Effect of a mobile app on breastfeeding among cesarean deliveries: A randomized controlled trial

Aim

Cesarean section has negative impacts on breastfeeding rates. This study is to evaluate the effect of a mobile application on breastfeeding outcomes among mothers who had cesarean section using a randomized control trial in Vietnam in 2020 - 2022.

Methods

A triple-blinded randomized trial of a mobile application was conducted. The mobile application was tailored to Vietnamese culture with two separate versions for the intervention and the control group. The intervention version auto-generated three messages per week and linked the information in the library content to improve breastfeeding while the control version sent messages on maternal and child health care. Pregnant mothers were recruited during their antenatal visits and randomly assigned to two groups. Outcomes of interest included early initiation of breastfeeding and exclusive breastfeeding rates.

Results

A total of 275 mothers in the control and 293 in the intervention group who had undergone a cesarean section were included in the analyses. Significant increases were observed for early initiated breastfeeding within two hours (aOR= 1.51, 95%CI: 1.01 to 2.27) and exclusive breastfeeding during hospital stay (aOR=1.59, 95%CI: 1.02 to 2.49).

Conclusions

Our results support the use of a theory-based design mobile phone application as a part of a promising intervention to improve breastfeeding outcomes.

Key messages

• A mobile phone application could be a widely accessible, acceptable, and effective intervention to improve breastfeeding outcomes.

• To improve exclusive breastfeeding rates, comprehensive interventions at different levels of sociocultural and market contexts, settings, and individuals are needed.

[Twin-twin transfusion syndrome--front line in fetal medicine]

Twin-twin transfusion develops in 10-20% of monochorionic twin pregnancies. As far as we know the underlying disturbance is an unbalanced anastomosis between the two fetuses on the placental surface. Without treatment mortality is as high as 80% if diagnosed before viability. One of this article's authors spent two months in Hamburg at the "Allgemeine Krankenhaus", Barmbeck in Germany and describes the technique used there to coagulate these anastomoses via fetoscope. The outcome seems very promising with overall survival of 80% using this method. In the article pathogenesis and alternative treatments are also discussed.

[Twin-twin transfusion syndrome--front line in fetal medicine]

Twin-twin transfusion develops in 10-20% of monochorionic twin pregnancies. As far as we know the underlying disturbance is an unbalanced anastomosis between the two fetuses on the placental surface. Without treatment mortality is as high as 80% if diagnosed before viability. One of this article's authors spent two months in Hamburg at the 'Allgemeine Krankenhaus', Barmbeck in Germany and describes the technique used there to coagulate these anastomoses via fetoscope. The outcome seems very promising with overall survival of 80% using this method. In the article pathogenesis and alternative treatments are also discussed.

Second-trimester biochemical screening

The past years have seen considerable progress in the area of biochemical screening. Increasing data have now clearly shown the advantages of multiple markers, particularly beta-hCG over AFP alone. There continues to be considerable controversy over the best mathematic algorithm and which markers are best (e.g., beta-HCG, uE3, and so forth). There seems to be a plateau of detection frequencies at about 65% to 70% with current methodologies. Further work needs to be done, however, including some new approaches, if there is to be substantial improvement of screening sensitivity. The combination of biochemical with biophysical parameters as discussed elsewhere in this issue represents the next level of sophistication in the attempt to identify the highest proportion of abnormalities with the fewest false-positives.

Early prenatal diagnosis of the ICF syndrome

The ICF syndrome (immunodeficiency, (para)centromeric instability and facial abnormalities) is a rare autosomal recessive disorder with characteristic cytogenetic aberrations of chromosomes 1, 9 and 16 in lymphocytes. Previously, only one case has been diagnosed prenatally in the second trimester of pregnancy by fetal blood sampling. We report the first early prenatal exclusion of the ICF syndrome by chorionic villous sampling (CVS) and linkage analysis in a family with a previous affected child. The fetus was heterozygous for marker D20S850 closely linked to the ICF locus. The family was counselled of a probability of over 90% that the fetus would be unaffected. Postnatal chromosome analysis on peripheral blood was normal and thus confirmed the prenatal diagnosis.

Successful EXIT (ex utero intrapartum treatment) procedure in a fetus diagnosed prenatally with congenital high-airway obstruction syndrome due to laryngeal atresia

Congenital high-airway obstruction syndrome (CHAOS) is due to rare malformations and has been reported previously in only few cases. If the diagnosis can be made prenatally, the ex utero intrapartum treatment (EXIT) procedure may be life-saving. A healthy 28-year old nulli-para was referred because of isolated ascites found at gestational week 16 during routine ultrasound scan. Repeated scans showed overdistended hyperechogenic lungs with inverted diaphragm and a dilated trachea, which was interpreted as a CHAOS resulting from laryngeal atresia. The ascites eventually disappeared. An EXIT procedure was performed at 35 weeks of gestation. Anesthesia of the mother was induced with thiopental, succinylcholine and fentanyl followed by intubation, and maintained with isoflurane and nitrous oxide. A low abdominal midline incision was performed followed by a low transverse incision of the uterus. The fetal head, right arm and shoulder were delivered and intramuscular anesthesia was administered to the fetus. Immediate laryngoscopy confirmed the diagnosis and a tracheostomy was therefore performed. Surfactant was given after a few minutes of ventilation. Compliance improved and when the fetus was easy to ventilate, it was delivered. The baby is developing normally at 18 months of age. Surgical correction of the malformation will be performed after two years of age. It is concluded that some fetuses with a prenatal diagnosis of CHAOS can benefit from the EXIT procedure at delivery. This necessitates a multidisciplinary management team.

Stereospecific versus nonstereospecific assessments for the bioequivalence of two formulations of racemic chlorpheniramine

Chlorpheniramine (chlorphenamine, CPAM) is a racemic antihistaminic H1 drug containing two enantiomers. The aim of this study was to assess the bioequivalence of two formulations (reference and Vietnamese-tested formulation) of racemic chlorpheniramine combined with phenylpropanolamine in an open-labeled, randomized, crossover two-period study, after administration of 8 mg of racemic chlorpheniramine in 12 healthy Vietnamese subjects. First, dissolution of both formulations was tested in vitro according to USP requirements. Then the 12 subjects received both formulations after an overnight fast and a 7-day wash-out period. Plasma samples were collected up to 168 h. Plasma concentrations of total chlorpheniramine and its individual enantiomers were determined with a validated chiral HPLC method and pharmacokinetic parameters were estimated using model-independent analysis. For the reference formulation, Cmax and AUC values were higher for (+)S-chlorpheniramine ((+)S-CPAM) compared to (-)R-chlorpheniramine ((-)R-CPAM) (13.3 vs. 6.8 ng/ml and 409 vs. 222 ng/ml/h, respectively) while Clt/F and Vd/F were lower (9.8 vs. 17.6 l/h and 321 vs. 627 l, respectively). No difference was observed for Tmax, t(1/2), and MRT. Pharmacokinetic parameters were similar for the reference and the Vietnamese-tested formulation. Bioequivalence was assessed by Schuirmann test, as recommended by the current FDA and European Community criteria. Dissolution tests showed that both formulations were equivalent. A nonstereospecific, but not a stereospecific, approach indicated bioequivalence between the formulations.

Complex genetic counselling and prenatal analysis in a woman with external ophthalmoplegia and deleted mtDNA

Single large mitochondrial DNA deletions (DeltamtDNA) are usually spontaneously occurring and cause a wide variety of symptoms, ranging from severe infantile multisystem disorders to adult onset progressive external ophthalmoplegia (PEO). There is always heteroplasmy with a mixture of normal and mutant mtDNA and the levels usually vary widely between tissues. There is at present insufficient scientific basis for accurate genetic counselling of women with DeltamtDNA, but it is reasonable to assume that DeltamtDNA can be transmitted if it is present in the female germ cells. Here, we present the results of prenatal analysis in a woman with DeltamtDNA and PEO. No DeltamtDNA was detected by Southern blot and PCR analyses of chorionic villi from the first trimester of pregnancy, in cord blood obtained at birth or in peripheral blood from the child at six months of age. This makes it unlikely that the child will develop a severe infantile mitochondrial disorder due to transmission of high levels of DeltamtDNA. However, the complex mitochondrial genetics and the limited access to human tissues makes it impossible to exclude transmission of low levels of DeltamtDNA that possibly could cause disease later in life.

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

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

[Folic acid protects against neural tube defects. But how many women of reproductive age have been informed about this fact?]

The involvement of folic acid in the aetiology of neural tube defects (NTDs) has been discussed for decades. Both observational and controlled intervention trials have shown periconceptional folic acid supplementation (PFAS) to significantly reduce the incidence both of first-time and recurrent NTDs. PFAS may also be associated with reduction in the incidence of certain other congenital malformations, preterm delivery, and intra-uterine growth retardation. However, the mechanism whereby folic acid exerts its protective effect remains unclear. Thermolabile 5,10-methyl-enetetrahydrofolate reductase was the first folate-related enzyme to be associated with an increased risk of NTDs. This genetic variant may result in increased plasma homocysteine levels, which have been linked to an increased risk of NTDs. The folate-dependent genetic variants known today can explain no more than 30-50 per cent of the observed protective effect of folate. However, available evidence suggests low maternal folate status itself to be the major determinant of NTD risk. Since the vast majority of NTDs are first occurrences, and in Sweden a large proportion of fetuses with spina bifida remain undetected at routine ultrasonography during pregnancy, primary prevention by means of PFAS represents a major potential public health asset, capable of reducing both mortality and morbidity due to NTDs. Accordingly, implementation of a national strategy to reduce the incidence of NTDs, and promote awareness among health care providers and women of reproductive age of the benefits of PFAS is strongly to be recommended. Although supplemental folic acid tablets are the best proven means of improving folate status, compliance may be a problem, which emphasises the importance of considering a nutrient fortification programme as a complementary strategy for reducing the incidence of NTDs.

Long-term somatic follow-up of prenatally treated children with congenital adrenal hyperplasia

Prenatal virilization of female fetuses is a serious symptom associated with severe congenital adrenal hyperplasia. In attempt to avoid sexual ambiguity, prenatal treatment of 21-hydroxylase deficiency was initiated in 1984, with the first Scandinavian case treated in 1985. Here we have studied the outcome of prenatal diagnosis and therapy of 44 at-risk pregnancies monitored during the years 1985-1995 in Scandinavia. Treated mothers and children were compared with matched controls. Compared to their elder affected sisters, all 5 girls with severe congenital adrenal hyperplasia who were treated until term showed little virilization. Only 1 required surgery for labial fusion. The majority of the 44 dexamethasone-treated fetuses demonstrated normal pre- and postnatal growth compared to matched controls. However, several adverse events such as failure to thrive and delayed psychomotor development, were reported among the treated infants. In addition, treated mothers reported more side-effects during pregnancy than did controls. A significant increase in weight gain was observed during early pregnancy when treatment was initiated, but this initial rapid weight gain declined during late pregnancy or when treatment was terminated. Thus, experience to date suggests that prenatal treatment of affected female fetuses is generally efficient in minimizing virilization of external genitalia. However, there is still a need to collect more data concerning possible rare unfavorable effects of this therapy on mother and child.

[Minimally invasive techniques make fetal surgery possible. Disabling abnormalities can be corrected]

Increases in our knowledge of the fetus and improved skill in early prenatal diagnosis inevitably result in attempts to treat some of the abnormalities detected. Although most fetal malformations diagnosed prenatally in continuing pregnancies are best managed by medical and surgical intervention after planned delivery, some structural defects may require in utero-treatment to forestall subsequent sequelae. The article consists in a review of the current status of ultrasound-guided invasive fetal therapy, including multifetal pregnancy reduction, manipulation of amniotic fluid, drainage and shunting procedures, fetal transfusion therapy, operative fetoscopy, and in utero stem cell transplantation. Future prospects and developments in this rapidly expanding field are also outlined.

[Successively improved prognosis in erythrocyte immunization]

Prognosis in cases of erythrocyte immunisation has improved continuously over the past decades. Morbidity and mortality have been reduced by improvements in management, including screening programmes, non-invasive ultrasound evaluation and invasive procedures. The article provides an outline of the latest developments in the management of erythrocyte immunisation, and several controversial issues are discussed, such as antibody screening, strategies for the reduction of antibody titres, and the organisation of care.

Stem cell transplantation into the fetal recipient: challenges and prospects

The interest in therapeutic intervention for those inherited disorders that can be diagnosed early in pregnancy has recently intensified. In-utero transplantation of haematopoietic stem cells (IUT-HSC), a therapy which could be proffered before pathological manifestations of a disorder become apparent, offers considerable potential benefit. However, as reports of IUT-HSC procedures become more prolific, it is necessary to consider the optimum modus operandi for each group of disorders targeted for therapy in order to develop effective procedures that make a real difference to the outcome. This review outlines the current status and prospects of IUT-HSC. It also offers a view of some of the challenges for IUT-HSC to overcome to find wider clinical applications.

Amniotic septostomy for the treatment of twin oligohydramnios-polyhydramnios sequence

OBJECTIVE

To report our experience with intentional puncture of the intervening membrane ('septostomy') for the treatment of the twin oligohydramnios-polyhydramnios sequence (TOPS).

METHODS

12 patients were diagnosed with TOPS based on ultrasonographic findings. A 20- to 22-gauge spinal needle was used to puncture the membrane between the twins without any attempt at amnioreduction in 9 patients, while the procedure was combined with amnioreductions in 3 patients.

RESULTS

Gestational age was 23.1 +/- 3.3 weeks at the time of septostomy and 31.1 +/- 4.4 weeks at delivery. Rapid accumulation of fluid around the 'stuck' fetus occurred in all cases following a single procedure. Three of the 24 fetuses died in utero and 1 died on the fifth day of life, for a combined survival of 83.3%. In the survivors, the septostomy to delivery interval ranged between 0.6 and 13 weeks (mean +/- SD 8.3 +/- 4.8).

CONCLUSION

Amniotic septostomy is a promising new method for the management of TOPS and is associated with survival rates that are better than, or comparable to, more invasive modalities. A multicenter trial comparing septostomy to other modalities is warranted.

Fetal therapy: prospects for transplantation early in pregnancy. In utero stem cell transplantation and gene therapy: second international meeting, Nottingham, UK, 1-2 September 1997

The meeting was punctuated by discussion sessions enabling delegates and speakers to debate issues raised. A number of questions were aired and areas that need to be addressed with some urgency were highlighted. Tolerance induction in utero is now considered feasible and can be added to the potential outcomes of IUT. Agreement must be reached on the source of stem cells for IUT, and stem cell banking will need to meet internationally accepted standards. Finally, the transplantation protocol itself must be agreed, a challenge that must be met if IUT is to join the mainstream of therapeutic protocols.

[Prenatal diagnosis and treatment of adrenogenital syndrome. Prevent virilization of female fetuses]

Congenital adrenal hyperplasia (CAH) is the common name of a constellation of diseases that impair cortisol synthesis in the adrenal cortex. As defects in each of three steroidogenic enzymes, 21-hydroxylase, 11 beta-hydroxylase, and 3 beta-hydroxysteroid dehydrogenase, promote overproduction of adrenal androgens, affected female fetuses may be virilised. The major cause of CAH is 21-hydroxylase deficiency, the incidence of which is 1:10,000 live births in the Swedish population. Of the 10-15 children born in Sweden each year with 21-hydroxylase deficiency, 3-5 will be virilised girls who must undergo traumatic surgery of the external genitalia. This can be prevented by administration of dexamethasone to the gravida during pregnancy. Prenatal treatment was introduced in Sweden in 1985, prenatal diagnosis being based in most cases on direct mutational analysis using allele-specific PCR on DNA from chorionic villus samples. In our experience, genotype corresponds well to phenotype, and we recommend that all children with 21-hydroxylase deficiency be genotyped in order to prepare the family for rapid and reliable prenatal diagnosis and possible treatment when the next child is awaited. Since 1985, 35 women have received prenatal treatment in Sweden, six of the 35 fetuses being found to be affected females and treated until term. As compared with their older sisters, all of these six girls were characterised by no signs, or only minor signs, of virilisation, and only one required surgery because of labial fusion and recurrent urinary tract infections. As a group, the 35 infants were characterised by normal birth weight and length, and normal growth during the first year of life. Passage of developmental milestones was normal though several adverse events, both in treated mothers and infants, have been reported. Approximately one fourth of the women treated throughout pregnancy reported some side-effect (e.g., excessive weight gain, severe cutaneous striae, mood fluctuations and irritability, acne and hirsutism, or oedema). One unaffected boy, treated for seven weeks, was born with severe hydrocephalus and agenesis of the corpus callosum; two affected sisters and one unaffected girl were characterised by failure to thrive during the first year of life, but later recovered (one of the affected sisters was later diagnosed as suffering from mitochondrial disease). Although in our experience prenatal treatment with dexamethasone is effective in preventing virilisation of girls with 21-hydroxylase deficiency, some adverse events have been noted in treated infants. As it remains unknown whether these events were attributable to the treatment, it must still be regarded as experimental, and its use should be centralised and meticulously monitored until more experience has been gained.

Prenatal diagnosis in Sweden: organisation and current issues

Invasive prenatal diagnosis was introduced in Sweden in the early 1970s and is an integral part of the public health care system. Funding is provided by taxation; the patient only pays a consultation fee. Genetic analyses on a broad range of cytogenetic and molecular disorders are performed at the 6 university-affiliated hospitals and in 1 county hospital. About 6% of all newborns have been cytogenetically screened during pregnancy, and about 90% of the analyses are performed after amniocentesis. The main indication is chromosome analysis because of advanced maternal age.

In utero haematopoietic stem cell transplantation: current perspectives and future potential

In utero transplantation (IUT) of haematopoietic cells is a new therapeutic option for families with increased risk of having a child with an inherited disorder. Immunological naiveté and the rapidly expanding haematopoietic system in the first trimester human fetus, make therapeutic intervention by IUT a real possibility for those disorders which can be diagnosed early in gestation. Fewer cells are required than in postnatal BMT and therapy can be offered before the pathological sequelae of a disorder become manifested. However, only a few cases of IUT have been performed in humans and it is imperative that consensus is reached quickly on issues such as cell numbers/cell types so that the benefits of this approach to treatment can be realised. This review presents the current status of IUT, the cases thus far recorded and offers a prospective view of developments in this rapidly expanding area.

Monosomy 1p36.31-33-->pter due to a paternal reciprocal translocation: prognostic significance of FISH analysis

A rare monosomy 1p36.31-33-->pter was found in a child with physical anomalies, psycho-motor retardation, and seizures. Cytogenetic investigation suggested an unbalanced translocation between 1p and an acrocentric chromosome, but the rearrangement was difficult to assess accurately using conventional chromosome banding techniques. The half-cryptic translocation was further characterized using fluorescence in situ hybridization, and the aberrant chromosome 1 was shown to be a derivate of a paternal reciprocal translocation t(1;15) (p36.31-33;p11.2-12). The breakpoints on chromosome 1 and 15 were defined in detail using locus specific probes. The rearrangement did not include the region on chromosome 1p which previously has been suggested to predispose to the development of neuroblastoma in a case with a constitutional translocation. At 3 6/12 years, the patient has no clinical signs of this disease, which illustrates the prognostic significance of this investigation.

The utilization rate and pregnancy outcome of multifetal pregnancy reduction in the Nordic countries

OBJECTIVE

To review the utilization rate and pregnancy outcome of multifetal pregnancy reductions (MFR) in the Nordic countries during the period January 1986-June 1992.

STUDY DESIGN

All centers offering assisted conception in Denmark, Finland, Norway and Sweden were retrospectively surveyed by means of a questionnaire with regard to the number and methods used for MFR, pregnancy loss and the outcomes of the pregnancies. The response rate was 100%.

RESULTS

During the period studied, 185 births of triplets or higher multiples occurred in Sweden, 120 in Finland and 102 in Denmark. MFR was performed in 42 women (Sweden 26, Finland 10, Denmark 6) but not in Norway at all. This gives an estimated average utilization rate of 1/7 multiple births of three or more in Sweden, 1/17 in Denmark and 1/12 in Finland. The most frequently used method was intracardiac or intrathoracic injection of a potassium chloride solution in gestational weeks 9-12. One pregnancy was reduced from seven to four fetuses, two from five to three, 10 from five to two, one from four to three, 17 from four to two, one from four to one, five from three to two, four from three to one and one from two to one. Nine (21%) pregnancies terminated in a spontaneous abortion within one week (n = 2) to several weeks (n = 7) after the procedure. Of the remaining 33 (79%) pregnancies which continued to delivery, two fetuses died in utero in the second trimester, three infants died perinatally and one child had transverse limb reduction defects. A successful pregnancy defined by the discharge home of at least one infant occurred in 79% of the cases.

CONCLUSION

This study gives national estimates on the utilization rate of MFR. Although MFR is performed more frequently in Sweden than in Denmark and Finland, the overall figures remain low in the Nordic countries. The incidence of pregnancy loss in this study is somewhat higher than in several larger reported series, probably reflecting the learning curve of the procedure. It seems reasonable that MFR should be performed in only a few centers in the Nordic countries.

Concentrations of mercury, cadmium and lead in brain and kidney of second trimester fetuses and infants

The concentrations of mercury (Hg), cadmium (Cd) and lead (Pb) in brain (cerebrum) and kidney during fetal (second trimester terminations or abortions, n = 20) and postnatal (infants deceased before three months of age, n = 15) development have been studied. Information on possible sources of exposure was obtained from the mothers of the fetuses, but not from those of the infants. The median concentration of Hg in the brain was 4 micrograms/ kg wet weight in both fetuses and infants (total range < or = 2-23 micrograms/kg). The concentrations of Hg in the kidneys were significantly higher than in brain, median of Hg 6 micrograms/kg (range < or = 5-34 micrograms/kg) in fetuses and 10 micrograms/kg (< or = 7-37) in infants. There was a tendency of increasing concentration of Hg in the fetal kidney, but not in the brain, with increasing number of amalgam fillings in the mothers. The concentration of Cd in the brain was less than 1 microgram/kg in most cases, both in fetuses and infants. The concentration of Cd in the kidneys was significantly higher, with a median of about 2 micrograms/kg (1-8 micrograms/kg) in both groups. There was no detectable association between tissue Cd concentrations and the smoking habits of the mothers. The concentration of Pb in brain was below 10 micrograms/kg in most cases. In the kidneys, the concentrations of Pb were significantly higher, with a median of 12 micrograms/kg in the fetuses (range < or = 6-20 micrograms/kg) and 15 micrograms/kg (< or = 9-36 micrograms/kg) in the infants. In general, the concentrations of Cd and Pb were lower than in previously reported studies.

Lack of evidence of permanent engraftment after in utero fetal stem cell transplantation in congenital hemoglobinopathies

The use of fetal hematopoietic stem cells for in utero transplantation to create permanent hematochimerism represents a new concept in fetal therapy. In one fetus with alpha-thalassemia, one with sickle cell anemia, and one with beta-thalassemia, we have transplanted fetal liver cells obtained from legal abortions in gestational weeks 6-11. The fetus with alpha-thalassemia was transplanted twice during pregnancy, in the 15th (20.4 x 10(8) cells/kg) and in the 31st weeks of gestation (1.2 x 10(8) cells/kg), and is now two years of age. One fetus with sickle cell anemia received its transplant in the 13th week of gestation (16.7 x 10(8) cells/kg), and is now one year old. The fetus with beta-thalassemia was transplanted in 18th week (8.6 x 10(8) cells/kg), and is now three months old. Engraftment was evaluated by chromosomal analysis (sex chromosomes), red cell phenotyping, HLA class I and II typing, and PCR (polymerase chain reaction) for Y chromosome-specific sequences and DNA polymorphisms in cord and peripheral blood. The children with alpha- and beta-thalassemia underwent bone marrow aspirations at 3 and 7 months of age, respectively. In neither of these cases were we able to detect convincing evidence of stem cell engraftment. Thus, the administration of fetal stem cells to fetal recipients after the 12th week of gestation did not result in permanent hematochimerism. It remains to be determined whether the engraftment process can be promoted by earlier transplantations and/or higher cell doses.

Swedish survey on extra structurally abnormal chromosomes in 39 105 consecutive prenatal diagnoses: prevalence and characterization by fluorescence in situ hybridization

During 7 years (1985-1992), 39,105 consecutive prenatal diagnoses (34,908 amniocenteses and 4197 chorionic villus samples) were made at the five largest clinical genetic laboratories in Sweden. Thirty-one cases of extra structurally abnormal chromosomes (ESACs) were found, giving a total prevalence of 0.8 per 1000. Twelve ESACs were inherited, 14 were de novo and in five the parental origin was unknown. This gives an estimated prevalence of 0.3-0.4 per 1000 for familial and 0.4-0.5 per 1000 for de novo ESACs. Retrospectively, the ESACs were characterized by fluorescence in situ hybridization (FISH). In nine cases, no material was available for this analysis. In 21 of the remaining 22 cases, the chromosomal origin could be identified by FISH. Seventeen of these (81 per cent) were derived from the acrocentric chromosomes, of which 13 originated from chromosome 15 (62 per cent). The most common ESAC was the inv dup(15) (57 per cent). Two cases were derived from chromosome 22, one from chromosome 14, and one from either chromosome 13 or chromosome 21. The four remaining cases consisted to two i(18p)s and two small ring chromosomes derived from chromosomes 4 and 19, respectively.

Screening of fetal stem cells for infection and cytogenetic abnormalities

Fetal stem cell transplantation may rely on material from therapeutic abortions. It is essential that the stem cell transplant does not transmit any microorganisms that may affect the fetus and that genetically abnormal cells are avoided. To evaluate such contamination, human fetal stem cells collected February 1992 - December 1993 were analyzed for bacterial and fungal growth, and the placentas were karyotyped. Four samples of 70 were positive for different pathogens. Serological screening of 43 women during this period resulted in five seroconversions and revealed one carrier of anti-HCV. Karyotyping revealed two abnormal findings out of 72 samples. Thus, the concept of using material from therapeutic abortions is safe.

Direct and inverted reciprocal chromosome insertions between chromosomes 7 and 14 in a woman with recurrent miscarriages

We present the first case of direct and inverted reciprocal chromosome insertions between human chromosomes 7 and 14, ascertained because of repeated spontaneous abortions. Prometaphase GTG banding analysis showed the karyotype to be 46, XX, inv ins (7;14)(7pter-->7q11.23::14q32.2-->14q 22::7q21.2-->7qter), dir ins(14;7)(14pter-->14q 22::7q11.23-->7q21.2::14q32.2-->14qter). Origins of the insertion have been confirmed by chromosome painting with libraries specific for chromosomes 7 and 14 using fluorescence in situ hybridization.

Multifetal pregnancy reduction in Sweden. Utilization rate and pregnancy outcome (1986-1992)

All departments of Obstetrics and Gynecology, as well as all private clinics in Sweden offering assisted conception, were surveyed by means of a questionnaire to determine the utilization rate and outcome of multifetal pregnancy reduction (MFR) for the period 1 January 1986 to 30 June 1992. The response rae was 100%. Multifetal reduction was performed in 26 women, giving an average utilization rate of 1/7 multiple births of three or more for the entire period. Of the various techniques used, intracardiac or intrathoracic injection of a potassium chloride solution was predominant. The experience of each center with multifetal reductions varied between one and six procedures. In this series, the overall complete pregnancy loss was 27% (n = 7). In 73% (n = 19) of women the pregnancy continued to delivery. One fetus died in utero in the second trimester, one child died from a subtentorial hemorrhage perinatally, and one child had a malformation of the right foot and hand. It seems necessary to limit MFR to a few centers in Sweden in order to maintain and increase the experience of the operators involved, and to decrease the fetal loss rate associated with the procedure. However, the ultimate goal is to make these procedures unnecessary when methods of avoiding excessive ovulation are refined and by limiting the number of replaced embryos in IVF-treatment.

Establishment of a tissue bank for fetal stem cell transplantation

STUDY OBJECTIVE

To analyse the yield of fetal liver tissue in first trimester abortions and to evaluate the number of nucleated cells obtained from each fetal liver during the sixth to twelfth week of gestation.

DESIGN

Prospective descriptive study:

LOCATION

University Hospital.

MATERIAL

Women seeking abortion during a 12 month period 1992/1993.

RESULTS

Out of 1271 women seeking abortion, 152 were asked whether they were willing to donate fetal tissue for fetal transplantation. Of these women, 105 (69%) accepted the proposal and underwent a modified low suction vacuum curettage. Fetal liver tissue was obtained in 61 (58%) of these procedures. The frequency at which tissue was retrieved was strongly related to gestational age and rose from 29% in week 6 to 79% in the tenth to twelfth week of gestation. The mean number of nucleated cells obtained from each fetal liver demonstrated a concomitant increase with gestational age, rising from 16 to 43 x 10(6) per liver during these weeks of gestation. Of the 61 cases in which fetal liver was obtained, four subjects were shown to be abnormal by laboratory analyses and 11 did not alter the mandatory follow-up appointment. This left 46 cases for use in the program of fetal to fetal transplantations.

CONCLUSIONS

Most women seeking abortion seem to be in favor of the idea of fetal tissue donation for the treatment of other fetuses. The possibility of obtaining fetal liver tissue and the number of fetal stem cells retrieved are closely correlated to gestational age. A tissue bank appears to facilitate the operation of a fetal to fetal stem cell transplantation program.

Complex genetic counseling and exclusion of Duchenne muscular dystrophy in a twin pregnancy after in vitro fertilization (IVF)

A twin pregnancy following in vitro fertilization-embryo transfer coincidentally at risk for the X-linked recessive Duchenne muscular dystrophy is described. First-trimester prenatal diagnosis by transabdominal chorionic villus samplings on the dichorionic placentae and molecular linkage analysis could exclude the disorder in both fetuses. Genetic counseling and prenatal diagnosis were particularly complex due to the twin pregnancy, the need for linkage analysis, and confined placental mosaicism 45,X/46XX in one of the fetuses. All parties should be aware that additional invasive diagnostic procedures in the second trimester might be required. It is proposed that, in similar situations, only one, arguably two, fertilized egg be transferred at a time to facilitate prenatal diagnosis and decision making for these rare couples. This problem, however, may be increasingly overcome by preimplantation diagnosis.

Characterization of supernumerary ring marker chromosomes by fluorescence in situ hybridization (FISH)

Five cases with small supernumerary ring chromosomes are characterized at the molecular level. Routine chromosome banding analysis was insufficient for identification of the ring chromosomes, and none of them was DA/DAPI positive. Fluorescence in situ hybridization utilizing repetitive centromeric probes for all chromosomes has determined that one of these five ring chromosomes originates in each of chromosomes 4, 7, 8, 9, and 20. Chromosome painting with chromosome-specific libraries has confirmed this and excluded the involvement of additional chromosomes in the rearrangements.

Prenatal diagnosis of distal arthrogryposis type I by ultrasonography

Two consecutive pregnancies in a woman with initially undiagnosed type I distal arthrogryposis (DA) are reported. A prenatal diagnosis of the condition was made by ultrasound in the 17th week of gestation in one of the pregnancies, whereas in the subsequent pregnancy the disorder was excluded as early as 13 weeks' gestation. The diagnoses were verified at birth. The feasibility of prenatal diagnosis of DA type I in the second trimester is thus confirmed and its possibility in the late first trimester is suggested.

Prenatal investigation of a 45,X/46,X,r(?) karyotype in amniocytes using fluorescence in situ hybridization with an X-centromeric probe

The karyotype of cultured amniotic fluid cells obtained on the indication of advanced maternal age was shown to be a mosaic 45,X/46,X,r(?). The small size and banding pattern made it difficult to determine whether the ring was derived from and X or a Y chromosome, or even from an autosome. By using an X-centromeric probe and fluorescence in situ hybridization (FISH), we demonstrated the ring to have an X centromere. Thus, a more complete genetic counselling was possible. This confirms the usefulness of FISH in identifying and characterizing this and other chromosome rearrangements in prenatal diagnosis.

Color Doppler studies in trophoblastic tumors: a preliminary report

Ten women, referred because of a strong suspicion of gestational trophoblastic neoplasia, were examined by abdominal real-time ultrasound and color Doppler. The results were compared to those of pelvic angiography. In all but one case color Doppler examination revealed areas of increased vascularity. In all cases the findings of color Doppler and pelvic angiography agreed. Real-time ultrasound failed to detect abnormal uterine echoes in three of the patients where the other methods indicated tumor. The present study indicates that color Doppler could be of great value in a non-invasive assessment of trophoblastic tumors.

European collaborative study on prenatal diagnosis: mosaicism, pseudomosaicism and single abnormal cells in amniotic fluid cell cultures

A report is given of the results of a European collaborative study on mosaicism, pseudomosaicism and single abnormal cells in amniotic fluid cell cultures. The mean frequency of cases with mosaicism was 0.10 per cent, with pseudomosaicism 0.64 per cent and with single abnormal cells 2.83 per cent in a series of 44 170 amniotic fluid samples. There was no significant difference between the colony (in situ) and the flask method with regard to the frequency of mosaicism. Pseudomosaicism and single abnormal cells were more frequent in cases studied with the flask method probably due to other factors than the method of cultivation of the cells. The frequency of maternal cell contamination was 0.17 per cent and the frequency of wrong sex assignment was 0.11 per cent. A more correct estimation is obtained if these frequencies are doubled. There was a considerable variation between laboratories with regard to the frequencies given above. One reason for this variation is that there are no sharp limits between mosaicism, pseudomosaicism and single abnormal cells. Thus the material contained cases diagnosed as having pseudomosaicism which turned out to be mosaics at birth and to have an abnormal phenotype. These cases were very rare but pose a definite problem in prenatal cytogenetic diagnosis.

Prenatal diagnosis of chondroectodermal dysplasia with fetoscopy

Chondroectodermal dysplasia (Ellis-van Creveld syndrome) has previously been diagnosed prenatally only once, using fetoscopy. We report on two consecutive pregnancies in a woman at risk of having a child with the syndrome during which fetoscopic visualization was performed. Ellis-van Creveld syndrome was diagnosed prenatally in one instance, while it could be excluded in the other one. Non-invasive prenatal diagnosis of the syndrome is discussed.

The 11q;22q translocation: a collaborative study of 20 new cases and analysis of 110 families

Following a previous collaborative study (Fraccaro et al. 1980), 20 new cases of 11q;22q translocation are described. Twelve families were ascertained through an unbalanced carrier of the translocation and eight cases were ascertained as balanced carriers. A segregation analysis was performed on the 110 families so far published. It was concluded that the 11q;22q translocation is a relatively frequent event, and that all the cases thus far reported might have the same breakpoints at 11q23.3 and 22q11.2. The translocation seems to be independent of environmental factors and it seems to have a low rate of mutation as indicated by the scarcity of de novo cases. The new data confirmed that only one type of unbalanced karyotype (47,XX or XY+der(22)t(11;22)(q23.3;q11.2)) is found among the offspring of the translocation carriers. The minimal overall recurrence risk for an unbalanced translocation was estimated to 2%. There was no difference between the recurrence risks for male and female balanced carriers, while the trend was confirmed of an excess of female balanced carriers among the phenotypically normal offspring of the t(11;22) female carriers.

Dyggve-Melchior-Clausen dysplasia. Morphological and biochemical findings in cartilage growth zones

The results of light and electron microscopic examination and of biochemical proteoglycan studies of costochondral and iliac crest biopsies from a recently diagnosed case of Dyggve-Melchior-Clausen dysplasia are reported. At light microscopy of resting cartilage large lacunae containing clusters of five or more chondrocytes were seen in some areas. In the hyaline cartilage there were scattered fibrous foci but no mineralized areas. Electron microscopy revealed chondrocytes containing widened cisternae of rough endoplasmic reticulum and vesicles coated with a smooth single-layered membrane. The content of the cisternae and of the vesicles was amorphous. Throughout the cartilage a considerable proportion of the chondrocytes displayed more or less pronounced necrobiotic changes. The biochemical analysis showed an increased amount of glucosaminoglycans in the cartilage and indicated that the ability of proteoglycan monomers to reaggregate to hyaluronic acid chains was decreased. Our findings support the suggestion that Dyggve-Melchior-Clausen dysplasia is due to a disturbance in proteoglycan metabolism.

A familial pericentric inversion of chromosome 8 analysed with a high resolution chromosome banding technique

A familial pericentric inversion of chromosome 8 is described. The break points were localized by a high resolution chromosome banding technique and found to be inv(8)(p23.108q12.100). None of the family members had an unbalanced product of the inversion. There were no phenotypical abnormalities in the carriers. The break points and segregation pattern are compared with those of previously reported pericentric inversion of chromosome 8.