Gonadotrophin regulation of production of tissue inhibitor of metalloproteinases-1 by luteinized human granulosa cells: a potential mechanism for luteal rescue

Human granulosa cells were maintained in culture with extracellular matrix in the presence or absence of human chorionic gonadotrophin (HCG) using a defined culture medium. Such cultures are maintained by gonadotrophin in a manner suggesting that features of 'luteal rescue' may be occurring in vitro. Western analysis of culture medium demonstrated that the granulosa cells produced tissue inhibitor of metalloproteinases (TIMP)-1 but not TIMP-2. The presence of TIMP-1 in cultured cells was also detected immunocytochemically. Immunoassay of TIMP-1 output revealed that HCG exposure for 7 days caused a 2-fold increase in TIMP-1 production versus control reaching maximum at approximately 1 ng HCG/ml. The sensitivity of this response to HCG was similar to that observed for stimulation of progesterone production. Delayed addition of HCG, from day 4 of culture, elicited increases in TIMP-1 which were evident within 24 hours, and were not explained by changes in cell replication or survival. Removal of HCG from cultures previously luteinized with HCG for 6 days resulted in a fall in TIMP-1 production. Thus TIMP-1 production by luteinized granulosa cells in culture is gonadotrophin dependent. We speculate that prolonged cellular function associated with 'luteal rescue' may result from increased extracellular matrix stability mediated by up-regulation of TIMP-1 production.

Analysis of the maternal components of the AIDS clinical trial group 076 zidovudine regimen in the prevention of mother-to-infant transmission of human immunodeficiency virus type 1

To gain insight into the protective effects of the three components of the zidovudine regimen used in AIDS Clinical Trial Group (ACTG) 076 on mother-to-infant transmission of human immunodeficiency virus (HIV) type 1, 188 zidovudine-treated women and their untreated infants from five HIV-1 obstetric centers were retrospectively studied. The overall rate of mother-to-infant transmission was 12.3% (95% confidence interval [CI], 7.9%-18.0%). When the 38 women with <200 CD4 cells/microL were excluded, the mother-to-infant transmission rate was 8.8% (95% CI, 4.6%-14.8%). This rate compares favorably with the 8.3% transmission in the zidovudine arm of the ACTG 076 study. Apart from low (<200/microL) maternal CD4 cells (P = .016), no factors, including the duration of zidovudine therapy during gestation and intravenous administration of zidovudine during labor, affected the rate of mother-to-infant transmission. These findings suggest that antenatal oral zidovudine may be as effective as antenatal oral plus intravenous zidovudine during labor and the three-component ACTG 076 regimen in decreasing mother-to-infant HIV-1 transmission.

Influence of diabetes on group B Streptococcus colonization in the pregnant patient

To compare the incidence of group B Streptococcus colonization in diabetic (n = 98) and nondiabetic (n = 10) patients, 199 pregnant women were cultured at the vaginal introitus using a standardised technique. Eight diabetic patients had positive findings for group B Streptococcus cultures, and three nondiabetic patients had positive cultures. No significant difference (P = .109) was found in the group B Streptococcus colonization rates between these two groups of patients. In addition, no significant difference was found in the group B Streptococcal colonization rates between gestational and pregestational diabetics (P = .498). A within-group comparison of diabetic patients revealed that ethnicity (Hispanics versus nonhispanics) did generate a significant difference in the rate of colonization (P = .033). The results of the present study suggest that there is no substantial evidence to consider diabetes mellitus as a higher risk criterion for group B Streptococcus screening. However, population differences and ethnicity should be noted as important contributing factors when considering the implementation of group B Streptococcus screening protocols for pregnant women.

Factors associated with achievement of goals for home health care

With the introduction of Medicare's Prospective Payment System (PPS) and DRGs, the economic value of home health care services lies in its ability to reduce total patient care costs by the substitution of outpatient home care for inpatient hospital care. Analysis of service delivery patterns utilized by home health agencies in meeting goals for patient care will be an important ingredient in meeting these objectives. The purpose of this study was to determine if important patient characteristics known at the onset of home health care are predictive of utilization of home health services and/or the likelihood of meeting goals for home care established at the time of certification of care. Multivariate models were developed which predicted the odds of terminating with goals met based upon age, intensity of utilization, functional limitations, prognosis, presence of a caregiver, and type of patient condition. Results indicated that variability in likelihood of meeting goals for care is much better predicted by patient characteristics than by utilization of home care services.

Maternal viral load, zidovudine treatment, and the risk of transmission of human immunodeficiency virus type 1 from mother to infant. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group

BACKGROUND AND METHODS

A placebo-controlled trial has shown that treatment with zidovudine reduces the rate at which human immunodeficiency virus type 1 (HIV-1) is transmitted from mother to infant. We present data from that trial showing the number of infected infants at 18 months of age and the relation between the maternal viral load, the risk of HIV-1 transmission, and the efficacy of zidovudine treatment. Viral cultures were obtained, and HIV-1 RNA was measured by two assays in samples of maternal blood obtained at study entry and at delivery.

RESULTS

In 402 mother-infant pairs, the rate of transmission of HIV-1 was 7.6 percent (95 percent confidence interval, 4.3 to 12.3 percent) with zidovudine treatment and 22.6 percent (95 percent confidence interval, 17.0 to 29.0 percent) with placebo (P<0.001). In the placebo group, a large viral burden at entry or delivery or a positive culture was associated with an increased risk of transmission (the transmission rate was greater than 40 percent in the highest quartile of the RNA level). In both groups, transmission occurred at a wide range of maternal plasma HIV-1 RNA levels. Zidovudine reduced plasma RNA levels somewhat (median reduction, 0.24 log). Zidovudine was effective regardless of the HIV-1 RNA level or the CD4+ count at entry. In the zidovudine group, however, after we adjusted for the base-line HIV-1 RNA level and CD4+ count, the reduction in viral RNA from base line to delivery was not significantly associated with the risk of transmission of HIV-1.

CONCLUSIONS

A high maternal plasma concentration of virus is a risk factor for the transmission of HIV-1 from an untreated mother to her infant. The reduction in such transmission after zidovudine treatment is only partly explained by the reduction in plasma levels of viral RNA. To prevent HIV-1 transmission, initiating maternal treatment with zidovudine is recommended regardless of the plasma level of HIV-1 RNA or the CD4+ count.

Suppression of matrix metalloproteinase production by hCG in cultures of human luteinized granulosa cells as a model for gonadotrophin-induced luteal rescue

Granulosa cells were isolated from follicular aspirates collected at ovum recovery for in vitro fertilization. Cells were cultured in a defined medium on artificial extracellular matrix (Matrigel) in the presence or absence of hCG as a model for corpus luteum function. Release of cells from this culture system is reduced by hCG and this effect may be mediated through an inhibition of extracellular matrix degradation. Using zymography and western blot analysis, we confirm the identity of matrix metalloproteinases-2 and -9 in culture media. Matrix metalloproteinase-9 was the predominant gelatinase in freshly prepared granulosa cells and in culture media, and also represented a major metalloproteinase component in homogenates of early and mid-luteal phase samples of corpora lutea. Quantitative analysis of matrix metalloproteinases in culture media, obtained throughout the 14 day culture period and expressed per microgram of DNA, showed that matrix metalloproteinase-2, undetectable on day 2, rose throughout the culture period and that this rise was significantly inhibited by hCG. In contrast, matrix metalloproteinase-9 was clearly detectable on day 2 and remained relatively constant throughout much of the culture (day 2 to day 12) in the presence of gonadotrophin. Significantly increased production of matrix metalloproteinase-9 (day 6 to day 12) was evident in the absence of hCG. Our results provide further evidence for the hypothesis that the rescue of the corpus luteum in early pregnancy involves the maintenance of cellular function through the stabilization of the extracellular matrix.

The influence of some perinatal variables on neonatal blood pressure

Adult hypertension has been linked to fetal growth. This study investigates whether this link is evident in the newborn. We measured blood pressure by oscillometry in 248 healthy neonates on day 3/4 of life. Antenatal data and neonatal measurements were obtained from hospital records. Elevated neonatal blood pressure correlated with higher birthweight. There was no correlation between placental weight and blood pressure. Babies born by caesarean section had lower systolic blood pressure. Babies of maternal smokers had higher diastolic blood pressure, but their mothers (45% of this study) had lower blood pressure than non-smokers. Thus, smoking was associated with a significant change in both maternal and neonatal blood pressure, and may be an important influence on the developing cardiovascular system.

Pentoxifylline does not delay bacterially induced preterm delivery in rabbits

OBJECTIVE

Our purpose was to determine whether pentoxifylline, a potent cytokine inhibitor, would delay bacterially induced preterm delivery in rabbits.

STUDY DESIGN

The study was a randomized, blinded, prospective trial. Twenty-seven rabbits underwent laparotomy. Of these, five (shams) received an intrauterine injection of endotoxin-free water, and the remaining 22 received an injection of 10(5) Escherichia coli into the lower uterine segment. Postoperatively the animals that received the Escherichia coli were divided into two groups. The placebo group (n = 11) received subcutaneous injections of saline solution three times a day and the treatment group (n = 11) received pentoxifylline 20 mg/kg/day in three divided doses. The following parameters were evaluated: (1) time until delivery, (2) time until death, and (3) intrauterine pathologic features.

RESULTS

All five of the sham rabbits were delivered at term without any evidence of infection. There were no differences in the preterm delivery rates between the placebo group (eight of 11) and the pentoxifylline-treated group (seven to 11). However, there was a trend toward prolonging time until death in the treatment group. There were no differences in intrauterine pathologic feature between the placebo and treatment groups.

CONCLUSION

Pentoxifylline does not delay Escherichia coli induced preterm delivery in rabbits.

Preventable hospitalizations: a tool for planning and marketing ambulatory health care services

As the health care system evolves towards increased levels of managed care, planners and managers will need to understand how the utilization of ambulatory care services influences the use of more expensive hospital care. Preventable hospitalization, an index based on Ambulatory Care Sensitive (ACS) conditions, is proposed as an indicator for identifying communities with significant ambulatory care needs. The design and marketing of ambulatory health care services functionally adapted to meet the challenges of managed care will require new forms of health care information to plan, market, monitor, and evaluate the outcomes of health care policies and programs. An example is presented of the use of preventable hospitalizations as indicators of ambulatory care needs in 48 communities in Massachusetts.

Diagnosing gestational diabetes mellitus: use of a glucose screen without administering the glucose tolerance test

OBJECTIVE

To determine if a 1-hour glucose screen value could be identified, above which gestational diabetes mellitus could be diagnosed without the 3-hour oral glucose tolerance test (GTT).

METHODS

Demographic, historic, obstetric, and neonatal data from 514 singleton pregnancies with glucose screen values at least 140 mg/dL followed by a GTT were reviewed (312 patients with normal GTTs and 202 with gestational diabetes mellitus). Statistical analyses used chi2, Fisher exact, Student t, and Mann-Whitney tests. After determining the optimal glucose screen cutoff point using receiver operating characteristic curve analyses, patients were regrouped according to this value and analyzed further.

RESULTS

The optimal cutoff point for the upper limit of the glucose screen was determined to be 186 mg/dL (95.9% specificity, 98.2% negative predictive value, 36.1% sensitivity, and 19.6% positive predictive value). Comparison of patients with elevated screens and normal GTTs versus those with gestational diabetes revealed significant differences only regarding a history of gestational diabetes mellitus and neonatal hypoglycemia in the studied pregnancy. Those with screens greater than 185 mg/dL behaved like diabetic patients and, when compared with subjects with screens of 140-185 mg/dL, also had a significantly greater proportion of large for gestational age infants.

CONCLUSION

Patients with 1-hour glucose screens greater than 185 mg/dL have a high probability of gestational diabetes mellitus and the diagnosis can be made without the GTT. Using this approach could allow prompt initiation of therapy without the inconvenience and discomfort of the GTT.

Effect of human chorionic gonadotrophin on the detachment of human granulosa cells from extracellular matrix layered onto glass or plastic

We have previously shown that human granulosa cells cultured on a thin layer of extracellular matrix (ECM) are lost from culture in the absence of gonadotrophin. We now examine the effect of plating ECM onto glass or plastic. Such a comparison revealed that loss of cells from control cultures was more rapid when ECM was on glass, whereas cultures maintained with human chorionic gonadotrophin (HCG) showed greater stability when ECM was on plastic. The dose range of HCG required for the effect on cell retention was similar to that required for stimulation of progesterone production. Electron microscopy of cells freshly released as clusters revealed that many cells appeared undamaged, and confocal microscopy of cells stained with propidium iodide showed an absence of fragmented nuclei. Taken together, this evidence suggests that apoptosis is not the cause of cell release. We conclude that cells are released from culture, not as a result of cell death, but via an active process suppressed by HCG.

Prenatal diagnosis and therapy for a fetal hepatic vascular malformation

BACKGROUND

Congenital hepatic arteriovenous malformations complicated by high-output heart failure and hematologic derangements are associated with up to 90% mortality. Prenatal diagnosis alerts the pediatrician to the need for early neonatal intervention.

CASE

A fetal hepatic arteriovenous malformation with associated high-output cardiac failure was diagnosed at 29 weeks' gestation using real-time and color flow Doppler sonography. Hydrocortisone injected directly into the umbilical vein and the amniotic sac resulted in appreciable improvement in hemodynamic and hematologic indices. The pregnancy ended in a preterm delivery at 31 weeks with no evidence of heart failure at birth.

CONCLUSION

The compromised preterm fetus with a hepatic arteriovenous malformation can be treated in utero, avoiding early emergency delivery.

Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group

BACKGROUND AND METHODS

Maternal-infant transmission is the primary means by which young children become infected with human immunodeficiency virus type 1 (HIV). We conducted a randomized, double-blind, placebo-controlled trial of the efficacy and safety of zidovudine in reducing the risk of maternal-infant HIV transmission. HIV-infected pregnant women (14 to 34 weeks' gestation) with CD4+ T-lymphocyte counts above 200 cells per cubic millimeter who had not received antiretroviral therapy during the current pregnancy were enrolled. The zidovudine regimen included antepartum zidovudine (100 mg orally five times daily), intrapartum zidovudine (2 mg per kilogram of body weight given intravenously over one hour, then 1 mg per kilogram per hour until delivery), and zidovudine for the newborn (2 mg per kilogram orally every six hours for six weeks). Infants with at least one positive HIV culture of peripheral-blood mononuclear cells were classified as HIV-infected.

RESULTS

From April 1991 through December 20, 1993, the cutoff date for the first interim analysis of efficacy, 477 pregnant women were enrolled; during the study period, 409 gave birth to 415 live-born infants. HIV-infection status was known for 363 births (180 in the zidovudine group and 183 in the placebo group). Thirteen infants in the zidovudine group and 40 in the placebo group were HIV-infected. The proportions infected at 18 months, as estimated by the Kaplan-Meier method, were 8.3 percent (95 percent confidence interval, 3.9 to 12.8 percent) in the zidovudine group and 25.5 percent (95 percent confidence interval, 18.4 to 32.5 percent) in the placebo group. This corresponds to a 67.5 percent (95 percent confidence interval, 40.7 to 82.1 percent) relative reduction in the risk of HIV transmission (Z = 4.03, P = 0.00006). Minimal short-term toxic effects were observed. The level of hemoglobin at birth in the infants in the zidovudine group was significantly lower than that in the infants in the placebo group. By 12 weeks of age, hemoglobin values in the two groups were similar.

CONCLUSIONS

In pregnant women with mildly symptomatic HIV disease and no prior treatment with antiretroviral drugs during the pregnancy, a regimen consisting of zidovudine given ante partum and intra partum to the mother and to the newborn for six weeks reduced the risk of maternal-infant HIV transmission by approximately two thirds.

Pulmonary artery sarcoma in a pregnant woman: report of a case

BACKGROUND

We report the case of a 23-year-old pregnant woman with hemoptysis, cor pulmonale, and pulmonary artery sarcoma. The physiologic changes of pregnancy may have unmasked the pulmonary lesion.

CASE

A 23-year-old woman presented at 28 weeks' gestation with acute onset of hemoptysis and dyspnea. A hilar mass was noted and a pulmonary embolus was diagnosed. Biopsy of the hilar mass was nondiagnostic. Emergency cesarean delivery was performed because of rapid clinical deterioration and an acute loss of fetal heart tones. Both mother and infant died. Autopsy of the mother demonstrated a large pulmonary artery sarcoma with metastases to both lungs and terminal bacterial bronchopneumonia.

CONCLUSION

Hemodynamic changes of pregnancy may have unmasked the pulmonary lesion in this case. Pulmonary artery sarcoma is an extremely rare tumor.

Abdominal rescue using the vacuum extractor after entrapment of the aftercoming head

BACKGROUND

Fetal replacement into the uterus for ceasarean delivery after failed vaginal delivery has been reported for both vertex and breech presentations. Although an option, this mode of delivery frequently is the last maneuver to deliver a viable infant after other methods to allow vaginal delivery have failed. We report the adjunctive use of a vacuum extractor to facilitate abdominal rescue after entrapment of the aftercoming head during an attempted vaginal breech delivery.

CASE

A multiparous woman presented at term with two fetal feet bulging through the membranes at the introitus. During vaginal breech delivery, the aftercoming head became entrapped. Unsuccessful maneuvers to facilitate descent included Dührssen incisions, the Mauriceau maneuver, placement of Piper forceps, and halothane administration. At emergency ceasarean delivery, the infant was pushed upward from below, and rapid, successful delivery of a 2530-g neonate was accomplished with assistance by a vacuum extractor. Apgar scores were 3, 6, and 7 at 1, 5, and 10 minutes, respectively. Umbilical artery blood gas revealed a pH of 7.18 and base excess of -6. A head sonogram and electroencephalogram were normal. Both mother and infant were discharged without complications.

CONCLUSION

After entrapment of the aftercoming head during attempted vaginal breech delivery, use of the vacuum extractor may expedite the abdominal rescue and ceasarean.

Potential for bias in studies of the influence of human immunodeficiency virus infection on the recognition, incidence, clinical course, and microbiology of pelvic inflammatory disease

As the human immunodeficiency virus (HIV) epidemic affects more women, clinicians are increasingly observing pelvic inflammatory disease (PID) in HIV-infected women. The extent to which PID is a factor in the recognition of HIV or HIV is a factor in the recognition of PID is unknown. Even less is known about how HIV infection influences the development, clinical course, and microbiology of PID. The paucity of existing data largely results from difficulties in designing studies that are free of bias. Several biases may distort studies of the effect of HIV on the recognition, incidence, clinical presentation and course, and microbiology of PID. Selection bias, diagnostic bias, and confounding bias are the most likely causes of invalid conclusions in studies of the influence of HIV infection on these aspects of PID, for three major reasons: Factors that determine patients' health care seeking behavior may be related to HIV status; the diagnosis of PID tends to be imprecise; and extraneous factors that cause or prevent PID may be distributed differently in HIV-infected and HIV-uninfected women. Appropriate study design and analytic techniques can eliminate, reduce, or estimate the magnitude and direction of these biases, thereby yielding more valid conclusions. To interpret properly existing and future studies of the influence of HIV infection on PID, clinicians must consider several biases that may distort results.

Caudal regression syndrome: etiopathogenesis, prenatal diagnosis, and perinatal management

Caudal regression syndrome represents a continuum of congenital malformations ranging from agenesis of the lumbosacral spine to the most severe cases of sirenomelia with lower extremities fusion and major visceral anomalies. The etiology of this syndrome is not well known. Maternal diabetes, genetic predisposition, and vascular hypoperfusion have been suggested as possible causative factors. The degree of associated anomalies usually parallels the severity of the primary defect. Ultrasonography is the diagnostic tool of choice revealing the absent distal vertebrae of the fetal spine. Amnioinfusion and magnetic resonance imaging (MRI) are of help in better evaluation of the fetal anatomy in cases with oligohydramnios. Perinatal management depends mainly on gestational age at diagnosis and severity of the lesion. It should include genetic counseling and serial sonography to assess interval growth and amniotic fluid volume. Surviving infants have usually a normal mental function and they require extensive urologic and orthopedic assistance. Their long-term morbidity consists mostly of neurogenic bladder dysfunction resulting in progressive renal damage and disabling neuromuscular deficits of the lower extremities. Neurosurgical and orthopedic intervention with physical rehabilitation is indicated to improve the quality of their lives.

Intraligamentary pregnancy

Intraligamentary pregnancy, although rare, tests the physician's acumen in diagnostic and therapeutic skills. Two cases illustrating this entity are presented, the first involves an 18-week fetus, the second a partial hydatidiform mole. Although their presentation and pathogenesis may be indistinguishable, their clinical course and management is different. To the best of our knowledge, this is the first reported case of an intraligamentary pregnancy involving a partial hydatidiform mole.

A non-hemorrhagic manifestation of vasa previa: a clinicopathologic case report

BACKGROUND

The rare entity of vasa previa occurs when fetal vessels lying between the amniotic and chorionic membranes cross the cervical os. This report presents a case that was associated with vessel compression and concomitant adverse effects on fetal hemodynamics.

CASE

A 23-year-old nulliparous woman at 36 weeks' gestation developed persistent, progressive severe variable decelerations several hours after spontaneous rupture of the membranes, resulting in a decision to perform a cesarean. At delivery, fetal vessels were noted in the membranes near the cervical os, leading into a marginally inserted cord. The decelerations were attributed to compression of the unprotected umbilical arteries by the fetal head.

CONCLUSION

Vasa previa often results in fetal death and may be associated with fetal hemorrhage, but lack of bleeding does not exclude the existence of vasa previa. Altered fetal hemodynamics from varying degrees of vessel compression by the presenting part during labor may result in hypoxia and acidosis. A high index of suspicion is necessary to make the diagnosis and institute proper, timely management.