[Mortality in pregnant and newly delivered women due to psychiatric disorders]. / Sterfte bij zwangeren en kraamvrouwen door psychiatrische stoornissen.

Two women, aged 28 and 37 years, both suffering from a psychiatric disorder i.e. puerperal psychosis and mood-disorder respectively, violently ended their lives at 12 days and 5 months after delivery. Early identification of risk factors in a multidisciplinary setting can lead to effective early management of psychiatric disorders during pregnancy and the puerperium. Negative outcomes such as suicide and even infanticide may consequently be prevented. The most common risk factors for suicide during pregnancy and the puerperium are: a history of psychiatric disorders, a family history of psychiatric disorders and current psychiatric symptomatology. Important recommendations to reduce maternal mortality due to psychiatric disorders include improvement of communication between health professionals and systematic registration of maternal mortality.

[The placing of an unborn child under formal supervision where there is doubt about the safety of the home situation]. / De mogelijkheid van ondertoezichtstelling van het nog ongeboren kind bij twijfels over de veiligheid van de thuissituatie.

Requests to place an unborn child under formal supervision was made in the course of two pregnancies. The first woman was 27 years old, she had a history of schizophrenia, forensic psychiatric care, and a personality disorder with impulsive aggressive behaviour. The second patient was 36 years old. She had a bipolar disorder due to which her firstborn had been placed in foster care. In the first case, formal supervision for the unborn child ensued. In the second case the request was initially denied, but due to the disordered domestic situation was granted ten days after birth. Prior to birth, a relevant risk assessment based on maternal characteristics can be made. In the Netherlands it is possible to place a foetus under formal supervision after 24 weeks gestation. This may prevent hospitalization of a healthy newborn in an unhealthy environment which is poor in stimuli. It also prevents the stressful situation that may arise when parents threaten to take their newborn child from the hospital, pending the inquiry into the domestic situation.

[Psychiatric disorders in pregnant and puerperal women]. / Psychiatrische stoornissen bij zwangeren en kraamvrouwen.

The most frequently occurring pre- and postpartum psychiatric disorders are depression and, to a lesser degree, panic disorder and psychosis. Apart from the negative effects on the psychological well-being of the mother, these psychiatric disorders may also result in obstetric complications and an impaired mother-infant relationship. In order to prevent these negative effects, mothers who are at risk for major psychiatric disorders need to be identified early, preferably before or during pregnancy. The most important risk factor is a history of psychiatric disorders. Obstetric risk factors for depression are unplanned or unwanted pregnancy, pregnancy-related hypertension, emergency caesarean section and early discharge from the hospital. Other factors are low socioeconomic status, recent life event, negative self-image, little social support, immigration in the last 5 years, feelings of loss of control during pregnancy and feeding problems with the child. For treatment, pregnant or puerperal women with a possible psychiatric disorder based on the presence of a serious risk factor, such as a previously experienced psychiatric disorder (related to pregnancy or not), serious current psychiatric symptoms or long-time use of psychoactive drugs, should be referred preferably to a combined psychiatric/obstetric clinic or, if unavailable, to a psychiatrist in a general hospital.

Luteinizing hormone secretion patterns in boys at the onset of puberty measured using a highly sensitive immunoradiometric assay.

Pulsatile LH secretion was studied in 3 prepubertal and 11 early pubertal boys by measuring plasma LH concentrations at 10-min intervals from 1200-1800 h and from 2400-0600 h using an immunoradiometric assay with a lower limit of detection of 0.10 IU/L. Plasma testosterone (T) was measured hourly. In the prepubertal boys plasma LH was not detectable during the daytime but at night 20- to 300-min periods of detectable, but low (less than 0.5 IU/L) plasma LH values occurred. A discrete episodic LH pattern was discernible, and the median number of pulses was 2 during the 6-h nocturnal sampling periods. Plasma T was not detectable (less than 1.0 nmol/L). In the pubertal boys most daytime plasma LH values were greater than 0.3 IU/L, with periods of values of 0.1-0.3 IU/L and short periods of undetectable levels as well. At night definite pulses, up to 4.7 IU/L, were found in all boys. The median number of pulses was 4 during the 6-h nocturnal sampling period. Plasma T was detectable at night in 5 of these 11 boys. The results strongly suggest that at the onset of puberty prepubertal boys (G1) have no LH secretion during the day but intermittent gonadotrophic activity during the night. In early puberty LH secretion increases in amplitude as well as frequency to a clear pulsatile pattern during the night, sometimes with pulses during the day as well.

[Involuntary admission of addict during early pregnancy]. / Wet BOPZ toegepast bij vroege zwangerschap van verslaafde.

A 30-year-old cocaine-dependent woman was 16 weeks pregnant. Because of possible endangerment of the fetus, an involuntary provisional admission was authorized. Of particular interest is the application of the Dutch Act on Formal Admissions to Psychiatric Hospitals for the primary diagnosis 'addiction' and the fact that the fetus was regarded as a legal 'other'. In severe cases of addiction combined with pregnancy an earlier intervention is needed and arrangement of accelerated legal custody of the newborn before birth should be considered. For the protection of the unborn, we advocate a stricter application of the United Nations Convention on the Rights of the Child. Information for addicted women with preconception counselling can help prevent a compulsory admission.

Maternal use of SSRIs, SNRIs and NaSSAs: practical recommendations during pregnancy and lactation.

Selective serotonin reuptake inhibitors (SSRIs) are increasingly used during pregnancy and lactation, with 1.8-2.8% exposed pregnancies. Given the risks of untreated maternal depression for both mother and child, adequate treatment is essential. If pharmacological treatment with SSRIs is indicated, the fetal and neonatal effects of SSRIs have to be considered, as SSRIs cross the placenta and are excreted into breast milk. The overall risk of major congenital malformations during SSRI exposure in the first trimester does not appear to be greatly increased. Depending on the variability in pharmacokinetic properties between the different SSRIs and the individual drug metabolism of mother and child, SSRI exposure during late pregnancy can lead to serotonin reuptake inhibitor-related symptoms in up to 30% of exposed infants postnatally. Symptoms are generally mild and self-limited, but need observation during at least 48 h as some infants develop severe symptoms needing intervention. Limited data are available about the long-term neurodevelopmental outcomes after SSRI exposure during pregnancy and lactation, but currently, cognitive development seems normal, while behavioural abnormalities may be increased. In this article, the available clinical data are reviewed. Additionally, the authors provide a multidisciplinary guideline for the monitoring and management of neonates exposed to SSRIs during pregnancy and lactation.

An audit of single drug (propofol) dental general anaesthesia in children.

AIM: The aim of this study was to evaluate and describe the (dis)advantages of intravenous single drug anaesthesia (IVA) using the target- controlled infusion of propofol in order to validate a protocol. The treatments were performed in two secondary dental care clinics in Amsterdam. METHODS: Retrospective study of the anaesthetic reports and medical history of 950 patients treated were screened for any irregularities and medical problems. RESULTS: Most children treated were in the age group 2-5 years, time needed to wake up decreased significantly with age. Fourteen children dropped out of the planned IVA treatment because of medical reasons, 12 of whom were treated under general anaesthesia (GA). A further 26 were treated under GA because of convenience reasons. Total number of medical problems prior to treatment was 45 and mild complications were 42. CONCLUSIONS: There was a low morbidity in patients treated. The method seems to be successful in young children and creates an increase of treatment capacity in the field of special dental care. Preoperative screening is necessary, on paper and after consultation of a specialist. However blood test screening for allergies seem to be questionable. The treatment method is not possible without the presence of the anaesthesiologist and his team.

Gonadotrophin and growth hormone secretion throughout puberty.

The secretion patterns of gonadotrophin and growth hormone (GH) were investigated in normal healthy children at different stages of pubertal development. The plasma levels of luteinizing hormone (LH) and GH were measured at 10-minute intervals from 12.00 h to 18.00 h and from 24.00 h to 06.00 h using immunoradiometric assays. The levels of follicle-stimulating hormone (FSH) and testosterone were measured hourly. In young prepubertal girls and boys LH was undetectable during the day or night. In children of pubertal chronological age, in whom secondary sexual characteristics had not appeared (stage 1 onset), LH was detectable during the night only. With the progression of puberty there was a gradual increase in the secretion of LH, resulting from increases in both the frequency and amplitude of LH pulses. There was a clear increase in the secretion of FSH during day and night from stage 2 onwards. The secretion of GH also increased with the progression of puberty, due to an increase in pulse amplitude. The increase in GH secretion did not appear to be related to the increase in LH secretion, but rather to changes in the sex steroids.

Luteinizing hormone and follicle stimulating hormone secretion patterns in boys throughout puberty measured using highly sensitive immunoradiometric assays.

Pulsatile gonadotrophin secretion patterns were studied in 32 normal boys (chronological age, CA 7.2-14.6 years) at different stages of pubertal development (5 in stage G1, 11 in G2, 5 in G3, 4 in G4, 7 in G5). Plasma LH and FSH concentrations were measured at 10 min intervals from 1200 to 1800 h and from 2400 to 0600 h using an immunoradiometric assay with a lower limit of detection of 0.15 IU/l for both LH and FSH. Plasma testosterone (T) was measured hourly. In the young prepubertal boys plasma LH was not detectable during day or night. In contrast, plasma FSH ranged from 0.7 to 1.4 IU/l. Plasma T was not detectable either (less than 0.25 nmol/l). In the older prepubertal boys a discrete pulsatile LH pattern (2 per 6 h) became discernible only during the night (range 0.1-0.4 IU/l). Plasma FSH also revealed a pulsatile pattern only during the night (2 per 6 h), while plasma T still remained undetectable. In the early pubertal boys (G2) a median daytime LH value of 0.37 IU/l was determined with 1 pulse per 6 h and at night definite LH pulses (4 per 6 h) were found in all boys (range 0.4-4.7 IU/l). Plasma FSH increased considerably to a median level of 2.50 IU/l during the day; most boys had a pulsatile FSH pattern (one per 6 h). Plasma T became detectable during the day (median 0.54 nmol/l) and night (median 1.16 nmol/l). With the progression of puberty the mean plasma level of LH and FSH, the LH/FSH pulse number and the LH/FSH pulse amplitude increased; plasma T rose as well, more obviously during the night. In G5, however, the LH pulse number decreased, while the LH level and pulse amplitude still increased, presumably as a result of the increased negative feedback action of sex steroids. Simultaneous LH/FSH pulses developed during the night at onset of puberty but during the day only towards the end of pubertal development. The use of these novel highly sensitive IRMA methods demonstrated nocturnal LH and both diurnal and nocturnal FSH pulsatility to be present in older prepubertal boys. The early detectable FSH level plus the existence of solitary FSH pulses throughout puberty as well as in adult men support the hypothesis of the existence of a GnRH-independent FSH secretion in men. Our results are in accordance with the following hypotheses: (1) puberty is brought about by GnRH secretion increasing with time, both in frequency and amplitude, and first appearing during the night.(ABSTRACT TRUNCATED AT 250 WORDS)

Luteinizing hormone and follicle stimulating hormone secretion patterns in girls throughout puberty measured using highly sensitive immunoradiometric assays.

Pulsatile gonadotrophin secretion patterns were studied in 36 healthy girls by measuring every 10 min and applying immunoradiometric assays (IRMA). Different stages of puberty were associated with significant changes in the plasma LH and FSH levels, pulse numbers (Pno) and pulse amplitudes (pA). Plasma LH was not detectable by day or night in young prepubertal girls (B1), neither was plasma oestradiol (E2); however, plasma FSH was detectable in a pulsatile pattern. In the older prepubertal girls (B1-onset) a discrete pulsatile LH pattern became detectable only during the night; plasma FSH tended to rise, while E2 became just detectable. In the early pubertal girls (B2) most daytime LH values were above the detection limit, in some with low-amplitude pulses. At night, pulses with a wide range of pulse amplitudes were detected. Plasma FSH increased further, plasma E2 only slightly. With the progression of puberty the plasma LH and FSH levels, Pno and pA increased significantly from stage B2 to B3 during the day (P less than or equal to 0.05) and close to significance during the night (0.05 less than or equal to P less than or equal to 0.1). However, in stage B4 the secretory characteristics tended to decline, while from stage B3 onwards plasma E2 started to rise rapidly (P less than or equal to 0.05, during the night from stage B2 to B3, during the day from B3 to B4m-). Simultaneous LH and FSH pulses were observed throughout puberty, usually during the night. Using these IRMA methods nocturnal LH in older prepubertal girls and both diurnal and nocturnal FSH pulsatility could be demonstrated in young prepubertal girls. From this study we conclude that (1) puberty in girls, as in boys, may be brought about by an increasing GnRH secretion both in frequency and amplitude, first appearing during the night. This increased GnRH stimulation results in LH secretion only during the night; (2) a cyclical pulsatile LH pattern including an LH surge can be established before the menarche; the capacity for positive feedback activity is not the final maturation characteristic to achieve an ovulatory menstrual cycle.

Growth hormone secretion patterns in relation to LH and estradiol secretion throughout normal female puberty.

Pulsatile growth hormone secretion patterns were studied in relation to luteinizing hormone and estradiol release in 33 healthy (pre)pubertal girls. Plasma GH was determined every 10 min, plasma LH and E2 every hour. Night-time GH release was always higher than daytime GH release. During daytime, all GH secretion parameters, except for the basal GH level, increased significantly from the prepubertal stage to stage B4 before (m-) the menarche (p = 0.05) and decreased thereafter (p = 0.05). During night-time, mean GH level and the fraction of GH in pulses also tended to increase from stage B1 to stage B4m-. The number of high pulses (greater than 8 micrograms/l) during day and night together tended to increase until stage B4m- and decreased after the menarche (p = 0.05). Height velocity did not correlate with the number of high pulses (Kendall tau = 0.14, p = 0.14). From stage B1 to B4m- high correlations were observed between E2 levels and GH secretion parameters, particularly during the day (tau = 0.59-0.71, p less than or equal to 0.01). The correlations between LH levels and GH secretion were high as well (tau = 0.50-0.81, p less than or equal to 0.01), but equal during day and night. It is concluded that during puberty 1. spontaneous GH release in girls increases 2-3 fold until the menarche and decreases thereafter, primarily as the result of an increasing and decreasing GH pulse amplitude; 2. diurnally increasing estradiol levels correlated with increasing GH secretion.

Bioactivity of luteinizing hormone during normal puberty in girls and boys.

In order to evaluate the in vitro bioactivity of LH during normal puberty compared to LH immunoactivity measured in a highly sensitive immunoassay, blood plasma samples from healthy children were analyzed in a mouse Leydig cell assay (MLCA). Blood samples were obtained from 60 healthy girls and boys during normal pubertal development. Samples were taken on two occasions with a 1-year interval. Three daytime samples and three nighttime samples were analyzed. The correlation of the LH immunoradiometric assay (IRMA) activity with the LH activity in the MLCA varied from 0.60 to 0.96 in the different pubertal stages. During pubertal development, a gradually increase in the activity of LH in both the IRMA and MLCA was found. The ratio of the in vitro bioactivity compared to the immunoreactivity (B/I ratio) did not change significantly during puberty: it was 0.84 (SD 0.58) and 0.66 (SD 0.40) during the first and second sampling period in girls and 0.88 (SD 0.38) and 0.91 (SD 0.46, NS) in the boys. The B/I ratio of LH does not change during puberty. With a high sensitivity and specificity, measurement of LH by IRMA gives representative measurements of the LH in vitro bioactivity in children during pubertal development. Copyrightz1999S. KargerAG,Basel

Growth hormone secretion patterns in relation to LH and testosterone secretion throughout normal male puberty.

Pulsatile growth hormone secretion patterns were studied in relation to LH and testosterone release in 30 healthy prepubertal boys and 2 adult men. Plasma GH was measured every 10 min, plasma LH and testosterone every hour. Night-time GH secretion parameters were 2-3 times higher than daytime values. During daytime, mean GH level and the fraction of GH in pulses increased from Tanner stage G2 to G4 (p = 0.01); during night-time these parameters increased as well (p less than or equal to 0.1) and decreased from stage G5 to adulthood (p = 0.05). GH pulse number did not increase; the number of high-amplitude (greater than 8 micrograms/l pulses, however, increased from stage G2 to G4 (p = 0.05) during the day. Height velocity correlated with their number of high pulses during day and night (tau = 0.39, p less than 0.003). From stage G2 to G4 significant correlations were observed between nocturnal testosterone levels and GH secretion parameters (tau = 0.53-0.57), in contrast to nocturnal LH levels. It is concluded that during puberty 1. GH secretion increases as a result of an increased pulse amplitude; 2. there is no consistent correlation between GH and LH levels; 3. increasing nocturnal testosterone levels are correlated with the increasing GH secretion; therefore GnRH does not seem to influence GH secretion directly, but an indirect effect via testosterone is more conceivable, and 4. height velocity is correlated with the number of high GH pulses.