Carcinoembryonic antigen in amniotic fluid

Carcinoembryonic antigen (CEA), a substance which is known to occur in high amounts in the fetal gut and also in certain tumors of the gastrointestinal tract, has been demonstrated in amniotic fluids from different stages of pregnancy. Radioimmunoassays of CEA in amniotic fluids of 91 normal pregnancies showed a decrease from a mean of 53 ng/ml at 19 weeks to 25 ng/ml at the end of gestation. The CEA activity in amniotic fluid was eluted in the same volume as a standard 125I-CEA on a Sephadex G200 column. Amniotic fluid therefore contains CEA similar in molecular weight to the CEA purified from liver metastases of colonic cancer. Among 17 cases of abnormal pregnancies, CEA elevations were observed in five with anomalous fetuses.

Ferastral, an iron-poly (sorbitol-gluconic acid) complex, in the treatment of severe iron-deficiency anaemia in pregnancy

Thirteen pregnant women with iron-deficiency anaemia have been treated with Ferastral. In a further seven women, Ferastral was given 24 hours before delivery, when induction of labour was indicated, to investigation of iron concentration in maternal serum, cord blood and amniotic fluid simultaneously. The efficacy of Ferastral was demonstrated by a significant increase in haemoglobin and haematocrit. No serious reactions occurred and no evidence was found of disturbance of liver or renal function. It was shown that Ferastral does not pass the placental barrier and that no direct transport takes place through the uterine wall or amnion. No effects on the newborn were demonstrated.

Vorbeugende Behandlung des Atemnotsyndroms des Neugeborenen durch antepartale Glukokortikoidgabe (Betamethason)

Betamethason was administered to 105 patients with threatened premature labour at risk for respiratory distress syndrome (RDS) of the newborn. The most important indications were premature rupture of the membranes (30%) and premature labour (40%). The betamethason treatment was given between the 27. and 35. week of gestation. 79% of the patients delivered prior to 36 weeks of gestation, over 50% prior to 34 weeks gestation. The total incidence of RDS was 25%. Severe types of RDS (stage III and IV) were rare (7%). The mortality of RDS after betamethason treatment was 5.4%. After 32 weeks gestation the mortality from RDS was 0%. Severe types of RDS appear to occur more often in male than in female infants. The incidence of RDS was not lowered further by premature of the membranes. The lecithin/sphingomyelin(L/S)-ratio in the amniotic fluid following treatment with betamethason increased to over 2 in only 2/3 of the cases. The predictive value of the L/S ratio that respiratory distress syndrome of the newborn only occurs rarely with values over 2 was maintained after treatment with betamethason. Our rate in cases with an L/S ratio over 2 was 7.9%.

Inherited metabolic disease: prospects for the future in both basic and clinical research

The birth of a child with an inherited disorder is often the beginning of a life-long problem for the whole family. About 8.5% of paediatric deaths and 4.7% of paediatric hospital admissions are due to autosomal and sex-linked recessive diseases. These figures are likely to be erroneously low because of incomplete ascertainment. The inherited metabolic diseases therefore merit study on economic as well as humanitarian grounds. Investigations of the disorders of purine metabolism have been conducted for more than a century and a half in the borderland between biochemistry and medicine, illuminating both disciplines and reflecting their separate developments. These studies are a general model for work in other branches of human intermediary metabolism. It is hoped that the basic study of the inborn errors or metabolism will expand our knowledge of the defective gene and of its product, the enzyme protein. Clinical studies should aim to improve the prenatal, postnatal and carrier-state diagnosis of these disorders, and to improve their treatment by methods which can be made practicable and generally available at the clinical level. There may be some hope for enzyme replacement in certain circumstances. The prospect for genetic modification at the clinical level is almost infinitely far away, where many would say that is should remain.

Fetal cardiovascular reactions during labour and asphyxia modified by adrenergic receptor agonists and antagonists

In the human fetus the adrenergic system develops morphologically at an early stage. The development of adrenergic receptors occurs to a large extent before birth. The human fetus is capable of a large production of catecholamines, particularly during the last two months of fetal life. Normal labour and delivery elicits an increased release of catecholamines, a reaction that is markedly enhanced by asphyxia. beta-Receptor stimulants not only relax the uterine smooth muscle but also tend to modify the concentration of surfactant in lung fluid. beta-Receptor blocking agents, both non-selective and cardioselective, create a problem in clinical medicine since they provide an effective means of treating hypertension in pregnancy. Theoretical implications of such treatment present a risk to the fetus. Experimental evidence from the fetal sheep preparation indicate that beta-receptor blockade carriers an immediate risk to the severely asphyxiated fetus when the blockade is induced acutely. In this situation heart muscle contractility, heart rate and cardiac output fall abruptly while the capacity for anaerobic glycolysis is greatly diminished. Even though such acute animal experiments are far removed from clinical practice the results suggest that great caution should be exercised in the use of adrenergic blocking agents in obstetric practice.

Fetal cortisol and the initiation of labour in the human

The role of the fetal adrenal activity in the initiation of parturition in the human has been investigated. Women were studied in the last trimester of pregnancy during treatment with betamethasone for prevention of the idiopathic respiratory distress syndrome. Although betamethasone caused a considerable drop in the cortisol concentrations of fetal plasma and amniotic fluid, the time to spontaneous delivery in this group was similar to that in matched controls. Moreover, cortisol in fetal scalp blood at the onset of parturition in untreated women did not differ between those with spontaneous and those with induced labour. Evidence is given that increase of circulating cortisol in the fetus during the course of parturition predominantly reflects a rise in maternal cortisol under the influence of labour. The strain of labour seems to partly override the betamethasone-induced inhibition of maternal cortisol release. The possible ability of the fetal adrenals to respond to stimuli is illustrated by comparison of cortisol concentrations in cord plasma after various forms of complicated deliveries.

The genesis of amniotic fluid infections

Amniotic fluid infections manifested by an inflammatory response in the extraplacental membranes and subchorionic plate of the placenta are a common phenomenon thought to be due in most cases to ascending bacterial infections via intact membranes. Fatal spread to the fetus is much less common and more likely to occur in underprivileged communities. The probable reasons are nutritional deprivation in the mother or both, leading to production of a liquor with diminished ability to suppress bacterial growth. Zinc is one component of the antibacterial system but liquor levels of zinc vary widely and inconsistently with antibacterial activity. Dietary supplementation with zinc did not improve antibacterial activity of liquors in a population with diminished liquor antibacterial activity and large number of fatal infections. Other factors in the genesis of amniotic fluid infections may be interference with normal defence mechanisms as a result of coitus in late pregnancy and vaginal infections with Trichomonas vaginalis. Socioeconomic factors may play a role apart from their association with maternal nutrition, through diminished hygiene associated with insufficient use of water and insufficient availability and use of medical facilities.

Der vorzeitige Blasensprung: Falldarstellung einer schweren intrauterinen Pilzinfektion

A case of extremely rare intra-uterine candida infection is reported following premature rupture of the membranes. The diagnostic possibilities by transabdominal amniocentesis and determination of the causative organism in the amniotic fluid are presented. Even systemic antimykotic treatment is not capable of treating intra-uterine candidiasis sufficiently. This is proved among other parameters by the concentration of miconazol in the amniotic fluid and in the plasma of the newborn.

Fetal lung maturity assessment by a modified A650 determination

This paper presents an evaluation of a modified absorbance method for estimating fetal lung maturity. Absorbance at 650 nm in combination with a two-step centrifugation procedure was used in an attempt to focus more directly on lamellar bodies and evaluate the contribution of residual absorbance due to non-lamellar body materials. Absorbance values after centrifugation at 250 X g for 5 minutes (A250) and 10,000 X g for 20 minutes (A10,000) were taken as estimates of total absorbance due to lamellar bodies plus non-lamellar body material and that due to non-sedimentable, non-lamellar body material respectively. These values were used to generate two new parameters: delta A (A250-A10,000), to better estimate absorbance due to lamellar bodies, and %A (delta A/A250 X 100), to express lamellar body absorbance in terms of total observable absorbance and thereby minimize effects of dilution. The three parameters (A250, delta A, %A) were used in combination to create a battery (ABatt) of absorbance values for each fluid sample. Absorbance after centrifugation at 2,000 X g for 10 minutes (A2,000), a widely used standard method, was also evaluated for purposes of comparison. A250 was designated as mature if greater than or equal to 0.350, delta A was called mature if greater than or equal to 0.250, and %A was considered mature if greater than or equal to 75%. If any of the parameters was immature, ABatt was called immature. The range of values for A250, A2,000, and A10,000, increased with gestational age in the total population as well as the corrected population (excluding amniotic fluid contaminants, and pregnancies with isoimmunization or diabetes.(ABSTRACT TRUNCATED AT 250 WORDS)

Infants of diabetic mothers with accelerated fetal growth by ultrasonography: are they all alike?

We studied longitudinal ultrasonographic growth patterns (abdominal circumference, biparietal diameter) initiated early in gestation in 52 pregnancies complicated by pregestational diabetes mellitus and 19 controls. Three predominant patterns of growth were ascertained including a heretofore unrecognized pattern characterized by accelerated abdominal circumference growth (greater than 90th percentile) before 24 weeks' gestational age. Maternal and neonatal anthropometric and metabolic parameters were contrasted for the three patterns. The findings suggest that in some cases of diabetic macrosomia that can be recognized before 24 weeks' gestation, augmented growth may be influenced by factors other than fetal hyperinsulinism.

Intrauterine diagnosis and treatment of fetal goitrous hypothyroidism

Newborn screening programs for the detection of congenital hypothyroidism have dramatically shortened the time before treatment is begun. However, concern still exists about central nervous system sequelae which may persist due to a period of untreated intrauterine hypothyroidism. Presence of polyhydramnios led to the ultrasound diagnosis of a fetal goiter. Hypothyroidism was confirmed at 34 weeks gestation by percutaneous fetal blood sampling, which revealed an elevated TSH (186 mU/L) and a low T4 (19.3 nmol/L). Intraamniotic fluid injections of 500 micrograms levothyroxine sodium (T4) every 10-14 days increased fetal serum T4 (59.2 nmol/L), decreased fetal serum TSH (14 mU/L), decreased amniotic fluid TSH, and decreased the size of the fetal goiter. The infant was born at term without perinatal complications. Thyroid function studies on cord blood were normal (T4, 109.4 nmol/L; TSH, 1.3 mU/L), and the infant was discharged on oral T4. Follow-up examination at age 6 weeks revealed that the infant was developmentally normal and clinically and chemically euthyroid. Intrauterine T4 therapy can suppress fetal TSH and treat fetal hypothyroidism despite hypothyroid levels of serum T3. Highly sensitive TSH assays may allow the use of amniotic fluid TSH as a marker for fetal hypothyroidism.

Amniotic fluid glucose concentration: a rapid and simple method for the detection of intraamniotic infection in preterm labor

The purpose of this study was to determine whether amniotic fluid glucose concentrations is of value in the rapid diagnosis of intraamniotic infection. Amniocenteses were performed in 168 patients with preterm labor and intact membranes. Amniotic fluid was cultured for aerobic and anaerobic bacteria, as well as Mycoplasma species. The prevalence of positive amniotic fluid cultures was 13.6% (23/168). Patients with positive amniotic fluid cultures for microorganisms had significantly lower median amniotic fluid glucose concentrations than patients with negative amniotic fluid cultures (median 11 mg/dl, range 2 to 30 mg/dl vs median 28 mg/dl, range 3 to 74, respectively; p less than 0.001). Amniotic fluid glucose concentrations below 14 mg/dl had a sensitivity of 86.9% (20/23), a specificity of 91.7% (133/145), a positive predictive value of 62.5% (20/32), and a negative predictive value of 97.8% (133/136) in the detection of a positive amniotic fluid culture. Amniotic fluid glucose determination is a rapid, sensitive, inexpensive, and simple test for the detection of intraamniotic infection in women with preterm labor and intact membranes.

Transcapillary permeability and subendothelial distribution of endothelial and amniotic fluid insulin-like growth factor binding proteins in the rat heart

Insulin-like growth factor (IGF) binding proteins (IGFBP) were purified from conditioned media of cultured bovine endothelial cells (ECBP) and from human amniotic fluid (IGFBP-1), and then labeled by radioiodination. 125I-ECBP and 125I-IGFBP-1 were perfused through isolated beating rat hearts for 1 and 5 min, and the hearts fixed and analyzed for 125I-BP content and distribution. One to 4% of the perfused 125I-ECBP and 125I-IGFBP-1 crossed the capillary boundary. The ECBPs predominantly localized as intact 125I-BP in connective tissue elements of the heart with less 125I-BP in cardiac muscle. The ratio of 125I-ECBP in connective tissue: muscle (normalized to percent vol of these compartments) was greater than or equal to 10:1. In contrast, the IGFBP-1 had a greater affinity for cardiac muscle with ratios of 125I-IGFBP-1 in connective tissue:muscle of approximately 1:2. When 125I-IGF-I, in the absence of any BPs, was perfused through the hearts approximately 3-5% left the microcirculation and was found in subendothelial tissues. 125I-IGF-I localized primarily to cardiac muscle with a distribution of connective tissue:cardiac muscle of about 1:3. The findings in the isolated perfused heart were confirmed in intact animals. After 125I-IGFBP-1 was injected into anesthetized rats and allowed to circulate for 5 min, substantial radioactivity was associated with the heart. As in the isolated heart, the IGFBP-1 preferentially localized to cardiac muscle with a connective tissue:cardiac muscle ratio of 1:3. We conclude that IGFBPs produced by endothelial cells and the IGFBP-1 contained in amniotic fluid can cross the capillary boundaries of the rat heart, and that the ECBPs preferentially localize in connective tissue elements of the myocardium, whereas IGFBP-1 predominantly localizes in cardiac muscle.

The relationship between maternal serum and amniotic fluid alpha-fetoprotein in women undergoing early amniocentesis

alpha-Fetoprotein levels were measured on 148 paired samples from the maternal serum and amniotic fluid in women greater than or equal to age 35, who were undergoing early amniocentesis (12 to 14 weeks) for chromosomal analysis. These 148 women were white, weighed less than 200 pounds, had no serious medical problems, and did not have a fetal abnormality detected by ultrasonography or karyotype analysis. There was a significant rise in the maternal serum alpha-fetoprotein concentration from 12 to 14 weeks' gestation. Amniotic fluid alpha-fetoprotein peaked at 13 weeks and then significantly declined by 14 weeks' gestation. Similar to reports from normal pregnancies at 16 and 17 weeks, we found no correlation between the maternal serum and amniotic fluid alpha-fetoprotein levels between 12 and 14 weeks. Amniotic fluid alpha-fetoprotein levels cannot be predicted by levels in the maternal serum in pregnancies between 12 and 14 weeks' gestation.

Transplacental passage of insulin in pregnant women with insulin-dependent diabetes mellitus. Its role in fetal macrosomia

BACKGROUND AND METHODS

Fetal macrosomia occurs despite nearly normal maternal blood glucose levels in women with diabetes treated with insulin. We examined the hypothesis that it may be caused by insulin transferred as an insulin-antibody complex from the mother to her fetus. We adapted and validated a method based on high-performance liquid chromatography and used it to quantitate insulin in small volumes (0.5 to 1.0 ml) of cord serum from 51 infants born to mothers with insulin-dependent diabetes mellitus.

RESULTS

In mothers receiving only human insulin (n = 6), only human insulin was detected in cord serum. Of the remaining 45 infants, whose mothers received animal insulin during pregnancy, 28 (group 1) had levels of animal (bovine or porcine) insulin (mean [+/- SE], 707 +/- 163 pmol per liter) that constituted 27.4 +/- 2.5 percent of the total insulin concentration (2393 +/- 500 pmol per liter) measured in the cord serum. The cord-serum insulin concentration in the remaining 17 infants (group 2), in whom only human insulin was detected (381 +/- 56 pmol per liter), was only 15 percent of that in group 1 (P less than 0.001). There was a significant correlation between the maternal and the cord-serum concentrations of anti-insulin antibody and the concentration of animal insulin in the baby (r = 0.77, P less than 0.01, and r = 0.76, P less than 0.001, respectively), suggesting that the animal insulin was transferred as an insulin-antibody complex. In group 1 the mean concentration of animal insulin in cord serum was higher in the 12 infants with macrosomia than in the 16 infants without the condition (1113 +/- 321 vs. 402 +/- 110 pmol per liter; P less than 0.05), and the concentration of animal insulin in cord serum correlated with birth weight (r = 0.39, P less than 0.05). The maternal glycosylated hemoglobin values and the incidence of respiratory distress syndrome were similar in groups 1 and 2.

CONCLUSIONS

Considerable amounts of antibody-bound insulin are transferred from mother to fetus during pregnancy in some women with insulin-dependent diabetes mellitus; the extent of transfer correlates with the maternal concentration of anti-insulin antibody. The correlation between macrosomia and the concentrations of animal insulin in cord serum indicates that the transferred insulin has biologic activity and suggests that the formation of antibody to insulin in the mother is a determinant of fetal outcome independent of maternal blood glucose levels.

Amniotic fluid index measurement with the four-quadrant technique during pregnancy

Eleven hundred thirty-four pregnant women with reliable dates underwent ultrasound evaluation for amniotic fluid index (AFI) measurement with the modified four-quadrant technique. We found that from 13 weeks' gestation the AFI rose progressively until 26 weeks. From then to 38 weeks the AFI measurements demonstrated little variation. After 38 weeks the AFI appeared to decline gradually. In the third trimester the mean AFI was 16.0 +/- 4.8 cm; 5% of cases had an AFI less than or equal to 8 cm, and 5% had an AFI greater than or equal to 24 cm. These results confirm the reproducibility of the semiquantitative technique and suggest that in estimating amniotic fluid volume, AFI measurement may be a more appropriate means than measurement of the single largest pocket or subjective assessment. Serial AFI measurement would be an effective way of assessing fetal status throughout pregnancy.

Intrapartum amniotic fluid volume at term. Association of ruptured membranes, oligohydramnios and increased fetal risk

The amniotic fluid index (AFI), a semiquantitative technique for assessing amniotic fluid volume, has been shown to be a useful adjunct in antepartum surveillance. We evaluated the usefulness of the AFI in the early intrapartum period as it relates to subsequent fetal morbidity and fetal heart rate patterns. Two hundred term gravidas presenting in the latent phase of labor with vertex-presenting fetuses were studied. An intrapartum AFI less than or equal to 5.0 cm was associated with a significant increase in the risk of cesarean section for fetal distress and of an Apgar score of less than 7 at one minute as well as abnormal fetal heart rate patterns in late labor. The majority (71.4%) of the patients with an intrapartum AFI less than or equal to 5.0 cm had ruptured membranes on entry; however, there was no significant difference in outcome when they were compared to patients with intact membranes and oligohydramnios. Variable decelerations on entry were associated with oligohydramnios in 43.8% of the patients. An AFI less than or equal to 5.0 cm in the early intrapartum period is a risk factor for perinatal morbidity and abnormal fetal heart rate patterns in subsequent labor, and ruptured membranes in early labor are a risk factor for oligohydramnios.

Amniotic fluid index: an appropriate predictor of perinatal outcome

Qualitative amniotic fluid volume determination is a routine part of the fetal biophysical profile score. Quantitative amniotic fluid volume measurement, however, is not a factor in the determination of the standard biophysical profile score. This study is a retrospective analysis of antepartum assessment of amniotic fluid volumes and their relationship to neonatal outcomes. The amniotic fluid index was calculated for all patients examined and perinatal outcome was studied for all patients assessed. Patients with reduced or increased amniotic fluid volume had a significant increase in meconium-stained amniotic fluid, Apgar scores less than 7 at 1 and 5 minutes, major congenital anomalies, admission to the neonatal intensive care unit, and were more likely to require delivery by cesarean section for fetal distress. This study suggests that a quantitative ultrasound measurement of amniotic fluid volume represents an effective discriminatory test to be used in pregnancy evaluation.

Detection of fetal blood contamination by amniotic fluid obtained during cordocentesis

When a fetal blood sample is obtained by cordocentesis it is important to know whether the sample is diluted with amniotic fluid. This study was designed to assess whether contaminated fetal blood samples could be discriminated from noncontaminated ones by the ferning test, and if so what is the minimum dilution ratio of amniotic fluid/fetal blood that is detectable. Fetal blood samples were diluted with amniotic fluid and were tested for ferning under the microscope after the plasma was separated from the cells. At a dilution ratio of 0.2 ml of amniotic fluid to 1 ml of fetal blood, 30% of the samples tested positive for ferning. A rate of 100% detection of ferning was achieved at a dilution ratio of 0.6:1. In conclusion, screening fetal blood samples for ferning can detect amniotic fluid contamination. The sensitivity of the test for ferning depends on the dilution ratio. The test cannot assess how much amniotic fluid was added to the blood sample.

Analysis of mosaic states in amniotic fluid using the in-situ colony technique

Appropriate counselling and clinical management of the pregnant woman with a mosaic amniotic fluid cell karyotype are difficult. The majority of the data on mosaicism and pseudomosaicism are derived from studies employing the flask technique for the analysis of amniotic fluid cell cultures. Since the majority of laboratories now utilize the in-situ technique, such data may not be relevant when analyzing results from the in-situ colony technique. We reviewed the incidence of mosaicism in 6339 amniotic fluid samples using the in-situ technique. Data are presented on the types of aberrations and clinical outcomes. A classification of mosaicism is presented that distinguishes mosaicism of clinical importance from that which is obviously of extrafetal origin or artifactual. This approach clarifies the significance of mosaic states detected by the in-situ colony technique and provides a rational foundation for genetic counselling and for planning clinical interventions.

Perinatal outcome after recent cocaine usage

Eighty-eight neonates born to mothers with a history of cocaine use during pregnancy were divided into two groups based upon the detection of cocaine metabolites in the first neonatal urine. Forty neonatal urine samples were positive for cocaine and 46 were negative. Preterm labor, premature rupture of membranes, and meconium-stained amniotic fluid were significantly more frequent in those mothers whose neonates tested positive for cocaine metabolites than in those whose infants were negative (P less than .05). Neonates testing positive were more likely to exhibit signs and symptoms of acute cocaine intoxication. Low birth weight, growth retardation, and abruptio placentae were also more frequent than would be expected in the general population, but were not statistically different between the groups. These findings suggest that the differences noted in the cocaine-positive group may represent acute and chronic exposure, whereas the negative group reflects the problems associated with chronic usage alone.

[Purification and characterization of insulin-like growth factor binding proteins (IGF-BP) in amniotic fluid--existence of a 160K IGF-BP]

Human amniotic fluid has been reported to contain 28-34K insulin-like growth factor (IGF) binding protein (32K-AFBP). The existence of 160K IGF-binding protein (160K-AFBP) in amniotic fluid was also demonstrated by affinity labeling studies. In this paper we describe procedures for purification of 160K-AFBP as well as 32K-AFBP from pre-term amniotic fluid and characterize these two binding proteins. IGF binding proteins were purified from batches of 500ml of pre-term amniotic fluid using ammonium sulphate precipitation, anion-exchange chromatography (Q-Sepharose) and Sephacryl S-200 HR chromatography. IGF binding activity during purification was quantitated by incubation with 125I-IGF-I and dextran-coated charcoal separation. The total recovery and purification of binding protein were 38% and 81.5-fold, respectively. The three major binding activities were eluted in fractions corresponding to a relative molecular mass of 160K, 60K and 30K when Q-Sepharose purified AFBPs were chromatographed on Sephacryl S-200 HR at neutral pH. HPLC of purified 160K binding activity on size exclusion column yielded a single peak of absorbance at 280nm, corresponding to an apparent molecular weight of 160K with three predominant peaks of binding to 125I-IGF-I, corresponding to molecular weights of 160K, 79K and 32K, respectively. On the other hand, purified 30K binding activity on HPLC yielded a single peak of absorbance at 280nm, corresponding to an apparent molecular weight of 32K coincident with a peak of binding to 125I-IGF-I. SDS-PAGE of HPLC purified 160K-AFBP in the presence of mercaptoethanol revealed eight bands by Coomassie Blue staining, five major bands corresponding to 160K, 78K, 69K, 54K, and 51K and three weaker bands corresponding to 45K, 36K, and 28K. The HPLC purified 32K-AFBP showed a single band of a molecular mass estimate of 32K on SDS-PAGE. These results indicate that human amniotic fluid contains at least two distinct IGF-binding proteins, and the structure of 160K-AFBP is similar to those of 150K binding protein in the circulation.

Determination of monoamines and indoles in amniotic fluid by high-performance liquid chromatography-electrochemical detection

A technique is presented for the separation and detection in amniotic fluid of various substances associated with catecholamine metabolism. Monoamines and their metabolites were separated using reversed-phase ion-pair high-performance liquid chromatography. Detection and quantification were performed electrochemically. The retention times of 28 standards associated with the monoamines and their precursors and metabolites were evaluated with 14 different eluents. On the basis of the retention times of each standard and the modification of the retention times of the various peaks detected in amniotic fluid, the following substances were identified in this biological fluid: 4-hydroxy-3-methoxyphenylacetic acid, 5-hydroxyindoleacetic acid, 3,4-dihydroxyphenylacetic acid, 4-hydroxy-3-methoxyphenylglycol, epinephrine, 4-hydroxy-3-methoxymandelic acid, octopamine, tyrosine and tryptophan.

Amino acid analysis of physiological fluids by high-performance liquid chromatography with phenylisothiocyanate derivatization and comparison with ion-exchange chromatography

The suitability of pre-column derivatization with phenylisothiocyanate followed by high-performance liquid chromatography was investigated as a means of analyzing free amino acids in plasma and other physiological fluids. A comparison was made between this method and a conventional ion-exchange method. The correlation coefficient for all the amino acids tested was greater than 0.9, except for proline and tryptophan. Various forms of sample preparation were tried for plasma and amniotic fluid; it was finally decided that protein precipitation with acetonitrile was most suitable. Ultrafiltration was used for cerebrospinal fluid preparation while urine was treated the same as a standard mixture. The retention times relative to the internal standard (nor-leucine) are given for over 90 compounds. Some of these were chromatographed underivatized because they are known to be present in some physiological fluids and absorb at 254 nm because of their aromaticity. The imprecision for this method compared favourably with the standard ion-exchange method although each had specific amino acids for which the imprecision was poor. The technique is suitable for the same routine clinical analysis purposes as high-resolution ion-exchange chromatography. It also offers the advantages of speed of analysis, sensitivity and equipment versatility over the conventional ion-exchange methods.

Laboratory measurement of bilirubin

Several methods for determination of total bilirubin and its fractions have been critically discussed. Methods for serum determinations are summarized in Table 1. Because results of direct bilirubin cannot necessarily be equated with conjugated bilirubin, care must be taken in interpreting results from different laboratories, and clinicians are encouraged to become familiar with methods in use at their own institutions. Despite problems reported in the literature, bilirubin determinations, together with a reference range established for one's own patient population, should provide valuable information for patient management.

Direct relationship of antepartum glucose control and fetal erythropoietin in human type 1 (insulin-dependent) diabetic pregnancy

In the present study the antepartum relationship between maternal diabetic glucose control and fetal hypoxaemia was examined in 44 Type 1 (insulin-dependent) diabetic and 23 non-diabetic control pregnancies. Maternal HbA1C was used to assess maternal integrated blood glucose control while fetal metabolic control was evaluated by antepartum glucose, insulin, and C-peptide determinations in amniotic fluid at elective caesarean delivery. Fetal hypoxaemia was assessed indirectly by fetal umbilical vein plasma erythropoietin level at delivery. A prospectively developed statistical pathway model was used to examine the relationship of these variables. In applying forced stepwise multiple regression with this model, we observed in the diabetic subjects that mean maternal HbA1C during the last month of pregnancy correlated significantly with fetal umbilical venous erythropoietin at delivery (r = 0.57, p less than 0.001). Additional significant contributions to umbilical venous erythropoietin were found for amniotic fluid glucose and amniotic fluid insulin when these two independent variables were added in stepwise fashion (p less than 0.01). We conclude that in diabetic pregnancy, antepartum control of maternal hyperglycaemia is a significant factor associated with fetal hypoxaemia. We speculate that this effect is mediated through perturbations which accelerate fetal metabolism and which is expressed by amniotic fluid levels of glucose and insulin.

Increased maternal plasma concentration of endothelin-1 during labor pain or on delivery and the existence of a large amount of endothelin-1 in amniotic fluid

The concentration of endothelin-1 (ET-1) in plasma and amniotic fluid from normal pregnant women was determined by a sensitive sandwich-enzyme immunoassay system, established recently. The plasma ET-1 level increased gradually during normal pregnancy as the pregnancy advanced, the levels (0.40 +/- 0.02 pmol/l, n = 45) being significantly (p less than 0.05) higher after 29 weeks of gestation than those (0.32 +/- 0.01 pmol/l, n = 30) before 28 weeks of gestation. The plasma ET-1 level during labor pain was significantly higher (0.59 +/- 0.06 pmol/l, n = 10) than that (0.40 +/- 0.02 pmol/l, n = 45) in the 3rd trimester of pregnancy without labor pain (p less than 0.02). Moreover, a high level of ET-1 (17.38 +/- 0.25 pmol/l, n = 18) was detected in amniotic fluid on term delivery. The ET-1 level in amniotic fluid was significantly higher than the levels in maternal and umbilical cord plasma (p less than 0.001 and p less than 0.001, respectively). After delivery the maternal ET-1 level decreased gradually and 2 day postpartum ET-1 levels reached the normal non-pregnant level.

Placental CSF-like activity

We have examined amniotic fluid and cultured supernatants of a variety of placental cells for the presence of colony-stimulating factor (CSF) activity. The supernatants of cultured human choriocarcinoma cell lines, Jeg and Jar, contained CSF activity that induced the formation of granulocyte-macrophage colony-forming unit (CFU-GM) and multipotential colony-forming unit (CFU-GEMM) colonies. Cultured supernatants of nontransformed rat placental cells, chorionic villous cells, and amniotic fluid also induced CFU-GM colonies.

Human placenta contains an epithelial scatter protein

Scatter factor (SF) is a protein produced by cultured fibroblasts which causes epithelia to "scatter" into isolated cells. We found significant scatter activity in vivo in second trimester (but not term) human amniotic fluid and in human placenta. Placental SF was purified 500,000-fold and identified as a protein with Mr 78 kd. Factor scattered Madin-Darby canine kidney and human squamous carcinoma cells at 15 pM. Amino acid sequences from tryptic peptides did not match any known protein. Human placental fibroblasts produced high titers of scatter activity. SF may be involved in development and may enhance carcinoma invasion.

Corticotropin-releasing factor and parturition: plasma and amniotic fluid levels and placental binding sites

We evaluated levels of corticotropin-releasing factor in the plasma and amniotic fluid of women who had spontaneous vaginal delivery or elective cesarean. Corticotropin-releasing factor binding sites were also studied in placental tissue collected from vaginal or cesarean birth. Plasma samples were collected hourly from seven women from the onset of labor until delivery, and from ten women before and during elective cesarean. Amniotic fluid samples were collected from 40 women at different stages of labor and from ten women during elective cesarean. Maternal plasma corticotropin-releasing factor levels increased during labor, showing the highest values at delivery. No significant differences in amniotic fluid immunoreactive corticotropin-releasing factor levels were observed at the different stages of cervical dilatation. At cesarean, maternal plasma levels did not differ significantly from those found before surgery, and in the amniotic fluid they were similar to those found in pregnancy. The number of 125I-corticotropin-releasing factor binding sites in placental tissue was higher after vaginal than after cesarean delivery. These results suggest that corticotropin-releasing factor secretion is activated by the stress of labor.

Recognition of insulin-like-growth-factor-binding proteins in serum and amniotic fluid by an antiserum against a low-molecular-mass insulin-like-growth-factor-inhibitor/binding protein

An antiserum (R8) raised against a purified specific low-Mr (16,000-18,000) insulin-like-growth-factor (IGF)-inhibitor/binding protein, which is immunologically related to the native growth hormone (GH)-dependent Mr-150,000 IGF-binding protein in serum, has been used to probe a possible additional relationship to the predominant non-GH-dependent IGF-binding protein (Mr approximately 30,000) of human amniotic fluid. Amniotic-fluid fractions and an IGF-inhibitory fraction of serum were analysed by covalent cross-linking, ligand-blotting and immunoblotting techniques. Western blotting of the serum fraction using the R8 antiserum gave five immunoreactive (ir) bands, of which at least three (Mr 38,000, 34,000 and 23,000) possessed IGF-binding activity, as indicated by ligand (125I-IGF-I) blotting. Western blotting of two differently prepared amniotic-fluid fractions, which both showed potent IGF-inhibitory bioactivity, gave several (Mr range 14,500-73,000) ir bands, of which two (Mr 28,000 and 17,000) were most prominent. Ligand-blotting analysis gave a single intensely labelled band at Mr 28,000, consistent with the major presence of the Mr-28,000-30,000 amniotic-fluid IGF-binding protein. Covalent cross-linking of the amniotic-fluid fractions to 125I-IGF-I gave three specifically cross-linked complexes (Mr 36,000, 32,000 and 23,000), which, assuming a 1:1 binding stoichiometry with IGF (Mr 7500), represent binding proteins of Mr 28,500, 24,500 and 15,500 respectively. The Mr-15,500 binding protein, very similar to the Mr-17,000 ir band, in all likelihood represents the IGF-inhibitor protein. Our results indicate that inhibitor-sized binding proteins and IGF-inhibitor bioactivity are present in human amniotic fluid, and that the IGF-inhibitor protein (Mr 16,000) and amniotic-fluid IGF-binding protein (Mr 28,000) are immunologically related. Since the IGF-inhibitor protein is also immunologically and structurally related to the native, GH-dependent, Mr-150,000 binding protein in serum, our data suggest a heretofore-unrecognized immunological similarity between the Mr-150,000 binding protein and the amniotic-fluid binding protein and its serum analogue, the Mr approximately 30,000, non-GH-dependent, binding protein.

Separation of the estrogen-activated growth-regulatory forms of alpha-fetoprotein in mouse amniotic fluid

We have previously reported that murine fetal alpha-fetoprotein (AFP) incubated for 1.0 h at room temperature in the presence of high concentrations of estradiol (E2) generates a growth-regulatory product designated AFP/E2. Subsequently we developed a bioassay in the immature mouse uterus to measure both the growth-inhibitory and growth-enhancing properties of AFP. In the present study, we have employed this bioassay to monitor each of the amniotic fluid-derived AFP isolates fractionated by various chromatographic and electrophoretic techniques. The objective of this investigation was to partition and isolate the various molecular forms of AFP contained in amniotic fluid and determine whether the growth-regulatory activities resided with one or more of the fractions. AFP was fractionated by three different chromatographic/electrophoretic methods: E2 affinity chromatography, preparative polyacrylamide-gel electrophoresis (PAGE), and high-performance liquid chromatography (HPLC); and one immunoaffinity method: gel-entrapped antibody filtration (GAF). Whereas E2 affinity chromatography separated the biological activity of AFP into inhibitory and possibly enhancing activities, PAGE purification yielded three fractions: an inhibitor, an enhancer, and a fraction without growth-regulatory activity. Immunoaffinity separation yielded an AFP product with only inhibitory activities. In comparison, fractionation by HPLC produced seven AFP fractions in which only three displayed growth-regulatory activities: two inhibitory and one enhancing. After subsequent HPLC rechromatography of these fractions, none displayed any biological activity. Thus, murine AFP derived from amniotic fluid is composed of potential heterofunctional forms that, depending on their relative abundance in the preparation, constitute a mixture capable of either (a) growth inhibition, (b) no effect, or (c) growth enhancement.

Radial "high-performance" thin-layer chromatography used to assess fetal lung maturity

A radial "high-performance" thin-layer chromatographic (HPTLC) method is described by which the percentages and ratios of phosphatidylinositol, sphingomyelin, lecithin, phosphatidylethanolamine, phosphatidylglycerol, and dimethyl phosphatidylethanolamine may be determined simultaneously. An additional method for radial HPTLC determination of saturated phosphatidylcholine is described. We report results of application of these methods to greater than 2000 specimens of amniotic fluid from both diabetic and nondiabetic cases.

Evaluation of elevations in maternal serum alpha-fetoprotein: a review

Maternal serum AFP screening has had significant clinical impact on reducing unrecognized anencephaly and open neural tube defects at delivery. In addition, a growing number of other associations with maternal serum AFP elevations have become apparent since antepartum screening has become commonplace. We present in this review a clinically oriented approach to understanding the physiologic basis of maternal serum AFP elevations, both true- and false-positives. Compartmentalization of etiology, fetal and maternal, and routes of communication, amniotic fluid and placenta, allows a more logical approach to developing a differential diagnosis in this group of patients. In evaluating an elevation in maternal serum AFP, it is first necessary to consider the amount of fetal production by confirming the gestational age of the fetus and the number of fetuses present. Adjustments for maternal factors (weight, race, diabetes) must also be made. Fetal developmental defects which may lead primarily to leakage of the fetal proteins into the surrounding amniotic fluid with secondary elevations of maternal serum AFP enter into the differential diagnosis. The placenta itself is probably not a production source of AFP, but when the placenta is abnormal, a greater amount of AFP may be transported to the maternal circulation. Although our thoughts frequently do turn first to an increased maternal serum AFP reflecting an increased AFP concentration in the amniotic cavity with greater transference "across the membranes," in fact a far more common etiology is an increased transfer from the fetal circulation to the maternal via the fetal-maternal interface within the placenta. This is supported by the simple fact that the vast majority of maternal serum AFP elevations are not associated with amniotic fluid AFP elevations; the amniotic fluid AFP concentrations are usually normal. Thus, in circumstances where the fetal anatomy is grossly normal and there is not another explanation for elevations in maternal serum AFP, the placenta, either secondary to providing increased areas of transport or in providing an abnormal endothelial barrier, allows for greater transfer of fetal serum, and thus AFP, into the maternal compartment. An abnormal placenta is also a likely explanation for the increased risk of adverse pregnancy outcome that is associated with increased maternal serum AFP elevations for which no obvious etiology is found. The case herein reported suggests that an abnormal placenta which provides an altered interface for AFP flow between the fetal and maternal circulations may in fact be the etiology of the significant elevations of maternal serum AFP seen in cases of triploidy.(ABSTRACT TRUNCATED AT 400 WORDS)

[Intersexual differences in the levels of trace elements in amniotic fluid in the 2d trimester of pregnancy]

The authors assessed during comprehensive examination of amniotic fluid obtained by transabdominal amniocentesis on account of genetic indication during the second trimester of normal pregnancy between the 15th and 22nd week of gestation four selected trace elements - Zn, Cu, Pb and Cd, using the method of atomic absorption spectrometry. One of the criteria for evaluation of the results was also the relationship of the concentration of the selected trace elements and sex of the foetus. In 157 amniotic fluids collected during the 16th-19th week of gestation they recorded a significantly elevated lead level in male foetuses. During the 17th week normal pregnancy they found also a significantly increased zinc concentration in amniotic fluid of female foetuses. The authors are so far unable to interpret these interesting results which will be the subject of future investigation.

The ferning test for detection of amniotic fluid contamination in umbilical blood samples

There is currently no standard means of detecting amniotic fluid contamination in fetal blood obtained by percutaneous umbilical blood sampling. The ferning test is proposed for this purpose. An in vitro model, using centrifuged serial dilutions of neonatal cord blood and amniotic fluid, showed that ferning of the supernatant occurs in proportion to the degree of contamination. A system for grading ferning was devised, and tested in a blind trial. For the detection of amniotic fluid contamination of 10% or more, the method showed a sensitivity of 98% and a specificity of 81%. The method may be useful in percutaneous umbilical blood sampling, and in the diagnosis of spontaneous rupture of membranes with vaginal bleeding.

[Prenatal diagnosis of Lesch-Nyhan syndrome]

A pregnant woman with Lesch-Nyhan's syndrome (hypoxanthine-guanine-phosphoribosyltransferase, or HGPRT deficiency) requested antenatal diagnosis. HGPRT and adenine phosphoribosyltransferase (APRT) activities were measured in fetal erythrocytes by funiculocentesis in the 21st gestational week. HGPRT activity was lower than 0.01 mmol/h/Hb g (normal value 87.0 +/- 16.05 mmol/h/Hb g). APRT activity was increased (44.0 mmol/h/Hb g) as compared with that from 50 normal individuals (28.1 +/- 6.9 mmol/h/Hb g). Pregnancy was interrupted and the antenatal diagnosis of Lesch-Nyhan's syndrome was confirmed after delivery. In the 20th gestational week, amniotic fluid showed a marked increase if oxypurines (hypoxanthine, xanthine and uric acid) as compared with the values in 14 amniotic fluids from normal pregnancies and gestational age within 15-22 weeks. The present study illustrates the possibility to make the antenatal diagnosis of Lesch-Nyhan's syndrome by funiculocentesis . The previously unreported finding of a marked abnormality of oxypurine concentration in amniotic fluid represents a new outlook for the diagnosis of enzymatic defects of synthesis and degradation of purine nucleotides.

Significance of observing no fluid at amniotomy

Thirty patients with oligohydramnios observed at artificial rupture of membranes were studied to determine the significance of this finding. Fifteen were subsequently found to have meconium-stained amniotic fluid and 21 had abnormal fetal heart rate tracings. This clinical observation warrants close intrapartum surveillance and preparation for delivery.

Correlation of absorbance at 650 nm with the presence of phosphatidylglycerol in amniotic fluid

Amniotic fluid absorbance at 650 nm was correlated with the presence of phosphatidylglycerol (PG) in the isolated surfactant fraction (10,000-g pellet). Shake test results were included. Two hundred ninety-seven samples were analyzed. PG was present in 222 of 226 samples in which the absorbance was greater than or equal to 0.250 and absent from 48 of 71 with an absorbance less than 0.250. PG was present in all 166 samples with a positive shake test and absent in 52 of 131 samples with a negative one. In 65 samples in which the shake test was negative and the absorbance greater than or equal to 0.250, PG was present in all but 4. The false-positive rate for the prediction of respiratory distress syndrome was 0.8% for the Shake test and 0.6% for the absorbance measurement. The results support the usefulness of the absorbance measurement as a simple and reliable procedure for assessing fetal lung maturity.

Circulating levels of GH-releasing hormone and GH during human pregnancy

To study the potential role of GH-releasing hormone (GHRH) in maintaining circulating levels of GH during pregnancy, 302 maternal plasma samples were collected from non-fasted subjects at various stages of pregnancy and assayed for GHRH using a 'two-site' immunoradiometric assay. The GH and placental lactogen levels were also determined. In addition, maternal plasma samples taken during labour, amniotic fluid and cord blood were also assayed for these hormones. Maternal plasma GHRH levels were similar to non-pregnant levels throughout gestation despite fluctuations in GH values which were always higher than non-pregnant levels. There was no significant difference between GHRH levels in maternal plasma and cord blood although high GH levels were observed in the latter. These findings suggest that peripheral GHRH levels do not play an important role in maintaining circulating GH levels during pregnancy.