[The medico-legal value of monitoring of the fetal heart rate during labor]

We show that most litigations against obstetricians have to do with fetal cardiotocography. The experts called upon in this matter are faced with great difficulties mainly because of the variability in the interpretation of the cardiotocogram. The following questions are addressed: can one do without the fetal heart rate recording during labor? What is the relevance of such recording? The issue of the quality and of the storage of the recordings is addressed. So as to avoid the litigations, we suggest to respect "the right practice" which is developed.

Fetal pulmonary artery Doppler waveform: a preliminary report

OBJECTIVE

The study of fetal lung circulation by means of pulmonary Doppler investigation.

METHODS

Pulmonary Doppler ultrasound obtained with color pulsed-Doppler with a 3.5- to 5-MHz probe. Measure of resistance index and pulsatility index.

PATIENTS

47 pregnant women with singleton, between 18 and 39.5 weeks of gestation, were recruited to have pulmonary Doppler ultrasound. Seven fetuses had intrauterine fetal growth retardation (IUGR). Overall, 50 Doppler velocity waveforms were measured.

RESULTS

Resistance and pulsatility index were measured in all patients and at each examination. Resistance index (0.86 +/- 0.03) and pulsatility index (2.46 +/- 0.34) were found to be stable during pregnancy. Pulmonary pulsatility index in IUGR fetuses (2.71 +/- 0.33) were found to be higher than those in normotrophic infants (p = 0.006), whereas no difference was found in resistance index between the same subgroups. Moreover, no difference was found in pulsatility index measurements between preterm small-for-gestational age fetuses and normotrophic fetuses measured between 36 and 39.5 weeks of gestation (2.68 +/- 0.31 vs. 2.49 +/- 0.28).

CONCLUSION

Pulmonary resistance index is not statistically different between normotrophic and IUGR fetuses. In contrast, pulmonary pulsatility index is significantly higher in IUGR fetuses when compared to normotrophic fetuses. Pulmonary Doppler ultrasound should be evaluated in a larger trial and correlation between Doppler measurements and fetal lung maturation should be studied.

Maturation of fetal human neural xenografts in the adult rat brain

Transplantation of human fetal neural cells has been used for several years as a treatment for Parkinson's disease. These therapeutic trials were based on a large number of rat allografts studies, and the species to species extrapolation appeared valid in many respects. One major difference between neurons of various species, however, is their rate of maturation; indeed, human neurons have been proven to grow much more slowly than rat neurons. This has been studied mostly, up to now, at the light microscope level. In an attempt to determine the fine structural correlates of this protracted development and to detail the schedule of morphogenesis and synaptogenesis, human fetal brain stem tissue (at 8 weeks of gestation) was transplanted into a previously lesioned brain area of immunosuppressed adult rats. Transplants, which were allowed to develop for 15 days to 3 months, were analyzed using the electron microscope. At 15 days, small cells containing a large nucleus were surrounded by wide extracellular spaces. At 1 month, grafted neurons displayed a thin rim of cytoplasm and few thin processes. At 2 months, extracellular spaces tended to diminish. Thin processes formed bundles and large processes extended from enlarged neurons. Major changes were observed at 3 months survival as the neuropile filled up with cells and processes and synaptogenesis began. Comparison with a similar ultrastructural study of thalamic rat allografts shows that human cells develop following a pattern similar to that in rat cells but that the duration of each maturation step is largely extended.

[Pulmonary doppler. Early results in normal pregnancies]

OBJECTIVE

The study of fetal lung circulation by means of pulmonary Doppler investigation.

METHODS

Pulmonary Doppler ultrasound obtained with color pulsed-Doppler with a 3.5-5 Mhz probe. Measure of resistance index and pulsatility index.

PATIENTS

Forty seven pregnant women with singleton, between 18 and 39.5 weeks gestation, were recruited to have a pulmonary Doppler ultrasound. 7 fetuses had intra uterine fetal growth retardation (IUGR). Overall, 50 Doppler velocity waveforms were measured.

RESULTS

Resistance and pulsatility index were measured in all patients and at each examination. Resistance index (0.86 +/- 0.03) and pulsatility index (2.46 +/- 0.34) were found to be stable during pregnancy. Pulmonary pulsatility index in IUGR fetuses (2.71 +/- 0.33) were found to be higher than those in normotrophic infants (p = 0.006), whereas no difference was found in resistance index between the same subgroups. Moreover, no difference was found in pulsatility index measurements between preterm small-for-gestational age fetuses and normotrophic fetuses measured between 36 and 39.5 weeks gestation (2.68 +/- 0.31 vs 2.49 +/- 0.28).

CONCLUSION

Pulmonary resistance index is not statistically different between nomotrophic and IUGR fetuses. In contrast pulmonary pulsatility index is significantly higher in IUGR fetuses when compared with normotrophic fetuses. Pulmonary Doppler ultrasound should be evaluated in a larger trial and correlation between Doppler measurements and fetal lung maturation should be studied.

Long-term outcome of unilaterally transplanted parkinsonian patients. I. Clinical approach

Five patients with Parkinson's disease, unilaterally transplanted with foetal mesencephalic cells into putamen (n=1) or putamen and caudate (n=4), were followed throughout a period of 15-36 months after surgery, according to the recommendations of the core assessment programme for intracerebral transplantations (CAPIT). All these patients exhibited an increase in the fluorodopa uptake in the grafted putamen, which was most significant in the first and last patient of the series. Long-term bilateral improvement of skilled hand movements was observed, starting between the third and sixth month after grafting, and confirmed by the statistical analysis of CAPIT timed tests. A mild to moderate effect on the amount of 'off' time and 'on-off' fluctuations was observed, whereas, apart from one case, no other clear effect on gait, walking and speech was found. One patient included in the study, already suffering slight cognitive impairment, clearly exhibited progression of a dementia process after surgery. Daily living activities were clearly improved in only one of the other four patients. At the end of the study period, all patients needed L-dopa therapy at a similar or higher dose than before grafting, but, in most of them, other dopaminergic drugs were reduced or stopped. All patients exhibited bilateral dyskinesias before grafting that were greatly decreased in intensity a few months after surgery. Delayed asymmetrical dyskinesias, occurring on the side displaying the better motor improvement, i.e. contralateral to the graft, were observed in three patients. These results suggest that neural transplants may influence two central mechanisms involved in motor function and the onset of dyskinesias. These effects are likely to occur through complex interactions with the post-synaptic dopaminergic receptors. The occurrence of dyskinesias might simply reflect increased presynaptic storage and release of dopamine. Alternatively, it might, in part, represent some other long-term deleterious effect of the graft. Since PET-scan data indicate that the reinnervation obtained is sub-optimal, it will be of interest to obtain a larger and denser reinnervation of the host striatum and to try, thereafter, to reduce the dose of L-dopa.

Ontogeny of human striatal DARPP-32 neurons in fetuses and following xenografting to the adult rat brain

After a number of reports indicating positive clinical outcome of intrastriatal transplantation of fetal ventral mesencephalic tissue into patients with Parkinson's disease, the time may have come to consider the possibility of using this technique to treat patients with Huntington's disease. On the basis of the available literature, the Network of European CNS Transplantation and Restoration has established a program aiming at defining the optimal conditions for such clinical trials. The present study, conducted within this framework, pursued the goal of providing information concerning the period of striatal neuronal ontogeny in humans, taking into account the technical and legal requirements imposed by the clinical procedure of neural transplantation using human tissue. On this basis, it aimed at establishing a reliable dissecting method for the intrastriatal grafting of human fetal striatal neurons. The ontogeny of medium-spiny neurons within the developing striatum was first studied in a series of human fetal brains, 5 to 10 weeks postconception, using immunocytochemical detection of DARPP-32. Immunoreactive neurons were observed in fetuses at 7 weeks of age and older. They were mostly localized in clusters, packed in the lateral ganglionic eminence. Over a 2-week-long period, DARPP-32 neurons increased in number. Their morphology remained poorly differentiated, however, with small cell bodies, few branched dendrites, and variable intensity of immunostaining. Based on these findings, selective dissection of the lateral ganglionic eminence was carried out. This tissue was stereotaxically implanted into the striatum of immunosuppressed adult rats previously lesioned. Two months postgrafting, DARPP-32 neurons were observed as discrete patches, embedded within areas of essentially DARPP-32-negative tissue. Up to 2 months after grafting, neurons remained poorly differentiated in general, with only a few neurons exhibiting a dense immunoreactivity and long processes. These results indicate that striatal DARPP-32-immunoreactive neurons are present in the lateral ganglionic eminence in fetuses as soon as 7 weeks postconception. The striatal tissue can be dissected out and successfully transplanted. Within the grafts, neuronal differentiation appears to be a very long process, suggesting that many months might be necessary for these neurons to become functionally integrated into an adult host brain.

Microglial chimaerism in human xenografts to the rat brain

Neural tissue from human fetuses is currently used for intracerebral transplantation to treat patients with Parkinson's disease. The development of the human fetal tissue following grafting has been considered mostly, up to now, from the neuronal point of view in xenografts. Very little is known, in contrast, about nonneuronal, glial, or vascular cells in the grafts. Comparison of the data gathered on the development of grafted human neurons with those obtained in comparable studies using rat transplants has demonstrated species-specific features. We have therefore undertaken a series of studies dealing with nonneuronal cells in human-to-rat transplants to reveal other possible species-specificity of the human tissue. This study has, accordingly, been devoted to the immunohistochemical analysis of microglia of host and donor origins in a human to rat xenograft paradigm allowing clear distinction of the origin of the cells. Human neural tissue was transplanted as a cell suspension into the thalamus of adult rats. Amoeboid human microglia were observed in 1-, 2-, and 3-month-old transplants, but their density, already relatively low at the first stage, decreased further over time. Ramified human microglia were only occasional. In sharp contrast, host rat microglia rapidly invaded the transplant in the absence of any sign of necrosis. The rat cells exhibited first an amoeboid morphology but progressed at the later stages toward a more mature, ramified morphology. These results indicate that donor microglia are quite few in number at first and, at least, do not proliferate actively after transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term delayed vascularization of human neural transplants to the rat brain

Human neural transplants are being developed to treat Parkinson's disease. Previous characterization of human transplants focused on neuronal development, while little is known of the interaction between the transplant and its environment, among which blood is of prime importance. We evaluated here the formation of blood vessels in human neural xenografts placed into the brain of rats immunosuppressed with cyclosporin A. Using capillary wall markers, we found that human transplants remain virtually nonvascularized for more than 1 month. Angiogenesis takes place very slowly and the density of blood vessels is still quite poor after 3 months, the fine structure of these capillaries, when they form, is apparently normal. Functional studies indicate that the vascular network formed in the transplant allows blood circulation and exhibits a working barrier to macromolecules. Glucose uptake and consumption and cytochrome oxidase activity are almost undetectable up to 3 months after grafting. These results demonstrate that vascularization is much delayed in human xenografts into the rat brain. This delay is likely to be dependent on the maturation of the transplanted tissue. A dedifferentiation of human endothelial cells cotransplanted with neural cells occurs since histochemical and immunocytochemical markers revealing endothelial cells in the human fetus are not present up to 1 month in the transplant. The origin of this phenomenon is a matter of speculation. How neural cells survive and mature in such conditions are issues of prime interest for the future of human neural grafting.

Bilateral motor improvement and alteration of L-dopa effect in two patients with Parkinson's disease following intrastriatal transplantation of foetal ventral mesencephalon

Several recent reports have suggested that foetal ventral mesencephalic transplants could alleviate motor symptoms in patients with Parkinson's disease. Expectations of future success must be clarified by precise analysis of the extent and limitation of recovery associated with an assessment of function of the graft using [18F]fluorodopa (18F-dopa) PET. Two patients with idiopathic Parkinson's disease, severely impaired despite optimal medication, have been followed 10 and 17 months after stereotaxic unilateral intrastriatal transplantation of neural cells dissociated from human foetal ventral mesencephalon. Analysis of the clinical evolution complied with the protocol established in the 'Core Assessment Program for Intracerebral Transplantation'. Both patients have benefited from the transplantation in their daily activities and in motor timed tests, although they still exhibit parkinsonian symptoms and require L-dopa therapy. This is associated with a gradual increase in 18F-dopa uptake at the site of grafting. There are two major clinical changes: (i) a bilateral motor improvement for the speed of movements (the quality of movements improved almost exclusively on the side contralateral to the graft); (ii) a change in the outcome of the L-dopa treatment as exemplified by a postoperative transient period of heavy dyskinesias and subsequent additive actions of the two treatments. These results confirm that neural transplantation may be useful for patients with Parkinson's disease. The improvement recorded on the side ipsilateral to the graft does not match that observed on the contralateral side and it is proposed that bilateral transplantation may be necessary. The existence of a transient postoperative period of heavy dyskinesias suggests that the patients may benefit from a controlled decrease of L-dopa intake after grafting.

Anti-müllerian hormone in early human development

Anti-müllerian hormone (AMH) is a glycoprotein produced by immature Sertoli cells and responsible for the regression of müllerian ducts in male fetuses. The ontogeny of the hormone in early human development was investigated. While no detectable AMH could be found in female fetal serum, in males, the mean +/- S.E.M. AMH serum concentration was 40.5 +/- 3.9 ng/ml from 19 to 30 weeks (n = 13), and 28.4 +/- 6.1 ng/ml from 30 weeks to term (n = 9). The latter value is significantly different from the mean AMH concentration in serum from boys aged 2 months to 2 years (43.1 +/- 3.7), suggesting that AMH production is sluggish during the perinatal period. The serum AMH concentration of a 46,XX male fetus was in the normal range for males. Using in situ hybridization, AMH transcripts were detected in the testicular tissue of all fetuses from 8 weeks onwards, but not in fetal ovaries nor in the yet undifferentiated gonadal tissue of a 7-week-old fetus bearing male-determining DNA sequences. Together, these data indicate that AMH is a reliable marker for the presence of functional testicular tissue and, as such, may be helpful for the diagnosis of fetal sex, particularly in the presence of sex chromosome abnormalities.

[Retroplacental hematoma and uterine Doppler scan]

The authors studied uterine Doppler findings in four cases of retroplacental hematoma at 26, 30.5, 31 and 37 weeks of amenorrhea. In all cases, the diastolic index was low, and a diastolic notch was present. In three cases, the hematoma was visualised under ultrasound. The literature on the subject confirms that the velocity of the uterine circulation is always abnormal in retroplacental hematoma. This test is therefore fundamental for the detection of clinically incomplete retroplacental hematomas and for determining the pregnancy prognosis in women with a history of vascular problems. Two of our patients received treatment with acetylsalicylic acid at an early stage of a subsequent pregnancy. The uterine Doppler scans carried out during this pregnancy at the same date as during the pregnancy with retroplacental hematoma revealed normal bloodflow velocity. The infants were born at term with normal weight. Uterine Doppler ultrasound is, therefore, an essential prognosis factor for these high-risk patients. In addition, routine performance of a uterine Doppler scan at about 22 weeks of amenorrhea in women in their first pregnancy could be useful, as any abnormal finding might be the indication for preventive treatment with acetylsalicylic acid.

Uterine height and umbilical perimeter curves in twin pregnancies

From previous research, which gave standard curves for the evolution of uterine height and umbilical perimeter according to gestational age in the case of single pregnancies, the authors propose curves which show the variations of these two parameters in twin pregnancies. The observed differences are sufficient to allow a diagnosis of twin pregnancy as soon as the 18th week of amenorrhea. This observation is interesting because, until now, a systematic early B-scan examination has not been performed as a rule.

Intrauterine growth charts for twin fetuses

In addition to centile curves for birth weight and height of single infants, the authors offer similar biometric references for twins derived from a large French data base. The aim of the work is to assist in discovering small-for-date twins. In the actual prenatal environment, the curves show a decrease in the evolution of these growth parameters in comparison with the single pregnancy standards as early as the 30th week of pregnancy.

[Comparative effects of 17 beta-oestradiol and ethinyl-oestradiol on plasma triglycerides in female rats (author's transl)]

Changes in plasma triglyceride levels were observed in female rats after castration and subsequent administration of incremental doses of 17 beta-oestradiol by injection or ethinyl-oestradiol orally. Castration significantly increased blood triglyceride levels and the dose of injected oestradiol which suppressed the effects of castration on vaginal smears and uterine weight also suppressed its effects on triglycerides. However, the oral dose of ethinyl-oestradiol which abolished the effects of castration on the genital tract further increased the levels of triglycerides. Differences in hepatic distribution of the two forms of oestrogen treatment may explain these discordant results.