Objective
To assess the cost‐effectiveness of treatment with nifedipine compared with atosiban in women with threatened preterm birth.
Design
An economic analysis alongside a randomised clinical ...trial (the APOSTEL III study).
Setting
Obstetric departments of 12 tertiary hospitals and seven secondary hospitals in the Netherlands and Belgium.
Population
Women with threatened preterm birth between 25 and 34 weeks of gestation, randomised for tocolysis with either nifedipine or atosiban.
Methods
We performed an economic analysis from a societal perspective. We estimated costs from randomisation until discharge. Analyses for singleton and multiple pregnancies were performed separately. The robustness of our findings was evaluated in sensitivity analyses.
Main outcome measures
Mean costs and differences were calculated per woman treated with nifedipine or atosiban. Health outcomes were expressed as the prevalence of a composite of adverse perinatal outcomes.
Results
Mean costs per patients were significantly lower in the nifedipine group singleton pregnancies: €34,897 versus €43,376, mean difference (MD) −€8479 95% confidence interval (CI) −€14,327 to −€2016); multiple pregnancies: €90,248 versus €102,292, MD −€12,044 (95% CI −€21,607 to € −1671). There was a non‐significantly higher death rate in the nifedipine group. The difference in costs was mainly driven by a lower neonatal intensive care unit admission (NICU) rate in the nifedipine group.
Conclusion
Treatment with nifedipine in women with threatened preterm birth results in lower costs when compared with treatment with atosiban. However, the safety of nifedipine warrants further investigation.
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In women with threatened preterm birth, tocolysis using nifedipine results in lower costs when compared with atosiban.
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In women with threatened preterm birth, tocolysis using nifedipine results in lower costs when compared with atosiban.
Early recognition is crucial, because treatment can reduce mortality and morbidity in relatively young people who often present with diseases such as stroke, myocardial infarction, and deep vein ...thrombosis. Because of its variable clinical presentation, patients with antiphospholipid syndrome present to a variety of medical practitioners. Because of the heart valves I had to postpone further pregnancies.
Recently, it has been proposed that abnormalities in coagulation and fibrinolysis contribute to the development of preeclampsia by increasing the thrombotic tendency. This hypothesis was tested in ...women who have had preeclampsia (cases) compared with matched controls. Polymorphisms in the thrombophilia genes plasminogen activator inhibitor type 1 PAI-1 -675(4G/5G), thrombin activatable fibrinolysis inhibitor (TAFI -438G/A and 1040C/T), methylenetetrahydrofolate reductase (MTHFR 677C/T), factor V (FV Leiden R/Q506), prothrombin (FII 20210G/A) and factor XIIIA (FXIIIA V/L34) were determined in 157 women with preeclampsia and 157 women with uncomplicated pregnancy. The associated risk of preeclampsia was analyzed using logistic regression methods. The frequency distributions of the genotypes of these six polymorphisms in thrombophilia genes were similar in the case and control groups. We found no differences in the prevalence of genetic risk factors of thrombosis in women with preeclampsia compared with controls, which makes it unlikely that these polymorphisms are risk factors for preeclampsia.
Abstract
Background
Pregnancy associated hypertensive disorders including pre-eclampsia/eclampsia and gestational hypertension have been related to unfavourable maternal cardiovascular risk factor ...profiles and a significantly higher risk to develop maternal cardiovascular disease (CVD) events in observational studies. However, whether these associations are causal is not yet fully understood.
Purpose
We conducted a Mendelian Randomisation study to investigate whether genetic liability to pre-eclampsia/eclampsia and gestational hypertension is related to cardiovascular risk factors and the risk of experiencing CVD outcomes.
Methods
We analysed individual-participant data of women and men from the UK Biobank. The rationale for also analysing men was to study the role of genetic liability to pre-eclampsia/eclampsia and gestational hypertension in CVD risk without experiencing the underlying phenotype. We studied a range of CVD outcomes including myocardial infarction, stroke (including subtypes), and combined CVD endpoints. Furthermore, we analysed a set of blood pressure-, lipid-, liver-, and kidney-related cardiovascular risk factors. To study the genetic association with pre-eclampsia/eclampsia and gestational hypertension we used effect sizes and standard errors from a large-scale genome-wide association study. For the genetic associations with cardiovascular risk factors and CVD outcomes, we used individual-participant data from the UK Biobank. We applied Mendelian Randomisation analysis using inverse variance weighted regression in our primary analysis and implemented additional regression methods as sensitivity analyses.
Results
We included 264,160 women and 223,043 men from the UK Biobank with available genetic data. Mean age at baseline was 56.5 (standard deviation 8.1) and 56.7 (8.2) years in women and men, respectively. Of all women and men, 44.3% and 50.9% had a history of hypertension and mean age at hypertension was 50.0 (10.8) and 51.2 (9.1) years, respectively. Genetically proxied pre-eclampsia/eclampsia and gestational hypertension were related to a higher risk of CVD in both sexes, with odds ratios of 1.20 (1.01, 1.43) and 1.22 (1.10, 1.36) in women and 1.29 (1.08, 1.53) and 1.28 (1.16, 1.42) in men, respectively. The relations were more pronounced for ischaemic than for haemorrhagic outcomes. Furthermore, genetically proxied pre-eclampsia/eclampsia and gestational hypertension were associated with higher levels of systolic and diastolic blood pressure and earlier age at hypertension in both women and men.
Conclusion
Genetic liability to pregnancy associated hypertensive disorders including pre-eclampsia/eclampsia and gestational hypertension is associated with higher CVD risk, implying biological mechanisms relating to these disorders are causally related to CVD risk in both women and men.
Objective
To assess the economic consequences of immediate delivery compared with expectant monitoring in women with preterm non‐severe hypertensive disorders of pregnancy.
Design
A ...cost‐effectiveness analysis alongside a randomised controlled trial (HYPITAT‐II).
Setting
Obstetric departments of seven academic hospitals and 44 non‐academic hospitals in the Netherlands.
Population
Women diagnosed with non‐severe hypertensive disorders of pregnancy between 340/7 and 370/7 weeks of gestation, randomly allocated to either immediate delivery or expectant monitoring.
Methods
A trial‐based cost‐effectiveness analysis was performed from a healthcare perspective until final maternal and neonatal discharge.
Main outcome measures
Health outcomes were expressed as the prevalence of respiratory distress syndrome, defined as the need for supplemental oxygen for >24 hours combined with radiographic findings typical for respiratory distress syndrome. Costs were estimated from a healthcare perspective until maternal and neonatal discharge.
Results
The average costs of immediate delivery (n = 352) were €10 245 versus €9563 for expectant monitoring (n = 351), with an average difference of €682 (95% confidence interval, 95% CI −€618 to €2126). This 7% difference predominantly originated from the neonatal admissions, which were €5672 in the immediate delivery arm and €3929 in the expectant monitoring arm.
Conclusion
In women with mild hypertensive disorders between 340/7 and 370/7 weeks of gestation, immediate delivery is more costly than expectant monitoring as a result of differences in neonatal admissions. These findings support expectant monitoring, as the clinical outcomes of the trial demonstrated that expectant monitoring reduced respiratory distress syndrome for a slightly increased risk of maternal complications.
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Expectant management in preterm hypertensive disorders is less costly compared with immediate delivery.
Expectant management in preterm hypertensive disorders is less costly compared with immediate delivery.
Abstract Objectives : To investigate the impact of the postcoital test on the pregnancy rate among subfertile couples and on the number of other diagnostic tests and treatments. Design : Randomised ...controlled study. Setting : A university and two non-university teaching hospitals in the Netherlands. Subjects : New couples at infertility clinics, 1 March 1993 to 1 October 1995; randomisation to an intervention group (series of infertility investigations that include the postcoital test) or to a control group (series excluding the test). Main outcome measure : Cumulative pregnancy rate. Results : Of 736 consecutive new couples, 444 fulfilled the inclusion criteria and consented to participate (intervention group, 227; control group, 217). Treatment was given more often in the intervention group than in the control group (54% v 41%; difference 13% (95% confidence interval 4% to 22%)). Yet cumulative pregnancy rates at 24 months in the intervention group (49% (42% to 55%)) and the control group (48% (42% to 55%)) were closely similar (difference 1% (−9.0% to 9.0%)). Conclusion : Routine use of the postcoital test in infertility investigations leads to more tests and treatments but has no significant effect on the pregnancy rate.
Velamentous cord insertion and vasa previa occur more frequently in monochorionic twin pregnancies than in singleton pregnancies. Both have been linked with poor perinatal outcome due to the ...increased risk of rupture of the velamentous vessels. We present a case of acute fetal distress in 2 fetuses in a monochorionic twin pregnancy caused by ruptured vasa previa that was not detected antenatally. Both infants were severely anemic at birth. Acute blood loss in twin 1 through the ruptured vessels, led to an acute feto-fetal transfusion from the co-twin through the placental vascular anastomoses. In monochorionic twins, ruptured vasa previa and acute hemorrhage in one fetus can lead to acute feto-fetal transfusion and result in severe hypovolemic shock and acute anemia in both fetuses. Increased awareness for vasa previa and the characteristic placental angioarchitecture in monochorionic twinning is of paramount importance.
Objective: To assess the effect of maintenance tocolysis in women who are at high or low risk for preterm delivery according to fetal fibronectin (fFN) status and cervical length (CL).
Study design: ...We compared the risk of preterm delivery in fFN pos and fFN neg women and in women with a CL <15 mm and ≥15 mm, by using the Cox regression. Differences between the effectiveness of maintenance tocolysis in high- and low-risk women were assessed by using an interaction term.
Results: 122 fFN tests were taken, of which 50 were fFN pos. CL was measured in 236 women, of whom 52 women had a CL <15 mm. The median gestational age at delivery was lower in fFN pos women; fFN pos women had a higher hazard for preterm delivery at any point of time (HR 4.7; 95% CI 2.9 to 7.6). Comparable results were seen for CL. Neither fFN status nor CL did alter the effect of maintenance tocolysis, which was ineffective in the total randomized group, on the risk of preterm delivery (p for interaction = 0.87 for fFN and 0.18 for CL).
Conclusion: Maintenance tocolytic therapy with nifedipine is ineffective and not dependent on fFN or CL status.
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