Psychosomatische Aspekte in der Urogynäkologie

A case report of a 46-year-old female patient with functional urinary incontinence serves to illustrate the influence of psychodynamic factors on the etiopathogenesis of this urogynecological disorder. The problems involved in the staging system devised by the International Continence Society to distinguish between stress incontinence and urge incontinence are discussed from a psychosomatic point of view and in addition differential diagnostic aspects (enuresis and female ejaculation) are considered. Furthermore, the clinical picture and pathogenesis of other psychosomatic urogynecological diseases are described, namely, in the order of decreasing involvement of psychosomatic causes: irritable bladder, chronic bladder inflammation, urinary retention, and interstitial cystitis. In conclusion, possible therapeutic measures are presented.     

Gesundheits?konomische Aspekte und finanzielle Probleme in der Pr?natalmedizin und Geburtshilfe

The diagnosis-related groups (DRG) system of financing healthcare in Germany will lead to disparities in patient care and medical services rendered in prenatal and obstetric medicine. The high costs related to the treatment of high-risk pregnancies in the level I clinics indicate that there are significant shortcomings in cost reimbursement and currently these issues are inadequately addressed by the DRG system. The high costs arise from the more specialized care provided by level I centers, which treat patients with more complicated conditions and require longer hours of hospital staff. The lack of a distinction between the requirements of different intrauterine treatment options in prenatal medicine leads to underfunding such that, for example, the material costs of some interventions are not covered by the DRG pricing and reimbursement system. Resulting from the financial deficits in the level I centers and facilities of specialized medicine is a major deterioration of their organization and staffing, which has significant implications on the training and continued education of young doctors. This system, which to the present time has been an inadequate means of covering the costs of hospital outpatient and inpatient services, raises concerns of insufficient incentives for the training and continued education of young physicians. This may result in a decrease in quality of care in the field of obstetric and prenatal medicine.     

Seltene Befunde und Diagnosen der Pr?natalmedizin

Rare constellations and diseases in prenatal medicine are especially challenging for the specialists who take care of the patient. Showing rare congenital malformations like transposition of the great arteries, gastroschisis, and agenesis of the corpus callosum with interhemispheric cysts we describe the up-to-date management from diagnosis until postpartum treatment as well as the important role of intense prenatal counseling in institutions like the interdisciplinary Fetal Board of the Department of Obstetrics and Gynecology in Heidelberg. Every congenital malformation is exemplified by a clinical case presentation.     

Neues und praktisch Relevantes der gynäkologischen Endokrinologie,Reproduktionsmedizin und Pränatalmedizin – Teil 1

Gynäkologische Endokrinologie -     

Neues und praktisch Relevantes der gynäkologischen Endokrinologie,Reproduktionsmedizin und Pränatalmedizin – Teil 2

Gynäkologische Endokrinologie -     

Zukunft der Pränataldiagnostik

The average maternal age is still increasing and so is the significance of aneuploidy. The greatest milestone in the past and the screening test of the future is testing for aneuploidy using cell-free DNA fragments in maternal blood. This has a particularly high accuracy for trisomy 21. Diagnosis of fetal structural abnormalities in the second trimester, especially concerning the central nervous system, is enhanced by fetal magnetic resonance imaging. Prenatal interventions for fetal therapy improve the prognosis in twin-twin transfusion syndrome and in certain forms of diaphragmatic hernia and spina bifida. Recently it was possible for the first time to show a significant effect of prophylactic measures in reducing the risk for placental insufficiency and preterm labor.     

Prävention der postmenopausalen Osteoporose

Background

Osteoporosis is one of the most frequent and cost-intensive diseases. In women aged >?50 years and in postmenopausal women of all ages suffering from malnutrition or having an insufficient exposition to sunlight leading to low serum vitamin D levels, an adequate calcium intake, a sufficiently high vitamin D supplementation increasing with age and a sufficient protein intake (minimally 1 g/kg body weight protein per day) are essential for primary prevention of osteoporotic fractures.

Vitamin D supplementation

Vitamin D prevents fractures through two mechanisms. Vitamin D has a positive effect on bone metabolism, and vitamin D increases muscle strength, resulting in a decreased risk of falls. Some sources recommend a vitamin D intake of 800–1000 IU/day. However, others suggest 1500–2000 IU/day vitamin D for adults aged >?19 years. In the elderly having a high fracture risk, up to 2000 IU vitamin D/day is recommended.

Calcium supplements

The preventive effect of vitamin D implies a sufficient, but not excessive daily calcium intake. To prevent osteoporotic fractures, a preferentially alimentary calcium supplementation of 1000–1200 mg/day calcium is recommended. The efficiency and safety of an adequate calcium and vitamin D supplementation has been proven. In particular, in studies observing the calcium intake limits defined above, no increased cardiovascular risk was observed. Uncontrolled additional calcium intake is not indicated.

General measures

General prevention includes regular physical exercise (including strength training) combined with equilibrium training to prevent falls. Risk factors such as cigarette smoking, excessive alcohol intake and—if possible—the intake of drugs having a negative impact on bone metabolism (e.g., glucocorticoids, antiepileptics, suppressive thyroid hormone therapy) should be avoided. General preventive measures can be recommended without specific diagnostic investigations. Each therapeutic decision has to be preceded by an appropriate investigation for osteoporosis and prevalent fractures     

Molekulare Mechanismen der Präeklampsie

Zusammenfassung Die normale Schwangerschaft geht mit einer Reduktion des totalen mütterlichen Gefäßwiderstands und des arteriellen Blutdrucks einher. Diese Veränderungen sind u. a. durch eine verminderte Ansprechbarkeit der Gefäße auf vasokonstriktorische Reize und auf eine vermehrte, endothelabhängige Vasodilatation zurückzuführen. Diese hämodynamisch günstige Kreislaufumstellung findet bei Schwangeren mit Präeklampsie nicht statt. Dafür kommt es bei einer Präeklampsie zu einem starken Anstieg des allgemeinen Gefäßwiderstands und des Blutdruckes.Obgleich die Präeklampsie immer noch an der Spitze der Ursachen für die Muttersterblichkeit steht und ein bedeutender Risikofaktor für die perinatale Mortalität und Morbidität ist, sind die zellulären und vaskulären Mechanismen der Präeklampsie nicht vollständig aufgeklärt. Klinische und experimentelle Daten belegen, dass eine Reduktion der uteroplazentaren Perfusion mit konsekutiver plazentarer Ischämie/Hypoxämie die Freisetzung verschiedener plazentarer Faktoren auslösen kann. Die Freisetzung dieser Faktoren wiederum bewirkt eine kaskadenartige Reaktion, an deren Ende die Dysfunktion des Endotheliums und der glatten Muskulatur der Gefäßwände mit Erhöhung des Gefäßwiderstands und des Blutdruckes stehen könnte.Die Reduktion der uteroplazentaren Perfusion und die plazentare Ischämie könnten durch eine inadäquate Trophoblastinvasion in die myometranen Segmente der uterinen Spiralarterien erklärt werden. Die plazentare Hypoxämie/Ischämie könnte dann zur Freisetzung verschiedener biologisch aktiver Substanzen wie z. B. Zytokine und zur endothelialen Dysfunktion mit verminderter Produktion/Freisetzung von vasodilatatorischen Substanzen wie z. B. nitric oxide, Prostazyklinen oder endothelium-derived hyperpolarizing factor führen.     

Prävention der postmenopausalen Osteoporose

The international recommendations for pharmacological fracture prevention in postmenopausal osteoporosis have changed in 2013. A distinction must now be made between patients who are still within the “window of opportunity” for estrogen administration and those who have already passed this limit. Following the new international recommendations substances acting through the estrogen receptor are the treatment of first choice for fracture prevention in perimenopausal or early postmenopausal women. For women within the “window of opportunity” the menopausal hormone therapy (MHT) including tibolone is the first choice. For subjects at high risk without vasomotor symptoms, selective estrogen receptor modulators (SERMs) are efficient in the prevention of vertebral fractures, particularly in women with an increased breast cancer risk. Non-hormonal drugs are recommended in the presence of contraindications or rejection of MHT or SERMs; however, the current German S3 guidelines established in 2009 still consider MHT as a therapy of second choice. As before, the new recommendations maintain that MHT should not be started in the later postmenopause beyond the “window of opportunity”. For women in the later postmenopause non-hormonal drugs, such as bisphosphonates (long-term effect on bone), denosumab (effect reversible) should be used. In cases of severe osteoporosis strontium ranelate may be prescribed (not approved in Switzerland). In patients of any age suffering from severe osteoporosis, the analogues of parathormone may be used by specialists. For fracture prevention only substances should be used the efficacy of which has been established by an evidence level of grade A. Not all drugs approved for fracture prevention simultaneously reduce the risks for vertebral, non-vertebral and hip fractures.     

Biomarker in der Pränataldiagnostik

Currently, personalized medicine relies largely on biomarkers. In prenatal diagnostics a variety of biomarkers can help to improve detection of fetal aneuploidy as well as prediction of preeclampsia. While clear cut algorithms exist for aneuploidy screening, prospective validation of biomarkers in preeclampsia diagnostics is still underway. The combination of maternal age, thickness of fetal nuchal translucency measured via ultrasound as well as maternal serum levels of pregnancy-associated plasma protein A (PAPP-A) and beta human chorionic gonadotropin (beta HCG) can detect up to 90 % of trisomies with a false positive rate of 3%. Prospectively, the automated measurement of cell-free fetal DNA (cffDNA) will bring a further reduction of invasive diagnostics for trisomy 21. The measurement of soluble fms-like tyrosine kinase 1 (sFlt-1) and placental growth factor (PlGF) can detect early onset preeclampsia with a sensitivity of 89 % and a specificity of 97 %. The measurement of the sFlt-1/PlGF ratio can accurately predict the onset of preeclampsia-associated adverse outcomes. The optimal timing for early recognition of preeclampsia with the help of angiogenic factors or other biomarkers is currently under investigation.     

Präinvasive Erkrankungen der Vulva

Vulvar intraepithelial neoplasia (VIN) and vulvar Paget’s disease are preinvasive diseases of the vulva that differ in some aspects and overlap in others. With the same symptomatology, the clinical picture may be very similar, too. The etiology is not quite clear for either disease: Only the so-called usual type of VIN seems to be induced by persistent HPV infection. Local excision is the most prevalent form of therapy, along with laser vaporization for VIN. There are some experimental treatments of various effectiveness and tolerance. Both VIN and vulvar Paget’s disease have a strong tendency to recur; therefore, competent follow-up is necessary.     

Aktuelle Aspekte zur Anästhesie in der Geburtshilfe

Die Besonderheit aller Ma?nahmen in der Geburtshilfe liegt in der Tatsache, dass es um das Wohl von – mindestens – zwei Menschen geht. In den vergangenen Jahren gelang es durch eine Weiterentwicklung von An?sthetika und An?sthesieverfahren, das peripartale Risiko für Mutter und Kind deutlich zu senken. Aktuelle Aspekte zu diesem Thema standen im Mittelpunkt eines Symposiums, das am 24. M?rz 2001 im Universit?tsklinikum rechts der Isar in stattfand.     

Prävention in der ganzheitlichen Frauengesundheit

Prevention in obstetrics and gynecology has a long tradition. It covers a broad range of areas, including cancer screening, contraception, preconception counseling, intrauterine programming, antenatal care, vaccinations, mammography screening, and hormone replacement therapy during menopause. Although many preventive services are already successful due to the engagement of physicians, the German Society of Obstetrics and Gynecology and the Professional Association of Gynecologists must continue to help women by supporting the development of new preventive services and their implementation by policy makers and health insurance companies.     

Prävention der Frühgeburt

Background

In recent years an improvement for the prevention of preterm birth has been achieved in evidence-based strategies by the use of progesterone with a proven prolongation of pregnancy and there is also an optimistic perspective for the use of vaginal pessaries; however, both interventions are only valid for singleton pregnancies. The most effective prevention of preterm birth was by reduction of multiple pregnancies in assisted reproductive techniques as well as the avoidance of elective deliveries in late preterm birth in 34 (0/7) to 36 (6/7) weeks of gestation.

Results

Prolongation of pregnancy by progesterone is achieved by the ability to modulate inflammatory mechanisms in cervical and myometrial tissue. Several studies showed a prolongation of pregnancy as well as improvement of perinatal outcome both in pregnancies after previous preterm births as well as in pregnancies with shortened cervix as assessed by sonography.

Discussion

The results on the indications for using cerclage for prevention of preterm birth are controversial. It is unclear where a cut-off for cervical length should be fixed for performing a cerclage to achieve a benefit. There are currently no relevant studies comparing the two methods of progesterone administration and cervical cerclage and no investigations on the combination of both methods. There is increasing discussion on whether routine sonographic assessment of cervical length should be carried out in all pregnancies including those women without previous preterm births.

Conclusion

Promising results have been obtained in a study assessing prolongation of pregnancy by prophylactic screening and treating vaginal infections; however, a meta-analysis failed to show any improvement in pregnancy duration. For more than half a century vaginal pessaries have been used to treat cervical incompetence. A recently conducted well-designed study using the Arabin pessary showed promising results both in prolonging pregnancy and improving perinatal outcome. The results of upcoming studies should be awaited before guideline recommendations for pessary use can be given.     

Urheber- und gesellschaftsrechtliche Aspekte der Fälschung von Forschungsdaten

Auf diese Art von Publicity h?tten sie gerne verzichtet, die beiden Ulmer Krebsforscher, als sie monatelang nahezu in allen Zeitungen mit F?lschungsvorwürfen bezüglich ihrer wissenschaftlichen Ver?ffentlichungen konfrontiert wurden. Je l?nger die Vorwürfe im Raume standen und je mehr Licht in die Vorg?nge kam, desto differenzierter wurden auch die rechtlichen Beurteilungen der Vorg?nge. Glücklicherweise sind v. a. bisher weder die Deutsche Forschungsgemeinschaft (DFG) in ihren Empfehlungen noch die ebenfalls betroffene Max-Planck-Gesellschaft der Versuchung erlegen, einen aufwendigen Kontrollapparat zur Vermeidung von F?lschungen nach dem Beispiel des amerikanischen “Office of Research Integrity” (ORI) zu fordern. Immerhin fordert die DFG die Forschungseinrichtungen, also in erster Linie die Universit?ten, als ihre F?rderungsempf?nger dazu auf, dafür zu sorgen, dass sie Grunds?tze zur Sicherung guter wissenschaftlicher Praxis verabschieden und diese in die Praxis umsetzen, anderenfalls werde es ab 2001 keine F?rderung durch die DFG mehr geben. Dieser vernünftigen Forderung werden sich die Universit?ten wohl nicht versagen k?nnen.