Doppler measurements in fetoplacental vessels after maternal betamethasone administration.

OBJECTIVE: To observe the influence of maternal betamethasone administration for fetal lung maturation on the arterial, venous and intracardiac blood flow of the fetus and the uterine arteries. METHODS: Twenty-seven women with singleton pregnancies were examined before the first, and 30 min and 8, 24, 48 and 72 h after the second of two single doses of 8 mg of betamethasone. We recorded blood flow velocity waveforms of the umbilical artery (UA), the middle cerebral artery, the uterine arteries, the ductus venosus, the inferior vena cava and the right hepatic vein, the pulmonary trunk, the ductus arteriosus and the right and left intraventricular inflow of the heart. RESULTS: The resistance index of the UA showed a significant transient decrease 30 min (p = 0.024) after the second betamethasone dose. The peak systolic velocity of the ductus arteriosus increased significantly 30 min after the 2nd dose (p = 0.009) and then returned to non-significant values. No significant change was observed in any of the other vessels. CONCLUSION: Betamethasone causes short-term changes in fetal blood flow. However, this effect seems to be mild and reversible and does not appear to contraindicate the use of corticosteroids to promote fetal lung maturation.

[Diagnosis of a Twin-Reversed-Arterial-Perfusion-Syndrome (TRAP) in the First Trimester of Pregnancy - Report on Two Cases]. / Diagnose eines Akardius-Akranius im ersten Trimenon der Schwangerschaft - Bericht von zwei Fällen.

The Twin-Reversed-Arterial-Perfusion-Syndrome (TRAP) is a rare complication of monocygotic multiple pregnancies. It is associated with a high perinatal mortality. One twin (recipient or acardius) is perfused by the other (donour) on the basis of vascular anastomoses. Several possible therapies have been suggested. One of them is the endoscopic laser coagulation of the umbilical artery. The success of this method seems to depend on an early diagnosis of TRAP in the first trimester, when no secondary complications are to be expected. We report the diagnosis of two cases of TRAP in the 12th gestational week by transvaginal ultrasound combined with colour and pulsed Doppler. The latter facilitates the differentiation of TRAP from other pathologic conditions or malformations as well as a detailed description of the blood flow in TRAP.

[Fetal hyperechogenic and cystic pulmonary masses: sonographic findings, antenatal management and outcome of 12 cases]. / Echogene und zystische Veränderungen in der fetalen Lunge: sonographische Befunde, pränatales Management und Outcome von zwölf Feten.

OBJECTIVE: Presentation of prenatal findings and postnatal outcome of cases with echogenic or cystic lesions of the lungs. Discussion of the prenatal diagnostic and clinical management. PATIENTS AND METHODS: Retrospective analysis of the antenatal sonographic findings, the management and outcome of 12 cases of fetal chest masses. RESULTS: The postnatal findings included cystic adenomatoid malformation of the lungs (CAML) (nine cases) and lung sequestration (LS) (one case). Five fetuses were observed up to term. Two of them underwent postnatal surgery and three fetuses revealed an antenatal decrease of the lesion. None of these surviving fetuses developed hydrops, but in three of them a mediastinal shift was seen. The other fetuses did not survive (termination of pregnancy: six cases, spontaneous fetal loss: one case). Four of them had bilateral solid lesions, hydrops or additional malformations. CONCLUSIONS: 1. Ultrasound evaluation of chest masses is useful in diagnosing of the type and the extent of the lesion, recognition of secondary alterations and exclusion of additional malformations. 2. Termination of pregnancy should be recommended in cases of hydrops that develops early in gestation, bilateral lesions with expected unfavourable outcome or life-threatening additional malformations. 3. Mediastinal shift does not seem to predict a poor perinatal outcome. 4. Spontaneous decrease of the size of the lesion is associated with a favourable outcome.

[Nitroglycerin patch for tocolysis--a prospective randomized comparison with fenoterol by infusion]. / Nitroglyzerinpflaster zur Tokolyse--ein prospektiv randomisierter Vergleich mit Fenoterol per infusionem.

OBJECTIVE: To evaluate tocolytic efficacy of transdermal glyceryl trinitrate (GTN) in comparison to fenoterol per infusionem in a prospective randomized multicenter study. PATIENTS AND METHODS: 50 pregnant women between 27 and 35 weeks of gestation with preterm labour were treated with either GTN patches (0.4-0.8 mg/h) or fenoterol per infusionem (60-120 micrograms/h) up to stop of contractions or 35 weeks in maximum. The primary outcomes were the prolongation of gestation by 48 h, 7 days or up to 37 weeks of gestation as well as the neonatal outcome. The progression of cervical ripening and maternal side effects during tocolysis were assessed as secondary outcome criteria. RESULTS: There was no difference in successful tocolysis for 48 h and 7 days in both groups, whereas significantly more women passed 37 weeks after GTN therapy. So mean duration of pregnancy, birth weight and height were greater, whereas transfer into neonatal care unit was significantly rare after GTN. There were no differences in neonatal outcome and progression of cervical ripening during tocolysis. Maternal side effects during GTN were fewer and weaker compared with fenoterol. Circa 70% of GTN treated women had a headache temporary, whereas more than 90% of the patients with fenoterol suffered from tachycardia and tremor. CONCLUSIONS: Tocolytic efficacy of transdermal GTN was at least equivalent to the established beta-mimetic therapy with fenoterol. Because of the lower preterm delivery rate transfer into neonatal care for control was significantly rarer after GTN with equally good neonatal outcome in both groups. Beside the headache transdermal GTN therapy had lower maternal side effects in comparison to fenoterol.

Signal analysis of auditory evoked cortical fields in fetal magnetoencephalography.

Magnetoencephalography (MEG) using auditory evoked cortical fields (AEF) is an absolutely non-invasive method of passive measurement which utilizes magnetic fields caused by specific cortical activity. By applying the exceptionally sensitive SQUID technology to record these fields of dipolar configuration produced by the fetal brain, MEG as an investigational tool could provide new insights into the development of the human brain in utero. The major constraint to this application is a very low signal-to-noise ratio (SNR) that has to be attributed to a variety of factors including the magnetic signals generated by the fetal and maternal hearts which inevitably obscure a straightforward signal analysis. By applying a new algorithm of specific heart artefact reduction based on the relative regularity of the heart signals, we were able to increase the chance of extracting a fetal AEF from the raw data by the means of averaging techniques and principle component analysis. Results from 27 pregnant, healthy women (third trimester of their uncomplicated pregnancy) indicate an improved detection rate and the reproducibility of the fetal MEG. We evaluate and discuss a-priori criteria for signal analyses which will enable us to systematically analyze additional limiting factors, to further enhance the efficiency of this method and to promote the assessment of its possible clinical value in the future.

The application of fetal magnetocardiography (FMCG) to investigate fetal arrhythmias and congenital heart defects (CHD).

OBJECTIVES: Fetal magnetocardiography (FMCG), a new non-invasive diagnostic tool in the analysis of the electrophysiological changes of the heart, was selectively applied in cases of fetal arrhythmias and congenital heart defect (CHD) to demonstrate its value for diagnosis and prenatal management. METHODS: The FMCG was analysed and compared to the postnatal ECG in four cases of fetal arrhythmia [supraventricular tachycardia (two cases), complex tachy-/bradycardia (one case), ventricular extrasystoles (one case)] and a case of right heart hypoplasia diagnosed by established methods prior to investigation. RESULTS: A Wolf-Parkinson-White (WPW) syndrome was diagnosed by its characteristic features and the appropriate transplacental therapy chosen. The types of arrhythmia could be characterised in accordance with postnatal ECG findings and irregular conduction was demonstrated in association with a CHD. CONCLUSIONS: The use of the FMCG provides additional information to the common diagnostic tools that influence therapeutic decisions and thus contributes to optimal pre- and postnatal management.

[The extralobar sequestration of the fetal lung]. / Die extralobare Sequestration einer fetalen Lunge.

The extralobar sequestration is a rare pulmonary malformation. An accurate antenatal evaluation is required for a timely therapy and subsequently a good outcome. Here an unusual case of extralobar pulmonary sequestration in a male human fetus is reported. Antenatal ultrasound at 28th week of gestation has revealed a fetal hydrothorax in coexistence with pulmonary hypoplasia and an isolated pulmonary structure. Authors summarise their postnatal findings with special reference to the pathogenesis of an accessory lung. The aim of this report is to define the association of clinical, gross, and histological features of this rare congential malformation in order to improve the antenatal diagnosis. This case indicates that an extralobar pulmonary sequester is not connected to the tracheobronchial tree, and that the arterial as well as the venous blood supply is realised by aberrant systemic vessels. Moreover, histologically revealed dilatations of the normally differentiated terminal airways within the sequester suggest that hyperechogenity can not be a reliable diagnostic criterion. For the accurate assessment of a pulmonary sequestration a detailed antenatal evaluation of both, the arterial and the venous blood supply is essential.

Fetal magnetoencephalography: a non-invasive method for the assessment of fetal neuronal maturation.

OBJECTIVE: To assess the maturation of auditory evoked cortical responses in the human fetus using fetal magnetoencephalography. DESIGN: Prospective case series over a three-year period. SETTING: Antenatal clinics, university hospital. POPULATION: Singleton pregnancies at 29-40 weeks of gestation. METHODS: We used a 31-channel-SQUID-biomagnetometer in a magnetically-shielded room to perform fetal magnetoencephalography. To record auditory evoked fields from the fetal brain we applied 500 monotonal bursts generated by a computerised sound generator directly to the maternal abdominal wall near the fetal head. The continuously recorded data sets were analysed stepwise using a specially developed heart artefact rejection software, Fourier filtering, principle component analysis and half split analysis of the averaged data. RESULTS: In 36 of 64 examinations we detected signals of auditory evoked fields comparable to the P2m component in adults. The earliest recording succeeded in the 29th gestational week. The latencies of the auditory evoked responses declined during the third trimester from 300 ms to nearly 150 ms at term. The maturation of different components of the auditory evoked field could be demonstrated from the 31st gestational week onwards. CONCLUSION: The maturation of a fetal auditory cortical function using fetal magnetoencephalography could be assessed directly for the first time. We believe that this method will add information to current indirect methods of assessing the normal maturation of the human fetal brain.

[Concentration of heavy metals (Pb, Cd, Hg) in maternal blood]. / Untersuchungen zu Schwermetallkonzentrationen (Pb, Cd, Hg) im Blut bei Wöchnerinnen.

BACKGROUND: It was the aim of these investigations to find out, whether or not pregnancy risks result from the heavy metal concentrations of the mother's blood (Pb, Cd, Hg). MATERIALS AND METHODS: The control group is composed of 125 women in child bed. Women with hypertonia during the pregnancy (n = 11), women after premature delivery (n = 25) and after a miscarriage (n = 21) are the risk collective. Blood: The investigations were carried out in EDTA-blood. Questionnaire: Place of residence, profession, nourishment and tooth amalgam surface. From this we received information about risk factors for a heavy metal burden. METHODS: The Cd- and Pb-concentrations were measured by "Graphitrohr-AAS with Zeemancorrection" and the Hg-concentration by "Cold-Vapour-AAS". RESULTS: 1. Women in child bed in the Jena area have a heavy metal concentration of Pb, Cd and Hg in the lower reference range. 2. At the risk pregnancies (hypertonia during the pregnancy, premature delivery and miscarriage) no increased heavy metal burden was found. 3. There was a significant correlation between the blood mercury level of women in child bed and the number of tooth amalgam fillings. DISCUSSION: In the Jena area women in child bed have a heavy metal concentration in the lower reference range. Environmental heavy metal burden producing frequent miscarriage, premature delivery and hypertonias in the pregnancy could not be shown. The tooth amalgam filling significantly increased the Hg-burden. Environmental stress and eating habits may also play a role. CONCLUSION: At the risk pregnancies (hypertonia during the pregnancy, premature delivery and miscarriage) no increased heavy metal burden was found.

[Acoustically evoked brain magnetic activity in normal and growth retarded fetuses during the third trimester of pregnancy]. / Akustisch ausgelöste hirnmagnetische Aktivitäten bei normotrophen und wachstumsretardierten Feten im III. Trimenon der Schwangerschaft.

The fetal magnetoencephalogram with a 31 chanal biomagnetometer made by Philips was measured in a fetal 1F-phase in 20 normotroph unimpaired and in 14 growth retarded fetuses with a birth weight < 5 percentile after completed 36th gestational week. Trough defined acoustic stimulations, which were applied over the maternal abdominal wall, it was possible to measure acoustic evoked cerebromagnetic field changes using a special computer programs. The registrated evoked cerebromagnetic field changes had a latence time of 112.8 +/- 18.4 ms in normotroph fetuses and 130.9 +/- 18.5 ms in hypotroph fetuses. The difference was significant (p < 0.01). The presented results lead to the conclusions that the fetal magnetoencephalography makes a differentiation between normal and disturbed fetal cerebral integrity possible.

[Levels of antioxidants after cesarean section and administration of Multibionta N, Inzolen and selenase]. / Das Verhalten von Antioxidanzien nach Schnittentbindung und Substitution von Multibionta N, Inzolen und selenase.

PATIENTS AND METHOD: In 29 women with the necessity to terminate pregnancy via Cesarean section, lipid peroxidation and antioxidative state were investigated before and 24 hours after the surgical intervention as well as after substitution of antioxidants and trace elements. RESULTS: The results indicate that administration of antioxidants protects at least partially from consequences of surgically induced oxidative burden.

Insulin-like growth factor I correlations to changes of the hormonal status in puberty and age.

IGF-I is considered to be one of the most important growth factors during puberty. Information concerning its correlation to thyroid hormones (T3, T4), adrenal and sex steroids is limited to puberty and the elderly. The presented study included 455 subjects (among them 259 children) ranging in age from newborn to 100 years. Serum IGF-I concentrations increase from childhood to the end of puberty (2 years earlier in girls). There are close positive correlations between IGF-I concentrations and age, height and weight and between IGF-I and estradiol or testosterone concentration in girls and boys respectively, and the DHEA-S level in boys during puberty. Correlations also exist with T3, aldosterone and 17 OH-progesterone in boys and girls in the pubertal stages I-V and with T4 in stages I-IV. Compared to 20-30 year-old subjects IGF-I concentrations amounted to 59% after 60 years, 43% in men and 54% in women after 70 years and 29% after 90 years. It is suggested that increasing adrenal DHEA-S concentrations stimulate IGF-I synthesis and by means of gonadal steroidogenesis, increase the pubertal GH secretion and the further pubertal IGF-I increase. The low IGF-I concentrations in patients > 60 years reflect the more catabolic metabolism of the elderly.

[Fetal movement and acceleration behavior in hypertension in pregnancy]. / Fetales Bewegungs- und Akzelerationsverhalten bei Schwangerschaftshypertonie.

Under standardized conditions, 26 pregnant women with pregnancy-related hypertension of different degrees were submitted to cardiogram-synchronous recording of fetal body and respiratory movements. The gestational age was between the completed 34th and 38th weeks. Of the 26 fetuses of the risk group, 20 were normotrophic and 6 hypotrophic. 40 normotrophic unimpaired fetuses of the same gestational age served as a control group. The average duration of the examination period was 70 minutes. The fetal movement and acceleration behaviours did not differ between the normotrophic fetuses of the risk group and those of the control group. The hypotrophic fetuses from the risk group, however, had significantly lower fetal body and respiratory activities than the normotrophic fetuses from this group. The same holds true for the degrees of heart rate activity. It can be concluded that pregnancy-related hypertension as the only pregnancy complication does not have a measurable influence on fetal movement and acceleration behaviours. This is true for both treated and untreated pregnancy-related hypertensions. The severity of pregnancy-related hypertension is not primarily reflected in changes of fetal movement and acceleration behaviours, either. This means that the parameters presented are not suited to prognosticate the effects of pregnancy-related hypertension on the fetus a priori. The situation becomes quite different if in addition to pregnancy-related hypertension some intrauterine fetal growth retardation develops. In this case, the fetus indicates its impairment by increasingly impaired movement and heart rate activities as a consequence of chronic oxygen deficiency.

[Fetal movement and acceleration behavior in unimpaired and impaired newborn infants]. / Fetales Bewegungs- und Akzelerationsverhalten unbeeinträchtigter und beeinträchtigter Neugeborener.

The following biophysical examination parameters were found by CTG-synchronous registration of fetal body and respiratory movements and compared in 7 fetuses impaired at birth (pHa less than 7.20, 1- and 5-minute Apgar scores less than or equal to 7 points) and 76 unimpaired born fetuses (pHa greater than or equal to 7.20, 1- and 5-minute Apgar scores greater than or equal to 8 points): number of fetal body movements per 10 minutes examination time; total and mean durations of these movements per 10 minutes; number of fetal respiratory movements per 10 minutes; number and total duration of fetal respiratory movement periods per 10 minutes; frequency of fetal respiratory movements; proportion of 10-minute periods with and without fetal body and/or respiratory movements and the amounts of the quotients from the amplitude of accelerations in fetal heart rate resulting from fetal body movements and the durations of these body movements. The mean interval between biophysical examination and childbirth was 11 days. Principally, the impaired born fetuses were less active in their movements than were unimpaired born fetuses. Apart from the frequency of fetal respiratory movements and the proportion of 10-minute periods without fetal body movements, the above mentioned parameters differ significantly with a probable error of alpha = 0.05. All biophysical parameters were registered on an uterus without labour and the cardiogram as well as the biophysical profile--with the exception of one fetus from the group of impaired borns--being unremarkable. The 10-minute periods without fetal body or respiratory movements were excluded from analysis.

[Correlation of the magnitude of fetal movement associated fetal heart rate accelerations, amplitude of "classical" accelerations and transcutaneous fetal oxygen partial pressure]. / Der Zusammenhang zwischen der Grösse kindsbewegungsassoziierter fetaler Herzfrequenzakzelerationen, der Amplitude "klassischer" Akzelerationen und dem transcutanen fetalen Sauerstoffpartialdruck.

An attempt is made to provide non-empirical evidence of the "classical" amplitude of sporadic fetal heart rate accelerations of 15 bpm. Sporadic, fetal movement associated fetal heart rate accelerations are generally regarded as an indication of fetal wellbeing. A minimal amplitude of 15 bpm with unknown duration of the associated fetal body movement seems to be a prerequisite to establish an unimpaired fetal condition as reliably as possible. Including the "classical" acceleration amplitude in a ratio from the acceleration amplitude and associated fetal body movement and comparison of these calculated values with a total of 3851 actual ration from acceleration amplitudes and durations of associated body movements of 175 normotrophic and 72 hypotrophic fetuses showed that only a hypothetical acceleration amplitude of 15 bpm yields ratios which correspond to the actual values of unimpaired fetuses. There is a significant positive correlation between the actual ration and the transcutaneous basal fetal partial pressure of oxygen during birth.

[Movement and acceleration behavior of eutrophic and hypotrophic fetuses sub partu]. / Bewegungs- und Akzelerationsverhalten eutropher und hypotropher Feten sub partu.

Cardiogram synchronous registration of fetal body and respiratory movements (real-time ultrasonic examination) was employed to compare the movement and acceleration behaviour of 130 normotrophic fetuses to that of 13 fetuses with body weights between the 6th and the 10th weight percentiles according to Kyank and of 13 fetuses with body weights less than or equal to the 5th percentile. The mean duration of examination was 80 minutes. The normotrophic fetuses exhibited the highest movement activity and reactivity of the cardiovascular system. In 88.6%, accelerations of fetal heart rate were associated with fetal body movements and were independent of fetal weight. Comparison with a previous communication of the authors revealed that intranatal fetal movement activity and reactivity of the cardiovascular system were only slightly below that with a uterus without labour. The only exception were fetal respiratory movements with significantly fewer intranasal observations.

[The extent of fetal heart rate accelerations associated with fetal body movements in relation to the duration of fetal body movement]. / Der Umfang der in Verbindung mit fetalen Körperbewegungen auftretenden fetalen Herzfrequenzakzelerationen in Abhängigkeit von der fetalen Körperbewegungsdauer.

The temporal relations between fetal body movements and associated fetal heart rate accelerations were shown as the ratios of duration of acceleration or acceleration amplitude and the duration of associated fetal body movements in 44 normotrophic and 40 hypotrophic fetuses (body weights within the 6th to 10th percentiles, n = 19, and less than or equal to the 5th percentile, n = 21) between the 36th and 40th gestational weeks. Related to the duration of associated fetal body movements, hypotrophic fetuses proved to have gradually smaller heart rate accelerations than normotrophic fetuses. Moreover, the acceleration parameters duration and amplitude were dependent on the relative duration of fetal body movements. Short fetal body movements were accompanied by fetal heart rate accelerations of relatively highest degree and vice versa. As a consequence, no comparison is possible between temporally different fetal body movements and their associated heart rate accelerations. Of the two acceleration parameters duration and amplitude, the inclusion of the accelerations amplitude in the above mentioned ratio yielded the most obvious results. Taking into consideration that fetuses with intrauterine growth retardation are often in a state of chronic hypoxia, the ratios of acceleration amplitude and durations of associated fetal body movements indicated different degrees of this metabolic situation.

[Movement and heart acceleration behavior of eutrophic fetuses in the early and late dilatation period]. / Bewegungs- und Akzelerationsverhalten eutropher Feten in der frühen und späten Eröffnungsperiode.

The degree of fetal respiratory and body movements as well as of fetal heart rate reactivity was checked by synchronous ultrasonic and cardiographic monitoring of 18 normotrophic fetuses in the early and late dilation period. Apart from the fetal respiratory movements, which could no longer be observed in the late dilatation period, the degree of fetal body movements remained unaffected during the birth process. In the late dilatation period, the mean amplitude of heart rate accelerations occurring in association with fetal body movements was significantly lower than in the early dilatation period. In the unimpaired normotrophic fetus, however, the reactivity of the fetal cardiovascular system increased during the birth process in relation to the ratio of the amplitude of heart rate accelerations and the duration of associated fetal body movements. Hence, a decrease in fetal heart rate reactivity signals intranatal disturbance of the materno-utero-placento-fetal entity.