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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.

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.

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.

24j IIG/ 0P, ca. 40. SSW. Verlegung der Mutter in das Perinatalzentrum bei Querlage und ausgepragtem Hydrocephalus und Aszites. Die aus Afrika stammende und in Frankreich lebende Mutter gab an, dass keine Schwangerschaftsvorsorge durchgefuhrt worden sei. Sonographisch und serologisch zeigte sich eine konnatale Toxoplasmoseinfektion. Bei beginnender Wehentatigkeit und Querlage wurde eine sekundare Sectio caesarea aus mutterlicher Indikation durchgefuhrt. NG: mannlich, Gewicht 4185g, Kopfumfang 42cm (>97. P.), pH 7,28, BE –5,3, APGAR 4/7/8. Erst postpartal berichtete die Mutter auf gezielte Nachfrage, dass bereits im 2. Trimenon eine Toxoplasmoseinfektion serologisch nachgewiesen worden sei. Sie habe sich trotz bereits bestehender cerebraler Auffalligkeiten gegen die empfohlene Abruptio aus medizinischer Indikation entschieden. Es erfolgte eine Therapie mit Spiramycin uber eine Woche. Eine postpartale Versorgung des Kindes war aufgrund der schweren Fehlbildungen von den franzosischen Kollegen abgelehnt worden, weshalb die Patientin sich zur Entbindung in Deutschland vorstellte. Beim Kind zeigte sich das Vollbild einer konnatalen Toxoplasmoseinfektion, die sich serologisch bestatigte (IgM hoch positiv). Hierzu zahlten ein ausgepragter Hydrocephalus internus et externus mit Krampfanfallen, eine Hepatosplenomegalie mit Hepatopathie, ein Mb. Hamolyticus neonatorum bei B–0-Inkompatibilitat, eine Choanalstenose sowie ein Mikrophthalmus. Die Gesamtprognose wurde vor allem aufgrund des massiv ausgepragten Hydrocephalus als infaust eingeschatzt, sodass nach ethischem Konsil die invasiven intensivmedizinschen Masnahmen beendet und das Kind extubiert wurde. Es verstarb am 12. Lebenstag. Literatur: Congenital Toxoplasmosis and Reinfection during Pregnancy: Case Report, Strain Characterization, Experimental Model of Reinfection, and Review. Elbez-Rubinstein A, Ajzenberg D, Darde ML, Cohen R, Dumetre A, Yera H, Gondon E, Janaud JC, Thulliez P. J Infect Dis. 2009 Jan 15;199(2):280-285. Prenatal education for congenital toxoplasmosis. Di Mario S, Basevi V, Gagliotti C, Spettoli D, Gori G, D'Amico R, Magrini N. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD006171. New insights in toxoplasmosis immunology during pregnancy. Perspective for vaccine prevention. Pfaff AW, Candolfi E. Parassitologia. 2008 Jun;50(1-2):55-8. Review. Sonographic examination of the fetal central nervous system: guidelines for performing the 'basic examination' and the 'fetal neurosonogram'. Ultrasound Obstet. Gynecol 2007; 29:109.