[Stillbirths in the Obstetrical Departments of Berlin from 2013 to 2014]. / Totgeburten der Jahre 2013 und 2014 in den Berliner Kliniken.

Objective: Review of anonymous data of all stillbirths in all 19 obstetrical departments in Berlin from 2013-2014 with the goal to develop strategies for prevention of stillbirths (≥500 g birth weight). Results: There were a total of 401 stillbirths,178 after fetocide or pregnancy termination and 223 were spontaneous stillbirths. Of this group an anatomical diagnosis from the autopsy was documented in 21 cases. When compared to live births, spontaneous stillbirths were significantly more likely to have intrauterine growth restriction (birth weight under the 10th percentile), a mother≥35 years of age, and a mother from a foreign country. Conclusions: In order to establish efficient strategies of stillbirth prevention, it is important to develop a uniform methodology for collecting stillbirth data on the mother, baby and placenta, and to develop a local or national registry of these data.

Effects of maternal dexamethasone treatment early in pregnancy on glucocorticoid receptors in the ovine placenta.

The effects of endogenous cortisol on binucleate cells (BNCs), which promote fetal growth, may be mediated by glucocorticoid receptors (GRs), and exposure to dexamethasone (DEX) in early pregnancy stages of placental development might modify this response. In this article, we have investigated the expression of GR as a determinant of these responses. Pregnant ewes carrying singleton fetuses (n = 119) were randomized to control (2 mL saline/ewe) or DEX-treated groups (intramuscular injections of 0.14 mg/kg ewe weight per 12 hours) at 40 to 41 days of gestation (dG). Placental tissue was collected at 50, 100, 125, and 140 dG. Total glucocorticoid receptor protein (GRt) was increased significantly by DEX at 50 and 125 dG in females only, but decreased in males at 125 dG as compared to controls. Glucocorticoid receptor α (GRα) protein was not changed after DEX treatment. Three BNC phenotypes were detected regarding GRα expression (++, +-, --), DEX increased the proportion of (++) and decreased (--) BNC at 140 dG. Effects were sex- and cell type dependent, modifying the responsiveness of the placenta to endogenous cortisol. We speculate that 3 maturational stages of BNCs exist and that the overall activity of BNCs is determined by the distribution of these 3 cell types, which may become altered through early pregnancy exposure to elevated glucocorticoids.

[Non-invasive genetic prenatal testing--an ethical discourse]. / Non-invasive Genetische Pränatale Testung--ein ethischer Diskurs.

The non-invasive genetic prenatal testing (NIPT) provides better diagnostic results for the autosomal aneuploidies and decreases the rate of invasive diagnostic methods. With NIPT the possibility for a real screening method is given while posing a lot of ethical questions which have to be answered by the scientific and public communities.

Prophylactic tranexamic acid in parturients at low risk for post-partum haemorrhage: systematic review and meta-analysis.

Tranexamic acid is effective in reducing blood loss during various types of surgery and after trauma. No compelling evidence has yet been presented for post-partum haemorrhage. A systematic literature search of relevant databases was performed to identify trials that assessed blood loss and transfusion incidence after tranexamic acid administration for post-partum haemorrhage. The random effects model was used for meta-analysis. Risk ratios (RRs) and weighted mean differences (WMDs) were calculated with 95% confidence intervals (CIs). Seven trials with a low risk of bias comparing tranexamic acid vs. placebo with a total of 1760 parturients were included in our systematic review and meta-analysis. Blood loss was significantly lower after tranexamic acid use (WMD -140.29 ml, 95% CI -189.64 to -90.93 ml; P<0.00001). Tranexamic acid reduced the risk for blood transfusions (RR 0.34, 95% CI 0.20-0.60, P=0.0001). The incidence of transfusions in the placebo group varied between 1.4% and 33%. When omitting the two trials with the highest incidence of transfusions, the RR was no longer significant. Additional uterotonics were necessary in the placebo groups; gastrointestinal adverse events were more common after tranexamic acid use. Only four cases of thrombosis were found, two each in the tranexamic acid and control groups. Tranexamic acid effectively reduced post-partum blood loss; the effect on the incidence of blood transfusions requires further studies. Only few trials observed adverse events including thromboembolic complications and seizures.

[Pharmacological prevention disease with vitamin D--epidemiological evidence using the example of complications during pregnancy and birth]. / Medikamentöse Krankheitsprävention mit Vitamin D--Epidemiologische Evidenz am Beispiel von Komplika-tionen im Verlauf der Schwangerschaft und bei der Geburt.

National and international epidemiological studies have shown that relevant segments of populations are - especially in the winter period - vitamin D deficient and for the entire year vitamin D intake is far too low. This also applies to pregnant women. In January 2012 the German Nutrition Society has increased the intake recommendations for vitamin D by a factor of 4. It is suggested that a sufficient supply with vitamin D has high preventive potentials with respect to several chronic diseases and will potentially reduce the incidence of preterm birth. This paper considers the evidence of associations between vitamin D deficiency and adverse pregnancy outcomes. Based on the current epidemiological knowledge which is, however, sparse there is very low evidence that vitamin D deficiency is a relevant risk factor for adverse pregnancy outcomes. This makes it even more difficult to give rationale answers to emerging questions with respect to supplementation, dosage and vitamin D diagnostic measures. An observational study with 2 or 3 large obstetric clinics should be undertaken to clarify the central question without delay.

Growth restricting effects of a single course of antenatal betamethasone treatment and the role of human placental lactogen.

UNLABELLED: Betamethasone (BET) is a widely used treatment for women who are at high risk of preterm delivery. In sheep, BET-induced growth restriction was found to be associated with reduced placenta lactogen (PL), a key regulator of fetal growth. We therefore hypothesized that also in humans a single course of BET administration is associated with a reduction of PL, associated with a deceleration in fetal growth. OBJECTIVE: To investigate effects of a single course of antenatal BET in humans on birth weight and PL. METHODS: Women exposed to BET (2 × 12 mg; n = 44) with normally grown fetuses between 23 + 5 and 34 + 0 wks (weeks + days of gestation) who delivered between 23 + 5 to 42 + 0 wks were compared to gestational age-matched controls (n = 49). Maternal gestational blood samples were obtained before, during and after BET treatment and at the time of birth. MAIN OUTCOME MEASURES: BET effects on fetal anthropometrics, placental morphometry and placental PL-protein and maternal plasma levels. RESULTS: The mean duration of days between BET administration and birth was 52 days. BET treatment was associated with decreased birth weight (-18.2%), head circumference (-8.6%), body length (-6.0%), and placental width (-5.5%), as compared to controls. These changes were irrespective of possible maternal confounders (gestational age at birth, maternal age, maternal BMI gain during pregnancy, smoking etc.). However, neither PL-plasma levels within 48 h after BET treatment nor placental PL-protein levels and maternal plasma levels at birth were changed after BET treatment. In central regions of the placenta, BET treatment increased the circumference of syncytiotrophoblast nuclei by +4.7% and nucleus surface area by +9.4% compared to controls, but these changes were not related to placental PL-protein or maternal PL-plasma levels at birth. CONCLUSION: A single course of BET treatment was accompanied with reduced fetal growth, but this growth restricting effect was not associated with altered placental or maternal plasma PL levels. Altered expression of PL appears not to be causal for BET-induced fetal growth restriction in the human.

Treatment of Iron Deficiency in Women.

Iron deficiency with and without anaemia is a common cause of morbidity, particularly in women. Iron deficiency is generally the result of an imbalance between iron loss and iron absorption. In women with symptoms suspicious for iron deficiency, it is important to confirm or exclude the suspicion using proper tests. The use of serum ferritin levels is considered the gold standard for diagnosis. Although the ideal ferritin levels are not unknown the current consent is that levels < 40 ng/ml indicate iron deficiency, which needs to be treated in symptomatic patients. However, symptoms can already occur at ferritin levels of < 100 ng/ml and treatment must be adapted to the individual patient. Iron supplementation is only indicated in symptomatic patients diagnosed with iron deficiency whose quality of life is affected. It is important to treat iron deficiency together with its causes or risk factors. For example, blood loss from hypermenorrhea should be reduced. Women also need to receive information about the benefits of an iron-rich diet. If oral treatment with iron supplements is ineffective, parenteral iron administration is recommended.

Impact of intrapartal ultrasound to assess fetal head position and station on the type of obstetrical interventions at full cervical dilatation.

OBJECTIVES: Recent ultrasound studies have shown that it is feasible to objectively and reproducibly assess fetal head position and station within the pelvis. We sought to evaluate the impact of this new approach on decision making by physicians in a cohort of women with a prolonged second stage of labor. METHODS: This was a retrospective cohort study that included all women with fetuses in cephalic presentation, who were diagnosed with a prolonged second stage of labor, and who delivered in a 1-year period. We compared a group of women (n = 121) with a prolonged second stage of labor who underwent intrapartal ultrasound prior to obstetrical intervention (Group A, n = 43) with a group of women for whom the delivery modus was decided upon after clinical digital examination alone (Group B, n = 78). RESULTS: There were no significant differences in maternal and neonatal morbidity between both groups. The rate of second-stage cesarean section was significantly higher (p < 0.50) in Group B without ultrasound compared to Group A with ultrasound prior to operative delivery (20/78 vs. 7/43). Seven patients in Group A delivered spontaneously, but none of the patients in Group B had spontaneous deliveries. CONCLUSIONS: Intrapartal ultrasound in patients with a prolonged second stage of labor may change obstetrical practice by reducing the number of second stage cesarean section without increasing maternal and neonatal morbidity.

Relationship between fetal head station established using an open magnetic resonance imaging scanner and the angle of progression determined by transperineal ultrasound.

OBJECTIVE: We investigated the correlation between the angle of progression measured by transperineal ultrasound and fetal head station measured by open magnetic resonance imaging (MRI), the gold standard, in pregnant women at full term. METHODS: Thirty-one pregnant women at full term with a fetus in the occipitoanterior position were enrolled. First, the distance between the leading part of the skull and the interspinal plane was obtained using an open MRI system with the patient in a supine position. Immediately after MRI, the angle of progression was obtained by transperineal ultrasound without changing the woman's posture. RESULTS: There was a significant correlation between the angle of progression determined by transperineal sonography and the distance between the presenting fetal part and the level of the maternal ischial spines (y = - 0.51x + 60.8, r(2) = 0.38, P < 0.001). None of the fetal heads was engaged at the time of MRI and ultrasound examinations. CONCLUSIONS: The present study demonstrated a predictable relationship between the angle of progression obtained by transperineal ultrasound and the traditional scale used to quantify fetal head descent. Based on our results, station 0 would correspond to a 120° angle of progression. However, this correlation is based on statistical assumptions only and has to be proven in future studies.

[Management of dichorionic twin delivery at term with cephalic-presenting first twin - a monocentric retrospective cohort study]. / Geburtsleitung bei dichorialen Zwillingen am Termin bei vorangehendem Zwilling in Schädellage - eine monozentrische retrospektive Kohortenstudie.

OBJECTIVE: To assess neonatal outcome and delivery mode in dichorionic twin delivery at term with a cephalic-presenting first twin. METHODS: A retrospective cohort study of 308 twin deliveries after 37 completed weeks of gestation with a cephalic-presenting first twin undertaken in one perinatal center with active management of second twin delivery. The neonatal outcome was measured by the Apgar score, the umbilical artery pH and the transfer into the neonatal unit. RESULTS: In the whole group, 57% were vaginally delivered and 43% needed a Cesarean delivery. The planned vaginal delivery group contained 71% while the planned elective Cesarean delivery group contained 29%. In the planned vaginal delivery group 80% were delivered vaginally, in 15% an emergency Cesarean was necessary, 5% had a vaginal delivery of the first twin followed by Cesarean delivery of the second twin. The neonatal outcome of the second twin shows a higher risk. There are significant differences in the rates of the second twin having lower rates of the umbilical artery pH >7.20 in the group of planned vaginal delivery. The higher risks are compensated in the group of planned elective Cesarean delivery. CONCLUSIONS: Planned vaginal delivery of dichorionic twins at term and active second-stage management is associated with lower rate of normal neonatal outcome. These risks should be considered in prenatal informed consent discussions with the pregnant woman.

Uterine compression sutures for preserving fertility in severe postpartum haemorrhage: an overview 13 years after the first description.

We performed a systematic review of the current literature on efficacy, complications and impact on future pregnancies of uterine compression sutures (UCS) applied in cases of severe postpartum haemorrhage (PPH) in women who wish to preserve fertility. Publications related to UCS from their initial description 03/1996-07/2009, were identified using PubMed and EMBASE. Numerous case series have demonstrated the high efficiency of UCS against PPH. When performed correctly, they are associated with a low complications rate. A higher risk of uterine ischaemia seems to be caused when combined with vessel ligation. No negative impact on fertility has been reported. Uncomplicated future pregnancies occur within a range of 1-3 years. UCS appear safe, simple to learn and preserve future reproductive potential. They should be considered prior to definite measures like hysterectomy in severe PPH. Long-term follow-up is recommended when additional combined vessel ligation is performed due to the potential risk of ischaemic necrosis.

Technical performance of lactate biosensors and a test-strip device during labour.

INTRODUCTION: Lactate in fetal blood has a high diagnostic power to detect fetal compromise due to hypoxia, as lactate allows an estimation of duration and intensity of metabolic acidemia. Biosensor technology allows an instantaneous diagnosis of fetal compromise in the delivery room. The goal of the current investigation is to define the preanalytical and analytical biases of this technology under routine conditions in a labour ward in comparison to test-strip technology, which allows measurement of lactate alone. MATERIAL AND METHODS: Three lactate biosensors (RapidLab 865, Siemens Medical Solutions Diagnostics, Bad Nauheim, Germany; Radiometer ABL625 and ABL 700, Radiometer Copenhagen, Denmark) and one test-strip device (Lactate Pro, Oxford Instruments, UK) were evaluated regarding precision in serial and repetitive measurements in over 1350 samples of fetal whole blood. The coefficient of variation (CV) and the standard deviation (SD) were calculated. The average value of all three biosensors was defined as an artificial reference value (refval). Blood tonometry was performed in order to test the quality of respiratory parameters and to simulate conditions of fetal hypoxia (pO (2): 10 and 20 mmHg). RESULTS: The precision of serial measurements of all biosensors indicated a coefficient of variation (CV) between 1.55 and 3.16% with an SD from 0.042 to 0.053 mmol/L. The test-strip device (Lactate Pro) mounted to 0.117 mmol/L and 3.99% (SD, CV). When compared to our reference value (refval) ABL 625 showed the closest correlation of -0.1%, while Siemens RapidLab 865 showed an overestimation of +8.9%, ABL700 an underestimation of -6.2% and Lactate Pro of -3.7%. CONCLUSION: For routine use all tested biosensors show sufficient precision. The test-strip device shows a slightly higher standard deviation. A direct comparison of measured lactate values from the various devices needs to be interpreted with caution as each method detects different lactate concentrations. Furthermore, the 40 min process of tonometry led to an increase of SD and coefficient of variation in all devices. This results in the important preanalytical finding that the precision of replicated measurements worsens significantly with time. The clinician should be aware of the type of analyser used and of preanalytical biases before making clinical decisions on the basis of lactate values.

Measurement of fetal head descent using the 'angle of progression' on transperineal ultrasound imaging is reliable regardless of fetal head station or ultrasound expertise.

OBJECTIVES: To assess whether ultrasound experience or fetal head station affects the reliability of measurement of fetal head descent using the angle of progression on intrapartum ultrasound images obtained by a single experienced operator, and to determine reliability of measurements when images were acquired by different operators with variable ultrasound experience. METHODS: One experienced obstetrician performed 44 transperineal ultrasound examinations of women at term and in prolonged second stage of labor with the fetus in the occipitoanterior position. Three midwives without ultrasound experience, three obstetricians with < 5 years' experience and three obstetricians with > 10 years' experience measured fetal head descent based on the angle of progression in the images obtained. The angle of progression was measured by two obstetricians in independent ultrasound examinations of 24 laboring women at term with the fetus in the cephalic position to allow assessment of the reliability of image acquisition. Intraclass correlation coefficients (ICCs) with 95% confidence interval (CI) were used to evaluate interobserver reliability and Bland-Altman analysis was used to assess interobserver agreement. RESULTS: In total, 444 measurements were performed and compared. Interobserver reliability with respect to offline image analysis was substantial (overall ICC, 0.72; 95% CI, 0.63-0.81). ICCs were 0.82 (95% CI, 0.70-0.89), 0.81 (95% CI, 0.71-0.88) and 0.61 (95% CI, 0.43-074) for observers with > 10 years', < 5 years' and no ultrasound experience, respectively. There were no significant differences between ICCs among observer groups according to ultrasound experience. Fetal head station did not affect reliability. Bland-Altman analysis indicated reasonable agreement between measurements obtained by two different operators with > 10 years' and < 5 years' ultrasound experience (bias, -1.09 degrees ; 95% limits of agreement, -8.76 to 6.58). The reliability of measurement of the angle of progression following separate image acquisition by two experienced operators was similar to the reliability of offline image analysis (ICC, 0.86; 95% CI, 0.70-0.93). CONCLUSIONS: Measurement of the angle of progression on transperineal ultrasound imaging is reliable regardless of fetal head station or the clinician's level of ultrasound experience.

[Early health promotion and prevention at the beginning of the 20th and 21st centuries. Data and thoughts on the 100th anniversary of the opening of the Empress Auguste Victoria House in Berlin]. / Frühe Gesundheitsförderung und Prävention am Beginn des 20. und des 21. Jahrhunderts. Daten und Gedanken zum 100. Jahrestag der Eröff nung des Kaiserin Auguste Victoria Hauses zu Berlin.

In June 1909, The Empress Auguste Victoria House in Berlin was opened. This first institute for preventive paediatrics had the objective to overcome infant mortality in Germany. This objective was attained. Since then, an unprecedented decrease of mortality in all age groups occurred as well as a doubling of life expectancy. With this "retreat of death", our concepts of health changed fundamentally, and a new spectrum of diseases emerged. This article discusses some mile stones of this change, and explains why we find more illness despite the great improvement in the field of health. The "new diseases" amenable to early prevention are presented in a table. To make disease prevention successful requires the participation of the individual. Therefore, it is important to know the demand to make a good programme effective in the population. Empirical results of a nationwide representative study on the demand by expecting and young parents for preventive consultation are presented. Anticipatory guidance of young parents is a modern approach to health promotion and disease prevention. A controlled trial shows that this approach improved knowledge, behaviour, health risk indicators, health, and development during the first two years after delivery. Future studies should focus on long term effects of early health promotion.

[Survey on breast-feeding initiation and potential impact factors in hospitals and birth centres in Berlin]. / Untersuchung in Berliner Geburtskliniken und Geburtshäusern über den Stillbeginn und mögliche Einflussfaktoren.

AIMS: The aim of this study was to collect information on and to evaluate the impact of the timing of first suckling and breast-feeding initiation in Berlin and to assess the practicability and acceptance of using a short questionnaire to collect breast-feeding data in hospitals and birth centres. METHODS: A three-month observational study was conducted in 19 maternity units and 4 birth centres, using a short questionnaire to collect quantitative data on the timing of first suckling and breast-feeding from mother-child pairs on the day of discharge. RESULTS: The data indicate a breast-feeding rate of 96.1% at discharge. Infants born in birth centres were more frequently put to their mother's breast within the first hour after birth (p<0.05), and were more frequently mainly (p<0.05) or exclusively (p<0.01) breast-fed at discharge than infants born in hospitals. Hospitals' breast-feeding policies (i.e., following the 'ten steps to successful breast-feeding') were not associated with a higher prevalence of early first suckling and any breast-feeding at discharge, but rather with exclusivity of breastfeeding (p<0.001). CONCLUSIONS: Breast-feeding initiation rates are satisfactorily high in Berlin. Rates of early first suckling and (exclusive) initial breast-feeding are highest in birth centres. No consistent association was found between hospitals' breast-feeding policy and initial breast-feeding variables. The questionnaire was well accepted and is deemed suitable for monitoring purposes.

Transperineal ultrasound imaging in prolonged second stage of labor with occipitoanterior presenting fetuses: how well does the 'angle of progression' predict the mode of delivery?

OBJECTIVES: To compare the angle of progression on transperineal ultrasound imaging between different modes of delivery in prolonged second stage of labor with occipitoanterior fetal position. METHODS: We prospectively evaluated 41 women at term (>or= 37 weeks) with failure to progress in the second stage of labor. Only cases with occipitoanterior fetal position were included in the final analysis. These cases were classified into three groups: Cesarean section for failure to progress, vacuum extraction for failure to progress, and spontaneous delivery following prolonged second stage of labor. Transperineal ultrasound examination was performed just before digital examination and subsequent delivery. The angle between a line placed through the midline of the pubic symphysis and a line running from the inferior apex of the symphysis tangentially to the fetal skull (the so-called 'angle of progression') was measured offline by an observer blinded to the mode of delivery. RESULTS: There were 26 cases with occipitoanterior fetal position (Cesarean section, n = 5; vacuum extraction, n = 16; spontaneous delivery, n = 5). Logistic regression analysis showed a strong relationship between the angle of progression and the need for Cesarean delivery (R(2) measure of fit = 55%, likelihood ratio chi-square P < 0.0001). When the angle of progression was 120 degrees , the fitted probability of either an easy and successful vacuum extraction or spontaneous vaginal delivery was 90%. CONCLUSIONS: This is the first report to document a strong relationship between an objective ultrasound marker (angle of progression) and the mode of delivery following prolonged second stage of labor with occipitoanterior fetal position. A predictive model using this parameter would allow better decision making regarding operative delivery for obstructed labor.

[Oral misoprostol against vaginal dinoprostone for labor induction at term: a randomized comparison]. / Prospektiv randomisierte Studie zum Vergleich von Misoprostol oral mit Dinoproston vaginal bei der Geburtseinleitung am Termin.

BACKGROUND: It was the objective of this study to compare the efficacy and safety of oral misoprostol with those of vaginal dinoprostone for the induction of labour at term. PATIENTS AND METHODS: Between 2003 and 2006 224 pregnant women were included in our prospective randomised clinical trial. All of them were admitted for induction of labor at term. Half of the patients received oral misoprostol, initially at a test dose of 25 microg, followed by 50 microg and 100 microg every 4 hours. The control group received 3 mg vaginal dinoprostone every 6 hours. Primary endpoints were time interval until delivery and mode of delivery as well as maternal and neonatal outcome, secondary endpoints were side effects and costs. RESULTS: In the dinoprostone group, the median time interval until delivery was 17.6 hours compared to 24.1 hours in the misoprostol group. Without the test dose, the difference was no longer significant. After dinoprostone induction, more patients had a vaginal delivery within 24 hours (n=60, 53.6%, vs. n=46, 41.1%). The frequencies of spontaneous deliveries and emergency Caesarean sections did not differ between the groups. The rate of vacuum extractions was higher in the misoprostol group (23 vs. 11, i. e. 20.5 vs. 9.8%, p<0.05). With regard to side effects there was no significant difference. No case of hyperstimulation was documented. CONCLUSION: Oral misoprostol is effective and safe for induction of labour at term. In addition, it is much cheaper and independent of storage conditions. At the doses and with the administration intervals used in this study, dinoprostone was slightly more effective than misoprostol.