Maternal mortality due to cardiovascular disease in the Netherlands:a 21-year experience

Objective Cardiovascular disorders are the leading cause of indirect maternal mortality in Europe. The aim of this study is to present an extensive overview concerning the specific cardiovascular causes of maternal death and to identify avoidable contributing care factors related to these deaths. Methods We assessed all cases of maternal death due to cardiovascular disorders collected by a systematic national confidential enquiry of maternal deaths published by the Dutch Maternal Mortality and Morbidity Committee on behalf of the Netherlands Society of Obstetrics and Gynaecology over a 21-year period (1993-2013) in the Netherlands. Results There were 96 maternal cardiovascular deaths (maternal mortality rate due to cardiovascular diseases 2.4/100,000 liveborn children). Causes were aortic dissection (n & x202f;= 20, 21%), ischaemic heart disease (n & x202f;= 17, 18%), cardiomyopathies (including peripartum cardiomyopathy and myocarditis, n & x202f;= 20, 21%) and (unexplained) sudden death (n & x202f;= 27, 28%). Fifty-five percent of the deaths occurred postpartum (n & x202f;= 55, 55%). Care factors that may have contributed to the adverse outcome were identified in 27 cases (28%). These factors were patient-related in 40% (pregnancy against medical advice, underestimation of symptoms) and healthcare-provider-related in 60% (symptoms not recognised, delay in diagnosis, delay in referral). Conclusion The maternal cardiovascular mortality ratio is low in the Netherlands and the main causes of maternal cardiovascular mortality are in line with other European reports. In a minority of cases, care factors that were possibly preventable were identified. Women with cardiovascular disease should be properly counselled about the risks of pregnancy and the symptoms of complications. Education of care providers regarding the incidence, presentation and diagnosis of cardiovascular disease during pregnancy is recommended

Design of a freeform two-reflector system to collimate and shape a point source distribution

In this paper we propose a method to compute a freeform reflector system for collimating and shaping a beam from a point source. We construct these reflectors such that the radiant intensity of the source is converted into a desired target. An important generalization in our approach compared to previous research is that the output beam can be in an arbitrary direction. The design problem is approached by using a generalized Monge-Amp\`ere equation. This equation is solved using a least-squares algorithm for non-quadratic cost functions. This algorithm calculates the optical map, from which we can then compute the surfaces. We test our algorithm on two cases. First we consider a uniform source and target distribution. Next, we use the model of a laser diode light source and a ring-shaped target distribution

Measurement of the local Jahn-Teller distortion in LaMnO_3.006

The atomic pair distribution function (PDF) of stoichiometric LaMnO_3 has been measured. This has been fit with a structural model to extract the local Jahn-Teller distortion for an ideal Mn(3+)O_6 octahedron. These results are compared to Rietveld refinements of the same data which give the average structure. Since the local structure is being measured in the PDF there is no assumption of long-range orbital order and the real, local, Jahn-Teller distortion is measured directly. We find good agreement both with published crystallographic results and our own Rietveld refinements suggesting that in an accurately stoichiometric material there is long range orbital order as expected. The local Jahn-Teller distortion has 2 short, 2 medium and 2 long bonds.Comment: 5 pages, 3 postscript figures, minor change

Repetition of a sisterhood survey at district level in Malawi: the challenge to achieve MDG 5.

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Readiness of emergency obstetric and newborn care in public health facilities in Afghanistan between 2010 and 2016

OBJECTIVE: To assess changes in readiness to provide emergency obstetric and newborn care (EmONC) in health facilities in Afghanistan between 2010 and 2016. METHODS: A secondary analysis was performed of a subset of data from cross-sectional health facility assessments conducted in December 2009 to February 2010 and May 2016 to January 2017. Interviews with health providers, facility inventory, and record review were conducted in both assessments. Descriptive statistics and χ2 tests were used to compare readiness of EmONC at 59 public health facilities expected to provide comprehensive EmONC. RESULTS: The proportion of facilities reporting provision of uterotonic drugs, anticonvulsants, parenteral antibiotics, newborn resuscitation, and cesarean delivery did not change significantly between 2010 and 2016. Provision of assisted vaginal deliveries increased from 78% in 2010 to 98% in 2016 (P<0.001). Fewer health facilities had amoxicillin (61% in 2016 vs 90% in 2010; P<0.001) and gentamicin (74% in 2016 vs 95% in 2010; P<0.002). The number of facilities with at least one midwife on duty 24 hours a day/7 days a week significantly declined (88% in 2016 vs 98% in 2010; P=0.028). CONCLUSION: Despite a few positive changes, readiness of EmONC services in Afghanistan in 2016 had declined from 2010 levels

Management of prolonged first stage of labour in a low-resource setting: lessons learnt from rural Malawi

Background Caesarean sections without medical indication cause substantial maternal and perinatal ill-health, particularly in low-income countries where surgery is often less safe. In presence of adequate labour monitoring and by appropriate use of evidence-based interventions for prolonged first stage of labour, unnecessary caesarean sections can be avoided. We aim to describe the incidence of prolonged first stage of labour and the use of amniotomy and augmentation with oxytocin in a low-resource setting in Malawi. Methods Retrospective analysis of medical records and partographs of all women who gave birth in 2015 and 2016 in a rural mission hospital in Malawi. Primary outcomes were incidence of prolonged first stage of labour based on partograph tracings, caesarean section indications and utilization of amniotomy and oxytocin augmentation. Results Out of 3246 women who gave birth in the study period, 178 (5.2%) crossed the action line in the first stage of labour, of whom 21 (11.8%) received oxytocin to augment labour. In total, 645 women gave birth by caesarean section, of whom 241 (37.4%) with an indication 'prolonged first stage of labour'. Only 113 (46.9%) of them crossed the action line and in 71/241 (29.5%) membranes were still intact at the start of caesarean section. Excluding the 60 women with prior caesarean sections, 14/181 (7.7%) received oxytocin prior to caesarean section for augmentation of labour. Conclusion The diagnosis prolonged first stage of labour was often made without being evident from labour tracings and two basic obstetric interventions to prevent caesarean section, amniotomy and labour augmentation with oxytocin, were underused.Perioperative Medicine: Efficacy, Safety and Outcome (Anesthesiology/Intensive Care

Exchange coupling in CaMnO3_3 and LaMnO3_3: configuration interaction and the coupling mechanism

The equilibrium structure and exchange constants of CaMnO$_3$ and LaMnO$_3$ have been investigated using total energy unrestricted Hartree-Fock (UHF) and localised orbital configuration interaction (CI) calculations on the bulk compounds and Mn$_2$O$_{11}^{14-}$ and Mn$_2$O$_{11}^{16-}$ clusters. The predicted structure and exchange constants for CaMnO$_3$ are in reasonable agreement with estimates based on its N\'eel temperature. A series of calculations on LaMnO$_3$ in the cubic perovskite structure shows that a Hamiltonian with independent orbital ordering and exchange terms accounts for the total energies of cubic LaMnO$_3$ with various spin and orbital orderings. Computed exchange constants depend on orbital ordering. UHF calculations tend to underestimate exchange constants in LaMnO$_3$, but have the correct sign when compared with values obtained by neutron scattering; exchange constants obtained from CI calculations are in good agreement with neutron scattering data provided the Madelung potential of the cluster is appropriate. Cluster CI calculations reveal a strong dependence of exchange constants on Mn d e$_g$ orbital populations in both compounds. CI wave functions are analysed in order to determine which exchange processes are important in exchange coupling in CaMnO$_3$ and LaMnO$_3$.Comment: 25 pages and 9 postscript figure