[Management of postpartum hemorrhage (PPH): algorithm of the interdisciplinary D-A-CH consensus group PPH (Germany - Austria - Switzerland)]. / Management der postpartalen Blutung (PPH): Algorithmus der Interdisziplinären D-A-CH-Konsensusgruppe PPH (Deutschland - Österreich - Schweiz).

Postpartum hemorrhage (PPH) is one of the main causes of maternal deaths even in industrialized countries. It represents an emergency situation which necessitates a rapid decision and in particular an exact diagnosis and root cause analysis in order to initiate the correct therapeutic measures in an interdisciplinary cooperation. In addition to established guidelines, the benefits of standardized therapy algorithms have been demonstrated. A therapy algorithm for the obstetric emergency of postpartum hemorrhage in the German language is not yet available. The establishment of an international (Germany, Austria and Switzerland D-A-CH) "treatment algorithm for postpartum hemorrhage" was an interdisciplinary project based on the guidelines of the corresponding specialist societies (anesthesia and intensive care medicine and obstetrics) in the three countries as well as comparable international algorithms for therapy of PPH.The obstetrics and anesthesiology personnel must possess sufficient expertise for emergency situations despite lower case numbers. The rarity of occurrence for individual patients and the life-threatening situation necessitate a structured approach according to predetermined treatment algorithms. This can then be carried out according to the established algorithm. Furthermore, this algorithm presents the opportunity to train for emergency situations in an interdisciplinary team.

Prenatal sonography can predict degree of placental invasion.

OBJECTIVE: To evaluate whether the maximum degree of placental invasion (placenta accreta, increta or percreta) can be predicted with ultrasound imaging, using criteria developed in our department. METHODS: This was a retrospective study of all 232 patients at risk for placental invasion who were part of a routine screening program for placental invasion from January 2001 to January 2011. The whole placenta was scanned in a systematic manner using both gray-scale ultrasound and color-flow mapping. Sonographic findings were compared with the clinical outcome during and after delivery and the histomorphological examination of the placenta. RESULTS: Placental invasion was suspected by ultrasound in 40 (17.2%) patients and was clinically/histopathologically confirmed in a total of 35 (15.1%) patients. The sensitivity, specificity and positive and negative predictive values of ultrasound for placental invasion were 91.4% (95% CI, 77.6-97.0%), 95.9% (95% CI, 92.2-97.9%), 80.0% (95% CI, 65.2-89.5%) and 98.4% (95% CI, 95.5-99.5%), respectively. No case of placenta increta (n = 7) or percreta (n = 17) was diagnosed as showing normal placentation or placenta accreta on ultrasound, giving an overall accuracy for the differentiation between normal placentation/placenta accreta and placenta increta/percreta of 100%. CONCLUSION: Our data suggest that prediction of the degree of placental invasion is possible using prenatal ultrasound, with high overall accuracy.

Impact of Doppler sonography on intrauterine management and neonatal outcome in preterm fetuses with intrauterine growth restriction.

OBJECTIVES: To test the hypothesis that earlier delivery may be warranted to improve neonatal outcome of fetuses with intrauterine growth restriction (IUGR) with abnormal Doppler parameters. METHODS: This was a retrospective cohort study of 110 fetuses with an antenatal diagnosis of IUGR due to placental insufficiency which had a very low birth weight (< 1500 g), delivered at the Department of Fetomaternal Medicine of the Medical University of Vienna, Austria, between January 1999 and July 2009. Doppler results before delivery were classified as follows: Group 1: abnormal umbilical artery (UA) pulsatility index (PI) more than 2 SD above the mean for normal reference data, or absent UA end-diastolic flow, both with normal middle cerebral artery (MCA) PI (mean ± 2 SD); Group 2: abnormal UA-PI > mean + 2 SD, or absent or reversed UA end-diastolic flow, with abnormal MCA-PI (< mean - 2 SD) and normal ductus venosus (DV) PI (mean ± 2 SD); Group 3: absent or reversed UA end-diastolic flow, with abnormal MCA-PI (< mean - 2 SD) and abnormal DV-PI (> mean + 2 SD) and/or absent or reversed end-diastolic DV flow. Pregnancy outcome was analyzed according to Doppler results. RESULTS: Due to very poor prognosis, 19 fetuses underwent expectant management and died in utero. These were excluded from further analyses. Of the remaining 91 cases, 17 were in Doppler Group 1, 44 in Group 2 and 30 in Group 3. Within 4 weeks after delivery, 0/17 (0%) infants in Group 1 died, 2/44 (4.5%) infants in Group 2 died and 7/30 (23.3%) infants in Group 3 died (P = 0.019). None of the 42 Group 2 cases that delivered at or after 28 completed gestational weeks died within 4 weeks after delivery, in contrast to 4/20 (20.0%) Group 3 cases (P = 0.009). In comparison, among infants delivered before 27 completed gestational weeks, 2/2 (100%) Group 2 cases died and 3/10 (30.0%) Group 3 cases died; P = 0.152). CONCLUSIONS: Doppler examinations are highly predictive in assessing the outcome of IUGR fetuses. From 28 completed gestational weeks, early delivery before the onset of fetal cardiac decompensation might be beneficial.

Placental MRI shows preservation of brain volume in growth-restricted fetuses who suffer substantial reduction of putative functional placenta tissue (PFPT).

OBJECTIVE: Recently, a potentially useful diagnostic approach based on MR diffusion-tensor-imaging (DTI) was reported for the estimation of putative functional placenta tissue (PFPT), thus providing direct information about placental function. Yet, the relation between reduced PFPT and the phenomenon of brain-sparing remains unclear. This study aimed to investigate the relation between brain-sparing and reduced PFPT volume, as found in fetuses with intrauterine growth restriction (IUGR). METHODS: A total of 40 consecutive patients with a US-based diagnosis of placental IUGR were examined using fetal MRI. A control group of 78 patients who received fetal MRI, due to non-placental pathologies, was established. A somatic energy index was calculated as IE=1-(Vbrain/Vpfpt) from brain and PFPT volumes measured with DTI in both groups. IE, Vpfpt, and Vbrain were analyzed with respect to the gestational week. RESULTS: Vbrain corrected for gestational weeks was no different between both groups, while Vpfpt was significantly reduced in IUGR patients. IE was significantly different between both groups and indicated a higher Vbrain at a comparable Vpfpt. CONCLUSIONS: Fetuses with IUGR show preserved energetic resources necessary for brain growth. Because IE drops in IUGR more rapidly as pregnancy progresses, depending on Vpfpt, IE could prove useful for estimating fetal well-being.

Vaginosonography for recording of cycle-related myometrial contractions.

It has been recognized from experimental or invasive studies that the nonpregnant human uterus has an inherent contractibility. We used vaginosonography for imaging contractions of the inner third of the myometrium. The direction, frequency, and symmetry of contractions were noted. We studied 53 women and subdivided them into four groups based on the cycle phase. During menstruation we found contractions toward the cervix with irregular frequency varying between 1 and 3/min. In the periovulatory period we noted the highest frequency of 10/min of regular contractions toward the fundus. The results showed that active myometrial contractions can be detected sonographically throughout the whole menstrual cycle. Increased myometrial contractions toward the fundus in the periovulatory period may be involved in sperm transport to the tubes.

[Positive diagnosis of irritable colon: a scored chart or standardized anamnesis?]. / Zur positiven Diagnose des Colon irritabile: Punktetabelle oder standardisierte Anamnese?

The diagnostic score of Kruis to diagnose the irritable bowel syndrome (IBS) has recently gained widespread application. We therefore evaluated the case histories of 373 patients attending the gastroenterological outpatient department retrospectively using the questionnaire of these authors. In contrast to Kruis et al's findings, by applying their discriminating score the diagnosis of irritable bowel syndrome was made in only 51% of the patients who underwent complete gastrointestinal survey without pathological findings. However, the group of IBS was significantly separable from malignant or inflammatory disease. We therefore conclude that the diagnosis of IBS should only be made by ruling out organic disease (except in the case of young people with normal physical and laboratory check up findings and a good response to treatment). For these patients we simplified the questionnaire, omitting calculations.

[Meconium peritonitis: intrauterine follow-up--postnatal outcome]. / Mekoniumperitonitis: Intrauteriner Verlauf--postnatales Outcome.

In nine patients with meconium peritonitis prenatal ultrasonographic findings were correlated with the clinical course and outcome. Ultrasound findings included polyhydramnion (n = 4), ascites (n = 4), disseminated (n = 3) and solitary echogenic areas (n = 1), echopoor cystic areas (n = 3) and echogenic-echopoor solitary areas (n = 1). Intra-abdominal calcifications were found in five patients before delivery. Eight neonates survived and were subsequently followed up, one fetus died in utero. Four of the eight survivors required surgery, namely for meconium ileus (n = 1), perforation secondary to intestinal volvulus (n = 2) and inguinal hernia associated with prenatal rubella infection (n = 1). Three patients were healthy, one patient required drainage of pleural effusion and respirator therapy but recovered without further problems. Cystic fibrosis was diagnosed in the patient with meconium ileus. Postnatal outcome could not be predicted from the prenatal sonographic findings.

In vivo assessment of putative functional placental tissue volume in placental intrauterine growth restriction (IUGR) in human fetuses using diffusion tensor magnetic resonance imaging.

OBJECTIVES: Intrauterine growth restriction (IUGR) is a diagnostic challenge, since ultrasound fetal biometry (UFB) provides only a 50% detection rate for IUGR. This may be attributable to the fact that UFB does not allow a direct evaluation of functional placental tissue. We hypothesized that direct assessment, using magnetic resonance diffusion tensor imaging (DT-MRI), can provide better detection of IUGR by reliably distinguishing between normal and non-functional placental tissue. METHODS: Patients with normal placenta function (n = 21) and suspected IUGR (n = 14) according to UFB were examined. DT-MRI-based properties of areas of the placenta that were judged to represent normal functional tissue, in normal pregnancies, were used to perform volumetry of the putative functional placental tissue (PFPT) in a control- and an IUGR-group. Fractional anisotropy (FRC), as well as maximum and mean diffusivity were also calculated. RESULTS: PFPT volumetry showed a significant reduction of functional placental tissue in the IUGR group of up to 33%. Analysis of global PFPT, maximum diffusivity, mean diffusivity, and FRC also showed a significant difference. CONCLUSIONS: PFPT volume is dramatically reduced in IUGR. Several DT-MRI parameters suggest an additional placental micro-architecture disturbance in IUGR. PFPT volumetry appears to be a promising tool for improving the detection of IUGR.

Placental pathologies in fetal MRI with pathohistological correlation.

INTRODUCTION: The purpose of this study was to evaluate whether currently available fetal Magnetic Resonance Imaging (MRI/MR) techniques are sufficient for the assessment of placental pathologies. We hypothesized that placental pathologies as detected and evaluated by MRI, would correlate with histological findings. PATIENTS AND METHODS: In a retrospective study, 45 singleton pregnancies from 19 to 35 gestational weeks, with placental pathologies on MR scans, were included. MRI was performed on a 1.5T unit using T2-, T1-, and diffusion-weighted and echo-planar sequences. Pathologies were categorized into infarction with/without hemorrhagic components, subchorionic/intervillous thrombi/hemorrhages, retroplacental hematoma, massive perivillous fibrin deposition, and chorioamnionitis. Pathohistological examination was performed postnatally within a median of seven days between MR examination and delivery. RESULTS AND DISCUSSION: Pathologically, 26 placentas showed infarctions (96.2% on MR scans), two retroplacental hematomas were detected by MRI and confirmed by pathology, and 9 of 14 subchorionic hematomas were confirmed. Six of eight intervillous hemorrhages were seen on MRI, and three of six cases of severe chorioamnionitis were diagnosed prenatally. Placental hemorrhages (retroplacental hematoma, intervillous thrombi, subchorionic hematoma), and ischemic lesions could be detected with fetal MRI, while chorioamnionitis and even massive perivillous fibrin deposition showed few signal changes, probably reflecting small macroscopic changes in the placenta. Fetal MRI, therefore, seems to be a promising tool for the assessment of placental insufficiency.

[Prenatal diagnosis of osteogenesis imperfecta. Report of a case classified as the classical Ekman Lobstein type]. / Zur pränatalen Diagnostik der Osteogenesis imperfecta. Bericht über einen Fall zugeordnet dem klassischen Typ Ekman Lobstein.

Report on prenatal sonographic diagnosis of osteogenesis imperfecta of the classical type Ekman Lobstein (osteopsathyrosis) in the 35th week of pregnancy. We could demonstrate the marked penetration of ultrasound through the characteristically very thin long bones even before the occurrence of fractures. Difficulties in attributing our case to one of the four groups of osteogenesis imperfecta according to Sillence are discussed, as well as the obstetrical management of these prenatally diagnosed cases.

Meconium peritonitis: extrusion of meconium and different sonographical appearances in relation to the stage of the disease.

By chance, we had the opportunity to make serial sonographic observations of the extrusion of meconium in a case of meconium peritonitis. Inflammation leads to exudative processes and production of fluid (ascites) in the fetal abdomen. Sonography at that stage of the disease may lead to a misdiagnosis such as 'fetal ascites' or 'non-immune hydrops'. After bowel perforation and extrusion of meconium, the latter appears as a solitary mass inside fetal ascites or as disseminated echogenic masses distributed subdiaphragmatically or perihepatically. Within a couple of days, in most cases the echogenicity of the masses increases. Calcifications lead to distinct shadowing. These calcifications are often the only visible signs of a previous meconium peritonitis. Serial sonograms are essential for the management of pregnancies with meconium peritonitis. If the amount of fetal ascites does not increase and no signs of cardiovascular stagnation appear, no invasive intrauterine diagnostic and therapeutic steps are required. In none out of the nine cases was a cause found.

[Prenatal diagnosis of osteogenesis imperfecta. Report of a case classified as the classical Vrolik lethal type]. / Zur pränatalen Diagnostik der Osteogenesis imperfecta (Fortsetzung). Bericht über einen Fall zugeordnet dem klassischen Typus letalis Vrolik.

Report on prenatal sonographic diagnosis of osteogenesis imperfecta of the classical type "letalis Vrolik" in the case of a fetus in the 20th/21st week of pregnancy. The prenatal diagnosis of this kind of osteogenesis imperfecta is based on the soft membranous cranium (Caput membranacium), the microthorax caused by the bell-shaped configuration of the ribs and the diaphysis of the long bones which are too short for the age of pregnancy. These symptoms are first of all the consequence of a disturbed bone formation and mineralisation; its basis is a connatal deficit of collagen synthesis. The sonographic differential diagnosis to the type "Ekman Lobstein" of osteogenesis imperfecta and thanatophoric dwarfism are discussed.

[Malignant lymphomas of the vulva and vagina]. / Maligne Lymphome an Vulva und Vagina.

Primary appearance of a malignant lymphoma in the vulvovaginal region is extremely rare. In this paper, we report on three such cases we observed during the last few years. There was no difference in clinical manifestation compared to cancer of the vulva/vagina. The diagnosis was made using histological and immunohistochemical methods. Choice of the treatment depended upon the stage of malignancy and spreading of the tumourous changes (radiation, chemotherapy). On reviewing the literature of the last 15 years, we could not find any description of primary malignant lymphoma in the vulva and vaginal region.

Ehlers-Danlos syndrome type II in pregnancy.

Ehlers-Danlos syndrome type II is a rare connective tissue disorder with unknown pregnancy-related maternal and fetal morbidity. The course and outcome of pregnancy in a primigravid woman with Ehlers-Danlos syndrome type II is described. At 17 weeks' gestation a prophylactic Shirodkar cerclage was performed without complications. From the 29th week on, decreased blood flow of the umbilical artery was measured, and fetal growth retardation was evident from 34 weeks' gestation on. Pregnancy ended at 41 weeks by spontaneous vaginal delivery of a healthy 2900-g female infant. Previous reports of 16 women with Ehlers-Danlos syndrome type II, who had a total of 24 pregnancies, are reviewed.

[When children "have children"--reproduction biological problems in girls between 11 and 15 years of age]. / Wenn Kinder "Kinder kriegen"--Reproduktionsbiologische Probleme bei Mädchen zwischen 11 und 15 Jahren.

The aim of the present study was to evaluate the obstetric risk in pregnant adolescents under 16 years of age. From July 1, 1970 to June 30, 1993, 188 girls aged 11-15 years were delivered at the 2nd Department of Obstetrics and Gynaecology, Vienna; 4569 primiparous women between 20 and 24 years with singleton pregnancies served as a control group. No significant differences between the two groups were found for the frequency of pregnancy-induced hypertension (2.1% vs. 3.5%), premature delivery rates (24.4% vs. 29.8%), percentage of babies weighing less than 2500 g (10.1% vs. 9.1%), mean birthweight (3082 g vs. 3117 g), frequency of intrauterine growth retardation (2.1% vs. 2.4%) and malformations (1.6% vs. 3.1%) and perinatal mortality to the end of the first week (1.1% vs. 0.5%). Adolescent mothers were found to have more spontaneous deliveries (85.1% vs. 74.9% in the control group, p < 0.005), lower Caesarean section rates (6.4% vs. 11.3%, p < 0.05) and fewer babies with a birthweight exceeding 4000 g (1.1% vs. 4.3%, p < 0.05). For the first time, the pregnancy outcome of European adolescents was studied over a period of 23 years. We conclude on the basis of our results that maternal and neonatal risk in mothers under 16 years of age does not exceed the obstetric risk in adult mothers.

Does acute hypoxia cause fetal arterial blood flow redistribution?

Chronic fetal hypoxia in fetal growth restriction due to impaired placentation is associated with centralization of blood flow to the vital organs, such as brain, heart and adrenal glands, in order to maintain oxygenation. There is a correlation between fetal hypoxemia and low impedance to blood flow in the middle cerebral artery. However, there is no association between abnormal flow velocity waveforms and fetal distress in an unselected population, and this reported case also suggests that Doppler ultrasound is of no value in identifying acute fetal distress.

Epidural anaesthesia in labour: influence on surgical delivery rates, intrapartum fever and blood loss.

We retrospectively analyzed 7,317 fully documented deliveries to assess the effect of epidural anaesthesia (EA) on surgical delivery rates, on the incidence of intrapartum fever and on peripartal blood loss. 1,056 (14.4%) had EA and 6,261 (85.6%) had no or other analgesia. The use of EA was associated with a decreased spontaneous delivery rate (50.0 vs. 79.2%), increased forceps delivery rate (30.7 vs. 4.0%) and increased vacuum extraction rate (3.5 vs. 0.7%). The caesarean section rate was not significantly changed in patients with EA (14.4 vs. 13.0%). Fever greater than 38 degrees C during labour and intrapartum haemorrhage exceeding 500 ml were associated with the use of EA.

Continuous vs interrupted sutures for single-layer closure of uterine incision at cesarean section.

In a non-randomized cohort study, we compared continuous with interrupted sutures for the closure of the lower uterine segment at cesarean section. Eighty-two women, who underwent cesarean section at the Department of Obstetrics at the University Hospital of Vienna between January and May 2000, were included in the study. Thirty-eight patients had single-layer closure of the lower uterine segment and 43 patients had closure with interrupted sutures. There were significant differences in total operating-time (32 min vs 40 min, P=0.001) and in the pre- and postoperative maternal hemoglobin (DeltaHb 0.6 g/dl vs 1.1 g/dl, P<0.01), but there was no significant difference in sonographically diagnosed hematomas (32% vs 21%, P=0.27). No woman had fever, the median hospitalization time was 6 days, and there were no re-admissions. In both groups, the median need for analgesics was 150 mg diclofenac ( P=0.22). Continuous single-layer closure of the lower uterine segment at cesarean section saves operating time, reduces blood loss, and introduces less foreign material into the wound.