Prävention von Frühgeburten

Zusammenfassung: Die Frühgeburt stellt heute, obwohl große Fortschritte im medizinisch-technischen Bereich gemacht wurden, immer noch eine Hauptursache der perinatalen Mortalität und Morbidität dar. Trotz intensiver Bemühungen im therapeutischen Bereich ist die Rate der Frühgeburten in den westlichen Ländern stabil oder - wie in den USA - sogar ansteigend. Präventive Maßnahmen rücken deswegen immer stärker in den Blickpunkt. In der vorliegenden Übersichtsarbeit werden basierend auf randomisierten oder Beobachtungsstudien die aktuellen Strategien zur Prävention diskutiert. Nach den derzeit vorliegenden Metaanalysen wird die perinatale Morbidität durch präventive Maßnahmen nicht verbessert, wohl aber das Gestationsalter verlängert. Was dies an Vorteilen für das Neugeborene bringt, bleibt zu kläre

Neues aus der geburtshilflichen Anästhesie

Zusammenfassung: Hintergrund: Das Risikoprofil der Patientinnen hat sich in der geburtshilflichen Anästhesie wesentlich verändert. Noch mehr als bei anderen Disziplinen lebt gerade die geburtshilfliche Anästhesie daher im wahrsten Sinne des Worts von der engen Abstimmung aller Beteiligten und einer guten interdisziplinären Zusammenarbeit. Ziel der Arbeit: Der Beitrag klärt über wichtige anästhesiologische Risiken im Rahmen der Geburt auf und vermittelt entsprechende Konzepte zur Prävention, Diagnose und zum Management peripartaler Komplikationen. Material und Methode: Die Steigerung von Risikoschwangerschaften, die zu einem großen Teil auf eine Zunahme der Adipositas zurückzuführen ist, verlangt nach klar definierten Richtlinien und interdisziplinären Konzepten, die im vorliegenden Beitrag beschrieben und diskutiert werden. Die neuroaxiale Blockade ist weiterhin das wirksamste Verfahren zur Behandlung des Geburtsschmerzes und bietet mit den im Beitrag vorgestellten programmierten intermittierenden epiduralen Boli einen vielversprechenden neuen Modus. Schlussendlich haben die deutschsprachigen Länder Deutschland, Österreich, Schweiz einen Behandlungsalgorithmus für die postpartale Blutung entwickelt, der erläutert wird. Ergebnisse: Die anästhesiologischen Komponenten einer Risikoschwangerschaft müssen frühzeitig erkannt werden; hierzu gehören u.a. Adipositas, Präeklampsie oder medikamentös-induzierte Koagulopathie. Die Epiduralanalgesie ist das effektivste Analgesieverfahren in der Geburtshilfe. Die patientinnengesteuerte Remifentanilanalgesie stellt - bei Kontraindikationen für ein neuroaxiales Verfahren - aktuell die beste Alternative dar. Schlussfolgerung: In Risikosituationen, wie bei (Prä-)Eklampsie, notfallmäßiger Sectio caesarea, massiven Blutverlusten oder anderen intrapartalen Notfallsituationen ist die optimale interdisziplinäre Zusammenarbeit zwischen Hebammen, Geburtshelfern und Anästhesisten gefragt. Es sind jedoch nicht nur Notfallsituationen, die eine gute interdisziplinäre Zusammenarbeit erfordern; genauso wichtig ist die Zusammenarbeit im Erkennen von Risikoschwangerschaften und einer frühzeitigen gemeinsamen Planung der bevorstehenden Gebur

Water birth: is the water an additional reservoir for group B streptococcus?

Objective: Water birth became popular in the last years, despite the fact that many questions like the risk of infection for the newborn remain unanswered. Group B streptococcal (GBS) infections in the newborn remain a challenge in obstetrics and neonatology. Method: We conducted a prospective trial to study the impact of water birth on the colonization rate of the bath water and, more importantly, the GBS-colonization rate of the newborn. Result: After water birth the bath water was significantly more often colonized with GBS than after immersion followed by a delivery in bed. The newborns, however, showed no difference in GBS colonization and there was even a trend towards less GBS colonization of the newborn after a water delivery. Conclusion: Regarding GBS colonization of the newborn during water birth there might be a wash out effect, which protects the children during the deliver

A fetal scalp electrode as a simple aid in the search for a lost needle fragment during sacrospinous ligament fixation

A needle fragment was lost during a sacrospinous ligament fixation. This was recognized during the procedure, but could not be found at that moment. The patient complained of severe buttock pain postoperatively. The needle fragment was localized on CT scan of the pelvis. A fetal scalp electrode helped as a search device to localize the needle on X-ray during the secondary surgery. The patient was operated successfully and was free of pain after 6 weeks

Perinatale Betreuung an der Grenze der Lebensfähigkeit zwischen 22 und 26 vollendeten Schwangerschaftswochen

Die ersten Empfehlungen zur Betreuung von Frühgeborenen an der Grenze der Lebensfähigkeit in der Schweiz wurden im Jahre 2002 veröffentlicht1). Als Grundlage dienten damals unter anderem Empfehlungen europäischer2), 3) und kanadischer Fachgruppen4), sowie die relevanten edizinischethischen Richtlinien der Schweizerischen Akademie der Medizinischen Wissenschaften (SAMW)5), 6). Revidierte Empfehlungen aus Nordamerika und Europa7)–11), neue Empfehlungen aus weiteren Ländern12)–17) und neue Daten zu Mortalität und Morbidität18)– 22), insbesondere auch aus der Schweiz23), 24), haben Anlass dazu gegeben, die Empfehlungen für die Schweiz zu überarbeiten

The Interplay Between Host Genetic Variation, Viral Replication, and Microbial Translocation in Untreated HIV-Infected Individuals

Systemic immune activation, a major determinant of human immunodeficiency virus (HIV) disease progression, is the result of a complex interplay between viral replication, dysregulation of the immune system, and microbial translocation due to gut mucosal damage. Although human genetic variants influencing HIV load have been identified, it is unknown how much the host genetic background contributes to interindividual differences in other determinants of HIV pathogenesis such as gut damage and microbial translocation. Using samples and data from 717 untreated participants in the Swiss HIV Cohort Study and a genome-wide association study design, we searched for human genetic determinants of plasma levels of intestinal fatty acid-binding protein (I-FABP/FABP2), a marker of gut damage, and of soluble CD14 (sCD14), a marker of lipopolysaccharide bioactivity and microbial translocation. We also assessed the correlations between HIV load, sCD14, and I-FABP. Although we found no genome-wide significant determinant of the tested plasma markers, we observed strong associations between sCD14 and both HIV load and I-FABP, shedding new light on the relationships between processes that drive progression of untreated HIV infectio

Ageing with HIV: medication use and risk for potential drug-drug interactions

Objectives To compare the use of co-medication, the potential drug-drug interactions (PDDIs) and the effect on antiretroviral therapy (ART) tolerability and efficacy in HIV-infected individuals according to age, ≥50 years or <50 years. Methods All ART-treated participants were prospectively included once during a follow-up visit of the Swiss HIV Cohort Study. Information on any current medication was obtained by participant self-report and medical prescription history. The complete treatment was subsequently screened for PDDIs using a customized version of the Liverpool drug interaction database. Results Drug prescriptions were analysed for 1497 HIV-infected individuals: 477 age ≥50 and 1020 age <50. Older patients were more likely to receive one or more co-medications compared with younger patients (82% versus 61%; P < 0.001) and thus had more frequent PDDIs (51% versus 35%; P < 0.001). Furthermore, older patients tended to use a higher number of co-medications and certain therapeutic drug classes more often, such as cardiovascular drugs (53% versus 19%; P < 0.001), gastrointestinal medications (10% versus 6%; P = 0.004) and hormonal agents (6% versus 3%; P = 0.04). PDDIs with ART occurred mainly with cardiovascular drugs (27%), CNS agents (22%) and methadone (6%) in older patients and with CNS agents (27%), methadone (15%) and cardiovascular drugs (11%) in younger patients. The response to ART did not differ between the two groups. Conclusions The risk for PDDIs with ART increased in older patients who take more drugs than their younger HIV-infected counterparts. However, medication use in older and younger patients did not differ in terms of effect on antiretroviral tolerability and respons

Obesity trends and body mass index changes after starting antiretroviral treatment : the Swiss HIV Cohort Study

BACKGROUND: The factors that contribute to increasing obesity rates in human immunodeficiency virus (HIV)-positive persons and to body mass index (BMI) increase that typically occurs after starting antiretroviral therapy (ART) are incompletely characterized. METHODS: We describe BMI trends in the entire Swiss HIV Cohort Study (SHCS) population and investigate the effects of demographics, HIV-related factors, and ART on BMI change in participants with data available before and 4 years after first starting ART. RESULTS: In the SHCS, overweight/obesity prevalence increased from 13% in 1990 (n = 1641) to 38% in 2012 (n = 8150). In the participants starting ART (n = 1601), mean BMI increase was 0.92 kg/m(2) per year (95% confidence interval, .83-1.0) during year 0-1 and 0.31 kg/m(2) per year (0.29-0.34) during years 1-4. In multivariable analyses, annualized BMI change during year 0-1 was associated with older age (0.15 [0.06-0.24] kg/m(2)) and CD4 nadir &lt;199 cells/µL compared to nadir &gt;350 (P &lt; .001). Annualized BMI change during years 1-4 was associated with CD4 nadir &lt;100 cells/µL compared to nadir &gt;350 (P = .001) and black compared to white ethnicity (0.28 [0.16-0.37] kg/m(2)). Individual ART combinations differed little in their contribution to BMI change. CONCLUSIONS: Increasing obesity rates in the SHCS over time occurred at the same time as aging of the SHCS population, demographic changes, earlier ART start, and increasingly widespread ART coverage. Body mass index increase after ART start was typically biphasic, the BMI increase in year 0-1 being as large as the increase in years 1-4 combined. The effect of ART regimen on BMI change was limited

Assessing the Paradox Between Transmitted and Acquired HIV Type 1 Drug Resistance Mutations in the Swiss HIV Cohort Study From 1998 to 2012

Background. Transmitted human immunodeficiency virus type 1 (HIV) drug resistance (TDR) mutations are transmitted from nonresponding patients (defined as patients with no initial response to treatment and those with an initial response for whom treatment later failed) or from patients who are naive to treatment. Although the prevalence of drug resistance in patients who are not responding to treatment has declined in developed countries, the prevalence of TDR mutations has not. Mechanisms causing this paradox are poorly explored. Methods. We included recently infected, treatment-naive patients with genotypic resistance tests performed ≤1 year after infection and before 2013. Potential risk factors for TDR mutations were analyzed using logistic regression. The association between the prevalence of TDR mutations and population viral load (PVL) among treated patients during 1997-2011 was estimated with Poisson regression for all TDR mutations and individually for the most frequent resistance mutations against each drug class (ie, M184V/L90M/K103N). Results. We included 2421 recently infected, treatment-naive patients and 5399 patients with no response to treatment. The prevalence of TDR mutations fluctuated considerably over time. Two opposing developments could explain these fluctuations: generally continuous increases in the prevalence of TDR mutations (odds ratio, 1.13; P = .010), punctuated by sharp decreases in the prevalence when new drug classes were introduced. Overall, the prevalence of TDR mutations increased with decreasing PVL (rate ratio [RR], 0.91 per 1000 decrease in PVL; P = .033). Additionally, we observed that the transmitted high-fitness-cost mutation M184V was positively associated with the PVL of nonresponding patients carrying M184V (RR, 1.50 per 100 increase in PVL; P < .001). Such association was absent for K103N (RR, 1.00 per 100 increase in PVL; P = .99) and negative for L90M (RR, 0.75 per 100 increase in PVL; P = .022). Conclusions. Transmission of antiretroviral drug resistance is temporarily reduced by the introduction of new drug classes and driven by nonresponding and treatment-naive patients. These findings suggest a continuous need for new drugs, early detection/treatment of HIV-1 infectio