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Most expert opinions and guidelines indicate the necessity for weight loss before in vitro fertilization (IVF) in women who are overweight or obese. This is based on the documented impact of obesity on pregnancy rates and pregnancy complications and the long-term impact on the child in natural conceptions. Some clinicians and authorities refuse to treat patients unless they are below a certain body mass index. In the past this advice has been hindered by a lack of opportunity for patients to join lifestyle programs and the high dropout failure before treatment. However, the ideal has remained in the search for effective methods for weight loss. New clinical trials have evaluated a lifestyle program before IVF treatment and compared the results with those who were merely given advice and allowed to proceed directly to other fertility treatments or IVF. No compelling evidence of the value of lifestyle intervention for weight loss on live-birth rates was gained from these well-conducted studies. The research and medical and ethical opinions may now favor moving to fertility treatment earlier than originally recommended for patients who are overweight or obese. [ABSTRACT FROM AUTHOR]

Introduction: Placental pathology is an important contributor in preterm birth, both spontaneous and indicated. The aim of this study was to describe and compare placental histological features of spontaneous preterm birth versus indicated preterm birth.Methods: A case control study was performed at the University Medical Center Utrecht. Women with spontaneous or indicated preterm birth (17-37 weeks of gestation) delivered in 2009 were included. Women with a pregnancy complicated by congenital and/or chromosomal abnormalities were excluded. Placentas were systematically examined by an expert pathologist blinded for pregnancy outcome, except for gestational age. Placental histological abnormalities were classified into infectious inflammatory lesions and maternal vascular malperfusion lesions and compared between spontaneous and indicated preterm birth. Analysis was stratified for immature (17-23+6 weeks), extremely (24-27+6 weeks), very (28-31+6 weeks) and moderate/late (32-36+6 weeks) preterm birth.Results: We included 233 women, 121 women with spontaneous preterm birth and 112 women with indicated preterm birth. Among women with spontaneous extremely preterm birth, higher rates of severe chorioamnionitis were found (56.0% vs. 0%). Furthermore, a shift from infectious-inflammatory lesions to maternal vascular malperfusion lesions was seen after 28 weeks; in women with spontaneous very and moderate/late preterm birth, maternal vascular malperfusion lesions were the main finding (46.8% and 47.7% respectively). In women with indicated preterm birth, maternal vascular malperfusion lesions were most often contributing through all gestational age categories.Conclusion: Maternal vascular malperfusion lesions are most frequent in both spontaneous and indicated very and moderate/late preterm birth. In spontaneous extreme preterm birth chorioamnionitis is the main finding. [ABSTRACT FROM AUTHOR]

Objective: guidelines recommend that external cephalic version (ECV) should be offered to all women with a fetus in breech presentation at term. However, only 50-60% of the women receive an ECV attempt. We explored the determinants (barriers and facilitators) affecting the uptake of the guidelines among gynaecologists and midwives in the Netherlands. Design: national online survey. Setting: the Netherlands. Participants: gynaecologists and midwives. Measurements: in the online survey, we identified the determinants that positively or negatively influenced the professionals' adherence to three key recommendations in the guidelines: (a) counselling, (b) advising for ECV, (c) arranging an ECV. Determinants were identified in a previously performed qualitative study and were categorised into five underlying constructs; attitude towards ECV, professional obligation, outcome expectations, self-efficacy and preconditions for successful ECV. We performed a multivariate analysis to assess the importance of the different constructs for adherence to the guideline. Findings: 364 professionals responded to the survey. Adherence varied: 84% counselled, 73% advised, and 82% arranged an ECV for (almost) all their clients. Although 90% of respondents considered ECV to be an effective treatment for preventing caesarean childbirths, only 30% agreed that 'every client should undergo ECV'. Self-efficacy (perceived skills) was the most important determinant influencing adherence. Key conclusions: self-efficacy appears to be the most significant determinant for counselling, advising and arranging an ECV. Implications for practice: to improve adherence to the guidelines on ECV we must improve self-efficacy. [ABSTRACT FROM AUTHOR]

Objective: To assess the value of antimullerian hormone (AMH) as a test to predict poor ovarian response and pregnancy occurrence after IVF and to compare it with the performance of the antral follicle count (AFC). Design: A systematic review of existing literature and a meta-analysis were carried out. After a comprehensive search, studies were included if 2 × 2 tables for outcomes poor response and pregnancy in IVF patients in relation to AMH or AFC could be constructed. Setting: Academic referral center for tertiary care. Patient(s): Cases indicated for IVF. Intervention(s): None. Main Outcome Measure(s): Poor response and nonpregnancy after IVF. Result(s): A total of 13 studies were found reporting on AMH and 17 on AFC. Because of heterogeneity among studies, calculation of a summary point estimate for sensitivity and specificity was not possible. However, for both tests summary receiver operating characteristic curves for the outcome measures poor response and nonpregnancy could be estimated and compared. The curves for the prediction of poor response indicated no significant difference between the performances of AMH and AFC. For the prediction of nonpregnancy, poor performance for both AMH and AFC was found. Conclusion(s): In this meta-analysis it was shown that AMH has at least the same level of accuracy and clinical value for the prediction of poor response and nonpregnancy as AFC. [Copyright &y& Elsevier]

Objective: To systematically review the value of the clomiphene citrate challenge test (CCCT) in the prediction of poor ovarian response and pregnancy in IVF. Design: Systematic review. Setting: All studies that evaluated the CCCT in the prediction of poor ovarian response or pregnancy after IVF. Patient(s): Infertility population undergoing an IVF treatment. Intervention(s): None. Main Outcome Measure(s): Poor ovarian response, nonpregnancy. Result(s): From the literature we identified and analyzed 12 studies on the CCCT according to preset criteria. In predicting poor response, the sensitivity and specificity of the CCCT varied from 35% to 93% and 47% to 98%, respectively. In predicting nonpregnancy, the sensitivity and specificityvaried from 13% to 66% and 73% to 97%, respectively. Because of heterogeneity among studies, a summary receiver operating characteristics (ROC) curve could not be estimated. Back-to-back comparison of the CCCT with basal FSH was possible in six studies. In predicting poor response, the sensitivity of the CCCT increased to some extent, whereas specificity did not increase or even diminished. In predicting nonpregnancy, the CCCT also showed an increase in sensitivity, counteracted by a decrease in specificity. Conclusion(s): Summary estimates of test accuracy for the CCCT in IVF are not possible, because of heterogeneity among individual studies. A subanalysis of studies comparing basal FSH and the full CCCT showed that the CCCT has hardly any additional value. [Copyright &y& Elsevier]

Objective: To assess the predictive performance of the antral follicle count (AFC) as a test for ovarian reserve in IVF patients and to compare this performance with that of basal FSH level. Design: Meta-analysis. Setting: Tertiary fertility center. Patient(s): Patients undergoing IVF. Intervention(s): None. Main Outcome Measure(s): Poor ovarian response, nonpregnancy. Result(s): We identified 11 studies on AFC and an updated total of 32 studies on basal FSH from the literature on the basis of preset criteria. The estimated summary receiver operating characteristic (ROC) curves showed AFC to perform well in the prediction of poor ovarian response. Also, prediction of poor ovarian response seemed to be more accurate with AFC compared with basal FSH. The estimated summary ROC curves for the prediction of nonpregnancy indicated a poor performance for both AFC and basal FSH. Conclusion(s): Transvaginal ultrasonography is an easy-to-perform and noninvasive method that provides essential predictive information on ovarian responsiveness. The predictive performance of AFC toward poor response is significantly better than that of basal FSH. Therefore, AFC might be considered the test of first choice in the assessment of ovarian reserve prior to IVF. [ABSTRACT FROM AUTHOR]

In reproductive medicine, the needs and desires of infertility patients drive future research, with the most important outcome being live birth of a baby. Large, multicenter, randomized clinical trials are considered the best research tool to evaluate the effectiveness of medical interventions, but they can often take a long time to find definitive answers. Advances in individual participant data (IPD) and network meta-analysis have enabled research questions to be answered more quickly, but better planning could streamline this process further. To harmonize research findings that are taking place globally in this way, it is crucial that the same outcomes are collected in clinical trials conducted in reproductive medicine. Furthermore, the conduct of clinical trials often requires collaboration on an international scale; however, individual countries have their own processes for research prioritization and delivery. We describe the perspective of high- and low-resourced settings and industry as well as the mechanisms of prioritization and coordination that are in place in different settings. In addition, we discuss the importance of the patient perspective, which can help shape the research question, clinical trial design, and the logistical operations of trial delivery. The need for increased global collaboration and coalitions within and between stakeholders is evident for the research community to accelerate advances and maximize benefits in reproductive medicine. [ABSTRACT FROM AUTHOR]

Health care provision is increasingly focused on the prediction of patients' individual risk for developing a particular health outcome in planning further tests and treatments. There has been a steady increase in the development and publication of prognostic models for various maternal and fetal outcomes in obstetrics. We undertook a systematic review to give an overview of the current status of available prognostic models in obstetrics in the context of their potential advantages and the process of developing and validating models. Important aspects to consider when assessing a prognostic model are discussed and recommendations on how to proceed on this within the obstetric domain are given. We searched MEDLINE (up to July 2012) for articles developing prognostic models in obstetrics. We identified 177 papers that reported the development of 263 prognostic models for 40 different outcomes. The most frequently predicted outcomes were preeclampsia (n = 69), preterm delivery (n = 63), mode of delivery (n = 22), gestational hypertension (n = 11), and small-for-gestational-age infants (n = 10). The performance of newer models was generally not better than that of older models predicting the same outcome. The most important measures of predictive accuracy (ie, a model's discrimination and calibration) were often (82.9%, 218/263) not both assessed. Very few developed models were validated in data other than the development data (8.7%, 23/263). Only two-thirds of the papers (62.4%, 164/263) presented the model such that validation in other populations was possible, and the clinical applicability was discussed in only 11.0% (29/263). The impact of developed models on clinical practice was unknown. We identified a large number of prognostic models in obstetrics, but there is relatively little evidence about their performance, impact, and usefulness in clinical practice so that at this point, clinical implementation cannot be recommended. New efforts should be directed toward evaluating the performance and impact of the existing models. [ABSTRACT FROM AUTHOR]

Objective: Women who have experienced a placental abruption have a risk of recurrence, but exact information to quantify this risk is currently not available. We studied the incidence and recurrence rate of placental abruption in a subsequent pregnancy and the influence of hypertensive disorders.Study Design: We conducted a retrospective national cohort study of all singleton pregnancies that ended from 1999-2007 in the Netherlands. A longitudinal linked national cohort of these women with information on a subsequent singleton delivery was used. We calculated and compared incidence and recurrence rates of placental abruption for women in total, stratified by gestational age of first placental abruption and by the presence of a hypertensive disorder in their first pregnancy.Results: We studied 1,570,635 women of which 3496 (0.22%) experienced a placental abruption. Information was available on a subsequent singleton delivery for 264,424 deliveries. Of these, 521 women (0.20%) had a placental abruption in the first pregnancy vs 214 women (0.08%) in the second pregnancy. The risk of placental abruption in a subsequent pregnancy was significantly higher in women with a previous placental abruption compared with women without (5.8% vs 0.06%; adjusted odds ratio [aOR], 93; 95% confidence interval [CI], 62-139). Women with a placental abruption that occurred at term in their first pregnancy were more at risk for recurrence (aOR, 188; 95% CI, 116-306) than women with a preterm (aOR, 52; 95% CI, 25-111) or early preterm (<32 weeks of gestation) placental abruption in their first pregnancy (aOR, 39; 95% CI, 13-116). Placental abruption was more frequent among women with a hypertensive disorder compared with normotensive women (0.44% vs 0.16%; odds ratio, 2.7; 95% CI, 2.3-3.3). Women with a hypertensive disorder were less at risk for recurrence than were normotensive women (aOR, 0.68; 95% CI, 0.27-1.6). No interaction between a hypertensive disorder in the first pregnancy and the recurrence risk was found.Conclusion: Women with a placental abruption in their first pregnancy have a greatly increased risk of placental abruption in a subsequent pregnancy. Hypertensive disorders increase the risk of placental abruption but do not increase the recurrence rate in a subsequent pregnancy. We suggest elective induction from 37 weeks of gestation for women with a history of placental abruption at term in a previous pregnancy. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to determine cardiovascular risk factors in women with a history of hypertensive pregnancy disorders at term (HTP) 2.5 years after pregnancy. Study Design: In a multicenter cohort study in The Netherlands from June 2008 through November 2010, cardiovascular risk factors were compared between women with a history of HTP (HTP cohort, n = 306) and women with a history of normotensive pregnancies at term (NTP cohort, n = 99). HTP women had participated in a randomized, longitudinal trial assessing the effectiveness of induction of labor in women with hypertensive pregnancy disorders at term. All women were assessed 2.5 years after pregnancy for blood pressure, anthropometrics, glucose, glycosylated hemoglobin, insulin, homeostatic model assessment score, total cholesterol, high-density lipoprotein cholesterol, triglycerides, high-sensitivity C-reactive protein, and microalbumin and metabolic syndrome. Results: After a mean follow-up period of 2.5 years, hypertension (HTP, 34%; NTP, 1%; P < .001) and metabolic syndrome (HTP, 25%; NTP, 5%; P < .001) were more prevalent in HTP women compared with NTP women. HTP women had significantly higher systolic and diastolic blood pressure, higher body mass index, and higher waist circumference. Glucose, glycosylated hemoglobin, insulin, homeostatic model assessment score, total cholesterol, triglycerides, and high-sensitivity C-reactive protein levels were significantly higher and high-density lipoprotein cholesterol was significantly lower in HTP women. Conclusion: In women with a history of HTP, hypertension and metabolic syndrome are more common, and they have higher levels of biochemical cardiovascular risk factors 2.5 years after pregnancy. [Copyright &y& Elsevier]

Objective: Small-for-gestational-age (SGA) neonates are at increased risk of adverse pregnancy outcome. Our objective was to study the recurrence rate of SGA in subsequent pregnancies. Study Design: A prospective national cohort study of all women with a structurally normal first and subsequent singleton pregnancy from 1999-2007. SGA was defined as birthweight <5th percentile for gestation. We compared the incidence and recurrence rate of SGA for women in total and with and without a hypertensive disorder (HTD) in their first pregnancy. Moreover, we assessed the association between gestational age at first delivery and SGA recurrence. Results: We studied 259,481 pregnant women, of whom 12,943 women (5.0%) had an SGA neonate in their first pregnancy. The risk of SGA in the second pregnancy was higher in women with a previous SGA neonate than for women without a previous SGA neonate (23% vs 3.4%; adjusted odds ratio, 8.1; 95% confidence interval, 7.8−8.5) and present in both women with and without an HTD in pregnancy. In women without an HTD, the increased recurrence risk was independent of the gestational age at delivery in the index pregnancy; whereas in women with an HTD, this recurrence risk was increased only when the woman with the index delivery delivered at >32 weeks'' gestation. Conclusion: Women with SGA in their first pregnancy have a strongly increased risk of SGA in the subsequent pregnancy and first pregnancy SGA delivers a significant contribution to the total number of second pregnancy SGA cases. [Copyright &y& Elsevier]

OBJECTIVE: The purpose of this study was to assess the effectiveness of electronic fetal monitoring (EFM) alone and with additional ST analysis (EFM + ST) in laboring women with a singleton term pregnancy that is in cephalic presentation in the prevention of metabolic acidosis by the application of individual patient data metaanalysis. STUDY DESIGN: We conducted an individual patient data metaanalysis using data from 4 randomized trials, which enabled us to account for missing data and investigate relevant subgroups. The primary outcome was metabolic acidosis, which was defined as an umbilical cord-artery pH <7.05 and a base deficit that had been calculated in the extra cellular fluid compartment >12 mmol/L. We performed 8 explanatory subgroup analyses for 8 different endpoints. RESULTS: We analyzed data from 12,987 women and their newborn infants. Metabolic acidosis was present in 57 women (0.9%) in the EFM + ST group and 73 women (1.1%) in the EFM alone group (relative risk [RR], 0.76; 95% CI, 0.53-1.10). Compared with EFM alone, the use of EFM + ST resulted in a reduction in the frequency of instrumental vaginal deliveries (RR, 0.90; 95% CI, 0.83-0.99) and fetal blood samples (RR, 0.49; 95% CI, 0.44-0.55). Cesarean delivery rates were comparable between both groups (RR, 0.99; 95% CI, 0.91-1.09). Subgroup analyses showed that EFM + ST resulted in fewer admissions to a neonatal intensive care unit for women with a duration of pregnancy of >41 weeks (RR, 0.61; 95% CI, 0.39-0.95). CONCLUSION: EFM + ST does not reduce the risk of metabolic acidosis, but it does reduce the need for instrumental vaginal deliveries and fetal blood sampling. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to assess the effectiveness of electronic fetal monitoring (EFM) alone and with additional ST analysis (EFM + ST) in laboring women with a singleton term pregnancy that is in cephalic presentation in the prevention of metabolic acidosis by the application of individual patient data metaanalysis. Study Design: We conducted an individual patient data metaanalysis using data from 4 randomized trials, which enabled us to account for missing data and investigate relevant subgroups. The primary outcome was metabolic acidosis, which was defined as an umbilical cord-artery pH <7.05 and a base deficit that had been calculated in the extra cellular fluid compartment >12 mmol/L. We performed 8 explanatory subgroup analyses for 8 different endpoints. Results: We analyzed data from 12,987 women and their newborn infants. Metabolic acidosis was present in 57 women (0.9%) in the EFM + ST group and 73 women (1.1%) in the EFM alone group (relative risk [RR], 0.76; 95% CI, 0.53–1.10). Compared with EFM alone, the use of EFM + ST resulted in a reduction in the frequency of instrumental vaginal deliveries (RR, 0.90; 95% CI, 0.83–0.99) and fetal blood samples (RR, 0.49; 95% CI, 0.44–0.55). Cesarean delivery rates were comparable between both groups (RR, 0.99; 95% CI, 0.91–1.09). Subgroup analyses showed that EFM + ST resulted in fewer admissions to a neonatal intensive care unit for women with a duration of pregnancy of >41 weeks (RR, 0.61; 95% CI, 0.39–0.95). Conclusion: EFM + ST does not reduce the risk of metabolic acidosis, but it does reduce the need for instrumental vaginal deliveries and fetal blood sampling. [ABSTRACT FROM AUTHOR]

Objective: We sought to assess neonatal morbidity and mortality of elective cesarean section (CS) of uncomplicated twin pregnancies per week of gestation >35+0. Study Design: We performed a retrospective cohort study in our nationwide database including all elective CS of twin pregnancies. Two main composite outcome measures were defined, ie, severe adverse neonatal outcome and mild neonatal morbidity. Results: We report on 2228 neonates. More than 17% were born <37+0 weeks of gestation. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for severe adverse neonatal outcome at 35+0-6, 36+0-6, and 37+0-6 weeks were, OR, 9.4; 95% CI, 3.2–27.6; OR, 1.7; 95% CI, 0.5–5.3; and OR, 0.7; 95% CI, 0.2–2.0, respectively; and for mild neonatal morbidity, OR, 4.7; 95% CI, 2.6–8.7; OR, 4.9; 95% CI, 3.1–7.9; and 1.4; 95% CI, 0.9–2.1, respectively, compared to neonates born ≥38+0 weeks of gestation. Conclusion: In uncomplicated twin pregnancies elective CS can best be performed between 37+0 and 39+6 weeks of gestation. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to investigate the recurrence risk of preterm birth (<37 weeks'' gestation) in a subsequent singleton pregnancy after a previous nulliparous preterm twin delivery. Study Design: We included 1957 women who delivered a twin gestation and a subsequent singleton pregnancy from the Netherlands Perinatal Registry. We compared the outcome of subsequent singleton pregnancy of women with a history of preterm delivery to the pregnancy outcome of women with a history of term twin delivery. Results: Preterm birth in the twin pregnancy occurred in 1075 women (55%) vs 882 women (45%) who delivered at term. The risk of subsequent spontaneous singleton preterm birth was significantly higher after preterm twin delivery (5.2% vs 0.8%; odds ratio, 6.9; 95% confidence interval, 3.1–15.2). Conclusion: Women who deliver a twin pregnancy are at greater risk for delivering prematurely in a subsequent singleton pregnancy. [Copyright &y& Elsevier]

Objective: The purpose of this study was to assess the relationship between neonatal respiratory morbidity and the interval between antenatal corticosteroids (ACS) administration and birth. Study Design: We performed a retrospective cohort study among women who had received ACS and delivered at <34 weeks of gestation. We categorized these women in 4 groups: ACS-to-delivery interval of 0-7, 8-14, 15-21, and 22-28 days. Multivariable logistic regression analysis assessed the association between the ACS-to-delivery interval and neonatal respiratory morbidity. Results: We included 254 neonates. Eighty-two neonates (32%) were intubated. In comparison with neonates with an ACS-to-delivery interval of 0-7 days, the risk for intubation was increased in all other groups (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.1–5.4; OR, 5.6; 95% CI, 1.8–18; and OR, 4.8; 95% CI, 0.71–32, not statistically significant, respectively). Conclusion: The effect of ACS decreases when the ACS-to-delivery interval exceeds 7 days. The first administration of ACS should be considered carefully. [ABSTRACT FROM AUTHOR]

Objective: Many obstetric interventions are performed to improve long-term neonatal outcome. However, long-term neonatal outcome is usually not a primary outcome because it is time-consuming and expensive. The aim of this project was to identify different perinatal risk indicators and to develop prediction models for neurologic morbidity at 2 and 5 years of age. Study design: Data from a Dutch cohort study of preterm and small-for-gestational-age infants was used. Neonates who were born in The Netherlands in 1983 with a gestational age of <34 weeks and without congenital abnormalities were included (n = 753). Infants were divided in 3 groups: no handicap, minor handicap, and major handicap. Results: Common risk indicators for major handicaps at 2 and 5 years of age were male sex (odds ratio, 2.7 and 3.0, respectively), seizures after ≥2 days of life (odds ratio, 5.8 and 5.8, respectively), and intracranial hemorrhage (odds ratio, 3.8 and 2.6, respectively). Conclusion: In this cohort, male sex, intracranial hemorrhage, and seizures seem to be important risk indicators for long-term neurologic morbidity. [ABSTRACT FROM AUTHOR]

Objective: We sought to evaluate number and timing of elective cesarean sections at term and to assess perinatal outcome associated with this timing. Study Design: We conducted a recent retrospective cohort study including all elective cesarean sections of singleton pregnancies at term (n = 20,973) with neonatal follow-up. Primary outcome was defined as a composite of neonatal mortality and morbidity. Results: More than half of the neonates were born at <39 weeks of gestation, and they were at significantly higher risk for the composite primary outcome than neonates born thereafter. The absolute risks were 20.6% and 12.5% for birth at <38 and 39 weeks, respectively, as compared to 9.5% for neonates born ≥39 weeks. The corresponding adjusted odds ratios (95% confidence interval) were 2.4 (2.1–2.8) and 1.4 (1.2–1.5), respectively. Conclusion: More than 50% of the elective cesarean sections are applied at <39 weeks, thus jeopardizing neonatal outcome. [Copyright &y& Elsevier]