[Thrombotic thrombocytopenic purpura--a rare and difficult differential diagnosis to HELLP syndrome in late pregnancy]. / Die thrombotisch thrombozytopenische Purpura--Eine seltene und schwierige Differenzialdiagnose zum HELLP-Syndrom in der Spätschwangerschaft.

Thrombotic thrombocytopenic purpura (TTP) represents a rare complication mainly in the second trimester and can, in its early stage, mimic HELLP syndrome. At 38 weeks of gestation, a 40-year-old primigravida with elevated blood pressure, thrombocytopenia and elevated liver enzymes was diagnosed with HELLP syndrome. Despite a Ceasarean section her laboratory parameters remained pathological with severe thrombocytopenia and hemolysis. In addition, the patient developed neurological comatose-like symptoms. The diagnosis of TTP was made after further tests revealed fragmented red cells in the blood, autoantibodies against ADAMTS13 and a nearly total loss of ADAMST13 plasma activity. The patient fully recovered following repeated plasmapheresis and plasma substitution as well as systemic treatment with dexamethasone. If laboratory parameters do not normalise promptly in spite of the correct treatment for an assumed HELLP syndrome, TTP may be the underlying pathology. As rapid assays for antibodies against ADAMTS13 are not available yet, special consideration must be given to the clinical details in order to make a correct diagnosis.

Hypoxic-ischemic encephalopathy with cystic brain stem necroses and thalamic calcifications in a preterm twin.

A severe and rare ischemic brain lesion in a preterm twin boy is reported. The boy was born after two weeks of anhydramnios and amnionic infection at 24 weeks of gestation. Following a difficult Caesarean section and prolonged umbilical cord compression he developed prenatal acidosis with an umbilical cord pH of 6.96. At the age of 7 h, heart rate variability narrowed due to severely disturbed brain stem function and the patient developed clinical signs of hypoxic-ischemic encephalopathy. Sonography demonstrated extensive symmetrical brain stem and basal ganglia lesions. After a prolonged comatose and apneic state, death occurred at the age of 25 days. Autopsy confirmed columnar bilateral cavitation of basal ganglia, diencephalon, brain stem and spinal gray matter, as well as focal calcifications in the palladium, thalamus, and brain stem. The findings highly resemble those observed after experimental or clinical cardiac arrest.

Demonstration of a recto-vaginal fistula with the ultrasound contrast medium Echovist.

The demonstration of a recto-vaginal fistula in a patient with Crohn's disease is described. The patient was examined by vaginal ultrasound using the contrast medium Echovist-200 (SHU 454, Schering AG, Berlin). This agent had not been used before under these circumstances and proved to be successful.

p21 (WAF1/CIP1) protein expression is associated with prolonged survival but not with p53 expression in epithelial ovarian carcinoma.

OBJECTIVE: The objective of this study was to clarify the influence of p21 protein expression in ovarian cancer. p21 (WAF1 [wild-type p53 activated fragment 1]/CIP1) is a universal cyclin-dependent kinase inhibitor and can be induced as a downstream effector of the p53 tumor suppressor gene. METHODS: The expression of p21 was evaluated by immunohistochemical analysis with the monoclonal antibody WAF1 (Oncogene Science) on 106 formalin-fixed, paraffin-embedded tissue samples of epithelial ovarian cancer. RESULTS: p21 was expressed in 65 (61%) of all cases. p21 expression was associated with early stage in FIGO classification (FIGO I and II, P = 0.003) and no tumor residues after primary tumor resection (P = 0.018). Immunohistochemical staining results were judged as negative if no tumor nuclei were stained, as weak positive if 1-49% were stained, and as strong positive if over 50% of nuclei were stained. Clinical follow-up showed a better overall survival for cases with strong p21 expression (79 months) versus 40 months for weak expression and 30 months for no expression (P = 0.033). Previously determined p53 expression of this cohort was compared with p21 status. p53 overexpression was observed in 49 cases (48%) and showed no association with p21 expression. CONCLUSION: No correlation was found between p21 and p53 expression. p21 expression is a significant prognostic marker for improved survival in ovarian cancer and is associated with early FIGO stage and zero tumor residues after primary tumor resection.

Perinatal differential diagnosis of cystic kidney disease and urinary tract obstruction: anatomic pathologic, ultrasonographic and genetic findings.

According to the classification of Osathanondh and Potter of cystic kidney diseases an antenatal differential diagnosis is presented, which is based on the anatomic pathologic, ultrasonographic and genetic findings. Since the ultrasound evaluation influences the obstetric and neonatal management, each second and third trimester sonography should consider the most common malformations in pediatric autopsies. The autosomal recessive polycystic kidney disease (ARPK), autosomal dominant polycystic kidney disease (ADPK), multicystic renal dysplasia, obstructive multicystic kidneys and cystic renal malformations found in other syndromes with genetic linkage are discussed in this review.

Prognostic significance of DNA content and S-phase fraction in epithelial ovarian carcinomas analyzed by image cytometry.

The objective of this study was to evaluate the prognostic significance of DNA ploidy and S-phase fraction (SPF) in epithelial ovarian carcinomas analyzed by image cytometry. Frozen tissue of 103 epithelial ovarian carcinomas was analyzed for DNA ploidy and SPF with a Cell Analysis System Image Analyser (CAS 200, Becton-Dickinson) and correlations with clinical and histomorphologic factors and time to progression and overall survival were evaluated by univariate and multivariable analysis. Fifty-four percent of the ovarian carcinomas were found to be diploid, 38% aneuploid, and 8% tetraploid. The S-phase fraction was low (<5%) in 27%, intermediate (5-14.5%) in 47%, and high (>/=14.5%) in 26% of the patients. By univariate analysis overall survival and time to progression were significantly correlated with the S-phase fraction (P = 0.003 and P = 0.003), but not with DNA ploidy (P = 0. 31 and P = 0.51). A DNA index > 1.4 was correlated with poor outcome but the result did not achieve formal statistical significance (P = 0.08 and P = 0.12). A high SPF was a strong predictor of early recurrence, while a low SPF identified patients with a favorable long-term outcome. Other significant predictors of survival were FIGO stage, grade of differentiation, presence of distant metastasis, residual tumor, lymph node metastasis, and patient age. In multivariable statistical analysis only FIGO stage, histologic grade, and residual tumor after surgery were independent predictors of overall survival and time to progression.

Correlation of fetal oxygen saturation to fetal heart rate patterns. Evaluation of fetal pulse oximetry with two different oxisensors.

BACKGROUND: The purpose of this study was the correlation of fetal oxygen saturation values to various fetal heart rate patterns, as well as to oxygen saturation values obtained by fetal blood analysis. These objectives need to be evaluated from the perspective that two generations of fetal oxisensors have been used. METHODS: Two different oxisensor systems (FS10: 660+890 nm and FS14: 735+890 nm) and a blinded pulse oximeter (type N400, Nellcor Puritan Bennett) were utilized to monitor 112 fetuses. All data, including oxygen saturation, fetal heart rate patterns, signal and contact quality were stored on a personal computer and evaluated after delivery. RESULTS: The following median fetal oxygen saturation values were obtained: during reassuring fetal heart rate sequences 54% with the oxisensor FS10 and 48% with the newer FS14 oxisensor, during intervals of variable decelerations 43% with the FS10 oxisensor and 40% with the FS14 oxisensor. These differences between values obtained during normal and abnormal fetal heart rate patterns are significant. Due to non-reassuring fetal heart rate patterns 81 fetal blood analyses were performed. The values of pulse oximetry were 9% higher (6% for the FS14) than those of spectrophotometry. Correlation of both methods was r=0.66 (0.74 for the FS14). CONCLUSIONS: In combination with fetal heart rate monitoring, fetal pulse oximetry promises a better differentiation between low and high risk heart rate patterns. Oxygen saturation values from intermittent fetal blood sampling reassure the clinician concerning the accuracy of this new method of intrapartum fetal surveillance and underline the increased quality of the new generation of oxisensor using light of a wavelength of 735 and 890 nm.

The safety of fetal pulse oximetry in parturients requiring fetal scalp blood sampling.

OBJECTIVE: To determine whether maternal or fetal morbidity is increased in association with fetal pulse oximetry monitoring using an atraumatic intrapartum transcervical fetal oxisensor. METHODS: In a prospective cohort study from January 1993 to June 1996, 196 fetuses were monitored during the intrapartum period with a fetal oximetry sensor placed between the uterine wall and the presenting fetal part. The oxisensors were in position for a median duration of 134 minutes. A total of 101 monitored fetuses underwent intrapartum fetal scalp blood sampling because of nonreassuring heart rate tracings. For a control group, we selected all cases during the same period in which fetal blood sampling was performed in the intrapartum period (n = 949) without pulse oximetry monitoring. Data for maternal and fetal morbidity were evaluated and tested for significant differences by the Mann-Whitney U test. RESULTS: There was no significant difference in gestational age, birth weight, duration of labor, fetal outcome parameters, cesarean rate, operative vaginal deliveries, episiotomy rate, or perineal injuries between the study and control groups. Similarly, the percentages of neonatal intensive care unit admissions, neonatal resuscitations, and neonatal infections were not statistically different in the two groups. A rare complication in the group with pulse oximetry monitoring was a transient impression of the oxisensor probe on the fetal cheek. The rates of postpartum maternal infections, anemia, or secondary wound disruptions were identical in both groups. CONCLUSION: There was no increased fetal or maternal morbidity associated with the use of an atraumatic intrapartum fetal pulse oxisensor.

[Lactate and glucose determination using biosensors in umbilical cord blood]. / Laktat- und Glucosebestimmung mittels Biosensoren im Nabelschnurblut.

Postpartal determination of lactate and glucose in the umbilical cord whole blood of 139 successive deliveries utilizing biosensors (blood gas analysator 865, Ciba Corning) are presented. The median lactate value in the umbilical arterial blood is 4.45 mmol/l and in the venous blood 4.23 mmol/l. Following categorization into control and high-risk groups, the arterial mean values are 4.23 mmol/l and 6.39 mmol/l and the respective venous values are 3.95 mmol/l and 5.04 mmol/l. Using the U-test these differences between the control and high-risk groups are significant. The mean of the measured lactate correlates significantly with the mean of the calculated base excess (< 0.001). The mean glucose value in the umbilical arterial blood is 78 mg/dl and in the venous 93 mg/dl. Between high-risk and control group no significant difference is found.

Prenatal diagnosis of a Currarino triad.

Prenatal diagnosis of the Currarino triad by means of obstetrical ultrasonography is described. Three related cases are presented. A literature review regarding the therapeutic, ultrasound-guided approach are discussed. The Currarino triad is a genetically transmitted syndrome consisting of an anorectal malformation, a sacral boney defect and a presacral mass. Prenatal diagnosis aids the early recognition and surgical management of persistent spinal-rectal fistulas, thus potentially avoiding life-threatening bacterial meningitis. Copyright 1997 Elsevier Science Ireland Ltd.

Immunostaining of p53 protein in ovarian carcinoma: correlation with histopathological data and clinical outcome.

OBJECTIVE: The objective of this study was to analyze the incidence of immunohistochemically detectable p53 protein accumulation in epithelial ovarian carcinomas and to correlate these data with the clinical outcome so as to clarify further the role of p53 mutations in prognosis with these patients. METHODS: Tumor tissues from 179 patients with epithelial ovarian carcinoma were used for immuno-histochemical analysis with monoclonal antibody DO1 and BP 53-12-1 on formalin-fixed, paraffin-embedded tissue. RESULTS: A total of 78 cases (44%) showed positive nuclear p53 staining. The p53-positive cases were found in all histological types of epithelial ovarian tumors. p53 staining was found in tumors of all stages with a higher percentage of positive cases in stage IV ovarian carcinomas (not significant). Poorly differentiated carcinomas showed a significantly higher percentage of p53 protein expression than did highly differentiated tumors (P = 0.0002). Clinical follow-up of up to 14 years (median 25 months) showed a slightly but not significantly shortened disease-free and overall survival time for patients with p53-positive epithelial ovarian carcinomas. CONCLUSIONS: We conclude from our data that p53 expression in ovarian carcinoma is associated with poor differentiation but not with the disease being in an advanced stage. There was a tendency for shortened disease-free and overall survival for patients with p53-positive tumors.

Continuous monitoring of fetal oxygen saturation by pulse oximetry.

OBJECTIVE: To compare spectrophotometric saturation values of fetal blood sampling to the saturation readings by pulse oximetry. METHODS: During a clinical trial, fetal oxygen saturation was monitored during labor by a fetal oxisensor and a fetal pulse oximeter. Fifty-one fetal scalp blood samples were assessed because of abnormal fetal heart rate (FHR) patterns. The pulse oximeter displayed only signal quality readings. The investigator had to perform adjustments if signal quality fell below 50%. After delivery, the saturation at the moment of fetal blood analysis could be read from a printout and compared to the saturation values of scalp blood sampling. RESULTS: The share of usable signal time was 51% overall, but only 40% in the 20-minute period during fetal blood sampling. Comparison with the reference method resulted in a median deviation of 6% (tenth percentile -10%; 90th percentile 18%) for pulse oximetry. The correlation coefficient between saturation values by pulse oximetry and fetal scalp blood sampling was 0.67. The correlation coefficient with the partial pressure of oxygen and oxygen saturation by pulse oximetry was 0.61, whereas it was 0.88 between partial pressure and saturation from the spectrophotometric analysis of the scalp sample. CONCLUSIONS: Fetal pulse oximetry corresponds satisfactorily to results from fetal blood analysis. Low invasiveness and continuous monitoring are the advantages of this method. At present, the available sensor generates only a limited amount of signal time. However, in combination with FHR monitoring, pulse oximetry promises greatly improved detection of fetal hypoxia.

Computer analysis of fetal heart rate during induction of labor with oxytocin.

We observed the influence of commonly used oxytocin infusion for inducing labor on the fetal heart rate (FHR). The FHR was analyzed on-line by Sonicaid Computer System 8000. There were no statistical changes in all analyzed parameters during infusion of oxytocin. Our study shows that the standard dosage of oxytocin used for induction of labor has no negative influence on the FHR.

[Value of measuring fetal oxygen saturation for reducing the need for fetal blood analysis in abnormal cardiotocogram. Experiences with 2 sensor generations of fetal reflexion pulse oximetry]. / Bedeutung der fetalen Sauerstoffsättingungsmessung zur Reduktion von Fetalblutanalysen bei suspektem Kardiotokogramm. Erfahrungen mit zwei Sensorgenerationen der Reflexionspulsoximetrie am Feten.

OBJECTIVES: Does the knowledge of fetal oxygen saturation allow to avoid fetal scalp blood sampling and to predict a pH < or = 7.25 of the fetal blood sample? STUDY DESIGN: Out of a group of 135 fetuses we determined the median, the 10th, 5th and 3rd percentile of oxygen saturation values by a blinded fetal pulse oximeter. Due to abnormal FHR-patterns, 110 fetal scalp blood samples (FBA) were assessed by the technique introduced by Saling. The pH of these FBA's ranged from 7,16-7,48 (median 7,28). We chose a 20 minute period before the FBA and calculated the individual median and percentiles. According to the pH of < or = 7,25 in FBA we calculated the chi-square test for significance. RESULTS: The median of <35% SpO2 has a sensitivity of 23%, specificity of 77%, positive predictive value of 27% and a negative predictive value of 73%. CONCLUSION: Fetal oxygen saturation alone shows a high specificity and a low sensitivity for pH < 7,25. In addition to FHR monitoring, pulse oximetry.

[Labor, method of delivery and maternofetal transmission of HIV]. / Wehen, Geburtsmodus und maternofetale Transmission von HIV.

Within a prospective study of the course of HIV-infection in women, 80 HIV-infected women without AIDS were delivered of 80 children between 1985 and September 1992. The median of the age of gestation was 38 weeks. Until 1988 Caesarean section was chosen as mode of delivery (45 women). Later when the mode of delivery appeared to have no influence on the frequency of maternofetal HIV transmission, vaginal delivery was preferred (35 women). None of the infants was breastfed. Three infants --delivered vaginally--died within the first 6 months of life before their infection status could be determined. Seventy-seven children could be observed for 18 months or longer regularly every three months. 10 of the 77 children were found to be HIV- infected by serological, virological and clinical criteria. Taking into account the mode of delivery, of 32 children who were delivered vaginally or by emergency Caesarean section 8 were found to be HIV-infected. None of 26 children delivered by elective Caesarean section after an uneventful pregnancy is infected. In 19 women Caesarean section was performed within 2 hours after onset of labour or after episodes of preterm labour which required hospital admission for treatment. Two children of these women are infected. No differences of CD4+ cell counts and p24 antigenaemia could be determined between the mothers of the three groups. The risk of fetal HIV infection was increased by preterm labour (p < 0.01) and the mode of delivery (p < 0.01). A correlation between loss of CD4 cells in the mother and increased risk of infection for the child is seen in children born spontaneously or delivered by emergency Caesarean section (p < 0.001). No correlation was found between the length of labour at delivery, the time of the rupture of membranes before birth as well as of the parity and the risk of fetal infection in that group. These findings point to labour as an important factor which increases the risk of maternofetal transmission of HIV. The onset of labour is accompanied by dramatic immunological alterations as a sudden increase of chemotactics and inflammatory cytokines at the maternofetal interface. The accumulation and stimulation of maternal immune cells will--if these cells are carriers of HIV--result in production and release of infectious HIV. This virus may accumulate in the maternofetal interface or gain access to the amniotic cavity. Since amniotic fluid is swallowed by the fetus, the largest potential port of entry for HIV in the fetus are the fetal lungs and the gastrointestinal tract. For the prevention of maternofetal transmission of HIV delivery before onset of labour or alternatively the protection of the fetus during parturition by means of potent antiviral compounds can be considered.

[Fetal oxygen saturation in suspected hypoxia and the normal cardiotocogram (CTG). A prospective study for validating pulse oximetry in the fetus]. / Fetale Sauerstoffsttigung bei hypoxieverdächtigem und unauffälligem Kardiotokogramm (CTG). Eine prospektive Untersuchung zur Validierung der Pulsoximetrie am Feten.

During a clinical study 70 women in labour were monitored with fetal pulse oximetry. The oxisensor (FS 10) was positioned between fetal cheek and the uterine wall at a cervical dilatation of 2 cm or more. The advantage of the method is its minimal invasive character and the continuous monitoring of oxygen saturation. The pulse oximeter (N 400, Nellcor) had been blinded for the investigation following criteria met by FDA, so that the investigator could not read the saturation values. Preliminary results of more than 120 hours of monitoring intervals of 10 seconds show the following saturation values (median): 55% under normal CTG (10. perc. 36%, 90. perc. 73%), 42% during episodes of variable decelerations (10. perc. 22%, 90. perc. 63%), 53% during episodes of early decelerations (10. perc. 39%, 90. perc. 74%). Due to pathological fetal heart rate patterns 42 fetal blood analysis were performed. Because of these spectrophotometric saturation measurements (ABL 330, OSM 3, Radiometer) the deviation of the two methods could be calculated. The values of pulse oximetry were 5% higher than those of spectrophotometry. Correlation of both methods was r = 0.64.

[Mucinous metaplasia of fallopian tube mucous membrane as a cause of pseudomyxoma peritonei]. / Muzinöse Metaplasie der Tubenschleimhaut als Ursache eines Pseudomyxoma peritonei.

A woman aged 49 years was relaparotomized at the Gynaecological Department of the "Rudolf Virchow" Medical Centre of the Free University of Berlin, following diagnosis of metastatic mucinous adenocarcinoma. Proliferative mucinous metaplasia of the Fallopian tube and consecutive peritoneal pseudomyxoma were established as clinical findings and were hypothetically attributed to mucinous metaplasia of the salpingofimbrial mucosa. Neither mucocele of the appendix nor ovarian tumour were found. This possible site origin has been rarely mentioned in any case report in the past.

[Disseminated lymphangioleiomyomatosis]. / Disseminierte Lymphangioleiomyomatose.

Clinical and histological findings of generalised lymphangioleiomyomatosis are demonstrated. A 40-year old woman died within a few weeks because of massive pulmonary involvement. Tumour mass in the area of the left ovary together with enlarged lymph nodes suggested a metastasising ovarian cancer.