[Preconceptional use of folic acid in the region of the Kantonsspital Münsterlingen/Thurgau: has it changed over the past 10 years?]. / Die Perikonzeptionelle Folsäureprophylaxe im Einzugsgebiet des Kantonsspitals Münsterlingen(KSM)/Thurgau: Was hat sich verändert von 2000 bis 2010?

BACKGROUND: Numerous studies have shown that the preconceptional use of folic acid prevents neural tube defects. We created a study to find out whether the preconceptional use of folic acid has improved in the past 10 years, in the area of Münsterlingen, Switzerland. MATERIAL AND METHODS: We interviewed 2 groups of patients who delivered at our Institution, namely between 2000 and 2002 (period A) involving 287 women and from 2009 to 2010 (period B) involving 305 pregnant women. We asked them whether they used folic acid by means of a standardised questionnaire. RESULTS: In period B significantly more women have taken folic acid preconceptionally (period A: 27.5% vs. period B: 40.7%; p=0.001). A significant increase in folic acid intake was seen in the German speaking group from period A to B (30.3% vs. 52.7%; p=0.0005), while this was not the case in the non-German speaking group (21.4% in both periods). More multiparaé women were taking folic acid compared to nulliparae. A significant increase from period A to B was noted only in the German speaking group. Unexpectedly, in nulliparae non-German speaking women, folic acid supplementation decreased from 14% to 6.1%. DISCUSSION: We have found a significant increase in preconceptional folic acid supplementation from 2001 to 2010. The percentage of women taking folic acid is disappointingly low in all groups, particularly in nulliparae women of non-German ethnicity.

[Shorter delivery time after induction with misoprostol]. / Kürzere Geburtsdauer nach Einleitung mit Misoprostol.

INTRODUCTION: Increasing evidence has demonstrated that intravaginal misoprostol (PGE1) is more effective in labor induction than dinoprostone (PGE2). Several studies have demonstrated that the administration of PGE1 instead of PGE2 reduces the induction-to-delivery interval. However, it has not been fully investigated on which phase of birth the activity of PGE1 is stronger than that of PGE2. We undertook this study to investigate whether the activity of the two prostaglandins are different over time during the induction-to-delivery interval. MATERIAL AND METHODS: 155 patients undergoing induction of labor with 50 micrograms intravaginal PGE1 were compared with 174 patients treated with 3 mg PGE2. In both groups the procedure was repeated 6, and 24 hours after the first dose until labor was achieved. Induction-to-initiation of labor time, duration of labor stages, induction-to-delivery time, mode of delivery, maternal and neonatal morbidity and changes in Bishop score were compared. RESULTS: Demographic characteristics, indications for induction, mode of delivery, fetal weight, maternal and neonatal morbidity and duration of the labor stages were similar between the groups. A significant difference was found in terms of: induction-to-initiation of labor interval (7.37 h [1-68] vs. 11.25 h [1-74], p < 0.01) and induction-to-delivery interval (11.5 h [2.5-89] vs. 14.4 h [2.7-94], p < 0.05). The Bishop score at the time of the second administration was significantly different from that at admission in the PGE1 group compared to the PGE2 group [PGE1: 4.8 +/- 2/5.6 +/- 1.9, p < 0.0005; PGE2: 3.9 +/- 2/4.2 +/- 1.4, p = 0.09]. This effect of PGE1 remained significant after correction for various explanatory variables. CONCLUSIONS: The stronger effect of PGE1 is the consequence of a faster cervical ripening, which in turn leads to a quicker achievement of active labor. DISCUSSION: Intravaginal PGE1 compared to PGE2 reduces significantly the induction-to-delivery time.

First-trimester sonographic umbilical cord diameter and the growth of the human embryo.

OBJECTIVES: Experimental and clinical evidence have shown that the morphometry of the umbilical cord in the second half of gestation might be useful in predicting adverse perinatal outcome. The purposes of this study were to generate a nomogram for the umbilical cord diameter in the first trimester and, in an observational study, to investigate whether the sonographic measurement of the umbilical cord diameter early in gestation has the same clinical value as that late in gestation. METHODS: The sonographic umbilical cord diameter, crown-rump length and biparietal diameter were measured in 439 fetuses at between 8 and 15 weeks of gestation. The perinatal outcome was recorded for all patients. RESULTS: The umbilical cord diameter increased steadily from 8 to 15 weeks of gestation. A significant correlation was found between umbilical cord diameter and gestational age (r = 0.78; P < 0.001), umbilical cord diameter and crown-rump length (r = 0.75; P < 0.001) and umbilical cord diameter and biparietal diameter (r = 0.81; P < 0.001). No correlation was found between umbilical cord diameter values and either birth weight or placental weight. Among patients who had a miscarriage (n = 7) and pre-eclampsia (n = 8) the umbilical cord diameter was below 2 standard deviations from the mean in three cases (42.9%) and three cases (37.5%), respectively. CONCLUSION: The measurement of the umbilical cord diameter in the first trimester is correlated with the growth of the embryo and may be a marker for identifying a subset of fetuses at risk of spontaneous miscarriage and pre-eclampsia.

[Severe autoimmune thrombocytopenia in pregnancy]. / Schwere Autoimmunthrombozytopenie in der Schwangerschaft.

Maternal thrombocytopenia is a frequent finding in pregnancy. The clinically important causes of maternal thrombocytopenia in pregnancy are gestational thrombocytopenia and autoimmune thrombocytopenia. We report a case of refractory idiopathic thrombocytopenic purpura by a 30-year-old pregnant woman, gravida 3, para 2, successfully treated with high dose corticosteroids and immune globulins.

Prenatal assessment of Wharton's jelly in umbilical cords with single artery.

OBJECTIVE: To investigate whether the amount of Wharton's jelly in non-malformed fetuses with a single umbilical artery is different from that of fetuses with a normal umbilical cord. METHODS: We evaluated patients with singleton pregnancies, non-malformed fetuses and single umbilical artery undergoing sonographic evaluation at a gestational age ranging from 19 to 41 weeks' gestation. The cross-sectional areas of the umbilical cord and of the umbilical vessels were measured. The amount of Wharton's jelly was calculated by subtracting from the total cross-sectional area of the umbilical cord the areas of the artery and of the vein. The umbilical cord cross-sectional area, the umbilical artery and vein areas as well as the amount of Wharton's jelly were plotted on previously published nomograms. RESULTS: Twenty-two patients met the inclusion criteria. The umbilical cord cross-sectional area was within the normal range in 20 (90.1%) cases. The umbilical artery and vein areas were above 2 standard deviations from the mean in 20 cases and in 11 cases (50%), respectively. The amount of Wharton's jelly was below 2 standard deviations from the mean in all cases. An abnormal insertion of the umbilical cord (marginal, velamentous) was present in five cases (22.7%). CONCLUSIONS: A reduction of Wharton's jelly is frequently present in cases of single umbilical artery. The increased perinatal morbidity and mortality observed in cases of single umbilical artery, even in the absence of congenital or chromosomal abnormalities, could be in part the consequence of a reduced amount of Wharton's jelly.

[Spontaneous hematoma of the abdominal wall: diagnostic error of abruptio placentae]. / Spontanes Bauchwandhämatom: Fehldiagnose einer vorzeitigen Plazentalösung.

An emergency cesarean section was performed in the 38th week of pregnancy in a patient with acute abdominal pain in the left upper quadrant. The ultrasound picture was interpreted as a retroplacentar hematoma. Cardiotocography demonstrated fetal tachycardia which was interpreted as asphyxia. A diagnosis of abruptio placentae was made, but was finally ruled out when the cesarean section was performed. The intraabdominal exploration revealed a large hematoma of the rectus sheath with about 800 ml of blood. After evacuation and drainage the postoperative recovery was uneventful. Sudden rupture of a deep epigastric vessel with formation of an abdominal wall hematoma also mimics intraabdominal conditions such as appendicitis, diverticulitis, cholecystitis, tumours and visceral injuries.

[Medically indicated termination of pregnancy in giant uterine myoma and mono-amniotic twin pregnancy: a case report]. / Medizinisch indizierter Schwangerschaftsabbruch bei riesigem Uterus myomatosus und monoamnioter Zwillingsschwangerschaft: eine Fallvorstellung.

We report the rare combination of a monoamniotic twin pregnancy with giant uterine leiomyomas in a 33-year-old para 0, gravida 1. Considering the restricted capacity of uterine expansion during pregnancy and the known complications associated with myomas, as well as the elevated morbidity and mortality of monoamniotic twin pregnancies, we opted for a medically indicated abortion at 12 weeks' gestation. After abortion the patient developed fever and abdominal pain. In differential diagnosis we considered endomyometritis and necrosis of the myomas. Despite adequate conservative treatment the symptoms persisted and myomectomy was performed in view of the patient's desire to maintain fertility.

Sonographic measurement of the umbilical cord and fetal anthropometric parameters.

OBJECTIVE: To determine reference ranges for the diameter and the cross-sectional area of the umbilical cord during pregnancy and to determine if umbilical cord morphometry is related to fetal size. METHODS: A prospective cross-sectional study was designed to assess the sonographic cross-sectional diameter and area of the umbilical cord. The sonographic umbilical cord measurements were obtained in a plane adjacent to the insertion of the cord into the fetal abdomen. Nomograms for the umbilical cord diameter and area were computed. Fetal biometry included: biparietal diameter, abdominal circumference, and femur length. Polynomial regression analysis was conducted. RESULTS: Five hundred and fifty seven patients were included into the study. The regression equation for the umbilical cord diameter (y) according to gestational age (x) was y=-10.0563+1.4265x+0.0194x2 and for the umbilical cord area (y') was y'=91.6-3.3x+0.03x2-0.00007x3. A significant relationship was found between umbilical cord measurements and fetal anthropometric parameters. CONCLUSION: Reference ranges for umbilical cord diameter and area have been generated. The sonographic diameter and cross-sectional area of the umbilical cord increase as a function of gestational age and both diameter and area correlate with fetal size.

Prenatal assessment of the Hyrtl anastomosis and evaluation of its function: case report.

The presence of a communicating vessel, the Hyrtl anastomosis, between the umbilical arteries is well described in pathological studies. Using different injection techniques, it has been speculated that this vessel acts as a pressure-equalizing mechanism between the different lobes of the placenta. However, its detection during fetal life has never been reported. We report on two cases of ultrasonographic detection and Doppler assessment of the Hyrtl anastomosis during pregnancy. A pulsatile blood flow from the umbilical artery with higher resistance to that with lower resistance has been demonstrated at the level of the Hyrtl anastomosis, which was confirmed after delivery. In addition, this report supports the hypothesis that the anastomosis plays an important role in regulating the blood pressure in the placental lobes and in equalizing the blood pressure between umbilical arteries.

Prenatal diagnosis of a lean umbilical cord: a simple marker for the fetus at risk of being small for gestational age at birth.

OBJECTIVE: The purpose of this study was to investigate whether the prenatal diagnosis of a 'lean' umbilical cord in otherwise normal fetuses identifies fetuses at risk of being small for gestational age (SGA) at birth and of having distress in labor. The umbilical cord was defined as lean when its cross-sectional area on ultrasound examination was below the 10th centile for gestational age. METHOD: Pregnant women undergoing routine sonographic examination were included in the study. Inclusion criteria were gestational age greater than 20 weeks, intact membranes, and singleton gestation. The sonographic cross-sectional area of the umbilical cord was measured in a plane adjacent to the insertion into the fetal abdomen. Umbilical artery Doppler waveforms were recorded during fetal apnea and fetal anthropometric parameters were measured. RESULTS: During the study period, 860 patients met the inclusion criteria, of whom 3.6% delivered a SGA infant. The proportion of SGA infants was higher among fetuses who had a lean umbilical cord on ultrasound examination than among those with a normal umbilical cord (11.5% vs. 2.6%, p < 0.05). Fetuses with a lean cord had a risk 4.4-fold higher of being SGA at birth than those with a normal umbilical cord. After 25 weeks of gestation, this risk was 12.4 times higher when the umbilical cord was lean than when it was of normal size. The proportion of fetuses with meconium-stained amniotic fluid at delivery was higher among fetuses with a lean cord than among those with a normal umbilical cord (14.6% vs. 3.1%, p < 0.001). The proportion of infants who had a 5-min Apgar score < 7 was higher among those who had a lean cord than among those with normal umbilical cord (5.2% vs. 1.3%, p < 0.05). Considering only patients admitted in labor with intact membranes and who delivered an appropriate-for-gestational-age infant, the proportion of fetuses who had oligohydramnios at the time of delivery was higher among those who had a lean cord than among those with a normal umbilical cord (17.6% versus 1.3%, p < 0.01). CONCLUSION: We conclude that fetuses with a lean umbilical cord have an increased risk of being small for gestational age at birth and of having signs of distress at the time of delivery.

[Vascular diameter and resistance indices in normal fetuses with a single umbilical artery]. / Gefässdurchmesser und Resistance-Indizes bei unauffälligen Feten mit singulärer Nabelschnurarterie.

OBJECTIVE: This study was undertaken to investigate the vascular-adaptive mechanism of fetuses with a single umbilical artery (SUA) and without structural anatomical abnormalities. METHODS: A cohort study including fetuses with the diagnosis of SUA at routine ultrasonographic examination was designed. The diagnosis of SUA was confirmed by color Doppler imaging and by histological examination of the umbilical cord after delivery. The inner artery and vein diameters were measured and the resistance-index (RI) of the SUA was calculated. RESULTS: Eleven fetuses were studied. The artery and vein diameters were 2 standard deviations above the mean, when plotted in reference ranges, in 12 out of 17 (70.5%) and 8 out of 16 (50%) measurements, respectively. The RI-values were below the 5th and 50th percentile in 50% (6/12) and 75% (9/12) of the measurements, respectively. CONCLUSION: A dilatation of the single artery occurs to reduce the impedance in this vessel and to preserve a sufficient feto-placental blood flow. In addition the umbilical vein also increases in size.

The clinical significance of antenatal detection of discordant umbilical arteries.

OBJECTIVE: To evaluate the clinical significance of the antenatally detected discordant umbilical arteries (UAs). METHODS: Women with singleton gestations undergoing sonographic evaluations were examined for the presence of discordant UAs. Transverse and longitudinal diameters as well as the area of both UAs were measured. Doppler flow velocity waveforms were recorded from both arteries. Macroscopic and microscopic examination of the umbilical cord was performed after delivery and the area of each artery was measured. Mann-Whitney U test and Spearman rank correlation were used for statistical purposes. RESULTS: Data are presented as median (range). Discordance between UAs was found in 14 of 1012 women who underwent sonographic examinations. The vessel diameters and areas differed significantly between the discordant UAs (diameter 2.9 [1-4.3] versus 4.5 [3.8-6.5] mm, P < .001; area 6.6 [0.78-14.5] versus 16.25 [11.33-33.16] mm2, P < .001). A significant difference between UA size was confirmed after delivery (area 1.68 [0.9-3.06] versus 4.17 [1.12-13.8] mm2, P < .005). The difference in the area of the UAs in utero and at microscopic examination correlated significantly (r = .94, P < .05). In all cases, the resistance index was higher in the smaller artery than in the larger artery (0.71 [0.59-0.8] versus 0.6 [0.48-0.75] P < .01). Abnormal insertion of the umbilical cord or an abnormality of the placenta was present in eight cases. Perinatal death occurred only in a trisomic infant born at 24 weeks' gestation. CONCLUSION: The clinical significance of discordant UAs is that newborns are generally in good condition at birth and placental anomalies are common in this group of parturients. Abnormal Doppler velocimetry of the smaller UA should be taken with caution, because it does not seem to be associated with poor perinatal outcome.

Higher rate of fetal acidemia after regional anesthesia for elective cesarean delivery.

OBJECTIVE: To determine the prevalence of fetal acidemia associated with regional anesthesia for elective cesarean delivery in healthy paturients with uncomplicated singleton term pregnancies. METHODS: This was an epidemiologic study using the data base of the Swiss obstetric study group (Arbeitsgemeinschaft Schweizerischer Frauenkliniken). After the exclusion of cases with extraneous factors that may have affected the health of the neonate, we analyzed the umbilical artery pH, Apgar score, and other neonatal outcome measures after cesarean delivery with reference to the anesthetic technique. RESULTS: From 1985 to 1994, 327,763 deliveries, including 40,858 (12.47%) by cesarean, were registered in the data base. Of these, 5806 patients fulfilled the study criteria. The study population included 1002 spinal, 2155 epidural, and 2649 cases of general anesthesia. The frequency of fetal acidemia (pH less than 7.10) was significantly increased in the spinal-anesthesia group (odds ratio [OR] 4.67; 95% confidence interval [CI] 2.73, 8.01) and in the epidural group (OR 2.39; 95% CI 1.42, 4.04) compared with the general-anesthesia group. CONCLUSION: The rate of fetal acidemia is significantly increased after regional anesthesia. This risk must be judged in light of the risks inherent with general anesthesia.

[Postpartum pelvic vein and vena cava thrombosis after water immersion delivery]. / Postpartale Beckenvenen- und Cavathrombose nach Wassergeburt.

A 26-years old primipara experienced a laparotomy with thrombectomy because of pelvic vein thrombophlebitis and cavathrombosis 18 days after ambulant water-birth. The pelvic vein thrombophlebitis is a potentially life-threatening complication in puerperium and to our knowledge, this is the first case reported after water-birth. Even after ambulant childbirth those rather rare complications are able to appear. To think of such events makes professional help possible in time.

[Discordant umbilical cord arteries: prenatal diagnosis and significance]. / Diskordante Nabelschnurarterien: Pränatale Diagnostik und Bedeutung.

Prenatal Diagnosis and Consequences. Prenatal diagnosis of discordant umbilical arteries is possible with ultrasound. Different umbilical artery flow waveforms may result in discordancy of umbilical arteries. Discordancy of size between the umbilical arteries is considered to be an incomplete form of the single umbilical artery syndrome, caused by abnormal placentation or insertion of the umbilical cord. To rule out fetal malformation detailed ultrasound examinations and fetal surveillance are mandatory.

[HELLP syndrome and trisomy 18 in a multi-parity patient]. / HELLP-Syndrom und Trisomie 18 bei einer Multipara.

Despite much interest in HELLP syndrome in the last years, the aetiology of this unique form of severe preeclampsia is still unknown. We report the case of a young multipara with HELLP syndrome and Trisomy 18, who had two uneventful pregnancies before and after the case reported here. This case let us presume, that Trisomy 18, as described for Trisomy 13, may be a risk factor for the development of a preeclampsia.

[Spontaneous uterine rupture in the 18th week of pregnancy in a primigravida patient with adenomyosis]. / Spontane Uterusruptur in der 18. Schwangerschaftswoche bei einer Primigravida mit einer ausgedehnten Adenomyose.

A 30-year-old primigravida experienced spontaneous uterine rupture at 18 weeks of gestation. The etiology for the rupture was an extensive, heavily decidualized adenomyosis. Although adenomyosis is relatively common, complications are rare.

[Ultrasound diagnosis of epignathus in the 17th week of pregnancy. Case report and review of the literature]. / Ultraschalldiagnose eines Epignathus in der 17.SSW. Fallbericht und Literaturübersicht.

An epignathus was found by routine screening ultrasound examination in the 17th week of pregnancy. Epignathi are teratomas in the oral cavity and are rarely found. The detection of an epignathus in the first half of pregnancy was described only three times in literature. The teratoma may also invade the cerebrum and is associated with a polyhydramnios and elevated alphafetoprotein. If the diagnosis is made in the first half of pregnancy a induced abortion is to be discussed.