[Less refusal to participate in HIV screening among pregnant women in the Amsterdam region since the introduction of standard HIV screening using the opting-out method]. / Minder weigering van deelname aan HIV-screening door zwangeren in Amsterdam sedert de invoering van de standaard-HIV-screening--tenzij weigering ('opting-out'-methode).

In 2003 the Municipal Health Service in Amsterdam started to screen pregnant women for HIV according to the opting-out method. In this method the HIV test is routinely included in the prenatal screening along with hepatitis B virus (HBV) and syphilis. If the woman does not want to be tested for HIV then she must actively opt out of this test. This screening method was chosen because in the universal screening method used in 2002, women had to give their explicit consent to test for HIV and this led to a high refusal rate (13.6%), especially among women from AIDS-endemic countries. After the introduction of the opting-out method, the refusal rate fell from 3% in the first quarter of 2003 to 1.4% in the last quarter of 2003. None of the women refused to be tested for HBV or syphilis. In 2003, the HIV prevalence among pregnant women was 0.3% (35/13.621). The experiences with this screening method in Amsterdam were used to implement the national opting-out method for HIV screening in pregnant women, which was introduced on 1 January 2004.

[HIV-screening among pregnant women in the region of Amsterdam in 2002]. / HIV-screening onder zwangere vrouwen in de regio Amsterdam in 2002.

In 2001, the Municipal Health Service started offering HIV tests to all pregnant women in and around Amsterdam. All midwives and all hospitals but one participated in this HIV screening. In 2002, of the 10,752 pregnant women offered HIV testing 13.6% refused. HIV antibodies were detected in 24 women (0.26%). The HIV prevalence was doubled compared to the prevalence in 1990-1991, but the number of newly HIV-infected pregnant women remained stable (0.1%). The high number of refusals, as a result of which many HIV-infected women might be missed, is alarming. For this reason, in January 2003, the Municipal Health Service started HIV testing by the opting-out approach. Under the opting-out approach, women are notified that an HIV test will be included in the standard test battery, together with tests for hepatitis B and syphilis, unless she explicitly refuses. It is expected that the opting-out approach for HIV screening of pregnant women will be implemented nationwide in 2003.

[Results of screening for HIV antibodies in pregnant women in Amsterdam reference stations, 1988-1995]. / Resultaten van de screening op HIV-antistoffen bij zwangere vrouwen in de Amsterdamse peilstations, 1988-1995.

In order to determine the prevalence of HIV in the general heterosexual population of Amsterdam, 16,709 pregnant women attending two hospitals and one maternity clinic in the period 1988-1995 were asked to undergo a HIV test, of whom 15,276 gave informed consent (91.4%). Pregnant women with a risk of HIV infection were possibly overrepresented in those who refused. The overall HIV prevalence in 1988-1995 was 0.28% and showed no significant differences over the years. In women with a known risk factor for infection the prevalence was 240:10,000, in those without 5:10,000. Whereas intravenous drug use was the most probable cause of infection before 1993, since then it was observed in only 2/20 of the HIV positive pregnant women. Heterosexual transmission appears to be increasing.

[Cause for referral by family physicians and obstetricians in Amsterdam in (threatened) miscarriage as reflected in the guideline '(Threatened) abortion' of the Dutch Society for Family Physicians]. / Verwijsredenen van huisartsen en verloskundigen in Amsterdam bij (dreigende) miskraam gespiegeld aan de standaard '(Dreigende) miskraam' van het Nederlands Huisartsen Genootschap.

OBJECTIVE: To determine the reasons general practitioners (GPs) and midwives have for referring patients with symptoms of imminent miscarriage to hospital and the management in hospital. DESIGN: Prospective and descriptive. SETTING: Research Centre Primary/Secondary Health Care, University Hospital Free University, the "Onze Lieve Vrouwe Gasthuis' hospital, both in Amsterdam, the Netherlands. METHOD: During the period August 1994-February 1995 anamnesis, diagnostics, diagnosis and further management were recorded for all patients who visited the "Onze Lieve Vrouwe Gasthuis' hospital with blood loss and/or pain in the first 16 weeks of gestation. Patients revealed their wishes concerning referral by filling in questionnaires. Their GPs/midwives were asked about the referral motives in a telephone interview. RESULTS: In the hospital 105 patients were recorded; 34% came on their own initiative. In hospital none of the patients with the diagnosis "imminent miscarriage' was referred back to the GP/midwife. Only 59% of the GPs/midwives performed the physical examinations the (imminent) miscarriage guideline of the Dutch College of General Practitioners advises. In 56% of the 32 patients referred there was no reason for referral according to the (imminent) miscarriage guideline. CONCLUSION: The (imminent) miscarriage guideline issued by the Dutch College of General Practitioners was not always followed because patients went to the hospital on their own account, GPs/midwives did not agree with the guideline, patients wanted another policy and obstetricians kept patients in their own care.

Pyogenic sacro-iliitis, a rare cause of peripartum pelvic pain.

A patient was presented suffering from severe pelvic pain several weeks after delivery. Symptoms pointed in the direction of a peripartum pelvic pain syndrome. One week after admission, the clinical course deteriorated. An infective endocarditis complicated by pyogenic sacro-iliitis was diagnosed.

[Prevalence of HIV antibodies in pregnant women in the Amsterdam HIV reference station research, 1988-1993]. / Prevalentie van HIV-antistoffen bij zwangere vrouwen in het Amsterdamse HIV-peilstationonderzoek, 1988-1993.

Pregnant women were asked to undergo a HIV test in two hospitals, one maternity clinic (n = 12.784; 1988-1993) and one abortion clinic (n = 2089; 1990-1993) in Amsterdam, in order to establish trends in HIV prevalence. Participation rates were 92.4% and 84.4%, respectively. Among pregnant women the overall HIV prevalence was 0.27% (0.04% for pregnant women without a known HIV risk and 2.6% for women with a known HIV risk) and in the abortion clinic the overall HIV prevalence was 0.91%. The HIV prevalence over the years remained fairly constant. In the most recent years a slight rise was noticed in the HIV prevalence in the group pregnant women with a known HIV risk caused by an increase in the number of women from AIDS endemic countries in this group.

The HIV prevalence among pregnant women in the Amsterdam region (1988-1991).

The objective of the study was to monitor the HIV prevalence in the years 1988-1991 among pregnant women in the Amsterdam region, visitors to an abortion clinic and 3 outpatient infertility clinics. All women attending these clinics were asked to participate in the study on a voluntary basis and were tested with informed consent. The women were questioned about risk-bearing behaviour of themselves and their sexual partner(s). In the period 1988-1991, of the 23,827 eligible pregnant women, 22,165 women participated (93.0%). Twenty-seven women were found to be positive for HIV antibodies (0.12%, 95% CI: 0.08%-0.17%), of whom twenty belonged to a known HIV risk group or had a partner who belonged to one of these groups and 7 women had no known HIV risk. Seventeen of the 27 women had a foreign nationality. The annual HIV prevalence among pregnant women was: 1988: 0.28%; 1989: 0.10%; 1990: 0.10%; 1991: 0.11%. In the years 1990 and 1991, of the 1,128 eligible women visiting the abortion clinic 953 (84.5%) were tested. Eleven women were HIV-seropositive (1.15%, 95% CI: 0.6%-2.0%), of whom 9 were from an AIDS endemic region, 1 woman had a partner from this region and 1 woman had no known HIV risk. Four African women had HIV-2 antibodies. At the 3 outpatient infertility clinics 1 woman was found to be HIV-positive (0.13%; 95% CI: 0.02-0.9). She had no other risk than a partner from an AIDS endemic area. In the Amsterdam region there was a steady and low HIV prevalence (0.1%) among pregnant women through the years 1988-1991. The prevalence in the abortion clinic was ten times higher. The program was able to detect possible high risk groups within the population. Migration and travelling can play an important role in the spread of HIV in the general heterosexual population.

Management of eclampsia: cardiopulmonary arrest resulting from magnesium sulfate overdose.

An eclamptic seizure occurring at 32+2 weeks of gestation was treated with magnesium sulfate. Accidentally an overdose was given. As a consequence, the patient had a cardiopulmonary arrest. Immediate resuscitation and calcium gluconate administration did restore vital functions. Pregnancy continued for 4 weeks after the accident. Both mother and child left the hospital in good condition.

Hydatidiform mole with coexisting twin pregnancy after gamete intra-fallopian transfer.

The pregnancy of a 31-year-old infertility patient is described. After gamete intra-Fallopian transfer, her pregnancy evolved uneventfully until the 18th week of gestation, when vaginal bleeding occurred. Ultrasonographic findings suggested a molar pregnancy with two live fetuses. At 24 weeks gestation, two male infants were spontaneously delivered. Fetal (46 XY) and molar (46 XX) karyotypes and post-mortem findings were consistent with a bizygotic twin pregnancy associated with a complete hydatidiform mole. The pathogenesis and obstetrical management are discussed.

The Zavanelli maneuver applied to locked twins.

The Zavanelli maneuver was applied to locked twins. After the first infant was returned into the vagina, an emergency cesarean section was performed. After a not-too-good start, both children did well. The Zavanelli maneuver is presented as a method to reverse the potentially catastrophic situation of locked twins.

Incarceration of the retroverted gravid uterus: a report of four cases.

Four cases of incarceration of the retroverted gravid uterus are described. Typical observations were: a rather low fundal height at vaginal examination, no detectable uterine cervix, and the fetal presenting part deeply impacted in the pelvic cavity. One spontaneous correction in the third trimester is described. In general a cesarean section under general anesthesia is indicated. Preoperative recognition of retroversion is important and may prevent intraoperative complications. Three cases showed micturition problems in the second trimester. All pregnant women with second trimester micturition problems should be examined for a possible retroverted uterus.

[HIV prevalence in pregnant women in and around Amsterdam in 1989]. / HIV-prevalentie bij zwangeren in en rond Amsterdam in 1989.

The HIV prevalence among pregnant women in 3 hospitals in Amsterdam was found to be 0.28% in 1988. As the population of these 3 hospitals is not representative of all pregnant women in Amsterdam, this study--which is done on a voluntary basis--in 1989 was slowly extended to all hospitals, clinics and practices of midwives. Of 5,176 pregnant women who were eligible in 1989, 4,812 (93.0%) participated in the study. Non-Dutch women were overrepresented among the refusers. Antibodies to HIV were found in 5/4, 812 women (0.10%, 95% confidence interval 0.01-0.19) and all 5 infected women reported an AIDS risk factor either for themselves or for their present or previous partner(s). Three of the infected women were only tested during the third trimester; the 2 others were tested in the first trimester of their pregnancy and underwent an abortion. The prevalence in 1989 was lower than that found in 1988 and this may have been influenced by an increased effort to counsel seropositive women--and especially intravenous drug users--on the risk of pregnancy.

Bartholin's abscess: the role of Chlamydia trachomatis.

Seventy-seven patients with a Bartholin's gland duct disorder were treated by incision and marsupialisation. At operation 18% were found to have a cyst and 82% an abscess. N gonorrhoea was isolated from four abscesses and C trachomatis from one. Bacteriological examination of the uterine cervix yielded one further case of N gonorrhoea and four more of C trachomatis. N gonorrhoea and C trachomatis are of limited aetiologic importance as causes of Bartholin's duct abscess. However, bacteriological examination for STD of the abscess and the cervix is mandatory because of adequate antibiotic treatment of the patients and their contacts.

[The prevalence of HIV in pregnant women at 3 outpatient clinics in Amsterdam]. / HIV-prevalentie bij zwangeren in drie poliklinieken in Amsterdam.

Pregnant women who were seen in 3 hospitals in Amsterdam were tested for antibodies to HIV, after informed consent. Out of 2,308 eligible pregnant women, 2,094 (90.7%) participated by name and 21 (0.9%) anonymously; 193 (8.4%) refused to participate. Among refusers there were significantly more women with a non-Dutch nationality or born in other countries. Of 2,115 pregnant women, 6 were found to be HIV-infected (0.28%, 95% confidence interval (0.05-0.51). Among women who at their first prenatal visit reported no AIDS-risk factor either for themselves or their partner(s), the HIV prevalence was 1/1,893 (0.05%) and among women with such risk factor the prevalence was 5/180 (2.78%). Three of the seropositive pregnant women knew before they were tested that they were HIV-infected. Of the 6 HIV-infected women one had a spontaneous abortion and the 4 women who were tested within the period when therapeutic abortion was still possible, decided to continue their pregnancy.

Elsberg syndrome: a neurologic basis for acute urinary retention in patients with genital herpes.

Three patients with genital herpes simplex type II primoinfection and acute urinary retention are described. All patients showed pleocytosis of the cerebrospinal fluid, substantiating central nervous involvement. The association of genital herpes and sacral (myelo-) radiculitis has gained little attention in gynecologic literature, yet it is not an uncommon finding in female patients suffering from herpes. The present report emphasizes the importance of urinary symptoms in genital herpes and reviews the literature on similar cases.

Perinatal mortality in breech presentations as compared to vertex presentations in singleton pregnancies: an analysis based upon 57819 computer-registered pregnancies in The Netherlands.

In 1982, nationwide registration of obstetric data was instituted in The Netherlands with about 70% of all Dutch hospitals participating. The resultant data from 57819 singleton pregnancies in vertex or breech presentation at delivery was studied. The vertex and breech groups were compared. The proportion of breech presentations relative to vertex presentations was greater in low gestational age infants and those of low birthweight. After correction for gestational age and birthweight, the perinatal mortality was higher in the breech groups than in the vertex groups. Congenital malformations occurred more frequently in the breech group but, even after exclusion of infants with congenital malformations, perinatal mortality remained higher in the breech group at any gestational age. Caesarean section was more frequently performed in the breech group than in the vertex group but did not appear to improve the outcome of breech presentation. It is possible that breech presentation is not coincidental but is a consequence of poor fetal quality, in which case medical intervention is unlikely to reduce the perinatal mortality associated with breech presentation to the level associated with vertex presentation.

Threatened preterm labor: the influence of time factors on the incidence of respiratory distress syndrome.

The interval between the first symptoms of threatened preterm labor and delivery was studied and found to be correlated with the incidence of respiratory distress syndrome (RDS), independent of treatment with corticosteroids or betamimetics and the state of the membranes. The incidence and severity of RDS decreased when labor was postponed for a period ranging from 12 hours to three weeks after admission. The decrease was most marked in a steroid-treated group but also occurred in the placebo-treated and untreated groups. The combination of orciprenaline and betamethasone was more effective in postponing delivery in early pregnancies than was the combination of orciprenaline and placebo. Treatment with betamimetics and corticosteroids is therefore indicated in cases of active preterm labor.

Management of premature rupture of membranes: the risk of vaginal examination to the infant.

Presented are the results over a 4-year period of the conservative management of cases of premature rupture of the membranes. Perinatal mortality in infants delivered more than 24 hours after rupture of the membranes is not higher than that in infants delivered within 24 hours of rupture of the membranes, if these results are based on pregnancies of comparable gestational age. Two independent factors influence the risk of infection: the duration of gestation, and the interval between vaginal examination and delivery. If corrections are made for these two factors, there appears to be no clear correlation between the incidence of infection and the period of time the membranes have been ruptured. Conservative management is justified if vaginal examination is avoided until delivery within 24 hours is expected to occur.