Treatment of very preterm preeclampsia via heparin-mediated extracorporeal LDL-precipitation (H.E.L.P.) apheresis: The Freiburg preeclampsia H.E.L.P.-Apheresis study

OBJECTIVE

Soluble Fms-like tyrosine kinase-1 (sFlt-1) is thought to be causative in the pathogenesis of preeclampsia (PE) and specific removal of sFlt-1 via dextran sulfate cellulose (DSC)-apheresis was suggested as cure to allow prolongation of pregnancy in preterm PE. However, in addition a deranged lipoprotein metabolism may impact endothelial and placental function in PE. Lipoprotein-apheresis by heparin-mediated extracorporeal LDL-precipitation (H.E.L.P.) was previously applied and has been shown to alleviate symptoms in PE. This clinical trial reevaluates the clinical efficacy of H.E.L.P.-apheresis in PE considering sFlt-1.

STUDY DESIGN

Open pilot study assessing the prolongation by H.E.L.P.-apheresis in 6 women (30-41 years) with very preterm PE (24+4 to 27+0 gestational weeks (GW)) (NCT01967355) compared to a historic control-group matched for GW at admission (<28 GW; n = 6). Clinical outcome of mothers and babies, and pre- and post H.E.L.P.-apheresis levels of sFlt-1 and PlGF were monitored.

MAIN OUTCOME MEASURES

In apheresis patients (2-6 treatments), average time from admission to birth was 15.0 days (6.3 days in controls; p = 0.027). Lung maturation was induced in all treated cases, and all children were released in healthy condition. Apheresis reduced triglycerides and LDL-cholesterol by more than 40%. Although H.E.L.P.-apheresis induced a transient peak baseline levels did not change and rather stabilized sFlt-1 levels at pre-apheresis levels throughout treatments, with sFlt-1/PLGF ratio remaining unaffected.

CONCLUSIONS

H.E.L.P.-apheresis proved again to be safe and prolongs pregnancies in PE. However, without changing sFlt-1 levels below baseline lowering lipids or other yet undefined factors appear to be of more relevance than reducing sFlt-1.

Screening of gestational diabetes mellitus in early pregnancy by oral glucose tolerance test and glycosylated fibronectin: study protocol for an international, prospective, multicentre cohort trial

INTRODUCTION

As the accurate diagnosis and treatment of gestational diabetes mellitus (GDM) is of increasing importance; new diagnostic approaches for the assessment of GDM in early pregnancy were recently suggested. We evaluate the diagnostic power of an 'early' oral glucose tolerance test (OGTT) 75 g and glycosylated fibronectin (glyFn) for GDM screening in a normal cohort.

METHODS AND ANALYSIS

In a prospective cohort study, 748 singleton pregnancies are recruited in 6 centres in Switzerland, Austria and Germany. Women are screened for pre-existing diabetes mellitus and GDM by an 'early' OGTT 75 g and/or the new biomarker, glyFn, at 12-15 weeks of gestation. Different screening strategies are compared to evaluate the impact on detection of GDM by an OGTT 75 g at 24-28 weeks of gestation as recommended by the International Association of Diabetes and Pregnancy Study Groups (IADPSG). A new screening algorithm is created by using multivariable risk estimation based on 'early' OGTT 75 g and/or glyFn results, incorporating maternal risk factors. Recruitment began in May 2014.

ETHICS AND DISSEMINATION

This study received ethical approval from the ethics committees in Basel, Zurich, Vienna, Salzburg and Freiburg. It was registered under http://www.ClinicalTrials.gov (NCT02035059) on 12 January 2014. Data will be presented at international conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02035059.

[Case Report on Treatment of Metastatic Breast Cancer with Trastuzumab during Pregnancy]

The increasing number of pregnant breast cancer patients calls for a therapy that is as efficient as possible. After 10 years of collecting data on pregnant breast cancer patients in the German Breast Group (GBG), proposals for diagnostic measures and therapy regarding this special situation have been developed on the basis of 500 observed cases. Chemotherapy is regarded as safe from the 14(th) week of gestation on, but it is strongly advised not to use trastuzumab. Adverse outcomes for the newborn were predominantly observed in cases of early preterms. In our department, a 29-year-old second gravida with metastatic breast cancer first diagnosed 7 years ago continued to receive trastuzumab treatment at her express request after detailed information and advice. Trastuzumab treatment had been started 1.5 years before the pregnancy after surgical removal of a lymph node metastasis. After 7 intravenous administrations at intervals of 3 weeks, an oligohydramnios occurred in the 24(th) week of pregnancy. For this reason, trastuzumab treatment was interrupted for 7 weeks, during which time the quantity of amniotic fluid returned to a normal level. As the 8(th) administration of trastuzumab led to a renewed oligohydramnios, the trastuzumab treatment was suspended until birth. The quantity of amniotic fluid having recovered to normal, labour was induced after 36 weeks of pregnancy, followed by a Caesarian section because of prolonged labour. The newborn boy showed no sign of respiratory or renal dysfunction and has developed normally, having at present reached the age of 3 years. From the few reported cases of pregnancies with trastuzumab therapy, it seems that an occurring oligohydramnios is the typical complication with the problem of life-threatening RDS after birth. Probably the reduction of amniotic fluid can be reversed by interrupting the trastuzumab therapy, as we observed in our case.

[Pneumomediastinum related to the second stage of labour - a report on 2 cases]

We report on 2 primigravidae developing pneumomediastinum and subcutaneous emphysema associated with the second stage of labor. Both of the newborns had a comparatively high birth-weight (3,855 g and 4,245 g, respectively). In the first case, the patient felt a sudden chest pain during expulsion followed by dyspnea and swelling of the face. The birth was terminated by vacuum extraction. In the second case, a mild shoulder dystocia occurred, which could be resolved by McRoberts maneuver. The patient exhibited a swollen face and shortness of breath on the first postpartum day. Physical examination revealed crackly skin over the lower face, both sides of the neck and the front of the chest. In both cases, CT scan of the chest revealed pneumomediastinum and a subcutaneous emphysema of the upper thorax, however without showing a pneumothorax. The first patient underwent bronchoscopy and esophagogastroduodenoscopy; there were no abnormalities detected. The pneumomediastinum and subcutaneous emphysema gradually diminished spontaneously in both cases. Appropriate pain management and empirical antibiotics were applied. Pneumomediastinum during labor and birth, typically with subcutaneous emphysema in the face and neck, is a rare condition, but there are reported cases in the literature. Based on the limited available evidence, it seems to have a benign, self-limiting course. A conservative management appears -appropriate and sufficient.

Factors Associated with the Duration of Breastfeeding in the Freiburg Birth Collective, Germany (FreiStill)

Purpose: The health benefits of breastfeeding for both infants and mothers are well-documented. The aim of this study was to clarify factors associated with successful breastfeeding. Methods: We performed a prospective, multi-centre cohort study of 443 mothers in person using a standardised questionnaire on postpartum day 1. Women who had started to breast-feed were interviewed by telephone after 3, 6 and 12 months. A statistical analysis was performed using the SAS system. Results: 92 % of women (409/443) were initially breastfeeding. After three months the rate decreased to 74 %, after six months to 61 % and after 12 months to 28 %, respectively. Bivariate analysis revealed a significant positive association with the following factors: maternal age > 35 years, higher educational level, intention to breastfeed on postpartum day one, high motivation after three months, partner's support of the decision to breastfeed, satisfaction with the care provided in the maternity clinic, a positive breastfeeding experience and follow-up care by a midwife. Elective caesarean delivery, the use of breastfeeding aids, formula supplementation early on and the mother's concern about the amount of milk correlated negatively. Following a multivariate logistic regression analysis, four factors were correlated with having a positive influence on duration of breastfeeding: higher educational level, satisfaction with the care provided within the maternity clinic, follow-up care by a midwife, and a positive current experience of breastfeeding. Conclusion: Our data demonstrate certain factors successfully influence breastfeeding. Competent care in the maternity clinic, postpartum care by a midwife and a positive experience with breastfeeding increase the rate of breastfeeding and thus have a positive impact on the health of mother and newborn.

[Fractures in neonates as a result of birth trauma caused by caesarean section]

BACKGROUND

The occurrence of 4 bone fractures associated with birth by Caesarean section (CS) prompted us to examine the incidence and predisposing factors of bone injuries sustained during birth.

CASE REPORT AND METHOD

The 4 cases with fractures were evaluated retrospectively and discussed in combination with a short review of the literature.

CONCLUSIONS

With the increasing number of Caesarean sections the incidence of birth trauma has decreased. Nevertheless, when performing a CS there is still a risk of serious trauma to the neonate, including bone fractures. A Caesarean section for breech presentation constitutes a predisposition for femoral fractures. When diagnosed early and treated properly, the prognosis for these fractures is good without sequelae and one can expect a satisfactory clinical outcome for the child. We suggest that the possibility of this complication be mentioned when counselling the mother and getting informed consent.

Three-dimensional ultrasound for the assessment of breast lesions

OBJECTIVE

To evaluate the diagnostic accuracy of three-dimensional (3D) ultrasound in comparison with conventional two-dimensional (2D) ultrasound in the characterization of breast lesions.

METHODS

The digitally stored 2D ultrasound images and the corresponding 3D scans of 100 breast lesions (57 malignant, 43 benign) that had been morphologically classified as solid tumors, were independently analyzed by six investigators. Ten 2D and 13 3D ultrasound characteristics were determined. Lesion characterization was classified on a four-point scale and a logistic regression model was used to analyze the data. A receiver-operating characteristics curve (ROC) analysis was performed to determine the diagnostic performance of 2D and 3D ultrasound, respectively.

RESULTS

Ultrasound criteria showed major differences between 2D and 3D ultrasound. Logistic regression revealed the retraction phenomenon in the coronal plane of the 3D ultrasound scan to be a significant and independent factor for lesion characterization. The characteristics determined on the conventional planes of 3D ultrasound differed from those determined on the 2D ultrasound images. The diagnostic accuracy of 2D and 3D ultrasound in the ROC analysis was almost identical (area under the curve 0.846 and 0.851, respectively).

CONCLUSIONS

Ultrasound features on 3D ultrasound differ significantly from those on 2D ultrasound. However, the diagnostic accuracy of both methods is almost identical. 3D ultrasound as an adjunct to conventional 2D ultrasound should be evaluated in larger trials to determine its clinical value in breast imaging.

[Hystero-salpingo-contrast-sonography with 3-d-ultrasound -- a pilot study]

Hystero-salpingo-contrast sonography (HyCoSy) is a sensitive method of assessing tubal patency but cannot completely substitute diagnostic laparoscopy with blue dye and hysteroscopy. Three-dimensional sonography has new imaging facilities which could lead to a reduction of invasive diagnostic procedures.

AIM

The aim of this pilot study was to analyse the feasibility of HyCoSy by 3D- and 3D-Doppler-sonography.

METHODS

In a prospective setting conventional (2D) HyCoSy was performed in 21 patients with an ultrasound device designed for 3D-ultrasound. After the completion of the 2D procedure, 3D-ultrasound was carried out. In five patients an additional 3D-Doppler-HyCoSy was performed. The generated 3D-volumina were then examined. Laparoscopy with blue dye was performed immediately after the ultrasound examination.

RESULTS

A total of 42 Fallopian tubes was assessed. On 2D-ultrasound, visibility of the tubes was excellent in 28 and limited in seven tubes. Of the seven tubes not visible on 2D-ultrasound, four were not patent on laparoscopy. On 3D-ultrasound, visibility of the tubes was excellent in 15 and limited in twelve tubes. 15 tubes were not visible on 3D-ultrasound. 3D-Doppler-HyCoSy revealed excellent assessment in eight of ten tubes, even in one of those with limited visibility on 2D- and 3D-HyCoSy. In 19 patients the assessment of the uterine cavity was excellent by 2D- and 3D-HyCoSy, whereas it was limited in two patients.

CONCLUSION

It is possible to visualise the full length of the tubes in a very detailed way from the uterine cavity to the fimbrial end in some patients, but the diagnostic power of HyCoSy is not improved by adding 3D-imaging. The accuracy of 3D-ultrasound seemed to be improved by 3D-Doppler-ultrasound.

Steroid receptor expression in endometria from women treated with tamoxifen

Breast cancer patients receiving tamoxifen (Tam) are at an increased risk for developing endometrial carcinomas, possibly due to the partial estrogenic effect of Tam on endometrial cells. Progestational therapy has not routinely been included in Tam regimens. It was our aim to determine the presence of estrogen receptors (ERs) and progesterone receptors (PRs) in normal and abnormal endometria from postmenopausal women with breast cancer who were treated with Tam. Standard immunohistochemical staining of ERs and PRs was performed on paraffin sections from formalin-fixed uterine curettings or hysterectomy specimens from 40 patients who had received 20-40 mg of Tam daily for a minimum of 3 months. For comparison, normal endometria from 20 women who had not received Tam (11 premenopausal, 9 postmenopausal) were also studied for ER and PR expression. Staining was evaluated using semiquantitative immunoreactivity scores (IRS) ranging from 0 (negative) to 12 (strongly positive). In the group of patients receiving Tam, ERs and PRs were detected in the nuclei of glandular cells in 24/24 cases of endometrial atrophy (ER/PR-IRS, 2-12), in 8/8 endometrial polyps (ER-IRS, 6-12; PR-IRS, 4-12), in 4/4 adenomatous endometrial hyperplasias (ER-IRS, 3-8; PR-IRS, 1-12), and in 4/4 well-differentiated endometrioid adenocarcinomas (ER-IRS, 2-12; PR-IRS, 6-8). Of the 11 endometria from premenopausal patients who had not received Tam, 8 were ER+/PR+ (ER-IRS, 1-12; PR-IRS, 1-12), 1 was ER+/PR- (ER-IRS, 3; PR-IRS, 0), 1 was ER-/PR+ (ER-IRS, 0; PR-IRS, 2), and 1 was ER-/PR- (ER/PR-IRS, 0). Among 9 atrophic endometria from women not treated with Tam, 6 were ER+/PR+ (ER-IRS, 4-12; PR-IRS, 3-6), 1 was ER+/PR- (ER-IRS, 4; PR-IRS, 0), and 2 were ER-/PR- (ER/PR-IRS, 0). The consistent finding of ER and PR expression in endometria from postmenopausal women receiving Tam further supports the suspected estrogenic effect exerted by Tam on endometrial cells. Progestational therapy could be beneficial in the prevention of Tam-induced abnormal endometrial proliferations.

[An unusual course of fetal gastroschisis]

We report on prenatal diagnosis of gastroschisis at 20th gestational week. In addition to gastroschisis intraabdominal intestinal stenosis was detected. As a consequence cesarean section was planned close to term. Control examinations in the last trimester didn't confirm initial diagnosis so that the recommended mode of delivery was changed. However postpartum diagnosis again confirmed the early diagnosis of gastroschisis including spontaneous necrosis of dislocated intraamniotic intestinal parts. The course demonstrates that even at unambiguous prenatal diagnosis control examinations are recommended as dynamic changes may occur in the second and third trimester. Thus mode of delivery may have to be adapted close to term to reduce maternal risk.