Basic Gynecologic Ultrasound Examination (Level I): DEGUM, ÖGUM, and SGUM Recommendations

Ultrasound has become an essential diagnostic tool in gynecology, and every practicing gynecologist must be able to differentiate normal from pathologic findings, such as benign or malignant pelvic masses, adnexal torsion, pelvic inflammation disease, endometriosis, ectopic pregnancies, and congenital uterine malformations at least on a basic level. A standardized approach to the correct settings of the ultrasound system, the indications for gynecologic ultrasound investigations, and the sonographic appearance of normal anatomy and common pathologic findings in the standard planes are important prerequisites for safe and confident clinical management of gynecologic patients. Based on current publications and different national and international guidelines, updated DEGUM, ÖGUM, and SGUM recommendations for the performance of basic gynecologic ultrasound examinations were established.

Basic Gynecologic Ultrasound Examination (Level I): DEGUM, ÖGUM, and SGUM Recommendations

Ultrasound has become an essential diagnostic tool in gynecology, and every practicing gynecologist must be able to differentiate normal from pathologic findings, such as benign or malignant pelvic masses, adnexal torsion, pelvic inflammation disease, endometriosis, ectopic pregnancies, and congenital uterine malformations at least on a basic level. A standardized approach to the correct settings of the ultrasound system, the indications for gynecologic ultrasound investigations, and the sonographic appearance of normal anatomy and common pathologic findings in the standard planes are important prerequisites for safe and confident clinical management of gynecologic patients. Based on current publications and different national and international guidelines, updated DEGUM, ÖGUM, and SGUM recommendations for the performance of basic gynecologic ultrasound examinations were established.

Quality Requirements for gynecological ultrasound examinations of DEGUM level II - Recommendations of the Sections/Working Groups Gynecology and Obstetrics of DEGUM, ÖGUM and SGUM

Gynecological sonography is the central and most frequently used technical examination method used by gynecologists. Its focus is on the clarification of masses of the uterus and the adnexa, fertility diagnosis, clarification of bleeding disorders and chronic and acute pelvic problems, pelvic floor and incontinence diagnosis as well as the differential diagnosis of disturbed early pregnancy. The indication for diagnostic and therapeutic interventions, preoperative planning and postoperative controls are largely based on the findings of gynecological sonography. These examinations are particularly dependent on the experience of the examiner.Based on the proven multi-stage concept of obstetric diagnostics, gynecological sonography should primarily be performed by an experienced and specialized examiner in patients for whom the initial gynecological examinations have not yet led to a sufficient assessment of the findings. So that the expert status required for this has an objective basis, the Gynecology and Obstetrics Section of DEGUM in cooperation with ÖGUM and SGUM implemented the option of acquiring DEGUM Level II for gynecological sonography. The effectiveness of the care in the multi-level concept depends on the quality of the ultrasound examination at level I. Quality requirements for the basic examination and the differentiation between the basic and further examination have therefore already been defined by DEGUM/ÖGUM. The present work is intended to set out quality requirements for gynecological sonography of DEGUM level II and for the correspondingly certified gynecologists.Common pathologies from gynecological sonography and requirements for imaging and documentation are described.

Updated DEGUM Quality Requirements for the Basic Prenatal Screening Ultrasound Examination (DEGUM Level I) between 18 + 0 and 21 + 6 weeks of gestation

A precondition for the early detection of fetal abnormalities is the high quality of prenatal basic ultrasound (screening examination). The objective of ultrasound screening is the recognition of abnormal fetal growth and fetal anatomical anomalies. The prenatal detection of fetal abnormalities enables detailed prenatal counselling of parents, improved care at birth and potentially a reduction in morbidity and mortality. In the guidelines for maternity care in Germany ("Mutterschaftsrichtlinien"), the performance of basic ultrasound in pregnancy is not clearly defined. The required image documentation includes a few biometric measurements only. Therefore, adherence to a standard technique and the possibility of audit are limited, thus not necessarily resulting in high screening quality. In this update of the DEGUM quality requirements for level I screening ultrasound examination between 18 + 0 and 21 + 6 weeks of gestation, the required parameters, standard planes and required documentation are described in detail. The greater experience of gynecologists in the field of sonographic screening examinations and the use of a modern ultrasound technique allow improvement of the screening quality. This will improve the standard of basic ultrasound screening. Due to the enhanced standard of the DEGUM I examination, more pregnant women may benefit from a detailed ultrasound examination and specialized therapy in DEGUM level II and III centers. The required fetal structures are described in detail. This update of the requirements for level I DEGUM basic ultrasound examination between 18 + 0 and 21 + 6 weeks of gestation goes far beyond the guidelines for maternity care in Germany (the "Mutterschaftsrichtlinien") thereby elevating standards.

Sonographic monitoring of systemic and local methotrexate (MTX) therapy in patients with intact interstitial pregnancies

OBJECTIVE

After the confirmation of an intact interstitial pregnancy through sonographic diagnosis and laparoscopy, systemic and local methotrexate therapy is a well established conservative treatment to preserve the uterus. The parameters of successful treatment are the course of serum hCG value and sonographic changes. In this case series we describe sonographic monitoring under methotrexate (MTX) application and the residual sonographic findings after completing therapy.

METHODS

Three consecutive patients (two singleton and one twin pregnancy) with intact interstitial pregnancies were diagnosed and treated with MTX between 2000 and 2004. During the treatment we recorded the hCG values, maximum size of the interstitial lesion, vitality of the pregnancy, and vascularization.

RESULTS

In all patients the sonographic diagnosis of an interstitial pregnancy was confirmed by laparoscopy. Following systemic MTX therapy, the hCG values normalised within 8 weeks in the singleton pregnancies and in 10 weeks in the twin pregnancy. During conservative therapy vascularization in the lesion withered continuously. The size of the primary myometrial lesion decreased at a slow rate and part of the lesion persisted in all three patients.

CONCLUSION

Despite decreasing hCG levels, residual sonographic patterns of an interstitial ectopic pregnancy persist in the uterine wall.

Dup(13)(q14.2-q14.3): yet another new differential diagnostic aspect for short stature-like phenotype

We report on the case of a pregnant woman with hyposomia who was previously suspected of having Turner syndrome. Prenatal cytogenetic diagnostics showed a fetal karyotype of 46,XX,dup(13)(q14.2q21.1) ish.13q14(RB1 x 3). Parental and grandparental chromosome analyses were performed and the dup(13) was found to be of maternal origin (de novo). The pregnancy was continued and a healthy female child was born with normal development apart from growth retardation. The reported chromosomal aberration is, together with two other cases reported in the literature, the first hint of a short stature-like phenotype due to dup(13)(q14.2q14.3).

Does recombinant human erythropoietin not only treat anemia but reduce postpartum (emotional) distress as well?

Based on the established rhEPO treatment of anemia in endstage renal failure, which results in improved quality of life, and on the clinical observation that patients with postpartum anemia treated with rhEPO seemed to gain a more stable mood, we inferred that there is a beneficial side-effect of rhEPO on postpartum blues. The aim of this study was to test the hypotheses 1) that postpartum anemia aggravates, and 2) that treatment of postpartum anemia with rhEPO reduces maternity blues. The results show that on the fifth day postpartum anemic patients score consistently worse than nonanemic women on the Symptom Checklist SCL-90-R, indicating more symptoms and distress in general, and also more symptoms characteristic of maternity blues (p < 0.05). On a "Blues Questionnaire," postpartum anemia expresses itself with a reduced "well-being" (p < 0.001). Thus, our first hypothesis was verified. There were no differences by the fifth day postpartum between anemic patients receiving either rhEPO or placebo. Our second hypothesis was thus not confirmed within this limited time. We conclude as clinicians that postpartum anemia should be treated effectively to reduce distress and hence the risk for postpartum affective disorders. Follow-up studies after rhEPO treatment beyond the first week post partum are needed. In addition, in investigations on postpartum affective disorders, the hemoglobin concentration should be considered.

[Correlation between reduced amniotic fluid volume and Doppler spectra of fetal blood vessels at term]

The aim of this study was to determine, whether foetuses with reduced amniotic fluid in other-wise uncomplicated pregnancies at term show signs of redistribution of blood flow analogous to foetuses with intrauterine growth retardation. In 33 pregnancies > or = 37 gestational weeks with the largest pocket of amniotic fluid < 2 cm, flow velocity waveforms were recorded for the umbilical artery, middle cerebral artery and renal artery and compared with those of foetuses of the same gestational age and normal amniotic fluid volume. No difference was found in the resistance index (umbilical artery and middle cerebral artery), the pulsatility index (renal artery), or for the cerebral-placental ratio between these two collectives. We conclude, that Doppler examination of foetal vessels does not help to clarify the phenomenon of decreasing amniotic fluid volume during the final period of gestation. We suggest, that the decrease is not caused by renovascular changes, but has intra- or extrarenal causes.

Lack of associations between fetal and maternal serum-erythropoietin at birth

Erythropoietin (EPO) is known to be the main regulator of erythropoiesis. We wanted to determine whether EPO production during pregnancy takes place independently in the mother and the fetus, and to identify the factors which set the EPO level. Endogenous EPO levels were determined in simultaneous samples from the umbilical vein, the umbilical artery and a maternal vein in 126 mother-child pairs and simultaneously from amniotic fluid (n = 14) in unselected births. Results were related to clinical and biochemical parameters of fetal well-being, mode of delivery, duration of labor, and infant parameters at birth. There was a weak correlation between maternal and fetal log EPO values (umbilical vein: r2 = 0.11; umbilical artery: r2 = 0.08), but a highly significant correlation between log EPO levels in the two umbilical vessels (r2 = 0.91) and between both umbilical blood and amniotic fluid (r2 = 0.41). Maternal EPO levels were lower than fetal levels in 76 cases, higher in 47, and nearly identical in 3. Increased fetal EPO levels were associated with clinical and biochemical indicators of fetal stress. These associations help to explain why EPO concentrations in fetal blood are independent of maternal levels and also indicate that EPO does not cross the placental barrier. These findings are discussed in the light of the animal experimental and in vitro evidence for placental transfer of EPO. Our data, and the work of others, make such a transfer in humans quite unlikely. This observation has therapeutical consequences for the treatment of maternal anemia with recombinant human EPO.

Doppler ultrasound examination of fetal renal arteries

This study used color Doppler imaging to establish the normal values of the pulsatility index in the fetal renal arteries in a group of 304 uncomplicated singleton pregnancies. The measurements were taken between 26 and 42 weeks of gestation. The median was 2.79 (95% confidence interval: 2.72-2.86) for 26 weeks' gestation, and it then fell linearly to 1.96 (95% confidence interval: 1.92-2.00) at 40 weeks. Compared with values published so far in the literature, the range was clearly smaller. These normal values could be used as a basis for further investigations on these vessels.

Recombinant human erythropoietin in the treatment of postpartum anemia

Postpartum maternal anemia (hemoglobin concentration below 10 g/dL) is a common problem in obstetrics. Human recombinant erythropoietin, which has been shown to correct the anemia of end-stage renal disease and eliminate the need for transfusions, was used in a comparative study of women with postpartum hemoglobin concentrations below 10 g/dL. Five daily doses of 4000 IU were given. Hematologic and clinical data were compared on days 5, 14, and 42 after therapy in the treated women and in untreated women. Both groups received the same iron and folic acid supplements. Significantly greater increases in reticulocytes, hemoglobin, and hematocrit were seen by day 5 for the treated subjects compared with controls. Ferritin levels were significantly lower in the therapy group than in controls. No differences were seen between the groups in the platelet counts or clinical characteristics. No negative side effects were observed. As in other studies in populations without renal disease, recombinant human erythropoietin enhanced endogenous erythropoiesis over and above the normal physiologic recovery rate.

[Fetal movement and acceleration behavior in unimpaired and impaired newborn infants]

The following biophysical examination parameters were found by CTG-synchronous registration of fetal body and respiratory movements and compared in 7 fetuses impaired at birth (pHa less than 7.20, 1- and 5-minute Apgar scores less than or equal to 7 points) and 76 unimpaired born fetuses (pHa greater than or equal to 7.20, 1- and 5-minute Apgar scores greater than or equal to 8 points): number of fetal body movements per 10 minutes examination time; total and mean durations of these movements per 10 minutes; number of fetal respiratory movements per 10 minutes; number and total duration of fetal respiratory movement periods per 10 minutes; frequency of fetal respiratory movements; proportion of 10-minute periods with and without fetal body and/or respiratory movements and the amounts of the quotients from the amplitude of accelerations in fetal heart rate resulting from fetal body movements and the durations of these body movements. The mean interval between biophysical examination and childbirth was 11 days. Principally, the impaired born fetuses were less active in their movements than were unimpaired born fetuses. Apart from the frequency of fetal respiratory movements and the proportion of 10-minute periods without fetal body movements, the above mentioned parameters differ significantly with a probable error of alpha = 0.05. All biophysical parameters were registered on an uterus without labour and the cardiogram as well as the biophysical profile--with the exception of one fetus from the group of impaired borns--being unremarkable. The 10-minute periods without fetal body or respiratory movements were excluded from analysis.

[Correlation of the magnitude of fetal movement associated fetal heart rate accelerations, amplitude of "classical" accelerations and transcutaneous fetal oxygen partial pressure]

An attempt is made to provide non-empirical evidence of the "classical" amplitude of sporadic fetal heart rate accelerations of 15 bpm. Sporadic, fetal movement associated fetal heart rate accelerations are generally regarded as an indication of fetal wellbeing. A minimal amplitude of 15 bpm with unknown duration of the associated fetal body movement seems to be a prerequisite to establish an unimpaired fetal condition as reliably as possible. Including the "classical" acceleration amplitude in a ratio from the acceleration amplitude and associated fetal body movement and comparison of these calculated values with a total of 3851 actual ration from acceleration amplitudes and durations of associated body movements of 175 normotrophic and 72 hypotrophic fetuses showed that only a hypothetical acceleration amplitude of 15 bpm yields ratios which correspond to the actual values of unimpaired fetuses. There is a significant positive correlation between the actual ration and the transcutaneous basal fetal partial pressure of oxygen during birth.

[Movement and acceleration behavior of eutrophic and hypotrophic fetuses sub partu]

Cardiogram synchronous registration of fetal body and respiratory movements (real-time ultrasonic examination) was employed to compare the movement and acceleration behaviour of 130 normotrophic fetuses to that of 13 fetuses with body weights between the 6th and the 10th weight percentiles according to Kyank and of 13 fetuses with body weights less than or equal to the 5th percentile. The mean duration of examination was 80 minutes. The normotrophic fetuses exhibited the highest movement activity and reactivity of the cardiovascular system. In 88.6%, accelerations of fetal heart rate were associated with fetal body movements and were independent of fetal weight. Comparison with a previous communication of the authors revealed that intranatal fetal movement activity and reactivity of the cardiovascular system were only slightly below that with a uterus without labour. The only exception were fetal respiratory movements with significantly fewer intranasal observations.

[Fetal movement and heart acceleration behavior in eutrophic and hypotrophic fetuses in the 36th to 40th week of pregnancy]

By means of combined ultrasonic and cardiographic monitoring, the movement and acceleration behaviours of 44 eutrophic fetuses were compared to those of 19 fetuses with body weights between the 6th and 10th weight percentiles according to Kyank and to 21 fetuses with body weight not greater than the 5th weight percentile. The eutrophic fetuses moved more frequently and--related to 10 minutes examination time--over longer total periods than did the fetuses with intrauterine growth retardation. The longest mean duration of isolated fetal movement, however, was observed in the hypotrophic fetuses. With regard to fetal resting and activity stages, the highest percentage (10%) of fetal resting stages was found in the fetuses less than or equal to the 5th weight percentile. 93% of all accelerations in fetal heart rate obviously resulted from fetal movements, duration and amplitude of the accelerations depending on the duration of fetal movements. The degree of heart rate responses to fetal movements was different in the three groups examined. Standard weight fetuses responded most intensively. The percentage of fetal movements resulting in accelerations was highest (76%) in the group of the eutrophic fetuses as well. The mean duration of acceleration was most marked in the group of fetuses less than or equal to the 5th weight percentile (32.8 sec) and so was the mean acceleration amplitude in the normotrophic fetuses (19.7 bpm). Decelerations following accelerations in fetal heart rate did not differ in the three groups examined with regard to their number, amplitude and duration.

[Methodologic problems and initial results of synchronous CTG computer-assisted registration of fetal movements by ultrasound]

Aim of the studies is the registration of latent criteria of hypoxia in fetuses with intrauterin growth retardation diagnosed by ultrasonography. Under standardized conditions, 19 pregnant women with hypotrophic and 20 with eutrophic fetuses were examined between weeks 36 and 40 of gestation. Concomitantly, fetal body and respiratory movements as well as the antenatal phonocardiotocogram were registered. The following apparatuses were used (fig. 1): ultrasound unit "sono Diagnost R" from Philips, FRG; six-channel recorder "6 NEK 401" from VEB Kombinat Messgerätewerk Zwönitz, GDR; lab-oriented computer "K 1520", VEB Kombinat Robotron Dresden, GDR; fetal monitor "MT 810" (with autocorrelation) from Toitu Co., LTD, Tokyo, Japan; There were close correlations between fetal body movements and accelerations in the cardiogram. The duration of the fetal body movements influenced the duration as well as the amplitude of the corresponding accelerations. A. comparison between the two groups examined reveals that these medium term changes in the heart rate were less marked in the hypotrophic fetuses than in the control group. The differences between the two groups were statistically significant (fig. 2, 3, 4, 5). Fetal respiratory movements influence the range of beat-to-beat-variability in the cardiogram. In the group of hypotrophic fetuses this range increased significantly by 1.4 bpm during one segments of respiratory movement. For the group of eutrophic fetuses the increase in the range of beat-to-beat-variability was 1.8 bpm. We did not find a significant difference between both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Classification of subpartal fetal heart rate oscillations by tcpO2 measurement]

There is no uniform opinion on the clinical value of FHR variability. It is possible to study connections between FHR variability and fetal oxygen tension by means of tcpO2 measurement. 856 episodes from 64 tcpO2 CTGs with more than 2 300 single characteristics were used for analysis. 31% of the fetuses examined exhibited signs of intrauterine growth retardation. The frequency of variability revealed a statistically significant correlation with oxygen tension (p less than 0,001). In hypotrophic fetuses the amplitude of variability was significantly correlated with oxygen tension (p less than 0,001). Silent and narrowly undulatory oscillations reached the significantly lowest oxygen tension values of 11,8 mmHg (1,6 kPa) and 15,2 mmHg (2,03 kPa), respectively, as compared to 20,5 mmHg (2,73 kPa) and 24,2 mmHg (3,23 kPa) for undulatory and saltatory oscillations, respectively. The control group of eutrophic fetuses revealed an inversely proportional, statistically significant behaviour of the amplitude of variability and fetal oxygen tension (p less than 0,001). Classification by means of tcpO2 limits (less than or equal to 11 mmHg = hypoxemic and greater than or equal to 12 mmHg = non hypoxemic) confirmed the traditional classification of the amplitude of variability in fetal growth retardation.

[Comparison of transcutaneous oxygen pressure measurement with computer automatic CTG analysis sub partu]

514 labors from 20 tcpO2-cardiotocograms with about 10 000 events were computerized. By means of tcpO2-measurement we found a higher correlation between the fetal condition basing on a discriminant function (DF) than to the quantitative solitary parameters (residual-bradycardia, fetal heart frequency, dip area, lag time and bradycardia-index). The boundary ranges from the quantitative CTG-interpretation: "normal", "praepathological" (warning signs) and "pathological" (hypoxie signs) were confirmed for practice. The tcpO2-curve basing on quantitative analysis of their parameters (base line, slope of pO2 referring to labors and the delay time) is good adapted for examination of solitary CTG-parameters in relation to clinical practice.

[Twin pregnancy--a special problem of modern obstetric medicine]

Basing on an exemplary organized health protection incorporating up-to-date technique, progressive management of delivery and optimal neonatal care, we were able to reduce the perinatal mortality of all pairs of twins at the UFK Jena in the periods between 1977/79 (n = 204) and 1980/82 (n = 174) from 8,33% to 3,30%. The difference was statistically significant (p less than 0.05). The late morbidity of these children also showed a statistically significant decline (p less than 0.05).

[Application possibilities of an automatic image analyzer ("Quantimet 720") in bone histomorphometry]

By the way of proofing of the preventive estrogen effect on the ovariectomy osteoporosis in rats the authors collected experiences in measuring of two histomorphometric parameters "trabecular bone volume" and "trabecular bone surface" with the automatic image analyser Quantimet 720. This method demands thin bone polishes or cuts, a very rich in contrast and selective colouring. The measurement with this device spares time and gives reliable results for "trabecular bone volume", but less reliable values for "trabecular bone surface".

[Studies on the kinetics of nitrofurantoin (Nifurantin) in normal pregnancy, gestoses, pyelonephritis and labor (author's transl)]

After oral administration of 300 mg of nitrofurantoin (Nifurantin) to various groups of pregnants, to women in labour and nonpregnant women the blood level and renal excretion of nitrofurantoin were investigated. We stated that gravidity, pyelonephritis and EPH-gestosis did not alter neither the renal excretion nor the blood level. In contrast to this during labour the renal elimination of nitrofurantoin was diminished and the blood concentration was enhanced. The biotransformation of nitrofurantoin seems not to be changed by pregnancy.

[Intrapartum tcpO2 measurement (author's transl)]

The value of intrapartum tcpO2 measurement is discussed, with reference being made to clinical examples. Also mentioned are certain setbacks of the method which, at present, still are limiting factors to general clinical intrapartum use.