Please cite this paper as: Schutte J, Steegers E, Schuitemaker N, Santema J, de Boer K, Pel M, Vermeulen G, Visser W, van Roosmalen J, the Netherlands Maternal Mortality Committee. Rise in maternal ...mortality in the Netherlands. BJOG 2009;117:399–406.
Objective To assess causes, trends and substandard care factors in maternal mortality in the Netherlands.
Design Confidential enquiry into the causes of maternal mortality.
Setting Nationwide in the Netherlands.
Population 2,557,208 live births.
Methods Data analysis of all maternal deaths in the period 1993–2005.
Main outcome measures Maternal mortality.
Results The overall maternal mortality ratio was 12.1 per 100 000 live births, which was a statistically significant rise compared with the maternal mortality ratio of 9.7 in the period 1983–1992 (OR 1.2, 95% CI 1.0–1.5). The most frequent direct causes were (pre‐)eclampsia, thromboembolism, sudden death in pregnancy, sepsis, obstetric haemorrhage and amniotic fluid embolism. The number of indirect deaths also increased, mainly caused by an increase in cardiovascular disorders (OR 2.5, 95% CI 1.4–4.6). Women younger than 20 years and older than 45 years, those with high parity or from nonwestern immigrant populations were at higher risk. Most substandard care was found in women with pre‐eclampsia (91%) and in immigrant populations (62%).
Conclusions Maternal mortality in the Netherlands has increased since 1983–1992. Pre‐eclampsia remains the number one cause. Groups at higher risk for complications during pregnancy should be better identified early in pregnancy or before conception, in order to receive preconception advice and more frequent antenatal visits. There is an urgent need for the better education of women and professionals concerning the danger signs, and for the training of professionals in order to improve maternal health care.
Autoimmune encephalitis (AE) represents a growing number of severe autoimmune-inflammatory diseases affecting both the white and grey matter of the brain. In part 1 of this series, we focused on the ...epidemiology, pathophysiology and clinical presentation of this condition, with two illustrative cases. In this part, we introduce the clinical criteria for AE, particularly for the diagnosis of anti-N-methyl-D-aspartate (NMDA) receptor encephalitis, which were developed to facilitate immune treatment in suspected cases before antibody results are available. We subsequently discuss the work-up, differential diagnosis and treatment options for patients with this disease.
The physical and chemical changes that accompany permafrost thaw directly influence the microbial communities that mediate the decomposition of formerly frozen organic matter, leading to uncertainty ...in permafrost–climate feedbacks. Although changes to microbial metabolism and community structure are documented following thaw, the generality of post‐thaw assembly patterns across permafrost soils of the world remains uncertain, limiting our ability to predict biogeochemistry and microbial community responses to climate change. Based on our review of the Arctic microbiome, permafrost microbiology, and community ecology, we propose that Assembly Theory provides a framework to better understand thaw‐mediated microbiome changes and the implications for community function and climate feedbacks. This framework posits that the prevalence of deterministic or stochastic processes indicates whether the community is well‐suited to thrive in changing environmental conditions. We predict that on a short timescale and following high‐disturbance thaw (e.g., thermokarst), stochasticity dominates post‐thaw microbiome assembly, suggesting that functional predictions will be aided by detailed information about the microbiome. At a longer timescale and lower‐intensity disturbance (e.g., active layer deepening), deterministic processes likely dominate, making environmental parameters sufficient for predicting function. We propose that the contribution of stochastic and deterministic processes to post‐thaw microbiome assembly depends on the characteristics of the thaw disturbance, as well as characteristics of the microbial community, such as the ecological and phylogenetic breadth of functional guilds, their functional redundancy, and biotic interactions. These propagate across space and time, potentially providing a means for predicting the microbial forcing of greenhouse gas feedbacks to global climate change.
Microbial communities are active players in climate feedbacks from permafrost thaw. Ecological assembly shapes post‐thaw microbial community composition through deterministic and stochastic processes. In intact permafrost, communities are shaped by selection for permafrost conditions and dispersal limitation. In early thaw, assembly is dominated by dispersal of new members (yellow and orange arrows) and drift (red x’s). Over time, the cumulative impact of selection by abiotic and biotic post‐thaw conditions increases (depicted by filters), and genetic diversification occurs (shown by changes in organism color). Functional guild composition of newly assembled communities impacts post‐thaw ecosystem processes. Artwork by Victor O. Leshyk.
Terminal restriction fragment length polymorphism (T-RFLP) analysis is a popular high-throughput fingerprinting technique used to monitor changes in the structure and composition of microbial ...communities. This approach is widely used because it offers a compromise between the information gained and labor intensity. In this review, we discuss the progress made in T-RFLP analysis of 16S rRNA genes and functional genes over the last 10 years and evaluate the performance of this technique when used in conjunction with different statistical methods. Web-based tools designed to perform virtual polymerase chain reaction and restriction enzyme digests greatly facilitate the choice of primers and restriction enzymes for T-RFLP analysis. Significant improvements have also been made in the statistical analysis of T-RFLP profiles such as the introduction of objective procedures to distinguish between signal and noise, the alignment of T-RFLP peaks between profiles, and the use of multivariate statistical methods to detect changes in the structure and composition of microbial communities due to spatial and temporal variation or treatment effects. The progress made in T-RFLP analysis of 16S rRNA and genes allows researchers to make methodological and statistical choices appropriate for the hypotheses of their studies.
Abstract Spectropolarimetry is a powerful tool to investigate the central regions of active galactic nuclei (AGNs) as polarization signatures are key to probing magnetic field structure, evolution, ...and the physics of particle acceleration in jets. Optical linear polarization of blazars is typically greater than a few percent, indicating the emission is dominated by nonthermal synchrotron radiation, while polarization less than a few percent is common for other type 1 AGNs. We present a spectropolarimetric study of PKS 0637–75 and PKS 1510–089 to determine how the head-on orientation of a jet and dominant emission processes influence polarimetric variations in the broad lines and continuum. Observations were obtained biweekly from the Robert Stobie Spectrograph on the Southern African Large Telescope. Variability in the continuum polarization is detected for both PKS 0637–75 and PKS 1510–089, with a total average level of 2.5% ± 0.1% and 7.5% ± 0.1%, respectively. There is no clear polarization in the broad Balmer emission lines and weak polarization in Mg ii as the average level across all observations is 0.2% ± 0.1% for H β , 0.2% ± 0.3% for H γ , and 0.6% ± 0.2% for Mg ii . We find that polarization measurements confirm the conclusions drawn from spectral energy distribution modeling of the disk–jet contributions to the emission as optical polarization and time variability for PKS 0637–75 are shown to be dominated by accretion disk emission while those of PKS 1510–089 are due to both disk and jet emission, with greater jet contribution during flaring states.
BACKGROUND We assessed all deaths in the Netherlands that might have been related to IVF or to an IVF pregnancy in order to investigate this most serious complication. METHODS All deaths related to ...IVF, within 1 year after IVF, from 1984 to 2008 were collected by sending a letter to all gynaecologists, and by retrieving data from a large cohort study examining the late effects of ovarian stimulation (OMEGA) and from the Dutch Maternal Mortality Committee. RESULTS Six deaths were directly related to IVF (6/100 000), 17 deaths were directly related to the IVF pregnancy (42.5/100 000) and eight deaths were neither related to the IVF nor to the IVF-related pregnancy. The overall mortality in patients undergoing IVF procedures was lower than in the general population, whereas the overall mortality related to IVF pregnancies was higher than the maternal mortality in the general population. CONCLUSION The decreased mortality is probably the result of a ‘healthy female effect’ in women undergoing IVF. The high maternal mortality in IVF pregnancies is probably related to the high number of multiple pregnancies and to the fact that (donor egg) IVF is successfully used in women who are older. The fact that only a few deaths directly related to IVF are reported in the literature whereas we observed six in the Netherlands indicates worldwide under-reporting of IVF-related mortality. We underline the importance of reporting all lethal cases to the European Society of Human Reproduction and Embryology Committee ‘Safety and Quality after IVF’.
Large individual differences exist in aerobic fitness in childhood and adolescence, but the relative contribution of genetic factors to this variation remains to be established. In a sample of ...adolescent twins and siblings (n = 479), heart rate (HR) and maximal oxygen uptake (V̇o2max) were recorded during the climax of a graded maximal exercise test. In addition, V̇o2max was predicted in two graded submaximal exercise tests on the cycle ergometer and the treadmill, using extrapolation of the HR/V̇o2 curve to the predicted HRmax. Heritability estimates for measured V̇o2max were 60% in ml/min and 55% for V̇o2max in ml·min(-1)·kg(-1). Phenotypic correlations between measured V̇o2max and predicted V̇o2max from either submaximal treadmill or cycle ergometer tests were modest (0.57 < r < 0.70), in part because of the poor agreement between predicted and actual HRmax. The majority of this correlation was explained by genetic factors; therefore, the submaximal exercise tests still led to very comparable estimates of heritability of V̇o2max. To arrive at a robust estimate for the heritability of V̇o2max in children to young adults, a sample size weighted meta-analysis was performed on all extant twin and sibling studies in this age range. Eight studies, including the current study, were meta-analyzed and resulted in a weighted heritability estimate of 59% (ml/min) and 72% (ml·min(-1)·kg(-1)) for V̇o2max. Taken together, the twin-sibling study and meta-analyses showed that from childhood to early adulthood genetic factors determine more than half of the individual differences in V̇o2max.
Please cite this paper as: Dijkman A, Huisman C, Smit M, Schutte J, Zwart J, van Roosmalen J, Oepkes D. Cardiac arrest in pregnancy: increasing use of perimortem caesarean section due to emergency ...skills training? BJOG 2010;117:282–287.
Objective Management of cardiac arrest in pregnancy is recommended to include perimortem caesarean section (PMCS) in the Managing Obstetric Emergencies and Trauma (MOET) course. In this study, we aimed to assess maternal and neonatal outcome of all cases of PMCS in the Netherlands performed in the last 15 years, and to test the hypothesis that PMCS was used more often since the introduction of the MOET‐course in 2004.
Design Retrospective cohort study.
Setting Nationwide assessment of all cases of PMCS inside or outside hospitals.
Population All known cases of PMCS in the Netherlands from 1993 to 2008.
Methods Data collection through contacting all Dutch obstetricians and all MOET and Advanced Trauma Life Support instructors. All cases of cardiac arrest during pregnancy were collected by cross‐checking with data from the Dutch Maternal Mortality Committee and a nationwide severe maternal morbidity study.
Main outcome measures Incidence and case fatality rate of PMCS. Incidence of PMCS before and after introduction of the MOET course. Maternal and neonatal outcome and the process of the PMCS were analysed.
Results During the study period, 55 women had a cardiac arrest, 12 of whom underwent a PMCS. Before the introduction of the MOET course, four PMCSs were performed (0.36/year), compared with eight cases after its introduction (1.6/year, P = 0.01). No PMCS was performed within the recommended 5 minutes after starting resuscitation. Eight of the twelve women (67%) regained cardiac output after PMCS, with two maternal and five neonatal survivors. Maternal case fatality rate was 83%. Neonatal case fatality rate was 58%.
Conclusions Since the introduction of the MOET course, the use of PMCS has increased. Outcome, however, was still poor. An important factor to improve outcome is more timely application of this potentially life‐saving procedure.
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