Randomized trial of cefotiam prophylaxis in the prevention of postoperative infectious morbidity after elective cesarean section.

A prospective, randomized study was performed in order to evaluate the effect of cefotiam in the prevention of postoperative infectious morbidity in patients undergoing low-risk elective cesarean section. A total of 146 patients were randomly assigned to receive either intraoperative single-shot prophylaxis with 2 g cefotiam (study group, n =76) or no prophylaxis (control group, n=70). Due to a higher rate of urinary tract infections, the incidence of infectious morbidity after cefotiam prophylaxis was higher in the study group than in the control group (16% vs. 9%, P=0.1). Postoperative infectious morbidity following low-risk elective cesarean section cannot be reduced by intraoperative cefotiam prophylaxis.

High-density vaginal Ureaplasma urealyticum colonization as a risk factor for chorioamnionitis and preterm delivery.

BACKGROUND: The aim of this case control study was to investigate the influence of genital Ureaplasma urealyticum colonization on pregnancy outcome. METHODS: One hundred and seventy-two women colonized with Ureaplasma urealyticum without co-existing other infections and 123 women with negative cultures for Ureaplasma urealyticum were enrolled. In a multivariate analysis the influence of quantitative Ureaplasma urealyticum colonization level was determined. RESULTS: Compared to the negative women increasing colonization with Ureaplasma urealyticum was associated with a significant decrease of birth weight (p<0.0001) and gestational age (p<0.0001) and with a significant increase of chorioamnionitis (p<0.0001) and preterm delivery (p<0.001). In a multivariate analysis high-density Ureaplasma urealyticum colonization was an independent risk factor for chorioamnionitis and preterm delivery, whereas low colonization levels had no effect on an adverse outcome of pregnancy. CONCLUSIONS: The degree of colonization with Ureaplasma urealyticum correlates strongly with an adverse effect on pregnancy outcome.

Downregulation of a mitogen-activated protein kinase signaling pathway in the placentas of women with preeclampsia.

OBJECTIVE: To investigate whether the activity of the three mitogen-activated protein kinases (Jun aminoterminal kinase, extracellular regulated kinase, and p38) is altered in placental tissue of women with preeclampsia and hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome. METHODS: Placental activity (measured by immunoprecipitation-kinase assay) and protein expression (measured by western blot) of Jun aminoterminal kinase, extracellular regulated kinase, and p38 mitogen-activated protein kinase were measured in four groups of eight women each with preeclampsia, HELLP syndrome, and normal vaginal or cesarean deliveries. To further characterize the Jun aminoterminal kinase signal transduction pathway, phosphorylation of c-Jun, a downstream effector of Jun aminoterminal kinase- mitogen-activated protein kinase, was analyzed by western blotting, and the activity of Rac1, an upstream activator of the Jun aminoterminal kinase signaling pathway, was determined by pull-down assay. RESULTS: The activity of Jun aminoterminal kinase was significantly lower in placentas of women with preeclampsia or HELLP syndrome compared with those who had normal vaginal or cesarean delivery, whereas levels of Jun aminoterminal kinase protein expression were similar. Phosphorylation of the transcription factor c-Jun and Rac1 activity also were significantly lower in women with preeclampsia and HELLP than in controls. p38 mitogen-activated protein kinase activity was significantly higher in women with preeclampsia than with HELLP syndrome. There was no change in extracellular regulated kinase activity or protein expression between subgroups. CONCLUSION: In placentas of women with preeclampsia or HELLP syndrome, a Rac1-Jun aminoterminal kinase-c-Jun-dependent signal transduction pathway was downregulated.

Postpartum curettage in patients with HELLP-syndrome does not result in accelerated recovery.

OBJECTIVE: Our purpose was to examine the impact of immediate postpartum curettage on the recovery of patients with HELLP-syndrome (hemolysis, elevated liver enzymes, and low platelets). SUBJECTS: Between January 1994 and July 1997 all patients who presented with HELLP-syndrome in our institution underwent immediate postpartum curettage (n=24). Their outcome was compared with the recovery of women with HELLP-syndrome who were delivered without postpartum curettage between 1987 and 1993 (n=20). Clinical and laboratory data were analyzed. RESULTS: No significant difference could be found between both groups in terms of normalization of serum glutamic-oxaloacetic transaminase (GOT), serum glutamic-pyruvic transaminase (GPT), lactic dehydrogenase (LDH), and quantitative platelet count. Postpartum hospitalization time was identical in both groups. CONCLUSION: In our retrospective study no benefit is achieved by immediate postpartum curettage in patients with HELLP-syndrome. In order to eliminate the possible bias of retrospective analysis, we now plan a randomized study to further investigate the impact of immediate postpartum curettage.

FDG PET evaluation of granular cell tumor of the breast.

Granular cell tumor is a rare, usually benign neoplasm of neural origin that may arise in virtually any site and, when situated in the breast, can mimic breast carcinoma. We describe a case of granular cell tumor of the breast in a 57-yr-old woman. Clinical evaluation, mammography, sonography and MRI suggested a carcinoma with infiltration of skin and muscle. However, the tumor did not display increased glucose metabolism on PET. Clinical findings, imaging results, histological characteristics and surgical management are discussed.

Angiogenin plasma levels during pregnancy.

OBJECTIVE: Our purpose was to determine the levels in plasma of angiogenin in healthy pregnant women and to examine whether there are differences between uncomplicated pregnancies and patients with the syndrome of hemolysis, elevated liver enzymes, and low platelets, preeclampsia-eclampsia, and highly pathologic Doppler flow findings without additional complications. STUDY DESIGN: Angiogenin was measured with a novel enzyme-linked immunosorbent assay. A case control and observational study was conducted in 68 healthy women from the tenth to fortieth weeks of pregnancy and in 18 patients with the syndrome of hemolysis, elevated liver enzymes, and low platelets, 21 with preeclampsia/eclampsia and 13 with highly pathologic Doppler flow findings at admission for delivery. RESULTS: Between the tenth and fortieth weeks of uncomplicated pregnancy angiogenin plasma levels rose from 150 to 250 ng/ml (significant correlation). In patients with highly pathologic Doppler flow findings angiogenin is significantly reduced compared with healthy pregnant matched pairs (150 vs 219 ng/ml, p < 0.01). CONCLUSION: Rising plasma angiogenin levels in pregnancy may reflect persisting placental transformation and remodeling processes: in patients with highly pathologic Doppler flow findings these processes are disturbed and thus placental function is impaired.

Proteases and their inhibitors are indicative in gestational disease.

OBJECTIVE: To assess whether various proteolytic factors which are involved in trophoblast invasion show different concentrations in plasma and placenta of patients with HELLP syndrome, pre-/eclampsia and highly pathological Doppler flow measurements but without additional complications (hpD). DESIGN: Case control and observational study; 18 women with HELLP syndrome, 21 with pre-/eclampsia, 13 with hpD, as well as healthy pregnant women (matched pairs); statistical analysis: sign test and Wilcoxon test. RESULTS: Urokinase-type plasminogen activator (uPA), uPA receptor, tissue-type plasminogen activator (tPA), plasminogen activator inhibitor 1 (PAI-1), matrix metalloproteinases MMP-8, MMP-9 and tissue inhibitor of metalloproteinases TIMP-1 were measured by ELISA. PAI-1 plasma levels are significantly elevated in all three groups studied. In HELLP syndrome, tPA and TIMP-1 are also elevated, and in patients with hpD, MMP-8 is increased, whereas MMP-9, and TIMP-1 are lower. In placenta extract, only pre-/eclampsia shows reduced MMP-9 concentrations. CONCLUSIONS: The increased frequency of small-for-gestational-age infants observed in all three study groups is an expression of impaired placental implantation and remodelling processes. These disturbances manifest themselves in the form of changes in some of the factors in plasma and placenta extract that are involved in these processes.

Intracardiac fibrin adhesive for selective fetocide in twin pregnancy: report of three cases.

Intracardiac fibrin adhesive was used for selective fetocide in three diamniotic twin pregnancies at 18-24 weeks' gestation (trisomy 21: n = 1; ultrasound evidence of major malformation: n = 2). Two of the three pregnancies were complicated by an intra-amniotic infection leading to pregnancy loss but one patient (with a monochorionic twin gestation) delivered a normal baby prematurely in the 31st week of pregnancy. The technique, complications and pregnancy outcomes are discussed.

[Streptococcus B screening with GBS medium in obstetrics]. / B-Streptokokken-Screening mittels GBS-Medium in der Geburtshilfe.

Pregnant women and newborn infants were screened for group B streptococcal (GBS) colonization by obtaining paired swabs from the cervix and urethra for the former group and from the ear, nose, umbilical cord, gastric juice and membranes for the latter. One swab was cultured on blood agar; the other was inoculated into serum-starch broth (GBS medium), which allows identification of GBS by production of a characteristic orange-colored pigment. From the 2105 paired swabs obtained, a total of 158 were GBS positive by either method; of these, 154 (97.5%) were recovered by the GBS medium and 89 (56.3%) by blood agar plate. No false positive color reactions were observed with GBS medium. 75% of the positive GBS media could be read within 24 h of incubation. The use of GBS medium proved to be an easy and reliable method for screening of maternal and neonatal GBS colonization.

[Measuring the concentration of various plasma and placenta extract proteolytic and vascular factors in pregnant patients with HELLP syndrome, pre-/eclampsia and highly pathologic Doppler flow values]. / Konzentrationsmessungen verschiedener Proteolyse- und Gefässfaktoren im Plasma und Plazentaextrakt bei Schwangeren mit HELLP-Syndrom, Prä-/Eklampsie und hoch-pathologischen Dopplerflussbefunden.

OBJECTIVE: Impaired trophoblast invasion plays a major role in the development of preeclampsia. Therefore various factors that are involved in invasion were investigated in gestational disease. METHODS: In pregnant women with HELLP-syndrome (n = 18), pre-/eclampsia (n = 21) and highly pathological Doppler flow measurements (hpD) (n = 13), plasma and placental tissue extract concentrations of uPA, uPA-receptor, tPA, PAI-1, MMP-8, MMP-9, TIMP-1, thrombomodulin, and angiogenin were measured using ELISA. RESULTS: In all three collectives, PAI-1 plasma concentrations were significantly higher (p < 0,05) than in normal pregnancies, in patients with HELLP-syndrome, tPA and TIMP-1 plasma levels were also elevated. MMP-9 concentrations in placental tissue extracts were lower in pre-/eclampsia than in normal pregnancies. CONCLUSIONS: Impaired placental implantation and remodelling in gestational disease is reflected by changes in plasma and placental tissue extract concentrations of various factors that are involved in these processes.

[Changes in fibrinolysis-associated parameters in HELLP syndrome]. / Veränderungen Fibrinolyse-assoziierter Parameter bei HELLP-Syndrom.

Various parameters associated with fibrinolysis were examined in plasma and placenta tissue extract in 18 patients with HELLP syndrome (haemolysis, elevated liver enzymes, and low platelet count). A significant increase in plasma concentrations of tPA and PAl-1 was observed in the HELLP patients in comparison to 18 pregnant women of the control group (equal duration of pregnancy). In contrast, there was no difference in plasma concentrations of uPA, uPA-receptor and D-dimer. In placenta tissue extract, significant differences were found just as rarely for uPA, uPA-receptor and PAl-1 as for tPA and D-dimer. Our findings indicate, that endothelial damage with release of tPA may be involved in the pathophysiological pathway of HELLP syndrome. Increased plasma levels of PAl-1 may reflect deficient fibrinolysis resulting in impairment in microcirculation. Clinical relevance of tPA and PAl-1 plasma concentration as possible predictor of hypertensive pregnancy complications will have to be studied further.

[Infected ovarian vein thrombosis in infection with Ureaplasma urealyticum and Mycoplasma hominis after cesarean section]. / Septische Ovarialvenenthrombose bei Infektion mit Ureaplasma urealyticum und Mycoplasma hominis nach Sectio caesarea.

Puerperal ovarian vein thrombophlebitis (POVT) is a rare but severe complication of the post partum period. We report on a patient, who developed a POVT based on an infection with Ureaplasma urealyticum and Mycoplasma hominis. Problems of diagnostic procedures in cases of POVT and the role of ureaplasma and mycoplasma in infectious obstetric complications are discussed.

[Obstetric aspects of post-cesarean section status]. / Geburtshilfliche Aspekte bei Zustand nach Sectio caesarea.

A rising Caesarean delivery rate is the reason, why the obstetrician should be very well informed about the management of vaginal birth after Caesarean section: It is feasible in almost all women with nonrecurrent indication for the preceeding Caesarean section. Suspected foetal macrosomia, twin gestation and breech presentation represent relative contraindications. External cephalic version is a reasonable option. In case of history of uterine scar dehiscence or rupture and in women with vertical uterine scar, repeat section should be performed.

[Acute pseudo-obstruction of the colon (Ogilvie syndrome) after cesarean section--a rare complication]. / Akute Pseudo-Obstruktion des Kolons (Ogilvie-Syndrom) nach Sectio caesarea--eine seltene Komplikation.

Despite the fact, that acute pseudo-obstruction of the colon (Ogilvie's syndrome) is a rare entity, many of the reported cases have occurred after gynaecologic and obstetric surgical procedures. In order to avoid life-threatening complications, such as caecal perforation, early detection and initiation of conservative treatment is necessary. We report on three cases with Ogilvie's syndrome after caesarean section. Symptoms and treatment are discussed.