Oral Misoprostol for the Induction of Labor: Comparison of Different Dosage Schemes With Respect to Maternal and Fetal Outcome in Patients Beyond 34 Weeks of Pregnancy.

BACKGROUND/AIM: Labor is induced in 1 out of 5 pregnancies. This is why we aimed to compare two different protocols of orally administered misoprostol for the induction of labor (IOL), with special regard to maternal and fetal outcome, delivery mode and duration. PATIENTS AND METHODS: One hundred and twenty four patients with a medical indication for IOL were divided into two groups: Group A (n=63), which initially received 50 µg misoprostol escalated to 100 and, subsequently, to 200 µg every 4 h with a daily maximum of 600µg, between 11/2007 and 01/2008; and Group B (n=61), which initially received 25 µg misoprostol followed by 100 µg every 4 h with a daily maximum of 300 µg, between 12/2009 and 04/2010. RESULTS: The mean administration-delivery interval was significantly lower in Group A (19.0 h) compared to Group B (27.1 h, p<0.05). Overall caesarean section rate, average birth weight, APGAR score, umbilical cord pH and meconium-stained fluid rates were similar between both groups. CONCLUSION: A higher dosage protocol of orally administered misoprostol significantly reduces the mean induction-delivery interval without increasing the risk for an adverse maternal or fetal outcome.

Severe direct and indirect complications of morcellation after hysterectomy or myomectomy.

INTRODUCTION: Despite the significant advantages of morcellation, it may be associated with severe complications. We aimed to determine both direct and indirect complication rates of morcellation at gynecological laparoscopy. MATERIAL AND METHODS: This multicenter retrospective study included patients traced from 2008 to 2017. We identified women who underwent an operation with the use of electromechanical power morcellation (EMM) or vaginal manual morcellation during laparoscopy. Clinical records, intraoperative-postoperative outcomes were reviewed. RESULTS: We analyzed 1795 patients who underwent laparoscopic supracervical hysterectomy (LASH), total hysterectomy (TLH), or myomectomy (45.5%, 14.2%, and 40.3%, respectively). No severe intraoperative complications associated with morcellation or parasitic leiomyoma were observed. Patients with unexpected sarcoma were detected in five cases (0.28%). Four of them were detected after LASH and one after vaginal manual morcellation following TLH, who had an intraabdominal recurrence and died after 18 months. The patients after LASH underwent secondary laparotomy for staging; no histological dissemination of sarcoma was observed, however two had a recurrence. The five-year survival rate was 80%. CONCLUSIONS: There is a small risk of intraoperative complications or unexpected malignancy following morcellation, provided the surgeon adheres to regular surgical standards. In patients with a normal size uterus, TLH could be preferred over LASH to avoid morcellation.

Postnatal neuro-development of fetuses with absent end-diastolic flow in the umbilical artery and/or fetal descending aorta.

OBJECTIVE: To determine whether absence of end-diastolic flow in the umbilical artery and/or fetal aorta impacts postnatal neuro-development in preterm-born children. METHODS: The study group, consisting of 43 fetuses with absent end-diastolic flow in the umbilical artery and/or fetal aorta, was compared with a control group, consisting of 30 fetuses, matching for gestational age but with normal doppler-flow results. The children's neuro-developmental status was assessed using the 'Munich functional developmental diagnostics' (MFDD), between the 2nd and 3rd year of life. RESULTS: Gestational age at birth was 33 + 6 weeks in the study group and 34 + 4 weeks in the control group. A brain-sparing effect was observed in 37.3% of fetuses in the study group compared with 10.0% in the control group (p = 0.014). For all seven MFDD domains, the number of children with deficiencies was higher in the study group. For the domains perception, active speech and comprehension this effect was statistically significant (p < 0.05). Overall, 30.2% of children in the study group and 16.7% of the control group had pathologic test results (p < 0.013). CONCLUSION: Pathological doppler-flow in the umbilical artery and/or fetal descending aorta in preterm born children is associated with neuro-developmental deficiencies. Intensive pediatric care is recommended to mitigate these deficiencies during early childhood.

The technique of robotic assisted laparoscopic surgery in gynaecology, its introduction into the clinical routine of a gynaecological department and the analysis of the perioperative courses - a German experience.

OBJECTIVE: Robotic assisted surgery is an advancement on conventional laparoscopy. The first and single FDA-approved device is the da-Vinci™ system, which provides means to overcome the limitations of conventional laparoscopy. In Germany the use of the robotic system in gynaecology is at the threshold of a promising development. There is a wide spectrum of indications, such as simple and radical hysterectomies, including pelvic and paraaortic lymph node dissection. The introduction of the robotic system into the clinical routine is demonstrated. MATERIAL AND METHODS: Robotic assisted laparoscopic interventions have been performed in the reporting hospital since April 2008. In the course of treatment of 172 cases, an increasing rise of complexity of surgical procedure has been achieved. The daVinci™ system is well adaptable in clinical routine. Hitherto, the clinical outcome has been favourable, higher-grade specific complications occurred very rarely. The short time advantages are a decrease of postoperative length of stay, a reduction of postinterventional need of analgetics and an overall accelerated period of recovery has been demonstrated compared to conventional abdominal procedures. It also shows that a drastic decrease of open conventional abdominal procedures concerning uterine pathologies appeared in the reporting department. RESULTS: Perioperative advantages of robotic assisted laparoscopic interventions are, above all, the decrease of morbidity (concerning blood loss, need of analgetics, length of stay, etc.). Surgical advantages are the more complex applicability, improved precision, dexterity and vision (3D), a greater autonomy of the surgeon, a smaller learning curve and an increase of preparation consistent with the anatomical structures. In contrast, disadvantages concern an initial greater time investment, the potentially different management of complications, the limited applicability in multiquadrant surgery and the difficulty regarding cost coverage respective to recovery. CONCLUSIONS: In conclusion, robotic assisted minimal invasive surgery has an enormous potential in gynaecology; by simplifying the essential surgical procedure. The advantages of this technique will be approachability for a majority of gynaecological patients. The feasibility of a multitude of gynaecological surgical interventions has already been approved partially in a small number of cases. The upcoming challenge now is to verify the short and long term advantages of robotic surgery in prospective trials, especially concerning gynaecological oncology.

Diagnosis and treatment of deep-vein thrombosis and approach to venous thromboembolism in obstetrics and gynecology.

Deep vein thrombosis (DVT) is a common condition in which the approach to its diagnosis has evolved over the years. Currently, an algorithm strategy combining pre-test probability, D-Dimer testing and compression ultrasound imaging allows for safe and convenient investigation of suspected lower-extremity thrombosis. Patients with low pre-test probability and a negative D-Dimer test result can have proximal DVT excluded without the need for diagnostic imaging. The mainstay of treatment of DVT is anticoagulation therapy, whereas interventions such as thrombolysis and placement of inferior vena cava filters are reserved for special situations. The use of low-molecular-weight heparin (LMW) allows for outpatient management of most patients with DVT. The duration of anticoagulation therapy depends on whether the primary event was idiopathic or secondary to a transient risk factor. More research is required to optimally define the factors that predict an increased risk of recurrent DVT to determine which patients can benefit from extended anticoagulant therapy. DVT is also a serious problem in the antenatal and postpartum period of pregnancy. Thromboembolic complications are the leading cause of both maternal and fetal morbidity and mortality. The incidence of venous thromboembolism during normal pregnancy is six-fold higher than in the general female population of childbearing age. The treatment of DVT during pregnancy deserves special mention, since oral anticoagulation therapy is generally avoided during pregnancy because of the teratogenic effects in the first trimester and the risk of fetal intracranial bleeding in the third trimester. LMW heparin is the treatment of choice for DVT during pregnancy. If acute DVT occurs near term, interrupting anticoagulation therapy may be hazardous because of the risk of pulmonary embolism. In this situation, placement of a retrievable inferior vena cava filter must be considered. However, there is no consensus as to what the appropriate dose should be and whether anti-Xa levels need to be monitored.

Doppler examinations of fetal and uteroplacental blood flow in AGA and IUGR fetuses before and after maternal physical exercise with the bicycle ergometer.

OBJECTIVE: To study changes in uteroplacental and fetal circulation after maternal exercise in appropriate-for-gestational-age fetuses (AGA) and intrauterine-growth-retarded fetuses (IUGR). MATERIALS AND METHOD: 33 women with an uncomplicated course of pregnancy and ten women with IUGR were examined. Physical stress was caused through a bicycle ergometer with 1.25 W/kg maternal weight. Doppler examinations were performed in the umbilical artery, fetal aorta, middle cerebral and in the uterine artery. Fetal heart rate was documented by monitoring. Maternal lactate and glucose levels as well as maternal blood pressure and heart rate were recorded. RESULTS: No significant changes after cycling could be observed in umbilical and uterine vessels either in the normal pregnancies or in pregnancies with IUGR. In contrast, in the fetal aorta an increase of the RI was recorded in both groups (an increase of 16% [P<0.01] and 18% [P<0.05], respectively for AGA and IUGR cases). In cerebral arteries a decrease of the RI was observed after cycling in both groups (a decrease of 24% [P<0.01] and 13% [P<0.05], respectively for AGA and IUGR cases). In AGA fetuses the RI of the aorta and middle cerebral artery returned to pre-test level by the 18th minute of examination. In IUGR fetuses the RI of the aorta and middle cerebral artery did not return to pre-test levels at the end of the test. Fetal heart rate remained unchanged in both groups. Maternal blood pressure and heart rate increased during the exertion phase but returned to initial values at the end of the test. A 21% and 24% (for AGA and IUGR groups respectively) reduction of maternal glucose values after exercise was observed (P<0.001). Lactate values doubled in both groups after exercise (P<0.001). CONCLUSION: From the results obtained we conclude that maternal exercise does not significantly alter uterine and umbilical perfusion in AGA and IUGR pregnancies, suggesting an absence of change in the uterine vascular bed resistance. However, submaximal maternal exercise was followed by fetal cerebral vasodilatation and an increase of resistance in the fetal aorta that was more evident in IUGR fetuses. This might be due to slight fetal hemoglobin desaturation in those cases.

Comparison of perinatal outcome in fetuses with reverse or absent enddiastolic flow in the umbilical artery and/or fetal descending aorta.

OBJECTIVES: To examine the differences of perinatal outcome in fetuses with absent and reversed enddiastolic flow velocity waveforms of the umbilical artery or fetal descending aorta. DESIGN: In a retrospective study, 30 pregnant women with reversed enddiastolic flow in the umbilical artery or fetal aorta (group I) were compared with 30 cases of absent enddiastolic flow (group II). Patients were included in the groups according to the last Doppler finding before delivery. Perinatal and neonatal outcome was correlated with antenatal Doppler flow findings. RESULTS: The mean gestational age at birth was 31 weeks in both groups. Fetuses with reverse flow showed higher perinatal (27% and 7% respectively) and overall mortality (53.3% and 10% respectively) compared to the absent enddiastolic flow group (p < 0.05). All the intrauterine fetal deaths occurred in the reversed flow group (n = 12). The rates of intrauterine growth retardation, oligohydramnios and hypocalcemia were different between the groups (p < 0.05). The cesarean section rate, perinatal and neonatal complications including the incidence of acidosis, the number of cases admitted to neonatal intensive care unit and mean treatment time were not different between the groups. A tendency to higher incidence of neonatal cerebral hemorrhage in reversed flow cases (28%) compared to absent enddiastolic flow cases (17%) was observed, but this was not statistically significant. CONCLUSIONS: The present study suggests that reversed flow should be seen as a particular clinical entity with higher incidences of perinatal and overall mortality, and severe intrauterine growth retardation (< 5. perc) compared to the absent enddiastolic flow group. The optimal timing of delivery in pregnancies complicated by highly pathological Doppler flow findings is only to be resolved in well-designed randomized, multicenter clinical trials.

Clinical and biophysical aspects of HELLP-syndrome.

OBJECTIVE: The maternal-perinatal outcome and the significance of biophysical parameters in HELPP syndrome patients were evaluated. METHODS: Sixty cases of HELLP syndrome were determined by retrospective analysis. Medical history, correlation of clinical, laboratory findings, records of fetomaternal Doppler studies, Nonstress test and maternal-perinatal outcome data were evaluated. Chi-square test was used for statistical analysis, and p < 0.05 was accepted as the significance level. RESULTS: The incidence of HELLP syndrome in our institution was 1.03%. Mean gestational age at birth was 33.2 weeks, mean birth weight was 1861 +/- 710 g and mean umbilical pH was 7.25 +/- 0.13. Neonatal thrombocytopenia was demonstrable in 38% of neonates. Patients with low antepartal platelets (< 60,000/microliter) had a significantly higher incidence of intrauterine growth retarded fetuses than patients with higher platelet counts (p = 0.002). Doppler flow measurements were performed in 33 patients (55%). In 16 (48.4%) a pathological Doppler flow was documented. Doppler findings demonstrated very high sensitivity (83%) and specificity (80%) in predicting adverse outcome in growth retarded fetuses. In 17 patients (27%) fetal heart rate monitoring had an obvious pathologic pattern. Respiratory distress syndrome (74.4%) was the main indication for NICU admission. Perinatal mortality rate was 8.3% and neonatal mortality rate was 11.6%. Maternal morbidity rate was 30%. The most commonly observed maternal complications were abruptio placentae (n = 8), disseminated intravascular coagulation (n = 3) and severe postpartal bleeding (n = 3). CONCLUSIONS: In HELLP syndrome patients it is very important to closely follow maternal vital signs and fluid intake and output, and to perform fetal status assessment tests. Of the biophysical parameters, Doppler flow measurement is an especially helpful predictor of poor perinatal outcome in growth retarded fetuses in HELLP patients. Patients with very low platelets have a significantly higher risk of intrauterine growth retarded fetuses.