Preterm delivery and growth restriction in multifetal pregnancies reduced to twins

Gestation at delivery, birthweight and pregnancy outcome of surviving fetuses from 127 multifetal pregnancies undergoing embryo reduction to twins were compared to 354 chromosomally normal non-reduced dichorionic twin pregnancies. First-trimester embryo reduction was carried out by intracardiac injection of KCl. In 16 (12.6%) of the 127 multifetal pregnancies reduced to twins, there was miscarriage of both fetuses before 24 weeks of gestation. The median interval between reduction and fetal loss was 5 weeks (range 1-12). In livebirths, the median gestation at delivery was 36 weeks (range 24-41) and the median difference in birthweight from the appropriate mean was -0.94 SD (range -3.89-1.73 SD). Both fetal loss before 24 weeks and the interval between embryo reduction and delivery were significantly associated with the gestation at reduction (r = 0.40, P < 0.001 and r = -0.57, P < 0.001 respectively). In the pregnancies reduced to twins compared to the non-reduced twins, the percentage of miscarriages was higher (12.6 compared to 2.5%; chi 2 = 19.2, P < 0.001), the median gestation at delivery was lower (36 compared to 37 weeks; t = -1.74, P < 0.05), and the median birthweight deficit was greater (-0.94 compared to -0.65 SD: t = -4.1, P < 0.001).

Homozygous deletions of p16(INK4) occur frequently in bilharziasis-associated bladder cancer

We have studied p16(INK4) mutation (by PCR-SSCP) and deletion (by Southern blotting and/or multiplex PCR) in a series of 47 bilharziasis-associated tumors from Egypt and compared the results with those obtained on a series of 17 established bladder cell lines and non-bilharziasis-associated bladder cancers from the Netherlands. In the cell lines we found 9 homozygous deletions and 1 mutation (59% of p16(INK4) alterations in cell lines), whereas in cases from the Netherlands deletions were found in 4 of 22 samples. No mutations were detected in the 46 samples screened. Interestingly, in bilharziasis-associated bladder cancer, deletions were present in 23 samples and mutations in a further 2 cases (53% of p16(INK4) alteration in bilharziasis-associated bladder cancer). No correlation was found between p16(INK4) alteration and histopathological data. Likewise, the same frequency of alteration was found in tumors with different differentiation patterns (squamous, transitional or adenocarcinoma). Three conclusions can be drawn from our findings: (i) p16(INK4) alterations are more frequent in cell lines than in primary tumors; (ii) in primary bladder tumors (bilharziasis-associated or not), p16(INK4) deletions are much more frequent than p16(INK4) mutations; (iii) p16(INK4) alterations are more frequent in bilharziasis-associated bladder tumors than in other bladder tumors. This high frequency of deletion is not related to a specific histological type but to the specific etiology of these tumors.

Structural status of the int loci in women showing high incidence of breast cancer

Mammary carcinomas in certain mice strains are induced following infection by the MMTV. Insertion of MMTV provirus into the int-1 and int-2 loci results in transcriptional activation of these two proto-oncogenes and is thought to be a key step in breast tumorigenesis in mice. A viral etiology for human breast cancers, though proposed several years ago, is far from proven. However, morphological structures resembling Bittner's particles have been observed earlier in about 39% samples of breast tumor and milk sediments of Parsi women. We therefore investigated in the Parsis, the structural integrity of two potential sites of integration (int-1 and int-2) of the hypothetical human mammary tumor virus and have used for this purpose a large number of patient DNA. The results obtained however failed to distinguish any major structural change existing at the int-1 or the int-2 sites that may point to a proviral integration event having occured in human breast cancers. We have, however, observed differences in the physical structure of the int-1 map, compared to the one reported and sequenced, and have therefore felt it necessary to present a new one indicating our findings, notably, the polymorphic PvuII sites. In addition, we report a single case of Parsi woman, with infiltrating grade 3 ductal carcinoma, whose DNA contains an alteration in the int-2 structure.

Maternal serum concentrations of pregnancy associated placental protein A and pregnancy specific beta-1-glycoprotein in multifetal pregnancies before and after fetal reduction

Placental function in multifetal pregnancies before and after embryo reduction was investigated by measuring maternal serum concentrations of pregnancy associated placental protein-A (PAPP-A) and pregnancy specific beta-1-glycoprotein (SP-1). Three groups of pregnant women were studied following assisted reproduction; groups 1 and 2, were 12 singleton and 12 twin pregnancies respectively, and group 3 comprised 12 women with multifetal pregnancies undergoing embryo reduction. PAPP-A and SP-1 were measured serially at 8-21 weeks gestation. In all pregnancies, maternal serum PAPP-A and SP-1 increased with gestation. In twin pregnancies the mean concentrations of SP-1 were significantly higher than in singletons at all gestations, whereas for PAPP-A, concentrations were similar between these groups. In multifetal pregnancies before embryo reduction, the serum concentrations of both proteins were significantly higher than in twin pregnancies. Following reduction, the concentrations of PAPP-A remained significantly higher than for twins throughout, whereas the concentrations of SP-1 gradually converged towards those of twins; by 19 weeks there was no difference between the means of the two groups. These findings suggest that circulating concentrations of SP-1 reflect total placental mass, which is proportional to the number of live fetuses, whereas the pattern of PAPP-A changes suggests that this protein is produced by the placenta, decidua and other tissues.

Fetal serum ferritin and cobalamin in red blood cell isoimmunisation

Fetal and maternal serum ferritin and cobalamin concentrations were examined in 40 red blood cell-isoimmunised pregnancies undergoing cordocentesis at 18-38 weeks of gestation and the values were compared to those of normal pregnancies. In the red blood cell-isoimmunised pregnancies, the fetal serum ferritin concentration was increased and the cobalamin concentration was decreased, whereas maternal serum ferritin was decreased and cobalamin was not significantly different from normals. There was a significant association between the degree of fetal anaemia and the increase in fetal serum ferritin concentration, but not with fetal serum cobalamin. This study suggests that fetal haemolytic anaemia is associated with iron overload and cobalamin deficiency.

Concentration of fetal plasma and amniotic fluid interleukin-1 in pregnancies complicated by preterm prelabour amniorrhexis

AIMS

To determine interleukin-1 beta (IL-1 beta) concentration in fetal and maternal plasma and amniotic fluid from pregnancies complicated by preterm prelabour amniorrhexis and to define the relation of this cytokine to intrauterine infection and the onset of labour.

METHODS

Cross-sectional study of 23 pregnancies complicated by preterm prelabour amniorrhexis. Enzyme linked immunoassay was used to measure IL-1 beta concentration in fetal and maternal plasma and amniotic fluid. In each case, fetal blood and amniotic fluid were cultured for micro-organisms.

RESULTS

In pregnancies with positive fetal blood and/or amniotic fluid cultures, plasma and amniotic fluid concentrations of IL-1 beta were higher and the interval between amniorrhexis and onset of labour was shorter than in the non-infected group. There were no significant associations between fetal plasma IL-1 beta and maternal plasma or amniotic fluid IL-1 beta concentrations, fetal leucocyte count or the interval between amniorrhexis and the onset of labour.

CONCLUSIONS

These findings suggest that although intrauterine infection is associated with increased IL-1 beta concentrations in fetal plasma and amniotic fluid, there is no significant association between the concentration of IL-1 beta and the interval between amniorrhexis and the onset of labour.

Maternal plasma concentrations of insulin-like growth factor binding protein-1 and placental protein 14 in multifetal pregnancies before and after fetal reduction

The aim of this study was to investigate the changes in maternal plasma insulin-like growth factor binding protein-1 (IGFBP-1) and placental protein 14 (PP14) in multifetal pregnancies before and after embryo reduction. Maternal plasma IGFBP-1 and PP14 were measured serially in three groups of pregnant women at 8-21 weeks gestation. Groups 1 and 2 were 12 singleton and 12 twin pregnancies achieved after in-vitro fertilization (IVF). Group 3 comprised 26 women with multifetal pregnancies undergoing embryo reduction to twins. In the IVF pregnancies maternal plasma IGFBP-1 and PP14 increased with gestation to reach a peak at 20 and 10 weeks respectively; the mean concentrations in twin pregnancies were significantly higher than in singletons. In multifetal pregnancies the mean plasma concentration of both proteins was similar to that of IVF twin pregnancies before reduction; after reduction, the values fell to less than those of twins. These findings suggest that the maximum secretory capacity of the endometrium is achieved with twin pregnancies. In multifetal pregnancies undergoing iatrogenic reduction to twins, total residual endometrial function was less than in twin conceptions.

Serum insulin-like growth factor-binding protein-3 (IGFBP-3) levels and IGFBP-3 protease activity in normal, abnormal, and multiple human pregnancy

Proteolytic activity directed against insulin-like growth factor (IGF)-binding protein-3 (IGFBP-3) is found in human pregnancy serum. We have investigated changes in this protease activity in pregnancies in which the fetus is small for gestational age and in multiple pregnancies. Maternal serum was obtained from 18 singleton pregnancies at 27 weeks gestational age (GA), and matched fetal serum was collected by cordocentesis. Fetuses were appropriate for GA (AGA; n = 6), small for gestational age (SGA) with evidence of uteroplacental insufficiency (UPI; starved SGA; n = 6), or SGA without UPI (nonstarved SGA; n = 6). In a second study, serum was obtained from women with singleton (n = 10), twin (n = 10), and higher multiple pregnancies (n = 10) at 9 weeks GA. All women with more than three fetuses underwent embryo reduction to 2 fetuses before 15 weeks gestation, when a second serum sample was obtained. Circulating IGF-I and IGF-II were measured by RIA, and IGFBP-3 was measured by both RIA and immunoradiometric assay. IGFBP-3 protease activity was assessed by Western ligand blotting after incubation with a normal nonpregnancy sera pool, immunoblotting, and specific protease assay. In the growth study, circulating maternal IGF-I and IGFBP-3 levels were not different in the three groups, but fetal IGF-I and IGFBP-3 levels were significantly lower in the UPI fetuses (IGF-I, 6.9 +/- 0.5 micrograms/L; IGFBP-3, 547 +/- 70 micrograms/L) than in either the nonstarved SGA fetuses (IGF-I, 27.8 +/- 6.3; IGFBP-3, 769 +/- 41 micrograms/L; P < 0.01) or the AGA fetuses (IGF-I, 39.4 +/- 3.4; IGFBP-3, 872 +/- 91 micrograms/L; P < 0.01). Maternal serum IGFBP-3 protease activity, measured by protease using [125I]IGFBP-3 as substrate, was increased in pregnancies complicated by UPI compared with GA-matched pregnancies in which the fetus was AGA or nonstarved SGA. No significant fetal serum protease activity was demonstrated. In the multiple pregnancies, IGFBP-3 rose significantly from 9-15 weeks GA in singleton (P = 0.005), twin (P = 0.004), and multiple (P = 0.007) pregnancies, and levels were higher in mothers of multiple pregnancies than in those of twin (P < 0.05) or singleton (P < 0.01) pregnancies at both 9 and 15 weeks GA. IGF-I levels were not different in the three groups and did not significantly increase between 9-15 weeks GA.(ABSTRACT TRUNCATED AT 400 WORDS)

Maternal plasma levels of human chorionic gonadotrophin, oestradiol and progesterone in multifetal pregnancies before and after fetal reduction

The aim of the study was to investigate the circulating levels of human chorionic gonadotrophin (hCG), oestradiol (OE2) and progesterone in multifetal pregnancies before and after embryo reduction. The levels of hCG, OE2 and progesterone were measured in plasma samples obtained from two groups of pregnant women: (i) singleton (n = 17), twin (n = 15) and triplet (n = 5) pregnancies achieved following superovulation; and (ii) multifetal pregnancies (three to ten embryos) undergoing fetal reduction to twin pregnancies (n = 31). The median value for each analyte at each gestational age in twin pregnancies was defined and used to derive multiples of the median (MoMs) for each analyte in samples obtained from multifetal pregnancies before and after reduction. The levels of hCG, OE2 and progesterone were significantly associated with the number of fetuses. Prior to reduction, the median MoMs for hCG, OE2 and progesterone were 1.54, 0.99 and 1.11 respectively. After reduction to twins the median MoMs decreased to 0.84 for hCG, 0.37 for progesterone and 0.51 for OE2. These data suggest that (i) the circulating levels of hCG, OE2 and progesterone increase with conceptus number; (ii) placental tissue does not remain active following fetal reduction; and (iii) the rate of steroid metabolism is increased in multiple pregnancy and remains elevated following fetal reduction.

The role of cytokines in the pathogenesis of Langerhans cell histiocytosis

Langerhans cell histiocytosis (LCH) is characterised by an accumulation of cells ('LCH cells') with the same phenotypic features as normal Langerhans cells found in skin and other organs. The pathogenesis of LCH is unknown but there is increasing evidence to implicate the involvement of lymphokines and proinflammatory cytokines in the tissue damage seen in this disorder. Apart from histiocytes, the lesions contain giant cells, macrophages, neutrophils, eosinophils, lymphocytes, plasma cells and occasional mast cells that are the hallmark of an inflammatory process. The role of cytokines in the recruitment of haemopoietic cells within inflammatory lesions has only recently been recognised. In this article, we review the possible role of cytokines in the pathogenesis of LCH, and provide an overview of the methods currently used to detect and quantitate them. An appreciation of the type, distribution and amount of different cytokines released within lesions can provide clues to the possible aetiology of LCH. Using immunoassays, in situ hybridisation and RT-PCR, increased amounts of IL-1, IL-3, IL-4, IL-8, GM-CSF, TNF alpha, TGF beta and LIF have been demonstrated in LCH lesions. Lymphocytes constitutively produce GM-CSF and IL-3 and, to a lesser degree, IL-1, IL-4 and LIF whilst histiocytes produce TNF alpha, IL-1 beta and GM-CSF.

Atrial natriuretic factor concentration in normal, growth-retarded, anemic, and hydropic fetuses

OBJECTIVE

Our purpose was to establish a reference range with gestation for plasma concentrations of atrial natriuretic factor in fetal blood and to examine whether the concentration is altered in fetal anemia, acidemia, or hydrops.

STUDY DESIGN

Atrial natriuretic factor was measured in umbilical venous blood taken by cordocentesis from pregnancies complicated by red blood cell isoimmunization (n = 17), intrauterine growth retardation (n = 12), and hydrops fetalis (n = 20) and from controls (n = 66). Additionally, maternal blood atrial natriuretic factor concentration was measured in 40 uncomplicated pregnancies.

RESULTS

In the control group detectable levels were found from 16 weeks onward, and the fetal plasma atrial natriuretic factor concentration did not change with gestation. In anemic, acidemic, and hydropic fetuses the concentration was higher than in controls.

CONCLUSION

Fetuses are capable of producing atrial natriuretic factor under physiologic conditions, and the concentration is increased appropriately in pathologic states.

Indentation cracking of composite matrix materials

Composite restorative materials wear by a fatigue mechanism in the occlusal contact area. Here, tooth cusps and food debris cyclically indent the restoration. Modeling this phenomenon requires an understanding of material response to indentation. The question in this study was whether material response depends on indenter size and geometry, and also, whether polymers used in restorative materials should be considered elastic and brittle, or plastic and ductile for modeling purposes. Three resins used as matrices in proprietary restorative composites were the experimental materials. To ascertain the influence of glass transition temperature, liquid sorption, and small amounts of filler on indentation response, we prepared materials with various degrees of cure; some samples were soaked in a 50/50 water/ethanol solution, and 3 vol% silica was added in some cases. Indentation experiments revealed that no cracking occurred in any material after indentation by Vickers pyramid or spherical indenters with diameters equal to or smaller than 0.254 mm. Larger spherical indenters induced subsurface median and surface radial and/or ring cracks. Critical loads causing subsurface cracks were measured. Indentation with suitably large spherical indenters provoked an elastoplastic response in polymers, and degree of cure and Tg had less influence on critical load than soaking in solution. Crack morphology was correlated with yield strain. Commonly held assumptions regarding the brittle elastic behavior of composite matrix materials may be incorrect.

Serum ferritin and cobalamin in growth retarded fetuses

OBJECTIVE

To examine fetal and maternal serum cobalamin and ferritin concentrations in pregnancies complicated by fetal growth retardation.

SETTING

Harris Birthright Research Centre for Fetal Medicine, King's College Hospital Medical School, London.

DESIGN

Cross sectional study.

SUBJECTS

Fetal blood samples obtained by cordocentesis from 20 growth retarded fetuses at 26 to 36 weeks of gestation. Maternal venous blood was also collected and serum ferritin and cobalamin concentrations were measured by radio-immunoassay in the fetal and maternal samples.

RESULTS

In the growth retarded group, the mean fetal serum concentration of cobalamin was higher than the normal mean for gestation (t = 3.27, P < 0.01), and this increase was significantly associated with fetal acidaemia (r = -0.686, P < 0.001) and erythroblastosis (r = 0.731, P < 0.001). In contrast, the fetal to maternal ferritin ratio was significantly reduced; there was a nonsignificant decrease in fetal serum and an increase in maternal serum ferritin concentration. There was an association between fetal serum ferritin concentration and erythrocyte count (r = -0.612, P < 0.01).

CONCLUSIONS

In placental insufficiency, as in postnatal starvation and Kwashiorkor syndrome, uptake and storage of cobalamin by the fetal liver may be impaired. The decrease in fetal to maternal ratio of ferritin could be the consequence of impaired placental perfusion.

Fetal blood ferritin and cobalamin in normal pregnancy

In a cross-sectional study of 75 singleton pregnancies at 16-38 weeks gestation serum cobalamin and ferritin concentrations were measured in fetal and maternal blood samples. Fetal serum cobalamin concentration did not change significantly with gestation but ferritin concentration increased. The median fetal serum concentrations of both ferritin and cobalamin were significantly higher than the respective values in the mother. The median fetal-maternal ratio for ferritin was 3.2 and for cobalamin 1.2. These findings demonstrate that from at least 16 weeks gestation, there is efficient iron storage in the fetus and transfer of cobalamin from the mother to the fetus against a concentration gradient.

Transient ischemic attacks: electrophysiological (conventional and topographic EEG) and radiological (CCT) evaluation

The value of electrophysiological tests: conventional electroencephalography (EEG), topographic EEG analysis as well as computerized tomography (CT) in the diagnosis and evaluation of 25 patients with manifestations of transient ischemic attacks (TIA) in the domain of the carotid system was assessed. Normal CT was the rule in TIA patients except in 8% of the cases, where nonspecific changes of brain atrophy were described. Conventional EEG, topographic EEG and spectral analysis could detect abnormalities in 48%, 80% and 64% of TIA cases respectively. None of the abnormal EEG records could be missed by topographic EEG analysis. 32% of the records were diagnosed as abnormal by topographic EEG, while conventional EEG failed to detect abnormalities. Spectral analysis of the EEG results revealed a significant decrease regarding mean high limit alpha percent power, and a significant increase regarding mean low and high limit theta percent power, as well as a significant increase of the mean high limit of the slow activities (delta + theta)/fast activities (alpha + beta) percent power ratio in the TIA group as compared to the normal control group.

Fetal plasma tumor necrosis factor concentration in normal pregnancy

The aim of the study was to investigate changes with gestation of fetal plasma tumor necrosis factor alpha (TNF-alpha) concentration. In a cross-sectional study, enzyme-linked immunoassay was used to measure plasma TNF-alpha concentration in 40 fetal blood samples obtained by cordocentesis (n = 25), cardiocentesis (n = 5) or at elective caesarean section (n = 10) at 12-38 weeks gestation. The fetal plasma concentration of TNF-alpha increased from a mean of 13.5 pg/ml at 12 weeks gestation to 37.5 pg/ml at 38 weeks (r = 0.59, p < 0.0001), and was significantly associated with the monocyte count (r = 0.56, p < 0.001). TNF-alpha is present in the fetal circulation from at least 12 weeks and the changes in plasma TNF-alpha concentration with gestation coincide with the development of the fetal monocyte-macrophage system.

Colocalization of centromeric and replicative functions on autonomously replicating sequences isolated from the yeast Yarrowia lipolytica

Two sequences (ARS18 and ARS68) displaying autonomous replication activity were previously cloned in the yeast Yarrowia lipolytica. The smallest fragment (1-1.3 kb) required for extrachromosomal replication of a plasmid is significantly larger in Y. lipolytica than in Saccharomyces cerevisiae. Neither autonomously replicating sequence (ARS) is homologous with known ARS or centromere (CEN) consensus sequences. They share short regions of sequence similarity with each other. These ARS fragments also contain Y. lipolytica centromeres: (i) integration of marker genes at the ARS loci results in a CEN-linked segregation of the markers, (ii) an ARS on a plasmid largely maintains sister chromatid attachment in meiosis I, and (iii) integration of these sequences at the LEU2 locus leads to chromosome breakage. Deletions performed on ARS18 show that CEN and ARS functions can be physically separated, but both are needed to establish a replicating plasmid.

Fetal blood natural killer cells in human pregnancy

Flow cytometry was used to determine the number of circulating natural killer (NK) cells in 170 pregnancies undergoing cordocentesis for prenatal diagnosis at 17-38 weeks gestation and 16 undergoing cardiocentesis before social termination of pregnancy at 13-17 weeks. The number of NK cells decreased exponentially with gestation from a mean of 0.26 x 10(9)/l at 13 weeks to 0.09 x 10(9)/l at 38 weeks (r = -0.356, p < 0.001). When expressed as a percentage of the total number of lymphocytes, the proportion of NK cells decreased from a mean of 29% at 13 weeks to 6% at 38 weeks (r = 0.680, p < 0.0001). These data suggest that in early pregnancy the fetal immune response is dependent on innate rather than adaptive mechanisms.

Fetal plasma interferon gamma concentration in normal pregnancy

OBJECTIVE

Our purpose was to investigate changes with gestation in fetal plasma interferon gamma concentration.

STUDY DESIGN

A cross-sectional study at the Harris Birthright Research Centre for Fetal Medicine, London, was performed. Enzyme-linked immunoassay was used to measure plasma concentration in 54 fetal blood samples obtained by cordocentesis or cardiocentesis at 12 to 37 weeks' gestation.

RESULTS

The concentration of interferon gamma in fetal plasma decreased exponentially from a mean of 1.2 U/ml at 12 weeks' gestation to a mean of 0.5 U/ml at 37 weeks (r = 0.460, p < 0.001).

CONCLUSIONS

The presence of high levels of fetal interferon gamma in the first trimester suggests that it may play an important role in early fetal immunologic development. Furthermore, this study has established reference ranges for interferon gamma that may be of value in the prenatal diagnosis of congenital infection.

Structure-function studies of yeast ferrochelatase. Identification and functional analysis of amino acid substitutions that increase Vmax and the KM for both substrates

The molecular basis of the ferrochelatase defects was investigated in two "protoporphyric" and partially heme-deficient yeast mutants. Ferrochelatase, a mitochondrial inner membrane-bound enzyme, catalyzes the incorporation of ferrous iron into protoporphyrin, the last step in protoheme biosynthesis. The mutant cells made normal amounts of normal-sized ferrochelatase, as detected by immunoblotting. The mutations were identified by sequencing the mutant hem15 alleles amplified in vitro from mutant strains genomic DNA. A single nucleotide change, causing an amino acid substitution, was found in each mutant. Substitution of the conserved Ser-169 by Phe caused a 10-fold increase in Vmax and a 45- and 35-fold increase in the KM for protoporphyrin and metal, respectively. Replacement of Ser-174 by Pro produced the same effects, but to a lesser degree. There was a good correlation between the ferrochelatase defects measured in vitro and the heme synthesis deficiencies estimated in vivo. The decreased in vivo heme synthesis is probably due to the lower affinity of the mutant enzymes for iron. We propose that the region identified by the two close mutations contributes to the binding domains of metal and protoporphyrin.

Living-related liver transplantation in Africa

Liver transplantation is an effective therapy for end stage liver disease. Nevertheless in many areas of the world organ availability remains a major problem. We report here the success of the first living-related liver transplantation in Africa. The left lateral lobe of the mother was transplanted orthotopically to her 6 year old child suffering from liver cirrhosis complicating glycogen storage disease. The social and medical problems encountered are discussed. Living-related liver transplantation is a viable option in countries where cadaveric organ donation is either illegal or socially unacceptable.

Circulating placental protein 14: in the first trimester of spontaneous and IVF pregnancies

Circulating placental protein 14 (PP14) levels were measured during the first trimester in three groups of pregnant women: (i) natural conception (n = 15); (ii) pituitary desensitization with buserelin and ovarian stimulation with human menopausal gonadotrophin (HMG) followed by in-vitro fertilization and embryo transfer (IVF-ET) (n = 15); and (iii) ovarian stimulation with clomiphene citrate and HMG, followed by IVF-ET (n = 16). A 7- to 8-fold increase in serum PP14 levels was observed in normal pregnancies between weeks 4 and 10. This increase was earlier and less marked in group (ii) and absent in group (iii). These findings support the concept that endometrial function is altered in pregnancies achieved following ovarian stimulation. Alternatively, if the ovary is an important source of PP14, then these data suggest that in contrast to ovarian synthesis of steroids and the peptide relaxin, ovarian stimulation results in an impairment of PP14 synthesis, and that this is most marked when clomiphene citrate has been used.

Fetal plasma erythropoietin concentration in severe growth retardation

OBJECTIVE

The aim of this study was to determine whether hypoxemia induces an increase in plasma erythropoietin concentration in human fetal life and, if so, whether this response stimulates fetal erythropoiesis.

STUDY DESIGN

The plasma erythropoietin concentration in blood samples from 33 small-for-gestational-age fetuses at 26 to 38 weeks' gestation was measured. Measurements were compared with the reference range for gestation, and associations with PO2, pH, and erythroblast and erythrocyte counts were examined.

RESULTS

The mean plasma erythropoietin concentration in the small-for-gestational-age fetuses was significantly increased, and the degree of increase was significantly associated both with fetal acidemia and, more strongly, with fetal erythroblastosis.

CONCLUSION

Erythropoietin production in response to tissue hypoxia occurs from at least 26 weeks' gestation with measurable physiologic effects on erythropoiesis. Furthermore, more accurate assessment of tissue oxygenation may be obtained by measuring the erythroblast count rather than the blood pH.

Fetal plasma erythropoietin concentration in red blood cell-isoimmunized pregnancies

OBJECTIVE

The aim of this study was to investigate the relationship between fetal anemia, plasma erythropoietin concentration, and erythroblastosis in red blood cell-isoimmunized pregnancies.

STUDY DESIGN

Fetal plasma erythropoietin concentration in umbilical venous blood samples from 68 red blood cell-isoimmunized pregnancies at 18 to 35 weeks' gestation was measured. Measurements were compared with the appropriate reference range with gestation, and associations with blood pH, erythroblast count, and hemoglobin concentration were examined.

RESULTS

The mean fetal plasma erythropoietin concentration and erythroblast count in red blood cell-isoimmunized pregnancies were significantly increased only in severe fetal anemia (hemoglobin deficit > 7 gm/dl). Furthermore, some severely anemic fetuses were hydropic and acidemic. The degree of increase in plasma erythropoietin was significantly associated with both fetal acidemia and, more strongly, fetal erythroblastosis.

CONCLUSION

These findings suggest that in fetuses from red blood cell-isoimmunized pregnancies the ability to prevent tissue hypoxia is present until anemia becomes severe, presumably by an increase in cardiac output and tissue perfusion. In severe anemia tissue hypoxia occurs, and the data indicate that fetuses respond by increasing erythropoietin production from at least 20 weeks' gestation. Furthermore, more accurate assessment of tissue oxygenation may be obtained by measuring the erythroblast count rather than the blood pH.

Distribution of relaxin between human maternal and fetal circulations and amniotic fluid

Relaxin was measured in maternal blood and amniotic fluid samples at 9-40 weeks and in fetal blood samples at 19-41 weeks of pregnancy. In amniotic fluid, concentrations of relaxin rose from 58 ng/l (geometric mean) at 10 weeks to 142 ng/l at 14 weeks and declined subsequently to 55 ng/l at 22 weeks. In maternal blood, mean relaxin concentrations were ten times greater than in amniotic fluid, and concentrations decreased with gestation. Since there was no significant association between the relaxin concentrations in the two compartments, relaxin in the amniotic fluid may be derived from the decidualized endometrium rather than the maternal circulation, alternatively its metabolism may be different in the two compartments. The absence of detectable concentrations of relaxin in any of the fetal blood samples demonstrates that there is no significant placental transfer or fetal synthesis of this peptide.

High expression of transforming growth factor-beta long cell cycle times and a unique clustering of S-phase cells in patients with acute promyelocytic leukemia

Expression of transforming growth factor-beta (TGF-beta), which inhibits the proliferation of hematopoietic progenitors, was investigated simultaneously with cell cycle characteristics in 63 bone marrow biopsies from 23 cases with acute promyelocytic leukemia (APL). Bromodeoxyuridine (BrdU) was administered to every patient (17 newly diagnosed) for determination of the labeling index (LI) and the durations of S-phase (Ts) and the cell cycle (Tc) of leukemic promyelocytes. APL cases had lower LI both in the bone marrow aspirate (6.1% v 11.4%, P = .008) and biopsy (21.1% v 28.0%, P = .001) and longer Tc (93.6 hours v 56.0 hours, P = .002) when compared with other French-American-British subtypes. TGF-beta expression (detected by a monoclonal anti-TGF-beta 2/beta 3 antibody) was dramatically high, especially in interstitial areas of the biopsies. S-phase cells were found as geographically restricted islands of proliferation (GRIPs) in 20 of 22 cases. Weekly biopsies showed an increment in TGF-beta on day 7 of therapy in 13 of 17 cases, while in vivo differentiation was noted in 9 of 15. We conclude that the presence of high TGF-beta expression may explain the biologic basis for the slowly cycling nature of leukemic promyelocytes in APL as well as the unique clustering of S-phase cells observed in GRIPs.

Fetal and maternal erythropoietin levels in normal pregnancy

In a cross-sectional study of 120 pregnancies undergoing cordocentesis for prenatal diagnosis (n = 90) or elective caesarean section (n = 30), the umbilical cord and maternal venous plasma erythropoietin (Epo) concentrations were measured. Fetal Epo levels increased from a mean of 4 mU/ml at 16 weeks to 13 mU/ml at 40 weeks' gestation. There were no significant associations between fetal plasma Epo concentration and fetal blood gases, haemoglobin concentration, oxygen content or erythroblast count. The maternal plasma Epo concentration (mean = 14 mU/ml, range 1-77 mU/ml) did not change with gestation but was significantly higher than levels in non-pregnant females (mean = 6.6 mU/ml, range 1-25 mU/ml).

Fetal renal defects: associated malformations and chromosomal defects

During a 6-year period (1985-1990) blood karyotyping was performed in 682 fetuses with renal defects. There were: 276 fetuses with mild hydronephrosis; 206 with moderate/severe hydronephrosis; 173 with multicystic dysplasia, and 27 with renal agenesis. The overall incidence of chromosomal abnormalities was 12% (trisomies, n = 63; deletions, n = 9; triploidies, n = 5, and sex chromosome aneuploidies, n = 8). There were more than twice as many males than females, but the incidence of chromosomal defects in females was almost double (18%) than in males (10%). Furthermore, compared to the overall maternal age-related risk, the risk for fetal chromosomal abnormalities was three times higher when there was an isolated renal defect and thirty times higher when there were additional malformations. The risk of chromosomal abnormalities was similar for fetuses with unilateral or bilateral involvement, different types of renal defects, urethral or ureteric obstruction, and oligohydramnios or normal/reduced amniotic fluid volume. Nevertheless, the patterns of chromosomal abnormalities, and consequently that of associated malformations, were related to the different types of renal defects.

Headache

Headache is one of the commonest problems to face the family doctor and hospital practitioners. Though migraine and tension headaches are the most common, other types could reflect serious underlying structural causes. Accurate diagnosis can usually be made from a complete history and examination. However, referral of some patients to a specialist clinic is inevitable.

Latent iron deficiency anaemia in schistosomiasis

This study was carried on 60 male patients, 20 have simple intestinal mansoniasis, 20 have simple urinary bilharziasis and 20 have hepatosplenic mansoniasis. Latent iron deficiency anaemia, defined as those having normal Hb content (greater than 13 g/dl) and low serum ferritin (less than 15 ng/mL). Such latent anaemia was found in 35% of cases with simple mansoniasis, 20% of cases with simple urinary bilharziasis but not in any case with hepatosplenic mansoniasis. Also it was associated with mild intensity of infection.

[Esophagogastroduodenal localizations of Crohn's disease are frequent]

The purpose of this study was to determine the endoscopic features, actual frequency and consequences of upper digestive involvement in Crohn's disease (CD). Between April 1973 and April 1985, one or several upper digestive tract endoscopies with biopsies were performed in 129 of 195 patients admitted for ileal and/or colorectal CD. Endoscopic lesions were small and superficial: aphtous and superficial ulcerations, or erythematous areas. The diagnosis of upper digestive involvement was probable in 36 of the 129 patients who underwent upper endoscopies (28 p. 100), certain (microscopic evidence of granuloma) in 21 patients (16 p. 100). Lesions were isolated or multifocal but their preferential sites were the antrum and proximal duodenum. Histologic study of biopsies showed that granuloma were as frequent in upper as in lower intestinal lesions of CD. A frequency of 20 p. 100 seems to us to be more correct than the 5 p. 100 usually admitted. In our experience, upper digestive involvement in CD could not be regarded as a pejorative prognostic factor. It was sometimes possible to identify colitis or a peptic ulcer disease as a lower or upper digestive manifestation of CD, respectively.

[Cholesterol crystals and biliary lithiasis. Importance of the study of bile collected by duodenal intubation]

Cholesterol crystallization in a necessary step in the formation of cholesterol gallstones. Our purpose was to study the relationship between the presence of biliary cholesterol crystals and radiolucent gallstones. Bile was obtained by duodenal intubation from 60 subjects free of hepatic disease: 40 patients had radiolucent gallstones and in the remaining 20 subjects no gallstones could be found either by oral cholecystography or by ultrasound examination. In each patient a bile sample was used to search for cholesterol crystals; in another sample, biliary cholesterol, phospholipids and bile acids were measured to calculate the lithogenic index. Among the 44 subjects with lithogenic bile, 34 had radiolucent gallstones. Twenty-two out of the 60 patients had both cholesterol crystals and radiolucent gallstones; 21 subjects out of the 22 had lithogenic bile. In patients with frequent biliary colic or subacute pancreatitis without visible gallstones, finding cholesterol crystals in bile might suggest medical or surgical specific treatment.