Maternal and neonatal outcome of preeclamptic pregnancies: the potential roles of factor V Leiden mutation and 5,10 methylenetetrahydrofolate reductase

OBJECTIVE

To investigate the potential perinatal effects of Factor V Leiden mutation and 5,10 methylenetetrahydrofolate reductase C677T polymorphism in preeclamptic women.

STUDY DESIGN

One hundred twenty preeclamptic women (N = 120) and 101 healthy pregnant controls (N = 101) were recruited and evaluated for frequency of Leiden and 5,10 methylenetetrahydrofolate reductase (MTHFR) mutations using polymerase chain reaction (PCR). Perinatal outcomes were then recorded and analyzed for all study participants and their neonates.

RESULTS

Laboratory analysis yielded 22 (18.33%) heterozygous carriers of Factor V Leiden mutation among preeclamptic women and 3 (2.97%) heterozygous carriers among the healthy controls; differences between the two groups were found to be statistically significant [p < 0.001, the relative risk (RR) = 6.17, 95% confidence interval (95% CI) = 1.90-20.02]. Homozygous MTHFR mutations were found in 8 of 120 (6.67%) preeclamptic women and in 6 of the 101 (5.94%) healthy controls evaluated. Among preeclamptic women, episodes of hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome were reported in 7 of 22 (31.81%) of those with Factor V Leiden mutation and in 11 of 98 (11.22%) of those who were negative for the mutation. Group differences were determined to be statistically significant (p < 0.015, RR = 2.83, 95% CI = 1.24-6. 48). Perinatal indicators collected from the two groups included frequency of intrauterine growth retardation, birth weight, and gestational age. No statistically different perinatal outcomes were found between Factor V Leiden positive and negative preeclamptic women. In addition, MTHFR gene polymorphism did not appear to be correlated with the development of preeclampsia.

CONCLUSION

Although the frequency of Factor V Leiden mutation appears to be significantly higher among preeclamptic women, the mechanism of pathogenesis and potential influence on perinatal outcomes is not yet well understood. Relatively high rates of HELLP syndrome among those with Factor V Leiden mutation suggest that this thrombogene mutation may play a significant role in hemostatic system activation. Our results suggest that the role of MTHFR polymorphism and other factors such as folic acid supplementation will require more extensive analysis in controlling worldwide morbidity and mortality associated with this important maternal condition.

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.

Distribution of apolipoprotein(a) isoforms in normotensive and severe preeclamptic women

OBJECTIVE

Preeclampsia is a pregnancy-related disorder constituting one of the primary causes of worldwide maternal and fetal mortality, but despite intensive research its pathogenesis remains unclear. Lipids have been implicated in the development of preeclampsia, although this possible association remains controversial and not yet fully investigated. This study set out to examine the potential association between lipoprotein(a) and the development of severe preeclampsia. The focus of this study was to investigate the potential utility of apolipoprotein(a) isoforms as possible diagnostic markers for identifying women at risk for developing preeclampsia.

METHODS

Study participants included a control group of nonpregnant female volunteers (n = 59), a group of healthy pregnant (normotensive) female volunteers (n = 51), and a group of severe preeclamptic female volunteers (n = 59). Serum lipoprotein(a) concentrations were measured using double-antibody ELISA methods and were found to be 17.0+/-23.6 mg/dl among nonpregnant controls (n = 51), 15.9+/-15.8 mg/dl among healthy pregnant normotensives (n = 51), and 16.2+/-16.7 mg/dl in the preeclamptic group (n = 59). In addition, apolipoprotein (a) isoforms were identified using high-resolution SDS-agarose electrophoresis followed by immunoblotting.

RESULTS

We detected no significant differences between the groups studied in the distribution of isoforms (Chi-square = 1.21, df = 4, P = 0.89); however, in a 1-week interval we detected a 42.2% rise in Lp(a) levels as well as a 67.1% rise in C-reactive protein concentrations among 10 volunteers in the preeclamptic group (median = 9.6; P < 0.05).

CONCLUSIONS

Although the exact mechanism of pathogenesis continues to elude investigators, our results suggest that lipoprotein(a) may act as an acute-phase reactant during preeclampsia. Although our results are preliminary, they are consistent with growing evidence implicating lipids as among those factors involved in the etiology of preeclampsia. Changes in apolipoprotein(a) may be among those important biochemical markers that are found to be useful in the early identification of high-risk women and warrant further study.

Apolipoprotein E gene polymorphism frequencies in a sample of healthy Hungarians

Apolipoprotein E (apo E) has been found to play an important role in lipid metabolism and has been associated with cardiovascular and neurodegenerative conditions. Hungarians have some of the highest rates of cardiovascular morbidity and mortality in the world. This study examines the distribution of apo E alleles and genotypes in a population of healthy ethnic Hungarian blood donors (n = 302). Male (n = 152) and female (n = 150) subjects ranging from 18 to 62 years of age (mean 37.0) were involved. To determine the frequency of apo E alleles, polymerase chain reaction followed by restriction length polymorphism was applied. The analyses of data showed that apo E allele epsilon3 had the greatest frequency in this group (0.807), followed by apo epsilon2 (0.104) and apo epsilon4 (0.087). The highest genotype frequency was found to be epsilon3/3 at 65.2% (n = 197) followed by genotype epsilon3/4 at 15.9% (n = 48), genotype epsilon2/3 at 15.2% (n = 46), genotype epsilon2/2 at 2.3% (n = 7), genotype epsilon2/4 at 1.0% (n = 3) and genotype epsilon4/4 at 0.4% (n = 1). The apo E frequencies found in this study appear to differ from an earlier study of blood donors, where the results are based on apo E phenotyping.

Apolipoprotein E alleles in women with severe pre-eclampsia

This study investigated the frequency of apolipoprotein E (apoE) alleles among women with severe pre-eclampsia. The presence of the three most common apoE alleles (epsilon 2, epsilon 3, epsilon 4) was determined by polymerase chain reaction-restriction fragment length polymorphism in three groups of white women: non-pregnant healthy (n = 101), pregnant healthy (n = 52), and pregnant with a diagnosis of severe pre-eclampsia (n = 54). The frequency of apo epsilon 2 was highest among women with severe pre-eclampsia (16.6%) followed by non-pregnant women (12.9%), and those experiencing a healthy pregnancy (10.6%). The higher frequency of the apo epsilon 2 allele detected among women with severe pre-eclampsia suggests that apoE may play a role in the development of pre-eclampsia.

The impact of mammography quality improvement legislation in Michigan: implications for the National Mammography Quality Standards Act

OBJECTIVES

This study examined the impact of state legislation on mammography quality and access in Michigan.

METHODS

The impact of state legislation was analyzed with respect to utilization, numbers of machines and facilities, and image quality.

RESULTS

The legislation had a positive effect on image quality improvement, had no impact on utilization by women aged 50 years and above, and resulted in few facility closures.

CONCLUSIONS

Michigan's legislative intervention appears to have had a positive effect on efforts to improve mammography quality assurance with implications for other federal and state efforts to achieve quality assurance in health care delivery.

U.S. screening mammography services with mobile units: results from the National Survey of Mammography Facilities

PURPOSE

To investigate elements of mobile facilities for mammography in the United States.

MATERIALS AND METHODS

The prevalence and performance of mobile facilities for mammography in the United States were studied with regard to cost, price, quality assurance, and access. Data were acquired from the National Cancer Institute's National Survey of Mammography Facilities, conducted in 1992.

RESULTS

Of the 1,057 facilities surveyed, 2.4% were identified as mobile and accounted for 3% of mammography examinations performed. All mobile facilities reported accreditation by the American College of Radiology, and 92% were in Statistically Metropolitan Areas. Most were affiliated with community hospitals or private radiology practice and were more likely to be associated with lower fees, convenient operating hours, batch interpretation, and computerized reporting than were their stationary counterparts.

CONCLUSION

Mobile mammography facilities compare favorably with stationary facilities. The use of these mobile units in the United States, however, has been limited.

Accreditation of mammography facilities by the American College of Radiology: results of a national survey

Mammographic screening for the early detection of breast cancer is rapidly becoming an increasingly common practice in the United States. With more than 20 million mammograms estimated to be performed annually by more than 11,000 units, ongoing quality assurance and evaluative programs have gained importance. Recent federal legislative and regulatory efforts augment a patchwork of state mandates establishing or encouraging specific quality control requirements for mammography facilities, personnel, equipment, and radiation exposure. Many of these requirements are based on the American College of Radiology's (ACR) voluntary accreditation program that has been offering facility certification since 1987. The ACR collects and maintains detailed data on the characteristics of accredited facilities; however, little is known about facilities not participating in the ACR program. This article describes national results from the 1992 National Mammography Facilities Survey, a representative sample of 1,057 mammography facilities. We found statistically significant (P < .05) differences between accredited and nonaccredited facilities in type of mammography practices, cost, personnel standards, variables linked to accessibility, and corollary screening practices (availability of breast self-examination instruction and breast physical examination). Other variables showed minor or little variation between accredited and nonaccredited facilities. The results of this study suggest that, although all facilities engage in various components of "good" quality assurance practices, ACR-accredited facilities reported conducting these programs more frequently. Further, despite the substantially increased costs associated with these programs, ACR-accredited facilities reported lower average charges for screening mammograms and were more likely to participate in reduced fee programs.

Cost-effectiveness of breast cancer screening: preliminary results of a systematic review of the literature

There is now considerable concern that universal access to health care within realistic resource constraints requires some sort of cost-effectiveness analysis of given medical procedures and interventions. One such intervention is routine mammographic screening for breast cancer. Here, we report preliminary results from an ongoing project to conduct a systematic and comprehensive review and comparison of the published cost-effectiveness analyses of screening for the early detection of breast cancer. We examine 16 such studies, and compare two studies in detail to explain how differences in assumptions and in consideration of down-stream effects have caused the published results for apparently comparable breast cancer screening programs to span a broad range.

Is screening for breast cancer cost-effective?

As the toll taken by breast cancer continues unabated, screening programs are widely perceived to play a critical role to improve diagnosis and successful treatment. Breast cancer screening programs are increasingly promoted to women; however, the economic implications of mass screening is a subject of much health policy debate. Cost-effectiveness analysis is an economic methodology widely used to inform such decisions, yet there is a dearth of information available on the economic consequences of mass breast cancer screening. The authors evaluated nine breast cancer screening cost-effectiveness studies that are based on computer simulations, observational trial data, or a combination of both. The results of these studies, conducted in the United States and other countries, indicate that the cost-effectiveness of screening for breast cancer generally compares favorably with other expenditures in the health-care field, although screening younger women does not appear to be as favorable. However, there is considerable variability in the methodology used and a need for more comprehensive research in this area.