[Gestosis, thrombophilia and pulmonary embolism in a primipara with twin pregnancy]. / Gestose, Thrombophilie und Lungenembolie bei einer Primipara mit Zwillingsschwangerschaft.

This is a case report on a course of gemini-pregnancy complicated by gestosis, recurrent submassive pulmonary embolism and discordant growth of the hypotrophic twins. It is concluded from this report that: 1. the AT-III-deficiency in gestosis can be caused by loss and consumption; 2. due to decrease below a critical AT-III-level the coagulation-fibrinolysis system tends to decompensate, reflected in a disseminated intravascular coagulation and/or a pulmonary embolism. The tendency consists particularly in immobilisation and stasis; 3. the daily determination of AT III, better of TAT-complex and D-dimer, the daily clinical examination regarding signs of thrombosis and in cases of heparinization the measurement of PTT several times daily, are necessary to avoid or recognise disorders, of the coagulation-fibrinolysis-system at an early stage. 4. The increased consumption in coagulation systems can be avoided by AT-III substitution and correct heparinisation. 5. In cases of risk of pulmonary embolisation in pregnancy a cava filter should be temporarily implanted. The filter must be changed every 3 days, if it is required for a longer period. 6. In high-risk pregnancy the check for factors of thrombophilia is a basic diagnostic procedure.

[Comparison of Doppler ultrasound assessment of utero-placento-fetal perfusion in normal pregnancies and in those with threatened premature labor]. / Vergleich dopplersonographisch gemessener utero-plazentofetaler Perfusion zwischen normalen Schwangerschaften und solchen mit drohender Frühgeburt.

The aim this study to compare perfusion parameters, measured by Doppler sonography, between normal pregnancies and pregnancies with symptoms of preterm labor. The patient collective comprised of 3 groups: 62 normal pregnancies (group 1), 23 preterm labor before tocolysis (group 2) and 114 preterm labor up to 48 hours under tocolysis (group 3). In each case pulsatility index was measured in the uterine artery on the placental side and non-placental side, umbilical artery, fetal descending aorta and middle cerebral artery. In the contrary to patients in group 1, patients in group 2 and 3 showed significantly elevated PI values in uterine artery placental side and non-placental side, respectively. The median of PI for both uterine arteries in both groups was significantly higher compared to that of group 1. However, 1/3 of patients with preterm labor showed pathologic uterine perfusion before or during tocolysis. The values of PI in umbilical artery, fetal descending aorta and middle cerebral artery did not reveal significant difference in all group. Nevertheless, 30% of pregnancies with preterm labor have pathological perfusion in the fetal descending aorta. We conclude that some patients with symptoms of preterm labor have pathological perfusion in uterine arteries and fetal descending aorta not induced by uterine contractions. We believe that the complex assessment of uterine perfusion should include the median PI value of both uterine arteries in order to have a reliable information. A short-term intravenous tocolysis with betamimetics does not seem to have a positive influence on the hemodynamic insufficiency.

[Value of perinatal characteristics for diagnosis of perinatal infections]. / Wertigkeit perinataler Charakteristika für die Diagnostik perinataler Infektionen.

A retrospective case control study was performed in order to evaluate the diagnostic validity of clinical and paraclinical signs for early detection of neonatal sepsis. The perinatal data of 45 newborns with sepsis on day 1 or 2 (early perinatal sepsis) after birth were compared with those of 34 newborns with sepsis on day 3 and 4 (late perinatal sepsis) and with 87 newborns as controls. The groups were comparable in respect of birth weight (1,972-2,114 g), gestational age (33.3-33.5 weeks), gender (prevalence of male), frequency of prematures (82-91%) and mode of delivery. In cases of early perinatal sepsis a significant higher incidence of fetal tachycardia was found (heart rate > 160/min in 50% versus 5% in late perinatal sepsis and 8% in controls respectively), of reduced fetal heart oscillation (56% versus 14 and 38%) and of loss of acceleration (76% versus 56 and 20%) in the CTG ante partum. Therefore, these signs have proved to have a better diagnostic validity for infection than premature rupture of membranes, a prolonged rupture of membranes and the chorioamnionitis. Another predominant finding was the significant greater need for resuscitation due to asphyxia (48% in early sepsis versus 14 and 7%) despite missing differences in pH of blood in umbilical artery at birth (7.28 +/- 0.07). The occurrence of such signs supports a suspicion of a fetal sepsis.

[Rate of intrauterine growth retardation at the Leipzig Perinatal Center comparing the years 1982 to 1984 with 1987 to 1989]. / Hypotrophen-Rate am Leipziger Perinatalzentrum im Vergleich der Jahre 1982 bis 1984 und 1987 bis 1989.

Referring to the number of all live-born children, hypotrophic newborn (IUGR) were classified at the Centre for Perinatal Care in Leipzig into two periods of time. Based on the 5th Kyank-percentile 6.5% hypotrophic newborn were classified into period A (1982-1984) and 5.0% hypotrophic newborn were classified in period B (1987-1989). The proportion of hypotrophic newborn with a birth weight < 2500 g amounted to one quarter of all infants (except multiple birth) with low birth weight in period A and to one fifth (20.7%) in period B. The decrease in the rate of hypotrophy in these infants affected nearly exclusively the mature ones. The number of infants with extreme intra-uterine growth retardation amounted to 29% (99 in 329) in period A and to 24% (58 in 238) in period B. The rate of hypotrophy in stillbirths decreased from 44% to 33%. In this process the proportion of extremely hypotrophic stillbirths amounted to 47% in period A, whereas it decreased to only 26% in period B.

[Diagnosis and therapy of hemodynamic disorders. A contribution to the management of pregnancies with threatened premature labor]. / Diagnostik und Therapie gestörter Hämodynamik. Ein Beitrag zum Management bei Schwangerschaften mit drohender Frühgeburt.

114 pregnant women (without multiple pregnancies) with premature labour were examined in a randomized prospective study. Pulsatility index (PI) in the uterine artery and fetal thoracic aorta was the parameter we used for the examination, the determination of which was done with doppler sonography at the time of hospital admission. Therapy with beta-sympathomimetics alone or additionally either Oxygen inhalation therapy or transcutaneous dorsal nerve stimulation were conducted and the pulsatility index was controlled at intervals of one and two weeks after initiation of the aforementioned therapy. The negative correlations which we determined between pulsatility index and prolongation of duration of pregnancy, gestational age at the time of delivery and birth weight were significant. This confirms the clinical importance of maternal perfusion already at the time of admission for the clinical end-results. Similarly significantly negative correlations between pulsatility index of uterine vessels, weight percentile of the corresponding newborns and antenatal CTG scores (Fischer) verify the close connections between the hemodynamic, nutritional and respiratory partial functions of the fetoplacento-maternal unit. The clinical results after normalization of an impaired perfusion were found to be improved significantly after a combined therapy with beta-sympathomimetics and transcutaneous dorsal nerve stimulation (TNS) as compared with beta-sympathomimetic therapy alone. These results justify the recommendation that doppler sonographic measurements of utero-placental perfusion can be used for the diagnostic and therapeutic concept in pregnancies with premature labour.

[Effect of maternal oxygen inhalation on uterine and fetal circulation in intrauterine retardation and its prognostic value]. / Einfluss von mütterlicher Sauerstoff-Inhalation auf uterine und fetale Durchblutung bei intrauteriner Retardierung und ihr prognostischer Wert.

In 15 cases of singleton pregnancies with a sonographically supported diagnosis of intra-uterine growth retardation, the effects of maternal oxygen inhalation on uterine and feto-placental circulation have been investigated. For this purpose, the resistance and pulsitility indices (RI and PI) were measured in uterine artery placental site and uterine artery non-placental site, in the umbilical artery, in the descending thoracic aorta and in the median cerebral artery immediately before and after a half-hour oxygen inhalation in each of these IUR pregnancies. The median PI of uterine artery placental site decreased from 0.90 to 0.82 after oxygen inhalation, that of uterine artery non-placental site dropped significantly from 1.26 to 0.75 (p less than 0.05). The number of pathological findings in uterine artery non-placental site was significantly reduced (p less than 0.01). The median RI of the umbilical artery showed a minor decrease. Pathological perfusion in the umbilical artery was not noticeably affected either. The pathological median RI of the descending thoracic aorta was clearly reduced from 1.0 to 0.93. The median RI of the median cerebral artery showed a significant increase from 0.78 to 0.84 (p less than 0.05). The number of pathological findings was reduced by 50%. Compared with only two vessel indices (uterine artery non-placental site, umbilical artery) prior to oxygen inhalation, there was a significant correlation of all vessel indices with subsequent birth weight after oxygen inhalation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of the efforts in prenatal care for the prevention of prematurity]. / Bewertung von Bemühungen in der Schwangerenvorsorge um Prävention der Frühgeburtlichkeit.

A retrospective analysis was done in 341 singleton premature deliveries to assess the practised activities in antenatal care for the prevention of premature delivery. This analysis, expressed in terms of adequacy revealed that 56% were adequate whereas 23% were conditionally adequate and 21% were inadequate. Clinically these activities were reflected in suppression of uterine contractions (80%/57%/40%-effective tocolysis), achieved prolongation of pregnancy (25d/8d/2d) and a lowered rate of premature delivery before the 32nd week of gestation (17%/31%/33%), respectively. A prospective study depending on these results (n = 450) done in 4 centers for antenatal care (under constant supervision to keep the respective recommended activities) showed a significant reduction in the rate of premature delivery compared to a similar control group (n = 458) in the year 1988. Simultaneously, we could demonstrate the influence of patient explanation and the growing patient satisfaction which resulted in reduction of premature delivery.

[Effect of pregnancy and perinatal parameters--including mode of delivery--on survival rate of "low birth weight premature infants" (less than 1,500 g)]. / Der Einfluss von Schwangerschafts- und perinatologischen Parametern--einschliesslich Entbindungsmodus--auf die Uberlebensrate "kleiner Frühgeborener" (less than 1500 g).

A retrospective analysis of 225 very low birth weight infants (less than 1500 g) was made, to assess the influence of the mode of delivery on the survival rate. In 186 preterm deliveries which could not be prevented by therapeutic measures, we included additionally certain gestational and perinatological parameters. Generally, an average survival rate of 72% was found in this study. In addition to the well-known negative influence of birth weight less than 1000 g and gestational age of less than 28 weeks, such parameters as antenatal pre-pathological CTG findings, haemorrhages at the time of hospitalisation, and ineffectuousness of tocolytic drugs, were associated with a reduced survival rate. In contrast, the presence of anamnestic risk factors of preterm delivery and prolongation of gestation by one day and more improved the survival rate. Additional consideration of foetal presentation showed, that abdominal delivery was fundamentally safer in cases with breech and transverse presentation. Whether a higher survival rate can be achieved by vaginal delivery in cases of breech presentation with premature rupture of membranes or a gestational age greater or equal to 28 weeks, remains to be proved. A gestational age of less than 28 weeks or antenatal prepathological cardiotocographic findings will facilitate in future the decision to perform Cesarean section in cases of inevitable premature deliveries with cephalic presentation.

Doppler sonographic examinations of uteroplacental, fetoplacental, and fetal hemodynamics and their prognostic value in preterm labor.

Doppler examinations of different uteroplacental vessels (uterine arteries, arcuate arteries), umbilical artery, fetal thoracic aorta, and median cerebral artery were performed on 55 patients with idiopathic preterm labor (24.5 to 32.5 weeks). Thirty normal pregnancies of corresponding gestational age served as a control group. Significant differences of median values between the preterm labor and control group were found only for the resistance index (RI) in the central arcuate artery and for the pulsatility index (PI) in the fetal thoracic aorta. In about twenty percent of pregnancies in preterm labor, pathological values of RI and PI in uteroplacental and fetal vessels account for the presence of an impaired perfusion. Elevated PI in the uterine artery placental site and normal RI in the fetal thoracic aorta, correlate significantly to a shorter prolongation of pregnancy, lower gestational age on birth, and lower birth weight. The combination of these two blood flow indices (maternal PI greater than 0.90 and fetal RI less than 0.90) allow us to predict a preterm birth in a high percentage of cases (sensitivity 87.5%, specificity 100%, positive predictive value 100%, negative predictive value 93%).

[15 years Perinatal Center of the Leipzig University]. / 15 Jahre Perinatalzentrum der Universität Leipzig.

Report about experiences with developing a perinatal center step by step an the University of Leipzig, primarily directed to improve the results of premature labour, then expanded by intensive diagnostics and treatment and uniform documentation of all risk pregnancies. Perinatal and neonatal mortality decreases following this management.

[Reproducibility of the Doppler ultrasound blood flow profile of the umbilical artery with special reference to threatened premature labor]. / Reproduzierbarkeit dopplersonographischer Blutströmungsprofile der A. umbilicalis unter besonderer Berücksichtigung der drohenden Frühgeburt.

The reproducibility of Doppler blood velocity profiles of the umbilical arteries within the umbilical cord is a special problem because of the difficult separation and extreme torsion of both vessels. Resistance-(RI) and pulsatility index (PI) have been assessed on two different locations immediately one after the other in 90 pregnancies with signs for premature labor, including 16 cases with premature rupture of membrane. For comparison the same measurements have been performed in 33 normal pregnancies. There was a significant correlation between the first and second assessment. However, the correlation coefficients of cases with premature labor are lower than in normal pregnancy. This underlines the necessity of at least two repeated measurements for these patients with signs of premature labor.

[Fetal systolic time intervals in threatened premature labor and their relation to therapeutic efforts]. / Fetale systolische Zeitintervalle bei drohender Frühgeburt und deren Abhängigkeit von therapeutischen Bemühungen.

In a total of 113 single pregnancies we determined foetal systolic time intervals (pre-ejection period, left ventricular ejection time, a quotient of both) in order to investigate the impact of threatened premature labour and the different therapeutic regimen (betamimetics, maternal O2-inhalation, maternal transcutaneous dorsal nerve stimulation) on the myocardial performance capacity. Prolonged systolic time intervals (significant for pre-ejection period) in threatened premature labour (compared with control) supplement the concept of a chronic respiratory impairment of the foe-to-materno-placental relationships. Therapeutic prolongation of the pregnancy by betamimetics led to further impairment of the myocardial contractility while additional oxygen inhalation brought about a positive effect. As indicated by "no changes" after transcutaneous dorsal nerve stimulation, the decisive effect apparently seems not to be in the improvement of the uteroplacental perfusion but more on the direct influence of the raised O2-provision on the foetal myocardium. Non-demonstrable obvious relations to the cardiotocographic findings, such as to the postnatal evaluation criteria, speak against a serious threat to the foetus as the advantages of a reasonable prolongation of the gestational period by betamimetics preponderate. More than that the foetal myocardial impairments are to be favourably influenced by additional O2-therapy.

[Relation of uteroplacental hemodynamics and fetal respiratory behavior in pregnancy with threatened premature labor or intrauterine retardation]. / Beziehungen zwischen uteroplazentarer Hämodynamik und fetalem respiratorischem Verhalten bei Schwangerschaft mit drohender Frühgeburt oder intrauteriner Retardierung.

The results of uteroplacental hemodynamics obtained by nuclear medicine were correlated with the corresponding antepartal and intrapartal cardiotocographic findings in 52 patients with preterm labor and in 53 patients with intrauterine-growth-retarded fetuses. With the existence of continued disturbance in pregnancy the relationship between primary maternal hemodynamic disorders and decreased fetal respiratory performance is already evident antepartum and unambiguously intrapartum. The dependence of the antepartal cardiotocographic findings on therapeutical improvements in perfusion is of clinical relevance.

[Effects of early therapy with indomethacin on the manifestation of a persistent ductus arteriosus in extremely underweight premature infants]. / Auswirkungen einer Frühtherapie mit Indomethazin auf die Manifestation eines persistierenden Ductus arteriosus bei extrem untergewichtigen Frühgeborenen.

In a randomized study the effect of an early prophylactic indomethacin treatment on the incidence of the patent ductus arteriosus (PDA) in very low birth weight infants (VLBWI) and their postnatal course were investigated. 19 VLBWI (weight 1221 +/- 158 g, gestational age 28.2 +/- 1.3 weeks) received 0.2 mg/kg indomethacin 3 times p.o. in 12 h intervals beginning on the 3rd day of life. 22 VLBWI with comparable weight (1250 +/- 154 g, gestational age 28.4 +/- 1 weeks), mode of delivery and postnatal adaptation served as controls. PDA was diagnosed clinically and by a decreased ratio of the systolic time intervals preejection period (PEP)/left ventricular ejection time (LVET) less than 0.3. PDA were seen in 7 indomethacin treated VLBWI and in 13 newborns of the control group. A symptomatic PDA developed in 4 infants of the latter group only. The indomethacin group was characterized by an increased ratio PEP/LVET from day 3 to 5 as an evidence for a diminished ductal shunt. Their weight loss was 3% lower and they regained their birth weight 5 days earlier. Otherwise, there were no differences in mortality and morbidity. Despite the proven efficacy of an early indomethacin treatment its use is recommended only for infants with a high risk for a PDA substantiated by a low ratio PEP/LVET less than or equal to 0.24 at the 3rd day of life.

Erythromycin therapy for subclinical intrauterine infections in threatened preterm delivery--a preliminary report.

Evidence suggests that subclinical intrauterine infections which can be indicated by elevated maternal CRP-values may cause preterm labor and that Ureaplasma urealyticum might play a role in the pathogenesis of preterm delivery. Since these organisms are sensitive to erythromycin, 43 patients with threatened preterm labor were at the time of tocolysis treated with erythromycin, or placebo in a randomized study. Treatment with erythromycin resulted in a greater mean delay of delivery for 9 days than among the placebo-treated women. This effect is statistically significant in patients with intact membranes and cervical dilatation: in contrast to the placebo group these women achieved an increased delay of 23 days before delivering. Moreover, successful erythromycin treatment was significantly associated with the isolation of ureaplasmas from vaginal swabs. Our results emphasize that in cases with cervical dilatation, vaginal microorganisms, especially ureaplasmas, are more liely to ascend and might be involved in the initiation of preterm labor. Therefore, additional treatment with erythromycin was beneficial only in these women.

[Premature labor in gestosis]. / Frühgeburtlichkeit bei Gestose.

796 pregnancies complicated by preeclampsia and 1,299 pregnancies without toxemia of the years 1981 to 1985 have been compared with regard to prematurity. Prematurity rates were 12.4 respectively 13.8 per cent, hypotrophy rates were 20 resp. 13 per cent, acidosis morbidity was 75 resp. 20 per cent and Apgar values below 8 were 63 resp. 24 per cent. Morbidity rate of respiratory distress syndrome was 8 resp. 12 per cent, of sepsis 2 resp. 7 per cent, intrauterine death rate 5 resp. 2 per cent, but survival rate overall was 93 resp. 90 per cent. Prematurity was influenced by severity of preeclampsia, time of onset and prenatal care. Prolongation of pregnancy by tocolysis is possible principally, but influenced in its effect by maternal and fetal symptoms and the necessity of termination of pregnancy by these factors.