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Summary The first German interdisciplinary S3-guideline on the diagnosis, therapy and follow-up of patients with endometrial cancer was published in April 2018. Funded by German Cancer Aid as part of an Oncology Guidelines Program, the lead coordinators of the guideline were the German Society of Gynecology and Obstetrics (DGGG) and the Gynecological Oncology Working Group (AGO) of the German Cancer Society (DKG). Purpose Using evidence-based, risk-adapted therapy to treat low-risk women with endometrial cancer avoids unnecessarily radical surgery and non-useful adjuvant radiotherapy and/or chemotherapy. This can significantly reduce therapy-induced morbidity and improve the patientʼs quality of life as well as avoiding unnecessary costs. For women with endometrial cancer and a high risk of recurrence, the guideline defines the optimal extent of surgical radicality together with the appropriate chemotherapy and/or adjuvant radiotherapy if required. An evidence-based optimal use of different therapeutic modalities should improve the survival rates and quality of life of these patients. This S3-guideline on endometrial cancer is intended as a basis for certified gynecological cancer centers. The aim is that the quality indicators established in this guideline will be incorporated in the certification processes of these centers. Methods The guideline was compiled in accordance with the requirements for S3-level guidelines. This includes, in the first instance, the adaptation of source guidelines selected using the DELBI instrument for appraising guidelines. Other consulted sources included reviews of evidence, which were compiled from literature selected during systematic searches of literature databases using the PICO scheme. In addition, an external biostatistics institute was commissioned to carry out a systematic search and assessment of the literature for one part of the guideline. Identified materials were used by the interdisciplinary working groups to develop suggestions for Recommendations and Statements, which were then subsequently modified during structured consensus conferences and/or additionally amended online using the DELPHI method, with consent between members achieved online. The guideline report is freely available online. Recommendations Part 2 of this short version of the guideline presents recommendations for the therapy of endometrial cancer including precancers and early endometrial cancer as well as recommendations on palliative medicine, psycho-oncology, rehabilitation, patient information and healthcare facilities to treat endometrial cancer. The management of precancers of early endometrial precancerous conditions including fertility-preserving strategies is presented. The concept used for surgical primary therapy of endometrial cancer is described. Radiotherapy and adjuvant medical therapy to treat endometrial cancer and uterine carcinosarcomas are described. Recommendations are given for the follow-up care of endometrial cancer, recurrence and metastasis. Palliative medicine, psycho-oncology including psychosocial care, and patient information and rehabilitation are presented. Finally, the care algorithm and quality assurance steps for the diagnosis, therapy and follow-up of patients with endometrial cancer are outlined.

Summary The first German interdisciplinary S3-guideline on the diagnosis, therapy and follow-up of patients with endometrial cancer was published in April 2018. Funded by German Cancer Aid as part of an Oncology Guidelines Program, the lead coordinators of the guideline were the German Society of Gynecology and Obstetrics (DGGG) and the Gynecological Oncology Working Group (AGO) of the German Cancer Society (DKG). Purpose The use of evidence-based, risk-adapted therapy to treat low-risk women with endometrial cancer avoids unnecessarily radical surgery and non-useful adjuvant radiotherapy and/or chemotherapy. This can significantly reduce therapy-induced morbidity and improve the patientʼs quality of life as well as avoiding unnecessary costs. For women with endometrial cancer and a high risk of recurrence, the guideline defines the optimal surgical radicality together with the appropriate chemotherapy and/or adjuvant radiotherapy where required. The evidence-based optimal use of different therapeutic modalities should improve survival rates and the quality of life of these patients. The S3-guideline on endometrial cancer is intended as a basis for certified gynecological cancer centers. The aim is that the quality indicators established in this guideline will be incorporated in the certification processes of these centers. Methods The guideline was compiled in accordance with the requirements for S3-level guidelines. This includes, in the first instance, the adaptation of source guidelines selected using the DELBI instrument for appraising guidelines. Other consulted sources include reviews of evidence which were compiled from literature selected during systematic searches of literature databases using the PICO scheme. In addition, an external biostatistics institute was commissioned to carry out a systematic search and assessment of the literature for one area of the guideline. The identified materials were used by the interdisciplinary working groups to develop suggestions for Recommendations and Statements, which were then modified during structured consensus conferences and/or additionally amended online using the DELPHI method with consent being reached online. The guideline report is freely available online. Recommendations Part 1 of this short version of the guideline presents recommendations on epidemiology, screening, diagnosis and hereditary factors, The epidemiology of endometrial cancer and the risk factors for developing endomentrial cancer are presented. The options for screening and the methods used to diagnose endometrial cancer including the pathology of the cancer are outlined. Recommendations are given for the prevention, diagnosis, and therapy of hereditary forms of endometrial cancer.

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.

Einleitung: Die Implantation einer Schwangerschaft in die Sectionarbe ist ein seltenes und schwerwiegendes Ereignis. Mogliche Komplikationen sind Ruptur in die Bauchhohle, operative fruhe Fruhgeburt und Hysterektomie. Behandlungsstrategie besteht ublicherweise in der operativen oder medikamentosen Beendigung der Graviditat. Das Austragen einer solchen Schwangerschaft ist mit einem hohen Risiko einer Ruptur mit vitaler Gefahrdung der Mutter verbunden. Fall: Eine 39-jahrige IV Gravida II Para, Z.n. 2 x Sectio, stellte sich in der 9+1. SSW in unserer Klinik vor. In der Sonografie zeigte sich die Graviditat in der Sectio-Narbe implantiert, das Cavum uteri leer. Der Trophoblast erschien nach ventral ohne myomentrane Wandung nur mit Serosa und Gefasen uberzogen. Trotz Risikoaufklarung und dringender Empfehlung zur Beendigung der Schwangerschaft entschied sich die Patientin fur das Austragen. Die stationare Uberwachung erfolgte ab der 26. SSW. Das Wachstum der Schwangerschaft entwickelte sich exzentrisch nach ventral und links entsprechend einer Zervixschwangerschaft mit extrauteriner Wachstumsrichtung. Bei unauffalligem weiterem Verlauf wurde die primare Sektio am 12.12.2013 in der 32+3 SSW durchgefuhrt. Intraoperativ prasentierte sich ein stark vorgewolbtes, aufgeweitetes und von Gefasen uberzogenes unteres Uterinsegment, lediglich von Serosa bedeckt. Nach problemloser Kindsentwicklung wurde nach Verschluss der Uterotomie bei belassener Plazenta die Hysterektomie durchgefuhrt. Der postoperative Verlauf war komplikationslos, der tiefste Hb lag bei 6,6 g/dl. Histologisch lag eine Plazenta accreta/increta in 90% der Haftungsfache vor. Kind: Junge, 1970 g, 8/10/10, pH: 7,29 Schlussfolgerung: Im hier vorgestellten Ausnahmefall kam es bei der beharrlichen Patientin mit guter Compliance zu einem uberraschend und nicht selbstverstandlich unauffalligen Verlauf der Schwangerschaft und relativ komplikationsarmer Geburt.

The confrontation with potential life-threatening diseases during pregnancy is rare. Especially haematologic malignancies as acute leukaemia and the myelodysplastic syndrome are rare events during pregnancy and childbed. The care of affected women and the management of birth and the postpartal period is non-standardized because of the small number of cases. The patients are risk-pregnancies and an interdisciplinary care by obstetricians and specialized haematooncologists is necessary. A lot of studies have demonstrated the benefit of a prophylactic intrapartal single-dose antibiotic during caesarean section and its routine use should be standardized. Especially in risk collectives with postpartal infect signs or postpartal fever an intravenous antibiotic should be administered soon and generously.

Purpose: The purpose ot this prospective study was to evaluate the usefulness of doppler sonography for monitoring of androgen iherapy in patients with gynecomastia. Patients and Methods: A total of 11 patients was included in the study. For five patients a complete follow up was performed prior to the beginning and four, eight and twelve weeks after initiation of testosterone therapy. High resolution sonography was performed (ATL UM 9HDI) using a 10 MHz transducer. Doppler sonography was performed using a 8 MHz-probe and a bi-directional system (Kranzbuhler Vasoscope 3), Results: By local or systemic testosterone therapy a marked release of symptoms (pain and tenderness) could be achieved for the five patients. Furthennore a significant reduction of blood flow in the breast tissue could be observed. This effect was pronounced in patients with high baseline blood flow (before the onset of therapy). Conclusion: Clinical evaluation and sonographic detection of differences in parenchymal mass are difficult to perform in short term testosterone treatment of patients with gynecomastia. Doppler sonography is a useful diagnostic tool to detect therapeutic response and thereby facilltate counseling patients with respect to further treatment strategies.

Purpose: Myometrial invasion depth of endometrial cancer is an important prognostic factor. Preoperative assessment is decisive for appropriate surgical treatment. The aim of the study is to assess the value of transvaginal sonography (TVS) for determining the myometrial invasion depth in endometrial cancer. Material and Methods: In 214 patients with endometrial cancer (118 patients before and 96 other patients after dilatation and curettage (D&C]), the myometral invasion depth (greater than 50% or less than 50%) was measured preoperatively. The maximum endometrial height (twice the thickness) was measured sonographically. The maximum endometrial height (E) was set in relation to the anterior-posterior diameter of the uterus (U). A myometrial invasion depth of greater than 50% was assumed with E/U >0.5. An invasion which was limited to the inner half of the myometrium was represented as E/U

Purpose: Due to their sonomorphical appearance mature cystic teratomas are often correctly diagnosed ,,at first sight. However the complex and variable architecture of the lesions frequently leads to their classification as malignant if sonographic tumour scores are applied. Material and Methods: In the Department of Gynaecology Hospital at the University of Freiburg, we performed between 1988 and 1996 a preoperative ultrasound examination of 117 cystic teratomas in 110 patients. In 63 of these tumours Colour-Doppler sonography was also used. Results: As typical sonographic markers for the diagnosis of cystic teratomas was used the following criteria: a line pattern in the fluid phase of the tumour (seen in 62 [53%] cases); homogeneous echogenic structure (seen in 102 [82%] cases); shadowing (seen in 50 [43%] cases). 96% of the tumours showed at least one of these markers. In 62% of dermoid plugs with hairs typical sonographic criteria were present. In 25% of the cases with osseous or dental structures characteristics shadowing was observed. The ranking of the sonographic diagnosis was assessed for 754 ovarian tumours including 71 cystic teratomas. The dermoid tumours were predicted with a sensitivity of 94.3%, a specificity of 99.3%, an accuracy of 98.8% and a positive or negative predictive value of 93% and 99.3%, respectively. Using the colour Doppler technique we were able to predict the tumour status of the complex cystic teratomas correctly in 91% and 93% of the cases, respectively, using one of the following parameters: number of tumour arteries, maximum systolic velocity or sum of maximum systolic velocities. This figure dropped to 68% if minimal resistance index was used. Conclusion: Basing on typical markers, sonographic diagnosis of cystic teratomas is very reliable. Colour Doppler sonography is a useful, independent method to supplement determination of the tumour status of teratomas.

Several complications of pregnancy have been reported to be associated with alterations of serotonin (5-HT). This study describes the changes in 5-HT metabolism in patients with preeclampsia. Our examination findings should explain if there are elevated 5-HT and 5-HIAA concentrations in urine and serum of women with preeclampsia. On the other hand it should be proved if the observed chances are due to a decreased kidney function and if there is an important prognostic factor to detect asymptomatic preeclamptic patients. 5-HT and its main metabolite 5-hydroxy-indol-acetic acid (5-HIAA) was evaluated in serum and urine of 24 pregnant women with preeclampsia and of 27 pregnant women without preeclampsia in the last month of pregnancy, within 24 hours after delivery and at the fourth day post partum. Besides 5-HIAA was ascertained in 24-h urine from the 24 th week of pregnancy until after delivery. 5-HIAA excretion increased continuously during pregnancy independently of whether the patients developed preeclampsia. A significant less increase and lower concentration of 5-HIAA pre and post partum were observed in preeclamptic patients when compared to non-preeclamptic patients. We noticed a remarkably lower 5-HIAA excretion and a higher concentration of 5-HT in women with preeclampsia. Preeclamptic patients demonstrate a lower decrease of 5-HIAA and a significantly greater increase of 5-HT than women without preeclampsia. These results could be explained by a decreased metabolism of 5-HT due to the placental MAO. The changes observed in our study are not due to a decreased kidney function because creatinine concentrations in women with and without preeclampsia were comparable. Our results indicate that 5-HIAA-/creatinine ratio might be an important prognostic factor.

Transvaginal sonomorphologie and colour Doppler measurements were obtained preoperatively in 212 adnexal tumours: 81 premenopausal tumours (13 malignant and 68 benign) and 131 postmenopausal tumours (55 vs 76). Tumours were divided into five different scores according to their sonomorphology [16]. Scores I and II are related to benign tumours. Score V represents typically malignant tumours. Scores III and IV are associated with benign and malignant tumours. If score I and II are considered as benign and score III to V as malignant the sensitivity in pre- and postmenopausal tumours is 90%. However, the specificity is only 56% vs 70% respectively. In order to improve the accuracy, colour Doppler was additionally performed in tumours with sonomorphological score III and IV. The following criteria were tested: minimum resistance index (Rlmin), number of tumour arteries (ART), maximum (Smax) and sum (Ssum) of peak systolic velocities. All criteria showed significant differences between benign and malignant tumours. Tumours of score III and IV were differentiated by colour Doppler with an accuracy between 66% and 81% for premenopausal and 69% to 86% for postmenopausal women. The combination of sonomorphology and colour Doppler increased the accuracy between 84% and 90% with a sensitivity of up to 92% in pre- and 89% in postmenopausal patients. Sequential colour Doppler sonography as a supplement to transvaginal sonography improves tumour differentiation. The limitation of colour Doppler measurements to score III and IV lesions reduced the length of examination time to a reasonable extent.

Several complications of pregnancy have been reported to be associated with alterations of serotonin (5-hydroxytryptamine; 5-HT) metabolism. Reported data regarding changes of 5-HT metabolism in pregnancy are partially contradictory. The presented study tries to describe pregnancy-associated changes in 5-HT metabolism. Urine and blood samples were taken from 20 pregnant women 4 weeks before, within 24 hours and on the 4th day following delivery. 17 non-pregnant age-matched women served as controls. 5-HT and its main metabolite 5-hydroxyindoleacetic acid (5-HIAA) were analysed. We observed a continuously increasing production and excretion of unbound 5-HT and 5-HIAA during pregnancy. Four days after delivery 5-HT production returned to baseline levels, while excretion remained elevated. 5-HIAA excretion increased in pregnancy and return to baseline levels on the day following delivery. Increased 5-HT metabolism and excretion results in a decreased 5-HT serum concentration despite increased 5-HT production during pregnancy. Our results help to understand the contradictory observations of elevated 5-HT production on the one hand and decreased 5-HT activity during pregnancy on the other.

In 129 patients with ovarian tumours, a preoperative examination by transvaginal colour Doppler sonography (ATL UM9 HDI) was performed. 45 were malignant and 84 benign. 46 patients were premenopausal and 83 postmenopausal. All tumour vessels were analysed by spectrum analysis. The number of tumour vessels and the lowest resistance index (RImin) and pulsatility index (PImin) of all vessels were evaluated as diagnostic criteria of the neovascularisation. Up to 19 vessels were found in 115 (89%) tumours. In benign lesions, the number of vessels was significantly lower than in malignancies (median 3 versus 9, p < 0.0001). The RImin and PImin values between benign and malignant tumours were also significantly different, independent of the menopausal status. In postmenopausal patients, the median RImin in 42 benign tumours was 0.62 (0.26-1.0) and in 41 malignancies 0.40 (0.22-0.66). The median PImin was 0.98 (0.31-5.84) in benign tumours and 0.53 (0.25-1.22) in malignant tumours. However, due to the overlapping range between benign and malignant tumours, these parameters do not allow an accurate differentiation. With a cut off value for RImin = 0.5 and PImin = 0.7, the sensitivity is 85% or 82.5% respectively. The specificity for RImin and PImin is 77%, and the diagnostic accuracy is 84% and 80% respectively. The correlation coefficient between RImin and PImin is 0.99 in benign and malignant tumours and both indices are adequate. The calculation of the RI is more easily available and should be preferred as a diagnostic parameter.

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, partnerʼs 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 motherʼs 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.

Doppler blood flow measurements allow differentiation of malignant lesions, that are characterised by an abnormal vascularity. The accuracy of this method is limited due to the physiological flow variation in normal breast parenchyma and in tumours. Magnetic resonance imaging in combination with contrast agents can also be used for flow assessment by measurement of the dynamic contrast enhancement. Recently, a new echo contrast agent (Levovist) has been developed, which survives pulmonary transit and increases the Doppler signal intensity after intravenous injection. Fourteen malignancies with low vascularity were selected for the study. Twenty-two seconds after injection of contrast agent, the Doppler signal intensity increased dramatically. This demonstrates, that echo contrast agents might improve the diagnosis of breast lesions in case of non-conclusive Doppler findings.

Fortunately, coincidence of pregnancy associated with malignant neoplasm is rare. As reported in the literature, incidence is 1.5-10: 10,000 pregnancies. The study presented reports data on the incidence and outcome of 16-35 years old female patients suffering from malignant neoplasms. Patients, who were treated in Freiburg 1980-1989, were considered for evaluation. We analysed the impact of pregnancy on the outcome of these patients by stratifying patients for the time of diagnosis (before, during, or after a pregnancy). 247 patients were included. 118 patients developed a neoplasia after a successful pregnancy. In 24 patients, neoplasia was diagnosed during pregnancy, and 28 patients became pregnant after diagnosis and therapy for a malignancy. Further 77 patients without pregnancy, but in whom neoplasia diagnosed at the age of 16-35 years were included. Cancer of the cervix uteri, breast cancer, ovarian cancer, and malignant lymphomas were the most frequent neoplasias diagnosed in young women. In an analysis stratified for stage of disease, we found no significant difference between 3- and 5-years survival of patients with pregnancies before, during, or after diagnosis and treatment of neoplasia. Due to the inhomogeneity of the subgroups analysed, the question, whether pregnancy has any impact on the outcome of neoplasm could not be conclusively answered. The necessity for the establishment of national and international registries collecting sufficient data about incidence and outcome of patients with pregnancies associated with malignant neoplasms is emphasised.

There is a low incidence of pregnancy associated with malignancy. We performed a retrospective analysis of patients of 16 to 35 years of age with malignancies, who had given birth to children in Freiburg 1980-1989. 170 patients were included. 118 patients became pregnant before a malignancy was diagnosed. Malignancy was diagnosed during pregnancy in 24 patients, and 28 patients became pregnant after diagnosis of and therapy for neoplasm. The frequency of preterm delivery, growth retardation and performance of Caesarean section was markedly increased only in patients with concurrent pregnancy and malignancy. 59 children were born after their mother had been treated for a malignancy. Treatment was started during pregnancy in 19 cases. 40 children were born to mothers who became pregnant after treatment. Malformations and abnormalities with respect to the development of the children were observed in similar frequency in both groups and occurred more frequently compared to the group of children, who were born before the treatment of the mother. These results were supported by an analysis of 16 siblings. We conclude, that there is a demand for national and international registries for all pregnancies associated with malignancies. Long-time observation of the children born to mothers, who had been treated for malignancy are necessary.

From 1987 until 1992, 16 triplets and 2 quadruplets were studied by pulsed Doppler ultrasound between 17 and 36 weeks of gestation. A resistance index (RI) of the foetal aorta and umbilical artery above the 95th percentile was considered pathological. Elevated RI-values of the umbilical artery as compared to the A. cerebri media were indicative of circulatory centralisation. Intrauterine growth retardation (IUGR) was found in 9 (16%) foetuses, discordant growth occurred in 7 (39%) pregnancies. 41 (73%) of 56 foetuses survived in good health. Four of 7 foetuses with pathological Doppler findings died. The three survivors were markedly retarded. Four of 6 cases of intrauterine endangered foetuses were detected by Doppler sonography. The diagnosis of IUGR or discordant growth was based more frequently on pathological Doppler findings than on biometry and improved upon by combinations of both methods. Doppler sonography proved to be an important complementary method in the monitoring of high-grade multiple pregnancies.

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.

We retrospectively analyzed 95 intact twin pregnancies (GG) only diagnosed by sonography during the period 1977-1987: 48 GG were registered up to the 10th week of pregnancy (G 10), 90 between the 11th and the 16th week of pregnancy inclusive (G 16). In the group G 10, this spontaneous fetal loss, including the perinatal mortality amounted to 10.9% (10 of 92) twins (GF). In 5 cases from this group, a previously vital twin was lost before the 10th week. The loss in group G 16, including the perinatal mortality, was 9.7% (17 of 176 twins GF). An early or late abortion occurred in 6 cases (6.8%) and dies perinatally in this group. 82 GG were carried out to full term. 38 women (46.3%) had premature births, 12 pregnancies (12.6%) ended before the 34th week of pregnancy. The perinatal mortality rate amounted to 3.0% (5 GF), 4 (2.3%) of 172 GF had serious malformations. In 6 GG (7.4%) the weight of the twins differed more than 25%.