Multi-organ Metastasis of Fibrolamellar Hepatocellular Carcinoma in a Malayan Gharial (Tomistoma schlegelii)

A 38-year-old Malayan gharial (Tomistoma schlegelii) with a 2-week history of anorexia was found dead and presented for post-mortem examination. Numerous white firm nodules of various sizes were found on the surface of the liver, both left and right kidneys, the spleen and the serosa of the intestinal tract. All masses had similar microscopical appearance and were diagnosed as metastasizing fibrolamellar hepatocellular carcinoma. Immunohistochemically, the tumour cells did not react with antibodies specific for pan-cytokeratin, vimentin or HepPar-1. The anti-HepPar-1 and anti-pan-cytokeratin antibodies also did not react with normal hepatocytes or exocrine pancreatic cells. This is the first description of fibrolamellar hepatocellular carcinoma with metastases in a crocodilian.

Probing the validity of average Hamiltonian theory for spin I=1, 3/2 and 5/2 nuclei by analyzing a simple two-pulse sequence

In this work, we investigate the accuracy of controlling spin I=1, 3/2 and 5/2 spin systems by average Hamiltonian theory. By way of example, we consider a simple two-pulse echo sequence and compare this perturbation scheme to a numerical solution of the Von Neumann equation. For the different values of I, we examine this precision as a function of the quadrupolar coupling as well as various experimental parameters such as the pulse spacing and pulse width. Experiments and simulations on I=3/2 and I=5/2 spin systems are presented that highlight a spectral artifact introduced due to finite pulse widths as predicted by average Hamiltonian theory. The control of these spin systems by this perturbation scheme is considered by investigating a phase cycling scheme that suppresses these artifacts to zeroth-order of the Magnus expansion.

The role of hyperglycosylated hCG in trophoblast invasion and the prediction of subsequent pre-eclampsia

OBJECTIVE

Hyperglycosylated hCG (HhCG) is the predominant form of chorionic gonadotrophin in states characterized by aggressive trophoblast invasion such as early pregnancy or choriocarcinoma. Pre-eclampsia may be the result of failed or inadequate trophoblast invasion. We investigated whether low levels of maternal urine HhCG levels would predict subsequent pre-eclampsia.

STUDY DESIGN

Mid-trimester urine (14-21 weeks) was collected and frozen from non-hypertensive women undergoing genetic amniocentesis. Inclusion criteria were: normal singleton pregnancies without a prior history of pre-eclampsia, hypertension, diabetes or other vascular disorders. The specimens were subsequently thawed, and HhCG levels standardized to urine creatinine were measured. Maternal charts were reviewed after delivery to determine the development of pre-eclampsia. There were a total of 568 study subjects.

RESULTS

Pre-eclampsia developed in 26 (4.6%) women. There was a significant correlation between low urine HhCG and subsequent pre-eclampsia (Mantel-Haenszel test of linear association: Chi-square 10.52, p=0.001). The mean HhCG level (ng/mg creatinine) was significantly greater in normals than in those destined to develop pre-eclampsia: 42.7 versus 20.3, p=0.002 (Mann-Whitney U-test). There was a progressive increase in the risk of subsequent pre-eclampsia as HhCG levels fell: HhCG < or =0.9 MoM RR (95% CI)=1.51 (1.15-1.98) compared with < or =0.1 MoM 10.42 (2.0-54.3).

CONCLUSION

Low maternal mid-trimester urine HhCG predicted subsequent pre-eclampsia. This appears to support the view that pre-eclampsia results at least in part from poor trophoblast invasion. Thus, HhCG may play a role in trophoblast invasion and measurement of this in urine identifies women at high risk for developing pre-eclampsia.

No association of vitamin D receptor gene BsmI polymorphisms with calcium oxalate stone formation

BACKGROUND AND PURPOSE

The formation of urinary stones is reported to be associated with the vitamin D receptor (VDR). As the most frequently seen polymorphism within the VDR gene is BsmI, it has been used as a genetic marker in searching for the cause of urolithiasis. We aimed to evaluate the association between calcium stone disease and the BsmI polymorphisms.

MATERIALS AND METHODS

A control group of 90 healthy people and a group of 124 patients with calcium oxalate stones were examined. The polymorphism was detected using polymerase chain reaction (PCR)-based restriction analysis. A PCR product length was determined to be 580 bp (BB) whereas two fragments of 405 bp and 175 bp were determined to be excisable (bb) by BsmI endonuclease. Associations between calcium stone disease and BsmI polymorphisms were evaluated.

RESULTS AND CONCLUSIONS

The results revealed no significant difference between normal individuals and stone patients (P = 0.891). The allelic distribution of B and b were similar within both the normal group and the stone patients. Therefore, the BsmI polymorphism of the VDR gene at intron 8 is not a suitable genetic marker for urinary stone disease.

Relation of BsmI vitamin D receptor gene polymorphism to bone mineral density and occurrence of osteoporosis in postmenopausal Chinese women in Taiwan

Osteoporosis is a common disorder with a strong genetic component. Our aim was to evaluate the correlation of the vitamin D receptor gene intron 8 BsmI polymorphism with bone mineral density (BMD) and their relationship to osteoporosis. We determined the vitamin D receptor gene intron 8 BsmI polymorphfsm using polymerase chain reaction-based restriction analysis in 171 postmenopausal Chinese women in Taiwan. The polymorphism was detected using the restriction enzyme BsmI, where the B allele indicated absence of the cuttable site and the b allele its presence. BMD of the lumbar spine and proximal femur were measured using dual-energy X-ray absorptiometry. The allelic frequencies for postmenopausal Chinese women in Taiwan were 12.3% for B and 87.7% for b in BsmI restriction fragment length polymorphisms. The prevalence of each genotype in the study population was: 6.4% BB, 11.7% Bb and 81.9% bb. The three genotypic groups differed significantly in BMD at the lumbar spine and the femoral neck. These differences corresponded to significant gene-dose effects at the lumbar spine and femoral neck (p<0.001 for both sites). The relative risk for the development of osteoporosis was about 2-3 times as great as that predicted by the differences between genotypes in BMD, and remained significant even after adjustment for age, height and weight. The vitamin D receptor gene intron 8 BsmI polymorphism is associated with reduced BMD and predisposes women to osteoporosis.

Lack of evidence for the association of tumor necrosis factor-alpha gene promoter polymorphism with calcium oxalate stone and bladder cancer patients

Urinary stone disease and bladder cancer are two of the most commonly seen urologic diseases in Taiwan. Tumor necrosis factor-alpha (TNF-alpha) is one of the cytokines secreted by macrophages and is related to a sequence of events in response to inflammation and cancer formation. We investigated the polymorphism of the TNF-alpha gene promoter -308 as a genetic marker in searching for the association between these two commonly seen urologic diseases. One hundred and fourteen patients with transitional cell carcinoma of the urinary bladder and 103 patients with calcium oxalate stone were compared with 150 healthy controls. The polymorphism was detected by polymerase chain reaction-based restriction analysis (Nco I endonuclease). The results revealed no significant differences between normal individuals and the patients with the two commonly seen urologic diseases (P > 0.05). We concluded that the polymorphism of the TNF-alpha promoter -308 is not a valid genetic marker for these two urologic diseases.

Relation of the estrogen receptor alpha gene microsatellite polymorphism to bone mineral density and the susceptibility to osteoporosis in postmenopausal Chinese women in Taiwan

OBJECTIVE

Osteoporosis is a common disorder with a strong genetic component. Our aim was to investigate the correlation of the estrogen receptor alpha gene microsatellite polymorphism (TA dinucleotide repeat polymorphism 5' upstream of exon 1) with bone mineral density and their relationship to osteoporosis.

METHODS

We determined the estrogen receptor alpha gene microsatellite polymorphism using polymerase chain reaction-based microsatellite analysis in postmenopausal Chinese women in Taiwan. Bone mineral density of the lumbar spine and proximal femur were measured using dual-energy X-ray absorptiometry.

RESULTS

The ERalpha genotype was classified into '12' through '27' according to the number of TA dinucleotide repeats they contained, as a 'signpost'. After adjustment for potential confounding factors including age, height, and weight, subjects with genotype 18+ (n=4) had lower bone mineral density values and a 54.5 times greater risk for osteoporosis when compared with subjects with genotype 18- (n=170) at the lumbar spine. This should be interpreted with caution because of the small number of subjects with the unfavorable genotype 18+. According to mean number of TA dinucleotide repeats, women with a high number of repeats (TA > or =20) (n=38) had the lowest bone mineral density and a 6.1 times greater risk for osteoporosis than women with a low number of repeats (TA < or =15) (n=61) at the femoral neck, after adjustment for potential confounding factors such as age, height, and weight.

CONCLUSION

The present study suggests that the estrogen receptor alpha gene microsatellite polymorphism may be a candidate genetic marker for risk of osteoporosis in postmenopausal Chinese women in Taiwan.

Amniotic fluid matrix metalloproteinase-8 indicates intra-amniotic infection

OBJECTIVE

This study was undertaken to determine whether matrix metalloproteinase-8, which is produced by neutrophils, is a useful marker for the detection of intra-amniotic infection.

STUDY DESIGN

We performed a case-control study using enzyme-linked immunosorbent assays to detect matrix metalloproteinase-8 in 77 amniotic fluid specimens that were obtained by amniocentesis from women with preterm contractions or preterm labor and intact fetal membranes (n = 66) and from women with preterm premature rupture of membranes (n = 11).

RESULTS

Thirty women had culture-proven intra-amniotic infection (cases), 21 of whom had intact membranes. After constructing receiver operating characteristic curves to establish the optimal threshold concentration of matrix metalloproteinase-8 for a positive test result, we detected matrix metalloproteinase-8 in 27 of 30 women with intra-amniotic infection; only 10 of 47 control specimens contained matrix metalloproteinase-8 (P <.001; odds ratio, 33.3; 95% CI, 8.4, 132.7). Matrix metalloproteinase-8 was present in 20 of 21 women with intact membranes and intra-amniotic infection and in only 10 of 45 control subjects (P <.001; odds ratio, 70.0; 95% CI, 8.3, 587.6). Among women with intact membranes, the sensitivity of the assay was 0.95 and the specificity was 0.78.

CONCLUSION

Our results indicate that matrix metalloproteinase-8 is highly correlated with intra-amniotic infection and that enzyme-linked immunosorbent assay for matrix metalloproteinase-8 may be a clinically useful test for the diagnosis of intra-amniotic infection in women with preterm contractions and preterm labor.

Interleukin-1beta gene and receptor antagonist gene polymorphisms in patients with calcium oxalate stones

Interleukin-1 (IL-1) might play a role in the process of bone loss and hypercalciuria and is therefore considered to be involved in the formation of urinary stones. The aim of this study is to test whether the IL-1beta promoter region, exon 5 region and IL-1 receptor antagonist gene intron 2 polymorphisms could be genetic markers for the susceptibility to the formation of urinary stones. A control group of 152 healthy people and a group of 105 patients with recurrent calcium oxalate stone were examined in this study. Polymerase chain reaction (PCR) analyzed the variable number tandem repeats at intron 2 of the IL-1Ra gene for the polymorphisms. PCR-based restriction analysis was done for the IL-1beta gene polymorphisms of the promoter region and exon 5 by the endonucleases Ava I and Taq I, respectively. The polymorphisms studied in the IL-1beta genes did not reveal a strong association with calcium oxalate stone disease when compared with the control group (promoter region by chi-square test, P=0.627: exon 5 region by Fisher's exact test, P = 0.403). Only two frequent alleles of the IL-1Ra gene corresponding to one and two copies of an 86-bp sequence repeat were identified by PCR. The result revealed significant differences between control individuals and stone patients (P < 0.01. Fisher's exact test). In addition, the frequency of the type I allele in the stone group (99.0%) was higher than in the control group (94.0%). The odds ratio for the type I allele of the IL-1Ra gene in calcium oxalate stone disease is 6.041 (95% CI: 1.683 approximately 21.687). There is an association between urolithiasis and polymorphism in the IL-1Ra gene. No significant difference was found when dividing the stone patients into groups with normocalciuria and hypercalciuria in relation to these genetic polymorphisms. Further studies of the type I allele of the IL-IRa gene are worthwhile because of its correlation with stone disease. In our study, neither the IL-1beta promoter region nor the exon 5 polymorphisms were significantly different when comparing control subjects and calcium oxalate stone patients.

The association of androgen- and oestrogen-receptor gene polymorphisms with urolithiasis in men

OBJECTIVE

To evaluate the association of urolithiasis with polymorphic microsatellite (encoding cytosine, adenine, and guanine, CAG) repeats in the exon 1 region of the androgen receptor (AR) gene and thymine/adenine (TA) repeats in the oestrogen receptor (ER).

PATIENTS AND METHODS

Patients with urolithiasis (149) and a group of normal controls (102) were examined and compared. The CAG repeats of the AR gene and TA repeats of the ER gene were detected by polymerase chain reaction. The CAG repeats ranged from 171 bp (10 CAG repeats with 141 bp of amplified flanking sequences) to 270 bp (43 CAG repeats). The TA repeats ranged from 160 bp to 194 bp. Associations between calcium oxalate stone disease and the CAG repeats in AR gene and TA repeats in ER gene were then evaluated. The results were classified according to sex and peaks in allelic frequency distribution.

RESULTS

There was a significant difference between the male stone patients and the normal controls in the distribution of CAG repeats in the AR gene. Both groups showed a high percentage of 21-repeats in the allelic distribution, at 17 (16%) and 20 (37%) in stone patients and normal controls, respectively. The results indicate that 21-CAG repeats might be related to a lower risk of stone formation in men (P < 0.05). In the ER gene, the peak allelic distribution of TA repeats was 14, showing a significant difference between male stone patients and the normal control subjects (P < 0.01). There were no statistical differences between female stone patients and the control subjects in either the AR or the ER gene.

CONCLUSION

Urolithiasis among men appears to be associated with AR gene CAG repeat and ER gene TA repeat polymorphisms, whereas there was no significant association among female stone patients. These sex hormone receptors seem to be related to the higher incidence of stone formation among men.

Serum soluble Fas in the syndrome of hemolysis, elevated liver enzymes, and low platelets

OBJECTIVE

To assess whether serum levels of soluble Fas and soluble Fas ligand are altered in the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP).

METHODS

Serum samples from 22 pregnant women diagnosed with HELLP syndrome were compared with sera from 37 healthy women with noncomplicated singleton pregnancies. Serum levels of soluble Fas and soluble Fas ligands were determined by enzyme immunoassay. Student t, chi(2), Pearson's correlation coefficient, and multiple regression tests were used for statistical analyses.

RESULTS

Both soluble Fas and soluble Fas ligand were detected in the sera of normal pregnancies as well as in those with HELLP syndrome. The mean serum level of soluble Fas was significantly higher in women with HELLP syndrome than in healthy gravidas (10.75 +/- 0.93 versus 5.81 +/- 0.37 U/mL, P <.001). However, there was no significant difference in mean serum soluble Fas ligand levels of the two groups (0.60 +/- 0.06 compared with 0.50 +/- 0.22 ng/mL, P =.23). In women with HELLP syndrome, there were no significant correlations between serum levels of soluble Fas or soluble Fas ligand with liver transaminases (aspartate and alanine aminotransferase) and platelet count.

CONCLUSION

Serum levels of soluble Fas, but not soluble Fas ligand, are significantly higher in women with HELLP syndrome than healthy gravidas. The source of elevated serum levels of soluble Fas in HELLP syndrome remains to be determined.

Monoamniotic twins in a triplet gestation with favorable outcome

BACKGROUND

Monoamniotic twins in a triplet gestation is a rare combination. Each condition is separately associated with significant perinatal morbidity and mortality. There are no data about the outcome and management of such gestations.

CASE

We report a case of monoamniotic twins in a spontaneous dichorionic triplet gestation with a favorable outcome. Transvaginal ultrasound examination at nine weeks confirmed the diagnosis. Close follow-up was established that included continuous fetal monitoring after 30 weeks. At 35 weeks and after confirming fetal lung maturity, elective cesarean delivery was performed resulting in three liveborn female infants.

CONCLUSION

Favorable outcome of such a rare coexistence of monoamniotic twins in a triplet gestation is possible. Vigilant fetal monitoring and timed delivery remain the mainstays of management.

Ratio of nuchal thickness to humerus length for Down syndrome detection

OBJECTIVE

Ultrasonographic biometry markers are now being used clinically to adjust Down syndrome risk. The limitations are that the definitions of "abnormal" measurements used are arbitrary, thus reducing screening performance, and also that patient-specific Down syndrome risks cannot be calculated. We report a new ultrasonographic algorithm that is sensitive for Down syndrome detection and that estimates individual risk.

STUDY DESIGN

Overall in fetal populations with Down syndrome the humerus length is decreased, whereas the nuchal thickness is increased relative to that of a normal population. The nuchal thickness/humerus length ratio therefore shows an even greater increase and magnifies the separation between Down syndrome and healthy groups. Prospective data were collected in midtrimester amniocentesis cases. A regression equation for the median nuchal thickness/humerus length ratio based on biparietal partial diameter was generated. The Down syndrome likelihood ratio, or the odds on the basis of the nuchal thickness/humerus length ratio (multiples of the median), was multiplied by the age-related risk to give the posterior Down syndrome risk. Charts for rapid estimation of individual Down syndrome risk on the basis of maternal age and the nuchal thickness/humerus length ratio were constructed.

RESULTS

There were 94 cases of Down syndrome and 4700 cases in which the karyotype was normal. The mean (+/-SD) gestational age of the study population was 16.1 +/- 1.6 weeks. Thirty-three fetuses with Down syndrome and 68 karyotypically normal fetuses had gross anomalies. The equation for the expected median nuchal thickness/humerus length ratio was as follows: 10e(1.7163 - 0.0292) x BPD + 0.0003 x BPD2, where BPD is the biparietal diameter. In the overall study population the nuchal thickness/humerus length ratio and maternal age had a 79.8% detection rate at a 22.1% false-positive rate, compared with maternal age plus humerus length (sensitivity, 55.1%) or maternal age plus nuchal thickness (sensitivity, 66.7%) at the same false-positive rate. For women > or =35 years old the values were 80% and 22.0%, respectively.

CONCLUSIONS

We report an ultrasonographic biometry algorithm that, in combination with maternal age, detects 79.6% of Down syndrome cases in a high-risk group. Individual Down syndrome risk can be quickly calculated at the bedside and made available to women who desire this information before making a decision on amniocentesis. On the basis of published standards, ultrasonographic biometry as described would be a cost-effective alternative to amniocentesis in this high-risk group.

Serum soluble Fas levels in preeclampsia

OBJECTIVE

To determine if serum soluble Fas levels are altered in women with preeclampsia.

METHODS

Thirty-four pregnant women with preeclampsia and 34 normotensive pregnant women were studied. Subjects were matched as much as possible for demographics. Preeclampsia was defined as proteinuric hypertension. Serum soluble Fas levels were measured by enzyme-linked immunoassay. Two-tailed Student t test, chi(2) test, Pearson correlation coefficients, and analysis of variance with post hoc test were used for statistical analyses.

RESULTS

Mean serum soluble Fas levels were significantly higher in preeclamptic than normotensive women (10.59 +/- 0.68 U/mL versus 5.65 +/- 0.35 U/mL, P <.001).

CONCLUSION

Elevated serum soluble Fas is associated with preeclampsia. Such elevation might indicate protection of maternal T-lymphocyte apoptosis and consequently lead to the maternal immune intolerance noted in preeclampsia.

Arginine form of p21 gene codon 31 is less prominent in patients with calcium oxalate stone

The formation of urinary stones is associated with cell death in response to various injuries. P21 (WAF1/CIP1) is a downstream protein of P53 and can arrest the cell cycle at G1/S with resulting cell death. We aimed to investigate the polymorphism of p2 gene codon 31 as the genetic marker in searching for the association of urolithiasis. One hundred and nineteen healthy controls and 95 patients with calcium oxalate stone were examined in this study. The polymorphism was seen from the result of polymerase chain reaction-based restriction analysis. The result revealed significant differences between normal individuals and stone patients (P < 0.05) and the distribution of arginine homozygote in the control group (31.9%) was higher than in the patient group (16.8%). It is concluded that polymorphisms of p21 codon 31 can be a genetic marker for urinary stone disease. Individuals possessing arginine form of p21 codon 31 have less risk of developing calcium stone disease.

Association of the vitamin D receptor gene start codon Fok I polymorphism with calcium oxalate stone disease

OBJECTIVE

To assess the use of Fok I polymorphism (the most frequent polymorphism, at the start codon of the vitamin D receptor gene, VDR) as a convenient genetic marker in identifying the cause of urolithiasis.

PATIENTS, SUBJECTS AND METHODS

A normal control group of 90 healthy subjects and 146 patients with calcium oxalate stones were examined. Using polymerase chain reaction (PCR)-based restriction analysis, the relationship between Fok I polymorphism and urolithiasis was evaluated. An unexcisable length of 265 bp was identified (allele CC) and two fragments (169 bp and 96 bp) identified as excisable lengths (allele TT).

RESULTS

There was a statistically significant difference between the groups (chi-square test, P < 0.05) for the genotype of the VDR Fok I start codon polymorphism. The odds ratio (95% confidence interval) for the C allele in those at risk of stone disease was 1.672 (1.149-2.432).

CONCLUSIONS

These results suggest that the VDR Fok I start codon polymorphism may be a good candidate for a genetic marker in calcium oxalate stone disease.

Splenic artery Doppler peak systolic velocity predicts severe fetal anemia in rhesus disease

OBJECTIVE

We sought to determine whether main splenic artery Doppler peak systolic velocity predicts severe anemia in the rhesus-alloimmunized fetus.

STUDY DESIGN

Splenic artery Doppler peak systolic velocity was obtained before cordocentesis in rhesus-alloimmunized fetuses. Normative values for mean peak systolic velocity based on gestational age were obtained cross-sectionally from a separate group of 144 normal fetuses. The peak systolic velocity values in the study group were expressed as multiples of the median for gestation, and threshold values were used as a screening test for severe anemia. The hemoglobin deficit was defined as mean hemoglobin for gestation minus measured hemoglobin. A hemoglobin deficit value of > or =5 g/dL was used to define severe anemia. We used the peak systolic velocity to screen for severe anemia in the overall study group and the subgroups with or without prior transfusions.

RESULTS

The study population consisted of 26 singleton nonhydropic fetuses in which cordocentesis and Doppler measurements were performed on a total of 55 occasions. The mean gestational age and standard deviation at cordocentesis was 29.6 +/- 4.0 weeks. Severe anemia was noted in 20% of fetal cord blood specimens obtained. On the basis of a receiver operating characteristic curve, a peak systolic velocity of > or =1.4 multiples of the median had a detection rate of 100%, with a false-positive rate of 20.8% in the subgroup with no prior transfusion (relative risk, 4.8; 95% confidence interval, 2.2-10.5). For peak systolic velocity threshold of > or =1.50 multiples of the median, corresponding values in the group with one prior transfusion were 80% and 12.5%, respectively (relative risk, 2.5; 95% confidence interval, 1.2-5.3). There was no risk of severe anemia with a peak systolic velocity below the median for gestation.

CONCLUSION

Fetal hydrops is rare, with a hemoglobin deficit of <5 g/dL. In the first such report the main splenic artery peak systolic velocity was noted to be a strong predictor of severe anemia. For the overall population, all such instances could be diagnosed while cordocentesis was performed 22.7% of the time. There is no risk of severe anemia with Doppler peak systolic velocities below the median for gestational age. The measurement is easily obtained and should be investigated as a clinical tool for minimizing the necessity for cordocentesis.

Increased apoptosis in human amnion is associated with labor at term

PROBLEM

To characterize whether increased apoptosis in human amnion was associated with labor at term.

METHOD OF STUDY

Human amnion were obtained from term patients with vaginal delivery (n = 5) or who underwent elective Cesarean section (C/S) without labor (n = 5). Apoptosis was performed by the TUNEL (Terminal dUTP Nuclear End Labeling) assay. All nucleated cells stained with propidium iodide in the amnion epithelial cells were identified in red fluorescence. TUNEL positive apoptotic nuclei were identified in green fluorescence. Five random fields of each specimen were blindly counted by investigators. The percentage of apoptotic nuclei of total nuclei (apoptotic index) was calculated and compared between the two groups (25 microscopic fields for each group, respectively).

RESULTS

Patients with term labor had a significantly higher mean apoptotic index in amnion epithelial cells than that with elective C/S without labor (27.3 +/- 4.1% versus 3.6 +/- 1.6%, P < 0.001).

CONCLUSIONS

Our data indicate that apoptosis in human amnion is significantly increased and associated with labor at term.

Amniotic fluid soluble fas levels in intra-amniotic infection

OBJECTIVE

Membrane Fas can induce apoptosis in sensitive cells. It has been reported that soluble Fas (sFas) is elevated in septicemia. We examined amniotic fluid (AF) sFas levels in patients with and without intra-amniotic infection.

METHODS

Forty-two AF specimens were studied. Intra-amniotic infection was defined as the presence of a positive AF culture. Twenty-one specimens were from patients with intra-amniotic infection and 21 were from patients without intra-ammotic infection. Amniotic fluid sFas was determined by an enzyme immunoassay and normalized by AF creatinine levels. The Mann-Whitney U test, contingency table method, and Spearman's rank correlation test were used for statistical analyses. Data were expressed as median with ranges.

RESULTS

There were no significant differences in maternal age, gestational age, parity, and race between the groups. The median AF sFas was significantly higher with intra-amniotic infection than without it (5.07 U/mL, range 0.32-13. 25 compared with 1.95 U/mL, range 0.01-5.35; P =.004). After normalizing to AF creatinine, infected fluids also had significantly higher median sFas/creatinine than uninfected amniotic fluids (289.1 U/mg creatinine, range 16.6-920.5 compared with 126.8 U/mg creatinine, range 0.5-546.2; P =.01). Amniotic fluid sFas and sFas/creatinine were positively correlated with AF leukocytes and negatively correlated with AF glucose.

CONCLUSION

Elevated AF sFas is associated with intra-amniotic infection. High production of AF sFas in intra-amniotic infection may play a role in the inhibition of apoptosis of AF leukocytes, leading to the persistence of inflammation.

The role of amniotic fluid interleukin-6, and cell adhesion molecules, intercellular adhesion molecule-1 and leukocyte adhesion molecule-1, in intra-amniotic infection

PROBLEM

To determine amniotic fluid concentrations and correlations of interleukin-6 (IL-6), intercellular adhesion molecule-1 (ICAM-1), and leukocyte adhesion molecule-1 (LAM-1) in patients with and without intra-amniotic infection.

METHOD OF STUDY

Fourteen specimens with intra-amniotic infection and 45 without intra-amniotic infection were studied. Intra-amniotic infection was defined as the presence of a positive amniotic fluid culture. Amniotic fluid IL-6, ICAM-1, and LAM-1 levels were determined by an enzyme-linked immunoassay, and normalized by amniotic fluid creatinine levels.

RESULTS

Amniotic fluid concentrations of IL-6 and LAM-1 were significantly higher in patients with than without intra-amniotic infection. However, amniotic fluid ICAM-1 concentrations were not significantly different between two groups. Amniotic fluid IL-6, LAM-1, and ICAM-1 were positively correlated.

CONCLUSIONS

Our data indicate that amniotic fluid IL-6 is significantly associated with an increased adhesion molecule expression in intra-amniotic infection. However, LAM-1 plays a more important role than ICAM-1 in intra-amniotic infection.

Abortion and its effect on risk of preeclampsia and transient hypertension

We examined the effect of abortion type, number, and gestational age on the risk of preeclampsia and transient hypertension among women who received prenatal care from 13 obstetric practices in southern Connecticut between April 1988 and December 1991 (N = 2,739). Subjects were interviewed before 16 weeks' gestation regarding reproductive history and pregnancy-related risk factors. We estimated the risk of preeclampsia (N = 44) and transient hypertension (N = 172) among nulliparous women who had had one or more abortions, with nulliparous women with no abortion as the referent group. Similar effects were seen for one spontaneous or induced abortion, when analyzed separately. A single prior abortion was associated with a decreased risk of preeclampsia [odds ratio (OR) = 0.35; 95% exact confidence interval (CI) = 0.09-1.01]. One abortion had only a small association with risk of transient hypertension (OR = 1.09, 95% exact CI = 0.68-1.72); however, a history of two or more abortions was associated with a decreased risk (OR = 0.42, 95% exact CI = 0.16-0.94). Among nulliparous women with a history of one abortion, a decreased risk of both hypertensive disorders was observed among women whose aborted pregnancy ended at > or =3 months gestation. These findings suggest that a history of abortion in nulliparous women is a protective factor against the risk of preeclampsia in the subsequent pregnancy.

Nitric oxide: a clinically important amniotic fluid marker to distinguish between intra-amniotic mycoplasma and non-mycoplasma infections

The objective of this study was to determine whether the measurements of amniotic fluid nitric oxide metabolite (NOx: nitrate + nitrite) concentrations could be a clinically useful marker to differentiate between intra-amniotic mycoplasma and nonmycoplasma infections. Amniocentesis was performed on 76 pregnant women with suspicion of intra-amniotic infection. Intra-amniotic infection was defined as the presence of a positive amniotic fluid culture with either mycoplasma or nonmycoplasma infections. Rapid amniotic fluid tests for Gram stain, glucose, leukocyte counts, interleukin-6, and NOx were performed. Amniotic fluid NOx was measured with aspergillus nitrate reductase and Griess reagent. Interleukin-6 was determined by enzyme immunoassays. Amniotic fluid NOx and interleukin-6 were normalized by amniotic fluid creatinine levels. Patients with intra-amniotic mycoplasma (n = 7) and nonmycoplasma infections (n = 8) had significantly higher amniotic fluid leukocyte counts and interleukin-6 concentrations and significantly lower amniotic fluid glucose levels than noninfected controls (n = 61). Amniotic fluid concentrations of NOx were significantly higher in those with intraamniotic nonmycoplasma infection as compared to those with intraamniotic mycoplasma infection and noninfected controls (NOx: 3.35+/-0.74 vs. 2.03+/-0.41 micromol/mg creatinine, p = 0.005, and 3.35+/-0.74 vs. 1.72+/-0.07 micromol/mg creatinine, p < 0.0001, respectively). However, patients with intra-amniotic mycoplasma infection did not differ significantly from noninfected controls. Our data indicate that clinical characteristics of intra-amniotic mycoplasma infection may differ from intra-amniotic nonmycoplasma infection. As delivery is not always indicated in intra-amniotic mycoplasma infection, elevated rapid amniotic fluid tests (leukocyte counts, interleukin-6, and glucose) may not be appropriate in the clinical management of intra-amniotic mycoplasma infection. In addition to these rapid amniotic fluid tests, incorporation of the measurement of amniotic fluid NOx may be of clinical importance in the differentiation and management of patients with suspected intra-amniotic mycoplasma and nonmycoplasma infection.

Placental pathologies are not associated with hyperuricemia in preeclamptic pregnancies

The mechanism of hyperuricemia in preeclampsia remains unknown. As the breakdown of the nuclear rich syncytiotrophoblast might result in the increased formation of uric acid from purine catabolism, the purpose of this study was to investigate whether placental pathologies were associated with hyperuricemia in preeclamptic pregnancies. We retrospectively reviewed medical reports with the availability of maternal serum uric acid levels and placental pathology reports of 83 singleton, preeclamptic pregnant women at Yale-New Haven Hospital. Preeclampsia was defined by the American College of Obstetricians and Gynecologists criteria. Hyperuricemia was defined as, at least greater than or equal to, two standard deviations of normal mean values for gestational age. The placental pathological findings include infarction, syncytial knots, abruption, intravillous thrombosis, and villous pathology (i.e., edema, villitis). The relevance of hyperuricemia to the individual placental pathologic finding and the numbers of placental pathologic findings were investigated. Statistical analyses were performed using contingency table methods. We found that there was no significant correlation between hyperuricemia and individual or multiple placental pathologic findings. We concluded that placental pathologies secondary to ischemic changes may not fully explain hyperuricemia in preeclamptic pregnancies. A prospective study using morphometric measurements is needed to understand the exact role of ischemic placental damage on the maternal serum uric acid level.

Elevated amniotic fluid nucleosome levels in women with intra-amniotic infection

OBJECTIVE

To compare amniotic fluid (AF) soluble nucleosome levels in pregnant women with and without intra-amniotic infection.

METHODS

Amniocentesis was performed in 74 pregnant women with preterm contractions, labor, or premature rupture of membranes. Intra-amniotic infection was defined as a positive AF culture. Amniotic fluid tests for Gram stain, glucose, neutrophils, creatinine, pH, and specific gravity were performed. Amniotic fluid soluble nucleosome levels were determined by enzyme-linked immunosorbent assay and were normalized by AF creatinine levels.

RESULTS

Twenty-eight patients had intra-amniotic infection and 46 did not. Amniotic fluid soluble nucleosome levels were significantly higher in pregnant women with intra-amniotic infection than in those without infection (48.1+/-21.3 compared with 0.0+/-0.0 U/mg creatinine; P = .005). The AF nucleosome levels were positively correlated with AF neutrophil counts and negatively correlated with AF glucose concentrations.

CONCLUSION

Our data indicate that elevated AF nucleosome levels are associated with intra-amniotic infection and may have potential as a clinical marker to detect intra-amniotic infection.

Dual roles of amniotic fluid nitric oxide and prostaglandin E2 in preterm labor with intra-amniotic infection

We hypothesized that induction of nitric oxide synthase and cyclo-oxygenase-2 by bacterial products in intra-amniotic infection could increase the production of proinflammatory nitric oxide and prostaglandin E2 (PGE2) and cause preterm labor. Thus, we sought to determine amniotic fluid levels of nitric oxide metabolites (NOx) and PGE2 in preterm labor patients with and without intra-amniotic infection. Amniotic fluid from 13 preterm labor patients with intra-amniotic infection and 24 without intra-amniotic infection were studied. Intra-amniotic infection was defined as the presence of a positive amniotic fluid culture. Amniotic fluid was tested for NOx, PGE2, glucose, leukocyte counts, Gram stains, creatinine, pH, and specific gravity. NOx was determined using Griess reagent after reduction of nitrate to nitrite with aspergillus nitrate reductase. PGE2 was measured by an enzyme-linked immunoassay. Both amniotic fluid NOx and PGE2 were normalized by amniotic fluid creatinine. We found that amniotic fluid concentrations of NOx and PGE2 were significantly higher in preterm labor patients with intra-amniotic infection compared to those without intraamniotic infection (NOx: median 1.8 micromol/mg creatinine, range 0.7 to 6.8 vs. 1.3 micromol/mg creatinine, range 0.9 to 2.1, p=0.03; PGE2: median 33.5 ng/mg creatinine, range 0.0 to 1048.6 vs. 0.0 ng/mg creatinine, range 0.0 to 33.6, p=0.004). In addition, amniotic fluid NOx and PGE2 were positively correlated (r=0.343, p=0.0398). We conclude that there may be an interaction between the nitric oxide and prostaglandin pathways in intraamniotic infection. Increased production of amniotic fluid pro-inflammatory nitric oxide and PGE2 may play an important role in the pathogenesis of preterm labor in patients with intra-amniotic infection.

Gestational age standardized nuchal thickness values for estimating mid-trimester Down's syndrome risk

OBJECTIVE

Our aim was to develop gestational age standardized indices of fetal nuchal thickening. In addition, we wanted to develop a method for combining nuchal thickness data with maternal age for calculating individual Down's syndrome risk.

METHODS

Nuchal thickness was measured prospectively in pregnancies undergoing genetic amniocentesis. A regression equation for expected median nuchal thickness based on the biparietal diameter (BPD) was developed. Nuchal thickness values were expressed as multiples of the median (MoM). Additionally, a new parameter, percentage increase in nuchal thickness (PIN) (measured minus expected nuchal thickness) X100/expected nuchal thickness, was used. Receiver operator characteristics curves for Down's syndrome detection based on nuchal thickness values expressed as MoM, PIN, and in mm were compared. Log10 transformation of MoM data resulted in a Gaussian distribution, and the Down's syndrome likelihood ratios were calculated based on the heights of the Gaussian curves. Likelihood ratios were also calculated based on PIN values. The screening efficiency of maternal age alone was compared to age plus MoM, and age plus PIN values by multiplying age-related risk by the likelihood ratio corresponding to the given nuchal thickness MoM or PIN values.

RESULTS

There were 3,574 chromosomally normal and 50 Down's syndrome fetuses in the study. Both PIN and MoM values for nuchal thickness were closely correlated (R = 1.00, P<0.001) and each was poorly correlated with gestational age (R = 0.018, P = 0.28). The Down's syndrome screening efficiency of PIN, MoM, and nuchal thickness values in mm were not significantly different. The addition of nuchal thickness data to maternal age-related risk significantly improved the Down's syndrome screening efficiency: Area under the ROC curve for maternal age risk = 0.58, maternal age + PIN area = 0.79 (P<0.001 compared to maternal age alone) and for maternal age + MoM = 0.77 (P<0.005 compared to maternal age alone).

CONCLUSIONS

The development of gestational age standardized nuchal thickness indices makes it possible to combine ultrasound and maternal age-related risk to derive individual Down's syndrome odds.

Thrombomodulin: a new marker for placental abruption

Thrombomodulin (TM), a marker of endothelial cell damage, has been localized to the placental syncytiotrophoblast. A prospective cohort study of twenty-five pregnant women who were admitted with a clinical diagnosis of placental abruption was undertaken. Abruption was confirmed after delivery in eight cases (Group 1). Group 2 consisted of seventeen patients with no clinical or pathologic evidence of placental abruption after delivery. TM was significantly elevated in Group 1 (71.59+/-5.35 vs. 48.29+/-3.53 ng/ml, p = 0.001). The sensitivity and specificity of TM > or =60 ng/ml as a marker for abruption was 87.5 and 76.5%, respectively. In comparison, the sensitivity of an abnormal coagulation profile, maternal Kleihauer-Betke and ultrasound in patients with abruption was 0, 16.7 and 28.6%, respectively. TM is a highly sensitive and specific marker for acute placental abruption.

Elevated amniotic fluid levels of leukemia inhibitory factor, interleukin 6, and interleukin 8 in intra-amniotic infection

OBJECTIVE

The study's objective was to determine and correlate amniotic fluid levels of leukemia inhibitory factor, interleukin 6, and interleukin 8 in patients with and without intra-amniotic infection.

STUDY DESIGN

Amniocentesis was performed on 41 pregnant women with preterm contractions, labor, or premature rupture of membranes. Intra-amniotic infection was defined as the presence of a positive amniotic fluid culture result. Amniotic fluid tests for Gram stain, glucose, leukocyte counts, creatinine level, pH, and specific gravity were performed. Amniotic fluid levels of leukemia inhibitory factor, interleukin 6, and interleukin 8 were measured by an enzyme-linked immunoassay. Unlike in previous reports, cytokines were normalized by amniotic fluid creatinine levels.

RESULTS

Fifteen patients had intra-amniotic infection and 26 did not. Amniotic fluid median levels of leukemia inhibitory factor, interleukin 6, and interleukin 8 were significantly higher in pregnant women with intra-amniotic infection than in those without intra-amniotic infection (leukemia inhibitory factor median 3912 pg/mg creatinine, range 0.0-199314, vs 56 pg/mg creatinine, range 0. 0-12148, P =.01; interleukin 6 median 2005 ng/mg creatinine, range 27-4071, vs 990 ng/mg creatinine, range 7.5-3409, P =.005; interleukin 8: median 4933 ng/mg creatinine, range 0.0-55058, vs 61 ng/mg creatinine, range 0.0-2399, P =.005). Amniotic fluid levels of leukemia inhibitory factor, interleukin 6, and interleukin 8 were positively correlated.

CONCLUSIONS

The data indicate that leukemia inhibitory factor plays an important role in the pathogenesis of intra-amniotic infection. In addition, significant elevations of and correlations among amniotic fluid levels of leukemia inhibitory factor, interleukin 6, and interleukin 8 suggest that measurements of these cytokines in amniotic fluid may be of diagnostic and prognostic importance.

Immunohistochemical localization of inducible nitric oxide synthase on human fetal amnion in intra-amniotic infection

OBJECTIVES

Amniotic fluid levels of nitric oxide metabolites are significantly elevated in intra-amniotic infection. We hypothesized that fetal amnion is a possible site for the production of nitric oxide. Because inducible nitric oxide synthase is the key enzyme responsible for the generation of nitric oxide in patients with intra-amniotic infection, we used immunohistochemistry to localize it on human fetal amnion.

STUDY DESIGN

Human fetal amnions were obtained from patients with and without intra-amniotic infection (n = 5, respectively). Intra-amniotic infection was diagnosed by positive amniotic fluid cultures and placental pathologic features. Human fetal amniotic membranes were processed into tissue blocks and embedded in paraffin. A rabbit polyclonal antibody against human inducible nitric oxide synthase was used as the primary antibody, followed by avidin-biotin immunoperoxidase localization. Normal rabbit serum was used as a negative control and ovarian carcinoma cells were used as the positive control.

RESULTS

Anti-inducible nitric oxide synthase labeling of human fetal amniotic membranes in patients with intra-amniotic infection showed positive immunostaining of epithelial cells, specifically in the cytoplasm of the perinuclear area. In contrast, no anti-inducible nitric oxide synthase immunostaining on human fetal amniotic membranes could be identified in patients without intra-amniotic infection.

CONCLUSIONS

Our data provide important evidence that inducible nitric oxide synthase can be induced on human fetal amnion in intra-amniotic infection. These findings strongly support our hypothesis that human fetal amnion may be a possible site for the synthesis of nitric oxide after inducible nitric oxide synthase is induced in response to infectious products in intra-amniotic infection.

Midtrimester urine human chorionic gonadotropin beta-subunit core fragment levels and the subsequent development of pre-eclampsia

OBJECTIVE

Our purpose was to determine whether midtrimester maternal urine human chorionic gonadotropin beta-subunit core fragment predicts later pre-eclampsia.

STUDY DESIGN

Urine beta-core fragment levels standardized to spot creatinine concentration and expressed as multiples of the median were prospectively determined in 347 midtrimester singleton pregnancies undergoing genetic amniocentesis. All women considered in the analysis were white and nonsmokers. Obstetric chart review was undertaken after delivery to identify cases in which pre-eclampsia developed. The risk of pre-eclampsia at different threshold levels of beta-core fragment of human chorionic gonadotropin was determined.

RESULTS

The median maternal age was 36.0 years, with a median gestational age at urine collection of 16.0 weeks. The median level of the beta-core fragment of human chorionic gonadotropin was 1385.5 ng/mg of creatinine in those with pre-eclampsia, whereas that in those without pre-eclampsia was 1061.2 ng/mg. The difference was significant (Mann-Whitney U test, P = .03). A significant linear association was found between the beta-core fragment concentration and the risk of pre-eclampsia (Mantel-Haenszel test of linear association, P = .03). The relative risk and 95% confidence interval of subsequent pre-eclampsia increased from 2.07 (1.06 to 4.05) at beta-core fragment levels of human chorionic gonadotropin > or = 2.0 multiples of the median to 5.17 (1.95 to 13.7) at > or = 4.0 multiples of the median.

CONCLUSION

Clinically normal patients with elevated midtrimester levels of urine beta-core fragment of human chorionic gonadotropin are at increased risk for the subsequent development of pre-eclampsia. The clinical value of this urine analyte as a marker for pre-eclampsia needs to be further investigated.

The role of amniotic fluid L-selectin, GRO-alpha, and interleukin-8 in the pathogenesis of intraamniotic infection

OBJECTIVE

Our purpose was to compare and correlate amniotic fluid GRO-alpha, interleukin-8, and L-selectin in patients with and without intraamniotic infection.

STUDY DESIGN

Amniocentesis was performed on 45 pregnant women with preterm contractions, labor, or rupture of membranes. Fourteen patients had intraamniotic infection, and 31 did not. Intraamniotic infection was defined as the presence of a positive amniotic fluid culture. Amniotic fluid tests for Gram stain, glucose, neutrophil counts, creatinine, pH, and specific gravity were performed. Amniotic fluid levels of soluble L-selectin, interleukin-8, and GRO-alpha were measured by an enzyme-linked immunoassay and normalized by amniotic fluid creatinine levels. The Mann-Whitney Utest and Spearman's rank correlation test were used for statistical analyses.

RESULTS

Amniotic fluid median levels of soluble L-selectin, interleukin-8, and GRO-alpha were significantly higher in pregnant women with intraamniotic infection than in those without intraamniotic infection (soluble L-selectin: median 3334.6 ng/mg creatinine, range 408.4 to 15,956.8 vs 717.2 ng/mg creatinine, range 129.4 to 4601.9, p = 0.009; GRO-alpha: median 841.6 ng/mg creatinine, range 28.1 to 8591.7 vs 56.8 ng/mg creatinine, range 0.0 to 440.2, p < 0.0001; interleukin-8: median 4932.7 ng/mg creatinine, range 0.0 to 55,058.7 vs 28.3 ng/mg creatinine, range 0.0 to 1161.6, p = 0.0004). Patients with intraamniotic infection had significantly higher amniotic fluid leukocyte counts and leukocyte esterase activities and significantly lower amniotic fluid glucose concentrations compared with those without intraamniotic infection. Amniotic fluid GRO-alpha, interleukin-8, and soluble L-selectin were positively correlated, and each was positively correlated with amniotic fluid leukocytes and negatively correlated with amniotic fluid levels of glucose.

CONCLUSIONS

Our data indicate amniotic fluid GRO-alpha and interleukin-8 may be two potent leukocyte chemoattractants and activators, and L-selectin is rapidly shed from leukocytes in the amniotic fluid in patients with intraamniotic infection.

Glycosylated hemoglobin in insulin-dependent diabetes mellitus related to preeclampsia

Preeclampsia may occur due to failure of the second wave of trophoblastic invasion between 16 to 20 weeks of gestation. We studied whether the mean value of glycosylated hemoglobin (HbA1c) during this gestational period was associated with an increased incidence of preeclampsia in insulin-dependent diabetes mellitus. We conducted a retrospective study of 131 insulin-dependent diabetes mellitus (IDDM) pregnancies with HbA1c values available in medical records over the past 10 years. The correlation between high mean HbA1c (>8%) before or after 20 weeks and the incidence of preeclampsia was determined. Mean HbA1c values before 20 weeks were further divided into 10- to 15- and 16- to 20-week intervals. Mean values of HbA1c in these different gestational periods were analyzed by chi(2) or Fisher's exact tests. P < 0.05 was considered statistically significant. We found that IDDM pregnant women with high mean values of HbA1c (>8%) had a significantly higher rate of preeclampsia than those with normal mean values (45 vs. 24%, p = 0.018). However, we found that IDDM pregnant women with an elevated mean HbA1c value at 16-20 weeks', but not 10-15 weeks' or after 20 weeks', gestation had a significantly higher incidence of preeclampsia than those with normal mean HbA1c value (chi(2) = 4.49, p = 0.03). We conclude that a significant association between elevated mean HbA1c values at 16-20 weeks' gestation and a high frequency of preeclampsia in IDDM pregnancies suggests that glycosylated hemoglobin may play an important role in the pathogenesis of preeclampsia in IDDM pregnant women.

Elevated amniotic fluid nitric oxide metabolites and interleukin-6 in intra-amniotic infection

OBJECTIVE

To compare amniotic fluid nitric oxide metabolites and interleukin-6 (IL-6) concentrations in patients with and without intra-amniotic infection.

METHODS

Amniotic fluid nitric oxide metabolites, IL-6, Gram stains, glucose, leukocyte counts, leukocyte esterase activity, creatinine, pH, and specific gravity were determined in 14 patients with intra-amniotic infection and 26 patients without intra-amniotic infection. Intra-amniotic infection was defined as the presence of a positive amniotic fluid culture. The nitric oxide metabolites, nitrate and nitrite (NOx), were measured using Greiss reagent after reduction of nitrate to nitrite with aspergillus nitrate reductase. Interleukin-6 was measured by a two-site, enzyme-linked immunosorbent assay. Amniotic fluid nitric oxide metabolites and IL-6 concentrations were normalized by amniotic fluid creatinine levels. The Mann-Whitney U test, contingency table method, and Spearman's rank correlation test were used for statistical analyses.

RESULTS

Amniotic fluid NOx and IL-6 levels were significantly higher in patients with intra-amniotic infection than in those without intra-amniotic infection (NOx: median = 2.06 mumol/mg creatinine, range = 0.74-6.81 versus 1.35 mumol/mg creatinine, range = 0.99-1.60, P = .01, IL-6: median = 2.00 micrograms/mg creatinine, range = 0.026-4.07 versus median = 0.04 micrograms/mg creatinine, range = 0.004-3.210, P = .0009, respectively). Patients with intra-amniotic infection had significantly elevated leukocyte counts, leukocyte esterase activity, Gram positive stains, and significantly lower amniotic fluid glucose levels compared with those without intra-amniotic infection. There were no differences in gestational age, maternal age, parity, race, pH, or specific gravity between the two groups. Amniotic fluid NOx was significantly correlated with IL-6 (r = .4, P = .02). Both amniotic fluid NOx and IL-6 were also positively correlated with amniotic fluid leukocyte counts, leukocyte esterase activity and Gram stains, and negatively correlated with glucose levels.

CONCLUSIONS

Amniotic fluid NOx and IL-6 are significantly elevated and positively correlated during intra-amniotic infection. Both increased amniotic fluid IL-6 and nitric oxide may exert cytotoxic and cytostatic effects on the target cells. We suggest that measurements of amniotic fluid NOx and IL-6 may serve as useful clinical markers in patients with intra-amniotic infection.

Elevated serum nicked and urinary beta-core fragment hCG in preeclamptic pregnancies

OBJECTIVE

To determine whether different molecular forms of hCG in serum and urine are elevated in preeclamptic pregnancies.

METHODS

Forty-three pregnant women were studied: 25 preeclamptic women and 18 normotensive women. Immediately after blood and urine samples were collected, the protease inhibitors leupeptin (0.35 mM) and phenanthroline (22 mM) were added. Various molecular forms of hCG in serum (complete hCG, nonnicked hCG, complete free beta hCG) and in urine (complete hCG, beta-core fragment hCG) were measured by matched immunoassays with a common enzyme-labeled tracer antibody. The nicked hCG assay used a coating of beta-subunit monoclonal antibody with the addition of scavenger antibody to remove nonnicked hCG. Mann-Whitney U test and chi 2 test were used for statistical analyses.

RESULTS

Preeclamptic women had significantly higher median (range) levels of serum complete and nicked hCG than did normotensive women (3620 [850-12,000] versus 2420 [310-4840] ng/mL, P = .024; and 102 [45-275] versus 71 [11-143] ng/mL, P = .010, respectively). Both median (range) urinary complete hCG-creatinine and beta-core fragment-creatinine ratios were significantly higher in preeclamptic women than in normotensive women (37.6 [0.5-185] versus 11.3 [1.9-54], P = .013; and 11.8 [2-67] versus 5.3 [0.3-29], P = .009, respectively).

CONCLUSIONS

Various molecular forms of hCG in serum and urine were significantly higher in preeclamptic than in normotensive pregnancies.

Maternal serum uric acid levels in preeclamptic women with multiple gestations

Our study was designed to determine serum uric acid levels and establish clinically useful cutoff values for the diagnosis of preeclampsia in twin and triplet gestations. We reviewed the medical records of 129 multiple gestations with serum uric acid levels available. Fifty-five twin gestations were complicated by preeclampsia, 51 were not. Fifteen triplet gestations were complicated by preeclampsia, and 8 were not. Preeclampsia was defined as a persistent blood pressure > or =140/90 mmHg, and proteinuria, or elevated liver enzymes, thrombocytopenia, or eclamptic seizure. Receiver operating characteristic curves were generated for twin and triplet gestations. Serum uric acid levels at different stages of gestation in twin gestations were determined. Maternal serum uric acid levels in preeclamptic twin and triplet gestations were significantly higher than those in nonpreeclamptics. Serum uric acid levels at varying gestational ages were significantly higher in preeclamptic twin gestations than in nonpreeclamptics. Maternal serum uric acid levels of 6.3 mg/dL and 6.8 mg/dL were found to be the most useful cutoff values for the diagnosis of preeclampsia in twin and triplet gestations, respectively. We conclude that compared to nonpreeclamptics, preeclamptic women with multiple gestations had significantly higher serum uric acid levels. Mean serum uric acid levels based on gestational age should be justified for the diagnosis of preeclampsia in multiple gestations.

Circulating thrombomodulin levels and clinical correlates in pregnant diabetics

The object of this study was to investigate the relationship of thrombomodulin (TM) and glycosylated hemoglobin (HbA1C) in pregnant diabetics and to determine clinical correlates. We performed a prospective cohort study of 53 patients: 25 women with insulin-dependent diabetes (group 1) and 28 with gestational diabetes (group 2). Group 1 underwent monthly determinations of HbA1C and TM. Group 2 underwent determination at 36 weeks of gestation. There was a significant difference in HbA1C between groups 1 and 2 (p=0.0005), but there was no difference in TM. There was no correlation between TM and HbA1C. TM levels correlated positively with serum creatinine (r=0.46, p=0.002), proteinuria (r=0.48, p=0.007), and duration of diabetes (r=0.41, p=0.042). TM was significantly higher in diabetics of advanced White Classification (p=0.008). With good control, TM does not appear to be elevated in a diabetic pregnancy. TM may be a marker of endothelial damage that correlates more with duration of diabetes and renal disease than with HbA1C, which reflects short-term control.

Elevated amniotic fluid nitric oxide metabolites and cyclic guanosine 3',5'-monophosphate in pregnant women with intraamniotic infection

OBJECTIVE

Our purpose was to compare amniotic fluid nitric oxide metabolites and cyclic guanosine 3',5'-monophosphate in pregnant women with and without intraamniotic infection.

STUDY DESIGN

Amniocentesis was performed on 72 pregnant women with preterm contractions, labor, or rupture of membranes. Fourteen patients had intraamniotic infection and 58 did not. Intraamniotic infection was defined as the presence of a positive amniotic fluid culture. Amniotic fluid Gram stain, glucose, leukocyte counts, leukocyte esterase activity, creatinine, pH, and specific gravity were performed. Endogenous nitrite was determined using Griess reagent. Amniotic fluid nitric oxide metabolites (nitrite and nitrate) were measured after reduction of nitrate to nitrite with Aspergillus nitrate reductase. Tests for amniotic fluid cyclic guanosine monophosphate levels were determined by enzyme immunoassay. Two-tailed t test, contingency table methods, linear regression, and correlation were used for statistical analyses.

RESULTS

Amniotic fluid levels of nitric oxide metabolites, endogenous nitrite, nitrate, and cyclic guanosine monophosphate were significantly higher in pregnant women with intraamniotic infection than in those without intraamniotic infection (2.66 +/- 0.49 vs 1.77 +/- 0.07 mumol/mg creatinine, p = 0.002; 0.69 +/- 0.15 vs 0.38 +/- 0.03 mumol/mg creatinine, p = 0.003; 1.99 +/- 0.41 vs 1.38 +/- 0.07 mumol/mg creatinine, p = 0.02; and 1.47 +/- 0.22 vs 0.90 +/- 0.08 nmol/mg creatinine, p = 0.004, respectively). Both amniotic fluid nitric oxide metabolites and cyclic guanosine monophosphate were positively correlated with amniotic fluid leukocyte counts and leukocyte esterase activity and negatively correlated with amniotic fluid glucose concentrations.

CONCLUSIONS

Our data indicate that amniotic fluid nitric oxide and cyclic guanosine monophosphate may play important roles in the pathogenesis of intraamniotic infection. Measurements of amniotic fluid nitric oxide metabolites and cyclic guanosine monophosphate may be part of a panel of tests that can be used to detect intraamniotic infection.

Antepartum and postpartum thrombomodulin levels in preeclamptic and normotensive pregnancies

OBJECTIVE

To determine whether changes in plasma levels of thrombomodulin from antepartum to postpartum reflect the postpartum regression of preeclampsia.

METHODS

Twenty-four preeclamptic women and 34 healthy, normotensive women with singleton pregnancies were studied in the third trimester. Plasma levels of thrombomodulin in the antepartum and postpartum periods were measured by a two-site immunoenzymatic assay. Two-tailed Student t test and paired-comparison t test were used for statistical analyses. The results were expressed as mean +/- standard error.

RESULTS

Antepartum plasma thrombomodulin levels in preeclampsia were significantly higher than postpartum levels (71.3 +/- 8.5 versus 55.5 +/- 5.4 ng/mL; P = .006), which was not seen in the normotensive controls (49.9 +/- 3.1 versus 44.2 +/- 3.8 ng/mL; P > .05). Antepartum plasma levels of thrombomodulin in preeclamptic women were significantly higher than those in the normotensive controls (P = .01). However, postpartum plasma levels of thrombomodulin in preeclamptic women were not significantly higher than those in the normotensive controls (P > .05).

CONCLUSION

Significantly decreased postpartum plasma thrombomodulin levels in preeclamptic pregnancies strongly correspond to clinical postpartum regression of preeclampsia.

Is maternal thyrotropin releasing hormone administration safe in the pregnant woman with preeclampsia?

Maternal intravenous administration of thyrotropin releasing hormone (TRH) is associated with rapid elevations of blood pressure potentially causative of cerebrovascular accidents. We report a case in which peak blood pressure of 220/120 mm Hg was attained from a baseline of 132/80 mm Hg following TRH administration in a preeclamptic patient.

Strategies for reducing the frequency of preeclampsia in pregnancies with insulin-dependent diabetes mellitus

The object of this study was whether improving glycemic control and maintaining normal glycosylated hemoglobin (HbA1c) through pregnancy can reduce the frequency of preeclampsia. One hundred and twenty-three complete medical records of pregnant insulin-dependent diabetics (IDDM) managed at Yale-New Haven Hospital from 1983 to 1993 were reviewed. Serial HbA1c measurements and the occurrence of preeclampsia were recorded. Based on the change of HbA1c values through the pregnancy, glycemic control was categorized into four groups: group 1, high to normal; group 2, high to high; group 3, normal to normal; group 4, normal to high. The association between HbA1c change and the incidence of preeclampsia was analyzed by chi-square test and Fisher's exact test. Among 123 IDDM pregnancies, 40 (32.5%) developed preeclampsia. High HbA1c levels at any time in IDDM pregnancies were associated with an increased incidence of preeclampsia (group 1 or 2 or 4 versus group 3). Reducing HbA1c by improving glycemic control both before and during pregnancy resulted in a significantly lower incidence of pre-eclampsia (group 3 versus groups 1+2+4, p < 0.05). The best strategy for reducing the frequency of preeclampsia in IDDM pregnancies is by improving glycemic control before pregnancy.

Thrombomodulin levels in preeclampsia, gestational hypertension, and chronic hypertension

OBJECTIVE

To measure the circulating levels of thrombomodulin in women with preeclampsia, gestational hypertension, and chronic hypertension.

METHODS

Serum levels of thrombomodulin were measured in 34 women with preeclampsia, 15 with gestational hypertension, 11 with chronic hypertension, and 34 normotensive pregnant women in the third trimester. Preeclampsia, gestational hypertension, and chronic hypertension were defined by ACOG criteria. Soluble thrombomodulin antigen was measured by a two-site enzyme-linked immunosorbent assay.

RESULTS

Mean (+/- standard error) serum thrombomodulin levels were significantly higher in patients with preeclampsia (69.7 +/- 6.3 ng/mL) than in those with gestational hypertension (46.0 +/- 3.2 ng/mL) or chronic hypertension (46.2 +/- 3.3 ng/mL), and normotensive controls (50.1 +/- 3.1 ng/mL). There were no significant differences among the gestational hypertension, chronic hypertension, and normotensive control groups.

CONCLUSION

Thrombomodulin may serve as a clinically meaningful marker to differentiate preeclampsia from other forms of hypertensive disorders in pregnancy.

Urogenital infection in preeclampsia

OBJECTIVE

The purpose of this study was to determine whether the incidence of urinary tract infections and postpartum endometritis were increased in preeclamptic pregnancies.

METHOD

We conducted a retrospective study of 13852 pregnant women, using a perinatal database at The Johns Hopkins Hospital, over the past 5 years. The incidence of urinary tract infections and postpartum endometritis was analyzed using the chi-squared test and logistic regression analysis. Statistical significance was set at P < 0.05.

RESULTS

There were 345 (2.5%) mild preeclamptics and 440 (3.2%) severe preeclamptics. The incidence of urinary tract infections and postpartum endometritis in preeclamptic patients was significantly higher than that in non-hypertensive pregnant patients. After controlling for confounding variables, severe preeclampsia was still found to be an independent significant risk factor for both urinary tract infections and postpartum endometritis.

CONCLUSION

Our data show a significant increase in urogenital infection in preeclamptic pregnancy. This may reflect higher rates of underlying renal disease and placental bed abnormalities occurring in preeclampsia.

Does preeclamptic pregnancy increase fetal-maternal hemorrhage?

Since pathologic changes of the placenta have been found in preeclamptic pregnancies, a relationship between fetal-maternal hemorrhage and preeclampsia was investigated. Sixty-two women with singleton pregnancies in the third trimester were studied. Thirty-one of these women with preeclampsia were matched with 31 normotensive healthy pregnant women. Maternal serum levels of alpha-fetoprotein (MSAFP) and Kleihauer-Betke (KB) test were determined to reflect the degree of fetal-maternal hemorrhage. There were no significant differences in MSAFP levels, MSAFP to creatinine ratio, or the appearance of fetal cells as measured by the KB test between preeclamptic pregnancies and matched controls. Our data do not suggest that fetal-maternal hemorrhage is increased in pregnant women with preeclampsia.

Plasma thrombomodulin levels in women with systemic lupus erythematosus

Thrombomodulin (TM), an endothelial cell membrane glycoprotein, is released into blood as a soluble TM antigen after inflammation or injury to endothelium. Systemic lupus erythematosus (SLE) is characterized by multisystem inflammation of vascular endothelium. The objective of this study is to determine the circulating TM levels in pregnant and nonpregnant SLE women and the correlation of plasma TM levels with variables used to assess SLE activity. We found that there were no significant differences in plasma TM levels among pregnant SLE, nonpregnant SLE, and normal pregnant patients. However, significantly higher plasma TM levels were found in some SLE women with active disease or preeclampsia.

Elevated urine thrombomodulin/creatinine ratio in severely preeclamptic pregnancies

A relationship between the urine thrombomodulin/creatinine ratio and preeclampsia was investigated. Preeclamptic women had a higher urine thrombomodulin/creatinine ratio than did matched controls. However, significantly elevated urine thrombomodulin/creatinine ratios were found in severely, but not mildly, preeclamptic pregnancies.

Uterine rupture associated with recent antepartum cocaine abuse

BACKGROUND

The diagnosis of uterine rupture is aided by the identification of risk factors, such as oxytocin administration. In several experiments, cocaine has been shown to stimulate uterine contractility. Complications from cocaine abuse during pregnancy have increased dramatically in the United States, and cocaine may increase the risk for uterine rupture.

CASES

Two cases of uterine rupture were associated with recent cocaine abuse.

CONCLUSION

These cases and recent experiments on the effect of cocaine on the pregnant uterus suggest that antepartum cocaine abuse may increase the risk of uterine rupture.

Elevated serum human chorionic gonadotropin as evidence of secretory response in severe preeclampsia

OBJECTIVE

Because preeclampsia is a trophoblastic disorder and human chorionic gonadotropin is secreted from trophoblast, we sought to determine whether measurement of serum human chorionic gonadotropin might reflect a different trophoblastic secretory response of preeclampsia.

STUDY DESIGN

Twenty patients with mild preeclampsia and 12 with severe preeclampsia were matched with 32 healthy, normotensive women in the third trimester with singleton pregnancies. Serum total human chorionic gonadotropin and total human chorionic gonadotropin-beta were measured by a two-site immunoenzymometric assay, and total hCG-alpha was determined by a double-antibody radioimmunoassay. Wilcoxon signed-rank and Mann-Whitney rank-sum tests were used for statistical analysis.

RESULTS

Serum total human chorionic gonadotropin, total human chorionic gonadotropin-alpha, and total human chorionic gonadotropin-beta levels were significantly higher in severely preeclamptic women (p < 0.05), but not in those with mild preeclampsia, compared with those in their matched controls.

CONCLUSION

Elevated serum human chorionic gonadotropin levels in severely preeclamptic women might reflect a significantly pathologic change and secretory reaction of the placenta.

Elevated circulating thrombomodulin in severe preeclampsia

A relationship between serum thrombomodulin and preeclampsia was investigated. In women with severely preeclamptic pregnancies, serum thrombomodulin levels were found to be significantly elevated as compared with those of matched control subjects (p < 0.005). Serum thrombomodulin levels correlated positively with serum creatinine (r = 0.854, p < 0.0001) and uric acid levels (r = 0.784, p < 0.001).