[Pathophysiology and clinical aspects of pre-eclampsia]. / Zur Pathophysiologie und Klinik der Präeklampsien.

From the pre-natal follow-up it was remarkable that cases have been admitted relatively late. Hints to a possible development of preeclampsia could be seen from patients history or the routine check up, for example the registration of edema, fetal growth retardation and oligohydramnios. For early diagnosis of preeclampsia we recommend: Calculation of mean arterial blood pressure or its non-invasive measurement; determination of hematocrit, uric acid and total plasma protein (in particular hemorheologic measurements). Hypomagnesemia in preeclampsia, as described by some authors, was also seen in our cases. The complex symptomatology of preeclampsia could be attributed to a generalised disturbance of microcirculation, which leads to definite reactions of the organs concerned. The microcirculatory failure is caused by vasoconstriction, hemoconcentration, hyperviscosity and hypercoagulation (up to DIC and consumption coagulopathy). The resulting symptoms and syndromes can be: EPH, HELLP, hemolytic-uremic Syndrome, hepato-renal Syndrome, thrombocyte and antithrombin III deficiency etc. The drug of choice for treatment of preeclampsia is magnesium sulfate. Its application is based on long-term clinical experience and new aspects on the physiologic and pharmacologic role of magnesium. The recommendations of the German High Blood Pressure League to use calcium antagonists as a basis in the treatment of high blood pressure can be fulfilled particularly in pregnancy by the physiologic calcium antagonist Mg++. Magnesium sulfate should be given in a dosage of 24-72 g daily. The dose should also be made dependent from urinary output. Further treatment patterns of preeclampsia should be adjusted according to each case. The present results also support our hypothesis that magnesium deficiency (besides predisposing factors) could be responsible for the development of preeclampsia (present model shown in detail). Consequently, the early and long-term substitution of magnesium in pregnancy could help reduce preeclampsia.

[Current concepts in the pathogenesis of gestosis with special reference to magnesium deficiency]. / Neuere Modellvorstellungen zur Pathogenese der Gestose unter besonderer Berücksichtigung eines Magnesium-Mangels.

Particular investigations and hints from the literature led to suggest that Magnesium deficiency in pregnancy plays a role in the development of pregnancy-induced hypertension as well as gestosis or pre-eclampsia. The integration of the already known facts about the physiopathology of Magnesium deficiency to those of the pathogenesis of gestosis led to the concept of a gestosis model which is based on Magnesium deficiency. In this way Magnesium deficiency represents the cause of (essential) gestosis. Further investigations should be done in this direction.

[Successful further prolongation of immature twin pregnancy by tocolysis and re-cerclage following unavoidable delivery of the first foetus after emergency cerclage (author's transl)]. / Erfolgreiche weitere Prolongation unreifer Zwillingsschwangerschaft durch Tokolyse und Re-Cerclage nach unaufhaltsamer Geburt des ersten Feten nach Notfall-Cerclage.

The article reports on a twin pregnancy with EPH gestosis in a 20-year old primipara which could be prolonged by tocolysis and emergency cerclage after signs of premature delivery and prolapse of the amniotic sac in the 28th/29th pregnancy week. At the beginning of the 30th gestation week there was an unavoidable delivery of the first twin (920 g) who survived for 5 days only due to immaturity and hypotrophy. Directly after delivery of the first twin the pregnancy for the second twin was prolonged by renewed tocolysis and renewed circular suture of the cervix. This enabled the second child, whose growth had been retarded like that of the first one, to continue to grow for some time. Unavoidable delivery of the second twin (1,650 g) eventually occurred at the beginning of the 32nd week of pregnancy. The eutrophic child survived without the slightest complication. This case is presented in detail and discussed, including the histology of the placenta. The most important points for enabling the survival of a twin foetus are sufficient tocolysis, a satisfactory technique for occlusion of the os uteri, as well as exclusion and prevention of chorioamnionitis.

[Clinical course of premature and newborn infants of mothers with HELLP syndrome]. / Klinische Verläufe bei Früh- und Neugeborenen von Müttern mit HELLP-Syndrom.

The HELLP-syndrome is complicated by a maternal mortality of 3.5% and a perinatal mortality between 9.5 and 60%. It is a variant of severe preeclampsia which includes hemolysis, elevated liver enzymes and low platelets. It is described in the literature that neonates of mothers with HELLP-syndrome show characteristic symptoms especially thrombocytopenia, leukocytopenia and prenatal somatic dystrophy. In this retrospective investigation of 36 preterm and term infants of mothers with HELLP-syndrome we found the following results: 1. Thrombocytopenia was seen in 11% and leucocytopenia in 12% of the analysed cases. Anemia was seen in 10% of the analysed neonates. They needed transfusion of blood. The rate of prenatal somatic dystrophy was increased (58%). 2. Elevated blood pressure was observed in 29% of the neonates within the analysed interval. The time of artificial ventilation of preterm infants with maternal HELLP-syndrome was in 37% extended in comparison with infants without HELLP-syndrome in pregnancy. 3. The perinatal mortality was 8%. All observed infants during delivery and of the neonatal period in our collective survived.

[The use of partusisten in the delivery of triplets with an incarcerated fetus (author's transl)]. / Einsatz von Partusisten bei einer Drillingsgeburt mit inkarzeriertem Feten.

A triplet delivery is reported. The multiple pregnancy was undiagnosed prior to labor. Twins were diagnosed on admission for delivery. The ultrasonic and abdominal EKG findings at term are discussed. The hitherto undiagnosed third triplet became incarcerated following the administration of two units of syntocinon after the delivery of the second triplet. The intrapartum tocolysis with partusisten became life saving for the third triplet on three counts. 1. The progressive acidosis was stopped. 2. Time was gained to prepared for delivery of the last triplet. 3. Internal podalic version and extraction was much easier.

[The significance of betamimetics and magnesium for the outcome of pregnancy: II. The role of magnesium in the development of gestosis and fetal hypotrophy]. / Die Bedeutung von Betamimetika und Magnesium für den Schwangerschaftsausgang: II. Zur Rolle des Magnesiums bei der Entstehung der Gestose und fetalen Hypotrophie.

Of 4905 single pregnancies between 1979 and 1982 the 882 (18.0%) risk pregnancies managed tocolytically with Betamimetics and Magnesium were retrospectively compared with the remaining collective (R) of 4023 (82.0%) patients without management. The tocolysed patients (B/Mg) received Magnesium in addition to Betamimetics: since 1979/1980 a low dose Mg containing drug (Feto-Longoral) aimed at "cardioprotection" (3-6 mval Mg++ daily), and since 1981 to "support tocolysis" 30-40 mval Mg++ daily per os in the form of Mg-aspartate (Mg 5-Longoral). All cases of gestosis (G) in both collectives B/Mg and R were investigated. A normal collective (N) is obtained by subtracting G from R. For all collectives N, G, and B/Mg the following data were compared: mean age, parity, percentage with supplement Mg medication (only the B/Mg collective), the pregnancy outcome with respect to pregnancy duration and the number of intrauterine retarded infants (IUR: less than 10th percentile of the Bavarian Perinatal Evaluation (BPE), less than 25th percentile according to Hohenauer). The number of gestosis in the 882 B/Mg cases is zero. It is 97 (2.0%) in the remaining 4023 patients. The IUR rate (less than 10th perc. BPE) is 9.4% in the 3926 N patients, and is 45.4% in the 97 gestosis patients. The IUR rate is 17.8% in the 398 B/Mg patients of 1979 and 1980 who had received less adjuvant Mg (B/Mg [1]), and it is 10.1% in the 484 B/Mg patients of 1981 and 1982 who had received much higher Magnesium (B/Mg [2]).(ABSTRACT TRUNCATED AT 250 WORDS)

Magnesium therapy decreased the rate of intrauterine fetal retardation, premature rupture of membranes and premature delivery in risk pregnancies treated with betamimetics.

A higher percentage of intrauterine growth retarded (IUR) infants was found in patients treated with tocolytic drugs, indicating that placental insufficiency could be the cause of both premature labor and IUR. In order to evaluate the results of oral treatment with betamimetics and magnesium at different dosages, 534 (10.9%) pregnancies treated with tocolysis + cerclage (TC) of 4,905 single pregnancies managed in our hospital between 1979 and 1982 wee studied retrospectively. Addition of magnesium to betamimetics: since 1979/1980 3-6 mEq Mg2+ daily per os aimed towards 'cardioprotection', and since 1981, to 'support tocolyis' 30-40 mEq Mg2+ daily per os in the form of Mg aspartate. We compared: mean age, parity, percentage supplemented with Mg and outcome of pregnancy for each year; these parameters were also compared with those of normal pregnancies. The frequency of (completed) gestational periods less than or equal to 36 weeks was about 11% in the TC groups (only 2% in normal pregnancies). However, this was reduced annually from 11.0% in 1979 to 4.9% in 1982. The frequency of premature ruptured membranes (PROM) in premature infants was about 6% in the TC groups from 1979 to 1980. It was reduced to 2.2% in 1981 and to 1.6% in 1982 (normal pregnancies, about 1%). In the TC group the frequency of IUR (less than 10th percentile; Bavarian Perinatal Evaluation; BPE) amounted to 20.5% in 1979, and to 17.5% in 1980. It was reduced to 8.8% in 1981 and to 10.6% in 1982 (normal groups, between 8.3 and 11.5%).(ABSTRACT TRUNCATED AT 250 WORDS)

[A test for early detection of hypertonias conditioned by pregnancy (gestosis selection test - GST) (author's transl)]. / Ein Test zur Früherkennung schwangerschaftsbedingter Hypertonien (Gestose-Selektions-Test = GST).

72 patients were subjected to the gestosis selection test (= GST) during the 28th (+/- 3 weeks) week of pregnancy in the sense of a "screening" with regard to potential risk of gestosis. A detailed description of GST, which consists of the injection of a bolus of fenoterol is given. Depending upon the possibility of reducing the diastolic blood pressure, 2 groups of pregnant women can be distinguished with regard to the prospective assessment of the course of pregnancy: GST Group I: The diastolic blood pressure can be reduced by 30 mmHg and more - Development of gestosis is hardly probable. GST Group II: The diastolic blood pressure can be reduced by less than 30 mmHg - Development of gestosis probable. Of the prospectively examined 72 patients, 40 have meanwhile delivered. There was no gestosis in group I, whereas in group II there were 8 gestoses. The GST is compared with other screening methods based on blood pressure which were also carried out at the same time: the "roll over test" (ROT) as well as calculation of the mean arterial blood pressure during the second trimenon (MAP-2).

[The importance of betamimetics and magnesium for the outcome of pregnancy: I. Reduction of intrauterine growth retardation, premature rupture of membranes and premature birth after supplemental magnesium therapy]. / Die Bedeutung von Betamimetika und Magnesium für den Schwangerschaftsausgang: I. Reduzierung der Mangelgeburt, sowie der vorzeitigen Amnionruptur und Frühgeburt nach Magnesium-Zusatztherapie.

Of 4 905 single pregnancies recorded within a 4 year period (1979-1982) 882 (18%) were risk pregnancies managed with Betamimetics (B); of these 348 (7,1%) had tocolysis (T) and 534 (10,9%) tocolysis and cerclage (T/C). Since the end of 1979 the patients received in addition to the Betamimetic a K-Mg-Vitamin drug (Feto-Longoral) aimed at "Cardioprotection", and since the beginning of 1981 30-40 mval oral Mg daily in the form of Magnesium aspartate (Mg 5-Longoral) to "support tocolysis". The mean age, parity, percentage with Magnesium therapy, the pregnancy outcome using a gestational age limit less than or equal to 36 weeks, the frequency of premature ruptured membranes (PROM) in premature and mature infants as well as the number of intrauterine growth retarded infants (IUR) (less than 10th percentile BPE) were yearly evaluated and compared for both risk collectives T and T/C as well as for the normal collectives (N). While only 2% of the normal collectives had a pregnancy duration of less than or equal to 36 weeks (completed) the figure was five fold in both T and T/C groups, and however was yearly reduced in the T/C group from 11,0% (1979) to 4,9% (1982). The frequency of PROM with premature infants in the T and T/C groups is about 6% (N-collectives about 1%). It is however reduced in the T/C group in 1981 to 2,2% and in 1982 to 1,6%. For mature infants it is N: 17-12% (fluctuating) and B (T + T/C): 22-11% (yearly decreasing). The rate of IUR (less than 10th percentile BPE) in the T and T/C groups in 1979 was 22,2 and 20,5% respectively and in 1980 12,6 and 17,5% respectively. It is further reduced in 1981 to 11,6 and 8,8% respectively and in 1982 to 9,7 and 10,6% respectively (N-collectives between 8,3 and 11,5%). The "weight gain" exceeds the 25th percentile (Hohenauer): 1979 and 1980 for B: 33,1 and 30,2% respectively, and 1981 and 1982 for B: 25,4 and 24,2% respectively (N between 26,5 and 19,5%). The results show that patients with tocolysis--with or without cerclage--have more premature and growth-retarded infants than normal collectives (a sign of more placenta insufficiencies). In the two years where Magnesium was supplemented at 30-40 mval daily, short term pregnancies, the PROM frequency and the IUR rate decreased (statistically evaluated). It could thus be concluded that a relative Magnesium deficiency might have been responsible for a certain percentage of premature births and hypotrophic infants and that better results were obtained after Magnesium substitution.

[Reduced frequency of gestoses in beta-mimetic treated risk pregnancies with added magnesium therapy]. / Reduzierte Frequenz von Gestosen bei Betamimetika-behandelten Risikoschwangerschaften mit Magnesium-Zusatztherapie.

Retrospectively the 4,905 single pregnancies of the four years 1979-1982 are divided into 882 (18.0%) patients treated by tocolysis and 4,023 (82.0%) patients treated without tocolysis (R). The patients with tocolysis (BMG) received in addition to the Betamimectic agents since 1979 a low dose of magnesium (feto- longoral ) to protect the heart (3-6 mval Mg ++) daily and since early in 1981 to assist in the tocolysis 30 to 40 mval Mg ++ daily in the oral from of magnesium aspartate (Mg 5- Longoral ). The incidence of pre-eclampsia (G) in the groups BMG and R is recorded. The R group constitutes the normal group (N) by substracting the group G. Compared were in the groups NG and BMG the mean age and parity, the incidence of adjuvant magnesium medication, the duration of pregnancy and the incidence of intra-uterine growth retardation ( IUR ). The incidence of pre-eclampsia (G) in the 882 patients treated with Betamimetics and magnesium was 0. In the other 4,093 patients the incidence was 97 (2%). The rate of intra-uterine growth (lower than the 10% BPE ) was 9.4% in the 3,093 normal patients, 45.4% in the 97 patients with pre-eclampsia and in the 398 BMG patients of the years 1979 and 1980 with the small addition of magnesium (BMG 1) the incidence was 17.8%. In the 484 patients of the years 1981 and 1982, with large additional doses of magnesium (BMG 2) the incidence was 10.1%. The correlation of the intra-uterine growth retardation degrees (lower than 25% Hohenauer , 10% BPE ) was highest in the group G (1.3:1).(ABSTRACT TRUNCATED AT 250 WORDS)

[Alpha 1 fetoprotein in pre-eclamptic toxemia (author's transl)]. / Alpha1-Fetoprotein bei der EPH-Gestose

From 1973 to 1975, 287 serum levels of alpha 1 fetoprotein in women with pre-eclamptic toxemia were determined. Pre-eclamptic toxemia was classified according to modified scheme of Goecke and Rippmann. 161 patients had mild pre-eclamptic toxemia (index 1-3), 72 patients had moderate pre-eclamptic toxemia (index 4-6), 54 patients had severe pre-eclamptic toxemia (index 7). In all types of severity of pre-eclamptic toxemia more levels of alpha fetoprotein were lower or higher than the normal levels including the standard deviations. The number of abnormal values rose with an increasing toxemia index. There was no statistically significant difference between too high values and too low values. Significantly more values were above and also below the normal values. Our investigations appear to indicate that the determination of the alpha fetoprotein is not only valuable as screening method for neural tube defects but also of value in the diagnosis and management of pre-eclamptic toxemia. Too high and too low values should not be differentiated but values both above and below the normal levels should be considered.