Prevalence of common aneuploidy in twin pregnancies.

The incidence of chromosomal abnormalities in twin pregnancies is not well-studied. In this retrospective study, we investigated the frequency of chromosomal abnormalities in twin pregnancies and compared the incidence of chromosomal abnormalities in dichorionic diamniotic (DD) and monochorionic diamniotic (MD) twins. We used data from 57 clinical facilities across Japan. Twin pregnancies of more than 12 weeks of gestation managed between January 2016 and December 2018 were included in the study. A total of 2899 and 1908 cases of DD and MD twins, respectively, were reported, and the incidence of chromosomal abnormalities in one or both fetuses was 0.9% (25/2899) and 0.2% (4/1908) in each group (p = 0.004). In this study, the most common chromosomal abnormality was trisomy 21 (51.7% [15/29]), followed by trisomy 18 (13.8% [4/29]) and trisomy 13 (6.9% [2/29]). The incidence of trisomy 21 in MD twins was lower than that in DD twins (0.05% vs. 0.5%, p = 0.007). Trisomy 21 was less common in MD twins, even when compared with the expected incidence in singletons (0.05% vs. 0.3%, RR 0.15 [95% CI 0.04-0.68]). The risk of chromosomal abnormality decreases in twin pregnancies, especially in MD twins.

IGF1 gene is epigenetically activated in preterm infants with intrauterine growth restriction.

BACKGROUND: IGF1 is a key molecule in the regulation of growth and metabolism. Low IGF1 secretion is known to cause growth restriction in childhood, as well as deregulated lipid metabolism, cardiovascular disease, and diabetes in adulthood. The IGF1 gene P2 promoter is highly methylated, resulting in low secretion of IGF1 in small infants and children. However, it is unknown when this methylation occurs. The aim of study was to clarify the point when this epigenetic program occurs during intrauterine development. We analyzed 56 preterm infants born before 32 weeks of gestation, including 19 intrauterine growth restriction (IUGR) infants whose birth weights were lower than - 2SD calculated by the Japanese datasets. We extracted genomic DNA from whole blood at birth; methylation of the six CpG sites in the IGF1 P2 promoter was analyzed by the bisulfite amplicon method using the MiSeq platform. RESULTS: In contrast to term infants and children, the methylation of all six CpG sites positively correlated with body weight and body length at birth. IGF1 P2 promoter methylation levels were significantly reduced in all six CpG sites in infants with IUGR. CONCLUSIONS: These findings indicated that the IGF1 gene is epigenetically activated before 32 weeks of gestation in infants with IUGR and that the activated gene may become suppressed after this time point. This study may provide new insights to prevent the onset of adult diseases and to aid in nutritional management for preterm birth infants in neonatal intensive care units.

Ultrasound evaluation of fetal critical aortic stenosis using the left atrium area/cardiac area ratio and the Doppler patterns in the pulmonary veins.

In fetal critical aortic stenosis (AS), a double reverse pattern in the pulmonary veins (PVs) is associated with a poor prognosis. We evaluated the hemodynamic changes using PV Doppler and the left atrium area/cardiac area (LA/CA) ratio in a fetus at 28 weeks of gestation with critical AS complicated with hydrops fetalis, polyhydramnios, and cardiac abnormality. A markedly enlarged LA and severe mitral regurgitation with critical AS were detected, with LA/CA ratio = 0.40 and double reverse pattern with forward/reverse velocity time integral ratio (FRVR) = 1.18 on PV Doppler. After amniotic reduction at 31 weeks, the LA/CA ratio decreased (0.24) and the FRVR in PV increased (7.11). Forward flow through the fetal aorta was seen spontaneously, and hydrops fetalis was relieved with LA volume reduction. A male neonate weighing 2171 g was delivered via cesarean section at 36 weeks with an Apgar score of 5 and 6 at 1 and 5 min, respectively. He required atrial septal opening and bilateral pulmonary artery banding after birth, followed by Norwood operation. The double reverse pattern in PVs might be reversible. The change in FRVR in PVs and LA/CA ratio would be helpful in understanding the hemodynamic change in fetal critical AS.

Effectiveness of delayed absorbable monofilament suture in emergency cerclage.

OBJECTIVE: To determine the sustained effects of emergency cerclage using slowly absorbable monofilament sutures, changes in cervical length after cerclage were evaluated in six cases. MATERIALS AND METHODS: A delayed absorbable monofilament suture (1 PDS-Plus; Ethicon, Inc., Somerville, NJ, USA) has been used for emergency cerclage after 20 weeks of gestation at Juntendo University Hospital since January 2011. A retrospective chart review was conducted including all of the patients undergoing emergency cerclage between January 2011 and August 2013. The patients' characteristics, perinatal outcome, cervical length, and obstetric data were collected. RESULTS: Six cases were identified from our medical records. Their characteristics and perinatal outcomes are shown in Table 1. Of the six cases, four had an extremely short cervix, with an average cervical length of 7.85 ± 3.38 mm, and two had prolapsed membranes. Fig. 1 shows the cervical length and the time elapsed after cerclage. There were no cases with shortening of the cervical length below the levels at the cerclage. CONCLUSION: This absorbable monofilament suture appears useful for emergency cerclage.

Double vertical compression sutures: A novel conservative approach to managing post-partum haemorrhage due to placenta praevia and atonic bleeding.

Compression has been regarded as the main haemostatic mechanism of compression sutures; however, we suggest that reduced uterine blood flow may be another important action. We suggest that our 'double vertical compression sutures' may have dual actions: haemostatic compression of the bleeding surface and reduced uterine blood flow.

Pulmonary artery size has prognostic value in low birth weight infants with congenital diaphragmatic hernia.

AIM: The aim of this study was to examine the relationship between birth weight, pulmonary artery (PA) size, and outcome in congenital diaphragmatic hernia (CDH) to establish if PA size has prognostic value. METHODS: The subjects for this study were 39 consecutive left-sided CDH patients treated at our institution according to the same protocol from 2002 to 2009. Other CDH patients with concurrent anomalies that eventually caused death or who became symptomatic more than 6 h after birth were excluded. Birth weight was used to create two groups; low birth weight (LBW; birth weight ≤ 2,500 g; n = 15) and normal birth weight (NBW; birth weight >2,500 g; n = 24). Right PA (RPA) and left PA (LPA) were measured by echocardiography (EC) during late pregnancy (fetal; gestational age (GA): 32-34 weeks), and on days 0, and 2 of life and compared. RESULTS: Mean birth weights were significantly different between the two groups; however, gender, mean GA, and outcome were similar. In LBW survivors, RPA was significantly larger than in non-survivors. PA size was not related to outcome in NBW. CONCLUSION: We are the first to show that RPA size has prognostic value in low birth weight infants with left-sided CDH.

Indications for thoracoscopic repair of congenital diaphragmatic hernia in neonates.

PURPOSE: We reviewed 26 consecutive cases of congenital diaphragmatic hernia (CDH) prospectively to establish selection criteria for successful thoracoscopic CDH repair (TR). METHODS: Five preoperative deaths were excluded, leaving 21 subjects. TR was only considered once pulmonary hypertension (PH) improved on echocardiography, and if cardiopulmonary status was stable in the decubitus position in the neonatal intensive care unit (NICU) under conventional mechanical or high-frequency oscillatory ventilation (HFOV) with/without nitric oxide (NO) for at least 10 min as a marker for tolerating surgery and manual ventilation was possible for transfer to the operating room. All other patients had open repair (OR). RESULTS: 8/21 had TR and 13/21 had OR. There were significant differences between TR and OR for prenatal diagnosis (37.5 vs. 84.6%, p < 0.05) and earlier surgery (1.4 ± 0.8 vs. 2.5 ± 1.1 days after birth, p < 0.05), respectively. Intraoperative HFOV was required in all OR and 3 TR (p < 0.01). NO was required in 1 TR and 10 OR (p < 0.01). Organ herniation was significantly less in TR (50 vs. 100%, p < 0.01 for stomach; 0 vs. 54%, p < 0.05 for liver). Three TR required conversion to OR because of technical difficulties. One OR died from deteriorating PH. CONCLUSIONS: Our selection criteria for TR would appear to be safe and reasonable.

Attempt to quantify uterine involution using acoustic radiation force impulse before and after placental delivery.

PURPOSE: The aim of the present study was to investigate whether baseline stiffness of the uterine corpus and cervix accurately estimated by acoustic radiation force impulse (AFRI) elastography changed after placental delivery. METHODS: Eleven patients with normal vaginal delivery underwent ARFI elastography before, immediately after, and 1 and 2 h after placental delivery, and the shear wave velocity was measured to determine the stiffness. Each measurement was performed in triplicate to obtain a mean ± SD. RESULTS: The shear wave velocity of the uterine corpus before, immediately after, and 1 and 2 h after placental delivery was 1.81 ± 0.60, 3.04 ± 0.76, 3.12 ± 0.95, and 2.72 ± 0.81 m/s, respectively, and the shear wave velocity of the uterine cervix was 1.35 ± 0.45, 1.87 ± 0.57, 1.68 ± 0.59, and 1.70 ± 0.5 m/s, respectively. The stiffness of the uterine corpus significantly changed over time, although that of the uterine cervix was not significantly altered. The stiffness of the uterine corpus was significantly higher immediately after and 1 and 2 h after placental delivery as compared with that before placental delivery. The uterine corpus had a significantly higher stiffness than the uterine cervix at each of the four time points examined. CONCLUSION: ARFI elastography may be useful to assess uterine involution using the shear wave velocity.

Disruption of the C-terminal helix by single amino acid deletion is directly responsible for impaired cholesterol efflux ability of apolipoprotein A-I Nichinan.

Apolipoprotein A-I (apoA-I) Nichinan, a naturally occurring variant with DeltaE235 in the C terminus, is associated with low plasma HDL levels. Here, we investigated the tertiary structure, lipid-binding properties, and ability to induce cellular cholesterol efflux of apoA-I Nichinan and its C-terminal peptide. Thermal and chemical denaturation experiments demonstrated that the DeltaE235 mutation decreased the protein stability compared with wild type (WT). ApoA-I Nichinan exhibited capabilities to bind to or solubilize lipid vesicles that are intermediate to that of WT and a L230P/L233P/Y236P variant in which the C-terminal alpha-helix folding is completely disrupted and forms relatively larger and unstable discoidal complexes, indicating that perturbation of the C-terminal alpha-helical structure by the DeltaE235 mutation leads to reduced lipid binding. Supporting this, apoA-I 209-241/DeltaE235 peptide showed significantly decreased ability to form alpha-helix both in the lipid-free and lipid-bound states, and reduced efficiency to solubilize vesicles. In addition, both apoA-I Nichinan and its C-terminal peptide exhibited reduced activity in ABCA1-mediated cellular cholesterol efflux. Thus, the disruption of the ability of the C-terminal region to form alpha-helix caused by the E235 deletion appears to be the important determinant of impaired lipid binding and cholesterol efflux ability and, consequently, the low plasma HDL levels of apoA-I Nichinan probands.

Deletion of single amino acid E235 affects the structure and lipid interaction of human apolipoprotein A-I C-terminal peptides.

The C-terminal domain of apolipoprotein (apo) A-I plays an important role in lipid binding. ApoA-I Nichinan, a naturally occurring human apoA-I variant with a deletion of E235 located in the C-terminus, is associated with low high-density lipoprotein (HDL) cholesterolemia. In the present study, a series of variant peptides corresponding to residues 220-241 of human apoA-I were examined to clarify the influences of E235 deletion (DeltaE235) on the structure and lipid interaction of the C-terminal region. NMR studies demonstrated that in trifluoroethanol, apoA-I 220-241/DeltaE235 peptide forms the alpha-helical structure similar to wild-type (WT) peptide. Circular dichroism measurements revealed that the interaction with phospholipid vesicles induced structural changes from random coil to alpha-helix both in apoA-I 220-241 WT and E235A, a variant with a negative charge ablation, peptides. These peptides also showed abilities to form HDL-like particles through microsolubilization of phospholipid vesicles, indicating that the negative charge ablation in E235 has no effect on the lipid interaction. By contrast, neither lipid binding-induced alpha-helix formation nor microsolubilization of vesicles were observed in apoA-I 220-241/DeltaE235 and L230P, a helix-breaking variant, peptides. In addition, fluorescence measurements showed that tryptophan fluorescence intensity of apoA-I 220-241/F225W greatly increased upon lipid binding, while only a little increase was observed for the corresponding DeltaE235 variant. Taken together, these results suggest that the deletion of E235 causes defective lipid binding of apoA-I Nichinan because of the impaired helix-forming ability of the C-terminal residues.

Evaluation of lipid-binding properties of the N-terminal helical segments in human apolipoprotein A-I using fragment peptides.

Although the N-terminal region in human apolipoprotein (apo) A-I is thought to stabilize the lipid-free structure of the protein, its role in lipid binding is unknown. Using synthetic fragment peptides, we examined the lipid-binding properties of the first 43 residues (1-43) of apoA-I in comparison with residues 44-65 and 220-241, which have strong lipid affinity in the molecule. Circular dichroism measurements demonstrated that peptides corresponding to each segment have potential propensity to form alpha-helical structure in trifluoroethanol. Spectroscopic and thermodynamic measurements revealed that apoA-I (1-43) peptide has the strong ability to bind to lipid vesicles and to form alpha-helical structure comparable to apoA-I (220-241) peptide. Substitution of Tyr-18 located at the center of the most hydrophobic region in residues 1-43 with a helix-breaking proline resulted in the impaired lipid binding, indicating that the alpha-helical structure in this region is required to trigger the lipid binding. In contrast, apoA-I (44-65) peptide exhibited a lower propensity to form alpha-helical structure upon binding to lipid, and apoA-I (44-65/S55P) peptide exhibited diminished, but not completely impaired, lipid binding, suggesting that the central region of residues 44-65 is not pivotally involved in the formation of the alpha-helical structure and lipid binding. These results indicate that the most N-terminal region of apoA-I molecule, residues 1-43, contributes to the lipid interaction of apoA-I through the hydrophobic helical residues.

Evaluation of congenital left ventricular aneurysm in the fetus by velocity vector imaging.

We report a case of left ventricular aneurysm evaluated using the velocity vector imaging (VVI) technique, an angle-independent method used to calculate the tissue velocity strain and strain rate on routine gray scale two-dimensional images and display the velocities of endocardial points as vectors overlaid on B-mode images. It uses a combination of speckle tracking and complex geometric analysis, allowing tracing of myocardial activity throughout the cardiac cycle. In this case, evaluation of the myocardial dynamics in the fetus by VVI was started at 27 weeks of gestation, and both the systolic and diastolic velocities and the ejection fraction in the aneurysmal segment were less than in the other segments. VVI imaging at 35 weeks of gestation showed this difference even more clearly. Postnatal VVI examination showed no significant difference between results for the systolic and diastolic velocities or ejection fraction and those obtained at the prenatal VVI examination. VVI seemed to be as useful at this time, especially for assessing ventricular systolic function, as it was for postnatal examination.

Prospective comparison of delivery outcomes of vaginal births after cesarean section versus laparoscopic myomectomy.

AIM: This study was designed to assess the delivery outcomes of vaginal birth after cesarean section in comparison with delivery after laparoscopic myomectomy. METHODS: The following data were collected: the proportion of patients who attempted vaginal birth, success rate, maternal age, previous number of vaginal deliveries, gestational weeks, birthweight, Apgar score, umbilical blood pH, and duration of labor in cases with a successful vaginal birth. RESULTS: The proportion of patients who attempted the vaginal birth differed significantly between the two groups (P < 0.0001). There were no significant differences in success rate, maternal age, number of previous vaginal deliveries, gestational weeks, birthweight, Apgar score or umbilical blood pH, although the mean duration of labor differed significantly (P = 0.006). CONCLUSIONS: The present investigation confirmed that vaginal birth after laparoscopic myomectomy is as safe as vaginal birth after cesarean section.

Significance of pulmonary artery size and blood flow as a predictor of outcome in congenital diaphragmatic hernia.

AIM: To determine if pulmonary artery size and blood flow have prognostic value in congenital diaphragmatic hernia (CDH). METHODS: Twenty-eight consecutive left-sided CDH patients treated according to a standard protocol with high frequency oscillatory ventilation (HFOV) + nitric oxide (NO) had right and left pulmonary artery (RPA, LPA) diameters, LPA/RPA diameter (L/R) ratios, and PA blood flows examined by echocardiography (EC) on days 0, 2, and 5 after birth and compared prospectively. RESULTS: Twenty-two patients (78.6%) survived. Of these, 15 required NO (NO-s), and seven did not (non-NO-s). All six patients that died required NO (NO-d). RPA in the NO-d group was significantly smaller than in the NO-s or non-NO-s groups on day 0 (2.90 +/- 0.41 vs. 3.40 +/- 0.49 or 4.01 +/- 0.43; P < 0.01, respectively). LPA in the NO-d group was significantly smaller than in the non-NO-s on day 0 (2.13 +/- 0.45 vs. 3.39 +/- 0.34; P < 0.01). L/R ratios in NO subjects were significantly smaller (NO-s 0.74 +/- 0.11; NO-d 0.73 +/- 0.11) than in non-NO-s subjects (0.84 +/- 0.03) on day 0 (P < 0.01). PA diameters and L/R ratios did not change significantly from day 0 to day 5 in all three groups. There was LPA flow on day 0 in all non-NO-s subjects, but none in all NO subjects. In the NO-s group, LPA flow was confirmed in 87% (13/15) on day 2 and in 100% on day 5, however, there was no LPA flow from day 0 to day 5 in any of the NO-d group. CONCLUSION: Our data indicate that PA diameters on day 0 and LPA flow are strongly prognostic in left-sided CDH and L/R ratio would appear to be a simple highly reliable indicator of the necessity for NO therapy.

Management of pulmonary hypertension in congenital diaphragmatic hernia: nitric oxide with prostaglandin-E1 versus nitric oxide alone.

AIM: Prostaglandin-E1 (PGE1) is used at most centers for treating pulmonary hypertension (PH) in congenital diaphragmatic hernia (CDH) because it has been regarded as effective. The aim of this study was to investigate the role of PGE1 for treating PH in CDH. METHODS: We reviewed 49 CDH cases with echocardiography-proven PH. PH was treated with PGE1 and nitric oxide (NO) and high frequency oscillatory ventilation (HFOV) from 1997 to 2001 (PG + NO; n = 19) and with NO and HFOV from 2002 to 2007 (NO; n = 30). RESULTS: Subject demographics, severity of PH, and presence of other anomalies were not significantly different between the two groups. In the PG + NO group, 12/19 (63.2%) survived (PG + NO-s) and 7/19 (36.8%) died (PG + NO-d). In the NO group, 21/30 (70.0%) survived (NO-s) and 9/30 (30.0%) died (NO-d). Survival rates were not significantly different. In the NO-s group, spontaneous closure of the ductus arteriosus (DA) was significantly earlier compared with the PG + NO-s group (P < 0.01; 4.0 +/- 0.9 vs. 9.5 +/- 2.2 days after birth). DA diameters were significantly larger in groups that died compared with groups that survived (P < 0.01), and PH persisted in groups that died. In the NO-s group, surgery was possible significantly earlier compared with the PG + NO-s group (P < 0.01; 3.75 +/- 0.67 vs. 6.12 +/- 0.78 days after birth). No NO-s case developed a PH crisis even though PGE1 was not used. Hospital stay was significantly shorter in the NO-s group compared with the PG + NO-s group (P < 0.05; 39.9 +/- 19 vs. 53.2 +/- 23 days). CONCLUSION: Nitric oxide alone would appear to simplify the management of CDH with PH and provide better outcome.

Beta2-microglobulin required for cell surface expression of blastocyst MHC.

Blastocyst MHC is a mouse MHC class Ib gene that is selectively expressed in blastocysts and placenta like human HLA-G, which protect fetal trophoblasts and some tumor cells from NK cell attack, and in TAP-dependent expression on the cell surface. We expressed blastocyst MHC cDNA in beta2-deficient EL-4 S3 or beta2m-transfected EL-4 S3 cells. In parental EL-4 S3 cells, only 47-kDa blastocyst MHC protein was expressed and retained in the cytoplasm. However, additional 51-kDa blastocyst MHC protein was expressed on the surface of beta2m-transfected EL-4 S3 cells. The 51-kDa protein was resistant to Endo-H, whereas the 47-kDa protein was sensitive for Endo-H. The results suggested that beta2m as well as TAP was necessary for the transportation of blastocyst MHC from endoplasmic reticulum to cell surfaces through the Golgi apparatus, similar to other MHC class I molecules.

Blastocyst MHC, a putative murine homologue of HLA-G, protects TAP-deficient tumor cells from natural killer cell-mediated rejection in vivo.

Blastocyst MHC is a recently identified mouse MHC class Ib gene, which is selectively expressed in blastocyst and placenta, and may be the mouse homolog of HLA-G gene the products of which have been implicated in protection of fetal trophoblasts from maternal NK cells and evasion of some tumor cells from NK cell attack. In this study, we identified two blastocyst MHC gene transcripts encoding a full-length alpha-chain (bc1) and an alternatively spliced form lacking the alpha2 domain (bc2), which may be homologous to HLA-G1 and HLA-G2, respectively. Both placenta and a teratocarcinoma cell line predominantly expressed the bc2 transcript. When these cDNAs were expressed in TAP-deficient RMA-S or TAP-sufficient RMA cells, only bc1 protein was expressed on the surface of RMA cells, but both bc1 and bc2 proteins were retained in the cytoplasm of RMA-S cells. Significantly, the RMA-S cells expressing either bc1 or bc2 were protected from lysis by NK cells in vitro. This protection was at least partly mediated by up-regulation of Qa-1(b) expression on the surface of RMA-S cells, which engaged the CD94/NKG2A inhibitory receptor on NK cells. More importantly, the bc1- or bc2-expressing RMA-S cells were significantly protected from NK cell-mediated rejection in vivo. These results suggested a role for blastocyst MHC in protecting TAP-deficient trophoblasts and tumor cells from NK cell attack in vivo.