Errors in the classification of pregnant women according to Robson ten-group classification system.

OBJECTIVES: The Robson Ten-Group Classification System (TGCS) is widely used as a classification system for perinatal analyses such as Caesarean section (CS) rates. In Germany, standardised data sets on deliveries are classified by quality assurance institutions using the TGCS. This observational study aims to evaluate potential errors in the TCGS classification of deliveries. STUDY DESIGN: Manual TGCS classification of all 1370 deliveries in an obstetric unit in 2018 and comparison with semi-automatic TGCS classifications of the quality assurance institution. RESULTS: In the manual classification, 259 out of 1370 births (18.9 %) were assigned to a different Robson group than in the semi-automatic classification. The proportions of births by Robson group were significantly different in TGCS group 1 (32.2 % vs. 37.6 %, p = 0.0034) and group 2 (18.4 % vs. 14.4 %, p = 0.0053). Concordance between manual and semi-automatic classifications ranged from 59.5 % in group 2 to 100.0 % in groups 6, 7, 8, and 9. The most frequent mismatches were for the parameters "onset of labour" in 184 cases (13.4 %), "parity" in 42 cases (3.1 %) and "previous uterine scars" in 23 cases (1.7 %). In the manual classification, there were significant differences in the CS rate in group 1 (7.9 % vs. 2.5 %, p < 0.0001), group 2 (30.2 % vs. 48.2 %, p < 0.0001), and group 4 (14.1 % vs. 37.4 %, p = 0.0004), compared to the semi-automatic classification. CONCLUSIONS: Due to incorrect data entry and unclear definitions of criteria, quality assurance data in obstetric databases may contain a relevant proportion of errors, which could influence statistics with TGCS in context of CS rates in international comparisons.

Development of a core outcome set for effectiveness studies of breech birth at term (Breech-COS): A systematic review on variations in outcome reporting.

Women pregnant with a breech-presenting fetus at term are at an increased risk of adverse outcomes. Although the most common intervention is planned delivery by caesarean section, this is not always possible or desirable. Comparing alternative interventions is difficult due to heterogeneity in reported outcomes and their measurements. Additionally, the evidence, particularly for women in labour with a breech-presenting fetus, is very low quality, with several outcomes viewed as critical and important to decision-making not reported at all. There is a need to develop a core outcome set of minimum outcomes in all studies evaluating the effectiveness of interventions to improve outcomes associated with term breech birth (Breech-COS). Our objectives were to (1) identify outcomes currently reported in effectiveness studies of breech birth at term using a systematic review of the literature; (2) assess the methodological quality of outcome reporting in the included studies; and (3) engage with members of an established Patient and Public Involvement (PPI) group about the results, to help frame our understanding from the perspective of service users. We searched three databases (MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials) for all effectiveness studies associated with vaginal breech birth published in English between 2000 and 2020. Two reviewers independently screened and extracted the data. Outcomes were categorised into neonatal, maternal, features of labour, and long-term maternal and hierarchy of outcome classification (primary, secondary, part of composite, or undesignated). Frequency of reporting was calculated for each. An adapted methodological assessment was done for each study investigating whether primary and secondary objectives were clearly stated and defined. The results of the systematic review were then discussed with a PPI group to consider importance and relevance to service users. A total of 211 outcomes were extracted from 108 included studies, comprising of short (43) and long-term (39) neonatal, short (54) and long-term (39) maternal and features of labour (36) outcomes. The most frequently reported outcome in each category was: APGAR score at 5 min, developmental vulnerability/neurological morbidity, maternal mortality, urinary incontinence, and actual mode of birth respectively. Long-term outcomes were infrequently reported in the included studies, with outcomes for future pregnancies not reported at all, although these were each deemed important by service users. There was a lack of consensus in definition and measurement of outcomes, with only 36% of the included studies having clearly stated primary and secondary objectives. The observed heterogeneity in reported outcomes, lack of consensus in definition and measurement, as well as desire expressed by service users to have robust risk statistics for outcomes important to them highlights the need to develop a core outcome set for evaluating effectiveness studies of breech birth at term. A Breech-COS will enable useful synthesis of evidence and contribute to supported decision-making for women pregnant with a breech-presenting fetus at term.

Not Recommended, But Done: Breastfeeding with HIV in Germany.

Breastfeeding (BF) in mothers living with HIV (MLWH) is still discussed controversially in resource-rich settings. In Germany, where formula feeding is recommended for MLWH single BF cases have been reported, but no systematic data collection and analysis are available so far. This study, titled HELENE, aims to fill this data gap. A questionnaire covering the course of BF was distributed by a graduate student visiting each study site. Information was collected from patient files and by personal communication with the health care provider. Primary study objectives were the duration of BF and the maternal antiretroviral treatment (ART). Fifteen treatment centers across Germany contributed a total of 42 BF cases, observed from May 2009 to July 2020. There was an increasing number of BF cases over time. The median duration of BF was 20 weeks varying from single BF of colostrum to 104 weeks. All BF women except one elite controller received ART: 39% non-nucleoside reverse transcriptase inhibitor-, 37% INSTI-, 29% protease inhibitor-based regimens; one woman was on maraviroc. Thirty-nine percent of the ART regimens included drugs that were not recommended by the German-Austrian pregnancy guidelines. Our findings highlight the diversity of BF cases in Germany in terms of duration, maternal ART, and monitoring. Since the number of BF cases is increasing, guidelines are obliged to implement more detailed recommendations on BF, the monitoring of BF mothers, and the follow-up of the infants. There is an urgent need for prospective national and European data collections to further improve HIV prevention of mother-to-child transmission (PMTCT) in the setting of BF.

Practical insight into upright breech birth from birth videos: A structured analysis.

BACKGROUND: We aimed to identify common features of upright vaginal breech births with good outcomes to refine a physiological approach to teaching breech birth. METHODS: We performed a structured analysis of 42 videos of successful upright breech births (eg, kneeling, hand/knees), facilitated by obstetricians (n = 34) and midwives (n = 8) in nine different countries. Precise timings and relevant clinical details were recorded on an Excel spreadsheet. Each video was analyzed twice by at least two members of the research team. Time-to-event intervals, frequencies of interventions, and descriptive statistics were calculated using SPSS. RESULTS: A completely spontaneous (labor mechanisms and maternal effort only) birth occurred in 14/42 (33%) cases. The median time between the birth of the fetal pelvis and the head in all births was 1:52 (IQR 1:05,2:46; min:sec). Lack of spontaneous rotation to a sacro-anterior position by the time the fetus had emerged to the nipple line was strongly associated with fetal arm entrapment. The following maneuvers were used: shoulder press to flex the aftercoming head in midpelvis or outlet (n = 24), sweeping down arm/s (n = 12), buttock lift to assist shoulder press (n = 6), modified Mauriceau (n = 6), rotational maneuvers to release an entrapped arm (n = 6), elevate and rotate fetal head to assist engagement (n = 2), and conversion into supine maternal position (n = 2). CONCLUSIONS: Most upright breech births occur within 3 minutes of the birth of the fetal pelvis. Upright breech birth attendants use variations of traditional maneuvers. We introduce a physiological breech algorithm as an initial timekeeping framework for teaching, research, and practice.

[Is it Reasonable to Establish an Independently Managed Obstetric Unit in a Small Hospital and Does it Result in Measurable Changes in Quality of Maternity Care?] / Ist eine eigenständige Geburtshilfe in einem Haus der Grund- und Regelversorgung sinnvoll und führt sie zu messbaren Veränderungen in der Versorgung?

INTRODUCTION: An independently managed, specialty obstetric unit in a small hospital setting resulted in measurable changes in quality of maternity care. MATERIAL AND METHODS: We present obstetric data from a level I (basic care) hospital in Frankfurt, Germany. We compare data from the mandatory state register collected in 2013, when the obstetric unit was under single management with the gynaecology department, with data collected in 2016 after the establishment of independent obstetric unit and a specialised service. RESULTS: Between 2013 and 2016, the birth rate in our hospital increased by 46.4%, from 803 to 1176 births/year. CS rates decreased by 8.9%, from 34.9 to 26% (p<0.01). Operative vaginal delivery rates increased by 5.2 (p<0.01%). Transfer of neonates to NICU decreased from 5.6% to 3.1% (p<0.01). Other obstetric interventions also decreased, including induction of labour (10.1 to 9.4%, p=0.632) and rate of episiotomy (13.4 to 1.1%, p<0.01). Rates of severe fetal acidosis (p<0.05) increased from no events in 2013 to 2 events in 2016. There were non-significant reductions in planned caesarean section for primiparous women and repeat caesarean section. CONCLUSION: An independently managed, specialised obstetric unit separate from an Obstetric & Gynaecology Department previously under single management can lead to measurable changes and quality improvement in a short period of time.

Does breech delivery in an upright position instead of on the back improve outcomes and avoid cesareans?

OBJECTIVE: To compare breech outcomes when mothers delivering vaginally are upright, on their back, or planning cesareans. METHODS: A retrospective cohort study was undertaken of all women who presented for singleton breech delivery at a center in Frankfurt, Germany, between January 2004 and June 2011. RESULTS: Of 750 women with term breech delivery, 315 (42.0%) planned and received a cesarean. Of 269 successful vaginal deliveries of neonates, 229 in the upright position were compared with 40 in the dorsal position. Upright deliveries were associated with significantly fewer delivery maneuvers (OR 0.45, 95% CI 0.31-0.68) and neonatal birth injuries (OR 0.08, 95% CI 0.01-0.58), second stages that were 42% shorter on average (1.02 vs 1.77 hours), and nonsignificantly decreased serious perineal lacerations (OR 0.34, 95% CI 0.05-3.99). When upright position was used almost exclusively, the cesarean rate decreased. Serious fetal and neonatal morbidity potentially related to birth mode was low, and similar for upright vaginal deliveries compared with planned cesareans (OR 1.37, 95% CI 0.10-19.11). Three neonates died; all had lethal birth defects. Forceps were never required. CONCLUSION: Upright vaginal breech delivery was associated with reductions in duration of the second stage of labor, maneuvers required, maternal/neonatal injuries, and cesarean rate when compared with vaginal delivery in the dorsal position.

Does pregnancy and/or shifting positions create more room in a woman's pelvis?

OBJECTIVE: The purpose of this study was to assess the impact of different positions on pelvic diameters by comparing pregnant and nonpregnant women who assumed a dorsal supine and kneeling squat position. STUDY DESIGN: In this cohort study from a tertiary referral center in Germany, we enrolled 50 pregnant women and 50 nonpregnant women. Pelvic measurements were obtained with obstetric magnetic resonance imaging pelvimetry with the use of a 1.5-T scanner. We compared measurements of the depth (anteroposterior (AP) and width (transverse diameters) of the pelvis between the 2 positions. RESULTS: The most striking finding was a significant 0.9-1.9 cm increase (7-15%) in the average transverse diameters in the kneeling squat position in both pregnant and nonpregnant groups. The average bispinous diameter in the pregnant group increased from 12.6 cm ± 0.65 cm in the supine dorsal to 14.5 cm ± 0.64 cm (P < .0001) in the kneeling squat; in the nonpregnant group the increase was from 12 cm ± 0.76 cm to 13.9 cm ± 1.04 cm (P < .0001). The average bituberous diameter in the pregnant group increased from 13.6 cm ± 0.93 cm in the supine dorsal to 14.5 cm ± 0.83 cm (P < .0001) in the kneeling squat position; in the nonpregnant women the increase was from 12.6 cm ± 0.92 cm to 13.5 cm ± 0.88 cm (P < .0001). CONCLUSION: A kneeling squat position significantly increases the bony transverse and anteroposterior dimension in the mid pelvic plane and the pelvic outlet. Because this indicates that pelvic diameters change when women change positions, the potential for facilitation of delivery of the fetal head suggests further research that will compare maternal delivery positions is warranted.

How does HIV affect the reproductive choices of women of childbearing age?

The majority of women living with HIV are of childbearing age and many of these women wish to have a family. As a result of advances in the treatment and management of HIV, more reproductive opportunities are now available to this group. However, women living with HIV may still require education and guidance in a range of reproductive situations, including avoiding pregnancy, seeking fertility treatment or having a child. HIV physicians should be aware of recent data and guidance on these situations--including areas where more data are required--and consider them when deciding on appropriate management for their patients.

Clinical hypnosis before external cephalic version.

Three to four percent of full-term singleton pregnancies present themselves as breech deliveries. External cephalic version (ECV) is a procedure to try to turn a breech fetus to cephalic by externally maneuvering the fetus through the maternal abdomen. This trial examines a clinical hypnosis intervention against standard medical care of women before ECV. A total of 78 women, who received a hypnosis intervention prior to ECV, had a 41.6% (n = 32) successful ECV, whereas the control group of 122, who had similar baseline characteristics, had a 27.3% (n = 33) successful ECV procedure (p < 0.05). This trial found that a relaxation technique with the help of clinical hypnosis was successful at increasing the likelihood of a successful ECV procedure.

Delayed interval delivery in twin and triplet pregnancies: 6 years of experience in one perinatal center.

OBJECTIVE: This study aimed to know the outcome of delayed-interval delivery for twin and triplet pregnancies at 22+0 to 25+0 weeks of gestation. STUDY DESIGN: A retrospective cohort of twin and triplet deliveries at the 23rd to 26th weeks of gestation were managed with delayed interval delivery from 2005 to 2011. RESULTS: From 2005 until 2011, delayed delivery in five twin pregnancies and two triplet pregnancies were performed. The interval between delivery of the first fetus and the remaining twin/triplets was 1-18 days (mean, 9.7 days). In all cases, the first fetus was born vaginally. Survival of the first twin/triplet was 14.3%, whereas 57.1% of the second born twin/triplets survived. Birth weight gained due to delayed delivery was 131 g on average. No severe maternal complications were observed. When compared with a gestation age-matched group, where the delay was not possible, the delayed twin/triplet had a higher survival rate (57.1% vs. 0%, P=0.05). CONCLUSION: In multiple pregnancies with preterm delivery between completed 22 and completed 25 weeks of gestational age, delayed delivery seems to be a useful therapeutic option to achieve a better outcome of the remaining fetus or fetuses.

A lesson for cancer research: placental microarray gene analysis in preeclampsia.

Tumor progression and pregnancy share many common features, such as immune tolerance and invasion. The invasion of trophoblasts in the placenta into the uterine wall is essential for fetal development, and is thus precisely regulated. Its deregulation has been implicated in preeclampsia, a leading cause for maternal and perinatal mortality and morbidity. Pathogenesis of preeclampsia remains to be defined. Microarray-based gene profiling has been widely used for identifying genes responsible for preeclampsia. In this review, we have summarized the recent data from the microarray studies with preeclamptic placentas. Despite the complex of gene signatures, suggestive of the heterogeneity of preeclampsia, these studies identified a number of differentially expressed genes associated with preeclampsia. Interestingly, most of them have been reported to be tightly involved in tumor progression. We have discussed these interesting genes and analyzed their potential molecular functions in preeclampsia, compared with their roles in malignancy development. Further investigations are warranted to explore the involvement in molecular network of each identified gene, which may provide not only novel strategies for prevention and therapy for preeclampsia but also a better understanding of cancer cells. The trophoblastic cells, with their capacity for proliferation and differentiation, apoptosis and survival, migration, angiogenesis and immune modulation by exploiting similar molecular pathways, make them a compelling model for cancer research.

Problems and challenges in the diagnosis of vertical infection with human cytomegalovirus (CMV): lessons from two accidental cases.

Human cytomegalovirus (CMV) is considered as the most common cause of congenital infection in humans and the overall burden for the public health system is rather high. About 1/10 of vertically infected newborns present or develop severe signs of cytomegalic inclusion disease (CID), with the classical triad of chorioretinitis, microcephaly and cerebral calcifications. However the most symptomatic cases are detected postnatal and methods of diagnostic virology raised the questions for the gold standard in laboratory screening. The current problems in diagnosis and therapy are outlined in two different cases: An acute primary CMV infection with no clinical signs of illness in both mother and child and a secondary CMV-infection resulting in necrotizing CMV encephalitis in the fetus. Beside virus detection in whole blood samples and other fluids, newly adopted laboratory assays like the destination of CMV-IgG avidity were necessary. Furthermore a serologic screening for pregnant women should be implicated routinely. Passive IgG treatment of the mother was helpful but the ultimate goal in prevention of congenital CMV infection is to develop a vaccine, which would be administered to seronegative women.