Incidence and Predictors of Maternal Cardiovascular Mortality and Severe Morbidity in the Netherlands: A Prospective Cohort Study

Objective: To assess incidence and possible risk factors of severe maternal morbidity and mortality from cardiovascular disease in the Netherlands. Design: A prospective population based cohort study. Setting: All 98 maternity units in the Netherlands. Population: All women delivering in the Netherlands between August 2004 and August 2006 (n = 371,021) Methods: Cases of severe maternal morbidity and mortality from cardiovascular disease were prospectively collected during a two-year period in the Netherlands. Women with cardiovascular complications during pregnancy or postpartum who were admitted to the ward, intensive care or coronary care unit were included. Cardiovascular morbidity was defined as cardiomyopathy, valvular disease, ischaemic heart disease, arrhythmias or aortic dissection. All women delivering in the same period served as a reference cohort. Main outcome measures: Incidence, case fatality rates and possible risk factors. Results: Incidence of severe maternal morbidity due to cardiovascular disease was 2.3 per 10,000 deliveries (84/358,874). Maternal mortality rate from cardiovascular disease was 3.0 per 100,000 deliveries (11/358,874). Case fatality rate in women with severe maternal morbidity due to cardiovascular disease was 13% (11/84). Case fatality rate was highes

A viable caesarean scar pregnancy in a woman using a levonorgestrel-releasing intrauterine device

__Background:__ Although the levonorgestrel-releasing intrauterine device (LNG-IUD) is one of the most reliable methods of contraception, it is associated with an increased risk of ectopic pregnancy in case of unintended pregnancy. A rare form of ectopic pregnancy is the caesarean scar pregnancy (CSP), with a high risk of serious maternal morbidity, such as uterine rupture, massive haemorrhage and resulting infertility. This report describes the first case of a viable CSP at 13 weeks of gestation in association with the use of a LNG-IUD. __Case-presentation:__ A 36-year-old Caucasian woman was referred to our outpatient clinic because of suspicion of a CSP. The pregnancy was unintended and was diagnosed during replacement of the LNG-IUD after five years. The patient had undergone two caesarean sections in the past. Ultrasound investigation showed an intact pregnancy of approximately 13 weeks of gestation located in the uterine scar. Because of the size of the gestational sac, a laparotomy was performed under general anaesthesia using a Joel-Cohen incision. The procedure was complicated by a total blood loss of 1500 mL, mostly caused by diffuse bleeding from the placental bed. __Conclusion:__ Unintended pregnancies in women using a LNG-IUD are frequently ectopic pregnancies with a preponderance to nidate outside the fallopian tube. Therefore, early diagnosis and location of the pregnancy in women using a LNG-IUD is essential

Gravid uterine torsion after prone positioning in SARS-CoV2 (COVID-19)-related acute respiratory distress syndrome

A multiparous pregnant patient was admitted to the intensive care unit in her third trimester of pregnancy for prone positioning mechanical ventilation after developing SARS-CoV2 (COVID-19)-related acute respiratory distress syndrome. Repositioning in left lateral tilt was followed by uterine contractions and cardiotocography alterations. Preterm caesarean section was performed based on persistent foetal tachycardia and suspected foetal distress, followed by a per-operative diagnosis of uterine levotorsion. This case report is the first to explore a potential causal link between prolonged prone positioning in late pregnancy and postural gravid uterine torsion and highlights the need for appropriate foetal monitoring during prone positioning mechanical ventilation support

Electroencephalography in normotensive and hypertensive pregnancies and subsequent quality of life

Objectives: To compare electroencephalography (EEG) findings during pregnancy and postpartum in women with normotensive pregnancies and pregnancies complicated by hypertensive disorders. Also the health related quality of life postpartum was related to these EEG findings. Materials and Methods: An observational case-control study in a university hospital in the Netherlands. Twenty-nine normotensive and 58 hypertensive pregnant women were included. EEG's were recorded on several occasions during pregnancy and 6-8 weeks postpartum. Postpartum, the women filled out health related quality of life questionnaires. Main outcome measures were qualitative and quantitative assessments on EEG, multidimensional fatigue inventory, Short Form (36) Health Survey and EuroQol visual analogue scale. Results: In women with severe preeclampsia significantly lower alpha peak frequency, more delta and theta activity bilaterally and a higher EEG Sum Score were seen. Postpartum, these women showed impaired mental health, mental fatigue and social functioning, which could not be related to the EEG findings. Conclusions: Severe preeclamptic patients show more EEG abnormalities and have impaired mental wellbeing postpartum, but these findings are not correlated

Analysis of prehospital perimortem caesarean deliveries performed by Helicopter Emergency Medical Services in the Netherlands and recommendations for the future

Background: Prehospital perimortem caesarean delivery (PCD) is a rarely performed procedure. In this study, we aimed to examine all PCDs performed by the four Helicopter Emergency Medical Services in the Netherlands; to describe the procedures, outcomes, complications, and compliance with the reco

Regional differences in severe postpartum hemorrhage: A nationwide comparative study of 1.6 million deliveries

Background: The incidence of severe postpartum hemorrhage (PPH) is increasing. Regional variation may be attributed to variation in provision of care, and as such contribute to this increasing incidence. We assessed reasons for regional variation in severe PPH in the Netherlands. Methods: We used the Netherlands Perinatal Registry and the Dutch Maternal Mortality Committee to study severe PPH incidences (defined as blood loss ≥ 1000 mL) across both regions and neighborhoods of cities among all deliveries between 2000 and 2008. We first calculated crude incidences. We then used logistic multilevel regression analyses, with hospital or midwife practice as second level to explore further reasons for the regional variation. Results: We analyzed 1599867 deliveries in which the incidence of severe PPH was 4.5%. Crude incidences of severe PPH varied with factor three between regions while between neighborhoods variation was even larger. We could not explain regional variation by maternal characteristics (age, parity, ethnicity, socioeconomic status), pregnancy characteristics (singleton, gestational age, birth weight, pre-eclampsia, perinatal death), medical interventions (induction of labor, mode of delivery, perineal laceration, placental removal) and health care setting. Conclusions: In a nationwide study in The Netherlands, we observed wide practice variation in PPH. This variation could not be explained by maternal characteristics, pregnancy characteristics, medical interventions or health care setting. Regional variation is either unavoidable or subsequent to regional variation of a yet unregistered variable

Elevated levels of protein AMBP in cerebrospinal fluid of women with preeclampsia compared to normotensive pregnant women

Purpose: To investigate the cerebrospinal fluid (CSF) proteome of patients with preeclampsia (PE) and normotensive pregnant women, in order to provide a better understanding of brain involvement in PE. Experimental design: Ninety-eight CSF samples (43 women with PE and 55 normotensive controls) were analyzed by LC-MS/MS proteome profiling. CSF was obtained during the spinal puncture before caesarean delivery. Results: Eight proteins were higher abundant and 17 proteins were lower abundant in patients with PE. The most significantly differentially abundant protein was protein AMBP (alpha-1-microglobulin/bikunin precursor). This finding was validated by performing an ELISA experiment (p = 0.002). Conclusions and clinical relevance: The current study showed a clear difference between the protein profiles of CSF from patients with PE and normotensive pregnant women. Protein AMBP is a precursor of a heme-binding protein that counteracts the damaging effects of free hemoglobin, which may be related to the presence of free hemoglobin in CSF. Protein levels showed correlations with clinical symptoms during pregnancy and postpartum. To our knowledge, this is the first LC-MS/MS proteome profiling study on a unique set of CSF samples from (severe) preeclamptic patients and normotensive pregnant women