The presence of brain white matter lesions in relation to preeclampsia and migraine.

INTRODUCTION: Identifying female-specific risk markers for cerebrovascular disease is becoming increasingly important. Both migraine and preeclampsia have been associated with higher incidence of brain white matter lesions (WML) and stroke. We assessed the association between WML and migraine among formerly (pre)eclamptic women. METHODS: A total of 118 women (76 formerly (pre)eclamptic and 42 control women) were screened for migraine and WML presence. Independent effects of migraine and (pre)eclampsia on WML were assessed. RESULTS: Migraine prevalence did not differ between the (pre)eclamptic (26/76; 34%); and control group (10/42; 24%), p = 0.17. Age-adjusted regression analysis failed to show a significant independent effect of migraine (OR 1.14; 95% CI 0.47-2.76; p = 0.77) on WML presence, and showed a non-significant effect of (pre)eclampsia (OR 2.30; 95% CI 0.90-5.83; p = 0.08). CONCLUSION: Migraine prevalence was not found to be an independent risk factor for WML prevalence in formerly (pre)eclamptic women. Since this study had a small sample size, larger prospective studies are needed to examine female-specific risk factors for WML and its consequences.

Impact of appendicitis during pregnancy: no delay in accurate diagnosis and treatment.

BACKGROUND: Acute appendicitis during pregnancy may be associated with serious maternal and/or fetal complications. To date, the optimal clinical approach to the management of pregnant women suspected of having acute appendicitis is subject to debate. The purpose of this retrospective study was to provide recommendations for prospective clinical management of pregnant patients with suspected appendicitis. METHOD: Case records of all pregnant patients suspected of having appendicitis whom underwent appendectomy at our hospital between 1990 and 2010 were reviewed. RESULTS: Appendicitis was histologically verified in fifteen of twenty-one pregnant women, of whom six were diagnosed with perforated appendicitis. Maternal morbidity was seen in two cases. Premature delivery occurred in two out of six cases with perforated appendicitis cases and two out of six cases following a negative appendectomy. Perinatal mortality did not occur. CONCLUSION: Both (perforated) appendicitis and negative appendectomy during pregnancy are associated with a high risk of premature delivery. Clinical presentation and imaging remains vital in deciding whether surgical intervention is indicated. We recommend to cautiously weigh the risks of delay until correct diagnosis with associated increased risk of appendiceal perforation and the risk of unnecessary surgical intervention. Based upon current literature, we recommend clinicians to consider an MRI following an inconclusive or negative abdominal ultrasound aiming to improve diagnostic accuracy to reduce the rate of negative appendectomies. Accurate and prompt diagnosis of acute appendicitis should be strived for to avoid unnecessary exploration and to aim for timely surgical intervention in pregnant women suspected of having appendicitis.

Termination of pregnancy for maternal indications at the limits of fetal viability: a retrospective cohort study in the Dutch tertiary care centres.

OBJECTIVE: Maternal morbidity, either pregnancy related or pre-existent, can become life threatening and of such severity as to warrant termination of pregnancy (TOP). In this situation, chances of fetal survival are usually poor, either because of low gestational age and/or because of the fetal effects of the maternal condition. Examples include severe growth restriction in pre-eclampsia and intrauterine infection due to the very early preterm prelabour rupture of membranes. There are very few reports on the prevalence of TOP for maternal indication at the limits of fetal viability. We investigated the prevalence of and indications for TOP on maternal indication in the 10 tertiary care centres in the Netherlands during the past decade. STUDY DESIGN: We conducted a retrospective review of the medical records of all women who underwent TOP for maternal indications between 22 and 27 completed weeks of gestation in all 10 tertiary care centres from 2000 to 2009. RESULTS: During the study period, there were 1 929 470 deliveries; 163 052 (8.4%) of these took place in one of the 10 tertiary care centres and 177 pregnancies were terminated for severe maternal disease, 131 for hypertensive disorders, 29 for intrauterine infection and 17 for other reasons. The mean gestational age at TOP was 171 days (24(3/7))±10 days. No maternal deaths were recorded. The overall perinatal mortality was 99.4%. CONCLUSIONS: Over a 10-year period, TOP for maternal indications was performed in 1 in 1000 deliveries in the 10 Dutch tertiary care centres. Hypertensive disorders comprised three-quarters of the cases.

The brain study: Cognition, quality of life and social functioning following preeclampsia; An observational study.

OBJECTIVES: Previously preeclamptic women may express cognitive difficulties, which have largely been unappreciated or attributed to stresses of a complicated pregnancy. This study aimed to explore the scope of perceived neurocognitive and psychosocial problems as well as quality of life following preeclampsia. STUDY DESIGN: Observational study. Through website promotion and e-mail, registrants of the USA-based Preeclampsia Foundation who experienced preeclampsia in the past 20years were invited to complete a web-based survey. Participants were requested to ask an acquaintance that had a normotensive pregnancy to also complete the survey (controls). MAIN OUTCOME MEASURES: The Cognitive Failures Questionnaire (CFQ), abbreviated WHO Quality Of Life questionnaire (WHOQOL-BREF), Social Functioning Questionnaire (SFQ) and Breslau Short Screening Scale for DSM-IV Posttraumatic Stress Disorder were used in the survey. Analysis was performed using Mann-Whitney U tests and linear regression. RESULTS: 966 cases and 342 controls completed the survey (median age 34, median time since first pregnancy 4 vs. 5years). Cases scored significantly worse on CFQ (median 35 vs. 27), WHOQOL-BREF domains physical health (15 vs. 17), psychological (13 vs. 15), social relationships (13 vs. 15) and environment (15 vs. 16), and SFQ (8 vs. 7). All p<0.001. Multivariable analysis showed an independent significant effect of eclampsia on CFQ and of migraine on all questionnaires and the effect of preeclampsia was still present after adjustment for confounders. Posttraumatic stress symptoms accounted for part of the relationships. CONCLUSIONS: Previously preeclamptic women appear to perceive more cognitive and social problems, and report poorer quality of life compared to a group of women with normotensive pregnancies. Research relating to the origin and management of these issues is needed.

Long-term cerebral imaging after pre-eclampsia.

OBJECTIVE: Formerly eclamptic women demonstrate cerebral white matter lesions (WMLs) several years following the index pregnancy. The pathophysiology is unclear and may be related to the predisposition for cerebrovascular/cardiovascular disease in such women and/or the occurrence of posterior reversible encephalopathy syndrome whilst pregnant. The aim of this study was to assess the presence and severity of WMLs and their relationship with the severity of the neurological symptoms during the index pregnancy and several current cardiovascular risk factors in formerly pre-eclamptic women. DESIGN: This was a retrospective cohort study. SETTING: The Neuroimaging Centre at the School for Behavioural and Cognitive Neurosciences, Groningen, the Netherlands. POPULATION: Seventy-three formerly pre-eclamptic women were matched for age (37 ± 6 years) and elapsed time since index pregnancy (5.1 ± 3.7 years) with parous control women. METHODS: Cerebral magnetic resonance imaging scans were performed on cases and controls. Scans were rated by a neuroradiologist blind to the patient category. MAIN OUTCOME MEASURES: The presence and severity of cerebral WMLs. RESULTS: Formerly pre-eclamptic women had WMLs significantly more often (37%) and more severely (mean, 0.11; median, 0.00; range, 0-2.34 ml) than controls (21%, P = 0.04; mean, 0.015; median, 0.00; range, 0-0.13 ml; P = 0.02). Current hypertension and a history of early-onset pre-eclampsia (<37 weeks) were independently associated with the presence of WMLs (ß = 1.34, P = 0.02 and ß = 1.73, P = 0.01, respectively). CONCLUSIONS: Our findings indicate that pre-eclampsia might be a risk marker for early cerebrovascular damage. The predisposition of formerly pre-eclamptic women to later cardiovascular and cerebrovascular disease may be an important factor for the development of cerebral WMLs. Whether a history of posterior reversible encephalopathy syndrome may be an additive risk factor for the development of these lesions remains unknown.

Perceptions of women, nurses, midwives and doctors about the use of video during birth to improve quality of care: focus group discussions.

The use of video during birth for quality of care was discussed in focus groups with women, nurses, midwives and doctors. Qualitative analysis revealed three categories of importance. First, goals and benefits: improving quality of care, teaching, research and legal issues are important potential applications. Second, limitations: concerns for privacy, fear of feedback and use of video in case of adverse events. Third, rules and regulations: goals and scope of the use of video need to be clearly described, access to video needs to be secured, and time until destruction needs to be specified. Video capture of birth is considered useful and seems acceptable if specific conditions are met.

S100B brain expression and plasma concentrations in a preeclampsia rat model.

OBJECTIVE: To assess brain damage using the neuroinflammation marker S100B in a preeclampsia rat model. METHODS: Non-pregnant and pregnant rats were infused with saline or low-dose-endotoxin on day 14 of pregnancy. S100B expression in the brain (immunohistochemistry) and S100B plasma concentrations (ELISA) were studied. RESULTS: No differences in S100B expression in brain tissue were observed between the four groups. Pregnant endotoxin treated animals did not show increased levels of plasma S100B levels as compared with control pregnant rats, while significantly higher plasma S100B levels were found in non-pregnant endotoxin versus pregnant endotoxin infused rats. CONCLUSION: Pregnancy nor experimental preeclampsia, alter S100B in rat brain, or in plasma. Increased plasma S100B in non-pregnant endotoxin-treated rats may indicate brain injury in these rats, whereas pregnancy might be protective.

Implementing safe motherhood: a low-cost intervention to improve the management of eclampsia in a referral hospital in Malawi.

We evaluated the effect of so-called monitoring and treatment charts on the management of eclampsia in a referral hospital in Malawi. Baseline characteristics, clinical management, as well as overall maternal and perinatal outcome were compared by reviewing the medical files of two groups, before and after introduction of the charts in 2006. The use of the charts has resulted in improved monitoring of women with eclampsia and may have contributed to the reduction in the planned prelabour caesarean section rate from 87% to 33%, as more women underwent induction of labour after stabilisation (P = 0.020). Overall maternal and perinatal outcomes were similar.

A novel approach to registration of adverse outcomes in obstetrics and gynaecology: a feasibility study.

OBJECTIVE: The central aim of this study was to assess the feasibility of the developed adverse outcome registration method. Furthermore, it was tested whether the information gathered through the registration system allowed for comparative analyses. DESIGN: Prospective observational multicentre study. SETTING: The obstetrics and gynaecology departments of three Dutch university and three general hospitals. Population Every consecutive admission to these departments during the 12-month study period. METHODS: All complications, during admission and up to 6 weeks after discharge, were registered using a standardised form. The complication type and origin were noted and the severity of the complications were graded. MAIN OUTCOME MEASURES: The differences in relative frequencies of complications between the participating university and general hospitals. RESULTS: A total of 10 470 admissions were observed at the obstetrics and gynaecology departments of the six hospitals combined. The standard complication registration form was completed for approximately 90% of these admissions. A total of 351 gynaecological (9.1%) and 960 obstetrical (14.5%) complications were reported. There was no significant difference in the percentage of complications between general hospitals and university hospitals. The severity of complications, however, varied significantly between the participating hospitals. CONCLUSIONS: A feasible framework for complication registration in the field of obstetrics and gynaecology has been developed. Before comparing frequencies of adverse events between hospitals, such outcome measures first need to be risk-adjusted to overcome the problem of patient variation and acuity between hospitals as a source of difference, leaving quality of care as a primary source of variation.

[Termination of pregnancy after the 20-week ultrasonographic examination: haste and caution]. / Zwangerschapsafbreking na de 20-wekenecho: haast en zorgvuldigheid.

The recently introduced ultrasonographic screening programme for the detection of fetal structural anomalies at 20 weeks' gestation is leading to a growing number of cases with an unclear prognosis. This article presents the decision-making process which followed the screening of two women: one aged 36 years, where a post-screening work-up was conducted and swiftly led to well-balanced decision making to abort a fetus with trisomy 21, and one woman aged 30 years, in whom repeated non-decisive results of further diagnostic tests ultimately led to a hasty decision to abort the pregnancy. Up to 24 weeks, current Dutch law allows the couple to decide to have a termination of pregnancy; thereafter the legal possibility of having a termination is very limited. This may lead to rushed decision-making. It is argued that careful decisions in these matters are more important than staying within the 24-week limit. The national central committee ofexperts which is responsible for the evaluation of all abortions after 24 weeks gestation in the so-called category 2 cases (conditions which will lead to serious and irreparable functional disorders, such as severe spina bifida and hydrocephalus, but which are compatible with life) should take account of this dilemma ofhaste and caution.

[Assessment of late pregnancy terminations, 2004-2007]. / Toetsing van late zwangerschapsafbreking, 2004-2007.

OBJECTIVE: To provide an inventory of the reported late terminations of pregnancy because ofa severe anomaly of the unborn child, i.e. termination after 24 weeks of pregnancy, in The Netherlands for the period 2004-2007. DESIGN: Inventory and descriptive. METHOD: A description is given of the various assessment procedures for the termination of pregnancy after 24 weeks. A distinction is made between abortion for lethal foetal abnormalities (category 1) and severe functional impairments with a limited chance for survival of the unborn (category 2). The level of caution exercised in decision making and performing category 1 terminations is assessed by the professional group, namely by the assessment committee for Late Pregnancy Termination of the Dutch Association for Gynaecology and Obstetrics. Since 15 March 2007, late pregnancy terminations that fall under category 2 have by law been assessed by a national central committee of experts. An overview of the reported cases of late terminations of pregnancy in the Netherlands for the period 2004-2007 is given. RESULTS AND CONCLUSION: The number of reported terminations of pregnancy after 24 weeks (n = 72) has declined considerably since the early 1990s. A possible explanation is that due to increasing technological improvements and the implementation of prenatal screening in early preg-nancy, an abortion can be performed before the 24th week of pregnancy if any severe abnormalities are observed.

Maternal and fetal artery Doppler findings in women with chronic hypertension who subsequently develop superimposed pre-eclampsia.

OBJECTIVE: To carry out a prospective study of Doppler velocimetry of the fetomaternal circulation in women with chronic hypertension, to evaluate whether the subsequent development of superimposed pre-eclampsia can be predicted. STUDY DESIGN: Serial Doppler studies of the maternal uterine and renal arteries, and fetal middle cerebral and umbilical arteries, were performed at 16-20 and at 28-32 weeks' gestation in 56 women with chronic hypertension. Pulsatility indices were compared using the Wilcoxon rank sum method. A p value of < 0.05 was considered significant. RESULTS: Uterine artery impedance was significantly elevated as early as 16-20 and at 28-32 weeks' gestation, while the cerebroplacental ratio was lower at 28-32 weeks' gestation, in the 14 women who developed superimposed pre-eclampsia. The maternal renal artery impedance remained constant throughout gestation, regardless of the development of pre-eclampsia. CONCLUSIONS: Uterine artery Doppler velocimetry at 16-20 and at 28-32 weeks' gestation showing increased impedance is predictive for the development of superimposed pre-eclampsia in women with chronic hypertension. The cerebroplacental ratio suggested early fetal brain sparing at 28-32 weeks' gestation in these women.

Hepatotoxicity with antiretroviral treatment of pregnant women.

BACKGROUND: Hepatotoxicity in adults with human immunodeficiency virus (HIV) infection has been associated with all classes of antiretroviral drugs and coinfection with hepatitis B and C virus. We treated two HIV-infected pregnant women in whom hepatotoxicity developed after initiating antiretroviral therapy. CASES: The first woman developed icterus, jaundice, hyperbilirubinemia, and elevated serum aminotransferase levels approximately 5 months after beginning combination antiretroviral therapy with zidovudine, lamivudine, and efavirenz. Serum aminotransferase abnormalities improved after discontinuation of antiretroviral medications. The second woman had similar symptoms and laboratory abnormalities 3 months after initiation of zidovudine, lamivudine, and nelfinavir. Despite initial improvement after discontinuing her antiretroviral medications, fulminant hepatic failure developed and she died. Both patients tested negative for hepatitis A, B, and C; Epstein-Barr virus; and cytomegalovirus. There was no history of illicit drug use, alcohol use, or blood transfusions in either case. CONCLUSION: We emphasize the need for careful monitoring for hepatotoxicity after initiation of antiretroviral therapy.

A case of acute inflammatory demyelinating polyradiculoneuropathy in early pregnancy.

Acute or chronic inflammatory demyelinating polyradiculoneuropathy is a rare disorder that presents with weakness, hyporeflexia, and sensory loss. Treatment consists of immunosuppression and/or plasma exchange. A woman in the first trimester of pregnancy presents with flaccid quadriplegia and numbness. Electromyography demonstrated a demyelinating polyneuropathy with active denervation. The diagnosis of acute inflammatory demyelinating polyradiculoneuropathy was made. She was treated with corticosteroids and plasmapheresis. Despite slow improvement, she decided to terminate the pregnancy at 18 weeks' gestation. At 1 year postpartum she is still in remission. Inflammatory demyelinating polyradiculoneuropathy should be considered in the differential diagnosis of every pregnant woman with new onset peripheral neuropathy. It is suggested that relapse occurs three times more common during pregnancy. Plasmapheresis is the recommended treatment.

Focus on primary care: periodontal disease: implications for women's health.

A definite relationship is emerging between periodontal infections and systemic conditions. The objective of this review is to address this relationship as it pertains to cardiovascular disease and diabetes mellitus. Furthermore, because recent reports link the presence of periodontal disease to preterm delivery, the possible relationship between the development and progression of periodontal disease and certain hormonal states in women such as puberty, oral contraceptive use, menopause, and pregnancy will also be discussed. Although the current literature suggests a strong association between periodontal disease and a number of the discussed systemic conditions, causality can only be established with prospective studies. Intervention studies are needed to address how treatment effects the incidence and/or severity of periodontal disease-related systemic illness.