Intrapartum uterine rupture.

The association between diethylstilbestrol (DES) exposure in utero and uterine malformations resulting in poor reproductive performance is well established. A case is presented of uterine rupture in a patient exposed to DES in utero who had no known predisposing factors for uterine rupture.

Fetal and maternal humoral immune response to cytomegalovirus infection.

The relationship between cytomegalovirus titers and immunoglobulin (Ig) levels in 514 paired maternal-fetal sera at term was studied. Positive cytomegalovirus titers were found in 192 (37.4%) maternal sera and 138 (26.8%) fetal sera. Fetal sera with positive cytomegalovirus titers had decreased IgM levels, and maternal sera with positive cytomegalovirus titers had increased IgG levels. There was a negative correlation between cytomegalovirus titer level and IgM concentration in fetal serum and a positive correlation between cytomegalovirus titers levels and IgG concentration in maternal serum in individual samples. After removal of IgG from samples with cytomegalovirus positive titers by column chromatography, 17 maternal and 22 fetal sera remained cytomegalovirus positive.

Correlation between maternal and fetal immunoglobulin E levels.

Immunoglobulin E (IgE) concentrations were measured in 157 paired samples of maternal-fetal sera. A correlation was found between maternal and fetal IgE levels, in contrast to earlier reports dealing with smaller series. The correlation is probably not due to placental transfer of maternal IgE but rather to genetic factors. The possible role of IgE in the fetal immune response is discussed.

The effect of smoking during pregnancy on cord blood and maternal serum immunoglobulin levels.

The effect of smoking on the fetal and maternal humoral immune parameters was evaluated in cord and maternal blood, collected at delivery from 163 mothers who smoked and 130 mothers who did not smoke, and their offspring. There was no difference in time of gestation between the two groups, but the mean birth weight of the offspring of mothers who smoked was decreased, as previously observed. There were higher levels of IgA (p less than 0.01), IgM (p less than 0.001), and IgG (p less than 0.001) in cord sera of children of mothers who smoked than in the offspring of mothers who did not smoke. Mothers themselves who smoked had higher levels of IgM (p less than 0.001) and IgG (p less than 0.001), but not IgA, as compared to control mothers who did not smoke. Since cord IgA and IgM are produced by the fetus, these results could be interpreted as being due to either a higher incidence of infection in utero or metabolic differences in the children of mothers who smoke. Either of these possibilities may explain the increased frequency of postpartum endometritis, increased incidence of fetal distress, and the characteristic of meconium-stained amniotic fluid in mothers who smoke.

PIP: The effect of smoking on the fetal and maternal humoral immune parameters was evaluated in cord and maternal blood, collected at delivery from 163 mothers who smoked and 130 who did not and their offspring. There was no difference in time of gestation between the 2 groups, but the mean birthweight of the offspring of mothers who smoked was decreased, as previously observed. There were higher levels of IgA (p0.01), IgM (p0.001), and IgG (p0.001) in cord sera of children whose mothers smoked than in the offspring of mothers who did not. Mothers themselves who smoked had higher levels of IgM (p0.001) and IgG (p0.001), but not IgA, as compared to control mothers who did not smoke. Since cord IgA and IgM are produced by the fetus, these results could be interpreted as being due to either a higher incidence of infection in utero or metabolic differences in the children of mothers who smoke. Either of these possibilities may explain the increased frequency of postpartum endometritis, increased incidence of fetal distress, and the characteristic of meconium stained amniotic fluid in mothers who smoke.

Ultrastructural cytochemistry of monoamines in cultured human fetal sympathetic neurons.

The presence and storage of adrenergic neurotransmitter (monoamines) in cultured human fetal sympathetic neurons was investigated by chromate-dichromate cytochemistry, formaldehyde-induced fluorescence and potassium permanganate fixation. Monoamines were specifically identified in the neurons by the presence of an electron dense precipitate following cytochemical treatment. Reaction product was found in cell somas and processes in all chromate-dichromate treated cultures. The size range and morphology of the precipitate indicated a vesicular storage site within large dense core vesicles. Neurons fluoresced after treatment with formaldehyde vapors, further confirming the presence of monoamines. When potassium permanganate was employed as the fixative, occasional positive dense core vesicles were found but their frequency was greatly reduced from that seen in the chromate-dichromate treated cultures. These findings show that cultured human fetal sympathetic neurons retain an adrenergic phenotype during long-term serum-free culture. In addition, the storage site for the adrenergic neurotransmitter in the developing neuron is within large dense core vesicles. The lack of dense core vesicles in potassium permanganate fixed material is believed to be due to the depletion of monoamines during fixation.

Prenatal diagnosis of congenital listeriosis.

A case of congenital listeriosis presenting with premature labor at 24 weeks' gestation is described. Listeria monocytogenes were isolated from the amniotic fluid, which also had an increased concentration of IgA. The significance of amniotic fluid Ig levels and their potential value in the diagnosis of intrauterine infections as an adjunct to the isolation of the infectious agent is discussed.

Determination of amniotic fluid IgM and IgA by hydroxyethylcellulose-agarose gel electroimmunodiffusion.

An electroimmunodiffusion method on hydroxyethylcellulose-agarose by which IgA and IgM concentrations down to 0.3 mg/dl can be measured in amniotic fluid is presented. Elevated Ig levels were found in both fetal infection and in congenital malformations. The potential value of Ig determination in amniotic fluid is discussed.

Fetal H-Y typing using human amniotic fluid.

The H-Y (male) antigen is phylogenetically conserved among vertebrate species, including the species man. Previous studies have indicated the presence of a "soluble" H-Y antigen in male serum and culture fluids of male cells. We examined over 50 samples of amniotic fluid from male and female fetuses to determine if H-Y typing could be correlated with the sex of the fetus. Samples of amniotic fluid were tested to inhibit the reactivity of monoclonal antibodies in a standard H-Y assay with protein A sheep red blood cells. We found that amniotic fluids from male fetuses inhibited 40% of the reactivity and that amniotic fluids from female fetuses inhibited 0.5% of reactivity. We could also correctly identify the sex of 90% of male fetuses and 100% of female fetuses. We have not yet identified the exact nature of the inhibiting antigen(s) in the amniotic fluids, but our results clearly indicate the feasibility of fetal H-Y typing.

The fetal serum alpha-fetoprotein and its relationship to immunoglobulins and birth weight at term.

The distribution of values of alpha-fetoprotein (AFP) was analyzed in the cord blood of 350 newborns divided into groups according to whether their mothers were normal, preeclamptic, or smokers. In addition, fetal birth weight and fetal IgA and IgM at term were correlated with AFP. Cord serum AFP values showed a unimodal bell-shaped distribution in 269 normal newborns with a mean of 22.7 +/- 11.3 (SD) micrograms/ml. The cord sera of infants of preeclamptic mothers and of smoking mothers showed a similar mean and distribution. As previously observed, AFP was correlated inversely with birth weight. No correlation existed between AFP and fetal Ig levels.

Immune complexes in pregnancy. III. Immune complexes in immune complex-associated conditions.

Seventeen patients during the third trimester of pregnancy with associated immune complex disease and/or immune complex state and their infants' cord blood were investigated for the presence of immune complexes. In comparing maternal levels of immune complex in normal third-trimester pregnancies to the study group, no statistical significant difference was noted. However, levels in cord blood were significantly lower (p less than 0.0025) than levels in paired maternal samples, but were found to correlate significantly (p less than 0.002). On the basis of the immunochemical analysis of selected pairs, the conclusion is that IgG-containing immune complexes may be responsible for this observed correlation and may represent the normal physiologic situation of pregnancy, whereas IgM-containing immune complexes may represent pathologic, and, therefore, abnormal, states. The suggestion is that the presence of such IgM-containing immune complexes may become predictive of fetoplacental compromise.

Decreased cord blood IgM and IgA in trisomy 21.

Disagreement as to whether Ig levels are high, low, or normal at different ages in different groups of trisomic children has interfered with defining the associated immunodeficiency state. Fetal Ig production was assessed by measuring cord blood IgM and IgA of five trisomy 21, 97 normal, and 37 control newborns with other birth defects. Trisomic infants showed significantly lower values. Cord blood IgG values showed no differences between groups when corrected for fetal blood weight. The data indicate that children with trisomy 21 have an impaired humoral immune response to utero.

Rupture of the uterus after midtrimester prostaglandin abortion.

A case is reported of rupture of the uterus after intraamniotic injection of prostaglandin F2 alpha followed by intravenous oxytocin. The literature is reviewed and the management discussed.

PIP: A 34-year old Puerto Rican woman gravida 8, para 5, abortions 1, miscarriage 1, living children 4 admitted to the New York Hospital-Cornell Medical Center for prostaglandin abortion had a delayed diagnosis of rupture of the left uterine artery. The delay in diagnosis was attributed to the intraligamentous and retroperitoneal location of the hematoma. The bleeding was controlled by performing a supracervical hysterectomy and ligation of the left hypogastric artery. The patient recovered uneventfully. Rupture of the uterus is a less common occurence than cervical lacerations, which occur in 1% to 2% of 2nd trimester abortions and most frequently among young primigravidas. Uterine rupture occurs mostly in multiparous women and does not appear to be prevented by laminaria tents. Uterine rupture at term following oxytocin induction has been related with multiparous patients. Uterine rupture has also ben observed following induction of midtrimester abortion with intraamniotic hypertonic saline or prostaglandin analogs, and the dilatation and evacuation method. Of 12 documented cases of uterine ruptures after saline/prostaglandin-induced abortion, 11 necessitated hysterectomy and 2 patients died from blood loss. Management of oxytocin and prostaglandin-induced abortion is briefly discussed.