Abstract LB-B25: Preliminary phase I data comparing HuMab-5B1 (MVT-5873), a monoclonal antibody targeting sLea, as a single agent and in combination with first line nab-paclitaxel and gemcitabine in patients with CA19-9 positive pancreatic cancer

IntroductionMVT-5873, a fully human IgG1 monoclonal antibody (mAb), targets sialyl Lewis A (sLea), an epitope on CA19-9. CA19-9 is expressed in pancreatic (PDAC) and other GI cancers, plays a role in tumor adhesion and metastasis, and is a marker of an aggressive tumor phenotype. MVT-5873 is active as a single agent and in combination with nab-paclitaxel (nab-P) and gemcitabine (gem) in murine xenografts. MethodsSingle agent: for each 28-day treatment cycle, MVT-5873 was given IV every second week (Group 1) or weekly (Group 2) at doses ranging from 1 to 3 mg/kg. Combination with nab-P and gem: for each 28-day treatment cycle MVT-5873 was administered IV weekly (1.0mg/kg or 0.125mg/kg) followed by IV infusion of 125 mg/m2 of nab-P and then 1000mg/m2 gem, on day 1, 8 and 15 (Group 3). Eligible patients had recurrent progressive (single agent) or newly diagnosed (combination), locally-advanced or metastatic PDAC or other CA19-9+ malignancy and ECOG PS ≤1. Dose escalation followed a standard 3+3 design with a 10 patient expansion at the maximally tolerated dose (MTD). Trial endpoints include safety, MTD, dose limiting toxicities (DLT), pharmacokinetics (PK) and efficacy. Exploratory endpoints include changes in serum CA19-9 levels.ResultsAs of 7-September-2017, data are available for single agent N=32 in Groups 1 (N=9) and 2 (N=23) at 1, 2, 2.5 and 3 mg/kg and combination Group 3 (N=6) at 1.0 and 0.125mg/kg. DLTs of transient grade 3 elevations in AST, ALT, and total bilirubin were encountered in the single agent groups at 2, 2.5 and 3mg/kg in both single agent groups and in the combination group at 1mg/kg. Single agent liver function laboratory abnormalities typically emerged and resolved within a week of dosing although they were more persistent in the combination treated patients. Other toxicities associated with all groups included low grade GI toxicity (abdominal pain/cramps/diarrhea/nausea) and infusion reactions. Infusion reactions were mitigated with pre-medications and an increase in the infusion time. Combination DLTs for MVT-5873 at 1mg/kg included AST, ALT, and bilirubin elevations as well as neutropenia and pneumonitis resulted in significant dose de-escalation. MVT-5873 dosed at 0.125 mg/kg in combination was generally well tolerated. Single agent activity included SD of >4 months in 5 of 32 of patients with an MTD established at 1 mg/kg. Combination activity at 0.125 mg/kg MVT-5873 with nab-P/gem included 2 PRs and 1 SD in 3 patients. Interestingly, sustained suppression below ULN of CA19-9 levels was observed in 3 of the 6 patients in the combination arm and >95% CA19-9 reduction at the 0.125mg/kg combination dose. Dose escalation in this arm is in progress, and updated safety, PK/PD, and efficacy data will be presented.ConclusionsSingle agent MVT-5873 appears safe and tolerable at biologically active doses. DLTs included reversible liver function abnormalities. Determination of the MTD in combination with first line nab-P/gem is underway and preliminary response data are encouraging. Overall, the safety profile, efficacy, and reductions in serum CA19-9 levels over time support further development of MVT-5873 in this indication both as a single agent and in combination.

Citation Format: Eileen Mary O'Reilly, Judy Sing-Zan Wang, Kenneth H. Yu, Maeve Aine Lowery, Anna M. Varghese, Johanna C. Bendell, Erkut Hasan Borazanci, Hayley Estrella, Kimberly Fowler, Mariella Hoskins, Stephanie Bussen, Teresa J. Melink, Christine M. Kearns, H Toni Jun, Paul W. Maffuid, John C. Gutheil, Todd Michael Bauer. Preliminary phase I data comparing HuMab-5B1 (MVT-5873), a monoclonal antibody targeting sLea, as a single agent and in combination with first line nab-paclitaxel and gemcitabine in patients with CA19-9 positive pancreatic cancer [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2017 Oct 26-30; Philadelphia, PA. Philadelphia (PA): AACR; Mol Cancer Ther 2018;17(1 Suppl):Abstract nr LB-B25.

Comparison of Conservative and Surgical Therapy Concepts for Synechia of the Labia in Pre-Pubertal Girls

Introduction: The aim of this study was to evaluate the primary and secondary therapeutic successes of different therapy schemes for the treatment of synechia of the labia in pre-pubertal girls. Materials and Methods: The treatment courses of 47 pre-pubertal girls who were treated between February 2007 and February 2013 in the special outpatient clinic for paediatric gynaecology of a department for gynaecology at a German university hospital and for whom information on the course of the disease was available for at least the six months following end of the treatment. 23 of these children were treated with a topical estriol therapy (treatment group A). For 24 of the girls a manual separation of the adhering labia minora was undertaken (treatment group B). Statistical evaluation was performed using the χ² test, Fischer's exact test and the Mann-Whitney U test. Results: For 18 of the 23 (80 %) girls in treatment group A topical estriol therapy alone led to a resolution of the synechia. Five of these 23 children (20 %) required a secondary manual separation. All girls for whom treatment was not successful were under 5 years of age. For all 24 girls (100 %) of treatment group B the primary manual separation was performed with success. The recurrence rates after ≥ 6 months in cases with identical after-care did not differ between the two treatment groups (treatment group A: 34 %, treatment group B: 33 %, χ² test: p = 0.853). 16 of the 17 recurrences occurred ≥ 3 months after the end of the therapy. Conclusion: Our results show that for children < 5 years of age a 4-week topical therapy with estriol is a promising therapy option for synechia of the labia that is less of a burden for the family situation. Especially for girls ≥ 5 years of age, primary therapy fails in up to 20 % of the cases. Primary manual separation represents a more effective therapeutic option. Irrespective of the treatment applied, a recurrence after ≥ 3 must be expected in one-third of the treated girls.

Anogenital Warts in Childhood - Always a Marker for Sexual Abuse?

Human papilloma viruses (HPV) are common pathogens associated with a wide range of cutaneous and mucosal infections in childhood. Different HPV types can cause common warts and anogenital warts. Condylomata acuminata in children may be, but are not necessarily, an indicator of sexual abuse. Each individual case therefore requires careful examination, with consideration of other possible means of transmission. Diagnosis of anogenital warts is generally by means of clinical examination. Additional histological, serological or molecular genetic investigation may be indicated occasionally. The high rate of spontaneous remission and the rate of recurrence after treatment should be considered. The available topical and surgical treatment options are discussed.

[Health-related quality of life after surgical haemorrhoid treatment - results, methods and problems]

In patients suffering from haemorrhoidal disease a hyperplasia of the corpus cavernosum recti is accompanied by various symptoms such as anal bleeding and minor continence disorders as well as itching, soiling and burning. According to the morphological findings, haemorrhoids are staged from grade I up to IV. Therapy strategies are adjusted to this staging. Early stages are treated by conservative measures, such as regulation of defaecation, sclerosis and rubber band ligations. Advanced stages require operative methods, such as segmental excision and stapled haemorrhoidopexy. Since patients demand a greater regard to the subjective experience of their disease and its treatment, quality of life evaluation has become an important issue in medical care. Therefore health-related quality of life is increasingly becoming a relevant primary or secondary end point of clinical studies. Since up to 4 % of the general adult population in industrial nations is annually diagnosed to suffer from haemorrhoidal disease, in Germany per annum 3.5 Mio patients seek medical advice due to this condition and 40 000-50 000 surgical procedures are performed. Nevertheless only very few studies have been carried out to investigate the influence of this widespread disease on the quality of life of those patients. Additionally cost-effectiveness analyses measuring quality-adjusted life years are becoming more and more decisive in health politics. The present article discusses the definitions of health-related as well as disease-related quality of life. Different psychometric tests applied to evaluate the quality of life are summarised, quality criteria are outlined and limitations discussed. Several studies were analysed in regard to the quality of life in patients with haemorrhoidal disease and the specific influence of different operative techniques was reviewed.

[Constipation--established and new diagnostic approaches]

The aim of this paper is to review diagnostic techniques which are useful and applicable in the evaluation of constipation. Besides widely-spread available techniques such as taking a specific and structured history and performing a clinical examination sophisticated diagnostic tools such as colon transit time, anal manometry, defecography endorectal ultrasonography as well as electrophysiological investigations such as anal sphincter electromyography and pudendal nerve terminal motor latency measurement are illustrated.

Ausgedehnte perineale Hernie bei Zustand nach wiederholter operativer Therapie eines Vaginalprolapses

The presented case reports the treatment of a 80-year-old V gravida IV para suffering from a large perineal hernia and rectocele after vaginal hysterectomy and subsequently performed threefold colpocleisis due to recurrent vault vaginal prolaps.[nl]Since perioperative morbidity and mortality of geriatric patients differ not significantly from thoses of younger women age should not be used as an argument to withhold elderly organ preserving operative strategies with low recurrence rates.

[Reversible loss of vision in severe preeclampsia: case report and review of the literature]

Visual disturbances occur in up to 25 % of the patients with preeclampsia. However, blindness remains a rare phenomenon. A 39 year old primigravida was admitted for observation at 30 weeks gestation with signs of preeclampsia. After 11 days she suffered a complete loss of vision. The blindness reversed completely after cesarean section and antihypertensive treatment. Blindness in preeclamptic patients is mostly caused by hypertensive encephalopathy. We discuss pathophysiological aspects as well as diagnostic approaches and therapeutic options with respect to the available literature.

[Plasma VEGF levels are increased in women with severe preeclampsia or HELLP syndrome]

AIM

To investigate vascular endothelial growth factor (VEGF) serum levels in severe preeclampsia (PE) and HELLP syndrome.

PATIENTS AND METHODS

Serum concentrations of VEGF, progesterone, estradiol and estriol were measured in 16 patients with PE and 14 patients with HELLP syndrome and in 30 well-matched normotensive pregnant controls. Determination of VEGF was performed by a commercially available immunoassay (Quantikine(R), R&D Systeme, Wiesbaden), those of sex steroids by a radioimmunoassay (Fa. Biermann, Bad Nauheim).

RESULTS

Serum VEGF levels were significantly higher in the study than in the control group (172.0 +/- 98.9 pg/ml versus 41.4 +/- 30.5 pg/ml, U-Test: p < 0.001). In patients with HELLP syndrome mean serum VEGF concentrations were increased when compared with healthy controls but serum levels were significantly lower than in patients with PE (109.2 +/- 68.5 pg/ml versus 219.0 +/- 72.9, U-Test: p < 0.05). We could demonstrate a positive correlation between VEGF and estradiol serum concentrations in the study and control patients (Spearman rang correlation: p < 0.05).

CONCLUSIONS

It is concluded that patients suffering from PE or HELLP syndrome have either an increased placental expression of VEGF as a result of hypoxia or show an increased extraplacental production of this growth factor such as in maternal or fetal endothelial cells, macrophages or smooth muscle tissue.

[Genital findings in sexually abused prepubertal girls]

Genital findings in sexually abused prepubertal girls. Childhood sexual abuse is defined as the involvement of dependent, developmentally immature children and adolescents in sexual activities that they do not fully comprehend, to which they are unable to give informed consent or that violate the social taboos of family roles. Essential to the diagnosis of sexual abuse is an awareness of the problem and acknowledgement of its manifestations. The evaluation of the sexually abused girl usually is performed in a pediatric and adolescent gynecology outpatient department. Thus, the gynecologist will be part of a multidisciplinary approach to the problem and will need to be competent in the basic skills of history taking, physical examination, selection of laboratory tests und differential diagnosis. Findings secondary to sexual abuse are often subtle. Acute tears or bruisings are rare, because force is seldom part of sexual acts committed against a child. A vaginal opening of greater than 5 mm is not common and may indicate vaginal penetration. An intact hymen not necessarily exclude vaginal intercourse. Lack of physical evidence never rules out abuse because sexual acts may leave no physical findings.

Increased prevalence of thyroid antibodies in euthyroid women with a history of recurrent in-vitro fertilization failure

This study was undertaken to evaluate whether the presence of thyroid antibodies in euthyroid women is associated with an adverse outcome in an in-vitro fertilization (IVF)-embryo transfer programme. In 24 women (study group: mean age +/- SD: 31.5 +/- 4.4 years) who failed to conceive after having three or more cycles of IVF and embryo transfer, serum concentrations of thyroglobulin (TG), thyroid peroxidase antibodies (TPO) and anticardiolipin antibodies (IgG and IgM) were measured using commercially available kits. The control group comprised 24 consecutive patients without endocrine dysfunction (mean age +/- SD: 30.3 +/- 4.1 years) seeking infertility treatment in our department of assisted reproduction. All patients in both the study and the control groups were determined to be euthyroid by demonstrating normal concentrations of thyroid-stimulating hormone (TSH). In the study and control groups respectively, 13 and two patients demonstrated positive titres of TG, TPO or both thyroid antibodies (Fisher's exact test: P = 0.002). Mean serum concentrations of TG were significantly increased in the study group compared to the control subjects (156 +/- 167 IU/ml versus 33.5 +/- 32.0 IU/ml; U-test: P = 0.009). Serum concentrations of TPO and anticardiolipin antibodies were similar in both groups. Our investigations revealed that thyroid antibodies might be independent markers for reproductive failure in an IVF-embryo transfer programme.

[Hyaluronan and CD44 in maternal serum in pre-eclampsia]

BACKGROUND

Pre-eclampsia is associated with serum factors which can activate blood vessel endothelial cells. Hyaluronan (HYA) and its specific receptor CD44 play a central role in cell activation processes. Our study focussed on the behavior of serum concentrations of HYA and the soluble standard form of CD44 (sCD44std) in the maternal serum from normotensive and pre-eclamptic pregnancies.

PATIENTS AND METHODS

Serum was collected from normotensive pregnant women (n = 10) and from pregnant women with a severe pre-eclampsia (n = 10). HYA-serum concentrations were measured with a radioimmunoassay while sCD44std were measured with an ELISA.

RESULTS

The pre-eclampsia group shows a significant (p < 0.001, Mann and Whitney u-test) increased HYA serum concentration (median 79 ng/ml, range 53-165 ng/ml) when compared to the normotensive group (n = 10, median 32 ng/ml, range 19-59 ng/ml). sCD44std-serumconcentration in the pre-eclampsia group (328.3 +/- 68.3 ng/ml) was weakly higher but not statistically significant (p > 0.05) when compared to the normotensive group (292.9 +/- 74.0 ng/ml). There exist no correlations between the HYA and sCD44std serum concentrations in both pre-eclamptic and normotensive groups.

CONCLUSION

The increased HYA-serumconcentration may indicate a pathophysiological role of the HYA/CD44-signal transduction system in pre-eclampsia. The existing overlap of HYA serum levels in the pre-eclampsia group with HYA serum levels in the normotensive control group limits the diagnostic precision of HYA serum concentration as a diagnostic parameter in pre-eclampsia. According CD44 it is not excluded that serum concentration of other soluble CD44-isoforms is increased in pre-eclampsia.

Interval of 9 h between birth of twins at term: case report and review of the literature

We report the case of a primipara who delivered healthy twins vaginally at term with a time interval between twins of 9 h and 19 min. Neonatal outcome and further development were normal in both twins.

Predictive value of CEA and CA 15-3 in the follow up of invasive breast cancer

BACKGROUND

The clinical usefulness of tumor markers in the follow-up care of invasive breast cancer is controversial.

METHODS

In 1228 serum samples of 664 women with history of breast cancer, the diagnostic accuracy and predictive power of CEA and CA 15-3 for the detection of disease relapse was determined prospectively by analyzing the clinical course for at least 6 months after the measurement of the tumor markers in 1994.

RESULTS

A total of 76 patients relapsed during the period of study. The diagnostic accuracy was 83% for CEA and 88% for CA 15-3. CEA and CA 15-3 had a positive predictive value of 27% and 47% as well as a negative prediction of 91% and 93%, respectively.

CONCLUSIONS

The low positive predictive value and sensitivity of these tumor markers clearly limit their clinical utility. Therefore, the effectiveness of routine determinations during the follow-up seems questionable.

Plasma endothelin and big endothelin levels in women with severe preeclampsia or HELLP-syndrome

OBJECTIVE

To compare maternal and umbilical venous big endothelin (big ET) and endothelin-1 (ET-1) levels of pregnancies complicated by severe preeclampsia (PE) or HELLP-syndrome to those of a well-matched normotensive pregnant control group.

METHODS

We measured plasma levels of ET-1 and big ET in 16 patients with severe PE and 14 patients with HELLP-syndrome by commercially available RIAs and compared them with those of well-matched normotensive pregnant controls. Additionally, the umbilical venous ET-1 and big ET levels were determined in 10 corresponding newborns.

RESULTS

The plasma concentrations of ET-1 and big ET were significantly higher in patients with severe PE and especially in women with HELLP-syndrome when-compared with controls. The molar ratios of big ET to ET-1 were significantly lower in the two study groups. The levels of ET-1 and big ET were higher in umbilical venous plasma than in maternal plasma, but there were no significant differences in the umbilical venous concentrations between normotensive and by severe PE or HELLP-syndrome complicated pregnancies.

CONCLUSIONS

These findings suggest that ET-1 may be considered as a marker of endothelial injury in by severe preeclampsia or HELLP-syndrome complicated pregnancies. The increase of the ET-1 plasma levels may be due, at least in part, to changes in the conversion of big ET to ET-1 by the endothelin-converting enzyme.

Endocrine abnormalities during the follicular phase in women with recurrent spontaneous abortion

The frequency of endocrine abnormalities during the follicular phase in non-pregnant women with a history of recurrent abortion was investigated in a case-control study. A total of 42 consecutive women with recurrent spontaneous abortion (three or more consecutive abortions, mean +/- SD: 3.9 +/- 1.1 range 3-8) with no parental chromosome rearrangement or uterine abnormality were studied during the early follicular phase under standardized conditions. Serum concentrations of follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, androstenedione, testosterone, dehydroepiandro-stenedione, 17-OH-progesterone, oestradiol, progesterone and thyroid stimulating hormone (TSH) were measured by commercially available radioimmunoassays. Controls were 42 nulligravid females with tubal or male factor infertility without miscarriage. Mean (SD) concentrations of prolactin and androstenedione were 14.2 +/- 6.7 ng/ml versus 10.5 +/- 3.5 ng/ml (95% CI 0.8-6.1) and 2.3 +/- 0.9 ng/ml versus 1.7 +/- 0.6 ng/ml (95% CI 0.2-0.9) in the study and control groups respectively. The other endocrine parameters were comparable in both groups. Obesity [BMI weight (kg)/height (m2) > or = 25] was more prevalent (23 versus 5 women, P = 0.0001) in the study than the control group. Recurrent spontaneous abortion is associated with abnormalities in prolactin and androgen secretion during the follicular phase, suggesting an endocrine aetiology in this disorder. Reduction of body weight and correction of hyperprolactinaemia and of hyperandrogenism may reduce the rate of miscarriage in a subsequent pregnancy in these women.

Prophylactic intravenous hydroxyethyle starch solution prevents moderate-severe ovarian hyperstimulation in in-vitro fertilization patients: a prospective, randomized, double-blind and placebo-controlled study

A prospective, randomized, double-blind and placebo-controlled study was conducted to assess the effectiveness of i.v. administration of 6% hydroxyethyle starch solution (HES) in preventing moderate and severe ovarian hyperstimulation syndrome (OHSS) in patients in an in-vitro fertilization programme. A total of 101 women who had serum oestradiol concentrations >1500 pg/ml and/or more than 10 follicles on day of human chorionic gonadotrophin (HCG) administration were recruited into two groups: HES group (n = 51) received 1000 ml 6% HES; and the placebo group (n = 50) received 1000 ml of sodium chloride 0.9% solution at the time shortly after embryo transfer. Follow-up examinations 7 +/- 1 and 14 +/- 1 days after embryo transfer included transvaginal ultrasound (diameters of each ovary and maximum cysts, number of cysts, ascites), blood tests (serum oestradiol, progesterone, beta-HCG, C-reactive protein, blood count, plasma proteins, electrolytes, kidney function tests) and evaluation of abdominal pain, nausea, diarrhoea, abdominal swelling and weight gain. Only one moderate OHSS developed in the HES group whereas seven moderate-severe cases were observed in the placebo group (P = 0.031). Furthermore, serum oestradiol concentration, leukocyte count, increase in abdominal circumference and weight gain 14 days after embryo transfer were significantly higher in the placebo group. There were no differences between the two groups in terms of age, oestradiol concentration and number of follicles at time of HCG injection. Administration of 6% HES prevents the development of moderate-severe OHSS in risk patients.

Significant decrease of maternal serum serotonin levels in singleton pregnancies complicated by the HELLP syndrome

The purpose of this study was to compare peripartum maternal and umbilical cord serum serotonin levels in singleton pregnancies complicated by the HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) or by severe preeclampsia with those of appropriate controls. The study population comprised 14 primigravidae women with class 1 or 2 HELLP syndrome (platelet count < 50,000 or < 100,000/mm3, elevated transaminase levels, evidence of hemolysis) and 17 women with severe preeclampsia (American College of Obstetricians and Gynecologists criteria). Serotonin was measured in maternal serum immediately before delivery and in umbilical cord serum by a highly sensitive 125I-radioimmunoassay. The control groups comprised 31 women who had uncomplicated deliveries at term (control group I) and another 31 at the gestational age matched to that of each patient (control group II). Maternal serum serotonin concentration was 59.5 +/- 36.1 ng/ml (mean +/- SD) in the HELLP group, versus 94.9 +/- 40.5 ng/ml in control group I (p = 0.043, U-test) and 88.7 +/- 29.4 ng/ml in control group II (p = 0.048). Levels in the preeclampsia group (51.6 +/- 32.2 ng/ml) were not different from those in the HELLP group but were equally decreased when compared to control groups I (p = 0.009) and II (p = 0.003). We have observed a similar depression of serum serotonin concentrations both in severe preeclampsia and in the HELLP syndrome, reflecting the decreased platelet content of serotonin. It is uncertain whether these changes may be causally involved in the pathogenesis of hypertensive disorders of pregnancy. Decreased serum serotonin concentration may serve as an additional marker for platelet activation in preeclampsia and in the HELLP syndrome.

Relationship of bacteriological characteristics to semen indices and its influence on fertilization and pregnancy rates after IVF

BACKGROUND

To determine if routine semen culture is useful in asymptomatic couples joining an in-vitro fertilization (IVF/ET) program.

METHODS

Bacterial cultures and semen analysis according to WHO recommendations were performed on semen samples obtained before oocyte recovery from 88 asymptomatic couples undergoing IVF during a 7-month period.

RESULTS

In 46 cultures at least one kind of microorganisms could be isolated. Forty-two cultures either contained bacterias regarded as normal skin flora (n = 14) or showed no growth of microorganisms (n = 28). No differences were found in sperm concentration, total sperm count and sperm morphology between the semen samples with positive bacteriology and those with negative culture results. Sperm motility was decreased before Percoll preparation if microorganisms were present. Positive culture results had no effect on either fertilization or pregnancy rates.

CONCLUSIONS

These observations suggest that bacteriospermia is not associated with abnormal sperm function after Percoll preparation or adverse IVF outcome.

Dizygotic twin pregnancy after intracytoplasmic sperm injection of 1 day old unfertilized oocytes

We report on a case where late intracytoplasmic sperm injection (ICSI) on unfertilized oocytes after standard in-vitro fertilization (IVF) cycles resulted in a dizygotic twin pregnancy. Fifteen oocytes were harvested from a patient with a history of salpingotomy. After a single cycle of IVF, only one oocyte showed two pronuclei. Subsequently ICSI was performed on six unfertilized metaphase II oocytes, and three of these oocytes showed two pronuclei. Three fertilized embryos were transferred (two derived from ICSI and one from IVF). A normal twin pregnancy resulted, and after delivery of two healthy boys the twins were confirmed to be dizygotic by DNA analysis of several loci. We conclude that at least one of the embryos was derived from the reinsemination by 'second day ICSI'.

Serum levels of folate and cobalamin in women with recurrent spontaneous abortion

We evaluated the folate and cobalamin status in 29 non-pregnant women with a history of recurrent spontaneous abortion (three or more consecutive) of unknown aetiology in comparison to 29 healthy nulligravidae of similar reproductive age (controls). Serum concentrations of folate and cobalamin showed no significant differences between the two groups. No correlation between age and vitamin concentrations was found. In the study group there was a significant negative correlation of the number of previous abortions and the concentration of serum folate. Patients with at least four previous miscarriages had significantly lower serum values of folic acid than women with three abortions, but not than controls. The underlying cause of this finding remains unclear. In conclusion, the serum concentrations of folic acid and vitamin B12 are not significantly altered in women with unexplained recurrent spontaneous abortions, and an association between a deficiency of these vitamins and an increased risk of pregnancy loss appears to be questionable in the majority of gestations.

[Clinical aspects and therapy of amniotic fluid embolism. Illustration based on a case report]

A case of amniotic fluid embolism during the delivery of an at term pregnancy is reported. The 34-year old primipara with an unremarkable medical history suddenly suffered from a seizure in the second stage of labor. Shortly prior to this event, a prolonged fetal bradycardia was recorded. After forceps delivery a massive postpartum haemorrhage as the result of a consumption coagulopathy occurred. Immediate resuscitation with artificial ventilation improved the condition of mother and child. The substitution of packed red cells and platelets, fresh frozen plasma and other blood derivates was necessary. Mother and child survived without any physical damage or neurological deficit. Because of the clinical pattern we diagnosed an amniotic fluid embolism.

Prolactin response to metoclopramide and thyrotropin-releasing hormone in normoprolactinemic and hyperprolactinemic women: a comparison of diagnostic validity

The objective was to define the diagnostic validity of prolactin response tests by comparing the stimulating effect of thyrotropin-releasing hormone (TRH) and metoclopramide on prolactin secretion in patients with and without functional hyperprolactinemia. Prolactin response studies were performed in 18 patients with functional hyperprolactinemia (defined as prolactin serum levels > or = 16 and < 50 ng/ml during the follicular phase without evidence of prolactinoma) and 18 controls with similar age who had normal serum prolactin levels. Tests were done on the 7th, 8th or 9th day of the follicular phase under standardized conditions (at 08.00-09.00, after a 1-h rest and overnight fasting) with 200 micrograms TRH or 10 mg metoclopramide i.v. After metoclopramide, higher maximal prolactin levels were observed in the study group as well as in the control group than after TRH (metoclopramide mean: 243 +/- 62 ng/ml vs. 181 +/- 100 ng/ml, U-test: p = 0.0019; TRH mean: 101 +/- 23 ng/ml vs. 41 +/- 20 ng/ml, U-test: p = 0.0001). There was no significant difference in the relative increment of prolactin serum levels between both groups, neither after metoclopramide nor after TRH (after metoclopramide, mean: 13.5 +/- 5.8 vs. 17.2 +/- 9.2, U-test: p = 0.137; after TRH, mean 3.6 +/- 1.1 vs. 3.8 +/- 1.9, U-test: p = 0.899). No correlation between prolactin basal and peak levels, either after TRH or after metoclopramide, could be found, neither in the study (metoclopramide test: p = 0.738; TRH test: p = 0.076) nor in the control group (metoclopramide test: p = 0.331; TRH test: p = 0.360). While significantly higher prolactin peaks were recorded after metoclopramide than after TRH in both groups, no difference in the response to TRH and metoclopramide, regarding absolute and relative increment, could be found.

Thyroid autoantibodies in euthyroid non-pregnant women with recurrent spontaneous abortions

This study was undertaken to evaluate the incidence of thyroid autoantibodies in women with a history of recurrent (three or more consecutive) spontaneous abortions. A total of 22 euthyroid non-pregnant habitual aborters were analysed for thyreoglobulin and thyroid peroxidase antibodies; 22 nulligravidae and 22 multigravidae without endocrine dysfunction served as controls. Both thyroid antibodies were assayed using highly sensitive, commercially available enzyme-linked immunosorbent assay kits. Eight of the 22 women with recurrent spontaneous abortions (36%) but only two of the 22 nulligravidae controls (9%; chi 2 test, P = 0.03) and one of 22 multigravidae subjects (5%; chi 2 test, P < 0.01) demonstrated positive titres (> 100 IU/ml, as recommended by the manufacturer) of thyreoglobulin, thyroid peroxidase or both antibodies. The mean +/- SD antibody concentrations were 102.5 +/- 226.5 in the study versus 20.9 +/- 68.8 in the nulligravidae (U-test, P = 0.057) and 26.4 +/- 60.2 IU/ml (P = 0.097) in the multigravidae population for thyroid peroxidase, and 47.7 +/- 57.9 versus 24.1 +/- 31.9 (U-test, P = 0.051) and 28.1 +/- 27.9 IU/ml (P = 0.059) for thyreoglobulin. In conclusion, the incidence of thyroid antibodies in euthyroid women with habitual abortions appears to be significantly increased compared with the controls of reproductive age without previous abortions. Although the important issue of cause and effect has not been fully clarified, this finding suggests that thyroid antibodies may be a marker for autoimmune-mediated recurrent spontaneous abortions, not dissimilar to, for example, anticardiolipin.

Surveillance of pregnant diabetics--comparison between outpatient and inpatient management

From 1982 to 1993 67 diabetic women attended the University Women's Hospital obstetric clinic at Würzburg. These women were separated into two groups: group 1 (inpatient group) delivered between 1/82 and 7/87, group 2 (outpatient group) delivered between 8/87 and 4/93. Between 1982 and 1987 we used extensive inpatient care. But did not so after 1987. The fetus was monitored by ultrasound scans, cardiotocography, oxytocin stress test and doppler measurements. Nearly all patients used home blood glucose monitoring. We compared blood glucose levels, mode of delivery and fetal outcome for the two groups. There was no significant difference in the average blood glucose levels between the two groups. Cesarean section rates (37%) and gestational age at delivery (37 weeks) were similar in both groups. Fetal macrosomia (birth weight > 4000 g) occured more frequently in the outpatient group (group 1: 4%, group 2: 25%, P < 0.01). This fact did not effect perinatal morbidity. Postnatal metabolic disorders did not increase. Fetal anomalies occurred less frequently in the outpatient group (group 1: 7%, group 2: 2%, P < 0.05).

[Manifestation of Lyme arthritis in the puerperal period]

Lyme disease, a tick-transmitted spirochetal illness caused by Borrelia burgdorferi, usually begins with a characteristic erythema chronicum migrans accompanied by flu-like symptoms. This phase may later be followed by meningitis, neuritis, carditis or arthritis. Congenital abnormalities due to maternal infection during pregnancy have been described. We report on a case of a 36-year old V gravida III para. After a normal pregnancy and a Cesarean section the patient developed postpartal an acute Lyme arthritis.