Recurrent incarceration of the retroverted gravid uterus at term - two times transvaginal caesarean section:a case report

INTRODUCTION: Persistent retroversion of a gravid uterus (incarceration) in the third trimester is an extremely rare diagnosis and is only scarcely been described. Its prevalence may lead to increased foetal mortality and maternal morbidity. CASE PRESENTATION: We present a case where a 35-year-old patient had undiagnosed (recurrent) uterine incarceration at term. Operative delivery proved difficult due to distorted anatomy. Therefore, in our case delivery of the fetus through transvaginal caesarean section was required. CONCLUSION: This case report discusses the diagnosis and management of (recurrent) incarceration of the retroverted uterus at term resulting in two successful transvaginal caesarean sections. In presenting this case, we aim at improving awareness, diagnosis and treatment of the retroverted incarcerated gravid uterus

External validation, update and development of prediction models for pre-eclampsia using an Individual Participant Data (IPD) meta-analysis: the International Prediction of Pregnancy Complication Network (IPPIC pre-eclampsia) protocol.

Background: Pre-eclampsia, a condition with raised blood pressure and proteinuria is associated with an increased risk of maternal and offspring mortality and morbidity. Early identification of mothers at risk is needed to target management. Methods/design: We aim to systematically review the existing literature to identify prediction models for pre-eclampsia. We have established the International Prediction of Pregnancy Complication Network (IPPIC), made up of 72 researchers from 21 countries who have carried out relevant primary studies or have access to existing registry databases, and collectively possess data from more than two million patients. We will use the individual participant data (IPD) from these studies to externally validate these existing prediction models and summarise model performance across studies using random-effects meta-analysis for any, late (after 34 weeks) and early (before 34 weeks) onset pre-eclampsia. If none of the models perform well, we will recalibrate (update), or develop and validate new prediction models using the IPD. We will assess the differential accuracy of the models in various settings and subgroups according to the risk status. We will also validate or develop prediction models based on clinical characteristics only; clinical and biochemical markers; clinical and ultrasound parameters; and clinical, biochemical and ultrasound tests. Discussion: Numerous systematic reviews with aggregate data meta-analysis have evaluated various risk factors separately or in combination for predicting pre-eclampsia, but these are affected by many limitations. Our large-scale collaborative IPD approach encourages consensus towards well developed, and validated prognostic models, rather than a number of competing non-validated ones. The large sample size from our IPD will also allow development and validation of multivariable prediction model for the relatively rare outcome of early onset pre-eclampsia. Trial registration: The project was registered on Prospero on the 27 November 2015 with ID: CRD42015029349

Impact of the HYPITAT trial on doctors' behaviour and prevalence of eclampsia in the Netherlands

Please cite this paper as: van der Tuuk K, Koopmans C, Groen H, Mol B, van Pampus M for the HYPITAT study group. Impact of the HYPITAT trial on doctors' behaviour and prevalence of eclampsia in the Netherlands. BJOG 2011; DOI: 10.1111/j.1471-0528.2011.03138.x. We questioned if participation in the HYPITAT trial (induction of labour versus expectant monitoring in women with gestational hypertension or pre-eclampsia at term) impacted implementation of its results and subsequently maternal health. We identified women with hypertensive disease from the Perinatal Registry, and distinguished the period before, during and after the trial. We included 43 641 women. Induction of labour increased from 58.3 to 67.1% (P < 0.001) and prevalence of eclampsia decreased from 0.85 to 0.19% (P < 0.001) before and after the trial. Concurrently, participation in the HYPITAT trial among others had immediate consequences for obstetric management and maternal health

Blood pressure patterns in women with gestational hypertension or mild preeclampsia at term

Gestational hypertension (GH) and mild preeclampsia (PE) represent the most common medical complications of pregnancy, with the majority of cases developing at or near term. There is little knowledge of the course of blood pressure over time in these women. We explored the pattern of systolic and diastolic blood pressure over time in women with GH or mild PE at term participating in the HYPITAT trial, and we attempted to identify clinical factors influencing these blood pressure patterns and the impact of severe hypertension on clinical management. We used data from the HYPITAT trial, that included women with a singleton pregnancy with a fetus in cephalic position between 36 and 41 weeks of gestation with the diagnosis of GH or mild PE. Blood pressure measurements were performed from randomization or admission until delivery or discharge from the hospital. We included the highest blood pressure of each day. We evaluated systolic and diastolic blood pressure change over time, as well as the influence of clinical characteristics and laboratory findings on the course of blood pressure. We used univariate and multivariate regression analysis with a backward stepwise algorithm for the selection of variables. The model with the best fit (lowest AIC) was selected as the final model. We also compared mode of delivery for women with and without severe hypertension. We studied 1076 women who had 4188 blood pressure measurements done. The systolic blood pressure showed a significant non-linear increase over time and for the diastolic blood pressure the pattern was also non-linear. In the multivariable model of systolic blood pressure change over time, nulliparity, ethnicity, systolic blood pressure (at baseline), BMI and LDH at randomization influenced the course of blood pressure. In the diastolic blood pressure model ALT and the baseline diastolic blood pressure had a significant influence. When we explored the association between blood pressure and mode of delivery, it appeared that development of severe hypertension was a risk factor for Caesarean section. The blood pressure in patients with GH or PE at term showed a non-linear increase with time, which was aggravated by clinical characteristics. Development of severe hypertension was a risk factor for Caesarean section, which may explain the elevated Caesarean section rates in the expectant monitoring group in the HYPITAT tria

Prediction of postpartum hemorrhage in women with gestational hypertension or mild preeclampsia at term

OBJECTIVE: To assess whether postpartum hemorrhage can be predicted in women with gestational hypertension or mild preeclampsia at term. DESIGN: A cohort study in which we used data from our multicentre randomized controlled trial (HYPITAT trial). SETTING: The study was conducted in 38 hospitals in the Netherlands between 2005 and 2008. POPULATION: Women with gestational hypertension or mild preeclampsia at term (n = 1132). METHODS: An antepartum model (model A) and an antepartum/intrapartum model (model B) were created using logistic regression. The predictive capacity of the models was assessed with receiver operating characteristic analysis and calibration. MAIN OUTCOME MEASURE: Postpartum hemorrhage, defined as blood loss >1000 mL within 24 h after delivery. RESULTS: Postpartum hemorrhage occurred in 118 (10.4%) women. Maternal age (odds ratio 1.03), prepregnancy body mass index (odds ratio 0.96), and women with preeclampsia (odds ratio 1.5) were independent antepartum prognostic variables of postpartum hemorrhage. Intrapartum variables incorporated in the model were gestational age at delivery (odds ratio 1.2), duration of dilatation stage (odds ratio 1.1), and episiotomy (odds ratio 1.5). Model A and model B showed moderate discrimination, with areas under the receiver operating characteristic curve of 0.59 (95% confidence interval 0.53-0.64) and 0.64 (95% confidence interval 0.59-0.70), respectively. Calibration was moderate for model A (Hosmer-Lemeshow p = 0.26) but better for model B (Hosmer-Lemeshow p = 0.36). The rates of postpartum hemorrhage ranged from 4% (lowest 10%) to 22% (highest 10%). CONCLUSION: In the assessment of performance of a prediction model, calibration is more important than discriminative capacity. Our prediction model shows that for women with gestational hypertension or mild preeclampsia at term, distinction between low and high risk of developing postpartum hemorrhage is possible when antepartum and intrapartum variables are combined.Corine M. Koopmans, Karin Van Der Tuuk, Hen K Groen, Johannes P.R. Doornbos, Irene M. De Graaf, Pauline C.M. van der Salm, Martina M. Porath, Simone M.I. Kuppens, Ella J. Wijnen, Robert Aardenburg, Aren J. Van Loon, Bettina M.C. Akerboom, Peggy J.A. van der Lans, Ben W.J. Mol, Maria G. Van Pampus & for the HYPITAT study grou

Cardiac complications relating to pregnancy and recurrence of disease in the offspring of women with atrioventricular septal defects

Aims In most pregnancy reports, atrioventricular septal defects (AVSD) are not differentiated from more simple septal defects, thus underestimating the risks of pregnancy. To investigate the magnitude and determinants of risk during pregnancy in female patients with balanced AVSD. Methods and results Using a nation-wide registry (CONCOR), 79 female patients with balanced/isolated AVSD were identified. A total of 29 patients had 62 pregnancies, including 12 miscarriages (19%) and two elective abortions. Detailed recordings of each completed (greater-than 20 weeks gestation) pregnancy (n=48, 26 women) were obtained. Cardiovascular events complicated almost 40% of the completed pregnancies. In particular, post-partum persistence of pregnancy-related New York Heart Association (NYHA) class deterioration [23% mainly patients with residual atrial septal defects (ASD)] and deterioration of pre-existing left AV-valvular regurgitation (17%) were frequently recorded. Additional cardiac complications were arrhythmias (19%) and symptomatic heart failure (2%). Congenital heart disease (CHD) recurred in six children (12%): AVSD (n=4, three with left-sided hypoplasia), patent ductus arteriosus (n=1), and ASD (n=1). Three children died including two children with left-sided hypoplasia. Conclusion Pregnancy is not always well tolerated in women with AVSD, predominantly due to NYHA class deterioration and worsening of pre-existing AV-valvular regurgitation. Offspring mortality is high (6.3%), primarily due to recurrence of complex CHD

Prediction of cesarean section risk in women with gestational hypertension or mild preeclampsia at term

Abstract not availableKarin van der Tuuk, Maria G. van Pampus, Corine M. Koopmans, Jan G. Aarnoudse, Paul P. van den Berg, Johannes J. van Beek, Frans J.A. Copraij, Gunilla Kleiverda, Martina Porath, Robbert J.P. Rijnders, Paulien C.M. van der Salm, Leonard P. Morssink, Rob H. Stigter, Ben W.J. Mol, Henk Groen, for the HYPITAT study grou