Clinical characteristics of women captured by extending the definition of severe postpartum haemorrhage with 'refractoriness to treatment': a cohort study

Background: The absence of a uniform and clinically relevant definition of severe postpartum haemorrhage hampers comparative studies and optimization of clinical management. The concept of persistent postpartum haemorrhage, based on refractoriness to initial first-line treatment, was proposed as an alternative to common definitions that are either based on estimations of blood loss or transfused units of packed red blood cells (RBC). We compared characteristics and outcomes of women with severe postpartum haemorrhage captured by these three types of definitions. Methods: In this large retrospective cohort study in 61 hospitals in the Netherlands we included 1391 consecutive women with postpartum haemorrhage who received either ≥4 units of RBC or a multicomponent transfusion. Clinical characteristics and outcomes of women with severe postpartum haemorrhage defined as persistent postpartum haemorrhage were compared to definitions based on estimated blood loss or transfused units of RBC within 24 h following birth. Adverse maternal outcome was a composite of maternal mortality, hysterectomy, arterial embolisation and intensive care unit admission. Results: One thousand two hundred sixty out of 1391 women (90.6%) with postpartum haemorrhage fulfilled the definition of persistent postpartum haemorrhage. The majority, 820/1260 (65.1%), fulfilled this definition within 1 h following birth, compared to 819/1391 (58.7%) applying the definition of ≥1 L blood loss and 37/845 (4.4%) applying the definition of ≥4 units of RBC. The definition persistent postpartum haemorrhage captured 430/471 adverse maternal outcomes (91.3%), compared to 471/471 (100%) for ≥1 L blood loss and 383/471 (81.3%) for ≥4 units of RBC. Persistent postpartum haemorrhage did not capture all adverse outcomes because of missing data on timing of initial, first-line treatment. Conclusion: The definition persistent postpartum haemo

A comparison of the impact of screen-positive results obtained from ultrasound and biochemical screening for Down syndrome in the first trimester: a pilot study

Objective To compare the experiences of women who received a screen-positive test result for Down syndrome after nuchal translucency screening or after biochemical screening in the first trimester of pregnancy in the Netherlands. Method Semi-quantitative questionnaires were sent to 40 women with a screen-positive test result for Down syndrome in the first trimester of pregnancy: 20 had undergone nuchal translucency screening (NT group) and 20 had undergone serum screening (PAPP-A and free beta-hCG) (SS group). In all the cases, chorionic villus sampling (CVS) had not revealed any chromosomal abnormalities. Results The major reason for undergoing the screening test in both groups of women was to be more reassured about the health of the baby. In the NT group, 5 out of the 20 women stated that they had suddenly been confronted with the NT measurement during the ultrasound examination without even being asked, or had been caught by surprise about the possibility. Together with two other women, they felt that at that stage they had been insufficiently informed about what the test meant. In the SS group, two women also held this opinion. In 10 out of the 20 women in the SS group, the positive-screening result had caused (a great deal of) anxiety. In the NT group, this proportion was as high as 18 out of the 20. Six of the women in the NT group mentioned that 'seeing the baby' had been an important factor in their decision to undergo CVS. Even after a favourable result of CVS, a proportion of the pregnant women were still feeling anxious about the health of their baby (5 women in the SS group and 12 in the NT group). Nevertheless, a large proportion of the women in both groups was pleased that they had undergone the screening test. Only a few of them stated that they would not choose the same screening test again in a future pregnancy. Conclusions An unfavourable screening result after NT screening appeared to have a greater impact than an unfavourable result after serum screening. This might partly be explained by the ultrasound examination visualising the increased risk during NT screening. An additional important role may have been played by the fact that an abnormal NT screening result implies an increased risk of other disorders besides Down syndrome, which the women should be informed about beforehand. Several factors place special demands on the counselling prior to NT screening. Copyright (C) 2004 John Wiley Sons, Lt

Bone remodelling around a cementless glenoid component

Post-operative change in the mechanical loading of bone may trigger its (mechanically induced) adaptation and hamper the mechanical stability of prostheses. This is especially important in cementless components, where the final fixation is achieved by the bone itself. The aim of this study is, first, to gain insight into the bone remodelling process around a cementless glenoid component, and second, to compare the possible bone adaptation when the implant is assumed to be fully bonded (best case scenario) or completely loose (worst case scenario). 3D finite element models of a scapula with and without a cementless glenoid component were created. 3D geometry of the scapula, material properties, and several physiological loading conditions were acquired from or estimated for a specific cadaver. Update of the bone density after implantation was done according to a node-based bone remodelling scheme. Strain energy density for different loading conditions was evaluated, weighted according to their frequencies in activities of daily life and used as a mechanical stimulus for bone adaptation. The average bone density in the glenoid increased after implantation. However, local bone resorption was significant in some regions next to the bone–implant interface, regardless of the interface condition (bonded or loose). The amount of bone resorption was determined by the condition imposed to the interface, being slightly larger when the interface was loose. An ideal screw, e.g. in which material fatigue was not considered, was enough to keep the interface micromotions small and constant during the entire bone adaptation simulation.Precision and Microsystems Engineering (PME)Mechanical, Maritime and Materials Engineerin

Economic analysis comparing induction of labor and expectant management in women with preterm prelabor rupture of membranes between 34 and 37 weeks (PPROMEXIL trial)

ObjectiveTo compare the costs of induction of labor and expectant management in women with preterm prelabor rupture of membranes (PPROM). DesignEconomic analysis based on a randomized clinical trial. SettingObstetric departments of eight academic and 52 non-academic hospitals in the Netherlands. PopulationWomen with PPROM near term who were not in labor 24h after PPROM. MethodsA cost-minimization analysis was done from a health care provider perspective, using a bottom-up approach to estimate resource utilization, valued with unit-costs reflecting actual costs. Main outcome measuresPrimary health outcome was the incidence of neonatal sepsis. Direct medical costs were estimated from start of randomization to hospital discharge of mother and child. ResultsInduction of labor did not significantly reduce the probability of neonatal sepsis [2.6% vs. 4.1%, relative risk 0.64 (95% confidence interval 0.25-1.6)]. Mean costs per woman were Euro8094 for induction and Euro7340 for expectant management (difference Euro754; 95% confidence interval -335 to 1802). This difference predominantly originated in the postpartum period, where the mean costs were Euro5669 for induction vs. Euro4801 for expectant management. Delivery costs were higher in women allocated to induction than in women allocated to expectant management (Euro1777 vs. Euro1153 per woman). Antepartum costs in the expectant management group were higher because of longer antepartum maternal stays in hospital. ConclusionsIn women with pregnancies complicated by PPROM near term, induction of labor does not reduce neonatal sepsis, whereas costs associated with this strategy are probably higher

Induction of labour at term with oral misoprostol versus a foley catheter (PROBAAT-II) : A multicentre randomised controlled non-inferiority trial

When pregnancy complications pose a threat to the mother or fetus or both, induction of labor is often required. Induction of labor is accomplished through a variety of methods; in pregnant women having an unfavourable cervix, cervical ripening of the cervix is accomplished through various mechanical and pharmacological means. Oral misoprostol and Foley catheter are believed to be equally effective in women with an unfavorable cervix in accomplishing vaginal birth. The current open-label randomized noninferiority trial was conducted in pregnant women with a singleton gestation in 29 hospitals in the Netherlands (2012 to 2013) to directly compare oral misoprostol with Foley catheter. Women with a viable singleton pregnancy in cephalic presentation, intact membranes, gestational age of 37 weeks or more, and an unfavorable cervix were included in the trial. The women were then randomly allocated (1:1) to oral misoprostol (n = 932) or Foley catheter (n = 927). Oral misoprostol dosage given was 50 µg orally once every 4 hours with a maximum of 3 times a day. Placement of a 30-mL Foley catheter in the cervix was done either digitally or using a vaginal speculum. The results of the study showed that the primary outcome (asphyxia or postpartum hemorrhage) occurred in 12.2% women in the misoprostol group and in 11.5% women in the Foley catheter group (adjusted relative risk [RR], 1.06; 90% confidence interval [CI], 0.86–1.31). Cesarean delivery resulted in 16.8% of labors in the misoprostol group and in 20.1% of the time in the Foley catheter group (no significant difference between groups [RR, 0.84; 95% CI, 0.69–1.01]). When the indication for cesarean delivery was examined, fewer cesarean deliveries for failure to progress in the first stage occurred after induction in the misoprostol group than in the Foley catheter group (6.2% vs 10.6%; RR, 0.58; 95% CI, 0.42–0.79). In addition, operative vaginal delivery occurred more frequently in the misoprostol group. Among the misoprostol group spontaneous membrane rupture was more common and labor augmentation with oxytocin was less likely. The study leads to a conclusion that in terms of safety and effectiveness, induction of labour using oral misoprostol is as safe as mechanical induction using Foley catheter

A randomized trial of training the non-dominant upper extremity to enhance laparoscopic performance.

Item does not contain fulltextAbstract Introduction: In laparoscopy, the surgeon's dominant arm will execute difficult tasks with less effort compared to the non-dominant arm. This leads to a relative overuse of muscles on this side. We hypothesized that training the non-dominant arm would improve laparoscopic skills. Material and methods: At baseline, all participants performed three validated tasks on a virtual reality simulator. After randomization, subjects in the intervention group were assigned training tasks. All these tasks had to be performed with the non-dominant hand. Within a week after a three-week study period, participants performed the same three tasks as before. Results: Twenty-six participants were included, 13 in each group. At baseline, there were no differences between groups on all tested parameters. Compliance to training tasks was good. At the end of three weeks, subjects in both groups showed similar improvement of skills on the non-dominant side. On the dominant side, however, subjects in the training group showed significant better improvement of skills on four out of eight parameters. Conclusion: Specific training of the non-dominant upper extremity appears to lead to improvement of skills on the dominant side, a phenomenon known in literature as intermanual transfer of skill learning. To improve laparoscopic skills, bimanual training is recommended.1 juli 201

Trial profile.

<p>Trial profile.</p

Maternal outcomes.

<p>Data are presented as number (percent).</p>a<p>Percents, RRs, 95% CIs, and <i>p</i>-values given are related to available data per characteristic and may differ from the total number of patients.</p>b<p>Outcome characteristic with more than 5% missing data. Histological chorioamnionitis data available for 396 women (74%); histological funisitis data available for 388 women (73%).</p

Meta-analysis.

<p>Risk ratio according to Mantel-Haenszel (M–H) with fixed effects and 95% CIs for neonatal sepsis, culture-proven neonatal sepsis, RDS, and cesarean section rates.</p