Fetal Assessment in Pregnancy (Indication and Methodology for Fetal Monitoring in a low-risk Population). Guideline of the DGGG, DEGUM, OEGGG and SGGG (S3-Level, AWMF Registry No. 015/089, February 2023). / Fetale Überwachung in der Schwangerschaft (Indikation und Methodik zur fetalen Zustandsdiagnostik im Low-Risk-Kollektiv). Leitlinie der DGGG, DEGUM, OEGGG und SGGG (S3-Level, AWMF-Registernummer 015/089, Februar 2023).

PURPOSE: The aim of this guideline was to find evidence on whether carrying out Doppler examinations and CTGs in low-risk cohorts of pregnant women improves outcomes. METHODS: First, a systematic search for guidelines was carried out. Identified guidelines were evaluated using the DELPHI instrument of the AWMF. Three guidelines were found to be suitable to evaluate CTG. Two DEGUM best practice guidelines were judged suitable to describe the methods. All studies on this issue were additionally analyzed using 8 PICO questions. A structured consensus of the participating professional societies was achieved using a nominal group process and a structured consensus conference moderated by an independent moderator. RECOMMENDATIONS: No antepartum Doppler sonography examinations should be carried out in low-risk cohorts in the context of antenatal care. No antepartum CTG should be carried out in low-risk cohorts. NOTE: The guideline will be published simultaneously in the official journals of both professional societies (i. e., Geburtshilfe und Frauenheilkunde for the DGGG and Ultraschall in der Medizin/European Journal of Ultrasound for the DEGUM).

Fetal Assessment in Pregnancy (Indication and Methodology for Fetal Monitoring in a Low-risk Population). Guideline of the DGGG, DEGUM, OEGGG and SGGG (S3-Level, AWMF Registry No. 015/089, February 2023).

Purpose The aim of this guideline was to find evidence on whether carrying out Doppler examinations and CTGs in low-risk cohorts of pregnant women improves outcomes. Methods First, a systematic search for guidelines was carried out. Identified guidelines were evaluated using the DELPHI instrument of the AWMF. Three guidelines were found to be suitable to evaluate CTG. Two DEGUM best practice guidelines were judged suitable to describe the methods. All studies on this issue were additionally analyzed using 8 PICO questions. A structured consensus of the participating professional societies was achieved using a nominal group process and a structured consensus conference moderated by an independent moderator. Recommendations No antepartum Doppler sonography examinations should be carried out in low-risk cohorts in the context of antenatal care. No antepartum CTG should be carried out in low-risk cohorts. Note The guideline will be published simultaneously in the official journals of both professional societies (i.e., Geburtshilfe und Frauenheilkunde for the DGGG and Ultraschall in der Medizin/European Journal of Ultrasound for the DEGUM).

Doppler ultrasound in pregnancy - quality requirements of DEGUM and clinical application (part 2). / Dopplersonografie in der Schwangerschaft ­ Qualitätsanforderungen der DEGUM und klinischer Einsatz (Teil 2).

This second part on Doppler sonography in prenatal medicine and obstetrics reviews its clinical applications. While this has not become the initially anticipated screening tool, it is used for the diagnosis and surveillance of a variety of fetal pathologies. For example, the sonography-based determination of uterine artery blood flow indices is an important parameter for the first trimester multimodal preeclampsia risk assessment, increasing accuracy and providing indication for the prophylactic treatment with aspirin. It also has significant implications for the diagnosis and surveillance of growth-restricted fetuses in the second and third trimesters through Doppler-sonographic analysis of umbilical artery, middle cerebral artery and ductus venosus. Here, especially the hemodynamics of the ductus venosus provides a critical criterium for birth management of severe, early-onset FGR before 34 + 0 weeks of gestation. Further, determination of maximum blood flow velocity of the middle cerebral artery is a central parameter in fetal diagnosis of anemia which has been significantly improved by this analysis. However, it is important to note that the mentioned improvements can only be achieved through highest methodological quality. Importantly, all these analyses are also applied to twins and higher order multiples. Here, for the differential diagnosis of specific complications such as TTTS, TAPS and TRAP, the application of Doppler sonography has become indispensable. To conclude, the successful application of Doppler sonography requires both exact methodology and precise pathophysiological interpretation of the data.

[Doppler Sonography during Pregnancy - DEGUM Quality Standards and Clinical Applications]. / Dopplersonografie in der Schwangerschaft ­ Qualitätsanforderungen der DEGUM und klinischer Einsatz (Teil 1).

Doppler sonography is widely established in prenatal medicine and obstetrics and is commonly used in screening for aneuploidy and preeclampsia during the first trimester. More importantly, during the 2nd and 3 rd trimester, it is used in the assessment of fetal health as well as the surveillance of underlying fetal conditions such as IUGR and anemia. Correct use of the method is vital for correct data interpretation and the inferred clinical decision process. Therefore, we aim to provide all users of doppler sonography with a guide for meeting the required quality standards. These quality standards will further be the basis of DEGUM-certified training courses. In the first part, we will introduce the technical principles of the method and potential error sources, vascular disciplines to which the method can be applied, analysis of the spectral curves, patient safety and the needed requirements for successful certification.

DEGUM, ÖGUM, SGUM and FMF Germany Recommendations for the Implementation of First-Trimester Screening, Detailed Ultrasound, Cell-Free DNA Screening and Diagnostic Procedures. / Empfehlungen der DEGUM, der ÖGUM, der SGUM und der FMF Deutschland zum Einsatz von Ersttrimester-Screening, früher Fehlbildungsdiagnostik, Screening an zellfreier DNA (NIPT) und diagnostischen Punktionen.

First-trimester screening between 11 + 0 and 13 + 6 weeks with qualified prenatal counseling, detailed ultrasound, biochemical markers and maternal factors has become the basis for decisions about further examinations. It detects numerous structural and genetic anomalies. The inclusion of uterine artery Doppler and PlGF screens for preeclampsia and fetal growth restriction. Low-dose aspirin significantly reduces the prevalence of severe preterm eclampsia. Cut-off values define groups of high, intermediate and low probability. Prenatal counseling uses detection and false-positive rates to work out the individual need profile and the corresponding decision: no further diagnosis/screening - cell-free DNA screening - diagnostic procedure and genetic analysis. In pre-test counseling it must be recognized that the prevalence of trisomy 21, 18 or 13 is low in younger women, as in submicroscopic anomalies in every maternal age. Even with high specificities, the positive predictive values of screening tests for rare anomalies are low. In the general population trisomies and sex chromosome aneuploidies account for approximately 70 % of anomalies recognizable by conventional genetic analysis. Screen positive results of cfDNA tests have to be proven by diagnostic procedure and genetic diagnosis. In cases of inconclusive results a higher rate of genetic anomalies is detected. Procedure-related fetal loss rates after chorionic biopsy and amniocentesis performed by experts are lower than 1 to 2 in 1000. Counseling should include the possible detection of submicroscopic anomalies by comparative genomic hybridization (array-CGH). At present, existing studies about screening for microdeletions and duplications do not provide reliable data to calculate sensitivities, false-positive rates and positive predictive values.

Migrants and obstetrics in Austria--applying a new questionnaire shows differences in obstetric care and outcome.

BACKGROUND: Immigration plays a major role in obstetrics in Austria, and about 18 % of the Austrian population are immigrants. Therefore, we aimed to (1) test the feasibility of a proposed questionnaire for assessment of migrant status in epidemiological research and (2) assess some important associations between procedures and outcomes in obstetrics and migration in selected departments in Austria. METHODS: We adapted a standardized questionnaire to the main immigration groups in Austria. Information on country of origin, length of residence in Austria and German-language ability was collected from eight selected obstetrics departments. Of the 1,971 questionnaires, 1,873 questionnaires of singleton births were selected and included in the analysis. RESULTS: We analyzed a total of 1,873 parturients with singleton births, of which 35 % had migrant status, 12 % were from ex-Yugoslavia, 12 % were from Turkey, and 12 % were from other countries. The proportion of parturients having their first care visit after the 12th week of pregnancy was higher in migrant groups (19 %). Smoking was highest in the migrants from ex-Yugoslavia (21 %). Vaginal delivery was more frequent in migrants from ex-Yugoslavia (78 %) and Turkey (83 %) than in nonmigrants (71 %) and episiotomy was more frequently performed in migrants from other countries. All differences are statistically significant. CONCLUSIONS: Administration of a standardized questionnaire for assessment of migrant status in obstetric departments in Austria was shown to be feasible. We assessed differences in obstetric care and outcome and consequently recommend that action should be initiated in Austria toward harmonizing obstetric procedures among the migrant and the nonmigrant groups and toward minimizing risk factors.

Incidence of perinatal complications in children with premature craniosynostosis.

AIMS: To study the incidence of perinatal complications in children diagnosed with premature craniosynostosis and their mothers. METHODS: Questionnaires were sent to all women (n=220) who delivered a child diagnosed either pre- or postnatally with craniosynostosis and treated at the University Hospital of Innsbruck, Austria between January 1, 1990 and October 10, 2007. The incidence of various complications in the group of children with craniosynostosis was compared with data from the Birth Registry of Tyrol, which served as a comparison population in this study (n=57,317). RESULTS: A total of 46.4% of the questionnaires were returned (n=102). Children diagnosed with craniosynostosis showed a significantly higher rate of fetal malpresentations at birth [P<0.001; OR 2.38 (CI 1.53-3.70)] compared to the general population. In particular, the rate of abnormal cephalic [P<0.001; OR 3.42 (CI 2.03-5.76)] and breech presentations [P=0.01; OR 2.39 (CI 1.27-4.49)] was significantly increased. In 10% of all neonates the Apgar score (P=0.001) as well as the pH-value (P<0.001) was found to be at least one category lower than in the comparison population. CONCLUSIONS: Children diagnosed with craniosynostosis have a significantly higher rate of numerous birth complications compared to the overall births documented at the Birth Registry of Tyrol.

Prenatal diagnosis of apert syndrome with cloverleaf skull deformity using ultrasound, fetal magnetic resonance imaging and genetic analysis.

Apert syndrome is characterized by craniosynostosis, midfacial hypoplasia and symmetric cutaneous and bony syndactyly of the limbs. The skull is usually hyperacrobrachycephalic, whereas frank cloverleafing, as a clinically obvious trilobed skull deformity, is rarely seen in these patients. We report a rare case of Apert syndrome with cloverleaf skull deformity, prenatally diagnosed at 26weeks' gestation in which the sonographic features of a characteristic trilobed skull, abnormal biparietal diameter and head circumference, as well as malformations of the upper and lower extremities led to the diagnosis, confirmed by prenatal fibroblast growth factor receptor type 2 mutation analysis and fetal magnetic resonance imaging. The genetic evaluation revealed a p.P253R mutation in fibroblast growth factor receptor type 2 consisting in a transversion C>G at nucleotide 758. We discuss the relevant prenatal morphologic and genetic findings of this patient and review previously published cases. Our report demonstrates the feasibility of the prenatal diagnosis of Apert syndrome with cloverleaf skull using ultrasound, fetal magnetic resonance imaging and mutation analysis, and also highlights the importance of the biparietal diameter as an early predictor of growth restriction in severe craniosynostosis cases.

[Delivery of multiples, particularly of twins]. / Entbindung von Mehrlingen, insbesondere von Zwillingen.

Multiples run various risks. While for triplets and higher-grade multiples caesarean section is the first-line mode of delivery, the method is still under discussion in the case of twins. Evidence-based data in favour of a general elective caesarean section are lacking but prospective randomized study results on this subject are expected. The organization of the clinic is essential for the safety of twins during vaginal delivery. The prerequisites for the vaginal delivery of twins and its management under various conditions are discussed in light of the literature.