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

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

Semi-Automatic Measurement of Fetal Cardiac Axis in Fetuses with Congenital Heart Disease (CHD) with Fetal Intelligent Navigation Echocardiography (FINE).

Congenital heart disease (CHD) is one of the most common organ-specific birth defects and a major cause of infant morbidity and mortality. Despite ultrasound screening guidelines, the detection rate of CHD is limited. Fetal intelligent navigation echocardiography (FINE) has been introduced to extract reference planes and cardiac axis from cardiac spatiotemporal image correlation (STIC) volume datasets. This study analyses the cardiac axis in fetuses affected by CHD/thoracic masses (n = 545) compared to healthy fetuses (n = 1543) generated by FINE. After marking seven anatomical structures, the FINE software generated semi-automatically nine echocardiography standard planes and calculated the cardiac axis. Our study reveals that depending on the type of CHD, the cardiac axis varies. In approximately 86% (471 of 542 volumes) of our pathological cases, an abnormal cardiac axis (normal median = 40-45°) was detectable. Significant differences between the fetal axis of the normal heart versus CHD were detected in HLHS, pulmonary atresia, TOF (p-value < 0.0001), RAA, situs ambiguus (p-value = 0.0001-0.001) and absent pulmonary valve syndrome, DORV, thoracic masses (p-value = 0.001-0.01). This analysis confirms that in fetuses with CHD, the cardiac axis can significantly deviate from the normal range. FINE appears to be a valuable tool to identify cardiac defects.

Fetal de novo heterozygous variant in the isocitrate dehydrogenase 1 gene associated with growth restriction, skeletal, cerebral and vascular anomalies.

Germline pathogenic variants in isocitrate dehydrogenase 1 (IDH1) can lead to a rare neurodevelopmental disorder called metaphyseal chondromatosis with D-2-hydroxyglutaric aciduria, including severe skeletal and cerebral anomalies. To the best of our knowledge, no prenatal case of an IDH1 pathogenic variant has been reported in literature. Somatic sequence variants in IDH1/2 genes are described in distinct cancers, premalignant diseases and rare inherited metabolic disorders. Amniocentesis and further genetic testing including trio exome sequencing were performed due to suspicious findings on a second trimester routine prenatal ultrasound examination. The fetus was found to have growth restriction, cerebral abnormalities (ex vacuo hydrocephalus, cerebellar and vermian hypoplasia, corpus callosum dysgenesis), brachycephaly, narrow chest, persistent left superior vena cava, liver calcifications, hyperechogenic bowel, short tubular bones and joint contractures. A de novo heterozygous variant in the IDH1 gene was detected via trio exome sequencing. The prenatal diagnosis of a de novo pathogenic variant in IDH1 in a fetus with the described phenotype, obtained through trio exome sequencing, helped parents and providers with an informed decision making about pregnancy management.

Spectrum of congenital anomalies of the kidney and urinary tract (CAKUT) including renal parenchymal malformations during fetal life and the implementation of prenatal exome sequencing (WES).

OBJECTIVES AND BACKGROUND: Congenital malformations of the kidney and urinary tract (CAKUT) have a prevalence of 4-60 in 10,000 livebirths and constitute for 40-50% of all end stage pediatric kidney disease. CAKUT can have a genetic background due to monogenetic inherited disease, such as PKD or ciliopathies. They can also be found in combination with extra-renal findings as part of a syndrome. Upon detection of genitourinary malformations during the fetal anomaly scan the question arises if further genetic testing is required. The purpose of this study was to determine the phenotypic presentation of CAKUT cases and the results of exome analysis (WES). METHODS: This is a retrospective analysis of 63 fetal cases with a diagnosis of CAKUT or DSD at a single center between August 2018 and December 2022. RESULTS: A total of 63 cases (5.6%) out of 1123 matched CAKUT phenotypes including renal parenchyma malformations. In 15 out of 63 WES analysis a pathogenic variant was detected (23.8%). In fetuses with isolated CAKUT the rate of detecting a pathogenic variant on exome sequencing was five out of 44 (11.4%). Ten out of 19 fetuses (52.6%) that displayed extra-renal findings in combination with CAKUT were diagnosed with a pathogenic variant. CONCLUSIONS: WES provides an increase in diagnosing pathogenic variants in cases of prenatally detected CAKUT. Especially in fetuses with extra-renal malformations, WES facilitates a gain in information on the fetal genotype to enhance prenatal counselling and management.

Advanced maternal age (AMA) and 75 g oGTT glucose levels are pedictors for insulin therapy in women with gestational diabetes (GDM).

OBJECTIVES: Gestational diabetes (GDM) is a common complication during pregnancy that is strongly associated with adverse fetal and maternal outcomes. Advanced maternal age (≥35 years) is a known risk factor for GDM. Studies advocate that GDM comprises distinctive metabolic entities, suggesting an individualized approach based on early pregnancy characteristics (such as 75 g oGTT values, maternal age, obstetric history). METHODS: The oGTT blood glucose levels of 1,664 women were categorized into isolated fasting hyperglycemia (GDM-IFH), isolated postprandial hyperglycemia (GDM-IPH) and combined hyperglycemia (GDM-CH), using the levels of the fasting, 1 h and 2 h values after glucose application. These three subtypes were analysed regarding baseline characteristics as well as fetal and maternal outcome in the context of maternal age. RESULTS: This analysis reveals that the 75 g oGTT levels and maternal age can distinguish metabolic phenotypes in women with GDM. The overall rate of insulin therapy required was higher in women from the GDM-CH group and increased with maternal age (31.7 %, 38.2 %, <35 years, ≥35-39 years respectively, vs. total insulin rate 22.3 %, p-value <0.001). Women ≥35 years displayed a significantly higher caesarean delivery (CD) rate (<35 years 34.6 %, 38.4 %, 41.1 % vs. ≥35 years 54.8 %, 47.6 %, 46.5 %, GDM-IFH, GDM-IPH, GDM-CH respectively, p-value <0.001). CONCLUSIONS: Women with fasting hyperglycemia, especially those with combined hyperglycemia and advanced maternal age (AMA) display a higher risk for unfavorable perinatal outcome. A categorization based on oGTT values and maternal age, as well as other characteristics can facilitate a basis for clinical risk stratification. Women at risk should receive an individualized and intensified perinatal care as well as interventional therapies.

The ICHOM Standard Set for Pregnancy and Childbirth - Translation and Linguistic Adaptation for Germany.

Introduction The gathering of health and quality-of-life issues that matter most to patients over so-called patient-reported outcomes (PROs) is a key aspect of patient-centered healthcare. In obstetrics, this approach has the potential to expand the current understanding of what quality entails by including patient perspectives. The International Consortium for Health Outcome Measures (ICHOM), founded in 2012, is a global organization which aims to standardise the collection of PROs and make the results comparable worldwide. A PRO Set for obstetrics, "Pregnancy and Childbirth", was published in 2018. The aim of our work was to translate the instruments of this set that are not yet available in German into German. Methods The instruments were translated from English into German using the Functional Assessment of Chronic Illness Therapy (FACIT) translation method. The translated instruments consisted of the Breastfeeding Self-Efficacy Scale - Short Form (BSES-SF), the Mother-to-Infant Bonding Scale (MIBS), and the Birth Satisfaction Scale - Revised (BSS-R) as well as a number of individual questions (items). Results The final version of the German translations were found to be easily comprehensible by the target group. During the cognitive debriefing, it became clear that pregnant women and women who had just given birth often used a number of medically incorrect terms to refer to their symptoms or complaints. In the translations great care was taken to ensure that the wording was as close as possible to the general usage of the language while at the same time the terminology was medically correct. To achieve a precise but comprehensible translation, the response structure of the BSES-SF also had to be adapted. Conclusions The instruments of the ICHOM Standard Set "Pregnancy and Childbirth", which were not previously available in German, were successfully translated into German. This meant dealing with a few challenges such as adapting questions or response structures. The cultural and linguistic comprehensibility of the German translations were confirmed during the subsequent cognitive debriefing. The translations offer the possibility of implementing the complete ICHOM Set for Pregnancy and Childbirth. This would provide an opportunity to expand the existing understanding of quality by including the subjective experience of women during and after childbirth and, in future, to compare outcomes with those of other hospitals across the world.

[Psychiatric Patients in Obstetrics in Germany - The Legal Basis and a Thematic Analysis of Case Reports]. / Psychiatrische Patientinnen in der Geburtsmedizin in Deutschland ­ die juristischen Grundlagen und eine thematische Analyse von Fallbeispielen.

The care of adult patients with particularly severe psychiatric illnesses in the daily routine of inpatient obstetrics is rare, but due to its complexity it represents a great challenge for all professions involved. The clinical pictures are very variable. There are a number of interlocking responsibilities in the provision of care. For planning of the birth, the medical-professional cooperation of psychiatry, obstetrics and pediatrics is necessary. Patients are often represented by legal guardians. The Youth Welfare Office is responsible for the welfare of the family and the children. The legal basis is essentially provided by the Civil Code, the Criminal Code and specific state laws, compliance with which is monitored by the courts. Typical psychiatric clinical pictures are presented by means of case reports. Legally defined applications such as accommodation, measures similar to deprivation of liberty, compulsory medical measures and justifiable necessity are explained. In the sense of a thematic analysis, these are applied to the case reports and peripartum management is discussed against the legal background. The precise knowledge of the legal background makes it easier for obstetricians to follow the procedures and interdisciplinary cooperation, especially at perinatalogical centres.

A 'holistic' sonographic view on congenital heart disease - How automatic reconstruction using fetal intelligent navigation echocardiography (FINE) eases the unveiling of abnormal cardiac anatomy part I: Right heart anomalies.

Attempting a comprehensive examination of the fetal heart remains challenging for unexperienced operators as it emphasizes the acquisition and documentation of sequential cross-sectional and sagittal views and inevitably results in diminished detection rates of fetuses affected by congenital heart disease. The introduction of four-dimensional spatio-temporal image correlation (4D STIC) technology facilitated a volumetric approach for thorough cardiac anatomic evaluation by the acquisition of cardiac 4D datasets. By analyzing and re-arranging of numerous frames according to their temporal event within the heart cycle, STIC allows visualization of cardiac structures as an endless cine loop sequence of a complete single cardiac cycle in motion. However, post-analysis with manipulation and repeated slicing of the volume usually requires experience and in-depth anatomic knowledge, which limits the widespread application of this advanced technique in clinical care and unfortunately leads to the underestimation of its diagnostic value to date. Fetal intelligent navigation echocardiography (FINE), a novel method that automatically generates and displays nine standard fetal echocardiographic views in normal hearts, has shown to be able to overcome these limitations. Very recent data on the detection of congenital heart defects (CHDs) using the FINE method revealed a high sensitivity and specificity of 98% and 93%, respectively. In this two-part manuscript, we focused on the performance of FINE in delineating abnormal anatomy of typical right and left heart lesions and thereby emphasized the educational potential of this technology for more than just teaching purposes. We further discussed recent findings in a pathophysiological and/or functional context.

A "holistic" sonographic view on congenital heart disease: How automatic reconstruction using fetal intelligent navigation echocardiography eases unveiling of abnormal cardiac anatomy part II-Left heart anomalies.

Volume ultrasound has been shown to provide valid complementary information on fetal anatomy. Four-dimensional assessment (4D) of the fetal cardiovascular system using spatial-temporal image correlation (STIC) allows for detailed examination of a highly complex organ from the early second trimester onward. There is compelling evidence that this technique harbors quite a number of diagnostic opportunities, but manual navigation through STIC volume datasets is highly operator dependent. In fact, STIC is not incorporated yet into daily practice. Application of the novel fetal intelligent navigation echocardiography (FINE) considerably simplifies fetal cardiac volumetric examinations. This automatic technique applied on cardiac volume datasets reportedly has both high sensitivity and specificity for the detection of congenital heart defects (CHDs). Part I reviewed current data regarding detection rates of CHDs and illustrated the additional value of an automatic approach in delineating cardiac anatomy exemplified by congenital lesions of the right heart. In part II of this pictorial essay, we focused on left heart anomalies and aimed to tabulate recent findings on the quantification of normal and abnormal cardiac anatomy.

Mode of delivery of women with Swyer syndrome in a German case series.

OBJECTIVES: For women with Swyer Syndrome, a 46,XY gonadal dysgenesis, full term pregnancies are possible after oocyte donation. According to literature, mode of delivery is almost always by Caesarean section for various reasons. Medical indications are multiple pregnancies and related complications, preeclampsia, an androgynous shaped pelvis and failed induction of labor. Elective Caesarean sections were performed based on maternal request and medical recommendation. METHODS: Following careful examination and shared decision making, we planned a spontaneous delivery with a patient with Swyer syndrome and tested the different hypotheses regarding anatomical and functional features according to literature. In addition, deliveries of women with Swyer Syndrome were analyzed in a German multicenter case series. RESULTS: A total of seven women with Swyer syndrome with a total of 10 pregnancies were identified, who later gave birth to twelve live-born children. Seven out of 10 births were performed by elective and non-elective Caesarean section, three births took place vaginally. CONCLUSIONS: In summary, the risk of Caesarean section delivery has increased, but spontaneous delivery can be attempted in the event of inconspicuous findings.

Association of peripartum management and high maternal blood loss at cesarean delivery for placenta accreta spectrum (PAS): A multinational database study.

INTRODUCTION: Placenta accreta spectrum (PAS) carries a high burden of adverse maternal outcomes, especially significant blood loss, which can be life-threatening. Different management strategies have been proposed but the association of clinical risk factors and surgical management options during cesarean delivery with high blood loss is not clear. MATERIAL AND METHODS: In this international multicenter study, 338 women with PAS undergoing cesarean delivery were included. Fourteen European and one non-European center (USA) provided cases treated retrospectively between 2008 and 2014 and prospectively from 2014 to 2019. Peripartum blood loss was estimated visually and/or by weighing and measuring of volume. Participants were grouped based on blood loss above or below the 75th percentile (>3500 ml) and the 90th percentile (>5500 ml). RESULTS: Placenta percreta was found in 58% of cases. Median blood loss was 2000 ml (range: 150-20 000 ml). Unplanned hysterectomy was associated with an increased risk of blood loss >3500 ml when compared with planned hysterectomy (adjusted OR [aOR] 3.7 [1.5-9.4], p = 0.01). Focal resection was associated with blood loss comparable to that of planned hysterectomy (crude OR 0.7 [0.2-2.1], p = 0.49). Blood loss >3500 ml was less common in patients undergoing successful conservative management (placenta left in situ, aOR 0.1 [0.0-0.6], p = 0.02) but was more common in patients who required delayed hysterectomy (aOR 6.5 [1.7-24.4], p = 0.001). Arterial occlusion methods (uterine or iliac artery ligation, embolization or intravascular balloons), application of uterotonic medication or tranexamic acid showed no significant effect on blood loss >3500 ml. Patients delivered by surgeons without experience in PAS were more likely to experience blood loss >3500 ml (aOR 3.0 [1.4-6.4], p = 0.01). CONCLUSIONS: In pregnant women with PAS, the likelihood of blood loss >3500 ml was reduced in planned vs unplanned cesarean delivery, and when the surgery was performed by a specialist experienced in the management of PAS. This reinforces the necessity of delivery by an expert team. Conservative management was also associated with less blood loss, but only if successful. Therefore, careful patient selection is of great importance. Our study showed no consistent benefit of other adjunct measures such as arterial occlusion techniques, uterotonics or tranexamic acid.

Furcate insertion of the umbilical cord: pathological and clinical characteristics in 132 cases.

Objectives Furcate cord insertion is a rare abnormality affecting approximately 0.1% of all pregnancies. Macroscopically, the umbilical vessels separate before reaching the placenta, lose their Wharton's jelly, and insert at the placenta centrally, eccentrically, or marginally. The aim of this retrospective study was to determine the prevalence of furcate cord insertion more accurately, the pathological characteristics, and clinical outcomes. Methods We conducted a retrospective study of 132 cases of furcate insertion of the umbilical cord using the pathological database of the Charité University Hospital Berlin, Germany, between 1993 and 2016. This included 99 cases, including one termination of pregnancy within our institution and 33 cases from external hospitals. An analysis of the pathological features of the 132 cases and the perinatal outcome of the 98 cases within our institution were performed. Results Furcate cord insertion occurred in 0.16% pregnancies. Of the 132 cases, seven cases of intrauterine fetal deaths were observed. Three of those could be linked to the furcate cord insertion. In two of those cases, single umbilical vessel rupture was identified as the cause of fetal death. Conclusions In most cases of furcate cord insertion, the outcome is good; however, intrauterine fetal death occurs in approximately 1.02% of cases.

Clinical outcome of prenatally suspected cardiac rhabdomyomas of the fetus.

Background The main objective of this retrospective analysis in a large tertiary center was the clinical outcome of prenatally diagnosed cardiac rhabdomyomas as well as the identification of factors influencing fetal prognosis. Methods A total of 45 cases of fetuses with prenatally suspected rhabdomyoma and their clinical outcome were analyzed retrospectively. A review of the literature was also performed. Results In five cases, after a tuberous sclerosis complex (TSC) mutation had been confirmed, termination of pregnancy was chosen. In 30 cases postnatal data were available. In 93% TSC was confirmed clinically or by mutational analysis. Two thirds of fetuses presented with multiple tumor while one third presented with a solitary tumor. In two fetuses mild pericardial effusions were observed. Another three fetuses presented with extrasystoles prenatally. No hydrops fetalis or fetal perinatal demise were observed. After birth 41% of the children suffered from arrhythmia including supra- and ventricular tachycardia, Wolff-Parkinson-White syndrome and atrioventricular block. One child received a Fontan procedure with Glenn anastomosis. Another child with a dilatative cardiomyopathy and a left ventricular ejection fraction of 15% died. Fifty-two percent of the children with TSC suffered from epilepsy ranging from absence epilepsy and West syndrome to generalized seizures with a frequency of up to 40 per day. Two children underwent neurosurgery to remove the epileptogenic focus. One child suffered from TSC and Lesch-Nyhan disease. In another case Beckwith-Wiedemann syndrome was identified as the causative disorder. Conclusion Rhabdomyoma are rare, benign tumors. There is an association with TSC. In the majority of cases rhabdomyoma are not hemodynamically relevant and do not increase in size. The quality of life of affected patients is impaired particularly due to epilepsy and psychomotor retardation.

Influence of Foetal Macrosomia on the Neonatal and Maternal Birth Outcome.

Introduction Foetal macrosomia is associated with various obstetrical complications and is a common reason for inductions and primary or secondary Caesarean sections. The objective of this study is the generation of descriptive data on the mode of delivery and on maternal and foetal complications in the case of foetal macrosomia. The causes and consequences of foetal macrosomia as well as the rate of shoulder dystocia are examined in relation to the severity of the macrosomia. Patients The study investigated all singleton births ≥ 37 + 0 weeks of pregnancy with a birth weight ≥ 4000 g at the Charité University Medicine Berlin (Campus Mitte 2001 - 2017, Campus Virchow Klinikum 2014 - 2017). Results 2277 consecutive newborns (birth weight 4000 - 4499 g [88%], 4500 - 4999 g [11%], ≥ 5000 g [1%]) were included. Maternal obesity and gestational diabetes were more common in the case of newborns weighing ≥ 4500 g than newborns weighing 4000 - 4499 g (p = 0.001 and p < 0.001). Women with newborns ≥ 5000 g were more often ≥ 40 years of age (p = 0.020) and multipara (p = 0.025). The mode of delivery was spontaneous in 60% of cases, vaginal-surgical in 9%, per primary section in 14% and per secondary section in 17%. With a birth weight ≥ 4500 g, a vaginal delivery was more rare (p < 0.001) and the rate of secondary sections was increased (p = 0.011). Women with newborns ≥ 4500 g suffered increased blood loss more frequently (p = 0.029). There was no significant difference with regard to the rate of episiotomies or serious birth injuries. Shoulder dystocia occurred more frequently at a birth weight of ≥ 4500 g (5 vs. 0.9%, p = 0.000). Perinatal acidosis occurred in 2% of newborns without significant differences between the groups. Newborns ≥ 4500 g were transferred to neonatology more frequently (p < 0.001). Conclusion An increased birth weight is associated with an increased maternal risk and an increased rate of primary and secondary sections as well as shoulder dystocia; no differences in the perinatal outcome between newborns with a birth weight of 4000 - 4499 g and ≥ 4500 g were seen. In our collective, a comparably low incidence of shoulder dystocia was seen. In the literature, the frequency is indicated with a large range (1.9 - 10% at 4000 - 4499 g, 2.5 - 20% at 4500 - 5000 g and 10 - 20% at ≥ 5000 g). One possible cause for the low rate could be the equally low prevalence of gestational diabetes in our collective. A risk stratification of the pregnant women (e.g. avoidance of vacuum extraction, taking gestational diabetes into account during delivery planning) is crucial. If macrosomia is presumed, it is recommended that delivery take place at a perinatal centre in the presence of a specialist physician, due to the increased incidence of foetal and maternal complications.

A 17-year analysis of pregnancies termination ≥14 weeks of gestation in a German level 1 perinatal center.

Background When discussing termination of pregnancy (TOP) after the first trimester, the main foci are the ethics and psychological reasoning/consequences. In daily clinical practice, physicians are often faced with affected women querying the frequency of their condition(s) and decisions made by women in similar situations. The present study aimed to provide an overview of a representable number of such cases. Methods Cases of TOP beyond 14 + 0 weeks of gestation were collected between January 2000 and December 2017 in the Department of Obstetrics. Fetal and/or maternal medical causes leading to TOP were extracted and presented. Results A total of 1746 TOPs ≥14 + 0 weeks were performed. Reasons leading to TOP were subcategorized into 23 groups. The main medical diagnoses were trisomy 21 (15.5%), neurological malformations (11.0%), and cardiac and major vessel malformations (7.9%). There was no statistical difference concerning maternal age or gravida/para between the groups. The average gestational age (GA) was 21.0 weeks, varying between 16.2 and 24.2 weeks in the 23 subgroups, with an average of 23.6% per year of TOPs after viability. Conclusion An overview of the various causes of TOP and their frequency within a large dataset are shown here. According to data provided by the German Federal Statistical Office, the overall number of TOPs has declined over the past two decades; however, the number and percentage of TOPs beyond viability have increased continuously in Germany. Only early detection of maternal and fetal constitution can prevent a portion of TOP after viability.

Evidence-based guidelines for the management of abnormally invasive placenta: recommendations from the International Society for Abnormally Invasive Placenta.

The worldwide incidence of abnormally invasive placenta is rapidly rising, following the trend of increasing cesarean delivery. It is a heterogeneous condition and has a high maternal morbidity and mortality rate, presenting specific intrapartum challenges. Its rarity makes developing individual expertise difficult for the majority of clinicians. The International Society for Abnormally Invasive Placenta aims to improve clinicians' understanding and skills in managing this difficult condition. By pooling knowledge, experience, and expertise gained within a variety of different healthcare systems, the Society seeks to improve the outcomes for women with abnormally invasive placenta globally. The recommendations presented herewith were reached using a modified Delphi technique and are based on the best available evidence. The evidence base for each is presented using a formal grading system. The topics chosen address the most pertinent questions regarding intrapartum management of abnormally invasive placenta with respect to clinically relevant outcomes, including the following: definition of a center of excellence; requirement for antenatal hospitalization; antenatal optimization of hemoglobin; gestational age for delivery; antenatal corticosteroid administration; use of preoperative cystoscopy, ureteric stents, and prophylactic pelvic arterial balloon catheters; maternal position for surgery; type of skin incision; position of the uterine incision; use of interoperative ultrasound; prophylactic administration of oxytocin; optimal method for intraoperative diagnosis; use of expectant management; adjuvant therapies for expectant management; use of local surgical resection; type of hysterectomy; use of delayed hysterectomy; intraoperative measures to treat life-threatening hemorrhage; and fertility after conservative management.

Perinatal outcomes after previable preterm premature rupture of membranes before 24 weeks of gestation.

OBJECTIVE: A current descriptive assessment of perinatal outcomes in pregnancies complicated by previable preterm premature rupture of membranes (pPPROM) at <24 weeks of gestation, after expectant treatment. STUDY DESIGN: Maternal and short-term neonatal data were collected for patients with pPPROM. RESULTS: Seventy-three patients with 93 fetuses were hospitalized with pPPROM at 15-24 weeks' gestation. Among these patients, 27.4% (n=20) chose pregnancy termination, 27.4% (n=20) miscarried and 45.2% (n=33) proceeded to live births. After a median latency period of 38 days, ranging from 1 to 126 days, 24 singletons and 20 multiples were live-born, of whom 79.5% (n=35) survived the perinatal period. The main neonatal sequelae were pulmonary hypoplasia (29.5%; n=13), connatal infection (56.8%; n=25), intraventricular hemorrhage (25%; n=11; resulting in five neonatal deaths) and Potter's syndrome (15.9%; n=7). Nine newborns died, within an average of 2.8 days (range, 1-10 days). The overall neonatal survival rate was 51.5% - including miscarriages but not elective terminations. The intact survival rate was 45.5% of all live-born neonates. CONCLUSIONS: Even with limited treatment options, overall neonatal survival is increasing. However, neonatal mortality and morbidity rates remain high. The gestational age at membrane rupture does not predict neonatal outcome.

Isolated Cleft Lip and Palate: Maxillary Gap Sign and Palatino-Maxillary Diameter at 11-13 Weeks.

OBJECTIVE: To evaluate the maxillary gap sign and describe markers for the first-trimester diagnosis of isolated cleft lip and palate (CLP) at 11-13 weeks. METHODS: Firstly, this was a prospective assessment of 1,087 fetuses including 5 cases of isolated CLP in 2 centers which were referred for the 11-13 weeks scan. Secondly, intra- and interobserver variability of the maxillary gap sign was evaluated for observers R.L. and A.B. in 2 sessions (affected cases vs. 50 normal fetuses in each session) to reduce the bias of different ultrasound manufacturer visualizations (Philips, GE). Thirdly, the palatino-maxillary diameter (PMD) was examined in stored images, DICOM loops and volumes of the midsagittal and parasagittal view of the fetal head and brain at 11+0-13+6 weeks of gestation from 5 fetuses with isolated CLP and 302 consecutively assessed normal controls. The PMD values in fetuses with isolated CLP and normal controls were compared. RESULTS: Firstly, 5 out of 6 referred pregnancies with isolated CLP were detected prospectively using the midsagittal view for measurement of nuchal translucency due to an abnormal appearance. One out of 6 patients with isolated CLP declined the 11-13 weeks scan. Secondly, intra- and interobserver variability showed no false positive cases; all cases with isolated CLP were identified by both sonographers; however, in 2 cases the maxillary gap sign was doubtful. Therefore, thirdly, we developed the PMD measurement which increased significantly with crown-rump length (CRL) from respective mean values at CRL of 45 mm to 4.66 mm and to 8.95 mm at CRL of 84 mm. In the CLP group, the PMD was below the 5th percentile of the control group in 4 out of 5 (80%) cases. CONCLUSIONS: The midsagittal view for measurement of nuchal translucency shows a high reproducibility regarding abnormal views for maxillary gap sign. In the midsagittal view of the fetal head, face, and brain at 11-13 weeks, the majority of fetuses with isolated CLP have a measurable abnormality in addition, the PMD.

[Intrapartum Translabial Ultrasound: A Systematic Analysis of The Fetal Head Station in The First Stage of Labor]. / Ultraschall unter der Geburt: Eine systematische Analyse des Höhenstandes des kindlichen Kopfes in der Eröffnungsperiode der Geburt.

INTRODUCTION: This prospective study aimed to define the angle of progression (AOP) in relation to the height position of the fetal head during the first stage of labour. It was investigated if it is possible to predict the mode of delivery or the duration of labour by AOP. METHODS: Influencing factors on delivery were head circumference, birth-weight, administration of oxytocin, epidural anaesthesia (EA) and parity, and their impact on AOP was analysed. AOP was calculated using three different formulas. Inclusion criteria were vaginal delivery of singletons in cephalic, occipito-anterior presentation. RESULTS: 30/80 recruited women met the study criteria. 90% delivered spontaneously vaginally, 10% had instrument-assisted vaginal delivery. The average AOP in spontaneous vaginal deliveries was 100.9° at cervical dilation less than 5 cm, and 125.3° at cervical dilatation more than 5 cm. The average AOP in instrument-assisted births was 93° and 113.9° when the cervical os was less than 5 cm and more than 5 cm, respectively. Analysis identified a predictive trend towards the duration of labour only by use of the first AOP formula but not regarding the mode of delivery. CONCLUSION: Sonographically assessed AOP during first stage of labour indicates trends regarding the duration of labour.

Reference Curve for the Mean Uterine Artery Pulsatility Index in Singleton Pregnancies.

INTRODUCTION: Doppler sonography of the uterine artery (UA) is done to monitor pregnancies, because the detected flow patterns are useful to draw inferences about possible disorders of trophoblast invasion. Increased resistance in the UA is associated with an increased risk of preeclampsia and/or intrauterine growth restriction (IUGR) and perinatal mortality. In the absence of standardized figures, the normal ranges of the various available reference curves sometimes differ quite substantially from one another. The causes for this are differences in the flow patterns of the UA depending on the position of the pulsed Doppler gates as well as branching of the UA. Because of the discrepancies between the different reference curves and the practical problems this poses for guideline recommendations, we thought it would be useful to create our own reference curves for Doppler measurements of the UA obtained from a singleton cohort under standardized conditions. MATERIAL AND METHODS: This retrospective cohort study was carried out in the Department of Obstetrics of the Charité - Universitätsmedizin Berlin, the Department for Obstetrics and Prenatal Medicine of the University Hospital Halle (Saale) and the Center for Prenatal Diagnostics and Human Genetics Kurfürstendamm 199. Available datasets from the three study locations were identified and reference curves were generated using the LMS method. Measured values were correlated with age of gestation, and a cubic model and Box-Cox power transformation (L), the median (M) and the coefficient of variation (S) were used to smooth the curves. RESULTS: 103 720 Doppler examinations of the UA carried out in singleton pregnancies from the 11th week of gestation (10 + 1 GW) were analyzed. The mean pulsatility index (Mean PI) showed a continuous decline over the course of pregnancy, dropping to a plateau of around 0.84 between the 23rd and 27th GW, after which it decreased again. CONCLUSION: Age of gestation, placental position, position of pulsed Doppler gates and branching of the UA can all change the flow pattern. The mean pulsatility index (Mean PI) showed a continuous decrease over time. There were significant differences between our data and alternative reference curves. A system of classifying Doppler studies and a reference curve adapted to the current technology are urgently required to differentiate better between physiological and pathological findings.