[Prenatal sonography and computed tomography of fetal cerebral malformations]. / Pränatale Sonographie und Computertomographie zerebraler Missbildungen des Feten.

In three pregnant women, sonography and amniocentesis suggested cranial abnormalities of the foetuses. In view of the far-reaching consequences of such a diagnosis, CT was carried out to confirm the diagnosis. It was possible to show the intra-uterine abnormalities and the type of malformation in considerable detail. In one case an encephalocele was demonstrated, in the two others, an anencephalic foetus was shown.

[Preoperative differential diagnosis of cystic adnexal tumors: double-contrast MRT]. / Präoperative Differentialdiagnostik zystischer Adnextumoren: Doppelkontrast-MRT.

PURPOSE: Preoperative assessment of adnexal lesions as benign or malignant by MRI with gastrointestinal and intravenous contrast. METHODS: 46 patients with benign (n = 42) and malignant (n = 4) cystic adnexal tumours underwent MRI of the pelvis. Transaxial and coronal images were acquired using conventional T1- and T2-weighted SE-sequences after oral administration of superparamagnetic iron oxide particles (Ferristene). Additional T1-weighted SE-images were obtained immediately following gadodiamide (Gd DTPA-BMA) injection. RESULTS: MRI correctly classified the four malignant lesions, whereas nine histologically benign lesions were misdiagnosed as malignant. Intravenous contrast yielded a superior delineation of intratumor architecture. CONCLUSION: Due to exclusion of solid structures. MRI with oral and i.v. contrast enables to dismiss suspected malignity in cystic adnexal lesions. Because of the non-specificity of the macroscopic criteria of dignity, the MR diagnosis "malignity" is of limited value.

[Ultrasonographic diagnosis of a stenocephalus in combination with intestinal atresia (author's transl)]. / Ultrasonographische Diagnose eines Stenocephalus in Kombination mit einer Dünndarmatresie.

Microcephalus and atresia of the small intestines can be demonstrated by ultrasonic examination. Malformations can occur at any time during pregnancy. The reasons for it are hard to find. A single diagnostic including ultrasonic investigations, chromosome analysis and alpha-fetoprotein determination in the amniotic fluid during the first half of pregnancy is unsufficient and leads to pseudosecurity. The ultrasonic investigation by an experienced means a marked enrichment of the prenatal diagnostic. Every ultrasonic examination during pregnancy should consider these diagnostic possibilities.

[Development of symptoms and perinatal complications in HELLP syndrome]. / Symptomentwicklung und perinatale Komplikationen bei HELLP-Syndrom.

At the Kiel University Department of Gynaecology, 21 patients between the 21th and 39th week of gestation were treated in 1987 and 1988 following diagnosis of HELLP syndrome. At the time of diagnosis all patients presented an advanced gestosis/eclampsia. 9 patients developed the classical signs and symptoms, while hospitalised. The typical signs of gestosis, hypertension, proteinurea, oedema and hypoproteinaemia preceded the changes in laboratory values caused by the HELLP syndrome. Upper abdominal pain and increase in transaminase values occurred on the average 3.4 or 2.7 days prior to the decrease of, thrombocyte count. In 19 of the 21 cases, pregnancy was terminated by caesarean section. Severe peripartal complications occurred in 7 cases e.g. foetal death in utero (n = 3), eclampsia (n = 5), renal failure (n = 2), cerebral oedema (n = 1), intracerebral haemorrhage (n = 1), disseminated intravascular coagulation (n = 1), abdominal wall haematoma (n = 1). 6 of these patients were admitted after complications had occurred prior to admittance. All 18 infants born alive survived the neonatal period. The average birth weight was 1,571 g. 11 infants were discharged clinically normal. The remaining infants included 5 cases pointing to retinopathy and 3 cases of cerebral palsy. One infant developed post-haemorrhagic hydrocephalus.

[Chicken pox infection in early pregnancy]. / Windpocken-Infektion in der Frühgravidität.

We report on a case of chicken pox in early pregnancy, which occurred despite administration of zoster hyperimmunoglobulin. In this case, a healthy child was born. We discuss the purpose and efficacy of passive immunisation in varicella-zoster infections.

[HELLP syndrome in the 23d week of pregnancy. A case report and literature discussion]. / HELLP-Syndrom der 23. Schwangerschaftswoche. Falldarstellung und Literaturdiskussion.

A case report is given on a 24 years old primipara who developed a progredient HELLP-syndrome (H = hemolysis, EL = elevated liver enzymes, LP = low platelet counts) in the 23rd week of gestation two days after first diagnosis of pregnancy induced hypertension. As the situation became increasingly critical, the pregnancy had to be terminated in the 23rd week of gestation by sectio parva. To our knowledge the development of a HELLP-syndrome at this early gestational age has not yet been described.

[Prenatal diagnosis of triploidy (69,XXX) in the 29th week of pregnancy with fetal death in the 37th week of pregnancy]. / Pränatale Diagnose einer Triploidie (69,XXX) in der 29. Schwangerschaftswoche mit intrauterinem Fruchttod in der 37. Schwangerschaftswoche.

A case report is given on a pregnancy in the 29th week of gestation. Sonographic control showed extensive oligohydramnions, a size date discrepancy was noted, and there was no spontaneous movement of the fetus. An amniocentesis revealed triploidy as the cause. The clinical, sonographic, and hormonal data as well as the autopsy findings are discussed.

[Sonographic diagnosis of amniotic band syndrome]. / Sonographische Diagnose des Amnionbänder-Syndroms.

A case is reported of sonographic diagnosis of ADAM-complex (amniotic band syndrome) in the 19th week of gestation of an otherwise healthy pregnancy. The ultrasonic investigation showed absence of bony structures in the skull area a direct connection to the placenta. The intra-cerebral structures showed no abnormalities. Aminocentesis demonstrated normal chromosomal analysis and an alpha-fetoprotein value was within normal limits. The acetylcholinesterase examination was negative. Following prostaglandin induction, a spontaneous delivery of a 230 g freshly dead fetus occurred, the latter exhibiting a broadly-based amniotic band connection between skull and placenta.

Perinatal glucose metabolism as an indicator for stress and hypoxia during different forms of delivery.

In 82 term newborns divided into three groups (spontaneous delivery, caesarean section and vacuum extraction) we investigated umbilical artery pH, artery and vein glucose levels and calculated the veno-arterial difference of glucose. The three groups showed significant differences of artery and vein glucose levels. The highest umbilical artery (UA) and umbilical vein (UV) glucose levels were found after vacuum extractions (n = 13, UA: 98 mg/dl, UV: 104 mg/dl), the lowest levels were present in the group of caesarean section (n = 16, UA: 52 mg/dl, UV: 65 mg/dl). After spontaneous deliveries the intermediate levels were observed (n = 55, UA: 70 mg/dl, UV: 84 mg/dl). The mean of UA-UV-glucose difference was low after vacuum extractions and statistically different from the values after caesarean section and spontaneous deliveries. The mean of UA-pH did not show statistically significant differences in the three groups. The regression analysis between UA-pH and UA-UV-glucose difference revealed a highly significant dependency in the group of caesarean section (p less than 0.01) but no dependency after vacuum extraction. Significant dependency was also found in the group of spontaneous delivery (p less than 0.05).

The corticotrophin releasing hormone test in late pregnancy: lack of adrenocorticotrophin and cortisol response.

Biologically active corticotrophin-releasing-hormone (CRH) is produced by the placenta in large amounts and can be measured in the maternal circulation during third trimester of pregnancy. Its physiological significance is unknown. To further investigate the action of CRH in pregnancy, we performed a standard CRH-test (1 micrograms/kg synthetic human CRH) in seven pregnant women 1 week prior to their calculated delivery data and 4-5 weeks post-partum. No response of plasma ACTH to CRH administration could be measured in any of the third trimester pregnant women. Post-partum, basal ACTH levels were significantly lower (1.6 +/- 0.3 vs 5.3 +/- 0.2 pmol/l) and reacted promptly to CRH administration (1.6 +/- 0.3-4.2 +/- 0.5 pmol/l; P less than 0.05). Concentration of cortisol in plasma and salivary cortisol paralleled the ACTH response to administration of CRH. However, one pregnant woman experienced physical and emotional stress during the CRH-test and reacted with a sharp rise in cortisol secretion. The lack of the ACTH and cortisol response in this study to exogenously administered CRH in third trimester pregnancy may be due to high circulating glucocorticoid concentrations, desensitization of the pituitary corticotroph and/or in part due to circulating specific CRH-carrier protein.

[Perinatal morbidity of breech children in relation to mode of delivery. A retrospective study]. / Perinatale Morbidität bei Beckenendlage-Kindern in Abhängigkeit vom Geburtsmodus. Eine retrospektive Untersuchung.

A retrospective study was made on the perinatal morbidity and mortality of 268 infants born from breech presentation in the years 1984-1986. The fraction of vaginal deliveries changed from 12.8% in 1984 to 41.2% in 1986. Criteria for perinatal morbidity were: frequency of transfers to the pediatric department; Apgar score; and the pH in the umbilical cord arteries (pHU.C.A.). After vaginal delivery from pelvic presentation, the average pHU.C.A. was significantly lower than after cesarean section (p less than 0.05) in infants with a birth weight over 2500 g. Severe acidosis (pHU.C.A. less than 7.1) was equally rare in both groups; mild acidosis (7.1 less than or equal to pHU.C.A. less than or equal to 7.2) was more frequent in the vaginally delivered infants greater than or equal to 2500 g; 18.4% as opposed to 3.4% after cesarean section. It is remarkable, however, that mild acidosis was registered in 13-15% of all deliveries in the years 1984-1986. The different frequencies of transfer to the pediatric department and Apgar scores were not due to the different delivery methods.

[Prenatal diagnosis of severe stenosis of the ductus arteriosus Botalli in a twin pregnancy]. / Pränatale Diagnose einer hochgradigen Stenose des Ductus arteriosus Botalli bei Zwillingsschwangerschaft.

Premature ductus arteriosus stenosis is a rare cardiovascular disease, which has a poor prognosis. The case presented was detected even in early pregnancy and was progressed rapidly to the stage of severe foetal heart failure. The patient was first seen at 20 weeks of gestation with one of the foetuses of a twin pregnancy, showing signs of cardiac decompensation and advanced hydrops fetalis universalis. Obstruction of the ductus arteriosus may result from maternal tocolysis treatment with prostaglandin synthetase inhibitors, such as indomethacin or maternal salicylate or in conjunction with foetal post maturity.

[An enlarged neck fold: a sonographic marker of Down's syndrome]. / Vergrösserte Nackenfalte: Ein sonographisches Merkmal des Down-Syndroms.

We report about one case of twin pregnancy where one fetus is healthy and the other has Trisomie 21. The one large skin fold on the neck is observe in the ultrasound. This ultrasound finds is noticed in the Ullrich-Turner-Syndrome as well as in the Down Syndrome. The Trisomie 21 was ascertained after the birth. The clinical meaning of this sonographic criterium will be discussed in this paper.

Delivery of breech presentation infants at term. An analysis of 304 breech-deliveries.

304 breech presentation infants greater than or equal to 2.500 g were delivered at the University Women's Clinic, Kiel, between 1984 and 1987. Only 2 of the vaginally delivered infants died; both had severe malformations sonographically diagnosed prior to delivery. The umbilical cord arterial PH was found to be significantly (p less than 0.001) higher in infants delivered per Caesarean Section as compared to those vaginally delivered. The same ratio was found in a control group of vaginally delivered infants compared to sectioned infants in the vertex presentation. In 13.3% of cases post primary section and in 14.4% of cases post vaginal delivery from breech presentation we found an apgar of less than or equal to 7 one minute post-partum. The transfer rate to a paediatric unit of vaginally delivered infants (7.2%) appeared to be double that of the infants delivered per Caesarean Section (3.6%). However, the indication for transferral is principally independent of the mode of delivery. Taking the 3-12fold increased maternal mortality rate post section as compared to vaginal delivery into consideration, a vaginal delivery of a breech presentation infant at term appears to be justifiable under certain presuppositions: exclusion of cranio-pelvic disproportion, and normal progression of labour. The indication for secondary Caesarean Section should be generously applied in cases of a suspicious C.T.G. and a slow progression of labour.

Fetal heart rate (FHR) pathology in labor related to preceeding Doppler sonographic results of the umbilical artery and fetal aorta in appropriate and small for gestational age babies. A longitudinal analysis.

The aim of this study was to ascertain the value of serially performed Doppler sonographic measurements of fetal vessels for the prediction of FHR alterations in labor a longitudinal analysis was conducted. 24 patients with SGA fetuses as the only risk factor and 38 patients without any risk factor were recruited for the study. Flow velocity waveforms of the fetal aorta and the umbilical artery were analyzed for systolic diastolic (S/D) ratio weekly at 20-39 weeks gestation and from 30 weeks gestation onwards twice weekly. Courses were related to complications during labor reflected by alterations of FHR tracings. The more numerous pathologie S/D ratios of both fetal vessels were recorded the more frequently complications in labor occurred (Chi Square test, p < 0.05). The mean value of the S/D ratios in fetuses with FHR pathology in labor differed significantly compared to the uncomplicated group (Wilcoxon rank sum test, p < 0.05). The fluctuation of S/D ratios was greater in the complicated than in the normal group (Wilcoxon rank sum test, p < 0.05). A combination of parameters describing S/D ratios showed a sensitivity of 86% and a specificity of 19% for the fetal aorta and a sensitivity of 71% and a specificity of 91% for the umbilical artery. Serial Doppler measurements of the fetal aorta and the umbilical artery aid in predicting pathologic FHR alterations in labor and may be of benefit in antenatal care to ensure fetal well being particularly in cases of IUGR.

[Bacteriological examinations of liquid drawn from the pouch of Douglas (author's transl)]. / Bakteriologische Untersuchungen von Douglasflüssigkeit.

The article reports on bacteriological examinations of 510 samples of liquid drawn from the pouch of Douglas (excavatio rectouterina) during pelviscopy in patients not displaying any signs of inflammation. Bacterial populations were found in 270 samples (= 52.9%). The results are subdivided according to aerobic and anaerobic types of pathogens and their incidence.

Prenatal diagnosis of a probable hereditary syndrome with holoprosencephaly, hydrocephaly, octodactyly, and cardiac malformations.

Following genetic counselling of a consanguineous couple because of a daughter born with peripheral hypoplasia of the left arm, ultrasonographic examination during the second pregnancy revealed marked hydrocephalus of the fetus in the 17th week of pregnancy. Pathologic examination of the female fetus disclosed severe cerebral, cardiac, and skeletal malformations including holoprosencephaly, absent corpus callosum, microphthalmia, facial clefts, tetramelic octodactyly, and cardiac defects. These findings indicate a possible genetically determined syndrome that appears to be distinct in spite of some overlap with other malformation syndromes.

[Marfan syndrome and pregnancy, complicated by dissecting aneurysm]. / Marfan-Syndrom und Schwangerschaft, kompliziert durch das Aneurysma dissecans.

Pregnant women with a Marfan syndrome carry a risk of developing an aortic arc dissection. As the developing aneurism may be diagnosed by echocardiography, this method should be applied repeatedly during pregnancy. We report the case of a Marfan patient, who developed an acute aortic dissection during the third trimester of her pregnancy and discuss the guidance and surveillance of Marfan patients who are or wish to become pregnant.

Ectopic pregnancy treatment using pelviscopic or vaginosonographically-guided intrachorionic injection of methotrexate and POR 8.

It is believed by some that the basis of modern first-trimester pregnancy care should involve screening for ectopic pregnancy using vaginal ultrasonography. This has led to this condition being diagnosed in most cases at an earlier stage than has previously been possible. This advance in diagnostic ability has introduced the concept of conservative management for this condition. The authors describe the conservative management of nine cases of ectopic pregnancy using intrachorionic injection of either methotrexate alone or in combination with POR 8. In all cases less than 9 weeks had passed since the last menstrual period, and the ectopic pregnancies treated under ultrasound control were all thought to be viable. Five cases were treated using pelviscopy, whilst in another four the needle was guided using vaginal ultrasonography. There were no procedure-related complications. Following therapy, the women were followed up using serial levels of serum beta-hCG. In seven cases there was a gradual reduction to normal levels. There were two treatment 'failures'. In both these cases methotrexate alone, rather than in combination with POR 8, was used for injection. Although formal tests of tubal patency have not been performed in all cases, one woman in the series has since conceived and has a normal intrauterine pregnancy. It is concluded that vaginal instillation of methotrexate is an alternative treatment for early ectopic pregnancy. It should be limited to viable ectopic pregnancies whose chorionic cavities are less than 2.0 cm in diameter. A plan for the management of ectopic pregnancy is presented, involving selection for both ultrasound-guided injection and pelviscopic surgery. Laparotomy is not considered to be a treatment option in the majority of cases.