Gastric cancer in pregnancy: do pregnancy, age or female sex alter the prognosis? Case reports and review.

The coincidence of gastric cancer and pregnancy is a rare event. By literature research of the last three decades only 31 cases from outside Japan were identified including two own patients. The analysis of these and another 61 cases from Japan revealed the same predominance of poorly differentiated diffuse carcinomas with peritoneal and lymphatic metastases as in other young patients (<40 years). The survival rate is not obviously affected by pregnancy, young age or female sex. Experimental and epidemiological data suggest a protective effect of oestrogen against the induction of (intestinal) gastric cancer, while the cancer growth itself seems to be enhanced. Oestrogen receptors (ER) are found in about 22% of gastric cancer cells, especially in the poorly differentiated type. In contrast to target organs like the breast, ER in gastric cancer seem to be a sign of tumour adaptation involving e.g. the pathway of the epidermal growth factor. The results of treatment with anti-oestrogen are controversial in experimental and clinical settings. Due to the very common epigastric complaints early diagnosis of gastric cancer is even more difficult in pregnancy, so that early gastroscopy is advisable in patients on risk. Main effort should be given, however, to primary prevention.

[Fetal movements in 4-channel tocography]. / Fetale Bewegungen in der Vierkanaltokographie.

INTRODUCTION: The four-channel-tocography was developed to register the spatial and temporal pattern of uterine contractions and to evaluate their clinical relevance. In this study it should be assessed whether the four-channel-tocography can also register fetal movements. MATERIAL AND METHODS: The study included 38 women with a gestational age between 28 and 43 weeks and singleton pregnancy. Four pressure transducers were attached in a square around the umbilicus. Parallel to the continuous registration of four-channel-tocography fetal movements were observed by conventional ultrasound. RESULTS: In a total of 23 hours and 11 minutes 403 fetal movements were registered by ultrasound and 405 by four-channel-tocography. 17% of the ultrasonically observed fetal movements were documented by the four-channel-tocography and 70% of the tocographically registered movements could be verified by ultrasound. CONCLUSION: Fetal movements can be registered by four-channel-tocography with good sensitivity and reliability. Essential for its clinical use is an automatic analysis, which is being developed.

[2 successful pregnancies in a woman with type I osteogenesis imperfecta]. / Zwei erfolgreiche Schwangerschaften einer an Osteogenesis imperfecta Typ I erkrankten Frau.

The chance of a woman with osteogenesis imperfecta to succeed in a pregnancy with a healthy baby and without any harm to herself, is poor. A case of a 37-year old patient is presented, who consciously became pregnant twice, despite her severe illness. Both pregnancies finally resulted in Caesarean section, but without any complications to the patient. While the first child, a boy, is healthy, the second, a girl, is expected to suffer from phosphate diabetes since the father suffered from this illness.

[Magnesium, calcium, hemoglobin, hematocrit, estriol and human placental lactogen with magnesium substitution in pregnancy]. / Magnesium, Kalzium, Hämoglobin, Hämatokrit, Ostriol und HPL unter Magnesiumsubstitution in der Schwangerschaft.

In a randomised double-blind study 568 women were given orally either 15 mmol magnesium-aspartate hydrochloride per day or aspartic acid as placebo. The outcome of pregnancy was significantly improved in the magnesium group (fewer maternal hospitalisations, reduction in preterm delivery and less frequent referral of newborn to the neonatal intensive care unit). In the 437 patients with regular intake of tablets, haematocrit, haemoglobin and calcium show a decrease up to 20 weeks of gestation (wks) and an increase during the last 8 wks, whereas magnesium stays at a low level. Oestriol and HPL are rising steadily during gestation. In all parameters, no differences were found between the magnesium and placebo group, except for a higher level of oestriol at 33 to 36 wks and a lower level above 36 wks in the magnesium group. Because of the numerous benefits throughout the pregnancy magnesium supplementation is recommended for all pregnancies.

[Treatment of malignant tumours of the genitalia in young girls (author's transl)]. / Die Behandlung von malignen Tumoren des Genitale bei kleinen Mädchen.

This is a report about three cases of malignant tumours in young girls (botryoid sarcoma--rhabdomyosarcoma and an endodermal sinus tumour). The surgical treatment consisted of radical excision of the tumour with subsequent lymphadenectomy. The ovaries remained in place. Chemotherapy has resulted in an improvement of 5 years survival of malignant tumours in children. Ultraradical surgery, the treatment of choice until 5 years ago seams to dispensable.

[Placenta percreta and rupture of the uterus (author's transl)]. / Placenta percreta und Ruptur des Uterus. Fallbericht.

A placenta percreta must be expected in 7% of all cases of abnormal implantation of the placenta. Placenta percreta is therefore a rare but serious complication of pregnancy. In 15% of the cases spontaneous rupture of the uterus occurs. Depending on the type of delivery, the maternal mortality ranges from 6-30%. Early hysterectomy is the method of choice to prevent serious complications of hermorrhage. Since the degree of infiltration of the myometrium with placenta can not be determined with accuracy, excision of the site of perforation to preserve the uterus does not appear to be indicated. The case of a 41 year old primigravida, with a previous history of infertility and myomectomy is described. Following primary Cesarean section for breech presentation an asymptomatic rupture of the uterus from the placenta percreta was detected. The rupture of the uterus was likely asymptomatic because a loop of sigmoid colon was adherent to the site of perforation.

[Questions of bio-ethics in the termination of pregnancy in the second and third trimester of pregnancy for eugenic indications (author's transl)]. / Fragen zur Bioethik. Terminierung der Schwangerschaft im II. und III. Trimenon aus eugenischer Indikation.

According to the paragraph 218 B of the Criminal Code termination of pregnancy for eugenic indications is prohibited. Since it is today possible to diagnose anencephaly at 30 weeks an ethical dilemma arises. The hypothesis is founded that an anencephalic is clinically a dead entity with continuing functions of live corresponding to clinical death following an accident when essential parts of the brain have been lost. If this thesis is accepted a pregnancy can be terminated immediately following diagnosis of anencephaly without using the questionable medical psychiatric indication for termination.

PIP: Paragraph 218B of the German Criminal Code allows induced abortion under eugenic indications. Anencephaly is legally considered a criterion for defining death. This condition can be diagnosed in a pregnancy after the 30th week. If anencephaly can be diagnosed in X-ray and ultrasonic scan, with below normal estriol values and elevated alpha-fetoprotein levels, the indications for a eugenic abortion are fulfilled if the mother gives her informed consent.

[Osteogenesis imperfecta in pregnancy (author's transl)]. / Osteogenesis imperfecta und Schwangerschaft.

Osteogenesis imperfecta is one of the most frequent hereditary anomalies. One personal case is described. The literature is reviewed. The disease entity, the heredity and the possibilities of antenatal diagnosis are described. A pregnant patient with osteogenesis imperfecta needs careful antenatal care. Delivery by primary Caesarean section with gentle delivery of the infant is the method of choice. The aim of the method of delivery is to avoid spontaneous fractures during the delivery.

[immunoglobulins in amniotic fluid in normal pregnancy and fetal malformation (author's transl)]. / Immunoglobuline im Fruchtwasser bei normaler Schwangerschaft und fötaler Missbildung.

In 20 cases of normal pregnancy and 9 cases of foetal monstrosities the immunoglobulins G, A, M and albumin C3C and alpha 2MG were determined in the amniotic fluid. In neural tube defects the IgG, IgA and albumin concentrations were clearly above those found in normal pregnancies. IgM was not found in any of the cases, whereas alpha 2MG occurred in two cases of foetal monstrosity. There was no difference in C3C concentrations of both groups.

[Incidental detection of ovarian vein thrombosis along with caesarean section (author's transl)]. / Ovarialvenenthrombose als Zufallsbefund beim Kaiserschnitt.

Reported in this paper are two case of ovarian vein thrombosis which were incidentally discovered, when caesarean section was performed. The two thromboses must have originated at some point during pregnancy. This observation is very rare, since ovarian vein thrombosis is generally known for its occurrence as a complication during the puerperium. The ovarian vein was proximally ligated close to the uterus, and the motivations for this approach are given. Treatment then was continued with heparin. The incidence postpartum of ovarian vein thrombosis accounted for one per cent of alle diagnoses to which reference is made in this paper.

[Biochemical and coagulation-physiology examinations before and after amniocentesis in early pregnancy]. / Biochemische und gerinnungsphysiologische Untersuchungen vor und nach Amniozentese in der Frühschwangerschaft.

In 46 women the alpha1-fetoprotein content, the soluble fibrin monomer complexes (LFMK), and the coagulation status were determined in the maternal serum at the beginning of the second trimester before and after amniocentesis. Increases of AFP by more than 100% of the original level pointed to fetomaternal microtransfusion, the quantity of which was calculated by means of a formula. Overall coagulation tests did not show any change after the puncture. A moderate LFMK increase was seen (p less than 0.05), which, however, was not clearly correlated with the AFP increase.

[Results of the follow-up of the position of intra-uterine device by ultra-sonography (author's transl)]. / Ergebnisse der Lageüberwachung von Intrauterinpessaren durch Ultraschall.

The position of the intra-uterine device copper-T in 1372 women was followed up by ultrasound for four years. During this time 2565 ultrasound studies for the position of the intra-uterine device were carried out. The intra-uterine device was found in the cervix in 81 ultrasound investigations and removed or exchanged. In 12 cases the device was pushed back into the uterine cavity. 12 women became pregnant. This corresponds to a Pearl index 0.72 with a mean insertion time of 14.6 months and 20.000 patient-months of wearing of an intra-uterine device. In 9 of the 12 pregnant cases the device was found in the cervix. 6 of these patients reported only once instead of the projected four times for ultra-sound follow-up and the last normal ultrasound follow-up was usually nine months or longer ago. Our findings suggest that the contraceptive effectiveness of an intra-uterine device can be improved by regular ultra-sonic control of the position and can by approximated to the effectiveness of hormonal contraception.

PIP: A report of 2565 ultrasonic examinations of 1372 women to determine the position of a Copper T IUD is presented. The mean length of IUD use was 14.6 months. In 139 cases the IUD was found in an intracervical position; in 93 of these cases the position of the IUD in the cervix was verified by pelvic examination and reinserted or replaced in 81 cases. The pregnancy rate was 12 for 20,031 use-months, corresponding to a Pearl index of .72. In 9 of these 12 pregnancies, the IUD was found in the intracervical position, and in the majority of these cases the most recent ultrasonic examination had been done more than 6 months previously. A large number of IUDs were found in an intracervical position in the first 2 months after insertion. It is recommended that an ultrasonic examination to determine the position of an IUD be given a few days following the insertion, after each of the first 2 months following insertion, and every 3-6 months afterwards.

[Results of the intraperitoneal application of radioactive gold in cases of ovarian cancer (author's transl)]. / Ergebnisse der intraperitonealen Applikation von radioaktivem Gold beim Ovarialkarzinom.

Radioactive gold was instilled once into the peritoneal cavity of 248 patients with ovarian carcinoma of varying stages. The criterium for the radioactive gold instillation was either for the post-operative treatment in stage 1A or for the treatment of ascites in more advanced stages. The treatment had no clear cut influence on the five year survival rate. The treatment with radioactive gold Au 198 was very effective in the treatment of ascites and had less side effects than other radioactive colloidal materials.

[Possibilities of ultrasonic diagnosis in fetal abdominal monstrosities (author's transl)]. / Möglichkeiten der Ultraschalldiagnostik bei fetalen abdominalen Missbildungen.

The diagnostic possibilities of intrauterine ultrasonic assessment of the fetal abdomen by rapid B-scan are described on the basis of two cases (megalocystis/megaloureter syndrome and omphalocele with cloaca formation). Other examination methods of prenatal diagnosis to confirm the findings are also discussed, but their diagnostic significance is even more limited than that of sonography, individual cases excepted. Although early detection of neural tube anomalies is the most important application of ultrasound, pronounced monstrosities of the fetal abdominal region are also definitely recognisable via ultrasonic examination.

[The evaluation of cortisol in amniotic fluid and in maternal blood as parameter for foetal lung maturity (author's transl)]. / Cortisol im Fruchtwasser und im mütterlichen Blut--Ein Parameter zur Bestimmung der fetalen Lungenreife?

The lecithin/sphingomyelin-ratio (L/S-ratio) in amniotic fluid has become established in recent years as a valuable laboratory parameter for determining foetal lung maturity and has thus helped to avoid the neonatal respiratory distress syndrome. Since glucocorticosteroids are a decisive factor in stimulating foetal lung development, we were prompted to investigate whether the determination of cortisol in amniotic fluid or maternal blood could also serve as an indicator of foetal lung maturity. The cortisol concentration was measured by radioimmunoassay in amniotic fluid (n = 91) and in maternal venous plasma (n = 70) from normal and complicated pregnancies and was compared with the L/S-ratio. A significant correlation between gestational age and cortisol in amniotic fluid (r = 0.711) and in maternal venous plasma (r = 0.625) was observed. There was also a significant correlation between the L/S-ratio and amniotic fluid cortisol (r = 0.701). However, compared to the L/S-ratio, measurements of cortisol yielded 10% false positive and 11% false negative results. A significant correlation between the L/S-ratio and the maternal plasma cortisol could also be demonstrated (r = 0.631). Here the comparison with the L/S-ratio gave even poorer results: 16% false positive and 6% false negative. The high percentage of false results, especially false positive results yielded by cortisol estimations in both fluids leads to the conclusion that the L/S-ratio remains the superior diagnostic parameter in determining foetal lung maturity.