J. Bennebroek Gravenhorst

Underreporting of maternal mortality in The Netherlands

Objective To establish the actual number of maternal deaths in The Netherlands by determining the degree of underreporting. Methods We conducted a nationwide, retrospective crosscheck of the three available maternal mortality registration systems and issued a questionnaire to senior obstetricians in all hospitals during the years 1983–1992. Results The officially reported maternal mortality rate during the study period was 7.1 per 100,000 live births (133 maternal deaths per 1,862,985 live births). After completion of the study, our data indicate that the rate should be at least 9.7 per 100,000 live births (180 maternal deaths). Early pregnancy and indirect deaths were more likely to be underreported than direct deaths during labor and the puerperium. Failure to register the recent pregnancy on the death certificate was a frequent problem. Misclassification was particularly evident for cerebrovascular disorders, cardiovascular disorders, and eclampsia. Conclusion The level of underreporting of maternal mortality in The Netherlands was estimated at 26%. The pregnancy status of women should be registered on death certificates. Officially reported maternal mortality rates are unreliable and international comparisons using these data thus are less meaningful.

Maternal Hydrops Syndrome: A Review

The maternal hydrops syndrome (Ballantyne syndrome, mirror syndrome, pseudotoxemia, triple edema) is a preeclampsia-like disease observed in some pregnancies with severe fetal and/or placental hydrops. We describe three pregnancies with severe immunological fetal-placental hydrops resulting in fetal death, in spite of intrauterine transfusions. The mothers suffered severe hydrops syndrome, one of which was complicated by an eclamptic convulsion. All three women had anemia, low hematocrit, and elevated plasma uric acid levels. It is suggested that low hematocrit is an important pathophysiological feature in maternal hydrops syndrome.

Management of Severe Hemolytic Disease with Ultrasound-Guided Intravascular Fetal Transfusions

Abstract. Between January 1987 and March 1989, 22 fetuses with severe hemolytic disease were treated with 64 ultrasound‐guided intrauterine intravascular transfusions. Eighteen infants survived and are doing well. In 12 fetuses, hydropic changes were present at the first transfusion; 9 of these survived. In 8 of the 10 fetuses with a gestational age < 26 weeks, intrauterine treatment was successful.

The disappearance of fetal and donor red blood cells in alloimmunised pregnancies: a reappraisal

Objective To determine the proportional reduction per day in the number of fetal and donor red blood cells from the fetal circulation after intrauterine intravascular transfusions.

Twenty-two years of intra-uterine intraperitoneal transfusions

Over a period of 22 years, 154 fetuses were treated with 270 intra-uterine intraperitoneal transfusions. The patients were divided into three groups, according to the period they were treated. The overall percentage of surviving infants increased from 33% during the first period to 58% in the last period. In the group of infants that were not hydropic at the time of the first transfusion, the survival rate increased from 35 to 83%. In the group of children that were hydropic during the first transfusion, the survival rate during the first and last period was 24 and 42%, respectively. The percentage of fetuses that needed their first transfusion before the 26th week of pregnancy increased from 15 to 32% during the study period. Only 13% of these children survived. Lately, the intravascular approach has been introduced. Intravascular transfusions seem to be very effective, especially in early pregnancies and in hydropic fetuses. Application of the two techniques each in the most appropriate situation might offer optimal results for the near future.

Evidence for the Protective Effect of Maternal FcR-Blocking IgG Alloantibodies HLA-DR in Rh D-Haemolytic Disease of the Newborn

In cases of Rh D alloimmunization, strong results in the antibody‐dependent cell‐mediated cytotoxicity (ADCC) assay (> 80% lysis as compared to that of the standard anti‐D serum) are indicative of severe hemolytic disease to occur in the newborn (HDN). However, discrepant cases were found in which the maternal anti‐D gave strong ADCC results and the newborns had no or only mild hemolysis. In the majority of these cases the mother had produced monocyte‐reactive IgG alloantibodies, mostly with HLA‐DR specificity. Such antibodies may be capable of blocking FcR‐mediated functions of the fetal MPS, and it has been postulated that they inhibit destruction of anti‐D‐sensitized red cells. We here describe 2 families in which such discrepancies were noticed. In 1 family, in spite of ADCC results of >80%, the Rh D‐positive second child was born without signs of hemolysis. However, the Rh D‐positive third child suffered from very severe hemolytic disease. The mother had produced monocyte‐reactive HLA‐DR antibodies in the second pregnancy which, however, did not react with the cells of the third child. In the other family, the severely Rh D‐alloimmu‐nized mother had lost her fourth child because of intrauterine death due to HDN. The Rh D‐positive fifth child was born with only mild HDN and only in this pregnancy had the mother produced such antibodies. These 2 case histories give further evidence that maternal monocyte‐reactive alloantibodies, in both these cases directed against HLA‐DR antigens, can protect the Rh D‐positive child against hemolytic disease in case of severe Rh D alloimmunization.

Management of Serious Alloimmunization in Pregnancy

Abstract. In the past 40 years, tremendous advances in the treatment of hemolytic disease have been made. The perinatal mortality has been reduced considerably. Rh immunoprophylaxis has decreased the incidence of Rh immunization to around 6 per 100,000 live births. Nevertheless, treatment of severe hemolytic disease is still essential. Increased reliability of diagnostic procedures have made early detection and optimal treatment of hemolytic disease possible. Treatment by plasmapheresis is still controversial. Although believed to be beneficial by some authors, conclusive evidence of its efficacy has not been obtained. With preterm induction of birth at 32 weeks of gestation, the chances for survival are 95%. Improvement of techniques and the use of modern real‐time ultrasound equipment have made intrauterine intraperitoneal transfusion, in experienced hands, a relatively safe and successful procedure. Intravascular transfusion appears beneficial in early pregnancy. Combination of both techniques will probably be the answer for the future. The development of neonatal intensive care facilities has made a major contribution to the survival of children with haemolytic disease. The relative low incidence of haemolytic disease has made it imperative that treatment should take place in centers where experience and special skill are available.

Prenatal diagnosis of congenital malformations in 500 pregnancies

The organization, techniques used and diagnostic findings of 500 prenatal diagnoses are reported in detail. In 15 cases the pregnancy was terminated because of abnormal laboratory findings. Follow-up of the remaining pregnancies revealed a perinatal mortality of 1.7%, and the risk of an abortion induced by amniocentesis, performed in the 15–16th wk, to be 1–2%. Serious counseling problems arose in 2 cases with trisomy X, in 2 instances of a balanced chromosome translocation and in 1 case of a de novo translocation.

Extraamniotic prostaglandin F2α for intrauterine death and fetal abnormality

Abstract Prostaglandin F 2α was administered extraamniotically for termination of pregnancy in 15 cases of intrauterine fetal death between 18 and 39 wk gestation and in 10 cases of fetal abnormality or hydatidiform mole between 16 and 28 wk gestation. Although delivery was achieved with minimal side effects in all cases, the best results were obtained in patients with intrauterine fetal death. It is concluded that discontinuous extraamniotic prostaglandin therapy constitutes a safe and effective approach for the active management of intrauterine fetal death.

Elevation of maternal α–fetoprotein serum levels in relation to fetomaternal haemorrhage after second trimester pregnancy termination by aspirotomy

Fetomaternal haemorrhage (FMH) after termination of pregnancy in the second trimester has been reported previously (Katz 1969; Queenan et al. 1971; Voigt & Britt 1969). Several authors have observed a rise in maternal serum a-fetoprotein (AFP) concentration in association with FMH (Seppala & Ruoslahti 1972; Norgaard Pedersen 1974; Kjessler & Johansson 1977; Los et al. 1979). The occurrence of an increase in maternal serum AFP after amniocentesis has also been documented (Chard et al. 1976; Mennuti er al. 1980). The discrepancy found between the results of fetal red cell count and the increased concentration of maternal serum AFP as an indicator of FMH has been attributed to a greater sensitivity of AFP changes than the Kleihauer test (Lachman et al. 1977). According to Dallaire et al. (1980), passage of amniotic fluid into the maternal circulation sometimes accounts for a rise in maternal serum AFP concentration following amniocentesis.