Perinatales Management und Ausgang von Drillingsschwangerschaften zwischen 1997 und 2001

BACKGROUND

Because of the trend for premature birth, multifetal pregnancies are at high risk for neonatal morbidity and mortality. This study presents our perinatal management scheme and the outcome of triplet pregnancies.

PATIENTS AND METHODS

From 1997 to 2001 we studied 31 triplet pregnancies. Their management consisted of cervical measurement at 20 weeks, admission from 25 weeks onwards, regular ultrasound examinations, intravenous tocolysis with preterm contractions or cervical shortening, promotion of fetal lung maturation, antibiotic therapy with evidence of vaginal infection, delivery by caesarean section ideally at 33 weeks.

RESULTS

In the studied group 4 triplet pregnancies were monochorionic, 6 dichorionic, and 21 (68 %) trichorionic. 2/31 triplet pregnancies finalized in late abortions. Furthermore, a single and a double intrauterine death occured in two triplet pregnancies. 6 (21 %) of triplet pregnancies were delivered before the 30th week and 23 (79 %) after the 30th week of gestation (median gestational age 31.5 weeks, median birth weight 1545g). Neonates of trichorionic pregnancies in comparison to those of mono- and dichorionic pregnancies were delivered two to three weeks later and presented with significantly higher birth weights (1660 g vs. 1245 g vs. 1240 g; p = 0.001 and 0.0009, respectively). 13/84 (15.5 %) of the neonates showed growth retardation. In 4/84 (4.1 %) children brochopulmonary dysplasia or cerebral haemorrhage was observed. Only one child developed enterocolitis. 19 % (16/84) of neonates showed evidence of retinopathy. No intrauterine death occured after 28 weeks and no child died after delivery.

CONCLUSION/DISCUSSION

With our well defined management of triplet pregnancies from 20 weeks onwards we reach similar gestational ages at delivery but remarkably lower neonatal complication rates compared to previous studies.

[Effect of peridural analgesia on labor progress]

Epidural analgesia (EDA) is the most effective method of intrapartum pain relief. Its influence on the course of labor continues to be controversial. Although a cause-and-effect relationship has not been proven, this form of analgesia has been blamed for a host of adverse maternal/fetal events during labor, including prolonged first and second stage of labor, dystocia, malrotation of the fetal head and an increased risk of operative delivery (instrumental delivery, Caesarean section). Our own data from the Department of Obstetrics and Gynaecology at the University of Leipzig demonstrate that women with epidural analgesia had a longer duration of labor (the greater proportion taking more than 13 hours), although labor was often already protracted before the start of epidural analgesia. Early epidural analgesia with a cervical dilatation of less than 4 cm does not have any negative impact on the progress of labor. The duration of second-stage pushing and the rate of instrumental deliveries were not increased in our patients. Although the Caesarean section rate for women with an EDA was elevated, the total proportion of secondary Caesarean section remained unchanged despite increased use of EDA. Our findings suggest that women selected for intrapartal EDA already represent a population with an increased risk of an unfavourable course of labor, priming of the cervix, increased need of oxytocin and nulliparity. Pain relief in itself is sufficient indication for the use of intrapartal epidural analgesia.

Associations between duration of breast-feeding, sensitization to hens' eggs and eczema infantum in one and two year old children at high risk of atopy

Through a cohort study, factors for the development of atopic disorders among children at high-risk of atopy were investigated by means of anamnesis, lifestyle factors and laboratory parameters. 475 high-risk children were selected out of the whole population of infants born within one year in the City and District of Leipzig. These 475 had an increased cord blood IgE (> 0.9 kU7l), double positive atopic family history (parents/siblings) or low birthweight (1500-2500 g). Questionnaires are answered regularly by the parents and the children are clinically examined annually.

RESULTS

In the first and second year of life there has been a statistically significant correlation (p < 0.0001) between increased cord blood IgE and increased total IgE. At the age of one year we found eczema infantum in 51 out of 323 high-risk children. There was a significant association (p = 0.0001) between sensitization against hens' eggs and eczema. Infants who had been exclusively breast-fed > or = 5 months were more frequently sensitized to hens' egg and an eczema infantum was to diagnose more frequently. Significant differences in this respect were found within the risk groups, depending on family history of atopy and cord blood IgE. The duration of breast-feeding showed no correlation with sensitization to hens' eggs or atopy in two-year-olds.

[Artificial amniotic fluid instillation in premature rupture of fetal membranes and extreme prematurity as alternative therapy]

We report two cases of premature rupture of membranes and oligohydramnios (gestational age: 23rd/24th week). In both pregnancies artificial instillation of amniotic fluid (AIF) was performed once a week. We hypothesize that fetal head compression with impaired cerebral perfusion due to oligohydramnios causes periventricular leukomalacia. Prolongation of gestation of 36/23 days without neurological lesion support this method. Surveillance of these pregnancies in a perinatal center has to include very early detection of chorioamnionitis. If not so, gained prolongation of pregnancy with a lower rate of cerebral damage becomes harmful due to infection. Clinical benefits and disadvantages of this technique have to be evaluated in a prospective randomized trial.

[Color Doppler ultrasound of uterine, fetoplacental and fetal blood vessels in the 2nd trimester in normal pregnancies]

We investigated 69 healthy women with normal pregnancy and delivery in order to establish normal values for the second trimester of gestation. In a cross-sectional study we measured the pulsatility index (PI), the maximal systolic velocity (V-MAX) and the mean velocity (V-MEAN) in the uterine arteries (UAA), the umbilical artery (UA), the fetal thoracic aorta (FTA) and the middle cerebral artery (MCA) from the 14th to the 24th week of gestation. A regression analysis shows a significant slope of the PI of UAA and UA (p < 0.01), whereas in contrast to the UA there is no significant difference of the median values of the UAA-PI from the 18th week of gestation. With progressive gestation V-MEAN of UAA increases more (p < 0.001) than V-MAX (p < 0.05) as a result of the increasing diastolic blood flow. In the UA there is also a significant rising trend of V-MAX and V-MEAN (p < 0.0001). No significant changes of the PI of FTA and MCA are seen, although there is a slight increasing trend. After the 20th week in the MCA a marked tendency to high PI-values is observed, whereas there is a change between different flowpatterns prior to the 20th week. V-MAX and V-MEAN of FTA increases significantly, but there is no change in the MCA. Our results for UAA and UA correspond to the known morphologic changes in the utero- and fetoplacental vessels in the second trimester and are comparable to other results. Particularly the physiology of the cerebral perfusion needs to be investigated more intensively. These normal values provide a good basis for early and complex assessment of a disturbed perfusion in the second trimester.

[From resuscitation space in the delivery room of the Women's hospital to the perinatal center of the Leipzig University]

Historical review on the development of neonatal intensive care and new-born nursing at the women hospital of Leipzig University from 1969 up to 1995 and the foundation of a Perinatal Center. The successes of perinatal care are demonstrated best by the decline of neonatal mortality of extremely low birth weight infants from more than 90% up to 20% in 1995. It is attributed to the progress in perinatal medicine as well as to a perfect functioning regionalization of high risk pregnancies.

[Multivariate analysis of the significance of vaginal bacterial colonization in the occurrence of a preterm birth with various risk parameters]

Using a discriminance analysis we investigated the interactions between parameters of the vaginal flora and subclinical infection regarding preterm birth. The prospective study includes 222 single pregnancies, 114 of them with preterm labour or premature rupture of the membranes (PROM). The analysis includes information of a vaginal/ cervical smear (total number of pathogenic germs, species and groups of pathogenic germs), vaginal pH, maternal white blood cell count (WBC), C-reactive protein (CRP) and temperature. A normal vaginal flora was found in only 19%. Pregnancies with preterm labour have a higher quantity of pathogenic germs, whereas there is no difference of the germ group distribution. Moreover, pregnancies with preterm labour and 2 or 3 pathogenic germs have a higher rate of preterm birth. The discriminance analysis shows that only the affiliation the risk group with preterm labour and the parameters CRP and WBC have a significant selectivity for consequent preterm birth, but not the parameters containing information of the vaginal flora. The same is valid for the group with preterm labour, where only the parameters PROM and WBC are able to select significantly for preterm birth.

[Usefulness of vaginal pH measurements in the identification of potential preterm births]

Ascending infections of the female genital tract as a cause of preterm birth have become major importance regarding the prevention of preterm birth. Measurements of the vaginal pH value are able to verify a alkalinisation of the vagina caused by a atypical vaginal flora. In a prospective study we measured the vaginal pH value using indicator paper and evaluated the results of a vaginal and cervical smear of 162 single pregnancies from 26 to 30 weeks of gestation. In contrast to normal pregnancies there is a relation between a pathological pH value > 4.5 and consequent preterm birth in pregnancies with preterm labour but also in pregnancies with other risk factors without symptoms of preterm labour.

[Severe protracted intrauterine impaired perfusion--a cause of enteral motility disorder in the premature infant]

The importance of measurement of blood flow in the fetal and uteroplacental circulations for the assessment of fetal wellbeing has been undisputed since some years. The present study is designed to prove if any relationship exists between severe hemodynamic disturbance in fetal as well as uteroplacental vessels and the occurrence of postnatal impairment of intestinal motility. The progress of 130 children, born in the University Women's Hospital Leipzig between 1991-1993 and with birth weights below 1500 g, has been analyzed. Doppler ultrasound examinations for detection of impairment in fetal and uteroplacental circulation were performed in all cases during pregnancy. A severe impairment of blood flow in the above mentioned circulations was defined by the presence of pathological pulsatility or resistance indices in both fetal and uteroplacental vessels as well as absent end diastolic flow in the umbilical artery and signs of centralization in the fetus. A severe hemodynamic impairment was found in 27 children and 26 of these were classified as severe hypotrophic after birth. The progress of these children was compared with this of other hypotrophic and euthrophic premature babies who had not revealed hemodynamic abnormalities. The incidence of disturbed postnatal intestinal motility (delayed meconium excretion, abdominal distention, retrograde peristalsis, subileus) was significantly higher in hypotrophic neonates with hemodynamic abnormalities in the course of pregnancy. Four of these newborns underwent surgery and surgical findings did not correlate with enterocolitis. The resumption of oral food intake for neonates who had hemodynamic impairments during pregnancy was delayed compared with the control groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Discriminant analytic model for prognostic assessment of pregnancies at risk for premature labor]

We examined 114 women with preterm labor using discriminance analysis to assess predictive values in terms of prolongation of gestational age and gestational age at the time of delivery. We used parameters like medical history, clinical features, infections, Doppler sonography and cardiotocography. Maternal temperature, cardiotocographic findings, premature rupture of membranes, number of abortions and pregnancy terminations and cervical dilatation at the time of admission contribute significantly to predict prolongation of pregnancy (< or = as well as > 7 days). Our results from this analysis showed sensitivity and specificity of 0.70 and 0.97 and positive and negative predictive values of 0.89 and 0.91, respectively. We observed significant differences concerning parameters like preterm rupture of membranes, cervical dilatation, pathological bacteria in the vagina and pathological Doppler values between subsequent preterm and term deliveries in pregnancies with a prolongation of > 7 days was. Upon reclassifying our results, we obtained sensitivity and specificity of 0.69 and 0.89 and positive and negative predictive values of 0.78 and 0.84, respectively. Early prognostic assessment of preterm labor can be made with discriminance analysis. The results inspire us to perform a prospective examination of the therapy plan that we have obtained.

[Diagnosis and therapy of hemodynamic disorders. A contribution to the management of pregnancies with threatened premature labor]

114 pregnant women (without multiple pregnancies) with premature labour were examined in a randomized prospective study. Pulsatility index (PI) in the uterine artery and fetal thoracic aorta was the parameter we used for the examination, the determination of which was done with doppler sonography at the time of hospital admission. Therapy with beta-sympathomimetics alone or additionally either Oxygen inhalation therapy or transcutaneous dorsal nerve stimulation were conducted and the pulsatility index was controlled at intervals of one and two weeks after initiation of the aforementioned therapy. The negative correlations which we determined between pulsatility index and prolongation of duration of pregnancy, gestational age at the time of delivery and birth weight were significant. This confirms the clinical importance of maternal perfusion already at the time of admission for the clinical end-results. Similarly significantly negative correlations between pulsatility index of uterine vessels, weight percentile of the corresponding newborns and antenatal CTG scores (Fischer) verify the close connections between the hemodynamic, nutritional and respiratory partial functions of the fetoplacento-maternal unit. The clinical results after normalization of an impaired perfusion were found to be improved significantly after a combined therapy with beta-sympathomimetics and transcutaneous dorsal nerve stimulation (TNS) as compared with beta-sympathomimetic therapy alone. These results justify the recommendation that doppler sonographic measurements of utero-placental perfusion can be used for the diagnostic and therapeutic concept in pregnancies with premature labour.

[Effect of pregnancy and perinatal parameters--including mode of delivery--on survival rate of "low birth weight premature infants" (less than 1,500 g)]

A retrospective analysis of 225 very low birth weight infants (less than 1500 g) was made, to assess the influence of the mode of delivery on the survival rate. In 186 preterm deliveries which could not be prevented by therapeutic measures, we included additionally certain gestational and perinatological parameters. Generally, an average survival rate of 72% was found in this study. In addition to the well-known negative influence of birth weight less than 1000 g and gestational age of less than 28 weeks, such parameters as antenatal pre-pathological CTG findings, haemorrhages at the time of hospitalisation, and ineffectuousness of tocolytic drugs, were associated with a reduced survival rate. In contrast, the presence of anamnestic risk factors of preterm delivery and prolongation of gestation by one day and more improved the survival rate. Additional consideration of foetal presentation showed, that abdominal delivery was fundamentally safer in cases with breech and transverse presentation. Whether a higher survival rate can be achieved by vaginal delivery in cases of breech presentation with premature rupture of membranes or a gestational age greater or equal to 28 weeks, remains to be proved. A gestational age of less than 28 weeks or antenatal prepathological cardiotocographic findings will facilitate in future the decision to perform Cesarean section in cases of inevitable premature deliveries with cephalic presentation.

Doppler sonographic examinations of uteroplacental, fetoplacental, and fetal hemodynamics and their prognostic value in preterm labor

Doppler examinations of different uteroplacental vessels (uterine arteries, arcuate arteries), umbilical artery, fetal thoracic aorta, and median cerebral artery were performed on 55 patients with idiopathic preterm labor (24.5 to 32.5 weeks). Thirty normal pregnancies of corresponding gestational age served as a control group. Significant differences of median values between the preterm labor and control group were found only for the resistance index (RI) in the central arcuate artery and for the pulsatility index (PI) in the fetal thoracic aorta. In about twenty percent of pregnancies in preterm labor, pathological values of RI and PI in uteroplacental and fetal vessels account for the presence of an impaired perfusion. Elevated PI in the uterine artery placental site and normal RI in the fetal thoracic aorta, correlate significantly to a shorter prolongation of pregnancy, lower gestational age on birth, and lower birth weight. The combination of these two blood flow indices (maternal PI greater than 0.90 and fetal RI less than 0.90) allow us to predict a preterm birth in a high percentage of cases (sensitivity 87.5%, specificity 100%, positive predictive value 100%, negative predictive value 93%).

[Fetal systolic time intervals in threatened premature labor and their relation to therapeutic efforts]

In a total of 113 single pregnancies we determined foetal systolic time intervals (pre-ejection period, left ventricular ejection time, a quotient of both) in order to investigate the impact of threatened premature labour and the different therapeutic regimen (betamimetics, maternal O2-inhalation, maternal transcutaneous dorsal nerve stimulation) on the myocardial performance capacity. Prolonged systolic time intervals (significant for pre-ejection period) in threatened premature labour (compared with control) supplement the concept of a chronic respiratory impairment of the foe-to-materno-placental relationships. Therapeutic prolongation of the pregnancy by betamimetics led to further impairment of the myocardial contractility while additional oxygen inhalation brought about a positive effect. As indicated by "no changes" after transcutaneous dorsal nerve stimulation, the decisive effect apparently seems not to be in the improvement of the uteroplacental perfusion but more on the direct influence of the raised O2-provision on the foetal myocardium. Non-demonstrable obvious relations to the cardiotocographic findings, such as to the postnatal evaluation criteria, speak against a serious threat to the foetus as the advantages of a reasonable prolongation of the gestational period by betamimetics preponderate. More than that the foetal myocardial impairments are to be favourably influenced by additional O2-therapy.

[Antepartal cardiotocographic studies in threatened premature labor and intravenous tocolysis]

In view of the connection which exists between premature birth and placental insufficiency and the means which are available for determining the respiratory performance of the fetoplacental unit by way of cardiotocography, the authors investigated the incidence of prepathological findings in the fetal heart frequency parameters for 81 cases of imminent premature delivery before, during and after intravenous tocolysis, and for 10 normal pregnancies between the 28th and 36th week. The greater number of prepathological cardiotocograms (oscillation amplitude and frequency, periodic acceleration and deceleration) found at the beginning of a trend toward premature delivery beginning with the 30th week of pregnancy, confirms the assumption of a restricted respiratory function of the fetoplacental unit. This restriction is, however, slight. The increase which is observed in these changes, particularly during up to 7 days of intravenous tocolysis in the 28th/29th week of pregnancy, and which continues after the end of intravenous therapy in the further course of pregnancy, is not seen as a result of the effect of betamimetics. The latter obviously do not succeed in positively influencing respiratory insufficiency in the event of imminent premature delivery. Neither the cardiotocographic findings from the beginning of the therapy nor later results permit conclusions to be drawn with regard to its possible success. On the other hand, a prepathological finding, especially where this occurs immediately before delivery, suggests possible larger disturbances of respiratory performance intrapartum, and problems with neonatal adaptation.

[Prematurity and placental insufficiency in twin pregnancies. Results during the care of multiple pregnancies at a center for premature births]

An analysis was made of 151 twin pregnancies, in 1975, 1978 and 1979, to study the effectiveness of obstetrico-neonatological attention to bigeminal pregnancies in a premature infant centre. -- Significant rise in early detection of bigeminal pregnancy due to much wider use of ultrasonic diagnosis and intensification of hospital treatment have drastically reduced the number of extremely immature twin births by delaying delivery to somewhere between the 34th and 36th weeks of gravidity. With the use of tocolysis nearly unchanged throughout the period of observation, change in average gestational age at birth should be interpreted primarily as the result of more long-time prepartum hospitalisation, with attention being offered for periods of more than three weeks. This conclusion was supported by unsatisfactory results regarding average gestational age and birth weight, following exclusive outpatient attention to women with bigeminal pregnancies. Improvement of foetal prognosis was found to depend primarily on proper therapeutic approach to prematurity. -- The authors' own experience differed from reports of other workers, in that the rate of hypotrophy declined in the wake of intensive prepartum care. Substantial reduction of the gap between average birth weights of first multiple foetuses and those of second multiple foetuses as well as declining differences between average birth weights of heavier twins, on the one hand, and those of less heavy twins, on the other, were recorded from all gestational age groups and attributed to improvement in intra-uterine care for all multiple foetuses due to intensified treatment. -- Significant rise in survival rates (after deduction of all foetal loss up to the 28th day of age) of all premature twins is considered an expression of increasingly improving life chances of twins, in general. It was based on growing numbers of highly immature survivors, but even more on significant rise in the number of premature survivors between the 34th and 36th weeks of gestation.

[Quantitative changes of the cytotrophoblast in underweight and normalweight newborn after risk pregnancy and antepartal therapy (author's transl)]

A histochemical-morphometric method was used to determine at the cytotrophoblast of 73 placentas, changes in the composition of the syncytium and in the Langhans' cell count in underweight and normalweight newborn with or without antepartal maternal therapy in comparison to newborn after uneventful pregnancy. The reduction of the percentage share of mature syncytium when the share of predegenerative and degenerative syncytium is increased, as weil as the increase in the average Langhans' cell count in the placentas of premature infants, hypotrophic and eutrophic infants delivered at term after risk pregnancy, compared with normal controls, is statistically significant. Significant differences in the percentage share of mature syncytium between the placentas of premature infants and hypotrophic infants delivered at term, as well as between placentas of eutrophic infants delivered at term, depending of the nature and severity of the risk, are discussed in connection with the significance of the syncytium for the processes of material transport. No correlation with the Apgar score and the occurrence of the respiratory distress syndrome of newborn, nor with the duration of the first and second stage of lavor with macroscopic placenta peculiarities, have been found. The good correlation between placenta findings and classification characteristics of newborn, and clinical aspects of the course of pregnancy, allows the possibility of diagnostic evaluation. Our results indicat also that the morphological performance must be included in the considerations explaining the success of treatment of placental insufficiency.