Rainer Terinde

DOPPLER SONOGRAPHIC FINDINGS AND THEIR CORRELATION WITH IMPLANTATION IN AN IN VITRO FERTILIZATION PROGRAM.

In 45 women from an in vitro fertilization (IVF) program, the uterine and ovarian blood flows were investigated by vaginal Doppler sonography. The resistance index was used to evaluate the blood pattern. When comparing the patients who became pregnant after embryo transfer (ET [group I, n = 12]) with those who did not conceive (group II, n = 33), it is evident that in group I the vascular resistance of the uterine arteries is significantly lower on the day of follicular aspiration. No differences could be detected in the ovarian vessels. The data obtained so far suggest that the receptivity of the endometrium is a crucial factor for successful implantation. In the final analysis, this can be appraised not only on the basis of morphological but also of hemodynamic parameters.

Coping styles of pregnant women after prenatal ultrasound screening for fetal malformation

OBJECTIVE Ultrasound is a widespread noninvasive method of prenatal diagnosis. The detection of fetal abnormalities can provoke anxiety, which needs coping. The coping process of pregnant women with different risk conditions for fetal abnormality were studied in a longitudinal design and compared with a nonrisk control group of women with healthy uncomplicated pregnancies. METHODS The coping strategies of women (n=664) during the second trimester were assessed with a questionnaire [Heim E, Augustiny KF, Blaser A, Schaffner L. Berner Bewältigungsformen (BEFO) Handbuch. Bern: Huber, 1991]. Data were collected at three points in time: immediately before the ultrasound scanning for fetal malformation, at 5-6 and 10-12 weeks after the prenatal ultrasound examination. Questionnaires were also used to collect information about sociodemographic data, anxiety, pregnancy data and personality. RESULTS The analysis of the coping strategies of women with high-risk pregnancies (n=497) and as well of these with no-risk conditions in the control group (n=167) revealed three different factors of coping: Factor I: positive emotional attitude/distance, Factor II: negative emotional attitude/disapproval and Factor III: active coping. At all three points in time, Factor I correlated significantly with anxiety decrease, Factor II with increase and Factor III did not correlate with anxiety at all. CONCLUSIONS Women with risk-pregnancies used coping strategies similar to those women in the control-group. Different spectrums of coping strategies corresponded significantly to increasing or decreasing anxiety. These women with high levels of anxiety, especially, should be offered sensitive care or psychotherapeutic counseling, as their coping processes did not lead to successful coping in the form of a reduction in anxiety.

Three-dimensional ultrasound-validated large-core needle biopsy: is it a reliable method for the histological assessment of breast lesions?

The use of three‐dimensional (3D) ultrasound may help to determine the exact position of the needle during breast biopsy, thereby reducing the number of core samples that are needed to achieve a reliable histological diagnosis. The aim of this study was to demonstrate the efficacy of 3D ultrasound‐validated large‐core needle biopsy (LCNB) of the breast.

Short-term outcome in infants with birth weights less than 1750 g born to mothers with HELLP syndrome.

Premature infants born to mothers with HELLP syndrome were reported to have a less favourable outcome compared to infants with uncomplicated maternal history. We investigated the short term outcome in 21 premature infants with birth weights less than 1750 g born to mothers with HELLP syndrome. Median birth weight was 1050 g (range 420 g-1750 g), corresponding gestational age 29 weeks (range 26-35 weeks). Mechanical ventilation for RDS was necessary in 15 infants. Intracranial hemorrhage was diagnosed in 2 infants, 1 of the surviving infants developed bronchopulmonary dysplasia. Acute renal failure was observed in 3 infants immediately after birth. Mortality was attributed to progressive respiratory failure in 2 patients (b.w. 420 g and 490 g) and persisting acute renal failure in 1 patient (b.w. 520 g) Leucocytopenia (less than 9000/mm3) was observed in 13 infants and thrombocytopenia (less than 115000/mm3) was noted in 4 infants during the first day. Eighteen infants survived. We conclude, that the short term outcome in infants born to mothers with HELLP syndrome is not as poor, as previously reported.

EFFECTS OF PREVIOUS PREGNANCY LOSS ON LEVEL OF MATERNAL ANXIETY AFTER PRENATAL ULTRASOUND SCREENING FOR FETAL MALFORMATION

ABSTRACT The impact of previous stillbirth, miscarriage, or preterm delivery on anxiety in pregnant women in various subgroups at high risk for fetal abnormality in comparison with a nonrisk control group of women with healthy uncomplicated pregnancies was studied longitudinally. The level of anxiety in women (n = 674) during early pregnancy was assessed by questionnaire. Data were collected at three points in time: immediately before the ultrasound scanning, at 5–6 weeks, and at 10–12 weeks after the prenatal examination for fetal malformation. In general, all women with high-risk pregnancies (n = 506) showed high levels of anxiety immediately before ultrasound scanning. There was a significant decrease in anxiety over the following 10–12 weeks. By contrast, level of anxiety was not raised in the no-risk control group (n = 168). However, pregnant women who had experienced miscarriage or stillbirth in previous pregnancies showed increasing or persistently high levels of anxiety over time. We believe it is very important to screen women whose levels of anxiety are consistently high or escalating and to offer psychotherapeutic counseling as a means of preventing pregnancy complications. Karl Heinz Brisch, is head of the Department of Pediatric Psychosomatic Medicine and Psychotherapy at the Dr. von Hauner Childrens Hospital, Ludwig-Maximilians-University, Munich, Germany. He is a child and adolescent psychiatrist, psychiatrist, and neurologist specializing in psychosomatic medicine. His main research areas include parent-infant interaction, attachment, coping with high-tech medicine, and diagnosis and treatment of attachment disorders. Dorothee Munz, is a psychologist, researcher, and psychotherapist in the Department of Psychosomatic Medicine and Psychotherapy, University of Ulm, Ulm, Germany. Her research areas include issues of coping with diagnostic procedures in medicine and psychotherapy. Horst Kächele, chair and director of the Department of Psychosomatic Medicine and Psychotherapy, University of Ulm, Ulm, Germany, is a psychoanalyst and psychotherapist. His research fields are psychotherapy process and outcome research, psychosocial aspects of bone marrow transplantation, eating disorders and clinical attachment research. Rainer Terinde, head of the Subdepartment of Prenatal Diagnosis and Sonography in Gynecology, Womens Hospital, University of Ulm, Ulm, Germany, is a gynecologist and obstetrician with specialization in prenatal diagnosis. His research areas are doppler sonography in pregnancy, laser coagulation in twin to twin transfusion syndrome, and diagnosis and treatment in high-risk pregnancies. Rolf Kreienberg, director of the Womens Hospital, University of Ulm, Ulm, Germany, is a gynecologist and obstetrician specializing in oncology.

False-negative findings in chorionic villus sampling. An experimental approach and review of the literature

61 fetuses/newborns who had an aberrant karyotype in amniocentesis (AC) or percutaneous umbilical blood sampling (PUBS) were followed‐up by chorionic villus sampling (CVS) at birth or after interruption.The overall rate of discrepancies is surprisingly high. Among 46 cases with a non‐mosaic numerical aberration in AC or PUBS three had a discrepant finding in placental tissue. This was also true in one of seven cases with non‐mosaic structural aberrations and in three of five cases with mosaic structural aberrations. All three cases with a mosaic numerical aberration in AC or PUBS were not represented by CVS and/or lymphocytes or fibroblasts, demonstrating the general problem of the unpredictable prognostic value of mosaicism. Our data suggest, that in case of prenatal diagnosis by CVS, using a combined procedure of short‐term (STC) and long‐term culture (LTC), in our sample we would have missed one case of 45, X (1·6 per cent). When relying only on STC another two cases, one with 47,+21 and one with 46, XX, der(22) would not have been recognized (4·9 per cent, n=3). All other chromosome aberrations would have been detected by STC alone. On the other hand, one case of 45, X was ‘nearly missed’ because of low‐grade mosaicism in AC (45, X[1]/46, XX[19]), whereas in placental tissues and PUBS only 45, X was represented. This study mimics a false‐negative rate of about 1:3000 (STC plus LTC) or about 1:1000 (STC alone) for an a priori risk group of two per cent (e.g., advanced maternal age). Copyright

In vitro studies on clonal growth of chondrocytes in thanatophoric dysplasia

Thanatophoric dysplasia (TD) is characterized by a disorganized growth plate with markedly reduced proliferative and hypertrophic cartilage zones. Therefore, we studied in vitro the proliferation rates of articular chondrocytes from five TD patients and age-matched controls in response to bFGF, IGF-I, IGF-II, and TGF-beta 1. In human fetal controls bFGF was the most potent growth factor. Clonal growth the articular chondrocytes in response to bFGF was reduced in two of five TD patients and slightly below the range of controls in a third case. Stimulation of chondrocyte proliferation by IGF I and II was reduced in the patient whose response to bFGF was most markedly impaired. The effect of TGF-beta 1 ranged from normal to slightly elevated values in TD fetuses. These results indicate heterogeneity of the underlying defects in TD. Low proliferative responses of chondrocytes to bFGF and IGF-I/II are likely to play a key role in the pathogenesis of some cases. In two of five patients studied, the mechanisms of bFGF and IGF-signal transduction are candidates for the primary molecular defect.

Reference values for resistance index and pulsatility index of uteroplacental Doppler flow velocity waveforms based on 612 uneventful pregnancies.

Using a 4-MHz continuous-wave Doppler device, standard rates were established for resistance index (RI) and pulsatility index (PI) of uterine and arcuate arteries of 612 patients with uneventful pregnancies and deliveries. From 18 to 41 weeks of gestation, neither RI nor PI of uterine or arcuate arteries proved to vary with gestational age, maternal heart rate, or maternal age. By contrast, a significant effect of placental location on the measurement results was found in both uterine and arcuate arteries. The differences between measurements on the placental or opposite site are more distinct in arcuate than in uterine arteries. Taking the 90th percentile as a localization gauge, cutoff levels of 0.52 (RI) and 0.98 (PI) were found in uterine arteries. In arcuate arteries, cutoff levels of 0.45 (RI) and 0.82 (PI) were found on the placental site or with a placenta without lateralization. On the nonplacental site of a lateralized placenta, the cutoff levels were 0.51 (RI) and 0.92 (PI).

Continuous-Wave Doppler Investigation of Uteroplacental Vessels in High-Risk Pregnancies as Predictor of Fetal Growth Retardation and Pregnancy-Induced Hypertension

Continuous-wave Doppler sonography of uteroplacental vessels and the umbilical artery was used as an additive method in the management of risk pregnancies. Its major advantage lies in permitting noninvasive access to placental perfusion. In a sample of 650 singleton pregnancies considered at risk, flow patterns of the right and left uterine and arcuate arteries and of the umbilical artery were obtained. Increased resistance in uteroplacental circulation alone (90th percentile of resistance index and/or notching) was seen in 62 of 100 patients with confirmed growth retardation, proving the key role played by uteroplacental perfusion disorders. Early diastolic notching as well as incomplete vascular flow patterns were also found significantly more often in the growth-retarded group compared to the controls, especially in pregnancies additionally beset by hypertensive disorders. Doppler study of both utero- and fetoplacental circulation increased the sensitivity to 76% in pregnancies with intrauterine growth retardation, and to 90% in those cases with an additional risk of pregnancy-induced hypertension, while the false-positive rate (100-specificity) remained acceptable (17%).

Polynomial Analysis of Placental Flow Patterns in Growth-Retarded Fetuses

Correct interpretation of conspicuous blood flow velocity waveforms cannot rely solely on the evaluation of uteroplacental vascular Doppler flow patterns by means of angle-independent indices such as the resistance or pulsatility index. In addition to the degree of pulsatility, the waveform shape between the systolic and diastolic peak values is of considerable consequence. A subdivision of the total flow waveform into orthogonal polynomial components allows both pulsatility evaluation and notching to be registered, providing a higher sensitivity in identification of pathological vascular resistance. Accurate recording and assessment of the flow waveform is therefore an important qualitative criterion for the classification of Doppler flow patterns in pregnancies with reduced uteroplacental perfusion.