[The practice guideline 'Hormonal contraception' (second revision) from the Dutch College of General Practitioners; a response from the perspective of obstetrics & gynaecology]. / De standaard 'Hormonale anticonceptie' (tweede herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de verloskunde-gynaecologie.

The Dutch College of General Practitioners' (NHG) guideline on hormonal contraception does not follow the WHO criteria for the use of oral contraceptives in contrast to the guideline of the Dutch Society of Obstetrics and Gynaecology. Contrary to the WHO criteria, the NHG guideline considers a blood-pressure measurement before starting with an oral contraceptive to be unnecessary. It also considers no form of migraine to be a contraindication for oral contraceptives. The NHG guideline further disclaims the (slightly) increased risk of developing breast cancer in women using oral contraceptives. It advises initiation of oral-contraceptive use two weeks postpartum in non-breastfeeding women and six weeks postpartum in breastfeeding women, instead of the three weeks and six months, respectively, indicated in the WHO guideline. Lastly, the NHG guideline is too optimistic as to the reliability of oral-contraceptive use, as no distinction is made between efficacy and effectiveness. Such discrepancies between two Dutch guidelines can be detrimental to women's health care. The WHO criteria for contraceptive use may be a valuable tool to overcome differences of opinion so as to achieve a badly needed full consensus.

[Vaginal contraception: new form of administration of hormonal contraception]. / Vaginale anticonceptie: hormonale anticonceptie in een andere toedieningsvorm.

The vaginal contraceptive ring works systemically by releasing 120 micrograms etonogestrel (a third generation progestogen) and 15 micrograms ethinylestradiol per day. As little independent research has been done on the efficacy and effectiveness of the vaginal contraceptive ring, it seems too early for the uncompromising propagation of systemic vaginal contraception. Women who occasionally omit to take the pill and those reluctant to use an intra-uterine device may possibly benefit from this form of contraception.

[The Dutch College of General Practitioners practice guideline 'The menopause'; reaction of the field of obstetrics and gynaecology]. / De standaard 'De overgang' van het Nederlands Huisartsen Genootschap; reactie vanuit de obstetrie en gynaecologie.

In the Dutch College of General Practitioners' (NHG) practice guideline on the menopause (which also covers hormone therapy), menopausal transition is considered as a physiological life process with inconveniences which can generally be settled by providing information, while leaving hormonal treatment for women who experience serious restrictions in their daily life as a consequence of vasomotor flushes or urogenital atrophy. In those cases, the guideline says, hormonal treatment should not be given for longer than three to six months, after which it should be stopped until a relapse arises. However, it usually takes at least six months of oestrogen replacement therapy to restore urogenital atrophy as well as for the woman to recover from its discomforts such as dyspareunia. Dosages of oestrogens in different hormonal therapies should be 50% or 25% of those advocated in the guideline, as the lowest effective dosage of oestrogen is sufficient. More generally, a woman affected by menopausal inconveniences is not a patient. She deserves to decide for herself whether or not she is willing to use hormone replacement therapy, and if so, she should be allowed to decide on the duration of hormone treatment. The physician should provide adequate information and benevolent supervision.

[Health Council of Netherlands recommendation 'Serum screening for risk assessment of Down syndrome for all women' poorly supported]. / Gezondheidsraadadvies 'Kansbepalende serumscreening op Down-syndroom voor alle vrouwen' onvoldoende doordacht.

The Health Council of the Netherlands has recommended a new policy of offering triple test-based serum screening for Down's syndrome to all pregnant women rather than the current policy of maternal age-based screening for pregnant women aged 36 years and above. In these older pregnant women, this risk-assessment serum screening would indeed prevent many miscarriages caused by the invasive procedure. However, in pregnant women under 30 years of age this policy would imply the need to counsel almost 80,000 young pregnant women each year, and the need to perform 2,200 invasive procedures in order to detect 29 Down's syndrome cases, while 45 cases would still remain undetected. Moreover, as only 11% of the detectable Down's syndrome cases are found in women under 30, it would appear advisable to only offer the risk-assessment serum screening to pregnant women aged 30 years and above.

[One year of neonatal screening for sickle-cell disease in Emma Children's Hospital/Academic Medical Center in Amsterdam]. / Een jaar neonatale screening op sikkelcelziekte in het Emma Kinderziekenhuis/Academisch Medisch Centrum te Amsterdam.

OBJECTIVE: Early detection of children with sickle cell disease, determination of carriership frequency as well as evaluation of the knowledge regarding this haemoglobinopathy in various ethnic risk groups. DESIGN: Prospective. METHODS: From 1 November 1998 through to 31 October 1999, the ethnic background was recorded for consecutive pregnant women under care of the Academic Medical Centre, Amsterdam, the Netherlands, and the presence of carriership for sickle cell disease was evaluated. Carriers were asked about their knowledge of sickle cell disease. A diagnostic blood test of cord blood was also performed using a PCR which could detect both haemoglobin S and C mutations. RESULTS: Fifty-five carriers were detected in a group of 1,016 investigated pregnant women (5.4%). The carriership frequencies in Surinam and African women were 12 and 15.7%, respectively. Knowledge of sickle cell disease, its occurrence in populations at risk, as well as the terms 'inheritance' and 'carriership', differed substantially between Surinam and African women, with awareness being lower in the latter group. In six cases informed consent was not asked. All other 49 carriers consented to a diagnostic test. Two intrauterine deaths occurred. Four children had sickle cell disease: three had HbSS, one had HbSC. Nineteen children proved to be carriers for sickle cell disease, 18 were heterozygotes for HbS, one for HbC. CONCLUSION: This targeted neonatal screening for sickle cell disease was feasible in a hospital setting. The number of children diagnosed with the disease supports the wider implementation of this method of early detection.

[Modern intra-uterine contraception: a better option]. / Moderne intra-uteriene anticonceptie: het betere alternatief.

Users of oral contraceptives have an increased risk of developing venous thromboembolism as well as mammary cancer. This raises the question as to whether locally applied (intrauterine) contraceptives can offer a valuable alternative with respect to efficiency and safety. During the past decade the use of modern intrauterine devices (IUDs) has made substantial progress in comparison with the use of IUDs during the 1970s and 1980s. Modern IUDs have become more efficient than oral contraception. Arguments against the use of IUDs (problems and complications in IUD insertion, the risk of pelvic inflammatory disease, ectopic pregnancy and infertility as well as side effects such as menorrhagia, pelvic cramps and IUD expulsion) generally appear to be based on a lack of awareness with respect to recent developments and on misunderstandings derived from bad experiences during the 1980s and earlier.

[Sodium intake during pregnancy]. / Natriumgebruik tijdens de zwangerschap.

International studies have yielded contradictory results on efficacy of a sodium-restricted diet during pregnancy in preventing and curing hypertension of pregnancy. In the Netherlands three studies have been performed to investigate the value of dietary sodium restriction in pregnancy; they concerned epidemiology, prevention and treatment. Midwives often prescribed this dietary intervention. Urinary sodium excretion was not related to blood pressure changes in pregnancy. Dietary sodium restriction from the third month of pregnancy onwards did not reduce the incidence of pregnancy-induced hypertension. Maternal side effects were a decreased intake of nutrients, decreased maternal weight gain, lowered plasma volume and stimulation of the renin-angiotensin-aldosterone system. A dietary sodium restriction in women with early symptoms of pregnancy-induced hypertension showed no therapeutic effect on blood pressure. There is no place for dietary sodium restriction in the prevention or treatment of hypertension in pregnancy.

Obstetric outcome of elderly low-risk nulliparae.

OBJECTIVE: To compare referrals and reasons for referral during pregnancy and labor, mode of delivery and obstetric outcome of first births in women 35 years and older with women 20-30 years old. METHODS: A prospective cohort study was performed of 146 elderly and 306 younger nulliparae in seven independent midwives' practices in and around Amsterdam. RESULTS: No significant differences in referrals were found between the two compared groups. After selection during pregnancy, obstetric outcome was not different between the groups. A higher percentage of episiotomies was found in the elderly group, compared to the younger group. CONCLUSIONS: After proper selection during pregnancy, the elderly nullipara under the care of a midwife does not have an increased risk of fetal distress or other emergency factors, compared to the younger nullipara. However, high referral rates during labor - both of younger and older women - were observed in this study.

Risk factors for preeclampsia in nulliparous women in distinct ethnic groups: a prospective cohort study.

OBJECTIVE: To determine whether baseline characteristics during early pregnancy, proposed as potential risk factors for preeclampsia, show differences in prevalence and effects within distinct ethnic groups. METHODS: In a prospective cohort study of 2413 healthy nulliparous women from eight midwives' practices, we analyzed risk factors for preeclampsia (maternal age, body mass index, blood pressure at booking, smoking habit, and abortion history) in white, Mediterranean, Asian, and black women. In a univariate analysis, we estimated the relative risk of preeclampsia for the baseline variables and for ethnicity. In a multivariate analysis, we evaluated the simultaneous effect of the baseline variables in white (n = 1641) and black (n = 317) women. RESULTS: Significant differences were found in the prevalence of the risk factors in different ethnic groups. In the univariate analysis, the relative risk (RR) of preeclampsia in black women was 2.4 (95% confidence interval [CI] 1.1, 5.6) compared with white women. In the multivariate analysis in white women, the adjusted RR of preeclampsia for a diastolic blood pressure at booking above 70 mmHg was 4.4 (CI 0.9, 20.8). Among black women, the adjusted RR of preeclampsia was increased for high maternal age (RR 1.2; CI 1.0, 1.4), but not for a diastolic blood pressure at booking above 70 mmHg (RR 0.8; CI 0.2, 3.9). CONCLUSION: In studies of risk factors for preeclampsia, black women should be analyzed separately from white women.

Intensification of fetal and maternal surveillance in pregnant women with hypertensive disorders.

OBJECTIVE: To examine the need to intensify fetal and maternal surveillance in pregnant women with mild pregnancy hypertension. METHODS: The multi-center cohort study in 2413 healthy nulliparae analyzed differences in hypertension-related adverse events (small-for-gestational age, perinatal mortality, eclampsia, abruptio placentae and HELLP syndrome) according to maximum diastolic blood pressure and proteinuria. RESULTS: Compared to the reference group (diastolic blood pressure 70-85 mmHg) (n = 1882) the relative risks of adverse fetal and maternal outcome in 34 proteinuric hypertensive women were 8.9 (95% CI 3.3-24.1) and 41.5 (95% CI 9.7-178.4), respectively. In 203 non-proteinuric women with a maximum diastolic blood pressure of > or = 95 mmHg only the relative risk of adverse maternal outcome was increased (11.6, 95% CI 3.1-42.8), but it was not increased in 230 non-proteinuric women with a maximum diastolic of 90 mmHg. CONCLUSIONS: Intensified surveillance in women with mild pregnancy hypertension is not indicated and should be reserved for groups with increased fetal and maternal risk.

Low sodium diet and pregnancy-induced hypertension: a multi-centre randomised controlled trial.

OBJECTIVE: To examine the effectiveness of the standard policy in the Netherlands to prescribe a sodium restricted diet to prevent or to treat mild pregnancy-induced hypertension. DESIGN: Multi-centre randomised controlled trial between April 1992 and April 1994. SETTING: Seven practices of independent midwives and one university hospital. PARTICIPANTS: The experimental group comprised 184 women given a low sodium diet (< or = 50 mmol sodium/day) and a control group of 177 women given a normal diet. Eligible women for inclusion had had a rise of blood pressure, or excessive weight gain or oedema during the antenatal period. The 361 women in the trial were recruited from 2020 nulliparae, of whom 1512 (75%) gave informed consent at the beginning of their pregnancy to participate in the study. MAIN OUTCOME MEASURES: The difference between highest diastolic blood pressure after randomisation and diastolic blood pressure at the moment of randomisation; referral and admission to hospital for hypertension. RESULTS: There was no difference in increase of diastolic blood pressure after randomisation, the percentage of referral and admission to hospital for hypertension, or in obstetric outcome between the two groups. Urinary sodium excretion after randomisation in the normal diet group was significantly higher than in the low sodium group. CONCLUSION: Prescribing a sodium-restricted diet to prevent or to treat mild pregnancy-induced hypertension is not effective. Therefore there is no need to introduce a salt restricted diet in prenatal care, although increasing evidence shows that a low sodium diet prevents hypertension in non-pregnant individuals.

Four cases of bladder exstrophy in two families.

Bladder exstrophy is a rare congenital anomaly, caused by abnormal development of the cloacal membrane. To our knowledge, 18 familial patients with this malformation have been described. Two sets of familial cases with bladder exstrophy are reported here: two cousins and a mother and son and the published reports of the 18 familial cases among 682 index patients with bladder exstrophy are reviewed. Ultrasonography is advocated as the investigation of choice for early prenatal diagnosis.

[Duration of the second stage and the condition of the neonate in midwife-managed deliveries]. / Uitdrijvingsduur en de toestand van de pasgeborene bij door vroedvrouwen geleide bevallingen.

The correlation between the duration of the second stage on the one hand, and arterial cord blood pH/neurological score on the other hand was calculated for 71 primi- and 77 multiparae. The pregnant women were selected during pregnancy as low risk cases and under care of midwives at the beginning of labour. The deliveries were attended by a midwife or, after referral during labour/delivery, by an obstetrician. It could not be established that a relatively long second stage substantially deteriorated the condition of the neonate. From the findings obtained it does not appear necessary to change the rules regarding maximal duration of second stage (currently two hours for primi- and one hour for multiparae).