Average acceleration and deceleration capacity of fetal heart rate in normal pregnancy and in pregnancies complicated by fetal growth restriction.

OBJECTIVE: To study fetal heart rate (FHR), its short term variability (STV), average acceleration capacity (AAC), and average deceleration capacity (ADC) throughout uncomplicated gestation, and to perform a preliminary comparison of these FHR parameters between small-for dates (SFD) and control fetuses. METHODS: Prospective observational study of 7 h FHR-recordings obtained with a fetal-ECG monitor in the second half of uncomplicated pregnancies (n = 90) and pregnancies complicated by fetal SFD (n = 30). FHR and STV were calculated according to established analysis. True beat-to-beat FHR, recorded at 1 ms accuracy, was used to calculate AAC and ADC using Phase Rectified Signal Averaging (PRSA). Mean values of FHR, STV, AAC, and ADC derived from recordings in SFD fetuses were compared with the reference curves. RESULTS: Compared with the control group the mean z-scores for STV, AAC, and ADC in SFD fetuses were lower by 1.0 SD, 1.5 SD, and 1.7 SD, respectively (p < 0.0001 for all comparisons). In SFD fetuses, both the AAC and ADC z-scores were lower than the STV z-scores (p < 0.02 and p < 0.002, respectively). CONCLUSIONS: Analysis of the AAC and ADC as recorded with a high resolution fECG recorder may differentiate better between normal and SFD fetuses than STV.

Phase-rectified signal averaging as a new method for surveillance of growth restricted fetuses.

OBJECTIVE: This study aims to compare average acceleration capacity (AAC), a new parameter to assess the dynamic capacity of the fetal autonomous nervous system, and short term variation (STV) in fetuses affected by intrauterine growth restriction (IUGR) and healthy fetuses. METHODS: A prospective observational study was performed, including 39 women with IUGR singleton pregnancies (estimated fetal weight <10th percentile and umbilical artery resistance index >95th percentile) and 43 healthy control pregnancies matched according to gestational age at recording. Ultrasound biometries and Doppler examination were performed for identification of IUGR and control fetuses, with subsequent analysis of fetal heart rate, resulting in STV and AAC. Follow-up for IUGR and control pregnancies was done, with perinatal outcome variables recorded. RESULTS: AAC [IUGR mean value 2.0 bpm (interquartile range = 1.6-2.1), control 2.7 bpm (2.6-3.0)] differentiates better than STV [IUGR 7.4 ms (5.3-8.9), control 10.9 ms (9.2-12.7)] between IUGR and control. The area under the curve for AAC is 97 % [95% CI = (0.95-1.0)], for STV 85 % (CI = 0.76-0.93; p < 0.01). Positive predictive value for STV is 77% and negative predictive value is 81%. For AAC both positive and negative predictive values are 90%. CONCLUSIONS: AAC shows an improvement to discriminate between normal and compromised fetuses at a single moment in time, in comparison with STV.

Reversible foetal cerebral ventriculomegaly and cardiomyopathy under chemotherapy for maternal AML.

BACKGROUND: Leukaemia in pregnancy is a rare complication demanding a multidisciplinary approach and careful management to handle potential complications and cope with ethical dilemmas. PATIENT AND METHODS: We report on a patient with acute myeloid leukaemia (AML) relapse in 22 weeks of gestation who received chemotherapy with cytarabine and mitoxantrone, as well as fludarabine, cytarabine, idarubicin, and gemtuzumabozogamicin. We describe findings on regular ultrasound examinations and successful management of complications. RESULTS: The foetus developed signs of anthracycline-induced cardiomyopathy, transient cerebral ventriculomegaly, anaemia, and intrauterine growth restriction. The child was delivered by Caesarean section at 33 + 1 weeks of gestation. The newborn showed no congenital malformations. CONCLUSION: This case report confirms that chemotherapy for treatment of AML can be applied in the second trimester of pregnancy under close and careful maternal and foetal monitoring.

Sensitivity and specificity of intrapartum computerised FIGO criteria for cardiotocography and fetal scalp pH during labour: multicentre, observational study.

OBJECTIVE: To identify sensitivity and specificity of computerised cardiotocography (CTG) analysis for fetal acidosis during delivery. DESIGN: Retrospective observational study. SETTING: Tertiary referral labour ward, Technical University München (TUM) and University Witten/Herdecke (UWH). POPULATION: All deliveries, which had at least one fetal scalp pH measurement and electronically saved CTG traces, between 2000 and 2002 (TUM) and between 2004 and 2005 (UWH). METHOD: Correlation analysis of fetal scalp pH values and computerised International Federation of Obstetrics and Gynecology (FIGO) classification using 'CTG Online' program of digitally saved CTG traces. MAIN OUTCOME MEASURES: Fetal scalp pH values, FIGO parameter (baseline, variability, acceleration and deceleration) using computerised analysis. RESULTS: Both collectives showed a high sensitivity (95.0%) for computerised FIGO classification 'suspect' and 'pathological', together with a low specificity (21.8%) for fetal acidosis. The most sensitive single FIGO parameter was deceleration. Very low sensitivity (<50%) was shown for the parameters variability and acceleration. CONCLUSIONS: Computerised CTG analysis is highly sensitive for fetal acidosis and can be used as an objective adjunctive criterion during delivery. Further CTG data are needed to adjust and optimise each FIGO parameter and increase sensitivity and specificity.

[Anticoagulation and thrombophilia in pregnancy]. / Antikoagulation und Gerinnungsstörungen in der Schwangerschaft.

A review of coagulation disturbances during pregnancy and the current management of the anticoagulated patient with heart valve prostheses, atrial fibrillation, and thromboembolic events is presented. All patients with mechanical heart valve prostheses require life-long oral anticoagulation with coumarin or one of its derivatives. Recommendations for the treatment and prevention of thromboembolic events are discussed. The advantages and disadvantages of three different treatment approaches to anticoagulation during pregnancy are discussed and recommendations for the management in different situations are outlined with delineation of specific risks for the mother and the fetus.

[Standard values for the weight gain in pregnancy according to maternal height and weight]. / Vorstellung von Normwerten der Gewichtszunahme in der Schwangerschaft (20-43 vollendete Schwangerschaftswochen) unter Berücksichtigung von Körperhöhe und Körpergewicht der Frauen.

BACKGROUND: The weight gain during pregnancy is influenced by maternal body weight and height and is an important determinant of maternal and neonatal health. In this study we present standard values for the weight gain in pregnancy depending on maternal weight and height. MATERIALS AND METHODS: Data of about 2.3 million singleton pregnancies were taken from the German perinatal statistics of 1995-2000. The data were analysed with regard to maternal height, weight and weight gain in pregnancy. The weight gain during pregnancy was calculated as the difference between the weight at the end of pregnancy and the weight at first consultation. RESULTS: We divided the pregnant women into 12 groups according to weight and height and calculated the standard values for the weight gain for these groups. Weight gain differs significantly between the groups. The most pronounced difference appears when the group of the relatively heavy and short women is compared to the group of the relatively tall and thin women. The former gain comparatively little weight during pregnancy and the latter gain rather more. CONCLUSIONS: Height and body weight are important determinants of the weight gain during pregnancy. They should therefore be used when assessing the weight gain in clinical practice. With the standard values introduced here such an assessment is possible.

[Prevention of preeclampsia]. / Prävention der Präeklampsie.

Preeclampsia is accompanied by high fetal and maternal morbidity and mortality and to a high degree responsible for preterm delivery. The pathophysiologic mechanisms underlying this disease remain poorly understood. Accordingly, only few causative or preventive therapeutical strategies are known. One such example for a preventive strategy is the use of aspirin (ASA) which directly affects the imbalance of vasodilative prostacycline and vasoconstrictive thromboxane. Recently, some studies are indicating a preventive effect of vitamin C and E substitution. In contrast, early antihypertensive therapy did not prevent later progression of the disease. Furthermore, sodium restriction, calcium and magnesium substitution, fish oil substitution, or steroid therapy are without any effect regarding the later development of preeclampsia. It is of utmost importance to further elucidate underlying pathophysiological mechanisms to improve therapeutical and preventive strategies.

[Pregnancy-associated femoral nerve affection]. / Schwangerschafts-induzierte Nervus femoralis-Läsion.

BACKGROUND: Common neuropathies during pregnancy are carpal tunnel syndrome or peripheral facial paralysis. However, there is little information about femoral nerve affection during pregnancy. CASE REPORT: We report on a female at 30 weeks of gestation, complaining of pain in hips and thighs and gait difficulty. Pregnancy was normally developed. Neurological examination showed a bilateral weakness in both quadriceps and iliopsoas muscles combined with soreness in hips and thighs, without deficits of sensibility. Laboratory findings and results of a lumbar punction were normal. Pelvic ultrasound and an MRI scan of the spine and pelvis showed no mass or disc prolaps. Neuromyographic evaluation bilaterally revealed acute signs of denervation of the muscles innervated by femoral nerve. Caesarean section was performed at 32 gestational weeks, as pain was unbearable and refractory to treatment with even opiates. Post partum, pain relieved immediately, and after weeks of physiotherapy, complete remission was achieved. CONCLUSION: This unusual manifestation of a neuropathy in pregnancy could be due to pressure on the femoral nerve. The patients' anxiety can be eliminated, as the described cases in literature show an excellent prognosis. However, the severity of symptoms can lead us to necessity of premature delivery.

Downregulation of a mitogen-activated protein kinase signaling pathway in the placentas of women with preeclampsia.

OBJECTIVE: To investigate whether the activity of the three mitogen-activated protein kinases (Jun aminoterminal kinase, extracellular regulated kinase, and p38) is altered in placental tissue of women with preeclampsia and hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome. METHODS: Placental activity (measured by immunoprecipitation-kinase assay) and protein expression (measured by western blot) of Jun aminoterminal kinase, extracellular regulated kinase, and p38 mitogen-activated protein kinase were measured in four groups of eight women each with preeclampsia, HELLP syndrome, and normal vaginal or cesarean deliveries. To further characterize the Jun aminoterminal kinase signal transduction pathway, phosphorylation of c-Jun, a downstream effector of Jun aminoterminal kinase- mitogen-activated protein kinase, was analyzed by western blotting, and the activity of Rac1, an upstream activator of the Jun aminoterminal kinase signaling pathway, was determined by pull-down assay. RESULTS: The activity of Jun aminoterminal kinase was significantly lower in placentas of women with preeclampsia or HELLP syndrome compared with those who had normal vaginal or cesarean delivery, whereas levels of Jun aminoterminal kinase protein expression were similar. Phosphorylation of the transcription factor c-Jun and Rac1 activity also were significantly lower in women with preeclampsia and HELLP than in controls. p38 mitogen-activated protein kinase activity was significantly higher in women with preeclampsia than with HELLP syndrome. There was no change in extracellular regulated kinase activity or protein expression between subgroups. CONCLUSION: In placentas of women with preeclampsia or HELLP syndrome, a Rac1-Jun aminoterminal kinase-c-Jun-dependent signal transduction pathway was downregulated.