5 research outputs found
Follow-up studies in prenatal medicine
With the availability of prenatal diagnostics in the last century, the fetus became a
patient. Obstetricians looked togheter with neonatologist and pediatric surgeons,
who in the past needed to treat sick neonates, for an earlier moment of treatment.
An example of such a shift towards an earlier moment of treatment is the
treatment of fetal tachycardia. Allready in utero medication can be given to
the fetus transplacentally or direct fetally. In order to convert the tachycardia
into a sinus rhythm. Another example is the anemic fetus who can be given an
intrauterine blood transfusion to treat the anemia. A further example is the
monochorionic twin with twin to twin transfusion syndrome. It is possible to
coagulate the pathologic bloodvessel connections which cause the syndrome.
Fetal death can be prevented by performing this procedure.
A condition for the introduction of new techniques in medicine is that they are
tested on efficacy and safety. That’s why new diagnostic and therapeutic
procedures demand proper follow-up. Unwanted side effects, such as clubfeet
after early amniocentesis, can be detected through careful and thorough follow-up
before new techniques are applied on larger scale. Because follow-up research is
needed after introduction of new techniques and because prognosis of the future
child is very important for the expectant parents, we conducted the following
studies.
Chapter one comprehends the introduction of the thesis with a brief history of
prenatal medicine. The introduction of new intrauterine treatment options
increased possibilities. Not only can we timely diagnose abnormalities that cannot
be treated (eg Down syndrome) but we can also diagnose diseases timely and
treat abnormalities. Abnormalities that otherwise would lead to intrauterine fetal
death (eg hydrops fetalis). Even performing intrauterine procedures that will
increase a better start in life and therefore better starting point for postnatal
treatment (eg prune belly syndrome). The importance of follow-up at infancy is
on the one hand for the evaluation of new techniques, and on the other hand to
inform parents adequately in case the fetus has an abnormality. Information on
prognosis is important in making difficult decisions on either terminating the
pregnancy, start intrauterine treatment or expectant management.
Chapter two describes the annual results from all centers for invasive prenatal
diagnosis in the Netherlands over the period 1991-2000, with particular emphasis
on indications, abnormal results, type of invasive procedures, and terminations of
pregnancy. The percentage of invasive prenatal diagnosis increased from 5% of
births in 1991 to 6% in 1996 and subsequently remained level. During the study
period, the number of pregnant women aged 36 and older increased by 70%,
but the number of procedures because of maternal age remained stable. The
percentage abnormal test results was 4.7 and increased from 3.6 in 1991 to 5.4
in 2000. The detection rate for abnormal results varied from 2% for maternal
age to 28% for abnormalities detected by ultrasound examination. Important
trends were the relative decrease of cordocentesis (-82%) and chorionic villi
biopsy (-18%) in favour of amniocentesis. There was a significant decrease in
the percentage of pregnant women aged 36 or older who underwent invasive
prenatal diagnosis without previous screening.
Chapter three represents de results of a (semi) randomized controlled study
that compared the effects of transabdominal chorionic villus sampling and early
amniocentesis on fetal mortality and child morbidity. Women requesting early
prenatal diagnosis for advanced maternal age were allocated to early
amniocentesis or transabdominal chorionic villus sampling either by
randomization or, if they declined randomization, by their own choice.
Of the 212 women who entered the study, 117 were randomized, 70 chose early
amniocentesis and 25 chose transabdominal chorionic villus sampling. Overall,
130 women underwent early amniocentesis and 74 underwent transabdominal
chorionic villus sampling at a median gestation of 12 weeks. Mosaic karyotypes
were found in 5.4% of the early amniocenteses and in none of the chorionic
villus samples. All unintended fetal losses occurred after early amniocentesis
with a frequency of 6.2%. Talipes equinovarus was only observed after early
amniocentesis with a frequency of 3.1%. The results of this study are in the
Cochrane Database. In the nineties the early amniocentesis was abandonded
because of the results of 3 controlled studies, including our study, that showed
an increased risk of miscarriages and higher incidence of clubfeet. The conclusion
of this chapter is that chorionic villus sampling remains the method of choice if
prenatal diagnosis is needed in the first trimester of pregnancy.
In chapter four the outcome of pregnancies with prenatally diagnosed central
nervous system (CNS) malformations are described. Maternal and neonatal
records of prenatally diagnosed CNS malformations were retrospectively reviewed
over a 6-year period (1993–1998). Information on current development of
surviving children was obtained by contacting the care-giving pediatric
neurologist. During the study period 124 fetuses were diagnosed with a CNS
malformation. Data on pregnancy and delivery were available for 118 pregnancies.
Additional malformations were present in 47% of fetuses. A total of 46% of
pregnancies were terminated, and 15% ended in spontaneous intrauterine death.
A total of 39% of pregnancies resulted in live birth, and 25% of the infants were
still alive at the age of 3 months. One child was lost to follow-up, one infant died
at the age of 4 months, and two children died at the age of 3 years. Psychomotor
development of the remaining 25 children was normal for 5, slightly disabled for 7,
moderately disabled for 5 and severely disabled for 8.
The conclusion of this chapter is that due to the high rate of termination
of pregnancy and to the frequent association with other anomalies, the survival
rate of pregnancies in which a CNS defect had been diagnosed prenatally was only
25%. More than 50% of surviving children were moderately or severely disabled.
Chapter five decribes the neurodevelopmental assessment in children born with
an umbilical artery pH < 7 in the period 1991-1992. During the study period, 1614
umbilical artery pH measurements were performed. Thirty (1.9%) were < 7. Of
all infants born with an umbilical artery pH < 7 obstetric, neonatal, and pediatric
records were reviewed. From this group 23 infants were admitted to the neonatal
intensive care unit, and 8 of them required intubation. Twenty-eight children
survived the neonatal period. At an age of 1 to 3 years, children were visited at
home for semi-structured questioning of the mother and a Denver Developmental
Screening Test of the child.Three children experienced an episode of mild
hypertonia. One child had a mild motor developmental delay.
The conclusion of this study is that babies born with an umbilical artery
pH < 7 are at great risk to experience considerable short-term morbidity. Those
who leave the neonatal intensive care unit without major problems have good
outcomes, and pessimism in counselling their parents is unwarranted.
Chapter six describes the long-term neurodevelopmental outcome in 33 children
after twin-to-twin transfusion syndrome (TTTS). Maternal and neonatal medical
records of all TTTS-cases admitted to our center between 1990 and 1998 were
reviewed. Neurological and mental development at school age was assessed
during a home visit in all TTTS-survivors. A total of 33 pregnancies with TTTS
were identified. Four couples opted for termination of pregnancy. All other
pregnancies were managed conservatively, 18 (62%) with serial amnioreductions
and 11 (38%) without intrauterine interventions. Mean gestational age at delivery
was 28 (range: 20-37) weeks. Perinatal mortality was 50% (29/58). Birth weight of
donor twins was less than recipient twins. Systolic blood pressure at birth was
lower in donors than in recipients and donors required more frequently inotropic
support postnatally than recipients. The incidence of hypertension at birth was
higher in recipients than in donors. Abnormal cranial ultrasonographic findings
were reported in 41% (12/29) of the neonates. All long-term survivors (n = 29)
were assessed during a home visit. Mean gestational age at birth of the surviving
twins was 31 (range: 25-37) weeks. Mean age at follow-up was 6 (range: 4-11)
years. The incidence of cerebral palsy was 21% (6/29). Five out of six children
with cerebral palsy had an abnormal mental development. The incidence of
cerebral palsy in the group of survivors treated with serial amnioreduction was
26% (5/19). Four children were born after intrauterine fetal death of their co-twin:
two of them had cerebral palsy. The conclusion therefore is: the incidence of
adverse neurodevelopmental outcome in TTTS-survivors is high, especially after
intrauterine fetal death of a co-twin.
In chapter seven the long-term neurodevelopmental status of children treated with
intrauterine red blood cell and platelet transfusion (IUT) for fetal hydrops caused
by parvovirus B19 infection is described. Maternal and neonatal records of all
intrauterine transfusions for congenital parvovirus B19 infection in our center
between 1997 - 2005 were reviewed. A total of 25 IUT sessions were performed in
24 hydropic fetuses. Sixteen survivors aged 6 months to 8 years were included in
the follow-up study. All children underwent a general pediatric, a neurological
examination and a neurodevelopment examination (developmental index by
Bayley Scales of Infant Development or Snijders-Oomen test). Eleven children
(68%) were normal and 5 children (32%) demonstrated a delayed psychomotor
development with a suboptimal neurological examination (mild delay n=3, severe
delay n=2). Neurodevelopmental status did not correlate with pre-IUT hemoglobin,
platelet, or blood pH values. Growth and general health status were normal in all.
Two children had minor congenital defects. Neurodevelopmental status was
abnormal in 5 out of 16 survivors and was not related with the severity of fetal
anemia and acidemia. We hypothesize that fetal parvovirus B19 infection may
induce central nervous system damage.
Chapter eight describes the results of a retrospective cohort study of children with
fetal arrhythmia. In the Leiden University Medical Center, 44 fetuses were diagnosed
with fetal cardiac arrhythmia between January 1990 and December 2005.
Twenty-eight with supravenricular tachycardia (SVT), 7 with atrial flutter (AF) and
9 with atrioventricular block (AVB). The incidence of cardiac anomalies was 18%.
Hydrops was seen in 42-50%. Direct or transplacental fetal antiarrhythmic
medication was given in 76% of cases. In the SVT group, 19 children needed
medication postpartum. In 16/19 infants, the arrhythmia ceased within the first
year of life. In the SVT and AF group mortality was 6%. In 21% of these cases
Wolff Parkinson White (WPW) syndrome was diagnosed. Mental scores were
normal in all survivors. Of the seven cases of AVB included in the follow-up there
is no survivor. The other two cases were lost for long-term follow-up, but their
medical records noted pacemaker therapy in one and severe mental retardation
in the other. In conclusion, mortality in SVT and AF patients in our study was
6% but mental scores were normal in all survivors. Twenty-one per cent of
survivors had WPW syndrome. Prognosis in AVB patients was poor.
Chapter nine comprehends the general discussion. We look into the demands
of follow-up after prenatal diagnosis and therapy. How does loss to follow-up
influence outcome? What is the best age to test for follow-up? Which test to use.
After prenatal therapy, follow-up should always be performed as a standard
procedure. Follow-up needs to comprehend the review of the medical records,
specific testing and standard neurologic and developmental tests. An example of
a good test, and age of testing is to perform a Bayley Scale of Infant Development
test at the age of 2 with neurologic testing (e.g. Touwen). At the age of 5-6 years a
further examination can be performed. Follow-up at a later age looks less sensible
because postnatal factors influence outcome and prenatal techniques are
developing continuously.</table
Alterations in classical and nonclassical HLA expression in recurrent and progressive HPV-induced usual vulvar intraepithelial neoplasia and implications for immunotherapy
TI9 - Endometriumpathologi
Immediate versus delayed removal of urinary catheter after laparoscopic hysterectomy: A randomised controlled trial
Objective: To evaluate if immediate catheter removal (ICR) after laparoscopic hysterectomy is associated with similar retention outcomes compared with delayed removal (DCR). Study design: Non-inferiority randomised controlled trial. Population: Women undergoing laparoscopic hysterectomy in six hospitals in the Netherlands. Methods: Women were randomised to ICR or DCR (between 18 and 24 hours after surgery). Primary outcome: The inability to void within 6 hours after catheter removal. Results: One hundred and fifty-five women were randomised to ICR (n = 74) and DCR (n = 81). The intention-to-treat and per-protocol analysis could not demonstrate the non-inferiority of ICR: ten women with ICR could not urinate spontaneously within 6 hours compared with none in the delayed group (risk difference 13.5%, 5.6–24.8, P = 0.88). However, seven of these women could void spontaneously within 9 hours without additional intervention. Regarding the secondary outcomes, eight women from the delayed group requested earlier catheter removal because of complaints (9.9%). Three women with ICR (4.1%) had a urinary tract infection postoperatively versus eight with DCR (9.9%, risk difference −5.8%, −15.1 to 3.5, P = 0.215). Women with ICR mobilised significantly earlier (5.7 hours, 0.8–23.3 versus 21.0 hours, 1.4–29.9; P ≤ 0.001). Conclusion: The non-inferiority of ICR could not be demonstrated in terms of urinary retention 6 hours after procedure. However, 70% of the women with voiding difficulties could void spontaneously within 9 hours after laparoscopic hysterectomy. It is therefore questionable if all observed urinary retention cases were clinically relevant. As a result, the clinical advantages of ICR may still outweigh the risk of bladder retention and it should therefore be considered after uncomplicated laparoscopic hysterectomy. Tweetable abstract: The advantages of immediate catheter removal after laparoscopic hysterectomy seem to outweigh the risk of bladder retention.Medical Instruments & Bio-Inspired Technolog
Impact of the COVID-19-pandemic on patients with gynecological malignancies undergoing surgery: A Dutch population-based study using data from the 'Dutch Gynecological Oncology Audit'
Objective. The COVID-19-pandemic caused drastic healthcare changes worldwide. To date, the impact of these changes on gynecological cancer healthcare is relatively unknown. This study aimed to assess the impact of the COVID-19-pandemic on surgical gynecological-oncology healthcare.Methods. This population-based cohort study included all surgical procedures with curative intent for gynecological malignancies, registered in the Dutch Gynecological Oncology Audit, in 2018-2020. Four periods were identified based on COVID-19 hospital admission rates: 'Pre-COVID-19', 'Firstwave', 'Interimperiod', and'Second wave'. Surgical volume, perioperative care processes, and postoperative outcomes from 2020 were compared with 2018-2019.Results. A total of 11,488 surgical procedureswere analyzed. For cervical cancer, surgical volume decreased by 17.2% in 2020 compared to 2018-2019 (mean 2018-2019: n= 542.5, 2020: n= 449). At nadir (interimperiod), only 51% of the expected cervical cancer procedures were performed. For ovarian, vulvar, and endometrial cancer, volumes remained stable. Patients with advanced-stage ovarian cancer more frequently received neoadjuvant chemotherapy in 2020 compared to 2018-2019 (67.7% (n = 432) vs. 61.8% (n = 783), p = 0.011). Median time to first treatmentwas significantly shorter in all four malignancies in 2020. For vulvar and endometrial cancer, the length of hospital staywas significantly shorter in 2020. No significant differences in complicated course and 30-day-mortality were observed.Conclusions. The COVID-19-pandemic impacted surgical gynecological-oncology healthcare: in 2020, surgical volume for cervical cancer dropped considerably, waiting time was significantly shorter for all malignancies, while neoadjuvant chemotherapy administration for advanced-stage ovarian cancer increased. The safety of perioperative healthcare was not negatively impacted by the pandemic, as complications and 30-day-mortality remained stable. (C) 2022 The Authors. Published by Elsevier Inc.Analysis and support of clinical decision makin
Clinical auditing as an instrument to improve care for patients with ovarian cancer: The Dutch Gynecological Oncology Audit (DGOA)
Introduction: The Dutch Gynecological Oncology Audit (DGOA) was initiated in 2014 to serve as a nationwide audit, which registers the four most prevalent gynecological malignancies. This study presents the first results of clinical auditing for ovarian cancer in the Netherlands. Methods: The Dutch Gynecological Oncology Audit is facilitated by the Dutch Institute of Clinical Auditing (DICA) an