Gynäkologie und Geburtshilfe – gestern, heute, morgen

Ohne ZusammenfassungVortrag im Klinikum Krefeld anlässlich der Verabschiedung von Prof. Dr. Jörg Baltzer, 18.10.2006.

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Medico-legal issues in obstetric anesthesia: what does an obstetrician need to know?

Background  Obstetric anesthesia has become a recognized subspecialty of anesthesiology and an integral part of practice of most anesthesiologists. Perhaps no other subspecialty of anesthesiology provides more personal gratification and clinical challenges than the practice of obstetric anesthesia. However, in addition to clinical challenges obstetric anesthesia is laden with medico-legal liability. Objective  This review article attempts to highlight the influence of the current medico-legal climate on the practice of obstetric anesthesia. Methods  All articles relevant to the subject of this investigation were retrieved from a Medline search. Results  Obstetric anesthesiologists are frequently named (besides obstetricians) in claims involving bad neonatal outcomes. Obstetric anesthesia is also the most common subspecialty of practice to be ceased due to medico-legal concerns. Conclusions  Good perioperative evaluation of all patients, detailed review of patient’s medical records, and constant vigilance can decrease the incidence of complications and subsequently medico-legal issues.

Current evidence in the management of previous caesarean section: clinical review

The safety of women undergoing childbirth with prior caesarean delivery is a major public health concern. Most of the earlier studies focused on the success rate of vaginal birth after caesarean section; later focus shifted to maternal and neonatal safety, and presently, each factor that would influence the outcome of trial of labour is being considered on both the success and the safety of vaginal birth following caesarean delivery. The contribution of induction of labour to uterine rupture is not entirely clear. Although large multi-center randomised trials comparing planned elective repeat caesarean delivery vs vaginal delivery following prior caesarean delivery are required for conclusive evidence; current evidence suggests that, in properly selected women, vaginal birth can be safely achieved if adequate facilities to monitor the foetus and immediate caesarean can be performed. Unbiased evidence-based information should be given to patients in making decisions about mode of delivery based on individual characteristics. The purpose of this review is to understand each factor that would influence the success and safety of vaginal birth after caesarean delivery.

Dokumentation

Zusammenfassung  Alle Maßnahmen zur Behandlung von Patienten sind zu dokumentieren. Einerseits handelt es sich dabei um vorwiegend organisatorische Maßnahmen, für die der Krankenhausträger und der von ihm beauftragte Chefarzt oder Belegarzt verantwortlich sind und andererseits um die ärztlichen Maßnahmen am Patienten selbst. Zu dokumentieren ist daher die Erfüllung

Verordnung von Kontrazeptiva an Minderjährige

Ohne Zusammenfassung

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Bestimmungen des SGB V zu Qualitätssicherung/-management und ärztlicher Fortbildung nach den Änderungen durch das GMG

Ohne Zusammenfassung

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Embryonenauslese und „Dreierregel“

Ohne Zusammenfassung

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Alexandre Couvelaire und die Abruptio placentae

Ohne Zusammenfassung

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The role of clinical governance in CPD

The concept of clinical governance and the philosophy of quality-centred care are being implemented throughout the National Health Service in England. Clinical governance integrates the behaviours, systems, processes and mechanisms necessary to ensure high quality and safe care. It also demands high standards, rigorous assessment and meaningful staff and patient engagement. Continuing Professional Development (CPD) is a principal component of the clinical governance quality framework. Appropriately skilled and competent obstetricians and gynaecologists, working in integrated, multidisciplinary, teams are fundamental to the delivery of safe and high quality care centred on the needs of women, their families and communities. Clinical governance and CPD are a means to the same end: quality assuring patient safety and care.

Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) affects between 2% and 5% of pregnant women. Data show that increasing levels of plasma glucose are associated with birth weight above the 90th percentile, cord blood serum C-peptide level above the 90th percentile, and, to a lesser degree, primary cesarean deliveries and neonatal hypoglycemia. Risk factors for GDM include history of macrosomia, strong family history of diabetes, and obesity. Screening protocol for GDM is controversial; some recommend a universal approach, whereas others exempt low-risk patients. The cornerstone of management is glycemic control. Quality nutritional intake is essential. Patients with GDM who cannot control their glucose levels with diet alone will require insulin. There is no consensus as to when to initiate insulin therapy, but more conservative guidelines are in place to help minimize macrosomia and its associated risks to the infant. It is generally recommended that pregnancies complicated by GDM do not go beyond term.Key words: Gestational diabetes mellitus, Plasma glucose, Hyperglycemia, Glycemic control, InsulinPregnancy confers a state of insulin resistance and hyperinsulinemia that may predispose some women to develop diabetes. Gestational diabetes mellitus (GDM) occurs when a woman’s pancreatic function is not sufficient to overcome the diabetogenic environment of pregnancy. GDM is defined as glucose intolerance that was not present or recognized prior to pregnancy.¹ In the United States, prevalence rates for GDM are higher for African American, Hispanic, American Indian, and Asian women than for white women. The prevalence of GDM in the United States varies from 1.4% to 14%. Most commonly, GDM affects between 2% and 5% of pregnant women. The amount of GDM varies in direct proportion to the prevalence of type II diabetes.²There are 2 different methods of classifying diabetes in pregnancy. The first is the White classification (Table 1),³ and the second is the American Diabetes Association (ADA) classification (Table 2).⁴

Table 1

White Classification

The Impact of Maternal Obesity on Maternal and Fetal Health

The increasing rate of maternal obesity provides a major challenge to obstetric practice. Maternal obesity can result in negative outcomes for both women and fetuses. The maternal risks during pregnancy include gestational diabetes and preeclampsia. The fetus is at risk for stillbirth and congenital anomalies. Obesity in pregnancy can also affect health later in life for both mother and child. For women, these risks include heart disease and hypertension. Children have a risk of future obesity and heart disease. Women and their offspring are at increased risk for diabetes. Obstetrician-gynecologists are well positioned to prevent and treat this epidemic.Key words: Obesity, Maternal health, Diabetes, Fetal health, Birth outcomesThe worldwide prevalence of obesity has increased substantially over the past few decades. Economic, technologic, and lifestyle changes have created an abundance of cheap, high-calorie food coupled with decreased required physical activity. We are eating more and moving less. There is evidence for metabolic dysregulation among obese individuals that has been linked with a number of possible environmental factors, including contaminants from modern industry. Obesity is a significant public health concern and is likely to remain so for the foreseeable future. Maternal obesity increases the risk of a number of pregnancy complications, including preeclampsia, gestational diabetes mellitus (GDM), and cesarean delivery (Table 1).¹ Excessive weight gain during pregnancy and postpartum retention of pregnancy weight gain are significant risk factors for later obesity in women.² Additionally, maternal health can have a significant impact on the in utero environment and, thus, on fetal development and the health of the child later in life (Table 1).³

Table 1

Obstetric Complications in Obese Pregnant Women

Listeriosis in Pregnancy: Diagnosis, Treatment, and Prevention

Listeriosis is a rare disease that causes mild maternal illness, but can be devastating to the fetus. Listeria’s rare microbiologic features make it a difficult infection to diagnose and treat: it is an intracellular organism that hides within host cells. Because of the potentially severe consequences, it is important that obstetricians are familiar with the diagnosis, treatment, and prevention of listerial infection.Key words: Listeriosis, Intracellular transmission, Fetal listerial infection, Neonatal listerial infectionListeriosis is a rare infection, but is about 20 times more common in pregnant women than in the general population.¹ Pregnant women account for 27% of all listerial infections,² which can cause mild illness in mothers, but can be devastating to the fetus, in some cases leading to severe disease or fetal death.³ Pregnant women may be able to reduce risk of listerial infection by following dietary guidelines recommended by the Centers for Disease Control and Prevention (CDC) (see Table 3). National food agencies, such as the United States Department of Agriculture (USDA) and the Food and Drug Administration (FDA) have also lowered risk of listerial infection by monitoring potential sources of contamination.⁴ Because of the potentially severe consequences, it is important that practicing obstetricians are familiar with the diagnosis, treatment, and prevention of listerial infection.

Table 3

Centers for Disease Control and Prevention Recommendations on Listeriosis Prevention

Der Anfang menschlichen Lebens

Zusammenfassung  In diesem Beitrag soll versucht werden, einen Überblick über die verschiedenen Positionen zu verschaffen, welche in der europäischen Diskussion von Ethik und Recht zur Frage des Lebensbeginns vertreten werden. Der Fokus liegt dabei auf denjenigen Regelungen, die europaweite Geltung haben oder zumindest in einem supranationalen Rahmen stehen. Normen des nationalen Rechtes finden nur auszugsweise Beachtung. Soweit es die ethischen Positionen betrifft, werden lediglich grobe Argumentationslinien in Form von Schutzkonzepten bezüglich des menschlichen Embryos vorgestellt. Absicht des Beitrages ist es zudem zu zeigen, wie der rechtliche Diskurs mit dem ethischen zusammenhängt. Dabei wird die Position vertreten, dass eine Betrachtung der Rechtsnorm als "geronnene Ethik" der Komplexität der Interaktion von Recht und Ethik zumindest dann nicht gerecht werden kann, wenn dies nur auf den Prozess der Rechtsentstehung bezogen wird. Vielmehr fließen ethische Positionen auch in der Rechtsanwendung mit ein, sodass sich ein komplexes Wechselspiel zwischen ethischer und juristischer Reflexion ergibt.

Ärztliche Fortbildung

Zusammenfassung  Fortbildung ist eine lebensbegleitende Aufgabe der ärztlichen Tätigkeit. Für sie ist neben dem Arzt selbst—im Klinikbetrieb—der Abteilungsleiter verantwortlich. Sie ist zu organisieren und zu strukturieren und sollte in unserem Fachgebiet auch die Hebammen einschließen. Ziel ist dabei neben der notwendigen Entwicklung eines Teamgefühls im Kreißsaal, den Wissensstand der häufig sehr selbständig arbeitenden Hebamme auf einem modernen Kenntnisstand zu halten. Neben theoretischen Fortbildungsveranstaltungen sind sog. Trockenübungen erforderlich, um Trainingsdefizite bei selten vorkommenden Komplikationen auszugleichen.

Psychosoziale Interventionen bei Kinderwunsch*

Zusammenfassung  Viele staatliche, medizinische und kommunale Stellen empfehlen nachdrücklich psychologische Beratung für Kinderwunschpatienten. Zweck dieser Arbeit war es festzustellen, ob psychosoziale Interventionen das Befinden und die Schwangerschaftsraten verbessern, sowie zu bestimmen, welches die effektivsten Interventionen sind. Es wurde eine systematische Recherche aller Artikel durchgeführt, die 1. eine psychosoziale Intervention beschreiben und 2. ihre Wirkung auf mindestens 1 Ergebnismaß in einer Kinderwunschpopulation evaluieren. Das erste Kriterium erfüllen insgesamt 380 Studien, von denen aber nur 6,6% (n=25) unabhängige Evaluierungsstudien sind. Eine Analyse zeigte, dass psychosoziale Interventionen eher einen Abbau des negativen Affekts bewirkten als eine Veränderung des interpersonalen Funktionierens. Eine Auswirkung der psychosozialen Interventionen auf die Schwangerschaftsrate war nicht wahrscheinlich. Weiter wurde festgestellt, dass Gruppeninterventionen mit Schwerpunkt Wissensvermittlung und Trainieren von Fähigkeiten eine signifikant stärkere positive Veränderung herbeiführten als Beratungen, die sich auf emotionalen Ausdruck und Unterstützung oder die Diskussion von Gedanken und Gefühlen zum Thema Kinderwunsch konzentrierten. Männer und Frauen profitierten gleichermaßen von psychosozialen Interventionen. Die künftige Ausrichtung der Forschung im Bereich der Evaluierung psychosozialer Interventionen wird diskutiert.

Human Papillomavirus-Related Gynecologic Neoplasms: Screening and Prevention

The recent recognition of oncogenic human papillomavirus (HPV) as a key component of female lower genital tract malignancies has led to significant changes in many screening and prevention guidelines for cervical cancer, and, combined with the advent of vaccination, will likely have sweeping repercussions on the incidence of cervical, vulvar, and vaginal carcinoma. This article focuses on the specific principles of cancer screening and prevention with an emphasis on HPV-mediated disease.Key words: Human papillomavirus, Cervical cancer, Vulvar cancer, Vaginal cancer, Screening programsOver the past 25 years, the human papillomavirus (HPV) has been identified as the etiologic agent driving much of the neoplasia observed in the lower female reproductive tract (Table 1).^1–3 HPV has been implicated in close to 100% of cervical cancers,⁴ up to 70% of squamous cell carcinomas (SCCs)⁵ of the vulva, and 60% of SCCs of the vagina.⁶ Given the high worldwide prevalence of preinvasive and invasive disease, cervical cancer has been the historical focus of extensive screening programs that began with the Papanicolaou test, and now continue with the emergence of vaccines that target the oncogenic strains of HPV known to cause the majority of cervical dysplasia and carcinoma. This recent recognition of oncogenic HPV as a key component of female lower genital tract malignancies has led to significant changes in many screening and prevention guidelines for cervical cancer, and, combined with the advent of vaccination, will likely have sweeping repercussions on the incidence of cervical, vulvar, and vaginal carcinoma.

Table 1

Prevalence of HPV Infection by Lower Genital Tract Dysplasia and Malignancy