Interleukin (IL)-15 in combination with IL-2, fms-like tyrosine kinase-3 ligand and anti-CD3 significantly enhances umbilical cord blood natural killer (NK) cell and NK-cell subset expansion and NK function

BACKGROUND AIMS

Interleukin (IL)-15 and fms-like tyrosine kinase-3 (FLT-3) are crucial factors for the development of human and murine natural killer (NK) cells. Previously, we have demonstrated significant ex vivo expansion and activation of unrelated cord blood (UCB) NK cells with an antibody/cytokine cocktail consisting of anti-CD3 + IL-2 + IL-12 + IL-7 and anti-CD3 + IL-2 + IL-12 + IL-18.

METHODS

In the current experiments, we investigated the effects of short-term culture with anti-CD3 + IL-2 + FLT-3 + IL-15 on cord blood (CB) NK cell and NK-cell subset expansion and function. CB mononuclear cells were cultured for 48 h in AIM-V media or AIM-V + IL-2 (5 ng/mL) + anti-CD3 (50 ng/mL) + FLT-3 (50 ng/mL) ± escalating doses of IL-15 (1, 10 or 100 ng/mL). Flow cytometric analysis was performed using various fluorescent-conjugated monoclonal antibodies. In vitro cytotoxicity was determined with a standard europium assay against K562 and Daudi cells.

RESULTS

There was a 4.8-fold significant increase in NK-cell population (CD3(-)/16(+)/56(+); P < 0.03), 21-fold significant increase in CD3(-)/56(+)/158a(+) (KIR2DL1/S1; P < 0.002), 46-fold significant increase in CD3(-)/56(+)/158b(+) (KIR2DL1/S2; P < 0.002) and 11.5-fold significant increase in CD3(-)/56(+)/NKB1(+) (KIR3DL1; P < 0.01). We also noted a significant increase in both NK and lymphokine-activated killer (LAK) cytotoxicity with IL-2 + anti-CD3 + FLT-3 + IL-15 (100 ng/mL) compared with IL-2 + anti-CD3 + FLT-3 and media alone against K562 (P < 0.01) and Daudi (P < 0.001), respectively.

CONCLUSIONS

We have demonstrated a significant increase in UCB NK cells and NK cells expressing a variety of killer immunoglobulin-like receptor (KIR) receptors after short-term culture with anti-CD3, IL-2, FLT-3 and IL-15. Furthermore, there was a significant increase in in vitro NK/LAK cell cytotoxicity.

Differential gene expression signatures of adult peripheral blood vs cord blood monocyte-derived immature and mature dendritic cells

OBJECTIVE

Our previous studies have demonstrated differentially expressed genetic signature patterns in adult peripheral blood (APB) monocytes (Mos) vs cord blood (CB) Mos.

MATERIALS AND METHODS

In this study, we examined the differential gene expression profiles of APB vs CB immature dendritic cells (iDCs) and mature dendritic cells (mDCs) derived from Mos.

RESULTS

By utilizing oligonucleotide microarray, significant differential gene expression signature patterns were identified in APB vs CB mDCs, including increased expression of chemokines, cytokine receptors, and cell surface molecules. Additionally, signaling protein genes were significantly overexpressed in APB vs CB mDCs. There was also a significant amplification of expression of transcription factor interferon (IFN) regulatory factors and structure regulatory genes in APB vs CB mDCs. In contrast, there were genes expressed significantly higher in CB vs APB mDCs, including cell-cycle regulators and signaling molecule gene.

CONCLUSION

Taken together, these results suggest that specific genetic signatures might be responsible for differential DC differentiation and maturation between APB vs CB, and may provide insight into molecular mechanisms regulating differential immune responses between neonates and adults.

Characterization of natural killer and natural killer-like T cells derived from ex vivo expanded and activated cord blood mononuclear cells: implications for adoptive cellular immunotherapy

OBJECTIVE

Cord blood (CB) is limited by the absence of available donor effector cells for post-unrelated CB transplantation adoptive cellular immunotherapy. We reported the ability to ex vivo expand (EvE) CB mononuclear cells (MNC) after short-term incubation with anti-CD3, interleukin (IL)-2, IL-7, and IL-12 (antibody/cytokine [AB/CY]) into subpopulations of CD3(-)/56(+) natural killer (NK) cells with enhanced in vitro and in vivo tumor cytotoxicity.

MATERIALS AND METHODS

We compared 2- vs 7-day EvE of rethawed CB MNCs in AB/CY and activation of NK and NK-like T (NKT) cell (CD3(+)/56(+)) subsets expressing specific NK-cell receptors along with IL-15, IL-18, and interferon-gamma production.

RESULTS

Nonadherent total cell number were significantly increased at day 7 (p<0.001) along with NK-cell number (20-fold) and an enrichment in NKT-like subsets (36-fold). There was no change in the NK(dim) subset; yet the NKT(bright) and NKT KIR3DL1(dim) subsets were significantly increased (p<0.05). NK cells expressing the inhibitory natural cytoxicity receptor CD94/NKG2A were decreased (p<0.001), while those expressing activating natural cytoxicity receptor CD94/NKG2D receptor and activating NK and NKT KIR2DS4 subsets were significantly increased (p<0.001). IL-18 and interferon-gamma protein production was also significantly increased (p<0.001 and p<0.05, respectively). Lysosomal-associated membrane protein-1 and granzyme B expression were increased (p<0.001 and p>0.01, respectively), which correlated with the significant increase in NK, LAK, and tumor cytotoxicity of the EvE cells.

CONCLUSION

This study demonstrates that previously cryopreserved and rethawed CB MNCs can be EvE up to 7 days to yield viable and activated NK and NKT-like subsets that appear to be cytolytic based on the cell repertoire and could be utilized in the future as adoptive cellular immunotherapy post-unrelated CB transplantation.

Preliminary open trial of interpersonal counseling for subsyndromal depression following miscarriage

Miscarriage occurs in 10-20% of clinically recognized pregnancies and is associated with two- to fourfold increases in depressive symptoms. No counseling programs for depressed miscarrying women have been manualized or evaluated for safety and efficacy. We investigated whether depressive symptoms decline substantially among miscarrying women receiving one to six weekly sessions of manualized, telephone-administered interpersonal counseling (IPC), a variant of interpersonal psychotherapy (IPT) in an open trial. Depressive symptom levels were measured with the Center for Epidemiologic Studies-Depression (CES-D) scale. Of 65 women evaluated, 24 were study eligible; 17 consented to participate. Change in symptom levels was evaluated by comparing baseline to postintervention CES-D scores in an intention to treat (ITT) sample (n=17) and a completer subsample (n=9). The latter sample comprised women reevaluated postintervention. In the ITT sample, the CES-D mean score declined from 25.4 to 18.8 [mean within-subject change=6.6, 95% confidence interval (CI)=1.4-11.6]; in the completer subsample, it declined from 23.6 to 11.2 (mean within-subject change=12.3, 95% CI=4.0-20.7). Findings from this small open trial suggest that IPC decreases depressive symptoms after miscarriage. A randomized, controlled trial of IPC's safety and efficacy with depressed miscarrying women is warranted.

False-positive quadruple screen test for trisomy 18 in a patient with a fetus with Bloom's syndrome

In the literature, conflicting reports on the significance of false-positive maternal serum multiple marker testing for trisomy 18 are encountered; however, the biology of this finding is discussed infrequently. We present such a case in association with Bloom's syndrome in the fetus. The fetus had intrauterine growth restriction, seen early in the second trimester, oligohydramnios, and was delivered at 34 weeks of gestation for impending fetal compromise. We propose that the adverse outcome of the pregnancy with false-positive serum analyte testing for trisomy 18 might result from a small-sized placenta and perhaps pathology at receptor level.

Characterization of cord blood natural killer and lymphokine activated killer lymphocytes following ex vivo cellular engineering

Cord blood (CB) natural killer (NK) and lymphokine-activated killer (LAK) cytotoxic cells are poorly characterized but might be used to treat minimal residual and/or recurrent malignant disease. Currently, there is no mechanism to use CB for adoptive cancer cellular immunotherapy after CB transplantation (CBT). Recognizing this as a deficiency, we hypothesized that CB aliquots could be engineered ex vivo for potential donor lymphocyte infusion after CBT. Cryopreserved CB aliquots were thawed, depleted of monocytes, and cultured in serum-free medium alone or serum-free medium with anti-CD3 and interleukins 2, 7, and 12 combined with antibody/cytokines for 48 hours. Immunophenotyping, cytotoxicity, and proliferation were evaluated. A significant expansion of CD3+ was seen, in addition to increases in lymphocyte subsets of CD8+, CD8+/CD25+, and CD3+/45RO+ versus medium alone. A significant enhancement of CD3 proliferation (P<.001), NK cytotoxicity, NK subset expansion, LAK cytotoxicity, and T-helper 1 subset expansion was also demonstrated. Significant enrichment was seen in NK CD16+/CD56+bright, CD16+/CD56+dim, CD56+bright and CD56+dim/KIR3DL1+, CD56+bright and CD56+dim/KIR2DL1+, CD56+bright and CD56+dim/KIR2DL2+ and CD94+/NKG2a+ subsets. These increases in CB NK subsets were in part secondary to augmentation of cell survival. Further, survival of NOD-SCID mice xenografted with human K562 cells and treated with CB cells expanded with antibody/cytokines was significantly higher than that in animals that received no treatment (phosphate buffered saline) and those that were treated with CB ex vivo expanded in medium alone (P<.005, respectively). These data suggest that cryopreserved CB cells could be ex vivo engineered for potential use as adoptive cancer cellular immunotherapy for donor lymphocyte infusion after CBT.

Pilot randomized controlled trial of interpersonal counseling for subsyndromal depression following miscarriage

OBJECTIVE

Miscarriage, which occurs in 10% to 20% of clinically recognized pregnancies, is associated with an increased risk for subsyndromal depression. We examined whether Interpersonal Counseling (IPC) was superior to treatment as usual (TAU) in reducing subsyndromal depression among miscarrying women and, secondarily, superior to TAU in improving role functioning.

METHOD

Nineteen of 20 eligible women participated in a randomized controlled trial of 1 to 6 weekly telephone sessions of IPC versus TAU, which consisted of whatever lay counseling or professional care women sought on their own initiative, from October 2001 to April 2002. The 2 trial arms were compared on mean within-subject change in Hamilton Rating Scale for Depression-17-item (HAM-D-17) scores and in role functioning scale scores (a 5-item modification of the 36-item Medical Outcomes Study questionnaire) from baseline to post-intervention.

RESULTS

In the primary intent-to-treat analysis, the baseline mean HAM-D-17 scores were 18.0 (SD +/- 8.4) and 14.8 (SD +/- 6.6) in the IPC (N = 10) and TAU (N = 9) arms, respectively; post-intervention, the corresponding means were 11.6 (SD +/- 8.2) and 12.9 (SD +/- 8.3). The mean within-subject decline in HAM-D-17 scores was significantly greater in the IPC (6.4) than in the TAU (1.9) arm (difference in mean within-subject score decline, adjusted for design features, baseline HAM-D-17 scores and for baseline ethnic imbalance between study arms, 6.2 [95% CI = 0.4 to 12.0]). In a subordinate completers' analysis (N = 15), the corresponding mean decline and difference in adjusted mean decline were 8.0, 2.4, and 6.7 (95% CI = 0.4 to 13.1), respectively. Treatment was unrelated to improved role functioning.

CONCLUSION

The efficacy of telephone-administered IPC for subsyndromal depression after miscarriage warrants testing in a full-scale randomized controlled trial.

Immaturity of IL-18 gene expression and protein production in cord blood (CB) versus peripheral blood (PB) mononuclear cells and differential effects in natural killer (NK) cell development and function

We have previously demonstrated dysregulation of IL-12 and IL-15 gene and protein expression between activated cord blood (CB) versus peripheral blood (PB) mononuclear cells (MNCs). In the present study, we compared IL-18 gene expression and protein production and IL-18 mRNA half-life in basal versus activated CB versus PB MNCs, the effects of IL-18 +/- IL-12 on MNCs IFN-gamma protein production and ex vivo expansion and activation of CB with IL-12 + IL-2 + anti-CD3 +/- IL-18. Basal and activated levels of IL-18 were significantly higher in PB versus CB MNCs (P < 0.05). IL-18 mRNA was coincidental with protein levels and significantly lower in CB (P < 0.05) and its half-life significantly shorter in CB versus PB MNCs (P < 0.05). IL-18 synergistically with IL-12 induced IFN-gamma production from PB greater than CB MNCs (P < 0.05). NK cells expansion (P < 0.001) and cytotoxicity (P < 0.01) was significantly increased with IL-12 + IL-2 + anti-CD3 and IL-18. In summary IL-18 gene expression and protein production are significantly decreased in activated CB versus PB MNCs, in part secondary to increased degradation of CB IL-18 mRNA. These results may have implications for the mechanism(s) in part responsible for the immaturity of CB T-cell immunity.

Congenital Cystic Adenomatoid Malformation in the Fetus: A Hypothesis of Its Development

We present a case of congenital cystic adenomatoid malformation of the lung diagnosed at 34 weeks of gestation in the setting of polyhydramnios. The fetus had CCAM in the L lung, with mediastinal shift to the right and ascites. The neonate underwent drainage of cysts and subsequent left lung lobar resection with improvement in respiratory function. The pathology of CCAM is reviewed in detail. We speculate the role of alcohol as a teratogen through retinoic acid at 8-10 weeks of gestation when fetal lungs are actively developing.

A stable murine-based RD114 retroviral packaging line efficiently transduces human hematopoietic cells

Several barriers exist to high-efficiency transfer of therapeutic genes into human hematopoietic stem cells (HSCs) using complex oncoretroviral vectors. Human clinical trials to date have used Moloney leukemia virus-based amphotropic and gibbon ape leukemia virus-based envelopes in stable retroviral packaging lines. However, retroviruses pseudotyped with these envelopes have low titers due to the inability to concentrate viral supernatants efficiently by centrifugation without damaging the virus and low transduction efficiencies because of low-level expression of viral target receptors on human HSC. The RD114 envelope from the feline endogenous virus has been shown to transduce human CD34+ cells using transient packaging systems and to be concentrated to high titers by centrifugation. Stable packaging systems have potential advantages over transient systems because greater and more reproducible viral productions can be attained. We have, therefore, constructed and tested a stable RD114-expressing packaging line capable of high-level transduction of human CD34+ cells. Viral particles from this cell line were concentrated up to 100-fold (up to 10(7) viral particles/ml) by ultracentrifugation. Human hematopoietic progenitors from cord blood and sickle cell CD34+ cells were efficiently transduced with a Neo(R)-containing vector after a single exposure to concentrated RD114-pseudotyped virus produced from this cell line. Up to 78% of progenitors from transduced cord blood CD34+ cells and 51% of progenitors from sickle cell CD34+ cells expressed the NeoR gene. We also show transfer of a human beta-globin gene into progenitor cells from CD34+ cells from sickle cell patients with this new RD114 stable packaging system. The results indicate that this packaging line may eventually be useful in human clinical trials of globin gene therapy.

Perinatal mortality in diabetic patients undergoing antepartum fetal evaluation: a case-control study

OBJECTIVE

To identify changing trends, if any, of fetal loss in diabetic patients undergoing antepartum fetal evaluation in a case-control study.

METHODS

Fetal assessment (non-stress test and/or biophysical profile) logbooks from January 1981 to June 1998 were reviewed and the patients with diabetes were identified. The study group comprised patients with pregnancy loss. Each case was matched by year of delivery and class of diabetes with four randomly selected controls with no pregnancy loss. All patients in both groups were at > 26 weeks' gestation.

RESULTS

Thirteen stillbirths and four neonatal deaths occurred in 1,935 diabetic patients who underwent fetal evaluation. There was no significant difference in age, race, gravidity, parity, clinic or private service, or the type of delivery in the two groups. Losses were more likely (p < 0.001) to occur before 32 weeks, with birth weights < 2,500 g, with a greater time interval from their last fetal evaluation, with poor glycemic control and with congenital malformations (six of seven occurred before 1990). In this study, perinatal losses were associated with non-compliance and other associated problems in the mother. Overall perinatal mortality in these patients was 17 per 1935 and corrected 11 per 1935 or 5.6 per 1,000.

CONCLUSION

In the 1980s suboptimal glycemic control with major fetal malformations emerged as the major contributory factor to perinatal loss and, in the 1990s, this was associated medical problems. With a better awareness of the adverse effect of suboptimal glycemic control at the time of organogenesis and advances in fetal diagnosis and evaluation, fetal loss due to diabetes has become a rarity. Patients with associated medical problems and those at risk for abruptio placentae should be managed more aggressively.

Transcranial Doppler blood flow measurement during cesarean section in two patients with cerebral vascular disease

We present two cases of neurovascular disease in pregnancy in which transcranial Doppler was used to assess the status of the cerebral circulation during cesarean section under regional anesthesia. One woman had been found to have moyamoya disease, following a series of transient ischemic attacks during her first pregnancy, which ended in spontaneous abortion. On this occasion she was delivered by cesarean section under slowly-induced epidural anesthesia, using ephedrine to maintain the blood pressure, and transcranial Doppler revealed no change in signal in her left middle cerebral artery. Both mother and baby had an uneventful post natal course. The second case involved a primiparous woman with a large arteriovenous malformation that had been detected following generalized seizures, which were treated with valproic acid. Her cesarean section was conducted under spinal anesthesia, and her blood pressure maintained with ephedrine. Again transcranial Doppler revealed no change in signal in her middle cerebral artery during the procedure. We believe this is a potentially useful technique to monitor the cerebral circulation intraoperatively in the presence of cerebrovascular disease.

Congenital cataract in triplet pregnancy after ivf with frozen embryos: prenatal diagnosis and management

Unilateral congenital cataract was diagnosed at the 2nd trimester ultrasonography in a triplet pregnancy following in vitro fertilization (with frozen embryos). Congenital cataract could be hereditary or related to metabolic and infectious disorders. To our knowledge this is the first antenatal diagnosis of the disorder in triplets after IVF with frozen embryos.

Laparoscopic cholecystectomy during pregnancy: a case series and review of the literature

This study was conducted to evaluate the role of antepartum laparoscopic cholecystectomy (LC). Patients who underwent LC were identified from a hospital database with the use of CPT/ICD codes. Of 2093 cases performed at a major center (October 1991 to November 1997), only six were performed during pregnancy. On reviewing the English literature, gestational age at surgery and delivery and outcome of delivery were provided in only 69 of 105 patients (33 papers with 1-10 cases) and we tabulated different variables from the cases in this review. In this series, two patients who had LC in the first trimester underwent elective termination of pregnancy. Of the seven published cases of first trimester LC followed to delivery, one had preterm delivery. First trimester open cholecystectomy (OC) has a 12 percent spontaneous abortion rate. The four patients who had second trimester LC had normal deliveries at term. Of the 43 published cases of second trimester LC followed to delivery, 39 ended in uncomplicated, full-term deliveries. Three of four second trimester cases at one institution had spontaneous abortions. None of our patients underwent LC in the third trimester. Of the 12 published cases of third trimester LC followed to delivery, one had preterm delivery. Third trimester OC is reported to have a 40 percent rate of preterm delivery. There were no intraoperative cholangiograms (IOC), prophylactic or postoperative use of tocolytics, or intraoperative fetal monitoring in our series. We added six cases of LC during pregnancy to the previously reported 105 cases. The successful outcome in all trimesters suggests that LC is a safe procedure throughout pregnancy; however, surgery in the second trimester is preferable. Compared with OC, there is a decreased risk of spontaneous abortion in the first trimester and preterm labor in the third trimester.

Attempted vaginal birth after cesarean section: a multicenter comparison of outpatient prostaglandin E(2) gel with expectant management

Objective: To compare the clinical effectiveness and safety of outpatient administration of an intracervical prostaglandin (PG) E(2) gel with expectant management for women with an unfavorable cervix who wish to attempt a vaginal birth after cesarean section.Study Design: This outpatient study was a randomized, multicenter investigation involving pregnant women at term with one previous low transverse cesarean section. Each had an unfavorable cervix (Bishop score </=4) and was a candidate for vaginal delivery. Those randomly assigned to receive the gel, rather than expectant management, were given a 0.5 mg dose of PGE(2) (Prepidil) intracervically at 39 weeks gestation. This cervical ripening treatment was repeated at weekly office visits for up to 3 doses.Results: Of the 294 cases, 143 received the gel while 151 underwent expectant management. No differences between the two groups were found for maternal demographics, race, parity, or predose Bishop score. The rates of repeat cesarean section did not differ (P =.68) with use of the gel (61, 42%) or with expectant therapy (48, 45%). The onset of active labor, the duration of labor among those delivering vaginally, and the 1-minute and 5-minute Apgar scores were not different between the two groups. No uterine rupture was apparent, and adverse effects during labor were as likely to occur in the two groups.Conclusions: Although its safety was confirmed for outpatient use and for persons with a prior cesarean delivery, intracervical prostaglandin E(2) gel did not improve the chance of a vaginal birth after a cesarean delivery.

Exencephaly-anencephaly sequence: proof by ultrasound imaging and amniotic fluid cytology

We present and discuss major current theories about the developmental natural history of the anencephalic human fetus. We confirm previous observations made using transvaginal ultrasonography of exencephalic fetuses which were later imaged and/or delivered as anencephalic fetuses. We explore the possibility of proving the theory of the slowly rubbed-off exposed brain tissue by cytologic examination and special staining of aspirated cells in amniotic fluid. Three fetuses with a typical sonographic picture of exencephaly at 13-15 postmenstrual weeks underwent amniocentesis. The aspirated fluid contained pathognomonic neural cells. The same fetuses later showed the characteristic sonographic and postabortion picture of anencephaly. Our results support the theory that exencephaly is the forerunner of anencephaly.

Tamoxifen-induced growth of leiomyomas. A case report

BACKGROUND

Tamoxifen, a nonsteroidal estrogen agonist-antagonist, is used in the treatment of breast cancer.

CASE

A postmenopausal woman, aged 73, while being treated with Tamoxifen, developed continuous growth of her myomatous uterus, became symptomatic and required surgery.

CONCLUSION

Tamoxifen at a dose of 40 mg/d has been associated with endometrial carcinoma. The growth of myomas seen with Tamoxifen in this patient seems to be a result of its direct agonist properties.

Significance of prenatal diagnosis of umbilical cord cyst in a fetus with trisomy 18

An umbilical cord cyst was detected in a fetus who underwent ultrasonography at 38 weeks' gestation for clinical suspicion of intrauterine growth retardation. Such an association should alert the clinician to the possibility of aneuploidy, thus guiding clinical management. This case represents the second report of a cystic umbilical lesion in a fetus with trisomy 18.

Fetal faciocervical teratoma with anemia and thrombocytopenia. A case report

A massive teratoma in the faciocervical region was found in a fetus at 21 weeks, with laboratory evidence of anemia and thrombocytopenia. Vaginal delivery was achieved by cardiocentesis followed by Laminaria tent insertion, dilation and evacuation.

Alpha-fetoprotein in diabetic pregnancy. A reassessment

We correlated glycosylated hemoglobin (HbA1) with maternal serum alpha-fetoprotein (MSAFP) in 92 and amniotic fluid AFP (AFAFP) in 27 patients with pregestational and gestational diabetes. MSAFP and AFAFP were measured between 15 and 20 weeks and correlated with HbA1. In group 1, HbA1 was measured at < or = 12 weeks' gestation; in group 2, it was measured 0-6 weeks before MSAFP measurement; and in group 3, it was measured within 6 weeks after MSAFP. Mean MSAFP was 1.02 +/- 0.77 multiples of the median (MOM) (+/- SD) in all diabetics, 1.1 +/- 0.93 MOM in gestational diabetics and 0.89 +/- 0.33 MOM in pregestational diabetics (P = NS). There was no correlation between MSAFP and HbA1 in groups 1-3. Patients with HbA1 > 9 g% had a mean MSAFP of 0.84 MOM as compared to 0.85 MOM in those with HbA1 < 9 g% (P = NS). AFAFP values were within normal limits even in patients with HbA1 > 9 g% in early pregnancy (n = 8). No significant decrease in MSAFP was seen in pregestational diabetics, and no correlation was seen with HbA1 levels. AFAFP levels were unchanged in diabetics.

Subchorionic hematoma: a review

A review of the English literature on subchorionic hematoma (SCH) is presented. Fourteen studies are reviewed. The incidence of SCH varied greatly among studies from 4 to 48 per cent. Small SCH tend to be more common in the first trimester and appear to pose no added risk to the ongoing pregnancy. Conversely, SCH in the second trimester often are larger and may be associated with an increased risk of preterm delivery. The etiology of these hematomas remains unclear. Pathological changes that might contribute to their formation are reviewed. Larger studies with controls, including data on the incidence of SCH in a population of normal obstetric patients are needed.

Screening recommendations for gestational diabetes mellitus

As a result of extensive experiences in multiple centers and a review of the current literature, we conclude that a plasma glucose level obtained 1 hour after a 50 gm oral glucose challenge is the "best" gestational diabetes mellitus screening test. This universal screening is performed at least once during pregnancy. The screening threshold should be no higher than 140 mg/dl, or an unacceptable loss in sensitivity occurs. Universal screening for gestational diabetes mellitus is justified by morbidity reduction, cost, and protocol simplicity and ease.

Early detection of caudal regression syndrome with transvaginal scanning

High-resolution transvaginal ultrasonography may recognize structures in the first- and early second-trimester fetus. In a patient with pregestational diabetes, caudal regression syndrome in the fetus was diagnosed using transvaginal ultrasonography. At 9 weeks of gestation, a shortening of the crown-rump length and a protuberance of the lower spine suggested caudal regression syndrome. By 17 weeks of gestation, the diagnosis was made with certainty. The transvaginal approach has changed the role of first-trimester ultrasound in the diabetic pregnancy. We suggest that transvaginal ultrasonography be used for purposes of accurate dating and for early detection of diabetic embryopathy, particularly in patients with poor periconceptional glycemic control.

Mitochondrial myopathy and preeclampsia associated with pregnancy

Mitochondrial myopathy is characterized by weakness, exercise intolerance, and acidosis. Pregnancy has been reported to accelerate the disease process. This report discusses pregnancy and management of labor complicated by mitochondrial myopathy and the therapeutic dilemmas that arise when preeclampsia is diagnosed.

Transvaginal salpingocentesis: a new technique for treating ectopic pregnancy

Transvaginal sonography is an important tool for diagnosing ectopic pregnancy. In this report the transvaginal passage of a needle, with sonographic guidance, into a tubal gestational sac with a live fetus is demonstrated. We injected potassium chloride solution to arrest cardiac activity, terminating the ectopic pregnancy without surgical intervention. The new therapeutic use of transvaginal sonography is an important addition to the treatment of this prevalent disease.

Bilateral luteomas of pregnancy in a patient with diabetes

A patient with diabetes and luteomas of the ovaries demonstrated a significant and progressive rise in the serum levels of androstenedione and testosterone during pregnancy. The levels of these hormones were also elevated in cord blood and ovarian fluid. The increased insulin requirement to maintain euglycemia was observed at an earlier date in this pregnancy than in her previous pregnancy.

Complete congenital heart block: risk of occurrence and therapeutic approach to prevention

A retrospective literature review revealed that in 41% of cases of complete congenital heart block (CCHB) there was at least one other affected sibling, emphasizing the considerable risk of carrying a second affected fetus with CCHB. Therefore an aggressive approach was taken to prevent CCHB in a fetus with a high risk for the condition as defined by (1) presence of DR3 and high titers of antibodies to SSA(Ro) and SSB(La) in the mother (2) previous history of CCHB in a sibling. In a feasibility study, thrice weekly plasmapheresis was initiated in the 19th week of gestation to remove antibodies from the maternal circulation in advance of major placental transport to the developing fetus. Prednisone was also administered to decrease antibody synthesis. The concentration of total maternal IgG and antibodies to SSA(Ro) and SSB(La) were decreased by greater than 60% during the course of therapy. Planned delivery of a healthy baby was done at 36 weeks.

Pregnancy complicated by maternal spina bifida. A report of two cases

Pregnancy occurred in two women who had undergone corrective surgery for meningomyelocele. Both women had urinary incontinence leading to urinary tract infections and, in one, to vulvitis urinosa. There is limited literature on maternal meningomyelocele and its complications.

Evolution of complete heart block in a fetus and its perinatal management

The antepartum course of a patient with a fetus showing heart block and complex congenital heart disease was followed closely using serial nonstress tests, ultrasonograms, and echocardiograms. Internal fetal heart rate and capillary pH monitoring during labor were useful in guiding the successful vaginal delivery.

Use of glycosylated hemoglobin as a screen for macrosomia in gestational diabetes

Glycosylated hemoglobin and blood sugar levels in the fasting state and two hours after oral 100 g glucose load were measured in 180 patients. Glycosylated hemoglobin was measured by cation exchange column chromatography, and blood sugar was measured by hexokinase reaction. Patients with an elevated postprandial and/or fasting blood sugar level (positive screen) subsequently underwent three-hour glucose tolerance test. The mean value of glycosylated hemoglobin in patients with a negative screen and normal hemoglobin was 6.17 +/- 0.61%; and the value for glycosylated hemoglobin in patients with class A diabetes and normal hemoglobin electrophoresis was 6.85 +/- 0.73% (P less than .001). A glycosylated hemoglobin value greater than 6.78 (mean + 1 SD) was considered elevated. Glycosylated hemoglobin values were elevated in 21 of 33 patients with gestational diabetes and in 27 of 147 patients with normal blood sugar levels. The sensitivity and specificity of glycosylated hemoglobin for the diagnosis of gestational diabetes were 63.6 and 81.6%, respectively. Fifty percent of patients with an initially elevated glycosylated hemoglobin value delivered macrosomic infants, whereas no patient with a normal glycosylated hemoglobin value had a macrosomic infant. An elevated glycosylated hemoglobin value may alert the obstetrician of a potentially elevated mean blood sugar level and may warrant aggressive management of gestational diabetes.

Glycosylated hemoglobin (HbA1) and hemoglobinopathies in pregnancy

Glycosylated hemoglobin (HbA1) is considered to be representative of prior blood-glucose levels and is being used in pregnant and nonpregnant diabetic patients as a possible index of both long and short-term glucose-control. Factors other than blood-glucose concentration have been reported to affect its value. Variant hemoglobin is one of them. HbA1 and blood-glucose levels were measured in pregnant patients at high risk for diabetes for screening for abnormal carbohydrate metabolism. HbA1 was measured by cation exchange column chromatography and glucose was measured by hexokinase reaction. The mean HbA1 in patients with normal blood sugars was 6.17 +/- 0.6 percent. A value of HbA1 of less than 5 percent as measured by cation exchange column chromatography was highly predictive (P less than 0.001) of hemoglobinopathies (S or C). The mean HbA1 of randomly selected matched patients with "normal" Hb was 5.94 +/- 0.72 percent. In patients with thalassemia, HbA1 values as measured by cation exchange column chromatography were elevated despite normal carbohydrate tolerance. While interpreting the results of HbA1 in the management of pregnant diabetics, the above fact should be kept in mind.

Plasma beta-endorphin and beta-lipotropin in the human fetus at delivery: correlation with arterial pH and pO2

Beta-endorphin-like immunoactivity was measured in the umbilical cord plasma of 45 term human fetuses. Mean concentration was 91 +/- 16 (SEM) pg/ml,an the normal adult level of 30.7 +/- 2.7 pg/ml. This immunoactivity was further characterized in 10 cases by Sephadex G-50 chromatography to separate beta-endorphin from beta-lipotropin (beta-LPH). Mean beta-endorphin and beta-LPH concentrations were 57 +/- 12.8 and 455 +/- 101 pg/ml, respectively. Both were higher (P less than 0.01) than the mean beta-endorphin and beta-LPH concentrations reported in the adult. The mean molar beta-endorphin to beta-LPH ratio was 0.35 in the fetus and 0.36 in the adult. In 17 fetuses whose umbilical arterial and venous concentrations were measured separately, mean beta-endorphin-like immunoactivity was higher in the artery than in the vein. A highly significant negative correlation (r = -0.831; P less than 0.001) was present between umbilical arteiral pH and beta-endorphin-like immunoactivity. A negative correlation (r = -0.611; P less than 0.005) with arterial pO2 was also noted. We conclude that high levels of beta-endorphin-like immunoactivity, composed of both beta-endorphin and beta-LPH, circulate in the human fetus at term, and that hypoxia and secondary acidosis may be major stimuli to the release of these peptides.