A double-blind, cross-over study of the effects of terodiline in women with unstable bladder

In a double-blind, cross-over study, the effects of terodiline were evaluated in 12 women with motor urge incontinence. The patients were investigated by simultaneous urethro-cystometry before and after treatment fo 2-week periods with placebo and terodiline 12.5 mg twice daily. The effects on subjective symptoms were also assessed. In all patients but one, terodiline increased the bladder capacity and also the bladder volume at which urgency was experienced. No effects on the urethral pressure profile or residual urine were found. Subjective improvement was reported by all but one of the patients. Placebo treatment had no effect on the measured parameters or on the subjective symptoms. No side effects were reported during any of the treatment periods. --It is concluded that terodiline can be used for treatment of female motor urge incontinence, and that it is a promising alternative to drugs presently used for this disorder.

Differential regulation of the progesterone receptor A and B in the human uterine cervix at parturition

The concept of a blockade of progesterone during human pregnancy and withdrawal of this blockade at parturition remains controversial There is no sharp fall in serum progesterone before parturition, but treatment with an antiprogestin is successful for labor induction at term pregnancy. The human progesterone receptor (PR) exists in two isoforms (PR-A and PR-B), mediating different biological responses. Here, the hypothesis of a progesterone withdrawal at parturition in terms of a change in PR isoforms was tested. Cervical biopsies were obtained at term before the onset of labor, immediately after parturition and from non-pregnant women. Solution hybridization showed a tendency for the PR mRNA level to be decreased at parturition. Immunohistochemistry displayed decreased PR(A + B) and PR-B levels (p < 0.05) immediately after parturition. The relative importance of PR-A seemed higher immediately after parturition as compared to its importance in non-pregnant and term pregnant women. Our results are consistent with the concept of a functional progesterone blockade at the receptor level at term pregnancy, and withdrawal of this blockade at parturition. These observations may have important clinical and therapeutic implications.

Co-localization of oestrogen receptor beta and leukocyte markers in the human cervix

Cervical ripening during parturition is associated with rapid production of catabolic enzymes by invading leukocytes and increased collagen metabolism. The recruitment of leukocytes is regulated by various factors including inflammatory mediators, prostaglandins and matrix metalloproteinases. Sex steroids may be indirectly or directly involved in this process. This study aimed to evaluate the expression of oestrogen receptor beta (ER beta) in blood cells infiltrating the cervix during pregnancy and parturition. Cervical biopsies were obtained from term pregnant, post-partal and non-pregnant women. The ER beta protein and leukocyte markers CD45 and CD68 were evaluated by single and double labelling immunohistochemistry. Quantitative values were assessed using a microscope and a high-resolution camera connected to a computer with image analysis program. The number of CD45(+) and CD68(+) cells in the cervix increased in term pregnancy and post-partum compared with the non-pregnant state. The ER beta antigen was co-localized with CD45 leukocyte common antigen and CD68 macrophage specific antigen in blood leukocytes infiltrating the cervical tissue. The presence of ER beta in the cervical leukocytes suggests that oestrogen may directly regulate leukocyte functions in the cervix.

Different regulation of oestrogen receptors alpha and beta in the human cervix at term pregnancy

During pregnancy, a cervical connective tissue remodelling takes place, clinically recognized as softening, effacement and dilatation. The role of oestrogens and their receptors (ER) in this process is not clear. ERalpha is a ligand-activated transcription factor involved in many physiological processes. The identification of a second oestrogen receptor, ERbeta, has led to a re-evaluation of oestrogen signalling and physiology. The aim of this study was to monitor the expression of the two ERs in the cervix from women at term pregnancy (TP) and after parturition (PP) compared with that of non-pregnant (NP). A solution hybridization assay showed that the level of ERalpha mRNA was significantly decreased in the PP group, when compared with the NP and TP groups. In contrast the ERbeta mRNA level was increased in the TP group compared with the NP and PP groups. These results were supported by reverse transcription-polymerase chain reaction (RT-PCR). Similar results were observed for the protein with immunohistochemistry. Intense ERbeta immunostaining was observed in neutrophils and the endothelial cells of blood vessels. In conclusion, this study supports a concept according to which oestrogen might be involved in the final remodelling of the cervix via the modulating effects of the two ERs. Furthermore, oestrogen may mediate some effects on cervical ripening via ERbeta present in the invading neutrophils. Further studies are needed to elucidate this finding.

The expression of glutaredoxin is increased in the human cervix in term pregnancy and immediately post-partum, particularly after prostaglandin-induced delivery

Glutaredoxins are glutathione disulphide oxidoreductases catalysing disulphide reductions via a redox active disulphide. We have examined the presence of glutaredoxin in the human cervix, and its differential expression during cervical remodelling in term pregnancy and immediately post-partum as compared to the non-pregnant state. Cervical biopsies were obtained from 24 term-pregnant and 24 post-partal women, of which 10 were taken after spontaneous delivery, 10 after prostaglandin-induced delivery and four after mifepristone-induced delivery, all obtained within 15 min after delivery. Six non-pregnant women served as controls. The tissues were analysed for the glutaredoxin mRNA levels using a solution hybridization method. Glutaredoxin mRNA was expressed in the human cervix, the level increased > or =2-fold at term pregnancy and immediately post-partum. The level of cervical glutaredoxin mRNA from prostaglandin E(2)-treated women was 3-fold higher than after spontaneous ripening and delivery. Localization of glutaredoxin was visualized with immunohistochemistry in cervices from two post-partal women, and was compared to that of thioredoxin. We conclude that glutaredoxin may be involved in the regulation of cervical ripening in humans, particularly in the inflammatory reaction seen during this process. Glutaredoxin mRNA levels are up-regulated after prostaglandin treatment, which is effective and the most commonly used substance for cervical priming and induction of labour.

Caesarean section in previously untreated acute promyelocytic leukaemia. Report of two patients

Acute promyelocytic leukaemia (APL) is characterised by a life-threatening hemorrhagic diathesis which is attributed to a DIC-like coagulopathy. This report describes the problems of childbirth in two patients with untreated APL. It is concluded that caesarean section can be performed without major complications. A prerequisite is an active treatment of the coagulopathy and a close collaboration between the obstetrician and the haematologist.

Neurochemical and cellular markers in human cervix of late pregnant, postpartal and non-pregnant women

BACKGROUND

The aim was to evaluate the peptidergic innervation and the dendritic cell content in the cervix uteri.

METHODS

Cervical biopsies were obtained from late pregnant (n=5), postpartal (n=5) and non-pregnant (n=5) women. The samples were prepared for immunohistochemistry using antibodies to protein S-100 (S-100), calcitonin gene-related peptide (CGRP), vasoactive intestinal polypeptide (VIP), human peptide histidine isoleucine amide (PHM 27), neuropeptide tyrosine (NPY), and human histocompatibility complex class II subregion DR (HLA-DR).

RESULTS

Nerve fibers positive for protein S-100, and dendritic cells positive for S-100 and HLA-DR were abundant in the cervix, especially at late pregnancy. CGRP, VIP, PHM-27 and NPY positive nerve fibers were present in non-pregnant, short nerve fibers and scattered immunoreactivity at term, and further scattered immunoreactivity after parturition. NPY positive nerve fibers were decreased at term, and after parturition a scattered immunoreactivity was observed.

CONCLUSIONS

The abundant protein S-100 positive nerve fibers implies an impact of myelinated nerves in the cervix uteri during pregnancy. The abundant dendritic cells, positive for HLA-DR and S-100, especially at term, indicates a general activation of the immune system until late pregnancy and parturition. The changed occurrence and distribution of immunoreactivity for CGRP, VIP and PHM-27 suggest a release of these neuropeptides until term. The changes in NPY immunoreactivity indicate a release of NPY around parturition.

Human cervical ripening, an inflammatory process mediated by cytokines

An extensive remodelling process, referred to as cervical ripening, takes place in the cervical tissue during pregnancy and labour. It is recognized as softening and dilation of the cervical canal, and starts as a slow process during pregnancy, becoming rapid close to partum. In this study we focus on cytokines as possible mediators of this final remodelling. mRNA levels for interleukin (IL)-8, IL-6 and granulocyte colony-stimulating factor (G-CSF) were upregulated in the ripe postpartum cervical tissue (n = 8) compared to the unripe state (n = 9). Likewise, released cytokine concentrations increased from non-pregnant (n = 11) to the term-pregnant group (n = 13) with a further increase at partum (n = 16). IL-8 concentrations increased 4-fold from non-pregnant to term-pregnant (P<0.01), and a further 10-fold to postpartum state (P<0.0001). Concentrations of IL-6 and G-CSF were similarly increased. Specific IL-8 immunostaining was identified in the epithelia of pregnant cervical tissue (n = 7) and was most pronounced in the epithelia and stroma of postpartum tissue (n = 4). In conclusion, IL-8, IL-6 and G-CSF increase in the human cervix during the ripening process, indicating their important role in the cervical remodelling. These data demonstrate that cervical ripening is similar to an inflammatory process.

Induction of labor with mifepristone--a randomized, double-blind study versus placebo

OBJECTIVE

To evaluate the efficacy of mifepristone in inducing labor in women with an unripe cervix, its effect on the cervix and on the status of the newborn.

METHODS

In a prospective double-blind study, 36 post-term pregnant women with a Bishop score of 5 or less received either 400 mg mifepristone (n=24) or placebo (n=12). If, 48 hours after the treatment was started, labor had not begun or the Bishop score was 5 or less, the women were given 0.5 mg prostaglandin E2 intracervically, a treatment which was repeated 12 hours later, if necessary.

RESULTS

During the first 48 hours following treatment, 19 (79.2%) of the women treated with mifepristone and two of the women (16.7%) treated with placebo went into labor. In addition, one and three women, respectively, had a ripe cervix at the end of the 48h period. The overall success rate was thus 83.3% for mifepristone and 41.7% for placebo (p=0.008; OR 14.8; 95% CI 2.1-107.6). The median time from the start of treatment to delivery was also shorter (mifepristone 36h23' and placebo 53h17'). Treatment with intracervical PGE2 was needed more often after the placebo. The duration of labor, however, tended to be shorter after placebo than after mifepristone in the women who delivered vaginally. The frequencies of instrumental delivery were similar in both treatment groups. The median Apgar score was slightly lower at 1 minute (p<0.05) following mifepristone treatment, but did not differ at 5 and 10 minutes. There was no difference between the two treatment groups in the umbilical pH at delivery.

CONCLUSION

The results of the present study show that mifepristone is a simple and effective treatment for inducing labor in post-term women with an unripe cervix.

Protein gene product 9.5-immunoreactive nerve fibers and cells in human cervix of late pregnant, postpartal and non-pregnant women

BACKGROUND

The aim of this study was to examine the occurrence and distribution of the general neuronal marker protein gene product (PGP) 9.5 in the cervix uteri.

METHODS

Cervical biopsies were obtained from late pregnant (n=5), postpartal (n=5) and non-pregnant (n=5) women. The samples were prepared for immunohistochemistry using antibodies to PGP 9.5.

RESULTS

Nerve fibers were found consistently in all biopsies. There were differences in the occurrence and distribution of PGP 9.5 immunoreactive nerve fibers and cells between the three groups. Immunoreactive nerve fibers were observed at a moderate to abundant frequency in the stroma and around arterial vessel walls, in all groups. Immunoreactive nerve fibers were also observed at high frequency within and around glandular epithelium in the late pregnant and postpartal groups. PGP 9.5 immunoreactive cells were seen occasionally in the stroma of the non-pregnant group, but at a high frequency in the stroma, around arterial blood vessel walls, around and within the glandular epithelium in the late pregnant and postpartal groups. The total frequency of immunoreactive nerve fibers and cells was the highest in the late pregnant group, slightly lower in the postpartal group, and the lowest in the non-pregnant group.

CONCLUSIONS

These findings show that changes in the general innervation take place during human cervical ripening until late pregnancy and parturition.

Differential expressions of mRNA for proteoglycans, collagens and transforming growth factor-beta in the human cervix during pregnancy and involution

During pregnancy and involution, an extensive remodelling of the human cervical connective tissue occurs. This cervical ripening is one of the most pronounced physiological remodelling processes known in human connective tissue. To investigate how the remodelling is accomplished, the levels of mRNA for collagen I and III, versican and three small proteoglycans, biglycan, decorin and fibromodulin, were evaluated using Northern blots at different stages of cervical ripening. In the corresponding biopsies the concentration of collagen and of small and large proteoglycans were determined. The role of transforming growth factor-beta (TGF-beta) as a mediator of the remodelling process was also investigated. The concentration of collagen decreased and 1 week before partus, 50% of the nonpregnant level was attained. No further decrease was noted after partus. The mRNA for collagen I and III did, however, not decrease in the term pregnant cervix 1 week before partus. Only 20-30% decrease during the final ripening just before partus was recorded. Neither did the mRNA levels of the small proteoglycans change significantly during the ripening, despite an almost 50% decrease in the concentration of the small proteoglycans. The message for versican was, however, 5-fold increased at partus and then gradually returned to nonpregnant levels within 4 days after delivery. These changes corresponded to similar changes in the concentration of the large proteoglycan. Thus, the remodelling of the cervical connective tissue is achieved by two different mechanisms, on one hand an increased turnover of collagen and the small proteoglycans, on the other a changed transcription followed by an increased production of versican. During the involution 2- to 3-fold increases in the messages for collagen I and III, and the small proteoglycans, biglycan and decorin, corresponded to increases in the concentration of the small proteoglycans and non-extractable collagen. The message for TGF-beta was increased 2-fold immediately after delivery compared with the term pregnant state. Thus, TGF-beta may be of importance for the reconstruction of the cervix, which starts immediately after partus.

The expression of thioredoxin mRNA is increased in the human cervix during pregnancy

The classic function for thioredoxin is to act as a hydrogen donor for the enzyme ribonucleotide reductase, which is essential for DNA synthesis. In addition, thioredoxin participates in the regulation of different metabolic processes via thiol redox control. These kind of processes involve changes in the activity of different enzymes, receptors or transcription factors via dithiol/disulphide interchange reactions. Thioredoxin is present in the human decidua and trophoblasts. This study was performed to investigate whether thioredoxin mRNA is present in the human cervix, and differently expressed during pregnancy as compared with the non-pregnant state. Cervical biopsies and serum samples were obtained from 28 late pregnant, 41 post-partum and 15 non-pregnant menstruating women. The tissues were analysed for thioredoxin mRNA content using a solution hybridization technique. The thioredoxin mRNA level increased 3-fold at late pregnancy in comparison with the non-pregnant state. No further increase was seen immediately after parturition, either after spontaneous delivery or after pharmacological induction. There was a positive correlation between the cervical thioredoxin mRNA level and the serum oestradiol concentration in the non-pregnant group. We suggest that thioredoxin mRNA in the human cervix is regulated, at least partly, by oestradiol.

Potential roles for gonadal steroids and insulin-like growth factor I during final cervical ripening

OBJECTIVE

To determine whether gonadal steroids and insulin-like growth factor I influence the final cervical remodeling during parturition.

METHODS

Cervical biopsies were obtained transvaginally before labor (n = 10) and after spontaneous cervical ripening and vaginal delivery (n = 20). Levels of estrogen and progesterone receptors, their messenger RNAs, insulin-like growth factor I messenger RNA, and serum estradiol and progesterone were measured. Collagen and proteoglycan concentrations and compositions were measured to estimate the degree of cervical ripeness.

RESULTS

The concentrations of estrogen and progesterone receptors decreased in comparison with the clinically unripe cervix before labor. The median estrogen receptor concentration (range) decreased from 10 (2-18) to 4.5 (2-14) fmol/mg protein (P < .01), and the progesterone receptor concentration from 105.5 (32-153) to 74 (30-115) fmol/mg protein (P < .05), whereas their messenger RNA levels were unchanged. The insulin-like growth factor I messenger RNA concentration declined from 16.1 (8.4-20.4) at term to 8.9 (1.5-18.5) amol/microgram DNA after parturition (P < .01). The collagen solubility by pepsin increased, but not significantly, and the collagen concentration was unchanged. The concentration of small proteoglycans, mainly decorin, decreased from 1.59 (1.20-1.97) to 0.84 (0.24-1.41) micrograms/mg wet weight (P < .001), and the concentration of versican increased, but not significantly (P = .07).

CONCLUSION

Concentrations of estrogen and progesterone receptors and insulin-like growth factor I messenger RNA were decreased significantly after spontaneous cervical ripening in comparison to levels before labor. These changes coincided with a tendency toward increased collagen solubility and a decline in concentration of small proteoglycans, which probably alters collagen organization, thus allowing for cervical softening and dilation. These observations suggest that gonadal steroids influence the final cervical remodeling during parturition, an influence perhaps mediated by insulin-like growth factor I.

Cervical ripening in humans: potential roles of estrogen, progesterone, and insulin-like growth factor-I

OBJECTIVE

During pregnancy in humans a gradual connective tissue remodeling takes place in the cervix. The aim of this study was to examine a possible relationship between the action of gonadal steroids and growth factors and the biochemically identifiable changes in connective tissues during cervical ripening.

STUDY DESIGN

Cervical biopsy specimens and serum samples were taken from 20 term pregnant and 20 nonpregnant menstruating women. Estrogen receptors and progesterone receptors were measured with enzyme immunoassays. The messenger ribonucleic acid levels for estrogen receptors, progesterone receptors, and insulin-like growth factor-I were determined by solution hybridization with human complementary deoxyribonucleic acid probes. The concentration of collagen and its solubility by pepsin digestion were measured. Statistical evaluations were done with the Student t test.

RESULTS

In term pregnancy the estrogen receptor level decreased to 14% and the progesterone receptor level to 24% of nonpregnant levels (p <0.001 and p <0.01). The insulin-like growth factor-I messenger ribonucleic acid level increased 400% (p <0.01), whereas the messenger ribonucleic acid levels for estrogen receptors and progesterone receptors were unchanged. The changes coincided with a twofold decrease in collagen concentration (hydroxyproline) and a twofold increase in collagen solubility.

CONCLUSION

Estrogen receptors and progesterone receptors are present in human cervix. A significant down-regulation of estrogen receptors and progesterone receptors and a fourfold increase in the insulin-like growth factor-I messenger ribonucleic acid level were registered in term pregnant cervix. These findings coincided with the remodeling of the cervical connective tissue.

Cervical fetal fibronectin correlates to cervical ripening

AIM OF STUDY

It is well established that the cervical ripeness is of great prognostic value at labor induction. The available methods of measuring the cervical ripeness are not satisfactory. This study was therefore initiated to investigate if there is any correlation between cervical fetal fibronectin and cervical ripening at term.

METHOD

Three groups were included in this study: women with unripe cervices, women with spontaneous cervical ripening and those with PGE2-induced cervical ripening. Fetal fibronectin was measured by ELIZA after sampling from the cervical canal.

RESULTS

The cervical fetal fibronectin was low in women with unripe cervices. In women with favorable cervices a ten fold higher level was found. The fibronectin level was even higher after PGE2-induced ripening.

CONCLUSION

Conclusively an increased amount of cervical fetal fibronectin is registered during the cervical ripening process. A level of > 0.80 microgram/ml of cervical fetal fibronectin seems to indicate a favorable cervix.

Serial antenatal monitoring compared with labor induction in post-term pregnancies

OBJECTIVE

In view of the increased risk of obstetric and perinatal complications in post-term pregnancy, and the lack of consensus regarding clinical routines for fetal surveillance and labor induction, the aim of this prospective controlled study was to compare obstetric and perinatal outcome after serial monitoring until 43 weeks of gestation with that after labor induction at 42 gestational weeks.

MATERIALS AND METHODS

A study group of 193 gravidae scheduled for serial monitoring until 43 weeks of gestation was compared with a control group of 205 gravidae admitted for induction of labor at 42 weeks. A third, high-risk, group comprised gravidae (from either of the foregoing groups) who had to be admitted for emergency induction of labor owing to increased fetal risk (i.e., the presence of oligohydramnios or a small-for-gestational-age fetus).

RESULTS

The frequency of labor induction was significantly lower in the study group than among controls (p < 0.001), but the two groups did not differ in obstetric or perinatal outcome. As compared with these two low-risk groups, the high-risk group was characterized by significantly higher frequencies of instrumental delivery (p < 0.01), operative delivery for fetal distress (p < 0.001) and infants requiring neonatal intensive care (p < 0.001).

CONCLUSION

As the wait-and-see policy with serial monitoring resulted in a lower rate of labor induction, but not in a lower rate of instrumental delivery or perinatal complication, medically the two routines would appear to be comparable. However, an individual approach with intensified fetal surveillance is to be recommended, as it is vital to identify post-term pregnancies where the fetus is at increased risk. The use of such new techniques as umbilical artery flow velocimetry would no doubt improve the management of high-risk post-term pregnancies.

Umbilical artery velocimetry may influence clinical interpretation of intrapartum cardiotocograms

BACKGROUND

In a previous prospective randomised trial on pregnancies complicated by small-for-gestational-age fetuses fewer operative deliveries for fetal distress were found after antenatal surveillance with umbilical artery Doppler velocimetry (Doppler group) than after surveillance with cardiotocography (CTG group). Despite that, the neonatal outcome was similar in both groups. This raised the question whether the knowledge of the antenatal Doppler results had influenced the obstetric management of labor.

METHODS

In this retrospective study 242 intrapartum cardiotocogram tracings, obtained from the above mentioned prospective trial, were re-interpreted by an expert without knowledge of the results in the original study. The re-interpretation was then compared to the original interpretation.

RESULTS

The expert interpreted 18 intrapartum tracings in the Doppler group and 18 in the CTG group as abnormal, whereas the clinicians interpreted only 8 tracings as abnormal in the Doppler group and 18 tracings in the CTG group.

CONCLUSIONS

The results of this retrospective study lend support to our hypothesis that the obstetricians in clinical practice are influenced by the knowledge of a normal umbilical Doppler velocimetry when interpreting an intrapartum CTG. This finding may partly explain why there were fewer emergency cesarean sections for fetal distress in the Doppler group than in the CTG group in the original prospective study.

Decreased collagen synthesis in stress-incontinent women

OBJECTIVE

To determine whether there is a difference in collagen metabolism between comparable urinary stress-incontinent and -continent women.

METHODS

Fibroblast cultures from skin biopsies were established from seven stress-incontinent and four continent women. Collagen production was investigated in these cultures between passages 3 and 7 by incubation with 3H-proline, followed by quantitation of 3H-proline and 3H-hydroxyproline after hydrolysis of proteins and separation by high-pressure liquid chromatography. The chemical amount of collagen was also quantitated using Sircol Red.

RESULTS

Fibroblast cultures established from urinary stress-incontinent women accumulated 30% less collagen than comparable cultures from continent women. The differences were statistically significant (cell layer P = .038, medium P = .004; Student t test). These results were observed both when collagen concentration was measured with chemical methods and when the production of protein-bound 3H-hydroxyproline was quantitated. General protein synthesis was similar in the two groups.

CONCLUSION

Our results suggest that women with urinary stress incontinence have an altered connective tissue metabolism causing decreased collagen production, which may result in insufficient support of the urogenital tract.

Prostaglandin E2-induced ripening of the human cervix involves changes in proteoglycan metabolism

OBJECTIVE

To elucidate how prostaglandin E2 (PGE2) induces cervical ripening.

METHODS

Cervical biopsies were obtained immediately postpartum from women successfully treated with PGE2 gel intracervically. Six specimens were incubated with [35S]sulfate and five were used to characterize the nonlabeled proteoglycan composition. In separate experiments, biopsy specimens from three term pregnant women with unripe cervices were incubated with PGE2 in organ cultures. Proteoglycans were isolated and characterized using ion-exchange and gel chromatography and sodium dodecyl sulfate-polyacrylamide gel electrophoresis.

RESULTS

During PGE2-induced cervical ripening, the synthesis of proteoglycans, especially a large chondroitin/dermatan sulfate proteoglycan and biglycan, increased three- to sixfold. This resulted in a net increase in the large proteoglycan in the PGE2-treated cervices. In organ culture, on the contrary, incubation with PGE2 decreased the proteoglycan synthesis.

CONCLUSION

Prostaglandin E2-induced cervical ripening is accomplished by increased remodeling of the cervical connective tissue, involving changed proteoglycan metabolism and composition.

Clinical evaluation of the fetus and neonate. Relation between intra-partum cardiotocography, Apgar score, cord blood acid-base status and neonatal morbidity

The relation between intra-partum cardiotocography (CTG), cord blood acid-base status, Apgar score and neonatal morbidity was studied in 1228 consecutively live-born babies and in a subgroup of 200 babies (148 babies with a 1 min Apgar score < or = 8 and 52 randomly selected babies with a 1 min Apgar score > or = 9). The scores for the individual components of the 1 min Apgar score were strongly associated with each other, whereas the scores for the individual components of the 5 min Apgar score were less strongly associated. At 1 min the scores for muscle tone, reflex irritability and respiration but not the scores for heart rate and skin colour were associated with arterial and venous cord blood pH (low scores being associated with low pH). Out of the individual components of the Apgar score, heart rate and reflex irritability at 1 min were the best discriminators between "healthy or relatively healthy" and "severely ill" babies. Intrapartum CTG, total Apgar score and cord blood acid-base status were only weakly related. Venous cord blood pH was the best predictor of the 1 min Apgar score. Intra-partum CTG (silent pattern), 5 min Apgar score and venous cord blood pH were the best predictors of severe neonatal morbidity.

Changed proteoglycan metabolism in human cervix immediately after spontaneous vaginal delivery

OBJECTIVE

To investigate whether the final cervical ripening just before or during labor corresponds to changes in cervical connective tissue metabolism and composition.

METHODS

Cervical biopsies taken transvaginally immediately after normal vaginal delivery and at hysterectomy were incubated with [35S] sulfate. In other biopsy specimens, the nonlabeled proteoglycan pattern was studied. Collagen concentration and organization were monitored to estimate the degree of cervical ripeness. Labeled and nonlabeled proteoglycans were isolated, characterized, and quantitated. Collagen concentration and collagen, extractable and not extractable by pepsin digestion, were quantitated as hydroxyproline.

RESULTS

A marked increase in the accumulation rate of labeled proteoglycans was observed in cervical biopsies obtained immediately after vaginal delivery. This increase was markedly larger than that previously noted in term pregnant women with unfavorable cervices. In particular, the accumulation of one labeled large chondroitin sulfate proteoglycan and one small dermatan sulfate proteoglycan, biglycan, increased significantly compared with the unfavorable cervices. In contrast, the small dermatan sulfate proteoglycan, decorin, showed a relative decrease. The changed synthesis of proteoglycans resulted in a two- to threefold increase in chemical amounts of the large proteoglycan, while the small dermatan sulfate proteoglycans decreased to approximately half of that in the nonpregnant cervix.

CONCLUSION

The changed cervical proteoglycan metabolism results in a changed proteoglycan composition of the tissue. This alteration probably influences collagen organization, contributing to the cervical softening and dilatation essential for an uncomplicated vaginal delivery.

Comparison of umbilical-artery velocimetry and cardiotocography for surveillance of small-for-gestational-age fetuses

Intrauterine growth retardation is associated with an increased risk of fetal asphyxia as well as greater perinatal morbidity and mortality. Ultrasound fetometry enables detection of fetuses that are small for gestational age. Doppler velocimetry of the umbilical artery has good predictive ability for fetal distress, but it is not yet clear whether it could replace cardiotocography in antenatal surveillance of small-for-gestational-age fetuses. We have done a randomised comparison of the two methods. At four obstetric departments in Sweden, women with fetuses found to be small on ultrasound examination at 31 completed weeks of pregnancy or later were randomly assigned to antenatal surveillance with either doppler velocimetry (doppler; 214) or cardiotocography (CTG; 212). Pregnancies in the doppler group were managed according to a protocol based on blood-flow classes deriving from the semiquantitative evaluation of umbilical-artery velocity waveforms; unless the pregnancy was complicated by any other disorder, no antenatal cardiotocography was done. By comparison with the CTG group, the doppler group had fewer monitoring occasions (mean 4.1 [SD 3.1] vs 8.2 [6.2], p < 0.01), antenatal hospital admissions (68 [31.3%] vs 97 [45.8%], p < 0.01), inductions of labour (22 [10.3%] vs 46 [21.7%], p < 0.01), emergency caesarean sections for fetal distress (11 [5.1] vs 30 [14.2%], p < 0.01), and admissions to neonatal intensive care (76 [35.5%] vs 92 [43.4%], p = 0.10). The groups did not differ in gestational age at birth, birthweight, Apgar scores, or total number of caesarean deliveries. Umbilical-artery doppler velocimetry of small-for-gestational-age fetuses allows antenatal monitoring and obstetric interventions to be aimed more precisely than does cardiotocography.

Preinductive cervical ripening with prostaglandin E2 in women with one previous cesarean section

Thirty term pregnant women with one previous cesarean section and with unripe cervices were given 0.5 mg prostaglandin E2 in gel strictly intracervically for cervical ripening and labor induction. Fifteen out of these 30 women (50%) were vaginally delivered within 24 hours. The cervical ripening/labor induction was considered a failure in two women. In one woman, an episode of hypercontractility was registered. After tocolytic therapy the uterine activity was normalised and the woman had a normal vaginal delivery. The frequency of cesarean sections was 8/30 (27%). At the operations no insufficiencies in the uterine scars were noted. Conclusively, strict intracervical application of 0.5 mg prostaglandin E2 in gel can be used for cervical ripening and labor induction also in women with one previous cesarean section.

Intrauterine fetal death due to echovirus 11

In a case of intrauterine fetal death in the 29th week of gestation, echovirus 11 could be isolated from the umbilical cord of the fetus. The mother had no apparent signs of infection but serological evidence of current echovirus 11 infection. Enterovirus PCR performed on paraffin-embedded specimens of various tissues (myocardium, lung, liver and placenta) from the fetus yielded positive results in all cases. These findings, together with supporting serological and epidemiological findings--e.g. proven echovirus 11 infection 3 weeks before in the 18-month-old son of the woman--constituted strong evidence that echovirus 11 infection was responsible for the fetal death.

Insufficient remodelling of the uterine connective tissue in women with protracted labour

OBJECTIVE

To investigate the association between a slow progress of labour and insufficient remodelling of the uterine connective tissue.

DESIGN

An open comparative study.

SETTING

Danderyd Hospital, Department of Obstetrics and Gynaecology, referral centre.

SUBJECTS

Eleven women (study group) in oxytocin augmented labour but with an unripe cervix in whom vaginal delivery could not be accomplished and 12 women (normal labour group) in normally progressing spontaneous labour and a favourable cervix but who needed to be delivered by caesarean section due to signs of fetal distress.

INTERVENTIONS

At caesarean section tissue specimens were obtained from the fundus, the isthmus and the cervix uteri.

MAIN OUTCOME MEASURES

Collagen concentration and extractability, collagenolytic activity expressed as DNP-peptide hydrolytic activity and the concentrations of sulphated glycosaminoglycans (S-GAG) and hyaluronic acid (HA) in the tissue specimens.

RESULTS

Statistically significantly higher concentrations and lower extractability of collagen in the isthmus and the cervix uteri was found in women with slow progress of labour compared with those with normal labour.

CONCLUSIONS

An insufficient remodelling of the connective tissue in the cervix and isthmus uteri may contribute to slow progress of labour.

Proteoglycan metabolism in the connective tissue of pregnant and non-pregnant human cervix. An in vitro study

Profound changes occur in the cervix during pregnancy. In particular, the connective tissue is remodelled. To elucidate the mechanisms behind this process, the metabolism of cervical connective tissue was studied using tissue cultures. Cervical biopsies from non-pregnant and pregnant women were incubated with [35S]sulphate. The proteoglycans of the tissue specimens were purified by ion-exchange and gel chromatography and characterized by SDS/PAGE and by enzymic degradation. In the non-pregnant cervix, the incorporation of [35S]sulphate into the proteoglycans was linear for 48 h. During the first 6 h of incubation the accumulation of chiefly one small labelled proteoglycan (apparent Mr 110,000) substituted with dermatan sulphate was recorded. This is in accordance with the known proteoglycan composition of non-pregnant cervical tissue. In addition, small amounts of two larger radioactive dermatan/chondroitin sulphate proteoglycans (apparent Mr values 220,000 and greater than 500,000) were recorded. After longer periods of incubation the proportion of heparan sulphate proteoglycans increased considerably. The pregnant tissue showed a clearly different composition of labelled proteoglycans. An increased accumulation of the two larger dermatan/chondroitin sulphate proteoglycans was seen in addition to the dominant small dermatan sulphate proteoglycan of the non-pregnant cervix. The rate of accumulation of these two proteoglycans was about 3 times higher in the pregnant tissue, whereas that of the small dermatan sulphate proteoglycan was only increased 2-fold. The fact that the concentration of proteoglycans in the pregnant cervix is approximately one-half of that in the non-pregnant cervix indicates that the turnover of proteoglycans in pregnant cervical tissue is significantly increased. The major effect of this profound change of metabolism was a 50% decrease in proteoglycan content and a 2-fold increased proportion of a dermatan sulphate proteoglycan with an apparent Mr of 220,000.

Low field magnetic resonance imaging of the central nervous system in 15 children with autistic disorder

Fifteen children, 10 boys and 5 girls, with autistic disorder, were studied with low field magnetic resonance imaging (MRI). The age ranged from 2.7-13.1 years, with a mean of 8.3 years. All patients but one (who refused) had a normal CT scan of the C.N.S. The MRI investigation was performed during anaesthesia with a low field magnetic resonance imager. The cerebrum, cerebellum, and brain stem were examined. No pathological changes were found in any of the patients studied.

Preinductive cervical ripening with PgE2 gel in term pregnant women with ultrasonically diagnosed intra-uterine growth-retarded fetuses

Intra-uterine growth retardation (IUGR), often combined with other pregnancy-related complications, constitutes a rather common indication for labor induction. The objective of this prospective study was to evaluate a strict intracervical application of 0.5 mg PgE2 in gel for cervical ripening and labor induction. Eighty term pregnant women with an ultrasonically diagnosed IUGR (less than -2 SD) and an unripe cervix were given PgE2-gel. The main indication for labor induction was IUGR, but 26 women had other complications. IUGR was verified at delivery in 50 women (study group), whereas 30 women (control group) gave birth to infants of normal birth weight (greater than -2 SD). The cervical ripening effect did not differ between the groups. In the study group, 19 nulliparous and 15 parous women out of 50 had a favorable cervix after 12 h and were delivered within 24 h of gel application. The corresponding result for the control group was 11 nulliparous and 8 parous women out of 30. Failed induction was registered in 2 and one woman respectively. On the other hand, the number of instrumental deliveries was greater in the study group, 11 caesarean sections (CS) and seven ventouses, compared with one CS and three ventouses in the control group (p less than 0.05). The frequency of operative deliveries for fetal distress (ODFD) was higher among the women with verified IUGR (14/50) than in the controls, where the corresponding figure was 3/30. No side effects were observed. We conclude that strict intracervical application of 0.5 mg PgE2 is a safe and effective method for cervical ripening and labor induction in women with IUGR.

Myometrial activity after local application of prostaglandin E2 for cervical ripening and term labor induction

Twelve pregnant women at term with unfavorable cervices (less than or equal to 5 points according to Bishop score) were given prostaglandin E2 for cervical priming and labor induction. Prostaglandin E2 was given in the following manner: 0.5 mg in gel strictly intracervically (n = 4), extraamniotically (n = 4), or prostaglandin E2 (4 mg) in gel vaginally (n = 4). The myometrial activity was registered over a period of 30 minutes before and at least 3 hours after gel application by means of an extraamniotic microtransducer catheter. After both extraamniotic and vaginal gel application, myometrial activity was significantly increased compared with intracervical application. All the women had favorable cervical states 6 hours after treatment and were delivered vaginally within 24 hours. All infants were delivered in good condition with 1-minute Apgar scores greater than 7. From these results we conclude that proper intracervical prostaglandin E2 gel application, in contrast to extraamniotic or vaginal application, induces cervical ripening without significant myometrial activity. Because careful intracervical application appears to avoid or minimize the risks of myometrial hyperstimulation, this technique should be considered particularly in women with unfavorable cervices and delicate fetuses.

Circulatory monitoring of children during anaesthesia in low-field magnetic resonance imaging

Anaesthesia for patients in a Magnetic Resonance Imaging (MRI) scanner provides some problems for the design of both the anaesthetic and the monitoring equipment. This report presents a technique for continuously displaying the heart rate during anaesthesia for children in an MRI scanner. The monitoring system used light to detect differences in skin capillary circulation, and the light was transferred to and from the patient via fiberoptic cables. After amplification, the signal was displayed "on line" on a cardioscope, thus continuously presenting heart rate and, in part, a qualitative view of the skin vascular resistance.

Epidemiological studies of geographic variations of cancer incidence in Sweden. Choice of variables and statistical units

The Swedish Cancer-Environment Registry has been used for studies of the parts of cancer incidences and of their variations between subpopulations, which, in a statistical sense, can be 'explained' by environmental variables. In previous studies the dependence of age-standardized incidences in municipalities (279 in Sweden) on population density, socio-economic variables, smoking habits and a variable for 'diagnostic intensity', assumed to allow for variations in under-diagnosing and under-reporting, was studied in, i.a., multiple-regression analyses. Due to intrinsic variation in potentially etiologic factors and in size, municipalities are less suitable as geographic units. Therefore a system was developed to build up, from parishes (about 2,600), pseudo-municipalities standardized with respect to size and some environmental variable(s), in the present study population density. This paper shows, for a number of cancer diseases and for total cancer, the superiority of pseudo-municipalities to municipalities with respect to power of explaining variation and, preliminarily, also incidence.

Fenfluramine treatment of twenty children with autism

The effects of fenfluramine were examined on 20 children with autism over a 48-week period utilizing a double-blind placebo-controlled crossover design. Blood and urine samples and psychological tests (Griffith's Developmental Scales and Real Life Rating Scale) were obtained at each crossover period. The only significant improvement was a decrease in abnormal motor behavior. We did not find any significant improvement in intellectual functioning or any correlation between good clinical response and low baseline serotonin levels or high baseline IQ. Serotonin decreased 53% after fenfluramine treatment and rebounded to a level 35% higher than baseline following a placebo period. Fenfluramine and the active metabolite norfenfluramine were determined in plasma samples.

Changes in the connective tissue of corpus and cervix uteri during ripening and labour in term pregnancy

The composition of the connective tissue of human cervix and corpus uteri was studied in tissue specimens from seven nonpregnant women and 14 pregnant women, delivered at term by section, to examine spontaneous cervical ripening and labour-induced changes in both the uterine and the cervical connective tissue. The main finding in both the cervix and the corpus was a large (40-60%) decrease of the collagen concentration. The collagen extractability, obtained by pepsin digestion, was increased twofold, suggesting a change of the organization of the collagen fibrils. This reorganization process could also be demonstrated by a large increase of the collagenolytic activity demonstrated with an artificial DNP-peptide substrate. The concentrations of sulphated glycosaminoglycans was lower in pregnant women than in non-pregnant women. The results show that both the cervix and the corpus uteri contain substantial amounts of connective tissue components (collagen, sulphated glycosaminoglycans and hyaluronic acid) and that during ripening, reconstruction of the connective tissue components occurs in both sites. This indicates that the cervical state reflects that of the myometrium.

Changes in the connective tissue of corpus and cervix uteri during ripening and labour in term pregnancy

The composition of the connective tissue of human cervix and corpus uteri was studied in tissue specimens from seven nonpregnant women and 14 pregnant women, delivered at term by section, to examine spontaneous cervical ripening and labour-induced changes in both the uterine and the cervical connective tissue. The main finding in both the cervix and the corpus was a large (40-60%) decrease of the collagen concentration. The collagen extractability, obtained by pepsin digestion, was increased twofold, suggesting a change of the organization of the collagen fibrils. This reorganization process could also be demonstrated by a large increase of the collagenolytic activity demonstrated with an artificial DNP-peptide substrate. The concentrations of sulphated glycosaminoglycans was lower in pregnant women than in non-pregnant women. The results show that both the cervix and the corpus uteri contain substantial amounts of connective tissue components (collagen, sulphated glycosaminoglycans and hyaluronic acid) and that during ripening, reconstruction of the connective tissue components occurs in both sites. This indicates that the cervical state reflects that of the myometrium.

Intravenous infusion of 15 methyl-prostaglandin F2 alpha (Prostinfenem) in women with heavy post-partum hemorrhage

Post-partum hemorrhage is a serious complication in obstetric practice. The aim of this study was to investigate, in vivo, the effects of 15 methyl-prostaglandin F2 alpha (Prostinfenem, Upjohn, Sweden) on uterine activity and hemorrhage. Twenty-seven women were included in the study and, in accordance with our clinical routine, all were given oxytocin (10 IE Syntocinon) intramuscularly immediately after delivery. In cases of heavy bleeding and signs of uterine atony, ethylergometrine (0.2 mg Methergin) and oxytocin (40 i.e. Syntocinon in 500 ml, 5.5% glucose) were administered intravenously. If this therapy failed, the woman was given an intravenous infusion of 15-methyl-prostaglandin F2 alpha (0.25 mg Prostinfenom, in 500 ml, 5.5% glucose). Myometrial activity was quantitated in 5 women by a micro-transducer introduced into the uterine cavity. The treatment resulted in a contracted uterus and cessation of bleeding within 12.5 min (mean). The intra-uterine pressure registered a prompt effect regarding both amplitude and frequency of uterine contractions.

Cervical priming and labor induction with vaginal application of 3 mg PGE2 in suppositories in term pregnant women with premature rupture of amniotic membranes and unfavorable cervix

Sixty-one term pregnant women, 29 nulliparous (Group A) and 32 multiparous (Group B) with unfavorable cervix and premature rupture of the membranes (PROM) were given 3 mg PGE2 in suppository form for cervical ripening and labor induction. Five hours after starting the treatment, 12 women of the 29 in Group A and 21 of the 31 in Group B had a favorable cervix and established labor. The remaining 17 nulliparae and 11 multiparae still had an unfavorable cervix and were then given another PGE2 suppository. Until the next morning, i.e. within 24 h, 19 nulliparous and 22 multiparous women gave birth whereas a further 5 nulliparous women who now had favorable cervix but no uterine contractions were delivered after stimulation with intravenous oxytocin. The remaining undelivered women were given another PGE2 suppository. With or without additional oxytocin stimulation, all but 2 multiparous women could be delivered within a further 12 hours. The total number of instrumental deliveries in Group A was 2 caesarean sections due to disproportion (7%) and 5 ventouses. In Group B, 3 caesarean sections (9%) had to be carried out, one due to fetal distress and 2 due to failed induction. From the results of this study we conclude that vaginal application of 3 mg PGE2 in suppository form can be used to induce labor in patients with PROM and unripe cervix. However, when the results are compared with those obtained in previous studies after application of PGE2 in gel, the latter technique seems preferable.

Different biochemical composition of connective tissue in continent and stress incontinent women

The collagen content in biopsies from skin and ligamentum rotundum of 7 women with a long history of stress incontinence was compared with that of continent controls. The collagen was extracted with 0.5 M acetic acid, followed by digestion with pepsin and quantitated as hydroxyproline. The skin of stress incontinent women contained 40% less collagen than that of continent women. The findings for ligamentum rotundum were similar. These results suggest a deteriorated connective tissue in stress-incontinent women and cast new light on the etiology of the disease.

Cervical collagen: an important regulator of cervical function in term labor

This study provides the first clear evidence of a close correlation between the biochemical composition of the cervix and the clinical course of delivery in terms of cervical dilatation. Cervical biopsy specimens were obtained from three groups of patients: Group A, ten women with favorable cervix and spontaneous labor; group B, 12 women with unfavorable cervix given 0.5 mg prostaglandin E2 in gel intracervically for cervical priming and induction of labor; and group C, five women with unfavorable cervix and spontaneous labor. Cervical dilatation time was significantly longer (18 hours) for women in group C compared with women in group A (6.7 hours) and in group B (5.0 hours; P less than .001). The total amount of cervical collagen was significantly higher in women in group C at 8.58 micrograms/mg compared with 6.7 micrograms/mg in women in group A and 5.47 micrograms/mg in prostaglandin E2-treated women in group B. The amount of nonextractable collagen also was significantly higher in women in group C, 23.6% compared with 11.3% in group A, and 12.4% in group B (P less than .01). The collagenolytic activity was significantly increased in cervical biopsy specimens from prostaglandin E2 gel-treated patients--520 U/100 mg wet weight compared with 380 U/100 mg wet weight in untreated patients in group A (P less than .05). From these results it is concluded that cervical collagen is an important regulator of cervical function in late pregnancy and term labor; that prostaglandin E2 is involved in cervical priming, initiation, and progress of term labor.(ABSTRACT TRUNCATED AT 250 WORDS)

Induction of labor in postterm pregnant women

We have studied the outcome of labor induction in 145 postterm pregnant women in whom gestational age was properly assessed by ultrasound scanning. The induction techniques were adapted to the cervical states of the patients. Seventy-five patients (32 nulliparous and 43 multiparous) with favorable cervical states were successfully induced with intravenous oxytocin. In this group the frequency of Caesarean section was 2%. Seventy patients (45 nulliparous and 25 multiparous) with unripe cervices received 0.5 mg PGE2 in viscous gel intracervically to prime the cervix and to induce labor; 38 (52%) were induced into labor after a single PGE2-gel application whereas 26 (48%) needed labor augmentation with intravenous oxytocin after PGE2-gel obtained cervical ripening. In 6 of the 20 patients the cervix did not ripen and the PGE2-gel application had then to be repeated. The frequency of cesarean sections was 11%. In 5 out of the 145 patients (4%) the fetuses had signs of intrauterine growth retardation (IUGR) as assessed by ultrasound scanning, and postmaturity as verified by pediatric examination at delivery. All these fetuses belonged to nulliparous women with unripe cervices and all had to be delivered instrumentally (3 by cesarean section and 2 by ventouse) indicating the fragility of these children. If postterm pregnancy is complicated by an unfavorable cervical state intracervical application of PGE2-gel seems to be an efficient method to prime the cervix and to induce labor. In most patients an uncomplicated vaginal delivery can be achieved by this procedure. However, nulliparous women with unfavorable cervices and signs of IUGR constitute a high risk group of patients at labor induction.

Induction of labor with intravenous oxytocin or vaginal PGE2 suppositories. A randomized study

Thirty-eight term pregnant women with a moderately unfavorable cervix (cervical score 4-5 p.) were randomly given intravenous oxytocin (Group A) or 3 mg PGE2 as a vaginal suppository (Group B) for labor induction. Eight out of 19 in Group A and 17 out of 19 in Group B gave birth vaginally within 24 h. The remaining 11 women in Group A had still an unfavorable cervix after 24 h. They were then given 3 mg PGE2 as a vaginal suppository and all but one had given birth vaginally without complications within 24 h. In Group B only 2 were still undelivered after 24 h. Both had a favorable cervix and were delivered vaginally within 12 h after intravenous infusion of oxytocin. The number of instrumental deliveries in Group A was one cesarean section and two vacuum extractions and in Group B three vacuum extractions. One woman in Group B reported nausea and vomiting and in one had strong uterine contractions in the second stage of labor. Otherwise no side effects were registered. All babies were born in good condition with Apgar scores greater than or equal to 7. In conclusion, vaginal application of 3 mg PGE2 as a suppository seems to be more effective than intravenous infusion of oxytocin for labor induction in women with half-ripened cervices, i.e. cervical scores of 4-5 p.

The effect of terodiline treatment in women with motor urge incontinence. Results from a double-blind study and long-term treatment

The effects of terodiline were evaluated in 24 women with genuine motor urge incontinence: Twelve patients participated in a double-blind crossover study and 12 in a subsequent long-term study. All patients were investigated by simultaneous urethrocystometry before and after treatment. During the controlled study the subjects were treated with placebo or 37.5 mg of terodiline daily for two 3-week periods. The long-term study covered a period from 6 months to 3 years. A significantly higher increase in both bladder volume at urinary leakage (from 170 to 270 ml, p less than 0.001) and bladder capacity (from 320 to 390 ml, p less than 0.01) was registered after terodiline treatment compared to placebo. In the long-term study the effects on these parameters were still more pronounced with an increase in bladder volume at leakage (from 180 to 300 ml, p less than 0.001) and in bladder capacity (from 290 to 430 ml, p less than 0.0001). Subjective improvement with terodiline treatment was reported by all but two patients in the double-blind study and by all in the long-term study. Side effects such as dryness of the mouth were reported by four patients receiving terodiline in the double-blind study and by six in the long-term study. No patient discontinued the treatment. Terodiline seems to be a promising alternative for treatment of motor urge incontinence in women.

Fetal circulation 60 to 80 minutes after vaginal prostaglandin E2 in pregnant women at term

We combined real-time B-mode ultrasonography with a 2 MHz pulsed Doppler technique to record blood flow in the fetal descending aorta and in the intra-abdominal part of the umbilical vein in 14 pregnant women at term. The blood flow was studied before and after instillation into the vagina of either 4 mg prostaglandin E2 (PGE2) gel or placebo gel. The PGE2 gel was significantly more effective in cervical priming and labor induction than the placebo gel. After instillation of the gel neither group showed a change in the fetal volume blood flow or in the aortic blood velocity waveform. We conclude that the instillation of 4 mg of PGE2 gel does not affect fetal hemodynamics at term.

Intracervical versus intravaginal PGE2 for induction of labor at term in patients with an unfavorable cervix

In a randomized double-blind study we evaluated the effects on cervical ripening and labor induction of 0.5 mg PGE2 in gel given intracervically and 2.0 mg PGE2 given as a vaginal suppository. All patients were at term with unfavorable cervical scores. The indications for induction were toxemia, diabetes mellitus, Rh-immunization, or intrauterine growth retardation. Significantly better results for both cervical priming and labor induction were obtained after intracervical PGE2-gel application than after treatment with placebo or vaginal suppositories. Eleven out of 19 patients (58%) were delivered within 24 h after intracervical PGE2-gel compared to two out of 19 patients given placebo (p less than 0.01). In patients not delivered 24 h after the start of treatment, the mean cervical score had changed from 3.7 to 6.0 (p less than 0.05) after PGE2-gel application compared to a change from 3.9 to 4.3 after placebo treatment (n.s.). The outcome after treatment with PGE2 suppositories did not differ significantly from that with placebo treatment. In a subsequent study 25 patients were given 0.5 mg PGE2-gel intracervically. The results were consistent with those obtained in patients receiving PGE2-gel intracervically in the double-blind study. Few side effects were noted. No patient complained of gastro-intestinal discomfort but increased myometrial activity was observed in two patients; one after placebo and the other after active intracervical PGE2-gel treatment. The hyperactivity was readily countered with the beta 2-agonist, terbutaline. All infants were born in good condition with Apgar scores of 7 or more within 5 min. At pediatric examinations at 1 week and at 6 months of age all children seemed healthy.

The integrity of cervical collagen during pregnancy and labor

The concentration of collagen in the human uterine cervix decreases during pregnancy. This change contributes to the ripening process, which facilitates cervical dilatation during labor. It has been suggested that cervical collagen is partly degraded at term and after delivery. In order to evaluate this hypothesis we investigated the proportion of intact to degraded collagen after solubilization of about 86% of the collagen with pepsin in acetic acid. Total collagen was quantitated as hydroxyproline whereas intact collagen was estimated by SDS-gel electrophoresis. The proportion of intact collagen to total collagen did not change during pregnancy and delivery. Furthermore it was similar to that of intact standard collagen. Thus, even if the concentration of collagen is diminished during pregnancy as a result of increased collagenolytic activity, there is no indication of a qualitative change of the remaining collagen.

Proteoglycans from cultures of fibroblast from the human uterine cervix

A small dermatan sulphate proteoglycan has been isolated from the human uterine cervix. The concentration of this proteoglycan has been shown to decrease during pregnancy. To study the mechanism behind this change fibroblasts from the human uterine cervix were established in culture. Their synthesis and secretion of proteoglycans were investigated by incubating the monolayer with 35SO4 and (3H) leucine for 48 h. Two dermatan sulphate proteoglycans and one heparan sulphate proteoglycan were isolated from the medium. The cell layer contained the same proteoglycans although in different proportions. The major dermatan sulphate proteoglycan accounting for 55% of the total macromolecular 35S was small with a molecular weight (MW) of 100,000 daltons. The side chains were calculated to be approximately 1-3 per protein core and included more than 50% iduronic acid containing disaccharides. This small dermatan sulphate proteoglycan is very similar to that isolated from the intact human uterine cervix. However, when cells were established in culture an additional larger dermatan sulphate proteoglycan with an MW of 400,000 daltons was synthesized. This proteoglycan was substituted for 4-8 polysaccharide side chains rich in glucuronic acid. 24% of the total macromolecular 35S were found in this proteoglycan.

Cervical priming and/or induction by intracervical application of PGE2-gel in term patients with preeclampsia and unfavorable cervical states

92 preeclamptic women with unfavorable cervical states were treated with intracervical application of prostaglandin E2 (PGE2) in gel for cervical priming and/or labor induction. 55 (60%) were delivered after a single PGE2-gel application. In 27 (29%) the cervical state was improved after 24 h and labor could be induced by oxytocin infusion. Thus, 89% of the women were delivered within 48 h after a single PGE2-gel application. In 10 women (11%) a second PGE2-gel application had to be done before oxytocin infusion. The frequency of cesarean sections was low (5%). No case of uterine hypertonus was seen. No gastrointestinal side effects were observed. All newborn infants had an apgar score at 5 min of more than 7 and were in good condition.

Intravaginal versus intracervical application of prostaglandin E2 in viscous gel for cervical priming and induction of labor at term in patients with an unfavorable cervical state

Sixty term pregnant women with unripe cervix were randomly given either 0.5 mg of prostaglandin E2 (PGE2) in 2 ml of gel intracervically or 4 mg of PGE2 in 3 ml of gel intravaginally to prime the cervix and/or to induce labor. In patients with a highly unfavorable cervix (cervical score less than or equal to 3), the intracervical application was significantly more effective than the intravaginal. In patients with a more favorable cervical state (cervical score 4 or 5), the two routes of application were equipotent. Gastrointestinal side effects were registered after intravaginal but not after intracervical application. Myometrial activity was significantly more increased after intravaginal than after intracervical gel application. All children were born in good condition with an Apgar score greater than 7 within 5 minutes.

Ripening of the human uterine cervix related to changes in collagen, glycosaminoglycans, and collagenolytic activity

Connective tissue in biopsy specimens taken from the lower part of the uterine cervix in 40 pregnant women at various gestational ages was compared to that in similar biopsy specimens from 15 nonpregnant women. The concentrations of collagen, sulfated glycosaminoglycans, and hyaluronic acid decreased during pregnancy. At the gestational age of 10 weeks, the collagen concentration was 70%, and at term 30%, of that in the nonpregnant cervix. After delivery, no further decrease was observed. The extractability of collagen increased during pregnancy, as well as during labor. Also, the water concentration increased. An increase in the collagenolytic activity was observed with advancing gestational age. The 2,4-dinitrophenyl-Pro-Gln-Gly-Ile-Ala-Gly-Gin-D-Arg hydrolytic activity (collagenase) and the concentration of leukocyte elastase increased gradually by a factor of 10. The physiologic importance of the collagen was also demonstrated, since the cervical dilatation time during spontaneous labor was long in women with high concentrations of collagen and short in women with low concentrations of collagen.