[Impact and limitations of ultrasound examination immediately before delivery--a prospective evaluation with 1127 pregnant women]. / Möglichkeiten und Grenzen der Ultraschalluntersuchung zur Gewichtsermittlung des Kindes unmittelbar vor der Geburt - Eine prospektive Untersuchung an 1127 Schwangeren.

OBJECTIVE: Birth weight is an important confounder to foetal morbidity and mortality. There is controversy about the necessity of ultrasound examinations immediately before delivery. As only few studies on unselected populations have been published, some recommendations exist in the context with shoulder dystocia, water delivery and breech delivery. PATIENTS AND METHODS: Within 1 year we examined 1,127 consecutive pregnant women with 1,151 foetuses on the basis of a routine ultrasound examination. RESULTS: A total of 92% of all women were examined by ultrasound. Nearly 80% of these examinations took place within 72 h prior to delivery. The accuracy of foetal weight estimate (±10% variance) was 72% and did not gain due to the grade of the examiner's experience. There was no difference between routine and complicated conditions such as oligohydramnios, obesity, contractions. Also week of gestation had no influence. Macrosomic foetuses were underestimated in more than 50%. In 85% of pregnancies there was at least one risk factor and rate of Cesarean sections was due to this fact. Overall there were 8.5% macrosomic foetuses and 15.1% were SGA. 16.5% of the women were obese with BMI >30. CONCLUSION: Foetal weight estimation by means of ultrasound is easy and fast and does not need a high level of experience. There is no negative influence on accuracy of weight estimate by examination conditions and week of gestation. Ultrasound examinations also give information about foetal position, placental localisation and amount of amniotic fluid. Together with maternal risk factors, the prospective planning and leading of birth requires ultrasound biometry prior to delivery.

[Shoulder dystocia--risk factors and indicators. A retrospective analysis within an obstetric collective of 14,913 deliveries]. / Schulterdystokie--Risikofaktoren und Hinweiszeichen. Retrospektive Analyse an einem geburtshilflichen Kollektiv von 14,913 Geburten mit 53 Schulterdystokien.

PURPOSE: Shoulder dystocia represents a severe obstetric emergency with the risk of injury to the newborn even in cases with adequate reactions by the obstetrician. Therefore, the potential benefit of early diagnosis is obvious. MATERIAL AND METHODS: Using the cases of 53 newborns out of 14,193 births within 11 years we have analysed the association between a BIP-thoracic diameter difference greater 14 mm and the obstetric manoeuvres for foetal birth. RESULTS: With classic foetal ultrasound biometry, most of the birth weights near or beyond term were underestimated. In the group with a BIP-thoracic diameter difference greater than 14 mm, all the obstetric manoeuvres with internal rotation of the baby were found as well as all cases of foetal acidosis and reduced Apgar scores, whereas the other babies were born after McRoberts manoeuvre alone. The medium birth weight was not different between the two groups. Therefore, the obstetric procedures as well as the foetal outcome are dependent on foetal biometry. Multiparae do have greater risks for complicated shoulder dystocia compared with primiparae. CONCLUSION: A BIP-thoracic diameter difference of greater than 14 mm is able to predict probable difficult courses of birth. This means that, from our point of view, ultrasonography close before delivery is an obligate necessity.

[Emergency cervix cerclage in amniotic sac prolapse--a realistic option for prolonging pregnancy]. / Notfallmässiger Muttermundverschluss bei Fruchtblasenprolaps--eine realistische Option zur Schwangerschaftsverlängerung.

BACKGROUND: We tried to evaluate, whether emergency operative closure of the cervix (EOCC) is a realistic option for prolongation of pregnancy in cases with early opening of the cervix and prolapse of the amniotic sac (PAS) into the vagina. PATIENTS AND METHODS: We report on 16 patients with PAS between 15 + 3 and 28 + 1 weeks of gestation and cervix dilatation between 2 and 8 cm. After antibiotic and tocolytic treatment we performed EOCC in 7 cases and EOCC + Cerclage in 9 cases. Pregnancy follow up and fetal outcome were analysed retrospectively. RESULTS: Mean gestational age at delivery was 33 + 1 weeks (9 cases > 32 + 0 weeks, 2 cases between 28 + 0 and 31 + 6 weeks, 3 cases between 25 + 0 and 27 + 6 weeks, 1 case with rupture of membranes during operation and immediate cesarean section at 28 + 1 weeks, 1 miscarriage at 23 + 3 weeks). Time between EOCC and delivery was between 0 and 146 days (mean 56.3 days), 14 fetuses survived healthy. The best results were obtained after EOCC + cerclage. CONCLUSION: If antibiotic and tocolytic treatment was successful in stopping local infection and contractions, EOCC is an acceptable and mostly successful procedure to prolong pregnancy.

[Single umbilical artery. Effect on fetal growth and doppler flow velocity wave form]. / Singuläre Nabelarterie. Einfluss auf das fetale Wachstum und den Dopplerflow.

OBJECTIVE: Fetuses with single umbilical arteries (SUA) are often small for gestational age (SGA). We tried to clarify the following questions: 1. In which range of the normal reference chart for 2 umbilical arteries are the S/D-ratios of SUA located? 2. Is it possible to correctly predict the fetuses at risk for asphyxia or fetal death using these reference charts in SNA fetuses? 3. How do placental weight and histological findings in the fetoplacental vessel influence flow patterns in SUAs? 4. How does the vessel diameter of SUAs influence fetal growth? PATIENTS AND METHODS: 25 fetuses with SUA were examined by means of ultrasound and Doppler ultrasound 1 to 9 times with measurements of arterial diameter and S/D-ratio. These data were compared with results of normal umbilical cords (data from the literature) and correlated with fetal outcome and histological placental findings. RESULTS: Out of 94 individual measurements the S/D-ratio was found to be below the 10th percentile in 28 cases (30%), between the 10th and 50th percentile in 31 cases (33%), between 50 and 90th 20 cases (21%), and above the 90th percentile of the reference chart in 15 cases (16%). 14 fetuses were SGA, 2 presented an intrauterine death, 2 were born with chromosomal aberrations and 3 with malformations. 5/6 fetuses with caesarean section for asphyxia or fetal demise were correctly detected to show an elevated S/D-ratio, 1 case of intrauterine death was not. 16/19 placentas were found to be of low weight, in 14 we found villous malmaturation. 18/22 examined SNAs had an elevated diameter above the +2s range of the reference chart for normal arteries. The ratio of the diameters of the umbilical vein and artery was above 2 in 12/14 SGA fetuses, indicating that the SNA's diameter was less than 50% of that of the veins in these cases. CONCLUSION: Widening of the SNA lumen leads to a reduction of the S/D-ratio. An SNA diameter of less than 50% of that of the vein results in intrauterine growth retardation. Elevated S/D-ratio correctly identifies SNA-fetuses at risk.

Doppler flow velocity waveforms of the umbilical arteries correlate with intravillous blood volume.

OBJECTIVE: My purpose was to measure the volume of the fetoplacental vessel tree and to relate findings to Doppler flow patterns of the umbilical arteries. STUDY DESIGN: One hundred sixty placentas were examined by means of standardized random block placental histomorphometry after delivery and the results were compared with antenatal Doppler findings. RESULTS: There was a high correlation (r = -0.703) between the intravillous blood volume obtained from measurements of intermediate and terminal villi and the Doppler flow velocity waveforms detected within the last week before delivery. Moreover, the reduced size of a vessel tree less than 85 mL is highly predictive of perinatal complications, such as fetal growth restriction, low umbilical artery pH values after birth, reduced Apgar scores, and cesarean section for fetal distress. CONCLUSION: These data suggest that reduced end-diastolic flow velocities in the umbilical arteries are associated with elevated fetoplacental impedance owing to reduced vascularization of intermediate and terminal villi.

[Transabdominal chorionic villi and placental biopsy: rapid karyotyping in the 1st-3rd trimester of pregnancy]. / Transabdominale Chorionzotten-und Plazentabiopsie: Rasche Karyotypisierung im 1.-3. Trimenon der Schwangerschaft.

AIM: The diagnostic value and the complication rate of transabdominal chorionic villi and placental sampling was compared with standard amniocenteses. The method ist especially helpful in cases with conspicuous fetal sonographic findings. METHODS: The results of 475 biopsies were retrospectively compared with 983 amniocenteses and chorionic villi samplings (CVS). RESULTS: 64% of chorionic villi samplings (CVS) were performed in the first, 30% in the second and 6% in the third trimester. The indications were advanced maternal age (45%) and psychological problems (14%) in the first trimester and conspicuous maternal serum markers (11%) or fetal ultrasound anomalies (12%) in the second and third trimester, respectively. 10 out of 20 aneuploid cytogenetic results were found in fetuses with sonographic anomalies. In 4 cases we found confined placental mosaicism, which was clarified by means of amniocentesis and cordocentesis. We had 8 miscarriages in a total of 475 CVS procedures; 6 in 304 before the 15th week of gestation (1.97%). The natural abortion rate in this gestational age is about 1%, the CVS-related abortion rate therefore is near 1%. CONCLUSION: Transabdominal CVS is a low risk method for rapid karyotyping during the entire pregnancy.

[Doppler sonographic flow measurements of the middle cerebral artery in end-diastolic zero flow in the umbilical arteries in relation to fetal outcome]. / Dopplersonographische Verlaufsmessungen der Arteria cerebri media bei enddiastolischem Nullflow in den Nabelarterien in Relation zum fetalen outcome.

Absent or reverse end-diastolic flow velocities (AREDFV) of the umbilical arteries are associated with fetal distress. We studied 74 fetuses with AREDFV with respect to the resistance index of the middle cerebral artery (MCA). The change in the resistance index of MCA was applied to the fetal outcome. The fetuses were retrospectively divided into 3 groups: 1) The fetuses in the first group did not show any changes in the course of observation of the MCA. 2) In the second group a drop followed by an increase in the resistance index of the MCA was confirmed. This is known in literature as "cerebral oedema". 3) The third group showed only a drop in the resistance index, described in literature as "brain-sparing-effect". The increase in the resistance index of the MCA points to a danger for the fetus, since the incidence of fetal acidosis, low birth weight, severe idiopathic respiratory distress syndrome in these fetuses was extremely high. In particular every second fetus in this group showed neurological complications. The change in the cerebral perfusion known as "cerebral oedema" which is extremely dangerous for the fetus has to be avoided.

[Prognostic value of Doppler flow measurement of the middle cerebral artery for morbidity of premature infants with null or negative flow in umbilical arteries]. / Die prognostische Bedeutung der Dopplerflussmessung der Arteria cerebri media für die Morbidität der Frühgeborenen mit Null- oder Negativflow der Nabelarterien.

We analysed 78 fetuses with absent or reverse endiastolic flow velocities (AREDFV) of the umbilical arteries with respect to fetal acidosis, resistance index of the middle cerebral artery (MCA) and abnormal neurological evaluations. A control group was matched for gestational age and normal umbilical artery flow velocity waveforms. Fetuses with AREDFV showed an increased incidence of fetal acidosis. The number of fetuses with abnormal neurological signs was significantly increased compared to the control group. Most of these fetuses (86%) showed abnormal blood flow velocity waveforms of the middle cerebral arteries called "brain-sparing effect". The combination of premature delivery in the 30th week of gestation, severe idiopathic respiratory distress syndrome, and a resistance index under the 10th percentile in the middle cerebral arteries seems to be a risk factor of the early neurological morbidity in fetus with AREDFV.

[Blood flow profile in the uterine artery. Correlation with placental morphology and clinico-obstetrical data within the scope of pre-eclampsia]. / Blutströmungsprofile der Arteria Uterina. Korrelation zur Plazentamorphologie und zu klinisch-geburtshilflichen Daten im Rahmen der Präeklampsie.

Within a group of preeclamptic women we found severe histologic placental pathology with functional relevance when both the uteroplacental and fetoplacental flow velocity waveforms showed elevated resistance indices. These pathological findings were a reduced decidual area, infarction and villus maturation failures with a high rate of intrauterine growth retardation, acidosis and premature delivery. In cases with normal flow velocity waveforms these pathologic findings were much rarer although the patients were preeclamptic, too.

[Fetal development in mild and severe pre-eclampsia: correlation with maternal laboratory parameters and Doppler ultrasound]. / Fetale Entwicklung bei der leichten und schweren Praeeklampsie: Korrelation zu mütterlichen Laborparametern und der Dopplersonographie.

During three and a half years we observed 83 single pregnancies all delivered by caesarean section. All of them had a mild (systolic blood pressure > 140, diastolic > 90 and proteinuria > 0.5 g/dl) or a severe preeclampsia (systolic blood pressure > 160, diastolic > 100 and proteinuria > 3.0 g/dl). We found significantly twice as many abnormal uteroplacental blood flow velocities in the severe preeclampsia group than in the mild one. These results draw us to the conclusion that possible pathological changing of the vessels is due to preeclampsia which does not need to correlate with a placental insufficiency and fetal growth retardation. An abnormal uteroplacental blood flow velocity connected with an abnormal umbilical blood flow velocity raises the fetal morbidity and the early childhood morbidity. Fetal outcome in mild compared to severe preeclampsia definitively shows a worse prognosis for those fetuses whose mother developed a prepartal severe preeclampsia. A distinctly increased rate of cerebral haemorrhages, abnormal neurological signs, acute respiratory distress syndromes and bronchopulmonary dysplasia was found. Finally we show an additional risk for fetal outcome in absent or reverse enddiastolic flow velocity (AREDFV) in the severe preeclampsia group. We observed in the AREDFV group with severe preeclampsia in comparison to a group of AREDFV without maternal preeclampsia more than twice as many cerebral haemorrhages, abnormal neurological signs and bronchopulmonary dysplasia.

Low target birth weight or growth retardation? Umbilical Doppler flow velocity waveforms and histometric analysis of fetoplacental vascular tree.

OBJECTIVE: The placental vascular architecture of small-for-gestational-age fetuses seems to have an impact on the flow patterns in the umbilical arteries. STUDY DESIGN: Blood flow velocity waveforms of the umbilical arteries were measured by Doppler ultrasonography in nine small-for-gestational-age fetuses with elevated systolic/diastolic ratios of the umbilical arteries, seven small-for-gestational-age fetuses with normal flow patterns, and 14 appropriate-for-gestational-age fetuses with normal flow patterns. After delivery histomorphometric placental investigations were performed. RESULTS: Reduced end-diastolic flow velocities were significantly associated with both a reduction of vascularization within the terminal villi and adverse diffusion conditions, indicating insufficient functional maturity. The perfusion and diffusion capacity of small-for-gestational-age placentas with normal umbilical artery flow velocity waveforms was similar or even slightly better compared with the appropriate-for-gestational-age control values. CONCLUSION: These data suggest that Doppler flow velocimetry in the umbilical arteries is predictive of a vascular lesion within the placentas of small-for-gestational-age fetuses.

[Doppler sonography of the umbilical artery for evaluating the fetoplacental vascular tree: a prospective histologic comparison]. / Dopplersonographie der A. umbilicalis zur Beurteilung des fetoplazentaren Gefässbaumes: ein prospektiver histologischer Vergleich.

We compared the clinical data, Doppler sonographic results and histological placental findings of 252 patients prospectively. A normal flow velocity wave form may be related either to a normal placenta villous and vessel architecture or to an at least focal leason with compensatory angiosis and/or high placental weight, whereas in cases with missing compensation phenomenon the end-diastolic blood flow velocities in the umbilical arteries are reduced.

[Placental morphometry in diastolic zero and negative flow of the umbilical arteries]. / Plazentamorphometrie bei diastolischem Null- und Negativflow der Nabelarterien.

Macromorphometric and histometric placental data, in cases with enddiastolic zero flow or reverse flow (dZRF), reveal a lower placental weight and smaller attachment area as well as bigger terminal villi with a reduced amount of epithelial plates with comparable vascularisation. In cases with reverse flow, all parameters were worse, either compared to the controls or to the zero flow cases. With advancing duration of clinical observation, we find a maturation of the terminal villi, with the cross-sectional areas getting smaller, diffusion distances becoming shorter and vessels bigger. This proves the dependence of foetal outcome by dZRF on the compensatory capacity of the terminal villi. The planimetric area in the forward flow channel depends on the foetal intravillous blood volume.

[Histologic placenta findings in diastolic zero or negative flow of the umbilical arteries: a prospective study with reference to the duration of clinical observation]. / Histologische Plazentabefunde bei diastolischem Null- oder Negativflow der Nabelarterien: Eine prospektive Untersuchung unter Berücksichtigung der Dauer der klinischen Beobachtung.

37 cases with enddiastolic zero flow or reverse flow (dZRF) in the umbilical arteries were compared with 37 gestational age-matched controls. In dZRF the placenta is significantly smaller (weight and basal area) throughout the entire gestational age. Vascularisation of the villous tree is often reduced in cases with dZRF, but the findings are not uniform. However, there is a direct interdependence of the histologic findings of villous maturation, terminal villus deficiency, reduced vascularisation and endangiopathia obliterans from the duration of clinical observation. The longer the control period was, the higher was the amount of accelerated villous maturation, angiosis of terminal villous vessels, less endangiopathia obliterans, with simultaneously improved foetal outcome. We conclude from these data, that the main placental lesion, which may cause dZRF, is located in the central villous tree and vascular tree, which is possibly related to the smallness of the placenta, whereas the changes in the terminal villi may exercise compensatory functions and may influence foetal outcome.

Umbilical artery blood flow velocity waveforms during variable deceleration of the fetal heart rate.

Blood flow velocities of the umbilical arteries were measured by Doppler ultrasonography during variable decelerations of the fetal heart rate. The flow velocity waveforms, being normal between uterine contractions, showed either an unchanged flow velocity waveform with an exclusive fetal heart rate effect on end-diastolic velocities or a rapid change to absent and reverse diastolic flow during the decelerations, indicating an abrupt increase in placental resistance with a halt in placental perfusion. Computer-aided reconstruction of the fetal heart rate curve revealed the exact temporal relationship between the reduction of umbilical artery perfusion and deceleration of fetal heart rate. We showed that variable decelerations of fetal heart rate can be observed during only slightly changed umbilical perfusion or can be caused by a halt in placental perfusion, which does not necessarily mean an absence of any movement of the fetal blood column, but is a result of a systolic forward and diastolic reverse flow to the same extent.

[Effectiveness of infection prevention with latamoxef in vaginal hysterectomy. A prospective study]. / Zur Wirksamkeit der Infektionsprophylaxe mit Latamoxef bei vaginalen Hysterektomien. Eine prospektive Studie.

A prospective clinical trial was designed to examine the influence of a single-dose prophylaxis with 2 g Latamoxef on postoperative infectious morbidity in women undergoing vaginal hysterectomy. 91 vaginal hysterectomies with latamoxef prophylaxis were compared with a similar group of 99 patients without prophylaxis. Patients in the latamoxef group had significantly less postoperative infectious morbidity (23.1%) than those in the non prophylaxis group (45.1%). Prophylactic latamoxef reduced postoperative additional antibiotic therapy in the prophylaxis group significantly. The postoperative infectious morbidity (urinary tract infections, pelvic infections, febrile morbidity) was significantly reduced by a single-dose prophylaxis with 2 g Latamoxef.

[Breech presentation of the second twin. Effect on early morbidity and perinatal mortality]. / Beckenendlage des zweiten Zwillings. Einfluss auf Frühmorbidität und perinatale Mortalität.

Twin delivery is often complicated by breech presentation of the second twin. To investigate the influence of breech presentation of the second twin, we reviewed all 259 twin deliveries from the 18,404 deliveries at our institution over 11 years between 1978 to 1989. The neonatal morbidity of the second twin in breech presentation (pH less than 7,15; 1-minute-Apgar less than 7, transfer to newborn hospital) was significantly higher in comparison to vertex presentation of the second twin. A dependence of neonatal morbidity on the time interval was not found. Where the second twin was in vertex presentation, a higher neonatal morbidity rate with increasing interval was seen. No significant differences were noted for neonatal morbidity between vaginal and caesarean delivery by breech presentation to the second twin.

[Acute and chronic reduction of diastolic blood flow velocity in fetal umbilical arteries: a Doppler ultrasound study]. / Akute und chronische Reduktion diastolischer Blutflussgeschwindigkeiten der fetalen Nabelarterien: Eine dopplersonographische Untersuchung.

The significance of increased placental resistance for the development of fetal distress was examined in 800 pregnant women by pulsed Doppler flow velocimetry of the umbilical arteries. Moderately elevated resistance with reduced diastolic flow velocities with forward flow throughout the diastole, leads to an increased frequency of cesarean section for fetal distress and to a more negative fetal outcome. Severely elevated resistance of the fetal placental circulation shows absent diastolic velocities or even a diastolic reverse flow in the umbilical arteries. In 90% of 25 pregnancies this flow pattern leads to a premature delivery by cesarean section for fetal distress or to intrauterine fetal death. Standardised conditions of the Doppler signal measurement are required, before an absence of diastolic flow velocities is diagnosed. Acute changes in the resistance of the fetoplacental circulation were measured in 6 fetuses showing variable decelerations of the fetal heart rate (FHR). In 3 fetuses the flow curves showed a rapid change from normal to absent and to reverse diastolic flow during a period of time of 20-25 sec, which can indicate an acute resistance and a mechanical occlusion of the umbilical cord. Nevertheless, we found in 2 fetuses variable decelerations without any changes in the flow pattern of the umbilical arteries except for a frequency effect. One fetus showed both types of flow changes. Since two completely different sorts of flow changes exist, we conclude, that umbilical cord compression is not always the cause of variable decelerations of the FHR.

[Does vascularization of the fetal placenta modify end-diastolic blood flow velocity in umbilical arteries? A histometric contribution to the validation of Doppler ultrasound]. / Beeinflusst die Vaskularisation der Placenta fetalis die enddiastolischen Blutflussgeschwindigkeiten in den Nabelarterien? Ein histometrischer Beitrag zur Validierung der Dopplersonographie.

The foetal intravillous blood volume was approximately determined in 90 cases, using placental histiometry post partum. This was compared with the Doppler sonographic flow patterns in the umbilical arteries determined during the last week ante partum. A direct dependence was seen: The larger the peripheral vascular tree of the placenta fetalis, the lower the resistance against the blood flow in the umbilical artery, i.e. the higher the enddiastolic blood flow velocities and vice versa. There is a highly significant correlation between the foetal intravillous blood volume and the foetal risks of Caesarean section performed, because of intrauterine asphyxia, growth retardation or reduced foetal outcome.