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Prostaglandin-mediated inflammatory reactions play a major role in different cancers. Prostaglandin E2-receptor 3 (EP3) expression correlates with FIGO stages in cervical cancer and has been shown to be an independent prognostic factor for overall survival. EP3 expression levels in cervical intraepithelial neoplasia (CIN) as the precursor lesion of cervical cancer are currently unknown. EP3 expression was analyzed by immunohistochemistry in 124 patient samples (CIN 1–3 and healthy controls) using the IR-scoring system. Expression levels were correlated with clinical outcome to assess for prognostic relevance in patients with CIN 2. Data analysis was performed using Kruskal–Wallis and Mann–Whitney U test. EP3 expression levels significantly correlated with different grades of cervical dysplasia. Median EP3-IRS in healthy cervical tissue was 12 (n = 13) compared to 9 in CIN 1 (n = 38; p = 0.031 vs. healthy control), 6 in CIN 2 (n = 45; p

OBJECTIVE To show noninferiority of a limited-excision (resection of the dysplastic lesion only) vs. classical Large Loop Excision of the Transformation Zone (LLETZ). METHODS In this prospective, randomized, multicenter trial, women with human papillomavirus (HPV) positive cervical intraepithelial neoplasia grade 3 were randomized into two groups (1:1). Primary outcome was the rate of negative HPV tests after 6 months, secondary outcomes included cone size, complete resection rates as well as cytological and histological results after 6 and 12 months. A sample size of 1,000 was calculated to show noninferiority of the limited-excision compared to the LLETZ group using a noninferiority margin of 5%. Enrollment was stopped after 100 patients due to slow accrual. RESULTS Patients in the limited-excision group did not show a lower number of negative HPV tests (78% [LLETZ]-80% [limited-excision]=-2%; 90% confidence interval=-15%, 12%). The limited-excision resulted in a substantially lower cone size (LLETZ: 1.97 mL vs. limited-excision: 1.02 mL; p

Arteritic anterior ischemic optic neuropathy (A-AION) caused by inflammatory occlusion of the posterior ciliary arteries is the most common reason for irreversible vision loss in patients with giant cell arteritis. Atypical clinical presentation and negative funduscopy can delay systemic high-dose corticosteroid therapy to prevent impending permanent blindness and involvement of the contralateral eye.The purpose of this study was to assess the diagnostic accuracy of 3-dimensional (3D) high-resolution T1-weighted black-blood magnetic resonance imaging (T1-BB-MRI) for the detection of posterior ciliary artery involvement in patients with giant cell arteritis and funduscopic A-AION.After institutional review board approval and informed consent, 27 patients with suspected giant cell arteritis and vision disturbances were included in this monocentric prospective cohort study. Giant cell arteritis was diagnosed in 18 patients according to the diagnostic reference standard (6 men, 73.8 [69.0-78.0] years); 14 of those were positive for A-AION. Precontrast and postcontrast 3D T1-BB-MRI was performed in all 27 patients. Two radiologists separately assessed image quality and local fat suppression (4-point scale), visual contrast enhancement (3-point scale), and diagnostic confidence (5-point scale) regarding arteritic posterior ciliary artery involvement. Magnetic resonance imaging findings were assessed in comparison to funduscopy. Statistical analysis included accuracy parameters and interrater agreement.Sensitivity of 3D T1-BB-MRI was 92.9% (95% confidence interval, 66.1%-99.8%) and specificity was 92.3% (95% confidence interval, 64.0%-99.8%) for detection of A-AION-positive patients. Image quality and local fat suppression were assessed with 3.2 ± 0.8 (median 3) and 3.8 ± 0.5 (median 4). Visual contrast enhancement with 2.3 ± 0.8 (median 3) and diagnostic confidence was rated at 4.7 ± 0.5 (median 5). Interrater agreement was high (κ = 0.85, P0.001). Three-dimensional T1-BB-MRI displayed bilateral findings in 50% of the cases, whereas only unilateral A-AION was detected in funduscopy as a possible indication for the contralateral eye at risk.Three-dimensional T1-BB-MRI allows accurate detection of arteritic posterior ciliary artery involvement in patients with A-AION. Further, 3D T1-BB-MRI seems to display arteritic involvement of the posterior ciliary arteries earlier than funduscopy and might, therefore, display "vision-at-risk" in patients with visual impairment and suspected giant cell arteritis but unremarkable funduscopy.

PPAR&gamma, belongs to the group of nuclear receptors which is expressed in the trophoblast and together with other factors is responsible for the maintenance of pregnancy. Apart from that PPAR&gamma, is also a main factor for macrophage polarization. The aim of this study was to investigate the combined expression pattern and frequency of PPAR&gamma, under physiological circumstances and in spontaneous and recurrent miscarriages in the trophoblast and in maternal macrophages of the decidua. Human placental tissues of the first trimester (15 physiologic pregnancies, 15 spontaneous abortion and 16 recurrent miscarriage placentas) were analyzed for expression of the nuclear receptor PPAR&gamma, Expression changes were evaluated by immunohistochemistry and real time PCR (RT-PCR) in trophoblast and in maternal macrophages of the decidua. Maternal macrophages were identified by double immunofluorescence using cluster of differentiation 68 (CD68) as marker for macrophages and further characterized regarding their M1/M2 polarization status. The intermediate villous trophoblast revealed a significantly lower PPAR&gamma, expression in spontaneous and recurrent abortion. Maternal macrophages express PPAR&gamma, Their number is significantly enhanced in the decidua of spontaneous miscarriages whereas in recurrent miscarriages maternal macrophages seem to express PPAR&gamma, only in very few cases. PPAR&gamma, is associated with an M2 polarization state that is common for decidual macrophages. The lack of PPAR&gamma, in recurrent miscarriage decidual macrophages seems to be associated with a specific inflammatory response against the fetus.

Purpose of the investigation: Vulvovaginal candidosis (VVC) is a common vaginal infection affecting almost 75% of all women once per lifetime. Vaginal associated immunity is important in the protection against VVC. The purpose of this study was to evaluate a potential role of IL-23, IFN-α, and IFN-β in the local immune response against VVC.The study included 202 non-pregnant women; 71 patients with clinical symptoms of VVC and 131 asymptomatic patients served as control. IL-23, IFN-α, and IFN-β were measured in the vaginal fluid by ELISA. Microbiological cultures were used for Candida detection.C. albicans was detected in 67.6% of patients, C. glabrata in 2 1.1% of patients, and 5.6% were infected with C. krusei or coinfected with C. albicans and C. krusei. Levels of IL-23 (p0.001) and IFN-β (p0.017) were significantly lower in the VVC group. IFN-α was elevated in the VVC group compared to the asymptomatic patients (p0.001).IL-23 and IEFN-β seem to play a protective role against VVC. Decreased levels in VVC patients suggest a compromised local immune response at the time of occurrence of symptoms. In contrast, IFN-α seems to be released once the infection has occurred. These cytokines may be prospective targets in the treatment and prevention of primary and recurrent vaginal infections with Candida species.

Background The purpose of this study was to analyze the involvement of signaling via Interleukin-4-Receptor α (IL4Rα) and Toll like receptor (TLR) 4 at the fetomaternal interface in the process of early pregnancy. Patients And Methods Placenta specimens of 46 patients in early pregnancy were analyzed (normal pregnancy (n = 15), spontaneous (n = 15) and habitual abortion (n = 16)). TLR4 and IL4Rα were analyzed by immunohistochemistry, immunofluorescence and real time PCR. Statistical analysis was carried out using SPSS 23 and Microsoft Excel. Results IL4Rα could be detected in trophoblast cells of all groups. It was significantly downregulated in the syncytiotrophoblast of spontaneous and recurrent abortions (p = 0.001), and in decidual tissue of spontaneous abortions (p = 0.001). Expression of TLR4 was decreased in the intermediate villous trophoblast (IVT) and decidua of spontaneous abortions (p = 0.04 & 0.003, respectively). On mRNA level expression of IL4Rα and TLR4 was significantly decreased in the group of recurrent miscarriages (IL4Rα p = 0.002, TLR4 p = 0.004). Conclusion This study contributes new findings to the understanding of the complex molecular interplay at the fetomaternal interface in normal pregnancy and miscarriages. For the first time signaling via IL4Rα being involved at the very beginning of the generation of new life could demonstrated. Moreover, new evidence was provided regarding TLR4 playing a pivotal role in early pregnancy.

Background: This study aimed to identify the association of local surgery of the primary tumor in metastatic breast cancer (MBC) patients with overall survival (OS) and prognostic factors. Patients and Methods: Patients with primary MBC (1990-2006) were included in our retrospective analysis (n = 236). 83.1% had surgery for the primary tumor. OS was evaluated using Kaplan-Meier estimates. Predictive factors for OS were determined. Results: Median follow-up was 123 months for all patients still alive at the time of analysis. In univariate analysis, patients with surgery of the primary tumor had significantly prolonged OS (28.9 vs. 23.9 months). Within the surgery group, patients with MBC limited to 1 organ system had a better outcome (39.3 vs. 24.9 months), as did asymptomatic patients. Independent risk factors for shorter OS were hormone receptor negativity, symptoms, and involvement of ≥ 1 organ system. Conclusion: Patient selection for local therapy was confounded by a more favorable profile and a lesser tumor burden before surgery, which might implicate a bias. Nevertheless, our univariate results indicate that local surgery of the primary tumor in MBC patients could be considered as part of the therapeutic regimen in selected patients. However, larger patient numbers are needed to prove these findings in the multivariate model.

Purpose Approximately 10–15% of breast cancer patients treated by breast conserving surgery (BCS) and adjuvant radiotherapy (RT) will develop ipsilateral breast tumor recurrence (IBTR). International guidelines suggest total mastectomy as treatment of choice for IBTR following lumpectomy and RT. Nevertheless, there is evidence that second BCS might be equally sufficient. Patients and methods Patients with IBTR diagnosed between 1990 and 2014 after BCS and RT were included (n = 170). 34.1% women underwent secondary BCS, whereas 65.9% were treated by mastectomy. We determined predictive factors for time to local progression (TTP), disease free survival (DFS), and overall survival (OS) comparing these two groups. Results Median follow-up after primary IBTR was 49 months (59 months for patients still alive at time of analysis). Five-year IBTR-free rate after secondary BCS was 77.6% (SD ± 6.1%) and 75.0% (SD ± 4.5%) for patients after mastectomy. Five-year DFS was 57.3% (SD ± 8.2%), and 61.9% (SD ± 5.5%), five-year OS was 84.7% (SD ± 5.8%), and 72.6% (SD ± 5.1%), respectively. Prior adjuvant systemic therapy, muscular invasion, and skin infiltration were independent significant risk factors for a shorter TTP. Additionally, lymphovascular infiltration (LVI) in the IBTR increased the risk for a shorter DFS. LVI, muscular invasion, and skin infiltration were identified as independent significant risk factors for a shorter OS. Conclusion No significant difference in local control, DFS, and OS was seen between IBTR patients treated either by secondary BCS or mastectomy. Our data suggest that secondary BCS for IBTR patients after initial BCS and RT is feasible in selected patients.

In clinical routine, adjuvant systemic therapy in small node-negative (N0) BC is controversial, in particular in HER2-positive disease. We aimed to evaluate outcome of consecutive patients with small N0 BC in a population-based cancer registry and thus consequently substantiate indications for chemotherapy in those patient subgroups at increased relapse risk or poor survival.From 2002 to 2009 (median follow-up 6 years), 9707 primary breast cancer patients with N0 tumors2 cm (pTis, pT1N0M0) were reported to the Munich Cancer Registry. Patients with pTis tumors (n = 1870) served as internal comparator. Time to progression, observed (OS) and relative survival rates (Kaplan-Meier estimates) are presented. Cox regression analysis was used to assess the influence of tumor size, age, HR-, and HER2-status.10-year-OS for pTis was 94.0%. In HR-positive tumors it was 91.9% in pT1a, 90.6% in pT1b, and 86.8% in pT1c. In HR-negative tumors, rates were 91.7%, 86.8%, and 86.8%, respectively. In HER2-positive tumors it was 81.2%, 88.1%, and 86.7%, in HER2-negative 93.1%, 90.6%, and 86.0%, respectively. In the multivariate model, age, tumor size, and HR-status showed a significant impact on OS (HRneg. vs. HRpos.: hazard ratio 1.50 (95% CI; 1.12-1.99), while HER2-status was not an independent prognostic factor.Prognosis of N0 tumors1 cm is excellent, especially if they are HR-positive, even in HER2-positive cases. Weighing potential benefits vs. side-effects, there seems to be no need for chemotherapy in tumors0.5 cm. In pT1b chemotherapy may be considered, if tumors are triple negative or HER2-positive and HR-negative. In pT1c guideline-based adjuvant therapy using all therapeutic options seems to be warranted.

A repeat Pap smear is sometimes necessary after a short time interval or even immediately, when patients seek for a second opinion or due to study participation. Only limited information is available on the possible impact of a short interval between two Pap smears. Most institutions therefore practice a minimum time span of 6–8 weeks before obtaining a second smear since a short interval is commonly believed to be associated with an increase of false negative results in the second smear. Two consecutive Pap smears were obtained from 81 women. 41 smears were processed using the conventional technique, whereas liquid-based cytology was used in the remaining 40 women. Smears were independently evaluated by four different cytopathologists. We analyzed the effect of time interval, both processing techniques and inter-observer variance in cytological evaluation. While the result of the second smear shows a tendency towards a more benign outcome (odds ratio (OR) 1.436, 95% CI 0.972–2.121), this difference was not statistically significant (p = 0.07). No significant differences were observed between conservative and liquid-based cytology (OR 1.554, 95% CI 0.659–3.667, p = 0.31). There was considerable inter-observer variability, and the observer was a strong predictor of the cytological result (OR 0.632–5.083, 95% CI 0.355–8.975, p

Zielsetzung: Ovarialkarzinome (OC) sind hormonabhangige Tumore und in ca. 5 – 10% mit einer BRCA1/2-Mutation assoziiert. Neben der bekannten Ostrogen- und Progesteronrezeptor-Expression gibt es erste Studien zu Kernrezeptoren wie Thyroid- und Vitamin D-Rezeptoren. Daruber hinaus bestehen Hinweise fur einen Zusammenhang zwischen Schilddrusendysfunktionen und der Erkrankung an einem OC. Die aktuelle Untersuchung fokussiert auf die Untersuchung des Schilddrusenhormonstatus und Vitamin D bei Ovarialkarzinompatientinnen mit BRCA-Mutation im Vergleich zu Nicht-Mutationstragerinnen in BRCA1/2. Zusatzlich wurden die Hormonspiegel von Ostradiol, Progesteron, FSH, LH und AMH bestimmt. Material und Methoden: Im Serum von 60 Ovarialkarzinompatientinnen (n = 30 mit somatischer und/oder Keimbahnmutation versus n = 30 ohne nachgewiesene Mutation) wurden o.g. Hormone praoperativ und im Krankheitsverlauf bestimmt. Zusatzlich wurden anhand eines Fragebogens anamnestische Angaben zu Schilddrusendysfunktionen, Einnahme von Vitamin D und hormoneller Therapie erfasst. Ergebnisse: Die pra- und postoperativ bzw. post-chemotherapeutischen Hormonwerte von BRCA-mutierten und nicht-mutierten Patientinnen werden verglichen und im Hinblick auf Tumorbiologie und Krankheitsverlauf der einzelnen Gruppen untersucht. Die Ergebnisse werden aktuell ausgewertet und liegen bis Oktober 2016 vor.

Purpose: In order to achieve a higher vaccination rate, education on HPV as well as options for prophylaxis performed by doctors is of great importance. One opportunity to increase the protection against HPV would be vaccinating boys. This study evaluated attitude and knowledge among German gynecologists regarding HPV vaccination, especially in boys. Material and Methods: A questionnaire with 42 questions about demographics, attitude and knowledge about HPV and HPV vaccination was sent to members of the German Society for Gynecology and Obstetrics (DGGG). Results: 998 out of 6567 addressed gynecologists participated. Knowledge about HPV, associated diseases and possible HPV vaccines was high among participants. The attitude towards vaccination in boys as well as girls was positive. Only 8.2 % refused to vaccinate their sons whereas 2.2 % refused to do this for their daughters. However, only few gynecologists vaccinated their daughters and sons against HPV. Main reason for girls was an age outside of vaccination guidelines; for boys it was the lack of cost coverage. Conclusion: The willingness of gynecologists to perform HPV vaccination in boys is as high as for girls. However, sons of gynecologists are only rarely vaccinated against HPV. Main reason is the lack of cost coverage. Vaccinating boys could decrease the disease burden in males, as well as protect women by interrupting ways of transmission. Since the main argument against vaccination of boys is only of financial nature, the necessity of a vaccination recommendation for boys needs to be re-evaluated taking into account the cost-reduced 2-dose vaccination scheme.

The incidence of cardiovascular morbidity and mortality in premenopausal women is comparatively low, but increases sharply after menopause. The principal aim of this study was to determine whether women with ascending aortic disease (AAD) have a different reproductive history from that of an age-matched control group.In this retrospective study, women who had undergone ascending aortic aneurysm (AscAA) repair between 2000 and 2010 were asked to complete a questionnaire concerning risk factors and reproductive history. Data from 142 women with AAD were evaluated, and a subgroup (n = 64) with AscAA ≥5 cm was analyzed and compared to an age-matched random control group without known aortic diseases.Almost all women were menopausal at the time of the questionnaire (98.4% vs. 90.6%, AscAA ≥5 cm subcohort vs. control, p = 0.12) and all subjects presented with a comparable age of menarche (13.7 ± 2.6 years vs. 14.2 ± 1.8 years, AscAA ≥5 cm subcohort vs. control, log-rank 0.04, p = 0.84). However, mean menopausal age was significantly lower in the case subcohort than in controls (48.1 ± 4.8 years vs. 50.6 ± 5.8 years, AscAA ≥5 cm subcohort vs. control, log-rank 8.35, p = 0.004), and reproductive life span was correspondingly shorter (34.2 ± 5.2 years vs. 36.2 ± 5.7 years, p = 0.04). Furthermore, hypertension was more prevalent in women with AscAA ≥5 cm compared to controls (89.1% vs. 61.9%, AscAA ≥5 cm subcohort vs. control, p 0.001).Women who experience menopause at an earlier age than the regional mean could profit from screening for cardiovascular disease in general and particularly for AAD. Screening would enable early aneurysm detection and could, therefore, reduce morbidity and mortality.

Zielsetzung: Welche Auswirkungen hat die LEEP-Konisation auf Fluor vaginalis, auf die Haufigkeit vaginaler Infektionen, auf die Sexualitat und auf die psychische Belastung der Patientinnen? Methoden: Diese prospektive Fall-Kontroll-Studie untersucht Frauen nach Konisation (Gruppe_A) im Vergleich zu einer Kontrollgruppe (Gruppe_B) mit ahnlich kleinen operativen Eingriffen (Ausschlusskriterien: Malignome, Hysterektomie, beidseitige Adnexektomie, > 50. Lj). Alle Teilnehmerinnen fullten praoperativ, 6 und 12 Monate postoperativ einen Fragebogen zur gynakologischen Anamnese sowie zwei sehr differenzierte validierte Fragebogen zur psychischen Belastungssituation (FKB-R23) und Sexualitat (FSFI-d) aus. Der FSFI-d differenziert 6 Domanen der Sexualitat (Lust, Erregung, Lubrikation, Orgasmus, Zufriedenheit, Schmerz), hier wird eine Zwischenauswertung der Unterpunkte Zufriedenheit und Orgasmus vorgestellt. Durch je 3 Items ist in beiden Domanen eine Punktzahl von 1,2 (sehr unzufrieden) bis 6 (sehr zufrieden) erreichbar. Ergebnisse: In die noch laufende Studie wurden bisher 302 Frauen aufgenommen (Gruppe_A n = 173, Gruppe_B n = 129). Beide Gruppen sind hinsichtlich Alter vergleichbar. Die Antwortrate nach 6 und 12 Monaten betragt aktuell 71%. Hinsichtlich Zufriedenheit mit dem Sexualleben war bei einer maximal erreichbaren Punktzahl von 6 der Mittelwert praoperativ 4,15 (A) versus 3,91 (B). 12 Monate postoperativ betrugen die Mittelwerte 4,31 versus 4,69. Die Unterschiede waren zu beiden Zeitpunkten statistisch nicht signifikant (p > 0,05). Bei der Domane Orgasmus war der Mittelwert praoperativ 3,99 (A) versus 3,52 (B) und 12 Monate postoperativ 4,43 (A) versus 4,28 (B). Auch hier unterschieden sich die beiden Gruppen nicht signifikant. Zusammenfassung: In dieser Studie zeigt die LEEP-Konisation im Vergleich zu anderen gynakologischen Eingriffen weder einen signifikanten Einfluss auf die Zufriedenheit mit dem Sexualleben noch auf die Orgasmus-Fahigkeit und -Haufigkeit.

The purpose of this study was to evaluate the influence of guideline-based prospective use of uPA/PAI-1 on clinical outcome in an intermediate-risk cohort of breast cancer patients. We analyzed 381 consecutive primary breast cancer patients (2003-2011) at the breast center Ostbayern meeting the following criteria: M0/N0/estrogen receptor (ER)+/G2. Clinical-pathological data, uPA/PAI-1, and follow-up data were collected. Decisions for adjuvant chemotherapy were made upon consideration of prospectively measured uPA/PAI-1. Observed disease-free survival (DFS) and overall survival (OS) were calculated by Kaplan-Meier estimates. Using guideline-based analysis of uPA/PAI-1, treatment with adjuvant chemotherapy was avoided in 86.5 % of patients with low uPA/PAI-1, i.e., 38.8 % of the total patient collective. Median follow-up was 52.5 months. Five-year relapse-free survival in intermediate-risk patients (N0, G2) without chemotherapy was 99 %. Five-year overall survival including all causes of death was 95 %. By using uPA/PAI-1, adjuvant chemotherapy can be avoided in a major part of patients with intermediate-risk breast cancer. Nevertheless, DFS and OS of these patients at 5 years remain excellent. The potential, but hardly measurable, benefit of adjuvant chemotherapy has to be set in contrast with its associated side effects and increased morbidity. Patients with high uPA/PAI-1 show benefit from chemotherapy. In this subgroup, a very good OS was observed as well. These findings strongly support the use of uPA/PAI-1 together with clinic-pathological parameters as an evidence-based, clinically relevant and inexpensive decision tool in the routine of a breast center.

Introduction/Question: The goal of this study was to compare the function and the usability of an industrially manufactured fetal pulse oximetry sensor, DualSens and the FetalSAT Fetal Pulse Oximetry System which can be used with ordinary CTG equipment. The DualSens sensor is an improved version of the electrode developed by Knitza and Rall [1]. It provides an internal CTG signal similar to a fetal scalp electrode, while simultaneously measuring fetal oxygen saturation and fetal heart rate. Material and Methods: Throughout 2003, the following hospitals participated in the study: WolfartKlinik Grafelfing, Klinikum Mannheim, Klinikum Memmingen, Klinikum Rosenheim, Stadtisches Krankenhaus Munchen-Schwabing, Frauenklinik vom Roten Kreuz Munchen. To conduct the study, NONIN Medical Inc., a medical device manufacturer in Plymouth, Minnesota, USA provided each hospital with a FetalSAT Fetal Pulse Oximetry System and Dualsens sensors. The following points were analyzed during the study: 1) overall usability of the system, including ease of sensor application (e.g. ease of handling during the attachment, necessity of reattachment, and patient impairment); 2) distribution of the displayed oxygen saturation values during the course of deliveries with normal fetal outcome based on ca. 800000 data pairs; 3) registration time as a percentage of the total duration of labor and delivery. Results: A total of 120 deliveries were evaluated with an average of measurement time of 146 min per delivery (min: 13; max: 576). The following results were noted: 1) sensor application and use is simple and easy to learn; it is very similar to the application of an fetal scalp electrode. Sensor reapplication is typically unnecessary, and special anesthesia is not required. Typically, patient's movement is not restricted, and patients do not feel any limitations; 2) The results support assumptions in the literature that the borderline to fetal hypoxia during delivery should be in the range of 25 to 30% oxygen saturation; 3) Fetal oxygen saturation data could be obtained during 93% of the monitoring time including all phases of the delivery process (1st stage, 2nd stage and even during the pushing period). Conclusion: The unique attachment of the sensor to the scalp clearly allows for much higher and more reliable registration times, providing increased and improved pulse oximetry data compared to previously available systems [2,3]. With its almost uninterrupted registration time of fetal oxygen saturation in combination with the internal CTG, we can reasonable expect that the FetalSAT System will allow for more precise and informed judgments concerning fetal wellbeing, providing additional safety and security for everyone involved.

Objective: We surveyed the attitudes of practicing obstetrician-gynecologists to elective cesarean delivery in light of their personal experience and estimated the effects of elective cesarean delivery on the overall rate of cesarean delivery. Methods: In January 2002 we sent questionnaires to all 1502 practicing obstetrician-gynecologists and the chairpersons of all 164 obstetric units in Bavaria. Results: The response rate was 36% (594/1666). 7.6% of practicing obstetricians and 8.7% of department chairpersons would prefer elective cesarean delivery for themselves or their partner for an uncomplicated pregnancy with cephalic presentation. There were no differences regarding age or sex of the respondents. All obstetricians who themselves or their partner had had an operative vaginal delivery would retrospectively prefer vaginal over cesarean delivery for themselves or their partner. 56% (292/525) of practicing physicians agreed that the option of elective cesarean delivery should be available. 71 % (49(69) of obstetric units performed elective cesarean deliveries, 29% (20) did not. The cesarean delivery rates at units offering elective cesarean delivery did not differ from that at units that did not. Elective cesarean deliveries were estimated to account for 6.2% of all cesarean deliveries at the units where it was available. Conclusion: Most practicing obstetricians, both male and female, in Bavaria prefer vaginal delivery. However, elective cesarean delivery is accepted by an increasing number of practicing physicians and department chairpersons. There does not appear to be an effect on the overall rate of cesarean delivery.

The aim of this case control study was to investigate the influence of genital Ureaplasma urealyticum colonization on pregnancy outcome.One hundred and seventy-two women colonized with Ureaplasma urealyticum without co-existing other infections and 123 women with negative cultures for Ureaplasma urealyticum were enrolled. In a multivariate analysis the influence of quantitative Ureaplasma urealyticum colonization level was determined.Compared to the negative women increasing colonization with Ureaplasma urealyticum was associated with a significant decrease of birth weight (p0.0001) and gestational age (p0.0001) and with a significant increase of chorioamnionitis (p0.0001) and preterm delivery (p0.001). In a multivariate analysis high-density Ureaplasma urealyticum colonization was an independent risk factor for chorioamnionitis and preterm delivery, whereas low colonization levels had no effect on an adverse outcome of pregnancy.The degree of colonization with Ureaplasma urealyticum correlates strongly with an adverse effect on pregnancy outcome.

Objective: The incidence of preterm birth has remained unchanged for years at about 8-10%. Prematurity remains the leading cause of neonatal mortality, accounting for 70-85% of all neonatal deaths, so that the prevention and treatment of preterm labor is a central issue in pregnancy care. Methods: We review possible risk factors for preterm labor and strategies for prevention and treatment. Results: Although infections play an important role in the etiology of preterm labor, antibiotics should not be used prophylactically without evidence of infection in patients with intact membranes. In contrast, a beneficial effect for antibiotics has been proved for preterm premature rupture of the membranes. Only 10-20% of women with preterm labor have an indication for tocolytic treatment. The use of tocolytics before 24 and after 36 weeks' gestation should be limited to special situations. Tocolytic treatment with intravenous β 2 -sympatheticomimetic agents can significantly reduce the rate of delivery within 48 hours, a period sufficient to reduce the risk for the respiratory distress syndrome with corticosteroids. In contrast, the efficacy of longterm parenteral tocolysis or oral tocolysis is unproved. In certain situations tocolysis can be achieved with intravenous magnesium, nifedipine, or inhibitors of prostaglandin synthesis. The psychosocial situation should also be taken into account because there is evidence that psychologic aspects play a role in the etiology of preterm labor.

Spontaneous heterotopic pregnancy, i.e. simultaneous intra- and extrauterine gestation, is as rare as 1 : 10 000 to 1 : 30 000 of spontaneous conceptions [ ]. Usually heterotopic pregnancies are diagnosed later than the ectopic pregnancy, often not until clinical signs of intraabdominal bleeding appear due to tubal rupture, though due to modern reproductive procedures an increase in heterotopic pregnancies has been registered [ , ]. We describe our operative procedure in a woman with previous bilateral salpingectomy followed by in vitro fertilization and an interstitial and intrauterine pregnancy. The interstitial pregnancy could be removed 27 days after embryo transfer with laparoscopic excision of the ectopic implantation and conservation of the intrauterine pregnancy which subsequently had an uneventful obstetrical course till term.

Visual disturbances of physical origin are not uncommon during the course of severe preeclampsia or eclampsia. We report on a case of temporary psychogenic blindness in a patient with postpartum HELLP syndrome.

Purpose: The fetal movement profile (FMP) is often used as an additional tool for FHR interpretation. Aim of this study was to establish reference curves for the FMP dependent on gestational age and to evaluate a cut off value for the selection of pregnancies at risk. Method and Material: 250 normal pregnancies and 56 high-risk pregnancies with IUGR (birthweight < 5 th perc.) were investigated between 28 th and 42 nd week of gestation using the FMP every 8-10 days. Fetal motor activity was analyzed quantitatively. The diagnostic value of FMP was evaluated with respect to fetal outcome parameters. Results: Fetal motor activity showed a peak at 35 th week of gestation. With respect to ROC diagrams the cut off value for the selection of fetuses at risk was defined at the fifth percentile of the established reference curves. For the fetal outcome parameters umbilical cord pH < 7.20, 5 min Apgar score < 7 and operative delivery because of fetal distress, the sensitivity of FMP was 33%, 12% and 28%, the specificity 97%, 97%, 98%, the positive predictive value 50%, 66%, 98%, and the negative predictive value 94%, 72% and 72%, respectively. Conclusion: The fetal movement profile (FMP), as available in Kineto-Cardiotocography, has a higher specificity than antepartum CTG. The reference curves for FMP are calculated in relation to changes of fetal motor activity depending on gestational age and may improve the evaluation of this parameter.

Caesarean section rates are rising continually during the last years (Bavarian Perinatal Inquiry/BPI 1994: 17.7%). Consequently, the number of women who become pregnant after previous Caesarean section is increasing (BPI 1994: 8%). Trial of labour is fearible in almost all women with nonrecurrent indication for the preceding Caesarean section. Despite this fact, elective repeat Caesarean section is performed in many cases. The aim of the study presented here is to clarify according to which criteria obstetric management is effected in women after previous Caesarean section. 329 German hospitals were addressed, 53.5% answered the questionnaire. The evaluation of the inquiry shows considerable discrepancies concerning obstetric management of women after previous Caesarean section: Trial of labour after one preceding Caesarean section was allowed in 79% (min: 26.5%; max: 100%) and completed successfully in 71.2% (min: 47%; max: 92%). Obviously there is a need for an official state-ment by the relevant professional associations or societies in respect of this problem.

Overweight is one of the most formidable health problems in Germany. Therefore, the risk factor obesity is gaining importance in pregnant women. The investigation presented here deals with the influence of maternal weight on the course of pregnancy, delivery, post partum period and the condition of the newborn. 6747 deliveries at the Department of Obstetrics and Gynecology, Technical University of Munich, were evaluated (1987-1993). Four groups were defined according to body mass index (BMI, calculated as maternal pre-pregnancy weight divided by the square of maternal length): BMI 1 - subnormal weight (19.2%), BMI 2 - normal weight (67.8%), BMI 3 - obese (8.2%) and BMI 4 extremely obese women (4.8%). Statistical evaluation was performed by comparison of the parameters of normal-weight and adipose women with the H-test (Kruskal and Wallis), Mann-Whitney-U- and X 2 -test. Hypertension, proteinuria, placental insufficiency, and gestational diabetes were more common in obese women. The rate of spontaneous vaginal deliveries was significantly lower in adipose women, and additionally they experienced more birth injuries. Non-elective Caesarean section rate was significantly higher in class BMI 4-women. Macrosomia, birth-related injuries (BMI 3), and the need for ventilation (BMI 4) were found more often in newborn of obese women. Prenatal care of adipose women deserves special attention. Prevention of obstetric problems associated with adiposity can only be achieved by weight reduction before conception.

Endometriosis is a possible and likely cause of periodically recurrent pelvic pain in premenopausal women. We report on a patient with a history of a vaginal hysterectomy with morcellation of the uterus who presented with monthly recurrent heavy lower abdominal pain. A solid tumour adherent to the lower anterior abdominal wall was diagnosed. Surgery revealed a significant portion of the uterus that showed intramural endometriosis. After completion hysterectomy the patient was completely free of pain.

Chorionic villi obtained at curettage are generally accepted as proof of intrauterine pregnancy. We report on a patient in whom suction curettage for molar pregnancy yielded chorionic villi but who had persistent bleeding and rising serum hCG levels after the procedure. Repeat curettage and laparoscopy showed a tubal pregnancy, which was evacuated by salpingotomy. Combined intrauterine and extrauterine (heterotopic) pregnancy is rare, and if vili are found in the uterus it is generally not necessary to rule out ectopic pregnancy. In our patient the chorionic villi obtained at the first curettage appear to have been displaced from the fallopian tube into the uterus.

Various parameters associated with fibrinolysis were examined in plasma and placenta tissue extract in 18 patients with HELLP syndrome (haemolysis, elevated liver enzymes, and low platelet count). A significant increase in plasma concentrations of tPA and PAl-1 was observed in the HELLP patients in comparison to 18 pregnant women of the control group (equal duration of pregnancy). In contrast, there was no difference in plasma concentrations of uPA, uPA-receptor and D-dimer. In placenta tissue extract, significant differences were found just as rarely for uPA, uPA-receptor and PAl-1 as for tPA and D-dimer. Our findings indicate, that endothelial damage with release of tPA may be involved in the pathophysiological pathway of HELLP syndrome. Increased plasma levels of PAl-1 may reflect deficient fibrinolysis resulting in impairment in microcirculation. Clinical relevance of tPA and PAl-1 plasma concentration as possible predictor of hypertensive pregnancy complications will have to be studied further.

Puerperal ovarian vein thrombophlebitis (POVT) is a rare but severe complication of the post partum period. We report on a patient, who developed a POVT based on an infection with Ureaplasma urealyticum and Mycoplasma hominis. Problems of diagnostic procedures in cases of POVT and the role of ureaplasma and mycoplasma in infectious obstetric complications are discussed.

A rising Caesarean delivery rate is the reason, why the obstetrician should be very well informed about the management of vaginal birth after Caesarean section: It is feasible in almost all women with nonrecurrent indication for the preceeding Caesarean section. Suspected foetal macrosomia, twin gestation and breech presentation represent relative contraindications. External cephalic version is a reasonable option. In case of history of uterine scar dehiscence or rupture and in women with vertical uterine scar, repeat section should be performed.

The aetiology of preterm rupture of membranes is not yet completely understood. Local infections of the vagina and cervix have attracted special attention during the last years. Ascending infection with subsequent chorioamnionitis is a common complication of preterm rupture of membranes. Recognition of the beginning of a chorioamnionitis is usually based on clinical symptoms and laboratory findings like white blood cell count and C-reactive protein. The purpose of this study was to find out the diagnostic value of elastase, a protease of polymorphonuclear granulocytes, which is known to be involved in inflammatory processes. Fifteen out of thirty-three patients with preterm rupture of membranes developed a chorioamnionitis. Elastase plasma concentration levels > or = 32 ng/ml one day before delivery showed a significant correlation (p = 0.02) to the development of a chorioamnionitis. At this time neither white blood cell count, nor rectal body temperature showed significant correlations. Low elastase levels do not exclude an infection, whereas high levels indicate an infectious process. We conclude that elastase is a relevant marker of chorioamnionitis.