Background: Placenta accreta spectrum (PAS) can be the cause of major morbidity and its optimal management is still controversial. The aim of this study was to compare the traditional one-step surgery with a two-step surgical approach in which the placenta is left in situ and the second final operation is delayed to minimise blood loss. Methods: We conducted a single-centre retrospective cohort study including all patients managed for PAS between 2007 and 2023. The number of units of red blood cells (RBCs) needed during surgery was the primary outcome used to compare these two approaches. Results: A total of 43 cases were included in this analysis. Twenty of these were managed with the delayed two-step surgical approach, whereas 23 received one-step surgery. The median estimated blood loss during surgery was 2000 mL and 2800 mL for two-step and one-step surgery, respectively (p = 0.095). In the two-step surgical approach, the median number of RBC units transfused during surgery was significantly lower (p = 0.049) and the odds ratio for needing more than four units of RBCs was 0.28 (95%-CI: 0.08–0.98, p = 0.043). A longer interval between the caesarean section and the second operation showed a trend toward lower blood loss (p = 0.065) and was associated with a significantly lower number of RBC units needed during surgery (p = 0.019). Conclusions: Two-step surgery for the treatment of PAS was safe in our cohort and could lead to a reduction in blood transfusion. Leaving the placenta in situ and delaying the final operation represents a possible alternative to traditional caesarean hysterectomy.

Zielsetzung Psychosoziale und biologische Faktoren beeinflussen die Wahrnehmung von körperlichen Veränderungen während der Schwangerschaft. Einige Schwangere präsentieren sich in der geburtshilflichen Notaufnahme (NA) mit verschiedenen Symptomen ohne medizinischen Interventionsbedarf. Diese Besuche führen zu einer übermäßigen Beanspruchung, die Ressourcen bindet und die Gesundheitskosten in die Höhe treibt. In dieser Studie haben wir Faktoren analysiert, die mit mehrfachen NA-Besuchen während der Schwangerschaft verbunden sind, die Prävalenz von Angst und Depression ermittelt und versucht, die Optionen für Verbesserung von Versorgungsstrategien aufzuzeigen.

Purpose Psychosocial and biological factors influence the perception of physical changes during pregnancy. Some pregnant women present to the obstetric emergency department (ED) with diverse symptoms not requiring urgent medical action. These visits result in over-consultation, tying up resources and inflating health care expenses. This study outlines factors associated with multiple ED visits during pregnancy, measures the prevalence of anxiety and depression, and explores the choice of maternity clinic for delivery aiming to elucidate options for care strategies. Methods This prospective, cross-sectional, questionnaire-based bicentric study was performed in the obstetric outpatient departments of two university hospitals in Germany and recruited pregnant women between 12/2016 and 11/2017. The questionnaire included socio-demographics, obstetric history, anxiety (GAD-7), depression (PHQ-9), and health status (WHO-5, SF-12). Results This analysis included 496 women and showed that women with numerous ED visits were significantly younger ( p < 0.0001), less educated ( p = 0.0002), and more likely to be unemployed and single. Different prevalences for anxiety and depression were detected correlating with the number of ED visits although each showing only low effect sizes (0.024 resp. 0.015). Conclusions Pregnant women attending the ED more often might benefit from health education, psychosomatic interventions, and social support to overcome their depression and anxiety to avoid non-urgent ED consultations. Further prospective studies are needed to support these findings.

Introduction Lower uterine segment (LUS) thickness measurement is frequently used to select patients for trial of labor after a previous cesarean section (TOLAC). To date no significant benefit of LUS measurement has ever been proven, and no standard protocol or clear cut-off value exists. The aim of this study was to evaluate the benefit of LUS measurement in a daily routine setting. Material and Methods In this retrospective study, we evaluated 631 pregnancies after previous cesarean section (CS). Ultrasound measurements of myometrial (mLUS) and/or full LUS (fLUS) thickness were performed in 399 (63 %) patients. The incidence, time, and mode of detection of uterine defects were studied. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were calculated for different cut-off values of LUS thickness. Results Uterine defects were diagnosed in 28 (4.4 %) patients. Detection rate of ultrasound was low (13.6 %), with better sensitivity, specificity, PPV, and NPV at lower (2 mm (fLUS) / 1 mm mLUS): 75/96/48.3/98.7 %) than at higher cut-off values (3 mm (fLUS) / 2 mm (mLUS): 15.8/ 93.2/10.4/68.7 %). Discussion The benefit of LUS thickness measurement appears overestimated. As a large number of methodological factors trigger inaccuracy, a consistent protocol including both a transabdominal and a transvaginal scan performed by a trained examiner might improve accuracy. Exclusion of uterine defects might be more useful for prenatal selection after CS.

Prenatal risk stratification of women with previous cesarean section (CS) by ultrasound thickness measurement of the lower uterine segment (LUS) is challenging. There is a wide range of proposed cutoff values and a valuable algorithm for selection before birth is not available. Using 3 T magnetic resonance imaging (MRI), we aimed to identify possible shortcomings of the current protocols used for birth selection after CS. Therefore, we evaluated anatomic and morphologic differences of the LUS and its thickness in patients with CS and those without. Possible impact factors on LUS thickness were studied. We retrospectively analyzed 3 T MRI scans of 164 pregnant women in their second or third trimester, with (patient group, n = 60) and without previous CS (control group, n = 104). Sagittal T2-weighted images were studied. Normal findings of the LUS in MRI, reliability of MRI measurements, as well as factors influencing LUS thickness were assessed. MRI findings were compared to intraoperative findings. MRI provided good intra- (ICC 0.872) and fair inter-rater reliability (ICC 0.643). The relationship of the LUS and the cesarean scar to the surrounding anatomical structures and also its morphology varied strongly in patients and controls. Scar identification was possible in only 9/60 (15.0%) patients. The LUS was thinner in patients (1.9 ± 0.7 mm) than in controls (2.7 ± 1.3 mm). An LUS thinning up to 1 mm was observed in 23% of women without a previous CS and in 34% of women with normal intraoperative findings. Suspicion of a uterine dehiscence (LUS thickness < 1 mm) was only found in the patient group (5/59 (8.5%)) and was intraoperatively confirmed. In controls, LUS thickness was influenced by fetal weight, gestational age and amniotic fluid amounts. Variability in anatomy, thickness and morphology seem to limit common prenatal LUS imaging diagnostics. Therefore, we consider that diagnostic protocols must be re-evaluated and imaging should be adjusted to the individual patient conditions. Due to its independency of ultrasound limitations, an additional MRI might be useful for altered anatomy and impaired ultrasound conditions. An LUS thinning up to 1 mm might be a normal finding and should be further investigated as reference value.

Annual cervical cancer screening is recommended in Germany as a part of the statutory preventive care. Abnormal results can provoke psychological distress and anxiety, compromising women’s adherence. Little is known about how a cervical dysplasia impacts adherence follow-up visits and prevention habits over time. To optimize care strategies, this study aims to identify women at risk for nonadherence to follow-up visits after a screening event.

Dental and cervical controls are two established screening programs in Germany. Compliance to orthodontic treatment in childhood is essential for dental health and one of the first health interventions that requires adherent behavior; therefore, it may be associated with participation in further screening programs in adulthood. However, it is not yet known whether early orthodontic treatment influences long-term screening adherence.

BACKGROUND:Pregnancy can be distressing, particularly if expectant mothers are worried about the well-being of their fetus. Consequently, the desire for reassurance and frequent fetal monitoring is often pronounced. Smart wearable devices and telemedicine are promising tools that could assist women in self-monitoring their pregnancy at home, hence disburdening emergency departments (EDs). They present the possibility to clarify the need for urgent care remotely and offer tighter pregnancy monitoring. However, patients' acceptance of such new technologies for fetal monitoring has not yet been explored extensively.OBJECTIVE:This survey aimed to elucidate the attitudes of women toward self-monitoring of their pregnancy using noninvasive electronic devices. The technical details of the proposed devices were not specified.METHODS:A cross-sectional multicenter study was conducted at the departments of obstetrics of the University Hospitals of Heidelberg and Leipzig, Germany. All patients seen in the obstetrics clinic who were above 18 years were offered participation. We designed a survey questionnaire including validated instruments covering population characteristics, issues in current and past pregnancies, as well as attitudes toward self-monitoring of pregnancy with smart devices.RESULTS:A total of 509 pregnant women with no previous experience in telemedicine participated. Only a small minority of 5.9% (29/493) regarded self-monitoring with wearable devices as an alternative to consulting their physicians. Along these lines, only 7.7% (38/496) strongly believed they would visit the ED less often if such devices were readily available. However, if the procedure were combined with a Web-based telemetric physician consult, 13.5% (66/487) would be highly motivated to use the devices. Furthermore, significantly more women regarded it as an alternative prior to seeing a doctor when they perceived a decline in fetal movements (P<.001). Interestingly, women with university degrees had a higher propensity to engage in pregnancy self-monitoring compared with women without one (37% vs 23%; P=.001). Of the participants, 77.9% (381/489) would like smart wearable devices to measure fetal heart sounds, and 62.6% (306/489) wished to use the devices on their own. Feedback from a doctor or midwife was also very important in their choice of such devices (61.8%, 301/487 wished feedback). The intended frequency of use differed vastly among women, ranging from 13.8% (65/471) who would like to use such a device several times per day to 31.6% (149/471) who favored once per week at most.CONCLUSIONS:Our results point to a skeptical attitude toward pregnancy self-monitoring among pregnant women. Nevertheless, many women are open to using devices for pregnancy monitoring in parallel to consulting their physician. The intention to use such devices several times daily or weekly, expressed by more than half of the participants, highlights the potential of such technologies.

One of the main concerns in planning a vaginal birth after previous cesarean section is the risk for uterine rupture which is considered to be associated with the wall thickness in the scar area. Assuming the uterine scar to be located within the lower uterine segment (LUS), ultrasound diagnostic with LUS thickness measurement is widely used for prenatal risk assessment. Although intensively investigated there is a strong inhomogeneity of study results and reliable examination protocols and reference values are still missing 1,2 .

Bei Patientinnen mit Z.n. Sectio steht die Vermeidung einer Uterusruptur und auch unnötiger weiterer Kaiserschnitte im Fokus der Geburtsplanung. Die sonografische Dickenmessung des unteren Uterinsegmentes (LUS) soll hierbei zur Abschätzung von Risiken und Chancen dienen. Der Wert einer zusätzlichen MRT-Untersuchung ist für die LUS Diagnostik nicht hinreichend untersucht. Ziel der Studie ist die Evaluation der Machbarkeit einer MRT-Bildgebung und Dickenmessung des LUS bei Z.n. Sectio sowie die Erhebung typischer MRT-Befunde und der Vergleich zum Ultraschall.

Aufgrund des erhöhten Uterusrupturrisikos wird bei der Planung einer vaginalen Geburt nach Sectio häufig die Dicke des unteren Uterinsegments (uUS) sonografisch bestimmt. Ein geeignetes Untersuchungsprotokoll und ein zuverlässiger Referenzwert können wegen der inhomogenen Datenlage bisher nicht empfohlen werden. Da Limitationen der Ultraschalldiagnostik denkbare Gründe hierfür sind, haben wir die MRT als alternatives, nichtinvasives bildgebendes Verfahren genutzt, um die pränatale Diagnostik des uUS weiter zu erörtern.

Purpose Uterine rupture during labor is a rare but life-threatening complication after previous cesarean section (CS). Prenatal risk is assessed using ultrasound thickness measurement of the lower uterine segment (LUS). Due to inhomogeneous study results, however, clinical obstetrics still lacks for standard protocols and reliable reference values. As 3 T magnetic resonance imaging (MRI) has not yet been sufficiently studied regarding LUS diagnostics after previous CS, we sought to evaluate its feasibility focusing on thickness measurements and typical characteristics of the CS-scar region in comparison to ultrasound and the intraoperative status. Methods In this prospective study, 25 asymptomatic patients with one previous CS and inconspicuous ultrasound findings were included. An additional 3 T MRI with either a T2-weighted Turbo-Spin-Echo or a Half Fourier-Acquired-Single-shot-Turbo-spin-Echo sequence in a sagittal orientation was performed. We analyzed categorical image quality, inter- and intra-rater reliability as well as anatomy, morphology and thickness of the LUS. Results were compared to ultrasound and intraoperative findings. Results MRI provided good to excellent image quality in all patients. The imaged structures presented with a high variability in anatomy and morphology. Image characteristics indicating the uterine scar were only found in 11/25 (44%) patients. LUS thickness measurements with MRI showed good inter- and intra-rater reliability but poor agreement with ultrasound. Conclusions MRI is appropriate for additional LUS diagnostics in patients with previous CS. The strong individual variability of LUS-anatomy and morphology might explain the difficulties in establishing uniform diagnostic standards after CS.

Aufgrund des erhöhten Uterusrupturrisikos wird bei der Planung einer vaginalen Geburt nach Sectio häufig die Dicke des unteren Uterinsegments (uUS) sonografisch gemessen. Wegen der inhomogenen Datenlage wird dieses Vorgehen bisher nicht in den deutschen Leitlinien empfohlen. Es fehlen ein geeignetes Untersuchungsprotokoll und ein zuverlässiger Referenzwert. Die MRT ist ein alternatives, nichtinvasives bildgebendes Verfahren, das für die Erörterung von Problemen der pränatalen Ultraschalldiagnostik des uUS vielversprechend aber bisher wenig genutzt ist.

Die sFlt-1/PlGF-Ratio ist als Biomarker sowohl für die Prädiktion als auch für die Diagnosesicherung der Präeklampsie in der klinischen Routine etabliert. Der Wert der sFlt-1/PlGF-Ratio korreliert mit der Krankheitsschwere und Progression bzw. negativ mit dem Zeitintervall zur Entbindung. Ziel dieser Studie war zu untersuchen, inwieweit die Implementierung des angiogenen Biomarkers mit der klinischen Entscheidungsfindung bei hypertensiven Schwangerschaftskomplikationen assoziiert ist.

Due to novel scientific knowledge about molecular pathomechanisms, there is a new understanding of preeclampsia as a placental disease. Angiogenic factors were shown to influence placentation, and in the last decade, intensive research emerged particularly the antiangiogenic factor soluble fms-like tyrosine kinase-1 (sFlt-1) and the pro-angiogenic placental growth factor (PlGF) to be most relevant in this process. Technical efforts and the development of commercially available automated methods firstly enabled maternal serum measurements of these factors and the introduction into daily clinical use. In various clinical studies, the additional value of sFlt-1 and PlGF for diagnosis and even prediction of preeclampsia have been confirmed. This major advance firstly allows a better diagnosis and distinction of preeclampsia, a disease with an extremely heterogeneous clinical appearance, from various different gestation-associated symptoms or diseases. A more precise diagnosis and the feasibility of prediction opened new horizons in clinical management of preeclampsia. This article gives an overview about the latest scientific knowledge about the angiogenic factors sFlt-1 and PlGF and provides actual recommendations for its clinical use for suspected preeclampsia.

Aufgrund des erhöhten Uterusrupturrisikos wird bei der Planung einer vaginalen Geburt nach Sectio häufig die Dicke des unteren Uterinsegments (uUS) sonografisch gemessen. Wegen der inhomogenen Datenlage wird dieses Vorgehen bisher jedoch nicht in den deutschen Leitlinien empfohlen. Es fehlen sowohl ein geeignetes Untersuchungsprotokoll als auch ein zuverlässiger Referenzwert. Die MRT ist ein alternatives, nichtinvasives bildgebendes Verfahren, das für die Diagnostik des uUS bisher nur unzureichend untersucht ist. Da sie einen anderen diagnostischen Blickwinkel erlaubt, haben wir in der vorliegenden Studie untersucht, inwiefern die MRT genutzt werden kann, Probleme der pränatalen Ultraschalldiagnostik des uUS weiter zu erörtern.

In this case–control study, the impact on quality of life and sexual function in women with cervical dysplasia and conization will be evaluated, in order to address coping with such a premalignant lesion and to improve strategies for salutogenesis.

OBJECTIVE:The sFlt-1/PlGF ratio is a valid marker in diagnosing or excluding preeclampsia. The currently used cut offs frame an intermediate zone of 33-85 (<340 weeks) or 33-110 (≥340 weeks), respectively. In this study we sought to evaluate the relevance of an intermediate sFlt-1/PlGF ratio for the clinical pregnancy course and outcome. MATERIAL AND METHODS:We retrospectively analysed 533 consecutive patients with sFlt-1/PlGF ratio measurements for suspected preeclampsia. In patients with an intermediate sFlt-1/PlGF ratio, fetal and maternal characteristics and also pregnancy outcome were documented. Furthermore, we compared the patient groups with <340/340-366/≥370 gestational weeks at first visit. RESULTS:83/533 (15.6%) patients had an intermediate sFlt-1/PlGF ratio. Maternal or fetal diseases or twin pregnancies occurred in 87.9%. Preeclampsia/HELLP syndrome developed in 31.3% but were mostly mild or moderate (65.4%). However, severe adverse outcome was observed in 36.1% with severe preeclampsia in 10.8%. Even if further pregnancy duration and gestational week correlated negatively (r=-0.424; p<0.001), 92% of patients, tested with <340 weeks delivered prematurely. The overall preterm birth rate was 27.7%. CONCLUSIONS:Patients with an intermediate sFlt-1/PlGF ratio are at risk for severe adverse outcome. An intermediate sFlt-1/PlGF ratio indicates a risk for preterm birth, independent from the occurrence of preeclampsia.

Eine vaginale Entbindung ist bei einer Beckenendlage (BEL) bei entsprechenden Voraussetzungen auch heute noch eine mögliche und sichere Option. Hierbei ist eine sorgfältige Präselektion jedoch entscheidend. Eine zusätzliche MRT-Pelvimetrie wird mittlerweile an vielen Kliniken, vor allem bei Erstgebärenden, durchgeführt. Definierte Grenzwerte für die klassischen Beckenmaße gibt es bis heute hierfür nicht. Da die MRT-Pelvimetrie aber einen guten Einblick in die Beckenanatomie erlaubt, haben wir verschiedene Beckenmaße hinsichtlich einer möglichen Relevanz auf das geburtshilfliche Outcome untersucht.

Eine Dysbalance angiogener Faktoren gilt heutzutage als wichtiger Pathomechanismus bei der Entstehung einer Präeklampsie. Insbesondere der sFlt-1/PlGF Quotient hat sich als besonders hilfreich bei der Diagnostik und auch Prognose etabliert. Für die Diagnosestellung bzw. den Ausschluss einer Präeklampsie stehen in der klinischen Routine untere (33) und obere (abhängig vom Gestationsalter: 85 (< 340 SSW) bzw. 110 (≥340 SSW)) Cut-off-Werte zur Verfügung. Für den Wertebereich zwischen 33 und 85 bzw. 110 ist wenig hinsichtlich klinischer Wertigkeit, Verlauf und Prognose bekannt. Dieser als Intermediärzone bezeichnete Wertebereich bildet somit eine besondere Herausforderung, insbesondere dann, wenn sich die Patientin ohne Symptome vorstellt.