Analysis of maternal mortality in Berlin, Germany - discrepancy between reported maternal mortality and comprehensive death certificate exploration.

OBJECTIVES: The Organisation for Economic Cooperation and Development (OECD) estimates an average maternal mortality rate (MMR) of around 3.4 maternal deaths per 100,000 live births for 2019-2021, based on relevant diagnoses on death certificates. However, Germany does not currently have a registry for recording the number of maternal deaths. The aim of this study is to identify the actual number of maternal deaths in Berlin between 2019 and 2022, as well as sources of underreporting and causes of death. METHODS: Potential maternal mortality cases were identified through a search at the Berlin Central Archive for Death Certificates, inquiring women aged 15-50 years with indications of present or recent pregnancy on the death certificate. To cross match the database, an additional search at the Charité University Hospital Berlin was carried out, checking each individual file for pregnancy-association. RESULTS: The data search resulted in 2,316 women, 18 of which presented an association to pregnancy. Of these, 12 could be classified as maternal mortality cases (MMR 7.8/100,000). The additional search in a university setting revealed two further maternal mortality cases without prior indication of pregnancy on the death certificate. This results in a total MMR of 9.1/100,000 live births, which is over double the official estimate by the OECD. CONCLUSIONS: Based on our findings in Berlin, it can be estimated that there is significant underreporting regarding maternal death cases in Germany. A more comprehensive recording system is needed to more accurately portray maternal mortality.

[Prenatal care]. / Schwangerenvorsorge.

Through rational antenatal care, it is possible to identify maternal and fetal risks at an early stage of pregnancy. These risks, which are detected by medical history and examinations, serve as the basis for further medical care and interventions in pregnancy and during birth. Studies show that maternal and fetal mortality and morbidity can be reduced by applying structured and comprehensive national prenatal care concepts. The World Health Organization (WHO) recommends at least eight antenatal controls. According to WHO guidelines, clinical documentation in the form of women-held case notes should be used to ensure good traceability of the medical examinations and findings in the individual pregnancy. For more than 50 years, antenatal care in Germany has been provided in a standardized and clearly structured manner and implemented nationwide. The established maternity document ("Mutterpass") and regular adaptations to the maternity guidelines form the foundation for this. This CME article presents international recommendations and publications focusing on the prenatal care, current developments in Germany, and controversies regarding antenatal care.

DEGUM, ÖGUM, SGUM and FMF Germany Recommendations for the Implementation of First-Trimester Screening, Detailed Ultrasound, Cell-Free DNA Screening and Diagnostic Procedures. / Empfehlungen der DEGUM, der ÖGUM, der SGUM und der FMF Deutschland zum Einsatz von Ersttrimester-Screening, früher Fehlbildungsdiagnostik, Screening an zellfreier DNA (NIPT) und diagnostischen Punktionen.

First-trimester screening between 11 + 0 and 13 + 6 weeks with qualified prenatal counseling, detailed ultrasound, biochemical markers and maternal factors has become the basis for decisions about further examinations. It detects numerous structural and genetic anomalies. The inclusion of uterine artery Doppler and PlGF screens for preeclampsia and fetal growth restriction. Low-dose aspirin significantly reduces the prevalence of severe preterm eclampsia. Cut-off values define groups of high, intermediate and low probability. Prenatal counseling uses detection and false-positive rates to work out the individual need profile and the corresponding decision: no further diagnosis/screening - cell-free DNA screening - diagnostic procedure and genetic analysis. In pre-test counseling it must be recognized that the prevalence of trisomy 21, 18 or 13 is low in younger women, as in submicroscopic anomalies in every maternal age. Even with high specificities, the positive predictive values of screening tests for rare anomalies are low. In the general population trisomies and sex chromosome aneuploidies account for approximately 70 % of anomalies recognizable by conventional genetic analysis. Screen positive results of cfDNA tests have to be proven by diagnostic procedure and genetic diagnosis. In cases of inconclusive results a higher rate of genetic anomalies is detected. Procedure-related fetal loss rates after chorionic biopsy and amniocentesis performed by experts are lower than 1 to 2 in 1000. Counseling should include the possible detection of submicroscopic anomalies by comparative genomic hybridization (array-CGH). At present, existing studies about screening for microdeletions and duplications do not provide reliable data to calculate sensitivities, false-positive rates and positive predictive values.

Prevalence and Infant Mortality of Major Congenital Malformations Stratified by Birthweight.

BACKGROUND: Low birthweight and major congenital malformations (MCMs) are key causes of infant mortality. OBJECTIVES: The aim of this study was to explore the prevalence of MCMs in infants with low and very low birthweight and analyze the impact of MCMs and birthweight on infant mortality. METHODS: We determined prevalence and infant mortality of 28 life-threatening MCMs in very-low-birthweight (<1,500 g, VLBW), low-birthweight (1,500-2,499 g, LBW), or normal-birthweight (≥2,500 g, NBW) infants in a cohort of 2,727,002 infants born in Germany in 2006-2017, using de-identified administrative data of the largest statutory public health insurance system in Germany. RESULTS: The rates of VLBW, LBW, and NBW infants studied were 1.3% (34,401), 4.0% (109,558), and 94.7% (2,583,043). MCMs affected 0.5% (13,563) infants, of whom >75% (10,316) had severe congenital heart disease. The prevalence (per 10,000) of any/cardiac MCM was increased in VLBW (286/176) and LBW (244/143), as compared to NBW infants (38/32). Infant mortality rates were significantly higher in infants with an MCM, as opposed to infants without an MCM, in each birthweight group (VLBW 28.5% vs. 11.5%, LBW 16.7% vs. 0.9%, and NBW 8.6% vs. 0.1%). For most MCMs, observed survival rates in VLBW and LBW infants were lower than expected, as calculated from survival rates of VLBW or LBW infants without an MCM, and NBW infants with an MCM. CONCLUSIONS: Infants with an MCM are more often born with LBW or VLBW, as opposed to infants without an MCM. Many MCMs carry significant excess mortality when occurring in VLBW or LBW infants.

Diet and Lifestyle Before and During Pregnancy - Practical Recommendations of the Germany-wide Healthy Start - Young Family Network.

Diet and exercise before and during pregnancy affect the course of the pregnancy, the child's development and the short- and long-term health of mother and child. The Healthy Start - Young Family Network has updated the recommendations on nutrition in pregnancy that first appeared in 2012 and supplemented them with recommendations on a preconception lifestyle. The recommendations address body weight before conception, weight gain in pregnancy, energy and nutritional requirements and diet (including a vegetarian/vegan diet), the supplements folic acid/folate, iodine, iron and docosahexaenoic acid (DHA), protection against food-borne illnesses, physical activity before and during pregnancy, alcohol, smoking, caffeinated drinks, oral and dental hygiene and the use of medicinal products. Preparation for breast-feeding is recommended already during pregnancy. Vaccination recommendations for women planning a pregnancy are also included. These practical recommendations of the Germany-wide Healthy Start - Young Family Network are intended to assist all professional groups that counsel women and couples wishing to have children and during pregnancy with uniform, scientifically-based and practical information.

Birth weight and parental BMI predict overweight in children from mothers with gestational diabetes.

OBJECTIVE: To investigate the growth of children from pregnancies with gestational diabetes mellitus (GDM) and its association with antenatal maternal, fetal, and recent anthropometric parameters of mother and father. RESEARCH DESIGN AND METHODS: In 324 pregnancies of Caucasian women with GDM, BMI before pregnancy, maternal glycemic values, and measurements of the fetal abdominal circumference were recorded. The weight and height of infants were measured at birth and at follow-up at 5.4 years (range 2.5-8.5). In addition, somatic data from routine examinations at 6, 12, and 24 months and the BMI of parents at follow-up were obtained. BMI standard deviation scores (SDSs) were calculated based on age-correspondent data. RESULTS: At all time points, BMI was significantly above average (+0.82 SDS at birth; +0.56 at 6, +0.35 at 12, and +0.32 at 24 months; and +0.66 at follow-up; P < 0.001). BMI at birth was related to BMI at follow-up (r = 0.27, P < 0.001). The rate of overweight at follow-up was 37% in children with birth BMI > or =90th percentile and 25% in those with normal BMI at birth (P < 0.05). Abdominal circumference of third trimester and postprandial glucose values were related to BMI at follow-up (r = 0.22 and r = 0.18, P < 0.01). Recent maternal, paternal, and birth BMI were independent predictors of BMI at follow-up (r = 0.42, P < 0.001). Sixty-nine percent of children of parents with BMI > or =30 kg/m(2) were overweight at follow-up compared with 20% of those with parental BMI <30 kg/m(2) (P < 0.001). CONCLUSIONS: Children of mothers with GDM have a high rate of overweight that is associated both with intrauterine growth and parental obesity.

A randomized trial evaluating a predominantly fetal growth-based strategy to guide management of gestational diabetes in Caucasian women.

OBJECTIVE: To compare the management of Caucasian women with gestational diabetes (GDM) based predominantly on monthly fetal growth ultrasound examinations with an approach based solely on maternal glycemia. RESEARCH DESIGN AND METHODS: Women with GDM who attained fasting capillary glucose (FCG) <120 mg/dl and 2-h postprandial capillary glucose (2h-CG) <200 mg/dl after 1 week of diet were randomized to management based on maternal glycemia alone (standard) or glycemia plus ultrasound. In the standard group, insulin was initiated if FCG was repeatedly >90 mg/dl or 2h-CG was >120 mg/dl. In the ultrasound group, thresholds were 120 and 200 mg/dl, respectively, or a fetal abdominal circumference >75th percentile (AC>p75). Outcome criteria were rates of C-section, small-for-gestational-age (SGA) or large-for-gestational-age (LGA) infants, neonatal hypoglycemia (<40 mg/dl), and neonatal care admission. RESULTS: Maternal characteristics and fetal AC>p75 (36.0 vs. 38.4%) at entry did not differ between the standard (n = 100) and ultrasound groups (n = 99). Assignment to (30.0 vs. 40.4%) and mean duration of insulin treatment (8.3 vs. 8.1 weeks) did not differ between groups. In the ultrasound group, AC>p75 was the sole indication for insulin. The ultrasound-based strategy, as compared with the maternal glycemia-only strategy, resulted in a different treatment assignment in 34% of women. Rates of C-section (19.0 vs. 18.2%), LGA (10.0 vs. 12.1%), SGA (13.0 vs. 12.1%), hypoglycemia (16.0 vs. 17.0%), and admission (15.0 vs. 14.1%) did not differ significantly. CONCLUSIONS: GDM management based on fetal growth combined with high glycemic criteria provides outcomes equivalent to management based on strict glycemic criteria alone. Inclusion of fetal growth might provide the opportunity to reduce glucose testing in low-risk pregnancies.

Determinants of fetal growth at different periods of pregnancies complicated by gestational diabetes mellitus or impaired glucose tolerance.

OBJECTIVE: To determine maternal parameters with the strongest influence on fetal growth in different periods of pregnancies complicated by an abnormal glucose tolerance test (GTT). RESEARCH DESIGN AND METHODS: Retrospective study of 368 women with gestational diabetes mellitus (GDM; > or = 2 abnormal GTT values, n = 280) and impaired glucose tolerance (IGT; one abnormal value, n = 88) with 869 ultrasound examinations at entry to and during diabetic care. Both groups were managed comparably. Abdominal circumference (AC) > or = 90th percentile defined fetal macrosomia. Maternal historical and clinical parameters, and diagnostic and glycemic values of glucose profiles divided into five categories of 4 weeks of gestational age (GA; <24 weeks, 24 weeks/0 days to 27 weeks/6 days, 28/0-31/6, 32/0-35/6, and 36/0-40/0 [referred to as <24 GA, 24 GA, 28 GA, 32 GA, and 36 GA categories, respectively]) were tested by univariate and multiple logistic regression analysis for their ability to predict an AC > or = 90th percentile at each GA group and large-for-gestational-age (LGA) newborn. Data obtained at entry were also analyzed separately irrespective of the GA. RESULTS: Maternal weight, glycemia after therapy, rates of fetal macrosomia, and LGA were not significantly different between GDM and IGT; thus, both groups were analyzed together. LGA in a previous pregnancy, (odds ratio [OR] 3.6; 95% CI 1.8-7.3) and prepregnancy obesity (BMI > or = 30 kg/m(2); 2.1; 1.2-3.7) independently predicted AC > or = 90th percentile at entry. When data for each GA category were analyzed, no predictors were found for <24 GA. Independent predictors for each subsequent GA category were as follows: at 24 GA, LGA history (OR 9.8); at 28 GA, LGA history (OR 4.2), and obesity (OR 3.3); at 32 GA, fasting glucose of 32 GA (OR 1.6 per 5-mg/dl increase); at 36 GA, fasting glucose of 32 GA (OR 1.6); and for LGA at birth, LGA history (OR 2.7), and obesity (OR 2.4). CONCLUSIONS: In the late second and early third trimester, maternal BMI and LGA in a previous pregnancy appear to have the strongest influence on fetal growth, while later in the third trimester coincident with the period of maximum growth described in diabetic pregnancies, maternal glycemia predominates.

Decrease of elastic tissue fibres in stem villus blood vessels of the human placenta during IUGR and IUGR with concomitant pre-eclampsia.

In a recent study we described an increase of elastic tissue fibres in blood vessel walls of placental stem villi during pre-eclampsia when compared to uncomplicated pregnancies. Furthermore, the thickness of these blood vessel walls was enhanced in pre-eclampsia. Since it is known that elastic tissue fibres increase in systemic hypertension, it may be assumed that the enhancement of elastic tissue fibres in placental stem villi during pre-eclampsia may be induced by the hypertension. To get further insight into this assumption, we examined the amount of elastic tissue fibres in stem villus blood vessels of placentae of pregnancies complicated by intrauterine growth retardation (isolated IUGR, fourteen cases), a disease without hypertension of the mother and such with pre-eclampsia and concomitant IUGR (IUGR+PE, nine cases). Each study group was compared with uncomplicated pregnancies (twenty-six cases). Unfixed cryostat serial sections were processed for conventional orcein staining and for the demonstration of alpha-actin-immunoreactivity. The intensity of orcein staining of stem villus blood vessel walls was evaluated by a semiquantitative score method. Significant lower intensities of orcein staining were calculated for blood vessel walls of placentae of isolated IUGR (P=0.0007) and IUGR+PE (P=0.0039) when compared to uncomplicated pregnancies each. Additionally, the blood vessel wall thickness of stem villi of isolated IUGR (P=0.0081) and IUGR+PE (P=0.0007) was significantly reduced. In comparison to the above mentioned investigation, our results show that, in contrast to isolated pre-eclampsia, elastic tissue fibres are decreased during pregnancies complicated by IUGR, independently of the occurrence of concomitant pre-eclampsia when compared to uncomplicated pregnancies. From our studies it may be considered that the increase of elastic tissue fibres in placentae of patients with isolated pre-eclampsia may be induced by systemic hypertension. Furthermore, our study underline arguments that IUGR may be an independent disease of the fetus.

[Guidelines for obstetrics in Germany]. / Leitlinien in der Geburtshilfe in Deutschland.

In a more broader sense guidelines are generally available recommendations for physicians. Ideally, they describe treatment and decision pathways. Most guidelines for obstetrics published by the Association of the Scientific Medical Societies in Germany (AWMF, http://leitlinien.net) do not fulfill the quality requirements of the Agency for Quality in Medicine (AQuMed, http://www.aezq.de) in either their goals or their formal presentation. Currently, clinical practice is guided by a consensus of existing expert opinions. Obstetric guidelines are poorly developed at level 1. It is uncertain whether additional scientific evidence can improve already published guidelines. Nonetheless, existing guidelines should be re-evaluated and revised regularly--as has been done in some instances.

Obstetrics and gynaecology training in Europe needs a next step.

Changing societal demands on doctors necessitate changes in the training of gynaecologists. Adapting this training will need well-thought-out and comprehensive planning that addresses the needs of the major stakeholders: society, patients, and doctors themselves. Doctors need to be cognizant of societal issues such as rapidly rising healthcare costs and budgetary crises, and be able to participate in the solutions. This demands effective medical leadership, which has been a neglected area in postgraduate training. It has become increasingly evident that a holistic view of the patient rooted in proper teamwork and systems-based practice is essential to provide patient-centered care. Specialists need to expand their skill set to participate in this kind of care. Furthermore, the feminisation of the medical profession and a new generation of doctors rejecting the constraints of the traditional model of medical care introduce new professional perspectives. This manuscript briefly reviews the challenges faced in the training of European gynaecologists in an effort to provoke discussion about how to best train the gynaecologists of the future.

Risks associated with delivering infants 2 to 6 weeks before term--a review of recent data.

BACKGROUND: There is an increasing trend towards delivery before 39 weeks of gestational age. The short- and long-term effects of early delivery on the infant have only recently received scientific attention. METHODS: Selective review of the literature RESULTS: Delivery at any time before 39 weeks is associated with significantly higher infant mortality and with an increase of the risk of impairments after birth from 8% to 11%. The increase in risks of various kinds is disproportionately more pronounced the earlier the child is delivered. For example, the risk of needing respiratory support or artificial ventilation after birth increases from 0.3% with delivery at 39-41 weeks of gestational age to 1.4% at 37 weeks and 10% at 35 weeks, while the risk of death or neurological complications increases from 0.15% at 39-41 weeks of gestation to 0.66% at 35 weeks. Delivery at 34.0 to 36.6 weeks of gestation also has long-term effects. Compared to delivery at term, the frequency of cerebral palsy rises threefold, from 0.14% to 0.43%; the risk of death in early adulthood rises by about half, from 0.046 to 0.065%; and the risk of dependence on government benefits in early adulthood also rises by about half, from 1.7% to 2.5%. CONCLUSION: Studies from the USA have shown that the number of medically indicated deliveries before 39 weeks can be lowered by 70% to 80% through consistently applied measures for quality improvement. If similar results could be achieved in Germany, the iatrogenic complications of delivery would become less common in this country as well.

How many sonograms are needed to reliably predict the absence of fetal overgrowth in gestational diabetes mellitus pregnancies?

OBJECTIVE: Serial measurements of the fetal abdominal circumference have been used to guide metabolic management of pregnancies complicated by gestational diabetes mellitus (GDM). A reduction in the number of repeat ultrasound examinations would save resources. Our purpose was to determine the number of serial abdominal circumference measurements per patient necessary to reliably predict the absence of fetal overgrowth. RESEARCH DESIGN AND METHODS: Women who had GDM were asked to return for repeat ultrasound at 3- to 4-week intervals starting at initiation of care (mean 26.9 ± 5.7 weeks). Maternal risk factors associated with fetal overgrowth were determined. RESULTS: A total of 4,478 ultrasound examinations were performed on 1,914 subjects (2.3 ± 1.2 per pregnancy). Of the 518 women with fetal abdominal circumference >90th percentile, it was diagnosed in 73.9% with the first ultrasound examination at entry and in 13.1% with the second ultrasound examination. Of the fetuses, 85.9 and 86.9% of the fetuses were born non-large for gestational age (LGA) when abdominal circumference was <90th percentile at 24-27 weeks and 28-32 weeks, respectively, and 88.0% were born non-LGA when both scans showed normal growth. For those women who had no risk factors for fetal overgrowth (risk factors: BMI >30 kg/m², history of macrosomia, and fasting glucose > 100 mg/dl), the accuracy of prediction of a non-LGA neonate was 90.0, 89.5, and 95.2%. The predictive ability did not increase with more than two normal scans. CONCLUSIONS: The yield of sonographic diagnosis of a large fetus drops markedly after the finding of a fetal abdominal circumference <90th percentile on two sonograms, which excludes with high reliability the risk of a LGA newborn. The ability was enhanced in women who had no risk factors for neonatal macrosomia.

Prior cesarean section--an acceptable risk for vaginal delivery at free-standing midwife-led birth centers? Results of the analysis of vaginal birth after cesarean section (VBAC) in German birth centers.

OBJECTIVES: Is out-of-hospital vaginal birth at a birth center safe for women with a previous cesarean section? Do their maternal or neonatal outcomes vary significantly from those of a "non-cesarean" control group? STUDY DESIGN: Retrospective evaluation of prospectively collected data on documented singleton births (cephalic presentation, >34/0 weeks of gestation), all of which were second births, occurring between 2000 and 2004 in 1 of 80 German birth centers. Births that occurred in the birth center or when labor had started in the birth center prior to transfer were included for analysis. RESULTS: Three hundred and sixty four women (5.3%) had a previous cesarean. The control group included 6448 parae II with no previous cesarean. Significant differences (p<0.05) between these two groups included: the transfer rate of mothers from a birth center to a hospital clinic during labor, the number of emergency transfers, the method of delivery (repeat cesarean), and the Apgar score at 5 min

How do we reduce the number of cases of missed postpartum diabetes in women with recent gestational diabetes mellitus?

OBJECTIVE: Up to 30% of women with recent gestational diabetes mellitus (GDM) remain glucose intolerant after delivery. However, the rate of postpartum oral glucose tolerance tests (ppOGTTs) is low. Our aim in this study was to develop a model for risk assessment to target women with high risk for postpartum diabetes. RESEARCH DESIGN AND METHODS: In 605 Caucasian women with GDM, antenatal obstetrical and glucose data and the glucose data of the ppOGTTs performed 13 weeks (median) after delivery were prospectively collected. RESULTS: A total of 132 (21.8%) women had an abnormal ppOGTT (2.8% impaired fasting glucose, 13.6% impaired glucose tolerance, and 5.5% diabetes). Independent risk factors were BMI >or=30 kg/m(2) (prevalence of abnormal ppOGTT 36.0 vs. 17.3%), gestational age at diagnosis <24 weeks (32.4 vs. 18.0%), 1-h antenatal value >200 mg/dl (11.1 mmol/l) (35.2 vs. 14.8%), and insulin therapy (30.3 vs. 14.5%). The prevalence of an abnormal ppOGTT was assessed according to the number of risk factors: 0, 9.2% (14 of 153); 1, 13.4% (25 of 186); 2, 28.5% (43 of 151); 3, 45.6% (26 of 57); and 4, 68.4% (13 of 19). Subjects were divided according to a significant increase of prevalence and risk for a ppOGTT: low risk (59.9% of subjects), <2 risk factors, 11.6%, odds ratio 1.3; intermediate risk, 2 risk factors, 28.5%, 4.0; and high risk, >2 risk factors, 51.3%, 10.5. The intermediate/high-risk group included 86.6% of those with diabetes and 67% of all those with abnormal ppOGTTs. CONCLUSIONS: Women with >or=2 risk factors have a high risk for an abnormal ppOGTT, and 86% of postpartum diabetes is diagnosed within this group. Targeting women for ppOGTTs based on a risk assessment using available antenatal risk factors might reduce the number of missed cases of postpartum diabetes.