[Epilepsy and pregnancy]

One out of 200 pregnant women suffers from epilepsy. Pregnancy and epileptic disease or its medical treatment, respectively, do interfere, as on the one hand serum concentration of antiepileptic drugs can severely be altered during pregnancy. On the other hand these drugs cause a fetal malformation rate 2-3 times higher than in an average population. These facts demand an interdisciplinary cooperation between neurologists, pediatricians and obstetricians. Preconceptional advice should lead to a preventive folic acid medication and information about the higher risk for preterm delivery, intrauterine growth retardation or fetal death as sequelae of epileptic attacks. In antepartal investigations the emphasis should be on the sonographic diagnosis of fetal malformations and on regular control of serum concentration of antiepileptic drugs. During labor a tight fetal monitoring is obligatory. There is no indication for a primary cesarean section. The risk of neonatal hemorrhage due to a lack of vitamin K is reduced by prophylactic medication. Under optimal conditions about 90% of pregnancies and deliveries will be uncomplicated. During puerperium serum levels of antiepileptics should be controlled again. Breastfeeding is possible.

Three dimensional volume measurement of the cervix during pregnancy compared to conventional 2D-sonography

OBJECTIVE

To compare the three dimensional (3D) volume assessment of the cervix with the conventional two-dimensional cervical length measurement in a low and a high risk group for cervical incompetence.

METHODS

In an observational study, we investigated a group A of low risk pregnancies (no preterm contractions, no vaginal bleeding or vaginal infections and no history of preterm delivery) and a group B of high risk pregnancies (preterm contractions or PROM). All patients underwent a transvaginal ultrasound investigation with a 7.5 MHz probe using a three-dimensional ultrasound system (Combison 530, Kretztechnik, Austria). After measuring the cervical length, the internal os and the funneling with the B-mode, 3D-volume was recorded twice by the same investigator using the same machine. Since 2D-length measurement of the cervix has been established to be predictive for spontaneous preterm delivery, we wanted to test whether 3D-volume assessment has a better discriminative power to differentiate a high-risk from a low-risk group. Therefore the 2D and 3D measurements (mm, resp. cm3) were compared between patient groups A and B using the two tailed Student t-test and Fisher's Exact test.

RESULTS

In 2D cervical length measurement the mean cervical length in group A was significantly longer than in group B: 41.1 +/- 8.61 mm and 27.77 +/- 10.42 mm, P = 0.00000017. In 3D-sonography the mean cervical volume was larger in group A, but the difference compared to group B was not significant: 47.71 +/- 18.38 mm and 39.90 +/- 12.57 mm, P = 0.07.

CONCLUSION

Contrary to our hypothesis cervical length measurement therefore was superior to cervical volume measurement assessed by 3D ultrasound for identifying women with increased risk of spontaneous preterm delivery. This may be due to the larger distribution of measurement values in the 3D group.

Low rates of pregnancy termination for prenatally diagnosed Klinefelter syndrome and other sex chromosome polysomies

Over the past 9 years we counseled 55 couples whose unborn child was found to carry a sex chromosome polysomy. We performed a survey of postcounseling parental decisions about continuation or termination of these pregnancies. Of the 55 embryos or fetuses, 23 had the karyotype 47,XXY, 10 had 47,XYY, and 12 had 47,XXX. In addition, there were 10 instances of true mosaicism, i.e. 47,XXY/46,XY (n = 5), 47,XYY/46,XY (n = 2), or 47,XXX/46,XX (n = 3). Mean gestational age (+/-standard deviation) at diagnosis was 18.3+/-3.0 weeks. After comprehensive genetic counseling 48 (87.3%) of these pregnancies were carried to term. In seven cases (12.7%) the parents elected a pregnancy termination. Two of 31 pregnancies (6.5%) primarily ascertained at our center were aborted, whereas amongst the 24 referred cases, 5 couples (20.8%) opted for a termination. The mean gestational age of the terminated pregnancies was 19.7 weeks. The overall termination rate of 12.7% appears low in comparison with literature data. Most reports from other institutions present termination rates between 32 and 66%. The reason for the low rate of induced abortions in our study cohort is not clear. Cultural differences in parental perception of sex chromosomal polysomies may be of importance, and peculiarities of genetic counseling at our institution could also play a role. Although counseling was nondirective, we did put emphasis on providing prospective parents with information from unbiased follow-up studies of children with Klinefelter syndrome and other sex chromosome polysomies.

Quantitative immunophenotypic characterization, cryopreservation, and enrichment of second- and third-trimester human fetal cord blood hematopoietic stem cells (progenitor cells)

OBJECTIVE

The aims of this study were (1) to assess the hematopoietic stem cell (progenitor cell) contents of umbilical cord blood samples from second-trimester and early-third-trimester fetuses versus term fetuses and (2) to determine the feasibility of cryopreservation and enrichment of cord blood from fetuses of different gestational ages.

STUDY DESIGN

Cord blood between 13 and 42 weeks' gestation (n = 31) was sampled after delivery or fetal expulsion. Fluorescence-activated cell sorting was used to measure CD34(+) and CD34(+)CD38(-) cell numbers. Samples were cryopreserved with 10% dimethylsulfoxide, and CD34(+) enrichment was performed by magnetically activated cell sorting with the MiniMACS system (Miltenyi Biotech, Bergisch Gladbach, Germany). Kruskal-Wallis analysis of variance and the Mann-Whitney U test were used for analysis of data.

RESULTS

CD34(+) and CD34(+)CD38(-) cell contents were significantly higher in second- and early third-trimester fetuses than in term fetuses (CD34(+) 2.57% +/- 0.38%, 1.48% +/- 0. 31%, and 0.7% +/- 0.13%, respectively, P =.0067; CD34(+)CD38(-) 0. 72% +/- 0.26%, 0.18% +/- 0.05%, and 0.06% +/- 0.02%, respectively, P =.0132). Mononuclear cell recovery, viability, and CD34(+) cell purity after cryopreservation and enrichment were similar among different gestational ages.

CONCLUSION

Cord blood stem cell content decreases significantly from the second trimester to term. Cryopreservation and enrichment of these cells from earlier gestational ages is feasible. This might be especially useful for allogeneic stem cell transplantation and for in utero gene therapy.

[Prenatal diagnosis with fetal cells in maternal blood: report of experiences in Basal]

Currently prenatal diagnosis relies on invasive procedures such as chorion villus sampling (CVS) or amniocentesis (AC). Many parents are reluctant to expose themselves and their child to the small, but significant risk posed by these procedures to mother and child. There is, hence, a great need for a risk-free non-invasive alternative. To achieve this goal most research has been focussed on enriching fetal cells from the blood of pregnant women. The erythroblast has emerged as the target cell of choice, since it is abundant in the early fetus, rare in normal adult blood, and since it has a very short half life, there is no risk of obtaining cells from previous pregnancies. Most enrichment protocols rely either on magnetic- or fluorescent activated cell sorting (MACS and FACS) using fetal specific antibodies. These enriched cells can be examined by FISH (fluorescence in-situ hybridisation) for the presence of the most common fetal chromosomal aneuploidies (13, 18, 21, X and Y) or by polymerase chain reaction (PCR) on singly manipulated cells for genetic disorders. The efficacy in detecting fetal aneuploidies is currently being evaluated in a phase II clinical trial under the auspices of the NIH-NICHD, the so-called NIFTY Trial, in which our group is a participant. By modifying our enrichment protocols we have recently been able to obtain detection sensitivities of almost 80%, thereby renewing our optimism that this methodology provides a solid basis for an effective non-invasive prenatal diagnostic test.

[Establishing an umbilical cord blood bank for unrelated allogenic stem cell transplantation]

We report the establishment of a cord-blood bank in a routine hematological laboratory. Cord-blood collection was performed with placenta in utero by a trained team and immediately sent to the cord-blood bank. There, 6.8 ml cord-blood was used for analysis of nucleated cell counts, counts of CD34-positive cells, CFU's, complete HLA-typing, ABO and Rhesus blood groups, bacteriologic cultures and serology for HIV 1 and 2, HbsAg, HVC, CMV, syphilis and toxoplasmosis. The cord-blood collection was frozen and conserved at -192 degrees C. From each cord-blood vials of DNA, viable cells and plasma were cryopreserved. Between June 1997 and April 1998, 54 cord-bloods were collected. 40 of them were cryo-preserved, and 14 discarded because of low cell counts. The median volume was 109 ml with 1.4 x 10(9) nucleated cells. The in vitro capacity of proliferation of the cord-blood correlated well with the absolute counts of CD34-positive cells (r = 0.93), moderately with the relative counts of CD34 (r = 0.68) as well as the nucleated cells (r = 0.70), poorly with the volume (r = 0.44). Three of the 40 (7.5%) cord-blood products contained a bacterial contamination. This study shows that a cord-blood bank can be organised in a routine hematological laboratory, which is familiar with transplantation products. However, the procedure is time consuming, expensive and requires a highly qualified team and specialised technical equipment.

Pregnancy and lactation in homozygous beta-thalassemia major

Successful pregnancies in patients with transfusion-dependent homozygous beta-thalassemia major are rare. We report the course of a pregnancy and newborn data during lactation and desferrioxamine therapy in the mother. The twin-pregnancy was complicated by preeclampsia. Besides normal iron level in breast milk, no clinical or hematological abnormalities due to desferrioxamine therapy could be shown in the newborns. Our observation suggests that chelating therapy during lactation does not alter iron excretion in breast milk or iron metabolism in offsprings. Breast feeding in newborns from patients with thalassemia major and desferrioxamine therapy seems justified.

Enrichment of fetal nucleated red blood cells from the maternal circulation for prenatal diagnosis: experiences with triple density gradient and MACS based on more than 600 cases

OBJECTIVE

We wanted to obtain statistically relevant data about the efficiency of our method for the isolation of fetal nucleated red blood cells (NRBCs) from the maternal circulation.

METHODS

More than 600 samples were investigated using a triple density gradient followed by magnetic separation of anti-CD71-labeled cells, and yields and purities of recovered NRBCs were determined.

RESULTS

The enrichment effectivity as well as the morphological condition of cells was reproducibly good, if blood samples were enriched within 48 h after sampling. The efficacy was independent of various methodological parameters and our technique was superior to other magnetic cell-sorting techniques. Mean yields and purities of NRBCs increased with increasing gestational age, ranging from 100 to 1,000 cells per 40-ml blood sample and from 0.1 to 1%, respectively, from the 6th week of gestation to term. In pregnancies with preeclampsia NRBCs were increased by a factor of 10.

CONCLUSION

Our enrichment technique proved to be optimized with respect to various methodological parameters, which were compared in the present study, and it is efficient and reproducible for the enrichment of NRBCs from the maternal circulation in all three gestational trimesters.

Highly accurate analysis of heterozygous loci bysingle cell PCR

Single cell PCR is a powerful method for determining the genetic properties of individual cells. In the instance of heterozygous loci, however, preferential amplification of one allele can lead to allele drop out (ADO) of the other allele. Fortunately ADO does not occur in all amplifications, and is usually random when it does occur, with both alleles being equally susceptible to drop out. Therefore pooling of results from multiple independently amplified cells should greatly improve the analysis of diallelic loci, and the misdiagnosis rate of diallelic loci should decrease exponentially with the number of cells analysed. We have shown that this is true and that multiplex PCR allows for the simultaneous identification of a cell in a mixture of cells using microsatellite loci known to be informative, and accurate genotyping at other loci. This approach has practical applications to non-invasive prenatal diagnosis where small numbers of fetal cells in the presence of maternal cells must be both identified and genotyped at loci involved in genetic disease.

Detection of fetal messenger ribonucleic acid in maternal blood to determine fetal RhD status as a strategy for noninvasive prenatal diagnosis

OBJECTIVES

Our purpose was to test the hypothesis that reverse transcriptase-polymerase chain reaction for fetal messenger ribonucleic acid in maternal blood is more sensitive than polymerase chain reaction from genomic deoxyribonucleic acid in prenatal determination of fetal RhD blood type.

STUDY DESIGN

Fetal nucleated erythrocytes in peripheral blood from 35 RhD-negative women were enriched by triple-density gradient centrifugation, anti-CD71 magnetic sorted, and deoxyribonucleic acid and ribonucleic acid extracted. Sensitivities of reverse transcriptase-polymerase chain reaction and polymerase chain reaction were compared to predict definitive fetal RhD blood type determined in fetal tissues.

RESULTS

Reverse transcriptase-polymerase chain reaction was significantly more accurate (P = .03) than genomic-polymerase chain reaction in predicting fetal RhD blood type, both overall (28 of 35 vs 22 of 35) and when the fetus was RhD-positive (12 of 19 vs 6 of 19).

CONCLUSIONS

Reverse transcriptase-polymerase chain reaction is more sensitive than genomic-polymerase chain reaction in detection of fetal RhD sequences in maternal blood.

Prenatal diagnosis using fetal cells enriched from maternal blood

The ability to use fetal cells enriched from the blood of pregnant women for prenatal diagnosis has been a long-sought goal for those pursuing a non-invasive alternative to current methods, such as amniocentesis or chorionic villus sampling. Several new developments, which rely either on fluorescence in situ hybridization or the combination of single-cell manipulation and subsequent polymerase chain reaction practices, which are common to the field of preimplantation genetics, have been tested. We discuss the significance of these developments and the obstacles that still have to be surmounted before this technology becomes available in a broad diagnostic use. The research in the field yielded important observations regarding the traffic of cells between the fetus and the mother, which may provide a new insight into the development of disorders such as preeclampsia and the associated HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome.

[Umbilical cord blood transplantation: acceptance of umbilical cord blood donation by pregnant patients]

BACKGROUND/OBJECTIVE

Umbilical cord blood is an alternative source for allogeneic transplantation of hematopoietic stem cells from related and unrelated donors. It can easily be collected, cryopreserved and stored in cord blood banks for later use. In Switzerland, cord blood banks for related and unrelated stem cell transplantation are being established. The aim of the study was to evaluate previous knowledge of the possible medical use of cord blood and acceptance of cord blood banking in pregnant women.

METHODS

We performed a prospective open study using a structured, anonymous questionnaire at the University of Basel Women's Hospital pregnancy outpatient clinic. After concise information on the use of cord blood for transplantation, questions were asked concerning previous knowledge of the use of placenta and cord blood in general, concerning the attitude to donation of cord blood for transplantation, and the respondent's willingness to donate cord blood of her own child. Women of different ethnic background were compared.

RESULTS

From 300 questionnaires handed out to pregnant women of different ethnic background attending our outpatient clinic, 250 (83%) were returned, and 245 could be evaluated for final analysis. Only 40% indicated that they did know what usually happens to the placenta after birth. In contrast, the vast majority (95%) supported the idea of umbilical cord blood for banking and later use for stem cell transplantation. Similarly, 93% stated that they would agree to donate the cord blood from their own child for this purpose, while no statistically significant differences could be identified either between women with or without previous knowledge or of different ethnic background.

CONCLUSIONS

This study shows the high acceptance of umbilical cord blood donation for banking and stem cell transplantation purposes in pregnant women, irrespective of previous knowledge. As there are no major differences between women of different ethnic background, a high degree of diversity of HLA-types of donated cord blood samples can be expected and may offset the underrepresentation of ethnic minorities in bone marrow donor registries.

Disturbed feto-maternal cell traffic in preeclampsia

OBJECTIVE

To investigate whether the transfer of fetal blood cells to the maternal circulation is perturbed in pregnancies affected by preeclampsia.

METHODS

Fetal erythroblasts were isolated from eight women with clinically diagnosed preeclampsia (blood pressure values of at least 140/90 mmHg and associated proteinuria) and an equal number of matched corresponding controls. All patients in both groups were pregnant with male singleton fetuses. The presence of fetal cells was evaluated histologically and by fluorescence in situ hybridization for X and Y chromosomes.

RESULTS

The number of fetal cells was higher in preeclamptic patients than in controls, with respect to both nucleated red blood cells (median per 200 cells 38 versus 7; P < .001) and the proportion of these cells that were of fetal origin (median per 2000 cells 9 versus 2; P = .001).

CONCLUSION

These results suggest that the trafficking of fetal cells into the maternal periphery is disturbed in patients with preeclampsia. Because it is unlikely that such an altered flow of cells is restricted to the erythroblasts examined in this study, these findings also may lead to interesting new concepts regarding the development of preeclampsia and possibly the associated syndrome of hemolysis, elevated liver enzymes, and low platelets.

Virilizing ovarian tumor of low malignant potential associated with antecedent tamoxifen use for breast cancer

A patient is described who was treated with tamoxifen for breast cancer and developed an androgen-producing ovarian tumor of low malignant potential, which itself is a rare condition. Clinically overt virilism was leading to the diagnosis and promptly improved after surgical removal of the tumor. A causal relationship between tamoxifen use and the tumor is discussed on the basis of the known tumor-inducing potential of tamoxifen.

In vitro volume measurement by three-dimensional ultrasound: comparison of two different systems

The aim of this study was to compare volumetric capabilities in vitro between two different three-dimensional technical modalities with a transvaginal transducer. We intended to evaluate the effect of different sizes and shapes on the accuracy of the measurements, and to establish criteria for choosing the appropriate system for three-dimensional volume measurement. We did not find significant differences between the two systems, either in the results or in their operation. We confirmed the high accuracy of three-dimensional volume measurements in vitro.

Cystic hygroma as an early first-trimester ultrasound marker for recurrent Fryns' syndrome

We present a case of a fetus who at a 12-week ultrasound examination was shown to have a large cystic hygroma. Fryns' syndrome was suspected because the mother's previous pregnancy had been affected by the condition. Pathological examination confirmed the diagnosis at this early stage of gestation. In families with increased risk for Fryns' syndrome, first-trimester ultrasound screening should be offered to exclude cystic hygroma as an ultrasound marker for this most often lethal malformation.

Neural tube defects in chromosomally normal and abnormal human embryos

Neural tube defects (NTDs) were recognized in eight out of 91 intact embryos from spontaneous abortions and in one case of an induced abortion following prenatal diagnosis of a chromosomal disorder. Five of the nine cases showed chromosomal abnormalities. Trisomy 18 and triploidy were associated with spina bifida in three cases, trisomy 7 with parieto-occipital encephalocele and monosomy X with spina bifida and iniencephaly in one case. A sixth anencephalic embryo in which chromosomal analysis was not performed showed a malformation pattern highly suggestive for trisomy 18. Discussion focuses on the high rate and the type of chromosomal abnormalities among spontaneously aborted NTD embryos, on the contrasting phenotype of 45,X conceptions and on the morphogenesis of the different neural tube defects in early development. In view of future early endovaginal ultrasound diagnosis, the changing morphological pattern is exemplified, and ranges from apparently hyperplastic to degenerative alterations of the exposed neural tissue.

Transcervical intrapartum amnioinfusion: a simple and effective technique

OBJECTIVE

To test a simple method of intrapartum amnioinfusion to replace amniotic fluid during labor in cases of prolonged labor and severe variable fetal heart rate decelerations or thick meconium.

STUDY DESIGN

We conducted a prospective study of intrapartum amnioinfusion in sixteen consecutive patients. A simple transcervically placed Foley bladder catheter was used for intrauterine infusion of saline solution, while monitoring was performed by external cardiotocography.

RESULTS

In twelve patients, catheter placement was easily performed; the remaining four required stabilization by a mandrel for insertion. Amnioinfusion was effective in ten out of thirteen patients for relief of fetal heart rate anomalies. No complications were observed; all had good neonatal outcome.

CONCLUSIONS

In our small, uncontrolled study, this amnioinfusion method proved to be a simple, inexpensive, effective and safe technique for the relief of severe heart rate anomalies in prolonged labor.

A double-blind comparison of the safety and efficacy of intravaginal misoprostol and prostaglandin E2 to induce labor

OBJECTIVE

Our purpose was to compare the safety and efficacy of intravaginally administered misoprostol versus prostaglandin E2 for labor induction in a double-blind, randomized trial.

STUDY DESIGN

One hundred three patients with indications for labor induction (including prelabor rupture of membranes) were randomized and received either misoprostol 50 micrograms or prostaglandin E2 (dinoprostone) 3 mg intravaginally. The dose was repeated 6, 24, and 30 hours after the first dose until active labor was achieved. For proper blinding, the drugs were prepared as identical-looking vaginal tablets.

RESULTS

With use of a random number-generated table 52 patients were allocated to the misoprostol group and 51 to the prostaglandin E2 group. After exclusion of 3 patients, 50 in each group were evaluated. Delivery within 24 hours after administration occurred more often in the misoprostol group (70% vs 46% in the prostaglandin E2 group, p = 0.009), and fewer patients in this group needed more than two doses (12% vs 30%, p = 0.027). No difference in cesarean section rate (12% vs 14%, p = 0.67), fetal heart rate anomalies (33% vs 34%, p = 0.89), tachysystole (8% vs 14%, p = 0.37), hyperstimulation syndrome (0% vs 2%, not significant), meconium passage (28% vs 18%, p = 0.22), and fetal outcome (Apgar score at 1 and 5 minutes, arterial and venous umbilical cord blood pH, transfer to neonatal intensive care unit) was noted between the two groups.

CONCLUSION

Intravaginal misoprostol is a safe drug for labor induction with superior effectiveness compared with intravaginal prostaglandin E2.