[Pregnancy and coma: more than one dilemma]

A previously healthy 33-year-old woman presented at 13 weeks gestation in a comatose state after a new onset of seizures. Evaluation revealed an intraventricular haemorrhage from an arterioventricular malformation. Coma in pregnancy is a rare event. The moral, legal and medical aspects of prolongation of pregnancy, termination, withdrawal of medical treatment and organ donation are discussed.

Maternal TLR4 and NOD2 gene variants, pro-inflammatory phenotype and susceptibility to early-onset preeclampsia and HELLP syndrome

BACKGROUND

Altered maternal inflammatory responses play a role in the development of preeclampsia and the hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome. We examined whether allelic variants of the innate immune receptors Toll-like receptor 4 (TLR4) and nucleotide-binding oligomerization domain 2 (NOD2), that impair the inflammatory response to endotoxin, are related to preeclampsia and HELLP syndrome.

METHODS AND FINDINGS

We determined five common mutations in TLR4 (D299G and T399I) and NOD2 (R702W, G908R and L1007fs) in 340 primiparous women with a history of early-onset preeclampsia, of whom 177 women developed HELLP syndrome and in 113 women with a history of only uneventful pregnancies as controls. In addition, we assessed plasma levels of pro-inflammatory biomarkers C-reactive protein, interleukin-6, soluble intercellular adhesion molecule-1, fibrinogen and von Willebrand factor in a subset of 214 women included at least six months after delivery. After adjustment for maternal age and chronic hypertension, attenuating allelic variants of TLR4 were more common in women with a history of early-onset preeclampsia than in controls (OR 2.9 [95% CI 1.2-6.7]). Highest frequencies for TLR4 variants were observed in women who developed HELLP syndrome (adjusted OR 4.1 [95% CI 1.7-9.8]). In addition, high levels of interleukin-6 and fibrinogen were associated with a history of early-onset preeclampsia. Combined positivity for any of the TLR4 and NOD2 allelic variants and high levels of interleukin-6 was 6.9-fold more common in women with a history of early-onset preeclampsia (95% CI 2.1-23.2) compared to controls.

CONCLUSIONS

We observed an association of common TLR4 and NOD2 gene variants, and pro-inflammatory phenotype with a history of early-onset preeclampsia and HELLP syndrome. These findings suggest involvement of the maternal innate immune system in severe hypertensive disorders of pregnancy.

Maternal and perinatal outcome of preeclampsia with an onset before 24 weeks’ gestation

OBJECTIVE

Preeclampsia, with an onset before 24 weeks' gestation is a rare but severe condition in pregnancy with little data of maternal and perinatal outcome, particularly after expectant management. We therefore, evaluated pregnancy outcome in these women at our department where temporising management was introduced as the standard policy in early onset preeclampsia.

STUDY DESIGN

We analysed retrospectively all consecutive women with preeclampsia, with an onset before 24 weeks' gestation, between 1 January 1993 and 31 December 2002 at a tertiary university referral center.

RESULTS

Twenty-six pregnancies, of which two were twin pregnancies, resulted in 65% of the women in at least one major maternal complication: maternal death (n=1), HELLP syndrome (n=16), eclampsia (n=5) and pulmonary edema (n=4). Thirty percent of these women presented already with serious morbidity at admission. The median prolongation of the pregnancy was 24 days (range 3-46 days). The overall perinatal mortality was 82%: 19 fetal deaths and 4 neonatal deaths.

CONCLUSION

Early onset preeclampsia, with an onset before 24 weeks' gestation, results in considerable maternal and perinatal morbidity and mortality. Therefore, expectant management should not be considered as a routine treatment option in these patients.

Concentrations of plasminogen activators and their inhibitors in blood preconceptionally, during and after pregnancy

BACKGROUND

Haemostasis is a complex balance of activating and inhibitory pathways resulting in coagulation and lysis. Normal pregnancy is associated with hypercoagulation that is even more profound in complicated pregnancies.

OBJECTIVE

To study the role of the plasminogen-activator system in complicated pregnancy with regard to haemostasis, it is essential to have reference values of components of this system during uneventful pregnancy. In this study we investigated the concentrations of six different components of the plasminogen-activator system preconceptionally, during and after uncomplicated pregnancies.

MATERIAL AND METHODS

Tissue-type and urokinase-type plasminogen activator (tPA and uPA), plasminogen inhibitor type-1 and -2 (PAI-1 and-2), and the complexes between tPA and PAI-1, and between uPA and PAI-1 (tPA-PAI-1, uPA-PAI-1) were measured by ELISAs in blood obtained preconceptionally, at 6, 10, 20, 32 weeks of gestation, and 6 weeks after delivery in uncomplicated pregnancies (n=41; all six parameters n=22).

RESULTS

tPA and uPA concentrations decreased in the first 10 weeks of pregnancy and subsequently increased in the third trimester. PAI-1 concentrations increased in the third trimester and PAI-2 concentrations increased throughout pregnancy (preconception versus 32 weeks of gestation; 38.73 versus 102.23ng/ml, and 0.024 versus 151.06ng/ml, respectively). tPA-PAI-1 and uPA-PAI-1 complex concentrations decreased in the first trimester, followed by an increase in the third trimester. The concentrations of all components returned to the preconception values 6 weeks after delivery.

CONCLUSION

This study provides longitudinal data on activating and inhibitory components of the plasminogen-activator system during pregnancy. Insight in the longitudinal changes in these concentrations may be of help in the understanding of the thrombotic tendency in pregnancy complications such as preeclampsia.

Human thymus contains multipotent progenitors with T/B lymphoid, myeloid, and erythroid lineage potential

It is a longstanding question which bone marrow-derived cell seeds the thymus and to what level this cell is committed to the T-cell lineage. We sought to elucidate this issue by examining gene expression, lineage potential, and self-renewal capacity of the 2 most immature subsets in the human thymus, namely CD34+ CD1a- and CD34+ CD1a+ thymocytes. DNA microarrays revealed the presence of several myeloid and erythroid transcripts in CD34+ CD1a- thymocytes but not in CD34+ CD1a+ thymocytes. Lineage potential of both subpopulations was assessed using in vitro colony assays, bone marrow stroma cultures, and in vivo transplantation into nonobese diabetic/severe combined immunodeficient (NOD/SCID) mice. The CD34+ CD1a- subset contained progenitors with lymphoid (both T and B), myeloid, and erythroid lineage potential. Remarkably, development of CD34+ CD1a- thymocytes toward the T-cell lineage, as shown by T-cell receptor delta gene rearrangements, could be reversed into a myeloid-cell fate. In contrast, the CD34+ CD1a+ cells yielded only T-cell progenitors, demonstrating their irreversible commitment to the T-cell lineage. Both CD34+ CD1a- and CD34+ CD1a+ thymocytes failed to repopulate NOD/SCID mice. We conclude that the human thymus is seeded by multipotent progenitors with a much broader lineage potential than previously assumed. These cells resemble hematopoietic stem cells but, by analogy with murine thymocytes, apparently lack sufficient self-renewal capacity.

Peptide patterns of laser dissected human trophoblasts analyzed by matrix-assisted laser desorption/ionisation-time of flight mass spectrometry

This study describes the first promising steps in the comparison of peptide patterns of laser capture microdissected trophoblast cells obtained from frozen tissue sections in relative low numbers, approximately 125 cells. Trophoblasts were collected by laser capture microdissection from a terme human placenta and dissolved in detergents, sonified, and digested with trypsin. The resulting peptide mixtures were directly analyzed by matrix-assisted laser desorption/ionisation-time of flight mass spectrometry. Using this approach specific peptide patterns that consist on average of approximately 35 peptide peaks for trophoblast cells, and surrounding villous stroma cells could be obtained. From the results it was concluded that trophoblast and surrounding villous stroma cells show exclusive discriminating peptide patterns. In the future this method is potentially suitable for finding specific peptides and identification of proteins that are related to the pathogenesis of trophoblast pregnancy diseases such as preeclampsia.

Inherited risk of thrombosis of the fetus and intrauterine fetal death

OBJECTIVE

To test the hypothesis that abnormal placentation resulting in intrauterine fetal death (IUFD) is associated with coagulation abnormalities in the fetus.

STUDY DESIGN

We analyzed fetal DNA from umbilical cords from 139 pregnancies complicated by intrauterine fetal death during 1994-1998 (cases). Fetal DNA was tested for the presence of factor V Leiden and prothrombin G20210A mutations. The prevalence of these thrombophilic mutations among cases were compared with the prevalence in a historic control group.

RESULTS

Overall, a higher prevalence of fetal genetic risk factors was found in cases (9.8%) as compared to fetuses born from an uncomplicated pregnancy (2%, odds ratio 4.8, 95% CI 1.1-22). Second trimester intrauterine fetal death occurred more frequently in cases with the factor V Leiden mutation as compared with the control group (8/64 versus 0/92). For intrauterine fetal death and factor V Leiden a high risk was found concerning abruption placentae (odds ratio 7.6, 95% CI 1.5-37).

CONCLUSION

The prevalence of fetal genetic risk factors associated with an increased risk for thrombosis was higher in pregnancies complicated by intrauterine fetal death suggesting an important role of abnormal coagulation in placentation.

New onset seizures in pregnancy caused by an unexpected neurologic disorder

Seizures in pregnancy are a life-threatening emergency that continues to be a major cause of serious maternal and fetal morbidity and mortality. We report a rare cause of new onset of seizures in pregnancy: hydrocephalus caused by aqueductal stenosis. The differential diagnosis of seizures in pregnancy is discussed in detail.

C825T Polymorphism in the Human G Protein Beta 3 Subunit Gene and Preeclampsia; a Case Control Study

OBJECTIVE

Recently, a polymorphism of the gene encoding for the G protein beta3-subunit (GNB3) has been described. The T allele of this polymorphism (825T) is associated with endothelium dysfunction. Endothelium dysfunction has been described in women with preeclampsia. We, therefore, tested the hypothesis that in women who have had preeclampsia the T allele is more prevalent than in controls.

STUDY DESIGN

We conducted a case-control study of 157 women with preeclampsia during 1991-1996. Cases and controls were tested for the presence of 825T by genotyping. Logistic regression methods were used for data analysis.

RESULTS

The frequency of the T allele of the GNB3 gene was similar in cases (0.30) and controls (0.27) (odds ratio 1.24, 95% confidence interval 0.88-1.75). Compared to controls, we found a high frequency of the T allele in patients with the hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome (odds ratio 4.25, 95% confidence interval 1.12-16.05).

CONCLUSION

The frequency of the T allele of the GNB3 gene, which serves as a marker for endothelium dysfunction, was not different between women with preeclampsia and controls. Women with the HELLP syndrome had a high frequency of the T allele. This suggests that this polymorphism in the GNB3 gene does not contribute to endothelium dysfunction in women with preeclampsia while it does contribute in women with the HELLP syndrome.

Pregnant women with a low milk intake have an increased risk of developing preeclampsia

OBJECTIVE

Several studies have suggested a relation between calcium intake and preeclampsia. In this study, we test the hypothesis that a low calcium intake by milk products increases the risk of developing preeclampsia in The Netherlands, a country where milk consumption is assumed to be high.

STUDY DESIGN

We conducted a case-control study of 163 women with preeclampsia during 1991-1996. Controls were matched for age and delivery date. Data from cases and controls were obtained by questionnaire.

RESULTS

The mean milk consumption per day was higher in the control group (3.0+/-0.1 units per day) than in the preeclampsia group (2.4+/-0.1 units per day, P<0.01). There was no difference in calcium intake by tablets: eight women (9.4%) with preeclampsia and seven controls (9.3%) used calcium tablets.

CONCLUSIONS

This study shows an increased risk of developing preeclampsia associated with lower milk intake.