Predictors of Ominous Outcome in Infants Undergone to Cardiac Surgery and Cardiopulmonary by-Pass: S100B Protein

S100B protein has been recently proposed as a consolidated marker of brain damage and death in adult, children and newborn patients. The present study evaluates whether the longitudinal measurement of S100B at different perioperative time-points may be a useful tool to identify the occurrence of perioperative early death in congenital heart disease (CHD) newborns. We conducted a case-control study in 88 CHD infants, without pre-existing neurological disorders or other co-morbidities, of whom 22 were complicated by perioperative death in the first week from surgery. Control group was composed by 66 uncomplicated CHD infants matched for age at surgical procedure. Blood samples were drawn at five predetermined time-points before during and after surgery. In all CHD children, S100B values showed a pattern characterized by a significant increase in protein's concentration from hospital admission up to 24-h after procedure reaching their maximum peak (P<0.01) during cardiopulmonary by-pass and at the end of the surgical procedure. Moreover, S100B concentrations in CHD death group were significantly higher (P<0.01) than controls at all monitoring time-points. The ROC curve analysis showed that S100B measured before surgical procedure was the best predictor of perioperative death, among a series of clinical and laboratory parameters, reaching at a cut-off of 0.1 μg/L a sensitivity of 100% and a specificity of 63.7%. The present data suggest that in CHD infants biochemical monitoring in the perioperative period is becoming possible and S100B can be include among a series of parameters for adverse outcome prediction.

What kind of surgery for cervical carcinoma?

The incidence and mortality of cervical cancer have changed over the past 50 years in developed countries, but this kind of tumor still remains a significant clinical problem because it is the second most common cause of morbidity and mortality from cancer among women. After histological confirmation of invasive cervical cancer, the extent of disease was determined using clinical criteria to assign a stage. This assessment is important because, while for the other gynecologic cancers clinical information obtained by surgery and histopathological examination is implemented and concurs to define the staging of the disease, the cervical cancer tumor stage is given after the primary diagnosis. In this review we discuss how the surgical approach to cervical cancer has been evolved, in order to modulate the radicality of the intervention itself and thus to preserve the pelvic innervation. This step has been achieved by deepening knowledge of functional pelvic anatomy and modulating the radicality of hysterectomy according to well defined surgical landmarks.

Cervical ripening and induction of labor by prostaglandin E2: a comparison between intracervical gel and vaginal pessary

OBJECTIVE

To compare the effectiveness and safety of two formulations of prostaglandin (PG) E2 (gel and pessary) for induction of labor. Primary outcomes were cervical ripening, initiation/duration of labor, and type of delivery.

STUDY DESIGN

A total of 115 women with singleton gestations were consecutively enrolled and assigned to receive intracervical PGE2 (dinoprostone 0.5 mg) by gel (n = 66) or PGE2 (dinoprostone 10 mg) by intravaginal pessary (n = 49).

RESULTS

Independently from parity, the vaginal pessary induced successful cervical ripening with a slightly higher but not statistically significant occurrence of vaginal delivery with respect to gel induction. The mean time interval from induction to vaginal delivery did not differ between groups, despite being shorter for the pessary group in inducation-delivery intervals > 12 h. No significant differences were found between the groups with respect to patients who required a second course of PGE2 (9% vs. 2%), as well as oxytocin (11% vs. 13%) induction. No significant difference was found in the incidence of uterine hyperstimulation and other adverse reactions in nulliparas, or in fetal and neonatal outcome.

CONCLUSION

Independently from parity, both PGE2 administration routes appeared to be effective in achieving cervical ripening, initiation of labor and optimal type of delivery, and showed the same incidence of side-effects.

Menopause alters the metabolism of serum serotonin precursors and their correlation with gonadotropins and estradiol

OBJECTIVE

Tryptophan, the serotonin (5-HT) precursor, is circulating in blood in both free (FT) and protein-bound forms. The free form crosses the hematoencephalic barrier and is converted into 5-HT. During the fertile years, tryptophan levels are negatively correlated to gonadotropin concentrations. The present study aims to evaluate the correlation between circulating tryptophan, gonadotropin and estradiol (E2) levels postmenopause.

METHODS

Serum levels of total tryptophan (TT, free + protein-bound) and FT, and plasma luteinizing hormone (LH), follicle stimulating hormone (FSH), and E2 were determined in 15 postmenopausal women and 15 cycling women during follicular (days 7-10), periovulatory (days 13-16) and luteal (days 21-24) phases of the menstrual cycle. Data were analyzed by ANOVA, linear correlation coefficients and hierarchical cluster analysis of variables.

RESULTS

TT, but not FT, levels were significantly (p<0.05) higher in postmenopausal (12.07+/-0.40 microg/ml) than fertile women in the periovulatory period (10.46+/-0.36 microg/ml). In postmenopausal women, there was no significant correlation between TT and FT, nor between these tryptophan forms and gonadotropins, but only between FT and E2. Cluster analysis showed that the main cluster composed by FSH-LH-TT-FT observed in fertile women was absent in postmenopause, since both serum tryptophan forms were distant from gonadotropins.

CONCLUSION

High TT levels circulate in postmenopausal women, with lack of correlation between TT and FT, and FT/TT and gonadotropins. Since estrogens play a pivotal role on central 5-HT metabolism, estrogen deprivation may alter the brain tryptophan utilization for 5-HT synthesis and its relation to gonadotropin release.

Thickness of fetal membranes: a possible ultrasound marker for preterm delivery

OBJECTIVE

To evaluate whether measurement of the thickness of the fetal membranes by high-resolution ultrasound is a useful marker to predict preterm delivery.

METHODS

One hundred and fifty-eight women with singleton pregnancies at 18-35 gestational weeks were enrolled consecutively at our referral center for obstetric care and the thickness of their fetal membranes was measured using high-resolution ultrasound equipment. Data were analyzed to determine whether there were significant differences between those delivering at term and those delivering preterm. Receiver-operating characteristics (ROC) curves were used to determine the best cut-off point of membrane thickness for predicting preterm birth.

RESULTS

Women who delivered preterm had greater fetal membrane thickness than did those who delivered at term (1.67 +/- 0.27 mm vs. 1.14 +/- 0.30 mm, P < 0.0001). For the best cut-off indicated by ROC curve analysis (1.2 mm), the sensitivity and specificity for predicting preterm birth were 100% (95% CI, 80.3-100) and 69.5% (95% CI, 61.2-77.0), respectively, and positive and negative likelihood ratios were 3.3 and 0.0, respectively.

CONCLUSION

Sonographic measurement of fetal membrane thickness could be helpful in the prediction of preterm delivery.

Maternal plasma corticotropin-releasing factor (CRF) and CRF-binding protein (CRF-BP) levels in post-term pregnancy: effect of prostaglandin administration

OBJECTIVE

Placental corticotropin-releasing factor (CRF) affects myometrial contractility and the secretion of several uterotonins such as prostaglandins (PGs); however, the activity of CRF is counteracted by CRF-binding protein (CRF-BP). At term and pre-term labor, CRF levels in maternal plasma are highest whereas those of CRF-BP are falling, and the cause of this fall is unknown. Thus, in this study, we investigated the effect of PG administration for labor induction on maternal plasma CRF and CRF-BP concentrations.

DESIGN

Maternal plasma CRF and CRF-BP levels were assayed before and after (2 h later) induction of labor by intracervical administration of prostaglandin E(2) (PGE(2)), and at delivery in a group of healthy post-term pregnancies (n=18). Controls were women at term out of labor (n=22), who subsequently progressed to deliver a healthy singleton baby.

METHODS

CRF was measured by two-site immunoradiometric assay, and CRF-BP was assayed by radioimmunoassay.

RESULTS

Maternal plasma CRF levels were significantly (P<0.0001) lower and CRF-BP significantly (P<0.0005) higher in post-term than in term pregnancies. With respect to induction of labor, 2 mg PGE(2) were sufficient to increase maternal plasma CRF levels at delivery (P<0.005). While 0.5 mg PGE(2) significantly decreased maternal plasma CRF-BP levels at delivery (P<0.001), 2.0 mg PGE(2) significantly reduced CRF-BP concentrations both after 2 h (P<0.05) and at delivery (P<0.0001).

CONCLUSIONS

In the light of the well-known stimulation of prostaglandin release by CRF, these data suggest a positive feedback effect of PGE(2) on maternal CRF release during induced labor.

The detection of anti-β2-glycoprotein I antibodies is associated with increased risk of pregnancy loss in women with threatened abortion in the first trimester

OBJECTIVE

This study was designed to evaluate whether the detection of serum antiphospholipid autoantibodies may be useful in predicting pregnancy outcome in women with threatened abortion in the first trimester.

STUDY DESIGN

A group of 77 pregnant women of between 8 and 12 weeks' gestation with vaginal bleeding was tested for serum antiphospholipid, lupus anticoagulants, anticardiolipin, antinuclear antibodies, and anti-beta2-glycoprotein I antibodies, and was followed up until the spontaneous end of pregnancy. A control group composed of 15 healthy women with uncomplicated gestation was tested contemporarily for the same antibody panel.

RESULTS

Of the 77 patients with threatened abortion, 32 (41.5%) progressed to deliver at term and 45 (58.5%) experienced early pregnancy loss. Among the antibodies evaluated, only anti-beta2-glycoprotein I was significantly more frequent in those women whose pregnancy resulted in spontaneous abortion (22/45, 49%) than in those who progressed to term (6/32, 19%) or in the control group (2/15, 13%; p=0.004). This difference was specific to the IgM isotype (p=0.001). After adjustment by multivariate analysis, the odds ratio for pregnancy loss associated with a positive beta2-glycoprotein I antibody test was 5.18 (p=0.001).

CONCLUSION

The detection of anti-beta2-glycoprotein I antibodies is associated with an increased risk of pregnancy loss in women with threatened abortion in the first trimester.

Placental neurokinin B mRNA expression increases at preterm labor

INTRODUCTION

Neurokinin B (NKB) is a neuropeptide belonging to the family of tachykinins-related peptides that elicits contractility of human myometrial strips in vitro. The present study evaluates whether placental mRNA and peptide expression of NKB change in women at preterm labor.

METHODS

A group of 26 women with singleton pregnancies were enrolled in the study. Placental tissue specimens were collected from pregnant women delivering after elective cesarean section, after labor at term, or after preterm labor. Changes in placental NKB mRNA and protein expression were evaluated by real-time quantitative RT-PCR analysis and by immunofluorescence respectively.

RESULTS

Placental mRNA expression of NKB was significantly higher after term and preterm labor (P<0.001) than cesarean section, and highest after preterm labor. Immunofluorescent staining in placentas from preterm or term labor was more intense than after cesarean section (P<0.001). In particular, NKB protein expression was higher in placentas collected after preterm labor than those collected after term labor.

DISCUSSION

Neurokinin B mRNA and protein are highly expressed in placenta at term and preterm labor; thus, the involvement of this neuropeptide in the events cascade leading to parturition may be suggested.

Secretory endometrium highly expresses urocortin messenger RNA and peptide: possible role in the decidualization process

BACKGROUND

Urocortin (UCN) gene expression and synthesis have been reported in epithelial and stromal cells of the human endometrium. In this study we evaluated (i) UCN messenger RNA (mRNA) expression and peptide production in uterine specimens collected throughout the endometrial cycle, (ii) UCN secretion after decidualization of cultured human endometrial stromal cells (HESCs) and (iii) the effect of UCN on endometrial decidualization.

METHODS

HESCs were isolated from samples of human endometrium collected from healthy patients with normal menstrual cycle and cultured in presence of cAMP, 17-beta-estradiol (E(2)) + medroxyprogesterone acetate (MPA) and UCN. UCN levels were measured in endometrial extracts by an enzyme immunoassay, and changes of endometrial UCN mRNA expression were measured by RT-PCR analysis.

RESULTS

UCN peptide concentrations and mRNA expression were highest in the secretory phase of the menstrual cycle (P < 0.001, late secretory versus early and late proliferative phase) and higher in the late than the early secretory phase (P < 0.01). After decidualization of HESC with cAMP or E(2) + MPA, UCN levels rose in parallel with prolactin concentrations by days 6 (P < 0.01, for all). Finally, the addition of UCN to HESCs, with or without E(2) + MPA, induced the release of prolactin.

CONCLUSIONS

The evidence that (i) UCN is highly expressed in the secretory phase of the endometrial cycle; (ii) cAMP and E(2) + MPA modulate secretion of UCN and (iii) UCN induces HESCs decidualization together suggest a possible role for UCN in endometrial physiology.

Umbilical Cord Serum Activin A Levels are Increased in Pre-eclampsia with Impaired Blood Flow in the Uteroplacental and Fetal Circulation

The aims of the present study were to evaluate the umbilical cord serum activin A concentrations in complicated pregnancies and also to explore the relationship between activin A levels and blood flow velocity in fetal arteries. Umbilical cord blood samples were obtained postpartum after a full term uneventful gestation (control group, n=40), and from pregnancies complicated by gestational diabetes (n=13), preterm labour (n=18), or pre-eclampsia (n=19). Cord serum activin A levels were three-fold higher in pregnancies complicated by pre-eclampsia (1.17+/-0.14 ng/ml, p<0.01) than in the control group (0.43+/-0.03 ng/ml), but were unaltered in the diabetes and preterm labour groups. The pre-eclampsia group had a marked increase of umbilical artery pulsatility index (PI) and also a decrease of middle cerebral artery PI (p<0.01). Furthermore, activin A concentration correlated directly with the umbilical artery PI (r=0.540, p=0.021), with the length of stay in the Neonatal Intensive Care Unit (r=0.857, p<0.001) and also with cord blood pH (r=-0.886, p<0.001). In conclusion, umbilical cord serum activin A levels are increased in the presence of pre-eclampsia and provide an indirect marker of impaired blood flow in the uteroplacental and fetal circulation.

Human placenta and fetal membranes express nerve growth factor mRNA and protein

The present study investigated whether trophoblast, decidua and fetal membranes express nerve growth factor (NGF) mRNA and peptide. Tissue specimens were collected in the first and third trimester of pregnancy from women undergoing voluntary pregnancy interruption (no.= 6; from 8 to 12 gestational weeks) and from women having an elective caesarean section at term (no.= 6; week 39-40 of pregnancy). Using reverse transcriptase-polymerase chain reaction (RT-PCR), trophoblast, amnion/chorion and maternal decidua showed the expression of NGF mRNA both in early gestation and at term. By immunohistochemistry, the immunoreactive NGF was found in the cyto and syncytial trophoblast cells, chorionic mesodermic cells and in decidua. Vessel endothelial cells were stained in maternal compartments, while fetal vessels were unstained. These results, showing the expression and localization of NGF, support the current concept that human placenta is a potent neuroendocrine organ throughout gestation.

High fetal urocortin levels at term and preterm labor

CONTEXT

Placental urocortin has a role in the cascade of events leading to parturition by stimulating myometrial contractility and placental uterotonins secretion.

OBJECTIVE

The objective of this study was to evaluate urocortin levels in maternal and fetal [umbilical cord artery (UCA) and vein (UCV)] plasma at term and preterm labor.

DESIGN

The study design was a controlled cross-sectional study performed from November 2003 to June 2004.

SETTING

This study was performed at the Division of Obstetrics and Gynecology, University of Siena (Siena, Italy).

PATIENTS

Plasma samples were collected at term in the absence of labor (TNL; n = 27; 39.3 +/- 0.1 gestational weeks), at term spontaneous vaginal delivery (TL; n = 24; 40.1 +/- 0.2 gestational weeks), and at preterm labor (PTL; n = 19; 32.4 +/- 0.4 gestational weeks). Changes in urocortin mRNA expression were also evaluated in placentas collected from TNL (n = 11), TL (n = 11), and PTL (n = 10).

INTERVENTION

Urocortin levels were measured by specific RIA. Changes in placental mRNA expression were determined by real-time quantitative RT-PCR analysis.

RESULTS

Maternal and UCA plasma urocortin levels were significantly (P < 0.0001 for all) higher in TL and PTL than in TNL. Furthermore, UCA concentrations were significantly (P < 0.0001 for all) higher than and correlated with maternal concentrations (TNL: r = 0.45; P < 0.05; TL: r = 0.959; P < 0.0001; PTL: r = 0.7719; P < 0.0001). UCV levels were significantly (P < 0.001) higher in TL and PTL than in TNL and were significantly (P < 0.0001 for all) higher than and significantly (P < 0.0001 for all) correlated with maternal values, but were significantly (P < 0.0001 for all) lower than and correlated with UCA values (TNL: r = 0.9548; P < 0.0001; TL: r = 0.927; P < 0.0001; PTL: r = 0.838; P < 0.0001). Placental urocortin mRNA expression did not differ among TNL, TL, and PTL samples.

CONCLUSIONS

Fetal urocortin secretion is increased in term and preterm labor. Whether these changes are a consequence rather than a cause of human parturition remains to be addressed.

Serum fluctuations of total and free tryptophan levels during the menstrual cycle are related to gonadotrophins and reflect brain serotonin utilization

BACKGROUND

Serotoninergic (5-HT) neurons are suggested to regulate estrous cycle in animal models. In the present study we evaluated whether a relationship exists between the serotoninergic precursors in the central nervous system and the gonadotrophin-ovarian cyclic function.

METHODS

We measured 5-HT precursors [free (FT) and total (TT) tryptophan] and LH, FSH and 17beta-estradiol (E2) levels in the serum of 15 fertile women with normal menstrual cycles during the follicular (cycle days 1-5, 7-11), mid-cycle (cycle days 14-16) and luteal (cycle days 17-19, 22-24) phases.

RESULTS

TT and FT were significantly increased in the 7-11 and 17-19 cycle days and were decreased at mid-cycle (P < 0.01), with a cyclic and opposite behaviour when compared to that of FSH and LH. Indeed, correlation analysis through the matrix of mean values showed that LH was negatively correlated to TT (r = -0.636) and FT (r = -0.574), as well as FSH (TT, r = -0.655; FT, r = -0.663), and that TT and FT were positively correlated to each other (r = 0.801; P < 0.001). Furthermore, whilst the two FT peaks reached approximately the same levels in the follicular and luteal phase, TT levels were approximately 30% higher in the luteal than in the follicular phase of the cycle: thus in the first (follicular) phase FT peak was relatively higher than that of TT, whereas the contrary occurred in the second (luteal) phase of the cycle.

CONCLUSIONS

Both TT and FT levels have cyclic variations throughout the menstrual cycle, being lowest at mid-cycle (14-16 cycle days), concomitant with the highest LH and FSH concentrations, and higher before and after mid-cycle phase, coinciding with the lowest circulating LH/FSH levels. Since TT and FT levels in the plasma have cyclic changes, our study: (i) suggests that a consumption of serum serotonin precursors takes place concomitant with gonadotrophin release during menstrual cycle; (ii) may represent an in vivo model to investigate this relationship in women in different physiopathological conditions.

Placental expression of substance P and vasoactive intestinal peptide: evidence for a local effect on hormone release

The present study evaluated vasoactive intestinal peptide (VIP) and substance P (SP) mRNA expressions and the localization of both peptides in first- and third-trimester human placentas. VIP and SP mRNAs were detected by slot blot analysis in first- and third-trimester placental tissues. By immunohistochemistry both neuropeptides were localized in the trophoblast (syncytium and cytotrophoblastic cells) of the chorionic villi. Because little information is available on the role of VIP and/or SP on the secretion of placental hormones, we investigated the effect of these neuropeptides on human chorionic gonadotropin (hCG) and progesterone release from primary cultured human trophoblastic and JEG-3 cells. The addition of increasing doses of VIP resulted in a dose-dependent stimulation of hCG release from cultured human trophoblast and JEG-3 cells. Increasing doses of VIP also dose-dependently stimulated progesterone secretion from primary cultured trophoblastic cells at all time points evaluated and from JEG-3 cells only after 3 h. SP did not affect hCG and progesterone secretion either in cultured human trophoblast or in JEG-3 cells. In conclusion, the present study demonstrates that VIP and SP are mainly expressed in human trophoblasts, and that VIP modulates the in vitro secretion of hCG and progesterone, suggesting a different role in trophoblastic function of the two peptides.

Mutational analysis of the inhibin alpha gene in preeclamptic women

BACKGROUND

Preeclampsia (PE) is a disorder that occurs in at least 5% of pregnancies and affects both the mother and the unborn baby. A dramatic increase of maternal serum inhibin A concentration in the second and third trimester of pregnancy is a common feature of PE and inhibin A measurement may add significant prognostic information for predicting PE in pregnant women.

DESIGN

We evaluated the presence and prevalence of gene polymorphisms for inhibin alpha subunit (INHalpha) in patients affected by PE (no.=50; study group), and in the general population (control group composed of 103 women and 42 men).

METHODS

DNA extraction, single strand conformation polymorphism analysis, DNA sequencing, restriction fragment length polymorphism analysis, and Fisher's exact test were used.

RESULTS

A 769G-->A transition was found in INHalpha1, but not in INHalpha2 or INHalpha3 fragment. This variant was found in 10/145 normal controls (7,6%), and in 1/50 preeclamptic patients (2%), without significant difference between the two groups (p=0.29).

CONCLUSIONS

The prevalence of INHalpha gene variants is not increased in PE. Due to its frequency, the 769G-->A transition may be considered a polymorphism present in the general Italian population.

Inhibins and activins in pregnancy

Human placenta, decidua, and fetal membranes are the major sites of production and secretion of inhibin A and activin A in maternal serum, amniotic fluid, and umbilical cord blood. These tissues also express follistatin-related gene and betaglycan, the binding proteins of activin A and inhibin A, respectively, recently identified. They show a different expression throughout pregnancy, suggesting new functional roles into gestational tissues. The availability of suitable assays for measuring inhibin A and activin A lead us the possibility to investigate their secretion in healthy pregnancy. In addition, several evidences underline the potential role and the clinical usefulness of their measurement in the diagnosis, prevention, prognosis and follow-up of different gestational pathologies such as: threatened abortion, placental tumors, hypertensive disorders of pregnancy, intrauterine growth restriction, fetal hypoxia. The measurement of inhibin A and activin A into the biological fluids of pregnancy will offer in the future further possibilities in early diagnosis, prediction, and monitoring pregnancy diseases.

The measurement of maternal plasma corticotropin-releasing factor (CRF) and CRF-binding protein improves the early prediction of preeclampsia

In the present study we measured maternal plasma concentrations of two placental neurohormones, corticotropin-releasing factor (CRF) and CRF-binding protein (CRF-BP), in 58 at-risk pregnant women consecutively enrolled between 28 and 29 wk of pregnancy to evaluate whether their evaluation may predict third trimester-onset preeclampsia (PE). The statistical significance was assessed by t test. The cut-off points for defining altered CRF and CRF-BP levels for prediction of PE were chosen by receiving operator characteristics curve analysis, and the probability of developing PE was calculated for several combinations of hormone testing results. CRF and CRF-BP levels were significantly (both P < 0.0001) higher and lower, respectively, in the patients (n = 20) who later developed PE than in those who did not present PE at follow-up. CRF at the cut-off 425.95 pmol/liter achieved a sensitivity of 94.8% and a specificity of 96.9%, whereas CRF-BP at the cut-off 125.8 nmol/liter combined a sensitivity of 92.5% and a specificity of 82.5% as single markers for prediction of PE. The probability of PE was 34.5% in the whole study population, 93.75% when both CRF and CRF-BP levels were changed, and 0% if both hormone markers were unaltered. The measurement of CRF and CRF-BP levels may add significant prognostic information for predicting PE in at-risk pregnant women.

Abnormal Umbilical Artery Doppler Waveforms and Cord Blood Inhibin A and Inhibin B Levels

Inhibin A and inhibin B are glycoprotein hormones produced by human placenta and by several fetal organs during pregnancy. They are secreted in maternal circulation in increasing amounts from early until term pregnancy, and in umbilical cord blood levels are significantly lower than in maternal serum and do not differ from mid-pregnancy to term gestation. In the present study, we aimed to determine whether secretion of inhibin A and inhibin B into the fetal circulation is increased in pregnancies complicated by umbilical-placental vascular insufficiency. A group of women (n = 13) with abnormal Doppler umbilical artery flow velocimetry and a group of control women (n = 11) with uncomplicated term pregnancies and normal umbilical artery flow velocity waveforms were studied. In each woman, inhibin A and inhibin B concentrations were estimated in umbilical cord artery and vein. In the two groups of women, mean inhibin A levels did not differ between umbilical cord artery and vein. In addition, no difference was retrieved both in umbilical cord artery and vein values between healthy controls and patients with abnormal Doppler umbilical artery flow velocimetry. On the contrary, inhibin B levels were significantly higher in samples from umbilical cord vein than artery, in both groups of pregnant women (both p < 0.001). However, women with abnormal Doppler umbilical artery flow velocimetry had inhibin B levels significantly higher than healthy controls (p = 0.005) only in the umbilical cord artery, but not in the vein. In the presence of abnormal Doppler umbilical artery flow velocity, the concentrations of inhibin B are increased in the arterial umbilical circulation, suggesting that inhibin B is released from multiple fetal sources as a response to hypoxemic stress. As inhibins may affect the hypothalamus-pituitary-adrenal axis which plays an important role in the mechanisms of adaptations to the post-natal life, inhibin B in fetal circulation might then be beneficial to a fetus whose intrauterine survival is threatened by impaired umbilical-placental blood flow.

Prediction of successful induction of labor at term: role of clinical history, digital examination, ultrasound assessment of the cervix, and fetal fibronectin assay

OBJECTIVE

The purpose of this study was to evaluate whether biochemical (fetal fibronectin assay) or biophysical (cervical assessment by transvaginal ultrasound) tests may have more value than digital examination in predicting successful induction of labor at term.

STUDY DESIGN

The study enrolled prospectively 134 women undergoing labor induction at term caused by several obstetric conditions. All participants submitted to digital examination, fetal fibronectin assay, and transvaginal ultrasound for measurement of the cervical length and detection of funneling. The performance of each test in predicting delivery within 24 hours of labor induction was evaluated. Cox multiple regression analysis was performed to identify, among clinical and laboratory tests, which variables were independently associated with the duration of the latent phase and with the total duration of induced labor.

RESULTS

The likelihood ratios for positive results (predicting that delivery would occur within 24 hours) were 6.61 (95% CI, 1.7-25.8) for a positive obstetric history (previous vaginal delivery), 2.61 (95% CI, 1.6-4.3) for a "favorable" digital examination, 1.41 (95% CI, 0.9-2.2) for a positive fetal fibronectin test, 1.61 (95% CI, 0.9-3.0) for cervical length, and 2.20 (95% CI, 1.1-4.4) for the presence of funneling at transvaginal ultrasound. The likelihood ratios for negative results were 1.81 (1.3-2.5) for obstetric history, 4.34 (2.5-7.7) for digital examination, 1.41 (0.9-2.1) for fetal fibronectin, 1.29 (1.0-1.7) for cervical length, and 1.48 (1.1-2.0) for funneling. On multiple regression, the only variables independently associated with the duration of the latent phase and with the total duration of induced labor were obstetric history and digital examination.

CONCLUSION

Only obstetric history and digital examination predicted accurately vaginal delivery within 24 hours and were independently associated with labor duration. Fetal fibronectin and ultrasound measurements failed to predict accurately the outcome of induced labor.

Increase of enamel fluoride retention by low fluence argon laser in vivo

BACKGROUND AND OBJECTIVES

The aim of this in vivo study was to investigate if argon laser irradiation of enamel can increase the retention of fluoride.

STUDY DESIGN/MATERIALS AND METHODS

Ninety-eight teeth in 12 patients were randomly divided into three groups: (1) EF group: 40 teeth were only treated by fluoride gel (application for 5 minutes followed by 1 minute rinsing with distilled water). (2) EFL group: 40 teeth were treated the same way as in the EF group but they were lased after fluoridation. (3) E group of 18 teeth were kept without any treatment and considered as reference. In order to quantify the fluoride content in the enamel samples, the teeth were analyzed by proton beam delivered by a tandem accelerator (PIgammaE, particle induced gamma-ray emission). The fluoride content of enamel surface is not homogeneous. Therefore, it is necessary to analyze the same enamel area after each treatment. Each tooth was maintained in a fixed tooth holder which was designed to analyze the tooth enamel surface at the same place (1 mm(2) and around 20 mum in depth) after various treatments. A low energy density of argon laser beam was used: 10.74 J/cm(2), 30 seconds of irradiation time and 340 m W of output power.

RESULTS

The results after 7 days showed that the lased enamel still retained 157.4 +/- 23.371 ppm or 42.29% of fluoride after fluoridation process whereas the unlased enamel retained 45.59 +/- 9.377 ppm or 12.25% of fluoride.

CONCLUSIONS

We concluded that the use of argon laser at low energy density (10.74 J/cm(2)) significantly increases the fluoride retention in lased enamel which had approximately three times more fluoride than the unlased enamel.

Human placenta and fetal membranes express follistatin-related gene mRNA and protein

Activin A is a placental glycoprotein and possible biological actions during pregnancy, suggested by experimental data, are the modulation of cytotrophoblast differentiation, placental hormonogenesis and uterotonins secretion. Follistatin-related gene (FLRG) is a 70 amino acids protein which binds activin A with high affinity, and which modulates its biological effects on target tissues by preventing the activin A interaction with its receptors. The present study investigated whether trophoblast, decidua and fetal membranes express FLRG mRNA (by RT-PCR) and peptide (by immunohistochemistry). Tissue specimens were collected at first and third trimester of pregnancy, from patients undergoing voluntary pregnancy interruption (no.=6; from 8 to 12 gestational weeks) and elective caesarean section at term (no.=6; 39-40 weeks of pregnancy). FLRG mRNA was expressed by the various gestational tissues both at early gestation and at term pregnancy. Immunoreactive protein was found in the trophoblast cells, epithelial amniotic and chorionic cells and maternal decidua; nevertheless, the most intense FLRG stain was detected in the walls of decidual and placental blood vessels. In conclusion, FLRG mRNA and peptide are expressed by placenta and fetal membranes. Its different immunolocalization with respect to follistatin and activin A supports a different role for FLRG in modulating activin A actions into gestational tissues.

Inhibin A, inhibin B and activin A concentrations in umbilical cord artery and vein

Activin A and inhibins (A and B) are growth factors expressed during pregnancy by the human placenta, decidua and fetal membranes, and by several fetal organs. They are secreted in both the maternal and the fetal circulations, but the net contribution of the fetus to inhibins/activin A production is still unclear. In the present study we determined whether there was a difference in the serum concentration of activin A, inhibin A and inhibin B between the artery and vein of the umbilical cord. Arterial and venous umbilical cord blood was obtained immediately before elective Cesarean section of 16 term infants from uncomplicated pregnancies. Inhibins and activin A levels were assayed by specific enzyme-linked immunosorbent assays. The paired t-test and linear regression analysis were used to calculate statistical significance. Inhibin A levels did not differ between the artery and vein of the umbilical cord. In contrast, arterial inhibin B levels were significantly (p < 0.001) lower, and activin A concentrations significantly (p < 0.05) higher than the respective venous concentrations. A significant correlation between arterial and venous levels of inhibin A (r = 0.591; p < 0.05), inhibin B (r = 0.749; p < 0.0001) and activin A (r = 0.571; p < 0.05) was found. The present findings suggest that the human placenta is the main source of inhibin B, and the fetus of activin A, in the umbilical cord. In light of the possible roles played by inhibin and activin in erythroid differentiation, protection of neurons against brain injury and modulation of adrenal and pancreatic hormone release, the present data may be of help in evaluating their changes in the umbilical cord when gestational diseases occur.

Maternal serum inhibin A levels are a marker of a viable trophoblast in incomplete and complete miscarriage

OBJECTIVE

From early gestation the human trophoblast secretes large amounts of inhibin A and activin A, and their measurement provides a value for predicting the outcome in women who become pregnant after assisted reproductive techniques. The aim of the study was to investigate the putative role of maternal serum inhibin A and activin A levels as markers of a viable trophoblast in women who miscarry.

DESIGN

Controlled cross-sectional study.

METHODS

One group consisted of 65 healthy pregnant women (controls), progressing to deliver a healthy singleton baby and another group consisted of 54 miscarriages (38 incomplete (27 non-viable, 11 anembryonic pregnancies) and 16 complete). Maternal blood samples were collected between 5 and 12 weeks of gestation.

RESULTS

Serum human chorionic gonadotrophin concentrations in women with incomplete or complete miscarriages were significantly (both P<0.001) lower than in controls; activin A levels being lowest only in women with a complete miscarriage (P<0.001). On the other hand, inhibin A levels were significantly lower in incomplete or complete miscarriage than in controls (both P<0.0001).

CONCLUSIONS

Maternal serum inhibin A, but not activin A, determination reflects the lack of a viable trophoblast in complete miscarriage.

The addition of activin A and inhibin A measurement to uterine artery Doppler velocimetry to improve the early prediction of pre-eclampsia

OBJECTIVE

To evaluate whether the measurement of maternal serum activin A and inhibin A adds any clinically relevant information for the prediction of pre-eclampsia in women with altered uterine artery Doppler velocimetry at 24 weeks of gestation.

METHODS

This was a prospective, controlled, hospital-based study involving 58 asymptomatic pregnant women at 24 weeks' gestation in whom a diastolic notch of the uterine artery waveform was noted at routine Doppler examination. Doppler assessment of the uterine artery waveform and measurement of maternal activin A and inhibin A serum levels by specific two-site enzyme immunoassays were performed. The cut-off points for defining 'high' serum activin A and inhibin A levels for prediction of pre-eclampsia were chosen by receiver-operating characteristics (ROC) curve analysis. The probability of developing pre-eclampsia was calculated for several combinations of results of hormone testing.

RESULTS

Activin A and inhibin A levels were higher in patients who developed pre-eclampsia (n = 18; mean +/- standard error: 2.69 +/- 0.35 ng/mL and 131.2 +/- 22.7 pg/mL, respectively) than in those who did not present with pre-eclampsia at follow-up (n = 40; activin A: 1.79 +/- 0.18 ng/mL and inhibin A: 91.9 +/- 6.2 pg/mL; P < 0.05). Activin A at the cut-off value of 1.7 multiples of the median (MoM) achieved a sensitivity of 61% and a specificity of 89%, whereas inhibin A at the cut-off value of 1.8 MoM combined a sensitivity of 39% with a specificity of 92% for prediction of pre-eclampsia. The probability of pre-eclampsia was 31% in the whole study population, 86% if both activin A and inhibin A were elevated and 17% if both hormone markers were unaltered.

CONCLUSION

The measurement of serum activin A and inhibin A levels may add significant prognostic information for predicting pre-eclampsia in pregnant women showing specific Doppler alterations in the late second trimester.

Pre-eclampsia with fetal growth restriction: placental and serum activin A and inhibin A levels

Activin A (beta A beta A) and inhibin A (alpha beta A) are dimeric glycoproteins secreted from early to term pregnancy in the maternal circulation. They circulate in higher amounts in women with gestational hypertension and/or pre-eclampsia, the most important gestational diseases also causing fetal growth restriction (FGR). Since no data are available in patients with pre-eclampsia and superimposed FGR, by using two-site immunoassays we evaluated serum activin A and inhibin A levels in serum samples collected from: healthy normotensive pregnant controls (n = 42); and women with pre-eclampsia with (n = 19) or without superimposed FGR (n = 21). In addition, by quantitative reverse transcriptase-polymerase chain reaction the changes of alpha- and beta A-subunit mRNA expression in placentas collected from healthy controls (n = 7) and pre-eclamptic pregnancies with (n = 6) or without (n = 6) superimposed FGR was also investigated. Activin A and inhibin A serum levels were significantly higher in pre-eclampsia, and the presence of FGR did not significantly modify these concentrations. Similarly, inhibin-subunit mRNA levels in placentas from pre-eclampsia were significantly higher than in controls, and FGR did not significantly affect this expression. The present data suggest that the increased placental expression of inhibin subunit mRNAs is part of the mechanism leading to increased serum activin A and inhibin A levels.

Corticotropin-releasing factor, urocortin and endothelin-1 stimulate activin A release from cultured human placental cells

Human placenta produces activin A, a glycoprotein belonging to the transforming growth factor beta superfamily, which modulates several placental immune and endocrine functions. However, substances involved in controlling placental activin A production are not yet completely elucidated. The aim of the present study was to investigate the effects of placental products, corticotropin-releasing factor (CRF), urocortin, prostaglandin E(2) (PGE(2)) and endothelin-1 (ET-1) on activin A release from cultured human placental cells. Placental tissue was collected at term from normal pregnancies and a trophoblast-enriched cell preparation was cultured for 48 h. The test substances were applied (concentration from 10(-9)-10(-7)M) and the medium was harvested after 3 h incubation; vehicle-treated cells (controls) were present in each experiment. Activin A concentrations in culture medium were measured by using a specific two-site enzyme immunoassay. The addition of CRF resulted in a dose-related increase of activin A concentrations (P < 0.01). The stimulatory effect of CRF was significantly reversed by alpha-helical CRF(9-41), the CRF receptor antagonist. Urocortin showed a stimulating effect on activin A release from placental cells (P < 0.05) but not dose-related; the effect of urocortin was reversed by an equimolar dose of CRF antagonist, astressin. ET-1 significantly increased activin A concentrations in the culture medium only at the highest concentration, 10(-7)M (P < 0.05). No difference in activin A release was observed after incubating the cells with PGE(2). The evidence that CRF, urocortin and ET-1 stimulate activin A secretion from cultured placental cells suggests that these vasoactive factors may affect the changes of placental activin A secretion in pre-eclamptic woman.

Identification of urocortin mRNA and peptide in the human endometrium

Urocortin is a 40-amino acid peptide belonging to the corticotropin-releasing factor (CRF) family. In human reproductive tissues, urocortin expression has been previously demonstrated in the ovary, in the placenta and fetal membranes and in pregnant uterine tissues, while no data are available on the expression of the peptide in the nonpregnant uterus. In this study, urocortin expression was evaluated by both immunohistochemistry and reverse transcription-polymerase chain reaction, in human uterine tissues and cells at different phases of the menstrual cycle. Urocortin was immunolocalized in endometrial epithelial and stromal cells, as well as in the myometrium, and in vascular smooth muscle cells. No differences between proliferative and secretory phase were observed. These results were confirmed by reverse transcription-polymerase chain reaction analysis of isolated endometrial epithelial and stromal cells, and myometrial specimens. These findings open new questions on the roles played by urocortin in the human uterus.

Uterine and fetal cerebral Doppler predict the outcome of third-trimester small-for-gestational age fetuses with normal umbilical artery Doppler

OBJECTIVE

To assess the value of different admission tests in predicting the outcome of small-for-gestational age (SGA) fetuses with normal Doppler waveforms in the umbilical artery.

METHODS

Criteria for admission into this retrospective study included: singleton pregnancy with a birth weight < 10th centile; absence of severe maternal complications; no evidence of fetal anomalies on the sonogram; normal umbilical artery Doppler; and availability of complete follow-up. At the first antenatal sonogram classifying the fetus as SGA, Doppler analysis of the uterine and middle cerebral arteries was performed and amniotic fluid volume was assessed. Outcome variables included adverse perinatal outcome (perinatal death, severe morbidity) and emergency Cesarean section for fetal distress.

RESULTS

Two hundred and thirty-one pregnancies were included in the study. The mean +/- standard deviation birth weight and gestational age at delivery were 2222 +/- 502 g and 37.3 +/- 2.9 weeks, respectively. In 37 cases (16%), an emergency Cesarean section was performed. There was one intrauterine death and three fetuses delivered by emergency Cesarean section developed severe morbidity. Logistic regression demonstrated that abnormal velocimetry of the uterine arteries and fetal middle cerebral artery were independently correlated with the occurrence of Cesarean section.

CONCLUSIONS

SGA fetuses with normal umbilical artery Doppler waveforms and abnormal uterine arteries and fetal middle cerebral artery waveforms have an increased risk of developing distress and being delivered by emergency Cesarean section. Particularly when both uterine and fetal cerebral waveforms are altered at the same time, the risk is exceedingly high (86%) and delivery as soon as fetal maturity is achieved seems advisable. On the other hand, when both vessels have normal waveforms, the chances of fetal distress are small (4%) and expectant management is the most reasonable choice.

Human placental corticotropin-releasing factor (CRF) in the adaptive response to pregnancy

Several findings suggest a role of placental hormones in the regulation of maternal and fetal physiology during pregnancy. The placenta and its accessory membranes, amnion and chorion, although of fetal origin, actually undertake the role of intermediary barriers and active messengers in the maternal-fetal dialogue. They synthesize, metabolize and serve as targets for numerous hormones and cytokines which control all aspects of pregnancy and parturition. Among these, corticotropin-releasing factor (CRF) has been one of the most investigated in the last decade. The secretion of placental CRF is autonomous, but increasing evidence indicates that maternal or fetal physiological and pathological conditions may influence such secretion. In the event of acute or chronic metabolic, physical or infection stress, the placenta takes part in a stress syndrome by releasing CRF, which may contribute to restore local blood flow, and to influence the timing of delivery. Placental CRF and cytokines produced in case of intrauterine infection may activate labour, thereby helping the fetus to escape from a hostile environment.On the background of maternal and/or fetal stress elicited by a number of pathological conditions, CRF appears to play a role in coordinating adaptive changes in uterine perfusion,maternal metabolism, fluid balance and possibly uterine contractility.

Neuroendocrine effects of raloxifene hydrochloride in postmenopausal women

Raloxifene is a selective estrogen modulator able to exert an estrogen-like action on some target tissues and a specific antiestrogenic action on the uterus and breast. In ovariectomized rats, it has been shown to stimulate the beta-endorphin and allopregnanolone concentrations of the anterior and neurointermediate pituitary lobes, the hypothalamus and the hippocampus. The present study aimed to evaluate, in 12 healthy postmenopausal women, the effect of 60 mg/day raloxifene hydrochloride administration for 6 months on plasma beta-endorphin and allopregnanolone levels, and on the dynamic changes of both beta-endorphin and allopregnanolone secretion after the administration of: (1) clonidine, an alpha 2-presynaptic adrenergic agonist; (2) naloxone, an opioid receptor antagonist; and (3) fluoxetine, a serotonin selective reuptake inhibitor. The administration of raloxifene significantly increased both circulating beta-endorphin and allopregnanolone concentrations, at both the third and sixth months of treatment (p < 0.01). Clonidine, fluoxetine and naloxone administration before therapy was not able to stimulate the release of beta-endorphin, but the response was completely restored after raloxifene administration. Before therapy, clonidine and naloxone tests were accompanied by a significant rise in allopregnanolone secretion; the same changes were observed after raloxifene administration, but with significantly higher allopregnanolone concentrations at each time considered. While the fluoxetine test before therapy failed to increase the release of allopregnanolone, the same test after 6 months of raloxifene administration was characterized by a significant release of allopregnanolone at 60 and 90 minutes. The present data indicate that raloxifene has an estrogen-like effect on neuroendocrine pathways in postmenopausal women.