Prevalence, Clinical Significance and Risk Factors for Developing Scar Pain and Sensibility Disorders in Breast Cancer Patients after Breast-Conserving Therapy and Mastectomy.

INTRODUCTION: The aim of this study was to gather information on the prevalence and risk factors for scar pain and sensibility disorders after breast cancer surgery, as only limited information of these complaints are available. MATERIAL AND METHODS: A clinical cohort study using a non-validated questionnaire was conducted among women who presented to routine follow-up at the Breast Cancer Center Rostock, Germany. The subjects were informed that the subjective perception and sensation were in the foreground and that the questionnaire had to be filled out independently according to the current feeling. RESULTS: Overall 175 patients could be evaluated. The prevalence of scar pain was 30.8% after breast conserving therapy (BCT) and 34.5% after mastectomy. Following BCT 87.5%, respectively 81.8% of women after mastectomy were very satisfied or satisfied with the scarring. Sensory disorders were increased in the mastectomy group (p = 0.001). Scar pain after previous surgery was a risk factor to develop sensory disorders after BCT (p = 0.008) and mastectomy (p = 0.029). For patients receiving mastectomy, sensory disorders after previous breast surgeries increased the risk for sensory disorders (p = 0.029). Smoking was a risk factor for sensory disorders after mastectomy (p = 0.048). Multivariate analysis could not confirm any of the risk factors. CONCLUSION: This study demonstrated a high satisfaction with scarring after breast surgery and a low level of scar pain. A lack of postoperative information, as well as a low level of actually performed scar care after surgery were observed. Increased focus should be on improved information on postoperative scare care.

Prediction of Spontaneous Preterm Birth in At-risk Women Using Thrombospondin 1 from Cervicovaginal Fluid: A Prospective Observational Study.

Introduction Thrombospondin 1, desmoplakin and stratifin are putative biomarkers for the prediction of preterm birth. This study aimed to validate the predictive capability of these biomarkers in patients at risk of preterm birth. Materials and Methods We included 109 women with symptoms of threatened spontaneous preterm birth between weeks 20 0/7 and 31 6/7 of gestation. Inclusion criteria were uterine contractions, cervical length of less than 25 mm, or a personal history of spontaneous preterm birth. Multiple gestations were also included. Samples of cervicovaginal fluid were taken before performing a digital examination and transvaginal ultrasound. Levels of cervicovaginal thrombospondin 1, desmoplakin and stratifin were quantified by enzyme-linked immunosorbent assays. The primary endpoint was spontaneous preterm birth before 34 + 0 weeks of gestation. Results Sixteen women (14.7%) delivered before 34 + 0 weeks. Median levels of thrombospondin 1 were higher in samples where birth occurred before 34 weeks vs. ≥ 34 weeks of gestation (4904 vs. 469 pg/mL, p < 0.001). Receiver operator characteristics analysis resulted in an area under the curve of 0.86 (p < 0.0001). At an optimal cut-off value of 2163 pg/mL, sensitivity, specificity, positive predictive value and negative predictive value were 0.94, 0.77, 0.42 and 0.99, respectively, with an adjusted odds ratio of 32.9 (95% CI: 3.1 - 345, p = 0.004). Multiple gestation, cervical length, and preterm labor had no impact on the results. Survival analysis revealed a predictive period of more than eight weeks. Levels of desmoplakin and stratifin did not differ between groups. Conclusion Thrombospondin 1 allowed long-term risk estimation of spontaneous preterm birth.

The Significance of Preoperative Computed Tomography for Predicting Optimal Cytoreduction in Advanced Ovarian Cancer.

Introduction Optimal cytoreduction is the most important prognostic factor in advanced ovarian cancer. Although staging and assessment of operability are made by exploratory surgery, preoperative computed tomography (CT) of the abdomen is regarded as standard. The aim of this study was to examine various CT parameters with regard to prediction of optimal cytoreduction. Patients and Methods The retrospective study included 131 patients with ovarian cancer newly diagnosed between 2010 and 2014. Of these, n = 36 with FIGO stage I to IIB were excluded from the study. A preoperative abdominal CT was available for n = 75 of the 95 patients with FIGO stage IIC to IV. The CT scans underwent blinded review. The 11 evaluated CT parameters were examined by means of χ 2 test and logistic regression analysis with regard to the endpoints of macroscopic residual tumour and residual tumour > 1 cm. Survival analyses used the Kaplan-Meier method and log rank test. Results Of 75 patients, 28 (37.3%) had complete tumour resection and 26 (34.7%) had residual tumour ≤ 1 cm. Residual tumours > 1 cm were found in 21 (28%) patients, five of which were not resectable. Overall survival with residual tumour > 1 cm differed significantly from the group with no macroscopic residual tumour (p = 0.003) and with residual tumour ≤ 1 cm (p = 0.04). The CT parameters tumour foci in the diaphragm, mesocolon, greater omentum and peritoneum as well as ascites correlated with macroscopic residual tumour. In the multivariate logistic regression analysis only the CT parameter intraparenchymal liver metastasis was statistically significant with regard to prediction of suboptimal tumour resection (> 1 cm) (OR 8.04; 95% CI 1.57 - 42.4; p = 0.0134). The sensitivity, specificity, PPV and NPV were 37.5, 89.7, 66.7 and 72.2%. Conclusion Although risk parameters for suboptimal tumour reduction can be identified by CT of the abdomen, surgical exploration with histological confirmation of the diagnosis is essential because of the poor diagnostic accuracy.

Oncologic Outcome of Patients with (Low-Risk) Endometrial Carcinoma Undergoing Laparotomy versus Minimally Invasive Hysterectomy: A Retrospective Analysis.

BACKGROUND: Patients with endometrial carcinoma (EC) frequently are obese and have various secondary diseases. We investigated the oncologic safety and complication rates of early-stage EC treated with laparotomy (LAP) versus minimally invasive hysterectomy (MIH). A secondary study aim was the evaluation of risk factors for relapse and complications. METHODS: Data from the Cancer Registry Rostock, Germany, and the medical records of women diagnosed with type 1 EC between January 2005 and December 2014 were retrospectively evaluated. The baseline characteristics were analyzed with the χ2 test and Fisher's exact test. Multivariate analysis with the Cox proportional-hazards model and logistic regression were performed to identify prognostic factors for time to event and risk factors for complications. Kaplan-Meier analysis was performed for disease-free and overall survival. RESULTS: Of 350 evaluated patients, 242 underwent traditional LAP; on 108 patients, MIH was performed. The median follow-up period in the LAP group and the MIH group was 82 ± 31.1 and 71.1 ± 33.6 months, respectively (p = 0.10). The median time to event was 40.3 ± 28.1 months in the LAP group and 38.0 ± 27.5 months in the MIH group (p = 0.476). Significantly longer surgery times (p < 0.001) and more complications (p < 0.001) were observed in the LAP group. Disease-free survival after MIH was not significantly different from that after LAP (log-rank p = 0.052). Multimorbidity remained as the single risk factor for event/recurrence (p = 0.019) in multivariate analysis. CONCLUSIONS: MIH for early-stage EC may be an oncologically safe approach when compared to LAP, and its complication rates are lower; therefore, MIH represents the preferred approach for this patient cohort.

Clinical Approaches to Breast Reconstruction: What Is the Appropriate Reconstructive Procedure for My Patient?

Breast reconstruction after breast cancer is an emotional subject for women. Consequently, the correct timing and surgical procedure for each individual woman are important. In general, heterologous or autologous reconstructive procedures are available, both having advantages and disadvantages. Breast size, patient habitus, and previous surgeries or radiation therapy need to be considered, independent of the chosen procedure. New surgical techniques, refinement of surgical procedures, and the development of supportive materials have increased the general patient collective eligible for breast reconstruction. This review highlights the different approaches to immediate breast reconstruction using autologous or heterologous techniques.

Acute-phase proteins in prediction of preeclampsia in patients with abnormal midtrimester uterine Doppler velocimetry.

AIMS: Manifestation of preeclampsia is characterized by an inflammatory response and altered expression of acute-phase proteins. In this study, we examined the predictive value of serum amyloid A, progranulin, transthyretin, C-reactive protein and interleukin-6. Soluble endoglin was used as control. METHODS: Maternal serum levels of the putative biomarkers were measured in 49 women with a midtrimester bilateral abnormal uterine artery Doppler velocimetry. RESULTS: Preeclampsia developed in 26.5 %. 75.0 % had an early-onset disease (<34 + 0 weeks). Delivery <34 + 0 weeks was indicated in 16.3 %. 12.2 % of patients developed a normotensive intrauterine growth restriction. All of the putative biomarkers were not predictive for preeclampsia. But serum levels of progranulin and also of soluble endoglin were increased in cases with development of a severe normotensive intrauterine growth restriction. Only soluble endoglin was predictive for the development of preeclampsia with an area under curve in the receiver operating curve analysis of 0.761 (P = 0.006). Using a cut-off level of ≥9.14 ng/mL, sensitivity, specificity, positive predictive value and negative predictive value were 53.9, 88.9, 63.6 and 84.2 %, respectively. CONCLUSIONS: Inflammation is a late event during development of preeclampsia, and acute-phase proteins are not predictive for the disease in a high-risk population without clinical symptoms during the second trimester. Progranulin is a putative new biomarker for an early detection of intrauterine growth restriction in women without concomitant hypertensive disorders. Soluble endoglin improved predictive values for preeclampsia in patients with abnormal uterine Doppler.

Diagnosis of ruptured breast implants through high-resolution ultrasound combined with real-time elastography.

BACKGROUND: Implant rupture as a late complication of breast implant surgery is often a silent phenomenon that is difficult to diagnose. Sonoelastography is a new ultrasound-based technique that allows assessment of tissue elasticity. OBJECTIVES: This study was undertaken to evaluate elastographic findings in normal and ruptured breast implants. METHODS: This prospective study included 28 implants in 16 patients, all of whom underwent high-resolution ultrasound and real-time elastography. The diagnosis of implant rupture was confirmed by surgery. RESULTS: Implant rupture was diagnosed in 5 out of 28 implants (17.9%). In those patients with ruptured implants, 3 had no symptoms, 1 presented with pain, and 1 complained of ipsilateral axillary lymph node swelling. Implants with a homogenous anechoic interior were considered to be intact. Ultrasound findings indicating implant rupture included multiple parallel echogenic lines in the implant interior in 2 cases and a mix of hyperechoic and hypoechoic masses in 3 cases. The feasibility of real-time elastography of implants was demonstrated in all cases. Elastograms of intact implants revealed a typical blue-green-red pattern familiar from cystic lesions. In all 5 ruptured implants, elastography revealed yellow-green figures without typical layering. CONCLUSIONS: To the authors' knowledge this is the first series to combine high-resolution ultrasound with real-time elastography for the diagnosis of implant rupture. Since there are distinct differences between elastograms of intact and ruptured implants, addition of real-time elastography to conventional ultrasound may improve implant surveillance and obviate the need for magnetic resonance imaging.

Biocompatibility, cell growth and clinical relevance of synthetic meshes and biological matrixes for internal support in implant-based breast reconstruction.

PURPOSE: Biological matrixes and synthetic meshes are increasingly used in implant-based breast reconstruction (IBBR). The objective was to test different materials used for internal support in IBBR in regards to biocompatibility and discuss possible limitations in a clinical context. MATERIALS AND METHODS: In vitro investigations were performed on four relevant cell lines: Normal Human Dermal Fibroblasts (NHDF), Human White Preadipocytes (HWP), Endothelial cells (HDMEC) and Skeletal muscle cells (SkMC). A titanium-coated polypropylene mesh (TiLOOP Bra), a partially resorbable mesh (SERAGYN BR) and a porcine derived biologic matrix (Strattice) were investigated. Test of cytotoxicity, cell proliferation and oxidative stress was performed. Real-time cell analysis was used to determine adhesion rate. Light- and scanning electron microscopy investigated cell migration. RESULTS: No relevant cytotoxicity was detected for any mesh or matrix. Good cell proliferation was observed in all materials with best results for NHDF and SkMC. For HWP and HDMEC decreased proliferation and adherence to the synthetic meshes and biologic matrix were observed. Real-time cell analysis of fibroblasts incubated with the corresponding material, showed increased impedance for the synthetic meshes. A morphologic cell change was observed within all materials. Scanning electron microscopy showed good cell penetration into the meshes and matrix. The material compositions did not seem to influence the clinical outcome, although the biological matrix was much thicker compared to the synthetic meshes. CONCLUSION: Biochemical examination showed good biocompatibility for the investigated meshes and matrix. All products seem to have their value in IBBR and can be recommended for IBBR.

Prediction of preeclampsia and induced delivery at <34 weeks gestation by sFLT-1 and PlGF in patients with abnormal midtrimester uterine Doppler velocimetry: a prospective cohort analysis.

BACKGROUND: Women with bilateral abnormal uterine artery Doppler velocimetry (UtADV) are at increased risk for an adverse pregnancy outcome. This study aimed to determine if additional assessment of midtrimester angiogenic factors improves the predictive accuracy of Doppler results for various outcome parameters. METHODS: Women with a bilateral abnormal UtADV, which was defined as a postsystolic incision and/or an increased pulsatility index greater than the 95th centile, and a singleton pregnancy were prospectively recruited between 19 + 0 and 26 + 6 weeks of gestation. Maternal serum levels of placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFLT-1) were measured with a fully automated immunoassay and their ratio was calculated. RESULTS: Angiogenic factors could predict the development of preeclampsia (PE), as well as induced delivery at <34 weeks of gestation, but failed to predict the development of normotensive intrauterine growth restriction. Twelve (24.0%) of the 50 recruited women developed PE. Nine of these patients had early-onset disease (<34 + 0 weeks). Six (12.0%) patients were delivered at <34 + 0 weeks. The most useful test results in the prediction of PE and induced delivery at <34 + 0 weeks were observed using the sFLT-1/PlGF >95th centile ratio with a sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of 66.7%, 89.5%, 66.7%, and 89.5% for PE, and 85.7%, 86.1%, 50.1%, and 97.4% for induced delivery, respectively. Positive and negative likelihood ratios were 6.33 (95% CI 2.31-17.38) and 0.37 (95% CI 0.17-0.84) for PE, and 6.14 (95% CI 2.76-13.69) and 0.17 (0.03-1.02) for induced delivery, respectively. Corresponding odds ratios were 17.0 (95% CI 3.5-83.0) and 37.0 (95% CI 3.8-363.9), respectively. CONCLUSIONS: Measurement of angiogenic factors improves the specificity of an abnormal UtADV for prediction of PE. Compared with prediction of PE an abnormal sFLT-1/PlGF ratio revealed higher sensitivity for prediction of induced delivery at <34 + 0 weeks. The NPV of 97% will help to reassure most patients with an abnormal UtADV and a normal sFLT-1/PlGF ratio.

Progranulin shows cytoprotective effects on trophoblast cells in vitro but does not antagonize TNF-α-induced apoptosis.

AIMS: The glycoprotein progranulin directly binds to TNF-receptors and thereby can antagonize the inflammatory effects of TNF-α. Here we analyzed the impact of both cytokines on cytotoxicity and viability of trophoblast cells. METHODS: Isolated villous first trimester human trophoblast cells and the human choriocarcinoma cell line BeWo were treated with recombinant human progranulin and TNF-α. Analyses were performed by LDH- and MTT-assay and measurement of caspase-8-activity. RESULTS: Progranulin treatment showed some cytoprotective effects on isolated trophoblast cells. However, TNF-α-induced apoptosis was not antagonized by addition of progranulin. Effects were similar, but more pronounced in BeWo cells. CONCLUSION: The cytoprotective activity of progranulin on trophoblast cells in vitro was only weak and of doubtful biologic relevance. It was not able to antagonize TNF-α. Future studies should focus on possible paracrine activities of progranulin.

Clinical differences between early- and late-onset severe preeclampsia and analysis of predictors for perinatal outcome.

AIMS: To analyze the clinical differences between early- and late-onset cases of severe preeclampsia and to evaluate parameters that could help to predict perinatal outcome. METHODS: Over a period of 6 years, all cases of severe preeclampsia (n=68) at our institution were included in a retrospective cohort analysis. Differences between early (<34 weeks, n=44) and late (≥34 weeks, n=24) onset of the disease were evaluated. Risk factors for low 5-min Apgar score (≤7), small-for-gestational-age (SGA) infants and neonatal acidosis (umbilical arterial pH <7.20) were identified and considered in a multiple logistic regression model. RESULTS: Early- and late-onset severe preeclampsia differed from each other remarkably. Perinatal outcome was unfavorable in early-onset disease and seemed to be mainly a result of premature delivery and development of fetal growth restriction. Abnormal uterine Doppler velocimetry increased the risk of low 5-min Apgar values [odds ratio (OR) 8.0, P=0.012] and preterm birth <34+0 weeks (OR 17.9, P<0.001). An increased resistance of the umbilical artery was associated with a higher risk for SGA birth weight (OR 4.9, P=0.010). CONCLUSION: Preeclampsia is a heterogeneous syndrome even if only severe cases were analyzed. Abnormal Doppler flow characteristics facilitated the identification of patients who were at increased risk for worse perinatal outcome.

Medical prevention of breast cancer.

Breast cancer is the most common cancer of women in Western Europe and North America. Effective strategies of medical prevention could reduce the burden of breast cancer mortality. The best evidence for a risk reduction exists for hormonal agents such as tamoxifen and raloxifene (22-72%) or aromatase inhibitors (50-65%). However, the severity of side effects and the lack of evidence for an improved survival compromise the risk/benefit balance. In this review the results of chemoprevention studies, including new treatment approaches, are summarized with critical discussion of their use in clinical practice.

Influence of lifestyle factors on breast cancer risk.

Breast Cancer (BC) is a life-changing event. Compared to other malignancies in women, BC has received considerably more public attention. Despite improved neoadjuvant, adjuvant, and palliative treatment strategies for each characteristic molecular BC subtype, recommendations for evidence-based preventive strategies for BC treatment are not given equivalent attention. This may be partly due to the fact that high-quality long-term prevention studies are still difficult to carry out and are thus underrepresented in international studies. The aim of this review is to discuss the most relevant lifestyle factors associated with BC and to identify and discuss the evidence supporting practical prevention strategies that can be used in everyday clinical practice.

miRNA expression profiles determined in maternal sera of patients with HELLP syndrome.

OBJECTIVE: Syndrome of hemolysis, elevated liver enzymes and low platelets (HELLP) represents a distinct subgroup of severe preeclampsia. The aim of our study was to identify differentially expressed miRNAs in sera of patients with HELLP syndrome in comparison to unaffected controls. STUDY DESIGN: Blood samples were obtained from patients with manifest HELLP syndrome and matched unaffected controls. The expression of 754 mature miRNAs was assessed using the TaqMan Array format (n = 12). Results of seven differentially expressed miRNAs were further validated by single quantitative real-time polymerase chain reaction (qPCR) assays. RESULTS: Serum miRNA analysis allowed detection of maternal and fetal miRNAs. Distinct miRNA expressions were confirmed for miR-122, miR-758 and miR-133a represented by a median up-regulation ≥ two-fold in the HELLP group. The liver specific miR-122 was 11.5-fold increased with an area under curve (AUC) of 0.82 in the receiver operating characteristic (ROC) analysis. Cluster analyses of our data uncovered subgroups of HELLP patients were associated with clinical subtypes and differences in organ manifestation. CONCLUSION: In our proof of principle study, we demonstrated that patients with HELLP syndrome showed alterations of serum miRNA expression patterns. Data analysis goes along with the hypothesis that HELLP syndrome is regarded to be a heterogeneous disease.

Accuracy of axillary ultrasound in preoperative nodal staging of breast cancer - size of metastases as limiting factor.

Since the performance of surgical procedures of the axilla in the treatment of early breast cancer is decreasing, the role of axillary ultrasound (AUS) as staging procedere has newly to be addressed. The aim of this study was to determine which patient or histopathological characteristics are related to false-negative AUS. In a retrospective study design data of 470 women with primary breast cancer were collected from patient charts and imaging and pathology records were reviewed. True positive and false negative axillary ultrasound groups were compared in terms of tumor size, histological subtype, grade, estrogen receptor (ER) and HER2 status, proliferation index, number and size of nodal metastases, extracapsular extension (ECE) and lymphovascular invasion (LVI). Of 470 patients, 166 (35%) were node positive, 79 of them with suspicious AUS. Factors associated with false negative AUS by univariate analysis were included in a multivariate model. By multivariate analysis, only size of nodal metastases was an independent factor for false negative AUS. In the sentinel lymph node biopsy (SLNB) subgroup, 45% of patients had nodal metastasis size less than or equal to 5 mm. In conclusion, AUS in preoperative staging of early stage breast cancer is limited by small size of metastases in a substantial number of patients. Prospective studies have to show whether small metastatic deposits leaving in patients in case of no axillary surgery have no negative effect on disease free and overall survival.

Implant-based breast reconstruction using a titanium-coated polypropylene mesh (TiLOOP Bra): a multicenter study of 231 cases.

BACKGROUND: An alternative to implant-based breast reconstruction using acellular dermal matrix is the use of a titanium-coated polypropylene mesh. The mesh was approved for implant-based breast reconstruction in Europe in 2008, but only limited clinical data are available. METHODS: Two hundred seven patients (231 breasts) with skin-sparing/nipple-sparing or modified radical mastectomy and immediate or delayed implant-based breast reconstruction using titanium-coated polypropylene mesh were evaluated retrospectively. The primary endpoints were identification of patient-related and surgical factors that were predictive for an adverse outcome and the development of recommendations for patients eligible for implant-based breast reconstruction using the mesh. Complications were divided into major (need for additional surgery), minor (conservative treatment), and implant loss. Univariate and multivariate logistic regression analyses were performed to determine the influence of the patient- and procedure-related characteristics on postoperative complications and implant loss. RESULTS: No risk factors were observed for patient-associated complications. Major complications occurred in 13.4 percent, minor complications in 15.6 percent, and implant loss in 8.7 percent of patients. Univariate analysis revealed procedure-related risk factors for postoperative complications with a bilateral procedure (p = 0.013) or skin expansion before implant surgery (p = 0.043). Multivariate analysis confirmed these risk factors and revealed an increased risk for implant loss in patients with skin necrosis (p < 0.001) and capsule fibrosis (p < 0.001). CONCLUSIONS: This titanium-coated polypropylene mesh shows acceptable complication rates and can be a helpful device in implant-based breast reconstruction. The mesh should only be used in primary cases and, when adhering to the proposed indications, is a safe and convenient option in implant-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The role of hydroxyethyl starch in preventing surgical-site infections and nipple necrosis in patients undergoing reduction mammaplasty: a prospective case-control study of 334 patients.

BACKGROUND: Surgical-site infections after reduction mammaplasty are associated with poor cosmetic results. This study investigated the postoperative antiinflammatory influence of hydroxyethyl starch and its effect on surgical-site infections after breast reduction. METHODS: In this prospective case-control study, 334 patients undergoing reduction mammaplasty were prospectively assigned in a 2:1 ratio to receive either 2 × 250 ml of hydroxyethyl starch 6 % or saline solution 0.9 % for 3 days postoperatively. Patient follow-up evaluation was at least 1 month. Using uni- and multivariate analyses, this study aimed to identify risk factors for surgical-site infections and nipple necrosis. RESULTS: Surgical-site infections occurred in 6.6 % of the hydroxyethyl starch group and in 3.6 % of the control group (p = 0.704). Hydroxyethyl starch had no effect of reducing surgical-site infections [p = 0.212; odds ratio (OR), 0.317; confidence interval (CI), 0.052-1.925]. According to univariate analyses, hydroxyethyl starch reduced the occurrence of postoperative fever (p = 0.085; OR 0.608; CI 0.345-1.072), and fever was associated with increased infection rates (p = 0.033; OR 2.335; CI 1.071-5.089). Additional risk factors for postoperative infections were diabetes (p = 0.051; OR 4.051; CI 0.997-16.463) and obesity (normal weight vs grade ≥2: p = 0.003; OR 7.612; CI 2.031-28.529). Multivariate analysis showed no independent predictors for surgical-site infections. Nipple necrosis were equally observed in the two groups (p = 0.458; OR 1.643; CI 0.443-6.097). CONCLUSION: The antiinflammatory approach of hydroxyethyl starch did not lead to a decrease in infections or nipple necrosis. No difference in surgical-site infections was observed between aesthetic and oncologic procedures. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Trophoblastic progranulin expression is upregulated in cases of fetal growth restriction and preeclampsia.

AIMS: The expression of the anti-inflammatory glycoprotein progranulin and the hypoxia-induced transcription factor 1α (HIF-1α) in the villous trophoblast was compared between placentae from patients with preeclampsia (PE), fetal growth restriction (FGR), and normal controls. STUDY DESIGN: Matched pairs analysis of third trimester placentae specimens (mean gestational age 36+2) was performed by semiquantitative measurements of the immunohistochemical staining intensities for progranulin and HIF-1α expression (PE n=13, FGR n=9 and controls n=11). Further, placental progranulin mRNA expression was analyzed by qRT-PCR on term placentae (n=3 for each group). RESULTS: Compared to controls, villous trophoblast revealed a significantly higher expression of progranulin in cases of PE (P<0.05) and FGR (P<0.01). Similar results were shown for HIF-1α expression (P<0.01 for PE and <0.05 for FGR). The increase of the progranulin protein was not accompanied by an increase of the progranulin mRNA in term placentae. CONCLUSIONS: Increased expression of progranulin protein in villous trophoblast cells in cases of PE and FGR may result from disturbed placental development and, therefore, may be of pathogenetic importance. The increase was correlated to HIF-1α expression. Further evaluation of this potential mechanism of regulation is required.

Pain management after cesarean: a randomized controlled trial of oxycodone versus intravenous piritramide.

PURPOSE: Primary objective was to assess whether oral analgesia with oxycodone offers superior pain relief after cesareans than patient controlled analgesia (PCA). Secondary outcomes were additional pain medication, time to first mobilization, therapeutic side effects, postoperative restrictions, overall satisfaction and costs. MATERIALS AND METHODS: Randomized controlled trial at a University Hospital conduct between July 2009 and November 2009. Of the 1,112 patients, 257 met the inclusion criteria and 239 agreed to participate. Patients were randomly assigned to either receive intravenous piritramide PCA (2 mg piritramide/ml 0.9 % saline) or oral oxycodone (20 mg). Pain was assessed on a visual analog pain scale (VAS) at 2, 12, 24, 32, 40, 48 and 72 h after cesarean. RESULTS: No differences in VAS scores were observed within the general study population. Pain scores of oxycodone versus PCA were comparable at 24 h. Patients randomized to PCA demonstrated increased demand for rescue medication 48 h after cesarean (p = 0.057). In the PCA group, patients with previous cesarean had increased operative times, a trend towards increased VAS scores after 48 h (p = 0.081) and increased VAS scores in comparison to patients who did not have cesarean before (p = 0.044). For this subgroup, no difference was seen in the oxycodone patients (p = 0.883). CONCLUSION: General satisfaction with both treatment regimes was high. The results support the potential use of oral pain regimes and emphasis the importance of a multimodal approach to treat post-cesarean pain. Oral oxycodone is a not expensive, convenient and comparable analgesic to PCA devices with opioids after cesarean. Trial registration at clinicaltrials.gov identifier: NCT 01115101.

Desmopressin-induced Moschcowitz-like syndrome after treatment of uterine atonic bleeding in a 28-year-old pregnant woman: case report and overview of the literature.

Here we report of a patient who developed a Moschcowitz-like syndrome following a desmopressin treatment of severe postpartum hemorrhage. The patient got an anaphylactic reaction after cervical ripening with dinoproston, leading to an emergency cesarean. A postpartum uterine atony with a blood loss more than 1500 ml resulted in a disseminated intravascular coagulation that was treated with mass transfusion of blood products, including platelets and factor VII. Desmopressin is used as rescue medication in situations of severe bleeding. It was given in this life-threatening situation and presumably triggered a Moschcowitz-like syndrome. Desmopressin exerts its haemostatic effect by releasing von Willebrand factor, which is elevated in pregnancy per se. This results in an increased risk of developing microthrombi, leading to a Moschcowitz-like syndrome. In conclusion, desmopressin should not be administered in pregnant patients owing to its potential risk of triggering the development of thrombotic-thrombocytopenic purpura.