Dapoxetine for premature ejaculation.

Premature ejaculation (PE) is the most common form of male sexual dysfunction, with an estimated worldwide prevalence of 20­30%.1 Although PE is not life threatening, it has significant impact on quality of life. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)defines PE as "persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it" that "causes marked distress or interpersonal difficulty" and "is not due exclusively to the direct effects of a substance."2 The International Society for Sexual Medicine, which recently modified the definition to include the threshold ejaculatory latency time, defines PEas "male sexual dysfunction characterized by ejaculation which always or nearly always occurs prior to or within 1 min of vaginal penetration; the inability to delay ejaculation on all or nearly all vaginal penetrations; and negative personal consequences such as distress, bother, frustration, and/or the avoidance of sexual intimacy."3 The lack of ejaculatory control is consistent among all clinical definitions of PE and is a highly sensitive predictor of the condition.

[Shoulder dystocia from a legal standpoint]. / Die Schulterdystokie im Spannungsfeld medicolegaler Auseinandersetzungen.

Even though a shoulder dystocia occurs very seldom it plays an important part in obstetrical medical opinions since it is quite often associated with infant plexus brachialis injuries. In legal medical discussions it is necessary to determine whether there were certain antepartal risks, if diagnosis and therapy were carried out correctly and whether a shoulder dystocia resp. plexus brachialis injury could have been prevented. In general one is looking for answers to prevent both serious complications. In the past a great number of articles were published referring to these answers. Especially in Anglo-American literature of the last few years one can find more and more indications that a clear cause-effect between shoulder dystocia and plexus brachialis injuries does not exist in every case. Also the value of typical or historical factors concerning association between the two are criticised in different publications. In addition the therapy strategies for shoulder dystocia treatments are momentarily analyzed in scientific discussions. Which treatment should be used first? Which ones are actually effective or do they even increase the risk of plexus brachialis injuries? Answers to these questions are given in the following abstract.

[Breech presentation in obstetrics in Germany--an assessment of current status]. / Beckenendlagengeburtshilfe in Deutschland--eine Bestandesaufnahme.

Nowadays, the CS seems to be the most favourite way of delivery in case of breech presentation. Our opinion is that the vaginal delivery has no disadvantage for the physical and mental development of the newborns [11, 12]. The outcome depends on the set-up and organisation of each department. The most important condition to reach a good outcome by breech presentation is a well-established practical training of the whole team, a careful risk selection and a well structured perinatal centre. In our opinion the CS is the second choice to deliver a pregnant woman with a breech presentation at term. High CS-rates as well as a increased perinatal morbidity at vaginal breech delivery are a sign for insufficient training of the staff and insufficient organisation in small departments not being perinatal centres. Not the breech presentation is the real risk factor, but the unqualified Obstetrician and the insufficient set-up in the most of OB/Gyn-departments. We have a very high ethic responsibility against young women resultating from our profession. It's our duty to decide and recommend the best way to save the wellbeing of the mother and the unborn child. It's also our duty to avoid surgical manoeuvers resulting from economic reasons. Therefore a complete, sufficient practical training concerning breech delivery technics is absolutely needed. In future the answer of the question: "Delivery of breech presentation--vaginally or through CS?" will depend on, if we will be able to change this politic and professional undesirable trend.

[Damage to the brachial plexus in vaginal delivery from breech presentation--correlation with reducing the extended arm]. / Schädigung des Plexus brachialis bei vaginaler Beckenendlagengeburt--Zusammenhang mit einer Armlösung?

BACKGROUND: Brachial plexus injuries in foetuses delivered spontaneously by breech presentation is very rare. The aim of this study was to evaluate the frequency of brachial plexus injuries in connection with the rate of the reduction of the extended arm. MATERIALS AND METHODS: In our retrospective study we examined 1194 vaginally intended breech deliveries (> 32 completed weeks) for the frequency of extended arms and subsequent plexus brachialis palsies. RESULTS: One brachial plexus injury occurred in 796 vaginally delivered newborns (1.2@1000). The outcome corresponds with the frequency of brachial plexus palsy in spontaneous deliveries with cephalic presentation (1@1000). The mean frequency of reduction of the extended arm in vaginal deliveries in breech is 10-20%. CONCLUSION: We found that the rate of reduction of the extended arm was not associated with an increase in morbidity of newborns. DISCUSSION: Many reports in the literature demonstrate that a higher rate of caesarean section does not prevent these severe foetal injuries. Noxious factors already occurring during the prenatal phase of development can be suspected as possible causes.

[What effect does leg position in breech presentation have on mode of delivery and early neonatal morbidity?]. / Welchen Einfluss hat die Stellung der Beine bei der Beckenendlage auf den Entbindungsmodus und die neonatale Frühmorbidität?

The objective of the present study is to establish whether the position of the legs in breech presentation deliveries affects the vaginal or abdominal mode of surgical delivery and the early neonatal morbidity. The patient population investigated (n = 266) comprised 163 primiparae (61.3%) and 103 multiparae (38.7%). Of the 266 term infants (more than 37 complete WOP) with breech presentation, 71.3% (127/178) could be delivered vaginally from a simple pelvic presentation and 55.3% (42/76) from an incomplete or complete footling presentation. The average duration of labor was 460 minutes in a pelvic presentation delivery, and 400 minutes in a footling presentation delivery. The rate of acidosis (pHNA < 7.20) was 26% in the neonates delivered from the pelvic presentation as compared to 11.9% in the footling presentation deliveries. The number of neonates with a 5/10 minute APGAR score of seven points was 0/0% in pelvic and 4.8/2.4% in footling presentation. Of the neonates delivered from pelvic presentation, 10.2% (13/127) were moved to the neonatology department as compared to 14.3% (6/42) babies delivered from footling presentation. A secondary Cesarean section was indicated in 28.7% of pelvic presentation deliveries commenced vaginally (51/178) and in 44.7% of the footling deliveries (34/76). The rate of acidosis was 49% (25/51) in the babies with pelvic presentation and 21% (7/34) in the babies with footling presentation. The percentage of neonates with respiratory depression (5/10 minute APGAR score < 7 points) was 3.9/2.9% in the babies delivered from pelvic presentation and 2/0% in the babies delivered from footling presentation. Correspondingly, the rate of transfer to the neonatology ward was extremely high: 33.3% (17/51) of the pelvic presentation babies and 8.8% (3/34) of footling babies. In 11 pregnant women (5.8%) with a fetus in pelvic presentation, a primary Cesarean section was indicated, in half of these cases (n = 5) because of "suspicion of a discrepancy", three times at request of the patients and three based on fetal and on maternal indication. Because she had rejected vaginal delivery, primary Cesarean section was performed in one pregnant mother (1.3%) with a fetus in footling presentation. Fetuses with simple pelvic presentation at term were more frequently delivered vaginally than fetuses in footling presentation (71.3% compared to 55.3%). The rate of respiratory acidosis was higher in the neonates with pelvic presentation than those with footling presentation (26% as compared to 11.9%). They compensated this acidotic metabolism within a short time, so that the transfer to the neonatology ward was only temporary. The same applied to the babies delivered by secondary Cesarean section.

[Deciding criteria for vaginal delivery from breech presentation--effect on neonatal early and late morbidity]. / Entscheidungskriterien zur vaginalen Beckenendlagengeburt--Einfluss auf die kindliche Früh- und Spätmorbidität.

In the past 20 years, breech presentation obstetrics has been characterised mainly by the work of Kubli (1975): "The safest and most simple way to prevent the foetal obstetric risk of breech presentation is the systematic Caesarean section." In the past, this resulted in judicial decisions in which due to vaginal delivery a child has been damaged and the doctor has been reproached for not performing a Caesarean section. In the report of the "Standardkommission BEL" (1983) as well as in the Guidelines for the Management of Breech Delivery (FIGO 1993), subtile criteria of decision were demanded for the vaginal delivery method. To an increasing extent clinics lack the necessary training for vaginal-operative delivery for breech presentation, followed by economic obligations and, as a result, in 1994 the frequency of Caesarean sections in cases of breech presentation was 86.9% in Bavaria. Investigations should be made as to whether it is actually necessary, for the benefit of the child, to subject a mother of a breech baby to such high-risk operations. From 1988 to 1995, 1116 breech babies were born in the Gynaecological Clinic Nürnberg, Dept. of Obstetrics. The case history of 650 children with a period of gestation > 32 weeks of pregnancy were evaluated: parity, period of gestation, method of delivery, condition after Caesarean section, premature rupture of the foetal membranes, position of legs, weight of child, Apgar score, umbilical artery pH, base excess in umbilical artery mval/l, transfer ratio to paediatric clinic, reason of transfer to paediatric clinic, rate and duration of intubation, cranial sonogram and electroencephalogram.

[Mortality and morbidity of small premature infants (<1,500 g) in relation to presentation and delivery mode]. / Mortalität und Morbidität kleiner Frühgeborener ( < 1500 g) in Abhängigkeit von Poleinstellung und Entbindungsmodus.

It is generally recommended in the literature that small premature babies with an expected weight of < 1500 g or < 32 WOP be delivered by cesarean section. The development of some of these small babies from the uterine muscle is very time-consuming and rough. For this reason, we have established the mode of the delivery at the Nuremberg Women's Hospital on the basis of the criteria which also applies to the delivery of mature term babies irrespective of the gestational age and irrespective of their presentation. Of a total number of 10542 babies delivered, 219 babies < 1500 g in weight (2.07%) were born from 1987 to 1991. The extent to which differences in the mode of deliveries spontaneous/cesarean section result from the presentation of the small premature babies was investigates after five years. The mortality and morbidity were calculated separately for babies the weighing between 1500 g and 1000 g and for babies of < or = 999 g. Besides the perinatal and neonatal mortality, the mortality after the 29th day of life was also determined. The following parameters of early morbidity were established: 1. Respiratory distress syndrome++ (none/grade I-grade IV) 2. Intracranial hemorrhages (none/grade I-grade IV) Furthermore, the following parameters of late infant morbidity were determined after the first year of life. 1. Movement capacity (normal/hyperkinetic/apathic) 2. Development of the baby (corresponding to age/ slightly/severely retarded) Severely retarded fetuses with a gestational age of more than 32 weeks and a birth rate of < 1500 g were excluded from all calculations, so that ultimately 176 babies were included in the overall analysis. The total mortality of the children < 1500 g in weight was 14.3%, 15.7% were in the group between 1500 g and 1000 g and 25% were the mortality with regard to the presentation and the mode of delivery. The morbidity results indicate that only the group of babies between 1500 g and 1000 g in weight with breech presentation benefit from cesarean section. In the group of babies < or = 999 g, there are no differences in morbidity with regard to the mode of delivery and the presentation. The results found show that frequencies of cesarean section in excess of 40% improve neither the mortality nor the morbidity of small premature babies. The decision to carry out cesarean section is based more on individual influences and the situation in the hospital in which the delivery takes place than on mortality of the baby or the mother.

[Breech presentation--information, anxiety and pattern of expectations of established obstetricians and pregnant patients. 2: Results of a survey of women with breech presentation]. / Beckenendlage--Informations-, Angst- und Erwartungsmuster von niedergelassenen Frauenärzten und Schwangeren. Teil 2: Ergebnisse einer Umfrage unter Frauen mit einer BEL-Schwangerschaft.

The frequency of caesarean section is increasing. A corresponding reason for this development is the increasing quota of primary caesarean section in patients with breech presentation. The aim of this study was to extend the expectation- fear- and information-profile in these patients and therefore the influence on the caesarean section rate. 100 patients with breech presentation were randomized and prospectively questionnaired. In summary, the study shows that women with breech presentation prefer primary caesarean section as the favourite delivery mode. Fears experienced before the delivery were focused accordingly on the condition of the child were in conflict to the higher incidence of maternal risk factors. Only an objective clearing of the obstetrical conditions and risk factors of the delivery modes (vaginal delivery mode, caesarean section) can induce patient's compliance which is the presupposition for a vaginal delivery mode of breech presentation.

[Puerperal inhibition of lactation with metergoline or bromocriptine]. / Die puerperale Laktationshemmung mit Metergolin oder Bromocriptin.

In a controlled, randomised, prospective, clinical study, the effect of prolactin suppression and clinical course of the lactation suppressors Bromocriptine and Metergoline were investigated. During 7 months 150 patients were studied. 81 of those patients, who did not nurse, were treated by Bromocriptine (primary lactation suppression: n = 62, secondary suppression: n = 19) and 69 of the patients were treated by Metergoline (primary suppression: n = 54, secondary suppression: n = 15). The drugs were administrated orally to all subjects, dosed 2 x 2.5 mg/d of Bromocriptine for 14 days and 3 x 4 mg/d of Metergoline for 10 days, starting in average after 13 hours. Puerperal suppression of prolactine were compared with randomised breast feeding subjects (n = 30). In Bromocriptine treated women the average plasma prolactin level decreased from 78.4 +/- 22 ng/ml to 17.0 +/- 3.3 ng/ml during five days of treatment. In Metergoline treated women the plasma prolactin level decreased from 129.7 +/- 15.1 ng/ml to 56.9 +/- 10.0 ng/ml during the first days of treatment. Prolactin level of breast feeding subjects decreased from 233.6 +/- 21.4 ng/ml to 185.8 +/- 23.7 ng/ml during the same period (p < 0.05). There is no statistical significancy of clinical difference of both drugs, but a statistical trend was seen. With Bromocriptine treated women were suppressed efficiently in 71 of 81 cases, 10 refused. Refusals were divided in two quality levels, level I with subjects with moderate complaints and little puerperal lactation, level II with subjects with considerable complaints including strong puerperal lactation. With Metergoline suppressed women, treatment was efficiently in 51 of 69 cases, but refusals of level I were observed in 11 cases and refusals of level II were observed in 7 cases. The results show that Bromocriptine and Metergoline are effective on suppression of lactation. Under the current drug dose of Metergoline an advantage of Bromocriptine were observed. Only further studies could investigate, whether an adaptation of drug dose would improve the clinical efficiency of Metergoline.

[Prenatal diagnosis of hypoplastic left heart syndrome--indications for abortion or transplantation?]. / Pränatale Diagnostik eines hypoplastischen Linksherzsyndroms--Indikation zur Abruptio oder zur Transplantation?

Early diagnosis of fetal cardiac malformations in center of Perinatal Medicine is now possible with the use of modern high frequency ultrasound technics in combination with the 3-step-program of the DEGUM. The diagnosis of most cardiac malformations can early already be obtained in the 2nd trimester as for example the lethal hypoplastic left ventricle syndrome. We want to discuss the problem of prenatal diagnosis of the hypoplastic left heart syndrome and the possibilities of therapeutic procedures.

[Breech presentation--information, anxiety and expectations of established obstetricians and pregnant patients. 1: Results of a survey of established obstetricians]. / Beckenendlage--Informations-, Angst- und Erwartungsmuster von niedergelassenen Frauenärzten und Schwangeren. Teil 1: Ergebnisse einer Umfrage unter niedergelassenen Frauenärzten.

In a anonymous questionnaire we studied the advise of gynecologists to breech presented pregnant women in the area around Nürnberg-Fürth-Erlangen in Germany. 61.5% of gynecologists participated the study, 71.2% of them (n = 57) prefer primary caesarean section in primapara. 13.8% (n = 11) of the questioned doctors favour a vaginally delivery procedure. Advise to multiparas for primarous caesarean section was given in 8.8% (n = 7) and for vaginally delivery mode in 80.0% (n = 64). Reasons for caesarean section was a decreased fetal delivery risk (90%, n = 72) and the possibility of prospective delivery planing (26.3%, n = 21). Other reasons were various obstetrical risk factors and forensic aspects. Benefits of vaginally delivery mode in multiparas was a low fetal delivery risk (72.5%, n = 58) and a low maternal morbidity (66.3%, n = 53). Results of actual studies are suggesting, that there is a controlled fetal risk of vaginally delivery mode in breech presented labour. According to these studies a change of labour procedure is essential.

[Vaginal delivery in breech presentation does not increase early newborn morbidity. Results of 423 infants with breech presentation 1988-1992]. / Vaginale Geburt aus Beckenendlage erhöht nicht die kindliche Frühmorbidität. Ergebnisse von 423 aus Beckenendlage geborenen Kindern aus den Jahren 1988-1992.

423 deliveries by breech presentation (1988-1992), delivered by vaginally or abdominally management, were analysed. 72 preterm (32nd to 36th gestational week) and 351 term labours were studied. In 239/423 (56.5%) cases neonates were delivered vaginally, in 54/423 (12.8%) and 130/423 (30.7%) cases primary or secondary cesarean section was necessary. In 120/423 (51.9%) cases of all primaparous spontaneously delivery were realized. There was no difference in early morbidity of vaginal und abdominal delivered neonates (pHNA, APGAR-Score, intracranially bleeding). Three intracranially bleedings (I degrees, II degrees, III degrees) observed in the vaginally delivery group (n = 239), were not the result of breech presentation or vaginally management. No correlation between vaginally management, acidosis and intracranially bleeding were observed. In patients presented with preterm labour (32nd to 36th gestational week) and/or fetal intrauterin growth retardation, cesarean section could be indicated. In postnatal sonographic screening of all neonates hip joint disorders were twice more frequently in female neonates (n = 51 vs. n = 26) without correlation to delivery mode. In conclusion, if certain personally and equipmently conditions are considered, vaginally delivery mode does not correlate to an increase of early neonatal morbidity.

["Facing"--a preliminary parameter in diagnosis of fetal skeletal abnormalities]. / "Facing"--Ein Einstiegsparameter in die Diagnostik fetaler Skelettfehlbildungen.

Four cases with abnormalities of foetal faces are demonstrated--thanatophoric dwarfism, cheilognathopalotoschisis, osteogenesis imperfecta, achondrogenesis (Type I). A relationship to skeletal dysplasia was shown. We think, that the representation of foetal faces and their profile plays an important part in second trimester ultrasound screening between 18 and 22 weeks of gestational age.

[Obstetric and ethical-legal problems in a twin pregnancy with anencephalus and polyhydramnios of the leading twin beyond the 28th week of pregnancy]. / Geburtshilfliche und ethisch-juristische Problematik bei einer Geminigravidität mit Anenzephalus und Polyhydramnion des führenden Zwilling I jenseits von 28 Schwangerschaftswochen.

Malformations are found twice as often in twins than in singletons. In the following case, we report on a twin pregnancy with anencephaly and polyhydramnion of the leading twin I, which was first diagnosed after 28 weeks of pregnancy. The foetal disease of twin I led to an appreciable dyspnoea of the mother that exacerbated to an incipient respiratory failure by the thirty-second week of pregnancy. The projected termination of pregnancy by Caesarean section based on a maternal indication was not performed, but instead a selective foetocide of the diseased twin. The live twin was delivered spontaneously without complications after thirty-eight weeks of pregnancy. The obstetric and legal ethical problems are discussed.