Simone M. Kuppens

Maternal thyroid parameters, body mass index and subsequent weight gain during pregnancy in healthy euthyroid women

Obesity and too much weight gain during gestation have a negative effect on obstetric and neonatal outcomes.

The HAPPY study (Holistic Approach to Pregnancy and the First Postpartum Year): design of a large prospective cohort study

BackgroundThe HAPPY study is a large prospective longitudinal cohort study in which pregnant women (Nu2009≈u20092,500) are followed during the entire pregnancy and the whole first year postpartum. The study collects a substantial amount of psychological and physiological data investigating all kinds of determinants that might interfere with general well-being during pregnancy and postpartum, with special attention to the effect of maternal mood, pregnancy-related somatic symptoms (including nausea and vomiting (NVP) and carpal tunnel syndrome (CTS) symptoms), thyroid function, and human chorionic gonadotropin (HCG) on pregnancy outcome of mother and foetus.Methods/designDuring pregnancy, participants receive questionnaires at 12, 22 and 32xa0weeks of gestation. Apart from a previous obstetric history, demographic features, distress symptoms, and pregnancy-related somatic symptoms are assessed. Furthermore, obstetrical data of the obstetric record form and ultrasound data are collected during pregnancy. At 12 and 30xa0weeks, thyroid function is assessed by blood analysis of thyroid stimulating hormone (TSH), free thyroxine (FT4) and thyroid peroxidase antibodies (TPO-Ab), as well as HCG. Also, depression is assessed with special focus on the two key symptoms: depressed mood and anhedonia. After childbirth, cord blood, neonatal heel screening results and all obstetrical data with regard to start of labour, mode of delivery and complications are collected. Moreover, mothers receive questionnaires at one week, six weeks, four, eight, and twelve months postpartum, to investigate recovery after pregnancy and delivery, including postpartum mood changes, emotional distress, feeding and development of the newborn.DiscussionThe key strength of this large prospective cohort study is the holistic (multifactorial) approach on perinatal well-being combined with a longitudinal design with measurements during all trimesters of pregnancy and the whole first year postpartum, taking into account two physiological possible markers of complaints and symptoms throughout gestation: thyroid function and HCG. The HAPPY study is among the first to investigate within one design physiological and psychological aspects of NVP and CTS symptoms during pregnancy. Finally, the concept of anhedonia and depressed mood as two distinct aspects of depression and its possible relation on obstetric outcome, breastfeeding, and postpartum well-being will be studied.

Mode of Delivery Following Successful External Cephalic Version: Comparison With Spontaneous Cephalic Presentations at Delivery

OBJECTIVEnTo compare the obstetric outcomes of pregnant women after successful external cephalic version (ECV) (cases) with a large group of pregnant women with a spontaneously occurring cephalic fetal position at delivery (controls).nnnMETHODSnWe conducted a retrospective matched cohort study in a teaching hospital in the Netherlands. Delivery outcomes of women with a successful ECV were compared with those of women with spontaneously occurring cephalic presentations, controlling for maternal age, parity, gestational age at delivery, and onset of labour (spontaneous or induced). Exclusion criteria were a history of Caesarean section, delivery at < 35 weeks, and elective Caesarean section. The primary outcome was the prevalence of Caesarean section and instrumental delivery in both groups; secondary outcomes were the characteristics of cases requiring intervention such as Caesarean section or instrumental delivery.nnnRESULTSnWomen who had a successful ECV had a significantly higher Caesarean section rate than the women in the control group (33/220 [15%] vs. 62/1030 [6.0 %]; P < 0.001). There was no difference in the incidence of instrumental delivery (20/220 [9.1%] vs. 103/1030 [10%]). Comparison of characteristics of women in the cases group showed that nulliparity, induction of labour, and occiput posterior presentation were associated with Caesarean section and instrumental deliveries.nnnCONCLUSIONnCompared with delivery of spontaneous cephalic presenta-tions, delivery of cephalic presenting babies following successful ECV is associated with an increased rate of Caesarean section, especially in nulliparous women and women whose labour is induced.

Fear for external cephalic version and depression: predictors of successful external cephalic version for breech presentation at term?

BackgroundObjective was to determine whether fear for external cephalic version (ECV) and depression are associated with the success rate of ECV in women with a breech presentation at term.MethodsProspective study conducted in the Catharina Hospital Eindhoven between October 2007 and May 2012. Participants fulfilled The Edinburgh Depression Scale (EDS) questionnaire and expressed their degree of fear on a visual analogue scale from one to ten before ECV. Obstetric factors were evaluated as well. Primary outcome was the relation between psychological factors (fear for ECV and depression EDS scores) and ECV success rate. Secondary outcome was a possible relation between fear for ECV and increased abdominal muscle tension.ResultsThe overall success rate was 55% and was significantly lower (pu2009<u20090.001) in nulliparous women (44.3%) compared with parous women (78.0%). Fear for ECV and depression EDS-scores were not related with ECV success rate. Parity, placental location, BMI and engagement of the fetal breech were obstetric factors associated with ECV outcome. There was no relation between fear for ECV and abdominal muscle tone.ConclusionFear for ECV and depression were not related with ECV success rate in this study. Engagement of the fetal breech was the most important factor associated with a successful ECV.Trial registrationEBIS: The Eindhoven Breech Intervention Study, NCT00516555.

The Effect of Change in a Labour Management Protocol on Caesarean Section Rate in Nulliparous Women

OBJECTIVEnTo investigate the impact on obstetric outcome in nulliparous women of changing labour management from an expectant approach to proactive support of labour.nnnMETHODSnWe conducted a retrospective cohort study in a teaching hospital in the Netherlands among 858 women ≥ 37 weeks gestation with a singleton fetus in cephalic position and spontaneous labour who planned to have a vaginal birth in the hospital under the care of an obstetrician. Exclusion criteria were gestational age < 37 weeks, induction of labour, primary Caesarean section, non-cephalic position, and non-Caucasian ethnicity. Labour outcomes in the period 1999 to 2002 (using an expectant approach) were compared with labour outcomes in the period 2008 to 2010 (using proactive support of labour). The primary outcome measure was the relationship between the CS rate and the form of labour management (expectant approach vs. proactive support). The secondary outcome measure was to identify risk factors for repeat CS.nnnRESULTSnThe overall prevalence of CS in the study population was 12.2%. The CS rate increased significantly from 9.7% between 1999 and 2002, to 15.4% between 2008 and 2010 (P < 0.001). Meanwhile, the assisted vaginal delivery rate decreased from 22.7% to 16.7% (P = 0.03). Multiple logistic regression showed that epidural analgesia (OR 4.6; 95% CI 2.6 to 8.4), occiput posterior position (OR 7.4; 95% CI 4.3 to 12.8), and advanced maternal age (OR 1.91; 95% 1.31 to 2.76) were risk factors for CS.nnnCONCLUSIONnChanging labour management from an expectant approach to proactive support of labour did not decrease the Caesarean section rate.

Determinants of pain perception after external cephalic version in pregnant women

OBJECTIVEnA considerable proportion of pregnant women with a fetus in breech position refuses external cephalic version (ECV), with fear of pain as important barrier. As a consequence, they are at high risk for caesarean section at term. The current study investigated determinants of pain perception during ECV, with special attention to maternal mental state such as depression and fear of ECV.nnnDESIGNnProspective study of 249 third-trimester pregnant women with breech position with a request for an ECV attempt.nnnSETTINGnDepartment of Obstetrics and Gynaecology in a large teaching hospital in the Netherlands.nnnMETHODSnPrior to the ECV attempts, obstetric factors were registered, participants fulfilled the Edinburgh Depression Scale (EDS) and reported fear of ECV on a 10-point visual analog scale. Perception of pain intensity was measured with a 10-point visual analog scale, immediately after ECV.nnnFINDINGSnMultivariate linear regression analyses showed success of ECV to be the strongest predictor of pain perception. Furthermore, scores on the depression questionnaire and degree of fear of ECV independently explained pain perception, which was not the case for obstetrical or ECV related factors.nnnCONCLUSIONnApart from ECV outcome, psychological factors like depression and fear of ECV were independently related to pain perception of an ECV attempt.nnnIMPLICATION FOR PRACTICEnMaternal mood state should be taken into account when offering an ECV attempt to women with a fetus in breech position. Due to the painful experience and the importance of successful outcome, ECV should only be attempted in institutions with experienced practitioners and with careful attention to maternal mood and the way a woman is coping with the ECV attempt.

Management strategy in case of meconium stained amniotic fluid

The management strategies can generally be divided in two categories: preventive intervention and “wait and watch” strategy. The first group again can be divided in two categories: the prevention of MSAF to occur and the prevention of any fetal or neonatal complication once MSAF is diagnosed. The possible benefit of the “wait and watch” strategy, in which neonatal complications when they occur after a MSAF delivery are vigorously monitored and treated, is largely dependent on the level of peripartum facilities. Interestingly, these facilities in turn have largely influenced the evidence of benefit of intervention within the first attitude, as very recently shown in the 2014 Cochrane review of the effect of amnio-infusion. The corresponding author, Prof. G. Hofmeyr, kindly gave permission to describe these finding in details in this section of the BP issue. It is beyond the scope of this review to discuss interventions that are commonly used in obstetrics when – in the case of MSAF – during labor objective parameters are found of fetal distress. Moreover, evaluation of treatment strategies in case of a meconium aspiration syndrome (MAS) is also beyond the scope of this review. As in the introduction, we will evaluate the current concepts of treatment strategies also in the light of the recent paper of Hiersch et al., discriminating between primary MSAF and secondary MSAF.

Fetal heart rate abnormalities during and after external cephalic version: Which fetuses are at risk and how are they delivered?

BackgroundFetal heart rate abnormalities (FHR) during and after external cephalic version (ECV) are relatively frequent. They may raise concern about fetal wellbeing. Only occasionally they may lead to an emergency cesarean section.MethodsProspective cohort study in 980 women (>u200934xa0weeks gestation) with a singleton fetus in breech presentation. During and after external cephalic version (ECV) FHR abnormalities were recorded. Obstetric variables and delivery outcome were evaluated. Primary outcome was to identify which fetuses are at risk for FHR abnormalities. Secondary outcome was to identify a possible relationship between FHR abnormalities during and after ECV and mode of delivery and fetal distress during subsequent labor.ResultsThe overall success rate of ECV was 60% and in 9% of the attempts there was an abnormal FHR pattern. In two cases FHR abnormalities after ECV led to an emergency CS. Estimated fetal weight per 100xa0g (OR 0.90, CI: 0.87–0.94) and longer duration of the ECV-procedure (OR 1.13, CI: 1.05–1.21) were factors significantly associated with the occurrence of FHR abnormalities. FHR abnormalities were not associated with the mode of delivery or the occurrence of fetal distress during subsequent labor.ConclusionsFHR abnormalities during and after ECV are more frequent with lower estimated fetal weight and longer duration of the procedure. FHR abnormalities during and after ECV have no consequences for subsequent mode of delivery. They do not predict whether fetal distress will occur during labor.Trial registrationThe Eindhoven Breech Intervention Study, NCT00516555. Date of registration: August 13, 2007.

Did the classical concept of meconium according to Aristotle induce not only the fetus into sleep, but also us, researchers and clinicians?

The rather intriguing concept of meconium stained amniotic fluid to carefully observe whether MSAF is present immediately with (MSAF) still puzzles theworld of researchers and clinicians in obstetrics. Since the best practice issue on this topic in EHD, five years ago, still many basic questions remained unresolved. How is it possible that at one hand, there is abundant evidence that MSAF should be regarded as a physiological concept reflecting fetal maturation, while on the other hand there is clear evidence thatMSAF has repeatedly been related to adverse neonatal outcome including the meconium aspiration syndrome (MAS)? A very recent paper of the group of Hiersch et al. proposes an important newapproach (ormore precisely proposes a further thorough elaboration of a concept which goes back thirty years ago) when looking at MSAF [1].We believe that this approachmight help to reconcile the two opposite poles of the physiological concept versus the serious risk concept of severe neonatal problems of MSAF and might push forward the discussion of better understanding the mechanism behind MSAF. Hiersch et al. propose that, when looking at possible negative effects of MSAF, it is important to evaluate in further detail the discrimination between primary and secondary MSAF (1). Primary MSF refers to the presence ofmeconium in amnioticfluid at the time ofmembrane rupture and reflects most likely fetal maturation. Secondary MSAF refers to a transformation of color of amniotic fluid from clear to meconium during labor and more likely reflects fetal distress. In their retrospective cohort study of 694 term born deliveries with MSAF (out of over 8000 term pregnancies), obstetric and neonatal outcomes were compared between primary (77%) and secondaryMSAF (23%). They accurately definedwhen MSAF did occur (membrane rupture, during the active phase, at late 2nd stage). Moreover, they compared the MSAF group with 314 control women with clear amniotic fluid who were similar with respect to age, rate of previous CS, diabetes, birth weight outcome and fetal sex. Important findings were: (1) Secondary MSAF was independently associated with an increased risk of operative vaginal delivery, but not primary MSAF; (2) secondary MSAF deliveries had a more than 2-fold increased risk of adverse neonatal outcome compared to primary MSAF independently of gestational age but the risk attenuated in post term pregnancies within the group but also in relation to controls; (3) the possible negative effect ofMSAF on neonatal outcome is higherwhen the transition of clear to meconium stained amniotic fluid is observed at late 2nd stage; (4) thick meconium occurred more often in the primary MSAF group (with less adverse neonatal outcome) compared to thin meconium. It is beyond the scope of this comment to discuss the paper in further detail. However, we believe that the following interpretationmight help in better understanding the concept of MSAF in the future. MSAF delivery most likely consists of a heterogeneous group. Research on MSAF should preferentially be prospective. It is important