Influence of the second stage of labor on maternal and neonatal outcomes in vaginal births after caesarean section: a multicenter study in Germany

Background: The American College of Obstetricians and Gynecologists (ACOG) introduced a new standard of care in 2014, extending the duration of the second stage of labor in order to reduce caesarean delivery (CD) rates and its severe complications. The aim of the present study is to evaluate success rates of trial of labor after caesarean section (TOLAC), as well as maternal and neonatal outcomes after the establishment of the recent guidelines. Methods: A retrospective study was performed at two large departments in Germany from January 2008 to January 2018. Patients undergoing TOLAC were divided into two groups. Group I (958 patients) was constituted before the establishment of the current guidelines, and Group II (588 patients) after the establishment of the guidelines. A subgroup analysis was performed to compare neonatal outcomes after successful TOLAC and operative vaginal delivery with those after failed TOLAC and secondary CD. Results: The success rate of vaginal births after cesarean section (VBAC) fell from 66.4 in Group I to 55.8 in Group II (p < 0.001). The median duration of the second stage of labor was statistically significantly longer in Group II than in Group I (79.3 ± 61.9 vs. 69.3 ± 58.2 min) for patients without previous vaginal birth. The incidence of operative vaginal delivery decreased from Group I to Group II (9.6 vs. 6.8). The incidence of third- and fourth-degree perineal lacerations, blood loss and emergency CD were similar in the two groups. Concerning the neonatal outcome, our groups did not differ significantly in regard of rates of umbilical artery cord pH < 7.1 (p = 0.108), the 5-min Apgar scores below 7 (p = 0.224) and intubation (p = 0.547). However, the transfer rates to the neonatal care unit were significantly higher in Group II than in Group I (p < 0.001). Neonatal outcomes did not differ significantly in the subgroup analysis. Conclusion: Extending the second stage of labor does not necessarily result in more vaginal births after TOLAC. Maternal and neonatal outcomes were similar in both groups. Further studies will be needed to evaluate the role of operative vaginal delivery and the duration of the second stage of labor in TOLAC. © 2021, The Author(s)

Recent Progress on Anomalous X-ray Pulsars

I review recent observational progress on Anomalous X-ray Pulsars, with an emphasis on timing, variability, and spectra. Highlighted results include the recent timing and flux stabilization of the notoriously unstable AXP 1E 1048.1-5937, the remarkable glitches seen in two AXPs, the newly recognized variety of AXP variability types, including outbursts, bursts, flares, and pulse profile changes, as well as recent discoveries regarding AXP spectra, including their surprising hard X-ray and far-infrared emission, as well as the pulsed radio emission seen in one source. Much has been learned about these enigmatic objects over the past few years, with the pace of discoveries remaining steady. However additional work on both observational and theoretical fronts is needed before we have a comprehensive understanding of AXPs and their place in the zoo of manifestations of young neutron stars.Comment: 10 pages, 6 figures; to appear in proceedings of the conference "Isolated Neutron Stars: From the Interior to the Surface" eds. S. Zane, R. Turolla, D. Page; Astrophysics & Space Science in pres

First Trimester Screening Tests [İlk Trimestre Tarama Testleri]

Screening for chromosomal anomalies in pregnancy is widely practiced throughout the world. Screening for trisomy 21, often in conjunction with screening for neural tube defects, by measuring second trimester maternal serum biochemical markers, has become an established part of obstetric practice in many countries. Although trisomy 21 screening protocols vary between different centers, the average detection rate in prospective studies has been 64 % (range 48-75 %) for a false positive rate of about 5 %. During the last decade, extensive research has demonstrated that effective screening in the first trimester of pregnancy for chromosomal abnormalities can be achieved by assessing levels of maternal serum free b-hCG and pregnancy associated plasma protein-A (PAPP-A) and the ultrasonographic measurement of fetal nuchal translucency. Screening by fetal nuchal translucency reaches a detection rate of about 73 % for trisomy 21 with a 5 % false positive rate. Subsequently, it is estimated that a combination of fetal nuchal translucency with maternal serum free B-hCG and PAPP-A would increase the detection rate to about 90 % for trisomy 21 and also allow the detection of 90 % of other chromosomal abnormalities, including trisomy 13, trisomy 18, Turner syndrome and triploidy. The advent of rapid immunoassay tests has enabled the development of multidisciplinary techniques to replace invasive prenatal diagnostic methods and their inherent risks to the mother and the fetus with noninvasive alternatives. The isolation of fetal cells and DNA from the maternal circulation represents a promising noninvasive approach to prenatal diagnosis. Advances in molecular biology have provided new and sensitive tools for detecting and confirming the existence of fetal cells. However, because of the inconsistent number of fetal cells found in maternal circulation, these techniques have not yet entered routine clinical practice. In this manuscript, we have reviewed and discussed the developments in first trimester screening and noninvasive prenatal diagnostic techniques

Physiological color Doppler sonographic changes of the embryonic and uteroplacental vessels in early pregnancy

Objective. To evaluate the changes of uteroplacental, fetal aorta and umbilical circulation during early pregnancy (from 7 to 16 weeks' gestation) in non-complicated pregnancies. Material and methods. A 5-MHz broad-band transvaginal sonographic transducer combined with pulsed color Doppler was used to scan 42 healthy volunteer pregnant women. Results. Vascular impedance to blood flow in all examined vessels decreased significantly throughout the first gestational trimester Resistance to flow was highest in the main uterine artery and decreased towards the spiral artery. When the flow velocity waveform patterns of the arteries under investigation were analyzed, specific changes were observed. In all cases during early gestational development, an early diastolic notching was determined in the uterine arteries. The flow velocity waveforms of the fetal aorta and umbilical artery were similar: until week 10 the arteries were typically without diastolic flow. From week 16 onwards, diastolic velocities were present in all signals at the fetal aorta and umbilical artery Conclusion. Fetal and uteroplacental velocities increase gradually during early pregnancy, and velocimetric indices show a progressive decrease of the fetal and uteroplacental resistances. However, Doppler sonography in the first trimester of pregnancy is not a routine diagnostic tool, although it has potential to reflect the pathophysiological changes in early pregnancy

Perinatal risk factors for neonatal intracerebral hemorrhage in preterm infants

Objective: To investigate the perinatal factors related to neonatal intracerebral hemorrhage (ICH) and possibly to define obstetric and perinatal risk factors. Study design: All medical records of women who delivered in the period from 1 January 1991 to 1 January 2000 were reviewed for intracerebral hemorrhages in infants born between 24 and 34 weeks of gestation and treated in the postnatal period. Sixty infants with ICH (Group I) and 60 infants without ICH (Group II, matched controls) were determined for comparison. Obstetrical parameters and risk factors and perinatal outcome parameters were evaluated and statistically analyzed. Results: Neonatal intracerebral hemorrhage prevalence was 0.8% (60/7635 births). Betamethasone administration was significantly less in Group I than in Group II (27% versus 46%). Although Doppler-sonography of the middle cerebral artery was performed in a minority of the cases, it showed a significant tendency of lower resistance indices (brain sparing) in the intracerebral hemorrhage group (66.7% versus 21.1%). Postnatally, infants with intracerebral hemorrhage showed a significantly more often umbilical arterial acidosis (18% versus 10%), a greater base deficit, lower median 5 min Apgar scores (6 and 8, respectively for Groups I and II), and a lower thrombocyte count (Group I 190,000 ± 76,000 µl-1, and Group II 227,000 ± 96,000 µl-1). Infants in Group I were more often (93% versus 76%) and longer (26.7 ± 30.5 days versus 15.4 ± 11.7 days) dependent on ventilatory support than infants in Group II. Mortality rate in Group I (35%) was significantly higher compared to Group II (17%). Conclusions: Antenatal Doppler sonography in predicting intracerebral hemorrhage in preterm infants should be investigated in large scale prospective studies. Postnatal low pH-values (pH < 7.1) and a base deficit of more than -16 mmol/L in the umbilical artery, low Apgar scores and thrombocytopenia are associated with a neonatal intracerebral hemorrhage and prophylaxis with corticosteroids reduces the risk for it. A higher neonatal mortality and morbidity, including neurological and neuromotoric dysfunctions is expected in this clinical entity. © 2004 Elsevier Ireland Ltd. All rights reserved

Outcome of cystic hygroma in fetuses with normal karyotypes depends on associated findings

Objective: To determine the associated diagnostic findings which are linked with adverse fetal outcome in nuchal cystic hygroma. Study design: Based on a series of 32 cases, we determined the sonographic morphology of the hygroma, associated structural anomalies, karyotypes and autopsy findings. Intrauterine fetal death, spontaneous abortion and abnormal karyotypes were assigned as adverse outcome parameters. Results: The mean gestational age at diagnosis was 14.4 weeks (range 10-21). There were 18 nonseptated and 14 septated hygromas. Besides hygroma, associated sonographic detectable structural anomalies were observed in 17 cases (53.1%). The greatest number of associated sonographic anomalies were hydrops (31.3%), generalised skin oedema (6.3%) and pterygium colli (6.3%). Cytogenetic analysis revealed an abnormal karyotype in 13 of 26 (50%) invasive procedures. Turner syndrome and Trisomy 18 (both 15.4%) were the most frequent cytogenetic abnormalities. Autopsy was performed in 24 cases and 16 cases (66.7%) had an associated autopsy finding to hygroma colli. The most frequent associated autopsy findings were limb and craniofacial anomalies (both 25%). Only 3 (9.4%) mothers gave birth to healthy newborns. The overall fetal adverse outcome rate was 68.8% (22 cases). Conclusions: Fetuses with NCH are at high risk for adverse outcome and detailed prenatal diagnosis including invasive procedures should be offered. According to the presented autopsy findings, to determine fetal outcome in NCH cases with normal karyotypes, detailed sonography should be concentrated beside the exclusion of fetal heart defects and existence of hydrops fetalis, on the skeletal, urogenital and craniofacial anomalies, as these might cause severe morbidity. © 2004 Elsevier Ireland Ltd. All rights reserved

Doppler examinations of fetal and uteroplacental blood flow in AGA and IUGR fetuses before and after maternal physical exercise with the bicycle ergometer

Objective: To study changes in uteroplacental and fetal circulation after maternal exercise in appropriate-for-gestational-age fetuses (AGA) and intrauterine-growth-retarded fetuses (IUGR). Materials and method: 33 women with an uncomplicated course of pregnancy and ten women with IUGR were examined. Physical stress was caused through a bicycle ergometer with 1.25 W/kg maternal weight. Doppler examinations were performed in the umbilical artery, fetal aorta, middle cerebral and in the uterine artery. Fetal heart rate was documented by monitoring. Maternal lactate and glucose levels as well as maternal blood pressure and heart rate were recorded. Results: No significant changes after cycling could be observed in umbilical and uterine vessels either in the normal pregnancies or in pregnancies with IUGR. In contrast, in the fetal aorta an increase of the RI was recorded in both groups (an increase of 16% [P < 0.01] and 18% [P < 0.05], respectively for AGA and IUGR cases). In cerebral arteries a decrease of the RI was observed after cycling in both groups (a decrease of 24% [P < 0.01] and 13% [P < 0.05], respectively for AGA and IUGR cases). In AGA fetuses the RI of the aorta and middle cerebral artery returned to pre-test level by the 18th minute of examination. In IUGR fetuses the RI of the aorta and middle cerebral artery did not return to pre-test levels at the end of the test. Fetal heart rate remained unchanged in both groups. Maternal blood pressure and heart rate increased during the exertion phase but returned to initial values at the end of the test. A 21% and 24% (for AGA and IUGR groups respectively) reduction of maternal glucose values after exercise was observed (P < 0.001). Lactate values doubled in both groups after exercise (P < 0.001). Conclusion: From the results obtained we conclude that maternal exercise does not significantly alter uterine and umbilical perfusion in AGA and IUGR pregnancies, suggesting an absence of change in the uterine vascular bed resistance. However, submaximal maternal exercise was followed by fetal cerebral vasodilatation and an increase of resistance in the fetal aorta that was more evident in IUGR fetuses. This might be due to slight fetal hemoglobin desaturation in those cases

Clinical and biophysical aspects of HELLP-syndrome

Objective: The maternal-perinatal outcome and the significance of biophysical parameters in HELPP syndrome patients were evaluated. Methods: Sixty cases of HELLP syndrome were determined by retrospective analysis. Medical history, correlation of clinical, laboratory findings, records of fetomaternal Doppler studies, Nonstress test and maternal-perinatal outcome data were evaluated. Chi-square test was used for statistical analysis, and p < 0.05 was accepted as the significance level. Results: The incidence of HELLP syndrome in our institution was 1.03%. Mean gestational age at birth was 33.2 weeks, mean birth weight was 1861 ± 710 g and mean umbilical pH was 7.25 ± 0.13. Neonatal thrombocytopenia was demonstrable in 38% of neonates. Patients with low antepartal platelets (< 60 000/µl) had a significantly higher incidence of intrauterine growth retarded fetuses than patients with higher platelet counts (p = 0,002). Doppler flow measurements were performed in 33 patients (55%). In 16 (48.4%) a pathological Doppler flow was documented. Doppler findings demonstrated very high sensitivity (83%) and specificity (80%) in predicting adverse outcome in growth retarded fetuses. In 17 patients (27%) fetal heart rate monitoring had an obvious pathologic pattern. Respiratory distress syndrome (74.4%) was the main indication for NICU admission. Perinatal mortality rate was 8.3% and neonatal mortality rate was 11.6%. Maternal morbidity rate was 30%. The most commonly observed maternal complications were abruptio placentae (n = 8), disseminated intravascular coagulation (n = 3) and severe postpartal bleeding (n = 3). Conclusions: In HELLP syndrome patients it is very important to closely follow maternal vital signs and fluid intake and output, and to perform fetal status assessment tests. Of the biophysical parameters, Doppler flow measurement is an especially helpful predictor of poor perinatal outcome in growth retarded fetuses in HELLP patients. Patients with very low platelets have a significantly higher risk of intrauterine growth retarded fetuses

Comparison of perinatal outcome in fetuses with reverse or absent enddiastolic flow in the umbilical artery and/or fetal descending aorta

Objectives: To examine the differences of perinatal outcome in fetuses with absent and reversed enddiastolic flow velocity waveforms of the umbilical artery or fetal descending aorta. Design: In a retrospective study, 30 pregnant women with reversed enddiastolic flow in the umbilical artery or fetal aorta (group I) were compared with 30 cases of absent enddiastolic flow (group II). Patients were included in the groups according to the last Doppler finding before delivery. Perinatal and neonatal outcome was correlated with antenatal Doppler flow findings. Results: The mean gestational age at birth was 31 weeks in both groups. Fetuses with reverse flow showed higher perinatal (27% and 7% respectively) and overall mortality (53.3% and 10% respectively) compared to the absent enddiastolic flow group (p < 0.05). All the intrauterine fetal deaths occurred in the reversed flow group (n = 12). The rates of intrauterine growth retardation, oligohydramnios and hypocalcemia were different between the groups (p < 0.05). The cesarean section rate, perinatal and neonatal complications including the incidence of acidosis, the number of cases admitted to neonatal intensive care unit and mean treatment time were not different between the groups. A tendency to higher incidence of neonatal cerebral hemorrhage in reversed flow cases (28%) compared to absent enddiastolic flow cases (17%) was observed, but this was not statistically significant. Conclusions: The present study suggests that reversed flow should be seen as a particular clinical entity with higher incidences of perinatal and overall mortality, and severe intrauterine growth retardation (< 5. perc) compared to the absent enddiastolic flow group. The optimal timing of delivery in pregnancies complicated by highly pathological Doppler flow findings is only to be resolved in well-designed randomized, multicenter clinical trials