[Transcervical Embryoscopy after Missed Abortion in Monoamniotic Twins with Discordant Exencephaly]. / Transzervikale Embryoskopie nach verhaltenem Abort in monoamnioten Zwillingen mit diskordanter Exenzephalie.

INTRODUCTION: Monoamniotic twins are considered a cause of high-risk pregnancies. Thereby, discordant malformations do occur rarely. A discordant exencephaly has been described in only a few cases. Transcervical embryoscopy can be performed in cases of monoamniotic twins with missed abortion directly before the abort-curettage. CASE REPORT: The case of a 35-year-old G1/P0 women in the 12(th) week of pregnancy is described. She had a monoamniotic twin pregnancy with discordant exencephaly and missed abortion diagnosed at 11+2 weeks. A transcervical embryoscopy was performed immediately before the abort-curettage and identified the discordant exencephaly and an additional umbilical cord knot of the 2 foetuses as a probable cause for the abortion. DISCUSSION: The transcervical embryoscopy lead in our case report to the diagnosis of a umbilical cord knot in a monoamniotic twin pregnancy with missed abortion. We also identified a discordant exencephaly by embryoscopy. With blunt access to the amniotic cavity, the transcervical embryoscopy applies only a minor additional risk to the abort-curettage. However, it should only be performed when the patient explicitly asks for enhanced diagnostics. CONCLUSION: Transcervical embryoscopy can be performed as an additional diagnostic tool in cases of monoamniotic twins with missed abortion. However, a detailed risk-benefit analysis should be done upfront in consultation with the patient.

RXRα is upregulated in first trimester endometrial glands of spontaneous abortions unlike LXR and PPARγ.

Nuclear receptors are necessary for uterine invasion of the trophoblast and therefore important for maintaining a viable pregnancy. The aim of this study was to investigate the expression pattern and frequency of LXR, PPARγ and RXRα under physiological circumstances and in spontaneous abortions in endometrial glands and decidual tissue cells. A total of 28 (14 physiologic pregnancies/14 spontaneous abortion) human pregnancies in first trimester were analysed for expression of the nuclear receptors LXR, RXRα and PPARγ. Expression changes were evaluated by immunohistochemistry in decidual tissue and endometrial glands of the decidua. RXRα expression was up-regulated in the endometrial glands of spontaneous abortion (P<0.015). Similar up regulation of RXRα was found in decidual tissue (P<0.05). LXR and PPARγ expression was unchanged in spontaneous abortion. Via Correlation analysis we found a trend to positive correlation of LXR and PPARγ (Spearman correlation coefficient r=0.56 P=0.07) in endometrial glands. In decidual tissue, we found significant negative correlation in the control group, for the combination of RXRα and PPARγ (Spearman correlation coefficient r=0.913, P=0.03). Our data show that RXRα expression is increased in miscarriage in endometrial glands and correlation analysis showed that negative correlation between RXRα and PPARγ disappears in miscarriage. This shift is supposable responsible for the loss of regular function in trophoblast and embryonic tissue.

Galectin 2 (gal-2) expression is downregulated on protein and mRNA level in placentas of preeclamptic (PE) patients.

INTRODUCTION: Galectin 2 (gal-2) belongs to the proto type group and consists of two homologous carbohydrate recognition domains (CRDs) resulting in multiple sugar binding sites. The expression of gal-2 has been shown to be involved in processes of angiogenesis and inflammation but was not analyzed before in preeclamptic (PE) placentas. Therefore the aim of this study was an analysis of expression and localization of gal-2 in placentas from patients suffering from PE. METHODS: Placental tissues were obtained from 14 women following a normal course of pregnancy and 13 women with PE. Expression of gal-2 was evaluated with immunohistochemistry and a semi quantitative score. Gal-2 mRNA expression was quantified in placental tissue using real time TaqMan PCR. Identification of gal-2 expressing cells in the decidua was achieved by double immunofluorescence microscopy. RESULTS: Expression of gal-2 is downregulated in the syncytiotrophoblast of preeclamptic placentas. Downregulation of gal-2 could also be identified in the decidua of PE patients. These findings on protein level could be supported by the results of TaqMan PCR. Gal-2 is downregulated in PE placentas on mRNA level. Finally, gal-2 expressing cells could be identified as extravillous trophoblast cells in both normal pregnancy and PE. DISCUSSION: Gal-2 was identified as an inhibitor of arteriogenesis in a murine model supposedly via modulation of the monocyte/macrophage population. In PE, both the formation of spiral arteries as well as influx of macrophages are dramatically changed. Therefore we might speculate that disturbed transformation of spiral arteries in PE might correlate with the downregulated gal-2 expression by the trophoblast.

Galectin-13/PP-13 expression in term placentas of gestational diabetes mellitus pregnancies.

INTRODUCTION: Gestational diabetes mellitus (GDM) is an increasing harm in pregnancy. Inflammatory processes in the placenta seem to have an influence on pathogenesis besides known factors like maternal BMI. Galectin-13 (gal-13) is an immunoregulatory protein, which is suspected to play a role in development of GDM in the placenta. METHODS: A total of 40 placentas were obtained from women treated for gestational diabetes mellitus. Placental tissue for control group was obtained from 40 women with normal pregnancy. We investigated the protein expression of gal-13 in term placentas with immunohistochemistry and immunofluorescence. Immunohistochemical staining was analyzed with the semi-quantified IRS score. Gal-13 serum levels were performed with ELISA on a total of 20 probes from women with GDM and healthy control pregnancies in the third trimester. RESULTS: Gal-13 was found in syncytiotrophoblast, in nuclei of syncytiotrophoblast and trophoblast cells as well in extravillous trophoblast cells of normal placentas. In GDM placentas, gal-13 expression was significantly decreased in all of these examined cell types (syncytiotrophoblast p = 0.003, nuclei of syncytiotrophoblast p = 0.007; extravillous trophoblast cells p = 0.001). The ELISA showed a significant lower gal-13 serum level in blood from pregnant women with GDM in comparison to healthy controls. DISCUSSION: As gal-13 with its anti-inflammatory functions plays a role in regulation of maternal immune system, a lack of gal-13 may contribute to an imbalance in inflammation processes in the placenta during pregnancy and therefore influences development of GDM.

Prediction of excessive gestational weight gain from week-specific cutoff values: a cohort study.

OBJECTIVE: To assess the prognostic validity of the Institute of Medicine/National Research Council (IOM/NRC) week-specific cutoff values for inadequate or excessive total gestational weight gain (GWG) by 4-week intervals. STUDY DESIGN: We merged data from two German cohorts (LMU cohort (all maternal-weight categories) and PEACHES cohort (obese women)) to provide information on GWG for 749 women (365 normal weight, 199 overweight and 185 obese). We calculated the prognostic values for suboptimal and excessive GWG according to the IOM/NRC cutoff values. RESULT: The positive predictive values for excessive total GWG for those who experienced excessive GWG early in pregnancy was 70.1% (95% confidence interval (CI) 60.5; 78.6) as of week 12/1 to 16/0 in normal-weight women, 89.5% (95% CI 75.2; 97.1) and 95.2 (76.2; 99.9) 95.2% (95% CI 76.2; 99.9) as of week 8/1 to 12/0 for overweight and obese women, respectively. In absence of excessive GWG as of week 12/1 to 16/0, normal-weight women had 77.5% (95% CI 77.1; 83.1) probability of not experiencing excessive total GWG (negative predictive value). In overweight and obese women, the negative predictive value was considerably lower up to week 24/1 to 28/0 (60.0% (95% CI 48.8; 70.5) in week 20/1 to 24/0 and 50.6% (95% CI 39.3; 61.9) in week 24/1 to 28/0). Most women with inadequate GWG in the first and second trimester had adequate total final GWG (positive predictive value for total inadequate GWG <50% up to week 16/1 to 20/0 in all groups). CONCLUSION: As women with excessive weight gain can be identified with high confidence if the GWG exceeds the IOM/NRC week-specific cutoff values, interventions may be initiated early in pregnancy.

Placental syncytiotrophoblast maintains a specific type of glycocalyx at the fetomaternal border: the glycocalyx at the fetomaternal interface in healthy women and patients with HELLP syndrome.

Recent studies showed that considerable amounts of glycosaminoglycans are released into maternal blood during normal pregnancy and in hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. Maternal endothelia and the syncytiotrophoblast layer have been discussed as a possible origin of these glycocalyx components. Our study aimed to visualize the glycocalyx on the syncytiotrophoblast by electron microscopy, to analyze its structure and composition by immunohistochemistry, and to determine potential differences between healthy women and women with HELLP syndrome. For electron microscopy, a cotyledon was fixed by perfusion of the intervillous space with a 2% lanthanum-nitrate glutaraldehyde solution followed by immersion fixation in the same fixative. For immunohistochemistry, sections of 16 placentas (HELLP patients/healthy women, n = 8 each) were stained with monoclonal antibodies against the main glycocalyx constituents syndecan 1, hyaluronic acid, and heparan sulfate. Semiquantitative evaluation of staining intensity focused on the apical surface of the syncytiotrophoblast and fetal intravillous endothelia as possible localizations of a placental glycocalyx. Electron microscopy revealed a glycocalyx of approximately 250 nm, covering the syncytiotrophoblast layer. This was found to contain large amounts of syndecan 1, but neither hyaluronic acid nor heparan sulfate as major components. Intravillous fetal endothelium did not express any of the investigated glycosaminoglycans. Healthy women and patients with HELLP showed no differences concerning glycocalyx composition and thickness of the syncytiotrophoblast. The composition of the "placental" glycocalyx differs from the adult and fetal vascular glycocalyx. Obviously, the human placental syncytiotrophoblast maintains a special kind of glycocalyx at the fetomaternal interface.

Increased serum concentrations of circulating glycocalyx components in HELLP syndrome compared to healthy pregnancy: an observational study.

Severe inflammation has been shown to induce a shedding of the endothelial glycocalyx (EGX). Inflammatory cytokines, such as tumor necrosis factor α (TNF-α), impede the thickness of the EGX. While a controlled inflammatory reaction occurs already in normal pregnancy, women with hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome had an exaggerated inflammatory response. This study investigates the shedding of the glycocalyx during normal pregnancy and in women with HELLP syndrome. Glycocalyx components (syndecan 1, heparan sulfate, and hyaluronic acid) were measured in serum of healthy women throughout pregnancy (4 time points, n = 26), in women with HELLP syndrome (n = 17) before delivery and in nonpregnant volunteers (n = 10). Serum concentrations of TNF-α and soluble TNF-α receptors (sTNF-Rs) were assessed once in all 3 groups. Syndecan 1 serum concentrations constantly rose throughout normal pregnancy. Immediately before delivery, a 159-fold increase was measured compared to nonpregnant controls (P < .01). Even higher amounts were observed in patients with HELLP prior to delivery (median 12 252 ng/mL) compared to healthy women matched by gestational age (median 5943 ng/mL; P < .01). Relevantly, increased serum levels of heparan sulfate, hyaluronic acid, and sTNF-Rs were only detected in patients with HELLP (P < .01). These findings suggest that considerable amounts of syndecan 1 are released into maternal blood during uncomplicated pregnancy. The HELLP syndrome is associated with an even more pronounced shedding of glycocalyx components. The maternal vasculature as well as the placenta has to be discussed as a possible origin of circulating glycocalyx components.

[Total ulnar nerve paralysis due to acute traumatic aneurysm at the forearm]. / Komplette Parese des Nervus ulnaris durch ein traumatisches Aneurysma - Wiederherstellung der Nervenfunktion durch rechtzeitige Neurolyse.

We are reporting a case of complete ulnar nerve paralysis due to compression from a false aneurysm located in the distal forearm. The aneurysm developed after the patient stabbed himself with a meat hook. The ulnar paralysis developed after a 14-day period of latency. The diagnosis was made using detailed patient history, clinical examination, and a sonogram. Early surgical decompression of the nerve led to complete restitution of all functions.

[Revascularization and defect coverage of the hand: special applications of the radialis forearm flap]. / Revaskularisation und Defektdeckung der Hand: Spezielle Einsatzmöglichkeiten des Radialis-Unterarmlappens.

During the last years, a large number of newly designed flaps have been presented, suitable to cover defects of the hand. Some of them, namely the retrograde interossea-posterior and the lateral arm flaps, found their way into daily clinical routine. They even seem to have replaced the standard flaps for defect coverage to the hand, the pedicled groin flap and the radial forearm flap. Especially the radial forearm flap seems to become an obsolete procedure, as it requires sacrificing a main forearm artery. Three patients are presented who suffered from complex injuries to their hands and were treated with radial forearm flaps in a single-stage primary procedure. In two hands, the arterial palmar arches and the soft-tissues of the palm were reconstructed by use of a distally pedicled radial forearm flap. Collateral arteries of ischemic fingers were implanted into the flap artery to achieve revascularization and a vein graft was interposed between the stumps of the radial artery to reestablish an orthograde blood flow. A free radial forearm flap harvested from the contralateral uninjured forearm was used to replant a torn-out forearm. In all cases, primary healing was achieved without complications. Primary treatment of complex injuries to the hand and forearm often requires revascularization of ischemic parts of the limb and coverage of large soft-tissue defects at the same time. The radial forearm flap, either as a distally pedicled flap or as a free flap, meets all the needs or in particular is appropriate to perform such demanding primary procedures. The destruction of the arterial palmar arches does not present a contraindication against the use of a distally pedicled radial forearm flap, but actually is a strong indication to reconstruct the radial artery by a vein graft.

Controlled partial skin thickness burns: an animal model for studies of burnwound progression.

A practicable, reliable and reproducible model for infliction of partial skin thickness burn lesions in rabbits is presented. The model is dedicated to experimental studies investigating the influence of drugs on burn wounds. A round aluminium stamp with a contact area of 4 cm2, weight 85 g, was heated up to 80 degrees C and applied for 14 s without additional pressure on the depilated dorsal skin of rabbits. This procedure produced the desired partial skin thickness burn injury. The depth of the burn lesions was investigated by HE-stained paraffin sections. The border of the necrotic zone was found in the central third of the dermis in 80% of cases, and in the central two quarters in 100%. These results are achieved when the rabbit's hair at the site of infliction is in the anagen phase of the hair growth cycle. For obtaining reproducible results we recommend using rabbits of the same strain and weight, anagen hair growth phase, the described procedure of infliction, an identical stamp and the specified temperature and infliction time.

Progression of burn wound depth by systemical application of a vasoconstrictor: an experimental study with a new rabbit model.

The final depth of a necrosis resulting from burn trauma is determined within 3 days. The zone of stasis has the potential for complete regeneration or there may be ischemic influences that lead to necrosis. In our model, we examined the dermal influence of vasoconstrictors with reference to the development of burn necrosis. On the backs of New Zealand white rabbits (4.0-4.5 kg) standardized lesions were made with a heated aluminum stamp at 80 degrees C, 14 s in duration. The lesions were intradermal, whereby the border zone of the coagulated tissue was found in the middle two quarters of the dermis in 100% of untreated animals after 72 h. For dermal vasoconstriction epinephrine in a dose of 0.5 microg/kg/min was used. There were two groups of seven animals each. One group received epinephrine and the dosage was dependent on the clinical state of the animal. Several cycles were administered within a 3-day period. The reduction of skin perfusion was documented by Laser-Doppler-flowmetry. After 3 days, the skin with the lesions was excised and using a hematoxylin dye, a histological examination followed. The parameter used to determine the efficacy was the thickness of the uncoagulated part of the excised dermis. Over a period of 48 h, an average of 2.3 epinephrine cycles of average of 88 min per animal in duration resulted in an average reduction of skin diffusion of 41%. The uncoagulated part of the dermis in the epinephrine group was 28.6% average; in the control group, this was 43.5%. The statistical analysis revealed significant differences with a p-value of 0.0312 (significant, when value is less than 0.05). The test results indicate that temporary reduction of skin perfusion through external administration of vasocontrictors may lead to progression of burn necrosis in our animal model. Clinically, this result indicates that for patients with burn injuries and systemic inflammatory response syndrome who have insufficient volume therapy, the administration of vasocontrictors may produce similar results in the injured area.

[Analysis of hand function with the Millesi examination scale in patients with pollicisation after aplasia or hypoplasia of the thumb]. / Handfunktionsanalyse mit dem Untersuchungsschema nach Millesi bei Patienten mit Pollizisation nach Aplasie oder Hypoplasie des Daumens.

Pollicisation of a single long finger is the method of choice to treat congenital thumb aplasia or thumb hypoplasia. Using Millesi's scale for the functional analysis of the hand, we examined six patients treated in the years 1983 to 1994 in our service. Average age at the time of surgery was 2.4 years and the follow-up time was seven years on average. Of the six patients, four suffered from additional malformations of the ipsilateral arm. These anomalies required early surgical treatment and therefore delayed the pollicisation procedure. The results of the anatomical part of the examination ranged between 39 and 94% of the achievable value. The final results including sensibility, strength, and skills reached 11 to 50%. Development of skills and muscle strength in the operated hand was dependent on the follow-up time. Millesi's scale could be applied successfully in this special group of children with congenital malformation of hands.

[Technique and applications of stereolithographic cranial models]. / Technik und Anwendungsmöglichkeiten der stereolithographischen Schädelmodellherstellung.

3-D-modelling of the skull is useful referring to improve diagnostics, for surgical planning and simulation of surgical procedure. Stereolithography is a constructive process producing a model by building it up layer by layer with plastic using an "ultraviolet" laser to catalyse the polymerization of a liquid plastic solution. This fast prototyping derives from using a new interface between a CT-Scanner and a SLA. By avoiding the tool path problems inherent in conventional computerdriven CNC milling machines we succeeded in producing closed cavities and even intraosseous course of vessels and nerves. The compact and smooth surface makes manual postprocessing unnecessary. By using a new software (interpolation +/- 0.25 mm) we could improve the accuracy. At our studies we found a maximum aberration of at least 0.25 mm.