Burkhard Schauf

A multicenter survey of complications associated with 21 676 operative hysteroscopies

OBJECTIVE The following study analyses the hysteroscopic experience of multiple gynecologic centers throughout Germany in regard to the incidence of complications, the therapy of these complications and anesthesiological management during 21,676 hysteroscopic procedures. METHODS AND MATERIAL Under the supervision of the German Society of Gynecology Endoscopy, 92 hysteroscopic centers were evaluated and the following information was collected: hysteroscopic experience in years, number of surgical hysteroscopies per year, total number of operative hysteroscopies, types of hysteroscopic procedures, intra- and post-operative complications. RESULTS AND CONCLUSION The results of the study show that in most German centers, hysteroscopy is just being established. Nevertheless, the rate of complications such as perforation of the uterus, fluid-overload syndrome, infection and perioperative bleeding is small. This may be due to the high proportion of documented procedures performed by the more experienced centers.

Delayed maturation of auditory-evoked responses in growth-restricted fetuses revealed by magnetoencephalographic recordings

OBJECTIVE The purpose of this study was to investigate fetal brain development of growth-restricted fetuses with auditory evoked responses (AER) that were recorded by the noninvasive magnetoencephalographic technique. STUDY DESIGN Serial fetal recordings that started at 27 weeks of gestation were conducted on a fetal magnetoencephalographic device that was especially designed for obstetric assessment. Fifteen normotrophic fetuses were compared with 14 hypotrophic fetuses. After birth, 10 of the hypotrophic fetuses were diagnosed with asymmetric growth restriction; 4 fetuses were classified as symmetrically small for gestational age. RESULTS Fetal AER latencies in both groups showed an average developmental decrease of 12.74 msec/wk (P = .0035). Hypotrophic fetuses had longer age-adjusted latencies compared with normotrophic fetuses, with a difference of 73.5 msec (P = .034). The subgroup of symmetrically growth-restricted fetuses showed the longest latencies for age, with a difference from the normotrophic fetuses of 120.0 msec (P = .045). CONCLUSION The results indicate that biomagnetically recorded AER can be used to monitor functional brain development in growth-restricted fetuses.

Effect of Magnesium on Red Blood Cell Deformability in Pregnancy

Objective. Red blood cell (RBC) deformability is an important factor in determining movement of red blood cells through the microcirculation. In preeclampsia and some cases of intrauterine growth restriction (IUGR), RBC deformability and microcirculation are reduced. Magnesium is administered to reduce the risk of seizures. The aim of this study was first to detect the effect of intravenous magnesium application (2 g/h) on the deformability of RBCs in pregnancies with normal RBC deformability, receiving magnesium as tocolytic agent. The second aim was to examine the effect of calcium-antagonists (magnesium, nifedipin) on the deformability of RBC of preeclamptic patients in vitro. Methods. Part 1: magnesium (2 g/h), fenoterol (270 µg/h) + verapamil (0.2 mg/h) or placebo (NaCl 0.9%) was administered intravenously to pregnant women with premature contractions to test the tocolytic effect. RBC-deformability was measured by laser diffractoscopy in all three groups. Blood samples were taken before, after 1 h and after 24 h of administration. Magnesium-plasma-levels were measured. Part 2: Blood samples from patients with preeclampsia were incubated in vitro with magnesium (2 mmol), nifedipine (0.25 mg/ml), or placebo (NaCl 0.9%). RBC deformability was measured before and 15 min, 1h, 2h, 6h, and 10h after start of the incubation. Results. Part 1: The initial RBC-deformability was the same in all groups (E=0.232 ± 0.017 in NaCl, 0.232 ± 0.023 in fenoterol + verapamil, 0.232 ± 0.019 in magnesium). After 1 h of administration, RBC-deformability was significantly greater with magnesium (0.254 ± 0.020) and Fenoterol + Verapamil (0.238 ± 0.02) compared to placebo (0.231 ± 0.015). After 24 h the effect on RBC deformability in the fenoterol + verapamil-group was gone (0.234 ± 0.021 compared to 0.234 ± 0.016 in placebo), while in the IV-magnesium-group RBC-deformability remained increased (E=0.241 ± 0.019). Statistical analysis of the influence of magnesium-plasma-levels showed the maximum effect at concentrations of 1.95–2.15mmol/l. Part 2: RBC-deformability in preeclampsia was reduced as predicted by previous studies (0.120 + 0.0086 versus 0.232 in normal pregnancy). In vitro incubation with magnesium enhanced RBC-deformability in preeclampsia. Even after 15 min, a statistically significant effect was seen (0.127 ± 0.0091 versus 0.121 ± 0.0091 in placebo). Maximum effect was reached after 6 h of incubation (0.159 ± 0.0093 versus 0.133 ± 0.0091). Incubation with Nifedipine also enhanced RBC deformability [0.127 ± 0.0091 after 15 min, 0.149 ± 0.010 after 6 h (maximum effect)], but the effect was less pronounced than with magnesium. Conclusion. Intravenous magnesium therapy over a 24-hour period increases RBC-deformability even in pregnancies with normal RBC-deformability. In vitro measurements show an increase of RBC-deformability in preeclampsia in response to magnesium, which could offer additional therapeutic benefit for the treatment of reduced blood flow seen in most cases of preeclampsia.

Evaluation of Red Blood Cell Deformability and Uterine Blood Flow in Pregnant Women with Preeclampsia or IUGR and Reduced Uterine Blood Flow Following the Intravenous Application of Magnesium

Objective: Red blood cell (RBC) deformability is one of the factors determining microcirculation. In preeclampsia (PE) and some cases of intrauterine growth restriction (IUGR), RBC deformability and, consequently, microcirculation appear to be impaired. Magnesium sulfate is administered to reduce the risk of seizures in PE. The aim of our study was to detect the effect of 24‐hour intravenous (IV) magnesium on RBC deformability and on uterine artery blood flow in pregnant patients with preeclampsia or IUGR and pathologic uterine blood flow. Methods: Magnesium IV (1 g/h) was administered to 25 pregnant women with reduced uterine blood flow for a period of at least 24 hours. The RBC deformability was measured by laser diffractoscopy, blood volume flow was measured by uterine artery Doppler. Measurements were taken before the start of magnesium therapy and 24 h later. Magnesium plasma levels were measured at the same time. Results: High plasma levels of magnesium improve RBC deformability from E = 0,109 (SD ± 0.023) to E = 0.115 (SD ± 0.021) after 24 h IV magnesium (p = 0.043). There is no correlation of E to the plasma magnesium level either before or after 24 h magnesium treatment. Blood volume flow in the uterine arteries increased significantly from 5.09 mL/s (SD ± 3.03) to 10.02 mL/s (SD ± 5.86) after 24 h magnesium (p = 0.0002). The differences in the resistance index do not significantly differ from 0 (p = 0.46). Conclusion: A high IV dosage of magnesium over a period of 24 hours dilates the uterine arteries of pregnant women with PE and/or IUGR, reduces uterine blood flow, and improves the deformability of RBC. Both parameters enhance the oxygen supply to the fetus, a critical parameter in these pregnancies. Thus magnesium might not only be effective as phrophylaxis against seizures but also in cases of IUGR with a reduced uterine blood flow. The clinically observed beneficial effect of magnesium in PE could be due to the improved blood supply for the fetus.

REDUCED RED BLOOD CELL DEFORMABILITY, AN INDICATOR FOR HIGH FETAL OR MATERNAL RISK, IS FOUND IN PREECLAMPSIA AND IUGR

Objective: Red blood cell (RBC) deformability is one of the factors determining microcirculation. In preeclampsia (PE) and some cases of intrauterine growth restriction (IUGR), microcirculation appears to be reduced. The aim of the study is to examine whether there are differences in RBC deformability in uncomplicated pregnancy when compared to pregnancies complicated by PE and/or IUGR. Material and methods: RBC deformability of 87 pregnant women with initially normal pregnancies was evaluated with the laser diffractoscope. RBC deformability was measured beginning in week 16 of gestation up to 5 days after delivery. Thirty-seven women had an uncomplicated pregnancy. In addition, RBC deformability of 10 nonpregnant women was measured on days 5 and 22 of their menstrual cycle. RBC deformability of women with preeclampsia (PE, N=15), intrauterine growth restriction (IUGR, N=17), or PE plus IUGR (N=17) was measured weekly, beginning with the onset of clinical symptoms, up to 5 days after delivery. Results: In early uncomplicated pregnancies, RBC deformability does not differ from the nonpregnant state. At week 30 of gestation, there is a slight decrease in RBC deformability followed by a return back to the values of nonpregnant women after delivery. Women with PE and/or IUGR show reduced RBC deformability. This is most pronounced in cases with severe fetal or maternal complications. After delivery, RBC deformability also returns to nonpregnancy values within 5 days. Conclusion: Reduced RBC deformability may contribute to a reduced microcirculation in PE and IUGR. Increasing RBC deformability therapeutically in these cases could offer new options for the treatment of decreased uterine and fetal perfusion and their sequelae.

Prophylaxe der Präeklampsie

: The pathophysiology of preeclampsia is still unknown. Low-dose aspirin showed a reduction of the preeclampsia rate in a high-risk situation.There is a lack of prospective randomized studies to prove the benefit of heparin treatment in patients with hereditary thrombophilia. Different prophylactic therapies did not show any benefit in the prevention of preeclampsia in clinical studies.

Embolisation of uterine arteries or laparascopic uterine artery ligation as possible treatment of uterine leiomyoma

BackgroundMany women with symptomatic uterine leiomyomata wish to preserve their uterus. Novel organ- and fertility-preserving treatment options such as embolisation of uterine arteries or laparascopic uterine artery ligation have frequently been discussed as viable alternatives to myomectomy. This article strives to bring together the conclusions of major studies on novel organ-preserving treatment alternatives for uterine myoma.MethodsMinimally invasive organ-preserving laparascopic myomectomy remains the best treatment option for patients with symptomatic fibroids who wish to retain their uterus. However, in certain cases other options such as embolisation or laparascopic ligation of uterine arteries can serve as viable alternativesResultsA failure rate of up to 39% and complications such as reduced fertility because of ovarian failure after transcatheter embolisation of uterine arteries might restrict the use of this method.ConclusionsFor postmenopausal women, transcatheter embolisation of uterine arteries is a possible treatment alternative. Laparascopic ligation of uterine arteries and anastomotic sites of uterine arteries with ovarian arteries might also be viable for young women who desire to preserve future fertility. Further data and studies on the long-term follow-up after ligation are yet to come.

Interventional fetal balloon valvuloplasty for congenital heart disease—current shortcomings and possible perspectives

Fetal cardiac interventions are new and relatively unknown investigational options for modifying congenital heart disease in utero. Techniques for safer access to the fetus must be improved, and selection criteria for patients for whom these procedures are potentially beneficial must be developed. Currently, antenatal cardiac intervention attempts are being made to either prevent or reverse hydrops in fetuses with cardiac valve disease or outflow tract obstruction or to recruit hypoplastic ventricles. Most important are early detection and referral of these fetuses, thereby enabling timely procedures with improved outcomes. However, performing successful fetal cardiac interventions requires multidisciplinary collaboration between obstetricians, pediatric cardiologists, pediatric cardiac surgeons, and anesthesiologists, as each discipline provides specific skills for these critically ill babies.

New perspectives in intrauterine surveillance with the fetal magnetoencephalogram

PURPOSE Despite intensive research and surveillance up to now one has failed to reduce cerebral handicaps in newborn. Fetal heart rate tracing (CTG) and Doppler have reduced the number of subpartal severe asphyxia and fetal death. But, 90% of cerebral damage is a result of antepartal problems. Thus only 10% can be avoided by intensive surveillance during labor. Detection of antenatal cerebral injury is a rare case and its impact on later fetal life can only be estimated. Insight in fetal neuronal function is not possible. Factors and time pattern determining fetal cerebral injury are thus not known. This publication explains a new system with whom one might be able to get more insight in cerebral wellbeing during the fetal intrauterine life. METHODS AND RESULTS A new diagnostic approach is set up by recording fetal magnet encephalographic signals (fMEG) thus offering the opportunity to detect fetal brain function. An array which was especially designed to fit to the pregnant body consists of 151 sensors which are able to record the fMEG. Clinical testing is performed in the moment at the UAMS in Little Rock, Arkansas in Cooperation with the Institutes for Medical Psychology and the Frauenklinik in Tiibingen. First results and arising questions are published. CONCLUSION With this new system a deeper insight into the fetal neuronal development and fetal wellbeing during pregnancy might be achieved thus reforming the fetal surveillance in the 21st century.