A Case of Successful Selective Abortion Using Radio-frequency Ablation in Twin Pregnancy Suffering from Severe Twin to Twin Transfusion Syndrome

Twin to twin transfusion syndrome (TTTS) is one of the major complication of monochorionic twin pregnancy which is mainly understood by placental vascular anastomosis. Perinatal mortality and morbidity is high as 80-100% if untreated and even higher if the disease is developed at early stage. Variety of methods of isolating or intercepting placental vascular anastomosis are introduced, but they are only available in centers where all the required equipments are prepared. We report here a case of TTTS complicated with severe polyhydroamnios during the second trimester. The blood supply to donor twin was interrupted successfully at 19+2 weeks of gestation by minimally invasive radio-frequency cord ablation, under ultrasound guidance. The normal recipient twin was delivered successfully at 35 weeks of gestation and had no eventful neonatal course.

A Case of Successful Selective Abortion Using Radio-frequency Ablation in Twin Pregnancy Suffering from Severe Twin to Twin Transfusion Syndrome

Twin to twin transfusion syndrome (TTTS) is one of the major complication of monochorionic twin pregnancy which is mainly understood by placental vascular anastomosis. Perinatal mortality and morbidity is high as 80-100% if untreated and even higher if the disease is developed at early stage. Variety of methods of isolating or intercepting placental vascular anastomosis are introduced, but they are only available in centers where all the required equipments are prepared. We report here a case of TTTS complicated with severe polyhydroamnios during the second trimester. The blood supply to donor twin was interrupted successfully at 19+2 weeks of gestation by minimally invasive radio-frequency cord ablation, under ultrasound guidance. The normal recipient twin was delivered successfully at 35 weeks of gestation and had no eventful neonatal course.

The value of serum CA 125 in tubo-ovarian abscess / 대한산부인과학회지

OBJECTIVE: The aim of this study is to measure the serum levels of CA 125, ESR and CRP in patients with tubo-ovarian abscess (TOA) before and after treatment of abscess and to assess the usefulness of CA 125 in the diagnosis, prediction of the outcome of TOA treatment and clinical follow-up of patient's condition. METHODS: This retrospective study included 65 patients with TOA. Serum CA 125, ESR, CRP and WBC counts were measured. The treatment was done conservatively with antibiotics. The patients were divided into two groups: those with successful results into group 1 (29 cases) and those with unsuccessful results into group 2 (36 cases). If treatment was considered to be unsuccessful, surgical intervention was additionally performed. RESULTS: The serum levels of CA 125, ESR and abscess size on admission in group 2 were significantly higher than in group 1. ESR, abscess size and CA 125 in order were valuable predictive factors affecting the success of medical treatment. And the new cutoff value was 36.5 mm/h, 4.2 cm and 68.3 U/ml, respectively. The sensitivity rate of CA 125, ESR levels was significantly higher in group 2 than in group 1. Although CRP was decreased significantly 10 days after treatment, the serum CA 125 was not decreased significantly. And it took 51.5 days for CA 125 to be normalized after the initiation of treatment. CONCLUSIONS: The serum CA125, ESR levels and abscess sizes are predictive factors affecting the success of medical treatment of abscess treatment. And CA 125 and ESR are useful for diagnosing severity of disease. But serum CA 125 level is an inappropriate marker for monitoring short-term efficacy of treatment.

Evaluation of the factors affecting the success of the trial of vaginal birth and duration of labor in women with previous cesarean section / 대한산부인과학회지

OBJECTIVE: The purpose of this study was to determine which factors influence the likelihood of successful trial of labor, to evaluate the risks of VBAC and to evaluate the criteria of dystocia and the safety of VBAC. METHODS: This retrospective study was peformed based on 61 pregnant women who succeeded VBAC, 37 VBAC failure women, 100 nulliparas and 100 multiparas. RESULTS: In clinical characteristics, the parity, the number of previous cesarean section, gestational age, estimated fetal body weight by ultrasonography, and neonatal body weight had notable differences between the success and the failure group. In obstetric and historical factors, cervical effacement, dilation, and Bishop score at admission, spontaneous labor and method of induction of labor had differences. Among these factors, estimated fetal body weight by ultrasonography, cervical effacement and augmentation of labor using oxytocin were the most prognostic factors affecting the success of VBAC. In VBAC group, the duration of active-phase, second phase and total duration of labor were 313.5, 36.4 and 350.2 minutes, which were significantly shorter than nulliparas, but longer than multiparas. CONCLUSION: The trial of labor after cesarean section will decrease repeat operation, if it is performed under exact understanding of successful prognostic factors and the unique time length of labor. It will contribute to increase advantages for mother and economic benefits.

Prenatal ultrasonographic diagnosis of Fetus in Fetu at 2nd trimester: A case report / 대한산부인과학회지

Fetus in fetu is an very rare condition in which a vertebrate fetus is incorporated within its twin. Although a number of cases were reported at 3rd trimester of gestation or postnatally, the authors present a retroperitoneal fetus in fetu with 9 x 7 x 6 cm sized cystic mass that was diagnosed at 2nd trimester using ultrasonography and confirmed on a computed tomography scan after birth. The mass was successfully excised postnatally and consistent with a fetus in fetu by pathological confirmation. Solid mass was surrounded by a fluid-containing sac and showed highly ordered organogenesis around an axial vertebral column.

Association of genetic polymorphisms in the peroxisome proliferator-activated receptor-gamma and methylenetetrahydrofolate reductase with preeclampsia in Korean women / 대한산부인과학회지

OBJECTIVE: To investigate whether polymorphisms of genes encoding peroxisome proliferator-activated receptor-gamma (PPAR gamma) and methylenetetrahydrofolate reductase (MTHFR) are associated with preeclmapsia in Korean women and also to demonstrate whether there is any haplotypic association between preeclampsia and those genes. METHODS: DNA was extracted from whole blood of 226 preeclampsia patients and 235 healthy pregnant women. The genotypes of SNPs in PPAR gamma (-796A>G, P12A (C>G), H447H (161C>T)) and MTHFR (A222V (677C>T), E429A (1298A>C), R594Q (1793G>A)) were analyzed by a single base primer extension assay using a SNaPShot assay kit. Results were analyzed with the Student's t-test, Chi-square test, and Logistic regression analysis. Haplotype analyses were performed using Haploview 3.2 version. RESULTS: There were no significant differences in genotype or allele frequencies of PPAR gamma and MTHFR gene polymorphisms between preeclampsia patients and controls (p>0.05). No increase in the risk of preeclampsia for those genes was observed under any model of inheritance. Among SNPs of the PPAR gamma, MTHFR genes, only SNPs in MTHFR gene (677C>T, 1298A>C, 1793G>A) were in a strong linkage disequilibrium with each other (Lod score>2.0), but there were no significant differences in genotype distribution of haplotypes of MTHFR gene (TAG, CAG, CCA, CCG) between preeclampsia patients and controls (p>0.05). No statistically significant associations were observed between any haplotypes of MTHFR gene and preeclampsia risk. CONCLUSION: This study suggest that SNPs in PPAR gamma and MTHFR gene were not associated with preeclampsia in Korean women, and its haplotypes were also not associated with preeclampsia.

Tailored selective termination in second trimester in twin pregnancy / 대한산부인과학회지

OBJECTIVE: Recently, selective termination is employed in multifetal pregnancies, in the presence of an abnormal fetus, or in the complication of twin pregnancies. The purpose of this study is to evaluate effectiveness, safety of the tailored selective termination in multifetal pregnancies. METHODS: This study was retrospective and involved six cases. Indication of termination were 3 cases of structural anomalies (anencephaly, encephalocele, body stalk anomaly), 1 case of chromosomal anomaly (21 trisomy) and 2 cases of monochorionic twin complications (acardiac twin, twin to twin transfusion syndrome). RESULTS: We used KCL injection in 4 cases, they were all confirmed dichorionic twin, and in 2 cases of monochorionic twin, we used alcohol ablation of intra-abdominal umbilical artery in 1 case, and radiofrequency ablation of the cord in 1 case. CONCLUSION: All procedures were successful, and all normal infants were delivered in 3rd trimester. Tailored selective termination in 2nd trimester is effective and safe in abnormal multifetal pregnancies.

Association of the vascular endothelial damage and estrogen, progesterone / 대한산부인과학회지

OBJECTIVE: The aim of this study were to examine the serum level of estradiol, estriol, progesterone, oxidized LDL in preeclamtic patients and to evaluate the protective effects of estrogen and progesterone against lysophosphatidylcholine (LPC) induced cell death in Human umbilical vein endothelial cells (HUVECs). METHODS: We analysed the serum level of estradiol, estriol, progesterone, oxidized LDL in patients with preeclampsia and control. We used LPC to induce cell death in HUVECs. For cytotoxic assay, we did LDL assay for cell death and Resazurin assay for cell viability. HUVECs were exposed to various concentrations of LPC, LPC+estrogen, LPC+progesterone and we did cytotoxic assay. RESULTS: The serum estradiol, estriol were lower in the preeclamptic patients (P<0.05). Oxidized LDL were higher in the preeclamptic patients(P<0.05). LPC induced cell death in a concentration-dependant manner. Estrogen or progesterone inhibited LPC-induced cell death in a concentration-dependant manner (P<0.05). CONCLUSION: Estrogen and progesterone attenuated LPC-induced cytotoxicity. The results suggest that Oxidized LDL induced endothelial damage in preeclampsia may be induced by low serum estradiol, estriol and progesterone levels and prevented by estrogen and progesterone addition.

Prenatal Ultrasonographic and Molecular Diagnosis of Apert Syndrome: A case report / 대한산부인과학회지

Apert Syndrome is a kind of developmental disorder characterized by the craniosynostosis by synostosis of the coronal suture, bilateral symmetric syndactyly of the limbs (mitten-like hands and feet), midfacial hypoplasia, and variable degree of mental retardation. In 1894, Wheaton did the first description, and in 1906, it was named by Apert. Apert Syndrome is a rare autosomal dominent disorder and the prevalance at birth is estimated from 1:100000 to 160000. This syndrome is developed by the result of a mutation in the fibroblast growth factor receptor 2 gene (FGFR 2) located at 10q25.3-26. In familial cases, diagnosis in the first trimester sometimes has been made. But In sporadic cases, mostly it has been diagnosed in the second or third trimester by ultrasonography. In Korea, Apert syndrome is so rare, and it has not yet been reported that Apert syndrome is defined by prenatal molecular diagnosis with ultrasonographic detection. We present a case of prenatal molecular definitive diagnosis of Apert syndrome suspected strongly by ultrasonographic finding with a brief review of literature. Mother of affected fetus was transferred to our hospital at 31(2) weeks' gestation due to abnormal fetal ultrasound finding of severe polyhydroamnios and bilateral syndactyly of hands detected at 26(3) weeks' gestation. We suspected Apert syndrome by fetal ultrasonographic finding, and then confirmed Apert syndrome by DNA analysis of fetal amniocyte from therapeutic amnioredution at 31(4) weeks' gestation.

The Study of 5,10-Methylenetetrahydrofolate Reductase Polymorphism and Its Effect on Pregnancy Outcomes among the Korean Population / 대한주산의학회잡지

OBJECTIVE: The purpose of this study was to analyze MTHFR polymorphism among the Korean population and to evaluate the relationship between serum levels of homocysteine and MTHFR polymorphism and also to investigate the effect on pregnancy outcomes. METHODS: DNA was extracted from whole blood of 600 pregnant women. All samples were genotyped for the C677T and A1298C polymorphisms in MTHFR gene by PCR-RELP assay. Serum levels of homocysteine and folate were measured by high performance liquid chromatography for homocysteine and radioassay for folate. Pregnancy outcomes were estimated by gestational weeks and birth weights of newborns. RESULTS: Serum homocysteine was higher in women with the T/T genotype than those with the C/T or C/C genotype of the MTHFR C677T polymorphism (p<0.05). And also serum homocysteine was higher in women with the A/A genotype than those with the A/C or C/C genotype of the MTHFR A1298C polymorphism (p<0.05). Serum homocysteine was negatively correlated with serum folate in all MTHFR genotypes, especially prominent in T/T genotype of MTHFR C677T polymorphism and A/A genotype of MTHFR A1298C polymorphism. Gestational age and the birth weight of infant from hyperhomocysteinemic mothers whose homocysteine levels higher than 15 micromol/L were 36.1 weeks, 3053.8g, respectively, which were significant lower than those from normohomocysteinemic mothers (38.3 weeks, 3,215.3g) (p<0.05). CONCLUSION: Serum homocysteine was influenced significantly by MTHFR C677T polymorphism and MTHFR A1298C polymorphism. MTHFR C677T and A1298C polymorphism and serum homocysteine levels affect pregnancy outcomes, although not mainly by serum folate level.

Fetal pulmonary sequestration complicated hydrops: Successful fetal therapy by thoracoamniotic shunting / 대한산부인과학회지

Pulmonary sequestration is development mass of nonfunctioning bronchopulmonary tissue that is separate from the normal tracheobroncheal tree and receives arterial blood from the systemic circulation. Pulmonary sequestration has an excellent prognosis and frequently can be seen to regress spontaneously on serial prenatal sonogram. But in cases with hydrops the prognosis is poor and associated with a high rate of perinatal mortality and severe respiratory insufficiency in the newborn. We report the case of a fetus presenting at 31 weeks with generalized hydrops, bilateral hydrothorax and a left pulmonary hyperechogenic mass, successfully treated by thoracoamniotic shunting using a catheter and amniodrainage. Serial ultrasound showed normal growth and normal amniotic fluid volume. The newborn did not require surgery and long-term outcome was normal. Based on this observation, the natural history of pulmonary sequestration and prenatal management options are reviewed and discussed.

Vascular Endothelial Growth Factor and Angiopoietin-1 and -2 mRNA Expressions in Invasive Cervical Carcinoma / 대한산부인과학회잡지

OBJECTIVE: This study was aimed to investigate the vascular endothelial growth factor (VEGF) mRNA and angiopoietin (Ang) -1 and -2 mRNA expressions between cervical cancer and normal cervix, and to assess the relationships among their expression and other prognostic factors of invasive cervical cancer. METHODS: The tissues were obtained from 34 patients with cervical cancer and 14 patients with normal cervix undergoing hysterectomy. Total RNA was extracted and reverse transcribed into cDNA. RT-PCR and QC-PCR was performed to evaluate VEGF and Ang-1 and -2 mRNA expressions. Clinicopathologic factors of cervical cancer were reviewed with the patient's charts and results were analyzed with Mann-Whitney U test, Spearman correlation test and logistic regression analysis. RESULTS: VEGF, Ang-1 and -2 mRNA expression in cervical cancer was higher than that in normal cervix (p<0.05) and there were significant correlations between Ang-2 mRNA expression and VEGF mRNA expression in all stage of cervical cancer (p<0.05). A definite correlation was found between VEGF mRNA expression and clinical stage, SCC-Ag levels, lymph node metastasis of cervical cancer (p<0.05). Also, There was significant correlation among Ang-2 mRNA expression and clinical stage, tumor sizes, SCC-Ag levels, lymph node metastasis of cervical cancer (p<0.05). Ang-1 mRNA expression was significantly correlated with clinical stage of cervical cancer (p<0.05). CONCLUSION: The expression of VEGF mRNA, Ang-1 and -2 mRNA could be associated with the progression and metastasis of cervical cancer and might have a role as prognostic parameters in cervical cancer.

Successful Management with Intra-abdominal Alcohol Ablation of Acardiac Twin and Amniodrainage in Twin Reversed Arterial Perfusion Sequence with Severe Polyhydramnios / 대한산부인과학회잡지

Twin reversed arterial perfusion (TRAP) sequence is a unique complication of monochorionic twinning, in which normal pump or donor twin paradoxically perfuses the recipient or acardiac twin through arterial- arterial anastomoses. This results in reversed flow of poorly oxygenated blood through the recipient twin and is usually associated with partial or complete lack of heart development. The pump twin has a mortality rate of 50% as a result of high-output heart failure, preterm labor, and polyhydramnios. We present here a case of twin reversed arterial perfusion (TRAP) sequence complicated by severe polyhydramnios during the second trimester. The blood supply to acardiac twin was interrupted successfully at 25 weeks of gestation by injecting 1.5 mL of absolute alcohol into the intra-abdominal portion of the single umbilical artery, under ultrasound guidance. Serial ultrasound showed normal growth and normal amniotic fluid volume in normal pump twin, but arrest of growth in femur length and decrease in amniotic fluid volume in acardiac twin. The normal pump twin was delivered at 384 weeks of gestation and had uneventful neonatal course.

Synchronous Multiple Primary Malignant Neoplasm Involving the Uterine Endometrium and Ovary / 대한산부인과학회잡지

Multiple primary malignant neoplasm means that more than 2 cancers are independently developed in one individual. In general, the neoplasms are diagnosed simultaneously or within 6 month interval. Simultaneous presentation of carcinomas involving ovary and uterus is not a common event and presents a diagnostic dilemma when they are of the same histology. We experienced a rare case of multiple primary malignant neoplasm involving the uterine endometrium and the ovary synchronously. Thus we report this case with a review of literatures.

Relationship between Genetic Polymorphisms of the Gltathione S-transferase and Endometriosis Susceptibility in Korean Populations / 대한산부인과학회잡지

OBJECTIVE: The aim of this study was to examine whether polymorphic variation in GSTs confers susceptibility to Endometriosis in Korean populations. METHODS: The GSTM1, GSTT1, and GSTP1 genotypes were determined in 124 patients with Endometriosis (stage 3, 4) and 155 healthy control subjects at Ewha woman's university Mok-dong hospital from 1996 to 2003. RESULTS: The homozygous wild allele in GSTP1 gene was most common genotypes both Endometriosis and healthy control groups (69.4% vs. 64.5%). Neither the heterozygous nor homozygous mutant allele in GSTP1 gene differed in frequency between the two groups (30.6% vs 35.5%). When null mutations in GSTM1, GSTT1 were combined with GSTP1 polymorphism, there was no evidence of increase in the risk of endometriosis, as the number of high risk alleles of the GST family increased. CONCLUSION: Our findings suggest that GSTP1 genetic polymorphism may not be associated with development of Endometriosis in Korean populations. There is no evidence of a trend in increasing risk with the number of putative high risk alleles of the GST family carried.

The Effect of Hyperhomocysteinemia on the Preeclampsia / 대한산부인과학회잡지

OBJECTIVE: The purpose of this study was, at the time of delivery, to determine if an elevated plasma homocysteine level is associated with the development of preeclampsia and to investigate whether 677 (C->T) polymorphism in the 5, 10-methylenetetrahydrofolate reductase (MTHFR) gene, folate status and vitamin B12 levels are risk factors for the development of preeclampsia for Korean pregnant women. METHODS: DNA was extracted from whole blood of 191 healthy pregnant women and 84 preeclampsia patients. All samples were genotyped for the 677 (C->T) polymorphism in MTHFR gene by polymerase chain reaction (PCR-RELP). Serum levels of homocysteine, folate, and vitamin B12 were measured by high preformance liquid chromatography for homocysteine, and radioassay for folate and vitamin B12. RESULTS: Women with severe preeclampsia showed higher concentrations of serum homocysteine (10.5 micro mol/L) than healthy pregnant women (8.46 micro mol/L) and women with mild preeclampsia (8.24 micro mol/L) (p=0.09). For serum folate levels, women with severe (12.7 ng/ml) or mild (13.2 ng/ml) preeclampsia showed increased level compare to healthy pregnant women (9.23 ng/ml) (p=0.0046). Increased homocysteine level (>14 micro mol/L) was associated with preeclampsia (odds ratio=2.86, 95% confidence intervals: 1.27-6.45). CONCLUSION: These results are suggesting that hyperhomocysteinemia in pregnancy could be a risk factor of preeclampsia. Preeclampsia patients with higher serum folate level are speculated to represent a compensatory response to oxidative stress.

Association Studies of the Relationship Between Endometriosis and Polymorphism of the Detoxification Enzymes GSTT1, GSTM1, and CYP1A1 / 대한산부인과학회잡지

OBJECTIVE: Enzymes belonging to the Glutathione S transferase and cytochrome P450 families are involved in the two-stage detoxification process of a number of pro-carcinogens. We genotyped each 74 women with moderate or severe endometriosis and a control group of 93 women with a normal pelvis at cesarian section to investigate whether genetic polymorphism of CYP1A1, GSTT1, and GSTM1 are associated with endometriosis. MATERIALS AND METHODS: We investigate 74 women who were operated for endometriosis and 93 women who had no endometriotic lesion proved by operation. Polymerase chain reaction (PCR) and restriction fragment length polymorphism of PCR was done to determine each participant's genotype. RESULTS: We have found no significant differences between cases and controls in the frequencies of the GSTM1 and GSTT1 null mutations, or of the CYP1A1 MspI polymorphism does not differ significantly between groups. When GSTT1 and GSTM1 null mutation was combined with CYP1A1 MspI polymorphism, there was no significant differences between groups, either. CONCLUSION: Therefore, These low penetrance genes are not associated with increased susceptibility to endometriosis. Further studies are warranted to identify major susceptibility gene (s) and the mechanism involved in endometriosis to assist in the development of better methods for early detection, diagnosis and prevention.

A Case of Primitive Neuroectodermal Tumor of the Uterus / 대한산부인과학회잡지

Primitive neuroectodermal tumor (PNET) is a rare tumor derived from fetal neuroectodermal cells. These tumors occur in the central nervous system and peripheral locations, but the occurrence of primitive neuroectodermal tumors located in the uterus is extremely rare. We present a 53-year-old woman with primitive neuroectodermal tumor of the uterus confirmed by immunohistochemical staining. We have experienced one case of PNET of the uterus and wish to report with brief review of concerned literature.

Birth Defects Monitoring Systems Utilizing Public and Private Medical Resources in Incheon / 대한산부인과학회잡지

OBJECTIVE: To discover the etiology of birth defects and low birth weight, it is necessary to establish epidemiological birth defects monitoring system in Korea. Our aim was to develop new practical model in Incheon to establish birth defects monitoring system to evaluate the incidence rate and patterns of birth defects in Korea. METHODS: Public health center and private hospitals and clinics participated in this monitoring system. Web based reporting system have been built. Trained nurses actively collected the records obtained from delivery units in the participating hospitals during 2 years (first year: December 1st, 1998-November. 31, 1999; second year: January 1 st, 2000-December 31 th, 2000). RESULTS: Through this monitoring system at 1 st year and 2 nd year, we observed 25 birth defect cases from 2482 births, 28 birth defect cases from 3490 births including live births and stillbirths. The incidence of birth defect per thousand person was 10.1, 8.0 respectively. At 1st year, the highest proportion of birth defects was 28.0% in musculoskeletal system. The proportion of birth defects in gastrointestinal system, cardiovascular system and cleft lip & cleft palate were 20.0%, 12.0%. 12.0%. At 2 nd year, the highest proportion of birth defects was 21.4% in gastrointestinal system The proportion of birth defects in cardiovascular system and musculoskeletal system were 17.9% and 14.3%. CONCLUION: In conclusion, we could build population-based monitoring system for birth defects successfully in Yonsu gu, Incheon. To establish population-based monitoring system for birth defects in Korea, it is necessary to organize the reporters of public health center and private hospitals and clinics, to build an available reporting system, and to extend participating centers for birth defects monitoring systems.

A study on the association between angiotensinogen gene and angiotensin-converting-enzyme gene and pregnancy-induced hypertension in Korean women / 대한산부인과학회잡지

OBJECTIVES: Previous studies have suggested an association of pregnancy-induced hypertension(PIH) with several genes involved in cardiovascular control. The objectives of this study were to evaluate the association between PIH and angiotensinogen(AGT) M235T gene and also to study the association between PIH and angiotensin-converting- enzyme(ACE). METHODS: DNA was extracted from whole blood, cheek swabs, and blood spot cards of 39 PIH patients and 54 controls. Controls consisted of women who had undergone at least two term pregnancies unaffected by PIH. All samples were genotyped for all the polymorphism using PCR of known alleic variants. Results were ananlyzed with a kappa2 contingency table. RESULTS: Four of 13 women with mild PIH(30.8%) and thirteen of 26 women with severe PIH(50.0%) were heterozygous for AGT M235T mutation compared with 26 of 54 controls(48.1%). Two of 13 women with mild PIH(15.4%) and two of 26 women with severe PIH(7.7%) were homozygous for AGT M235T mutation compared with 10 of 54 controls(18.6%). Six of 7 women with mild PIH(85.7%) and ten of 21 women with severe PIH(47.6%) were ID type for ACE gene compared with 31 of 56 controls(55.4%). One of 7 women with mild PIH(14.3%) and seven of 21 women with severe PIH(33.4%) were DD type for ACE gene compared with 15 of 56 controls(26.7%). There was no significance between mild, severe PIH patients and controls for AGT M235T mutation and ACE gene polymorphism. CONCLUSION: In Korean population, AGT M235T mutation and ACE gene are not associated with an increased risk for PIH.