Early Stages Of Gestation Research Articles

Tumor Necrosis Factor‐α in the Placenta is not Elevated in Pre‐eclamptic Patients Despite its Elevation in Peripheral Blood

Tumor necrosis factor-alpha (TNF-alpha) is present in human placental and uterine cells at the early and late stages of gestation and promotes the regulation of trophoblast growth and invasion. We evaluated whether TNF-alpha levels in the placenta and blood of pre-eclamptic women differed from those with normal pregnancies. The subjects were 39 pregnant women carrying single fetuses (21 normal-pregnant and 18 pre-eclamptic patients). Their average gestational age at entry was 38-39 weeks. Peripheral blood was collected before the onset of labor and separated serum was stored at -20 degrees C. A tissue segment of the placenta was cut and frozen in liquid nitrogen immediately after delivery at -80 degrees C. The frozen placental tissue was added to phosphate-buffered saline. The tissue was fully homogenized and centrifuged. Separated supernatant was stored at -80 degrees C. TNF-alpha levels in separated serum and TNF-alpha and total protein (TP) levels in separated supernatant were measured. The presence of TNF-alpha in the placenta was evaluated by immunohistochemistry in five pre-eclamptic and five normal-pregnant patients. Serum TNF-alpha levels were higher in pre-eclampsia than in normal pregnancies. However, TNF-alpha/TP levels in the placenta did not differ significantly between the two groups. As for TNF-alpha immunostaining of trophoblastic cells in the placenta, it was weak in three and moderate in two of the normal pregnancies, while it was absent in two, weak in one, and moderate in two in the pre-eclampsia group. We demonstrated no significant increase in TNF-alpha/TP levels in the placenta in pre-eclampsia despite a significant increase in serum TNF-alpha levels. There was no strong immunostaining for TNF-alpha detected by immunohistochemistry in the pre-eclampsia group. These findings suggest that TNF-alpha in the placenta is not a key cytokine to interfere with normal trophoblast invasion into the myometrium in pre-eclampsia, and that sources other than the placenta may contribute to the elevated levels of TNF-alpha found in the circulation of pre-eclamptic patients.

201. Effects of relaxin deficiency on matrix metalloproteinase expression in the cervix and vagina of pregnant mice

The major functions of relaxin are associated with female reproductive physiology, especially the regulation of biochemical processes involved in the remodelling of the reproductive tract at term. Studies in relaxin deficient mice (Rlx–/–) demonstrate that although females give birth to live young without apparent dystocia, they have abnormal cervices and vaginae. This phenotype is attributed to an increase in stromal collagen, but the mechanism(s) by which relaxin regulates extracellular matrix (ECM) production in reproductive tissues is poorly understood. In this study, we assessed the expression of matrix metalloproteinases (MMPs) in the cervix and vagina of pregnant wild-type (Rlx+/+) and Rlx–/– mice. Tissues were obtained from adult C57/Blk6J Rlx+/+ mice on days 7.5, 14.5, 17.5, 18.5 pc and Rlx–/– littermates on days 7.5, 14.5 and 18.5 pc. Real-time PCR using dual-labelled fluorogenic probes was performed in an Opticon 2 cycler (MJ Research) to quantify MMP-2, -3, -7, -9 and -13 gene expression. In the cervix and vagina of Rlx+/+ mice, only MMP-2 mRNA levels were significantly higher at term compared with earlier stages of gestation. There were significant decreases in MMP-7 and -13 expression at term, but no change in MMP-3 and -9. In contrast, MMP-3, -7, -9 and -13 mRNA levels were significantly higher in the cervix and vagina of late pregnant Rlx–/– mice. The expression of MMP-2 did not differ between Rlx+/+ and Rlx–/– mice at term. Despite the higher expression of the majority of MMPs we examined in Rlx–/– mice, there was no histological evidence of increased ECM degradation in the cervix and vagina in late gestation. Although previous in vitro studies suggest that relaxin positively regulates MMP activity, our data demonstrate that relaxin deficiency does not result in decreased MMP expression in the mouse cervix and vagina in vivo.

A comprehensive teratological assessment of isosulfan blue (Lymphazurin 1%) in the pregnant sprague Dawley rat

No study has reported an evaluation of the teratogenicity of isosulfan blue (Lymphazurin 1%) in a developing fetus. This study evaluated the effects of isosulfan blue in fetuses of the pregnant female rat during early, middle, and late gestational stages. Isosulfan Blue (Lymphazurin 1%) is a rosaniline dye of the triphenylmethane type that is injected intraoperatively to detect sentinel lymph nodes in patients undergoing breast cancer or melanoma treatment. If isosulfan blue were found to be safe in a pregnant human patient for injection during sentinel lymph node biopsy, a full lymph node dissection could be avoided in selected cases of breast cancer or melanoma that occurs in association with pregnancy.

Genetic mapping of dominant white (W), a homozygous lethal condition in the horse (Equus caballus)

SummaryDominant white coat colour (W) is a depigmentation syndrome, known in miscellaneous species. When homozygous in the horse (similar in mice), the mutation responsible for the white phenotype is lethal in a very early stage of gestation. It seems, that the action of the dominant white allele is not always fully penetrant, resulting occasionally in spotted look alike offspring. These horses resemble a coat colour pattern known as sabino spotting. So far, it is not known whether dominant white (W) and sabino spotting (S) share a common genetic background. In this study, a pedigree consisting of 87 horses segregating for dominant white (W) was used to genetically localize the horse (W)‐locus. Microsatellite ASB23 was found linked to (W), which allowed us to map dominant white to a region on horse chromosome 3q22. Tyrosine kinase receptor (KIT) was previously mapped to this same chromosome region (3q21–22). KIT and its ligand (KITLG) are responsible for the normal function of melanogenesis, haematopoiesis and gametogenesis. So far, sequence analysis of different KIT gene fragments did not lead to new polymorphisms, except for a SNP detected in KIT intron 3 (KITSNPIn3). Additional microsatellites from ECA3q (TKY353 and LEX7), together with KITSNPIn3 allowed us to state more precisely the (W)‐mutation. The positional results and comparative functional data strongly suggest that KIT encodes for the horse (W)‐locus.

Placental vascular compromise in jejunoileal atresia

Background/Purpose The mechanisms of intrauterine vascular disruptions that result in the development of jejunoileal atresia (JIA) are not fully understood. Monochorionic twinning with fetal death of a cotwin is known to be correlated with the development of JIA in the survivor through placental communication. The aim of this study was to evaluate whether other placental vascular compromises might contribute to the development of JIA. Methods Forty-five newborns (23 boys and 22 girls) who were treated for JIA at Tsukuba University Hospital from 1978 to 2003 were reviewed. Placental findings were informative in 23 cases. Results No or slight abnormality of the placenta was found in 19 cases. Significant placental abnormalities were found in 4 patients who also had a low birth weight. One patient with apple peel atresia (APA) had excessive torsion of the umbilical cord (UC), which was inserted at the margin of the placenta, and there was an adjacent area of infarction. One patent with multiple atresia (MA) was a surviving monochorionic twin with intrauterine fetal death of the other. Another case of MA showed marginal insertion of the UC. Severe placental abnormalities including wide infarction, cyst formation, and marginal insertion of the UC were found in 1 case of MA. These 3 cases of MA were complicated with other anomalies including brain anomaly. Conclusions Placental vascular compromises were involved infrequently in JIA but might possibly be responsible for the development of JIA as well as associated anomalies and a low birth weight as chronic insults since an early stage of gestation in some cases.

Programming of obesity and cardiovascular disease

There is evidence that malnutrition in early life induces a growth retardation leading, in adult life, to manifest components of the metabolic syndrome. However, the impact on obesity seems less clearly established. To review the effects of foetal and postnatal malnutrition on the programming of obesity in the context of the metabolic syndrome, as well as the link between central obesity and cardiovascular diseases. Included in the review were recent papers exploring the mechanisms linking maternal nutrition with impaired foetal growth and later obesity, cardiovascular disease, hypertension and diabetes in humans and animals. The programming of obesity during foetal and early postnatal life depends of the timing of maternal malnutrition as well as the postnatal environment. Obesity arises principally in offspring submitted to malnutrition during early stages of gestation and which presented early catch-up growth. The programming may involve the dysregulation of appetite control or the hormonal environment leading to a context favourable to obesity development (hypersecretion of corticosteroids, hyperinsulinaemia and hyperleptinaemia and anomalies in the IGF axis). Adipose tissue secretes actively several factors implicated in inflammation, blood pressure, coagulation and fibrinolysis. The programmed development of intra-abdominal obesity after early growth restriction may thus favour higher prevalence of hypertension and cardiovascular diseases. Abdominal obesity appears in malnourished offspring and is aggravated by early catch-up growth. Higher rates of intra-abdominal obesity observed after growth restriction may participate to hypertension and create atherothrombotic conditions leading to the development of cardiovascular diseases.

Blockade of CD86 signaling facilitates a Th2 bias at the maternal-fetal interface and expands peripheral CD4+CD25+ regulatory T cells to rescue abortion-prone fetuses.

Intervention in B7 (CD80/CD86)/B7-ligand (CD28/CTLA-4) pathways is an effective way of preventing unwanted immune responses, such as allograft rejection. Pregnancy maintenance represents maternal tolerance to the fetal allograft, which is accompanied by a type 2 helper cell (Th2) bias at the maternal-fetal interface. Here, the costimulatory signal of CD86 was selectively blocked, and that of CD80 was kept unimpaired by administration of anti-murine CD86 monoclonal antibody at the early gestational stage in abortion-prone CBA/JxDBA/2 matings and normal pregnant CBA/JxBALB/c matings. It was demonstrated that in vivo blockade of CD86 costimulation could suppress maternal immune attack to the fetus by shifting cytokines from Th1 predominance to Th2 bias at the maternal-fetal interface, and expanding peripheral CD4+CD25+ regulatory T cells, which play an important role in the development and maintenance of maternal-fetal tolerance. Furthermore, the expression of CD28 and its ligands CD80/CD86 on peripheral lymphocytes was down-regulated, whereas that of CTLA-4 was up-regulated, which might facilitate the suppressive effect of CD4+CD25+ regulatory T cells on the alloreactive T cells. The maternal-fetal immunotolerance induced by CD86 blockade decreased fetal resorption in CBA/JxDBA/2 matings, but did not affect normal pregnant CBA/JxBALB/c matings. These results suggest that selective blockade of CD86 costimulation leads to maternal immune tolerance to embryo antigen, and might contribute to a rational immunoregulatory regimen for recurrent spontaneous abortion.

Fetal omphalocele detected early in pregnancy: associated anomalies and outcomes.

To detect omphalocele and associated anomalies at ultrasonography (US) early in pregnancy and to describe the outcomes in fetuses with isolated and nonisolated omphalocele. Fetal endovaginal US was performed in 43,896 pregnant women at 12-16 weeks gestation. The women found to have fetal omphalocele were offered an amniocentesis to determine the fetal karyotype. For parents who decided to continue the pregnancy, repeat targeted transabdominal fetal US was performed at 20-24 weeks gestation. Additional follow-up US examinations performed until delivery were recommended. Postnatal pediatric examinations were performed in all of these fetuses. For the pregnancies in which no anomaly was detected at early US, the women were advised to undergo repeat US at about 24 weeks gestation for the detection of late-manifesting fetal anomalies. For pregnancies in which the baby was not delivered at the authors' affiliated hospital, the woman, her obstetrician, and her pediatrician were asked to inform the authors of any detected anomaly. Omphalocele was visualized at US in 38 fetuses, who were categorized into two groups. One group consisted of 22 (58%) fetuses with associated structural anomalies. According to the karyotype determined for 18 of these fetuses, 11 of them also had chromosomal anomalies. The pregnancy was terminated at the parents' request in 19 of these 22 cases. There were two cases of missed abortion, and a small omphalocele in one fetus disappeared at 21 weeks gestation. The second group consisted of 16 (42%) fetuses with a normal karyotype and an omphalocele as an isolated US finding. In eight of these fetuses, the omphalocele disappeared at 20-24 weeks gestation and no defect was seen at delivery. In six other fetuses, omphalocele was identified at delivery. There was one case each of missed abortion and pregnancy termination. There were no false-negative diagnoses of omphalocele. Isolated omphalocele diagnosed during the early stages of gestation typically has a good prognosis. In cases of a small defect, the anomaly may disappear later in the pregnancy.

Placental hormones and fetal–placental development

Production of growth promoting substances by the placenta is regulated differently from the way production of similar compounds is regulated by maternal organs in various cases. Gene duplication is one of the mechanisms that facilitated the evolution of placental specific endocrine activity. Cattle, sheep and goats, although evolutionarily related, differ significantly from each other in the way their placental growth hormone (GH) and prolactin (PRL)-like hormones have evolved. Cattle carry one copy of the GH gene and there is no evidence yet for expression of that single GH gene copy in the placenta. On the other hand, the ovine GH gene has been duplicated and both oGH copies are expressed in the placenta during early stages of gestation. Prolactin gene duplication in ruminants resulted in the formation of specific placental-expressed prolactin-related genes including the placental lactogen (PL) gene. In homologous state, ovine PL manifests PRL activity, but antagonizes GH activity. Ovine PL activity which can be mediated by PRL receptors or by hetero-dimerization of GH and PRL receptors, provide a novel regulatory mechanism for somatogenic activity dependent on the coexistence of both GH and PRL receptors in the same cells. Another mechanism for specific placental endocrine activity is silencing of the alleles through genetic imprinting. Disruption of genetic imprinting of placental genes has been proposed as one of the explanations for the loss of cloned fetuses generated by somatic cell nuclear transfer.

Placental hormones and fetal?placental development

Production of growth promoting substances by the placenta is regulated differently from the way production of similar compounds is regulated by maternal organs in various cases. Gene duplication is one of the mechanisms that facilitated the evolution of placental specific endocrine activity. Cattle, sheep and goats, although evolutionarily related, differ significantly from each other in the way their placental growth hormone (GH) and prolactin (PRL)-like hormones have evolved. Cattle carry one copy of the GH gene and there is no evidence yet for expression of that single GH gene copy in the placenta. On the other hand, the ovine GH gene has been duplicated and both oGH copies are expressed in the placenta during early stages of gestation. Prolactin gene duplication in ruminants resulted in the formation of specific placental-expressed prolactin-related genes including the placental lactogen (PL) gene. In homologous state, ovine PL manifests PRL activity, but antagonizes GH activity. Ovine PL activity which can be mediated by PRL receptors or by hetero-dimerization of GH and PRL receptors, provide a novel regulatory mechanism for somatogenic activity dependent on the coexistence of both GH and PRL receptors in the same cells. Another mechanism for specific placental endocrine activity is silencing of the alleles through genetic imprinting. Disruption of genetic imprinting of placental genes has been proposed as one of the explanations for the loss of cloned fetuses generated by somatic cell nuclear transfer.

CD56-positive cells with or without synaptophysin expression are recognized in the pancreatic duct epithelium: a study with adult and fetal tissues and specimens from chronic pancreatitis.

We observed the distribution of CD56+ epithelial cells in the pancreatic duct system using 25 fetal, one infantile, 3 normal adult, 4 diabetic, and 8 chronically inflamed pancreatic tissue samples. In the early stage of gestation (12 to 17 weeks), CD56+ cells were commonly seen in the immature tubular structures. They were often continuous to pancreatic islets, and their distribution was similar to that of synaptophysin (Syn)+ cells, suggesting that they are precursors of islet neogenesis. Their number decreased in proportion to gestational age. Instead, from 24 weeks of gestation, luminal cell clusters that were common in interlobular ducts revealed CD56+. These cell clusters were unrelated to islet neogenesis and Syn expression. Similar CD56+ luminal cell clusters were also observed in cases of chronic pancreatitis, whereas they were scarce in normal adult and diabetic tissues. CD56+ cells were also occasionally seen in intralobular ducts, intercalated ducts, and centroacinar cells in cases of chronic pancreatitis. We conclude that there are two types of CD56+ epithelial cells in the pancreatic duct system: CD56+ endocrine cells are numerous during the early stage of gestation, when islet neogenesis appears, while CD56+ luminal cells may represent developmental and regenerative changes of pancreatic ducts.

Immunohistological Localization of Insulin-like Growth Factor Binding Protein-1 in Primary Implantation Sites and Trauma-induced Deciduomal Tissues of the Rhesus Monkey

We have earlier demonstrated that there is a close similarity in the temporo-spatial pattern in the onset of oedema, epithelial-plaque transformation, stromal decidualization and influx of granulated lymphocytes in artificially trauma-induced deciduomal endometrium with such events in maternal endometrium at the primary implantation site during early stages of pregnancy in the rhesus monkey. In the present study, we have immunohistochemicaly examined whether the pattern of insulin-like growth factor-binding protein 1 (IGFBP-1) protein expression in conceptus tissue and maternal endometrium during lacunae and villous placenta stages of gestation in the rhesus monkey is developmental stage-specific and whether a discernible difference exists in the temporo-spatial characteristics of IGFBP-1 protein expression between conceptus associated implantation-decidualization and trauma induced deciduoma in the rhesus monkey. Trophoblast cells failed to exhibit IGFBP-1 immunopositive staining at any stage of implantation–placentation studied. Epithelial cells in plaque acini, endothelial cells, and vascular smooth muscle also did not show any immunopositive staining for IGFBP-1 in samples of primary implantation sites and trauma-induced deciduoma. Maternal endometrial epithelial and stromal-decidual cells however exhibited a temporal and spatial pattern of IGFBP-1 expression in cell-type specific manner and clear distinctions were observed between conception and deciduoma samples. Our results suggest that IGFBP-1 expression is highly tissue and development-specific and that conceptus-derived signals are necessary to initiate the glandular expression of IGFBP-1 during the early stage of gestation.

The Effect of Gestational State on Oxygen Consumption and Response to Hypoxia in the Sailfin Molly, Poecilia latipinna

Metabolic activity in livebearing fishes increases with embryonic development so that embryos prior to parturition may have a higher mass-specific oxygen requirement than maternal tissues, temporarily increasing the total routine oxygen requirement of the female. We examined whether females of the livebearing poeciliid Poecilia latipinna (sailfin molly) increase their routine metabolic oxygen consumption during development of their broods. We also quantified effects of gestation on time allocation to aquatic surface respiration (ASR) under hypoxic conditions. Mass-adjusted routine metabolic rate (RMR) of female mollies showed a significant increase during late gestation. The RMR of males did not differ from females that were in their early or mid stage of gestation, but was lower than females in late gestation. Gestating females spent approximately 27% more time conducting ASR than non-gestating females when exposed to chronic hypoxia (1 mg l−1), further supporting a brood-related increase in oxygen demand. Increased time allocation to ASR may directly affect maternal predation risk in low-oxygen conditions.

Expression of integrins and extracellular matrix proteins at the maternal-fetal interface during tubal implantation.

Investigation of the expression pattern of integrins and their extracellular matrix (ECM) ligands in trophoblasts at the maternal-fetal interface during tubal pregnancy may aid better understanding of the adhesion and invasion of acceptable maternal endometrium by trophoblast cells at the very early stage of human gestation. In this study, spatial and temporal alterations of integrins and ECM ligands were examined in specimens of tubal pregnancies during weeks 3-9 of gestation. In situ hybridization and immunohistochemistry revealed that relatively high levels of integrin alpha(1), beta(1), alpha(5) subunits and heterdimer alpha(5)beta(1) as well as ECM ligands, were displayed in trophoblast cells as early as weeks 3-4 of gestation. Expression peaked during weeks 5-7 and then, with the exception of integrin alpha(1), which remained high, declined slightly up to weeks 8-9 of gestation. Immunoreactive fibronectin, laminin and type IV collagen were detected in column cytotrophoblastic cells (CTB) and some invasive extravillous cytotrophoblast (EVCT) cells and the alterations were coincident with those of the corresponding integrin receptors in EVCT cells. Laminin was strongly stained in EVCT cells that had invaded maternal blood vessels and deep into the interstitium. Maternal epithelial, endothelial and stromal cells also expressed these integrins and ECM ligands. The results indicate their involvement in mediating the adhesion of trophoblasts to the epithelium of the maternal Fallopian tube. The upregulated expression of these molecules in column CTB and invasive EVCT cells may also facilitate the invasion of trophoblasts into the maternal interstitium. Moreover, trophoblasts possessed the potential for self-controlled adhesion and invasion and appear to reach peak invasive capability in the second month of tubal implantation.

Expression of integrins and extracellular matrix proteins at the maternal-fetal interface during tubal implantation

Investigation of the expression pattern of integrins and their extracellular matrix (ECM) ligands in trophoblasts at the maternal-fetal interface during tubal pregnancy may aid better understanding of the adhesion and invasion of acceptable maternal endometrium by trophoblast cells at the very early stage of human gestation. In this study, spatial and temporal alterations of integrins and ECM ligands were examined in specimens of tubal pregnancies during weeks 3-9 of gestation. In situ hybridization and immunohistochemistry revealed that relatively high levels of integrin alpha(1), beta(1), alpha(5) subunits and heterdimer alpha(5)beta(1) as well as ECM ligands, were displayed in trophoblast cells as early as weeks 3-4 of gestation. Expression peaked during weeks 5-7 and then, with the exception of integrin alpha(1), which remained high, declined slightly up to weeks 8-9 of gestation. Immunoreactive fibronectin, laminin and type IV collagen were detected in column cytotrophoblastic cells (CTB) and some invasive extravillous cytotrophoblast (EVCT) cells and the alterations were coincident with those of the corresponding integrin receptors in EVCT cells. Laminin was strongly stained in EVCT cells that had invaded maternal blood vessels and deep into the interstitium. Maternal epithelial, endothelial and stromal cells also expressed these integrins and ECM ligands. The results indicate their involvement in mediating the adhesion of trophoblasts to the epithelium of the maternal Fallopian tube. The upregulated expression of these molecules in column CTB and invasive EVCT cells may also facilitate the invasion of trophoblasts into the maternal interstitium. Moreover, trophoblasts possessed the potential for self-controlled adhesion and invasion and appear to reach peak invasive capability in the second month of tubal implantation.

Inhibition of oxytocin receptor and estrogen receptor-alpha expression, but not relaxin receptors (LGR7), in the myometrium of late pregnant relaxin gene knockout mice.

This study used relaxin (RLX) gene knockout mice (Rlx-/-) to investigate the effects of RLX on myometrial oxytocin receptor (OTR) and estrogen receptor (ER)-alpha gene expression in late gestation. We also characterized the temporal expression of the RLX receptor (LGR7) and demonstrated gene transcripts in the myometrium of Rlx+/+ and Rlx-/- mice. There was a significant (P < 0.05) decrease in myometrial LGR7 gene expression on d 17.5 and 18.5 post coitum (pc) compared with earlier stages of gestation, but no differences between Rlx+/+ and Rlx-/- mice. Myometrial OTR mRNA levels increased at the end of gestation in Rlx+/+ but not Rlx-/- mice. ERalpha gene expression was up-regulated on d 14.5 pc in Rlx+/+ mice, with mRNA levels remaining high throughout late gestation. In contrast, ERalpha mRNA levels were significantly lower in Rlx-/- mice on d 14.5 and 18.5 pc. These data show that the increases in myometrial OTR and ERalpha expression in late pregnant Rlx+/+ mice were attenuated in Rlx-/- mice. The effects of RLX on OTRs are probably mediated via activation of ERalpha. Finally, RLX receptor expression in the myometrium of Rlx-/- mice did not differ from wild-type mice, implying that RLX does not influence expression of its receptor.

Calcitonin-like immunoreactivity in serum and tissues of the bonnethead shark, Sphyrna tiburo.

Calcitonin is a 32-amino acid peptide hormone that is best known for its actions in maintaining skeletal integrity and calcium homeostasis in mammals. Calcitonin also appears to function in regulating certain aspects of animal reproduction, but the nature of this role remains unclear, particularly in nonmammalian vertebrates. The present study investigated the relationship between calcitonin and reproduction in the bonnethead shark (Sphyrna tiburo), a well-studied member of the oldest living vertebrate group (i.e. elasmobranchs) known to possess a calcitonin-producing organ. Serum calcitonin concentrations were measured in 28 reproductively mature female S. tiburo using a heterologous enzyme-linked immunosorbent assay (ELISA) system. Sites of calcitonin immunoreactivity were detected in tissues of mature female and embryonic S. tiburo using immunocytochemistry. Significant increases in serum calcitonin concentrations of mature female S. tiburo occurred during early stages of gestation, a period characterized by yolk-dependency of developing embryos. Immunoreactive calcitonin was detected in the duodenum and pancreas of embryonic S. tiburo sampled during the same period. The results from this study suggest that calcitonin obtained from endogenous and/or maternal sources may function in regulating yolk digestion in embryonic S. tiburo. Therefore, the association between calcitonin and reproduction in elasmobranchs may reflect an important role for this hormone in embryonic development.

Predictable changes in double (rate-pressure) product along gestation in normotensive and hypertensive pregnant women

The double (rate-pressure) product (DP), systolic blood pressure (BP) multiplied by heart rate (HR), is an increasingly used surrogate measure of myocardial oxygen demand and cardiac workload. The DP is more strongly correlated with left ventricular mass than the daily BP mean, and it has thus been identified as a determinant of cardiovascular risk in hypertensive patients [White. Am J Hypertens. 1999;12:50S–55S]. However, there is no previous study on the potential diagnostic use of the DP in pregnancy. Accordingly, we quantified changes in DP with gestational age in pregnant women studied by ambulatory BP monitoring (ABPM) throughout pregnancy. We analyzed 2430 BP series obtained from 235 normotensive pregnant women and 168 women who developed gestational hypertension or preeclampsia. BP was measured at 20-minute intervals during the day (07:00 to 23:00 hours) and at 30-minute intervals at night for 48 consecutive hours once every 4 weeks from the first obstetric visit (mostly before 14 weeks of gestation) until delivery. The pattern of variation along gestation of the 24-hour mean of DP was established by polynomial regression analysis. For normotensive women, results indicate a steady decrease in BP up to 20 weeks of pregnancy, followed by an increase in BP up to delivery (P<0.001). In complicated pregnancies, BP is stable until 22 weeks of gestation, and then increases linearly for the remaining of pregnancy. For both healthy and complicated pregnancies, HR increases until the end of the second trimester, and slightly decreases thereafter. For all groups of pregnant women, the DP linearly increases throughout gestation until the 34th week of pregnancy, and then it is stable until delivery (mainly due to the decrease in HR). The DP is highly significantly elevated (difference between 1300 and 1500 mm Hg x beats/minute; P<0.001) at all stages of pregnancy in hypertensive women as compared to normotensive pregnant women. This study on women systematically studied by ABPM throughout gestation indicates that the DP shows a highly predictable pattern of variation along gestation, with values significantly elevated in complicated pregnancies even at the earliest stages of gestation. These results could be taken into consideration for an improved early identification of preeclampsia by the use of ABPM.

Stem Cell Research

Stem cell research involves destruction of the developing embryo and hence poses issues regarding the sanctity of nascent human life. Jewish law issues related to that matter are discussed. Among those are the parameters of the obligation to engage in medical research, the status of a subvisual fetus, of the fetus in the very early stages of gestation and of a fetus conceived ex utero. Public policy considerations in a pluralistic society are also addressed.

Dysfibrinogenemia during pregnancy treated successfully with fibrinogen

There are three types of congenital abnormalities associated with fibrinogen: afibrinogenemia, hypofibrinogenemia and dysfibrinogenemia. Of these, dysfibrinogenemia is usually clinically silent or is associated with mild to moderate bleeding tendency or defective wound healing. The obstetric complications of dysfibrinogenemia include first-trimester abortion, hemorrhage and placental abruption during pregnancy, and thrombophlebitis (1). We report a case of a dysfibrinogenemic patient with a history of recurrent fetal loss due to placental abruption, which was successfully treated with fibrinogen prophylaxis. The patient was a 38-year-old woman who had no bleeding diathesis. Her obstetric history was complicated, with two miscarriages at 8 weeks' gestation and two second-trimester fetal losses at 25 and 26 weeks' gestation because of placental abruption. After the last fetal loss at 26 weeks' gestation she was referred to Kobe University Hospital to investigate the etiological background of these episodes. Blood coagulation tests performed at that time were as follows: clottable fibrinogen (66 mg/dL; normal 170–350 mg/dL), immunologic fibrinogen (225 mg/dL; normal 170–350 mg/dL). Congenital dysfibrinogenemia was diagnosed by discrepancy between clottable and immunologic fibrinogen. Thereafter, she became pregnant and received our consultation at 8 weeks' gestation in the hope of maintaining the pregnancy. She was treated with 2 g of fibrinogen three times a week from 8 weeks' gestation to maintain a fibrinogen level of more than 100 mg/dL, as recommended in a previous report (2). At 16 weeks' gestation, she developed uterine contractions followed by moderate vaginal bleeding, when the level of fibrinogen was 138 mg/dL. Systemic tocolysis by beta- sympathomimetic drug therapy was needed during the rest of the pregnancy due to persistent uterine contractions. As pregnancy progressed, the fibrinogen requirement increased to a dose of 10–14 g/week to control the vaginal bleeding and uterine contractions. Fetal growth was normal. At 29 weeks' gestation, uterine contractions became stronger, and she developed moderate vaginal bleeding again. The fibrinogen level was 191 mg/dL. Emergency cesarean section was performed under general anesthesia and she delivered a male infant (weight 1622 g) with Apgar scores of 3 and 7 at 1 and 5 min, respectively. There were no findings of placental abruption at the time of surgery. The fibrinogen level of the newborn was 147 mg/dL. He had no episodes of bleeding and developed normally. Before and during operation 6 g of fibrinogen was infused continuously, considering the rapid consumption of fibrinogen with the operation. The estimated blood loss during operation was about 2500 mL and she received 1200 mL of blood transfusion. She had a normal puerperium with a reduced dose of fibrinogen infusion, which was stopped on the seventh day postpartum. Two cases have been reported of pregnancy associated with dysfibrinogenemia: one case diagnosed at 9 weeks' gestation was treated with subcutaneous heparin administration because of clear thromboembolic tendencies and had a third-trimester fetal loss due to placental abruption (3). The other case diagnosed at 24 weeks' gestation developed placental abruption 5 days after the diagnosis (4). These two cases had no fibrinogen replacement. The present case is unique because there are no other reported cases of dysfibrinogenemia in pregnancy with a history of recurrent fetal loss that were successfully treated with fibrinogen replacement from the early stage of gestation. Poor pregnancy outcomes were reported in all cases if fibrinogen levels were less than 60 mg/dL. Therefore, it has been suggested that the minimum level of fibrinogen to maintain pregnancy might be about 60 mg/dL (5,6). In our case, however, the fibrinogen level of 60 mg/dL was insufficient to prevent placental abruptions in the previous pregnancies. Kobayashi et al. (2) proposed that the fibrinogen level should be at least 60 mg/dL and, if possible, greater than 100 mg/dL during the pregnancy to prevent bleeding and abortion. We therefore elected to maintain our case's fibrinogen levels at quasi-physiological levels throughout her fifth pregnancy, where the development of placental abruption was prevented. Nevertheless, vaginal bleeding subsequent to uterine contractions developed at 16 weeks' gestation despite maintaining the fibrinogen level of 120 mg/dL. This implies that the fibrinogen requirement increases because of the rapid consumption of fibrinogen in the uteroplacental unit in dysfibrinogenemic women with increased uterine contractions.