Gynakologisch-geburtshilfliche Rundschau最新文献

Intrauterine growth restriction (IUGR) is associated with an increased prevalence of renal malfunction. Two principal pathogenetic pathways appear to be involved: on the one hand non-renal mechanisms such as hypertension and type 2 diabetes, both associated with previous IUGR, predispose to secondary renal damage; on the other hand, renal mechanisms are involved such as the reduced number of nephrons in low-birth-weight children, which is a risk factor for future renal failure. In addition, glomerular diseases show a severer course in IUGR children. The course of the nephrotic syndrome is less favourable, and IgA nephropathy is associated with a higher prevalence of glomerular sclerosis. Data from animal experiments suggest an increased susceptibility of glomeruli to inflammatory stimuli and reduced regenerative capacities. However, not only prenatal environment, but also postnatal hyperalimentation is responsible for the manifestation of renal disease after IUGR.

Ovarian stimulation contributes to the overall effectiveness of in vitro fertilization treatment. However, ovarian stimulation is also associated with health risks, adverse events, treatment burden for the patient and high financial costs. Ovarian stimulation therefore needs to be continuously improved. In this literature review, three important new developments in the field of ovarian stimulation have been selected for discussion. Human chorionic gonadotropin as the triggering agent for ovarian hyperstimulation syndrome (OHSS) can now safely be replaced with a bolus dose of a gonadotropin-releasing hormone agonist. This has been shown to reliably prevent OHSS, the most serious complication of ovarian stimulation. To reduce the injection frequency of gonadotropins, a long-acting follicle-stimulating hormone molecule (C-terminal peptide, FSH-CTP) has been developed and tested in a large set of clinical trials. It was shown that long-acting FSH-CTP is able to stimulate the ovaries for 7 days at doses of 150 and 100 microg, respectively, and that the outcome in terms of pregnancy likelihood is similar to conventional gonadotropin stimulation by daily injection. Orally active non-peptide mimetics of luteinizing hormone and FSH are currently being developed. However, no data on the administration to humans have been published to date, and only scarce data on in vitro and animal experiments are available.

Early intrauterine fetal (mis)programming determines not only cardiovascular and metabolic regulation in later life, but also reproductive function. Intrauterine growth restriction may be associated with precocious maturation of gonadal function and an earlier onset of puberty and menarche. Especially prenatal androgen excess has negative effects on the development of the ovaries and female genital phenotype itself as well as on the neuroendocrine feedback regulation of the hypothalamic-pituitary-gonadal axis followed by a polycystic ovary syndrome with hyperandrogenism and anovulation in later life. These associations, which can be clearly demonstrated in animal experiments, need further confirmation by epidemiological and clinical trials in humans.

Fetal malnutrition or prenatally enhanced stress hormone levels have the potential to program brain function in later life. Even modest malnutrition has direct effects on brain development mainly via modulation of the insulin-like growth factor system. Nutrient restriction also increases maternal stress hormone concentrations in the fetal circulation. Increased fetal cortisol concentrations due to restricted fetal nutrient supply, prenatal stress or glucocorticoid treatment affect structural and functional brain development. Increased cortisol concentrations during maturation of the fetal hypothalamic-pituitary-adrenal (HPA) axis in the last weeks of pregnancy induce hyperactivity of the HPA axis due to permanent desensitization of glucocorticoid receptors in the hippocampus and a subsequent decrease in negative feedback regulation of the HPA axis. Increased responsiveness of the HPA axis to stress in later life is associated with perturbation of the activity of neurotransmitter systems such as the serotonergic, dopaminergic and GABAergic systems predisposing to discrete cognitive disturbances, behavioral disorders and depressive and schizophrenic diseases.

Polar body diagnosis (PBD) is a diagnostic method for the indirect genetic analysis of oocytes. Polar bodies are by-products of the meiotic cell cycle which have no influence on further embryo development. The biopsy of polar bodies can be accomplished either by zona drilling or laser drilling within a very short time period. The paternal contribution to the genetic constitution of the developing embryo cannot be diagnosed by PBD. The major application of PBD is the detection of maternally derived chromosomal aneuploidies and translocations in oocytes. For these indications, PBD may offer a viable alternative to blastomere biopsy as the embryo's integrity remains unaffected in contrast to preimplantation genetic diagnosis by blastomere biopsy. The fast development in the field of molecular diagnostics will also influence PBD and probably allow a more general diagnosis in the future.

Gestational diabetes mellitus is defined as glucose intolerance that first occurs or is first identified during pregnancy. The incidence of this condition varies depending on the population studied and the intensity of the diagnostic search. Gestational diabetes is a recognized risk factor for short- and long-term adverse developments in mother and fetus during pregnancy and their subsequent lifespans. Their pathophysiological base is the strong continuous association between maternal blood glucose concentrations and increasing pre-, peri- and postpartum complication rates. Standardized diagnostic criteria and therapy requirements, on the basis of well-defined criteria of morbidity, and their application would be most desirable considering especially the long-term and lifetime risks for the unborn child.

The treatment of pregnant women with gestational diabetes mellitus (GDM) is an increasingly important field in obstetrical clinical practice. In recent years, the impact of GDM has been examined in terms of its psychological and medical treatment consequences. In this paper, we present a review of studies of the psychological outcomes of GDM and pre-existent diabetes. In addition, we describe the influence of GDM on health behaviour. Pre-existent diabetes is associated with decreases in well-being and should be recognized and treated by health care providers. Medical and psychological treatment should be offered in a specialized outpatient setting. In addition, diet and exercise counselling is recommended to give women the best control and responsibility for their health and that of their newborn.

The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study is a trial on a high evidence level that included 25,000 women recruited in 15 centers all over the world who underwent a 75-gram oral glucose tolerance test (oGTT) at 24-32 weeks of gestation. Data remained blinded if the fasting plasma glucose level was below 105 mg/dl (5.8 mmol/l) and the 2-hour plasma glucose level was below 200 mg/dl (11.1 mmol/l). The aim of the study was to clarify whether maternal hyperglycemia less severe than that in diabetes mellitus is associated with increased risks of adverse pregnancy outcomes. The results indicate a continuous association of maternal glucose levels below those diagnostic of diabetes with an adverse outcome, with the strongest risk for increased birth weight and cord blood serum C peptide levels indicating fetal hyperinsulinism. Additionally an increased risk for maternal complications like preeclampsia was seen. Like in many biological processes, there were no obvious thresholds at which risks increased. An international expert committee proposed how to transfer the HAPO data into criteria for the oGTT in pregnancy for the future diagnosis of gestational diabetes mellitus (GDM) which will be based on acute pregnancy problems in contrast to the recent Carpenter and Coustan criteria. The availability of uniform, internationally accepted and applied GDM criteria will provide more clinical and legal security for the caregivers which will be a big advantage also in Germany where a wide diversity of GDM criteria is used. Beside the threshold discussion, the HAPO data are of enormous relevance for Germany. The HAPO data will significantly influence the decision of the German Health Authorities whether to finally establish a general screening for GDM as obligatory part of prenatal care. A report from the German Institute for Quality and Efficiency in Health Care (IQWiG) which was ordered from the German Health Authorities describes--mainly based on the HAPO Study--an indirect benefit of blood glucose screening for GDM for all pregnant women.

By now laparoscopy has become an established access route in gynaecological surgery. It took many years to get to this stage for various obstacles had to be overcome. In the end, it was the low intra- and postoperative complication rates together with the rapid reconvalescence of the patients and their wish to be quickly discharged from hospital which led to an unstoppable diffusion of the method. With the increased use of the procedure and the expertise of the surgeons, it entered the field of gynaecological oncology and met similar reservations. Once again the same convincing advantages helped overcome the resistance. Thus, laparoscopic surgical procedures have secured a place in the treatment of corpus and cervical carcinomas, as their surgical safety has been proved. The aim of future examinations should be the proof of non-inferiority compared to the open techniques because the advantages of the laparoscopic procedure have been sufficiently proved. Regardless of the required proof, the method is rapidly expanding with robot-assisted procedures, while surgeons develop exenterative techniques.