The cesarean section rates for twin births vary widely across the world and across Europe. Mothers of twins, however, prefer a vaginal birth following a competent counselling in which they can have a say. The prerequisite is that multiple birth mothers are advised, monitored and delivered by experienced obstetric teams, which should be available and reachable 24 h a day. Regardless of the chorionicity, gestational age and fetal weight discrepancy, a vaginal birth is recommended if the presenting fetus is in a cephalic presentation, regardless of the position of the second twin. In the case of a high position of the nonpresenting fetus either in a cephalic, breech or transverse position, the birth management requires a special set of birth maneuvers and procedures. A timely epidural anesthesia may be helpful in performing these maneuvers. The birth of the second twin should take place quickly when possible by a well-drilled birth maneuver and in cases of a standing amniotic sac, as a short birth interval between the two fetuses (< 10 min) is associated with a better outcome. The vaginal birth in cases of triplets is also possible depending on the experience of the team but involves more logistical challenges. Through regular simulations and exercises, the awareness and acceptance of vaginal birth in multiple pregnancies can be increased within the obstetrical team.

Die Kaiserschnittraten bei Zwillingsgeburten variieren welt- und europaweit stark. Zwillingsmütter wünschen sich allerdings eine Vaginalgeburt nach kompetenter Beratung, in der sie über ihr Geburtserlebnis mitentscheiden dürfen. Voraussetzung ist, dass Mehrlingsmütter durch erfahrene geburtsmedizinische Teams beraten, überwacht und entbunden werden. Diese sollten 24 h erreichbar und abrufbar sein. Unabhängig von der Eihautkonstellation, Schwangerschaftsalter und kindlicher Gewichtsdiskrepanz wird bei einer Schädellage des führenden Kindes unabhängig von der Lage des zweiten Zwillings eine vaginale Geburt empfohlen. Bei einem hochstehenden zweiten Fetus in Schädel‑, Beckenend- oder Querlage erfordert die Geburtsleitung besondere Geburtsmanöver und -prozeduren, für dessen einfache Umsetzung eine frühzeitige Periduralanästhesie hilfreich sein kann. Die Geburt des zweiten Zwillings sollte nach Möglichkeit durch geübte Geburtsmanöver schnell und bei stehender Fruchtblase erfolgen, da ein kurzes Geburtsintervall zwischen beiden Feten (< 10 min) mit einem besseren Outcome assoziiert ist. Die vaginale Geburt bei Drillingsschwangerschaften ist ebenso bei Erfahrung des Teams möglich, birgt jedoch mehr logistische Probleme. Durch regelmäßige Simulationen und Übungen können Bewusstsein und Akzeptanz für die vaginale Geburt bei Mehrlingsschwangerschaft im geburtshilflichen Team gesteigert werden.

Objective These recommendations from the AGG (Committee for Obstetrics, Department of Maternal Diseases) on how to treat thyroid function disorder during pregnancy aim to improve the diagnosis and management of thyroid anomalies during pregnancy. Methods Based on the current literature, the task force members have developed the following recommendations and statements. These recommendations were adopted after a consensus by the members of the working group. Recommendations The following manuscript gives an insight into physiological and pathophysiological thyroid changes during pregnancy, recommendations for clinical and subclinical hypo- and hyperthyroidism, as well as fetal and neonatal diagnostic and management strategies.

Background: Malaria continues to remain a global challenge. The study assesses Malaria in Pregnancy Prevention Information Comprehension and Adherence. Methodology: A descriptive survey using the IMB model. A validated questionnaire was used to gather information from 404 ANC attendees. Descriptive statistics and frequency distributions were employed in the analysis of data and simple linear regression analysis was used to determine the relationship among variables. Results: The result showed respondents' mean age of 28.74 ± 68.07, married (70%), self-employed (48.8%), Muslims (52%) of Fulani ethnic origin (25.3%), and secondary educational attainments (39.9%). Information on the 22-point scale reported a mean of 17.8 (0.1) ± 1.9 having a significant relationship with behavioral skills (r = 0.199 and R2 = 0.040), p <0.0001 and adherence (r= 0.114 and R2= 0.013), p-value <0.022; Comprehension on 74-points scale reported a mean score of 47.6 (0.6) ± 12.5. Motivation on the 40-point scale reported 28.4 (0.2) ±3.7 having a significant relationship with behavioral skills (r= 0.255, R2= 0.065), P-value= <0.0001 and Adherence (r= 0.159, R2=0.025), P-value= <0.001). Behavioral skills on a 36-point scale scored 30 (0.2) ± 3.2, having a significant relationship with Adherence (r= 0.101, R2=0.010), P value= <0.042). Adherence on 45-point scale reported 27.1 (0.3) ± 5.0. However, respondents achieved an adherence prevalence rate of 60.2% away from the minimum adherence rate of 95%. Conclusion: Though information facilitates behavior change, this is not guaranteed. Recommendation: Motivational components should be inculcated in all behavior change interventions than the usual clinic-based counseling.

Background: Malaria constitutes grave consequences on the health of the mother and her fetus especially, in sub-Saharan Africa where the burden is most severe. Methodology: This study utilizes a descriptive survey design to optimize Malaria in Pregnancy Prevention (MIPP) Information Adherence to at least a 95% prevalence rate and improve appointment keeping to 100%. The information Motivation Behavioral skills model (IMB) was used to explain how MIPP information adherence can be achieved efficiently in malaria treatment. A validated questionnaire was used to gather information from 384 ANC attendees. This followed ethical permission from the Taraba state ministry of Health and informed consent from participants. Descriptive statistics and frequency distributions were employed in the analysis of data. Simple linear regression analysis was used to determine the relationship among variables. Results: The respondents' mean age was 29.38 ± 8.73. The majority were married (88%), self-employed (40.1%), Christians (73.7%) of Kuteb ethnic origin (25.3%), and having secondary educational attainments (39.3%). A study on a 10-point scale reported the level of MIPP of malaria in pregnancy-related information, = 9.1 (0.86) ± 1.20 having a significant relationship with adherence (p<0.001); comprehension on a 40-point scale reported =33.2 (0.43) ±8.43 also having a significant relationship with adherence (p<0.001): motivation on 18-points scale, scored, =13.5(14.4) ±2.8) having a significant relationship with the outcome variable (p<0.001) and self-ported adherence on a 32-points scale, scored = 21.6 (0.36) ±6.99 Conclusion: Information is important but does not guarantee behavior change. Recommendation: Information should be accompanied by motivational components, to be more effective than the usual clinic-based health talk.

The goal of this study was to examine how regular physical activity before and during pregnancy affected life quality throughout pregnancy. Between July 2020 and May 2021, 218 pregnant women were recruited from 11 outpatient clinics for this survey. Data were collected prospectively in a panel format beginning with the 10th gestational week over a 20-week period. Prior to pregnancy, a previous time point was also defined. The International Physical Activity Questionnaire, the EQ-5D-3L questionnaire, and the EQ-VAS questionnaire were used to collect data on the duration and intensity of daily physical exercises, as well as to assess health-related quality of life and self-estimated health status. The final survey included data from 113 women. During pregnancy, physical activity decreased dramatically. The duration of strenuous activities, but not moderate activities, was significantly reduced. Continuous physical activity independently predicted higher life quality scores at all points of assessment. Cases who participated in moderate and strenuous activities on a regular basis had higher self-estimated health status scores than cases who only participated in moderate activity. Instead of focusing solely on specific types of physical activity, we believe that strategies for motivating all pregnant women to be constantly active should be developed.

Intrahepatic cholestasis of pregnancy (ICP) is associated with adverse fetal and neonatal outcome. Evidence for improvement by obstetric management is sparse. Common international guidelines recommend induction of labor before term, however, they differ in recommendations of monitoring the disease and time point of active management. So far, an official guideline for treatment and management of ICP in Germany does not exist. This study aims to compile common practice and policy in obstetric management of ICP in German maternity units. The objective is to gather obstetricians’ opinion on management of ICP, and to estimate the need for standardization of current practice in Germany on the background of existing evidence. A questionnaire focusing on indications for interventions was developed including fourteen multiple-choice questions comprising the areas of diagnostic criteria, laboratory testing, fetal monitoring, treatment, and delivery timing. The survey was sent to 699 maternity clinics and was distributed to participants of the annual congress hosted by the German society of perinatal medicine (DGPM). Collected data were summarized and evaluated in relation to available evidence and existing guidelines. Descriptive statistics and Fisher's exact test were used. 334 completed questionnaires returned corresponding to a response rate of 48.1%. Coinciding with existing international guidelines, 48.8% of the participants acknowledge bile acid concentrations above 10 µmol/L to be indicative of ICP. 85.0% of obstetricians recommend antenatal testing with cardiotocography, exceeding common standards of maternity policy guidelines; 50.3% execute active management in ICP-affected pregnancies as they generally recommend a delivery between 37 + 0 and 38 + 6 weeks of gestation. Although recent studies evinced a risk of stillbirth in ICP-affected pregnancies not until a bile acid concentration of > 100 µmol/L, 22.2% of the respondents recommend delivery before 37 + 0 weeks of gestation due to raised bile acids of 40–99 µmol/L. Opinions on the management of ICP in German maternity units differ widely and partly deviate by large from international standards. Reasons for this may be the lack of a national guideline and the low awareness due to the rarity of the disease on the one hand and the very slow dynamics in evidence generation and thus the uncertainty about the actual risks and optimal management on the other. The present data highlight the need for further research and clinical guidelines to standardize and optimize treatment based on the best available evidence.

Intestinal and urinary helminth infections affect up to a quarter of the world’s population, with the potential of causing significant public health and economic burden. The occurrence of helminth parasites in stool and urine of residents, and water and soil samples of some communities around Lake Alau, Maiduguri, Nigeria was determined using direct microscopy, floatation and sedimentation techniques. A total of 349 (34.7%) residents were infected out of the 1,005 examined, consisting of 220 (21.9%) males and 129 (12.8%) females, with significant (p<0.05) variation based on gender. Similarly, the infection was significantly (p<0.05) higher among young individuals 197(19.6%) than the adults 152(15.1%). Among the ten communities (Logajiri, Melari, Dumbari, AlauLimanti, Awa Isari, Limanti, Gaskeri, Attakeri, Chellomi and Gomari Karekǝri) examined, the infection was significantly (p<0.05) highest at Gomari Karekǝri 57 (5.7%) and Alau Limanti 55(5.5%) and least at Gaskeri 19 (1.9%) and Chellomari 20 (2.0%). Intestinal parasites encountered consist of Ascaris lumbricoides 234 (23.3%), Trichuris trichiura 24 (2.4%), Strongyloides stercoralis 10 (1.0%), Schistosoma mansoni 8 (0.8%), and Taenia species 1 (0.1%) (p<0.05). Schistosoma haematobium 72 (7.2%) was the only helminth parasite recovered from urine samples examined. Environmental (water and soil) contamination with parasite stages was predominantly with pre-parasitic nematode larvae 50 (25%), eggs of Strongyloides stercoralis 50 (25%), Ascaris lumbricoides 30 (15%), Strongyle spp. 30 (15%) and cysts of protozoans; Entamoeba histolytica 30 (15%) and Giardia intestinalis 10 (5%). The results suggest that infection with intestinal and urinary parasites is common among the residents of the study area and that socio-cultural habits may favour the survival and transmission of these parasites in the area.

Introduction Our study assesses the patients’ opinion about gynecological examination performed by undergraduate students (UgSts). This assessment will be used in improving our undergraduate training program. A positive opinion would mean a lower chance of a patient refusing to be examined by a tutor or student, taking into account vaginal examination (VE). Materials and methods We performed a prospective cross-sectional survey on 1194 patients, consisting of outpatient and inpatient at the departments of obstetrics and gynecology from November 2015 to May 2016. The questionnaire consisted of 46 questions. Besides demographic data, we assessed the mindset of patients regarding the involvement of undergraduate student (UgSt) in gynecological and obstetrical examinations. We used SPSS version 23 for the statistical analysis. For reporting the data, we followed the STROBE statement of reporting observational studies. Results The median age was 38 years having a median of one child. 34% presented due to obstetrical problems, 38% due to gynecological complaints, and 19% due to known gynecological malignancies. Generally, we retrieved a positive opinion of patients towards the involvement of students in gynecological and obstetrical examination under supervision in 2/3 of the cases. Conclusions There is no reason to exclude medical UgSts from gynecological and obstetrical examinations after obtaining a written or oral consent.

Abstract Background Preeclampsia remains a major cause of perinatal and maternal mortality and morbidity worldwide. Wnt/β-catenin signaling is known to be critically involved in placenta development processes. Dickkopf-1 (DKK1) is a key regulator of this transduction pathway. The aim of this study is to compare maternal serum DKK1 levels and placental mRNA levels of DKK1 and β-catenin in preeclamptic and normal pregnant women at delivery. Methods The present study included 30 women with preeclampsia and 30 women with normal pregnancy. Maternal serum DKK1 levels were measured by ELISA. Placental mRNA levels of DKK1 and β-catenin were detected using RT-PCR. Results Decreased maternal serum DKK1 levels were associated with worse maternal and fetal complications including HELLP syndrome, determination of one or more pathological symptom and IUGR diagnosis. No significant difference in maternal serum DKK1 levels was reported between preeclamptic women and women with normal pregnancy. Placental mRNA DKK1 levels were lower in preeclamptic women compared with normal pregnant women. Placental mRNA β-catenin levels showed no significant difference between two groups. Conclusions Our findings reported the aberrant placental mRNA DKK1 levels in patients with preeclampsia. In addition, worse preeclampsia features were associated with decreased maternal serum DKK1 levels. Hence, aberrant Wnt/β-catenin signaling might present a plausible mechanism in preeclampsia pathogenicity. Dysregulated expression of DKK1 at gene level in the placenta but not at protein level in the maternal serum might confirm the notion that preeclampsia is a type of placenta-derived disease.

Purpose The purpose of this survey was to assess medical students’ opinions about online learning programs and their preferences for specific teaching formats during COVID 19 pandemic. Methods Between May and July 2020, medical students who took an online gynecology and obstetrics course were asked to fill in a questionnaire anonymously. The questionnaire solicited their opinions about the course, the teaching formats used (online lectures, video tutorials featuring real patient scenarios, and online practical skills training), and digital learning in general. Results Of 103 students, 98 (95%) submitted questionnaires that were included in the analysis. 84 (86%) students had no problem with the online course and 70 (72%) desired more online teaching in the future. 37 (38%) respondents preferred online to traditional lectures. 72 (74%) students missed learning with real patients. All digital teaching formats received good and excellent ratings from > 80% of the students. Conclusion The survey results show medical students’ broad acceptance of the online course during COVID 19 pandemic and indicates that digital learning options can partially replace conventional face-to-face teaching. For content taught by lecture, online teaching might be an alternative or complement to traditional education. However, bedside-teaching remains a key pillar of medical education.

Background: In forensics, sex estimation is an important step in identification process which can be seen from gonial angle. The purpose of this study was to identify sexual dimorphism in gonial angle based on the difference of external factors such as diet and environment in children, and to assess their capacity as a sex estimator. Study design: The present study consists of 104 subjects (51 males and 53 females) between 7 to 12 years of age which were divided into 2 groups, with prolonged sun exposure-hard diet (Group A) and low sun exposure-soft diet (Group B). The measurements were made using goniometer directly to the subjects. Results: The mean gonial angle in females is higher than in males and shows significant difference. However, there is no significant difference between Group A and B. Obtained logistic regression achieves an overall accuracy of 68% with cutoff value of 0.46, where the discriminative ability values are not higher than 0.80. Conclusions: Although there is a significant difference in sex, external factor such as sunlight exposure does not influence in gonial angle. Current results indicate that using mean gonial angle as sex estimation parameter is not advised for children aged 7-12 years.

Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disease specific to pregnancy. The cardinal symptom of pruritus and a concomitant elevated level of bile acids in the serum and/or alanine aminotransferase (ALT) are suggestive for the diagnosis. Overall, the maternal prognosis is good. The fetal outcome depends on the bile acid level. ICP is associated with increased risks for adverse perinatal outcomes, including preterm delivery, meconium-stained amniotic fluid, and stillbirth. Acute fetal asphyxia and not chronic uteroplacental dysfunction leads to stillbirth. Therefore, predictive fetal monitoring is not possible. While medication with ursodeoxycholic acid (UDCA) improves pruritus, it has not been shown to affect fetal outcome. The indication for induction of labour depends on bile acid levels and gestational age. There is a high risk of recurrence in subsequent pregnancies.

These statements and recommendations should provide appropriate information about maternal and fetal routes of infection, screening, detection of risk factors, diagnostic procedures, treatment, birth planning and peripartum and postpartum management of maternal hepatitis infection and offer pointers for prenatal counselling and routine clinical care on delivery wards.

Vaginal cuff dehiscence (VCD) is one of the major surgical complications following hysterectomy with data on incidence rates varying largely and studies assessing risk factors being sparse with contradictive results. The aim of this study was to assess the incidence rate of and risk factors for VCD in a homogenous cohort of women treated for benign uterine pathologies via total laparoscopic hysterectomy (TLH) with standardized follow-up. All patients undergoing TLH at the Department of Gynecology and Obstetrics, Saarland University Hospital between November 2010 and February 2019 were retrospectively identified from a prospectively maintained service database. VCD occurred in 18 (2.9%) of 617 patients included. In univariate and multivariate analyses, a lower level of surgeon laparoscopic expertise (odds ratio 3.19, 95% confidence interval (CI) 1.0–9.38; p = 0.03) and lower weight of removed uterus (odds ratio 0.99, 95% CI 0.98–0.99; p = 0.02) were associated positively with the risk of VCD. In this homogenous cohort undergoing TLH, laparoscopic expertise and uterine weight influenced the risk of postoperative VCD. These findings might help to further reduce the rate of this complication.

AIM:To evaluate the role of cerebral ultrasonography studies (CUSS) in detecting intracerebral and cranial pathologies (hemorrhages, ischemia, skull fractures) in near-term and term neonates following assisted vaginal delivery.PATIENTS AND METHODS:Prospective single-center study (11/2017-11/2018) at the University Children's Hospital of Saarland, Homburg, Germany including newborns with a gestational age ≥ 36 weeks born by assisted vaginal delivery. In all newborns, a standardized CUSS was performed within the first three days of life prior to discharge.RESULTS:200 neonates (43.0 % female, 57.0 % male; gestational age 39.6 ± 1.3 weeks) were included in this study (birth weight 3345.6 ± 450.6 g, body length 51.7 ± 2.5 cm, head circumference 35.0 ± 1.5 cm). 67 (33.5 %) neonates had minor external injuries of the scalp. 5 children showed clinical neurologic abnormalities: 4 (2.0 %) seizures and 1 facial palsy (0.5 %). In 34 (17.0 %) patients, minor incidental intracranial abnormalities unrelated to mode of delivery were detected on CUSS. No intracerebral, cranial pathologies or skull fractures were seen on routine CUSS.CONCLUSION:Routine CUSS in newborns after assisted vaginal delivery did not yield clinically relevant results in our cohort. Clinical observation and selective CUSS in symptomatic newborns might be more efficient than routine CUSS.