Considering multifetal pregnancy reduction in triplet pregnancies: do we forget the emotional impact on fathers? A qualitative study from The Netherlands

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.

Vaccination from the early second trimester onwards gives a robust SARS-CoV-2 antibody response throughout pregnancy and provides antibodies for the neonate

OBJECTIVES

Preventative measures against Coronavirus Disease 2019 (COVID-19) are essential for pregnant women; they are particularly vulnerable to emerging infectious pathogens due to alterations in their physiology. We aimed to determine the optimum timing of vaccination to protect pregnant women and their neonates from COVID-19.

METHODS

A prospective observational longitudinal cohort study in pregnant women who received COVID-19 vaccination. We collected blood samples to evaluate levels of anti-spike, receptor binding domain (RBD) and nucleocapsid antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) before vaccination, and 15 days after first and second vaccination. We determined neutralizing antibodies from mother-infant dyads in maternal and umbilical cord blood at birth. If available, IgA was measured in human milk.

RESULTS

We included 178 pregnant women. Median anti-spike IgG levels increased significantly from 1.8 to 5431 binding antibody units/milliliter (BAU/mL) and RBD from 6 to 4466 BAU/mL. Virus neutralization showed similar results between different weeks' gestations at vaccination (p > 0.3).

CONCLUSIONS

We advise vaccination in the early second trimester of pregnancy for the optimum balance between maternal antibody response and placental antibody transfer to the neonate.

The barriers and needs of transgender men in pregnancy and childbirth: A qualitative interview study

OBJECTIVE

Transgender and gender diverse individuals are individuals whose gender identity differs from their sex assigned at birth. The discordance between gender identity and sex assignment may cause significant psychological distress: gender dysphoria. Transgender individuals may choose to undergo gender-affirming hormone treatment or surgery, but some decide to (temporarily) refrain from surgery and gender affirming hormone treatment and hence retain the possibility to become pregnant. Pregnancy may enhance feelings of gender dysphoria and isolation. To improve perinatal care for transgender individuals and their health care providers, we conducted interviews to explore the needs and barriers of transgender men in family planning, pregnancy, childbirth, puerperium and perinatal care.

DESIGN

In this qualitative study five in-depth semi-structured interviews were conducted with Dutch transgender men who had given birth while identifying on the transmasculine spectrum. The interviews were conducted online through a video remote-conferencing software program (n=4) or live (n=1). Interviews were transcribed verbatim. An inductive approach was used to find patterns and collect data from the participants' narratives and constant comparative method was adapted in analysing the interviews.

MEASUREMENTS AND FINDINGS

The experiences of transgender men regarding the preconception period, pregnancy and puerperium and with perinatal care varied widely. Though all participants expressed overall positive experiences, their narratives emphasized they had to overcome substantial hurdles pursuing pregnancy. For instance the necessity to prioritise becoming pregnant over gender transitioning, lack of support by healthcare providers and increased gender dysphoria and isolation during pregnancy KEY CONCLUSIONS: Since pregnancy in transgender men enhances feelings of gender dysphoria, transgender men comprise a vulnerable group in perinatal care. Health care providers are perceived as feeling unaccustomed for the care of transgender patients, as they are perceived to often lack the right tools and knowledge to provide adequate care. Our findings help strengthen the foundation of insight in the needs and hurdles of transgender men pursuing pregnancy and therefore may guide health care providers to provide equitable perinatal care, and emphasize the necessity of patient-centred gender-inclusive perinatal care. A guideline including the option for consultation of an expertise center is advised to facilitate patient-centered gender-inclusive perinatal care.

Stress, anxiety and depression in 1466 pregnant women during and before the COVID-19 pandemic: a Dutch cohort study

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.

Feasibility study for performing uterus transplantation in the Netherlands

STUDY QUESTION

Is it feasible to perform uterus transplantations (UTx) in a tertiary centre in the Netherlands?

SUMMARY ANSWER

Considering all ethical principles, surgical risks and financial aspects, we have concluded that at this time, it is not feasible to establish the UTx procedure at our hospital.

WHAT IS KNOWN ALREADY

UTx is a promising treatment for absolute uterine factor infertility. It is currently being investigated within several clinical trials worldwide and has resulted in the live birth of 19 children so far. Most UTx procedures are performed in women with the Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, a congenital disorder characterized by absence of the uterus. In the Netherlands, the only possible option for these women for having children is adoption or surrogacy.

STUDY DESIGN SIZE DURATION

We performed a feasibility study to search for ethical, medical and financial support for performing UTx at the Amsterdam UMC, location VUmc.

PARTICIPANTS/MATERIALS SETTING METHODS

For this feasibility study, we created a special interest group, including gynaecologists, transplant surgeons, researchers and a financial advisor. Also, in collaboration with the patients' association for women with MRKH, a questionnaire study was performed to research the decision-making in possible recipients. In this paper, we present an overview of current practices and literature on UTx and discuss the results of our feasibility study.

MAIN RESULTS AND THE ROLE OF CHANCE

A high level of interest from the possible recipients became apparent from our questionnaire amongst women with MRKH. The majority (64.8%) positively considered UTx with a live donor, with 69.6% having a potential donor available. However, this 'non-life-saving transplantation' requires careful balancing of risks and benefits. The UTx procedure includes two complex surgeries and unknown consequences for the unborn child. The costs for one UTx are calculated to be around €100 000 and will not be compensated by medical insurance. The Clinical Ethics Committee places great emphasis on the principle of non-maleficence and the 'fair distribution of health services'.

LIMITATIONS REASONS FOR CAUTION

In the Netherlands, alternatives for having children are available and future collaboration with experienced foreign clinics that offer the procedure is a possibility not yet investigated.

WIDER IMPLICATIONS OF THE FINDINGS

The final assessment of this feasibility study is that that there are not enough grounds to support this procedure at our hospital at this point in time. We will closely follow the developments and will re-evaluate the feasibility in the future.

STUDY FUNDING/COMPETING INTERESTS

This feasibility study was funded by the VU Medical Center (Innovation grant 2017). No conflicts of interest have been reported relevant to the subject of all authors.

TRIAL REGISTRATION NUMBER

n.a.

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

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.

Influence of cut-off value on prevalence of short cervical length

OBJECTIVE

To assess the distribution of cervical length (CL) in a large cohort of asymptomatic low-risk women with singleton pregnancy and no previous preterm birth and to explain the low prevalence of short CL ≤ 30 mm in this cohort.

METHODS

This was a secondary analysis of a multicenter cohort study with an embedded randomized controlled trial (Triple P trial; NTR-2078) on the prevention of preterm birth with progesterone. In the cohort study, CL was measured in asymptomatic low-risk women with singleton pregnancy to investigate its predictive capacity to identify those at increased risk for preterm birth. A short CL was defined by a cut-off value of ≤ 30 mm, based on existing literature. Women with a short CL were subsequently included in a randomized controlled trial evaluating the effect of progesterone, compared with placebo, on preterm birth. In total, 57 centers and 20 234 women participated in the study. Normal distributions for CL were simulated based on the mean and SD of the original data. The distribution of CL was assessed for each individual center and measurements were compared between levels of care: primary (29 ultrasound centers), secondary (21 general hospitals) and tertiary (seven university medical centers) care institutions. Comparison was also performed between centers with low, intermediate and high volume of CL measurements. CL distributions before (n = 12 284 women) and after (n = 7950 women) a national symposium, at which the prevalence of short CL measurements was addressed publicly, were analyzed.

RESULTS

Between November 2009 and August 2013, 20 234 women had CL measurements, of whom 367 (1.8%) had a short CL. Mean ± SD CL was 44.2 ± 7.8 mm. A 'dip' in the distribution of CL measurements between 20 and 30 mm was observed, defined by a ratio of < 50% when comparing the number of measurements in observed and simulated normal distributions. The dip was present in 89% of participating centers. All centers showed a dip in the distribution of measurements ≤ 30 mm when analyzed according to the level of care and volume of measurements. A significant difference was found when comparing the distribution before and after publicly addressing the low prevalence of short CL (1.7% vs 2.0% of measurements were ≤ 30 mm, respectively; P < 0.001).

CONCLUSIONS

A cut-off value of 30 mm for CL was used to include women in a randomized clinical trial that was embedded in a cohort study. We suggest that the use of a predefined cut-off value for a short cervix influences the distribution of the CL measurements. Since the measurement is not blinded, preference of assessors for the control or intervention arms may have introduced selection bias. This might have resulted in fewer measurements around the cut-off value. Other trials using similar designs could benefit from this observation and take precautions to avoid selection bias. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Prenatal diagnosis of congenital heart defects: accuracy and discrepancies in a multicenter cohort

OBJECTIVE

To examine the accuracy of fetal echocardiography in diagnosing congenital heart disease (CHD) at the fetal medicine units of three tertiary care centers.

METHODS

This was a multicenter cohort study of tertiary echocardiography referrals between 2002 and 2012. Prenatal and postnatal diagnoses were compared and the degree of agreement was classified as 'correct' (anatomy correct and the postnatal diagnosis led to a similar outcome as expected), 'discrepant' (anatomical discrepancies present but the severity and prognosis of the defect were diagnosed correctly) or 'no similarity' (the pre- and postnatal diagnoses differed completely).

RESULTS

We included 708 cases with CHD for which both prenatal and postnatal data were available. The prenatal diagnosis was correct in 82.1% of cases and discrepancies present were present in 9.9%; however, these did not result in a different outcome. In 8.1% there was no similarity between prenatal and postnatal diagnoses. Disagreement between pre- and postnatal diagnoses occurred significantly more frequently in cases that presented with a normal four-chamber view than in those with an abnormal four-chamber view (5.5% vs 1.9%). Incorrect identification of the outflow tracts and incorrect differentiation between unbalanced atrioventricular septal defect and hypoplastic left heart syndrome were relatively commonly encountered. In many cases with disagreement, trisomy 21, extracardiac anomaly or a high maternal body mass index was present.

CONCLUSIONS

The prenatal diagnosis and estimated prognosis of fetal echocardiography in our tertiary referral centers were appropriate in 92% of cases. Some types of CHD remain difficult to diagnose or rule-out prenatally, therefore awareness and education are of considerable importance. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Midpregnancy Cervical Length in Nulliparous Women and its Association with Postterm Delivery and Intrapartum Cesarean Delivery

OBJECTIVE

To evaluate the association between midpregnancy cervical length and postterm delivery and cesarean delivery during labor.

STUDY DESIGN

In a multicenter cohort study, cervical length was measured in low-risk singleton pregnancies between 16 and 22 weeks of gestation. From this cohort, we identified nulliparous women who delivered beyond 34 weeks and calculated cervical length quartiles. We performed logistic regression to compare the risk of postterm delivery and intrapartum cesarean delivery to cervical length quartiles, using the lowest quartile as a reference. We adjusted for induction of labor, maternal age, ethnicity, cephalic position, preexisting hypertension, and gestational age at delivery.

RESULTS

We studied 5,321 nulliparous women. Women with cervical length in the 3rd and 4th quartile were more likely to deliver at 42(+0) to 42(+6) weeks (adjusted odds ratio [aOR] 2.02, 95% confidence interval [CI] 1.07-3.79 and aOR 1.97, 95% CI 1.06-3.67, respectively). The frequency of intrapartum cesarean delivery increased with cervical length quartile from 9.4% in the 1st to 14.9% in the 4th quartile (p = 0.01). This increase was only present in intrapartum cesarean delivery because of failure to progress and not because of fetal distress.

CONCLUSION

The longer the cervix at midtrimester the higher the risk of both postterm delivery and intrapartum cesarean delivery.

Second-trimester cervical length as risk indicator for Cesarean delivery in women with twin pregnancy

OBJECTIVE

To determine whether second-trimester cervical length (CL) in women with a twin pregnancy is associated with the risk of emergency Cesarean section.

METHODS

This was a secondary analysis of two randomized trials conducted in 57 hospitals in The Netherlands. We assessed the univariable association between risk indicators, including second-trimester CL in quartiles, and emergency Cesarean delivery using a logistic regression model. For multivariable analysis, we assessed whether adjustment for other risk indicators altered the associations found in univariable (unadjusted) analysis. Separate analyses were performed for suspected fetal distress and failure to progress in labor as indications for Cesarean section.

RESULTS

In total, 311 women with a twin pregnancy attempted vaginal delivery after 34 weeks' gestation. Emergency Cesarean delivery was performed in 111 (36%) women, of which 67 (60%) were performed owing to arrest of labor. There was no relationship between second-trimester CL and Cesarean delivery (adjusted odds ratio (aOR): 0.97 for CL 26(th) -50(th) percentiles; 0.71 for CL 51(st)  - 75(th) percentiles; and 0.92 for CL > 75(th) percentile, using CL ≤ 25(th) percentile as reference). In multivariable analysis, the only variables associated with emergency Cesarean delivery were maternal age (aOR, 1.07 (95% CI, 1.00-1.13)), body mass index (BMI) (aOR, 3.99 (95% CI, 1.07-14.9) for BMI 20-23 kg/m(2) ; 5.04 (95% CI, 1.34-19.03) for BMI 24-28 kg/m(2) ; and 3.1 (95% CI, 0.65-14.78) for BMI > 28 kg/m(2) ) and induction of labor (aOR, 1.92 (95% CI, 1.05-3.5)).

CONCLUSION

In nulliparous women with a twin pregnancy, second-trimester CL is not associated with risk of emergency Cesarean delivery.

Effect of e-learning on quality of cervical-length measurements

OBJECTIVES

To assess the effect of implementation of a newly developed e-learning module on the quality of cervical-length measurements.

METHODS

With the introduction of cervical-length (CL) measurement in a research setting, a CL measurement e-learning module (CLEM) was developed with the purpose to enhance the knowledge and skills of experienced ultrasonographers. CLEM was designed specifically for ultrasonographers who perform ultrasound in a general obstetrical practice but who do not regularly perform CL measurements. CLEM consists of five theoretical questions and three caliper-placement tests to learn the CL measurement technique. The quality of the CL measurements of CLEM participants was compared with images of non-participants using a CL measurement image score (CIS), defined as the sum of six items which assess the quality of the image. Each CLEM participant submitted five CL images and the images of non-CLEM participants were selected randomly from an ultrasound database.

RESULTS

The CIS of the CLEM participants (n = 61) were significantly higher than those of non-CLEM participants (n = 23) (164.9 vs 155.6, respectively; P = 0.03). Visualization of the internal os and positioning of the calipers on the internal and external ora were found to have significantly higher CIS among the CLEM participants than among the non-CLEM participants (P = 0.001 and P < 0.001, respectively).

CONCLUSIONS

Introducing CLEM may improve the quality of CL measurements obtained by trained and untrained sonographers.

Pregnancy outcome after fetal reduction in women with a dichorionic twin pregnancy

STUDY QUESTION

What are the pregnancy outcomes for women with a twin pregnancy that is reduced to a singleton pregnancy?

SUMMARY ANSWER

Fetal reduction of a twin pregnancy significantly improves gestational age at birth and neonatal birthweight, however at an increased risk of pregnancy loss and preterm delivery.

WHAT IS KNOWN ALREADY

Women with a multiple pregnancy are at increased risk for preterm delivery. Fetal reduction can be considered in these women.

STUDY DESIGN, SIZE, AND DURATION

Retrospective cohort study of 118 women with a twin pregnancy reduced to a singleton pregnancy between 2000 and 2010.

PARTICIPANTS/MATERIALS, SETTING, AND METHODS

We compared the outcome of pregnancy in consecutive women with a dichorionic twin pregnancy that was reduced to a singleton pregnancy to that of women with a dichorionic twin pregnancy that was managed expectantly and women with a primary singleton pregnancy. Reductions were performed between 10-23(6/7) weeks' gestation by intracardiac or intrathoracic injection of potassium chloride, mostly for congenital anomalies. We compared median gestational age, pregnancy loss <24 weeks, preterm delivery <32 weeks, neonatal birthweight and perinatal deaths.

MAIN RESULTS AND THE ROLE OF CHANCE

We studied 118 women with a twin pregnancy that was reduced to a singleton, 818 women with an ongoing dichorionic twin pregnancy and 611 women with a primary singleton pregnancy. Loss of the entire pregnancy <24 weeks and preterm delivery occurred significantly more in the reduction group compared with the ongoing twin group (11.9 versus 3.1% <24 weeks, P< 0.001 and 18.6 versus 11.5% <32 weeks, respectively, P < 0.001). In the reduction group, the percentage of women without any surviving child was significantly higher compared with the ongoing twin and primary singleton group (14.4, 3.4 and 0.7%, respectively, P < 0.001). Median gestational age was 38.9 weeks (interquartile range (IQR) 34.7-40.3) for reduced pregnancies, 37.1 weeks (IQR 35.3-38.1) for ongoing twin pregnancies and 40.1 (IQR 39.1-40.9) for primary singletons (P < 0.001 for all comparisons).

LIMITATIONS, REASONS FOR CAUTION

The main limitations of the study were its retrospective character, and the fact that indications for reduction were heterogeneous.

WIDER IMPLICATIONS OF THE FINDINGS

In women with a dichorionic twin pregnancy fetal reduction increases median gestational age only at considerable risk of complete early pregnancy loss.

STUDY FUNDING/COMPETING INTERESTS

The study was not funded. None of the authors has conflicts of interest.

Reproductive outcomes of women and men born very preterm and/or with a very low birth weight in 1983: a longitudinal cohort study in the Netherlands

The aims of this study were to analyze reproductive outcomes of women and men born very preterm (gestational age <32 weeks) or with a very low birth weight (<1500 g) in 1983 in the Netherlands and to compare their reproductive outcomes with the total population at a similar age of 28 years. Young adults who were born after a pregnancy complicated by very preterm (VP) delivery or with a very low birth weight (VLBW) in the Netherlands in 1983 (Project on Preterm and Small for Gestational Age Infants (POPS) cohort) were invited to complete an online questionnaire at the age of 28. In total, 293 POPS-28 participants (31.6%) completed the questionnaire including 185 female and 108 male participants. Female and male participants who were born VP or with a VLBW had significant reduced reproductive rates compared to the total Dutch population at 28 years of age (female 23.2 vs 31.9% and male 7.4 vs 22.2%). Pregnancies of the female participants were in 14% complicated by preterm delivery in at least one pregnancy.

CONCLUSION

This study indicates that women and men born VP or with a VLBW have reduced reproductive rates at the age of 28 compared to the total Dutch population at a similar age.

Trial of labor after cesarean: attempted operative vaginal delivery versus emergency repeat cesarean, a prospective national cohort study

OBJECTIVE

To compare neonatal and maternal outcomes of attempted operative vaginal delivery with emergency repeat cesarean in trial of labor after cesarean.

STUDY DESIGN

Prospective 8-year cohort analysis using the Netherlands Perinatal Registry, including women with one prior cesarean giving birth through operative vaginal delivery or emergency repeat cesarean (n=12860). A multivariate analysis was performed. Odds ratios (OR) and adjusted odds ratios (aOR) were calculated.

RESULTS

Attempted operative vaginal delivery increases the risk on neonatal birth trauma (aOR 15.0 (5.94 to 38.0)) and postpartum hemorrhage (aOR 2.59 (2.17 to 3.09)), and lowers the risk of wet lung syndrome (aOR 0.53 (0.35 to 0.80)) and neonatal convulsions (aOR 0.47 (0.24 to 0.91)).

CONCLUSION

We found a highly increased risk of neonatal birth trauma and a moderately increased risk of postpartum hemorrhage but slightly lower risks of wet lung syndrome and neonatal convulsions after attempted operative vaginal delivery compared with emergency repeat cesarean.

Prenatal detection of transposition of the great arteries reduces mortality and morbidity

OBJECTIVES

To evaluate the prenatal detection of transposition of the great arteries (TGA), after the introduction of a Dutch screening program in 2007, as well as the effect of prenatal detection on pre- and postsurgical mortality and morbidity.

METHODS

In a geographical cohort study, all infants with TGA who were born between 1 January 2002 and 1 January 2012 were included. The cases were divided into two groups: those with and those without a prenatal diagnosis. Pre- and postsurgical mortality was assessed, with a follow-up of 1 year. Presurgical morbidity was assessed in terms of cardiovascular compromise, metabolic acidosis, renal and/or hepatic dysfunction and closure of the duct before initiation of therapy.

RESULTS

Of all cases (n = 144), 26.4% were diagnosed prenatally, with detection rates of 15.7% and 41.0% in the first and last 5 years of the study period, respectively. First-year mortality was significantly lower in cases with a prenatal diagnosis of TGA than in those without (0.0% vs 11.4%, respectively). Presurgical mortality (4.9%) only occurred in undetected simple TGA cases. Closure of the duct before treatment, renal dysfunction and hypoxia occurred significantly more often in the group without a prenatal diagnosis.

CONCLUSIONS

The prenatal detection rate of TGA has increased significantly since the introduction of the screening program in 2007. Prenatal diagnosis is an important factor that contributes to survival of the infant in the first postnatal year. Furthermore, some morbidity indicators were significantly higher in the group without a prenatal diagnosis. These results justify efforts to improve prenatal screening programs.

Is cervical length associated with maternal characteristics?

OBJECTIVE

Women with a mid-trimester short cervical length (CL) are at increased risk for preterm delivery. Consequently, CL measurement is a potential screening tool to identify women at risk for preterm birth. Our objective was to assess possible associations between CL and maternal characteristics.

STUDY DESIGN

A nationwide screening study was performed in which CL was measured during the standard anomaly scan among low risk women with a singleton pregnancy. Data on maternal height, pre-pregnancy weight, ethnicity, parity and gestational age at the time of the CL measurement were collected from January 2010 to December 2012. Univariable and multivariable linear regression analyses were performed to assess the relationship between CL and maternal characteristics.

RESULTS

We included 5092 women. The mean CL was 44.3mm. No association was found between CL and maternal height or gestational age of the measurement. Maternal weight was associated with CL (p=0.007, adjusted R(2) 0.03). Separate analysis for BMI did not change these results. Ethnicity, known in 2702 out of 5092 women, was associated with CL (mean CL in Caucasian women 45.0mm, Asian 43.9mm, Mediterranean 43.1mm, and African 41.8mm, p=0.003), as well as parity (mean CL multiparous 45.3mm, nulliparous 43.5mm, p<0.0001).

CONCLUSION

Shorter mid-trimester cervical length is associated with higher maternal weight, younger maternal age, nulliparity and non-Caucasian ethnicity, but not with maternal height.

Optimal timing of delivery in small for gestational age fetuses near term: a national cohort study

OBJECTIVE

Our aim was to study the competing risks of antepartum versus intrapartum/neonatal death in small for gestational age (SGA) and non-SGA fetuses.

STUDY DESIGN

We performed a national cohort study using all singletons delivered between 36 and 42(6/7) weeks without hypertension, preeclampsia, diabetes, congenital anomalies, or noncephalic presentation from the Netherlands Perinatal Registry (1999-2007). The resultant cohort was divided in three groups based on birth weight by gestational age (SGA < P5 group, 61,021 deliveries; SGA P5-10 group, 58,902 deliveries; non-SGA group 1,168,523 deliveries). We compared the mortality risk of delivery with expectant management.

RESULTS

Delivery was associated with more mortality than expectant management for 1 week from 39 weeks onward in the non-SGA group (relative risk [RR], 1.26; 95% confidence interval [CI], 1.05-1.50). For the SGA < P5, expectant management for 1 more week was associated with more mortality from 38 weeks onward although this only reached statistical significance from 40 weeks onward (RR, 2.46; 95% CI, 1.80-3.36).

CONCLUSION

At 36 and 37 weeks, delivery is associated with a higher risk of mortality in SGA < P5 fetuses than expectant management. Delivery of SGA < P5 fetuses at 38 and 39 weeks is associated with the best perinatal outcome whereas for non-SGA fetuses this is at 39 to 40 weeks.

Prenatal detection of congenital heart disease--results of a national screening programme

OBJECTIVE

Congenital heart disease (CHD) is the most common congenital malformation and causes major morbidity and mortality. Prenatal detection improves the neonatal condition before surgery, resulting in less morbidity and mortality. In the Netherlands a national prenatal screening programme was introduced in 2007. This study evaluates the effects of this screening programme.

DESIGN

Geographical cohort study.

SETTING

Large referral region of three tertiary care centres.

POPULATION

Fetuses and infants diagnosed with severe CHD born between 1 January 2002 and 1 January 2012.

METHODS

Cases were divided into two groups: before and after the introduction of screening.

MAIN OUTCOME MEASURES

Detection rates were calculated.

RESULTS

The prenatal detection rate (n = 1912) increased with 23.9% (95% confidence interval [95% CI] 19.5-28.3) from 35.8 to 59.7% after the introduction of screening and of isolated CHD with 21.4% (95% CI 16.0-26.8) from 22.8 to 44.2%. The highest detection rates were found in the hypoplastic left heart syndrome, other univentricular defects and complex defects with atrial isomerism (>93%). Since the introduction of screening, the 'late' referrals (after 24 weeks of gestation) decreased by 24.3% (95% CI 19.3-29.3).

CONCLUSIONS

This is the largest cohort study to investigate the prenatal detection rate of severe CHD in an unselected population. A nationally organised screening has resulted in a remarkably high detection rate of CHD (59.7%) compared with earlier literature.

The influence of vitamin D on postpartum relapse and quality of life in pregnant multiple sclerosis patients

BACKGROUND AND PURPOSE

In relapsing-remitting MS patients, lower serum vitamin D concentrations are associated with higher relapse risk. In a number of conditions, low vitamin D has been associated with fatigue. Pregnant women are at particular risk for vitamin D insufficiency. Our objective was to investigate whether vitamin D status is associated with postpartum relapse and quality of life during pregnancy.

METHODS

Forty-three pregnant relapsing-remitting MS patients and 21 pregnant controls were seen at regular times before, during and after pregnancy. At every clinical assessment visit, samples for 25-hydroxyvitamin D (25(OH)D) measurements and quality of life questionnaires were taken.

RESULTS

Lower 25(OH)D concentrations were not associated with postpartum relapse risk. Pregnancy 25(OH)D levels of patients and controls were not significantly different. In controls, but not patients, higher 25(OH)D concentrations were correlated with better general health, social functioning and mental health, but not with vitality.

CONCLUSION

Low vitamin D levels are not associated with postpartum relapse. In pregnant MS patients, vitamin D levels are similar to levels in healthy women and are not associated with quality of life. Therefore, with regard to quality of life and postpartum relapse, no arguments were found for advising pregnant MS patients to take more vitamin D supplements than healthy women.

Termination of pregnancy for maternal indications at the limits of fetal viability: a retrospective cohort study in the Dutch tertiary care centres

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.

Association between weight gain during pregnancy and pregnancy outcomes after dietary and lifestyle interventions: a meta-analysis

OBJECTIVES

Lifestyle interventions in obese pregnant women reduce adverse maternal outcomes of pregnancy. However, the association between weight change due to interventions and the actual reduction in complications is unknown. The objective of this study was to determine the association between gestational weight gain (GWG) and the rate of pregnancy complications.

STUDY DESIGN

The authors included randomized controlled trials (RCTs) assessing the effect of lifestyle interventions during pregnancy on GWG and adverse maternal and fetal outcomes. For each outcome they assessed the association between GWG and the risk of adverse pregnancy outcomes.

RESULTS

They analyzed data of 23 RCTs (4,990 women). Increased GWG was associated with a nonsignificant increase in the incidence of preeclampsia (PE) (0.2% per gained kg, 95% confidence interval [CI] 0.5 to 0.9%, p > 0.05), gestational diabetes (GDM) (0.3% per gained kg, 95% CI -0.5 to 1.0%, p > 0.05), and induction of labor (IOL) (1.5% per gained kg, 95% CI -0.9 to 3.9%, p > 0.05).

CONCLUSIONS

Reduction in GWG due to lifestyle interventions in pregnancy had statistically nonsignificant effects on lowering the incidence of PE, GDM, and IOL. Possibly, the beneficial effect of lifestyle interventions on pregnancy outcomes is due to an effect independent of the reduction of GWG.

High blood pressure six weeks postpartum after hypertensive pregnancy disorders at term is associated with chronic hypertension

OBJECTIVES

Hypertension in pregnancy is associated with cardiovascular disease (CVD) later in life. Blood pressure monitoring in women who experienced hypertension in pregnancy after puerperium has been suggested to be important for early detection and prevention of CVD. The aim of this study is to evaluate if hypertension six weeks postpartum is associated with chronic hypertension in women with a history of term hypertensive pregnancy disorders.

STUDY DESIGN

Women with a history of term gestational hypertension or preeclampsia were included in a follow up study of the HYPITAT trial. Blood pressures were measured six weeks and 2.5years postpartum according to the study protocol.

MAIN OUTCOME MEASURES

Hypertension was defined as a diastolic blood pressure ⩾90mmHg and/or a systolic blood pressure ⩾140mmHg or use of antihypertensive medication. Differences in categorical variables between groups were analyzed by Chi-Square tests. Blood pressure was analyzed using unpaired t-tests and Wilcox ranked tests.

RESULTS

Among 187 women who had term hypertensive pregnancy disorders, 75 (40%) had hypertension at six weeks postpartum. Of these 46 (61%) had hypertension 2.5years postpartum. In contrast, of 112 women without hypertension at six weeks postpartum, 36 (32%) had hypertension 2.5years (OR 3.3, 95% CI 1.8-6.2).

CONCLUSION

Among 61% of women who had hypertensive pregnancy disorders at term, high blood pressure at six weeks postpartum indicated chronic hypertension. This warrants the importance of identification of hypertension 6weeks postpartum for women's future health.

Should cervical favourability play a role in the decision for labour induction in gestational hypertension or mild pre-eclampsia at term? An exploratory analysis of the HYPITAT trial

OBJECTIVE

To examine whether cervical favourability (measured by cervical length and the Bishop score) should inform obstetricians' decision regarding labour induction for women with gestational hypertension or mild pre-eclampsia at term.

DESIGN

A post hoc analysis of the Hypertension and Pre-eclampsia Intervention Trial At Term (HYPITAT).

SETTING

Obstetric departments of six university and 32 teaching and district hospitals in the Netherlands.

POPULATION

A total of 756 women diagnosed with gestational hypertension or pre-eclampsia between 36 + 0 and 41 + 0 weeks of gestation randomly allocated to induction of labour or expectant management.

METHODS

Data were analysed using logistic regression modelling.

MAIN OUTCOME MEASURES

The occurrence of a high-risk maternal situation defined as either maternal complications or progression to severe disease. Secondary outcomes were caesarean delivery and adverse neonatal outcomes.

RESULTS

The superiority of labour induction in preventing high-risk situations in women with gestational hypertension or mild pre-eclampsia at term varied significantly according to cervical favourability. In women who were managed expectantly, the longer the cervix the higher the risk of developing maternal high-risk situations, whereas in women in whom labour was induced, cervical length was not associated with a higher probability of maternal high-risk situations (test of interaction P = 0.03). Similarly, the beneficial effect of labour induction on reducing the caesarean section rate was stronger in women with an unfavourable cervix.

CONCLUSION

Against widely held opinion, our exploratory analysis showed that women with gestational hypertension or mild pre-eclampsia at term who have an unfavourable cervix benefited more from labour induction than other women.

TRIAL REGISTRATION

The trial has been registered in the clinical trial register as ISRCTN08132825.

Explaining ethnic differences in late antenatal care entry by predisposing, enabling and need factors in The Netherlands. The Generation R Study

Despite compulsory health insurance in Europe, ethnic differences in access to health care exist. The objective of this study is to investigate how ethnic differences between Dutch and non-Dutch women with respect to late entry into antenatal care provided by community midwifes can be explained by need, predisposing and enabling factors. Data were obtained from the Generation R Study. The Generation R Study is a multi-ethnic population-based prospective cohort study conducted in the city of Rotterdam. In total, 2,093 pregnant women with a Dutch, Moroccan, Turkish, Cape Verdean, Antillean, Surinamese Creole and Surinamese Hindustani background were included in this study. We examined whether ethnic differences in late antenatal care entry could be explained by need, predisposing and enabling factors. Subsequently, logistic regression analysis was used to assess the independent role of explanatory variables in the timing of antenatal care entry. The main outcome measure was late entry into antenatal care (gestational age at first visit after 14 weeks). With the exception of Surinamese-Hindustani women, the percentage of mothers entering antenatal care late was higher in all non-Dutch compared to Dutch mothers. We could explain differences between Turkish (OR = 0.95, CI: 0.57–1.58), Cape Verdean (OR = 1.65. CI: 0.96–2.82) and Dutch women. Other differences diminished but remained significant (Moroccan: OR = 1,74, CI: 1.07–2.85; Dutch Antillean OR 1.80, CI: 1.04–3.13). We found that non-Dutch mothers were more likely to enter antenatal care later than Dutch mothers. Because we are unable to explain fully the differences regarding Moroccan, Surinamese-Creole and Antillean women, future research should focus on differences between 1st and 2nd generation migrants, as well as on language barriers that may hinder access to adequate information about the Dutch obstetric system.

Body composition by dual-energy X-ray absorptiometry in women with previous pre-eclampsia or small-for-gestational-age offspring

OBJECTIVE

To investigate differences in body composition and fat distribution between women with previous pre-eclampsia or small-for-gestational-age (SGA) offspring and those with uncomplicated pregnancies.

DESIGN

Cohort study.

SETTING

Population-based study in a genetically isolated population in the southwest of the Netherlands.

POPULATION

Women after pregnancies complicated by pre-eclampsia (n=45), SGA offspring (n=53) and uncomplicated pregnancies (n=106).

METHODS

Women were compared for body composition and fat distribution variables, assessed by dual-energy X-ray absorptiometry (DXA) and anthropometrics at a mean follow-up time of 10.8 (SD +/- 5.9) years after pregnancy.

MAIN OUTCOME MEASURES

Total lean and fat mass, android fat mass, gynoid fat mass, android-to-gynoid fat ratio, waist and hip circumference, waist-to-hip ratio.

RESULTS

Women with previous pre-eclampsia compared with controls had higher mean total fat mass index (11.5 +/- 0.6 versus 9.7 +/- 0.4 kg/m(2); P = 0.03), lean mass index (15.8 +/- 0.3 versus 14.5 +/- 0.2 kg/m(2); P =0.001) and body mass index ([BMI]; 28.4 +/- 0.8 versus 25.4 +/- 0.5 kg/m(2); P = 0.005). Their waist circumferences (90.7 +/- 2.0 versus 78.5 +/- 1.3 cm; P < 0.001) and waist-to-hip ratios (0.86 +/- 0.01 versus 0.77 +/- 0.01; P < 0.001) were also higher as well as android fat mass (2.8 +/- 0.2 versus 2.1 +/- 0.1 kg; P = 0.01) and android-to-gynoid fat ratios (0.45 +/- 0.02 versus 0.39 +/- 0.01; P = 0.02). Mean total fat, lean and BMI was not significantly different between women with previous SGA offspring and controls, yet waist-to-hip ratios (0.83 +/- 0.01; P < 0.001) were higher. The observed differences in waist and hip circumference, waist-to-hip ratio and gynoid fat mass could not be attributed to differences in BMI.

CONCLUSION

Women with previous pre-eclampsia or SGA offspring pregnancies compared with those with uncomplicated pregnancies have a preferential fat accumulation in the abdominal over hip region, which may explain, at least partly, their increased cardiovascular risk.

[Acute abdominal pain in the third trimester of pregnancy caused by adnexal torsion based on a small cystic adenoma]

A 25-year-old woman presented in the third trimester of pregnancy with severe abdominal pain in the lower right abdominal quadrant. Differential diagnosis included urolithiasis, adnexal torsion and appendicitis. A definitive diagnosis could not be made based on clinical and laboratory examination. Ultrasonography revealed a 3-cm cyst in the lower right abdomen, which was considered unlikely to cause abdominal pain. During laparotomy, adnexal torsion was found, which was deemed to be the cause of the abdominal pain. The twisted portion was uncoiled and the dark-coloured cyst was extirpated. The cyst was determined to be a cystic adenoma. Adnexal torsion is rarely caused by cysts smaller than 5 cm, especially in the third trimester. Emergency laparoscopyllaparotomy should be performed if adnexal torsion is suspected to confirm the diagnosis and uncoil the twist to prevent ovarian damage. Adnexal torsion should be considered in the differential diagnosis of acute abdominal pain in the third trimester of pregnancy.

STOX1 gene in pre-eclampsia and intrauterine growth restriction

The STOX1 gene, identified as a candidate gene for pre-eclampsia in Dutch women, is placentally expressed and subject to imprinting with preferential transmission of the maternal allele. In our study, STOX1-Y153H frequencies were similar in 157 women with pre-eclampsia (65%) and in 157 controls (64%) from the general Dutch population. In an isolated Dutch population, a distortion could not be demonstrated in the transmission of STOX1-Y153H variation from heterozygous mothers to offspring in 50 and 56 families with pregnancies complicated by pre-eclampsia or intrauterine growth restriction, respectively. Our findings do not confirm previous suggestions that STOX1 plays a major role in Dutch women with pre-eclampsia.

[Pregnancy and the mechanical prosthetic valve: dilemmas about the choice of antithrombotic prophylaxis]

Two pregnant women aged 32 and 34, both of whom had mechanical prosthetic mitral valves, for which they were using low molecular weight heparin. One developed orthopnoea and dyspnoea at 36 weeks amenorrhoea, and the other suffered an acute myocardial infarction at 18 weeks. Both had valvular thrombosis. Following effective treatment, both women delivered at term and one week later after an uncomplicated course, were discharged home from hospital. Clinicians caring for pregnantwomen with mechanical prosthetic valves are faced with a dilemma when trying to provide optimal treatment. Inadequate anticoagulant therapy can result in thrombosis of the mechanical prosthetic valve while, on the other hand, anticoagulant therapy is associated with foetal and maternal bleeding and teratogenic effects. Pregnant women with mechanical prosthetic valves should be thoroughly counselled before or shortly after the confirmation of pregnancy regarding the risks associated with available anticoagulant options, allowing them to make an informed decision concerning the best management plan. This is an algorithm for optimal care of these patients.

Mannose-binding lectin levels during pregnancy: a longitudinal study

BACKGROUND

Pregnancy is associated with changes in the immune system. Although previous studies have focussed mainly on adaptive immunity, there are indications that components of innate immunity, such as mannose-binding lectin (MBL), are associated with pregnancy outcome. Although this would suggest that pregnancy also involves adaptations in innate immunity, there are few studies in this area. Therefore, we aimed to determine whether MBL concentrations and the following steps in complement pathway activation are influenced by pregnancy.

METHODS

MBL and Ficolin-2 concentrations, MBL-MBL-associated serine protease (MASP) complex activity, MBL pathway activity and classical complement pathway activity were determined by enzyme-linked immunosorbent assay (ELISA) in sera from pregnant women (n=32) during each trimester and post-partum. MBL genotyping was performed by PCR.

RESULTS

During pregnancy, MBL concentrations increased to 140% [interquartile range (IQR) 116-181%, P < 0.0001]. This increase was already present at 12 weeks of pregnancy and was most pronounced in the high-production AA-genotype. Directly Post-partum MBL concentrations dropped to 57% of baseline (IQR 44-66%, P < 0.0001). Variations in MBL levels were reflected by similar changes in the following steps of complement activation, r > 0.93 (P < 0.01). Ficolin-2 levels and classical complement pathway activity were not similarly influenced by pregnancy.

CONCLUSIONS

Pregnancy and the post-partum period profoundly influence MBL serum concentration and MBL complement pathway activity.

Matrix metalloproteinase-9 gene -1562C/T polymorphism mitigates preeclampsia

Although the aetiology of preeclampsia is unknown, there is substantial evidence that it finds its roots in abnormal placentation. Prerequisites for successful placentation include trophoblast invasion, degradation and remodelling of the uterine decidual extracellular matrix, and apoptosis without thrombosis. We tested this hypothesis by analysing the effect of functional polymorphisms in the genes coding for MMP9, MMP3 and annexin A5 on the risk of preeclampsia using a case-control design. In 163 women with preeclampsia and 163 controls we studied the association with polymorphisms in the MMP9 (-1562 C/T), MMP3 (-1612 5A/6A) and annexin A5 (-1 C/T) genes using logistic regression analysis. A lower prevalence of the rare T allele of the MMP9 (-1562 C/T) polymorphism in women with preeclampsia was found (odds ratio 0.48, 95% confidence interval 0.25-0.90). The distribution of the MMP3 (-1612 5A/6A) and annexin A5 (-1 C/T) gene polymorphisms were similar in cases and controls. Our results suggest that the MMP9-1562T allele is associated with a reduced risk of preeclampsia and therefore may protect against maladaptation of the spiral arteries and decreased decidual degradation. The elevated MMP9 concentrations reported to be associated with the -1562T allele might be essential for the development of an adequate maternal-fetal interface early in pregnancy by facilitating trophoblast apoptosis and degradation.

Acute coronary syndrome during pregnancy

Two cases of myocardial infarction during the second trimester of pregnancy are presented. Both patients were treated with thrombolytic therapy. In the first case the treatment was successful, in the other patient thrombolysis only temporarily relieved the symptoms. Therefore, angiography was performed and a significant stenosis in the left anterior descending coronary artery was successfully treated with balloon angioplasty. Both women delivered a healthy child, the first child was born at term, the second at a gestational age of 33 weeks. Percutaneous intervention versus thrombolytic therapy in pregnancy is discussed.

Interleukin 10-2849AA genotype protects against pre-eclampsia

Recently, it has been described that human fertility is associated with the interleukin 10 (IL10) -2849 AA genotype. Pre-eclampsia is the most common pregnancy-specific complication. In the pathogenesis of pre-eclampsia, IL10 may affect maternal intravascular inflammation as well as endothelial dysfunction. Therefore, we tested the hypothesis that pre-eclampsia is associated with genetic variation in the IL10 promoter region in a case-control study for pre-eclampsia. Women homozygous for the IL10 -2849A allele have a threefold reduced risk for pre-eclampsia compared to controls (odds ratio 0.29; 95% CI 0.10-0.83). No differences in genotype frequency were found for polymorphisms in the IL10 promoter region at positions -1082, -819 and -592. This suggests that there is a genetically determined mechanism which protects the mother against pre-eclampsia, as reflected in the lower frequency of the IL10 -2849AA genotype in pre-eclamptic women.

New approach for the identification of folate-related pathways in human embryogenesis

The role of natural folate intake and synthetic folic acid supplementation in the prevention of some congenital malformations is known, but on a molecular biological level poorly understood. In a first approach to identify folate-regulated pathways in human embryogenesis, tryptic digests of Epstein Barr Virus-immortalized B-lymphoblasts proteins from 6 cleft lip and/or palate patients and 2 controls were compared using matrix assisted laser desorption ionisation--time of flight (MALDI-TOF) mass spectrometry. After immortalisation, the lymphoblasts were cultured for 22 days in folate-rich, i.e. 5-methyltetrahydrofolate (5-mTHF), or folate-free medium. On day 22, 5-mTHF was added to the folate-free cultures and the profiles on day 22 and 23 were compared. After background correction for the peptide profiles of the folate-rich cultures, we found in the folate-free mediaseveral differentially expressed peptide peaks upon addition of 5-mTHF. These peptide peaks were mass annotated and matched withthe MSDB human database. The results suggest some folate-regulated protein candidates as Frizzled and the Rho GTP-ases WRCH and Chp that are known in human embryogenesis. Differential folate expressed proteins in patients and controls, however, have to be further investigated.

Recurrence rate of pre-eclampsia in women with thrombophilia influenced by low-molecular-weight heparin treatment?

OBJECTIVES

(1) To assess the recurrence rate of pre-eclampsia in women with this history before 34 weeks of pregnancy and thrombophilia. (2) To evaluate the effects of low-molecular-weight heparin (LMWH) on pregnancy outcome.

METHODS

In a multicentre retrospective study subsequent pregnancies of women with a history of pre-eclampsia necessitating birth before 34 weeks and thrombophilia were analysed. Of 58 women, 26 received LMWH and aspirin (ASA) and 32 ASA (22) or no (10) medication in their subsequent pregnancies.

RESULTS

In eight women treated with LMWH and ASA and in 16 women receiving ASA or no medication pre-eclampsia recurred in the subsequent pregnancy. (OR 0.55, 95% CI 0.15-1.31) There were no significant differences in birth weight or gestational age between both groups.

CONCLUSIONS

The recurrence rate of pre-eclampsia in women with thrombophilic disorders is high in this small retrospective study. No positive effect was found for LMWH treatment. A multicentred randomised study has been started to reach an adequate number of patients to evaluate the influence of LMWH treatment.

[The pregnant patient with acute liver disease]

Acute liver disease was diagnosed in three pregnant patients: two 30-year-old women had a 'haemolysis, elevated liver enzymes, low platelets' (HELLP) syndrome and acute fatty liver of pregnancy, respectively, and a 20-year-old woman had acute liver failure due to acute hepatitis B. The first two patients had a caesarean section, the third one delivered her child, which died spontaneously shortly after birth at a gestational age of 23 weeks. She was then treated by liver transplantation. All three patients left the hospital in good condition. Liver diseases in pregnancy may be pregnancy-related, e.g. the HELLP syndrome and acute fatty liver of pregnancy, but they may also be coincidental phenomena, e.g. viral hepatitis. The HELLP syndrome is often associated with pre-eclampsia, and presents with epigastric pain and thrombocytopenia with haemolysis. Acute fatty liver disease and acute liver failure due to hepatitis present with liver insufficiency characterised by anorexia, nausea, coagulopathy, hypoglycaemia and elevated serum ammonia levels. Management depends on the diagnosis and the gestational age; pregnancy complicated by acute fatty liver disease should be terminated while pregnancy complicated by the HELLP syndrome early in pregnancy may be maintained to improve the outcome of the foetus. In acute liver failure due to viral hepatitis, termination of pregnancy alone does not affect the disease.