Laparoscopic Pectopexy: A Biomechanical Analysis.

INTRODUCTION: Pectopexy, a laparoscopic method for prolapse surgery, showed promising results in recent literature. Further improving this approach by reducing surgical time may decrease complication rates and patient morbidity. Since laparoscopic suturing is a time consuming task, we propose a single suture /mesh ileo-pectineal ligament fixation as opposed to the commonly used continues approach. METHODS: Evaluation was performed on human non-embalmed, fresh cadaver pelves. A total of 33 trials was performed. Eight female pelves with an average age of 75, were used. This resulted in 16 available ligaments. Recorded parameters were ultimate load, displacement at failure and stiffness. RESULTS: The ultimate load for the mesh + simplified single "interrupted" suture (MIS) group was 35 (± 12) N and 48 (± 7) N for the mesh + continuous suture (MCS) group. There was no significant difference in the ultimate load between both groups (p> 0.05). This was also true for displacement at failure measured at 37 (± 12) mm and 36 (±5) mm respectively. There was also no significant difference in stiffness and failure modes. CONCLUSION: Given the data above we must conclude that a continuous suture is not necessary in laparoscopic mesh / ileo-pectineal ligament fixation during pectopexy. Ultimate load and displacement at failure results clearly indicate that a single suture is not inferior to a continuous approach. The use of two single sutures may improve ligamental fixation. However, overall stability should not benefit since the surgical mesh remains the limiting factor.

Progression or Regression? - Strengths and Weaknesses of the New Munich Nomenclature III for Cervix Cytology.

Introduction: Since 01. 01. 2015 the new Munich nomenclature III for gynaecological diagnostics of the cervix has been in force. The changes have led to controversial scientific discussions. This study reports for the first time on the consequences. Materials and Methods: The present data are based on smear screening results for the year 2014. The data of 63 134 patients were evaluated. Results: 2.27 % of all smears were remarkable. Group IIa was assigned to 0.91 %. Group II-p was somewhat more frequently recorded than group IIID1 (0.59 vs. 0.53 %). Groups IIID1 and IIID2 were found in 0.53 and 0.61 %, respectively, of the cases. Agreement with histology was found in 36.84 and 44.68 %, respectively. Glandular lesions represented the most frequent changes in group III. Histological clarification was obtained for 0.18 % of all remarkable findings. The relative incidence of high-grade precancerous conditions (CIN III) and invasive tumours amounted to 0.1 %. Conclusion: A close communication between gynaecologists and cytologists is mandatory for the correct usage of the new nomenclature. The future annual statistics of the health insurances can now be analysed in more detail. A statistical classification of glandular epithelial changes is now also possible for the first time. The heterogeneous group IIa constitutes an unnecessary uncertainty for patients and physicians. The splitting of the group IIID does not appear to have any advantage for the further clinical management. Further studies are needed to show whether or not the classification can stand up to international comparisons.

Clinical Study: Change in Outlook Towards Birth After a Midwife Led Antenatal Education Programme Versus Hypnoreflexogenous Self-Hypnosis Training for Childbirth.

Aim: To compare the change of maternal outlook towards birth due to a midwife led antenatal education programme versus hypnoreflexogenous self-hypnosis training for childbirth. Method: Before beginning of the classes and after the last class maternal perception on birth was evaluated using Osgood semantic differential questionnaire. The Gießen personality score was evaluated once. Results: 213 patients were enrolled in this study. 155 were in the midwife led education programme and 58 in the self-hypnosis training programme. There was no statistically significant difference between the two groups in regard of participants' characteristics, Gießen personality score and initial Osgood semantic differential scores. After the midwife led course childbirth was emotionally more negatively scored (displeasure, tarnishing, dimension evaluation [p < 0.05]), whereas after the hypnosis course childbirth was emotionally more positively evaluated (pleasure, harmony, dimension evaluation [p < 0.01] and brightness [p < 0.05]). Summary: In this study hypnoreflexogenous self-hypnosis training resulted in a positive maternal outlook towards childbirth, in comparison to the midwife led course. Further prospective randomised studies are required to test these initial results.

[Requirements and current state of birth documentation in Germany]. / Moderne Anforderungen und derzeitiger Standard in der Geburtsdokumentation in Deutschland.

INTRODUCTION: The partogram is a central record in everyday practice for midwifes and obstetricians. For legal enquiries it is one of the most important documents, however, so far there is no standardised partogram in use in Germany. This study explores the current requirements and develops a standardised partogram. MATERIAL AND METHODS: In Germany 95 hospitals with a focus on tertiary referral centres were randomly selected to be questioned. Obstetricians and midwifes were asked to answer a questionnaire, which was based on a current literature search and expert interviews. RESULTS: 49 obstetricians (51.6%) and 24 midwives (25.3%) returned the questionnaires. 80% of those regularly cooperate with the other specialty with a partogram. 75% are using a standardised partogram, 8% an empty page and 6% computerised obstetric records. Most responders are using parameters which are defined in the current guidelines of the German Society of Obstetrics and Gynaecology. Variations were especially pronounced in the scoring system of the cardiotocogram and on legal issues. Room for improvement of the current documentation was documented in half of the cases. DISCUSSION: There is a need for optimising the current birth documentation. With the results of the questionnaire a standardised model for a partogram was developed.

Intrapartum ST segment analyses (STAN) using simultaneous invasive and non-invasive fetal electrocardiography: a report of 6 cases.

The objective of this study was to analyze ST segment analyses (STAN) using simultaneous traditional - gold standard invasive (fetal scalp electrode) and newly available non-invasive abdominal fetal electrocardiography (fECG) during delivery.This was a prospective observational study of non-invasive fetal ECG using 5 abdominally sited electrodes (Monica AN24) against the traditional fetal scalp electrodes (STAN S31) on 6 patients. Data were analyzed when the STAN S31 found the baseline and when there was a baseline rise.Successful fECG signal acquisition was achieved in 6/6 (100%) patients. Using the non-invasive fECG, P and QRS waves were seen in all cases, and T waves in 3/6 (50%). ST segment analysis analysis was possible in 6/6 (100%) and 3/6 (50%) using invasive and non-invasive fECG, respectively.This study demonstrates that ST segment analysis is feasible using invasive and non-invasive fECG. Further studies are warranted to confirm the preliminary results and improve ECG morphology of non-invasive fECG.

Prenatal Foetal Non-invasive ECG instead of Doppler CTG - A Better Alternative?

Introduction: This study aimed to evaluate foetal signal quality obtained using an antenatal foetal ECG system (Monica 24™) and compare it with Doppler ultrasound CTG monitoring (Corometrics® 250 series). Material and Methods: Seventy pregnant women (gestational age: between 20 + 0 weeks and 40 + 0 weeks) were examined using the Monica AN24™ system and also underwent Doppler CTG. The signal quality of both methods was compared and correlated with gestational age and pre-pregnancy body mass index (BMI). Results: Overall, ECG had a signal quality of 77.4 % and CTG had a signal quality of 73.1 % (p > 0.05). In gestational weeks (GW) 20-26, the signal quality of ECG was significantly better compared to that obtained with CTG (75.5 vs. 45.3 %; p = 0.003), while in GW 27-36, the signal quality was better with CTG (72.3 vs. 83.0 %, p = 0.001). No difference in signal quality was found between the two methods after the 37th GW (87.7 vs. 86.1 %; p > 0.05). CTG showed a statistically significant correlation with BMI (rho 0.25, p < 0.05) while ECG showed no such correlation. Conclusion: The use of non-invasive ECG is particularly indicated in the early weeks of pregnancy, while CTG offers superior results during the vernix period. There was no difference in signal quality after the vernix period. The signal quality with ECG was found to be independent of BMI, while the signal quality of CTG deteriorated with increasing BMI.

Change of Spectral Analysis of Fetal Heart Rate During Clinical Hypnosis: a Prospective Randomised Trial from the 20th Week of Gestation Till Term.

Objective: To investigate the functional adaptive process of the fetal autonomic nervous system during hypnosis from the 20th week of gestation till term. Are there changes in the power spectrum analysis of fetal heart rate when the mother is having a clinical hypnosis or control period? Study Design: Fourty-nine FHR recordings were analysed. Included recordings were from singletons and abdominal fetal ECG-monitored pregnancies. All women were randomised to receive clinical hypnosis followed by a period with no intervention or vice versa. Statistical analyses were performed with the Wilcoxon signed ranks and Spearman rho correlation tests. Results: There was a significant difference found between fetal heart rate at baseline (144.3 ± 6.0) and hypnosis (142.1 ± 6.4). A difference was also detected between the standard deviation of the heart rate between baseline (6.7 ± 1.9) and hypnosis (6.8 ± 3.5). LFnu was smaller during baseline (80.2 ± 5.3) than during hypnosis (82.1 ± 5.7), whereas HFnu was significantly larger (19.8 ± 5.3 vs. 17.9 ± 5.7). There was no correlation between the gestation age and the change in LFnu, HFnu or ratio LF/HF due to the hypnosis intervention. Conclusion: The functional adaptive process of the fetal autonomic system during hypnosis is reflected by a sympathovagal shift towards increased sympathetic modulation.

Uterine activity monitoring during labour--a multi-centre, blinded two-way trial of external tocodynamometry against electrohysterography.

PURPOSE: The aim of this study was to determine the quality of intrapartum uterine activity (UA) monitoring in daily practice during the first and second stages of labour. The total duration of inadequate UA monitoring is quantified in relation to the technique applied, namely, external tocodynamometry (TOCO) or electrohysterography (EHG). MATERIAL AND METHODS: 144 UA recordings, collected from 1st September 2008 until 15th October 2009 from deliveries at the Marien-Hospital Witten, Germany, were analysed by obstetricians based at different centres. The included recordings were from singleton and simultaneously with external TOCO and EHG monitored pregnancies. External TOCO and EHG UA recordings were blinded. RESULTS: The percentages of "adequate" UA recordings in the first and second stages of labour were much higher for the external EHG than the external TOCO mode (p<0.001). All doctors evaluated the UA assessment as "easier" (p <0.001) using the EHG compared with TOCO. CONCLUSION: Intrapartum UA monitoring in -daily practice via the EHG mode provides a more recognisable UA trace than the TOCO.

Intra- and interobserver variability of intrapartum cardiotocography: a multicenter study comparing the FIGO classification with computer analysis software.

OBJECTIVE: To evaluate and compare the computer analyzing software system with subjective interpretation using the FIGO classification of intrapartum cardiotocograms. METHODS: Twenty-four obstetricians and 19 midwives from 3 hospitals [19 junior (≤3 years) and 24 senior (>3 years) experience] participated in this study. Forty-three doctors and midwives interpreted intrapartum cardiotocographic (CTG) readings from 12 parturients without knowing the clinical outcome. Two CTG readings were repeated for evaluation of the intraobserver variability. Inter- and intraobserver agreement in CTG interpretation using the FIGO score and the computer analyzing software was assessed via proportions of agreement (Pa), with 95% confidence intervals. The level of inter- and intraobserver agreement was analyzed by calculating Pa values for CTG baseline, variability, accelerations and decelerations. RESULTS: In total, for all parameters of the FIGO classification, Pa was very low. The highest 95% confidence level of Pa was found for the baseline parameter (0.49-1.01), and the lowest for the parameter acceleration. No significant difference was seen between obstetricians and midwives as well as between junior and senior experience. In assessments of normal cases, the Pa were significantly higher than in pathological readings. CONCLUSION: Computer analyzing software can reduce the high inter- and intraobserver variability; however, further studies are needed to find out whether this can improve fetal outcome and reduce the number of Cesarean sections.

[Hypnotherapy, gestational age and incidence of preterm labour]. / Hypnotherapie, Gestationsalter und Frühgeburtenrate.

PURPOSE: This study examines whether or not those women who have participated in a hypnoreflexogenous birth preparation course have a lower incidence of preterm labour and higher gestational age. MATERIAL AND METHODS: 101 women participated in the birth preparation hypnosis course (hypnomental birth preparation) and were evaluated against a parallelised control group. The following parameters were evaluated: education, number of previous pregnancies and live births, average number of cigarettes smoked per day and age of the mother. The control group was selected out of the hospital birth register from 2001 to 2008 (n=10 812). RESULTS: In the hypnosis group (n=101) there were six late preterm deliveries (5.49%) whereas in the parallelised control group there were significantly more preterm deliveries (n=11; 11.3%; p=0.02). There was also a statistically significant correlation between gestational age and maternal participation in the hypnomental birth preparation. CONCLUSION: In the hypnosis group there were significantly less preterm deliveries after parallelising the socio-economical demographics. A planned randomised controlled study of preterm labour should identify whether clinical hypnosis can reduce the incidence of preterm labour.

[Pulse oximetry as an additive procedure in modern fetal assessment during labour]. / Die Pulsoxymetrie als additives Verfahren in der modernen Uberwachung des Feten unter der Entbindung.

INTRODUCTION: The low specificity, together with the high intra- and interobserver variability, of cardiotocography (CTG) necessitates the use of additive fetal assessment methods. The German Society of Obstetrics and Gynaecology (DGGG) advises the use of computerised CTG analysis software systems. In this study we have examined the use of computerised CTG analysis together with the fetal pulse oximetry. MATERIALS AND METHODS: Using the "CTG-Online ((R))" software five consecutive deliveries were simultaneously analysed by the FIGO score and the saturation rate of fetal pulse oximetry. All CTGs were classified as pathological and at least one fetal scalp pH measurement was carried out. Fetal outcome and results of the fetal scalp pH values were evaluated against the fetal pulse oximetry rates. RESULTS: Signal loss was low at less than 5%. No fetus showed a hypoxic state. Only 0.98% of the fetal pulse oximetry saturation rates were below 30% oxygen saturation. No fetus showed an oxygen saturation of below 35% for 10 min duration or more. CONCLUSION: Fetal pulse oximetry saturation rates can be another helpful marker for fetal well-being in a modern labour ward. Further studies are required to verify whether fetal pulse oximetry saturation rates can improve the specificity of CTG for fetal acidosis.

[Changes in resistance of the umbilical artery, foetal movements and short time variation through clinical hypnosis--preliminary results]. / Veränderung des Gefässwiderstands der Arteria umbilicalis, der fetalen Bewegung und der Herzzeitvariation durch Hypnose - Erste Ergebnisse.

BACKGROUND: The aim of this study was to determine whether there are any changes in short time variation (STV), foetal movements, and blood flow in the umbilical artery in the trance state. METHODS: Six pregnant patients who had already attended two hypnoreflexogenous birth preparation course units had a standardised hypnosis intervention under cardiotocography (CTG). Using the CTG-Player ((R)) STVs and foetal movements were calculated from the electronically saved CTG traces and evaluated against control CTGs recorded before and after hypnosis. Before and after the induction of hypnosis, blood flow in the umbilical artery was measured. RESULTS: Using the Wilcoxon test there is a significant lowering of blood flow resistance in the umbilical artery after hypnosis (p=0.042). There was a trend that the foetal movements increas at the beginning of the trance (Wilcoxon test, p=0.075). There was no significant difference in the STVs before, during and after trance. CONCLUSIONS: Preliminary results showed that blood flow of the umbilical artery can be improved by hypnosis. Further clinical studies are required to verify this hypothesis. The subjective impression of participants that foetal movements increase at the beginning of the trance seems to be correct.

[Foetal electrocardiography (ECG) is an alternative to Doppler ultrasound cardiotocogram (CTG) for antenatal assessment of foetal well-being--preliminary results]. / Fetales Elektrokardiogramm (EKG) als Alternative der Doppler-Kardiotokografie (CTG) zur antepartualen Uberwachung des Feten--erste Ergebnisse.

INTRODUCTION: Computer analysing software is required for the assessment of CTGs because of the low sensitivity and high intra- and interobserver variability. The German Society of Gynaecology and Obstetrics advises the use of computer analysing CTG software. This study is aimed at evaluating the use of a new foetal ECG analysis system as an alternative to the traditional Doppler ultrasound CTGs in the setting of a university labour suite. MATERIALS AND METHODS: 10 pregnant women beyond the 32 (nd) week of gestation, who were admitted to hospital and gave informed consent to this study, were connected to the foetal EKG monitor system Monica AN24. Patient satisfaction, maternal and foetal EKG detection rates and time required to connect the patient were evaluated. RESULTS: 8 out of 10 women would prefer the Monica AN24 monitor system over the traditional Doppler ultrasound CTG. In total, the mean foetal ECG detection rate was 62.3 % (SD +/- 30.4) during the recorded time interval; at rest the detection rate was 75.3 % (SD +/- 33.2); during the night time (23.00 to 7.00) the detection rate was 78.3 % (SD +/- 25.4); and during night time and at rest the detection rate was 82.2 % (SD +/- 24.3). The mean recorded time interval was 6 h and 54 min (SD +/- 2 h and 43 min). In total, the maternal ECG detection rate was as high as 99.7 % (SD +/- 0.4). The mean time required for applying the Monica AN24 monitor system was 3.2 min (SD +/- 0.6). CONCLUSION: The foetal ECG monitor system may be a good alternative to Doppler ultrasound CTGs. With the perspective to analyse in a beat to beat manner foetal EKG heart rates, this new monitor system should be superior to Doppler ultrasound CTGs, however further larger studies are needed to confirm this hypothesis.

[The value of Doppler cardiotocogram computer analysis system 70 minutes before delivery]. / Die Wertigkeit der computergestützten CTG-Analyse in den letzten 70 Minuten vor der Entbindung.

BACKGROUND: Since the second half of the 20th century, foetal wellbeing has been assessed using cardiotocography (CTG) during labour. Many studies have shown that the CTG has very high intra- and interobserver variability. Many score systems have been developed for more objective analysis of the foetal heart rate. The German Society of Obstetrics and Gynaecology recommends the use of computerised analysis programmes for CTG evaluation in order to reduce subjectivity. This study examines whether there is a correlation of foetal outcome with computerised CTG analysis using the "CTG-Online" programme. MATERIALS AND METHODS: Out of 1,251 consecutive deliveries, two groups were selected depending on foetal outcome (very good foetal outcome [n=76] and poor foetal outcome [n=56]). The last 70 min before delivery were evaluated using "CTG-Online" and "CTG-Player". These results were correlated with foetal outcome. RESULTS: In the time interval of 25 to 5 min before delivery, the FIGO parameter "deceleration" had a statistically significant correlation with poor foetal outcome (p<0.0199). Variability and acceleration showed no correlation during the evaluation period. Five minutes before delivery the baseline showed a weak statistically significant correlation with foetal outcome (p<0.0290). CONCLUSIONS: Norm values of the FIGO parameters baseline, acceleration and deceleration should be re-examined using large computer databases. Computerised analyses of the FIGO parameter for deceleration is promising, however, further studies are needed to increase its sensitivity and specificity.

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.

[The significance of electronic CTG for intrauterine volvulus in the 32nd week of gestation]. / Die bedeutung der elektronischen CTG-analyse bei einem fetalen Volvulus in der 32. SSW.

Intrauterine intestinal volvulus is a difficult diagnosis to make, but has life-threatening implications for the fetus. We present a case of vulvulus without malrotation in a single fetus revealed in the 32nd gestation week in a 44-year-old woman. The presenting complaint of this patient was reduced fetal movements. Ultrasound examination showed a normal result except for a dilated stomach. Doppler ultrasound results were within the normal range. Computed cardiotocography (CTG) showed pathological results for acceleration and suspect values for variability. Short-term variability (STV) was at 2.80 ms. Due to the pathological computed CTG results a Caesarian section was carried out. The newborn received prompt postnatal surgical treatment and continues to be in good overall condition.

[Fetal heart rate variation in magnetocardiography and cardiotocography--a direct comparison of the two methods]. / Die fetale Herzfrequenzvariation in der Magnetokardiografie und der Kardiotokografie--direkter Vergleich beider Verfahren.

BACKGROUND: Heart rate variability (HRV) is becoming increasingly important in the analysis of prepartal cardiotocography (CTG). Dawes and Redmann have developed a computer algorithm which can calculate short-term variability on the basis of CTG data. In dealing with artefacts, CTG monitors average heart rate values over several beats which makes the use of standard measures of HRV such as the root mean square of successive differences (RMSSD) inappropriate. Fetal magnetocardiography (FMCG) enables the registration of signals similar to the electrocardiogram and this permits the precise determination of heart beat duration and, in consequence, of measures of fetal HRV. METHODS: In this study we applied both methods--CTG and FMCG--sequentially and simultaneously in healthy pregnancies. Fetal short-term HRV was estimated on the basis of RMSSD values for both methods. RESULTS: The RMSSD values of the FMCG data were generally higher and showed a wider dynamic range than those of the CTG. The direct comparison of the simultaneously acquired data demonstrated that the data processing of the CTG signal leads to a suppression of essential aspects of short-term HRV. CONCLUSION: FMCG permits a substantially more differentiated examination of fetal HRV and offers new possibilities in the analysis of fetal cardiac activity.

[Childbirth preparation through the hypnoreflexogenous protocol developed by Schauble]. / Hypnoreflexogene Methode der Geburtsvorbereitung nach Schauble.

BACKGROUND/METHODS: This article presents the results of the application of hypnotherapy for obstetrics with a special focus on the hypnoreflexogenous method of childbirth preparation. RESULTS/CONCLUSION: The programme specifically developed by Schauble as the hypnoreflexogenous method is an appropiate and efficient tool to interrupt the fear-tension-pain / pain-tension-fear circuit. Women who were prepared with the hypnoreflexogenous method had significantly less fear and pain, required significantly less analgesia, had a shorter period of labour and delivery and recovered faster from labour.

[Short time variation of foetal heart rate: therapeutic management and effect on heart rate variation in the context of chronic hypotension in the 27th week of gestation]. / Die Kurzzeitvariabilität der fetalen Herzfrequenz - Therapeutisches Management und Auswirkungen auf die Herzfrequenzvariabilität bei einer drohenden Entgleisung einer chronischen Hypertonie in der 27. SSW.

The non-stress test is the most commonly used method in prepartal surveillance. Due to the high intra- and interobserver variability involved in subjective evaluation, the computer-assisted analysis is gaining in importance. Some studies have shown that low foetal STV may be associated with higher rates of acidosis and intrauterine mortality. Other factors influencing STV are largely not known. Low STV has been found as an effect of cortisone. In this case report, we illustrate the relevance of haemodilation therapy in the context of essential hypertension in the 27 (th) week of gestation and its effect on SVT. The treatment led to a prolongation of pregnancy to the 32 (nd) week. At the start of treatment STV increased to 4.5 ms and dropped back below this value concurrently with centralisation as documented by Doppler sonography. STV correlated clearly with the foetal condition. However, STV is dependent on numerous factors which should be investigated in further studies in order to determine appropriate reference values.