Ambulatory blood pressure monitoring during pregnancy: validation of the TM-2420 monitor

To validate the accuracy of the TM-2420 ambulatory blood pressure monitor in pregnant women, its measurements were compared with those taken simultaneously by two trained observers using a random zero sphygmomanometer. Each of 30 pregnant women had her blood pressure measured three times. The mean differences between the monitor and the averaged observer measurements were -0.53 +/- 2.7 mmHg for systolic blood pressure, -5.4 +/- 5.3 mmHg for Korotkoff phase 4 (P less than .001), and 0.87 +/- 3.7 mmHg for phase 5 diastolic blood pressure. The TM-2420 ambulatory monitor provides reliable estimates of systolic and Korotkoff phase 5 diastolic blood pressures during pregnancy.

Cytotoxic activity against trophoblast and choriocarcinoma cells of large granular lymphocytes from human early pregnancy decidua

Large granular lymphocytes (LGL) are the most abundant cell type in first trimester human pregnancy decidua. We have shown previously that CD56-positive decidual LGL have cytotoxic activity against the natural killer (NK) target K562, and that this cytotoxicity is augmented by pretreatment with interleukin-2 (IL-2). We now report that flow cytometrically purified populations of CD56-positive decidual LGL have no cytotoxic activity against either the BeWo choriocarcinoma cell line or freshly isolated term trophoblast. Incubation of unfractionated decidual cells with IL-2 induced cytotoxicity against BeWo, but term trophoblast remained resistant to lysis. Both BeWo and trophoblast showed much lower binding frequencies to decidual or peripheral blood cells than K56 targets, and excess trophoblast did not inhibit cytotoxic activity against K562. This suggests that the resistance of trophoblast to lysis by either decidual or peripheral blood LGL is due to the lack of accessible NK target structures on the surface of trophoblast.

The advantages of computerized fetal heart rate analysis

A brief account is given of the advantages of computerized analysis of human fetal heart rate (FHR) traces antenatally, based on clinical use over 8 years. Accuracy is greater. Results are presented quantitatively and consistently. The numerical measures of the FHR pattern are related to other objective measures of fetal health, e.g. initial compensated hypoxaemia or terminal acidaemia. Computerized analysis has shown that changes in FHR variation are a better guide than the presence or absence of large decelerations. Recording time is used better. Synoptic displays of data over 4 weeks show significant trends in fetal heart rate variation and movements with time. And the problems generated by the limitations of fetal heart rate monitors are identified to exclude spurious information.

System 8000: computerized antenatal FHR analysis

SYSTEM 8000 is a computerized system for antenatal fetal heart rate (FHR) analysis, with interaction online to ensure good quality recording and to minimize the time required to obtain the necessary information (based on fetal movements and tocodynamometer readings as well as FHR). The equipment consists of a Personal Computer with hard disk, interfaced to a fetal monitor. Software is written in C. An extensive definition is given on most of the functions and parameters as calculated by the system, e.g. record quality, uterine contraction peaks, basal heart rate, variation, decelerations and accelerations. System 8000 is designed to take account of the episodic changes in FHR and fetal movements characteristic of sleep states. Their presence naturally affects the mean FHR variation calculated over, say 20-30 mins. But, as the amplitude of these episodes is attenuated in association with growth retardation and hypoxaemia, the measurements of variation decline. In practice inter- and intra-observer variation is greatest in assessing FHR variation. Yet a decrease in variation is the most reliable index of fetal deterioration. The system measures FHR variation accurately and reproducibly, as well as fetal movements. In the synoptic display these two equally important fetal variables are given their rightful prominence. It has been interesting to observe how rarely the basal FHR changes in fetuses suffering progressive respiratory insufficiency, and how extreme tachycardia (a basal rate greater than 170/min) tends to reflect other fetal problems such as infection or maternal pyrexia.

Obstetric audit using routinely collected computerised data

OBJECTIVE

To examine the use of routinely collected computerised data in clinical audit.

DESIGN

Retrospective review of all analyses of obstetric practice based on a computerised data system from January 1983 to June 1988.

SETTING

Maternity department of the regional referral hospital in Oxford.

MAIN OUTCOME MEASURES

Congruence with the principles of clinical audit; that is, comparing clinical practice with previously agreed standards and changing practice to meet these standards if necessary.

RESULTS

Over the five and a half years of the study the data formed the basis of 130 special inquiries into different aspects of obstetric practice. Most inquiries seemed to be aimed only at describing current activities and identifying trends. Genuine clinical audit was rare. Simple audits--for example, concerning induction for pregnancy after term--could be supported by the computerised data, but for detailed and wide ranging audits--for example, reducing antenatal clinic visits for low risk multiparas--the data had to be supplemented from other sources.

CONCLUSIONS

Routinely collected computerised data enable ongoing clinical audit, but it becomes a reality only when clinicians agree on standards of practice and have a flexible attitude towards change. Even then, genuine clinical audits of obstetric practice demand more detailed and comprehensive data than are generally available on such systems.

Purification of human cytotrophoblast from term amniochorion by flow cytometry

Term cytotrophoblast do not express polymorphic MHC Class I antigens, unlike other fetal and maternal cells in the amniochorion/decidua. This allows cytotrophoblast to be isolated and purified from this tissue, utilizing 4E, a monoclonal antibody specific for HLA-B, which labels only non-trophoblast. We have developed a method using enzymic dispersion and Percoll gradient centrifugation, followed by flow cytometry, that yields, on average, a total of 5 X 10(6) term extravillous cytotrophoblast, 97 per cent pure. The availability of highly purified extravillous cytotrophoblast, for the first time, permits precise investigation of trophoblast function.

Patient consent for gynaecological examination

Pelvic examination of women patients under general anaesthesia has long been practised by gynaecologists in order to teach clinical findings to medical students. Although this practice may spare patients discomfort and embarrassment, a recent survey has shown that it should not be carried out without patient consent. Consent, however, is rarely withheld.

Early second surgery in ovarian cancer--improving the potential for cure or another unnecessary operation?

The presence and amount of residual disease after primary surgery is a major adverse prognostic factor in epithelial ovarian cancer [EOC]. Rapid initial cytoreduction employing second surgery early in the primary chemotherapeutic management of patients with gross residual disease has been advocated as a means of improving outcome. To evaluate the prognostic value of such an approach we have reviewed the outcome of 24 patients with gross residual disease, who were debulked to less than 2 cm residuum at a second operation, performed after three cycles of cis-platinum-based chemotherapy (a median of 14 weeks from the initial laparotomy), and compared this with an historical series of 195 patients with residual disease (70 patients with less than 2 cm residuum) who received cis-platinum but no early secondary surgery. In the control series, stage and residual disease status were important prognostic factors. There was no significant difference in patient or disease characteristics between those patients in the early second surgery group and control patients with greater than 2 cm disease (n = 125). Initially the survival curve for the early second surgery group was similar to the less than 2 cm disease group, but at about 18 months, there was a rapid deterioration until the survival parallels that of the patients with bulky disease at presentation. Early secondary surgery did not significantly prolong survival in patients with greater than 2 cm of residual disease.

Flow cytometric characterisation of cell populations in human pregnancy decidua and isolation of decidual macrophages

Methods have been developed for isolating human tissue macrophages from first trimester or term pregnancy decidua. After a two stage enzymic digestion, viable cells were separated from cellular debris by velocity sedimentation at unit gravity or by Percoll centrifugation. Cell populations were analysed by flow cytometry after labelling with monoclonal antibodies. In term decidua, 47% of the cells were of bone marrow origin, comprising 18% macrophages, 3% large granular lymphocytes and 8% T cells. The remaining cells, the proportion of which varied between individuals, were CD16-positive granulocytes. Macrophages were isolated flow cytometrically from both first trimester and term decidual cell dispersions after labelling with an antibody to MHC class II. Yields of up to 4 X 10(6) macrophages, greater than 95% pure, were routinely obtained.

Cell populations in the human early pregnancy decidua: natural killer activity and response to interleukin-2 of CD56-positive large granular lymphocytes

Large granular lymphocytes (LGL) have been shown previously to be the most abundant cell type in the first trimester human decidua. Purified populations of decidual LGL were prepared by flow cytometry of cell dispersions labelled with NKH1 (CD56), an antibody specific for peripheral blood LGL, and the functional properties of CD56-positive cells, CD56-negative and unsorted decidual cells compared. Both CD56-positive cells and unsorted decidual cells have cytotoxic activity against the natural killer (NK) cell target K562 which was weak compared with that of peripheral blood mononuclear cells (PBMC). The CD56-negative cells had no cytotoxic activity against K562. All three decidual cell populations proliferated in response to recombinant human interleukin-2 (rIL-2), but none produced detectable levels of IL-2 in culture. When unsorted decidual cells were cultured for 7 days in rIL-2 the proportion of CD56-positive cells increased and NK activity against K562 was augmented. The NK activity of purified CD56-positive decidual cells was also augmented by culturing in rIL-2. The potential role of decidual LGL in regulating the development of the semi-allogeneic placenta is discussed.

Loop diathermy excision of the cervical transformation zone in patients with abnormal cervical smears

OBJECTIVE

To determine the efficacy and morbidity of fine loop diathermy excision of the cervical transformation zone as applied to the management of outpatients with abnormal cervical smears.

DESIGN

Prospective programme trial with six month follow up.

SETTING

Two hospital based colposcopy clinics.

PATIENTS

616 Patients aged 16-60 with abnormal cervical smears.

INTERVENTIONS

After colposcopic and cytological assessment excision of the cervical transformation zone by fine loop diathermy under local anaesthesia in the outpatient department.

MAIN OUTCOME MEASURES

Time to complete the treatment, immediate morbidity in terms of discomfort and bleeding, and cytological and colposcopic findings at six months.

RESULTS

Treatment was completed in a mean of 3.47 minutes (SD 1.99). Immediate morbidity was minimal, and histological specimens were adequate in over 90% of cases. Almost two thirds of patients were treated at their first visit to the clinic. 58 Patients (9.4%) failed to attend for follow up at six months and one had had a hysterectomy. Of the 557 patients who attended for colposcopic and cytological follow up at six months, 506 (91%) were normal cytologically and 19 (3.4%) had histologically confirmed persistence of cervical intraepithelial neoplasia. The overall confirmed failure rate of the technique was 4.4%.

CONCLUSION

Loop diathermy excision is an effective treatment with low morbidity and is an appropriate modality for patients with abnormal cervical smears.

Tumour cell activity markers in epithelial ovarian cancer: are biochemical and cytometric indices complementary?

Flow cytometry has enabled the objective assessment of cellular morphology and activity, which can also be biochemically evaluated by measuring products of cellular metabolism, such as cyclic 3'5' guanosine monophosphate (cGMP). Using paraffin-embedded formalin-fixed material obtained from the primary operation, an analysis of the correlation between nuclear ploidy and the proliferative index (PI) as quantified by flow cytometry with pre-treatment urinary cGMP was performed in 40 epithelial ovarian cancer (EOC) patients. The majority of the study group had advanced disease (28 FIGO III/IV) and residual disease (31). All but three (stage I) patients received single agent high dose cisplatinum as first-line therapy (100 mg m-2 x 5); in patients with evaluable disease there was a response rate of 64%. Thirty-one patients have died; the median survival of the study population being 27 months. There was a significant association between cGMP and PI. Significantly more aneuploid tumours had elevated PI values (P = 0.02). No variable predicted response. An initial univariate log rank analysis identified stage, the amount of residual disease, cGMP and PI as prognostic factors. Because of the interrelation between these and other factors and because PI did not conform to the proportional hazards model, a multivariate stepwise discriminant analysis was performed using survival at 36 months (the minimum follow-up for surviving patients) as the end-point. On the basis of this analysis, stage and residual disease were the most important prognostic factors, but cyclic GMP continued to have prognostic value even when these other factors were entered into the predictive model. However, the additional information gained has little clinical relevance.

Criteria for the design of fetal heart rate analysis systems

Criteria are described for the automated analysis of fetal pulse intervals, fetal movements and of uterine contractions measured externally, antenatally and interactively on-line, for implementation on a personal computer interfaced to an appropriate fetal monitor, and tested on 10,000 records. Measurements of short and longer term fetal heart rate variation are compared; both are required to identify sinister records. Recall and display of records acquired on the same patient over several weeks has proved a useful diagnostic aid.

Prevention of post-cone biopsy cervical stenosis using a temporary cervical stent

Stenosis of the residual cervix is not an infrequent complication of cone biopsy which may result in subfertility, problems with adequate follow-up and dysmenorrhoea. In an attempt to minimize this complication a temporary indwelling cervical support stent has been developed. This is sutured into the exposed cone bed immediately after cutting the cone specimen and removed 2 weeks later. A pilot study using this device in 33 cold knife conizations has been performed. There were no primary or secondary haemorrhages and no post-conization pelvic infections. At follow-up, 6 months after cone biopsy two patients (6%) had clinical cervical stenosis, and one patient (3%) complained of dysmenorrhoea (although the cervix was not stenosed). The cervical transformation zone was fully visible in 21/33 patients (64%) (95% CI 48 to 80) and follow-up smears contained endocervical cells in 20/33 patients (61%) (95% CI 44 to 78). These results compare very favourably with historical controls from the same unit and suggest that cone biopsy support stents should now be assessed in a prospective randomized trial.

Limitations of antenatal fetal heart rate monitors

Erroneous or doubtful decelerations in fetal heart traces were present in 111 of 1000 consecutive antenatal clinical records obtained by monitors with autocorrelation. The incidence was 20% in fetuses less than 30 weeks of gestational age. Their elimination reduced the number of "decelerative" records by 42%. Erroneous or doubtful accelerations were also present in 11% of records. These errors are caused by the fetal heart rate monitor and may contribute to the high intraobserver and interobserver variation on visual analysis. They can be detected by computer analysis.

Early serum CA125 response and outcome in epithelial ovarian cancer

The prognostic value of serum CA125 levels before and after two courses of chemotherapy was assessed in 50 patients with advanced epithelial ovarian cancer. Patients with serum CA125 values below 35 U/ml after two courses were significantly more likely to achieve complete remission and had a significantly longer median survival. In multivariate analysis, serum CA125 levels after two courses were the most important independent prognostic factor: it was possible to predict survival status at 12 months with an overall accuracy of 93%. Serum CA125 can be used to evaluate quantitatively chemotherapeutic response and at an early stage classify patients into good and poor risk groups. Such an approach would facilitate the selection of appropriate therapy and could reduce toxicity.

The potential for adjuvant therapy in early-stage cervical cancer

Adjuvant therapy may potentially improve prognosis in women with early-stage cervical cancer who are at high risk of relapse after primary therapy. Patients with lymph node involvement at surgery are at high risk of recurrence and may benefit from adjuvant therapy, but many patients are treated with radical radiotherapy. At present there is no method of accurately identifying patients at high risk of recurrence in the latter group. A retrospective analysis of 141 surgically managed cases with stage I/II a cervical cancer is presented. The study aims were to characterize patients at high risk of relapse, identify independent prognostic variables predicting for relapse and, using these variables, develop a model, that would accurately predict high-risk patients. Univariate analysis identified depth of invasion, substage, lymph node involvement, lymphatic and blood vessel invasion and tumour differentiation as significant prognostic variables. After stratification for depth of invasion, which did not conform to the proportional hazards assumption implicit in the Cox model, Cox regression analysis showed substage, lymphatic and vascular invasion and histological tumour type to be independent prognostic variables. Using these variables, classification models were constructed that would be applicable to patients treated with either surgery or radiotherapy. Applying the models to 110 cases with greater than 18 months follow-up, 11/18 (61%) and 11/19 cases (58%) predicted as being at high risk of relapse have developed recurrence. Highly active chemotherapy is now available for this disease. We have demonstrated that combined bleomycin, ifosfamide and cisplatin (BIP) is one of the most active regimens in this disease. BIP produces cytoreduction in around 70% of patients with recurrent and primary advanced disease. Responses are achieved rapidly and acute radiotherapy toxicity is not enhanced by giving chemotherapy prior to radical local radiotherapy. A multicentre, prospective randomized trial testing the role of BIP as adjuvant therapy in patients with positive nodes at radical hysterectomy is now in progress. A complementary study testing the role of adjuvant chemotherapy in high-risk patients treated with radical radiotherapy is in preparation.

Isolation and characterization of human fetal macrophages from placenta

Human fetal macrophages expressing class II major histocompatibility complex (MHC) antigens have been isolated from the stroma of the chorionic plate of term placentas, using enzymatic digestion procedures, and enriched by Percoll density centrifugation. These cells are adherent, phagocytic and express Fc receptors for IgG. By rosetting with bovine erythrocytes coated with IgG, they can be enriched to 77-95% purity. Placental macrophages isolated in this way stimulate the proliferation of lymphocytes from unrelated donors in mixed-cell cultures, and act as accessory cells in oxidative mitogenesis. In a family study, placental macrophages stimulated proliferation of maternal and paternal lymphocytes but there was no evidence for either priming to, or suppression by, the fetal cells when the responses of lymphocytes from the mother and her HLA identical twin were compared. The possibility that these cells can protect the fetus from infection and/or stimulate the production of maternal anti-fetal HLA-antibodies is discussed.

Vulval intraepithelial neoplasia--management and outcome

Forty-six patients with a primary diagnosis of vulval intraepithelial neoplasia (VIN) have been managed over a 10-year period. The prevalence of VIN has increased and the age at presentation has decreased over the last decade; 59% of our patients had histological evidence of human papillomavirus infection. Pruritus was the commonest symptom at presentation (59%). Of the 46 patients 44 were treated by laser skinning vulvectomy, local excision or simple vulvectomy. Symptomatic relief was best achieved by local excision. Clinical and definitive relapse occurred more often in the laser-treated group. The median time to relapse was 38 months in the laser-treated group and 74 months in the surgically treated group (excision and simple vulvectomy). Two patients have not been treated and their disease has not progressed. The carbon dioxide laser almost certainly has a role in conservative management and although our data possibly do not reflect its full potential they demonstrate a need for a controlled prospective study.