Cost-effectiveness of diagnostic testing strategies including cervical-length measurement and fibronectin testing in women with symptoms of preterm labor

OBJECTIVE

To evaluate the cost-effectiveness of combining cervical-length (CL) measurement and fetal fibronectin (fFN) testing in women with symptoms of preterm labor between 24 and 34 weeks' gestation.

METHODS

This was a model-based cost-effectiveness analysis evaluating seven test-treatment strategies based on CL measurement and/or fFN testing in women with symptoms of preterm labor from a societal perspective, in which neonatal outcomes and costs were weighted. Estimates of disease prevalence, test accuracy and costs were based on two recently performed nationwide cohort studies in The Netherlands.

RESULTS

Strategies using fFN testing and CL measurement separately to predict preterm delivery are associated with higher costs and incidence of adverse neonatal outcomes compared with strategies that combine both tests. Additional fFN testing when CL is 15-30 mm was considered cost effective, leading to a cost saving of €3919 per woman when compared with a treat-all strategy, with a small deterioration in neonatal health outcomes, namely one additional perinatal death and 21 adverse outcomes per 10 000 women with signs of preterm labor (incremental cost-effectiveness ratios €39 million and €1.9 million, respectively). Implementing this strategy in The Netherlands, a country with about 180 000 deliveries annually, could lead to an annual cost saving of between €2.4 million and €7.6 million, with only a small deterioration in neonatal health outcomes.

CONCLUSION

In women with symptoms of preterm labor at 24-34 weeks' gestation, performing additional fFN testing when CL is between 15 and 30 mm is a viable and cost-saving strategy. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Variation in xylem vulnerability to embolism in European beech from geographically marginal populations

Climate change is expected to increase the frequency and intensity of droughts and heatwaves in Europe, leading to effects on forest growth and major forest dieback events due to hydraulic failure caused by xylem embolism. Inter-specific variability in embolism resistance has been studied in detail, but little is known about intra-specific variability, particularly in marginal populations. We evaluated 15 European beech populations, mostly from geographically marginal sites of the species distribution range, focusing particularly on populations from the dry southern margin. We found small, but significant differences in resistance to embolism between populations, with xylem pressures causing 50% loss of hydraulic conductivity ranging from -2.84 to -3.55 MPa. Significant phenotypic clines of increasing embolism resistance with increasing temperature and aridity were observed: the southernmost beech populations growing in a warmer drier climate and with lower habitat suitability have higher resistance to embolism than those from Northern Europe growing more favourable conditions. Previous studies have shown that there is little or no difference in embolism resistance between core populations, but our findings show that marginal populations have developed ways of protecting their xylem based on either evolution or plasticity.

Termination of pregnancy for maternal indications at the limits of fetal viability: a retrospective cohort study in the Dutch tertiary care centres

OBJECTIVE

Maternal morbidity, either pregnancy related or pre-existent, can become life threatening and of such severity as to warrant termination of pregnancy (TOP). In this situation, chances of fetal survival are usually poor, either because of low gestational age and/or because of the fetal effects of the maternal condition. Examples include severe growth restriction in pre-eclampsia and intrauterine infection due to the very early preterm prelabour rupture of membranes. There are very few reports on the prevalence of TOP for maternal indication at the limits of fetal viability. We investigated the prevalence of and indications for TOP on maternal indication in the 10 tertiary care centres in the Netherlands during the past decade.

STUDY DESIGN

We conducted a retrospective review of the medical records of all women who underwent TOP for maternal indications between 22 and 27 completed weeks of gestation in all 10 tertiary care centres from 2000 to 2009.

RESULTS

During the study period, there were 1 929 470 deliveries; 163 052 (8.4%) of these took place in one of the 10 tertiary care centres and 177 pregnancies were terminated for severe maternal disease, 131 for hypertensive disorders, 29 for intrauterine infection and 17 for other reasons. The mean gestational age at TOP was 171 days (24(3/7))±10 days. No maternal deaths were recorded. The overall perinatal mortality was 99.4%.

CONCLUSIONS

Over a 10-year period, TOP for maternal indications was performed in 1 in 1000 deliveries in the 10 Dutch tertiary care centres. Hypertensive disorders comprised three-quarters of the cases.

Is intrapartum fever associated with ST-waveform changes of the fetal electrocardiogram? A retrospective cohort study

OBJECTIVE

To investigate the association between maternal intrapartum fever and ST-waveform changes of the fetal electrocardiogram.

DESIGN

Retrospective cohort study.

SETTING

Three academic and six non-academic teaching hospitals in the Netherlands.

POPULATION

Labouring women with a high-risk singleton pregnancy in cephalic position beyond 36 weeks of gestation.

METHODS

We studied 142 women with fever (≥38.0°C) during labour and 141 women with normal temperature who had been included in two previous studies. In both groups, we counted the number and type of ST-events and classified them as significant (intervention needed) or not significant, based on STAN(®) clinical guidelines.

MAIN OUTCOME MEASURES

Number and type of ST-events.

RESULTS

Both univariable and multivariable regression analysis showed no association between the presence of maternal intrapartum fever and the number or type of ST-events.

CONCLUSIONS

Maternal intrapartum fever is not associated with ST-segment changes of the fetal electrocardiogram. Interpretation of ST-changes in labouring women with fever should therefore not differ from other situations.

PP150. Pregnancy outcome in women with heart disease in a single tertiary care center

INTRODUCTION

The number of women presenting with cardiac disease during pregnancy is increasing because more women with repaired congenital heart disease are reaching childbearing age and because of more pregnancies occurring in women with ischemic heart disease. Cardiac disease is the leading cause of indirect maternal mortality in the Netherlands.

OBJECTIVES

Clinical data of pregnant women with heart disease that received obstetric care and delivered in our center have been obtained with the intention to evaluate the cardiac and obstetric pregnancy outcomes and to provide data for local counseling and management guidelines.

METHODS

Data were collected from all pregnant women with congenital or acquired heart disease who delivered between 2000 and 2010 in the VU University Medical Center Amsterdam. At least one consultation of a cardiologist during pregnancy was advised. The maternal outcomes of these pregnancies were evaluated.

RESULTS

Data of 122 women with 160 pregnancies were obtained. In this study the main heart diseases in pregnancy were congenital heart disease (n=75.61%) and arrhythmia (n=22.18%). Rheumatic heart disease was accountable for 6% (n=7) and ischemic heart disease for 4% (n=5) of inclusions. Based on the functional criteria of the New York Heart Association (NYHA), 114/122 patients (93.4%) were classified NYHA Class I-II. Patients in NYHA Class III-IV (n=8/122, 6.6%), mainly had a history of myocardial infarction or pulmonary hypertension. Of all the women, 35 had cardiac surgery before pregnancy, mainly repair of congenital heart disease. In women with acquired heart disease the interventions before pregnancy included permanent cardiac pace-maker implantation (n=2), radiofrequency catheter ablation (RFCA) (n=4) and percutaneous transluminal coronary angioplasty or coronary artery bypass graft (n=4). There were 156 singleton and 4 twin pregnancies. Termination of pregnancy was performed in 3 cases; 1 for maternal cardiac and 2 for obstetric indications. There were 156 life-births of which 100 (64.1%) were spontaneous vaginal deliveries, 17 (10.9%) operative vaginal deliveries and 39 (25%) cesarean sections: 9 for maternal cardiac indication and 30 for obstetric reasons. 36 (36%) women received epidural analgesia during labor and delivery. Cesarean section under general anesthesia was performed in 14 cases (7 for maternal cardiac indication); 25 were performed under spinal/epidural anesthesia. Induction of labour occurred in 48 pregnancies: 10 for maternal cardiac indications and 38 for other maternal and fetal indications. 28 (17.5%) pregnancies were complicated by hypertensive disorders. Cardiac complications such as heart failure developed in 15 (9.4%) pregnancies. There were two maternal deaths (1.6%).

CONCLUSION

Congenital heart disease is the type of heart disease that has the highest incidence in pregnancy, while main types of heart disease that lead to impaired cardiac function during pregnancy are ischemic disease and pulmonary hypertension. Incidence of pregnancy induced hypertensive disorders is increased in women with preexistent cardiac disorders. Maternal outcome is generally favourable for women with cardiac heart in NYHA class I/II.

PP095. Guideline-based development of quality indicators for hypertensive diseases in pregnancy

INTRODUCTION

Hypertensive disorders in pregnancy are one of the main causes of maternal morbidity and mortality. Internationally, several organizations have developed clinical guidelines to assist professionals and to supply patients with the best possible care. To improve the care for this group of patients, insight into the application of clinical guidelines in daily practice is needed. Valid quality indicators are necessary to estimate actual guideline adherence. In this study, we developed a set of valid guidelines based quality indicators for hypertensive diseases in pregnancy.

OBJECTIVES

None.

METHODS

A systematic RAND-modified Delphi method was used to develop a set of quality indicators based on evidence-based guidelines and the literature, about hypertension and pregnancy. Experts' opinions were used to select the indicators regarding specific criteria such as efficacy, level of health gain and potential for care improvement.

RESULTS

A representative set of 14 quality indicators was selected from 48 initial guideline recommendations. Indicators concerned both professional performance and organisation of care for patients with hypertension in pregnancy.

CONCLUSION

This study describes the systematic, stepwise method used to develop quality indicators that can be used to monitor care for hypertensive diseases in pregnancy.

[Tertiary obstetric care: the aims of the planning decree on perinatal care of 2001 have not yet been achieved]

OBJECTIVE

To compare the actual situation in tertiary perinatal care in the Netherlands with the objectives laid down in the 2001 decree on perinatal care by the Dutch Ministry of Health, Welfare and Sport.

DESIGN

Descriptive, retrospective.

METHOD

Data on tertiary perinatal care, the transfer or refusal of women with very endangered pregnancies and the personnel of obstetric high care (OHC) units in 2006 were compared with the targets laid down in the planning decree on perinatal care and in a report by the Dutch Health Council from 2000. Parameters of tertiary perinatal care output were the number of admissions, and the number of beds in OHC units and neonatal intensive care units (NICU).

RESULTS

In 2006, 128 of the 250 beds intended for OHC had been obtained. The degree of capacity utilisation was 94%, while the norm is 80%. 312 women were transferred due to lack of capacity of OHC units and NICU. The number of staff, specialised physicians as well as nurses, was considerably lower than the planned capacity. But training for obstetric perinatologists and OHC nurses was given.

CONCLUSION

The targets for the number of beds for tertiary obstetric care and associated medical personnel have not been achieved as yet. As a consequence, the number of transfers is still too high. The funding of OHC units is not attuned to the complexity of tertiary perinatal care. Closer supervision of the execution of the planning decree and an adequate financing system are needed to achieve the objectives of the planning decree in the next 3 years.

Color Doppler ultrasound of spiral artery blood flow for prediction of hypertensive disorders and intra uterine growth restriction: a longitudinal study

OBJECTIVE

To construct reference ranges for spiral artery (SA) flow velocities and examine the possibility to predict intra uterine growth restricted (IUGR) fetuses, pregnancy-induced hypertension (PIH) and/or preeclampsia.

METHODS

Spiral artery flow velocity measurements were performed using Color Doppler between 11 to 13 + 6, between 14 to 17 + 6 and between 18 to 24 weeks of gestation, each measurement was performed twice. Spiral artery flow velocities were analyzed with multilevel modeling: individual regression curves were estimated and combined to obtain the reference intervals for SA flow velocities in normal pregnancies. Mann-Whitney U tests was used to compare the deviation from expected flow velocity between normal and complicated pregnancies.

RESULTS

One hundred and eight pregnancies were included; 4 pregnancies were complicated with preeclampsia, 10 pregnancies with IUGR fetuses (<P10) and 7 with PIH. In the uncomplicated pregnancies, systolic/diastolic (SD) ratios, resistance index (RI) and pulsatility index (PI) decreased progressively with advancing gestational age. The best fits for SD, RI and PI versus gestational age were linear regression equations. According to these equations, the mean predicted SD ratio decreased from 1.75 at 11 weeks of gestation (P5-P95: 1.32-2.17) to 1.48 at 24 weeks of gestation (P5-P95: 1.01-2.20). The predicted RI en PI showed similar decrement: mean RI from 0.44 (P5-P95: 0.26-0.60) at 11 weeks of gestation to 0.34 (P5-P95: 0.15-0.50) at 24 weeks of gestation, mean PI from 0.59 (P5-P95: 0.31-0.75) at 11 weeks of gestation to 0.40 (P5-P95: 0.11-0.66) at 24 weeks of gestation. The Mann-Whitney tests found no difference in PI, SD-ratio or PI in pregnancies complicated by PE and IUGR fetuses. However, significantly lower RI, PI and SD-ratio were found preclinically in pregnancies complicated by PIH.

CONCLUSION

Spiral artery flow velocities decrease progressively with advancing gestational age. Reference ranges for SA blood velocities are wide and early measurements of PI, RI or SD-ratios are not sensitive enough to predict preeclampsia, PIH or IUGR fetuses. The significantly lower spiral artery impedance values preceding pregnancies complicated by PIH are likely caused by a hyperdynamic circulation in women with preexistent hypertension.

[Indications for respiratory complications during the use of oral nifedipine as a tocolytic agent, especially in patients with multiple pregnancies]

In 7 women with premature labour pains, severe dyspnoea developed that was possibly related to the use of nifedipine as an 'off-label' tocolytic. 6 of these women had a twin pregnancy. Diuretics and oxygen therapy had little effect, but the patients recovered after the administration of nifedipine was stopped. The efficacy and safety of nifedipine as a tocolytic agent has been investigated in a number of well-designed randomised studies. However, these studies were performed in a selected group of pregnant women and women with multiple pregnancies or prematurely ruptured membranes were mostly excluded. It can be hypothesised that the respiratory complications in these cases are due to unequal ventilation/perfusion of the lungs in the presence of a physiologically elevated diaphragm due to the pregnancy. These changes are more pronounced in multiple pregnancies. After administration ofnifedipine, there is perfusion of atelectatic areas of the lung that are not or not well ventilated, resulting in ventilation-perfusion discrepancy and hence dyspnoea. Although case reports permit only limited extrapolation, these observations warrant caution with regard to the safety ofnifedipine as a tocolytic agent in patients with multiple pregnancies. The use of medication in groups of patients for which the agent has not been investigated, or which were explicitly excluded from the study, should be done with extreme caution. One should in any case be aware of the possible risks.

Discrepancy in CD3-Transmembrane Peptide Activity between In Vitro and In Vivo T-Cell Inhibition

Electrostatic amino acid interactions between receptor subunits within the T-cell antigen receptor (TCR) transmembrane domain are critical for the formation of the TCR-CD3 complex. Core peptide, a short peptide corresponding to the TCR-alpha transmembrane region, containing two positively charged amino acids, is known to inhibit T-cell function in vitro and in vivo. The aim of this study was to examine peptides corresponding to the syntactic transmembrane CD3 region binding to TCR-alpha for their ability to inhibit T-cell activation in vitro and in vivo. Three peptides matching the transmembrane sequence of CD3-delta, -epsilon and -gamma were synthesized and tested in different biological in vitro and in vivo systems for their effect on T-cell activity. The CD3-peptides had no impact on T-cell function in vitro, but surprisingly, decreased signs of inflammation in the adjuvant arthritis rat model in vivo. Preliminary evidence suggests that peptides with CD3 transmembrane-derived sequences can inhibit an immune response as assessed by adjuvant-induced arthritis. The lack of in vitro activity may lead to a wasteful disregard of active compounds in the process of drug discovery and development.

Pharmacological and surgical therapy for primary postpartum hemorrhage

Early postpartum hemorrhage remains a significant cause of maternal morbidity and mortality. Postpartum hemorrhage is most commonly due to uterine atony and often responds to medical treatments such as administration of uterotonic drugs, alone or in combination with uterine massage or bimanual compression. As the incidence of cesarean section continues to rise, the problem of placenta previa and accreta is likely to become more common. For first-line management of postpartum hemorrhage adequate blood and fluid replacement is mandatory. In recent years new therapeutic measures to control the bleeding have gained attention. Although, these newer therapies focus on avoiding the need for emergency hysterectomy and preservation of reproductive function, reports of subsequent pregnancies are still scarce. Established management options are shortly reviewed and novel medical and surgical treatments are more extensively discussed.

Ketanserin for the treatment of preeclampsia

OBJECTIVE

To compare maternal and perinatal outcome with the use of either intravenous ketanserin or dihydralazine in treatment of women with preeclampsia.

METHODS

The records from January 1989 to January 1997 of all patients receiving intravenous ketanserin or dihydralazine as first line antihypertensive therapy were reviewed and standardized data forms were completed. 315 charts of patients were identified and evaluated for effects on blood pressure, laboratory parameters, maternal and perinatal outcome.

RESULTS

During the study interval 169 patients received ketanserin and 146 dihydralazine. Significantly fewer antepartum (27% versus 38%, p = 0.04) and postpartum (25% versus 39%, p = 0.01) maternal complications were noted in patients receiving ketanserin. Occurrence of HELLP syndrome was significantly lower among patients who received ketanserin (20%) than among those who received dihydralazine (40%, p = 0.0001). Side-effects were reported with significantly higher frequency in patients receiving dihydralazine (60%) as compared to those receiving ketanserin (17%, p < 0.0001). Perinatal outcome was comparable, however, umbilical cord arterial pH values (mean +/- SD) were higher with ketanserin compared to dihydralazine (7.25 +/- 0.07 vs 7.23 +/- 0.09, p = 0.038). The incidence of placental abruption was higher in patients receiving dihydralazine (5.5%) versus those receiving ketanserin (0.6%, p = 0.014).

CONCLUSION

Ketanserin appears to be a better option than dihydralazine for treatment of severe preeclampsia since fewer maternal complications and side-effects were observed in patients receiving ketanserin.

Management and monitoring of severe preeclampsia

Preeclampsia is associated with increased maternal and perinatal morbidity and mortality. Preeclampsia is more than pregnancy-induced hypertension. The hypertension is only one manifestation of an underlying multifactorial, multisystem disorder, initiated early in pregnancy. In established severe disease there is volume contraction, reduced cardiac output, enhanced vascular reactivity, increased vascular permeability and platelet consumption. Medical treatment of severe hypertension in pregnancy is required. The more controversial issues are the role of pharmacological treatment in conservative management of severe preeclampsia aiming at prolongation of pregnancy, the ability of such therapy to modify the course of the underlying systemic disorder and the effects on fetal and maternal outcome. This paper presents an overview concerning the current developments in management and monitoring of severe preeclampsia. Controversial topics such as the role of plasma volume expansion in preeclampsia, expectant versus aggressive management of severe preeclampsia remote from term, and pharmacological interventions in the management of eclampsia and the HELLP syndrome are addressed.

[Risk of uterine rupture after cesarean section--analysis of 1,086 births]

OBJECTIVE

In the presented paper, obstetrical management after previous caesarian section was studied in a large patient collective at the University Department of Gynaecology and Obstetrics in Cologne from 1979 to 1995. Particular attention was given to the feared complication of rupture of the uterus.

PATIENTS

From a total of 15,166 deliveries, 1,086 of the births had been preceded by one or more caesarian section. These 1,086 births formed the patient collective for the present study.

RESULTS

Vaginal delivery was attempted in 44.5% of patients and was successful in 86% of those cases. If there had been a previous caesarian section, the percentage shifted in favour of vaginal delivery. All patients with more than two previous caesarian sections were delivered by a primary caesarian section. The feared complication of rupture of the uterus occurred in four cases, for which case reports are presented. In view of such cases, signs of imminent uterus rupture often constitute an indication for primary (11.5%) or secondary resectioning (31.9%). No relationship was found between fetal outcome and mode of delivery.

CONCLUSION

This retrospective study confirms the general recommendation of vaginal delivery following previous caesarian section as long as risks are minimized by a readiness to proceed with resectioning when signs of imminent rupture of the uterus arise.

Pharmacological treatment of severe hypertension in pregnancy and the role of serotonin(2)-receptor blockers

Hypertensive disorders of pregnancy are the leading cause of maternal and perinatal mortality and morbidity in developing and developed countries. The etiology of preeclampsia is still unknown. Delivering the baby is the only definite treatment. The benefits of acute pharmacological control of severe hypertension prior to and/or post-delivery are generally accepted. Most drugs commonly used in the management of severe hypertension in pregnancy have significant maternal and/or neonatal adverse side effects. Furthermore, some are not effective to acutely lower the blood pressure in patients with a hypertensive crisis. Until recently not one of the commonly used antihypertensive drugs has been tailored to the pathophysiology of severe preeclampsia, being a clinical syndrome characterized by endothelial cell dysfunction, vasospasm and platelet aggregation. Ketanserin, a serotonin(2)-receptor blocker, is a drug that appears to be tailored for treating this pregnancy-associated enthothelial cell dysfunction. The results of several prospective trials show that there is a definite place for serotonin(2)-receptor blockers in the treatment of pregnancy-induced hypertensive disorders. This review provides a summary on the more established drugs as well as on some of the newer antihypertensive drugs used in pregnancy with emphasis on the existing experience with ketanserin.

Pathophysiology of preeclampsia and the role of serotonin

Hypertensive disorders constitute the most common medical complications of pregnancy. In normal pregnancy, impressive physiological changes take place in the maternal cardiovascular system. Morphological changes are the result of invasion of migratory trophoblast cells into the walls of the spiral arteries. After destruction of elastic, muscular and neural tissue in the media, the trophoblast cells get incorporated into the vessel wall and the endothelial lining of the spiral arteries is restored. The physiological changes create a low-resistance, low-pressure, high-flow system with the absence of maternal vasomotor control. Biochemical adaptations in maternal vasculature include changes in the prostaglandin system, the renin-angiotensin-aldosteron system and the kallikrein-kinin system. In preeclampsia, physiological changes in the spiral arteries are confined to the decidual portion of the arteries. Myometrial segments remain anatomically intact and fail to dilate. In addition, the adrenergic nerve supply is left intact. The cause of this impaired endovascular trophoblast invasion is not yet elucidated. But in combination with the imbalance between vasodilator and vasoconstrictor eicosanoids, it gives rise to reduced perfusion of the intervillous space. In the absence of an adequate production of antiaggregatory prostacyclin (PGI(2)), nitric oxide, or both, surface-mediated platelet activation is supposed to occur on the surface of the spiral arteries. Because platelets are the principal source of circulating serotonin, the increased platelet aggregation in preeclampsia causes an increase in serotonin levels. Interaction of serotonin with serotonin(1)- or serotonin(2)-receptors depends on the state of the endovascular trophoblast or endothelium in the spiral arteries and has opposite effects with regard to vasodilating and vasoconstrictive influences.

Lack of agreement between central venous pressure and pulmonary capillary wedge pressure in preeclampsia

OBJECTIVE

To establish if agreement exists between central venous pressure (CVP) and pulmonary capillary wedge pressure (PCWP) measurements in severe hypertension in pregnancy as analyzed by tests of bias, precision, and 95% limits of agreement.

METHODS

In a prospective study, CVP and PCWP data in 30 patients were collected by means of a pulmonary artery catheter from initiation of therapy until delivery. Patients with a diastolic blood pressure of more than 110 mm Hg were included. Correlation and agreement between CVP and PCWP before and after treatment were evaluated.

RESULTS

The correlation coefficient (r) for CVP-PCWP data in 30 untreated patients was r = 0.64 (p = 0.0002) and for 256 pairs of posttreatment data, it was r = 0.53 (p < 0.0001). Linear regression and correlation for each individual patient in 29 patients with more than 3 measurements showed a significant correlation (p < 0.05) in 19 patients (66%). Correlation was poor (p > 0.05) in 10 patients (34%). The mean difference between PCWP and CVP was 3.5 +/- 2.6 mm Hg (limits of agreement: -1.6 to 8.7) in untreated patients. The mean difference between PCWP and CVP for 256 pairs of data derived posttreatment was 4.9 +/- 3.8 mm Hg (limits of agreement: -2.7 to 12. 5).

CONCLUSION

Invasive measurements of CVP and PCWP were found to agree poorly. Until a reliable noninvasive method is available to measure left ventricular preload, PCWP is the measurement of choice when invasive hemodynamic monitoring is necessary in patients with severe preeclampsia.

Ketanserin versus dihydralazine in the management of severe early-onset preeclampsia: maternal outcome

OBJECTIVE

An open, randomized, prospective, multicenter trial was conducted to compare the efficacy and safety of intravenous ketanserin, a selective serotonin 2 receptor blocker, with that of intravenous dihydralazine in the management of severe early-onset (<32 weeks' gestation) preeclampsia. End points of this study were blood pressure control and maternal outcome.

STUDY DESIGN

Patients with a diastolic blood pressure >110 mm Hg were randomly assigned to receive either ketanserin (n = 22) or dihydralazine (n = 22) as initial therapy. Plasma volume expansion preceded antihypertensive treatment, which was administered according to a fixed schedule.

RESULTS

The reductions in blood pressure with the 2 drugs were similar; however, adequate blood pressure control was reached significantly earlier with ketanserin (84 +/_ 63 vs 171 +/- 142 minutes, P = .017). Occurrence of maternal complications was significantly lower among patients who received ketanserin than among patients who received dihydralazine (n = 6 vs n = 18, P =.0007). A significant difference in favor of ketanserin was noted in daily fluid balance.

CONCLUSION

Antihypertensive efficacies of ketanserin and dihydralazine were comparable, but significantly fewer maternal complications were noted among the patients receiving ketanserin. Ketanserin is an attractive alternative in the management of severe early-onset preeclampsia.

The haemodynamic effects of ketanserin versus dihydralazine in severe early-onset hypertension in pregnancy

OBJECTIVE

To compare the haemodynamic efficacy of ketanserin (a selective serotonin2-receptor blocker) with dihydralazine in the management of severe early-onset hypertension in pregnancy.

DESIGN

Subgroup analysis within a randomised prospective multicentre trial to compare haemodynamic effects as measured by pulmonary artery catherization.

SETTING

Departments of Obstetrics and Gynaecology and Intensive Care Medicine, Free University Hospital, Amsterdam and Sophia Hospital, Zwolle.

PARTICIPANTS

Thirty-one women with a diastolic blood pressure > 110 mmHg and a gestational age between 26 and 32 weeks.

RESULTS

The antihypertensive efficacy of both drugs was comparable. Dihydralazine significantly increased cardiac output (P < 0.01), while ketanserin induced only minor changes in cardiac output. Systemic vascular resistance decreased in both groups, but the decrease was significantly more pronounced with dihydralazine compared with ketanserin. Ketanserin induced a significant but not clinically relevant increase in heart rate (P < 001, while dihydralazine caused marked tachycardia (P < 0.005). Left ventricular stroke work index was reduced to similar values in both groups.

CONCLUSIONS

The antihypertensive profile of ketanserin is characterised by an early and gradual reduction of blood pressure in combination with a moderate decrease in systemic vascular resistance and no significant change in cardiac output. Dihydralazine causes market tachycardia resulting in a considerable increase in cardiac output.

[Pregnancy-saving measures in premature rupture of fetal membranes in the 22nd week of pregnancy]

The obstetric-perinatologic problems raised by premature rupturing of the membranes in the 22nd gestational week is presented in the form of a case report from the Perinatal Centre of the University of Cologne. By close ultrasonic monitoring of the course of development, measurement of parameters of inflammation and administration of prophylactic antibiotics pregnancy could be prolonged by 9 weeks with good fetal outcome.

Relationship between amniotic fluid insulin and maternal blood glucose concentrations in patients with carbohydrate intolerance during pregnancy

In contrast to maternal blood glucose, amniotic fluid insulin (AFI) directly reflects the functional state of the fetal pancreas. In a prospective study we evaluated the correlation of AFI with maternal metabolic control in 70 amniotic fluid specimens from 61 women having carbohydrate intolerance during pregnancy (White A n = 44, B0 n = 17). AFI was measured with the Insulin RIA 100 kit from Pharmacia (Freiburg). The normal range of AFI was established in 304 healthy pregnant women (16th-42nd gestational week). AFI concentrations increased by a factor of 1.5 to 2 during gestation reflecting the maturation of the fetal pancreas. Elevated AFI levels (> 97th centile) were found in 11% of normoglycemic diabetics and in 50% of women with insufficient metabolic control. Despite a high overall concordance (81%) no direct relationship could be found between fetal and maternal parameters. Patients with increased AFI values had a 5-fold higher rate of large-for-gestational age (LGA) infants than women with normal levels. This finding confirms the pathogenetic role of hyperinsulinism in the development of fetal macrosomia.

[An consultation concept for integrating psychosomatic medicine in gynecology]

This paper is meant to survey the results of an interdisciplinary concept of psychosomatic patient treatment carried out for two years at the Department of Gynaecology and Obstetrics of the University of Cologne. This integral programme offers a psychosomatic consultation hour taking place once a week at the Department of Gynaecology and Obstetrics. Each first consultation is attended both by a psychosomatic specialist and a gynaecologist. The hypothesis underlying this new programme, which supposes that the integration of the psychosomatic treatment into the everyday routine of the clinic would make it easier for the patients to find access to psychological help, has proved right in view of the experience made so far. In comparison to the former counselling concept, the newly established gynaecologic-psychosomatical programme has increased the attendance by 300%. Thanks to the integrated consultation hour the way of seeing gynaecological problems in a psychosomatic context has increased considerably within the clinic itself so that these problems can now often be solved directly between gynaecologist and patient without making use of the offered consultation hour. Experiences made so far prove that the psychosomatic consultation hours are a valuable contribution to the diagnostic and therapeutic spectrum of the Department of Gynaecology and Obstetrics.

Prognostic factors for preoperative consultation of women desiring sterilization: findings of a retrospective analysis

In this exploratory study, 37 sterilized women applying for sterilization reversal were questioned thoroughly to establish why they had decided to undergo sterilization and why they now wished for it to be reversed. Taking an interactive behavioral model as our starting point, we concentrated on the psychosocial circumstances leading to the definitive decision to be sterilized. A relationship crisis at the time of sterilization was found to be a prognostically unfavorable factor. Furthermore, 20 of the 37 patients cited new partnerships as their main reason for seeking reversal. Those who felt pressurized by their gynecologist or partner into undergoing sterilization had significantly more problems in overcoming the psychological stress accompanying such an operation than those who, through a series of consultations on contraception, had had sufficient time and opportunity to make their own decisions. Sterilization performed for medical reasons was found to have particularly problematical consequences, especially where the doctor had made the decision largely on his own, failing to give an adequate explanation for the medical necessity of the operation. Regarding the time chosen for sterilization, the study revealed that the patient's postoperative psychological condition was significantly worse when sterilization was carried out immediately after a delivery, after abortion or after Caesarean section, rather than in the interval between pregnancies. The resulting increase in the incidence of psychosomatic complaints and depressive states is also confirmed in the literature. The findings of this study offer practical suggestions for improved preoperative consultation and should help to determine the course of action to be taken when a patient wishes to be sterilized.

[Obstetric prognostic factors of newborn infants with very low birth weight (< or = 1,500 gram) with reference to survival rate and early childhood development]

Prognostic factors influencing survival in 235 very low birthweight prematures (< or = 1500 g) born between 1986 and 15.11. 1993 at the Department of Obstetrics and Gynaecology, University Hospital of Cologne, were retrospectively evaluated. Chromosomal anomalies and severe congenital malformations were excluded. Of 180 singletons 84 were classified as appropriate-for-gestational-age (AGA) and 96 as small-for-gestational-age (SGA). By interrogating the attending paediatricians data regarding the early development of 62/65 surviving singletons born between 1986 to 1990 were recorded (follow-up rate 95%). Survival was significantly correlated to singleton pregnancy (p < 0.05), female sex (p = 0.001) and in the AGA-prematures to prenatal corticoid prophylaxis. With similar mean birthweight SGA-singletons showed a three weeks higher mean gestational age; the mortality showed an inverse correlation to birthweight and gestational age being 11% higher in the AGA-group compared with the SGA-group (32% versus 21%). At the age of between 11 months and 6 years severe handicaps and developmental retardations were found more often in previous AGA-prematures (6/26) than in previous SGA-prematures (4/36); type and degree of later handicap were not correlated to birthweight. According to our results survival rates of very low birthweight prematures are strongly influenced by singleton pregnancy, by fetal sex, by gestational age and in the AGA-group by prenatal corticoid prophylaxis; mortality shows an inverted correlation to birthweight and gestational age, whereas the later prognosis of survivors does not seem to be influenced by birthweight or gestational age.

A case of HELLP syndrome at 23 weeks' gestation

We report a case of the HELLP syndrome at 23 weeks' gestation. Prolongation of pregnancy until the fetus was viable was not possible.

[Psychological disease adjustment in breast cancer patients]

In a prospective follow-up study, attention was focused on adjustment to disease in breast cancer patients one year after diagnosis. Prebioptic data was collected in the original patient group consisting of 95 women with mammary tissue findings that required clarification. Twenty-nine women with histological confirmation of breast cancer and 37 patients of the control group with benign histological findings were recontacted after an interval of one year. Data was collected by means of psychological test questionnaires (STAI, SVF, FPI, CIP-DS), the patients with breast cancer were given an additional problem-oriented questionnaire about coping with disease, compiled by the author. Most denied having disease-related fears-progression of the disease, premature death; instead, marked sleep disturbances, regularly, recurring nightmares, and depressed states of mind characterized the psychosomatic correlate of the mental burden. The psychological consequences of cancer are related to some extent to the stage of tumour growth at the time of diagnosis; the process of social reintegration appears to be facilitated in women whose biopsy operation did not involve removal of a breast. An clear characterization of breast cancer patients could not be established using psychological testing procedures one year after diagnosis of the disease.

[The prognostic significance of cathepsin D in primary breast cancer]

The prognostic significance of the lysosomal protease cathepsin D in breast cancer was evaluated in a retrospective study. Cathepsin D was measured in 346 deep-frozen (-70 degrees C) cytosol specimens of primary breast carcinomas (1982-1990). Among the established prognostic factors, only axillary lymph node involvement correlated with the expression of cathepsin D (> 40/60 pmol/mg) (p = 0.04-0.05). Univariate analyses of disease-free survival (DFS) and overall survival (OS) showed, that the expression of cathepsin D had no effect on the prognosis either in the whole population of breast cancer patients during long-term follow-up (n = 302; median observation time 51 months) or in the group of women with positive lymph nodes (n = 157; 46 months). However, within the group of N0 patients (n = 145; 57 months), high cathepsin D levels were associated with an unfavourable OS, but this relationship was statistically insignificant (p = 0.08-0.13). A similar influence of cathepsin D on DFS could not be demonstrated. Compared to tumour size, grading and receptor status in multivariate analysis, cathepsin D was a more indicative, but finally insignificant prognostic factor for OS. According to these results, cathepsin D may contribute only in combination with other prognostic factors to identify those 20-30% of node-negative patients with unfavourable prognosis, who may benefit from adjuvant therapy.

Prenatal expectations and fears in pregnant women

The aim of this study was to extend the medical knowledge of the prenatal expectations and wishes of pregnant women with respect to themselves, their partners and the maternity ward selected for the approaching birth, and also of the anxieties arising in this connection. In summary, our study shows that the desire to experience birth in the most natural, undisturbed and unmanipulated form possible is reiterated frequently, but is relativized by the intense need to be reassured of the safety of the unborn child. Fears experienced before the birth were focused accordingly on the condition of the child, although 25% of the women questioned acknowledged a marked fear of helplessness and failure. The obstetric team were expected to offer, as far as possible, the continuous personal supervision of a doctor and a midwife who were prepared to allow the patient the responsibility of being involved in obstetric decisions.

[Premature rupture of fetal membranes: problems and obstetric management]

The treatment of a premature rupture of the foetal membrane (prom) has up to now been a subject of controversy. Depending on the stage of gestation, the prompt birth ensuing as a result of prom, involves the risk of immaturity of the child. Conservative waiting by contrast, exposes mother and child to a potential risk of infection. The retrospective study presented, summarises the strategies for treating prom used at the Cologne University Department of Obstetrics and Gynaecology during the period from 1984 to 1989, and attempts to develop from these data proposals for the treatment of prom. With an increase in latency of over 24 hours between prom and delivery, the maternal and neonatal rate of infection also increased significantly. An effective result of a prophylaxis with antibiotics could only be shown in the reduction of incidence of infection in the mother. An effect on the neonatal rate of infection could not be seen. Inducing prepartually lung-maturity with glucocorticoides or ambroxol resulted in a significant decrease of the RDS-rate in new born children up to the 34th week of gestation. Beyond the 34th week of gestation, this effect could not be found. Whereas after completion of the 37th week of gestation, the preferred treatment used by doctors is allowing the shortest possible time of latency between prom and delivery, the expected pulmonary immaturity before the 34th week of gestation has to be treated by prolonging the pregnancy and inducing pulmonary maturity under antibiotic prophylaxis and at the same time controlling infection.(ABSTRACT TRUNCATED AT 250 WORDS)

[Prolongation of a primary twin pregnancy to the 31st week of pregnancy by surgical extraction of the 1st twin in the 17th week of pregnancy for umbilical cord prolapse]

A 24-year-old woman with a twin pregnancy had a premature rupture of membranes (PROM) of the first foetus in the 16th gestational week (gw). After 9 days the umbilical cord prolapsed. In the 17th gw the foetus was extracted by vaginal hysterotomy, because of an inferior anterior wall placenta. The patient remained hospitalised receiving tocolysis, lung maturation induction and prophylactic antibiosis. The pregnancy could be prolonged for 109 days after PROM and 99 days after the extraction of the first twin. The second child was born in the 31st gw by Caesarean section, following uncontrollable labour.

[On the value of "informational evening classes for mothers and fathers" within the scope of prenatal care]

In 1989, the Department of Gynaecology and Obstetrics, University of Cologne, questioned the 288 participants of the "informative evenings for mothers and fathers", a primarily preventive measure offered as a preparation for childbirth. The survey aimed at reviewing these evenings, i.e. to make a critical and exact evaluation of their usefulness and quality as one of the numerous events offered to expectant mothers. The following results were obtained: The women who visited the informative evenings were mostly pregnant for the first time, educated above average, for the most part working women and of German nationality. Their attitude towards preventive measures, i.e. regular check-ups during pregnancy as well as smoking behaviour, the wish to breast-feed and the attendance of other birth preparation courses, is well founded. Consequently, this group of women can be described as a highly selected. Their motivation to come to the evenings resulted mostly from the wish to obtain specific clinical information, to become familiar with the maternity ward, to meet midwives and doctors, in order to lose some of their fears and to increase confidence. Contents and structure of these evenings were mostly able to meet the expectations of the visitors. Unsatisfactory, however, was the low number of foreign woman, those with difficult pregnancies and women of a low social status i.e. patients, who above all, need intensive assistance and attention.

[Retrosternal lymph node metastases in breast cancer: lymphoscintigraphy and magnetic resonance tomography]

In 21 patients with breast cancer (pT1-4, N0, M0) internal mammary lymphoscintigraphy and magnetic resonance imaging (MRI) were performed to evaluate retrosternal lymph node metastases. In 6 patients normal findings of lymphoscintigraphy were confirmed by MRI. In the 15 patients with focal defects seen by lymphoscintigraphy no lymph nodes were found by MRI in 5 in the corresponding area, 5 showed normal-sized lymph nodes (less than 1 cm) and 5 enlarged lymph nodes indicating metastatic infiltration. In addition to internal mammary lymphoscintigraphy MRI may offer the possibility to improve TNM staging in patients with breast cancer.

Natural lymphocyte cytotoxicity of women with different symptoms of toxemia

Natural cytotoxic activity of lymphocytes from 113 pregnant women presenting one or more symptoms of the toxemic triad (E, P or H) was tested. According to the clinical symptoms, groups EH + H, EP + P and PH + EPH were formed. The control group consisted of 56 healthy pregnant patients. Significantly increased cytotoxicity was observed in toxemic pregnancies with proteinuria (group EP + P, 35.8 +/- 14.3%, P less than 0.001) and with proteinuria and hypertension (group PH + EPH, 27.2 +/- 13.3%, P less than 0.001%), but not in the group with hypertension (EH + H, 13.0 + 9.9%), compared to that of controls (11.0 + 11.5%). The relative number of patients with cytotoxicity greater than or equal to 40% was also higher in groups with proteinuria presenting with or without other symptoms of the disease. Increased cytotoxicity in proteinuric form of gestosis seemed to be independent of the incidence of low birthweight deliveries and intra-uterine growth retardation.

[Analysis of motivation of sterilized women requesting sterilization reversal]

Within the framework of this exploratory study, 37 sterilised women wishing to be refertilised, were questioned thoroughly on what had indicated their sterilisation and why they wish to be refertilised. Assuming the existence of an interactive behaviour pattern, we concentrated on the psycho-social circumstances accompanying the definitive decision to be sterilised. Here, a critical situation in the relationship between the partners at the time of sterilisation could be established as a prognostically unfavourable factor. Accordingly, 20 of the 37 patients developed the wish to be refertilized because of a new partnership. Those who felt induced by their gynaecologist or partner to undergo sterilisation had significantly more problems in overcoming the psychological stress accompanying such an operation than those who, after repeated consultations, had enough time and possibilities to make their own decision concerning contraception. Furthermore, sterilisation due to medical indication could be suggested as another highly critical factor, especially where the gynaecologist failed to give sufficient explanation of its medical necessity. With regard to the time set for the sterilisation, the study revealed that the patient's psychological condition after the operation was significantly worse, when sterilisation was carried out immediately after a delivery or an abortion. The fact that in such cases sterilisation is often followed by an increase in psychosomatic trouble and depressive states, of mind is also confirmed by literature. The results of the study are a practical contribution towards improving preoperative consultation and coordinating the course of action to be taken where a patient has the wish to be sterilised.

Untersuchung retrosternaler Lymphknotenmetastasen beim Mammakarzinom: Lymphszintigraphie und Kernspintomographie

In 21 patients with breast cancer (pT1–4, N0, M0) internal mammary lymphoscintigraphy and magnetic resonance imaging (MRI) were performed to evaluate retrosternal lymph node metastases. In 6 patients normal findings of lymphoscintigraphy were confirmed by MRI. In the 15 patients with focal defects seen by lymphoscintigraphy no lymph nodes were found by MRI in 5 in the corresponding area, 5 showed normal-sized lymph nodes (<1 cm) and 5 enlarged lymph nodes indicating metastatic infiltration. In addition to internal mammary lymphoscintigraphy MRI may offer the possibility to improve TNM staging in patients with breast cancer.

[Pregnancy-induced hypotonia. A prospective study of fetal development, labor and morbidity of newborn infants]

Maternal and foetal risk of hypotension in pregnancy were examined in a prospective study, comprising a total of 770 pregnant women i.e. 700 normotensives and 70 hypotensives. We conducted a minimum of 5 pressure controls beginning after the 20th week of gestation. All pressure controls were conducted by the same person and in each control 4 pressure values were taken (left and right arm, lying, standing). No difference was discovered in the statistical analysis of our data of pregnancy, delivery and foetal outcome. Our special interest was in the frequency of preterm delivery and foetal growth retardation. The rate was similar in the hypotensive group (6.7/3.1%) compared to the normotensive group (6.8/2.8%). From our results we conclude, that maternal hypotension is not a risk factor in pregnancy, and that no therapy is needed.

[Alloimmune thrombocytopenia in the newborn infant caused by maternal PlA1 antibodies]

The case of pregnant woman, whose first child was born with neonatal alloimmune thrombocytopenia (NATP) and PlA2/PlA1 constellation, is used as an example to draw up a programme for the care of pregnant women whose children are expected to be born with NATP. In one of 2,000 to one of 3,000 cases, the PlA1-positive foetal platelets cause a sensitization of the PlA1-negative mother. Transplacental passage of maternal IgG alloantibodies leads to accelerated destruction of foetal platelets. The pathophysiologic process is similar to Rh-erythroblastosis foetalis. The infants show symptoms ranging from cutaneous manifestations to intracranial haemorrhages.