Levels of Circulating Cell-Free Serum DNA in Benign and Malignant Breast Lesions

Purposes of the study: We analyzed circulating cell-free DNA in the serum of patients with benign and malignant breast disease and in healthy individuals to determine its diagnostic value.

Basic procedures: Serum samples were obtained from 50 healthy individuals, 33 patients with malignant breast disease and 32 patients with benign breast disease. Circulatory DNA was extracted from serum samples. Cell-free DNA was quantified by real-time quantitative PCR for the glyceraldehyde-3-phosphate dehydrogenase (GAPDH) gene. Tissue samples from patients with malignant and benign breast lesions were histopathologically examined.

Main findings: The mean levels of circulating cell-free DNA in serum samples were 41,149 genome equivalents (GE)/mL in patients with malignant disease, 30,826 GE/mL in patients with benign disease, and 13,267 GE/mL in healthy individuals. Healthy individuals had significantly lower levels of cell-free DNA than patients with malignant or benign breast disease (p=0.001, p=0.031). No significant difference was observed between malignant and benign disease. There was a correlation between cell-free DNA levels and tumor size but not with other tumor characteristics.

Principal conclusion: Our results suggest that levels of circulating cell-free DNA in serum could have diagnostic value to discriminate between healthy individuals and patients with breast lesions but not between patients with malignant and benign breast lesions.

Parallel Assessment of Circulatory Cell-Free DNA by PCR and Nucleosomes by ELISA in Breast Tumors

Objectives

In order to assess the potential biomolecules for breast cancer, we analyzed in parallel the levels of cell-free glyceraldehyde 3-phosphate dehydrogenase (GAPDH) and cell-free nucleosomes in serum samples from patients with benign and malignant breast tumors. The levels of cell-free DNA obtained by quantitative PCR were compared with those obtained by enzyme-linked immunosorbent assay (ELISA).

Methods

Twenty-three patients with benign breast tumors, 27 patients with breast cancer, and 32 age-matched healthy women were recruited. The amounts of serum nucleosomes were analyzed by ELISA and the levels of cell-free GAPDH were measured by real-time quantitative PCR. The correlation between nucleosome and cell-free GAPDH levels was examined using the Spearman rank test.

Results

The levels of cell-free GAPDH were significantly higher in the serum samples of patients with benign and malignant breast tumors than in those of the control group (median 37,966 GE/mL, range 3,802–130,104 versus 11,770 GE/mL, range 2,198–73,522, p=0.035 and median 40,698 GE/mL, range 3,644–192,482 versus 11,770 GE/mL range 2,198–73,522, p=0.001). The concentration of cell-free GAPDH correlated significantly with the quantities of nucleosomes in serum samples (r=0.451, p=0.000). There was, however, no significant difference between healthy individuals and women with benign breast tumors or breast cancer in terms of nucleosomes determined by ELISA.

Conclusion

Our data suggest that the cell-free serum GAPDH DNA assayed by quantitative PCR is a better biomarker than nucleosomes assayed by ELISA in patients with breast tumors.

The Effect of the Elapsed Time Between Blood Draw and Processing on the Recovery of Fetal Cells From Maternal Blood

OBJECTIVE

To test the hypothesis that a delay in initial fetal cell enrichment processing of maternal blood samples (defined as the time between blood draw and the initial density gradient centrifugation step) compromises the ability to recover fetal cells, we performed a randomized comparison of immediate (within 4 hours of draw) versus delayed (between 18-24 hours of draw) processing.

METHODS

Four centers participated: two centers utilized flow cytometry (FLOW), and two centers utilized magnetic-activated cell sorting (MACS) techniques. Each center collected 34 samples. The outcome was the percentage of gamma positive (gamma(+)) cells for FLOW or the number of nucleated red blood cells (NRBCs) for MACS, found in the final enriched cell population. Both outcomes reflect cell properties that are potentially fetal in origin, thus making them representative of the ability to recover fetal cells.

RESULTS

Our results did not support our hypothesis that delay in processing compromises fetal cell recovery. Instead, in MACS processing, we observed an increase in recovered NRBCs when blood sample processing was delayed compared with immediate processing. There was no significant difference in gamma(+) cells with FLOW.

CONCLUSION

Time-related changes in the density of target cells, perhaps associated with their progress towards apoptosis during the delay period, may result in increased intact fetal cells with the study methods utilized.

Methylation profiles of 22 candidate genes in breast cancer using high-throughput MALDI-TOF mass array

Alterations of DNA methylation patterns have been suggested as biomarkers for diagnostics and therapy of cancers. Every novel discovery in the epigenetic landscape and every development of an improved approach for accurate analysis of the events may offer new opportunity for the management of patients. Using a novel high-throughput mass spectrometry on matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) silico-chips, we determined semiquantitative methylation changes of 22 candidate genes in breast cancer tissues. For the first time we analysed the methylation status of a total of 42 528 CpG dinucleotides on 22 genes in 96 different paraffin-embedded tissues (48 breast cancerous tissues and 48 paired normal tissues). A two-way hierarchical cluster analysis was used to classify methylation profiles. In this study, 10 hypermethylated genes (APC, BIN1, BMP6, BRCA1, CST6, ESRb, GSTP1, P16, P21 and TIMP3) were identified to distinguish between cancerous and normal tissues according to the extent of methylation. Individual assessment of the methylation status for each CpG dinucleotide indicated that cytosine hypermethylation in the cancerous tissue samples was mostly located near the consensus sequences of the transcription factor binding sites. These hypermethylated genes may serve as biomarkers for clinical molecular diagnosis and targeted treatments of patients with breast cancer.

Cord blood banks collect units with different HLA alleles and haplotypes to volunteer donor banks: a comparative report from Swiss Blood stem cells

Allogeneic haematopoietic SCT is a standard therapy for many patients with haematological diseases. A major aim of public umbilical cord blood (UCB) banking is to establish an inventory with a large HLA diversity. Few studies have compared HLA diversity between UCB banks and volunteer unrelated donor (VUD) registries and examined whether UCB banks indeed collect more units with rare alleles and haplotypes. This study compares HLA-A/B/DRB1 allele frequencies and inferred A/B/DRB1-haplotypes in 1602 UCB units and 3093 VUD from two centres in distinct recruitment areas in Switzerland. The results show that the frequencies of HLA-DRB1 alleles as well as of the HLA-A/B/DRB1 haplotypes differ between UCB and VUD. Ten DRB1 alleles occurred at a 2- to 12-fold higher relative frequency in UCB than in VUD and 27 rare alleles were identified in UCB. Out of these 27 alleles, 15 were absent in the entire VUD data set of the national registry. This difference in allele frequencies was found only by intermediate/high-resolution typing. Targeted recruitment of UCB units from non-Caucasian donors could further increase HLA allele and haplotype diversity of available donors. Intermediate or high-resolution DNA typing is essential to identify rare alleles or allele groups.

[Pregnant women's assessment and level of knowledge of prenatal counseling]

PURPOSE

Informed decision making and informed consent prior to any intervention are crucial in the ethically and psychologically complex field of prenatal diagnosis (PND). The aim of this study was to investigate whether and to what extent pregnant women understand the information provided by their physicians.

MATERIALS AND METHODS

Fifty pregnant women in the first trimester answered a structured questionnaire after their first visit between 7 to 10 weeks of gestation that routinely includes basic prenatal counseling. A special focus was put on information transfer, knowledge about and understanding of prenatal tests, as well as previous experiences with PND. The results were analyzed with regard to differences due to background, educational level and previous experiences with PND.

RESULTS

The maternal mean age was 31.1 years (SD 6.7). 38 patients (76 %) had at least one previous pregnancy and two thirds of them had experiences with PND. Their experience was mainly positive. About three quarters of the women stated that they had been informed about the test methods during the consultation and had understood the explanations. Uncertainty was reported in 12.2 % and 23.3 % of the women said they had further questions. The percentage of questions related to appropriate understanding that were answered correctly was only 44 % to 77.5 %. The percentage of correct answers was lower in women without experience with PND, with a lower educational level and born in countries outside the EU and Switzerland.

CONCLUSION

Pregnant women are relatively well informed about prenatal tests. Their actual knowledge of the meaning of the tests, however, seems to be incomplete. Especially in the case of immigrants and women without previous experience with PND, it is therefore doubtful whether the preconditions for an informed consent are met. Further research needs to focus on more helpful information and individually adapted counseling concepts for decision making in PND.

Metastatic involvement of the urinary tract in patients with advanced ovarian carcinoma: lessons from the autopsy for an interdisciplinary treatment approach

PURPOSE OF INVESTIGATION

Frequency and extent of metastases in urologic organs found at autopsy of ovarian carcinoma patients were evaluated.

METHODS

Autopsy reports from 170 patients who died of advanced ovarian carcinoma between 1975 and 2005 were studied. The distribution of abdominal metastatic sites with particular attention to the involvement of the urologic organs, and hydronephrosis was analyzed.

RESULTS

The distribution of metastatic sites was as follows: kidney (n = 6, 3.5%), urinary bladder (n = 38, 22.4%), and ureter (n = 20, 11.8%). In 36 patients, hydronephrosis was observed (21.2%); of these patients, 20 (55.6%) also had ureteral involvement. All patients with ureteral involvement had hydronephrosis.

CONCLUSION

Hydronephrosis in late stages of ovarian carcinoma, usually attributed to extrinsic compression of the ureter by an abdominal tumor, may also be explained by ureteral metastases. This fact must be considered in the clinical management of these patients, particularly in the restoration of luminal patency through an endoscopically placed internal ureteral stent.

The effect of labour and placental separation on the shedding of syncytiotrophoblast microparticles, cell-free DNA and mRNA in normal pregnancy and pre-eclampsia

The clinical features of the maternal syndrome of pre-eclampsia can be explained by generalised maternal endothelial cell dysfunction, which is a part of a more global maternal systemic inflammatory response. There is growing evidence that these effects are associated with the shedding of cellular debris, including syncytiotrophoblast microparticles (STBM), cell-free DNA and mRNA, from the surface of the placenta (syncytiotrophoblast) into the maternal circulation. The increased shedding of this debris seen in pre-eclampsia is believed to be caused by placental ischaemia, reperfusion and oxidative stress. This study was carried out to determine whether uterine contractions during labour and subsequent placental separation lead to an acute increase in the release of placental debris into the maternal circulation. To assess the effects of labour, samples were taken from 10 normal pregnant (NP) and 10 pre-eclamptic (PE) women at varied time points. Similarly to assess the effects of placental delivery, plasma samples were taken from 10 NP and 10 PE women undergoing elective caesarean section. There was a significant increase in the shedding of STBM in pre-eclampsia which was not seen in normal pregnancy and there was a small rise in STBM levels at placental separation in both normal pregnant and pre-eclamptic women undergoing caesarean section, but the differences were not significant. However, levels of placental cell-free corticotrophin releasing hormone mRNA were significantly increased in labour in both normal pregnancy and pre-eclampsia and were still high 24 h after delivery in the pre-eclamptic women. There was no significant increase in fetal or total DNA in labour, but the overall levels of total DNA (maternal and fetal) was increased in labour in pre-eclampsia compared to normal labour. The enhanced shedding of STBM and CRH mRNA in pre-eclampsia labour may have a role in cases of postpartum worsening of pre-eclampsia.

Target and reality of adjuvant endocrine therapy in postmenopausal patients with invasive breast cancer

Previous research evaluating the use of adjuvant endocrine therapy among postmenopausal breast cancer patients showed with 15–50% wide ranges of non-adherence rates. We evaluated this issue by analysing an unselected study group comprising of 325 postmenopausal women, diagnosed from 1997 to 2003 with hormonal receptor-positive invasive breast cancer. The different clinical situations that led to the discontinuation of adjuvant endocrine therapy were clearly defined and differentiated: non-adherence was not simply the act of stopping medication, but rather the manifestation of an intentional behaviour of the patient. Of the 287 patients who initiated endocrine therapy, 191 (66.6%) fully completed this treatment. Thirty-one patients (10.8%) showed non-adherence to therapy. Patients who had follow-up with a general practitioner, rather than in an oncologic unit, were more likely to be non-adherent (P=0.0088). Of 25 patients who changed medication due to therapy-related adverse effects, 20 (80%) patients fully completed the therapy after drug change. In adjuvant endocrine therapy, a lowering of the non-adherence rate to 10.8%, the lowest reported in the literature, is realistic when patients are cared for by a specialised oncologic unit focusing on the individual needs of the patients.

Genes controlling spread of breast cancer to lung "gang of 4"

Cancer-related mortality is caused in a large part by the metastasis of primary tumor. Each cancer has a particular way of spreading cancerous cells. Recently, genetic and pharmacological analysis identified the set of genes, such as epidermal growth factor receptor ligand epiregulin (EREG), cyclooxygenase-2 (COX2) and matrix metalloproteinases 1 and 2 (MMP-1 and MMP-2) that have been found to be associated with metastasis of breast cancer to lung. Inhibition of EGFR and COX2 could minimize lung metastasis of breast cancer in a clinical setting. In this review, we summarized the current knowledge on EREG, COX2, MMP-1 and MMP-2 in tumor development and metastasis.

[Prenatal diagnosis of diastematomyelia and tethered cord - a case report and review of the literature]

Diastematomyelia is a rare form of occult spinal dysraphism. It is characterized by longitudinal clefting and separating of the spinal cord by a bony or fibrous spur. Diastematomyelia is associated with other anomalies, i. e. spina bifida, scoliosis, visceral malformations or anomalies of the overlying skin. Prenatal diagnosis is based on fetal ultrasound supplemented by fetal MRI. We present a case of diastematomyelia and prenatal diagnosis in the 23rd gestational week using routine ultrasound scanning and confirmation by fetal MRI. After vaginal delivery at term, the child's development is normal. Prenatal diagnosis of isolated diastematomyelia is challenging. Management and prognosis are still controversial as only few cases have been reported. Affected fetuses might benefit from early diagnosis enabling surgical intervention before the development of neurological sequelae.

Quality management of nuchal translucency measurement in residents

PURPOSE

The measurement of the nuchal translucency (NT) in the 1st trimester is a sensitive, reliable method to assess the risk of specific fetal chromosomal and other defects. Training, however, is an issue not only among experienced sonographers, but especially for ObGyn residents, since all NT measurements in a true screening setting should fulfil the quality standards. The aim of this study was therefore the evaluation of the learning curve of residents and determination of the number of measurements necessary to achieve acceptable results.

MATERIALS AND METHODS

Between 30th June, 1997 and 8th August, 2003, we included 4450 subsequent pregnant women between 11+0 and 13+6 weeks of gestation referred for an NT scan and prenatal counselling (low and high risk patients) in the study. For analysis of the learning curve in residents, all NT scans performed either by the experienced sonographers only or by residents with less than 70 scans at the end of their training were excluded. As the main quality criterion, the percentage of cases above the median was used. To test for normal distribution of NT scans, the Kolmogorov-Smirnov test was used.

RESULTS

Each of 19 residents fulfilling these criteria performed 131 NT scans (73-242) on average. 13 of 19 residents ultimately met the quality criteria, but the majority of residents achieved good quality only after 100 scans, whereas 6 of 19 never did. Only after at least 50 NT scans, 50% of measurements were above the median, whereas before these 50 scans, NT was usually underestimated.

CONCLUSION

It became obvious that regular supervision and quality control is mandatory to provide exact NT measurements by residents. Based on our results, a minimum of 100 NT scans is recommended before diagnostic application, which is a higher requirement than implemented in widely accepted quality assurance programs.

[Communication skills for prenatal counselling]

Prenatal counselling is characterized by specific characteristics: A):The communication is about the values of the pregnant woman and her relationship with the child to be. B) The communication deals with patient's images and emotions. C) It is a communication about risks, numbers and statistics. D) Physician and patient deal with important ethical issues. In this specific setting of prenatal diagnosis and care physicians should therefore learn to apply basic principles of patient-centred communication with elements of non directive counselling, patient education and shared decision making. These elements are integrated into a process which comprises the following "steps": 1. Clarification of the patient's objectives and the obstetrician's mandate. 2. The providing of individualized information and education about prenatal tests and investigations. 3. Shared decision making regarding tests and investigations 4. Eventually Breaking (bad, ambivalent) news. 5. Caring for patients with an affected child.

[New options in prenatal and preimplantation diagnosis of genetic disorders]

During recent years the progress with the most important practical impact in prenatal diagnosis has been the implementation of first trimester risk screening for common aneuploidies leading to a much improved identification of pregnancies at risk. Molecular methods for a rapid, cost-effective, but selective aneuploidy diagnosis such as interphase FISH or QF-PCR have been around for years, do have their specific indications, but will unlikely replace conventional cytogenetic tools in routine diagnosis. They apparently do also play a role as marketing instruments in the competition among cytogenetic laboratories. The most thrilling issue for all cytogeneticists in the years to come will be the introduction of array-based methods in the prenatal routine diagnosis of chromosomal abnormalities. Polar body diagnosis has been the only option available for preimplantation genetic diagnosis in german speaking countries. The overwhelming majority of all professionals involved and many families concerned share the hope that the legal situation will improve in these countries to allow the examination of early embryos in high risk situations.

Neue Möglichkeiten in der pränatalen Diagnostik

Mit den technischen Entwicklungen erweiterten sich in den letzten Jahren die Einsatzmöglichkeiten des pränatalen Ultraschalls. So konnten in den 80er und 90er-Jahren zunehmend fetale Fehlbildungen diagnostiziert und spezifiziert werden. Die Untersuchung mit der sonographischen Nackentransparenzmessung in der 11. bis 14. Schwangerschaftswoche findet nunmehr als wichtiges pränatales Screening zur individuellen Risikoabschätzung für Chromosomenstörungen Eingang in die pränatale Medizin. Neben der standardisierten Untersuchungstechnik sollte größter Wert auf die ausführliche Information und Beratung der Schwangeren sowie auf die Qualitätssicherung gelegt werden. Durch die Verbesserung der individuellen Risikospezifizierung mittels Sonographie, biochemischen Markern und dem mütterlichen Alter können unnötige invasive Untersuchungen vermieden und ihre Zahl insgesamt deutlich reduziert werden. Ein Trend, der sich auch anhand des nicht-invasiven Nachweises des fetalen Rhesus D Status und mit dem Einsatz der Dopplersonographie im Management fetaler Anämien verfolgen lässt.

Ethische Aspekte bei Schwangerschaften an der Grenze der kindlichen Lebensfähigkeit

Trotz weiterer Verbesserungen in der perinatologischen Betreuung von Frühgeborenen an der Grenze der kindlichen Lebensfähigkeit sind die Mortalitätsraten für Frühgeborene mit einem Gestationsalter von weniger als 24 vollendeten Schwangerschaftswochen (SSW) in den letzten 10 Jahren hoch geblieben, und die Mehrzahl der überlebenden Kinder zeigen Auffälligkeiten in ihrer psychomotorischen Entwicklung. Ausgelöst durch neue Erkenntnisse über die Prognose dieser Patienten spielen Fragen zum zumutbaren Leiden und zur erreichbaren Lebensqualität in den ethischen Diskussionen um Therapieentscheidungen zunehmend eine zentrale Rolle. Fachgesellschaften in verschiedenen Ländern haben inzwischen ihre Überlegungen dazu in Publikationen zur Betreuung dieser Patienten festgehalten, um ihren in der Entscheidung stehenden Mitgliedern eine Hilfe zu geben. Sämtliche Empfehlungen geben ein Gestationsalter an, unterhalb dessen in der Regel auf den Einsatz intensivmedizinischer Maßnahmen primär verzichtet werden sollte. Diese absolute Interventionsgrenze variiert allerdings erheblich (Deutschland, Japan: < 22 SSW; USA, Kanada und England: < 23 SSW, Schweiz: < 24 SSW, Niederlande: < 25 SSW). Oberhalb dieser Grenzen wird eine Grauzone von 1–2 SSW definiert, innerhalb derer im Sinne einer individualisierten Strategie intensivmedizinische Maßnahmen initiiert werden können («provisional intensive care») und aufgrund engmaschiger Verlaufsbeobachtungen beurteilt wird, ob der fortgesetzte Einsatz solcher Maßnahmen weiterhin gerechtfertigt scheint. Bei Auftreten schwerwiegender Komplikationen besteht die Möglichkeit, den Einsatz lebenserhaltender Maßnahmen zu begrenzen oder zugunsten einer palliativen Betreuung («comfort care») zu sistieren. Jenseits dieser Grauzone wird die intensivmedizinische Betreuung zur Regel. Hier reicht die Interventionsgrenze von 22 SSW (Japan) bis 26 SSW (Niederlande). Die Erfolge der Frühgeborenenmedizin dürfen sich aber sicher nicht alleine an Überlebensraten messen. Berichte über neue Rekorde – ob in der Laienpresse oder der medizinischen Fachliteratur – sind grundsätzlich als problematisch zu werten, da sie einerseits unrealistische Hoffnungen schüren und andererseits dazu führen können, dass falsche Ziele anvisiert werden. Es gilt zu bedenken, dass sich im Schatten jedes publizierten «miracle baby» zahlreiche verstorbene Frühgeborene verbergen, deren (Leidens-)Geschichten anonym bleiben. Die Perinatologie sollte ihre Forschungsbestrebungen auf die Prävention der Frühgeburtlichkeit und die Verbesserung der Langzeitresultate von Frühgeborenen mit einem Gestationsalter von mehr als 23–24 SSW konzentrieren. Ein weiteres Absenken der Grenze der Lebensfähigkeit hat dagegen keine Priorität.

Oral misoprostol vs. intravenous oxytocin in reducing blood loss after emergency cesarean delivery

OBJECTIVE

To compare the effectiveness of oral misoprostol and intravenous oxytocin in reducing blood loss in women undergoing indicated or elective cesarean delivery (CD) under spinal anesthesia.

METHODS

In this prospective, double-blind pilot study, 56 parturients who received 5 IU of intravenous oxytocin after cord clamping were randomized to further receive either misoprostol orally and a placebo infusion intravenously or placebo orally and an oxytocin infusion intravenously.

RESULTS

After adjustment was made for the sonographically estimated amniotic fluid volume, there was no statistical difference in blood loss between the 2 groups (mean+/-S.D., 1083+/-920 mL in the oxytocin group vs. 970+/-560 mL in the misoprostol group; P=.59).

CONCLUSION

Oxytocin followed by oral misoprostol is as effective as an oxytocin injection followed by an oxytocin infusion in reducing postoperative blood loss after CD, and the protocol may be a safe, valuable, and cost-effective alternative to oxytocin alone. Visual estimation of intraoperative blood loss undervalues the effective value of misoprostol use by 30%.

Georg Schmorl on trophoblasts in the maternal circulation

Trafficking of cells between the fetus and its mother provides indirect clues to the underlying pathophysiology of pregnancy. Georg Schmorl first documented the presence of fetal cells in the maternal body and emphasized the importance of the placenta in eclampsia. Although his classic paper, written in 1893, is widely cited today, few investigators have actually read the paper, as it was published in German [Schmorl G., Pathologisch-anatomische Untersuchungen über Puerperal-Eklampsie. Verlag FCW Vogel, Leipzig; 1893]. Our goal was to translate the paper into English and critically re-evaluate its conclusions from a 21st century perspective. Schmorl was remarkably astute in his assessment of the pathologic changes that were seen in the 17 women on whom he performed complete autopsies. He found similar severe changes in all of the women, implying a common pathogenesis. This was in direct contrast to the then current doctrine. He was the first to observe the presence of thrombi containing multinucleated syncytial giant cells in the lungs of the women and speculated that they were of placental origin. To support his hypothesis he performed animal experiments. He also recognized that feto-maternal trafficking occurred in normal gestations but was increased in pregnancies affected by eclampsia. Using sophisticated molecular techniques we can now precisely confirm what Schmorl so elegantly described.

Breast cancer sagittal/horizontal plane location influences axillary lymph node involvement

AIM

To assess the influence of tumour location on axillary lymph node involvement (ALNI) and prognosis in breast cancer by evaluating the significance of the sagittal/horizontal alignment.

METHODS

We compared 57 patients with superficially located breast carcinomas up to 3.0 cm with patients having lesions in posterior planes of the breast. Both groups were matched according to age, time of diagnosis, tumour size, grade, hormonal receptor status and tumour site within the frontal plane. Histologic evidence of skin involvement, excluding tumours fulfilling the criteria for pT4b, was defined as inclusion criteria and reference plane for superficial tumour location.

RESULTS

Tumours situated in the superficial region of the breast, compared to those located in deeper planes, have an increased risk of ALNI (p=0.023), whereas no difference was observed with reference to disease-specific survival (p=0.203).

CONCLUSION

This study shows that ALNI is dependent on sagittal/horizontal as well as frontal tumour location. Clinicians should be aware that tumours lying posteriorly may be at increased risk of occult spread outside axillary lymph nodes.

Comparative birth weights of singletons born after assisted reproduction and natural conception in previously infertile women

BACKGROUND

The possible interference of assisted reproduction techniques (ART) with epigenetic reprogramming during early embryo development has recently sparked renewed interest about the reported lower birth weight among infants born as a consequence of infertility treatments. However, the latter finding so far has relied on the comparison of the birth weight of infants conceived with ART to general population data. A more appropriate comparison group should involve pregnancies in infertile women after natural conception. Therefore, we compared neonatal birth weight data of infants born after various ART treatments, including intrauterine insemination (IUI), with those of previously infertile women achieving pregnancy after sexual intercourse.

METHODS

Between August 1996 and March 2004 the data of all infertile women presenting in the infertility unit of the University Women's Hospital of Basel, Switzerland, were collected prospectively, adding up to 995 intact pregnancies and deliveries. The birth weight of all infants resulting from 741 singleton pregnancies were analysed with regard to the patients' characteristics, the occurrence of complications during pregnancy and the type of infertility treatment with which the pregnancies were achieved.

RESULTS

Comparison of duration of pregnancy and birth weight of infants born after infertility treatment confirms a shorter pregnancy span and a lower mean birth weight in infants born after IVF and ICSI. If women with pregnancies after ART deliver before term, neonatal birth weight is significantly lower.

CONCLUSIONS

There is a specific effect of ART, mainly IVF and ICSI, on both shortening the duration of pregnancy and lowering neonatal birth weight. Both these parameters seem to be interrelated consequences of some modification in the gestational process induced by the infertility treatment. Freezing and thawing of oocytes in the pronucleate stage had a lesser impact on pregnancy span and on neonatal birth weight.

Water birth: is the water an additional reservoir for group B streptococcus?

OBJECTIVE

Water birth became popular in the last years, despite the fact that many questions like the risk of infection for the newborn remain unanswered. Group B streptococcal (GBS) infections in the newborn remain a challenge in obstetrics and neonatology.

METHOD

We conducted a prospective trial to study the impact of water birth on the colonization rate of the bath water and, more importantly, the GBS-colonization rate of the newborn.

RESULT

After water birth the bath water was significantly more often colonized with GBS than after immersion followed by a delivery in bed. The newborns, however, showed no difference in GBS colonization and there was even a trend towards less GBS colonization of the newborn after a water delivery.

CONCLUSION

Regarding GBS colonization of the newborn during water birth there might be a wash out effect, which protects the children during the delivery.

Scope and significance of non-uniform classification practices in breast cancer with non-inflammatory skin involvement: a clinicopathologic study and an international survey

BACKGROUND

The study evaluates the scope of non-uniform classification practices concerning breast carcinomas with non-inflammatory skin involvement.

PATIENTS AND METHODS

We compared the clinical course of patients with histologically proven non-inflammatory skin involvement: 119 (65.4%) with clinically obvious 'classical' skin changes (Group A) and 63 (34.6%) with no or only discreet changes (Group B). A questionnaire was circulated to pathology departments in 24 countries to assess the practice concerning the placement of skin- involved breast carcinomas in the TNM classification.

RESULTS

Patients in Group B showed a significantly better disease specific survival (P=0.0002). Eighty-six respondents (70.5%) of the survey preferred the 'histological view' and classified tumors with only histological proven skin involvement as T 4 b/stage IIIB. The opposing classification principle ('clinical view'), which dictates that T 4 b breast cancer is a clinical diagnosis and the classical signs must be present, was supported by 31 respondents (25.4%).

CONCLUSIONS

A large number of breast cancer patients with non-inflammatory skin involvement are only histologically proven and show, compared with cases exhibiting the classical clinical signs, significant differences in clinical course and prognosis. In general, both subsets were aggregated in one T category/stage (T 4 b/IIIB). This results in a considerable distortion of the reported statistical data.

Uteriner Gasbrand mit Clostridium Perfringens Sepsis nach intrapartaler gedeckter Uterusruptur

Anaerobic infections with Clostridium perfringens (CP) occur rarely but are associated with considerable maternal mortality. We report the case of a patient who developed uterine gas gangrene postpartum and discuss the management of this infection. A 28-year-old patient, GII, PII with history of Caesarean in 2002, delivered a healthy girl per vacuum extraction. Postpartally she presented with an acute abdomen and a laparotomy was performed. The uterotomy suture was intact but a parametrane tear had to be resutured. 36 hours later the patient's condition worsened quickly. Cellulitis was diagnosed and after receiving the results of the wound swabs (CP positive) from the uterus and haematoma, tazobactam and clindamycin were administered. Her condition continued to deteriorate and gaseous gangrene was seen with unilateral extension to the abdomen reaching as far as the axilla cranially and to the thigh caudally. Due to the extensive infection it was necessary to perform a hysterectomy, necrosis removal and splitting of the fascia followed by several debridements and leaving the wound open in order to avoid anaerobic conditions. The patient was discharged after 21 days. She developed a post-traumatic syndrome with severe depression. Clostridium perfringens is ubiquitous and is found vaginally in ca. 1 - 10 % of healthy women and usually does not cause a serious infection. Under the right conditions it can cause an endometritis leading to sepsis. Early recognition and interdisciplinary treatment are of extreme importance. In this case the surgical treatment through hysterectomy combined with targeted antibiotic therapy, ultimately saved the patient's life.

Fetal Cells and Cell Free Fetal Nucleic Acids in Maternal Blood: New Tools to Study Abnormal Placentation?

The analysis of fetal cells, and more recently cell free fetal nucleic acids, in maternal blood has to date largely been concerned with the development of risk free methods for prenatal diagnosis. Although elevated feto-maternal cell trafficking has long been associated with preeclampsia, it has only recently been shown that this perturbation is an early event in these pregnancies, occurring well in advance of the onset of symptoms. In a separate development, analogous observations have been made concerning the levels of circulatory fetal nucleic acids in maternal plasma. Subsequent studies have shown that changes in these two parameters may also occur in other pregnancy related disorders including preterm labour, intra-uterine growth retardation, hyperemesis gravidarum or even pregnancies at high altitude. A striking finding of these examinations was that preterm labour was associated with an elevated release of cell free fetal nucleic acids but not with an increment in feto-maternal cell trafficking. This suggested that the analysis of the mechanisms regulating trans-placental cell trafficking or liberation of circulatory fetal nucleic acids may provide key insights into the fundamentally different placental lesions underlying these disorders. As such, circulatory fetal cells and nucleic acids may be viewed as new tools to study alterations in placentation.

First trimester maternal serum alpha-fetoprotein screening for Down syndrome and other aneuploidies

Low maternal serum AFP (MSAFP) values in the first trimester of pregnancy have been associated with an increased risk for chromosome disorders. In our own first trimester chorionic villus sampling (CVS) series, MSAFP determinations were carried out in 1,448 singleton pregnancies. Aneuploidies were detected in 26 of these. The pre-CVS MSAFP values in these pregnancies were compared to those in pregnancies with normal outcome. Statistical analysis did not show a diagnostically useful correlation between low first trimester MSAFP values and aneuploidy in our cohort.