[25 years of Integral Theory by Petros : What remains and what's next?] / 25 Jahre Integraltheorie nach Petros : Was bleibt? Was kommt?

BACKGROUND: The Integral Theory (IT) states that urinary stress and urge symptoms mainly arise from lax suspensory ligaments, which are a consequence of altered collagen/elastin. Four important muscle groups (pubococcygeal muscle, levatorplate, longitudinal muscle of the anus, and the puborectalis muscle) are only able to guarantee the opening and closure mechanism of the bladder, the urethra and the anal tube if the suspensory ligaments are intact. The first practical application of the IT was the repair of the pubourethral ligament (PUL) known as tension-free vaginal tape (TVT). OBJECTIVES: What is the practical impact of the IT today? Do lax suspensory ligaments play a role in stress and urge urinary incontinence, fecal incontinence, voiding difficulties, and pelvic pain? MATERIALS AND METHODS: Evaluation of the literature, data, and experiences concerning IT. RESULTS: The pathophysiology of pelvic floor disorders has been widely proven and surgical concepts were developed to reconstruct the ligaments with the result of regaining function. Suburethral tapes are accepted as the standard of care for urinary stress incontinence. In addition, the correction of cervical ring defects, the lateral and central cystoceles, the uterosacral ligaments, the perineal body, and the rectovaginal fascia were adapted and newly developed with the aim of alleviating symptoms. Newly published data prove the cure of symptoms in a high percentage of cases. The complex conditions and function of the pelvic floor can be understood much better by using the diagnostic algorithm and with knowledge of the basic pathophysiology. CONCLUSION: The basic IT message: repair the structure (ligaments) and you will restore the function is true for all pelvic floor ligaments.

The surgical anatomy of rectocele and anterior rectal wall intussusception.

The aim of the study was to analyse the dynamic anatomical supports of the posterior vaginal wall from the perspective of rectocele and rectal intussusception repair. Two groups of patients were studied. Group 1 (n = 24) with genuine stress incontinence but no major vault prolapse had vagino/proctomyograms and transperineal ultrasound examinations. Group 2 with vaginal vault prolapse, clinical rectoceles and obstructive defecation symptoms (n = 19 had single-contrast defecating proctography before and after posterior-sling surgery. The posterior vaginal wall is suspended between perineal body, which underlies half its length, and uterosacral ligaments, which also support the anterior wall of rectum. Muscle forces stretch the vagina and rectum against the perineal body and uterosacral ligaments, creating shape and strength, like a suspension bridge. Postoperative proctogram studies indicated that anterior rectal wall intussusception has the same etiology as rectocele, deficient recto-vaginal ligamentous support. Repair to uterosacral ligaments and perineal body should be considered with large rectoceles, anterior rectal wall intussusception and obstructive defecation disorders.

[Typical forms of choriocarcinoma in clinical practice--diagnosis and therapeutic course in four patients]. / Typische Erscheinungsformen des Chorionkarzinoms in der klinischen Praxis--Diagnosestellung und therapeutischer Verlauf bei vier Patientinnen.

The paper reports on four patients with choriocarcinoma. In two of them, the choriocarcinoma was found after abortion, in one of them following termination of pregnancy, and in the last patient a hydatidiform mole was present. In all patients increased beta-HCG was found. One patient had lung metastasis at the time of diagnosis. In another patient, choriocarcinoma was suspected owing to ultrasonographic vaginal examination. According to the Bagshawe Score, 3 patients were low-risk and were subjected to methotrexate. One patient was medium-risk and received PEB chemotherapy. All four patients are regarded as cured.

[Pronounced bilateral mammary hypertrophy as a rare manifestation of acute lymphatic leukemia]. / Ausgeprägte bilaterale Mammahypertrophie als ungewöhnliche Manifestation einer akuten lymphatischen Leukämie.

A 33-year-old patient, hitherto healthy, has been admitted for clarification of bilateral mammary hypertrophy. In the course of the usual routine examination a lump of the size of a cherry was identified in the right breast. Within 6 weeks both breasts had become tight and grown symmetrically to three times their original size. A provisionary diagnosis of high malignant non-hodgkin lymphoma was made by multiple high speed needle biopsies and was later confirmed by a surgical tissue specimen of the right breast. For further classification a bone-marrow biopsy was taken from the pelvic bone and an immature acute lymphoblastic leukemia (ALL), known as preB1-ALL, diagnosed. Sonographic examination, computer tomography of the thorax and mammographical findings, as well as symptoms, outcome and differential diagnosis of a proliferative lymphatic disease with first manifestation in both breasts are presented and discussed.

[Terminal CTG as an expression of high degree fetal distress--1 case reports]. / Das terminale CTG als Ausdruck einer hochgradigen Gefährdung des Kindes--zwei Kasuistiken.

The cases of two patients, in whom conspicuous CTGs with restricted oscillation and late decelerations were registered in the final trimester of pregnancy, are presented. Following immediate hospitalisation and the rapid execution of a caesarean section, two depressed, severely acidotic neonates were born. Whilst the course of the pregnancy in the first case had been completely inconspicuous up to that point, and the acute occurrence of placental insufficiency must be assumed, the second patient was subject to pregnancy-induced hypertension with discrete foetal growth retardation. It is shown that two almost identical pathological CTG registrations may have different causes but that one must assume a high degree of sub partu risk to the child on the occurrence of a terminal CTG witch is characterised by line-shaped oscillation, possibly in combination with late decelerations.

[Prognostic value of cardiotocography in pregnancy with pathologic Doppler findings]. / Prognostischer Wert der Kardiotokographie bei Schwangerschaften mit pathologischem Dopplerbefund.

Absent (absent-EDF) or reversed (RF) end-diastolic flow in Doppler velocimetry in the umbilical artery and fetal aorta indicates highly disturbed fetoplacental perfusion, which often occurs early in pregnancy. Perinatal mortality and morbidity is very high. In this situation it is not clear how long pregnancy can be continued to achieve better conditions for the preterm fetus. This study was performed to investigate the value of fetal heart rate recordings (FHR) in patients with absent EDF or RF as a parameter to determine the optimum time of delivery. 25 pregnancies with absent (n = 21) or reversed end-diastolic velocity (n = 4) were analysed. Gestational age was between 24 and 34 weeks. 17 children showed compensatory dilatation of the middle cerebral artery (68%). 15 (60%) were growth retarded, 8 of them below the 3% percentile, while 3 had normal weight. Maximum time interval until delivery was 18 days, median was 2 days. Five children died before, 2 during delivery. As none died after delivery, perinatal mortality was 28%. 4 of the survivers (22%) showed arterial acidosis. Only three children had completely normal fetal heart rate recordings on the day of diagnosis of absent EDF or RF. All others showed at least suspicious FHR (according to Hammacher), 8 of them (32%) even pathological FHR, including all children who died later. Early suspicious changes in FHR were the reduction in frequency and amplitude of oscillation, while decelerations occurred later. Additional unfavourable parameters in FHR were roundings of the oscillatory inversions as well as missing reactivity to fetal movements. Fetal heart rate monitoring is a reliable tool for determination of the optimum time of delivery in children with absent EDF or RF. The decision has to be made in relation to the gestational age. If possible, the fetus should be born before FHR becomes pathological. In this manner perinatal mortality and morbidity should be kept at a low level even in high-risk patients with absent EDF or RF.

Fetal monitoring by combined CTG and FBA.

Cardiotocography still is the main method to monitor the unborn child during birth. Today, problems occurring during CTG-surveillance are not so much due to the method, but a consequence of insufficient management. Fetal monitoring by combined CTG and FBA brings advantages for mother and child. The use of FBA in cases with pathological fetal heart patterns leads to a significant reduction in cesarean section rate, neonatal morbidity and perinatal mortality.

[Induced labor with prostaglandin E2 gel after previous cesarean section]. / Geburtseinleitung mit Prostaglandin-E2-Gel bei Zustand nach Sectio.

With the rising rate of Caesarean sections, the number of pregnant patients with a previous Caesarean is increasing. Taking into consideration certain contraindications, it seems to be justified, to attempt induction of labour for vaginal delivery without major risk. However, the use of prostaglandins for cervical ripening in women with an unfavourable cervical status is particularly controversial. Thus, we analysed data from 385 trials of vaginal labour induction in a total of 522 patients with previous Caesarean section. Single or multiple cervical doses of prostaglandin-E2-gel had to be administered because of an unripe cervix (Bishop-score < 8) in 161 women for induction of labour for medical indications. 84.9% of those patients, in which labour induction was attempted after previous Caesarean section, delivered vaginally; 70% after two Caesareans. The highest success rates were seen after previous Caesarean for breech presentation, while there was still a vaginal delivery rate above 60% even after Caesarean for cephalopelvic disproportion or failure to progress. Maternal and foetal complications were seen with equal incidence in both study groups. Uterine ruptures totalling 0.5% were seen only in patients without cervical priming. Taking into consideration contraindications, intracervical application of PGE2-gel is a safe and effective method, even in patients after previous Caesarean section with clear advantages in case of an unripe cervix.

Effects of lumbar epidural analgesia on prostaglandin F2 alpha release and oxytocin secretion during labor.

The concentrations of plasma oxytocin and prostaglandin F2 alpha metabolite (PGFM) were measured in 10 parturients with and 10 without lumbar epidural analgesia. A blood sample was taken immediately before analgesia and another 60 min later. The control patients were matched for the stage of cervical dilatation at the time of the first blood sample; the second was drawn 60 min later. Plasma PGFM decreased significantly after lumbar epidural anesthesia and increased in controls resulting in a highly significant difference between the groups (P < 0.005). Plasma oxytocin concentrations levels also changed in opposite directions in the two groups but the difference did not reach statistical significance (P < 0.1). Uterine activity increased in the controls and decreased in the analgesia group resulting in a significant difference between the groups (P < 0.05). All subjects delivered vaginally. The total duration of labor was longer in the analgesia group (7.8 +/- 1.0 h vs. 4.7 +/- 0.6 h; P < 0.05) as was the duration after analgesia (5.1 +/- 0.9 h vs. 2.5 +/- 0.8 h; P < 0.05), whereas the duration of the second stage was not significantly different. We conclude that lumbar epidural anesthesia results in suppression of PGF2 alpha release which may be the cause of the diminished uterine activity and the prolonged duration of the first stage of labor.

Plasma prostacyclin and thromboxane concentrations in 160 normotensive, hypotensive, and preeclamptic patients during pregnancy, delivery, and the post partum period.

Plasma concentrations of 6-keto-prostaglandin F1 alpha, a stable metabolite of prostacyclin, and TxB2 were measured in 160 women during pregnancy (n = 106), delivery (n = 40), and in the postpartum period (n = 14). Fifty nine patients had normal blood pressure, 10 had mild and 9 severe preeclampsia while 38 patients were hypotensive. Normotensive patients were grouped according to their gestational age: 22-26 weeks (n = 22), 27-31 weeks (n = 22), and 32-38 weeks (n = 15). 20 patients were in early first stage of delivery (cervical dilatation < or = 5 cm), 20 patients in late first stage (cervical dilatation > or = 6 cm). The concentration (mean value +/- SEM) of the PGI2 metabolite tended to increase during pregnancy without reaching significance (218 +/- 11; 225 +/- 10; 250 +/- 15 pg/ml). At the same time, TxB2 showed a decrease, which was most pronounced at 27-31 weeks (65 +/- 15; 40 +/- 2; 48 +/- 4 pg/ml; p < 0.001). The ratio of PGI2/TxA2 increased in parallel (4.9 +/- 0.4; 6 +/- 0.4; 4 +/- 0.5). There was no difference in plasma concentrations of PGI2 (figure 4) and TxA2 in patients with normal blood pressure, mild preeclampsia and hypotension, whereas in severe preeclampsia, the plasma concentration of PGI2 was significantly lower (p < 0.001) and of TxA2 significantly higher (p < 0.001). The ratio of PGI2/TxA2 shifted significantly to vasoconstriction in patients with severe preeclampsia (p < 0.0001) and to vasodilatation in those with hypotension (p < 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

[Combined monitoring of labor: maternal and neonatal results]. / Kombinierte Geburtsüberwachung: Mütterliche und kindliche Ergebnisse.

The purpose of this study was to prove, whether intrapartum fetal monitoring by cardiotocography and fetal blood analysis brings advantages for mother and child. The data of 10,234 patients, delivered in 5 different hospitals in 1988 and 1989, were analyzed by a computer. The results show that nonpermanent in comparison to permanent monitoring lead to a significant increase in cesarean section rate, neonatal morbidity and perinatal mortality. Furthermore we found a negative correlation between cesarean section rate and frequency of fetal blood analysis (r = -0.54). The use of fetal blood analysis in cases with pathological fetal heart patterns lead to a significant reduction in cesarean section rate, neonatal morbidity and perinatal mortality. In summary the study shows that a combined intrapartum monitoring improve the results.

Plasma oxytocin but not prostaglandin F2 alpha metabolite levels at cerclage may predict preterm delivery.

Plasma oxytocin and prostaglandin F2 alpha metabolite (PGFM) concentrations were measured in 45 patients admitted for cerclage during the second trimester. Samples were collected before, 3 hours after, and 3 days after the Shirodkar procedure. Uterine activity was recorded by external tocography twice daily for 30 minutes. Twenty-eight women with uncomplicated pregnancy and commensurate gestational age served as controls. Cervical length, measured by ultrasonography, was significantly shorter before cerclage (36 +/- 2 mm) than after cerclage (43 +/- 2 mm) or compared with controls (48 +/- 1 mm). Bishop scores ranged from 3-6 (median 4) in the cerclage group and 0-1 (median 0) in controls. Fifteen cerclage patients and one control delivered preterm 5-22 weeks after the procedure. Initial plasma PGFM levels were significantly higher in cerclage patients than in controls. The cerclage procedure caused an immediate rise in plasma PGFM and a subsequent fall below initial levels to control values. Neither the initial levels of PGFM nor the increments 3 hours after cerclage correlated with the outcome of pregnancy. By contrast, plasma oxytocin levels before cerclage were significantly higher in patients who subsequently delivered preterm than in those who delivered at term. Cerclage resulted in a significant fall in plasma oxytocin at 3 hours in patients with preterm delivery, but after 3 days the oxytocin levels had returned to the precerclage values. Patients who had increased uterine contractions had significantly higher plasma oxytocin levels but lower PGFM levels than those without contractions.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effect of dihydroergotamine (DHE) on fetal hemodynamics]. / Wirkung von Dihydroergotamin (DHE) auf die fetale Hämodynamik.

With this article we have pursued the question if the fetal hemodynamic will change under Dihydroergotamine-treatment (DHE) of the mother during pregnancy. For that purpose, the S/D-ratio in 20 hypotensive pregnant women was determined before and one week after treatment with 2 x 2.5 mg DHE (DETMS retard) daily by Doppler-sonographic measurement in the fetal aorta. The control group consisted of 20 healthy, untreated normotensive pregnant women not differing from the hypotensives as regards age, parity, and gestational age. The results show that in hypotensive pregnant women the S/D-ratio, and therefore the resistance in the fetal periphery respectively in the placenta circulation is increased by 22% (p less than 0.002) on the average compared with the normotensives. A one week's treatment with DHE led to a significant decrease of the S/D-ratio by 20% (p less than 0.001). Herewith, the values after DHE-treatment did not differ from those of the normotensives. Therefore we conclude that the treatment of hypotensive pregnant women with DHE in the above mentioned dosage produces a significant improvement of fetal hemodynamic.