Progesterone receptor isoform A inhibits isoform B-mediated transactivation in human amnion.

Human amnion cells were transfected with progesterone receptor A and/or B, and the progesterone-dependent reporter construct, mouse mammary tumor virus promoter (MMTV), linked to a luciferase gene. In progesterone receptor B-expressing amnion that had been cultured before the onset of labour, treatment with progesterone resulted in an eightfold increase of the reporter activity, whereas in laboured cells, no such increase was seen. In contrast, progesterone receptor A was a weak activator of transcription in laboured and non-laboured amniocytes. When the isoforms A and B of the progesterone receptor were co-transfected, progesterone receptor A exhibited a marked inhibitory effect on progesterone receptor B-mediated transcription. These results show that progesterone receptors A and B function differentially, and progesterone receptor A is a transdominant repressor of progesterone receptor B-mediated transcription in human term amnion.

Interactions between progesterone receptor isoforms in myometrial cells in human labour.

Progesterone acts to maintain uterine quiescence during pregnancy. In contrast to many other species, no decrease in maternal serum levels of progesterone can be observed in humans before the onset of labour. Therefore, a 'functional' progesterone withdrawal in association with labour has been proposed. In humans the progesterone receptor (PR) exists in two isoforms, PR-A and PR-B. While PR-B generally mediates the effects of progesterone upon gene transcription, the role of PR-A during pregnancy, and in parturition, is unknown. In this study, term myometrium cells cultured before the onset of labour were transiently transfected with expression vectors for either PR-A or PR-B. Only those cells expressing PR-B significantly increased expression of a progesterone-sensitive reporter when stimulated with progesterone. Co-transfection of both isoforms of PR demonstrated that PR-A is a dominant repressor of transactivation in these cells. Western blot analysis showed that PR-A is present in human myometrium samples taken only after, but not before, the onset of labour. These data suggest that increased expression of PR-A in human myometrium may contribute to 'functional' progesterone withdrawal and the initiation of human labour.

Human labour is associated with nuclear factor-kappaB activity which mediates cyclo-oxygenase-2 expression and is involved with the 'functional progesterone withdrawal'.

Human labour is associated with the up-regulation of prostaglandins within the uterus, synthesized via the type-2 cyclo-oxygenase enzyme (COX-2). These lead to remodelling of the fetal membranes and cervix and to stimulation of myometrial contractions. In the human, the principal source of prostaglandins is the amnion. Progesterone acts to promote myometrial quiescence, and in many species the onset of labour is preceded by withdrawal of progesterone. Humans show no systemic progesterone withdrawal, although biochemical changes within the uterus are similar to those in other species. A mutual negative interaction between the transcription factor nuclear factor (NF)-kappaB and the progesterone receptor (PR) has been reported. Using transient transfections and assays for transcriptional activation and promoter binding, we have shown that there is constitutive activity of NF-kappaB in amnion cells at the time of labour, and that COX-2 expression depends upon NF-kappaB. In cells obtained before labour, in which NF-kappaB activity is low, increasing the concentration of PR represses NF-kappaB dependent transcription, while stimulation with IL-1beta both increases NF-kappaB activity and represses PR activity. Our data suggest that human labour is associated with constitutive NF-kappaB activity within the amnion, which functions to increase the expression of COX-2 and appears to contribute to the 'functional progesterone withdrawal'.

[The pregnant patient in dental care. Survey results and therapeutic guidelines]. / Die schwangere Patientin in zahnärztlicher Behandlung. Umfrageergebnisse und therapeutische Richtlinien.

In a telephone survey using a standardized questionnaire, 78 resident dentists in Germany, Switzerland and Austria were interviewed with respect to several aspects of the dental treatment of pregnant women. Only 58% of the interviewees decided clearly in favour of local anaesthetics, 59% supported the use of analgesics, 70% a possible antibiotic therapy and 33% a radiological examination during pregnancy. In addition, according to references in the specialist literature guidelines for the dental treatment, drug therapy and radiological diagnosis of pregnant women are presented. The local anaesthetics should have a high plasma protein bonding (articain, bupivacain, etidocain) and a minimum adrenaline concentration. Paracetamol is the analgesic of choice. If an antibiotic treatment is required, penicillin, cephalosporin and erythromycin are recommended. In particular during the first three-month period, radiological examinations should be restricted to the absolute minimum and performed only if no reasonable alternative is available, even though the radiological burden on the foetus falls 500,000 times short of the limit value of 50 mgray (5 rad) in the case of a microradiogram, and 50,000 times short of the limit value in the case of an orthopantomogram.

RhD genotyping by quantitative fluorescent polymerase chain reaction: a new approach.

OBJECTIVE: To develop a new method of RhD/d genotype determination using a quantitative fluorescent PCR (QF-PCR) assay. METHODS: Polymerase chain reaction amplification (PCR) of fragments of exon 7 of both the RHD and RHCE genes was performed from 32 amniotic fluid and 26 chorionic villus samples known to be heterozygous for the RHD gene, 74 peripheral blood samples of RhD-positive blood donors (homozygous or heterozygous) estimated by serologic typing and 24 RhD-negative fetal samples. The number of copies of the RHD gene in RhD-positive samples was determined by comparing the fluorescent intensities of the amplification products specific for the RHD and the RHCE genes. RESULTS: A ratio of fluorescent intensities of 1:1 clearly indicated D/D homozygous individuals whereas a ratio of 1:2 was demonstrated in samples from D/d heterozygous individuals. The mean fluorescent intensity ratio of the peak areas of homozygous samples was 1.12 (SD 0.128), the mean ratio of the peak areas of heterozygous samples was 0.51 (SD 0.060). Complete agreement was obtained between RhD/d typing by QF-PCR and RhD genotypes assessed by family studies and serological methods. CONCLUSIONS: The fluorescent PCR-based DNA test allows easy, rapid and accurate determination of the zygosity for the RHD gene. This new technique provides useful information for the clinical management of pregnancies of sensitised RhD-negative mothers.

Numerical chromosomal aberrations of chromosome 1 and 7 in dysplastic cervical smears.

Cervical smears with Papanicolaou's staining (PAP) reveal only morphological characteristics of epithelial cells of the cervix uteri. Since chromosomal aberrations are known to play a role in malignant transition, we analyzed cervical smears for numerical changes of the chromosomes 1 and 7 with fluorescence in-situ hybridization to probe for a diagnostic value of these chromosomes in the characterization of cervical dysplasia. Cervical smears were collected from 21 patients with suspect histology of curettage or biopsy specimen, 14 of them having been subsequently graded as cervical intraepithelial neoplasia (CIN) III and 5 as CIN II. Nineteen normal cervical smears (PAP I-II) served as controls. Smears were hybridized with chromosomal enumeration probes for chromosome 1 and 7. Disomic cells (2 copies of chromosome 1 and 7) were decreased in the CIN II (63%) and CIN III group (57%) with respect to the control group (77%). Cells with 3 signals for chromosome 7 were significantly more frequent in the CIN III and the CIN II group than in the control group (6.7, 6.4 and 0.7%, respectively). Only the CIN II group (10%), but not CIN II (6%), showed a significant trisomy for chromosome 1 as compared with the controls (3.8%). A close correlation between the incidence of trisomy 1 or 7 and PAP grading was observed. PAP III-IIID smears with high trisomy 1 counts corresponded to CIN III histology, while all CIN II patients were PAP III-IIID with low incidence of trisomy 1. We conclude that trisomy of chromosome 7 is a feature of cervical dysplasia and seems to be an early event in dysplastic transition. In contrast, trisomy of chromosome 1 is observed only in high grade dysplasia and may be a marker for pre-malignant lesions.

Rapid prenatal diagnosis of aneuploidy by quantitative fluorescent PCR on fetal samples from mothers at high risk for chromosome disorders.

We report the results of a prospective study using quantitative fluorescent polymerase chain reaction (QF-PCR) and small tandem repeat markers (STR) for the rapid prenatal detection of aneuploidies in a group of pregnant women at increased risk of having fetuses with numerical chromosome disorders. Amniotic fluid samples (n = 52) were collected from mothers undergoing prenatal invasive testing for fetal abnormalities on ultrasonographic examination or abnormal maternal serum aneuploidy screening results. All samples were tested by cytogenetic analysis, but rapid diagnoses of aneuploidies were offered and performed using QF-PCR analysis with several STRs specific for chromosomes 21, 18, 13 and X. All cases with numerical chromosome aberrations involving chromosomes 21, 18 and 13 (n = 8) were correctly diagnosed. Three gonosomal aneuplodies (one 47,XXY and two 45,X) were not detected because they were uninformative for the X markers. Another sample with a deletion (46,XX,7q-), that the present assay was not designed to detect, was not identified. One sample was heavily contaminated with maternal blood and the results of the QF-PCR assays were uninformative. The remaining samples from normal fetuses provided QF-PCR patterns disomic for chromosomes 21, 18, 13 and X. Our study demonstrates that QF-PCR is a rapid method for the detection of common numerical chromosome disorders and it may play an important role in prenatal diagnosis for women at high risk for fetal aneuploidy.

Five-year results after anti-incontinence operations.

OBJECTIVE: This study was undertaken to evaluate continence rates 5 years after anterior colporrhaphy, anterior colporrhaphy with needle suspension of the bladder neck, and Burch colposuspension. STUDY DESIGN: Among 544 women with stress incontinence who were operated on between 1989 and 1993, 327 women (60%) underwent clinical and urodynamic reevaluation 5 years after the operation. Choice of surgical procedure was made on the basis of clinical and urodynamic findings and of physician preference. Continence was defined as no loss of urine during cystometry or during coughing with the bladder filled to 300 mL. RESULTS: The 327 patients underwent a total of 334 operations. The objective overall continence rates at 5 years were 61% (65/107) after anterior repair, 49% (59/121) after anterior repair with needle suspension, and 79% (84/106) after Burch colposuspension. Continence rates after anterior colporrhaphy were 82% (32/39) among patients with mild stress incontinence but 49% (33/68) among those with moderate or severe incontinence (P <.02). Continence rates among patients with moderate or severe incontinence were 49% (59/121) after anterior repair with needle suspension and 79% (84/106) after the Burch operation (P <.02). CONCLUSION: Anterior colporrhaphy can cure mild stress incontinence but is inadequate to correct severe incontinence. Additional needle suspension may be of benefit for patients with moderate to severe incontinence. Abdominal colposuspension is superior to the vaginal operations for long-term cure of stress incontinence.

Pressor and mesenteric arterial hyporesponsiveness to angiotensin II is an early event in haemorrhagic hypotension in anaesthetised rats.

OBJECTIVE: Vascular responsiveness to vasoconstrictors is known to be attenuated in haemorrhagic shock. In this study we assessed the temporal development and the underlying mechanisms of haemorrhage-induced vascular hyporeactivity to pressor agents. METHODS: In phenobarbital-anaesthetised rats hypotension was induced by graded haemorrhage (8 ml blood total). Sham-manipulated rats served as controls. Blood flow (BF) was recorded with ultrasonic transit time flow probes. RESULTS: Following haemorrhage mean arterial pressure (MAP) fell by 25-45 mm Hg and was accompanied by a reduction in mesenteric BF without any alteration of mesenteric vascular conductance (VC). While pressor responses to arginine vasopressin remained unaltered, hyporesponsiveness to phenylephrine (10 nmol kg-1) developed 120-180 min after hypotension had been induced. Pressor and mesenteric constrictor responses to angiotensin II (30 pmol kg-1) became significantly blunted as early as 60 min post haemorrhage. The hypotensive effect of an angiotensin1 receptor antagonist, telmisartan (1 mg kg-1), was likewise blunted 3 h after haemorrhage. Pretreatment with the cyclooxygenase inhibitor indomethacin (10 mg kg-1) exaggerated the hypotensive reaction to haemorrhage but did not prevent the development of angiotensin II hyporesponsiveness. In contrast, the nitric oxide (NO) synthase inhibitor NG-nitro-L-arginine methyl ester (10 mg kg-1), as investigated 3 h post haemorrhage, restored the systemic pressor responses to angiotensin II and phenylephrine as well as the mesenteric constrictor responses to phenylephrine to normal level and diminished the mesenteric hyporesponsiveness to angiotensin II. Glibenclamide (20 mg kg-1), an inhibitor of ATP-sensitive K- channels given 180 min post haemorrhage, partially reversed haemorrhage-induced hypotension but did not modify angiotensin II hyporesponsiveness. CONCLUSION: Systemic pressor responsiveness and mesenteric arterial reactivity to endogenous and exogenous angiotensin II is selectively impaired at an early stage of haemorrhagic hypotension. This phenomenon partially involves NO and is not related to ATP-sensitive K+ channels.

Body mass index and outcome of incontinence surgery.

OBJECTIVE: To analyze the influence of body mass on the outcome of surgery for urinary incontinence. METHODS: Among 291 women operated on for stress incontinence, 187 (64%) were available for follow-up at 5 years. Eighty women had anterior colporrhaphy, 49 anterior colporrhaphy with needle suspension of the bladder neck, and 58 Burch colposuspension. Body mass index was calculated preoperatively and at follow-up. Women were classified as being of normal weight (body mass index [BMI] 20-25), overweight (BMI 26-30), or obese (BMI greater than 30). Reported continence rates were analyzed according to BMI for each operation and the BMIs of continent patients were compared with those of incontinent patients. RESULTS: The continence rates at 5-year follow-up for anterior colporrhaphy, anterior colporrhaphy with needle suspension of bladder neck, and Burch colposuspension were 58, 51, and 86%, respectively (P < .001). The continence rates did not differ significantly among the three BMI groups for each procedure. A statistical power of 26% was found for the hypothesis that the outcome of the procedures does not depend on BMI. The preoperative and postoperative BMIs of continent and incontinent women for each procedure did not differ significantly. CONCLUSION: We did not find preoperative obesity to be a risk factor for failure of incontinence surgery, but the power of our study was limited.

Concomitant endometrial hyperplasia in patients with endometrial carcinoma.

OBJECTIVES: The aim of this study was to compare the histopathologic features and prognosis of patients with endometrial carcinoma with and without concomitant hyperplasia. METHODS: Histologic slides of the surgical specimens of 214 consecutive patients who underwent surgery as primary treatment for endometrial carcinoma from 1985 through 1991 were reviewed. RESULTS: Ninety-two of the 214 patients (43%) with endometrial carcinoma had concomitant endometrial hyperplasia. Patients with endometrial carcinoma with hyperplasia were significantly younger than those without hyperplasia (mean age 62 +/- 10 vs 65 +/- 9 years, P < 0.05). Carcinomas associated with hyperplasia were better differentiated and of lower surgical stage. By univariate analysis the frequency of recurrence was significantly lower (4% vs 17%, P < 0.004) and the estimated 5-year survival rate significantly higher (96% vs 85%, P < 0.01) in patients with endometrial carcinoma with concomitant hyperplasia. However, in multivariate analysis the presence of endometrial hyperplasia was not an independent prognostic factor and the 5-year survival rates of patients with or without hyperplasia did not differ significantly in any surgical stage. CONCLUSION: The presence or absence of concomitant endometrial hyperplasia is strongly correlated with the surgical stage of endometrial carcinoma.

[Needle suspension methods in the treatment of urinary stress incontinence]. / Nadelsuspensionsmethoden für die Behandlung der Stressinkontinenz.

In 1959 A.J. Pereyra published a simple transvaginal surgical method to elevate and fixate the bladder neck and proximal urethra with a specially designed needle in women with stress urinary incontinence. This method was repeatedly modified during the last 35 years. Mild to moderate stress incontinence with or without pelvic floor relaxation is regarded as an indication for needle bladder neck suspension. Contraindications include severe stress incontinence, low-pressure urethra, urge incontinence and recurrent stress incontinence. Postoperative continence rates range from 40% to 91% depending on inclusion criteria, preoperative diagnostics, criteria for success or failure, and duration of follow-up. There are no controlled clinical studies comparing different needle suspension techniques.

Malignancy arising in extraovarian endometriosis during estrogen stimulation.

OBJECTIVE: Endometriosis can undergo estrogen-dependent changes similar to endometrium and may carry a risk of developing hyperplasia and carcinoma during unopposed estrogen stimulation. MATERIAL-METHOD: We reviewed the existing literature to analyze the potential of a malignancy arising from extraovarian endometriosis by estrogen stimulation. RESULTS: To our knowledge, there are 20 published cases so far, with a malign transformed endometriosis during estrogen stimulation at an extraovarian site. The most common site of malignancy arising from endometriosis was the vagina (n = 5). The most common histological finding was adenocarcinoma (n = 13). The incidence of malignant transformation in extraovarian endometriosis during unopposed estrogen replacement can not be estimated based upon these case reports. CONCLUSION: Unopposed estrogen stimulation may lead to premalignant or malignant transformation in the residual foci of endometriosis. Therefore, the addition of progestins to estrogen replacement therapy should be considered in women who have undergone hysterectomy with oophorectomy because of endometriosis, especially if they are known to have residual endometriosis.

Timing of urethral pressure pulses before and after continence surgery.

In continent women, urethral pressure with stress events has been found to rise approximately 200 msec before pressure in the bladder begins to rise. We studied the time difference in incontinent women, women after successful and unsuccessful incontinence procedures, and continent women, to evaluate the timing of urethral pressure rises in correlation with continence status. We analyzed the urodynamic data of 20 incontinent patients before and after successful or unsuccessful (n = 10 each) Raz needle suspension. Ten continent women served as controls. The time difference between onset of the pressure increase in the urethra and in the bladder was noted before and after surgery. In all 10 continent women the pressure increase in the urethra started to rise approximately 160 msec before the pressure increase in the bladder. In 16 of 20 incontinent patients the pressure in the urethra and bladder rose simultaneously. Successful antiincontinence procedures restored the early onset of urethral pressure increases. Unsuccessful operations did not produce this effect. Successful antiincontinence operations permit timely compression of the urethra. This timely compression is associated with continence.

Tumor angiogenesis as a prognostic factor in ovarian carcinoma: quantification of endothelial immunoreactivity by image analysis.

BACKGROUND: The growth of a malignant tumor requires the formation of new capillaries. Quantification of these microvessels is difficult. The purpose of this study was to establish an objective technique for quantifying angiogenesis and to evaluate whether microvessel quantity may predict tumor aggressiveness in patients with ovarian carcinoma. METHODS: Endothelial area was used to quantify microvessel density in immunohistochemically stained sections of 28 International Federation of Gynecology and Obstetrics Stage IIIC ovarian carcinomas. The endothelial area was measured with a computer-aided image analysis system in the subepithelial stroma of highest vascularization. The endothelial area in the specimens of 14 patients who survived for > or =6 years was compared with that of 14 patients matched for stage and treatment who died of the disease. RESULTS: The mean tumor area analyzed was 5.04 +/- 0.23 mm2. The mean endothelial area per mm2 of stroma from survivors and dead patients was 0.038 +/- 0.026 mm2 and 0.110 +/- 0.034 mm2, respectively (P < 0.0001). No significant differences were found in histology, tumor grade, status of lymph nodes, and amount of residual tumor. CONCLUSIONS: Image analysis was used to overcome the potential subjectivity of manual counts. Computer-assisted image analysis can evaluate accurately the angiogenic potential in ovarian carcinomas. Tumor angiogenesis may prove to be a prognostic factor in patients with ovarian carcinoma. This study suggests that the measurement of the endothelial area would be clinically useful in determining microvessel density [See editorial on pages 2219-21, this issue.]

Endometroid carcinoma arising with a scar endometriosis.

Malignant alteration of endometriosis has already been reported. Endometroid carcinoma is the most common histological differentiation. However, this is the first report of an endometroid carcinoma arising within a scar endometriosis.

Pregnancies in patients with premature ovarian failure.

We present 5 women with premature ovarian failure (POF) who were treated with different regimes and conceived. Three patients conceived spontaneously while on cyclic estrogen/progestagen replacement therapy. One patient conceived after high-dose gonadotrophin treatment. Embryo transfer with oocytes donated from a third party donor was performed in one patient abroad. Due to legal reasons the heterogeneous oocyte donation for patients with POF cannot be performed in some countries such as Austria. Therefore, many patients who desire pregnancy cannot receive optimal treatment for their condition.

Contrast sonography for inconclusive findings on routine sonography.

OBJECTIVES: We conducted a pilot study in 20 women with sonographically suspect endometria, to assess the value of contrast sonography and patient acceptance of this procedure. METHODS: Saline solution 4-20 ml was injected into the uterine cavity using an embryo transfer catheter, followed by hysteroscopy in 19 cases and hysterectomy in one case. RESULTS: A polyp was diagnosed in 12 patients, a submucous myoma in one patient, a proliferated endometrium in five patients and a placental polyp in one patient. A sonographic irregular structure was diagnosed in one patient which turned out to be coagula on hysteroscopy and histology. The procedure was well accepted by all patients. The diagnosis found by contrast sonography agreed in all cases with that found by hysteroscopy. CONCLUSION: Our results show that contrast sonography is an easy, quick and inexpensive procedure which increases the diagnostic value of vaginal sonography. The indications for contrast sonography are based on inconclusive sonographic findings, especially if polyps or submucous myoma are suspected.

[Value of ultrasound in early detection of endometrial carcinoma]. / Stellenwert der Sonographie bei der Früherkennung des Endometriumkarzinoms.

OBJECTIVE: The purpose of our study was to examine the diagnostic value of the biometry of the endometrium for the early detection of endometrial carcinomas in postmenopausal women as well as to compare our results with those of other authors. METHODS: In 69 post menopausal women the endometrial thickness measured by vaginosonography before diagnostic curettage or hysterectomy was compared with the histological results. RESULTS: Using a cutoff value of 6 mm, a sensitivity of 96%, a specificity of 24%, a positive predictive value of 16%, and a negative predictive value of 97% were established. CONCLUSIONS: Endovaginal ultrasound evaluation of the endometrial thickness is not specific enough to be used screening method for the early detection of endometrial carcinoma.