[Maternal mortality in HELLP syndrome in Bavaria 1983-1992]. / Mütterliche Mortalität bei HELLP-Syndrom in Bayern 1983-1992.

150 cases of maternal death were registered in Bavaria from 1.1.1983-31.12.1992. 15 women (10%) died in the puerperal period due to preeclampsia. 14 of these patients either had single or complete laboratory findings in HELLP-Syndrom. Anamnesis, age, parity, nationality, way of delivery and causes of death are analysed. To improve the prognosis of patients with HELLP-Syndrom early diagnosis and immediate delivery are necessary. First signs of pre-eclampsia require regular liver-enzymes and platelet controls. In the occurrence of right upper abdominal pain in the second half of pregnancy precise diagnostics and close supervision in hospital is mandatory.

[Stillbirth--an analysis of 354 cases 1966-88]. / Die Totgeburt--eine Analyse von 354 Fällen aus den Jahren 1966-1988.

A study was conducted on the collection of stillbirths occurring during the last 23 years in the Gynaecological Hospital in Bamberg. The data were taken from the birth reports and the recorded course of each pregnancy. The results of the first 22 years were divided into 2 groups, the first 11 years and the subsequent 11 years, to enable better judgement of trend changes. A total number of 354 children died antepartum or subpartum, the larger group (249) being that in the first 11 years of the observation period. The number of stillborn babies decreased from 40 per year (15%) to 3 per year (1.1%) in the first period. In the collective group the regular participation in prenatal visits increased from 24% to 56%. The percentage of single mothers (9%) remained constant. The number of foreign mothers, who are non-German citizens rose from 2% to 8%. As expected, the rate of stillbirths for twins was almost 4 times higher (5.3%) than for the single pregnancies. The percentage of multiparous women decreased from 66% to 48%. The number of stillbirths, preceded by a miscarriage and abortion in the patient's clinical history, remained constant at 17%. The age distribution of the mothers was almost the same for both observation periods. The usual age of the pregnancy at the time of the stillbirth shifted from the 39th-42nd week to the 35th-38th week. The main complication for the entire group was pre-eclampsia, at the rate of 30%. Amnion infection syndrome (4%) and diabetes mellitus (2%) were rare. The primary cause of foetal death was related to placental dysfunction (40%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Bulimia, induced vomiting, hypochloremic-hypokalemic alkalosis and fetal distress in the 33rd week of pregnancy. Obstetric and anesthesiologic management]. / Bulimie, provoziertes Erbrechen, hypochlorämisch-hypokaliämische Alkalose und fetaler Distress in der 33. Schwangerschaftswoche. Geburtshilflich-anaesthesiologisches Vorgehen.

A 39-year-old primigravida was admitted to the hospital in the 33rd week of pregnancy due to fetal retardation and placental insufficiency, malnutrition, decreased cutaneous turgor, and cardiotocographic (CTG) fetal distress. Body weight had increased subnormally through the 29th week of gestation and had since decreased by 2.5 kg. The following laboratory tests were obtained (normal values for pregnant women in parentheses): serum bicarbonate 50.9 (20-24) mmol/l, pH 7.61 (7.4), PCO2 52.4 (31) mmHg, SaO2 89-91 (greater than 95%); serum sodium 125 (137-145), potassium 1.8 (3.6-5.5), chloride 55 (94-111) mmol/l; colloid osmotic pressure 20.7 (19-22) mmHg. A decompensated hypochloremic-hypokalemic acidosis together with hypovolemic, isotonic hyponatremia was diagnosed and bulimic vomiting that had existed for two decades was discovered as the underlying cause. The acute therapy was aimed at normalization of the fluid-electrolyte status, oxygenation, utero-placental perfusion, and placental-fetal O2 transfer and was carried out under close clinical, biochemical, and CTG surveillance. In addition to the basic measures (lateral tilt position, nasal O2 application, isotonic electrolyte solutions, parenteral nutrition), 158 mmol H+, 240 mmol K+, and 414 mmol Na+ ions were administered. This therapy improved the maternal and fetal parameters continuously (Table 3, Fig. 1). Twenty-six hours following the initiation of treatment, a cesarean section was performed after induction of catheter-epidural anesthesia.

[Preventive appendectomy in gynecologic surgery. Report of 1,718 cases]. / Die prophylaktische Appendektomie bei gynäkologischen Eingriffen. Bericht über 1718 Fälle.

In the period between 1965-1986 with a collective sum of 5369 gynecological laparotomies, the appendix was removed as a preventive measure in 1718 cases (32%). In all these cases, the recovery period proceeded without any complications. The results of the histological studies on the appendices showed an acute appendicitis in 136 cases (7.9%). In 1118 cases (65.1%) a chronic appendicitis was found, with differing severity of fibroid scarring, including total obliteration. In 96 cases (5.6%), there was evidence of carcinoid, mucocele, and endometriosis. Only 368 appendices (21.4%) were normal morphologically. The large percentage of histopathological findings confirms, that the appendix--being a rudimentary lymphatic organ--appears to be predestined for inflammatory changes. For this reason, the risk of illness and death from appendicitis remains, especially for older people. It is usually possible, to perform a prophylactic appendectomy under optimal conditions and we experienced, that this additional operation does not increase the risk to the patient. We consider, that the routine practice of the prophylactic simultaneous appendectomy during gynecological laparotomies is justified, providing, that the contra-indications mentioned are observed.

[Maternal mortality, its definition and assessment. Report of maternal mortality at the Bamberg Gynecologic Clinic 1963-1988]. / Zur Frage der mütterlichen Mortalität, ihrer Definition und Erfassung. Bericht über die Müttersterblichkeit an der Frauenklinik Bamberg in den Jahren 1963-1988.

During the period of observation from 1963-1988 (26 years) 16 maternal deaths during pregnancy, birth and post partum were registered among 59,681 births at the Departm. of Obstetr. and Gynaec. Bamberg. This corresponds to a maternal mortality ratio of 0.26%. Thirteen of the deaths were direct material deaths, three cases of death belong in the category of indirect deaths. In this timeframe 4,257 (7.13%) C-sections were done. The rate of C-sections has almost tripled during the last 26 years, increasing from 3.6% in 1963 to 10.1% in 1988. In 10 cases maternal death followed a C-section. Taking the complete period of observation into account, the mortality rate after C-section of 2.34% is about 20 times higher than the mortality risk after vaginal delivery. This heightened mortality risk after C-section is clearly diminishing. In the years 1973-1982 the C-section mortality rate was only 6 times higher than maternal deaths after vaginal deliveries.

[Amniotic fluid embolism]. / Fruchtwasserembolie.

A 38-year old quintipara with an unremarkable medical history suddenly complained of nausea during delivery, became pulseless and cyanotic, and lost consciousness. The ECG showed evidence of tachycardia, ventricular extrasystoles, and right-ventricular strain. Within 30 min there were also hemorrhage and a consumption coagulopathy (Table 1). Kerato-hyaline cell material was found in central-venous blood. Following cardiopulmonary resuscitation, emergency cesarean section, hemotherapy (Table 2), and intensive care (acute renal failure, ARDS, sepsis) the patient was able to be released with no permanent sequelae. The etiology, epidemiology, and clinical aspects of amniotic fluid embolism are discussed.

[The HELLP syndrome--a rare form of preeclampsia. Anesthesiologic and obstetric aspects]. / Das HELLP-Syndrom--eine seltene Form der Präeklampsie. Anaesthesiologische und geburtshilfliche Gesichtspunkte.

A 34-year-old quadripara was hospitalized in the 33rd gestational week due to an acute hypertensive crisis, headache, upper abdominal pain, icterus, and proteinuria. Laboratory testing revealed hemolysis, hepatic dysfunction, and thrombopenia. The values returned toward normal after delivery by cesarean section. Diffuse bleeding in the surgical wound and acute renal failure necessitated two relaparotomies, intensive hemotherapy, and hemodialysis. Mother and child were released in good condition. Anesthesiological and obstetrical aspects of the HELLP syndrome are discussed.

Experience with the Bamberg obstetrical forceps.

The design and use of a divergent obstetrical forceps, which was developed at the Staatliche Frauenklinik und Hebammenschule in Bamberg by Sipli and Krone are presented. The major advantage associated with the use of this instrument is that it permits the exertion of a limited constant application force (max 300 g) on the fetal head. Thus, compression injuries are effectively prevented and slippage of the forceps with resultant trauma is precluded. The Bamberg forceps was evaluated at the Frauenklinik und Poliklinik der Technischen Universität München and at the Staatliche Frauenklinik und Hebammenschule Bamberg, Federal Republic of Germany. An evaluation of 483 cases where this forceps was used is presented. No serious complications directly attributable to the use of this instrument could be documented.

[Improved Bamberg divergence forceps. Modification for the prevention of soft tissue injuries of the pelvis]. / Die weiterentwickelte Bamberger Divergenzzange. Modifikationen zur Vermeidung pelviner Weichteilverletzungen.

Constant and limited (max. 300 g) force of application by the Bamberg divergent forceps helps to prevent compression injuries and slippage of the forceps with resultant trauma. No serious foetal lesions have been observed over a period of 9 years. Maternal soft-tissue injuries were somewhat above the range of vacuum extractions. This prompted us to consider modifying the Bamberg forceps with a view towards preventing such maternal injuries.

Invasive dysgerminoma in a girl with 45,X/46,X; mar mosaicism.

We report a 16-year-old girl with features of Turner's syndrome from whom an invasive dysgerminoma was removed. Cytotoxic drugs were given for the next 12 months. Mosaicism of two karyotypes (45,X/46,X; mar) was found in various tissues. The literature is reviewed with special regard to cytogenetic findings and prognosis of malignant growth and differentiation of dysgenetic gonads.

[On the position of the human foetus and the probability of spontaneous change in position during pregnancy (author's transl)]. / Uber die Lage des Menschlichen Feten und die Wahrscheinlichkeit einer spontanen Lageänderung im Verlauf der Schwangerschaft. Eine Prospektive Studie anhand von 2.240 ausgewerteten Ultraschalluntersuchungen in der Schwangerschaft.

Since ultrasonic examinations became routine practice in pregnancy rather often breech presentations are being found in the course of pregnancy. The amounts of breech, vertex presentation and cross position in the course of pregnancy are shown in a curve which is made from 2.240 single measurements. There are significant differences between primiparae and multiparae as to the frequency of breech and vertex presentation. The analysis of all repeated determinations of fetal presentations allows predications about the probability of changing of a breech into a vertex presentation and vice versa in a determined week of pregnancy. For example the probability of the turning of a breech presentation into a vertex presentation is 44.6% in the 29th week post menstruation, 23.2% in the 33rd week post menstruation. From the 37th week onwards the fetus won't turn any more into the vertex presentation. A vertex presentation, for example in the 29th week post menstruation changes into a breech presentation with a probability of only 0.55%. From the 33rd week onwards a turn into a breech presentation is no longer to be expected. A diagram for the probabilities of the fetal presentations' turnings into the opposite presentations is given for the 13.-40. week post menstruation, from which the patient can immediately be informed about the individual chance. The turn into the vertex presentation is the most common one and seems to be the physiologic one. This turn occurs more or less constantly, not abruptly.

[The biparietal fetal diameter during twin and normal pregnancy. An ultrasonographic comparison (author's transl)]. / Der biparietale Durchmesser des fetalen Kopfes bei Zwillingen und Einlingen im Verlauf der Schwangerschaft. Eine vergleichende Studie.

The growth of the fetal biparietal diameter (BPD) of twins is compared with the BPD of the normal pregnancy during gestation. Until 26th week of gestation the growth curves of both groups are nearly identic. From the 28th week onwards the growth of the twins' BPD is remarkably less than in normal pregnancies. The difference in the 40th week is about 10 mm, it is statistically highly significant. In pregnancies of unknown duration the BPD should be measured early, i.e. before 28th-30th week with a control 4 weeks later. No twin pregnancy lasted until the 280th day post menstruationem. So in twin pregnancies the day of delivery should be determined to an earlier date, i.e. ca the 27th day post menstruationem.

[Biparietal diameter of the fetal head during pregnancy. A comparative study]. / Der biparietale Durchmesser des fetalen Kopfes in der Schwangerschaft - Eine vergleichende Studie

A growth curve of the diameter of the biparietal fetal head during pregnancy was presented which was plotted with the help of a computer on the basis of 660 measurements. From this curve, an additional curve and 1 table were presented for the estimation of the age of the fetus on the basis of the measurements of the fetal biparietal diameter.

[A new obstetric forceps: the Bamberger divergent forceps (author's transl)]. / Ein neues Zangenmodell. Bamberger Divergenzzange

A new obstetric forceps is presented which has been used since April 1975 in 52 cases for outlet forceps deliveries. The model is a divergent forceps with the rotational axis in the posterior 1/3. The forceps is applied as usual. The shanks do not cross. The distance between the blades is variable by a mechanism in the handle with an automatic stopping mechanism. Pressure on the fetal head is largely avoided. Our experience has shown that this forceps has advantages over the types of forceps in common usage.

[Maternal mortality in cesarean section as compared to vaginal delivery]. / Die mütterliche Mortalität beim Kaiserschnitt im Vergleich zur vaninalen Entbindung

Caesarean section-rates of more than 10% in our days are not seldom; the reasons are the changed and enlarged indications for Caesarean section. The increase of the Caesarean section-frequency is parallel to the decrease of maternal mortality. The authors' investigations came to the same results. From 1963-1974 they examined 29534 deliveries (28184 spontaneous deliveries and 1350 Caesarean sections). In the examined years the Caesarean section-frequency increased from 3.6% to 5.7%. The maternal mortality of all deliveries was 5.47% (14 from 29534);the maternal mortality of the spontaneous vaginal deliveries was 0.14% (4 from 28184), in the Caesarean sections the maternal mortality was 7.41% (10 from 1350). The different causes of exitus in Caesarean section are discussed. Even "adjusted statistics" show that maternal mortality in Caesarean section is until today 10 to 15 times as high as in vaginal deliveries. Therefore Caesarean section means a ten times higher risk than a spontaneous delivery. For these reasons Caesarean section should not develop to the delivery's "method of choice" and we should keep our intentions also in future to the vaginal methods of delivery.