[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.

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 beta-mimetic tocolysis on cervical ripening and plasma prostaglandin F2 alpha metabolite after endocervical application of prostaglandin E2.

To suppress uterine contractions during cervical ripening induced by prostaglandin E2 (PGE2) gel, beta-mimetic drugs were given orally 30 minutes before PGE2 application to 17 patients with unripe cervix. This prevented the increase in contraction frequency observed during the first four hours after PGE2 application in 17 controls. Nevertheless, cervical ripening proceeded at a similar rate and the clinical outcome was comparable in both groups. Prostaglandin E2 application caused a transient rise in plasma levels of the PGE2 alpha metabolite (13,14-dihydro-15-keto), which was not prevented by pretreatment with beta-mimetics. Patients with premature rupture of the membranes had higher initial plasma PGF2 alpha metabolite levels than those with intact membranes but cervical ripening proceeded with the same rate, and the effect of beta-mimetics was the same in both groups. Thus, cervical ripening induced by PGE2 does not depend on uterine contractions, and increased production of PGF2 alpha is unrelated to the ripening process. There was no difference between the three beta-mimetic agents in the present study.

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.

Premature rupture of membranes near term: induction of labor with endocervical prostaglandin E2 gel or intravenous oxytocin.

We have studied the influence of endocervical application of 0.4 mg prostaglandin E2 (PGE2) in gel on the clinical outcome of pregnancies of at least 36 weeks' duration complicated with premature rupture of the membranes (PROM) and unripe cervix, (modified Bishop score of 7 or less). There were 579 women in the study. The PGE2 gel was applied within the first 12 hours after PROM. The first 60 women were randomly divided into controls given oxytocin infusions and experimental subjects given PGE2 gel. All others were given PGE2 gel, and the results were compared with those obtained in patients with similar criteria who were treated with oxytocin infusions during the preceding year. The clinical outcome was significantly better in the PGE2-treated patients than oxytocin-infused patients. PROM to delivery interval and the incidence of operative deliveries were significantly reduced. No adverse effects on the neonates were observed and the incidence of neonatal infection declined. It is concluded that cervical ripening with PGE2 gel in patients with PROM and unripe cervix near term significantly improves the outcome for both mother and child.

[Programmed breech deliveries (author's transl)]. / Die programmierte Beckenendlagen-Geburt

The question whether the termination of a breech pregnancy by a programmed breech delivery would reduce the fetal risk was investigated. In 71 of 433 singleton breech deliveries (16%) the breech delivery was induced by oxytocin infusion. There were 38 primigravidas and 33 multi-gravidas. The Apgar and pH values showed the same results as in 3904 vertex deliveries with spontaneous onset of labour. The duration of labour was shortened. The incidence of Caesarean Section in programmed breech deliveries was 9.86%. All 71 infants were mature and healthy. There were no perinatal deaths. The results show that the fetal risk in breech deliveries is reduced by programmed breech delivery to the same risk as in vertex deliveries with spontaneous onset of labour.

[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.

[Risks in intensive care of twin pregnancies (author's transl)]. / Gefahren bei der Intensivbetreuung von Zwillingsschwangerschaften.

While organic immaturity used to be the most common cause of death among twins, in the past, prenatal death of the embryo due to hypotrophy has increasingly come to the fore, in our days. The reasons for such change in causes of death are discussed together with conclusions, on the basis of the author's own results.

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.

[Prognostic and therapeutic implications of the antenatal care of multiple pregnancies]. / Prognostische und therapeutische Konsequenzen bei der Uberwachung von Mehrlingsgraviditäten.

From January 1967 to April 1978, 175 twin deliveries occurred among 19,935 deliveries (.88%). A comparison to the literature a low perinatal mortality of 4.57% (adjusted 2.84%) was noted. The reason for the 3 to 5 fold increase in perinatal mortality compared to single on pregnancies was investigated. Review of the records showed conditions specific for twin pregnancies. The treatment necessary to improve the prognosis for twin pregnancies was discussed. It is suggested that the perinatal mortality of 2% for twin pregnancies can be achieved with intensive antenatal care for twin pregnancies.

[Induction of cervix maturation by oxytocin vs. PGF2 alpha infusion, vs. intracervical PGE2 gel in risk cases with immature cervix]. / Induktion der Zervixreife mit Oxytocin- versus PGF2 alpha-Infusion versus PGE2-Gel intrazervikal bei Risikoschwangeren mit unreifer Zervix.

From April 1, 1978 to March 31, 1979 199 patients with a high risk pregnancy and a Bishop score of less than 7 among a total number of deliveries of 2075 needed induction of labour for medical indications. In 143 patients oxytocin infusions were given, in 56 patients PGF2 alpha infusions were given. It was shown that PGF2 alpha by infusion showed no advantages over oxytocin infusions. The duration of labour and delivery was not shortened. The foetal morbidity was not decreased. The incidence of Caesarean section remained unchanged at a high 32% and the incidence of vaginal operative delivery remained high at 50%. The incidence of post-partum acidosis in the newborn remained at around 14%. Therefore induction of labour was tried on the unripe cervix in the following 12 months with the intra-cervical application of 0.4 mg. PGE2 gel in 202 patients. The same criteria of high risk pregnancies and unripe cervices were used in the following 12 months. In contradistinction to the induction of labour with oxytocin infusion or PGF2 alpha infusion statistically very significant differences in favor of PGE2 gel were found. The foetal morbidity during labour, the duration of labour, the mode of delivery, the neonatal morbidity and the post-partum maternal condition regarding haemoglobin and pyrexia were improved. The low incidence of Caesarean section at 8% and the low incidence of post-partum acidosis in the newborn was especially noteworthy in the PGE2 gel group. Although excellence of prenatal care is essential for the improvement of obstetric results the timely termination of a high risk pregnancy is the second important step to reduce maternal and foetal morbidity. PGE2 gel intracervically improves this second step.

[Value of treatment with dihydroergotamine for hypotension in pregnancy]. / Wert der Dihydroergotamin-Behandlung bei der Hypotonie in der Schwangerschaft.

Hypotension during pregnancy must be taken seriously. This complication is definitely serious enough to merit treatment. However, examinations have been lacking so far proving the advantages or possible risks of antihypotensive therapy. A short while ago the authors reported on favourable results obtained with dihydroergotamin (DHE) in hypotensive patients. It was the aim of the present study to test this finding, which had been obtained with a relatively small group of patients, by employing a large group. The evaluation was based on the statistical data from 400 hypotensive pregnant women who had delivered during the time between 1.1. 1982 and 31.8. 1983 in the obstetrical department of the Berlin-Neukölln Hospital Pregnant women were considered to be hypotensive if they had appeared for examination at least three times up to the 28th week of pregnancy with a maximum systolic blood pressure of less than or equal to 110 mmHg and diastolic pressure of less than or equal to 60 mm Hg. In relation to the total number of births of 4763, the proportion of hypotensives was 8.4%. 204 (4.3%) hypotensive women were subjected to DHE treatment; 156 of these took regularly 2 X 2.5 mg DETMS retard, whereas compliance was irregular with the remaining 50 patients. 196 (4.1%) refused treatment. The fact that the percentage of women willing to undergo treatment was relatively low (39%) is attributed partly to pregnant women being afraid of taking drugs, and partly to the attitude adopted by gynaecologists who are often hardly convinced that hypotension is a grave sign.(ABSTRACT TRUNCATED AT 250 WORDS)

[Can fetal blood analysis be avoided during the expulsion period?]. / Kann in der Austreibungsperiode auf die Fetalblutanalyse verzichtet werden?

The examinations described here were made in order to answer the question - how often, in spite of suspicious CTG patterns during the second stage of labor, were the fetal blood tests normal, and a spontaneous delivery or a further propulsion of the presenting part could be expected? The data of 201 patients formed the statistical basis for this survey; these patients were delivered at the Department of Obstetrics in Berlin- Neuk olln Hospital during the period from September 1975 to September 1976. Each patient had a suspicious Hammacher Score (greater than or equal to 3 points) during the second stage of labor, and due to this, the fetal acid-base balance had been examined. The course of 201 labors was divided up into those where the CTG first necessitated a fetal blood analysis in the mid-pelvic plane (n = 159) and those where the FBA was not necessary before the fetus was on the pelvic floor (n = 42). It was shown that with an increase in CTG score points the proportion of pH levels less than or equal to 7.24 increased. The peak of frequency division was at 4 points. In this group however, there was only a pH level of less than or equal to 7.24 in 4.2% of the infants. Acidotic pH levels were only present after greater than or equal to 5 score points. Here it was not possible with the CTG score to give definite evidence about the real risk to the fetus in a single case.(ABSTRACT TRUNCATED AT 250 WORDS)

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)

[Hypotension in pregnancy, a sequela of adrenal cortex insufficiency?]. / Hypotonie in der Schwangerschaft, Folge einer Nebennierenrinden-insuffizienz?

Because of certain similarities in the symptoms of hypotension and adrenal cortical insufficiency, etiological connections have long been postulated. In the prospective study reported here the behavior of plasma renin activity, angiotensin II, aldosterone and cortisol values were therefore investigated in 10 normotensive and 20 hypotensive women during pregnancy. Blood samples were taken from all women at the start of the study and 10-14 days later, in each case following orthostatic loading. Following randomization between taking blood samples, the hypotensive gravidae were given either 2 X 1 placebo tablets (n = 10) or 2 X 2.5 mg dihydroergotamine (DETMS retard) (n = 10) daily on a double-blind basis and continued to take the tablets until their children were born. Among the hypotensive gravidae there were no low aldosterone or cortisol values typical of Addison's disease, nor any severely increased PRA and angiotensin II values. Therefore, adrenal cortex insufficiency can be ruled out as a cause of their hypotension. While no differences were found between the hypotensives treated with DHE and the normotensive women as regards gestation period, birth weight and body length of the newborn, statistically significant abnormalities were found among the hypotensive patients: the mean gestation period was two weeks shorter, birth weight was around 400 g lower and body length approx. 2 cm shorter. The cause of these obstetrically undesirable results among untreated hypotensive patients cannot be explained by adrenal cortical insufficiency. Rather, a prime etiologic factor seems to be a disorder of venous hemodynamics.

[Value of the Hammacher score and fetal blood analysis in subpartal monitoring of the child]. / Stellenwert des Hammacher-Scores und der Fetalblutanalyse bei der subpartualen Uberwachung des Kindes.

Although it has been documented in many studies that optimal monitoring of the fetus during labor is only achieved through a combination of cardiotocography (CTG) and fetal blood analysis, up to now no uniform guidelines exist as to when fetal blood analysis should be performed. Furthermore, there are still many obstetricians who decide on their delivery procedure entirely on the basis of CTG. We have therefore examined the question of how accurately intrauterine risk situations of the fetus can be recognized in individual cases by using the Hammacher score only from particular CTG patterns. The data from 407 patients formed the statistical basis. All these patients had been delivered between January and September 1979 at the Department of Obstetrics at the Women's Hospital in Berlin-Neukölln. In all cases, at least one fetal blood analysis had been performed on account of a suspicious CTG during the course of labor. All actual pH values were combined with the Hammacher score of the corresponding 30-min-interval, and in addition we recorded the CTG patterns seen. We observed that the CTG was at least suspicious (greater than or equal to 3 points) in 79,3%, while the fetal blood analyses performed immediately afterwards were normal in 78,1%; only in 11,7% it was reduced to 7,29-7,25 and in 10,2% it was less than or equal to 7,24 (incl. 3,9% less than or equal to 7,19). The probability that a high score was associated with a reduced pH increased from 2% at 0-2 points, to 26,3% at greater than or equal to 5 points.(ABSTRACT TRUNCATED AT 250 WORDS)

[Avoiding cesarean deliveries by intravenous prostaglandin E2 administration (PGE2)]. / Einsparung von Schnittentbindungen durch intravenöse Prostaglandin-E2-Gabe (PGE2).

The study reported here was prompted by the question whether caesarean deliveries which would otherwise be necessary can be avoided by intravenous infusion of prostaglandin E2 (PGE2). The authors consider intravenous administration of PGE2 during delivery to be indicated in cases which fail to respond to therapy after three local cervical maturation attempts and in standstills where oxytocin has no effect. Out of a total of 5835 women who gave birth at the Obstetrics Department of the Berlin-Neukölln Gynecological Clinic between 1980 and 1981, those who had been given intravenous infusions of PGE2 were identified and a check was made to establish whether this treatment offers any advantages. PGE2 infusion after unsuccessful intracervical application of PGE2 gel: Out of 1122 risk patients in whom cervical maturation prior to induction of birth appeared desirable, 43 (3.8%) still had a Bishop Score of less than or equal to 7 after three local applications of PGE2 gel. Attempts to achieve a vaginal delivery in spite of this, by means of PGE2 infusion, were successful in 60% of the cases. The mean rate of PGE2 infusion was 1.1 +/- 0.3 microgram/min. Four women were given oxytocin in addition, in an average dose of 9.3 +/- 1.1 mU/min. The average duration of labour was 10 hours 30 min. Complications in mother and child occurred no more frequently than in other risk births. PGE2 infusion in cases with standstill not responding to oxytocin treatment: In 82 parturients (1.4%) a standstill occurred during labour after initially normal dilation of the cervix, and could not be overcome by administration of oxytocin.(ABSTRACT TRUNCATED AT 250 WORDS)

[Hematologic diseases in pregnancy; a danger to mother and child or a calculable risk?]. / Hämatologische Erkrankungen in der Schwangerschaft; eine Gefahr für Mutter und Kind oder ein kalkulierbares Risiko?

In 1985 the authors delivered six gravidae who had blood diseases during pregnancy; they included one patient with thalassemia minor, one with Hodgkin's disease, one with Glanzmann's thromboasthenia, one with Von Willebrand-Jürgens syndrome, one with Werlhof's disease and one with HELLP syndrome. The problems which arose were managed in close collaboration with internists and pediatricians and healthy infants were born in all cases. No aggravation of the basic disease was seen in any of the mothers. Cesarean section was necessary in two cases, while vaginal deliveries were accomplished in the other four. The chances of vaginal delivery were improved in particular by prior cervix priming with prostaglandin E2. In summary it may be said that with present-day monitoring and treatment possibilities, blood diseases during pregnancy have become a calculable risk. However, the cost--in terms both of equipment and personnel--must not be underestimated.