Elisabeth Gottschalk

Fertility outcome after radical vaginal trachelectomy: a prospective study of 212 patients.

Objective For treatment in patients with early-stage cervical cancer, radical vaginal trachelectomy (RVT) as a fertility-preserving surgery can be put on a par with radical hysterectomy as to oncologic safety. Our aim was to investigate the fertility concerns and outcome. Methods Prospective collection of fertility data of patients treated with RVT. The data were collected on personal communication, by telephone, or e-mail correspondence. Descriptive statistical analysis was performed. Results Between March 2005 and April 2010, 212 patients were followed up after RVT. Only 76 patients (35.9%) were seeking parenthood currently. Sixty pregnancies occurred in 50 women. Five patients (8.3%) had first-trimester miscarriage, 3 had second-trimester miscarriage (5.0%), 2 patients decided for pregnancy termination (3.3%), and 1 patient (1.7%) had an ectopic pregnancy. Three women (5.0%) delivered prematurely before 28th weeks of gestation, 15 (25.0%) delivered between 28 and 36 weeks, and 27 women (45.0%) reached full term. Four pregnancies are ongoing. Conclusions Preservation of childbearing function is a great advantage for patients with early-stage cervical cancer. Many patients do not seek parenthood immediately. We see no impairment of fertility and have solid data on pregnancy outcome. Premature labor is the main problem in pregnancy after RVT.

Fetal fibronectin as a predictor of spontaneous preterm birth : a European perspective

Preterm birth (PTB) is estimated to account for 6–10% of all births worldwide with 13 million PTBs occurring annually and 1 million resulting in death. The diagnosis of spontaneous preterm labor and accurate prediction of preterm delivery is notoriously difficult. Identification of effective risk assessment markers can potentially improve outcomes by enabling targeted therapy while allowing efficient use of resources and avoiding unnecessary interventions. Advances in perinatal medicine have not reduced PTB and effective measures that improve outcome are yet to be established. However, considerable progress has been made in the development of accurate methods (fetal fibronectin and cervical length assessment) to predict PTB in both symptomatic and asymptomatic high-risk women. The excellent negative predictive value of fFN has the ability to facilitate decision-making regarding admission, in utero transfer, administration of antenatal corticosteroids and/or tocolysis and has been shown to be cost-effective. This review describes the European perspective on the use of fFN and describes ongoing European clinical studies, which are appropriately designed with meaningful endpoints, which will undoubtedly facilitate a better understanding of test accuracy and cost-effectiveness within different populations.

Addressing concerns about cisplatin application during pregnancy.

Abstract Introduction: Cervical cancer in second trimester of pregnancy is an oncologic challenge. Cisplatin is recommended to prevent cancer progression. This is a series correlating in vivo cisplatin concentration in the fetomaternal compartment and in breast milk with child development. Methods: Eight consecutive patients with cervical cancer diagnosed during the second trimester underwent conization/biopsy and/or pelvic laparoscopic lymphadenectomy (LAE). Delay of pregnancy in combination with neoadjuvant monochemotherapy was performed. After 2–4 cycles of cisplatin monochemotherapy cesarean section followed by radical hysterectomy was performed above 31 weeks of gestation. Synchronous samples from maternal blood, umbilical cord blood, and amniotic fluid were taken and analyzed. A probe of breast milk was taken from three patients. Pediatric aftercare was done every three months postpartum. Results: Laparoscopic LAE was uncomplicated in all patients. In seven out of eight patients lymph nodes were tumor free. Nine healthy babies were delivered. Pediatric follow-up showed normal development. Cisplatin concentrations in the umbilical cord and amniotic fluid were 31–65% and 13–42% of the amount in maternal blood, respectively. In breast milk, cisplatin was detectable in 1–10% of maternal blood concentration. Conclusion: Knowledge of significant lower cisplatin concentrations in fetal compartment and normal child growth provides additional security to apply cisplatin in pregnancy. Breastfeeding cannot be recommended.

Vaginal-Assisted Laparoscopic Radical Hysterectomy: Rationale, Technique, Results

The authors conclude that vaginal-assisted laparoscopic radical hysterectomy is an oncologic viable alternative to abdominal radical hysterectomy, laparoscopic-assisted radical vaginal hysterectomy, totally laparoscopic radical hysterectomy, and robotic radical hysterectomy.

Assessment of long-axis ventricular function in the fetal heart with a tissue-tracking algorithm.

Abstract Objective: Tissue-tracking echocardiography (TTE) is a method for quantitative assessment of myocardial contraction and relaxation. The purpose of this study was to assess the feasibility of TTE in fetuses and investigate fetal myocardial properties in normal pregnancies. Methods: Two hundred thirty pregnant women participated in the study. Fetal four-chamber-view cineloops were saved for off-line analysis. Reference values for the global longitudinal peak velocity (V), strain (S), strain rate (SR), and displacement (D) in the fetal heart were established using data from 62 right ventricles (RV) and 68 left ventricles (LV). Furthermore, the change of the motion (V and D) and deformation (S and SR) in the course of the pregnancy was analyzed. Intraobserver variability was assessed in a total of 137 cases. The remaining 93 cases were excluded, as there was no tracking possible. Results: Normal fetuses exhibit a statistically significant increase in all motion parameters in both ventricles with increasing gestational age (GA). In contrast, the deformation parameters with advancing GA decrease. RV has a higher diastolic V and SR than LV. Conclusions: The increase in motion is attributable to fetal cardiac growth, whereas the decrease in deformation para\xadmeters indicates an intrauterine adaptation mechanism. RV appears to have a different relaxation pattern than LV. This study establishes a base for further utilization of TTE in fetal medicine and emphasizes a distinct diastolic difference between RV and LV function.

P34.15: Evaluation of the new pocket-size ultrasound system ‘ACUSON P10 TM’ in routine obstetric use

following laparascopic myomectomy. This is believed to be secondary to inadequate healing of the uterine incision. There are no reports however of pregnancy management following a history of such an event. We report a case of a 30yo 2/0100 with a history of laparoscopic myomectomy in June 2005. She subsequently underwent intrauterine insemination and became pregnant in Aug 2005. In January 2006 she underwent an emergent laparotomy for a spontaneous uterine rupture with fetal demise at 25 weeks. In Aug 2006 she underwent a laparatomy for uterine scar revision, and in April 2007 she conceived again. She was admitted to the antepartum unit at our institution at 24 weeks. Uterine scar thickness was sonographically monitored by the same physician at frequent intervals. At 24 weeks the myometrium measured 5.6 mm. She received antenatal steroids at 25 weeks. Our plan was for cesarean delivery at 32 weeks. At 30 weeks the fundal myometrial thickness measured 3.3 mm. At 31 weeks she complained of increased tenderness at the fundus; an urgent ultrasound was performed consistent with possible uterine dehiscence. Only an intact uterine serosa was noted measuring 1.8 mm and a myometrial defect measuring 13 mm wide. The patient was taken for emergent cesarean section where the above findings were confirmed. A viable female neonate was delivered with Apgars of 7.8. The patient did well and was discharged home on post operative day number 3. Ultrasound monitoring of the uterine scar thickness is a novel approach for following these high risk patients status post laparoscopic myomectomy. Based on our findings the decision for inpatient close monitoring and evaluation should be considered when the myometrial thickness approaches 2 mm.

OP23.02: Assessing the risk of spontaneous preterm birth using ultrasound cervical length and fetal fibronectin

Aims: To determine predictive value of AF real-time PCR for the presence of congenital CMV infection and to examine the possible correlation of AF viral load with prenatal ultrasound findings and disease status. Methods: AF specimens were obtained prospectively from women with suspected infection by U/S or maternal disease. AF samples were collected at GA ≥ 21wks and ≥ 6 wks from known maternal infection. gB RT-PCR was performed with a sensitivity of 50 cop/ml and a linear quantitation over a 6-log range. IE RT-PCR was used to detect viral strains not detected by the gB assay. Congenital infection and disease outcomes were evaluated with fetal U/S, histopathologic findings, newborn urine cultures, and/or hearing and developmental evaluation. Results: 539 AF specimens were examined, 462 had known serology data. CMV was detected in 28/462 (6.1%), all from women with primary CMV infection (149 patients), for transmission rate of 18.8%. Only 5/28 (17.9%) with positive AF RT-PCR had positive U/S. 8/28 cases, 5 w/abnormal U/S and 3 without, had congenital disease (8/28, 28.6%). 20 were terminated, including 15 w/normal U/S. The 8 newborns showed no congenital disease. 121 pts with primary CMV infection returned negative AF RTPCR results:1 had congenital infection. In primary CMV infection sensitivity of RT-PCR was 94.7%, specificity 100%, PPV 100%, NPV 98.5%, compared with culture and PCR, with sensitivity of 89.5%, specificity 100%, PPV 100%, and NPV 96.9%. No disease developed with viral load < 105 cop/ml (NPV 100%). Conclusions: AF RT-PCR is a reliable prenatal diagnostic assay for congenital infection. U/S correlates poorly with congenital disease status.

P33.15: Prenatal diagnosis of Larsen syndrome by 2D and 3D/4D ultrasound

The VACTERL (Vertebral defects; Anal atresia; Cardiac anomaly; Tracheal-Esophageal fistula; Renal defects; Limb defects) association is a rare, usually sporadic, disorder. Prenatal ultrasound features are few and early prenatal diagnosis is difficult. We report a case of prenatal diagnosis of VACTERL syndrome diagnosed by 3D/4D maximum render mode in second trimester ultrasound screening. A 31-year-old woman gravida 1, was referred to our private clinic for a routine second trimester scan at 21 weeks and 3 days of gestation. The 2D scan revealed a single umbilical artery, an enlarged intrahepatic umbilical vein and a small gallbladder. No other structural or biometrical defects were visible. In particular the 2D ultrasound sagittal view of fetal spina did not show abnormal features. The 3D/4D maximum render mode (Voluson 730 Expert, GE) utilized to visualize fetal spina, routinely performed in our clinic, showed a disrupted architecture of the vertebral bodies in the lumbarsacral tract of the fetal spina. VACTERL syndrome was suspected. The parents opted for termination of pregnancy. Post-mortem examination confirmed prenatal findings and revealed furthermore imperforate anus and aorta coartation. Diagnosis of VACTERL syndrome was confirmed. 3D/4D maximum render mode is an easy and useful technique to study fetal spina. The post-processing imaging of the volume sectional planes, give the possibility to visualize the spina in the three planes simultaneously and allows the identification of subtle vertebral defects. In our opinion 3D/4D maximum render mode visualization of fetal spina should therefore be included in a detailed fetal anomaly scan when a single umbilical artery or other features of VACTERL syndrome are present.

P51.02: Increased middle cerebral artery systolic velocity in maternal red cell alloimunization—false positive Doppler ultrasonography

Congenital brain tumors are rare and have an incidence of 3 to 4/100 000 among live births. Teratomas are the most frequent histological type of brain tumors and represent about 62% of cases. Diagnosis relies on fetal ultrasound and is usually made during second or third trimester. We report herein a case of first trimester diagnostic of cerebral teratoma. A 35-year-old gravida 5, para 1 woman was referred at 13 weeks of gestation after first trimester routine scan because of an intracranial mild hyperechoic lesion. The lesion measured 12 mm of diameter and was located in the right frontal area. It was well-defined, rounded, echoic and homogenous with few hyperechogenic spots. Colour Doppler showed a mild vascularization into the lesion. The other cerebral structures had a normal appearance but midline was moved on the left in its anterior part. There was no extra-cranial abnormality. Nuchal translucency was measured at 1.4 mm, crown rump length at 70 mm and biparietal diameter at 25 mm. Fetal karyotype was normal, 46 XY. Despite the lack of anterior description of such a case in the literature during the first trimester, the diagnosis of teratoma was suspected antenatally because the mass showed all ultrasonographic criteria of such an anomaly. Because of the early appearance of the lesion and its large size, prognosis was considered to be poor and a termination of pregnancy was achieved at 14 weeks of gestation, according to French laws. Labour was induced by intravaginal misoprostol. Postmortem examination confirmed the diagnosis.