[Pregnancy-saving measures in premature rupture of fetal membranes in the 22nd week of pregnancy]

The obstetric-perinatologic problems raised by premature rupturing of the membranes in the 22nd gestational week is presented in the form of a case report from the Perinatal Centre of the University of Cologne. By close ultrasonic monitoring of the course of development, measurement of parameters of inflammation and administration of prophylactic antibiotics pregnancy could be prolonged by 9 weeks with good fetal outcome.

Relationship between amniotic fluid insulin and maternal blood glucose concentrations in patients with carbohydrate intolerance during pregnancy

In contrast to maternal blood glucose, amniotic fluid insulin (AFI) directly reflects the functional state of the fetal pancreas. In a prospective study we evaluated the correlation of AFI with maternal metabolic control in 70 amniotic fluid specimens from 61 women having carbohydrate intolerance during pregnancy (White A n = 44, B0 n = 17). AFI was measured with the Insulin RIA 100 kit from Pharmacia (Freiburg). The normal range of AFI was established in 304 healthy pregnant women (16th-42nd gestational week). AFI concentrations increased by a factor of 1.5 to 2 during gestation reflecting the maturation of the fetal pancreas. Elevated AFI levels (> 97th centile) were found in 11% of normoglycemic diabetics and in 50% of women with insufficient metabolic control. Despite a high overall concordance (81%) no direct relationship could be found between fetal and maternal parameters. Patients with increased AFI values had a 5-fold higher rate of large-for-gestational age (LGA) infants than women with normal levels. This finding confirms the pathogenetic role of hyperinsulinism in the development of fetal macrosomia.

[An consultation concept for integrating psychosomatic medicine in gynecology]

This paper is meant to survey the results of an interdisciplinary concept of psychosomatic patient treatment carried out for two years at the Department of Gynaecology and Obstetrics of the University of Cologne. This integral programme offers a psychosomatic consultation hour taking place once a week at the Department of Gynaecology and Obstetrics. Each first consultation is attended both by a psychosomatic specialist and a gynaecologist. The hypothesis underlying this new programme, which supposes that the integration of the psychosomatic treatment into the everyday routine of the clinic would make it easier for the patients to find access to psychological help, has proved right in view of the experience made so far. In comparison to the former counselling concept, the newly established gynaecologic-psychosomatical programme has increased the attendance by 300%. Thanks to the integrated consultation hour the way of seeing gynaecological problems in a psychosomatic context has increased considerably within the clinic itself so that these problems can now often be solved directly between gynaecologist and patient without making use of the offered consultation hour. Experiences made so far prove that the psychosomatic consultation hours are a valuable contribution to the diagnostic and therapeutic spectrum of the Department of Gynaecology and Obstetrics.

Prognostic factors for preoperative consultation of women desiring sterilization: findings of a retrospective analysis

In this exploratory study, 37 sterilized women applying for sterilization reversal were questioned thoroughly to establish why they had decided to undergo sterilization and why they now wished for it to be reversed. Taking an interactive behavioral model as our starting point, we concentrated on the psychosocial circumstances leading to the definitive decision to be sterilized. A relationship crisis at the time of sterilization was found to be a prognostically unfavorable factor. Furthermore, 20 of the 37 patients cited new partnerships as their main reason for seeking reversal. Those who felt pressurized by their gynecologist or partner into undergoing sterilization had significantly more problems in overcoming the psychological stress accompanying such an operation than those who, through a series of consultations on contraception, had had sufficient time and opportunity to make their own decisions. Sterilization performed for medical reasons was found to have particularly problematical consequences, especially where the doctor had made the decision largely on his own, failing to give an adequate explanation for the medical necessity of the operation. Regarding the time chosen for sterilization, the study revealed that the patient's postoperative psychological condition was significantly worse when sterilization was carried out immediately after a delivery, after abortion or after Caesarean section, rather than in the interval between pregnancies. The resulting increase in the incidence of psychosomatic complaints and depressive states is also confirmed in the literature. The findings of this study offer practical suggestions for improved preoperative consultation and should help to determine the course of action to be taken when a patient wishes to be sterilized.

[Obstetric prognostic factors of newborn infants with very low birth weight (< or = 1,500 gram) with reference to survival rate and early childhood development]

Prognostic factors influencing survival in 235 very low birthweight prematures (< or = 1500 g) born between 1986 and 15.11. 1993 at the Department of Obstetrics and Gynaecology, University Hospital of Cologne, were retrospectively evaluated. Chromosomal anomalies and severe congenital malformations were excluded. Of 180 singletons 84 were classified as appropriate-for-gestational-age (AGA) and 96 as small-for-gestational-age (SGA). By interrogating the attending paediatricians data regarding the early development of 62/65 surviving singletons born between 1986 to 1990 were recorded (follow-up rate 95%). Survival was significantly correlated to singleton pregnancy (p < 0.05), female sex (p = 0.001) and in the AGA-prematures to prenatal corticoid prophylaxis. With similar mean birthweight SGA-singletons showed a three weeks higher mean gestational age; the mortality showed an inverse correlation to birthweight and gestational age being 11% higher in the AGA-group compared with the SGA-group (32% versus 21%). At the age of between 11 months and 6 years severe handicaps and developmental retardations were found more often in previous AGA-prematures (6/26) than in previous SGA-prematures (4/36); type and degree of later handicap were not correlated to birthweight. According to our results survival rates of very low birthweight prematures are strongly influenced by singleton pregnancy, by fetal sex, by gestational age and in the AGA-group by prenatal corticoid prophylaxis; mortality shows an inverted correlation to birthweight and gestational age, whereas the later prognosis of survivors does not seem to be influenced by birthweight or gestational age.

A case of HELLP syndrome at 23 weeks' gestation

We report a case of the HELLP syndrome at 23 weeks' gestation. Prolongation of pregnancy until the fetus was viable was not possible.

[Psychological disease adjustment in breast cancer patients]

In a prospective follow-up study, attention was focused on adjustment to disease in breast cancer patients one year after diagnosis. Prebioptic data was collected in the original patient group consisting of 95 women with mammary tissue findings that required clarification. Twenty-nine women with histological confirmation of breast cancer and 37 patients of the control group with benign histological findings were recontacted after an interval of one year. Data was collected by means of psychological test questionnaires (STAI, SVF, FPI, CIP-DS), the patients with breast cancer were given an additional problem-oriented questionnaire about coping with disease, compiled by the author. Most denied having disease-related fears-progression of the disease, premature death; instead, marked sleep disturbances, regularly, recurring nightmares, and depressed states of mind characterized the psychosomatic correlate of the mental burden. The psychological consequences of cancer are related to some extent to the stage of tumour growth at the time of diagnosis; the process of social reintegration appears to be facilitated in women whose biopsy operation did not involve removal of a breast. An clear characterization of breast cancer patients could not be established using psychological testing procedures one year after diagnosis of the disease.

[The prognostic significance of cathepsin D in primary breast cancer]

The prognostic significance of the lysosomal protease cathepsin D in breast cancer was evaluated in a retrospective study. Cathepsin D was measured in 346 deep-frozen (-70 degrees C) cytosol specimens of primary breast carcinomas (1982-1990). Among the established prognostic factors, only axillary lymph node involvement correlated with the expression of cathepsin D (> 40/60 pmol/mg) (p = 0.04-0.05). Univariate analyses of disease-free survival (DFS) and overall survival (OS) showed, that the expression of cathepsin D had no effect on the prognosis either in the whole population of breast cancer patients during long-term follow-up (n = 302; median observation time 51 months) or in the group of women with positive lymph nodes (n = 157; 46 months). However, within the group of N0 patients (n = 145; 57 months), high cathepsin D levels were associated with an unfavourable OS, but this relationship was statistically insignificant (p = 0.08-0.13). A similar influence of cathepsin D on DFS could not be demonstrated. Compared to tumour size, grading and receptor status in multivariate analysis, cathepsin D was a more indicative, but finally insignificant prognostic factor for OS. According to these results, cathepsin D may contribute only in combination with other prognostic factors to identify those 20-30% of node-negative patients with unfavourable prognosis, who may benefit from adjuvant therapy.

Prenatal expectations and fears in pregnant women

The aim of this study was to extend the medical knowledge of the prenatal expectations and wishes of pregnant women with respect to themselves, their partners and the maternity ward selected for the approaching birth, and also of the anxieties arising in this connection. In summary, our study shows that the desire to experience birth in the most natural, undisturbed and unmanipulated form possible is reiterated frequently, but is relativized by the intense need to be reassured of the safety of the unborn child. Fears experienced before the birth were focused accordingly on the condition of the child, although 25% of the women questioned acknowledged a marked fear of helplessness and failure. The obstetric team were expected to offer, as far as possible, the continuous personal supervision of a doctor and a midwife who were prepared to allow the patient the responsibility of being involved in obstetric decisions.

[Premature rupture of fetal membranes: problems and obstetric management]

The treatment of a premature rupture of the foetal membrane (prom) has up to now been a subject of controversy. Depending on the stage of gestation, the prompt birth ensuing as a result of prom, involves the risk of immaturity of the child. Conservative waiting by contrast, exposes mother and child to a potential risk of infection. The retrospective study presented, summarises the strategies for treating prom used at the Cologne University Department of Obstetrics and Gynaecology during the period from 1984 to 1989, and attempts to develop from these data proposals for the treatment of prom. With an increase in latency of over 24 hours between prom and delivery, the maternal and neonatal rate of infection also increased significantly. An effective result of a prophylaxis with antibiotics could only be shown in the reduction of incidence of infection in the mother. An effect on the neonatal rate of infection could not be seen. Inducing prepartually lung-maturity with glucocorticoides or ambroxol resulted in a significant decrease of the RDS-rate in new born children up to the 34th week of gestation. Beyond the 34th week of gestation, this effect could not be found. Whereas after completion of the 37th week of gestation, the preferred treatment used by doctors is allowing the shortest possible time of latency between prom and delivery, the expected pulmonary immaturity before the 34th week of gestation has to be treated by prolonging the pregnancy and inducing pulmonary maturity under antibiotic prophylaxis and at the same time controlling infection.(ABSTRACT TRUNCATED AT 250 WORDS)

[Prolongation of a primary twin pregnancy to the 31st week of pregnancy by surgical extraction of the 1st twin in the 17th week of pregnancy for umbilical cord prolapse]

A 24-year-old woman with a twin pregnancy had a premature rupture of membranes (PROM) of the first foetus in the 16th gestational week (gw). After 9 days the umbilical cord prolapsed. In the 17th gw the foetus was extracted by vaginal hysterotomy, because of an inferior anterior wall placenta. The patient remained hospitalised receiving tocolysis, lung maturation induction and prophylactic antibiosis. The pregnancy could be prolonged for 109 days after PROM and 99 days after the extraction of the first twin. The second child was born in the 31st gw by Caesarean section, following uncontrollable labour.

[On the value of "informational evening classes for mothers and fathers" within the scope of prenatal care]

In 1989, the Department of Gynaecology and Obstetrics, University of Cologne, questioned the 288 participants of the "informative evenings for mothers and fathers", a primarily preventive measure offered as a preparation for childbirth. The survey aimed at reviewing these evenings, i.e. to make a critical and exact evaluation of their usefulness and quality as one of the numerous events offered to expectant mothers. The following results were obtained: The women who visited the informative evenings were mostly pregnant for the first time, educated above average, for the most part working women and of German nationality. Their attitude towards preventive measures, i.e. regular check-ups during pregnancy as well as smoking behaviour, the wish to breast-feed and the attendance of other birth preparation courses, is well founded. Consequently, this group of women can be described as a highly selected. Their motivation to come to the evenings resulted mostly from the wish to obtain specific clinical information, to become familiar with the maternity ward, to meet midwives and doctors, in order to lose some of their fears and to increase confidence. Contents and structure of these evenings were mostly able to meet the expectations of the visitors. Unsatisfactory, however, was the low number of foreign woman, those with difficult pregnancies and women of a low social status i.e. patients, who above all, need intensive assistance and attention.

[Retrosternal lymph node metastases in breast cancer: lymphoscintigraphy and magnetic resonance tomography]

In 21 patients with breast cancer (pT1-4, N0, M0) internal mammary lymphoscintigraphy and magnetic resonance imaging (MRI) were performed to evaluate retrosternal lymph node metastases. In 6 patients normal findings of lymphoscintigraphy were confirmed by MRI. In the 15 patients with focal defects seen by lymphoscintigraphy no lymph nodes were found by MRI in 5 in the corresponding area, 5 showed normal-sized lymph nodes (less than 1 cm) and 5 enlarged lymph nodes indicating metastatic infiltration. In addition to internal mammary lymphoscintigraphy MRI may offer the possibility to improve TNM staging in patients with breast cancer.

Natural lymphocyte cytotoxicity of women with different symptoms of toxemia

Natural cytotoxic activity of lymphocytes from 113 pregnant women presenting one or more symptoms of the toxemic triad (E, P or H) was tested. According to the clinical symptoms, groups EH + H, EP + P and PH + EPH were formed. The control group consisted of 56 healthy pregnant patients. Significantly increased cytotoxicity was observed in toxemic pregnancies with proteinuria (group EP + P, 35.8 +/- 14.3%, P less than 0.001) and with proteinuria and hypertension (group PH + EPH, 27.2 +/- 13.3%, P less than 0.001%), but not in the group with hypertension (EH + H, 13.0 + 9.9%), compared to that of controls (11.0 + 11.5%). The relative number of patients with cytotoxicity greater than or equal to 40% was also higher in groups with proteinuria presenting with or without other symptoms of the disease. Increased cytotoxicity in proteinuric form of gestosis seemed to be independent of the incidence of low birthweight deliveries and intra-uterine growth retardation.

[Analysis of motivation of sterilized women requesting sterilization reversal]

Within the framework of this exploratory study, 37 sterilised women wishing to be refertilised, were questioned thoroughly on what had indicated their sterilisation and why they wish to be refertilised. Assuming the existence of an interactive behaviour pattern, we concentrated on the psycho-social circumstances accompanying the definitive decision to be sterilised. Here, a critical situation in the relationship between the partners at the time of sterilisation could be established as a prognostically unfavourable factor. Accordingly, 20 of the 37 patients developed the wish to be refertilized because of a new partnership. Those who felt induced by their gynaecologist or partner to undergo sterilisation had significantly more problems in overcoming the psychological stress accompanying such an operation than those who, after repeated consultations, had enough time and possibilities to make their own decision concerning contraception. Furthermore, sterilisation due to medical indication could be suggested as another highly critical factor, especially where the gynaecologist failed to give sufficient explanation of its medical necessity. With regard to the time set for the sterilisation, the study revealed that the patient's psychological condition after the operation was significantly worse, when sterilisation was carried out immediately after a delivery or an abortion. The fact that in such cases sterilisation is often followed by an increase in psychosomatic trouble and depressive states, of mind is also confirmed by literature. The results of the study are a practical contribution towards improving preoperative consultation and coordinating the course of action to be taken where a patient has the wish to be sterilised.

Untersuchung retrosternaler Lymphknotenmetastasen beim Mammakarzinom: Lymphszintigraphie und Kernspintomographie

In 21 patients with breast cancer (pT1–4, N0, M0) internal mammary lymphoscintigraphy and magnetic resonance imaging (MRI) were performed to evaluate retrosternal lymph node metastases. In 6 patients normal findings of lymphoscintigraphy were confirmed by MRI. In the 15 patients with focal defects seen by lymphoscintigraphy no lymph nodes were found by MRI in 5 in the corresponding area, 5 showed normal-sized lymph nodes (<1 cm) and 5 enlarged lymph nodes indicating metastatic infiltration. In addition to internal mammary lymphoscintigraphy MRI may offer the possibility to improve TNM staging in patients with breast cancer.

[Pregnancy-induced hypotonia. A prospective study of fetal development, labor and morbidity of newborn infants]

Maternal and foetal risk of hypotension in pregnancy were examined in a prospective study, comprising a total of 770 pregnant women i.e. 700 normotensives and 70 hypotensives. We conducted a minimum of 5 pressure controls beginning after the 20th week of gestation. All pressure controls were conducted by the same person and in each control 4 pressure values were taken (left and right arm, lying, standing). No difference was discovered in the statistical analysis of our data of pregnancy, delivery and foetal outcome. Our special interest was in the frequency of preterm delivery and foetal growth retardation. The rate was similar in the hypotensive group (6.7/3.1%) compared to the normotensive group (6.8/2.8%). From our results we conclude, that maternal hypotension is not a risk factor in pregnancy, and that no therapy is needed.

[Alloimmune thrombocytopenia in the newborn infant caused by maternal PlA1 antibodies]

The case of pregnant woman, whose first child was born with neonatal alloimmune thrombocytopenia (NATP) and PlA2/PlA1 constellation, is used as an example to draw up a programme for the care of pregnant women whose children are expected to be born with NATP. In one of 2,000 to one of 3,000 cases, the PlA1-positive foetal platelets cause a sensitization of the PlA1-negative mother. Transplacental passage of maternal IgG alloantibodies leads to accelerated destruction of foetal platelets. The pathophysiologic process is similar to Rh-erythroblastosis foetalis. The infants show symptoms ranging from cutaneous manifestations to intracranial haemorrhages.