Determinants of successful breastfeeding initiation in healthy term singletons: a Swiss university hospital observational study

Aims: Breastfeeding significantly benefits mothers and infants. We aimed to identify the determinants of its successful initiation. Methods: A retrospective study of 1893 mothers delivering healthy term singletons at a Swiss university hospital from 1/2008 to 3/2009 determined the associations between multiple breastfeeding and early postpartum parameters by univariate and multiple regression analysis. Results: Multiparity was associated with nursing exclusively at the breast at discharge (P<0.001), less use of maltodextrin supplement (P<0.05), bottle/cup (both P<0.001), but more pacifier use (P<0.05). Among obese mothers, nursing exclusively at the breast at discharge was less frequent, and use of all feeding aids more frequent, than among normal-weight women (both P<0.001). Neuraxial anesthesia was associated with use of maltodextrin and bottle (both P<0.05) compared to no anesthesia. Delayed first skin-to-skin contact and rooming-in for <24 h/day were each associated with maltodextrin and cup (P<0.05). Nursing exclusively at the breast at discharge was less frequent (P<0.001), and bottle use more frequent (P<0.05), in women with sore nipples than in those without. Conclusions: Obesity is a potent inhibitor of breastfeeding initiation. Delivery without anesthesia by a multiparous normal-weight mother, followed by immediate skin-to-skin contact, rooming-in for 24 h/day, and dedicated nipple care, provides the best conditions for successful early postpartum breastfeeding without the need for feeding aids or nutritional supplement

Maternal and neonatal outcome of labour induction at term comparing two regimens of misoprostol

Aim: To compare the efficacy and safety of two misoprostol dosing regimens for induction of labour in primiparous (1P) and multiparous (>1P) women. Methods: Retrospective study of induction of labour using vaginal misoprostol 25 μg vs. 50 μg every 6 h in 942 women at a tertiary centre. The main outcome variables are induction-to-delivery interval, latency period duration, vaginal delivery within 24 h, and maternal and foetal safety outcome. Results: With the 50 μg regimen, induction-to-delivery intervals were significantly shorter: 18.4 h vs. 24.6 h (1P) and 14 h vs. 17.9 h (>1P), as was latency period duration (by 5.4 and 4 h, respectively). Vaginal delivery within 24 h was significantly more frequent, as were non-reassuring foetal heart rate (1P: 20% vs. 14%) and tachysystole (1P: 31% vs. 11%; >1P: 21% vs. 7%). No uterine rupture was reported. Neonatal outcomes were similar except for significantly more frequent infant referral to neonatal intensive care in the >1P group receiving the 50 μg regimen (11% vs. 4%). Conclusion: Vaginal misoprostol 25 μg seems to maintain efficacy with more acceptable maternal and neonatal safety. As induction of labour is an off-label use for misoprostol, safety should be prioritised with the lower dosage regimen despite the longer induction-to-delivery interva

Spontaneous carotid artery dissection in pregnancy

We report on a 35-year-old woman who presented at 36 weeks of gestation with headaches and arterial hypertension. She was discharged after ruling out pre-eclampsia. The next day she returned with worsening headaches and an onset of Horner's syndrome. A magnetic resonance (MR) angiography showed extensive dissection of the right-sided internal carotid artery. Anticoagulation and antihypertensive therapies were initiated after delivery of the baby by caesarean. The patient recovered fully. Headache in pregnancy is not always due to pre-eclampsia. Carotid artery dissection (CAD) is a rare but severe cause of headache that typically presents with neck pain and focal neurologic symptoms. Once the diagnosis is established, an immediate treatment should be started in order to minimise damage, especially ischaemic lesions

Subsequent Pregnancy Outcomes after Open in utero Spina Bifida Repair

INTRODUCTION: Fetal spina bifida (SB) repair is a distinct therapeutic option in selected cases. Since this procedure may not only be associated with short-term obstetrical complications, the aim of this study was to assess the outcomes of subsequent pregnancies after open fetal SB repair. METHODS: 138 patients having had open fetal SB repair at our center received a questionnaire regarding the occurrence, course, and outcome of subsequent pregnancies. Additionally, medical records were reviewed. All subsequent pregnancies with complete outcome data that progressed beyond 20 gestational weeks (GW) were included for further analysis. RESULTS: 70% of all women answered the questionnaire. Out of this cohort, 35 subsequent pregnancies were reported in 29% of women. The rate of early pregnancy loss including elective terminations was 14%. All 29 pregnancies processing >20 GW ended in live births without preterm births <34th GW. Mean gestational age at delivery was 37.3 ± 1.4 GW. Uterine rupture occurred in two cases (7%) and uterine thinning/dehiscence was present in six cases (21%). No maternal transfusions were required. CONCLUSION: When counseling women undergoing open fetal SB repair, one should consider possible risks for subsequent pregnancies, especially the one of uterine dehiscence and rupture that is similar compared to numbers reported after classical cesarean deliveries

Prenatal Spina Bifida Repair: Defendable Trespassing of MOMS Criteria Results in Commendable Personalized Medicine

Introduction We hypothesize that after publication of the quintessence of the MOMS-Trial, eligibility criteria for prenatal spina bifida repair may be modified if a tenable argumentation underlies this decision. Methods Our first 154 fetal surgery patients were analyzed with particular focus on how many, which, and why the original eligibility criteria, set forth by the MOMS Trial Protocol, were disobeyed, and what the eventually detectable, negative and positive, impact of these deviations on outcomes was. Results A total of 152 patients (2 missing consent) were included (100%). In 69 patients (45.4%), a total of 89 eligibility criteria were disobeyed. In 54 (35.6%) cases, maternal criteria were concerned: Gestational age at operation of >25+6 weeks in 17 (11.2%), uterine pathologies in 13 (8.6%) women, preoperative BMI≥35 kg/m2 in 12 (7.9%), previous hysterotomy in 7 (4.6,%), previous prematurity in 3 (2%), HIV/hepatitis B in 2 (1.3%), psychosocial issues in 2 (1.3%), and placenta praevia in 1 (0.7%). In 32 (21.1%) cases, fetal criteria were disobeyed: Fetal anomaly unrelated to spina bifida in 19 (12.5%), no/minimal evidence of hindbrain herniation in 13 (8.6%), and severe kyphosis in 2 (1.3%). We could not identify cases where non-observation of criteria led to clear-cut maternal and/or fetal disadvantages. Conclusion This study shows that MOMS-Trial eligibility criteria for prenatal spina bifida repair should be modified or even abandoned with adequate medical and ethical argumentation, and with written parental informed consent after non-directive, full disclosure counseling. This clear cut change of paradigm is a necessity as it leads towards personalized medicine allowing more fetuses to benefit from fetal surgery than would have benefitted with the former published MOMS criteria in place

Negative pressure wound treatment for uterine incision necrosis following a cesarean section

Extended-spectrum β-lactamase sepsis with concurrent uterine incision dehiscence after cesarean section with T-shaped incision for chorioamnionitis occurred in a 29-year-old patient after her first delivery. Following an exploratory laparotomy with a diagnosis of necrosis of the anterior uterine wall, a uterine negative-pressure wound treatment (NPWT) was performed, successfully avoiding hysterectomy and enabling secondary suture of the uterine wall

Stage 2: The Vaginal Flora in Women Undergoing Fetal Spina Bifida Repair and Its Potential Association with Preterm Rupture of Membranes and Preterm Birth

Introduction: Vaginal dysbiosis affects pregnancy outcomes, however, the relevance of abnormal findings on pre/post-surgical vaginal culture in women undergoing fetal spina bifida (fSB) repair is unknown. Objectives: To describe the incidence of normal and abnormal pre- and post-surgical vaginal microorganisms in fSB patients and to investigate potential associations between the type of vaginal flora and the occurrence of preterm prelabour rupture of membranes (PPROM) and preterm birth (PTB). Methods: 99 women undergoing fSB repair were eligible (2010–2019). Pre-surgical vaginal culture was routinely taken before surgery. Post-surgical cultures were taken on indication. Vaginal flora was categorized into four categories: healthy vaginal flora (HVF), bacterial vaginosis (BV), desquamative inflammatory vaginitis (DIV), and yeast infection. Results: The incidence of HVF, BV, DIV, or yeast infections was not statistically different between the pre- and postoperative patients. Furthermore, an abnormal pre/post-surgical vaginal flora was not associated with PPROM (OR 1.57 (0.74–3.32), p = 0.213)/OR 1.26 (0.62–2.55), p = 0.515), or with PTB (OR 1.19 (0.82–1.73), p = 0.315)/(OR 0.86 (0.60–1.24), p = 0.425). Conclusions: Abnormal vaginal microbiome was not associated with PPROM and PTB when appropriate treatment was performed. Keywords: fetal spina bifida (fSB) repair; preterm prelabour rupture of the membranes (PPROM); preterm birth (PTB); vaginal flor

Clinical and Histologic Evaluation of the Hysterotomy Site and Fetal Membranes after Open Fetal Surgery for Fetal Spina Bifida Repair

INTRODUCTION Among the risks associated with open fetal surgery, myometrium and fetal membrane issues are vexing problems since they may lead to uterine dehiscence or preterm premature rupture of membranes resulting in uterine rupture or preterm birth or both. The aim of this study was to examine whether stapled and sutured hysterotomy scars demonstrate partial or complete healing. METHODS Hysterotomy sites after open fetal surgery were clinically evaluated in 36 women during Caesarean section, classified into the categories intact, thin, and partially or completely dehiscent, then completely excised and histologically analyzed in 25 cases. The histological examination focused on wound healing of myometrium and fetal membranes. RESULTS The myometrium was intact, thin, and partially or completely dehiscent in 33, 58, and 9%, respectively. The interval between myelomeningocele repair and delivery did not correlate with the healing process. The myometrium showed a reparative zone (scar) with adjacent avital myometrium tissue, fibrosis, and inflammation with foreign body reaction. The intact myometrium was below 1 mm thickness in 56%. All fetal membranes showed complete dehiscence; in 41% they were completely avital. CONCLUSION Our study provides evidence that the myometrium shows scarring with substantial thinning or dehiscence. Fetal membranes do not heal spontaneously. In order to prevent uterine rupture in subsequent pregnancies, we recommend the hysterotomy site to be completely excised after birth