Transvaginal uterine and umbilical artery Doppler examination of 12-16 weeks and the subsequent development of pre-eclampsia and intrauterine growth retardation

We aimed to determine whether Doppler measurements obtained from the uterine and umbilical arteries in early pregnancy correlate with the subsequent development of pre-eclampsia, or the delivery of a small-for-gestational-age (SGA) baby. A follow-up study was carried out in 652 women with singleton pregnancies who had transvaginal uterine and umbilical artery Doppler examinations performed at 12-16 weeks' gestation. Measurements included: the presence or absence of an early diastolic notch, vessel diameter, resistance index (RI), pulsatility index (PI), time-averaged mean velocity (TAV), maximum systolic velocity and volume flow in the right and left uterine arteries and RI and PI in the umbilical arteries. The main outcome measures were: intrauterine death, birth weight, pre-eclampsia (proteinuric pregnancy-induced hypertension, PPIH) and antepartum hemorrhage. Twelve pregnancies terminated in the second trimester, and in 14 the outcome is unknown. In the remaining 626 women, 44 (7.0%) pregnancies ended in a premature delivery, 30 (4.7%) women developed PPIH, 60 (9.6%) infants were SGA (< 10th centile), of which 19 were < 5th centile and five were < 3rd centile, and 23 (3.7%) women suffered an antepartum hemorrhage. At 12-16 weeks, 205 (32.7%) women had bilateral (right and left) notching of the uterine artery waveforms. When compared to values from women with a normal pregnancy outcome, women who subsequently developed PPIH demonstrated a significant difference in mean uterine artery TAV (24.6 cm/s for PPIH vs. 33.25 cm/s for normal outcome, p < 0.003), volume flow (120.5 ml/min vs. 184.5 ml/min, p < 0.001) and elevated resistance (mean RI = 0.80 vs. 0.695, p < 0.001). In women with bilateral notching, there were significant differences between values for pregnancies with PPIH (odds ratio (OR) 42.02, 95% confidence interval (CI) 5.66, 311.99), being SGA at birth (OR 8.61, 95% CI 4.0, 20.0) or delivering prematurely (OR 2.38, 95% CI 1.19, 4.75), compared with pregnancies with a normal outcome. We conclude that abnormal Doppler values, indicative of a failure to modify the uterine circulation in early pregnancy, are associated with premature delivery, the development of PPIH and the delivery of an SGA baby. This information may be of value in increasing our understanding of the pathophysiological events that lead to the subsequent development of uteroplacental complications such as pre-eclampsia.

Control of G1 in the developing Drosophila eye: rca1 regulates Cyclin A

In the developing eye of Drosophila melanogaster, cells become synchronized in the G1 phase of the cell cycle just prior to the onset of cellular differentiation and morphogenesis. In roughex (rux) mutants, cells enter S phase precociously because of ectopic activation of a Cyclin A/Cdk complex in early G1. This leads to defects in cell fate and pattern formation, and results in abnormalities in the morphology of the adult eye. A screen for dominant suppressors of the rux eye phenotype led to the identification of mutations in cyclin A, string (cdc25), and new cell cycle genes. One of these genes, regulator of cyclin A (rca1), encodes a novel protein required for both mitotic and meiotic cell cycle progression. rca1 mutants arrest in G2 of embryonic cell cycle 16 with a phenotype very similar to cyclin A loss of function mutants. Expression of rca1 transgenes in G1 or in postmitotic neurons promotes Cyclin A protein accumulation and drives cells into S phase in a Cyclin A-dependent fashion.

Expression of endothelial and inducible nitric oxide synthase in non-pregnant and decidualized human endometrium

Immunocytochemistry was used to localize endothelial (eNOS) and inducible (iNOS) nitric oxide synthase in human uterine tissues collected at various stages of the menstrual cycle, after exposure to exogenous progestagens, and in early pregnancy. Endothelial NOS-like immunoreactivity was detected in all specimens in endothelial cells lining blood vessels in the myometrium and endometrium, and in endometrial glandular epithelial cells. Inducible NOS-like immunoreactivity was also demonstrated in glandular epithelial cells. For both eNOS and iNOS there was considerable variation in the intensity of epithelial cell staining between samples, which was not related to the stage of the menstrual cycle at which the tissue was collected. Messenger RNA for eNOS and iNOS was detected by reverse transcription-polymerase chain reaction (RT-PCR) using total RNA purified from isolated endometrial gland fragments. Immunoreactivity for eNOS and iNOS was not present in endometrial stroma throughout the menstrual cycle, but iNOS-like immunoreactivity was seen in decidualized stromal cells both following treatment with exogenous progestagen (intrauterine L-norgestrel) and in tissues obtained in the first trimester of pregnancy. The detection of protein and mRNA for eNOS and iNOS in normal human endometrium suggests that NO may play a role in the local control of endometrial function.

Transfer of inulin across the first-trimester human placenta

OBJECTIVE

Our aim was to investigate the transfer of inulin from the mother to the first-trimester fetus.

STUDY DESIGN

A bolus of inulin (5 mg/kg) was administered to nine healthy volunteers with pregnancies between 6 and 12 weeks of gestation scheduled for elective termination of pregnancy. Coelomic and amniotic fluid samples were obtained from the corresponding cavities between 8 and 25 minutes after the end of the bolus of inulin. Fetal fluid inulin concentrations were compared with those of matched samples of maternal blood and urine collected simultaneously.

RESULTS

Inulin was detected in all fetal and maternal samples. A trend toward an increasing inulin concentration was noted in the exocoelomic cavity with advancing time. Coelomic and maternal serum inulin concentrations were similar within 20 minutes after injection. Amniotic inulin concentrations were always lower than coelomic concentrations irrespective of gestational age or advancing time after injection.

CONCLUSIONS

Inulin crosses the first-trimester human placenta from 7 weeks of gestation in quantities that yield measurable concentrations in both coelomic and amniotic fluids. These results suggest that the study of drug transfer in the first trimester of human pregnancy is feasible with use of samples obtained from the exocoelomic cavity.

Breast cancer management: is volume related to quality? Clinical Advisory Panel

A method of carrying out region-wide audit for breast cancer was developed by collaboration between the cancer registry, providers and purchasers as part of work to fulfill the 'Calman-Hine' recommendations. In order to test the audit method, a retrospective audit in North Thames East compared practice in 1992 against current guidelines. The analysis compared care in specialist and non-specialist centres. A stratified random sample comprising 28% of all breast cancer patients diagnosed in 1992 was selected from the population-based Thames Cancer Registry. The data for 309 patients with stage I-III tumours were analysed by hospital type using local guidelines. No difference between specialist (high volume) and non-specialist centres was detected for factors important in survival. Pathological staging was good with over 70% reporting tumour size and grade. A small number of patients were undertreated; after conservative surgery, 10% (19) of women did not receive radiotherapy, and 15% (8) of node-positive premenopausal women did not receive chemotherapy or ovarian ablation. In contrast, a significant trend with hospital volume was found for several quality of life factors. These included access to a specialist breast surgeon and specialist breast nurses, availability of fine-needle aspiration (FNA), which ranged from 84% in high-volume to 42% in low-volume centres, and quality of surgery (axillary clearance rates ranged from 51% to 8% and sampling of less than three nodes from 3% to 25% for high- and very low-volume centres respectively). Confidential feedback of results to surgeons was welcomed and initiated change. The summary information gave purchasers information relevant to the evaluation of cancer services. While the audit applied present standards to past practice, it provided the impetus for prospective audit of current practice (now being implemented in North Thames).

Maternal serum testing for alpha-fetoprotein and human chorionic gonadotropin in high-risk pregnancies

To evaluate the variations and potential clinical use of serial maternal alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG) in pregnancies at risk of pregnancy-induced hypertension (PIH) and/or intrauterine growth retardation (IUGR), we investigated the relationship between placental sonographic findings, uterine artery Doppler measurements, and maternal serum AFP, hCG, and uric acid levels between 20 and 34 weeks of pregnancy. Maternal serum samples were collected from 41 singleton pregnancies with bilateral uterine notches and/or an increased uterine artery pulsatility index at 20-24 weeks. Maternal serum AFP, intact hCG and free alpha and beta subunits, and uric acid circulating levels were measured in all cases at 20-24 weeks and 25-28 weeks. Placental sonographic investigations comprised measurements of thickness and morphology. Twenty pregnancies had a normal outcome and 21 had an adverse outcome, including eight complicated by severe PIH with fetal IUGR, eight by isolated IUGR, three by mild PIH with normal fetal growth, and two by placental abruption. At the time of the first scan, the placental thickness and maternal serum levels of AFP, hCG, and uric acid were significantly increased in pregnancies with adverse outcomes, compared with those with a normal outcome. In subsequent maternal serum examinations, the incidence of elevated hormonal levels fell for AFP, intact hCG, and beta-hCG, whereas it increased for the uric acid level. No difference was found at any stage for the alpha-hCG level. Seven out of 11 pregnancies complicated by PIH presented with elevated MSAFP and MShCG and a large heterogeneous placenta at the first visit, whereas no pregnancy with a normal outcome presented with similar features. This study has shown a significant association between abnormal development of the utero-placental circulation, elevated MSAFP and MShCG at mid-gestation, and subsequent adverse pregnancy outcome. Serial measurements of MSAFP and MShCG do not provide extra information for the follow-up of these pregnancies.

Diagnosis and treatment of early cervical pregnancy: a review and a report of two cases treated conservatively

We report two cases of cervical pregnancy which were diagnosed by ultrasound at 5 and 8 weeks' gestation. In both cases a gestational sac was visualized below the internal os and color Doppler examination demonstrated peritrophoblastic blood flow characteristic of early implantation. Both patients were successfully treated with systemic methotrexate. Including these two cases, a total of 83 early cervical pregnancies have been reported in the literature over the last 10 years. Of these, 40 patients were primarily treated by conservative surgery, 40 by non-surgical methods using methotrexate or potassium chloride, and the remaining three by other chemotherapeutic agents. The likelihood of being cured was similar in the surgical and non-surgical groups (odds ratio 1.1; 95% confidence interval 0.4-3.2). However, patients who were primarily treated by surgery were more likely to sustain major hemorrhage (odds ratio 8.0; 95% confidence interval 2.4-26.5) and to require hysterectomy (odds ratio 7.4; 95% confidence interval 0.9-63.8) than those treated medically. This indicates that non-surgical methods should be used for primary treatment of cervical pregnancy, while surgery should be reserved for those patients in whom medical therapy is not successful.

The life and afterlife of AT&T's HealthSite

What was going to be the richest, most potent healthcare web site died only 30 days after it debuted. Its strategic partners, surprised and feeling a little abandoned, say they learned a critical lesson in the new field of marketing on the Internet.

Relationship of ovarian stromal blood flow at the baseline ultrasound scan to subsequent follicular response in an in vitro fertilization program

OBJECTIVE

To assess whether Doppler indices of intraovarian blood flow are related to the subsequent follicular response in an in vitro fertilization (IVF) program.

METHODS

One hundred five women underwent ultrasonographic assessment of ovarian morphology, transvaginal color Doppler measurement of intraovarian blood flow and immunoassay of serum FSH during the early follicular phase of an IVF cycle. The subsequent follicular response was related to the Doppler data.

RESULTS

Mean ovarian stromal peak systolic blood flow velocity was significantly correlated with the follicular response (P = .001), even after adjusting for the age of patient, type of ovary (polycystic or normal), total number of human menopausal gonadotropin ampules used, and serum FSH. Mean ovarian stromal pulsatility index was not related to the follicular response. Mean ovarian stromal peak systolic blood flow velocity was significantly lower (P = .007) in the poor-response group. The adjusted odds of a poor response increased significantly by an estimated 22% per cm/second decrease in velocity (P = .02).

CONCLUSION

Ovarian stromal blood flow at the baseline ultrasound scan is correlated with subsequent follicular response and may be a new indicator for predicting ovarian responsiveness in an IVF program.

Transvaginal three-dimensional ultrasound: reproducibility of ovarian and endometrial volume measurements

OBJECTIVE

To assess the reproducibility of ovarian and endometrial volume measurements obtained using transvaginal three-dimensional (3D) ultrasound (US).

DESIGN

Prospective clinical study.

SETTING

A tertiary referral center for assisted reproduction.

PATIENTS

Forty women undergoing ovarian stimulation for IVF-ET using the long protocol of GnRH agonist.

INTERVENTION

Three observers independently measured 20 stored ovarian scanned volumes and 20 endometrial volumes. Also, ovarian volume was calculated from three diameters obtained by two-dimensional (2D) US.

MAIN OUTCOME MEASURE

Analysis of variance, the paired Student's t-test, and calculation of intraclass and interclass correlation coefficients were used for statistical analysis.

RESULTS

Three-dimensional ovarian volume measurements were not significantly different from ovarian volume calculated from three diameters (7.98 versus 7.58 mL). The mean endometrial volume measurement was 3.56 mL. The intraobserver coefficient of variation for both ovarian and endometrial volume was 8%. The interobserver coefficient of variation was 9% for ovarian volume and 11% for endometrial volume. Intraclass and interclass correlation coefficients were 0.95 and 0.95 for ovarian volume and 0.90 and 0.82, respectively, for endometrial volume.

CONCLUSION

Transvaginal 3D US produces highly reproducible ovarian and endometrial volume measurements.

Fetal sexing by ultrasound in the second trimester: maternal preference and professional ability

The study was planned to determine the proportion of parents that wish to know the sex of their fetus at the 20-week anomaly scan, and to investigate our ability to diagnose correctly the sex of the fetus when undertaken as part of a routine scan. A total of 472 patients gave their informed consent. An attempt was made to identify the genitalia as part of the routine scan. No extra time was allowed to determine the sex of the fetus. Altogether 353 (74.7%) women wanted to know the sex, of which four (0.9%) wanted to know but did not want their partners to know. In 50 (10.6%) cases, it was not possible to determine the fetal sex in the time allowed. When the sex was identified, it was correct in 408 (96.7%) cases, and incorrect in 14 (3.3%) cases. Where the parents wanted to know the sex of the fetus, 24 (6.8%) scans were inconclusive, 319 (97%) were correctly identified, and ten (3%) were incorrectly identified (six male, four female). There were no terminations of pregnancy. The majority of prospective parents wish to know the sex of their child, and, in most cases, it is possible to determine the fetal sex at the time of the routine anomaly scan. During the time allowed, the fetal sex was undetermined in one in ten cases, and 3% were sexed incorrectly. If parents wish to know the gender of their fetus, it would appear reasonable to provide this information, provided that the parents are aware of the failure and error rates of sex identification using ultrasound.

Ultrasound derived indices of follicular blood flow before HCG administration and the prediction of oocyte recovery and preimplantation embryo quality

The principal aim of the study was to relate ultrasound-derived indices of blood flow in individual follicles on the day of, but before, the administration of human chorionic gonadotrophin (HCG) to the subsequent recovery of oocytes and the production of preimplantation embryos. Data were obtained from 21 women (aged 29-43 years) with bilateral tubal occlusion, who were undergoing treatment by in-vitro fertilization (IVF) and embryo transfer. Transvaginal ultrasonography with colour Doppler imaging and pulsed Doppler spectral analysis were used to measure follicular volume and derive indices of blood flow. The end-points for each follicle were the volume, peak systolic velocity (PSV), pulsatility index (PI), and the recovery or non-recovery of an oocyte, the subsequent production or non-production of a preimplantation embryo and the morphological grade of each embryo. A total of 94 follicles were studied; 74 oocytes were recovered (79%) and 40 embryos (33 grade I or II) were produced. There were four clinical pregnancies (pregnancy rate 25.0% per transfer, 19.0% per patient). There was a significant correlation between whether or not follicular blood flow was detected and whether or not an oocyte was recovered (P < 0.05, chi 2 test). The values for volume and PI were not clinically useful. The PSV (cm/s, mean +/- SD) was higher in follicles that were associated with the production of an embryo (12.7 +/- 5.9) compared with those that were not (8.5 +/- 5.0; P < 0.05, Student's t-test). The probability of producing a grade I or grade II embryo was 75% if the PSV was > or = 10 cm/s. The corresponding value was 40% if the PSV was < 10 cm/s and 24% if blood flow was not detected (i.e. PSV < 3 cm/s). There was a significant increase (P < 0.05, Student's t-test) in the PSV before aspiration in those follicles associated with the subsequent production of an embryo. We conclude that the value for PSV, before the administration of HCG, can be used to identify follicles with a high probability of producing an oocyte and a high grade preimplantation embryo. The information may also be used to time the administration of HCG to achieve the optimum number and quality of embryos for patient management.

Reinventing AHCs to meet financial, clinical, research and educational demands

Declining profit margins for clinical services are forcing academic health centers to look for other ways to increase revenues to support their research and education missions. One revenue source is the sale of research and education products on the private market.

Measurement of volume flow with time domain and M-mode imaging: in vitro and in vivo validation studies

Color velocity imaging quantification is a commercially available technique that estimates volume flow within vessels by combining velocity data, acquired by time domain correlation, with vessel diameter measurements obtained by M-mode imaging. By integrating the velocity profile over time, quantitative volume flow calculations may be made. To investigate the accuracy of this system, we used two flow phantoms over a range of steady and pulsatile flows for in vitro evaluation, and the common carotid artery of 10 women on five consecutive occasions was insonated for in vivo assessment. In flow phantom studies, accuracy was within 8% for flows above 200 ml/min, but decreased at lower flows depending on the depth, beam-vessel angle used, and steering of the beam. At angles greater than 70 degrees, velocity errors made quantitative measurement of flow unreliable, whereas at angles less than 30 degrees, the increased error in calculating vessel diameter led to large errors of area estimation, and hence made flow measurements unreliable. For the in vivo studies on the carotid artery the intraoperator repeatability values for the three operators were 9.92% (A), 13.74% (B), and 13.24% (C). The interoperator repeatability for the group was 15.30%. This study suggests that the color velocity imaging quantification technique is an accurate and reproducible method of assessing volume flow in vessels. However, in our experience, obtaining volume flow data is more time consuming and operator dependent than traditional Doppler techniques. The color velocity imaging quantification system may be of use in monitoring conditions in which changes in volume flow in a vessel or to an organ is an important part of the disease process.

A comparison of the inactive urinary kallikrein:creatinine ratio and the angiotensin sensitivity test for the prediction of pre-eclampsia

OBJECTIVE

To determine the relation between the inactive urinary kallikrein: creatinine ratio (IUK:Cr) and the angiotensin sensitivity test (AST) at 28 weeks of gestation and to assess each as a screening test for pre-eclampsia.

DESIGN

Prospective interventional study.

SUBJECTS

Four hundred and fifty-nine normotensive nulliparous women recruited from hospital antenatal clinics.

SETTING

John Radcliffe Maternity Hospital, Oxford, and Queen Charlotte's and Chelsea Hospital, London.

INTERVENTIONS

A urine sample for IUK:Cr measurement was provided before performing the AST at 28 weeks of gestation. Those women who demonstrated increased sensitivity to angiotensin II were entered into a randomised placebo controlled trial of low dose aspirin for the prevention of pre-eclampsia (CLASP).

MAIN OUTCOME MEASURES

The development of pre-eclampsia.

RESULTS

The IUK:Cr ratio was significantly lower in those women who showed increased sensitivity to angiotensin II (P < 0.0001 Student's t test). The sensitivity and specificity for detecting pre-eclampsia were, respectively, 22% and 85% for the AST and 67% and 75% for the IUK:Cr. Low-dose aspirin (60 mg) had no effect on the pregnancy outcome.

CONCLUSION

There appears to be some relation between the IUK:Cr and AST tests in pregnancy. However, in this population, the IUK:Cr ratio was a better screening test for pre-eclampsia than the AST, but overall neither test was a powerful predictor for the syndrome.