B‐cell receptors of EBV‐negative Burkitt lymphoma bind modified isoforms of autoantigens

Burkitt lymphoma (BL) represents the most aggressive B‐cell‐lymphoma. Beside the hallmark of IG‐MYC‐translocation, surface B‐cell receptor (BCR) is expressed, and mutations in the BCR pathway are frequent. Coincidental infections in endemic BL, and specific extra‐nodal sites suggest antigenic triggers. To explore this hypothesis, BCRs of BL cell lines and cases were screened for reactivities against a panel of bacterial lysates, lysates of Plasmodium falciparum, a custom‐made virome array and against self‐antigens, including post‐translationally modified antigens.

An atypically modified, SUMOylated isoform of Bystin, that is, SUMO1‐BYSL was identified as the antigen of the BCR of cell line CA46. SUMO1‐BYSL was exclusively expressed in CA46 cells with K139 as site of the SUMOylation. Secondly, an atypically acetylated isoform of HSP40 was identified as the antigen of the BCR of cell line BL41. K104 and K179 were the sites of immunogenic acetylation, and the acetylated HSP40 isoform was solely present in BL41 cells. Functionally, addition of SUMO1‐BYSL and acetylated HSP40 induced BCR pathway activation in CA46 and BL41 cells, respectively. Accordingly, SUMO1‐BYSL‐ETA’ immunotoxin, produced by a two‐step intein‐based conjugation, led to the specific killing of CA46 cells. Autoantibodies directed against SUMO1‐BYSL were found in 3 of 14 (21.4%), and autoantibodies against acetylated HSP40 in 1/14(7.1%) patients with sporadic Burkitt‐lymphoma. No reactivities against antigens of the infectious agent spectrum could be observed.

These results indicate a pathogenic role of autoreactivity evoked by immunogenic post‐translational modifications in a subgroup of sporadic BL including two EBV‐negative BL cell lines.

Lymphocyte predominant cells of nodular lymphocyte predominant Hodgkin lymphoma interact with rosetting T cells in an immunological synapse

Nodular lymphocyte predominant Hodgkin lymphoma (NLPHL) is a subtype of Hodgkin lymphoma with a preserved B-cell phenotype and follicular T helper (T_FH ) cells rosetting around the tumor cells, the lymphocyte-predominant (LP) cells. As we recently described reactivity of the B-cell receptors of LP cells of some NLPHL cases with Moraxella spp. proteins, we hypothesized that LP cells could present peptides to rosetting T cells in a major histocompatibility complex class II (MHCII)-bound manner. Rosetting PD1⁺ T cells were present in the majority of NLPHL cases, both in typical (17/20) and variant patterns (16/19). In most cases, T-cell rosettes were CD69⁺ (typical NLPHL, 17/20; NLPHL variant, 14/19). Furthermore, both MHCII alpha and beta chains were expressed in the LP cells in 23/39 NLPHL. Proximity ligation assay and confocal laser imaging demonstrated interaction of the MHCII beta chain expressed by the LP cells and the T-cell receptor alpha chain expressed by rosetting T cells. We thus conclude that rosetting T cells in NLPHL express markers that are encountered after antigenic exposure, that MHCII is expressed by the LP cells, and that LP cells interact with rosetting T cells in an immunological synapse in a subset of cases. As they likely receive growth stimulatory signals in this way, blockade of this interaction, for example, by PD1-directed checkpoint inhibitors, could be a treatment option in a subset of cases in the future.

The time to relapse correlates with the histopathological growth pattern in nodular lymphocyte predominant Hodgkin lymphoma

Nodular lymphocyte predominant Hodgkin lymphoma (NLPHL) can present with different histopathological growth patterns. The impact of these histopathological growth patterns on relapse characteristics is unknown. We therefore analyzed paired biopsies obtained at initial diagnosis and relapse from 33 NLPHL patients who had received first-line treatment within German Hodgkin Study Group (GHSG) trial protocols, and from a second cohort of 41 relapsed NLPHL patients who had been treated outside GHSG studies. Among the 33 GHSG patients, 21 patients presented with a typical growth pattern at initial diagnosis, whereas 12 patients had a variant histology. The histopathological growth patterns at initial diagnosis and at relapse were consistent in 67% of cases. A variant histology at initial diagnosis was associated with a shorter median time to lymphoma recurrence (2.8 vs 5.2 years; P = .0219). A similar tendency towards a shorter median time to lymphoma recurrence was observed for patients presenting with a variant histology at relapse, irrespective of the growth pattern at initial diagnosis. Results obtained from the 41 NLPHL patients who had been treated outside GHSG studies were comparable (median time to lymphoma recurrence for variant histology vs typical growth pattern at initial diagnosis: 1.5 vs 7.0 years). In conclusion, the histopathological growth pattern remains consistent at relapse in the majority of NLPHL cases, and has major impact on the time of relapse.

Prenatal diagnosis of craniomaxillofacial malformations: a characterization of phenotypes in trisomies 13, 18, and 21 by ultrasound and pathology

OBJECTIVE

To determine the relationship between trisomies 13, 18, and 21 and craniofacial malformations detected by prenatal sonography.

DESIGN

During a 29-year period (1976 through 2004), prenatal sonographic findings of 69 fetuses with trisomy 13; 171 fetuses with trisomy 18; 302 fetuses with trisomy 21; and 17 fetuses with other trisomies were evaluated retrospectively, after fetal karyotype identification. Sonographic findings were compared with autopsy results in 209 patients (trisomy 13, n=39; trisomy 18, n=64; and trisomy 21, n=106).

RESULTS

For trisomy 13, cleft deformities were detected prenatally in 65.2%, and of the 39 cases with pathological information, 76.9% were found to have a cleft deformity. Ocular and orbital abnormalities were found in 28%. Malformations of the jaws and abnormal profiles were more frequently diagnosed postnatally than prenatally. For trisomy 18, abnormal profiles (41.5%) and ear abnormalities (5.3%) were the most noticeable ultrasound markers, next to abnormalities of the neurocranium (36.8%) and cranial bone configuration (21.6%). Dysmorphisms of the eye, ear, or nose were detected more frequently in autopsy cases. For trisomy 21, ultrasound showed an aberrant shape of the skull in 14.2% of fetuses. In general, the ocular-orbital and nasal abnormalities in fetuses with trisomy 18 or 21 were more evident in pathological examination than in prenatal ultrasound imaging.

CONCLUSIONS

Facial anomalies are common in the major trisomies, and their prenatal sonographic identification should be improved. The above-mentioned facial anomalies provide sufficient reason to consider performing cytogenic evaluation.

Prenatal diagnosis of craniomaxillofacial malformations: a characterization of phenotypes in trisomies 13, 18, and 21 by ultrasound and pathology

OBJECTIVE

To determine the relationship between trisomies 13, 18, and 21 and craniofacial malformations detected by prenatal sonography.

DESIGN

During a 29-year period (1976 through 2004), prenatal sonographic findings of 69 fetuses with trisomy 13; 171 fetuses with trisomy 18; 302 fetuses with trisomy 21; and 17 fetuses with other trisomies were evaluated retrospectively, after fetal karyotype identification. Sonographic findings were compared with autopsy results in 209 patients (trisomy 13, n=39; trisomy 18, n=64; and trisomy 21, n=106).

RESULTS

For trisomy 13, cleft deformities were detected prenatally in 65.2%, and of the 39 cases with pathological information, 76.9% were found to have a cleft deformity. Ocular and orbital abnormalities were found in 28%. Malformations of the jaws and abnormal profiles were more frequently diagnosed postnatally than prenatally. For trisomy 18, abnormal profiles (41.5%) and ear abnormalities (5.3%) were the most noticeable ultrasound markers, next to abnormalities of the neurocranium (36.8%) and cranial bone configuration (21.6%). Dysmorphisms of the eye, ear, or nose were detected more frequently in autopsy cases. For trisomy 21, ultrasound showed an aberrant shape of the skull in 14.2% of fetuses. In general, the ocular-orbital and nasal abnormalities in fetuses with trisomy 18 or 21 were more evident in pathological examination than in prenatal ultrasound imaging.

CONCLUSIONS

Facial anomalies are common in the major trisomies, and their prenatal sonographic identification should be improved. The above-mentioned facial anomalies provide sufficient reason to consider performing cytogenic evaluation.

Prenatal diagnosis of craniomaxillofacial malformations: a characterization of phenotypes in trisomies 13, 18, and 21 by ultrasound and pathology

OBJECTIVE

To determine the relationship between trisomies 13, 18, and 21 and craniofacial malformations detected by prenatal sonography.

DESIGN

During a 29-year period (1976 through 2004), prenatal sonographic findings of 69 fetuses with trisomy 13; 171 fetuses with trisomy 18; 302 fetuses with trisomy 21; and 17 fetuses with other trisomies were evaluated retrospectively, after fetal karyotype identification. Sonographic findings were compared with autopsy results in 209 patients (trisomy 13, n=39; trisomy 18, n=64; and trisomy 21, n=106).

RESULTS

For trisomy 13, cleft deformities were detected prenatally in 65.2%, and of the 39 cases with pathological information, 76.9% were found to have a cleft deformity. Ocular and orbital abnormalities were found in 28%. Malformations of the jaws and abnormal profiles were more frequently diagnosed postnatally than prenatally. For trisomy 18, abnormal profiles (41.5%) and ear abnormalities (5.3%) were the most noticeable ultrasound markers, next to abnormalities of the neurocranium (36.8%) and cranial bone configuration (21.6%). Dysmorphisms of the eye, ear, or nose were detected more frequently in autopsy cases. For trisomy 21, ultrasound showed an aberrant shape of the skull in 14.2% of fetuses. In general, the ocular-orbital and nasal abnormalities in fetuses with trisomy 18 or 21 were more evident in pathological examination than in prenatal ultrasound imaging.

CONCLUSIONS

Facial anomalies are common in the major trisomies, and their prenatal sonographic identification should be improved. The above-mentioned facial anomalies provide sufficient reason to consider performing cytogenic evaluation.

A new approach to calculating the risk of chromosomal abnormalities with first-trimester screening data

PURPOSE

First-trimester screening at 11 - 14 weeks has been proven to be very useful in the early detection of chromosomal defects. The aim of this project was to develop a CE-certified new risk calculation program (PRC = Prenatal Risk Calculation) using a nationwide database.

MATERIALS AND METHODS

The database underlying the new risk calculation procedure was established in Germany from 2003 through 2006. Overall, the database includes measurements from 70,030 pregnant women having given birth to healthy children. Following consideration of all pregnancies associated with a chromosomally abnormal outcome, the sample size was 451. The algorithm used for calculating the risk of a chromosomally abnormal outcome comprises the following variables: maternal age, crown-rump length (CRL) (restricted to a range from 45 - 84 mm or, equivalently, 11 + 1 - 14 + 0 weeks of gestation), nuchal translucency (NT), as well as the maternal serum parameters PAPP-A (pregnancy associated plasma protein A) and free beta-hCG (free human chorionic gonadotropin). In a preliminary cross-validation study, we applied both the new algorithm and the FMF UK program to an independent sample containing n = 40,568 pregnancies with negative outcome, n = 187 cases of trisomy 21, n = 34 trisomies 18 and n = 13 trisomies 13.

RESULTS

Using the primary sample of 70,030 pregnancies with a negative outcome, reference bands were constructed for the sonographic parameter fetal nuchal translucency and the biochemical parameters PAPP-A and free beta-HCG. Instead of MoM values we used "degree of extremeness" (DoE) values. This statistical parameter has been proven to give more precise results than the MoM measure because it assesses the deviation of the actual measurement value from the centre of the reference band expressed as a multiple of the width of the respective band section. The result of the risk calculation is visualized by means of a traffic light graph which allows the patient to comprehend her individual risk at first glance. The red color indicates a high risk, green a low risk, and yellow represents a moderate risk. In our preliminary cross-validation study the detection rate obtained for the German algorithm was 86.6 % for trisomy 21, 94.1 % for trisomy 18 and 92.4 for trisomy 13. The corresponding detection rates obtained with the same data by the FMF UK program were 86.1 %, 82.3 % and 69.2 % throughout. The false-positive rate was 5.0 % throughout.

CONCLUSION

The new risk calculation procedure of the FMF Germany (PRC) has been made available as a CE-certified computer program. In screening for trisomy 21 it yields results comparable to those of the program used by the FMF UK. Regarding the diagnosis of trisomy 13 and 18, even higher detection rates are currently achieved with the German algorithm. Program, data base and license key are available free of charge to registered members of the FMF Germany.

Absence of ductus venosus-importance of umbilical venous drainage site

OBJECTIVE

To evaluate the conditions associated with absent ductus venosus (ADV) diagnosed by prenatal ultrasonography.

METHODS

Retrospective review of 23 cases with ADV diagnosed in two tertiary referral centers with a general screening policy concerning Doppler assessment of the ductus venosus. The results are discussed together with 63 cases from a review of the literature.

RESULTS

In 19 fetuses the umbilical vein connected to the portal sinus, while the remaining four fetuses had extrahepatic umbilical venous drainage. Associated anomalies were present in 15 out of 23 fetuses: complex malformation syndromes (n = 6), chromosomal anomalies (n = 4), isolated cardiac defects (n = 4) and isolated extracardiac anomalies (n = 1). Eight fetuses had either no associated anomalies or minor anomalies. Hydropic changes were present in 12 of the 23 fetuses. In common with the reviewed cases, the presence of cardiac malformations, complex non-chromosomal malformation syndromes and hydrops was significantly associated with intrauterine or postnatal death while the type of umbilical venous drainage was not significantly different between survivors and non-survivors. However, among fetuses with no or minor associated anomalies the outcome was significantly better in the group without liver bypass.

CONCLUSIONS

ADV is significantly associated with fetal cardiac and extracardiac anomalies, aneuploidies and hydrops. Fetuses with liver bypass have an additional risk of developing congestive heart failure that significantly affects outcome, even if the fetal cardiovascular anatomy is otherwise normal. ADV without liver bypass seems to have a more favorable prognosis if it is not associated with other malformations.

The syndrome of right isomerism -- prenatal diagnosis and outcome

OBJECTIVE

To evaluate the accuracy of the prenatal diagnosis of right isomerism and to assess possible diagnostic and prognostic markers.

METHODS

Retrospective review of all cases of right isomerism identified between 1989 and 2003 in two tertiary referral centres in Germany.

RESULTS

Among 21 foetuses, 16 had a correct prenatal diagnosis of right isomerism. 19 showed different types of viscerocardiac heterotaxy, 12 of them in combination with juxtaposition of vena cava inferior and aorta. 20 had cardiac defects, with a high prevalence of atrioventricular septal defect (CAVSD) (62 %), right outflow tract obstruction (48 %), anomalous pulmonary venous return (33 %) and double outlet right ventricle (29 %). 4 out of 6 cases with total anomalous pulmonary venous return were overseen on prenatal ultrasound. Only 6 children survived. The highest loss occurred in the neonatal period. Two out of 6 survivors underwent single ventricle palliation, while another two had a biventricular repair. One child is awaiting mitral valve replacement. The remaining case has no cardiac defect and lives with supraventricular re-entry tachycardia. Only the presence of CAVSD was significantly correlated with non-survival (p < 0.05).

CONCLUSIONS

The prenatal diagnosis of right isomerism remains a difficult task. Important sonographic markers are viscerocardiac heterotaxy, complex cardiac malformations and juxtaposition of vena cava inferior and aorta. Special attention has to be paid to the pattern of pulmonary venous drainage, as it is often misdiagnosed. The mortality in neonates is high, especially in the presence of CAVSD. Survivors suffer from significant morbidity.

Prenatal diagnosis of persistent left superior vena cava and its associated congenital anomalies

OBJECTIVE

To evaluate the associated conditions and the outcome of persistent left superior vena cava (PLSVC) detected in fetal life.

METHODS

This was a retrospective review of all cases of PLSVC detected prenatally between 1998 and 2004 in two tertiary referral centers in Germany. Patient charts, ultrasound video recordings and still frames of all cases were reviewed for associated conditions and outcome.

RESULTS

Eighty-two cases of PLSVC were detected in the study period. Thirty-seven cases (45%) were associated with heterotaxy syndromes, 19 (23%) with isolated cardiac malformations, seven (9%) with aneuploidy, six (7%) with complex malformation syndromes and six (7%) with isolated extracardiac malformations. Seven cases (9%) had no associated condition. Eighty-three percent of the fetuses in this series had associated cardiac malformations; the most frequent cardiac malformations in those with heterotaxy syndromes were complete atrioventricular septal defect (75%) and right outflow tract obstruction (58%). After exclusion of cases with heterotaxy, most congenital heart defects were ventricular septal defects (41%) and coarctation (34%). The outcome of PLSVC was determined solely by the associated conditions. After exclusion of terminated cases, heterotaxy syndromes as well as complete atrioventricular septal defects were associated significantly with perinatal and infant death. In contrast, all cases with isolated PLSVC or associated correctable extracardiac malformations survived and were doing well at the time of writing.

CONCLUSIONS

PLSVC detected in fetal life has to be followed by a meticulous inspection of the fetal anatomy as it is frequently associated with heterotaxy syndromes, other cardiac/non-cardiac malformations and aneuploidy that determine the outcome. Isolated PLSVC is a benign vascular anomaly and may not affect the outcome.

Bulk electronic structure of metals resolved with scanning tunneling microscopy

We demonstrate that bulk band structure can have a strong influence in scanning tunneling microscopy measurements by resolving electronic interference patterns associated with scattering phenomena of bulk states at a metal surface and reconstructing the bulk band topology. Our data reveal that bulk information can be detected because states at the edge of the surface-projected bulk band have a predominant role on the scattering patterns. With the aid of density functional calculations, we associate this effect with an intrinsic increase in the projected density of states of edge states. This enhancement is characteristic of the three-dimensional bulk band curvature, a phenomenon analog to a van Hove singularity.

Fetal echocardiographic evaluation of atrial morphology and the prediction of laterality in cases of heterotaxy syndromes

OBJECTIVE

To evaluate whether abnormal atrial morphology, which is well recognized in autopsy series, is detectable by fetal echocardiographic examination of the four-chamber view, and can therefore be utilized to differentiate left from right isomerism in heterotaxy syndromes.

METHODS

This study was a retrospective review of 30 cases with prenatally diagnosed heterotaxy syndromes. Ultrasound video recordings and still images were reviewed with respect to atrial morphology in the four-chamber view. In 25 cases the morphology of both atria was sufficiently well visualized on the recordings to be evaluated and only these were included in the study.

RESULTS

Two types of atrial morphology were distinguished in our cohort: a sickle-shape with the tip pointing laterally and apically, and a blunt shape resembling the usual atrial appearance in the four-chamber view. Nineteen out of the 25 cases (76%) presented with isomerism of the atria in the four-chamber view. Thirteen had bilateral sickle-shaped atrial morphology, all associated with left isomerism. Six had bilateral blunt-shaped atrial morphology, all associated with right isomerism. The atria of the remaining six cases were not isomeric, the right atrium being sickle-shaped and the left blunt-shaped. Five of the latter cases were associated with left and one with right isomerism.

CONCLUSIONS

The majority of prenatally diagnosed heterotaxy syndromes seem to present with isomeric atrial morphology in the four-chamber view. In these cases a differentiation between left and right isomerism can be based on the two distinct types of atrial morphology. This may further enhance the prenatal differentiation of these syndromes.

Atrioventricular block detected in fetal life: associated anomalies and potential prognostic markers

OBJECTIVES

To assess the spectrum of anomalies associated with fetal heart block and to identify possible prognostic markers.

METHODS

Retrospective review of all cases of second- or third-degree heart block identified in two tertiary referral centers in Germany (Bonn and Lübeck) and one in the USA (Baltimore).

RESULTS

Sixty fetuses with heart block were identified in the study period. Thirty-two had complex cardiac malformations, 31 of them associated with left isomerism. The outcomes of these fetuses were 22 terminations of pregnancy (TOP), three intrauterine fetal deaths (IUFD), three neonatal deaths (NND), two childhood deaths (CD) and there were two survivors. In 20 cases without complex cardiac malformations maternal antinuclear-antibodies were detected. Their outcomes were 2 TOP, 1 IUFD, 1 NND and 16 survived. The remaining eight cases had neither complex cardiac malformations nor associated maternal antibodies. Their outcomes were 1 TOP, 2 IUFD, 2 NND and 3 survived. After exclusion of terminated cases, hydrops as well as the presence of cardiac defects was significantly associated with non-survival (P < 0.01). The cardiothoracic circumference ratio was significantly higher in hydropic fetuses and significantly negatively correlated with survival in immune-mediated cases (P < 0.01). Atrial and ventricular frequencies and their evolution did not accurately predict fetal or neonatal outcome. Sympathomimetic treatment in seven cases was not associated with favorable fetal outcome in cases of hydrops or cardiac malformations.

CONCLUSIONS

The most important marker predicting adverse outcome in cases of heart block is fetal hydrops, followed by the association with complex cardiac malformations. Cases without cardiac malformations have a significantly better prognosis, especially in the absence of severe cardiomegaly.

A new formula for calculating weight in the fetus of < or = 1600 g

OBJECTIVE

To develop and test a new formula for estimating weight in the fetus of < or = 1600 g.

METHODS

A formula for sonographic estimation of fetal weight was produced retrospectively from 84 singleton fetuses with a birth weight of < or = 1600 g, examined sonographically within 1 week before delivery. Exclusion criteria were multiple pregnancy, intrauterine death and major structural or chromosomal anomalies. The new formula was then compared prospectively in an evaluation group of fetuses (n = 87) with six currently available equations for estimating weight in the preterm fetus.

RESULTS

Stepwise regression analysis with gestational age (in days) and fetal biometric parameters was employed to yield the best-fit formula for predicting fetal weight at birth. The new formula (estimated fetal weight = 5381.193 + 150.324 x head circumference + 2.069 x femur length3 + 0.0232 x abdominal circumference3-6235.478 x log(head circumference)) proved to be superior to established equations. The lowest mean +/- SD absolute error was 66.2 +/- 59 g and the lowest mean absolute percentage error was 7.1 +/- 5.9% SD when studied prospectively in the evaluation group. With the new formula, 48.3% of estimates fell within +/-5% of the actual weight at birth, 73.6% fell within +/-10%, 90.8% fell within +/-15% and 95.4% fell within +/-20%.

CONCLUSION

Our new formula is relatively easy to use and needs no adjustment to weight centiles or to fetal lie. It allows reliable weight estimation in the fetus < or = 1600 g.

Targeted first-trimester prenatal diagnosis before fetal reduction in triplet gestations and subsequent outcome

OBJECTIVE

To assess the feasibility of targeted first-trimester ultrasound evaluation in triplet gestations and to report the outcome in reduced and expectantly managed triplets.

METHODS

This was a retrospective analysis of 127 triplets at 11-14 weeks with targeted ultrasound examination including nuchal translucency (NT) screening.

RESULTS

One or more abnormal findings were observed in 33 of 381 fetuses (8.7%), including increased NT (n = 18), malformations (n = 4), aneuploidy (n = 3), relative intrauterine growth restriction (n = 2) or spontaneous demise (n = 13). Of 63 patients (49%) who chose reduction, selective termination due to abnormal findings was performed in 13 fetuses. The rates of complete abortion <24 weeks were 9.8% and 3.2% for those with expectant management and fetal reduction, respectively. Expectantly managed triplets delivered significantly earlier (31.1 +/- 3.8 vs. 35.6 +/- 3.3 weeks) (P < 0.01) with a lower mean birth weight (1483 +/- 552 g vs. 2305 +/- 557 g) (P < 0.01) and a lower number of liveborn fetuses (85.6% vs. 97.4%) (P < 0.01) than those reduced.

CONCLUSION

Targeted first-trimester ultrasound is feasible and reliable in triplet gestations and should be an integral part of the counseling process. It results in more accurate selection for those who consider fetal reduction. Our data further support fetal reduction as a valuable strategy to improve perinatal outcome in triplet pregnancies.

Role of spin in quasiparticle interference

Quasiparticle interference patterns measured by scanning tunneling microscopy can be used to study the local electronic structure of metal surfaces and high-temperature superconductors. Here, we show that even in nonmagnetic systems the spin of the quasiparticles can have a profound effect on the interference patterns. On Bi(110), where the surface state bands are not spin degenerate, the patterns are not related to the dispersion of the electronic states in a simple way. In fact, the features which are expected for the spin-independent situation are absent and the observed interference patterns can be interpreted only by taking spin-conserving scattering events into account.

Congenital chylothorax: lymphopenia and high risk of neonatal infections

AIM

To describe the clinical course of patients with congenital chylothorax focusing on infectious complications. Congenital chylothorax is a common manifestation of non-immune hydrops fetalis (NIHF). The drainage of chyle leads to loss of cellular and plasmatic factors that influence the patient's immune response and increase the risk of infections.

METHODS

In a retrospective analysis of 24 preterm infants with NIHF treated between 1998 and 2002, congenital chylothorax was diagnosed in 7 patients.

RESULTS

All 7 patients were treated conservatively with pleural drainage over a median period of 22 d (range 10-36 d). Lymphopenia was found in all patients (median of minimal lymphocyte counts 285/microl, range 80-770). The nadir was on day 5 (2-6 d). Lymphopenia lasted for 12 d median (range 4-39 d) and was significantly correlated with the duration of lymph drainage (p = 0.001). Cell-surface analysis of peripheral blood lymphocytes was performed in two patients. Both patients had a decreased number of total T cells. Four out of seven (57%) patients developed nosocomial infections. This incidence of nosocomial infections in patients with congenital chylothorax is about three times higher than that in other neonatal patients. None of the children suffered from fungal or viral infection. Although there was a very high incidence of infections, no correlation between lymphopenia and the occurrence of infections could be shown.

CONCLUSION

Drainage of congenital chylothorax results in the loss of lymphocytes and bears a high risk of infections.

Sex-specific fetal weight prediction by ultrasound

OBJECTIVE

To improve sonographic birth-weight prediction by developing fetal gender-specific formulae.

METHODS

This was a retrospective cross-sectional study. Two gender-specific formulae were produced from the data of 527 patients and the data of a further 349 patients were used to evaluate the formulae. Inclusion criteria were a singleton live fetus, gestational age above 25 weeks, birth weight between 1000 g and 4500 g and fetal biometry within 8 days of delivery. Data retrieval was specifically for the purpose of this study.

RESULTS

To yield the best-fit weight formula for each fetal gender we employed step-wise regression analysis based on fractional polynomials with the biometric parameters biparietal diameter (BPD), head circumference (HC), transverse abdominal diameter (TAD), abdominal circumference (AC) and femur length (FL): estimated fetal weight for girls (g) = - 4035.275 + 1.143 x BPD3 + 1159.878 x AC1/2 + 10.079 x FL3 - 81.277 x FL2 [in cm]; estimated fetal weight for boys (g) = 43576.579 + 1913.853 x log10BPD + 0.01323 x HC3 + 55.532 x AC2 - 13602.664 x AC1/2 - 0.721 x AC3 + 2.31 x FL3 [in cm]. These formulae showed superior results compared with those of conventional weight formulae.

CONCLUSION

Gender-related fetal weight calculation allows optimized prediction of fetal weight at birth.

Neurodevelopmental outcome after intrauterine red cell transfusion for parvovirus B19-induced fetal hydrops

OBJECTIVE

To assess long term neurodevelopmental outcome of children after intrauterine intravascular red cell transfusion (JUT) for Parvovirus B19-induced fetal hydrops.

DESIGN

Data of study children were investigated retrospectively. Neurodevelopmental evaluation was performed by appropriate standard tests (Griffiths, Snijders-Oomen, Kaufmann Assessment Battery for Children tests).

SETTING

Tertiary care university teaching hospital.

SAMPLE

Twenty children who had Parvovirus-induced fetal hydrops and intrauterine transfusion of packed red blood cells (IUT).

METHODS

Retrospective chart analysis and standard neurodevelopmental testing.

MAIN OUTCOME MEASURES

Developmental quotient (DQ) and intelligence quotient (IQ) according to the age at testing.

RESULTS

Twenty survivors of Parvovirus B19-induced fetal hydrops successfully treated by IUT were followed until 13 months to nine years of age. On clinical follow up, no neurologic sequelae were evident. Neurodevelopmental scores of all children ranged within two standard deviations of a normal population (median 101, range 86-116) and exceeded one standard deviation in three children. There was no significant neurodevelopmental delay.

CONCLUSION

Children having survived successful IUT for Parvovirus B19-induced fetal anaemia and hydrops have a good neurodevelopmental prognosis. Our results support the use of IUT for correction of Parvovirus B19-induced fetal anaemia and subsequent hydrops.

Venous Doppler velocimetry in the surveillance of severely compromised fetuses

OBJECTIVE

To investigate whether venous Doppler velocimetric signs of cardiac decompensation might predict fetal demise in severely compromised fetuses.

MATERIAL AND METHODS

This was a prospective study involving 154 growth-restricted fetuses, 37 of which were found to have reversed flow in the umbilical artery (BFC III). Doppler velocimetry of the right hepatic vein and ductus venosus were investigated serially and the presence of umbilical venous pulsations also registered. Only the final examination prior to birth or fetal demise was accepted for analysis and related to obstetric outcome defined as gestational age at birth, birth weight and perinatal mortality. In cases of BFC III the venous velocimetry of 15 nonsurviving fetuses was compared to that of the 22 survivors.

RESULTS

There was a significant correlation between venous blood velocity and placental vascular resistance. In the right hepatic vein there was a significant decrease in peak systolic and end-systolic velocities and an increase of maximum velocity during atrial contraction and pulsatility (P < 0.05). A decrease of all velocities and increase of pulsatility were noted in the ductus venosus (P < 0.05). A reversed flow in the ductus venosus was found in 9/37 fetuses and double umbilical venous pulsations in 16/37 fetuses. However, the hepatic vein seemed to be a better predictor of impending mortality than the ductus venosus. Changes in diastolic venous blood velocity and a double pulsation in the umbilical vein were closely related to perinatal mortality, although these parameters did not provide a useful threshold to optimize the timing of delivery.

CONCLUSION

Diastolic venous velocimetry changes significantly in severely compromised fetuses. These changes might be of great clinical value in deciding on the timing of delivery to minimize damage to the fetus and newborn.

[Significance of prenatal diagnosis of lip-jaw-palatal clefts]

AIMS AND PATIENTS: Visualization of sonographic anatomy of the fetal face has acquired special importance, as conspicuous features in the phenotype facilitate the diagnosis of syndrome-like or chromosomally induced clinical conditions. Between 1990 and 1999, an orofacial cleft was diagnosed sonographically in 70 fetuses at the Clinic for Prenatal Diagnosis and Therapy of Bonn University Hospital. The aim of the study was to investigate whether the type of cleft correlates with the prevalence of associated anomalies or with karyotyping after amniocentesis. The types of associated anomalies and the neonatal outcome of these 70 fetuses were also reexamined.

RESULTS

We found a clearly positive correlation with the type of cleft, both for the associated anomalies and for the karyotype. The size of the cleft was much smaller with normal karyotypes than in the case of fetuses with trisomy 18. The trisomy 13 fetuses displayed the most pronounced clefts. None of the fetuses with an isolated lip cleft had an associated anomaly; all were born alive and could be treated surgically. In contrast, all the fetuses with a median cleft had severe associated anomalies that were incompatible with life. Associated anomalies occur more frequently with bilateral cleft lip and palate than with unilateral clefts. The fetuses with a unilateral cleft had a higher survival rate than those with a bilateral cleft. The most common associated anomaly in cleft fetuses is located in the region of the central nervous system.

DISCUSSION

Early sonographic information on cleft formation in combination with the karyotype can give rise to differentiated obstetric measures up to the point of termination of pregnancy in the event of an infaust prognosis.

Fetal cleft lip and palate: sonographic diagnosis, chromosomal abnormalities, associated anomalies and postnatal outcome in 70 fetuses

OBJECTIVE

The aim of this study was to determine the relationship between facial clefts, associated malformations and chromosomal abnormalities.

STUDY DESIGN

Sonograms of 70 fetuses with cleft lip with or without cleft palate were prospectively and retrospectively evaluated in our tertiary referral center for the nature of the cleft lip or palate and for the nature of the associated anomalies. Additionally, karyotyping was performed in 63 of the 70 patients (90%).

RESULTS

The frequency of additional anomalies and the mortality rate in this selected population varied with the type of cleft. None of the fetuses presenting an isolated cleft lip had additional anomalies and all survived. All fetuses presenting a median facial cleft had concurrent anomalies (particularly of the central nervous system (90%)) and a fatal outcome. Associated defects were more frequent in fetuses with bilateral clefts (72%) than in those with unilateral clefts (48%). Fetuses with a unilateral cleft lip with or without cleft palate had a better survival rate (52%) than those with a bilateral cleft lip with or without cleft palate (35%). The frequency and type of chromosomal abnormalities varied with the type of cleft. The highest rate of chromosomal abnormalities was found in fetuses with median clefts (82%).

CONCLUSIONS

Although no conclusions regarding the prevalence of chromosomal or other anomalies in patients with a cleft lip with or without cleft palate in the general population could be drawn, the study revealed a strong relationship between the type of facial cleft, associated malformations, chromosomal abnormalities and fetal outcome.

The role of ovarian volume in an in vitro fertilization programme as assessed by 3D ultrasound

The study was designed to investigate the role of ovarian volume, as assessed by three-dimensional (3D) sonography, in predicting conception in an in-vitro fertilization-embryo transfer (IVF-ET) programme. Transvaginal 3D sonography was performed in 152 cycles before initiation of ovarian stimulation (day 1) and on the day of oocyte retrieval. Ovarian volume showed no significant correlation with IVF outcome. On the contrary, all ovarian measurements were lower, albeit nonsignificantly, in the conception group. Fifteen patients (15/152, 9.9%) had a minimum unilateral ovarian volume of < or =3 mL (1 SD below the mean) on day 1 of the stimulation cycle. In this subgroup, the likelihood of conception was 6.7% (1/15) versus 21.9% (30/137) in patients with an initial minimum ovarian volume of >3 mL. This difference did not reach statistical significance. In both groups, cancellation rates due to poor ovarian response or lack of fertilization were similar. In conclusion, ovarian volumetry as assessed by three-dimensional ultrasound failed to predict conception in women undergoing IVF treatment.

[Intrauterine herpes simplex virus infection]

BACKGROUND

Early fetal herpes simplex virus (HSV) infection is rarely documented. Only the minority of affected fetuses survive this condition.

PATIENT AND METHODS

At 19 weeks of gestation the first episode of a genital HSV-infection of a pregnant woman was treated with local interferon beta. At 34 weeks of gestation hydrocephalus with secondary microcephaly and microphthalmia of both eyes was detected by ultrasonography. In the amniotic fluid HSV type 2 (HSV-2) was isolated and HSV-2-DNA was detected by PCR. The serum of the mother proved positive for HSV-2 (glycoprotein G2)-specific IgG-antibodies. No other infectious causes were apparent on further testing. At 35 + 4 weeks gestation a small-for-gestational-age neonate (2130 g) with microcephaly (29 cm head circumference) was born by spontaneous vaginal delivery. Scarce ulcerative skin lesions and vesicles, hepatosplenomegaly and microphthalmia were diagnosed. Furthermore, encephalomalacia with parenchymal destruction, cataract of both eyes and aplasia of the maculae and papillae were found. HSV-2-PCR was tested positive in chorionic cells and an umbilical segment of the placenta as well as in swabs from both eyes, throat, and a herpetic skin lesion collected during the first 5 days of life. HSV-IgM-antibodies were found in the umbilical cord blood. Local and intravenous treatment with aciclovir was started. The infant exhibited signs of a severely malfunctioning central nervous system. At the age of 4 months the boy suffered from generalised cerebral seizures. He died at the age of 9 months as a consequence of respiratory insufficiency with consecutive circulation failure.

RESULTS

The case of an intrauterine HSV-2-infection is presented. The time of onset of fetal infection was most probably at the time of the maternal disease (19 weeks of gestation). Inspite of the very early infection the fetus did not die in utero.

CONCLUSIONS

Especially, if a primary genital HSV-2-infection of a pregnant woman is suspected, which can be proven by serological means only several weeks after infection, systemic therapy of the mother with aciclovir should be considered since materno-fetal transmission may occur due to the risk of maternal viraemia.

Endometrial receptivity in an in vitro fertilization program as assessed by spiral artery blood flow, endometrial thickness, endometrial volume, and uterine artery blood flow

OBJECTIVE

To investigate the role of sonographic parameters in assessing endometrial receptivity in an in vitro fertilization (IVF) program.

DESIGN

Prospective clinical study.

SETTING

University setting.

PATIENT(S)

One hundred thirty-five patients in our IVF program, selected prospectively on the day of oocyte retrieval.

INTERVENTION(S)

Transvaginal ultrasound examination was performed before oocyte collection.

MAIN OUTCOME MEASURE(S)

Association between implantation rate and spiral artery blood flow (primary outcome measure) and between implantation rate and endometrial measurements as well as uterine artery blood flow (secondary outcome measures).

RESULT(S)

Overall implantation rate was 23.7% per cycle. Subendometrial blood flow was detected in 113 (83.7%) cases, with pregnancy occurring in 21.2%. Mean spiral artery pulsatility index values were 1.12 +/- 0.28 and 1.21 +/- 0.27 for nonconception and conception cycles, respectively. Nondetectable spiral artery blood flow was not associated with a lower implantation rate. Neither endometrial thickness nor endometrial volume was correlated with the likelihood of successful implantation. Minimum endometrial thickness and volume associated with pregnancy were 6.9 mm and 1.59 mL, respectively.

CONCLUSION(S)

Neither Doppler sonography of the spiral or uterine arteries nor measurement of the endometrial thickness or volume allowed a reliable prediction of subsequent IVF outcome.

Fetal weight estimation by three-dimensional ultrasound

OBJECTIVE

To assess the value of three-dimensional volume scanning in predicting fetal weight at birth.

STUDY DESIGN

Prospective cross-sectional study within 7 days of delivery. A total of 190 patients were considered for final analysis (formula-finding group: n = 125, formula evaluation group: n = 65). Inclusion criteria were a singleton pregnancy and absence of chromosomal or significant structural anomalies. Three-dimensional (3D) volumetric measurements of the fetal thigh, upper arm and abdomen were performed together with conventional two-dimensional (2D) biometry.

RESULTS

All measurements were completed successfully in each patient. Polynomial regression analysis with standard biometric parameters and volumes of the upper arm, the thigh and the abdomen was employed to yield the best-fit formula for prediction of fetal weight at birth. The new 3D formula (estimated fetal weight (EFW) = -1478.557 + 7.242 x thigh volume + 13.309 x upper arm volume + 852.998 x log10 abdominal volume + 0.526 x BPD3) proved to be superior to established 2D equations with the lowest mean error (25.8 +/- 194.4 g), the lowest mean absolute error (155.2 +/- 118.2 g) and the lowest mean absolute percentage error (6.1 +/- 5.0%) when studied prospectively in the evaluation group.

CONCLUSION

3D sonography allows superior fetal weight estimation by including soft tissue volume. Further studies at the extremes of fetal weight are needed to confirm the value of our formula in these subsets.

The size of the fetal thoracolumbar spine: a three-dimensional ultrasound study

OBJECTIVE

To evaluate three-dimensional sonographic measurements of the thoracolumbar spine in the 16-37 week fetus.

DESIGN

Prospective cross-sectional study.

SUBJECTS

Two hundred and eighty-nine patients between 16 and 37 weeks of gestation were enrolled at the time of their anomaly scan or routine third trimester scan if fetal size was appropriate for gestational age and if no fetal anomalies were apparent.

METHODS

Three-dimensional (3D) volume calculation of the first and fifth lumbar vertebral body, the 12th thoracic vertebral body and the whole lumbar spine was performed in the transverse plane of the multiplanar mode while lumbar spine length was determined in the sagittal plane.

RESULTS

All volumetric measurements were significantly correlated with gestational age and estimated fetal weight. For each examined parameter regression analysis was performed to describe the 'best-fit' equation.

CONCLUSIONS

3D sonography allows volume calculation of the fetal spine. Our study provides further data relating to volume changes in the developing fetal spine between 16 and 37 weeks of gestation.

Congenital intrapulmonary bronchogenic cyst in the neonate--perinatal management

Approximately 50% of all congenital lung malformations are pulmonary and mediastinal bronchogenic cysts (BC). Therefore, their diagnosis and management is of clinical importance. Usually asymptomatic in the first months of life, bronchogenic cysts are frequently clinically inapparent even adulthood. Early diagnosis and elective surgery can prevent late complications such as pneumothorax, pulmonary hypertension, and recurrent infections; prognosis after surgery is excellent. If mediastinal shifting is present, fetal thoracocentesis is indicated to prevent cardiovascular insufficiency. We report a case of a prenatally diagnosed intrapulmonary BC of the right lung. Following in utero thoracocentesis of the cyst and transient spontaneous regression postnatal onset of severe clinical symptoms due to rapidly developing hyperinflation and mediastinal shifting within the first days of life required early surgical intervention.

Parvovirus B19 infection in pregnancy

Transplacental transmission of human parvovirus B19 (B19 virus) to the fetus is an important cause of intrauterine death, abortion, stillbirth, and nonimmune hydrops fetalis. Adverse outcome of pregnancy can occur after symptomatic and asymptomatic maternal infection. Only rare cases of congenital malformations and fetal disease in live-born infants have been associated with intrauterine B19 virus infection. Laboratory results obtained from paired maternal and fetal cord blood samples indicate that a reliable diagnosis of fetal B19 virus infection should be based on detection of parvovirus B19 DNA.

Diagnosis of a fetal mesoblastic nephroma by 3D-ultrasound

We report a case of a fetal renal tumor detected prenatally on 3D-ultrasound. As the lesion was well encapsulated the initial sonographic diagnosis was that of a nephroblastoma. Volume calculation by the 3D technique gave a reliable estimation of the tumor size. Contrary to all published case reports concerning antenatally diagnosed mesoblastic nephromas, there was no polyhydramnios. Elective delivery was performed by Cesarean section at 38+ weeks gestation. The neonate underwent left nephrectomy on the second day of life. The subsequent course was uneventful without recurrence of the tumor.

Maternal and fetal hepatitis C virus exposure by intrauterine transfusion

We report a case of accidental exposure to hepatitis C virus by an intrauterine transfusion that resulted in infection of the mother but not the child.

Prenatal diagnosis of abnormalities of the fetal venous system

OBJECTIVE

To present our experience in the prenatal diagnosis of anomalies of fetal veins using high-resolution color Doppler ultrasound.

DESIGN

An observational study of 16 fetuses with abnormalities of the umbilical, portal, hepatic and caval venous system being diagnosed at the Division of Prenatal Diagnosis and Therapy (Bonn, Germany) over the past 5 years. The abnormality of the venous system, the underlying embryologic disorder and the outcome of the pregnancy are presented and compared with the literature.

RESULTS

In group A, eight fetuses had an abnormal course of the umbilical vein with a patent (n = 3) or absent (n = 5) ductus venosus. No portal veins and absent or abnormal hepatic veins were visualized by color Doppler sonography. Six fetuses (75%) did not have an associated malformation and have survived. Two pregnancies with fetal hydrops due to a small heart and to Turner's syndrome were terminated or ended in fetal demise. In group B, seven of eight fetuses with an abnormal caval system had a situs ambiguus or an atrial isomerism. A cardiac defect was detected in six cases (86%). These six pregnancies ended in four terminations of pregnancy and two infant deaths due to the severity of the congenital cardiac defect. One child with a normal heart and a child with an isolated abnormal course of the lower inferior vena cava are developing well.

CONCLUSIONS

In a targeted fetal scan the course of the umbilical vein, ductus venosus, the portal and hepatic veins and inferior vena cava should be carefully examined using color Doppler. Any suspicious finding should be followed by a detailed assessment of the specificity of this abnormality taking into consideration the embryologic development of the fetal venous system together with the associated malformations.

Quantitative assessment of subendometrial blood flow by three-dimensional-ultrasound is an important predictive factor of implantation in an in-vitro fertilization programme

This study was designed to investigate the role of three-dimensional (3D) power Doppler sonography of the (sub-) endometrial area on the first day of ovarian stimulation in predicting the outcome of an in-vitro fertilization (IVF) programme. Among the 75 cycles analysed, the overall pregnancy rate was 20% (15/75) per cycle and 23.8% (15/63) per embryo transfer. Intra-observer variability of the colour histogram was checked in 14 patients with the results demonstrating a high level of agreement. Neither endometrial measurements nor uterine blood flow were correlated with the pregnancy rate. In contrast, all 3D indices were significantly lower in conception compared with non-conception cycles (P < 0.05). Logistic regression analysis found the subendometrial flow index to be the strongest predictive factor of IVF success among the tested sonographic parameters (P = 0.04). In conclusion, quantitative assessment of spiral artery blood flow may be of predictive value for implantation in IVF cycles even before ovarian stimulation therapy is started.

Analysis of a de novo complex chromosome rearrangement involving chromosomes 4, 11, 12 and 13 and eight breakpoints by conventional cytogenetic, fluorescence in situ hybridization and spectral karyotyping

A complex chromosome rearrangement (CCR) with eight breakpoints resulting in four derivative chromosomes (4, 11, 12 and 13) was detected prenatally in a male fetus of a twin pregnancy. The karyotype of the female second fetus was normal. The apparently balanced de novo CCR was identified by classical cytogenetic methods and fluorescence in situ hybridization (FISH). We compared these findings with results from spectral karyotyping (SKY).

Prenatal diagnosis of congenital parvovirus B19 infection: value of serological and PCR techniques in maternal and fetal serum

Intrauterine infection with parvovirus B19 (B19) is associated with non-immune hydrops fetalis, miscarriage and stillbirth. Accurate laboratory tests for diagnosis of B19 infection are required to exclude other diagnoses. We analysed the diagnostic value of B19 IgM antibody testing and polymerase chain reaction (PCR) in the sera from 57 patients and their fetuses with abnormal ultrasonography. Viral DNA was found in 16 of the 58 fetuses (one twin pregnancy) whereas only 7 of these were tested positive for B19 IgM antibodies. The sera of all 16 mothers were also positive for B19 DNA. False-positive B19 IgM results were obtained from two fetuses. The study highlights the limitations of B19 IgM serology and shows for the first time that, if a sensitive PCR assay is used, DNA measurement is the best indicator of infection not only in the fetal blood but also in the maternal blood. This improves the diagnostic value of the laboratory results considerably. DNA assays are essential in cases of doubtful serological results.

First-trimester fetal heart block: a marker for cardiac anomaly

BACKGROUND

Fetal heart block in the second and third trimesters may be caused by transplacental passage of auto-antibodies or cardiac defects. Little is known about the etiology of first-trimester fetal heart block.

MATERIALS AND METHODS

Fetal heart block was diagnosed in four patients (negative antibody serology) referred for first-trimester sonographic evaluation of increased fetal nuchal fold thickness with bradycardia. Two-dimensional echocardiography was complemented by color Doppler flow imaging of the fetal heart. Fetal arrhythmia was verified by M-mode, pulsed wave Doppler and/or color M-mode echocardiography.

RESULTS

All fetuses had congenital heart disease, atrioventricular valve regurgitation, heart block and edema. Autopsy confirmed heterotaxy in three cases (left atrial isomerism with atrial septal defect; left isomerism with double-outlet right ventricle, great artery malposition and ventricular septal defect. The third case had dextrocardia with atrioventricular canal defect and the fourth case dextrocardia with great artery transposition.

CONCLUSION

First-trimester fetal bradycardia may result from heart block of the type associated with complex congenital heart disease. Accelerated edema formation in this setting may be the basis of nuchal edema formation. First-trimester fetal echocardiography offers the potential for early diagnosis and intervention in these cases with poor prognosis.

Perinatal hypophosphatasia: diagnosis and detection of heterozygote carriers within the family

We report on two families in which one or two children had a severe disorder of skeletal development detected by prenatal ultrasonography. The children died postnatally and showed typical radiological and biochemical findings of perinatal hypophosphatasia. Biochemical analysis revealed a low activity of alkaline phosphatase (AP) and a high value of pyridoxal-5-phosphate (PLP), one of its natural substrates. The screening for mutations of the tissue nonspecific alkaline phosphatase (TNSALP) gene showed homozygosity for a point mutation (G 317 --> D) in the two affected children of the first family. The affected child of the second family was homozygous for a nonsense mutation (R 411 --> X). Family screening revealed that the determination of AP and PLP is helpful for detection of heterozygotes. However, heterozygote children had values of AP in the lower normal range during phases of rapid growth. The determination of PLP proved to be more sensitive in these cases. It should be kept in mind that during the last trimester of gestation there is an increase in maternal AP activity and a normalization of PLP due to placental AP, which is not affected. Therefore, in the course of a prenatal diagnosis in an index case, paternal blood should be analyzed in parallel. For detailed genetic counseling and early prenatal diagnosis in following pregnancies, the possibility of mutation analysis should be used.