Valvuloplasty in 103 fetuses with critical aortic stenosis: outcome and new predictors for postnatal circulation

OBJECTIVES

To review our experience with fetal aortic valvuloplasty (FAV) in fetuses with critical aortic stenosis (CAS) and evolving hypoplastic left heart syndrome (eHLHS), including short- and medium-term postnatal outcome, and to refine selection criteria for FAV by identifying preprocedural predictors of biventricular (BV) outcome.

METHODS

This was a retrospective review of all fetuses with CAS and eHLHS undergoing FAV at our center between December 2001 and September 2020. Echocardiograms and patient charts were analyzed for pre-FAV ventricular and valvular dimensions and hemodynamics and for postnatal procedures and outcomes. The primary endpoints were type of circulation 28 days after birth and at 1 year of age. Classification and regression-tree analysis was performed to investigate the predictive capacity of pre-FAV parameters for BV circulation at 1 year of age.

RESULTS

During the study period, 103 fetuses underwent 125 FAVs at our center, of which 87.4% had a technically successful procedure. Technical success per fetus was higher in the more recent period (from 2014) than in the earlier period (96.2% (51/53) vs 78.0% (39/50); P = 0.0068). Eighty fetuses were liveborn after successful intervention and received further treatment. BV outcome at 1 year of age was achieved in 55% of liveborn patients in our cohort after successful FAV, which is significantly higher than the BV-outcome rate (23.7%) in a previously published natural history cohort fulfilling the same criteria for eHLHS (P = 0.0015). Decision-tree analysis based on the ratio of right to left ventricular (RV/LV) length combined with LV pressure (mitral valve regurgitation maximum velocity (MR-Vmax)) had a sensitivity of 96.97% and a specificity of 94.44% for predicting BV outcome without signs of pulmonary arterial hypertension at 1 year of age. The highest probability for a BV outcome was reached for fetuses with a pre-FAV RV/LV length ratio of < 1.094 (96.4%) and for those fetuses with a RV/LV length ratio ≥ 1.094 to < 1.135 combined with a MR-Vmax of ≥ 3.14 m/s (100%).

CONCLUSIONS

FAV could be performed with high success rates and an acceptable risk with improving results after a learning curve. Pre-FAV RV/LV length ratio combined with LV pressure estimates were able to predict a successful BV outcome at 1 year of age with high sensitivity and specificity. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Fetal aortic valvuloplasty may rescue fetuses with critical aortic stenosis and hydrops

OBJECTIVE

Critical aortic stenosis (CAS) with a restrictive interatrial septum may lead to fetal congestive heart failure and hydrops, usually culminating in fetal demise if left untreated. The aim of this study was to assess the effects of fetal aortic valvuloplasty (FAV) on hemodynamics and outcome in these patients.

METHODS

This was a retrospective review of fetuses with CAS and signs of hydrops that underwent FAV in our center between 2000 and 2020. Echocardiograms and patients' charts were analyzed for ventricular and valvular dimensions and for outcome.

RESULTS

Hydrops was present at the time of intervention in 15 fetuses with CAS that underwent FAV at our center during the study period. All but one patient had at least one technically successful procedure. There were no procedure-related deaths, but three intrauterine deaths occurred. Twelve subjects were liveborn, of whom two died within 24 h after birth owing to persistent hydrops. Ventricular function improved and hydrops resolved within 3-4 weeks after FAV in 71.4% (10/14) of fetuses with a technically successful intervention. A biventricular outcome was achieved in 50% of the successfully treated patients.

CONCLUSIONS

Fetuses with CAS and hydrops can be successfully treated with FAV. The procedure has the potential to restore sufficient fetal cardiac output, which may lead to resolution of hydrops. Surviving patients seem to be good candidates for a biventricular outcome. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Immediate effects and outcome of in-utero pulmonary valvuloplasty in fetuses with pulmonary atresia with intact ventricular septum or critical pulmonary stenosis

OBJECTIVE

To assess the immediate effects of fetal pulmonary valvuloplasty on right ventricular (RV) size and function as well as in-utero RV growth and postnatal outcome.

METHODS

Patients with pulmonary atresia with intact ventricular septum (PAIVS) or critical pulmonary stenosis (CPS) who underwent fetal pulmonary valvuloplasty at our center between October 2000 and July 2017 were included. Echocardiographic data obtained before and after the procedure were analyzed retrospectively (median interval after intervention, 1 (range, 1-3) days) for ventricular and valvular dimensions and ratios, RV filling time (duration of tricuspid valve (TV) inflow/cardiac cycle length), TV velocity time integral (TV-VTI) × heart rate (HR) and tricuspid regurgitation (TR) velocity. Longitudinal data were collected from only those fetuses followed up in our center. Outcome was assessed using the scoring system as described by Roman et al. for non-biventricular outcome.

RESULTS

Thirty-five pulmonary valvuloplasties were performed in our institution on 23 fetuses with PAIVS (n = 15) or CPS (n = 8). Median gestational age at intervention was 28 + 4 (range, 23 + 6 to 32 + 1) weeks. No fetal death occurred. Immediately after successful intervention, RV/left ventricular length (RV/LV) ratio (P ≤ 0.0001), TV/mitral valve annular diameter (TV/MV) ratio (P ≤ 0.001), RV filling time (P ≤ 0.00001) and TV-VTI × HR (P ≤ 0.001) increased significantly and TR velocity (P ≤ 0.001) decreased significantly. In fetuses followed longitudinally to delivery (n = 5), RV/LV and TV/MV ratios improved further or remained constant until birth. Fetuses with unsuccessful intervention (n = 2) became univentricular, all others had either a biventricular (n = 15), one-and-a-half ventricular (n = 3) or still undetermined (n = 3) outcome. Five of nine fetuses with a predicted non-biventricular outcome, in which the procedure was successful, became biventricular, while two of nine had an undetermined circulation.

CONCLUSION

In selected fetuses with PAIVS or CPS, in-utero pulmonary valvuloplasty led immediately to larger RV caused by reduced afterload and increased filling, thus improving the likelihood of biventricular outcome even in fetuses with a predicted non-biventricular circulation. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Tissue Doppler imaging in fetuses with aortic stenosis and evolving hypoplastic left heart syndrome before and after fetal aortic valvuloplasty

OBJECTIVES

Fetal aortic valvuloplasty can improve filling and reduce afterload of the left ventricle in critical aortic stenosis. Success of an intrauterine intervention is currently measured by technical success, clinical survival and eventual postnatal biventricular physiology. In the present study we investigated the use of tissue Doppler imaging (TDI) to evaluate changes in ventricular function assessed before and after prenatal aortic valvuloplasty.

METHODS

Between October 2008 and December 2012, cardiac function was assessed by TDI before and after intervention in 23 fetuses that underwent technically successful valvuloplasty for critical aortic stenosis and in which postnatal outcome was known. The measurements were transformed into gestational age-independent Z-scores where appropriate.

RESULTS

Mean ± SD gestational age at intervention was 27.5 ± 3.1 weeks. Of the 23 fetuses, 14 had biventricular outcome. Before intervention all left ventricular (LV) TDI-derived parameters and mitral annular plane systolic excursion (MAPSE) were severely abnormal. It was possible to demonstrate considerably improved cardiac function after technically successful valvuloplasty. Among fetuses with postnatal biventricular outcome, TDI-derived LV myocardial peak velocity during early diastole (E') and myocardial peak velocity during systole in the ejection phase (S') significantly increased, E'/myocardial peak velocity during late diastole with atrial contraction (A') increased towards normal values, and LV transmitral-to-mitral-annular diastolic velocity ratio (E/E') and myocardial performance index (MPI') decreased but remained abnormally elevated. In addition, right ventricular A', S' and MPI' significantly improved after intervention.

CONCLUSION

Technically successful fetal aortic valvuloplasty led to significantly improved myocardial performance. It was possible to use TDI to detect distinct changes in ventricular function and TDI-derived parameters correlated with a biventricular outcome after birth. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

[Management of postpartum hemorrhage (PPH): algorithm of the interdisciplinary D-A-CH consensus group PPH (Germany - Austria - Switzerland)]

Postpartum hemorrhage (PPH) is one of the main causes of maternal deaths even in industrialized countries. It represents an emergency situation which necessitates a rapid decision and in particular an exact diagnosis and root cause analysis in order to initiate the correct therapeutic measures in an interdisciplinary cooperation. In addition to established guidelines, the benefits of standardized therapy algorithms have been demonstrated. A therapy algorithm for the obstetric emergency of postpartum hemorrhage in the German language is not yet available. The establishment of an international (Germany, Austria and Switzerland D-A-CH) "treatment algorithm for postpartum hemorrhage" was an interdisciplinary project based on the guidelines of the corresponding specialist societies (anesthesia and intensive care medicine and obstetrics) in the three countries as well as comparable international algorithms for therapy of PPH.The obstetrics and anesthesiology personnel must possess sufficient expertise for emergency situations despite lower case numbers. The rarity of occurrence for individual patients and the life-threatening situation necessitate a structured approach according to predetermined treatment algorithms. This can then be carried out according to the established algorithm. Furthermore, this algorithm presents the opportunity to train for emergency situations in an interdisciplinary team.

Maternal aspects of fetal cardiac intervention

OBJECTIVES

Fetal cardiac interventions have the potential to alter natural disease progression and reduce morbidity and mortality in children. Although there are already encouraging data on fetal outcome, information on maternal morbidity and mortality after intervention is scarce. The aim of the present study was to assess maternal aspects, pregnancy-associated risks and adverse events in 53 intrauterine cardiac interventions.

METHODS

Between October 2000 and December 2012, 53 fetal cardiac interventions were performed in 47 patients (43 aortic valve dilations in 39 patients, seven pulmonary valve dilations in six patients and three balloon atrioseptostomies in two patients). Median gestational age was 26 + 4 (range, 20 + 3 to 33 + 1) weeks. Interventions were performed by an ultrasound-guided percutaneous approach under general anesthesia. All medical records and patient charts were analyzed retrospectively.

RESULTS

All women were considered to be healthy in the preoperative assessment; 39 (83%) patients continued pregnancy until term and eight of 47 patients had an intrauterine fetal death (IUFD) and were induced. Postoperative nausea was reported in 29.8% of patients and abdominal pain in 36.2% of patients on the day of surgery. Preterm contractions were observed in two patients; no preterm prelabor rupture of membranes occurred. One severe postpartum hemorrhage was observed in a patient with IUFD and subsequent induction; however, this was unrelated to the balloon valvuloplasty. No intensive care unit admission and no major anesthesia-associated complications (aspiration, anaphylactic reaction, cardiovascular collapse, damage to teeth, laryngeal damage, awareness or hypoxic brain damage) were observed. Maternal mortality was zero. A significant learning curve was observed in terms of duration of intervention.

CONCLUSION

In our experience, percutaneous needle-guided fetal cardiac intervention seems to be a safe procedure for the mother. In 53 procedures no major maternal complication directly related to the intervention was observed.

[Closing gastroschisis: a distinct entity with high morbidity and mortality]

PURPOSE

We correlate severe bowel damage in gastroschisis to the rare intrauterine event of narrowing of the abdominal wall around the protruding intestines. We describe this "closing gastroschisis" as a distinct entity. Prenatal ultrasound findings as gastric or bowel dilation were compared to the postnatal findings in order to find markers for an early in utero diagnosis of closing gastroschisis. Early diagnosis could prompt timely delivery to save the compromised bowel and avoid short gut syndrome.

MATERIALS AND METHODS

We documented the pre- and postnatal course of our patients with gastroschisis from 2007 to 2009.  Closing gastroschisis was suspected antenatally and confirmed postnatally. We identified 5 out of 18 patients showing closure of the abdominal wall with varying degrees of bowel damage. Prenatal ultrasound findings were correlated to the postnatally confirmed extent of intestinal damage.

RESULTS

We could not find consistent ultrasound markers for prenatal diagnosis of closing gastroschisis. In prenatal ultrasound three patients presented significant gastric dilation and then experienced severe courses postnatally due to segmental gut necrosis. One of these three died and the other two developed short gut syndrome. In one case progressive intraabdominal loop dilation with simultaneous shrinking of the extraabdominal loops occurred corresponding to closing gastroschisis with segmental midgut necrosis.

CONCLUSION

Closing gastroschisis must be seen as a special form of gastroschisis. Extended intestinal damage is often life-threatening. In longitudinal observation dynamics of fetal ultrasound findings can lead to the diagnosis of closing gastroschisis. Progressive intraabdominal loop dilation is always highly suspicious and must lead to close follow-up and timely delivery.

[Effect of noninvasive first trimester diagnosis on indications and results of chorion villi sampling]

AIM

In this explorative study it should be evaluated how the introduction of non invasive first trimester diagnosis (nuchal translucency measurement, Combined Test, first trimester ultrasound screening) has influenced the indications and cytogenetic results of chorion villi samplings.

MATERIALS AND METHODS

Between 1989 and 2008 3337 pregnancies with CVS between 11 and 14 weeks of gestation were examined retrospectively. They were divided in two groups: CVS 1989 - 2001 before introduction of non invasive first trimester diagnosis (n = 1698) and CVS 2002 - 2008 after introducing non invasive testing at the end of 2001 (n = 1639). In both groups the indications for CVS (maternal age, sonographic findings, past history, maternal anxiety, and abnormal results of the Combined Test only in the second group) and the cytogenetic results were evaluated.

RESULTS

In the first group (1989 - 2001, n = 1698) 85,6% (n = 1454) of all CVS were performed because of maternal age and only 3% (n = 51) due to sonographic findings. In the second group (2002 - 2008, n = 1639) there was a distinct increase of sonographic findings leading to CVS (33,9%, n = 555) with a clear decrease of maternal age to 37,9% (n = 621). Abnormal cytogenetic results were found in 10,5% (n = 172) in the second group, in the first group only in 4,5% (n = 76), respectively. The parameter with the highest rate of chromosomal disorders was fetal hydrops (66,1%), follwed by hygroma colli (48,2%), malformations (12,9%) and increased nuchal translucency (11,2%). Regarding maternal age alone the rate of abnormal chromosomes was 3,1%.

CONCLUSIONS

It could be shown that non invasive first trimester diagnosis has lead to a more specific indication for invasive fetal testing (sonographic findings 33,9 vs. 3%, maternal age 37,9 vs. 85,6%) with a higher rate of chromosomal disorder in this group (10,5 vs. 4,5%).

Intrauterine aortic valvuloplasty in fetuses with critical aortic stenosis: experience and results of 24 procedures

OBJECTIVE

Valvuloplasty of the fetal aortic valve has the potential to prevent progression of critical aortic stenosis (AS) to hypoplastic left heart syndrome (HLHS). The aim of the study was to assess 24 aortic valvuloplasties regarding indications, success rate, procedure-related risks and outcome.

METHODS

Between January 2001 and December 2009 we performed 24 aortic valvuloplasties in 23 fetuses with critical AS at a median gestational age of 26 + 4 (range, 21 + 3 to 32 + 5) weeks by a transabdominal ultrasound-guided approach. Four fetuses had hydrops as a late sign of heart failure.

RESULTS

In 16/24 procedures (66.7%) corresponding to 16/23 fetuses (69.6%) the procedures were technically successful, with one intrauterine death in this group. After an initial learning curve, success rate improved to 78.6% (11 of the last 14 interventions were successful). In 10 out of the 15 (66.7%) successfully-treated and liveborn fetuses a biventricular circulation could be achieved postnatally. All four fetuses with hydrops had successful interventions, hydrops disappearing within 5 weeks. In 8/24 interventions (33.3%) the aortic valve could not be treated successfully, with intrauterine fetal death in two of these cases. In one fetus a repeat procedure was successful. All surviving fetuses with unsuccessful (n = 5) or no (n = 5) procedure performed developed HLHS until delivery.

CONCLUSIONS

Fetal aortic valvuloplasty could be performed successfully in selected fetuses with critical AS and evolving HLHS, with a biventricular outcome in two thirds of the patients. Safety and success rate were dependent on patient selection and the level of experience of the whole interventional team. In fetuses with AS and hydrops, aortic valvuloplasty could reverse end-stage heart failure and hydrops and ensure fetal survival.

Invasive intrauterine treatment of pulmonary atresia/intact ventricular septum with heart failure

The mortality and morbidity of children with pulmonary atresia/intact ventricular septum (PA/IVS) are linked to the degree of right ventricular (RV) hypoplasia. Opening up the pulmonary valve (PV) in fetal life could result in improved growth of the RV making it amenable to biventricular repair postnatally. Successful valvulotomy of the PV was performed in a fetus with heart failure at 28 weeks. Following the procedure there was significant growth of the tricuspid valve and RV. The neonate was delivered at 38 weeks with a RV suitable for biventricular repair. In utero pulmonary valvulotomy is feasible and may change the natural history of the condition in affected fetuses with PA/IVS.

[Real time 3D sonography of the normal fetal heart--clinical evaluation]

AIM

Aim of the study was to determine the clinical feasibility of real time 3D ultrasound in the examination of the normal fetal heart compared to conventional 2D fetal echocardiography.

METHOD

Twenty fetuses with normal hearts at 20 to 38 weeks of gestation underwent real time 3D ultrasound. Examination data were stored on an external notebook. Later analysis and interpretation was done by a different sonographer using a special software.

RESULTS

In the assessment of the four chamber view and the out flow tracts real time 3D ultrasound was equivalent to conventional ultrasound. Advantages of realtime 3D ultrasound were the possibility of later time-independent off-line analysis and post-processing of volume data and generation of new views not available in 2D imaging. Disadvantages included low frame rate (16 frames/s), low lateral resolution and the lack of Doppler and colour information.

CONCLUSION

Simultaneous display of 3 different views of the fetal heart as well as the construction of spatial perspectives ("new views") provide additional useful information to conventional fetal echocardiography. Later off-line analysis of 3D volume data can be used for sequential analysis of the normal fetal heart with good diagnostic results. Currently it remains unclear whether this new method may provide additional important information in the assessment of fetal congenital heart defects.

[Spontaneous constriction of the fetal ductus arteriosus]

The case report describes the pre- and postnatal clinical and sonographic findings of a fetus with spontaneous constriction of Ductus arteriosus at 39 weeks gestation. An abnormal four-chamber view due to a hypertrophied and enlarged right ventricle, increased peak systolic (2.39 m/sec), increased peak diastolic (0.88 m/sec) velocities and the decreased pulsatility index of 0.92 were the diagnostic criteria. The flow of the right pulmonary artery was retrograde. After birth estimated pulmonary pressure was 50 mmHg. It is concluded that constriction of the fetal ductus arteriosus may also occur spontaneously in the absence of maternal drugs.

[Pulsations of the umbilical vein: pathophysiologic aspects and fetal outcome]

Continuous forward flow to the fetal heart in the umbilical vein is a normal Doppler finding. Altered fetal hemodynamics can cause a pulsatile flow pattern in the umbilical vein. Pulsations in the umbilical vein were diagnosed in 14 pregnancies complicated by fetal hydrops, cardiac malformations, arrhythmia or severe intrauterine growth retardation. To document the fetal outcome, the results were analysed retrospectively. Compared with a normal Doppler group (N = 56), a significantly higher rate of perinatal death (Alpha < 1%), (64% vs 1.75%) was diagnosed, when pulsations in the umbilical vein were present. The Apgar-score was significantly lower (4.5 vs 8.4) (p < 0.0002) in the group with pulsations in the umbilical vein. There was no significant difference of pH between the newborns of the two groups. Eight fetuses developed hydrops. Thirteen fetuses had increased reverse flow in the inferior vena cava. The vena cava of the acardiac fetus could not be identified. The knowledge of the poor outcome and the pathophysiologic relationships of fetal hemodynamics may be useful in clinical management. Therefore Doppler examination of the umbilical vein should be performed in high-risk pregnancies.

[Fetal outcome in reduced flow in the ductus venosus during atrial contraction]

OBJECTIVE

To document the fetal outcome in cases with pathologic Doppler findings in the fetal ductus venosus.

METHODS

The outcome of 12 fetuses with reduced velocities in the ductus venosus during atrial contraction was analyzed retrospectively and compared with that of a group of 57 fetuses with normal flow velocities in the umbilical artery and in the fetal ductus venosus.

RESULTS

The perinatal mortality was higher in the group with pathologic Doppler findings. There was no significant difference of pH (7.20 vs. 7.24) and Apgar scores (7.57 vs. 8.36) of survivors between the two groups. All 12 fetuses showed increased retrograde velocities in the inferior vena cava. Seven fetuses showed umbilical vein pulsations.

CONCLUSIONS

The diagnosis of altered velocities in the ductus venosus may influence prenatal decisions. Therefore Doppler examinations of the fetal ductus venosus should be performed in high-risk pregnancies.

[Doppler ultrasound of the umbilical vein in fetal 3rd degree atrioventricular block]

A 21 week fetus was diagnosed with complete heart block. From the first diagnosis until 38 weeks gestation, umbilical venous pulsations occurred during ventricular systole. The ventricular frequency was 49 bpm. The venous pulsations corresponded with the ventricular frequency. At 38 weeks venous pulsations also occurred during ventricular diastole. Umbilical pulsations during diastole were associated with a decrease of ventricular frequency to 28 bpm and fetal hydrops. The venous pulsations during ventricular systole seem to be characteristic of complete heart block. The pulsations during ventricular diastole reflect the fetal heart failure. Doppler ultrasound aids in the diagnosis and surveillance of the fetus with complete heart block.

[Tetralogy of Fallot with absent pulmonary valve--prenatal diagnosis and management in the 2nd trimester]

Tetralogy of Fallot with absent pulmonary valve is a rare congenital cardiac malformation detected in 3% to 6% of tetralogy of Fallot patients. The prognosis depends on respiratory complications. In the present case the diagnosis was made at 18 week's gestation with two-dimensional and Doppler echocardiography. A ventricular septal defect and overriding aorta, absent valve echo, pulmonary regurgitation, and cystic pulsatile dilatation of the left pulmonary artery were the main diagnostic criteria. Severe respiratory complications were assumed in combination with a hyperechogenic left lung and termination of pregnancy was performed at 20 weeks' of gestation.

[The polyhydramnios symptom: analysis of 56 cases]

Analysis of 56 CASES: 56 cases of polyhydramnios, which were diagnosed sonographically over a period of three years, were analysed retrospectively in this study. In 9334 births, the prevalence of this symptom was 0.6%. Malformations were the most common cause (26.7%) of polyhydramnios (p < 0.001). In comparison to our normal patient group gestational diabetes, twin pregnancies with elevated amniotic fluid of one twin, virus infections, fetal chromosome abnormalities were diagnosed at a significantly higher rate (p < 0.001). The perinatal mortality rate (28.5%) in comparison to our normal collective (1.6%) was also significantly higher. Because of the high mortality, polyhydramnios must be assessed precisely and treated if possible. Fetal karyotyping should be routinely performed in the second trimester.

[Fetal supraventricular extrasystole: indication for fetal echocardiography?]

The purpose of this study was to assess the incidence of congenital heart disease (CHD) in fetuses with premature atrial contractions (PAC) and to check whether these fetuses should be referred for a special fetal echocardiogram. Out of 120 fetuses with PACs and 75 fetuses with CHD both conditions were present in only 9 fetuses (= 7.5%). Two pregnancies were terminated because of associated severe fetal anomalies. After birth PACs disappeared in all other cases spontaneously. Despite higher numbers, the incidence of fetal CHD was not statistically significant higher in fetuses with PACs. Thus, recognition of fetal PACs should lead to a referral for a special fetal echocardiographic examination.

[Acute effects of cigarette smoking on fetal cardiovascular and uterine Doppler parameters]

The purpose of this study was to assess the effects of smoking one cigarette (nicotine mean 0.63 +/- 0.17 mg) on uterine- and foetal cardiovascular Doppler parameters in healthy pregnant smokers. All pregnancies (n = 16; mean gestational age: 36 +/- 4 weeks) had been uneventful and all foetuses were appropriate for gestational age with normal baseline Doppler parameters and normal foetal outcome (birthweight: 3254 +/- 340 grams). Measurements, performed immediately before and after smoking, included pulsatility index (PI) of umbilical artery (UA), middle cerebral artery (MCA), foetal descending aorta and uterine artery as well as maternal and foetal heart rate. The ratio of UA/MCA PI was used to assess centralisation. Changes in foetal cardiac output were determined by: time-velocity integral times heart rate, at aortic and pulmonary valve level. Foetal heart rate (p < 0.0005, paired t-test) and maternal heart rate (p < 0.05) increased significantly. All other parameters did not change significantly. However, in one additional woman with labile hypertension and increased baseline uterine artery PI (1.9), smoking of one cigarette caused a substantial rise in uterine artery PI to 3.25 ten minutes after smoking. Middle cerebral artery PI decreased from 2.2 to 1.18 with an unchanged cardiac output and umbilical artery PI raising the UA/MCA PI ratio from 0.51 to 0.81, suggesting a brain sparing effect. Smoking of one cigarette raised maternal and foetal heart rate. There was no evidence of other cardiovascular effects or centralisation in healthy foetuses of normal pregnancies, but this might not be true in foetus of pathologic pregnancies.

[Decreasing the surgical risk of laparoscopy by using a newly developed, blunt trocar]

Laparoscopy is one of the most frequent interventions used in operative gynaecology. Because of the possible, occasionally grave complications through the use of the trocar forms applied so far, we have developed a new blunt trocar. By using this trocar throughout 1889 interventions, we have had no complications which could be ascribed to the use of this blunt instrument. The advantage of this trocar lies in the avoidance of the possible and feared injuries to the intestines and vessels. Even though overall complication rates in laparoscopy are low and there is no evidence of a statistically significant reduction compared with the use of the sharp trocar, the advantages of the blunt trocar are obvious. There is only one disadvantage, namely the slightly prolonged training time of the younger colleagues, as well as the theoretical possibility of a prolapse of the omentum. Nevertheless, in our opinion, the use of the blunt trocar is advisable to reduce the complication rate in laparoscopy.

[Harmful effects in early pregnancy--results of a teratological counseling center]

In the years 1986, 1987, and 1988 altogether 132 consultations were conducted during pregnancy at the Landesfrauenklinik Linz. These pregnant women had all been exposed to potentially harmful influences (drugs, maternal diseases and as infections or cancer, X-rays or pregnancy despite IUD). In most of the cases we recommended carrying the pregnancy to full term; only a few were interrupted, sometimes against on recommendation to proceed with the pregnancy. The rate of abortion and the frequency of ectopic pregnancies were within normal limits. Due to personal investigations after birth we registered postnatal findings in nearly all cases. No serious malformations were recorded. Detailed teratological knowledge is necessary for correct advice at consultation after exposure to harmful influences during early pregnancy. In most cases it is possible to avoid interruption without risking an increased rate of malformations.

[Prostaglandins for termination of pregnancy in the 2d and 3d trimester]

38 abnormal pregnancies in the second and third trimenon have been terminated by a combined therapy of natural prostaglandine, locally applied for ripening the cervix, followed by systemic application of synthetic prostaglandine of the third generation Sulproston. 8 pregnancies have been terminated only after ripening the portio with prostaglandine vaginal tablets. The other 30 women were injected with 500 micrograms Sulproston intramuscular after local priming. All the pregnancies were terminated by this procedure. In 25 cases the effective dose was 500 micrograms, three times 1000 micrograms, once 1500 and 2000 micrograms. 13 women suffered from side effects like vomiting and pain, which could be treated easily. In 27 cases the abortion took place within 20 hours after the first application of Sulproston. Our procedure obviously has a very good labour inducing effect and seems to be the ideal method for inducing artificial abortion.

[3 pregnancies carried to term following vaginal administration of 3 mg prostaglandin E 2 in the 1st trimester]

In the years 1985 and 1986 three women decided in the last minute not to undergo a planned abortion after vaginal application of prostaglandin E 2 twenty-four hours before the intended operation. These women came to our genetic clinic in order to obtain some information on the teratogenic risks of prostaglandins applied during early pregnancy. On the basis of these consultation and risk assessment, all three women decided to continue their pregnancy, resulting in the delivery of a healthy child in each case.

[Drug use and ionizing radiation in early pregnancy. Risk assessment and postpartum results]

The influence of medical drugs and X-rays upon early pregnancy causes problems of great responsibility for the physician. He is supposed to grant optimum consultation to the anxious women who finally have to decide to carry on their pregnancy or not. This topic is difficult to value as controlled prospective studies are not practicable for ethical reasons, and the results of animal experiments are rarely transferable to human medicine. In this paper the facts and data of our consulting activities are summarized from April 1985 to May 1986 in the sense of a prospective study. Over all 64 consultations were performed in these 14 months, up to now 30 women have been delivered of a newborn. The procedure and the principles of our consultations and the postnatal results are presented below.