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INTRODUCTION: Doppler sonography is an established method in fetal medicine. Up to now a possible circadian rhythm of fetal and maternal Doppler parameters has only been insufficiently characterized and documented. This survey aimed at evaluating the significance of Doppler parameters with regard to diurnal variations. We have analyzed whether or not a circadian rhythm of fetal and maternal Doppler parameters is detectable. MATERIAL AND METHODS: A non-selected collective of 100 patients with a singleton pregnancy between the 20 th and 39 th week of gestation was examined with Doppler sonography at the Medical School of Hannover. Besides the Doppler sonography, which was performed at three fixed times a day, the maternal blood pressure was examined each time. Outcome parameters were resistance index (RI), pulsatility index (PI) and the maximum velocity (V max ) of the A. umbilicalis, A. cerebri media and the Aa. uterinae as well as the maternal blood pressure. RESULTS: There were no significant differences for the RI, PI and V max of the Aa. uterinae for the whole collective, nor for the subgroups of maternal hypertonia, preeclampsia, notching and fetal growth restriction (IUGR). There were also no significant diurnal variations of the Doppler parameters for the fetal vessels. In particular, there were no differences in the measured Doppler parameters in comparison to the collective with unremarkable gravidity. In some subgroups statistical significance could be achieved, but due to the minor variations, no clinical importance has to be considered. CONCLUSION: A circadian rhythm of the Doppler parameters could not be confirmed in the examined collective. The time of the applied Doppler sonography on physiological conditions might represent a factor which does not affect the validity of the Doppler sonographic results. As a consequence a single Doppler examination at a freely chosen time seems to be sufficient to obtain a correct assessment of fetal and maternal blood perfusion. Further studies on larger collectives are necessary to evaluate the clinical importance of a possible circadian rhythm, especially in fetuses with pathological Doppler values.

Von Marz 1983 bis Juli 1985 wurde bei 31 Patienten im Alter zwischen 7 und 45 Jahren (Median 18 Jahre) eine allogene Knochenmarktransplantation durchgefuhrt. Bei acht Patienten bestand eine akute lymphatische Leukamie in erster bis funfter Remission, bei vier eine akute myeloische Leukamie in erster und zweiter Remission, bei sechs eine chronische myeloische Leukamie in verschiedenen Stadien, bei drei Patienten eine schwere aplastische Anamie und bei jeweils einem Patienten eine Myelodysplasie und eine unreifzellige megakaryozytare Myelose. Bei acht Patienten mit akuter myeloischer bzw. lymphatischer Leukamie erfolgte die Transplantation im Rezidiv. Als Knochenmarkspender dienten phanotypisch HLA-identische Mutter (n = 2) sowie genotypisch HLA-identische Geschwister (n = 27), in zwei Fallen auch HLA-nicht-identische Mutter. Die Konditionierungsbehandlung vor der Transplantation bestand fur Leukamiepatienten in einer fraktionierten Ganzkorperbestrahlung und hochdosiertem Cyclophosphamid oder Etoposid. Patienten mit schwerer aplastischer Anamie erhielten Cyclophosphamid (viermal 50 mg/kg) und eine fraktionierte totallymphatische Bestrahlung (Gesamtdosis 8 Gy). 19 Patienten (61 %) leben 14 bis 605 Tage nach der Knochenmarktransplantation, 15 Patienten (48 %) befinden sich in kontinuierlicher kompletter Remission mit einem Karnofsky-Index von ≥ 90 %. Todesursachen bei den gestorbenen Patienten waren Infektionen (n = 3), interstitielle Pneumonien (n = 3), Rezidive (n = 3) sowie akute Transplantat-gegen-Wirt-Reaktion, Nichtanwachsen des Spenderknochenmarks und Venenverschluskrankheit der Leber in jeweils einem Fall. Allogeneic bone marrow transplantations were carried out between March 1983 and July 1985 in 31 patients aged 7 to 45 years (median 18 years). Acute lymphoblastic leukaemia in 1st to 5th remission was present in 8 patients, acute myeloblastic leukaemia in 1st and 2nd remission in 4 patients, chronic myeloid leukaemia, with various remission status, in 6 patients, 3 patients had severe aplastic anaemia and there were single cases of myclodysplasia and immature cell megakaryocytic myelosis. Transplantation was carried out during relapse in 8 patients with either acute myeloid or lymphoblastic leukaemia. Phenotypic HLA-identical mothers (n = 2) as well as genotypic HLA-identical siblings (n = 27), and in two cases HLA-non-identical mothers, served as bone marrow donors. In leukaemia patients the conditioning treatment consisted of fractionated total body irradiation and high dose cyclophosphamide or etoposide. Patients with severe aplastic anaemia received cyclophosphamide (4 × 50 mg/kg) and fractionated total nodal irradiation (total dose 8 Gy). 19 patients (61 %) survived 14 to 605 days after bone marrow transplantation. 15 patients (48 %) continue to remain in complete remission with Karnofsky indices of ≥ 90 %. Causes for death were infection (n = 3), interstitial pneumonia (n = 3), relapse (n = 3) as well as single cases involving acute graft-versus-host-disease, non-engraftment of donor marrow and veno-occlusive disease of the liver.

Posterior urethral valves are the main cause of fetal lower urinary tract obstruction (LUTO) with typical sonographic signs like urinary tract dilatation and reduction of amniotic fluid. LUTO is associated with a high rate of perinatal mortality and is the main cause of kidney failure in early childhood. In such cases vesico-amniotic shunting is a common but risky procedure of fetal surgery to prevent anhydramnion and lethal lung hypoplasia. This case report demonstrates that lung hypoplasia can be prevented by vesico-amniotic shunting of the fetal megacytis in the 23 rd week of gestation in a fetus with lower urinary tract obstruction and anhydramnion. The prenatal measured concentration of cystatin C in the fetal urine correlated with the postnatal impaired kidney function. The indication and therapeutic benefit of vesico-amniotic shunting remain controversially discussed in the literature because until today there is no evidence for a reduction in perinatal or long-term morbidity due to early fetal kidney damage. The earlier ultrasound detection of LUTO during the first trimester of pregnancy proposes the possibility of earlier intervention and protection of nephrogenesis. First case studies about first trimester vesico-amniotic shunting have been published; the influence on the postnatal kidney function merits further well-structured investigation.

INTRODUCTION: The factual sonographic training in obstetrics differs in Germany in a broad range. In this context, a tendency towards minimalistic dealings with this issue prevails. In contrast to this, the provisions of the German maternity guidelines relating to ultrasound clearly define quality oriented requirements serving altogether as a basic sonographic standard which mandatorily has to be met by all German Obstetricians. In order to close this gap between professional education and social demand, a training concept regarding obstetric ultrasound was devised by the German Association of Gynecologists utilizing the ultrasound simulator system. The aim of this study was to evaluate the usefulness and the effectiveness of this method and its potential role and benefit in structured sonographic training. MATERIAL AND METHODS: Between October 2004 and August 2005, 74 obstetric ultrasound training courses according to the ultrasound simulator concept of the Medical School of Hanover were realized in nine federal states of Germany by the German Academy of Gynecology. The aim of these courses was it to procure ultrasound knowledge regarding the structured sonographic exclusion of fetal malformations in a compact manner. As a measure of quality assurance, a standardized questionnaire was issued before and after the courses in order to analyze the benefit of these simulator-based ultrasound courses. RESULTS: The concept found prevailing approval (90 %) at the level of principle, practical implementation and clinical usefulness. 88,2 % of the participants estimated their subjective training effect as being good. The analysis of the questionnaire showed a statistically significant improvement of sonographic knowledge. On average, 74.1 % of the questions were answered correctly by the end of the course as opposed to a mere 46.3 % at the beginning. CONCLUSION: Structured ultrasound training courses based on the ultrasound simulator system seem to be able to define a basic quality of training and significantly improves examiners' skills in prenatal medicine possible independent of local or structural factors. Hence they seem to be a suitable instrument to close the gap between the sonographic education worthy of improvement and the existing social demand for efficiacy of obstetric sonography.

Increased fetal nuchal translucency (NT) is not only associated with chromosomal aberrations such as Down syndrome but is also predictive for fetal malformations such as cardiac anomalies or an omphalocele. Conversely, an omphalocele can be associated with other structural or chromosomal abnormalities. Cantrell's pentalogy is a rare congenital syndrome involving a midline supraumbilical abdominal wall defect, a defect of the lower part of the sternum, a deficiency of the anterior diaphragm, a defect in the diaphragmatic pericardium and congenital heart malformation. Its prevalence amounts to 5.5 per 1 million neonates. The aetiology is still unknown. We present a case with a pentalogy of Cantrell detected by an increased NT. A 23-year-old woman, primigravida, was referred to our unit at 10 + 3 weeks gestation with an increased NT. Ultrasound scan revealed a CRL of 31.1 mm and an NT of 3.2 mm. In addition to this an omphalocele with a herniac sac involving a part of the liver was suspected. Because of these sonographic findings a chromosomal analysis (CVS) was performed. The karyotype of the fetus showed to be normal (46 XX). A follow-up scan at 13 + 3 weeks gestation demonstrated the foetal abdomen with a supraumbilical midline abdominal wall defect with a large omphalocele containing the liver and stomach as well as an ectopia cordis. The extremities, head and spine seemed to be normal. After detailed counselling about the severity of the syndrome and its dismal prognosis the couple decided for a termination of pregnancy. Autopsy confirmed the prenatal sonographic findings. Measurement of foetal nuchal translucency at first-trimester screening has become a routine procedure in the early targeted search for foetal Down syndrome and other aneuploides. Investigations showed that increased NT is also associated with cardiac malformations. As a special form of a cardiac abnormality in conjunction with an omphalocele, it seems that the pentalogy of Cantrell is facultatively also associated with an increased NT at the end of the first trimenon and should be considered in the differential diagnosis as a cause of increased NT.

Ultrasound has become indispensable in prenatal diagnosis. Ultrasound training, however, still lacks proper quality assessment and control. Moreover, most fetal anomalies which must be diagnosed during pregnancy are extremely rare. Ultrasound simulators could provide an opportunity to overcome this dilemma. This review summarizes the potential benefits of simulator-based ultrasound training, briefly describes the properties of a variety of ultrasound simulators that have been developed for various applications including prenatal diagnosis, and presents the SonoTrainer sonography simulation system which makes it possible to run a real-time simulation of a complete prenatal ultrasound examination. We evaluated the system for the training of first- and second-trimester screening for both normal and pathological findings and found that physicians who received theoretical training and were additionally trained with the simulator (T + S) significantly improved their skills in measurements of nuchal translucency thickness (NT) and crown–rump length (CRL) as compared with colleagues who only underwent theoretical instruction (T) [mean ± SD NT deviation: 0.31 ± 0.1 mm (T + S) vs. 0.62 ± 0.2 mm (T), P < 0.05; mean ± SD CRL deviation: 1.48 ± 2.0 mm (T + S) vs. 3.27 ± 2.5 (T), P < 0.05]. Simulator-based training enabled physicians to diagnose rare fetal anomalies in the second trimester with a sensitivity of 86% and a specificity of 100%. In a study in which second-trimester scans including fetal anomalies were presented to physicians, 96% of the participants subjectively estimated their training effect as being good. We therefore conclude that simulator-based training would provide an ideal educational tool to test, improve and monitor a physician's or technician's ultrasound skills in detecting fetal anomalies. Copyright © 2004 ISUOG. Published by John Wiley & Sons, Ltd.

BACKGROUND Acupuncture as a non-evidence-based therapy modality is widely used in obstetrics prior to and during delivery. Thus far, only few studies investigated the impact of acupuncture on obstetric surveillance parameters like cardiotocography. The aim of this study was to control the effect of clearly-defined acupuncture on CTG parameters. PATIENTS AND METHODS 61 low-risk singleton pregnancies between 30 + 0 and 39 + 6 weeks of gestation were prospectively treated with acupuncture at GV 20 and ST 36 bilaterally for the purpose of maternal relaxation by the same investigator under CTG control. Before (Phase 1), during (Phase 2) and after (Phase 3) treatment the cardiotocogram was recorded. Controlled parameters of outcome were the Fisher score, uterine activity (Phase 1, 2, 3) and maternal blood pressure and pulse before (Phase 1) and after (Phase 2) administration of acupuncture. In a matched control group, 60 pregnant women were monitored by an identical scheme without application of acupuncture and the same outcome parameters were recorded. RESULTS : The CTG analysis revealed a statistically significant increase of the Fisher score as well as uterine activity which tended to trace back to pretherapeutic initial values. The systolic maternal blood pressure was found to show a statistically significant decrease while diastolic blood pressure and pulse frequency remained unchanged. In the control group, the comparison of phase 1 vs. phase 2 showed a statistically significant increase of the Fischer score and uterine activity. During phase 3 the Fischer score further increased in contrast to a statistically significant slight reduction of uterine activity. Maternal systolic blood pressure measured at the end of phase 2 was found to be statistically reduced while diastolic blood pressure and pulse remained unchanged. The extent of the systolic blood pressure reduction was markedly higher in the acupuncture group as compared to the control group. CONCLUSIONS Antenatal acupuncture as a reflex therapy for the purpose of maternal relaxation seems to exert an influence on short-term alterations of the fetal activity (transient increase in terms of Fischer score) with reversibly increased uterine activity as detected by cardiotocography. Also, a slight reduction of the maternal blood pressure seems to be effected. The phenomena recorded in the control group (relaxation without supportive acupuncture treatment) revealed to be partially concordant (reversibly increased uterine activity, mild maternal reduction of systolic blood pressure) and partially discordant (persisting increase of Fischer score) as compared with the acupuncture group. Acupuncture seems not only to have a psychological, but also a short-term somatic effect with direct influence on maternal and fetal circulation parameters. Other established surveillance parameters and different points of acupuncture should be studied to further elucidate the underlying interaction as well as the duration of this effect.

Die individuelle Risikoabschatzung fur das Vorliegen einer Schwangerschaft mit Down-Syndrom uber das maternale Alter und die fetale Nackentransparenz (NT) nach Snijders und Nicolaides hat in Deutschland andere Suchstrategien nach fetaler Aneuploidie weitestgehend verdrangt. Sie kann damit derzeit als bevorzugtes Screeningverfahren in diesem Bereich betrachtet werden. Ziel unserer retrospektiven Untersuchung war, die Ergebnisse der ersten 744 an der Frauenklinik der Medizinischen Hochschule Hannover nach Nicolaides erstellten NT-Risikoberechnungen (PIA Fetal Database Modul) retrospektiv mit einer neu entwickelten Software (NT-Risikokalkulationsmodul der Patienten-Datenbank JOY) zu vergleichen. Die Risikoabschatzungen der PIA-Software wurden fur jeden einzelnen Fall mit der neu entwickelten JOY-Software nachberechnet und die Ergebnisse im Sinne einer Einzelfallbetrachtung verglichen. Ein Risiko von groser als 1 : 300 wurde dabei nach beiden Berechnungen als Grenzwert fur eine weiterfuhrende invasive Diagnostik angesehen. Bei den untersuchten 744 Fallen fand sich in 95,8 % ein kalkulierter Risikounterschied im Vergleich zu der Nicolaides-Software von weniger als 0,1 %. Dabei lag die Screen-positiv-Rate der JOY-Software um 18,6 % niedriger als bei der Nicolaides-Kalkulation, wobei die Detektionsraten fur M. Down nach beiden Berechnungen identisch waren. Die neu entwickelte JOY-Software errechnete das Risiko fur das Auftreten von Chromosomenanomalien mit erhohter Spezifitat, wobei die Sensitivitat unbeeinflusst blieb. Dabei basieren unsere Berechnungen auf den gleichen Risikoparametern wie die von Nicolaides. Diese Software stellt somit nach unseren ersten Untersuchungen eine mogliche Verbesserung beim Screening auf Aneuploidien im ersten Trimenon gegenuber der herkommlichen Methode dar: Bei gleicher Entdeckungsrate konnte die Rate an unnotigen invasiven Masnahmen gesenkt werden. The individual risk assessment for the presence of a pregnancy complicated by Down's syndrome based on maternal age and measurement of nuchal translucency (NT) according to Snijders and Nicolaides has progressively supplanted other search strategies for fetal aneuploidies in Germany. At present, this method can be regarded as the preferred method in first trimester screening. The objective of our study was to re-evaluate the first consecutive 744 NT-risk calculations determined by Nicolaides' method and to compare these with the findings of a novel, recently developed software (NT-risk calculation module, JOY Patient Database). The risk assessment based on Nicolaides (PIA Fetal Database NT-Module) was compared with the re-calculated risk evaluation as determined by a recently developed software (JOY Patient Database). The calculated risks were compared on a case-by-case basis. A risk greater than 1 : 300 was considered to indicate the need for further invasive testing. Among the 744 cases included in our investigation, 95.8 % exhibited a calculated risk difference of less than 0.1 % as compared to the Nicolaides software. The screen-positive rate of the JOY software was found to be 18.6 % lower than in the Nicolaides software. However, the detection rate for Down syndrome remained unchanged. The novel, recently developed JOY software package allowed reliable evaluation of the risk for aneuploidy with increased specificity whereas sensitivity was left unchanged. The calculations are based on the same risk parameters as Nicolaides' software. According to the results of this preliminary study, our data suggest a possible improvement in the screening for aneuploidy when using this novel software: Therefore, with an identical detection rate, the number of unnecessary invasive measures might be reduced.

Purpose: Although ultrasound examination became almost indispensable to perform the first trimester screening for chromosomal abnormalities, there are still a lot of deficits to improve levels of skills from potential examiners. The purpose of this study was to evaluate the efficiency of a new training method for measuring the nuchal translucency with a new ultrasound simulation system. Material and Methods: The ultrasound simulator simulates a complete ultrasound examination including the measurement of the nuchal translucency (nt) and the crown rump length (cr1) in real-time. The measurement of the nuchal translucency and the crown rump length in 9 pregnant women in the first trimester was performed by two groups of doctors for gynecology and obstetrics: Group 1 (n=24) had only a theoretical instruction and Group 2 (n = 21) had an additional virtual training for measuring the nt and the crl using the ultrasound simulator. Registrated were the differences of the measurements from the defined standard of two certified (Fetal Medicine Foundation London) pre-examiners. Results: The variability expressed as mean of differences to the defined standard concerning the nuchal translucency thickness was significantly lower in the group of virtually trained examiners (NT: group I: 0,31 mm; ±0,14; vs. group II: 0,62 mm; ±0,23, p

Introduction: Will a simple analysis of Power-Doppler sonography permit preoperative prediction of prognosis in breast cancer patients? Material and Methods: 77 breast cancer patients were preoperatively examined by high resolution ultrasound equipment using the Power-Doppler technology. The semiquantitative parameter was to analyse blood flow by Power-Doppler with regard to the relation to established parameters of prognosis (TNM; Grading; Nodalstatus). Results: Female patients with lymph node metastasis showed in every case blood flow, nodal negative patients in 85.7%. Minor differentiated tumors showed in 86% blood flow, well differentiated only in 45%. All T3 and T4 tumors examined by the Power-Doppler showed blood flow but just 33% of the Tis breast cancer. Conclusion: The assessment of Power-Doppler sonography seems to allow preoperative statements with regard to tumor grading, a possible metastatic invasion of lymph nodes and TNM stage.

PURPOSE: Examination of fetal nasal bone (NB) by ultrasound between 11 + 0 and 13 + 6 gestation weeks has been proposed as an additional tool in the detection of trisomy 21 and therefore its application and implementation are used in a broad range. The study aimed at evaluating the interobserver feasibility of the measurement of fetal nasal bone length in comparison with experienced and inexperienced sonographers. MATERIALS AND METHODS: The study population was comprised of women who chose to have first trimester screening (FTS) at the Fetal Medicine Unit of the University Medical School of Hannover. Two experienced (> 400 FTS examinations, sonographer 1 and 2) and one inexperienced sonographer (95 FTS examinations, sonographer 3) were asked to measure the nasal bone length consecutively and independently of each other. Statistical analysis was performed for any differences and variations in the results. RESULTS: The fetal profile was examined in 220 cases. The median nasal bone length by sonographer one was 2.4 cm, sonographer two 2.4 cm and sonographer three 2 cm. The differences between the results of sonographer 1 and 3 as well 2 and 3 were statistically significant. There were no significant variations between the results of sonographer 1 and 2. There was also no significant difference in the results concerning nuchal translucency and crown-rump length among the three examiners. CONCLUSION: The uncertainty and the difficulties of an inexperienced examiner with the presenting of the nasal bone, as shown by published data sets as well as by the variability of the measurement results of this study, with all the consequences in the risk calculation and counseling show that this tool should only be implemented by experienced and quality-controlled sonographers with a minimum amount of examinations. Because of its major impact in risk calculation and the importance of the nasal bone as a sonographic marker, documentation of the sonographer’s skills is mandatory for the use of the nasal bones as an additional sonographic marker in first trimester screening.

Doppler sonography is an established method in fetal medicine. Up to now a possible circadian rhythm of fetal and maternal Doppler parameters has only been insufficiently characterized and documented. This survey aimed at evaluating the significance of Doppler parameters with regard to diurnal variations. We have analyzed whether or not a circadian rhythm of fetal and maternal Doppler parameters is detectable.A non-selected collective of 100 patients with a singleton pregnancy between the 20th and 39th week of gestation was examined with Doppler sonography at the Medical School of Hannover. Besides the Doppler sonography, which was performed at three fixed times a day, the maternal blood pressure was examined each time. Outcome parameters were resistance index (RI), pulsatility index (PI) and the maximum velocity (V (max)) of the A. umbilicalis, A. cerebri media and the Aa. uterinae as well as the maternal blood pressure.There were no significant differences for the RI, PI and V (max) of the Aa. uterinae for the whole collective, nor for the subgroups of maternal hypertonia, preeclampsia, notching and fetal growth restriction (IUGR). There were also no significant diurnal variations of the Doppler parameters for the fetal vessels. In particular, there were no differences in the measured Doppler parameters in comparison to the collective with unremarkable gravidity. In some subgroups statistical significance could be achieved, but due to the minor variations, no clinical importance has to be considered.A circadian rhythm of the Doppler parameters could not be confirmed in the examined collective. The time of the applied Doppler sonography on physiological conditions might represent a factor which does not affect the validity of the Doppler sonographic results. As a consequence a single Doppler examination at a freely chosen time seems to be sufficient to obtain a correct assessment of fetal and maternal blood perfusion. Further studies on larger collectives are necessary to evaluate the clinical importance of a possible circadian rhythm, especially in fetuses with pathological Doppler values.

Posterior urethral valves are the main cause of fetal lower urinary tract obstruction (LUTO) with typical sonographic signs like urinary tract dilatation and reduction of amniotic fluid. LUTO is associated with a high rate of perinatal mortality and is the main cause of kidney failure in early childhood. In such cases vesico-amniotic shunting is a common but risky procedure of fetal surgery to prevent anhydramnion and lethal lung hypoplasia. This case report demonstrates that lung hypoplasia can be prevented by vesico-amniotic shunting of the fetal megacytis in the 23rd week of gestation in a fetus with lower urinary tract obstruction and anhydramnion. The prenatal measured concentration of cystatin C in the fetal urine correlated with the postnatal impaired kidney function. The indication and therapeutic benefit of vesico-amniotic shunting remain controversially discussed in the literature because until today there is no evidence for a reduction in perinatal or long-term morbidity due to early fetal kidney damage. The earlier ultrasound detection of LUTO during the first trimester of pregnancy proposes the possibility of earlier intervention and protection of nephrogenesis. First case studies about first trimester vesico-amniotic shunting have been published; the influence on the postnatal kidney function merits further well-structured investigation.

Although spontaneous simultaneous intrauterine and ectopic pregnancy was an extremely rare event in the past, it is increasingly being diagnosed since the rate of assisted reproduction technique (ART) gestations increased. Due to the serious consequences, delayed diagnosis should be prevented in order to salvage the viable intrauterine fetus and avoid maternal morbidity and mortality. This case report demonstrates that the pitfalls of the diagnosis of heterotopic pregnancy make early diagnosis difficult and the prevention of heterotopic pregnancies by single embryo transfer should be continuously discussed. The role of high resolution ultrasound scans and the importance of close monitoring of early pregnancies following ART are emphasized because early diagnosis of heterotopic pregnancy results in a similar perinatal outcome as singleton pregnancies.

Background: Epignathus is a rare form of congenital teratoma, originating from the base of the skull, most commonly the hard palate, or mandible. It has been associated with a poor prognosis due to complications including polyhydramnios and respiratory compromise at birth as a consequence of upper airway obstructions. It is usually not associated with chromosomal aberrations. We present a case of prenatally diagnosed epignathus associated with a gonosomal pentasomy 49,XXXXY. Case: A 34-year-old gravida 1, para 0 was referred to our unit with a sonographically suspected gastroschisis at 26+6 weeks’ gestation. A detailed ultrasound scan revealed a large mixed echogenic mass seen in continuation with the mouth in the midline. Based on the appearance, an epignathus was suspected. No other fetal anomalies were detected. Karyotyping showed a 49,XXXXY karyotype of the fetus. The couple decided to continue the pregnancy after detailed counseling about results and prognosis. A cesarean section was necessary and performed at 29+0 weeks’ gestation due to a pathological Doppler and cardiotocogram. Because of the enormous epignathus intubation of the newborn was not possible. A tracheostomy was performed for ventilation and oxygenation, which failed and the newborn died 30 min after birth. Conclusion: Prenatal diagnosis by ultrasound has improved perinatal management. This should include assessment of the tumor size and spread in order to establish an accurate prognosis and to anticipate likely problems which are to be encountered during pregnancy or at the time of delivery. To our knowledge, this is the first reported case of a prenatally diagnosed epignathus with a gonosomal pentasomy 49,XXXXY.

The factual sonographic training in obstetrics differs in Germany in a broad range. In this context, a tendency towards minimalistic dealings with this issue prevails. In contrast to this, the provisions of the German maternity guidelines relating to ultrasound clearly define quality oriented requirements serving altogether as a basic sonographic standard which mandatorily has to be met by all German Obstetricians. In order to close this gap between professional education and social demand, a training concept regarding obstetric ultrasound was devised by the German Association of Gynecologists utilizing the ultrasound simulator system. The aim of this study was to evaluate the usefulness and the effectiveness of this method and its potential role and benefit in structured sonographic training.Between October 2004 and August 2005, 74 obstetric ultrasound training courses according to the ultrasound simulator concept of the Medical School of Hanover were realized in nine federal states of Germany by the German Academy of Gynecology. The aim of these courses was it to procure ultrasound knowledge regarding the structured sonographic exclusion of fetal malformations in a compact manner. As a measure of quality assurance, a standardized questionnaire was issued before and after the courses in order to analyze the benefit of these simulator-based ultrasound courses.The concept found prevailing approval (90 %) at the level of principle, practical implementation and clinical usefulness. 88,2 % of the participants estimated their subjective training effect as being good. The analysis of the questionnaire showed a statistically significant improvement of sonographic knowledge. On average, 74.1 % of the questions were answered correctly by the end of the course as opposed to a mere 46.3 % at the beginning.Structured ultrasound training courses based on the ultrasound simulator system seem to be able to define a basic quality of training and significantly improves examiners' skills in prenatal medicine possible independent of local or structural factors. Hence they seem to be a suitable instrument to close the gap between the sonographic education worthy of improvement and the existing social demand for efficiacy of obstetric sonography.

Increased fetal nuchal translucency (NT) is not only associated with chromosomal aberrations such as Down syndrome but is also predictive for fetal malformations such as cardiac anomalies or an omphalocele. Conversely, an omphalocele can be associated with other structural or chromosomal abnormalities. Cantrell's pentalogy is a rare congenital syndrome involving a midline supraumbilical abdominal wall defect, a defect of the lower part of the sternum, a deficiency of the anterior diaphragm, a defect in the diaphragmatic pericardium and congenital heart malformation. Its prevalence amounts to 5.5 per 1 million neonates. The aetiology is still unknown. We present a case with a pentalogy of Cantrell detected by an increased NT. A 23-year-old woman, primigravida, was referred to our unit at 10 + 3 weeks gestation with an increased NT. Ultrasound scan revealed a CRL of 31.1 mm and an NT of 3.2 mm. In addition to this an omphalocele with a herniac sac involving a part of the liver was suspected. Because of these sonographic findings a chromosomal analysis (CVS) was performed. The karyotype of the fetus showed to be normal (46 XX). A follow-up scan at 13 + 3 weeks gestation demonstrated the foetal abdomen with a supraumbilical midline abdominal wall defect with a large omphalocele containing the liver and stomach as well as an ectopia cordis. The extremities, head and spine seemed to be normal. After detailed counselling about the severity of the syndrome and its dismal prognosis the couple decided for a termination of pregnancy. Autopsy confirmed the prenatal sonographic findings. Measurement of foetal nuchal translucency at first-trimester screening has become a routine procedure in the early targeted search for foetal Down syndrome and other aneuploides. Investigations showed that increased NT is also associated with cardiac malformations. As a special form of a cardiac abnormality in conjunction with an omphalocele, it seems that the pentalogy of Cantrell is facultatively also associated with an increased NT at the end of the first trimenon and should be considered in the differential diagnosis as a cause of increased NT.

Ultrasound has become indispensable in prenatal diagnosis. Ultrasound training, however, still lacks proper quality assessment and control. Moreover, most fetal anomalies which must be diagnosed during pregnancy are extremely rare. Ultrasound simulators could provide an opportunity to overcome this dilemma. This review summarizes the potential benefits of simulator-based ultrasound training, briefly describes the properties of a variety of ultrasound simulators that have been developed for various applications including prenatal diagnosis, and presents the SonoTrainer sonography simulation system which makes it possible to run a real-time simulation of a complete prenatal ultrasound examination. We evaluated the system for the training of first- and second-trimester screening for both normal and pathological findings and found that physicians who received theoretical training and were additionally trained with the simulator (T + S) significantly improved their skills in measurements of nuchal translucency thickness (NT) and crown-rump length (CRL) as compared with colleagues who only underwent theoretical instruction (T) [mean +/- SD NT deviation: 0.31 +/- 0.1 mm (T + S) vs. 0.62 +/- 0.2 mm (T), P0.05; mean +/- SD CRL deviation: 1.48 +/- 2.0 mm (T + S) vs. 3.27 +/- 2.5 (T), P0.05]. Simulator-based training enabled physicians to diagnose rare fetal anomalies in the second trimester with a sensitivity of 86% and a specificity of 100%. In a study in which second-trimester scans including fetal anomalies were presented to physicians, 96% of the participants subjectively estimated their training effect as being good. We therefore conclude that simulator-based training would provide an ideal educational tool to test, improve and monitor a physician's or technician's ultrasound skills in detecting fetal anomalies.

Acupuncture as a non-evidence-based therapy modality is widely used in obstetrics prior to and during delivery. Thus far, only few studies investigated the impact of acupuncture on obstetric surveillance parameters like cardiotocography. The aim of this study was to control the effect of clearly-defined acupuncture on CTG parameters.61 low-risk singleton pregnancies between 30 + 0 and 39 + 6 weeks of gestation were prospectively treated with acupuncture at GV 20 and ST 36 bilaterally for the purpose of maternal relaxation by the same investigator under CTG control. Before (Phase 1), during (Phase 2) and after (Phase 3) treatment the cardiotocogram was recorded. Controlled parameters of outcome were the Fisher score, uterine activity (Phase 1, 2, 3) and maternal blood pressure and pulse before (Phase 1) and after (Phase 2) administration of acupuncture. In a matched control group, 60 pregnant women were monitored by an identical scheme without application of acupuncture and the same outcome parameters were recorded.: The CTG analysis revealed a statistically significant increase of the Fisher score as well as uterine activity which tended to trace back to pretherapeutic initial values. The systolic maternal blood pressure was found to show a statistically significant decrease while diastolic blood pressure and pulse frequency remained unchanged. In the control group, the comparison of phase 1 vs. phase 2 showed a statistically significant increase of the Fischer score and uterine activity. During phase 3 the Fischer score further increased in contrast to a statistically significant slight reduction of uterine activity. Maternal systolic blood pressure measured at the end of phase 2 was found to be statistically reduced while diastolic blood pressure and pulse remained unchanged. The extent of the systolic blood pressure reduction was markedly higher in the acupuncture group as compared to the control group.Antenatal acupuncture as a reflex therapy for the purpose of maternal relaxation seems to exert an influence on short-term alterations of the fetal activity (transient increase in terms of Fischer score) with reversibly increased uterine activity as detected by cardiotocography. Also, a slight reduction of the maternal blood pressure seems to be effected. The phenomena recorded in the control group (relaxation without supportive acupuncture treatment) revealed to be partially concordant (reversibly increased uterine activity, mild maternal reduction of systolic blood pressure) and partially discordant (persisting increase of Fischer score) as compared with the acupuncture group. Acupuncture seems not only to have a psychological, but also a short-term somatic effect with direct influence on maternal and fetal circulation parameters. Other established surveillance parameters and different points of acupuncture should be studied to further elucidate the underlying interaction as well as the duration of this effect.

This retrospective study reports data from 28 children with malignancy aged from 4 months to 15 years to whom 32 Broviac/Hickman indwelling central venous catheters were inserted. Catheter placement ranged from 36 to 381 days with a median of 177 days; thus a cumulative period of more than 12 patients' years could be analyzed. The patients were not continuously hospitalized but spent a median of 44% of their time as catheter-patients at home. The maintenance of the catheter was performed by the parents in an uniformed regimen daily. We registered a total of 22 manageable complications - corresponding to one complication per 202 implantation days. No patient suffered sequelae from the Broviac/Hickman-catheter. Occlusion (12 times) was the most common mechanical complication but patency could be resolved in all cases by installing streptokinase. Four dislocations demanded reimplantation of the catheter. One leak of the external segment was repaired using the commercial repair kit. There were 62 febrile episodes in 22 of 28 patients with simultaneously profound neutropenia in 45% of the febrile episodes. Blood cultures were positive in 11 patients and in 5 of these a catheter-related bacteremia persisted during antibiotic treatment thus requiring catheter explantation. At the end of therapy 40% of the catheters could be removed by manual pull, the rest required surgical explantation. These results demonstrate that with strict maintenance the implantation of a Broviac-Hickman-catheter is associated with an acceptable complication rate even in immunocompromized patients.

Der Zusatz von Fibrinogenspaltprodukten zu Normalplasma in Mengen, wie sie bei Hyperfibrinolyse auftreten konnen, verursacht bei uber 1 mg/ml Plasma eine starke scheinbare Senkung der Gerinnungsfaktoren II, VII, VIII und X und, wie bekannt, eine Verlangerung der Fibrinpolymerisationszeit und Thrombinzeit. Bei niedrigeren Konzentrationen als 1 mg/ml kann es jedoch bei der Bestimmung der Faktoren II, VIII und der Fibrinpolymerisationszeit zu einer Verkurzung der Gerinnungszeit und gleichzeitig bei der Bestimmung der ubrigen Faktoren zur Verlangerung der Gerinnungszeit des jeweiligen Testsystems kommen. Dies spricht dafur, das die Fibrinogenspaltprodukte nicht nur die Phase der Fibrinogen-Fibrinumwandlung, sondern auch andere Gerinnungsfaktoren direkt beeinflussen. Der Aktivitatsverlust der Faktoren, welche nicht Fibrinogen oder Fibrin sind, liese sich demnach in einem hyperfibrinolytischen Plasma allein durch die Wirkung der Spaltprodukte und ohne die Annahme einer Zerstorung ihrer Molekule durch Plasmin erklaren.

Allogeneic bone marrow transplantations were carried out between March 1983 and July 1985 in 31 patients aged 7 to 45 years (median 18 years). Acute lymphoblastic leukaemia in 1st to 5th remission was present in 8 patients, acute myeloblastic leukaemia in 1st and 2nd remission in 4 patients, chronic myeloid leukaemia, with various remission status, in 6 patients, 3 patients had severe aplastic anaemia and there were single cases of myelodysplasia and immature cell megakaryocytic myelosis. Transplantation was carried out during relapse in 8 patients with either acute myeloid or lymphoblastic leukaemia. Phenotypic HLA-identical mothers (n = 2) as well as genotypic HLA-identical siblings (n = 27), and in two cases HLA-non-identical mothers, served as bone marrow donors. In leukaemia patients the conditioning treatment consisted of fractionated total body irradiation and high dose cyclophosphamide or etoposide. Patients with severe aplastic anaemia received cyclophosphamide (4 X 50 mg/kg) and fractionated total nodal irradiation (total dose 8 Gy). 19 patients (61%) survived 14 to 605 days after bone marrow transplantation. 15 patients (48%) continue to remain in complete remission with Karnofsky indices of greater than or equal to 90%. Causes for death were infection (n = 3), interstitial pneumonia (n = 3), relapse (n = 3) as well as single cases involving acute graft-versus-host-disease, non-engraftment of donor marrow and veno-occlusive disease of the liver.

This retrospective study reports data from 28 children with malignancy aged from 4 months to 15 years to whom 32 Broviac/Hickman indwelling central venous catheters were inserted. Catheter placement ranged from 36 to 381 days with a median of 177 days; thus a cumulative period of more than 12 patients' years could be analyzed. The patients were not continuously hospitalized but spent a median of 44% of their time as catheter-patients at home. The maintenance of the catheter was performed by the parents in an uniformed regimen daily. We registered a total of 22 manageable complications - corresponding to one complication per 202 implantation days. No patient suffered sequelae from the Broviac/Hickman-catheter. Occlusion (12 times) was the most common mechanical complication but patency could be resolved in all cases by installing streptokinase. Four dislocations demanded reimplantation of the catheter. One leak of the external segment was repaired using the commercial repair kit. There were 62 febrile episodes in 22 of 28 patients with simultaneously profound neutropenia in 45% of the febrile episodes. Blood cultures were positive in 11 patients and in 5 of these a catheter-related bacteremia persisted during antibiotic treatment thus requiring catheter explantation. At the end of therapy 40% of the catheters could be removed by manual pull, the rest required surgical explantation. These results demonstrate that with strict maintenance the implantation of a Broviac-Hickman-catheter is associated with an acceptable complication rate even in immunocompromized patients.

An intensive 7-day combination chemotherapy protocol was designed to reinduce children with early bone marrow relapse of acute lymphoblastic leukemia (less than 6 months after the end of or during preceding treatment). This aggressive approach seemed to be justified for a group of patients who were at the highest risk for ultimate treatment failure. In all, 38 children were enrolled for study. The ratio of male (median age, 10 years) to female (median age, 13 years) subjects was 27:11. Thirty patients were treated for their first relapse and eight for their second or subsequent relapse. Isolated bone marrow involvement was present in 24 cases. All patients had received heavy pretreatment including anthracyclines with cumulative doses of between 120 and 240 mg/m2.

About 10 years ago allogeneic bone marrow transplantation (BMT) became established in West Germany as a therapeutic method for hematological malignancies. Between 1975 and April 1984, more than 300 patients were transplanted for various forms of leukemia [1]. Between 1975 and the end of 1985, 108 children up to the age of 16 years with leukemia were transplanted in five different centers. They now present a combined report for the first time. Sixty percent of the children were transplanted in the last 3 years whereas the remaining 40% were treated in the last 7 years. The total number of patients is rather small compared with other countries, and it is only recently that transplantations have been performed frequently in children in this country. The main reason for this slow development are the good results of conventional chemotherapy of acute lymphocytic leukemia (ALL) [2] and acute nonlymphocytic leukemia (ANLL) [3]. Not a single child with ALL, and only nine children with ANLL and two with acute undifferentiated leukemia (AUL) have been transplanted during first complete remission. In contrast, 39 children (36%) were not in remission at the time of transplantation. This point and the fact that the relapses of acute leukemia occurred after the very intensive chemotherapy used in this country has to be considered when the combined results are reviewed in the following.