Publications by authors named "Nicole Ochsenbein-Kölble"

42 Publications

Twin pregnancies.

Ultraschall Med 2021 Feb 23. Epub 2021 Feb 23.

Department of Obstetrics, University Hospital Zürich and University of Zurich, Zurich, Switzerland.

Twin pregnancies, resulting in 2-3 % of all deliveries, are high risk pregnancies which need specialized care. A correct dating of pregnancy and the assessment of the chorionicity/amnionicity in the first trimester (< = 13 + 6 gestational weeks, GW) is essential for further monitoring. During first trimester risk stratification of monochorionic pregnancies includes evaluation of discordance of crown-rump-lengths, nuchal translucencies and amniotic fluid. At 16 GW sonographic risk evaluation of monochorionic twins involves differences in amniotic fluid and abdominal circumferences and detection of a velamentous cord insertion. A screening for fetal malformations with cervical length measurement as screening for preterm birth (cut-off < 25 mm) should be offered all twin pregnancies around 20 GW. In uncomplicated dichorionic pregnancies US examination should be performed every 4 weeks onwards to check fetal growth and amniotic fluid. An intertwin weight discordance > 20 % identifies pregnancies at increased risk of adverse outcome. Monochorionic pregnancies should be followed at least every two weeks for screening of twin-twin transfusion syndrome (TTTS), twin-anemia-polycythemia-sequence (TAPS) and selective fetal growth retardation (sFGR) with a start at 16 GW. The type 1-3 classification of sFGR in monochorionic twins depends on the pattern of end-diastolic velocity at the umbilical artery Doppler. The diagnosis of TTTS requires the presence of an oligyohydramnios (deepest vertical pocket (DVP) < 2 cm) in the donor twin and a polyhydramnios (DVP > 8 cm) in the recipient twin. However, the diagnosis of TAPS is based on the finding of discordant MCA Doppler values with a delta-MCA PV > 0.5 MoM.
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http://dx.doi.org/10.1055/a-1344-4812DOI Listing
February 2021

Screening, Management and Delivery in Twin Pregnancy.

Ultraschall Med 2020 Oct 5. Epub 2020 Oct 5.

Department of Obstetrics and Fetal Medicine, University Hospital Hamburg-Eppendorf, Hamburg, Germany.

The following AWMF guideline (DGGG/AGG & DEGUM responsible) deals with the diagnosis, screening and management of twins as well as the timing and mode of birth.Twin pregnancies can be classified as dichorionic diamniotic (DC DA), monochorionic diamniotic (MC DA) and monochorionic monoamniotic (MC MA) which are always monochorionic.Twin pregnancies can be concordant (both twins are affected) or discordant (only one twin is affected) for chromosomal defects, malformations, growth restriction and hemodynamic disorders.Chorionicity is the prognostically most significant parameter. Monochorial twins have significantly higher risks of intrauterine morbidity and mortality compared to dichorial twins.In particular, general aspects of twin pregnancies such as dating, determination of chorionicity and amnionicity, the labeling of twin fetuses and the perinatal switch phenomenon are discussed.Routine monitoring of MC and DC twin pregnancies with ultrasound at 11-13 weeks of gestation for chromosomal defects, invasive prenatal diagnosis, first-trimester NT or CRL discrepancies, early diagnosis of fetal anatomical defects, and management of twins with abnormalities, including selective fetocide, is described.Second trimester screening and management for preterm birth, intrauterine selective growth restriction (sFGR), classification of monochorial twins with sFGR, and management of the surviving twin after the death of the co-twin are described.Complications exclusively affecting MC twins include Twin to Twin Transfusion Syndrome (TTTS) with the important topics screening, prognosis, complications of laser therapy, timing of delivery, risks for brain abnormalities and delayed neurological development, Twin Anemia-Polycythemia Sequence (TAPS) and Twin Reversed Arterial Perfusion (TRAP) Sequence. This also includes MC MA twins as well as conjoined twins.Finally, the birth mode and time for DC and MC twin pregnancies are described.The information is summarized in 62 recommendations for action, 4 tables and 8 illustrations with comprehensive background texts.The guideline is an international guideline adaptation (ISUOG, NICE) as well as a systematic literature search and is up-to-date.
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http://dx.doi.org/10.1055/a-1248-8896DOI Listing
October 2020

Determination of Anatomical Levels in Spina Bifida Fetuses with Ultrasound and MRI.

Ultraschall Med 2020 Oct 2. Epub 2020 Oct 2.

Department of Pediatric Surgery, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland.

Purpose:  The goal of this study was to assess the accuracy of prenatal anatomical level determination by ultrasound (US) and magnetic resonance imaging (MRI) by analyzing the congruence with the "true" anatomical level identified by postnatal MRI.

Patients And Methods:  The first 60 patients undergoing fetal myelomeningocele surgery at The Zurich Center for Fetal Diangosis and Therapy were included in this study. Anatomical levels (i. e., first dysraphic vertebra) determined by prenatal US and MRI were compared to postnatal MRI. The level of agreement between the imaging modalities was evaluated with a Cohen's kappa test. Results > 0.6 were interpreted as good agreement, > 0.8 as excellent.

Results:  The exact congruence between prenatal US and MRI compared to postnatal MRI was 33 % and 48 %, respectively, for an accuracy within one level difference of 80 % and 90 %, and within two levels difference of 95 % and 98 %, respectively. The level of agreement of prenatal US and MRI compared to postnatal MRI was 0.62 and 0.79, respectively. Most of the prenatally incorrectly assigned levels were assigned too high (worse) than the "true" level (US 88 % vs. MRI 65 %).

Conclusion:  Reliable exact prenatal level determination by US and MRI is not possible. However, the prenatal determination of the anatomical level of the lesion is good within one level margin of error. Prenatal US as well as MRI demonstrate a systematic error towards higher levels. The above considerations must be integrated into prenatal counselling.
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http://dx.doi.org/10.1055/a-1264-7785DOI Listing
October 2020

Long-Term Outcome of Monochorionic Twins after Fetoscopic Laser Therapy Compared to Matched Dichorionic Twins.

Fetal Diagn Ther 2020 2;47(12):947-954. Epub 2020 Sep 2.

Department of Obstetrics, University Hospital Zurich, Zurich City, Switzerland,

Introduction: The only causal therapy is fetoscopic laser surgery (FLS). The aims of this study were to analyze the long-term outcome of monochorionic twins treated by FLS, including their school career, need for therapy and special aid equipment, and free-time activities, and compare their outcome to matched dichorionic twins.

Material And Methods: Among the 57 women treated at a single fetal treatment center between 2008 and 2017 with FLS because of twin-to-twin transfusion syndrome, 25 women with 42 children were included in the FLS group. The control group consisted of 16 dichorionic twin pairs matched for birth year, gestational age (GA), birth weight, and sex. The long-term outcome was assessed by a parental questionnaire and a standardized neurodevelopmental examination for children born before 32 gestational weeks or with a birth weight lower than 1500 g. They were also registered into the Swiss Neonatal Network database. The primary outcome was event-free survival, defined as normal neurology, behavior, vision, and hearing. The secondary outcomes were school career, need for therapy and special aid equipment, and free-time activities.

Results: An event-free survival was found in 32 children (76%) in the laser and in 24 children (75%) in the control group (p = 0.91). Neurological anomalies were found in 5 children (12%) in the laser group and 3 children (9%) in the control group (p = 1.00). Multiple logistic regression analysis showed that GA at delivery was the only predictive factor for event-free survival. There were no significant differences regarding school career, therapies, or special aid equipment between the 2 groups. We found that children without FLS were involved in more free-time activities and needed fewer breaks during physical activity than children with FLS during pregnancy.

Conclusion: The outcome of monochorionic twins treated with FLS is comparable to the outcome of dichorionic twins. Long-term neurodevelopment in the cohort was mainly dependent on GA at birth.
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http://dx.doi.org/10.1159/000509400DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7845414PMC
September 2020

Genome-wide non-invasive prenatal testing in single- and multiple-pregnancies at any risk: Identification of maternal polymorphisms to reduce the number of unnecessary invasive confirmation testing.

Eur J Obstet Gynecol Reprod Biol 2020 Sep 2;252:19-29. Epub 2020 Jun 2.

Institute of Medical Genetics, University of Zurich, Zurich, Switzerland.

Objective: Non-invasive prenatal testing by targeted or genome-wide copy number profiling (cnNIPT) has the potential to outperform standard NIPT targeting the common trisomies 13, 18, and 21, only. Nevertheless, prospective results and outcome data on cnNIPT are still scarce and there is increasing evidence for maternal copy number variants (CNVs) interfering with results of both, standard and cnNIPT.

Study Design: We assessed the performance of cnNIPT in 3053 prospective and 116 retrospective cases with special consideration of maternal CNVs in singleton and multiple gestational pregnancies at any risk, as well as comprehensive follow-up.

Results: A result was achieved in 2998 (98.2%) of total prospective cases (89.2% analyzed genome-wide). Confirmed fetal chromosomal abnormalities were detected in 45 (1.5%) cases, of which five (11%) would have remained undetected in standard NIPTs. Additionally, we observed 4 likely fetal trisomies without follow-up and a likely phenotype associated placental partial trisomy 16. Moreover, we observed clinically relevant confirmed maternal CNVs in 9 (0.3%) cases and likely maternal clonal hematopoiesis in 3 (0.1%). For common fetal trisomies we prospectively observed a very high sensitivity (100% [95% CI: 91.96-100%]) and specificity (>99.9% [95% CI: 99.8-100%]), and positive predictive value (PPV) (97.8% [95% CI: 86.1-99.7%]), but our retrospective control cases demonstrated that due to cases of fetal restricted mosaicism the true sensitivity of NIPT is lower. After showing that 97.3% of small CNVs prospectively observed in 8.3% of genome-wide tests were mostly benign maternal variants, sensitivity (75.0% [95% CI: 19.4%-99.4%]), specificity (99.7% [99.5%-99.9%]) and PPV (30.0% [14.5%-52.1%]) for relevant fetal CNVs were relatively high, too. Maternal autoimmune disorders and medication, such as dalteparin, seem to impair assay quality.

Conclusion: When maternal CNVs are recognized as such, cnNIPT showed a very high sensitivity, specificity and PPV for common trisomies in single and multiple pregnancies at any risk and very good values genome-wide. We found that the resolution for segmental aberrations is generally comparable to standard karyotyping, and exceeds the latter if the fetal fraction is above 10%, which allows detection of the 2.5 Mb 22q11.2 microdeletion associated with the velocardiofacial syndrome, even if the mother is not a carrier.
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http://dx.doi.org/10.1016/j.ejogrb.2020.05.070DOI Listing
September 2020

Hindbrain Herniation and Banana and Lemon Sign After Open Fetal Myelomeningocele Repair - When Do These Signs Disappear and is Shunting Predictable?

Ultraschall Med 2020 Apr 24. Epub 2020 Apr 24.

University Hospital Zurich, The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland.

Purpose:  The aim was to describe the sonographic follow-up of hindbrain herniation (HH), the banana and lemon sign after fetal myelomeningocele (fMMC) repair, and the time of disappearance of these signs after the intervention, and to investigate any predictive value for the necessity of shunting during the infant's first year of life. Additionally, the sonographic evolution of the transcerebellar diameter (TCD) before and after fetal intervention was assessed.

Patients And Methods:  The first 50 patients that underwent fMMC repair at Zurich Center for Fetal Diagnosis and Therapy (www.swissfetus.ch) were included in this study. Sonographic scans performed weekly after fMMC repair focusing on HH and banana and lemon signs were analyzed and compared between the shunted and the non-shunted group. ROC curves were generated for the time intervals of resolution of the signs in order to show their predictive accuracy for the need for shunting until 1 year of age.

Results:  HH resolved in 48 fetuses (96 %) before delivery. The sonographic disappearance of HH within the first two weeks after fMMC repair was associated with a significantly lower incidence of shunt placement (OR 0.19; 95 % CI 0.4-0.9) during the first year of life (p = 0.03). All fetuses with persistent HH before delivery received a shunt. TCD growth was observed in all fetuses.

Conclusion:  The reversibility of HH within two weeks after fMMC repair is associated with an 80 % lower incidence of shunt placement during the infant's first year of life. Moreover, it allows the cerebellum to grow and to normalize its configuration.
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http://dx.doi.org/10.1055/a-1112-7096DOI Listing
April 2020

COVID-19 in pregnant women.

Lancet Infect Dis 2020 06 17;20(6):653. Epub 2020 Mar 17.

University Hospital Zurich, Neonatal Department, 8091 Zurich, Switzerland.

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http://dx.doi.org/10.1016/S1473-3099(20)30175-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7270341PMC
June 2020

Open Intrauterine Fetal Myelomeningocele Repair: Changes in the Surgical Procedure and Perinatal Complications during the First 8 Years of Experience at a Single Center.

Fetal Diagn Ther 2020 4;47(6):485-490. Epub 2019 Dec 4.

Division of Obstetrics, University Hospital of Zurich, Zurich, Switzerland.

Introduction: Open fetal myelomeningocele (fMMC) repair is nowadays a therapeutic option in selected cases. We aimed to evaluate changes in maternal and fetal outcome after fMMC repair during the first 8 years of experience at a tertiary referral fetal medicine center in Switzerland. -Materials and Methods: Between 2010 and 2018, fMMC repair and delivery of the neonate via planned cesarean section was performed in 67 cases. Cases were retrospectively stratified into 2 groups: a "training phase" (TP) with supervision from an external surgeon during 11 operations (2010-2014, 15 cases) followed by an "experienced phase" (EP, 2014-2018, 52 cases); each phase lasted about 4 years. Both phases were compared with regard to various maternal and fetal outcome parameters.

Results: Analyses did not reveal differences between TP and EP in major outcome parameters such as gestational age at delivery, chorionic membrane separation, or the incidence of placental abruption. Although more complex surgical techniques were applied in EP (e.g., dermal closure using a rotational flap), surgery time was not different from TP. At the same time, surgical complications such as oligohydramnios (27 vs. 8%, p = 0.046) with MRI-confirmed leakage (13 vs. 4%, nonsignificant) and subchorionic hematoma (20 vs. 2%, p = 0.009) were less common in EP than TP.

Conclusions: This study shows that the level of competence at our center with regard to major perinatal outcome parameters was already high in the first years of fMMC repair. However, more complex surgical techniques and significantly less minor complications were observed during the most recent years.
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http://dx.doi.org/10.1159/000503388DOI Listing
April 2021

In utero Hepatitis B Immunization during Fetal Surgery for Spina Bifida.

Fetal Diagn Ther 2020 13;47(4):328-332. Epub 2019 Nov 13.

Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland,

Background: Fetal surgery for spina bifida aperta may lead to significantly better outcomes than postnatal repair, particularly regarding shunt-dependent hydrocephalus, independent ambulation, and voiding functions. The "Management of Myelomeningocele Study" (MOMS) represents the current benchmark, also in terms of eligibility criteria.

Case Report: A positive maternal hepatitis B virus (HBV) status is a MOMS exclusion criterion. Here, we report on the first successful active and passive in utero HBV vaccination of a spina bifida fetus carried by a HBV-positive mother undergoing maternal-fetal surgery. The now 2-year-old infant is healthy, HBV negative, and drew maximal benefit from prenatal surgery.

Discussion And Conclusion: Taken together, this patient benefitted maximally from fetal surgery for spina bifida, despite meeting an exclusion criterion. Thus, generally speaking, eligibility criteria for fetal surgery can be challenged under certain circumstances for the benefit of the patient.
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http://dx.doi.org/10.1159/000503447DOI Listing
January 2021

Influence of osmolarity and hydration on the tear resistance of the human amniotic membrane.

J Biomech 2020 01 16;98:109419. Epub 2019 Oct 16.

ETH Zurich, Institute for Mechanical Systems, 8092 Zurich, Switzerland; Empa, Swiss Federal Laboratories for Materials Science and Technology, 8600 Dübendorf, Switzerland. Electronic address:

The amnion is considered to be the load-bearing part of the fetal membranes. We investigated the influence of osmolarity of the testing medium and hydration on its fracture toughness. Mode I fracture tests revealed that physiological variations in the bath osmolarity do not influence the tear resistance of amnion, while larger changes, i.e. from physiological saline solution to distilled water, lead to a significant reduction of the fracture toughness. Uniaxial tensile tests on collagen hydrogels confirmed the reduction in toughness, suggesting that lower bath osmolarity triggers changes in the failure properties of single collagen fibers. Prenatal surgeries, in particular fetoscopic procedures with partial amniotic carbon dioxide insufflation, might result in dehydration of the amnion. Dehydration induced a brittle behavior; however, subsequent rehydration for 15 min resulted in a similar tear resistance as for the fresh tissue.
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http://dx.doi.org/10.1016/j.jbiomech.2019.109419DOI Listing
January 2020

Bioengineering and in utero transplantation of fetal skin in the sheep model: A crucial step towards clinical application in human fetal spina bifida repair.

J Tissue Eng Regen Med 2020 01 29;14(1):58-65. Epub 2019 Nov 29.

Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland.

An intricate problem during open human fetal surgery for spina bifida regards back skin closure, particularly in those cases where the skin defect is much too large for primary closure. We hypothesize that tissue engineering of fetal skin might provide an adequate autologous skin substitute for in utero application in such situations. Eight sheep fetuses of four time-mated ewes underwent fetoscopic skin biopsy at 65 days of gestation. Fibroblasts and keratinocytes isolated from the biopsy were used to create fetal dermo-epidermal skin substitutes. These were transplanted on the fetuses by open fetal surgery at 90 days of gestation on skin defects (excisional wounds) created during the same procedure. Pregnancy was allowed to continue until euthanasia at 120 days of gestation. The graft area was analyzed macroscopically and microscopically. The transplanted fetal dermo-epidermal skin substitutes was well discernable in situ in three of the four fetuses available for analysis. Histology confirmed healed grafts with a close to natural histological skin architecture four weeks after in utero transplantation. This experimental study generates evidence that laboratory grown autologous fetal skin analogues can successfully be transplanted in utero. These results have clinical implications as an analogous procedure might be applied in human fetuses undergoing prenatal repair to facilitate primary skin closure. Finally, this study may also fertilize the field of fetal tissue engineering in general, particularly when more interventional, minimally invasive, and open fetal surgical procedures become available.
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http://dx.doi.org/10.1002/term.2963DOI Listing
January 2020

On the defect tolerance of fetal membranes.

Interface Focus 2019 Oct 16;9(5):20190010. Epub 2019 Aug 16.

ETH Zurich, Institute for Mechanical Systems, 8092 Zurich, Switzerland.

A series of mechanical experiments were performed to quantify the strength and fracture toughness of human amnion and chorion. The experiments were complemented with computational investigations using a 'hybrid' model that includes an explicit representation of the collagen fibre network of amnion. Despite its much smaller thickness, amnion is shown to be stiffer, stronger and tougher than chorion, and thus to determine the mechanical response of fetal membranes, with respect to both, deformation and fracture behaviour. Data from uniaxial tension and fracture tests were used to inform and validate the computational model, which was then applied to rationalize measurements of the tear resistance of tissue samples containing crack-like defects. Experiments and computations show that the strength of amnion is not significantly reduced by defects smaller than 1 mm, but the crack size induced by perforations for amniocentesis and fetal membrane suturing during fetal surgery might be larger than this value. In line with previous experimental observations, the computational model predicts a very narrow near field at the crack tip of amnion, due to localized fibre alignment and collagen compaction. This mechanism shields the tissue from the defect and strongly reduces the interaction of multiple adjacent cracks. These findings were confirmed through corresponding experiments, showing that no interaction is expected for multiple sutures for an inter-suture distance larger than 1 mm and 3 mm for amnion and chorion, respectively. The experimental procedures and numerical models applied in the present study might be used to optimize needle and/or staple dimensions and inter-suture distance, and thus to reduce the risk of iatrogenic preterm premature rupture of the membranes from amniocentesis, fetoscopic and open prenatal surgery.
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http://dx.doi.org/10.1098/rsfs.2019.0010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6710661PMC
October 2019

Benchmarking against the MOMS Trial: Zurich Results of Open Fetal Surgery for Spina Bifida.

Fetal Diagn Ther 2020 5;47(2):91-97. Epub 2019 Jun 5.

Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland,

Introduction: The Management of Myelomeningocele Study, a.k.a. the MOMS trial, was published in 2011 in the New England Journal of Medicine. This prospective randomized controlled trial proved to be a milestone publication that provided definitive evidence that fetal surgery is a novel standard of care for select fetuses with spina bifida aperta (SB). The goal of our study is to assess whether our center can match these benchmark results.

Materials And Methods: Our study was conducted according to the MOMS protocol using the same inclusion and exclusion criteria and looked at the same outcome parameters that were used in the MOMS trial. Zurich and MOMS results were compared.

Results: We enrolled 20 patients between December 2010 and May 2015 all of whom underwent fetal surgery for SB. Among 51 different outcome variables, there were only 3 favorable (multiplicity-adjusted) significant differences (gestational age at birth, hindbrain herniation, and psychomotor development). There were no statistically significant differences regarding any other parameters.

Conclusion: Our findings confirm that rigorous apprenticeship, training, and comprehensive prospective data collection enable centers like the Zurich Center for Fetal Diagnosis and Therapy to achieve benchmark results for open fetal surgery for myelomeningocele and myeloschisis. These results justify the existence and continuation of our program. Outcome documentation is an essential element of quality management. It is medically and ethically fundamental for fetal medicine and surgery centers offering high-end innovative medical care.
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http://dx.doi.org/10.1159/000500049DOI Listing
November 2020

Risk Factors for Preterm Birth following Open Fetal Myelomeningocele Repair: Results from a Prospective Cohort.

Fetal Diagn Ther 2020 17;47(1):15-23. Epub 2019 May 17.

Division of Obstetrics, University Hospital of Zürich, Zurich, Switzerland.

Background: Fetal myelomeningocele (fMMC) repair is a therapeutic option in selected cases. This study aimed to identify risk factors for preterm birth (PTB) following open fMMC repair.

Methods: Sixty-seven women underwent fMMC repair and delivered a baby between 2010 and 2018 at our center. Demographic, surgical, and pregnancy complications, including potential risk factors for PTB such as preterm premature rupture of membranes (PPROM), chorioamniotic membrane separation (CMS), and placental abruption were evaluated.

Results: Maternal body mass index, maternal age, parity, previous uterine surgery, gestational age at fetal surgery, total surgery duration, surgical subcutaneous hematoma, oligohydramnios, and amniotic fluid leakage were not identified as risk factors for PTB. CMS (p = 0.028, 92 vs. 52%) and PPROM (p = 0.001, 95 vs. 52%) were highly associated with PTB. Placental abruption was found more often in women after fMMC repair than in a general obstetrical population (12 vs. 1%) and ended in premature birth in all cases (p = 0.024, 100 vs. 60%). However, the majority of women delivered at a gestational age >35 weeks.

Conclusions: In our study cohort, risk factors for PTB were PPROM, CMS, and placental abruption, whereas surgery duration did not influence outcome. We conclude that the surgery technique should aim to minimize CMS and amniotic fluid leakage.
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http://dx.doi.org/10.1159/000500048DOI Listing
November 2020

Maternal Complications following Open Fetal Myelomeningocele Repair at the Zurich Center for Fetal Diagnosis and Therapy.

Fetal Diagn Ther 2019 14;46(3):153-158. Epub 2018 Nov 14.

Department of Obstetrics, Zurich Center for Fetal Diagnosis and Therapy, University Hospital Zurich, Zurich, Switzerland.

Introduction: Despite undoubtable benefits of open fetal myelomeningocele (fMMC) repair, there are considerable maternal risks. The aim of this study was to evaluate and systematically categorize maternal complications after open fMMC repair.

Methods: We analyzed data of 40 fMMC repairs performed at the Zurich Center for Fetal Diagnosis and Therapy. Maternal complications were classified according to a 5-level grading system based on a classification of surgical complications proposed by Clavien and Dindo.

Results: We observed no grade 5 complication (death of a patient). Five (12.5%) women demonstrated severe grade 4 complications: 1 case of uterine rupture in a nullipara at 36 gestational weeks (GW), a third-degree atrioventricular block which needed short mechanical resuscitation, a bilateral lung embolism requiring intensive care unit (ICU) management due to low-output syndrome, and chorioamnionitis and urosepsis both requiring ICU management at 31 GW. Twenty-six (65%) women had minor (grade 1-3) complications.

Conclusions: Only one grade 4 complication (uterine rupture, 2.5%) was a clear-cut direct consequence of fetal surgery. The other four grade 4 complications (10%) occurred in the context of, but cannot unequivocally be attributed to, fetal surgery, since they may occur also in other circumstances. The classification system used is a tenable step towards stringent documentation of maternal complications.
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http://dx.doi.org/10.1159/000494024DOI Listing
February 2020

Open Spina Bifida: Why Not Fetal Surgery?

Fetal Diagn Ther 2019 11;45(6):430-434. Epub 2018 Sep 11.

Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland.

Objective: The majority of patients counseled for prenatal open spina bifida repair (SBR) do not undergo fetal surgery. The aim of this study was to analyze the reasons for this phenomenon.

Materials And Methods: The data of the first 160 patients seeking counseling or referred to the Zurich Center for Fetal Diagnosis and Therapy for prenatal SBR between December 2010 and March 2017 were retrospectively analyzed.

Results: A total of 104 (65%) patients did not undergo prenatal SBR. Of this subgroup, 52% met the exclusion criteria, 35% decided to terminate pregnancy, 4% chose to continue pregnancy without fetal intervention, and 3% sought care in other European centers. In 6%, data about the ensuing course of pregnancy were not recorded. The main exclusion criteria were delayed presentation (30%), absence of hindbrain herniation (28%), and concomitant spinal anomalies (17%).

Conclusion: The high percentage of patients not qualifying for prenatal SBR underscores the necessity of a standard evaluation of every single patient at a qualified referral center. To allow a higher proportion of women carrying a fetus with open spina bifida to be timely and correctly informed about a potential fetal intervention, much more effort is mandatory to spawn correct, objective, and understandable information among all groups of people potentially exposed to this topic.
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http://dx.doi.org/10.1159/000491751DOI Listing
January 2020

Outcome after fetoscopic laser coagulation in twin-twin transfusion syndrome - is the survival rate of at least one child at 6 months of age dependent on preoperative cervical length and preterm prelabour rupture of fetal membranes?

J Matern Fetal Neonatal Med 2020 Mar 10;33(5):852-860. Epub 2018 Sep 10.

Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland.

Twin-to-twin transfusion syndrome (TTTS) complicates 10-15% of all monochorionic twin pregnancies. Selective laser coagulation of placental anastomoses is the only causal therapy. The aim of this study was to analyze the neonatal survival, the survival rate of at least one child at 6 months of age, and maternal outcome after laser therapy in a Swiss cohort. Between 2008 and 2014, 39 women were treated with fetoscopic laser procedure due to TTTS. Two women were excluded from the study because of missing informed consent or loss of follow-up. The women were divided into two groups: group 1 with a cervical length >25 mm and group 2 with a cervical length ≤25 mm. The primary end point was the survival rate of at least one child at 6 months of age and its dependence on maternal preoperative cervical length or the time interval between operation (OP)-preterm prelabour rupture of fetal membranes (PPROM). Secondary outcomes were neonatal complications and maternal complications due to the procedure. Statistical analysis was performed using the program SPSS 22. A -value of <.05 was considered statistically significant. Mean gestational age (GA) at OP of group 1 (20.3 ± 3 GW) was comparable with group 2 (21.5 ± 2.4 GW;  = .27). The GA at birth was significantly higher in group 1 (31.5 ± 5.9 GW) than in group 2 (27.0 ± 4.7 GW:  = .02). The survival rate of at least one child at 30 days and 6 months of age was 81% in group 1 and only 60% in group 2 ( = .1). PPROM <32 GW occurred in 43%. The survival rate of at least one child was significantly higher if the OP-PPROM interval was >28 days (93 versus 43%;  = .02). Major brain injury was observed in 11% of infants. Severe maternal complications (pulmonary edema) occurred in three cases (8%). Our survival rate of at least one child at 30 days and 6 months of age and the outcome of the mothers is well comparable to other international studies. A preoperative maternal cervical length of >25 mm and an occurrence of PPROM more than 28 days after the laser therapy is associated with a higher survival rate of at least one child at 6 months of age.
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http://dx.doi.org/10.1080/14767058.2018.1506441DOI Listing
March 2020

Clinical and Histologic Evaluation of the Hysterotomy Site and Fetal Membranes after Open Fetal Surgery for Fetal Spina Bifida Repair.

Fetal Diagn Ther 2019 26;45(4):248-255. Epub 2018 Jul 26.

Department of Obstetrics and Gynecology, University Hospital Zurich, Zurich, Switzerland.

Introduction: Among the risks associated with open fetal surgery, myometrium and fetal membrane issues are vexing problems since they may lead to uterine dehiscence or preterm premature rupture of membranes resulting in uterine rupture or preterm birth or both. The aim of this study was to examine whether stapled and sutured hysterotomy scars demonstrate partial or complete healing.

Methods: Hysterotomy sites after open fetal surgery were clinically evaluated in 36 women during Caesarean section, classified into the categories intact, thin, and partially or completely dehiscent, then completely excised and histologically analyzed in 25 cases. The histological examination focused on wound healing of myometrium and fetal membranes.

Results: The myometrium was intact, thin, and partially or completely dehiscent in 33, 58, and 9%, respectively. The interval between myelomeningocele repair and delivery did not correlate with the healing process. The myometrium showed a reparative zone (scar) with adjacent avital myometrium tissue, fibrosis, and inflammation with foreign body reaction. The intact myometrium was below 1 mm thickness in 56%. All fetal membranes showed complete dehiscence; in 41% they were completely avital.

Conclusion: Our study provides evidence that the myometrium shows scarring with substantial thinning or dehiscence. Fetal membranes do not heal spontaneously. In order to prevent uterine rupture in subsequent pregnancies, we recommend the hysterotomy site to be completely excised after birth.
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http://dx.doi.org/10.1159/000488941DOI Listing
August 2019

Minimally Invasive Surgical Device for Precise Application of Bioadhesives to Prevent iPPROM.

Fetal Diagn Ther 2019 19;45(2):102-110. Epub 2018 Jun 19.

Laboratory for Cell and Tissue Engineering, Department of Obstetrics, University Hospital Zurich, Zurich,

Introduction: The benefits of endoscopic fetal surgery are deteriorated by the high risk of iatrogenic preterm prelabor rupture of fetal membranes (iPPROM). While previous studies have reported good sealing candidates to prevent membrane rupture, the delivery of these materials to the location of membrane puncture remains unsolved.

Materials And Methods: We describe an approach to apply sealing materials onto the amnion through the fetoscopy port. We developed a device composed of an umbrella-shaped polyester coated nitinol mesh and an applicator. The spontaneously unfolding umbrella is pushed through the port, pulled against the amnion, and glued onto the amnion defect site. We tested the adhesion strength of multiple glues and tested the feasibility and reproducibility of this fetal membrane sealing approach in an ex vivo model.

Results: The umbrella unfolded and was well positioned in all tests (n = 18). When applied via the fetoscopy port, umbrellas were successfully glued onto the fetal membrane, and all of them completely covered the defect (n = 5). The mean time needed for the whole procedure was 3 min.

Discussion: This study is a proof of concept presenting a potential future solution for the precise local application of bioadhesives for the prevention of iPPROM.
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http://dx.doi.org/10.1159/000487393DOI Listing
September 2019

The effect of pregnancy on endometriosis-facts or fiction?

Hum Reprod Update 2018 05;24(3):290-299

Department of Gynaecology and Obstetrics, University Hospital Auckland, Park Road, 1023 Auckland, New Zealand.

Background: It is not uncommon for women with endometriosis to be advised that becoming pregnant might be a useful strategy to manage their symptoms and reduce disease progression. Consequently, many women diagnosed with endometriosis and motivated to become pregnant, may also have expectations regarding improvement of symptoms and the disease. However, study results on the effect of pregnancy on endometriosis are controversial and pregnancy in women with endometriosis is not always associated with improved symptoms. Moreover, there is increasing evidence that endometriosis may interfere with a successful pregnancy outcome.

Objective And Rationale: The objective was to evaluate the evidence on whether pregnancy and lactation has a beneficiary effect on growth characteristics and symptoms of endometriosis diagnosed prior to pregnancy.

Search Methods: A search for articles containing keywords related to pregnancy and endometriosis was performed via PubMed. Manuscripts dealing with a potential effect of pregnancy on endometriosis were systematically reviewed. We included English, French and German language publications on human studies from 1966 to May 2017. Bibliographies of these manuscripts were searched for further relevant literature.

Outcomes: Five small observational studies were identified concerning the longitudinal development of endometriotic lesions during and after pregnancy, four of medium and one of low quality. Eleven publications reported measurements of endometriomas during pregnancy and the postpartum period (the five studies just mentioned and six case reports). Another 22 case reports/small case series (maximum of five cases), six studies on histology of endometriotic lesions in pregnancy, plus eight studies on the role of pregnancy in initial development and recurrence of endometriosis were included. Few studies of very limited quality are available to evaluate the effect of pregnancy and the postnatal period on the development of endometriosis. The development of endometriosis is variable and there is no evidence that pregnancy can be expected to generally reduce the size and number of endometriotic lesions. Growth and structural changes of lesions during pregnancy may occur with decidualization. Results on the association between pregnancy and symptoms of endometriosis are controversial and strongly biased.

Wider Implications: Available data on the development of endometriosis during and after pregnancy show fewer beneficial effects than previously reported. Therefore, women aiming for pregnancy on the background of endometriosis should not be told that pregnancy may be a strategy for managing symptoms and reducing progression of the disease.
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http://dx.doi.org/10.1093/humupd/dmy004DOI Listing
May 2018

Microvascular perfusion of the placenta, developing fetal liver, and lungs assessed with intravoxel incoherent motion imaging.

J Magn Reson Imaging 2018 07 27;48(1):214-225. Epub 2017 Dec 27.

Department of Diagnostic Imaging, University Children's Hospital, Zurich, Switzerland.

Background: In utero intravoxel incoherent motion magnetic resonance imaging (IVIM-MRI) provides a novel method for examining microvascular perfusion fraction and diffusion in the developing human fetus.

Purpose: To characterize gestational changes in the microvascular perfusion fraction of the placenta, fetal liver, and lungs using IVIM-MRI.

Study Type: Retrospective, cross-sectional study.

Subjects: Fifty-five datasets from 33 singleton pregnancies were acquired (17-36 gestational weeks).

Field Strength/sequence: In utero diffusion-weighted echo-planar imaging at 1.5T and 3.0T with b-factors ranging from 0 to 900 s/mm in 16 steps.

Assessment: Using the IVIM principle, microvascular perfusion fraction (f), pseudodiffusion (D*), and diffusion coefficients (d) were estimated for the placenta, liver, and lungs with a biexponential model. A free-form nonlinear deformation algorithm was used to correct for the frame-by-frame motion of the fetal organs and the placenta. The IVIM parameters were then compared to a Doppler ultrasound-based assessment of the umbilical artery resistance index.

Statistical Tests: Pearson product-moment correlation coefficient (PMCC) to reveal outlier corrected correlations between Doppler and IVIM parameters. Gestational age-related changes were assessed using linear regression analysis (LR).

Results: Placental f (0.29 ± 0.08) indicates high blood volume in the microvascular compartment, moderately increased during gestation (LR, R = 0.338), and correlated negatively with the umbilical artery resistance index (PMCC, R = -0.457). The f of the liver decreased sharply during gestation (LR, R = -0.436). Lung maturation was characterized by increasing perfusion fraction (LR, R = 0.547), and we found no gestational changes in d and D* values (LR, R = -0.013 and R = 0.051, respectively). The Doppler measurements of the umbilical artery and middle cerebral artery did not correlate with the IVIM parameters of the lungs and liver.

Data Conclusion: Gestational age-associated changes of the placental, liver, and lung IVIM parameters likely reflect changes in placental and fetal circulation, and characterize the trajectory of microstructural and functional maturation of the fetal vasculature.

Level Of Evidence: 2 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2017.
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http://dx.doi.org/10.1002/jmri.25933DOI Listing
July 2018

Tocolysis for in utero Surgery: Atosiban Performs Distinctly Better than Magnesium Sulfate.

Fetal Diagn Ther 2018 17;44(1):59-64. Epub 2017 Aug 17.

Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland.

Introduction: To compare tocolysis with magnesium sulfate versus atosiban regarding the occurrence of short-term preterm labor and maternal side effects during and after open fetal myelomeningocele (MMC) repair.

Material And Methods: A prospective nonrandomized cohort study was performed including 30 fetal MMC cases. The first 15 cases (group 1) received magnesium sulfate according to the MOMS protocol. In the following 15 cases (group 2), magnesium sulfate was substituted by atosiban. Chorioamniotic membrane separation (CMS), premature prelabor rupture of the fetal membranes (PPROM), preterm delivery <3 weeks after fetal MMC repair, and maternal complications due to the tocolytic medication were the major endpoints.

Results: In both groups, one CMS but no PPROM was diagnosed <3 weeks after fetal MMC repair. One patient of group 2 delivered <3 weeks after fetal MMC repair because of an intraoperative placental abruption at 25 weeks. All women of group 1 showed an electrolyte imbalance during magnesium sulfate administration. One woman of group 1 developed several episodes of a third-degree atrioventricular block within the first 3 days after fetal surgery. Lethargy was found in all women during magnesium sulfate therapy. No maternal side effects were found under atosiban.

Discussion: The use of atosiban resulted in an almost identical short-term uterine outcome without any serious maternal complications as seen when magnesium sulfate was given. Thus, the authors suggest using atosiban instead of magnesium sulfate in the context of open fetal surgery.
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http://dx.doi.org/10.1159/000478261DOI Listing
November 2018

Impact factors on fetal descent rates in the active phase of labor: a retrospective cohort study.

J Perinat Med 2018 Aug;46(6):579-585

Division of Obstetrics, University Hospital of Zurich, Frauenklinikstr. 10, 8091 Zurich, Switzerland.

Aim: To assess fetal descent rates of nulliparous and multiparous women in the active phase of labor and to evaluate significant impact factors.

Methods: In a retrospective cohort study at the University Hospital of Zurich, Switzerland, we evaluated 6045 spontaneous vaginal deliveries with a singleton in vertex presentation between January 2007 and July 2014 at 34 0/7 to 42 0/7 gestational weeks. Median fetal descent rates and their 10th and 90th percentiles were assessed in the active phase of labor and different impact factors were evaluated.

Results: Fetal descent rates are exponentially increasing. Nulliparous women have slower fetal descent than multiparous women (P<0.001), ranging from 0 to 5.81 cm/h and from 0 to 15 cm/h, respectively. The total duration of fetal descent in labor is 5.42 h for nulliparous and 2.71 h for multiparous women. Accelerating impact factors are a lower fetal station, multiparity, increasing maternal weight and fetal occipitoanterior position, whereas epidural anesthesia decelerates fetal descent (P<0.001).

Conclusions: Fetal descent is a hyperbolic increasing process with faster descent in multiparous women compared to nulliparous women, is highly inter individual and is associated with different impact factors. The diagnosis of labor arrest or prolonged labor should therefore be based on such rates as well as on individual evaluation of every parturient.
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http://dx.doi.org/10.1515/jpm-2017-0075DOI Listing
August 2018

Neurodevelopmental outcome in very low birthweight infants with pathological umbilical artery flow.

Arch Dis Child Fetal Neonatal Ed 2016 May 24;101(3):F212-6. Epub 2015 Aug 24.

Obstetric Research Unit, Clinic of Obstetrics, Zurich University Hospital, Zurich, Switzerland.

Objective: To assess neurodevelopmental outcome during toddlerhood in very low birthweight (VLBW) infants with absent or reverse end-diastolic flow (AREDF) in the umbilical artery (UA) during pregnancy.

Design: Retrospective cohort study with matched control group.

Setting: Tertiary perinatal centre.

Patients And Outcome Measures: We compared longitudinally collected data on neonatal and neurodevelopmental outcomes among 41 infants born in our institution from 1997 to 2010 with birth weight <1500 g and UA AREDF and 41 infants with prenatally normal UA Doppler parameters matched for gestational age, birth weight, sex and year of birth. We evaluated neurodevelopmental outcome at a median (range) corrected age of 23.3 (10.1-29.6) months using the Bayley scales of infant development, 2nd edition (BSID-II), and neurological examination.

Results: The mental development index in UA AREDF children (median (range) 84 (49-116)) was significantly lower than in controls (median (range) 91 (62-140)), including after adjustment for confounders. Intergroup differences in psychomotor development index (PDI; BSID-II) and the rate of cerebral palsy or minor neuromotor dysfunction were non-significant.

Conclusions: VLBW infants with UA AREDF have a higher risk of poorer mental development during toddlerhood than controls matched for gestational age, birth weight, sex and year of birth. UA AREDF may be considered a prenatal predictor of poorer mental development in this population. Long-term follow-up studies with larger cohorts are needed to better evaluate the impact of this prenatal factor on later neurodevelopment.
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http://dx.doi.org/10.1136/archdischild-2014-307820DOI Listing
May 2016

Deformation mechanisms of human amnion: Quantitative studies based on second harmonic generation microscopy.

J Biomech 2015 Jun 7;48(9):1606-13. Epub 2015 Feb 7.

Department of Mechanical and Process Engineering, ETH Zurich, 8092 Zurich, Switzerland; Swiss Federal Laboratories for Materials Science and Technology, EMPA, 8600 Dübendorf, Switzerland.

Multiphoton microscopy has proven to be a versatile tool to analyze the three-dimensional microstructure of the fetal membrane and the mechanisms of deformation on the length scale of cells and the collagen network. In the present contribution, dedicated microscopic tools for in situ mechanical characterization of tissue under applied mechanical loads and the related methods for data interpretation are presented with emphasis on new stepwise monotonic uniaxial experiments. The resulting microscopic parameters are consistent with previous ones quantified for cyclic and relaxation tests, underlining the reliability of these techniques. The thickness reduction and the substantial alignment of collagen fiber bundles in the compact and fibroblast layer starting at very small loads are highlighted, which challenges the definition of a reference configuration in terms of a force threshold. The findings presented in this paper intend to inform the development of models towards a better understanding of fetal membrane deformation and failure, and thus of related problems in obstetrics and other clinical conditions.
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http://dx.doi.org/10.1016/j.jbiomech.2015.01.045DOI Listing
June 2015

Mechanical and microstructural investigation of the cyclic behavior of human amnion.

J Biomech Eng 2015 Jun 15;137(6):061010. Epub 2015 Apr 15.

The structural and mechanical integrity of amnion is essential to prevent preterm premature rupture (PPROM) of the fetal membrane. In this study, the mechanical response of human amnion to repeated loading and the microstructural mechanisms determining its behavior were investigated. Inflation and uniaxial cyclic tests were combined with corresponding in situ experiments in a multiphoton microscope (MPM). Fresh unfixed amnion was imaged during loading and changes in thickness and collagen orientation were quantified. Mechanical and in situ experiments revealed differences between the investigated configurations in the deformation and microstructural mechanisms. Repeated inflation induces a significant but reversible volume change and is characterized by high energy dissipation. Under uniaxial tension, volume reduction is associated with low energy, unrecoverable in-plane fiber reorientation.
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http://dx.doi.org/10.1115/1.4030054DOI Listing
June 2015

High-resolution chromosomal microarrays in prenatal diagnosis significantly increase diagnostic power.

Prenat Diagn 2014 Jun 21;34(6):525-33. Epub 2014 Mar 21.

Institute of Medical Genetics, University of Zurich, Zurich, Switzerland.

Objective: The objective of this study was to determine for the first time the reliability and the diagnostic power of high-resolution microarray testing in routine prenatal diagnostics.

Methods: We applied high-resolution chromosomal microarray testing in 464 cytogenetically normal prenatal samples with any indication for invasive testing.

Results: High-resolution testing revealed a diagnostic yield of 6.9% and 1.6% in cases of fetal ultrasound anomalies and cases of advanced maternal age (AMA), respectively, which is similar to previous studies using low-resolution microarrays. In three (0.6%) additional cases with an indication of AMA, an aberration in susceptibility risk loci was detected. Moreover, one case (0.2%) showed an X-linked aberration in a female fetus, a finding relevant for future family planning. We found the rate of cases, in which the parents had to be tested for interpretation of unreported copy number variants (3.7%), and the rate of remaining variants of unknown significance (0.4%) acceptably low. Of note, these findings did not cause termination of pregnancy after expert genetic counseling. The 0.4% rate of confined placental mosaicism was similar to that observed by conventional karyotyping and notably involved a case of placental microdeletion.

Conclusion: High-resolution prenatal microarray testing is a reliable technique that increases diagnostic yield by at least 17.3% when compared with conventional karyotyping, without an increase in the frequency of variants of uncertain significance.
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http://dx.doi.org/10.1002/pd.4342DOI Listing
June 2014

Maternal and neonatal outcome of labour induction at term comparing two regimens of misoprostol.

J Perinat Med 2014 Sep;42(5):603-9

Aim: To compare the efficacy and safety of two misoprostol dosing regimens for induction of labour in primiparous (1P) and multiparous (>1P) women.

Methods: Retrospective study of induction of labour using vaginal misoprostol 25 μg vs. 50 μg every 6 h in 942 women at a tertiary centre. The main outcome variables are induction-to-delivery interval, latency period duration, vaginal delivery within 24 h, and maternal and foetal safety outcome.

Results: With the 50 μg regimen, induction-to-delivery intervals were significantly shorter: 18.4 h vs. 24.6 h (1P) and 14 h vs. 17.9 h (>1P), as was latency period duration (by 5.4 and 4 h, respectively). Vaginal delivery within 24 h was significantly more frequent, as were non-reassuring foetal heart rate (1P: 20% vs. 14%) and tachysystole (1P: 31% vs. 11%; >1P: 21% vs. 7%). No uterine rupture was reported. Neonatal outcomes were similar except for significantly more frequent infant referral to neonatal intensive care in the >1P group receiving the 50 μg regimen (11% vs. 4%).

Conclusion: Vaginal misoprostol 25 μg seems to maintain efficacy with more acceptable maternal and neonatal safety. As induction of labour is an off-label use for misoprostol, safety should be prioritised with the lower dosage regimen despite the longer induction-to-delivery interval.
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http://dx.doi.org/10.1515/jpm-2013-0215DOI Listing
September 2014

Liver Transplantation during Pregnancy for Acute Liver Failure due to HBV Infection: A Case Report.

Case Rep Obstet Gynecol 2013 9;2013:356560. Epub 2013 Dec 9.

Department of Obstetrics, University Hospital of Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland.

Acute hepatic failure during pregnancy is a life-threatening situation for the mother and fetus and might need a super-urgent liver transplantation. Many pregnancies with positive outcomes are reported after a previous liver transplantation before the pregnancy, but only a few of them are mentioned with transplantation during pregnancy. In these few cases, fetal outcome is mostly adverse. Experience with liver failure during pregnancy and its management is still deficient and needs to be approved. For sure, patients need to be treated in highly qualified centers in a multidisciplinary approach. We present a case of successful super-urgent liver transplantation during the second trimester of pregnancy after acute hepatic failure due to an acute hepatitis B infection with positive maternal and fetal outcome. Liver transplantation during pregnancy due to an acute liver failure can be a life-saving procedure for the mother and fetus. An early initiated maternal therapy with antiviral drugs and immunoglobulins seems to be safe and able to prevent fetal infection and immunosuppressive therapy after transplantation seems to be well tolerated. Nevertheless, fetal outcome differs widely and long-term outcome is deficiently known.
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http://dx.doi.org/10.1155/2013/356560DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3872232PMC
January 2014

Determinants of successful breastfeeding initiation in healthy term singletons: a Swiss university hospital observational study.

J Perinat Med 2013 May;41(3):331-9

Obstetric Research Unit, Department of Obstetrics, Zurich University Hospital, Zurich, Switzerland.

Aims: Breastfeeding significantly benefits mothers and infants. We aimed to identify the determinants of its successful initiation.

Methods: A retrospective study of 1893 mothers delivering healthy term singletons at a Swiss university hospital from 1/2008 to 3/2009 determined the associations between multiple breastfeeding and early postpartum parameters by univariate and multiple regression analysis.

Results: Multiparity was associated with nursing exclusively at the breast at discharge (P<0.001), less use of maltodextrin supplement (P<0.05), bottle/cup (both P<0.001), but more pacifier use (P<0.05). Among obese mothers, nursing exclusively at the breast at discharge was less frequent, and use of all feeding aids more frequent, than among normal-weight women (both P<0.001). Neuraxial anesthesia was associated with use of maltodextrin and bottle (both P<0.05) compared to no anesthesia. Delayed first skin-to-skin contact and rooming-in for <24 h/day were each associated with maltodextrin and cup (P<0.05). Nursing exclusively at the breast at discharge was less frequent (P<0.001), and bottle use more frequent (P<0.05), in women with sore nipples than in those without.

Conclusions: Obesity is a potent inhibitor of breastfeeding initiation. Delivery without anesthesia by a multiparous normal-weight mother, followed by immediate skin-to-skin contact, rooming-in for 24 h/day, and dedicated nipple care, provides the best conditions for successful early postpartum breastfeeding without the need for feeding aids or nutritional supplements
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http://dx.doi.org/10.1515/jpm-2012-0102DOI Listing
May 2013