Birth during off-hours: Impact of time of birth, staff´s seniority, and unit volume on maternal adverse outcomes-a population-based cross-sectional study of 87 065 deliveries.

BACKGROUND: The aim of this study was to investigate whether time of birth, unit volume, and staff seniority impact the incidence of maternal complications in deliveries ≥34 + 0 gestational weeks. METHODS: We conducted a population-based cross-sectional study of 87 065 deliveries occurring between 2004 and 2015 in ten public hospitals in Styria, Austria. A composite adverse maternal outcome measure of uterine atony, postpartum hysterectomy, postpartum bleeding, impaired wound healing, postpartum infections requiring antibiotic treatment, sepsis, or maternal death was used to compare outcomes by time of birth, unit volume, and staff seniority. Based on delivery data, generalized estimating equations (GEEs) were used to calculate the risk of maternal adverse outcomes. RESULTS: Maternal adverse events occurred in 1.33% of deliveries. Incidence of maternal adverse events was highest for units with >1000 deliveries (adjusted OR 1.40; CI 95%: 1.16-1.69) and higher for perinatal centers (adjusted OR 1.35; CI 95%: 1.15-1.57) compared with reference units (500-1000 deliveries/year). Delivery during the daytime compared with the afternoon and nighttime did not affect the incidence of maternal complications (P = 0.765 and P = 0.136, respectively). Compared with resident-guided deliveries, the odds ratio for an adverse event was the same when a consultant attended the delivery (adjusted OR 1.13; CI 95%: 0.98-1.30) but lower in deliveries managed by midwives only (adjusted OR 0.21; CI 95%: 0.07-0.64). CONCLUSION: Procedures performed during the night shift were not associated with increased complication rates. Delivery volume and high-volume centers were associated with the highest risk of maternal complications, and units with 500-1000 deliveries per year were the lowest. With increasing odds of pregnancy risks, these results change, and delivering in a high-volume center becomes at least as safe as delivering in a smaller unit.

A novel Bacteroides metallo-ß-lactamase (MBL) and its gene (crxA) in Bacteroides xylanisolvens revealed by genomic sequencing and functional analysis.

OBJECTIVES: We sought to characterize the carbapenem resistance mechanism of Bacteroides xylanisolvens 14880, an imipenem-resistant strain from Germany, and assess its prevalence. METHODS: Antimicrobial susceptibilities were determined using agar dilution or Etest methodology and specific imipenemase activity was detected. The genomic sequence of B. xylanisolvens 14880 was determined and analysed for antibiotic resistance genes and genomic islands. We also used gene transfer to a carbapenem susceptible host, along with 5'-RACE, conventional PCR with capillary sequencing and RT-PCR-based screening. RESULTS: B. xylanisolvens 14880 displayed resistance to carbapenems and produced high specific imipenemase activity. Its genomic sequence was 6.1 Mbp and a class B1 ß-lactamase gene (termed crxA) was detected in it. crxA was carried on a putative genomic island with insertion sequence (IS) elements and a putative GNAT (Gcn5-like acetyltransferase) toxin gene. Promoter localization by 5'-RACE and gene targeting to an imipenem-susceptible Bacteroides host indicated that it is activated by an IS1380-like IS element and it can confer carbapenem resistance. The PCR screening of Bacteroides strains showed that crxA was specific to B. xylanisolvens with a carriage rate of 16.7%. CONCLUSIONS: B. xylanisolvens strains can harbour a carbapenem resistance gene, which has many similarities to the 'cfiA system': metallo-ß-lactamase (MBL), IS element activation, carriage of a GNAT toxin gene, specific for a unique Bacteroides species with a significant prevalence.

The Distinct Role of the HDL Receptor SR-BI in Cholesterol Homeostasis of Human Placental Arterial and Venous Endothelial Cells.

As opposed to adults, high-density lipoprotein (HDL) is the main cholesterol carrying lipoprotein in fetal circulation. The major HDL receptor, scavenger receptor class B type I (SR-BI), contributes to local cholesterol homeostasis. Arterial endothelial cells (ECA) from human placenta are enriched with cholesterol compared to venous endothelial cells (ECV). Moreover, umbilical venous and arterial plasma cholesterol levels differ markedly. We tested the hypothesis that the uptake of HDL-cholesteryl esters differs between ECA and ECV because of the differential expression of SR-BI. We aimed to identify the key regulators underlying these differences and the functional consequences. Immunohistochemistry was used for visualization of SR-BI in situ. ECA and ECV were isolated from the chorionic plate of human placenta and used for RT-qPCR, Western Blot, and HDL uptake assays with 3H- and 125I-labeled HDL. DNA was extracted for the methylation profiling of the SR-BI promoter. SR-BI regulation was studied by exposing ECA and ECV to differential oxygen concentrations or shear stress. Our results show elevated SR-BI expression and protein abundance in ECA compared to ECV in situ and in vitro. Immunohistochemistry demonstrated that SR-BI is mainly expressed on the apical side of placental endothelial cells in situ, allowing interaction with mature HDL circulating in the fetal blood. This was functionally linked to a higher increase of selective cholesterol ester uptake from fetal HDL in ECA than in ECV, and resulted in increased cholesterol availability in ECA. SR-BI expression on ECV tended to decrease with shear stress, which, together with heterogeneous immunostaining, suggests that SR-BI expression is locally regulated in the placental vasculature. In addition, hypomethylation of several CpG sites within the SR-BI promoter region might contribute to differential expression of SR-BI between chorionic arteries and veins. Therefore, SR-BI contributes to a local cholesterol homeostasis in ECA and ECV of the human feto-placental vasculature.

Sex-specific associations of insulin-like peptides in cord blood with size at birth.

OBJECTIVE: Insulin-like peptides (insulin, IGF-1, IGF-2) are essential regulators of foetal growth. We assessed the role of these peptides for birth size in a sex-specific manner. DESIGN: Cross-sectional cohort analysis. PATIENTS AND MEASUREMENTS: In 369 neonates, cord blood insulin, C-peptide, IGF-1 and IGF-2 levels were measured. Outcomes were placenta weight, birthweight, length and ponderal index. In linear regression models, the association of insulin-like peptides with growth outcomes was assessed, adjusted for gestational age and delivery mode. Interaction between insulin-like peptides and neonatal sex was assessed. RESULTS: No sex differences in levels of insulin-like peptides were observed. Significant interactions were found of sex with IGF-1 for birthweight, and of sex with C-peptide for all outcomes, except ponderal index. The association of IGF-1 (ng/mL) with birthweight was stronger and only significant in males (beta coefficient 3.30 g; 95%CI 1.98-4.63 in males and 1.45 g; -0.09-2.99 in females). Associations of C-peptide (ng/mL) with growth outcomes were stronger and only significant in females (placenta weight females: 181.3 g; 109.3-253.3; P < .001, males: 29.8 g; -51.5-111.1; P = .47, birthweight females: 598.5 g; 358.3-838.7: P < .001, males: 113.7 g; -154.0-381.4; P = .40). Associations of IGF2 with birthweight were similar in males and females. No associations were found with ponderal index. CONCLUSIONS: C-peptide and IGF-1 in cord blood associate with birthweight, length and placenta weight in a sex-specific manner, with stronger associations of C-peptide levels with placenta weight, birthweight and length in females and stronger associations of IGF-1 levels with birthweight in males.

Prenatal acupuncture: Women's expectations and satisfaction and influence on labor.

BACKGROUND: Use of prenatal acupuncture for labor preparation is common, but there is still conflicting evidence with respect to its objective obstetric benefits. There is little information on women's expectations and subjective experiences with acupuncture treatments. METHODS: In this retrospective cohort study, a validated questionnaire on women's treatment satisfaction was sent to women who had received prenatal acupuncture at the obstetric clinic of the Medical University of Graz, Austria within the last 3 years. The electronic obstetric database was used to extract detailed clinical and obstetric data of women who received acupuncture and delivered at the hospital. For comparison, obstetric data were matched with a control group of women without prenatal acupuncture, who had given birth at the hospital during the study period. RESULTS: The questionnaire was sent to 150 women, out of which 70 (46.7%) completed and returned the questionnaire. Analysis of the questionnaire indicated good overall satisfaction (mean sum score 26.22 ± 4.72) with acupuncture treatment-97.1% indicated that they were very or quite satisfied. Responders did not differ from nonresponders, except for the time between delivery and questionnaire (P = .015). Comparisons between the deliveries after prenatal acupuncture (n = 144) and the matched control deliveries (n = 576) showed no statistical significant differences in the length of labor and use of analgesics. CONCLUSION: Prenatal acupuncture is likely to have positive effects on pregnant women, aside from an objective influence on labor duration and pain.

A Modified Technique for Cord Transection in Monochorionic Monoamniotic Twin Pregnancies.

Monochorionic monoamniotic (MA) twins are at increased risk for intrauterine demise (IUD) and discordant anomalies. Selective feticide by cord occlusion may be an option in case of unfavorable discordant problems. In MA pregnancies, however, the surviving co-twin still remains at serious risk for IUD due to progressive cord entanglement. Cord transection has therefore been recommended to protect the survivor. This procedure may turn out to be difficult. We herein describe a modified fetoscopic technique for laser transection using a grasping forceps. We present technical details and clinical outcome in 2 cases of cord transection: one following cord occlusion and the other following spontaneous IUD. Cord transection was performed at 19 and 26 weeks gestation, respectively. A 3 Fr grasping forceps with a working length of 35 cm was used for controlled manipulation of the umbilical cord during transection. There were no procedure-related complications and both surviving co-twins had favorable neonatal outcome. Cord transection using a grasping forceps facilitates easy and precise fetoscopic release of the umbilical cord. To the best of our knowledge, this is the first report on post mortem cord transection after spontaneous single IUD with favorable outcome for the survivor.

Endothelin-1 down-regulates matrix metalloproteinase 14 and 15 expression in human first trimester trophoblasts via endothelin receptor type B.

STUDY QUESTION: Does endothelin-1 (ET-1) regulate matrix metalloproteinase (MMP) 14 and 15 production and invasion of human first trimester trophoblasts? SUMMARY ANSWER: ET-1 in pathophysiological concentrations down-regulates MMP14 and MMP15 expression via endothelin receptor (ETR) type B and decreases trophoblast migration and invasion. WHAT IS KNOWN ALREADY: MMP14 and MMP15 are involved in trophoblast invasion. Impairment of invasion has been linked to pregnancy complications such as pre-eclampsia (PE). ET-1 is up-regulated in PE. STUDY DESIGN, SIZE, DURATION: In vitro study using primary human trophoblasts from 50 first trimester placentas (gestational week 7-12). PARTICIPANTS/MATERIALS, SETTING, METHODS: Trophoblasts were cultured in the absence or presence of 10-100 nM ET-1. MMP14 and MMP15 mRNA and protein were quantified by RT-qPCR and Western blotting, respectively. Selective antagonists for ETRA (BQ-123) or ETRB (BQ-788) were used to identify ETR subtypes involved. Functional ET-1 effects were tested in first trimester chorionic villous explants and transwell invasion assays. The roles of tumor necrosis factor (TNF)-α (25 ng/ml) and oxygen (1%) in ET-1 regulation of MMP14 and 15 expression were assessed by Western blotting. MAIN RESULTS AND THE ROLE OF CHANCE: ET-1 down-regulated MMP14 and MMP15 mRNA (-21% and -26%, respectively, P < 0.05) and protein levels (-18% and -22%, respectively, P < 0.05). This effect was mediated via ETRB. ET-1 decreased trophoblast outgrowth in placental explants (-24%, P < 0.05) and trophoblast invasion (-26%, P ≤ 0.01). TNF-α enhanced ET-1 mediated MMP15 down-regulation (by 10%, P < 0.05), whereas hypoxia abolished the effect of ET-1 on both MMPs. LARGE SCALE DATA: N/A. LIMITATIONS, REASONS FOR CAUTION: Only primary trophoblasts were used in this study. Since trophoblast yield from first trimester placental material is limited, further aspects of MMP14 and 15 regulation could not be characterized. Other anti-invasive factors may be altered by ET-1 in trophoblasts and, thus, contribute to the reduced invasion, but have not been investigated. Oxygen levels similar to those found in the decidua (5-8% O2) were not analyzed in this study. WIDER IMPLICATIONS OF THE FINDINGS: ET-1 modifies placental function already during the first trimester of pregnancy, the time-window when the placental changes implicated in PE occur. Thus, our results improve the understanding of the placental mechanisms underlying trophoblast invasion and PE. STUDY FUNDING/COMPETING INTERESTS: The study was funded by the Oesterreichische Nationalbank (Anniversary Fund, project number: 14796) and the Herzfelder'sche Familienstiftung (to J.P.; number: 00685). AMM received funding from the Austrian Science Fund FWF (W1241) and the Medical University Graz through the PhD Program Molecular Fundamentals of Inflammation (DK-MOLIN). The authors have no conflict of interest.

Going into labor and beyond: phospholipase A2 in pregnancy.

The phospholipase A2 (PLA2) family is a very diverse group of enzymes, all serving in the cleavage of phospholipids, thereby releasing high amounts of arachidonic acid (AA) and lysophospholipids. AA serves as a substrate for prostaglandin production, which is of special importance in pregnancy for the onset of parturition. Novel research demonstrates that PLA2 action affects the immune response of the mother toward the child and is therefore probably implied in the tolerance of the fetus and prevention of miscarriage. This review presents data on the biochemical and enzymatic properties of PLA2 during gestation with a special emphasis on its role for the placental function and development of the fetus. We also critically discuss the possible pathophysiological significance of PLA2 alterations and its possible functional consequences. These alterations are often associated with pregnancy pathologies such as preeclampsia and villitis or pregnancy complications such as obesity and diabetes in the mother as well as preterm onset of labor.

Gestational diabetes mellitus modulates neonatal high-density lipoprotein composition and its functional heterogeneity.

Gestational diabetes mellitus (GDM) is related to neonatal macrosomia and an increased risk of vascular events. We hypothesized that GDM exerts qualitative effects on neonatal high-density lipoprotein (HDL). HDL was isolated from control (n=11) and GDM maternal/neonatal donors (n=9) and subjected to shotgun proteomics. Differences in HDL mobility were assessed by FPLC and native gel-electrophoresis. Paraoxonase (PON1) activity, cholesterol ester-transfer protein (CETP) mass and activity, phospholipid, triglyceride and cholesterol concentrations were quantified with commercial kits. Total anti-oxidative capacity and cholesterol efflux capability of HDLs were measured. Four proteins involved in lipid metabolism, inflammation and innate immunity were differentially expressed between controls and GDM neonates. ApoM (decreased, p<0.05) and SAA1 (increased, p<0.05) showed the same differences on both, maternal and neonatal GDM HDL. Lower PON1 protein expression was corroborated by lower activity (p<0.05) which in turn was associated with attenuated anti-oxidant capacity of GDM HDL. Protein changes were accompanied by increased levels of triglycerides and decreased levels of cholesterol esters, respectively. The observed differences in GDM HDL lipid moiety may be related to CETP mass and activity alterations. The rate of cholesterol efflux from term trophoblasts to maternal and from placental endothelial cells to neonatal GDM HDL was impaired (p<0.05). In conclusion, GDM causes changes in HDL composition and is intimately associated with impaired cholesterol efflux capability as well as diminished anti-oxidative particle properties. Remodeling of neonatal GDM HDL in utero supports the hypothesis that maternal conditions in pregnancy impact neonatal lipoprotein metabolism.

Distinct composition of human fetal HDL attenuates its anti-oxidative capacity.

In human high-density lipoprotein (HDL) represents the major cholesterol carrying lipoprotein class in cord blood, while cholesterol is mainly carried by low-density lipoprotein in maternal serum. Additionally, to carrying cholesterol, HDL also associates with a range of proteins as cargo. We tested the hypothesis that fetal HDL carries proteins qualitatively and quantitatively different from maternal HDL. These differences then contribute to distinct HDL functionality in both circulations. Shotgun proteomics and biochemical analyses were used to assess composition/function of fetal and maternal HDL isolated from uncomplicated human pregnancies at term of gestation. The pattern of analyzed proteins that were statistically elevated in fetal HDL (apoE, proteins involved in coagulation, transport processes) suggests a particle characteristic for the light HDL2 sub-fraction. In contrast, proteins that were enriched in maternal HDL (apoL, apoF, PON1, apoD, apoCs) have been described almost exclusively in the dense HDL3 fraction and relevant to its anti-oxidative function and role in innate immunity. Strikingly, PON1 mass and activity were 5-fold lower (p<0.01) in the fetus, which was accompanied by attenuation of anti-oxidant capacity of fetal HDL. Despite almost equal quantity of CETP in maternal and fetal HDL, its enzymatic activity was 55% lower (p<0.001) in the fetal circulation, whereas LCAT activity was not altered. These findings indicate that maternally derived HDL differs from fetal HDL with respect to its proteome, size and function. Absence of apoA-1, apoL and PON1 on fetal HDL is associated with decreased anti-oxidative properties together with deficiency in innate immunity collectively indicating distinct HDLs in fetuses.

Description of the metallo-ß-lactamase GIM-1 in Acinetobacter pittii.

OBJECTIVES: To characterize the mechanisms involved in the reduced carbapenem susceptibility of five Acinetobacter pittii strains isolated from different regions of Germany. METHODS: The strains were analysed by susceptibility testing, phenotypic tests for metallo-ß-lactamase production, sequencing of the integron structure and strain typing by PFGE, as well as multilocus sequence typing (MLST) and plasmid analysis by S1 restriction and hybridization. RESULTS: Despite GIM-1 production, the MICs of imipenem were only 4 mg/L for four strains and some methods of phenotypic MBL detection failed. According to PFGE and MLST, the strains belonged to four different clones, but blaGIM-1 was present in identical integron structures in all strains and carried on plasmids of ∼60 kb. CONCLUSIONS: For the first time, GIM-1 has been demonstrated in A. pittii. This resistance mechanism has previously been reported only in Enterobacteriaceae and Pseudomonas aeruginosa. As GIM-1 was found in strains with diverse clonal backgrounds, but encoded on plasmids of a similar size, further spread among Acinetobacter spp. seems possible. The detection of GIM-1 production might be challenging in some strains due to the low MICs of carbapenems.

Membrane-type matrix metalloproteinase 1 regulates trophoblast functions and is reduced in fetal growth restriction.

Fetal growth restriction (FGR) results from placental insufficiency to adequately supply the fetus. This insufficiency involves impaired cytotrophoblast functions, including reduced migration and invasion, proliferation, and syncytium formation. Membrane-type matrix metalloproteinase 1 (MT1-MMP) is a key enzyme in these cellular processes. MT1-MMP exists in various forms: a 63-kDa proenzyme is synthesized as primary translation product, which is cleaved into a 57-kDa membrane-anchored active form. We hypothesized that reduced placental MT1-MMP in FGR impairs trophoblast functions. MT1-MMP mRNA and active enzyme was quantified in placentas from FGR and age-matched control pregnancies. MT1-MMP protein was localized in first-trimester and term placentas. Putative MT1-MMP functions in trophoblasts were determined using two blocking antibodies for measuring migration and proliferation, as well as fusion of primary trophoblasts and trophoblast-derived cells. MT1-MMP was expressed predominantly in the syncytiotrophoblast and the villous and extravillous cytotrophoblasts. In FGR placentas, levels of MT1-MMP mRNA and of active MT1-MMP protein were reduced (-34.2%, P < 0.05, and -21.5%, P < 0.01, respectively), compared with age-matched controls. MT1-MMP-blocking antibodies diminished migration, proliferation, and trophoblast fusion. We conclude that reduced placental MT1-MMP in FGR may contribute to the impaired trophoblast functions associated with this pathology.

Cord blood chemerin: differential effects of gestational diabetes mellitus and maternal obesity.

OBJECTIVE: Chemerin is a novel adipokine implicated in inflammation and obesity. We hypothesized that foetal chemerin would be elevated in gestational diabetes mellitus (GDM) and correlate with foetal and maternal adiposity. DESIGN: Observational, longitudinal study. SUBJECTS AND MEASUREMENTS: Foetal chemerin was measured separately in arterial and venous cord blood of 30 infants born to mothers with (n = 15) and without GDM (n = 15), in their mothers in early third trimester and at delivery and in amniotic fluid (week 32) of women with GDM. Expression of chemerin and its receptor in human foetal tissues commercially available and in placental cells was measured by quantitative PCR. Associations between foetal and maternal anthropometric and metabolic variables were assessed in multivariate regression models. RESULTS: In GDM, foetal arterial but not venous cord blood chemerin levels were elevated by about 60% (P < 0·05). Venous cord blood chemerin was higher in infants of obese women (P < 0·01). In multivariate analyses, neither amniotic fluid nor cord blood chemerin levels correlated with birth weight or ponderal index. Both arterial and venous chemerin levels were related to maternal chemerin at birth, and arterial chemerin was associated with GDM status in addition. Maternal levels were unaltered in GDM, but higher in maternal obesity. Foetal liver produces fourfold more chemerin mRNA than other foetal tissues, whereas its receptor prevails in spleen. CONCLUSIONS: Based on multivariate analyses, foetal growth appears unrelated to foetal chemerin. Maternal obesity and GDM have differential effects on foetal chemerin levels. Site of major production (liver) and action (spleen) differ in human foetal tissues.

Validation of a point-of-care (POC) lactate testing device for fetal scalp blood sampling during labor: clinical considerations, practicalities and realities.

BACKGROUND: Although fetal blood sampling for pH is well established the use of lactate has not been widely adopted. This study validated the performance and utility of a handheld point-of-care (POC) lactate device in comparison with the lactate and pH values obtained by the ABL 800 blood gas analyzer. METHODS: The clinical performance and influences on accuracy and decision-making criteria were assessed with freshly taken fetal blood scalp samples (n=57) and umbilical cord samples (n=310). Bland-Altman plot was used for data plotting and analyzing the agreement between the two measurement devices and correlation coefficients (R²) were determined using Passing-Bablok regression analysis. RESULTS: Sample processing errors were much lower in the testing device (22.8% vs. 0.5%). Following a preclinical assessment and calibration offset alignment (0.5 mmol/L) the test POC device showed good correlation with the reference method for lactate FBS (R²=0.977, p<0.0001, 95% CI 0.9 59-0.988), arterial cord blood (R²=0.976, p<0.0001, 95% CI 0.967-0.983) and venous cord blood (R²=0.977, p<0.0001, 95% CI 0.968-0.984). CONCLUSIONS: A POC device which allows for a calibration adjustment to be made following preclinical testing can provide results that will correlate closely to an incumbent lactate method such as a blood gas analyzer. The use of a POC lactate device can address the impracticality and reality of pH sample collection and testing failures experienced in day to day clinical practice. For the StatStrip Lactate meter we suggest using a lactate cut-off of 5.1 mmol/L for predicting fetal acidosis (pH<7.20).

The impact of severe preeclampsia on maternal quality of life.

PURPOSE: Preeclampsia (PE) is a serious life event that can change women's psychological profile. The aim of this study was to evaluate the physical and mental health-related quality of life (HR-QoL) in women after PE and the impact of contributing factors. METHODS: Ninety-five women who had suffered from PE answered the Short-Form-12 Health Survey on general state of health. Comparison was made with the reference values and among the study cohorts, namely mild (14.7 %), severe (74.7 %) and superimposed PE (10.5 %). Medical parameters were evaluated as additional factors, and age served as covariate. RESULTS: Quality of mental life was significantly worse in all patients (p < 0.01), especially in those after severe PE (p < 0.01) compared to the reference range. These women demonstrated significantly worse results than those affected by the mild form (p = 0.03). Women who had had superimposed PE were neither physically nor mentally impaired compared to the standard population values (p = 0.94 and p = 0.90, respectively). After controlling for medical parameters and age, differences remained statistically significant. Multiparous women scored significantly worse on the mental scale than primiparous (p = 0.02), and pregnant women scored significantly worse than non-pregnant women on the physical level (p = 0.04). CONCLUSIONS: This study shows that women who have suffered from severe PE are substantially reduced in their mental quality of life. An extensive medical care including HR-QoL parameters might improve pregnancy outcome.

Prevalence of bisphosphonate-associated osteonecrosis of the jaw after intravenous zoledronate infusions in patients with early breast cancer.

OBJECTIVES: The definite incidence rate of bisphosphonate-related osteonecrosis of the jaws (BRONJ) is still unknown. The aim of this study was to investigate prevalence of BRONJ in a group of breast cancer patients applying the classification of the Association of Oral and Maxillofacial Surgeons 2009. PATIENTS AND METHODS: Between 2000 and 2008, 63 premenopausal early breast cancer patients who were free of metastases were treated with 4 mg zoledronic acid every 6 months over 3 years as participants of a multicenter, randomized, controlled, adjuvant breast cancer medication trial. Patients were not informed about the risk of jaw necrosis. None reported tooth or jaw complaints during the breast cancer follow-up examinations. In 2010, 48 patients of this cohort were investigated concerning BRONJ by clinical and radiological examinations. RESULTS: No advanced stages (AAOMS 2009)were detected. However, five patients (10.4%) presented purulent (2) and nonpurulent (3) fistulas and radiological signs correlating to BRONJ stage 0. CONCLUSION: Although no case of advanced BRONJ was detected, the study revealed a high prevalence of BRONJ stage 0. This supports the need for tight cooperation between dentists and medical specialists prescribing bisphosphonates including dental pre-therapeutic and follow-up examinations. Adaption of the BRONJ classification taking account to bone exposure via fistulas is recommended. CLINICAL RELEVANCE: BRONJ is said to be a complication linked to high-dosage bisphosphonate therapy. The study demonstrates that even after application of zoledronate in a low-dose protocol, early BRONJ occurred. Radiological signs solely are not sufficient to confirm BRONJ; clinical signs are mandatory.

Extraperitoneal versus transperitoneal cesarean section: a prospective randomized comparison of surgical morbidity.

OBJECTIVE: We sought to test the hypothesis that an extraperitoneal cesarean section (ECS) technique reduces postoperative pain without increasing intraoperative and postoperative complications. STUDY DESIGN: In a single-center, single-blinded prospective trial we randomized 54 patients with an indication for primary or first repeat cesarean section at term pregnancy to an ECS (n = 27) or transperitoneal cesarean section (TCS) (n = 27) procedure. Patients with suspected abnormal placentation, a history of >1 cesarean section, or major abdominal surgery were excluded. The primary endpoint of the study was maximum abdominal pain measured by numeric rating scale ranging from 0-10. RESULTS: Patients after ECS had significantly less maximum surgical site pain than patients after TCS. Median peak pain scores on postoperative day 1 were 4.00 (interquartile range, 3.00-5.00) for ECS and 5.00 (interquartile range, 4.00-7.00) for TCS, respectively (P = .031). Analgesic requirements, intraoperative nausea, and postoperative shoulder pain were significantly less after ECS. Overall operative time was significantly shorter in ECS, with no difference in delivery time. No bladder injury occurred in either group. There were no differences in estimated blood loss and neonatal outcome. Urogenital distress, urinary tract infection, and bowel dysfunction did not differ at discharge from hospital and 6 weeks after. CONCLUSION: An extraperitoneal approach to cesarean section appears to reduce postoperative pain, usage of analgesics, and intraoperative nausea without an increase in significant complications.

Perinatal complications and long-term neurodevelopmental outcome of infants with intrauterine growth restriction.

OBJECTIVE: The objective of the study was to evaluate perinatal and long-term complications of fetuses with intrauterine growth restriction (IUGR) compared with constitutionally small for gestational age (SGA) ones. STUDY DESIGN: The outcome of infants with IUGR and SGA born at the Medical University Graz (Austria) between 2003 and 2009 was retrospectively analyzed. Group assignment was based on birthweight, Doppler ultrasound, and placental morphology. The primary outcome was neurodevelopmental delay at 2 years corrected age. The secondary outcomes were perinatal complications. RESULTS: We included 219 IUGR and 299 SGA infants for perinatal and 146 and 215 for long-term analysis. Fetuses with IUGR were delivered earlier (35 vs 38 weeks) and had higher rates of mortality (8% vs 1%; odds ratio [OR], 8.3) as well as perinatal complications (24.4% vs 1.0%; OR, 31.6). The long-term outcome was affected by increased risk for neurodevelopmental impairment (24.7% vs 5.6%; OR, 5.5) and growth delay (21.2% vs 7.4%; OR, 3.4). CONCLUSION: IUGR infants are subject to an increased risk for adverse short- and long-term outcome compared with SGA children.

The impact of resilience on psychological outcomes in women after preeclampsia: an observational cohort study.

BACKGROUND: Preeclampsia is a frequent obstetric complication which affects the mother`s and the fetus's health and can be life threatening. It also has an impact on psychological outcomes. There may be protective variables such as resilience shielding against psychosocial distress in women experiencing these pregnancy complications. The aim of this study was to examine differences in resilience in terms of quality of life, depression and post-traumatic stress symptoms in women after preeclampsia. METHODS: Four international validated questionnaires were used to measure the psychological outcomes (Medical Outcome Study Short-Form SF12, Edinburgh Postnatal Depression Scale EPDS, Resilience Scale RS13, Impact of Event Scale IES-R). Statistical analyses were performed using independent-samples t-test and chi-square test. RESULTS: 67 women with previous preeclampsia returned the questionnaires. Women with high resilience showed significantly less depression (p = 0.001) and better mental quality of life (p = 0.002) compared to women with low resilience. No group differences were found on the medical and socio-demographic characteristics. CONCLUSIONS: Resilience has an important impact on the psychological outcomes in women after preeclampsia. A screening for resilience, depression and quality of life may be appropriate to identify these women.

Fetal HDL/apoE: a novel regulator of gene expression in human placental endothelial cells.

Maternal lipoproteins have been studied extensively in human pregnancies, but little is known about the role of fetal lipoproteins. The vascularized human placenta interfaces between the mother and fetus to transfer nutrients for sustaining pregnancy. Unlike that of adults, fetal high-density lipoprotein (HDL), which is in contact with placental vessels, is characterized by a high proportion of apolipoprotein E (apoE). We hypothesize this unique composition of fetal HDL affects key functions of the growing fetal tissues. The aim was to identify genes regulated by apoE-HDL by incubating human placental endothelial cells (HPEC) with either fetal HDL or apoE-rich reconstituted HDL particles (apoE-rHDL). HPEC were exposed to 15 µg/ml fetal HDL, 15 µg/ml apoE-rHDL, or medium for 16 h, respectively. Microarray analysis determined genes regulated by fetal HDL and apoE. Characterization of HDL particles revealed a different hydrodynamic radius for apoE-rHDL (13.70 nm) compared with fetal HDL (18.11 nm). Stepwise gene clustering after microarray experiments identified 79 differentially expressed genes (P < 0.05) when cells were exposed to HDL compared with controls. Among them 16 genes were downregulated, whereas five genes were upregulated by twofold, respectively. When HPEC were incubated with apoE-rHDL 18-fold more genes (1,417, 12% of transcripts) were regulated (P < 0.05) in contrast to HDL. Thereof, 172 genes were downregulated and 376 genes upregulated (twofold). In the common subset of 38 genes regulated by both HDL particles, genes involved in cholesterol biosynthesis and cell protection prevailed. Strikingly, results suggest that HDL has the capability of regulating metallothioneins, which may have an effect on oxidative stress in HPEC.