GerOSS (German Obstetric Surveillance System). A Project to Improve the Treatment of Obstetric Rare Diseases and Complications Using a Web Based Documentation and Information Platform.

BACKGROUND: Severe and very rare obstetric complications (e.g. eclampsia, postpartum haemorrhage or uterine rupture), typically culminate in a chaotic, uncontrollable sequence of events. Outcome for mother and child depends on whether doctors and midwives are able to quickly take correct decisions and initiate optimal treatment. OBJECTIVES: GerOSS (German Obstetric Surveillance System) aims at generating deeper insight into relevant risk factors to improve diagnosis and treatment of severe complications during pregnancy and delivery. As such it is primarily conceived as a system for quality improvement and less as a register. Another focus is the provision of an information and communication platform for dissemination of these insights. Finally, incidences of selected rare obstetric events may be derived. METHODS: These rare events are monitored for two to five years in Lower Saxony, Bavaria and Berlin. Quantitative analyses of aggregate data are complemented with in depth case based anonymised evaluations by experts. The temporal sequence of measures taken as well as the management of care is inspected. Participants receive a feedback of comments on the synopsis of individual cases. Aggregate data results are published and made available through the GerOSS platform. A scientific advisory committee ensures the link with the professional scientific bodies. A comparison within INOSS (International Network of Obstetric Survey Systems) allows additional insights into the treatment of obstetric rare diseases and complications. More reliable estimates of the incidence of such events can be computed and compared within a larger database. RESULTS: Following the implementation in three federal states in Germany in 2010, participation in GerOSS-Project has increased to 100% of all hospitals with a delivery unit in Lower Saxony, 30% in Bavaria and 80% in Berlin. Feasibility of the project is shown by successful implementation of GerOSS. Quantitative analyses enable construction of risk profiles (e.g. for the prevalence of hysterectomies and uterine ruptures) such that tailored treatment algorithms may be derived. Age, body mass index and previous caesarean section are common risk factors when complications occur. Respective recommendations have not always been adhered to in the diagnosis and therapy of such cases. The presentation of initial GerOSS results has paved the path for first changes in obstetric care. CONCLUSIONS: The envisaged expansion of GerOSS to an interactive platform will allow dissemination of insights such that optimal obstetric care and transferal among all involved medical facilities may see future enhancements via the internet or even through smartphone applications.

[Increased signal intensity of velocity measurements in duplex sonography by using the contrast agent levovist: a prospective, randomized study in a fetal sheep model]. / Verbesserte Signalintensität durch kontrastverstärkte Duplexsonographie mittels Levovist: Eine prospektive randomisierte Untersuchung beim Schaf-Feten.

PURPOSE: To evaluate the potential diagnostic advantages of the contrast agent Levovist for signal enhancement of small adjoining fetal vessels and to study the effect of Levovist before and during acute fetal hypoxia on the fetal circulation and the fetal blood flow velocities. MATERIALS AND METHODS: A prospective, randomized study was performed in 12 fetal sheep before and during acute fetal hypoxia produced by complete occlusion of the maternal common iliac artery. Two groups of animals were studied, comprising animals with (study group, n = 6) and without (control group, n = 6) Levovist. In the study group, Levovist was administered intravenously by a pump (modified IVAC P 4000, Schering, Berlin). Duration and intensity of signal enhancement were measured in the fetal aorta, the common carotid artery and the ophthalmic artery of both groups before and during hypoxia. Concurrently, fetal heart rates as well as systolic and diastolic blood flow velocities in all three vessels were recorded in both groups. RESULTS: The increased signal intensity of up to 15 dB in the study group resulted in improved differentiation and imaging quality of adjoining small fetal vessels when compared with the control group. Neither before nor during acute hypoxia, significant differences of the fetal heart rate and the systolic and diastolic blood flow velocities were observed between the two groups (p > 0.05). In the study group, no emboli were caused by Levovist in any fetal tissue or in the placenta. CONCLUSION: The contrast agent Levovist improves the detection and accuracy of monitoring flow velocities in small fetal vessels by increasing the intensity of the Doppler signal without affecting fetal heart rate or fetal blood flow velocities.

[Cranial sonography for newborn screening: a 10-year retrospective study in 11,887 newborns]. / Schädelsonographisches Neugeborenenscreening: Eine retrospektive 10-Jahresstudie an 11 887 Neugeborenen.

We retrospectively analyzed the results of a sonographic cranial screening study, performed between 1985 and 1994 to determine the incidence of intracranial hemorrhage and cerebral anomalies based on obstetrical risk factors. In the Department of Obstetrics and Gynecology of the University Giessen, Giessen, Germany, 94.6 % (n = 11,887) of all children born during the study period were included and underwent sonographic cranial screening within the first 10 days after birth. Cerebral abnormalities were found in 653 (= 5.5 %) cases, and peri-/intraventricular hemorrhages (PIVH, grade I-IV) in 303 cases. Periventricular leucomalacia, porencephaly, subarachnoidal hemorrhage and hydrocephaly were rare (< or = 0.2 %). The Apgar index proved to be a good prognostic factor, particularly at 1 and 5 minutes after birth (p < 0.0001). In contrast, correlation between PIVH and cardiotocography, arterial cord blood gases, and pH was poor. We did not observe a higher incidence of PIVH in newborns with growth retardation, preeclampsia and premature ruptures of membranes or prolonged labor. With decreasing gestational age, the frequency of PIVH increased progressively from 0.4 % at 39 weeks to 53.2 % at 27 weeks (p < 0.001). We also found a higher risk of intracranial hemorrhage in preterm newborns with amniotic infections (38.1 %, p < 0.001). In mature babies, we did not find a difference between the incidence of PIVH and delivery-modes; however, we noted a higher risk of PIVH Grade IV in preterm newborns with breech presentation for vaginal delivery versus caesarean section (38.5 % versus 7.4 %, p = 0.005). The incidence of PIVH over this 10 year time period did not increase despite an increasing number of preterm newborns over time. In conclusion, this study, which represents one of the largest patient cohorts studied for PIVH, indicates that neonatal sonographic cranial screening is an important tool to define quality control in obstetrics.

Blood flow velocity in the fetal abdominal aorta and in the umbilical artery in uncomplicated pregnancies.

The blood flow velocity waveform (BFWV) in fetal vessels depends on the stroke volume and the frequency of the fetal heart, the compliance of the vessel and the peripheral resistance of the fetal vascular bed. The objective of the present study was to establish the change of the BFVW throughout gestation and whether the change of the resistance indices are related to the peak flow velocity and/or the end-diastolic flow velocity. The BFVW of the fetal abdominal aorta and of the umbilical artery at 27th-30th week and at 37th-40th week of gestation were analysed in fifteen patients with uncomplicated pregnancies and subsequent normal outcome. The measurement was performed with a pulsed duplex scanner (Kranzbühler). The Doppler beam had a fixed angle of 50 degrees to the fetal vessel in all cases. The peak flow velocity in the fetal aorta remained constant from the 27th-30th week to the 37th-40th week of gestation: 1418 +/- 248 Hz vs. 1448 +/- 269 Hz. The end-diastolic flow, however, showed a significant increase during the respective periods: from 270 +/- 59 Hz to 325 +/- 69 Hz. The peak flow velocity in the umbilical artery was about 25% below that of the fetal aorta: 1028 +/- 149 Hz (27th-30th week) and 1106 +/- 196 Hz (37th-40th week). The end-diastolic flow, however, increased by about 41%: 292 +/- 86 Hz vs. 412 +/- 83 Hz demonstrating a tremendous change of the compliance and the peripheral resistance in the umbilical vascular system. These alterations are also exhibited by the resistance indices. The resistance indices S/D, PI and RI of both vessels were related to the EDF of the abdominal aorta and the umbilical artery at the respective gestational age. It demonstrated that the EDF is of major influence on the calculated resistance indices. The blood flow in the aorta and the umbilical artery was 135(+/- 18) ml/kg/min and 143 (+/- 21) ml/kg/min, respectively. In conclusion, the BFVW for fetal surveillance should be measured under a constant angle in the fetal abdominal aorta. It gives a good information concerning the peripheral resistance and compliance in the respective vascular areas. The EDFV has its lowest value at 200 Hz in the fetal aorta and in the umbilical artery under physiological conditions.

Social sex selection and the balance of the sexes: empirical evidence from Germany, the UK, and the US.

Preconception sex selection for nonmedical reasons is one of the most controversial issues in bioethics today. The most powerful objection to social sex selection is based on the assumption that it may severely distort the natural sex ratio and lead to a socially disruptive imbalance of the sexes. Based on representative social surveys conducted in Germany, the United Kingdom, and the United States, this paper argues that the fear of an impending sex ratio distortion is unfounded. Given the predominant preference for a "gender balanced family," a widely available service for social sex selection is highly unlikely to upset the balance of the sexes in Western societies.

[Blood flow in the umbilical vein and artery in pregnancy]. / Der Blutfluss in der Vena und Arteria umbilicalis während der Schwangerschaft.

Transplacental gas exchange and supply of nutritive substances to the foetus is guaranteed by an increase of umbilical blood flow (Qnv). It was investigated, whether the umbilical blood flow (Qnv) is influenced by physiological conditions during pregnancy and if changes occur in the umbilical blood flow velocity wave forms. In this study, 31 pregnant women between the 24th to 40th week of gestation were examined with a pulsed wave duplex scanner ADR Kranzbühler 8150. The mean flow velocity (Vnv) of the umbilical vein and the diameter of the vessel were parameters, which were included in the calculation of the umbilical blood flow. The flow profile of the umbilical artery allowed determination of the maximum systolic frequency (Fmax) and the end-diastolic frequency (Fmin). Based on these data, three indices--RI, PI, S/D ratio were calculated. The blood flow of the umbilical vein (Qnv) shows a linear increase up to the 36th week of gestation and remains at this level thereafter. The increase of umbilical blood flow (Qnv) is mainly caused by an increase of the diameter of the umbilical vein (81%, 26th-40th week of gestation) and to a lesser degree by an increase of the mean flow velocity (Vnv) (18%, 26th-40th week of gestation). The diameter of the vein is highly correlated both with the foetal birth weight (r = 0.60) and the umbilical blood flow (Qnv) (r = 0.73). Throughout pregnancy, flow velocity waveforms showed significant changes of the maximum systolic frequency (Fmax) from 973 Hz (SD 128 Hz; 26th week of gestation) to 1130 Hz (SD 152 Hz; 40th week of gestation) and an increase of the end-diastolic frequency (Fmin) from 246 Hz (SD 58 Hz; 26th week of gestation) to 423 Hz (SD 91 Hz; 40th week of gestation). The higher increase of the end-diastolic frequency (Fmin) results in a decrease of the resistance index (RI), pulsatility index (PI) and SD-ratio. None of the investigated cases showed an end-diastolic frequency (Fmin) of less than 200 Hz. These results reveal, that determination of the blood flow of the umbilical vein mainly depends on measuring the diameter of the vessel rather than on measurements of the blood flow velocity (Qnv) of the vein. With the presently available equipment, accurate measurements of the diameter are very difficult. The increase of blood flow of the umbilical vein is not proportional to the foetal growth; moreover, it remains constant from the 36th week of gestation.(ABSTRACT TRUNCATED AT 400 WORDS)

[3D-spectrogram of the doppler signal in real time]. / 3D-Spektrogramm des Dopplersignals in Echtzeit.

AIM: Doppler signals are normally displayed as an x/y-graph. The frequency is plotted in the y-direction, and the intensity is represented by the brightness. This represents less information than is contained in the acoustic signal: often one can hear more one can see. We are investigating the question as to whether it is feasible to render the complete information visible without the use of expensive additional equipment. METHOD: The sound card (SB16 P&P value edition) in a Pentium-PC (200 MHz 32 MB RAM) was used as a 16 bit dual channel a/d converter and connected to the ultrasound system Sonoline Elegra (Siemens, Erlangen, Germany). We used a standard 32 bit dual channel real-time FFT-software (SpectraPro, Sound Technology, California) to display a 3D-spectrogram on the PC-screen in real-time mode. This system was first tested on a flow model both with laminar steady flow and with pulsatile flow. Following this, measurements were made of the arteries and veins in healthy volunteers. RESULTS: In the 3D-Spectrogram the character of the flow can easily be seen. The quantitative parameters of velocity (Doppler frequency), direction and intensity of flow can be readily determined. Additional information about quality of flow, erythrocyte clusters and changes occurring in areas of slight stenoses can be used for diagnostic evaluation. The orthograde and retrograde flow are displayed separately using the dual channel technique. The arterial and venous flow in small and closely neighbouring vessels, such as the central retinal artery and vein, can easily be differentiated. The venous flow in particular is more turbulent in the 3D-spectrogram than would be expected from the normal display mode. CONCLUSION: The 3D-spectrogram provides much additional information in comparison with the normal Doppler spectrogram of the ultrasound system. This 3D-spectrogram can be easily obtained using inexpensive standard hard- and software.