Rise in maternal mortality in the Netherlands.

OBJECTIVE: To assess causes, trends and substandard care factors in maternal mortality in the Netherlands. Design Confidential enquiry into the causes of maternal mortality. SETTING: Nationwide in the Netherlands. POPULATION: 2,557,208 live births. METHODS: Data analysis of all maternal deaths in the period 1993-2005. MAIN OUTCOME MEASURES: Maternal mortality. RESULTS: The overall maternal mortality ratio was 12.1 per 100 000 live births, which was a statistically significant rise compared with the maternal mortality ratio of 9.7 in the period 1983-1992 (OR 1.2, 95% CI 1.0-1.5). The most frequent direct causes were (pre-)eclampsia, thromboembolism, sudden death in pregnancy, sepsis, obstetric haemorrhage and amniotic fluid embolism. The number of indirect deaths also increased, mainly caused by an increase in cardiovascular disorders (OR 2.5, 95% CI 1.4-4.6). Women younger than 20 years and older than 45 years, those with high parity or from nonwestern immigrant populations were at higher risk. Most substandard care was found in women with pre-eclampsia (91%) and in immigrant populations (62%). CONCLUSIONS: Maternal mortality in the Netherlands has increased since 1983-1992. Pre-eclampsia remains the number one cause. Groups at higher risk for complications during pregnancy should be better identified early in pregnancy or before conception, in order to receive preconception advice and more frequent antenatal visits. There is an urgent need for the better education of women and professionals concerning the danger signs, and for the training of professionals in order to improve maternal health care.

A serious complication in the puerperium: peripartum cardiomyopathy.

Two women, aged 27, presented with different symptoms shortly after giving birth to their first child. Peripartum cardiomyopathy (PPCM) was diagnosed. PPCM is a rare form of cardiac failure occurring late in pregnancy or in the postpartum period. Many women experience dyspnoea, fatigue, and pedal oedema in the last month of pregnancy or postpartum, symptoms which are identical to early congestive heart failure. Therefore, the diagnosis of PPCM requires vigilance. A high mortality rate and overall poor clinical outcome has been reported in a high percentage of these patients. Subsequent pregnancies remain controversial. (Neth Heart J 2008;16:415-8.).

[Diagnostic image (242). Intrauterine fetal demise at term]. / Een aterme, in utero overleden vrucht.

In a 32-year-old woman, fetal demise at term was caused by constriction of the umbilical cord by an amniotic band.

Is aromatase cytochrome P450 involved in the pathogenesis of endometrioid endometrial cancer?

Prospectively, the relationship between androgen levels in the utero-ovarian circulation, aromatase activity in endometrial and body fat tissue, and the presence or absence of endometrioid endometrial cancer was studied in postmenopausal women. In 43 women with endometrioid endometrial cancer and 8 women with a benign gynecological condition, a hysterectomy with bilateral salpingo-oophorectomy was performed. Using tritium water-release assays, aromatase activities in endometrial and body fat tissue were determined and related to the steroid levels from the peripheral and the utero-ovarian venous circulation (estradiol, androstenedione, testosterone) and to the presence or absence of endometrial cancer. Significant aromatase activity was found in both benign and malignant endometrial tissue samples. Aromatase activity in samples of endometrial tissue and in samples of body fat did not correlate with steroid levels in peripheral or utero-ovarian venous blood. Aromatase activity in samples of benign or malignant endometrium did not differ. Remarkably, in four women with mainly poorly differentiated endometrial cancer, very high aromatase activity was found in endometrial tissue. It is likely that multiple pathogenetic pathways exist that eventually lead to the formation of endometrioid endometrial cancer. The local availability of androgens and the finding that aromatase activity is present in both endometrial cancer and benign endometrial tissue support the hypothesis that aromatase activity in the endometrium may play a role in malignant transformation by converting androgens into mitogenic estrogens in the endometrial tissue.

Ovarian stromal hyperplasia and ovarian vein steroid levels in relation to endometrioid endometrial cancer.

OBJECTIVE: To study the relationship between the presence of endometrioid endometrial cancer, the degree of ovarian stromal hyperplasia and ovarian steroid production in postmenopausal women. DESIGN: Retrospective and prospective study, respectively. SETTING: Medical Centre Leeuwarden and the University Hospital Groningen, The Netherlands. Postmenopausal women with or without endometrial cancer, undergoing a hysterectomy with bilateral salpingo-oophorectomy. METHODS: In 112 women with endometrioid endometrial cancer, 47 women with a benign gynaecological condition and 10 women with non-endometrioid endometrial cancer, the degree of ovarian stromal hyperplasia was scored retrospectively on a semi-quantitative scale (atrophy, slight, marked). All women were postmenopausal and had undergone a hysterectomy with bilateral salpingo-oophorectomy. Prospectively, blood sampling from the ovarian veins was performed in a further 60 women. Steroid levels (oestrone, oestradiol, androstenedione, testosterone) were determined and related to the degree of ovarian stromal hyperplasia and the presence (n = 52) or absence (n = 8) of endometrioid endometrial cancer. MAIN OUTCOME MEASURES: Degree of ovarian stromal hyperplasia and steroid levels in the utero-ovarian circulation. RESULTS: In the retrospective study, the degree of ovarian stromal hyperplasia was higher in the presence of endometrioid endometrial cancer (P = 0.0001). The prospective study showed that an increasing degree of ovarian stromal hyperplasia was related to higher ovarian levels of both testosterone and androstenedione (P < 0.05 and P < 0.005, respectively), but not to oestrone or oestradiol. A non-significant increase in mean ovarian vein levels of both testosterone and androstenedione was seen in patients with endometrial cancer as compared with patients with benign conditions. CONCLUSION: In endometrioid endometrial cancer, higher degrees of ovarian stromal hyperplasia were found and with increasing degrees of ovarian stromal hyperplasia, levels of ovarian vein androgens were higher. A causal relationship in the origin of hormone-dependent endometrial pathology may exist between ovarian stromal hyperplasia, ovarian vein androgen levels and endometrioid endometrial carcinoma.

[Neonatal outcome after a planned vaginal breech birth: no association with parity or birth weight, but more birth injuries than in planned cesarean section]. / Neonatale uitkomst na een in opzet vaginale bevalling bij aterme stuitligging: geen verband met pariteit of geboortegewicht, maar wel meer geboorteletsels dan bij primaire keizersnede.

OBJECTIVE: To investigate if in a planned vaginal breech delivery parity or birthweight is associated with neonatal outcome. DESIGN: Retrospective analysis of local data from the National Obstetric Registration of the Netherlands. METHOD: The study concerned outcomes of 516 births of singletons with breech presentation after pregnancies > 37 weeks in the period 1 January 1995 to 31 December 1999 at the Medical Centre Leeuwarden, the Netherlands; there were 448 planned vaginal breech deliveries. Nulliparous and multiparous were separately studied in four birthweight groups (< 3000 g, 3000-3499 g, 3500-3999 g and > or = 4000 g). RESULTS: None of the neonates born by primary caesarean experienced birth trauma. In the group with planned vaginal breech delivery 2% of the neonates of nulliparous and 3% of multiparous mothers experienced neonatal morbidity. There was one case of perinatal mortality due to birth trauma (0.2%). The total perinatal morbidity was 6% with no differences between nulliparae and multiparae and between the birthweight groups. In nulliparous, the percentage of emergency caesarean sections rose from 20% in the < 3000 g birthweight group to 62% in the > or = 4000 g birthweight group. CONCLUSION: Following a planned vaginal breech delivery, no differences were observed in neonatal outcome between nulliparous and multiparous women and between the four birthweight groups. The extent to which the figures were influenced by the selection for primary caesarean section is not clear.

Pre-eclampsia and the HELLP syndrome still cause maternal mortality in The Netherlands and other developed countries; can we reduce it?

Maternal mortality in developed countries does not seem to have decreased during the past decade, despite good prenatal care. Hypertensive disorders of pregnancy are the main cause of maternal mortality in most countries. In more than half of these cases, the HELLP syndrome is involved. In this article attention is drawn again to the life-threatening complications that might occur in cases of pre- eclampsia and the HELLP syndrome. Two case histories with fatal outcomes are described to provide extra emphasis. The literature indicates that some cases of maternal mortality might be avoidable. From a review of the literature, suggestions and recommendations are made about how to achieve a decrease in maternal mortality from pre-eclampsia/the HELLP syndrome. The most important are the making of an early, correct diagnosis, anticipating the possibilities of serious complications, and, if necessary, early referral to a regional centre with special expertise.

Maternal and perinatal complications in triplet compared with twin pregnancy.

OBJECTIVE: To compare maternal and perinatal complications in triplet and twin pregnancies. STUDY DESIGN: Case-controlled study in the setting of a University Hospital. Each pregnancy of a consecutive series of 40 triplet pregnancies of 20 weeks or more was matched for parity and maternal age with two sets of twins delivered in the same year. Primary end points of the analysis were maternal complications and perinatal outcome. RESULTS: Of the triplets 82% and of the twins 36% were a result of assisted reproduction. Pre-term labor occurred significantly more often in triplet than in twin gestation. Triplets had a significantly lower median birth-weight (1478 vs. 2030 g) and gestational age at delivery (32 vs. 35.5 weeks). The mean neonatal hospital stay was significantly longer in triplets, mainly related to the lower birth-weight, but there was no significant difference between triplets and twins in the incidence of major neonatal complications. CONCLUSION: This data of the anticipated perinatal outcome in triplet and twin pregnancies may be used to counsel women with a triplet pregnancy considering selective reduction to twins. All methods of assisted reproduction should aim at prevention of multifetal gestation.

Expectant management of twin pregnancy with single fetal death.

OBJECTIVE: To evaluate the course and outcome of expectantly managed twin pregnancies with single fetal death in the second half of gestation. DESIGN: Case-controlled study of 29 consecutive pregnancies from 1973 to 1993, with sonographic evidence of a twin at 20 weeks gestation with antenatal demise later in pregnancy, matched for maternal parity with 58 twin pregnancies without fetal death and delivered in the same year as the index case. Outcome measures included the incidence of complications of pregnancy, gestational age and mode of delivery, placentation, and perinatal outcome. SETTING: University Hospital Rotterdam. RESULTS: The frequency and severity of pregnancy-induced hypertensive disorders was significantly higher in the study group than in controls. We found no differences between the study group and controls with regard to median gestational age at delivery (33 weeks versus 34 weeks) and median birthweight of liveborn infants (1880 g versus 2160 g). No consumptive coagulopathy was apparent in our 29 patients. The main cause of neonatal death was prematurity; multicystic encephalomalacia was not observed. CONCLUSIONS: Our results support expectant management in twin pregnancies complicated by single fetal death.

Hypertensive disorders in twin pregnancy.

OBJECTIVE: To compare the incidence and severity of pregnancy-induced hypertensive disorders in twin pregnancy and in singleton gestation. STUDY DESIGN: Case-control study in the setting of a University Hospital. Each pregnancy of a consecutive series of 187 twin pregnancies attending the antenatal clinic and booked before a gestational age of 24 weeks was matched for maternal age, parity, and gestational age at delivery with a singleton pregnancy delivered in the same year. Primary end points of the analysis of the course and outcome of pregnancy were pregnancy-induced hypertension and proteinuric pre-eclampsia. RESULTS: In the twin pregnancy group, 21% of patients met the criteria for the diagnosis of a pregnancy-induced hypertensive disorder, compared with 13% in the singleton pregnancy group (P < 0.05). The difference was due to a significantly higher incidence of pregnancy-induced hypertension in twin (15%) than in singleton (6%) pregnancy (P < 0.05), in particular in nulliparous women. The incidence of pre-eclampsia was similar in twin (6%) and singleton pregnancies (6.5%), without a difference in severity and in the occurrence of the HELLP syndrome. CONCLUSION: The incidence of non-proteinuric pregnancy-induced hypertension, but not of proteinuric pre-eclampsia, is increased in twin pregnancy.

Perinatal listeriosis in a Dutch woman returning from holiday in France.

A case is reported of perinatal infection and fetal death due to Listeria monocytogenes serotype 4B in a 28-weeks pregnant woman, who had spent her holiday in an area in France where an epidemic outbreak of listeriosis had occurred. Sero- and phage-typing combined with sensitive DNA-typing demonstrated that the Listeria was identical to the strain responsible for the outbreak in France. Although listeriosis appears to be an uncommon cause of perinatal infection, practicing obstetricians should be aware of the possibility.

Preterm delivery rate and fetal outcome in structurally affected twin pregnancies: a retrospective matched control study.

Data from 23 twin pregnancies with one structurally affected fetus were compared with data from 23 twin pregnancies with proven absence of structural fetal anomalies and matched for maternal age, parity, and year of delivery. The preterm delivery rate (< 37 weeks) was high in both groups but not significantly different (57 vs. 48 per cent). Perinatal mortality was significantly higher in the structurally affected twin pregnancies (65 vs. 9 per cent). In the affected twins, birth weight of the anomalous fetus was significantly lower than that of the normal co-twin. Since there was no difference in the incidence of maternal disease (hypertensive disorders, diabetes), it was concluded that the higher perinatal mortality was determined mainly by the nature of the anomaly and not by the preterm delivery rate.

The predictive value of Doppler flow velocity waveforms in the development of abnormal fetal heart rate traces in intrauterine growth retardation: a longitudinal study.

In a longitudinal, blinded study design the predictive value of Doppler velocimetry for the development of an abnormal fetal heart rate trace was assessed in 42 cases of intrauterine growth retardation. Doppler velocity waveform recordings were obtained at 2- to 3-day intervals and characterized by the standard deviation score of the pulsatility index in the umbilical artery and internal carotid artery, and the peak systolic and time-averaged velocity in the ascending aorta and pulmonary artery. Twenty-seven patients did not display an abnormal fetal heart rate trace on the day of entry into the study. During follow-up of these patients, the pulsatility index in the umbilical artery and internal carotid artery were the most predictive parameters for the development of an abnormal fetal heart rate trace. The resulting prognostic index was found to have an acceptable discriminative power in the prediction of abnormal fetal heart rate traces as established in a second group of growth-retarded fetuses.

Perinatal mortality in Curacao, Netherlands Antilles

The Perinatal Mortality Rate (PNMR) is considered to be an indicator of perinatal health. To ascertain the validity of the perinatal mortality statistics in Curacao, medical records and death certificates were reviewed over a five year period. Using a birth weight of 1,000 gm as a cut-off point, 366 foetal and first-week deaths were recovered from the statutory death certificates. Using similar criteria, 19 perinatal deaths, identified in the medical records, were not registered as such on the death certificates (registration failure 4.9 percent). Hence, the revised annual PNMR ranged from 19.0 to 31.2 per 1,000 births during the period 1979-1983. Additionally, the contribution of low birth weight (LBW)(<2,500gm) to perinatal mortality was examined during 1984-1985. LBW was associated with 68.6 percent of all perinatal deaths using a birth weight of 500gm as truncation point. However, it is argued that the high proportion of LBW to perinatal mortality is not the result of an adverse birth weight distribution of the Curacao population (AU)