Probiotic use may be an efficacious treatment option to effectively manage symptoms of prenatal maternal anxiety and depression. Our primary aim was to test feasibility and acceptability for a ...probiotic randomized controlled trial (RCT) in pregnant women with pre-existing symptoms. This double-blind pilot RCT included 40 pregnant women with low-risk pregnancies and elevated depressive symptoms and/or anxiety. Once daily, participants orally consumed a probiotic (Ecologic Barrier) or a placebo, from 26 to 30 weeks gestation until delivery. A priori key progression criteria for primary outcomes were determined to decide whether or not a full RCT was feasible and acceptable. Secondary outcomes included depressive symptoms, anxiety, stress, and maternal bonding to offspring. In 19 months, 1573 women were screened; following screening, 155 women (10%) were invited for participation, of whom 135 (87%) received study information, and 40 women (30%) were included. Four out of six a priori determined criteria for success on feasibility and acceptability were met. After 8 weeks of intervention, there was no significant difference between the probiotic and placebo groups for secondary outcomes. The pilot trial was feasible and acceptable, but hampered by recruitment method and study design. Secondary endpoints did not reveal differences between the groups for improving maternal mood.
To estimate the performance of combining cervical length measurement with fetal fibronectin testing in predicting delivery in women with symptoms of preterm labor.
We conducted a prospective ...nationwide cohort study in all 10 perinatal centers in The Netherlands. Women with symptoms of preterm labor between 24 and 34 weeks of gestation with intact membranes were included. In all women, qualitative fibronectin testing (0.050-microgram/mL cutoff) and cervical length measurement were performed. Logistic regression was used to predict spontaneous preterm delivery within 7 days after testing. A risk less than 5%, corresponding to the risk for women with a cervical length of at least 25 mm, was considered as low risk.
Between December 2009 and August 2012, 714 women were enrolled. Fibronectin results and cervical length were available for 665 women, of whom 80 (12%) delivered within 7 days. Women with a cervical length of at least 30 mm or with a cervical length between 15 and 30 mm with a negative fibronectin result were at low risk (less than 5%) of spontaneous delivery within 7 days. Fibronectin testing in case of a cervical length between 15 and 30 mm additionally classified 103 women (15% of the cohort) as low risk and 36 women (5% of the cohort) as high risk.
Cervical length measurement, combined with fetal fibronectin testing in case of a cervical length between 15 and 30 mm, improves identification of women with a low risk to deliver spontaneously within 7 days.
II.
Purpose
In early-onset preeclampsia, each additional day of pregnancy prolongation reduces offspring infant mortality about 9%. We evaluated if maternal stress at admission to hospital for ...early-onset preeclampsia predicted admission-to-delivery intervals in days.
Methods
This prospective, longitudinal cohort-study involved 15 singleton pregnancies with a diagnosis of preeclampsia before 34 weeks gestation with intended expectant management. Upon hospital admission, maternal psychological stress was assessed with questionnaires and physiological stress with hair cortisol. Hair samples were analyzed in three hair segments representing the preconception period, and the first and second trimester of pregnancy.
Results
Mean pregnancy prolongation was 16.2 days. Higher maternal anxiety at hospital admission significantly correlated with shorter admission-to-delivery intervals (
r
= − 0.54,
p
= 0.04). Chronically increased hair cortisol concentrations (i.e. from preconception through the second trimester) of pregnancy tended to be related to shorter admission-to-delivery intervals (
p
<. 10).
Conclusion
Higher reported anxiety is, and chronically high hair cortisol tended to be, related with fewer days of prolongation from admission to delivery in women with early-onset preeclampsia. These findings suggest that maternal stress might be a potential determinant of disease progression. Future research into early innovative stress-reducing interventions for early-onset preeclampsia may shed more light on the etiology and treatment of this disease.
In threatened preterm labor, maintenance tocolysis with nifedipine, after an initial course of tocolysis and corticosteroids for 48 hours, may improve perinatal outcome.
To determine whether ...maintenance tocolysis with nifedipine will reduce adverse perinatal outcomes due to premature birth.
APOSTEL-II (Assessment of Perinatal Outcome with Sustained Tocolysis in Early Labor) is a double-blind, placebo-controlled trial performed in 11 perinatal units including all tertiary centers in The Netherlands. From June 2008 to February 2010, women with threatened preterm labor between 26 weeks (plus 0 days) and 32 weeks (plus 2 days) gestation, who had not delivered after 48 hours of tocolysis and a completed course of corticosteroids, were enrolled. Surviving infants were followed up until 6 months after birth (ended August 2010).
Randomization assigned 406 women to maintenance tocolysis with nifedipine orally (80 mg/d; n = 201) or placebo (n = 205) for 12 days. Assigned treatment was masked from investigators, participants, clinicians, and research nurses.
Primary outcome was a composite of adverse perinatal outcomes (perinatal death, chronic lung disease, neonatal sepsis, intraventricular hemorrhage >grade 2, periventricular leukomalacia >grade 1, or necrotizing enterocolitis). Analyses were completed on an intention-to-treat basis.
Mean (SD) gestational age at randomization was 29.2 (1.7) weeks for both groups. Adverse perinatal outcome was not significantly different between groups: 11.9% (24/201; 95% CI, 7.5%-16.4%) for nifedipine vs 13.7% (28/205; 95% CI, 9.0%-18.4%) for placebo (relative risk, 0.87; 95% CI, 0.53-1.45).
In patients with threatened preterm labor, nifedipine-maintained tocolysis did not result in a statistically significant reduction in adverse perinatal outcomes when compared with placebo. Although the lower than anticipated rate of adverse perinatal outcomes in the control group indicates that a benefit of nifedipine cannot completely be excluded, its use for maintenance tocolysis does not appear beneficial at this time.
trialregister.nl Identifier: NTR1336.
Preeclampsia with an onset before 28 weeks' gestation poses dilemmas for the obstetrician with regard to the mode of delivery.
The aim of this study was to analyze the success rate of attempted ...vaginal delivery and the maternal and neonatal outcome according to the mode of delivery in women with preeclampsia and an indicated delivery before 28 weeks' gestation.
A comprehensive search was performed in the bibliographic databases PubMed, Embase.com, and Wiley Cochrane Library. The main outcome was success rate of attempted vaginal delivery. Secondary outcomes were maternal and neonatal outcomes.
Eight studies describing a total of 800 women were included. Success rates of vaginal delivery varied from 1.8% to 80%, and rates for cesarean delivery after induction of labor varied from 13% to 51%. The rates for planned cesarean delivery varied from 0% to 73%. Two studies (n = 53) described no statistical significant differences in maternal outcomes. Two other studies (n = 107) report no statistical difference in neonatal outcome.
Studies that report the success rate of attempted vaginal delivery are limited in size. However, giving the available evidence in the reported studies a trial of labor is a considerable option in counseling women with a pregnancy complicated by preeclampsia before 28 weeks' gestation due to the similar maternal and neonatal outcome. No differences in maternal or neonatal outcome were attributed to the mode of delivery, however, numbers are small.
Abstract Objective To investigate frequency and practise of termination of pregnancy for early-onset hypertensive disorders where the foetus is considered to be non-viable. Study Design Retrospective ...cohort study in all Dutch tertiary perinatal care centres (n = 10), between January 2000 and January 2014. All women who underwent termination of pregnancy, without foetal surveillance or intention to intervene for foetal reasons, for early-onset hypertensive disorders in pregnancy, were analysed. Women eligible for this study were identified in the local delivery databases. Medical records were used to collect relevant data. Results Between January 2000 and January 2014, 2.456.584 women delivered in The Netherlands, of which 238.448 (9.7%) in a tertiary care centre. A total of 161 pregnancy terminations (11-12 per year) for severe early-onset preeclampsia were identified, including 6 women with a twin pregnancy. Mean gestational age at termination was 172 days (GA 244/7 ) ± 9.4 days. In 70% of cases termination was performed at or shortly after 24 weeks’ gestation. 74.5%% of women developed HELLP syndrome (n = 96), eclampsia (n = 10) or needed admission to an ICU (n = 14). Birth weight was below 500 grams in 64% of cases. In 69% of the cases the estimated foetal weight was within a 10% margin of the actual birth weight. Conclusion Termination of pregnancy for early-onset hypertensive disorders without intervention for foetal indication occurs approximately 12 times per year in The Netherlands. More data are needed to investigate contemporary best practice regarding termination of pregnancy for early-onset hypertensive indications at the limits of foetal viability. Considering the frequency of maternal complications termination of pregnancy and not expectant management should be considered for all women presenting with severe early onset hypertensive disorders at the limits of foetal viability.
Abstract
Background
In cases of life-threatening maternal conditions in the periviable period, professionals may consider immediate delivery with fetal demise as a consequence of the treatment. We ...sought the opinion of involved medical professionals on management, reporting, and auditing in these cases.
Methods
We performed an online survey amongst all registered maternal-fetal medicine (MFM) specialists and neonatologists in the Netherlands. The survey presented two hypothetical cases of severe early-onset pre-eclampsia at periviable gestational ages. Management consisted of immediate termination or expectant management directed towards newborn survival.
Findings
In the case managed by immediate termination, 62% percent answered that fetal demise resulting from induction of labor for maternal indications should be audited only within the medical profession. In the case of expectant management, 17% of the participants agreed with this management. Some answers revealed a significant difference in opinion between the medical specialists.
Conclusion
Perspective of MFM specialists and neonatologists differs with regard to counseling prospect parents in case of severe early onset pre-eclampsia. The majority of professionals is willing to report late termination (after 24 weeks' gestation) for severe maternal disease to medical experts for internal audits but not for legal auditing.
•General anxiety was higher in women with early-onset and late-onset preeclampsia.•Women with early-onset preeclampsia had steeper cortisol increases across pregnancy.•Hair cortisol levels are higher ...in early-onset preeclampsia during second trimester.
This Dutch multicenter case-controlled study investigated whether cortisol concentrations and psychosocial stress during pregnancy differed between women with early-onset preeclampsia, late-onset preeclampsia, and uncomplicated pregnancies. Cortisol concentrations were analyzed in three hair segments representing the preconception period, first, and second trimester of pregnancy. Cortisol trajectories differed, with early-onset preeclampsia showing steeper increases in cortisol and higher cortisol concentrations during the second trimester. Reported anxiety in women with preeclampsia was higher compared to women with uncomplicated pregnancies. These results indicate that measures of cortisol and reported anxiety differ between early-onset, late-onset preeclampsia, and uncomplicated pregnancies.
To save fertility, hysterectomy may be avoided with abnormal placental adherence by leaving the placenta in situ. Several reports support this strategy, but no reports are available on optimal ...follow‐up strategies. We present two women with conservative treatment of placenta accreta and describe the prospective monitoring of the clinical course, placental regression, and recovery of the uterine anatomy using serial sonography, hysteroscopy and magnetic resonance imaging. There was no postpartum hemorrhage. Menstrual cyclicity resumed within 18 weeks. The human chorionic gonadotropin serum levels normalized within 10 weeks, whereas regression of placenta tissue was slow and continued up to nine months after delivery. In both cases placental remnants persisted; in one woman they were removed and uterine anatomy restored. She had a subsequent uneventful pregnancy afterwards. The presented systematic follow‐up provides tools to monitor and treat other women in similar ways.
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