[Stillbirths in Germany: Retrospective Analysis of 168 Cases between 2003 and 2011]. / Totgeburten in Deutschland: Retrospektive Datenanalyse von 168 Fällen zwischen 2003 und 2011.

BACKGROUND: The decline in the incidence of stillbirths in Germany has remained static in recent years. This study aims to analyse the current situation of data documentation and examination of stillbirths. Furthermore, possible stillbirth prevention strategies should be developed. METHODS: Searches in the international peer-reviewed literature, retrospective data collection of 168 stillbirths in 8 hospitals, (in the area of Bonn) with subsequent statistical evaluation (descriptive statistics, t-test and binominal test) were undertaken. RESULTS: This study shows considerable deficits in data documentation, interdisciplinary communication and postmortal examination. Only in 51.8% (87/168) of the cases was a certain or uncertain cause of death found (42.3% placental, 1.2% foetal, 3.6% chromosomal, 4.8% umbilical cord abnormalities). Severe foetal growth restriction (<5(th) percentile) was observed in 29.2%; 44.9% (22/49) of them died at the age of ≥36+0 weeks of gestation. CONCLUSION: The first step to reduce the rate of stillbirths in Germany is to increase the identified causes of foetal death: Therefore, an interdisciplinary case report form was compiled to improve data collection and interdisciplinary collaboration. To standardise and complete postmortal management, an algorithm was created. The long-term aim is the development of a central data register for statistical analysis, to identify goals of research and to organise conferences with interdisciplinary reports of diagnostic findings.

Doppler sonography of the fetal middle cerebral artery in the management of massive fetomaternal hemorrhage.

Massive fetomaternal hemorrhage (FMH) is a rare complication in pregnancy that may cause hydrops or can even be life-threatening for the fetus. We report on the case of a 19-year-old gravida I, para 0, who presented to our clinic at 32 weeks of gestation due to decreased fetal movements. The initial fetal heart rate tracing at admission showed a sinusoidal pattern without decelerations. The ultrasound examination performed immediately described a normally developed fetus with normal amounts of amniotic fluid and without abnormities of the placental structure. Doppler sonography of the fetal middle cerebral artery gave rise to the strong suspicion of fetal anemia, so that a cordocentesis was prepared for potential intrauterine blood transfusion. Meanwhile, the rate of fetal hemoglobin (HbF) cells in the maternal blood was found to be markedly increased with 66 per thousand. Correspondingly, cardiotocographic findings worsened with repeated decelerations, thus an immediate cesarean section was performed based on the suspected diagnosis of an acute FMH. A fetus weighing 1,860 g was delivered, who had severe anemia with hemoglobin level of 4.0 g/dl. After a direct blood transfusion, HbF levels normalized rapidly, the fetus stabilized, and a normal recovery has thus far been reported. The presented case demonstrates the successful and straightforward diagnosis, as well as the management of a case of severe FMH and illustrates the special value of Doppler sonography in this context.

[Hygroma colli (cervical neck edema) as an ultrasonographic parameter of fetal chromosome anomalies]. / Das Hygroma colli (Nackenödem) als ultrasonographischer Parameter fetaler Chromosomenanomalien.

A two year retrospective study of 57 women with fetal hygroma colli between 2 and 15 mm was carried out at the University Women Hospital in Heidelberg. In this study maternal age, week of gestation, thickness of the nuchal oedema and the genetic results of amniocentesis were documented. Chromosomal abnormalities were found in 20 cases (35%), monosomy X in eleven, trisomy 21 in five and trisomy 18 in four. No connection between an individual syndrome and a particular week of gestation could be found. An increase of the thickness of the nuchal oedema showed a significant correlation to the incidence of aneuploidies. Chromosomal abnormalities were not observed in cases of less than 3 mm thickness (0/5). Between 3 and 4.9 mm one abnormal karyotype (4 mm) was found (1/18) whereas in the group of 5-6.9 mm approximately one third (6/15) of all fetuses showed chromosomal abnormalities. Aneuploid karyotypes were found in two thirds of cases (14/20) with a fetal nuchal translucency of 7 mm and more. Surprisingly, a correlation between maternal age and incidence of fetal chromosomal abnormality could be seen, but it was not significant. While a chromosomal aberration could be connected to age in 50% of mothers under the age of 25 and over 34, only a third of women aged 25-29 and only one fifth aged 30-34 showed chromosomal abnormalities in combination with hygroma colli. Our results confirm the recommendation of previous studies for extensive ultrasound examination during the first and second trimester in order to improve early detection of fetal chromosomal abnormalities particularly in women not normally covered by the age-related indication for amniocentesis.

Isolated fetal choroid plexus cysts: not an indication for genetic diagnosis?

Offering invasive prenatal cytogenetic testing in cases of isolated choroid plexus cysts is controversial. To give a contribution to this discussion we recorded prospectively the course of 41 fetuses with cysts of the choroid plexus diagnosed in 4,326 pregnancies sonographically scanned in our center between January 1994 and August 1995. The fetuses were all in the 13th to 24th week of gestation, with an average of 19.3 weeks. Only 1 of these fetuses (with large bilateral choroid plexus cysts) had further sonographically visible malformations (renal and cardiac anomalies, malposition of the hands). 34 fetuses had bilateral and 7 one-sided plexus cysts. 38 of the 41 patients decided on invasive diagnosis; karyotyping was successful in all these cases. The complete follow-up until 5 days after birth is known in 38 fetuses, including 3 without genetic diagnosis. A chromosomal aberration was detectable only in 1 fetus (trisomy 18, this fetus had the additional malformations described above), the other fetuses all displaying neither chromosomal nor morphological abnormalities. All fetuses, excluding 1 (the pregnancy was terminated due to trisomy 18) were re-examined before the 25th week of gestation, plexus cysts only still being visible in 3 fetuses. By the 30th week of gestation in these 3 fetuses the cysts had also disappeared. Furthermore, 20 pregnancies with confirmed trisomy 18 diagnosed between 1990 and 1996 were analyzed retrospectively. In 19 cases heart defects had been detected by prenatal ultrasound, cervical hygroma being less common (6 cases) and other malformations still rarer. Choroid plexus cysts had, however, been seen only in the 1 case described above. There was no case of isolated choroid plexus cysts in this group. From our data and current literature we conclude that isolated choroid plexus cysts are not an absolute indication for fetal karyotyping. In our opinion a detailed ultrasound assessment to seek for further malformations in a specialized center would be necessary if fetal choroid plexus cysts have been diagnosed, and only if additional fetal malformations are indeed detectable a fetal karyotype should be recommended.

[Ultrasound diagnosis of fetal lung maturity]. / Die sonographische Diagnostik der fetalen Lungenreife.

The immaturity of the fetal lung and the resulting respiratory distress syndrome are the main problems of obstetrics. Over a long period of time the only possibility to recognize the maturity of fetal lungs certainly was the determination of the L/S-ratio by amniocentesis. Two years ago first results were presented to determine fetal lung maturity by sonography. We examined 428 patients between 29 and 40 completed weeks of gestation. By comparing the characteristics of frequency of fetal lung echoes to those from the fetal liver as a reference organ it becomes possible to standardize fetal lung changes with gestation. In one ultrasound section we depicted lung and liver as well. According the A-mode we registered frequencies of both. The registered frequencies were entered digitally into a computer to evaluate the mean, maximal and minimal frequencies. Afterwards quotients of the frequencies of fetal lung and liver were calculated. For all weeks of gestation, mean values and standard deviations were made. It has been shown, that the liver is an adequate reference organ since the reflection pattern between the different weeks of gestation does not change, however significant changes have been seen in the fetal lungs. Q-mean, the quotient of fetal lung and liver reflection can be calculated. A quotient of Q-mean < 1.10 suggests lung maturity, while values > 1.10 speak for immaturity. Ultrasound examinations with 55 expectant women were compared with the lung conditions after delivery. 30 examinations were correlated with the results of the L/S-Ratio by amniocentesis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ultrasound diagnosis of fetal lung maturity]. / Die sonographische Diagnostik der fetalen Lungenreife.

Until now, it has been possible to determine fetal pulmonary maturity only by amniocentesis. Since the functional changes of the fetal lung leading to maturity are also morphologically apparent, pulmonary maturity can be demonstrated sonographically. Obtaining a uniform value for maturity is a problem, since the position of the fetus, the mother's constitution and the instrument setting all influence assessment. The fetal liver was therefore used as a reference organ, since it is subject to the same influences. By frequency analysis of both organs and calculation of the ratio between the frequencies obtained, a mathematical value can be calculated by which pregnancies can be compared and which, as our studies showed, represents a measure of pulmonary maturity. This was documented in 348 patients. It was shown by amniocentesis in 32 patients and the postpartal condition of 25 premature births that a value of 1.11 for this ratio between lung and liver represents the borderline between pulmonary immaturity and maturity. Lower values indicate maturity. If these results are confirmed by further studies on larger groups of patients, it will in future be possible to determine fetal pulmonary maturity very easily and non-invasively.