Comparison of Conservative and Surgical Therapy Concepts for Synechia of the Labia in Pre-Pubertal Girls.

Introduction: The aim of this study was to evaluate the primary and secondary therapeutic successes of different therapy schemes for the treatment of synechia of the labia in pre-pubertal girls. Materials and Methods: The treatment courses of 47 pre-pubertal girls who were treated between February 2007 and February 2013 in the special outpatient clinic for paediatric gynaecology of a department for gynaecology at a German university hospital and for whom information on the course of the disease was available for at least the six months following end of the treatment. 23 of these children were treated with a topical estriol therapy (treatment group A). For 24 of the girls a manual separation of the adhering labia minora was undertaken (treatment group B). Statistical evaluation was performed using the χ2 test, Fischer's exact test and the Mann-Whitney U test. Results: For 18 of the 23 (80 %) girls in treatment group A topical estriol therapy alone led to a resolution of the synechia. Five of these 23 children (20 %) required a secondary manual separation. All girls for whom treatment was not successful were under 5 years of age. For all 24 girls (100 %) of treatment group B the primary manual separation was performed with success. The recurrence rates after ≥ 6 months in cases with identical after-care did not differ between the two treatment groups (treatment group A: 34 %, treatment group B: 33 %, χ2 test: p = 0.853). 16 of the 17 recurrences occurred ≥ 3 months after the end of the therapy. Conclusion: Our results show that for children < 5 years of age a 4-week topical therapy with estriol is a promising therapy option for synechia of the labia that is less of a burden for the family situation. Especially for girls ≥ 5 years of age, primary therapy fails in up to 20 % of the cases. Primary manual separation represents a more effective therapeutic option. Irrespective of the treatment applied, a recurrence after ≥ 3 must be expected in one-third of the treated girls.

Anogenital Warts in Childhood - Always a Marker for Sexual Abuse?

Human papilloma viruses (HPV) are common pathogens associated with a wide range of cutaneous and mucosal infections in childhood. Different HPV types can cause common warts and anogenital warts. Condylomata acuminata in children may be, but are not necessarily, an indicator of sexual abuse. Each individual case therefore requires careful examination, with consideration of other possible means of transmission. Diagnosis of anogenital warts is generally by means of clinical examination. Additional histological, serological or molecular genetic investigation may be indicated occasionally. The high rate of spontaneous remission and the rate of recurrence after treatment should be considered. The available topical and surgical treatment options are discussed.

Serum Folate and Cobalamin Levels in Women Using Combined Contraceptive Vaginal Ring.

Purpose: The aim of our study was to evaluate the effects of combined contraceptive vaginal rings on serum concentrations of folate and cobalamin in healthy users. Material and Methods: Case-control study on cobalamin and folate status of 45 healthy female nulligravidae using a combined contraceptive vaginal ring for > 3 months and 45 healthy controls. Factors interfering with vitamin metabolism were thoroughly controlled. Results: Cobalamin and folate levels did not differ between the groups. Vegetarian diet, smoking or obesity did not have a significant influence. Conclusions: The use of a combined contraceptive vaginal ring provides an appropriate hormonal contraception in women with pre-existing cobalamin deficiency or restrictive diet habit in order to avoid interferences between vitamin B12 metabolism and exogenously applied estrogens.

[Health-related quality of life after surgical haemorrhoid treatment - results, methods and problems]. / Gesundheitsbezogene Lebensqualität nach operativer Hämorrhoidaltherapie - Ergebnisse, Methoden und Probleme.

In patients suffering from haemorrhoidal disease a hyperplasia of the corpus cavernosum recti is accompanied by various symptoms such as anal bleeding and minor continence disorders as well as itching, soiling and burning. According to the morphological findings, haemorrhoids are staged from grade I up to IV. Therapy strategies are adjusted to this staging. Early stages are treated by conservative measures, such as regulation of defaecation, sclerosis and rubber band ligations. Advanced stages require operative methods, such as segmental excision and stapled haemorrhoidopexy. Since patients demand a greater regard to the subjective experience of their disease and its treatment, quality of life evaluation has become an important issue in medical care. Therefore health-related quality of life is increasingly becoming a relevant primary or secondary end point of clinical studies. Since up to 4 % of the general adult population in industrial nations is annually diagnosed to suffer from haemorrhoidal disease, in Germany per annum 3.5 Mio patients seek medical advice due to this condition and 40 000-50 000 surgical procedures are performed. Nevertheless only very few studies have been carried out to investigate the influence of this widespread disease on the quality of life of those patients. Additionally cost-effectiveness analyses measuring quality-adjusted life years are becoming more and more decisive in health politics. The present article discusses the definitions of health-related as well as disease-related quality of life. Different psychometric tests applied to evaluate the quality of life are summarised, quality criteria are outlined and limitations discussed. Several studies were analysed in regard to the quality of life in patients with haemorrhoidal disease and the specific influence of different operative techniques was reviewed.

[Constipation--established and new diagnostic approaches]. / Obstipation - Bewährtes und Neues in der Diagnostik.

The aim of this paper is to review diagnostic techniques which are useful and applicable in the evaluation of constipation. Besides widely-spread available techniques such as taking a specific and structured history and performing a clinical examination sophisticated diagnostic tools such as colon transit time, anal manometry, defecography endorectal ultrasonography as well as electrophysiological investigations such as anal sphincter electromyography and pudendal nerve terminal motor latency measurement are illustrated.

[Perineal hernia: an undescribed complication following operative repair of vault vaginal prolaps]. / Ausgedehnte perineale Hernie bei Zustand nach wiederholter operativer Therapie eines Vaginalprolapses.

The presented case reports the treatment of a 80-year-old V gravida IV para suffering from a large perineal hernia and rectocele after vaginal hysterectomy and subsequently performed threefold colpocleisis due to recurrent vault vaginal prolaps.[nl]Since perioperative morbidity and mortality of geriatric patients differ not significantly from thoses of younger women age should not be used as an argument to withhold elderly organ preserving operative strategies with low recurrence rates.

[Reversible loss of vision in severe preeclampsia: case report and review of the literature]. / Reversibler Visusverlust bei schwerer Präeklampsie - Fallbericht und Literaturübersicht.

Visual disturbances occur in up to 25 % of the patients with preeclampsia. However, blindness remains a rare phenomenon. A 39 year old primigravida was admitted for observation at 30 weeks gestation with signs of preeclampsia. After 11 days she suffered a complete loss of vision. The blindness reversed completely after cesarean section and antihypertensive treatment. Blindness in preeclamptic patients is mostly caused by hypertensive encephalopathy. We discuss pathophysiological aspects as well as diagnostic approaches and therapeutic options with respect to the available literature.

[Plasma VEGF levels are increased in women with severe preeclampsia or HELLP syndrome]. / Einfluss des Vascular Endothelial Growth Factor (VEGF) auf die Entwicklung der schweren Präeklampsie oder des HELLP-Syndroms.

AIM: To investigate vascular endothelial growth factor (VEGF) serum levels in severe preeclampsia (PE) and HELLP syndrome. PATIENTS AND METHODS: Serum concentrations of VEGF, progesterone, estradiol and estriol were measured in 16 patients with PE and 14 patients with HELLP syndrome and in 30 well-matched normotensive pregnant controls. Determination of VEGF was performed by a commercially available immunoassay (Quantikine(R), R&D Systeme, Wiesbaden), those of sex steroids by a radioimmunoassay (Fa. Biermann, Bad Nauheim). RESULTS: Serum VEGF levels were significantly higher in the study than in the control group (172.0 +/- 98.9 pg/ml versus 41.4 +/- 30.5 pg/ml, U-Test: p < 0.001). In patients with HELLP syndrome mean serum VEGF concentrations were increased when compared with healthy controls but serum levels were significantly lower than in patients with PE (109.2 +/- 68.5 pg/ml versus 219.0 +/- 72.9, U-Test: p < 0.05). We could demonstrate a positive correlation between VEGF and estradiol serum concentrations in the study and control patients (Spearman rang correlation: p < 0.05). CONCLUSIONS: It is concluded that patients suffering from PE or HELLP syndrome have either an increased placental expression of VEGF as a result of hypoxia or show an increased extraplacental production of this growth factor such as in maternal or fetal endothelial cells, macrophages or smooth muscle tissue.

[Genital findings in sexually abused prepubertal girls]. / Kindergynäkologische Aspekte des sexuellen Missbrauchs.

Genital findings in sexually abused prepubertal girls. Childhood sexual abuse is defined as the involvement of dependent, developmentally immature children and adolescents in sexual activities that they do not fully comprehend, to which they are unable to give informed consent or that violate the social taboos of family roles. Essential to the diagnosis of sexual abuse is an awareness of the problem and acknowledgement of its manifestations. The evaluation of the sexually abused girl usually is performed in a pediatric and adolescent gynecology outpatient department. Thus, the gynecologist will be part of a multidisciplinary approach to the problem and will need to be competent in the basic skills of history taking, physical examination, selection of laboratory tests und differential diagnosis. Findings secondary to sexual abuse are often subtle. Acute tears or bruisings are rare, because force is seldom part of sexual acts committed against a child. A vaginal opening of greater than 5 mm is not common and may indicate vaginal penetration. An intact hymen not necessarily exclude vaginal intercourse. Lack of physical evidence never rules out abuse because sexual acts may leave no physical findings.

Increased prevalence of thyroid antibodies in euthyroid women with a history of recurrent in-vitro fertilization failure.

This study was undertaken to evaluate whether the presence of thyroid antibodies in euthyroid women is associated with an adverse outcome in an in-vitro fertilization (IVF)-embryo transfer programme. In 24 women (study group: mean age +/- SD: 31.5 +/- 4.4 years) who failed to conceive after having three or more cycles of IVF and embryo transfer, serum concentrations of thyroglobulin (TG), thyroid peroxidase antibodies (TPO) and anticardiolipin antibodies (IgG and IgM) were measured using commercially available kits. The control group comprised 24 consecutive patients without endocrine dysfunction (mean age +/- SD: 30.3 +/- 4.1 years) seeking infertility treatment in our department of assisted reproduction. All patients in both the study and the control groups were determined to be euthyroid by demonstrating normal concentrations of thyroid-stimulating hormone (TSH). In the study and control groups respectively, 13 and two patients demonstrated positive titres of TG, TPO or both thyroid antibodies (Fisher's exact test: P = 0.002). Mean serum concentrations of TG were significantly increased in the study group compared to the control subjects (156 +/- 167 IU/ml versus 33.5 +/- 32.0 IU/ml; U-test: P = 0.009). Serum concentrations of TPO and anticardiolipin antibodies were similar in both groups. Our investigations revealed that thyroid antibodies might be independent markers for reproductive failure in an IVF-embryo transfer programme.

[Hyaluronan and CD44 in maternal serum in pre-eclampsia]. / Hyaluronan und CD44 im mütterlichen Serum bei Präeklampsie.

BACKGROUND: Pre-eclampsia is associated with serum factors which can activate blood vessel endothelial cells. Hyaluronan (HYA) and its specific receptor CD44 play a central role in cell activation processes. Our study focussed on the behavior of serum concentrations of HYA and the soluble standard form of CD44 (sCD44std) in the maternal serum from normotensive and pre-eclamptic pregnancies. PATIENTS AND METHODS: Serum was collected from normotensive pregnant women (n = 10) and from pregnant women with a severe pre-eclampsia (n = 10). HYA-serum concentrations were measured with a radioimmunoassay while sCD44std were measured with an ELISA. RESULTS: The pre-eclampsia group shows a significant (p < 0.001, Mann and Whitney u-test) increased HYA serum concentration (median 79 ng/ml, range 53-165 ng/ml) when compared to the normotensive group (n = 10, median 32 ng/ml, range 19-59 ng/ml). sCD44std-serumconcentration in the pre-eclampsia group (328.3 +/- 68.3 ng/ml) was weakly higher but not statistically significant (p > 0.05) when compared to the normotensive group (292.9 +/- 74.0 ng/ml). There exist no correlations between the HYA and sCD44std serum concentrations in both pre-eclamptic and normotensive groups. CONCLUSION: The increased HYA-serumconcentration may indicate a pathophysiological role of the HYA/CD44-signal transduction system in pre-eclampsia. The existing overlap of HYA serum levels in the pre-eclampsia group with HYA serum levels in the normotensive control group limits the diagnostic precision of HYA serum concentration as a diagnostic parameter in pre-eclampsia. According CD44 it is not excluded that serum concentration of other soluble CD44-isoforms is increased in pre-eclampsia.

Predictive value of CEA and CA 15-3 in the follow up of invasive breast cancer.

BACKGROUND: The clinical usefulness of tumor markers in the follow-up care of invasive breast cancer is controversial. METHODS: In 1228 serum samples of 664 women with history of breast cancer, the diagnostic accuracy and predictive power of CEA and CA 15-3 for the detection of disease relapse was determined prospectively by analyzing the clinical course for at least 6 months after the measurement of the tumor markers in 1994. RESULTS: A total of 76 patients relapsed during the period of study. The diagnostic accuracy was 83% for CEA and 88% for CA 15-3. CEA and CA 15-3 had a positive predictive value of 27% and 47% as well as a negative prediction of 91% and 93%, respectively. CONCLUSIONS: The low positive predictive value and sensitivity of these tumor markers clearly limit their clinical utility. Therefore, the effectiveness of routine determinations during the follow-up seems questionable.

Endocrine abnormalities during the follicular phase in women with recurrent spontaneous abortion.

The frequency of endocrine abnormalities during the follicular phase in non-pregnant women with a history of recurrent abortion was investigated in a case-control study. A total of 42 consecutive women with recurrent spontaneous abortion (three or more consecutive abortions, mean +/- SD: 3.9 +/- 1.1 range 3-8) with no parental chromosome rearrangement or uterine abnormality were studied during the early follicular phase under standardized conditions. Serum concentrations of follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, androstenedione, testosterone, dehydroepiandro-stenedione, 17-OH-progesterone, oestradiol, progesterone and thyroid stimulating hormone (TSH) were measured by commercially available radioimmunoassays. Controls were 42 nulligravid females with tubal or male factor infertility without miscarriage. Mean (SD) concentrations of prolactin and androstenedione were 14.2 +/- 6.7 ng/ml versus 10.5 +/- 3.5 ng/ml (95% CI 0.8-6.1) and 2.3 +/- 0.9 ng/ml versus 1.7 +/- 0.6 ng/ml (95% CI 0.2-0.9) in the study and control groups respectively. The other endocrine parameters were comparable in both groups. Obesity [BMI weight (kg)/height (m2) > or = 25] was more prevalent (23 versus 5 women, P = 0.0001) in the study than the control group. Recurrent spontaneous abortion is associated with abnormalities in prolactin and androgen secretion during the follicular phase, suggesting an endocrine aetiology in this disorder. Reduction of body weight and correction of hyperprolactinaemia and of hyperandrogenism may reduce the rate of miscarriage in a subsequent pregnancy in these women.

Plasma endothelin and big endothelin levels in women with severe preeclampsia or HELLP-syndrome.

OBJECTIVE: To compare maternal and umbilical venous big endothelin (big ET) and endothelin-1 (ET-1) levels of pregnancies complicated by severe preeclampsia (PE) or HELLP-syndrome to those of a well-matched normotensive pregnant control group. METHODS: We measured plasma levels of ET-1 and big ET in 16 patients with severe PE and 14 patients with HELLP-syndrome by commercially available RIAs and compared them with those of well-matched normotensive pregnant controls. Additionally, the umbilical venous ET-1 and big ET levels were determined in 10 corresponding newborns. RESULTS: The plasma concentrations of ET-1 and big ET were significantly higher in patients with severe PE and especially in women with HELLP-syndrome when-compared with controls. The molar ratios of big ET to ET-1 were significantly lower in the two study groups. The levels of ET-1 and big ET were higher in umbilical venous plasma than in maternal plasma, but there were no significant differences in the umbilical venous concentrations between normotensive and by severe PE or HELLP-syndrome complicated pregnancies. CONCLUSIONS: These findings suggest that ET-1 may be considered as a marker of endothelial injury in by severe preeclampsia or HELLP-syndrome complicated pregnancies. The increase of the ET-1 plasma levels may be due, at least in part, to changes in the conversion of big ET to ET-1 by the endothelin-converting enzyme.

Interval of 9 h between birth of twins at term: case report and review of the literature.

We report the case of a primipara who delivered healthy twins vaginally at term with a time interval between twins of 9 h and 19 min. Neonatal outcome and further development were normal in both twins.

Prophylactic intravenous hydroxyethyle starch solution prevents moderate-severe ovarian hyperstimulation in in-vitro fertilization patients: a prospective, randomized, double-blind and placebo-controlled study.

A prospective, randomized, double-blind and placebo-controlled study was conducted to assess the effectiveness of i.v. administration of 6% hydroxyethyle starch solution (HES) in preventing moderate and severe ovarian hyperstimulation syndrome (OHSS) in patients in an in-vitro fertilization programme. A total of 101 women who had serum oestradiol concentrations >1500 pg/ml and/or more than 10 follicles on day of human chorionic gonadotrophin (HCG) administration were recruited into two groups: HES group (n = 51) received 1000 ml 6% HES; and the placebo group (n = 50) received 1000 ml of sodium chloride 0.9% solution at the time shortly after embryo transfer. Follow-up examinations 7 +/- 1 and 14 +/- 1 days after embryo transfer included transvaginal ultrasound (diameters of each ovary and maximum cysts, number of cysts, ascites), blood tests (serum oestradiol, progesterone, beta-HCG, C-reactive protein, blood count, plasma proteins, electrolytes, kidney function tests) and evaluation of abdominal pain, nausea, diarrhoea, abdominal swelling and weight gain. Only one moderate OHSS developed in the HES group whereas seven moderate-severe cases were observed in the placebo group (P = 0.031). Furthermore, serum oestradiol concentration, leukocyte count, increase in abdominal circumference and weight gain 14 days after embryo transfer were significantly higher in the placebo group. There were no differences between the two groups in terms of age, oestradiol concentration and number of follicles at time of HCG injection. Administration of 6% HES prevents the development of moderate-severe OHSS in risk patients.

Plasma renin activity and aldosterone serum concentration are decreased in severe preeclampsia but not in the HELLP-syndrome.

BACKGROUND: To investigate plasma renin activity and aldosterone serum concentrations in severe preeclampsia (PE) or HELLP-syndrome. METHODS: We measured plasma renin activity and serum concentrations of aldosterone, progesterone, estradiol and estriol in 16 patients with PE and 14 patients with HELLP-syndrome and in well-matched normotensive pregnant controls. Additionally, the umbilical venous levels of aldosterone and plasma renin activity were determined in ten corresponding newborns. RESULTS: Serum aldosterone levels as well as plasma renin activity were significantly lower in patients with PE but not in women with HELLP-syndrome when compared to controls. We did not find any relationship either between aldosterone serum concentration or plasma renin activity and progesterone, estradiol or estriol levels in PE or in the HELLP-syndrome. Umbilical venous renin activity and aldosterone levels were higher than in maternal blood, but there were no significant differences in the umbilical venous levels between normotensive pregnancies and pregnancies complicated by either severe PE or HELLP-syndrome. CONCLUSION: It is concluded that in patients with PE well-known changes in the renin-angiotensin-aldosterone system cannot be found in patients with HELLP- syndrome. This finding is not related to alterations in sex steroid levels.

Serum levels of folate and cobalamin in women with recurrent spontaneous abortion.

We evaluated the folate and cobalamin status in 29 non-pregnant women with a history of recurrent spontaneous abortion (three or more consecutive) of unknown aetiology in comparison to 29 healthy nulligravidae of similar reproductive age (controls). Serum concentrations of folate and cobalamin showed no significant differences between the two groups. No correlation between age and vitamin concentrations was found. In the study group there was a significant negative correlation of the number of previous abortions and the concentration of serum folate. Patients with at least four previous miscarriages had significantly lower serum values of folic acid than women with three abortions, but not than controls. The underlying cause of this finding remains unclear. In conclusion, the serum concentrations of folic acid and vitamin B12 are not significantly altered in women with unexplained recurrent spontaneous abortions, and an association between a deficiency of these vitamins and an increased risk of pregnancy loss appears to be questionable in the majority of gestations.