Obstetrician involvement in planned midwife-led births: a cohort study in an obstetric department of a University Hospital in Switzerland.

BACKGROUND: Healthy women with low risk singleton pregnancies are offered a midwife-led birth model at our department. Exclusion criteria for midwife-led births include a range of abnormalities in medical history and during the course of pregnancy. In case of complications before, during or after labor and birth, an obstetrician is involved. The purpose of this study was 1) to evaluate the frequency of and reasons for secondary obstetrician involvement in planned midwife-led births and 2) to assess the maternal and neonatal outcome. METHODS: We analyzed a cohort of planned midwife-led births during a 14 years period (2006-2019). Evaluation included a comparison between midwife-led births with or without secondary obstetrician involvement, regarding maternal characteristics, birth mode, and maternal and neonatal outcome. Statistical analysis was performed by unpaired t-tests and Chi-square tests. RESULTS: In total, there were 532 intended midwife-led births between 2006 and 2019 (2.6% of all births during this time-period at the department). Among these, 302 (57%) women had spontaneous vaginal births as midwife-led births. In the remaining 230 (43%) births, obstetricians were involved: 62% of women with obstetrician involvement had spontaneous vaginal births, 25% instrumental vaginal births and 13% caesarean sections. Overall, the caesarean section rate was 5.6% in the whole cohort of women with intended midwife-led births. Reasons for obstetrician involvement primarily included necessity for labor induction, abnormal fetal heart rate monitoring, thick meconium-stained amniotic fluid, prolonged first or second stage of labor, desire for epidural analgesia, obstetrical anal sphincter injuries, retention of placenta and postpartum hemorrhage. There was a significantly higher rate of primiparous women in the group with obstetrician involvement. Arterial umbilical cord pH < 7.10 occurred significantly more often in the group with obstetrician involvement, while 5' Apgar score < 7 did not differ significantly. The overall transfer rate of newborns to neonatal intensive care unit was low (1.3%). CONCLUSION: A midwife-led birth in our setting is a safe alternative to a primarily obstetrician-led birth, provided that selection criteria are being followed and prompt obstetrician involvement is available in case of abnormal course of labor and birth or postpartum complications.

High prevalence of severe vitamin D deficiency during the first trimester in pregnant women in Switzerland and its potential contributions to adverse outcomes in the pregnancy.

PURPOSE: Vitamin D is primarily known for its role in bone health. However, it has a much more diverse role in the human metabolism. Specifically, deficiency of vitamin D has recently been studied for its possible role in adverse pregnancy outcomes such as preeclampsia, gestational diabetes and preterm birth. Vitamin D levels largely depend on exposure to the sun and are influenced by nutritional habits at only a minimal level. In Switzerland, it is estimated that 40–50% of the population is vitamin D deficient. No specific data on pregnant women is available. The recommendations of the Swiss Federal Commission for Nutrition include a supplement of 600 IU of vitamin D to all pregnant women, despite the lack of data for this population in Switzerland. The primary aim of this study was to determine the prevalence of vitamin D deficiency among the population of pregnant women receiving prenatal care and giving birth at our clinic. We assumed that the prevalence of vitamin D deficiency in pregnant women in Switzerland is significantly higher than what has been estimated. Therefore, the current recommendations for vitamin D supplementation in pregnant women may be insufficient to achieve appropriate vitamin D levels. Furthermore, we aimed to address the issue of the potential influence of vitamin D deficiency on adverse pregnancy outcomes. METHODS: We performed a retrospective, observational cross-sectional study of 1382 pregnant women attending prenatal care at our department between 2012 and 2015. Serum 25-dihydroxycholecalciferol (25(OH)D) levels were determined in the first trimester, and the patient’s characteristics, the course of the pregnancy, any complications, the delivery and the neonatal outcome were analysed. The risk factors for vitamin D deficiency and its correlation with adverse pregnancy outcomes were assessed using a multivariate analysis. RESULTS: The clear majority (73.23%) of the population studied were found to be vitamin D deficient, with serum levels of 25(OH)D <50 nmol/l. More importantly, severe vitamin D deficiency (25(OH)D levels below 25 nmol/l) was present in one third (34.2%) of all pregnant women. The mean 25(OH)D level was 36.72 ± 19.63 nmol/l. In the multivariate analysis, those with a high BMI and who belonged to ethnicities comprising people who are generally dark-skinned were found to be associated with lower 25(OH)D serum levels (p <0.0001). We detected a seasonal influence: the mean 25(OH)D level was significantly higher during the summer season (April–September) compared to the winter season (October–March) (p <0.0001). We found an association between low 25(OH)D serum level and gestational diabetes (p = 0.0116). Surprisingly, a low 25(OH)D level was also associated with decreased incidence of postpartum hemorrhage and placental retention (p = 0.02). We found no association between the 25(OH)D serum level and preeclampsia, preterm birth, postdate pregnancy, miscarriage, intrauterine growth restriction, bacterial vaginosis, mode of delivery, or neonatal birth weight and length. CONCLUSION: We performed a retrospective analysis of serum 25(OH)D concentrations in pregnant Swiss women and found a mean serum 25(OH)D level of about 37 nmol/l and that one third of the overall study population had a serum 25(OH)D level below 25 nmol/l, and were thus seriously vitamin D deficient. Furthermore, the data demonstrate that vitamin D deficiency is associated with gestational diabetes. The current recommendations of vitamin D supplementation of 600 IU in pregnant women are therefore insufficient, and novel strategies, such as general screening for vitamin D deficiency, pre-conceptional timing of the supplementation and individually tailored dosing of vitamin D supplementation seem mandatory, potentially leading to improved maternal health and benefits to children’s long-term health in Switzerland and worldwide. (trial registration ClinicalTrial.gov. Identifier: NCT02904720).

Shrunken pore syndrome, preeclampsia, and markers of NO metabolism in pregnant women during the first trimester.

Shrunken pore syndrome (SPS) is a condition that manifests itself as the decreased renal clearance of low-molecular-weight proteins but normal clearance of creatinine. Pregnant women with evidence of SPS during the first trimester have an increased risk of developing preeclampsia (PE). The nitric oxide (NO) metabolism markers arginine and ADMA, especially their ratio (Arg/ADMA), are recognized markers of endothelial dysfunction. The aim of this nested case-control study was to establish first-trimester reference intervals (RI) for markers of NO metabolism and to study these markers in women with evidence of SPS at the end of the first trimester. Seventy-four women were stratified in the first trimester according to evidence of SPS (SPS + or SPS-) and the occurrence of PE during subsequent pregnancy (PE + or PE-), as follows: SPS-/PE-, SPS+/PE-, SPS-/PE+, and SPS+/PE+. RIs were determined according to the CLSI EP28-A3c guidelines. Serum Arg and ADMA levels were analyzed. The Arg and ADMA concentrations did not differ among the four groups. However, women in the SPS+/PE + group had a significantly lower Arg/ADMA ratio than those in the other 3 groups (p = .02). In conclusion, we defined the first-trimester RI of Arg, ADMA and the Arg/ADMA ratio as markers of NO metabolism. Our results suggest that SPS in the first trimester predicts a pathophysiological hallmark of subsequent PE, i.e. lower NO production leading to increased vessel tone. Early identification of women at risk for later PE could lead to adaptive prophylactic interventions, such as supplementation with Arg or an NO-donor drug in order to mitigate the risk of developing PE.

Effects of Passive Hydrotherapy WATSU (WaterShiatsu) in the Third Trimester of Pregnancy: Results of a Controlled Pilot Study.

Background. WATSU (WaterShiatsu) is a complementary therapeutic treatment method comprising passive stretches and massage techniques administered in 35°C warm water. Pregnant women claim safe methods to reduce pain, stress, and fatigue. Therefore, we conducted a pilot study evaluating the effects of WATSU on pregnancy-related complaints in third trimester pregnant women. Methods. Nine healthy pregnant women at gestational week ≥34 were included in an intervention group (receiving WATSU) and compared to eight women in a passive control group (receiving no treatment). WATSU was performed on days 1 and 4 of the study, accompanied by ultrasound examinations. Outcomes include physiological and psychometric as well as qualitative data. Participants in the control group completed questionnaires only. Results. WATSU was found to significantly lower participants' levels of stress and pain and to improve their mental health-related quality of life and mood. In comparison to the passive control group, participants in the intervention group reported reduction in perceived stress from day 1 to day 8 (P = 0.036, Cohen's f = 0.57). Qualitative data indicate that WATSU was appreciated as enjoyable and deeply relaxing. No negative side effects were reported. Conclusion. Our findings support the notion that WATSU yields therapeutic benefits for pregnant women and warrant further research. This study has been registered at ClinicalTrials.gov: NCT01708018.

Hyaluronan content of Wharton's jelly in healthy and Down syndrome fetuses.

The mechanisms by which the excess genetic material of chromosome 21 results in the dysmorphologic features of Down syndrome (DS) are largely unknown. It has been found that the extracellular matrix of nuchal skin of DS fetuses exhibits an higher content of hyaluronan (HA) compared to that of euploid fetuses. Since HA plays a central role in many morphogenetic processes during embryogenesis, an alteration in its metabolism could be involved in the pathogenesis of several structural defects of DS. The extracellular matrix of umbilical cord (UC) is the mammalian tissue with one of the highest content of HA. Therefore we sought to explore the quantitative HA modifications during gestation, tissue distribution and HA metabolism in euploid and DS UCs. Euploid UCs (n=28) and UCs from DS fetuses (n=13) were obtained after termination of pregnancy, spontaneous abortion, or at delivery. Quantitative and molecular size analysis were performed using HPLC and FPLC. Tissue distribution was visualized by immunohistochemistry. Gene expression for HA synthases (HAS) and hyaluronidases (HYAL) were quantified by real-time PCR techniques and HYAL activity was detected by zymography. In euploid UC only HA of a molecular weight of 1700 kDA was present while in DS UC an additional lower weight HA molecule of 1100 kDA was found. Immunohistochemistry showed a larger amount of Wharton's jelly HA in DS UCs than in euploid UC. Real-time PCR analysis showed that HAS 2 and HYAL 2 were expressed at significant levels in all specimens. A higher expression of HAS 2 and a lower expression of HYAL 2 was found in the Wharton's jelly of DS fetuses compared to that of euploid fetuses at 14 weeks of gestation. On the contrary, at term HYAL 2 expression was higher in DS specimens than in those from euploid fetuses. Zymographic studies showed a similar behavior with a lower HYAL activity at early gestation and a higher HYAL activity at term gestation in DS UCs compared to euploid specimens. Therefore we can conclude that HA is more represented in DS UCs than in euploid UCs. A complex alteration of the HA metabolism characterized by an increased synthesis of lower weight HA molecules is a peculiarity of DS UCs.

Plasma homocysteine levels after hormone therapy with and without folic acid supplementation: a randomized study.

Sequential transdermal estrogen-progestin therapy induced a significant reduction in fasting serum homocysteine levels in postmenopausal women. The addition of folic acid supplementation for 6 months did not further lower the homocysteine concentrations.