Deep brain stimulation (DBS) to different sites allows interfering with dysfunctional network function implicated in major depression.Because a prominent clinical feature of depression is anhedoniaFthe inability to experience pleasure from previously pleasurable activitiesFand because there is clear evidence of dysfunctions of the reward system in depression, DBS to the nucleus accumbens might offer a new possibility to target depressive symptomatology in otherwise treatment-resistant depression. Three patients suffering from extremely resistant forms of depression, who did not respond to pharmacotherapy, psychotherapy, and electroconvulsive therapy, were implanted with bilateral DBS electrodes in the nucleus accumbens. Stimulation parameters were modified in a double-blind manner, and clinical ratings were assessed at each modification. Additionally, brain metabolism was assessed 1 week before and 1 week after stimulation onset. Clinical ratings improved in all three patients when the stimulator was on, and worsened in all three patients when the stimulator was turned off. Effects were observable immediately, and no side effects occurred in any of the patients. Using FDG-PET, significant changes in brain metabolism as a function of the stimulation in fronto-striatal networks were observed. No unwanted effects of DBS other than those directly related to the surgical procedure (eg pain at sites of implantation) were observed. Dysfunctions of the reward systemFin which the nucleus accumbens is a key structureFare implicated in the neurobiology of major depression and might be responsible for impaired reward processing, as evidenced by the symptom of anhedonia. These preliminary findings suggest that DBS to the nucleus accumbens might be a hypothesis-guided approach for refractory major depression. Neuropsychopharmacology (2008) 33, 368-377; doi:10.1038/sj.npp.1301408; published online 11 April 2007 Keywords: deep brain stimulation; major depression; anhedonia; nucleus accumbens; brain stimulation; Cg25 INTRODUCTIONTraditional methods of alleviating depression largely stem from serendipitous observations of antidepressant effects of substances such as iproniazid (originally developed as a treatment for tuberculosis) or imipramine (originally developed as a treatment for schizophrenia). In particular, increasing levels of monoamine neurotransmitters in the synaptic cleft are associated with improvements of depressive symptoms. This insight led to a more targeted drug discovery process, resulting in drugs with fewer side effects, such as SSRIs. These medication treatments, in conjunction with certain methods of psychotherapy and electroconvulsive therapy, are effective at alleviating depressive symptomatology in most patients (Andrews and Nemeroff, 1994;Mann, 2005). However, these treatments do not work for all patients. A sizable minority of patients does not respond. Indeed, twelve percent of patients suffering from major depression have a poor outcome even after 5 years of treatment (Keller et al, 1992). Patien...

Background Caesarean section with extraction of a deeply impacted fetal head is technically challenging and is associated with serious maternal and neonatal complications. The purpose of the study was to identify risks and evaluate selected outcome parameters associated with difficult fetal head extraction during caesarean section in advanced labour comparing two different extraction techniques (head pushing vs. reverse breech). Methods This retrospective cohort study was conducted at the Division of Obstetrics in a tertiary care hospital in Zurich, Switzerland. 629 women at term with a singleton pregnancy in cephalic presentation during advanced intrapartum caesarean section from December 2012 until December 2016 were evaluated. Primary outcome was the incidence of uterine incision extensions. Secondary outcomes were other selected maternal and neonatal outcome parameters. Data analysis was performed using SPSS with Mann-Whitney U independent sampling test and two-tailed Fisher’s exact test ( p < 0.01). Results Difficult fetal head extractions are associated with significantly elevated maternal and neonatal risks. When performed by reverse breech technique, significant lower rates of extensions of the uterine incision, shorter operation times and less operative blood loss were identified compared to the head pushing method. No statistically significant differences for the neonatal outcomes were described so far. However, among the group of difficult fetal delivery with the head pushing method two neonates had perinatal skull fractures, with one of those resulting in neonatal death. Conclusions The head pushing method is associated with higher maternal morbidity than the reverse breech method for extraction of a deeply engaged fetus during intrapartum caesarean section in advanced stage of labour.

Contraceptive counsellors should be aware that women's wishes differ widely. Predictability of bleeding seems to be more important to them than postponing it.

IntroductionAs the accurate diagnosis and treatment of gestational diabetes mellitus (GDM) is of increasing importance; new diagnostic approaches for the assessment of GDM in early pregnancy were recently suggested. We evaluate the diagnostic power of an ‘early’ oral glucose tolerance test (OGTT) 75 g and glycosylated fibronectin (glyFn) for GDM screening in a normal cohort.Methods and analysisIn a prospective cohort study, 748 singleton pregnancies are recruited in 6 centres in Switzerland, Austria and Germany. Women are screened for pre-existing diabetes mellitus and GDM by an ‘early’ OGTT 75 g and/or the new biomarker, glyFn, at 12–15 weeks of gestation. Different screening strategies are compared to evaluate the impact on detection of GDM by an OGTT 75 g at 24–28 weeks of gestation as recommended by the International Association of Diabetes and Pregnancy Study Groups (IADPSG). A new screening algorithm is created by using multivariable risk estimation based on ‘early’ OGTT 75 g and/or glyFn results, incorporating maternal risk factors. Recruitment began in May 2014.Ethics and disseminationThis study received ethical approval from the ethics committees in Basel, Zurich, Vienna, Salzburg and Freiburg. It was registered under http://www.ClinicalTrials.gov (NCT02035059) on 12 January 2014. Data will be presented at international conferences and published in peer-reviewed journals.Trial registration numberNCT02035059.

Introduction Lacerations are common in vaginal births, but little is known about tears other than perineal tears and their association with maternal impairment. This study aimed to evaluate the frequency and distribution of birth lacerations and their association with maternal discomfort. Methods From 2/2015 to 12/2016, we conducted a prospective observational study on 140 women with singletons in vertex presentation at term, who gave birth vaginally in our center and were affected by a laceration. The lacerations were assigned objectively and subjectively to eight genital tract compartments. The presence and effect of lacerations on maternal health were assessed by questionnaires for the time before birth (T1), 1–4 days (T2), and 6–8 weeks postpartum (T3). Results The number of affected compartments was 1.33 objectively and 2.99 at T2 and 1.27 at T3 subjectively. The most affected compartment was the right perineum (73%) followed by the right inner posterior (21%) and the right outer anterior (14%) compartment. Subjective and objective assessment concurred in 83% at T2 and 69% of cases at T3. Overall, impairment of women was low, reversible, and not directly associated with the location of lacerations, although women were psychologically affected. Conclusion Birth lacerations predominantly appear at the right perineum. Physical impairment from these lacerations is generally low, reversible, and not directly associated with the location of lacerations, although psychological impairment is not negligible.

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.

Diastasis recti abdominis during pregnancy is a frequent phenomenon with a prevalence of 30–70%. It is associated with functional and cosmetic limitations. Gold standard in diagnosis during pregnancy is the transabdominal ultrasonography. The most frequent localization is in the periumbilical region and persistence postpartum is found in about 60% of cases. Either conservative or surgical treatments seem to be effective, but relapse rates, especially after surgical therapy, are unclear. It is a problem that no standard values of diastasis recti are given, no evidence-based therapy schemes are implemented and only rare and insufficient studies exist.

Cervical dilation is a hyperbolic increasing process, with faster dilation rates in multiparous compared to nulliparous women and a reversal point of labor around 6-7 cm, respectively. Besides, cervical dilation is highly individual and affected by several impact factors. The diagnosis of labor arrest or prolonged labor should therefore be based on such rates and on the individual evaluation of every woman.