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While preterm premature rupture of membranes complicates an estimated 3 % of pregnancies, rupture near the limit of fetal viability is rarer (estimated 0.04 %). This study aimed to analyze maternal and neonatal outcomes in patients with premature preterm rupture of membranes (PPROM) before 20This retrospective cohort study examined 60 patients with preterm premature rupture of membranes before 20Thirty-three patients (Range 12Anhydramnios combined with low gestational age at PPROM appear to negatively influence neonatal outcome after pre-viable preterm premature rupture of membranes. The incidence of neonatal complications decreased with increasing gestational age. Survival without long term severe morbidity is possible. Maximal therapy is an interdisciplinary decision and the patients should be counseled accordingly. Delivery in centers where potential postnatal complications including pulmonary hypoplasia, severe bronchopulmonary dysplasia and respiratory distress syndrome can be aggressively treated is recommended.

From March 3 to October 13, 2020, 27 cases with diabetes comorbidity have been recorded in the CRONOS registry (Covid-19 Related Obstetric and Neonatal Outcome Study in Germany) among 262 registered women with SARS-CoV‑2 infection during their pregnancy. Of those, 21 presented with gestational diabetes, 5 with type 2 diabetes and 1 with type 1 diabetes. About half of the women were asymptomatic and were diagnosed via general screening at hospital admission. The most common symptoms were nasal congestion, cough, tiredness, malaise and changes in smell and taste. The majority of pregnant women showed a mild to moderate course, three women were admitted to the intensive care unit and none required invasive ventilation. In the type 2 diabetes group, there were two cases with late fetal death (37 and 40 weeks of gestation) and one with a malformation, an association with diabetes being most likely. Pregnant women with diabetes mellitus represent a special subgroup; 1 in 10 women in this small cohort required intensive care monitoring due to COVID-19. In addition, this case series underscores the need for unrestricted access to pregnancy care, especially in times of pandemic, for optimal perinatal outcome.

Vom 03.03.–13.10.2020 wurden im CRONOS-Register („COVID-19 Related Obstetric and Neonatal Outcome Study in Germany“) 27 Falle mit der Komorbiditat Diabetes unter 262 registrierten Schwangeren mit intragravide gesicherter SARS-CoV-2(„severe acute respiratory syndrome coronavirus type 2“)-Infektion erfasst. Von diesen hatten 21 Gestationsdiabetes, 5 Typ-2-Diabetes und 1 Typ-1-Diabetes. Etwa die Halfte der Frauen war asymptomatisch und wurde durch ein generelles SARS-CoV-2-Screening bei Krankenhausaufnahme entdeckt. Die haufigsten Symptome waren Schnupfen, Husten, Mudigkeit, Malaise und verandertes Geruchs- und Geschmacksempfinden. Die Mehrzahl der Schwangeren zeigte einen milden bis moderaten Verlauf, 3 Frauen wurden auf die Intensivstation aufgenommen; keine musste invasiv beatmet werden. In der Gruppe mit Typ-2-Diabetes traten 2 Falle mit spatem intrauterinem Fruchttod (37 und 40 Schwangerschaftswochen [SSW]) und 1 Fall mit einer Fehlbildung auf, wobei eine Assoziation mit dem Diabetes am wahrscheinlichsten ist. Schwangere mit Diabetes mellitus stellen eine besonderes zu berucksichtigende Subgruppe dar; 1 von 10 Frauen in dieser kleinen Kohorte bedurfte einer intensivmedizinischen Uberwachung aufgrund COVID-19. Daruber hinaus unterstreicht diese Fallserie die Notwendigkeit eines uneingeschrankten Zugangs zu einer intensiven Schwangerenbetreuung fur ein optimales perinatales Outcome insbesondere in Zeiten der Pandemie.

Purpose Obstetric anal sphincter injuries (OASIS) increase the risk for pelvic floor dysfunctions. The goal of this study was to examine the long-term outcomes after OASIS on pelvic floor functions and quality of life. Material and methods Between 2005 and 2013, 424 women had an OASIS at the Women University Hospital Ulm. Out of these 71 women completed the German pelvic floor questionnaire, which includes questions regarding prolapse symptoms as well as bladder, bowel and sexual function. In addition, 64 women were physically examined, including a speculum examination to evaluate the degree of prolapse, a cough test to evaluate urinary stress incontinence (SI) and an evaluation of both pelvic floor sphincter (modified Oxford score) and anal sphincter contraction. Results A high rate of pelvic floor disorders after OASIS was found, as 74.6% of women reported SI, 64.8% flatus incontinence and 18.3% stool incontinence, respectively. However, only few women stated a substantial negative impact on quality of life. The clinical examination showed that a positive cough test, a weak anal sphincter tone and a diagnosed prolapse correlated with the results of the self-reported questionnaire. Conclusion On one hand, OASIS has an influence on pelvic floor function going along with lots of complaints, while on the other hand, it still seems to be a taboo topic, as none of the participants spoke about the complaints after OASIS with a doctor. Therefore, the gynecologist should actively address these issues and offer therapy options for the women with persisting problems.

Zusammenfassung Ziel Die Geburtseinleitung in frühen Schwangerschaftswochen ab 34+0 SSW wird häufig in Verbindung mit einem erhöhten Risiko für einen Kaiserschnitt gebracht. Zuletzt wies der PPROMT Trial auf eine erhöhte Kaiserschnitt-Rate hin, wenn wegen einem frühen vorzeitigen Blasensprung (PPROM) die Schwangerschaft vorzeitig beendet wird. Ziel dieser Untersuchung war daher zu überprüfen, wie die Effektivität einer Geburtseinleitung nach einem PPROM mit 34 und 35 SSW im Vergleich zu einem höheren Gestationsalter ist. Material und Methodik In diese historische Kohortenstudie wurden Geburtseinleitungen ab 34+0 SSW wegen eines PPROM an zwei Perinatalzentren eingeschlossen. Geburtseinleitungen mit 34 und 35 SSW (Gruppe 1) wurden mit denen zwischen 36+0 und 36+6 SSW (Gruppe 2) respektive 37+0 bis 37+6 SSW (Gruppe 3) verglichen. Die Geburtseinleitung erfolgte 12–24 Stunden nach dem Blasensprung, und eine antibiotische Prophylaxe wurde routinemäßig gegeben. Der primäre Zielparameter war die Kaiserschnitt-Rate. Ergebnisse Es gab signifikant mehr Kaiserschnitte in der Gruppe 3 im Vergleich zur Gruppe 2 (7 vs. 25%, p=0,0136), jedoch konnte dieses Ergebnis in der univariablen und multiplen Regressionsanalyse nicht bestätigt werden. Hierbei zeigte sich kein signifikanter Einfluss des Gestationsalters (Gruppenzugehörigkeit) auf die Kaiserschnitt-Rate. Signifikante Parameter, die dieses Risiko erhöhten, waren der Body mass index und der Bishop score. Schlussfolgerung Die Geburtseinleitung ab 34+0 SSW wegen eines frühen vorzeitigen Blasensprungs ist nicht mit einer erhöhten Rate an Kaiserschnitten assoziiert.

(1) Background: Data on coronavirus 2 infection during pregnancy vary. We aimed to describe maternal characteristics and clinical presentation of SARS-CoV-2 positive women requiring intensive care treatment for COVID-19 during pregnancy and postpartum period based on data of a comprehensive German surveillance system in obstetric patients. (2) Methods: Data from COVID-19 Related Obstetric and Neonatal Outcome Study (CRONOS), a prospective multicenter registry for SARS-CoV-2 positive pregnant women, was analyzed with respect to ICU treatment. All women requiring intensive care treatment for COVID-19 were included and compared regarding maternal characteristics, course of disease, as well as maternal and neonatal outcomes. (3) Results: Of 2650 cases in CRONOS, 101 women (4%) had a documented ICU stay. Median maternal age was 33 (IQR, 30–36) years. COVID-19 was diagnosed at a median gestational age of 33 (IQR, 28–35) weeks. As the most invasive form of COVID-19 treatment interventions, patients received either continuous monitoring of vital signs without further treatment requirement (n = 6), insufflation of oxygen (n = 30), non-invasive ventilation (n = 22), invasive ventilation (n = 28), or escalation to extracorporeal membrane oxygenation (n = 15). No significant clinical differences were identified between patients receiving different forms of ventilatory support for COVID-19. Prevalence of preterm delivery was significantly higher in women receiving invasive respiratory treatments. Four women died of COVID-19 and six fetuses were stillborn. (4) Conclusions: Our cohort shows that progression of COVID-19 is rare in pregnant and postpartum women treated in the ICU. Preterm birth rate is high and COVID-19 requiring respiratory support increases the risk of poor maternal and neonatal outcome.

Fetal growth restriction is strongly associated with impaired placentation and abnormal uteroplacental blood flow. Nitric oxide donors such as pentaerythritol tetranitrate are strong vasodilators and protect the endothelium. Recently, we demonstrated in a randomized controlled pilot study a 38% relative risk reduction for the development of fetal growth restriction or perinatal death following administration of pentaerythritol tetranitrate to pregnant women at risk, identified by impaired uterine perfusion at midgestation. Results of this monocenter study prompted the hypothesis that pentaerythritol tetranitrate might have an effect in pregnancies with compromised placental function as a secondary prophylaxis.This study aimed to test the hypothesis that the nitric oxide donor pentaerythritol tetranitrate reduces fetal growth restriction and perinatal death in pregnant women with impaired placental perfusion at midgestation in a multicenter trial.In this multicenter, randomized, double-blind, placebo-controlled trial, 2 parallel groups of pregnant women presenting with a mean uterine artery pulsatility index95th percentile at 19+0 to 22+6 weeks of gestation were randomized to 50-mg Pentalong or placebo twice daily. Participants were assigned to high- or low-risk groups according to their medical history before randomization was performed block-wise with a fixed block length stratified by center and risk group. The primary efficacy endpoint was the composite outcome of perinatal death or development of fetal growth restriction. Secondary endpoints were neonatal and maternal outcome parameters.Between August 2017 and March 2020, 317 participants were included in the study and 307 were analyzed. The cumulative incidence of the primary outcome was 41.1% in the pentaerythritol tetranitrate group and 45.5% in the placebo group (unadjusted relative risk, 0.90; 95% confidence interval, 0.69-1.17; adjusted relative risk, 0.90; 95% confidence interval, 0.69-1.17; P=.43). Secondary outcomes such as preterm birth (unadjusted relative risk, 0.73; 95% confidence interval, 0.56-0.94; adjusted relative risk, 0.73; 95% confidence interval, 0.56-0.94; P=.01) and pregnancy-induced hypertension (unadjusted relative risk, 0.65; 95% confidence interval, 0.46-0.93; adjusted relative risk, 0.65; 95% confidence interval, 0.46-0.92; P=0.01) were reduced.Our study failed to show an impact of pentaerythritol tetranitrate on the development of fetal growth restriction and perinatal death in pregnant women with impaired uterine perfusion at midgestation. Pentaerythritol tetranitrate significantly reduced secondary outcome parameters such as the incidence of preterm birth and pregnancy-induced hypertension in these pregnancies.

This position paper describes clinically important, practical aspects of cervical pessary treatment. Transvaginal ultrasound is standard for the assessment of cervical length and selection of patients who may benefit from pessary treatment. Similar to other treatment modalities, the clinical use and placement of pessaries requires regular training. This training is essential for proper pessary placement in patients in emergency situations to prevent preterm delivery and optimize neonatal outcomes. Consequently, pessaries should only be applied by healthcare professionals who are not only familiar with the clinical implications of preterm birth as a syndrome but are also trained in the practical application of the devices. The following statements on the clinical use of pessary application and its removal serve as an addendum to the recently published German S2-consensus guideline on the prevention and treatment of preterm birth.Dieses Positionspapier beschreibt klinisch wichtige praktische Aspekte der Zervixpessartherapie. Zur Beurteilung der Zervixlänge und um Patientinnen auszuwählen, die von einer Pessartherapie profitieren könnten, wird standardmäßig transvaginaler Ultraschall eingesetzt. Wie bei anderen Behandlungsmodalitäten auch, ist es wichtig, regelmäßig Schulungen zum klinischen Einsatz und zur Pessarplatzierung durchzuführen. Diese Schulungen sind unerlässlich, um eine korrekte Platzierung von Pessaren im Notfall zu gewährleisten, Frühgeburten zu verhindern und die neonatale Ausgangssituation zu optimieren. Pessare sollten nur von medizinischen Fachleuten eingesetzt werden, die nicht nur mit den klinischen Implikationen einer Frühgeburt als Syndrom vertraut sind, sondern auch in der praktischen Anwendung von Pessaren geschult sind. Die folgenden Aussagen zum klinischen Einsatz von Pessaren und deren Entfernung dienen als Ergänzung der vor Kurzem veröffentlichten deutschen S2-Richtlinie zur Prävention und Therapie der Frühgeburt.

Background: Gestational diabetes mellitus is one of the most frequent pregnancy complications with a global prevalence of 13.4% in 2021. Pregnant women with COVID-19 and gestational diabetes mellitus are 3.3 times more likely to be admitted to an intensive care unit than women without gestational diabetes mellitus. Data on the association of gestational diabetes mellitus with maternal and neonatal pregnancy outcomes in pregnant women with SARS-CoV-2 infection are lacking. Objective: This study aimed to investigate whether gestational diabetes mellitus is an independent risk factor for adverse maternal and fetal and neonatal outcomes in pregnant women with COVID-19. Study Design: The COVID-19-Related Obstetric and Neonatal Outcome Study is a registry-based multicentric prospective observational study from Germany and Linz, Austria. Pregnant women with clinically confirmed COVID-19 were enrolled between April 3, 2020, and August 24, 2021, at any stage of pregnancy. Obstetricians and neonatologists of 115 hospitals actively provided data to the COVID-19-Related Obstetric and Neonatal Outcome Study. For collecting data, a cloud-based electronic data platform was developed. Women and neonates were observed until hospital discharge. Information on demographic characteristics, comorbidities, medical history, COVID-19–associated symptoms and treatments, pregnancy, and birth outcomes were entered by the local sites. Information on the periconceptional body mass index was collected. A primary combined maternal endpoint was defined as (1) admission to an intensive care unit (including maternal mortality), (2) viral pneumonia, and/or (3) oxygen supplementation. A primary combined fetal and neonatal endpoint was defined as (1) stillbirth at ≥24 0/7 weeks of gestation, (2) neonatal death ≤7 days after delivery, and/or (3) transfer to a neonatal intensive care unit. Multivariable logistic regression analysis was performed to evaluate the modulating effect of gestational diabetes mellitus on the defined endpoints. Results: Of the 1490 women with COVID-19 (mean age, 31.0±5.2 years; 40.7% nulliparous), 140 (9.4%) were diagnosed with gestational diabetes mellitus; of these, 42.9% were treated with insulin. Overall, gestational diabetes mellitus was not associated with an adverse maternal outcome (odds ratio, 1.50; 95% confidence interval, 0.88–2.57). However, in women who were overweight or obese, gestational diabetes mellitus was independently associated with the primary maternal outcome (adjusted odds ratio, 2.69; 95% confidence interval, 1.43–5.07). Women who were overweight or obese with gestational diabetes mellitus requiring insulin treatment were found to have an increased risk of a severe course of COVID-19 (adjusted odds ratio, 3.05; 95% confidence interval, 1.38–6.73). Adverse maternal outcomes were more common when COVID-19 was diagnosed with or shortly after gestational diabetes mellitus diagnosis than COVID-19 diagnosis before gestational diabetes mellitus diagnosis (19.6% vs 5.6%; P

Vom 03.03.–13.10.2020 wurden im CRONOS-Register („COVID-19 Related Obstetric and Neonatal Outcome Study in Germany“) 27 Fälle mit der Komorbidität Diabetes unter 262 registrierten Schwangeren mit intragravide gesicherter SARS-CoV-2(„severe acute respiratory syndrome coronavirus type 2“)-Infektion erfasst. Von diesen hatten 21 Gestationsdiabetes, 5 Typ-2-Diabetes und 1 Typ-1-Diabetes. Etwa die Hälfte der Frauen war asymptomatisch und wurde durch ein generelles SARS-CoV-2-Screening bei Krankenhausaufnahme entdeckt. Die häufigsten Symptome waren Schnupfen, Husten, Müdigkeit, Malaise und verändertes Geruchs- und Geschmacksempfinden. Die Mehrzahl der Schwangeren zeigte einen milden bis moderaten Verlauf, 3 Frauen wurden auf die Intensivstation aufgenommen; keine musste invasiv beatmet werden. In der Gruppe mit Typ-2-Diabetes traten 2 Fälle mit spätem intrauterinem Fruchttod (37 und 40 Schwangerschaftswochen [SSW]) und 1 Fall mit einer Fehlbildung auf, wobei eine Assoziation mit dem Diabetes am wahrscheinlichsten ist. Schwangere mit Diabetes mellitus stellen eine besonderes zu berücksichtigende Subgruppe dar; 1 von 10 Frauen in dieser kleinen Kohorte bedurfte einer intensivmedizinischen Überwachung aufgrund COVID-19. Darüber hinaus unterstreicht diese Fallserie die Notwendigkeit eines uneingeschränkten Zugangs zu einer intensiven Schwangerenbetreuung für ein optimales perinatales Outcome insbesondere in Zeiten der Pandemie.

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.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.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.Induction of labor for PPROM at 34 weeks of gestation is not associated with an increased rate of cesarean section.ZIEL: Die Geburtseinleitung in frühen Schwangerschaftswochen ab 34+0 SSW wird häufig in Verbindung mit einem erhöhten Risiko für einen Kaiserschnitt gebracht. Zuletzt wies der PPROMT Trial auf eine erhöhte Kaiserschnitt-Rate hin, wenn wegen einem frühen vorzeitigen Blasensprung (PPROM) die Schwangerschaft vorzeitig beendet wird. Ziel dieser Untersuchung war daher zu überprüfen, wie die Effektivität einer Geburtseinleitung nach einem PPROM mit 34 und 35 SSW im Vergleich zu einem höheren Gestationsalter ist.In diese historische Kohortenstudie wurden Geburtseinleitungen ab 34+0 SSW wegen eines PPROM an zwei Perinatalzentren eingeschlossen. Geburtseinleitungen mit 34 und 35 SSW (Gruppe 1) wurden mit denen zwischen 36+0 und 36+6 SSW (Gruppe 2) respektive 37+0 bis 37+6 SSW (Gruppe 3) verglichen. Die Geburtseinleitung erfolgte 12–24 Stunden nach dem Blasensprung, und eine antibiotische Prophylaxe wurde routinemäßig gegeben. Der primäre Zielparameter war die Kaiserschnitt-Rate.Es gab signifikant mehr Kaiserschnitte in der Gruppe 3 im Vergleich zur Gruppe 2 (7 vs. 25%, p=0,0136), jedoch konnte dieses Ergebnis in der univariablen und multiplen Regressionsanalyse nicht bestätigt werden. Hierbei zeigte sich kein signifikanter Einfluss des Gestationsalters (Gruppenzugehörigkeit) auf die Kaiserschnitt-Rate. Signifikante Parameter, die dieses Risiko erhöhten, waren der Body mass index und der Bishop score.Die Geburtseinleitung ab 34+0 SSW wegen eines frühen vorzeitigen Blasensprungs ist nicht mit einer erhöhten Rate an Kaiserschnitten assoziiert.

Background Patient safety is a key target in public health, health services and medicine. Communication between all parties involved in gynecology and obstetrics (clinical staff/professionals, expectant mothers/patients and their partners, close relatives or friends providing social support) should be improved to ensure patient safety, including the avoidance of preventable adverse events (pAEs). Therefore, interventions including an app will be developed in this project through a participatory approach integrating two theoretical models. The interventions will be designed to support participants in their communication with each other and to overcome difficulties in everyday hospital life. The aim is to foster effective communication in order to reduce the frequency of pAEs. If communication is improved, clinical staff should show an increase in work satisfaction and patients should show an increase in patient satisfaction. Methods The study will take place in two maternity clinics in Germany. In line with previous studies of complex interventions, it is divided into three interdependent phases. Each phase provides its own methods and data. Phase 1: Needs assessment and a training for staff (n = 140) tested in a pre-experimental study with a pre/post-design. Phase 2: Assessment of communication training for patients and their social support providers (n = 423) in a randomized controlled study. Phase 3: Assessment of an app supporting the communication between staff, patients, and their social support providers (n = 423) in a case-control study. The primary outcome is improvement of communication competencies. A range of other implementation outcomes will also be assessed (i.e. pAEs, patient/treatment satisfaction, work satisfaction, safety culture, training-related outcomes). Discussion This is the first large intervention study on communication and patient safety in gynecology and obstetrics integrating two theoretical models that have not been applied to this setting. It is expected that the interventions, including the app, will improve communication practice which is linked to a lower probability of pAEs. The app will offer an effective and inexpensive way to promote effective communication independent of users’ motivation. Insights gained from this study can inform other patient safety interventions and health policy developments. Trial registration ClinicalTrials.gov Identifier: NCT03855735; date of registration: February 27, 2019.

Background First manifestation of Cushing’s syndrome during pregnancy is rare. The diagnosis of both Cushing’s and primary aldosteronism within a pregnancy has not been previously documented. Diagnosis is especially challenging due to the normal physiological changes that occur during pregnancy. Consequently, many tests that are normally used for diagnosis are not reliable. Tumor based etiologies can be surgically removed. Etiologies that are not tumor based are challenging to treat during pregnancy. Case presentation A 25 year old G1P0 was admitted in the 22 5/7 week of pregnancy with elevated blood pressure (200/100 mm Hg), acne, moon facies, abdominal striae and hirsutism. With five antihypertensive medications her blood pressure remained 190/100 mm Hg. The patient was admitted to the ICU for intravenous medications and monitoring. She was diagnosed with Cushing’s syndrome and primary aldosteronism. In spite of therapy with spironolactone and metyrapone she developed preeclampsia and was delivered in the 26 0/7 week of pregnancy. At her follow up visit eight weeks postpartum she had blood pressure within normal limits, no clinical signs or symptoms, and all medications had been discontinued. Conclusions Early diagnosis of pregnancy induced Cushing’s syndrome and primary aldosteronism requires an interdisciplinary approach. Late detection has been associated with increased perinatal morbidity and mortality including but not limited to placental abruption and intrauterine demise. Collaboration is essential in the optimization of maternal and fetal outcomes.

BACKGROUND Takotsubo syndrome is a rare, stress-related, and reversible form of acute heart failure primarily affecting postmenopausal women. It is characterized by left ventricular dysfunction with a classic apical and midventricular wall motion abnormality (apical ballooning). CASE A 28-year-old woman, gravida 2 para 1, at 30 4/7 weeks of gestation was admitted with fetal bradycardia, a fully dilated cervix, and breech presentation. During emergency cesarean delivery, the patient had intraoperative cardiac arrest. Resuscitation was successful. Twelve hours postoperatively, after demonstrating symptoms of acute heart failure, she was diagnosed with Takotsubo syndrome. CONCLUSION Peripartum Takotsubo syndrome must be differentiated from peripartum cardiomyopathy. Cesarean delivery and sympathomimetic medications can increase the risk of occurrence. Early recognition and interdisciplinary management are essential in the prevention of serious and potentially fatal complications.