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Background: To evaluate the use and effect of cervical stitch cerclage, pessary, and progesterone on pregnancy outcome in mothers of very low birth weight infants (VLBWI) born<32 weeks of gestation in the German Neonatal Network (GNN)., Methods: The GNN is a population-based cohort study enrolling VLBWI since 2009. We included 575 neonates from 424 mothers into our analysis, who were born between 2015 and 2019, after prenatal intervention with cerclage, pessary, progesterone or a combination between 20/0 to 25/0 weeks of gestation to prevent preterm birth. Median intervention-to-birth interval was the primary endpoint., Results: 231 of 424 pregnant women had a cerclage only (54.5%), 76 women a pessary only (17.9%), and 27 were prescribed progesterone only (15.3%). The most common combination treatment (>1 intervention group) was cerclage plus progesterone (n=27), followed by cerclage plus pessary (n=13). The median intervention-to-birth interval for the whole cohort was 24 days (IQR 19.0 days). The earlier the intervention was started, the longer the intervention-to-birth interval lasted: When started at 20 weeks, the interval was 34 days in contrast to 11.5 days, when started at 25 weeks. The >1 group was born at a significantly higher median GA with 27.0 weeks (IQR 2.9 weeks) and a higher median birth weight of 980 g (IQR 394 g) accordingly., Conclusion: We propose that the earliest possible start of intervention leads to the most efficient pregnancy prolongation., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background Anthropometric parameters such as birth weight (BW) and adult body height vary between ethnic groups. Ethnic-specific percentile charts are currently being used for the assessment of newborns. However, due to globalization and interethnic families, it is unclear which charts should be used. A correlation between a mother's height and her child's BW (1 cm accounts for a 17 g increase in BW) has been observed. The study aims to test differences in small for gestational age (SGA) and large for gestational age (LGA) rates, employing BW percentile charts based on maternal height between ethnic groups. Methods This retrospective study of 2.3 million mother/newborn pairs analyzed BW, gestational age, sex, maternal height and ethnicity from the German perinatal survey (1995-2000). These data were stratified for maternal height (≤157, 158-163, 164-169, 170-175, ≥176 cm) and region of origin (Germany, Central and Northern Europe, North America, Mediterranean region, Eastern Europe, Middle East and North Africa, and Asia excluding Middle East). Percentile charts were calculated for each maternal height group. Results The average BW and maternal height differ significantly between ethnic groups. On current percentile charts, newborns of taller mothers (≥176 cm) have a low rate of SGA and a high rate of LGA, whereas newborns of shorter mothers (≤157 cm) have a high rate of SGA and a low rate of LGA. When the BW data are stratified based on the maternal height, mothers of similar height from different ethnic groups show similar average BWs, SGA and LGA rates. Conclusion Maternal body height has a greater influence on BW than maternal ethnicity. The use of BW percentile charts for maternal height should be considered.

Objective: It was the aim of our study to evaluate the independent effect of preterm prelabor rupture of membranes (PPROM) as a cause of preterm delivery on mortality during primary hospital stay and significant morbidities in very-low-birth-weight (VLBW) infants < 32 weeks of gestation., Design: Observational, epidemiological study design., Setting: Population-based cohort, German Neonatal Network (GNN)., Population: 6102 VLBW infants were enrolled in GNN from 2009-2012, n=4120 fulfilled criteria for primary analysis (< 32 gestational weeks, no pre-eclampsia, HELLP (highly elevated liver enzymes and low platelets syndrome) or placental abruption as cause of preterm birth)., Methods: Multivariable logistic regression analyses included PPROM as potential risk factors for adverse outcomes and well established items such as gestational age in weeks, birth weight, antenatal steroids, center, inborn delivery, multiple birth, gender and being small-for-gestational-age., Results: PPROM as cause of preterm delivery had no independent effect on the risk of early-onset sepsis, clinical sepsis and blood-culture proven sepsis, while gestational age proved to be the most important contributor to sepsis risk. The diagnosis of PPROM was associated with an increased risk for bronchopulmonary dysplasia (BPD; OR: 1.25, 95% CI: 1.02-1.55, p=0.03) but not with other major outcomes., Conclusions: The diagnosis of PPROM per se is not associated with adverse outcome in VLBW infants < 32 weeks apart from a moderately increased risk for BPD. Randomized controlled trials with primary neonatal outcomes are needed to determine which subgroup of VLBW infants benefit from expectant or intentional management of PPROM.

Aim: The aim of this study was to develop new national standards for birth weight, length, head circumference, and weight for length for newborn twins based on the German perinatal survey of 2007-2011. We also assessed trends in anthropometric measurements by comparing these new percentile values with the percentile values of 1990-1994., Material and Methods: Perinatal survey data of 110,313 newborn twins from all the states of Germany collected in the years 2007-2011 were kindly provided by the AQUA Institute in Göttingen, Germany. Sex specific percentile values were calculated using cumulative frequencies. Percentile values at birth were computed for the 3rd, 10th, 25th, 50th, 75th, 90th, and 97th percentiles for 21-40 completed weeks of gestation. Percentile curves and tabulated values for the years 2007-2011 were compared with the published values of 1990-1994., Results and Discussion: The new percentile curves (2007-2011) closely resemble the previous ones (1990-1994). Small differences can nonetheless be found. For example, for birth weight the new values for the 10th percentile are a little higher., Conclusions: We recommend using the new percentile values instead of the old ones., (© Georg Thieme Verlag KG Stuttgart · New York.)

Aim: The aim of this study was to derive percentile values for birth weight, length, head circumference, and weight for length for singleton neonates based on the German perinatal survey of 2007-2011 (using data from all 16 states of Germany). We also compared these new percentile values with the percentile values of 1995-2000 that so far have been considered standard values., Material and Methods: Data of 3 187 920 singleton neonates from the German perinatal survey of the years 2007-2011 were kindly provided to us by the AQUA Institute in Göttingen, Germany. Sex specific percentile values were calculated using cumulative frequencies. Percentile values at birth were computed for the 3(rd), 10(th), 25(th), 50(th), 75(th), 90(th), and 97(th) percentiles for 21-43 completed weeks of gestation. Percentile curves and tabulated values for the years 2007-2011 were compared with the published values of 1995-2000., Results and Discussion: Overall the new percentile curves closely resemble the previous ones. Minimal differences can be found for the 10(th) percentile and generally for early weeks of gestation. Values for the 10(th) percentile in the 2007-2011 dataset are somewhat higher than values of 1995-2000 for birth weight, length, and weight for length., Conclusions: We recommend the use of these new percentile values instead of the old ones., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Aim: We have previously analysed neonatal characteristics and duration of pregnancy in Germany based on data from the German Perinatal Survey of 1995-1997. Here we describe neonatal characteristics and duration of pregnancy based on the German Perinatal Survey of 2007-2011., Material and Methods: We had been provided with data from the German Perinatal Survey of 1995-1997 by the chambers of physicians of all the states of Germany except Baden-Württemberg (1 815 318 singleton neonates). We were also provided with access to the perinatal survey data of 2007-2011 by the AQUA Institute in Göttingen, Germany (3 187 920 singleton neonates). We investigated regional differences within Germany and also compared the 2 periods of time. We used the computer programme SPSS for data analysis and performed plausibility checks on the survey data., Results: Comparing the states of Germany, we found that birth weight was largest for neonates born in Schleswig-Holstein (3 407 g) and Mecklenburg-Western Pomerania (3 392 g); the lowest mean birth weight was observed in the Saarland (3 283 g). Preterm birth rate varied between 6.3% (Saxony) and 8.1% (Bremen, Saarland). Comparing 1995-1997 vs. 2007-2011, deliveries after 37 and 38 weeks of gestation were more common and deliveries after 39 and more weeks of gestation were less common in the later period of time., Conclusions: Regional differences in the anthropometric characteristics of neonates exist between the states of Germany. The proportion of deliveries after 39 and more weeks of gestation has decreased., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: Very premature delivery is a major cause of infant morbidity and mortality. Obesity, diabetes and pregnancy hypertension are known risk factors for pregnancy complications. The study aimed to scrutinize differences of pregnancy complications in a cohort of very premature deliveries compared to a national group., Methods: In a multicenter study performed between January 2009 and December 2010 including 1,577 very low birth weight (VLBW) infants, we compared parental reported pregnancy problems of VLBW infants with a national cohort (KIGGS). We compared reported pregnancy complications to reasons for premature delivery and neonatal outcome within the group of VLBW infants., Results: While parents of the national cohort reported pregnancy-induced hypertension in 8 %, parents of VLBW infants reported this complication more frequently (27 %). Mothers of the national cohort were significantly younger (1 year), suffered less from obesity, anaemia, diabetes. Regression analysis showed that hypertension (OR = 5.11) and advanced maternal age (OR = 1.03) increased the risk for premature birth. Women with hypertension were likely to experience a clinically indicated premature delivery, had more VLBW infants with a moderate growth restriction, but less multiples and their infants had less intraventricular haemorrhages grade 3 or 4. Otherwise, neonatal outcome was correlated with gestational age but not with the pregnancy complications diabetes, hypertension or obesity., Conclusion: Premature birth seems to be correlated to gestational hypertension and associated problems in about ¼ of VLBW infants. Further studies should focus on preventing and treating gestational hypertension to avoid premature delivery and associated neonatal morbidity.

This study examines the quantitative changes in the somatic classification according to birth weight and duration of pregnancy of German neonates when maternal height is considered (5 maternal height groups). Our calculations were performed using data of 319 884 girls born in 2010. Overall, about 6% (18 792 girls) are classified differently (more appropriately) when group-specific norm values were used., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: We have previously described the prevalence in pregnancy of hypertension, proteinuria, oedema and preeclampsia/eclampsia according to maternal body mass index (BMI) and smoking status. We found that these disorders were less frequent among smoking women. To investigate whether this relationship is causal or a chance finding, we here present an analysis according to BMI and smoking specified according to the number of cigarettes consumed per day., Materials and Methods: Data were from the German Perinatal Survey of 1998-2000. We classified women by BMI as underweight (BMI<18.5 kg/m2), normal weight (BMI 18.5-24.99 kg/m2), overweight (25.0-29.99 kg/m2), or obese (BMI≥30 kg/m2). Smoking was categorised as being a non-smoker or smoking 1-7, 8-14 or ≥ 15 cigarettes per day. Datasets from 433 669 singleton pregnancies with information on maternal BMI and smoking were included in the analysis., Results: In all BMI categories hypertension, moderate to severe oedema, and preeclampsia/eclampsia became less prevalent with increasing maternal cigarette consumption., Conclusions: Dose-dependence was not convincing for proteinuria.Dose-dependence in the relationship between smoking and hypertensive disorders of pregnancy argues against a chance finding and for a causal relationship., (© Georg Thieme Verlag KG Stuttgart · New York.)

The German Neonatal Network (GNN) is a prospective cohort study with the focus on long term development of very-low-birth-weight infants. It was the aim of this study to determine detailed information on causes of mortality in the GNN birth cohort 2010.Major contributors to hospital mortality were recorded by the attending neonatologists for the cohort of very-low-birth-weight (VLBW) infants born in centres of the German Neonatal Network (GNN) in 2010. The data quality was approved by on-site monitoring.2 221 VLBW infants were born in GNN centres in 2010, and death occurred in 221 infants. Male infants carried a higher risk than females (58.8% males among non-survivors vs. 51.7% among survivors, p=0.047). In 11 infants, the major contributor to death was not determined by the attending neonatologist. In 25 infants born at the limit of viability, comfort palliative care was primarily initiated and 14 infants had lethal malformations. The majority of non-survivors suffered from inflammatory diseases including sepsis- or necrotizing enterocolitis (NEC)-associated death (n=56). Respiratory pathology was a major contributor to death in 65 infants including 11 infants who died from pulmonary haemorrhage.Potentially preventable complications of preterm birth such as sepsis, NEC and pulmonary haemorrhage predominate the major contributors to mortality in the GNN 2010 cohort. In order to decrease the rate of these associated deaths, future trials should focus on prophylaxis and therapy optimization strategies for these outcomes., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: We evaluated blood culture-proven sepsis episodes occurring in microclusters in very-low-birth-weight infants born in the German Neonatal Network (GNN) during 2009-2010., Methods: Thirty-seven centers participated in GNN; 23 centers enrolled ≥50 VLBW infants in the study period. Data quality was approved by on-site monitoring. Microclusters of sepsis were defined as occurrence of at least two blood-culture proven sepsis events in different patients of one center within 3 months with the same bacterial species. For microcluster analysis, we selected sepsis episodes with typically cross-transmitted bacteria of high clinical significance including gram-negative rods and Enterococcus spp., Results: In our cohort, 12/2110 (0.6%) infants were documented with an early-onset sepsis and 235 late-onset sepsis episodes (≥72 h of age) occurred in 203/2110 (9.6%) VLBW infants. In 182/235 (77.4%) late-onset sepsis episodes gram-positive bacteria were documented, while coagulase negative staphylococci were found to be the most predominant pathogens (48.5%, 95%CI: 42.01-55.01). Candida spp. and gram-negative bacilli caused 10/235 (4.3%, 95%CI: 1.68% -6.83%) and 43/235 (18.5%) late-onset sepsis episodes, respectively. Eleven microclusters of blood-culture proven sepsis were detected in 7 hospitals involving a total 26 infants. 16/26 cluster patients suffered from Klebsiella spp. sepsis. The median time interval between the first patient's Klebsiella spp. sepsis and cluster cases was 14.1 days (interquartile range: 1-27 days). First patients in the cluster, their linked cases and sporadic sepsis events did not show significant differences in short term outcome parameters., Discussion: Microclusters of infection are an important phenomenon for late-onset sepsis. Most gram-negative cluster infections occur within 30 days after the first patient was diagnosed and Klebsiella spp. play a major role. It is essential to monitor epidemic microclusters of sepsis in surveillance networks to adapt clinical practice, inform policy and further improve quality of care.

Aim: We aimed to set-up a passive malformations registry for 2002-2004 for the German Federal State of Mecklenburg-Western Pomerania in order to estimate the prevalence of congenital malformations among live births, stillbirths, miscarriages, and induced abortions. POPULATION AND STUDY DESIGN: Under the guidance of the working group "Neonatology Mecklenburg-Vorpommern" a standardised malformations record form modelled after the Mainz registry was developed and used to record malformations among live births, stillbirths, miscarriages, and induced abortions in all 21 obstetric departments in Mecklenburg-Western Pomerania between 2002 and 2004. We compared the population of neonates with malformations with a general population sample from the German Perinatal Survey of 1995-1997., Results: There were 768 neonates with at least one major malformation among a total of 37 634 neonates in Mecklenburg-Western Pomerania; this means that the prevalence of major malformations was 203.53 per 10 000 neonates. The prevalence of major malformations in liveborn infants was 178.61 per 10 000. The most common malformations in the total study population were ventricular septal defect (prevalence: 37.2 per 10 000), hydronephrosis (16.7 per 10 000), hypospadias (14.8 per 10 000), Down syndrome (10.1 per 10 000), and cleft lip and palate (9.0 per 10 000). Among the induced abortions the most common diagnoses were Down syndrome, anencephalus, Edwards syndrome, and congenital hydrocephalus. The preterm birth rate among the 637 liveborn and stillborn infants with malformations was 19.6%; 5.6% were born before 32 completed weeks of gestation. The small for gestational age rate for infants with malformations was 14.2% for girls and 14.5% for boys, thus increased compared with the general population sample (9.7%)., Conclusions: Congenital malformations are important determinants of childhood morbidity and mortality. Malformation prevalence and types of malformations, along with morbidity and mortality, are important parameters in perinatal medicine. The establishment of active malformation registries is therefore an important task., (© Georg Thieme Verlag KG Stuttgart · New York.)

Aim: The influence of previous interruptions, miscarriages and IUFD on the IUGR and preterm rate as well as on the somatic staging (gestational age and birth weight) of the new born is a subject of controversial discussion in the literature. The present paper attempts to quantify these risks of the medical history. 2 282 412 singleton pregnancies of the period 1995 to 2000 were evaluated from the German Perinatal Database. For the analysis 1 065 202 pregnancies (46.7 %) of those mothers without any live birth in the medical history were assessed. To exclude any influence from previous abortions patients with previous miscarriages and IUFDs were excluded. The control collective were new borns whose mothers had suffered neither from miscarriages nor from abortions or IUFD., Results: Previous interruptions, miscarriages and IUFD influence the rate of new borns with low birth weight and increase the rate of prematurity. With increasing numbers of isolated or combined risks in the medical history, the rate of newborns with a low birth weight or with prematurity is increased. The lowest risk was found after one interruption, the highest rate with two or more IUFDs. Interruptions, miscarriages or IUFD are not risk factors for IUGR or SGA., Conclusion: Previous interruptions, miscarriages and IUFD are relevant risk factors for prematurity and are related with low birth weight of the new borns. Pregnant women with such risk factors have to been considered as risk pregnancies and need intensive surveillance.

Background: As about 20 % of pregnant women smoke, 137,000 of the 685,795 neonates delivered in Germany in 2005 have been affected by smoking during pregnancy. Caring for neonates born prematurely because of smoking results in additional costs. We have attempted to estimate these costs., Material and Methods: Data of 1,815,318 pregnancies were collected from the German perinatal statistics of 1995-1997. In 876,645 cases there was information regarding smoking. Of these, 699,134 pregnant women were non-smokers and 177,511 were smokers. To determine the number of preterm births due to smoking, we compared the distribution of the duration of pregnancy of the non-smoking cohort to that of the smoking cohort. From the difference between this and the actual distribution of the duration of pregnancy among smokers we determined the number of additional preterm births caused by smoking. For the analysis of the associated costs we used the actual costs of care and daily rates used in neonatology., Results: For 2002 we estimate 43 million Euros of additional costs due to neonates born prematurely because of smoking., Conclusions: We present a rough estimate of the additional health care costs for neonates because of smoking. Costs were estimated only with regard to premature deliveries. Other effects of smoking during pregnancy on neonatal health were not considered. More detailed cost analyses will likely reveal even higher costs.

Background: The weight gain during pregnancy is influenced by maternal body weight and height. With this study we want to illustrate the relationship between weight, height, body mass index (BMI) and the weight gain in pregnancy., Materials and Methods: Data of about 2.3 million singleton pregnancies were taken from the German perinatal statistics of 1995-2000. Weight gain was calculated as the difference between the weight at the end of the pregnancy and the weight at the first consultation., Results: The distribution of the weight gain resembles a normal distribution. Overall mean weight gain is 12.8 kg. For women weighing < 63 kg, there is a rise in weight gain with increasing body weight at the first consultation. Beyond 63 kg the amount of weight gain falls with increasing body weight at the first consultation. Weight gain increases with increasing height. Overall there is a negative correlation between BMI and weight gain. However, women with the same BMI but different body weights and heights can differ significantly with regard to their weight gain., Conclusions: Height and body weight at the beginning of pregnancy are important determinants of the weight gain. They should therefore be used when assessing the weight gain in clinical practice. Use of the BMI, however, is not appropriate. We are investigating other ways of combining body weight and height. This will be discussed in a later publication.