Crash emergency cesarean section: decision-to-delivery interval under 30 min and its effect on Apgar and umbilical artery pH

PURPOSE

The objective of this study was to investigate the effect of decision-to-delivery interval of crash emergency cesarean section on Apgar and umbilical artery pH in a level-3 university hospital.

MATERIALS AND METHODS

In a retrospective analysis, all women undergoing "crash" emergency cesarean section were evaluated. Emergency cesarean sections were performed in the delivery room. Data relating to indication, Apgar score, arterial cord pH, and time intervals between decision-to-deliver and actual delivery were collected retrospectively.

RESULTS

All 109 crash emergency cesarean sections were performed within a decision-to-delivery time of 30 min. The median (with 10-90th percentile) time was 10 min (5-19). Thirty-three (30.3%) of the emergency cesarean sections had a gestational age below 32 weeks and 60 (55%) below 37 weeks. An abnormal fetal heart rate pattern was noted in most of the cases (91%). Prolapsed cord (21%) and placental abruption (20%) were the most frequent reasons for emergency cesarean section but in one-fourth (25.7%) no morphological reason could be identified. Very short decision-to-delivery times below 20 min were inversely correlated to fetal outcome, i.e., lower umbilical blood pH and Apgar scores (P < 0.01).

CONCLUSION

The 30-min standard for the decision-to-delivery time interval set by Anglo-American countries may be a feasible guideline at least for level-3 hospitals. The 20-min interval set by the German Society of Gynecology and Obstetrics could not be achieved in all cases. The positive effect of very short intervals on neonatal outcome still needs to be proven.

Topical 5-aminolaevulinic acid-photodynamic therapy for the treatment of urethral condylomata acuminata

BACKGROUND

Electrocoagulation and laser evaporation for urethral condylomata acuminata have high recurrence rates and can be associated with urethral malformations.

OBJECTIVES

To investigate the effect of photodynamic therapy (PDT) with topical 5-aminolaevulinic acid (ALA) on urethral condylomata acuminata and to examine the histological changes in lesions of condylomata acuminata after ALA-PDT.

METHODS

Patients with urethral condylomata (n = 164) were given topical ALA followed by intraurethral PDT through a cylindrical fibre. Patients included 11 individuals with 16 penile or vulval condylomatous lesions which were biopsied before or after treatment; the histological changes were then evaluated by light microscopy and electron microscopy.

RESULTS

The complete response rate was 95% and the recurrence rate was 5% after 6-24 months of follow-up. Light microscopy revealed keratinocytes in the middle and upper layers of the epidermis showing marked vacuolation and some necrocytosis 1 and 3 h after PDT. Necrosis in all layers of the epidermis was noted 5 h after PDT. Electron microscopy of keratinocytes revealed distinct ultrastructural abnormalities of mitochondria and the endoplasmic reticulum, and membrane damage. Apoptotic bodies were detected 3 h after PDT and a large number of keratinocytes exhibited necrosis 5 h after PDT.

CONCLUSIONS

Results suggest that, compared with conventional therapies, topical ALA-PDT is a simple, effective, safe and well-tolerated treatment for urethral condylomata acuminata that is associated with a low recurrence rate. The mechanism might be the triggering of both apoptosis and necrosis by ALA-PDT in human papillomavirus-infected keratinocytes.

Primary cervical cancer screening by self-sampling of human papillomavirus DNA in internal medicine outpatient clinics

BACKGROUND

We determined whether testing of self-collected vaginal swabs for human papillomavirus (HPV) DNA can be used to screen for cervical disease within internal medicine outpatient clinics.

PATIENTS AND METHODS

In this prospective study, 560 patients visiting two referral outpatient clinics for internal medicine were asked to take an HPV self-sample. Acceptability of self sampling, HPV prevalence and cervical intraepithelial neoplasia (CIN) detection rate were evaluated.

RESULTS

435 women (78%) performed HPV self-sampling; 1.5% considered self-sampling to be difficult. 134 women (31%) tested positive for high-risk type of HPV. There were significant differences between HPV-positive and -negative women with respect to the following: mean age (42 versus 46 years), number of women aged <16 years at first coitus (35% versus 23%) and history of drug abuse (8.3% versus 2.6%). Colposcopy could be performed for 70 HPV positive women: CIN 1-3 was identified in 24%. Two of 52 women with HPV-negative results undergoing colposcopy had biopsy-confirmed CIN 1. Test performance for detection of CIN 2-3 after correction for verification bias: sensitivity, 100%; specificity, 71%; negative predictive value, 100%; positive predictive value, 10%. HPV persistence was associated with a 5.7-fold risk of CIN 2-3 detection at follow-up.

CONCLUSIONS

Self-assessment for HPV DNA is an easy, feasible and well-accepted method for HPV testing and for cervical cancer screening in internal medicine outpatient clinics.

Analysis of HER-2/neu amplification in endometrial carcinoma by chromogenic in situ hybridization. Correlation with fluorescence in situ hybridization, HER-2/neu, p53 and Ki-67 protein expression, and outcome

Fluorescence in situ hybridization (FISH) is the most widely used technique to detect HER-2/neu gene amplification; however, it is only available in some institutions. In contrast, chromogenic in situ hybridization (CISH) can be evaluated by routine light microscopy. In endometrial carcinoma there are few data concerning HER-2/neu status and prognosis. Therefore, we determined HER-2/neu gene status by CISH using a digoxigenin-labelled probe on 60 formalin-fixed paraffin-embedded endometrial carcinomas. The data were compared with the immunohistochemistry of HER-2/neu (A0485, TAB250), p53, Ki-67, clinicopathological factors, and survival. By conventional light microscopy, HER-2/neu amplification (>/=6 copies >50% cancer cells) was detected in 14% (8/59) tumours, HER-2/neu overexpression (>10% cells moderate/strong complete membrane staining) in 22% (13/60) for A0485, and 18% (11/60) for TAB250, p53 (>10% +cells) in 61% (36/59), and Ki-67 (>50% +cells) in 50% (30/60). Discordant cases for CISH and immunohistochemistry, as well as all (2+) were further analysed by FISH (Vysis). Among 10 cases (2+) and not amplified by CISH, two showed low-level amplification by FISH. Significant correlation was found between amplification and protein overexpression (P</=0.001), and a trend with nonendometrioid type, higher grade, and older age. A better outcome (Kaplan-Meier) was observed for patients with nonamplified (1-5 copies per nucleus) or low-level (6-10 copies) amplification tumours, low Ki-67 expression, age <50 years, endometrioid type, low FIGO (International Federation of Obstetrics and Gynaecology) grade and stage, superficial myometrial infiltration, and no lymph-vascular invasion (P</=0.036), but only as a trend for HER-2/neu protein negative (P=0.13). Cox analysis revealed age, FIGO grade and stage, myometrial infiltration, and lymph-vascular invasion to be independent prognostic factors (P</=0.05), and a trend for HER-2/neu gene copy number (0.18). In endometrial carcinoma, HER-2/neu gene status can be readily assessed by CISH in routine clinical practice, and it gives more prognostic information than HER-2/neu by immunohistochemistry. FISH analysis in (2+) cases but negative by CISH may detect additional tumours with low-level amplification.

Localization and staging of cervical intraepithelial neoplasia using double ratio fluorescence imaging

A phase zero evaluation of a new fluorescence imaging technique for diagnosing cervical intraepithelial neoplasia (CIN) was performed. The fluorescence imaging prototype performed quantitative imaging of Protoporphyrin induced by a topically applied aminolevulinic acid using double ratio (DR) fluorescence imaging technique developed by our group. A total of 38 patients were in the protocol, with 16 colposcopically selected for biopsy. Fluorescence images of these 16 patients were taken, 19 sites were biopsied, and the disease was staged histopathologically. DR fluorescence imaging of the cervix using our general purpose prototype appeared to be cumbersome but feasible. In four cases strongly localized fluorescent hotspots were observed at the location where the disease was colposcopically visible. In the other cases the fluorescence showed a more diffuse multifocal image. The value of the DR determined at the site of biopsy correlated in a statistically significant way with the histopathologically determined stage of the disease [Spearman rank correlation, r=0.881, p<0.001 (confidence interval 0.7044-0.9552)]. This suggests that noninvasive staging of CIN using this technique is feasible. We believe that the results of this study justify the development of a dedicated device that combines regular white light colposcopy with DR fluorescence imaging.

[Human papillomaviruses (HPV) in urology. I: 10 years results of interdisciplinary HPV diagnosis]

Human papillomaviruses play a pre-eminent role as the most frequent sexually transmitted virus in urology. However, a pathogenetic connection between these viruses and urological cancers has not been proved so far, in contrast to the correlation with cervical cancer. Our 10-year experience with urological partner diagnostics and therapy surveillance in 788 patients form the empirical basis for the detection of clinical and subclinical HPV efflorescences, rates of partner infection and the benefit of laboratory techniques for HPV detection. Commercial HPV test methods only detect a fraction of the HPV types affecting the external genitals and the urethra that are demonstrated in a reference laboratory. HPV analyses are not appropriate for routine diagnostics, but should be used solely in research projects.

Photodynamic effects induced by aminolevulinic acid esters on human cervical carcinoma cells in culture

Fluorescence diagnosis and photodynamic therapy using 5-aminolevulinic acid (ALA) provide new methods for the detection and treatment of cervical cancer and especially its precursors. However, these techniques are restricted by the rate of uptake of the hydrophilic ALA, its poor diffusion through the bilayer of biological membranes or both. In this study we evaluated the effect of some esterified ALA derivatives on the induction of the endogenous photosensitizer, protoporphyrin IX (PpIX), and the photodamage in cultured human cervical cells (C33-A and CaSki). The kinetics of PpIX accumulation showed that ALA esters, especially the ALA-hexylester (h-ALA), induced significantly faster PpIX formation than ALA at the same concentration (0.5 mM). The PpIX induction showed a dose-dependent characteristic. The highest PpIX values could be achieved by an up to 1.3-13-fold lower concentration of ALA esters than with ALA. Using the Annexin V assay, apoptosis was found to be induced rapidly after irradiation in both ALA- and ALA esters-treated cells. On measuring mitochondrial activity, the incubation with h-ALA induced a more pronounced photodamage. The results indicate that improved or at least comparable photodynamic effects can be achieved by using remarkably lower doses of ALA esters.

Sonographic cervical volumetry in higher order multiple gestation

OBJECTIVE

The aim of this study of multifetal pregnancies was the comparison of three-dimensional (3D) volumetry of the cervix, conventional sonographic cervical length measurement and clinical assessment.

METHODS

10 mothers were investigated in an observational study between 5/1999 and 9/2000. A total of 34 consecutive 2D- and 3D-transabdominal ultrasound measurements were performed.

RESULTS

Volumetry of the cervix was possible in all 34 exams. 2D-cervical length assessment could not be obtained in 6% because the presenting fetal part obstructed the sonographic plane. Both methods allowed equal judgement of the configuration of the cervix. A significant correlation was found between mean 2D-cervical length (28.7 mm, 7.7 SD) and mean cervical volume (30.0 cm3, 16.0 SD). Parity, subjective preterm labor or need of tocolytics showed no correlation with any biometrical parameter studied.

CONCLUSION

Volumetry was superior for the assessment of cervical biometry and conformation in women when the transabdominal 2D-plane was obstructed. When cervical length was obtainable by a conventional scan, the technically more complex 3D-imaging did not provide further information.

Photodynamic effects induced by aminolevulinic acid esters on human cervical carcinoma cells in culture

Fluorescence diagnosis and photodynamic therapy using 5-aminolevulinic acid (ALA) provide new methods for the detection and treatment of cervical cancer and especially its precursors. However, these techniques are restricted by the rate of uptake of the hydrophilic ALA, its poor diffusion through the bilayer of biological membranes or both. In this study we evaluated the effect of some esterified ALA derivatives on the induction of the endogenous photosensitizer, protoporphyrin IX (PpIX), and the photodamage in cultured human cervical cells (C33-A and CaSki). The kinetics of PpIX accumulation showed that ALA esters, especially the ALA-hexylester (h-ALA), induced significantly faster PpIX formation than ALA at the same concentration (0.5 mM). The PpIX induction showed a dose-dependent characteristic. The highest PpIX values could be achieved by an up to 1.3-13-fold lower concentration of ALA esters than with ALA. Using the Annexin V assay, apoptosis was found to be induced rapidly after irradiation in both ALA- and ALA esters-treated cells. On measuring mitochondrial activity, the incubation with h-ALA induced a more pronounced photodamage. The results indicate that improved or at least comparable photodynamic effects can be achieved by using remarkably lower doses of ALA esters.

[Paravaginal abscess in pregnancy]

Paravaginal abscess in pregnancy. We report the diagnosis and treatment of an infected Gartner's duct cyst during pregnancy. The patient presented with lower abdominal pain, fever (38.5 degrees C) and an elevated C-reactive Protein level. Pelvic examination revealed a painful paravaginal mass. Sonography was not able to detect the cranial border of the tumor. Magnetic resonance imaging (MRI) revealed fluid accumulation laterodorsal to the vagina without evidence of a connection with the retroperitoneal space. An infected Gartner's duct cyst with consecutive abscess formation along the mesonephric duct system, was diagnosed. Following transvaginal drainage, the remainder of the pregnancy was uneventful and the patient was delivered vaginally at 40 + 5 weeks without complications. - The rare clinical finding of a paravaginal abscess in pregnancy was treated without termination of the pregnancy. Preoperative planning of the surgical approach using MRI can be easier for pelvic processes extending out of the pelvis than using ultrasound and is less painful for the patient.

[Effect of repetitive prenatal corticosteroid medication on intrauterine growth and growth in early childhood]

OBJECTIVE

The evaluation of the effects of repeated antenatal corticosteriod (CS) medication on birth size and size at the age of 4 years.

METHODS

82 children exposed to CS initially between 26 and 28 weeks of gestation were matched with 82 controls of the same gestational age and sex.

RESULTS

No differences were observed between the CS and control groups with regard to weight, head circumference, and length at birth and at the age of 4 years.

CONCLUSIONS

Our study failed to demonstrate that repetitive antenatal medication with CS in order to induce lung maturation has a negative impact on intrauterine growth and growth in early childhood.