Zeitschrift fur Geburtshilfe und Perinatologie最新文献

Analysis of more than 2500 doppler flow signals in three patients was performed to evaluate the influence of fetal heart rate (fhr) variation on S/D-ratio in fetal vessels. Little differences of S/D-ratio in fetal vessels (descending aorta, umbilical arteries) were detected within the physiological variations of fhr (120-160 bpm) (envelope of regression line -0.007, -0.006). Analysing inter- as well as intraindividual variation only minor effects of fhr alteration can be observed in clinical application of doppler flow velocimetry. Dopplersonographic measurements, however, should be performed for at least a three minute period (for each vessel) to avoid false-positive or false-negative interpretation of short term changes of doppler signals. This is especially important in distressed fetuses.

Fetal supraventricular tachycardia may cause intrauterine heart failure and thus require transplacental treatment. During a period of nine years, we treated nine of eleven fetuses (gestational age ranging from the 26th to the 36th week) suffering from paroxysmal supraventricular tachycardia (10) or atrial flutter (1). The remaining two fetuses did not receive antiarrhythmic therapy because of only short lasting supraventricular tachycardia. Two fetuses were hydropic at the onset of therapy. Diagnosis of the rhythm disorder was established by m-mode echocardiography. All nine fetuses treated received digoxin after diagnosis of supraventricular tachycardia. Three of these reverted to sinus rhythm, one remained in supraventricular tachycardia which, however, was well tolerated. Five fetuses (three because of failure of digoxin alone and two because of a severely symptomatic supraventricular tachycardia) were treated with a combination of digoxin and verapamil. All five fetuses responded to the combined treatment, two of them, however, were delivered prematurely because of recurrence of supraventricular tachycardia in one and amnion-infection syndrome in the other. All patients survived and no severe fetal or maternal side effects were observed. Our experience confirms that digoxin and verapamil are usually effective in treating fetal supraventricular tachycardia. Some fetuses with short lasting and self limiting supraventricular tachycardia may not need any treatment, and a few not responding to digoxin and verapamil may require other antiarrhythmic drugs.

The dopplersonographic data of 1926 pregnant women in the 3. trimester of pregnancy was used to evaluate a graphic system for the analysis of A/B-ratio in fetal vessels (pulsed wave duplex system; descending aorta and umbilical arteries). The basis of the newly developed combination diagram were dopplersonographic standard values (single cut off and pregnancy duration related percentiles). One of the results was the fact, that the combined measurement and analysis of both fetal vessels increased the positive predictive value compared to single measurements. The value of dopplersonographic examinations in the aorta was slightly better than those in the umbilical arteries. The combined diagram showed a marked improvement in graphicness, especially in follow-up cases, and a partial improvement in statistical values.

In a pilot study, 25 patients with histories of repeated abortion were treated by passive immunotherapy with high-dosage immunoglobulin administration (Sandoglobulin). Plasma viscosity, RBC aggregation, hematocrit, PAI, D-dimer and Factor VIIIR:AG were studied in order to detect risks. By September 1, 1992, 16 women had given birth; abortion had recurred in 2 women and 7 were pregnant between the 10th and 37th GW. Five pregnancies terminated in premature/small-for-date births and one neonate had a congenital malformation syndrome. Under immunoglobulin therapy no hyperviscosity or excessive fibronolysis defects with a tendency to thrombosis or restriction of intervillous perfusion were observed. Besides safety for mother and fetus, intravenous immunoglobulin administration has the added advantage that it can be used in cases of primary and secondary abortion and for women with deficient immune response.

In a retrospective study data from more than 9000 live births were analyzed. Our aim was to compare the significance of Apgar-Score and umbilical artery pH in predicting the condition and development of the newborn. We were particularly interested in three groups of patients: "Group A" included patients with a 5 minute Apgar-Score < or = 7 and a normal pH > 7,2. In "Group P" the pH was < 7,10 combined with a normal Apgar-Score (8 to 10). Both groups were compared with a "normal group" (pH > 7,20 and Apgar-Score between 8 and 10). There was a higher percentage of operative deliveries in group A (38%) and group P (20%) compared to the normal group (15%). The only predictor of a low Apgar-Score was meconium stained amniotic fluid (Group A 16%). A poor condition of the newborn correlated much better with a low Apgar-Score than with a low umbilical artery pH. In group A the rate of newborns transferred to the neonatology unit was 43% and the perinatal mortality rate was 50%. The poor correlation of a low umbilical artery pH and the fetal outcome is partly explainable by the standard cut off level of 7,20 for acidosis, which seems to be too high.

Continuous measurement of normal contractions in 57 primiparae and multiparae showed a minimum in the mornings and a marked peaking of frequency between 8:30 PM and 2:00 AM. This could be due to a periodic fluctuation in the parameters influencing uterine motility. At night, motility-enhancing factors such as estrogens and prostaglandins predominate. These results suggest that in cases at high risk for premature delivery, with high pelvic scores, therapy should be continued at night. In addition, the time when the contractions were recorded should be taken into account when assessing their frequency, and the measurement repeated if necessary.

In a double-blind study, 12 patients with an Hb > 13 g/dl in the second trimester, a pretherapeutic hematocrit > 38%, and a fetal aortal resistance index > 0.75 underwent hemodilution. The patients were given either 500 ml hydroxyethyl starch (HAES) or 500 ml NaCl 0.9%. In addition, all patients received 500 ml NaCl 0.9% by infusion. HAES therapy caused a lowering of the fetal aortal and uterine artery resistance indices. This was not the case with NaCl. The causes for this lie in the specific anti-aggregation and viscosity-reducing effect of hydroxyethyl starch with an identical lowering of hematocrit.

On the background of the first All-German-Perinatal-Study in 1992 the results in obstetrics and perinatology in the Oder-Region (east part of the State of Brandenbourg) in 1990 are described. In comparison to the results in a previous study (1985) we found a drastical decline in the number of births (newborns 1985: 10244; 1990: 7723); in addition to the changing in the reproduction- and health-care behaviour, too, we have noted a decreasing perinatal mortality from 7.5% in 1985 to 4.9% in 1990. The ameliorated monitoring-rate (cardiotocography-rate) of the fetus (1985: 71%, 1990: 88.4%) and the decreasing still-birth-rate may be the main cause of this phenomenon. Clinic-births were the most common deliveries, the house-birth was the great exception; only 0.2% of all deliveries occurred at home or otherwhere. Our data support that there is no difference, except the birth-rate, in relation to the situation in the "old" Federal Republic of Germany.

Three-dimensional sonography is a logical development of conventional sonography, and is a consequence of the fact that every examiner tries to imagine the three-dimensional appearance of an organ on the basis of the tomographic images of it. In a long development process starting with the first 3D images in 1986/87 and lasting until today, we succeeded in developing a 3D system suitable for routine examinations, which the manufacturer is now marketing commercially. With a 3D transducer a coordinated sequence of tomograms is obtained; all the images are then computed transparently and subsequently imaged three-dimensionally as a crystalline volume. Movement of the 3D image on the computer screen is important for three-dimensional identification. The volume thus computed can then be bisected in longitudinal, transverse and horizontal planes and thus examined in real-time without any interference such as fetal movements. The horizontal sections cannot be obtained by conventional sonography. On the basis of more than 600 patients examined by this new method it was established that 3D imaging of malformations improves diagnosis and assessment, that examinations deliver accurate and reproducible results, and that section analysis can substantially facilitate diagnosis of fetal malformations.

In an open prospective investigation the median levels of C-reactive protein were determined in annormal collective. The median lies at 0.8 mg/dl in maternal serum withdrawn sub partu and in umbilical vein blood, and at 1.45 mg/dl immediately after ligation of the cord. Hopes on finding a biochemical parameter that could supply reliable information already during labour on a possible inflammatory infection in mother and child, did not materialize from the data found. Prediction of an infection of the newborn using CPR is only minimal. The most important practical information is given by the negative CRP in the umbilical vein blood. In this case the probability of an infection of the newborn is very slight. A high temperature during labour was the best predictor of the probability of endometritis puerperalis. This clinical finding, due to its specificity, is superior to CRP and the other parameters investigated.