Does vaginal bacterial colonization contribute to preterm birth in women with asymptomatic shortened cervix?

PURPOSE: The aim of this study is to describe the typical microbial spectrum and the influence of distinct vaginal infections on preterm birth in pregnancies affected by cervical incompetence. METHODS: 327 patients were admitted because of asymptomatic shortening of the cervix in the second and third trimester of pregnancy. Clinical data such as age, cervical length, gestational age at admission and at delivery and vaginal microbiologic findings were collected and analyzed. RESULTS: The spectrum of germs in the vagina revealed seven different distinct species; the most common bacteria were Ureaplasma spp. and E. coli. In 327 included patients, 217 revealed a bacterial colonization, 110 did not. Most common bacteria in women with preterm birth before 34 weeks were Ureaplasma spp., while E. coli was most common in women undergoing preterm birth after 34 weeks. Nevertheless, the rates of occurrence of these bacterial taxa were not significantly different between who underwent preterm birth to those who did not. CONCLUSIONS: This study gives an overview over the vaginal bacterial colonization in pregnant women with cervical incompetence. The clinical relevance of vaginal bacterial colonization remains unclear.

Post-traumatic stress disorder following childbirth: prevalence and associated factors-a prospective cohort study.

OBJECTIVE: Traumatic experiences during or after childbirth are subject of intense discussions in mainstream and social media as well as in scientific literature. Aim of this evaluation is to estimate the prevalence of post-traumatic stress disorder (PTSD) following childbirth in postpartum women and to evaluate the influence of maternal, obstetrical and neonatal characteristics on the degree of PTSD symptoms measured by the Impact of Events Scale questionnaire (IES-R). METHODS: In total, 589 women who gave birth in the University Medical Center Mainz, Germany in 2016, participated in a survey within the first days after birth. Of these, 278 also participated 6 months later. All participants received the validated Impact of Events Scale questionnaire (IES-R). The influence of maternal, obstetric and fetal parameters on PTSD score was evaluated. RESULTS: PTSD overall prevalence was 2.9%. Patients with PTSD had significantly less often personal support during labor (p < 0.001). Maternal age (p < 0.001), parity (p < 0.001), migration background (p < 0.001), mode of delivery (p < 0.001) and assistance during labor (p < 0.001) were parameters significantly influential on the PTSD symptom level measured by the IES-R. CONCLUSIONS: Maternal PTSD prevalence after childbirth seems to be quite rare with 2.9%. Nevertheless, recent findings assume that this prevalence may only represent the "tip of the iceberg". PTSD after childbirth should not be underestimated. As PTSD depends on personal vulnerability and existing risk factors, patients at risk have to be detected before childbirth, which appears to be challenging especially for obstetric and family care professionals.

EndoPredict® in early hormone receptor-positive, HER2-negative breast cancer.

PURPOSE: Evaluating consecutive early breast cancer patients, we analyzed both the impact of EndoPredict® on clinical decisions as well as clinico-pathological factors influencing the decision to perform this gene expression test. METHODS: Hormone receptor (HR)-positive and human epidermal growth factor receptor 2 (HER2)-negative early breast cancer patients treated between 2011 and 2016 were included in this study to investigate the role of EndoPredict® (EPclin) in the treatment of early breast cancer. A main study aim was to analyze the changes in therapy recommendations with and without EPclin. In addition, the impact of clinico-pathological parameters for the decision to perform EPclin was examined by Pearson's chi-squared test (χ2-test) and Fisher's exact test as well as univariate and multivariate logistic regressions. RESULTS: In a cohort of 869 consecutive early HR-positive, HER-negative breast cancer patients, EPclin was utilized in 156 (18.0%) patients. EPclin led to changes in therapy recommendations in 33.3% (n = 52), with both therapy escalation in 19.2% (n = 30) and de-escalation in 14.1% (n = 22). The clinico-pathological factors influencing the use of EPclin were age (P < 0.001, odds ratio [OR] 0.498), tumor size (P = 0.011, OR 0.071), nodal status (P = 0.021, OR 1.674), histological grade (P = 0.043, OR 0.432), and Ki-67 (P < 0.001, OR 3.599). CONCLUSIONS: EPclin led to a change in therapy recommendations in one third of the patients. Clinico-pathological parameters such as younger age, smaller tumor size, positive nodal status, intermediate histological grade and intermediate Ki-67 had a significant influence on the use of EndoPredict®.

How common is ballooning? Hiatal area on 3D transperineal ultrasound in urogynecological patients and its association with lower urinary tract symptoms.

INTRODUCTION: Pelvic floor ultrasound plays a major role in urogynecologic diagnostics. Using 3D ultrasound we can identify integrity of levator ani and measure hiatal area in the axial plane. The main goal of our study was to measure hiatal area on Valsalva in a cohort of urogynecological patients. Furthermore, we aimed to correlate hiatal area with urogynecological symptoms, levator integrity and evaluate cut-off values for pelvic organ prolapse. MATERIALS AND METHODS: In a retrospective analysis, we included 246 patients seen for urogynecological problems in our tertiary urogynecological unit. After a standardized interview and physical examination, a 3D pelvic floor ultrasound was performed. According to the cardinal urogynecological symptoms and signs, patients were categorized into three groups: pelvic organ prolapse, stress urinary incontinence and overactive bladder symptoms. RESULTS: Median age of our study population was 66 (range 29-94) years, median parity was 2.1 (range 0-9) with 17 (6.9 %) nulliparous women. Symptoms of overactive bladder in 71.1 % were most common, followed by 54.5 % symptoms of stress incontinence and 32.1 % symptoms of prolapse. On examination 49.2 % showed signs of prolapse. Levator avulsions on 3D ultrasound were detected in 20.7 %. Hiatal area was normally distributed with a median of 28.7 cm2 (range 10.4-50.0 cm2). Patients with levator avulsion had a significantly larger hiatal area (p < 0.001). Also patients with signs of prolapse had a significantly larger hiatal area (p < 0.001). There was no correlation between hiatal area and symptoms of overactive bladder (p = 0.374). Although not reaching statistical significance there was evidence of a smaller hiatal area for patients with stress incontinence (p = 0.016). In our cohort there were 33.7 % (83) women without ballooning, 27.2 % (67) showed mild, 18.3 % (45) moderate, 12.3 % (30) marked and 8.5 % (21) severe ballooning. The ROC curve analysis for hiatal area on patients with prolapse yielded an AUC of 0.755 [95 % CI (0.696-0.814)]. Using the Youden-Index we obtained 27.53 cm2 as a cut-off with a sensitivity of 0.70 and a specificity of 0.69. DISCUSSION: Hiatal area is a new repeatable diagnostic parameter. Its clinical application could improve our understanding of the pathophysiology of pelvic organ prolapse as a form of hiatal hernia.

Detection of Subpubic Tumor Causing Bladder Outlet Obstruction by 3D Perineal Ultrasound.

This case report shows that 3D perineal ultrasound can be superior to clinical examination and routine 2D perineal ultrasound in the detection of an unusual subpubic tumor. A 73-year-old female patient was referred to our urogynecological outpatient unit complaining of over-active bladder symptoms and voiding dysfunction for 3 years. Gynecological examination found no signs of pelvic organ prolapse or abnormality in the vaginal cavity. Routine 2D perineal ultrasound showed substantial residual urine (ca. 300 ml on catheter) and limited bladder neck mobility, but no signs of pelvic organ prolapse. Use of standardized 3D perineal ultrasound revealed a 24 × 26 × 32 mm spherical, hypoechoic tumor below the pubic symphysis between the distal urethra and the pubic bones. This structure was mistaken for the pubic symphysis in the midline on 2D ultrasound performed earlier. At surgery, the tumor was completely excised through a vaginal incision between the urethra and the pubic symphysis. After an uneventful postoperative recovery the patient developed de-novo stress urinary incontinence, which was corrected successfully by the insertion of a retropubic tension-free suburethral sling after an interval of 8 weeks. After a further follow-up of 8 weeks the patient reported well-being, urinary continence and no voiding dysfunction; no abnormalities were found on examination. In conclusion, 3D perineal ultrasound is a useful additional tool for the diagnostic workup of bladder outlet obstruction.

Prevalence of Levator Ani Defects in Urogynecological Patients.

Introduction: Defects of the levator ani muscle complex could represent a pathophysiological link between vaginal birth trauma and urogynecological symptoms many years later. The aim of our study was to determine the prevalence of levator ani muscle defects using 3D or 4D ultrasound and palpation in urogynecological patients. Material and Methods: Urogynecological patients were retrospectively investigated using 3D or 4D ultrasound. Clinical examination consisted of palpation and 3D or 4D imaging of the levator ani muscle. Results: A total of 319 women were included in the analysis. Mean age was 64.9 years, average parity was 2.1. Stress incontinence was present in 50.8 %, overactive bladder symptoms in 69.3 % and pelvic organ prolapse in 42.3 % of patients. A levator ani defect was found on ultrasound in 76 patients (23.8 %) and on palpation in 64 women (20.0 %). In the group of patients with pelvic organ prolapse, levator ani defects were found in 32.6 % of patients using ultrasound and in 26.7 % of patients using palpation. The odds ratio (OR) for levator ani defects in women with pelvic organ prolapse was 2.3 (95 % CI [CI: confidence interval]: 1.36-3.88], p = 0.002). Conclusion: In a cohort of urogynecological patients seen at a tertiary urogynecological unit, the prevalence of levator ani defects was significantly higher in women with pelvic organ prolapse compared to women with stress incontinence or urge symptoms.

[Clinical and economic challenges of moderate preterm babies born between 32+0 and 36+6 weeks of gestation]. / Klinische und ökonomische Herausforderung der moderaten Frühgeburt zwischen 32+0 und 36+6 SSW.

BACKGROUND: Preterm births show a worldwide increasing incidence. The majority of preterm births occur between 32+0 and 36+6 weeks of gestation and are associated with an increased rate of maternal and neonatal morbidity. The focus of our research is the clinical and economical analysis of all preterm births between 32+0 and 36+6 weeks of gestation in a German level 1 perinatal centre over a period of 3 years. MATERIALS AND METHODS: A retrospective analysis of all preterm births between 32+0 and 36+6 weeks of gestation in the University Hospital Mainz from 2007 to 2009 was undertaken. Data were collected using our electronic documentation system. Gestational age at delivery, mode of birth, indication for delivery, duration of the peripartum treatment, treatment of the newborn in the children's hospital, birth weight and therapy costs were evaluated. RESULTS: We recorded 407 moderate preterm births in total; this amounts to a rate of of 10% of all births. Major causes of prematurity were PPROM, preterm labour and preeclampsia/HELLP. Maternal and fetal systemic diseases were more uncommon. Rates of Caesarean sections (62%) and of neonatal inpatient treatment needs (58.5%) were high. Maternal treatment costs were 332 Euro/day. The mean duration of maternal inpatient treatment was 13.15 days. DISCUSSION: Moderate preterm birth is associated with maternal morbidity frequently due to a high rate of Caesarean sections. Neonatal morbidity is also increased. In comparison with previous research, we saw an increased rate of pregnancy complications. This could be typical for a level 1 perinatal centre. Moderate preterm birth is seen as the cause of considerable treatment costs.

Treatment of growth-restricted human fetuses with amino acids and glucose supplementation through a chronic fetal intravascular perinatal port system.

OBJECTIVE: Intrauterine growth restriction (IUGR) carries an increased risk of mortality and morbidity. The accepted procedure to treat IUGR fetuses is premature delivery, which may increase neonatal mortality and morbidity and retards neonatal brain development. MATERIAL AND METHODS: We report here on intravascular supplementation with amino acids and glucose of an IUGR human fetus at 33 weeks of gestation with oligohydramnios and placental insufficiency using the port system (Norfolk Medical Products, Skokie, Ill., USA). The catheter was implanted into the umbilical vein (UV) by cordocentesis, and was then connected to a subcutaneously implanted port system. The treatment course included daily infusions of amino acid solution and 10% glucose into the UV. RESULTS: Daily intravascular fetal nutrition significantly improved both fetal condition and fetal weight gain. No complications were seen. The patient was delivered by cesarean section in the 38th week of gestation. The female newborn weighed 2,130 g and was 47 cm long. Blood sampling from the UV after delivery showed no deviations of amino acids in comparison to standardized curves. In one-year follow-up the child's development and weight gain was like that of children without IUGR in the anamnesis. CONCLUSION: This is the first report of the successful use of a subcutaneously implanted intravascular perinatal port system in IUGR human fetuses for long-term administration of nutriments into the UV of a fetus.