1
|
Duvekot JJ, Duijnhoven RG, van Horen E, Bax CJ, Bloemenkamp KW, Brussé IA, Dijk PH, Franssen MT, Franx A, Oudijk MA, Porath MM, Scheepers HC, van Wassenaer-Leemhuis AG, van Drongelen J, Mol BW, Ganzevoort W. Temporizing management vs immediate delivery in early-onset severe preeclampsia between 28 and 34 weeks of gestation (TOTEM study): An open-label randomized controlled trial. Acta Obstet Gynecol Scand 2020; 100:109-118. [PMID: 33319930 PMCID: PMC7754130 DOI: 10.1111/aogs.13976] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 08/02/2020] [Accepted: 08/09/2020] [Indexed: 12/11/2022]
Abstract
Introduction There is little evidence to guide the timing of delivery of women with early‐onset severe preeclampsia. We hypothesize that immediate delivery is not inferior for neonatal outcome but reduces maternal complications compared with temporizing management. Material and methods This Dutch multicenter open‐label randomized clinical trial investigated non‐inferiority for neonatal outcome of temporizing management as compared with immediate delivery (TOTEM NTR 2986) in women between 27+5 and 33+5 weeks of gestation admitted for early‐onset severe preeclampsia with or without HELLP syndrome. In participants allocated to receive immediate delivery, either induction of labor or cesarean section was initiated at least 48 hours after admission. Primary outcomes were adverse perinatal outcome, defined as a composite of severe respiratory distress syndrome, bronchopulmonary dysplasia, culture proven sepsis, intraventricular hemorrhage grade 3 or worse, periventricular leukomalacia grade 2 or worse, necrotizing enterocolitis stage 2 or worse, and perinatal death. Major maternal complications were secondary outcomes. It was estimated 1130 women needed to be enrolled. Analysis was by intention‐to‐treat. Results The trial was halted after 35 months because of slow recruitment. Between February 2011 and December 2013, a total of 56 women were randomized to immediate delivery (n = 26) or temporizing management (n = 30). Median gestational age at randomization was 30 weeks. Median prolongation of pregnancy was 2 days (interquartile range 1‐3 days) in the temporizing management group. Mean birthweight was 1435 g after immediate delivery vs 1294 g after temporizing management (P = .14). The adverse perinatal outcome rate was 55% in the immediate delivery group vs 52% in the temporizing management group (relative risk 1.06; 95% confidence interval 0.67‐1.70). In both groups there was one neonatal death and no maternal deaths. In the temporizing treatment group, one woman experienced pulmonary edema and one placental abruption. Analyses of only the singleton pregnancies did not result in other outcomes. Conclusions Early termination of the trial precluded any conclusions for the main outcomes. We observed that temporizing management resulted in a modest prolongation of pregnancy without changes in perinatal and maternal outcome. Conducting a randomized study for this important research question did not prove feasible.
Collapse
Affiliation(s)
- Johannes J Duvekot
- Department of Obstetrics and Gynecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ruben G Duijnhoven
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam Medical Center, Amsterdam, The Netherlands
| | - Eva van Horen
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam Medical Center, Amsterdam, The Netherlands
| | - Caroline J Bax
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam Medical Center, Amsterdam, The Netherlands
| | - Kitty W Bloemenkamp
- Department of Obstetrics, Division Woman and Baby, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ingrid A Brussé
- Department of Obstetrics and Gynecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Peter H Dijk
- Department of Neonatology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maureen T Franssen
- Department of Obstetrics and Gynecology, University Medical Center Groningen, Groningen, The Netherlands
| | - Arie Franx
- Department of Obstetrics and Gynecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Martijn A Oudijk
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam Medical Center, Amsterdam, The Netherlands
| | - Martina M Porath
- Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven, The Netherlands
| | - Hubertina C Scheepers
- Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Joris van Drongelen
- Department of Obstetrics and Gynecology, Radboud University Medical Cernter, Nijmegen, The Netherlands
| | - Ben W Mol
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam Medical Center, Amsterdam, The Netherlands.,Department of Obstetrics and Gynecology, Monash University, Clayton, VIC, Australia
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam Medical Center, Amsterdam, The Netherlands
| | | |
Collapse
|
2
|
Witteveen T, Kallianidis A, Zwart JJ, Bloemenkamp KW, van Roosmalen J, van den Akker T. Laparotomy in women with severe acute maternal morbidity: secondary analysis of a nationwide cohort study. BMC Pregnancy Childbirth 2018; 18:61. [PMID: 29482505 PMCID: PMC5828385 DOI: 10.1186/s12884-018-1688-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 02/14/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although pregnancy-related laparotomy is a major intervention, literature is limited to small case-control or single center studies. We aimed to identify national incidence rates for postpartum laparotomy related to severe acute maternal morbidity (SAMM) in a high-income country and test the hypothesis that risk of postpartum laparotomy differs by mode of birth. METHODS In a population-based cohort study in all 98 hospitals with a maternity unit in the Netherlands, pregnant women with SAMM according to specified disease and management criteria were included from 01/08/2004 to 01/08/2006. We calculated the incidence of postpartum laparotomy after vaginal and cesarean births. Laparotomies were analyzed in relation to mode of birth using all births in the country as reference. Relative risks (RR) were calculated for laparotomy following emergency and planned cesarean section compared to vaginal birth, excluding laparotomies following births before 24 weeks' gestation and hysterectomies performed during cesarean section. RESULTS The incidence of postpartum laparotomy in women with SAMM in the Netherlands was 6.0 per 10,000 births. Incidence was 30.1 and 1.8 per 10,000 following cesarean and vaginal birth respectively. Compared to vaginal birth, RR of laparotomy after cesarean birth was 16.7 (95% confidence interval [95% CI] 12.2-22.6). RR was 21.8 (95% CI 15.8-30.2) for emergency and 10.5 (95% CI 7.1-15.6) for planned cesarean section. CONCLUSIONS Risk of laparotomy, although small, was considerably elevated in women who gave birth by cesarean section. This should be considered in counseling and clinical decision making.
Collapse
Affiliation(s)
- Tom Witteveen
- Department of Obstetrics, Leiden University Medical Center, building 1, room K-6-P-35, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - Athanasios Kallianidis
- Department of Obstetrics, Leiden University Medical Center, building 1, room K-6-P-35, P.O. Box 9600, 2300 RC Leiden, The Netherlands
- Department of Obstetrics and Gynecology, Haga Teaching Hospital, Els Borst-Eilersplein 275, 2545 AA Den Haag, The Netherlands
| | - Joost J. Zwart
- Department of Obstetrics and Gynecology, Deventer Ziekenhuis, Nico Bolkesteinlaan 75, 7416 SE Deventer, The Netherlands
| | - Kitty W. Bloemenkamp
- Department of Obstetrics, Wilhelmina Children’s Hospital Birth Centre, University Medical Centre Utrecht, Lundlaan 6, 3584 EA Utrecht, The Netherlands
| | - Jos van Roosmalen
- Department of Obstetrics, Leiden University Medical Center, building 1, room K-6-P-35, P.O. Box 9600, 2300 RC Leiden, The Netherlands
- Athena Institute, Faculty of Science, VU University Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands
| | - Thomas van den Akker
- Department of Obstetrics, Leiden University Medical Center, building 1, room K-6-P-35, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| |
Collapse
|
3
|
Witteveen T, Bezstarosti H, de Koning I, Nelissen E, Bloemenkamp KW, van Roosmalen J, van den Akker T. Validating the WHO maternal near miss tool: comparing high- and low-resource settings. BMC Pregnancy Childbirth 2017. [PMID: 28629394 PMCID: PMC5477239 DOI: 10.1186/s12884-017-1370-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background WHO proposed the WHO Maternal Near Miss (MNM) tool, classifying women according to several (potentially) life-threatening conditions, to monitor and improve quality of obstetric care. The objective of this study is to analyse merged data of one high- and two low-resource settings where this tool was applied and test whether the tool may be suitable for comparing severe maternal outcome (SMO) between these settings. Methods Using three cohort studies that included SMO cases, during two-year time frames in the Netherlands, Tanzania and Malawi we reassessed all SMO cases (as defined by the original studies) with the WHO MNM tool (five disease-, four intervention- and seven organ dysfunction-based criteria). Main outcome measures were prevalence of MNM criteria and case fatality rates (CFR). Results A total of 3172 women were studied; 2538 (80.0%) from the Netherlands, 248 (7.8%) from Tanzania and 386 (12.2%) from Malawi. Total SMO detection was 2767 (87.2%) for disease-based criteria, 2504 (78.9%) for intervention-based criteria and 1211 (38.2%) for organ dysfunction-based criteria. Including every woman who received ≥1 unit of blood in low-resource settings as life-threatening, as defined by organ dysfunction criteria, led to more equally distributed populations. In one third of all Dutch and Malawian maternal death cases, organ dysfunction criteria could not be identified from medical records. Conclusions Applying solely organ dysfunction-based criteria may lead to underreporting of SMO. Therefore, a tool based on defining MNM only upon establishing organ failure is of limited use for comparing settings with varying resources. In low-resource settings, lowering the threshold of transfused units of blood leads to a higher detection rate of MNM. We recommend refined disease-based criteria, accompanied by a limited set of intervention- and organ dysfunction-based criteria to set a measure of severity. Electronic supplementary material The online version of this article (doi:10.1186/s12884-017-1370-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Tom Witteveen
- Department of Obstetrics, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, the Netherlands.
| | - Hans Bezstarosti
- Department of Obstetrics, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, the Netherlands
| | - Ilona de Koning
- Department of Obstetrics, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, the Netherlands
| | - Ellen Nelissen
- Department of Obstetrics and Gynaecology, North Bristol NHS Trust, Southmead Hospital, Westbury-on-Trym, Bristol, BS10 5NB, UK
| | - Kitty W Bloemenkamp
- Department of Obstetrics, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, the Netherlands.,Wilhelmina Children's Hospital Birth Center, University Medical Center Utrecht, Lundlaan 6, 3584 EA, Utrecht, the Netherlands
| | - Jos van Roosmalen
- Department of Obstetrics, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, the Netherlands.,Athena Institute, VU University Amsterdam, De Boelelaan 1085, 1081 HV, Amsterdam, the Netherlands
| | - Thomas van den Akker
- Department of Obstetrics, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, the Netherlands
| |
Collapse
|
4
|
Witteveen T, Van Den Akker T, Zwart JJ, Bloemenkamp KW, Van Roosmalen J. Severe acute maternal morbidity in multiple pregnancies: a nationwide cohort study. Am J Obstet Gynecol 2016; 214:641.e1-641.e10. [PMID: 26576487 DOI: 10.1016/j.ajog.2015.11.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 10/14/2015] [Accepted: 11/05/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Adverse neonatal outcomes in multiple pregnancies have been documented extensively, in particular those associated with the increased risk of preterm birth. Paradoxically, much less is known about adverse maternal events. The combined risk of severe acute maternal morbidity in multiple pregnancies has not been documented previously in any nationwide prospective study. OBJECTIVE The objective of the study was to assess the risk of severe acute maternal morbidity in multiple pregnancies in a high-income European country and identify possible risk indicators. STUDY DESIGN In a population-based cohort study including all 98 hospitals with a maternity unit in The Netherlands, pregnant women with severe acute maternal morbidity were included in the period Aug. 1, 2004, until Aug. 1, 2006. We calculated the incidence of severe acute maternal morbidity in multiple pregnancies in The Netherlands using The Netherlands Perinatal Registry. Relative risks (RR) of severe acute maternal morbidity in multiple pregnancies compared with singletons were calculated. To identify possible risk indicators, we also compared age, parity, method of conception, onset of labor, and mode of delivery for multiple pregnancies using The Netherlands Perinatal Registry as reference. RESULTS A total of 2552 cases of severe acute maternal morbidity were reported during the 2 year study period. Among 202 multiple pregnancies (8.0%), there were 197 twins (7.8%) and 5 triplets (0.2%). The overall incidence of severe acute maternal morbidity was 7.0 per 1000 deliveries and 6.5 and 28.0 per 1000 for singletons and multiple pregnancies, respectively. The relative risk of severe acute maternal morbidity compared with singleton pregnancies was 4.3 (95% confidence interval [CI], 3.7-5.0) and increased to 6.2 (95% CI 2.5-15.3) in triplet pregnancies. Risk indicators for developing severe acute maternal morbidity in women with multiple pregnancies were age of ≥ 40 years, (RR, 2.5 95% CI, 1.4-4.3), nulliparity (RR, 1.8, 95% CI, 1.4-2.4), use of assisted reproductive techniques (RR, 1.9, 95% CI, 1.4-2.5), and nonspontaneous onset of delivery (RR, 1.6, 95% CI, 1.2-2.1). No significant difference was found between mono- and dichorionic twins (RR, 0.8, 95% CI, 0.6-1.2). CONCLUSION Women with multiple pregnancies in The Netherlands have a more than 4 times elevated risk of sustaining severe acute maternal morbidity as compared with singletons.
Collapse
|
5
|
Witteveen T, de Koning I, Bezstarosti H, van den Akker T, van Roosmalen J, Bloemenkamp KW. Validating the WHO Maternal Near Miss Tool in a high-income country. Acta Obstet Gynecol Scand 2015; 95:106-11. [PMID: 26456014 DOI: 10.1111/aogs.12793] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 09/19/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION This study was performed to assess the applicability of the WHO Maternal Near Miss Tool (MNM Tool) and the organ dysfunction criteria in a high-income country. MATERIAL AND METHODS The MNM tool was applied to 2552 women who died of pregnancy-related causes or sustained severe acute maternal morbidity between August 2004 and August 2006 in one of the 98 hospitals with a maternity unit in the Netherlands. Fourteen (0.6%) cases had insufficient data for application. Each case was assessed according to the three main "MNM categories" specified in the MNM tool and their subcategory criteria: five disease-, four intervention- and seven organ dysfunction-based criteria. Potentially life-threatening conditions (disease-based inclusions) and life-threatening cases (organ dysfunction-based inclusions) were differentiated according to WHO methodology. Outcomes were incidence of all (sub)categories and case-fatality rates. RESULTS Of the 2538 cases, 2308 (90.9%) women fulfilled disease-based, 2116 (83.4%) intervention-based and 1024 (40.3%) organ dysfunction-based criteria. Maternal death occurred in 48 women, of whom 23 (47.9%) fulfilled disease-based, 33 (68.8%) intervention-based and 31 (64.6%) organ dysfunction-based criteria. Case-fatality rates were 23/2308 (1.0%) for cases fulfilling the disease-based criteria, 33/2116 (1.6%) for intervention-based criteria and 31/1024 (3.0%) for women fulfilling the organ dysfunction-based criteria. CONCLUSIONS In the Netherlands, where advanced laboratory and clinical monitoring are available, organ dysfunction-based criteria of the MNM tool failed to identify nearly two-thirds of sustained severe acute maternal morbidity cases and more than one-third of maternal deaths. Disease-based criteria remain important, and using only organ dysfunction-based criteria would lead to underestimating severe acute maternal morbidity.
Collapse
Affiliation(s)
- Tom Witteveen
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Ilona de Koning
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Hans Bezstarosti
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Thomas van den Akker
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Jos van Roosmalen
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands.,Athena Institute, VU University Amsterdam, Amsterdam, the Netherlands
| | - Kitty W Bloemenkamp
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
6
|
Vis JY, van Baaren GJ, Wilms FF, Oudijk MA, Kwee A, Porath MM, Scheepers HC, Spaanderman ME, Bloemenkamp KW, van Lith JM, Bolte AC, Bax CJ, Cornette J, Duvekot JJ, Nij Bijvank SW, van Eyck J, Franssen MT, Sollie KM, Woiski M, Vandenbussche FP, van der Post JA, Bossuyt PM, Opmeer BC, Mol BW. Randomized comparison of nifedipine and placebo in fibronectin-negative women with symptoms of preterm labor and a short cervix (APOSTEL-I Trial). Am J Perinatol 2015; 32:451-60. [PMID: 25486290 DOI: 10.1055/s-0034-1390346] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate whether tocolysis with nifedipine can be omitted in women with symptoms of preterm labor, a shortened cervix, and negative fetal fibronectin test. STUDY DESIGN A randomized noninferiority trial was performed in all Dutch perinatal centers. Women with symptoms of preterm labor between 24 and 34 weeks, intact membranes, cervical length between 10 and 30 mm, and negative fibronectin test were randomly allocated to nifedipine (80 mg/day) or placebo. The primary outcome was delivery within 7 days. Secondary outcomes were severe neonatal morbidity and mortality. We also followed all eligible nonrandomized women. RESULTS We allocated 37 women to nifedipine and 36 women to placebo. In the nifedipine group, three women (8.1%) delivered within 7 days, compared with one woman (2.8%) in the placebo group (difference -5.3%; one-sided 95% confidence limit 4.5%). Median gestational age at delivery were respectively 37 + 0 (interquartile range [IQR] 34 + 6 to 38 + 5) and 38 + 2 (IQR 37 + 0 to 39 + 6) weeks (p = 0.008). In the nifedipine group, three pregnancies (8.1%) had a poor outcome; there were no poor outcomes in the placebo group. We observed similar trends in eligible nonrandomized women. CONCLUSION In symptomatic women with preterm labor, a shortened cervix, and negative fibronectin test, placebo treatment is not inferior to tocolysis with nifedipine.
Collapse
Affiliation(s)
- Jolande Y Vis
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert-Jan van Baaren
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, The Netherlands
| | - Femke F Wilms
- Department of Obstetrics and Gynaecology, Máxima Medical Center, Veldhoven, The Netherlands
| | - Martijn A Oudijk
- Department of Obstetrics and Gynaecology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anneke Kwee
- Department of Obstetrics and Gynaecology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martina M Porath
- Department of Obstetrics and Gynaecology, University Hospital Maastricht, Maastricht, The Netherlands
| | - Hubertina C Scheepers
- Department of Obstetrics and Gynaecology, University Hospital Maastricht, Maastricht, The Netherlands
| | - Marc E Spaanderman
- Department of Obstetrics and Gynaecology, University Hospital Maastricht, Maastricht, The Netherlands
| | - Kitty W Bloemenkamp
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan M van Lith
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Antoinette C Bolte
- Department of Obstetrics and Gynaecology, VU University Medical Center, Amsterdam, The Netherlands
| | - Caroline J Bax
- Department of Obstetrics and Gynaecology, VU University Medical Center, Amsterdam, The Netherlands
| | - Jérôme Cornette
- Department of Obstetrics and Gynaecology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Johannes J Duvekot
- Department of Obstetrics and Gynaecology, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Jim van Eyck
- Department of Obstetrics and Gynaecology, Isala Clinics, Zwolle, The Netherlands
| | - Maureen T Franssen
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, Groningen, The Netherlands
| | - Krystyna M Sollie
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, Groningen, The Netherlands
| | - Mallory Woiski
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Frank P Vandenbussche
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Joris A van der Post
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, The Netherlands
| | - Patrick M Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Amsterdam, The Netherlands
| | - Brent C Opmeer
- Clinical Research Unit, Academic Medical Center, Amsterdam, The Netherlands
| | - Ben W Mol
- School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, Australia
| |
Collapse
|
7
|
Freeman LM, Bloemenkamp KW, Franssen MT, Papatsonis DN, Hajenius PJ, Hollmann MW, Woiski MD, Porath M, van den Berg HJ, van Beek E, Borchert OWHM, Schuitemaker N, Sikkema JM, Kuipers AHM, Logtenberg SLM, van der Salm PCM, Oude Rengerink K, Lopriore E, van den Akker-van Marle ME, le Cessie S, van Lith JM, Struys MM, Mol BWJ, Dahan A, Middeldorp JM. Patient controlled analgesia with remifentanil versus epidural analgesia in labour: randomised multicentre equivalence trial. BMJ 2015; 350:h846. [PMID: 25713015 PMCID: PMC4353278 DOI: 10.1136/bmj.h846] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine women's satisfaction with pain relief using patient controlled analgesia with remifentanil compared with epidural analgesia during labour. DESIGN Multicentre randomised controlled equivalence trial. SETTING 15 hospitals in the Netherlands. PARTICIPANTS Women with an intermediate to high obstetric risk with an intention to deliver vaginally. To exclude a clinically relevant difference in satisfaction with pain relief of more than 10%, we needed to include 1136 women. Because of missing values for satisfaction this number was increased to 1400 before any analysis. We used multiple imputation to correct for missing data. INTERVENTION Before the onset of active labour consenting women were randomised to a pain relief strategy with patient controlled remifentanil or epidural analgesia if they requested pain relief during labour. MAIN OUTCOME MEASURES Primary outcome was satisfaction with pain relief, measured hourly on a visual analogue scale and expressed as area under the curve (AUC), thus providing a time weighted measure of total satisfaction with pain relief. A higher AUC represents higher satisfaction with pain relief. Secondary outcomes were pain intensity scores, mode of delivery, and maternal and neonatal outcomes. Analysis was done by intention to treat. The study was defined as an equivalence study for the primary outcome. RESULTS 1414 women were randomised, of whom 709 were allocated to patient controlled remifentanil and 705 to epidural analgesia. Baseline characteristics were comparable. Pain relief was ultimately used in 65% (447/687) in the remifentanil group and 52% (347/671) in the epidural analgesia group (relative risk 1.32, 95% confidence interval 1.18 to 1.48). Cross over occurred in 7% (45/687) and 8% (51/671) of women, respectively. Of women primarily treated with remifentanil, 13% (53/402) converted to epidural analgesia, while in women primarily treated with epidural analgesia 1% (3/296) converted to remifentanil. The area under the curve for total satisfaction with pain relief was 30.9 in the remifentanil group versus 33.7 in the epidural analgesia group (mean difference -2.8, 95% confidence interval -6.9 to 1.3). For who actually received pain relief the area under the curve for satisfaction with pain relief after the start of pain relief was 25.6 in the remifentanil group versus 36.1 in the epidural analgesia group (mean difference -10.4, -13.9 to -7.0). The rate of caesarean section was 15% in both groups. Oxygen saturation was significantly lower (SpO2 <92%) in women who used remifentanil (relative risk 1.5, 1.4 to 1.7). Maternal and neonatal outcomes were comparable between both groups. CONCLUSION In women in labour, patient controlled analgesia with remifentanil is not equivalent to epidural analgesia with respect to scores on satisfaction with pain relief. Satisfaction with pain relief was significantly higher in women who were allocated to and received epidural analgesia. TRIAL REGISTRATION Netherlands Trial Register NTR2551.
Collapse
Affiliation(s)
- Liv M Freeman
- Obstetrics, Leiden University Medical Centre, Leiden, Netherlands
| | | | - Maureen T Franssen
- Obstetrics and Gynaecology, University Medical Centre Groningen, Groningen, Netherlands
| | | | - Petra J Hajenius
- Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, Netherlands
| | | | - Mallory D Woiski
- Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Martina Porath
- Obstetrics and Gynaecology, Maxima Medical Centre, Veldhoven, Netherlands
| | | | - Erik van Beek
- Obstetrics and Gynaecology, Saint Antonius Hospital, Nieuwegein, Netherlands
| | | | - Nico Schuitemaker
- Obstetrics and Gynaecology, Diakonessen Hospital, Utrecht, Netherlands
| | - J Marko Sikkema
- Obstetrics and Gynaecology, Hospital Group Twente, Almelo, Netherlands
| | - A H M Kuipers
- Anaesthesiology, Hospital Group Twente, Almelo, Netherlands
| | | | | | | | - Enrico Lopriore
- Paediatrics, Leiden University Medical Centre, Leiden, Netherlands
| | | | - Saskia le Cessie
- Medical Statistics and Clinical Epidemiology, Leiden University Medical Centre, Leiden, Netherlands
| | - Jan M van Lith
- Obstetrics, Leiden University Medical Centre, Leiden, Netherlands
| | - Michel M Struys
- Anaesthesiology, University of Groningen and University Medical Centre Groningen, Groningen, Netherlands
| | - Ben Willem J Mol
- Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide, Australia
| | - Albert Dahan
- Anaesthesiology, Leiden University Medical Centre, Leiden, Netherlands
| | | |
Collapse
|
8
|
Buurma A, Cohen D, Veraar K, Schonkeren D, Claas FH, Bruijn JA, Bloemenkamp KW, Baelde HJ. Preeclampsia is characterized by placental complement dysregulation. Hypertension 2012; 60:1332-7. [PMID: 23006730 DOI: 10.1161/hypertensionaha.112.194324] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Increasing evidence suggests that preeclampsia is associated with complement dysregulation. The origin of complement dysregulation in preeclampsia is unknown, and further unraveling this mechanism could provide both diagnostic tools and therapeutic targets. Because the placenta is believed to play a crucial role in the pathogenesis of preeclampsia, we investigated placentas from preeclamptic women (n=28) and controls (n=44) for the presence of complement activation products. Immunohistochemistry was performed for C1q, mannose-binding lectin, properdin, and C4d. Staining patterns were related to pregnancy outcome. Possible causes of complement activation were investigated, including the presence of immune deposits at the syncytiotrophoblast and changes in the placental mRNA expression of complement regulatory proteins. C4d was rarely present in placentas from healthy controls (3%), whereas it was observed in 50% of placentas obtained from preeclamptic women (P=0.001). In these placentas, C4d was observed in a focal (9/14) or diffuse (5/14) staining pattern at the syncytiotrophoblast. With respect to C1q, mannose-binding lectin, and properdin, no differences were observed between cases and controls. In preeclamptic women, diffuse placental C4d was associated with a significantly lower gestational age at delivery. Furthermore, the mRNA expression of the complement regulatory proteins CD55 and CD59 was significantly upregulated in preeclampsia. In conclusion, there is evidence for increased classical pathway activation and altered complement regulation in preeclampsia. The relation between C4d and lower gestational age at birth suggests that the extent of complement dysregulation is associated with the severity of preeclampsia. Inhibiting excessive complement activation may be a promising therapeutic approach in the management of preeclampsia.
Collapse
Affiliation(s)
- Aletta Buurma
- Department of Pathology, Leiden University Medical Center, L1 Q, PO Box 9600, P0-107, 2300 RC Leiden, the Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|
9
|
Tajik P, van der Tuuk K, Koopmans CM, Groen H, van Pampus MG, van der Berg PP, van der Post JA, van Loon AJ, de Groot CJM, Kwee A, Huisjes AJM, van Beek E, Papatsonis DNM, Bloemenkamp KW, van Unnik GA, Porath M, Rijnders RJ, Stigter RH, de Boer K, Scheepers HC, Zwinderman AH, Bossuyt PM, Mol BW. Should cervical favourability play a role in the decision for labour induction in gestational hypertension or mild pre-eclampsia at term? An exploratory analysis of the HYPITAT trial. BJOG 2012; 119:1123-30. [PMID: 22703475 PMCID: PMC3440582 DOI: 10.1111/j.1471-0528.2012.03405.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2012] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To examine whether cervical favourability (measured by cervical length and the Bishop score) should inform obstetricians' decision regarding labour induction for women with gestational hypertension or mild pre-eclampsia at term. DESIGN A post hoc analysis of the Hypertension and Pre-eclampsia Intervention Trial At Term (HYPITAT). SETTING Obstetric departments of six university and 32 teaching and district hospitals in the Netherlands. POPULATION A total of 756 women diagnosed with gestational hypertension or pre-eclampsia between 36 + 0 and 41 + 0 weeks of gestation randomly allocated to induction of labour or expectant management. METHODS Data were analysed using logistic regression modelling. MAIN OUTCOME MEASURES The occurrence of a high-risk maternal situation defined as either maternal complications or progression to severe disease. Secondary outcomes were caesarean delivery and adverse neonatal outcomes. RESULTS The superiority of labour induction in preventing high-risk situations in women with gestational hypertension or mild pre-eclampsia at term varied significantly according to cervical favourability. In women who were managed expectantly, the longer the cervix the higher the risk of developing maternal high-risk situations, whereas in women in whom labour was induced, cervical length was not associated with a higher probability of maternal high-risk situations (test of interaction P = 0.03). Similarly, the beneficial effect of labour induction on reducing the caesarean section rate was stronger in women with an unfavourable cervix. CONCLUSION Against widely held opinion, our exploratory analysis showed that women with gestational hypertension or mild pre-eclampsia at term who have an unfavourable cervix benefited more from labour induction than other women. TRIAL REGISTRATION The trial has been registered in the clinical trial register as ISRCTN08132825.
Collapse
Affiliation(s)
- P Tajik
- Academic Medical Centre, Amsterdam, the Netherlands.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
van Mello NM, Zietse CS, Mol F, Zwart JJ, van Roosmalen J, Bloemenkamp KW, Ankum WM, van der Veen F, Mol BWJ, Hajenius PJ. Severe maternal morbidity in ectopic pregnancy is not associated with maternal factors but may be associated with quality of care. Fertil Steril 2012; 97:623-9. [DOI: 10.1016/j.fertnstert.2011.12.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Revised: 12/13/2011] [Accepted: 12/16/2011] [Indexed: 11/26/2022]
|
11
|
Bijlenga D, Koopmans CM, Birnie E, Mol BWJ, van der Post JA, Bloemenkamp KW, Scheepers HC, Willekes C, Kwee A, Heres MH, Van Beek E, Van Meir CA, Van Huizen ME, Van Pampus MG, Bonsel GJ. Health-Related Quality of Life after Induction of Labor versus Expectant Monitoring in Gestational Hypertension or Preeclampsia at Term. Hypertens Pregnancy 2011; 30:260-74. [DOI: 10.3109/10641955.2010.486458] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
12
|
Langenveld J, Broekhuijsen K, van Baaren GJ, van Pampus MG, van Kaam AH, Groen H, Porath M, Oudijk MA, Bloemenkamp KW, Groot CJD, van Beek E, van Huizen ME, Oosterbaan HP, Willekes C, Wijnen-Duvekot EJ, Franssen MTM, Perquin DAM, Sporken JMJ, Woiski MD, Bremer HA, Papatsonis DNM, Brons JTJ, Kaplan M, Nij Bijvanck BWA, Mol BWJ. Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia between 34 and 37 weeks' gestation (HYPITAT-II): a multicentre, open-label randomised controlled trial. BMC Pregnancy Childbirth 2011; 11:50. [PMID: 21736705 PMCID: PMC3161905 DOI: 10.1186/1471-2393-11-50] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Accepted: 07/07/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Gestational hypertension (GH) and pre-eclampsia (PE) can result in severe complications such as eclampsia, placental abruption, syndrome of Hemolysis, Elevated Liver enzymes and Low Platelets (HELLP) and ultimately even neonatal or maternal death. We recently showed that in women with GH or mild PE at term induction of labour reduces both high risk situations for mothers as well as the caesarean section rate. In view of this knowledge, one can raise the question whether women with severe hypertension, pre-eclampsia or deterioration chronic hypertension between 34 and 37 weeks of gestation should be delivered or monitored expectantly. Induction of labour might prevent maternal complications. However, induction of labour in late pre-term pregnancy might increase neonatal morbidity and mortality compared with delivery at term. METHODS/DESIGN Pregnant women with severe gestational hypertension, mild pre-eclampsia or deteriorating chronic hypertension at a gestational age between 34+0 and 36+6 weeks will be asked to participate in a multi-centre randomised controlled trial. Women will be randomised to either induction of labour or expectant monitoring. In the expectant monitoring arm, women will be induced only when the maternal or fetal condition detoriates or at 37+0 weeks of gestation. The primary outcome measure is a composite endpoint of maternal mortality, severe maternal complications (eclampsia, HELLP syndrome, pulmonary oedema and thromboembolic disease) and progression to severe pre-eclampsia. Secondary outcomes measures are respiratory distress syndrome (RDS), neonatal morbidity and mortality, caesarean section and vaginal instrumental delivery rates, maternal quality of life and costs. Analysis will be intention to treat. The power calculation is based on an expectant reduction of the maternal composite endpoint from 5% to 1% for an expected increase in neonatal RDS from 1% at 37 weeks to 10% at 34 weeks. This implies that 680 women have to be randomised. DISCUSSION This trial will provide insight as to whether in women with hypertensive disorders late pre-term, induction of labour is an effective treatment to prevent severe maternal complications without compromising the neonatal morbidity. TRIAL REGISTRATION NTR1792 CLINICAL TRIAL REGISTRATION: http://www.trialregister.nl.
Collapse
Affiliation(s)
- Josje Langenveld
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre. GROW - School for Oncology and Developmental Biology, The Netherlands
| | - Kim Broekhuijsen
- Department of Obstetrics and Gynecology, Martini hospital, Groningen, The Netherlands
| | - Gert-Jan van Baaren
- Department of Obstetrics and Gynecology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Maria G van Pampus
- Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis Amsterdam
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Academic Medical Centre, Amsterdam, The Netherlands
| | - Henk Groen
- Department of Epidemiology, University Medical Centre Groningen, The Netherlands
| | - Martina Porath
- Department of Obstetrics and Gynecology, Maxima Medical Centre, Veldhoven, The Netherlands
| | - Martijn A Oudijk
- Department of Obstetrics and Gynecology, University Medical Centre Utrecht, The Netherlands
| | - Kitty W Bloemenkamp
- Department of Obstetrics and Gynecology, Leiden University Medical Centre, The Netherlands
| | | | - Erik van Beek
- Department of Obstetrics and Gynecology, St. Antonius Hospital Nieuwegein, The Netherlands
| | - Marloes E van Huizen
- Department of Obstetrics and Gynecology, Haga Hospital Den Haag, The Netherlands
| | - Herman P Oosterbaan
- Department of Obstetrics and Gynecology, Jeroen Bosch Hospital, s’-Hertogenbosch, The Netherlands
| | - Christine Willekes
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre. GROW - School for Oncology and Developmental Biology, The Netherlands
| | - Ella J Wijnen-Duvekot
- Department of Obstetrics and Gynecology, VieCuri Medical Centre, Venlo, The Netherlands
| | - Maureen T M Franssen
- Department of Epidemiology, University Medical Centre Groningen, The Netherlands
| | - Denise A M Perquin
- Department of Obstetrics and Gynecology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Jan M J Sporken
- Department of Obstetrics and Gynecology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Mallory D Woiski
- Department of Obstetrics and Gynecology, Radboud Univeristy Nijmegen, Nijmegen, The Netherlands
| | - Henk A Bremer
- Department of Obstetrics and Gynecology, Reinier de Graaf Hospital, Delft, The Netherlands
| | | | - Jozien T J Brons
- Department of Obstetrics and Gynecology, Medical Spectrum Enschede, The Netherlands
| | - Mesruwe Kaplan
- Department of Obstetrics and Gynecology, Saxenburgh Group, Hardenberg, The Netherlands
| | - Bas W A Nij Bijvanck
- Department of Obstetrics and Gynecology, Isala Hospital, Zwolle, The Netherlands
| | - Ben-Willen J Mol
- Department of Obstetrics and Gynecology, Academic Medical Centre, Amsterdam, The Netherlands
| |
Collapse
|
13
|
Halem KV, Bakker JJH, Verhoeven CJ, Papatsonis DNM, Oudgaarden EDV, Janssen P, Bloemenkamp KW, Mol BWJ, Van Der Post JAM. Does use of an intrauterine catheter during labor increase risk of infection? J Matern Fetal Neonatal Med 2011; 25:415-8. [PMID: 21649507 DOI: 10.3109/14767058.2011.582905] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine whether the use of an intrauterine catheter during labor is related to the occurrence of infection in mother or newborn during labor and up to 3 weeks postpartum. METHODS We performed a follow-up study of 1435 women who participated in a previously published multicentre randomized controlled trial in the Netherlands that assigned women in whom labor was induced or augmented with intravenous oxytocin to internal or external tocodynamometry. In the present post hoc analysis, we assessed the risk for infection, defined as a composite measure of any clinical sign of infection, treatment with antibiotics or sepsis during labor or in the postpartum period up to 3 weeks in mother or newborn. RESULTS There were 64 cases with indication of infection in the intrauterine catheter group (8.8%) versus 74 cases in the external monitoring group (10.4%). Relative risk: 0.91, 95% confidence interval: 0.77-1.1, and p: 0.33. CONCLUSION Use of an intrauterine catheter during labor does not increase the risk of infection.
Collapse
Affiliation(s)
- Karlijn Van Halem
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, The Netherlands
| | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Lopriore E, Walther FJ, Papathanasiou D, Witlox RS, Bloemenkamp KW, Oepkes D. Reply. Fetal Diagn Ther 2011. [DOI: 10.1159/000321690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
15
|
Zwart JJ, Jonkers MD, Richters A, Ory F, Bloemenkamp KW, Duvekot JJ, van Roosmalen J. Ethnic disparity in severe acute maternal morbidity: a nationwide cohort study in the Netherlands. Eur J Public Health 2010; 21:229-34. [PMID: 20522516 DOI: 10.1093/eurpub/ckq046] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There are concerns about ethnic disparity in outcome of obstetric health care in high-income countries. Our aim was to assess these differences in a large cohort of women having experienced severe acute maternal morbidity (SAMM) during pregnancy, delivery and puerperium. METHODS All women experiencing SAMM were prospectively collected in a nationwide population-based design from August 2004 to August 2006. Women delivering in the same period served as reference cohort. Population-based risks were calculated by ethnicity and by type of morbidity. Additionally, non-Western and Western women having experienced SAMM were compared in multivariable logistic regression analysis. RESULTS All 98 Dutch maternity units participated. There were 371 021 deliveries during the study period. A total of 2506 women with SAMM were included, 21.1% of whom were non-Western immigrants. Non-Western immigrants showed a 1.3-fold [95% confidence interval (CI) 1.2-1.5] increased risk to develop SAMM. Large differences were observed among different ethnic minority groups, ranging from a non-increased risk for Moroccan and Turkish women to a 3.5-fold (95% CI 2.8-4.3) increased risk for sub-Saharan African women. Low socio-economic status, unemployment, single household, high parity and prior caesarean were independent explanatory factors for SAMM, although they did not fully explain the differences. Immigration-related characteristics differed by ethnic background. CONCLUSIONS Non-Western immigrants have an increased risk of developing SAMM as compared to Western women. Risks varied largely by ethnic origin. Immigration-related characteristics might partly explain the increased risk. The results suggest that there are opportunities for quality improvement by targeting specific disadvantaged groups.
Collapse
Affiliation(s)
- Joost J Zwart
- Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands.
| | | | | | | | | | | | | |
Collapse
|
16
|
Hermes W, Franx A, van Pampus MG, Bloemenkamp KW, van der Post JA, Porath M, Ponjee G, Tamsma JT, Mol BW, de Groot CJ. 10-Year cardiovascular event risks for women who experienced hypertensive disorders in late pregnancy: the HyRAS study. BMC Pregnancy Childbirth 2010; 10:28. [PMID: 20515501 PMCID: PMC2889848 DOI: 10.1186/1471-2393-10-28] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2009] [Accepted: 06/01/2010] [Indexed: 11/21/2022] Open
Abstract
Background Cardiovascular disease is the cause of death in 32% of women in the Netherlands. Prediction of an individual's risk for cardiovascular disease is difficult, in particular in younger women due to low sensitive and specific tests for these women. 10% to 15% of all pregnancies are complicated by hypertensive disorders, the vast majority of which develop only after 36 weeks of gestation. Preeclampsia and cardiovascular disease in later life show both features of "the metabolic syndrome" and atherosclerosis. Hypertensive disorders in pregnancy and cardiovascular disease may develop by common pathophysiologic pathways initiated by similar vascular risk factors. Vascular damage occurring during preeclampsia or gestational hypertension may contribute to the development of future cardiovascular disease, or is already present before pregnancy. At present clinicians do not systematically aim at the possible cardiovascular consequences in later life after a hypertensive pregnancy disorder at term. However, screening for risk factors after preeclampsia or gestational hypertension at term may give insight into an individual's cardiovascular risk profile. Methods/Design Women with a history of preeclampsia or gestational hypertension will be invited to participate in a cohort study 2 1/2 years after delivery. Participants will be screened for established modifiable cardiovascular risk indicators. The primary outcome is the 10-year cardiovascular event risk. Secondary outcomes include differences in cardiovascular parameters, SNP's in glucose metabolism, and neonatal outcome. Discussion This study will provide evidence on the potential health gains of a modifiable cardiovascular risk factor screening program for women whose pregnancy was complicated by hypertension or preeclampsia. The calculation of individual 10-year cardiovascular event risks will allow identification of those women who will benefit from primary prevention by tailored interventions, at a relatively young age. Trial registration The HYPITAT trial is registered in the clinical trial register as ISRCTN08132825.
Collapse
Affiliation(s)
- Wietske Hermes
- Department of Obstetrics and Gynecology, Medical Centre Haaglanden Den Haag, the Netherlands.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Affiliation(s)
- J P Vandenbroucke
- Department of Clinical Epidemiology, Leiden University Medical Center, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
18
|
Bloemenkamp KW, de Groot CJ, Ronde HD, Duvekot EJ, Helmerhorst FM, Bertina RM. The effect of factor V Leiden, oral contraceptive use, type of oral contraceptives and pregnancy on APC-r levels in women with or without a history of pre-eclampsia. Eur J Obstet Gynecol Reprod Biol 2001; 95:225. [PMID: 11301177 DOI: 10.1016/s0301-2115(00)00496-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- K W Bloemenkamp
- Department of Obstetrics, Gynecology and Reproductive Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | | | | | | | | | | |
Collapse
|
19
|
Vandenbroucke JP, Bloemenkamp KW, Helmerhorst FM, Büller HR, Rosendaal FR. Diagnostic suspicion and referral bias in studies of venous thromboembolism and oral contraceptive use. EUR J CONTRACEP REPR 2001; 6:56-7. [PMID: 11334478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
|
20
|
Vandenbroucke JP, Bloemenkamp KW, Helmerhorst FM, Rosendaal FR. [Handling small relative risks in science and management: the third-generation pill]. Ned Tijdschr Geneeskd 2000; 144:254-8. [PMID: 10687016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
Small relative risks (a twofold or lesser increase in disease frequency) become scientifically acceptable with (a) repeated consistent findings from studies that (b) address the most important forms of bias and confounding, and (c) when there is a plausible biologic mechanism. The third-generation oral contraceptive controversy is an example of such a relevant but small relative risk and demonstrates the problem of interpretation and implementation into medical practice guidelines.
Collapse
Affiliation(s)
- J P Vandenbroucke
- Afd. Klinische Epidemiologie, Leids Universitair Medisch Centrum, Leiden
| | | | | | | |
Collapse
|
21
|
Bloemenkamp KW, Rosendaal FR, Helmerhorst FM, Vandenbroucke JP. Higher risk of venous thrombosis during early use of oral contraceptives in women with inherited clotting defects. Arch Intern Med 2000; 160:49-52. [PMID: 10632304 DOI: 10.1001/archinte.160.1.49] [Citation(s) in RCA: 127] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Results of recent studies show that the risk for venous thrombosis is highest during initial oral contraceptive use. This suggests a subgroup of females who are at immediate risk of thrombosis when exposed to oral contraceptives. OBJECTIVE To determine whether women with inherited clotting defects who use oral contraceptives develop venous thrombosis at an earlier stage than do those without inherited clotting defects. METHODS Analysis of the data from the Leiden Thrombophilia Study, a population-based case-control study with data on duration of oral contraceptive use and recently detected genetic coagulation disorders. Patients had a first episode of objectively proven deep vein thrombosis. Patients and controls were considered thrombophilic when they had protein C deficiency, protein S deficiency, antithrombin deficiency, factor V Leiden mutation, or prothrombin 20210 A mutation. RESULTS Risk of developing deep vein thrombosis was greatest in the first 6 months and the first year of oral contraceptive use. Compared with prolonged use, the risk of developing deep vein thrombosis was 3-fold higher in the first 6 months of use (95% confidence interval [CI], 0.6-14.8) and 2-fold higher in the first year of use (95% CI, 0.6-6.1). Patients who developed venous thrombosis in the early periods of use were more often thrombophilic. Among women with thrombophilia, the risk of developing deep vein thrombosis during the first 6 months of oral contraceptive use (compared with prolonged use) was increased 19-fold (95% CI, 1.9-175.7), and in the first year of use, it was increased 11-fold (95% CI, 2.1-57.3). CONCLUSIONS Women with inherited clotting defects who use oral contraceptives develop venous thrombosis not only more often but also sooner than do those without inherited clotting defects. Venous thrombosis in the first period of oral contraceptive use might indicate the presence of an inherited clotting defect.
Collapse
Affiliation(s)
- K W Bloemenkamp
- Department of Obstetrics, Gynecology, and Reproductive Medicine, University Hospital Leiden, The Netherlands
| | | | | | | |
Collapse
|
22
|
Vandenbrouke JP, Bloemenkamp KW, Rosendaal FR, Helmerhorst FM. Incidence of venous thromboembolism in users of combined oral contraceptives. Risk is particularly high with first use of oral contraceptives. BMJ 2000; 320:57-8. [PMID: 10671043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
|
23
|
|
24
|
De Groot CJ, Bloemenkamp KW, Duvekot EJ, Helmerhorst FM, Bertina RM, Van Der Meer F, De Ronde H, Oei SG, Kanhai HH, Rosendaal FR. Preeclampsia and genetic risk factors for thrombosis: a case-control study. Am J Obstet Gynecol 1999; 181:975-80. [PMID: 10521764 DOI: 10.1016/s0002-9378(99)70335-2] [Citation(s) in RCA: 95] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Recently, it has been proposed that hereditary coagulation abnormalities leading to an increased venous thrombosis risk may play a role in the development of preeclampsia. We tested this hypothesis in women who have had preeclampsia compared with matched control subjects. STUDY DESIGN We conducted a case-control study of 163 women with preeclampsia during 1991-1996. Control subjects were matched for age and delivery date. Patients and control subjects were tested for the presence of factor V Leiden, prothrombin 20210A allele, protein C, protein S, and antithrombin deficiency. Logistic regression methods were used for data analysis. RESULTS The prevalence of these genetic risk factors was similar in the patient group (12.9%) and the control group (12.9%; odds ratio, 1.0; 95% confidence interval, 0.5-3.9). Unexpectedly, we found a high prevalence of factor V Leiden in the control group (9.2%). CONCLUSION We found no differences in the prevalence of genetic risk factors of thrombosis in women with preeclampsia compared with control subjects.
Collapse
Affiliation(s)
- C J De Groot
- Department of Obstetrics, Leiden University Medical Center, The Netherlands
| | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Bloemenkamp KW, Helmerhorst FM, Rosendaal FR, Vandenbroucke JP. Venous thrombosis, oral contraceptives and high factor VIII levels. Thromb Haemost 1999; 82:1024-7. [PMID: 10494758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
Recently, it has been described that elevated plasma levels of factor VIII are a strong risk factor for venous thrombosis. We analysed the data of the Leiden Thrombophilia Study, a population based case-control study on the causes of venous thrombosis, to verify whether the risk due to oral contraceptive use was higher in women with higher factor VIII levels. Furthermore we investigated the joint risk of high factor VIII levels and oral contraceptive use. We selected 155 premenopausal women with deep-vein thrombosis and 169 control subjects, aged 15-49, who were at the time of their thrombosis (or similar date in control) not pregnant, nor in the puerperium, did not have a recent miscarriage, and were not using injectable progestogens. Of the patients, 109 (70%) women had used oral contraceptives during the month preceding their deep-vein thrombosis, in contrast to 65 (38%) of the control subjects (index date), yielding an odds ratio for oral contraceptive use of 3.8 (95% CI 2.4-6.0). Of the women who suffered a deep-vein thrombosis 56 (36%) had high factor VIII levels (> or =150 IU/dl) as compared with 29 (17%) of the control subjects, yielding an odds ratio for high factor VIII of 4.0 (95% CI 2.0-8.0), relative to factor VIII levels <100 IU/dl. The joint effect of oral contraceptive use and high factor VIII resulted in an odds ratio of 10.3 (95% CI 3.7-28.9), comparing women who had both with women who had neither. We conclude that there is an increase in risk due to oral contraceptive use in women with higher factor VIII levels and that both factors have additive effects.
Collapse
Affiliation(s)
- K W Bloemenkamp
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Leiden University Medical Center, The Netherlands
| | | | | | | |
Collapse
|
26
|
Bloemenkamp KW, Rosendaal FR, Büller HR, Helmerhorst FM, Colly LP, Vandenbroucke JP. Risk of venous thrombosis with use of current low-dose oral contraceptives is not explained by diagnostic suspicion and referral bias. Arch Intern Med 1999; 159:65-70. [PMID: 9892332 DOI: 10.1001/archinte.159.1.65] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The magnitude of the relative risk of venous thrombosis caused by low-dose oral contraceptive use is still debated because previous studies might have been affected by diagnostic suspicion and referral bias. METHODS We conducted a case-control study in which the effect of diagnostic suspicion and referral bias was excluded. The study was performed in 2 diagnostic centers to which patients with clinically suspected deep vein thrombosis of the leg were referred. History of oral contraceptive use was obtained before objective testing for thrombosis. Young females with an objective diagnosis of deep vein thrombosis were considered case patients, and those who were referred with the same clinical suspicion but who had no thrombosis served as control subjects. Participants were seen between September 1, 1982, and October 18, 1995: 185 consecutive patients and 591 controls aged 15 to 49 years with a first episode of venous thrombosis and without malignant neoplasms, pregnancy, or known inherited clotting defects. RESULTS The overall odds ratio for oral contraceptive use was 3.2 (95% confidence interval [CI], 2.3-4.5); after adjustment for age, family history of venous thrombosis, calendar time, and center, the odds ratio was 3.9 (95% CI, 2.6-5.7). In the idiopathic group (120 patients and 413 controls, excluding recent surgery, trauma, or immobilization), the odds ratio for oral contraceptive use was 3.8 (95% CI, 2.5-5.9); after adjustment, the odds ratio was 5.0 (95% CI, 3.1-8.2). CONCLUSIONS In this study, in which patients and controls were subj ect to the same referral and diagnostic procedures, we found similar relative risk estimates for oral contraceptive use as in previous studies. We conclude that diagnostic suspicion and referral bias did not play an important role in previous studies and that the risk of venous thrombosis with use of current brands of oral contraceptives still exists.
Collapse
Affiliation(s)
- K W Bloemenkamp
- Department of Obstetrics, Gynecology, Thrombosis and Hemostasis Research Centre, University Hospital Leiden, The Netherlands
| | | | | | | | | | | |
Collapse
|
27
|
Bloemenkamp KW, Rosendaal FR, Helmerhorst FM, Koster T, Bertina RM, Vandenbroucke JP. Hemostatic effects of oral contraceptives in women who developed deep-vein thrombosis while using oral contraceptives. Thromb Haemost 1998; 80:382-7. [PMID: 9759614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Comparison of the effect of oral contraceptives on hemostatic variables in venous thrombosis patients (thrombosis while using oral contraceptives) with the effect in healthy control subjects. Our aim was to assess whether some of these effects were more pronounced in women who had suffered thrombosis, i.e., whether these were "hemostatic hyperresponders". STUDY DESIGN A population-based case-control study, the Leiden Thrombophilia Study. MATERIALS AND METHODS We investigated 99 pre-menopausal women, age 15-49 years, who had used oral contraceptives at the time of a first, objectively confirmed episode of deep-vein thrombosis. They were not pregnant, nor in puerperium, nor had had a recent miscarriage, and were not using injectable progestogens, nor suffering from inherited coagulation defects. The median time between occurrence of deep-vein thrombosis and venepuncture was 18 months, and 30 of the 99 women were still using oral contraceptives, while 69 had discontinued oral contraceptive use. In addition, a group of 153 control women (54 of them were oral contraceptive users and 99 were non-users) were studied. The following hemostatic variables were measured: APTT, factor VII, factor VIII, factor XII, fibrinogen, prothrombin, total antithrombin, normalised activated protein C sensitivity ratio (n-APC-sr), protein C, protein S and free protein S. RESULTS We found marked and significant effects of oral contraceptive use on the levels of several clotting factors, with an increase in factor VII, factor XII, protein C and a decrease in antithrombin, n-APC-sr and protein S. Less marked effects that were non-significant or only significant in either patients or controls, were an increase in factor VIII, fibrinogen and prothrombin and a decrease in the APTT and free protein S. In the former thrombosis patients several of these effects of oral contraceptives were more pronounced than in healthy women: specifically on factor VII, antithrombin, n-APC-sr and protein C. CONCLUSIONS Our results of the effects of oral contraceptives generally confirm previous reports in healthy volunteers. Our data also show that in former deep-vein thrombosis patients these effects are more pronounced. Apparently some women become "high hemostatic responders" when exposed to oral contraceptives, and they may be the women most vulnerable to its thrombogenic effects.
Collapse
Affiliation(s)
- K W Bloemenkamp
- Department of Obstetrics, Gynaecology and Reproductive Medicine, University Hospital Leiden, The Netherlands
| | | | | | | | | | | |
Collapse
|
28
|
Oei SG, Helmerhorst FM, Bloemenkamp KW, Hollants FA, Meerpoel DE, Keirse MJ. Effectiveness of the postcoital test: randomised controlled trial. BMJ 1998; 317:502-5. [PMID: 9712594 PMCID: PMC28641 DOI: 10.1136/bmj.317.7157.502] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To investigate the impact of the postcoital test on the pregnancy rate among subfertile couples and on the number of other diagnostic tests and treatments. DESIGN Randomised controlled study. SETTING A university and two non-university teaching hospitals in the Netherlands. SUBJECTS New couples at infertility clinics, 1 March 1993 to 1 October 1995; randomisation to an intervention group (series of infertility investigations that include the postcoital test) or to a control group (series excluding the test). MAIN OUTCOME MEASURE Cumulative pregnancy rate. RESULTS Of 736 consecutive new couples, 444 fulfilled the inclusion criteria and consented to participate (intervention group, 227; control group, 217). Treatment was given more often in the intervention group than in the control group (54% v 41%; difference 13% (95% confidence interval 4% to 22%)). Yet cumulative pregnancy rates at 24 months in the intervention group (49% (42% to 55%)) and the control group (48% (42% to 55%)) were closely similar (difference 1% (-9.0% to 9.0%)). CONCLUSION Routine use of the postcoital test in infertility investigations leads to more tests and treatments but has no significant effect on the pregnancy rate.
Collapse
Affiliation(s)
- S G Oei
- Department of Obstetrics and Gynaecology, Saint Joseph Hospital, 5500 MB Veldhoven, Netherlands
| | | | | | | | | | | |
Collapse
|
29
|
Vandenbroucke JP, Helmerhorst FM, Bloemenkamp KW, Rosendaal FR. Third-generation oral contraceptive and deep venous thrombosis: from epidemiologic controversy to new insight in coagulation. Am J Obstet Gynecol 1997; 177:887-91. [PMID: 9369840 DOI: 10.1016/s0002-9378(97)70289-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Four epidemiologic studies showed a twofold increase in risk of deep venous thrombosis with the use of oral contraceptives containing third-generation progestins, relative to second-generation products. These findings have been strongly debated ever since, and new studies have been added. In the current article we examine whether the findings can be explained by potential biases or other shortcomings of the epidemiologic studies. We conclude that complete certainty cannot exist but that the most rational conclusion from the epidemiologic findings and their discussion is that an increased risk of deep venous thrombosis with third-generation contraceptives is likely, especially in first-time and young users. The controversy has recently led to new insights in coagulation: Women who use third-generation contraceptives acquire a resistance to the blood's own anticoagulation system, similar to the activated protein C resistance that is seen in persons who carry the factor V Leiden mutation but different from that in women using second-generation contraceptives.
Collapse
Affiliation(s)
- J P Vandenbroucke
- Department of Clinical Epidemiology, University Hospital Leiden, The Netherlands
| | | | | | | |
Collapse
|
30
|
Helmerhorst FM, Bloemenkamp KW, Rosendaal FR, Vandenbroucke JP. Oral contraceptives and thrombotic disease: risk of venous thromboembolism. Thromb Haemost 1997; 78:327-33. [PMID: 9198174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Studies conducted in the first three decades after discovery of a link between venous thromboembolism and oral contraceptive users showed a relative risk of first thrombosis during oral contraceptive use of 2.9 (95% CI 0.5-17). In recent studies in which the sub-50 micrograms ethinyl estrodiol containing pills were investigated comparing current users with non-users, the RR is 3.8 for non-fatal deep VTE and 2.7 for superficial VTE, deep VTE and pulmonary embolism (PE) together and 2.1 for fatal VT and PE together. The association is attributed to the estrogenic component and not related to duration of pill use. The risk disappears once the pill has been stopped, and it is not elevated among past users. Smoking does not appear to be risk factor for VTE; obesity and varicose veins are, at the most, weak risk factors. Since a causal relationship between OC use and VTE is tempting, clues for unraveling the mechanism were sought in the hemostatic system. Studies of the coagulation system found changes in the activation of coagulation and fibrinolytic compartments, but within the normal range. An epidemiologic study showed that the risk of VTE among women using OCs is 30-fold increased by the presence of a mutation of factor V, called Factor V Leiden (5% prevalence in the Caucasian population). Selective screening for the mutated factor V should be limited to women with a personal or family history of VTE. Four epidemiologic studies showed a two-fold increase in risk of VTE with the use of OCs containing third-generation progestins (gestodene and desogestrel), relative to second-generations products (levonorgestrel). Biases cannot devaluate the conclusion that the increased risk of VTE in especially first-time and younger users of third-generation OCs is highly likely. The clinical consequence is therefore that second-generation OCs are the first choice in prescription to first-time users.
Collapse
Affiliation(s)
- F M Helmerhorst
- Department of Obstetrics, Gynecology and Reproductive Medicine, Leiden University, The Netherlands.
| | | | | | | |
Collapse
|
31
|
Abstract
OBJECTIVE We studied the relationship between cervical mucus evaluations and daily fertility examinations in order to find monitoring techniques that can predict optimal mucus one day before it occurs. METHODS Twenty-three healthy young female volunteers were followed during one spontaneous cycle with serial measurements of serum estradiol, progesterone, LH and FSH, urinary LH, and transvaginal ultrasound measurements of endometrial thickness and follicles. Data were related to cervical mucus scores. RESULTS All cycles were ovulatory with optimal mucus, but in 14 optimal mucus was present for only one day. Echographic measurement of the leading follicle (mean diameter > or = 18 mm) could predict the day of optimal mucus in 78% and estradiol (> 700 pmol/l) in 83% of the cases. These two measurements combined predicted optimal mucus in 100% of the investigated women one day in advance. CONCLUSION Optimal cervical mucus parameters can be predicted one day in advance by serial measurements of serum estradiol and follicular diameters.
Collapse
Affiliation(s)
- S G Oei
- Department of Obstetrics and Gynaecology, St. Joseph Hospital, Veldhoven, The Netherlands
| | | | | | | | | |
Collapse
|
32
|
|
33
|
Vandenbroucke JP, Bloemenkamp KW, Helmerhorst FM, Rosendaal FR. Risk of oral contraceptives and recency of market introduction. Contraception 1997; 55:191-2; discussion 192-4. [PMID: 9115010 DOI: 10.1016/s0010-7824(97)00001-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
|
34
|
Vandenbroucke JP, Bloemenkamp KW, Helmerhorst FM, Rosendaal FR. Mortality from venous thromboembolism and myocardial infarction in young women in the Netherlands. Lancet 1996; 348:401-2. [PMID: 8709744 DOI: 10.1016/s0140-6736(96)24032-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
|
35
|
Oei SG, Helmerhorst FM, Bloemenkamp KW, Keirse MJ. Effect of the postcoital test on the sexual relationship of infertile couples: a randomized controlled trial. Fertil Steril 1996; 65:771-5. [PMID: 8654637 DOI: 10.1016/s0015-0282(16)58212-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To investigate the impact of the postcoital test (PCT) on the sexual relationship and functioning of infertile couples. DESIGN Randomized controlled study. SETTING University hospital. PATIENTS New infertility patients were randomized to an infertility work-up with (PCT group) or without (non-PCT group) postcoital test as integral part of the investigation. INTERVENTION Performance of the PCT. MAIN OUTCOME MEASURE Both partners completed a questionnaire on their sexual relationship and functioning at the initial visit and after 3 months. RESULTS Of 500 consecutive new couples, 304 fulfilled inclusion criteria and 290 consented to participate (PCT group: 152; non-PCT group: 138). Answers to both the first and second questionnaire were obtained from 84 couples (PCT: 43; non-PCT: 41). After 3 months, couples in the PCT group were at least as satisfied with their sexual relationship as couples in the non-PCT group with little difference having occurred in the 3 months of investigation. CONCLUSION Overall, the influence of the PCT on the sexual relationship of infertile couples is more positive than negative.
Collapse
Affiliation(s)
- S G Oei
- Department of Obstetrics, Gynecology and Reproductive Medicine, Leiden University Hospital, The Netherlands
| | | | | | | |
Collapse
|
36
|
Oei SG, Bloemenkamp KW, Helmerhorst FM, Naaktgeboren N, Keirse MJ. Evaluation of the postcoital test for assessment of 'cervical factor' infertility. Eur J Obstet Gynecol Reprod Biol 1996; 64:217-20. [PMID: 8820006 DOI: 10.1016/0301-2115(95)02287-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the test properties of the postcoital test (PCT). STUDY DESIGN Retrospective analysis of prospectively collected data on a cohort of infertile couples with complete follow up. SETTING Fertility clinic of a Dutch university hospital. SUBJECTS A continuous series of 224 couples of whom 24 were excluded for reasons of anovulation, coital problems, proven sterility or incomplete follow-up. ANALYSIS Cumulative pregnancy rates in relation to PCT results with and without treatment for 'cervical factor' infertility. RESULTS The predictive values of normal and abnormal PCTs were 0.54 and 0.58 overall and 0.74 and 0.47 if only untreated women were considered. Sensitivity and specificity were, respectively, 0.47 and 0.65 for all women and 0.54 and 0.68 for untreated women only. Likelihood ratios for normal and abnormal PCTs were 0.83 and 1.32 overall and 0.67 and 1.72 in untreated women. CONCLUSION The PCT has poor predictive power. This and the psychological impact on subfertile couples attest to the need for more rigorous study designs in evaluating this test.
Collapse
Affiliation(s)
- S G Oei
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Leiden University Hospital, The Netherlands
| | | | | | | | | |
Collapse
|
37
|
Bloemenkamp KW, Rosendaal FR, Helmerhorst FM, Büller HR, Vandenbroucke JP. Enhancement by factor V Leiden mutation of risk of deep-vein thrombosis associated with oral contraceptives containing a third-generation progestagen. Lancet 1995; 346:1593-6. [PMID: 7500751 DOI: 10.1016/s0140-6736(95)91929-5] [Citation(s) in RCA: 435] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Recent concern about the safety of combined oral contraceptives (OCs) with third-generation progestagens prompted an examination of data from a population-based case-control study (Leiden Thrombophilia Study). We compared the risk of deep-vein thrombosis (DVT) during use of the newest OCs, containing a third-generation progestagen, with the risk of "older" products. We also investigated the influence of family history of thrombosis, previous pregnancy, age, and the thrombogenic factor V Leiden mutation. We selected 126 women with DVT and 159 controls aged 15-49 (mean age 34.9) and premenopausal and found, as compared with non-users, the highest age-adjusted relative risks to be that for an OC containing desogestrel and 30 micrograms ethinyloestradiol (relative risk [RR] 8.7, 95% CI 3.9-19.3). We found lower relative risks for all other types of OC, ranging from 2.2 to 3.8. In a direct comparison, users of the desogestrel-containing oral contraceptive had a 2.5-fold higher risk (95% CI 1.2-5.2) than users of all other OC types combined. The relative risk for the desogestrel-containing OC was similar among women with and without a family history--ie, preferential prescription because of family history cannot explain our findings. Nor could the excess risk be explained by previous pregnancy, and it was highest in the youngest age categories, where we would expect most new users. The age-adjusted RR for the desogestrel-containing contraceptive was 9.2 (3.9-21.4) among non-carriers of the factor V Leiden mutation and 6.0 (1.9-19.0) among carriers of the mutation. This latter risk is superimposed on the 8-fold increased risk of venous thrombosis for carriers of the factor V Leiden mutation. The risk of carriers using the desogestrel-containing OC as compared with noncarrier non-users will therefore be increased almost 50-fold. Use of low-dose OCs with a third-generation progestagen carries a higher risk of DVT than the previous generation of OCs. The absolute risk of DVT associated with these OCs seems to be especially high among carriers of the factor V Leiden mutation and among women with a family history of thrombosis. However, the higher risk associated with OC with a third-generation progestagen compared with previous generations was also present in women without factor V Leiden and with no family history.
Collapse
Affiliation(s)
- K W Bloemenkamp
- Department of Obstetrics, Gynaecology, and Reproductive Medicine, University Hospital Leiden, Netherlands
| | | | | | | | | |
Collapse
|
38
|
Helmerhorst FM, Oei SG, Bloemenkamp KW, Keirse MJ. [Variations in fertility studies in The Netherlands]. Ned Tijdschr Geneeskd 1995; 139:2088-91. [PMID: 7477567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To determine how a standard infertility investigation is conducted and to determine the use of fertility tests used in such investigations in relation to WHO guidelines. DESIGN Questionnaire survey. SETTING Dutch medical schools. METHOD A questionnaire survey among the heads of all 8 university and 20 non-university teaching departments of obstetrics and gynaecology or their fertility units was conducted. One non-university department failed to respond. RESULTS The examinations recommended by the WHO (general physical examination, andrological and gynaecological examination, semen analysis, ovulation detection, tubal patency testing) in general were carried out, but general physical examination of the male as a rule was only carried out if indicated. Popular routine examinations not recommended by the WHO were the postcoital test and hysterosalpingography. Regarding the postcoital test, there was variation in the time interval after coitus and the standards for spermatozoal motility. CONCLUSION Standard fertility investigations are usually based on empiricism and tradition, including the testing recommended by the WHO.
Collapse
Affiliation(s)
- F M Helmerhorst
- Academisch Ziekenhuis, afd. Obstetrie, Gynaecologie & Voortplanting, Leiden
| | | | | | | |
Collapse
|
39
|
Abstract
OBJECTIVE To assess differences in opinion and practice with regard to the postcoital test in Europe. DESIGN Multilingual questionnaire survey among heads of departments of obstetrics and gynaecology with large fertility clinics in 16 European countries. SUBJECTS Of 203 heads of departments, each responsible for 882 infertility cases per year (95% CI 657-1107) 145 (71%) responded. INFORMATION SOUGHT: Use of the postcoital test: its timing in relation to cycle and coitus, methodology used for the test, cut-off level of normality and treatments applied for abnormal test results. RESULTS The postcoital test is used in 92% (and routinely in 68%) of departments. There are large differences in timing of the test in relation to menstrual cycle and coitus, in microscopic magnification used, and in cut-off levels of normality. More than 10 different treatments are applied for abnormal test results. CONCLUSION Guidelines of the World Health Organisation are not followed and divergence in practice and opinion is wide enough to question whether infertile couples are better off with than without the test.
Collapse
Affiliation(s)
- S G Oei
- Departmentof Obstetrics, Gynaecology and Reproductive Medicine, Leiden University Hospital, The Netherlands
| | | | | | | |
Collapse
|
40
|
Abstract
A questionnaire survey among the teaching departments of obstetrics and gynaecology in Western Europe (response rate 71%) revealed only weak adherence to the World Health Organization recommendations for the standard investigation of the infertile couple. Both general and specific examinations were applied more frequently in the female than in the male partner. Although semen analysis and the ascertainment of ovulation were standard in virtually all departments, the criteria for normal semen and the methods used for the detection of ovulation varied greatly among both departments and countries. There were also large differences among countries in the preferred standard method for testing tubal patency. The data suggest that fertility investigations are based more on tradition and personal preferences than on the demonstrated utility of its components.
Collapse
Affiliation(s)
- F M Helmerhorst
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Leiden University Hospital, The Netherlands
| | | | | | | |
Collapse
|