Increased Sylvian fissure angle as early sonographic sign of malformation of cortical development

OBJECTIVE

To evaluate Sylvian fissure development by assessing Sylvian fissure angles in fetuses with malformation of cortical development (MCD).

METHODS

This was a retrospective study of 22 fetuses with MCD. Cases with a stored three-dimensional (3D) brain volume acquired at 18 + 0 to 30 + 6 weeks of gestation at an ultrasound-based research clinic between January 2010 and December 2017 were identified through a database. Of the 22 fetuses, seven had an extracranial abnormality, such as cardiac, renal, gastrointestinal and/or digital anomalies, and five had a minor abnormality such as micrognathia, low-set ears and/or single umbilical artery. To confirm the final clinical diagnosis of brain abnormality, postmortem histological findings or prenatal or postnatal magnetic resonance images were used. For measurement of Sylvian fissure angle, an anterior coronal plane of the fetal brain on transvaginal 3D volume multiplanar imaging was visualized as a single image from the three orthogonal views. The right and left Sylvian fissure angles were measured between a horizontal reference line (0°) and a line drawn along the upper side of the respective Sylvian fissure. The Sylvian fissure angle on both sides was plotted on the graphs of the reference ranges for gestational age in weeks.

RESULTS

In 21 (95.5%; 95% CI, 86.8-100.0%) of 22 fetuses with MCD, the Sylvian fissure angle on one or both sides was larger than the 90^th percentile of the normal reference. There was one case with apparent focal MCD in the parietal lobe, but the Sylvian fissure angles were normal. A case with apparent unilateral cortical dysplasia and one with apparent unilateral schizencephaly had conspicuous discrepancies between the left and right Sylvian fissure angles. Abnormal genetic test results were obtained in six cases, including four cases with a mutation in a single gene.

CONCLUSIONS

This study has shown that the Sylvian fissures, as defined by the Sylvian fissure angle, have delayed development in most MCD cases prior to the diagnosis of the condition. The Sylvian fissure angle may potentially be a strong indicator for the subsequent development of cortical malformation, before the time point at which the gyri and sulci become obvious on the fetal brain surface. Further research is required to validate these findings. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Plasma natriuretic peptide levels in fetuses with congenital heart defect and/or arrhythmia

OBJECTIVE

Diagnosing fetal heart failure remains challenging because it is difficult to know how well the fetal myocardium will perform as loading conditions change. In adult cardiology, natriuretic peptides (NPs) are established markers of heart failure. However, the number of studies investigating NP levels in fetuses is quite limited. The aim of this study was to evaluate the significance of plasma NP levels in the assessment of heart failure in fetuses with a congenital heart defect (CHD) and/or arrhythmia.

METHODS

This was a prospective observational study conducted at a tertiary pediatric cardiac center. A total of 129 singletons with CHD and/or arrhythmia and 127 controls were analyzed between 2012 and 2015. Umbilical cord plasma atrial NP, brain NP and N-terminal pro-brain NP levels at birth were compared with ultrasonography findings indicating fetal heart failure, such as cardiovascular profile (CVP) score and morphological characteristics.

RESULTS

Fetuses with CHD and/or arrhythmia had higher NP levels than did controls (P < 0.01). NP levels of fetuses with CHD and/or arrhythmia were correlated inversely with CVP score (P for trend < 0.01). No differences in NP levels were found in fetuses with CHD and/or arrhythmia and a CVP score of ≥ 8 in comparison to controls. Multivariate analysis showed that a CVP score of ≤ 5, tachy- or bradyarrhythmia at birth, preterm birth and umbilical artery pH < 7.15 were associated independently with high NP levels (P < 0.01). Among fetuses with a CVP score of ≤ 7, abnormal venous Doppler sonography findings were significantly more common and more severe in fetuses with tachy- or bradyarrhythmia than in those with CHD, and those with tachy- or bradyarrhythmia had higher NP levels than did those with CHD (P = 0.01). Fetuses with right-heart defect and moderate or severe tricuspid valve regurgitation had significantly higher NP levels than did fetuses with other types of CHD (P < 0.01).

CONCLUSIONS

Plasma NP levels in fetuses with CHD and/or arrhythmia are correlated with the severity of fetal heart failure. Elevated NP levels are attributed mainly to an increase in central venous pressure secondary to arrhythmia or atrioventricular valve regurgitation due to CHD, rather than to the morphological abnormality itself. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Risk factors for maternal outcome in pregnancy complicated with dilated cardiomyopathy

OBJECTIVE

The goal of the study was to determine risk factors for maternal cardiac failure in pregnancy complicated with dilated cardiomyopathy (DCM).

STUDY DESIGN

The subjects were 29 patients diagnosed with DCM before conception or during the first 7 months of pregnancy. DCM was defined as left ventricle end-diastolic dimension (LVDd)≥48 mm and/or fractional shortening (%FS)≤30% on echocardiography. Patients were followed until at least 1 year after delivery and were categorized into a poor prognosis group (n=6; death or end stage heart failure of New York Heart Association (NYHA) class III and IV) and a good prognosis group (n=23; all other cases).

RESULT

DCM was initially diagnosed during pregnancy in 6/6 and 8/23 patients in the poor and good prognosis groups, respectively (P<0.005). The %FS of the first test during pregnancy was 17.5±6.2 and 27.4±9.3% in the respective groups (P<0.005). In eight abortion cases with %FS 15.2±3.1%, %FS, cardiac function and NYHA class were maintained until 20 months after abortion. There was no relationship between LVDd and maternal outcome.

CONCLUSION

Onset during pregnancy and decreased %FS are risk factors for a poor maternal outcome in patients with DCM. Abortion prevents further deterioration of cardiac function in patients with a very low %FS.

Unexplained fetal death is associated with changes in the adaptive limb of the maternal immune response consistent with prior antigenic exposure

OBJECTIVE

The causes of fetal death are largely unknown. CD4 T cells have been classified according to the expression of the CD45 isoforms into 'naive-like' T cells (CD45RA) and 'memory-like' T cells (CD45RO). An increase in the percentage of the CD45RO has been interpreted as indicating prior antigenic exposure of the host and, in newborns, evidence of infection. The purpose of this study was to determine whether unexplained fetal death was associated with a change in the proportion of 'naive-like' and 'memory-like T cells' in the maternal blood, as determined by the CD45 isoforms on the surface of CD4+ lymphocytes.

STUDY DESIGN

A prospective study was conducted to compare the CD45 sub-population of lymphocytes in patients with intrauterine fetal death (n = 26) and normal pregnancy (n = 89). The percentages of CD45RA+, CD45RO+ and CD45RA+/CD45RO+ on CD4+ T lymphocytes were determined in maternal blood using flow cytometry and monoclonal antibodies. Results were reported as a percentage of CD4+ lymphocytes. Non-parametric statistics were used for analysis. A p value of < 0.05 was considered significant.

RESULTS

Patients with intrauterine fetal death had a higher percentage of CD45RO+ CD4+ T lymphocytes than normal pregnant women (fetal death: median 57.7%, range 35.4-78.6 vs. normal pregnancy: median 49.9%, range 19.1-86.8; p = 0.004). Fetal death was associated with a lower median percentage of CD45RA+ CD4+ lymphocytes than in normal pregnant women (fetal death: median 32.3%, range 15.3-58.0 vs. normal pregnancy: median 40.2%, range 11.2-67.3; p = 0.01). There was no significant difference in the percentage of cells with dual expression (CD45RA+/CD45RO+) between the study groups.

CONCLUSION

Prior exposure to microbial products (bacterial or viral) or other unidentified antigens may result in a shift of the sub-population of 'naive-like' T cells to 'memory-like' T cells in mothers with unexplained fetal death.

Evidence of participation of soluble CD14 in the host response to microbial invasion of the amniotic cavity and intra-amniotic inflammation in term and preterm gestations

OBJECTIVE

Endotoxin has been implicated in the mechanism responsible for the setting of infection in preterm labor. To exert its biological effects, endotoxin binds to a circulating protein known as lipopolysaccharide binding protein (LBP) and presents endotoxin monomers to CD14, which may be a membrane-bound receptor or a soluble molecule. The endotoxin-LBP-CD14 complex interacts with Toll-like receptor 4 and other regulatory proteins leading to cellular activation and an inflammatory response. The purpose of this study was to determine whether microbial invasion of the amniotic cavity (MIAC)/intra-amniotic inflammation (both preterm and term) and parturition at term are associated with changes in the amniotic fluid and umbilical plasma soluble concentrations of CD14 (sCD14).

STUDY DESIGN

Amniotic fluid was retrieved by amniocentesis from 88 patients in the following groups: group 1, preterm labor with intact membranes with MIAC/intra-amniotic inflammation (n = 18) and without these conditions (n = 26); group 2, term gestations not in labor without MIAC/intra-amniotic inflammation (n = 11), in labor without MIAC/intra-amniotic inflammation (n = 12) and in labor with MIAC/intra-amniotic inflammation (n = 13); and group 3, patients who underwent genetic amniocentesis at mid-trimester (n = 8). A sample of cord blood was obtained after delivery in all patients except those in group 3. sCD14 was assayed with a sensitive and specific immunoassay. Non-parametric statistics were used for analysis. A p value of < 0.05 was considered significant.

RESULTS

sCD14 was detectable in 97% (85/88) of the amniotic fluid samples. Amniotic fluid sCD14 concentrations were lower in patients at term than in the mid-trimester of pregnancy (mid-trimester: median 482 ng/ml, range 258-838 ng/ml vs. term no labor: median 7 ng/ml, range 2-274 ng/ml, p = 0.01). Among patients with preterm labor with intact membranes, the median amniotic fluid sCD14 level of patients with MIAC/intra-amniotic inflammation was higher than in patients without these conditions (median 1568 ng/ml, range 98-5887 ng/ml vs. median 645 ng/ml, range 0-3961 ng/ml, respectively; p = 0.01). Among women at term in labor, those with MIAC/intra-amniotic inflammation had a higher median amniotic fluid sCD14 concentration than those without these conditions (median 85 ng/ml, range 2-1113 ng/ml vs. median 17 ng/ml, range 0-186 ng/ml; p = 0.01). MIAC/intra-amniotic inflammation in women with preterm labor with intact membranes was associated with a higher median umbilical venous plasma sCD14 concentration (median 744 ng/ml, range 0-3620 ng/ml vs. median 0 ng/ml, range 0-2060 ng/ml; p = 0.04). sCD14 was undetectable in plasma from umbilical cords of all neonates born to women at term. An increase in amniotic fluid concentration of sCD14 was observed in cases of intrauterine infection, not only by gram-negative bacteria, but also gram-positive bacteria and Ureaplasma spp.

CONCLUSION

sCD14 is a physiological constituent of amniotic fluid, and its concentrations at term are lower than in the mid-trimester. Intrauterine infection/inflammation is associated with a higher median amniotic fluid sCD14 concentration in both preterm and term parturition. Neonates born from mothers with preterm labor with intact membranes and MIAC/intra-amniotic inflammation had a higher median concentration of sCD14 in umbilical cord plasma than those without these conditions. sCD14 concentrations are increased in the amniotic fluid and umbilical cord blood even in the absence of a microbiologically proven gram-negative infection. CD14 appears to participate in the host response to intrauterine infection even in cases involving genital mycoplasmas.

Lipopolysaccharide-binding protein in microbial invasion of the amniotic cavity and human parturition

OBJECTIVE

Lipopolysaccharide-binding protein (LBP) is an acute-phase protein of predominantly hepatic origin, capable of binding the lipid A fraction of bacterial lipopolysaccharide (LPS). The complex LBP-LPS binds to CD14, and has been implicated in the host response to gram-negative infection. The purpose of this study was to determine whether microbial invasion of the amniotic cavity (MIAC) and parturition (term and preterm) are associated with changes in the amniotic fluid concentration of LBP.

STUDY DESIGN

Amniotic fluid was retrieved by amniocentesis from 343 patients in the following groups: (1) those in mid-trimester with a subsequent normal pregnancy outcome (n = 84); (2) those in mid-trimester with a fetal loss after the procedure (n = 10); (3) those with preterm labor and intact membranes without MIAC who delivered at term (n = 36) or prematurely (n = 52), and those with preterm labor with MIAC (n = 26); (4) those with preterm premature rupture of membranes (PROM) with (n = 26) and without (n = 26) MIAC; and (5) those delivering at term with intact membranes in the absence of MIAC, in labor (n = 52) and not in labor (n = 31). The concentration of LBP in amniotic fluid was determined with a specific and sensitive immunoassay. Non-parametric statistics were used. A p value of < 0.05 was considered significant.

RESULTS

LBP was detected in 98% (335/343) of the amniotic fluid samples. MIAC was associated with a significant increase in amniotic fluid concentration of LBP in women with preterm labor and intact membranes, but not in preterm PROM. Spontaneous preterm parturition was associated with a significant increase in amniotic fluid concentration of LBP. Patients who had a spontaneous fetal loss after a mid-trimester amniocentesis had a significantly higher median amniotic fluid LBP concentration than those who had a mid-trimester amniocentesis and a normal perinatal outcome.

CONCLUSION

Preterm labor with MIAC and preterm parturition are associated with higher amniotic fluid concentrations of LBP than those with sterile amniotic fluid.

Elevated monocyte chemotactic protein-1 in amniotic fluid is a risk factor for pregnancy loss

OBJECTIVE

Pregnancy loss after mid-trimester amniocentesis occurs in 0.5-1% of cases and is frequently attributed to the procedure. Accumulating evidence implicates a pre-existing, but clinically silent, intra-amniotic inflammation in the etiology of adverse pregnancy outcome after mid-trimester amniocentesis. Monocyte chemotactic protein-1 (MCP-1) is a potent chemokine produced by a wide variety of cells during the course of an inflammatory response. This study was designed to assess if the amniotic fluid concentration of this chemokine identifies patients at risk for spontaneous abortion and/or fetal death.

METHOD

A retrospective case-control study of women who had a mid-trimester amniocentesis was designed. Cases (n = 10) consisted of patients who had a spontaneous pregnancy loss after the procedure, while the control group (n = 84) consisted of patients who had a normal pregnancy outcome after mid-trimester amniocentesis. MCP-1 was measured by a specific enzyme immunoassay (sensitivity, 18.3 pg/ml). The Kolmogorov-Smirnov test was utilized to assess normal distribution of the data. Logarithmic transformation was applied to achieve normality. Statistical analysis was performed using Student's t test. A receiver operating characteristic (ROC) curve analysis was used to select a cut-off to dichotomize amniotic fluid concentrations of MCP-1.

RESULTS

MCP-1 was detectable in all amniotic fluid samples. Patients who had a mid-trimester amniocentesis and a subsequent pregnancy loss had a higher mean amniotic fluid log MCP-1 concentration than those with a normal pregnancy outcome (pregnancy loss, mean 2.95 +/- 0.19 pg/ml vs. normal outcome, mean 2.78 +/- 0.19 pg/ml; p = 0.01). A cut-off of > 765 pg/ml was selected by ROC curve analysis (area under the curve, 0.74; p = 0.01). An amniotic fluid concentration of MCP-1 above this level was strongly associated with pregnancy loss (odds ratio, 7.35; 95% confidence interval, 1.7-31.1), a sensitivity of 70%, and a specificity of 76%.

CONCLUSION

A subset of women who had a pregnancy loss after a mid-trimester amniocentesis had higher concentrations of the chemokine MCP-1 than those who had a normal pregnancy outcome. Subclinical intra-amniotic inflammation is a risk factor for pregnancy loss after mid-trimester amniocentesis. This observation may have medicolegal and clinical implications. An elevated MCP-1 concentration in amniotic fluid of patients with a pregnancy loss after a mid-trimester amniocentesis indicates that a pathological condition was present at the time of the procedure.

Soluble adhesion molecule profile in normal pregnancy and pre-eclampsia

OBJECTIVE

An exaggerated inflammatory response has been implicated as the cause of endothelial cell dysfunction and the maternal syndrome of pre-eclampsia. Adhesion molecules play a central role in the adherence of leukocytes to endothelial cells and the subsequent migration of white blood cells into perivascular tissue. Cellular forms of adhesion molecules mediate specific steps of leukocyte-endothelial cell interaction, and have been implicated in the pathophysiology of preeclampsia. Soluble forms of these molecules can be detected in plasma, and their concentrations are thought to reflect the degree of activation of a particular cell type. Elevations in soluble P-selectin (sP-selectin) reflect platelet activation; changes in soluble L-selectin (sL-selectin) suggest leukocyte activation; and an increase in soluble forms of E-selectin (sE-selectin), vascular cell adhesion molecule 1 (sVCAM-1), intercellular adhesion molecule 1 (sICAM-1) and platelet endothelial cell adhesion molecule (sPECAM-1) indicate endothelial cell activation/dysfunction. The objective of this study was to determine whether normal pregnancy and pre-eclampsia were associated with changes in the concentrations of soluble selectins and members of the immunoglobulin superfamily of adhesion molecules.

STUDY DESIGN

A cross-sectional study was conducted to determine the plasma concentrations of sL-selectin, sE-selectin, sP-selectin, sVCAM-1, sICAM-1 and sPECAM-1 in peripheral blood obtained from non-pregnant women (n = 20), normal pregnant women (n = 100) and patients with pre-eclampsia (n = 55). Concentrations of soluble adhesion molecules were determined with enzyme-linked immunoassays. Parametric statistics were used for data analysis.

RESULTS

Normal pregnancy was associated with a significant increase in the maternal plasma concentration of sP-selectin, a decrease in sL-selectin, and no change in sE-selectin, sVCAM-1, sICAM-1 and sPECAM-1. In contrast, pre-eclampsia was associated with a significant increase in sP-selectin, sE-selectin and sVCAM-1, a decrease in sL-selectin, but no change in sICAM-1 and sPECAM-1 concentrations.

CONCLUSIONS

The increased concentration of sP-selectin and decreased sL-selectin, as well as the lack of change in endothelial cell-associated soluble adhesion molecules suggest that pregnancy is associated with platelet and leukocyte activation, but not endothelial cell activation. In contrast, pre-eclampsia appears to be characterized by activation of platelets, leukocytes and endothelial cells.

Subclinical myocardial injury in small-for-gestational-age neonates

OBJECTIVE

Small-for-gestational-age (SGA) infants are at risk for premature death from cardiovascular disease (myocardial infarction and stroke), hypertension, and diabetes in adult life. Severe intrauterine growth restriction is often associated with subclinical cardiovascular abnormalities detectable during fetal echocardiography. The objective of this study was to determine whether SGA newborns have evidence of myocardial injury at birth.

STUDY DESIGN

Cardiac troponin I, a specific marker of myocardial injury widely used for the diagnosis of myocardial infarction in adults, was determined in umbilical cord blood. Umbilical cord venous blood was obtained at the time of birth from 72 SGA newborns (birth weight below the 10th centile for gestational age) and 309 newborns whose birth weights were appropriate for gestational age (AGA). Cardiac troponin I was determined with a commercially available immunoassay (sensitivity 0.2 ng/ml) employed in clinical laboratories (Immulite 2000, Diagnostic Products Corp., Los Angeles, CA).

RESULTS

Cardiac troponin I was not detectable in any of the blood samples from AGA infants. In contrast, 4.2% (3/72) of SGA infants had detectable cardiac troponin I in umbilical cord blood (Fisher's exact test, p = 0.007).

CONCLUSION

A subgroup of SGA newborns undergoes myocardial injury before birth. This insult may predispose to the development of adult premature cardiovascular disease and death.

Activation of coagulation system in preterm labor and preterm premature rupture of membranes

OBJECTIVE

Thrombin, originally discovered as a coagulation factor, is a multifunctional protease capable of inducing myometrial contractions in vitro and in vivo. This enzyme has been implicated in the mechanisms of premature labor. Plasma concentrations of thrombin-antithrombin (TAT) complexes are an index of in vivo thrombin generation. The purpose of this study was to determine whether patients with premature labor and preterm premature rupture of membranes (PROM) have evidence of increased thrombin generation in maternal blood, as determined by the TAT complex concentrations.

METHODS

A cross-sectional study was designed to determine plasma concentrations of TAT complexes in 110 women in the following groups: non-pregnant women (n = 20); normal pregnant women (n = 30); women in preterm labor with intact membranes (n = 30); and women with preterm PROM (n = 30). TAT complex concentrations were determined with a sensitive and specific immunoassay. Statistical analysis was conducted with non-parametric statistics.

RESULTS

Patients with preterm labor and intact membranes had a significantly higher median plasma TAT complex concentration than normal pregnant women (women in preterm labor, median 19.1 microg/l; range 7.4-406 vs. normal pregnant women, median 15 microg/l; range 6.8-32.5; p = 0.03). Patients with preterm PROM had a higher median TAT complex concentration than normal pregnant women (preterm PROM, median 19.1 microg/l; range 4.7-738.6 vs. normal pregnant women, median 15 microg/l; range 6.8-32.5; p = 0.03). Normal pregnancy was associated with a higher median plasma TAT complex concentration than the non-pregnant state (normal pregnant women, median 15 microg/l; range 6.8-32.5 vs. non-pregnant women, median 2.7 microg/l; range 0.9-14.2; p < 0.001).

CONCLUSION

Preterm labor and preterm PROM are associated with an excess generation of thrombin.

Evidence of in vivo generation of thrombin in patients with small-for-gestational-age fetuses and pre-eclampsia

OBJECTIVE

Thrombotic lesions in the maternal or fetal compartments are frequently observed in the placentas of patients with small-for-gestational-age (SGA) fetuses and in pre-eclampsia. The objective of this study was to determine whether there was evidence of in vivo generation of thrombin, the rate-limiting enzyme responsible for the formation of fibrin. The plasma concentrations of thrombin-antithrombin (TAT) complexes were used as an index of thrombin generation.

METHODS

TAT complexes were measured in the plasma from 68 women from the following groups: normal pregnancy (n = 29); pre-eclampsia (n = 26); and SGA (defined as estimated fetal weight below the 10th centile for gestational age, which was confirmed by neonatal birth weight) (n = 13). TAT complex plasma concentrations were determined with a specific and sensitive immunoassay. Statistical analysis was performed with non-parametric statistics.

RESULTS

The median plasma TAT complex concentrations were significantly higher in patients who delivered SGA neonates than in normal pregnant women (SGA, median 24.2 microg/l; range 11.9-788.7 vs. normal pregnancy, median: 14.4 microg/l; range 6.8-26.9; p = 0.001). Patients with pre-eclampsia had a higher median plasma TAT complex concentration than normal pregnant women (pre-eclampsia, median 18.1 microg/l; range 10.0-75.2 vs. normal pregnancy, median 14.4 microg/l; range 6.8-26.9; p = 0.02).

CONCLUSION

In vivo generation of thrombin, determined by the plasma concentrations of TAT complexes, is higher in patients with SGA fetuses and patients with pre-eclampsia than in normal pregnancy.

Maternal intravascular inflammation in preterm premature rupture of membranes

OBJECTIVE

Intrauterine inflammation has been implicated in the mechanisms responsible for preterm premature rupture of membranes (PROM). However, it is unclear whether this inflammatory process remains localized to the uterus, at the site of membrane rupture, or extends to the maternal compartment. Flow cytometric analysis is a sensitive method to assess the presence and magnitude of in vivo inflammation. This study was conducted to determine whether preterm PROM is associated with changes in the phenotypic and metabolic characteristics of maternal granulocytes and monocytes consistent with the presence of maternal intravascular inflammation.

STUDY DESIGN

A prospective cross-sectional study was performed including patients with preterm PROM (n = 43) and normal pregnancy (n = 51). Maternal intravascular inflammation was studied using flow cytometry. Maternal blood was assayed to determine granulocyte and monocyte phenotype using monoclonal antibodies, which included cluster differentiation (CD) markers CD11b, CD14, CD15, CD16, CD18, CD49d, CD62L, CD64, CD66b and human leukocyte antigen (HLA)-DR. The quantities of basal intracellular reactive oxygen species (iROS) and oxidative burst was assessed. Statistical analysis was conducted with the use of non-parametric methods. A p value < 0.01 was considered significant.

RESULTS

Preterm PROM was associated with a significant increase in the median mean channel brightness (MCB) of CD11b, CD14, CD64 and CD66b on granulocytes and median MCB of CD11b on monocytes. The oxidative burst and the stimulation index in both cell types were higher in preterm PROM than in normal pregnancy (p < 0.01).

CONCLUSION

Preterm PROM is associated with phenotypic and metabolic changes in circulating granulocytes and monocytes.

Platelet-activating factor-induced intracellular calcium waves in human uterine myometrial cells

OBJECTIVE

We visualized and investigated the intracellular calcium waves propagated by platelet-activating factor (PAF) in cultured human myometrial cells.

STUDY DESIGN

Myometrial cells were stimulated with PAF ranging between 10(-8) and 10(-15) M. For the observation of calcium waves, calcium green-1 and a confocal laser microscopy were used. Cells were also stimulated with 10(-9) M of PAF in a calcium-free solution.

RESULTS

In physiological solution, PAF at concentrations ranging between 10(-9) and 10(-15) M induced intracellular calcium waves. Mean wave speed was 16.1+/-5.6 microm/s. Wave speeds were independent of the PAF concentration. Similar results were observed in the absence of added calcium, with the exception that the wave speeds were significantly slower (7.3+/-3.3 microm/s). CONCLUSIONS This is the first study to demonstrate the calcium waves propagated by PAF stimulation in human myometrial cells. These observations further support the proposed role of PAF in parturition.

Treatment with a metallic endovascular stent in a patient with iliac venous stenosis due to endometrial cancer

There are few cases, to our knowledge, that report the successful treatment of iliac venous stenosis due to gynecologic malignancies with the use of self-expanding metallic endovascular stents. Our patient, who had right lower limb edema, had iliac lymph node metastases which caused iliac vein stenosis by direct invasion from endometrial cancer. The patient was not considered to be a good surgical candidate. A 10-mm diameter self-expanding metallic endovascular stent was placed in the external iliac vein. The patient's symptoms of right lower limb edema improved dramatically, and she was discharged at 3 weeks after stent placement. The patient had no further symptoms, with continued resolution of the right leg edema during the 10 months following stent placement, at which time she died from the primary disease. The treatment to this patient with a self-expanding metallic endovascular stent proved to be very efficacious and less stressful than direct venous reconstruction or femorofemoral venous bypass grafting. In addition, this procedure dramatically improved the patient's quality of life.

Intraplacental choriocarcinoma with fetomaternal transfusion

Intraplacental choriocarcinoma is very rare, and is usually found only after maternal and fetal metastatic disease is identified. The purpose of this case report is to review the incidence and findings of intraplacental choriocarcinoma. A term placenta was investigated because the newborn was born with severe anemia (Hb 3.0 g/dL). A 2 cm nodule was noted on the surface of the amniotic membrane and grossly resembled an infarction. The tumor was examined microscopically with immunohistochemical staining for the alpha- and beta-human chorionic gonadotropin (alpha-hCG, beta-hCG) subunits, human placental lactogen (hPL) and Ki-67. Microscopically, the tumor consisted of necrotic areas with proliferation of atypical trophoblastic cells and destruction of the villi and capillaries. The cells were positive for the alpha-hCG, beta-hCG subunits, hPL and Ki-67, consistent with intraplacental choriocarcinoma. The mother and newborn were investigated for the presence of metastatic disease. Computed tomography scans and magnetic resonance imaging of the mother and infant were negative for metastatic disease. Choriocarcinoma, limited only to the placenta with no evidence of metastatic disease is very rare. Primary intraplacental choriocarcinoma may frequently be overlooked or missed, and choriocarcinoma may possibly arise in the placenta more often than in retained or persistent trophoblast following pregnancy.

Immunohistochemical localization of polo like kinase in early human placenta

Polo like kinase (PLK) is the kinase that was first cloned by us from the cDNA library of human placenta. It belongs to the serine/threonine kinase family and plays a very important role in cell proliferation. In this study, the localization of PLK in early human placenta in vivo was investigated. Immunostaining revealed PLK protein in syncytiotrophoblastic cells and extravillous trophoblastic cells; however proliferating cell nuclear antigen was not. It is known that cytotrophoblastic cells proliferate highly in early human placental villi; however, PLK was not detected in those cells. These results suggest that PLK plays a different role in syncytiotrophoblastic cells than it does in other proliferating cells.

Expression of polo-like kinase (PLK) in the mouse placenta and ovary

The polo-like kinase (PLK) is a mammalian serine/threonine kinase involved in cell cycle regulation. Much evidence for the role of PLK in the cell cycle has come from studies of cultured cells; however, little is known about its function or even expression in vivo. The present study examined the features of PLK expression in the mouse placenta and ovary. Immunohistochemical studies showed that PLK is highly expressed in the basement membrane of the endometrial gland, in some endothelial cells, in endometrium after embryo implantation, in trophoblastic tissue invading the decidua, in the ovarian stroma and in some lutein bodies. In contrast, PLK was not detectable by immunohistochemistry in endometrial stroma before decidualization, in decidua, in trophoblastic tissue not invading the decidua or in ovarian follicles. PLK expression seemed to be correlated with the expression of proliferation cellular nuclear antigen (PCNA) in many placental and ovarian cells, reflecting a role in cellular proliferation. Nevertheless, in ovarian stroma and lutein bodies where PCNA was not expressed, PLK was strongly expressed. This finding indicates that PLK may have some post mitotic functions in certain specialized cell types.

Interleukin-1beta and interleukin-8 in cervicovaginal fluid during pregnancy

OBJECTIVE

We investigated the usefulness of cervicovaginal interleukin-1beta and interleukin-8 levels during pregnancy as markers of preterm and term parturition.

STUDY DESIGN

Cervicovaginal fluids were obtained from 119 pregnant women at 24 to 41 weeks' gestation. Cytokine concentrations were measured by enzyme-linked immunoassay.

RESULTS

Interleukin-1beta and interleukin-8 concentrations in cervicovaginal fluids obtained from women not in labor increased exponentially as gestational age increased. Interleukin-1beta and interleukin-8 concentrations were significantly correlated. These cytokine concentrations were significantly higher in patients in preterm labor than in patients at preterm not in labor and were significantly higher in women at term in labor than in women at term not in labor. These cytokine levels were significantly correlated with the degree of cervical dilation and tocolytic index.

CONCLUSIONS

These findings suggest that cervicovaginal interleukin-1beta and interleukin-8 contribute to term and preterm parturition. Measurement of cervicovaginal concentrations of these cytokines may be clinically useful in patients with threatened premature delivery.

CT and MRI findings in a case of pelvic schwannoma

We compared the diagnostic utility of computed tomography (CT) and magnetic resonance imaging (MRI) in a patient with a pelvic schwannoma. This 46-year-old woman was admitted for evaluation of a retroperitoneal pelvic mass and myoma uteri. The retroperitoneal pelvic mass had been detected by a CT scan at a routine health examination. A CT scan revealed a well-circumscribed cystic tumor (4 x 3 cm) at the right internal obturator muscle portion. The CT number of the inner part of the tumor was 21. Only the cyst wall was enhanced by injection of a contrast medium. MRI showed a 4 x 3 x 3-cm retroperitoneal cystic tumor that demonstrated low-intensity signals on T1-weighted images and high-intensity signals on T2-weighted images. Small areas of low intensity inside the tumor were observed on T2-weighted images. Histological examination revealed a typical schwannoma of mixed Antoni type A and type B. These findings indicate that both MRI and CT are useful for diagnosis of retroperitoneal schwannomas.

A case of primary non-Hodgkin's lymphoma of the uterine cervix treated by combination chemotherapy (THP-COP)

We present a case of primary non-Hodgkin's lymphoma of the uterine cervix, Ann Arbor stage IE. This 64-year-old multiparous Japanese woman showed markedly elevated serum levels of lactate dehydrogenase (LDH) and of soluble interleukin-2 receptor (sIL-2R) at the time of diagnosis. Combination chemotherapy was administered and consisted of pirarubicin, cyclophosphamide, vincristine sulfate, and prednisolone (THP-COP). After 3 courses of such therapy, the serum levels of LDH and of sIL-2R decreased within normal limits, and the patient achieved a complete remission.

Magnetic resonance imaging of fetal autosomal recessive polycystic kidney disease

We present a case of fetal autosomal recessive polycystic kidney disease (ARPKD) at 34 weeks of gestation, diagnosed by magnetic resonance imaging (MRI). MRI demonstrated enlarged fetal kidneys that were low signal intensity on T1-weighted images and high signal intensity on T2-weighted images. These MRI findings suggested a high water content in the renal parenchyma, consistent with the innumerable, tiny renal cysts present in ARPKD.

Adenomyomatous polyp of the uterus in a patient receiving tamoxifen

We report a case of adenomyomatous polyp that developed during treatment with tamoxifen for breast cancer. A 63-year-old Japanese woman was admitted complaining of atypical genital bleeding. Nine months earlier, she had undergone a modified radical mastectomy for cancer of her right breast, estrogen receptor-positive stage I (T1N0M0). The administration of tamoxifen, 20 mg/day, was started immediately postoperatively. Pelvic examination after tamoxifen administration for 9 months revealed that the uterus was enlarged to the size of a fist. Transvaginal ultrasonography and magnetic resonance imaging revealed a large solid mass with multiple cystic areas in the uterine cavity. The pathological diagnosis of the tumor after total hysterectomy was typical adenomyomatous polyp. It was believed to have developed during tamoxifen administration.

Absence of vagina and hypoplasia of the urethra and ectopia of the ureter

A 16-year-old Japanese girl was admitted for evaluation of complaints of primary amenorrhea, cyclic lower abdominal pain, and urinary incontinence. Her vaginal introitus appeared rudimentary with a depth of 0.5 cm and hypoplasia of the hymenal ring. A hypoplastic urethra (diameter: 1 cm; length: 0.5 cm) and 1 of 2 right ectopic ureters opened into the introitus. Transabdominal ultrasonography demonstrated fluid distending the uterus, the proximal 1/3 of the vagina, and the pouch of Douglas. Computed tomography (CT) and magnetic resonance imaging (MRI) confirmed the presence of hematometrocolpos and fluid collection in the pouch of Douglas. These associated anomalies can be due to faulty growth of the urogenital sinus. In addition to the transabdominal ultrasonography and CT, MRI was useful in the diagnosis and evaluation of vaginal agenesis.

Serum levels of cytokeratin 19 fragments in cervical cancer

Serum levels of a cytokeratin 19 fragment, Cyfra 21-1, were measured using an immunoradiometric assay in 33 women before initial treatment and in 8 women with recurrent tumor. The serum level of Cyfra 21-1 was significantly increased in women with tumors of advanced stage (FIGO) and those with recurrence. The incidence of positivity for Cyfra 21-1 tended to increase with tumor spread. Compared with squamous cell carcinoma (SCC) antigen, the sensitivity of Cyfra 21-1 was comparable to that of SCC antigen. The serum level of Cyfra 21-1 and that of SCC antigen showed a positive correlation. While the use of the serum Cyfra 21-1 level may be limited in cervical cancer by its relatively low sensitivity, a combination assay of Cyfra 21-1 and SCC antigen may be useful in the diagnosis and follow-up of patients with cervical squamous cell carcinoma.

Low-dose dopamine in treating acute renal failure caused by preeclampsia

Acute renal failure is a serious complication of preeclampsia that usually requires the termination of pregnancy. We present a case of acute renal failure due to severe preeclampsia successfully treated with the infusion of a low dose of dopamine. This 25-year-old Japanese primigravida was admitted at 31 weeks of gestation for the treatment of preeclampsia. Urine output was decreased to 380 ml/day; 24-hour creatinine clearance was decreased to 13.7 liters/day. Blood urea nitrogen was elevated to 31.9 mg/dl; serum creatinine was elevated to 3.34 mg/dl. The diagnosis was acute renal failure related to preeclampsia. A low dose of dopamine, 1 microgram/kg/min, was infused daily for 7 days at 32 weeks of gestation to maintain urine output. Renal function improved markedly without any adverse effect on the patient's blood pressure which was controlled on hydralazine. Fetal distress developed 4 days later and emergency cesarean section was performed. A healthy female was delivered. The infusion of a low dose of dopamine appeared to be highly effective in managing acute renal failure caused by preeclampsia with no serious side effects.

Infant with thanatophoric dwarfism in triplet pregnancy

The case of a Japanese female infant with thanatophoric dwarfism, a triplet, is reported. The diagnosis was made at 18 weeks' gestation. Triplets were delivered at 30 weeks' gestation by cesarean section. Two infants, both males, were normal; the female with dwarfism died of respiratory distress 34 min after delivery. This is the first known case of one fraternal triplet being affected by thanatophoric dwarfism.

Fetal bladder outlet obstruction diagnosed at 13-weeks' gestation

An ultrasonographic examination revealed increased fetal bladder size as well as fetal bilateral hydronephrosis at 13-weeks' gestation. Diagnosis of the fetal urethral obstruction was made. Repeated ultrasonography was undertaken from the 13th to through 16th weeks of gestation. Percutaneous puncture with aspiration and laboratory analysis of fetal urine was performed at 15-weeks' gestation. The fetal renal function seemed not to be damaged by use of these antenatal procedures. Following induced abortion at 16-weeks' gestation, an autopsy showed that the fetal urethral obstruction was caused by a posterior valve, with no histological evidence of fetal renal dysplasia.

Copper disposition of the fetus and placenta in a patient with untreated Wilson's disease

A patient with untreated Wilson's disease showed the possibility of fetal liver damage and copper accumulation in the placenta by this disease. This is the first report of copper disposition on the fetus and placenta in a patient with untreated Wilson's disease.

Can prenatal vitamin K1 (phylloquinone) supplementation replace prophylaxis at birth?

OBJECTIVE

To assess the effect of prenatal vitamin K1 on the coagulation status of newborns.

METHODS

We measured noncarboxylated prothrombin and performed the Normotest in two groups of 5-day-old infants whose mothers were given oral vitamin K1, 10 mg/day for 2 weeks at least 10 days before delivery, or were untreated.

RESULTS

Noncarboxylated prothrombin was found in one of 74 treated women and 13 of 186 controls, a nonsignificant difference. The mean (+/- standard deviation) Normotest value was 59.6 +/- 10.1% (range 38.9-84.4) for the treated group and 53.4 +/- 9.9% (range 16.3-89.9) for the controls, a statistically significant difference (P < .001).

CONCLUSION

Based on the Normotest results, we suggest that vitamin K crosses the placenta and persists to activate the vitamin K-dependent coagulant factors until at least the fifth day of life. Thus, prenatal vitamin K1 administration may replace prophylaxis at birth.

Retrohymenal vaginal atresia with perforate transverse vaginal septum

A transverse vaginal septum is the most common congenital anomaly of the vagina. Vaginal atresia is seen less frequently. There have been some variations in cases of transverse vaginal septum and vaginal atresia. This is the first report of a patient with retrohymenal vaginal atresia and perforate transverse vaginal septum.

[Hypocalciuria in women with preeclampsia]

To assess the significance of hypocalciuria in pregnant women, 24-hour urinary calcium excretion and the calcium/creatinine ratio (mg/g) in random urine samples were measured with a Toshiba TDA-30R autoanalyzer in the following 4 groups: 3 mild preeclamptic patients, 5 severe preeclamptic patients, 4 patients with intrauterine growth retardation (IUGR), and 10 healthy pregnant women. The mean 24-hour urinary calcium excretion in the 4 groups was 44.3 +/- 21.3 mg/day, 11.6 +/- 2.7 mg/day, 161.4 +/- 80.4 mg/day and 145.0 +/- 45.0 mg/day, respectively. Calcium excretion was significantly lower in the mild and severe preeclamptic patients than in the women with IUGR and the normal pregnant women. There was also a significant difference between the value in the mild and severe preeclamptic patients. The mean calcium/creatinine ratio in random urine samples was 53 +/- 30 mg/g, 18 +/- 5.6 mg/g, 192 +/- 85 mg/g and 169 +/- 70 mg/g, respectively. Also, such significant as 24-hour urinary calcium excretion were found in the mean calcium/creatinine ratio. From these results we conclude that determination of the 24-hour urinary calcium excretion or the calcium/creatinine ratio in random urine samples is a reliable index of preeclampsia.

[Studies on metoclopramide (MCP) loading test during pregnancy and puerperium for the evaluation of lactating capacity]

To evaluate the correlation between prolactin (PRL) secreting capacity and puerperal lactation, 66 women who had delivered normally without any complications during pregnancy were studied. They were divided into two groups depending on the lactating state a month after the delivery: The breast feeding group (group A, 40 cases), and the supplementary feeding group (group B, 26 cases), respectively. 10 mg of metoclopramide (MCP) loading was carried out in the 36th week of gestation and in the third day of the puerperium, and serum levels of PRL (at 0, 30, 60 min. after the MCP loading) were measured by RIA. Serum levels of insulin, glucose, triglyceride, free fatty acid, cholesterol and lipoproteins were also examined. There was no significant change in the serum levels of the various, substances during pregnancy and puerperium. Also, no significant change could be seen in the MCP loading test in the 36th week of gestation. However, on the third day of puerperium, serum PRL after 30 min. of the MCP loading showed a significant increase in group B compared with group A (587.1 +/- 202.9 vs. 431.2 +/- 196.6 ng/ml, p less than 0.02, mean +/- standard deviation). These results suggested that the MCP loading test during the early stage of puerperium might be an important index to use in determining whether the mother was ready to breast feed.

Seasonal incidence of subclinical vitamin K deficiency during early newborn period

Eleven-Sixty six healthy, non-vitamin K treated and exclusively breast-fed 5-day-old newborns were screened with PIVKA-II and Hepaplastin test for subclinical vitamin K deficiency for two years. PIVKA-II values in 96 babies (8.2%) ranged from 1 to 8 micrograms/ml. These babies were divided into two groups: 83 (86.5%) had relatively low values ranging from 1 to 2 micrograms/ml, and 13 (13.5%) had higher values ranging from 2 to 8 micrograms/ml. Eleven babies in the latter group (84.6%) had a seasonal deviation in incidence in the summer and early fall (p less than 0.05). This seasonal variation in severe subclinical vitamin K deficiency during the early newborn period corresponds with the results of an epidemical survey of idiopathic late onset hemorrhagic disease in newborns in Japan, suggesting similar causative factors in both of these hemorrhagic diseases.

PIVKA-II (protein induced by vitamin K absence-II) status in newborns exposed to anticonvulsant drugs in utero

Using PIVKA-II and Hepaplastin test, 5 neonates exposed to anticonvulsant drugs in utero were assessed 5 days after birth. None showed any sign of clinical bleeding, but all had PIVKA-II values over 1 microgram/ml. In controls, only 96 of 1,166 (8.2%) neonates had PIVKA-II values over 1 microgram/ml. The difference in the incidence rate was significant (p less than 0.005). Three of 5 epileptic mothers received valproatic acid and/or diazepam but no barbiturates and/or hydantoin.

[Intended super-ovulation with HMG in the treatment of so-called functional sterility]

To investigate a new treatment for so-called functional sterility, 17 out of 456 infertile patients were treated in the past three years (age: 32.7 +/- 3.6 years old, infertile period: 5.9 +/- 1.4 years, M +/- S.D.). These patients were treated with HMG-HCG. The injection of HMG (75-450iu) was started on the 5th day of the menstrual cycle, and the follicular development was observed by ultrasonography. Then, HCG (10,000-20,000iu) was injected when 3 or 4 matured follicles (with a diameter greater than 20mm) were observed. In some cases, the endometrial biopsy was done in the mid-luteal phase and the effect of the treatment was examined morphologically. Pregnancies were observed in 6 cases (35.3%) and all of them were singletons. One of them spontaneously aborted at 9 weeks of gestation, but remaining five cases delivered at full term without any complications. The total dose of HMG was 2,116.8 +/- 843.3iu, and OHSS was observed in 5 cycles out of 31 cycles (16.1%). There was no other severe complication during the treatment. The growth of the endometrium thickened in the treated cases, but no time lag in endometrial dating could be found in the morphological study. These results indicated that the intended superovulation method for the treatment of so-called functional sterility was effective through the mechanism of the improvement of the implantation ratio.

[Effects of obesity and weight gain during pregnancy on obstetrical factors]

The relationship between the body weight or weight gain during pregnancy and various obstetrical factors was investigated in 731 patients who delivered in San-ikukai Hospital for in the year 1986. The patients were classified into three groups according to their body weight in non-pregnant states: slender (n = 214), ordinary (n = 379) and obese (n = 138), according to the standard for "The decision diagram for the estimation of obesity and emaciation in Japanese" published in 1986 by the Ministry of Health and Welfare, Japan. Each of these groups was further divided into two groups according to the degree of weight gain during pregnancy (more or less than 15kg). Then, the duration of labor, the blood loss during delivery, the birth weight, the placental weight and the obstetrical abnormalities (prolonged labor, arrested labor, blood loss of more than 500 ml, fetal distress and toxemia of pregnancy) were investigated in these groups. The blood loss, the neonatal birth weight and the placental weight in the obese groups were much greater than those in the ordinary or the slender group (p less than 0.005). However, there was no significant difference in the duration of the labor among these groups. The incidence of obstetrical abnormalities in the obese group was significantly higher than in the ordinary or the slender group (chi 2 = 4.37, p less than 0.05, chi 2 = 5.27, p less than 0.025).(ABSTRACT TRUNCATED AT 250 WORDS)