[Perinatal management of triplet pregnancies from 1997 to 2001]. / Perinatales Management und Ausgang von Drillingsschwangerschaften zwischen 1997 und 2001.

BACKGROUND: Because of the trend for premature birth, multifetal pregnancies are at high risk for neonatal morbidity and mortality. This study presents our perinatal management scheme and the outcome of triplet pregnancies. PATIENTS AND METHODS: From 1997 to 2001 we studied 31 triplet pregnancies. Their management consisted of cervical measurement at 20 weeks, admission from 25 weeks onwards, regular ultrasound examinations, intravenous tocolysis with preterm contractions or cervical shortening, promotion of fetal lung maturation, antibiotic therapy with evidence of vaginal infection, delivery by caesarean section ideally at 33 weeks. RESULTS: In the studied group 4 triplet pregnancies were monochorionic, 6 dichorionic, and 21 (68 %) trichorionic. 2/31 triplet pregnancies finalized in late abortions. Furthermore, a single and a double intrauterine death occured in two triplet pregnancies. 6 (21 %) of triplet pregnancies were delivered before the 30th week and 23 (79 %) after the 30th week of gestation (median gestational age 31.5 weeks, median birth weight 1545g). Neonates of trichorionic pregnancies in comparison to those of mono- and dichorionic pregnancies were delivered two to three weeks later and presented with significantly higher birth weights (1660 g vs. 1245 g vs. 1240 g; p = 0.001 and 0.0009, respectively). 13/84 (15.5 %) of the neonates showed growth retardation. In 4/84 (4.1 %) children brochopulmonary dysplasia or cerebral haemorrhage was observed. Only one child developed enterocolitis. 19 % (16/84) of neonates showed evidence of retinopathy. No intrauterine death occured after 28 weeks and no child died after delivery. CONCLUSION/DISCUSSION: With our well defined management of triplet pregnancies from 20 weeks onwards we reach similar gestational ages at delivery but remarkably lower neonatal complication rates compared to previous studies.

[Effect of peridural analgesia on labor progress]. / Der Einfluss der Periduralanalgesie auf den Geburtsverlauf.

Epidural analgesia (EDA) is the most effective method of intrapartum pain relief. Its influence on the course of labor continues to be controversial. Although a cause-and-effect relationship has not been proven, this form of analgesia has been blamed for a host of adverse maternal/fetal events during labor, including prolonged first and second stage of labor, dystocia, malrotation of the fetal head and an increased risk of operative delivery (instrumental delivery, Caesarean section). Our own data from the Department of Obstetrics and Gynaecology at the University of Leipzig demonstrate that women with epidural analgesia had a longer duration of labor (the greater proportion taking more than 13 hours), although labor was often already protracted before the start of epidural analgesia. Early epidural analgesia with a cervical dilatation of less than 4 cm does not have any negative impact on the progress of labor. The duration of second-stage pushing and the rate of instrumental deliveries were not increased in our patients. Although the Caesarean section rate for women with an EDA was elevated, the total proportion of secondary Caesarean section remained unchanged despite increased use of EDA. Our findings suggest that women selected for intrapartal EDA already represent a population with an increased risk of an unfavourable course of labor, priming of the cervix, increased need of oxytocin and nulliparity. Pain relief in itself is sufficient indication for the use of intrapartal epidural analgesia.

Associations between duration of breast-feeding, sensitization to hens' eggs and eczema infantum in one and two year old children at high risk of atopy.

UNLABELLED: Through a cohort study, factors for the development of atopic disorders among children at high-risk of atopy were investigated by means of anamnesis, lifestyle factors and laboratory parameters. 475 high-risk children were selected out of the whole population of infants born within one year in the City and District of Leipzig. These 475 had an increased cord blood IgE (> 0.9 kU7l), double positive atopic family history (parents/siblings) or low birthweight (1500-2500 g). Questionnaires are answered regularly by the parents and the children are clinically examined annually. RESULTS: In the first and second year of life there has been a statistically significant correlation (p < 0.0001) between increased cord blood IgE and increased total IgE. At the age of one year we found eczema infantum in 51 out of 323 high-risk children. There was a significant association (p = 0.0001) between sensitization against hens' eggs and eczema. Infants who had been exclusively breast-fed > or = 5 months were more frequently sensitized to hens' egg and an eczema infantum was to diagnose more frequently. Significant differences in this respect were found within the risk groups, depending on family history of atopy and cord blood IgE. The duration of breast-feeding showed no correlation with sensitization to hens' eggs or atopy in two-year-olds.

[Artificial amniotic fluid instillation in premature rupture of fetal membranes and extreme prematurity as alternative therapy]. / Artifizielle Fruchtwasser-Instillation bei vorzeitigem Blasensprung und extremer Unreife als alternative Therapie.

We report two cases of premature rupture of membranes and oligohydramnios (gestational age: 23rd/24th week). In both pregnancies artificial instillation of amniotic fluid (AIF) was performed once a week. We hypothesize that fetal head compression with impaired cerebral perfusion due to oligohydramnios causes periventricular leukomalacia. Prolongation of gestation of 36/23 days without neurological lesion support this method. Surveillance of these pregnancies in a perinatal center has to include very early detection of chorioamnionitis. If not so, gained prolongation of pregnancy with a lower rate of cerebral damage becomes harmful due to infection. Clinical benefits and disadvantages of this technique have to be evaluated in a prospective randomized trial.

[Multivariate analysis of the significance of vaginal bacterial colonization in the occurrence of a preterm birth with various risk parameters]. / Multivariate Analyse zur Bedeutung vaginaler Keimbesiedlung für das Auftreten einer Frühgeburt bei verschiedenen Risikokollektiven.

Using a discriminance analysis we investigated the interactions between parameters of the vaginal flora and subclinical infection regarding preterm birth. The prospective study includes 222 single pregnancies, 114 of them with preterm labour or premature rupture of the membranes (PROM). The analysis includes information of a vaginal/ cervical smear (total number of pathogenic germs, species and groups of pathogenic germs), vaginal pH, maternal white blood cell count (WBC), C-reactive protein (CRP) and temperature. A normal vaginal flora was found in only 19%. Pregnancies with preterm labour have a higher quantity of pathogenic germs, whereas there is no difference of the germ group distribution. Moreover, pregnancies with preterm labour and 2 or 3 pathogenic germs have a higher rate of preterm birth. The discriminance analysis shows that only the affiliation the risk group with preterm labour and the parameters CRP and WBC have a significant selectivity for consequent preterm birth, but not the parameters containing information of the vaginal flora. The same is valid for the group with preterm labour, where only the parameters PROM and WBC are able to select significantly for preterm birth.

[Usefulness of vaginal pH measurements in the identification of potential preterm births]. / Der Nutzen vaginaler pH-Messungen für die Erkennung potentieller Frühgeburten.

Ascending infections of the female genital tract as a cause of preterm birth have become major importance regarding the prevention of preterm birth. Measurements of the vaginal pH value are able to verify a alkalinisation of the vagina caused by a atypical vaginal flora. In a prospective study we measured the vaginal pH value using indicator paper and evaluated the results of a vaginal and cervical smear of 162 single pregnancies from 26 to 30 weeks of gestation. In contrast to normal pregnancies there is a relation between a pathological pH value > 4.5 and consequent preterm birth in pregnancies with preterm labour but also in pregnancies with other risk factors without symptoms of preterm labour.

[From resuscitation space in the delivery room of the Women's hospital to the perinatal center of the Leipzig University]. / Vom Reanimationsplatz im Kreisssaal der Frauenklinik zum Perinatalzentrum der Universität Leipzig.

Historical review on the development of neonatal intensive care and new-born nursing at the women hospital of Leipzig University from 1969 up to 1995 and the foundation of a Perinatal Center. The successes of perinatal care are demonstrated best by the decline of neonatal mortality of extremely low birth weight infants from more than 90% up to 20% in 1995. It is attributed to the progress in perinatal medicine as well as to a perfect functioning regionalization of high risk pregnancies.

[Color Doppler ultrasound of uterine, fetoplacental and fetal blood vessels in the 2nd trimester in normal pregnancies]. / Farbdopplersonographie uteriner, fetoplazentarer und fetaler Gefässe im 2. Trimenon bei ungestörten Schwangerschaften.

We investigated 69 healthy women with normal pregnancy and delivery in order to establish normal values for the second trimester of gestation. In a cross-sectional study we measured the pulsatility index (PI), the maximal systolic velocity (V-MAX) and the mean velocity (V-MEAN) in the uterine arteries (UAA), the umbilical artery (UA), the fetal thoracic aorta (FTA) and the middle cerebral artery (MCA) from the 14th to the 24th week of gestation. A regression analysis shows a significant slope of the PI of UAA and UA (p < 0.01), whereas in contrast to the UA there is no significant difference of the median values of the UAA-PI from the 18th week of gestation. With progressive gestation V-MEAN of UAA increases more (p < 0.001) than V-MAX (p < 0.05) as a result of the increasing diastolic blood flow. In the UA there is also a significant rising trend of V-MAX and V-MEAN (p < 0.0001). No significant changes of the PI of FTA and MCA are seen, although there is a slight increasing trend. After the 20th week in the MCA a marked tendency to high PI-values is observed, whereas there is a change between different flowpatterns prior to the 20th week. V-MAX and V-MEAN of FTA increases significantly, but there is no change in the MCA. Our results for UAA and UA correspond to the known morphologic changes in the utero- and fetoplacental vessels in the second trimester and are comparable to other results. Particularly the physiology of the cerebral perfusion needs to be investigated more intensively. These normal values provide a good basis for early and complex assessment of a disturbed perfusion in the second trimester.

[Severe protracted intrauterine impaired perfusion--a cause of enteral motility disorder in the premature infant]. / Die schwere protrahierte intrauterine Perfusionsstörung--eine Ursache der enteralen Motilitätsstörung des Frühgeborenen.

The importance of measurement of blood flow in the fetal and uteroplacental circulations for the assessment of fetal wellbeing has been undisputed since some years. The present study is designed to prove if any relationship exists between severe hemodynamic disturbance in fetal as well as uteroplacental vessels and the occurrence of postnatal impairment of intestinal motility. The progress of 130 children, born in the University Women's Hospital Leipzig between 1991-1993 and with birth weights below 1500 g, has been analyzed. Doppler ultrasound examinations for detection of impairment in fetal and uteroplacental circulation were performed in all cases during pregnancy. A severe impairment of blood flow in the above mentioned circulations was defined by the presence of pathological pulsatility or resistance indices in both fetal and uteroplacental vessels as well as absent end diastolic flow in the umbilical artery and signs of centralization in the fetus. A severe hemodynamic impairment was found in 27 children and 26 of these were classified as severe hypotrophic after birth. The progress of these children was compared with this of other hypotrophic and euthrophic premature babies who had not revealed hemodynamic abnormalities. The incidence of disturbed postnatal intestinal motility (delayed meconium excretion, abdominal distention, retrograde peristalsis, subileus) was significantly higher in hypotrophic neonates with hemodynamic abnormalities in the course of pregnancy. Four of these newborns underwent surgery and surgical findings did not correlate with enterocolitis. The resumption of oral food intake for neonates who had hemodynamic impairments during pregnancy was delayed compared with the control groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Discriminant analytic model for prognostic assessment of pregnancies at risk for premature labor]. / Diskriminanzanalytisches Modell zur Prognoseeinschätzung bei Schwangerschaften mit drohender Frühgeburt.

We examined 114 women with preterm labor using discriminance analysis to assess predictive values in terms of prolongation of gestational age and gestational age at the time of delivery. We used parameters like medical history, clinical features, infections, Doppler sonography and cardiotocography. Maternal temperature, cardiotocographic findings, premature rupture of membranes, number of abortions and pregnancy terminations and cervical dilatation at the time of admission contribute significantly to predict prolongation of pregnancy (< or = as well as > 7 days). Our results from this analysis showed sensitivity and specificity of 0.70 and 0.97 and positive and negative predictive values of 0.89 and 0.91, respectively. We observed significant differences concerning parameters like preterm rupture of membranes, cervical dilatation, pathological bacteria in the vagina and pathological Doppler values between subsequent preterm and term deliveries in pregnancies with a prolongation of > 7 days was. Upon reclassifying our results, we obtained sensitivity and specificity of 0.69 and 0.89 and positive and negative predictive values of 0.78 and 0.84, respectively. Early prognostic assessment of preterm labor can be made with discriminance analysis. The results inspire us to perform a prospective examination of the therapy plan that we have obtained.

[Predictive value of Doppler ultrasound findings in twin pregnancies]. / Prädiktive Wertigkeit dopplersonographischer Befunde bei Geminischwangerschaften.

In a prospective study we investigated 100 twin pregnancies in order to assess the predictive value of doppler-sonographic measurements regarding the pregnancy outcome. We used the pulsatility index of the uterine arteries, the umbilical artery, the fetal aorta thoracica and the fetal middle cerebral artery. The measurements were obtained at various gestational ages between 24 and 32 weeks. Significant differences between unselected twin pregnancies and normal single pregnancies were not found. Moreover, there is no relation between the severity of an impaired perfusion and an adverse outcome of the pregnancy. The prediction of fetal distress (hypoxia, preterm birth, poor fetal growth, acidosis, and disturbed neonatal adaption) with doppler-score has a sensitivity of 25% and a positive predictive value of 63%. From this rather insufficient result we conclude that doppler screening in unselected twin pregnancies hardly proves to be useful.

[Clinical results of perfusion-oriented therapy of threatened premature labor]. / Klinische Ergebnisse einer perfusionsorientierten Therapie der drohenden Frühgeburt.

The aim of this study is to show whether a perfusion-oriented treatment of preterm labour under routine conditions has a positive impact on the outcome of these risk pregnancies and is able to reduce neonatal morbidity. We compared a group of 143 cases of preterm labour under tocolytic therapy to a group of 164 cases with comparable conditions and dopplersonographic measurements of the uteroplacental and fetal perfusion. Depending on the resistance- and pulsatility index of both uterine arteries, umbilical artery, fetal descending aorta and fetal middle cerebral artery an additional therapy (oxygen administration or transcutaneous dorsal nerve stimulation (TENS) was performed. 53 cases with pathologic uterine perfusion underwent in addition to tocolytic therapy a treatment with TENS. 18 cases with pathologic fetal perfusion were treated with oxygen administration. With comparable conditions at admission the group with a perfusion-oriented treatment has a significantly higher gestational age at delivery and prolongation of gestation. The percentage of preterm infants with a gestational age at delivery < 31 weeks is lower. Particularly cases with a low gestational age at the onset of preterm labour prior to 30 weeks of gestation do benefit. The comparison regarding the percentage of neonatal diagnosis and resulting methods of therapy, especially initial resuscication and CPAP, indicates a positive impact on fetal outcome of a perfusion-oriented treatment in pregnancies with preterm labour.

[Doppler ultrasound perfusion measurements of uterine, fetal and fetoplacental vessels in pregnancies with ultrasonically suspected fetal growth retardation]. / Dopplersonographische Perfusionsmessungen uteriner, fetaler und fetoplazentarer Gefässe bei Schwangerschaften mit sonographischem Verdacht auf eine fetale Wachstumsretardierung.

The aim of the present study was determination of the complex character of hemodynamic disturbances in uteroplacental, fetoplacental and fetal vessels as well as their influence on the outcome of pregnancies suspected to have IUGR on ultrasound examination. A special form of Doppler scoring was implemented for documentation of the hemodynamic disturbances. Of 82 single pregnancies with sonographically suspected IUGR, 30 women gave birth to eutrophic babies whereas 52 mothers delivered hypotrophic newborns. However, 43 cases of the hypotrophic babies had birth weight below the 5th percentile. The median values of Doppler indices for those with eutrophic babies revealed no significant differences compared to normal collective. However, significantly elevated RI and PI values in both uterine arteries, the umbilical artery and fetal descending aorta of pregnancies which resulted in hypotrophic babies indicated hemodynamic disturbance. The umbilicoplacental and uteroplacental vasculature compartments were almost equal involved with a proportion of 39% or 30% respectively. Birth weight < or = 5th percentile was associated with a further increase of pathological values in this both vascular areas. Significant rang correlations between values of Doppler indices and clinical parameters indicated a direct association between perfusion disturbances and fetal outcome of the pregnancies studied. The present Doppler score, which is a summary of all separately evaluated examined blood vessels, is suitable for clinical implementation and showed a good correlation to the clinical parameters in our study. Therefore Doppler perfusion measurements should play an important role in the clarification of suspected fetal growth retardation.

[Value of perinatal characteristics for diagnosis of perinatal infections]. / Wertigkeit perinataler Charakteristika für die Diagnostik perinataler Infektionen.

A retrospective case control study was performed in order to evaluate the diagnostic validity of clinical and paraclinical signs for early detection of neonatal sepsis. The perinatal data of 45 newborns with sepsis on day 1 or 2 (early perinatal sepsis) after birth were compared with those of 34 newborns with sepsis on day 3 and 4 (late perinatal sepsis) and with 87 newborns as controls. The groups were comparable in respect of birth weight (1,972-2,114 g), gestational age (33.3-33.5 weeks), gender (prevalence of male), frequency of prematures (82-91%) and mode of delivery. In cases of early perinatal sepsis a significant higher incidence of fetal tachycardia was found (heart rate > 160/min in 50% versus 5% in late perinatal sepsis and 8% in controls respectively), of reduced fetal heart oscillation (56% versus 14 and 38%) and of loss of acceleration (76% versus 56 and 20%) in the CTG ante partum. Therefore, these signs have proved to have a better diagnostic validity for infection than premature rupture of membranes, a prolonged rupture of membranes and the chorioamnionitis. Another predominant finding was the significant greater need for resuscitation due to asphyxia (48% in early sepsis versus 14 and 7%) despite missing differences in pH of blood in umbilical artery at birth (7.28 +/- 0.07). The occurrence of such signs supports a suspicion of a fetal sepsis.

[Diagnosis and therapy of hemodynamic disorders. A contribution to the management of pregnancies with threatened premature labor]. / Diagnostik und Therapie gestörter Hämodynamik. Ein Beitrag zum Management bei Schwangerschaften mit drohender Frühgeburt.

114 pregnant women (without multiple pregnancies) with premature labour were examined in a randomized prospective study. Pulsatility index (PI) in the uterine artery and fetal thoracic aorta was the parameter we used for the examination, the determination of which was done with doppler sonography at the time of hospital admission. Therapy with beta-sympathomimetics alone or additionally either Oxygen inhalation therapy or transcutaneous dorsal nerve stimulation were conducted and the pulsatility index was controlled at intervals of one and two weeks after initiation of the aforementioned therapy. The negative correlations which we determined between pulsatility index and prolongation of duration of pregnancy, gestational age at the time of delivery and birth weight were significant. This confirms the clinical importance of maternal perfusion already at the time of admission for the clinical end-results. Similarly significantly negative correlations between pulsatility index of uterine vessels, weight percentile of the corresponding newborns and antenatal CTG scores (Fischer) verify the close connections between the hemodynamic, nutritional and respiratory partial functions of the fetoplacento-maternal unit. The clinical results after normalization of an impaired perfusion were found to be improved significantly after a combined therapy with beta-sympathomimetics and transcutaneous dorsal nerve stimulation (TNS) as compared with beta-sympathomimetic therapy alone. These results justify the recommendation that doppler sonographic measurements of utero-placental perfusion can be used for the diagnostic and therapeutic concept in pregnancies with premature labour.

[Evaluation of the efforts in prenatal care for the prevention of prematurity]. / Bewertung von Bemühungen in der Schwangerenvorsorge um Prävention der Frühgeburtlichkeit.

A retrospective analysis was done in 341 singleton premature deliveries to assess the practised activities in antenatal care for the prevention of premature delivery. This analysis, expressed in terms of adequacy revealed that 56% were adequate whereas 23% were conditionally adequate and 21% were inadequate. Clinically these activities were reflected in suppression of uterine contractions (80%/57%/40%-effective tocolysis), achieved prolongation of pregnancy (25d/8d/2d) and a lowered rate of premature delivery before the 32nd week of gestation (17%/31%/33%), respectively. A prospective study depending on these results (n = 450) done in 4 centers for antenatal care (under constant supervision to keep the respective recommended activities) showed a significant reduction in the rate of premature delivery compared to a similar control group (n = 458) in the year 1988. Simultaneously, we could demonstrate the influence of patient explanation and the growing patient satisfaction which resulted in reduction of premature delivery.

[Effect of pregnancy and perinatal parameters--including mode of delivery--on survival rate of "low birth weight premature infants" (less than 1,500 g)]. / Der Einfluss von Schwangerschafts- und perinatologischen Parametern--einschliesslich Entbindungsmodus--auf die Uberlebensrate "kleiner Frühgeborener" (less than 1500 g).

A retrospective analysis of 225 very low birth weight infants (less than 1500 g) was made, to assess the influence of the mode of delivery on the survival rate. In 186 preterm deliveries which could not be prevented by therapeutic measures, we included additionally certain gestational and perinatological parameters. Generally, an average survival rate of 72% was found in this study. In addition to the well-known negative influence of birth weight less than 1000 g and gestational age of less than 28 weeks, such parameters as antenatal pre-pathological CTG findings, haemorrhages at the time of hospitalisation, and ineffectuousness of tocolytic drugs, were associated with a reduced survival rate. In contrast, the presence of anamnestic risk factors of preterm delivery and prolongation of gestation by one day and more improved the survival rate. Additional consideration of foetal presentation showed, that abdominal delivery was fundamentally safer in cases with breech and transverse presentation. Whether a higher survival rate can be achieved by vaginal delivery in cases of breech presentation with premature rupture of membranes or a gestational age greater or equal to 28 weeks, remains to be proved. A gestational age of less than 28 weeks or antenatal prepathological cardiotocographic findings will facilitate in future the decision to perform Cesarean section in cases of inevitable premature deliveries with cephalic presentation.

Doppler sonographic examinations of uteroplacental, fetoplacental, and fetal hemodynamics and their prognostic value in preterm labor.

Doppler examinations of different uteroplacental vessels (uterine arteries, arcuate arteries), umbilical artery, fetal thoracic aorta, and median cerebral artery were performed on 55 patients with idiopathic preterm labor (24.5 to 32.5 weeks). Thirty normal pregnancies of corresponding gestational age served as a control group. Significant differences of median values between the preterm labor and control group were found only for the resistance index (RI) in the central arcuate artery and for the pulsatility index (PI) in the fetal thoracic aorta. In about twenty percent of pregnancies in preterm labor, pathological values of RI and PI in uteroplacental and fetal vessels account for the presence of an impaired perfusion. Elevated PI in the uterine artery placental site and normal RI in the fetal thoracic aorta, correlate significantly to a shorter prolongation of pregnancy, lower gestational age on birth, and lower birth weight. The combination of these two blood flow indices (maternal PI greater than 0.90 and fetal RI less than 0.90) allow us to predict a preterm birth in a high percentage of cases (sensitivity 87.5%, specificity 100%, positive predictive value 100%, negative predictive value 93%).