Influence of the second stage of labor on maternal and neonatal outcomes in vaginal births after caesarean section: a multicenter study in Germany.

BACKGROUND: The American College of Obstetricians and Gynecologists (ACOG) introduced a new standard of care in 2014, extending the duration of the second stage of labor in order to reduce caesarean delivery (CD) rates and its severe complications. The aim of the present study is to evaluate success rates of trial of labor after caesarean section (TOLAC), as well as maternal and neonatal outcomes after the establishment of the recent guidelines. METHODS: A retrospective study was performed at two large departments in Germany from January 2008 to January 2018. Patients undergoing TOLAC were divided into two groups. Group I (958 patients) was constituted before the establishment of the current guidelines, and Group II (588 patients) after the establishment of the guidelines. A subgroup analysis was performed to compare neonatal outcomes after successful TOLAC and operative vaginal delivery with those after failed TOLAC and secondary CD. RESULTS: The success rate of vaginal births after cesarean section (VBAC) fell from 66.4% in Group I to 55.8% in Group II (p < 0.001). The median duration of the second stage of labor was statistically significantly longer in Group II than in Group I (79.3 ± 61.9 vs. 69.3 ± 58.2 min) for patients without previous vaginal birth. The incidence of operative vaginal delivery decreased from Group I to Group II (9.6% vs. 6.8%). The incidence of third- and fourth-degree perineal lacerations, blood loss and emergency CD were similar in the two groups. Concerning the neonatal outcome, our groups did not differ significantly in regard of rates of umbilical artery cord pH < 7.1 (p = 0.108), the 5-min Apgar scores below 7 (p = 0.224) and intubation (p = 0.547). However, the transfer rates to the neonatal care unit were significantly higher in Group II than in Group I (p < 0.001). Neonatal outcomes did not differ significantly in the subgroup analysis. CONCLUSION: Extending the second stage of labor does not necessarily result in more vaginal births after TOLAC. Maternal and neonatal outcomes were similar in both groups. Further studies will be needed to evaluate the role of operative vaginal delivery and the duration of the second stage of labor in TOLAC.

An unprecedented occult non-communicating rudimentary uterine horn treated with laparoscopic excision and preservation of both fallopian tubes: a case report and review of the literature.

BACKGROUND: Müllerian duct anomalies are congenital malformations of the female genital tract and may be of various types. For decades they have been classified according to the American Society of Reproductive Medicine, which mentions unicornuate uterine malformations as the second subgroup. They result from the arrested development of one of the Müllerian ducts and appear in approximately 1/1000 women. These anomalies are usually diagnosed in the second decade of life, because they tend to remain asymptomatic until adolescence and their initial symptoms may vary. Patients present with symptoms such as dysmenorrhea, infertility, and chronic or acute abdominal pain. CASE PRESENTATION: We report on a 21-year-old Caucasian German patient who suffered from dysmenorrhea for 7 years. After a transvaginal ultrasound and magnetic resonance tomography of the pelvis was performed, the patient underwent a diagnostic hysteroscopy and operative laparoscopy, and was finally diagnosed with a Müllerian duct anomaly presenting with a non-communicating rudimentary uterine horn. The left tube arose directly in orthotopic location from the cornua of uterus, with no connection to the rudimentary uterine horn or structure. CONCLUSION: The anatomic features of this case have not been reported previously and were not consistent with any existing classification. More cases are needed in order to confirm our hypothesis. Gynecologists should always consider Müllerian anomalies as an important differential diagnosis in young patients with abdominal pain.

Incidence of unexpected uterine malignancies after electromechanical power morcellation: a retrospective multicenter analysis in Germany.

PURPOSE: During the last decade, electromechanical power morcellation (EMM) was more frequently used but it may be associated with the dissemination of occult malignancies. The aim of the present study was to determine the frequency of unexpected uterine malignancies after EMM. METHODS: This retrospective study consisted of patients who were treated at three departments of Gynecology in Germany from 2008 to 2017. We identified women who underwent an operation with the use of EMM. Clinical records, risk factors, and the outcomes of the patients were reviewed. RESULTS: We performed an analysis of 1683 patients who had undergone laparoscopic supracervical hysterectomy (LASH), total hysterectomy, or myomectomy (LM) (48.6%, 8.4%, and 43.0%, respectively). Unexpected malignancies were detected in 4 of 1683 patients (0.24%). In all cases, the malignancy proved to be a sarcoma and was detected after LASH. All patients with occult sarcomas were older than 45 years and the most common (75%) risk factor was the appearance of a solitary tumor. The patients underwent secondary laparotomy for complete oncological staging, and no histological dissemination of the sarcoma was registered. Two patients had a recurrence. At the final follow-up investigation all four patients were in good general health. CONCLUSION: Occult malignancies are liable to spread after EMM, although the overall risk of being diagnosed with an occult malignancy and the risk of dissemination appear to be low. Once the preoperative diagnostic investigation has yielded no suspicious findings, laparoscopic morcellation may be considered a safe method, especially LM in patients of reproductive age.

Accuracy of physician and nurse practitioner colposcopy to effect improved surveillance of cervical cancer.

PURPOSE: To compare physician and nurse practitioner accuracy in recognizing cervical dysplasia during colposcopy. MATERIALS AND METHODS: A retrospective review was performed of cervical excisional biopsies from 2007 to 2009 performed by gynecologists and nurse practitioners in the same patient population. Cervical cone biopsy and loop electrosurgical excision procedure (LEEP) pathology were used as a gold standard compared to the previous colposcopy biopsies. RESULTS: Four hundred fifty-five patients qualified for the study. Patients were stratified according to age: under 30 years, 30-39, and 40 and above. For physicians, 77% of high-grade colposcopy biopsy results agreed with high-grade pathology on cone biopsy or LEEP. This was statistically similar to nurse practitioner results (p = 0.12). Likewise, there was no significant difference between physician and nurse practitioner accuracy within the various patient age strata. CONCLUSION: Colposcopy biopsy results compared to cone biopsy or LEEP results were statistically similar between gynecologists and nurse practitioners.

[Placenta praevia totalis et increta. Cause of life-threatening haemorrhaging during a caesarean section]. / Placenta praevia totalis et increta. Ursache einer lebensbedrohlichen Blutung während einer Sectio caesarea.

Placenta increta is a rare but potentially life-threatening risk constellation after a previous caesarean section. We present the case of a 29-year-old gravida 2 para 1 patient, who developed dramatic haemorrhaging caused by this abnormal placentation, which could only be resolved by a postpartal hysterectomy. This demonstrates that in the case of a combination of the two most common predisposing factors, repeat caesarean section and placenta praevia, the possibility of a placenta increta should be considered and suitable precautions should be taken.

Perinatal risk factors for neonatal intracerebral hemorrhage in preterm infants.

OBJECTIVE: To investigate the perinatal factors related to neonatal intracerebral hemorrhage (ICH) and possibly to define obstetric and perinatal risk factors. STUDY DESIGN: All medical records of women who delivered in the period from 1 January 1991 to 1 January 2000 were reviewed for intracerebral hemorrhages in infants born between 24 and 34 weeks of gestation and treated in the postnatal period. Sixty infants with ICH (Group I) and 60 infants without ICH (Group II, matched controls) were determined for comparison. Obstetrical parameters and risk factors and perinatal outcome parameters were evaluated and statistically analyzed. RESULTS: Neonatal intracerebral hemorrhage prevalence was 0.8% (60/7635 births). Betamethasone administration was significantly less in Group I than in Group II (27% versus 46%). Although Doppler-sonography of the middle cerebral artery was performed in a minority of the cases, it showed a significant tendency of lower resistance indices (brain sparing) in the intracerebral hemorrhage group (66.7% versus 21.1%). Postnatally, infants with intracerebral hemorrhage showed a significantly more often umbilical arterial acidosis (18% versus 10%), a greater base deficit, lower median 5 min Apgar scores (6 and 8, respectively for Groups I and II), and a lower thrombocyte count (Group I 190,000 +/- 76,000 microl(-1), and Group II 227,000 +/- 96,000 microl(-1)). Infants in Group I were more often (93% versus 76%) and longer (26.7 +/- 30.5 days versus 15.4 +/- 11.7 days) dependent on ventilatory support than infants in Group II. Mortality rate in Group I (35%) was significantly higher compared to Group II (17%). CONCLUSIONS: Antenatal Doppler sonography in predicting intracerebral hemorrhage in preterm infants should be investigated in large scale prospective studies. Postnatal low pH-values (pH < 7.1) and a base deficit of more than -16 mmol/L in the umbilical artery, low Apgar scores and thrombocytopenia are associated with a neonatal intracerebral hemorrhage and prophylaxis with corticosteroids reduces the risk for it. A higher neonatal mortality and morbidity, including neurological and neuromotoric dysfunctions is expected in this clinical entity.

Outcome of cystic hygroma in fetuses with normal karyotypes depends on associated findings.

OBJECTIVE: To determine the associated diagnostic findings which are linked with adverse fetal outcome in nuchal cystic hygroma. STUDY DESIGN: Based on a series of 32 cases, we determined the sonographic morphology of the hygroma, associated structural anomalies, karyotypes and autopsy findings. Intrauterine fetal death, spontaneous abortion and abnormal karyotypes were assigned as adverse outcome parameters. RESULTS: The mean gestational age at diagnosis was 14.4 weeks (range 10-21). There were 18 nonseptated and 14 septated hygromas. Besides hygroma, associated sonographic detectable structural anomalies were observed in 17 cases (53.1%). The greatest number of associated sonographic anomalies were hydrops (31.3%), generalised skin oedema (6.3%) and pterygium colli (6.3%). Cytogenetic analysis revealed an abnormal karyotype in 13 of 26 (50%) invasive procedures. Turner syndrome and Trisomy 18 (both 15.4%) were the most frequent cytogenetic abnormalities. Autopsy was performed in 24 cases and 16 cases (66.7%) had an associated autopsy finding to hygroma colli. The most frequent associated autopsy findings were limb and craniofacial anomalies (both 25%). Only 3 (9.4%) mothers gave birth to healthy newborns. The overall fetal adverse outcome rate was 68.8% (22 cases). CONCLUSIONS: Fetuses with NCH are at high risk for adverse outcome and detailed prenatal diagnosis including invasive procedures should be offered. According to the presented autopsy findings, to determine fetal outcome in NCH cases with normal karyotypes, detailed sonography should be concentrated beside the exclusion of fetal heart defects and existence of hydrops fetalis, on the skeletal, urogenital and craniofacial anomalies, as these might cause severe morbidity.

[Reverse flow in fetal vessels and perinatal events]. / Reverse Flow in den fetalen Gefässen - Klinische Bedeutung und perinatale Auffälligkeiten.

UNLABELLED: BACKGROUND/PATIENTS: A reverse flow in the umbilical artery and/or fetal aorta is associated with a higher perinatal and neonatal mortality. 30 fetuses showed a reverse flow using pulsed wave Doppler sonography (group I). A matched-pair control group including 30 fetuses with the same gestational age as well as a normal Doppler flow pattern in the umbilical artery and/or fetal aorta was taken for comparison (group II). RESULTS: In the group with reverse flow the rates of pregnancies with pre-eclampsia (n = 19/30, p < 0.0001), intrauterine growth retardation (n = 25/30, p < 0.0001), oligohydramnios (n = 21/30, p < 0.0001) and nicotine abuse (n = 15/30, p < 0.01) were significantly higher compared to the control group. Postnatal data showed significantly lower pH values in group I (p < 0.01). 40 % of the fetuses with reverse flow died in utero whereas in 67 % the reverse flow was accompanied by an insufficiency of the placenta (IUGR, oligohydramnios, histopathological abnormalities of the placenta). None of the fetuses in the control group died in utero. The incidence of IUGR (< 5ht percentile) was 83 % in group I but only 3 % in group II. The perinatal and overall mortality (including neonatal mortality 7 - 28 days after birth) amounted to 27 % and 53 % in group I, respectively, compared to 3 % and 0 % in the control group (p < 0.001). In addition cerebral anomalies could be found by ultrasound in 50 % of the neonates who presented a reverse flow prenatally. In 28 % of the surviving newborns an intracerebral hemorrhage (ICH) could be detected. None of the newborns of group II developed an ICH. CONCLUSIONS: Pregnancies with a reverse flow in the umbilical artery and/or fetal aorta have to be considered as a high risk group with a poor prognosis. The reverse flow is mainly caused by chronic placental insufficiency with IUGR. With respect to the further neuromotor development the incidence and severity of cerebral lesions in affected fetuses should be considered when discussing the perinatal situation with the parents.

Fetomaternal Doppler sonography nomograms.

PURPOSE: To constitute Doppler flow velocity nomograms for use in obstetric clinics and to analyse the technical infrastructure of constructing Doppler sonography nomograms for clinical use. METHODS: On a cross-sectional study plan basis 602 flow results of 370 pregnant women were used. Pregnancy gestational ages were confirmed with an early sonogram prior to the 14th gestational week. Patients in whom primary section for placental insufficiency had to be done, who had pathological fetal heart rate monitoring, signs of intrauterine asphyxia, multiple pregnancy or a fetal anomaly were excluded. Every two gestational weeks patients were grouped and for these groups the 5th, 10th, 50th, 90th and 95th percentiles were calculated to represent the umbilical artery, fetal aorta, middle cerebral artery (MCA) and uterine artery S/D ratio, resistence index (RI) and pulsatility index (PI) Doppler flow velocity nomograms. RESULTS: In normal pregnancies, after the 22nd-24th gestational week, the uteroplacental flow velocities were constant, but at the fetal vessels there were changes in velocity waveforms after this period. With advancing gestation in the third trimester, umbilical artery and middle cerebral artery impedance was lower and the resistance in the descending fetal aorta remained nearly constant. CONCLUSION: With growing gestational age the Doppler velocity forms change. In fact because of this, for Doppler velocity studies and to differentiate between normal and abnormal pregnancy status, nomograms adapted to gestational age should be used. For practical use in different obstetrics clinics, we are presenting our Doppler velocity norm-curves.

[Placental morphometry in pregnancies with reversed enddiastolic flow in the umbilical artery or fetal aorta]. / Plazentamorphometrie: Auffälligkeiten der Endzotten bei Fällen mit einem enddiastolischen "Reverse Flow" in der Umbilikalarterie/fetalen Aorta.

BACKGROUND: Fetuses with a reversed enddiastolic flow in the umbilical artery and/or aorta are at risk pregnancies and show a higher incidence of perinatal morbidity and mortality. The aim of this study was to evaluate the pathological changes in the terminal villous tree in fetuses with a reverse flow in the fetal aorta or umbilical artery. MATERIALS AND METHODS: In this retrospective study, 16 cases with a reverse flow in the fetal aorta or umbilical artery (Gr. 1) were compared with gestational age matched 16 healthy pregnant women (Gr. 2). The following morphometric parameters were evaluated in 50 sections in each placenta (1600 measurements): mean vessel diameter, volume density of the villous tissue, stem villi and terminal villi. Measurements were performed using a computerized Video Image Analysis system. RESULTS: The mean gestational age at birth was similar in both groups (30 + 4 weeks gestation vs. 30 + 6 weeks gestation, respectively, for Gr. 1 and Gr. 2). The birth weights (985 g vs. 1780 g) and the placental weights (216 g vs. 385 g) were significantly lower in the reverse flow group. There was a significant reduction in the proportion of total villous tissue (19 % versus 45 %) and in the diameter of tissue at the terminal villi (2.1 % versus 7.6 %) in the reverse flow group. Although the mean number of vessels at the terminal villi was lower than the control group (4.1 versus 5.6), the mean and total areas of the vessels were not different. CONCLUSION: Our observations showed a significant association between the placental morphometric parameters and reversed enddiastolic flow in the umbilical artery or fetal aorta. The reduced number of functional placental units is responsible for the diminished exchange function of the placental vessels in "reverse flow" cases. This could partially explain the adverse outcome in this clinical situation.

Prenatal diagnosis of sacrococcygeal teratoma: a review of cases between 1993 and 2000.

Sacrococcygeal teratoma is the most common fetal neoplasm with a reported incidence of 1 in 30,000 to 40,000 births. Affected fetuses carry a high perinatal mortality and morbidity. The aim of this retrospective study was to assess prenatal sonographic aspects and pathological details of our cases with sacroccocygeal teratoma. Over the last seven years we identified six cases by retrospective chart review in our institution. Four fetuses were electively aborted, in two of these four fetuses the diagnosis was made before the 16th week of gestation. Two caesarean sections were performed at 35 + 5 and 37 + 0 weeks of gestation, respectively. In those two cases the diagnosis was only made in the late second and third trimester. No case of neonatal mortality occurred. In one of the two resected sacroccocygeal teratomas potential malignancy was diagnosed. A multidisciplinary approach seems advisible for optimal perinatal management.

Unilateral massive ovarian edema (MOE): a case report.

Massive ovarian edema is an unusual cause of ovarian enlargement in young patients. Venous end lymphatic obstruction producing edema is thought to be the reason for enlargement of the ovaries in most cases. We report the case of a 23-year-old woman with unilateral massive ovarian edema, findings on ultrasound imaging, and a review of the literature. The ultrasound findings have been reported as a solid tumour-like mass or as a solid mass containing a cystic component, which is non-specific and can mimic neoplasia. Thus, the definitive diagnosis requires histological examination. Because conservative treatment with preservation of the ovaries is often possible, ovarian edema is an important condition to consider in a young patient with a complex but non-specific ovarian mass and appropriate preoperative clinical treatment should be started.

Prenatal and perinatal aspects of a giant fetal cervicothoracal lymphangioma.

A massive cervicothoracal lymphangioma was diagnosed in a fetus at 25 weeks of gestation. On ultrasound study, the mass showed septated, cystic components and extended from the right submandibular region to the right anterolateral thoracic wall including the right axilla and right scapula. Close sonographic follow-up revealed an increase in the size of the lymphangioma without fetal hydrops. An interdisciplinary approach including a pediatric surgeon, neonatologist, perinatologist and anesthesiologist was chosen. Elective cesarean section under general anesthesia was planned at 37 + 0 weeks of gestation. Surgical correction of the lymphangioma was successfully performed on the 4th day of life. Possible differential diagnoses and the obstetrical management are presented.

Relationship between ovarian stimulation regimen and interleukin level in pre-ovulatory follicular fluid and their effect on ICSI outcome.

PROBLEM: The aims of this study were (i) to identify the presence and concentration of interleukin-6 (IL-6), IL-8 and granulocyte-macrophage colony-stimulating factor (GM-CSF) in pre-ovulatory follicular fluid (FF) in patients undergoing controlled ovarian hyperstimulation regimen for intracytoplasmic sperm injection (ICSI) with recombinant human follicle stimulating hormone (rFSH) (G.1), hMG (G.2) or rFSH/ hMG (G.3) treatment and (ii) to determine whether controlled ovarian hyperstimulation stimulation regimen could affect the concentration of these investigated interleukins and as a consequences the ICSI outcome. (iii) Moreover, it was intended to clarify the association between these investigated parameters and the peripheral blood level of estradiol 17-beta, progesterone, leuteinizing hormone (LH) at the day of oocyte retrieval and (iv) finally to find out whether these interleukin concentrations in FF could be considered as an additional parameter for predicting fertilization and pregnancy outcome in ICSI patients. MATERIAL AND METHODS: Interleukin-6, IL-8 and GM-CSF concentrations were determined in the FF of 85 patients. The levels of these interleukins were measured by the enzyme-linked immunosorbent assay (ELISA) technique, using commercially available kits. RESULTS: Interleukin-6 (6.5 +/- 4.6 pg/mL), IL-8 (222.9 +/- 163.4 pg/mL) and GM-CSF (1.6 +/- 2.7 pg/mL) were present in pre-ovulatory FF in ICSI patients. No significant difference in the mean concentration of IL-6, IL-8 and GM-CSF was found between the groups. Moreover, there was no correlation between these interleukin levels in FF and steroid hormone concentration in the peripheral blood. CONCLUSIONS: Interleukin-6, IL-8 and GM-CSF were found in FF of patients undergoing ovarian hyperstimulation for ICSI treatment. The stimulation protocols showed no influence on these interleukin levels in FF. Moreover, no correlation was found between these investigated interleukins and steroid hormone concentrations in peripheral blood or ICSI outcome. Therefore, the determination of interleukin level in FF of patients undergoing ovarian hyperstimulation for ICSI therapy could not be recommended as a prognostic factor for ICSI outcome.

Hygroma colli cysticum: prenatal diagnosis and prognosis.

The objective of this study is to analyze the prenatal management and prognostic factors of hygroma colli cysticum by using cytogenetic tests and sonographic morphological features. All cases with hygroma colli cysticum diagnosed and managed at our Prenatal Diagnostics Unit between January 96 and September 2000 were analyzed. Sonographic morphological features were divided in two groups; nonseptated (n = 18) and septated (n = 12) hygroma colli cysticum lesions were compared with fetal karyotype results and pregnancy outcome data. Statistical analysis was performed by Chi-square test and statistical significance was defined as p <0.05. In 5 years, 30 cases with hygroma colli cysticum were identified. Cytogenetic results were obtained from 23 (76.7%) cases (four chorionic villus sampling and 19 amniocentesis). Chromosomal abnormalities were present in 13 cases (56.5%). The most common chromosomal abnormality was Turner Syndrome (four cases, 17.4%) and Trisomy 18 (four cases, 17.4%). Pregnancy outcome data were available for 29 patients. Those fetuses with septated hygroma colli cysticum tended to have a worse fetal outcome, without statistical significance (p >0.05), compared with the nonseptated hygroma colli cysticum cases (75 vs. 61.1%, respectively). Fetal hygroma colli cysticum, either septated or not, carries high risks of aneuploidies and adverse fetal outcome. Recommended management includes karyotyping and if parents decide to continue the pregnancy ultrasound scan at 20 to 22 weeks' gestation is necessary, for excluding associated anomalies. At birth, if the cystic hygroma persists, it should be noted that a respiratory difficulty can happen and a pediatrician should standby as a precaution.

The clinical significance of antenatal pathological Doppler findings in the fetal middle cerebral artery in cases with peripheral reduced diastolic doppler flow but no absence of end-diastolic flow in the umbilical artery or fetal aorta.

PURPOSE: The effects of antepartum pathological Doppler findings in the fetal middle cerebral artery in cases with simultaneously peripheral reduced diastolic Doppler flow on perinatal outcome and the odds ratio of perinatal risks were studied. METHODS: 214 patients were examined by color Doppler ultrasound in relationship to complications in gestation and labor and fetal outcome. One thousand and seventy Doppler flow measurements of the middle cerebral artery, the umbilical artery and the fetal aorta between 28 and 40 weeks of gestation were performed. Sensitivity and odds ratio of synchronous cerebral pathological and peripheral pathological Doppler blood flow with regard to the prediction of intrauterine growth retardation, rate of cesarean section, preterm delivery and newborn depression was calculated. In all Doppler measurements there were no cases with absence of end-diastolic flow. RESULTS: Preterm delivery rate and intrauterine growth retardation rate were significantly higher in cases of synchronous cerebral pathological and peripheral pathological Doppler blood flow as in cases of isolated reduced peripheral blood flow (p<0.001; odds ratio 13.2 and 16.6). CONCLUSION: Pregnancies with no absence of end-diastolic flow in the fetal aorta or umbilical artery, but with reduced diastolic flow in these vessels and simultaneous pathological Doppler findings in the fetal middle cerebral artery are high risk pregnancies, above all in respect to intrauterine growth retardation, preterm delivery and newborn depression. Surveillance of pregnant women should be performed in a perinatal centre.

Association between interleukin concentration in follicular fluid and intracytoplasmic sperm injection (ICSI) outcome.

PROBLEM: The aim of this study was to determine the presence and concentration of interleukin IL-6, IL-8, and granulocyte-macrophage-colony-stimulating factor (GM-CSF) in pre-ovulatory ovarian follicular fluid (FF) of patients undergoing controlled ovarian hyperstimulation for intracytoplasmic sperm injection (ICSI) therapy on one hand, and to find out whether these cytotokine concentrations could be used as a predictive parameter for ICSI outcome. DESIGN: The levels of IL-6, IL-8, and GM-CSF were measured from women that underwent ICSI therapy and the results were compared between the patients who became pregnant after IC

Nucleated red blood cell count and doppler ultrasound in low- and high-risk pregnancies.

OBJECTIVE: The aim of this study was to evaluate the influence of circulatory deterioration in small-for-gestational-age fetuses (SGA) on the nucleated red blood cell count (NRBC). PATIENTS AND METHODS: During a 12-month period 194 patients with a complete NRBC count post-partum were enrolled in the study. Using pulsed wave colour Doppler ultrasound we recorded blood flow velocity waveforms from both uterine arteries and from the umbilical artery and/or from the fetal aorta. Patients were assigned to seven groups according to the results of the Doppler examination. Mean outcome measures were birthweight, gestational age at delivery, NRBC count, incidence of preeclampsia or SGA and need of neonatal intensive care. RESULTS: Significantly higher nucleated red blood cell counts than in all other groups were found in cases with abnormal Doppler findings in both uterine arteries and the umbilical artery and/or fetal aorta (p<0.001). These newborns had significantly lower birth weights (p<0.01, p<0.001), lower gestational age (p<0.001), an increased likelihood of caesarean section for clinical signs of fetal distress (p<0.001) and had to be transfered more frequently to the neonatal intensive care unit (p<0.01, p<0.001). CONCLUSION: Patients with abnormal Doppler velocimetry waveforms of the uterine arteries in the presence of an abnormal umbilical artery or fetal aorta Doppler findings have a high risk of prematurity, preeclampsia or delivering a small-for-gestational-age newborn. Fetal response to uteroplacental insufficiency may lead to elevated nucleated red blood cells in the fetal blood. This fact might help to discriminate the small-for-gestational-age fetus who is growth-retarded and suffers from chronic placental insufficiency from the small but healthy fetus.

The clinical significance of antenatal pathological Doppler findings in fetal middle cerebral artery compared to umbilical artery and fetal aorta.

PURPOSE: To compare the diagnostic capacity of fetal Doppler velocimetry in fetal middle cerebral artery to umbilical artery and fetal aorta to the prediction of fetal outcome. METHODS: 229 patients between 28 weeks of gestation (weeks) and 40 weeks were examined by Doppler ultrasound in relationship to complications in gestation and labor, and fetal outcome. One thousand two hundred and seventy doppler blood flow velocity waveforms in the middle cerebral artery, umbilical artery and fetal aorta were recorded. Sensitivity of these vessels with regard to the prediction of intrauterine growth retardation, rate of cesarean section, preterm delivery and new-born depression was calculated. In all Doppler measurements there were no cases with absence of end-diastolic flow. RESULTS: The differences between pathological fetal outcome were not statistically significant, but diagnostic capacity of the middle cerebral artery velocimetry with regard to the prediction of pathological fetal outcome was on average 11% below the diagnostic capacity of the fetal aorta and umbilical artery. CONCLUSION: There is no benefit in examining fetal middle cerebral artery Doppler measurements in clinical routine in patients with normal velocity waveforms in the umbilical artery and fetal aorta.

Reference ranges and standard percentile-curves for the Doppler indices RI and S/D ratio of the fetal middle cerebral artery. Color Doppler measurements in a perinatal centre.

PURPOSE: To perform reference ranges and standard percentile-curves for the Doppler indices resistance index (RI) and systolic/diastolic (S/D) ratio of the fetal middle cerebral artery, periodical color doppler sonographic measurements of 70 pregnant women in the 3rd trimester of pregnancy were done. METHODS: 600 Doppler flow measurements of the fetal middle cerebral artery between 28 and 40 weeks of gestation were performed. The patients had no previous obstetric complications, no apparent medical problems and no complications in pregnancy and labor. Percentiles curves were performed for the RI and the S/D ratio from the 10th percentile up to the 90th percentile. RESULTS: In the 3rd trimester of pregnancy fetal cerebral circulation shows an increase of the diastolic component and simultaneous decrease in cerebral resistance. The average S/D ratio in week 29 is 8.0, in week 34 6.0 and in the 40th week 3.5. The RI decrement is from 0.88 to 0.67. Other groups demonstrated similar ranges however absolute data are different. CONCLUSION: The increase in the diastolic component in the middle cerebral artery of the last third of the pregnancy demands reference ranges by using percentile curves. Knowledge of the reference range helps to discriminate between a normal fetal situation and disease. Because of different absolute ranges in the literature each perinatal centre should develop their own data.