A severe case of pemphigoid gestationis persisting after labour - case report and review of the literature.

BACKGROUND AND AIM: Pemphigoid gestationis (PG) is a rare skin disease of pregnancy. Given its incidence in pregnant women, physicians and especially obstetricians may not encounter this diagnosis in their entire career. We find this to be a major problem and there is an obligation to report it in as much detail as possible along with recommended treatments with proven efficacy. CASE REPORT: We describe the case of a 27 year old patient who was referred to the dermatology department with severe dissemination of blisters in the 9th week of pregnancy. She was diagnosed with pemphigoid gestationis in her first pregnancy. High doses of corticosteroids were initiated but due to inadequate effect cyclosporine was added. The pregnancy was complicated with gestational diabetes. The patient gave birth in her 33rd week by caesarian section due to premature rupture of the membrane. Vesicles were seen on the newborn immediately after birth which diminished spontaneously over 2 weeks. Blisters were still seen on the patient 1 month after labor even with the combination of systemic corticosteroids with cyclosporine. CONCLUSION: PG is a rare dermatosis of pregnancy. The course of the disease can be severe, necessitating systemic therapy. As described in this patient, systemic corticosteroids may not be sufficient and adding another immunosuppressive treatment may be needed. If pemphigoid gestationis has occurred during a previous pregnancy it is advised to reconsider another pregnancy.

Complications of planned home births in the Czech Republic.

OBJECTIVES: This study evaluated complications that can occur during planned home births that require transfer to the hospital. These factors were assessed to improve the current status of deliveries performed outside health care facilities in the Czech Republic. MATERIALS AND METHODS: This prospective cohort study included data on 105 cases of complicated home births during 2017 to 2021 using an online form accessible to all hospital maternity wards in the Czech Republic. RESULTS: Planned home births were complicated by fetal/neonatal causes, maternal causes, and combined fetomaternal complications in 28 (26.7%), 20 (19%), and 2 (1.9%) cases, respectively. The need for transfer was most often realized after the birth of the fetus (86; 81.9%); however, it was realized during birth in 19 (18.1%) cases. The following complications were noted most often: postpartum hemorrhage (23; 21.9%); neonatal asphyxia (17; 16.2); placental retention (14; 13.3%); birth injury (12; 11.4%); neonatal hypothermia (5; 4.8%); and placental birth (5; 4.8%). Indications for transfer during labor were as follows: labor obstruction (10; 9.5%); fetal hypoxia (5; 4.8%); bleeding during labor (2; 1.9%); preeclampsia (1; 0.9%); and fetal malformation (1; 0.9%). Perinatal death occurred in 8 (7.6%) cases. Permanent neonatal morbidity occurred in 4 (3.8%) cases. CONCLUSIONS: Patients with home birth complications were transferred to the hospital most often after the birth of the fetus. The low proportion of transfers during childbirth is caused by the unprofessional management of planned home births, resulting in a high number of perinatal deaths and high rate of permanent neonatal morbidity.

Telemedicine in prenatal care.

Telemedicine, as a health service provided remotely, is increasingly becoming a common part of health care. Telemedicine is defined as "an umbrella term for health activities, services and systems operated remotely through information and communication technologies to promote global health, prevention and health care, as well as education, health management and health research". It also describes telemedicine as "the provision of services where distance is a critical factor, using information and communication technologies to exchange valid information for the diagnosis, treatment and prevention of disease and injury, for research and evaluation, and for the continuing education of healthcare providers to improve the health of individuals and communities". Both definitions imply that two of the hallmarks of telemedicine include the use of communication and information technologies to overcome distance as a critical factor, a factor that is well known to us, not least from the recent months of the COVID-19 pandemic. Distance medicine can thus act as a tool for improving access to health care and also complement health care itself in a very appropriate way.

Multilevel musculo-fascial defect magnetic resonance study of female pelvic floor: retrospective case control study in women with pelvic floor dysfunction after the first vaginal delivery.

INTRODUCTION: Magnetic resonance imaging (MRI) provides a detailed display of the pelvic floor structures responsible for normal pelvic floor anatomy. The aim of the study is to assess the appearance of musculo-fascial defects in women with pelvic floor dysfunction following first vaginal delivery. MATERIAL AND METHODS: Analysis of axial T3 (Tesla 3) MRI scans from a case control study of symptomatic (n = 149) and asymptomatic (n = 60) women after first vaginal delivery. Presence and severity of pelvic organ support and attachment system defects in three axial pelvic planes were assessed. RESULTS: In the symptomatic group, major muscular defects were found in 67.1% (for pubovisceral muscle complex) and 87.9% (for iliococcygeal muscle). Only 6.7% of major pubovisceral and 35.0% of major iliococcygeal defects were identified in the controls (p = 0.000). Prolapse patients had an odds ratio (OR) of 22.1 (95% CI 8.94-54.67) to have major pubovisceral muscle complex defect and OR of 4.9 (95% CI 1.51-15.71) to have major iliococcygeal muscle defect. Fascial defects were found in 60.4% and 83.2% the symptomatic group, respectively. Those with prolapse had an OR of 29.1 (95% CI 9.77-86.31) to have facial defect at the level of pubovisceral muscle complex and an OR of 16.9 (95% CI 7.62-37.69) to have fascial defect at the level of iliococcygeal muscle. Uterosacral ligaments detachment was associated with prolapse with an OR of 10.1 (95% CI 4.01-25.29). For the model based on combination on all MRI markers, the area under the receiver operating characteristic curve is 0.921. CONCLUSIONS: This study provides comprehensive data about first vaginal delivery-induced changes in the levator ani muscle and endopelvic fascial attachment system. These changes are seen also in asymptomatic controls, but they are significantly less expressed.

Peripartum rupture of renal artery aneurysm - case report.

We present a case of silent rupture of the renal artery aneurysm in a pregnant woman brought to the maternity hospital in shock. Renal artery aneurysms (RAA) are rare and account for 0.01-0.5% of all aneurysms with an incidence of approximately 0.09%. Rupture of the renal artery aneurysm is a rare and severe complication associated with extremely high morbidity and mortality in both mother and fetus. Thanks to the improvement and effectiveness of medical care in the 21st century, fetal mortality decreased by 70-80%, and 60-70 % for the mother. The essence of a successful management of this serious, life-threatening condition is a close cooperation between obstetricians, midwives, anesthesiologists, general surgeons, and vascular surgeons.

In vitro simulation of acute feto-fetal transfusion in case of single intrauterine fetal death in monochorionic twins.

INTRODUCTION: Thanks to shared circulation in monochorionic twins, single intrauterine fetal death (IUD) may lead to acute feto-fetal transfusion (aFFTR). The objective of the study was to describe our model of aFFTR simulation after IUD in monochorionic (MC) twins. METHODS: Prospective study analyzed 99 fresh MC placentas with the physiological course. A specially designed protocol was used for the preparation and analysis of the placentas. A pair of infusion sets fixed together using a mechanical mercury sphygmomanometer cuff was connected to the cannulated umbilical arteries. The tonometer was pressurized up to 30 and 40 mmHg. A positive finding of aFFTR was determined as the amount exceeding 1 ml of dye flowed out of the umbilical cord simulating a dead fetus. The number and types of anastomoses, types, and distances between cords insertions, and the size of the placental areas for each fetus were also statistically analyzed. The placental angioarchitecture with and without proven aFFTR was statistically compared, odds ratio (OR) and multivariable logistic analysis were performed. RESULTS: A total of 49/99 (49.5%) cases of aFFTR was proven, and the average transfusion time of 1 ml was 30 s (19-46 s). aFFTR was present in 49/78 (62.8%) of placentas with arterio-arterial (AA) anastomosis. The median diameter of AA anastomoses with the present, and absent aFFTRF was 2.0 mm and 1.0 mm, respectively. The proven interfetal transfusion was 8%, 31%, and 61% in AA anastomoses with a diameter below 0,5 mm, 0,5-1,5 mm, and above 1,5 mm, respectively (p < 0,001). AA anastomoses diameter >1.5 mm had OR of 44.2 (95% CI 5.54-352.39). In the case of coexistence of AA anastomosis and umbilical cord distance ≤5th percentile, the aFFTRF occurred in 90.9%. DISCUSSION: The potential risk of aFFTR in monochorionic twins is mainly due to the presence and nature of AA anastomoses. The diameter and length of the vessels play a crucial role, which is clinically related to the distance of the umbilical cords insertions.

Role of umbilical interleukin-6, procalcitonin and C-reactive protein measurement in the diagnosis of fetal inflammatory response syndrome.

OBJECTIVE: Fetal Inflammatory Response Syndrome (FIRS) is a serious complication accompanied by increased neonatal mortality and morbidity. Early dia-gnosis of FIRS is essential to detect high risk infants. The aim of the study was to evaluate the correlation between interleukin-6 (IL-6), procalcitonin (PCT), C-reactive protein (CRP) in cord blood and histologically proven funisitis;chorioamnionitis in high-risk infants after preterm birth. METHODS: Blood sampling for the measurement of inflammatory bio-markers was performed immediately after placental delivery and umbilical cutting. Umbilical and placental inflammatory changes were assessed using a recently released scoring system (Amsterdam Placental Workshop Group Consensus). RESULTS: One hundred preterm infants (30.5 ± 2.5 gestational week, birth weight 1,443 ± 566 grams) and 21 health term infants were analyzed. Histologic chorioamnionitis was confirmed in 19% cases and chorioamnionitis with funisitis in 7% cases. Thirty-three infants (33%) fulfilled criteria of FIRS (funistis and/ or umbilical IL-6 > 11 ng/ L). The presence of FIRS correlated significantly with maternal leukocytosis (P < 0.001), preterm premature rupture of membrane (P < 0.001) and preterm uterine contraction (P < 0.0001). In comparison to preterm and healthy term infants we found statistically significant higher levels of umbilical inflammatory bio­markers (IL-6, PCT, CRP) in FIRS group (P < 0.0001). Composite mortality and morbidity (bronchopulmonary dysplasia, intraventricular haemorrhage, periventricular leukomalacia) was higher in FIRS group (28.1 vs 22.4% in preterm group). However, the difference was not statistically significant (P = 0.53). CONCLUSION: Our study confirmed the correlation of umbilical inflammatory bio­markers levels (IL-6, PCT, CRP) and the presence of FIRS. We did not find significant adverse impact of FIRS on neonatal mortality and morbidity. Nevertheless, our results could be influenced by the size of study group and strict inclusion criteria (only cases after C-section were analyzed).

Complications of planned home births in the Czech Republic between 2016‒2017.

OBJECTIVE: This study aimed to analyze the complications of planned home births treated at healthcare facilities in the Czech Republic. METHODS: This prospective cohort observational study is based on analysis of women hospitalized with complications related to planned home deliveries in the Czech Republic between 2016 and 2017. The data were collected using an online form made accessible to the directors of all maternity hospitals in the Czech Republic. The results were statistically evaluated. RESULTS: We identified 45 complications during planned home deliveries. Complications occurred most often among women living in largely populated cities with higher levels of education. Overall, 40% of patients did not receive routine antenatal care, and 38% of women gave birth after the 41st week of pregnancy. In 60% of cases, no professionals attended the birth. Hospital transfer frequencies were 42% after delivery, 36% at third-stage labour, 11% first-stage labour, 9% second-stage labour, and 2% before delivery. We recorded four neonatal deaths and one severe newborn morbidity. There was one maternal death unrelated to the home-birthing process and six cases of severe maternal haemorrhagic shock requiring intensive care. CONCLUSION: Complications of planned home births occurred more frequently in women living in largely populated cities and with higher education levels. Planned home births were also observed among women who were at a higher risk of complications. Risk factors included nulliparity, postdate pregnancy, and lack of prenatal care. Hospital transfers occurred most often in the third stage of labour and postpartum.

Persistent occiput posterior position and stress distribution in levator ani muscle during vaginal delivery computed by a finite element model.

INTRODUCTION AND HYPOTHESIS: Objective of this study was to develop an MRI-based finite element model and simulate a childbirth considering the fetal head position in a persistent occiput posterior position. METHODS: The model involves the pelvis, fetal head and soft tissues including the levator ani and obturator muscles simulated by the hyperelastic nonlinear Ogden material model. The uniaxial test was measured using pig samples of the levator to determine the material constants. Vaginal deliveries considering two positions of the fetal head were simulated: persistent occiput posterior position and uncomplicated occiput anterior position. The von Mises stress distribution was analyzed. RESULTS: The material constants of the hyperelastic Ogden model were measured for the samples of pig levator ani. The mean values of Ogden parameters were calculated as: µ1 = 8.2 ± 8.9 GPa; µ2 = 21.6 ± 17.3 GPa; α1 = 0.1803 ± 0.1299; α2 = 15.112 ± 3.1704. The results show the significant increase of the von Mises stress in the levator muscle for the case of a persistent occiput posterior position. For the optimal head position, the maximum stress was found in the anteromedial levator portion at station +8 (mean: 44.53 MPa). For the persistent occiput posterior position, the maximum was detected in the distal posteromedial levator portion at station +6 (mean: 120.28 MPa). CONCLUSIONS: The fetal head position during vaginal delivery significantly affects the stress distribution in the levator muscle. Considering the persistent occiput posterior position, the stress increases evenly 3.6 times compared with the optimal head position.

Ultrasound cesarean scar assessment one year postpartum in relation to one- or two-layer uterine suture closure.

INTRODUCTION: This study compared healing of the scars after cesarean section during the first postpartum year using a single- or double-layer suturing technique. Scarring was assessed by a transvaginal ultrasound. We explored the appearance and localization of uterine scars with regard to the obstetric history. Our aim was to compare the position of the scar or defect, if present, its dimensions, and any residual myometrium with respect to the suturing technique during the cesarean section. MATERIAL AND METHODS: Women with uncomplicated singleton pregnancies indicated for elective or acute cesarean section were randomly allocated to the uterine closure technique group. During the first postpartum year, their lower uterine segment was examined with a transvaginal ultrasound in three consecutive visits at 6 weeks, 6 months and 12 months. RESULTS: 324 women attended the 12-month visit; of these, 149 underwent single-layer closure of the uterine incision and 175 double-layer technique. A higher proportion of the defects is seen in the single-layer closure technique of suturing. Defects in the single-layer group were wider (0.002) and the residual myometrial thickness in the single-layer group were thinner (0.019). Women who underwent cesarean section at the stage of full cervical dilation had scars that were closer to the external cervical os (0.000). The position of the uterus varies greatly between controls (0.000). The combination of uterine position and scar defect presence changed significantly between controls (0.001), and was significantly dependent on the suturing method (0.003). Defects with or without contact with the uterine cavity changed statistically between controls (0.017). Both types of defects were more common in the single-layer closure technique group. CONCLUSIONS: The findings of this study demonstrate that double-layer technique with the first continuous nonlocking suture followed by a second continuous nonlocking suture is associated with better suture healing and greater residual myometrial thickness. No difference was observed between single- and double-layer closure for the presence of maternal infectious morbidity, wound infection or blood transfusion.

The effect of the first vaginal birth on pelvic floor anatomy and dysfunction.

INTRODUCTION AND HYPOTHESIS: First vaginal delivery severely interferes with pelvic floor anatomy and function. This study determines maternal and pregnancy-related risk factors for pelvic floor dysfunction (PFD), including urinary incontinence (UI), urgency, anal incontinence (AI), pelvic organ prolapse (POP) and levator ani muscle (LAM) avulsion. METHODS: This is a single-centre prospective observational cohort study on healthy women in their first singleton pregnancy. All underwent clinical and 3D transperineal ultrasound examination at 6 weeks and 12 months postpartum. Objective outcomes were POP-Q and presence or absence of LAM trauma. Functional outcomes were measured by the ICIQ-SF and PISQ 12. Multivariate regression was performed to determine birth and maternal habitus-related risk factors for UI, urgency, AI, dyspareunia, LAM avulsion and ballooning. RESULTS: Nine hundred eighty-seven women were included. Risk factors for UI were maternal age per year of age (OR: 1.09; 95% CI: 1.04-1.13; p = 0.0001) and BMI before pregnancy (OR: 1.08; 95% CI: 1.04-1.13; p = 0.001); for POP stage II+ maternal age (OR: 1.08; 95% CI: 1.08-1.14; p = 0.005). Avulsion was more likely after forceps (OR: 3.22; 95% CI:1.54-8.22; p = 0.015) but less likely after epidural analgesia (OR: 0.58; 95% CI: 0.37-0.90; p = 0.015) and grade I perineal rupture (OR: 0.50; 95% CI: 0.29-0.85; p = 0.012). Ballooning was more likely at increased maternal age (OR: 1.08; 95% CI: 1.02-1.13; p = 0.005), epidural (OR: 1.64; 95% CI: 1.06-2.55; p = 0.027) and grade I perineal rupture (OR: 1.79; 95% CI: 1.10-2.90; p = 0.018). CONCLUSION: Though maternal characteristics at birth such as age or BMI increase the risk of PFD, labour and birth factors play a similarly important role. The most critical risk factor for MLA avulsion was forceps delivery, while an epidural had a protective effect.

Interposition of the mesorectal flap as prevention of rectovaginal fistula in patients with endometriosis.

INTRODUCTION AND HYPOTHESIS: Endometriosis is a gynecological condition characterized by endometrial tissue outside of the uterus. It affects up to 15% of women of reproductive age. In the case of bowel infiltration, about 90% of lesions are localized on the sigmoid colon or the rectum and may interfere with bowel function. Three surgical approaches are possible: (1) shaving technique, (2) discoid resection of the nodule, and (3) segmental resection with end-to-end anastomosis. A rectovaginal fistula is feared as a postoperative complication mainly in simultaneous resection of the vaginal and the rectosigmoid nodules. Its prevention is a two-step surgery (the first operation on the vagina and the second on the colon) or a preventive colostomy, both of which are often thought to be too invasive for a benign condition. Herein, we suggest a one-step surgery to prevent its development. METHODS: In three women, a concomitant laparoscopic resection of the vaginal and rectosigmoid endometrial nodule was completed with interposition of a mesorectal flap. RESULTS: All surgeries were uncomplicated with no rectovaginal fistula in the postoperative period. CONCLUSION: In the hands of skilled surgeons, this one-step technique can be used to prevent rectovaginal fistula development.

Bronchopulmonary Sequestration with Fetal Hydrops in a Monochorionic Twin Successfully Treated with Multiple Courses of Betamethasone.

Aim We present a case of severe bronchopulmonary sequestration (BPS) and fetal hydrops in one of the monochorionic twin successfully treated with multiple courses of betamethasone. Case Report A 21-year-old gravida 2 para 1 was referred to our hospital for suspected twin-to-twin transfusion syndrome (TTTS) at 28 0/7 weeks of gestational age. However, prenatal ultrasound of the larger twin revealed a chest lesion that was associated with significant ascites, massive hydrothorax, scant hepatomegaly, subcutaneous edema, and severe polyhydramnios. Magnetic resonance imaging confirmed the diagnosis of BPS and fetal hydrops. The estimated fetal weight discrepancy between the fetuses was 39% but the criteria for TTTS were not met. Repeated courses of betamethasone (3 courses, each with 2 × 14 mg of betamethasone intramuscularly/week) were administered with subsequent recovery from hydrops and reduction in BPS parameters. Amniodrainage was performed twice to reduce the amniotic fluid amount in affected twin. Postnatally, surgery of BPS was not required and follow-up at 6 months of corrected age revealed no side effects of antenatal steroids in either twin. Conclusion Antenatal steroids might be considered for noninvasive therapy in high-risk fetal patients with BPS especially when fetal intervention is unsuitable or not available.

Intestinal Perforation during the Stabilization Period in a Preterm Infant with Congenital Diaphragmatic Hernia.

Background Delayed surgery after stabilization of infants with congenital diaphragmatic hernia (CDH) is an accepted strategy. However, the evidence favoring delayed versus immediate surgical repair is limited. We present an extremely rare case of a very low-birth-weight infant with prenatally diagnosed left-sided CDH and unexpected transmural bowel perforations developing within the postnatal stabilization period. Case Report A neonate born at 31st week of gestation with a birth weight of 1,470 g with antenatally diagnosed left-sided CDH presented with bowel dilation leading to transmural bowel perforations on the 2nd day of life. Meconium pleuroperitonitis resulted in severe systemic inflammatory response syndrome, pulmonary hypertension, multiple organ failure, and death. Conclusion In neonates with CDH deteriorating under standard postnatal management, intestinal perforation, and early surgical intervention should be considered.

What European gynaecologists need to master: Consensus on medical expertise outcomes of pan-European postgraduate training in obstetrics & gynaecology.

OBJECTIVE: European harmonisation of training standards in postgraduate medical education in Obstetrics and Gynaecology is needed because of the increasing mobility of medical specialists. Harmonisation of training will provide quality assurance of training and promote high quality care throughout Europe. Pan-European training standards should describe medical expertise outcomes that are required from the European gynaecologist. This paper reports on consensus development on the medical expertise outcomes of pan-European training in Obstetrics and Gynaecology. STUDY DESIGN: A Delphi procedure was performed amongst European gynaecologists and trainees in Obstetrics & Gynaecology, to develop consensus on outcomes of training. The consensus procedure consisted of two questionnaire rounds, followed by a consensus meeting. To ensure reasonability and feasibility for implementation of the training standards in Europe, implications of the outcomes were considered in a working group thereafter. We invited 142 gynaecologists and trainees in Obstetrics & Gynaecology for participation representing a wide range of European countries. They were selected through the European Board & College of Obstetrics and Gynaecology and the European Network of Trainees in Obstetrics & Gynaecology. RESULTS: Sixty people participated in round 1 and 2 of the consensus procedure, 38 (63.3%) of whom were gynaecologists and 22 (36.7%) were trainees in Obstetrics & Gynaecology. Twenty-eight European countries were represented in this response. Round 3 of the consensus procedure was performed in a consensus meeting with six experts. Implications of the training outcomes were discussed in a working group meeting, to ensure reasonability and feasibility of the material for implementation in Europe. The entire consensus procedure resulted in a core content of training standards of 188 outcomes, categorised in ten topics. CONCLUSION: European consensus was developed regarding the medical expertise outcomes of pan-European training in Obstetrics and Gynaecology. The outcomes will be described in core trainings standards, aimed at harmonising training in Obstetrics and Gynaecology in Europe to promote high quality care.

Antenatal assessment of liver position, rather than lung-to-head ratio (LHR) or observed/expected LHR, is predictive of outcome in fetuses with isolated left-sided congenital diaphragmatic hernia.

OBJECTIVES: Respiratory morbidity in congenital diaphragmatic hernia (CDH) is associated with high mortality and adverse outcome. Accurate prenatal diagnosis is essential for prognosis and potential treatment in utero. The aim was to evaluate the prenatal ultrasound findings in assessing the respiratory prognosis in fetuses with isolated left-sided CDH. METHODS: We retrospectively analyzed the medical records of 59 prenatally diagnosed left-sided CDH cases managed at a tertiary perinatal center. RESULTS: Survival rate in the study group was 73% (43/59). We found no statistically significant relationship between survival and the presence of polyhydramnios, gestational age at diagnosis, lung-to-head ratio (LHR) and observed/expected LHR (O/E LHR) values, gestational age at birth and birth weight. Intrathoracic liver herniation was a statistically significant parameter adversely affecting survival (37.2% in survivors, 68.8% in non-survivors, p = 0.031) and logistic regression confirmed this relationship. The presence of pneumothorax and severe pulmonary hypertension were significantly associated with mortality (82% non-survivors versus 15% in survivors, p = 0.0001). CONCLUSION: Intrathoracic liver herniation seems to be a reliable parameter in the prediction of survival and neonatal respiratory morbidity in fetuses with isolated left-sided CDH. In contrast, we found no significant correlation between perinatal outcome and LHR, O/E LHR values, birth weight and gestational age.

Finite element model focused on stress distribution in the levator ani muscle during vaginal delivery.

INTRODUCTION AND HYPOTHESIS: During vaginal delivery, the levator ani muscle (LAM) undergoes severe deformation. This stress can lead to stretch-related LAM injuries. The objective of this study was to develop a sophisticated MRI-based model to simulate changes in the LAM during vaginal delivery. METHODS: A 3D finite element model of the female pelvic floor and fetal head was developed. The model geometry was based on MRI data from a nulliparous woman and 1-day-old neonate. Material parameters were estimated using uniaxial test data from the literature and by least-square minimization method. The boundary conditions reflected all anatomical constraints and supports. A simulation of vaginal delivery with regard to the cardinal movements of labor was then performed. RESULTS: The mean stress values in the iliococcygeus portion of the LAM during fetal head extension were 4.91-7.93 MPa. The highest stress values were induced in the pubovisceral and puborectal LAM portions (mean 27.46 MPa) at the outset of fetal head extension. The last LAM subdivision engaged in the changes in stress was the posteromedial section of the puborectal muscle. The mean stress values were 16.89 MPa at the end of fetal head extension. The LAM was elongated by nearly 2.5 times from its initial resting position. CONCLUSIONS: The cardinal movements of labor significantly affect the subsequent heterogeneous stress distribution in the LAM. The absolute stress values were highest in portions of the muscle that arise from the pubic bone. These areas are at the highest risk for muscle injuries with long-term complications.

Procalcitonin is more likely to be released by the fetus rather than placental tissue during chorioamnionitis.

AIMS: To analyze the relationship between maternal, cord blood and neonatal procalcitonin (PCT) levels in preterm deliveries with and without histologically proven chorioamnionitis (HCA). METHODS: 91 mother-infant pairs from 24+0 to 33+0 gestational weeks were analyzed. Procalcitonin was measured in all mothers within 24 hours before and subsequently in cord blood and in neonates within the first two hours after delivery. PCT levels were analysed in relationship to HCA and clinical outcome. RESULTS: HCA was confirmed in 28 cases (31%). We found no differences in PCT values between HCA positive and negative groups in maternal blood (0.1±0.1 vs 0.09±0.09 ng/L, P = 0.76). PCT values in cord blood and neonates were significantly higher in the HCA positive compared to HCA negative group (0.23±0.1 vs 1.2±2.7 ng/L, P < 0.001 and 0.89±3.4 vs 4.2±9.3 ng/L, P < 0.0001 respectively). PCT values in neonates were significantly higher than those of cord blood. Levels were not influenced by the mode of delivery, gestational age or premature rupture of membranes. Chorioamnionitis was more frequently associated with early onset neonatal sepsis (36% in HCA group vs 5% in non HCA group, P < 0.0001). Comparison of other clinical data revealed no differences between HCA positive and negative groups. CONCLUSION: This study showed higher PCT in cord and neonatal blood in the presence of proven histological chorioamnionitis. The measurement of PCT in mothers' blood is not helpful for diagnosis of HCA. The changes in PCT values shown suggest its production and release by fetal tissue.

Limited Amount of Formula May Facilitate Breastfeeding: Randomized, Controlled Trial to Compare Standard Clinical Practice versus Limited Supplemental Feeding.

OBJECTIVES: Breastfeeding is known to reduce infant morbidity and improve well-being. Nevertheless, breastfeeding rates remain low despite public health efforts. Our study aims to investigate the effect of controlled limited formula usage during birth hospitalisation on breastfeeding, using the primary hypothesis that early limited formula feeds in infants with early weight loss will not adversely affect the rate of exclusive or any breastfeeding as measured at discharge, 3 and 6 months of age. MATERIAL AND METHODS: We randomly assigned 104 healthy term infants, 24 to 48 hours old, with ≥ 5% loss of birth weight to controlled limited formula (CLF) intervention (10 ml formula by syringe after each breastfeeding, discontinued at onset of lactation) or control group (standard approach, SA). Groups were compared for demographic data and breastfeeding rates at discharge, 3 months and 6 months of age (p-values adjusted for multiple testing). RESULTS: Fifty newborns were analysed in CLF and 50 in SA group. There were no differences in demographic data or clinical characteristics between groups. We found no evidence of difference between treatment groups in the rates of exclusive as well as any breastfeeding at discharge (p-value 0.2 and >0.99 respectively), 3 months (p-value 0.12 and 0.10) and 6 months of infants' age (p-value 0.45 and 0.34 respectively). The percentage weight loss during hospitalisation was significantly higher in the SA group (7.3% in CLF group, 8.4% in SA group, p = 0.002). CONCLUSION: The study shows that controlled limited formula use does not have an adverse effect on rates of breastfeeding in the short and long term. Larger studies are needed to confirm a possible potential in controlled limited formula use to support establishing breastfeeding and to help to improve the rates of breastfeeding overall. TRIAL REGISTRATION: ISRCTN registry ISRCTN61915183.

Evaluation of Cell-Free Urine microRNAs Expression for the Use in Diagnosis of Ovarian and Endometrial Cancers. A Pilot Study.

Among gynaecological cancers, epithelial ovarian cancers are the most deadly cancers while endometrial cancers are the most common diseases. Efforts to establish relevant novel diagnostic, screening and prognostic markers are aimed to help reduce the high level of mortality, chemoresistance and recurrence, particularly in ovarian cancer. MicroRNAs, the class of post-transcriptional regulators, have emerged as the promising diagnostic and prognostic markers associated with various diseased states recently. Urine has been shown as the source of microRNAs several years ago; however, there has been lack of information on urine microRNA expression in ovarian and endometrial cancers till now. In this pilot study, we examined the expression of candidate cell-free urine microRNAs in ovarian cancer and endometrial cancer patients using quantitative real-time PCR. We compared the expression between pre- and post-surgery ovarian cancer samples, and between patients with ovarian and endometrial cancers and healthy controls, within three types of experiments. These experiments evaluated three different isolation methods of urine RNA, representing two supernatant and one exosome fractions of extracellular microRNA. In ovarian cancer, we found miR-92a significantly up-regulated, and miR-106b significantly down-regulated in comparison with control samples. In endometrial cancer, only miR-106b was found down-regulated significantly compared to control samples. Using exosome RNA, no significant de-regulations in microRNAs expression could be found in either of the cancers investigated. We propose that more research should now focus on confirming the diagnostic potential of urine microRNAs in gynaecological cancers using more clinical samples and large-scale expression profiling methods.