Arie Franx

Erasmus MC | Erasmus MC · Department of Obstetrics and Gynaecology

Background Recent research within the context of Obstetrics shows the added value of patient participation in in-hospital patient safety. Notwithstanding these benefits, recent research within an Obstetrics department shows that four different negative effects of patient participation in patient safety have emerged. However, the approach to address...

( BJOG . 2024;130(7):813–822) Women admitted to the intensive care unit (ICU) during pregnancy or postpartum have altered their physical and psychological quality of life (QoL). Maternal and perinatal mortality and morbidity are distressing issues impacting many facilities. The long-term impact of peripartum ICU admission is unknown. Two prior stud...

Introduction In clinical practice, fetal heart rate monitoring is performed intermittently using Doppler ultrasound, typically for 30 minutes. In case of a non‐reassuring heart rate pattern, monitoring is usually prolonged. Noninvasive fetal electrocardiography may be more suitable for prolonged monitoring due to improved patient comfort and signal...

( Acta Obstet Gynecol Scand . 2023;102:82–91) The risks of maternal, fetal and neonatal adverse outcomes have a wide variance within the window of full-term gestation, 37+0/7 to 41+6/7 weeks. For uncomplicated pregnancies, the prevalence of complications is generally low. However, the optimal timing of delivery especially for pregnancies with added...

Background The impact of maternal metformin use during pregnancy on fetal, infant, childhood and adolescent growth, development and health remains unclear. Objectives Our objective was to systematically review the available evidence from animal experiments on the effects of intrauterine metformin exposure on offspring's anthropometric, cardiovascu...

Aim: To investigate the association between continuous glucose monitoring (CGM) metrics and perinatal outcomes in insulin-treated diabetes mellitus in pregnancy. Materials and methods: In a post-hoc analysis of the GlucoMOMS randomized controlled trial, we investigated the association between the metrics of an offline, intermittent CGM, glycated...

Besides age, estrogen exposure plays a crucial role in changes in bone density (BD) in women. Premature ovarian insufficiency (POI) and polycystic ovary syndrome (PCOS) are conditions in reproductive-aged women in which the exposure to estrogen is substantially different. Women with a history of preeclampsia (PE) are expected to have normal estroge...

(Abstracted from Acta Obstet Gynecol Scand 2023;102:82–91) A human pregnancy at term is defined as being from 37 +0/7 to 41 +6/7 weeks of gestation. In uncomplicated pregnancies within this range, maternal, fetal, and neonatal risks are considered low, and expectant management is associated with positive outcomes, including increased odds of vagina...

Introduction: Patient-reported outcome and experience measures (PROM and PREM) are used to guide individual care and quality improvement (QI). QI with patient-reported data is preferably organized around patients, which is challenging across organisations. We aimed to investigate network-broad learning for QI with outcome data. Methods: In three...

Objectives: Fetal growth restriction (FGR) remains a challenging condition in diagnosis and monitoring-management strategies. The underlying placental dysfunction may result in severe adverse perinatal outcomes (SAPO) related to fetal hypoxia. The traditional diagnostic criteria for FGR are based on fetal size: small-for-gestational-age (SGA), wit...

Introduction In recent years, Value-Based Healthcare (VBHC) has been gaining traction, particularly in hospitals. A core VBHC element is patient value, i.e., what matters most to the patient and at what cost can this be delivered. This interpretation of value implies patient engagement in patient–doctor communication. Although patient engagement in...

Hypertensive disorders in pregnancy (HDP) and cardiometabolic and kidney diseases are rising in low- and middle-income countries (LMICs). While HDP are risk factors for cardiometabolic and kidney diseases, cost-effective, scalable strategies for screening and prevention in women with a history of HDP are lacking. Existing guidelines and recommendat...

Plain language summary High blood pressure (hypertension) in pregnancy can have severe complications for both mother and fetus including loss of life. The outcome of pregnancy for women who develop hypertension during pregnancy can be improved by ensuring optimal quality of care. In this study, we explored the opinions and experiences of women whos...

Objectives To gain insight into the experiences of women with completing and discussing patient-reported outcome measures (PROM) and patient-reported experience measures (PREM), and tailoring their care based on their outcomes. Design A mixed-methods prospective cohort study. Setting Seven obstetric care networks in the Netherlands that implement...

Background: In the transition towards value-based healthcare, patient-reported outcome and experience measures (PROM and PREM) are recommended by international collaborations and government programs to guide clinical practice and quality improvement. For many conditions, using PROM/PREM over the complete continuum of care requires implementation a...

Background Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) can highlight issues that remain unnoticed when using standard clinical quality indicators. However, estimations of the potential power of measuring PROMs and PREMs to identify unrecognised areas suitable for quality improvement are often limited b...

Background: Women with complicated pregnancies often require hospital admission. Telemonitoring at home is a promising alternative that fulfils a worldwide need in obstetric health care. Moreover, the COVID-19 pandemic has accelerated the transformation to digital care. The aim of this study was to evaluate safety, clinical effectiveness, patient...

Background: Severe maternal morbidity has been shown to have specific, long-term effects on health and wellbeing, such as daily functioning and mental health. Objective: This study aimed to multidimensionally assess the long-term impact of maternal near-miss complications in Zanzibar. Study design: A prospective cohort study was conducted in Z...

Objective: To assess the long-term quality of life (QoL) after obstetric Intensive Care Unit (ICU) admission. Design: Cross-sectional survey study. Setting: Tertiary care center. Population: Women admitted to the level 3 ICU during pregnancy or ≤6 weeks postpartum, between 2000-2015. Methods: QoL measures were compared with the population...

Objectives: To examine implications of third trimester small-for-gestational-age (SGA) screening accuracy on severe adverse perinatal outcomes (SAPO) and obstetric interventions in a low-risk population. Furthermore, we aimed to explore the additive value of third trimester sonographic growth-trajectory measurements in predicting SAPO and obstetri...

Objective Although previous studies largely emphasize the positive effects of patient participation in patient safety, negative effects have also been observed. This study focuses on bringing together the separate negative effects that have been previously reported in the literature. This study set out to uncover how these negative effects manifest...

Objective To determine the prevalence of incidental findings (IFs) on coronary computed tomography (CCT) in women aged 45–55 years and previously diagnosed with reproductive disorders such as polycystic ovary syndrome (PCOS), premature ovarian insufficiency (POI) or preeclampsia (PE). Methods A total of 486 middle-aged women with PCOS ( n = 101),...

Objective: To evaluate the incidence of termination of pregnancies (TOP) and factors associated with the decision for TOP in prenatally detected congenital diaphragmatic hernia (CDH). Study design: Single-centre retrospective cohort including all prenatally detected CDH cases born between January 2009-December 2021. Parental factors, such as par...

Background The preconception period provides a window of opportunity for interventions aiming to reduce unhealthy lifestyle behaviours and their negative effect on pregnancy outcomes. This study aimed to assess the effectiveness of a locally tailored preconception care (PCC) intervention in a hybrid-II effectiveness implementation design. Methods...

Objective Reproductive disorders, such as premature ovarian insufficiency (POI) and polycystic ovary syndrome (PCOS), are associated with hormonal and metabolic changes, which might lead to changes in bone mineral density (BMD). On the one hand women with POI enter menopause too early and have less estrogen exposure rendering them more prone to dev...

Introduction Human pregnancy is considered term from 37+0/7 to 41+6/7 weeks. Within this range, both maternal, fetal and neonatal risks may vary considerably. This study investigates how gestational age per week is related to the components of perinatal mortality and parameters of adverse neonatal and maternal outcome at term. Material and Methods...

This study analyses the contribution of system-related factors to maternal mortality in the low-resource setting of Mnazi Mmoja Hospital in Zanzibar, Tanzania. It is a retrospective cohort study including all maternal deaths (MD, n = 139) and maternal near-misses (MNM, n = 122) in Mnazi Mmoja Hospital with sufficient documentation during 2015 to 20...

Background Unhealthy prenatal lifestyle behaviours are associated with adverse pregnancy outcomes, but little is known about what motivates women to comply with preconceptional lifestyle recommendations or consciously plan their pregnancy. Therefore, the objective of this study is to explore the associations between preconceptional lifestyle behavi...

Background: The International Consortium for Health Outcomes Measurement has published a set of patient-centered outcome measures for pregnancy and childbirth (PCB set), including patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs). To establish value-based pregnancy and childbirth care, the PCB set was imple...

Aims Hypertensive disorders of pregnancy (HDP) occur in 10% of pregnancies in the general population, pre-eclampsia specifically in 3–5%. Hypertensive disorders of pregnancy may have a high prevalence in, and be poorly tolerated by, women with heart disease. Methods and results The prevalence and outcomes of HDP (chronic hypertension, gestational...

Objective To identify neonatal risk for severe adverse perinatal outcomes across birth weight centiles in two Dutch and one international birth weight chart. Background Growth restricted newborns have not reached their intrinsic growth potential in utero and are at risk of perinatal morbidity and mortality. There is no golden standard for the conf...

Background The national health care response to coronavirus (COVID-19) has varied between countries. The United Kingdom (UK) and the Netherlands (NL) have comparable maternity and neonatal care systems, and experienced similar numbers of COVID-19 infections, but had different organisational responses to the pandemic. Understanding why and how simil...

Purpose: While most preconception care (PCC) interventions are aimed at women, men are also in need of PCC to reduce risk factors affecting the spermatozoa quality. The objective of this study is to explore male perceptions regarding the need to engage in PCC. Materials and methods: In a mixed-method cross-sectional study, 229 men participated w...

Routine third trimester ultrasonography is increasingly used to screen for fetal growth restriction. However, evidence regarding its cost-effectiveness is lacking. We aimed to evaluate the cost-effectiveness of routine third trimester ultrasonography to reduce adverse perinatal outcomes compared to usual care (selective ultrasonography). An economi...

BACKGROUND The International Consortium for Health Outcomes Measurement has published a set of patient-centered outcome measures for pregnancy and childbirth (PCB set), including patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs). To establish value-based pregnancy and childbirth care, the PCB set was impleme...

Background Maternal characteristics, such as parity and age, are increasingly considered indications for routine induction of labor of otherwise healthy women to prevent fetal and neonatal mortality. To fully balance the risks and benefits of induction of labor, we examined the association of additional relevant maternal characteristics and gestati...

Purpose Exposure to unhealthy lifestyle behaviours before pregnancy affects the health of mothers and their (unborn) children. A social marketing strategy could empower prospective parents to actively prepare for pregnancy through preconception care (PCC). This study aims to describe the development of a PCC social marketing strategy based on the e...

Objective To explore healthcare providers’ views on improving preconception care in their region. Design Mixed-methods study Setting Working conferences aimed to educate healthcare providers on preconceptional risk factors and conduct a region-specific analysis of barriers and facilitators for implementing preconception care, were organised in te...

Background Most pregnancy-related deaths in low and middle income countries occur around the time of birth and are avoidable with timely care. This study aimed to develop a prognostic model to identify women at risk of intrapartum-related perinatal deaths in low-resourced settings, by (1) external validation of an existing prediction model, and sub...

Objective To develop a prediction model for recurrent preeclampsia using patient-reported preconceptional characteristics, which can be used for risk stratification of subsequent pregnancies. Study design Retrospective cohort study using data from The Preeclampsia RegistryTM of 1028 women with a history of preeclampsia and at least one subsequent p...

Current guidelines lack sufficient evidence to recommend a specific blood pressure lowering strategy to prevent cardiovascular disease after preeclampsia. We conducted a double-blind cross-over trial to identify the most potent antihypertensive strategy: renin-angiotensin-aldosterone system (RAAS) inhibition (losartan), sympathoinhibition (moxonidi...

Background Although promising results have been reported for Magnetic Resonance image-guided High-Intensity Focused Ultrasound (MR-HIFU) treatment of uterine fibroids, this treatment is not yet widely implemented in clinical practice. During the implementation of a new technology, lessons are learned and an institutional learning-curve often has to...

Rationale: Functional characteristics of endothelial cells (ECs) within the human placental bed are unknown and may provide insight into the adaptive biology of ECs in disorders of vascular remodelling like preeclampsia. Objective: To determine transcriptional profiles of human placental bed ECs and systemic biomarker profiles in women with normal...

Background Maternal body mass index (BMI) below or above the reference interval (18.5–24.9 kg/m ² ) is associated with adverse pregnancy outcomes. Whether BMI exerts an effect within the reference interval is unclear. Therefore, we assessed the association between adverse pregnancy outcomes and BMI, in particular within the reference interval, in a...

Background: The majority of evidence on associations between pregnancy complications and future maternal disease focuses on hypertensive (Ht) complications. We hypothesize that impaired cardiometabolic health after pregnancies complicated by severe fetal growth restriction (FGR) is independent of the co-occurrence of hypertension. Materials and Met...

Background: Hypertensive disorders in pregnancy (HDPs) are associated with lifelong cardiovascular disease risk. Persistent postpartum hypertension in HDPs could suggest progression to chronic hypertension. This phenomenon has not been well examined in low- and middle-income countries (LIMCs), and most previous follow-ups typically last for maxima...

Objective To gain insight into the process of postpartum care utilisation and in-home support among vulnerable women. Design, method, participants and setting A qualitative interview study was conducted among 23 pregnant and postpartum vulnerable women in the Netherlands, following a grounded theory approach. Women were determined as vulnerable by...

Hypertensive disorders in pregnancy (HDPs) are a leading cause of maternal morbidity and mortality. Available guidelines for their postpartum management are expected to be optimally utilized. This study aimed to determine adherence to guidelines in selected Nigerian tertiary hospitals. It was nested in a cohort of women with HDPs who delivered in e...

Background While the potential adverse outcomes of prenatal exposure to unhealthy lifestyle are widely evidenced, little is known about these exposures in the periconception period. We investigated the associations between lifestyle behaviours and adverse pregnancy outcomes with a unique distinction between preconceptional- and prenatal lifestyle b...

Background To evaluate the indications for admission and mortality rates of women of reproductive age admitted to a tertiary Intensive Care Unit (ICU) and to compare the outcomes of obstetric and non-obstetric admissions. Methods A retrospective cohort study was performed, including all women aged 17–41 years admitted to a level 3 ICU in the Nethe...

Background: Worldwide, hypertensive disorders in pregnancy (HDPs) complicate between 5 and 10% of pregnancies. Sub-Saharan Africa (SSA) is disproportionately affected by a high burden of HDPs and chronic kidney disease (CKD). Despite mounting evidence associating HDPs with the development of CKD, data from SSA are scarce. Methods: Women with HDP...

Background: Implementation of new diagnostic criteria for gestational diabetes mellitus (GDM) are still a subject of debate, mostly due to concerns regarding the effects on the number of women diagnosed with GDM and the risk profile of the women newly diagnosed. Aim: To estimate the impact of the World Health Organization (WHO) 2013 criteria com...

Objectives: Hypertensive disorders in pregnancy (HDPs) are associated with risk of future metabolic syndrome. Despite the huge burden of HDPs in sub-Saharan Africa, this association has not been adequately studied in this population. Study design: This was a prospective cohort study on pregnant women recruited between August 2017 - April 2018 an...

Background Improvement in the accuracy of identifying women who are at risk to develop gestational diabetes mellitus (GDM) is warranted, since timely diagnosis and treatment improves the outcomes of this common pregnancy disorder. Although prognostic models for GDM are externally validated and outperform current risk factor based selective approach...

Objective To perform a cost analysis of the use of a new care pathway with a digital health platform for blood pressure telemonitoring for women at risk of preeclampsia Study design This is a cost analysis of a case-control study with women with chronic hypertension, history of preeclampsia, maternal cardiac or kidney disease at intake of pregnanc...

Background To improve their quality, healthcare systems are increasingly focused on value delivered to patients. For perinatal care, the International Consortium for Health Outcomes Measurement (ICHOM) proposed a patient-centred outcome set with both clinical and patient-reported measures for pregnancy and childbirth (PCB set). This study aimed to...

Introduction Tackling substandard maternity care in health facilities requires engaging women’s perspectives in strategies to improve outcomes. This study aims to provide insights in the perspectives of women with severe maternal morbidity on preparedness, access and quality of care in Zanzibar’s referral hospital. Methods In a prospective cohort...

Background While the effect of prenatal exposure to unhealthy lifestyle is widely evidenced, little is known about these exposures in the periconception period. We investigated associations between periconceptional lifestyle behaviour change and adverse pregnancy outcomes. Methods A retrospective secondary analysis took place within a prospective...

Hypertensive disorders in pregnancy (HDPs) are a leading cause of maternal morbidity and mortality. Available guidelines for their postpartum management are expected to be optimally utilized. This study aimed to determine adherence to guidelines in selected Nigerian tertiary hospitals. It was nested in a cohort of women with HDPs who delivered in e...

Objective To perform a retrospective external validation of miniPIERS in Zanzibar's referral hospital. Methods From February to December 2017, data were collected retrospectively on all cases of hypertensive disorders of pregnancy (HDP) admitted to Mnazi Mmoja Hospital, Zanzibar, Tanzania. The primary outcome was the predictive performance of mini...

Objective Intrauterine growth restriction is a major risk factor for perinatal morbidity and mortality. Ultrasonic foetal biometry is an important tool to monitor foetal growth. Therefore, the quality of these biometry scans is vital to achieve good diagnostic accuracy. We assessed the quality of foetal biometry during a nationwide trial and explor...

( BMJ . 2019;367:l5517) Fetal growth restriction affects 7% to 10% of pregnancies and is a major risk factor for perinatal morbidity and death, as well as cardiovascular disease in adulthood. Small for gestational age (SGA) infants can be detected during usual prenatal care with serial fundal height measurements. While routine ultrasonography durin...

Background The aim of this study was to evaluate whether soluble frizzled-related protein 4 (sFRP4) concentration in the first trimester of pregnancy is individually, or in combination with Leptin, Chemerin and/or Adiponectin, associated with the development of gestational diabetes (GDM). Methods In a nested case-control study, 50 women with GDM w...

Background Worldwide, hypertensive disorders in pregnancy (HDPs) complicate between 5–10% of pregnancies. Sub-Saharan Africa is disproportionately affected by a high burden of HDPs and chronic kidney disease (CKD). Despite mounting evidence associating HDPs with the development of CKD, data from SSA are scarce. Methods Women with HDPs (n=410) and n...

Given all its systemic adaptive requirements, pregnancy shares several features with physical exercise. In this pilot study, we aimed to assess the physiological response to submaximal cardiopulmonary exercise testing (CPET) in early pregnancy. In 20 healthy, pregnant women (<13 weeks gestation) and 20 healthy, non‐pregnant women, we performed a CP...

Background Preeclampsia, coronary artery calcification (CAC), and atherosclerotic plaque are risk factors for the development of cardiovascular disease. We determined at what age CAC becomes apparent on coronary computed tomography after preeclampsia and to what extent modifiable cardiovascular risk factors were associated. Methods We measured car...

Background Daily monitoring of fetal and maternal conditions in complicated pregnancies leads to recurrent outpatient visits or (prolonged) hospitalization. Alternatives for hospital admissions include home-based monitoring with home visits by professionals or telemonitoring with self-measurements performed by pregnant women and uploaded for in-cli...

Background: This study aims to explore the stories of three women from Zanzibar, Tanzania, who survived life-threatening obstetric complications. Their narratives will increase understanding of the individual and community-level burden masked behind the statistics of maternal morbidity and mortality in Tanzania. In line with a recent systematic rev...

Objectives: To evaluate whether I) first trimester prognostic models for gestational diabetes mellitus (GDM) outperform the currently used single risk factor approach, and II) a first trimester random venous glucose measurement improves model performance. Design: Prospective population-based multicentre cohort. Setting: 31 independent midwifer...

Introduction: There is little evidence to guide the timing of delivery of women with early-onset severe preeclampsia. We hypothesize that immediate delivery is not inferior for neonatal outcome but reduces maternal complications compared with temporizing management. Material and methods: This Dutch multicenter open-label randomized clinical tria...

Objective In women at risk of developing preeclampsia, we evaluated the use of a digital health platform for telemonitoring blood pressure and symptoms combined with a minimal antenatal visit schedule. Study design A case-control study for women with chronic hypertension, history of preeclampsia, or maternal cardiac or kidney disease. A care path...

Objective Preeclampsia, a multi-system hypertensive disorder, is associated with perturbations in the maternal cardiovascular system during early pregnancy. The corpus luteal hormone relaxin, a potent vasodilator, may contribute to physiological circulatory changes especially in early gestation when circulating levels are highest. This study invest...

Background and Aims Patient‐reported outcome and experience measures (PROM and PREM) can facilitate shared decision making and hold potential to improve healthcare quality. However, their adoption in perinatal care is still limited. The International Consortium for Health Outcomes Measurement (ICHOM) developed a Pregnancy and Childbirth (PCB) outco...

BACKGROUND Daily monitoring of fetal and maternal conditions in complicated pregnancies leads to recurrent outpatient visits or (prolonged) hospitalization. Alternatives for hospital admissions include home-based monitoring with home visits by professionals or telemonitoring with self-measurements performed by pregnant women and uploaded for in-cli...

Background Although the biological characteristics of uterine fibroids (UF) have implications for therapy choice and effectiveness, there is limited MRI data about these characteristics. Currently, the Funaki classification and Scaled Signal Intensity (SSI) are used to predict treatment outcome but both screening-tools appear to be suboptimal. Ther...

Background: The majority of the world's perinatal deaths occur in low- and middle-income countries. A substantial proportion occurs intrapartum and is avoidable with better care. At a low-resource tertiary hospital, this study assessed the quality of intrapartum care and adherence to locally-tailored clinical guidelines. Methods: A non-participa...

Objectives The clinical applicability of magnetic resonance image−guided high-intensity focused ultrasound (MR-HIFU) treatment of uterine fibroids is often limited due to inaccessible fibroids or bowel interference. The aim of this study was to implement a newly developed 3-step modified manipulation protocol and to evaluate its influence on the nu...

: Introduction: Preeclampsia (PE) represents a hypertensive pregnancy disorder that is associated with increased cardiovascular disease (CVD) risk. This increased risk has been attributed to accelerated atherosclerosis, with inflammation being a major contributor. Neutrophils play an important role in the onset and progression of atherosclerosis an...

Background: In a previous feasibility study (APROPOS) in a single municipality of the Netherlands, we showed that a locally tailored preconception care (PCC) approach has the potential to positively affect preconceptional lifestyle behaviours. Therefore, we designed a second study (APROPOS-II) to obtain a more robust body of evidence: a larger gro...

Background Preeclampsia is a female-specific risk factor for the development of future cardiovascular disease. Whether early preventive cardiovascular disease risk screenings combined with risk-based lifestyle interventions in women with previous preeclampsia are beneficial and cost-effective is unknown. Methods A micro-simulation model was develo...

Objectives Since 2004, uterine fibroids have been treated with MR-HIFU, but there are persevering doubts on long-term efficacy to date. In the Focused Ultrasound Myoma Outcome Study (FUMOS), we evaluated long-term outcomes after MR-HIFU therapy, primarily to assess the reintervention rate. Methods Data was retrospectively collected from 123 patien...

Background: Hospital admission during pregnancy complications is considered to be an event of significant impact. Besides conventional in-clinic maternal and fetal monitoring, recent technologies enable home-based telemonitoring with self-measurements in high risk pregnancy. This study is part of a feasibility pilot to explore the usability and ac...

Low birth weight is associated with hypertension. Low birth weight can result from fetal growth restriction (FGR) or prematurity. FGR is postulated to impact blood pressure (BP) by developmental programming. This systematic review and meta-analysis studies BP in human and animal offspring following FGR. Pubmed and Web of Science were searched for s...

Formerly preeclamptic (fPE) women are reported to have an increased risk to develop end stage kidney disease. To gain more insight in the course of kidney function after preeclampsia we assessed blood pressure, eGFR and urinary protein loss in 75 fPE women at 11 and 18 years postpartum. We found that during follow-up blood pressure did not increase...