Doppler sonography of the uterine and the cubital arteries in normal pregnancies, preeclampsia and intrauterine growth restriction: evidence for a systemic vessel involvement

Aims: The decrease in uterine resistance during normal pregnancy is known to be related to invading trophoblast cells which derive from placental tissue. Uterine and peripheral resistance is elevated in preeclampsia. The aim of the present study was to prospectively examine uterine and peripheral resistance in pregnancies complicated by preeclampsia (PE), fetal intrauterine growth restriction (IUGR) and pregnancy induced hypertension (PIH). Methods: Sixty-seven women with normal pregnancies, 17 with PE, 12 with IUGR underwent Doppler sonographic investigation of the uterine and the cubital arteries. The Pulsatility Index (PI) was calculated for each vessel. Statistical analysis was performed and a P-value < 0.05 was considered significant. Results: Patients with preeclampsia and IUGR showed a significant higher resistance at the placental (mean PI 1.267 and 1.063), nonplacental (mean PI 1.631 and 1.124) and cubital artery (mean PI 3,777 and 3.995) compared to the normal pregnancy group (mean PI 0.678; 0.859 and 2.95 respectively). Mean birth weight in the PE group was 1409 g, in the IUGR group 1649 g and 3419 g in the normal pregnancy group. Conclusions: Pregnancies with IUGR are associated with elevated peripheral resistance in the maternal arterial system as seen in pregnancies with preeclampsia. Our findings encourage to further investigate the maternal vascular system in high risk pregnancies

Decreasing resistance in the maternal uterine and peripheral arterial system is apparently unrelated to plasma and urinary levels of nitrite/nitrate and cyclic-guanosinmonophosohate during the course of normal pregnancies

Aims: The aim of the presented study was to clarify the relationship between the pulsatility index of the uterine arteries and the maternal cubital artery and peripheral concentrations of the metabolites of nitric oxide (NO) and its second messenger cyclic guanosinmonophophate (cGMP) during the normal course of pregnancy and postpartum. Methods: 49 uncomplicated pregnancies were investigated every 46 weeks until delivery, 29 of them were additionally investigated postpartum. Paralleling each Doppler sonografic investigation maternal blood and urine samples were taken. The measurements of nitrite/ nitrate and cGMP were performed with a colorimetric and radio immuno assay. We demonstrate a significant decrease of the PI of the uterine arteries and of the cubital artery with inverse correlation to advancing gestational age. Results: The concentrations of nitrite/nitrate and cGMP remain stable during gestation and do not correlate to the PI of the uterine and cubital artery. Postpartum a reincrease in the uterine and peripheral resistance can be shown. The concentrations of urinary cGMP and nitrite/ nitrate as well as plasma cGMP remain unchanged, whereas plasma nitrite/nitrate decreases postpartum. Conclusions: The status of NO biosyntheses in normal pregnancy remains controversial. We hypothesize further systemically acting mediators which contribute to the decreasing vascular resistance

High-fidelity simulation increases obstetric self-assurance and skills in undergraduate medical students

Objective: Teaching intrapartum care is one of the most challenging tasks in undergraduate medical education. High-fidelity obstetric simulators might support students' learning experience. The specific educational impact of these simulators compared with traditional methods of model-based obstetric teaching has not yet been determined. Study design: We randomly assigned 46 undergraduate medical students to be taught using either a high-fidelity simulator or a scale wood-and-leather phantom. Their self-assessments were evaluated using a validated questionnaire. We assessed obstetric skills and asked students to solve obstetric paper cases. Main outcome measures: Assessment of fidelity-specific teaching impact on procedural knowledge, motivation, and interest in obstetrics as well as obstetric skills using high- and low-fidelity training models. Results: High-fidelity simulation specifically improved students' feeling that they understood both the physiology of parturition and the obstetric procedures. Students in the simulation group also felt better prepared for obstetric house jobs and performed better in obstetric skills evaluations. However, the two groups made equivalent obstetric decisions. Conclusion: This study provides first data on the impact of high-fidelity simulation in an undergraduate setting

Flowcytometric assessment of fetomaternal hemorrhage during external cephalic version at term

External cephalic version (ECV) at term is a safe procedure and reduces the incidence of cesarean sections for breech presentation. One of the known complications, however, is an ECV-related disruption of the placental barrier and a subsequent transfusion of fetal blood into maternal circulation. While the incidence of ECV-related fetomaternal hemorrhage (FMH) has been determined recently in a large trial using a manual Kleihauer-Betke test (KBT), questions remain on the amount of ECV-related FMH. KBT, which detects fetal red blood cells (RBC) on the basis of acidic resistance of fetal hemoglobin (HbF), is known to be a sensitive test, yet prone to procedural errors limiting its accuracy in quantifying FMH. In this study we investigated 50 patients for FMH before and after ECV, using a dual-color flow cytometric test kit with a lower limit of quantification of 0.05% fetal RBC in maternal peripheral blood. Three patients had a quantifiable increase of fetal RBC detected after ECV (0.06%; 0.08%; 0.1%). None of these subtle increments was predictable by ECV-related clinical parameters or translated into fetal compromise. Using a sensitive and accurate flow cytometric test method, our data provide further assurance to mothers on the safety of ECV at term

Diagnosis and treatment of peripartum bleeding

Severe peripartum hemorrhage (PPH) contributes to maternal morbidity and mortality and is one of the most frequent emergencies in obstetrics, occurring at a prevalence of 0.5-5.0%. Detection of antepartum risk factors is essential in order to implement preventive measures. Proper training of obstetric staff and publication of recommendations and guidelines can effectively reduce the frequency of PPH and its resulting morbidity and mortality. Therefore, an interdisciplinary expert committee was formed, with members from Germany, Austria, and Switzerland, to summarize recent scientific findings. An up-to-date presentation of the importance of embolization and of the diagnosis of coagulopathy in PPH is provided. Furthermore, the committee recommends changes in the management of PPH including new surgical options and the off-label use of recombinant factor VII

Role of Placental VDR Expression and Function in Common Late Pregnancy Disorders

Vitamin D, besides its classical role in bone metabolism, plays a distinct role in multiple pathways of the feto-maternal unit. Calcitriol is the major active ligand of the nuclear vitamin D receptor (VDR). The vitamin D receptor (VDR) is expressed in different uteroplacental parts and exerts a variety of functions in physiologic pregnancy. It regulates decidualisation and implantation, influences hormone secretion and placental immune modulations. This review highlights the role of the vitamin D receptor in physiologic and disturbed pregnancy, as preeclampsia, fetal growth restriction, gestational diabetes and preterm birth. We discuss the existing literature regarding common VDR polymorphisms in these pregnancy disorders