Maternal vascular malperfusion in spontaneous preterm birth placentas related to clinical outcome of subsequent pregnancy.

INTRODUCTION: Spontaneous preterm birth (SPTB) has several causes and its pathophysiology remains unclear. In a significant proportion of SPTB, placental histology shows signs of maternal vascular malperfusion (MVM); commonly associated with hypertensive disorders of pregnancy (HD), fetal growth restriction (FGR) and placental abruption, together referred to as clinical ischemic placental diseases (IPD). We hypothesized that women with SPTB and placental MVM are at elevated risk for IPD in a subsequent pregnancy. METHODS: We included women with SPTB in our cohort and followed the subsequent ongoing pregnancy (n = 110). Histological placental characteristics in the index were reported according to new international guidelines, and related to the clinical outcome of the subsequent pregnancy. RESULTS: In the SPTB placentas, we observed MVM in 61.8% (n = 68). In the subsequent pregnancies in 19.1% (n = 21) at least one clinical sign of IPD was present (HD (12.7%), FGR (5.5%) or placental abruption (0.9%)). There was no significant difference in the prevalence of clinical IPD or recurrence of SPTB in the subsequent pregnancy between women with and without placental MVM in the index pregnancy, although our study was not powered to detect small differences. DISCUSSION: Women with a history of SPTB have an elevated risk of IPD in the subsequent pregnancy. MVM is present in a large proportion of SPTB placentas. The presence of placental MVM in the index pregnancy does not predict clinical IPD or recurrent SPTB in a subsequent pregnancy.

Organizational determinants of patient-centered fertility care: a multilevel analysis.

OBJECTIVE: To identify organizational determinants of positive patient experiences with fertility care, with the goal of improving patient centeredness of care. DESIGN: Cross-sectional survey. SETTING: One large university clinic and 12 medium-sized fertility clinics in the Netherlands. PATIENT(S): Three hundred and sixty-nine couples receiving medically assisted reproduction in one of the participating clinics between March and May 2008. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Organizational determinants of patients' experiences with patient centeredness in fertility care. RESULT(S): Of the patients during the relevant period, 78% of the women and 76% of their partners participated in the study. Infertile couples who have a lead physician, have access to an electronic personal health record, or see trained fertility nurses have more positive experiences with aspects of patient-centered care, like continuity of care and partner involvement. Moreover, receiving a treatment other than in vitro fertilization was negatively associated with the perceived patient centeredness of care. The identified determinants explained 5.1% to 22.4% of the total variance. CONCLUSION(S): This study provides organizational determinants of patients' experiences with fertility care on numerous facets of patient centeredness. These organizational determinants can be used as valuable tools to enable clinics to provide a more positive patient experience.