The demand for surgery to treat the external female genital area has increased significantly in recent years. Since 2001, the author and his colleagues have performed more than 2,100 surgical procedures to enhance the shape and function of the female genital area. The majority of these procedures were aimed at reduction of the labia minora. Drawing on the technique for labia minora reduction (labiaplasty) that the author first described in 2007 (Gress S, Gynäkologisch-Geburtshilfliche Rundschau 47:23-32, 2007), the technique was advanced such that in addition to an even reduction of the labia over their entire length (i.e., not only the part below the clitoris but also the part of the clitoral hood and above), it currently is possible to achieve further tightening of the clitoral hood and correction of a protruding clitoris (clitoral protrusion). This technique creates separate labial segments, the composition of which allows for an optimal shaping and reduction of the labia minora. Since 2006, the author and his colleagues have managed 812 cases using this technique, which has been named "composite reduction labiaplasty." After removal of the excessive tissue in an S-shaped line along the internal and external aspects of the labium minus and after cutting of a cranial pedicle flap approximately 2-3 cm long (seen as the caudal extension of the clitoral hood), a crescent-shaped skin segment below the clitoris and a centrally pointed rectangular skin segment above the clitoral hood are removed. By joining the wound margins, a tightening and balanced reduction of the labia minora as well as a correction for the protruding tip of the clitoris (clitoral protrusion) is achieved. All the patients received postoperative care and follow-up assessments during a period of 6 months. Except for a few cases of wound dehiscence requiring surgical correction, wound healing was without complications, and the outcomes were both aesthetically and functionally very satisfactory. In contrast to most techniques published to date, the "composite reduction labiaplasty" technique ensures a balanced reduction and a tightening of all parts of the labia minora, especially in the region of the clitoral hood. In addition, this technique results in an optimal correction of clitoris positioning in cases of clitoral protrusion. Concerns regarding impairment of sexual sensation or the ability to be sexually stimulated are unfounded. Approximately 35 % of the patients even reported a postoperative increase in their ability to be sexually stimulated. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
This article aims to describe the pathophysiology of glucose metabolism in newborns of mothers with diabetes in pregnancy, the clinical signs of diabetic fetopathy and hypoglycaemia of the newborn, clinical practical procedures of post-partum blood glucose measurement and definition of hypoglycaemia, as well as prophylaxis and treatment of postpartal hypoglycaemia. In studies, newborns have been described with possibly severe mental retardation in the first years of life after post-partum recurrent hypoglycaemia with or without symptoms. Therefore, it is indicated to measure blood glucose levels regularly on the first day of life. Finally a flowchart for the measurement of glucose and therapy in newborns is presented.
Fetal malnutrition or prenatally enhanced stress hormone levels have the potential to program brain function in later life. Even modest malnutrition has direct effects on brain development mainly via modulation of the insulin-like growth factor system. Nutrient restriction also increases maternal stress hormone concentrations in the fetal circulation. Increased fetal cortisol concentrations due to restricted fetal nutrient supply, prenatal stress or glucocorticoid treatment affect structural and functional brain development. Increased cortisol concentrations during maturation of the fetal hypothalamic-pituitary-adrenal (HPA) axis in the last weeks of pregnancy induce hyperactivity of the HPA axis due to permanent desensitization of glucocorticoid receptors in the hippocampus and a subsequent decrease in negative feedback regulation of the HPA axis. Increased responsiveness of the HPA axis to stress in later life is associated with perturbation of the activity of neurotransmitter systems such as the serotonergic, dopaminergic and GABAergic systems predisposing to discrete cognitive disturbances, behavioral disorders and depressive and schizophrenic diseases.
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Evaluation of the diagnostic quality of high-resolution B-mode sonography for the detection of microcalcifications and calcification-associated focal findings in patients with BI-RADS lesions of subtype 4a. 40 patients underwent X-ray mammography and 13-MHz B-mode sonography. The following parameters were examined: with X-ray mammography: extent of microcalcification and visibility of associated focal areas; with ultrasound: sensitivity of microcalcification findings, quality of presentation, extent of microcalcification, visibility of associated focal areas and feasibility of ultrasound-assisted biopsy. X-ray mammography showed a mean extent of microcalcification of 28 8 21 mm. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) and accuracy of microcalcification-associated focal findings were 61.5, 57.9, 50, 45.8 and 47.5%. B-mode sonography achieved a sensitivity of 100%. Sonographically, the mean extent of microcalcification was 7 +/- 3 mm and thus significantly smaller (p < 0.01). Sensitivity, specificity, PPV, NPV and accuracy were 14.3, 84.2, 50, 47.1 and 47.5%. Ultrasound-assisted biopsy appeared feasible in 22 patients (55%). High-frequency B-mode sonography allows a highly sensitive confirmation of microcalcifications in the case of BI-RADS 4a lesions and seems to allow ultrasound-assisted biopsy in about half the patients.
By now laparoscopy has become an established access route in gynaecological surgery. It took many years to get to this stage for various obstacles had to be overcome. In the end, it was the low intra- and postoperative complication rates together with the rapid reconvalescence of the patients and their wish to be quickly discharged from hospital which led to an unstoppable diffusion of the method. With the increased use of the procedure and the expertise of the surgeons, it entered the field of gynaecological oncology and met similar reservations. Once again the same convincing advantages helped overcome the resistance. Thus, laparoscopic surgical procedures have secured a place in the treatment of corpus and cervical carcinomas, as their surgical safety has been proved. The aim of future examinations should be the proof of non-inferiority compared to the open techniques because the advantages of the laparoscopic procedure have been sufficiently proved. Regardless of the required proof, the method is rapidly expanding with robot-assisted procedures, while surgeons develop exenterative techniques.
Endometrial cancer is the most common gynecologic malignancy in Switzerland. Nowadays the gold standard for the treatment of endometrial cancer is total abdominal hysterectomy, bilateral salpingo-oophorectomy and in most cases pelvic and para-aortic lymphadenectomy. However, the use of minimally invasive surgical techniques has increased in recent years. Several prospective, randomized trials demonstrate the safety, feasibility and effectiveness of laparoscopy; the impact on survival and disease-free survival is equivalent to that of laparotomy. In future, laparoscopy and maybe robotic surgery could be effective in a selected population. Until then, further large-scale, prospective multicenter studies with longer follow-ups are required to confirm the current data.
Apart from long-term cardiovascular and metabolic effects of intrauterine deficiency or oversupply situations of the fetus, cerebral, renal and reproductive functions also seem to be influenced by a disturbed intrauterine environment.
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Paget disease is a rare disorder of the skin of the vulva, comprising less than 1% of vulvar neoplasms. Surgical excision is considered the standard of care. While the invasive variant of Paget disease is rare, frequent local recurrences from non-invasive disease, which are inoperable, constitute a major clinical problem. In this article we report on a 71-year-old patient with recurrent disease treated successfully with imiquimod cream. Symptoms such as local itching subsided shortly after initiation of treatment. Four weeks later, first signs of resolution could be demonstrated colposcopically. Within 8 weeks, complete clinical remission was achieved. Thus, topical imiquimod is not only effective as treatment of vulvar intraepithelial neoplasia, but may also be used for selected patients with recurrent Paget disease as an alternative to repeat surgical interventions.
To compare the obstetric and neonatal outcome in pregnancies complicated by gestational diabetes mellitus after amniocentesis for amniotic fluid insulin measurement or maternal blood glucose monitoring or both as selection criterion for therapy. In a retrospective study, 408 diabetic pregnancies were analyzed; 307 were treated with diet alone (group 1) and 101 with diet and insulin (group 2). Pearson's chi2 or Fisher's exact test was used to assess obstetric and anthropometric data within these groups, and p values <0.05 were considered statistically significant. Group 1 - According to the method used, no significant differences were found for gestational age at birth (p = 0.396), mode of delivery (p = 0.79) and neonatal outcome parameters determined as mean birth weight (p = 0.348), birth weight above the 75th percentile (p = 0.473), mean ponderal index (PI; p = 0.434), pH of umbilical artery (p = 0.065) and of umbilical-vein blood (p = 0.052), mean Apgar scores at 1 (p = 0.56) and 5 min (p = 0.072), insulin (p = 0.25) and glucose (p = 0.535) in cord blood. Significant differences were found for birth weight above the 90th percentile (p = 0.005) and Apgar score <7 at 1 min (p = 0.019). Group 2 - Again, no significant differences were observed in terms of gestational age at birth (p = 0.219), mode of delivery (p = 0.386), mean birth weight (p = 0.59), birth weight above the 75th (p = 0.701) and 90th percentiles (p = 0.487), mean PI (p = 0.156), pH of umbilical-artery (p = 0.197) and umbilical vein blood (p = 0.056), Apgar scores at 1 (p = 0.58) and 5 min (p = 0.52), insulin (p = 0.67) and glucose (p = 0.11) in cord blood. In retrospective analysis there was no significant difference in outcome parameters in pregnancies complicated by gestational diabetes dependent on the method used as selection criterion for therapy.
'Fetal programming' describes the association of alterations of the intrauterine fetal environment and the subsequent development of cardiovascular, metabolic and endocrine disorders in adult life. It is now commonly accepted that beside these so-called lifestyle disorders hypertensive disorders in pregnancy have also an intrauterine determination. It is commonly agreed that women born with low birth weight do have an elevated risk for the development of hyper-tensive pregnancy disorders, which is pronounced especially in those women born with low birth weight, who become obese in later life. Until now the exact pathophysiological mechanisms remain elusive: beside placental mechanisms intrauterine alterations in kidney development and insulin resistance seem to be major key factors. The pathophysiological similarities and risks of hypertensive pregnancy disorders (especially preeclampsia) and these 'lifestyle disorders' - both are also considered to be mutual risk factors for the development of the other disorder - suggest the possibility of a general impairment of the maternal cardiovascular system by intrauterine factors.
The success rates of present-day chemotherapy have provoked a rising awareness with regard to the preservation of quality of life among successfully treated patients. Among other factors, quality of life also implies the capacity to procreate. Unfortunately, both in men and women chemotherapy often irreversibly destroys the production of gametes, thereby causing permanent infertility. By its long-standing experience with the cryopreservation of oocytes, zygotes and embryos, reproductive medicine may offer assistance to those patients. Whereas the storage of cryopreserved semen has now become standard in most institutions, the options for the preservation of fertility in women suffering of malignant disease are still limited. Although cryopreservation of non-fertilized oocytes or of pronuclear cells has been established, both the number of oocytes that can be collected within the short time interval between the first detection of the tumour and the initiation of chemotherapy and the modest developmental capacity per frozen/thawed oocyte markedly limit the option of ovarian hyperstimulation and assisted reproduction. Several successful deliveries of healthy infants have now proven the feasibility of ovarian tissue cryopreservation and later orthotopic transplantation after successful tumour therapy. Further refinement of the techniques involved, but also the formation of multidisciplinary networks are expected to offer a solution for young women struck by cancer but striving to survive and to lead a fulfilled life.
About 3-4% of all pregnant women will have a fetus presenting by the breech at term. External cephalic version offers the opportunity to reduce the rate of caesarean sections caused by breech presentation. We analysed retrospectively 51 cases of external cephalic version at our clinic. External cephalic version was performed 51 times between 37 and 41 weeks of pregnancy. External cephalic version was successful in 32/51 cases (62,7%) with a consecutive rate of vaginal delivery of 71,9%. The best results were seen at 37 weeks of pregnancy with 81,25% of successful versions followed by 76,9% of vaginal deliveries. Complications were rare. There was just 1 case of emergency caesarean section due to persisting fetal bradycardia. External cephalic version is an effective and safe treatment to enable vaginal delivery of cephalic presentation. For this operation, 37 weeks of pregnancy can be considered the best time.
To provide a detailed description of abdominal sacrocolpopexy and to present a retrospective evaluation of the outcomes. 78 patients underwent sacrocolpopexy between January 2004 and July 2006; 72% had concomitant procedures; 53 patients participated in the follow-up. Anatomical success was defined as any leading point of the vaginal wall remaining >1 cm above the hymen. Failures were split into 3 groups: (1) asymptomatic, no further treatment; (2) symptomatic, conservative treatment; (3) symptomatic, requiring repeat surgery. The key points of the surgical technique were standardized mesh shape, reasonable choice of fixation of the mesh to the anterior and posterior vaginal walls as well as to the longitudinal ligament at S(2), and short operating time. Standardization kept the mean operating time short (72.7 +/- 14.5 min for sacrocolpopexy only, 86.4 +/- 21.0 min if combined with the Burch procedure; p = 0.03). At the follow-up, none of the 53 patients (100%) presented with a recurrent apical prolapse; 17% (n = 9) had stage II anterior wall prolapse, and 69.8% (n = 37) did not show symptoms specific to anterior wall prolapse. Regarding the posterior compartment, 38% (n = 20) had stage II and 1 stage III posterior wall prolapse; 86.8% (n = 46) did not show symptoms specific to posterior wall prolapse. Questionnaire items showed improvement of quality of life. Nine patients required reinterventions: suburethral sling (3), excision due to erosion (2), anterior (1) and posterior (1) repair, stapled transanal rectal resection (1), botulinum toxin injection (1). Every fourth woman presented with symptoms requiring further treatment. Sacrocolpopexy is a valid technique to treat apical and anterior vaginal wall prolapse.
The phylloid tumor (PT, formerly called cystosarcoma phylloides) is a rare neoplasia of the female breast. Usually the PT is treated with breast-conserving surgery. In spite of progress in early diagnosis, PTs recur frequently--independently of tumor's degree of malignancy. Especially in cases of malignant PT, complete resection with tumor-free margins is seen as the only predictive marker for tumor recurrence or metastases. Benign PT is also often resected with wide tumor-free margins. Because of the tumor's occasionally enormous dimensions, this therapy concept makes breast-conserving surgery almost impossible. A simple enucleation of benign PT is an option to facilitate the preservation of breast tissue and a cosmetically satisfactory breast reconstruction. In the case of particularly large benign PT, enucleation even without wide margins prevents tumor recurrence.
The aim of this study was to validate a German pelvic floor questionnaire that integrates bladder, bowel and sexual function, pelvic organ prolapse, severity, bothersomeness and condition-specific quality of life. Full psychometric testing of a self- and an interviewer-administered questionnaire was performed in 63 urogynaecological patients. Missing data did not exceed 4% for any question. The questionnaire clearly distinguished between urogynaecological and other gynaecological (n = 24) populations. Urodynamics, stress test and prolapse quantification correlated with the questionnaire. Cronbach's C values in the self- and interviewer-administered questionnaires were: bladder domain 0.86 and 0.77, bowel function 0.76 and 0.77, prolapse symptoms 0.82 and 0.83, sexual function 0.80 and 0.71. kappa values in the test-retest analyses varied from 0.61 to 1.0. The pelvic floor questionnaire assessed all aspects of pelvic floor function in a reproducible and valid fashion.
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An imbalance between angiogenic and antiangiogenic factors plays a fundamental role in the pathogenesis of preeclampsia. Serum levels of placental growth factor (PLGF), a factor promoting angiogenesis, in patients with preeclampsia are significantly lower than in nonpreeclamptic pregnancies. This study was designed to answer the question whether the measurement of PLGF at the beginning of the second trimester might be a predictive factor for the appearance of preeclampsia. Serum samples of 61 women were collected between 15 and 18 weeks of pregnancy. PLGF levels were measured using a human PLGF ELISA and correlated with the outcomes of pregnancy. 7 women (11.47%) developed preeclampsia during pregnancy. Their PLGF levels between 15 and 18 weeks of pregnancy were significantly lower (p < 0.001) compared to the nonpreeclamptic pregnancies. Using a PLGF level of 41.84 pg/ml as a cutoff, this test has a sensitivity of 0.87 and a specificity of 0.83. Women who will develop preeclampsia in the course of pregnancy already have a significantly lower expression of PLGF between 15 and 18 weeks of pregnancy compared to those who will not. This test offers new possibilities in the prediction of preeclampsia.
The treatment of pregnant women with gestational diabetes mellitus (GDM) is an increasingly important field in obstetrical clinical practice. In recent years, the impact of GDM has been examined in terms of its psychological and medical treatment consequences. In this paper, we present a review of studies of the psychological outcomes of GDM and pre-existent diabetes. In addition, we describe the influence of GDM on health behaviour. Pre-existent diabetes is associated with decreases in well-being and should be recognized and treated by health care providers. Medical and psychological treatment should be offered in a specialized outpatient setting. In addition, diet and exercise counselling is recommended to give women the best control and responsibility for their health and that of their newborn.