Changes in placental adipocytokine gene expression associated with gestational diabetes mellitus.

Leptin and adiponectin, two adipocytokines, may work together in regulating energy homeostasis and insulin action. Leptin gene expression has been investigated in term placental tissue complicated by gestational diabetes mellitus (GDM), but never in conjunction with all isoforms of the leptin receptor (LEPR A-D), or with adiponectin receptors (ADIPOR1 and 2). In this study we examined the association between changes in expression of these genes in placental tissue and GDM risk. We assessed placental gene expression of leptin, LEPR A-D and ADIPOR1 and 2 by real time PCR using mRNA from maternal and fetal biopsies. Tissues were collected from uncomplicated pregnancies (n=28) and those complicated by GDM (n=19). Gene expression was normalized to three endogenous housekeeping genes. Relative gene expression values were reported as fold change between groups. Adiponectin gene expression was out of the sensitive range of our assay. There were increases in leptin mRNA expression in GDM cases compared with controls for maternal-side (p=0.06), and fetal-side (p=0.09) placental biopsies. No significant changes were seen in GDM cases compared with controls in LEPR A-D or ADIPOR1 and 2. mRNA derived from maternal-side tissue was positively correlated with tissue from the fetal side for all genes studied (all p<0.01). Finally, we noted that absence or presence of GDM was a major factor in leptin mRNA expression after adjusting for maternal age, mode of delivery, parity and smoking status. In conclusion, increases in leptin mRNA expression in term placenta, but not that of its receptors, are associated with the diagnosis of GDM. Changes seen in the ligand, but not the receptor, of the leptin pathway in GDM-complicated pregnancies may also apply to the adiponectin pathway, as the ADIPOR1 and 2 mRNAs do not change with GDM diagnosis.

Evaluation of housekeeping genes in placental comparative expression studies.

Preeclampsia and diabetes are complications of pregnancy that contribute to maternal and perinatal mortality worldwide. Results emerging from molecular studies of placentae may elucidate etiologically important genomic alterations. Appropriate application of real time reverse transcription (RT) PCR in comparative gene expression studies requires endogenous housekeeping genes to normalize between sample variations. Ideal housekeeping genes must have stable tissue expression, but few have been specifically studied in the placenta. We sought to identify candidate control genes by analyzing seven functionally distinct housekeeping genes (B2M, GAPDH, HMBS, HPRT, SDHA, TBP, YWHAZ) for their expression stability and level in the placenta. mRNA isolated from 20 placentae was analyzed for gene expression using RT-PCR. Expression stability (M) was assessed using normalization strategies previously used for other tissues. TBP and SDHA were the most stable, with an average expression stability of M = 0.43, followed by YWHAZ (M = 0.44) > HPRT (M = 0.53) > HMBS (M = 0.57) > GAPDH (M = 0.61) > B2M (M = 0.69). The genes tested ranged in abundance, with an approximately 300-fold increase from the lowest (HMBS) to the highest (B2M). By using TBP, SDHA and YWHAZ, with greater expression stability than those housekeeping genes commonly used in placenta studies, gene expression profile comparisons will have more sensitivity and specificity.

Leptin, soluble leptin receptor and leptin gene polymorphism in relation to preeclampsia risk.

Few investigators have simultaneously evaluated leptin, soluble leptin receptor (SLR) and leptin gene polymorphisms in preeclampsia cases and controls. We examined these three biomolecular markers in 40 preeclampsia cases and 39 controls. Plasma leptin and SLR concentrations were determined using immunoassays. Genotype for the tetranucleotide repeat (TTTC)(n), polymorphism in the 3 -flanking region of the leptin gene was determined using PCR. Alleles of the polymorphism were characterized by size distributions [short repeats (class I); and long repeats (class II)]. Logistic regression was used to calculate odds ratios (OR) and 95 % confidence intervals (CI). Leptin concentrations were higher in our cases than in the controls (53.1 4.7 vs. 17.7+/-2.4 ng/ml, p<0.05). SLR concentrations were slightly lower in our patients than in the controls (25.7+/-1.9 vs. 29.1+/-1.1 ng/ml, p>0.05). Elevated leptin (? 14.5 ng/ml) was associated with a 3.8-fold (CI 1.0-14.4) increased risk; whereas low SLR (< 28.5 ng/ml) was associated with a 6.3-fold (CI 1.7-23.2) increased risk of preeclampsia. The I/II genotype was associated with a 3.8-fold increased risk of preeclampsia (OR=3.8; 95 % CI 0.8-18.0); and the II/II genotype was not observed among our cases (0 % vs. 33 % p<0.001). Larger studies would be needed to confirm and further clarify the relations between functional variants in the leptin gene and preeclampsia risk.

Infantile polycystic kidney disease: observations from attempts at prenatal diagnosis.

Three successive pregnancies of a couple at risk for infantile polycystic kidney disease were evaluated by sequential ultrasound examinations to attempt prenatal diagnosis of the disorder. The gestational age at which renal sonographic changes were noted varied from 20 to 34 weeks and resulted in both false-positive and false-negative diagnoses.

Maternal serum alpha-fetoprotein and fetal trisomy-21 in women 35 years and older: implications for alpha-fetoprotein screening programs.

A retrospective study of 3,411 women who underwent midtrimester amniocentesis for fetal chromosome analysis between June 1979 and August 1984 was performed to evaluate an association between low maternal serum alpha-fetoprotein (AFP) concentrations and Down syndrome (DS) pregnancies. A total of 71 pregnancies was found with abnormal fetal chromosomes; of these, 26 cases were trisomy-21 and 10 cases were trisomy-18. The maternal serum AFP in women with DS fetuses was relatively lower than levels in women with fetuses that had normal chromosomes. In addition, the AFP concentrations in amniotic fluid were decreased in cases involving DS fetuses. We have estimated the risks for DS pregnancy at all maternal ages and most serum AFP concentrations. Using these calculations, genetic counselors will be able to provide more accurate risk estimates for trisomy-21 following maternal serum AFP testing.

Prenatal diagnosis of neural tube defects: predictive value of AF-AFP in a low-risk population.

Amniotic fluid alpha-fetoprotein (AF-AFP) determinations were performed on 1,215 women who were at low risk for fetal neural tube defects and who were undergoing mid-trimester amniocentesis for cytogenetic indications, primarily age-related aneuploidy. Maternal sera obtained before amniocentesis and amniotic fluids were assayed in duplicate for alpha-fetoprotein by radioimmunoassay. Of the 1,215 low-risk women, eight (0.7%) had significant elevations of AF-AFP (greater than or equal to +5 SD). In none of the cases was the elevation associated with a fetal neural tube defect. Two cases with elevated AF-AFP were associated with chromosome aberrations; one with impending fetal demise; one with fetal blood contamination; and one case was due to a laboratory error. In one case, no source for the elevated AFP was found, and a normal infant was delivered at term. In the final two cases, the cause of the elevated AF-AFP was a fetal abdominal wall defect (one gastroschisis and one omphalocele). The predictive value of an elevated AFP varies with the population screened, and is reduced by routine ultrasonography before amniocentesis, which at least identifies anencephaly. In a low-risk population, an elevated AF-AFP is most often not associated with a fetal neural tube defect. Because of the low predictive value and the nonspecificity of AF-AFP, genetic counselors should reconsider the recommendation of routine AF-AFP in low-risk maternal populations.

Rh isoimmunization related to amniocentesis.

We report on the incidence of Rh isoimmunization after genetic amniocentesis at our institution. In 115 Rh negative women who underwent amniocentesis and subsequently delivered Rh positive infants, there were 4 (3.4%) sensitizations before birth. This was significantly greater than the 1.5% rate of gestational sensitization found in pooled populations of women who did not undergo amniocentesis. We also noted a significant increase in the number of sensitizations that occurred before 28 weeks. The results were consistent with those of previous studies of this issue, and are discussed in relation to current policies for managing Rh negative women who have second trimester amniocentesis.

Prenatal genetic diagnosis and elective abortion in women over 35: utilization and relative impact on the birth prevalence of Down syndrome in Washington State.

We have examined the relative contributions of a population-based antenatal detection program and unrestricted elective abortion used by women 35 years old and over in Washington State and King County for 1976--1977 to the declining birth prevalence of Down syndrome (DS). The amniocentesis/live birth (LB) ratio for women 35 years old and over was 20.5/100 LBs for King County and 11.7/100 LBs for Washington State in 1977. For the state in 1976, abortion ratios/1,000 LBs were 571 for women 35 to 39 years old and 1,096 for women 40 years old and over. Based on the total Washington State data, elective abortion has a greater impact on averting DS births than does the antenatal detection program. The impact of elective abortion appears to be related to its disproportionate use by women 35 years old and over compared to their contribution to the population of of LBs.

Low material serum alpha-fetoprotein levels and congenital diaphragmatic defects.

We report on 2 cases of fetal congenital diaphragmatic defects with normal chromosomes among 105 patients referred for evaluation for low maternal serum alpha-fetoprotein (MSAFP) levels. The mechanism for this striking association is not clear. The association of low MSAFP levels and congenital diaphragmatic defects may have importance for MSAFP screening programs.

Umbilical cord hemangioma associated with extremely high alpha-fetoprotein levels.

We report a case of an umbilical cord hemangioma associated with extremely high alpha-fetoprotein levels in maternal serum and amniotic fluid, as well as a positive acetylcholinesterase band.

Cervical cytology. Increased sensitivity with a second cervical smear.

Two consecutive Papanicolaou smears were obtained in 3524 patients during a single clinic visit. The first smear consisted of a combined cervical scrape and vaginal pool sample (Fast smear) while the second smear contained only a cervical scrape. Of the 93 patients with abnormal cytology, 71 (76%) patients were identified by the first smear and 74 (80%) by the second smear. The interpretation of the two smears correlated in 51 patients (54.8%). Of the remaining 42 patients, the cytologic findings were more advanced in the second smear in 19 cases, and in 23 cases the reverse was true. There were 19 instances in which the cytologic findings were suspicious or positive. In 8 (42.1%) of these 19, one of the two smears contained either negative (7) or atypical (1) cytologic findings. The histologic diagnosis corresponded to the more advanced cytologic findings in all cases. The addition of the second cervical smear increased the detection rate of suspicious of positive cytology by 26.3%.

Enlarged cisterna magna and the Dandy-Walker malformation: factors associated with chromosome abnormalities.

Thirty-three fetuses with an enlarged cisterna magna (10 mm or more) were evaluated to determine factors that might be associated with an underlying chromosome abnormality. Eighteen fetuses (55%) proved to have a chromosome abnormality, including trisomy 18 or trisomy 18 variant (12), trisomy 13 (three), Turner syndrome (one), or other rearrangements (two). Among various risk factors analyzed, the absence of ventricular dilatation correlated most strongly with a chromosome abnormality. Chromosome abnormalities were found in 17 of 22 fetuses (77%) lacking ventricular dilatation, compared with only one of 11 fetuses (9%) with ventricular dilatation (P less than .001). Other factors statistically associated (P less than .01) with an underlying chromosome abnormality included mild enlargement of the cisterna magna (10-14 mm), concurrent anomalies detected sonographically, and fetal growth retardation. However, stepwise logistic regression showed that only the absence of ventricular dilatation and the presence of concurrent anomalies were significant when multiple factors were evaluated. These observations support the utility of evaluating the cisterna magna as part of a routine anatomical survey.

Fetal monitoring and predictions by clinicians: observations during a randomized clinical trial in very low birth weight infants.

Predictions about perinatal outcome in very low birth weight infants were studied in a randomized clinical trial of electronic fetal monitoring and periodic auscultation to assess the effect of diagnostic monitoring information on clinicians' ability to predict perinatal outcomes. The only predictions consistently correct before monitoring information was available were those regarding infant survival (88% correct, kappa [kappa] = 0.40, P less than .001 for the electronic fetal monitoring group; 80% correct, kappa = 0.35, P less than .01 for the periodic auscultation group). After monitoring, predictions of 5-minute Apgar scores and arterial cord pH were significantly more accurate, and clinicians' confidence in their predictions increased significantly in both the electronic fetal monitoring and the auscultation groups. Predictions of 5-minute Apgar scores were significantly more accurate in the electronic fetal monitoring group (92% correct, kappa = 0.80) than in the periodic auscultation group (61% correct, kappa = 0.28) (Z difference = 3.04; P less than .01). We conclude that clinicians gain information during intrapartum monitoring that generally leads to improved predictions and increased confidence in predictions. In this study, they made more accurate predictions about 5-minute Apgar scores with electronic fetal monitoring, suggesting that electronic fetal monitoring may provide better information about neonatal well-being than does periodic auscultation. Improved information, as measured by clinical predictions, is probably highly valued by patients and clinicians and may be an important determinant of acceptance of this diagnostic technology.

Intraperitoneal fetal transfusion under direct ultrasound guidance.

The outcomes of 77 fetal intraperitoneal transfusions in 35 pregnancies managed with direct ultrasound guidance and intensive perinatal management were reviewed. Patients were monitored with amniocentesis, and standard indications were used for timing of transfusions. The mean gestational age at first transfusion was 27.3 weeks (range 22-33). The overall mortality rate was 14% (five of 35). No immediate transfusion-related deaths occurred; all fetuses who were not hydropic at first transfusion survived (26 of 26). The mean gestational age at delivery was 33.6 weeks (range 25-36). One infant developed respiratory distress syndrome (RDS). Transfusion-related complications occurred in five cases (fetal colon infusions in two, fetal retroperitoneal infusion in two, and fetal abdominal wall hematoma in one). None of these infants required urgent delivery or suffered long-term sequelae. In nonhydropic fetuses, intraperitoneal transfusions under direct ultrasound guidance had a low incidence of morbidity and no mortality. These results should provide baseline data against which to compare new techniques, such as direct cord transfusion. With neonatal mortality rates of 10% and significant morbidity rates of 10-20% in infants delivered at 32 weeks who develop RDS, intraperitoneal transfusion should be considered in the 32- to 33-week fetus with marked pulmonary immaturity.

Prenatal sonographic findings of Down syndrome: review of 94 cases.

Prenatal ultrasound findings were reviewed in 94 consecutive fetuses with proved Down syndrome (trisomy 21) during a 6-year period at a single institution. One or more abnormalities were found in 31 fetuses (33%), including two of 11 fetuses seen before 14 weeks, 17 of 68 fetuses seen between 14-24 weeks, and 12 of 15 fetuses seen after 24 weeks. Major anomalies detected included cardiac defects (five), duodenal atresia (four), cystic hygromas (four), omphalocele (two), hydrops (two), and hydrothorax (one). Nuchal thickening was observed in five fetuses, including four of 25 second-trimester fetuses evaluated prospectively during the last 2 years of the study. Mild cerebral ventricular dilatation (three) and hyperechogenic bowel (five) are new findings that have not been generally associated with Down syndrome. A variety of prenatal sonographic abnormalities may be associated with Down syndrome, and the frequency of detecting most abnormalities increases with menstrual age. Anomalies more frequently detected before 20 weeks include cystic hygromas, nuchal thickening, and hyperechogenic bowel. Awareness of the sonographic findings associated with Down syndrome should result in improved detection of this disorder.

Cesarean birth and neonatal mortality in very low birth weight infants.

The authors attempted to relate neonatal mortality to method of delivery in a series of 345 infants, weighing 700 to 1500 g, who were born in King County, Washington, from 1977 to 1979. Overall, 38% of infants delivered vaginally died as opposed to 32% of those with cesarean births. However, after adjustment for birth weight, presentation, and place of delivery, cesarean birth was not associated with reduction in mortality. Even among those infants with a breech presentation, a group believed (on the basis of previous studies) to particularly benefit from cesarean birth, the data failed to show any mortality reduction. Based on the results of this study of very low birth weight singleton infants, it appears that the reduced neonatal mortality associated with cesarean birth, if present at all, is small in magnitude.

A prospective evaluation of a second-trimester screening test for fetal Down syndrome using maternal serum alpha-fetoprotein, hCG, and unconjugated estriol.

OBJECTIVE: To test the efficacy of a screening protocol using a combination of maternal age plus three biochemical markers--maternal serum alpha-fetoprotein (MSAFP), hCG, and unconjugated estriol (E3)--for the antenatal detection of fetal Down syndrome. METHODS: We conducted a prospective cohort study of 7718 women who underwent the triple-marker analysis between weeks 15-18 of pregnancy. A second-trimester risk for Down syndrome of 1:195 or greater was considered positive. Sensitivity, specificity, positive predictive value, and their 95% confidence intervals (CIs) were calculated. We evaluated test performance for various maternal age groups and screen-positive cutoffs, as well as the relative screening efficacies of maternal age and MSAFP, MSAFP plus hCG, and MSAFP, hCG, and unconjugated E3. RESULTS: Four hundred sixty-one of the 7718 women screened (6%) were identified as positive; 319 women chose amniocentesis, for an overall amniocentesis rate of 4.1%. Twenty of 22 pregnancies affected with Down syndrome were correctly identified, as were 7255 of 7696 unaffected pregnancies, yielding a sensitivity and specificity of 91% (95% CI 79-100%) and 94% (95% CI 93.8-94.8%), respectively. The use of maternal age plus all three analytes improved test performance compared with maternal age plus MSAFP and hCG, but either had a significantly improved detection rate compared with that for maternal age and MSAFP alone. CONCLUSION: The triple-marker screen appears to be an effective method of detecting Down syndrome pregnancies while maintaining an acceptable amniocentesis rate.

A randomized trial of electronic fetal monitoring in preterm labor.

Intrapartum electronic fetal heart rate (FHR) monitoring and fetal blood gas sampling were compared with periodic auscultation of FHR in a multicentered randomized trial of preterm singleton pregnancies with fetal weights of 700-1750 g. Two hundred forty-six pregnancies were studied (electronic FHR monitoring N = 122, auscultation N = 124). Perinatal or infant death was associated with 14% of pregnancies with electronic FHR monitoring and 15% with auscultation. No significant differences were noted in the prevalence of low five-minute Apgar scores, intrapartum acidosis, intracranial hemorrhage, or frequency of cesarean section (P greater than .10). Compared with electronic FHR monitoring, intrapartum auscultation as done in this study is unlikely to be associated with detectable differences in perinatal outcomes within the high-risk setting of preterm labor.

Influence of pre-eclampsia on fetal growth.

OBJECTIVE: We examined the effect of pre-eclampsia on fetal growth in a cohort of pregnant women delivering singleton infants. METHODS: Analyses were restricted to 155 women with pre-eclampsia and 5570 normotensive women. Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) after adjusting for confounders. We estimated ORs for very low birth weight (VLBW; < 1500 g), low birth weight (LBW; < 2500 g), and small for gestational age (SGA; weight < or = 10th centile by each gestational age, race, sex and parity strata) in relation to maternal pre-eclampsia status. RESULTS: After adjusting for maternal age, race, smoking, Medicaid status and gestational age, the OR for VLBW was 30.7 (95% CI 7.0-134.9). Pre-eclampsia was associated with a 3.8-fold increased risk of LBW (95% CI 1.9-7.5). Women with pre-eclampsia were 3.6 times more likely to deliver an SGA newborn as compared with normotensive women (95% CI 2.3-5.7). Advanced maternal age, African-American race, parity or smoking status did not modify the associations of pre-eclampsia with LBW and SGA. CONCLUSIONS: Our results are consistent with other reports that have documented a strong relationship between pre-eclampsia and restricted fetal growth. Further, our results expand the literature by documenting a particularly strong association between pre-eclampsia and VLBW. However, our findings regarding the relationship between pre-eclampsia and fetal growth may be confounded by unmeasured factors including maternal weight prior to pregnancy and pregnancy weight gain.

Relationship of maternal plasma leptin and risk of pre-eclampsia: a prospective study.

OBJECTIVE: We measured maternal plasma leptin concentrations in 55 women with pre-eclampsia and 487 normotensive women to determine whether elevated leptin concentrations were associated with the occurrence of pre-eclampsia. METHODS: Maternal blood samples were collected at 13 weeks' gestation, on average. Plasma leptin concentrations were determined using immunoassay. Logistic regression procedures were used to calculate odds ratios (OR) and 95% confidence intervals (95% CI). RESULTS: Leptin concentrations were 78% higher in cases than control subjects (median 34.6 vs. 19.5 ng/ml; p < 0.001). Relative to women with leptin concentrations of < 27.4 ng/ml, those with elevated leptin concentrations (> or = 27.4 ng/ml) experienced a 2.3-fold increased risk of pre-eclampsia (OR 2.3; 95% CI 1.1-4.6). We observed evidence of a strong linear component of trend in risk of pre-eclampsia with increasing maternal plasma leptin concentration. Each 10-ng/ml increase in leptin concentration was associated with a 30% increase in pre-eclampsia risk (OR 1.3; 95% CI 1.1-1.5). Overweight women with elevated leptin concentrations experienced the highest risk of pre-eclampsia (OR 6.4; 95% CI 3.1-13.2) as compared with lean women with no leptin elevations. CONCLUSION: Elevated plasma leptin concentration and maternal overweight status appear to be independently associated with an increased risk of pre-eclampsia.