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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.

Im April 2018 erschien die erste deutsche interdisziplinare S3-Leitlinie fur die Diagnostik, Therapie und Nachsorge der Patientinnen mit Endometriumkarzinom. Dieser Beitrag ist die Zusammenfassung des Kap. 4: „Diagnose, Fruherkennung, Bildgebung und Pathologie“ mit dem Ziel, dem Leser eine Kurzfassung an die Hand zu geben. Dargestellt sind die Empfehlungen zur Diagnose und Fruherkennung von Endometriumkarzinomen, ferner die Indikationen zur Bildergebung und die Anforderungen fur die pathologische Aufarbeitung.

Soluble Fms-like tyrosine kinase-1 (sFlt-1) is thought to be causative in the pathogenesis of preeclampsia (PE) and specific removal of sFlt-1 via dextran sulfate cellulose (DSC)-apheresis was suggested as cure to allow prolongation of pregnancy in preterm PE. However, in addition a deranged lipoprotein metabolism may impact endothelial and placental function in PE. Lipoprotein-apheresis by heparin-mediated extracorporeal LDL-precipitation (H.E.L.P.) was previously applied and has been shown to alleviate symptoms in PE. This clinical trial reevaluates the clinical efficacy of H.E.L.P.-apheresis in PE considering sFlt-1.Open pilot study assessing the prolongation by H.E.L.P.-apheresis in 6 women (30-41 years) with very preterm PE (24+4 to 27+0 gestational weeks (GW)) (NCT01967355) compared to a historic control-group matched for GW at admission (28 GW; n = 6). Clinical outcome of mothers and babies, and pre- and post H.E.L.P.-apheresis levels of sFlt-1 and PlGF were monitored.In apheresis patients (2-6 treatments), average time from admission to birth was 15.0 days (6.3 days in controls; p = 0.027). Lung maturation was induced in all treated cases, and all children were released in healthy condition. Apheresis reduced triglycerides and LDL-cholesterol by more than 40%. Although H.E.L.P.-apheresis induced a transient peak baseline levels did not change and rather stabilized sFlt-1 levels at pre-apheresis levels throughout treatments, with sFlt-1/PLGF ratio remaining unaffected.H.E.L.P.-apheresis proved again to be safe and prolongs pregnancies in PE. However, without changing sFlt-1 levels below baseline lowering lipids or other yet undefined factors appear to be of more relevance than reducing sFlt-1.

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.

Objective Soluble Fms-like tyrosine kinase-1 (sFlt-1) is thought to be causative in the pathogenesis of preeclampsia (PE) and specific removal of sFlt-1 via dextran sulfate cellulose (DSC)-apheresis was suggested as a cure to allow for prolongation of pregnancy in preterm PE. However, in addition a deranged lipoprotein metabolism may impact endothelial and placental function in PE. Lipoprotein-apheresis by heparin-mediated extracorporeal LDL-precipitation (H.E.L.P.) was previously applied and has been shown to alleviate symptoms in PE. This clinical trial reevaluates the clinical efficacy of H.E.L.P.-apheresis in PE considering sFlt-1. Methods Open pilot study assessing the prolongation by H.E.L.P.-apheresis in 6 women (30–41 years) with very preterm PE (24 + 4 to 27 + 0 gestational weeks (GW)) (NCT01967355) compared to a historic control-group matched for GW at admission. Clinical outcome of mothers and babies, and pre- and post H.E.L.P.-apheresis levels of sFlt-1and PlGF were monitored. Results In apheresis patients (2–6 treatments), average time from admission to birth was 15.0 days (6.3 days in controls; p = 0.027). Lung maturation was induced in all treated cases, and all children were released in healthy condition. Apheresis reduced triglycerides and LDL-cholesterol by more than 40%. Although H.E.L.P.-apheresis induced a transient peak, baseline levels did not change and rather stabilized sFlt-1 levels at pre-apheresis levels Discussion Lipoprotein-apheresis proved again to be safe and prolongs pregnancies in PE. However, without changing sFlt-1 levels below baseline lowering lipids or other yet undefined factors appear to be of more relevance than reducing sFlt-1.

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.

Preeclampsia may affect severely the cerebral circulation leading to impairment of cerebral autoregulation, edema, and ischemia. It is not known whether impaired autoregulation occurs before the clinical onset of preeclampsia, and whether this can predict the occurrence of preeclampsia. Seventy-two women at 25 to 28 weeks of gestation were studied. Control values were derived from 26 nonpregnant women. Dynamic properties of cerebral autoregulation (DCA) were measured in the middle and posterior cerebral artery using transcranial Doppler and transfer function analysis (phase and gain) of respiratory-induced 0.1 Hz hemodynamic oscillations. Uterine artery ultrasound was performed to search for a notch sign as an early marker of general endothelial dysfunction. All women were followed up until 6 weeks after delivery for the occurrence of preeclampsia. The autoregulation parameter gain did not differ between pregnant and nonpregnant women. Phase was slightly but significantly higher in pregnant women, indicating better DCA. Women with a notch sign did not show altered DCA. A history of preeclampsia during a previous pregnancy was associated with lower phase in middle cerebral artery and posterior cerebral artery ( P

Introduction As the accurate diagnosis and treatment of gestational diabetes mellitus (GDM) is of increasing importance; new diagnostic approaches for the assessment of GDM in early pregnancy were recently suggested. We evaluate the diagnostic power of an ‘early’ oral glucose tolerance test (OGTT) 75 g and glycosylated fibronectin (glyFn) for GDM screening in a normal cohort. Methods and analysis In a prospective cohort study, 748 singleton pregnancies are recruited in 6 centres in Switzerland, Austria and Germany. Women are screened for pre-existing diabetes mellitus and GDM by an ‘early’ OGTT 75 g and/or the new biomarker, glyFn, at 12–15 weeks of gestation. Different screening strategies are compared to evaluate the impact on detection of GDM by an OGTT 75 g at 24–28 weeks of gestation as recommended by the International Association of Diabetes and Pregnancy Study Groups (IADPSG). A new screening algorithm is created by using multivariable risk estimation based on ‘early’ OGTT 75 g and/or glyFn results, incorporating maternal risk factors. Recruitment began in May 2014. Ethics and dissemination This study received ethical approval from the ethics committees in Basel, Zurich, Vienna, Salzburg and Freiburg. It was registered under http://www.ClinicalTrials.gov (NCT02035059) on 12 January 2014. Data will be presented at international conferences and published in peer-reviewed journals. Trial registration number NCT02035059.

Introduction Preeclampsia is a potentially life threatening disease occurring in pregnancy. The only causative cure consists in delivery with all the risks for a premature fetus. In preeclampsia, the lipid metabolism is substantially altered and lipid apheresis is being explored as a possible therapeutic approach to prolong preeclamptic pregnancies and allow further maturation of the fetus. In the Freiburg H.E.L.P.-Apheresis Study, 6 early onset preeclamptic patients were treated with H.E.L.P. apheresis. Objective/hypothesis Detailed analysis of apheresis-induced dynamics in serum lipid parameters. Methods 6 early onset preeclamptic patients underwent repeated apheresis treatments (n = 23). We evaluated parameters of the lipoprotein metabolism in 6 preeclamptic patients in detail. Results Reduction of lipoproteins by apheresis was lower than theoretically expected. Lipids reached previous pre-apheresis levels before the next apheresis even though apheresis was repeated within 2.9 ± 1.2 days. Fractional catabolic rates and synthetic rates were found to be substantially elevated, with fractional catabolic rates for ApoB/ LDL-cholesterol being 0.7 ± 0.3/ 0.4 ± 0.2 [day−1] and synthetic rates being 26 ± 8/ 17 ± 8 [mg*kg−1*day−1]. The distribution of LDL-subclasses after apheresis shifted to larger buoyant LDL, while IDL levels remained unaffected. Discussion Apheresis induced changes in lipoprotein profiles point to an underlying remnant removal disease like imbalance in plasma lipid conversion during preeclamptic conditions.

Multiple myeloma is the second most commonly diagnosed hematologic malignancy. It is characterized by the accumulation of monoclonal plasma cells. It typically manifests in the sixth decade of life or later, whereas the incidence in patients who are younger than 40 years old is extremely rare. Here, we report the case of a 34-year-old prima gravida, diagnosed with a κ light-chain myeloma (Durie&Salmon stage IIIA, International Staging System I) in the 23rd week of pregnancy. Our multimodal therapeutic approach during pregnancy, the delivery of a healthy male, and initiation of intensive anti-myeloma treatment thereafter (induction with bortezomib, cyclophosphamide, and dexamethasone, followed by tandem autologous peripheral blood stem cell transplantation) are described. Furthermore, we provide a comprehensive review of all 18 cases published between 1965 and 2010 in which a multiple myeloma was diagnosed and treated following different regimes and approaches before, during, or shortly after pregnancy. All delivered newborns were healthy, whereas the mothers' outcomes varied strongly. In our specific case, complete remission was achieved after tandem autologous peripheral blood stem cell transplantation. Emerging from these literature data and our case, we conclude that while awaiting delivery, the application of prednisolone as a nontoxic, but active anti-myeloma therapy can be recommended. Intensified postpartum anti-myeloma therapy should be induced as soon as possible to efficiently reduce myeloma burden and avoid organ damage in these young females.

Background and Purpose— This study investigated whether a short testing of neurovascular coupling during midterm pregnancy could identify women at risk for subsequent preeclampsia. Methods— Transcranial Doppler sonography of the posterior cerebral artery during a brief visual stimulation was analyzed in 68 women at midterm pregnancy, the primary clinical end point was preeclampsia. Results— Women with bilateral notching of the uterine arteries showed an exaggerated visually evoked blood flow increase and longer time-to-peak. Neurovascular coupling was not significantly associated with the occurrence of preeclampsia. Conclusions— Neurovascular coupling was altered in women with impaired uteroplacentar vasoregulation but not a significant predictor of preeclampsia.

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.

Background: The incidence of caesarean section (CS) is steadily rising world-wide. In particular, CS on maternal demand is performed more frequently. In parts, this might be due to insufficient information of pregnant women about neonatal risks of CS. We sought to specify neonatal outcomes following different modes of delivery, i.e. vaginal delivery, primary CS and secondary CS and to define risk factors for respiratory morbidity and hospitalization. Methods: We analysed 2073 births (gestational age > 35 weeks) during a two-year period at a tertiary obstetric and neonatal centre in Germany. Statistical analyses were performed for single parameters by SPSS as well as by logistic regression to account for possible confounders. Furthermore, extensive model calculation was done. Results: Respiratory morbidity was increased following primary and secondary CS (p = 0.001). By multiple logistic regression, the strongest effect on respiratory symptoms was seen with gestational age, each week more in utero reducing the risk by an odds ratio (OR) of 0.69 (95% CI: [0.61; 0.79]; p = 1.9 × 10−8). Furthermore, a significant interaction between mode of delivery and gestational age was found for the risk of respiratory symptoms (p = 0.0035). Conclusion: For every eight newborns delivered by primary CS one more than expected with vaginal delivery is hospitalized. It is highly relevant to recognize that each week of gestational age reduces the risk of respiratory symptoms, especially if primary CS is performed. The higher rate of respiratory morbidity and neonatal admission following CS should be clearly recognized in counselling of pregnant women.

The recent development of high-quality colour Doppler instruments allows flow detection in small vessels below the resolution of B-mode imaging. Therefore, Doppler is now frequently used for flow detection in tumours. For breast examinations, CW Doppler has been in use for many years, which allows a sufficient definition of diagnostic criteria. Nevertheless, it is surprising that new studies using colour Doppler try to define different diagnostic criteria. To characterise the vascularity of breast lesions by colour Doppler we investigated 127 symptomatic patients. In 54 carcinomas the average flow velocity was 32 cm/s and 12.6 cm/s in 73 benign conditions (p > 0.0001). Total tumour vascularisation was characterised by a new parameter: the sum of all flow velocities in all tumour vessels. In carcinomas the mean total flow as 197.9 cm/s, and 52.7 cm/s in benign pathologies (p > 0.0001). Mean RI (resistance index) and PI (pulsatility index) were calculated to describe the flow profiles. The wide variation did not allow for a differentiation between benign and malignant lesions.

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.

AIM According to the German guidelines for quality control of ultrasonic equipment, the following conditions are required for breast ultrasound: A transducer frequency between 5-7.5 MHz and a minimum field of view of 5 cm. Satisfactory images must be obtained in a depth between 0.5 and 4 cm with a wide tolerance of the focal zones. This allows the use of poor quality equipment which does not produce satisfactory image quality and it excludes a number of high frequency and high resolution transducers with a field of view below 5 cm. This study with a test phantom was performed to define image quality objectively. METHOD Sixteen ultrasound instruments in different price categories were used to perform standardized examinations on a breast phantom model 550 (ATS Laboratories, Bridgeport, USA). Contrast and spatial resolution in different penetration depths were investigated on cyst phantoms from 1-4 mm diameter and wire targets with defined distances between 0.5-3 mm 4 investigations reported the images. RESULTS A positive correlation was seen between price category and image quality. CONCLUSION This study demonstrates that transducer frequency and image geometry do not allow sufficient quality control. An improvement of ultrasound diagnosis is only possible if equipment guidelines are based on standard examinations with test phantoms.

Implementation of guidelines for group B streptococcal (GBS) prepartum screening (PS) rarely has been prospectively evaluated. To assess PS at 35-37 weeks of gestation and compare its predictive value to that of an intrapartum screening (IS) within 7 days of delivery, a surveillance cohort study was conducted at a tertiary care center in Freiburg, Germany, during 2011-2012. Study participants included 937 pregnant women who had intrapartum cultures taken for vaginal and rectal GBS colonization. Colonization status was compared to PS, and intrapartum antibiotic prophylaxis (IAP) rates calculated. The neonates were tested for GBS transmission via cultures from their throats and external ear canals. While 67.5% (633/937) of study participants had a PS, only 22.7% (144/633) underwent a fully guideline-compatible PS. However, maternal GBS colonization rates were similar when comparing PS (18.5% [117/633]) versus IS (17.0% [133/784]). The positive predictive value of a positive PS result for GBS positivity at delivery was 77.2 %. Women with a positive PS received IAP in 89.3% of cases (75/84). The capsular serotype distribution pattern of colonizing GBS strains has not changed in comparison to our 2003-2004 study--one with a similar study design.Improved strategies for adoption of prepartum GBS screening are needed.• The prediction of prepartum GBS screening for intrapartum colonization status has not been well studied. • Longitudinal studies of GBS screening are needed for screening program evaluations and vaccine development. What is New: • The rate of GBS screening has improved over 10 years, and intrapartum GBS colonization prediction was accurate. • Serotype distribution was stable and suggests the potential long-term efficacy of GBS vaccines.

Objective To evaluate the diagnostic accuracy of three-dimensional (3D) ultrasound in comparison with conventional two-dimensional (2D) ultrasound in the characterization of breast lesions. Methods The digitally stored 2D ultrasound images and the corresponding 3D scans of 100 breast lesions (57 malignant, 43 benign) that had been morphologically classified as solid tumors, were independently analyzed by six investigators. Ten 2D and 13 3D ultrasound characteristics were determined. Lesion characterization was classified on a four-point scale and a logistic regression model was used to analyze the data. A receiver–operating characteristics curve (ROC) analysis was performed to determine the diagnostic performance of 2D and 3D ultrasound, respectively. Results Ultrasound criteria showed major differences between 2D and 3D ultrasound. Logistic regression revealed the retraction phenomenon in the coronal plane of the 3D ultrasound scan to be a significant and independent factor for lesion characterization. The characteristics determined on the conventional planes of 3D ultrasound differed from those determined on the 2D ultrasound images. The diagnostic accuracy of 2D and 3D ultrasound in the ROC analysis was almost identical (area under the curve 0.846 and 0.851, respectively). Conclusions Ultrasound features on 3D ultrasound differ significantly from those on 2D ultrasound. However, the diagnostic accuracy of both methods is almost identical. 3D ultrasound as an adjunct to conventional 2D ultrasound should be evaluated in larger trials to determine its clinical value in breast imaging. Copyright © 2005 ISUOG. Published by John Wiley & Sons, Ltd.

UNLABELLED Hystero-salpingo-contrast sonography (HyCoSy) is a sensitive method of assessing tubal patency but cannot completely substitute diagnostic laparoscopy with blue dye and hysteroscopy. Three-dimensional sonography has new imaging facilities which could lead to a reduction of invasive diagnostic procedures. AIM The aim of this pilot study was to analyse the feasibility of HyCoSy by 3D- and 3D-Doppler-sonography. METHODS In a prospective setting conventional (2D) HyCoSy was performed in 21 patients with an ultrasound device designed for 3D-ultrasound. After the completion of the 2D procedure, 3D-ultrasound was carried out. In five patients an additional 3D-Doppler-HyCoSy was performed. The generated 3D-volumina were then examined. Laparoscopy with blue dye was performed immediately after the ultrasound examination. RESULTS A total of 42 Fallopian tubes was assessed. On 2D-ultrasound, visibility of the tubes was excellent in 28 and limited in seven tubes. Of the seven tubes not visible on 2D-ultrasound, four were not patent on laparoscopy. On 3D-ultrasound, visibility of the tubes was excellent in 15 and limited in twelve tubes. 15 tubes were not visible on 3D-ultrasound. 3D-Doppler-HyCoSy revealed excellent assessment in eight of ten tubes, even in one of those with limited visibility on 2D- and 3D-HyCoSy. In 19 patients the assessment of the uterine cavity was excellent by 2D- and 3D-HyCoSy, whereas it was limited in two patients. CONCLUSION It is possible to visualise the full length of the tubes in a very detailed way from the uterine cavity to the fimbrial end in some patients, but the diagnostic power of HyCoSy is not improved by adding 3D-imaging. The accuracy of 3D-ultrasound seemed to be improved by 3D-Doppler-ultrasound.

Background Preeclampsia (PE) is a life-threatening complication of pregnancy. To date the only therapy of severe PE consists in timely delivery of the fetus. In PE a deranged lipoprotein metabolism considered to impair endothelial function is observed. Heparin-mediated extracorporeal LDL-precipitation (H.E.L.P.)-apheresis is an established method for lipoprotein removal and has already been successfully applied in PE. Recently, angiogenetic and anti-angiogenetic factors like placenta growth factor (PlGF) and soluble Fms-like tyrosine kinase-1 (sFlt-1) are discussed as risk factors and removal of sFlt-1 by dextran sulfate column (DCS) apheresis is suggested as specific cure for PE. By contrast, H.E.L.P.-apheresis does not remove sFlt-1. The present clinical trial revaluates the clinical efficacy of H.E.L.P.-apheresis in PE with focus on sFlt-1 and PlGF. Methods Open pilot study assessing the prolongation by H.E.L.P.-apheresis in 6 women (30–41 years) with very preterm PE (24 + 4 to 27 + 0 gestational weeks (GW)) (NCT01967355) compared to a historic untreated PE-group matching treated patients by GW at admission ( Results Women with PE received apheresis 2–6 times. In treated patients the average time from admission to birth was 15.0 days compared to 6.3 days in controls (p = 0.027). In treated patients the prolongation of gestation by apheresis converted to a mean fetal weight gain of 101 grams (p = 0.029). Lung maturation could be induced in all treated cases and all children could be dismissed in healthy condition. Apheresis significantly reduced levels of total cholesterol (−33%), triglycerides (−43%), and LDL-cholesterol (−44%). However, sFlt-1 was not reduced but levels significantly increased initially by H.E.L.P.-apheresis and dropped to almost pre-apheresis levels before next apheresis, with sFlt-1/PLGF ratio remaining unaffected. Conclusions H.E.L.P.-apheresis proved again to be a safe therapeutic option to prolong pregnancies in PE and results in significant fetal weight gain. However, H.E.L.P.-apheresis does not reduce circulating sFlt-1 levels. Thus, reducing lipids and other pro-inflammatory factors may be more relevant than reducing circulating sFlt-1 to improve outcome in PE.

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

In breast examinations with Doppler, an increased flow is found in malignant tumors. With the relatively new color Doppler, we measured different flow values in 133 cancer patients and in 325 women with benign disease. These measurements were used to develop diagnostic rules. For the highly correlated flow values, we used a stepwise procedure to select a final logistic regression model and a tree-based approach, which is a different way of modeling. With both approaches we developed simple diagnostic rules of which the sensitivity and the specificity exceeded 90%. There are no differences between the two approaches concerning discriminative ability. As complex statistical modeling leads to an overoptimism in the assessment of the error rates, we applied sensitivity analysis, investigated the stability of the selected logistic regression model, and estimated the magnitude of the overoptimism of the diagnostic rules with resampling methods. The results indicate that the estimates of sensitivity and specificity are probably close to realistic values for a clinical setting.

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.