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IntroductionStudies on maternal weight, gestational weight gain and associated outcomes in twin pregnancies are scarce. Therefore, we analyzed these items in a large cohort.MethodsData from 10,603/13,725 total twin pregnancies from the perinatal database in Hessen, Germany between 2000 and 2015 were used after exclusion of incomplete or non-plausible data sets. The course of maternal and perinatal outcomes was evaluated by linear and logistic regression models.ResultsThe rate of twin pregnancies increased from 1.5 to 1.9% (p < 0.00001). Mean maternal age and pre-pregnancy weight rose from 31.4 to 32.9 years and from 68.2 to 71.2 kg, respectively (p < 0.001). The rates of women with a body mass index ≥ 30 kg/m2 increased from 11.9 to 16.9% with a mean of 24.4–25.4 kg/m2 (p < 0.001). The overall increase of maternal weight/week was 568 g, the 25th quartile was 419, the 75th quartile 692 g/week. The total and secondary caesareans increased from 68.6 to 73.3% and from 20.6 to 39.8%, respectively (p < 0.001). Rates of birthweight < 1500 g and of preterm birth < 28 and from 28 to 33 + 6 weeks all increased (p < 0.01). No significant changes were observed in the rates of stillbirth, perinatal mortality and NICU admissions.ConclusionThe global trend of the obesity epidemic is equally observed in German twin pregnancies. The increase of mean maternal weight and the calculated quartiles specific for twin pregnancies help to identify inadequate weight gain in twin gestations. Policy makers should be aware of future health risks specified for singleton and twin gestations.

The United States is with 37,451 home births in 2014 the country with the largest absolute number of home births among all developed countries. The purpose of this study was to examine the occurrence and risks of a 5-minute Apgar score of zero and neonatal seizures or serious neurologic dysfunction in women with a history of prior cesarean delivery for planned home vaginal birth after cesarean (VBAC), compared to hospital VBAC and hospital birth cesarean deliveries for term normal weight infants in the United States from 2007-2014. We report in this study outcomes of women who had one or more prior cesarean deliveries and included women who had a successful vaginal birth after a trial of labor after cesarean (TOLAC) at home and in the hospital, and a repeat cesarean delivery in the hospital. We excluded preterm births (<37 weeks) and infants weighing under 2500 g. Hospital VBACS were the reference. Women with a planned home birth VBAC had an approximately 10-fold and higher increase in adverse neonatal outcomes when compared to hospital VBACS and hospital repeat cesarean deliveries, a significantly higher incidence and risk of a 5-minute Apgar score of 0 of 1 in 890 (11.24/10,000, relative risk 9.04, 95% confidence interval 4-20.39, p<.0001) and an incidence of neonatal seizures or severe neurologic dysfunction of 1 in 814 (Incidence: 12.27/10,000, relative risk 11.19, 95% confidence interval 5.13-24.29, p<.0001). Because of the significantly increased neonatal risks, obstetric providers should therefore not offer or perform planned home TOLACs and for those desiring a VBAC should strongly recommend a planned TOLAC in the appropriate hospital setting. We emphasize that this stance should be accompanied by effective efforts to make TOLAC available in the appropriate hospital setting.

Over the last decade, planned home births in the United States (US) have increased, and have been associated with increased neonatal mortality and other morbidities. In a previous study we reported that neonatal mortality is increased in planned home births but we did not perform an analysis for the presence of professional certification status. The objective of this study therefore was to undertake an analysis to determine whether the professional certification status of midwives or the home birth setting are more closely associated with the increased neonatal mortality of planned midwife-attended home births in the United States. This study is a secondary analysis of our prior study. The 2006-2009 period linked birth/infant deaths data set was analyzed to examine total neonatal deaths (deaths less than 28 days of life) in term singleton births (37+ weeks and newborn weight ≥ 2,500 grams) without documented congenital malformations by certification status of the midwife: certified nurse midwives (CNM), nurse midwives certified by the American Midwifery Certification Board, and \"other\" or uncertified midwives who are not certified by the American Midwifery Certification Board. Neonatal mortality rates in hospital births attended by certified midwives were significantly lower (3.2/10,000, RR 0.33 95% CI 0.21-0.53) than home births attended by certified midwives (NNM: 10.0/10,000; RR 1) and uncertified midwives (13.7/10,000; RR 1.41 [95% CI, 0.83-2.38]). The difference in neonatal mortality between certified and uncertified midwives at home births did not reach statistical levels (10.0/10,000 births versus 13.7/10,000 births p = 0.2). This study confirms that when compared to midwife-attended hospital births, neonatal mortality rates at home births are significantly increased. While NNM was increased in planned homebirths attended by uncertified midwives when compared to certified midwives, this difference was not statistically significant. Neonatal mortality rates at home births were not significantly different in relationship to professional certification status of the birth attendant, whether the delivery was by a certified or an uncertified birth attendant.

Objective International guidelines recommend vaginal pessaries as a first-choice treatment of symptomatic pelvic organ prolapse (POP). Gynecologists rarely receive systematic training or just do not take the time to communicate with their patients. We hypothesized that we could identify key deficits and limitations of counseling before or during pessary therapy from questions directed to manufacturers with the aim to improve and promote health literacy of women with POP. Methods We approached five manufacturers to provide anonymized inquiries related to pessary use. After exclusion of duplicates and questions about obstetric pessaries, 174 data sets from 145 patients remained. Results In 19/145 patients (13.1%), a 2nd degree, and in 94/145 (64.8%), a 3rd–4th degree of POP was identified. Four patients had additional urinary incontinence. In 32/145 (22.1%), the severity of POP could not be identified. The age of patients ranged from 27 to 98 (mean = 63.7) years. Most inquiries were related to the selected pessary models or sizes (40/174; 22.9%), self-management (20/174; 11.5%), and technical aspects such as shelf life or appropriate cleaning (26/174; 14.9%). Pain or voiding dysfunction was present in 17/174 remarks (9.7%). Lifestyle questions related to the use of pessaries during sport, menstruation, or mechanical anticonception. The cube pessary was in the focus of interest followed by the sieve bowl, urethra, ring, and Gellhorn device. The list of questions was summarized as a checklist stratified according to priorities. Conclusion The checklist should help improve counseling and self-management of patients to optimize the benefit/risk ratio of conservative treatment of pelvic floor diseases.

Purpose The aim of this paper is to analyze the impact of prior breast cancer (BC) on mode of delivery and pregnancy-associated disorders. Methods A database from 262 German gynecological practices including 289,712 women between the ages of 18 and 45 with documented pregnancies between 2000 and 2014 was used to search for patients with a history of BC up to 10 years prior to pregnancy. A total of 165 patients with a history of BC were found and matched with 165 patients without a history of any cancer (1:1) by age, physician, obesity, and documented referral to a fertility center up to 12 months before the index pregnancy. The impact of prior BC on the mode of delivery and pregnancy-associated disorders was analyzed using Cox regression models. Results The mean maternal age at first visit was 34.6 years in both groups. The early and late pregnancy loss was significantly reduced (17.7 versus 29.9%, OR 0.50) and delivery of a live-born child more frequent (82.3 versus 70.1%, OR 2.00) in women who had had BC than in controls. Furthermore, preterm contractions without preterm birth were less frequent in women with BC compared to controls (9.2 versus 18.9%, OR 0.43). No significant differences were found for other pregnancy complications, such as suspected fetal growth restriction, genito-urinary infections, fetal malpresentation, gestational diabetes, pre-eclampsia, or breastfeeding issues. Conclusions Based on the decreased rate of early and late pregnancy loss and the absence of significant differences in most documented pregnancy-associated disorders, women with the previous BC can be assured of the possibility of a good outcome on a subsequent pregnancy.

Last year, in two widely discussed articles, Eduard Verhagen and Pieter Sauer reported on the Dutch experience with euthanasia in newborns under current Dutch law and medical practice and proposed a protocol, called the Groningen Protocol, to guide the decision-making.1 The protocol has two parts.

Radical and repeated cone biopsies are associated with a high risk of spontaneous preterm birth. A 30-year-old gravida 1 presented with a spontaneous dichorionic twin pregnancy. She had a history of two radical surgical conizations. By speculum examination, no cervical tissue was detected. A history-indicated transabdominal cervicoisthmic cerclage was performed at 12 + 4/7 gestational weeks because of assumed cervicoisthmic insufficiency. The pregnancy continued until 34 + 3/7 weeks when the patient developed preeclampsia indicating Cesarean delivery. Transabdominal cerclage in twin pregnancy has rarely been described, but it may be considered in case of extreme cervical shortening after radical cervical surgery, as it would in singleton pregnancy.

No consensus exists for the best way to monitor and when to trigger delivery in mothers of babies with fetal growth restriction. We aimed to assess whether changes in the fetal ductus venosus Doppler waveform (DV) could be used as indications for delivery instead of cardiotocography short-term variation (STV). In this prospective, European multicentre, unblinded, randomised study, we included women with singleton fetuses at 26–32 weeks of gestation who had very preterm fetal growth restriction (ie, low abdominal circumference [<10th percentile] and a high umbilical artery Doppler pulsatility index [>95th percentile]). We randomly allocated women 1:1:1, with randomly sized blocks and stratified by participating centre and gestational age (<29 weeks vs ≥29 weeks), to three timing of delivery plans, which differed according to antenatal monitoring strategies: reduced cardiotocograph fetal heart rate STV (CTG STV), early DV changes (pulsatility index >95th percentile; DV p95), or late DV changes (A wave [the deflection within the venous waveform signifying atrial contraction] at or below baseline; DV no A). The primary outcome was survival without cerebral palsy or neurosensory impairment, or a Bayley III developmental score of less than 85, at 2 years of age. We assessed outcomes in surviving infants with known outcomes at 2 years. We did an intention to treat study for all participants for whom we had data. Safety outcomes were deaths in utero and neonatal deaths and were assessed in all randomly allocated women. This study is registered with ISRCTN, number 56204499. Between Jan 1, 2005 and Oct 1, 2010, 503 of 542 eligible women were randomly allocated to monitoring groups (166 to CTG STV, 167 to DV p95, and 170 to DV no A). The median gestational age at delivery was 30·7 weeks (IQR 29·1–32·1) and mean birthweight was 1019 g (SD 322). The proportion of infants surviving without neuroimpairment did not differ between the CTG STV (111 [77%] of 144 infants with known outcome), DV p95 (119 [84%] of 142), and DV no A (133 [85%] of 157) groups (ptrend=0·09). 12 fetuses (2%) died in utero and 27 (6%) neonatal deaths occurred. Of survivors, more infants where women were randomly assigned to delivery according to late ductus changes (133 [95%] of 140, 95%, 95% CI 90–98) were free of neuroimpairment when compared with those randomly assigned to CTG (111 [85%] of 131, 95% CI 78–90; p=0.005), but this was accompanied by a non-significant increase in perinatal and infant mortality. Although the difference in the proportion of infants surviving without neuroimpairment was non-significant at the primary endpoint, timing of delivery based on the study protocol using late changes in the DV waveform might produce an improvement in developmental outcomes at 2 years of age. ZonMw, The Netherlands and Dr Hans Ludwig Geisenhofer Foundation, Germany.