[Birth in the Midwife-Led Delivery Room of a Perinatal Center - Learning Curve, Outcomes and Benchmark]. / Geburt im hebammengeleiteten Kreißsaal eines Perinatalzentrums ­ Lernkurve, Ergebnisse und Benchmark.

INTRODUCTION: Most births in Germany take place in a clinical setting. Midwife-led units have been offered in Germany since 2003 as an addition to the primarily physician-led obstetric care. The purpose of this study was to analyze differences regarding medical parameters between a midwife-led and a primarily physician-led unit in a level 1 perinatal center. MATERIAL AND METHODS: Between 12/2020 and 12/2021, all births begun in the midwife-led unit were retrospectively analyzed and compared to a physician-led control cohort. Outcome measures were defined as obstetric interventions, delivery mode and duration, delivery position, and maternal and neonatal outcome. RESULTS: The percentage of deliveries started in the midwife-led unit out of the total birth rate was 4.8% (n=132). Most transfers were made for more effective analgesia (52.6%). Among medically indicated transfers (n=30, 39.5%), transfers due to CTG abnormalities and failure to progress in labor after rupture of membranes predominated. 43.9% (n=58) of patients gave birth successfully in the midwife-led unit. The rate of episiotomy was significantly higher in the primarily physician-led unit compared to the successful midwife-led unit (p=0.019). CONCLUSION: Birth in a midwife-led unit within a perinatal center can be considered an equivalent alternative to primarily physician-led birth for low-risk pregnant women.

Real-world data on the clinical use of angiogenic factors in pregnancies with placental dysfunction.

BACKGROUND: In routine clinical practice, angiogenic factor measurement can facilitate prediction and diagnosis of preeclampsia and other manifestations of placental dysfunction (eg, intrauterine growth restriction). OBJECTIVE: This real-world data analysis investigated the utility of soluble fms-like tyrosine kinase-1 and placental growth factor for preeclampsia and placental dysfunction. STUDY DESIGN: Blood serum soluble fms-like tyrosine kinase-1 and placental growth factor were measured using Elecsys soluble fms-like tyrosine kinase-1 and placental growth factor immunoassays (cobas e analyzer; Roche Diagnostics). Overall, 283 unselected singleton pregnancies with ≥1 determination of soluble fms-like tyrosine kinase-1-to-placental growth factor ratio were included. Distribution of the ratio at admission was normal (<38 [58.7%]), intermediate (38-85/110 [19.1%]), or pathologic (>85/110 [22.3%]). Overall, 15.5% had preeclampsia or hemolysis, elevated liver enzyme levels, and low platelet count, and 15.5% of women had intrauterine growth restriction. RESULTS: Increasing soluble fms-like tyrosine kinase-1-to-placental growth factor ratio was associated with an increase in priority of delivery (r=0.38; P<.001). The percentage of patients who developed preeclampsia by soluble fms-like tyrosine kinase-1-to-placental growth factor ratio at admission was 5.4% (normal), 7.4% (intermediate), and 49.2% (pathologic). The greatest difference in soluble fms-like tyrosine kinase-1-to-placental growth factor ratio from admission to birth occurred in pathologic pregnancies (171.12 vs 39.84 for normal pregnancies). Soluble fms-like tyrosine kinase-1-to-placental growth factor ratio correlated inversely with gestational age at delivery, birthweight, and prolongation time. There was no significant relation between the prolongation period or the gestational age at first determination to the increase of soluble fms-like tyrosine kinase-1 and placental growth factor between admission and delivery (ΔQ). This analysis used a real-world approach to investigate the clinical utility of the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio in placental dysfunction. CONCLUSIONS: Confirming the results of prospective studies, we observed a positive correlation between soluble fms-like tyrosine kinase-1-to-placental growth factor ratio and severity of placental dysfunction and a negative association with time to delivery. In a real-world setting, the soluble fms-like tyrosine kinase-1-placental growth factor ratio stratifies patients with normal outcome and outcome complicated by placental dysfunction.

Combining Biomarkers to Predict Pregnancy Complications and Redefine Preeclampsia: The Angiogenic-Placental Syndrome.

Placental dysfunction underlies a spectrum of perinatal pathologies, including preeclampsia and fetal growth restriction. Angiogenesis-related factors, including sFlt-1 (soluble fms-like tyrosine kinase 1) and PlGF (placental growth factor), play an important role in placental dysfunction; altered levels are detectable several weeks before onset of pregnancy complications. In vitro diagnostic tests for these biomarkers can improve early diagnosis and facilitate prediction of maternal and fetal outcomes. We assessed evidence for combining angiogenic biomarkers with other biomarkers or clinical parameters to predict maternal/fetal outcomes in pregnant women with placental dysfunction. Pooled information on placental perfusion (ultrasonography, mean arterial pressure), clinical characteristics, and biomarker levels (PlGF) can improve first-trimester prediction and preeclampsia diagnosis. Angiogenic factors (sFlt-1/PlGF ratio; PlGF alone) with or without clinical characteristics can facilitate second-/third-trimester prediction of early-onset and late-onset preeclampsia. A combination of increased sFlt-1/PlGF ratio and ultrasound can rule out early fetal growth restriction. The sFlt-1/PlGF ratio is also a reliable tool for discriminating between pregnancy-related hypertensive disorders, including superimposed preeclampsia and gestational hypertension. Analysis of angiogenic factors with or without uterine Doppler substantially improves sensitivity and specificity for predicting adverse outcomes and iatrogenic preterm delivery. We propose to extend the American College of Obstetricians and Gynecologists definition of preeclampsia in the future to include the combination of new-onset hypertension and new-onset of altered angiogenic factors (sFlt-1/PlGF ratio or PlGF alone). In summary, altered angiogenic biomarkers indicate placental dysfunction, and their implementation into clinical practice will help reduce the considerable burden of morbidity and mortality associated with adverse pregnancy outcomes as a consequence of angiogenic-placental syndrome.