Precardiac venous blood flow, umbilical artery and aortal blood flow of 120 unselected patients has been investigated by means of Doppler ultrasound. Measuring a hepatic vein directly before entering the inferior vena cava we found a characteristic blood flow pattern with a moderate foreward flow during systole and a small foreward flow during early diastole and a very small reverse flow because of atrial contraction during late diastole. We found changes in this flow pattern with reduction of the mean velocity in cases of high risk pregnancies with intrauterine growth retardation. Comparing normally developed fetuses with growth-retarded fetuses and vaginal delivery or caesarean sections without fetal distress with caesarean sections because of fetal distress we found significant differences with lower mean velocities in the precardiac veins of the latters. Comparing the precardiac venous flow velocities with the umbilical artery flow velocities and the fetal descending aortal flow velocities we found similar results of statistical values predicting growth retardation and caesarean section because of fetal distress. We concluded that venous Doppler flow velocity analysis is also able to predict perinatal risks like intrauterine growth retardation or caesarean section because of fetal distress as good as flow velocimetry of the umbilical artery or the fetal aorta; if it is impossible to demonstrate the fetal descending aorta or the vena cava inferior sonographically correctly the investigation of the hepatic vein may give you more reliable Doppler values for your clinical management.
95 patients were investigated using Doppler ultrasound to evaluate its usefulness during the clinical management of patients with preterm labor, preterm rupture of membranes and incompetent cervix. Cases with additional pregnancy complications as preeclampsia or intrauterine growth retardation or infection of the amnion or the birth canal were excluded from our study. We examined the umbilical artery and the uterine arteries. Predicting preterm birth we found a sensitivity of 31.4% and a specificity of 70% for the former and a sensitivity of 34.3% and a specificity of 83.3% for the latter. As a result of our investigation we have to conclude that Doppler ultrasound is not able to predict sufficiently reliable preterm birth to use it in clinical management. Normal uterine blood flow in cases with preterm labor seems to indicate birth at term in a high degree.
In a quarter of our Doppler investigations differences between the S/D-ratios of the arteries of one umbilical cord were more than 20%. In these cases one Doppler value was decided to be normal and the other to be pathological. In cases with two pathological values most caesarean sections because of fetal distress had to be performed and most SGA babies were born. There were relatively more caesarean sections and SGA babies in cases with one normal value and one pathological value than in cases with two normal Doppler values. Sensitivity and specificity of perinatal risks like intrauterine growth retardation or caesarean section because of fetal distress were different depending on which Doppler value was used to calculate these statistical parameters. Taking always the better values compared to the worse ones we found as greatest difference 20.0% for sensitivities and 24.1% for specificities. Taking the means of the better and the worse Doppler values we found as greatest difference 5.6% for sensitivities and 8.7% for specificities compared to the cases with two identical Doppler results. To decide whether the fetus is jeopardized and to describe the nutritional function of the placenta correctly by means of Doppler ultrasound of the umbilical artery we conclude that in some cases the investigation of both arteries is important to avoid false positive or false negative results.
The need for alternatives to amniocentesis, beset by 1% abortion rate, has been increasingly voiced over the past years and also includes the under 35 age group. However, the known age-dependent screening programs such as Alpha program according to Wald (1988) and the Dermalog Program according to Norgaard-Pederson (1990) only yield a detection rate of 50 or, at best, 70% (Müller, 1992) for this age group. We tried to improve this result by index calculation. Compared to the tested age-dependent screening programs the Ulm Index achieves a 25 to 40% higher detection rate (85%). For pregnant women beyond 35 years the detection rate of Down's syndrome can even be raised to 95-100% by a combination of the Alpha or Dermalog program with the Ulm Index, without entailling an increase in the rate of false-positive results.
We performed a study in dopplersonography of the A. umbilicalis in pregnant women, who had either an untreated or a with Pholedrin longo (alpha receptor stimulating substance) treated hypotension. These study groups were compared with patients who had a normal blood pressure. In patients with hypotension we found higher values of the qualitative flow indices than women with normotension reflecting a low uterine perfusion. In the group with therapy of hypotension we could analyse a normalisation of the values without decrease of uteroplacental perfusion. These findings show, that hypotension is a high risk in pregnancy which we have to care for.
The cervix uteri is of greatest importance for the environment of the fetus. The sonographic imaging of the cervix uteri can be done by transabdominal, perineal and transvaginal route. Each of these methods are associated with specific advantages and disadvantages. During the time of gestation the cervix uteri can be measured sonographically concerning the length, the thickness, the width of the cervical canal and in addition the diameter of the internal and the external os. At the beginning of labour the cervix shows a transformation: a shortening with an increase of thickness. The phase of contraction is followed by a phase of reformation. Individual formations of the cervix regarding the a premature opening of the internal os or the external os could be demonstrable without clinical symptoms. By W. Eppel a score-like formula "Incompetence-Factor" was described for a quantification of these measurements.
Doppler-sonography was performed in 16 newborns with prenatally diagnosed unilateral cystic renal malformation. 11 babies with multicystic dysplastic kidneys showed doppler-sonographically reduced systolic flow velocities and elevated resistive index (RI) [RI = 90-100%] or lack of obtainable perfusion signals. 4 of them had to undergo nephrectomy, the other asymptomatic patients could be managed conservatively, spontaneous regression could be observed. 5 other infants suffering from cystic nephroma, severe ureteropelvic junction obstruction, hudge bleeding of the adrenal gland and hydronephrosis due to ectopic ureter, having been prenatally presented as "cystic renal malformations", initially showed normal systolic flow velocities within renal parenchyma and only slightly elevated RI (mean = 83%). By this they could be differentiated from multicystic kidney dysplasia. We therefore propose to use doppler-sonography for differential diagnosis of prenatally assumed cystic kidney malformations.
In addition to the flowmetrie of aorta fetalis and a. umbilicalis, color flow mapping enables the examination of the renal and middle cerebral arteries in the assessment of the fetal blood circulation. The resistance and pulsatility-indices of aorta fetalis, umbilical artery, renal artery and middle cerebral artery were calculated in a prospective examination of a normal study group of 123 pregnant women. Moreover, ratios were established from the pulsatility-indices of renal artery and aorta fetalis, renal artery and umbilical artery, middle cerebral artery and aorta fetalis, middle cerebral artery and umbilical artery. By the use of these ratios, we hope to detect more reliably changes in the fetal blood circulation.
The case report is about an infant suffering from coumarin embryopathy and coumarin syndrome after its mother underwent phenprocoumon treatment (Marcumar, Falithrom) during pregnancy (until 26th week of gestation). Interestingly, a hearing disorder was diagnosed, which had never been described in context with this substance. The coumarin derivatives warfarin, acenocoumarol and phenoprocoumon were compared with regards to spontaneous abortion rate, perinatal mortality and teratogenic risk. Eye anomalies or malformations seem to appear only under warfarin treatment, whereas CNS-malformations are more frequent under phenprocoumon. As a consequence, phenprocoumon treatment of fertile women seems rather doubtful. Upon discovery of a pregnancy under coumarin treatment, vitamin K should immediately be substituted in order to minimize the risk of anomalies and malformation.
A four-channel topographic technique was developed in order to improve information about spatial uterine motility. 54 women were monitored during delivery. Four pressure transducers were attached in a square around the umbilicus. Most frequently the origin of labour could be determined in the upper right segment of the uterus. The rate of operative deliveries was decreased in case of predominant upper right origin of labour. The majority of contractions with clear propagation patterns originated at the upper right site, continued to the left and then to the lower right part of the uterus. The highest relative intensity was also measured at the upper right site. Predominant upper right origin of labour may be important for undisturbed delivery. The probability of a preterm delivery is increased in case of an upper right origin of labour.
Size and shape of the bony pelvis are important factors determining the progress of labor and delivery. Clinical evaluation of the pelvis and sonographic examination of the fetal size are important tools for the planning of labor and in most cases allow to diagnose cephalopelvic disproportion. Pelvimetry by computed tomography (CT) and by magnetic resonance imaging (MRI) are exact and simple techniques with low or absent ionizing radiation. These new techniques offer distinct advantages over conventional X-ray pelvimetry. However, the value of the measurements of the pelvic dimensions in predicting labor outcome and in the diagnosis of cephalopelvic disproportion remains limited. Only if the pelvimetric data are combined with data on fetal dimensions obtained by ultrasound or by postpartum measurements, the efficacy of the examination in predicting the success of labor and identifying the presence or absence of cephalopelvic disproportion is increased. This combination therefore may confirm the diagnosis of cephalopelvic disproportion after operative delivery, which is important with respect to subsequent deliveries. Furthermore this method could play and important role in selecting patients with term breech presentation for possible vaginal delivery.
Presented is one rare case in a family affected by a Holt- Oram-Syndrome. This syndrome is associated with an upper limb malformation and a congenital heart disease. In our case we found radiusaplasia on both sides, thenaraplasia on the left hand, a hypoplastic thumb on the right hand. The heart was malformed as a Fallot tetralogy, the left kidney was absent. Four additional affected members of the family are described. By routine ultrasound examination we could not find this malformation syndrome. In families with affected history ultrasound screening examination should be done on a center for prenatal diagnosis.
The central function of the cervix to maintain pregnancy is biochemically characterized by an increased synthesis of collagen, proteins, glycosaminoglycans (GAG) and fibronectin within the extracellular matrix, thus leading to an increase of cervical volume without significant changes of cervical consistency. During the time of cervical ripening we found a marked reduction of collagen concentration, a 2.5-fold increase in GAG content, a significant fall in dermatan sulfate concentrations from 41% to 15% of total GAG content, a 12-fold increase in hyaluronate concentrations, and a marked reduction in fibronectin, demonstrated by immunhistochemical methods. Thus, the loss of collagen and sulfated GAGs may facilitate distensibility in the ripened cervix, while the significant gain in hyaluronate associated with hydratation may explain the soft and swollen consistency. In this connection increased hyaluronate concentrations and degradation of fibronectin may play a trigger role for subsequent cervical dilatation. The dramatic changes of the cervix during parturition occurring within a few hours require the rapid activation and action of catabolic enzyme systems. Our studies showed a significant increase of sialidase-, collagenase- and elastase activities during cervical dilatation. These proteinases originate from polymorphonuclear leucocytes (pml), which accumulate in cervical capillaries at the onset of labor; this is followed by a massive leucocyte infiltration of the cervical stroma at the beginning of cervical dilatation and a degranulation of the pml at further dilatation, thus releasing collagenase and other proteinases. This process is limited by the immediate post partum insudation of the cervix by plasma containing highly potent proteinase inhibitors. The clinical aim of our basic biochemical studies is to develop new concepts in the causal treatment of cervical pathology during pregnancy.
In a two-centre prospective study 20 patients with a history of unsuccessful sterility treatment underwent immunization with paternal lymphocytes to improve the pregnancy rate in the subsequent therapeutic AIH or IVF/ET cycle. Unsuccessful sterility treatment was defined as no pregnancy after 8 properly monitored AIH cycles and at least one diagnostic IVF/ET or more than 3 IVF with transfer of 3 embryos. After successful immunization expressed by the induction of Fc-receptor blocking antibodies 10/20 patients became pregnant. Nine of these patients delivered healthy children, one patient experienced a first trimester abortion. A successful second pregnancy occurred in 6 of these patients. No significant correlation between the previous history and pregnancy success could be found, except a slight advantage for patients with a history other than tubal sterility. There were no differences in the anamnestic data as well as in the success rate between the two independent centres Göttingen and Leuven (10 patients each). These data suggest, that adjuvant immunotherapy might improve markedly the pregnancy rates in selected cases of sterility.
The recurrence risk of HELLP-syndrome is reported to be between 2.6% and 24%. But yet, there are no accurate case reports about this topic available. In a retrospective study, 25 patients, which had suffered from a pre partum HELLP-syndrome, were interviewed about possible subsequent pregnancies. In 7 patients 8 pregnancies were found, which began between 5 and 55 months after the HELLP-syndrome. No recurrence of a HELLP-syndrome was observed in these 7 patients. Although in 71% a hypertension had been present during the HELLP-syndrome, only 1 patient had an elevated blood pressure in the subsequent pregnancy. Whilst all of the patients with HELLP-syndrome had been delivered by cesarean section, 50% of the patients were delivered vaginally in the subsequent pregnancy. There was no evidence of maternal or neonatal complications related to HELLP-syndrome. Nevertheless, even if the recurrence risk seems to be low, pregnancies after HELLP syndrome should be observed carefully.
It is especially in the long-term application where the pharmacodynamics of the betamimetics determine their effectiveness. According to the time and dosis, there is a decrease in the density and function of the beta 2-adrenoceptors (desensitization). Clinically, this means a loss of effectiveness. This study investigated whether in the course of a normal pregnancy (n = 22) there is a change in the effectiveness of the betamimetics, as expressed by a change in the number of beta 2-adrenoceptors or their function. The results show a 50% decrease in the number of beta 2-adrenoceptors to the 36th gestational week and an increase to initial values after delivery. A similar pattern is found for the function of the beta 2-adrenoceptors (cyclic AMP). The implications for the uterus might be that, with advancing pregnancy, it becomes less prone to relaxation and that the betaadrenergic system, as a mechanism supporting prepare the way for delivery at term, becomes less significant. For tocolysis with betamimetics, the decrease of the beta 2-adrenoceptor density means that, with increasing gestational age, the responsiveness of the uterus to betamimetics decreases.
423 deliveries by breech presentation (1988-1992), delivered by vaginally or abdominally management, were analysed. 72 preterm (32nd to 36th gestational week) and 351 term labours were studied. In 239/423 (56.5%) cases neonates were delivered vaginally, in 54/423 (12.8%) and 130/423 (30.7%) cases primary or secondary cesarean section was necessary. In 120/423 (51.9%) cases of all primaparous spontaneously delivery were realized. There was no difference in early morbidity of vaginal und abdominal delivered neonates (pHNA, APGAR-Score, intracranially bleeding). Three intracranially bleedings (I degrees, II degrees, III degrees) observed in the vaginally delivery group (n = 239), were not the result of breech presentation or vaginally management. No correlation between vaginally management, acidosis and intracranially bleeding were observed. In patients presented with preterm labour (32nd to 36th gestational week) and/or fetal intrauterin growth retardation, cesarean section could be indicated. In postnatal sonographic screening of all neonates hip joint disorders were twice more frequently in female neonates (n = 51 vs. n = 26) without correlation to delivery mode. In conclusion, if certain personally and equipmently conditions are considered, vaginally delivery mode does not correlate to an increase of early neonatal morbidity.
This study was designed to answer three questions: 1. Is there a change in systolic blood pressure, diastolic blood pressure and heart rate during pregnancy? 2. Are there alterations of these parameters during standing? 3. Is there a relationship between mean arterial blood pressure and heart rate at rest and during standing? In a randomized study 161 clinically healthy pregnant women between 8th and 41st week of pregnancy were tested with a modified orthostatic test over defined time periods during pregnancy. Systolic and diastolic blood pressure and heart rate were registered in one minute intervals over a 30 minute period with an automatic Dinamap measuring device. This period was subdivided in a 10 minutes lying period, 10 minutes standing period followed by a 10 minutes lying period. There was a marked increase in systolic and diastolic blood pressure at rest with the beginning of the 34th week of gestation (p < 0.05 and p < 0.01). Despite this, maternal heart rate continued to rise over the whole course of pregnancy (p < 0.01). Furthermore, women with a fall in heart rate on standing were only seen in late pregnancy. Finally, pregnant women with a low mean arterial blood pressure (< or = 85 mmHg) did not experience a fall in blood pressure on standing more frequently than normal controls (> 85 mmHg). We conclude that a fall in blood pressure on standing is not dependent on blood pressure at rest during pregnancy.
While the mechanism of the initiation of labor in humans has not been clarified satisfactorily, it is of major clinical interest, particularly with a view to understanding and avoiding preterm labor. Progesterone, whose role can now be determined in greater detail by the use of newly developed progesterone antagonists, and estrogens both play a role. Recently, attention has focused not only on contraction-stimulating substances such as oxytocin and prostaglandins, but also on cytokines, which have been implicated in the pathogenesis of preterm labor related to intrauterine infection. A model describing the various steps leading to regular uterine contractions is discussed and the resulting implications on stimulation and inhibition by pharmacological substances are outlined.
The aim of this study was to extend the medical knowledge of the prenatal expectations and wishes of pregnant women with respect to themselves, their partners and the maternity ward selected for the approaching birth, and also of the anxieties arising in this connection. In summary, our study shows that the desire to experience birth in the most natural, undisturbed and unmanipulated form possible is reiterated frequently, but is relativized by the intense need to be reassured of the safety of the unborn child. Fears experienced before the birth were focused accordingly on the condition of the child, although 25% of the women questioned acknowledged a marked fear of helplessness and failure. The obstetric team were expected to offer, as far as possible, the continuous personal supervision of a doctor and a midwife who were prepared to allow the patient the responsibility of being involved in obstetric decisions.