Morbiditäts- und Mortalitätskonferenz

Die Morbiditäts- und Mortalitätskonferenz (MuM-Konferenz) definiert sich als regelmäßige interdisziplinäre Fallkonferenz von vermeidbaren und/oder unerwünschten Ereignissen. Ziel ist die Sicherstellung eines zeitnahen und kontinuierlichen Verbesserungsprozesses von Behandlungsqualität und Patientensicherheit sowie der Stärkung der Zusammenarbeit und Sicherheitskultur. Dieser Beitrag bietet praktische Tipps und Tricks für die Vorbereitung, Durchführung und Nachbereitung einer MuM-Konferenz anhand unserer Erfahrungen in der Klinik für Geburtshilfe des UniversitätsSpitals Zürich. Die MuM-Konferenz reiht sich in eine Reihe von Maßnahmen ein, welche maßgebend zur Verbesserung von Zusammenarbeit, Behandlungsqualität, Patientensicherheit und Sicherheitskultur sowie der Erweiterung relevanter Wissens- und Handlungskompetenzen beitragen

Invasive intrauterine Therapien

Fortschritte in Bildgebung und Medizintechnik haben mittlerweile dazu geführt, dass fetale Erkrankungen früh erkannt und in bestimmten Fällen auch intrauterin behandeln werden können. Ethisch darf eine fetale Therapie nur dann angeboten werden, wenn die intrauterine Behandlung einen deutlichen Vorteil gegenüber der postnatalen Behandlung darstellt bzw. wenn die intrauterine Therapie bleibende Schäden oder den intrauterinen Fruchttod (IUFT) verhindern kann. Invasive fetale Therapien werden z. B. bei einer fetalen Anämie, dem fetofetalen Transfusionssyndroms, der fetalen Spina bifida und der kongenitalen Zwerchfellhernie angeboten. Eine der Hauptkomplikationen der invasiven fetalen Eingriffe ist der vorzeitige Blasensprung

Are Cervical Length and Fibronectin Predictors of Preterm Birth after Fetal Spina Bifida Repair? A Single Center Cohort Study

BACKGROUND: A remaining risk of fetal spina bifida (fSB) repair is preterm delivery. This study assessed the value of preoperative cervical length (CL), CL dynamics (∆CL) and fetal fibronectin (fFN) tests to predict obstetric complications and length of stay (LOS) around fSB repair. METHODS: 134 patients were included in this study. All patients had CL measurement and fFN testing before fSB repair. ∆CL within the first 14 days after intervention and until discharge after fSB repair were compared in groups (∆CL ≥ 10 mm/<10 mm; ≥20 mm/<20 mm). CL before surgery, ∆CL's, and positive fFN tests were correlated to obstetric complications and LOS. RESULTS: Mean CL before surgery was 41 ± 7 mm. Mean GA at birth was 35.4 ± 2.2 weeks. In the group of ∆CL ≥ 10 mm within the first 14 days after intervention, LOS was significantly longer (p = 0.02). ∆CL ≥ 10 mm until discharge after fSB was associated with a significantly higher rate of GA at birth <34 weeks (p = 0.03). The 3 positive fFN tests before fSB repair showed no correlation with GA at birth. CONCLUSION: Perioperative ∆CL influences LOS after fetal surgery. ∆CL ≥ 10 mm until discharge after fSB repair has a 3-times higher rate of preterm delivery before 34 weeks. Preoperative fFN testing showed no predictive value for preterm birth after fSB repair and was stopped

Information Gathering about Pregnancy, Birth, and Puerperium—Good and Fake Information

Recent research on the subject of information-gathering processes among pregnant women has revealed a shift towards online sources. Health professionals’ knowledge about sources of information has been shown to improve the understanding and counseling of patients. The objective of this study was to create an overview of all types of sources relevant to information gathering and to put their role and perception into perspective. Methods: A total of 249 women were included in this study and recruited over a period of one month at the University Hospital of Zurich (USZ). Exclusion criteria included cases of fetal demise and late abortions. The survey on information-gathering processes was divided into three stages: pregnancy, birth, and puerperium. The different sources of information were compared based on women’s characteristics. Results: The response rate was 78% (n = 197). The main findings include a significant difference in information gathering based on varying levels of education, with women at the lowest educational level using the Internet the least during pregnancy (p = 0.029). During puerperium, significant differences could be observed in the involvement of the gynecologist. Primipara women as well as women of lower educational levels contacted their gynecologist less in contrast to multipara women (p = 0.006) and women of higher educational levels (p = 0.011). Overall, health professionals were considered to be the most important source of information. Conclusions: This study demonstrates that parity and educational level influence the information-gathering process. As the most important source for information gathering, health professionals must use this advantage to better assist their patients in accessing reliable information

Miniaturized Bioengineered Models for Preterm Fetal Membrane Healing

Introduction: The reason for the absence of fetal membrane (FM) healing after a fetoscopic intervention is still unknown. We hypothesize that the lack of robust miniaturized models to study preterm FM functions is currently hampering the development of new treatments for FM healing. Specifically, miniaturized models to study preterm FM healing with minimal amounts of tissue are currently lacking. Methods: In this study, we collected FMs from planned cesarean deliveries and developed different ex vivo models with an engineered biomaterial to study FM healing. Then, the effect of platelet-derived growth factor BB (PDGF-BB) on the migration of cells from preterm and term FMs was evaluated. Results: FMs could be viably cultured ex vivo for 14 days. In a model of punctured FMs, migration of cells into FM defects was less pronounced than migration out of the tissue into the biomaterial. In a miniaturized model of preterm cell migration, PDGF-BB promoted migration of preterm amnion cells into the biomaterial. Discussion and Conclusion: By using a novel miniaturized model of preterm tissue, we here successfully demonstrate that PDGF-BB can promote preterm FM cell migration of microtissues encapsulated in a three-dimensional environment

Serum Pancreatic Stone Protein Reference Values in Healthy Pregnant Women: A Prospective Cohort Study

Background: In non-pregnant populations, pancreatic stone protein (PSP) has been reported to have a higher diagnostic performance for identifying severe inflammatory and infectious disease than other established biomarkers. Objective: To generate reference values for serum PSP in pregnancy and compare them to the values of the general healthy population. Design: A prospective cohort study. Setting: A single center. Population: Healthy women with singleton and multiple pregnancies. Methods: This is a prospective single-center cohort study. Between 2013 and 2021, samples of 5 mL peripheral blood were drawn from 440 healthy pregnant women. Therein, 393 cases were singletons and 47 were multiple pregnancies. Serum PSP levels were measured by specific enzyme-linked immunosorbent assay. The main outcome measures were serum PSP level (ng/mL) reference values in healthy pregnant women. Results: The mean PSP reference values in women with singleton pregnancies were 7.9 ± 2.6 ng/mL (95% CI; 2.69–13.03 ng/mL). The PSP values in women with multiple pregnancies (9.17 ± 3.06 ng/mL (95% CI; 3.05–15.28 ng/mL)) were significantly higher (p = 0.001). The PSP values in the first trimester (6.94 ± 2.53 ng/mL) were lower compared to the second (7.42 ± 2.21 ng/mL) and third trimesters (8.33 ± 2.68 ng/mL, p = 0.0001). Subgroup analyses in singletons revealed no correlations between PSP values, maternal characteristics, and pre-existing medical conditions. Conclusion: The PSP values in healthy pregnant women (4–12 ng/mL) were in the range of the reference values of the general healthy population (8–16 ng/mL). This insight blazes a trail for further clinical studies on the use of PSP as a potential novel biomarker for the early detection of pregnancy-related diseases such as chorioamnionitis

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

The Role of Pancreatic Stone Protein (PSP) as a Biomarker of Pregnancy-Related Diseases

Background: Pancreatic stone protein (PSP) is a biochemical serum marker that contains levels that are elevated in various inflammatory and infectious diseases. The role of PSP in the diagnosis of these diseases seems to be more important compared to clinically established biochemical serum markers in discriminating the severity of the same diseases. Standard values for PSP in pregnant women in relation to gestational age have been reported recently. Additionally, increased PSP levels have been observed to be associated with renal dysfunction in pregnant women. The aim of this study is to evaluate the diagnostic role of PSP in pregnancy-related diseases, such as pre-eclampsia (PE), hemolysis-elevated liver enzymes, and low platelet (HELLP) syndrome. In addition, the study aims to assess its diagnostic role in inflammation-triggered diseases as preterm premature rupture of membranes (PPROM) or COVID-19-positive pregnant women. Materials and Methods: In this single-centred prospective study performed at a tertiary university hospital between 2013 and 2021, we included 152 pregnant women who were diagnosed with either PE, HELLP syndrome, or PPROM. In December 2020, in the context of the COVID-19 pandemic, the Independent Ethics Committee (IEC) approved an amendment to the study protocol. Depending on the underlying disease, single or serial-serum PSP measurements were assessed. These PSP values were compared to PSP levels of women with normal pregnancies. Results: Pregnant women diagnosed with pre-eclampsia or HELLP syndrome had significantly increased PSP values (mean 9.8 ng/mL, SD 2.6) compared to healthy singleton pregnant women (mean 7.9 ng/mL, SD 2.6, p ≤ 0.001). There was no difference in serum PSP in pregnant women with PPROM compared to women with uncomplicated singleton pregnancies (mean in PPROM: 7.9 ng/mL; SD 2.9 versus mean in healthy pregnancies: 7.9 ng/mL; SD 2.6, p = 0.98). Furthermore, no difference in the PSP values in women with or without intra-amniotic infection was observed (infection: mean 7.9 ng/mL; SD 2.8 versus no infection: mean 7.8 ng/mL; SD 3, p = 0.85). The mean value of PSP in COVID-19-infected women during pregnancy (8.5 ng/mL, SD 2.3) was comparable to healthy singleton pregnancies (mean 7.9 ng/mL, SD 2.6), p = 0.24. Conclusions: The novel serum biomarker PSP is significantly upregulated in pregnant women with pre-eclampsia and HELLP syndrome. Our observations call for the further evaluation of PSP in randomized controlled clinical trials to demonstrate the actual role of PSP in pregnancy-related diseases and whether it may provide new approaches for the management and discrimination of the severity of these gestational conditions

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