B. Arabin

Obstetrical Characteristics of a Loss of End-Diastolic Velocities in the Fetal Aorta and/or Umbilical Artery Using Doppler Ultrasound

In 30 of 137 high-risk pregnancies we observed absent end-diastolic velocities indicating a high downstream impedance, which could be proved by histomorphological findings of the placenta. On the average the loss of end-diastolic velocities occurred 2-3 days before suspicious and nearly 8 days before pathological cardiotocographic findings. The perinatal mortality was high when absent velocities had been observed before the 32nd week, a cesarean section was obligatory in all but 1 case. All fetuses were growth-retarded. In 9 cases we were able to determine the ratio of blood flow volume in the common carotid arteries to that of the fetal aorta. The values were significantly increased as compared to values of undisturbed pregnancies, demonstrating a redistribution of fetal blood in favor of cerebral circulation.

Feto-Feto-Fetal Triplet Transfusion Syndrome (FFFTTS)

We report a case of feto-feto-fetal-transfusion-syndrome (FFFTS) in a spontaneous monochorionic triamniotic triplet pregnancy primarily diagnosed at 17 weeks of gestation. During the course of pregnancy, sequentially two triplets appeared as donor. Symptoms of a recipient (polyhydramnios, tricuspid valve insufficiency, and ascites) were present in the third triplet. The second of the donor twins died in utero at 25 weeks. At 27 weeks, a cesarean section was performed mainly due to pre-eclampsia. The first donor triplet developed normally, whereas the recipient showed periventricular leucomalacia and neurological impairment.

Simultaneous Assessment of Blood Flow Velocity Waveforms in Uteroplacental Vessels, the Umbilical Artery, the Fetal Aorta and the Fetal Common Carotid Artery

We investigated simultaneously blood flow velocity waveforms of uteroplacental vessels, the umbilical artery, the fetal aorta and the fetal common carotid artery. In pregnancies with intrauterine growth retardation or preeclampsia we found low diastolic velocities in uteroplacental vessels, the umbilical artery and the fetal aorta and high diastolic velocities in the common carotid artery. Abnormal waveforms of the common carotid artery were most effective in predicting fetal compromise and might be a valuable clinical tool for the supervision and therapy of high-risk pregnancies in the future.

Quantitative Analysis of Fetal Behavioural Patterns with Real-Time Sonography and the Actocardiograph

Fetal heart rate patterns, isolated and clustered fetal movements, fetal eye and breathing movements were analysed simultaneously and semiquantitatively in 20 uncomplicated pregnancies in accordance with the classification of fetal behavioural states by Nijhuis and with the aid of two ultrasound scanners and the actocardiograph. According to our own definition state 1 F, 2 F, 3 F and 4 F were observed in 29, 34, 8, and 14% of the registration time. In 15% no state could be identified. Using only the actocardiograph state 1 F, 2 F and 4 F could be identified in around 75%. Periods without a state diagnosis could not be assessed by the actocardiograph alone. The combination of the actocardiograph and one ultrasound scanner for the observation of fetal eye movements reached a similar diagnostic accuracy as the polygraphic monitoring with two ultrasound scanners.

Relationship of utero- and fetoplacental blood flow velocity wave forms with pathomorphological placental findings.

Pulsed Doppler examinations were performed in 143 risk pregnancies. The resistance index (RI) values of the uteroplacental vessels and umbilical artery on the last examination before delivery were correlated to specific patterns of morphological placental findings. The sensitivity and specificity of Doppler blood flow velocity wave forms to predict placental disease as well as the significant relationships were calculated. Impaired uteroplacental perfusion is correlated with: disturbances in growth, such as reduced weight and reduced basal area (p < 0.005, p < 0.05); disturbances in villous maturation, such as prematurity or a reduction in intermediate sized villi (p < 0.05, p < 0.01), and circulation disorders, such as acute or chronic infarcts (p < 0.05), villous fibrosis (p < 0.005) or microfibrin deposits (p < 0.05). Villous immaturity was not correlated to either pathological utero- or fetoplacental blood flow. Except for acute infarcts, all these findings as well as endangiopathy of truncal arteries are also combined with high RI values in umbilical arteries (p < 0.005) possibly reflecting the down-stream impedance of the fetoplacental circulation.

Prediction of Fetal Distress and Poor Outcome in Intrauterine Growth Retardation – A Comparison of Fetal Heart Rate Monitoring Combined with Stress Tests and Doppler Ultrasound

One hundred and three intrauterine growth retardation (IUGR) pregnancies were scheduled for pulsed Doppler ultrasound of the common carotid and the umbilical artery, nonstress and contraction stress tests (NST/CST) as well as vibroacoustic stimulation tests (VAST). The last examinations < 3 days before birth were compared by receiver-operator characteristics: Results of the resistance indices of fetal common carotid/umbilical artery and NST were more predictive of later fetal distress during labour, compared to CST and VAST (p < 0.001/< 0.01). Similar results were found for the prediction of low pH and Apgar values, though differences were less pronounced. Our results suggest that stressful examinations should be abolished from mother and fetus in the supervision of IUGR.

Successful Treatment of Primary Fetal Hydrothorax by Long-Time Drainage from Week 23

We report on a case of unilateral primary fetal hydrothorax leading to nonimmunological fetal hydrops (NIHF). The NIHF was treated successfully by inserting two consecutive intrauterine catheters at 23 weeks gestation. The first catheter was dislocated through the uterine wall to the maternal peritoneal cavity. At 36 weeks gestation, the mother had a spontaneous onset of labor after premature rupture of membranes and a normal vaginal delivery of a healthy infant with good perinatal outcome. Shunting of PFHT has rarely been described up to now. This case report supports observations of previous authors that early shunting of pleural effusions may prevent progression of NIHF as well as postnatal pulmonary hypoplasia. Unexpected perinatal complications of fetus, mother or both should not be neglected.

Effect of dexamethasone, triiodothyronine and dimethyl-isopropyl-thyronine on lung maturation of the fetal rat lung.

Abstract Our purpose was to elucidate why clinical studies have up to now failed to demonstrate a positive effect of TRH combined with glucocorticosteroids on fetal lung maturity. Morphological and biochemical lung maturation were determined by electron microscopy, choline incorporation, and surfactant-protein-A m-RNA synthesis in rat lung organoid cultures after exposure with a series of concentrations of dexamethasone, triiodothyronine, and dimethyl-isopropyl-thyronine. Thyroid hormones improved morphogenesis of lung histotypic structures but had a negative effect on surfactant synthesis whereas glucocorticosteroids had a positive effect on the surfactant synthesis but a negative effect on morphogenesis. The combination of both substances even had the most negative effect on morphogenesis. Since morphogenesis of lung histotypic structures is prerequisite for surfactant synthesis and secretion, we hypothesize that a sequential treatment of thyroid hormones to improve morphogenesis followed by the application of glucocorticosteroids might be an option to improve neonatal lung function.

Prediction of Fetal Distress and Poor Outcome in Prolonged Pregnancy Using Doppler Ultrasound and Fetal Heart Rate Monitoring Combined with Stress Tests (II)

Postterm pregnancies of more than 290 completed gestational days (n = 110) were simultaneously supervised after admission by pulsed Doppler ultrasound of the common carotid and the umbilical arteries, nonstress and contraction stress tests (NST/CST) and vibroacoustic stimulation tests (VAST). The results of these tests were blinded for the clinicians. Further decision making was based mainly on fetal heart rate (FHR) monitoring. The prognostic value of tests performed < 3 days before birth predicting fetal distress, low Apgar and pH values in the umbilical artery were compared by receiver operator characteristics. Results of the NSTs and fetal Doppler measurements of the ratio of resistance indices of common carotid/umbilical artery were more predictive of later fetal distress than both, VAST and CST (p < 0.01, p > 0.05, respectively). There were no significant differences in the prediction of low Apgar values. NST was the only significant test for predicting a low pH in the umbilical artery immediately after birth compared to the other examinations (p < 0.05). The results suggest that even in prolonged pregnancies VAST and CST might be released from routine supervision.

Prediction of RDS by amniotic fluid analysis: a comparison of the prognostic value of traditional and recent methods.

The determination of lecithin or even more the lecithin/sphingomyelin (L/S) ratio in amniotic fluid are both well established in the prediction of neonatal RDS. The immunological measurement of phosphatidylglycerol (PG) and the determination of the surfactant/albumin (S/A) ratio by fluorescence polarization (TDx FLMR) have recently been introduced for the detection of fetal lung maturity. In order to compare traditional versus recent methods L/S ratio and PG determination by one dimensional thin-layer chromatography, enzymatic analysis of lecithin, immunological determination of PG by Amniostat-FLMR and the fluorescence polarization of S/A-ratio by the TDx FLMR were all performed in 141 amniotic fluid samples of 122 patients. Only one out of 72 samples was false negative in the enzymatic lecithin determination (sensitivity 88%). All other methods have a sensitivity and a negative predictive value of 100%. The positive predictive values and the specificity varied between 22%-50% and 58%-87% respectively. The false positive rate, which is high for all methods, is lowest for the L/S ratio. This study demonstrates, that the recent methods are reasonable alternatives in all cases with a positive test. In clinical practice they have the advantage, that the result can be obtained in 15 minutes. If the test is predictive for lung immaturity the L/S ratio should be performed in addition to decrease the false positive rate before any clinical decision is made.