Indication and results of insulin therapy for gestational diabetes mellitus.

The aim of this study was to determine whether amniotic fluid insulin concentration (AFI) is a better parameter than mean maternal blood glucose values (MBG) for deciding about insulin therapy in patients with gestational diabetes. MBG's were calculated on the base of 9 blood glucose levels during a 24 hour period after one week of diet therapy. In a prospective trial between 1987 and 1989 in Karlsburg, 123 gestational diabetic patients were randomized into two groups. Treatment was either based on the concentration of AFI or MBG levels. In a second series in Berlin, 103 patients were offered amniocentesis. 81 patients agreed and 22 refused. Treatment was then analogous to that in Karlsburg. In both groups of the randomized population, strict metabolic control was achieved. There was no difference regarding pregnancy complications. Earlier labor induction and higher cesarean section rates were seen in the non-invasive group (p < 0.05). The incidence of diabetic fetopathy and neonatal hypoglycemia was significantly lower in the invasive group (p < 0.01), even though the metabolic control parameters did not differ between the two groups. The results in Berlin correspond to these findings. In conclusion, AFI enables the recognition of any hyperinsulinism reaction to the maternal metabolic situation. We recommend the additional measurement of the AFI concentration between 28 and 36 weeks as the direct fetal parameter for deciding about insulin treatment.

[Diagnostic reliability of vaginal ultrasound in ectopic pregnancy]. / Diagnostische Sicherheit der Vaginalsonographie bei ektoper Gravidität.

The therapeutic approach to ectopic pregnancy (EP) has changed over the last decade. A prerequisite for a differentiated management is an early diagnosis of EP. This can be achieved by transvaginal sonography (TVS). The purpose of this study was to evaluate the accuracy of TVS in the diagnosis of EP. 184 patients with clinically suspected ectopic pregnancy were examined by TVS. In 103 cases suspicion of EP was confirmed, in 81 cases it was ruled out. All cases were evaluated by laparoscopy, D&C, serial HCG determinations or sonographic follow-up in case of an intrauterine pregnancy. Sensitivity of TVS in the diagnosis of EP was 96%, specificity 88%, the positive predictive value was 89%, the negative predictive value was 95%. Four cases with a false negative result at TVS were very early in pregnancy and were subjected to laparoscopy because of persistent high HCG values without demonstration of an intrauterine pregnancy. Five cases of sonographically confirmed ectopic pregnancies were missed by the first laparoscopy. These cases required intervention because of clinical symptoms and had low levels of HCG. TVS has a high diagnostic accuracy in the diagnosis of ectopic pregnancy.

[Diabetic retinopathy and nephropathy--complications in pregnancy and labor]. / Diabetische Retinopathie und Nephropathie--Komplikationen während Schwangerschaft und Geburt.

The purpose of this retrospective study was to determine the risk factors for the morbidity of the mothers and their fetus in patients with diabetic retinopathy and/or nephropathy with an open family planning. We compared the course of pregnancies, complications as well as the maternal and neonatal morbidity in 76 patients with diabetic retinopathy or nephropathy (White R F) with 85 patients without severe microangiopathy (White C D). We found a correlation between retinopathy progression and hyperglycaemia during the first trimester (p < 0.05). There was an increase in the deterioration of visual acuity up to blindness due to the progression of this microangiopathy in cases of proliferative retinopathy. There was a significant increase of the mean diastolic blood pressure (mdp) and preeclamptic symptoms occurred in 71% of the cases with severe microangiopathy (p < 0.05). Deterioration of the diabetic nephropathy with excessive proteinuria (> 10 g/d) and unmanageable hypertension or a progression of the retinopathy led to an earlier delivery in 80% of the patients (p < 0.05). A high rate of preterm deliveries (39%) and a frequent occurrence of intrauterine growth retardation's (9%) characterised the fetal outcome. The following examinations for a patient with an open family planning, if diabetes is diagnosed during childhood or the course of the disease is between 10 and 15 years, should be done: Ophthalmological evaluation, control of the renal function, contraceptive advice and an improvement of the metabolic situation. In case of a diabetic nephropathy in combination with hypertonus the patients shoud be warned against pregnancy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Fetal macrosomy and hydramnios. Intrauterine symptoms of a combination of Sturge-Weber-Krabbe- and Klippel-Trenaunay syndrome]. / Fetale Makrosomie und Hydramnion. Intrauterine Symptome einer Kombination von Sturge-Weber-Krabbe-und Klippel-Trenaunay-Syndrom.

The authors report on a case where the Klippel-Trenaunay symptom complex was combined with a Sturge-Weber-Krabbe syndrome, which, however, was only noticeable during pregnancy by fetal macrosomy and hydramnios. The child was delivered on term by Caesarean section and presented no paediatric problems; however, during the first few years of its life mental retardation became clearly evident.

[Prevention of neonatal risk by general screening for diabetes in pregnancy, intensive diagnosis and subsequent therapy]. / Vermeidung kindlicher Risiken durch ein generelles Gestationsdiabetes-Screening, intensivierte Diagnostik und konsequente Therapie.

Only 10% of all gestational diabetic mothers in Germany are diagnosed with the current risk-screening. The elevated perinatal risks in case of an unrecognized or insufficiently treated gestational diabetes remains controversial. The purpose of our study was to determine if the number of recognized cases could be increased by a general screening method, and with intensive medical diagnostics the complication rate reduced. Routine blood glucose samplings during the outpatient care were performed throughout the pregnancy. In case of values over 100 mg/dl a 75 g OGTT was done for an exclusion of gestational diabetes. In case of gestational diabetes the patients were asked to follow a special exercise and diet programme as well as self-blood glucose determinations throughout the day. The amniotic fluid insulin level was of substantial value for the indication of insulin therapy. In 6% of the screened patients a gestational diabetes was diagnosed. There was a significant increase (p < 0.001) of fetal macrosomia and diabetic fetopathy in the group without amniocentesis (n = 22) in comparison to the group with invasive (n = 81). We demand the introduction of a general screening for every pregnant patient. By an intensification of the diagnostic methods as well as by a strictly appropriate therapy it should be possible to reduce the fetal and neonatal complications.

[Kinetocardiotocographic and Doppler ultrasound findings before termination of risk pregnancies]. / Kinetokardiotokographische und dopplersonographische Befunde vor Terminierung von Risikoschwangerschaften.

42 pregnancies complicated by severe intrauterine growth retardation (IUGR) were monitored between 1991 and 1992 with the kinetocardiotocogram (K-CTG) comparing them with normal pregnancies of the same gestational age. We evaluated the foetal movements and the heart rate patterns establishing a correlation with pulsed Doppler ultrasound findings. There was a significant reduction of foetal activity in cases of IUGR and pathological Doppler sonography (p < 0.01). The reduction of foetal movements was noticed several days prior to pathological FHR patterns. There was a significant reactivity after vibroacoustical stimulation (VAS) correlating with the Doppler findings. The evaluation of foetal movement patterns in the kinetocardiotocogram proved to be an important complementary method in the monitoring of severe IUGR.

Prediction of fetal distress and poor outcome in prolonged pregnancy using Doppler ultrasound and fetal heart rate monitoring combined with stress tests (II).

Postterm pregnancies of more than 290 completed gestational days (n = 110) were simultaneously supervised after admission by pulsed Doppler ultrasound of the common carotid and the umbilical arteries, nonstress and contraction stress tests (NST/CST) and vibroacoustic stimulation tests (VAST). The results of these tests were blinded for the clinicians. Further decision making was based mainly on fetal heart rate (FHR) monitoring. The prognostic value of tests performed < 3 days before birth predicting fetal distress, low Apgar and pH values in the umbilical artery were compared by receiver operator characteristics. Results of the NSTs and fetal Doppler measurements of the ratio of resistance indices of common carotid/umbilical artery were more predictive of later fetal distress than both, VAST and CST (p < 0.01, p > 0.05, respectively). There were no significant differences in the prediction of low Apgar values. NST was the only significant test for predicting a low pH in the umbilical artery immediately after birth compared to the other examinations (p < 0.05). The results suggest that even in prolonged pregnancies VAST and CST might be released from routine supervision.