Progesterone-induced blocking factor (PIBF) modulates cytokine production by lymphocytes from women with recurrent miscarriage or preterm delivery

Spontaneous miscarriage and preterm delivery are common complications of pregnancy. Pro-inflammatory cytokines have been shown to be associated with recurrent spontaneous miscarriage (RSM) and preterm delivery (PTD) and these have led to exploration of ways to downregulate pro-inflammatory cytokines and/or to upregulate anti-inflammatory cytokines. Progesterone-induced blocking factor (PIBF) is a molecule with inhibitory effects on cell-mediated immune reactions. We have ascertained the effects of PIBF on secretion of selected type 1 and type 2 cytokines by peripheral blood mononuclear cells from healthy non-pregnant women, women undergoing normal pregnancy, women with unexplained RSM and women with PTD. Peripheral blood mononuclear cells from 30 women with a history of unexplained RSM, 18 women undergoing PTD, 11 women with normal pregnancy and 13 non-pregnant healthy women were stimulated with a mitogen in the absence and presence of PIBF after which the levels of cytokines released into culture supernatants were determined by ELISA. Production of the type 2 cytokines IL-4, IL-6 and IL-10 by lymphocytes from the RSM and PTD groups and of IL-4 and IL-10 by lymphocytes from healthy pregnant women was significantly increased upon exposure to PIBF, while the levels of type 1 cytokines were not affected. Ratios of type 1:type 2 cytokines were decreased, suggesting a shift towards Th2 bias. PIBF did not affect cytokine production by lymphocytes from non-pregnant women. Thus, PIBF acts on lymphocytes in pregnancy to induce a type 1 to type 2 cytokine shift by upregulating the production of type 2 cytokines.

Pro-inflammatory maternal cytokine profile in preterm delivery

PROBLEM

The objective of this study was to determine the levels of cytokines produced by maternal peripheral blood mononuclear cells (PBMC) upon stimulation with a mitogen, with autologous placental cells and with a trophoblast antigen extract.

METHOD OF STUDY

Peripheral blood mononuclear cells from 54 women with a history of successful pregnancy and 30 women undergoing preterm delivery (PTD) were stimulated with the mitogen and antigens, and the cytokine levels in mitogen-stimulated culture supernatants assessed.

RESULTS

Significantly higher levels of the type 1 cytokines, interferon (IFN)-gamma and interleukin (IL)-2, were produced by the PTD group than by the normal pregnancy group, which on the contrary showed significantly greater production of the type 2 cytokines, IL-4, IL-5 and IL-10. A comparison of the ratios of type 2 to type 1 cytokines is indicative of a type 1 cytokine bias in PTD.

CONCLUSIONS

These data are suggestive of a maternal type 1 cytokine bias in PTD.

Placental pathology in relation to the White's classification of diabetes mellitus

The objective of this study was to investigate various macroscopic and microscopic features of the placenta in pregnancies complicated by diabetes according to White's classification. A total of 148 placentas were studied. Sixty-five were from control patients and 83 from diabetic mothers. The diabetic mothers were further divided into three groups according to White's classification. There were 40 cases in White's group A and 36 cases in White's group B. There were 7 cases in White's groups C and D combined. Advanced maternal age and grandmultiparity were significantly higher in White A, White B and White C&D compared to the normal group. Mean weight of the mother was higher in White group A and group B compared to the control group and group C&D. The placental weight and neonatal weight were increased provided the diabetes was not complicated by vascular disease. With accompanying vascular disease the placental weight and neonatal weight were reduced compared to the controls. As a result of increased perinatal jeopardy the rate of operative delivery was higher in diabetic mothers. No major difference was observed in microscopic changes of placentas in different groups according to White's classification and the normal group.

Effect of insulin on transport kinetics of alpha-aminoisobutyric acid in the perfused human placental lobule in vitro

BACKGROUND

The limited data available on the role of insulin on maternal-fetal transport of amino acids prompted us to undertake this study.

METHODS

Transport kinetics of a model amino acid, alpha-aminoisobutyric acid (AIB) was investigated in perfusion of isolated human placental lobules in vitro in non steady-state conditions and the effect of therapeutic dose of insulin was assessed in parallel series of perfusions. National Culture and Tissue Collection medium diluted with Earle's buffered salt solution was used as the perfusate and tritiated water was used as the reference marker for comparison.

RESULTS

In five successful perfusions with insulin, differential transport rate indices of AIB for 10, 25, 50, 75 and 90% of efflux fractions in the fetal venous outflow averaged 0.76, 1.03, 1.02, 1.09, 1.04 and 1.03 times those of reference values, respectively. The indices differed significantly than in controls for 10, 25 and 50% efflux fractions, but not in the case of 75 and 90% efflux values. The AIB transport fraction (TF), expressed as percentage of injected maternal dose, averaged 29.4 +/- 5.4% and 38.7 +/- 6.2% of the corresponding reference marker value in control and insulin series, respectively. With regards to the pharmacokinetic transport parameters, the absorption and elimination rates of the amino acid were significantly higher in the study group than in the control.

CONCLUSION

We conclude that insulin, in physiological and therapeutic doses, stimulates maternal-fetal AIB transport in vitro, in the perfused human placental lobule.

Th1 and Th2 cytokine profiles in recurrent aborters with successful pregnancy and with subsequent abortions

BACKGROUND

This study compared Th1-Th2 cytokine profiles in a subgroup of recurrent aborters who had an abortion with those in a subgroup of recurrent aborters who had a successful pregnancy.

METHODS

Fifty-four women with a history of at least three normal pregnancies, 24 women with a history of recurrent spontaneous abortion (RSA) followed by abortion (RSA-->A) and 39 women with a history of RSA followed by normal pregnancy (RSA-->N) were studied. Blood samples and placentas were obtained at the time of delivery or abortion; peripheral blood mononuclear cells were stimulated separately with phytohaemagglutinin and with autologous placental cells, and the secreted cytokines estimated.

RESULTS

Peripheral blood mononuclear cells from the RSA-->N subgroup secreted higher concentrations of Th1-type cytokines as compared with normal pregnant women, indicating a higher Th1 bias in these women. However, women in the RSA-->N subgroup had significantly higher concentrations of Th2 cytokines as compared with women in the RSA-->A subgroup. A comparison of Th1:Th2 cytokine ratios indicated a higher Th2 bias in RSA-->N women as compared with RSA-->A women.

CONCLUSIONS

We conclude that abortion-prone women who proceed to have successful pregnancy are more Th2-biased than abortion-prone women who abort, and that recurrent aborters who undergo spontaneous abortion have a stronger Th1 bias than aborters who have normal pregnancy.

Cytokine patterns in maternal blood after premature rupture of membranes

OBJECTIVE

To compare two types of cytokines, type 1, which activate cell-mediated reactions and are important in cytotoxic and delayed-type hypersensitivity reactions, and type 2, which encourage vigorous antibody production and are commonly found in association with humoral immune responses, in blood of women with premature rupture of membranes (PROM).

METHODS

Forty-four women with histories of at least three successful pregnancies and who currently delivered normally served as controls. The PROM group consisted of 30 women with spontaneous rupture of fetal membranes at term. Peripheral blood mononuclear cells were stimulated separately with a mitogen, placental cells, and a trophoblast antigen extract, and the supernatants examined for type 1 and type 2 cytokines.

RESULTS

Mitogen-stimulated blood cells produced significantly higher levels of type 1 cytokines in PROM women than in normal controls. Higher levels of the type 1 cytokine interferon-gamma were produced by PROM samples stimulated with autologous placental cells and with trophoblast antigens. Ratios of type 1 to type 2 cytokines were higher in PROM compared with normal pregnancy, and in some cases as much as 25-fold higher.

CONCLUSION

Women in the PROM group had a stronger type 1 reactivity whereas normal women were more predisposed to type 2 immunity; thus, PROM appears to be associated with a maternal type 1 bias.

The status of rubella immunity among pregnant women in Kuwait: screening in childbearing age should be reintroduced

The objective of this study was to investigate the immunity against rubella in the obstetric population in Kuwait by testing 600 pregnant women at a prenatal clinic, using the haemagglutination inhibition technique. In addition, a comparison was made between this study and one done in 1978 at the same clinic; its relation to the vaccination programme is also discussed. 7.7% of the population under study were non-immune. Statistically significant effect was demonstrated for maternal age but not for parity and nationality. Though it has been almost 20 years since an intense rubella vaccination programme was implemented, the percentage of non-immune pregnant women has not decreased. In Kuwait, termination of pregnancy for congenital rubella syndrome is prohibited. As a result, it is recommended that women be screened and vaccinated at the time of marriage.

Middle cerebral artery to umbilical artery resistance index ratio in the prediction of neonatal outcome

OBJECTIVE

The objectives of this study were to evaluate the usefulness of the middle cerebral artery to umbilical artery resistance index ratio (C/U ratio) as a predictor of adverse perinatal outcome, and to show that the absence of fetal umbilical artery end-diastolic velocity (AEDV) in SGA fetuses is associated with high morbidity and mortality.

METHOD

In this prospective study, color Doppler flow imaging was used for the estimation of the C/U ratio in fetuses that were small for their gestational age, in 70 singleton pregnancies between 29 and 42 weeks of gestation. The subjects were categorized into two groups, with Group A consisting of 35 small for gestational age (SGA) fetuses with a normal C/U ratio (1.05 or higher), and Group B comprising 35 SGA fetuses with an abnormal C/U ratio (below 1.05).

RESULT

The mean C/U ratio values for birth weight and gestational age were higher in group A than in group B. Fetuses born to mothers in group B stayed longer in the neonatal special care unit (NSCU), whereas the period from ultrasound examination to delivery was higher in the cases in group A. A higher percentage of mothers with an abnormal C/U ratio underwent cesarean section. Fetuses with an absent end-diastolic velocity of the umbilical artery had a higher morbidity. Three stillbirths occurred in fetuses with an absent end-diastolic velocity of the umbilical artery.

CONCLUSION

Our results suggest that the C/U ratio is a good predictor of neonatal outcome, and could be used to identify fetuses at risk of morbidity and mortality. Fetal umbilical artery AEDV with intrauterine growth restriction is associated with high perinatal morbidity and mortality.

Circulating cytokines and CD30 in normal human pregnancy and recurrent spontaneous abortions

Concentrations of the T-helper (Th) 1 cytokines interleukin (IL)-2, tumour necrosis factor (TNF) -alpha, TNF-beta and interferon-gamma, Th2 cytokines IL-4, IL-5, IL-6, IL-10 as well as those of soluble CD30 in sera have been examined during the three trimesters of gestation, at delivery in normal pregnancy, and at the time of spontaneous abortion in women with a history of unexplained recurrent spontaneous abortion (RSA). Significantly higher concentrations of the Th2 cytokines IL-6 and IL-10 were found at normal delivery than in women with RSA, and conversely significantly increased concentrations of the Th1-type cytokine TNF-alpha were found in RSA as compared with successful pregnancy. In abortion-prone women who had a successful pregnancy, significantly higher concentrations of IL-6 and significantly lower concentrations of TNF-alpha were found as compared with abortion-prone women who had another abortion, supporting the notion that Th2- and Th1-bias are associated with successful and unsuccessful pregnancy respectively. Serum CD30 concentrations did not correlate with the outcome of pregnancy. These findings support observations drawn from experiments on the cytokine secretion profiles of peripheral blood mononuclear cells and decidual lymphocytes which suggest that normal pregnancy is Th2-biased and that unexplained RSA is associated with Th1-type reactivity.

Kinetics of palmitic acid transport in insulin-dependent diabetic pregnancies: in vitro study

BACKGROUND

The paucity of data relating to transport kinetics of free fatty acids (FFA) in pregnant diabetic women prompted the undertaking of the present study.

METHODS

Transport kinetics of a model FFA, palmitic acid, have been investigated in Type I diabetic pregnancies, using in vitro perfusion of isolated placental lobules. National Cancer Tissue Culture medium diluted with Earle's buffered salt solution was used as the perfusate and control placental lobules were perfused for comparison.

RESULTS

In five Type I diabetic women, the palmitic acid transport fraction (TF) averaged 5.6 +/- 0.42% of injected maternal bolus dose, representing 11.8 +/- 2.1% that of tritiated water used as reference. In control perfusions (n = 5), the palmitic acid TF represented 10.2 +/- 1.3% of tritiated water TF. Differential transport rates of palmitic acid for 10, 25, 50, 75 and 90% of efflux in fetal veins differed significantly from the corresponding values for tritiated water in both study and control series. However, palmitic acid transport rates for the various efflux fractions in the two series were not significantly different. For kinetic parameters, such as area under the curve, clearance, elimination constant, time for maximum response, absorption rate and elimination rate, the values for palmitic acid in the diabetic and control series also did not differ significantly.

CONCLUSION

Transport kinetics of palmitic acid in Type I human diabetic pregnancies in in vitro conditions do not differ significantly from those observed in normal pregnancies.

Cytokine production by maternal lymphocytes during normal human pregnancy and in unexplained recurrent spontaneous abortion

It has been proposed that successful pregnancy is a T helper 2-type phenomenon, and that T helper (Th)1-type reactivity is deleterious to pregnancy. The objective of this study was to compare the concentrations of Th1 and Th2 cytokines produced by peripheral blood mononuclear cells from women undergoing unexplained recurrent spontaneous abortion (RSA) with those produced during normal pregnancy at a similar gestational stage. The control group consisted of 24 women with a history of successful pregnancies and the abortion group comprised of 23 women with a history of unexplained RSA. Blood from the control group was obtained at the end of the first trimester as gestational age controls for the abortion group from whom blood was collected at the time of abortion. Phytohaemagglutinin-stimulated peripheral blood cell culture supernatants were analysed for concentrations of cytokines. Significantly higher concentrations of Th2 cytokines were produced by the first trimester normal group than by the RSA group, while significantly higher concentrations of Th1 cytokines were produced by the abortion group as compared to first trimester normal pregnancy, indicating a distinct Th2-bias in normal pregnancy and a Th1-bias in unexplained RSA.

Mitogen-induced cytokine responses of maternal peripheral blood lymphocytes indicate a differential Th-type bias in normal pregnancy and pregnancy failure

PROBLEM

Profiles of Th1- and Th2-type cytokines were studied in women with a history of successful pregnancy and in women with a history of unexplained recurrent spontaneous abortions (RSA) with the objective of elucidating Th1- and Th2-type bias in normal pregnancy and pregnancy failure.

METHOD OF STUDY

Peripheral blood mononuclear cells (PBMCs) from 54 women with a history of normal pregnancy and 23 women with a history of unexplained RSA, obtained at delivery or on the day of abortion, respectively, were stimulated with phytohemagglutinin (PHA), followed by the estimation of four Th2 cytokines and four Th1 cytokines.

RESULTS

Significantly greater levels of Th2 cytokines were produced by the normal group than by the RSA group. On the other hand, significantly higher levels of Th1 cytokines were produced by the RSA group than by the normal pregnancy group.

CONCLUSIONS

These data support the concept that unexplained recurrent spontaneous abortion is associated with an increase in Th1-type reactivity, while Th2 dominance is a feature of successful pregnancy.

Placenta accreta in Kuwait: does a discrepancy exist between fundal and praevia accreta?

OBJECTIVE

The purpose of this retrospective study was to compare maternal and neonatal outcome in relation to site of placenta accreta by stratifying the site of placenta accreta into upper and lower uterine segment implantation.

SUBJECTS AND METHODS

Sixteen cases of placenta accreta which were reported in the Maternity Hospital of Kuwait over 11 years from January 1981 to July 1993 - (1990 and 1991 excluded) were retrospectively analyzed using the hospital medical records.

RESULTS

The incidence of placenta accreta was 9.8 per 100,000 deliveries. The rate of accreta in patients with placenta praevia was 880 per 100,000 placenta praevia, compared to a rate of 5 accreta per 100,000 placenta implanting in the upper uterine segment. There were no differences between accreta found in the upper segment and lower segment for maternal and neonatal mortality, maternal complication, past obstetric history and possibility of conserving the uterus. Significant differences were found in the birth weight, gestational age at birth, antenatal symptoms, time of diagnosis and mode of delivery when accreta was stratified by site of implantation.

CONCLUSION

Placenta praevia is a definite risk factor for placenta accreta. Combined abnormal penetration of placenta as in accreta and abnormality in site as in praevia does have a significant clinical implications.

Maternal Th1- and Th2-type reactivity to placental antigens in normal human pregnancy and unexplained recurrent spontaneous abortions

Spontaneous abortion is the most common complication of pregnancy, but the etiology of a significant proportion of abortions is still unknown. We have examined the production of Th1- and Th2-type cytokines by women with unexplained recurrent spontaneous abortion (RSA) since it appears that successful murine pregnancy occurs in a Th2-dominant situation and that Th1-type immunity is associated with pregnancy failure. We have compared maternal reactivity toward placental antigens in women with a history of successful pregnancy with that in women with a history of RSA. This was done by coculturing maternal peripheral blood mononuclear cells (PBMC) with autologous placental cells and also by stimulating maternal PBMC with antigens from a choriocarcinoma cell line of trophoblastic origin. We detected significantly greater levels of the Th2 cytokines IL-6 and IL-10 in normal pregnancy compared to unexplained RSA and significantly higher levels of the Th1 cytokine IFN-gamma in RSA compared to normal pregnancy. These results suggest that women with normal pregnancy have a higher Th2 bias, while women with a history of RSA evince a bias toward Th1-type reactivity.

Influence of seasonal variation on pregnancy-induced hypertension and/or preeclampsia

Seasonal variation of temperature and humidity are said to influence the incidence of hypertensive disorders of pregnancy. The aim of this study was to determine if temperature and humidity exert any influence on the incidence of pregnancy-induced hypertension and preeclampsia in Kuwait. This is a retrospective study performed in the Maternity Hospital, Kuwait (MHK) in the years 1992-1994. Monthly distribution of all deliveries and those in which the patients had pregnancy-induced hypertension and preeclampsia were recorded. There are some studies including ours which do not show any significant correlation between meteorological factors and hypertensive disorders of pregnancy. We found that the incidence of pregnancy-induced hypertension per 1,000 deliveries was high in June when the temperature was very high and the humidity at its lowest. The reverse was true for the incidence of preeclampsia per 1,000 deliveries, which was high in November when the temperature was low and the humidity high.

Post-invasion change in the trend of complications and outcome of pregnancy in Maternity Hospital Kuwait from 1981 to 1995

To assess the trend in the complications and outcome of pregnancy in Maternity Hospital, Kuwait, a retrospective analysis of yearly hospital statistics books and labour ward records of patients delivering in Maternity Hospital Kuwait was carried out for the period 1981 to 1995. In the post-invasion period there is a significant rise in: primiparity; mothers aged 35 years or older; Kuwaiti mothers; and in multiple pregnancy. The incidence of pregnancy-induced hypertension, pre-eclampsia, and hysterectomy for postpartum haemorrhage also increased. There was a significant increase in spontaneous abortions and low birth weight babies. The incidence of hydatidiform mole has significantly decreased. Still birth rate shows a decreasing trend in the study period. The significant change in the age and parity of the mothers delivering in the post-invasion period might partly explain the above changes. However, the effect of environmental pollution, social and psychological stress, and anxiety due to war may have also contributed to an increase in the complications and adverse outcomes of pregnancy.

Pattern of parvovirus B 19 infection during different trimesters of pregnancy in Kuwait

OBJECTIVE

Aims of this study were to determine the IgG and IgM seropositivity to parvovirus B19 during the three trimesters of pregnancy.

METHODS

Initially, a total of 1,047 pregnant women were included in a prospective study. Blood samples were obtained from 343, 406 and 298 cases in the first, second and third trimesters, respectively. To study the incidence of seroconversion, a second sample of blood was obtained 2-4 weeks later from the first 100 cases, who were IgG and IgM negative in the first trimester.

RESULTS

The seroprevalence of parvovirus B19 IgG and IgM was 53.3% and 2.2%, respectively. The incidence of seroconversion was 16.5%. The rate of fetal loss was 15.4% in patients with acute infection, all of which occurred in the first two trimesters.

CONCLUSIONS

The percentage of IgG positive cases is significantly higher in first and second trimesters compared to the third trimester. The seroconversion rate was 16.5%.

Pattern of parvovirus B 19 infection during different trimesters of pregnancy in Kuwait

OBJECTIVE

Aims of this study were to determine the IgG and IgM seropositivity to parvovirus B19 during the three trimesters of pregnancy.

METHODS

Initially, a total of 1,047 pregnant women were included in a prospective study. Blood samples were obtained from 343, 406 and 298 cases in the first, second and third trimesters, respectively. To study the incidence of seroconversion, a second sample of blood was obtained 2-4 weeks later from the first 100 cases, who were IgG and IgM negative in the first trimester.

RESULTS

The seroprevalence of parvovirus B19 IgG and IgM was 53.3% and 2.2%, respectively. The incidence of seroconversion was 16.5%. The rate of fetal loss was 15.4% in patients with acute infection, all of which occurred in the first two trimesters.

CONCLUSIONS

The percentage of IgG positive cases is significantly higher in first and second trimesters compared to the third trimester. The seroconversion rate was 16.5%.

Assessment of D-glucose transport kinetics in the perfused human placenta: an in vitro study

BACKGROUND

There have been no reports to date on glucose transport kinetics and the effect of graded hyperglycemia in the human placenta in non-steady-state conditions.

METHODS

The transport kinetics of D-glucose in the human placenta was investigated in non-steady state conditions in vitro using perfusion of isolated placental lobules. National Cancer Tissue Culture (NCTC) 135 culture medium, diluted with Earle's buffered salt solution was used as the perfusate. 14C-Labeled D-glucose and water as reference were injected as a single bolus into the maternal arterial perfusate. Perfusate samples were collected and analyzed from the maternal and fetal venous outflows.

RESULTS

In four successful perfusions, differential transport rates of glucose in the maternal-fetal direction averaged 1.03, 1.02, 1.09, 1.04 and 1.03 times those of corresponding tritiated water transport rates for 10, 25, 50, 75 and 90% of efflux fractions, respectively. Glucose transport fraction, expressed as percentage of injected maternal dose averaged 84 +/- 3.1% of water transport fraction in the four perfusions. Glucose kinetic parameters expressed as area under the curve, elimination constant (Kel), clearance, time for maximum response, absorption rate and elimination rate averaged 0.25, 0.29, 3.96, 1.02, 0.25 and 0.18 times that of the corresponding tritiated water value, respectively. Neither the different kinetic parameters nor the transport fraction indices differed significantly when glucose concentrations in the same perfusions were raised successively from 5.56 to 27.80 and then to 55.6 mmol/L.

CONCLUSIONS

We speculate that within physiological limits, hyperglycemia per se plays no significant part in altering glucose transport kinetics across the human placenta in the maternal-fetal direction.

Obstetric and gynecologic implication of brucellosis in Kuwait

OBJECTIVE

To study the possible correlation between maternal Brucella infection and reproductive failure as expressed by abortion, intrauterine fetal death, and preterm delivery.

STUDY DESIGN

Maternal enzyme-linked immunosorbent assay serologic and microagglutination testing and conception product culture for Brucella were done in 227 women with preterm delivery, 51 with intrauterine fetal death, 29 with spontaneous abortion, and 39 with term delivery of a normal baby.

RESULTS

Ingestion of raw milk was positive in 18% of the control cases, 28% of preterm delivery cases, 30% of intrauterine fetal death cases, and 21% of spontaneous abortion cases. Acute or chronic Brucella infection was found in 8% of preterm, 10% of intrauterine fetal death, and 7% of abortion cases. None of the control cases had evidence of Brucella infection. None of the four groups showed positive culture of the placenta for Brucella. The titres of Brucella-specific immunoglobulin G and M were significantly higher in the preterm, abortion, and intrauterine fetal death groups than in the control group.

CONCLUSION

A possible correlation may exist between Brucella infection and preterm and intrauterine fetal death, which does not seem to be related to transplacental infection but possibly may relate to the acute illness.

Maternal and perinatal outcomes of multiple pregnancy following IVF-ET

OBJECTIVE

To analyze the course of pregnancy and perinatal outcome in 31 twins, 22 sets of triplets and five quadruplet clinical pregnancies following conventional in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) procedures and in relation to 58 singleton pregnancy following the same procedure.

METHODS

Retrospective analysis of maternal and neonatal medical records of 58 singleton, 31 twin, 22 triplet and five quadruplet pregnancies diagnosed at 7-8 weeks gestation following 561 embryo transfer procedures in 628 oocyte collections at the IVF Center in the Maternity Hospital, Kuwait from July 1994 to December 1996.

RESULTS

The clinical pregnancy rate in 628 cycles proceeding to oocyte collection was 32.6%, there being 58 singletons (50.6%), 31 twins (33.5%), 22 triplets (10.8%) and five quadruplets (2.5%). Early complicated outcomes included 47 miscarriages (23.7%), four ectopic pregnancies (1.9%) and one hydatidiform mole. The spontaneous fetal reduction rate was 20.6% in twin, 45.5% in triplet and 40% in quadruplet pregnancies. There was a significantly higher maternal and neonatal complication rate in the triplet group compared to singletons and twins, including threatened miscarriage, pre-eclampsia, antepartum hemorrhage, longer hospital stay and preterm labor. The chance of operative delivery was higher in high-order multiple pregnancy (HOMP). The major neonatal complications were related to prematurity. Neonatal morbidity and mortality were significantly higher in the triplet group. The need for admission to the Special Care Baby Unit (SCBU) and the Neonatal Intensive Care Unit (NICU) was significantly higher in HOMP. However, there were no statistically significant differences in the perinatal mortality in relation to the degree of HOMP.

CONCLUSION

Maternal complications, perinatal and neonatal morbidity after 2 years activities in the IVF Center have been reviewed leading to changes in policies of management, notably a reduction in the number of embryos transferred.

Timed unilateral ovarian follicular aspiration prior to administration of human chorionic gonadotrophin for the prevention of severe ovarian hyperstimulation syndrome in in-vitro fertilization: a prospective randomized study

Unilateral ovarian follicular aspiration 6-8 h prior to trigger administration of human chorionic gonadotrophin (HCG) was performed or not in 31 women at serious risk of ovarian hyperstimulation syndrome (OHSS) after ovarian stimulation for in-vitro fertilization (IVF)-embryo transfer or intracytoplasmic sperm injection (ICSI) in this prospective randomized study. Unilateral follicular aspiration was performed in 16 women (group 1) matched for age, indication for fertility treatment, and the amount and duration of gonadotrophin exposure with 15 women not receiving aspiration treatment (group 2). There was a statistically significantly (P < 0.001) lower mean number of oocytes obtained from group 1 women (14.9 +/- 1.8 vs 22.6 +/- 2.4). The fertilization (53.2 +/- 2.6 vs 65.5 +/- 1.35%) and embryonic cleavage (91.3 +/- 2.1 vs 90.2 +/- 1.75%) rates were similar in both groups. OHSS occurred in women from both groups (group 1: 25% vs group 2: 33.3%) being severe OHSS in two women from group 1 and one from group 2. We conclude that unilateral ovarian early follicular aspiration prior to HCG trigger administration does not reduce the occurrence of severe OHSS in women at risk.

Characteristics of men and women with circulating antisperm antibodies in a combined infertility clinic in Kuwait

Antisperm antibodies were determined in the sera of 250 infertile couples and 100 puerperal women as controls using the immunofluorescence technique. Couples with significant circulating antisperm antibodies were placed on low-dose prednisolone 5 mg daily for 3-6 months. Initial routine semen analysis and hypoosmotic swelling test were done and repeated after 3 months of therapy. The incidence of antisperm antibodies (ASA) was 18.8 and 17.6% in the men and women, respectively, compared to 4% in the women controls (p < .02). In the men, the main determinants (with incidence) of ASA included smoking (33.9%), past history of sexually transmitted disease (33.3%), surgery to genital tract (28.6%), trauma (27.3%), and unexplained infertility (18.5%). In women whose husbands had antisperm antibodies the incidence of circulating antisperm antibodies was 38.3%, while endometriosis and thyroid dysfunction had incidence of antisperm antibodies of 21.4 and 16.7%, respectively. In the 27 (10.8%) case of unexplained infertility, the incidence of antisperm antibodies was 22.2%. High follicle-stimulating hormone (FSH) in the men and low midluteal-phase progesterone in the women were associated with increased expression of antisperm antibodies. Antisperm antibodies adversely affected quality of sperm. Low-dose prednisolone significantly reduced the titer of antisperm antibodies and improved the sperm parameters and conception rate.

Eclampsia in Kuwait 1981-1993

The aim of this study is to investigate the maternal and fetal outcome and the risk factors for developing eclampsia in Kuwait. The study includes all patients with eclampsia observed at the Maternity Hospital, Kuwait during the period from 1981 to 1993. It revealed that the risk factors predisposing to eclampsia were primiparity, a maternal age below 30 years, multiple pregnancy and the presence of preeclampsia. The pregnancy outcome in terms of the stillbirth rate, neonatal death rate and low birth-weight babies was significantly higher in mothers with eclampsia than in noneclamptic mothers. The operative delivery and maternal mortality rates were also significantly higher in these patients.

Post-war changes in the outcome of pregnancy in Maternity Hospital, Kuwait

To analyse the pre- and post-Gulf War changes in the outcome of pregnancy and to explore the possible causes that could have affected these changes, a retrospective analysis of medical records of patients delivering in Maternity Hospital Kuwait (MHK) was carried out for the period 1987-89 (pre-Gulf-War) and 1992 (post-Gulf War). The records of 1991 were used when adequate information was available. The normal z test was used to assess the significance between two proportions. There is a significant rise in abortion, low birth weight babies, triplet pregnancies, and major congenital anomalies in the post-war period. The still-birth rate, early neonatal mortality rate and perinatal mortality rate significantly increased in the immediate post-war period in 1991, but decreased to levels below the pre-war period in 1992. It should be investigated whether these changes are secondary to the changes in the population structure; the effects of war in terms of deterioration of health care services; environmental pollution caused by oil well fires, oil spills; or the psychological trauma, anxiety and stress caused by the Iraqi invasion of Kuwait.

Effect of antihypertensive therapy in preeclampsia on levels of serum interleukin-4

We investigated the effects of antihypertensive therapy on serum levels of interleukin-4 using InterTest-4 ELISA in 25 preeclamptic women; 14 were placed on treatment, while 11 were not. Comparison was made with 14 non-preeclamptic pregnant controls. Interleukin-4 levels were significantly lower in the controls than in the treated preeclamptic women (p < 0.001): 68.6 +/- 10.9 versus 106.1 +/- 13.2, 64.7 +/- 9.6 versus 119.8 +/- 11.4, 90.2 +/- 9.1 versus 124.3 +/- 15.7, and 65.6 +/- 3.6 versus 109.7 +/- 11.4 pg/ml, during antepartum, early intrapartum, late intrapartum and postpartum periods, respectively. No significant differences were detected between the therapy and no therapy subgroups (p > 0.05). This shows that antihypertensive therapy has no effect on interleukin-4 levels.

The comparative value of interleukin-4 in sera of women with preeclampsia and cord sera

Cytokines are of central importance in the regulation of immunity, inflammation, tissue remodeling, and embryonic development. Uncontrolled or excessive cytokine production may contribute to the pathophysiology of acute and constant infections, autoimmune disease, and neoplasia. Interleukin-4 was first observed as a costimulator of B-cell DNA synthesis in response to antiimmunoglobulin M antibodies. Within hours of contact with interleukin-4, resting B cells and macrophages increase their expression of the class II histocompatibility antigen needed for immune cell interaction. The aim of this study was to evaluate the levels of interleukin-4 in the sera of preeclamptic women and the cord blood of their newborn infants. Five milliliters of blood were withdrawn from the cubital vein of 25 women with preeclampsia at 24 and 36 wk gestation, at term, and just before onset of labor or in early labor. At delivery, cord blood was withdrawn from each woman's corresponding newborn. The control group was 25 women without any obstetric complication. Interleukin-4 levels were significantly higher in the preeclamptic women than the control women (p < 0.05). Similarly, the interleukin-4 level was significantly higher in the maternal blood of the preeclamptic women than in the cord blood of their newborns (p < 0.01). Because interleukin-4 increases the expression of class II histocompatibility, it may be important in immunorecognition and immunosuppression. However, excessive interleukin-4 production may contribute to the pathophysiology of preeclampsia.

The outcome of placenta accreta in Kuwait (1981-1993)

OBJECTIVES

To study the demographic characteristics of patients with placenta accreta and to identify the clinical features, maternal and neonatal complications of this condition.

METHODS

Sixteen cases of placenta accreta were identified in the Maternity Hospital of Kuwait during the period January 1981 to July 1993. Medical records were reviewed regarding past obstetric history, type of placenta, clinical presentation, maternal and fetal outcome.

RESULTS

The rate of placenta accreta was found to be 98 per 1,000,000 deliveries. Emergency hysterectomy was needed in 87.5% of cases. There was one maternal death (6.25%) and three perinatal deaths (18.75%). Hemorrhage was the major presenting symptom either externally and antenatally in previa accreta or postpartum in accreta of the upper segment or internally in the same cases. The major postoperative complications were coagulopathy, urinary injury, pelvic hematoma and abscess, in addition to cardiac arrest. These complications, when considered separately, were not affected by a previous history of uterine scarring.

CONCLUSIONS

Placenta accreta is a major cause of obstetric hemorrhage and has an adverse effect on maternal and neonatal outcome. It ought to be considered a possibility in patients with previous uterine scarring, placenta previa or retained placenta. It will remain a growing problem in the developing countries due to the rising incidence of previous multiple cesarean sections. Unfortunately the latter do not deter women in this part of the world from insisting upon having big families and refusing tubal ligation.

A retrospective analysis of pathological placental implantation--site and penetration

OBJECTIVES

To determine the incidence of pathologically implanted placenta, i.e. placenta previa and accreta, at the Maternity Hospital of Kuwait. In addition the study aimed to identify the risk factors for such conditions, and test the hypothesis that previous cesarean section increases the likelihood of abnormal placentation.

METHODS

Analysis of all deliveries in the Maternity Hospital of Kuwait with identification of cases of placenta previa, placenta accreta, previous cesarean section and manual removal of placenta. Information was obtained from the medical records of the hospital between 1981 and 1992 except for the period 1990-1991 due to incomplete information as a consequence of the Iraqi invasion. The incidences of these conditions were calculated followed by identification of risk factors for placenta accreta and previa.

RESULTS

The incidence of placenta previa was 0.5% and that of placenta accreta 9.5 per 100,000 deliveries. Placenta previa and previous cesarean section were found to be significant predisposing factors for placenta accreta. The increased risk for placenta accreta in the presence of these factors was much less than that reported in the international literature. Abnormal placentation was responsible for 34% of peripartum hysterectomies.

CONCLUSIONS

Placenta accreta and previa are major causes of massive obstetric hemorrhage. They are interrelated with a common predisposing factor, cesarean section. Even though the rate of cesarean section and placenta previa is increasing, the incidence of placenta accreta remains stable in Kuwait.