H. Brühwiler

Perinatal outcome of fetuses with a birth weight greater than 4500 g: an analysis of 3356 cases

OBJECTIVE To assess the perinatal outcome in a series of macrosomic fetuses according to the intended mode of delivery, and to estimate the individual risk of shoulder dystocia and brachial plexus injury upon information available either prior the onset of labor or at delivery. STUDY DESIGN Perinatal and postnatal information of 3356 women who delivered during a 10-year period a macrosomic fetus (>4500 g) in vertex presentation were analyzed. After the exclusion of cases with extraneous factors that may have affected the health of the neonate, patient and neonatal characteristics were compared according to the intended mode of delivery. The contribution of factors known prior labor and at the time of deliver on the occurrence of shoulder dystocia and brachial plexus injury was analyzed using multiple logistic regression analysis. RESULTS During the study period, 2371 women were admitted to spontaneous labor, 778 underwent an induction of labor, and 207 had an elective cesarean section. All cases of shoulder dystocia (n=310), and brachial plexus injury (n=94) occurred among women who delivered vaginally. The rate of brachial plexus injury was higher in cases who had shoulder dystocia than in those who did not (58/310 versus 36/2329, P<0.001). The incidence of brachial plexus injury increases steadily from 0.8 in fetuses weighing 4500-4599 g to 2.86% in those weighing more than 5000 g (P<0.01) and from 2.1 in women taller than 180 cm to 12.5% in those shorter than 155 cm (P<0.05). After adjustment for confounding variables shoulder dystocia (OR 9.2, 95% C.I. 5.38; 15.59), operative vaginal delivery (OR 1.96, 95% C.I. 1.10; 3.49) and clavicular fracture (OR 2.9, 95% C.I. 1.31; 6.44) remained predictors of brachial plexus injury. CONCLUSION Since some of these risk factors are known prior to delivery, each woman whose fetus is suspected to weight more than 4500 g should be counseled on her individual risk of severe perinatal morbidity before a decision on the mode of delivery is taken.

[Preconceptional use of folic acid in the region of the Kantonsspital Münsterlingen/Thurgau: has it changed over the past 10 years?].

BACKGROUND  Numerous studies have shown that the preconceptional use of folic acid prevents neural tube defects. We created a study to find out whether the preconceptional use of folic acid has improved in the past 10 years, in the area of Münsterlingen, Switzerland. MATERIAL AND METHODS  We interviewed 2 groups of patients who delivered at our Institution, namely between 2000 and 2002 (period A) involving 287 women and from 2009 to 2010 (period B) involving 305 pregnant women. We asked them whether they used folic acid by means of a standardised questionnaire. RESULTS  In period B significantly more women have taken folic acid preconceptionally (period A: 27.5% vs. period B: 40.7%; p=0.001). A significant increase in folic acid intake was seen in the German speaking group from period A to B (30.3% vs. 52.7%; p=0.0005), while this was not the case in the non-German speaking group (21.4% in both periods). More multiparaé women were taking folic acid compared to nulliparae. A significant increase from period A to B was noted only in the German speaking group. Unexpectedly, in nulliparae non-German speaking women, folic acid supplementation decreased from 14% to 6.1%. DISCUSSION  We have found a significant increase in preconceptional folic acid supplementation from 2001 to 2010. The percentage of women taking folic acid is disappointingly low in all groups, particularly in nulliparae women of non-German ethnicity.Hintergrund:  Zahlreiche Studien zeigen, dass die Entstehung von kindlichen Neuralrohrdefekten durch eine ausreichende prakonzeptionelle bzw. perikonzeptionelle Gabe von Folsaure als Prophylaxe an die Mutter weitgehend verhindert werden kann. Unser Team fuhrte im Abstand von 9 Jahren 2 Studien zur Verbreitung der Folsaureprophylaxe in der Region Munsterlingen (Thurgau, Schweiz) durch. Material und Methoden:  Zwischen 2000 und 2002 (Periode A) haben wir 287 von uns behandelte Frauen zu deren Gebrauch von Folsaure interviewt. Im Vergleich dazu befragten wir eine Gruppe von 305 schwangeren Frauen in unserer Sprechstunde vom Juli 2009 bis Januar 2010 (Periode B) mithilfe eines standardisierten Fragebogens. Die Auswertung erfolgte unter den Gesichtspunkten der Parititat und der Herkunft. Ergebnisse:  In Periode B haben signifikant mehr Frauen prakonzeptionell Folsaure eingenommen als in Periode A (Periode A: 27,5% vs. Periode B: 40,7%; p=0,001). Dies zeigt sich aber nur bei Frauen aus der Schweiz, Deutschland oder Osterreich (30,3% vs. 52,7%; p=0,0005). In der Gruppe aus den anderen Landern blieb der Stand gleich (21,4% in beiden Perioden). Im Gegensatz zu den Erstgebarenden nahmen deutlich mehr 1 Multiparas Folsaure ein. Ein signifikanter Anstieg zwischen beiden Perioden konnte aber auch hier nur in der Gruppe aus der Schweiz, Deutschland oder Osterreich verzeichnet werden. Bei den Primiparas aus anderen Landern sank der Prozentsatz unerwartet von 14% auf 6,1%. Schlussfolgerung:  Obwohl die Anzahl der Frauen mit prakonzeptioneller Folsaureeinnahme zwischen 2001 und 2010 signifikant gestiegen ist, bleibt sie doch indiskutabel niedrig. Dies trifft vor allem auf fremdsprachige Primipara zu.

The non-communicating rudimentary horn: diagnostic and therapeutic challenges

We describe the case of a 23-year-old nulligravid woman who complained of increasing post-menstrual lower abdominal pain. She used contraceptives permanently for three months and was referred with a sub-mucosal lesion suspicious for a type 2 fibroid to be resected. During hysteroscopy, no fibroid mass could be confirmed. A post-operatively performed ultrasound including hydrosonography demonstrated a lesion highly suspicious for a uterus unicollis with a non-communicating uterine horn and a haematometra. Laparoscopy confirmed a normal outer lining of the uterus with hypoplastic tube on the right side. Referring to pre-operative findings, a broadly based uterine horn including a large haematometra was diagnosed. We performed a laparoscopic resection of the rudimentary horn and a right salpingectomy. The patient could be discharged without any complications three days later.

F116Wharton's jelly quantification during gestation and its correlation with fetal biometry

Background