Clinical maternal risk parameters for the occurrence of maternal and fetal complications during preeclampsia in Congolese women.

Several studies have demonstrated that predicting complications of preeclampsia up to 48 h before their occurrence enhances clinical management. This predictive ability allows for rational approaches in dealing with groups at high risk of maternal-fetal complications. OBJECTIVE: This study aims to identify the clinical parameters strongly associated with maternal-fetal complications during preeclampsia in Congolese pregnant women. METHOD: A descriptive and analytical study was conducted in the provincial city of Kinshasa from July 2018 to December 2021. The study population consisted of pregnant women with preeclampsia in three maternity units in Kinshasa. Determinants of complications were assessed using univariate and multivariate logistic regression. RESULTS: In univariate logistic regression models, obesity, a history of hypertension, severe hypertension, and SpO2 < 90 % were identified as determinants of maternal-fetal complications. Conversely, a history of preeclampsia, treatment with MgSO4, or a combination of AntiHTA and MgSO4 reduced the risk of complications. In the multivariate model, after adjusting for all significant variables in the univariate model, severe hypertension, obesity, and SpO2 < 90 % were identified as independent determinants of maternal-fetal complications. The risk of complication was multiplied by 5 for severe hypertension, by 4 for obesity, and by 2 for SpO2 < 90 %. However, treating women with MgSO4 or a combination of AntiHTA and MgSO4 reduced the risk of complications by a factor of 4 and 6, respectively. CONCLUSION: The presence of symptoms is more useful in predicting complications of preeclampsia than their absence in ruling out adverse events.

Preeclampsia and toxic metals: a case-control study in Kinshasa, DR Congo.

BACKGROUND: Preeclampsia is frequent in Kinshasa (Democratic Republic of Congo), especially during the dry season. We tested whether preeclampsia was associated with exposure to environmental metals. METHODS: Using a case-control design, 88 women hospitalized with preeclampsia (cases) and 88 healthy pregnant women from the antenatal clinic (controls) were included in the study; 67 and 109 women were enrolled during the rainy and dry season, respectively. The concentrations of 24 elements were quantified by inductively coupled plasma mass spectrometry (ICP-MS) in 24-h urine collections. Differences in the urinary excretion of metals were investigated between cases and controls, and the interaction with season was assessed. RESULTS: Cases and controls were well matched regarding age, parity and duration of pregnancy. In controls, the urinary concentrations of most elements were substantially higher than reference values for adults from industrially developed countries, e.g. for lead: geometric mean (GM) 8.0 µg/L [25(th)-75(th) percentile 3.1-13.8]. The daily urinary excretions of 14 metals were significantly higher in women with preeclampsia than in control women, e.g. for lead: GM 61 µg/day (25(th)-75(th) percentile 8-345) in women with preeclampsia vs 9 µg/day (25(th)-75(th) percentile 3-21) in controls (p < 0.001). A significant interaction was found between season and preeclampsia for several elements, with higher urinary excretions in preeclamptic women than controls during the dry season, but not during the rainy season. CONCLUSIONS: This study revealed not only that women with preeclampsia excrete higher amounts of several toxic metals, especially lead, than control women, but also that this excretion exhibits seasonal variation, thus possibly explaining the high incidence and seasonal variation of preeclampsia in Kinshasa. Although the exact sources of this exposure are unknown, these findings underscore the need for preventing environmental exposures to lead and other toxic metals.

Investigating the influence of maternal cortisol and emotional state during pregnancy on the DNA methylation status of the glucocorticoid receptor gene (NR3C1) promoter region in cord blood.

BACKGROUND: The methylation status of the human glucocorticoid receptor gene NR3C1 in newborns has been reported to be sensitive to prenatal maternal mood. This study investigates both the association between maternal cortisol and emotional state during pregnancy and the methylation state of the promoter region of NR3C1 gene. METHODS: We examined 83 pregnant women. Psychological data and diurnal cortisol data were assessed to evaluate maternal stress once each trimester. DNA methylation at different loci of the NR3C1 gene, including exon 1B, 1D and 1F, was analyzed in genomic DNA from cord blood mononuclear cells. RESULTS: Univariable analyses indicated pregnancy related anxiety to be the strongest psychological parameter throughout pregnancy. Most significant findings concerned 1F. Particularly the methylation state of CpG9 was significantly associated with maternal emotional wellbeing. In a multivariable model the proportion of variance in methylation state of F9 explained (PVE) by pregnancy related anxiety was 7.8% (p = 0.023) during T1. Furthermore different CpG-units located at the nerve growth factor inducible protein A (NGFI-A) binding sites of 1F were associated with maternal anxiety [(F20.21: PC PRAQ and fear of integrity in T1: respectively PVE:8.9% and PVE:9.0%; Fear of delivery T2: PVE:8.0%, Fear of integrity T2: PVE:6.0% and STAI T2: PVE:5.9%) - (F12.13: PC PRAQ T1: PVE:6.9%, fear of integrity T2: PVE:6.0% and fear of delivery T2: PVE:8.0%)] and cortisol (F38.39: PVE:8.9%) in T2. CONCLUSION: These data indicate that prenatal maternal emotional state, particularly pregnancy related anxiety, are associated with the methylation state of the NR3C1 gene in the child.

A hermeneutic phenomenological study of Belgian midwives' views on ideal and actual maternity care.

OBJECTIVE: to explore midwives' views on ideal and actual maternity care. DESIGN: a qualitative hermeneutic phenomenological study based on the method of van Manen (1997) using individual in-depth interviews to gather data. SETTING: Flanders, Belgium. PARTICIPANTS: 12 purposively sampled midwives, of whom nine from three different non-university hospitals and three independent midwives conducting home births. FINDINGS: five major themes were identified: 'woman-centred care', 'cultural change', 'support', 'midwife and obstetrician as equal partners' and 'inter-collegial harmony'. In this paper 'woman-centred care', 'cultural change' and 'support' are discussed along with their subthemes. Midwives thought ideal maternity care should be woman-centred in which there were no unnecessary interventions, women were able to make an informed choice and there was continuity of care. Furthermore, ideal maternity care should be supported by midwifery education and an adequate staffing level. Also, a cultural change was wanted as actual maternity care was perceived to be highly medicalised. Barriers to achieving woman-centred care and possible strategies to overcome these were described. CONCLUSIONS: findings from this study were consistent with those of other studies on midwives' experience with obstetric-led care. Despite the medicalised care, midwives still held a woman-centred ideology. In order to be able to work according to their ideology, different barriers need to be addressed. Although midwives suggested strategies to overcome these barriers, some were considered to be very difficult to overcome.

Variation in 17 obstetric care pathways: potential danger for health professionals and patient safety?

AIM: To report a study to determine whether or not variations exist in evidence-based key interventions in pathway documents for normal delivery across hospitals. BACKGROUND: Care pathways are used worldwide to standardize and follow up patient-focused care. Minimal variations in pathway documents increase standardization and patient safety. DESIGN: A descriptive study design using qualitative methods was used, to examine the various key interventions present in care pathway documents for normal delivery. METHODS: Between January-March 2009, we evaluated the content of the care pathway document for normal delivery from 17 different hospitals. The key interventions in these pathways were compared with the 40 evidence-based key interventions of Map of Medicine®. RESULTS: There was much variation in the characteristics and the presence of key interventions in the pathway documents. Only 6 of the 40 evidence-based key interventions (15%) were found in all 17 pathway documents and 20 of the 40 interventions (50%) were found in only 10 pathway documents. CONCLUSION: If variation already exists among the care pathway documents, this may lead to a high probability of variation in the actual performance of daily care. In this study is shown that, even for highly predictable medical conditions, there are huge differences in the evidence-based content and structure of pathways. Lack of evidence base could potentially endanger both patient safety and the health professional.

Student midwives' views on maternity care just before their graduation.

AIM: To report a hermeneutic study of student midwives' views on maternity care just before their graduation. background: Woman-centred care, which is the hallmark of midwifery, is taught to midwifery students around the globe. Woman-centred care is advantageous for women at low obstetric risk. However, adopting this ideology might be a problem for student midwives whose clinical placements are mainly in a medicalized obstetric-led hospital setting. DESIGN: A hermeneutic phenomenological study was conducted. METHODS: In 2010, three focus groups were held where 19 student midwives participated. Data were transcribed verbatim and analysed using van Manen's approach. FINDINGS: The choice for midwifery was a 'positive' choice and not the result of an elimination process. Students' description of a midwife as a coach was in line with the international definition of a midwife. With regard to maternity care, midwifery students identified two types of care, factory-style care and tailored care, both of which were ascribed to caregivers and hospital culture. Furthermore, student midwives made the distinction between hierarchy and teamwork, referring to the professional relations in maternity care. Hierarchy was driven by tradition, it implied that decisions were made top-down, and it resulted in impersonal relations. Midwifery students felt it was unjust that midwives were not allowed to perform deliveries while having the legal autonomy to do so. CONCLUSION: In spite of the medicalized context, midwifery education succeeded in educating midwives who hold a woman-centred ideology. Midwifery students linked style of care to a person rather than to a profession.

The influence of maternal cortisol and emotional state during pregnancy on fetal intrauterine growth.

BACKGROUND: This exploratory study investigates the influence of maternal cortisol and emotional state during pregnancy on fetal intrauterine growth (IUG). We expected higher basal cortisol levels, or more depressive and anxious complaints during pregnancy, to be associated with slower IUG and lower birth weight. METHODS: A total of 91 pregnant women were recruited from the antenatal clinic and were seen once each trimester. In addition to psychological assessments, a diurnal cortisol profile was derived from saliva samples. IUG was evaluated using ultrasound. RESULTS: In mid-pregnancy (trimester (T)2), basal cortisol levels significantly predicted the variance of weight (proportion of variance in growth variable explained (PVE) = 11.6%) and body mass index (BMI) at birth (PVE = 6.8%). In late pregnancy (T3) emotional state, particularly depressive symptoms (BMI at birth: PVE = 6.9%; ponderal index (PI) at birth: PVE = 8.2%; head circumference at T3: PVE = 10.3%; head circumference at birth PVE = 9.1%) and attachment (BMI at birth: PVE = 6.9%; PI at birth: PVE = 7.2%) had an influence on growth. Analysis of growth between T2 and T3 showed that attachment and cortisol in T3 had an influence on the variation in increase in estimated fetal weight (PVE = 12.5-8.6%). CONCLUSION: These data indicate basal cortisol levels were more important in T2 whereas emotional state was more important in T3.

Outcome of pregnancy in women with inflammatory bowel disease treated with antitumor necrosis factor therapy.

BACKGROUND: Infliximab (IFX) and adalimumab (ADA) are attractive treatment options in patients with inflammatory bowel disease (IBD) also during pregnancy but there is still limited data on the benefit/risk profile of IFX and ADA during pregnancy. METHODS: This observational study assessed pregnancy outcomes in 212 women with IBD under antitumor necrosis factor alpha (TNF) treatment at our IBD unit. Pregnancy outcomes in 42 pregnancies with direct exposure to anti-TNF treatment (35 IFX, 7 ADA) were compared with that in 23 pregnancies prior to IBD diagnosis, 78 pregnancies before start of IFX, 53 pregnancies with indirect exposure to IFX, and 56 matched pregnancies in healthy women. RESULTS: Thirty-two of the 42 pregnancies ended in live births with a median gestational age of 38 weeks (interquartile range [IQR] 37-39). There were seven premature deliveries, six children had low birth weight, and there was one stillbirth. One boy weighed 1640 g delivered at week 33, died at age of 13 days because of necrotizing enterocolitis. A total of eight abortions (one patient wish) occurred in seven women. Trisomy 18 was diagnosed in one fetus of a mother with CD at age 37 under ADA treatment (40 mg weekly) and pregnancy was terminated. Pregnancy outcomes after direct exposure to anti-TNF treatment were not different from those in pregnancies before anti-TNF treatment or with indirect exposure to anti-TNF treatment but outcomes were worse than in pregnancies before IBD diagnosis. CONCLUSIONS: Direct exposure to anti-TNF treatment during pregnancy was not related to a higher incidence of adverse pregnancy outcomes than IBD overall.

Three self-report questionnaires of the early mother-to-infant bond: reliability and validity of the Dutch version of the MPAS, PBQ and MIBS.

In this study, we investigated the reliability and validity of three self-report questionnaires measuring the early emotional bond between a mother and her newborn infant: the Maternal Postpartum Attachment Scale (MPAS), the Postpartum Bonding Questionnaire (PBQ) and the Mother-to-Infant Bonding Scale (MIBS). In a monocentric prospective observational cohort study, 263 mothers completed the MPAS, the PBQ and the MIBS at 8-12 and at 20-25 weeks postpartum. The participants also completed measures of mental health and, during their pregnancy, measures of recalled parental bonding, adult romantic attachment, antenatal attachment and social desirability. In our study, the internal reliabilities of the PBQ and the MPAS were high at 8-12 weeks postpartum but dropped significantly at 20-25 weeks postpartum. Moderately strong correlations between the scales of the PBQ, the MPAS and the MIBS supported their construct validity. Further, weak correlations were found with social desirability and adult attachment representations, whereas moderate correlations were found with antenatal feelings of attachment and antenatal attitudes to motherhood. Finally, maternal feelings of bonding were also moderately associated with maternal mood. Overall, our findings suggest that the MPAS, the PBQ and the MIBS provide a reliable and valid indication of the early emotional tie between a woman and her newborn infant.

Reliability and validity of the Dutch version of the maternal antenatal attachment scale.

In this study, we investigated the psychometric qualities of the Dutch version of the Maternal Antenatal Attachment Scale (MAAS). In a monocentric prospective observational cohort study, 403 expectant mothers completed a booklet with questionnaires in the first (T1), second (T2), and third (T3) pregnancy trimesters. In addition to the MAAS (T1-T3), the following measures were used: the Marlowe-Crowne Social Desirability Scale (T1), the Parental Bonding Inventory (T1), the Relationship Questionnaire (T1) the Facilitator scale and the Regulator scale (T3), the Edinburgh Postnatal Depression Scale (T1-T3) and the Pregnancy Related Anxiety Questionnaire (T1-T3). In this study, the mean of the MAAS scales increased as the pregnancy progressed. Good internal reliabilities were found for the Total MAAS scale, the Quality subscale and the Preoccupation subscale. Small-to-moderate correlations were found with social desirability, maternal orientation, parental care and adult attachment. Maternal mood was weakly associated with the quality but not with the intensity of the maternal attachment feelings. Overall, our findings suggest that the Dutch version of the Maternal Antenatal Attachment Scale is a reliable and valid measure of the early emotional tie between a pregnant woman and her unborn child.

Depressive symptomatology in pregnant and postpartum women. An exploratory study of the role of maternal antenatal orientations.

Little is known about how an expecting woman's view of pregnancy, the child, and motherhood relates to antenatal and postpartum depressive symptomatology. In this study, we investigated the influence of the maternal orientations, as described by Raphael-Leff (Psychological processes of childbearing. The Anna Freud Centre, London, 2005), on the prevalence of depressive symptoms in pregnant and postpartum women. Four hundred three pregnant women participated in a longitudinal study and completed the EPDS and the HADS-D in each pregnancy trimester and between 8 to 12 and 20 to 25 weeks postpartum. In addition, measures of maternal orientation (PPQ), personality (NEO-FFI), coping styles (UCL), adult attachment (RQ), and parental bonding (PBI) were completed antenatally. Bivariate and multivariate analyses revealed that Neuroticism and the Regulator orientation are positively associated with the EPDS and HADS-D in both pregnant and postpartum women. These associations decreased in strength but remained significant after controlling for previous responses on the EPDS and HADS-D. Small negative associations were found between the Facilitator orientation and the HADS-D scores during pregnancy and the early postpartum period. However, this association did not hold its statistical significance within the hierarchical multiple regression models. The maternal orientations have a small but significant and independent contribution in the variance of depressive symptomatology in pregnant and postpartum women.

Anxiety in pregnant and postpartum women. An exploratory study of the role of maternal orientations.

BACKGROUND: Little is known about why some women are anxious during pregnancy but not in the postpartum period, or vice versa. We aimed to determine the influence of maternal antenatal orientations (Raphael-Leff, J. (2005) Psychological Processes of Childbearing, London, The Anna Freud Centre.) on the prevalence of general anxiety symptoms and specific anxiety in pregnant and postpartum women. METHODS: Four hundred and three pregnant women participated in a longitudinal study and completed general (HADS-A) and specific (PRAQ, MSAS) anxiety questionnaires and measures of maternal antenatal orientations, personality traits, cognitive and behavioural coping styles and attachment. RESULTS: Higher scores on the neuroticism and regulator orientation scale consistently predicted higher scores on the general and pregnancy related anxiety measures. Also, an interaction effect was found between the regulator scale and the neuroticism scale on the general anxiety symptoms and pregnancy related anxiety. Finally, the facilitator orientation scale and the neuroticism scale, predicted maternal separation anxiety in the postpartum period. CONCLUSION: Women differ in the risk factors, the nature and timing of heightened anxiety during the transition to motherhood. The anxieties of women tending to the regulator orientation are pregnancy related, whereas women tending to the facilitator orientation fear the separation from their child in the postpartum period.

Women's mental health before, during, and after pregnancy: a population-based controlled cohort study.

BACKGROUND: Common mental health disorders like depressive and anxiety disorders are frequent in antenatal and postpartum women. However, no agreement about the prevalence of these disorders and the course of women's mental health during the transition to motherhood exists. This study compared women's mental health before, during, and after pregnancy with a control group of nonpregnant women. METHODS: Three hundred and twenty-four women were assessed before, during, and after their pregnancy with the 12-item version of the General Health Questionnaire (GHQ-12). A control group of 324 women who did not deliver during 3 subsequent years was assessed with the GHQ-12 at corresponding time-points. RESULTS: No differences in GHQ-12 mean scores, prevalence, and incidence of common mental health disorders between the study and control groups were found. No differences in prevalence and incidence rates within each group were found. The presence of a common mental health disorder before pregnancy or in early pregnancy predicted common mental health disorders in the postpartum period. CONCLUSIONS: Common mental health disorders are frequent during pregnancy and the postpartum period, but pregnant or postpartum women are not more at risk than those who are not pregnant or who did not deliver.

Fetal magnetic resonance imaging of an intracranial venous thrombosis. Case report.

OBJECTIVE: To describe the magnetic resonance imaging findings of an antenatal intracranial venous thrombosis. METHODS: Prenatal ultrasound (US) at 22 weeks' gestational age (GA) in a 27-year-old patient (G2 P1) revealed a nonspecific avascular echogenic mass above the cerebellum evaluated with MRI at 23 weeks' GA. RESULTS: With MRI an enlarged occipital pericerebral space with a layered ovoid mass at the torcular herophili was demonstrated and MRI characteristics suggested a subacute cloth. In follow-up, an important enlargement of the mass was noticed on US examinations. After multidisciplinary consult and parental consent, a prostaglandin induction was performed at 25 weeks' GA. The baby died immediately after birth. Pathology confirmed the diagnosis of a venous thrombosis at the torcular herophili with extension into the superior sagittal sinus. CONCLUSION: In our case, MRI findings were helpful in diagnosing an intracranial fetal venous thrombosis.

Predictive models for long term survival after premature rupture of membranes.

Premature rupture of the membranes complicates 30 to 40% of the preterm deliveries. The purpose of this study is to assess the outcome of preterm prelabor rupture of the membranes (PPROM) before 26 weeks of gestation and to develop a predictive model for survival. We apply four statistical methods in order to construct a predictive model: Cox's proportional hazards model, logistic regression, least squares - support vector machines and generalized estimating equations. The obtained predictive models are tested on a prospective set and have a very good performance of > 95% for the area under the ROC-curve.

Complete chorioamniotic membrane separation. Case report and review of the literature.

We present a patient who developed complete chorioamniotic membrane separation (CMS) in two consecutive pregnancies. The first pregnancy ended with an intrauterine fetal death at 25 weeks of gestation. The entire separated amniotic sac had twisted around the umbilical cord. In the subsequent pregnancy, a complete CMS was diagnosed at 34 weeks of gestation. In both pregnancies, the patient underwent an early 2nd-trimester genetic amniocentesis. A review of the literature shows that extensive CMS is associated with miscarriage, in utero fetal death, umbilical cord complications, and preterm delivery. Most reported cases occurred after invasive intrauterine procedures.

Vaginal cytokines in normal pregnancy.

OBJECTIVE: The purpose of this study was to determine whether the vaginal cytokine concentration varies during the course of uncomplicated pregnancy. STUDY DESIGN: Prenatal visits of healthy women to University Hospital Gasthuisberg, Leuven, Belgium were considered. Cytokine levels in vaginal washings from 30 unselected healthy women with uncomplicated pregnancies were monitored during pregnancy and compared with those from 62 nonpregnant healthy control subjects. Exclusion criteria included bacterial vaginosis, moderate or severe aerobic vaginitis, Trichomonas vaginalis, Candida vaginitis (wet mount or culture), gonorrhea, and Chlamydia. Interleukin-6, interleukin-8, interleukin-1beta, interleukin-1-receptor antagonist, leukemia inhibitory factor, and tumor necrosis factor were measured. Nonparametric Kruskal-Wallis and Welch tests were used for univariate analysis, and the Spearman rank test was used for multivariate analysis. RESULTS: Compared with concentrations in nonpregnant women, interleukin-1beta concentrations were similar, but interleukin-1-receptor antagonist production was depressed throughout pregnancy. Vaginal interleukin-6 and interleukin-8 were less often discovered during pregnancy than outside pregnancy and dipped significantly in the middle trimester, to rise again to prepregnancy levels in the third trimester. Leukemia inhibitory factor was lower during the beginning of pregnancy (P=.038) but otherwise did not differ from nonpregnant values throughout pregnancy nor did tumor necrosis factor. Sexual activity could not explain these findings. CONCLUSION: Vaginal cytokine levels, especially interleukin-1 receptor antagonist, from pregnant women may differ from nonpregnant values; some levels, such as interleukin-6 and interleukin-8, may fluctuate during normal pregnancy. These spontaneous variations during pregnancy must be taken into account when mucosal immunologic responses to infection of the lower genital tract are being studied.

Definition of a type of abnormal vaginal flora that is distinct from bacterial vaginosis: aerobic vaginitis.

OBJECTIVE: To define an entity of abnormal vaginal flora: aerobic vaginitis. DESIGN: Observational study. SETTING: University Hospital Gasthuisberg, Leuven, Belgium. SAMPLE: 631 women attending for routine prenatal care or attending vaginitis clinic. METHODS: Samples were taken for fresh wet mount microscopy of vaginal fluid, vaginal cultures and measurement of lactate, succinate and cytokine levels in vaginal fluid. Smears deficient in lactobacilli and positive for clue cells were considered to indicate a diagnosis of bacterial vaginosis. Aerobic vaginitis was diagnosed if smears were deficient in lactobacilli, positive for cocci or coarse bacilli, positive for parabasal epithelial cells, and/or positive for vaginal leucocytes (plus their granular aspect). RESULTS: Genital complaints include red inflammation, yellow discharge, vaginal dyspareunia. Group B streptococci, escherichia coli, staphylococcus aureus and trichomonas vaginalis are frequently cultured. Vaginal lactate concentration is severely depressed in women with aerobic vaginitis, as in bacterial vaginosis, but vaginal succinate is not produced. Also in contrast to bacterial vaginosis, aerobic vaginitis produces a host immune response that leads to high production of interleukin-6, interleukin-1-beta and leukaemia inhibitory factor in the vaginal fluid. CONCLUSION: Aerobic vaginitis is associated with aerobic micro-organisms, mainly group B streptococci and E. coli. Its characteristics are different from those of bacterial vaginosis and elicit an important host response. The most severe form of aerobic vaginitis equals desquamative inflammatory vaginitis. In theory, aerobic vaginitis may be a better candidate than bacterial vaginosis as the cause of pregnancy complications, such as ascending chorioamnionitis, preterm rupture of the membranes and preterm delivery.