M. Langer

Elective cesarean section vs. spontaneous delivery: a comparative study of birth experience

Background.  To investigate birth experience and medical outcome in women with elective cesarean section (CS) compared with women with intended vaginal delivery.

Extracorporeal lipid elimination for treatment of gestational hyperlipidemic pancreatitis

Gestational hyperlipidemia complicated by pancreatitis during the 24th week of gestation has been successfully managed by long-term extracorporeal elimination of triglyceride-rich lipoproteins. Three modes of treatment (plasma exchange, immunospecific apheresis, and a combination of both treatments) were compared for efficacy as therapy for metabolic derangements, altered blood rheology, and the loss of immunoglobulins. Treatments were performed by means of a peripheral venovenous approach. A combination plasma exchange/apheresis technique was highly effective; the loss of immunoglobulins remained acceptable. Clinical symptoms of pancreatitis subsided within 24 hours of the first treatment. A relapse during the 32nd week of gestation necessitated treatments more frequently than once a week. At the 36th week of gestation, after confirming lung maturity as indicated by a lecithin-sphingomyelin ratio of > 2.0, a cesarean section was performed. A healthy boy was delivered (2470 g; Apgar score, 9/10). This is the first report to show that long-term extracorporeal elimination of lipoproteins is a highly effective treatment of hyperlipidemic gestational pancreatitis.

Immunoadsorption and plasma exchange in pregnancy.

Background: During pregnancy, familial hyperlipidemia or systemic lupus erythematosus (SLE) can exacerbate having devastating consequences for both mother and fetus. Immunoadsorption is established for removal of pathogenic proteins lipoproteins or autoantibodies, but this procedure has only rarely been used in pregnancy. Methods: We evaluated retrospectively 126 extracorporeal treatments during six pregnancies. Forty low-density lipoprotein immunoadsorptions, 6 sole plasma exchanges and 36 combined procedures (plasma exchange followed by immunoadsorption) were performed for severe hypertriglyceridemia, complicated by acute pancreatitis. Forty-four IgG immunoadsorptions were executed in 2 pregnant women suffering from SLE with a disastrous course during prior pregnancies. Results: In hyperlipidemic pregnant women, mean triglyceride levels prior to treatment were 3,841 ± 2,076 mg/dl (mean ± SD) and total cholesterol was 617 ± 354 mg/dl. Until delivery, a 27% reduction of triglycerides could be achieved. Clinical and serological signs of pancreatitis disappeared after initiation of extracorporeal therapy. Four healthy babies were delivered (birthweights between 2,250 and 3,360 g). In 1 woman suffering from SLE, intrauterine fetal death occurred in the 22nd week of gestation despite a reduction of cardiolipin antibodies by 69%. The second case (a twin pregnancy) was complicated by steroid-resistant antibody-mediated anemia. Due to frequent immunoadsorptions, red blood cell count improved (reduction of antierythrocyte antibodies by 66.6%) and 2 healthy babies (birthweights 2,120 and 2,350 g) were delivered by cesarean section. Conclusion: Long-term antibody-based immunoadsorption has been demonstrated to be safe and well tolerated in pregnant women and enables normal intrauterine/fetal development. Although rarely indicated during pregnancy, this treatment modality might be a promising new technique for removal of autoantibodies and lipoproteins in patients with serious gestational complications without sufficient response to conventional therapy.

Vaginal Agenesis and Congenital Adrenal Hyperplasia Psychosocial Sequelae of Diagnosis and Neovagina Formation

Eleven patients with Mayer‐Rokitansky‐Küster syndrome (MRK) and 7 patients with adrenogenital syndrome (CVAH) were interviewed and tested pre‐and postoperatively. MRK subjects were operated on with a modified Vecchietti procedure, CVAH subjects underwent genitoplastic and clitoroplastic operation. Psychosocial sequelae of and coping with malformation and treatment were assessed with semistructured interviews and the Giessen test. Anatomical and functional results of the vaginoplastic operation were excellent, and sexual satisfaction correlated with coping. 7/11 MRK patients were capable of good to fair adaptation to the malformation, whereas CVAH patients suffered severe distortions of body image. the malformation caused narcissistic damage in all cases. Circumstances of diagnosis, prevailing defense mechanism and consequences for counselling are discussed.

Psychological effects of ultrasound examinations: changes of body perception and child image in pregnancy

Ultrasound scanning is known to have psychological effects due to its vivid imagery. In a prospective study on 60 healthy gravidae in midtrimester pregnancy the impact of a single scan upon child image and body perception was evaluated. Seven-point numerical scales were filled in by the women before and after ultrasound and high feedback of the screen image was given during the scan. Medical and socio-economic information was collected in an interview.Child image changed considerably towards a brisker, more active and more familiar view; for body image, an increase in reassurance could be observed. Parity and partner status had an influence on the experience of the scan. Primiparae without partners and women with pregnancy complaints could benefit by the scan in certain aspects of their body perception.Implications of these findings for early mother-infant bonding, abortion and daily clinical practice are discussed. Careful and conscientious use of ultrasound as a psychologically potent agent is recommended.

Prospective Counselling after Prenatal Diagnosis of Fetal Malformations: Interventions and Parental Reactlons

A model of prospective counselling and intervention after prenatal diagnosis of fetal malformation is presented. 13 patients/couples with severe malformations were fully counselled, 3 patients/couples interviewed post‐termination. Objectives of the counselling strategy were to support patient autonomy, facilitate mourning and reduce narcissistic damage.

Reduction of preeclampsia in multiple pregnancies by a dedicated monitoring protocol.

Objective: To evaluate the effect of a dedicated monitoring protocol on the incidence of pregnancy-induced hypertension disorders (preeclampsia, HELLP [hemolysis, elevated liver enzymes, low platelets] syndrome, gestational hypertension) during a 5-year period in 417 women with multiple gestations. Methods: At the Department of Obstetrics and Fetomaternal Medicine, Vienna University, an outpatient care protocol for women with multiple pregnancies was established. Between March 1997 and February 2002, 379 twins and 38 triplets were followed up. Mean visits of dichorial and monochorial twins were nine and 11, respectively. Triplets were asked to at least 12 follow-up visits. Results: Any kind of pregnancy-associated hypertensive disorders necessitating cesarean delivery developed in eight women (seven with twins, one with triplets; 1.76%). Three cases of preeclampsia, three cases of HELLP syndrome, and two cases of pregnancy-induced hypertension were diagnosed. Perinatal outcome of all 17 newborns was excellent without any mortality and only minor morbidity. All mothers left the hospital in a fully recovered condition. Conclusion: Because of our results we hypothesize that our monitoring protocol with frequent visits, continuous personal obstetric care, and timed delivery is effective in reduction of pregnancy-induced hypertension in multiple pregnancies.