Posterior sacculation of the uterus in a patient presenting with flank pain at 29 weeks of gestation.

BACKGROUND: Uterine sacculation is a rare complication of pregnancy and may cause substantial peripartal morbidity. CASE: A possible diagnosis of posterior uterine sacculation was raised when a 34-year-old Gravida 1 Para 1 presented with bilateral flank pain at 29 weeks. Sonographic and magnetic resonance imaging findings confirmed the diagnosis and demonstrated bilateral dilated renal pelvises. Bilateral nephrostomas were placed, offering the patient considerable relief. A healthy female newborn was delivered by cesarean at 34 1/7 weeks. Operative findings confirmed the posterior sacculation of the uterus. CONCLUSION: Early diagnosis of sacculation of the uterus is necessary to limit maternal and fetal morbidity and mortality. For a detailed evaluation of the pelvic anatomy, we recommend the use of magnetic resonance imaging in the third trimester.

Ductus venosus blood flow velocity characteristics of fetuses with single umbilical artery.

OBJECTIVES: Sonographic Doppler evaluation of the fetal ductus venosus has been proved to be useful in the evaluation of fetal cardiac function. The aim of this study was to investigate the ductus venosus blood flow profile in fetuses with single umbilical artery and to correlate it with the umbilical cord morphology. METHODS: Fetuses at >20 weeks' gestation with single umbilical artery who were otherwise healthy were consecutively enrolled into the study. The sonographic examination included evaluation of the following Doppler parameters: umbilical artery resistance index, maximum blood flow velocity of the ductus venosus during ventricular systole (S-peak) and atrial contraction (A-wave), ductus venosus time-averaged maximum velocity (TAMXV), and pulsatility index for veins (PIV). The cross-sectional area of the umbilical cord and its vessels were measured in all cases. The Doppler and morphometric values obtained were plotted on reference ranges. RESULTS: A total of 88 fetuses with single umbilical artery were scanned during the study period. Of these 52 met the inclusion criteria. The S-peak velocity, A-wave velocity, and TAMXV were below the 5th centile for gestational age in 57.7%, 59.6%, and 57.7% of cases, respectively. The PIV was within the normal range in 80.1% of cases. The umbilical vein cross-sectional area of fetuses with single umbilical artery was above the 95th centile for gestational age in 34.6% cases. CONCLUSIONS: The ductus venosus blood flow pattern is different in fetuses with single umbilical artery from that in those with a three-vessel cord. This difference may be caused in part by the particular morphology of umbilical cords with a single artery.

[Diabetes mellitus and pregnancy: screening and therapy]. / Diabetes mellitus und Schwangerschaft: Screening und Therapie.

There are two entities to differentiate: 1. Diabetes in pregnancy (pre-existent type 1 or type 2 diabetes with tendency of deterioration during pregnancy or first occurrence of a type 1 or type 2 diabetes with persistence after pregnancy. 2. Impaired Glucose Tolerance = IGT (Diagnosis of an impairment of glucose tolerance during pregnancy) Aims of the screening are the avoidance of complications for mother and child. There is no uniform consent regarding screening during pregnancy. With pregnant women without risk factors, the blood sugar is determined without eating and drinking in plasma between 24 and 28 weeks of gestation. If values are > 4.8 mmol/l, an oral 75 g glucose tolerance test is carried out. Alternatively, a 50 g oral glucose tolerance test can be made. With pregnant women with risk factors, we already carry out an oral 75 g glucose tolerance test in the first trimester. If the values are normal, we repeat the 75 g glucose tolerance test between 24 and 28 weeks of gestation. Main pillars of therapy are diet and movement. In gestational diabetes, an insulin therapy is indicated if blood sugars are too high, fetal growth is sonographically accelerated or a polyhydramnion is present. Oral antidiabetic medicaments are contraindicated during pregnancy. Pregnancies with diabetes in pregnancy or gestational diabetes are risk pregnancies, which are controlled more intensively. Delivery is ideally at term or with confirmed lung maturity. If an impaired glucose tolerance is diagnosed during pregnancy, an oral 75 g glucose tolerance test as well as annually blood sugar controls are carried out because of the augmented risk of developing a type 2 diabetes later in life.

Single and multiple umbilical cord cysts in early gestation: two different entities.

OBJECTIVE: To investigate the prevalence of single and multiple umbilical cord cysts in the first trimester and to assess whether there is a difference in the pregnancy outcome between them. METHODS: A targeted sonographic morphological and morphometric evaluation of the umbilical cord was performed in consecutive patients between 7 and 14 weeks of gestation. Crown-rump length and umbilical cord diameter were measured in all cases. Nuchal translucency thickness was measured between 11 and 14 weeks' gestation. In pregnancies at very early gestational ages (7-10 weeks) an additional scan was performed between 11 and 14 weeks. RESULTS: A total of 1159 patients was screened. The prevalence of umbilical cord cysts was 2.1% (24/1159). The cysts were single and multiple in 18 and six cases, respectively. The median (range) largest umbilical cord cyst diameter was no different between multiple and single umbilical cord cysts (3.8 (2.1-18) mm vs. 3.05 (2.0-7.8) mm; P = 0.386). All women with a single umbilical cord cyst delivered an infant without structural abnormalities and without features suggestive of chromosomal abnormalities. Among the women with multiple umbilical cord cysts, four had a missed miscarriage and one had a fetus with obstructive uropathy. CONCLUSION: Single and multiple umbilical cord cysts in the first trimester of gestation represent two different entities. While single cysts in the first trimester are associated with a favorable pregnancy outcome, the presence of multiple umbilical cord cysts is associated with an increased risk of miscarriage and aneuploidy.

In-utero characterization of the blood flow in the Hyrtl anastomosis.

An anastomosis between the two umbilical arteries, located approximately within 3 cm from the placental insertion, has been previously described at delivery and in utero. However, the prenatal investigation of the Hyrtl anastomosis is limited to case reports. We report a series of antenatal functional evaluations of this vessel. Forty-one women underwent a target ultrasonography to evaluate the blood flow characteristics of the Hyrtl anastomosis. The resistance index of the anastomosis and the umbilical arteries resistance indices before and after the anastomosis were obtained. The direction of the blood flow in the anastomosis was determined by color Doppler evaluation. An anastomosis between the two stems of the umbilical arteries was present in 36 cases while a fusion of the two umbilical arteries was found in the remaining five cases. The median (range) gestational age at diagnosis was 33.1 weeks (25.5-40.1). The median diameter of the anastomosis was 2.3 mm (1.3-7.1). The blood flow in the anastomosis was pulsatile with a median resistance index of 0.62 (0.45-0.85) and unidirectional toward the umbilical artery with lower resistance index. The difference between the resistance indices of the two umbilical arteries was higher after than before the anastomosis [0.07 (0-0.3) versus 0.04 (0-0.17), P=0.05]. The median diameter of the Hyrtl anastomosis was significantly higher when the anastomosis was oblique (n=8) than when it was transverse (n=28) (4.8 mm [2-7.1] versus 2.3 mm [1.3-5.3], P< 0.05). In three out of the five cases with fusion of the two umbilical arteries the placental insertion was marginal or velamentous. We conclude that the Hyrtl anastomosis may act as a pressure-equalizing system between umbilical arteries. This supports the hypothesis that the Hyrtl anastomosis plays an important role when the placental territories supplied by the umbilical arteries are different in size.

[Hypertensive disorders in pregnancy]. / Hypertensive Schwangerschaftserkrankungen.

Hypertension in pregnancy is defined by a systolic blood pressure > or = 140 mm Hg and a diastolic blood pressure of > or = 90 mm Hg or by a rise in blood pressure of systolic > or = 30 mm Hg and diastolic > or = 15 mm Hg. High blood pressures are found in 5-10% of all pregnancies. The outcome of pregnancy is influenced by the fact whether there occurs a proteinuria in addition to hypertension. While the prognosis of an isolated hypotension is good, the combination of hypertension and proteinuria leading to preeclampsia is the primary cause of maternal death in many countries and is responsible for 20-25% of perinatal mortality. A simple classification divides between chronic hypertension, preeclampsia, preeclampsia superimposed on chronic hypertension and transient hypertension. With chronic hypertension pregnancy outcome is determined by a preexisting nephropathy and the occurrence of a superimposed preeclampsia. Preeclampsia and superimposed preeclampsia are pregnancy induced multiorganic diseases, endangering both the mother and the fetus. Transient hypertension is a benign pathology, which occurs toward the end of pregnancy usually on the basis of a latent essential hypertension, which is laid open through pregnancy. While a severe chronic hypertension in pregnancy must be treated to prevent a hypertensive maternal encephalopathy, a less severe chronic hypertension should not be treated as the risk of a superimposed preeclampsia and the maternal and fetal outcome cannot be influenced by antihypertensive therapy. The incidence of preeclampsia is 3-5% in nulliparae and 0.5% in multiparae. Preeclampsia is a severe and dangerous pathology with an unknown etiology. Pregnancy termination is the only causal therapy. At present it is still recommended to terminate a severe preeclampsia after stabilizing the mother, irrespective of gestational age. In less severe preeclampsia occurring before 32 weeks of gestation, termination of pregnancy can be postponed under intensive monitoring and a prophylaxis with magnesium sulfate in order to accelerate the fetal lung maturation with glucocorticoids. A conservative management in the case of a HELLP-syndrome (Haemolyis, Elevated Liver enzymes, Low Platelets), which is a very severe form of preeclampsia, is not recommended because it hasn't been validated in prospective controlled studies. The most dangerous complication of preeclampsia is eclampsia, which is defined by general tonic-clonic convulsions before or after birth. The most effective prophylaxis of eclamptic attacks is the intravenous therapy with magnesium sulfate. A primary prohylaxis for preeclampsia doesn't exist. Treatment with low-dose aspirin in high-risk patients, i.e. after a severe preeclampsia, in cases of chronic hypertension, in cases of nephropathy and in cases with antiphospholipid-syndrome++ can be recommended. The prophylactic use of low-dose heparin, which has lead to a significant decreased incidence of preeclampsia in retrospective analysis, is now the object of a randomized, controlled trial in our hospital. All women who suffered from a preeclampsia should have a check-up after 3-6 months. Preexisting pathologies are found in up to 40% of patients, mostly in multiparae, i.e. chronic hypertension, nephropathy, endocrine pathologies, anomalies of blood coagulation and antiphospolipid-syndrome.

Perinatal ultrasonography and magnetic resonance imaging findings in congenital hydrocephalus associated with fetal intraventricular hemorrhage.

OBJECTIVE: We present the case histories of three premature infants with congenital posthemorrhagic hydrocephalus. STUDY DESIGN: The timing of the lesion was monitored in utero in two of the three cases. Magnetic resonance imaging studies (prenatal in one case, within 24 hours of birth in all three cases) established the duration of the lesions and thereby added to the ultrasonographic findings. RESULTS: All three patients demonstrated a similar pattern of lesions, consisting of (1) unilateral germinal matrix hemorrhage with cystic resorption, (2) residual blood in the cerebrospinal fluid with a "granular" ependymal reaction, (3) asymmetric ventriculomegaly predominating on the side of the hemorrhage with mild atrophy and periventricular cysts, and (4) partial hypoplasia of the ipsilateral thalamus. On the basis of two cases in which information about the pregnancy was available and in which fetal oligohydramnios without ruptured membranes was detected, we assume that this pattern of lesions may have resulted from a hypoxic-ischemic episode followed by intraventricular hemorrhage. CONCLUSIONS: Because these three infants with congenital hydrocephalus were born during a period of only 18 months in a perinatal center serving a region with 16,000 live births per year, we speculate that a posthemorrhagic cause for congenital hydrocephalus underestimated.

Cardiac arrhythmias mimicking primary neurological disorders: a difficult diagnostic situation.

Cardiac arrhythmias can present with the signs and symptoms of a seizure disorder. This potentially life-threatening underlying cause of non-febrile seizures should be recognized early, since successful specific treatment is possible. The purpose of this retrospective study was to examine common features in such patients. Over a period of 25 years, eight patients were initially treated for up to 5 years at our institution for a seizure disorder until dysrhythmia as the underlying cause of the seizures was disclosed. The main symptom was drop attacks coinciding with physical activity or emotional stress. Convulsions were only rarely observed. In five of the eight patients the underlying disorder was the long-QT-syndrome (Romano-Ward syndrome). In one patient intermittent complete atrioventricular block was found, another patient showed ventricular tachydysrhythmia of unknown etiology and the last patient suffered from hypertrophic cardiomyopathy.

[Induction of labor with a new intracervically administered prostaglandin E2 gel. Report of initial experience]. / Geburtseinleitung mit einem neuen intrazervikal applizierbaren Prostaglandin E2-Gel. Ein erster Erfahrungsbericht.

We report on our experience with the induction of labour using 0.5 mg of prostaglandin E2 gel (Cerviprost, Organon) intracervically. Out of 43 cases, 27 were primiparae. Indication for induction was: 10 post-term pregnancies, 9 PROM's > 24h, 12 foetal and 11 maternal indications. Mean Bishop score before induction was 3.1 and 9 hours later or at the beginning of regular contractions 6.7. In 9 of the 43 cases induction was unsuccessful. There were 23 spontaneous vaginal deliveries, 6 forceps and 5 Caesarean sections. Uterine hyperstimulation was found in 6 cases, 5 of which occurred during the first 16 inductions, and only one was seen during the following 27. A possible reason may be unrecognised extra-amniotic application of the gel. Intracervical prostaglandin seems to be an appropriate method not only for cervical ripening but also for induction of labour in cases with a low Bishop score. Although side effects are rare, sufficient monitoring and control of mother and foetus are mandatory.

Fetal ventriculomegaly due to isolated brain malformations.

Management of 32 consecutive cases of fetal hydrocephalus diagnosed prenatally during a five years period is presented. Thirteen cases (40%) being patients with ventriculomegaly due to isolated brain malformation are the topic of this paper. In this group, management was conservative and consisted of termination of pregnancy by elective cesarean section after prenatal fetal assessment. Agenesis of corpus callosum (6 cases) and Dandy-Walker malformation (7 cases) were the most common observed forms. Antenatal sonography improved intrauterine follow-up. Skillful perinatal management and support facilities after birth have been found a reliable approach to conservative management of fetal hydrocephalus by lacking of satisfactory techniques for in utero permanent cerebrospinal fluid shunting.

[Diagnosis of malignant tumors of the uterus by transabdominal ultrasonography: a utopia?]. / Diagnostik maligner Tumoren des Uterus durch transabdominale Sonographie: Eine Utopie?

Two hundred non-pregnant women with suspected uterine disease were included in a prospective study designed to assess the accuracy of sonography in conforming or excluding the presence of uterine cancer. All patients were operated on and the preoperative sonographic findings were compared with the final histological diagnosis. The predictive value of sonographic evidence of malignancy was 43.9% (18/41), the predictive value of benign disease was 94.8% (147/155). Sensitivity was 66.7% (18/27) and specificity 85% (147/173). The sonographic detection of uterine cancer is in need of improvement. At present it cannot be used as a substitute of invasive diagnostic tools in patients with suspected uterine cancer.