Effects of nifedipine on endothelial function, assessed by flow-mediated vasodilatation in pregnant patients

OBJECTIVES

To evaluate the endothelial function, through flow-mediated vasodilation parameters from brachial artery test in women receiving nifedipine for acute tocolysis with threatened preterm delivery.

METHODS

In a prospective study in a university-affiliated hospital, each participant served as herself control. We evaluated various parameters of endothelial function in 22 patients between 27 and 33 weeks of gestation with a diagnosis of threatened preterm delivery (TPTD) before and after 48 h of nifedipine treatment. Each patient received 80 mg nifedipine per day. The assessment tool was Brachial artery reactivity test (BART). Primary outcome was flow mediated vasodilation (FMD).

RESULTS

The average participant's age was 27 ± 4.5 years, median gestational age of 28.5 weeks, BMI, kg/m² (mean ± SD) 28.4 ± 3.3. Systolic blood pressure (mmHg) and diastolic blood pressure (mmHg) decreased from 108 ± 6 to 104 ± 5, p < .001 and from 66 ± 4 to 63 ± 4, p < .001, respectively. FMD (%) significantly decrease from 10.8 ± 6.1 to 7.2 ± 4.7, p = .03 prior to and after nifedipine treatment. The basal brachial artery diameter (mm) at rest was (3.19 ± 0.38 versus 3.39 ± 0.49, p = .28) before versus after nifedipine. The largest brachial artery diameter (mm) was (3.54 ± 0.35 versus 3.58 ± 0.44, p = .76) before versus after nifedipine.

CONCLUSIONS

Our results suggest unfavorable changes in FMD probably as a result of nifedipine used for acute tocolysis. Future prospective studies should try to evaluate the safety of acute and maintenance tocolytic therapy with nifedipine on endothelial function in pregnant women.

Impact on pregnancy outcomes of exposure to military stress during the first or second trimester as compared with the third trimester

OBJECTIVE

To compare pregnancy outcomes after exposure to military stress in different trimesters of pregnancy.

METHODS

A retrospective study of medical records of deliveries in the Wolfson (WMC) and Barzilai (BMC) medical centers in Israel between July 2014 and April 2015. All parturients were exposed to military stress for 51 days during pregnancy. Pregnancy outcomes were compared between those exposed to military stress in the first or second trimester, and those exposed in the third trimester. Outcomes were also compared between WMC (a new-onset military stress exposure area) and BMC (a chronic military stress exposure area).

RESULTS

At WMC, women exposed in the first or second trimester (n=2657) had a higher rate of preterm delivery (<37 weeks) as compared with those exposed in the third trimester (n=2037; 214 [8.1%] vs 121 [5.9%]; P=0.005). At BMC, women exposed in the first or second trimester (n=2208) had a tendency toward lower rates of diabetes mellitus (P=0.055) and macrosomia [103 (4.7%) vs 84 (6.3%); P=0.037], as compared with those exposed in the third trimester (n=1337).

CONCLUSION

Exposure to military stress during pregnancy had different impacts on pregnancy outcomes, depending on the time of exposure and whether continuous exposure to stress occurred.

Fetal sex modifies effects of prenatal stress exposure and adverse birth outcomes

Prenatal maternal stress is associated with pregnancy complications, poor fetal development and poor birth outcomes. Fetal sex has also been shown to affect the course of pregnancy and its outcomes. The aim of this study was to evaluate whether fetal sex modifies the association between continuous exposure to life-threatening rocket attack alarms and adverse pregnancy outcomes. A retrospective cohort study was conducted in which the exposed group was comprised of 1846 women exposed to rocket-attack alarms before and during pregnancy. The unexposed group, with similar sociodemographic characteristics, delivered during the same period of time at the same medical center, but resided out of rocket-attack range. Multivariable models for each gender separately, controlling for possible confounders, evaluated the risk associated with exposure for preterm births (PTB), low birthweight (LBW), small for gestational age and small head circumference (HC). In both univariable and multivariable analyses exposure status was a significant risk factor in female fetuses only: PTB (adj. OR = 1.43; 1.04-1.96), LBW (adj. OR = 1.41; 1.02-1.95) and HC < 31 cm (adj. OR = 1.78; 1.11-2.88). In addition, regarding all adverse outcomes, the male-to-female ratio was higher in the exposed group than in the unexposed group. The findings support the hypothesis that male and female fetuses respond differentially to chronic maternal stress.

Prenatal maternal stress predicts cord-blood ferritin concentration

AIM

To examine the relationship between maternal stress in early pregnancy and cord-blood ferritin concentration.

METHODS

The sample consisted of 140 pregnant women who lived in a region that was under rocket attack during a military operation (December 2008 to January 2009). Mothers in the stress group (n=63) were in their first trimester during this period. Mothers in the control group (n=77) became pregnant 4-5 months after the attacks ended. Maternal subjective stress was reported retrospectively. Cord-blood ferritin concentration was compared between stress and control groups, and was the dependent variable in a hierarchical multiple regression analysis.

RESULTS

The mean cord-blood ferritin concentration was lower in the stress group compared to the control group (145.7±62.0 vs. 169.3±85.4 ng/mL, P<0.05). The cumulative distribution of cord-blood ferritin showed a shift to the left for the stress group. Hierarchical multiple regression analysis revealed that maternal subjective stress was a predictor for cord-blood ferritin concentration (hierarchical regression: β=-0.18, P<0.05), especially in the stress group (simple slope analysis: β=-0.32, P<0.01).

CONCLUSION

Maternal stress during the first trimester of pregnancy is associated with lower cord-blood ferritin concentration.

Left atrial function during pregnancy: a three-dimensional echocardiographic study

BACKGROUND

Alteration of diastolic function is considered a sensitive means for detecting changes in the normal cardiac adaptation to pregnancy. Our aim was to evaluate volumetric and functional atrial parameters, using real time three-dimensional echocardiography (RT3DE) in women in early and late third trimester of pregnancy.

METHODS

We studied pregnant women in early third trimester (III-E = gestational age 26-33 weeks), in late third trimester (III-L = gestational age 34-40 weeks), and control nonpregnant women (C). Two-dimensional (2D-Echo) and RT3DE were used to study 3D left atrial (LA) systolic and diastolic stroke volumes and index (LASVI, LAEDVI), emptying fraction, left ventricular and LA cavities.

RESULTS

Although the LA end systolic volume index increased significantly (from 19.42 ± 0.1 to 24.7 ± 3.5 mm(2), P < 0.01), the EF did not change significantly. This was mainly achieved by increasing atrial contraction (A-wave), maintaining cardiac output by increasing heart rate. A decrease in diastolic E-wave, increased atrial kick (A-wave) with reduced E/A ratio, was noted as the pregnancy progressed. Pulmonary pressure increased from 16.9 ± 6.6 to 20.5 ± 2.9 mmHg (P < 0.01), Using 2D-Echo revealed no change in LA diameter from control to III-E and III-L, respectively (from 17.1 ± 2.3 to 16.7 ± 2.6, 17.5 ± 2.2 mm) and area (from 11.7 ± 3.1 to 16.5 ± 2.3, 17.6 ± 1.6 cm(2)). However, using RT3DE, a significant increase in the LASVI, LAEDVI, and LA stroke volume index (from 12.02 ± 2.5 to 14.7 ± 3.2, and 15.1 ± 2.7 mL/m(2)) was detected.

CONCLUSIONS

Enlargement of the LA volume with unchanged blood pressure values, as found using RT3DE, may be part of the adaptation to increased blood volume during pregnancy.

The outcome of patients with stage I endometrial cancer involving the lower uterine segment

The objective of this study was to evaluate whether lower uterine segment involvement (LUSI) correlates with recurrence and survival in women with stage I endometrial adenocarcinoma and whether it is associated with poor prognostic histopathologic features. Three hundred seventy-five consecutive patients with endometrial carcinoma stage I compromised the study population. The patients were divided into two groups according to the presence of LUSI with endometrial carcinoma. The two groups were compared with regard to prognostic factors and outcome measures by using the Pearson χ2 test, log-rank test, and Cox proportional hazards model. LUSI was present in 89 (24%) patients with stage I endometrial carcinoma. LUSI was significantly associated with grade 3 tumor (P= 0.022), deep myometrial invasion (P< 0.0001), and the presence of capillary space-like involvement (CSLI) (P= 0.003). Kaplan–Meier survival curves demonstrated that patients with LUSI had a lower recurrence-free survival (log-rank test; P= 0.009) and a worse overall survival (log-rank test; P= 0.0008). In the Cox proportional hazards model, only a trend toward higher recurrence rate (HR = 2.4, 95% CI 0.7, 8.2; P= 0.16) and a trend toward poorer overall survival (HR = 1.54, 95% CI 0.82, 2.91; P= 0.18) were noted when LUSI was present. In patients with stage I endometrial cancer, the presence of LUSI is associated with grade 3 tumor, deep myometrial invasion, and the presence of CSLI. A larger group of patients is necessary to conclude whether higher recurrence rate and poorer overall survival are associated with the presence of LUSI.

Lymphvascular space involvement compromises the survival of patients with stage I endometrial cancer: Results of a multicenter study

AIMS

To quantify the relative risk associated with lymphvascular space involvement (LVSI) on outcome measures in patients with apparent stage I endometrial cancer.

METHODS

Six hundred and ninety nine consecutive patients with endometrial carcinoma apparent stage I, who underwent surgery in one of four gynecological oncology centers in Israel, comprised the study population. Forty cases with and 659 without LVSI were followed for a median time of 39 months. Recurrence free, disease specific and overall survival was compared between the two groups. The effect of LVSI, adjusted for other clinical and histo-pathological prognostic factors, was assessed by multivariate analysis.

RESULTS

The univariate Kaplan-Meier procedure for survival analysis showed that patients with LVSI had lower recurrence free survival (p=0.0003), worse disease specific (p=0.0007) and overall survival (p<0.0001). Cox proportional hazards model demonstrated a trend toward shorter recurrence free survival (HR=2.0, 95% CI 0.9, 4.5; p=0.08), a worse disease specific survival (HR=2.8, 95% CI 1.1, 7.4; p=0.04) and decreased overall survival (HR=2.0, 95% CI 1.1, 3.8; p=0.03) in cases with LVSI.

CONCLUSIONS

In patients with apparent stage I endometrial cancer the presence of LVSI, an independent poor prognostic factor, is associated with a two fold increased risk of death. The presence of LVSI warrants consideration when deciding upon post operative management.

A radiological study on the anatomical proximity of the ureters and the cervix

In order to evaluate risk factors for anatomical proximity between the cervix and the ureters the distance between the ureters and the cervix was measured in 499 computerized tomography (CT) studies at the most dorsal reflection of the ureters. The relationship between the ureter-cervical distance and the presence of pelvic pathology was assessed by correlation tests and regression analysis. Of the 499 CT studies, 252 demonstrated radiographic pathologies. Among abnormal scans, 126 (50%) involved cervical pathology. At least one ureter was within 0.5 cm of the cervix in 3.6% of patients with normal CT scans and in 10.3% of patients with cervical pathology. Overall, the right ureter was significantly closer to the cervix than the left (2.0 +/- -0.8 cm vs. 2.2 +/- 1.0 cm, p < 0.05). In cases were the pathology was limited to the cervix, the right ureter was more distant than the left (2.0 +/- 0.6 cm vs. 1.7 +/- 0.6 cm, p < 0.05). The distance between the ureters and the cervix was inversely correlated with the lateral diameter of the cervix (r = 0.18, p < 0.001) and its anterior-posterior diameter (r = 0.11, p < 0.001). Age did not correlate with the distance of the ureters from the cervix (r = 0.002, p = N.S). In conclusion, approximately 10% of patients with cervical pathology can be expected to have a ureter proximate less than 5 mm from the cervix. For patients with cervical pathology undergoing a planned hysterectomy, preoperative measurement of cervical-ureteric distance may be warranted. In these circumstances intra-operative measures to protect the ureter and ascertain its integrity may be invaluable.

Perioperative Predictors of Successful Hysteroscopic Endometrial Ablation

OBJECTIVE

To determine which perioperative factors influence the success of hysteroscopic endometrial ablation in patients with menorrhagia.

STUDY DESIGN

A longitudinal study of 128 women who underwent hysteroscopic endometrial ablation or resection. Clinical data included age, uterine size, the presence of intramural or submucosal myomas and polyps, and length of follow-up from initial hysteroscopic ablation to re-ablation or hysterectomy ('failure'). Kaplan-Meier survival analysis, log-rank tests and Cox proportional hazard regression were used to evaluate the equality of survival distributions and to model the overall effects of the various predictor variables on surgical outcomes.

RESULTS

Patients were followed for a median time of 44 months. Thirteen women (10.2%) underwent a second operative procedure. Multivariate analysis identified submucosal myoma as a statistically significant positive predictor of the risk of failure [hazard ratio (HR) 5.22, 95% confidence interval (CI) = 1.63, 16.73)]. Older age was associated with a marginally lower risk of subsequent surgery (HR 0.90 per additional year of age, 95% CI = 0.81, 1.00).

CONCLUSIONS

The presence of submucosal myoma increases the risk of subsequent surgery in patients undergoing endometrial ablation.

Does gravidity influence the success of in vitro fertilization-embryo transfer cycles?

OBJECTIVE

To evaluate the influence of gravidity on the results of in vitro fertilization (IVF)-embryo transfer (ET) cycles.

PATIENTS AND METHODS

All consecutive women aged <35 years admitted to our IVF unit from January 2002 to December 2004 were enrolled in the study. Only patients undergoing one of their first three IVF cycle attempts were included. Gravidity, ovarian stimulation characteristics, number of oocytes retrieved, number of embryo transferred and clinical pregnancy rate were assessed.

RESULTS

Three hundred and forty-two consecutive IVF cycles were evaluated. One hundred and sixty-one cycles were from nulligravidas and 181 from women with a history of at least one previous clinical pregnancy. Forty-eight (29.8%) clinical pregnancies were observed in the nulligravida group and 56 (30.9%) in the gravida group. There were no differences between nulligravidas and gravidas in causes of infertility, length of ovarian stimulation, peak estradiol and progesterone levels, number of oocytes retrieved, fertilization rate and number of embryos transferred. Gravidas were significantly older (30.4 vs. 27.6 years, p < 0.001) and used more gonadotropin ampoules (36.1 vs. 31.8, p < 0.004) compared with the nulligravidas.

CONCLUSIONS

Patient gravidity has no influence on the likelihood of achieving pregnancy in IVF-ET cycles.

GnRH agonist versus GnRH antagonist in ovarian stimulation: is the emperor naked?

OBJECTIVE

The aim of the study was to evaluate the influence of type of GnRH-analog used during controlled ovarian hyperstimulation (COH) on the outcome of in vitro fertilization (IVF) cycles.

PATIENTS AND METHODS

All consecutive women aged < or = 35 years admitted to our IVF unit from January 2001 to December 2004 were enrolled in the study. Only patients undergoing up to their third IVF cycle attempt were included. Ovarian stimulation characteristics, number of oocytes retrieved, number of embryos transferred, and clinical pregnancy rate were compared between women given GnRH-agonist or GnRH-antagonist during COH.

RESULTS

Four hundred and eighty-seven consecutive IVF cycles were evaluated, 226 in the agonist group and 261 in the antagonist group. A clinical pregnancy was achieved in 93 patients in the agonist group (pregnancy rate 41.2% per cycle) and 66 patients in the antagonist grup (pregnancy rate 25.3%); this difference was statistically significant (p < 0.01). The agonist group also used significantly more gonadotropin ampoules, required longer stimulation, and had higher estradiol levels on the day of human chorionic gonadotropin administration.

CONCLUSION

The midluteal long GhRH-agonist suppressive protocol should be the protocol of choice in young patients in their first three IVF cycle attempts.

Substituting HCG with GnRH agonist to trigger final follicular maturation – a retrospective comparison of three different ovarian stimulation protocols

The study retrospectively evaluated the influence of triggering final oocyte maturation with gonadotrophin-releasing hormone (GnRH) agonist on the outcome of IVF cycles. Four hundred and sixty consecutive women admitted to the IVF unit during a 4-year period were enrolled in the study. Ovarian stimulation characteristics and clinical pregnancy rate were compared between three groups: patients at risk of developing ovarian hyperstimulation syndrome (OHSS), undergoing either the long GnRH-agonist protocol (agonist group) or the flexible multidose GnRH-antagonist protocol who received GnRH-agonist for final oocyte maturation (antagonist-agonist group); and patients not at risk of developing severe OHSS undergoing the flexible multidose GnRH-antagonist protocol who received human chorionic gonadotrophin (HCG) for final oocyte maturation (antagonist-HCG group). Implantation and clinical pregnancy rates were lowest in the antagonist-agonist group despite the fact that no difference were was observed in fertilization rates between the groups. Moreover, the high-responder antagonist-agonist group required shorter stimulation and had higher numbers of oocytes retrieved as compared with the high-responder agonist-group. No case of severe OHSS was observed in the antagonist-agonist group. The use of flexible multidose GnRH-antagonist protocol with GnRH-agonist for final oocyte maturation, in high-responder patients, eliminates the risk of OHSS but results in decreased implantation and pregnancy rates.

Placental pathology in fetal thrombophilia

The aim of this study was to test the hypothesis that placental vascular lesions of the fetal circulation are caused by fetal thrombophilic mutations. The study included 64 newborns of women with one or more of the following pregnancy complications: preeclampsia, placental abruption, and intrauterine growth restriction. The most prevalent inherited thrombophilias--factor V Leiden, factor II (prothrombin) G20210A, and homozygosity for methyltetrahydrofolate reductase C677T--were examined in maternal blood and fetal umbilical cord blood. One pathologist reviewed all of the slides for fetal vascular lesions. Associations between fetal thrombotic vasculopathy and fetal thrombophilia were tested for using Fisher's exact test; Z scores and gestational age were compared using the Student t-test. Fetal thrombophilic mutations were diagnosed in 19 of 64 newborns, 15 of whom had coexistent maternal thrombophilia. There was no statistical difference in the prevalence of thrombotic lesions of the fetal circulation between newborns with and without thrombophilia. The combination of maternal and fetal thrombophilia was also not associated with increased fetal vascular lesions. The results indicate that fetal thrombophilia alone, even in the context of maternal underperfusion, is not associated with fetal vascular lesions of the placenta, although it may represent an underlying risk factor for lesions triggered by other process(es).

Beta-cell protein kinases and the dynamics of the insulin response to glucose

A full biphasic insulin response is the most sensitive index for well-coupled beta-cell signal transduction. While first-phase insulin response is extremely sensitive to potentiating and inhibiting modulations, full expression of second-phase response requires near maximally activated beta-cell fuel metabolism. In the isolated rat pancreas, accelerated calcium entry or activation of protein kinase (PK)-A or PKC result in no insulin response in the absence of fuel metabolism. At submaximal levels of beta-cell fuel secretagogue, arginine (which promotes calcium entry) or glucagon (which activates PKA) produces a small first-phase insulin response but minimal or no second-phase response; carbachol (which activates PKC and promotes calcium entry) generates biphasic insulin response in the presence of minimal fuel (3.3 mmol/l glucose). Glucagon produces full biphasic response in the presence of 10.0 mmol/l glucose, whereas arginine requires near-maximal stimulatory glucose (16.7 mmol) to produce full biphasic insulin response. Thus, PKA and PKC signal pathways potentiate primary signals generated by fuel secretagogues to induce full biphasic insulin response, while calcium recruitment alone is insufficient to potentiate primary signals generated at low levels of fuel secretagogue. We suggest that three families of PKs (calmodulin-dependent PK [CaMK], PKA, and PKC) function as distal amplifiers for stimulus-secretion coupling signals originating from fuel metabolism, as well as from incretins acting through membrane receptors, adenylate cyclase, and phospholipase C. Several isoenzymes of PKA and PKC are present in pancreatic beta-cells, but the specific function of most is still undefined. Each PK isoenzyme is activated and subsequently phosphorylates its specific effector protein by binding to a highly specific anchoring protein. Some diabetes-related beta-cell derangements may be linked to abnormal function of one or more PK isoenzymes. Identification and characterization of the specific function of the individual PK isoenzymes may provide the tool to improve the insulin response of the diabetic patient.

Ocular manifestations in children born after in vitro fertilization

OBJECTIVE

To report the ocular abnormalities found in children born after in vitro fertilization.

METHODS

Forty-seven children (25 girls and 22 boys) born after an in vitro fertilization pregnancy (mean +/- SD birth weight, 2335 +/- 817 g; range, 924-4300 g) and referred for ophthalmic evaluation were included in the study. All underwent a thorough ocular examination. Obstetric history was gathered following a detailed questionnaire with the mothers.

RESULTS

Of 70 eyes among nonverbal children, visual acuity was "normal for age" in 60 (86%), "fair" in 4 (6%), and "poor" in 6 (9%). Visual acuity in 24 eyes in verbal children ranged from 6/6 to no light perception, with 4 (17%) having poor vision. Cycloplegic refraction disclosed an emmetropia in 22 (27%), hypermetropia in 47 (57%), and myopia in 13 (16%) of the eyes. Anisometropia of more than 1.0 diopters was found in 8 children. Major ocular malformations were observed in 12 (26%) of the 47 children. These malformations included Coats disease, congenital cataract, congenital glaucoma, hypoplastic optic nerve head, idiopathic optic atrophy, coloboma with microphthalmos, and retinoblastoma.

CONCLUSIONS

Ocular anomalies were frequently observed in this cohort of offspring born after in vitro fertilization. A diligent and prospective prenatal search for such malformations should unveil the real prevalence of ocular malformations in children born after in vitro fertilization.

Expression of gelatinase B by trophoblast cells: down-regulation by progesterone

OBJECTIVE

It is now accepted that gelatinase B (92 kd type IV collagenase) is involved in blastocyst implantation and trophoblast invasion. However, little is known about the regulation of this enzyme at the fetomaternal interface. Progesterone has been demonstrated to inhibit gelatinase B secretion from endometrial cells, myometrium, and cervical fibroblasts. Interestingly, the promotor of gelatinase B contains a progesterone-responsive element that may explain transcriptional activation of this metalloproteinase by progesterone. It may be hypothesized that progesterone secreted from trophoblast cells, representing the fetal part of the fetomaternal interface, may have a role in the regulation of gelatinase secretion and blastocyst implantation.

STUDY DESIGN

To this end, use was made of first-trimester trophoblast cells obtained from first-trimester pregnancy terminations. The trophoblast cells were separated by trypsin degradation and fractionation on Percoll gradients. Metalloproteinase activity was measured by zymography, and the expression of the gelatinase B messenger ribonucleic acid was determined by the solution hybridization/ribonuclease protection assay.

RESULTS

Primary cell cultures of trophoblasts from first trimesters of pregnancy constitutively elaborated two species of type IV collagenases (gelatinase A and B) as assessed on a gelatin matrix. Treatment with progesterone decreased the accumulation of a gelatinase B species in a dose-dependent fashion. Administration of a progesterone receptor antagonist onapristone (ZK-98.299) neutralized the progesterone inhibitory effect on the gelatinase B in a dose-dependent fashion, thus supporting the presumption that the progesterone effect is receptor mediated. Progesterone significantly attenuated the expression of gelatinase B by trophoblast cells, an effect that was neutralized by ZK-98.299.

CONCLUSION

These observations provide strong indirect support for the participation of progesterone in the regulation of gelatinase B in trophoblast cells. It may be an important regulator of gelatinase production at the fetomaternal interface.

Transcriptional regulation of human placental corticotropin-releasing factor by prostaglandins and estradiol

The mechanism of labor initiation in humans has not been completely elucidated. Prostaglandins, estrogens, and corticotropin-releasing factor (CRF) have all been shown to affect uterine myocytes and enhance uterine contractility. There are also indications that these uterine regulators have additional effects on other sites involved in labor and that they may act in concert or, perhaps, by regulating each other. Therefore, we evaluated the CRF promoter for transcriptional regulation by prostaglandins and estrogens. Human placental choriocarcinoma cell lines were transfected with CRF-luciferase reporter genes and treated with prostaglandins. Prostaglandin E2 (PGE2), but not prostaglandin F2alpha (PGF2alpha), stimulated CRF-luciferase expression in choriocarcinoma cell lines via a cAMP-dependent pathway. A combination of transfections and in vitro binding studies tested for potential regulation of CRF by estrogen receptor (ER). ER neither regulated the CRF promoter nor interacted with steroid response half-sites from the CRF promoter. Our results provide a molecular regulatory link between PGE2 and CRF, two compounds that enhance uterine contractile function. Combined with the stimulation of prostaglandin release by CRF, these data support a potentially important "feed-forward" regulatory loop involving CRF and PGE2 in parturition. In contrast, we found no evidence for direct effects of estrogens or PGF2alpha on CRF transcription.

Congenital heart defects: natural course and in utero development

BACKGROUND

Most congenital heart defects (CHDs) are diagnosed on targeted prenatal transvaginal (TVS) or transabdominal (TAS) ultrasonography during the early second trimester or at midgestation. Nevertheless, delayed diagnosis in some cardiac malformations still remains despite detailed echocardiographic examination. The present study was conducted to evaluate the evolution of fetal cardiac anomalies and assess their development in utero.

METHODS AND RESULTS

We retrospectively reviewed 22,050 pregnant women who were divided into two groups: 6924 who had initial TVSs at 13 to 16 weeks' gestation, followed by TASs at 20 to 22 weeks, and 15,126 who had initial TASs at 20 to 22 weeks. Both groups were subsequently examined in their third trimester. All newborns were examined by certified pediatricians. CHD was diagnosed in 168 babies: 66 in group A and 102 in group B. In group A, 42 malformations (64%) were detected at the first TVS examination, and 11 (17%) were found during the subsequent TAS. Three additional anomalies (4%) were found during the third trimester, and 10 malformations (15%) were detected postnatally. In group B, 80 malformations (78%) were detected in the initial examination at midtrimester, and an additional 7 (7%) were found in the third trimester, whereas 15 (15%) were diagnosed postnatally. The 10 anomalies (group A, n=3; group B, n=7) that were detected only during the third trimester comprised aortic stenosis (n=2), cardiac rhabdomyoma (n=2), subaortic stenosis (n=1), tetralogy of Fallot (n= 1), aortic coarctation (n=1), sealed foramen ovale (n=1), ventricular septal defects (n=1), and hypertrophic cardiomyopathy (n=1).

CONCLUSIONS

Although most fetal cardiac anomalies are detectable early in gestation, some may evolve in utero at different stages of pregnancy.

Cytokine-mediated regulation of type IV collagenase expression and production in human trophoblast cells

The invasive property of trophoblast cells is dependent on the activity of proteolytic enzymes of the metallo- and serine proteases family. Interleukin-1 (IL-1) was found to be involved in the regulation of these proteases in various systems, serving as an important modulator in trophoblast physiology (e.g. induction of hCG beta, cytokines, and others). Therefore, consideration is given in this report to the role of IL-1 in the regulation of metalloprotease activity in human trophoblasts. Human trophoblast cells were isolated from first trimester placentas by trypsin degradation and Percoll fractionation. Primary cell cultures of first trimester trophoblasts constitutively elaborated two species of collagenase type IV (92 and 72 kDa), as assessed in gelatin matrix. Treatment with IL-1 further augmented the 92-kDa type IV collagenase secretion in a dose-dependent manner. Furthermore, IL-1 significantly (P < 0.01) increased 92-kDa collagenase gene expression by trophoblast cells, as determined by solution hybridization/ribonuclease protection assay. Both the increase in gene expression and protein biosynthesis of the 92-kDa collagenase type IV were neutralized by the soluble IL-1 receptor, indirectly suggesting a receptor-mediated response. Interestingly, transforming growth factor-beta a putative modulator of IL-1 induced effects, was shown to induce the 92-kDa collagenase type IV secretion as well. These results provide indirect evidence supporting the idea that IL-1 and transforming growth factor-beta may play an intermediary role in trophoblast invasion at the feto-maternal interface by regulating trophoblast expression of 92-kDa type IV collagenase, a protease of prime importance in trophoblast invasion.

Characterization of intraperitoneal cytokines and nitrites in women with severe ovarian hyperstimulation syndrome

OBJECTIVE

To assess the potential involvement of cytokines and nitrites in the hyperpermeability characterizing the ovarian hyperstimulation syndrome (OHSS).

DESIGN

A controlled clinical study comparing peritoneal fluid (PF) from patients with severe OHSS and from non-OHSS controls.

SETTING

Women hospitalized with severe OHSS in three tertiary medical centers.

PATIENTS

Twelve patients with severe OHSS necessitating paracentesis and 20 non-OHSS controls.

INTERVENTIONS

The criteria for ultrasound-guided paracentesis were tense ascites, hydrothorax, hemoconcentration, or oliguria.

MAIN OUTCOME MEASURES

Interleukin (IL) 1 beta IL-1 receptor agonist, IL-2, IL-6, IL-8, and tumor necrosis factor alpha (TNF alpha) levels in PF were assayed by ELISA; nitrites were measured by the "Griess" reaction. Estradiol and P were determined by RIA.

RESULTS

Ovarian hyperstimulation syndrome patients had significantly higher PF IL-6 (3,523 versus 30 pg/mL), TNF alpha (14 versus 4.2 pg/mL), and IL-8 (1,695 versus 900 pg/mL). In the serum, only IL-6 levels were significantly higher (375 versus 11 pg/mL). Conversely, nitrite levels were significantly lower in PF of OHSS patients (0.5 versus 34 nmol/mL). Interleukin 1 levels were higher and IL-1 receptor antagonist levels were lower in OHSS patients, suggesting potentially increased biologic potency of IL-1.

CONCLUSION

These findings suggest that these substances could be involved in mediating the capillary hyperpermeability characterizing this syndrome.

Interleukin-1 stimulates prostaglandin E production by human trophoblast cells from first and third trimesters

Prostaglandins (PGs) play a major role during implantation and labor, and their level is regulated by various cytokines. Interleukin-1 (IL-1) is a known mediator of prostaglandin E (PGE) production in various cell types, including endothelial, amniotic, and endometrial cells; however, its role in the regulation of PGE production in the trophoblast cells is yet unknown. As IL-1 and PGE are both known to be synthesized in the human trophoblast cells, we examined the possibility that IL-1 regulates PG production in human trophoblast cells. To this end, use was made of first and third trimester trophoblast cells, obtained from first trimester terminations of pregnancies and elective cesarean sections. The trophoblast cells were separated by trypsin degradation and fractionation on Percoll gradients, and cultured for 18 h under serum-free conditions in the absence or presence of IL-1 (10 ng/mL). IL-1 induced a 5-fold increase in PGE production, a response that was cell density, time, and dose dependent. IL-1-induced PGE biosynthesis was prevented in the presence of either IL-1 receptor antagonist or the soluble IL-1 receptor, suggesting a receptor-mediated response. Significantly, de novo production of PGE by trophoblast cells in the absence of IL-1 was also markedly (50%) reduced by either the IL-1 receptor antagonist or the soluble IL-1 receptor, further supporting the notion that IL-1 is involved in PGE synthesis even under basal conditions. Transforming growth factor-beta 1, a putative modulator of the effects of IL-1, significantly attenuated IL-1-stimulated PGE production, supporting the possibility that transforming growth factor-beta 1 may serve as a regulator of the effects of IL-1 in trophoblast cells. These observations suggest a pivotal role of IL-1 in the regulation of PGE economy by trophoblast cells. As trophoblast cells are in intimate contact with maternal cells, understanding the regulation of PGE levels may explain crucial processes at the feto-maternal interface, including implantation of the developing blastocyst, immunosurveilance, and the initiation of labor.

Transvaginal ultrasonography at early pregnancy cannot be used alone for targeted organ ultrasonographic examination in a high-risk population

OBJECTIVE

A study was performed to evaluate whether early second-trimester (13 to 16 weeks) transvaginal scan can be used alone for structure evaluation of the fetus or whether it should be followed by a transabdominal scan performed at 18 to 20 weeks of gestation.

STUDY DESIGN

A total of 536 pregnant women at high risk for birth defects were examined by transvaginal ultrasonography at 13 to 16 weeks' gestation. This was followed by a transabdominal scan at 18 to 20 weeks of pregnancy. Aborted specimens were examined by a pediatric pathologist in terminated pregnancies, and newborn babies were examined by a pediatrician to detect congenital anomalies.

RESULTS

Transvaginal ultrasonography performed at 13 to 16 weeks' gestation identified 42 structural anomalies. Of these, 24 pregnancies were terminated and one fetus died. The other 17 fetuses and the rest of the population underwent a second transabdominal survey at 18 to 20 weeks' gestation, which identified eight structural anomalies that were not diagnosed by the previous examination. In five cases the diagnosed anomaly disappeared. Together, the scans brought about the detection of 41 of 46 abnormal fetuses (89%).

CONCLUSIONS

Because a significant number of birth defects (17.4%) was not detected by early second-trimester vaginal scan, we recommend that whenever early transvaginal ultrasonographic examination is performed it should be followed by a transabdominal scan at the most advanced stage of pregnancy at which an abortion is still feasible.

Clinical relevance of gestational thrombocytopenia of < 100,000/microliters

We identified 22 women with thrombocytopenia of < 100,000/microliters found incidentally during pregnancy and prospectively monitored their platelet count and clinical outcome for a minimum of 6 months postpartum. During the study period, four women became pregnant twice, accounting for a total of 26 pregnancies. The lowest platelet count during pregnancy was 65,600/microliters +/- 19,400 (mean +/- SD), and at delivery 84,500/microliters +/- 32,300 (P < 0.02). The thrombocytopenia was virtually asymptomatic in all patients during the pregnancy and delivery, whether vaginal or surgical. Neonatal platelet counts (n = 18) were normal (270,700/microliters +/- 69,900), and none of the newborns (n = 24) had a bleeding diathesis. Normalization of the platelet count (i.e., > 150,000/microliters) was documented in 18 patients within 1 month postpartum, in five within 3 months postpartum, and in two as late as 5 months after delivery. One woman did not recover from the thrombocytopenia and eventually developed other stigmata of an autoimmune disease. Long-term follow-up showed recurrence of thrombocytopenia in four patients: three in the context of a subsequent pregnancy and one who developed idiopathic thrombocytopenic purpura. Retrospective analysis of blood counts obtained from 12 previous pregnancies demonstrated thrombocytopenia of a similar degree to the index pregnancy. We conclude that gestational thrombocytopenia of < 100,000/microliters is clinically a benign phenomenon that can recur in subsequent pregnancies and is not accompanied by neonatal thrombocytopenia. In some cases, however, pregnancy-associated thrombocytopenia may be a manifestation of an autoimmune disease with its attendant implications for the neonate. Since the differential diagnosis between the two conditions may be difficult to establish when first encountered during pregnancy, a conservative approach emphasizing careful surveillance and guarded reassurance is justified as long as the platelet counts are > 50,000/microliters.

Simultaneous detection of three common sexually transmitted agents by polymerase chain reaction

OBJECTIVE

Human papillomaviruses, herpes simplex viruses, and Chlamydia trachomatis are very common infections of the genital tract. The purpose of our study was to develop a polymerase chain reaction-based assay for the simultaneous detection of these organisms from a single genital swab.

STUDY DESIGN

To prove the technical feasibility of a simultaneous polymerase chain reaction assay for these organisms, a mixture of deoxyribonucleic acids extracted from cells infected by these three agents was amplified in the same tube with three different sets of primers corresponding to specific regions of the human papillomavirus genome, the herpes simplex virus 1 and 2 genomes, and the Chlamydia trachomatis plasmid, respectively. Then genital swabs from patients with suspected infection by one or more of these agents were assayed by polymerase chain reaction for the presence of herpes simplex virus, human papillomavirus, and Chlamydia trachomatis independently and simultaneously. Most of the samples were analyzed in parallel by other methods: herpes simplex virus by culture., Chlamydia trachomatis by culture and antigen staining, and human papillomavirus by the filter in situ hybridization method.

RESULTS

Analysis of the polymerase chain reaction products amplified from the deoxyribonucleic acid mixture revealed three bands corresponding to the respective amplified region of each microorganism. A total of 391 genital swabs were assayed independently by polymerase chain reaction for the presence of herpes simplex virus (113 samples), human papillomavirus (200 samples), and Chlamydia trachomatis (78 genital swabs and four urethral swabs). Forty-nine were herpes simplex virus positive (47 by culture), 45 were human papillomavirus positive (43 by filter in situ hybridization), and one sample was positive for Chlamydia trachomatis, both by polymerase chain reaction and by culture. Ninety-two of the 391 samples were analyzed simultaneously by polymerase chain reaction for the presence of the three agents. The correlation between the results obtained independently and simultaneously was of the order of 100%: 29 were positive for herpes simplex virus, 16 were positive for human papillomavirus, and one was positive for Chlamydia trachomatis, in one sample we could detect both human papillomavirus and herpes simplex virus.

CONCLUSIONS

The polymerase chain reaction simultaneous assay is a quick and efficient way of detecting herpes simplex virus, human papillomavirus, and Chlamydia trachomatis from a single genital swab. This method can greatly simplify the diagnostic procedures in the laboratory.

Developmental regulation of the expression of 72 and 92 kd type IV collagenases in human trophoblasts: a possible mechanism for control of trophoblast invasion

OBJECTIVE

During early pregnancy fetal cytotrophoblast cells invade the uterus and penetrate the basement membrane, a property that is characteristic of malignant cells. However, unlike tumor invasion, trophoblast invasion of the uterus is under strict control. This control limits invasion, so that it primarily remains confined to the endometrial aspect of the myometrium and continues only until midgestation. The invasive properties of the trophoblast cells are made possible by the activity of proteolytic enzymes that belong to the metalloproteinases and serine proteinases. Type IV collagenase (metalloproteinase) is considered crucial in the extracellular matrix remodeling that takes place during the invasion process. In this study we set out to characterize the invasive properties of trophoblast cells at different stages of pregnancy.

STUDY DESIGN

Human trophoblast cells were isolated from first- and third-trimester placentas by trypsin digestion and Percoll fractionation and were then cultured under serum-free conditions. The invasive ability of trophoblast cells was determined by the in vitro invasion assay, in which the ability of cells to penetrate an artificial basement membrane was examined. Metalloproteinase activity was measured by zymography, and the expression of messenger ribonucleic acid transcripts of 72 and 92 kd type IV collagenases was examined by reverse transcriptase polymerase chain reaction.

RESULTS

First-trimester trophoblasts were 3.5 time more invasive in vitro than were third-trimester trophoblast cells (p < 0.005). Although first-trimester trophoblasts secreted both species of type IV collagenase, 72 and 92 kd, in large amounts, third-trimester cells secreted the 92 kd and only minimal amounts of 72 kd type IV collagenase. Moreover, first-trimester trophoblasts secreted significantly more (p < 0.05) 92 kd type IV collagenase than did third-trimester trophoblast. The messenger ribonucleic acid transcript expression of 72 and 92 kd type IV collagenases correlated with the activity of these enzymes secreted by first- and third-trimester trophoblasts.

CONCLUSION

The described high in situ invasive capacity of first-trimester trophoblast might be explained by the increased expression and production of 72 kd type IV collagenase and the higher expression of 92 kd type IV collagenase by first-trimester trophoblast cells.

Monosomy 8q: prenatal diagnosis and autopsy findings

The autopsy findings of a fetus with deletion of the long arm of chromosome 8 are described. Many of the features are similar to those of the tricho-rhino-phalangeal syndromes, types I and II, which are associated with deletions on chromosome 8q24. Other findings in this case, such as total absence of the corpus callosum and intestinal malrotation, have not been described in these syndromes. Genes involved in the development of the latter malformations may reside in adjacent regions on the long arm of chromosome 8. An elevated serum level of beta human chorionic gonadotropin (beta hCG) was found during pregnancy. This aberration should be included with other chromosomal disorders which may be detected by this test.

Continuous determination of umbilical artery flow parameters during fetal bradycardia using computerized analysis of Doppler wave forms

Umbilical artery flow curves were obtained by Doppler ultrasonography before, during, and after episodes of fetal bradycardia in the active stage of labor in 6 women. Between 126 and 1,607 Doppler wave forms were analyzed for each patient. During the periods of bradycardia all the umbilical artery resistance flow parameters increased (p < 0.00001). The increase in resistance did not precede the change in heart rate. This study presents an accurate and reproducible method for continuous evaluation of the changes in the impedance of fetal blood flow during fetal heart rate changes, thereby enabling detailed assessment of circulatory disturbances occurring during labor and delivery.

[Adverse effects of tamoxifen on the female genital tract]

Tamoxifen is an established adjuvant therapy for breast cancer. It exerts both estrogenic agonist and antagonist effects on target tissues. Since the use of tamoxifen is expanding, it is expected that more women will suffer from its side-effects. 3 women aged 48, 48, and 65, respectively, who were treated with tamoxifen, were referred for evaluation of possible side-effects. They had, respectively, endometrial hyperplasia, a unique sonographic appearance of the endometrium resembling neoplasia, and an ovarian cyst.

The regulatory role of tri-iodothyronine on the production of alpha-fetoprotein and albumin by mouse fetal liver cells

The purpose of this study was to assess possible effects of tri-iodothyronine (T3) on the production of alpha fetoprotein (AFP) and albumin by mouse fetal liver cells. AFP from serum-free conditioned media of TIB73 mouse fetal liver cells was measured by immunoradiometric assay and albumin was measured by chromogenic assay. The expression of mRNAs was quantified by Northern blotting analysis. A marked inhibition of AFP secretion was found as well as an increase in albumin produced by T3 in a dose-dependent manner. The effects of T3 AFP and albumin secretion paralleled the effects of T3 on the steady-state expression of mRNAs encoding albumin and AFP. These data may point to a possible role of T3 in the transcriptional switch from AFP to albumin during fetal development and may explain the observation of high levels of AFP in cases of congenital hypothyroidism.

Intrauterine device failure: relation to its location within the uterine cavity

OBJECTIVE

To investigate the possible role of position of the intrauterine device (IUD) in accidental pregnancies.

METHODS

We examined the location of the IUD in 97 normal women 45-60 days post-insertion, and in 25 pregnant women with the device in situ.

RESULTS

A cervically located IUD was identified in seven of 97 women (7.2%) after insertion and in 13 of 25 pregnant women (52%) with the device in situ. The odds ratio for a woman with an intracervical IUD to be pregnant compared with a woman with an IUD in the uterus was 13.93 (95% confidence limits 4.13-48.96). Sonographic follow-up of the pregnant women revealed no change in IUD location during early gestation.

CONCLUSIONS

We suggest that cases of failed contraceptive action of the IUD may be secondary to a malpositioned device. A sonographic survey can identify displaced devices. Reinsertion of the IUD in such cases is recommended.

The role of abnormal fetal heart rate in scheduling chorionic villus sampling

OBJECTIVE

To assess the value of fetal heart rate (FHR) measurements in predicting spontaneous fetal loss in pregnancies scheduled for chorionic villus sampling (CVS).

DESIGN

A prospective descriptive study.

SETTING

Two hospital departments of obstetrics and gynaecology in Israel.

SUBJECTS

114 women between 9 and 11 weeks gestation scheduled for chorionic villus sampling (CVS).

INTERVENTIONS

Fetal heart rate was measured by transvaginal Doppler ultrasound and compared with a monogram established from 75 fetuses. Whenever a normal FHR was recorded, CVS was performed immediately.

RESULTS

106 women had a normal FHR and underwent CVS; two of these pregnancies ended in miscarriage. In five pregnancies no fetal heart beats could be identified and fetal death was diagnosed. In three pregnancies an abnormal FHR was recorded and CVS was postponed; all three pregnancies ended in miscarriage within 2 weeks.

CONCLUSION

Determination of FHR correlated with crown-rump length could be useful in predicting spontaneous miscarriage before performing any invasive procedure late in the first trimester.

Fetal middle cerebral artery blood flow during normal active labour and in labour with variable decelerations

OBJECTIVE

To assess the distribution of fetal blood flow impedance of the umbilical and middle cerebral artery in active uncomplicated labour and in labour complicated by variable decelerations.

INTERVENTIONS

Blood flow impedance of the umbilical and fetal middle cerebral arteries was assessed by means of pulsed Doppler ultrasonography and measured by the resistance index (RI) and the systolic/diastolic ratio.

SUBJECTS

35 women at 38-40 weeks gestation admitted to, or monitored in the intrapartum unit. One group of 25 women had a normal active labour, the second group of 10 women were in active labour with moderate variable decelerations. A control group of 25 women--healthy pregnant women at term but not in active labour. All three groups were comparable for maternal age and parity.

SETTING

Hospital department of obstetrics and gynaecology, Israel.

DESIGN

A prospective descriptive study.

RESULTS

There was a 40% reduction in middle cerebral artery blood flow impedance in the two groups of women in active labour compared with the control group. Umbilical blood flow did not differ significantly between the three groups. Fetal middle cerebral blood flow impedance in labour was not significantly different in uncomplicated labours and those complicated by fetal heart rate decelerations.

CONCLUSIONS

During active labour, mechanisms that may be unrelated to low fetal blood oxygen content reduce fetal brain blood vessel impedance.

Primary fibrinogenolysis complicating second trimester placental separation

We present a case of second trimester placental separation complicated by severe bleeding diathesis. Primary fibrinogenolysis is suggested as the cause of the coagulopathy.

The effect of ethinyl estradiol on endometrial thickness and uterine volume during ovulation induction by clomiphene citrate

OBJECTIVE

To assess the deleterious effect of clomiphene citrate (CC) on the development of the endometrium and its improvement by the addition of ethinyl estradiol (E2). PARTICIPATING PATIENTS: Infertility-treated patients, monitored for induction of ovulation or timing of insemination (control group).

DESIGN

We studied four groups of women during an ovulatory cycle with various treatment schedules. Group 1: untreated patients; group 2: patients treated by CC; group 3: patients treated by CC + ethinyl E2; group 4: patients treated by human menopausal gonadotropin. Follow-up of the patients was done by vaginal ultrasonography and measurements of blood E2.

RESULTS

In the group treated by CC, both endometrial thickness and uterine volume growth during the follicular phase were lower as compared with untreated controls and menotropin-treated patients. The addition of ethinyl E2 to these patients reversed this deleterious effect of CC without interfering with ovulation.

CONCLUSION

Ethinyl E2 may reverse the deleterious effect of CC on endometrial development during the follicular phase.