Christian Haslinger

Risk factors of uterine rupture with a special interest to uterine fundal pressure

Abstract Purpose: Uterine rupture is a rare but serious event with a median incidence of 0.09%. Previous uterine surgery is the most common risk factor. The aim of our study was to analyze retrospectively women with uterine rupture during labor and to evaluate postulated risk factors such as uterine fundal pressure (UFP). Methods: Twenty thousand one hundred and fifty-two deliveries were analyzed retrospectively. Inclusion criteria were 22 weeks and 0 days–42 weeks and 0 days of gestation, singleton pregnancy and cephalic presentation. Women with primary cesarean section were excluded. A logistic regression analysis adjusting for possible risk factors was conducted and a subgroup analysis of women with unscarred uterus was performed. Results: Twenty-eight cases of uterine rupture were identified (incidence: 0.14%). Uterine rupture was noticed in multipara patients only. In the multivariate analysis among all study patients, only previous cesarean section remained a statistically significant risk factor [adjusted odds ration (adj. OR) 12.52 confidence interval (CI) 95% 5.21–30.09]. In the subgroup analysis among women with unscarred uterus (n=19,415) three risk factors were associated with uterine rupture: UFP (adj. OR 5.22 CI 95% 1.07–25.55), abnormal placentation (adj. OR 20.82 CI 95% 2.48–175.16) and age at delivery >40 years (adj. OR 4.77 CI 95% 1.44–15.85). Conclusions: The main risk factor for uterine rupture in the whole study population is previous uterine surgery. Risk factors in women with unscarred uterus were UFP, abnormal placentation, and age at delivery >40 years. The only factor which can be modified is UFP. We suggest that UFP should be used with caution at least in presence of other supposed risk factors.

Position at birth as an important factor for the occurrence of anal sphincter tears: a retrospective cohort study.

Abstract Objective: This work aimed to analyze the association between maternal position at birth in spontaneous deliveries and the occurrence of anal sphincter tears (AST) given the lack of evidence related to the least traumatic birth position. Study design: A total of 7832 vaginal deliveries were included. Vaginal-operative deliveries and deliveries with fundal pressure were excluded. Birth positions on bed, in water, kneeling, and in a squatting position on a low stool were compared. Birth position on bed was considered as the reference group, and a logistic regression analysis adjusting for important fetomaternal parameters was performed. Results: The overall incidence of AST was 1.1%. AST rate was significantly increased in squatting (2.9%) and kneeling (2.1%) positions compared with birth position on bed (1.0%) or in water (0.9%). Logistic regression analysis revealed a significantly higher risk for ASTs in squatting (OR 2.92, CI 95% 1.04–8.18) and in kneeling positions (OR 2.14, CI 95% 1.05–4.37) compared with the reference group on bed. When adjusting for risk factors, birth in a kneeling position remained significantly associated with ASTs (adj. OR 2.21, CI 95% 1.07–4.54). Conclusions: Birth in squatting or in kneeling position is associated with an elevated risk for ASTs. Birth in water is not associated with an increased risk for AST. Based on the results, women should be informed about the association of certain birth positions with the occurrence of AST.

Maternal and fetal outcomes after uterine fundal pressure in spontaneous and assisted vaginal deliveries

Abstract Aim: This study aimed to evaluate maternal and fetal outcomes after uterine fundal pressure (UFP) in spontaneous and assisted vaginal deliveries. Methods: In a retrospective cohort study, 9743 singleton term deliveries with cephalic presentation were analyzed from 2004 to 2013. Spontaneous and assisted vaginal deliveries were analyzed separately with and without the application of UFP. Odds ratios were adjusted in a multivariate logistic regression analysis. Results: Prevalence of UFP was 8.9% in spontaneous and 12.1% in assisted vaginal deliveries. UFP was associated with a higher incidence of shoulder dystocia in both spontaneous (adjusted odds ratio [adj. OR] 2.44, confidence interval [CI] 95% 1.23–4.84) and assisted vaginal deliveries (adj. OR 6.88 CI 95% 3.50–13.53). Fetal acidosis (arterial umbilical pH<7.2) was seen more often after the application of UFP in spontaneous vaginal deliveries (adj. OR 3.18, CI 95% 2.64–3.82) and assisted vaginal deliveries (adj. OR 1.59 CI 95% 1.17–2.16). The incidence of 5′-Apgar<7 (adj. OR 2.19 CI 95% 1.04–4.6) and 10′-Apgar<7 (adj. OR 3.04 CI 95% 1.17–7.88) was also increased after the application of UFP in spontaneous deliveries. A higher incidence of anal sphincter tears (AST) (adj. OR 46.25 CI 95% 11.78–181.6) in the UFP group of spontaneous deliveries was observed. Conclusions: UFP is associated with increased occurrence of shoulder dystocia and fetal acidosis. In spontaneous deliveries, the risk for lower Apgar scores after 5 and 10 min is increased, as well as the risk for AST.

Rektusdiastase und Schwangerschaft

Diastasis recti abdominis during pregnancy is a frequent phenomenon with a prevalence of 30–70%. It is associated with functional and cosmetic limitations. Gold standard in diagnosis during pregnancy is the transabdominal ultrasonography. The most frequent localization is in the periumbilical region and persistence postpartum is found in about 60% of cases. Either conservative or surgical treatments seem to be effective, but relapse rates, especially after surgical therapy, are unclear. It is a problem that no standard values of diastasis recti are given, no evidence-based therapy schemes are implemented and only rare and insufficient studies exist.

Effect of dual tocolysis with fenoterol and atosiban in human myometrium

Abstract Objectives To measure the tocolytic effect of the combination of the oxytocin receptor antagonist atosiban with the β-mimetic agent fenoterol on human myometrium of pregnant women. Methods An in vitro study of contractility in human myometrium at the Laboratory of the Department of Obstetrics, University Hospital of Zürich, Switzerland, was performed. Thirty-six human myometrial biopsies were obtained during elective caesarean sections of singleton pregnancies at term. Tissue samples were exposed to atosiban, fenoterol and the combination of atosiban with fenoterol. Contractility was measured as area under the curve during 30 min of spontaneous contractions. The effect of treatment was expressed as the percentage of change from basal activity during 30 min of exposure. Differences were calculated using a paired Wilcoxon signed-rank test. An additive effect of dual tocolysis was assumed when no significant difference was detected between the observed and expected inhibition of dual tocolysis. When inhibition was greater or lower than expected, the dual combination was characterised as “synergistic” or “antagonistic”, respectively. Results Atosiban and fenoterol alone suppressed contractions by a median of 43.2% and 29.8%, respectively. The combination of atosiban plus fenoterol was measured at a level of 67.3% inhibition. There was no significant difference in the expected (63.2%) and observed inhibition effect of dual tocolysis (P=0.945). Conclusion This study demonstrated an additive effect of dual tocolysis of atosiban and fenoterol on human myometrium in vitro, but no synergistic or antagonistic effect.

Validation of a quantitative system for real-time measurement of postpartum blood loss

PurposeReliable real-time estimation of blood loss is crucial for the prompt management of postpartum hemorrhage (PPH), which is one of the major obstetric complications worldwide. Our study aims at the validation of feasibility and precision of measured blood loss (MBL) with a quantitative real-time measurement system during (1) vaginal delivery and (2) cesarean section by comparison with a hemoglobin-based formula for blood loss as an objective control. This is the first study to include a reasonable number of patients in an everyday clinical setting.Methods921 patients were prospectively enrolled into this study (vaginal delivery: n = 461, cesarean delivery: n = 460) at a tertiary care hospital in Switzerland. Blood loss was measured by quantitative fluid collection bags. “Calculated blood loss” (CBL) was determined by modified Brecher`s formula based on the drop of hemoglobin after delivery. MBL based on our measurement system was compared to CBL by correlation analysis and stratified by the mode of delivery.ResultsDuring vaginal delivery, MBL as determined by our quantitative measurement system highly correlated with CBL (p < 0.001, r = 0.683). This was also true for patients with cesarean deliveries (p < 0.001, r = 0.402), however, in a less linear amount. In women with cesarean deliveries, objectively low blood loss tended to be rather overestimated, while objectively high blood loss was more likely underestimated.ConclusionsThe technique of real-time measurement of postpartum blood loss after vaginal delivery as presented in this study is practicable, reliable and strongly correlated with the actual blood loss and, therefore, poses an actual improvement in the management of PPH.

Postpartum Blood Loss in Women Treated for Intrahepatic Cholestasis of Pregnancy

OBJECTIVE: To evaluate postpartum blood loss in women with treated intrahepatic cholestasis of pregnancy. METHODS: In a retrospective case–control study, 15,083 deliveries including 348 women with intrahepatic cholestasis of pregnancy (2.3%) were analyzed from 2004 to 2014. To adjust for differences in baseline characteristics, a propensity analysis was performed and women in the control group were matched to the women in the intrahepatic cholestasis of pregnancy group in a 5:1 ratio. Blood loss was analyzed by estimated blood loss and &Dgr; hemoglobin (Hb, difference between prepartum and postpartum Hb). A subgroup analysis regarding severity of intrahepatic cholestasis of pregnancy based on maximum bile acid level (mild [less than 40 micromoles/L], moderate [40–99 micromoles/L], and severe intrahepatic cholestasis of pregnancy [100 micromoles/L or greater]) was performed. Differences in estimated blood loss, &Dgr;Hb, and meconium staining between subgroups were analyzed. A Spearman rank correlation was performed to evaluate the association of bile acid levels and blood loss within subgroups. RESULTS: Estimated blood loss (median 400 [300–600] mL compared with 400 [300–600] mL, P=.22), &Dgr;Hb (14.0 [5.0–22.0] compared with 12.0 [4.0–21.0] g/L, P=.09), meconium staining (14.5% compared with 11.4%, P=.12), and number of stillbirths after 26 weeks of gestation (0.6% compared with 1.8%, P=.10) were not significantly different in the study compared with the control group. In moderate and severe intrahepatic cholestasis of pregnancy, meconium staining was observed significantly more often compared with that in a control group (23.0% and 32.3% compared with 11.4%, P<.01). There was no correlation between estimated blood loss or &Dgr;Hb and severity of intrahepatic cholestasis of pregnancy. CONCLUSIONS: In our cohort of women with intrahepatic cholestasis of pregnancy who are treated with ursodeoxycholic acid and have planned delivery (induction of labor or planned cesarean delivery) at 38 weeks of gestation, no differences in postpartum blood loss were seen.