Cesarean Section Rate and Perinatal Outcome Analyses According to Robson's 10-Group Classification System.

OBJECTIVES: The cesarean delivery (CD) rate is increasing worldwide. An internationally recognized classification system had been required to analyse the trend and its possible consequences in a standardized manner. The goal of this study was to identify the main contributors to the CD rate at the Medical University of Vienna in an 11-year time period (2003-2013) and to analyse neonatal outcome parameters within the ten Robson categories. METHODS: This is a retrospective data-analysis of singleton and twin pregnancies in cephalic, breech and transverse presentation with a gestational age between 23 and 42 weeks. The cases were divided into ten classes based on the Robson criteria. CD rates and perinatal outcome parameters were analysed within each Robson class. The outcome parameters included: NICU-admission rate and 5 min Apgar score values < 7. RESULTS: The overall CD rate was at 44.2%. Within Robson class 5 the CD rate was the highest at 99.1%. Main contributors were Robson class 5 at 20.6%, followed by class 2 at 17.1% and class 8 at 15.0%. Neonatal outcome analyses revealed significant differences between the Robson classes. CONCLUSIONS: The main contributors to the CD rate were determined. We suggest reconsidering the frequently applied birth mode especially for Robson class 2, 4, 5 and 8. Lowering the CD rate could be achievable, if a careful delivery management and an individual risk evaluation is provided. It is important to reduce the CD rate in the individual Robson classes under consideration of perinatal outcome parameters, since a reduction should only take place where it is clinically useful and relevant.

Outcomes and trends of peripartum maternal admission to the intensive care unit.

BACKGROUND: The number of pregnant women with severe comorbidities is increasing. The aim of the present study was to analyze outcomes and determine trends in women who required peripartum admission to the intensive care unit (ICU). METHODS: In this retrospective study, we identified all women who were admitted to the ICU between the second trimester of pregnancy and 6 weeks postpartum. Women with ICU admission between 2011 and 2014 were assigned to the study group, whereas those admitted between 1996 and 2003 were assigned to the historical group. Comorbidities, characteristics, outcomes, and treatment efforts were assessed. Descriptive analysis, Fisher's exact test, unpaired Student's t-test and one-way ANOVA were performed. RESULTS: We identified 238 cases, including 135 (56.7%) in the study group and 103 (43.3%) in the historical group. In 83 (34.9%) women, deterioration of the pre-existing medical condition was causal for ICU admission. Overall, preterm delivery and mean gestational age were 81.5% and 31.6 ± 6.2 weeks, respectively. In comparison to the historical group, women of the study group were older (p = 0.005), more frequently presented with multiple comorbidities (p = 0.003), pre-existing conditions (p < 0.001), and congenital heart disease (p = 0.012). Moreover, they had a shorter length of stay at the ICU than those of the historical group (p = 0.02). CONCLUSIONS: Peripartum ICU admissions are increasing in frequency. As maternal characteristics are changing, adequate risk stratification with multidisciplinary care are essential, and access to intermediate care units would be preferable for patients with short-term admission.

Effect of delivery mode on neonatal outcome among preterm infants: an observational study.

BACKGROUND: The optimal mode of delivery as a predictor for outcomes in preterm infants is under debate. The purpose of this study was to evaluate the effect of the delivery mode on neonatal outcome among preterm infants in different birthweight categories. METHODS: A retrospective analysis of singleton preterm deliveries from 23 + 0 to 33 + 6 gestational weeks was performed. Infants were categorized based on birthweight as large for gestational age (LGA), appropriate for gestational age (AGA) and small for gestational age (SGA). The Apgar score at 5 min served as the main outcome parameter. A sensitivity analysis was performed to adjust for maternal age, parity and fetal malformations as potential confounders. RESULTS: Out of 1320 singleton preterm infants, 970 (73.5%) were delivered by cesarean section and 350 (26.5%) were delivered vaginally. The AGA infants between 23 + 0 and 27 + 6 weeks showed better outcomes after cesarean section (p < 0.01 from 23 + 0-24 + 6; p = 0.03 from 25 + 0-27 + 6), whereas AGA infants between 31 + 0 and 33 + 6 gestational weeks showed better outcomes after vaginal delivery (p = 0.02). Cesarean section was beneficial in extremely and very preterm SGA infants (p = 0.01 from 25 + 0-27 + 6; p = 0.02 from 28 + 0-30 + 6). The sensitivity analysis showed no confounding effect of other variables. CONCLUSION: There is a benefit from cesarean section in AGA preterm infants until 28 weeks of gestation and in SGA preterm infants until 31 weeks of gestation. Vaginal delivery should be chosen for moderately preterm AGA infants.

The mode of delivery in patients with preeclampsia at term subject to elective or emergency Cesarean section.

PURPOSE: Preeclampsia is accompanied by high maternal and fetal morbidity and mortality. Thus, delivery needs to be planned carefully. The aim of this study was to determine the most favorable delivery for patients with preeclampsia between the week 37 and 41 of gestation. METHODS: For this retrospective study, patient data from 2003 to 2011 was collected. Study participants were women having a Cesarean section during week 37 and 41 of gestation. The population was classified into four groups: patients without hypertensive disorders having an elective or emergency Cesarean section and patients suffering from preeclampsia with elective or emergency Cesarean section. Analysis included mode of delivery and neonatal outcome, defined by Apgar score, rate of NICU admission and pH value of the umbilical cord. RESULTS: A total of 130 cases of preeclampsia were recorded. Compared to the control group, we observed a significantly higher Apgar score in the study group with emergency Cesarean section. Furthermore, within the study group the Apgar score at 5 and 10 min was also significantly increased in cases delivered by emergency Cesarean section. Moreover, the pH value of the umbilical cord was significantly higher in the study group. Considering the delivery mode, significant differences were found in favor of the elective Cesarean section. There were no differences in the rate of NICU admission between the groups. CONCLUSION: The most frequent mode of delivery for women suffering from preeclampsia is elective Cesarean section; however, neonates delivered by emergency Cesarean section did not show an adverse neonatal outcome.

The fibrinogen/CRP ratio as a new parameter for the diagnosis of disseminated intravascular coagulation in patients with HELLP syndrome and as a predictive factor for neonatal outcome.

OBJECTIVE: The aim of this study was to determine if the fibrinogen/C-reactive protein (CRP) ratio could be used in obstetrics as a predictor for a disseminated intravascular coagulation. STUDY DESIGN: One hundred eleven patients with hemolysis, elevated liver enzymes, and low platelet count syndrome at the Department of Obstetrics and Fetomaternal Medicine (General Hospital, Vienna, Austria) were selected and divided into 2 groups (overt disseminated intravascular coagulation, no overt disseminated intravascular coagulation). The classical parameters and the fibrinogen/CRP ratio were compared. The analysis was carried out using IBM SPSS statistical package (SPSS, Inc, Cary, NC). RESULTS: The fibrinogen/CRP ratio showed significant differences. The receiver-operating characteristic analysis showed for the ratio (area under the curve, 0.74) significantly better discriminative power than for fibrinogen (area under curve, 0.59). The odds ratio for the fibrinogen/CRP ratio was 7.04. Finally, significant correlations between the ratio and the neonatal outcome were found. CONCLUSION: We suggest the implementation of the fibrinogen/CRP ratio within patients with hemolysis, elevated liver enzymes, and low platelet count syndrome as a diagnostic and prognostic factor for the occurrence of disseminated intravascular coagulation.

Maternal outcome monitoring: induction of labor versus spontaneous onset of labor­a retrospective data analysis.

PURPOSE: To determine the efficacy and maternal complication rates of induction of labor, and to identify a concrete point in time for induction with the lowest possible risk for adverse events. METHODS: We designed a retrospective data analysis of all births at the general hospital of Vienna from 2003 to 2008(n = 16,872) and compared maternal complications of induced labors from 38 or more weeks of gestation versus spontaneous deliveries. The ethical committee of the General Hospital of Vienna and the Medical University of Vienna monitored this study and provided approval. RESULTS: Women who had induction between 38 and 42 weeks of gestation (n = 1,254) had a significant higher risk for the need of a secondary cesarean (15.2 vs. 8.6%;p\0.001) and a higher chance for abnormally adherent placentas (1.5 vs. 2.5%; p = 0.13). The amount of maternal blood loss was equal in both groups. Concerning the question when to induct labor, there was no significant difference of distribution of complications between induced labors at term and induction within the next 10 days. CONCLUSIONS: This study suggests that induction is associated with a higher risk for secondary cesareans and abnormally adherent placentas. The exact time of induction seems to be irrelevant between expected date of delivery and the next 10 days.

Early postpartum hysterectomy: incidence and risk factors.

OBJECTIVE: To determine the incidence and risk factors of early postpartum hysterectomy at the University Hospital in Vienna. DESIGN: Retrospective case-control study. SETTING: General Hospital Vienna, a tertiary referral center. POPULATION: All 15,858 women who gave birth between 1st January 2003 and 31st December 2008. METHODS: Analysis of all cases of early postpartum hysterectomy using data from the clinical documentation system. MAIN OUTCOME MEASURE: Postpartum hysterectomy done during or within 24 hours of birth. RESULTS: The incidence of early postpartum hysterectomy was 1.39/1,000. Abnormally adherent placenta was the most common cause for hysterectomy followed by uterine atony and uterine rupture. There were no maternal deaths. Abnormal placentation, increased blood loss and lower gestational age were significant risk factors in women undergoing hysterectomy. The newborns of these women had a lower birthweight, significantly lower Apgar scores at 1 and 5 minutes and were more often transferred to the neonatal intensive care unit (NICU). An additional analysis in a sample of women with uterine atony identified age as risk factor for hysterectomy. CONCLUSION: Abnormal placentation, increased blood loss, low gestational age and maternal age are risk factors for early postpartum hysterectomy.

Immunohistochemical localization of survivin in serous tumors of the ovary.

The aim of this study was to determine the immunohistochemical distribution of survivin in benign, borderline, and malignant serous tumors of the ovary. Survivin was localized by an indirect immunoperoxidase method in 42 cases of serous tumors of the ovary (15 cystadenomas, 15 borderline tumors, and 12 cystadenocarcinomas). Nuclear staining and cytoplasmic staining were separately scored. Cytoplasmic staining was detected in 27% of adenomas/borderline tumors and in 58% of carcinomas. Nuclear staining was detected in 87% of adenomas/borderline tumors but in only 42% of carcinomas. Although the differences in the intensity of cytoplasmic staining between adenomas and borderline tumors versus carcinomas were not significant, the differences in the intensity of nuclear staining between low-grade versus malignant tumors were significant. These findings suggest that survivin is widely expressed in benign, borderline, and malignant serous tumors but that nuclear localization of survivin is more common in benign or borderline tumors than in malignant serous tumors of the ovary. The molecular mechanisms that determine the subcellular distribution of this protein may reflect the role of survivin in the regulation of apoptosis during the processes of malignant transformation.

Pedigree analysis and descriptive investigation of three classic phenotypes associated with Holt-Oram syndrome.

OBJECTIVE: To determine the frequency of sporadic and familial cases of three classic phenotypes associated with Holt-Oran syndrome (HOS). STUDY DESIGN: We determined the frequency of sporadic and familial cases based on the 179 patients with HOS reported in the literature. RESULTS: Clinically, there are three variations of HOS: affected individuals may have only skeletal anomalies (27.4%), only cardiac defects (3.9%) or both (68.7%). Of the 179 affected individuals, 17.3% had sporadic and 82.7% had familial disease. CONCLUSION: The equal distribution between the sexes (female 53%, male 47%) indicates that HOS is transmitted as an autosomal dominant trait. In contrast to familial cases, cardiac involvement alone was not reported in any of the sporadic cases. When a cardiac malformation is diagnosed, the family members of the affected individual should be carefully screened for Holt-Oram syndrome.

Immunohistochemical localization of the IAP protein survivin in bladder mucosa and transitional cell carcinoma.

In the current study, the immunohistochemical localization of survivin was correlated with the histologic diagnosis in healthy transitional cell epithelium, transitional cell carcinoma (TCC) in situ, and TCC of the urinary bladder. Forty-five TCCs (grades 1-3, 15 of each), 14 cases of TCC in situ, and II healthy bladder mucosal specimens were selected from archival collections of formalin-fixed bladder tissues. Slides were reacted with an anti-survivin antibody using a conventional immunohistochemical method and then were scored for nuclear and cytoplasmic staining. Statistical analysis of survivin expression was performed to evaluate the correlation of staining pattern with histologic diagnosis and clinical outcome. Nuclear staining for survivin was detected in 26 of 45 TCCs and in 2 of 14 cases of TCC in situ, but was not detected in healthy bladder mucosa. The association of nuclear staining with TCC versus both healthy bladder mucosa and TCC in situ was statistically significant (P < 0.001). Patients with TCC and a nuclear pattern of survivin localization had a greater period of disease-free survival (27.2 months) than was observed in patients with TCC that showed no nuclear staining for survivin (9.9 months); however, the differences were not statistically significant. Nuclear localization of survivin is a marker of TCC but is rarely present in premalignant or benign bladder mucosal specimens.

Premature labor in a women with perforating appendicitis at 36 weeks of gestation. A case report.

BACKGROUND: Acute appendicitis during pregnancy is a serious complication because of the difficult diagnosis and increased perinatal morbidity and mortality. CASE: A 29-year-old woman underwent cesarean section and an appendectomy because of clinical symptoms of an acute abdomen and fetal distress. CONCLUSION: Acute appendicitis in pregnancy is rare but requires special attention to maternal and fetal morbidity and mortality. In this case, acute appendicitis and peritonitis were associated with uterine contractions and fetal distress. How extrauterine infections may mediate uterine contractions and fetal distress remains unsolved.

Correlation of survivin mRNA detection with histologic diagnosis in normal endometrium and endometrial carcinoma.

BACKGROUND: The objective of this study was to determine if survivin mRNA expression is a marker of endometrioid adenocarcinoma and if survivin mRNA levels correlate with tumor grade and stage. METHODS: Twenty-six samples of endometrioid adenocarcinoma and 18 cases of benign endometrium were obtained at surgery. RNA was extracted from tissues and was used for quantitative real-time RT-PCR, targeting a 91-bp sequence of survivin mRNA and the levels were standardized to the levels of ribosomal RNA. Statistical analysis of the correlation between histologic diagnosis and the corrected survivin mRNA levels was performed by the Fisher Exact test and the Kruskal-Wallis test. RESULTS: Survivin mRNA was detected in all specimens. Survivin mRNA levels were increased in proliferative endometrium (P = 0.0509) and was increased in correlation with ascending grade in endometrioid adenocarcinoma (P = 0.01). CONCLUSION: Survivin mRNA is not a specific marker of endometrial cancer, but may reflect an important mechanism in tumor progression of the endometrial mucosa.

Quantitative analysis of telomerase hTERT mRNA and telomerase activity in endometrioid adenocarcinoma and in normal endometrium.

OBJECTIVES: In the current study, the quantitative levels of telomerase hTERT mRNA and the functional telomerase repeat amplification protocol (TRAP) assay were correlated with tumor grade in endometrial carcinomas and with the histologic phase of normal endometrium. METHODS: Twenty-six samples of endometroid adenocarcinoma and 20 cases of benign endometrium were obtained from hysterectomy specimens. Total RNA was extracted from each tissue sample and used for quantitative real-time RT-PCR of hTERT mRNA and the levels were standardized to the levels of ribosomal RNA. Quantitative determination of telomerase activity was performed by the polymerase chain-based TRAP assay and the levels of expression were defined by the ratio of radioactivity incorporated into the 6-bp telomerase amplification products versus the radioactivity incorporated into an internal standard (telomerase/ITAS x 100 = 1 RU). Statistical analyses were performed using the Fisher exact test or chi2 test, a Wilcoxon rank sum test, and a linear regression analysis. RESULTS: hTERT mRNA and telomerase activity levels showed a linear association in the study group (P = 0.006, R2 = 0.139). hTERT mRNA levels and telomerase activity levels were significantly higher in endometrial cancer (179 pg/ng rRNA, 44 relative units (RU)) than in normal endometrium (45 pg/ng), (15 RU) (P = 0.009, P = 0.006). In normal endometrium, hTERT mRNA and telomerase activity levels were highest in the proliferative phase (74 pg/ng rRNA, 25 RU) and were relatively low in secretory (13 pg/ng rRNA, 6 RU) and atrophic endometrium (9 pg/ng rRNA, 2 RU). CONCLUSION: These results suggest that the quantitative analysis of hTERT and telomerase activity may have potential roles as diagnostic or prognostic adjuncts for both premenopausal and postmenopausal patients with endometrial cancer.