[Prevention of neonatal risk by general screening for diabetes in pregnancy, intensive diagnosis and subsequent therapy]

Only 10% of all gestational diabetic mothers in Germany are diagnosed with the current risk-screening. The elevated perinatal risks in case of an unrecognized or insufficiently treated gestational diabetes remains controversial. The purpose of our study was to determine if the number of recognized cases could be increased by a general screening method, and with intensive medical diagnostics the complication rate reduced. Routine blood glucose samplings during the outpatient care were performed throughout the pregnancy. In case of values over 100 mg/dl a 75 g OGTT was done for an exclusion of gestational diabetes. In case of gestational diabetes the patients were asked to follow a special exercise and diet programme as well as self-blood glucose determinations throughout the day. The amniotic fluid insulin level was of substantial value for the indication of insulin therapy. In 6% of the screened patients a gestational diabetes was diagnosed. There was a significant increase (p < 0.001) of fetal macrosomia and diabetic fetopathy in the group without amniocentesis (n = 22) in comparison to the group with invasive (n = 81). We demand the introduction of a general screening for every pregnant patient. By an intensification of the diagnostic methods as well as by a strictly appropriate therapy it should be possible to reduce the fetal and neonatal complications.

[Kinetocardiotocographic and Doppler ultrasound findings before termination of risk pregnancies]

42 pregnancies complicated by severe intrauterine growth retardation (IUGR) were monitored between 1991 and 1992 with the kinetocardiotocogram (K-CTG) comparing them with normal pregnancies of the same gestational age. We evaluated the foetal movements and the heart rate patterns establishing a correlation with pulsed Doppler ultrasound findings. There was a significant reduction of foetal activity in cases of IUGR and pathological Doppler sonography (p < 0.01). The reduction of foetal movements was noticed several days prior to pathological FHR patterns. There was a significant reactivity after vibroacoustical stimulation (VAS) correlating with the Doppler findings. The evaluation of foetal movement patterns in the kinetocardiotocogram proved to be an important complementary method in the monitoring of severe IUGR.

Circulating levels of placental protein 10 (PP 10) in diabetic pregnancy complicated by retinopathy

Placental protein 10 (PP 10) is a soluble tissue antigen of the placenta. PP 10, a glycoprotein, was tested in diabetic pregnancy complicated by retinopathy. A continuous increase in PP 10 serum levels until weeks 35-36 is followed by a fall thereafter up to term. The mean of the healthy control group between 32 and 39 weeks gestation was 22 +/- 10 micrograms/l. In diabetic pregnancies complicated by retinopathy there were measured 69 +/- 24 micrograms/l in benign form and 77 +/- 26 micrograms/l in proliferative form. Both of these values are significantly (p less than 0.05) above the control values. Increased PP 10 levels in diabetic pregnancy complicated by retinopathy are probably caused by placental and amniotic leakages.

Circulating levels of placental protein 12 (PP 12) in diabetic pregnancy complicated by retinopathy

Placental protein 12 (PP 12) is a soluble tissue antigen. Immunohistochemical studies have localized PP 12 in the placental syncytiotrophoblast, chorion and amnion, and also in the decidua. During normal pregnancy serum-PP 12 is already raised in the first trimester, there is then a peak at 18 weeks, a gradual fall until 32 weeks, and a moderate increase thereafter. The mean of the healthy control group at 18 weeks of pregnancy was 122.9 +/- 47.5 micrograms/l. The mean of the diabetic group with retinopathy at the same time was 192.2 +/- 78.8 micrograms/l. There was no significant difference between background retinopathy and the proliferative form of diabetic retinopathy. At all times during pregnancy the median values of PP 12 in diabetic pregnancies were significantly (p less than 0.01) above the control values. Increased PP 12 levels in diabetic pregnancy complicated by retinopathy are probably caused by decidual, placental and amniotic leakages.

Neonatal jaundice in infants of diabetic mothers

357 IDMs and 20 healthy newborns of non-diabetic mothers were examined at term for body measurements, red blood cell count, serum bilirubin, cord blood insulin and blood glucose during the first postnatal week. The stage of maternal diabetes did not influence the course of neonatal bilirubin levels, but the IDMs had prolonged and higher bilirubinaemia compared with the controls. Hyperbilirubinaemia was found to be most prominent in newborns with an increased birthweight/length ratio and was not simply related to macrosomia (LGA). These infants had significantly lower blood glucose concentrations immediately after birth, whereas cord blood insulin was found to be identical between the IDM sub-groups. Bilirubinaemia in heavy for length infants was slightly correlated to haematocrit. For the pathogenesis of hyperbilirubinaemia in IDMs induction of heme oxygenase (due to a lack of energy provision following a phosphorylation disorder) is discussed. Nutritional support (early feeding, glucose infusions) does not affect the course of bilirubinaemia.

[A successful procedure in mitral valve rupture accompanied by rupture of the papillary muscle and the chordae tendinae following multiple injuries and blunt thoracic trauma]

In a considerable number of cases, blunt chest trauma also involves cardiac lesions including myocardial contusion or disruption pericardial effusion, or valve rupture. Definite cardiac trauma poses a challenge to everyone involved in intensive care, as early diagnosis and prompt treatment may be necessary to prevent a fatal outcome. We report a 32-year-old patient with fractures of the humerus, forearm, left clavicle and 2nd rib, and right ribs 4-6 after an 8 m fall. He was intubated in the emergency room because of arterial hypoxemia. Despite fluid administration the blood pressure deteriorated and the patient rapidly developed congestive heart failure that required huge doses of catecholamines. A systolic murmur was heard in the apex and left axilla. Conventional transthoracic echocardiography showed mitral valve prolapse and was suggestive of a flail mitral valve. Transesophageal echocardiography confirmed the diagnosis of mitral valve rupture, which proved to be grade IV by angiography. Because of continuous deterioration with low cardiac output and critical blood pressures and heart rates, surgery was carried out on the day of admission. Complete rupture of the anterolateral papillary muscle was found with laceration of the ventricular muscle, rupture of the secondary chordae tendineae, partial rupture of the valve base and partial dissection of the valve leaflets from the base. As expected from the echocardiography, there was no pericardial effusion. The destroyed valve was replaced by a Duromedics prosthesis. Operative stabilization of the subcapital humeral fracture followed 3 days later.(ABSTRACT TRUNCATED AT 250 WORDS)

Nocardial endocarditis after aortic valve replacement. Reports of two cases

Nocardial sepsis occurred after aortic valve replacement in two patients. A septic suture aneurysm of the aortotomy was resected and the prosthesis exchanged in one of them. The other received conservative treatment for sternal osteomyelitis and local mediastinitis. Clinical cure was followed by relapse and death from cerebral infarction, and necropsy revealed a septic suture aneurysm of the aortotomy. Radical surgical revision seems to be necessary for lasting cure in such infections.

Successful management of dissection of the aortic root during aortic valve replacement

We present a case of intraoperative dissection of the aortic root in a patient with non-calcified aortic valve incompetence. This complication led to life-threatening bleeding from the dissection line into the layers of the left ventricle as well as the aortic wall with formation of an increasing subadventitial hematoma. The only possible management was to remove the valve prosthesis and to close the entry site of the dissection when reinserting the valve implant. The mechanism of this complication is discussed.

[Continuous peridural anesthesia--results of fractionated application in comparison to catheter infusion]

This report presents 100 epidural analgesias using a catheter in a high risk group. Two groups are compared, one with intermittent manual injections, the other with constant infusion rate (CIR) by means of a syringe with bupivacaine solution 0,5% and a pump. The analgetic effect was stable, without fluctuations and was adequate during the first and the second stage of labour in the group with CIR. The CIR avoids plasma peaks with transient hypoxemia of the fetus. The high blood pressure in patients with severe pregnancy induced hypertension is more decreased with this technique. In comparison to deliveries without epidural analgesia the instrumental delivery rate was higher, the fetal outcome was equal. Severe complications are not seen. The indicated use of the epidural analgesia with CIR is recommended.