Efficacy of an acidic vaginal gel on vaginal pH and interleukin-6 levels in low-risk pregnant women: a double-blind, randomized placebo-controlled trial

BACKGROUND

Increased interleukin-6 (IL-6) levels and a vaginal pH of > 4.7 are associated with obstetric complications such as preterm delivery and low birth weight. Topical treatments, able to maintain a physiological vaginal pH, could help in the prevention of vaginal infections.

STUDY AIM

In a randomized, double-blind, placebo-controlled trial, we evaluated the effects of an acidic buffering vaginal gel (Miphil) on vaginal pH and IL-6 levels in pregnant women.

PATIENTS AND METHODS

Seventy low-risk women pregnant with a singleton (second trimester) were enrolled in the trial. Thirty-five were randomized to the acidic gel, 2.5 g every 3 days for 12 weeks, and 35 to the corresponding placebo. Vaginal pH and vaginal IL-6 level were measured at baseline and after 12 weeks. Women were then followed until delivery. The main outcome measures were vaginal pH, vaginal pH normalization (pH < 4.5) and vaginal IL-6 levels.

RESULTS

Vaginal pH at baseline was 4.6 +/- 0.4 and 4.4 +/- 0.3 in the acidic gel and the placebo group, respectively. At baseline, a total of 40% (14/35) and 22% (8/35) of women in each group, respectively, had a vaginal pH of > or = 4.7. At week 12, the vaginal pH was 4.3 +/- 0.3 in the acidic gel group and 4.3 +/- 0.3 in the placebo group (NS). The acidic gel normalized the vaginal pH in ten out of 14 women (p = 0.04) in comparison with only one out of eight women in the placebo group (NS). The acidic gel induced a significant (p < 0.02) reduction of vaginal IL-6 from 12.0 +/- 7 to 8.9 +/- 5 pg/l (-36%). In the placebo group, IL-6 increased from 9.0 +/- 5 to 13.5 +/- 6.8 pg/l (+50%) (p = 0.05). Birth weight was 2978 +/- 700 g in the placebo group and 3241 +/- 477 g in the acidic gel group (p = 0.06).

CONCLUSIONS

The use of the acidic gel in low-risk pregnant women is able to maintain a physiological vaginal ecosystem and prevents the increases of vaginal pH and vaginal IL-6. Prospective and controlled trials are warranted to evaluate whether this acidic gel can reduce obstetric complications linked to vaginal inflammation during pregnancy.

The management of feto-maternal alloimmune thrombocytopenia: Report of three cases

We report herein three cases of severe fetal thrombocytopenia due to anti-human platelet antigen (HPA)- 1a maternal antibodies. The first and the third cases were diagnosed on the basis of previously affected siblings and treated successfully by maternal intravenous human immunoglobulins and corticosteroids. In the second case an unexpected neonatal thrombocytopenia was found after birth without previously affected siblings and treated subsequently with intravenous immunoglobulins. Our experience supports a switch from an invasive management, including early FBS (fetal blood sampling) and platelet transfusions, to a more cautious approach. Also in severe HPA-1a alloimmunization and in 'high risk' fetuses, prenatal maternal treatment could be performed, without previous FBS, only on the basis of a risk score defined by sibling history and parents' genotypes.

Early detection by magnetic resonance imaging of fetal cerebral damage in a fetus with hydrops and cytomegalovirus infection

We discuss the use of magnetic resonance imaging (MRI) to reveal early fetal neurological involvement of cytomegalovirus (CMV) infection. A woman presented at 21 weeks of pregnancy with active CMV infection. Cerebral ultrasound examination had been normal. An MRI scan revealed a thickened germinal matrix, which was histologically confirmed, associated with underdevelopment of the gyri. Brain MRI proved particularly useful in identifying the findings not disclosed by routine ultrasound during pregnancy and subsequently confirmed at histology.

Human papilloma virus infection and cervical intraepithelial neoplasia in transplanted patients

Progress in diagnosis and treatment has led to an increased number of transplantation patients who consequently have immunological depression and emergence of tumors. The incidence of cervical neoplasia, according to previous studies, is 11%; this tumor is the only one that can be investigated by screening before and after a graft. Our purpose was to evaluate whether transplanted patients showed an increased incidence of genital human papilloma virus (HPV) infection and whether this infection produced greater progression of disease in cases of low-risk HPV infections. Our study involved 151 transplant patients who underwent Papanicolaou (Pap) and HPV tests. Patients listed for grafts underwent Pap and HPV tests 6 months before and 6 months after transplantation. All patients had negative Pap tests before their grafts. After their grafts 16 patients (10.59%) had negative Pap tests, but positive viral typing. Eleven patients (7.28%) showed positive Pap tests, 6 of whom had low-grade squamous intraepithelial lesion (SIL) and 5 patients high-grade SIL. The final HPV infection incidence (15.23%) was consistent with the literature. The incidence of lower female genital tract intraepithelial lesions (7.28%) was higher than the healthy population or analogous studies (4.5%-8.5%). We showed a constant association between high-risk HPV infection and gynecologic intraepithelial neoplasia, whereas there was no association between low-risk broods HPV infection and neoplasia. In conclusion, screening should start at almost 6 months before grafting to avoid an irreversible situation that is difficult to treat.

Extremely low ventricular rate in a fetus with an isolated non-autoimmune complete congenital heart block. Case report

Congenital complete heart block (CCHB) is an uncommon disorder with an incidence of about 1/20,000 in liveborn infants. It can occur in the setting of structurally normal heart or with structural disease; it is associated with high mortality and morbidity and requires a high index of suspicion for early diagnosis and therapy. Isolated CCHB in a fetus is usually associated with the presence of autoantibodies to SSA (Ro) and SSB (La) antigens in the maternal circulation. Such antibodies cross into the fetal circulation and cause inflammation of the conduction tissues; the causal mechanism is not known. Although the prognosis for the majority of fetuses is good, it is less favourable in fetuses with a ventricular rate <55 bpm in early pregnancy or with a decrease in the ventricular rate by >5 bpm during pregnancy. It is not known if the same prognostic criteria apply for fetuses with isolated non-autoimmune CCHB. This article reports authors' experience in managing a pregnancy with an extremely low fetal heart rate (47 bpm) in a single fetus with an isolated non-autoimmune CCHB in which the outcome was favorable.

Variations in fibrinolytic parameters and inhibin-A in pregnancy: related hypertensive disorders

BACKGROUND

The mechanisms leading to pregnancy-related hypertensive disorders, and pregnancy-induced hypertension (PIH) and pre-eclampsia (PE) in particular, are still not clear. Diagnostic criteria are clinical because specific markers of the condition are lacking. A role of the fibrinolytic system has been suggested.

OBJECTIVES

We aimed to evaluate the behavior of tissue-type plasminogen activator (t-PA), plasminogen activator inhibitor type 1 (PAI-1), PAI-2, and the placental hormone inhibin-A in women with a normal pregnancy vs. women with pregnancies complicated by PIH or PE.

METHODS

Blood samples were drawn between the 25th and 30th gestational week (GW) and between the 31st and 36th GW in order to assay t-PA, PAI-1, PAI-2 and inhibin-A; routine biochemical exams, ultrasonography umbilical artery pulsatility index (PI), placental weight and newborn weight were measured.

RESULTS

In pregnancies complicated by hypertensive disorders, PAI-1 levels were higher than in controls and increased significantly after the 25th GW, especially in PE, as did inhibin-A. PAI-2 levels were significantly lower after the 30th GW in patients with PIH and PE. The PAI-1/PAI-2 ratio was significantly higher in PE patients than in controls as of the 25th GW, but only after the 30th GW in patients with PIH. Inhibin-A was significantly correlated with fibrinolytic parameters, and inversely with newborn weight. Receiver-operator characteristic curves for PAI-1 and inhibin-A showed a high sensitivity and specificity for PE. PAI-2 correlated with newborn and placental weight, and inversely with PI of the umbilical artery.

CONCLUSIONS

Fibrinolytic tests (especially PAI-1) and inhibin-A monitoring during pregnancy may help in the early diagnosis of pregnancy-related hypertensive disorders.

Hypertrophic obstructive cardiomyopathy and pregnancy: anesthesiological observations and clinical series

Hypertrophic obstructive cardiomyopathy represents a genetic disorder characterized by hypertrophy, usually asymmetrical, of the ventricular musculature at the base of the septum in the left ventricular efflux tract. Patients suffering from this disorder can be extremely sensitive to small alterations in ventricular volumes, arterial pressure, cardiac frequency and rhythm. This disorder is found in pregnancy with an incidence of 0.1-0.5% and, because of its gravity, represents a contraindication which is often absolute to pregnancy. Hemodynamic variations such as those found in pregnancy, labor and delivery have complex influences on hypertrophic cardiomyopathy. Our clinical series includes 2 pregnant patients suffering from hypertrophic obstructive cardiomyopathy who both underwent caesarian section in general anesthesia, the first due to the gravity of cardiac obstruction and the second due to the emergent need to proceed after the beginning of labor. The small number of clinical cases in the literature, especially in the last few years, clearly underlines the difficulty of defining both the most correct method for delivery and the most appropriate anesthesiological techniques. In accordance with the literature and our clinical experience, we can conclude that a carefully managed pregnancy can proceed without complications in patients with moderate obstruction and that a regional anesthesiological approach is also possible with careful hemodynamic monitoring. General anesthesia, however, remains the safest method and has fewer risks for patients with serious obstruction or with worsening of their clinical condition during pregnancy.

Activated protein C resistance in normal and pre-eclamptic pregnancies

OBJECTIVES

A lower ratio in the classic activated protein C resistance (APC-R) test has been reported during pregnancy, which has been called 'acquired' APC-R. However, little is known about the cause of the lowered ratio, and whether or not there is a correlation with blood coagulation activation. The primary objective of our study was to determine changes in APC-R levels in each of the trimesters of normal pregnancy. The secondary objective was to confirm whether APC-R levels were lower in pregnancies complicated by pre-eclampsia than in a control group. Finally, this prospective study was performed to investigate the prevalence of APC-R among pregnant women and to elucidate its obstetric consequences.

METHODS

We enrolled 35 healthy pregnant women and 47 pregnant women affected by pre-eclampsia in our study. The following laboratory tests were performed: prothrombin time, partial thromboplastin time, fibrinogen levels, antithrombin III, plasmatic fibronectin (as a marker of endothelial damage), haptoglobin (as a marker of intravascular haemolysis), a functional test for APC-R and analysis of factor V Leiden mutation by polymerase chain reaction.

RESULTS

The activated protein C sensitivity ratio was lower in the pathological group than in the control group (p = 0.008 and p = 0.02, respectively). Plasmatic fibronectin was found to be higher in the pathological group than in the control group (p = 0.05). Finally, the overall prevalence of factor V Leiden mutation was 5.4%, i.e. 2/35 women (5.7%) in the control group and 3/47 women in the pathological group (6.38%).

CONCLUSIONS

The APC ratio decreased after 20 weeks of gestation until week 42. This decrease was most pronounced in the third trimester, in which resistance was demonstrated in 34.2% of control group patients. In pre-eclampsia, we found a greater reduction of the APC ratio than in controls. We hypothesise that this is due to a decrease in the plasmatic levels of coagulation inhibitors and an increase in coagulatory factors.

Biochemical markers for the prediction of spontaneous pre-term birth

OBJECTIVES

The aim of this study was to identify predictive biochemical markers for preterm labor.

METHODS

In this prospective study we included 225 asymptomatic Caucasian women consecutively enrolled at 24 weeks of gestation. The following data were collected only once at 24 weeks of gestation: vaginal pH, vaginal fFN, cervical and serum concentration of IL-6, IL-8 and TNFalpha, maternal blood serum, ferritin. Student's t-test, the chi(2)-test and multiple linear regression were used as statistical methods.

RESULTS

There were no differences between the age of patients, parity and gestational age at sampling between women who delivered at term and those who delivered pre-term (<37 weeks' gestation). There was a significant increase of cervical IL-6 (pre-term 608+/-1595 pg/l vs. at term 58.9+/-112 pg/l) and serum ferritin (pre-term microg/l 74.4+/-1.1 vs. at term 26.3+/-56.5 microg/l) in pregnant women who delivered pre-term (P<0.05). No differences in cervical IL-8 and cervical TNFalpha between pre-term and term deliveries were found. Multiple linear regression confirmed that the vaginal pH value and cervical fFN test were the best predictive biochemical markers of pre-term birth (standardized coefficient Beta=0.33 and 0.22, respectively).

CONCLUSIONS

In order to evaluate pregnancies for pre-term labor, the presence of pH>4.5 and a positive fFN test seems to be predictive of subsequent pre-term delivery.

[Pregnancy in women infected with the hepatitis C virus]

The prevalence of HCV-RNA positivity in pregnant women goes from 1.2% to 4.5% in different countries. The aim of our study is to show pregnancy outcome, vertical/perinatal transmission rate, the viral load and the tramnsaminases trend during pregnancy and after delivery. The study involved 11,681 pregnant women screened in the Obstetric Department for High Risk Pregnancy at the University of Padua between 1992 and 1999. We evaluated the markers of HCV, HBV, HIV, the viral load and genotype and AST/ALT in the mothers and positivity and viral load of HCV-RNA in the newborns at birth and at 3rd, 6th, 9th, 12th month. Of the 11,681 pregnant women, 135 (1.15%) tested positive for the presence of anti-HCV antibodies and of the 135 anti-HCV antibody-positive mothers, 80 were found to be positive for HCV-RNA. Of 80 pregnancies that were HCV-RNA positive, 4 termined in abortion, 1 in stillborn, 1 in neonatal death, 18 in preterm delivery and 56 were carried to term. We came to the conclusion that HCV infection does not increase the risk of obstetric complications and does not influence the fetal-neonatal status at delivery; the pregnancy evolution may be complicated by the onset of cholestatsis in the 2nd and 3rd trimester; vertical transmission of the infection develops in few cases (4.8%), more likely at delivery.

[Comparative analysis of premature labor markers]

We compared the diagnostic value of foetal fibronectin (fFN), phosphorilated insulin-like growth factor protein binding-1 (Birth test) and insulin-like growth factor protein binding-1 (PROM test) as markers of premature rupture of membrane (PROM) and in prediction of preterm labor with intact membranes. The study population included 120 asymptomatic women (group 1), with gestation of 24-34 weeks; we also considered 21 patients with clinically confirmed PROM (group 2) and 26 patients with suspected PROM with gestation between 15 and 24 weeks (group 3) (as measured by sonography data). From our data, it seems that only the predictive value of each test is related to the characteristics of the population considered. The fFN test and the Birth test prove to be highly predictive in pregnant women without PROM, on the contrary the use of the PROM test is optimal in pregnant women with suspected PROM or with PROM, regardless of risk factor or with contractile activity.

Viral load in HCV RNA-positive pregnant women

OBJECTIVES

The risk of hepatitis C virus (HCV) infection in the newborn is estimated to be around 5%, but becomes very high in the case of coinfection with HIV. One of the main factors associated with the vertical transmission of HCV is the viral load. Our objective was to investigate the behavior of HCV viral load during pregnancy in relation to HIV coinfection, liver enzymes, and vertical transmission.

METHODS

Three thousand seven hundred forty-eight women seen consecutively in their first trimester of pregnancy were screened for HCV infection. Sixty-five were found to be anti-HCV+/HCV RNA+ and were followed up with clinical and serological assessment (i.e., transaminases and quantitative polymerase chain reaction [PCR] for viral load) in their second and third trimesters and 6 months after delivery. All were anti-HIV and hepatitis B surface antigen negative. HCV RNA was 12.0+/-19.9 x 10(6) copies/ml in the first trimester and 10.9+/-13.3 x 10(6) in the second, but increased to 19.5+/-25.1 x 10(6) in the third trimester. Six months after delivery the viral load returned to the baseline levels; the changes in viral load did not reach any statistical significance, however. Transaminases tended toward a reduction from the baseline during the second and third trimesters, and then an increase in both AST and ALT was recorded 6 months after delivery. However, when the group whose AST/ALT were found abnormal at the first test was considered, no significant changes were recorded during the follow-up. The overall rate of vertical transmission was 4.6

CONCLUSIONS

With HCV+ mothers monitoring transaminases during pregnancy is unnecessary, and testing liver enzymes at the beginning of pregnancy is sufficient. Qualitative PCR should be done once during the pregnancy, but any staging of the liver disease should be taken after delivery. Quantitative PCR testing is expensive and pointless. Any decision for elective cesarean section in HCV RNA+ mothers should be confirmed by other studies.

The effects of epidural analgesia and uterine contractions on fetal oxygen saturation during the first stage of labour

The aim of this study was to investigate the effects of (1) maternal epidural analgesia and (2) uterine contractions on fetal oxygen saturation. After informed consent 18 women were included in our prospective, non-blinded, observational study. After 30 min of monitoring fetal oxygen saturation and uterine contractions, all the parturients, at cervical dilatation >/= 3 cm, received epidural analgesia for labour: a Pajunk epidural catheter was passed through a 17-gauge Tuohy needle and left in the lumbar epidural space (insertion level L3-4 or L2-3). Sufentanil 10 microg and 0.1% ropivacaine 15 mL were injected into the epidural catheter. A second and third 15-mL epidural dose of 0.1% ropivacaine were administered on patient demand. Fetal oxygen saturation was unaffected by epidural analgesia and there was no change in fetal SpO(2)following an uncomplicated epidural top-up. SpO(2)values (%) 30 s before, during and after contraction were 47.6 +/- 2.4, 52.5 +/- 5.3 and 42.9 +/- 7.2 respectively. These changes were significant. A contraction appeared to inject a bolus of oxygenated blood into the fetus, causing an initial increase in fetal oxygenation followed by a decline. The lowest SpO(2)values observed occurred 120 s after the start of contractions.

Hepatitis C virus, hepatitis B virus and human immunodeficiency virus infection in pregnant women in North-East Italy: a seroepidemiological study

BACKGROUND

Pregnant women can be considered a sentinel population, because they are a relatively unselected population whose prevalence data may be extended to the general population.

METHODS

A seroepidemiological study was carried out in Padua (North-East Italy) to assess the epidemiological aspects of HCV. HBV and HIV infection in 2059 pregnant women consecutively seen at the Department of Obstetrics and Gynaecology during 1996. Out of them, 1804 (87.2%) were indigenous and 255 (12.8%) immigrants. Sociodemographical and sanitary data were collected for each woman.

RESULTS

The overall prevalence of anti-HCV was 1.9% (42.5% with detectable HCV-RNA); HBsAg was found in 1.0%: the prevalence of anti-HIV was 0.3%. Findings are substantially consistent with the epidemiological picture of such infections in the general population of our geographic area. A parenteral risk factor for HCV infection was found in 19 subjects (47.5%): 18 were intravenous drug users and 1 a blood transfusion recipient. HBsAg seroprevalence was higher in immigrants than in autochthonous (3.1% vs. 0.7% respectively, p < 0.01). One of the 6 anti-HIV positive women was intravenous drug user. Logistic regression analysis was carried out for each viral agent to determine which characteristics were independently associated with infection: anti-HCV prevalence resulted independently associated to Italian origin (OR: 3.7), unmarried status (OR: 2.7), unemployed condition (OR: 6.1) and history of previous abortion (OR: 2.8). HBsAg prevalence was independently associated to unemployed condition (OR: 10.8), whereas HIV positivity was significantly related to the unmarried status (OR: 18.5).

CONCLUSION

Our study pinpoints the need of screening all pregnant women for HCV and HIV infection, in addition to the HBsAg screening which is compulsory in Italy.

Markers of tubular damage in pre-eclampsia

BACKGROUND

The aaim of this study is to investigate the tubular damage markers in pre-eclampsia and in pregnancy induced hypertension (PIH).

METHODS

This transversal study involved 111 women admitted to the Department of Obstetric and Gynaecology, University Hospital, Padua (Italy) and was conducted from the 24th week until delivery: 23 had normal pregnancies, 54 manifest pre-eclampsia, and 34 manifested pregnancy-induced hypertension (PIH) without superimposed pre-eclampsia. The following laboratory tests were performed: U-alpha 1 microglobulin, U-NAG, uric acid and microalbuminuria. The four groups were compared using the Mann-Whitney test and the Kruskall-Wallis test for multiple comparisons. A value of p < 0.05 was considered as statistically significant.

RESULTS

As for the markers of tubular damage, the values for urinary NAG were significantly lower in the control group (0.97 U/mmol Creat) than in the pre-eclampsia group (2.89 U/mmol Creat), and the PIH group (2.12 U/mmol Creat) (p < 0.01). Values for urinary alpha 1-microglobulin were higher in the pre-eclampsia group (4.03 U/mmol Creat) than in the control (0.74 U/mmol Creat), and PIH groups (1.88 U/mmol Creat) (p < 0.01). As for the markers of glomerular damage, the values of microalbuminuria were higher in the pre-eclampsia group (134 micrograms/min) than in the control (9.4 micrograms/min), and PIH groups (10 micrograms/min), (p < 0.05). Uric acid, the marker of glomerular and tubular damage, was higher in the pre-eclampsia group (0.27 mmol/L) than in the control (0.20 mmol/L), and PIH groups (0.24 mmol/L), (p < 0.05).

CONCLUSIONS

In pre-eclampsia there is a tubular and glomerular damage to point out by an increased urinary excretion of NAG. In pre-eclampsia, an increase of urinary alpha 1-microglobulin excretion may be considered to be partly due to the overloading of the tubule and partly due to a mixed glomerular and tubular lesion.

Predictive markers of pre-eclampsia in hypertensive disorders of pregnancy

OBJECTIVE

The aim of this work is to assess the most widespread methods currently proposed and two new markers for predicting the development of pre-eclampsia in pregnant women with hypertension.

METHODS

The study involved 212 pregnant Caucasian women: 104 normotensive, 68 pregnancy-induced hypertensive and 40 chronic hypertensive. Blood and urine were sampled between 28 and 30 weeks gestation. All 108 hypertensive pregnant women, at the time of sampling, demonstrated proteinuria below 0.3 g/24 h. The following laboratory tests were performed: fibronectin, antithrombin-III, alpha-1-microglobulin, U-N-acetyl-beta-glucosaminidase, uric acid and albumin excretion rate. Student's t-test, discriminant analysis and chi2 (chi-square) test were used as statistical methods. A P value less than 0.05 was considered significant.

RESULTS

After discriminating analysis, only three of the six variables analyzed were able to discriminate patients who would develop pre-eclampsia from the remaining hypertensive pregnant women: microalbuminuria, uric acid and fibronectin (chi2 = 29.122, P < 0.01).

CONCLUSIONS

In agreement with previous studies, albumin excretion rate appeared to be the best predictive test for pre-eclampsia in hypertensive pregnant women, giving a higher positive predictive value and specificity (87.5 and 98.9%, respectively).

Congenital heart disease in pregnancy

The clinical cases of three patients affected respectively by Eisenmerger's syndrome, Marfan syndrome, coarctation of the aorta are described. All patients belonged to NYHA class I or II. During pregnancy contact with cardiologists, anaesthetists, neonatologists was maintained and this allowed accurate management. Both pregnancy and delivery evolved without any complication and with a positive outcome for mother and newborn.

Primary abdominal pregnancy. A case report

Abdominal pregnancies are very uncommon; in the United States they are seen once every 10,000 births and consist of approximately 1% ectopic gestations. We report one case with a primary pelvic-peritoneal ectopic pregnancy, diagnosed by chance at 11 gestational weeks complicated by hemoperitoneum and acute abdomen. This case is interesting because the early diagnosis of abdominal pregnancy is frequently difficult. In fact the clinical history, physical examination, laboratory and ultrasonographic findings are non specific. The physical examination is inconclusive in most patients. Findings such as abdominal tenderness, a closed uneffaced cervix, palpation of a pelvic mass distinct from the uterus are described as being suggestive of the abdominal pregnancy. Once the diagnosis of abdominal pregnancy is made, management of these patients requires a careful and further evaluation. Most clinicians agree that immediate operative intervention is indicated for those pregnancies prior to 23 to 24 weeks, because of the high incidence of maternal morbidity with significant risks of maternal mortality, in light of the poor prognosis for the fetus. In patients who present after 24 weeks, debate has arisen in the literature concerning the appropriateness of a more conservative approach.

Acute pancreatitis and deep vein thrombosis associated with HELLP syndrome

The HELLP syndrome (HS) belongs to the list of obstetric complications believed to be associated with coagulation disorders. It was formerly thought that chronic intravascular clotting (DIC) in the placental vessels was the main cause. A hypercoagulable state has been reported in cases of severe HS associated with microvascular abnormalities that may involve cerebral, placental, hepatic and renal vessels. A case of acute pancreatitis and DVT of inferior cava in a pregnant woman, presenting with HS at 29 weeks, who was found to have a R506Q mutation, is reported. Preeclampsia-associated pancreatitis and DVT have rarely been reported. It is hypothesized that APC-R and Factor V Leiden mutation may prove to be new and more important markers capable of predicting a more significant maternal morbidity associated with HS. Thrombosis prophylaxis may be considered during pregnancy in order to reduce hazardous multiorgan failure (MOF) in women who are heterozygous for Factor V Leiden mutation.

Obstetric complications in Marfan's syndrome pregnancy

Marfan syndrome is usually inherited as an autosomal dominant trait with high degree of penetrance. It is caused by an abnormal fibrillin gene located on chromosome 15q. Cardiovascular involvement in Marfan syndrome has been overstressed, although very little attention has been given to obstetric complications. Marfan syndrome may be responsible of cervical incompetence, abnormal placental site and post partum haemorrhagic complications. A 22-year-old woman with Marfan syndrome had mitral regurgitation since childhood. In addition aortic root dilatation was documented over six years by means of echocardiography and had been followed up regularly in a district hospital. Echocardiography six months before pregnancy had shown minimal mitral and aortic regurgitation and aortic root dilatation of 4.1 cm; left ventricular function was normal. Repeat echocardiography evaluations during pregnancy confirmed an aortic root dilatation. Routine booking and screening investigations were all within normal limits. At the 25th week, admission was necessary following a vaginal bleeding, without pain contraction. Echography showed a placenta praevia and cervical dilatation 2.8 cm of diameter. Bed rest and intravenous thocolitic therapy were immediately enhanced. A cervical cerclage, as described by McDonald, was placed. At the 37th week the patient was admitted and cerclage removed before the caesarean section. A healthy female of 2900 g was born. The postoperative period was favourable and patient was discharge after 7 days. In the present case, it is suggested that cervical incompetence and placenta praevia may be caused by an alteration of microfibrillar fibers.

Congenital or torsion-induced absence of Fallopian tubes. Two case reports

Unilateral absence of a uterine tube is an extremely rare finding, for which there are two possible etiopathogenic causes: in some cases it is due to haemorrhage filling of the cavity and its reabsorption as a result of asymptomatic torsion of the uterine tube during adult life, in pediatric age or even during intrauterine life; alternatively, the absence may be congenital, associated with developmental alterations of the mesonephric and paramesonephric ducts. The article presents two cases of fallopian tube absence: a congenital monolateral absence and a tubal torsion during pregnancy. The symptomatology of the torsion of the fallopian tube in pregnancy can be milder than in the classic description with peritoneal reaction and severe clinical alteration. The main risk factors for tubal torsion are: adhesions and inflammatory processes, ovarian cysts, usually of dermoid type, menstrual period, pregnancy, abnormal long mesosalpinx and/or mesovarium, pelvic congestion induced by constipation and disturbed venous blood flow from the adnexa. A congenital defect of the mesonephric duct is followed by a homolateral defect of the paramesonephric duct. The resulting anomaly is characterized by the absence of the uterine tube, uterus-tube angle, kidney and ureter. Partial or total unilateral defects of a paramesonephric duct are more common than aplasia of both ducts. Some authors have suggested that an inadequate blood supply during the descent into the pelvis of the caudal part of the paramesonephric duct might feasibly lead to incomplete tube development.

Contraception in diabetic women

There is a very strong need for an effective and reliable method of contraception in the diabetic woman. An unplanned pregnancy that occurs when her diabetes is not under good control can have disastrous consequences, ranging from abortion to a congenitally malformed fetus. The most important factor in the contraceptive decision for the diabetic patient, especially the IDDM patient, is that the choice be made not by the clinician alone or the patient alone, but through a carefully through-out process that involves both patient and physician.

Protein S deficiency and pregnancy: is there a case for ylaxis?

Pregnancy reduces protein S to 40-50% of normal levels, but it is not clear whether lower protein S levels raise the risk of developing thrombo-embolism during pregnancy. This case report describes a primigravida with a documented protein S deficiency who delivered at 38 weeks of gestation with no thrombo-embolic complications.

Fibronectin and antithrombin as markers of pre-eclampsia in pregnancy

INTRODUCTION

The differential diagnosis between pre-eclampsia and chronic hypertension is not easy, but is essential to proper management of a pregnancy. Patients presenting pre-pregnancy hypertension can be treated conservatively, if not a superimposed pre-eclampsia occurs, controlling pressure pharmacologically and completing the pregnancy with a natural delivery. In pre-eclampsia, hypertension is merely the visible sign of a process of endothelial damage and coagulation cascade activation which is often destined to emerge clinically on a dramatic scale.

MATERIALS AND METHODS

The study involved 18 women with physiological pregnancies, 19 with pre-eclampsia and 13 with chronic hypertension since superimposed pre-eclampsia. The following laboratory tests were performed: PT, PTT, AT-III, proteins C and S, platelet count, D-dimer, fibrinogen and plasma fibronectin. The three groups were compared using the Kruskall Wallis test, the median test and, for multiple comparisons, the Mann-Whitney test. A 'P' value of < 0.01 was considered as statistically significant.

RESULTS

The values for plasma fibronectin were higher in the pre-eclampsia group (410 mg/l (253-727)) than in controls (262 mg/l (183-385)) (P < 0.01) and values for AT-III were lower in the pre-eclampsia group (73% (40-100)) than in controls (93% (80-126) (P < 0.01) (Table 2). The groups with chronic hypertension revealed no such significant differences, however, in relation to the control group (fibronectin = 296 mg/l (198-530), AT-III = 86% (75-103)).

CONCLUSIONS

Measuring antithrombin and fibronectin to monitor any onset of pre-eclampsia can help the obstetrician to avoid important diagnostic and therapeutic errors.

Persistent foetal tachycardia as an early marker of chorion-amnionitis. Description of a clinical case

Intra-amniotic infection (IAI) is uncommon in pregnancy (0.5-1%) and is rarely responsible for maternal mortality, but it does lead to a high rate of maternal and foetal morbidity, e.g. sepsis, septic shock, post-partum endometritis and neonatal sepsis. The diagnosis of IAI is immediate in the case of premature rupture of the membranes, whereas it is far more difficult to reach a correct and timely diagnosis when the amniotic sac is intact, as the mother's clinical symptoms are often scarce and non-specific. Foetal and maternal prognosis in IAI depends on the timely implementation of antibiotic treatment and induction of delivery in order to drain off the infected amniotic fluid. The clinical case described here not only illustrates the difficulty in diagnosing IAI, but also confirms that timely antibiotic therapy can prevent the onset of severe maternal and foetal complications.

Portal hypertension in a pregnant woman

We report a case of a patient with long-standing prehepatic portal hypertension. The patient (a 43-year-old parous 2012 female with a history of 2 full-term pregnancies and normal deliveries, plus a spontaneous abortion) incurred spontaneous abortion at the 7th week of gestation. An early, spontaneous abortion avoided this patient running severe risks in late pregnancy. The overall estimated risk of bleeding in patients with portal hypertension, reported in the literature, is 400 times greater than in normal pregnancy. The association with aneurysm of splenic artery increases the likelihood of bleeding because intra-abdominal pressure adds to the risk of rupture of the aneurysms. In our opinion, a patient of fertile age, with pre-hepatic hypertension and associated chronic liver disease, should be treated with contraceptives to avoid any pregnancy-induced risk of complications.

Transdermal estroprogestins versus transdermal estrogen plus oral dihydrogesterone replacement in menopause

We studied 18 early (6 to 36 months) postmenopausal patients with a mean age of 51 years (47-53), who had never undergone hormone replacement therapy before and had no contraindications to hormone replacement. All cases of menopause were spontaneous. The treatment consisted in the continuous transdermal administration of 17-beta-estradiol (50 microg/daily) by skin patch to be replaced every 84 hours. The patients were further treated with a two-week progestogen administration every fortnight. This consisted of transdermal norethisterone acetate (0.25 mg/daily) combined with estradiol in the same patch in the first year, and oral dihydrogesterone (10 mg/daily) in the second year, without wash-out period. Before treatment (T0), and at the 12th (T1) and 24th (T2) month we measured the body mass index, the arterial blood pressure (AP), lipoproteins, coagulation parameters and bone metabolism parameters. The systolic pressure presented mean values (+/-SD) equal to 128.5+/-10.2 mmHg (T0), 131.1+/-7.4 mmHg (T1) and 130.4+/-7.5 mmHg (T2). Diastolic pressure values showed mean value ranging from 85.4+/-8.7 mmHg (T0) to 83.9+/-5.3 (T1) and 83.4+/-5.8 mmHg (T2). The detailed analysis of values of triglycerides, HDL cholesterol, apolipoprotein A1, apolipoprotein B and coagulation parameters at different times of therapy showed no statistically significant changes. With regard to bone metabolism, no statistically significant changes from baseline values were observed in parathormone, alkaline phosphatase, calcitonin, urinary calcium/creatinine ratio, and bone mineral content expressed by the bone density.

Chronic recurrent pancreatitis in pregnancy

This report describes a case of chronic recurrent pancreatitis due to gallstones arising in the first trimester of pregnancy. Total parental nutrition produced a normalization of pancreatic enzymes and a rapid regression of symptoms. Following another relapse of acute pancreatitis, a laparoscopic cholecystectomy was performed. The pregnancy continued normally and the patient had a spontaneous delivery at the 37th week.

Coagulation and plasma fibronectin parameters in HELLP syndrome

OBJECTIVES

HELLP syndrome (hemolysis, elevated liver enzymes and low platelets) has a high fetal mortality and maternal morbidity, partly due to its late diagnosis. In order to facilitate earlier diagnosis, we studied the changes occurring in natural coagulation inhibitors, fibronectin and haptoglobin as potential early markers of endothelial damage, coagulation cascade activation and intravascular hemolysis.

METHODS

The study compared antithrombin (AT-III), protein C and S activity, plasma fibronectin, 'prothrombin time' and 'partial prothrombin time' (AST, ALT), lactate dehydrogenase (LDH), bilirubin and serum haptoglobin in 17 asymptomatic controls, 19 preeclampsia patients and 11 HELLP syndrome patients.

RESULTS

HELLP syndrome patients had higher fibronectin and D-dimer values, lower AT-III and protein C activity, a lower platelet count and higher LDH than healthy controls; only 25% had raised bilirubin. Serum haptoglobin was lower in HELLP syndrome.

CONCLUSIONS

Early on in HELLP syndrome, there is probably a pro-coagulatory imbalance in the placental microcirculation. Endothelial damage causes tissue thromboplastin release and coagulation cascade activation due to collagen exposure; the vascular lesion increases thromboplastin in the bloodstream and triggers distant coagulation processes, suggesting compensated disseminated intravascular coagulopathy. Measuring plasma fibronectin and coagulation inhibitors should be supported by testing haptoglobin as a marker of intravessel hemolysis to differentiate conventional preeclampsia from HELLP.

[Diabetic nephropathy and pregnancy]

Diabetes mellitus (or type 1) is a long-lasting disease (even twenty years or more) which causes kidney disease and, in the event of pregnancy, it can make differential diagnostic difficult even fort the most expert clinician. Metabolic changes caused by this type of diabetes (e.g., hypoglycemia, hyperglycemia, ketoacidosis) and their difficult compensation can often lead to the onset of eclampsia or convulsion. The diagnostic suspicion of diabetes is supported by the finding of proteinuria, edema and hypertension that are strictly correlated with the evolution of diabetic disease and sometimes exist prior to pregnancy. This cas report focuses on the diagnostic importance of clotting tests, especially in clarifying diagnostic doubts.

[Laparoscopic cholecystectomy in pregnancy]

After appendicectomy, cholecystectomy is the most frequently nongynecological operation performed in pregnant women. Pregnancy has been stated to be a contraindication to laparoscopic cholecystectomy (LC) because of the unknown effects of a prolonged CO2 pneumoperitoneum on the fetus. Between September 1990 and December 1993 451 patients underwent LC at the 2nd Surgical Department of the University of Padova-Italy. Two patients were operated during the second trimester of pregnancy. LC without cholangiograms was successful in both patients and uncomplicated term delivery occurred. The Authors conclude that pregnancy is not a contraindication to LC; it can be performed safely during pregnancy and should be scheduled during the second trimester.