Prenatal ultrasound screening and pregnancy outcomes in HIV-positive women in Germany: results from a retrospective single-center study at the Charité-Universitätsmedizin Berlin.

OBJECTIVES: The aim of this study was to investigate the rate of Mother-to-child-transmission (MTCT) in women living with HIV (WLWH) in a tertiary care institution. Furthermore, we aimed to assess prenatal ultrasound screening for fetal anomalies and outcomes in high-risk pregnancies due to maternal HIV infection." METHODS: In this single-center study, retrospective data related to pregnancy and childbirth were collected from 420 WLWH. All data were evaluated descriptively. RESULTS: From January 2014 to December 2020, a total number of 420 pregnant WLWH delivered 428 newborns. 415 (98.8%) were receiving antiretroviral therapy (ART) and 88.8% had a viral load of < 50 cop/ml prior delivery. 46 (11%) of the newborns were born prematurely. Low birth weight < 2500 g occurred in 38 (9.1%) of the children. 219 (52.1%) caesarean sections (CS) were performed. The most frequent indication for an elective CS was a previous CS (70.2%). 8 severe malformations were detected using first and second trimester ultrasound. In one child, MTCT was detected postpartum, resulting in an HIV transmission rate of 0.2% in the presented cohort. CONCLUSIONS: The low rate of vertical HIV-transmission in our cohort of 0.2% is the result of interdisciplinary prenatal care and high experience of healthcare providers in treatment of WLWH. Despite high ART coverage and adherence, good maternal immune system and very low vertical HIV transmission rate, maternal HIV infection remains a challenge in obstetric care. First and second ultrasound screening should be a part of prenatal care for HIV-infected women and should also be offered to HIV-negative women. A reduction of the rate of unnecessary elective caesarean deliveries in WLWH is necessary to reduce complications in subsequent pregnancies.

Assessment of high-risk human papillomavirus infections and associated cervical dysplasia in HIV-positive pregnant women in Germany: a prospective cross-sectional two-centre study.

PURPOSE: Invasive cervical cancer (ICC) is associated in nearly 100% with persistent high-risk Human Papillomavirus (HR-HPV) infection. ICC is still one of the leading causes for cancer mortality in women worldwide. The immunosuppressive influence of Human Immunodeficiency Virus (HIV) and the immunocompromised period of pregnancy due to tolerance induction against the hemiallogeneic fetus, are generally risk factors for acquisition and persistence of HR-HPV infections and their progression to precancerous lesions and HPV-associated carcinoma. METHODS: Overall, 81 pregnant women living with HIV (WLWH) were included. A medical history questionnaire was used to record clinical and HIV data. Participants received cervicovaginal cytological smear, colposcopy and HPV testing. HPV test was performed using BSGP5+/6+ PCR with Luminex read-out. The HR-HPV genotypes 16, 18, 31, 33, 45, 52, 58 were additionally grouped together as high-high-risk HPV (HHR-HPV) for the purpose of risk-adapted analysis. RESULTS: HR-HPV prevalence was 45.7%. Multiple HPV infections were detected in 27.2% of participants, of whom all had at least one HR-HPV genotype included. HR-HPV16 and HR-HPV52 were the most prevalent genotypes and found when high squamous intraepithelial lesion (HSIL) was detected by cytology. HIV viral load of ≥ 50 copies/ml was associated with higher prevalence of HR-HPV infections. Whereas, CD4 T cells < 350/µl showed association with occurrence of multiple HPV infections. Time since HIV diagnosis seemed to impact HPV prevalence. CONCLUSION: Pregnant WLWH require particularly attentive and extended HPV-, colposcopical- and cytological screening, whereby clinical and HIV-related risk factors should be taken into account.

Genotype-specific high-risk human papillomavirus infections and risk factors for cervical dysplasia in women with human immunodeficiency virus in Germany: results from a single-center cross-sectional study.

OBJECTIVE: Women living with HIV have an increased risk of human papillomavirus (HPV) infection and cervical cancer. Little is known about genotype-specific HPV prevalence, the impact of antiretroviral therapy, immunological status, and additional risk factors in women living with HIV in Germany. The goal of this study was to characterize the risk profile for cervical dysplasia in these women. METHODS: Patients with HIV infection presenting at Charité-Universitätsmedizin Berlin from October 2017 to September 2020 were included and underwent gynecological examination, colposcopy, cervical cytology and HPV genotype testing. HPV genotypes were stratified by carcinogenicity. Atypical squamous cells of undetermined significance or higher were considered abnormal cytology. Data were analyzed by SPSS software (version 26, 2019). A two-tailed p-value ≤0.05 was considered statistically significant. RESULTS: A total of 84 women were evaluated. The majority (95.2%) received antiretroviral therapy. Median CD4 cell count was 564 cells/µl (range 20-1969). 95.2% were previously screened for cervical cancer. High-risk HPV prevalence was 44%. High-high-risk HPV subtypes (16, 18, 31, 33, 45, 52, 58) were significantly associated with abnormal cytology (p<0.001). HPV16 was the most common genotype (23%), was significantly associated with abnormal cytology (p=0.002) and was the main risk factor for abnormal cytology (OR 8.55, 95% CI 2.15 to 34.13, p=0.002), followed by age <35 years (OR 4.96, 95% CI 1.23 to 19.61, p=0.033) and cigarette smoking (OR 3.944, 95% CI 0.98 to 15.88, p=0.053). CONCLUSIONS: Antiretroviral therapy and adherence to cervical cancer screening was high. High-high-risk HPV, especially HPV16, coincided with high incidence of cytological abnormalities. Women living with HIV in Germany have adequate immune status and are often pre-screened for cervical cancer, and therefore have a different risk profile for cervical dysplasia than in low-income or medium-income countries. Adapted screening programs should be defined.

Vaginal birth after cesarean (VBAC): fear it or dare it? An evaluation of potential risk factors.

OBJECTIVES: The consultation of women aspiring a vaginal birth after caesarean may be improved by integrating the individual evaluation of factors that predict their chance of success. Retrospective analysis of correlating factors for all trials of labor after caesarean that were conducted at the Department of Obstetrics of Charité-Universitätsmedizin Berlin, Campus Virchow Clinic from 2014 to October 2017. METHODS: Of 2,151 pregnant women with previous caesarean, 408 (19%) attempted a vaginal birth after cesarean. A total of 348 women could be included in the evaluation of factors, 60 pregnant women were excluded because they had obstetric factors (for example preterm birth, intrauterine fetal death) that required a different management. RESULTS: Spontaneous delivery occurred in 180 (51.7%) women and 64 (18.4%) had a vacuum extraction. 104 (29.9%) of the women had a repeated caesarean delivery. The three groups showed significant differences in body mass index, the number of prior vaginal deliveries and the child's birth weight at cesarean section. The indication for the previous cesarean section also represents a significant influencing factor. Other factors such as maternal age, gestational age, sex, birth weight and the head circumference of the child at trial of labor after caesarean showed no significant influence. CONCLUSIONS: The clear majority (70.1%) of trials of labor after caesarean resulted in vaginal delivery. High body mass index, no previous spontaneous delivery, and fetal distress as a cesarean indication correlated negatively with a successful vaginal birth after cesarean. These factors should be used for the consultation of pregnant women.

Online survey on uterotomy closure techniques in caesarean section.

OBJECTIVES: Uterine closure technique in caesarean section (CS) influences the rate of late complications in subsequent pregnancies. As no common recommendation on suture techniques exists, we developed a questionnaire to determine the techniques currently used and the frequencies of late complications. METHODS: The online questionnaire consisted of 13 questions and was sent to 648 obstetric hospitals (level I-IV) in Germany. Number of CS, rate of vaginal birth after caesarean section (VBAC), the type of uterus suturing technique and the frequency of uterine dehiscences, ruptures and placenta accreta spectrum (PAS) were queried. The answers were anonymous, and results were evaluated descriptively. RESULTS: The response rate was 24.7%. The mean CS rate was 27.3% (±6.2), the repeat CS rate 33.2% (±18.1). After CS, 46.2% (±20.2) women delivered vaginally. To close the uterotomy, 74.4% of hospitals used single layer continuous sutures, 16.3% single layer locked sutures, 3.8% interrupted sutures, 3.1% double layer continuous sutures and 2.5% used other suture techniques. The percentages of observed uterine dehiscences did not differ significantly between the different levels of care nor did the uterotomy suture techniques. CONCLUSIONS: There is no uniform suturing technique in Germany. A detailed description of suture technique in surgery reports is required to evaluate complications in subsequent pregnancies. National online surveys on obstetric topics are feasible and facilitate the discussion on the need to define a standardized uterine closure technique for CS.

Fetal and maternal outcome after hyperimmunoglobulin administration for prevention of maternal-fetal transmission of cytomegalovirus during pregnancy: retrospective cohort analysis.

PURPOSE: To determine the frequency of fetal infection as well as adverse pregnancy outcomes following antenatal hyperimmunoglobulin (HIG) treatment for primary cytomegalovirus (CMV) infection in pregnancy. METHODS: In our observational cohort study, data from 46 women with a primary CMV infection during pregnancy were evaluated. Primary CMV infection was defined by seroconversion or the presence of CMV-IgM and low CMV-IgG avidity. All women received at least two or more infusions of HIG treatment (200 IU/kg). Congenital CMV infection (cCMV) was diagnosed by detection of CMV in amniotic fluid and/or neonatal urine. We compared the rate of maternal-fetal transmission from our cohort to data without treatment in the literature. The frequency of adverse pregnancy outcomes was compared to those of live-born infants delivered in our clinic. RESULTS: We detected 11 intrauterine infections in our cohort, which correlates to a transmission rate of 23.9%. Compared to the transmission rate found in cases without treatment (39.9%), this is a significant reduction (P = 0.026). There were no adverse pregnancy outcomes in our cohort. The mean gestational age at delivery was 39 weeks gestation in treatment and control group. CONCLUSION: The administration of HIG for prevention of maternal-fetal CMV transmission during pregnancy seems safe and effective.

Intrauterine therapy of cytomegalovirus infection with valganciclovir: review of the literature.

Congenital cytomegalovirus (CMV) infection is the leading cause for sensorineural hearing loss and mental retardation in children without genetic diseases worldwide. There is little evidence guiding therapeutic strategies during pregnancy when intrauterine fetal CMV infection is confirmed. We provide a systematic review of the use of ganciclovir (GCV) or VGCV during pregnancy discussing safety of its use for mother and fetus and describe two cases of intrauterine therapy of fetal CMV infection with valganciclovir (VGCV). A PubMed database search was done up to November 16, 2016 without any restrictions of publication date or journal, using the following keywords: "valganciclovir" or "ganciclovir" and "pregnan*". Furthermore, citations were searched and expert references were obtained. Reported cases were considered if therapy was in humans and initiation of treatment of the CMV infection was during pregnancy. In total, seven case reports were retrieved which described GCV or VGCV use during pregnancy for fetal or maternal CMV infection. In the four cases of treatment for maternal CMV infection, no negative effects on the fetus were reported. Three cases of GCV administration to pregnant woman with the intention of fetal treatment after proven fetal infection were found. We additionally present two cases of VGCV treatment in pregnancy from our center of tertiary care. VGCV seems to be a safe treatment for congenital CMV infection for the mother and the fetus. Therapeutic concentrations can be achieved in the fetus by oral intake of the mother and CMV replication can be suppressed. Larger studies are needed to evaluate this therapeutic intervention and the long-term effects.

Influence of transvaginal ultrasound examination on quantitative vaginal fibronectin measurements: a prospective evaluation study.

OBJECTIVE: The most important parameter in prediction of preterm birth is the cervical length measured by transvaginal ultrasound. In cases with mid-range cervical length (10-30 mm), prediction of preterm birth is difficult. In these cases, testing for cervicovaginal fluid fetal fibronectin (fFN) can improve prediction. However, it is unclear whether transvaginal ultrasound itself influences the fFN result. The purpose of this study was to evaluate this issue independent of gestational age and cervical length. METHODS: A prospective evaluation study with 96 cases of pregnant women at 20-41 weeks of gestation was conducted in a tertiary perinatal center. A comparison of cervicovaginal fFN samples before and immediately after transvaginal ultrasound was performed. Fetal fibronectin was measured using the Hologic Rapid fFN 10Q system. It was analyzed quantitatively and qualitatively with ≥50 ng/mL as threshold for "positive". Changes in fFN values following transvaginal ultrasound were measured. RESULTS: Ninety-six percent (69/72) of women with a fFN concentration of <26 ng/mL before ultrasound had a corresponding fFN value <26 ng/mL after ultrasound. Ninety-three percent (13/14) of women with a fFN concentration of ≥100 ng/mL before ultrasound had a corresponding fFN value ≥100 ng/mL after ultrasound. In 80% (4/5) of women with a positive fFN sample but with a value <100 ng/mL, it turned negative (<50 ng/mL) after ultrasound. For fFN concentrations ≥100 ng/mL, there are high random fluctuations in the measurement results. CONCLUSIONS: Fetal fibronectin values of <26 ng/mL (for "negative") and ≥100 ng/mL (for "positive") from samples taken after ultrasound provide the same qualitative information as when sampled before ultrasound. For the correct interpretation however, quantitative analysis is necessary.

Correlation of intrapartum translabial ultrasound parameters with computed tomographic 3D reconstruction of the female pelvis.

AIMS: Intrapartum translabial ultrasound [ITU] can be an objective, reproducible and more reliable method than digital vaginal examination when evaluating fetal head position and station in prolonged second stage of labor. However, two-dimensional (2D) ultrasound is not sufficient to demonstrate the ischial spines and other important "landmarks" of the female pelvis. Therefore, the purpose of this study was to evaluate the distance of the interspinous plane as a parallel line to the infrapubic line in 2D ITU with the help of 3D computed tomography and digital reconstruction. RESULTS: Mean distance between the infrapubic plane and the tip of the ischiadic spine was 32.35 (±4.46) mm. The mean height was 166 (±7) cm; the mean weight was 67.5 (±18.4) kg. Body height and the measured distance were significantly correlated (P=0.025; correlation coefficient of 0.5), whereas body weight was not (P=0.37; correlation coefficient of -0.214). CONCLUSIONS: With the present results, clinicians were enabled to transfer the reproducible measurements of the "head station" by ITU to the widespread but observer-depending vaginal examination. Furthermore, ITU can be verified as an objective method in comparison to subjective palpation with the ability to optimize the evaluation of the head station according to bony structures as landmarks in a standardized application.

[Anesthesiological management of the drug-abusing parturient: relevance of maternal substance abuse for obstetric anesthesia]. / Kreißende mit Substanzkonsum - Bedeutung in der geburtshilflichen Anästhesie.

Most of the female consumers of legal and illegal substances are of childbearing age. Occasional use, use disorder and addiction commonly devolve into each other. A lot of young women quit consuming when planning a family or at the latest with the knowledge of pregnancy. The ongoing substance abuse during pregnancy requires a coordinated interdisciplinary collaboration for a sufficient care of these highly complex and individual cases.

Uterine packing with chitosan-covered gauze compared to balloon tamponade for managing postpartum hemorrhage.

BACKGROUND: Postpartum hemorrhage (PPH) is a major cause of maternal death worldwide. Management of PPH includes the administration of uterotonics, and intrauterine packing techniques. OBJECTIVE: In this study the effectiveness and safety of chitosan covered gauze versus a balloon tamponade for managing severe PPH should be assessed. STUDY DESIGN: This retrospective cohort study was conducted at the Department of Obstetrics, Charité, university hospital Berlin, between October 2016 and June 2018. Women with PPH were treated according to management guidelines. When bleeding persisted, we applied additional uterine packing with either chitosan covered gauze or a balloon tamponade. The primary outcome was uterine bleeding termination without additional surgical interventions. Secondary outcomes included the amount of blood loss, the amount of blood transfusions and maternal complications. RESULTS: Among the 78 patients included in this study, 47 (60.3%) received chitosan covered gauze tamponade and 31 (39.7%) received a balloon tamponade. The major reason for PPH was atonic bleeding, no statistically significant group differences were observed. With respect to the outcomes monitored, the groups were not significantly different in postpartum vital signs, hemoglobin levels, blood loss, admission to intensive care unit, or inflammation parameters. However, three patients in balloon tamponade group required a hysterectomy. No hysterectomy was required in gauze group. CONCLUSION: Chitosan covered gauze is an excellent option for treating PPH, it appeared to be at least equivalent to the balloon tamponade, in our experience particularly suitable for atony or placenta bed bleeding after spontaneous delivery or during cesarean sections, in cases of lower uterine segment atony, placenta previa bed bleeding, and/or coagulopathy.

Emergency cerclage versus bed rest for amniotic sac prolapse before 27 gestational weeks. A retrospective, comparative study of 161 women.

OBJECTIVE: The objective of the study is to compare outcomes after conservative management alone versus conservative management with cerclage in the treatment of amniotic sac prolapse in the second trimester. STUDY DESIGN: Retrospective, comparative study at a university hospital/tertiary referral centre. The medical data was provided by the files of 182 women who were in-patients between December 1989 and June 2005 as a result of prolapse of the amniotic sac during live pregnancies between the 17+0 and 26+0 weeks of gestation. The women were assigned to different groups on the basis of the type of treatment received (Group I: operative procedure=emergency cerclage or Group II: conservative procedure=bed rest, tocolysis, administration of antibiotics). Specified level of significance: p<0.05. MAIN OUTCOME MEASURES: prolongation of pregnancy, pregnancy outcome/infant mortality, and birth weight. RESULTS: The investigation covered 161 women with amniotic sac prolapse (operative management: n=89, conservative procedure: n=72). With operative procedures it was possible to prolong the pregnancy by 41 days (from the day of admission), compared with 3 days when conservative therapy was used (p<0.001, median values). In the group that received operative treatment, live births occurred in 72% of cases as opposed to 25% of cases in the group of women that received conservative therapy (p<0.001). There was also a significant difference in the median weight at birth of all live-born children: 1340g with operative therapy, 750g by conservative procedures (p<0.001). CONCLUSIONS: In the second trimester operative management of the amniotic sac was associated with improved perinatal outcomes including improved live-born rate, increased birth weight and prolonged pregnancy.

Surgical site infection in cesarean sections with the use of a plastic sheath wound retractor compared to the traditional self-retaining metal retractor.

OBJECTIVE: A cesarean section rate of up to 19.4% is reported worldwide. Surgical site infection occurs with rates of up to 13.5%. Plastic-sheath wound retractors show reduced rates of surgical site infections in abdominal surgery. There is limited evidence in women having cesarean sections. This study evaluates the use of the Alexis(®) O C-Section Retractor in the prevention of surgical site infection in patients undergoing their first planned cesarean section compared to the traditional Collins self-retaining metal retractor. STUDY DESIGN: A single center, prospective, randomized, controlled, observational trial. The primary outcome is surgical site infection as defined by the Centers for Disease Control and Prevention. The secondary outcomes included intraoperative surgical parameters, postoperative pain scores and the short and long-term satisfaction with wound healing. From October 2013 to December 2015 at the Charité University Hospital, Berlin. 98 patients to the Alexis(®) O C-Section Retractor group and 100 to the traditional Collins self-retaining metal retractor group. RESULTS: A statistically significant reduction in the rate of surgical site infections, when the Alexis(®) O C-Section Retractor was used for wound retraction compared to the traditional Collins metal self-retaining wound retractor, 1% vs. 8% (RR 7.84, 95% CI (2.45-70.71) p=0.035). CONCLUSIONS: The use of plastic-sheath wound retractors compared to the traditional self-retaining metal retractor in low risk women, having the first cesarean section is associated with a significantly reduced risk of surgical site infection.

Ethnic Turkish fathers in birth support roles in a Berlin labour and delivery room--motives, preparation and incidence in a 10-year comparison.

PURPOSE: Have there been changes among German (G) or ethnic Turkish (T) fathers with respect to birth preparation or motivation to participate in a birth support role? In a 10-year comparison is it possible to identify an increase among ethnic Turkish fathers in birth support roles in Germany? METHODS: (1) In 1995/96 and 2003, structured interviews were conducted with German and ethnic Turkish fathers on the second or third post-natal day, focusing on the following topics: birth preparation, motives for participating in the birth, anxieties experienced by the father in the labour and delivery room, the father's assessment of his role in the birth, information deficits. (2) In 1995 and 2006, the birth support roles of family members (partners, sisters, mothers-in-law etc.) were documented per 1000 consecutive hospital births and analysed according to parity and ethnicity. RESULTS: (1) Structured interviews based on guidelines: In comparing 1995/96 (G/T n = 100, in each case) to 2003 (G/ n = 54, T/ n = 42) there is a significant increase among both Germans and ethnic Turks in the number of fathers participating in courses preparing for birth; ethnic Turkish men attended birthing courses noticeably less often (1995/96 and 2003: 8%; G approx. 40%, respectively). During both interview cycles the most common motivation given for providing birth support was 'to solidify the relationship with the partner'. (2) Data on birth support roles: In the comparison between 1995/96 and 2006, more German fathers, as well as more ethnic Turkish fathers, were by the side of their wives/partners in the labour and delivery room; however, in contrast to the Germans, ethnic Turkish men more commonly tended to participate in a birth support role together with female family members, either simultaneously or by turns. CONCLUSIONS: The birth support role of the father has gained significant ground in the last 10 years, and is now also accepted among ethnic Turkish couples despite cultural differences. This is possibly the result of an acculturation process, in which a phenomenon within the host culture (fathers in the labour and delivery room) mixes with ancestral tradition (the birth support role of women).