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

Objective: We sought to investigate the incidence, maternal risk factors, and perinatal outcomes of women with complete and partial placental retention in a tertiary care teaching hospital in Southwestern Germany. Study design: We performed an unmatched case-control study with cases occurring between July 2000 and June 2007. Women were included into the study if they completed at least the 24th week of gestation and were diagnosed with placental retention requiring surgical intervention. We selected two controls per case and performed univariate and multivariate logistic regression analyses to identify risk factors for complete and partial placental retention. Results: A total of 161 cases (2.02%) were identified out of 7978 deliveries. The 1-year prevalence of all types of placental retention continuously increased during the 6-year study period from 0.93% to 3.26%. A significant independent risk factor for all types of placental retention in the multivariate logistic regression model was a previous retention of the placenta [odds ratio (OR)=21.723, 95% confidence interval (CI) 6.07–77.7]. Independent protective factors against all types of placental retention were a non-anterior and non-posterior placenta location (OR=0.561, 95% CI 0.35–0.91), and a cesarean delivery with (OR=0.193, 95% CI 0.09–0.40) and without labor (OR=0.482, 95% CI 0.27–0.86). Women without partial placental retention delivered neonates with better 5-min APGAR scores (OR=0.78, 95% CI 0.65–0.95). Conclusion: A thorough medical history and a vigilant prepartum ultrasound help in identifying women at risk for placental retention.

To estimate whether it is possible to define clinically a subgroup of women who have so high a cesarean delivery rate as to avoid spontaneous onset of labor or induced labor.We conducted a retrospective cohort study (October 2005 to January 2010) on a data set of women who had premature rupture of membranes (PROM) at greater than 24 weeks of gestation, a singleton pregnancy, and a viable fetus without congenital anomalies. Patients were treated in a common way regarding indications for delivery. The primary outcome was cesarean delivery.We identified 1,026 women (comprising 7.9% of all deliveries) who had PROM and met the inclusion criteria. There were 404 with preterm deliveries. One hundred thirty-seven (13.4%) had a contraindication to either labor or vaginal delivery. For women with induction (n=355), vaginal delivery occurred in 82%, whereas for those with spontaneous labor (n=534), vaginal delivery occurred in 87% (P=.03). No clinically defined subgroup had an observed cesarean delivery rate greater than 27%, and in most subgroups, it was lower, even when we built in multiple risk factors, including gestational age less than 34 weeks, chorioamnionitis, abruption, and nulliparity.In the absence of a contraindication to labor or to vaginal delivery, the likelihood of vaginal delivery after PROM, with either spontaneous or induced labor, is high, even when we included multiple risk factors for cesarean delivery.II.

Purpose: The health benefits of breastfeeding for both infants and mothers are well-documented. The aim of this study was to clarify factors associated with successful breastfeeding. Methods: We performed a prospective, multi-centre cohort study of 443 mothers in person using a standardised questionnaire on postpartum day 1. Women who had started to breast-feed were interviewed by telephone after 3, 6 and 12 months. A statistical analysis was performed using the SAS system. Results: 92 % of women (409/443) were initially breastfeeding. After three months the rate decreased to 74 %, after six months to 61 % and after 12 months to 28 %, respectively. Bivariate analysis revealed a significant positive association with the following factors: maternal age > 35 years, higher educational level, intention to breastfeed on postpartum day one, high motivation after three months, partnerʼs support of the decision to breastfeed, satisfaction with the care provided in the maternity clinic, a positive breastfeeding experience and follow-up care by a midwife. Elective caesarean delivery, the use of breastfeeding aids, formula supplementation early on and the motherʼs concern about the amount of milk correlated negatively. Following a multivariate logistic regression analysis, four factors were correlated with having a positive influence on duration of breastfeeding: higher educational level, satisfaction with the care provided within the maternity clinic, follow-up care by a midwife, and a positive current experience of breastfeeding. Conclusion: Our data demonstrate certain factors successfully influence breastfeeding. Competent care in the maternity clinic, postpartum care by a midwife and a positive experience with breastfeeding increase the rate of breastfeeding and thus have a positive impact on the health of mother and newborn.

Objective To evaluate colonization, transmission rate and serotype distribution of group B streptococci (GBS) in pregnant women and infants born in a single University Center in Germany. Methods In a prospective study we collected cultures from pregnant women and ear cultures from newborns. We performed serotyping and susceptibility testing. Obstetrical factors associated with mother to infant transmission were analyzed using logistic regression. Results We evaluated cultures of 869 pregnant women and 845 neonates including 657 paired maternal-neonatal cultures. Maternal colonization occurred in 21.1% (183/869), transmission from mother to newborn in 11.2% (17/152). Intrapartum antimicrobial prophylaxis (IAP) and cesarean delivery were associated with reduction of transmission rate (P=0.014 and 0.019, respectively). The incidence for early-onset disease (EOD) was 1.71 per 1000 live births. Of GBS positive women IAP was administered in only 39% (59/152). Serotype III was the most prevalent isolate (28% maternal; 52% neonatal) and transmission occurred more frequently compared to other serotypes. Conclusions The incidence of EOD and distribution of serotypes in Germany are similar to published data from the USA prior to 1996. Despite national guidelines with universal GBS screening, our study demonstrated a lack of adherence to this recommendation. There is a need for enhanced compliance.

24j IIG/ 0P, ca. 40. SSW. Verlegung der Mutter in das Perinatalzentrum bei Querlage und ausgepragtem Hydrocephalus und Aszites. Die aus Afrika stammende und in Frankreich lebende Mutter gab an, dass keine Schwangerschaftsvorsorge durchgefuhrt worden sei. Sonographisch und serologisch zeigte sich eine konnatale Toxoplasmoseinfektion. Bei beginnender Wehentatigkeit und Querlage wurde eine sekundare Sectio caesarea aus mutterlicher Indikation durchgefuhrt. NG: mannlich, Gewicht 4185g, Kopfumfang 42cm (>97. P.), pH 7,28, BE –5,3, APGAR 4/7/8. Erst postpartal berichtete die Mutter auf gezielte Nachfrage, dass bereits im 2. Trimenon eine Toxoplasmoseinfektion serologisch nachgewiesen worden sei. Sie habe sich trotz bereits bestehender cerebraler Auffalligkeiten gegen die empfohlene Abruptio aus medizinischer Indikation entschieden. Es erfolgte eine Therapie mit Spiramycin uber eine Woche. Eine postpartale Versorgung des Kindes war aufgrund der schweren Fehlbildungen von den franzosischen Kollegen abgelehnt worden, weshalb die Patientin sich zur Entbindung in Deutschland vorstellte. Beim Kind zeigte sich das Vollbild einer konnatalen Toxoplasmoseinfektion, die sich serologisch bestatigte (IgM hoch positiv). Hierzu zahlten ein ausgepragter Hydrocephalus internus et externus mit Krampfanfallen, eine Hepatosplenomegalie mit Hepatopathie, ein Mb. Hamolyticus neonatorum bei B–0-Inkompatibilitat, eine Choanalstenose sowie ein Mikrophthalmus. Die Gesamtprognose wurde vor allem aufgrund des massiv ausgepragten Hydrocephalus als infaust eingeschatzt, sodass nach ethischem Konsil die invasiven intensivmedizinschen Masnahmen beendet und das Kind extubiert wurde. Es verstarb am 12. Lebenstag. Literatur: Congenital Toxoplasmosis and Reinfection during Pregnancy: Case Report, Strain Characterization, Experimental Model of Reinfection, and Review. Elbez-Rubinstein A, Ajzenberg D, Darde ML, Cohen R, Dumetre A, Yera H, Gondon E, Janaud JC, Thulliez P. J Infect Dis. 2009 Jan 15;199(2):280-285. Prenatal education for congenital toxoplasmosis. Di Mario S, Basevi V, Gagliotti C, Spettoli D, Gori G, D'Amico R, Magrini N. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD006171. New insights in toxoplasmosis immunology during pregnancy. Perspective for vaccine prevention. Pfaff AW, Candolfi E. Parassitologia. 2008 Jun;50(1-2):55-8. Review. Sonographic examination of the fetal central nervous system: guidelines for performing the 'basic examination' and the 'fetal neurosonogram'. Ultrasound Obstet. Gynecol 2007; 29:109.

Pregnancies after perinatal loss occur often. However, little is known about the need of secondary psychological prevention in these instances. Therefore we investigated psychological disorder and distress during the subsequent pregnancy after perinatal loss.We compared psychological symptoms in pregnant women with and without previous perinatal loss.Pregnant women in the PL-group did not suffer more from depression, anxiety and other psychological distress than women without perinatal loss. Nearly a third of the women in the PL-group were classified as unresolved with regard to their mental representation of attachment indicating that their mourning process was still not completed.Women who have suffered from perinatal loss do not score higher on depression, anxiety or general psychopathology during subsequent pregnancies than women without loss experience. Only a minority of women, who have suffered from loss show ongoing signs of unresolved mourning. However, in order to detect criteria for the identification of those who might be at risk during subsequent pregnancies studies with larger samples size are necessary.

Background During and shortly after birth, newborn infants are colonized with enterococci. This study analyzes predictors for early enterococcal colonization of infants in a neonatal intensive care unit and describes risk factors associated with multidrugresistant enterococci colonization and its seasonal patterns. Methods Over a 12-month period, we performed a prospective epidemiological study in 274 infants admitted to a neonatal intensive care unit. On the first day of life, we compared infants with enterococcal isolates detected in meconium or body cultures to those without. We then tested the association of enterococcal colonization with peripartal predictors/risk factors by using bivariate and multivariate statistical methods. Results Twenty-three percent of the infants were colonized with enterococci. The three most common enterococcal species were E. faecium (48% of isolates), E. casseliflavus (25%) and E. faecalis (13%). Fifty-seven percent of the enterococci found were resistant to three of five antibiotic classes, but no vancomycin-resistant isolates were observed. During winter/spring months, the number of enterococci and multidrug-resistant enterococci were higher than in summer/fall months (p = 0.002 and p < 0.0001, respectively). With respect to enterococcal colonization on the first day of life, predictors were prematurity (p = 0.043) and low birth weight (p = 0.011). With respect to colonization with multidrug-resistant enterococci, risk factors were prematurity (p = 0.0006), low birth weight (p < 0.0001) and prepartal antibiotic treatment (p = 0.019). Using logistic regression, we determined that gestational age was the only parameter significantly correlated with multidrug-resistant enterococci colonization. No infection with enterococci or multidrugresistant enterococci in the infants was detected. The outcome of infants with and without enterococcal colonization was the same with respect to death, necrotizing enterocolitis, intracerebral hemorrhage and bronchopulmonary dysplasia. Conclusion In neonatal intensive care units, an infant's susceptibility to early colonization with enterococci in general, and his or her risk for colonization with multidrug-resistant enterococci in particular, is increased in preterm newborns, especially during the winter/spring months. The prepartal use of antibiotics with no known activity against enterococci appears to increase the risk for colonization with multidrug-resistant enterococci.

Objectives Alterations in lipoprotein metabolism have been proposed as a possible pathophysiologic factor for preeclampsia. Elevation of very low density lipoproteins (VLDL) and predominance of atherogenic small dense low density lipoproteins (sdLDL) have been demonstrated in preeclampsia. Heparin-mediated-extracorporeal-LDL-precipitation (H.E.L.P.)-apheresis is an established method for lipoprotein removal and regeneration of endothelial function in severe hyperlipidemia. Wang et al. (2006) successfully used H.E.L.P.-apheresis in a pilot study to prolong preeclamptic pregnancies. We investigated alterations in the lipidprofile and the effects of H.E.L.P.-apheresis in the prolongation of hypertensive pregnancies. Methods Six patients with early pregnancy complicated by hypertension were treated with H.E.L.P.-apheresis. Blood was collected before and after apheresis and subjected to ultracentrifugation for determination of lipid parameters. Results A total of 23 apheresis treatments (2–6 per patient) were performed without severe complications. Within apoB-containing lipoproteins, VLDL (−58%) and sdLDL (L5: −65% and L6: −68%) were removed at highest proportion. Cholesterol was reduced by 32% and triglycerides by 44%. Soluble fms-like tyrosine kinase-1 (sFlt-1) and placenta-growth-factor (PlGF) were not removed by H.E.L.P. Pregnancies continued for 4–14 days and lung maturation was successfully initiated before termination of pregnancy by caesarean section. Conclusions H.E.L.P.-apheresis appears to preferentially address atherogenic lipoproteins, relevant to preeclampsia. Disclosures C. Contini: None. B. Konig: None. F. Markfeld-Erol: None. M. Kunze: None. S. Zschiedrich: None. H. Prompeler: None. G. Putz: None. K. Winkler: Commercial Interest: BBraun Melsungen AG provided the H.E.L.P.-system; Research Support: BBraun Melsungen AG; Speaker: BBraun Melsungen AG.

Objective: We sought to develop a model of chronic intrauterine and fetal infection with Gardnerella vaginalis. Study Design: The uterine horns of pregnant New Zealand White rabbits were inoculated on day 21 of gestation with either 10 7 colony-forming units (cfu) of G vaginalis or saline solution. At necropsy, cultures were taken from blood, uterus, amniotic fluid, and fetal tissues. Amniotic fluid was assayed for tumor necrosis factor (TNF)-α by bioassay. Maternal and fetal tissue samples were evaluated using the histologic index score. A P value Results: Compared with saline solution–inoculated animals, the G vaginalis group had significantly more positive cultures from uterus, amniotic fluid, and fetal brain and lung ( P =.02 to G vaginalis group, mean TNF-α levels and fetal brain scores increased significantly over time ( P Conclusion: Chronic intrauterine and fetal infection with G vaginalis is accompanied by progressive increases in amniotic fluid TNF-α concentrations and fetal brain histologic index scores. (Am J Obstet Gynecol 2002;187:1263-6.)