[Infant mortality and births in the 19th and early 20th centuries]. / Zuigelingensterfte en geboorten in de 19e en begin 20e eeuw.

During the 19th century infant mortality was very high in the Netherlands, particularly in the provinces of South Holland and Zeeland (up to 300 per 1000 live births and more), and also in parts of North Brabant and Limburg. In the northern provinces (Drenthe, Groningen and Friesland) mortality was lower. Where breast-feeding was infrequently given (in rural areas of South Holland, Zeeland and from the 1850s also in North Brabant), infant mortality was relatively high. In the northern provinces many mothers breast-fed their infants. The fertility rate of married women was high, especially in those parts of the country where breast-feeding was infrequent. From 1875-1880 fertility rate and infant mortality decreased: the so-called demographic transition. Improved social conditions and employment opportunities played an important role in this as did the vertical social mobility: limitation of the size of families gave children opportunities to climb the social ladder.

[Induced abortion in The Netherlands in the twentieth century; from taboo to revolutionary change]. / Abortus provocatus in Nederland in de 20e eeuw: van stilzwijgen naar revolutionaire verandering.

Between 1890 and 1945 the number of induced (criminal) abortions increased in Amsterdam; from 1945 up until the 1960s the number decreased slightly. In 1965 the number of induced abortions that took place in Amsterdam was estimated at more than 2000. Complications were frequent and included infections, septicaemia, damage caused by injected soap and sometimes air embolism. Women in Amsterdam often used primitive methods of contraception, but effective methods, such as condoms and diaphragms, were also used to some degree. Oral contraception was introduced in The Netherlands in 1962. Its use increased rapidly and consequently many doctors were confronted with problems surrounding contraception, including failures and abortion requests. After a television programme on abortion in 1967, requests for abortion surged. Hospitals set up multidisciplinary abortion committees to assess the requests, but soon it became evident that the women themselves were better able to judge whether they should undergo the procedure. Abortion clinics were established outside hospitals. Support from the feminist movement played a role after changes were already underway. The nationwide number of abortions increased to 21,000 in 1972 and to about 25,000 in the 1990s. The number remained stable, even among teenagers, because caregivers placed a great deal of emphasis on adequate contraception.

Psychological development of children who were treated antenatally with corticosteroids to prevent respiratory distress syndrome.

Potential side effects of antenatal administration of corticosteroids to prevent neonatal respiratory distress syndrome were studied in 10- to 12-year-old children whose mothers had participated in a randomized, double-blind, placebo-controlled trial of betamethasone. Aspects of the children's intellectual and motor development, school achievement, and social-emotional functioning were investigated. There were no differences between the corticoid group and the placebo group on these variables, nor were there more children with learning difficulties and behavioral disturbances in either of the groups.

Physical development and medical history of children who were treated antenatally with corticosteroids to prevent respiratory distress syndrome: a 10- to 12-year follow-up.

Potential side effects of antenatal administration of corticosteroids to prevent neonatal respiratory distress syndrome were studied in 10- to 12-year-old children whose mothers had participated in a randomized, double-blind, placebo-controlled trial of betamethasone. The children had a general physical examination; parents were interviewed about the medical history of their child with special attention to infectious diseases; growth data were collected; and a developmental neurological examination, an ophthalmological examination, and a lung function test were conducted. In the corticosteroid group significantly more hospital admissions because of infectious diseases during the first years of life were reported. On the other variables no differences between the corticoid and the placebo groups were found.

Basal lamina thickening in the placentae of smoking mothers.

The thickness of the basal lamina in the placentae of 20 matched pairs of smoking and non-smoking mothers was measured using an electron microscopic method of quantification. A significant increase of the thickness of the trophoblastic basal lamina was found in the smokers' placentae: 181 nm (s.d. +/- 38.2 nm) in non-smokers versus 286 nm (s.d. +/- 69.9 nm) in smokers (P less than 0.005). A significant increase of the thickness of the capillary basal lamina was also found: 75 nm (s.d. +/- 12.1 nm) in non-smokers versus 111 nm (s.d. +/- 16.0 nm) in smokers (P less than 0.005). The number of duplications around the capillary basal lamina was found to be increased in the placentae of smoking women.

Structural changes in the placenta of smoking mothers: a quantitative study.

Placentae of matched pairs of smoking and non-smoking mothers have been investigated by quantitative light microscopic techniques. A smaller diameter of the villous capillaries, a decrease in vasculosyncytial membranes and basement membrane thickening were observed in the placenta of smoking mothers. Quantitative morphometric methods showed a significant decrease in volume density of the fetal vessels in the terminal villi of the smoker's placenta. The exchange area of the smoker's placenta was shown to be decreased. The pathophysiological mechanisms leading to these changes and the possible role of toxic agents (i.e., cadmium) are discussed.

Risk factors for preeclampsia in nulliparous women in distinct ethnic groups: a prospective cohort study.

OBJECTIVE: To determine whether baseline characteristics during early pregnancy, proposed as potential risk factors for preeclampsia, show differences in prevalence and effects within distinct ethnic groups. METHODS: In a prospective cohort study of 2413 healthy nulliparous women from eight midwives' practices, we analyzed risk factors for preeclampsia (maternal age, body mass index, blood pressure at booking, smoking habit, and abortion history) in white, Mediterranean, Asian, and black women. In a univariate analysis, we estimated the relative risk of preeclampsia for the baseline variables and for ethnicity. In a multivariate analysis, we evaluated the simultaneous effect of the baseline variables in white (n = 1641) and black (n = 317) women. RESULTS: Significant differences were found in the prevalence of the risk factors in different ethnic groups. In the univariate analysis, the relative risk (RR) of preeclampsia in black women was 2.4 (95% confidence interval [CI] 1.1, 5.6) compared with white women. In the multivariate analysis in white women, the adjusted RR of preeclampsia for a diastolic blood pressure at booking above 70 mmHg was 4.4 (CI 0.9, 20.8). Among black women, the adjusted RR of preeclampsia was increased for high maternal age (RR 1.2; CI 1.0, 1.4), but not for a diastolic blood pressure at booking above 70 mmHg (RR 0.8; CI 0.2, 3.9). CONCLUSION: In studies of risk factors for preeclampsia, black women should be analyzed separately from white women.

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.

Effects of antenatal corticosteroid administration on mortality and long-term morbidity in early preterm, growth-restricted infants.

OBJECTIVE: To evaluate the effect of antenatal corticosteroids on mortality, morbidity, and disability or handicap rate in early preterm, growth-restricted infants. METHODS: This case-control study in two tertiary care centers included all live-born singleton infants with growth-restriction due to placental insufficiency, who were delivered by cesarean because of cardiotocographic signs of fetal distress before the beginning of labor at a gestational age of 26-32 weeks during the years 1984-1991. Infants who had been treated antenatally with corticosteroids more than 24 hours and less than 7 days before birth were matched by birth weight, sex, and year of birth with infants whose mothers had been admitted more than 24 hours before delivery but were not treated antenatally with steroids. The main outcome measure was survival without disability or handicap at 2 years corrected age. A sample of 60 case-control pairs would give 81% power to demonstrate 50% increase of this outcome [odds ratio (OR) 3.0] by corticosteroid treatment. Behavior and physical growth were evaluated at school age by questionnaire. RESULTS: The study group and control group consisted of 62 infants each. Survival without disability or handicap at 2 years' corrected age was more frequent in the corticosteroid group [OR 3.2, confidence interval (CI) 1.1, 11.2]. In the long-term follow-up at school age there was a statistically significant negative effect on physical growth (OR 5.1, CI 1.4, 23.8), but no differences in behavior were detected. CONCLUSION: Benefits from antenatal corticosteroids for early preterm, growth-restricted infants appear to outweigh possible adverse effects.

Antithrombin III in normal pregnancy.

Plasma antithrombin III (AT III) was determined in 94 women during and after normal pregnancy employing an automated amidolytic technique. The patients were selected on the following criteria: no toxaemia, spontaneous delivery at term, birth-weight above the 10th percentile and discharged with a healthy baby. AT III levels during pregnancy and early puerperium were not lower than own control values obtained 6-8 weeks after delivery.

Predictors of foetal and neonatal mortality in Curaçao, Netherlands Antilles. A multivariate analysis.

In Curaçao a systematic and comprehensive investigation of numerous factors, potentially associated with an increased risk of foetal and neonatal mortality, was carried out in a 2-year period (1984-85). The inquiry was restricted to singleton births. Data on 205 women who experienced pregnancy loss were compared with those on 913 women who did not sustain foetal or neonatal loss. Data comprised information on maternal characteristics, clinical course of pregnancy and delivery, and neonatal characteristics. Of 130 factors measured, 14 were entered into a multivariate analysis. From the analysis 5 risk factors emerged as significant predictors of mortality: gestational age, birth weight, sex, foetal presentation and congenital anomalies. Factors such as social class, marital status, maternal age and parity were not associated with an increased risk of foetal and neonatal mortality in Curaçao.

Influence of obstetric management on outcome of extremely preterm growth retarded infants.

AIM: To describe the long term outcome of extremely preterm growth retarded infants in relation to obstetric management and various perinatal events. METHODS: A cohort study was undertaken in two tertiary care centres with different obstetric management. All infants with fetal growth retardation due to placental insufficiency and resulting in fetal distress at 26 to 32 weeks of gestation, were included for the years 1984-89. Main outcome measures were impairment, disability, or handicap at 2 years corrected age and at school age (4 1/2 to 10 1/2 years). RESULTS: One hundred and twenty five (98%) were followed up until 2 years corrected age in the outpatient department; 114 (90%) were assessed at school age. Impairments were found in 37% and disabilities or handicaps in 9% of the assessed infants, with no difference between centres. All disabled or handicapped children had already been identified by 2 years corrected age. CONCLUSIONS: Disability or handicap were related to neonatal complications (intracerebral haemorrhage or bronchopulmonary dysplasia) and not to obstetric variables, thus making antenatal prediction impossible. The incidence of disability or handicap in these growth retarded infants was comparable with that of other preterm infants.

A critical analysis of 75 therapeutic abortions.

An analysis is presented of the first 75 therapeutic abortions based on the results of laboratory investigations on midtrimester amniotic samples from 2816 pregnancies. The reasons for the abortions were: chromosome aberration (n = 36), male fetus at risk for X-linked disorder (n = 23), neural tube defect (n = 14), and metabolic disorders (n = 2). An estimation was made of the life expectancy of these 75 fetuses if no termination of pregnancy had taken place. We estimate that a maximum of about 40% of the aborted fetuses would have resulted in malformed children at the age of 1 year, or in boys developing serious disabilities during infancy. Financial (cost-benefit analysis) and psychologic aspects are discussed.

Maternal outcome following temporizing management of the (H)ELLP syndrome.

OBJECTIVE: The aim of the study was to describe the clinical progress and maternal outcome of the (H)ELLP syndrome following temporizing management. METHODS: All women (n = 127) admitted in the Academic Medical Center in Amsterdam between 1984 and 1996 with (H)ELLP syndrome and a live fetus in utero were included. The patients were treated by temporizing management, including the use of antihypertensives and magnesium sulfate. The predominant indication for terminating pregnancy was fetal distress or fetal death, and not maternal condition. MAIN OUTCOME MEASURES: Maternal mortality and morbidity. RESULTS: All serious maternal complications occurred at the onset of the syndrome. Two mothers with HELLP syndrome died following a cerebral hemorrhage. The remaining patients recovered completely. Serious maternal morbidity occurred more often in cases of HELLP than in cases of ELLP syndrome. Seventy-nine (62%) women were not delivered after 3 days and 65 (51%) after 7 days. CONCLUSIONS: Severe complications only occurred at the onset of (H)ELLP syndrome. It is unlikely that a more aggressive approach would have reduced maternal mortality or morbidity.

Long-term follow-up in patients with a history of (H)ELLP syndrome.

OBJECTIVE: To provide long-term follow-up data on women with a history of hemolysis, elevated liver enzymes, and low platelets [(H)ELLP] syndrome regarding the risk of recurrence in subsequent pregnancies and disease in later life. METHODS: All women admitted to the Academic Medical Centre between January 1984 and January 1996 with (H)ELLP syndrome and a living singleton fetus in utero were included. Women with known preexisting diseases were excluded. The (H)ELLP syndrome was defined as elevated liver enzymes (serum aspartate aminotransferase or serum alanine aminotransferase >or= 50 U/L) and low platelet count (< 100 x 10(9)/L). Those patients with hemolysis (LDH >or= 600 U/L) were classified as HELLP, the remaining ones were classified as ELLP. The participants were asked to fill out a questionnaire regarding their general health and their own obstetric and medical history and that of their first-and second-degree relatives. RESULTS: One hundred sixteen (94%) of 123 women responded; 4 women had died. The median age of the group was 36.0 years at completion of the questionnaire; the median interval after the index pregnancy was 5.7 years (3-12.9). The incidence of hypertension requiring medical treatment was three times higher than in a reference population of Dutch women between 20 and 40 years old. The need for psychological support was frequent. Thirty-nine patients (34%) refrained from further pregnancies. Twenty-nine percent of the first subsequent pregnancies were complicated by gestational hypertension (GH), but only 2% had (H)ELLP syndrome. Birth weight was, on average, 1385 g higher and gestational age at delivery 5 weeks later in the first subsequent pregnancy irrespective of a recurrence of GH. A family history of cardiovascular disease or preeclampsia was common in the total group; however, this did not influence the recurrence rate. Multiparity, gestational age at delivery <30 weeks, and birth weight <1000 g in the index pregnancy increased the risk of recurrence of GH in the first subsequent pregnancy significantly. CONCLUSIONS: (H)ELLP syndrome is a severe complication of pregnancy that has not only short-term but also long-term sequelae.

The Wormerveer study; perinatal mortality and non-optimal management in a practice of independent midwives.

In a prospective study in a group of 7980 pregnant women who booked in an independent midwife practice perinatal mortality was studied with the aim to assess non-optimal management. An internally generated audit proved not to be successful because of emotional involvement. A panel of independent experts seemed to be a better instrument to assess the quality of care. In 66 (75%) of all 89 cases complete consensus or near consensus was reached. In this group preventable factors were noticed in 29 cases (44%). In 30 cases (45%) the mortality was judged as inevitable. In 7 cases the information was insufficient. In the 29 cases with preventable factors, 12 cases concerned the skill of the obstetrician, seven cases the skill of the pediatrician, seven cases the skill of the midwife. In two cases the behaviour of the patient and in one case the skill of the general practitioner were blamed. Preventable factors are mainly present in decisions made during the prenatal period by the midwife (or general practitioner) and the obstetrician, and in care during labour and delivery and the postnatal period by the obstetrician and pediatrician. The care of the midwife during labour and delivery had little influence on preventable perinatal mortality. A further decrease of perinatal mortality may be achieved by analysis of the cases and continued education of all workers in perinatal care.

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.

Clinical bedrest in twin pregnancies.

A retrospective study was made of 148 sets of twins born at the Wilhelmina Gasthuis between 1969 and 1979. From 1969 to 1974, clinical bedrest was prescribed on indication only. From 1975 to 1979, prophylactic clinical bedrest was advocated. The duration of the period of bedrest was longer in the second period than in the first: the mean for primiparae was 3 wk, and for multiparae 2 wk. Both periods were compared with respect to gestational age, birthweight, placental weight and survival. No effect of longer clinical bedrest on gestational age was found. In primiparae, a small significant increase of both birthweight and placental weight was found, possibly related to clinical bedrest. The improvement of survival observed could not be ascribed to bedrest. Obviously, clinical bedrest may, to a limited extent, improve conditions for intrauterine growth in twins. However, because of emotional and economic damage, clinical bedrest in twin pregnancies should be advocated on a more individualized basis.

Estrogen excretion by a pregnant woman with an ileostoma.

The low values of urinary estrogen excretion in a woman who was finally delivered of a well-developed child with a normal weight could be explained by the loss of estrogens via an ileostoma. The patient had undergone a total colectomy some years before because of colitis ulcerosa. Our observations give information about the extent and localization of the enterohepatic circulation of estrogens.

Place of delivery in The Netherlands: actual location of confinement.

Preferred and actual locations of confinement were compared in a group of 170 nulliparous women. Voluntary changes in preferred location for birth were rare and concerned only changes from hospital to home confinement. Obligatory changes due to referral to consultant obstetricians occurred frequently: 58.8% of the total sample. Fewer referrals were found for women with an initial preference for a home confinement (53%) than for those who preferred a hospital confinement (64%). Most referrals occurred in the group of older women initially in doubt about their preferred location for giving birth: 72%. The differences were not significant, however. To reveal differences between referrals and non-referrals, discriminant analysis was performed at the 18th week of gestation. The explained variance for the total group of referrals was 64.7%. Partially, the variables pertaining to the explained variance were the same as those related to a preferred hospital confinement. The explained variance for the group of referrals in which psychosocial influences were presupposed was not better, with the exception of referrals due to insufficient progress during labour: 76.4% of the variance could be explained at the 34th gestational week. When birth weight and amenorrhoea were included, these percentages increased to 79.0 and 84.8%, respectively.