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Introduction: Recurrent mutations in calreticulin (CALR) are present in 70% to 80% of essential thrombocythemia (ET) and primary myelofibrosis (PMF) patients without a JAK2 or MPL mutation. Despite recent advances in understanding mutant CALR, the detailed mechanisms are not fully elucidated, and current knowledge is mainly based on transgenic mouse models or human cancer cell lines. Thus, to more faithfully model MPN pathogenesis, we first aimed to introduce heterozygous type-1 and type-2 CALR mutations into healthy human hematopoietic stem and progenitor cells (HSPCs) via targeted CRISPR/Cas9-mediated gene knock-in (KI) and investigate its impact on HSPC function in vitro and in vivo. Second, we aimed to correct CALR mutations in patient-derived HSPCs to study their dependence on the initial driver event to exert an MPN phenotype. Methods: We used CRISPR/Cas9 to introduce heterozygous CALR mutations into the endogenous gene locus of healthy cord blood-derived HSPCs. Our approach is based on homologous recombination using DNA repair templates delivered by adeno-associated virus serotype 6 (AAV6). Briefly, Cas9-sgRNA ribonucleoprotein (RNP) was used to cut the DNA. Simultaneously AAV6, carrying either a mutation-bearing or a wildtype control cDNA, was co-delivered to allow for targeted in-frame integration. This way, mutant CALR remains under the control of the endogenous promoter. Concurrent integration of a fluorescent reporter downstream of the mutated exon, enabled purification and tracking of modified cells via flow cytometry. Purified CRISPR-modified HSPCs were used for in vitro collagen-based colony-forming assays, proliferation and differentiation assays in liquid culture, and intrafemoral transplantation into immunodeficient NSG mice to assess their pathogenic potential. Results: Our CRISPR/Cas9 KI strategy enabled us to efficiently generate and enrich for heterozygous CALR mutant human HSPCs. Modified cells harbor the mutation at the endogenous CALR locus with intact gene regulatory regions. Correct integration and transcript expression were confirmed on DNA and RNA level by sanger sequencing. Additionally, CALR mutant protein expression was confirmed via immunohistochemistry using a diagnostically approved mutant-specific antibody. Type-1 and type-2 CALR mutations led to TPO-independent growth of CD34 + HSPC-derived cells and a two-fold (p When transplanted into sublethally irradiated immunodeficient NSG mice, CALR mutant HSPCs showed robust engraftment in the bone marrow with a myeloid lineage skewing, outcompetition of wildtype cells and increased formation of CALR mutant CD41 + megakaryocyte progenitors. To investigate, if removal of type-1 and type-2 CALR mutations can ameliorate MPNs, we utilized our KI strategy to correct both CALR mutations in MPN patient-derived HSPCs by replacing them with wildtype sequences. A successful correction was confirmed on DNA and RNA level and by the absence of mutant CALR protein. Opposite to the results from introducing CALR mutations, correcting the mutations led to a two-fold decrease in megakaryocyte colony formation. Interestingly this was only seen in ET and post-ET MF samples, whereas primary MF samples were unaffected, underscoring the importance of other secondary genetic driver events in the pathogenesis of primary MF. Conclusion: Our system allows us to investigate human MPN pathogenesis prospectively and shed light on the transforming mechanisms of mutant CALR in primary HSPCs. We could show that CALR mutations prime HSPCs toward the formation of platelet-producing megakaryocytes. Genetic correction of CALR mutations in MPN patient-derived HSPCs revealed a dependence on the oncogenic mutant CALR driver event in ET and post-ET MF patients, opening the possibility of an ex vivo gene correction approach to remove mutant CALR in patient-derived HSPCs . Lastly, since MPN patient-derived cells have notoriously low engraftment potential in mice, our CRISPR/Cas9-engineered CALR mutant model also provides a powerful new strategy to generate MPN xenotransplants with defined genotypes for the evaluation of novel therapies. Disclosures Greinix: Celgene: Consultancy; Therakos: Consultancy; Takeda: Consultancy; Sanofi: Consultancy; Novartis: Consultancy. Sill: Astellas: Consultancy, Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees; AbbVie: Consultancy, Membership on an entity's Board of Directors or advisory committees. Zebisch: Novartis: Consultancy; AbbVie: Consultancy; Celgene: Consultancy, Honoraria. Reinisch: Celgene: Research Funding; Pfizer: Consultancy.

Objective We investigated whether time of birth, unit volume, and staff seniority affect neonatal outcome in neonates born at ≥34+0 weeks of gestation. Design Population-based prospective cohort study. Setting Ten public hospitals in the Austrian province of Styria. Sample A total of 87 065 neonates delivered in the period 2004–2015. Methods Based on short-term outcome data, generalised linear mixed models were used to calculate the risk for adverse and severely adverse neonatal outcomes according to time of birth, unit volume, and staff seniority. Main outcome measures Neonatal composite adverse and severely adverse outcome measures. Results The odds ratio for severely adverse events during the night-time (22:01–07:29 hours) compared with the daytime (07:30–15:00 hours) was 1.35 (95% confidence interval, 95% CI 1.13–1.61). There were no significant differences in neonatal outcome comparing weekdays and weekends, and comparing office hours and shifts. Units with 500–1000 deliveries per year had the lowest risk for adverse events. Adverse and severely adverse neonatal outcomes were least common for midwife-guided deliveries, and became more frequent with the level of experience of the doctors attending the delivery. With increasing pregnancy risks, senior staff attending delivery and delivering in a tertiary centre reduce the odds ratio for adverse events. Conclusions Different times of delivery were associated with increased adverse neonatal outcomes. The management of uncomplicated deliveries by less experienced staff showed no negative impact on perinatal outcome. In contrast, riskier pregnancies delivered by senior staff in a tertiary centre favour a better outcome. Achieving a better balance in the total number of labour ward staff during the day and the night appears to be a greater priority than increasing the continuous presence of senior obstetrical staff on the labour ward during the out-of-hours period. Tweetable abstract Deliveries during night time lead to a greater number of neonates experiencing severely adverse events.

ObjectiveThe Robson ten group classification system is used as a global standard for assessing, monitoring and comparing caesarean delivery (CD) rates within and between maternity services. Our objective was to compare the changes of CD rates at our institution between the years 2008-2010 and 2017-2019 using the Robson ten group classification system.Study designData was collected retrospectively and all women were classified using the obstetric concepts and parameters described in the Robson ten group classification system.ResultsDuring 2008-2010 7,832 deliveries were performed, increasing to 9,490 in 2017-2019. The CD rate also increased from 29.1% to 32.2% (pConclusionThe biggest contributors to the CD rate in our hospital remain multiparous women at term with a previous CD. The CD rates, as well as the overall size of this group, keep rising, resulting in a need to establish more effective ways to motivate women with one previous CD towards vaginal birth after caesarean delivery (VBAC). Furthermore, the CD rate in preterm deliveries is increasing and approaching 50%. This illustrates the need to discuss whether CD is the appropriate mode of delivery in half of the preterm infants.

Introduction Preeclampsia complicates about 10–17 % of pregnancies with antiphospholipid syndrome (APS). It is often severe and might occur sometimes at early gestation. The development of preeclampsia before fetal viability is a huge challenge for obstetricians and demands an intensive discussion regarding the therapeutical options. Patients and methods We retrospectively reviewed the data of 7 women with primary APS who developed preeclampsia before 24 weeks of gestation. Plasma exchange had been performed in four of the cases and two women received corticosteroids. One of the women had received 20 mg of pravastatin daily, starting at 18 weeks of gestation. Neonatal outcome was: live birth in four cases and IUFD in three cases. The main pediatric complications were noted in a 28-week-old premature born boy, who developed severe IRDS and thrombocytopenia. At the present time, the boy continues to have a retarded status. Discussion This retrospective analysis revealed that women with APS can develop severe preeclampsia even before 20 weeks of gestation. Several management options for prolongation of pregnancy such as plasma exchange, pravastatin, LMHW, hydroxychloroquine/HCQ, or TNF-alpha blocker should be discussed with the patients. Optimal management of preeclampsia before 24 weeks of gestation usually depends on weighing the maternal and fetal complications from expectant management with prolongation of pregnancy versus the predominant fetal and neonatal risks of extreme prematurity from “aggressive” management with immediate delivery.

We investigated whether time of birth, unit volume, and staff seniority affect neonatal outcome in neonates born at ≥34Population-based prospective cohort study.Ten public hospitals in the Austrian province of Styria.A total of 87 065 neonates delivered in the period 2004-2015.Based on short-term outcome data, generalised linear mixed models were used to calculate the risk for adverse and severely adverse neonatal outcomes according to time of birth, unit volume, and staff seniority.Neonatal composite adverse and severely adverse outcome measures.The odds ratio for severely adverse events during the night-time (22:01-07:29 hours) compared with the daytime (07:30-15:00 hours) was 1.35 (95% confidence interval, 95% CI 1.13-1.61). There were no significant differences in neonatal outcome comparing weekdays and weekends, and comparing office hours and shifts. Units with 500-1000 deliveries per year had the lowest risk for adverse events. Adverse and severely adverse neonatal outcomes were least common for midwife-guided deliveries, and became more frequent with the level of experience of the doctors attending the delivery. With increasing pregnancy risks, senior staff attending delivery and delivering in a tertiary centre reduce the odds ratio for adverse events.Different times of delivery were associated with increased adverse neonatal outcomes. The management of uncomplicated deliveries by less experienced staff showed no negative impact on perinatal outcome. In contrast, riskier pregnancies delivered by senior staff in a tertiary centre favour a better outcome. Achieving a better balance in the total number of labour ward staff during the day and the night appears to be a greater priority than increasing the continuous presence of senior obstetrical staff on the labour ward during the out-of-hours period.Deliveries during night time lead to a greater number of neonates experiencing severely adverse events.

Objective We investigated whether time of birth, unit volume, and staff seniority affect neonatal outcome in neonates born at ≥34+0 weeks of gestation. Design Population-based prospective cohort study. Setting Ten public hospitals in the Austrian province of Styria. Sample A total of 87 065 neonates delivered in the period 2004–2015. Methods Based on short-term outcome data, generalised linear mixed models were used to calculate the risk for adverse and severely adverse neonatal outcomes according to time of birth, unit volume, and staff seniority. Main outcome measures Neonatal composite adverse and severely adverse outcome measures. Results The odds ratio for severely adverse events during the night-time (22:01–07:29 hours) compared with the daytime (07:30–15:00 hours) was 1.35 (95% confidence interval, 95% CI 1.13–1.61). There were no significant differences in neonatal outcome comparing weekdays and weekends, and comparing office hours and shifts. Units with 500–1000 deliveries per year had the lowest risk for adverse events. Adverse and severely adverse neonatal outcomes were least common for midwife-guided deliveries, and became more frequent with the level of experience of the doctors attending the delivery. With increasing pregnancy risks, senior staff attending delivery and delivering in a tertiary centre reduce the odds ratio for adverse events. Conclusions Different times of delivery were associated with increased adverse neonatal outcomes. The management of uncomplicated deliveries by less experienced staff showed no negative impact on perinatal outcome. In contrast, riskier pregnancies delivered by senior staff in a tertiary centre favour a better outcome. Achieving a better balance in the total number of labour ward staff during the day and the night appears to be a greater priority than increasing the continuous presence of senior obstetrical staff on the labour ward during the out-of-hours period. Tweetable abstract Deliveries during night time lead to a greater number of neonates experiencing severely adverse events.

Das Erkennen eines suspekten oder pathologischen CTGs lasst keine sichere Aussage uber das tatsachliche Vorliegen eines „fetal distress“, bzw. das Ausmas der fetalen Blutgas-u. pHWert-Veranderungen zu. Ohne den Einsatz der Mikroblutuntersuchung muss das Auftreten von suspekten oder pathologischen CTG-Veranderungen haufig eine raschest mogliche Geburtsbeendigung mittels vaginal-operativer Masnahme oder Kaiserschnitt nach sich ziehen. Diese Studie soll prufen, wie viele Kaiserschnitte und vaginal-operative Entbindungen durch den Einsatz von Mikroblutuntersuchungen (MBU) bei suspekten oder pathologischen Geburts-CTGs in der klinischen Realitat verhindert werden konnen. Retrospektive Analyse des Geburtsmodus mittels deskriptiver Statistik an 669 Patientinnen im Zeitraum 2008–2009, bei denen bei suspektem oder pathologischem CTG eine Mikroblutuntersuchung durchgefuhrt wurde. Auserdem sollte untersucht werden, ob eine Abhangigkeit der MBU-Verteilung vom Gestationsalter besteht. Durch den Einsatz der Mikroblutuntersuchung konnte bei 6,4% der im Studienkollektiv eingeschlossene Patientinnen mit suspektem oder pathologischem CTG, durch einen oder mehrere MBU-Werte im Normbereich, eine operative Entbindung umgangen und eine Spontangeburt ermoglicht werden. Weiters zeigt sich eine Haufung der Mikroblutuntersuchungen bei Gestationsaltern jenseits des Geburtstermins. Die fetale Mikroblutuntersuchung stellt ein effektives Hilfsmittel im geburtshilflichen Management dar und kann zur Reduktion der operativen Entbindungsrate beitragen. Das Risiko der Invasivitat des Eingriffs kann im Vergleich zur Reduktion der operativen Entbindungsrate als gering angesehen werden. Die Bereitschaft zur Durchfuhrung von Mikroblutuntersuchungen steigt mit Fortschreiten des Gestationsalters offensichtlich stetig an.

Aim: The incidence of lesions due to birth trauma can be generally regarded as a characteristic of obstetric management; since obstetric management has changed through the years, one might expect a decrease or increase of lesions due to birth trauma in mature newborn infants. Methods: In a retrospective study, the incidence of lesions due to birth trauma was recorded in the year 2000. In 1989, an identical study had already been carried out in the same department, employing the same criteria. The new findings were compared with the historical data. Results: In the year 1989 24.6% and in 2000 13.2% showed lesions due to obstetric trauma. The episiotomy rate and lesions due to birth trauma had significantly decreased. A decline regarding the traumas per se was noticed in caput succedaneum traumas, in hematomas due to birth trauma and in clavicle fracture. The cesarean section rate among the study group increased. The cesarean section rate among the traumatized newborns decreased. Conclusion: Episiotomy does not prevent newborns from traumatic lesions. Gestational age and birthweight have not significantly changed throughout the years; therefore an increase in the cesarean section rate must have contributed to the decrease of birth traumas. Even during abdominal operative delivery, obstetric traumas in newborns do occur. However, an increase in cesarean sections alone can not thoroughly explain the reduction of birth lesion among newborns. Improvement in prenatal diagnostic tools and procedures, respectively, and a goal-oriented use of labor induction might also play a major role.

Objective: Elective cesarean delivery has been postulated to improve the outcome of term fetuses in breech presentation. We retrospectively compared the short- and long-term outcomes of term infants who were delivered from a breech presentation at a single center. Study Design: We reviewed 699 consecutive term breech presentations according to the intended mode of delivery at a single center between January 1993 and December 1999. The short-term outcome measures were perinatal death, neonatal death, or serious neonatal morbidity; the long-term outcome measures were developmental delay and spasticity. Results: The rate of serious perinatal morbidity in the trial-of-labor and cesarean delivery groups was 2.3% and 0.5%, respectively ( P =.12). There was no perinatal or neonatal death in either group. With a median follow-up period of 57 months (range, 13-100 months), the rate of developmental delay was 1.9% and 0.5%, respectively ( P =.29). Spasticity was not noted in any of the children. Conclusion: Our data suggest that planned vaginal delivery remains an option for selected term breech presentations. (Am J Obstet Gynecol 2002;187:1694-8.)

Objective: The aim of this survey was to analyse published case reports describing malignancies arising from an extraovarian endometriosis and to list their symptoms, localisations and treatment modalities. Material and Methods: Seventy-five case reports from the world literature were reviewed and the main findings summarised. Results: Fifty-eight tumors were carcinomas and 17 were sarcomas. The most common tumor localisation was the rectovaginal septum. In 20 patients an exogenous (n=18) or endogenous (n=2) oestrogenic stimulation was documented. One patient received tamoxifen at the time of diagnosis. Conclusions: Malignancies arising from extraovarian endometriosis are extremely rare. In patients with a history of a hysterectomy and bilateral oophorectomy vaginal bleeding or a pelvic mass may represent signs of the malignant transformation of an extraovarian endometriosis. This is especially important if the patient's history includes endometriosis. In addition to surgical tumour reduction, hormone therapy with progestins is recommended.

Purpose: To evaluate the prognosis of patients with invasive cervical cancer related to pregnancy and to assess if survival is altered by pregnancy. Methods : We reviewed 20 patients (mean age 34.7 years) with invasive cervical carcinoma diagnosed during pregnancy between 1971 and 1995.This group was compared with 541 non-pregnant controls with invasive cervical cancer. All patients had had radical surgical treatment. Results: The overall (disease-free) 5year survival rates of the pregnant and non-pregnant patients were 74.4% (6/20 died of disease) and 78.2% (128/541), respectively (p=0.58). The survival rate of a matched group of non-pregnant patients younger than 44 years was 74.8% (57/220) (p = 0.77). Four of the pregnant patients had FIGO stage IA2,11 stage IB, 1 stage IIA, 3 stage IIB, 1 stage Illb disease. All 4 pregnant patients with stage IA2 disease survived free of recurrence. The 5-year survival rate of the 11 pregnant patients with stage IB did not differ from that of the non-pregnant patients (81.8% [2/11] versus 78.9% [28/126], p=0.65). The pregnant patients with stage II and III disease had a 5-year survival rate of 40% (4/5) and differed from the non-pregnant patients with 69% (66/94) (p = 0.0027). The 5-year survival rates of pregnant and non-pregnant patients with negative lymph nodes were 77.8% (2/9) and 83.6% (25/146), respectively (p=0.74). The 5-year survival rates of pregnant and non-pregnant patients with positive lymph nodes were 53.6% (4/7) and 56.5% (32/74), respectively (p = 0.53). There were no differences in survival rates between pregnant and non-pregnant patients according to squamous cell versus adenocarcinoma and capillary-like space involvement. 4 pregnant patients with stage IB delayed therapy for 13 to 26 weeks and survived free of disease. Only 10 of 15 pregnant patients treated immediately after diagnosis survived. Conclusions: Our data do not suggest that pregnancy has an adverse effect on the prognosis of patients with invasive cervical carcinoma. Delaying treatment until the fetus has achieved lung maturity appears to be a possible option for patients with stage I disease.

The null hypothesis of this study was that oral magnesium supplementation would not affect the incidence of preterm contractions, preterm labour and associated neonatal complications. 530 women with low-risk pregnancies were recruited until the 18 th week of gestation and assigned to receive 15 mmol magnesium citrate once daily PO (n=265) or no supplementation (n=265). 240 patients and 250 controls completed the study. The patients receiving magnesium had a significantly lower rate of hospitalisation due to threatened preterm labour (6.6% vs. 12.0%, p

BACKGROUND Although fetal blood sampling for pH is well established the use of lactate has not been widely adopted. This study validated the performance and utility of a handheld point-of-care (POC) lactate device in comparison with the lactate and pH values obtained by the ABL 800 blood gas analyzer. METHODS The clinical performance and influences on accuracy and decision-making criteria were assessed with freshly taken fetal blood scalp samples (n=57) and umbilical cord samples (n=310). Bland-Altman plot was used for data plotting and analyzing the agreement between the two measurement devices and correlation coefficients (R²) were determined using Passing-Bablok regression analysis. RESULTS Sample processing errors were much lower in the testing device (22.8% vs. 0.5%). Following a preclinical assessment and calibration offset alignment (0.5 mmol/L) the test POC device showed good correlation with the reference method for lactate FBS (R²=0.977, p

Status of Fetuses: Objective: Lymphocyte subpopulations and the differential blood count in umbilical cord blood yield information on the immunological status of fetuses. Is there a difference in the immunological status with increasing duration of labour after normal spontaneous deliveries? Study design: In a prospective non-randomised study the immunological status of 120 full term healthy neonates of mothers with uneventful pregnancies and spontaneous deliveries was determined in umbilical cord blood by flow cytometry after labelling lymphocytes with either PE or FITC conjugated monoclonal antibodies. 60 deliveries with duration of labour shorter than the median value were compared to 60 exceeding this period. Data were analysed via either the Student T test or the Mann-Whitney Wilcoxon U test on SPSS software. Results: The median value of the duration of labour of all 120 deliveries was 6:20 hours (median = 7:05, std = 2.46). The first group had a median duration of labour of 5:25 hours against a median of 8:10 hours of the second group. Significant elevations of total leukocyte count (16.40 x 10 9 L vs 14.75 x 10 9 /L), total lymphocyte count (5.93 x 10 9 /L vs 5.46 x 10 9 /L), T-suppressor cells (2.26 x 10 9 L vs 1.72 x 10 9 /L), cytotoxic T-cells (0.083 x 10 9 /L vs 0.05 x 10 9 /L) and total natural killer cells (1.51 x 10 9 /L vs 0.97 x 10 9 /L) were observed with prolonged labour. Total T cells (61.50% vs 66.50%), T helper/inducer cells (42.91% vs 49.45%) and the helper/suppressor ratio (1.20 vs 1.50) were significantly lower after prolonged duration of labour. No differences between the two groups were observed for neutrophiles, monocytes, total B cells, activated T (CD3 + /HLADR + ) cells, T &/or NK (CD57 + / CD8 -) cells, (CD57 + /CDB + ) cells, (CD4 + /Leu8 -) cells, (CD4 + / Leu8 +) cells and DR+ Non-T (CD3-/HLADR+) cells. Conclusions: Prolonged labour influences immunological competent cells of the fetus with stimulation of unspecific immunity and depression of specific cellular immunity.

Interpretation of a suspicious, non-reassuring or pathological foetal heart rate tracing does not provide any direct information about foetal oxygen saturation, blood gas status or the extent of changes in pH. Without foetal scalp blood sampling, such tracings often necessitate rapid intervention to deliver the baby by Caesarean section or assisted vaginal delivery. The aim of this study was to show the impact of foetal blood sampling on reducing the number of Caesarean sections and assisted vaginal deliveries in a clinical setting in such cases.A retrospective study of the mode of delivery in 669 women where foetal scalp blood sampling had been performed for suspicious or pathological foetal heart rate monitoring, in the period 2008-2009 was undertaken. The gestational age of the foetus was also investigated.Because one or more results of foetal scalp pH were within the normal range an operative delivery could be avoided in 6.4% of the study population, in spite of the non-reassuring foetal heart rate monitoring. Foetal blood sampling was performed more frequently in post-term pregnancies.Foetal blood analysis still is an effective tool to reduce unnecessary operative deliveries and should be regularly included in intrapartum monitoring. The risk of foetal complications is low compared with the reduction in the rate of Caesarean sections and assisted vaginal deliveries. Obstetricians are evidently becoming more willing to carry out foetal scalp blood sampling with rising gestational age.