Congenital malformation syndromes and elevation of amniotic fluid alpha-fetoprotein

Fetal malformations may introduce complications of maternal pregnancy. A polyhydramnios represents one such complication during pregnancy. We want to report five abnormal pregnancies which were marked by acute polyhydramnios and/or premature labor due to an amniotic band syndrome associated with cerebral herniation in two cases, malignant oral teratoma in one case, bilateral cystic hygromas associated with generalized fetal hydrops in one case, and multiple internal malformations in one case alpha-fetoprotein (AFP) values between the 25th and 34th week of gestation were elevated 3.5 to 44 times the normal median value. Since all fetuses showed severe malformations incompatible with life our observations indicate the necessity to determine AFP in cases of acute polyhydramnios independent of the week of gestation. Conversely, elevated AFP levels in amniotic fluid obtained during prenatal diagnosis in the 16th week of gestation may also suggest rare fetal malformations outlined above.     

Results of an experiment in systematic prenatal screening for neural tube malformations by assay of alpha fetoproteins in dried blood samples (12,480 pregnancies)

Measurement of alpha-fetoprotein (AFP) in eluate of dried blood was carried out in 12,480 pregnant women, between the 10th and 30th weeks of amenorrhea. In 348 cases, AFP level was greater than normal (greater than 99th centile). 225 control measurements were performed (123 women dropped out of the study). In 173 cases, the AFP level returned to normal (1.4% false positives). In 52 cases, AFP title remained above the 99th centile: in 8 cases, the fetus was malformed (4 anencephalics, 1 spina bifida, 1 hydrocephalus, 1 laparoschisis, 1 exomphalos). Of the 44 remaining cases, 26 were multiple pregnancies, 5 were cases of acute fetal distress, 7 false positives normalized when a second control was made, 5 false positives up to the end of pregnancy, and 1 spina bifida (normal ultrasound scan on two different occasions). During this prenatal screening, 7 false negatives (0.56%) not detected by AFP assay should be noted: 3 anencephalics, 2 spina bifida, 1 hydrocephalus, 1 exomphalos. In all cases except one, the AFP test was carried out too early (before the 10th week) or too late (after the 30th week). The authors stress that screening must be done during the precise period between the 16th and 20th weeks of amenorrhea, and that close collaboration with a competent ultrasonographist is necessary. In 5 cases of false negatives where AFP assay and ultrasound scan had been carried out, the two methods are compared. Measurement of AFP in eluate of dried blood thus seems a reliable test which could be the first stage in a plan for systematic prenatal screening for certain serious fetal malformations with high incidence (1,2% in the Midi-Pyrenees region).     

Premature labor and indomethacin

Women in the 29th – 32nd week of gestation were admitted to hospital following the onset of premature labor contractions. After treatment with bed rest and β-stimulating drugs, those patients with persistent uterine contractions were treated with oral indomethacin (25 mg every 6 hours for 5 days). The effect of indomethacin therapy was monitored by serial external tocometry recordings. This treatment schedule with indomethacin was repeated on several occasions at intervals of 5 to 10 days. Using a standardized technique, uterine contractility was monitored every second or third day throughout the entire treatment period. In this way, the frequency of contractions was evaluated in the presence or absence of indomethacin therapy.Following indomethacin treatment, there was a significant decrease in the frequency of contractions in all cases and a complete arrest of contractions occurred in some women. An increased frequency of contractions was observed during those times that the patient did not receive indomethacin.The plasma concentration of 15-keto-13, 14-dihydro-PGF_2α, the major serum metabolite of PGF_2α, was determined by the gas chromatography — mass spectrometry method before and after indomethacin in a limited number of cases.At the doses given for the duration of therapy used, no untoward effects could be detected in either the mother or the infant. These results indicate that indomethacin is a potent and useful drug in the treatment of premature labor.     

Pilot study of elevated levels of insulin-like growth factor-binding protein-2 as indicators of hepatocellular carcinoma

BACKGROUND/AIMS: Insulin-like growth factor-binding protein-2 (IGFBP-2) is expressed in many malignant tissues, and elevated serum levels can be indicators of tumour activity in addition to conventional tumour markers. Our aim was to evaluate the role of IGFBP-2 levels together with insulin-like growth factor (IGF)-I, IGF-II and IGFBP-3 in the diagnostic work-up of patients with hepatocellular carcinoma (HCC). METHODS: In 50 (39 males, 11 females) histologically confirmed and TNM-graded patients with HCC who had not received adjuvant chemotherapy, the basal serum levels of IGF-I, IGF-II, IGFBP-3, IGFBP-2 and alpha-fetoprotein (AFP) were measured. The median age of the patients was 66 (37-84) years, body mass index was normal (25 (35-16) kg/m2). RESULTS: The levels of IGF-I, IGF-II and IGFBP-3 were diminished, as is the case when nutrition, hepatic function and growth hormone (GH) secretion are decreased. The levels of AFP and IGFBP-2 were markedly high. In 37 cases, IGFBP-2 levels were above the age-related norm, and in 40 cases AFP levels were also elevated. In 3 cases, both AFP and IGFBP-3 were normal, and in 4 cases AFP was high but IGFBP-2 normal, whereas in 10 cases AFP was normal but IGFBP-2 was high. CONCLUSIONS: In addition to AFP, IGFBP-2 appears to be a suitable marker for the evaluation of the serological status of HCC patients. A longitudinal study during disease management is required to assess the full potential of IGFBP-2 measurements as a marker.     

Premature labor and indomethacin

Women in the 29th — 32nd week of gestation were admitted to hospital following the onset of premature labor contractions. After treatment with bed rest and β-stimulating drugs, those patients with persistent uterine contractions were treated with oral indomethacin (25 mg every 6 hours for 5 days). The effect of indomethacin therapy was monitored by serial external tocometry recordings. This treatment schedule with indomethacin was repeated on several occasions at intervals of 5 to 10 days. Using a standardized technique, uterine contractility was monitored every second or third day throughout the entire treatment period. In this way, the frequency of contractions was evaluated in the presence or absence of indomethacin therapy.Following indomethacin treatment, there was a significant decrease in the frequency of contractions in all cases and a complete arrest of contractions occurred in some women. An increased frequency of contractions was observed during those times that the patient did not receive indomethacin.The plasma concentration of 15-keto-13, 14-dihydro-PGF_2α, the major serum metabolite of PGF_2α, was determined by the gas chromatography — mass spectrometry method before and after indomethacin in a limited number of cases.At the doses given for the duration of therapy used, no untoward effects could be detected in either the mother or the infant. These results indicate that indomethacin is a potent and useful drug in the treatment of premature labor.     

Cytogenetic and histologic analyses of spontaneous abortions

Summary In a study of spontaneous abortions the correlations between karyotype (166 cases), anamnestic data, and macroscopic and histologic findings in placentas (107 cases) and embryos (73 cases) were analyzed. The main results were: 1. The rate of chromosomal aberrations was 39%. Trisomies predominated (60%), followed by monosomy X (20%), triploidies (14%), and structural aberrations (6%). 2. In trisomies a clear prevalence of female sex constitution (2:1) was observed. In normal karyotypes a slight prevalence of females was seen (1.2:1). 3. With increasing maternal age, more trisomies were found in the abortions. 4. Women whose index abortion had a normal karyotype had a history of fewer births but more abortions. 5. Trisomies of acrocentric chromosomes were mainly chorionic sacs with an embryo, while trisomies of the other autosomes resulted in intact empty sacs. 6. The average developmental stage of the embryos was 5 weeks, with a mean gestational age of 14 weeks. Gross malformations were found in 58% of the embryos.     

Alpha-fetoprotein in Abortion

The clinical value of maternal serum alpha-fetoprotein (AFP) as a guide to the outcome of threatened abortion was assessed. After the thirteenth week of gestation, abortion occurred more frequently (10/12) in women with abnormal serum AFP levels than in those (2/12) whose AFP concentrations were within the normal range. Low levels were present in women with blighted ovum and high concentrations were associated with intrauterine fetal death. In legal first and second trimester abortions, the circulating maternal AFP levels in postabortion samples were often higher than before abortion, irrespective of whether abortion was performed instrumentally or induced with prostaglandins. Maternal serum AFP levels provide a new means for prediction of the outcome of threatened abortion.     

Cervical ripening prior to induction of labor (intracervical application of a PG E2 viscous gel)

In 38 pregnant patients at term with unfavorable cervices labor induction was initiated with PG-E₂ after a preceding intracervical application of 0.1, 0.2 or 0.3 mg PG-E₂ in 1 ml viscous gel. The mean Bishop score improved from 3.36 to 7.0 in an average time of 2 h 37 min. The cervical diameter increased from 14 mm to 22.7 mm. 31 patients delivered their babies spontaneously, while 7 patients were delivered by cesarean section due to cervical dystocia and delayed labor. Fetal outcome was normal in all cases, with an average Apgar score of 8.7 and an average pH-value in the umbilical artery of 7.245. The study indicates that local application of PG-E₂ induces cervical dilatation, and is of particular use in patients presenting a low Bishop score. A possible local effect of PG E₂ is discussed.     

Small supernumerary marker chromosomes (SMCs): genotype-phenotype correlation and classification

Small supernumerary marker chromosomes (SMCs) are present in about 0.05% of the human population. In approximately 30% of SMC carriers (excluding the ~60% SMC derived from one of the acrocentric chromosomes), an abnormal phenotype is observed. The clinical outcome of an SMC is difficult to predict as they can have different phenotypic consequences because of (1) differences in euchromatic DNA-content, (2) different degrees of mosaicism, and/or (3) uniparental disomy (UPD) of the chromosomes homologous to the SMC. Here, we present 35 SMCs, which are derived from all human chromosomes, apart from chromosome 6, as demonstrated by the appropriate molecular cytogenetic approaches, such as centromere-specific multicolor fluoresence in situ hybridization (cenM-FISH), multicolor banding (MCB), and subcentromere-specific multicolor FISH (subcenM-FISH). In nine cases without an aberrant phenotype, neither partial proximal trisomies nor UPD could be detected. Abnormal clinical findings, such as psychomotoric retardation and/or craniofacial dysmorphisms, were associated with seven of the cases in which subcentromeric single-copy probes were proven to be present in three copies. Conversely, in eight cases with a normal phenotype, proximal euchromatic material was detected as partial trisomy. UPD was studied in 12 cases and subsequently detected in two of the cases with SMC (partial UPD 4p and maternal UPD 22 in a der(22)-syndrome patient), indicating that SMC carriers have an enhanced risk for UPD. At present, small proximal trisomies of 1p, 1q, 2p, 6p, 6q, 7q, 9p, and 12q seem to lead to clinical manifestations, whereas partial proximal trisomies of 2q, 3p, 3q, 5q, 7p, 8p, 17p, and 18p may not be associated with significant clinical symptoms. With respect to clinical outcome, a classification of SMCs is proposed that considers molecular genetic and molecular cytogenetic characteristics as demonstrated by presently available methods.Electronic database information: accession numbers and URLs for the data in this article are as follows:ENSEMBL-database, National Center for Biotechnology Information (NCBI), Genome Database (GDB), OMIM (Online Mendelian Inheritance in Man) Database,     

Amniotic fluid cell morphology in early antenatal prediction of abortion and low birth weight.

The morphology of rapidly adherent (RA) amniotic fluid cells was examined in 201 pregnant women referred for amniocentesis because of two sequential high serum alpha-fetoprotein (AFP) concentrations. Out of 43 amniotic fluid samples containing increased amounts of AFP, 42 had neural or peritoneal cells predominating among the RA cells, the outcome being an infant with a neural-tube defect or exomphalos. In the other case with a raised amniotic fluid AFP concentration but only anterior placental cells the infant was normal. In 25 amniotic fluid samples containing normal amounts of AFP distinctive new patterns of RA cells were observed, termed fetal distress cells. These pregnancies resulted in five spontaneous abortions and 20 infants with birth weights under 2500 g. Fetal distress cells were not detected in any of the remaining 133 samples. One pregnancy was terminated because of a chromosomal abnormality, and there were seven twin pairs not recognised on ultrasonography before amniocentesis. The remaining 125 pregnancies went to term, resulting in infants with birth weights exceeding 2500 g. The results suggest that RA-cell morphology will prove to be of value in the early antenatal prediction of spontaneous abortion and low birth weight.     

Cervical ripening prior to induction of labor (intracervical application of a PG E2 viscous gel).

In 38 pregnant patients at term with unfavorable cervices labor induction was initiated with PG-E2 after a preceding intracervical application of 0.1, 0.2 or 0.3 mg PG-E2 in 1 ml viscous gel. The mean Bishop score improved from 3.36 to 7.0 in an average time of 2 h 37 min. The cervical diameter increased from 14 mm to 22.7 mm. 31 patients delivered their babies spontaneously, while 7 patients were delivered by cesarean section due to cervical dystocia and delayed labor. Fetal outcome was normal in all cases, with an average Apgar score of 8.7 and an average pH-value in the umbilical artery of 7.245. The study indicates that local application of PG-E2 induces cervical dilatation, and is of particular use in patients presenting a low Bishop score. A possible local effect of PG E2 is discussed.     

Cellular and genetic restrictions in the immunoregulatory activity of alpha-fetoprotein. III. Role of the MLC-stimulating cell population in alpha-fetoprotein-induced suppression of T cell-mediated cytotoxicity

Alpha-fetoprotein (AFP), a normal component of fetal and newborn sera, exerts selective suppressive effects on various functions of thymus-derived (T) lymphocytes, including the T cell-mediated cytotoxic reaction. In the present study, AFP-induced suppression of the T cell-mediated allogeneic response was examined to define more precisely the mechanism by which AFP acts. Data presented indicate that AFP elicits its effect within the first 25 to 36 hr of culture. However, AFP apparently has no direct effect on T lymphocytes. T cells incubated in the presence of AFP retain full capacity to respond in MLC and CML. In contrast, AFP induces major changes in the functional status of monocyte-enriched, MLC-stimulating cell population. This monocyte-enriched population, after pretreatment with AFP, possesses strong stimulating capacity for the T suppressor cell limb of the immune response, while at the same time, suppresses the activity leading to the normal generation of cytotoxic T lymphocytes. These data correlate with the immune activity present in the newborn mouse.     

Premature labor and indomethacin.

Women in the 29th - 32nd week of gestation were admitted to hospital following the onset of premature labor contractions. After treatment with bed rest and beta-stimulating drugs, those patients with persistent uterine contractions were treated with oral indomethacin (25 mg every 6 hours for 5 days). The effect of indomethacin therapy was monitored by serial external tocometry recordings. This treatment schedule with indomethacin was repeated on several occasions at intervals of 5 to 10 days. Using a standardized technique, uterine contractility was monitored every second or third day throughout the entire treatment period. In this way, the frequency of contractions was evaluated in the presence or absence of indomethacin therapy. Following indomethacin treatment, there was a significant decrease in the frequency of contractions in all cases and a complete arrest of contractions occurred in some women. An increased frequency of contractions was observed during those times that the patient did not receive indomethacin. The plasms concentration of 15-keto-13, 14-dihydro-PGF2alpha, the major serum metabolite of PGF2alpha, was determined by the gas chromatography - mass spectrometry method before and after indomethacin in a limited number of cases. At the doses given for the duration of therapy used, no untoward effects could be detected in either the mother or the infant. These results indicate that indomethacin is a potent and useful drug in the treatment of premature labor.     

Endocrine Changes in Premature Labour

Plasma oestradiol and progesterone levels in peripheral blood have been studied before and during premature labour of unknown aetiology. Hormones were measured by radio-immunoassay using specific antisera. Levels in patients who delivered prematurely were compared with levels measured serially in 33 primigravidae during normal pregnancy and labour.In 19 out of 25 patients admitted in progressive premature labour the plasma oestradiol level was two standard deviations or more above the mean for the control patients of similar gestational age. The mean (± S.E. of mean) plasma oestradiol in premature labour was 19·1 ± 1·1 ng/ml, similar to levels found in labour at term (18·5 ± 1·4 ng/ml). In contrast, in over 50% of cases levels of plasma progesterone during premature labour lay below the mean for gestation though within the normal range. In six patients studied serially oestradiol levels rose dramatically, high values being detected one to 10 days before the onset of premature labour. Serial progesterone levels gave no consistent trend though one patient showed steadily decreasing values.These studies suggest that the onset of premature labour is preceded by a marked increase in peripheral plasma oestradiol levels, which may be of value not only in the prediction of premature labour but also in its prevention by suppression of the premature oestradiol surge.     

Signal for term parturition is of trophoblast and therefore of fetal origin

Up to now we know, that cytokines are key intermediates in the mechanisms, responsible for intrauterine activation in case of intra amniotic infection. The aim of our study was to investigate the role of cytokine- and prostaglandin production in normal term labor. Release of Il-6, Il-1β, TNF-, PGE₂, PGF₂ was monitored in vaginal secretions originating from uterine cavity, cervix and vagina during normal course of labor. Cells from fetal membranes, decidua and villous trophoblast, obtained from placentas of patients after spontaneous delivery (n = 12), or without labor, after elective cesarean section (n = 12), were cultured, in order to identify cytokine and prostaglandin producing cells. In all cases, term labor and parturition was associated with strongly elevated cytokine- and prostaglandin concentrations in cervical secretions. Cell culture experiments clearly demonstrated, that cells from villous trophoblast, cultured after spontaneous delivery produced significantly more cytokines and prostaglandins than cells form villous trophoblast, cultured after elective cesarean section. Cells from fetal membranes also produced more Il-6 and PGE2 after labor. In contrast to that, cells from decidua produced similar amounts of cytokines and prostaglandins before and after spontaneuos term labor. Therefore we conclude, that the signal for term labor and delivery is of trophoblast and so of fetal origin.     

Surveillance of acute flaccid paralysis in Belarus

The ten-years experience of acute flaccid paralysis (AFP) surveillance in Belarus has been summarized. Among 456 AFP cases reported from 1996 to 2005, 11 were classified as vaccine-associated paralytic poliomyelitis (VAPP), 445--as non-polio AFP. The risk of VAPP for the period 1996-2001 was 1 case per 745,000 used doses of oral poliovaccine (OPV). For the recipients of OPV the risk was 1 case per 911,700 doses and for the first-dose recipients--1 case per 96,000 doses. The high incidence of VAPP was a reason for implementation of sequential polio vaccination schedule in 2000. Guillain-Barre syndrome dominated among non-polio AFP (39.3% of cases); more rare were traumatic neuritis (27.9% of cases), transient monoparalysis (12.1%), myelitis (7.6%). Non-polio AFP differed from VAPP by following epidemiological and virological characteristics: predominance of previously repeatedly vaccinated against poliomyelitis; development of paralysis in long-term period after vaccination; isolation of non-polio viruses belonged to three serotypes of Coxsackie B viruses (B1, B4, B6) and six serotypes of Echo viruses (6, 7, 11, 14, 24, 25) in 8.1% of cases; absence of typical for polio residual paralyses in patients who excreted vaccine polioviruses.     

Trisomy and triploidy are sources of embryo mortality in the zebra finch

Hatching failure is a surprisingly common phenomenon given that natural selection constantly works against it. In birds, an average of about 10 per cent of eggs across species fail to hatch, often owing to the death of embryos. While embryo mortality owing to inbreeding is both well-documented and evolutionarily plausible, this is not true for other sources of mortality. In fact, the basis for hatching failure in natural populations remains largely unexplained. Here, we demonstrate that embryo mortality in captive zebra finches (Taeniopygia guttata) follows from chromosomal aneuploidy or polyploidy. As part of microsatellite genotyping of a captive breeding population, we found 12 individuals (3.6%) with three alleles among 331 embryos that had died during development, while there were no such cases observed among 1210 adult birds. Subsequent genotyping of 1920 single nucleotide polymorphism markers distributed across the genome in birds with three alleles at microsatellite loci, and in greater than 1000 normal birds, revealed that the aberrant karyotypes involved cases of both trisomies and triploidy. Cases of both maternally and paternally inherited trisomies resulted from non-disjunction during meiosis. Maternally inherited cases of triploidy were attributable to failure of meiosis leading to diploid eggs, while paternally inherited triploidy could have arisen either from diploid sperm or from dispermy. Our initial microsatellite screening set only had the power to detect less than 10 per cent of trisomies and by extrapolation, our data therefore tentatively suggest that trisomy might be a major cause of embryo mortality in zebra finches.     

Cytogenetic analysis of 750 spontaneous abortions with the direct-preparation method of chorionic villi and its implications for studying genetic causes of pregnancy wastage

Altogether, 750 cases of spontaneous abortion between the fifth and 25th week of gestation were analyzed cytogenetically by the direct-preparation method using chorionic villi. The majority of cases (68%) were derived from early abortions before the 12th week of gestation. The frequency of abnormal karyotypes was 50.1%; trisomy was predominant (62.1%), followed by triploidy (12.4%), monosomy X (10.5%), tetraploidy (9.2%), and structural chromosome anomalies (4.7%). Among trisomies, chromosomes 16 (21.8%), 22 (17.9%), and 21 (10.0%) were prevalent. The frequency of chromosomally abnormal abortions increased with maternal age but only because of an increase of trisomy. Polyploidy and monosomy X, however, decreased. Mean maternal age was significantly increased for trisomies 16, 21, and 22 and was highest for trisomies 18 and 20. The results obtained are within the range of variability reported earlier from tissue culture-type studies. A consistent feature during our study is the excess of females in chromosomally normal abortions (male:female sex ratio 0.71). According to the methodology applied, maternal cell contamination and undetected 46,XX molar samples cannot have influenced the sex ratio. However, a bias introduced by social status or maternal age cannot be excluded. With the more rapid and convenient direct preparation of chorionic villi, reliable cytogenetic data on causes of spontaneous abortions can be obtained.     

Pattern analysis of serum alpha-fetoprotein in the early diagnosis of hepatocellular carcinoma in liver cirrhosis

In a surveillance program for hepatocellular carcinoma (HCC), serum alpha-fetoprotein (AFP) was determined every 4 months in 164 patients with liver cirrhosis. Ultrasonography (US) was performed yearly or as dictated by abnormal AFP levels. During a follow-up of 32.5 +/- 20.8 months HCC was identified by US in 16 patients. In 9 of them the AFP levels rose steadily over 4 months, increasing 7, 8 and 12 months in 3 cases before the lesion became detectable by US. In 4 patients tumors developed despite persistently normal AFP levels. Nine more patients showed abnormal fluctuations of AFP but HCC was not detected. AFP sensitivity was higher at a low cut-off point (40 ng/ml) while specificity of the test appeared higher at the 200 ng/ml cut-off point. An AFP value rising steeply over a few months appeared more reliable than a fixed preset threshold in indicating carcinomatous transformation. Screening for AFP can be expected to uncover about 3/4 of HCC developing in cirrhotics with few false-positive reactions. The test may have a unique role in identifying a subset of liver tumors whose early expression is AFP production.