Multiple brain infarcts associated with severe preeclampsia

Posterior occipital and parietal lobe infarcts shown by computed tomography (CT) scan and magnetic resonance imaging have been associated with eclampsia. Gray-white matter, infarct-like lesions of the right basal ganglia, right posterior parietal, and left posterior parieto-occipital lobes were found by CT scan in a patient at 26 weeks gestation with severe preeclampsia and neurologic deficits. A magnetic resonance image taken 3 days postpartum had similar abnormalities, despite total resolution of the patient's symptomatology. A repeat CT scan performed 6 weeks postpartum showed complete resolution of the multiple infarctions. This is a unique case report that describes these severe brain-imaging findings in a patient with severe preeclampsia and neurologic deficits.

Labor induction for the preterm severe pre-eclamptic patient: is it worth the effort?

OBJECTIVE

The purpose of this study was to examine the success rate of labor induction in patients with severe pre-eclampsia delivered at < or = 34 weeks' gestation; to identify factors associated with its success; and to evaluate neonatal outcomes based on induction success or failure.

METHODS

We identified pregnancies complicated by severe pre-eclampsia delivered at < or = 34 weeks' at our institution from 1991 to 1998. Women who underwent labor induction and had successful vaginal delivery were compared to those who underwent labor induction, but required Cesarean delivery. Multiple logistic regression analyses were performed to assess factors associated with successful induction and neonatal outcome.

RESULTS

Over the 7-year study period, there were 215 patients meeting the criteria. Sixty-four (29.8%) did not undergo a labor attempt; 69 of 151 (46%) women who underwent labor induction achieved vaginal delivery. Labor induction was successful in 0%, 6.6%, 35.3% and 68.5% of cases at 24-26, 27-28, 29-31 and 32-34 weeks' gestation, respectively. By logistic regression the only factor positively associated with successful induction was gestational age at delivery (p = 0.001), while induction for non-reassuring fetal testing was inversely associated (p = 0.02). Induction attempt, failed induction and delivery mode were not associated with increased neonatal morbidity.

CONCLUSIONS

In women with severe pre-eclampsia remote from term, attempted labor induction did not appear to increase neonatal morbidity, but was rarely successful at < 28 weeks.

Obstetric uses of intravenous immunoglobulin: successes, failures, and promises

Intravenous immune globulin (IVIG) is approved for use in a number of conditions that may occur in obstetrical patients, including autoimmune thrombocytopenia and immune deficiency syndromes. IVIG also is widely used in obstetrics for nonapproved indications, such as fetal-neonatal alloimmune thrombocytopenia, antiphospholipid syndrome, and recurrent miscarriage. This review critically analyzes the use of IVIG for these indications based on the best available information. The authors conclude IVIG is effective in the management of fetal-neonatal alloimmune thrombocytopenia. IVIG appears promising as a treatment for severe fetal-neonatal alloimmune hemolysis due to antierythrocyte antibodies. A prospective multicenter trial should be undertaken. IVIG is no more effective than heparin and low-dose aspirin in the treatment of pregnancies complicated by antiphospholipid syndrome but has not been adequately evaluated in refractory cases. Finally, pending convincing studies, IVIG is not effective and should not be used for the management of recurrent miscarriage.

Adhesion development and the expression of endothelial nitric oxide synthase

OBJECTIVE

This study was conducted to determine whether nitric oxide (NO), a potent vasodilator and inhibitor of thrombus formation, is involved in the formation and maintenance of adhesions.

METHODS

Skin, subcutaneous tissues, peritoneum and adhesions were collected from surgical patients and total RNA was isolated. Quantitative reverse transcription polymerase chain reaction (QRT-PCR) was performed to quantitate endothelial nitric oxide synthase (eNOS) and beta-actin mRNA levels.

RESULTS

eNOS mRNA levels for skin, subcutaneous tissue, peritoneum and adhesions were < or = 3.12 x 10(-4), < or = 3.12 x 10(-4), 6.24 x 10(-4) and 2.5 x 10(-3) attomoles/microl, respectively. Beta-actin mRNA levels for all tissues were between 1.25 x 10(-1) and 6.25 x 10(-2) attomoles/microl.

CONCLUSION

eNOS mRNA can be identified in tissue adhesions, and may therefore play a role in adhesion formation and maintenance.

The obstetrician-gynecologist's role in vaccine-preventable diseases and immunization

OBJECTIVE

To assess by survey the immunization role currently played obstetrician-gynecologists in the state of Michigan.

METHODS

Masked questionnaires requesting demographic, knowledge-based, practice, and attitudinal data were sent to 850 ACOG-registered fellows.

RESULTS

Three hundred sixty-five physicians responded, 313 of whom were in active practice. Most were male (70%) and graduated from medical school between 1970 and 1989 (68%). The majority provided both obstetric and gynecologic services. The minority (47%) specifically identified themselves as primary care providers. Only 15% of respondents considered screening for vaccine-preventable diseases to be outside the realm of routine obstetric-gynecologic care. In practice, however, 19% did not screen their obstetric patients for any vaccine-preventable diseases, and only 10% assessed their patients for all nine vaccine-preventable diseases listed in the questionnaire. In gynecologic patients, almost 40% of physicians did not assess for any vaccine-preventable disease. A wide range in knowledge level was identified concerning vaccine-preventable diseases, immunization recommendations, and vaccine safety.

CONCLUSION

These data show a discrepancy between perceived responsibilities and actual practice patterns of obstetrician-gynecologists regarding vaccine-preventable diseases and the immunization of women. Limitations in current knowledge and practical concerns specific to vaccine administration contribute to this disparity.

Expression and regulation of vascular endothelial growth factor in a first trimester trophoblast cell line

Embryo implantation and development are critically dependent upon the spatial and temporal regulation of angiogenesis and localized vascular permeability. A key mediator of these effects is the endothelial cell mitogen vascular endothelial growth factor (VEGF). VEGF has been shown to promote endometrial vascular permeability, fetal vasculogenesis and placental, fetal and maternal angiogenesis. However, the mechanism through which this regulation occurs in the placenta is poorly understood. This study was conducted to determine if the pro-angiogenic cytokines, TNF-alpha and TGF-beta1, affect VEGF expression in human first trimester trophoblasts. Culture of a first trimester trophoblast cell line (HTR-8/SVneo), in the presence of either TNF-alpha or TGF-beta1, resulted in the expression of significant levels of VEGF in culture. The trophoblast cell line also showed a time-dependent and a dose-dependent increase in VEGF mRNA levels when cultured in the presence of either TNF-alpha or TGF-beta1. These results suggest that both TNF-alpha and TGF-beta1 may regulate the production of VEGF in early gestational trophoblasts and may therefore serve to modulate placental vascular permeability and angiogenesis that are necessary for embryo implantation and placentation.

Mathematic modeling of forces associated with shoulder dystocia: a comparison of endogenous and exogenous sources

OBJECTIVE

A mathematic model was developed to estimate the compressive pressure on the fetal neck overlying the roots of the brachial plexus by the symphysis pubis during a shoulder dystocia event. The induced pressure was calculated for both exogenous (clinician applied) and endogenous (maternal and uterine) forces during the second stage of labor.

STUDY DESIGN

Intrauterine pressure and clinician-applied force data were taken from the existing literature. A free-body diagram was generated and equilibrium equations were used to calculate the contact pressure between the base of the fetal neck and the symphysis pubis during a shoulder dystocia event.

RESULTS

Clinician-applied traction to the fetal head (exogenous force) led to an estimated contact pressure of 22.9 kPa between the fetal neck and the symphysis pubis. In contrast, uterine and maternal expulsive efforts (endogenous forces) resulted in contact pressures that ranged from 91.1 to 202.5 kPa. The estimated pressures resulting from endogenous forces are 4 to 9 times greater than the value calculated for clinician-applied forces.

CONCLUSION

Neonatal brachial plexus injury is not a priori explained by iatrogenically induced excessive traction. Spontaneous endogenous forces may contribute substantially to this type of neonatal trauma.

Effect of imiquimod on cytokine induction in first trimester trophoblasts

OBJECTIVES

Imiquimod (IQ) is used clinically for the topical treatment of external genital warts. IQ is an immune response modifier and induces the expression of interferon-alpha and other cytokines in human Peripheral Blood Monocytes (PBMC). Trophoblasts have been previously shown to express inflammatory cytokines upon lipopolysaccharide (LPS) stimulation. The objective of this study was to evaluate the ability of IQ to induce transcription of cytokines in trophoblasts.

METHODS

A transformed human first trimester trophoblast cell line, HTR-8/SVneo, was cultured in DMEM containing IQ at concentrations of 0 to 5.0 microg/ml. 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) viability assays were conducted to control for any drug-induced cell death. Total RNA was isolated from trophoblasts at 0, 8 and 24 hours of culture and Reverse Transcription-Polymerase Chain Reaction (RT-PCR) was conducted using specific amplimers for the inflammatory cytokines interleukin (IL)-1alpha, IL-1beta, IL-6 and IL-8. RT-PCR of beta-actin was performed to control for equal RNA loading.

RESULTS

RT-PCR was unable detect an increase in either IL-1alpha, IL-1beta, IL-6 or IL-8 mRNA in first trimester trophoblasts cultured in the presence of 0 to 5.0 microg/mL of IQ for up to 24 hours. RT-PCR confirmed equal RNA loading and MTT viability assays did not show loss of cell viability at concentrations of IQ up to 5.0 microg/ml.

CONCLUSIONS

IQ, at the concentrations tested, did not induce the transcriptional expression of inflammatory cytokines in human first trimester trophoblasts. These data suggest that IQ would not induce the expression of inflammatory cytokines in placental trophoblasts.

Effect of imiquimod on cytokine induction in first trimester trophoblasts

OBJECTIVES

Imiquimod (IQ) is used clinically for the topical treatment of external genital warts. IQ is an immune response modifier and induces the expression of interferon-alpha and other cytokines in human Peripheral Blood Monocytes (PBMC). Trophoblasts have been previously shown to express inflammatory cytokines upon lipopolysaccharide (LPS) stimulation. The objective of this study was to evaluate the ability of IQ to induce transcription of cytokines in trophoblasts.

METHODS

A transformed human first trimester trophoblast cell line, HTR-8/SVneo, was cultured in DMEM containing IQ at concentrations of 0 to 5.0 microg/ml. 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) viability assays were conducted to control for any drug-induced cell death. Total RNA was isolated from trophoblasts at 0, 8 and 24 hours of culture and Reverse Transcription-Polymerase Chain Reaction (RT-PCR) was conducted using specific amplimers for the inflammatory cytokines interleukin (IL)-1alpha, IL-1beta, IL-6 and IL-8. RT-PCR of beta-actin was performed to control for equal RNA loading.

RESULTS

RT-PCR was unable detect an increase in either IL-1alpha, IL-1beta, IL-6 or IL-8 mRNA in first trimester trophoblasts cultured in the presence of 0 to 5.0 microg/mL of IQ for up to 24 hours. RT-PCR confirmed equal RNA loading and MTT viability assays did not show loss of cell viability at concentrations of IQ up to 5.0 microg/ml.

CONCLUSIONS

IQ, at the concentrations tested, did not induce the transcriptional expression of inflammatory cytokines in human first trimester trophoblasts. These data suggest that IQ would not induce the expression of inflammatory cytokines in placental trophoblasts.

Non-surgical management of post-cesarean endomyometritis associated with myometrial gas formation

We present a case of post-cesarean delivery, nonclostridial endomyometritis in which uterine (myometrial) gas formation raised concern for myonecrosis and need for hysterectomy. The patient fully recovered without surgery. Myometrial gas formation in this setting and in an otherwise stable patient may be an insufficient reason for hysterectomy.

Detection of cytomegalovirus in the meconium of infected newborns by polymerase chain reaction

OBJECTIVE

Congenital cytomegalovirus (CMV) infection is a leading cause of hearing loss and mental retardation throughout the world. Detection of the CMV DNA by polymerase chain reaction (PCR) offers a sensitive, rapid, and specific means of identification. Meconium, the stool formed in utero, may be an ideal specimen for CMV detection. The objective of this study was to develop a PCR-based methodology for the detection of CMV in the meconium of neonates.

METHODS

Meconium was collected from 10 newborn infants (seven with positive viral cultures and three uninfected infants born to CMV-seropositive mothers). For each, DNA was isolated from meconium by organic extraction and attachment to a DNA-binding matrix, and PCR was performed using amplimers specific for the major intermediate early (MIE) and late antigenic (LA) regions of CMV.

RESULTS

Gel electrophoresis demonstrated an anticipated PCR product of 250 base pairs (bp) corresponding to the MIE region of CMV in all infected and positive control meconium samples. Furthermore, a single band of 150 bp corresponding to the LA region of CMV was also amplified in several of the infected infants. Conversely, no amplification of these antigenic regions was noted in either uninfected infants born to CMV-seropositive mothers or negative controls.

CONCLUSIONS

CMV is present within the meconium of infected neonates and is readily detectable by PCR.

Colonoscopic release of the incarcerated gravid uterus

BACKGROUND

Incarceration of the gravid uterus occurs in the early second trimester in approximately one in 3000 pregnancies. If conventional manual attempts at restoring the uterine fundus to the anterior position are unsuccessful, correction by an invasive laparotomy procedure is necessary. We describe a minimally invasive technique to dislodge the incarcerated gravid uterus.

TECHNIQUE

Gravid patients with an incarcerated uterus refractory to manual reduction are administered sedation, and one to two enemas. After sedation, manual reduction is attempted again. If unsuccessful, a colonoscope is passed above the level of the uterine fundus generating external anterior forces, which dislodge the uterus from beneath the sacral promontory.

EXPERIENCE

The procedure was performed six times in five patients. One patient required a second procedure because of recurrence of the condition. All procedures were successful. No pregnancy losses occurred after the procedure, and no complications of colonoscopy were encountered.

CONCLUSION

Colonoscopic release of the incarcerated gravid uterus is an option when attempts at manual reduction fail. This procedure may avoid laparotomy to correct this condition.

Partner notification of sexually transmitted disease in an obstetric and gynecologic setting

OBJECTIVE

To survey obstetrician-gynecologists regarding current approaches to partner notification of women with sexually transmitted diseases (STDs) and to relate reported practices to state requirements.

METHODS

An anonymous questionnaire was sent to community, hospital-employed, and university-based physicians within a single health care system. The survey was designed to assess physician demographics, knowledge, and attitudes about partner notification of women with STDs.

RESULTS

One hundred eight (49%) of 222 surveys were returned. Respondents were 36% private practitioners, 38% hospital-employed, and 23% university faculty physicians. Although most correctly identified the importance of partner notification for several STDs, they (63 of 108, 58%, confidence interval [CI] 50%, 67%) could not identify all of those conditions. Most respondents (84 of 108, 78%, CI 69%, 85%) were unaware of all required reportable STDs and the state's preferred method of partner notification. The vast majority of respondents (96 of 108, 89%, CI 82%, 94%) relied on women to notify their partners of the STD.

CONCLUSION

Educational efforts are needed to increase physician awareness of required reportable STDs and the role of partner notification and treatment in disease control. Physicians need to be aware of state regulations for partner notification when they are in practice. Development of standard algorithms for partner notification and treatment might be needed.

Shoulder dystocia

Shoulder dystocia is an infrequent and unexpected emergency requiring rapid and deft solution. Identifiable risk factors include maternal diabetes, fetal macrosomia (especially in the presence of diabetes), and maternal history of previous delivery of a large infant. Other reported risk factors include arrest and protraction disorders of labor and midpelvic operative delivery; however, more than 50% of shoulder dystocia occurs in instances without identifiable risk factors, and permanent neonatal injury is thus unpredictable. Therefore, all personnel in the delivery suite must be well versed in the timely and appropriate application of corrective measures. Although most instances of shoulder dystocia cannot be predicted, the judicious use of CS delivery in diabetic patients with expected birth weights of more than 4250 g should reduce the risk of shoulder dystocia in this subgroup of patients. A trial of labor for nondiabetic patients with suspected fetal macrosomia is recommended because predicting actual birth weights in this population remains difficult.

High levels of maternal serum human chorionic gonadotropin in Down syndrome pregnancies: the possible role of a transcription factor on chromosome 21

Increased levels of human chorionic gonadotropin (hCG) are used as markers for Down syndrome (DS) screening of low-risk populations. The pathophysiology for increased hCG levels remains unknown. In general, hCG synthesis is limited by the rate of beta-chain formation. In the placenta, 2 of a total of 6 hCG beta-genes are expressed. We hypothesized that in DS, a transcriptional factor may upregulate beta-chain transcription by interacting with the beta5-promoter. Primary cell cultures of skin fibroblasts from both normal and DS midtrimester fetuses were established and transfected with the beta5-promoter linked to the chloramphenicol-acetyl-transferase reporter gene. The chloramphenicol-acetyl-transferase activity was measured. Three of six DS-derived cell cultures showed a three-fold increase in acetylation. The increase in hCG promoter activity in DS-derived fibroblasts suggests a possible role for a transcriptional factor located on the human chromosome 21 by either directly or indirectly interacting with the beta5-promoter.

Single daily dosing of gentamicin: pharmacokinetic comparison of two dosing methodologies for postpartum endometritis

OBJECTIVE

We compared the pharmacokinetics of two methods for dosing gentamicin for the treatment of postpartum endometritis with the goal of achieving adequate peak serum concentrations (>12 mg/L) and prolonged trough levels below 2 mg/L.

METHODS

Group-I subjects (n = 5) received intravenous gentamicin, 5 mg/kg per total body weight over 60 min., with a maximum dose of 500 mg. Group-II subjects (n = 17) were dosed intravenously according to the following formula: Dose = desired peak concentration (fixed at 14 mg/L) * (volume of distribution, i.e., 0.35 L/kg) * adjusted body weight (in kilograms). Serum gentamicin levels were obtained 1 hr. and 8-12 hr. after infusion of the second dose. Pharmacokinetic parameters for the subjects in each group were calculated according to standard formulas.

RESULTS

Subjects in Group I had significantly higher doses and peak drug concentrations (P < 0.01), while in Group II, 76% of patients had peak levels less than desired (<12 mg/L). Both groups maintained trough levels of <2 mg/L in excess of 12 hr.

CONCLUSIONS

Changing to the adjusted body weight formula for Group I, while maintaining a dose between 4 and 5 mg/kg, would reduce excessive peak concentrations. Using a calculated volume of distribution of 0.4 L/kg in Group II would improve peak serum concentrations to the desired levels. Both dosing regimens ensure adequate aminoglycoside pharmacokinetic parameters and avoid the need for monitoring serial serum drug concentrations, provided the expected clinical response is also achieved. While the first dosing formula is simpler to calculate, the second dosing formula allows for more individualized dosing considerations.

Single daily dosing of gentamicin: pharmacokinetic comparison of two dosing methodologies for postpartum endometritis

OBJECTIVE

We compared the pharmacokinetics of two methods for dosing gentamicin for the treatment of postpartum endometritis with the goal of achieving adequate peak serum concentrations (>12 mg/L) and prolonged trough levels below 2 mg/L.

METHODS

Group-I subjects (n = 5) received intravenous gentamicin, 5 mg/kg per total body weight over 60 min., with a maximum dose of 500 mg. Group-II subjects (n = 17) were dosed intravenously according to the following formula: Dose = desired peak concentration (fixed at 14 mg/L) * (volume of distribution, i.e., 0.35 L/kg) * adjusted body weight (in kilograms). Serum gentamicin levels were obtained 1 hr. and 8-12 hr. after infusion of the second dose. Pharmacokinetic parameters for the subjects in each group were calculated according to standard formulas.

RESULTS

Subjects in Group I had significantly higher doses and peak drug concentrations (P < 0.01), while in Group II, 76% of patients had peak levels less than desired (<12 mg/L). Both groups maintained trough levels of <2 mg/L in excess of 12 hr.

CONCLUSIONS

Changing to the adjusted body weight formula for Group I, while maintaining a dose between 4 and 5 mg/kg, would reduce excessive peak concentrations. Using a calculated volume of distribution of 0.4 L/kg in Group II would improve peak serum concentrations to the desired levels. Both dosing regimens ensure adequate aminoglycoside pharmacokinetic parameters and avoid the need for monitoring serial serum drug concentrations, provided the expected clinical response is also achieved. While the first dosing formula is simpler to calculate, the second dosing formula allows for more individualized dosing considerations.

Transvaginal ultrasound-guided aspiration of pelvic abscesses

OBJECTIVE

To assess the utility of a less invasive approach to the care of women with a pelvic abscess, we retrospectively reviewed the outcome of women with pelvic abscesses managed by transvaginal ultrasound-guided aspiration.

METHODS

A retrospective analysis of 27 pelvic abscesses in 22 consecutive women undergoing transvaginal drainage, including 13 tuboovarian abscesses (TOAs) and 14 postoperative abscesses (POAs). All patients received broad-spectrum intravenous antibiotics from the time infection was diagnosed to resolution of signs and symptoms. Chart review and examination of ultrasound files were utilized to extract demographic clinical, laboratory, and outcome data.

RESULTS

The mean age for the study group was 30 years old. Mean duration from diagnosis to drainage was 5.6 days (TOA) and 2.0 days (POA), P < 0.01. The mean diameter of the abscesses was 86 mm. The volume of purulent material drained ranged from 70-750 mL. Perceived adequacy of drainage was correlated with lack of abscess septation. Cultures for aerobic and anaerobic pathogens were positive in 51% of cases (79% POA versus 23% TOA, P < 0.05) with 1.9 organisms/ positive culture. Transvaginal drainage was successful in 25 of 27 abscesses. No complications were reported.

CONCLUSION

In skilled hands, transvaginal guided aspiration of pelvic abscess is a highly successful technique with minimal risk to the patient. Follow-up studies are needed to assess the long-term sequelae, such as frequency of infertility, ectopic pregnancy, and chronic pelvic pain.

Transvaginal ultrasound-guided aspiration of pelvic abscesses

OBJECTIVE

To assess the utility of a less invasive approach to the care of women with a pelvic abscess, we retrospectively reviewed the outcome of women with pelvic abscesses managed by transvaginal ultrasound-guided aspiration.

METHODS

A retrospective analysis of 27 pelvic abscesses in 22 consecutive women undergoing transvaginal drainage, including 13 tuboovarian abscesses (TOAs) and 14 postoperative abscesses (POAs). All patients received broad-spectrum intravenous antibiotics from the time infection was diagnosed to resolution of signs and symptoms. Chart review and examination of ultrasound files were utilized to extract demographic clinical, laboratory, and outcome data.

RESULTS

The mean age for the study group was 30 years old. Mean duration from diagnosis to drainage was 5.6 days (TOA) and 2.0 days (POA), P < 0.01. The mean diameter of the abscesses was 86 mm. The volume of purulent material drained ranged from 70-750 mL. Perceived adequacy of drainage was correlated with lack of abscess septation. Cultures for aerobic and anaerobic pathogens were positive in 51% of cases (79% POA versus 23% TOA, P < 0.05) with 1.9 organisms/ positive culture. Transvaginal drainage was successful in 25 of 27 abscesses. No complications were reported.

CONCLUSION

In skilled hands, transvaginal guided aspiration of pelvic abscess is a highly successful technique with minimal risk to the patient. Follow-up studies are needed to assess the long-term sequelae, such as frequency of infertility, ectopic pregnancy, and chronic pelvic pain.

Ethanol-induced expression of cytokines in a first-trimester trophoblast cell line

OBJECTIVES

Altered cytokine expression at the fetoplacental interface may be a potential mechanism for the development of fetal immune dysfunction in children with fetal alcohol syndrome. This study was conducted to determine whether first-trimester trophoblasts respond to ethanol exposure by the induction of specific cytokines.

STUDY DESIGN

HTR-8/SVneo trophoblast cells were cultured in vitro in the presence of either ethanol (0.5% [vol/vol]), lipopolysaccharide (1 microg/mL), or ethanol and lipopolysaccharide. Expression of granulocyte colony-stimulating factor, regulated on activation normal T cell expressed and secreted, and interleukin-6 was examined by Northern analysis and enzyme-linked immunosorbent assay.

RESULTS

Culture in the presence of ethanol, lipopolysaccharide, or lipopolysaccharide and ethanol resulted in the increased transcription and secretion of granulocyte colony-stimulating factor, regulated on activation normal T cell expressed and secreted, and interleukin-6 at significantly greater levels (P < .01) than control cultures.

CONCLUSIONS

Human first-trimester trophoblasts express high levels of cytokines when cultured in the presence of ethanol. Trophoblasts may therefore be an important exogenous source of cytokines for the fetus, and altered cytokine levels during early gestation may have an adverse effect on the development of the fetal immune system.

The timing of congenital brachial plexus injury: a study of electromyography findings in the newborn piglet

OBJECTIVE

Permanent congenital brachial plexus palsy is a recognized serious complication associated with shoulder dystocia. The timing and etiology of this injury remains controversial. Previous authorities have used adult-derived, non-brachial plexus data to extrapolate the anticipated timing for electromyographic denervation changes to date such injuries in the newborn. With use of a domestic swine model, this investigation tests the hypothesis that electromyographic evidence of brachial plexus denervation in the newborn is temporally different than that in the adult.

STUDY DESIGN

Five healthy 2-day-old and two adult pigs underwent unilateral sharp transection of the brachial plexus. Daily electromyographic studies were performed in brachial plexus innervated muscle groups on the involved and contralateral (control) front limbs. Postmortem measurements of the transected nerve segments were obtained in one piglet and one adult animal. Representative hard copy recordings of individual electromyographic studies were collected.

RESULTS

Immediately after surgical transection of the brachial plexus, no electromyographic evidence of denervation was observed. Uniformly in the newborn piglets, at 24 hours after transection, denervation in the form of fibrillation potentials, positive sharp waves, and complex repetitive discharges was seen. Serial testing demonstrated proximal to distal gradients of denervation over the next 24 to 48 hours. A delay in electromyographic evidence of denervation was observed in the two adult pigs until days 5 and 8, respectively. Control limb studies remained normal throughout the study period. Nerve length measurements for individual muscle groups were as follows for the adult and newborn pigs, respectively: deltoid 11.4 cm, 2.5 cm; cleidobrachialis 16.0 cm, 4.0 cm; triceps 15.5 cm, 4.5 cm; forelimb flexors 26.0 cm, 6.5 cm; and extensor carpi radialis 31.0 cm, 9.0 cm.

CONCLUSION

Electromyographic evidence of brachial plexus denervation after surgical transection differs between the newborn and the adult pig. Consistent with wallerian degeneration, a correlation exists between length of the distal nerve segment and timing for electromyographic signs of denervation. These findings suggest it would be inappropriate to extrapolate the anticipated timing for electromyographic changes in the newborn on the basis of previously established adult non-brachial plexus data.

Applicability of the third-generation, thyroid-stimulating hormone assay in pregnancy

Use of the third-generation, thyroid-stimulating hormone (TSH) assay in gravid patients has not been validated. We obtained serum from 93 healthy women with a singleton gestation and measured TSH using a two-site immunochemiluminescent ("sandwich") assay. Standard immunoassays were employed for total T4, free T4, and T3 levels. Reference ranges (RR) established by the kit manufacturer were used for comparison. Although the mean TSH level for our population was within the RR, 12/93 women (13%) had a TSH value below the lower limit of normal. None, however, had clinical hyperthyroidism or an elevated free T4. Established RR for the third-generation TSH assay may not apply to pregnant women, and isolated TSH measurements during pregnancy should be interpreted with caution.

Does delivery improve maternal condition in the respiratory-compromised gravida?

OBJECTIVE

To describe the effect of delivery on respiratory status and outcome in the respiratory-compromised pregnant woman.

METHODS

During 1990-1994, 10 patients requiring intubation for respiratory compromise who delivered during ventilatory support were identified by International Classification of Diseases, Ninth Revision codes. Charts were reviewed retrospectively for cardiorespiratory variables and outcome.

RESULTS

Pneumonia led to intubation in all but one case. The onset of labor was spontaneous in eight. Three were delivered by cesarean. Mechanical ventilation was used for a median (range) of 7 (2-22) days in surviving patients. Fraction of inspired oxygen requirements decreased an average of 28% by 24 hours after delivery. Positive end-expiratory pressure requirements remained unaltered. Surviving patients remained intubated for a median (range) of 2.6 (1-19) days postpartum. Three women died, all after vaginal delivery (days 4-14).

CONCLUSION

Delivery of respiratory-compromised gravidas resulted in a 28% reduction in fraction of inspired oxygen requirement within 24 hours after delivery. Although most patients were then able to be maintained below critical fraction of inspired oxygen requirement levels (under 0.6), dramatic improvement in overall respiratory function was not observed uniformly. Given the limited benefit of delivery on maternal oxygenation, along with the inherent risks of labor induction in this critically ill population, caution should be exercised in initiating the induction process electively.

In utero progression of isolated renal pelvis dilation

The objective of this study to determine the risk of in uteroprogression of renal pelvis dilation when detected on antenatal ultrasound examination. We reviewed 230 fetuses with evidence of renal pelvis dilation. At least one exam was subsequently performed prior to delivery in all cases. Renal pelvis dilation was defined as an anterior-posterior renal pelvis measurement > 4 mm at < 32 weeks' and > 7 mm at > or = 32 weeks' gestation. Hydronephrosis was considered to be present when the renal pelvis measured +10 mm independent of gestational age. Multiple gestations and fetuses with additional congenital anomalies were excluded. The mean gestational age at diagnosis was 24 weeks. Renal pelvis dilation progressed to hydronephrosis in a total of 10.9% (25 of 230) of fetuses. There was a 3.3% chance of unilateral renal pelvis dilation progressing to hydronephrosis versus 26.0% in bilateral dilation (OR 10.4 [95% Cl 3.5-33.3]). Of those fetuses with progression, 80% had bilateral dilation (p < 0.0001). There was no difference in progression between right and left kidneys. Additionally, gender, gestational age at diagnosis and delivery, and birth weight did not differ between those fetuses with and without progression. The hydronephrosis in 7 of 25 (28%) regressed to pyelectasis on a subsequent ultrasound exam. Thus, the overall rate of progression of renal pelvis dilation to persistent hydronephrosis was 7.8% (18 of 230). In conclusion, the risk of isolated renal pelvis dilation progressing to hydronephrosis is low. Although bilateral pelvis dilation carries a higher risk for progression, no fetus in our study required in utero intervention. A follow up scan prior to delivery may be considered to identify those fetuses who will require postpartum intervention.

Meconium drug screening of stillborn infants: a feasibility study

OBJECTIVE

Meconium drug testing of liveborn infants is highly sensitive (87%) and specific (100%). Accurate knowledge of drug use in mothers of stillborns would be beneficial. We determined the feasibility of noninvasive meconium drug screening for opiates and cocaine in stillborns.

METHODS

Stillborn infants delivered at our hospital had meconium collected using a 4-mm spatula inserted into the anus. Specimens were analyzed using gas chromatography. Charts were reviewed.

RESULTS

Of the 30 specimens obtained, 26 were below the optimal amount needed (0.5 g). Regardless, all samples were analyzed and three were positive for cocaine (10%), none for opiates. Two of the 3 positive samples were of 'insufficient quantity'. In one, the presumptive cause of fetal demise was diabetes, with no additional factors suggesting substance abuse. The other fetal loss was due to idiopathic preterm labor at 21.5 weeks, with a positive UDS.

CONCLUSION

In this pilot study, inability to obtain an optimal volume of meconium occurred frequently. However, important and unexpected laboratory data were generated even with 'insufficient quantity'. This highlights the need to develop more refined methodologies for this screening tool in stillborn fetuses.

Detection of human defensin 5 in reproductive tissues

OBJECTIVES

This study was undertaken to determine whether tissue-specific defensins are expressed within female reproductive tissues.

STUDY DESIGN

Messenger ribonucleic acid from amnion, chorion, endometrium, endocervix, myometrium, placenta, small intestine, peripheral blood lymphocytes, and cervical, endometrial, and trophoblast cell lines was reverse transcribed with a 3'-RACE adapter. 3'-RACE polymerase chain reaction was conducted with an upstream human defensin 5 primer and 3'-RACE adapter primer. Polymerase chain reaction products hybridizing to a human defensin 5 probe were cloned for sequence analysis. Sequence data were compared against a nucleotide sequence database, and secondary structure predictions were made.

RESULTS

Chorionic tissue, endocervical tissue, endometrial tissue, and an endometrial cell line all demonstrated a single hybridizing 362 bp polymerase chain reaction product. Sequence analysis of all clones demonstrated near-perfect identity with human defensin 5.

CONCLUSIONS

Human endocervix, endometrium, and chorion express defensin 5 at the level of transcription. These findings suggest that a previously unrecognized mechanism of protecting female reproductive tissues against infection, by means of a natural antimicrobial system (defensins), may be present.

Induction and postranslational expression of G-CSF and RANTES in a first trimester trophoblast cell line by lipopolysaccharide

PROBLEM

Comparatively little is known about the capacity of first trimester trophoblasts to respond to an infection and coordinate an immune response. This study characterizes the LPS induction of G-CSF and RANTES in a first trimester trophoblast cell line.

METHODS

HTR-8/SV neo cells were exposed to LPS (1 micrograms/ml) for 0, 2, 4, 6, 8, and 24 hours in DMEM-Ham's F-12 media supplemented with 10% fetal bovine serum. Cytokine levels in culture supernatants were measured by ELISA. Northern analysis of total RNA was conducted using antisense cytokine probes.

RESULTS

Levels of immunoreactive G-CSF and RANTES from LPS induced cultures at 24 hours were 10-fold and 8.5-fold greater than cytokine levels from non-induced cells at 24 hours, respectively (P < 0.01). Under LPS induction, maximal rates of G-CSF and RANTES transcription occurred at 24 hours and 8 hours, respectively.

CONCLUSION

The LPS induction of proinflammatory cytokines in a first trimester trophoblast cell line supports the contention that first trimester trophoblasts participate in cytokine based immune signaling in response to infection.

Induction of inflammatory cytokines in placental monocytes of gravidae infected with the human immunodeficiency virus type 1

Placental mononuclear cells (PMC) are susceptible to infection with the human immunodeficiency virus (HIV). PMC secreted tumor necrosis factor-alpha (TNF-alpha), interleukin-1 beta), and IL-6 among other factors, which, in turn, regulate HIV replication in latently infected cells. We assessed the induction of these cytokines in PMC from HIV-infected (HIV+) and uninfected (control) gravidae following exposure to lipopolysaccharide (LPS), HIV lysate (iHIV), recombinant HIV env (GP160) and HIV gag (gag55), and synthetic HIV p17 (HGP30) antigens. In comparison to control PMC, HIV+ PMC constitutively secreted higher levels of IL-1beta and IL-6 and were refractory to stimulation by iHIV, GP160, gag55, and HGP30. Control PMC IL-1 beta levels were boosted by LPS; gag55 and HGP30 augmented IL-6 but not IL-1 beta. Both groups exhibited low basal TNF-alpha production that was augmented by LPS. HIV+ PMC exhibited higher constitutive levels of IL-1 beta, IL-6, and TNF-alpha gene transcription than control PMC. These levels could be further augmented by LPS, yet the incremental levels were lower than those obtained from PMC of uninfected women. The high basal constitutive secretion of cytokines by HIV+ PMC and their refractoriness to activation may reflect a virus-mediated dysregulation of cytokine expression culminating in compromised host defenses against secondary opportunistic infections associated with AIDS.

Characterization of the imprinted IPW gene: allelic expression in normal and tumorigenic human tissues

IPW (Imprinted gene in the Prader-Willi syndrome region) is a recently identified paternally expressed gene. Previous work has demonstrated IPW expression in the human fetus and adult, with monoallelic expression in adult lymphoblasts and fibroblasts, and in fetal tissues. To further examine the expression of IPW, a series of experiments were carried out using RT-PCR to measure IPW expression in placentae and various fetal and tumor tissues. Biallelic expression of IPW was found in testicular germ cell tumor and bladder cancer cells, suggesting loss of imprinting in the latter case. Both H19 and Insulin-like growth Factor 2 (IGF2), two additional imprinted genes, also showed biallelic expression in those same tumors that demonstrated IPW biallelic expression. Of note, the naturally occurring parthenogenetic-derived mature teratoma unexpectedly expressed large amounts of IPW. Lastly, the pluripotent embryonal cancer cell line Tera-2 expressed IPW at the same level before and after differentiation induced by retinoic acid, suggesting that this gene functions in a 'housekeeping' capacity throughout cell growth. This was in contradistinction to H19 and IGF2, both of which showed significant transcriptional upregulation after Tera-2 cell differentiation.

Induction and posttranslational expression of cytokines in a first-trimester trophoblast cell line by lipopolysaccharide

OBJECTIVES

The response to infection by human first-trimester trophoblasts is a poorly understood event. This study was undertaken to determine whether first-trimester trophoblasts are capable of responding to an infection stimulus and mediating an immune response.

STUDY DESIGN

HTR-8/SVneo cells were exposed to lipopolysaccharide (1 microgram/ml) or media alone for either 0, 2, 4, 6, 8, or 24 hours. Northern analysis was conducted by use of a panel of antisense cytokine probes. Enzyme-linked immunosorbent assays specific for either interleukin-1 alpha, interleukin-6, interleukin-8, or transforming growth factor-beta 1 were conducted on corresponding cell culture supernatants, and the kinetics of expression were determined.

RESULTS

Interleukin-1 alpha, interleukin-6, interleukin-8, and transforming growth factor-beta 1 transcription occurred maximally between 2 and 8 hours of culture in media containing lipopolysaccharide, with a subsequent diminution of response. Enzyme-linked immunosorbent assay analysis corroborated lipopolysaccharide induction seen at the level of transcription, with significant posttranslational expression of these cytokines being detected between 2 and 24 hours in culture (p < 0.01).

CONCLUSIONS

Expression of the proinflammatory cytokines interleukin-1 alpha, interleukin-6, interleukin-8 and transforming growth factor-beta 1 strongly support the contention that human first-trimester trophoblasts are capable of responding to an infection stimulus and eliciting an immune response through cytokine-based immune signaling.

Vulvar vestibulitis subjects undergoing surgical intervention: a descriptive analysis and histopathological correlates

OBJECTIVE

We describe here a series of selected patients from an established vaginitis research clinic diagnosed with vulvovestibulitis (VV) who underwent surgical intervention for focal disease. Long-term results of surgical correction are reported and characteristic histopathology findings associated with vulvar vestibulitis are emphasized.

STUDY DESIGN

A retrospective chart review was carried out to extract relevant clinical, histologic, and outcome data. Tissue blocks of resected specimens were re-examined for specific inflammatory response.

RESULTS

Complete data and long-term follow up were available in 16 patients who underwent surgical intervention. All were cared for by the same practitioner (CM). The mean (+/- S.D.) age and gravidity on presentation were 26.9 +/- 5.3 years and 0.9 +/- 1.5, respectively. All but one was caucasian, and 70% were nulliparous. Symptoms included entry dyspareunia (100%), discharge (70%), burning (66%), itching (20%) and other (30%). All patients had focal tenderness; other findings were erythema (50%), acetowhite staining (80%), edema (20%), micropapules (20%) and condyloma (10%). After diagnosis, initial duration of conservative management was 9.4 +/- 6.9 months (1-26 months). No patients received interferon therapy. Because of persistent symptoms the 16 subjects underwent targeted partial perineoplasties. Initial histopathology results revealed chronic inflammation, parakeratosis, hyperkeratosis, edema, koilocytosis and acanthosis. When tissue blocks were cut and stained with Giemsa, large numbers of mast cells were identified. Mean postoperative follow up was 42.0 +/- 22.4 months (10-70 months). Follow up after surgery showed an overall improvement in 15/16 patients (93.8%).

CONCLUSIONS

VV affects primarily white, nulliparous women. In the carefully selected subject, surgical intervention has a high success rate, even on long-term follow up. Although the exact etiology for this condition has yet to be elucidated, the presence of mast cells supports an association with other genitourinary inflammatory syndromes such as interstitial cystitis; and allows for speculation about a possible role played by mast cell activation in the etiology of VV.

Morphologic characteristics of the interaction between normal cytotrophoblasts and their malignant counterpart in the development of trophoblastic neoplasia

OBJECTIVES

To define the biology of the tumor-host cell interaction with regard to cellular kinetics and morphologic changes during cell-cell interaction in an in vitro model of trophoblastic neoplasia.

METHODS

Using a coculture in vitro system of cytotrophoblasts and choriocarcinoma cells, we investigated the cellular kinetics and the morphologic changes in these interacting cells. A fully automatic time-lapse image system was used to record phase contrast images of the cocultured cells in a tissue culture chamber. To examine cytoskeletal structure, immunofluorescent-labeled antibodies against intermediate filaments were used. Slides were examined with a confocal laser scanning microscope and subjected to computed analysis.

RESULTS

The choriocarcinoma cells attract normal cytotrophoblasts using what resembles pseudopodia to engulf the latter cells and thus form slow-growing colonies. In this process, new hybrid cells are formed, which can be differentiated from their original contributors by morphologic characteristics.

CONCLUSION

This phenomenon supports our previous biochemical and molecular data on the role of cell-cell interaction in the complex process of cytotrophoblast transformation and the development of gestational trophoblastic neoplasia.

Human trophoblast cell adhesion to extracellular matrix protein, entactin

PROBLEM

Trophoblast interaction with endometrial extracellular matrix (ECM) is crucial during human embryo implantation and placentation. Entactin, a ubiquitous basement membrane glycoprotein, plays a central role in ECM assembly, cell attachment, and chemotaxis. The present study was conducted to examine the possible role of entactin in promoting human trophoblast adhesion.

METHODS

Using an extended life span first trimester trophoblast cell line HTR-8/SVneo (HTR) and a cell adhesion assay, we measured the adherence of human first trimester trophoblasts to recombinant entactin and its domains. Also, we used flow cytometry and indirect immunofluorescence to detect the presence of integrins that may be involved in human trophoblast-entactin interaction; these methods were used to analyze HTR cells, as well as tissue sections and freshly isolated human trophoblasts from first trimester and term placenta.

RESULTS

We found that first trimester trophoblast cells were highly adherent to entactin and its E and G2 domains but not to G1 or G3 domains. Using indirect immunofluorescence and flow cytometry, we found that both beta 1 and beta 3 integrin subunits were expressed on the surface of HTR trophoblast cells adhering to entactin; in contrast, beta 2 and beta 4 integrin subunits were not detected. In addition, we found that alpha v beta 3 was expressed on freshly isolated villous cytotrophoblasts and cytotrophoblast and syncytiotrophoblasts in tissue sections from term placenta. The beta 3 integrin subunit was expressed in cytotrophoblasts and syncytiotrophoblasts in villi of first trimester placental tissue sections.

CONCLUSION

Recombinant entactin promotes human trophoblast cell adhesion through both its E and G2 domains and these specific adhesive interactions may be mediated by beta 1 and/or beta 3 class integrins.