Аксиологоческое пространство культуры

Introduction. This study was performed to assess the applicability of the WHO Maternal Near Miss Tool (MNM Tool) and the organ dysfunction criteria in a high-income country. Material and methods. The MNM tool was applied to 2552 women who died of pregnancy-related causes or sustained severe acute maternal morbidity between August 2004 and August 2006 in one of the 98 hospitals with a maternity unit in the Netherlands. Fourteen (0.6%) cases had insufficient data for application. Each case was assessed according to the three main "MNM categories" specified in the MNM tool and their subcategory criteria: five disease-, four intervention- and seven organ dysfunction-based criteria. Potentially life-threatening conditions (disease-based inclusions) and life-threatening cases (organ dysfunction-based inclusions) were differentiated according to WHO methodology. Outcomes were incidence of all (sub)categories and case-fatality rates. Results. Of the 2538 cases, 2308 (90.9%) women fulfilled disease-based, 2116 (83.4%) intervention-based and 1024 (40.3%) organ dysfunction-based criteria. Maternal death occurred in 48 women, of whom 23 (47.9%) fulfilled disease-based, 33 (68.8%) intervention-based and 31 (64.6%) organ dysfunction-based criteria. Case-fatality rates were 23/2308 (1.0%) for cases fulfilling the disease-based criteria, 33/2116 (1.6%) for intervention-based criteria and 31/1024 (3.0%) for women fulfilling the organ dysfunction-based criteria. Conclusions. In the Netherlands, where advanced laboratory and clinical monitoring are available, organ dysfunction-based criteria of the MNM tool failed to identify nearly two-thirds of sustained severe acute maternal morbidity cases and more than one-third of maternal deaths. Disease-based criteria remain important, and using only organ dysfunction-based criteria would lead to underestimating severe acute maternal morbidity

Learning from failure

We study decentralized learning in organizations. Decentralization is captured through a symmetry constraint on agents’ strategies. Among such attainable strategies, we solve for optimal and equilibrium strategies. We model the organization as a repeated game with imperfectly observable actions. A fixed but unknown subset of action profiles are successes and all other action profiles are failures. The game is played until either there is a success or the time horizon is reached. For any time horizon, including infinity, we demonstrate existence of optimal attainable strategies and show that they are Nash equilibria. For some time horizons, we can solve explicitly for the optimal attainable strategies and show uniqueness. The solution connects the learning behavior of agents to the fundamentals that characterize the organization: Agents in the organization respond more slowly to failure as the future becomes more important, the size of the organization increases and the probability of success decreases.Game theory

Liever inleiden dan afwachten bij aterme zwangerschapshypertensie en milde preeclampsie: HYPITAT-studie

OBJECTIVE: To investigate what would benefit women with mild full-term pregnancy-related hypertension most: induction of labour or expectant monitoring, from the perspective of clinical effectiveness, maternal quality of life, and costs. DESIGN: Randomised clinical trial. Trial registration number ISRCTN08132825. METHODS: We undertook a multicentre randomised controlled trial in 38 hospitals in the Netherlands between October 2005 and March 2008. We enrolled patients with a singleton pregnancy in cephalic presentation at 36-41 weeks' gestation, who had gestational hypertension or mild preeclampsia. Participants were randomly allocated to receive either induction of labour or expectant monitoring. The primary outcome was a composite measure of poor maternal outcome, defined as maternal mortality, maternal morbidity (eclampsia, 'haemolysis, elevated liver enzymes, low platelets' (HELLP) syndrome, pulmonary oedema, thrombo-embolic disease and abruptio placentae), progression to severe hypertension or proteinuria, and major postpartum haemorrhage. Secondary outcomes were mode of delivery, neonatal outcome, maternal quality of life and costs. Analysis was by intention to treat. RESULTS: A total of 756 patients were allocated to receive induction of labour (n = 377 patients) or expectant monitoring (n = 379). No cases of maternal or neonatal death or eclampsia were recorded. Development of poor maternal outcome was significantly lower in the induction of labour group (117 women) than the expectant monitoring group (166 women) (31% versus 44%; relative risk 0.71 (95% CI: 0.59-0.86); p < 0.001). The caesarean section rate was lower among women in the induction of labour group (n = 54) compared to women in the expectant monitoring group (n = 72) (14% versus 19%; relative risk 0.75 (95% CI: 0.55-1.04)< p = 0.085). Neonatal outcomes and quality of life were comparable between both groups. Induction of labour is a cost saving strategy (difference euro 831). CONCLUSION: For women with full-term gestational hypertension and pre-eclampsia, induction of labour is associated with improved maternal outcome and lower costs, without the additional risk of a caesarean section being necessary

Comment on Papathanasious D et al.: Monochorionic Twins with Ruptured Vasa Previa: Doulble Trouble! (Fetal Diagn Ther 2010;28:48-50) Reply

Developmen

Severe acute maternal morbidity and mode of delivery in the Netherlands.

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Severe acute maternal morbidity in multiple pregnancies : a nationwide cohort study.

Background Adverse neonatal outcomes in multiple pregnancies have been documented extensively, in particular those associated with the increased risk of preterm birth. Paradoxically, much less is known about adverse maternal events. The combined risk of severe acute maternal morbidity in multiple pregnancies has not been documented previously in any nationwide prospective study. Objective The objective of the study was to assess the risk of severe acute maternal morbidity in multiple pregnancies in a high-income European country and identify possible risk indicators. Study Design In a population-based cohort study including all 98 hospitals with a maternity unit in The Netherlands, pregnant women with severe acute maternal morbidity were included in the period Aug. 1, 2004, until Aug. 1, 2006. We calculated the incidence of severe acute maternal morbidity in multiple pregnancies in The Netherlands using The Netherlands Perinatal Registry. Relative risks (RR) of severe acute maternal morbidity in multiple pregnancies compared with singletons were calculated. To identify possible risk indicators, we also compared age, parity, method of conception, onset of labor, and mode of delivery for multiple pregnancies using The Netherlands Perinatal Registry as reference. Results A total of 2552 cases of severe acute maternal morbidity were reported during the 2 year study period. Among 202 multiple pregnancies (8.0%), there were 197 twins (7.8%) and 5 triplets (0.2%). The overall incidence of severe acute maternal morbidity was 7.0 per 1000 deliveries and 6.5 and 28.0 per 1000 for singletons and multiple pregnancies, respectively. The relative risk of severe acute maternal morbidity compared with singleton pregnancies was 4.3 (95% confidence interval [CI], 3.7-5.0) and increased to 6.2 (95% CI 2.5-15.3) in triplet pregnancies. Risk indicators for developing severe acute maternal morbidity in women with multiple pregnancies were age of ≥ 40 years, (RR, 2.5 95% CI, 1.4-4.3), nulliparity (RR, 1.8, 95% CI, 1.4-2.4), use of assisted reproductive techniques (RR, 1.9, 95% CI, 1.4-2.5), and nonspontaneous onset of delivery (RR, 1.6, 95% CI, 1.2-2.1). No significant difference was found between mono- and dichorionic twins (RR, 0.8, 95% CI, 0.6-1.2). Conclusion Women with multiple pregnancies in The Netherlands have a more than 4 times elevated risk of sustaining severe acute maternal morbidity as compared with singletons

Volume of fluid resuscitation in women with persistent postpartum haemorrhage and total blood loss, maternal mortality and severe maternal morbidity

Stemcel biology/Regenerative medicine (incl. bloodtransfusion

Volume of fluid resuscitation in women with persistent postpartum haemorrhage and total blood loss, maternal mortality and severe maternal morbidity

Stemcel biology/Regenerative medicine (incl. bloodtransfusion

Ethnic disparity in severe acute maternal morbidity: A nationwide cohort study in the Netherlands

Background: There are concerns about ethnic disparity in outcome of obstetric health care in high-income countries. Our aim was to assess these differences in a large cohort of women having experienced severe acute maternal morbidity (SAMM) during pregnancy, delivery and puerperium. Methods: All women experiencing SAMM were prospectively collected in a nationwide population-based design from August 2004 to August 2006. Women delivering in the same period served as reference cohort. Population-based risks were calculated by ethnicity and by type of morbidity. Additionally, non-Western and Western women having experienced SAMM were compared in multivariable logistic regression analysis. Results: All 98 Dutch maternity units participated. There were 371 021 deliveries during the study period. A total of 2506 women with SAMM were included, 21.1% of whom were non-Western immigrants. Non-Western immigrants showed a 1.3-fold [95% confidence interval (CI) 1.2-1.5] increased risk to develop SAMM. Large differences were observed among different ethnic minority groups, ranging from a non-increased risk for Moroccan and Turkish women to a 3.5-fold (95% CI 2.8-4.3) increased risk for sub-Saharan African women. Low socio-economic status, unemployment, single household, high parity and prior caesarean were independent explanatory factors for SAMM, although they did not fully explain the differences. Immigration-related characteristics differed by ethnic background. Conclusions: Non-Western immigrants have an increased risk of developing SAMM as compared to Western women. Risks varied largely by ethnic origin. Immigration-related characteristics might partly explain the increased risk. The results suggest that there are opportunities for quality improvement by targeting specific disadvantaged groups. © The Author 2010