Impact of Hypertension and Preeclampsia Intervention Trial At Near Term-I (HYPITAT-I) on obstetric management and outcome in The Netherlands.

OBJECTIVE: The Hypertension and Preeclampsia Intervention Trial At near Term-I (HYPITAT-I) randomized controlled trial showed that, in women with gestational hypertension or mild pre-eclampsia at term, induction of labor, compared with expectant management, was associated with improved maternal outcome without compromising neonatal outcome. The aim of the current study was to evaluate the impact of these findings on obstetric management and maternal and perinatal outcomes in The Netherlands. METHODS: We retrieved data for the period 2000-2014 from the Dutch National Perinatal Registry, including 143 749 women with gestational hypertension or pre-eclampsia and a singleton fetus in cephalic presentation, delivered between 36 + 0 and 40 + 6 weeks of gestation (hypertensive disorder of pregnancy (HDP) group). Pregnant women without HDP were used as the reference group (n = 1 649 510). The HYPITAT-I trial was conducted between 2005 and 2008. To study the impact of HYPITAT-I, we compared rate of induction of labor, mode of delivery and maternal and perinatal outcomes in the periods before (2000-2005) and after (2008-2014) the trial. We also differentiated between hospitals that participated in HYPITAT-I and those that did not. RESULTS: In the HDP group, the rate of induction of labor increased from 51.1% before the HYPITAT-I trial to 64.2% after it (relative risk (RR), 1.26; 95% CI, 1.24-1.27). Maternal mortality decreased from 0.022% before the trial to 0.004% after it (RR, 0.20; 95% CI, 0.06-0.70) and perinatal death decreased from 0.49% to 0.27% (RR, 0.54; 95% CI, 0.45-0.65), which was attributable mostly to a decrease in fetal death. Both the increase in induction rate and the reduction in hypertensive complications were more pronounced in hospitals that participated in the HYPITAT-I trial than in those that did not. Following HYPITAT-I, the rate of induction of labor also increased (by 4.6 percentage points) in the reference group; however, the relative increase in the HDP group (13.1 percentage points) was significantly greater (P < 0.001 for the interaction). The reduction in maternal and perinatal deaths did not differ significantly between the HDP and reference groups. There was a decreased incidence of placental abruption in both HDP and reference groups, which was significantly greater in the HDP than in the reference group (P < 0.001 for the interaction). There was also an increased incidence of emergency Cesarean section in both HDP and reference groups; however, this change was significantly greater in the reference than in the HDP group (P < 0.001 for the interaction). CONCLUSION: Following the HYPITAT-I trial, there was a higher rate of induction of labor and improved obstetric outcome in term pregnancies complicated by HDP in The Netherlands. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Mode of childbirth and neonatal outcome after external cephalic version: A prospective cohort study.

OBJECTIVE: to assess the mode of childbirth and adverse neonatal outcomes in women with a breech presentation with or without an external cephalic version attempt, and to compare the mode of childbirth among women with successful ECV to women with a spontaneous cephalic presentation. DESIGN: prospective matched cohort study. SETTING: 25 clusters (hospitals and its referring midwifery practices) in the Netherlands. Data of the Netherlands perinatal registry for the matched cohort. PARTICIPANTS: singleton pregnancies from January 2011 to August 2012 with a fetus in breech presentation and a childbirth from 36 weeks gestation onwards. Spontaneous cephalic presentations (selected from national registry 2009 and 2010) were matched in a 2:1 ratio to cephalic presentations after a successful version attempt. Matching criteria were maternal age, parity, gestational age at childbirth and fetal gender. Main outcomes were mode of childbirth and neonatal outcomes. MEASUREMENTS AND FINDINGS: of 1613 women eligible for external cephalic version, 1169 (72.5%) received an ECV attempt. The overall caesarean childbirth rate was significantly lower compared to women who did not receive a version attempt (57% versus 87%; RR 0.66 (0.62-0.70)). Women with a cephalic presentation after ECV compared to women with a spontaneous cephalic presentation had a decreased risk for instrumental vaginal childbirth (RR 0.52 (95% CI 0.29-0.94)) and an increased risk of overall caesarean childbirth (RR 1.7 (95%CI 1.2-2.5)). KEY CONCLUSIONS: women who had a successful ECV are at increased risk for a caesarean childbirth but overall, ECV is an important tool to reduce the caesarean rate. IMPLICATION FOR PRACTICE: ECV is an important tool to reduce the caesarean section rates.

Patients' and professionals' barriers and facilitators to external cephalic version for breech presentation at term, a qualitative analysis in the Netherlands.

OBJECTIVE: external cephalic version (ECV) is a relatively simple and safe manoeuvre and a proven effective approach in the reduction of breech presentation at term. There is professional consensus that ECV should be offered to all women with a fetus in breech presentation, but only up to 70% of women eligible for ECV undergo an ECV attempt. The aim of the study was to identify barriers and facilitators for ECV among professionals and women with a breech presentation at term. DESIGN: qualitative study with semi-structured interviews. SETTING: Dutch hospitals. PARTICIPANTS: pregnant women with a breech presentation who had decided on ECV, and midwives and gynaecologists treating women with a breech presentation. MEASUREMENTS: on the basis of national guidelines and expert opinions, we developed topic lists to guide the interviews and discuss barriers and facilitators in order to decide on ECV (pregnant women) or advice on ECV (midwives and gynaecologists). FINDINGS: among pregnant women the main barriers were fear, the preference to have a planned caesarean section (CS), incomplete information and having witnessed birth complications within the family or among friends. The main facilitators were the wish for a home birth, the wish for a vaginal delivery and confidence of the safety of ECV. Among professionals the main barriers were a lack of knowledge to fully inform and counsel patients on ECV, and the inability to counsel women who preferred a primary CS. The main facilitator was an unambiguous policy on (counselling for) ECV within the region. CONCLUSION: we identified several barriers and facilitators possibly explaining the suboptimal implementation of ECV for breech presentation in the Netherlands. This knowledge should be taken into account in designing implementation strategies for ECV to improve the uptake of ECV by professionals and patients.

Risk of developmental dysplasia of the hip in breech presentation: the effect of successful external cephalic version.

OBJECTIVE: To evaluate the effect of successful external cephalic version on the incidence of developmental dysplasia of the hip (DDH) requiring treatment in singleton breech presentation at term. DESIGN: Observational cohort study. SETTING: Three large teaching hospitals in the Netherlands. POPULATION: Women with a singleton breech presentation of 34 weeks of gestation or more, who underwent an external cephalic version attempt. METHODS: We made a comparison of the incidence of DDH between children born in breech presentation and children born in cephalic presentation after a successful external cephalic version. MAIN OUTCOME MEASURE: The incidence of DDH requiring either conservative treatment, with a harness, or surgical treatment. RESULTS: A total of 498 newborns were included in the study, of which 40 (8%) were diagnosed with DDH and 35 required treatment. Multivariate analysis showed that female gender (OR 2.79, 95% CI 1.23-6.35) and successful external cephalic version (OR 0.29, 95% CI 0.09-0.95) were independently associated with DDH. CONCLUSIONS: A successful external cephalic version is associated with a lower incidence of DDH, although a high percentage of children born after a successful external cephalic version still appear to have DDH. A larger cohort study is needed to establish the definite nature of this relationship. Until then, we recommend the same screening policy for infants born in cephalic position after a successful external cephalic version as for infants born in breech position.

Decision aids to improve informed decision-making in pregnancy care: a systematic review.

BACKGROUND: Rapid development in health care has resulted in an increasing number of screening and treatment options. Consequently, there is an urgency to provide people with relevant information about benefits and risks of healthcare options in an unbiased way. Decision aids help people to make decisions by providing unbiased non-directive research evidence about all treatment options. OBJECTIVE: To determine the effectiveness of decision aids to improve informed decision making in pregnancy care. SEARCH STRATEGY: We searched MEDLINE (1953-2011), EMBASE (1980-2011), CENTRAL (CENTRAL, the Cochrane Library; 2011, Issue 4), Psycinfo (1806-2011) and Research Registers of ongoing trials (www.clinicaltrials.gov, www.controlled-trials.com). SELECTION CRITERIA: We included randomised controlled trials comparing decision aids in addition to standard care. The study population needed to be pregnant women making actual decisions concerning their pregnancy. DATA COLLECTION AND ANALYSIS: Two independent researchers extracted data on quality of the randomised controlled trial (GRADE criteria), quality of the decision aid (IPDAS criteria), and outcome measures. Data analysis was undertaken by assessing group differences at first follow up after the interventions. MAIN RESULTS: Ten randomised controlled trials could be included. Pooled analyses showed that decision aids significantly increased knowledge, (weighted mean difference 11.06, 95% confidence interval 4.85-17.27), decreased decisional conflict scores (weighted mean difference -3.66, 95% confidence interval -6.65 to -0.68) and decreased anxiety (weighted mean difference -1.56, 95% confidence interval -2.75 to -0.43). CONCLUSIONS: Our systematic review showed the positive effect of decision aids on informed decision making in pregnancy care. Future studies should focus on increasing the uptake of decision aids in clinical practice by identifying barriers and facilitators to implementation.

Risk factors for developmental dysplasia of the hip: a meta-analysis.

Early detection and subsequent treatment of developmental dysplasia of the hip (DDH) is thought to improve its prognosis. Frequently reported risk factors for DDH are a positive family history of DDH, female sex and breech presentation, but there is not a lot of systematic knowledge about DDH risk factors. We performed a systematic review and meta-analysis of the available evidence on DDH risk factors. We searched Medline, EMBASE and The Cochrane Library from conception up until October 2011 for primary articles on the subject. All studies reporting on potential risk factors for DDH that allowed construction of a two-by-two table were selected. Language restrictions were not applied. Two reviewers independently selected studies, extracted data and assessed study quality. The association between risk factors and DDH was expressed as a common odds ratio (OR) with a 95% confidence interval (CI). We identified 30 relevant studies reporting on 1,494,387 children; 26 studies were cohort studies and four studies used a case-control design. The risk of DDH was strongly increased in case of breech delivery (OR 5.7, 95% CI 4.4-7.4), female sex (OR 3.8, 95% CI 3.0-4.6) a positive family history of DDH (OR 4.8, 95% CI 2.8-8.2) and clicking hips at clinical examination (OR 8.6, 95% CI 4.5-16.6). This meta-analysis shows that infants born in breech presentation, female infants, infants with a positive family history and clicking hips at clinical examination have an increased risk for DDH. This knowledge can be helpful in the development of screening programs for DDH.

Health-related quality of life in patients with cardiovascular disease--the effect of upper gastrointestinal symptom treatment.

BACKGROUND: Upper gastrointestinal discomfort decreases the already impaired health status of patients with cardiovascular disease. AIM: To evaluate whether acid suppressive therapy improves health-related quality of life in patients who developed upper gastrointestinal symptoms after starting low-dose acetylsalicylic acid. METHODS: In a double-blind, placebo-controlled randomized trail, cardiac patients using low-dose (80 mg) acetylsalicylic acid with (n = 142) and without (n = 90) upper gastrointestinal symptoms were included. Patients with symptoms were treated with rabeprazole or placebo for 4 weeks. At baseline and 4 weeks information about gastrointestinal symptoms and health-related quality of life was assessed. RESULTS: The 73 patients assigned to rabeprazole when compared with 69 patients given placebo reported the same quality of life scores 4 weeks after randomization. The differences in quality of life scores between patients with and without symptoms at baseline remained after 4 weeks. Patients in whom treatment led to complete symptom relief or those who remained symptom-free reported significantly higher scores for Physical Component Summary (P < 0.01) and Mental Component Summary (P < 0.01), when compared to those with persistent symptoms or new onset symptoms. CONCLUSION: Proton-pump inhibitor therapy did not improve quality of life. Upper gastrointestinal symptom relief in itself considerably increased quality of life.