[Skin-to-skin caesarean section: better patient care]. / De huid-op-huidsectio: betere patiëntenzorg.

Five years ago, we described the skin-to-skin caesarean section, a procedure in which parental participation, slow delivery and direct skin-to-skin contact are important aspects. By multiple research, the skin-to-skin CS has been shown to have positive outcomes for the child and parents, as long as there is attention for neonatal thermal regulation. These outcomes should lead to cost reduction, versus the extra personnel costs for the nurse. However, a proper cost-effectiveness analysis has not yet been described. There are still many local differences in availability and performance of the skin-to-skin CS in the Netherlands, often caused by logistical challenges. In the meanwhile the protocol has been further optimized. In our opinion, the skin-to-skin caesarean section is better care for parents and their child, and should be available anywhere anytime, as long as the fetal and maternal condition permits this.

Nationwide registry-based ecological analysis of Q fever incidence and pregnancy outcome during an outbreak in the Netherlands.

OBJECTIVE: Whether areas affected by Q fever during a large outbreak (2008-2010) had higher rates of adverse pregnancy outcomes than areas not affected by Q fever. DESIGN: Nationwide registry-based ecological study. SETTING: Pregnant women in areas affected and not affected by Q fever in the Netherlands, 2003-2004 and 2008-2010. PARTICIPANTS: Index group (N=58,737): pregnant women in 307 areas with more than two Q fever notifications. Reference group (N=310,635): pregnant women in 921 areas without Q fever notifications. As a baseline, pregnant women in index and reference areas in the years 2003-2004 were also included in the reference group to estimate the effect of Q fever in 2008-2010, and not the already existing differences before the outbreak. MAIN OUTCOME MEASURES: Preterm delivery, small for gestational age, perinatal mortality. RESULTS: In 2008-2010, there was no association between residing in a Q fever-affected area and both preterm delivery (adjusted OR 1.01 (95% CI 0.94 to 1.08)), and perinatal mortality (adjusted OR 0.87 (95% CI 0.72 to 1.05)). In contrast, we found a weak significant association between residing in a Q fever-affected area in 2008-2010 and small for gestational age (adjusted OR 1.06 (95% CI 1.01 to 1.12)), with a population-attributable fraction of 0.70% (95% CI 0.07% to 1.34%). We observed no dose-response relation for this outcome with increasing Q fever notifications, and we did not find a stronger association for women who were in their first trimester of pregnancy during the months of high human Q fever incidence. CONCLUSIONS: This study found a weak association between residing in a Q fever-affected area and the pregnancy outcome small for gestational age. Early detection of infection would require mass screening of pregnant women; this does not seem to be justified considering these results, and the uncertainties about its efficacy and the adverse effects of antibiotic treatment.

Prevalence and predictors of over-the-counter medication use among pregnant women: a cross-sectional study in the Netherlands.

BACKGROUND: Over-the-counter-medication (OTC-medication) use during pregnancy can be potentially harmful for the fetus. To successfully counsel the patient it is important to know if the patient is at risk. In this study possible predictors for OTC-medication use were identified and a model was designed to predict OTC-medication use during pregnancy. METHODS: We performed a post-hoc analysis on data collected for a clustered clinical trial to study a screening strategy for Query fever. Pregnant women under supervision of a midwife were eligible for inclusion. These women filled out questionnaires during their pregnancy and post-partum. These questionnaires were used to determine the prevalence and to select possible predictors for OTC-medication use. These predictors were included in a prediction model using multivariate analysis. The discrimination and calibration of the model were assessed with Receiver Operating Characteristic analysis and the Hosmer and Lemeshow test. RESULTS: Of the 1348 women enrolling in the clustered clinical trial, we included 1246 women in this analysis. The prevalence of OTC-medication use was 12.5%. The predictors for OTC-medication use in our cohort were: nulliparity, use of prescription medication, the presence of a comorbidity, Body Mass Index between 26 and 30 kg/m2 and General Practitioner visits. These predictors were used to design a prediction model for OTC-medication use. The area under the Receiver Operating Characteristic-curve of the prediction model was 0.667 (95% CI 0.620-0.714 P<0.001) and the predictive probabilities ranged from 6.6% to 57.4%. The Hosmer and Lemeshow goodness-of-fit test indicated good calibration of the model (P = 0.640). CONCLUSION: It is possible to indicate women at risk for OTC-medication use during pregnancy, using five maternal characteristics that independently contribute to the prediction model. The predictors are easy to estimate and the model is easy to implement in daily practice.

Risks, trust and knowledge: determinants of pregnant women's decisions regarding participation in a future Q fever screening and treatment program during a large epidemic in The Netherlands.

OBJECTIVE: Contracting Q fever during pregnancy carries a risk of developing obstetric complications. The aim of this study was to gain insight into pregnant women's decisions regarding participation in a future Q fever screening and treatment program. METHODS: Pregnant women (N = 148) in Q fever high-risk areas in The Netherlands were recruited via midwives' practices and via an online panel for a cross-sectional questionnaire survey. The outcome measures included intention to participate in the program, Q fever exposure risk, perceived Q fever risk, trust in health professionals and authorities, disease-related knowledge and additional outcome measures. RESULTS: Fifty-six percent of the respondents intended to participate in the screening and treatment program. The sole determinant of a higher intended program uptake was a more positive appraisal of program efficacy and convenience. This appraisal was in turn associated with perceived risk and knowledge. CONCLUSION: Women's appraisal of program efficacy and convenience, their disease-related knowledge and perceived Q fever risk seem to be crucial for their intended program uptake. A successful implementation of a Q fever screening and treatment program may thus depend on the benefits and downsides of the program, and on securing that women are aware of the risks of the disease.

[Chronic Q fever during pregnancy]. / Chronische Q-koorts tijdens de zwangerschap.

A 42-year-old woman visited the pulmonologist for follow-up after a pneumonia. In retrospect the pneumonia appeared to be a manifestation of an acute Q fever infection. A few weeks later the patient was found to be unexpectedly pregnant. At the normal serological follow-up six months after the primary infection chronic Q fever infection was diagnosed. Doxycycline and hydroxychloroquine are contraindicated in pregnancy and the patient was found to be allergic to co-trimoxazole. Therefore treatment with erythromycin was chosen on empirical grounds. The patient had many symptoms during pregnancy. After 38 weeks and 2 days amenorrhea labour was induced on maternal indication. Finally a healthy boy of 3850 grams was born by caesarean section. In view of the increased risk of chronic Q fever infection during pregnancy we advise intensified serological monitoring of patients with acute Q fever who subsequently become pregnant.

Cost-effectiveness of a screening strategy for Q fever among pregnant women in risk areas: a clustered randomized controlled trial.

BACKGROUND: In The Netherlands the largest human Q fever outbreak ever reported in the literature is currently ongoing with more than 2300 notified cases in 2009. Pregnant women are particularly at risk as Q fever during pregnancy may cause maternal and obstetric complications. Since the majority of infected pregnant women are asymptomatic, a screening strategy might be of great value to reduce Q fever related complications. We designed a trial to assess the (cost-)effectiveness of a screening program for Q fever in pregnant women living in risks areas in The Netherlands. METHODS/DESIGN: We will conduct a clustered randomized controlled trial in which primary care midwife centres in Q fever risk areas are randomized to recruit pregnant women for either the control group or the intervention group. In both groups a blood sample is taken around 20 weeks postmenstrual age. In the intervention group, this sample is immediately analyzed by indirect immunofluorescence assay for detection of IgG and IgM antibodies using a sensitive cut-off level of 1:32. In case of an active Q fever infection, antibiotic treatment is recommended and serological follow up is performed. In the control group, serum is frozen for analysis after delivery. The primary endpoint is a maternal (chronic Q fever or reactivation) or obstetric complication (low birth weight, preterm delivery or fetal death) in Q fever positive women. Secondary aims pertain to the course of infection in pregnant women, diagnostic accuracy of laboratory tests used for screening, histo-pathological abnormalities of the placenta of Q fever positive women, side effects of therapy, and costs. The analysis will be according to the intention-to-screen principle, and cost-effectiveness analysis will be performed by comparing the direct and indirect costs between the intervention and control group. DISCUSSION: With this study we aim to provide insight into the balance of risks of undetected and detected Q fever during pregnancy. TRIAL REGISTRATION: ClinicalTrials.gov, protocol record NL30340.042.09.

Association between donor MBL promoter haplotype and graft survival and the development of BOS after lung transplantation.

BACKGROUND: Lung transplantation is a well accepted therapy for end-stage lung disease, despite high mortality rates. Mortality after transplantation is mainly caused by allograft failure in the first years after transplantation. Mannose binding lectin (MBL), a recognition molecule of innate immunity, has been associated with transplant outcome in other solid organ transplantation. In this study, the effect of donor- and recipient-MBL genotype on lung transplant outcome was investigated. MATERIALS AND METHODS: All lung transplantations performed in our center, except from retransplantations and combined lung-liver or heart-lung transplantations, were included. Genotyping of the MBL2 variants (promoter: L/H, Y/X, and P/Q allele and exon 1: A/D, A/B, and A/C allele) was performed in donor and recipient DNA. Analyses on graft survival and the development of bronchiolitis obliterans syndrome were performed with Kaplan-Meier (log rank) survival analysis. RESULTS: Of the 277 included cases, DNA was available from 189 donors and 200 recipients and genotyping of the promoter single nucleotide polymorphisms was successful in 184 donors and 198 recipients and of the exon 1 single nucleotide polymorphisms in 181 donors and 193 recipients. Patients who received a graft from a donor with an X-allele had better graft survival (P=0.007) and bronchiolitis obliterans syndrome free survival (P=0.007). Recipient MBL genotype was not associated with transplant outcome. CONCLUSION: The donor X-allele, which corresponds to the LXPA haplotype is associated with superior lung transplant outcome. Our findings might prove to be important in finding ways to optimize outcome after lung transplantation.