Breuking
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - E. Schuit
- Julius Center for Health Sciences and Primary Care, University Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - M. N. Bekker
- Department of Obstetrics and GynaecologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - M. Woiski
- Department of Obstetrics and GynaecologyRadboud University Nijmegen Medical CenterNijmegenThe Netherlands
| | - M. A. de Boer
- Department of Obstetrics and GynaecologyAmsterdam Reproduction & Development Research Institute, Amsterdam UMC, Vrije UniversiteitAmsterdamThe Netherlands
| | - M. Sueters
- Department of Obstetrics and GynaecologyLeiden University Medical CenterLeidenThe Netherlands
| | - H. C. J. Scheepers
- Department of Obstetrics and GynaecologyMaastricht University Medical CenterMaastrichtThe Netherlands
| | - M. T. M. Franssen
- Department of ObstetricsUniversity Medical Center GroningenGroningenThe Netherlands
| | - E. Pajkrt
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - B. W. J. Mol
- Department of Obstetrics and Gynaecology, School of MedicineMonash UniversityMelbourneVictoriaAustralia
- Aberdeen Centre for Women's Health ResearchUniversity of AberdeenAberdeenUK
| | - M. Kok
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - F. J. R. Hermans
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
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Wind M, Gaasbeek AGA, Oosten LEM, Rabelink TJ, van Lith JMM, Sueters M, Teng YKO. Therapeutic plasma exchange in pregnancy: A literature review. Eur J Obstet Gynecol Reprod Biol 2021; 260:29-36. [PMID: 33713886 DOI: 10.1016/j.ejogrb.2021.02.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/24/2021] [Accepted: 02/25/2021] [Indexed: 01/13/2023]
Abstract
Therapeutic plasma exchange (TPE) is indicated as a treatment for a wide array of diseases, extensively addressed in the Guidelines of the American Society for Apheresis. In pregnancy, TPE is an uncommon event and application is largely based on extrapolation of efficacy and safety in a non-pregnant population. This review intends to describe the currently available experience of TPE in pregnancy to help clinicians recognise indications during pregnancy and to support current guideline recommendations with literature-based experiences. In order to identify the clinical indications for which TPE is applied in pregnant women, we performed a literature search including studies till November 2019, without a start date restriction. Data extraction included medical indication for TPE and safety of TPE in pregnant women. 279 studies were included for analysis. Nowadays, TPE is predominantly applied for thrombotic microangiopathies, lipid disorders and a variety of autoimmune diseases. The application of TPE during pregnancy remains largely empiric and relies on individual case reports in the absence of high-quality studies and definitive evidence-based guidelines. Safety profile of TPE during pregnancy appears to be comparable to application of TPE in non-pregnant patients. In conclusion, based on the limited evidence that we found in literature with a high risk of publication bias, TPE procedures can be used safely during pregnancy with the appropriate preparation and experience of a multidisciplinary team.
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Affiliation(s)
- M Wind
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands.
| | - A G A Gaasbeek
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
| | - L E M Oosten
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands
| | - T J Rabelink
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
| | - J M M van Lith
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - M Sueters
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Y K O Teng
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
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4
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Stegwee SI, Jordans IPM, van der Voet LF, Bongers MY, de Groot CJM, Lambalk CB, de Leeuw RA, Hehenkamp WJK, van de Ven PM, Bosmans JE, Pajkrt E, Bakkum EA, Radder CM, Hemelaar M, van Baal WM, Visser H, van Laar JOEH, van Vliet HAAM, Rijnders RJP, Sueters M, Janssen CAH, Hermes W, Feitsma AH, Kapiteijn K, Scheepers HCJ, Langenveld J, de Boer K, Coppus SFPJ, Schippers DH, Oei ALM, Kaplan M, Papatsonis DNM, de Vleeschouwer LHM, van Beek E, Bekker MN, Huisjes AJM, Meijer WJ, Deurloo KL, Boormans EMA, van Eijndhoven HWF, Huirne JAF. Single- versus double-layer closure of the caesarean (uterine) scar in the prevention of gynaecological symptoms in relation to niche development - the 2Close study: a multicentre randomised controlled trial. BMC Pregnancy Childbirth 2019; 19:85. [PMID: 30832681 PMCID: PMC6399840 DOI: 10.1186/s12884-019-2221-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 02/12/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Double-layer compared to single-layer closure of the uterus after a caesarean section (CS) leads to a thicker myometrial layer at the site of the CS scar, also called residual myometrium thickness (RMT). It possibly decreases the development of a niche, which is an interruption of the myometrium at the site of the uterine scar. Thin RMT and a niche are associated with gynaecological symptoms, obstetric complications in a subsequent pregnancy and delivery and possibly with subfertility. METHODS Women undergoing a first CS regardless of the gestational age will be asked to participate in this multicentre, double blinded randomised controlled trial (RCT). They will be randomised to single-layer closure or double-layer closure of the uterine incision. Single-layer closure (control group) is performed with a continuous running, unlocked suture, with or without endometrial saving technique. Double-layer closure (intervention group) is performed with the first layer in a continuous unlocked suture including the endometrial layer and the second layer is also continuous unlocked and imbricates the first. The primary outcome is the reported number of days with postmenstrual spotting during one menstrual cycle nine months after CS. Secondary outcomes include surgical data, ultrasound evaluation at three months, menstrual pattern, dysmenorrhea, quality of life, and sexual function at nine months. Structured transvaginal ultrasound (TVUS) evaluation is performed to assess the uterine scar and if necessary saline infusion sonohysterography (SIS) or gel instillation sonohysterography (GIS) will be added to the examination. Women and ultrasound examiners will be blinded for allocation. Reproductive outcomes at three years follow-up including fertility, mode of delivery and complications in subsequent deliveries will be studied as well. Analyses will be performed by intention to treat. 2290 women have to be randomised to show a reduction of 15% in the mean number of spotting days. Additionally, a cost-effectiveness analysis will be performed from a societal perspective. DISCUSSION This RCT will provide insight in the outcomes of single- compared to double-layer closure technique after CS, including postmenstrual spotting and subfertility in relation to niche development measured by ultrasound. TRIAL REGISTRATION Dutch Trial Register ( NTR5480 ). Registered 29 October 2015.
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Affiliation(s)
- S. I. Stegwee
- Department of Obstetrics and Gynaecology, Research institutes ‘Amsterdam Cardiovascular Sciences’ and ‘Amsterdam Reproduction and Development’, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands
| | - I. P. M. Jordans
- Department of Obstetrics and Gynaecology, Research institutes ‘Amsterdam Cardiovascular Sciences’ and ‘Amsterdam Reproduction and Development’, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands
| | - L. F. van der Voet
- Department of Obstetrics and Gynaecology, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE Deventer, the Netherlands
| | - M. Y. Bongers
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, De Run 4600, 5504 DB Veldhoven, the Netherlands
- Department of Obstetrics and Gynaecology, Research school ‘GROW’, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands
| | - C. J. M. de Groot
- Department of Obstetrics and Gynaecology, Research institutes ‘Amsterdam Cardiovascular Sciences’ and ‘Amsterdam Reproduction and Development’, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands
| | - C. B. Lambalk
- Department of Obstetrics and Gynaecology, Research institutes ‘Amsterdam Cardiovascular Sciences’ and ‘Amsterdam Reproduction and Development’, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands
| | - R. A. de Leeuw
- Department of Obstetrics and Gynaecology, Research institutes ‘Amsterdam Cardiovascular Sciences’ and ‘Amsterdam Reproduction and Development’, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands
| | - W. J. K. Hehenkamp
- Department of Obstetrics and Gynaecology, Research institutes ‘Amsterdam Cardiovascular Sciences’ and ‘Amsterdam Reproduction and Development’, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands
| | - P. M. van de Ven
- Department of Epidemiology and Biostatistics, Vrije Universiteit Amsterdam, De Boelelaan 1105, 1081 HV Amsterdam, the Netherlands
| | - J. E. Bosmans
- Department of Health sciences, Faculty of Science, Research institute ‘Amsterdam Public Health’, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, the Netherlands
| | - E. Pajkrt
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - E. A. Bakkum
- Department of Obstetrics and Gynaecology, OLVG-oost, Oosterpark 9, 1091 AC Amsterdam, the Netherlands
| | - C. M. Radder
- Department of Obstetrics and Gynaecology, OLVG-west, Jan Tooropstraat 164, 1061 AE Amsterdam, the Netherlands
| | - M. Hemelaar
- Department of Obstetrics and Gynaecology, Westfriesgasthuis, Maelsonstraat 3, 1624 NP Hoorn, the Netherlands
| | - W. M. van Baal
- Department of Obstetrics and Gynaecology, Flevo hospital, Hospitaalweg 1, 1315 RA Almere, the Netherlands
| | - H. Visser
- Department of Obstetrics and Gynaecology, Tergooi hospital, Rijksstraatweg 1, 1261 AN Blaricum, the Netherlands
| | - J. O. E. H. van Laar
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, De Run 4600, 5504 DB Veldhoven, the Netherlands
| | - H. A. A. M. van Vliet
- Department of Obstetrics and Gynaecology, Catharina hospital, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands
| | - R. J. P. Rijnders
- Department of Obstetrics and Gynaecology, Jeroen Bosch hospital, Henri Dunantstraat 1, 5223 GZ ‘s-Hertogenbosch, the Netherlands
| | - M. Sueters
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - C. A. H. Janssen
- Department of Obstetrics and Gynaecology, Groene Hart hospital, Bleulandweg 10, 2803 HH Gouda, the Netherlands
| | - W. Hermes
- Department of Obstetrics and Gynaecology, Haaglanden Medical Centre – Westeinde hospital, Lijnbaan 32, 2512 VA Den Haag, the Netherlands
| | - A. H. Feitsma
- Department of Obstetrics and Gynaecology, Haga hospital, Els-Borst-Eilersplein 275, 2545 AA Den Haag, the Netherlands
| | - K. Kapiteijn
- Department of Obstetrics and Gynaecology, Reinier de Graaf hospital, Reinier de Graafweg 5, 2625 AD Delft, the Netherlands
| | - H. C. J. Scheepers
- Department of Obstetrics and Gynaecology, Research school ‘GROW’, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands
| | - J. Langenveld
- Department of Obstetrics and Gynaecology, Zuyderland Medical Centre, Henri Dunantstraat 5, 6419 PC Heerlen, the Netherlands
| | - K. de Boer
- Department of Obstetrics and Gynaecology, Rijnstate hospital, Wagnerlaan 55, 6815 AD Arnhem, the Netherlands
| | - S. F. P. J. Coppus
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, the Netherlands
| | - D. H. Schippers
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina hospital, Weg door Jonkerbos 100, 6532 SZ Nijmegen, the Netherlands
| | - A. L. M. Oei
- Department of Obstetrics and Gynaecology, Bernhoven hospital, Nistelrodeseweg 10, 5406 PT Uden, the Netherlands
| | - M. Kaplan
- Department of Obstetrics and Gynaecology, Röpcke-Zweers hospital, Jan Weitkamplaan 4a, 7772 SE Hardenberg, the Netherlands
| | - D. N. M. Papatsonis
- Department of Obstetrics and Gynaecology, Amphia hospital, Langendijk 75, 4819 EV Breda, the Netherlands
| | - L. H. M. de Vleeschouwer
- Department of Obstetrics and Gynaecology, Sint Franciscus hospital, Kleiweg 500, 3045 PM Rotterdam, the Netherlands
| | - E. van Beek
- Department of Obstetrics and Gynaecology, Sint Antonius hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands
| | - M. N. Bekker
- Department of Obstetrics and Gynaecology, Birth Centre Wilhelmina Children hospital/University Medical Centre Utrecht, Lundlaan 6, 3584 EA Utrecht, the Netherlands
| | - A. J. M. Huisjes
- Department of Obstetrics and Gynaecology, Gelre hospital – location Apeldoorn, Albert Schweitzerlaan 31, 7334 DZ Apeldoorn, the Netherlands
| | - W. J. Meijer
- Department of Obstetrics and Gynaecology, Gelre hospital – location Zutphen, Den Elterweg 77, 7207 AE Zutphen, the Netherlands
| | - K. L. Deurloo
- Department of Obstetrics and Gynaecology, Diakonessenhuis, Bosboomstraat 1, 3582 KE Utrecht, the Netherlands
| | - E. M. A. Boormans
- Department of Obstetrics and Gynaecology, Meander Medical Centre, Maatweg 3, 3813 TZ Amersfoort, the Netherlands
| | - H. W. F. van Eijndhoven
- Department of Obstetrics and Gynaecology, Isala clinics, Dokter van Heesweg 2, 8025 AB Zwolle, the Netherlands
| | - J. A. F. Huirne
- Department of Obstetrics and Gynaecology, Research institutes ‘Amsterdam Cardiovascular Sciences’ and ‘Amsterdam Reproduction and Development’, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands
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5
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Nijman T, van Baaren GJ, van Vliet E, Kok M, Gyselaers W, Porath MM, Woiski M, de Boer MA, Bloemenkamp K, Sueters M, Franx A, Mol B, Oudijk MA. Cost effectiveness of nifedipine compared with atosiban in the treatment of threatened preterm birth (APOSTEL III trial). BJOG 2019; 126:875-883. [PMID: 30666783 DOI: 10.1111/1471-0528.15625] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess the cost-effectiveness of treatment with nifedipine compared with atosiban in women with threatened preterm birth. DESIGN An economic analysis alongside a randomised clinical trial (the APOSTEL III study). SETTING Obstetric departments of 12 tertiary hospitals and seven secondary hospitals in the Netherlands and Belgium. POPULATION Women with threatened preterm birth between 25 and 34 weeks of gestation, randomised for tocolysis with either nifedipine or atosiban. METHODS We performed an economic analysis from a societal perspective. We estimated costs from randomisation until discharge. Analyses for singleton and multiple pregnancies were performed separately. The robustness of our findings was evaluated in sensitivity analyses. MAIN OUTCOME MEASURES Mean costs and differences were calculated per woman treated with nifedipine or atosiban. Health outcomes were expressed as the prevalence of a composite of adverse perinatal outcomes. RESULTS Mean costs per patients were significantly lower in the nifedipine group [singleton pregnancies: €34,897 versus €43,376, mean difference (MD) -€8479 [95% confidence interval (CI) -€14,327 to -€2016)]; multiple pregnancies: €90,248 versus €102,292, MD -€12,044 (95% CI -€21,607 to € -1671). There was a non-significantly higher death rate in the nifedipine group. The difference in costs was mainly driven by a lower neonatal intensive care unit admission (NICU) rate in the nifedipine group. CONCLUSION Treatment with nifedipine in women with threatened preterm birth results in lower costs when compared with treatment with atosiban. However, the safety of nifedipine warrants further investigation. TWEETABLE ABSTRACT In women with threatened preterm birth, tocolysis using nifedipine results in lower costs when compared with atosiban.
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Affiliation(s)
- Taj Nijman
- Birth Centre, Division Woman and Baby, University Medical Centre Utrecht, Utrecht, the Netherlands.,Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, the Netherlands
| | - G J van Baaren
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Eog van Vliet
- Birth Centre, Division Woman and Baby, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - M Kok
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - W Gyselaers
- Department of Obstetrics and Gynecology, Ziekenhuis Oost-Limburg, Genk, Belgium.,Department of Physiology, Hasselt University, Diepenbeek, Belgium
| | - M M Porath
- Department of Obstetrics and Gynaecology, Maxima Medical Centre, Veldhoven, the Netherlands
| | - M Woiski
- Department of Obstetrics and Gynaecology, University Medical Centre Nijmegen, Nijmegen, the Netherlands
| | - M A de Boer
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Kwm Bloemenkamp
- Birth Centre, Division Woman and Baby, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - M Sueters
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, the Netherlands
| | - A Franx
- Birth Centre, Division Woman and Baby, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Bwj Mol
- Department of Obstetrics and Gynecology, School of Medicine, Monash University, Melbourne, Vic., Australia
| | - M A Oudijk
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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6
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van Klink JMM, van Steenis A, Steggerda SJ, Genova L, Sueters M, Oepkes D, Lopriore E. Single fetal demise in monochorionic pregnancies: incidence and patterns of cerebral injury. Ultrasound Obstet Gynecol 2015; 45:294-300. [PMID: 25377504 DOI: 10.1002/uog.14722] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 10/20/2014] [Accepted: 10/27/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To evaluate the incidence, type and severity of cerebral injury in the surviving monochorionic (MC) cotwin after single fetal demise in twin pregnancies. METHODS All MC pregnancies with single fetal demise that were evaluated at the Leiden University Medical Center between 2002 and 2013 were included. Perinatal characteristics, neonatal outcome and the presence of cerebral injury, observed on neuroimaging, were recorded for all cotwin survivors. RESULTS A total of 49 MC pregnancies with single fetal demise, including one MC triplet, were included in the study (n = 50 cotwins). Median gestational age at occurrence of single fetal demise was 25 weeks and median interval between single fetal demise and live birth was 61 days, with a median gestational age at birth of 36 weeks. Severe cerebral injury was diagnosed in 13 (26%) of the 50 cotwins and was detected antenatally in 4/50 (8%) and postnatally in 9/50 (18%) cases. Cerebral injury was mostly due to hypoxic-ischemic injury resulting in cystic periventricular leukomalacia, middle cerebral artery infarction or injury to basal ganglia, thalamus and/or cortex. Risk factors associated with severe cerebral injury were advanced gestational age at the occurrence of single fetal demise (odds ratio (OR), 1.14 (95% CI, 1.01-1.29) for each week of gestation; P = 0.03), twin-twin transfusion syndrome developing prior to single fetal demise (OR, 5.0 (95% CI, 1.30-19.13); P = 0.02) and a lower gestational age at birth (OR, 0.83 (95% CI, 0.69-0.99) for each week of gestation; P = 0.04). CONCLUSIONS Single fetal demise in MC pregnancies is associated with severe cerebral injury occurring in 1 in 4 surviving cotwins. Routine antenatal and postnatal neuroimaging, followed by standardized long-term follow-up, is mandatory.
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MESH Headings
- Basal Ganglia/embryology
- Basal Ganglia/injuries
- Basal Ganglia/pathology
- Diagnostic Techniques, Neurological
- Female
- Fetal Death/etiology
- Fetofetal Transfusion/embryology
- Fetofetal Transfusion/mortality
- Fetofetal Transfusion/pathology
- Gestational Age
- Humans
- Hypoxia-Ischemia, Brain/complications
- Hypoxia-Ischemia, Brain/embryology
- Hypoxia-Ischemia, Brain/mortality
- Hypoxia-Ischemia, Brain/pathology
- Incidence
- Leukomalacia, Periventricular/embryology
- Leukomalacia, Periventricular/etiology
- Leukomalacia, Periventricular/mortality
- Leukomalacia, Periventricular/pathology
- Perinatal Mortality
- Pregnancy
- Pregnancy Outcome
- Retrospective Studies
- Risk Factors
- Severity of Illness Index
- Twins, Monozygotic
- Ultrasonography, Prenatal
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Affiliation(s)
- J M M van Klink
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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7
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van Steenis A, Kromhout HE, Steggerda SJ, Sueters M, Rijken M, Oepkes D, Lopriore E. Perinatal asphyxia in monochorionic versus dichorionic twins: incidence, risk factors and outcome. Fetal Diagn Ther 2014; 35:87-91. [PMID: 24457466 DOI: 10.1159/000356433] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 10/13/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To estimate the incidence, risk factors, severity and outcome after perinatal asphyxia in monochorionic (MC) versus dichorionic (DC) twins. METHODS We included all consecutive near-term MC and DC twins with perinatal asphyxia admitted to our neonatal ward between 2004 and 2013 and compared the perinatal characteristics and neonatal outcome between both groups. RESULTS The incidence of perinatal asphyxia in MC and DC twin infants was 4.0 (11/272) and 4.0% (8/200; p = 1.00). In contrast to DC twins, asphyxia in MC twins was strongly associated with acute exsanguination and anemia at birth; 64% (7/11) in MC twins and 0% (0/8) in DC twins (p < 0.01). Median hemoglobin level at birth in the MC and DC groups was 11.5 and 18.6 g/dl, respectively (p < 0.01). CONCLUSIONS Perinatal asphyxia in MC twins is often associated with severe anemia at birth due to acute hemorrhage through the placental vascular anastomoses.
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Affiliation(s)
- A van Steenis
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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8
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Genova L, Sueters M, van Steenis A, Oepkes D, Steggerda S, Lopriore E. Renal Failure after Single Fetal Demise in Monochorionic Twins: Incidence and Description of a Case. Fetal Diagn Ther 2013; 35:302-5. [DOI: 10.1159/000354344] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 07/10/2013] [Indexed: 11/19/2022]
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9
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Gillissen A, Sueters M, van Lith J, Walther F, Lopriore E. Acute Hemorrhage in Monochorionic Twins with Ruptured Velamentous Vessels: Anemic Twin Resuscitated by Its Co-Twin through Placental Vascular Anastomoses? Fetal Diagn Ther 2013; 34:56-8. [DOI: 10.1159/000345649] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 11/05/2012] [Indexed: 11/19/2022]
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10
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Sueters M, Middeldorp JM, Lopriore E, Bökenkamp R, Oepkes D, Teunissen KA, Kanhai HHH, Le Cessie S, Vandenbussche FPHA. Fetal cardiac output in monochorionic twins. Ultrasound Obstet Gynecol 2008; 32:807-812. [PMID: 18956438 DOI: 10.1002/uog.6230] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVES To compare fetal cardiac output (CO) in donor and recipient twins of twin-twin transfusion syndrome (TTTS) pregnancies after laser therapy with that of monochorionic twins without TTTS and normal singletons. METHODS In a longitudinal, prospective study, we sonographically assessed fetal CO in donors (n = 10) and recipients (n = 10) with TTTS after fetoscopic laser therapy, in monochorionic twins without TTTS (n = 20) and in normal singleton pregnancies (n = 20). The fetal CO of TTTS twins was determined 1 day and 1 week after laser treatment, and from then on every 2-4 weeks until birth. Twins without TTTS were examined biweekly until birth. Singletons were examined twice, with an 8-week interval, at different gestational ages between 17 and 35 weeks. RESULTS Absolute CO increased exponentially with advancing gestational age (P < 0.0001), and was significantly related to fetal weight in all groups (P < 0.0001). The median CO/kg in donors after laser therapy, recipients after laser therapy and non-TTTS monochorionic twins was significantly higher than that in singletons (all P < 0.001). Median CO/kg in donors after laser therapy, recipients after laser therapy, and non-TTTS monochorionic twins was not significantly different between groups. CONCLUSIONS Monochorionic twins with TTTS have higher CO after laser therapy than normal singletons.
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Affiliation(s)
- M Sueters
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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11
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Sueters M, Middeldorp JM, Vandenbussche FPHA, Teunissen KA, Lopriore E, Kanhai HHH, Le Cessie S, Oepkes D. The effect of fetoscopic laser therapy on fetal cardiac size in twin-twin transfusion syndrome. Ultrasound Obstet Gynecol 2008; 31:158-163. [PMID: 18254146 DOI: 10.1002/uog.5246] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVES To evaluate the influence of fetoscopic laser therapy on fetal cardiac size in monochorionic twins complicated by twin-twin transfusion syndrome (TTTS). METHODS In a longitudinal, prospective study, we assessed fetal cardiac size sonographically in monochorionic diamniotic twins with TTTS treated by laser therapy and in monochorionic twins without TTTS. The fetal cardiothoracic ratio (cardiac circumference divided by thoracic circumference) of TTTS twins was determined within 24 h before, 12-24 h after and 1 week after laser treatment, and from then on every 2-4 weeks until birth. TTTS twins were classified into Quintero Stages 1-2 (n = 18) and Stages 3-4 (n = 16), and measurements were compared with biweekly measurements of non-TTTS monochorionic twins matched for gestational age (n = 38). Cardiomegaly was defined as a cardiothoracic ratio above the 97.5th percentile. RESULTS Before laser treatment, cardiomegaly was observed in 44% (8/18) and 50% (8/16) of recipients in Quintero Stages 1-2 and Stages 3-4, respectively. Cardiomegaly occurred in none of the donors before treatment. After laser treatment, cardiomegaly was observed in 76% (13/17) and 50% (7/14) of recipients in Stages 1-2 and Stages 3-4, respectively, and in 17% (3/18) and 13% (2/15) of donors in Stages 1-2 and Stages 3-4, respectively. Cardiomegaly was present in 18% (7/38) and 8% (2/25) of non-TTTS monochorionic twins and singletons. After laser therapy, the cardiothoracic ratio of recipients in Stages 1-2 and Stages 3-4 was not significantly changed (P = 0.34 and P = 0.67, respectively). The cardiothoracic ratio of donors in Stages 1-2 and Stages 3-4 was increased compared with that before laser therapy (P = 0.0002 and P = 0.005, respectively). Cardiothoracic ratios of non-TTTS monochorionic twins were not significantly different from our reference range in singletons throughout gestation, and were smaller than those in both recipients and donors after laser therapy. CONCLUSIONS TTTS recipients show cardiomegaly before as well as after fetoscopic laser therapy for TTTS. Donors develop cardiomegaly only after laser treatment. Our findings emphasize the significant effect of TTTS and fetoscopic laser therapy on the fetal heart of both recipient and donor twins.
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Affiliation(s)
- M Sueters
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands.
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12
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Middeldorp JM, Lopriore E, Sueters M, Klumper FJCM, Kanhai HHH, Vandenbussche FPHA, Oepkes D. Twin-to-twin transfusion syndrome after 26 weeks of gestation: is there a role for fetoscopic laser surgery? BJOG 2007; 114:694-8. [PMID: 17516960 DOI: 10.1111/j.1471-0528.2007.01337.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare fetoscopic laser surgery with amniodrainage in the treatment of twin-to-twin transfusion syndrome (TTTS) diagnosed after 26 weeks of gestation. DESIGN A retrospective cohort study. SETTING Leiden University Medical Centre, a tertiary referral hospital for fetal therapy. POPULATION Between January 1991 and February 2006, 21 TTTS cases were diagnosed and treated after 26 weeks of gestation. METHODS Treatment of TTTS consisted of either amniodrainage or fetoscopic laser coagulation of vascular anastomoses. MAIN OUTCOME MEASURES PRIMARY OUTCOME adverse outcome (intrauterine or neonatal death, major neonatal morbidity and/or severe cerebral injury). Secondary outcome: gestational age at birth. RESULTS Eleven TTTS cases were treated with amniodrainage and ten with laser surgery. Median gestational age at birth in the amniodrainage group and in the laser surgery group was 29 and 31 weeks, respectively (P = 0.17) All infants were born alive. Major neonatal morbidity occurred more often in the amniodrainage group than in the laser surgery group, 27% (6/22) and 0% (0/20), respectively (P = 0.02). Severe cerebral injury in the amniodrainage group and in the laser surgery group occurred in 23% (5/22) and 15% (3/20) of infants, respectively (P = 0.70). Neonatal mortality in the amniodrainage group and in the laser surgery group was 14% (3/22) and 0% (0/20), respectively (P = 0.23). Overall adverse outcome was 36% (8/22) in the amniodrainage group and 15% (3/20) in the laser surgery group (P = 0.17). CONCLUSION In TTTS diagnosed after 26 weeks of gestation, amniodrainage and laser surgery both result in 100% survival. However, infants born after laser surgery have less major neonatal morbidity.
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Affiliation(s)
- J M Middeldorp
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands.
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13
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Middeldorp JM, Sueters M, Lopriore E, Klumper FJCM, Oepkes D, Devlieger R, Kanhai HHH, Vandenbussche FPHA. Fetoscopic laser surgery in 100 pregnancies with severe twin-to-twin transfusion syndrome in the Netherlands. Fetal Diagn Ther 2007; 22:190-4. [PMID: 17228157 DOI: 10.1159/000098715] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2006] [Accepted: 05/15/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVE In this prospective cohort study, we evaluated the initial results of fetoscopic laser surgery for severe second trimester twin-to-twin transfusion syndrome (TTTS) treated at our centre. METHOD A total of 100 consecutive pregnancies with severe second trimester TTTS treated at our centre with selective fetoscopic laser coagulation of vascular anastomoses on the placental surface between August 2000 and November 2004 were included in the study. Perinatal survival was analysed in relation to Quintero stage. RESULTS Median gestational age was 20 weeks at fetoscopy (range: 16-26) and 33 weeks at delivery (range: 18-40). Perinatal survival rate was 70% (139/200). The treatment resulted in at least one survivor at the age of 4 weeks in 81% of pregnancies. Perinatal survival was significantly higher when treatment was performed in the early Quintero stages (95% in stage 1, 76% in stage 2, 70% in stage 3, 50% in stage 4) (p = 0.02). CONCLUSION Results of fetoscopic laser surgery for TTTS in our centre are similar to those in specialised centres in other countries. Diagnosis and treatment in the early Quintero stages resulted in significantly higher perinatal survival.
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Affiliation(s)
- J M Middeldorp
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands.
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14
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Sueters M, Middeldorp JM, Lopriore E, Oepkes D, Kanhai HHH, Vandenbussche FPHA. Timely diagnosis of twin-to-twin transfusion syndrome in monochorionic twin pregnancies by biweekly sonography combined with patient instruction to report onset of symptoms. Ultrasound Obstet Gynecol 2006; 28:659-64. [PMID: 16969785 DOI: 10.1002/uog.3819] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
OBJECTIVES To assess the value of serial ultrasound examinations together with patient instructions to report the onset of symptoms in achieving timely detection of twin-to-twin transfusion syndrome (TTTS) in a cohort of monochorionic diamniotic twin pregnancies, and to evaluate sonographic TTTS predictors. METHODS Timely detection of TTTS was defined as diagnosis before severe complications of TTTS occurred, such as preterm prelabor rupture of membranes, very preterm delivery (24-32 weeks of pregnancy), fetal hydrops, or intrauterine fetal death. During a 2-year period, a prospective series of 23 monochorionic twin pregnancies was monitored from the first trimester until delivery. At least every 2 weeks we performed ultrasound and Doppler measurements (nuchal translucency thickness, presence of membrane folding, estimated fetal weight, deepest vertical pocket, bladder filling, and Doppler waveforms of the umbilical artery, ductus venosus and umbilical vein). Measurements of TTTS cases were compared with those of non-TTTS cases matched for gestational age. Furthermore, patients were informed about the symptoms caused by TTTS, and instructed to consult us immediately in case of rapidly increasing abdominal size or premature contractions. RESULTS In all four TTTS cases, the diagnosis was timely. At the time of diagnosis, one case was at Quintero Stage 1, two at Quintero Stage 2, and one at Quintero Stage 3. Two of the TTTS cases became apparent after the patients' feeling of rapidly increasing girth. The identification of TTTS predictors was successful with respect to one parameter: isolated polyhydramnios in one sac, without oligohydramnios in the other, preceded the ultimate diagnosis of TTTS in two of the four TTTS cases. All other ultrasound measurements of TTTS cases, prior to the diagnosis of TTTS, were within the range of measurements of non-TTTS cases. CONCLUSION Biweekly ultrasound examinations, with special attention to the amniotic fluid compartments of both fetuses, combined with detailed patient instructions to report the onset of symptoms resulted in timely diagnosis of all TTTS cases and appears to be a safe program for monitoring monochorionic twin pregnancies.
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Affiliation(s)
- M Sueters
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
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15
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Sueters M, Arabin B, Oepkes D. Doppler sonography for predicting fetal anemia caused by massive fetomaternal hemorrhage. Ultrasound Obstet Gynecol 2003; 22:186-189. [PMID: 12905516 DOI: 10.1002/uog.190] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Fetomaternal hemorrhage (FMH) can cause severe anemia in the fetus. Untreated, this may cause hydrops or even fetal death. However, correct diagnosis of FMH followed by blood transfusion can prevent these life-threatening consequences. We describe two cases in which fetal anemia was suspected because of maternal reporting of decreased or absent fetal movements, the detection of a sinusoidal heart rate pattern and increased blood flow velocities of the middle cerebral artery and umbilical vein. Together with the Betke-Kleihauer test showing fetal cells in the maternal circulation, this led to the correct diagnosis of severe fetal anemia caused by FMH. A Cesarean section was performed within a few hours. Both neonates were severely anemic and received immediate blood transfusions. They are currently alive and well.
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Affiliation(s)
- M Sueters
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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