[Breech presentation at term: elective caesarean section is the wrong choice as a standard treatment because of too high risks for the mother and her future children]. / Aterme stuitligging: onterechte keus voor de electieve keizersnede als standaardbehandeling vanwege te hoge risico's voor de moeder en haar volgende kinderen.

The altered attitude of the obstetrician with regard to term breech delivery after the first results of the Term breech trial in 2000 has led to an increase in elective caesarean section in the Netherlands from 25% in 1999 to 64% in 2004 and a decrease in emergency caesarean section for term breech delivery from 26% in 1999 to I8% in 2004. This increase of about 8500 elective caesarean sections in the last four years probably prevented 19 perinatal deaths. However, this rise in caesarean section also resulted in four maternal deaths that may have been avoidable. Furthermore, in the future, nine perinatal deaths as a result of the uterine scar and 140 women with potentially life-threatening complications from that uterine scar during their future pregnancies can be expected. Information to the patient should take into account not only the short-term benefits but also the higher long-term risks. Vaginal delivery following strict selection is now preferred.

[Decreased fetal movement and a sinusoidal pattern on the cardiotocogram: 2 alarm signals]. / Verminderd leven voelen en een sinusoïdaal patroon op het cardiotocogram: 2 alarmsignalen.

A 24-year-old primigravida was referred at 35 weeks of gestation due to decreased foetal movement. External monitoring demonstrated a sinusoidal foetal heart rate pattern accompanied by late decelerations. A hydropic and severely anaemic infant with clinical signs of thrombocytopenia was delivered by emergency caesarean section. He failed to breath spontaneously and required positive pressure ventilation. Cranial ultrasound and computerised tomography of the brain revealed a massive intraparenchymal haemorrhage. After the infant had died, post mortem studies revealed the presence of maternal antibodies to the human platelet antigen (HPA) 1a which suggested neonatal isoimmune thrombocytopenia as cause of the intracranial haemorrhage. A sinusoidal foetal heart rate pattern is an alarm signal--it is not necessarily significant but is often associated with mortality or serious morbidity and is therefore a reason for quickly investigating the condition of the foetus.

Mortality and early neonatal morbidity in vaginal and abdominal deliveries in breech presentation.

From January 1984 to June 1986, 268 consecutive breech presentations in two university hospitals were studied prospectively. Vaginal delivery was attempted in all cases, under expert supervision and electronic monitoring, except in the presence of clear-cut contraindications. For most of the examined parameters no statistically significant differences were found in mortality and morbidity between the vaginally delivered group and the caesarean section group in three birth weight categories. Regarding mortality a relation with the mode of delivery was demonstrable in two cases in the vaginal group and one case in the caesarean section group in the low and very low birth weight category. In the 500-1499 g birth weight category, underestimation of the birth weight during pregnancies led to iatrogenic neonatal death in two cases. Our study shows that the management of breech presentation can be modified in order to stop the increase in caesarean section rate and diminish the degree of variation in operative delivery without affecting the perinatal outcome.

Spontaneous rupture of a utero-ovarian vein during pregnancy.

Atraumatic rupture of a utero-ovarian vein during pregnancy is a potentially lethal complication that is likely to be misdiagnosed because of its rarity. We report the case of a 31-year-old woman at 25 weeks' gestation who had an acute abdomen and shock.

Indications for caesarean section in breech presentation.

OBJECTIVE: The study was conducted because of the still considerable controversies about the variation in obstetric management in breech presentation, in combination with the still increasing caesarean section rate for this type of presentation, as well as doubt concerning the assumed improvement in neonatal and maternal morbidity and mortality obtained by increasing section rate in breeches. STUDY DESIGN: Two hundred and sixty eight consecutive breech presentations in two university hospitals were studied longitudinally and prospectively. In principle, vaginal delivery was attempted in all cases, under expert supervision and electronic monitoring, except in the presence of clear-cut contraindications. X-ray pelvimetry was not used. RESULTS: The incidence of caesarean section was 34%. The trial of vaginal delivery succeeded in 64% of the nulliparas and in 60% of the non-frank breeches, without statistically significant differences in outcome measures compared with the multiparous women and the frank group, respectively. Hyperextension of the foetal head rarely occurred. CONCLUSION: Several classic obstetric factors have a lower discriminating value for the route of delivery than is currently assumed. Progress of labour was an important factor in determining the route of delivery.

T lymphocytes determine the development of xeno GVHD and of human hemopoiesis in NOD/SCID mice following human umbilical cord blood transplantation.

Over the past decade the human-immunodeficient mouse chimera has become a well-established in vivo model for studying the human immune system and/or hemopoiesis. Under certain experimental conditions and depending on the composition of the human cell graft, the recipient mice may develop a fatal disease, designated as discordant xenogenic graft-versus-host-disease (GVHD), which differs in target tissues and histopathology from allogenic GVHD. Experimental evidence is presented that immunodeficient mice are equally susceptible to allogenic GVHD as normal immunocompetent mice. Whole human cord blood and distinct cellular subpopulations from a single cord blood harvest were transplanted in NOD/severe combined immunodeficient mice and the repopulation of human cells was monitored over time. Depending on the ratio of lymphocytes to hemopoietic stem cells, proliferation of human T cells, hemopoiesis or a combination of the two is observed in widely varying proportions. When the graft contains a preponderance of lymphocytes, fatal protracted discordant xenogenic GVHD develops. Mice receiving purified CD34 cells survived up to 207 days in good health with more than 95% human cells in the bone marrow. In those mice all lineages (B and T lymphocytes, monocytes, granulocytes, erythrocytes and thrombocytes) were demonstrated in the bone marrow and peripheral blood.