Herman P. van Geijn

Psychosocial factors and pregnancy outcome: A review with emphasis on methodological issues

This review focuses on the research concerning the relation between psychosocial factors and pregnancy outcome. The following four outcome measures are dealt with: (1) birth weight, (2) preeclampsia, (3) preterm labour, and (4) intrapartum complications. The most consistent finding concerns the association between maternal exposure to taxing situations and preterm delivery. Three possible pathways are hypothesized: (1) an indirect influence via unhealthy coping and life style behaviour, (2) a direct influence via stress-dependent hormones, and (3) an additional direct influence via psycho-immunological factors. Intervention studies aimed at improving pregnancy outcome show fairly mixed results. It is recommended that studies on the relationship between psychosocial factors and pregnancy outcome should employ a prospective design with due attention to chronic stressors, should include appropriate biochemical assessments, and multivariate techniques are applied.

Psychosocial predictors of low birthweight: a prospective study

Objective To examine the role of psychosocial risk factors for low birthweight.

Effects of folic acid and vitamin B6 supplementation on women with hyperhomocysteinemia and a history of preeclampsia or fetal growth restriction

OBJECTIVE Our purpose was to assess the incidence of hyperhomocysteinemia in patients with a history of preeclampsia or fetal growth restriction, to evaluate the effects of vitamin supplementation on the methionine loading test, and to study the course of subsequent pregnancies in women with hyperhomocysteinemia and a history of preeclampsia or fetal growth restriction. STUDY DESIGN A total of 207 consecutive patients with a history of preeclampsia or fetal growth restriction was tested for hyperhomocysteinemia. Thirty-seven were found to be positive and were treated with folic acid and vitamin B6, and 27 had a second methionine loading test after vitamin supplementation. Fourteen patients became pregnant again while receiving vitamins and aspirin. RESULTS All patients who underwent a methionine loading test after vitamin supplementation had a completely normalized methionine loading test. Of the 14 pregnancies in women receiving vitamins and aspirin, 7 were complicated by preeclampsia. Birth weights were 2867 +/- 648 g compared with 1088 +/- 570 g in the previous pregnancies. CONCLUSIONS Vitamin B6 and folic acid correct the methionine loading test in patients with hyperhomocysteinemia. Perinatal outcome in patients with a history of preeclampsia or fetal growth restriction and hyperhomocysteinemia appears to be favorable.

Application of a customised birthweight standard in the assessment of perinatal outcome in a high risk population

Objective Physiological as well as pathological variables influence birthweight. The aim of the present study was to examine perinatal outcome in relation to birthweight centiles applying a customised birthweight standard.

Successful treatment of life-threatening postpartum hemorrhage with recombinant activated factor VII.

BACKGROUND Postpartum hemorrhage is one of the most common causes of maternal mortality and morbidity worldwide. The aims of treatment are to maintain the circulation and to stop the bleeding. The latter is achieved by either medical or surgical management. In intractable bleeding, emergency hysterectomy is usually required. CASE A 30-year-old nullipara presented with major postpartum hemorrhage due to uterine atony and vaginal lacerations. The patient developed hemorrhagic shock, resulting in prolonged prothrombin time, prolonged activated partial thromboplastin time, and low levels of factor VIII and fibrinogen. Treatments with uterotonic drugs, suturing, ligation of internal iliac arteries, subtotal hysterectomy, packing of the pelvis, and blood transfusion failed to control diffuse pelvic and vaginal bleeding. Recombinant activated factor VIIa (60-μg/kg intravenous bolus injection) was given as a final attempt to control the bleeding. The bleeding was successfully controlled within 10 minutes after administration. No side effects were noted. CONCLUSION Recombinant factor VIIa may be an alternative hemostatic agent in a patient with life-threatening postpartum hemorrhage unresponsive to conventional therapy.

Low-molecular-weight heparin combined with aspirin in pregnant women with thrombophilia and a history of preeclampsia or fetal growth restriction: a preliminary study

OBJECTIVE To assess the prevalence of haemostatic abnormalities in patients with an obstetric history of preeclampsia and/or fetal growth restriction and documented thrombophilia, and to evaluate the effects of low-molecular-weight heparin (LMWH) and aspirin on pregnancy outcome. METHOD A total of 276 patients with a history of preeclampsia and/or fetal growth restriction were tested for the presence of coagulation abnormalities and anticardiolipin antibodies (ACA). Ninety patients with preeclampsia and 15 patients with isolated fetal growth restriction had haemostatic abnormalities. Twenty-six patients with coagulation abnormalities: protein S-deficiency, activated protein C (APC) resistance and/or > or =15 ACA GPL and/or MPL had a subsequent pregnancy and were treated with aspirin in combination with LMWH. Their pregnancy outcome was compared with all patients having a subsequent pregnancy from the same cohort without abnormalities, or <15 ACA GPL and/or MPL who received aspirin (n=19). RESULTS In subsequent pregnancies birth weight of babies born to patients with an unequivocal coagulation abnormality (i.e., protein S-deficiency, APC resistance, or ACA titres > or =15 GPL and/or MPL), were higher than in the group with no disorders or <15 ACA GPL and/or MPL (P=0.019). CONCLUSIONS In this preliminary study, LMWH appears to have a favourable effect on the pregnancy outcome of women with a history of preeclampsia and/or fetal growth restriction and documented thrombophilia. Randomised trials are required.

Neonatal respiratory morbidity following elective caesarean section in term infants. A 5-year retrospective study and a review of the literature.

Respiratory morbidity is an important complication of elective caesarean section. The presence of labour preceding caesarean section reduces the risk of neonatal respiratory morbidity. Recently, it has been shown that the incidence of respiratory morbidity is lower in infants with a gestational age of at least 39(+0) weeks at elective caesarean section compared to infants with a gestational age less than 39(+0) weeks.This article describes the results of a 5-year retrospective study on the incidence of respiratory distress in term neonates delivered by elective caesarean section in relation to gestational age and provides a literature review on neonatal respiratory morbidity following elective caesarean section.

Endothelial vasoactive mediators in preeclampsia

OBJECTIVE In recent years an increasing amount of evidence supports the concept that preeclampsia is an endothelial disease. The purpose of our study was to evaluate the extent to which endothelial cell dysfunction is involved in pathophysiology of preeclampsia. STUDY DESIGN We studied the urinary excretion of thromboxane B2 and 6-keto-prostaglandin F1 alpha and the venous plasma endothelin levels in 23 preeclamptic patients and in control subjects. In six of these patients and in six controls arterial plasma endothelin levels were also measured. In addition, plasma levels of calcitonin gene-related peptide and plasma fibronectin levels were measured. Results were analyzed by Wilcoxons rank-sum test or signed-rank test. RESULTS In preeclampsia the urinary thromboxane B2/6-keto-prostaglandin F1 alpha ratio (p < 0.001), venous plasma endothelin levels (p < 0.001), and plasma fibronectin levels (p < 0.001) were significantly elevated compared with normotensive pregnancy. Arterial plasma endothelin levels were significantly higher than venous plasma endothelin levels in normotensive and hypertensive patients (p < 0.05). Calcitonin gene-related peptide levels showed a wide range in normotensive pregnancy and in preeclampsia, but the difference was not significant. CONCLUSIONS These results confirm the extensive involvement of the endothelium in the pathophysiology of preeclampsia. Preeclamptic vasoconstriction seems to be mediated by an increase in the vasoconstrictor autocoids thromboxane A2 and endothelin. Production of prostacyclin by the vessel wall and endovascular trophoblast might be just a pivotal escape mechanism of the uteroplacental circulation. Calcitonin gene-related peptide appears not to be involved in the pathophysiology of preeclampsia.

Use of recombinant activated factor VII in primary postpartum hemorrhage - The northern European registry 2000-2004

OBJECTIVE: To collect data from nine European countries for cases of obstetric hemorrhage between 2000 and 2004 in which recombinant activated factor VII (rFVIIa) was used. METHODS: The cases were identified through national surveys. Standardized case report forms included sociodemographic details, past medical and obstetric history, and details of the progress and management of labor in which the postpartum hemorrhage occurred. Clinicians were asked to describe subjectively the effect of rFVIIa administration using two mutually exclusive categories: 1) bleeding reduced or 2) bleeding unchanged or worse. RESULTS: A total of 113 forms were returned (88%) with 97 (86%) classified as treatment, and 16 (14%) as “secondary prophylaxis.” Clinicians noted improvements after a single dose for 80% of women in the treatment group, and for 75% in the secondary “prophylaxis” group. However, rFVIIa failed in 15 cases (13.8%). Few serious adverse events were noted related to rFVIIa administration; there were four cases of thromboembolism, one myocardial infarction, and one skin rash. CONCLUSION: Clinical reports and hematologic data suggest improvement for more than 80% of women after rFVIIa administration and few adverse effects. LEVEL OF EVIDENCE: II

Confidential enquiry into maternal deaths in The Netherlands 1983–1992

OBJECTIVE To determine the causes of maternal death in The Netherlands. STUDY DESIGN Nationwide Confidential Enquiry into the Causes of Maternal Deaths during the period 1983-1992. RESULTS Of 192 direct and indirect maternal deaths, 154 (80%) were available for the Enquiry. The most frequent direct causes were (pre-)eclampsia, thrombo-embolism, obstetrical haemorrhage and sepsis. Cerebro- and cardiovascular disorders were the most frequent indirect causes of death. Age above 35 years and parity 3 or more are related to higher maternal mortality. Women from non-caucasian origin are more prone to death in comparison to caucasian women. Autopsy was performed in 88 cases (57%). Of the 24 women where labour started at home, the place of birth played a significant role in delay in four. CONCLUSIONS More efforts should be made to have a higher percentage than 80% available for the Confidential Enquiry as in the UK where only 1-4% of deaths are not available for similar purposes. Also, the autopsy rate of 57% is much lower than in the UK (82%). Special strategies should be developed to improve maternal health of populations at higher risk such as women of high age and parity and immigrant populations.