Morphology assessed by transvaginal ultrasonography differs in patients in preterm labor with vs. without bacterial vaginosis

OBJECTIVE

To determine whether cervical morphology in preterm labor patients differs in the presence or absence of bacterial vaginosis.

DESIGN

Observational study.

SUBJECTS

One hundred and twelve consecutive patients with objectively confirmed preterm labor admitted to a tertiary care centre were included in the study. Patients with placenta previa, active uterine bleeding or indication for an immediate delivery (e.g. severe pre-eclampsia or suspected fetal asphyxia), or severe fetal anomalies were excluded.

METHODS

Transvaginal ultrasonography was used to measure cervical length and internal os width. Bacterial vaginosis was diagnosed by Gram stain of a vaginal smear.

RESULTS

A total of 36 patients (32%) had bacterial vaginosis. Cervical length in this group was shorter than in patients with normal flora (mean 20.4 +/- 7.2 mm vs. 26.4 +/- 6.7 mm; P = 0.0002), and more patients with bacterial vaginosis had a dilated internal cervical os > or = 5 mm (67% vs. 30%, P = 0.001). There were no significant differences, however, in preterm delivery rate and birth weight between the two groups; the overall preterm delivery rate was 40%. A cervical length < 25 mm was predictive of preterm delivery (P = 0.001, RR 4.2, 95% CI 1.8-9.7).

CONCLUSIONS

These data suggest that cervical change in preterm labor is more pronounced in patients with bacterial vaginosis but without a concomitant increase in the risk for preterm delivery. Despite this association, the cervical length measured by transvaginal ultrasonography alone is a useful predictor of preterm delivery, independent of the presence or absence of bacterial vaginosis.

Choice of anticoagulant can influence the analysis using fluorescence in situ hybridization of fetal cells enriched from maternal blood

A notable degree of research attention is being focused on the use of fetal cells enriched from the blood of pregnant women as a non-invasive means of prenatal diagnosis. By using magnetic activated cells sorting (MACS) and fluorescence in situ hybridization (FISH), we have examined the efficacy of enriched fetal cells in determining fetal sex. An unexpected finding of this investigation was that the sensitivity of this analysis was influenced by the anticoagulant used to treat the maternal blood samples. As such, samples treated with heparin showed significantly lower detection rates than samples chelated with EDTA.

Characterization of an immortalized human granulosa cell line (COV434)

We have investigated the biological characteristics of an immortalized granulosa cell line (COV434), which may be used to study follicular and oocyte maturation in vitro. Granulosa cell function was defined as consisting of three distinct properties: (i) production of 17beta-oestradiol in response to follicle stimulating hormone (FSH); (ii) presence of specific molecular markers of apoptosis enabling the induction of follicular atresia; and (iii) capacity to form intercellular connections with cells surrounding an oocyte. The addition of FSH to the culture medium supplemented with 10% fetal calf serum and 4-androstene-3,17-dione resulted in proliferation of the COV434 granulosa cells and in an increased synthesis of 17beta-oestradiol, indicating the presence of the FSH receptor and cytochrome P450 aromatase in these cells. The receptor for luteinizing hormone (LH) was undetectable. Similar expression of various apoptosis-associated genes was found in COV434 granulosa cells and in granulosa cells of patients stimulated with gonadotrophins for in-vitro fertilization, thus indicating that the immortalized COV434 granulosa cells were able to sustain apoptosis. Multiple intercellular connections were formed during co-culture of COV434 granulosa cells with cumulus cells containing an immature oocyte but not with cumulus cells devoid of an oocyte. Detailed morphological analysis of the intercellular connections with scanning electron microscopy and confocal light microscopy demonstrated the presence of long slender structures. It is concluded that the immortalized human granulosa cell line COV434 may be useful for experimental studies on follicular development.

Current applications of single-cell PCR

The advent of the polymerase chain reaction (PCR) has revolutionised the way in which molecular biologists view their task at hand, for it is now possible to amplify and examine minute quantities of rare genetic material: the limit of this exploration being the single cell. It is especially in the field of prenatal diagnostics that this ability has been readily seized upon, as it has opened up the prospect of preimplantation genetic analysis and the use of fetal cells enriched from the blood of pregnant women for the assessment of single-gene Mendelian disorders. However, apart from diagnostic applications, single-cell PCR has proven to be of enormous use to basic scientists, addressing diverse immunological, neurological and developmental questions, where both the genome but also messenger RNA expression patterns were examined. Furthermore, recent advances, such as optimised whole genome amplification (WGA) procedures, single-cell complementary DNA arrays and perhaps even single-cell comparative genomic hybridisation will ensure that the genetic analysis of single cells will become common practice, thereby opening up new possibilities for diagnosis and research.

Prospective evaluation of the ultrasound appearance of the endometrium in a cohort of 1,186 infertile women

OBJECTIVE

To investigate the effect of differences in endometrial thickness and pattern as visualized with present-day high-resolution transvaginal ultrasound equipment on the outcome of assisted reproductive treatment.

DESIGN

Prospective cohort study.

SETTING

Two large infertility units in university hospitals.

PATIENT(S)

The endometrial characteristics of 981 patients during 1,600 assisted reproductive treatment cycles were compared with those of 205 untreated women. In addition, abnormal echogenic patterns of the endometrium were characterized histologically in 44 patients.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Pregnancy rates.

RESULT(S)

The endometrium was significantly thinner in untreated women and women treated with IUI than in women treated with IVF or intracytoplasmic sperm injection. The exponential proliferation of the endometrium was similar in conception and nonconception cycles. The odds for a successful pregnancy were significantly lower in the presence of a thin endometrium in women treated with IUI but not in women treated with the long stimulation protocol for IVF or intracytoplasmic sperm injection. Singleton pregnancies were more common than multiple pregnancies in patients with thin endometria.

CONCLUSION(S)

The pregnancy rates of assisted reproductive procedures are influenced only marginally by the degree of endometrial proliferation, and treatment should not be canceled because of inadequate endometrial thickness.

Impact on uterine bleeding and endometrial thickness: tibolone compared with continuous combined estradiol and norethisterone acetate replacement therapy

OBJECTIVE

To evaluate endometrial thickness and the incidence of uterine bleeding in postmenopausal women using either tibolone 2.5 mg or continuous combined 2 mg estradiol and 1 mg norethisterone acetate (E+NETA) daily as hormone replacement therapy.

DESIGN

We compared diary records of self-reported uterine bleeding and measurements of endometrial thickness, area, and volume by transvaginal sonography at baseline and after 1, 3, 6, and 12 months in a 1-year, prospective, randomized, double-blind, single-center trial of 100 postmenopausal women aged 46-69 years. Bleeding frequencies and endometrial thickness were assessed by Chi-square tests and analysis of covariance, respectively.

RESULTS

Self-reported bleeding was significantly less in the tibolone group. Bleeding episodes were reported by 27.7% of women in the tibolone group and by 59.2% in the E+NETA group. The mean number of days with bleeding was 5.8 +/- 27.0 in the tibolone group and 35.6 +/- 58.6 in the E+NETA group. Six women in the tibolone group and seven in the E+NETA group discontinued the study; three in the E+NETA group because of bleeding. The mean endometrial thickness at baseline was 2.56 +/- 0.81 mm in the tibolone group and 2.58 +/- 1.04 mm in the E+NETA group. After 1 year, the corresponding figures were 3.32 +/- 1.58 mm and 3.07 +/- 1.68 mm. Thus, 86% of women in the tibolone group and 93% in the E+NETA group had an endometrial thickness of less than 5 mm.

CONCLUSIONS

Use of tibolone 2.5 mg daily for 1 year was associated with significantly less bleeding and spotting compared with daily continuous combined 2 mg estradiol and 1 mg norethisterone acetate in postmenopausal women in the presence of both minimal and nonprogressive increase of endometrial thickness associated with the two regimens.

Approximately half of the erythroblasts in maternal blood are of fetal origin

The enrichment of fetal erythroblasts from the peripheral blood of pregnant women is currently actively pursued for the development of a non-invasive means of prenatal diagnosis. Since erythroblasts in maternal blood are not all of fetal origin, and currently no reliable method exists to distinguish between the maternal and fetal erythroblasts, their use for prenatal diagnosis is not without uncertainty. The purpose of this study was to determine the percentage of fetal erythroblasts in maternal blood at the single cell level and to what extent such cells can reproducibly be used for polymerase chain reaction (PCR)-based prenatal diagnostic analyses. Erythroblasts were enriched from the peripheral blood of rhesus negative pregnant women using magnetic cell sorting (MACS). Single erythroblasts identified morphologically were individually micromanipulated and analysed by a multiplex PCR reaction for the fetal SRY and rhesus D genes. As a control for the PCR reaction the beta-globin gene was used. The PCR results were validated by the results obtained by invasive procedures. In all instances where single erythroblasts were examined, the correct fetal genotype for the two fetal specific loci was detected. Furthermore, our results indicate that approximately 50% of the enriched erythroblasts are of fetal origin.

[Fetal cells in maternal blood--their significance in non-invasive prenatal diagnosis and in etiologically determined diseases]

The first report of the occurrence of fetal cells in maternal circulation dates back to 1893 when the German pathologist Schmorl identified trophoblast cells in the lungs of women who had died from eclampsia. Till recently, however, the existence of fetal cells in maternal blood was a matter of considerable debate. The main reason for this dispute was the inability to successfully and reliably enrich for these cells, which has also hindered their clinical use. In the meantime, this issue has been addressed and the both fetal aneuploidies and single gene defects can now be detected in a non-invasive manner using fetal cells enriched from maternal blood.

Selective termination for structural, chromosomal, and mendelian anomalies: international experience

OBJECTIVE

Our purpose was to evaluate the outcomes of selective termination for fetal anomalies at 8 centers with the largest known experiences worldwide.

STUDY DESIGN

Outcomes in 402 cases of selective termination in pregnancies with dizygotic twins from 8 centers in 4 countries were analyzed by year, gestational age at procedure, and indication. Reductions of fetuses were as follows: 2 to 1, n = 345; 3 to 2, 39; >/=4 to 2 or 3, n = 18. Potassium chloride was used in all procedures.

RESULTS

Selective termination resulted in delivery of a viable infant or infants in >90% of cases. Loss up to 24 weeks occurred in 7.1% of cases in which the final result was a singleton fetus and in 13.0% of cases in which the final result was twins. Loss was 6.6% as a result of structural abnormalities, 7.0% for chromosomal abnormalities, and 10% for mendelian abnormalities (difference not statistically significant). Loss rates for procedures were as follows: 9-12 weeks, 5.4%; 13-18 weeks, 8.7%; 19-24 weeks, 6.8%; and >/=25 weeks, 9.1% (difference not statistically significant). Mean gestational age at delivery was 35.7 weeks. No differences were seen in outcomes by maternal age. The rate of very early premature deliveries has fallen in recent years. There were no known cases of disseminated intravascular coagulation or serious maternal complications.

CONCLUSION

(1) Selective termination, in the most experienced hands, can be technically performed in all 3 trimesters with good outcomes in >90% of cases. (2) The previously observed increase in second- versus first-trimester losses has diminished. (3) Third-trimester procedures, where legal, can be performed with a good outcome for the surviving fetus.

[Malignant pheochromocytoma in the 17th week of gestation]

INTRODUCTION

Pheochromocytoma during pregnancy is rare and represents a high risk for mother and fetus. Due to the variable clinical presentation it may be mistaken for preeclampsia.

CASE

A 34-year-old primipara with hypertension up to 240/120 mmHg. After diagnosis of a pheochromocytoma its resection together with lymph node metastasis in the 17th week of gestation was performed.

CONCLUSION

The definitive diagnosis is confirmed by elevation of serum catecholamines and their metabolites in a 24-h urine collection. Localization during pregnancy can be made by ultrasound and MRI. The definitive treatment is surgical removal after administration of adrenergic blockers. If discovered later in pregnancy, delivery by elective caesarean section followed by tumor resection is recommended. Since about 10 % of pheochromocytomas are malignant, postpartum screening is required to detect and treat extraadrenal or metastatic tumors by MIBG scintigraphy, chemotherapy or surgical procedures.

Allele drop-out can occur in alleles differing by a single nucleotide and is not alleviated by preamplification or minor template increments

The ability to analyze the genetic material of single cells by the PCR opens up new prospects for diagnostics. Because only two copies of the genetic template are available for amplification, a problem that frequently arises when examining heterozygous loci in single cells is allele drop-out (ADO). ADO results from the preferential amplification of one of a pair of heterozygous alleles, in which the other allele is totally under-represented. In examining single cells from carriers heterozygous for beta-thalassemia mutations, we have found ADO to occur in alleles differing by a single nucleotide, where either the normal or the mutant genotype was absent. We have found that ADO is not overcome by either increasing the amount of DNA template to 20 pg or by primer extension preamplification (PEP), but rather that the best diagnostic accuracy is obtained by examining multiple single cells and basing a diagnosis on the combined results of such an examination.

Oral misoprostol for third stage of labor: a randomized placebo-controlled trial

OBJECTIVE

To investigate whether orally administered misoprostol during the third stage of labor is efficient in reducing postpartum blood loss.

METHODS

In a double-masked trial, during vaginal delivery women were randomly assigned to receive a single oral dose of misoprostol (600 microg) or placebo in third stage of labor, immediately after cord clamping. The third stage of labor was managed routinely by early cord clamping and controlled cord traction; oxytocin was administered only if blood loss seemed more than usual. Blood loss was estimated by the delivering physician and differences in hematocrit were measured before and after delivery.

RESULTS

Mean (+/- standard error of the mean) estimated blood loss (345 +/- 19.5 mL versus 417 +/- 25.9 mL, P = .031) and hematocrit difference (4.5 +/- 0.9% versus 7.9 +/- 1.2%, P = .014) were significantly lower in women who received misoprostol than those who received placebo. Fewer women in the misoprostol group had postpartum hemorrhage (blood loss of at least 500 mL), but that difference was not statistically significant (7% versus 15%, P = .43). Additional oxytocin before or after placental separation was used less often in the misoprostol group (16% versus 38%, P = .047). There were no differences in the length of third stage of labor (8 +/- 0.9 minutes versus 9 +/- 1 minutes, P = .947). There were no differences in pain during third stage of labor, postpartum fever, or diarrhea, but shivering was more frequent in the misoprostol group.

CONCLUSION

Oral misoprostol administered in the third stage of labor reduced postpartum blood loss and might be effective in reducing incidence of postpartum hemorrhage.

Umbilical cord blood from preterm human fetuses is rich in committed and primitive hematopoietic progenitors with high proliferative and self-renewal capacity

Human umbilical cord blood (CB) has been recognized as a source of hematopoietic stem cells for transplantation. While hematopoietic properties of neonatal CB from full-term pregnancies have been well characterized, little is known about CB from early gestational ages. We analyzed the content and the growth properties of primitive and committed hematopoietic progenitors in preterm CB from second trimester (week 16-28; n = 17) and early third trimester (week 29-34; n = 17) in comparison with term CB (n = 18). The frequency of CD34+ and CD34+CD38- cells was significantly higher in preterm than in term CB (mean, 2.51% and 0.56% vs 0.88% and 0.13%;p < 0.002). The number of colony forming units (CFU) in preterm CB was about twofold higher (230 +/- 6 vs 133 +/- 14/ 10(5) mononuclear cells; p < 0.05) and correlated with the content of CD34+ progenitors (r = 0.73). Long-term culture initiating cells (LTC-IC) were enriched about 2.5-fold (6.7 +/- 2.9 vs 2.6 +/- 1.2/10(5) cells; p < 0.05). Progenitors from preterm CB could be expanded in stroma-free liquid cultures supplemented with hematopoietic growth factors as efficiently as progenitors from term neonates. In short-term cultures containing erythropoietin (Epo), interleukin (IL)-1, IL-3, and IL-6, or granulocyte- (G-) and granulocyte-macrophage colony-stimulating factor (GM-CSF) together with stem cell factor (SCF) or Flt3 ligand (FL), expansion of CFUs was six- to eightfold at week 1. In long-term cultures containing thrombopoietin (TPO) and FL, an approximately 1000-fold expansion of multilineage progenitors was observed at week 10. In summary, we show that preterm CB compared with term CB is richer in hematopoietic progenitors, and that precursors from preterm CB can be extensively expanded ex vivo. This may have implications for the development of transplantation and gene transfer strategies targeting circulating fetal stem cells.

Prognostic value of genomic alterations in invasive cervical squamous cell carcinoma of clinical stage IB detected by comparative genomic hybridization

The clinical behavior of invasive cervical carcinoma of clinical stage IB varies considerably in tumors presenting without regional lymph node metastases. The early identification of patients at higher risk for poor outcome may prove useful because these patients would benefit from aggressive adjuvant treatments. In this study, comparative genomic hybridization was applied to evaluate whether genomic aberrations have prognostic significance in cervical carcinoma. Genomic alterations were evaluated in 62 cervical carcinomas of clinical stage IB. DNA sequence losses were most prevalent at chromosomes 4q (53%), 3p (52%), 13q (45%), 4p (44%), Xq (44%), 5q (40%), 18q (37%), and 6q (35%). Several genomic alterations were associated with poor clinical outcome or metastasis. The total number of DNA aberrations/tumor (P < 0.02) and the number of DNA sequence losses/tumor (P < 0.04) were associated with disease-specific survival. 9p deletions were significantly more frequent in carcinomas with lymph node metastasis than in node-negative tumors (P < 0.03). Losses of chromosome 11p (P < 0.0001) and 18q (P < 0.01) were associated with poor prognosis in cervical carcinomas without lymph node metastasis. These data suggest that inactivation of tumor suppressor genes on chromosomes 9p, 11p, and 18q may play a role in the progression of cervical carcinoma.

Fetal cells in maternal blood. An update from Basel

OBJECTIVE

The efficiency of two protocols for the enrichment of fetal cells from the blood of pregnant women was compared: a triple density gradient followed by twin magnetic separations (method A) versus a single density gradient and single magnetic separation (method B).

STUDY DESIGN

Blood samples were obtained from women prior to undergoing an invasive procedure. The processed samples, 87 by method A and 332 by method B, were examined for the presence of male cells by fluorescence in situ hybridisation.

RESULTS

The simpler protocol was found to be superior. The most critical component, however, is the ability of the reader to correctly evaluate the sample, where we observed large variations, with reader B attaining a sensitivity of 82.61% with a corresponding specificity of 86.96%.

CONCLUSION

A simpler enrichment protocol can be used from smaller blood samples to attain detection efficiencies which are similar to or superior to current noninvasive methods.

In utero hematopoietic stem cell transfer: current status and future strategies

Successful prenatal treatment of severe immunodeficiencies by allogeneic hematopoietic stem cell transplantation in utero has been reported. Though other diseases like hemoglobinopathies or storage diseases are potentially amenable to this novel therapeutic approach, no success has yet been achieved in recipients without severe immunodeficiency. Graft rejection by the developing fetus and/or lack of selective, competitive advantage of donor versus host stem cells preventing stable engraftment seem to be the major obstacles. Several strategies to overcome these hurdles are being explored in preclinical settings, including timing and repeated dosing of stem cell administration to the fetus, ex vivo modification of the transplant, using different fetal compartments as targets for early stem cell transfer, or inducing microchimerism for postnatal transplantation from the same donor. In addition, the exact definition of the basic concept of early fetal immunologic naivete and the understanding of the molecular basics of migration and homing in fetal hematopoiesis system seem mandatory for a successful approach. Gene therapy using ex vivo transduced autologous cord blood cells or direct gene targeting in utero are other potential means to correct hematopoietic and immunologic single gene disorders in utero, though this approach is still away from the stage of clinical trials.

A comparison of different density gradients and antibodies for enrichment of fetal erythroblasts by MACS

The enrichment of fetal cells, in particular fetal erythroblasts from the blood of pregnant women offers a promising non-invasive alternative for prenatal diagnosis. The purpose of this study was to compare the retrieval of erythroblasts by different density gradients and different antibodies against erythroid surface antigens, in both a model test system and in blood samples of pregnant women. We enriched erythroblasts from artificial mixtures of cord and adult blood (1:50) and from 16 ml of peripheral blood from pregnant women at a mean gestational age of 14+2 weeks. The yield of erythroblasts was calculated and compared using Wilcoxon's matched-pairs signed-rank test. In the artificial mixture most erythroblasts were retrieved using the heaviest density gradient (specific density of 1119) followed by antibody-labelled magnetic cell sorting (MACS). With anti-GPA the yield of erythroblasts from the artificial mixture was highest (9362.5 erythroblasts) compared with anti-CD36 (5164.3), anti-i (3455.2), anti-CD71 (3055.8) and HAE9 (2364.2). The difference between anti-GPA and anti-CD71, HAE9 and anti-i was significant (p=0.0277). The enrichment of erythroblasts from peripheral blood of pregnant women showed similar results. The yield of erythroblasts using anti-GPA was the highest. These results enable us to simplify our enrichment protocols to a single density gradient of 1119 specific density followed by MACS, with anti-GPA.

[Desire for children in tumor patients]

After a chemo- and/or radiotherapy not only acute side effects but also longterm side effects do occur. The following longterm side effects are observed: irregularities in the menstrual cycle, early onset of menopause and infertility. They are of special importance to children, teenagers and young adults having survived a malignancy. For young women experiencing a premature menopause a hormone replacement therapy is indicated. The degree of gonadal failure depends on the total dose of cytotoxics, radiation or the combination of both. Alkylating substances are responsible for gonadal failure whereas other cytotoxic agents lead to reversible gonadal dysfunction. An important risk factor for the development of ovarian failure is the woman's age at the time of treatment. A pregnancy in patients with a history of malignancy always is a high risk pregnancy and needs a close follow up. The offspring of cancer survivors do not show a higher rate of chromosomal abnormalities or neoplasms. Before starting a chemo- and/or radiotherapy the patient should be informed about acute and late effects. Men and adolescent boys should be given the opportunity for sperm cryopreservation. It is unclear whether a fertility reserve can be achieved by cryopreservation also in women.

International, collaborative assessment of 146,000 prenatal karyotypes: expected limitations if only chromosome-specific probes and fluorescent in-situ hybridization are used

The development of chromosome-specific probes (CSP) and fluorescent in-situ hybridization (FISH) has allowed for very rapid identification of selected numerical abnormalities. We attempt here to determine, in principle, what percentage of abnormalities would be detectable if only CSP-FISH were performed without karyotype for prenatal diagnosis. A total of 146 128 consecutive karyotypes for prenatal diagnosis from eight centres in four countries for 5 years were compared with predicted detection if probes for chromosomes 13, 18, 21, X and Y were used, and assuming 100% detection efficiency. A total of 4163 abnormalities (2.85%) were found including 2889 (69. 4%) (trisomy 21, trisomy 18, trisomy 13, numerical sex chromosome abnormalities, and triploidies) which were considered detectable by FISH. Of these, 1274 were mosaics, translocations, deletions, inversions, rings, and markers which would not be considered detectable. CSP-FISH is a useful adjunct to karyotype for high risk situations, and may be appropriate in low risk screening, but should not be seen as a replacement for karyotype as too many structural chromosome abnormalities will be missed.

Maternal age- and gestation-specific risk for trisomy 21

OBJECTIVE

To provide estimates of maternal age- and gestational age-related risks for trisomy 21.

METHODS

The prevalence of trisomy 21 was examined in 57,614 women who had fetal karyotyping at 9-16 weeks of gestation for the sole indication of maternal age of 35 years or more. On the basis of the maternal age distribution and the reported maternal age-related risk for trisomy 21 at birth, the expected number of trisomy 21 cases was calculated for each gestational age subgroup (9-10 weeks, 11-14 weeks and 15-16 weeks). The ratio of the observed to expected number of cases of trisomy 21 was then calculated and regression analysis was applied to derive a smoothened curve. The formula for maternal age- and gestational age-related risk was then applied to a population of 96,127 pregnancies that were examined at 10-14 weeks to calculate the expected number of trisomy 21 pregnancies, and this number was compared to the observed number of 326.

RESULTS

In the 57,614 pregnancies there were 538 cases of trisomy 21. The relative prevalences of trisomy 21, compared to a prevalence of 1.0 at 40 weeks, was 10 exp(0.2718 x log(10)(gestation)2 - 1.023 x log10(gestation) + 0.9425). On the basis of the estimated maternal age- and gestational age-related risks, the expected number of trisomy 21 cases at 10-14 weeks of gestation in the 96,127 pregnancies was 329 (95% confidence interval 291-361), which was not significantly different from the observed number of 326 cases (chi2 = 0.02).

CONCLUSION

The risk for trisomy 21 increases with maternal age and decreases with gestation. The prevalence of trisomy 21 at 12 and 16 weeks of gestation is higher than the prevalence at 40 weeks by 30% and 21%, respectively.

[Epilepsy and pregnancy]

One out of 200 pregnant women suffers from epilepsy. Pregnancy and epileptic disease or its medical treatment, respectively, do interfere, as on the one hand serum concentration of antiepileptic drugs can severely be altered during pregnancy. On the other hand these drugs cause a fetal malformation rate 2-3 times higher than in an average population. These facts demand an interdisciplinary cooperation between neurologists, pediatricians and obstetricians. Preconceptional advice should lead to a preventive folic acid medication and information about the higher risk for preterm delivery, intrauterine growth retardation or fetal death as sequelae of epileptic attacks. In antepartal investigations the emphasis should be on the sonographic diagnosis of fetal malformations and on regular control of serum concentration of antiepileptic drugs. During labor a tight fetal monitoring is obligatory. There is no indication for a primary cesarean section. The risk of neonatal hemorrhage due to a lack of vitamin K is reduced by prophylactic medication. Under optimal conditions about 90% of pregnancies and deliveries will be uncomplicated. During puerperium serum levels of antiepileptics should be controlled again. Breastfeeding is possible.

Three dimensional volume measurement of the cervix during pregnancy compared to conventional 2D-sonography

OBJECTIVE

To compare the three dimensional (3D) volume assessment of the cervix with the conventional two-dimensional cervical length measurement in a low and a high risk group for cervical incompetence.

METHODS

In an observational study, we investigated a group A of low risk pregnancies (no preterm contractions, no vaginal bleeding or vaginal infections and no history of preterm delivery) and a group B of high risk pregnancies (preterm contractions or PROM). All patients underwent a transvaginal ultrasound investigation with a 7.5 MHz probe using a three-dimensional ultrasound system (Combison 530, Kretztechnik, Austria). After measuring the cervical length, the internal os and the funneling with the B-mode, 3D-volume was recorded twice by the same investigator using the same machine. Since 2D-length measurement of the cervix has been established to be predictive for spontaneous preterm delivery, we wanted to test whether 3D-volume assessment has a better discriminative power to differentiate a high-risk from a low-risk group. Therefore the 2D and 3D measurements (mm, resp. cm3) were compared between patient groups A and B using the two tailed Student t-test and Fisher's Exact test.

RESULTS

In 2D cervical length measurement the mean cervical length in group A was significantly longer than in group B: 41.1 +/- 8.61 mm and 27.77 +/- 10.42 mm, P = 0.00000017. In 3D-sonography the mean cervical volume was larger in group A, but the difference compared to group B was not significant: 47.71 +/- 18.38 mm and 39.90 +/- 12.57 mm, P = 0.07.

CONCLUSION

Contrary to our hypothesis cervical length measurement therefore was superior to cervical volume measurement assessed by 3D ultrasound for identifying women with increased risk of spontaneous preterm delivery. This may be due to the larger distribution of measurement values in the 3D group.

Low rates of pregnancy termination for prenatally diagnosed Klinefelter syndrome and other sex chromosome polysomies

Over the past 9 years we counseled 55 couples whose unborn child was found to carry a sex chromosome polysomy. We performed a survey of postcounseling parental decisions about continuation or termination of these pregnancies. Of the 55 embryos or fetuses, 23 had the karyotype 47,XXY, 10 had 47,XYY, and 12 had 47,XXX. In addition, there were 10 instances of true mosaicism, i.e. 47,XXY/46,XY (n = 5), 47,XYY/46,XY (n = 2), or 47,XXX/46,XX (n = 3). Mean gestational age (+/-standard deviation) at diagnosis was 18.3+/-3.0 weeks. After comprehensive genetic counseling 48 (87.3%) of these pregnancies were carried to term. In seven cases (12.7%) the parents elected a pregnancy termination. Two of 31 pregnancies (6.5%) primarily ascertained at our center were aborted, whereas amongst the 24 referred cases, 5 couples (20.8%) opted for a termination. The mean gestational age of the terminated pregnancies was 19.7 weeks. The overall termination rate of 12.7% appears low in comparison with literature data. Most reports from other institutions present termination rates between 32 and 66%. The reason for the low rate of induced abortions in our study cohort is not clear. Cultural differences in parental perception of sex chromosomal polysomies may be of importance, and peculiarities of genetic counseling at our institution could also play a role. Although counseling was nondirective, we did put emphasis on providing prospective parents with information from unbiased follow-up studies of children with Klinefelter syndrome and other sex chromosome polysomies.

Quantitative immunophenotypic characterization, cryopreservation, and enrichment of second- and third-trimester human fetal cord blood hematopoietic stem cells (progenitor cells)

OBJECTIVE

The aims of this study were (1) to assess the hematopoietic stem cell (progenitor cell) contents of umbilical cord blood samples from second-trimester and early-third-trimester fetuses versus term fetuses and (2) to determine the feasibility of cryopreservation and enrichment of cord blood from fetuses of different gestational ages.

STUDY DESIGN

Cord blood between 13 and 42 weeks' gestation (n = 31) was sampled after delivery or fetal expulsion. Fluorescence-activated cell sorting was used to measure CD34(+) and CD34(+)CD38(-) cell numbers. Samples were cryopreserved with 10% dimethylsulfoxide, and CD34(+) enrichment was performed by magnetically activated cell sorting with the MiniMACS system (Miltenyi Biotech, Bergisch Gladbach, Germany). Kruskal-Wallis analysis of variance and the Mann-Whitney U test were used for analysis of data.

RESULTS

CD34(+) and CD34(+)CD38(-) cell contents were significantly higher in second- and early third-trimester fetuses than in term fetuses (CD34(+) 2.57% +/- 0.38%, 1.48% +/- 0. 31%, and 0.7% +/- 0.13%, respectively, P =.0067; CD34(+)CD38(-) 0. 72% +/- 0.26%, 0.18% +/- 0.05%, and 0.06% +/- 0.02%, respectively, P =.0132). Mononuclear cell recovery, viability, and CD34(+) cell purity after cryopreservation and enrichment were similar among different gestational ages.

CONCLUSION

Cord blood stem cell content decreases significantly from the second trimester to term. Cryopreservation and enrichment of these cells from earlier gestational ages is feasible. This might be especially useful for allogeneic stem cell transplantation and for in utero gene therapy.

[Prenatal diagnosis with fetal cells in maternal blood: report of experiences in Basal]

Currently prenatal diagnosis relies on invasive procedures such as chorion villus sampling (CVS) or amniocentesis (AC). Many parents are reluctant to expose themselves and their child to the small, but significant risk posed by these procedures to mother and child. There is, hence, a great need for a risk-free non-invasive alternative. To achieve this goal most research has been focussed on enriching fetal cells from the blood of pregnant women. The erythroblast has emerged as the target cell of choice, since it is abundant in the early fetus, rare in normal adult blood, and since it has a very short half life, there is no risk of obtaining cells from previous pregnancies. Most enrichment protocols rely either on magnetic- or fluorescent activated cell sorting (MACS and FACS) using fetal specific antibodies. These enriched cells can be examined by FISH (fluorescence in-situ hybridisation) for the presence of the most common fetal chromosomal aneuploidies (13, 18, 21, X and Y) or by polymerase chain reaction (PCR) on singly manipulated cells for genetic disorders. The efficacy in detecting fetal aneuploidies is currently being evaluated in a phase II clinical trial under the auspices of the NIH-NICHD, the so-called NIFTY Trial, in which our group is a participant. By modifying our enrichment protocols we have recently been able to obtain detection sensitivities of almost 80%, thereby renewing our optimism that this methodology provides a solid basis for an effective non-invasive prenatal diagnostic test.

[Establishing an umbilical cord blood bank for unrelated allogenic stem cell transplantation]

We report the establishment of a cord-blood bank in a routine hematological laboratory. Cord-blood collection was performed with placenta in utero by a trained team and immediately sent to the cord-blood bank. There, 6.8 ml cord-blood was used for analysis of nucleated cell counts, counts of CD34-positive cells, CFU's, complete HLA-typing, ABO and Rhesus blood groups, bacteriologic cultures and serology for HIV 1 and 2, HbsAg, HVC, CMV, syphilis and toxoplasmosis. The cord-blood collection was frozen and conserved at -192 degrees C. From each cord-blood vials of DNA, viable cells and plasma were cryopreserved. Between June 1997 and April 1998, 54 cord-bloods were collected. 40 of them were cryo-preserved, and 14 discarded because of low cell counts. The median volume was 109 ml with 1.4 x 10(9) nucleated cells. The in vitro capacity of proliferation of the cord-blood correlated well with the absolute counts of CD34-positive cells (r = 0.93), moderately with the relative counts of CD34 (r = 0.68) as well as the nucleated cells (r = 0.70), poorly with the volume (r = 0.44). Three of the 40 (7.5%) cord-blood products contained a bacterial contamination. This study shows that a cord-blood bank can be organised in a routine hematological laboratory, which is familiar with transplantation products. However, the procedure is time consuming, expensive and requires a highly qualified team and specialised technical equipment.

Pregnancy and lactation in homozygous beta-thalassemia major

Successful pregnancies in patients with transfusion-dependent homozygous beta-thalassemia major are rare. We report the course of a pregnancy and newborn data during lactation and desferrioxamine therapy in the mother. The twin-pregnancy was complicated by preeclampsia. Besides normal iron level in breast milk, no clinical or hematological abnormalities due to desferrioxamine therapy could be shown in the newborns. Our observation suggests that chelating therapy during lactation does not alter iron excretion in breast milk or iron metabolism in offsprings. Breast feeding in newborns from patients with thalassemia major and desferrioxamine therapy seems justified.

Enrichment of fetal nucleated red blood cells from the maternal circulation for prenatal diagnosis: experiences with triple density gradient and MACS based on more than 600 cases

OBJECTIVE

We wanted to obtain statistically relevant data about the efficiency of our method for the isolation of fetal nucleated red blood cells (NRBCs) from the maternal circulation.

METHODS

More than 600 samples were investigated using a triple density gradient followed by magnetic separation of anti-CD71-labeled cells, and yields and purities of recovered NRBCs were determined.

RESULTS

The enrichment effectivity as well as the morphological condition of cells was reproducibly good, if blood samples were enriched within 48 h after sampling. The efficacy was independent of various methodological parameters and our technique was superior to other magnetic cell-sorting techniques. Mean yields and purities of NRBCs increased with increasing gestational age, ranging from 100 to 1,000 cells per 40-ml blood sample and from 0.1 to 1%, respectively, from the 6th week of gestation to term. In pregnancies with preeclampsia NRBCs were increased by a factor of 10.

CONCLUSION

Our enrichment technique proved to be optimized with respect to various methodological parameters, which were compared in the present study, and it is efficient and reproducible for the enrichment of NRBCs from the maternal circulation in all three gestational trimesters.

Highly accurate analysis of heterozygous loci bysingle cell PCR

Single cell PCR is a powerful method for determining the genetic properties of individual cells. In the instance of heterozygous loci, however, preferential amplification of one allele can lead to allele drop out (ADO) of the other allele. Fortunately ADO does not occur in all amplifications, and is usually random when it does occur, with both alleles being equally susceptible to drop out. Therefore pooling of results from multiple independently amplified cells should greatly improve the analysis of diallelic loci, and the misdiagnosis rate of diallelic loci should decrease exponentially with the number of cells analysed. We have shown that this is true and that multiplex PCR allows for the simultaneous identification of a cell in a mixture of cells using microsatellite loci known to be informative, and accurate genotyping at other loci. This approach has practical applications to non-invasive prenatal diagnosis where small numbers of fetal cells in the presence of maternal cells must be both identified and genotyped at loci involved in genetic disease.

Detection of fetal messenger ribonucleic acid in maternal blood to determine fetal RhD status as a strategy for noninvasive prenatal diagnosis

OBJECTIVES

Our purpose was to test the hypothesis that reverse transcriptase-polymerase chain reaction for fetal messenger ribonucleic acid in maternal blood is more sensitive than polymerase chain reaction from genomic deoxyribonucleic acid in prenatal determination of fetal RhD blood type.

STUDY DESIGN

Fetal nucleated erythrocytes in peripheral blood from 35 RhD-negative women were enriched by triple-density gradient centrifugation, anti-CD71 magnetic sorted, and deoxyribonucleic acid and ribonucleic acid extracted. Sensitivities of reverse transcriptase-polymerase chain reaction and polymerase chain reaction were compared to predict definitive fetal RhD blood type determined in fetal tissues.

RESULTS

Reverse transcriptase-polymerase chain reaction was significantly more accurate (P = .03) than genomic-polymerase chain reaction in predicting fetal RhD blood type, both overall (28 of 35 vs 22 of 35) and when the fetus was RhD-positive (12 of 19 vs 6 of 19).

CONCLUSIONS

Reverse transcriptase-polymerase chain reaction is more sensitive than genomic-polymerase chain reaction in detection of fetal RhD sequences in maternal blood.

Prenatal diagnosis using fetal cells enriched from maternal blood

The ability to use fetal cells enriched from the blood of pregnant women for prenatal diagnosis has been a long-sought goal for those pursuing a non-invasive alternative to current methods, such as amniocentesis or chorionic villus sampling. Several new developments, which rely either on fluorescence in situ hybridization or the combination of single-cell manipulation and subsequent polymerase chain reaction practices, which are common to the field of preimplantation genetics, have been tested. We discuss the significance of these developments and the obstacles that still have to be surmounted before this technology becomes available in a broad diagnostic use. The research in the field yielded important observations regarding the traffic of cells between the fetus and the mother, which may provide a new insight into the development of disorders such as preeclampsia and the associated HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome.

[Umbilical cord blood transplantation: acceptance of umbilical cord blood donation by pregnant patients]

BACKGROUND/OBJECTIVE

Umbilical cord blood is an alternative source for allogeneic transplantation of hematopoietic stem cells from related and unrelated donors. It can easily be collected, cryopreserved and stored in cord blood banks for later use. In Switzerland, cord blood banks for related and unrelated stem cell transplantation are being established. The aim of the study was to evaluate previous knowledge of the possible medical use of cord blood and acceptance of cord blood banking in pregnant women.

METHODS

We performed a prospective open study using a structured, anonymous questionnaire at the University of Basel Women's Hospital pregnancy outpatient clinic. After concise information on the use of cord blood for transplantation, questions were asked concerning previous knowledge of the use of placenta and cord blood in general, concerning the attitude to donation of cord blood for transplantation, and the respondent's willingness to donate cord blood of her own child. Women of different ethnic background were compared.

RESULTS

From 300 questionnaires handed out to pregnant women of different ethnic background attending our outpatient clinic, 250 (83%) were returned, and 245 could be evaluated for final analysis. Only 40% indicated that they did know what usually happens to the placenta after birth. In contrast, the vast majority (95%) supported the idea of umbilical cord blood for banking and later use for stem cell transplantation. Similarly, 93% stated that they would agree to donate the cord blood from their own child for this purpose, while no statistically significant differences could be identified either between women with or without previous knowledge or of different ethnic background.

CONCLUSIONS

This study shows the high acceptance of umbilical cord blood donation for banking and stem cell transplantation purposes in pregnant women, irrespective of previous knowledge. As there are no major differences between women of different ethnic background, a high degree of diversity of HLA-types of donated cord blood samples can be expected and may offset the underrepresentation of ethnic minorities in bone marrow donor registries.

Disturbed feto-maternal cell traffic in preeclampsia

OBJECTIVE

To investigate whether the transfer of fetal blood cells to the maternal circulation is perturbed in pregnancies affected by preeclampsia.

METHODS

Fetal erythroblasts were isolated from eight women with clinically diagnosed preeclampsia (blood pressure values of at least 140/90 mmHg and associated proteinuria) and an equal number of matched corresponding controls. All patients in both groups were pregnant with male singleton fetuses. The presence of fetal cells was evaluated histologically and by fluorescence in situ hybridization for X and Y chromosomes.

RESULTS

The number of fetal cells was higher in preeclamptic patients than in controls, with respect to both nucleated red blood cells (median per 200 cells 38 versus 7; P < .001) and the proportion of these cells that were of fetal origin (median per 2000 cells 9 versus 2; P = .001).

CONCLUSION

These results suggest that the trafficking of fetal cells into the maternal periphery is disturbed in patients with preeclampsia. Because it is unlikely that such an altered flow of cells is restricted to the erythroblasts examined in this study, these findings also may lead to interesting new concepts regarding the development of preeclampsia and possibly the associated syndrome of hemolysis, elevated liver enzymes, and low platelets.

Virilizing ovarian tumor of low malignant potential associated with antecedent tamoxifen use for breast cancer

A patient is described who was treated with tamoxifen for breast cancer and developed an androgen-producing ovarian tumor of low malignant potential, which itself is a rare condition. Clinically overt virilism was leading to the diagnosis and promptly improved after surgical removal of the tumor. A causal relationship between tamoxifen use and the tumor is discussed on the basis of the known tumor-inducing potential of tamoxifen.

In vitro volume measurement by three-dimensional ultrasound: comparison of two different systems

The aim of this study was to compare volumetric capabilities in vitro between two different three-dimensional technical modalities with a transvaginal transducer. We intended to evaluate the effect of different sizes and shapes on the accuracy of the measurements, and to establish criteria for choosing the appropriate system for three-dimensional volume measurement. We did not find significant differences between the two systems, either in the results or in their operation. We confirmed the high accuracy of three-dimensional volume measurements in vitro.

Cystic hygroma as an early first-trimester ultrasound marker for recurrent Fryns' syndrome

We present a case of a fetus who at a 12-week ultrasound examination was shown to have a large cystic hygroma. Fryns' syndrome was suspected because the mother's previous pregnancy had been affected by the condition. Pathological examination confirmed the diagnosis at this early stage of gestation. In families with increased risk for Fryns' syndrome, first-trimester ultrasound screening should be offered to exclude cystic hygroma as an ultrasound marker for this most often lethal malformation.

Neural tube defects in chromosomally normal and abnormal human embryos

Neural tube defects (NTDs) were recognized in eight out of 91 intact embryos from spontaneous abortions and in one case of an induced abortion following prenatal diagnosis of a chromosomal disorder. Five of the nine cases showed chromosomal abnormalities. Trisomy 18 and triploidy were associated with spina bifida in three cases, trisomy 7 with parieto-occipital encephalocele and monosomy X with spina bifida and iniencephaly in one case. A sixth anencephalic embryo in which chromosomal analysis was not performed showed a malformation pattern highly suggestive for trisomy 18. Discussion focuses on the high rate and the type of chromosomal abnormalities among spontaneously aborted NTD embryos, on the contrasting phenotype of 45,X conceptions and on the morphogenesis of the different neural tube defects in early development. In view of future early endovaginal ultrasound diagnosis, the changing morphological pattern is exemplified, and ranges from apparently hyperplastic to degenerative alterations of the exposed neural tissue.

Transcervical intrapartum amnioinfusion: a simple and effective technique

OBJECTIVE

To test a simple method of intrapartum amnioinfusion to replace amniotic fluid during labor in cases of prolonged labor and severe variable fetal heart rate decelerations or thick meconium.

STUDY DESIGN

We conducted a prospective study of intrapartum amnioinfusion in sixteen consecutive patients. A simple transcervically placed Foley bladder catheter was used for intrauterine infusion of saline solution, while monitoring was performed by external cardiotocography.

RESULTS

In twelve patients, catheter placement was easily performed; the remaining four required stabilization by a mandrel for insertion. Amnioinfusion was effective in ten out of thirteen patients for relief of fetal heart rate anomalies. No complications were observed; all had good neonatal outcome.

CONCLUSIONS

In our small, uncontrolled study, this amnioinfusion method proved to be a simple, inexpensive, effective and safe technique for the relief of severe heart rate anomalies in prolonged labor.

A double-blind comparison of the safety and efficacy of intravaginal misoprostol and prostaglandin E2 to induce labor

OBJECTIVE

Our purpose was to compare the safety and efficacy of intravaginally administered misoprostol versus prostaglandin E2 for labor induction in a double-blind, randomized trial.

STUDY DESIGN

One hundred three patients with indications for labor induction (including prelabor rupture of membranes) were randomized and received either misoprostol 50 micrograms or prostaglandin E2 (dinoprostone) 3 mg intravaginally. The dose was repeated 6, 24, and 30 hours after the first dose until active labor was achieved. For proper blinding, the drugs were prepared as identical-looking vaginal tablets.

RESULTS

With use of a random number-generated table 52 patients were allocated to the misoprostol group and 51 to the prostaglandin E2 group. After exclusion of 3 patients, 50 in each group were evaluated. Delivery within 24 hours after administration occurred more often in the misoprostol group (70% vs 46% in the prostaglandin E2 group, p = 0.009), and fewer patients in this group needed more than two doses (12% vs 30%, p = 0.027). No difference in cesarean section rate (12% vs 14%, p = 0.67), fetal heart rate anomalies (33% vs 34%, p = 0.89), tachysystole (8% vs 14%, p = 0.37), hyperstimulation syndrome (0% vs 2%, not significant), meconium passage (28% vs 18%, p = 0.22), and fetal outcome (Apgar score at 1 and 5 minutes, arterial and venous umbilical cord blood pH, transfer to neonatal intensive care unit) was noted between the two groups.

CONCLUSION

Intravaginal misoprostol is a safe drug for labor induction with superior effectiveness compared with intravaginal prostaglandin E2.