Larry Hinkson

Human birth observed in real-time open magnetic resonance imaging

OBJECTIVE Knowledge about the mechanism of labor is based on assumptions and radiographic studies performed decades ago. The goal of this study was to describe the relationship between the fetus and the pelvis as the fetus travels through the birth canal, using an open magnetic resonance imaging (MRI) scanner. STUDY DESIGN The design of the study used a real-time MRI series during delivery of the fetal head. RESULTS Delivery occurred by progressive head extension. However, extension was a very late movement that was observed when the occiput was in close contact with the inferior margin of the symphysis pubis, occurring simultaneously with gliding downward of the fetal head. CONCLUSION This observational study shows, for the first time, that birth can be analyzed with real-time MRI. MRI technology allows assessment of maternal and fetal anatomy during labor and delivery.

Prenatal Detection and Consequences of Fetal Macrosomia

Macrosomia is diagnosed when excessive intrauterine fetal growth occurs and the birth weight surpasses an established limit. The causes and risk factors for fetal macrosomia are diverse. Pregnancies with fetal macrosomia are considered high risk and require intensive antenatal care. Prenatal ultrasound appears to be the best method for performing weight estimates before birth, as the correct birth weight is often underestimated when using biometric formulae to determine the fetal weight. Three-dimensional volume sonography has been shown to improve estimates of fetal weight by including limbs volumes. The recent Hart formula has been specifically developed for fetal macrosomia estimation and appears to improve accuracy. Delivery of a macrosomic baby is also high risk and should be performed in tertiary centres with experienced obstetricians.

Vasa praevia: risk-adapted modification of the conventional management--a retrospective study.

PURPOSE Undiagnosed vasa praevia carries an imminent risk of fetal death and increases with IVF. When diagnosed, the question arises as to whether the conventional prenatal management of routine steroid administration for fetal lung maturation and elective caesarean section in week 35 is generally justified in face of the risks involved. We present a retrospective study of a risk-adapted modification of the conventional management of vasa praevia. MATERIAL AND METHODS We analysed 11 years of records involving 18 cases of antenatally diagnosed vasa praevia at our perinatal centre. Each case was managed by a risk-adapted modification of the conventional treatment where both, the steroid administration and the timing of delivery, were dependent on the patient history and clinical signs for preterm birth. RESULTS There were no lethal fetal, neonatal, or maternal complications. The earliest caesarean section took place at 34 weeks 1 day, the latest at 37 weeks 1 day, and in more than half of the cases at ≥ 36 weeks. CONCLUSION Steroid application is generally recommended for pregnancies before 34 weeks carrying a risk for preterm birth. Thus, retrospectively, none of our cases required steroid administration. This supports our protocol of not obligatorily administering steroids. Delaying the caesarean section up to two weeks beyond the conventionally recommended date of 35 weeks in 78% of our cases resulted in no complications. This justifies the suitability of determining the timing of delivery based on our individual patient assessment. In conclusion, the following recommendations for a risk-adapted management of vasa praevia can be made: 1. weekly evaluation of risk factors for preterm delivery; 2. steroid administration only at risk for preterm birth; 3. admission to hospital with full obstetric and neonatal care facilities between 32 and 34 weeks; 4. elective caesarean section between 35 and 37 weeks, risk-adapted.

Radiofrequency ablation as a minimally invasive procedure in the treatment of twin reversed arterial perfusion sequence in twin pregnancy.

Twin reversed arterial perfusion sequence is a rare anomaly of monochorionic multiple pregnancies affecting 1 of 35,000 pregnancies and 1% of monochorionic twin pregnancies. In this condition the affected twin has lethal malformations including poor or absent heart development and is reversely perfused by a structurally normal co‐twin. We report a case of a 21‐year‐old woman with a monochorionic twin pregnancy affected by twin reversed arterial perfusion sequence. This case highlights the therapeutic options and the management by radiofrequency ablation, which has been shown to be an easy and reliable technique with a high success rate compared with technically demanding fetoscopic procedures.

Pregnancies in Women Aged 45 Years and Older – a 10-Year Retrospective Analysis in Berlin

Introduction Improved fertility treatment options and a change in the socio-cultural concept of family planning, especially in industrialized regions, has led to an increasing number of births by women of advanced maternal age, which is associated with a higher rate of complications. The aim of this study was to analyze pregnancy outcomes in women aged ≥ 45 years in an inner-city German hospital and to compare these results to those of a younger cohort. Materials and Methods Over a 10-year period from January 2004 to May 2015, the pregnancy outcomes of all 186 women aged ≥ 45 years who delivered in our hospital were compared in a 1 : 1 ratio to those of a cohort of 29-year old women. Results The rates of assisted reproduction (34 vs. 3 %), multiple pregnancies (16 vs. 5 %) and cesarean section (59 vs. 29 %) were significantly increased in the study group. There was an increased risk of preterm delivery (28 vs. 11 %), preeclampsia, gestational diabetes and premature rupture of membranes in the advanced maternal age group. Conclusion Advanced maternal age leads to higher rates of fetal and maternal complications. These findings should be taken into account when planning assisted reproduction and obstetrical care in women with advanced maternal age.

The misoprostol vaginal insert compared with oral misoprostol for labor induction in term pregnancies: a pair-matched case-control study

Abstract Aim: To compare the efficacy and safety of the misoprostol vaginal insert (MVI) with an off-label use of oral misoprostol (OM). Methods: Pair-matched case-control study comparing the induction of labor with a retrievable MVI to OM. The primary outcomes were the time from induction to delivery and the cesarean section rate. Secondary outcomes included uterine tachysystole, tocolysis, fetal scalp blood testing, meconium-stained amniotic fluid, umbilical arterial pH, and Apgar score. Results: One hundred and thirty eight women ≥37/0 weeks pregnant undergoing labor induction with misoprostol were included. The mean time from application to delivery was significantly shorter and the caesarean section rate significantly higher in the MVI group (P<0.01) with an odds ratio of 2.75 (95% CI: 1.21–6.25) in favor of vaginal delivery in the OM group. The mean 5-min Apgar scores and arterial cord pH values were significantly lower in the MVI group. An arterial pH value of 7.10–7.19 was found in 26.1% and 15.9%, and a value <7.10 was found in 4.3% and 0% of MVI and OM cases, respectively. Conclusion: The MVI compared with OM significantly shortened the time from application to delivery at the expense of a higher cesarean section rate and negative effects on neonatal outcomes.

Longitudinal transvaginal ultrasound evaluation of cesarean scar niche incidence and depth in the first two years after single‐ or double‐layer uterotomy closure: a randomized controlled trial

Cesarean deliveries are the most common abdominal surgery procedure globally, and the optimal way to suture the hysterotomy remains a matter of debate. The aim of this study was to assess the incidence of cesarean scar niches and the depth after single‐ or double‐layer uterine closure.

Correlation of intrapartum translabial ultrasound parameters with computed tomographic 3D reconstruction of the female pelvis.

Abstract Aims: Intrapartum translabial ultrasound [ITU] can be an objective, reproducible and more reliable method than digital vaginal examination when evaluating fetal head position and station in prolonged second stage of labor. However, two-dimensional (2D) ultrasound is not sufficient to demonstrate the ischial spines and other important “landmarks” of the female pelvis. Therefore, the purpose of this study was to evaluate the distance of the interspinous plane as a parallel line to the infrapubic line in 2D ITU with the help of 3D computed tomography and digital reconstruction. Results: Mean distance between the infrapubic plane and the tip of the ischiadic spine was 32.35 (±4.46) mm. The mean height was 166 (±7) cm; the mean weight was 67.5 (±18.4) kg. Body height and the measured distance were significantly correlated (P=0.025; correlation coefficient of 0.5), whereas body weight was not (P=0.37; correlation coefficient of –0.214). Conclusions: With the present results, clinicians were enabled to transfer the reproducible measurements of the “head station” by ITU to the widespread but observer-depending vaginal examination. Furthermore, ITU can be verified as an objective method in comparison to subjective palpation with the ability to optimize the evaluation of the head station according to bony structures as landmarks in a standardized application.

Evaluation of measured postpartum blood loss after vaginal delivery using a collector bag in relation to postpartum hemorrhage management strategies: a prospective observational study

Abstract Aim: To evaluate the incidence of postpartum hemorrhage (PPH) and severe PPH via routine use of a pelvic drape to objectively measure blood loss after vaginal delivery in connection with PPH management. Methods: This prospective observational study was undertaken at the obstetrical department of the Charité University Hospital from December 2011 to May 2013 and evaluated an unselected cohort of planned vaginal deliveries (n=1019 live singletons at term). A calibrated collecting drape was used to meassure blood loss in the third stage of labor. PPH and severe PPH were defined as blood loss ≥500 mL and ≥1000 mL, respectively. Maternal hemoglobin content was evaluated at admission to delivery and at the first day after childbirth. Results: During the study period, 809 vaginal deliveries were analysed. Direct measurement revealed a median blood loss of 250 mL. The incidences of PPH and severe PPH were 15% and 3%, respectively. Mean maternal hemoglobin content at admission was 11.9±1.1 g/dL, with a mean decrease of 1.0±1.1 g/dL. Blood loss measured after vaginal delivery correlated significantly with maternal hemoglobin decrease. Conclusions: This study suggests that PPH incidence may be higher than indicated by population-based data. Underbuttocks drapes are simple, objective bedside tools to diagnose PPH. Blood loss should be quantified systematically if PPH is suspected.

Surgical site infection in cesarean sections with the use of a plastic sheath wound retractor compared to the traditional self-retaining metal retractor.

OBJECTIVE A cesarean section rate of up to 19.4% is reported worldwide. Surgical site infection occurs with rates of up to 13.5%. Plastic-sheath wound retractors show reduced rates of surgical site infections in abdominal surgery. There is limited evidence in women having cesarean sections. This study evaluates the use of the Alexis(®) O C-Section Retractor in the prevention of surgical site infection in patients undergoing their first planned cesarean section compared to the traditional Collins self-retaining metal retractor. STUDY DESIGN A single center, prospective, randomized, controlled, observational trial. The primary outcome is surgical site infection as defined by the Centers for Disease Control and Prevention. The secondary outcomes included intraoperative surgical parameters, postoperative pain scores and the short and long-term satisfaction with wound healing. From October 2013 to December 2015 at the Charité University Hospital, Berlin. 98 patients to the Alexis(®) O C-Section Retractor group and 100 to the traditional Collins self-retaining metal retractor group. RESULTS A statistically significant reduction in the rate of surgical site infections, when the Alexis(®) O C-Section Retractor was used for wound retraction compared to the traditional Collins metal self-retaining wound retractor, 1% vs. 8% (RR 7.84, 95% CI (2.45-70.71) p=0.035). CONCLUSIONS The use of plastic-sheath wound retractors compared to the traditional self-retaining metal retractor in low risk women, having the first cesarean section is associated with a significantly reduced risk of surgical site infection.