Pain scores after open fetal spina bifida repair and caesarean section - a longitudinal cohort study.

INTRODUCTION: In fetal surgery, successful pain management is crucial for postoperative mobilization, prophylaxis of contractions, and fast recovery. This study analyzed patient's pain experience after open fetal spina bifida (fSB) repair in comparison to pain scores after the subsequent Caesarean section (C-section). MATERIALS AND METHODS: Data was collected with a questionnaire given to 91 women, who had fSB repair and then C-section at our center between 2019 and 2022. It comprised 12 questions covering different aspects of pain experience and satisfaction with pain therapy and was answered by 67 women after fSB repair and 53 after C-section. Postoperative pain was rated on a Likert scale from 0 (slight/rarely) to 100 (strongest/always). Outcomes after fSB repair were compared to those after C-section. Additionally, subgroup analysis compared outcomes of women with different pain levels (group 1-5) after fSB repair. RESULTS: Compared to women after C-section women after fSB repair reported significantly higher maximum pain scores (MPS) (p = 0.03), higher sleep disturbance due to pain (p = 0.03), and sedation rates (p = 0.001) as side effect from pain therapy. No differences were found regarding feelings of insecurity (p = 0.20) or helplessness (p = 0.40), as well as involvement in (p = 0.3) and satisfaction with pain therapy (p = 0.5). Subgroup analysis revealed that women with higher MPS after fSB repair were significantly more often non-Caucasians (p = 0.003) and more often affected by pain while lying in bed (p = 0.007) and during mobilization (p = 0.005). Additionally they reported higher rates of dizziness (p = 0.02) and lower satisfaction rates with pain therapy (p = 0.03). Postoperative complication rate did not differ among groups. CONCLUSION: Although women after fSB repair reported higher MPS compared to after C-section, the current pain management was generally perceived as satisfactory.

Enhanced Recovery after Surgery in Open Fetal Spina Bifida Repair.

INTRODUCTION: For open fetal spina bifida (fSB) repair, a maternal laparotomy is required. Hence, enhanced maternal recovery after surgery (ERAS) is paramount. A revision of our ERAS protocol was made, including changes in operative techniques and postoperative pain management. This study investigates eventual benefits. METHODS: Our study included 111 women with open fSB repair at our center. The old protocol group (group 1) either received a transverse incision of the fascia with transection of the rectus abdominis muscle (RAM) or a longitudinal incision of the fascia without RAM transection, depending on placental location. The new protocol required longitudinal incisions in all patients (group 2). Postoperative pain management was changed from tramadol to oxycodone/naloxone. Outcomes of the two different protocol groups were analyzed and compared regarding the primary endpoint, the length of hospital stay (LOS) after fetal surgery, as well as regarding the following secondary endpoints: postoperative pain scores, day of first mobilization, removal of urinary catheter, bowel movement, and the occurrence of maternal and fetal complications. RESULTS: Out of 111 women, 82 (73.9%) were in group 1 and 29 (26.1%) were in group 2. Women in group 2 showed a significantly shorter LOS (18 [14-23] days vs. 27 [18-39] days, p = 0.002), duration until mobilization (3 [2-3] days vs. 3 [3-4] days, p = 0.03), and removal of urinary catheter (day 3 [3-3] vs. day 4 [3-4], p = 0.004). Group 2 less often received morphine subcutaneously (0% vs. 35.4%, p < 0.001) or intravenously (0% vs. 17.1%, p = 0.02) but more often oxycodone (69.0% vs. 18.3%, p < 0.001). No significant differences were seen regarding pain scores, bowel movement, and maternal and/or fetal complications. CONCLUSION: The new ERAS protocol that combined changes in surgical technique and pain medication led to better outcomes while reducing LOS. Continuous revisions of current ERAS protocols are essential to improve patient care continuously.

Fetal Spina Bifida Repair in Obese Mothers: Is Maternal and Fetal Safety Compromised?

INTRODUCTION: The Management of Myelomeningocele Study (MOMS) eligibility criteria preclude in utero surgery for fetal spina bifida (fSB) when the maternal body mass index (BMI) is ≥35 kg/m2. Some centers still respect this criterion, while others, like ours, do not. This study aimed to assess whether maternal and fetal safety is compromised with higher maternal BMIs. METHODS: Data of 192 patients with open fSB repair at our center were retrospectively analyzed. According to their BMI, patients were divided into three groups: group 1 (BMI <30 kg/m2), group 2 (BMI 30-35 kg/m2), and group 3 (BMI >35 kg/m2). Subgroup analysis was performed to assess differences in maternal and fetal outcomes. Additionally, complications were divided into grades 1 to 5 according to their severity and outcome consequences and compared among groups. RESULTS: Out of 192 patients, 146 (76.0%) had a BMI <30 kg/m2, 28 (14.6%) had a BMI 30-35 kg/m2, and 18 (9.4%) had a BMI >35 kg/m2. Significant differences occurring more often in either group 2 or 3 compared to group 1 were maternal wound seroma (50% or 56% vs. 32%, p = 0.04), amniotic fluid leakage (14% or 6% vs. 2%, p = 0.01) as well as vaginal bleeding (11% or 35% vs. 9%, p = 0.01). On the contrary, duration of tocolysis with atosiban was shorter in patients with BMI >30 kg/m2 (4 or 5 vs. 6 days, p = 0.01). When comparing severity of maternal or fetal complications, grade 1 intervention-related complications occurred significantly more often in group 3 compared to group 1 or 2 (78% vs. 45% or 57%, p = 0.02). Gestational age at delivery was around 36 weeks in all groups without significant differences. CONCLUSION: This investigation did not identify clinically relevant maternal and/or fetal outcome problems related to BMIs >35 kg/m2. Additional studies are however needed to confirm our results.

Prenatal Spina Bifida Repair: Defendable Trespassing of MOMS Criteria Results in Commendable Personalized Medicine.

INTRODUCTION: We hypothesize that after publication of the quintessence of the MOMS trial, eligibility criteria for prenatal spina bifida (SB) repair may be modified if a tenable argumentation underlies this decision. METHODS: Our first 154 fetal surgery patients were analyzed with particular focus on how many, which, and why the original eligibility criteria, set forth by the MOMS Trial Protocol, were disobeyed, and what the eventually detectable, negative and positive impacts of these deviations on outcomes were. RESULTS: A total of 152 patients (2 missing consent) were included (100%). In 69 patients (45.4%), a total of 89 eligibility criteria were disobeyed. In 54 (35.6%) cases, the following maternal criteria were concerned: gestational age at operation of >25+6 weeks in 17 (11.2%), uterine pathologies in 13 (8.6%) women, preoperative BMI ≥35 kg/m2 in 12 (7.9%), previous hysterotomy in 7 (4.6%), previous prematurity in 3 (2%), HIV/hepatitis B in 2 (1.3%), psychosocial issues in 2 (1.3%), and placenta praevia in 1 (0.7%). In 32 (21.1%) cases, fetal criteria were disobeyed 34 times: Fetal anomaly unrelated to SB in 19 (12.5%), no/minimal evidence of hindbrain herniation in 13 (8.6%), and severe kyphosis in 2 (1.3%). We could not identify cases where non-observation of criteria led to clear-cut maternal and/or fetal disadvantages. CONCLUSION: This study shows that MOMS trial eligibility criteria for prenatal SB repair should be modified or even abandoned with adequate medical and ethical argumentation, and with written parental informed consent after non-directive, full disclosure counseling. This clear-cut change of paradigm is a necessity as it leads toward personalized medicine, allowing more fetuses to benefit from fetal surgery than would have benefitted with the former, published, MOMS criteria in place.

Stage 2: The Vaginal Flora in Women Undergoing Fetal Spina Bifida Repair and Its Potential Association with Preterm Rupture of Membranes and Preterm Birth.

INTRODUCTION: Vaginal dysbiosis affects pregnancy outcomes, however, the relevance of abnormal findings on pre/post-surgical vaginal culture in women undergoing fetal spina bifida (fSB) repair is unknown. OBJECTIVES: To describe the incidence of normal and abnormal pre- and post-surgical vaginal microorganisms in fSB patients and to investigate potential associations between the type of vaginal flora and the occurrence of preterm prelabour rupture of membranes (PPROM) and preterm birth (PTB). METHODS: 99 women undergoing fSB repair were eligible (2010-2019). Pre-surgical vaginal culture was routinely taken before surgery. Post-surgical cultures were taken on indication. Vaginal flora was categorized into four categories: healthy vaginal flora (HVF), bacterial vaginosis (BV), desquamative inflammatory vaginitis (DIV), and yeast infection. RESULTS: The incidence of HVF, BV, DIV, or yeast infections was not statistically different between the pre- and postoperative patients. Furthermore, an abnormal pre/post-surgical vaginal flora was not associated with PPROM (OR 1.57 (0.74-3.32), p = 0.213)/OR 1.26 (0.62-2.55), p = 0.515), or with PTB (OR 1.19 (0.82-1.73), p = 0.315)/(OR 0.86 (0.60-1.24), p = 0.425). CONCLUSIONS: Abnormal vaginal microbiome was not associated with PPROM and PTB when appropriate treatment was performed.

Subsequent Pregnancy Outcomes after Open in utero Spina Bifida Repair.

INTRODUCTION: Fetal spina bifida (SB) repair is a distinct therapeutic option in selected cases. Since this procedure may not only be associated with short-term obstetrical complications, the aim of this study was to assess the outcomes of subsequent pregnancies after open fetal SB repair. METHODS: 138 patients having had open fetal SB repair at our center received a questionnaire regarding the occurrence, course, and outcome of subsequent pregnancies. Additionally, medical records were reviewed. All subsequent pregnancies with complete outcome data that progressed beyond 20 gestational weeks (GW) were included for further analysis. RESULTS: 70% of all women answered the questionnaire. Out of this cohort, 35 subsequent pregnancies were reported in 29% of women. The rate of early pregnancy loss including elective terminations was 14%. All 29 pregnancies processing >20 GW ended in live births without preterm births <34th GW. Mean gestational age at delivery was 37.3 ± 1.4 GW. Uterine rupture occurred in two cases (7%) and uterine thinning/dehiscence was present in six cases (21%). No maternal transfusions were required. CONCLUSION: When counseling women undergoing open fetal SB repair, one should consider possible risks for subsequent pregnancies, especially the one of uterine dehiscence and rupture that is similar compared to numbers reported after classical cesarean deliveries.

Favorable Pregnancy Outcomes in Women With Well-Controlled Pulmonary Arterial Hypertension.

Introduction: Since pregnancy in women with pulmonary arterial hypertension (PAH) is associated with a high risk of morbidity and mortality, it is recommended that pregnancy should be avoided in PAH. However, some women with mild PAH may consider this recommendation as unsuitable. Unfortunately knowledge on pregnancy outcomes and best management of PAH during pregnancy is limited. Methods: Data from all women with PAH who were followed during pregnancy by a multidisciplinary team at a tertiary referral center for PAH and who delivered between 2004 and 2020 were retrospectively analyzed in a case series. PAH risk factor profiles including WHO functional class (WHO-FC), NT-pro-BNP, echocardiographic pulmonary arterial pressure (PAP) and right heart function were analyzed prior to, during and following pregnancy. Results: In seven pregnancies of five women with PAH (median age 29 (27; 31) years), there were no abortions or terminations. Five pregnancies were planned (all in WHO-FC I-II), two incidental (WHO-FC II, III). During pregnancy none of the women had complications or clinical worsening of PAH. After a median pregnancy duration of 37 1/7 weeks all gave birth to healthy babies by cesarean section in spinal anesthesia. During pregnancy, PAP tended to increase, whilst the course of WHO-FC and NT-pro-BNP were variable and no trend could be detected. Conclusion: Women with PAH with a low risk profile closely followed by a multidisciplinary team had a favorable course during and after pregnancy, resulting in successful deliveries of healthy newborns.

Long-Term Outcome of Monochorionic Twins after Fetoscopic Laser Therapy Compared to Matched Dichorionic Twins.

INTRODUCTION: The only causal therapy is fetoscopic laser surgery (FLS). The aims of this study were to analyze the long-term outcome of monochorionic twins treated by FLS, including their school career, need for therapy and special aid equipment, and free-time activities, and compare their outcome to matched dichorionic twins. MATERIAL AND METHODS: Among the 57 women treated at a single fetal treatment center between 2008 and 2017 with FLS because of twin-to-twin transfusion syndrome, 25 women with 42 children were included in the FLS group. The control group consisted of 16 dichorionic twin pairs matched for birth year, gestational age (GA), birth weight, and sex. The long-term outcome was assessed by a parental questionnaire and a standardized neurodevelopmental examination for children born before 32 gestational weeks or with a birth weight lower than 1500 g. They were also registered into the Swiss Neonatal Network database. The primary outcome was event-free survival, defined as normal neurology, behavior, vision, and hearing. The secondary outcomes were school career, need for therapy and special aid equipment, and free-time activities. RESULTS: An event-free survival was found in 32 children (76%) in the laser and in 24 children (75%) in the control group (p = 0.91). Neurological anomalies were found in 5 children (12%) in the laser group and 3 children (9%) in the control group (p = 1.00). Multiple logistic regression analysis showed that GA at delivery was the only predictive factor for event-free survival. There were no significant differences regarding school career, therapies, or special aid equipment between the 2 groups. We found that children without FLS were involved in more free-time activities and needed fewer breaks during physical activity than children with FLS during pregnancy. CONCLUSION: The outcome of monochorionic twins treated with FLS is comparable to the outcome of dichorionic twins. Long-term neurodevelopment in the cohort was mainly dependent on GA at birth.

[CME: Familial Hypercholesterolemia - Statin Treatment during Pregnancy and Breastfeeding]. / CME: Familiäre Hypercholesterinämie ­ Behandlung mit Statinen in der Schwangerschaft und Stillzeit.

CME: Familial Hypercholesterolemia - Statin Treatment during Pregnancy and Breastfeeding Abstract. Patients with familial hypercholesterolemia have a permanent increased cardiovascular risk. Thus, early detection and intensive treatment with statins is vital. However, treatment during pregnancy using statins remains unclear and limited. According to the NICE guidelines, women should stop statins three months before conception in order to avoid teratogenicity. In addition, contraception during statin treatment is recommended. Moreover, women should not take lipid-lowering drugs until the end of lactation. In the event of an unplanned pregnancy, a woman with familial hypercholesterolemia should discontinue the statins and consult her doctor.

Risk Factors for Preterm Birth following Open Fetal Myelomeningocele Repair: Results from a Prospective Cohort.

BACKGROUND: Fetal myelomeningocele (fMMC) repair is a therapeutic option in selected cases. This study aimed to identify risk factors for preterm birth (PTB) following open fMMC repair. METHODS: Sixty-seven women underwent fMMC repair and delivered a baby between 2010 and 2018 at our center. Demographic, surgical, and pregnancy complications, including potential risk factors for PTB such as preterm premature rupture of membranes (PPROM), chorioamniotic membrane separation (CMS), and placental abruption were evaluated. RESULTS: Maternal body mass index, maternal age, parity, previous uterine surgery, gestational age at fetal surgery, total surgery duration, surgical subcutaneous hematoma, oligohydramnios, and amniotic fluid leakage were not identified as risk factors for PTB. CMS (p = 0.028, 92 vs. 52%) and PPROM (p = 0.001, 95 vs. 52%) were highly associated with PTB. Placental abruption was found more often in women after fMMC repair than in a general obstetrical population (12 vs. 1%) and ended in premature birth in all cases (p = 0.024, 100 vs. 60%). However, the majority of women delivered at a gestational age >35 weeks. CONCLUSIONS: In our study cohort, risk factors for PTB were PPROM, CMS, and placental abruption, whereas surgery duration did not influence outcome. We conclude that the surgery technique should aim to minimize CMS and amniotic fluid leakage.

Outcome after fetoscopic laser coagulation in twin-twin transfusion syndrome - is the survival rate of at least one child at 6 months of age dependent on preoperative cervical length and preterm prelabour rupture of fetal membranes?

Purpose: Twin-to-twin transfusion syndrome (TTTS) complicates 10-15% of all monochorionic twin pregnancies. Selective laser coagulation of placental anastomoses is the only causal therapy. The aim of this study was to analyze the neonatal survival, the survival rate of at least one child at 6 months of age, and maternal outcome after laser therapy in a Swiss cohort.Material and methods: Between 2008 and 2014, 39 women were treated with fetoscopic laser procedure due to TTTS. Two women were excluded from the study because of missing informed consent or loss of follow-up. The women were divided into two groups: group 1 with a cervical length >25 mm and group 2 with a cervical length ≤25 mm. The primary end point was the survival rate of at least one child at 6 months of age and its dependence on maternal preoperative cervical length or the time interval between operation (OP)-preterm prelabour rupture of fetal membranes (PPROM). Secondary outcomes were neonatal complications and maternal complications due to the procedure. Statistical analysis was performed using the program SPSS 22. A p-value of <.05 was considered statistically significant.Results: Mean gestational age (GA) at OP of group 1 (20.3 ± 3 GW) was comparable with group 2 (21.5 ± 2.4 GW; p = .27). The GA at birth was significantly higher in group 1 (31.5 ± 5.9 GW) than in group 2 (27.0 ± 4.7 GW: p = .02). The survival rate of at least one child at 30 days and 6 months of age was 81% in group 1 and only 60% in group 2 (p = .1). PPROM <32 GW occurred in 43%. The survival rate of at least one child was significantly higher if the OP-PPROM interval was >28 days (93 versus 43%; p = .02). Major brain injury was observed in 11% of infants. Severe maternal complications (pulmonary edema) occurred in three cases (8%).Conclusions: Our survival rate of at least one child at 30 days and 6 months of age and the outcome of the mothers is well comparable to other international studies. A preoperative maternal cervical length of >25 mm and an occurrence of PPROM more than 28 days after the laser therapy is associated with a higher survival rate of at least one child at 6 months of age.

In utero Hepatitis B Immunization during Fetal Surgery for Spina Bifida.

BACKGROUND: Fetal surgery for spina bifida aperta may lead to significantly better outcomes than postnatal repair, particularly regarding shunt-dependent hydrocephalus, independent ambulation, and voiding functions. The "Management of Myelomeningocele Study" (MOMS) represents the current benchmark, also in terms of eligibility criteria. CASE REPORT: A positive maternal hepatitis B virus (HBV) status is a MOMS exclusion criterion. Here, we report on the first successful active and passive in utero HBV vaccination of a spina bifida fetus carried by a HBV-positive mother undergoing maternal-fetal surgery. The now 2-year-old infant is healthy, HBV negative, and drew maximal benefit from prenatal surgery. DISCUSSION AND CONCLUSION: Taken together, this patient benefitted maximally from fetal surgery for spina bifida, despite meeting an exclusion criterion. Thus, generally speaking, eligibility criteria for fetal surgery can be challenged under certain circumstances for the benefit of the patient.

Open Intrauterine Fetal Myelomeningocele Repair: Changes in the Surgical Procedure and Perinatal Complications during the First 8 Years of Experience at a Single Center.

INTRODUCTION: Open fetal myelomeningocele (fMMC) repair is nowadays a therapeutic option in selected cases. We aimed to evaluate changes in maternal and fetal outcome after fMMC repair during the first 8 years of experience at a tertiary referral fetal medicine center in Switzerland. -Materials and Methods: Between 2010 and 2018, fMMC repair and delivery of the neonate via planned cesarean section was performed in 67 cases. Cases were retrospectively stratified into 2 groups: a "training phase" (TP) with supervision from an external surgeon during 11 operations (2010-2014, 15 cases) followed by an "experienced phase" (EP, 2014-2018, 52 cases); each phase lasted about 4 years. Both phases were compared with regard to various maternal and fetal outcome parameters. RESULTS: Analyses did not reveal differences between TP and EP in major outcome parameters such as gestational age at delivery, chorionic membrane separation, or the incidence of placental abruption. Although more complex surgical techniques were applied in EP (e.g., dermal closure using a rotational flap), surgery time was not different from TP. At the same time, surgical complications such as oligohydramnios (27 vs. 8%, p = 0.046) with MRI-confirmed leakage (13 vs. 4%, nonsignificant) and subchorionic hematoma (20 vs. 2%, p = 0.009) were less common in EP than TP. CONCLUSIONS: This study shows that the level of competence at our center with regard to major perinatal outcome parameters was already high in the first years of fMMC repair. However, more complex surgical techniques and significantly less minor complications were observed during the most recent years.

Maternal Complications following Open Fetal Myelomeningocele Repair at the Zurich Center for Fetal Diagnosis and Therapy.

INTRODUCTION: Despite undoubtable benefits of open fetal myelomeningocele (fMMC) repair, there are considerable maternal risks. The aim of this study was to evaluate and systematically categorize maternal complications after open fMMC repair. METHODS: We analyzed data of 40 fMMC repairs performed at the Zurich Center for Fetal Diagnosis and Therapy. Maternal complications were classified according to a 5-level grading system based on a classification of surgical complications proposed by Clavien and Dindo. RESULTS: We observed no grade 5 complication (death of a patient). Five (12.5%) women demonstrated severe grade 4 complications: 1 case of uterine rupture in a nullipara at 36 gestational weeks (GW), a third-degree atrioventricular block which needed short mechanical resuscitation, a bilateral lung embolism requiring intensive care unit (ICU) management due to low-output syndrome, and chorioamnionitis and urosepsis both requiring ICU management at 31 GW. Twenty-six (65%) women had minor (grade 1-3) complications. CONCLUSIONS: Only one grade 4 complication (uterine rupture, 2.5%) was a clear-cut direct consequence of fetal surgery. The other four grade 4 complications (10%) occurred in the context of, but cannot unequivocally be attributed to, fetal surgery, since they may occur also in other circumstances. The classification system used is a tenable step towards stringent documentation of maternal complications.

Clinical and Histologic Evaluation of the Hysterotomy Site and Fetal Membranes after Open Fetal Surgery for Fetal Spina Bifida Repair.

INTRODUCTION: Among the risks associated with open fetal surgery, myometrium and fetal membrane issues are vexing problems since they may lead to uterine dehiscence or preterm premature rupture of membranes resulting in uterine rupture or preterm birth or both. The aim of this study was to examine whether stapled and sutured hysterotomy scars demonstrate partial or complete healing. METHODS: Hysterotomy sites after open fetal surgery were clinically evaluated in 36 women during Caesarean section, classified into the categories intact, thin, and partially or completely dehiscent, then completely excised and histologically analyzed in 25 cases. The histological examination focused on wound healing of myometrium and fetal membranes. RESULTS: The myometrium was intact, thin, and partially or completely dehiscent in 33, 58, and 9%, respectively. The interval between myelomeningocele repair and delivery did not correlate with the healing process. The myometrium showed a reparative zone (scar) with adjacent avital myometrium tissue, fibrosis, and inflammation with foreign body reaction. The intact myometrium was below 1 mm thickness in 56%. All fetal membranes showed complete dehiscence; in 41% they were completely avital. CONCLUSION: Our study provides evidence that the myometrium shows scarring with substantial thinning or dehiscence. Fetal membranes do not heal spontaneously. In order to prevent uterine rupture in subsequent pregnancies, we recommend the hysterotomy site to be completely excised after birth.

Tocolysis for in utero Surgery: Atosiban Performs Distinctly Better than Magnesium Sulfate.

INTRODUCTION: To compare tocolysis with magnesium sulfate versus atosiban regarding the occurrence of short-term preterm labor and maternal side effects during and after open fetal myelomeningocele (MMC) repair. MATERIAL AND METHODS: A prospective nonrandomized cohort study was performed including 30 fetal MMC cases. The first 15 cases (group 1) received magnesium sulfate according to the MOMS protocol. In the following 15 cases (group 2), magnesium sulfate was substituted by atosiban. Chorioamniotic membrane separation (CMS), premature prelabor rupture of the fetal membranes (PPROM), preterm delivery <3 weeks after fetal MMC repair, and maternal complications due to the tocolytic medication were the major endpoints. RESULTS: In both groups, one CMS but no PPROM was diagnosed <3 weeks after fetal MMC repair. One patient of group 2 delivered <3 weeks after fetal MMC repair because of an intraoperative placental abruption at 25 weeks. All women of group 1 showed an electrolyte imbalance during magnesium sulfate administration. One woman of group 1 developed several episodes of a third-degree atrioventricular block within the first 3 days after fetal surgery. Lethargy was found in all women during magnesium sulfate therapy. No maternal side effects were found under atosiban. DISCUSSION: The use of atosiban resulted in an almost identical short-term uterine outcome without any serious maternal complications as seen when magnesium sulfate was given. Thus, the authors suggest using atosiban instead of magnesium sulfate in the context of open fetal surgery.

Maternal and neonatal outcome of labour induction at term comparing two regimens of misoprostol.

AIM: To compare the efficacy and safety of two misoprostol dosing regimens for induction of labour in primiparous (1P) and multiparous (>1P) women. METHODS: Retrospective study of induction of labour using vaginal misoprostol 25 µg vs. 50 µg every 6 h in 942 women at a tertiary centre. The main outcome variables are induction-to-delivery interval, latency period duration, vaginal delivery within 24 h, and maternal and foetal safety outcome. RESULTS: With the 50 µg regimen, induction-to-delivery intervals were significantly shorter: 18.4 h vs. 24.6 h (1P) and 14 h vs. 17.9 h (>1P), as was latency period duration (by 5.4 and 4 h, respectively). Vaginal delivery within 24 h was significantly more frequent, as were non-reassuring foetal heart rate (1P: 20% vs. 14%) and tachysystole (1P: 31% vs. 11%; >1P: 21% vs. 7%). No uterine rupture was reported. Neonatal outcomes were similar except for significantly more frequent infant referral to neonatal intensive care in the >1P group receiving the 50 µg regimen (11% vs. 4%). CONCLUSION: Vaginal misoprostol 25 µg seems to maintain efficacy with more acceptable maternal and neonatal safety. As induction of labour is an off-label use for misoprostol, safety should be prioritised with the lower dosage regimen despite the longer induction-to-delivery interval.

Determinants of successful breastfeeding initiation in healthy term singletons: a Swiss university hospital observational study.

AIMS: Breastfeeding significantly benefits mothers and infants. We aimed to identify the determinants of its successful initiation. METHODS: A retrospective study of 1893 mothers delivering healthy term singletons at a Swiss university hospital from 1/2008 to 3/2009 determined the associations between multiple breastfeeding and early postpartum parameters by univariate and multiple regression analysis. RESULTS: Multiparity was associated with nursing exclusively at the breast at discharge (P<0.001), less use of maltodextrin supplement (P<0.05), bottle/cup (both P<0.001), but more pacifier use (P<0.05). Among obese mothers, nursing exclusively at the breast at discharge was less frequent, and use of all feeding aids more frequent, than among normal-weight women (both P<0.001). Neuraxial anesthesia was associated with use of maltodextrin and bottle (both P<0.05) compared to no anesthesia. Delayed first skin-to-skin contact and rooming-in for <24 h/day were each associated with maltodextrin and cup (P<0.05). Nursing exclusively at the breast at discharge was less frequent (P<0.001), and bottle use more frequent (P<0.05), in women with sore nipples than in those without. CONCLUSIONS: Obesity is a potent inhibitor of breastfeeding initiation. Delivery without anesthesia by a multiparous normal-weight mother, followed by immediate skin-to-skin contact, rooming-in for 24 h/day, and dedicated nipple care, provides the best conditions for successful early postpartum breastfeeding without the need for feeding aids or nutritional supplements

Liver Transplantation during Pregnancy for Acute Liver Failure due to HBV Infection: A Case Report.

Acute hepatic failure during pregnancy is a life-threatening situation for the mother and fetus and might need a super-urgent liver transplantation. Many pregnancies with positive outcomes are reported after a previous liver transplantation before the pregnancy, but only a few of them are mentioned with transplantation during pregnancy. In these few cases, fetal outcome is mostly adverse. Experience with liver failure during pregnancy and its management is still deficient and needs to be approved. For sure, patients need to be treated in highly qualified centers in a multidisciplinary approach. We present a case of successful super-urgent liver transplantation during the second trimester of pregnancy after acute hepatic failure due to an acute hepatitis B infection with positive maternal and fetal outcome. Liver transplantation during pregnancy due to an acute liver failure can be a life-saving procedure for the mother and fetus. An early initiated maternal therapy with antiviral drugs and immunoglobulins seems to be safe and able to prevent fetal infection and immunosuppressive therapy after transplantation seems to be well tolerated. Nevertheless, fetal outcome differs widely and long-term outcome is deficiently known.