[Intrapartum Foetal Heart Rate Monitoring and Rate of Caesarean Section: A National Survey]. / CTG-Analyse und Sectiorate ­ Ergebnisse einer deutschlandweiten Umfrage.

INTRODUCTION: The rate of Caesarean section has dramatically increased in recent decades. Foetal scalp blood sampling and computer software analysing foetal heart rate detection should help in the decision-making for or against Caesarean section. The main aim of this study was to examine how these 2 factors influence the Caesarean section rate. METHODS: A national survey of all maternity units in Germany was undertaken using a self-reported questionnaire via crowd sourcing. All variables were collected as categorised data sets. Using these data sets, correlation coefficients were calculated. The correlations were additionally analysed using visual mosaic plots. RESULTS: 97 questionnaires were analysed. There were several strong correlations between variables in the data set. Particularly, hospitals that assessed the foetal heart rate in the normal range (110-160 bpm) according to the current FIGO guidelines had a lower C-section rate. CONCLUSION: Computer-assisted foetal heart rate assessment that is based on the FIGO guidelines correlated with a lower Caesarean section rate. The use and further development of computer-based cardiotocograph assessment analysis should be continued.

[Comparison of International Guidelines For the Application of Cardiotocography]. / Vergleich internationaler Leitlinien zur Anwendung der Cardiotokografie.

OBJECTIVE: This study examines the recommendations of international guidelines on the use of antepartum and intrapartum cardiotocography. MATERIAL AND METHODS: The guidelines of Germany, Canada, UK, USA, Sri Lanka, Australia as well as FIGO have been compared. The recommendations on the use of cardiotocography were separately evaluated for antepartum and intrapartum use. RESULTS: Antepartum: In risk-free pregnancies the use of cardiotocography is not recommended in all countries. On the other hand the use of cardiotocography is indicated in the presence of a defined maternal and fetal risk factors. While the NICE guidelines recommend cardiotocography in the case of maternal hypertension, as well as preeclampsia, the German guidelines as well as SOGC list considerably more risk factors. Intrapartually, the recommendations vary greatly from country to country. While German guidelines suggest the use of cardiotocography from late 1st stage of labor, the other countries strongly recommend the auscultation of the fetal heart rate of non-risk pregnancies. This is due to the current study situation, which does not show any advantage of cardiotocography as opposed to intermittent auscultation. Furthermore studies have indicated that the use of cardiotocography caused an increase in iatrogenic induced cesarean sections. In high risk pregnancies the use of cardiotocography is strongly recommended in the compared countries, however there are major differences in the definition of high risk pregnancy and therefore the indication for cardiotocographic monitoring. CONCLUSION: Intermittent auscultation is a more cost-effective alternative compared to cardiotocography. However, in the case of legal litigation intermittent auscultation is harder to reconstruct the well-being of the newborn during birth. On the other hand cardiotocography might result in a higher cesarean section rate, but can be more helpful to prove fetal well-being during birth for a legal litigation process. Despite the lack of evidence only German guidelines recommend cardiotocographic monitoring from the late 1st stage of labor for risk-free pregnancies.

Targeted gene analysis: increased B-cell lymphoma 6 in preeclamptic placentas.

Preeclampsia is a leading cause for maternal and perinatal mortality and morbidity. Microarray-based transcriptional profiling has been widely used for identifying genes responsible for preeclampsia. These studies deliver multiple pictures of gene signatures, implying the complicated pathophysiology. In the present work, we designed our own gene array containing genes involved in various signaling transduction pathways and analyzed placental samples from patients with preeclampsia and controls. We verify that genes associated with angiogenesis and migration pathways are mostly altered in preeclamptic placentas. Interestingly, several genes including B-cell lymphoma 6 have been identified to be linked to preeclampsia. Increased expression of B-cell lymphoma 6 is correlated with enhanced FLT1 and LEPTIN, the hallmarks of preeclampsia. Moreover, the protein level of B-cell lymphoma 6 is elevated in preeclamptic placentas and is predominantly localized in the nucleus of villous cytotrophoblasts lying directly underneath the syncytial layer, suggestive of an involvement in the function of villous trophoblasts. Altered B-cell lymphoma 6, a key oncogene in B-cell lymphomagenesis, may be involved in the pathogenesis of preeclampsia, and further investigations are required to decipher the molecular mechanisms.

Prostaglandin E2 labour induction with intravaginal (Minprostin) versus intracervical (Prepidil) administration at term: randomized study of maternal and neonatal outcome and patient's perception using the osgood semantic differential scales.

AIM: To compare the efficacy, safety, and patient's perception of two prostaglandin E2 application methods for induction of labour. METHOD: Above 36th weeks of gestation, all women, who were admitted to hospital for induction of labour, were prospectively randomised to intravaginal 1 mg or intracervical 0.5 mg irrespective of cervical Bishop score. The main outcome variables were induction-to-delivery interval, number of foetal blood samples, PDA rate, rate of oxytocin augmentation, rate of vaginal delivery, and patient's perception using semantic differential questionnaire. RESULTS: Thirty-nine patients were enrolled in this study. There was no statistical significant difference between the two groups in regard to perceptions of induction. The median induction delivery time using intravaginal versus intracervical administration was 29.9 versus 12.8 hours, respectively (P = 0.04). No statistically difference between the groups was detected in regard to parity, gestation age, cervical Bishop score, number of foetal blood samples, PDA rate, rate of oxytocin augmentation, and mode of birth. SUMMARY: Irrespective of the cervical Bishop Score, intracervical gel had a shorter induction delivery time without impingement on the women's perception of induction.

Function of survivin in trophoblastic cells of the placenta.

BACKGROUND: Preeclampsia is one of the leading causes of maternal and perinatal mortality and morbidity worldwide and its pathogenesis is not totally understood. As a member of the chromosomal passenger complex and an inhibitor of apoptosis, survivin is a well-characterized oncoprotein. Its roles in trophoblastic cells remain to be defined. METHODS: The placental samples from 16 preeclampsia patients and 16 well-matched controls were included in this study. Real-time PCR, immunohistochemistry and Western blot analysis were carried out with placental tissues. Primary trophoblastic cells from term placentas were isolated for Western blot analysis. Cell proliferation, cell cycle analysis and immunofluorescence staining were performed in trophoblastic cell lines BeWo, JAR and HTR-8/SVneo. RESULTS: The survivin gene is reduced but the protein amount is hardly changed in preeclamptic placentas, compared to control placentas. Upon stress, survivin in trophoblastic cells is phosphorylated on its residue serine 20 by protein kinase A and becomes stabilized, accompanied by increased heat shock protein 90. Depletion of survivin induces chromosome misalignment, abnormal centrosome integrity, and reduced localization and activity of Aurora B at the centromeres/kinetochores in trophoblastic metaphase cells. CONCLUSIONS: Our data indicate that survivin plays pivotal roles in cell survival and proliferation of trophoblastic cells. Further investigations are required to define the function of survivin in each cell type of the placenta in the context of proliferation, differentiation, apoptosis, angiogenesis, migration and invasion.

Signal quality of non-invasive fetal electrocardiogram in vaginal breech delivery: a case-controlled study.

OBJECTIVE: Recently, a non-invasive fetal electrocardiogram monitor has been approved for clinical usage in labour and delivery. To determine the fetal signal quality of vaginal breech deliveries in comparison with a case-controlled cephalic group during labour. STUDY DESIGN: This case-control study was carried out at the Department of Obstetrics and Gynecology of the University Hospital Frankfurt between 1st July 2012 and 30th September 2012. A total of seven breech deliveries were evaluated. A case-controlled cephalic group with same gestational age and parity were selected from a previous trial. RESULTS: During first stage of labour, vaginal breech and cephalic delivery had no significant different fetal signal success rates (mean 87.8 vs. 85.7 %; p > 0.05). There was a trend of higher fetal signal success rates in the vaginal breech delivery group during second stage of labour (78.4 vs. 55.4 %; p = 0.08). CONCLUSION: Similar fetal signal success rates in vaginal breech delivery in comparison to cephalic presentation were demonstrated using the new commercially available non-invasive abdominal fECG device (the Monica AN24(TM)).

Prognostic impact of fascin-1 (FSCN1) in epithelial ovarian cancer.

BACKGROUND: Fascin-1 (FSCN1) plays an important role in cancer development and is associated with invasion and metastasis. Therefore, we explored the expression and localization of FSCN1 in epithelial ovarian cancer (EOC). MATERIALS AND METHODS: Expression analysis was performed by immunohistochemistry of paraffin-embedded tumor samples from 89 patients with EOC. Staining intensity and the percentage of positively stained tumor cells were used to calculate an immunoreactive score of 0-12 (IRS). These results were correlated to clinical and pathological characteristics as well as to patient survival. RESULTS: Negative (IRS=0), weak (IRS=0-2) and strong (IRS>2) expression of FSCN1 in EOC was found in 5 (5.6%), 30 (33.7%) and 54 (60.7%) tumor samples, respectively. There was a strong correlation of residual postoperative tumor of >1 cm with higher immunoexpression of FSCN1 (p=0.04). Lower FSCN1 expression was associated with significantly poorer overall survival (p=0.02). CONCLUSION: FSCN1 is frequently expressed in primary EOC. Its prognostic impact and function remains inconclusive and should be further examined in larger trials.

Intrapartum heart rate ambiguity: a comparison of cardiotocogram and abdominal fetal electrocardiogram with maternal electrocardiogram.

OBJECTIVE/AIMS: To investigate the presence of signal ambiguity of intrapartum fetal heart rate (FHR) monitoring during delivery by comparing simultaneous cardiotocogram (CTG), abdominal fetal electrocardiogram (ECG) with continuous maternal ECG. METHODS: A total of 144 simultaneous CTG (Corometrics 250 series), abdominal fetal ECG (Monica -AN24™) and maternal ECG (Monica AN24™) recordings were evaluated. MAIN OUTCOME MEASURES: When the FHR is within 5 bpm of the maternal heart rate (MHR) acquired from the ECG, it is classified as 'MHR/FHR ambiguity'. Statistical analyses were performed with Fisher's exact test and the Wilcoxon signed-rank test. RESULTS: Comparison of abdominal fetal ECG against CTG demonstrates significantly less 'MHR/FHR ambiguity' in both the first stage (mean 0.70 vs. 1.22%, p < 0.001) and second stage of labour (mean 3.30 vs. 6.20%, p < 0.001). CONCLUSION: Intrapartum FHR monitoring in daily practice via the CTG modality provides significantly more 'MHR/FHR ambiguity' than abdominal fetal ECG, which also provides additional information on the MHR.

Delivery mode and neonatal outcome after a trial of external cephalic version (ECV): a prospective trial of vaginal breech versus cephalic delivery.

OBJECTIVE: To examine the delivery mode and neonatal outcome after a trial of external cephalic version (ECV) procedures. STUDY DESIGN: This is an interim analysis of an ongoing larger prospective off-centre randomised trial, which compares a clinical hypnosis intervention against neuro-linguistic programming (NLP) of women with a singleton breech foetus at or after 37(0/7) (259 days) weeks of gestation and normal amniotic fluid index. Main outcome measures were delivery mode and neonatal outcome. RESULTS: On the same day after the ECV procedure two patients (2 %), who had unsuccessful ECVs, had Caesarean sections (one due to vaginal bleeding and one due to pathological CTG). After the ECV procedure 40.4 % of women had cephalic presentation (n = 38) and 58.5 % (n = 55) remained breech presentation. One patient remained transverse presentation (n = 1; 1.1 %). Vaginal delivery was observed by 73.7 % of cephalic presentation (n = 28), whereas 26.3 % (n = 10) had in-labour Caesarean sections. Of those, who selected a trial of vaginal breech delivery, 42.4 % (n = 14) delivered vaginally and 57.6 % (n = 19) delivered via Caesarean section. There is a statistically significant difference between the rate of vaginal birth between cephalic presentation and trial of vaginal breech delivery (p = 0.009), however, no difference in neonatal outcome was observed. CONCLUSION: ECV is a safe procedure and can reduce not only the rate of elective Caesarean sections due to breech presentation but also the rate of in-labour Caesarean sections even if a trial of vaginal breech delivery is attempted.

Clinical hypnosis before external cephalic version.

Three to four percent of full-term singleton pregnancies present themselves as breech deliveries. External cephalic version (ECV) is a procedure to try to turn a breech fetus to cephalic by externally maneuvering the fetus through the maternal abdomen. This trial examines a clinical hypnosis intervention against standard medical care of women before ECV. A total of 78 women, who received a hypnosis intervention prior to ECV, had a 41.6% (n = 32) successful ECV, whereas the control group of 122, who had similar baseline characteristics, had a 27.3% (n = 33) successful ECV procedure (p < 0.05). This trial found that a relaxation technique with the help of clinical hypnosis was successful at increasing the likelihood of a successful ECV procedure.

Delayed interval delivery in twin and triplet pregnancies: 6 years of experience in one perinatal center.

OBJECTIVE: This study aimed to know the outcome of delayed-interval delivery for twin and triplet pregnancies at 22+0 to 25+0 weeks of gestation. STUDY DESIGN: A retrospective cohort of twin and triplet deliveries at the 23rd to 26th weeks of gestation were managed with delayed interval delivery from 2005 to 2011. RESULTS: From 2005 until 2011, delayed delivery in five twin pregnancies and two triplet pregnancies were performed. The interval between delivery of the first fetus and the remaining twin/triplets was 1-18 days (mean, 9.7 days). In all cases, the first fetus was born vaginally. Survival of the first twin/triplet was 14.3%, whereas 57.1% of the second born twin/triplets survived. Birth weight gained due to delayed delivery was 131 g on average. No severe maternal complications were observed. When compared with a gestation age-matched group, where the delay was not possible, the delayed twin/triplet had a higher survival rate (57.1% vs. 0%, P=0.05). CONCLUSION: In multiple pregnancies with preterm delivery between completed 22 and completed 25 weeks of gestational age, delayed delivery seems to be a useful therapeutic option to achieve a better outcome of the remaining fetus or fetuses.

A lesson for cancer research: placental microarray gene analysis in preeclampsia.

Tumor progression and pregnancy share many common features, such as immune tolerance and invasion. The invasion of trophoblasts in the placenta into the uterine wall is essential for fetal development, and is thus precisely regulated. Its deregulation has been implicated in preeclampsia, a leading cause for maternal and perinatal mortality and morbidity. Pathogenesis of preeclampsia remains to be defined. Microarray-based gene profiling has been widely used for identifying genes responsible for preeclampsia. In this review, we have summarized the recent data from the microarray studies with preeclamptic placentas. Despite the complex of gene signatures, suggestive of the heterogeneity of preeclampsia, these studies identified a number of differentially expressed genes associated with preeclampsia. Interestingly, most of them have been reported to be tightly involved in tumor progression. We have discussed these interesting genes and analyzed their potential molecular functions in preeclampsia, compared with their roles in malignancy development. Further investigations are warranted to explore the involvement in molecular network of each identified gene, which may provide not only novel strategies for prevention and therapy for preeclampsia but also a better understanding of cancer cells. The trophoblastic cells, with their capacity for proliferation and differentiation, apoptosis and survival, migration, angiogenesis and immune modulation by exploiting similar molecular pathways, make them a compelling model for cancer research.

The Effects of Clinical Hypnosis versus Neurolinguistic Programming (NLP) before External Cephalic Version (ECV): A Prospective Off-Centre Randomised, Double-Blind, Controlled Trial.

Objective. To examine the effects of clinical hypnosis versus NLP intervention on the success rate of ECV procedures in comparison to a control group. Methods. A prospective off-centre randomised trial of a clinical hypnosis intervention against NLP of women with a singleton breech fetus at or after 37(0/7) (259 days) weeks of gestation and normal amniotic fluid index. All 80 participants heard a 20-minute recorded intervention via head phones. Main outcome assessed was success rate of ECV. The intervention groups were compared with a control group with standard medical care alone (n = 122). Results. A total of 42 women, who received a hypnosis intervention prior to ECV, had a 40.5% (n = 17), successful ECV, whereas 38 women, who received NLP, had a 44.7% (n = 17) successful ECV (P > 0.05). The control group had similar patient characteristics compared to the intervention groups (P > 0.05). In the control group (n = 122) 27.3% (n = 33) had a statistically significant lower successful ECV procedure than NLP (P = 0.05) and hypnosis and NLP (P = 0.03). Conclusions. These findings suggest that prior clinical hypnosis and NLP have similar success rates of ECV procedures and are both superior to standard medical care alone.

Intrapartum signal quality with external fetal heart rate monitoring: a two way trial of external Doppler CTG ultrasound and the abdominal fetal electrocardiogram.

OBJECTIVE: The objective of this study was to assess the fetal heart rate (FHR) signal quality of non-invasive abdominal fetal electrocardiogram (fECG) in comparison to the Doppler ultrasound cardiotocogram (CTG) during the first and second stage of labour. STUDY DESIGN: This was a prospective observational study of non-invasive fECG using five abdominally sited electrodes against the traditional Doppler ultrasound CTG probe on 144 patients. Data were analysed for signal quality before and after outlier removal. RESULTS: Abdominal fECG signal quality was significantly better during the first stage of labour in comparison to Doppler CTG (median fECG reliability of 95.7 % vs. median 87.3 % for Doppler, p < 0.001), whereas during second stage of labour, equivalence was demonstrated (p > 0.05). For the first and second stage of labour, fECG showed 106/135 (78.5 %) and 46/98 (46.9 %) women having fetal signal loss below 20 %, respectively. Similarly, Doppler ultrasound demonstrated 104/135 (77.0 %) and 51/98 (52.0 %) women having fetal signal loss below 20 % during first and second stage of labour, respectively. CONCLUSION: The non-invasive abdominal fECG presents an improved FHR signal quality during the first stage of labour and an equivalent signal quality during the second stage.

Comparison of non-invasive fetal electrocardiogram to Doppler cardiotocogram during the 1st stage of labor.

OBJECTIVE: We compared a non-invasive fetal electrocardiogram (fECG) to Doppler cardiotocogram (CTG) during the 1(st) stage of labor. STUDY DESIGN: This was a prospective observational study of non-invasive fECG using five abdominal electrodes and one Doppler ultrasound probe in 27 patients. Data were analyzed for reliability, clinical and statistical equivalence. RESULTS: The fECG was similar to the traditional Doppler method. The fECG characterizes a fetal heart rate (FHR) trace in a similar way with regards to acceleration count, decelerations count and coincidence, variability and baseline. The FHR was overall correlated (Pearson's r=0.91). CONCLUSION: This non-invasive fECG presents an alternative, reliable and accurate assessment for fetal well-being during the 1(st) stage of labor.

Fetal short time variation during labor: a non-invasive alternative to fetal scalp pH measurements?

OBJECTIVE: To determine whether short time variation (STV) of fetal heart beat correlates with scalp pH measurements during labor. PATIENTS AND METHODS: From 1279 deliveries, 197 women had at least one fetal scalp pH measurement. Using the CTG-Player, STVs were calculated from the electronically saved cardiotocography (CTG) traces and related to the fetal scalp pH measurements. RESULTS: There was no correlation between STV and fetal scalp pH measurements (r=-0.0592). CONCLUSIONS: Fetal STV is an important parameter with high sensitivity for antenatal fetal acidosis. This study shows that STV calculations do not correlate with fetal scalp pH measurements during labor, hence are not helpful in identifying fetal acidosis.

Diagnosis, treatment, observation and outcome of fetal supraventricular tachycardia in a twin pregnancy.

BACKGROUND: Magnetocardiography and M-mode fetal echocardiography are non-invasive techniques capable of identifying fetal arrhythmias. The STAN-fetal scalp electrode system can record the fetal echocardiogram in labor. CASE: A patient was admitted to hospital with preterm contractions and cervical insufficiency at 28 weeks of gestation. After treatment with a beta-sympathomimetic drug (Partusisten) one fetus developed supraventricular tachycardia. After terminating the Partusisten medication, there was no effect on the fetal arrhythmia and flecainide therapy was initiated. Maintenance dosages controlled the condition thereafter. Cardiac time intervals of a fetus in labor can be presented, which did not change significantly throughout the first stage of labor. CONCLUSION: Flecainide is an effective therapy for supraventricular tachycardias in a twin pregnancy. Analyzing the cardiac time intervals during pregnancy can improve perinatal outcome.