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The problem of foetal weight estimation has not been satisfactorily solved to date. We studied quantitatively the influence of the mathematical approach and the number of distance measurements of different parts of the foetal body, on the accuracy of prospective calculation of the actual foetal weight. Of 230 foetuses of known gestational age we measured via ultrasound 13 lengths of head, rump and extremities during the last three days before delivery. 22 types of formulas were analysed. To decide on the best mathematical way of calculation we recalculated all coefficients in all formulas for each study group. In this way each formula can yield best possible results for the presented group. Three formulas yield very good results--a logarithmic type using 7 measured distances, and 2 linear types of formulas using 10 and 11 measured distances. The standard deviations of the differences (calculated weight minus actual weight) range from 216 g to 219 g. The frequency of differences greater than +/- 15% of the calculated weight ranges between 3.0% and 4.3% of the cases. Miscalculations of more than 700 g (absolutely) have not been noted. In addition, five other formulas (logarithmic and linear types with 5 to 8 measurements) have yielded good results. Using 5 to 8 measurements, the logarithmic types of formulas are better than the linear ones. The mathematical types of formulas cannot achieve the improvements resulting from a greater number of measurements.

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The concentration of hypoxanthine in plasma was suggested as an indicator of hypoxic conditions in newborns. We examined the concentration of hypoxanthine in maternal venous as well as in umbilical cord blood during pregnancy and during and after labor. The concentration of hypoxanthine in the cubital venous blood of nonpregnant healthy women and in healthy pregnant women and in women with complicated pregnancies was the similar. During birth there is an increase of the hypoxanthine concentration in maternal blood. This could be caused by the muscular work involved in giving birth (contraction, pushing, breathing). The values increased from 2.0-4.1 mumol/l in normal and abnormal pregnancy up to values of 9.4-11.8 mumol/l immediately after delivery. At the end of delivery the level of hypoxanthine is higher in the venous blood of the mother than in the umbilical blood. The concentration of hypoxanthine in umbilical venous blood and umbilical arterial blood did not show any significant differences. When clinical symptoms of hypoxia (depressed state of the neonate, high Thiringer asphyxia score, low Apgar score) were observed in the neonate, the hypoxanthine concentration in the umbilical vessels was increased (normal 4.7 mumol(l; slightly depressed 7.6 mumol/l, severely depressed 10 mumol/l).

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In a prospective study process curves of fetal development were done for 1618 patients using humerus and femur with at least 5 ultrasound investigations per patient. These prenatal ultrasound values were divided in 7 groups and compared with the postnatal values of newborns to get a reliable statement. Typical curve processes have been demonstrated for low-profile development, mild and severe intrauterine growth-retardation, a macrosomy, and for a diabetic fetopathy. The following results have been gained from ultrasound values of prospective staging of fetal development. From 1618 cases 1263 cases (78.0%) have been staged exactly. 333 cases (20.6%) were not total exact. 22 cases (1.4%) have been evaluated wrong. From 121 cases of IUGR 95 cases (78.5%) have been staged correctly. Humerus and femur values are below the normal range in for IUGR group. 77 cases (62.1%) from the 124 macrosomal newborns have been detected right. Only 2 cases (4.9%) from the 41 cases of diabetic fetopathy have been evaluated lower. Humerus and femur values in severe macrosomia were over the normal range in contrast to the diabetic fetopathy. Our scheme for control of fetal development which use humerus and femur as additional parameters shows higher precision.

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It can be suggested that a NSE concentration in body fluids above the normal range may indicate brain damage, because NSE is found in neurons and neuroendocrine cells only. In this paper the concentration of the neuron specific enolase (NSE) in the amniotic fluid of normal and high risk pregnancies was investigated. Sixty-three samples of amniotic fluid were collected from 55 pregnant women and women in labor between the 19th and the 42nd gestational week. In 24 normal pregnancies 1.02 +/- 0.31 microgram NSE/L (mean +/- SD) were found. A relationship of NSE concentration was not found for gestational age, uterine contractions, age and parity of the mother, infant's birth weight or 1 min Apgar score. Maternal diseases such as diabetes mellitus, hypertension and others do not result in any increase of NSE concentration in the amniotic fluid (N = 20; 1.06 +/- 0.24 microgram NSE/L). Fetal and birth related high risk factors such as meconium stained amniotic fluid, cord around the neck, severe decelerations of the fetal heart rate or combinations of these factors caused the NSE concentration to exceed significantly normal values (N = 17; 2.22 +/- 0.87 microgram NSE/L). Due to its high organ and cell specificity, NSE may be a possible parameter for brain damage due to hypoxia in the fetus and newborn; however, only subsequent neurological and psychological examinations of these children can indicate the prognostic value of an elevation of NSE concentration in amniotic fluid.

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By means of a casuistic about successful course of pregnancy and labour by a patient with methaemoglobinemia (HbM Leipzig II) is reported.

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Within systematic fetal supervision by CTG of the risk pregnancies sometimes single decelerations of variable type are observed. Most they didn't repeat. In the majority of the cases in follow up pregnancy the child will be born spontaneously without complications. In a lot of other cases, however, there appears fetal distress. For prognostic statistical evaluation of antenatal decelerations we watched prospectively the following groups: 1.43 cases with severe antenatal variable decelerations, 2.39 cases with mild antenatal variable decelerations, 3.88 cases without antenatal decelerations. - The appearance of severe decelerations was followed by fetal distress in 42%, by perinatal death in 12%, and by caesarean delivery in 40%. Fetal prognosis in this group is significantly more unfavourable than in the two other groups with mild decelerations (fetal distress 15%, caesarean section 23%, no fetal loss) or without decelerations (fetal distress 13%, caesarean section 10%, no fetal loss). - Single severe decelerations in antenatal CTG must be evaluated as a symptom of high fetal risk.

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The possibility to diagnose slight masked malformations increased in the last years both by improving technical ultrasonic equipment and progressive personal experience of the examiners. With regard to time and technique it is impossible to treat fully all possibilities of ultrasonics, because the time-patient-ratio would be to enormous, the malformation rate would be to low and not any malformation is followed by an obstetric consequence. Additionally most of the malformations can be diagnosed or excluded only in determined gestational weeks. Therefore we present as a compromise a checklist which guarantees as well as examination of 8-10 patients per hour as a detection of the most important malformations. Abnormalities like double monsters, hydrocephalus, anencephaly, microcephalus, posterior and anterior tumors, thoracal and abdominal cysts, micromely and amely should not escape. Smaller abdominal cysts caused by filled intestines are very frequent. Controlling these findings, like looking for defects of extremities e.g. dub-feet is impossible, but not necessary, too, because of the lacking antenatal consequences.

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Ultrasonic findings in a women's clinic are very heterogeneous. In their totality they will be unmethodical very quick. Therefore we decided to organize four separate card indexes: 1. gynaecologic findings; 2. breast diagnostics; 3. supervision of pregnancy and look for fetal malformations; 4. single findings in pregnancy.--Each card index does not exceed 2000 to 3000 patients by appropriate actualization. A filing card for supervision of pregnancy and systemic detection of fetal malformations is created.

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From sonographic measurements, normal curves for the fetal growth of extremity bones (humerus, ulna, radius, femur, tibia) were established. They are based on 40 measurements for each bone weekly between the 17th and 41st gestational week. Tabs. II and III summarize the data. Figs. 4-8 furnish the smoothened normal curves for 10th, 50th and 90th percentile. Values for the 14-16 and the 42nd week were extrapolated from the results and the course of the curves. A comparison of sonographic measurements with findings from dissected stillborn fetuses (Tab. I) demonstrated an accuracy of the sonographic measurements of +/- 2 mm. We established that the radius is significantly shorter than the ulna (Figs. 1 and 2) whereas tibia and fibula are of identical length (Fig. 3). The growth rate of the femur throughout pregnancy is greater than that of the other bones. The mathematical correlation between pregnancy duration and length of bones is best described by polynomial formulas (Tabs. IV and V), because the growth rate declines from 4 mm per week in early mid-trimester to 1 mm per week toward the end of the third trimester. A comparison with other published data shows the values in the current study to be within the range of variability of these publications. Sonographic measurements of extremity bones are suitable for determining gestational age.

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We analyzed 5 cases of uterine rupture observed in our clinic in the last 8 years (= 0.36 per 1000 deliveries) because spontaneously appearing ruptures of a normal uterus often have symptoms which may mislead our efforts like amniotic fluid infusion or clotting defects. All our 5 cases were multiparous women, in 4 cases oxytocic drugs were applied and only in one case there was a histologic damage of the myometrium. In no case classic sharp pain and cessation of contractions could be observed, only in one case painful abdomen and tenderness of the uterus. On the other hand shock could be seen in every case, vaginal bleeding in 4 cases and alteration of fetal heart frequency in 3 of 4 cases with primary living fetus. The different symptoms may occur as to time in a variable sequence. Therefore the right diagnosis is made often very late. In accordance with the literature a digital control of the uterine cavity is proposed in every case of an acute event during childbirth, especially evidence of shock, also if another diagnosis than rupture of the uterus is more probable.

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Extrauterine pregnancies scarcely achieve an advanced developmental stage and were rarely diagnosed preoperatively. Even the ultrasonic B scanning don't eliminate the difficulties in recognising the ectopic pregnancy. We can demonstrate this by means of 3 case. In one of them, a case of full term abdominal pregnancy with healthy fetus, we could diagnose this preoperatively.

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Several authors have recommended [1, 3, 8, 12] that the fetus be mechanically stimulated if the abdominal pregnancy CTG shows no accelerations. One expects the fetus to show a motor response to mechanical stimulation. Fetal movements expressed as accelerations in the abdominal CTG are considered to reflect "arousal" of the previously asleep fetus and are thought to be normal. An absence of such a response in considered by some as a sign of pathological fetal changes [3, 8, 12]. Others, however, have found that the normal non-stressed fetus need not change its sleep-arousal state after mechanical stimulation [5, 14]. An attempt was made to clarify this in the present work. We studied the CTG recordings and the ultrasound pictures in 63 pregnancies in a total of 83 cases for an average of 56 minutes. Fetal movements were marked by pressing a lever on the labor pressure chart. The fetus was mechanically stimulated by shaking its head manually for 5 seconds. Control recordings were also made, when the fetus was not so stimulated. The following results were obtained: With a normal CTG (reactive nonstress test, FISCHER score 8-10 points) Mechanical stimulation led to no changes in 87% of NREM sleep and in 93.9% of REM sleep. A change to a more active state (REM sleep + arousal) due to stimulation was found in 13% of NREM sleep, which is significantly more frequent than the 2.9% found when no stimulation occurred. A change from REM sleep to arousal was found in 6.1%, not significantly different from 1.8% found without stimulation. Short-lasting reactions to mechanical stimulation included movements, acceleration of fetal heart rate and dip 0. These reactions were equally frequent in REM and NREM sleep, i.e. 75% and 68.5% respectively. These reactions occurred by chance less frequently, in 14.5% of cases in REM and in 3% of cases in NREM sleep (Tab. II). The occurrence is significantly higher in REM than in NREM sleep. In a pathological CTG (Fischer score 7 points or less) our technique does not permit us to distinguish the different sleep-arousal states. Only the short-lasting response to mechanical stimulation of the fetus was hence evaluated. Mechanical stimulation resulted in a fetal response in 19% with decelerations of variable expression (Figs. 1a, 1b, 2, 3) similar to the variable decelerations observed during labor. These decelerations occurred only together with other signs of fetal distress in the CTG.(ABSTRACT TRUNCATED AT 400 WORDS)

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In fetal anomalies we can follow the course by repeated ultrasound examinations and so decide the therapy. For collection of experience all rare cases should be published. Beginning in 25th gestational week we observed a triplet pregnancy, in which one fetus was a severe malformed acardius. Fetus I has been separated with an own placenta and was developing well. Fetus II had to supply the acardius with circulating blood and therefore it retarded beginning in the 28th week. Fetus III was the malformed acardius. Beginning in the 28th week it began to grow rapidly. Caused by this fact and an increasing hydramnios pregnancy was terminated by spontaneous delivery in 31th week. The normal fetus I (1320 g) survived. The retarded fetus II (830 g) died postnataly. The diagnosis of an acardius monster (triplet III, 2090 g) was confirmed by autopsy. Good collaboration with the pathologist is of great value, because he can show the clinician the degree of precision of his antenatal diagnosis.

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During hypoxia there is an increased formation of hypoxanthine from the consumption of ATP; simultaneously the oxidation into uric acid is decreased. The purpose of this study was to determine possible correlations between hypoxanthine concentrations in the amniotic fluid and states of fetal hypoxia. We obtained 83 amniotic fluid samples from 68 patients during pregnancy or delivery. Hypoxanthine was assayed fluorimetrically according to GARDINER [4]. In the course of pregnancy, hypoxanthine levels in the amniotic fluid rise slightly. A marked increase occurs during delivery (without labor mean = 3.4 +/- 0.9 mumol/l, with labor mean = 7.0 +/- 5.4 mumol/l, p less than 0.02). There is no significant difference in the levels obtained from the first and second stages of labor. In intrauterine fetal death (Fig. 1) and in depressed newborns (Tab. I) there were increased hypoxanthine levels in the amniotic fluid, this was not seen in other complications of pregnancy. Independently from the fetal state increased hypoxanthine concentrations may occur in the amniotic fluid evidently as a consequence of labor activity. Thus the determination of hypoxanthine levels in the amniotic fluid cannot be used for the diagnosis of fetal hypoxia.

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A 29 year old gravida 3, para 1 was referred in the 32nd pregnancy week for ultrasonography when a twin pregnancy was suspected. We found a fetal duplication with two heads in parallel position, biparietal diameter 81 mm (Fig. 1), a joint thoracic cavity measuring 86 x 92 mm (Fig. 2), reduced amniotic liquid and decreased spontaneous movements. The pelvic radiogram confirmed our suspension of an anterior duplication anomaly and showed only two arms and two legs for both fetuses but brought no additional information. The amniofetography failed. The contrast media ended up in the joint peritoneal cavity of the fetuses (Fig. 3). Delivery was in the 36th week by Cesarean section. The weight of the conjoint twins (Fig. 4) was 3210 grams, length 43 cm, and head circumference of each was 32 cm. Both fetuses showed independent respiratory movements and both briefly cried. Death occurred after 12 hours. Fig. 5 shows remnants of a scapula and Fig. 6 demonstrates a stump like leg remanent. Our prenatal diagnosis of an anterior duplication was confirmed by the autopsy. After a prenatal diagnosis of a duplication anomaly we recommend Cesarean section in term pregnancies. Considerations when deciding on the management of the pregnancy should include survival chances following possible surgical separation. If the diagnosis if made before the 24th week termination of the pregnancy might be considered.

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Analyses were applied by the authors to 278 samples of maternal serum, 106 amniotic fluid samples, and 81 samples of umbilical vein serum, since no complex study into alpha-amylase activity in the context of pregnancy and labour had been found in the literature. Rise in amylase activity in amniotic fluid, depending on length of gestation, had been one of the points made elsewhere in a publication and was confirmed by the authors' experiments (17th to 22nd weeks of pregnancy: means = 1,8 +/- 0,8 AU/1; 37th to 41st weeks of pregnancy: means = 10,3 +/- 6,0 AU/1). Somewhat relaxed relationships between amylase activity in maternal serum, on the one hand, and age of the pregnant woman as well as activity in amniotic fluid, on the other, were found to be without any clinical relevance. Additional correlations were not detected, not even those with complications in the course of pregnancy and in labour. Global measurement of amylase activity is of no importance to obstetric diagnosis.

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Large epidemiological studies with over 5000 cases have the advantage of providing sufficient case numbers for the statistical evaluation of sub-groups. They are associated with a higher error rate in data collection and the influence of differences in judgment on part of the collaborators. In order to quantitatively assess these problems two studies were performed with data material from the research project "Perinatology" in the German Democratic Republic. This project investigated questions of epidemiology of newborns at risk in the years 1970 to 1972 in eight medical institutions with a total of 6780 cases. 1) By comparing the original hospital records of 310 cases the errors for 33 criteria in the computer printout were determined. 2) For 7 subjective clinical criteria in the newborn the difference in opinions was demonstrated by determining the frequency of abnormal findings in the various institutions.

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Evaluation of more than 1500 cases has shown that real foetal weight can be calculated on the basis of mean thorax diameter, if linear ultrasonic measures are used. Addition of more parameters will render calculation more sophisticated and complex, though gain in accuracy will be unimportant. Accuracy depends not only on biological variation but even more on precise measurement by the examiner. An aid for more convenient calculation is described.

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