[What doe the obstetrician expect of the anesthetist?]. / Was erwartet der Geburtshelfer vom Anästhesisten?

The obstetrician's expectations of anaesthetists are high and include a high level of competence at a specialist level, experience of the delivery room, a calm but fast and ordered way of working, a tactful and enquiring approach and the ability to work in an interdisciplinary environment. In the area of organisation the obstetrician and the anaesthetist should, through optimal cooperation, have a good understanding of the procedural plan to ensure the safety of mother and child. This includes working in close proximity, regular joint consultations and early preinterventional contact with the pregnant patient in order to inform them of the anaesthetic options and their inherent risks. Despite the undoubted successes resulting from the cooperation between obstetricians and anaesthetists, as shown by the reduction in mother and child mortality rates, the current structured and medical circumstances are not optimal and should motivate both disciplines towards improved joint care.

[Uterine leiomyosarcoma with subsequent pregnancy]. / Uterine Leiomyosarkome mit nachfolgender Schwangerschaft.

Leiomyosarcoma are malignant tumors showing smooth muscle differentiation, they are rare, representing only about 25 percent of all uterine sarcomas and mixed malignant tumors and slightly more than 1 percent of all corporeal malignant tumors. Usually they arise in postmenopausal women and are not known to be related to the known risk factors for endometrial carcinoma (nulliparity, obesity, diabetes mellitus, hypertension, etc.) or carcinosarcoma (prior radiation therapy). They may occur in uteri that also bear typical benign leiomyomas, but leiomyosarcoma rarely can be proven to have arisen in or from benign leiomyomas. We report on two premenopausal women with leiomyosarcoma--out of totally 31 cases in our clinic from 1975-1995 who got pregnant after surgical treatment preserving the uterus. The patients are alive without evidence of disease 3 and 6 years after surgical resection.

[Status epilepticus late in pregnancy--eclampsia or subarachnoid hemorrhage?]. / Status epilepticus in der Spätschwangerschaft--Eklampsie oder Subarachnoidalblutung?

After a largely inconspicuous pregnancy, a 31-year old primipara suffered from a status epilepticus in the third trimenon. The convulsions could not be terminated by emergency medical services, resulting in aspiration of gastric contents. Assuming eclampsia, an emergency caesarean section was performed immediately in a central hospital. Postoperatively, a pathological pattern of tendon reflexes was noticed. A CT scan revealed subarachnoid haemorrhage. The causal aneurysm of the right A. pericallosa was clipped subsequently. Eclampsia is the leading cause of epileptic seizures during pregnancy. However, a different aetiology should always be considered, especially if medical history does not reveal symptoms of pre-eclampsia.

High-order harmonics from solid targets as a probe for high-density plasmas.

The interaction of 100-fs Ti:sapphire laser pulses with thin foil targets was experimentally investigated at intensities exceeding 10(18) W/cm(2). High harmonics were observed in transmission through an overdense plasma in the direction of the incident beam. From the cutoff frequency of the harmonics an electron density of 1 x 10(24) cm(-3) is inferred, indicating a compression of the plasma by the ponderomotive force of the laser pulse.

Twin pregnancies with single fetal death.

OBJECTIVE: Analysis of the fetal outcome of the surviving twin and the cause of fetal death. PATIENTS: Between January 1979 and December 1992, 43 twin pregnancies with single fetal death were observed: in 11 cases (group I) before 16 weeks of gestation, in 11 cases (group II) between 17 and 24 weeks, and in 21 cases (group III) after 24 weeks of gestation. RESULTS: The pregnancies in group I continued without complication. In groups II and III the incidence of preterm delivery was 50%, of cesarean section 59%, of growth retardation of the surviving twin 22% and perinatal mortality was 13%. Twenty-five (78%) of the surviving twins had a normal postnatal development and one (3%) was handicapped. CONCLUSION: Loss of one of the twins in the first trimester does not impair the development of the surviving fetus. In the second trimester however this even is associated with increased risk for the survivor as reflected by a high incidence of growth retardation, premature labor and perinatal mortality.

[Value of high resolution sonography in breast cancer screening]. / Einsatz der hochauflösenden Sonographie zur Brustkrebsvorsorge.

Breast ultrasound has mainly been used for differentiation of cystic and solid lesions. With high resolution technique, which was introduced several years ago, early cancers can now be detected by ultrasound. In this study, 1016 women were examined within 3 months. Mammography was used independently. According to the expected prevalence, 4 nonpalpable carcinomas were detected by sonography. The study proves that high-quality ultrasound equipment allows a primary detection of subclinical breast cancers. In premenopausal patients the sensitivity of mammography is reduced. Therefore, ultrasound should be used complementary to mammography in this age group. Widespread use is not possible due to a deficiency in experienced staff. However, in experienced centres, ultrasound could be used as a supplement to mammographic screening to prove if breast cancer mortality in premenopausal women can be reduced.

[The normal vascularization of the female breast in Doppler ultrasound]. / Untersuchungen zur normalen Vaskularisation der weiblichen Brust durch Doppler-Ultraschall.

Specific Doppler-Ultrasound methods for the differentiation of benign and malignant lesions by measurement of abnormal flow, have been known for more than 10 years. We used this method also in many patients without pathological breast problems and found a high physiological variation of blood flow. As basic definition of normal flow, to be compared with patients under medical treatment of mastopathy, we studied flow variations during menstrual cycles in normal volunteers. In both breasts we measured the amount of vessels, average frequency shifts according to flow velocity and the sum of all Doppler shifts, as measurement of the overall vascularity. Between different individuals the range of Doppler shifts was between 500 and 1000 Hz. However, in individual subjects the variation was only between 50-200 Hz, average 100 Hz. We also found between contralateral breasts no remarkable difference in vascularity. Flow increased at the 10th day after onset of menstruation, in 9 cycles with ovulation and in 8 cycles with a lack of gestagen production. Dramatic flow increase occurred in one early pregnancy. It appears that influences of drugs can be controlled, after basic measurements of individual vascularity.

[Therapy of hypotension in pregnancy using norfenefrine hydrochloride with special reference to the effects on fetal circulation--initial observations]. / Therapie der Hypotonie in der Schwangerschaft mit Norfenefrinhydrochlorid unter besonderer Berücksichtigung der Auswirkungen auf den fetalen Kreislauf--erste Beobachtungen.

Hypotension in pregnancy represents an often underestimated danger for mother and fetus. Several investigators have described an increased incidence of miscarriages, premature delivery and small for date babies. In a first study 10 pregnant women with hypotension and severe orthostatic dysregulation were treated with norfenefrine hydrochloride (3 x 45 mg p. os/day). To investigate the effects of this therapy we monitored maternal blood pressure, subjective well being, CTG and furthermore fetal circulation by using pulsed doppler sonography. An average 4.2 days of treatment were required for complete alleviation of symptoms. Blood flow volume and resistance-index were determined for the fetal aorta descendens, and were found to be the same as in normal pregnancies. In addition no difference in fetal outcome was seen and there was no occurrence of premature contractions.

Pathophysiology of polyhydramnios in twin transfusion syndrome.

In 3 cases of severe twin transfusion syndrome we demonstrate that the concentration of atrial natriuretic factor (ANF) in the cord blood of recipient twins is significantly elevated compared to that of donor twins. The discrepancy between recipient and donor concentration correlates with the volume of transfusion. The following pathophysiological mechanism for explaining polyhydramnios in recipient twins is proposed: chronic overload in recipient twins causes enhanced release of ANF from the fetal heart. Consequently, increased fetal urine production leads to polyhydramnios, which is additionally enhanced by inhibition of ADH release.

[Ultrasound biometry of the fetal heart]. / Sonographische Biometrie des fetalen Herzens.

We report on biometric measurements of the fetal heart with the TM-technique; these measurements were carried out between the 20th and 40th gestational week. The right and left endsystolic atrial and ventricular diameters were, measured, as well as the diameters of the large vessels, i.e. aorta and pulmonary artery; finally, the septal thickness was determined. Our measurements show a linear progression of the diameters in question, the right-left ratio of the atria and ventricles was close to one, so was the ratio between aorta and pulmonary artery. Our results are compared, as far as possible, to the literature.

[Sonographic biometry of fetal organs]. / Sonographische Biometrie fetaler Organe.

Over a period of 18 months measurements of fetal Organs (cornu anterius of the lateral ventricle, medium diameter of the four-chamber-view of the heart, transverse diameter of lungs, stomach, gall bladder, colon and urinary bladder) were carried out in a population of 223 normal pregnancies. The measurements were correlated to the age of pregnancy and sonographic growth parameters (biparietal diameter--BPD, mean cephalic diameter--MCD, mean abdominal diameter--MAD). The results show different growth velocities of the particular organs, obviously depending on physiological function. The variability is increasing with fetal growth. We found no fundamental difference as far as correlation of organ measurements to age of pregnancy, to BPD, MCD or MAD. In summary the imaging and biometries of the fetal organs appear to be possible in relatively little time and such is a valuable method for the detection of fetal anomalies.

[Semiquantitative determination of the amniotic fluid volume in normal pregnancies]. / Semiquantitative Fruchtwassermengenbestimmung bei normalen Schwangerschaften.

The amount of amniotic fluid was determined semiquantitatively in 600 pregnancies between the 12th and 41st week of gestation. Pregnancies at risk were excluded. The largest amniotic fluid area was measured sonographically in two dimensions. The mean plus/minus standard deviations are correlated with gestational age. A diagram has been prepared. Our results show good correlation with values from invasive quantitative examinations of amniotic fluid amount. However, our procedure is easy to perform and without hazard for the pregnancy, since it is non-invasive.

Fetal urinary tract obstructions: prenatal diagnosis--prenatal and postnatal therapy.

A retrospective study was conducted comprising 78 cases of fetal urinary tract obstructions diagnosed by ultrasound. Thirteen of the obstructions were subvesical and 65 supravesical. In only one fetus with a subvesical obstruction leading to megacystis was a puncture of the fetal bladder performed--in the 17th week of gestation--resulting in restitution of the bladder to its normal size. In all of the remaining fetuses the kidneys, lungs, and bladder changes had already reached an advanced stage by the time the ultrasound diagnosis was made. In the 65 fetuses with supravesical urinary tract obstructions in utero puncture to relieve a rapidly developing hydronephrosis only seemed advisable in two cases. All of the prenatal diagnoses were confirmed postpartum with the exception of two Potter IIa kidneys, which had been interpreted as being hydronephrosis. The time and method of postnatal management are described. The results of the study indicate that in utero intervention is only indicated in the very rare case. Nearly all of the supravesical obstructions remained unchanged, some even for months. In these cases there was no evidence of cystic-dysplastic renal changes after delivery.

Continuous-wave and pulsed Doppler studies of the breast: clinical results and effect of transducer frequency.

Malignant growth requires a high metabolism. This allows the differentiation of lesions by Doppler measurements of their vascularisation. In this study of 224 patients with 45 malignancies (37 breast cancers and 8 local recurrences), 87% of the cases were correctly identified. Differentiation of palpable lesions was possible in 93%. The flow in normal breast arteries was studied as well as in carcinomas, comparing continuous-wave (CW) Doppler with frequencies at 4 and 8 MHz. To improve flow evaluations in nonpalpable lesions, pulsed Doppler was used at 3 MHz and color mapping systems at 5 MHz in another 37 patients. Color Doppler at 5 MHz identified 17 of the 21 malignancies; in all cases pulsed Doppler at 3 MHz failed.

[Fetal complete heart block with myocarditis and maternal SS-A-/AA-B/antibodies]. / Fetaler kompletter Herzblock und Myokarditis bei mütterlichen SS-A-/SS-B-Antikörpern.

We report on a newborn with fetal acquired heart block (CHB). CHB is a rare, irreversible defect, commonly occurring in conjunction with myocarditis in the neonatal lupus syndrome. Development of CHB is strongly associated with maternal anti-SS-A(Ro)/SS-B(La) antibodies. Intrauterine therapy of CHB is not possible. Concomitant myocarditis, however, can be treated effectively with dexamethasone. Mothers with an elevated risk of fetal CHB can be identified by their history (underlying systemic connective tissue disease, previous pregnancies with CHB), an immunogenetic predisposition (HLA-DR3) and analysis of the SS-A/SS-B antibody pattern. In these pregnancies prevention of CHB with plasmapheresis plus dexamethasone during pregnancy may be possible.

[Prognosis of triplet pregnancies]. / Prognose von Drillingsschwangerschaften.

31 triplet pregnancies (DG), treated during 1975-1989, were analysed retrospectively. 13 DG (D10) were registered up to the end of the 10th week of pregnancy, 16 (DG) (D16) were intact between the 11th and the 16th gestational week. 3 DG resulted from the reduction of high grade multiple pregnancies. 18 DG (62%) of the initial 29 DG had previously been treated for sterility. The spontaneous foetal loss (DF) in group D10, including the perinatal mortality, amounted to 26% (10 of 39 DF). In one case of this group, a previously vital DF died. In another case, a partial bi-phasic abortion occurred followed by a premature birth of the surviving 3rd DF. The mortality rate in group D16, including the perinatal mortality (4 DF), was 25% (12 of 48 DF). 30 DG were still intact after the 16th week of pregnancy. 2 DG (7%) suffered from EPH-gestosis. In 4 DG (13%) a foeto-foetal transfusion syndrome occurred. 5 DF (6%) had some of the serious malformations. 27 DG were completed. 7 DG (26%) ended before the 32nd gestational week. In 13 DG (48%), a Caesarean section was performed. The perinatal mortality amounted to 11% (9 of the 81 DF) including all the births from the 25th gestational week upwards. On comparing these results with the data in the literature, a significant improvement in the prognosis of DG in recent years can be observed. This is due to the progress in antenatal and neonatal care.

[Analysis of a method for Doppler study of the female breast]. / Methodenanalyse zur Doppleruntersuchung der weiblichen Brust.

Besides characteristic morphological differences, carcinomas of the breast show remarkable changes of vascularity, which are essential for their enhanced metabolism. High-frequency CW Doppler allows to investigate normal and pathological vascularisation in the breast. In our basic study we examined 200 patients, 37 with breast malignancies (6 non-palpable lesions). 33 of the carcinomas showed pathological vascularisation. In an extended examination procedure we investigated also normal breast vascularisation and compared it with blood flow in lesions. We developed therefrom an easy and rational method which allows physiological blood flow measurements as well as a differentiation of breast lesions within a few minutes' time.

[The Arabin cerclage pessary--an alternative to surgical cerclage]. / Das Arabin-Cerclage-Pessar--Eine Alternative zur operativen Cerclage.

During 1986-1988, the Arabin-cerclage pessary was used alternatively to surgical cerclage in 58 patients for prophylactic and in 44 cases of therapeutic indications. In 5 additional patients, the pessary was applied instead of emergency cerclage. The advantages of the cerclage pessary compared to other rigid pessary types, are based on its flexibility and adjustment to the anatomic conditions of vagina and cervix. The bowl-shaped pessary is inserted with the curvature upwards and the cervix is fixed in the central opening of the cerclage pessary. Thus a constriction, reconfiguration, and elongation of the incompetent cervix is obtained as evidenced by ultrasonography. The only side effect of the pessary treatment is an increase in cervical secretion and subsequent vaginal discharge. No infectious complications occurred. In 92% of the treated gravidae the cerclage pessary could be removed after the 36th week of gestation. Cerclage pessary can be recommended as a favourable alternative to surgical procedures as prophylactic or therapeutic approach, reducing surgical treatment significantly to less than 0.5%.

[Differential breast diagnosis using CW-Doppler ultrasound]. / Differenzierte Mammadiagnostik durch CW-Doppler-Ultraschall.

There is no method that allows satisfactory differentiation between benign and malignant breast lesions. We were able to differentiate 94% of palpable malignant tumours with CW-doppler ultrasound, which helps to increase the efficiency of clinical examinations, breast sonography and mammography. Two hundred patients were examined with an 8 MHz CW-doppler probe. The symmetry of arterial vessels and flow velocity in normal breasts is very high. Carcinomas appear as areas with localized flow increase. Only in two normal patients was a minimal focus of two arteries found.

[Prenatal diagnosis of Pena-Shokeir syndrome in the 27th week of pregnancy]. / Pränataldiagnostik des Pena-Shokeir-Syndroms in der 27. Schwangerschaftswoche.

We report on the prenatal diagnosis of a Pena-Shokeir syndrome sporadic case of the 27th week of pregnancy. Typical sonographical features are polyhydramnios, hypoplasia of lungs, foetal akinesia, reduced length of proximal and distal extremities and a striking discrepancy between biparietal and abdominal diameter. Differential diagnosis of polyhydramnios caused by foetal neuromuscular disorders is discussed.