I. Hypogastric artery ligation for intractable pelvic hemorrhage

OBJECTIVE

To assess the outcomes of bilateral hypogastric (internal iliac) ligation performed to control intractable pelvic hemorrhage and avoid hysterectomy.

METHODS

A review of indications and outcomes for 117 cases of bilateral hypogastric artery ligation over 15 years (1990-2004).

RESULTS

Apart from a slight lesion to the hypogastric vein, no complications were observed. Hemorrhage was effectively controlled in all 37 obstetric cases. In 13 of these cases, the uterus was preserved even when there was cervical pregnancy, placenta previa, placental abruption, uterine atony, and uterine rupture, and 4 women were delivered of mature infants. Hemorrhage was effectively controlled in 41 of 80 gynecologic cases. Prophylactic reduction of pelvic blood flow was the indication for the procedure in 39 cases, 5 of whom involving Jehovah's Witnesses adverse to blood transfusion. The uterus was preserved in only a few of the 41 controlled cases, but one woman (so far) was delivered of a mature infant.

CONCLUSION

Hypogastric artery ligation was found to be indicated if (1) life-threatening pelvic hemorrhage could not be controlled by conservative methods; (2) prophylactic reduction of pelvic blood flow was needed to prevent anticipated hemorrhage; and (3) preservation of reproductive function was desired. The procedure was found to be safe and usually effective and should be taught during obstetric and gynecologic training.

[Pre- and perinatal aspects of hemophilia A and B]

Authors investigate in a retrospective study obstetrical and genetical data in 20 years period of 149 pregnancies of patients turning to genetical counselling because of haemophilia A and B. In case of heterozygote mother there have been fetal determination of sex, and in case of male fetus, there have been DNA examination in 23 of the 35 cases. In case of sick male fetus the couple made a decision on keeping the pregnancy or not, knowing well the genetical risk. Haemophilia A occurred in case of 135 pregnancies (98 pregnancies of 55 heterozygote mothers, and 37 pregnancies from 20 sick fathers). Haemophilia B occurred in case of 14 pregnancies (9 pregnancies of 3 heterozygote mothers, and 5 pregnancies from 4 sick fathers). In case of haemophilia A heterozygote pregnant women there were 32 proven male fetuses, and in 22 cases there have been DNA examinations. In 16 cases there have been artificial abortions (in 10 cases proven disease by DNA examination), and 4 sick male newborns were born from the 16 deliveries (the disease was proven during pregnancy by DNA examination). One male newborn (healthy) was born from the 3 proven male fetuses of haemophilia B heterozygote pregnant women, in 2 cases there have been artificial abortions (in one case on the basis of DNA diagnostics). In cases of heterozygote mothers (haemophilia A and B altogether) the ration of the spontaneous abortions was 13.1%. The rations of the premature deliveries (8.2%) and the Caesarean sections (8.2%) were not higher than the national average. The ration of the bleeding complications during pregnancy was 18.7%, in 2.7% of the cases transfusion was necessary. In case of sickness of the father (in heterozygote female fetuses the haemostasis may change from the fetal side) the ration of the bleeding complications during pregnancy was 18.2%. In connection with delivery, obstetrical bleeding complications occurred in 12.2%, atonia in 2%, abrasion after delivery in 4.1, transfusion in 10.2% in cases both of haemophilia A and B heterozygote mothers. From the neonatological complications in one case there was cerebral haemorrhage, and in one case bleeding from the umbilical stump. (Both newborns were male with haemophilia.) In connection with delivery there was no haematoma developing on the skull of the newborns, there was no need of giving transfusion. In case of sickness of the fathers the ration of the instrumental uterine examination was 6.7%, there were no neonatological and other obstetrical complications.

Apolipoprotein E allele distribution in trisomy 13, 18, and 21 conceptuses in a Hungarian population

Reports documented a higher frequency of apolipoprotein E (apoE) allele epsilon 4 among mothers of children diagnosed with Down syndrome. We studied the prevalence of apoE alleles among 56 conceptuses with trisomy 13, trisomy 18, or trisomy 21. The presence of the 3 most common apoE alleles (epsilon 2, epsilon 3, epsilon 4) was determined by polymerase chain reaction-restriction fragment length polymorphism, and trisomy status was detected by fluorescent polymerase chain reaction followed by DNA fragment analysis and by conventional cytologic methods. We found no significant difference in the distribution of apoE alleles in the group of trisomy 21 fetuses compared with samples from healthy blood donors. The odds of having trisomy 18 for the apoE epsilon 4 group was 3-fold as high as for apoE epsilon 3 allele compared with the healthy control group. Furthermore, a statistically significant association was found for those with trisomy 18 and apoE epsilon 4, while for those with trisomy 13 and apoE epsilon 4, the test showed no significant association. The observed apoE allele epsilon 3 frequencies among patients with Down syndrome and healthy control subjects may help explain and support previous work that did not find high rates of atherosclerosis among these persons. The role of apoE alleles in the development of trisomies needs further study.

Familial association of congenital left heart abnormalities and sustained fetal arrhythmia

Hypoplastic left heart syndrome (HLHS) is the most common cause of death from heart disease in the first week of life. There are reports about familial concordance by presumed morphogenetic mechanisms of abnormal embryonic blood flow with phenotypes of varying severity. The risk of having a child with a left heart lesion after a previously affected child may be as high as 5% to 12%. We present case reports from four families in which sustained fetal arrhythmia (three ectopic atrial tachycardias and one severe bradycardia due to excessive ectopic atrial beats) was demonstrated. Within these four families a close relative of the mother (a previous child, a brother, or a nephew) had severe left heart abnormality (three with HLHS and one with severe aortic valve stenosis). The association of sustained fetal arrhythmia of ectopic atrial origin and severe left heart abnormalities could be expected to occur by chance in a very low percentage of cases. We conclude that sustained fetal atrial ectopic arrhythmia is a congenital abnormality and should be considered as a risk factor for inherited congenital heart abnormalities.

Prenatal detection of trisomy 13 from amniotic fluid by quantitative fluorescent polymerase chain reaction

Prenatal diagnosis of fetal trisomies is usually performed by cytogenetic analysis from amniotic fluid. However, this requires lengthy laboratory procedures, high costs and is unsuitable for large-scale screening of pregnant women. An alternative method, which is rapid, inexpensive and suitable for diagnosing trisomies, even from single fetal cells, is the fluorescent polymerase chain reaction (PCR) using polymorphic small tandem repeats (STRs). In this paper, we present the method of rapid prenatal detection of trisomy 13 from amniotic fluid using fluorescent PCR and two highly polymorphic STRs (D13S258 and D13S631). The results obtained by quantitative fluorescent PCR amplification of fetal DNA were concordant with amniocyte karyotyping results in all cases. Two cases of trisomy 13 were detected from 212 amniotic fluids and the results obtained from D13S631 and D13S258 amplification are presented. In the first trisomy 13 case, a triallelic pattern was detected by both markers, and in the second case, D13 markers showed a characteristic 2:1 dosage allele ratio, both of which demonstrate trisomy 13 status. All other heterozygous disomic samples showed an allele intensity ratio of 1:1.

Central nervous system anomalies

The authors review the most common congenital anomalies of the central nervous system (CNS): neural tube defects (NTDs), ventriculomegaly/holoprosencephaly, hydranencephaly, holoprosencephaly sequence, iniencephaly, and microcephaly. They emphasize the importance of the diagnostic tools (biochemical markers of the maternal serum, ultrasound screening, invasive techniques), methods which are complementary to each other.

[Fetal atrioventricular septal defect associated with Patau and Edwards syndromes, as well as trisomy 22]

The atrioventricular septal defect is usually associated with trisomy 21 and it may be observed in the heterotaxia syndromes. Atrioventricular septal defect may be associated with 8p deletion. There are reported cases of familial atrioventricular septal defect. Atrioventicular septal defect is rarely associated with other chromosomal abnormalities. We are reporting three unusual cases of atrioventricular septal defect that were associated with trisomy 13, 18 and 22. This association may be due to effect of genetic loci on the 13, 18 and 22 chromosome which could play the role in the development and fusion of endocardial cushion and atrioventricular septal defect.

[Severe left heart developmental disorder and severe fetal arrhythmia in the same family--a coincidental association?]

The etiology, pathogenesis and risk for inheritance of congenital heart abnormalities are important questions. The development of fetal echocardiography and fetopathology helped in examination of this problem. Between September 1992 and June 1997 there were found four families where one member of the family had hypoplastic left heart syndrome and other member sustained fetal arrhythmia. The familiarity of hypoplastic left heart syndrome and some special forms of arrhythmias are well known. The reported familial association of these two abnormalities which in the first in the literature, may have a possibility that a sustained ectopic atrial arrhythmias are as severe risk factors for left heart abnormalities as other left heart abnormalities are.

Fetal RhD genotyping by analysis of maternal blood. A case report

BACKGROUND

Prenatal determination of fetal rhesus D (RhD) status is desirable in pregnancies in sensitized, RhD-negative women to prevent hydropic degeneration of the fetus. Recently, a polymerase chain reaction (PCR) test on amniocytes or chorionic villi has been in use to demonstrate the RhD status of the fetus in sensitized pregnancies. A more advisable, noninvasive approach is to determine the fetal RhD group from fetal cells circulating in maternal blood.

CASE

We report on a prenatal diagnosis where RhD-positive cells could be detected from peripheral blood of a sensitized, RhD-negative mother. The presence of an RhD-positive fetus was confirmed by subsequent amplification of fetal DNA obtained by chorionic villus biopsy.

CONCLUSION

In sensitized pregnancies, the number of fetal cells in maternal blood seems to be high enough to be detected by PCR in every case.

Prenatal detection of trisomy 21 and 18 from amniotic fluid by quantitative fluorescent polymerase chain reaction

Prenatal diagnosis of fetal trisomies is usually performed by cytogenetic analysis on amniotic fluid. This requires lengthy laboratory procedures and high costs, and is unsuitable for large scale screening of pregnant women. An alternative method, which is both rapid and inexpensive and suitable for diagnosing trisomies even from single fetal cells, is the fluorescent polymerase chain reaction using polymorphic small tandem repeats (STRs). In this paper we present the preliminary results of a larger study comparing parallel prenatal diagnoses of trisomies 21 and 18 using cytogenetics with quantitative fluorescent polymerase chain reaction using STR markers. The results obtained by the two techniques were concordant in all cases. This is the first study reporting significant numbers of prenatal diagnoses using the quantitative fluorescent polymerase chain reaction. We believe that further studies on greater numbers of samples will determine the absolute reliability of this technique. These results also provide a model for diagnosis of trisomy from single fetal cells isolated from maternal blood.

[DNA-based prenatal diagnosis in epidermolysis bullosa]

Authors report a prenatal diagnosis in a family of Herlitz junctional epidermolysis bullosa with risk of recurrence. The diagnosis in the family was established in the case of the affected older brother using electron microscopy and immunofluorescence microscopy. The underlying mutation was also detected in the gene LAMB3. The affected older brother was homozygous, the parents and one of the siblings proved to be heterozygous carriers for the mutation and the other sibling was genotypically normal. The chorionic villous sample biopsy was carried out in the 11, week of pregnancy in order to extract fetal desoxyribonucleic acid. The previously detected mutation generates new restriction enzyme site, which was tested after the polymerase chain reaction amplification of the exon. Desoxyribonucleic acid samples of the family members and an unaffected unrelated control person were used as controls. The fetus proved to be genotypically normal.

[Prenatal determination of fetal RhD-positivity from the blood of the RhD-negative mother]

It is reported on a prenatal determination of fetal RhD blood group from blood of a sensitized RhD-positive mother at 11th week gestation. The result was confirmed by a subsequent amplification of fetal DNA obtained by chorionic villus biopsy. It is supposed that in sensitized pregnancies the high number of fetal RhD-positive red blood cells in maternal blood is enough to be detectable by polymerase chain reaction.

[Prenatal diagnosis of hemophilia B]

The authors are reporting on the prenatal diagnosis of the X-linked haemophilia B for the first time in Hungary applying the polymerase chain reaction. DNA sequence containing a HhaI restriction endonuclease site close to the factor IX gene was amplified using polymerase chain reaction. The products from polymerase chain reaction were detected on polyacrylamide gel with ethidium bromide staining after the digestion with HhaI restriction enzyme. In the first step of the diagnosis DNA specimen was prepared from chorion derived from a 11th week gestation of haemophilia B carrier mother. The investigation of fetal DNA proved a male fetus. The detection of HhaI polymorphism of the fetus demonstrated the inheritance of the disease causing allele. The parents asked for the termination of pregnancy based on the result.

Risk of recurrence of craniospinal anomalies

The authors analyzed 1,655 situations from their Genetic Counseling Service over a 15 year period where the reason for counseling was craniospinal anomaly (neural tube defects and/or hydrocephalus) in the family. Excluding the obviously monogenically inherited cases, they investigated pregnancies undertaken after 1,285 isolated and 177 multiple forms of craniospinal abnormalities. The recurrence rate of craniospinal defects was found to be 3.66%, which is about ten times higher than the general population risk, supporting the theory of the multifactorial threshold model in the inheritance of these anomalies. The recurrence risks of neural tube defects and of hydrocephalus were 3.47% and 2.95%, respectively. The authors concluded that recurrence risk is mainly influenced by the pathoanatomic severity of the involved anomaly, the degree of relationship, and the number of affected relatives in the family. There is a positive correlation between the pathoanatomic severity of the anomaly in the proband and the offspring. At least in one-half of the cases the same type of anomaly was observed again in the offspring as in the proband. Attention is drawn to the fact that hydrocephalus (ventriculomegaly) is often manifested only in the second half of gestation. Therefore, performing ultrasound examination is strongly recommended not only at the 18th but at the 24th week of gestation, as well in pregnancies with a positive history of neural tube defects and/or hydrocephalus.

[Successful twin delivery following reduction of quadruplet pregnancy]

The authors report first time in the Hungarian literature on multifetal pregnancy reduction: a quadruplet pregnancy was reduced to twins on transabdominal way in the 16th week of gestation on request of the parents. The quadruplets resulted from a forcefully induced ovulation. First weeks of gestation were complicated by a severe but effectively treated ovarian hyperstimulation syndrome. Following the successful and uncomplicated intervention the course of pregnancy was undisturbed, two living healthy babies were delivered in the 35th gestation week. Placentae of the liveborn as well as of the stillborn fetuses were pathologically examined. On occasion of the case report theoretical and practical questions of multifetal pregnancy reduction are discussed in details from indications through technical implementation to a review of legal, ethical and also psychological relations of that intervention. A standpoint for the national practice is also framed by the authors.

Impact of prenatal mid-trimester screening on the prevalence of fetal structural anomalies: a prospective epidemiological study

The objective of this study was to evaluate the effectiveness of the measurement of maternal serum alpha-fetoprotein (MSAFP) at 16 weeks and a subsequent routine ultrasound screening at 18-20 weeks' gestation and the impact on the birth prevalence of congenital structural anomalies in an unselected pregnant population of Hungary in a prospective epidemiological study. A total of 63,794 pregnant women (representing one-sixth of the population of Hungary) were offered this screening program over 3 years (1988-90). Of the pregnant population, 75.7% (48,312) received MSAFP screening and in 81.0% (51,675), at least one ultrasound scan was performed. In the screened pregnancies, 496 craniospinal, thoraco-abdominal, urogenital and other severe major anomalies occurred; 317 were detected at 18-20 weeks (sensitivity 63.1%; specificity 100.0%; positive predictive value 100.0%). The sensitivity of ultrasound scanning was significantly higher (p < 0.05) than that of the MSAFP screening. (At the time of ultrasound scanning the MSAFP value was known.) In this study, the less serious anomalies such as hydrocele, hypospadias and undescended testicle were not systematically searched for, but the birth prevalences were calculated. The overall mid-trimester prevalence of severe plus less severe major anomalies was 2.26%. The birth prevalences of severe major anomalies were 0.57 (craniospinal), 4.36 (thoracoabdominal and urogenital) and 1.21 (other severe) per 1000. These values were lower than the mid-trimester prevalences which were 2.94, 5.20 and 2.06 per 1000, respectively. The prevalence values at the age of 1 year were also calculated (0.36, 2.21, 0.54 per 1000, respectively). We conclude that our screening program with availability of termination of pregnancy could significantly (p < 0.05) reduce the prevalence of severe major abnormalities at birth. Training programs in cardiac scanning are required.

[Prenatal diagnosis of left cardiac abnormality]

We found out of 1500 prenatal cardiac ultrasound examinations very small left heart in 14 cases. Six of the 14 cases were hypoplastic left heart syndrome and eight functional-secondary left heart hypoplasia. The most important signs the echocardiography in cases of hypoplastic left heart are as follow: hypoplasia of mitral valve with or without measurable flow, absence of the anterograde flow through the aortic valve, retrograde flow in the isthmus. In cases of functional left heart hypoplasia the size of the left ventricle, aorta and mitral valves were under the 3rd percentile but there were measurable anterograde flow through the aorta. In eleven cases there were other malformations: hygroma colli, diaphragmatic hernia and omphalokele. The differentiation of the hypoplastic left heart from the secondary left heart hypoplasia has a great importance because of the therapic planning and prognosis.

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

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

[Screening for congenital anomalies in mid-term pregnancy. Prospective epidemiologic study. Fetal trisomy]

The authors have presented their experiences on prenatal screening of fetal trisomies in this second part of a prospective study between 1988 and 1990. They gained their conclusions by processing 63,496 pregnancies during three years. The results show that maternal age plays the most important role in the prenatal screening of fetal trisomies in Hungary. They recommend fetal karyotyping for every pregnant woman aged 35 years or more. They emphasized that using of a combined screening method (i.e. maternal age, serum alpha-fetoprotein, human chorionic gonadotropin, oestriol) is only permissible if the hormonal and cytogenetic laboratory background are provided under standard circumstances. Since these are not available for the vast majority of pregnant women in Hungary they concluded that, at least for the time being, the main criteria for prenatal screening of fetal trisomies is the maternal age. By applying this recommendation 25-30 percentage of Down syndrome fetuses can be detected.

[Screening of congenital anomalies in the mid-trimester of pregnancy. Prospective epidemiologic study. Developmental anomalies]

Authors report about the data of 60,000 pregnant women from three district counties of Eastern-Hungary between 1988 and 1990, on whom both ultrasound and alfa-fetoprotein screenings were performed. They demonstrate the value of this screening for the detection of fetal malformations and for the birth prevalence rate as well. This effective screening-protocol is proposed for a nation-wide application.

[Prenatal diagnosis of cystic fibrosis by mutational analysis]

The authors give a review about the latest method of the prenatal diagnosis of cystic fibrosis. Examples were chosen from their own cases to illustrate the possibilities of the prenatal diagnosis based on the mutation analysis of the CFTR gene. Using both mutation and haplotype analysis, 10 prenatal diagnosis were performed from chorionic villus samples taken in the early stage of the pregnancy (10-12 weeks). There were 5 healthy and 5 affected fetuses found. The advantage of this method, that in certain cases, diagnosis is available for families having no live affected child.

[Fetal growth rate and its variations 1988/89]

Considering that the last intrauterine growth standards were constructed more than two decades ago, the authors defined the measure of 5, 10, 25, 50, 75, 90 and 95 percentiles of birth weight on the base of Genetic and Obstetric Computer Register of East-Hungary, birth data having epidemiological value in Szabolcs-Szatmár-Bereg, Hajdú-Bihar and Jász-Nagykun-Szolnok counties in 1988-89. From the 36th week of pregnancy the mean values of birth weights between boys and girls, boys and gipsy boys, girls and gipsy girls as well as singular and twin newborn infants differed from each other significantly. Possessing these standards, the clinical judgement and supplying of the various newborn infants can be more exact.

[Experience with chorionic villi sampling]

The authors discuss their experiences from 412 chorion villus samplings, (CVS), which they have done under four and a half years since 1985. They used eight types of instruments in performing their examinations and each instrument proved to be satisfactory in the gaining of chorion villus samples, suitable for further tests. They also discuss the bacteria found most frequently in the vagina on the basis of the examination and culturing of both vaginal and cervical fluid done prior to 151 CVS examinations and the effective method with which ascending infection can be prevented. They discuss a distributional pattern of their results based on the different indications for the CVS examinations, and the outcome of each of the pregnancies after CVS. In 377 cases they did direct karyotyping, in 30 cases DNA examination and in five cases enzyme determination also occurred.

[A computerized follow up system of obstetric and genetic care]

The authors have implemented and introduced a new filing system representing the complexity of obstetric, genetic and neonatal care for the three counties of the Eastern part of Hungary. Data about the pre-, peri- and postnatal management are supplied by the genetic/teratologic, obstetric, neonatal and pathological units and processed at the Department of Obstetrics and Gynaecology, University Medical School of Debrecen with an IBM compatible AT computer. This computerised registry is based on the personal identification number, so it is easy to handle for storing data about the course and outcome of a large number of pregnancies as well as the detection and follow-up of fetal malformations and genetic diseases. The computer register is suitable for easy and systematic storage of the more than 20 thousand pregnancies screened by both maternal serum AFP and ultrasound including nearly 500 prenatal diagnosis cases per year. When devising the system, the classic parameters of the "revised Tauffer statistics" have been taken into consideration, but the emphasis has been put mostly on the assessment of fetal/infantile health status and the prevention of malformations and genetic diseases. This computerised system greatly facilitates the correct assessment of statistical parameters in related medical fields and provides better possibilities for studying the cause and effect relationship between the efficacy of medical care and perinatal events.(ABSTRACT TRUNCATED AT 250 WORDS)