The effectiveness of an oral opioid rescue medication algorithm for postoperative pain management compared to PCIA : A cohort analysis.

BACKGROUND: Standard protocols or algorithms are considered essential to ensure adequate analgesia. Germany has widely adopted postoperative protocols for pain management including oral opioids for rescue medication, but the effectiveness of such protocols has only been evaluated longitudinally in a before and after setting. The aim of this cohort analysis was to compare the effectiveness of an oral opioid rescue medication algorithm for postoperative management of pain to the gold standard of patient-controlled intravenous analgesia (PCIA). MATERIAL AND METHODS: This study compared cohorts of patients of two prospective observational studies undergoing elective total hip replacement. After surgery patients received piritramide to achieve a pain score of ≤3 on the numeric rating scale (NRS 0-10). A protocol was started consisting of oral long-acting oxycodone and ibuprofen (basic analgesia). Cohort 1 (C1, 126 patients) additionally received an oral opioid rescue medication (hydromorphone) when reporting pain >3 on the NRS. Cohort 2 (C2, 88 patients) was provided with an opioid by PCIA (piritramide) for opioid rescue medication. Primary endpoints were pain intensity at rest, during movement, and maximum pain intensity within the first 24 h postoperative. Secondary endpoints were opioid consumption, functional outcome and patient satisfaction with pain management. RESULTS: Pain during movement and maximum pain intensity were higher in C1 compared to C2: pain on movement median 1st-3rd quartile: 6 (3.75-8) vs. 5 (3-7), p = 0.023; maximum pain intensity: 7 (5-9) vs. 5 (3-8), p = 0.008. There were no differences in pain intensity at rest or between women and men in either group. The mean opioid consumption in all patients (combined PACU, baseline, and rescue medication; mean ± SD mg ME) was 126.6 ± 51.8 mg oral ME (median 120 (87.47-154.25) mg ME). Total opioid consumption was lower in C1 than C2 (117 ± 46 mg vs 140 ± 56 mg, p = 0.002) due to differences in rescue opioids (C1: 57 ± 37 mg ME, C2: 73 ± 43 mg ME, p = 0.006, Z = -2.730). Basic analgesia opioid use was comparable (C1: 54 ± 31 mg ME, C2: 60 ± 36 mg ME, p = 0.288, Z = -1.063). There were no differences in respect to the addition of non-opioids and reported quality of mobilization, sleep, frequency of nausea and vomiting, or general satisfaction with pain management. CONCLUSION: In this study PCIA provided a better reduction of pain intensity, when compared to a standardized protocol with oral opioid rescue medication. This effect was associated with increased opioid consumption. There were no differences in frequencies of opioid side effects. This study was a retrospective analysis of two cohorts of a major project. As with all retrospective studies, our analysis has several limitations to consider. Data can only represent the observation of clinical practice. It cannot reflect the quality of a statement of a randomized controlled trial. Observational studies do not permit conclusions on causal relationships.

Morbidity, fertility and pregnancy outcomes after myoma enucleation by laparoscopy versus laparotomy.

OBJECTIVES: Myomas are defined as benign tumours that arise from smooth muscle cells of the uterus. Clinically, they are found in 5-77% of women of reproductive age. The prevalence rate varies considerably in the literature and a large number of fibroids do not cause symptoms. The lifetime risk of acquiring myomas is 70% for Caucasian women and ≥ 80% for African American women. MATERIALS/METHODS: The data of 265 patients undergoing surgery for symptomatic myomas by laparoscopy or laparotomy, performed in the gynaecological department of Hannover Medical School, Hannover, Germany, between 2009 and 2013, were retrospectively analysed in this retrospective design study. RESULTS: High pregnancy rates (up to 70%) and birth rates (up to 86%) after myomectomy, regardless of the surgical approach adopted, were found in the current study. The trend was that ≥ 3 myomas and those that were ≥ 6 cm in size were almost always removed by laparotomy in our clinic. It was possible to remove up to 42 myomas without having to perform a hysterectomy. A statistically significant negative correlation was observed in relation to the association between the size of the largest myoma extracted and the pregnancy rate (p = 0.02). A statistically significant correlation between the number of removed myomas and the pregnancy rate was observed for patients who wished to bear children (p = 0.010). Elevated complication rates (of up to 50%) were reported for more than three extracted myomas with a statistically significance (p = 0.0471). CONCLUSIONS: It is necessary to ensure sound preoperative selection of the surgical approach in order to achieve the most optimal results, especially for those patients who wished to bear children.

Background Knowledge and Attitude of Pregnant Women towards Ultrasound Screening at 20-23 Weeks Gestation.

BACKGROUND: Prenatal ultrasound screening in the second trimester is widely used in maternal health care. Prenatal diagnosis and prenatal screening is often exposed to several accusation, such as inducing unnecessary anxiety, carrying out a selection and forcing pregnant women into attending ultrasound screening. The aim of this study was to investigate the knowledge and the intention of pregnant women attending the second trimester ultrasound screening. PATIENTS AND METHODS: This was a prospective study. Women attending the 20 weeks anomaly scan were given an anonymous questionnaire to evaluate the background knowledge about the anomaly scan and their opinion about prenatal screening. RESULTS: 600 (96.7%) of 620 recruited women filled in the questionnaire completely. To the majority (>80%) of women it is important to exclude severe fetal anomalies and to secure normal fetal growth. The background knowledge of the women was good, but a clear supply of information and a detail counselling would improve the understanding, especially in the group of lower education. The majority of the women stated that the 20 weeks anomaly scan should be offered to every woman. CONCLUSION: Prenatal ultrasound examination is not only essential from a medical point of view for example for important information regarding the status of the fetus, but also has a major impact as a positive psychological factor for pregnant women.

Attitude toward, acceptance of and knowledge about female sterilization as a method of contraception.

OBJECTIVE: Surgical sterilization via tubal ligation or the disconnection of the tubes is a method of permanent contraception. The aim of this study was to evaluate the attitude, acceptance and knowledge of women about female sterilization as a method of contraception in terms of the social and cultural backgrounds of those women. STUDY DESIGN: Prospective study based on an anonymous questionnaire that analyzed background knowledge, attitude, influence factors and motivation regarding sterilization, as well as the reasons for declining. The questionnaire also attempted to evaluate the effects on the self-esteem of the women, as well as the impact of religious dogma and the related beliefs. RESULTS: One thousand, eight hundred questionnaires were distributed, and 1247 women completed the questionnaire­a response rate of 69.3%. There were mainly positive attitudes toward sterilization as a contraceptive method. Cultural background, including religion and faith; the mother's experiences and point of view; knowledge; family planning and the actual life situation have an influence on the attitudes toward and acceptance of sterilization as a contraceptive method and on the final choice of a contraceptive method. CONCLUSION: Cultural background and present life situation have a great impact on the attitude toward and acceptance of sterilization as a method of contraception, thus influencing the final choice of a contraceptive method. Detailed counselling about this topic is essential and should be improved.

A mixture model of nuchal translucency thickness in screening for chromosomal defects: validation of a single operator dataset.

OBJECTIVE: (1) To validate the mixture model in a single operator dataset and (2) to compare the detection rates for fetal chromosomal defects obtained from the mixture model with those obtained from either the delta nuchal translucency (NT) or log multiple of the median (MoM) approach. METHODS: Database query, viable singletons [crown-rump length (CRL) 45-84 mm corresponding to 11-13(+6) weeks], December 1997 to November 2006, examined by Adam Gasiorek-Wiens, the statistical mixture model was applied. RESULTS: Seventy-four of 4171 were lost to follow-up (1.8%), 4097 singleton pregnancies included trisomy 21 (n = 34, 0.8%), trisomy 18 (n = 20, 0.5%), trisomy 13 (n = 8, 0.2%), Turner syndrome (n = 9, 0.2%) and other chromosomal abnormalities (n = 14, 0.3%). The main findings are that (1) the log-transformed NT measurements follow a mixture of two Gaussian distributions and (2) the criteria to apply either the delta-NT or log MoM models are not met. In the normal group, the majority of NT measurements were dependent on the CRL, a small group showed a median independent of the CRL. In the abnormal group it was the opposite. For a 5% false-positive rate (FPR), the trisomy 21 detection rate was 83%. CONCLUSIONS: The use of the mixture model in a single operator dataset produces results compatible with the original study. The mixture model has thus been validated.

The 11-13-week scan: diagnosis and outcome of holoprosencephaly, exomphalos and megacystis.

OBJECTIVE: To determine the prevalence and outcome of fetuses with holoprosencephaly, exomphalos and megacystis diagnosed at 11-13 weeks of gestation. METHODS: As part of a prospective screening study for trisomy 21 in singleton pregnancies at 11 + 0 to 13 + 6 weeks' gestation, transabdominal ultrasound examination was performed to diagnose holoprosencephaly, exomphalos and megacystis. Fetal karyotype and pregnancy outcome in fetuses with these defects were examined. RESULTS: Screening was carried out in 57 119 pregnancies. The prevalence of holoprosencephaly, exomphalos and megacystis was 1 : 1298, 1 : 381 and 1 : 1632, respectively. Chromosomal abnormalities, mainly trisomies 18 and 13, were found in 65.9% of fetuses with holoprosencephaly, in 55.3% with exomphalos and in 31.4% with megacystis. There was spontaneous resolution of the defect by 20 weeks in 92.5% of euploid fetuses with exomphalos containing only bowel and in 90% of the euploid fetuses with megacystis and bladder length of < or = 15 mm. CONCLUSIONS: A high proportion of fetuses with holoprosencephaly, exomphalos and megacystis diagnosed at 11-13 weeks of gestation are aneuploid, but in the majority of cases exomphalos and megacystis represent temporary abnormalities that resolve spontaneously.

Isolated single umbilical artery and fetal karyotype.

OBJECTIVE: To determine the need for fetal karyotyping in cases of an isolated single umbilical artery (SUA) identified during the second-trimester routine anomaly scan. METHODS: All patients booked for antenatal care and delivery in our hospital are offered two ultrasound scans in pregnancy, one at 11-13 weeks' gestation as part of screening for chromosomal defects and another at 20-23 weeks for detailed fetal examination. In addition we examine patients referred from other hospitals because of suspected fetal abnormalities during their routine second-trimester scan. We performed a search of the database to retrieve all cases with an SUA and reviewed the ultrasound findings, fetal karyotype and pregnancy outcome. RESULTS: There were 643 cases with SUA, including 424 (65.9%) where the condition was isolated, 133 (20.7%) with one major fetal defect and 86 (13.4%) with multiple defects. The incidence of chromosomal abnormalities was 0% in the isolated SUA group, 3.7% in those with one defect and 50.7% in those with multiple defects. The commonest chromosomal abnormalities were trisomy 18, trisomy 13 and triploidy, which together accounted for 82.9% of cases. CONCLUSION: The finding of an SUA should prompt the sonographer to search for fetal defects and if these are found the risk for chromosomal abnormalities is increased. In cases of apparently isolated SUA there is no evidence of increased risk of chromosomal abnormalities.

Two-stage first-trimester screening for trisomy 21 by ultrasound assessment and biochemical testing.

OBJECTIVES: This study was carried out to examine the performance of a contingent policy in first-trimester screening for trisomy 21, in which the estimated risk was first derived by a combination of maternal age, fetal nuchal translucency (NT) thickness, presence/absence of the nasal bone, blood flow in the ductus venosus or flow across the tricuspid valve, and biochemical testing was carried out only in those who were found to have an intermediate risk. We also examined the performance of a policy in which the estimated risk was first derived by a combination of maternal age and biochemical testing, and ultrasound examination was carried out only in those with an intermediate risk. METHODS: The data for this study were derived from prospective screening for trisomy 21 in singleton pregnancies, using, as markers, a combination of maternal age, fetal NT thickness and maternal-serum free ß-human chorionic gonadotropin (ß-hCG) and pregnancy-associated plasma protein-A (PAPP-A), in a one-stop clinic for first-trimester assessment of risk at 11 + 0 to 13 + 6 weeks of gestation. Assessment of the fetal nasal bone, ductus venosus flow and tricuspid flow were also routinely performed by appropriately trained sonographers. The performance of different screening policies was examined. RESULTS: The study population consisted of 19 614 pregnancies with a normal karyotype or delivery of a phenotypically normal baby (euploid group) and 122 cases of trisomy 21. The best performance was achieved by a contingent policy in which first-stage screening was based on maternal age, fetal NT thickness and either tricuspid valve or ductus venosus blood flow, followed by biochemical testing only those with an intermediate risk, of 1 in 51 to 1 in 1000 (which constituted about 20% of the total). The performance of contingent screening in which first-stage testing relies on biochemistry was poorer than when first-stage screening was performed by ultrasound examination because, in order to achieve the same detection rate, the false-positive rate was twice as high. CONCLUSION: Effective first-trimester screening for trisomy 21 can be achieved by a contingent policy in which first-stage testing is based on ultrasound examination and second-stage biochemical testing is carried out in only 20% of the patients.

Early vaginal bleeding has no impact on markers used in first trimester aneuploidy screening.

OBJECTIVE: To assess the impact of early vaginal bleeding on the levels of markers used in first trimester screening for aneuploidy. METHODS: A retrospective analysis was carried out on the free beta human chorionic gonadotrophin (beta-hCG) and pregnancy associated plasma protein-A (PAPP-A) levels and nuchal translucency thickness in 49 653 women with a normal singleton fetus who had first trimester combined screening for Down Syndrome in three centres. Median MoMs and the distribution of log MoMs of the two markers were compared in two groups-7470 women who self-reported vaginal bleeding and 42 183 women who reported no vaginal bleeding at any stage prior to the screening test. RESULTS: The overall median MoM free beta-hCG and that in the bleeding and non-bleeding group were 0.9854, 1.0012 and 0.9832, and for PAPP-A were 1.0407, 1.0413 and 1.037. There was no significant difference between the bleeding and non-bleeding group by median test (p = 0.080) or by t-test comparing log MoMs (p = 0.1305) for free beta-hCG and for PAPP-A with median test (p = 0.5071) or by t-test comparing log MoMs (p = 0.1740). For delta nuchal translucency (NT) there was also no significant difference between the bleeding and non-bleeding group (p = 0.055). CONCLUSION: Vaginal bleeding has little or no impact on first trimester marker levels and no correction is necessary.

First trimester aneuploidy screening in the presence of a vanishing twin: implications for maternal serum markers.

OBJECTIVE: To assess the impact of a vanishing twin on the levels of the biochemical markers used in the first trimester aneuploidy screening. METHODS: A retrospective analysis of free beta-hCG and PAPP-A levels in 270 women with a normal singleton fetus with ultrasound evidence of a vanishing twin pregnancy. Marker levels (as MoM) were compared in three groups-76 women with a second empty gestational sac, 194 women with a second gestational sac containing a dead fetus with a measurable crown rump length (CRL), and 1360 matched singleton pregnancies. RESULTS: In women with a second empty gestational sac, the median free beta-hCG and PAPP-A MoMs (0.968 and 1.040, respectively) were not significantly different from the 1.0 MoM in singleton pregnancies. In the group with a vanished twin with a measurable-CRL-there was a significantly increased median PAPP-A MoM (1.317) but the median free beta-hCG MoM was not changed (1.024). Modelling this bias in PAPP-A MoM the detection rate for trisomy 21 would fall from 85 to 75%. CONCLUSION: First trimester screening in the presence of a vanishing twin may lead to errors in risk estimation. In such circumstances it may be advisable to restrict screening to the use of nuchal translucency (NT) alone.

Hypertensive disorders in pregnancy: screening by uterine artery Doppler at 11-13 weeks.

OBJECTIVES: To examine the performance of screening for hypertensive disorders in pregnancy by a combination of the maternal factor-derived a-priori risk with the uterine artery (UtA) pulsatility index (PI) and to determine whether it is best in such screening to use the mean PI of the two arteries, the highest PI or the lowest PI. METHODS: This was a prospective screening study for pre-eclampsia (PE) requiring delivery before 34 weeks (early PE), late PE and gestational hypertension (GH) in women attending their routine first hospital visit in pregnancy at 11 + 0 to 13 + 6 weeks of gestation. Maternal history was recorded and color flow Doppler imaging was used to measure the left and right UtA-PI. The performance of screening for PE and GH by a combination of the maternal factor-derived a-priori risks determined in a previous study and the UtA-PI was assessed. RESULTS: There were 8061 (96.4%) cases unaffected by PE or GH, 37 (0.4%) that developed early PE, 128 (1.5%) with late PE and 140 (1.7%) with GH. The lowest, mean and highest UtA-PI were significantly higher in early PE and late PE than in the controls (P < 0.0001) and in early PE than late PE (P < 0.0001). The lowest UtA-PI was higher in GH than in controls (P = 0.014). The best performance in screening was provided by the lowest PI. The detection rate of early PE at a 10% false-positive rate increased from 47% in screening by maternal factors alone to 81% in screening by maternal factors and the lowest UtA-PI. The respective detection rates for late PE increased from 41% to 45% and those for GH increased from 31% to 35%. CONCLUSIONS: The patient-specific risk for PE and GH can be derived by combining the disease-specific maternal factor-derived a-priori risk with the measurement of the lowest UtA-PI in a multivariate regression model.

Fetal nasal bone in screening for trisomies 21, 18 and 13 and Turner syndrome at 11-13 weeks of gestation.

OBJECTIVE: To investigate the performance of first-trimester screening for aneuploidies by including assessment of the fetal nasal bone in the combined test of maternal age, fetal nuchal translucency (NT) thickness, fetal heart rate (FHR) and serum free beta-human chorionic gonadotropin (beta-hCG) and pregnancy-associated plasma protein-A (PAPP-A). METHODS: Screening by the combined test was performed in singleton pregnancies, including 19,614 with euploid fetuses, 122 with trisomy 21, 36 with trisomy 18, 20 with trisomy 13 and eight with Turner syndrome. In all cases the fetal nasal bone was assessed and classified as present or absent. We examined the performance of two screening strategies: firstly, assessment of the nasal bone in all patients and secondly, first-stage screening using the combined test in all patients followed by second-stage assessment of the nasal bone only in those with an intermediate risk of 1 in 51 to 1 in 1000 after the first stage. To validate the new risk algorithm we used a second independent dataset of 19 651 fetuses, including 139 with trisomy 21. RESULTS: The nasal bone was absent in 2.6% of the euploid fetuses, 59.8% with trisomy 21, 52.8% with trisomy 18, 45.0% with trisomy 13 and in none of the fetuses with Turner syndrome. Respective figures for an absent nasal bone in the validation population, which contained fewer Black women, were 0.6%, 62.6%, 55.3%, 35.3% and 41.7%. In a screening policy based on maternal age, fetal NT, FHR, serum free beta-hCG and PAPP-A, for a fixed risk cut-off of 1 : 100, the false-positive rate was 3.0%. The standardized detection rates were 91% for trisomy 21 and 100% for trisomy 18, trisomy 13 and Turner syndrome, respectively. Assessment of the nasal bone in all pregnancies reduced the false-positive rate to 2.5% without changing the detection rate. A detection rate of 93% was achieved with the two-stage strategy at a false-positive rate of 2.4% in which it was necessary to assess the nasal bone in only 15% of the total population. In the validation dataset, screening by the combined test and using a risk cut-off of 1 : 100 detected 90% of the cases with trisomy 21 for a false-positive rate of 4%. Inclusion of the nasal bone increased the detection rate to 92% for a false-positive rate of 2.9%. Contingent screening detected 92% of cases for a false-positive rate of 2.9%. CONCLUSIONS: Assessment of the fetal nasal bone improves the performance of first-trimester screening for trisomy 21.

Heterotopic pregnancy: simultaneous intrauterine and ectopic pregnancy following IVF treatment with the birth of a healthy child.

Although spontaneous simultaneous intrauterine and ectopic pregnancy was an extremely rare event in the past, it is increasingly being diagnosed since the rate of assisted reproduction technique (ART) gestations increased. Due to the serious consequences, delayed diagnosis should be prevented in order to salvage the viable intrauterine fetus and avoid maternal morbidity and mortality. This case report demonstrates that the pitfalls of the diagnosis of heterotopic pregnancy make early diagnosis difficult and the prevention of heterotopic pregnancies by single embryo transfer should be continuously discussed. The role of high resolution ultrasound scans and the importance of close monitoring of early pregnancies following ART are emphasized because early diagnosis of heterotopic pregnancy results in a similar perinatal outcome as singleton pregnancies.

Interobserver variability of the measurement of fetal nasal bone length between 11+0 and 13+6 gestation weeks among experienced and inexperienced sonographers.

PURPOSE: Examination of fetal nasal bone (NB) by ultrasound between 11 + 0 and 13 + 6 gestation weeks has been proposed as an additional tool in the detection of trisomy 21 and therefore its application and implementation are used in a broad range. The study aimed at evaluating the interobserver feasibility of the measurement of fetal nasal bone length in comparison with experienced and inexperienced sonographers. MATERIALS AND METHODS: The study population was comprised of women who chose to have first trimester screening (FTS) at the Fetal Medicine Unit of the University Medical School of Hannover. Two experienced (> 400 FTS examinations, sonographer 1 and 2) and one inexperienced sonographer (95 FTS examinations, sonographer 3) were asked to measure the nasal bone length consecutively and independently of each other. Statistical analysis was performed for any differences and variations in the results. RESULTS: The fetal profile was examined in 220 cases. The median nasal bone length by sonographer one was 2.4 cm, sonographer two 2.4 cm and sonographer three 2 cm. The differences between the results of sonographer 1 and 3 as well 2 and 3 were statistically significant. There were no significant variations between the results of sonographer 1 and 2. There was also no significant difference in the results concerning nuchal translucency and crown-rump length among the three examiners. CONCLUSION: The uncertainty and the difficulties of an inexperienced examiner with the presenting of the nasal bone, as shown by published data sets as well as by the variability of the measurement results of this study, with all the consequences in the risk calculation and counseling show that this tool should only be implemented by experienced and quality-controlled sonographers with a minimum amount of examinations. Because of its major impact in risk calculation and the importance of the nasal bone as a sonographic marker, documentation of the sonographer's skills is mandatory for the use of the nasal bones as an additional sonographic marker in first trimester screening.

How imprecise may the measurement of fetal nuchal translucency be without worsening first-trimester screening?

OBJECTIVE: First-trimester screening (FTS) has a trisomy 21 detection rate of about 90%. Despite profound training, the practically reached measurement quality of nuchal translucency (NT) is probably not optimal. This study investigated the impact of measurement errors on FTS. METHODS: The data on 10,116 combined FTSs were obtained in a multicenter study. Risk assessment was performed by the JOY software following the Nicolaides risk calculation principles. To investigate the impact of measurement errors, the NT values were artificially altered and the adjusted risks were recalculated. Test performance parameters were obtained and compared with the correct measurements. RESULTS: In this study 85 fetuses were genetically affected. The screening was wrongly inconspicuous in 12 cases and in 479 cases the FTS offered false-positive results. An assumed NT error of +/-0.1 mm already causes a highly significant change in the false-positive rate. A difference of -0.2 mm leads to a visible change in false negatives. DISCUSSION: This study demonstrates that even the smallest deviations will significantly affect the false-negative rate. The detection of really diseased fetuses is influenced at a -0.2-mm measurement error. Therefore the NT measurement has to be as precise as possible.

[Influence of circadian rhythm on fetal and maternal Doppler parameters--is a diurnal variation detectable?]. / Einfluss von zirkadianer rhythmik auf fetale und maternale Dopplerparameter--ist eine tageszeitliche veränderung nachweisbar?

INTRODUCTION: Doppler sonography is an established method in fetal medicine. Up to now a possible circadian rhythm of fetal and maternal Doppler parameters has only been insufficiently characterized and documented. This survey aimed at evaluating the significance of Doppler parameters with regard to diurnal variations. We have analyzed whether or not a circadian rhythm of fetal and maternal Doppler parameters is detectable. MATERIAL AND METHODS: A non-selected collective of 100 patients with a singleton pregnancy between the 20th and 39th week of gestation was examined with Doppler sonography at the Medical School of Hannover. Besides the Doppler sonography, which was performed at three fixed times a day, the maternal blood pressure was examined each time. Outcome parameters were resistance index (RI), pulsatility index (PI) and the maximum velocity (V (max)) of the A. umbilicalis, A. cerebri media and the Aa. uterinae as well as the maternal blood pressure. RESULTS: There were no significant differences for the RI, PI and V (max) of the Aa. uterinae for the whole collective, nor for the subgroups of maternal hypertonia, preeclampsia, notching and fetal growth restriction (IUGR). There were also no significant diurnal variations of the Doppler parameters for the fetal vessels. In particular, there were no differences in the measured Doppler parameters in comparison to the collective with unremarkable gravidity. In some subgroups statistical significance could be achieved, but due to the minor variations, no clinical importance has to be considered. CONCLUSION: A circadian rhythm of the Doppler parameters could not be confirmed in the examined collective. The time of the applied Doppler sonography on physiological conditions might represent a factor which does not affect the validity of the Doppler sonographic results. As a consequence a single Doppler examination at a freely chosen time seems to be sufficient to obtain a correct assessment of fetal and maternal blood perfusion. Further studies on larger collectives are necessary to evaluate the clinical importance of a possible circadian rhythm, especially in fetuses with pathological Doppler values.

Using "Degree of Extremeness" instead of "Multiples of Median" in first trimester risk assessment for Down syndrome-an improved method or just a gimmick in face of political motivations?

INTRODUCTION: The concept of first trimester Down syndrome screening based on (NT) nuchal translucency measurement was introduced by the Fetal Medicine Foundation (FMF), London, in the late 1990s. For Germany, the mandate of NT training and auditing was assigned to the newly established German branch of the FMF in 2002. In January 2007, following the organisational split between FMF London and FMF Germany, the FMF Germany released its own, novel calculation software ("Prenatal risk calculation", PRC), for this field. It is the aim of this study to compare the modified biochemical calculation method based on "Degree of Extremeness" (DoE) with the well-proven concept of "Multiple of Median" (MoM). MATERIALS AND METHODS: The fbeta-hCG and PAPP-A values of 266 first trimester examinations were categorised by gestational age, nicotine consumption and body weight. For each, a scatter plot and Pearson correlation was derived. As a second step, only patients with no nicotine consumption and a body weight between 55 and 65 kg were considered. The remaining 84 cases were again classified by gestational age and a statistical analysis was performed. RESULTS: The correlation of the DoEs with the respective MoM values was found to be quite good (r = 0.76, P < 0.01). After dividing the population by gestational age, the cohort of early pregnancies showed a steeper fss-hCG correlation curve than later stages. The examination regarding nicotine consumption showed no significant differences between smokers and non-smokers. In contrast, maternal body weight was found to have a marked influence. When only body weights between 55 and 65 kg were included and smokers were excluded, the Pearson correlations clearly converged. DISCUSSION: In this study, the utilisation of DoEs instead of MoMs was not clearly superior but it also did not seem to be inappropriate. However, it is most problematic to ignore evidently meaningful factors like body weight and ethnicity. It must also be considered risky to introduce a new calculation software to the market, when it is not clear whether the test performance is in fact comparable to established software concepts, especially in view of the fact that not only a new (unproven) database, but also a new (again unproven) algorithm is used in the PRC software. As the new program has not been evaluated yet, the test performance parameters should be validated urgently.

[Gestational diabetes under clinical conditions in aspired normoglycemia: investigation for correlation of blood glucose daily profiles and fetometric ultrasound parameters]. / Der Gestationsdiabetes unter klinischen Bedingungen bei angestrebter Normoglykämie: Korrelationsuntersuchungen zwischen maternalen Blutzuckertagesprofilen und fetometrischen Ultraschallparametern.

BACKGROUND: One of the therapeutic aims in gestational diabetes (GDM) is to prevent the development of fetal hypertrophy by adaptation of maternal glycemic control. Relating to this context, maternal blood glucose daily profiles and fetal biometry ultrasound parameters were analysed for a possible correlation. A special focus was given to the question as to whether a latency period exists for this possible connection. PATIENTS AND METHODS: 152 pregnancies affected by GDM, without fetal malformations or aneuploidies, were enrolled. Altogether, 746 ultrasound examinations consisting of 7 fetometric parameters each and 1 288 blood glucose daily profiles originating from the 20 (th) to 40 (th) gestational week were systematically investigated for interrelation by correlation and multiple regression analysis. RESULTS: No robust, constant correlation between the analysed parameters could be observed. However, marked differences between latency periods were noticed. Blood glucose parameters, which revealed significant regressions with fetal abdominal circumference, had an average time lag of 6.2 +/- 2.5 weeks, whereas the latency period for head circumference averaged 2.4 +/- 1.2 weeks. The overall small-for-gestational-age (SGA) rate was 20 %, pregnant women with a body mass index > 30 kg / m (2) revealed the highest rate of 28 %. CONCLUSIONS: Therapeutic intervention depending on sonographically detected hypertrophy must be considered as being delayed. The currently valid therapeutic criteria including intended normoglycemia and regular fetometric ultrasound controls cannot prevent markedly high SGA rates, especially among obese women, in adequately treated GDM.

[Marfan syndrome in pregnancy: presentation of four cases and discussion]. / Das Marfan-Syndrom in der Schwangerschaft: Vorstellung von vier Kasuistiken und Diskussion dieser Koinzidenz.

The coincidence of Marfan syndrome and pregnancy means a high risk for mother and child, as it is associated with cardiovascular and obstetric complications. We report our experience of four pregnancies with the Marfan syndrome. The course of pregnancy, the peripartum management and both the maternal and neonatal outcomes of four pregnant women with the Marfan syndrome, who were treated in our department between 1995 and 2005, were retrospectively analysed. The pregnancies of two women were complicated by premature rupture of membranes (36 (th) gestational week) and premature uterine contractions with cervical incompetence (30 (th) gestational week), respectively. One patient developed class 3 (NYHA) heart failure in the 3 (rd) trimenon. Two out of four women had mild cardiovascular disease and could deliver vaginally. In the other two cases a primary Caesarean section was performed at the 36 (th) week of gestation because of severe cardiovascular morbidity. No patient had a progressive aortic dilatation, dissection or rupture. The neonatal outcome was uneventful in all cases. Three newborns underwent a genetic evaluation for the Marfan syndrome, in two of them mutations in the fibrillin 1 gene were detected. Women with the Marfan syndrome should be counselled pre-conception and observed by an interdisciplinary team during pregnancy. If the aortic root diameter is < 40 mm, without progression in pregnancy, and in the absence of severe valve insufficiency, then pregnancy is in most cases well tolerated and vaginal delivery can be performed.