Does structured obstetric management play a role in the delivery mode and neonatal outcome of twin pregnancies?

PURPOSE: While the optimal delivery method of twin pregnancies is debated, the rate of cesarean deliveries is increasing. This retrospective study evaluates delivery methods and neonatal outcome of twin pregnancies during two time periods and aims to identify predictive factors for the delivery outcome. METHODS: 553 twin pregnancies were identified in the institutional database of the University Women's Hospital Freiburg, Germany. 230 and 323 deliveries occurred in period I (2009-2014) and period II (2015-2021), respectively. Cesarean births due to non-vertex position of the first fetus were excluded. In period II, the management of twin pregnancies was reviewed; adjusted and systematic training with standardized procedures was implemented. RESULTS: Period II showed significantly lower rates of planned cesarean deliveries (44.0% vs. 63.5%, p < 0.0001) and higher rates of vaginal deliveries (68% vs. 52.4%, p = 0.02). Independent risk factors for primary cesarean delivery were period I, maternal age > 40 years, nulliparity, a history with a previous cesarean, gestational age < 37 completed weeks, monochorionicity and increasing birth weight difference (per 100 g or > 20%). Predictive factors for successful vaginal delivery were previous vaginal delivery gestational age between 34 and 36 weeks and vertex/vertex presentation of the fetuses. The neonatal outcomes of period I and II were not significantly different, but planned cesareans in general were associated with increased admission rates to the neonatal intensive care units. Inter-twin interval had no significant impact on neonatal outcome. CONCLUSION: Structured regular training of obstetrical procedures may significantly reduce high cesarean rates and increase the benefit-risk ratio of vaginal deliveries.

Placenta Accreta Spectrum (PAS): Diagnosis, Clinical Presentation, Therapeutic Approaches, and Clinical Outcomes.

Placenta accreta spectrum (PAS) refers to the abnormal adhesion of the placenta to the myometrium, with varying degrees of severity. Placenta accreta involves adhesion to the myometrium, placenta increta invades the myometrium, and placenta percreta extends through the serosa to adjacent organs. The condition is linked to deficient decidualization in scarred uterine tissue, and the risk increases when placenta previa is present and with each prior cesarean delivery. Other risk factors include advanced maternal age, IVF, short intervals between cesareans, and smoking. PAS incidence has risen due to the increase in cesarean deliveries. Placenta previa combined with PAS significantly raises the risk of severe peripartum bleeding, often necessitating a cesarean section with a total hysterectomy. Recognizing PAS prepartum is essential, with sonographic indicators including intraplacental lacunae and uterovesical hypervascularization. However, PAS can be present without sonographic signs, making clinical risk factors crucial for diagnosis. Effective management requires a multidisciplinary approach and proper infrastructure. This presentation covers PAS cases treated at University Hospital Freiburg, detailing patient conditions, diagnostic methods, treatments and outcomes.

Lipoprotein turnover and possible remnant accumulation in preeclampsia: insights from the Freiburg Preeclampsia H.E.L.P.-apheresis study.

BACKGROUND: Preeclampsia is a life-threatening disease in pregnancy, and its complex pathomechanisms are poorly understood. In preeclampsia, lipid metabolism is substantially altered. In late onset preeclampsia, remnant removal disease like lipoprotein profiles have been observed. Lipid apheresis is currently being explored as a possible therapeutic approach to prolong preeclamptic pregnancies. Here, apheresis-induced changes in serum lipid parameters are analyzed in detail and their implications for preeclamptic lipid metabolism are discussed. METHODS: In the Freiburg H.E.L.P.-Apheresis Study, 6 early onset preeclamptic patients underwent repeated apheresis treatments. Serum lipids pre- and post-apheresis and during lipid rebound were analyzed in depth via ultracentrifugation to yield lipoprotein subclasses. RESULTS: The net elimination of Apolipoprotein B and plasma lipids was lower than theoretically expected. Lipids returned to previous pre-apheresis levels before the next apheresis even though apheresis was repeated within 2.9 ± 1.2 days. Apparent fractional catabolic rates and synthetic rates were substantially elevated, with fractional catabolic rates for Apolipoprotein B / LDL-cholesterol being 0.7 ± 0.3 / 0.4 ± 0.2 [day- 1] and synthetic rates being 26 ± 8 / 17 ± 8 [mg*kg- 1*day- 1]. The distribution of LDL-subclasses after apheresis shifted to larger buoyant LDL, while intermediate-density lipoprotein-levels remained unaffected, supporting the notion of an underlying remnant removal disorder in preeclampsia. CONCLUSION: Lipid metabolism seems to be highly accelerated in preeclampsia, likely outbalancing remnant removal mechanisms. Since cholesterol-rich lipoprotein remnants are able to accumulate in the vessel wall, remnant lipoproteins may contribute to the severe endothelial dysfunction observed in preeclampsia. TRIAL REGISTRATION: ClinicalTrails.gov, NCT01967355 .

Overexpression of hypoxia-inducible factor-1 alpha improves vasculogenesis-related functions of endothelial progenitor cells.

Postnatal vasculogenesis is mediated by mobilization of endothelial progenitor cells (EPCs) from bone marrow and homing to ischemic tissues. This feature emphasizes this cell type for cell-based therapies aiming at the improvement of neovascularization in tissue engineering applications and regenerative medicine. In animal models, it was demonstrated that implantation of EPCs from cord blood (cbEPCs) led to the formation of a complex functional neovasculature, whereas EPCs isolated from adult peripheral blood (pbEPCs) showed a limited vasculogenic potential, which may be attributed to age-related dysfunction. Recently, it was demonstrated that activation of hypoxia-inducible factor-1α (Hif-1α) improves cell functions of progenitor cells of mesenchymal and endothelial origin. Thus, we hypothesized that overexpression of Hif-1α may improve the vasculogenesis-related phenotype of pbEPCs. In the present study, we overexpressed Hif-1α in pbEPCs and cbEPCs by using recombinant adenoviruses and investigated effects on stem cell- and vasculogenesis-related cell parameters. Overexpression of Hif-1α enhanced proliferation, invasion, cell survival and in vitro capillary sprout formation of both EPC populations. Migration was increased in cbEPCs upon Hif-1α overexpression, but not in pbEPCs. Cellular senescence was decreased in pbEPCs, while remained in cbEPCs, which showed, as expected, intrinsically a dramatically lower senescent phenotype in relation to pbEPCs. Similarly, the colony-formation capacity was much higher in cbEPCs in comparison to pbEPCs and was further increased by Hif-1α overexpression, whereas Hif-1α transduction exerted no significant influence on colony formation of pbEPCs. In summary, our experiments illustrated multifarious effects of Hif-1α overexpression on stem cell and vasculogenic parameters. Therefore, Hif-1α overexpression may represent a therapeutic option to improve cellular functions of adult as well as postnatal EPCs.

Cytokines in noninvasively obtained amniotic fluid as predictors of fetal inflammatory response syndrome.

BACKGROUND: In patients with preterm premature rupture of membranes, intrauterine inflammation and/or infection is frequently present, can lead to fetal inflammatory response syndrome, and is associated with adverse neonatal outcome. Clinical decision making requires balancing the potential benefits of pregnancy prolongation against the risk of intrauterine infection. Diagnostic tests in maternal serum are of moderate prediction value and amniocentesis is an invasive procedure. Therefore, markers obtained noninvasively would be helpful in patients with expectant management. OBJECTIVES: To determine the predictive values of amniotic fluid interleukin-6 and tumor necrosis factor-α in vaginal secretions for fetal inflammatory response syndrome and/or histologic funisitis and for adverse neonatal outcome in patients with preterm premature rupture of membranes. STUDY DESIGN: In this prospective multicenter case-control study, vaginal secretions were sampled daily with a noninvasive method from 99 women with preterm premature rupture of membranes and expectant management. Amniotic fluid interleukin-6 and tumor necrosis factor-α were measured by 2 different immunoassays (an automated chemiluminescent enzyme immunoassay and a lateral flow immunoassay). After delivery, patients were divided into a control or a fetal inflammatory response syndrome group according to neonatal interleukin-6 in cord plasma and/or the presence of funisitis. Univariate and multivariate regression analyses were performed and prediction models were developed by calculating receiver operating characteristic curves. RESULTS: Gestational age at delivery was lower and latency period was longer in the fetal inflammatory response syndrome group compared to the control group. The strongest risk factor for composite adverse neonatal outcome was fetal inflammatory response syndrome (odds ratio, 2.48; confidence interval, 1.40-4.38). The median concentrations of amniotic fluid interleukin-6 and tumor necrosis factor-α in vaginal secretions were significantly higher in the fetal inflammatory response group compared to the control group in both immunoassays (P < .001). The area under the curve of the clinical reference model (including common clinical parameters) was 0.66. Adding interleukin-6 and tumor necrosis factor-α into the model improved the area under the curve to 0.92 (in both assays, interleukin-6 IMMULITE and QuickLine); 0.87 (tumor necrosis factor-α IMMULITE) and 0.94 (tumor necrosis factor-α QuickLine), respectively. CONCLUSION: The strongest risk factor for worse neonatal outcome (composite neonatal outcome) was fetal inflammatory response syndrome. Amniotic fluid interleukin-6 and tumor necrosis factor-α seem to be good predictors for fetal inflammatory response syndrome and for histologic funisitis and may improve the clinical management of patients with preterm premature rupture of membranes. The noninvasive technique of sampling amniotic fluid from vaginal secretions facilitates daily measurements and bedside assessment of cytokines and is in this respect preferable to invasive amniocentesis.

Comparison of pre- and intrapartum screening of group B streptococci and adherence to screening guidelines: a cohort study.

UNLABELLED: Implementation of guidelines for group B streptococcal (GBS) prepartum screening (PS) rarely has been prospectively evaluated. To assess PS at 35-37 weeks of gestation and compare its predictive value to that of an intrapartum screening (IS) within 7 days of delivery, a surveillance cohort study was conducted at a tertiary care center in Freiburg, Germany, during 2011-2012. Study participants included 937 pregnant women who had intrapartum cultures taken for vaginal and rectal GBS colonization. Colonization status was compared to PS, and intrapartum antibiotic prophylaxis (IAP) rates calculated. The neonates were tested for GBS transmission via cultures from their throats and external ear canals. While 67.5% (633/937) of study participants had a PS, only 22.7% (144/633) underwent a fully guideline-compatible PS. However, maternal GBS colonization rates were similar when comparing PS (18.5% [117/633]) versus IS (17.0% [133/784]). The positive predictive value of a positive PS result for GBS positivity at delivery was 77.2 %. Women with a positive PS received IAP in 89.3% of cases (75/84). The capsular serotype distribution pattern of colonizing GBS strains has not changed in comparison to our 2003-2004 study--one with a similar study design. CONCLUSIONS: Improved strategies for adoption of prepartum GBS screening are needed. WHAT IS KNOWN: • The prediction of prepartum GBS screening for intrapartum colonization status has not been well studied. • Longitudinal studies of GBS screening are needed for screening program evaluations and vaccine development. What is New: • The rate of GBS screening has improved over 10 years, and intrapartum GBS colonization prediction was accurate. • Serotype distribution was stable and suggests the potential long-term efficacy of GBS vaccines.

Comparison of double-filtration plasmapheresis (DFPP) versus heparin-mediated extracorporeal LDL-precipitation (HELP)-apheresis in early-onset preeclampsia.

OBJECTIVES: Preeclampsia (PE) is a major cause of maternal and fetal mortality, and preterm birth. Previous studies indicate that lipid-apheresis may prolong pregnancy, namely heparin-mediated extracorporeal LDL-precipitation (HELP)- and dextran sulfate cellulose (DSC)-apheresis. We now report on double membrane plasmapheresis (DFPP) in early-onset preeclampsia (eoPE). STUDY DESIGN: Open pilot study assessing the prolongation of pregnancy in PE by lipoprotein-apheresis (DRKS00004527). Two women with eoPE were treated by DFPP and compared to a historical cohort of 6 patients with eoPE treated by HELP-apheresis (NCT01967355). MAIN OUTCOME MEASURES: Clinical outcome of mothers and babies and prolongation of pregnancies (time of admission to birth). RESULTS: Patient 1 (33y; 22 + 5/7GW) received 4 DFPP. Delivery day 19; birthweight 270 g; weight at discharge 2134 g on day 132. Patient 2 (35y; 21 + 4/7GW) received 2 DFPP. Delivery day 19; birthweight 465 g; weight at discharge 2540 g on day 104. DFPP was well tolerated by both patients. CONCLUSIONS: DFPP proved to be save and pregnancies remained stable as long as 19 days. Although babies were born very preterm both babies could finally be dismissed from hospital. No relevant clinical differences between DFPP and HELP-apheresis could be observed. Therefore, DFPP may extend the range of available apheresis techniques to prolong pregnancies in early-onset preeclampsia. However, further studies are necessary to gain more information. REGISTER: (DRKS00004527).

Multiomic spatial landscape of innate immune cells at human central nervous system borders.

The innate immune compartment of the human central nervous system (CNS) is highly diverse and includes several immune-cell populations such as macrophages that are frequent in the brain parenchyma (microglia) and less numerous at the brain interfaces as CNS-associated macrophages (CAMs). Due to their scantiness and particular location, little is known about the presence of temporally and spatially restricted CAM subclasses during development, health and perturbation. Here we combined single-cell RNA sequencing, time-of-flight mass cytometry and single-cell spatial transcriptomics with fate mapping and advanced immunohistochemistry to comprehensively characterize the immune system at human CNS interfaces with over 356,000 analyzed transcriptomes from 102 individuals. We also provide a comprehensive analysis of resident and engrafted myeloid cells in the brains of 15 individuals with peripheral blood stem cell transplantation, revealing compartment-specific engraftment rates across different CNS interfaces. Integrated multiomic and high-resolution spatial transcriptome analysis of anatomically dissected glioblastoma samples shows regionally distinct myeloid cell-type distributions driven by hypoxia. Notably, the glioblastoma-associated hypoxia response was distinct from the physiological hypoxia response in fetal microglia and CAMs. Our results highlight myeloid diversity at the interfaces of the human CNS with the periphery and provide insights into the complexities of the human brain's immune system.

Multiple Gestation as a Risk Factor for SARS-CoV-2-Associated Adverse Maternal Outcome: Data From the COVID-19 Related Obstetric and Neonatal Outcome Study (CRONOS).

Introduction: Studies have shown that pregnant women with COVID-19 have a higher risk of intensive care unit admission and invasive mechanical ventilation support than non-pregnant women. Pregnancy-associated physiological changes in respiratory function may contribute to the elevated risk. Alteration in lung volumes and capacities are attributed to the mechanical impediment caused by the growing fetus. Multiple pregnancies may therefore compromise functional lung capacity earlier than singleton pregnancies and contribute to severe respiratory symptoms of COVID-19. Materials and Methods: A total of 5514 women with a symptomatic SARS-CoV-2 infection during pregnancy registered in the COVID-19 Related Obstetric and Neonatal Outcome Study were included. The COVID-19-related adverse maternal outcomes were compared in 165 multiple versus 5349 singleton pregnancies. Combined adverse maternal outcome was defined as presence of COVID-19-related hospitalization and/or pneumonia and/or oxygen administration and/or transfer to ICU and/or death. Multivariate logistic regression was used to estimate the odds ratios and 95% confidence intervals were calculated. Results: The frequency of dyspnea, likelihood of developing dyspnea in a defined pregnancy week and duration of the symptomatic phase of the COVID-19 infection did not differ between the two groups. On average, COVID-19-related combined adverse outcome occurred earlier during pregnancy in women expecting more than one child than in singleton pregnancies. The overall incidence of singular and combined COVID-19-associated adverse maternal outcomes was not significantly different between groups. However, regression analysis revealed that multiple gestation, preconceptional BMI > 30 kg/m 2 and gestational age correlated significantly with an increased risk of combined adverse maternal outcome. Conversely, maternal age and medically assisted reproduction were not significant risk factors for combined adverse maternal outcome. Conclusion: Our data show that multiple gestation alone is a risk factor for COVID-19-associated combined adverse maternal outcome. Moreover, severe courses of COVID-19 in women expecting more than one child are observed earlier in pregnancy than in singleton pregnancies.

Correction: Multiple Gestation as a Risk Factor for SARS-CoV-2-Associated Adverse Maternal Outcome: Data From the COVID-19 Related Obstetric and Neonatal Outcome Study (CRONOS).

[This corrects the article DOI: 10.1055/a-2196-6224.].

Exercise During Pregnancy.

BACKGROUND: Pregnancy is a good time to motivate women to implement health-promoting behaviors in their everyday lives. There is no official German-language guideline for the counseling of pregnant women by professionals involved in their care. The goal of this review is, therefore, to discuss the links between exercise and gestational diabetes mellitus (GDM), low birth weight, and prematurity. METHODS: This review is based on pertinent articles retrieved by a systematic search of PubMed and the Web of Science. The articles included in the evaluation were reports of randomized controlled trials (RCTs) and meta-analyses of RCTs of exercise interventions in pregnant women that were published from 1 January 2011 to 15 November 2021. RESULTS: A structured exercise program during pregnancy can lower the risk of gestational diabetes by as much as 49%. A 25% risk reduction for GDM was achieved with 140 minutes of exercise per week. The mean birth weight was not affected but the rate of excessively heavy newborns was lowered by 32-59% in the normal-weight subgroup. This effect was not seen in the overweight subgroup, possibly because of poorer compliance. Exercise did not elevate the risk of preterm delivery. CONCLUSION: Regular exercise during pregnancy lessens gestationally induced weight gain and lowers the risk of excessive weight gain, as well as the risk of GDM, without elevating the risk of preterm delivery.

[Prenatal care in patients with renal disease]. / Betreuung der Schwangerschaft bei maternalen Nierenerkrankungen.

HISTORY AND CLINICAL FINDINGS: We report of three pregnancies, two with renal insufficiency and one with a history of renal transplantation. Pat.1 is a 32y at 20 weeks of gestation with acute renal failure, nephrotic syndrome and history of familial Mediterranean fever. Case 2 is a 23y with cirrhotic kidneys, stage 5 of chronic kidney disease and dialysis treatment 3â€Š× a week. The pregnancy was an incidental finding. Pat. 3 is a 29y I/0 with history of renal transplantation years ago. DIAGNOSIS, TREATMENT AND COURSE: In pat. 1a renal biopsy confirmed the suspected diagnosis of AA amyloidosis. Due to deterioration of the kidney function, she required dialysis up to 6â€Š× a week. In Case 2 the dialysis increased to 6â€Š× a week as well. In both patients, we indicated delivery at 35 weeks of gestational age. Pat. 3 delivered at term without complications. CONCLUSION: A close interdisciplinary cooperation improves neonatal outcome in pregnant women with CKD. Counseling and risk assessment of these patients should be initiated before pregnancy. The care of these high-risk pregnancies needs to be performed at a tertiary care center with the above-mentioned specialists.

Preeclampsia postpartum: Impairment of cerebral autoregulation and reversible cerebral hyperperfusion.

OBJECTIVES: Preeclampsia is a pregnancy-related hypertensive disorder with endothelial dysfunction. Impaired cerebral autoregulation may lead to symptomatic cerebral hyperperfusion, which sometimes manifests not until after delivery. This study investigated, whether cerebral autoregulation was altered after delivery in healthy and preeclamptic women, and whether this associated with cerebral hyperperfusion. STUDY DESIGN: In a prospective study, 35 preeclamptic and 35 healthy women were examined with transcranial Doppler within 10 days postpartum and 6 months later. Continuous arterial blood pressure and cerebral blood flow velocities (CBFV) in the middle (MCA) and posterior cerebral arteries (PCA) were recorded at rest. MAIN OUTCOME MEASURES: Dynamic cerebral autoregulation was assessed upon regular breathing at 0.1 Hz via transfer function phase and gain between arterial blood pressure and CBFV oscillations. RESULTS: In preeclamptic women, phase was reduced after delivery in both, MCA and PCA. During the postpartum period, CBFV of the MCA, but not PCA, correlated with higher arterial blood pressure and poorer dynamic cerebral autoregulation. In healthy women with only moderately altered cerebral autoregulation, CBFV remained in the normal range. At both measurements, arterial blood pressure was higher in preeclamptic compared to healthy women. CONCLUSIONS: Women with preeclampsia had poorer cerebral autoregulation and an increased risk of transient cerebral hyperperfusion after delivery.

No long-term impairment of cerebral autoregulation after preeclampsia.

INTRODUCTION: Preeclampsia is a pregnancy-related hypertensive disorder with strongly impaired cerebral autoregulation in the acute stage. A history of preeclampsia is an independent cardiovascular and cerebrovascular risk factor. It is unclear whether impaired cerebral autoregulation persists after preeclampsia and thus contributes to the known increased cerebrovascular morbidity. METHODS: Using transcranial Doppler, we compared cerebral hemodynamics and dynamic cerebral autoregulation of 25 women with a history of severe preeclampsia and 25 healthy mothers, on average 2-3 years postpartum. Mean arterial blood pressure (MAP) and cerebral blood flow velocities (CBFV) in the middle and posterior cerebral artery were recorded at rest, dynamic cerebral autoregulation was assessed via transfer function phase and gain between oscillations of CBFV and MAP during regular breathing at 0.1 Hz. RESULTS: MAP and body mass index were higher in former preeclamptic women compared with healthy mothers (p-value <0.001 and 0.006, respectively). CBFV in the middle cerebral artery was slightly increased in former preeclamptic women compared with healthy mothers (p-value 0.004), intima-media thickness (IMT) of the common carotid artery was higher by trend (p-value 0.065). Dynamic cerebral autoregulation was not impaired in women with a history of preeclampsia, phase even tended to be higher than in healthy mothers. CONCLUSION: Dynamic cerebral autoregulation is not persistently impaired in women after severe preeclampsia. Long-term cerebrovascular changes rather result from a higher incidence of cerebrovascular risk factors in women with a history of preeclampsia.

New gestational phase-specific cutoff values for the use of the soluble fms-like tyrosine kinase-1/placental growth factor ratio as a diagnostic test for preeclampsia.

To establish gestational phase adapted cutoffs for the use of the soluble fms-like tyrosine kinase-1 (sFlt-1)/placental growth factor (PlGF) ratio as a diagnostic tool for preeclampsia in the clinical setting, a multicenter case-control study including a total of 1149 patients was performed. We report normal values of sFlt-1, PlGF, and the sFlt-1/PlGF ratio based on the analysis of a total of 877 patients with uneventful pregnancy outcome. A total of 234 patients with preeclampsia and a matched cohort consisting of 468 patients with normal pregnancy outcome were compared, and sFlt-1 and PlGF were measured on an automated platform. Separate cutoffs for the sFlt-1/PlGF ratio were determined for the early (20+0-33+6 weeks) and the late gestational phase (34+0 weeks-delivery). For each of the 2 gestational phases, 2 independent cutoffs framing an equivocal zone were determined: the first cutoff with focus on high sensitivity, and the second focusing on high specificity. Between 20+0 and 33+6 weeks, the cutoffs at ≤33 and ≥85 resulted in a sensitivity/specificity of 95%/94% and 88%/99.5%, respectively. An sFlt-1/PlGF ratio of ≤33 had the lowest likelihood of a negative test (0.05; 95% confidence interval, 0.02-0.13), whereas values ≥85 had the highest likelihood of a positive test (176; 95% confidence interval, 24.88-1245). After 34+0 weeks, the cutoffs at ≤33 and ≥110 yielded a sensitivity/specificity of 89.6%/73.1% and 58.2%/95.5%, respectively. The approach to use multiple cutoffs for the early and late gestational phase enhances the diagnostic accuracy of the sFlt-1/PlGF ratio as a diagnostic tool for preeclampsia.