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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.

Anamnese und klinischer Befund: Eine 36-jahrige Schwangere (I Gravida/ 0 Para) in der 25. und eine 27-jahrige (ebenfalls I Gravida/ 0 Para) in der 22. Schwangerschaftswoche wurden in unserer geburtshilflichen Abteilung mit Oligo-/Anhydramnion vorgestellt. Beide Patientinnen waren an einem Diabetes mellitus (Typ 1 beziehungsweise Typ 2) erkrankt, der durch eine diabetische Nephropathie mit renaler Hypertonie und Retinopathie kompliziert war. Der Hypertonus war bei der ersten Patientin mit einem AT 1 -Rezeptorblocker und einem Betablocker, bei der zweiten Patientin mit einem ACE-Hemmer und einem Betablocker suffizient eingestellt. Untersuchungen: Bei der initialen klinischen Untersuchung war der Allgemeinzustand der Patientinnen unauffallig. Atemfrequenz und Herzfrequenz waren in der Norm, der Blutdruck betrug bei der ersten Patientin 150 /95 mm Hg und 145 /90 mm Hg bei der zweiten. Im Ultraschall zeigten sich in beiden Fallen ein Oligo-/Anhydramnion und beidseits deutlich echogen vergroserte Nieren der Feten. Nachdem ein vorzeitiger Blasensprung ausgeschlossen werden konnte, wurde der Befund als Folge einer durch die Blutdruckmedikation verursachte fetale Niereninsuffizienz interpretiert. Diagnose, Therapie und Verlauf: Nach Umstellung der Medikation auf Methyldopa in beiden Fallen konnte im Verlauf im ersten Fall eine leichte, und im zweiten Fall eine deutliche Zunahme der Fruchtwasserdepots beobachtet werden. Postpartal bestatigten sich die Verdachtsdiagnosen der fetalen Niereninsuffizienz. Im ersten Fall leidet der Junge nach 2 Jahren weiterhin an einer chronischen Niereninsuffizienz (Stadium II) mit einer Hypertonie, die eine Therapie mit einem ACE-Hemmer erfordert. Im zweiten Fall war der Verlauf bisher deutlich besser mit einem normalen Nierenwachstum und unauffalligen Blutdruckwerten. Folgerung: Bei der Planung einer Schwangerschaft sollte eine arterielle Hypertonie bevorzugt mit Methyldopa (erste Wahl) bzw. einem Betablocker (i. d. R. Metoprolol) als Mittel der zweiten Wahl behandelt werden. Die wahrend einer Schwangerschaft nicht geeigneten Antihypertensiva (ACE-Hemmer, AT 1 -Antagonisten) sollten unmittelbar nach Feststellung einer Schwangerschaft auf die bewahrten Praparate umgestellt werden.

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.

Acute abdominal pain during pregnancy is rare and mostly caused by contractions. Since ileus during pregnancy is extremely seldom it is often overlooked and right management often starts too late. Only the correct diagnosis and subsequent operation will improve the prognosis for mother and child. Likewise the life-threatening risk for the mother needs to be weighed up against the risk of preterm birth for the child.

HISTORY AND AIM: A 36-year-old woman (primigravida, nullipara) at 25 + 3 weeks of gestation and a 27-year-old (primigravida, nullipara) at 22 + 7 weeks of gestation presented with oligo-/anhydramnios at our department of obstetrics. Both patients suffered from diabetes type 1 and 2, respectively, complicated by diabetic nephropathy, renal hypertension and retinopathy. The first woman had received an AT1 receptor antagonist and a beta blocker, the other one an ACE inhibitor and a beta blocker. At initial clinical examination both patients were in a good general state of health. Respiration, pulse and blood pressure were within normal limits.Sonography showed oligy-/anhydramnion with enlarged echogenic kidneys of both fetuses. Having ruled out premature rupture of the membranes the reduced amount of amniotic fluid was interpreted as a consequence of the antihypertensive medication.The medication was changed to methyldopa which resulted in an adequate and moderate increase of amniotic fluid in both patients. At post partum examination renal failure was confirmed in both infants. The first infant, now a boy at the age of two years, still suffers from chronic renal failure, needing antihypertensive medication with an ACE blocker. Follow-up of the second baby has so far shown normal growth of the kidneys and normotensive blood pressure.When planning a pregnancy, a preexisting hypertension should be treated with either methyldopa (1st choice) or a beta blocker as a second choice (e. g. Metoprolol). In patients who are treated with ACE blockers or AT1 antagonists, medication should be changed as soon as the pregnancy is ascertained.

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

To evaluate the diagnostic accuracy of three-dimensional (3D) ultrasound in comparison with conventional two-dimensional (2D) ultrasound in the characterization of breast lesions.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.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).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 (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.The aim of this pilot study was to analyse the feasibility of HyCoSy by 3D- and 3D-Doppler-sonography.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.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.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.

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.

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 24th 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.

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.

Der mutterliche Tod durch Embolie wurde von Th. Koller, W.R. Merz, H. Stamm u. R. Marbet 1957 in einer grosen Ubersicht fur das abgelaufene Jahrhundert umfassend dargestellt [13]. Der immer bedrohliche Embolietod der Mutter in Schwangerschaft, Geburt und Wochenbett war im 1. Viertel dieses Jahrhunderts ge genuber den dominierenden Todesursachen — dem Infektionstod, der Verblutung und der Eklampsie — noch von untergeordneter Bedeutung. Dann kam es zur relativen und absoluten Zunahme, die erst nach 1950 durch die moderne Thromboseprophylaxe und Therapie gesenkt werden konnte. Die Bedeutung des Embolietodes hat jedoch keineswegs abgenommen (Abb. 1.5), wie die Haufigkeiten der Thrombosemorbiditat und der Emboliemortalitat in der Geburtshilfe in Abhangigkeit von Risikoschwangerschaft und vom Enbindungsmodus eindrucksvoll belegen (Tabelle 1.23–1.25). Man mus heute von einer Thrombose-Embolierate im Verlauf der Schwangerschaft und im Wochenbett von 0,1% der Entbindungen ausgehen (Perinatalerhebung Baden-Wurttemberg) [31]. Unter den Muttersterbefallen steht heute der Embolietod an erster Stelle (Tabelle 1.26; Abb. 6.30).

Breast vascularization was measured with an 8-MHz continuous wave Doppler pencil probe. Flow values were low in asymptomatic women and high in patients with severe pain or dysplastic changes. Mild treatment with a plant extract produced only a small decrease in breast vascularization. Treatment with norethisterone acetate showed a dose-dependent decrease in blood flow. A good response was seen with a dosage of 5 mg/d, and a dramatic decrease was seen when 10 mg/d was taken. These results showed a good correlation with the patients' symptoms.

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.

In breast cancer preoperative determination of the tumor size is important for planning breast-conserving operations. In 100 patients with breast cancer, the preoperative tumor size was measured using clinical, mammographic and sonographic examinations and correlated with the results of a subsequent histological examination. Using a high-resolution real-time system, 98 tumors were visible. It was possible to detect not only early tumors under 1 cm in diameter, but also intraductal tumor components. This contributed greatly to the accuracy of the diagnosis. The sonographic measurement of tumor size demonstrated a correlation coefficient of 0.91 and was thus superior to mammography (0.79) and palpation (0.77). Measurement of the total tumor spread, including 39 multicentric lesions, showed an overestimation of 5% for the mammographic measurements and an overestimation of 4% for the sonographic measurements. Tumor extension was underestimated in 33% of the mammograms but in only 3% using ultrasound examination. The results, along with those of other studies, highlight the role of sonography in the diagnosis of breast cancer.

Improvements in breast cancer detection are underway with work being done on different imaging techniques and the assessment of abnormal vascularity. In an earlier study we used a 10 MHz CW Doppler pencil probe. In palpable carcinomas 94% had shown abnormal vascularity. However, in nonpalpable lesions, this method did not allow flow detection in combination with imaging. Recent developments in color flow mapping allow detection of small tumor vessels, which are invisible on B-mode ultrasound. Registration of vessels simultaneously to B-mode imaging allows this method to be used for nonpalpable lesions. The sensitivity of diverse Doppler instruments shows remarkable differences. This makes uniform evaluation of the method difficult. We examined 94 symptomatic women using different equipment. In 9 of 32 carcinomas no Doppler signals were found. However, CW Doppler showed low vascularity in these 9 false-negative cases. However, the variation of vascularity in malignancies does not yet allow routine application of this method and needs further scientific evaluation.

We report on biometric measurements of the fetal heart with the TM-technique; these measurements were carried out between the 20th and 40th gestational week. The right and left endsystolic atrial and ventricular diameters were, measured, as well as the diameters of the large vessels, i.e. aorta and pulmonary artery; finally, the septal thickness was determined. Our measurements show a linear progression of the diameters in question, the right-left ratio of the atria and ventricles was close to one, so was the ratio between aorta and pulmonary artery. Our results are compared, as far as possible, to the literature.

Over a period of 18 months measurements of fetal Organs (cornu anterius of the lateral ventricle, medium diameter of the four-chamber-view of the heart, transverse diameter of lungs, stomach, gall bladder, colon and urinary bladder) were carried out in a population of 223 normal pregnancies. The measurements were correlated to the age of pregnancy and sonographic growth parameters (biparietal diameter--BPD, mean cephalic diameter--MCD, mean abdominal diameter--MAD). The results show different growth velocities of the particular organs, obviously depending on physiological function. The variability is increasing with fetal growth. We found no fundamental difference as far as correlation of organ measurements to age of pregnancy, to BPD, MCD or MAD. In summary the imaging and biometries of the fetal organs appear to be possible in relatively little time and such is a valuable method for the detection of fetal anomalies.

Besides characteristic morphological differences, carcinomas of the breast show remarkable changes of vascularity, which are essential for their enhanced metabolism. High-frequency CW Doppler allows to investigate normal and pathological vascularisation in the breast. In our basic study we examined 200 patients, 37 with breast malignancies (6 non-palpable lesions). 33 of the carcinomas showed pathological vascularisation. In an extended examination procedure we investigated also normal breast vascularisation and compared it with blood flow in lesions. We developed therefrom an easy and rational method which allows physiological blood flow measurements as well as a differentiation of breast lesions within a few minutes' time.

Der vorzeitige Blasensprung (VBS) tritt mit einer Haufigkeit von 15–20% im Verlauf einer Schwangerschaft auf. Er ist eine der Hauptursachen der Fruhgeburtlichkeit und somit einer der Hauptfaktoren der perinatalen Morbiditat und Mortalitat.

Der folgende Beitrag gibt eine Ubersicht uber Gerinnungsstorungen in der Geburtshilfe, die in der Regel als chronische oder akute Verbrauchsreaktion mit einer sekundaren Fibrinolyse auftreten. Dabei wird zusatzlich auf die Gefahr einer Verlustkoagulopathie zur Abgrenzung hingewiesen.

Five severe cases of intra-abdominal gynaecological haemorrhage (four haemorrhages from corpora lutea haemorrhagica and one haemorrhage of the endometritis genitalis externa) are described in relation to prolonged marcumar therapy. The problem of contraception in patients under marcumar therapy is highlighted and the possibility is discussed of prevention of ovulation and cardio-vascularly neutral treatment, to achieve contraception as well as avoidance of haemorrhage at ovulation with the Gn-RH analogue Buserelin.