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ABSTRACT: OBJECTIVE: To evaluate the accuracy of antenatal sonographical measurement of the lower uterine segment (LUS) thickness in the prediction of the risk of uterine rupture during a trial of labour (TOL) in women with a previous Caesarean section (CS). METHODS: Pubmed and EMBASE were searched to identify articles published on the subject of sonographic LUS measurement and the occurrence of a uterine defect after delivery. Four independent researchers performed identification of papers and data extraction. The selected studies were scored on methodological quality, sensitivity and specificity of measurement of LUS thickness in the prediction of a uterine defect were calculated. We performed bivariate meta-analysis to estimate summary Receiver Operating Characteristic (sROC) curves. RESULTS: We included 21 studies with a total of 2,239 analysed patients. The quality of the included studies was good, although comparison was difficult because of heterogeneity. The estimated sROC curves showed that measurement of LUS thickness seems promising in the prediction of the occurrence of uterine defects (dehiscence and rupture) in the uterine wall. The pooled sensitivity and specificity of myometrial LUS thickness for cut-offs between 0.6-2.0 mm was 0.76 (95% CI: 0.60 to 0.87) and 0.92 (95% CI: 0.82 to 0.97), cut-offs between 2.1-4.0 reached a sensitivity and specificity of 0.94 (95% CI: 0.81 to 0.98) and 0.64 (95% CI: 0.26 to 0.90). The pooled sensitivity and specificity of full LUS thickness for cut-offs between 2.0-3.0 mm was 0.61 (95% CI: 0.42 to 0.77) and 0.91 (95% CI: 0.80 to 0.96), cut-offs between 3.1-5.1 reached a sensitivity and specificity of 0.96 (95% CI: 0.89 to 0.98) and 0.63 (95% CI: 0.30 to 0.87). CONCLUSIONS: The meta-analysis gives support to the use of the antenatal LUS measurements in the prediction of a uterine defect during trial of labour. Clinical applicability should be assessed in prospective observational studies using a standardized method of measurement.
Ultrasound in Obstetrics and Gynecology 04/2013; · 3.01 Impact Factor
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ABSTRACT: STUDY QUESTION: What are the dropout rates in lifestyle intervention programs (LIPs) for overweight and obese infertile women and can intervention- or patient-related baseline factors associated with dropout be identified in these women? SUMMARY ANSWER: The median dropout rate was 24% in overweight and obese infertile women who participated in a LIP; clinical useful intervention or patient-related factors associated with dropout could not be identified. WHAT IS KNOWN ALREADY: Overweight and obese infertile women might improve their chance of conception when they improve their lifestyle and lose weight. Dropout from LIPs reduces the chance of losing considerable weight and is therefore considered to be an important limiting factor of the success of LIPs. STUDY DESIGN, SIZE, DURATION: This systematic review included 15 studies published between January 1980 and December 2012. PARTICIPANTS/MATERIALS, SETTING, METHODS: The included studies investigated the effect of LIPs for overweight and obese infertile women with infertility. From these studies, dropout rates and intervention- and patient-related baseline factors associated with dropout, as well as weight loss and pregnancy rates, were recorded. MAIN RESULTS AND THE ROLE OF CHANCE: There were 15 studies identified, of which 10 reported dropout rates. The median dropout rate was 24% (range: 0-31%). Four studies reported baseline characteristics of women who dropped out, but modifiable predictors of dropout could not be identified. Weight loss and pregnancy rates were lower in women who dropped out than in women who completed the LIPs. LIMITATIONS, REASONS FOR CAUTION: There were limited numbers of studies investigating patient-related factors associated with dropout. The heterogeneity in the studies precluded us from drawing firm conclusions on the relation between the type of intervention and dropout. WIDER IMPLICATIONS OF THE FINDINGS: Dropout from LIPs is a major drawback because it predisposes to less weight loss and lower pregnancy rates. Identification of predictors of dropout is needed to identify overweight and obese infertile women who are prone for dropout. These women might benefit from extra support and monitoring, to potentially increasing adherence rates, weight loss and pregnancy chances. STUDY FUNDING/COMPETING INTEREST(S): M.A.Q.M. was supported by a research grant from the Dutch Organization for Health Research and Development (ZonMw). The department of obstetrics and gynaecology received research grants from Merck Sharpe and Dohme BV, feering pharmaceuticals, Merck Serono, the Netherlands.
Human Reproduction 02/2013; · 4.47 Impact Factor
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ABSTRACT: STUDY QUESTION: Can mixture survival models help distinguish infertility from subfertility in couples with an unexplained unfulfilled child wish? SUMMARY ANSWER: Mixture models estimated that 47% of the couples were infertile; female age and previous pregnancy were significantly related to infertility, whereas duration of child wish was associated with a longer time to pregnancy for subfertile couples. WHAT IS KNOWN ALREADY: To differentiate between couples who require assisted conception and couples who still have good chances of natural, i.e. unassisted, conception, several prediction models of natural conception have been developed. Prognostic factors in these models are usually assessed by Cox proportional hazard models that cannot differentiate between couples with an unfulfilled child wish who are subfertile, i.e. have reduced ability to conceive naturally, and couples who are really infertile, i.e. are completely unable to conceive naturally. We evaluated whether a mixture survival model can make such a distinction. STUDY DESIGN, SIZE, DURATION: Consecutive couples presenting at the fertility clinics of 38 centres in the Netherlands between January 2002 and February 2004 joined a prospective cohort study. Of the 7860 couples in the cohort, 3917 couples met our inclusion criteria. The median follow-up was 219 days, with a maximum of 5 years. PARTICIPANTS, SETTING, METHODS: Couples had to present with an unexplained cause of an unfulfilled child wish. A mixture model was used to estimate the proportion of couples who were infertile and the time to pregnancy for the subfertile couples. MAIN RESULTS AND THE ROLE OF CHANCE: During the follow-up, 794 couples conceived naturally. The mixture model estimated that 47% [95% confidence interval (CI): 33-56%] of couples were infertile, despite the absence of objective factors indicating a cause for infertility. Of the evaluated prognostic factors, female age, duration of child wish, previous pregnancy, semen quality, BMI and cycle length, female age [odds ratio (OR): 1.11, 95% CI: 1.03-1.19] and previous pregnancy (0.22, 95% CI: 0.07-0.67) were significant predictors of infertility. Among subfertile couples, a longer duration of a child wish (FFR: 0.72, 95% CI: 0.61-0.85) was a significant prognostic factor for time to pregnancy. In the Cox models, all variables except BMI were significant predictors of time to pregnancy. LIMITATIONS, REASONS FOR CAUTION: The mixture model had limited power due to a low number of couples at the end of the follow-up period. Mixture model analyses on external, long-term follow-up data are necessary to validate our results. WIDER IMPLICATIONS OF THE FINDINGS: Mixture models could be a useful tool in selecting couples who require assisted reproductive technology because the effects of prognostic factors can be subdivided into effects on the fraction of infertile couples and effects on the time to pregnancy for subfertile couples, which is not possible in conventional models. STUDY FUNDING/COMPETING INTEREST(S): This study was supported by grant 945/12/002 from ZonMw, the Netherlands Organization for Health Research and Development, The Hague, the Netherlands.
Human Reproduction 12/2012; · 4.47 Impact Factor
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N M van Mello,
F Mol,
H R Verhoeve,
M van Wely,
A H Adriaanse,
E A Boss,
A B Dijkman,
N Bayram,
M H Emanuel,
J Friederich,
L van der Leeuw-Harmsen,
J P Lips,
M A Van Kessel,
W M Ankum,
F van der Veen, B W Mol,
P J Hajenius
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ABSTRACT: STUDY QUESTION: What is the treatment success rate of systemic methotrexate (MTX) compared with expectant management in women with an ectopic pregnancy or a pregnancy of unknown location (PUL) with low and plateauing serum hCG concentrations? SUMMARY ANSWER: In women with an ectopic pregnancy or a PUL and low and plateauing serum hCG concentrations, expectant management is an alternative to medical treatment with single-dose systemic MTX. WHAT IS KNOWN AND WHAT THIS PAPER ADDS: MTX is often used in asymptomatic women with an ectopic pregnancy or a PUL with low and plateauing serum hCG concentrations. These pregnancies may be self-limiting and watchful waiting is suggested as an alternative, but evidence from RCTs is lacking. The results of this RCT show that expectant management is an alternative to treatment with systemic MTX in a single-dose regimen in these women. STUDY DESIGN, SIZE, DURATION: A multicentre RCT women were assigned to systemic MTX (single dose) treatment or expectant management, using a web-based randomization program, block randomization with stratification for hospital and serum hCG concentration (<1000 versus 1000-2000 IU/l). The primary outcome measure was an uneventful decline of serum hCG to an undetectable level (<2 IU/l) by the initial intervention strategy. Secondary outcome measures included additional treatment, side effects and serum hCG clearance time. PARTICIPANTS, SETTING, METHODS: From April 2007 to January 2012, we performed a multicentre study in The Netherlands. All haemodynamically stable women >18 years old with both an ectopic pregnancy visible on transvaginal sonography and a plateauing serum hCG concentration <1500 IU/l or with a PUL and a plateauing serum hCG concentration <2000 IU/l were eligible for the trial. MAIN RESULTS: We included 73 women of whom 41 were allocated to single-dose MTX and 32 to expectant management. There was no difference in primary treatment success rate of single-dose MTX versus expectant management, 31/41 (76%) and 19/32 (59%), respectively [relative risk (RR) 1.3 95% confidence interval (CI) 0.9-1.8]. In nine women (22%), additional MTX injections were needed, compared with nine women (28%) in whom systemic MTX was administered after initial expectant management (RR 0.8; 95% CI 0.4-1.7). One woman (2%) from the MTX group underwent surgery compared with four women (13%) in the expectant management group (RR 0.2; 95% CI 0.02-1.7), all after experiencing abdominal pain within the first week of follow-up. In the MTX group, nine women reported side effects versus none in the expectant management group. No serious adverse events were reported. Single-dose systemic MTX does not have a larger treatment effect compared with expectant management in women with an ectopic pregnancy or a PUL and low and plateauing serum hCG concentrations. WIDER IMPLICATIONS OF THE FINDINGS: Sixty percent of women after expectant management had an uneventful clinical course with steadily declining serum hCG levels without any intervention, which means that MTX, a potentially harmful drug, can be withheld in these women. BIAS, LIMITATION AND GENERALISABILITY: A limitation of this RCT is that it was an open (not placebo controlled) trial. Nevertheless, introduction of bias was probably limited by the strict criteria to be fulfilled for treatment with MTX. STUDY FUNDING: This trial is supported by a grant of the Netherlands Organization for Health Research and Development (ZonMw Clinical fellow grant 90700154). TRIAL REGISTRATION: ISRCTN 48210491.
Human Reproduction 10/2012; · 4.47 Impact Factor
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ABSTRACT: BACKGROUND The term 'pregnancy of unknown location' (PUL) refers to cases where a pregnancy test is positive but the pregnancy cannot be visualized by transvaginal sonography (TVS). Various strategies integrating TVS and serum hCG measures are used to follow-up until the location and/or viability of the pregnancy becomes clear; however, the optimal strategy to predict the outcome of pregnancy in women with PUL is unknown. Therefore, we performed a systematic review and meta-analysis to determine the diagnostic accuracy of the various serum hCG strategies in women with PUL. METHODS We searched Medline and EMBASE for articles which were published (in any language) from 1980 to January 2012 on strategies using serum hCG in women with PUL and reporting on the final outcome of pregnancy. RESULTS From 980 selected titles, 23 articles, all cohort studies, were included. There were 10 studies on a single serum hCG cut-off level, 4 on serum hCG ratio (hCG 48 h/hCG 0 h) and 6 on logistic regression modelling. Three other strategies were reported using serum hCG, serum progesterone and/or uterine curettage findings; each of these strategies comprised a single study. Comparative diagnostic studies have not been performed on the diagnostic value of serum hCG in women with PUL. Included studies showed substantial clinical heterogeneity in the definition of the outcome, and only data for the pregnancy outcome ectopic pregnancy (EP) were suitable for meta-analysis. The receiver operating characteristic curves showed that the serum hCG ratios and logistic regression models had a better performance as compared with an absolute single serum hCG level (as the curve was considerably closer to the diagonal, indicating no diagnostic value). CONCLUSIONS Overall the study was limited by the high clinical heterogeneity of the data but in women with PUL diagnostic strategies using serum hCG ratios, either alone or in logistic regression models, have the best diagnostic performance in the case of EP. Well defined prospective comparative studies using standardized diagnostics and clinical application plus agreed definitions of outcome are required to identify the best strategy to diagnose pregnancy outcome in women with PUL.
Human Reproduction Update 09/2012; 18(6):603-17. · 9.23 Impact Factor
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ABSTRACT: OBJECTIVE: It is unclear which technique for skin closure should be used at caesarean section (CS) in order to get the best cosmetic result. STUDY DESIGN: We conducted a randomized controlled trial to assess the cosmetic result of different techniques for skin closure after CS. A two-center single-blind randomized controlled trial was performed in The Netherlands. Women undergoing their first CS were eligible for the trial. In a factorial design, women were randomly allocated to (1) closure of the fat layer versus non-closure and (2) staples or intracutaneous stitches for skin closure. The cosmetic result was assessed using the Patient and Observer Scar Assessment Scale (POSAS). RESULTS: We included 124 women. In the stitches group 63% [39/62] women judged the scar as satisfactory, versus 63% [38/60] in the staples group (RR 1.01; 95% CI 0.64-1.6). When the subcutaneous fat layer was closed, 52% [33/63] of the women scored the scar as satisfactory, versus 75% [44/59] of the women in whom the fat layer was not separately closed (RR 0.53; 95% CI 0.32-0.89). This effect was independent of the subcutaneous thickness (p-value for interaction 0.64). Of the secondary outcomes, subcutaneous closure of the fat layer was associated with a longer admission time (median 4 days; IQR 3-5 versus 3 days; IQR 3-5, p-value 0.023). CONCLUSIONS: The choice of staples or stitches does not affect the cosmetic result after a caesarean section. Closing of the subcutaneous fat layer, however, negatively affects the cosmetic result and is associated with a longer admission time.
European journal of obstetrics, gynecology, and reproductive biology 08/2012; · 1.97 Impact Factor
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K A Broeze,
B C Opmeer,
S F Coppus,
N Van Geloven,
J E Den Hartog,
J A Land,
P J Q Van der Linden,
E H Y Ng,
J W Van der Steeg,
P Steures,
F Van der Veen, B W Mol
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ABSTRACT: Tubal patency tests are routinely performed in the diagnostic work-up of subfertile patients, but it is unknown whether these diagnostic tests add value beyond the information obtained by medical history taking and findings at physical examination. We used individual patient data meta-analysis to assess this question.
We approached authors of primary studies for data sets containing information on patient characteristics and results from tubal patency tests, such as Chlamydia antibody test (CAT), hysterosalpingography (HSG) and laparoscopy. We used logistic regression to create models that predict tubal pathology from medical history and physical examination alone, as well as models in which the results of tubal patency tests are integrated in the patient characteristics model. Laparoscopy was considered to be the reference test.
We obtained data from four studies reporting on 4883 women. The duration of subfertility, number of previous pregnancies and a history of previous pelvic inflammatory disease (PID), pelvic surgery or Chlamydia infection qualified for the patient characteristics model. This model showed an area under the receiver operating characteristic curve (AUC) of 0.63 [95% confidence interval (CI) 0.61-0.65]. For any tubal pathology, the addition of HSG significantly improved the predictive performance to an AUC of 0.74 (95% CI 0.73-0.76) (P < 0.001). For bilateral tubal pathology, the addition of both CAT and HSG increased the predictive performance to an AUC of 0.76 (95% CI 0.74-0.79).
In the work-up for subfertile couples, the combination of patient characteristics with CAT and HSG results gives the best diagnostic performance for the diagnosis of bilateral tubal pathology.
Human Reproduction 07/2012; 27(10):2979-90. · 4.47 Impact Factor
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ABSTRACT: Alle behandelingen gericht op preventie van spontane vroeggeboorte, behoudens de profylactische cerclage in geval van een
evidente cervixinsufficiëntie, waren tot voor kort niet effectief. Echter, profylactische toediening van progesteron in de
vorm van een depotpreparaat of vaginale tabletten toegediend vanaf 16-20 weken verminderde in twee recente gerandomiseerde
onderzoeken significant de incidentie van spontane vroeggeboorte bij zwangeren met een verhoogd risico hierop. Na een spontane
vroeggeboorte dienen echtparen geïnformeerd te worden over deze mogelijkheid van preventie van een vroeggeboorte in een volgende
zwangerschap.
All treatment modalities aimed at prevention of a spontaneous preterm delivery – with the exception of a prophylactic cerclage
in case of an evident insufficiency of the cervix – were till recently ineffective. However, prophylactic administration of
progesterone by weekly injections or by daily vaginal administration from the 16th week of gestation onwards reduced significantly
the incidence of spontaneous preterm delivery in pregnancies at high risk for preterm delivery as recently described in two
randomised studies. After a spontaneous preterm delivery couples need to be informed about this prophylactic treatment in
a next pregnancy.
Tijdschrift voor kindergeneeskunde 04/2012; 73(4):127-129.
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ABSTRACT: Prediction of natural conception in subfertile couples can help to differentiate between couples who should have immediate treatment and couples who can aim for natural conception for some time. Natural conception rates are often estimated using standard techniques such as Kaplan-Meier or Cox proportional hazard models. These estimates can be biased by incorrect handling of data from women who start assisted reproductive technology therapy before the end of the follow-up period. This paper discusses the validity and the impact of the assumption of non-informative censoring as used in the Kaplan-Meier and Cox models.
In a cohort of 5360 subfertile couples with suspected tubal pathology, the probability of natural conception and the prognostic value of additional tests for tubal pathology were estimated using traditional methods and with a competing risks analysis.
The estimated probability of natural conception within 3 years was almost 2-fold higher when assuming non-informative censoring compared with the competing risks model, 41 versus 22%. The prognostic value of tests was more conservative using the competing risks model than with the traditional methods, the fecundity rate ratio for Chlamydia antibody testing was 0.72 versus 0.67, for hysterosalpingography, 0.83 versus 0.71 and for diagnostic laparoscopy, 0.89 versus 0.74.
Given the improbable validity of the non-informative censoring assumption, the predictions of natural conception and of the prognostic value of tests are likely to be overestimated by the traditional analytic methods. We suggest the use of competing risks models as an alternative, more conservative, form of analysis when predicting natural conception and evaluating prognostic fertility tests.
Human Reproduction 03/2012; 27(3):889-95. · 4.47 Impact Factor
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ABSTRACT: PURPOSE OF REVIEW: To evaluate diagnostic accuracy studies for rupture of the fetal membranes (ROM). RECENT FINDINGS: Sample sizes of recent studies are small and studies used different 'silver standard' definitions for ROM. Therefore, reported results should be interpreted with caution. Over the review period the focus of diagnostic studies has been on two bedside test strips: insulin-like growth factor-binding protein-1 (IGFBP-1) and placental alpha microglobulin-1 (PAMG-1). Bedside tests improve the confidence of the clinician about their diagnosis. Compared to nitrazine or ferning test alone, IGFBP-1 and PAMG-1 are more accurate. However, compared to the conventional testing (combination of history, ferning, nitrazine, speculum and ultrasound) no statistical difference in accuracy was found. In-vitro PAMG-1 is shown to be superior to IGFPB-1. Furthermore, soluble intercellular adhesion molecule-1 and Axl receptor tyrosine kinase (Axl) seem to be promising new specific biomarkers for diagnosing ROM. SUMMARY: IGFBP-1 and PAMG-1 are the most commonly used bedside tests for diagnosing ROM. Both tests seem to be sensitive and specific, however, evidence is lacking especially in equivocal cases and comparative studies against the real gold standard (amnio-dye) have still not been published. Further effectiveness research is needed before tests can be applied in practice.
Current opinion in obstetrics & gynecology. 01/2012; 24(6):408-12.
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ABSTRACT: Based on a presumed negative impact of overweight and obesity on reproductive capacity and pregnancy outcome, some national guidelines and clinicians have argued that there should be an upper limit for a woman's BMI to access assisted reproductive technologies (ART). However, evidence on the risk of complications or expected success rate of ART in obese women is scarce. We therefore performed a systematic review on the subject.
We searched the literature for studies reporting on complications or success rates in overweight and obese women undergoing ART. Articles were scored on methodological quality. We calculated pooled odds ratios (ORs) to express the association between overweight and obesity on the one hand, and complications and success rates of ART on the other hand. We only pooled results if data were available per woman instead of per cycle or embryo transfer.
We detected 14 studies that reported on the association between overweight and complications during or after ART, of which 6 reported on ovarian hyperstimulation syndrome (OHSS), 7 on multiple pregnancies and 6 on ectopic pregnancies. None of the individual studies found a positive association between overweight and ART complications. The pooled ORs for overweight versus normal weight for OHSS, multiple pregnancy and ectopic pregnancy were 1.0 [95% confidence interval (CI) 0.77-1.3], 0.97 (95% CI 0.91-1.04) and 0.96 (95% CI 0.54-1.7), respectively. In 27 studies that reported on BMI and the success of ART, the pooled ORs for overweight versus normal weight on live birth, ongoing and clinical pregnancy following ART were OR 0.90 (95% CI 0.82-1.0), 1.01 (95% CI 0.75-1.4) and OR 0.94 (95% CI 0.69-1.3), respectively.
Data on complications following ART are scarce and therefore a registration system should be implemented in order to gain more insight into this subject. In the available literature, there is no evidence of overweight or obesity increasing the risk of complications following ART. Furthermore, they only marginally reduce the success rates. Based on the currently available data, overweight and obesity in itself should not be a reason to withhold ART.
Human Reproduction 12/2011; 27(2):457-67. · 4.47 Impact Factor
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ABSTRACT: To describe the consequences in terms of health outcomes, care and associated healthcare costs for three hypothetical cohorts of women planning their first pregnancy at a fixed, different age.
Decision model based on data from perinatal registries and the literature.
The Netherlands.
3 hypothetical cohorts of 100, 000 women aged 23, 29 and 36 years, planning a first pregnancy.
Live birth, pregnancy complications for mother and child and associated healthcare costs. Results For the three cohorts of 23-, 29- and 36-year-old women, 1.6%, 4.6% and 14% of women would not succeed in an ongoing pregnancy (spontaneous or after assisted reproductive technology). The cohort aged 36 gave 9% more miscarriages, 8% more fertility treatment and 1.4% more multiple births than the cohort aged 29. The proportion of caesarean sections among low risk women was 4.9% and 11% higher respectively for the cohorts aged 29 and 36, compared with the cohort aged 23 at start. Eventually, 98%, 95% and 85% of the women in each of the three cohorts gave live birth. The costs for the two older cohorts were €415 and €1662 higher per ongoing pregnancy than the cohort aged 23 years.
Spontaneous conception and mode of delivery are most susceptible to increasing maternal age leading to involuntary childlessness and non-spontaneous labour. The increase in assisted reproduction technology, twin pregnancies and delivery complications results in higher costs along with fewer ongoing pregnancies at higher age.
Journal of epidemiology and community health 12/2011; 65(12):1083-90. · 3.04 Impact Factor
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ABSTRACT: We questioned if participation in the HYPITAT trial (induction of labour versus expectant monitoring in women with gestational hypertension or pre-eclampsia at term) impacted implementation of its results and subsequently maternal health. We identified women with hypertensive disease from the Perinatal Registry, and distinguished the period before, during and after the trial. We included 43 641 women. Induction of labour increased from 58.3 to 67.1% (P < 0.001) and prevalence of eclampsia decreased from 0.85 to 0.19% (P < 0.001) before and after the trial. Concurrently, participation in the HYPITAT trial among others had immediate consequences for obstetric management and maternal health.
BJOG An International Journal of Obstetrics & Gynaecology 12/2011; 118(13):1658-60. · 3.41 Impact Factor
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European journal of obstetrics, gynecology, and reproductive biology 11/2011; · 1.97 Impact Factor
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ABSTRACT: Ethnic disparities in perinatal mortality are well known. This study aimed to explore the contribution of demographic, socioeconomic, health behavioural and pre-existent medical risk factors among different ethnic groups on fetal and early neonatal mortality.
We assessed perinatal mortality from 24.0 weeks' gestation onwards in 554 234 singleton pregnancies of nulliparous women in the linked Netherlands Perinatal Registry over the period 2000-2006. Logistic regression modelling was used.
Considerable ethnic differences in perinatal mortality exist especially in fetal mortality. Maternal age, socioeconomic status and pre-existent diseases could not explain these ethnic differences. Late booking visit could explain some differences. Compared with the Dutch, African women had an increased fetal mortality risk of OR 1.7 (95% CI 1.4 to 2.1); South Asian women, 1.8 (1.4 to 2.3); other non-Western women, 1.3 (1.1 to 1.6) and Turkish/Moroccan women, 1.3 (1.1 to 1.4). The risk on early neonatal mortality was only increased in other non-Western women, OR 1.3 (1.0 to 1.8). Ethnic differences were even present in the women without risk factors including preterm births. Mortality risk for East Asian and other Western women was lower or comparable with the Dutch.
Important ethnic differences in fetal mortality exist, especially among women of African and South Asian origin. Ethnic minorities should be more acquainted with the significance of early start of prenatal care. Tailored prenatal care for women with African and South Asian origin seems necessary. More research on underlying cause of deaths is needed by ethnic group.
Journal of epidemiology and community health 08/2011; 65(8):696-701. · 3.04 Impact Factor
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ABSTRACT: An increased nuchal translucency (NT) is more common in males. A delayed diastolic cardiac function maturation has been proposed to explain this and the reported gender-related differences in ductus venosus (DV) flow.
To investigate gender-related differences in fetal cardiac function.
One hundred and ninety karyotypically/phenotypically normal fetuses with structurally normal hearts and known NT measurement, (104 > 95th percentile), were prospectively included between 1 October 2003 and 1 April 2009. They had been referred for fetal echocardiography. Three hundred and nine echocardiograms were performed between 11 and 35 weeks' gestation. The atrioventricular valve E- and A-wave peak velocity, E/A-velocity ratio and E/TVI ratio, myocardial performance index, semilunar valves acceleration time (AT) and peak velocity, stroke volume and cardiac output as well as DV pulsatility index for veins at 11-14 weeks' gestation, were measured. A multilevel analysis was performed using the NT (multiples of the median) as a continuous variable.
The male : female ratio was 1.56:1. The tricuspid valve E/TVI was significantly higher and pulmonary valve AT significantly lower in females compared to males. No other significant differences in cardiac function were found.
Our findings suggest better right ventricular (RV) relaxation and increased RV afterload in female fetuses, independent of NT thickness, between 11 and 35 weeks' gestation.
Prenatal Diagnosis 03/2011; 31(6):536-42. · 2.11 Impact Factor
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E Groeneveld,
K A Broeze,
M J Lambers,
M Haapsamo,
K Dirckx,
B C Schoot,
B Salle,
C I Duvan,
R Schats, B W Mol,
P G A Hompes
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ABSTRACT: Aspirin is believed to improve the outcome of IVF, but previous conventional meta-analyses on the subject are conflicting. Therefore, we performed a meta-analysis with individual patient data (IPD MA) of randomized clinical trials (RCTs) on the subject.
A systematic literature search was conducted to identify RCTs assessing the effectiveness of aspirin in IVF. Authors were asked to share their original data. In a one step meta-analytic approach, the treatment effect of aspirin was estimated with odds ratios (ORs) and 95% confidence intervals (CIs) using logistic regression, based on the intention to treat principle.
Ten studies fulfilled the inclusion criteria. Authors of six studies provided IPD, including 1119 patients (562 placebo and 557 aspirin). There were 160 clinical pregnancies in the aspirin (28.8%) and 179 (31.9%) in the placebo group [OR 0.86, 95% CI (0.69-1.1)]. There were 129 ongoing pregnancies in the aspirin (23.6%) and 147 in the placebo group (26.7%) [OR 0.85, 95% CI (0.65-1.1)]. Whereas the conventional meta-analysis limited to studies that could provide IPD showed an OR of 0.89 (95% CI 0.69-1.2), the conventional meta-analysis limited to the eight studies of which method of randomization could be confirmed showed an OR of 0.94 (95% CI 0.76-1.17) and the conventional meta-analysis including all 10 eligible RCTs identified with our search changed the OR to 1.07 (95% CI 0.81-1.41). This difference in direction of effect, derived from the studies not able to share IPD of which quality of randomization could not be confirmed.
Aspirin does not improve pregnancy rates after IVF.
Human Reproduction Update 03/2011; 17(4):501-9. · 9.23 Impact Factor
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ABSTRACT: The evidence underpinning the timing of an oocyte collection in IVF or ICSI is limited. The aim of this study was to assess the effect of the follicle diameter size of the dominant follicle on ongoing pregnancy rates.
We conducted a randomized controlled trial, including women aged between 18 and 43 years who were scheduled for GnRH agonist down-regulated IVF/ICSI treatment in four assisted conception units. Women were randomized between timing oocyte collection when the leading follicle had a diameter of 22 mm or when the leading follicle had a diameter of 18 mm. The primary end-point was ongoing pregnancy, defined as a viable pregnancy at 12 weeks of gestation.
The trial had major problems with recruiting patients and after the planned 2 years of recruiting only half of the aimed 400 inclusions were obtained. We allocated 97 women to the 22-mm group and 93 women to the 18-mm group. In the 22-mm group more women reached an ongoing pregnancy (37 of 97 women, 38%) compared with the 18-mm group (22 of 93 women, 24%) resulting in a relative risk of 1.6 [95% confidence interval (CI): 1.03-2.5]. In a logistic regression analysis, the timing of oocyte collection, adjusted for female age, IVF/ICSI and centre, was still associated with ongoing pregnancy, although the association was no longer statistically significant (OR: 2.0; 95% CI: 0.96-4.2)
This study suggests that delaying the timing of oocyte collection in IVF or ICSI results in better ongoing pregnancy rates, however, larger studies have to be performed to prove or refute these findings. Trial registration: ISRCTN24724622.
Human Reproduction 02/2011; 26(5):1091-6. · 4.47 Impact Factor
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K A Broeze,
B C Opmeer,
S F P J Coppus,
N Van Geloven,
M F C Alves,
G Anestad,
S Bhattacharya,
J Allan,
M F Guerra-Infante,
J E Den Hartog, [......],
P J Q Van der Linden,
J W Mouton,
E H Y Ng,
J W Van der Steeg,
P Steures,
H F Svenstrup,
A Tiitinen,
B Toye,
F Van der Veen, B W Mol
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ABSTRACT: The Chlamydia IgG antibody test (CAT) shows considerable variations in reported estimates of test accuracy, partly because of the use of different assays and cut-off values. The aim of this study was to reassess the accuracy of CAT in diagnosing tubal pathology by individual patient data (IPD) meta-analysis for three different CAT assays.
We approached authors of primary studies that used micro-immunofluorescence tests (MIF), immunofluorescence tests (IF) or enzyme-linked immunosorbent assay tests (ELISA). Using the obtained IPD, we performed pooled receiver operator characteristics analysis and logistic regression analysis with a random effects model to compare the three assays. Tubal pathology was defined as either any tubal obstruction or bilateral tubal obstruction.
We acquired data of 14 primary studies containing data of 6191 women, of which data of 3453 women were available for analysis. The areas under the curve for ELISA, IF and MIF were 0.64, 0.65 and 0.75, respectively (P-value < 0.001) for any tubal pathology and 0.66, 0.66 and 0.77, respectively (P-value = 0.01) for bilateral tubal pathology.
In Chlamydia antibody testing, MIF is superior in the assessment of tubal pathology. In the initial screen for tubal pathology MIF should therefore be the test of first choice.
Human Reproduction Update 01/2011; 17(3):301-10. · 9.23 Impact Factor
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Ultrasound in Obstetrics and Gynecology 06/2010; 35(6):756; author reply 756-7. · 3.01 Impact Factor
