Visualization of sacral nerve roots and sacral plexus on gynecological transvaginal ultrasound: feasibility study

OBJECTIVE

To investigate the feasibility of identifying and measuring the normal sacral plexus (SP) on gynecological transvaginal ultrasound (TVS) examination.

METHODS

This was a prospective observational study conducted at a single tertiary gynecological referral center, including consecutive women undergoing TVS for various indications between November 2021 and January 2022. A standardized assessment of the pelvic organs was performed and the presence of any congenital or acquired uterine pathology or ovarian abnormality was recorded. Visualization of the right and left SP was attempted in all cases. The success rate and the time needed to identify the SP were recorded and measurements of the SP were made.

RESULTS

A total of 326 patients were included in the study. In all women, the SP was identified successfully on at least one side. SP were visualized bilaterally in 317 (97.2% (95% CI, 94.4-98.5%)) women. Only the right SP was seen in 3/326 (0.9% (95% CI, 0.2-2.7%)) and only the left in 6/326 (1.8% (95% CI, 0.6-4.0%)) (P = 0.5048). There was no significant difference in the median time required to visualize the right vs left SP (9.0 (interquartile range (IQR), 8.0-10.0) s  vs 9.0 (IQR, 8.0-10.0) s; P = 0.0770). The median transverse diameter of the right SP was 15.0 (IQR, 14.2-15.6) mm and that of the left SP was 14.9 (IQR, 14.4-15.6) mm.

CONCLUSIONS

We describe a novel method which allows for the consistent and rapid identification of the SP on TVS. Integrating assessment of the SP into routine pelvic TVS may be helpful particularly for women suffering from deep endometriosis. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Relation of circulating T cell profiles to airway inflammation and asthma control in asthmatic pregnancy

Asthmatic inflammation during pregnancy poses a risk for maternal and fetal morbidities. Circulating T cell immune phenotype is known to correlate with airway inflammation (detectable by fractional concentration of nitric oxide present in exhaled breath (FENO)) in non-pregnant allergic asthmatics. The aim of this study was to assess the relationship of peripheral T cell phenotype to FENO and clinical variables of asthma during pregnancy.We examined 22 pregnant women with allergic asthma in the 2nd/3rd trimester. The prevalence of Th1, Th2, regulatory T (Treg) and natural killer (NK) cell subsets was identified with flow cytometry using cell-specific markers. FENO, Asthma Control Test (ACT) total score and lung function were evaluated.Peripheral blood Th1, Th2, Treg, and NK cell prevalence were not significantly correlated to airway inflammation assessed by FENO in asthmatic pregnant women (all cells p > 0.05; study power > 75%). However, an inverse correlation was detected between Th2 cell prevalence and ACT total scores (p = 0.03) in asthmatic pregnancy.Blunted relationship between T cell profile and airway inflammation may be the result of pregnancy induced immune tolerance in asthmatic pregnancy. On the other hand, increased Th2 response impairs disease control that supports direct relationship between symptoms and cellular mechanisms of asthma during pregnancy.

Circulating ficolin-2 and ficolin-3 in normal pregnancy and pre-eclampsia

Ficolins are soluble molecules of the innate immune system that recognize carbohydrate molecules on microbial pathogens, apoptotic and necrotic cells. They act through two distinct routes: initiating the lectin pathway of complement activation and mediating a primitive opsonophagocytosis. In this study, we measured plasma levels of ficolin-2 and ficolin-3 in 60 pre-eclamptic patients, 60 healthy pregnant women and 59 healthy non-pregnant women by enzyme-linked immunosorbent assay (ELISA). Circulating levels of complement activation products (C4d, C3a, SC5b9), angiogenic factors (soluble fms-like tyrosine kinase-1, placental growth factor) and markers of endothelial activation (von Willebrand factor antigen), endothelial injury (fibronectin) and trophoblast debris (cell-free fetal DNA) were also determined. Plasma levels of ficolin-2 were significantly lower in healthy pregnant than in healthy non-pregnant women, while ficolin-3 levels did not differ significantly between the two groups. Furthermore, pre-eclamptic patients had significantly lower ficolin-2 and ficolin-3 concentrations than healthy non-pregnant and pregnant women. In the pre-eclamptic group, plasma ficolin-2 levels showed a significant positive correlation with serum placental growth factor (PlGF) concentrations and significant inverse correlations with serum levels of soluble fms-like tyrosine kinase-1 (sFlt-1), blood urea nitrogen and creatinine, serum lactate dehydrogenase activities, as well as with plasma VWF:antigen, fibronectin and cell-free fetal DNA concentrations. In conclusion, circulating levels of ficolin-2 are decreased in the third trimester of normal pregnancy. There is a further decrease in plasma ficolin-2 concentrations in pre-eclampsia, which might contribute to the development of the maternal syndrome of the disease through impaired removal of the trophoblast-derived material released into the maternal circulation by the hypoxic and oxidatively stressed pre-eclamptic placenta.

Importance of cytoplasmic granularity of human oocytes in in vitro fertilization treatments

The aim of this study was to examine the effect of different stimulation protocols on oocyte granularity and to determine the influence of cytoplasmic granularity on further embryo development. A total of 2448 oocytes from 393 intracytoplasmic sperm injection (ICSI) cycles were analysed retrospectively. Oocytes were classified into 5 groups according to cytoplasmic granularity. (A) no granule or 1-2 small (<5 μm) granules; (B) more than 3 small granules; (C) large granules (>5 μm); (D) refractile body; (E) dense centrally located granular area. Correlation between characteristics of hormonal stimulation, oocyte granularity and embryo development was analysed. The occurrence of cytoplasmic granularity was influenced by the patient's age and characteristics of stimulation. The type of granulation had no effect on fertilization rate and zygote morphology. However, some type of granulation resulted in a lower cleavage rate and more fragmented embryos. Our results provided additional information on how hormonal stimulation affects oocyte quality. While cytoplasmic granularity seems not to have an effect on fertilization and embryo development, the presence of refractile body in the oocyte is associated with reduced cleavage rates and impaired embryo development.

Preserved structural and functional characteristics of common carotid artery in properly treated normoglycemic women with gestational diabetes mellitus

Women with gestational diabetes mellitus (GDM) are at high risk of subsequently developing type 2 diabetes mellitus which is an important cardiovascular risk factor. We have evaluated whether preclinical morphological and functional arterial changes are present in GDM. Diameter, intima-media thickness (IMT), intima-media cross-section area (IMCSA) and elasticity features (compliance, distensibility coefficient, circumferential strain, stiffness index (SI) α and β, incremental elastic modulus) of the common carotid arteries (CCA) were studied in the 3rd trimester in 25 women with GDM, and 17 normal pregnant women matched for age and body mass index using an ultrasonographic vessel wall-movement tracking system and applanation tonometry. Mean IMT, IMCSA and SI α tended to be larger, whereas compliance was smaller in women with GDM but none of these differences were significant. Serum glucose (4.99 ± 0.51 vs. 4.79 ± 0.61 mmol/L, p=0.37) and HbA1c (5.33 ± 0.27 vs. 5.36 ± 0.47 mmol/L, p=0.85) proved normoglycemia in both groups. In conclusion, by the combination of methods we applied in this case control study, neither morphological nor functional characteristics of large elastic arteries differ significantly between well-treated normoglycemic women with GDM and non-diabetic pregnant women in the 3rd trimester.

Childbirth after organ transplantation in Hungary

BACKGROUND

The first successfully delivered newborn after organ transplantation was reported in 1963; since then, >14,000 women have delivered after transplantation. Patients with an end-stage organ disease develop fertility disturbances. One year after a successful solid organ transplantation with stable graft function, fertile women can give birth to a child from a medical point of view. Pregnant transplant patients do experience a high risk of graft function worsening, a rejection episode, and opportunistic infections. Furthermore, the medical therapy may influence teratogenicity.

METHODS

Between 1974 and September 1, 2010, 5 Hungarian centers performed 6802 solid organ transplantation and lungs were grafted in Vienna, Austria. The organ distribution was: 5971 kidney, 454 liver, 187 heart, 90 combined pancreas-kidney, 5 combined islet-kidney, and 95 lung transplantation. There were no pregnancies among heart, lung, and pancreas recipients.

RESULTS

In all, 3.9% of the renal and 14.3% of the fertile liver transplanted women gave birth to children. To wit, 23 kidney recipients delivered 27 healthy children (17 boys and 10 girls). In 4 cases, 2 children were born, twice as twins. Among liver recipients, 8 women delivered 8 healthy babies. There was no hepatitis C or B virus-positive patient among the mothers. There was no graft insufficiency, rejection or birth defect. Transplanted mothers often display toxemia or preeclampsia during pregnancy requiring cesarean section. The relatively higher ratio of liver recipients was perhaps due to the rarer occurrence of extrahepatic organ damage, like diabetic nephropathy or cardiomyopathy, and the reversible nature of hepatorenal or hepatopulmonary syndrome.

CONCLUSION

Delivery of a child by a transplanted mother carries an high risk, requiring interdisciplinary cooperation. The quality of life of solid organ recipients can be significantly raised by childbirth under appropriate circumstances.

Impact of highly purified versus recombinant follicle stimulating hormone on oocyte quality and embryo development in intracytoplasmic sperm injection cycles

The quality of oocytes and developing embryos are the most relevant factors determining the success of an in vitro fertilization (IVF) treatment. However, there are very few studies analyzing the effects of different gonadotrophin preparations on oocyte and embryo quality. A retrospective secondary analysis of data collected from a prospective randomized study was performed to compare highly purified versus recombinant follicle stimulating hormone (HP-FSH vs. rFSH). The main outcome measures were quantity and quality of oocytes and embryos, dynamics of embryo development, cryopreservation, clinical pregnancy and live birth rate. The number of retrieved and of mature (MII) oocytes showed no significant differences. Fertilization rate was significantly higher in the HP-FSH group (68.9% vs. 59.9%, p = 0.01). We also found significantly higher rate of cryopreserved embryos per all retrieved oocytes (23.4% vs. 14.5%, p = 0.002) in the HP-FSH group. There were no significant differences in clinical pregnancy and in live birth rates. Oocytes obtained with HP-FSH stimulation showed higher fertilisability, whereas pregnancy and live birth rates did not differ between the groups. However, patients treated with HP-FSH may benefit from the higher rate of embryos capable for cryopreservation, suggesting that cumulative pregnancy rates might be higher in this group.

Clinical microbiology of neonatal candidiasis in Hungary

The occurrence of Candida spp. was investigated during a three-year period in two neonatal intensive care units, Budapest, Hungary. The species distribution among the 41 analysed cases was the following: C. albicans (30/41, 73%), C. parapsilosis (10/41, 24%) and C. glabrata (1/41, 3%). All of the isolates were susceptible to the tested drugs. There was a significant difference in the birth weight, the gestational age <30 weeks and the occurrence of caesarean section between the C. albicans and the C. parapsilosis groups of the cases. Respiratory tract colonization was the same (76-77%) in the extremely low birth weight (ELBW) and the very low birth weight (VLBW) groups. Comparing the ELBW, VLBW, and >1500 g birth weight groups, significant difference was found in the parenteral nutrition, the gestation weeks <36 or <30, the polymicrobial infection and the transfusion. The ratio of C. albicans, C. parapsilosis and C. glabrata was 9:7:1 in ELBW group; 6:3:0 in VLBW group and 15:1:0 in >1500 g group. The mortality rate for C. parapsilosis was higher than for C. albicans.

Association of elevated serum heat-shock protein 70 concentration with transient hypertension of pregnancy, preeclampsia and superimposed preeclampsia: a case-control study

Our aim was to investigate the association between serum heat-shock protein (Hsp) 70 concentration and hypertensive disorders of pregnancy. One hundred and forty-two pregnant women with hypertensive disorders (93 with preeclampsia, 29 with transient hypertension of pregnancy and 20 with superimposed preeclampsia) and 127 normotensive, healthy pregnant women were included in the study. Serum Hsp70 concentration was measured using enzyme-linked immunosorbent assay. The serum Hsp70 concentration was significantly higher in patients with transient hypertension of pregnancy, in preeclamptic patients and in patients with superimposed preeclampsia than in the control group (median (25-75 percentile): 0.66 (0.52-0.84), 0.55 (0.42-0.80), 0.61 (0.42-0.91) ng/ml vs 0.31 (0.27-0.39) ng/ml, respectively; P<0.001). Multivariate logistic regression analysis showed independent association of elevated serum Hsp70 level with transient hypertension of pregnancy, preeclampsia and superimposed preeclampsia. The difference in serum Hsp70 concentration between preeclamptic patients and the control group was statistically significant in each gestational age category. In the groups of preeclamptic and superimposed preeclamptic patients, there was no significant difference in serum Hsp70 concentration between mild and severe preeclamptic patients, between patients with late and early onset of the disease, as well as between preeclamptic patients without and with foetal growth restriction. In conclusion, serum Hsp70 concentration is elevated in transient hypertension of pregnancy, in preeclampsia and in superimposed preeclampsia. Circulating Hsp70 may not only be a marker for these conditions, but might also play a role in their pathogenesis. However, further studies are needed to explore its role in the pathogenesis of hypertensive disorders of pregnancy.

Increased interferon-gamma- and interleukin-4-synthesizing subsets of circulating T lymphocytes in pregnant asthmatics

BACKGROUND

Pregnancy frequently interferes with the course of bronchial asthma, and asthmatic pregnant women experience less successful pregnancies. T lymphocytes synthesizing IL-4 or IFN-gamma are important in allergic mechanisms of the airways as well as in materno-fetal immunity.

OBJECTIVE

We hypothesized that pregnancy (a T helper-2 polarized state) of asthmatics will enhance the number of circulating T2 lymphocytes, but decrease the subset-producing IFN-gamma (T1 lymphocytes) and thereby cause a culminating T2 dominance with possible clinical consequences.

METHODS

IL-4- or IFN-gamma-producing T lymphocytes were determined by flow cytometry in healthy (n=8) and asthmatic (n=13) non-pregnant women and healthy (n=18) and asthmatic (n=48) pregnant women of similar chronological and gestational (2nd-3rd trimester) age and asthma severity (Global Initiative for Asthma II-III).

RESULTS

In the blood of non-pregnant women--healthy or asthmatic--the numbers of IL-4- and IFN-gamma+ T cells were very low (<10/microL blood). In contrast, in asthmatic pregnant women, the cell counts were 182+/-27 and 39+/-6 for IFN-gamma+ and IL-4+ T cells/microL blood, respectively (both P<0.05 vs. respective control values of non-pregnant asthmatics). Within the asthmatic pregnant group, significant negative correlations were revealed between the numbers of IFN-gamma+ or IL-4+ T cells and maternal peak expiratory flow as well as birth weight of newborns (both P<0.05).

CONCLUSION

These data show a previously unknown immunological interference between asthma and pregnancy. The culminating proliferation of IFN-gamma+ and IL-4+ T lymphocytes may potentially impair maternal airway symptoms as well as fetal development.

Three mechanisms in the pathogenesis of pre-eclampsia suggested by over-represented transcription factor-binding sites detected with comparative promoter analysis

Microarray studies generating lists of genes with altered expression in placentas from pregnancies complicated with pre-eclampsia (PE) have so far been published in several different studies. Working under the assumption that altered gene expression in PE may be the result of altered expression of regulatory transcription factors (TFs), we looked for over-represented TF-binding sites (TFBSs)-which indicate the involvement of TFs in gene regulatory networks-in lists of genes (n = 143) compiled in these studies. We compared the prevalence of TFBSs in the promoter regions of 68 genes with the background prevalence of TFBSs in promoters of the human genome. The prevalence of the E47, sterol regulatory element binding protein (SREBP) and NFKB-p50 TFBSs was higher (P < 0.005) in the promoter sequences of the PE gene lists than in the background model. Each of these TFBSs could be implicated in the development of PE. The E47 protein is an E-protein or basic helix-loop-helix (bHLH) TF. Data support the role of bHLHs in the differentiation of placental tissue. SREBP-1, a lipid-sensing sterol regulatory element-binding protein, is a critical regulator of fatty acid homeostasis in the placenta. The target genes of NFKB-p50 determine inflammatory response, and aberrant cytokine homeostasis is a further sign of PE. These TFs may provide an insight into the pathogenesis of the disease.

The relationship between pacifier use, bottle feeding and breast feeding

OBJECTIVE

To investigate the influence of pacifier use and the introduction of formula milk on breast feeding.

METHODS

The mothers of 356 healthy newborn infants who initiated breast feeding while in-patients were interviewed within 3 days of birth and later at 2 and 6 months postpartum. Information regarding previous birth, breast-feeding frequency, pacifier use and the adoption of formula milk were obtained. The data were analyzed using chi2 and Kruskal-Wallis tests.

RESULTS

At the end of the second month, 264 (74%) of the mothers were still breast feeding; by the end of the sixth month this had fallen to 236 (66%). Among the 356 mothers, 152 had at least one previous infant, and 132 (86.8%) of them had breast fed a previous infant. Of the women who breast fed their previous infant for more than 2 months, 112 (84.8%) breast fed the current child until the end of the second month and 104 (78.7%) until the end of the sixth month after delivery. Of all investigated patients, 204 were primiparous (57.3%). Of these, 152 (74.5%) breast fed until the end of the second month, and 132 (64.7%) until the end of the sixth month after delivery. Amongthe 204 primiparae, 92 (45%) gave formula to their newborn infants. Forty-four of these 92 mothers (47.8%) had discontinued breast feeding by the end of the second month. Among the 356 newborn infants, 220 used pacifiers at the end of the second month. Within this group, 72 (33%) of the infants did not breast feed, while 148 (67%) did breast feed. Of all investigated mothers, 136 did not give pacifiers to their infants and only eight of these mothers (6%) had stopped breast feeding at the end of the second month.

CONCLUSIONS

We found an inverse correlation between pacifier usage and breast feeding. Breast feeding was most common among multiparous mothers.

Evaluation of the tyrosine kinase domain of the Met proto-oncogene in sporadic ovarian carcinomas*

Most of the ovarian cancers originate from the ovarian surface epithelium derived from the coelomic mesothelium. The Met proto-oncogene encodes a transmembrane tyrosine kinase receptor (Met) that has the capacity to regulate cell proliferation and differentation and it is activated by hepatocyte growth factor. Trisomy of chromosome 7 and Met protein overexpression have been were observed in ovarian carcinomas, the papillary renal cancers and other solid tumors. Frequent mutations of Met proto-oncogene have been found in hereditary papillary renal cancer (HPRC) and most of the mutations are located in the tyrosine kinase domain. The aim of this study to perform a mutation analysis of exons 17 19 of Met proto-oncogene in epithelial ovarian tumors (EOTs). We have examined 24 tumor samples from patients, operated with EOTs. Mutation was detected in exon 18 in only one sample of 24 EOTs. Our results indicate that mutations located in the Met proto-oncogene is not a common event in EOT. It is not clear whether the mutation plays a role in the tumorigenesis or progression of EOT or not.

Signal transduction in human myometrial cells

Calcium plays a pivotal role in the contraction-relaxation cycle of uterine smooth muscle. We investigated the effects of three uterine agonists; prostaglandin F2 alpha (PGF2 alpha), oxytocin and platelet activating factor (PAF) on intracellular levels of Ca ([Ca2+]i) in intact human myometrial cells and 45Ca2+ efflux from permeabilized myocytes. We observed that, whereas oxytocin and PAF activated the phosphoinositide cycle, generating inositol triphosphate to mobilize intracellular Ca2+, PGF2 alpha acted mainly to enhance Ca2+ influx. Oxytocin-, but not PGF2 alpha-elicited responses were suppressed by pertussis toxin. It is concluded that all three agonists act by regulating [Ca2+]i in myometrial cells, but the signal transduction mechanism of PGF2 alpha differs from that of oxytocin and PAF.

[Atypical process of acute disturbance of liver function with severe thrombocytopenia in the third trimester]

The authors diagnosed disturbance of liver-function associated with severe thrombopenia in a pregnant woman in the third trimester. Principally, acute fatty liver of pregnancy can be characterized by existing symptoms, e.g. nausea, vomiting, epigastric pain, jaundice, hyperbilirubinemia, moderately elevated SGOT and SGPT levels, thrombopenia, leukocytosis, low fibrinogen level and disseminated intravascular coagulopathy, but hepatomegaly, purpura and petechia on lower and upper extremities, and high ALP and GGT levels during postpartum period do not confirm suspicion of this diagnosis. The present report draws attention to the difficulties of differential diagnosis of pregnancy-induced elevated liver enzymes diseases associated with low platelets, as there are several identical pathophysiological processes. Although causes and exact pathophysiology of disorders are unknown, similar symptoms during the process of diseases leave the question open whether they are different diseases or whether they are different manifestations of the same disease, and what kind of relationship exists between these diseases and preeclampsia. This case suggests careful evaluation of the whole clinical picture, moreover it is emphasized that prompt, aggressive treatment of hemostatic disturbance and the expeditious delivery can save maternal life.

Maternal and neonatal outcome of preeclamptic pregnancies: the potential roles of factor V Leiden mutation and 5,10 methylenetetrahydrofolate reductase

OBJECTIVE

To investigate the potential perinatal effects of Factor V Leiden mutation and 5,10 methylenetetrahydrofolate reductase C677T polymorphism in preeclamptic women.

STUDY DESIGN

One hundred twenty preeclamptic women (N = 120) and 101 healthy pregnant controls (N = 101) were recruited and evaluated for frequency of Leiden and 5,10 methylenetetrahydrofolate reductase (MTHFR) mutations using polymerase chain reaction (PCR). Perinatal outcomes were then recorded and analyzed for all study participants and their neonates.

RESULTS

Laboratory analysis yielded 22 (18.33%) heterozygous carriers of Factor V Leiden mutation among preeclamptic women and 3 (2.97%) heterozygous carriers among the healthy controls; differences between the two groups were found to be statistically significant [p < 0.001, the relative risk (RR) = 6.17, 95% confidence interval (95% CI) = 1.90-20.02]. Homozygous MTHFR mutations were found in 8 of 120 (6.67%) preeclamptic women and in 6 of the 101 (5.94%) healthy controls evaluated. Among preeclamptic women, episodes of hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome were reported in 7 of 22 (31.81%) of those with Factor V Leiden mutation and in 11 of 98 (11.22%) of those who were negative for the mutation. Group differences were determined to be statistically significant (p < 0.015, RR = 2.83, 95% CI = 1.24-6. 48). Perinatal indicators collected from the two groups included frequency of intrauterine growth retardation, birth weight, and gestational age. No statistically different perinatal outcomes were found between Factor V Leiden positive and negative preeclamptic women. In addition, MTHFR gene polymorphism did not appear to be correlated with the development of preeclampsia.

CONCLUSION

Although the frequency of Factor V Leiden mutation appears to be significantly higher among preeclamptic women, the mechanism of pathogenesis and potential influence on perinatal outcomes is not yet well understood. Relatively high rates of HELLP syndrome among those with Factor V Leiden mutation suggest that this thrombogene mutation may play a significant role in hemostatic system activation. Our results suggest that the role of MTHFR polymorphism and other factors such as folic acid supplementation will require more extensive analysis in controlling worldwide morbidity and mortality associated with this important maternal condition.

[Mutation analysis of the beta-catenin gene in epithelial carcinomas of the ovaries]

beta-catenin is a continuously expressed cytoplasmic protein that has an important role is both E-cadherin-mediated cell-cell adhesion and in activation of Wnt/Wingless transcriptional pathway. The accumulation of stabilized beta-catenin caused by the mutation of the exon 3 of beta-catenin gene can stimulate the T-cell factor/Lymphoid enhancing factor-mediated transcriptional activation. The activation of transcriptional pathway may through oncogenes is an important step of the oncogenesis in solid tumors. In this study we analyzed mutations in exon 3 of the beta-catenin gene in 18 sporadic epithelial ovarian tumors. Three mutations were found from these 18 ovarian tumor samples which contained 8 serous, 3 mucinous, 5 endometrioid, one malignant Brenner-type tumor and one transitional cell carcinoma. Two mutations occurred in endometrioid-type (in 47 and 55 codons) and one in serous-type (in 47 codon) ovarian carcinomas, and both mutations were missense and somatic. The patients with mutated beta-catenin gene appeared from the younger patients under the age of 50. Our results suggest that the stabilization of beta-catenin protein by the mutation of CTNNB1 gene can contribute to the multistep process of the oncogenesis of epithelial ovarian tumors. Furthermore these mutations mostly occurs in the endometrioid-type of EOT, but can appear in other types such as serous-type ovarian tumor.

Follow-up studies of newborn-babies with congenital ventriculomegaly

The authors present the results of their follow-up studies of data from the last four years on patients with congenital ventriculomegaly.

OBJECTIVE

To study the psychomotor and mental developmental outcome of neonates with congenital ventriculomegaly diagnosed prenatally. In addition, patients were also classified into subgroups with subgrouping based on the etiology and complications of congenital ventriculomegaly and on the absence of ventriculoperitoneal shunt placement, and the findings compared between the different subgroups.

METHODS

Level 3 fetal ultrasonography was used for the prenatal diagnosis of congenital ventriculomegaly in 30 infants. Using neurological examination and the modified Brunet-Lézine infant test performed postnatal follow-up of motor and sensory development and intelligence, respectively.

RESULTS

The results show thirteen symptomless, well-developing patients, ten moderately handicapped patients and seven severely handicapped patients. Newborns with isolated, moderate ventriculomegaly have the best outcome.

Analysis of maternal circulation and renal function in physiologic pregnancies; parallel examinations of the changes in the cardiac output and the glomerular filtration rate

OBJECTIVE

The aim of the study was to examine the temporal relations between the parameters of the maternal hemodynamics and homeostasis in different phases of pregnancy and the postpartum period.

METHODS

Eleven healthy pregnant women were involved in the study. The value of the peripheric vasodilatation was measured by the ratio I/A of the maternal sphygmogram (I: incisure point, A: amplitude of the carotid pressure curve). The change of the cardiac output was determined by the ejection angle composed from maternal carotid sphygmogram and its first electrical derivate (dP/dT). The glomerular filtration rate (GFR) was measured with the in vitro radiofluorescent method.

RESULTS

The primary peripheral vasodilatation and GFR increase occur early in the first trimester of a normal pregnancy, start to decrease at the end of the third trimester, and return to the normal value in the postpartum period. The increase of GFR precedes the increase of cardiac output. The cardiac output increases progressively from the first trimester and starts to decrease in the third trimester of a normal pregnancy. The extracellular volume increases at the beginning of first trimester progressively until the end of pregnancy and returns to the normal value in the postpartum period.

DISCUSSION

The increase of GFR and the cardiac output during pregnancy are contributed to volume-establishment and to the cessation of the special "underfilled" condition of the maternal circulation in the normal pregnancy. We suppose that the maximal increase of GFR precedes the maximal increase of the cardiac output because the GFR increase is caused by maximal renal vasodilatation. The increase of cardiac output is caused in the first trimester by the shunt effect of the enhanced renal blood flow of maternal kidneys, and in the second and third trimester by the shunt effect of the feto-placental unit and the shunt effect of the maternal kidneys.

Distribution of apolipoprotein(a) isoforms in normotensive and severe preeclamptic women

OBJECTIVE

Preeclampsia is a pregnancy-related disorder constituting one of the primary causes of worldwide maternal and fetal mortality, but despite intensive research its pathogenesis remains unclear. Lipids have been implicated in the development of preeclampsia, although this possible association remains controversial and not yet fully investigated. This study set out to examine the potential association between lipoprotein(a) and the development of severe preeclampsia. The focus of this study was to investigate the potential utility of apolipoprotein(a) isoforms as possible diagnostic markers for identifying women at risk for developing preeclampsia.

METHODS

Study participants included a control group of nonpregnant female volunteers (n = 59), a group of healthy pregnant (normotensive) female volunteers (n = 51), and a group of severe preeclamptic female volunteers (n = 59). Serum lipoprotein(a) concentrations were measured using double-antibody ELISA methods and were found to be 17.0+/-23.6 mg/dl among nonpregnant controls (n = 51), 15.9+/-15.8 mg/dl among healthy pregnant normotensives (n = 51), and 16.2+/-16.7 mg/dl in the preeclamptic group (n = 59). In addition, apolipoprotein (a) isoforms were identified using high-resolution SDS-agarose electrophoresis followed by immunoblotting.

RESULTS

We detected no significant differences between the groups studied in the distribution of isoforms (Chi-square = 1.21, df = 4, P = 0.89); however, in a 1-week interval we detected a 42.2% rise in Lp(a) levels as well as a 67.1% rise in C-reactive protein concentrations among 10 volunteers in the preeclamptic group (median = 9.6; P < 0.05).

CONCLUSIONS

Although the exact mechanism of pathogenesis continues to elude investigators, our results suggest that lipoprotein(a) may act as an acute-phase reactant during preeclampsia. Although our results are preliminary, they are consistent with growing evidence implicating lipids as among those factors involved in the etiology of preeclampsia. Changes in apolipoprotein(a) may be among those important biochemical markers that are found to be useful in the early identification of high-risk women and warrant further study.

Trisomy 12 in juvenile granulosa cell tumor of the ovary during pregnancy. A report of two cases

BACKGROUND

Granulosa cell tumors constitute only 5% of ovarian neoplasms, and their coexistence with pregnancy is extremely rare. Juvenile granulosa cell tumor has a good prognosis if it is confined to the ovary, but this type behaves more aggressively than the adult type at advanced stages.

CASES

We report on successful completion of two singleton pregnancies and deliveries of normal infants in two young women with juvenile granulosa cell tumor diagnosed and treated during pregnancy. This tumor has rarely been described in association with pregnancy. The presence of trisomy 12 as a single chromosomal abnormality was detected in these two tumors. Both tumors were localized strictly to the ovary, so conservative surgery was applied and proved sufficient to remove all tumor tissue. Follow-up showed no signs of recurrence 18 and 53 months after the interventions.

CONCLUSION

These cases support the contention that trisomy 12 is a nonrandom chromosome abnormality in juvenile granulosa cell tumors and that pregnancy may affect nuclear stability in this tumor.

["Maternal floor infarct", simultaneous manifestation of intrauterine fetal retardation and high maternal AFP level]

High AFP level (386.9 ng/ml) at the 16th gestational week in a 23-year old pregnant woman was observed. Fetal malformations or maternal causes could not be detected. Monitoring of fetal development and that of the fetal heart rate showed a worsening intrauterine growth retardation (IUGR). Due to the chronic hypoxia and IUGR cesarean section was performed in the 32nd gestational week and a 960 g female newborn was delivered. Histological examination of the placenta showed signs of maternal floor infarct (MFI): intervillous fibrin netlike deposition with the increase of extravillous trophoblast (X cells) and septal cystic formation. High unexplained AFP level and IUGR can draw attention to the possibility of intrauterine fetal demise, which indicates intensive intrauterine fetal monitoring.

Oxytocin activates mitogen-activated protein kinase and up-regulates cyclooxygenase-2 and prostaglandin production in human myometrial cells

OBJECTIVE

The objective of our study was to test the hypothesis that oxytocin promotes prostaglandin production by up-regulating cyclooxygenase-2 via activation of mitogen-activated protein kinase cascade in human myometrial cells.

STUDY DESIGN

Confluent cultures of human myometrial cells obtained from uterine specimens of premenopausal women undergoing hysterectomy were serum starved for 48 hours before oxytocin stimulation. Prostacyclin levels, as 6-keto-prostaglandin F(1) (alpha), were measured by radioimmunoassay, and the cellular cyclooxygenase-2 protein content was determined by Western blot. Mitogen-activated protein kinase activity was assessed by measuring the phosphorylation of myelin basic protein.

RESULTS

In a time- and dose-dependent manner oxytocin promoted prostacyclin production in human myometrial cells. Maximal responses were observed after 8 hours of stimulation at a dose of 100 nmol/L. This effect was mainly due to the expression of cyclooxygenase-2 protein. Within 5 minutes oxytocin significantly stimulated mitogen-activated protein kinase, as compared with the expression in untreated controls. The maximal increase in enzyme activity (2.5-fold) was obtained at 45 minutes. A selective inhibitor of mitogen-activated protein kinase activation (PD98059), as well as herbimycin, a tyrosine kinase inhibitor, and the transcriptional blocker actinomycin D, suppressed oxytocin-induced cyclooxygenase-2 expression and prostacyclin production. The stimulatory action of oxytocin was also sensitive to inhibition by pertussis toxin but appeared to be independent of protein kinase C activation.

CONCLUSION

Our data indicate a largely unrecognized signal transduction mechanism for oxytocin, involving G-protein-coupled activation of mitogen-activated protein kinase and cyclooxygenase-2 gene expression, leading to increased prostaglandin production in human myometrial cells. This signaling pathway complements the rapid activation of the phosphoinositide cycle and may be responsible for sustained release of prostaglandins in uterine tissues, promoting labor and parturition.

Apolipoprotein E gene polymorphism frequencies in a sample of healthy Hungarians

Apolipoprotein E (apo E) has been found to play an important role in lipid metabolism and has been associated with cardiovascular and neurodegenerative conditions. Hungarians have some of the highest rates of cardiovascular morbidity and mortality in the world. This study examines the distribution of apo E alleles and genotypes in a population of healthy ethnic Hungarian blood donors (n = 302). Male (n = 152) and female (n = 150) subjects ranging from 18 to 62 years of age (mean 37.0) were involved. To determine the frequency of apo E alleles, polymerase chain reaction followed by restriction length polymorphism was applied. The analyses of data showed that apo E allele epsilon3 had the greatest frequency in this group (0.807), followed by apo epsilon2 (0.104) and apo epsilon4 (0.087). The highest genotype frequency was found to be epsilon3/3 at 65.2% (n = 197) followed by genotype epsilon3/4 at 15.9% (n = 48), genotype epsilon2/3 at 15.2% (n = 46), genotype epsilon2/2 at 2.3% (n = 7), genotype epsilon2/4 at 1.0% (n = 3) and genotype epsilon4/4 at 0.4% (n = 1). The apo E frequencies found in this study appear to differ from an earlier study of blood donors, where the results are based on apo E phenotyping.

Neurofibromatosis type 1 with pregnancy-associated renovascular hypertension and the syndrome of hemolysis, elevated liver enzymes, and low platelets

The authors detected a case of neurofibromatosis type 1 complicated with preeclampsia and the syndrome of hemolysis, elevated liver enzymes, and low platelets, which developed during pregnancy. When the cause of the patient's hypertension was investigated after birth, renal stenosis of the right artery was detected, which was then successfully treated with percutaneous transluminal angioplasty.

Detection of factor V Leiden mutation in severe pre-eclamptic Hungarian women

Pre-eclampsia is a pregnancy-related disorder that complicates approximately 5% of all pregnancies and is cited as the primary cause of worldwide maternal and fetal mortality. The factor V Leiden mutation has been implicated in the development of severe pre-eclampsia. In order to investigate this association, a sample of 198 Hungarian women was recruited and enrolled in one of the three groups based on reproductive and health status: those as classified as pregnant and healthy (n = 71), those diagnosed as pregnant and severe pre-eclamptic (n = 69), and those found to be healthy and non-pregnant (n = 58). The presence of factor V Leiden mutation was determined by using polymerase chain reaction (PCR) followed by restriction fragment length polymorphism analysis (RFLP). We identified three (5.2%) heterozygous among healthy non-pregnant participants, five (7.0%) heterozygous among healthy pregnant participants and 13 (18.8%) heterozygous among pre-eclamptic women (p < 0.05, 95% CI). Our result supports the previous observation that carriers of factor V Leiden mutation are at increased risk for developing severe pre-eclampsia.

Apolipoprotein E alleles in women with severe pre-eclampsia

This study investigated the frequency of apolipoprotein E (apoE) alleles among women with severe pre-eclampsia. The presence of the three most common apoE alleles (epsilon 2, epsilon 3, epsilon 4) was determined by polymerase chain reaction-restriction fragment length polymorphism in three groups of white women: non-pregnant healthy (n = 101), pregnant healthy (n = 52), and pregnant with a diagnosis of severe pre-eclampsia (n = 54). The frequency of apo epsilon 2 was highest among women with severe pre-eclampsia (16.6%) followed by non-pregnant women (12.9%), and those experiencing a healthy pregnancy (10.6%). The higher frequency of the apo epsilon 2 allele detected among women with severe pre-eclampsia suggests that apoE may play a role in the development of pre-eclampsia.

[Pregnancy complicated by ovarian cysts]

This study included all the patients with ovarial cysts > or = 6 cm that were persisted during pregnancy in the 1st. Department of Obstetrics and Gynecology of Semmelweis University Medical School between 1. January 1991. and 31. December 1996. There were 14,640 deliveries and 15 cases which presented by above mentioned criteria with 1/976 incidency and 3 cases from all were malignant tumor with 1/4880 incidency. All patients underwent surgical intervention. Surgical management were spreaded on one adnexa in 12 cases of all, on both adnexum in only 3 cases and hysterectomy with both side adnexectomies was performed in only one case. Based on complications in two cases emergency laparotomies and in 13 cases elective extirpation of ovarial cysts were performed. There was no loss of pregnancy in the postoperative period. Because of the high risk of complications and malignancy we supported that surgical intervention in the second trimester is a definitive therapy for ovarial cysts complicated pregnancy.

[Bilateral renal artery stenosis diagnosed during pregnancy]

Bilateral renal artery stenosis was diagnosed noninvasively in the 17th gestational week, in a chronically hypertensive pregnant woman, by renal artery duplex ultrasound examination, MRI and MR angiography. Continuous monitoring of the mother and the fetus was performed. Blood pressure was stabilized by complex antihypertensive therapy, but from the beginning of the third trimester superimposed preeclampsia developed gradually. In the 34th gestational week a 1600-g newborn was delivered by elective cesarean section. The case report draws attention to the significance of the thorough examination of hypertensive women before pregnancy.

Coumarin-induced skin necrosis following heparin-induced thrombocytopenia and thrombosis. A case report

A severe thrombotic thrombocytopenic status, induced by heparin in a sixty-nine-year-old woman undergoing total hip joint arthroplasty, was treated by switching the anticoagulant therapy to coumarin, which induced skin necrosis. There appeared to be a possible causal relation between the severe immune reaction to heparin and the condition that predisposed to skin necrosis in the presence of coumarin. In patients who express a strong immune response to heparin, a different anticoagulant approach other than use of coumarin congeners appears to be justified.

Pemberton's pericapsular osteotomy for the treatment of acetabular dysplasia

We present the results of 80 Pemberton procedures carried out between 1977 and 1990. The patient age at the time of operation ranged between 2 and 12 years, and follow-up was between 1 and 15 years. Before Pemberton's operation, conservative treatment, closed and open reduction, and derotation femoral osteotomy were used. Pemberton's operation was combined with intertrochanteric femoral osteotomy in 30 cases. The mean values of the acetabular and center edge angle of Wiberg showed postoperative improvement of 19 and 17 degrees, respectively; whereas at follow-up, improvement was 20 and 23 degrees, respectively. Radiologically, 79% of the cases met Severin's classification grade I-II criteria. Clinically, 81% were classified as excellent and good. The results were closely correlated with ischemic necrosis due to preoperative treatment. Only patients belonging to groups II-IV of Kalamchi and MacEwen, plus one patient operated on at relatively old age (12 years), were found radiologically to be in Severin's groups III and IV. The results among patients operated on before age 7 were more favorable than those of patients operated on at an older age.

[The role of vascular nitric oxide (NO) in the pathomechanism of pre-eclampsia]

The significance of nitric-oxide as a biological mediator is increasingly elucidated in various physiological processes. In addition to the endothelium dependent vasodilator effect it also plays an important role as a neurotransmitter. Possible synthesis of endothelial nitric-oxide is an essential factor in the regulation of blood pressure and utero-placental circulation. Recently the relationship of nitric-oxide and preeclampsia has extensively been studied. The results of human studies and animal experiments suggest that insufficient production of endothelial nitric-oxide probably has an important role in the pathomechanism of preeclampsia.

[Effect of preeclampsia on neonatal morbidity]

In this study the outcome of two groups of premature infants born by caesarean section were compared from 52 hypertensive mothers with severe pre-eclampsia and from 30 normotensive mothers. The indication of caesarean section in pre-eclampsia was: proteinuria (> 500 mg/24 h), high blood pressure (> 160/100 mmHg), abnormal cardiotocogram and abnormality in flowmetry (fetal distress). Every infant was premature as well as in the control group. Significantly smaller mean birthweight and longer nursing-time in neonatal intensive care unit (NICU) were found in the pre-eclamptic group. Neonatal illnesses and complications are more frequent in the pre-eclamptic group. The time of ventilation was also longer. There are more early neurological disorders in the pre-eclamptic group than in the control one. The authors can establish that pre-eclamptic toxemia increases the morbidity in the neonatal period. This is due to the chronic intrauterine fetal distress as well as the retardation.

[Syncumar-induced necrosis following heparin-induced thrombocytopenia and thrombosis]

The authors describe the combined occurrence of heparin-induced thrombocytopenia and cumarin-induced skin necrosis, a rare condition that has not yet been reported in Hungary. The 69-year-old woman had received prophylactic heparin treatment prior to total hip arthroplasty. The first complication that the anticoagulant therapy brought about was serious thrombocytopenia paradoxically associated not with bleeding but with deep vein thrombosis. The latter necessitated coumarin therapy which resulted in severe skin necrosis.

Proposed signaling role of arachidonic acid in human myometrium

The objective of this study was to test the hypothesis that, in human myometrial cells (HMC), PGF2 alpha and oxytocin promote the release of arachidonic acid (AA) which, in turn, acts to mobilize intracellular Ca2+. Primary monolayer cultures of HMC were labeled with [3H]arachidonic acid ([3H]AA) to isotopic equilibrium before exposure to PGF2 alpha or oxytocin. Radiolabeled phospholipids were separated on thin layer chromatography and quantitated by scintillation counting. Prostanoids were analyzed by high performance liquid chromatography. Calcium release was quantitated in digitonin-permeabilized myocytes preloaded with 45Ca, in the presence of ATP and ruthenium red. PGF2 alpha (10(-7) M) caused a rapid (peaking at 2 min), and significant (P < 0.01) increase in [3H]AA release that was derived selectively from phosphatidylethanolamine (PE), indicative of phospholipase A2 activation. Oxytocin caused a rapid (30 s) and significant increase in diacylglycerol, concomitant with a drop in phosphoinositides, as well as an increase in [3H]AA and a fall in PE and phosphatidylcholine. Exogenous AA caused a rapid and dose-related efflux of 45Ca2+, which was not inhibited by blockers of AA metabolism, or by heparin that abolished inositol 1,4,5-trisphosphate-induced 45Ca2+ release. It is concluded that PGF2 alpha and oxytocin promote, by different mechanisms, the release of AA, which in turn may amplify their action by enhancing Ca2+ mobilization from the sarcoplasmic reticulum, thereby fulfilling the role of intracellular signaling molecule in human myometrium.

[Insulin concentration in amniotic fluid in mid-term pregnancy]

Insulin concentrations of 284 amniotic fluid samples were assessed, obtained from pregnant women by genetic amniocentesis between the 16-18 gestational weeks. The indication of amniocentesis was either advanced maternal age (> 35 years) or high risk genetic history. The amniotic fluid insulin concentration (mean +/- SD) was found 3.8 +/- 3.0 microIU/ml. The insulin concentration in 4.3% of all pregnant women was higher than the mean value +2 SD (9.8 microIU/ml) which represents individual pathological value, characteristic for gestational diabetes. Our data suggest that one part of gestational diabetes might be detected between the 16-18 gestational weeks, therefore we propose an earlier screening as the usual one. At institutes where the possibility of genetic amniocentesis is given the determination of insulin level in amniotic fluid may be reasonable. We could analyze the outcome of 230 pregnancies analysed. A close correlation was found between the amniotic fluid insulin concentration and birthweights of female newborns. It could not found such correlation at male newborn. A more careful screening test for gestational diabetes should be performed at mothers with female fetuses.

[Indication for Chiari's pelvic osteotomy]

The results of 61 Chiari's pelvic osteotomies carried out during a 10 years period are reported. Present role of the operation in the correction of acetabular dysplasia in comparison to Pemberton's acetabuloplasty, to triple pelvic osteotomies and to the prosthetic replacement of the hip joint is discussed. In conclusion the operation is still indicated in special cases. Depending on the age of the patients pain can be observed already after 3-5 years however a great part of the patients is completely free of complaints even 10 years postoperatively.