Frans J. M. E. Roumen

Avulsion of puborectalis muscle and other risk factors for cystocele recurrence: a 2-year follow-up study

Introduction and hypothesisThis study aimed to determine the relationship of recurrent cystocele with avulsion of puborectalis muscle and other risk factors.MethodsIn this prospective observational cohort study, 245 women undergoing anterior colporrhaphy were invited for a 2-year follow-up visit consisting of a questionnaire, physical examination, and translabial 3D ultrasonography. Women with and without recurrent cystocele were compared to identify recurrence risk factors.ResultsOf the 245 women, 156 agreed to the follow-up visit (63.7%). Objective recurrence rate was 80 of 156 (51.3%). Seventeen of the 156 (10.9%) reported subjective recurrence. Risk factors for anatomical recurrence were complete avulsion of puborectalis muscle (OR, 2.4; 95% CI, 1.3, 4.7), advanced preoperative stage (OR, 2.0; 95% CI, 1.0, 4.1), family history of prolapse (OR, 2.4; 95% CI, 1.2, 4.9), and sacrospinous fixation (OR, 6.5; 95% CI, 2.0, 21.2).ConclusionsRisk factors for anatomical cystocele recurrence after anterior colporrhaphy were complete avulsion of puborectalis muscle, advanced preoperative stage, family history of prolapse, and sacrospinous fixation.

The essential fatty acid status of mother and child in pregnancy-induced hypertension: A prospective longitudinal study

OBJECTIVEnOur purpose was to investigate, in a prospective way, whether the altered essential fatty acid status observed in pregnancy-induced hypertension is a consequence of the disease or may contribute to its cause.nnnSTUDY DESIGNnPregnant women healthy at the start of the study were asked to give a blood sample before 16 weeks, at 22 weeks, and at 32 weeks of gestation. After delivery a blood sample from the umbilical vein, a piece of the umbilical cord, and a maternal blood sample were collected. Fatty acid compositions were determined of the phospholipids isolated from plasma and umbilical arterial and venous vessel walls. The nutrient intake of the pregnant women was assessed by use of the dietary history method and food frequency questionnaires. The results of each woman with pregnancy-induced hypertension were compared with the results of three matched healthy controls.nnnRESULTSnDuring pregnancy (16 to 32 weeks) no significant differences were observed in nutrient intake and maternal plasma fatty acid composition between the group with pregnancy-induced hypertension (n = 52) and the control group (n = 156). After delivery the relative amounts of 18:2(n-6) and 18:3(n-3) in maternal plasma were significantly lower in pregnancy-induced hypertension than in normal pregnancy. This was associated with significantly higher levels of (n-6) long-chain polyenes and cervonic acid (22:6[n-3]). In comparison with the situation at 32 weeks, the postpartum cervonic acid status increased in pregnancy-induced hypertension, whereas it decreased in normal pregnancy. The cervonic acid levels in umbilical plasma phospholipids were significantly higher after pregnancy-induced hypertension than after normal pregnancy. No significant differences were observed for the fatty acid content in umbilical vessel walls.nnnCONCLUSIONnThe results indicate that the altered essential fatty acid status in pregnancy-induced hypertension is a late phenomenon and is therefore unlikely to have contributed to the pathogenesis of pregnancy-induced hypertension. Moreover, the neonatal essential fatty acid status is not negatively affected by pregnancy-induced hypertension.

Early versus late epidural analgesia and risk of instrumental delivery in nulliparous women: a systematic review.

Please cite this paper as: Wassen M, Zuijlen J, Roumen F, Smits L, Marcus M, Nijhuis J. Early versus late epidural analgesia and risk of instrumental delivery in nulliparous women: a systematic review. BJOG 2011;118:655–661.

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

BACKGROUNDnLabour is induced in 20-30% of all pregnancies. In women with an unfavourable cervix, both oral misoprostol and Foley catheter are equally effective compared with dinoprostone in establishing vaginal birth, but each has a better safety profile. We did a trial to directly compare oral misoprostol with Foley catheter alone.nnnMETHODSnWe did an open-label randomised non-inferiority trial in 29 hospitals in the Netherlands. Women with a term singleton pregnancy in cephalic presentation, an unfavourable cervix, intact membranes, and without a previous caesarean section who were scheduled for induction of labour were randomly allocated to cervical ripening with 50 μg oral misoprostol once every 4 h or to a 30 mL transcervical Foley catheter. The primary outcome was a composite of asphyxia (pH ≤7·05 or 5-min Apgar score <7) or post-partum haemorrhage (≥1000 mL). The non-inferiority margin was 5%. The trial is registered with the Netherlands Trial Register, NTR3466.nnnFINDINGSnBetween July, 2012, and October, 2013, we randomly assigned 932 women to oral misoprostol and 927 women to Foley catheter. The composite primary outcome occurred in 113 (12·2%) of 924 participants in the misoprostol group versus 106 (11·5%) of 921 in the Foley catheter group (adjusted relative risk 1·06, 90% CI 0·86-1·31). Caesarean section occurred in 155 (16·8%) women versus 185 (20·1%; relative risk 0·84, 95% CI 0·69-1·02, p=0·067). 27 adverse events were reported in the misoprostol group versus 25 in the Foley catheter group. None were directly related to the study procedure.nnnINTERPRETATIONnIn women with an unfavourable cervix at term, induction of labour with oral misoprostol and Foley catheter has similar safety and effectiveness.nnnFUNDINGnFondsNutsOhra.

Suspected versus non-suspected small-for-gestational age fetuses at term: perinatal outcomes

Objective: To compare perinatal outcomes of suspected versus non-suspected small-for-gestational age fetuses (SGA) at term. Methods: Retrospective cohort study among all term singleton neonates with a birth weight <10th percentile born in the Parkstad region between 1 January 2006 and 3 March 2008. The subjects were assigned to a prenatally suspected or non-suspected SGA group. Primary outcome was adverse neonatal outcome at birth, defined as a composite of intrauterine fetal death, Apgar <7 at 5u2009min, or pH umbilical artery <7.05. Secondary outcome included neonatal medium care unit (NMCU) admission ≥7 days. Results: 430 subjects were included in the study; 36.7% was suspected of SGA. In the suspected SGA group mean gestational age at birth and birth weight were significantly lower, whereas maternal morbidity was significantly higher. The incidence of labor induction and elective cesarean section were also significantly higher in the suspected SGA group. Total perinatal mortality was 2.1%. Identification of SGA and subsequent management led to a significant decrease of adverse neonatal outcome at birth, but did not lead to a significant decrease in NMCU admission ≥7 days. Conclusions: Suspicion of SGA was associated with a more active management of labor and delivery, resulting in a better neonatal outcome at birth.

Well being of obstetric patients on minimal blood transfusions (WOMB trial)

BackgroundPrimary postpartum haemorrhage is an obstetrical emergency often causing acute anaemia that may require immediate red blood cell (RBC) transfusion. This anaemia results in symptoms such as fatigue, which may have major impact on the health-related quality of life. RBC transfusion is generally thought to alleviate these undesirable effects although it may cause transfusion reactions. Moreover, the postpartum haemoglobin level seems to influence fatigue only for a short period of time. At present, there are no strict transfusion criteria for this specific indication, resulting in a wide variation in postpartum policy of RBC transfusion in the Netherlands.Methods/DesignThe WOMB trial is a multicentre randomised non-inferiority trial. Women with acute anaemia due to postpartum haemorrhage, 12-24 hours after delivery and not initially treated with RBC transfusion, are eligible for randomisation. Patients with severe physical complaints are excluded. Patients are randomised for either RBC transfusion or expectant management. Health related quality of life (HRQoL) will be assessed at inclusion, at three days and one, three and six weeks postpartum with three validated measures (Multi-dimensional Fatigue Inventory, ShortForm-36, EuroQol-5D). Primary outcome of the study is physical fatigue three days postpartum. Secondary outcome measures are general and mental fatigue scores and generic health related quality of life scores, the number of RBC transfusions, length of hospital stay, complications and health-care costs.The primary analysis will be by intention-to-treat. The various longitudinal scores will be evaluated using Repeated Measurements ANOVA. A costs benefit analysis will also be performed. The power calculation is based on the exclusion of a difference in means of 1.3 points or greater in favour of RBC transfusion arm regarding physical fatigue subscale. With missing data not exceeding 20%, 250 patients per arm have to be randomised (one-sided alpha = 0.025, power = 80%).DiscussionThis study will provide evidence for a guideline regarding RBC transfusion in the postpartum patient suffering from acute anaemia. Equivalence in fatigue score, remaining HRQoL scores and physical complications between both groups is assumed, in which case an expectant management would be preferred to minimise transfusion reactions and costs.Trial registrationClinicalTrials.gov NCT00335023, Nederlands Trial Register NTR335

Postoperative catheterization after anterior colporrhaphy: 2 versus 5 days. A multicentre randomized controlled trial

Introduction and hypothesisThe aim of this study was to compare the number of temporary catheter replacements and urinary tract infections after indwelling catheterization for 2 versus 5xa0days following an anterior colporrhaphy.MethodsTwo hundred forty-six patients were randomly assigned to 2 or 5xa0days of indwelling catheterization. Outcome measures were temporary catheter replacements because of post-voiding residual >200xa0mL after removal of the indwelling catheter, urinary tract infections, and hospital stay. All patients were analyzed according to the intention to treat principle.ResultsCompared to the 5-day protocol group, in the 2-day protocol group more patients needed temporary catheter replacement (9% versus 28%, odds ratio (OR) 4.0, confidence interval (CI) 1.9–8.3, pu2009<u20090.01), whereas less patients had a urinary tract infection (37% versus 22%, OR 0.5, CI 0.3–0.9, pu2009=u20090.02) and median hospital stay was lower.ConclusionsRemoval of an indwelling catheter after 2 versus 5xa0days following anterior colporrhaphy is associated with more temporary catheter replacements, but less urinary tract infections and a shorter hospital stay.

The capacity of mid-pregnancy cervical length to predict preterm birth in low-risk women: a national cohort study

We investigated the predictive capacity of mid‐trimester cervical length (CL) measurement for spontaneous and iatrogenic preterm birth.

Maternal health outcomes two years after term breech delivery.

Objective. To evaluate maternal health outcomes two years after term breech delivery. Design. This was a non-randomized single-center prospective cohort study. Mothers were asked to fill out questionnaires at two years postpartum to judge their health in the previous three to six months. Outcomes of the planned cesarean section group were compared with outcomes of the planned vaginal delivery group, whether or not a vaginal birth was realized or an emergency cesarean section was performed. Results. One hundred and eighty-three women completed a follow-up questionnaire at two years postpartum. Outcomes of the planned cesarean section group were compared with her partner were found between the two groups. Also, no differences were found in all investigated maternal health items, or in sexual activity and fertility. Conclusion. Maternal health outcomes two years after term breech delivery were similar after planned cesarean section and planned vaginal delivery.

Indications and results of labour induction in nulliparous women: An interview among obstetricians, residents and clinical midwives

OBJECTIVEnTo investigate which clinical factors are important in management decisions that clinicians make in the process of labour induction, and which clinical factors they estimate as predictive of labour outcome after induction.nnnSTUDY DESIGNnA written interview was conducted among obstetricians, residents and clinical midwives in five teaching hospitals in the south of the Netherlands. Sixteen fictive vignettes were constructed of pregnant nulliparous women who were candidates for induction of labour. The vignettes differed on eight clinical variables: maternal age, BMI, gestational age, indication for induction (maternal request vs mild pre-eclampsia), dilation, position, consistency and effacement of the cervix. For each case presentation, the inclination to induce labour was calculated for the three groups, and their estimates of the probability of a spontaneous vaginal delivery or a caesarean delivery were analyzed.nnnRESULTSnOf the 80 questionnaires sent, 60 (75%) were completed. Mild pre-eclampsia and post-term pregnancy were the most important clinical factors for the decision to induce or not in all three groups. Gestational age, effacement and dilation of the cervix were considered as the most important predictors of labour outcome after induction.nnnCONCLUSIONSnIn this interview, obstetricians, residents and clinical midwives based their decision-making whether or not to induce labour predominantly on medical indications. Outcome of labour after induction was estimated to depend on gestational age and cervical status at the start of induction.