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Subject While the synthetic prostaglandin E1 analogue misoprostol is the most effect labour induction agent, its use is off-label for the most part. For this reason, and in view of its potential adverse effects and varying approaches to its administration, the drug has recently once again become a focus of critical attention. The objective of this survey was thus to establish a record of labour induction with misoprostol in German clinics and determine the impact of the negative reporting on everyday obstetric practice. Material and Methods In this cross-sectional study, 635 obstetrics and gynaecology departments in Germany were requested by email to participate in our survey in February/March 2020. Online responses to 19 questions were requested regarding the clinic, use of misoprostol before and after the critical reporting, use of misoprostol (sourcing, method of administration, dosage, monitoring) and other labour induction methods. Results A total of 262 (41.3%) of the clinics solicited for the survey completed the questionnaire. There were no differences regarding the care level (Perinatal Centre Level I, Perinatal Centre Level II, Clinic with Perinatal Focus or Obstetric/Private Clinic; p = 0.2104) or birth counts (p = 0.1845). In most cases, misoprostol was prepared in the clinic's own pharmacy (54%) or imported from another country (46%) and administered orally in tablet form (95%). Misoprostol dosage levels varied (25 µg [48%], 50 µg [83%], 75 µg [6%], 100 µg [47%] and > 100 µg [5%]). Most of the clinics used premanufactured tablets/capsules (59%), although Cytotec tablets were also divided (35%) or dissolved in water (5%). Misoprostol administration intervals were mainly every 4 hours (64%) or every 6 hours (30%). CTG checks were run in most cases before and after administration of a dose of misoprostol (78% and 76%) and before and after administration of a dose of prostaglandin E2 (both 88%). Presence of contractions led to no misoprostol (59%) or no prostaglandin E2 (64%) being administered in most cases. The critical reporting resulted in discontinuation of use of misoprostol in 17% of the clinics - mainly smaller obstetric/private clinics with fewer than 1000 births. Labour cocktails were used mainly in obstetric and private clinics (61%). Conclusion Misoprostol is an established agent for labour induction in German clinics. The dosing schemes used vary. Improvements of currently common management practices are required, especially in the area of labour induction (CTG checks before and after administration of labour-inducing medication, no administration of prostaglandin if contractions are ongoing). The discussion of use of misoprostol in the media resulted in stoppage of its use mainly in smaller clinics., Competing Interests: Conflict of Interest/Interessenkonflikt The authors declare that they have no conflict of interest./Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Purpose: Labor is a complex process involving multiple para-, auto- and endocrine cascades. The interaction of cortisol, corticotropin-releasing hormone (CRH) and progesterone is essential. The action of cortisol on the human feto-placental unit is regulated by 11beta-hydroxysteroid dehydrogenase type 2 (11β-HSD2/HSD11B2) that converts cortisol into inactive cortisone. The majority of studies on the assessment of placental 11β-HSD2 function determined indirect activity parameters. It remains elusive if indirect measurements correlate with enzymatic function and if these parameters are affected by potential confounders (e.g., mode of delivery). Thus, we compared determinants of indirect 11β-HSD2 tissue activity with its direct enzymatic turnover rate in placental samples from spontaneous births and cesarean (C)-sections., Methods: Using LC-MS/MS, we determined CRH, cortisol, cortisone, progesterone and 17-hydroxy(OH)-progesterone in human term placentas (spontaneous birth vs. C-section, n = 5 each) and measured the enzymatic glucocorticoid conversion rates in placental microsomes. Expression of HSD11B1, 2 and CRH was determined via qRT-PCR in the same samples., Results: Cortisol-cortisone ratio correlated with direct microsomal enzymatic turnover. While this observation seemed independent of sampling site, a strong influence of mode of delivery on tissue steroids was observed. The mRNA expression of HSD11B2 correlated with indirect and direct cortisol turnover rates in C-section placentas only. In contrast to C-sections, CRH, cortisol and cortisone levels were significantly increased in placental samples following spontaneous birth., Conclusion: Labor involves a series of complex hormonal processes including activation of placental CRH and glucocorticoid metabolism. This has to be taken into account when selecting human cohorts for comparative analysis of placental steroids.

Intrahepatic cholestasis of pregnancy (ICP) is the most frequent pregnancy-specific liver disease. It is characterized by pruritus and an accompanying elevation of serum bile acid concentrations and/or alanine aminotransferase (ALT), which are the key parameters in the diagnosis. Despite good maternal prognosis, elevated bile acid concentration in maternal blood is an influencing factor to advers fetal outcome. The ICP is associated with increased rates of preterm birth, neonatal unit admission and stillbirth. This is the result of acute fetal asphyxia as opposed to a chronic uteroplacental insufficiency. Reliable monitoring or predictive tools (e.g. cardiotocography (CTG) or ultrasound) that help to prevent advers events are yet to be explored. Medicinal treatment with ursodeoxycholic acid (UDCA) does not demonstrably reduce adverse perinatal outcomes but does improve pruritus and liver function test results. Bile acid concentrations and gestational age should be used as indications to determine delivery. There is a high risk of recurrence in subsequent pregnancies., (© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2021.)

Purpose:  To evaluate the longitudinal pattern of fetal heart rate short term variation (STV) and Doppler indices and their correlation to each other in severe growth restricted (IUGR) fetuses., Materials and Methods:  In this retrospective study, pregnancies with a birth weight below the 10th percentile, born between 24 and 34 gestational weeks with serial Doppler measurements in combination with a computerized CTG (cCTG) with calculated STV were included. Longitudinal changes of both Doppler indices and STV values were evaluated with generalized additive models, adjusted for gestational age and the individual. For all measurements the frequency of abnormal values with regard to the time interval before delivery and Pearson correlations between Doppler indices and STV values were calculated., Results:  41 fetuses with a total of 1413 observations were included. Over the course of the whole study period, regression analyses showed no significant change of STV values (p = 0.38). Only on the day of delivery, a prominent decrease was observed (mean STV d28-22: 7.97 vs. mean STV on day 0: 6.8). Doppler indices of UA and MCA showed a continuous, significant deterioration starting about three weeks prior to delivery (p = 0.007; UA and p < 0.001, MCA). Correlation between any Doppler index and STV values was poor., Conclusion:  Fetal heart rate STV does not deteriorate continuously. Therefore, cCTG monitoring should be performed at least daily in these high-risk fetuses. Doppler indices of umbilical artery (UA) and middle cerebral artery (MCA), however, showed continuous deterioration starting about 3 weeks prior to delivery., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Purpose: Induction of labor at 34 weeks of gestation is often linked to increased risk for cesarean section. Recently, the PPROMT trial demonstrated a higher cesarean section rate when labor was induced for preterm premature rupture of membranes (PPROM). The purpose of this study was therefore to evaluate the success rate of induction of labor for PPROM at 34 and 35 weeks of gestation in comparison with a higher gestational age., Material and Methods: In this historic cohort study, cases with labor inductions for PPROM ≥ 34 weeks of gestation were included. Induction of labor at 34 and 35 weeks of gestation (group 1) were compared with those performed at 36 weeks (group 2) and 37 weeks (group 3). Induction of labor was started 12 to 24 hours after (preterm) premature rupture of membranes. Antibiotics were given routinely. The primary outcome was the rate of cesarean section., Results: There were significantly more cesarean sections in group 3 in comparison with group 2 (7 vs. 25%, p=0.0136). However, univariable and multiple logistic regression analysis of the primary outcome measure showed that there was no impact of the group affiliation on cesarean section rate. Significant parameters influencing the risk of cesarean section were body mass index and Bishop score., Conclusion: Induction of labor for PPROM at 34 weeks of gestation is not associated with an increased rate of cesarean section., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Introduction: Maintenance tocolysis, mostly defined as the continuation of tocolytic treatment beyond 48 h, remains a matter of debate. There is no sufficient evidence from randomized controlled trials, that maintenance tocolysis is able to prolong pregnancy significantly and to reduce severe neonatal morbidity and mortality. Hence, it is not recommended in current guidelines. On the contrary, maintenance tocolysis is commonly used in clinical practice and subject of current clinical-scientific investigations., Tocolytics for Maintenance Treatment: None of the conventional tocolytics (beta-sympathomimetics, calcium-channel blockers, magnesium, cyclooxygenase inhibitors, and oxytocin receptor antagonists) have proven to be appropriate for maintenance treatment. Progesterone and 17-α-hydroxyprogesterone caproate have shown promising results in low-quality randomized trials, but not in high-quality studies., Discussion: Basically, the value of studies regarding maintenance tocolysis is limited by a considerable heterogeneity, its mostly low quality, significant differences in methodology as well as the inadequate statistical power due to the small number of women studied. So far, maintenance tocolysis is a case-by-case decision outweighing the benefits and harms of tocolytic treatment.

Objective: To evaluate the association of short-term variation (STV) and Doppler parameters with adverse perinatal outcome in small-for-gestational-age (SGA) fetuses at term., Methods: In this retrospective single-center study 97 patients with singleton SGA fetuses at term (≥ 37 + 0 weeks' gestation) were examined. Inclusion criteria were a birth weight < 10th centile, cephalic presentation and planned vaginal birth. Only cases with available Doppler measurements of umbilical artery (UA) and middle cerebral artery (MCA) with calculated cerebroplacental ratio (CPR) in combination with a computerized CTG (cCTG) and STV 72 h prior to delivery were eligible for analysis. Pulsatility indices (PI) were converted into multiples of median (MoM), adjusted for gestational age. The association between Doppler indices and STV values with mode of delivery [secondary cesarean delivery (CD), operative vaginal delivery (OVD), as well as secondary CD and OVD due to fetal distress] and neonatal outcome [UA blood pH ≤ 7.15 and the need of admission to the neonatal intensive care unit (NICU)] was analyzed using logistic regression analysis., Results: There was a significant association between UA PI MoM and the rate of CD. CD due to fetal distress, OVD and OVD due to fetal distress did not show a correlation with the evaluated Doppler parameters. Furthermore, we did not find an association between low UA birth pH and Doppler parameters while neonates with the need of admission to NICU had significant higher UA PI MoM and significant lower MCA PI MoM and CPR MoM. Regarding STV, a significant effect of low STV on NICU admission was found while none of the other assessed outcome parameters were significantly associated with STV., Conclusion: STV and Doppler parameters in SGA fetuses at term are significantly associated to the rate of NICU admission.

Objective: To evaluate the efficacy of induction of labour in obese women using sequential double-balloon catheter and oral misoprostol in comparison with oral misoprostol alone., Study Design: In this cohort study, 400 pregnant women with BMI higher than 35 kg/m2 undergoing labour induction at term were included. Induction of labour with a double-balloon catheter and, if necessary, sequential oral misoprostol (n = 216) was compared to oral misoprostol alone (n = 184). The primary outcome measure was the caesarean section rate. Secondary outcome parameters were, among others, the induction-to-delivery-interval, the rate of vaginal delivery within 24 and 48 h as well as fetal outcome parameters., Results: The caesarean section rate was significantly lower in the group with sequential use of double-balloon catheter and oral misoprostol (27.6% versus 37.5%, p = 0.0345). After stratification for parity this reduction was seen especially in nulliparous (38.6% versus 56.9%, p = 0.0039). The rate of abnormal CTG was significantly lower as well (19.9% versus 30.4%, p = 0.0150), particularly in nulliparous (25.9% versus 40.4%, p = 0.0138). Uni- and multivariable analyzes showed that the caesarean section rate was significantly influenced by the method of induction of labour (p = 0.0026), parity (p < 0.0001) and Bishop score (p = 0.0425)., Conclusion: In obese women, induction of labour with sequential use of double-balloon catheter and oral misoprostol is associated with significantly more normal vaginal deliveries and less caesarean sections.

Objective:  To evaluate the association of sonographic fetal biometry (sonographic head circumference (soHC), sonographic abdominal circumference (soAC), estimated fetal weight (EFW)) with mode of delivery and adverse perinatal outcome., Methods:  Singleton pregnancies with a gestational age ≥ 37 weeks and an ultrasound examination with complete biometric parameters within 7 days before delivery were retrospectively included. The association between soHC, soAC, EFW and fetal (5-min Apgar < 7, pH < 7.1, neonatal intensive care unit (NICU) admission, shoulder dystocia (ShD)) and maternal (obstetric intervention (OI): caesarean or vaginal operative delivery, obstetric anal sphincter injury syndrome (OASIS), postpartum hemorrhage (pph)) adverse outcomes were analyzed using univariate and multivariate logistic regression analyses., Results:  12 396 women were included and 3479 (28.07 %) needed an OI. Multivariate analyses demonstrated significant contributions for the prediction of OI by soHC and soAC, whereas EFW did not reach significance. The highest OR was shown for soHC (1087, p < 0.001). ShD occurred in 73 (0.59 %) of the deliveries. Multivariate analyses showed that significant contributions for the prediction of ShD were provided only by soAC (OR 1460, p = 0.007). For the other maternal and neonatal adverse outcome parameters, no significant association with the biometric measurements could be demonstrated in the multivariate analyses. The overall detection rates for the prediction of adverse perinatal outcome by the different biometric parameters and EFW were poor., Conclusion:  Obstetric management decisions should not be based solely on measurements of biometric parameters or EFW., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: Colposcopy-directed biopsy is a cornerstone method for diagnosing cervical intraepithelial neoplasia. The aim of this study was to evaluate the accuracy of colposcopy-directed biopsy in comparison with definitive surgery., Methods: The accuracy of colposcopy-directed biopsy was compared with the final histology in relation to different types of transformation zone (TZ), the patient's age, and the examiner's level of training., Results: The overall accuracy of biopsy in comparison with definitive surgery was 71.9% for all entities-benign lesions, low-grade squamous intraepithelial lesions, high-grade squamous intraepithelial lesions (HSILs), and cervical carcinoma-with an underdiagnosis rate of 11.8% and an overdiagnosis rate of 16.5%. The accuracy for detecting HSIL was 88% (401/455), with an underdiagnosis rate of 10.5% and overdiagnosis rate of 1.3%. The accuracy rates for detecting HSIL in women with TZ 1, TZ 2, or TZ 3 were 92.2, 90.5, and 76.5%, respectively. The accuracy rates for detecting HSIL in the different age groups were 93.1% (age 0-34), 83.6% (age 34-55), and 80% (age 55 or older)., Conclusions: A combination of the colposcopic findings, cytology, human papillomavirus testing, and colposcopy-directed biopsy is necessary for the correct diagnosis of HSIL. The accuracy rate depends on the TZ and the patient's age. The examiner's level of training does not have any substantial influence on the accuracy.

Purpose: To evaluate the influence of gestational age on induction of labour in nulliparous women., Material and Methods: This historical cohort study analyzed inductions of labour in low-risk nulliparous women. Therefore the collective was divided into 3 groups (group 1: 40+0 to 40+6 weeks of gestation, group 2: 41+0 to 41+3 weeks of gestation, group 3:>41+3 weeks of gestation). The primary outcome measure was the caesarean section rate., Results: The caesarean section rate was not different among the 3 groups (p=0.4036). The impact of gestational age on induction in multivariable analysis was not significant. Maternal BMI (p<0.0001), maternal age (p=0.0005) and birth weight (p=0.0151) had an influence on the caesarean section rate. Regarding the secondary outcome measures such as umbilical cord blood pH, Apgar score and postpartal neonatal intensive care unit admission, no statistically significant differences have been revealed among the groups., Conclusion: Timing of labour induction after 40+0 weeks of gestation in a low-risk population of nulliparous women did not influence the caesarean section rate., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: To evaluate the association of short-term variation (STV) and Doppler parameters with adverse perinatal outcome in low-risk fetuses at term., Methods: This was a retrospective study of 1008 appropriate-for-gestational age (AGA) term fetuses. Doppler measurements [umbilical artery (UA), middle cerebral artery (MCA), and cerebroplacental ratio (CPR)] and computerized CTG (cCTG) with STV analysis were performed prior to active labor (≤ 4 cm cervical dilatation) within 72 h of delivery. The association between Doppler indices and STV values with adverse perinatal outcome was analyzed using univariate regression analysis., Results: No significant association between Doppler parameters and the need for secondary cesarean delivery (CD) or operative vaginal delivery (OVD) was shown. Regarding fetuses delivered by CD due to fetal distress, regression analyzes revealed significantly higher UA PI MoM. However, the differences in MCA PI MoM and CPR MoM were not statistically significant. Fetuses with the need for emergency CD showed significantly higher UA PI MoM, lower MCA PI MoM and lower CPR MoM. Neonates with a 5-min Apgar score < 7 had significantly lower MCA PI MoM and neonatal acidosis (UA pH ≤ 7.10) showed a significant association with UA PI MoM. None of the assessed outcome parameters were significantly associated to STV., Conclusion: Doppler indices assessed close to delivery in low-risk fetuses at term show a moderate association with adverse outcome parameters, whereas STV does not appear to predict poor perinatal outcome in this group of fetuses.

Purpose: The aim of this study was to evaluate maternal, prenatal, perinatal, and postpartum parameters as risk factors for the later development of an attention deficit hyperactivity disorder (ADHD) in the child., Methods: Women who had given birth at Erlangen University Hospital between 1996 and 1999 were sent a questionnaire in 2009. The results of the questionnaire were correlated with the prospectively collected data for the births in 1996-1999., Results: A total of 573 mother and child pairs were analyzed. Forty-four of the mothers reported that their child had ADHD (7.7%). No significant associations were found for the following parameters: mother's age; mother's educational level; number of the pregnancy; maternal weight before and at the end of pregnancy; mother's height; alcohol consumption during pregnancy; mode of delivery; gestational week; birthweight; umbilical artery blood values; Apgar score at 5 and 10 min; or breastfeeding. The parameters of smoking in pregnancy and an Apgar score lower than 7 after 1 min were significantly associated with a risk for later development of ADHD., Conclusions: This analysis of maternal, prenatal, perinatal, and postnatal parameters found that smoking in pregnancy and a low Apgar score 1 min after birth are associated with a significantly greater risk for the development of ADHD. Beyond the question of the causal mechanism involved, this is a relevant finding, since smoking during pregnancy is a preventable risk factor.

Objective of this randomized-controlled multicenter-trial was to determine whether the amniotic fluid index (AFI) or the single deepest vertical pocket (SDP) technique for estimating amniotic fluid volume is superior for predicting adverse perinatal outcome. Pregnant women at term were randomized in AFI or SDP group for assessing amniotic fluid at four unversitary hospitals. These two groups were not different with regards to primary outcome parameter (rate of postpartum admission to NICU), but concerning secondary outcome parameters: there were significantly more cases with the diagnosis oligohydramnios (9,8 vs. 2.2%), more induction of labour for oligohydrmanios (12.7 vs. 3.6%) and more abnormal CTG (32.3 vs. 26.2%) in the AFI group. None of the methods were superior to predict adverse perinatal outcome. However, the probability to diagnose oligohydramnios and to induce labour for oligohydramnios was higher when AFI technique was used., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background Our aim was to evaluate the prognostic value of magnetic resonance imaging (MRI)-based ratio of fetal lung volume (FLV) to fetal body volume (FBV) as a marker for development of chronic lung disease (CLD) in fetuses with congenital diaphragmatic hernia (CDH). Patients and Methods FLV and FBV were measured and the individual FLV/FBV ratio was calculated in 132 fetuses. Diagnosis of CLD was established following prespecified criteria and graded into mild/moderate/severe if present. Logistic regression analysis was used to calculate the probability of postnatal development of CLD in dependence of the FLV/FBV ratio. Receiver operating characteristic curves were analysed by calculating the area under the curve to evaluate the prognostic accuracy of this marker. Results 61 of 132 fetuses developed CLD (46.21%). The FLV/FBV ratio was significantly lower in fetuses with CLD (p=0.0008; AUC 0.743). Development of CLD was significantly associated with thoracic herniation of liver parenchyma (p<0.0001), requirement of extracorporal membrane oxygenation (ECMO) (p<0.0001) and gestational age at delivery (p=0.0052). Conclusion The MRI-based ratio of FLV to FBV is a highly valuable prenatal parameter for development of CLD. The ratio is helpful for early therapeutic decisions by estimating the probability to develop CLD. Perinatally, gestational age at delivery and ECMO requirement are useful additional parameters to further improve prediction of CLD., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: To evaluate the influence of examiner experience on the accuracy of sonographic weight estimation and to further analyze examiners' individual learning curves., Methods: In this multicenter study, 4613 sonographic weight estimations performed by 18 examiners at the beginning of their ultrasound training were included. To assess the effect of experience on the accuracy of weight estimation, a multivariable mixed regression model analysis was performed, with percentage error and absolute percentage error as outcome variables and the examiner, the examiner's experience (number of examinations), birth weight, gestational age, scan-to-delivery interval, and maternal body mass index as fixed effects and the perinatal center as random intercepts. To further analyze the individual learning curves of the examiners, the cumulative summation technique was used., Results: Regression analyses showed a significant influence of the number of examinations on the accuracy of sonographic weight estimation after adjustment for the above-mentioned parameters (P < .001). A typical learning curve with improving accuracy was found until approximately 200 examinations. Between 200 and 300 examinations, the diagnostic performance started to deteriorate again, with a continuous decrease until the end of the study period. Cumulative summation charts representing individual learning curves varied greatly between different examiners., Conclusions: These findings indicate the great importance of continuous quality control systems in sonographic weight estimation., (© 2016 by the American Institute of Ultrasound in Medicine.)

Purpose: To assess the effects of mechanical dilatation of the cervix during cesarean section on postoperative morbidity., Methods: A total of 447 women with elective cesarean section were included in the Dondi trial (Dilatation or no dilatation of the cervix during cesarean section). The primary outcome measure of this randomized controlled trial was postpartum hemorrhage (PPH) within 6 weeks. Infectious morbidity (puerperal fever, endometritis, wound infection, and urinary tract infection), blood loss (need for blood transfusion or change in hemoglobin levels), and operating time were also evaluated., Results: The rate of PPH within 6 weeks was not different between the two groups [dilatation group: 5 (2.4 %), no dilatation group: 3 (1.2 %), p = 0.479]. Infectious morbidity, blood loss, and operating time were not diverse as well. The only significant difference between the two groups was the rate of retained products of conception with fewer cases after cervical dilatation (0 versus 6.2 %, p < 0.001)., Conclusions: Dilatation of the cervix during cesarean section compared with no dilatation of the cervix did not influence the risk of postpartum hemorrhage. However, there were fewer cases with retained products of conception after dilatation.

Objective: To evaluate the efficacy of induction of labour using a double-balloon catheter and, if necessary, sequential oral misoprostol without delay after removal of the catheter, in comparison with oral misoprostol alone., Study Design: This retrospective cohort study included women undergoing induction of labour with oral misoprostol or double-balloon catheter with sequential oral misoprostol in singleton pregnancies at term. The catheter was placed in the evening and removed when there was no onset of labour within 12h. Then oral misoprostol was started within 3h. Primary outcome measure was the caesarean section rate., Results: There were 13,082 deliveries during the study period with 3466 labour inductions out of which 1032 were eligible and analysed. The caesarean section rate was significantly lower in the double-balloon catheter group (26.1% vs. 17.3, p=0.021). Furthermore, in the combination group, the induction-to-delivery interval was shorter (median values 1144 vs. 1365min, p=0.001) and there were more deliveries within 24h (51.9 vs. 64.7%, p=0.003) and 48h (87.4 vs. 95.8%, p=0.002). When stratifying for parity, there were less caesarean sections in the combination group (37.2% vs. 24.2%, p=0.015) in nulliparous women, too. In both, nulliparous and parous women, the induction-to-delivery interval was shorter (1742 vs. 1400min, 0.005; 1020 vs. 912min, p=0.018). Especially in parous women, the rates of delivery within 24h (62.6% vs. 79.0%, p=0.007) and 48h (88.6% vs. 99.0%, p=0.007) were higher in the combination group., Conclusion: Double-balloon catheter and sequential oral misoprostol without long delay in absent onset of labour after removal of the catheter resulted in less caesarean section and shorter induction-to-delivery interval in comparison with oral misoprostol alone., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

To systematically review the application of balloon catheters for cervical ripening and labor induction at term after previous cesarean section. All pregnancies at term with previous cesarean section were included when cervical ripening or labor induction was conducted with balloon catheters. MEDLINE, Cochrane database and bibliography of identified articles were searched for English language studies. Reviews and meta-analysis, randomized and non-randomized controlled trials, prospective and retrospective cohort studies as well as case-control studies were considered. A total of 48 potentially relevant studies were identified. The title and abstract were screened for eligibility and 32 articles were excluded. The remaining 16 publications included 1447 women (single-balloon catheter: n=1329, double-balloon catheter: n=118). There were no randomized controlled trials. Most of the trials were retrospective studies (n=10). The rate of uterine rupture after labor induction was low (n=18, 1.2%). Meta-analysis of studies comparing the risk of uterine rupture between labor induction and spontaneous onset of labor found a higher risk after induction (OR 2.45, 95%CI 1.34-4.47, NNH 186). The average rate of oxytocin application was 68.4%, and vaginal birth was achieved in 56.4%. The risk for cesarean delivery was higher when labor was induced (OR 2.63, 95%CI 2.24-3.10). Data on balloon catheters for labor induction after previous cesarean section are limited by small sample size and retrospective analyses. The present data show a moderately increased risk for uterine rupture (OR=2.45) compared to spontaneous onset of labor. However, for evidence based recommendations much more well-conducted trials are needed., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objective: The purpose of this study is to compare the observed-to-expected MRI fetal lung volume and the observed-to-expected ultrasound lung-to-head ratio intraindividually for prediction of survival, the need for extracorporeal membrane oxygenation (ECMO) therapy, and the development of chronic lung disease (CLD) at different times of gestation (< 28, 28-32, and > 32 weeks) in fetuses with congenital diaphragmatic hernia (CDH), and to analyze the intraindividual correlation of observed-to-expected MRI fetal lung volume and observed-to-expected ultrasound lung-to-head ratio., Materials and Methods: Two hundred one fetuses were included in our study. Observed-to-expected MRI fetal lung volume and observed-to-expected ultrasound lung-to-head ratio were calculated for 270 MRI and ultrasound examinations performed within 72 hours of each other. The prognostic accuracy of observed-to-expected MRI fetal lung volume and observed-to-expected ultrasound lung-to-head ratio was assessed by performing ROC analysis. Correlation was determined using linear regression analysis., Results: The results revealed statistically significant differences between the observed-to-expected MRI fetal lung volume and observed-to-expected ultrasound lung-to-head ratio for the prediction of survival, the need for ECMO therapy, and the development of CLD in fetuses with left-sided CDH (p ≤ 0.0444), with the highest prognostic accuracy for survival (AUC = 0.863). Observed-to-expected MRI fetal lung volume and observed-to-expected ultrasound lung-to-head ratio correlated statistically significantly (p < 0.0001) for left-sided CDH with correlation coefficients (r) of 0.71, 0.71, and 0.56 for early, intermediate, and late times of gestation, respectively. The correlation was not statistically significant at any time for right-sided CDH (p ≥ 0.3947; r ≤ 0.26)., Conclusion: Observed-to-expected MRI fetal lung volume and observed-to-expected ultrasound lung-to-head ratio are valuable prognostic parameters for prenatal prediction of survival, the need for ECMO therapy, and the development of CLD in fetuses with left-sided CDH at all times of gestation. Observed-to-expected MRI fetal lung volume and observed-to-expected ultrasound lung-to-head ratio correlate statistically significantly for left-sided CDH, and the correlation is best before 32 weeks' gestation, but they do not correlate statistically significantly for right-sided CDH.

Purpose: To evaluate the efficacy of inducing labor using a double-balloon catheter and vaginal prostaglandin E2 (PGE2) sequentially, in comparison with vaginal PGE2 alone after previous cesarean section., Methods: A total of 264 pregnant women with previous cesarean section undergoing labor induction at term were included in this prospective multicentre cohort study. Induction of labor was performed either by vaginal PGE2 gel or double-balloon catheter followed by vaginal PGE2. The primary outcome measure was the cesarean section rate., Results: The cesarean section rate was 37 % without any statistically significant difference between the two groups (PGE2: n = 41, 37 % vs. balloon catheter/PGE2: n = 41, 42 %; P = 0.438). The median (range) number of applications of PGE2 [2 (1-10) versus 1 (0-8), P < 0.001] and the total amount of PGE2 used in median (range) mg [2 (1-15) vs. 1 (0-14), P = 0.001] was less in the balloon catheter/PGE2 group. Factors significantly increasing risk for cesarean section were "no previous vaginal delivery" (OR 5.391; CI 2.671-10.882) and "no oxytocin augmentation during childbirth" (OR 2.119; CI 1.215-3.695)., Conclusions: The sequential application of double-balloon catheter and vaginal PGE2 is as effective as the sole use of vaginal PGE2 with less applications and total amount of PGE2.

Gastrokines (GKNs) were originally described as stomach-specific tumor suppressor genes. Recently, we identified GKN1 in extravillous trophoblasts (EVT) of human placenta. GKN1 treatment reduced the migration of the trophoblast cell line JEG-3. GKN2 is known to inhibit the proliferation, migration and invasion of gastric cancer cells and may interact with GKN1. Recently, GKN2 was detected in the placental yolk sac of mice. We therefore aimed to further characterize placental GKN2 expression. By immunohistochemistry, healthy first-trimester placenta showed ubiquitous staining for GKN2 at its early gestational stage. At later gestational stages, a more differentiated expression pattern in EVT and villous cytotrophoblasts became evident. In healthy third-trimester placenta, only EVT retained strong GKN2 immunoreactivity. In contrast, HELLP placentas showed a tendency of increased levels of GKN2 expression with a more prominent GKN2 staining in their syncytiotrophoblast. Choriocarcinoma cell lines did not express GKN2. Besides its trophoblastic expression, we found human GKN2 in fibrotic villi, in amniotic membrane and umbilical cord. GKN2 co-localized with smooth muscle actin in villous myofibroblasts and with HLA-G and GKN1 in EVT. In the rodent placenta, GKN2 was specifically located in the spongiotrophoblast layer. Thus, the gestational age-dependent and compartment-specific expression pattern of GKN2 points to a role for placental development. The syncytial expression of GKN2 in HELLP placentas might represent a reduced state of functional differentiation of the syncytiotrophoblast. Moreover, the specific GKN2 expression in the rodent spongiotrophoblast layer (equivalent to human EVT) might suggest an important role in EVT physiology.

Aim: The aim of the present study was to provide information for better obstetric counselling by analyzing the impact of fetal birth weight on the caesarean section rate and fetal outcome after induction of labor., Materials and Methods: In this retrospective study from January 2010 to December 2013, 1,474 singleton deliveries with labor induction at or greater than 37 gestational weeks were analyzed for their impact of fetal birth weight on delivery outcome. The normal birth weight group was defined as 2,500 g to less than 4,000 g. For comparison, further birth weight groups were defined as: group 1 <2,500 g, group 2 4,000 to <4,250 g; group 3 ≥4,250 g. The primary outcome was the caesarean section rate; secondary outcome measures were fetal complications monitored by pH and base excess (BE) of the umbilical cord artery, Apgar score after 5 min (Apgar-5) and postpartum transfer to the Neonatal Care Unit. The set of controlling variables included maternal body mass index and age, gestational age, neonatal sex, maternal diabetes, maternal hypertension disorder, parity and method of induction of labor., Results: Second-stage caesarean section is significantly more likely when fetal birth weight is below 2,500 g (42.9% vs. 24.2% in the normal birth weight group, odds ratio=3.11, 95% confidence interval=1.48-6.51, p=0.003). A birth weight of 4,000 g or more did not have a significant influence on the caesarean section rate. Only the mean Apgar-5 for group 1 was significantly lower (p=0.044). The non-parametric tests and regression analyzes of pH and BE of the umbilical cord and of the Apgar-5 for adverse fetal outcome (pH<7.05, BE<-12 or Apgar-5 <7) showed no significant differences in the three birth weight groups when compared to the normal group. Neonates were significantly more often transferred to the Neonatal Care Unit after delivery when birth weight was below 2,500 g (odds ratio=9.68, 95% confidence interval=4.33-21.65, p<0.001) or above 4,250 g (odds ratio=2.68, 95% confidence interval=1.34-5.36, p=0.005)., Conclusion: Although a fetal birth weight of under 2500 g and a birth weight over 4,250 g are associated with some risks, there is no general contraindication against performing induction of labor in regards to fetal birth weight., (Copyright © 2015 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)

Purpose: Aim of this prospective investigation was to assess pre-eclampsia by bioelectrical impedance analysis (BIA)., Methods: A total of 22 pre-eclamptic as well as matched (patients' age, gestational age, parity, gravidity) healthy pregnant women underwent whole body BIA on admission and then, pre-eclamptic patients, every 2 days until childbirth. For all measured BIA single values and their corresponding reference value mean, standard deviation, minimum and maximum were calculated to compare pre-eclamptic women with corresponding reference values. Furthermore a paired t test and an ANOVA of repeated measurements were performed to detect differences of intraindividual measurements. Subsequently an analysis of variance was accomplished to analyse general changes in the course of time of investigated patients, who were measured more than once., Results: Except for the phase angle, BIA parameters of pre-eclamptic women compared to corresponding reference values were significantly different, suggesting an increase of total body water in pre-eclampsia. Repeated measurements did not reveal statistically significant intra- or interindividual differences in the course of time., Conclusion: Bioelectrical impedance analysis allows differentiating healthy from pre-eclamptic women. Further investigations are needed to analyse if BIA is capable to serve as a prognostic diagnostic tool in the detection of deterioration of pre-eclampsia.

Objective: Accurate measurement of fetal head biometry is important for fetal weight estimation (FWE) and is therefore an important prognostic parameter for neonatal morbidity and mortality and a valuable tool for determining the further obstetric management. Measurement of the head circumference (HC) in particular is employed in many commonly used weight equations. The aim of the present study was to find the most accurate method to measure head circumference for fetal weight estimation., Study Design: This prospective study included 481 term pregnancies. Inclusion criteria were a singleton pregnancy and ultrasound examination with complete fetal biometric parameters within 3 days of delivery, and an absence of structural or chromosomal malformations. Different methods were used for ultrasound measurement of the HC (ellipse-traced, ellipse-calculated, and circle-calculated). As a reference method, HC was also determined using a measuring tape immediately after birth. FWE was carried out with Hadlock formulas, including either HC or biparietal diameter (BPD), and differences were compared using percentage error (PE), absolute percentage error (APE), limits of agreement (LOA), and cumulative distribution., Results: The ellipse-traced method showed the best results for FWE among all of the ultrasound methods assessed. It had the lowest median APE and the narrowest LOA. With regard to the cumulative distribution, it included the largest number of cases at a discrepancy level of ±10%. The accuracy of BPD was similar to that of the ellipse-traced method when it was used instead of HC for weight estimation., Conclusion: Differences between the three techniques for calculating HC were small but significant. For clinical use, the ellipse-traced method should be recommended. However, when BPD is used instead of HC for FWE, the accuracy is similar to that of the ellipse-traced method. The BPD might therefore be a good alternative to head measurements in estimating fetal weight., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objective: The objective of our study was to evaluate the prognostic accuracy of the MRI-based ratio of fetal lung volume (FLV) to fetal body volume (FBV) for predicting survival and the need for extracorporeal membrane oxygenation (ECMO) therapy in fetuses with congenital diaphragmatic hernia (CDH)., Materials and Methods: MRI was performed in 96 fetuses (34 females and 62 males; mean gestational age, 33 ± 5 [SD] weeks; range, 23-39 weeks) with CDH and 44 healthy control subjects. FLV and FBV were measured for each fetus by one of three investigators, and we calculated the FLV/FBV ratio. Additionally, a subgroup analysis of growth-restricted fetuses was performed. Logistic regression analysis was used to model the dependence of survival and ECMO requirement on the FLV/FBV ratio. Prognostic accuracy was evaluated by applying the area under the curve (AUC)., Results: Seventy-eight of the 96 (81%) fetuses survived and 35 (36%) neonates needed ECMO therapy. The FLV/FBV ratio was significantly higher in fetuses who survived (p < 0.0001; AUC = 0.829). Neonates who received ECMO therapy showed a significantly lower prenatal FLV/FBV ratio (p = 0.0001; AUC = 0.811) than neonates who did not need ECMO therapy. A subgroup analysis (n = 13) showed a trend toward a higher FLV/FBV ratio of survivors in comparison with nonsurvivors (p = 0.065; AUC = 0.875)., Conclusion: In our study, the MRI-based FLV/FBV ratio was able to predict neonatal survival and ECMO requirement in children with CDH with high accuracy. Unlike other prognostic parameters, FLV/FBV ratio is independent of a reference to a control group and may enhance prognostic accuracy particularly in growth-restricted neonatal patients.

Objective: To investigate individual changes in fetal lung volume (FLV) in fetuses with isolated congenital diaphragmatic hernia (CDH) and to calculate weekly growth rates of the FLV using serial MR examinations during pregnancy., Methods: MR-FLV was measured in 89 fetuses with CDH. All fetuses received two MRIs. A mean weekly growth rate of the FLV was determined for each fetus and compared with the growth rate of healthy fetuses., Results: Mean observed-to-expected MR-FLV (o/e MR-FLV) measured at the first MRI was 33.3 ± 12.2% and 29.5 ± 10.9% at the second MRI. In 61% of all fetuses (54/89) the o/e MR-FLV decreased during pregnancy, 26% (23/89) showed an increase in the o/e MR-FLV and 13 % (12/89) had stable values. First and last o/e MR-FLV values were significantly associated with mortality and neonatal extracorporeal membrane oxygenation (ECMO) requirement with a higher prognostic accuracy of MR-FLV measurements near delivery. Patients with CDH had lower weekly lung growth rates than healthy fetuses. There was a significant difference in the mean weekly growth rate between survivors and non-survivors and patients with and without ECMO requirement., Conclusion: Individual development of FLV in patients with CDH during pregnancy is extremely variable. Follow-up MR-FLV measurements are advisable before deciding upon pre- and postnatal therapeutic options., Key Points: • Lung development in congenital diaphragmatic hernia (CDH) during pregnancy is extremely variable. • MRI demonstrates that lung growth rate is reduced in fetuses with CDH. • The final observed-to-expected fetal lung volume provides the best prognostic information. • Follow-up measurements are advisable before deciding upon therapeutic options.

Objective: The aim of this study was to provide information for better obstetric counseling by analyzing the impact of fetal birth weight (BW) on fetal and maternal outcome when vaginal birth is planned in a university hospital., Methods: In this retrospective study from January 1st 2006 to December 31st 2011, 5,177 singleton, alive deliveries at or >37 gestational weeks were assessed with regard to the fetal BW when vaginal birth was attempted. The normal BW group was defined as ≥2,500 <4,500 g. For comparison, further BW groups were defined as: group 1 <2,500 g, group 2 ≥4,000 <4,250 g, group 3 ≥4,250 <4,500 g and group 4 ≥4,500 g. Outcome criteria were mode of delivery and perineal lacerations as well as the pH and base excess of the umbilical cord artery, the Apgar score after 5 min and occurrence of shoulder dystocia. The set of controlling variables included maternal height, maternal weight, maternal age, gestational age, neonatal sex and parity., Results: Second stage caesarean section is significantly more likely when fetal BW is under 2,500 g (30.7 vs. 15.5 % in the normal BW group, odds ratio 3.01, 95 % confidence interval 2.03-4.46, p value < 0.001). Shoulder dystocia occurred significantly more often when fetal BW was over 4,250 g (group 3: odds ratio 4.95, 95 % confidence interval 1.74-14.10, p value 0.003, group 4: odds ratio 19.96, 95 % confidence interval 7.61-52.38, p value < 0.001). The risk of an Apgar score after 5 min below 7 increased, when fetal BW was below 2,500 g (odds ratio 9.28, 95 % confidence interval 3.15-27.35, p value < 0.001) or above 4,500 g (odds ratio 5.65, 95 % confidence interval 1.22-26.24, p value 0.027). All groups were comparable to the normal group regarding pH and base excess of the umbilical cord artery as well as the risk for severe (third and fourth degree) perineal lacerations., Conclusion: Although a fetal birth weight under 2,500 g and a birth weight over 4,250 g are associated with some risks, there is no general contraindication for an attempt to deliver vaginally in a university hospital with regard to fetal birth weight.

Aim: To investigate the validity and reproducibility of touch imprint cytology (TIC) of core needle biopsies (CNBs) in the assessment of conspicuous breast findings., Materials and Methods: One hundred and fifty-eight conspicuous breast findings were assessed by CNB during a two-year period in this prospective study. TIC of the CNBs was used for cytological analysis. The performance of this technique was evaluated by comparing the results with the histology of the CNB, and in cases of a subsequent surgery, with the final histology. In addition, inter-observer reproducibility was analyzed., Results: The inter-observer variability was very high (kappa-value of 0.8508; excluding inadequate imprints, 0.9502). Inadequate cellularity for cytological analysis was found in 11.4% (18/158) of findings. Compared with CNB histology, the sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of TIC was 99%, 100%, 100%, 94%, and 99%, respectively., Conclusion: TIC of CNB specimens of the breast may be a valid option for providing a diagnosis without delay for a histological procedure, assuming good quality of the specimen.

Aim: To generate reference values for bioelectrical impedance analysis (BIA) in a German collective of healthy pregnant women., Materials and Methods: A total of 90 women with a singleton gestation from 23+0 to 40+6 weeks of pregnancy were enrolled from April 2012 until May 2013. Each week of gestation was represented by the same number of women (n=5). Mean BIA indices were generated for all patients and according to gestational age so that three collectives <30, 30 to 35 and >35 weeks of gestation were formed. Multiple regression analysis was implemented using maternal height, weight, body-mass index, gestational age, hematocrit and abdominal circumference to generate formulae to calculate individualized reference values for resistance, reactance, phase angle, height(2)/resistance, and total body water adjusted for gestation., Results: Individualised reference values using the new formulae led to results which are more accurate than general mean values or mean values corresponding to the gestational age only., Conclusion: As far as we are aware of the present study is the first to report reference values for BIA indices in a German collective of healthy pregnant women. The new formulae generated by multiple regression analysis enabled for assessment of individualized reference values for BIA indices.

Objective: Many factors affect women's satisfaction with the experience of childbirth. Some of these are known, but most have not been fully evaluated. The influence of the mode of delivery is unclear. This study investigated the extent to which satisfaction with childbirth depends on the mode of delivery, and evaluated factors determining postpartum satisfaction., Study Design: Women with singleton pregnancies at term were included prospectively. After childbirth, all women meeting the inclusion criteria received a standardised questionnaire - the German version of Salmon's Item List (SIL-Ger) - for completion before discharge to evaluate the birth experience. The chi-squared test, Fisher's exact test, and Kruskal-Wallis test were used for statistical analysis. Univariate and multivariate linear regression analyses were used to assess associations between demographic and pregnancy-associated variables and variables influencing the perception of childbirth in the total SIL-Ger score. Univariate and multivariate binary logistic regression models were used to evaluate effects of demographic and clinical parameters on SIL-Ger scores of <70 versus SIL-Ger scores of ≥ 70. All covariates with a P value ≤ 0.10 in the univariate analysis were included in multivariate logistic regression models. All tests were two-sided, and P values<0.05 were considered statistically significant., Results: The analysis included 335 questionnaires. No differences were observed between different modes of delivery (normal 84.5 ± 14.6, primary caesarean 87.0 ± 13.5, secondary caesarean 83.2 ± 13.8, emergency caesarean 79.3 ± 7.3, operative vaginal delivery 83.9 ± 13.6; P=0.503). Multivariate analysis identified two independent factors associated with higher SIL-Ger scores: good/very good satisfaction with childbirth (P<0.001) and good/very good involvement in decision-making afterwards (P=0.005). Severe pain perception during childbirth was associated with lower SIL-Ger scores (P=0.003). Absence of a person of trust during childbirth was linked with scores<70 (P=0.005), indicating a negative experience. Good/very good satisfaction with childbirth (P<0.001) reduced the probability of a score<70., Conclusion: Mode of delivery does not directly influence women's satisfaction with childbirth. Involvement in decision-making, support during labour and effective analgesia appear to be the most important factors that improve women's birth experience., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: To compare the effectiveness of self-administered 50% nitrous oxide and conventional infiltrative anaesthesia with 1% prilocaine hydrochloride in postpartum perineal repair., Study Design: A total of 100 women were prospectively enrolled and randomised to receive either infiltrative anaesthesia or a self-administered nitrous oxide mixture (Livopan(©)) for pain relief during postpartum perineal suturing. Besides data concerning anaesthesia, characteristics of patients and labour were documented for statistical analysis. Pain experienced during perineal repair was assessed using the short form of the McGill Pain Questionnaire (SF-MPQ)., Results: Forty-eight women received nitrous oxide and 52 underwent perineal suturing after infiltrative anaesthesia. There were no statistically significant differences regarding maternal age, body mass index (BMI), duration of pregnancy and suturing time between the groups. The most frequent birth injury was second-degree perineal laceration in the study group [22/48; 46%] and episiotomy in the control group [18/52; 35%]. Pain experienced during genital tract suturing and patients' satisfaction showed no statistically significant differences between the groups. Thirty-seven women in the study group and 47 in the control group were satisfied with the anaesthesia during perineal repair and would recommend it to other parturients [37/48, 77% vs. 47/52, 90%; p=0.0699)., Conclusion: Nitrous oxide self-administration during genital tract suturing after vaginal childbirth is a satisfactory and effective alternative to infiltrative anaesthesia., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Background/aim: To analyze the influence of intraoperative cervical dilatation and curettage during elective Caesarean section (CS) on maternal morbidity., Patients and Methods: A total of 1,003 elective CS were retrospectively evaluated. Primary outcome measure was the influence of cervical dilatation and curettage on postpartum haemorrhage (PPH). Several subgroup analyses were performed and a multiple logistic regression model was used in order to identify risk factors affecting PPH., Results: Multiple pregnancy (p=0.0025) and body mass index (p=0.0251) were identified as risk factors for PPH. Curettage, cervical dilatation, prior CS, age, and duration of pregnancy were statistically not significant at a level of α=0.10. There was a significantly higher proportion of women suffering from uterine sub-involution when the cervix was dilated (p=0.0482). The operating time was significantly longer when curettage and/or dilatation were performed (p<0.0001)., Conclusion: Routine cervical dilatation and/or curettage in elective Caesarean section are not beneficial. Accomplishment of either or both of these measures led to a prolonged operating time, without improving the postoperative outcome.

Background: We investigated the influence of age on short-term complications in women undergoing intraoperative radiotherapy (IORT) for early breast cancer., Patients and Methods: We retrospectively analyzed data of 188 women who underwent IORT during breast-conserving surgery (BCS). The study group consisted of 54 patients aged 70 years or older. One hundred and thirty four patients aged less than 70 years served as the control group., Results: In both collectives, the acute toxicity was low. There were no significant differences regarding type and duration of surgery, and type of radiation treatment, comparing both collectives. The most frequent postoperative side-effects were haematoma/suggillation (13/54, 24.1% vs. 28/134, 20.9%; p=0.633). There was a significantly higher incidence of postoperative axillary haematoma in the study group (10/54, 18.5% vs. 10/134, 7.5%; p=0.026)., Conclusion: Acute toxicity after BCS with IORT in women aged 70 years and older does not seem to be higher compared to younger patients.

Objective: The purpose of the study was to investigate the ability to predict survival, need for extracorporeal membrane oxygenation (ECMO), and incidence of chronic lung disease in patients with congenital diaphragmatic hernia in the context of a classification into three different times of gestation (< 28, 28-32, and > 32 weeks) by assessing the ratio between observed and expected MRI fetal lung volume., Materials and Methods: The data analysis included 226 fetuses with congenital diaphragmatic hernia. MRI was performed at different times of gestation with a T2-weighted HASTE sequence. Receiver operating characteristic curve analysis was performed to investigate the prognostic value of assessment of the ratio between observed and expected MRI fetal lung volumes at different stages of fetal growth., Results: For all reviewed times of gestation, the ratio between observed and expected MRI fetal lung volumes had almost equivalent statistically significant differences for neonatal survival (p ≤ 0.0029), need for ECMO therapy (p ≤ 0.0195), and development of chronic lung disease (p ≤ 0.0064). Results with high prognostic accuracy for early and for medium and late times in gestation also were obtained. Receiver operating characteristic analysis showed the highest area under the curve (≥ 0.819) for neonatal survival., Conclusion: In patients with congenital diaphragmatic hernia, the relation between observed and expected MRI fetal lung volume is a valuable prognostic parameter for predicting neonatal mortality, morbidity represented by the development of chronic lung disease, and the need for ECMO therapy in early gestation (< 28 weeks) as well as later gestation with no statistically significant differences.

Aim: The aim of this investigation was to analyze the feasibility and postoperative outcome of laparoscopic supracervical hysterectomy (LASH) with and without bilateral salpingectomy., Patients and Methods: Between February and October 2012, a total of 25 patients were prospectively enrolled to undergo LASH with bilateral salpingectomy. A retrospective cohort of 25 matched patients who underwent LASH without bilateral salpingectomy at our Institution, performed by the same surgeon, served as the control collective., Results: Comparing both collectives, there were no statistically significant differences concerning overall hospital stay, duration of surgery and blood loss., Conclusion: LASH with bilateral salpingectomy is a fast and safe procedure.

Objective: A wide variety of pharmacological and mechanical methods (e.g. balloon devices) are available for inducing labour, but little information is available about the way in which women regard balloon devices. The aim of this study was to investigate women's acceptance of and satisfaction with the induction of labour by administration of oral misoprostol and the combination of that with a double-balloon device., Study Design: The study included 122 women with term pregnancies who required induction of labour between August 2009 and November 2010. They all participated in a randomized controlled trial to test different ways of inducing labour and were randomly assigned either to a 'study group' (with a combination of oral misoprostol and a double-balloon catheter) or a 'control group' (with oral misoprostol alone). After childbirth, a standardized questionnaire was given to all of the women for them to complete before discharge. In addition to assessing the induction of labour and their level of satisfaction with regard to delivery, the birth experience was objectively evaluated using the German-language version of Salmon's Item List (SIL-Ger). For statistical analysis, the chi-squared test, Fisher's exact test, the binomial test, the t-test, or the Mann-Whitney U-test for independent samples were used as appropriate. A significance level of 5% was chosen., Results: Seventy-eight questionnaires were included in the analysis. The women were not bothered either by the placement of the double-balloon device (P=0.017) or by the presence of the catheter (P=0.002). In comparison with the control group, women in the study group would consider their method in a subsequent pregnancy and would recommend it to others more often (P=0.040). The SIL-Ger score showed a positive birth experience in both groups, with a significantly better score in the study group (87.7 ± 15.8 vs 79.3 ± 17.3 in the control group; P=0.030). The multivariate analysis identified three factors influencing the SIL-Ger score: satisfaction with childbirth (P<0.001), involvement in decision-making after childbirth (P=0.041), and the method of labour induction (combination of oral misoprostol and double-balloon catheter vs oral misoprostol alone; P=0.005)., Conclusion: The women were satisfied with the induction of labour using oral misoprostol and the combination of that with a double-balloon catheter. The double-balloon catheter was accepted by the women, and surprisingly was found to have a positive impact on the birth experience., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objective: Primary aim of the study was to identify risk factors for an adverse neonatal outcome in emergency caesarean deliveries (ECD). Secondary, the influence of the decision-to-delivery interval (DDI) on neonatal outcome was evaluated., Methods: Study period of this retrospective investigation was 2001-2011, in which 336 ECD were evaluated. Main outcome measures were risk factors associated with an adverse neonatal outcome (umbilical cord arterial pH < 7.05, umbilical cord arterial base excess (BE) < -12, Apgar score at 5 min <5 and the combination of umbilical cord arterial pH < 7.0, and umbilical cord arterial BE < -12). Secondary, the influence of the DDI on neonatal outcome was assessed. These parameters were tested in univariate and multivariate analyses., Results: Prematurity (<37 + 0 weeks of gestation) and silent cardiotocography (CTG) were identified as the major risk factors for an adverse neonatal outcome. Statistical analyses of the influence of the DDI on umbilical cord arterial pH and BE as well as the Apgar score at 5 min revealed no significant results., Conclusion: Our results emphasize the necessity of attendance in a level-3 department of obstetrics in case of conceivable compromised neonatal conditions. Prematurity and silent CTG were identified as the major risk factors for an adverse neonatal outcome. As long as the DDI is under 20 min, it did not have an impact on neonatal outcome.

Aim: To evaluate the feasibility and safety of vaginal surgery for treatment of genital prolapse in overweight compared to normal weight patients aged 50 years or older., Patients and Methods: We retrospectively reviewed the perioperative data of 93 patients aged between 50 and 87 years undergoing surgery due to pelvic floor disorders. A total of 54 women had a body mass index (BMI) of 25 kg/m(2) or higher and were defined as the study collective. Thirty-nine patients undergoing similar surgical procedures during the same period of time had a BMI less than 25 kg/m(2) and served as the control group. Operating time, duration of hospital stay, intra- and postoperative complications were evaluated as comorbidities. χ(2)-test, Fisher's exact test, Student's t-test and non-parametric Mann-Whitney U-test were applied to compare the results of both collectives., Results: There were no significant differences between study and control collectives regarding time of surgery, duration of hospital stay or intra- and postoperative complications, although a significant difference was found with regard to the prevalence of pre-existing diabetes mellitus (17% in the study group, versus 5% in the control group, respectively, Fisher's exact test: p=0.04)., Conclusion: Overweight in elderly patients undergoing vaginal surgery due to pelvic floor disorders does not affect the perioperative outcome and is not a risk factor for perioperative complications.

Aim: To evaluate the influence of gender in neonates with congenital diaphragmatic hernia (CDH) on survival and to assess the necessity of extracorporeal membrane oxygenation (ECMO) therapy., Patients and Methods: All parturients with newborns suffering from CDH were included. A total of 425 infants with CDH were analyzed. The primary outcome parameters evaluated were the necessity of ECMO and the survival. Secondary outcome parameters were the mode of delivery, the arterial umbilical cord pH value, the Apgar score, and the postpartum day of death. Cases with incomplete data were excluded., Results: An analysis of the gender distribution of neonates in our study revealed that more males (n=248) than females (n=177) suffered from CDH. This represented a male versus female gender ratio of 58.4% to 41.6%, a significantly different ratio from that for neonates without CDH (p=0.003). Comparing both groups, statistical analysis showed no significant differences in mode of delivery, arterial umbilical cord blood pH, Apgar score, or CDH-relevant parameters of postpartum survival, including the need for ECMO therapy., Conclusion: CDH occurred significantly more frequently in male newborns. However, there were no significant differences in postnatal survival nor in the necessity of ECMO therapy.

Objective: To evaluate a combination of oral misoprostol (OM) and mechanical dilation of the cervix to improve efficacy in inducing labour., Study Design: This prospective, randomized study included 122 term pregnancies with an indication for induced labour. Each woman was randomly assigned to one of two groups. In the study group, a combination of OM and mechanical dilation with a double-balloon catheter for cervical ripening was used. In the control group, only OM was administered. The primary outcome measure was the rate of failure to induce labour, defined as no vaginal delivery within 48h., Results: In the study group, the rate of failure to induce labour was significantly lower in comparison with the control group (9.3% vs. 21.2%; P=0.007). The median times for inducing labour were 15.3h in the study group and 20.8h in the control group (P=0.158). There were no significant differences between the two groups with regard to other outcome parameters. As there were no failures of induced labour among women with premature rupture of membranes, the study results were also evaluated after excluding these cases. Among those women without rupture of membranes, the median times for induction were 15.8h in the study group and 32.6h in the control group (P=0.024). The rates of failure to induce labour were 10.8% vs. 28.2% (P=0.002)., Conclusion: A combination of OM and a double-balloon catheter improves the efficacy of labour induction in term pregnancies, particularly in women without premature rupture of the membranes., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objectives: The purpose of this study was to evaluate the influence of different rotation angles in assessment of the contralateral lung volume by 3-dimensional (3D) sonography in comparison to magnetic resonance imaging (MRI) in fetuses with congenital diaphragmatic hernias., Methods: A total of 126 measurements by 3D sonography and MRI were conducted in 81 patients between 18 and 39 weeks' gestation. The 3D sonographic volumes of the contralateral fetal lung were calculated by the rotational technique (virtual organ computer-aided analysis) with rotation angles of 6°, 15°, and 30°. Transverse multiplanar T2-weighted MRI was performed for the MRI measurements. To compare the accuracy of 3D sonographic volumetry using different rotation angles, MRI assessment was taken as the reference method, and percentage errors and limits of agreement were calculated for each angle., Results: Three-dimensional sonographic volume measurements showed a high correlation with MRI (6° angle, R(2) = 0.86; 15° angle, R(2) = 0.78; 30° angle, R(2) = 0.68). The mean percentage error showed no systematic error. With regard to random error, the 6° step had significantly lower values than the larger angles 30° step (R = 0.472) and the narrowest limits of agreement., Conclusions: Especially when using a small rotation angle, assessment of the contralateral fetal lung volume by 3D sonography in congenital diaphragmatic hernias is a reliable alternative to MRI.

Background: Umbilical cord blood haematopoietic stem cell donation (UCBD) has increased in recent years. While performing UCBD during caesarean section, suturing the uterotomy is delayed for a few minutes. The aim of our study was to analyse if this causes an increase in maternal blood loss., Patients and Methods: In this retrospective study, we compared pre- and postpartal haemoglobin levels of 100 patients who delivered by caesarean, either with UCBD (study group) or without UCBD (control group). P-values < or = 0.05 were regarded as significant., Results: The main clinical characteristics did not show any significant differences between the two groups. There was no significant difference of decrease in haemoglobin between the study group and the control group (p=0.747)., Conclusion: UCBD during caesarean section does not lead to increased maternal blood loss. Objections to the safety of UCBD regarding increased maternal blood loss during caesarean section can be dispelled.