Fetal behavioural states and controlled sound stimulation.

The aim of this study was to investigate responses of human fetuses near term (37-42 wks) (increase/decrease of fetal heart rate and/or fetal motility) to acoustic stimuli. The study group consisted of 43 patients and the control group of 27 patients. Polygraphic recordings of 5 different fetal variables were carried out synchronously for the categorization of the actual fetal behavioural state according to Nijhuis et al. (Nijhuis, J.G., Prechtl, H.F.R., Martin, C.B., Jr. and Bots, R.S.A.M. (1982): Early Hum. Dev., 6, 177-195). Controlled acoustic stimulation was performed either with sine wave tone (2 kHz, 120 dB and 5 s duration) or modulated sine wave tone (0.5-2 kHz, 'sawtooth' modulation, 120 dB and 5 s duration). An additional group of patients received 'sham' stimulation. Overall 84 acoustic stimulations have been carried out. In 26 out of 84 stimulations (30%) a fetal response could be observed within 5 s after acoustic stimulation. In general, there were far fewer fetal responses in sleep states than in states of wakefulness. Whereas in state 1 F only 1 out of 28 acoustic stimulations was followed by an immediate fetal response, more responses were observed in state 2 F. An obvious increase in fetal reactivity to acoustic stimulation was noted in states of wakefulness (states 3 F and 4 F). Comparison between the true and sham stimulations revealed a relatively high level of spontaneous fetal activity (high variation of fetal heart rate and fetal motility) present in states 2 F and 4 F. This must be taken into account in all assessments of fetal responses.(ABSTRACT TRUNCATED AT 250 WORDS)

[Complexity analysis and intrapartum CTG]. / Komplexitätsanalyse und intrapartuales CTG.

OBJECTIVES: This study was performed to prove, if the use of methods, that are based on procedures for analysis of chaotic systems ("complexity analysis"), can give information on the fetal condition during birth and predict both the course of delivery and fetal outcome. PATIENTS AND METHODS: Fetal ECG was derived in 37 pregnancies (36-42 weeks of gestation) during birth for two to seven hours. In 12 cases delivery was uncomplicated, in 24 cases FHR tracings had been pathological. RESULTS: Complexity analysis of fetal ECG signals showed within short observation intervals criteria that may be a hint for imminent fetal distress and acidosis. CONCLUSIONS: Application of complexity analysis in the future may give additional information for evaluation of intrapartum CTG in cases of suspicious FHR patterns.

[Ultrasound diagnosis of fetal urinary tract abnormalities--incidence, therapy and follow-up]. / Sonographische Diagnostik fetaler Harntraktanomalien-Inzidenz, Therapie und Verlauf.

561 severe foetal malformations were seen from 1975 to 1986 in a total of 17,057 births (3.3%). The urogenital tract was involved in 164 cases only (1.0%). The proportion of malformations of the urinary tract was 29% of all observed anomalies. In 31% of the cases (51 of 164) there were isolated malformations, and in 20% (33 of 164) combined malformations of the urinary tract. 58% (96 of 164) of the urinary tract anomalies definitely belonged to syndromes (e.g. Potter's syndrome). Of 68 newborns with correctable urogenital changes, 42 were diagnosed as obstructive uropathy, 7 of which with urethral valves. A highly critical view is taken of the possibilities of intrauterine therapy in obstructive uropathies.

[The kinetocardiotocogram--initial clinical experiences using the kinetocardiotocogram]. / Das KCTG--erste klinische Erfahrungen beim Einsatz des Kinetokardiotokogramms.

160 woman patients in whom the course of pregnancy was uneventful or pathological (intrauterine growth retardation, percentile less than 5) were investigated at the Department of Obstetrics and Gynaecology of the University of Homburg/Saar between the 28th and 42nd week of pregnancy, using a newly developed cardiotocograph (HP M1350A Hewlett-Packard, Böblingen, FRG). By means of the kinetocardiotocogram (KCTG), fetal mobility (fetal movements of the whole body or of the extremities) was recorded simultaneously with the conventional recording of the fetal heart rate and uterine contractions. One of the aims in developing the KCTG was to record as far as possible all fetal movements synchronous to the recordings of heart rate and uterine contractions. To this end, the recording algorithm of the KCTG was adapted to the examination results obtained by two simultaneously operating ultrasound investigators. After the 28th week of pregnancy it was possible to record by the KCTG fetal "movement clusters" (combined body and limb movements) independent of the weight of the fetus and of amniotic fluid volume or positional anomalies, reliably and with good correlation with the results of the sonographic control investigations (r = 0.88-0.97). In cases of intrauterine growth retardation (percentile less than 5) a significantly reduced motility was observed on average as early as 13 days before delivery (p less than 0.005). It must be emphasized that, at this stage, most of the antenatal CTGs were normal. These findings indicate that KCTG can contribute to improved monitoring in high-risk pregnancies.

[Fetal heart rate and Doppler flow parameters in fetal blood vessels--evaluation of 2,517 individual signals]. / Fetale Herzfrequenz und Doppler-Flow-Parameter in fetalen Gefässen--Auswertung von 2517 Einzelsignalen.

Analysis of more than 2500 doppler flow signals in three patients was performed to evaluate the influence of fetal heart rate (fhr) variation on S/D-ratio in fetal vessels. Little differences of S/D-ratio in fetal vessels (descending aorta, umbilical arteries) were detected within the physiological variations of fhr (120-160 bpm) (envelope of regression line -0.007, -0.006). Analysing inter- as well as intraindividual variation only minor effects of fhr alteration can be observed in clinical application of doppler flow velocimetry. Dopplersonographic measurements, however, should be performed for at least a three minute period (for each vessel) to avoid false-positive or false-negative interpretation of short term changes of doppler signals. This is especially important in distressed fetuses.

[Doppler flow studies (duplex sonography). Differential diagnostic assessment of intrauterine growth retardation and uncertain gestational age]. / Doppler-Flow-Untersuchungen (Duplex-Sonographie). Differentialdiagnostische Abklärung intrauterine Wachstumsretardierung und unsicheres Schwangerschaftsalter.

In 116 patients referred to Heidelberg University Gynecological Clinic because of a discrepancy between calculated and biologically determined gestational age, the suitability of the Doppler Flow examination method (duplex method) for resolving this question was studied. The signals from the fetal descending aorta, the umbilical artery, and from maternal placental vessels were used. An A/B ratio of over 7 in the fetal aorta, an A/B ratio of over 4 in the umbilical artery, and detection of an early diastolic incisure in the so-called arcuate arteries were considered pathologic. The relatively high accuracy of this examination method is expressed by its sensitivity (91%) and likewise high specificity (86%) for this diagnostic question. In view of the predictive value of 88% thus determined, reliable differential diagnostic distinction between intrauterine growth retardation and uncertainty regarding term appears possible. Doppler sonographic examination can be performed without causing any serious discomfort to the patient and within a short period of time. While the number of false-positive results in this study was in any case relatively low (11%), an in-depth analysis showed that an "acute placental insufficiency" had occurred in the peripartum in more than one-half of the cases.

[Controlled acoustic and photic stimulation of the fetus in the last pregnancy trimester]. / Kontrollierte akustische und lichtoptische Stimulation des Feten im letzen Schwangerschaftsdrittel.

The aim of the study communicated here was to check any fetal reactions occurring after external stimulation (light-optic and acoustic stimuli), depending on fetal behavioral status. The group studied (acoustic/light stimulation) comprised 85 patients with normal course of pregnancy at term (37th to 42nd week of gestation). They were compared with a control group of nonstimulated patients (n = 26), also with normal course of pregnancy and corresponding gestational age. Fetal heart frequencies and an external tokogram were recorded synchronously with the fetal respiration, body, limb and eye movements registered simultaneously by two independent observers and the fetal behavioral statuses were defined (Nijhuis, Prechtl et al. 1982; Boos and Schmidt 1984; van Vliet et al. 1985). The stimulation methods used were as follows: 1. Single-frequency pure tone (2 kHz, 120 dB, 5 sec) 2. Sawtooth-modulated pure tone (0.5-2.0 kHz, modulation frequency 10 Hz, 120 dB, 5 sec) 3. Low-frequency, sawtooth-modulated pure tone (with vibration effect), (0.1-0.3 kHz, modulation frequency 10 Hz, 120 dB, 5 sec) 4. Light stimulation: electronic photographic flash, luminous intensity 25 X 10(6) Lux/10(-3) sec, 8 flash sequences in 10 sec, distance from maternal abdomen 20 cm. In order to rule out purely coincidental changes in fetal attitude, both genuine and "sham" stimulations were performed in randomized sequence, in the latter case without any acoustic or light-optic signals. No differences in fetal reactions were found with the three different acoustic stimulation methods.(ABSTRACT TRUNCATED AT 250 WORDS)

[Vascular abnormalities of the umbilical cord--incidence, significance and possibility for prenatal ultrasonic detection]. / Gefässanomalien der Nabelschnur--Inzidenz, Bedeutung und Möglichkeit der pränatalen ultrasonographischen Erfassung.

Vascular anomalies of the umbilical cord are amongst the most frequent congenital malformations, their incidence being 0.2% to 1.4%. As a result of the latter the risk of occurrence of other malformations and chromosomal anomalies is markedly elevated. Between January 1977 and July 1987 a total of 78 cases (0.51%) of umbilical cord vascular anomalies were recorded at the Department of Gynaecology of the University of Heidelberg. Malformations occurred in 37% of the foetuses involved. 28% showed retarded growth and 9% had an abnormal set of chromosomes. Anomalies of the urinary tract and malformations of the thoracic organs were very frequent. Total mortality after the 28th pregnancy was about 14%. Currently available high-resolution real-time ultrasound equipment can show up even prenatally pathological variations of the umbilical vascular pedicle (e.g. a single umbilical artery). Because of the manifold risk involved, routine ultrasound control is recommended. If this anomaly is diagnosed, the pregnancy should be classified and treated immediately as a high-risk pregnancy.

[Prune belly syndrome. Prenatal diagnosis and obstetric procedure]. / Das Prune-Belly-Syndrom. Pränatale Diagnose und geburtshilfliches Vorgehen.

With an incidence of between 1 in 30,000 and 1 in 50,000 births, prune-belly syndrome (PBS) is a rare malformation syndrome. The phenotypical and pathoanatomic changes range from discrete expression to very severe malformation complexes with extremely poor prognosis. Malformations of the kidneys and the efferent urinary tract are common. In such cases, oligohydramnios often develops early in such fetuses, followed by Potter's sequence. This syndrome can generally be diagnosed by timely ultrasound investigations, i.e., before the end of the first half of pregnancy. Striking features in the fetus are often oligohydramnios and a greatly dilated urinary bladder, more rarely multicystic-dysplastic kidneys and other malformations of the urogenital tract. Diagnostic possibilities and obstetric procedure are described on the basis of ten cases seen between January 1984 and July 1987 at Heidelberg University Gynecological Clinic.

[Comparison of perineal sonography and abdominal ultrasound examination in placenta praevia]. / Vergleich der Perinealsonographie und der abdominalen Ultraschalluntersuchung bei Placenta praevia.

This study describes a comparison between two different ultrasound methods used to localize a low-lying placenta or a placenta previa. The methods implemented were the abdominal ultrasound and the so-called "perineal scan", an ultrasound examination of the female urogenital tract, which is performed by using the perineum as an acoustic window. Between 1985 and 1988, 84 patients, suspected of having a low-lying placenta, were examined by perineal scanning. In all these cases it was possible to compare the results with those of abdominal ultrasound examinations documented in the patient's records. The "perineal scan"-examinations were performed "blind", i.e., without knowledge of the results of prior abdominal ultrasound. Abdominal sonography was performed by a different examiner using the full-bladder-technique. Perineal scanning was done a short time after voiding. The results showed considerable and significant (p less than 0.001) discrepancies between the two methods; perineal scanning more often demonstrated higher grade diagnoses (27 patients, 32%) than vice versa (9 patients, 11%). These differences may be at least partially explained by the influence of bladder distension. Probably a full bladder produces false negative results more often than previously suspected. An analysis of pregnancy outcome yielded positive predictive values of 78% (abdominal ultrasound) and 86% (perineal scanning). Perineal scanning therefore seems to provide an uncomplicated and reliable means to verify an abdominal placenta localisation.

[Doppler ultrasound in obstetrics--contribution to understanding reverse flow in the umbilical artery]. / Dopplersonographie in der Geburtshilfe--Beitrag zum Verständnis des "Reverse Flow" in der Arteria umbilicalis.

"Reverse Flow" as a Doppler sonographic finding indicates the appearance of retrograde blood flow in the diastolic part of the cardiac cycle. It has so far not been observed in uncomplicated pregnancies and seems to be an indicator of severe deterioration of the foetal condition. Several pathophysiological hypotheses are discussed in this paper on the basis of own results and the findings of other investigators.

[Discolored amniotic fluid--results of prenatal diagnosis and clinical significance]. / Missfarbenes Fruchtwasser--Ergebnisse der pränatalen Diagnostik und klinische Bedeutung.

7000 pregnancies were analysed after genetic amniocentesis in respect of the further course and results of prenatal diagnosis (observation period 1975-1988). In 3.1% (217 cases) samples of amniotic fluid were discoloured. Vaginal haemorrhages prior to amniocentesis were recorded with significantly higher incidence (18%) in patients with discoloured amniotic fluid than in a control group (n = 217) with normal colour of the amniotic fluid (4.6%) (p less than 0.001). Miscarriages and chromosome anomalies occurred more often in the study group (3.7%/2.8%, control group: 0.9%/1.8%, n.s.). The risk of miscarriages was increased in cases with sanguineous amniotic fluid if the amniotic fluid alpha-fetoprotein values were enhanced at the same time. Significant differences were observed in respect of the incidence of foetal malformations in patients with discoloured amniotic fluid (7.8%) and in the control group (2.3%) (p less than 0.01). Borderline or definitely pathological amniotic fluid AFP concentrations were found often if the amniotic fluid was discoloured (6.9%, control group 3.2%). If discoloured amniotic fluid was sampled, foetal malformations should be excluded sonographically. In 82% of all cases with discoloured amniotic fluid and foetal malformations pathological sonographic findings and/or enhanced MS-AFP values were recorded even prior to amniocentesis.

[Premature separation of the placenta--clinical findings and fetal monitoring]. / Vorzeitige Plazentalösung--klinische Befunde und fetale Uberwachungsmethoden.

In a study group of 41 pregnant women of postpartally confirmed placental abruption, the prognostic value of clinical and diagnostic findings was investigated. The incidence of placental abruption was 1.4% of all deliveries within a three-year interval. 51% of patients showed vaginal bleeding before delivery. Retroplacental haematoma was found in 49% of cases ultrasonographically. A total of 75% had a pathological CTG test. More than 95% of these findings occurred within 3 days before delivery. Abnormal Doppler flow findings in foetal vessels more than 3 days before delivery were seen in 62% of cases. In the last three days before delivery, 86% were abnormal. Preterm delivery before 37 weeks of gestation was registered in 82% of patients. Perinatal mortality amounted to 12%. The rate of severely dystrophic newborn was 30%. Even in cases with lack of the clinical and/or sonographical findings, the possibility of placental abruption should be considered, if an acute deterioration of cardiotocographic or Doppler-sonographic findings.

[Doppler ultrasonography--perinatal data in cases with end-diastolic block and reverse flow]. / Doppler-Sonographie--Perinatologische Daten bei Fällen mit enddiastolischem Block bzw. Reverse Flow.

In 50 cases with an end-diastolic zero flow or reverse flow all antenatal and perinatal abnormalities have been recorded. The fetal outcome was registered. The percentage of highly dystrophic newborns (percentile less than 5) was 88%. The perinatal mortality counted up to 16% and the percentage of congenital malformations (including chromosomal anomalies) was 12%. A reverse flow was registered in 4 cases. The perinatal mortality of those cases with reverse flow was 100%. In approx. one-quarter of those pregnancies and in 50% of the perinatally deceased newborns, there were no pathological or suspicious changes in the antepartal and/or subpartal CTG-recordings. The Duplex sonographical diagnosis of an end-diastolic zero flow/reverse flow, has a highly positive predictive value, whereas its sensitivity is low. It can be regarded as a very helpful parameter in clinical diagnosis, particularly as it is independent of borderline values. The correct choice of the high-pass wall filter (50-100 Hz) is important.

[Value of vaginal ultrasonography in noninvasive assessment of the endometrium of the postmenopausal uterus]. / Der Stellenwert der Vaginosonographie in der non-invasiven Beurteilung des Endometriums am postmenopausalen Uterus.

The endometrial carcinoma shows an increasing incidence and represents today the most frequent malignoma of the female pelvis. Until now all techniques of detection of this carcinoma or its precursors are invasive and thus are not suitable for screening investigations. Vaginosonography, as the first non-invasive diagnostic method, now supplies knowledge about the state of the endometrium. At the Gynaecological Department of the University of Homburg/Saar, West Germany, 221 patients had been preoperatively subjected to vaginosonography before they underwent surgery. Sonographical and histological findings corresponded in atrophic endometrium in 82%, in regular, perimenopausal endometrium in 91%, in endometrial polyps and hyperplasia of the endometrium in 56%, and in endometrial carcinoma in 79%. With regard to the detection of endometrial cancer, a specificity of 96%, a sensitivity of 93%, a positive predictive value of 79% and an accuracy of 96% were established. Thus, according to our experience, vaginosonography represents a valid, non-invasive diagnostical method as a suitable instrument for screening the endometrium.

[Doppler sonography--effect of fetal position, site of the placenta and measurement site of the fetal aorta]. / Doppler-Sonographie--Einfluss des fetalen Lagetyps, des Plazentasitzes sowie des Messortes an der fetalen Aorta.

The influence of fetal position, the site of placenta and the site of measurement in the fetal aorta on doppler-flow parameters was investigated in patients with uncomplicated pregnancies. In 20 cases the S/D-ratio was obtained in three different regions of the descending aorta. Measurements superior the renal vessels showed comparable values (4.1-4.3). No differences were found between signals obtained cranial or caudal of the diaphragma. Measurements at the aortal bifurcation showed significantly increased median values (6.6, p less than 0.05). No differences could be obtained concerning the influence of fetal position or site of placenta on S/D-ratio. All median values of a total of 197 patients were in the range of 4.8. Therefore it may be concluded that the above mentioned parameters do not have significant influence on doppler flow parameters in fetal vessels. However, a proximal site of measurement in the descending aorta fetalis should be reassured.