Blood group O: A novel risk factor for increased postpartum blood loss?

INTRODUCTION: Blood group O is known to be associated with lower levels of von Willebrand factor (VWF) and with increased bleeding complications. The influence of blood group O on postpartum blood loss was assessed by a few studies, however, without adjustment for important obstetric risk factors for postpartum blood loss. AIM: Aim of this study was to investigate whether women with blood group O exhibit increased blood loss after delivery in consideration of established risk factors for postpartum bleeding. METHODS: A total of 1487 patients were prospectively included into this cohort study. Blood loss was assessed by estimated blood loss (in mL), and drop of haemoglobin (Δ haemoglobin) was calculated. Association of blood loss with risk factors (such as blood group O, cervical tears, morbidly adherent placenta, placenta praevia and uterine atony amongst others) was assessed with appropriate tests. Significant variables were entered into a stepwise multivariate regression analysis. RESULTS: Women with blood group O showed a significantly higher blood loss when compared to women with blood group non-O (529.2 mL ± 380.4 mL and 490.5 mL ± 276.4 mL, respectively, P = .024)). The increased blood loss in women with blood group O remained significant after multivariate regression analysis (difference 47 mL, P = .019). CONCLUSION: This is the first study reporting significantly increased blood loss following delivery in women with blood group O after adjustment for major risk factors for postpartum blood loss. Albeit having a statistically significant, but clinically minor effect on absolute blood loss, blood group O carriers may suffer from aggravated bleeding in the presence of additional obstetric bleeding pathologies.

Quality Requirements for the early Fetal Ultrasound Assessment at 11-13+6 Weeks of Gestation (DEGUM Levels II and III).

The early fetal ultrasound assessment at 11 - 13(+6) weeks of gestation remains the cornerstone of care despite the progress in diagnosing fetal chromosomal defects using cell-free fetal DNA (cffDNA) from the maternal circulation. The measurement of nuchal translucency (NT) allows the risk calculation for the fetal trisomies 21, 18 and 13 but also gives information on those fetal chromosomal defects which are at present unable to be detected using cffDNA. Nuchal translucency is the only auditable parameter at 11 - 13(+6) weeks and gives thus information on the quality of the first trimester anomaly scan. In addition it gives indirect information on the risks for fetal defects and for cardiac anomalies. Also the chances for a healthy live baby can be estimated. As experience with first trimester anomaly scanning increases, and the resolution of the ultrasound equipment has increased substantially, more and more details of the fetal anatomy become accessible at the first trimester scan. Therefore fetal anatomical defects and complex anomalies have become amenable to examination in the first trimester. This guideline describes compulsory and optional parameters for investigation at the first trimester scan and outlines a structured method of examining a first trimester fetus at 11 - 13(+6) weeks of gestation.

Continuous independent quality control for fetal nuchal translucency measurements provided by the cumulative summation technique.

PURPOSE: The cumulative summation technique (CUSUM) is an innovative method for the quality control of nuchal translucency (NT) measurements. CUSUM allows immediate corrective intervention as soon as an unacceptable tendency is noted. The aim of this study was to implement an objective and dynamic quality control method based on the CUSUM technique for prompt analysis of fetal NT measurement which would be compatible with different standards in routine clinical practice. The findings were compared to the standard NT quality control methods currently in use. MATERIALS AND METHODS: Three sets of fetal NT measurements performed by three experienced examiners (I, II and III) were selected for retrospective evaluation. One additional set of NT measurements performed by examiner IV was prospectively assessed to approve the practicability of the method. NT measurements were conducted according to the recommendations of Fetal Medical Foundation (FMF) Germany and London. NT values were converted to Z-scores. For quality and accuracy evaluation, data were fed into the Digisono CUSUM software to create double CUSUM charts of Z-scores. In addition, histograms were composed from the Z-scores of each set of measurements and plotted against a normal Gaussian distribution. RESULTS: Three different patterns of retrospective performance and one set of NT measurements that was evaluated prospectively are presented. The full alignment of Z-scores using CUSUM curves reflected exact periods of under- and overestimation of NT measurements. The CUSUM chart of the prospective data set reveals that prompt corrective intervention of poor performance resulted in reconstitution of optimal results and provided sufficient control. In contrast, histograms of NT Z-scores only showed a minor positive or negative shift as compared to the expected values on the basis of Gaussian distribution, but could not identify poor performance. CONCLUSION: Use of the CUSUM technique analysing the quality of sonographic NT measurements provides the possibility to prospectively observe the development of the examiner's skills, to maintain competence and to promptly define the time when inaccurate measurements start to occur.

Continuous independent quality control for fetal ultrasound biometry provided by the cumulative summation technique.

OBJECTIVE: To apply the cumulative summation (CUSUM) technique for an evaluation of the learning process of sonographic fetal weight estimation at term in combination with the z-scores of biometry determinants and to assess the time of appearance and sources of errors. METHODS: Learning curve (LC-CUSUM) and double CUSUM charts for systematic error detection based on absolute and signed mean percentage error were generated to retrospectively estimate the longitudinal accuracy of sonographic fetal weight estimation conducted by three trainees and one experienced examiner. For LC-CUSUM analysis an examination was considered to be a failure when there was an absolute error in birth weight estimation >/= 15%. Fetal biometry measurements (head circumference, abdominal circumference (AC) and femur length (FL)) from 227 routine ultrasound scans of one examiner were separately transformed into z-scores and double CUSUM charts were generated to assess the systematic errors for each determinant. RESULTS: The LC-CUSUM charts revealed that different numbers of scans are required for different examiners to achieve competence in estimating birth weight. AC and FL deviated most significantly from expected values (P < 0.05). The double CUSUM charts revealed exact periods of systematic errors in the measurement of biometry determinants, clearly reflecting errors of fetal weight estimation. CONCLUSIONS: The use of CUSUM techniques in the analysis of sonographic data allows observation of the development of an examiner's skill and maintenance of competence. The CUSUM technique not only allows the reasons for impaired fetal weight estimation to be revealed but also allows determination of the exact time when inaccurate measurements start to occur. We suggest that CUSUM charts should be implemented in routine clinical practice as a measure of objective quality evaluation of sonographic fetal biometry.

[Does a combination of foetal biometry and maternal MRI pelvimetry decrease the frequency of secondary caesarean section?]. / Senkt die Kombination von fetaler Biometrie und MRT-Pelvimetrie die Rate an sekundären Sectiones?

OBJECTIVE: Cephalopelvic disproportion (CPD) is a frequent indication for secondary Caesarean section. The delivery simulation software Anapelvis was developed to predict a CPD on the basis of foetal ultrasound biometry and maternal pelvimetry data. The objective of this retrospective study was to analyse the predictive value of Anapelvis software in consideration of antenatal foetal biometry quality. PATIENTS AND METHODS: 162 pregnant women with suspected CPD who had undergone a magnetic resonance imaging pelvimetry were included in this study. The antenatal foetal biometry was carried out within a week before delivery. RESULTS: The positive predictive value (PPV) for arrest of delivery was 85.7% in the group of 79 pregnancies with planned vaginal delivery. Sensitivity was 56.3%, specificity 60.0% and negative predictive value (NPV) 24.3% accordingly. The highest accuracy [percent error (PE) -0.1%] of fetal weight estimation was found in the group where an arrest of delivery was predicted. The lowest accuracy (PE -4.4%) was detected in the group with the prediction of vaginal delivery. CONCLUSIONS: Labour simulation software can be helpful only in such cases where an arrest of delivery was predicted. The accuracy of delivery simulation with the Anapelvis software was considerably affected by the quality of antenatal foetal ultrasound biometry.

Sonographic prediction of macrosomia cannot be improved by combination with pregnancy-specific characteristics.

OBJECTIVE: To evaluate the predictive value of a combination of sonographic, clinical and demographic data for detecting fetal macrosomia compared to ultrasound fetal weight estimation alone. METHODS: Retrospective cohort data were obtained from 1062 pregnancies in an unselected population. Estimated fetal sonographic weight was obtained within the last week prior to delivery. Two different combination models-published by Mazouni et al. and Nahum and Stanislaw-were employed to predict the presence of macrosomia at birth in these infants. Receiver-operating characteristics (ROC) curves were generated to compare the prediction of macrosomia when using different observation methods and sensitivity, specificity, positive predictive value, negative predictive value (NPV) and accuracy were calculated. RESULTS: Macrosomia (birth weight >or= 4000 g) was present in 135/1062 (12.7%) newborns. ROC curve analysis revealed the prediction of macrosomia using ultrasound alone to be significantly superior to the combined method of Mazouni et al. (area under the curve (AUC) 0.922, 95% CI 0.902-0.943 vs. 0.747, 95% CI 0.700-0.794, respectively; P < 0.0005), whereas the performance of the Nahum and Stanislaw equation was similar but not superior to ultrasound alone (AUC 0.895, 95% CI 0.839-0.950 vs. 0.912, 95% CI 0.867-0.958, respectively; P > 0.05). The accuracy of macrosomia prediction was similar for ultrasound alone and the Nahum and Stanislaw equation (approximately 90%), whereas the nomogram of Mazouni et al. reached only 51.7% accuracy (using a probability cut-off level of 50%). The NPV was found to be over 90% for all methods. CONCLUSIONS: Combination of sonographic estimates with clinical and demographic variables does not improve the prediction of macrosomia at delivery in comparison with a routine ultrasound scan within a week before delivery, at least in unselected populations.

Prenatal diagnosis in Switzerland.

Switzerland, with a population of slightly over 7 million, has about 83,000 births per year. There is no comprehensive national registry for prenatal diagnosis (PND) or congenital malformations. Health care is largely organised within each of the 23 countries. Whereas ultrasound screening is available to all pregnant women, the availability of other types of PND is largely determined by proximity to the university medical centres or specialised clinics. Maternal biochemical serum screening is offered by some 15-20 laboratories, and cytogenetic analyses are performed in 8. DNA-based diagnosis is essentially limited to the medical genetics departments/divisions of the 5 university medical schools. It can be estimated that slightly over 10% of gestations are monitored by invasive prenatal diagnostic techniques. The greatest challenge for the future will be the training of the medical and paramedical personnel necessary for the current and future pre- and postnatal diagnostic testing.

Lethal multiple pterygium syndrome: suggestion for a consistent pathological workup and review of reported cases.

We report on 2 brothers with lethal multiple pterygium syndrome (LMPS) born to non-consanguineous parents as late spontaneous abortions. Both fetuses presented with massive nuchal edema, and facial anomalies including cleft palate and broad ribs. Apparently, several subgroups of LMPS exist. Differentiation is difficult, as there is no consistent agreement on a workup protocol for autopsies. We compared the findings in the literature on cases with LMPS, and we suggest a standardized workup as an initial step for more efficient differentiation between various subgroups.

Diaphragmatic defects, limb deficiencies, and ossification defects of the skull: a distinctive malformation syndrome.

We report on prenatal and postnatal findings in 4 consecutive fetuses with a pattern of severe congenital anomalies who were born to a healthy nonconsanguineous couple. The spectrum of malformations includes diaphragmatic defects, hypoplastic lungs, omphalocele, limb deficiencies, syndactyly of toes, and ossification defects of the skull. This specific spectrum of anomalies is not fully compatible with that of any established syndrome. No prenatal exposure to any possible teratogen was found. Family history is suggestive for autosomal recessive inheritance, even though germ-line mosaicism in one of the parents cannot completely be excluded.

Embryonic heart rate in dated human embryos.

Using simultaneous B-mode and time-motion transvaginal ultrasonography we measured embryonic heart rate (EHR) in dated human embryos during the first trimester in a prospective study. In 160 pregnant women who had undergone assisted reproductive procedures, 139 singleton embryos and 46 embryos from 21 multiple pregnancies were studied between the 37th and 98th postmenstrual day. Because multiple measurements in one embryo at different ages were possible, a total of 348 measurements were taken. EHR in dated human embryos shows an increase up to 63 postmenstrual days or 22 mm greatest length. Thereafter a steady decrease of EHR was noted. Maximal EHR is reached when morphological development of the embryonic heart is completed. Furthermore, we examined 27 embryos with low EHR compared with greatest embryonic length. All of these ended in missed abortion within the embryonic period. According to our data the increase of EHR parallels the morphological development of the embryonic heart. Decline of EHR afterwards is interpreted as a functional adaption to muscular development of the heart.

[Diagnostic and therapeutic aspects of antegrade ureteropyelography and percutaneous nephropyelostomy in childhood]. / Diagnostische und therapeutische Aspekte der antegraden Ureteropyelographie und der perkutanen Nephropyelostomie im Kindesalter.

In a sample of 18 children aging one day to eighteen years 21 percutaneous nephrostomies and 27 antegrade pyelographies were performed using sonography and fluoroscopy. Thirteen patients had both nephrostomy and pyelography and 5 had only pyelography. Three of 13 patients needed bilateral nephrostomies. The results indicate that the combination of percutaneous nephrostomy and antegrade pyelography is helpful in diagnosis and treatment of various obstructive disorders of the urinary tract especially in the newborn period.

Report of dysgerminoma in the ovaries of a snapping turtle (Chelydra serpentina) with discussion of ovarian neoplasms reported in reptilians and women.

A malnourished, captive, young adult (weight-11 kg, carapace length-25 cm), female snapping turtle (Chelydra serpentina) was presented for examination and treatment of malnutrition and multiple carapace necroses. Because treatment was unsuccessful, the animal was euthanatized and necropsied. The main necropsy observations showed the presence of a 9 cm greyish-white/yellow, soft, fleshy to fatlike mass involving the right ovary near the oviduct opening and multiple similar, pea-to-walnut sized masses involving both ovaries. Microscopic examination of formalin fixed, hematoxylin and eosin and silver stained tissue sections revealed the masses to be composed of primordial germ cells arranged in a pattern morphologically compatible with dysgerminoma as described in women and other mammals. Very rarely have ovarian neoplasms been reported in turtles or other reptiles. This is the first neoplasm described in the snapping turtle ovary and the first dysgerminoma reported in reptilians. A tabulation of previously documented ovarian neoplasia in reptiles and a comparison of this cancer to those occurring in women will be discussed.

Human acardiac anomaly: a report of three cases.

We report on three cases of acardia, all of which had to be classified as acardius anceps. The degree of cardiac malformation ranged between a completely missing heart and a malrotation of a relatively well-developed heart. One fetus showed an intermediate form of cardiac malformation with a hypoplastic cor triloculare. Our findings suggest that the defect in cardiac development may take place at different times in early embryogenesis, resulting in differing degrees of cardiac malformation.

[Significance of sonographic diagnosis of fetal abnormalities of the urinary tract]. / Bedeutung der sonographischen Diagnostik fetaler Fehlbildungen des Harntraktes.

Out of 5,209 fetuses, routinely screened at our prenatal clinic 56 fetuses with malformations of the urinary tract were diagnosed. In 37 cases dilatation of the urinary tract was found. Five fetuses presented with unilateral multicystic kidneys whereas 3 fetuses suffered from bilateral polycystic kidney disease and 11 were found to have bilateral non-functioning kidneys. Prenatal diagnosis of dilatation of fetal urinary tract and of unilateral multicystic kidneys allows referral of these newborns for further urological evaluation before symptoms are present. Refinement in prenatal diagnosis of bilateral polycystic kidney disease and bilateral non-functioning kidneys helps evaluating fetal viability.

Chronic tubulointerstitial nephropathy in six okapis (Okapia johnstoni).

Renal tubular atrophy with conical and medullary interstitial fibrosis with severe thickening of the basement membranes of atrophic tubules was found in six okapis (Okapia johnstoni). Focal glomerular atrophy, probably secondary to ischemic collapse of the glomerular capillary tuft, was also observed. Although the etiologies and pathogeneses of these nephropathies are unclear, primary damage of the tubular epithelium appears to be the most likely cause, and toxicity from ingested plant material, possibly willow (Salix sp.), is a possibility.

[LSD and cannabis abuse in early pregnancy with good perinatal outcome. Case report and review of the literature]. / LSD- und Cannabis-Konsum während der frühen Schwangerschaft mit gutem perinatalen Ausgang. Fallbericht und Literaturübersicht.

This is a case report of a 27-year-old patient who had smoked a joint (cannabis) and 20 cigarettes (tobacco) daily up to the time of a positive pregnancy test at 7 4/7 weeks (p.c.). On day 20 p.c. she had an LSD minitrip. There are reports of chromosome aberrations in in vitro animal studies with LSD. In humans the main consequences are malformations of the fetal extremities and dysplasias of the eye. In both animals and humans cannabis causes changes in dopaminergic activity. Our recommendation was to continue the pregnancy, but to monitor it closely. The patient had a spontaneous term delivery-a lively boy with weight between the 5th and the 50th percentile, length between the 50th and the 90th percentile, normal umbilical arterial and venous pH values, and Apgar scores 7/9/10. There were no visible abnormalities, and behaviour was normal. If it is suspected that a pregnant patient consumes LSD, dysplasias of the fetal skeleton and eye should be checked for. With respect to LSD and to cannabis, too, the intellectual development of the child should be closely followed.