Clinical associations of striae gravidarum

Striae gravidarum are a common finding in the abdominal skin of pregnant women. This study of 128 pregnant women examined factors which are associated with their occurrence. It is clear that women with higher body mass indices have more striae and that striae are also more common in younger women. These findings may be explained by the greater degrees of stretch applied to the skin in obese women with larger babies, and by changes in skin collagen and connective tissue that are age-related and affect its tendency to tear.

Maternal obesity, length of gestation, risk of postdates pregnancy and spontaneous onset of labour at term

OBJECTIVE

To investigate the effect of maternal body mass index (BMI) on postdates pregnancy, length of gestation and likelihood of spontaneous onset of labour at term.

DESIGN

Retrospective cohort study.

SETTING

Swedish Medical Birth Register.

POPULATION

A total of 186 087 primiparous women (of whom 143 519 had spontaneous onset of labour at term) who gave birth between 1998 and 2002.

METHODS

Mann-Whitney test, one-way analysis of variance, linear regression and single variable logistic regression.

MAIN OUTCOME MEASURES

Postdates pregnancy (>/=294 days or 42(+0) weeks), length of gestation and likelihood of spontaneous onset of labour at term.

RESULTS

About 6.8% of pregnancies delivered postdates. Higher maternal BMI (kg/m(2)) during the first trimester was associated with longer gestation (P < 0.001) as was a greater change in BMI between the first and third trimesters (BMI measured on admission prior to delivery) with mean (SD) gestation at delivery of 280.7 (8.6) and 283.2 (8.6) days for increases in BMI of <2 and >/=10 kg/m(2), respectively. Higher BMI during the first trimester was associated with a lower chance of spontaneous onset of labour at term. Compared with BMI 20 to <25 kg/m(2), the odds ratios (95% CI) for spontaneous onset of labour at term were 1.21 (1.15-1.27) for BMI of <20 kg/m(2), 0.71 (0.69-0.74) for BMI of 25 to <30 kg/m(2), 0.57 (0.54-0.60) for BMI of 30 to <35 kg/m(2) and 0.43 (0.40-0.47) for BMI of >/=35 kg/m(2). Higher BMI during the first trimester (BMI of >/=35 kg/m(2) compared with BMI of 20 to <25 kg/m(2)) was also associated with an increased risk of complications including stillbirth (OR 3.90, 95% CI 2.44-6.22), gestational diabetes (OR 5.61, 95% CI 4.61-6.83) and caesarean section (OR 2.39; 95% CI 2.20-2.59).

CONCLUSIONS

Higher maternal BMI in the first trimester and a greater change in BMI during pregnancy were associated with longer gestation and an increased risk of postdates pregnancy. Higher maternal BMI during the first trimester was also associated with decreased likelihood of spontaneous onset of labour at term and increased likelihood of complications.

Review article: Operating on the obese woman-a review

In this review the authors recognise the growing contribution of obesity to problems in obstetrics and gynaecology. They then focus on methods to reduce complications in intrapartum and gynaecological care particularly in relation to operating on the obese woman. Strategies to reduce surgical morbidity are discussed including consideration of the site of incision, asepsis and reduction in postoperative complications.

Sleep-disordered breathing and upper airway size in pregnancy and post-partum

Sleep-disordered breathing and snoring are common in pregnancy. The aim of this study was to determine whether pregnancy was associated with upper airway narrowing. One-hundred females in the third trimester of pregnancy were recruited and 50 agreed to be restudied 3 months after delivery. One-hundred nonpregnant females were also recruited. Upper airway dimensions were measured using acoustic reflection. Snoring was less common in nonpregnant (17%) than pregnant females (41%; odds ratio (OR) 3.34; 95% confidence interval (CI) 1.65-6.74) and returned to nonpregnant levels after delivery (18%; OR 0.15; 95% CI 0.06-0.40). Pregnant females had significantly smaller upper airways than nonpregnant females at the oropharyngeal junction when seated (mean difference 0.12; 95% CI 0.008-0.25), and smaller mean pharyngeal areas in the seated (mean difference 0.14; 95% CI 0.001-0.28), supine (mean difference 0.11; 95% CI 0.01-0.22) and lateral postures (mean difference 0.13; 95% CI 0.02-0.24) compared with the nonpregnant females. Pregnant females had smaller mean pharyngeal areas compared with post-partum in the seated (mean difference 0.18; 95% CI 0.02-0.32), supine (mean difference 0.20; 95% CI 0.06-0.35) and lateral postures (mean difference 0.26; 95% CI 0.12-0.39). In conclusion, this study confirmed increased snoring and showed narrower upper airways during the third trimester of pregnancy.

The Scottish Perinatal Neuropathology Study-clinicopathological correlation in stillbirths

OBJECTIVE

To examine the neuropathology of fetuses dying before birth, to determine the timing of any brain damage seen and to ascertain clinical associations of pre-existing brain damage.

DESIGN

Population-based observational study.

SETTING

All 22 delivery units within Scotland, 1995-1998.

SAMPLE

All stillborn fetuses > or =24 weeks of gestation excluding those with chromosomal abnormality or central nervous system/cardiothoracic malformation.

METHODS

Clinical detail was collected on all stillborn fetuses. Requests for postmortem included separate request for detailed neuropathological examination. Stillborn fetuses were classified as full term antepartum (normal growth/growth restricted), preterm antepartum (normal growth/growth restricted), intrapartum (full term/preterm), multiple births and stillborn fetuses following abruptions. Clinicopathological correlation attempted to define the timing of brain insult. Placentas were examined for each case where available.

MAIN OUTCOME MEASURES

Presence of established and/or recent brain damage. RESULTS Clinical details were available for 471 stillborn fetuses, and detailed neuropathology was possible in 191 cases. Of these 191, 13 were multiple births, 9 died following abruption, 12 were intrapartum deaths and 157 were antepartum stillborn fetuses (99 preterm and 58 full term). Recent or established brain damage was seen in 66% of the entire cohort. Thirty-five percent of all cases showed well-established hypoxic damage predating the last evidence of fetal life, and this was more common in preterm fetuses (P = 0.015), those fetuses with evidence of recent damage (P < 0.001), in pregnancies complicated by pregnancy-induced hypertension (P = 0.044) and those in whom the placenta was <10th centile (P = 0.002).

CONCLUSIONS

Brain damage is commonly seen in stillborn infants, and in around one-third of cases, damage predates the period immediately before death. Factors suggesting suboptimal placental function are associated with such damage. Early identification of placental impairment may lead to improved pregnancy outcome.

Mannan binding lectin concentration and risk of miscarriage

Recurrent miscarriage is associated with low concentrations of mannan-binding lectin (MBL), but it is not known below which value relative MBL deficiency becomes a significant risk factor. The sera of 397 patients (male and female) suffering from recurrent miscarriage and 376 controls were assayed for MBL and the data analysed. It was found that the lower the cut-off value, the greater the statistical strength of the association. It was concluded that only MBL concentrations </=0.1 microg/ml were clinically significant in this context. A corollary of this conclusion is that genotyping for point mutations in the structural gene for MBL would be a much less sensitive means of identifying couples at risk of experiencing recurrent miscarriage.

Attitudes of general practitioners to screening for cystic fibrosis

OBJECTIVE

To ascertain the views of general practitioners (GPs) about screening for cystic fibrosis. To find out whether and under what conditions they might play a part in the delivery of such programmes.

SETTING

All GP practices within the Lothian Health Board area.

METHODS

A self administered questionnaire was sent to each of the 532 GPs in the area.

RESULTS

334 (63%) GPs participated in the study. Only 23% of these claimed to have no professional or personal experience of the disorder. 77% of GPs were aware of the existence of a programme of antenatal screening for cystic fibrosis (CF), which had been running in Edinburgh for the past six years, with only 2% unfavourably disposed to it. However, when asked to rank CF screening against antenatal screening for spina bifida and Down's syndrome, or cervical and breast screening, 55% gave it the lowest priority. There was fairly equal support for the screening site being an antenatal clinic, a genetic centre, a family planning clinic, or a GP surgery, but little enthusiasm for programmes in schools or the workplace. Surprisingly, only 13% of GPs thought that screening should be offered to those with a negative family history of the disorder. Although the idea of involvement in screening was favoured, GPs claimed that any aspect of delivery that they undertook would need to be supported. There were no significant differences between the responses of fundholding GPs and non-fundholders.

CONCLUSIONS

The low ranking by GPs of CF screening against other programmes, together with the need for support if they were to be involved, suggests that it is currently impractical to move the programme from its existing site in antenatal clinics.

Mannan-binding protein in human umbilical cord blood

Mannan binding protein (MBP) may be important for host defence particularly in infancy. MBP concentration was measured in 237 umbilical cord blood samples from singleton pregnancies and compared to those of 352 blood donors. Both data sets yielded a bimodal frequency distribution, consisting of a log-normal peak and a long tail of lower values. The range (0-23 U/ml) and median (7.2 U/ml) of cord blood values were significantly lower than those of blood donors (range 0-43 U/ml; median 8.3 U/ml). MBP was also measured in the cord blood samples of 8 pairs of twin siblings. Discordant values in two pairs of twins suggest that cord blood MBP is derived from the fetoplacental unit and not from the maternal circulation by transplacental passage.

Prenatal screening for cystic fibrosis carriers: does the method of testing affect the longer-term understanding and reproductive behaviour of women?

A comparative study of women who underwent prenatal cystic fibrosis (CF) carrier screening by either the 'two-step method' or the 'couple method' was carried out 2-4 years after testing. Recall of the screening test and test result, understanding of the implications of the test result, and reproductive intentions and behaviour were compared. Women screened by the two-step method were significantly better informed on the genetic implications of the test result and the significance of being a single gene carrier than their couple screen counterparts. Regardless of the method of screening, a majority of those who had received a negative test result erroneously believed that they were definitely not a carrier. However, women who intended having further children were significantly more likely to understand correctly that a negative test result meant that they were unlikely to be a CF carrier. The method of testing had no influence on reproductive intentions or behaviour. Differences in emphasis, content and presentation of pre-screening information and counselling between the two methods of screening are identified. Reasons for variation in the long-term understanding between women screened by the two methods are discussed.

Evidence for a familial pregnancy-induced hypertension locus in the eNOS-gene region

Pregnancy-induced hypertension may be regarded as a manifestation of endothelial-cell dysfunction. The role of the eNOS gene in the development of a familial pregnancy-induced hypertension was evaluated by analysis of linkage among affected sisters and in multiplex families (n = 50). Markers from a 4-cM region encoding the eNOS gene showed distortion from the expected allele sharing among affected sisters (P = .001-.05), and the statistic obtained from the multilocus application of the affected-pedigree-member method also showed distortion (T[f(P)=sqrt(P)] = 3.53; P < .001). A LOD score of 3.36 was obtained for D7S505 when a best-fitting model derived from genetic epidemiological data was used, and LOD scores of 2.54-4.03 were obtained when various other genetic models were used. Estimates of recombination rate, rather than maximum LOD-score values, were affected by changes in the genetic parameters. The transmission-disequilibrium test, a model-free estimate of linkage, showed strongest association and linkage with a microsatellite within intron 13 of the eNOS gene (P = .005). These results support the localization of a familial pregnancy-induced hypertension-susceptibility locus in the region of chromosome 7q36 encoding the eNOS gene.

Routine antenatal screening for syphilis in Lothian: a study of the results 1988 to 1994

A retrospective study was carried out of the cases of positive syphilis serology detected by routine antenatal screening within Edinburgh (and surrounding district) over the six years 1988 to 1994. The study demonstrated a low incidence of syphilis with only 15 pregnancies in 58,445 screened. In eight cases serology and history were suggestive of late latent syphilis and in the remainder of previous infection which had been treated. All women were delivered of liveborn infants at term without stigmata of congenital syphilis. Lack of identifiable risk factors in women with positive serology suggests that routine rather than selective screening should continue.

Diverticulitis. A comprehensive follow-up

PURPOSE

This study was undertaken to examine the longterm results of medical and surgical management for diverticulitis.

METHODS

A retrospective review of all patients admitted to Naval Medical Center Portsmouth, Virginia, between January 1991 and February 1994, was conducted. Of 78 patients included in the study, 65 were able to be contacted for follow-up.

RESULTS

The surgically treated group consisted of 33 patients, and medically treated group had 32 patients. Of the medically treated group, 62.5 percent were found to have continuing symptoms. Medically treated patients with a long history and infrequent flares tended to be less symptomatic after hospitalization. Conversely, those medical patients with a short intense history were more likely to have symptoms. The frequency of symptoms in the surgical group was surprising, because 27.2 percent of this group reported continuing symptoms.

CONCLUSIONS

Close follow-up of medically treated patients for objective evidence of diverticulitis is indicated. When surgical therapy is undertaken, patients should be counseled that symptoms may be largely unchanged following operation.

Association between mannan binding protein deficiency and recurrent miscarriage

The distribution of mannan binding protein (MBP) in blood donor sera was determined by enzyme-linked immunosorbent assay to establish normal concentrations. Abnormally low MBP concentrations were found in 16% (21 out of 135) of female partners and 14% (15 out of 108) of male partners of couples experiencing recurrent miscarriage, compared with < 5% of obstetrically normal controls (P < 0.005). This relationship was even stronger (9.5 versus 1.0%) and more significant (P < 0.002) when only subjects presumed to be homozygous for the mutant allele responsible for MBP deficiency were considered. By immunohistochemistry, MBP could be demonstrated in first trimester placenta. We suggest that low concentrations of MBP within the feto-placental unit increase susceptibility to fetal loss, possibly via an infection-induced placental cytokine imbalance.

Gene therapy for cystic fibrosis: will it affect the uptake of prenatal carrier screening?

We report a study which examined whether the decision of 135 couples to accept prenatal cystic fibrosis (CF) carrier screening would be influenced by the advent of gene therapy. A majority (91 couples; 67 per cent) felt that gene therapy for CF would not influence their decision to be screened. Twenty-two couples (16 per cent) stated that they would decline to be screened and an equal number felt ambivalent. Even if the life expectancy of a CF sufferer were increased by gene therapy to normal, 78 per cent of couples would still wish to avail themselves of prenatal carrier screening. A majority of women who decline screening do so because they are opposed to termination of pregnancy. The availability of gene therapy could increase the proportion of couples who accept screening.

Evaluation of maternal serum immunoreactive inhibin as a first trimester marker of Down's syndrome

BACKGROUND AND OBJECTIVE

Maternal serum immunoreactive inhibin has been shown to be significantly elevated in Down's affected pregnancies in the second trimester, suggesting that it may be useful in prenatal diagnosis. We have investigated whether it is similarly elevated in the first trimester.

DESIGN

Stored maternal sera from women with Down's affected pregnancies and chromosomally normal control pregnancies were retrieved for analysis. These sera had been collected prospectively at either 11 or 12 weeks gestation as a routine antenatal booking procedure.

SUBJECTS

From records, 11 women were identified as having had a Down's pregnancy. For each of these, 4 controls matched for gestation and duration-of-storage were also identified.

MEASUREMENTS

Two different inhibin immunoassays were evaluated, one using an antibody raised against 31 kDa bovine inhibin and the other, a commercial two-site assay, using two antibodies directed against two distinct alpha-subunit epitopes.

RESULTS

Neither assay detected a significant effect of gestation on serum inhibin levels. After combining the data from both gestations, no significant difference between the Down's samples and controls for either assay was detected. However, analysis of the data for each gestation separately revealed that one assay detected a significant difference in inhibin levels between Down's affected and unaffected pregnancies at 11 weeks gestation (mean +/- SEM 3186 +/- 195 vs 2020 +/- 172 ng/l, P < 0.01) but not at 12 weeks. The other, commercial, assay did not detect a significant difference at either gestation. In addition, there was poor association between the results of the two assays.

CONCLUSIONS

These data suggest that immunoreactive inhibin, as detected by these assays, will not be useful as a late first trimester marker for Down's syndrome and also that these two assays detect different inhibin species in pregnancy serum.

Remote pregnancy outcome after leukocyte immunotherapy

Twenty-eight recurrent miscarriage patients who had live births after leukocyte immunization were followed. Sixteen had subsequent pregnancies (without further treatment). One pregnancy was terminated, and five others were spontaneously aborted. The live birth rate was therefore 10 of 15 (67%). Any benefit from leukocyte immunotherapy does not appear to be long lasting.

Immunohistochemical localization of a beta-D-galactoside-binding lectin at the human maternofetal interface

The 14 kD S-type lectin from human placenta may have a role in regulating the maternal immune response to fetal antigens. In this study, an immunoperoxidase technique was used to determine the distribution of the lectin at the human maternofetal interface. Tissue obtained during the first trimester of pregnancy and at term was used. The lectin was not detectable in either the villous syncytiotrophoblast or the underlying cytotrophoblast in first-trimester tissue, although some cells of the cytotrophoblast columns were reactive. It was also not detectable in villous or extravillous trophoblast populations at term. In contrast, strong reactivity was found in decidual stromal cells throughout gestation, and endometrial stromal cells were also positive. The lectin is, therefore, not a component of the immunosuppressive factors associated with syncytiotrophoblast membranes, but may have a role in either the decidual control of trophoblast migration or some functions unrelated to pregnancy, or both.

Antenatal screening for cystic fibrosis: a trial of the couple model

OBJECTIVE

To assess the delivery and acceptability of antenatal couple screening for cystic fibrosis. Carrier status was notified only when both members of a partnership had cystic fibrosis alleles and therefore a one in four risk of having an affected child.

DESIGN

Mouthwash samples were tested when both partners participated. Results were returned only to positive couples.

SETTING

Two large maternity hospitals in Edinburgh.

SUBJECTS

Screening was offered to all couples who booked at one of the two hospitals.

MAIN OUTCOME MEASURES

(a) The take up of screening, carriers and carrier couples identified, take up of prenatal diagnosis, and numbers of affected fetuses detected; (b) questionnaire measures of patient satisfaction and stress.

RESULTS

Screening was offered to 8536 couples. 714 (8.4%) were regarded as ineligible, usually because of late booking or absence of a partner. 1900 (24.3%) of the remainder declined screening. Among the 5922 screened couples, four tested positive--that is, both partners were cystic fibrosis heterozygotes. All four elected to have prenatal diagnosis. There were three terminations of pregnancy because of an affected fetus, one couple having two successive pregnancies with affected fetuses. The participation rate was 76% for eligible couples (5922/7822) and 69% for all couples (5922/8536). Only 89 screened couples (1.5%) requested information on individual carrier status. No anxiety was detected among a cohort of the screened population, and 99% of questioned participants expressed satisfaction with the concept of couple screening.

CONCLUSIONS

Antenatal couple screening is a satisfactory and acceptable way of screening for cystic fibrosis and has been adopted as routine in the two trial hospitals.

Chlamydial serologic studies and recurrent spontaneous abortion

OBJECTIVE

Our purpose was to investigate the putative association between immunoglobulin G antibodies to Chlamydia trachomatis and recurrent spontaneous abortions.

STUDY DESIGN

Sera from 106 idiopathic recurrent aborters and 81 of their partners were tested for immunoglobulin G antichlamydial antibodies by whole inclusion immunofluorescence and compared with 3890 sera from a general antenatal population. Positive sera were further investigated by microimmunofluorescence to determine species (Chlamydia trachomatis, Chlamydia pneumoniae, Chlamydia psittaci) specificity.

RESULTS

Twenty-six (24.5%) of women with recurrent spontaneous abortions had immunoglobulin G antichlamydial antibodies compared with 28 (34.6%) of their partners (chi 2 2.25, p < 0.05) and 788 (20.3%) of the general antenatal population (chi 2 1.16, p < 0.05), and the incidence of antibody positivity showed no trend with increasing number of previous abortions. Fourteen women with recurrent spontaneous abortions had antibodies to Chlamydia trachomatis, 12 to Chlamydia pneumoniae. The prevalence of antibodies to C. trachomatis did not differ significantly between women with recurrent spontaneous abortions and their partners, but the male partners had a significantly (p = 0.005) higher prevalence of Chlamydia pneumoniae antibodies. Chlamydial antibody seropositivity did not correlate with subfertility or subsequent pregnancy outcome.

CONCLUSION

There is no association between immunoglobulin G antibodies to Chlamydia trachomatis and recurrent spontaneous abortion.

Influence of histocompatibility antigens in recurrent spontaneous abortion and its relevance to leukocyte immunotherapy

A total of 108 couples with recurrent spontaneous abortion (RSA) were studied to investigate the possible influence of histocompatibility antigens (HLA) on their condition and its management. HLA-B18 was shown to be at a higher frequency in RSA women, but not significantly so after statistical correction. Just over half the RSA women shared two or more HLA-A, B or DR antigens with their partners (P < 0.01), but this group did not differ from the others in clinical or laboratory features, nor in subsequent pregnancy success rate. Leukocyte immunotherapy in which the donor shared at least one HLA-DR antigen with his partner was not associated with a significant improvement in subsequent pregnancy outcome compared with HLA-DR mismatched immunotherapy. HLA antibody production following leukocyte immunotherapy was influenced by both inoculum size and degree of HLA incompatibility, but had no effect on birthweight. Tissue-typing investigations are not indicated for individual RSA patients seeking advice or treatment.

Prenatal cystic fibrosis carrier screening: factors in a woman's decision to decline testing

Among 2207 women eligible to be screened for cystic fibrosis (CF) carrier status during pregnancy, 325 (15 per cent) declined to be tested. Of these, 260 (80 per cent) answered a questionnaire soliciting their reasons for not participating. The main factor was opposition to termination of pregnancy, with 43 per cent being against termination for any reason and another 11 per cent against termination of a CF fetus. Other reasons given were partner's disapproval or non-participation (10 per cent), perceived risk of a CF child being low (7 per cent), the error rate of the test (6 per cent), and the generation of unacceptable levels of anxiety (5 per cent). Eleven women (4 per cent) said that they did not wish to be tested during pregnancy, but only six of these would have accepted screening at another time.

Parental HLA sharing, feto-maternal compatibility and neonatal birthweight in families with a history of recurrent spontaneous abortion

The mean birthweight of babies eventually born to couples with a history of recurrent spontaneous abortion (RSA) is allegedly lower if the parents have a high degree of HLA antigen sharing (Reznikoff-Etievant et al., 1991), but this relationship has not been independently confirmed. We have re-investigated this question by analysing data from 36 families. In 22 instances, we were able to relate birthweight directly to feto-maternal HLA compatibility for the first time in such families. We were unable to confirm any appreciable influence of paternal or feto-maternal HLA sharing on birthweight or placental weight and conclude that RSA families do not differ markedly from normal families in this respect.

Prenatal screening for cystic fibrosis: attitudes and responses of participants

A screening programme to detect cystic fibrosis heterozygotes has been running in the antenatal clinics of a major Edinburgh maternity hospital for more than 2 years. A questionnaire was used to assess participants' knowledge of the genetics of the disorder and their attitudes to being screened. The respondents were 64 female heterozygotes and 63 of their non-heterozygous male partners, 101 female controls and 100 male controls. Although the two groups of controls received far less direct information than the carriers and their partners, all four groups were well informed about the genetics of cystic fibrosis and the significance of being a gene carrier. A majority of each group felt that adequate information had been given in the information leaflet, that they understood the purpose of screening and that they were glad to have participated. There was a consensus that CF carrier testing should be routinely offered to pregnant women, and also that it should be available in family planning clinics and GP health centres, but not in schools.

Prenatal screening for cystic fibrosis: psychological effects on carriers and their partners

This study aimed to assess the psychological impact of screening for cystic fibrosis (CF) carrier status in a population of pregnant women. A cohort of 1798 women, who accepted the offer of testing before 18 weeks of pregnancy, filled in a self administered questionnaire seeking information on their perceived risk of carrier status and their emotional response, as well as a general health questionnaire (GHQ). Sixty-four women identified as CF carriers had partners who received a negative test result. This group and their partners were assessed, together with selected controls, on four further occasions: (1) on receiving the carrier's positive test result; (2) on receiving the partner's negative test result; (3) six weeks later; (4) six weeks after delivery. The instruments used were the GHQ and the Symptom Rating Test (SRT). When compared to control subjects, carriers showed a significant increase in generalised psychological disturbance which could be attributed specifically to symptoms of anxiety and depression during the period (average four days) that they awaited their partner's test result. On receiving a partner's negative test result, the carriers returned to control levels and maintained this equilibrium. Although there was no significant difference in generalised psychological disturbance between partners and their selected controls, partners did become significantly more anxious and manifested feelings of inadequacy while awaiting their own test result. Both male partners and male control subjects were more likely to become anxious if their partner was distressed.

Prenatal screening for cystic fibrosis

Screening for carriers of CF (cystic fibrosis) is now possible but the best way of delivering such a service is unknown. In one model 4348 women attending antenatal clinics in an Edinburgh maternity hospital were invited to participate in a trial of prenatal screening. Mouthwash samples were tested for six CF alleles (85% of mutant genes) and when a woman was found to be a CF carrier her partner was also tested. Heterozygous couples were offered prenatal diagnosis. 609 (14%) women declined to enter the trial and another 574 (13%) were not screened, usually because of late booking. Among the remaining 3165 women there were 111 carriers of a CF gene (1 in 29). 4 of these 111 had carrier partners and these couples opted for prenatal diagnosis, the 1 pregnancy with an affected fetus being terminated. The psychological impact of screening was assessed by the general health questionnaire. There was a significant increase in stress at the time of the test result among women identified as carriers. However, this disappeared when their male partners tested normal and did not reappear later in the pregnancy. By providing time for couples to discuss the possibility of screening and by offering the test at a point (the antenatal booking clinic) at which most pregnant women are seen, this approach has advantages, provided that counselling is readily available.

Prenatal cystic fibrosis carrier testing: designing an information leaflet to meet the specific needs of the target population

A questionnaire was given to 180 patients in an antenatal clinic, who were eligible to enter a pilot trial of cystic fibrosis (CF) carrier testing, seeking their views on the information leaflet inviting them to participate; 161 patients (89%) entered the trial and 145 patients (81%) responded to the questionnaire, including 10 who did not enter the trial. Ninety-six percent of these found the leaflet easy to understand, and 97% of those partners who read the leaflet also found it easy to understand. Fifteen percent of patients thought the leaflet should give additional information. Most (92%) had heard of CF before reading the leaflet, television being the most common source of information. Although avoiding the birth of a child with CF was the reason most patients gave for wishing to be screened, almost as many were interested to know their carrier status. The decision to accept or decline testing was taken in conjunction with their partner by 63% of women. Of those who were screened, 59% stated that taking the test made them feel reassured, while 38% felt slightly apprehensive. It was concluded that, with a number of minor amendments, the leaflet met the specific needs of the target patient population.

An exclusion map for pre-eclampsia: assuming autosomal recessive inheritance

Pre-eclampsia is a common complication of the second half of pregnancy that is associated with substantial fetal and maternal morbidity. Although the genetic basis of the disorder is unclear, epidemiological studies suggest that it occurs predominantly in the first pregnancies of women who are homozygous for a relatively common susceptibility gene. Using this epidemiological model, we have begun to construct an exclusion map by using both candidate genes and random DNA markers on a panel of two-generation families in which pre-eclampsia was rigorously defined. No evidence was found for linkage to the HLA region or to several genes implicated in the pathogenesis of hypertension.

Anti-paternal lymphocyte antibodies: a modified cellular enzyme-linked immunospecific assay (CELISA)

A cellular enzyme-linked immunospecific assay is described which is ideally suited to measuring the IgG antibody response to donor-specific lymphocyte infusions. The procedure is simple, sensitive, specific and objective.

Is genetic susceptibility to pre-eclampsia conferred by homozygosity for the same single recessive gene in mother and fetus?

OBJECTIVE

To determine whether any simple, purely genetic mechanism can account for susceptibility to pre-eclampsia.

DESIGN

Six simple Mendelian models of inheritance were considered, and predictions concerning the incidence of pre-eclampsia in various family members of index cases were calculated for each genetic model. Data were then extracted from published family studies in which a suitable disease definition had been used, and compared to our theoretical expectations.

RESULTS

Only one of the genetic models considered, in which both mother and fetus must express the same recessive gene to confer susceptibility, was consistent with the observed incidence values for relatives of index cases. This model was also consistent with the putative association with HLA-DR4, but could not account for the comparative rarity of pre-eclampsia in parous women.

CONCLUSION

Homozygosity for a single recessive gene shared by mother and fetus, unlike five other genetic mechanisms tested, is consistent with published family studies in pre-eclampsia, and should be considered the best working hypothesis at present.

Immunocytochemical localization of neutrophil elastase in term placenta decidua and myometrium in pregnancy-induced hypertension

OBJECTIVE

The aim of the study was to determine whether there was evidence of elastase containing neutrophils at the materno-fetal interface in women with pregnancy-induced hypertension (PIH).

DESIGN

An observational prospective study.

SETTING

The Simpson Memorial Maternal Pavilion Edinburgh.

METHODS

Placentas were obtained at vaginal or abdominal delivery from 51 consecutive women, 23 had normal pregnancies (13 caesarean sections) and 28 had PIH (18 caesarean sections). An immunocytochemical technique was used to localize elastase containing neutrophils in the placenta, decidua and myometrium.

MAIN OUTCOME MEASURES

The numbers of positively stained cells, estimated subjectively as minimal, moderate or heavy, in subchorionic plate, perivillous fibrin and decidua.

RESULTS

In both normal and PIH pregnancies neutrophils were absent from the myometrium. However, elastase containing neutrophils were located in areas of fibrin in the subchorionic plate and around the villi although there was no significant difference between the normal and PIH group. Neutrophils were also located in the fibrin of the decidua and in this case the number was significantly greater in the PIH group than in the normal group and correlated with plasma urate.

CONCLUSION

The release of neutrophil elastase in the decidua could contribute to the vascular damage evident in PIH.