Bifid choroid plexus: always a normal fetal brain structure variant?

Choroid plexus, a fetal organ developing approximately from the sixth week of gestation, plays a fundamental role in developing fetal brain organization. As relatively little is known about the relationship between anomalies of choroid plexuses structure and their role in brain function, we examined cases of bifid choroid plexus (BCP) and discussed their potential association with lateral ventriculomegaly, other abnormal ultrasound findings, and their potential role as markers of fetal chromosomal abnormalities. In the present study, we described 23 cases of fetal BCP found in 2145 routine second trimester ultrasounds. For each patient 2D and 3D ultrasound volumes were acquired. BCP was defined as a choroid plexus whose body was divided into two portions (arms) differently located and oriented on the three spatial axes in correspondence to the lateral ventricle, in one or both sides. The entity of the separation and reciprocal orientation of the two arms was examined. The presence of BCP in a low-risk population of pregnant women undergoing routine second trimester ultrasound was showed. Lateral ventricles significantly increased in the presence of BCP. Malformations were found in four of 23 fetuses with BCP. Pregnancy outcome was favorable only in one of these four cases. We suggest that in the presence of mono or bilateral BCP without associated abnormal ultrasound findings, a closer look at fetal brain or extra-cranial structures is recommended. If no related abnormalities are found, serial prenatal and postnatal sonographic follow-up should be considered. In the presence of concomitant abnormal findings, genetic counseling, fetal karyotyping and magnetic resonance imaging, if possible by gestational age, are strongly advised.

Mesial side ovarian incision for laparoscopic dermoid cystectomy: a safe and ovarian tissue-preserving technique.

OBJECTIVE: To evaluate safety and efficacy, in terms of spillage risk and ovarian tissue preservation, of mesial incision for laparoscopic dermoid cystectomy. DESIGN: Randomized controlled trial. SETTING: University. PATIENT(S): Sixty-seven women with dermoid cysts. INTERVENTION(S): Laparoscopic dermoid cystectomy performed by mesial incision (33 patients, study group) or antimesial incision (34 patients, control group). MAIN OUTCOME MEASURE(S): Spillage of intracystic content rate, operative times, chemical peritonitis rate, and intraoperative blood loss (ΔHb) as primary outcomes. Postoperative ovarian reserve (ΔFSH levels, basal antral follicle number, mean ovarian diameter, and peak systolic velocity at 3 and 12 months after surgery) as secondary outcome. RESULT(S): Spillage of intracystic content rate and operative time were significantly lower in the study than in the control group. None developed chemical peritonitis. ΔHb was higher in the study group but not significantly. During the follow-up, median FSH values were significantly lower in the study group, with no differences in the E(2) levels. Moreover, median basal antral follicle number, median ovarian diameter, and median peak systolic velocity were significantly higher in the study group. CONCLUSION(S): Ovarian mesial-side incision appears to be a safe as well as tissue-sparing technique. CLINICAL TRIAL REGISTRATION NUMBER: .

Ultrasound estimated fetal weight slightly below the median is associated with increased risk of spontaneous preterm birth.

BACKGROUND: This study investigates the possible relationship between ultrasound estimated fetal weight (EFW) at third trimester and the risk of preterm birth following spontaneous preterm labor in otherwise uncomplicated pregnancies. METHODS: We performed a nested case-control study including 281 cases of spontaneous preterm labor with preterm delivery in the third trimester and 3372 matched controls within a cohort of 6207 consecutive pregnant women. Pregnancies with fetal growth restriction (birth weight <10th centile of population-based normograms) or fetal anomalies were not included. EFW was calculated by using Hadlock's formula and converted to fetal gender adjusted multiples of median (MoM) for each gestational age. RESULTS: EFW correlated with birth weight (r = 0.959, p < 0.0001) and was lower in preterm than in control fetuses (p < 0.0001). The odds ratios (95% confidence intervals) for preterm birth for fetuses below 0.9 MoM, 0.85 MoM, 0.80 MoM, and 0.75 MoM of EFW were, respectively, 4.6 (3.6-5.9), 5.7 (4.3-7.5), 8.5 (5.9-12.1), and 11.2 (6.8-18.3). The independent relationship between preterm birth and lower EFW was confirmed in multivariate analysis with adjustment for potential confounders, such as maternal age, parity, and fetal gender. CONCLUSION: In asymptomatic women between 28 and 36 weeks of gestation, an EFW lower than 0.90 MoM increases by 4.6 times the risk of spontaneous preterm birth, and the risk increases proportionally to the degree of weight reduction.

The practicability and surgeons' subjective experiences with vaginal danazol before an operative hysteroscopy.

This randomized, double blind, placebo-controlled study compared the usefulness of danazol 400mg vaginally versus 600mg orally in women as a preoperative preparation for hysteroscopic surgery. Ninety-one fertile women were randomly allocated to Group A (46 patients received 400mg of danazol placed into the posterior vaginal fornix and three oral tablets of commercially available folic acid as a placebo), and Group B [45 women treated with 600mg of danazol orally (200mg three times daily) and two vaginal tablets of Lactobacillus rhamnosus as a placebo]. The patients underwent an operative hysteroscopy, transvaginal sonography, blood tests, and a histological assay. A visual analog scale (VAS) score to compute the degree of the surgeon's satisfaction was used. The outcome measures were as follows: an evaluation of the changes in the endometrial thickness, the prevalence of endometrial atrophy, changes in the blood tests, any collateral effects, the degree of difficulty and view, the duration of the surgical procedure, any complications during the operative hysteroscopy and associated side effects, and the surgeon's satisfaction with the endometrial preparation. The vaginal administration route was associated with a more pronounced effect on the endometrial thickness. Significantly more patients receiving vaginal danazol (45/46) had a hypotrophic endometrium than those receiving oral danazol (37/45, P<0.01). In addition, the patients receiving danazol vaginally had a shorter operating time, lower infusion volume, fewer side effects, and a higher surgeon satisfaction. Vaginal danazol adequately prepares the endometrium for an operative hysteroscopy by thinning the endometrium effectively with few side effects and little impact on the metabolic parameters.

Essure transcervical tubal sterilization: a 5-year x-ray follow up.

OBJECTIVE: To evaluate the x-ray appearance of Essure microinserts 5 years after their insertion. DESIGN: Prospective controlled study. SETTING: Tertiary referral centers for gynecologic care. PATIENT(S): Forty-five consecutive women with successful hysteroscopic bilateral placement of the Essure devices and postprocedure satisfactory hysterosalpingography confirmation test. INTERVENTION(S): Pelvic anteroposterior x-ray. MAIN OUTCOME MEASURE(S): Stability and and symmetric appearance of Essure microinsert positions; measurement of the intrauterine distance between the two devices. RESULT(S): After 5 years from their placement, no detachment nor fracture of devices was observed. x-Ray recognition of the device after 5 years showed findings similar to those recorded at 3 months' follow-through hysterosalpingography. CONCLUSION(S): x-Ray evaluation of findings related to stability of position, symmetric appearance, and distance between the two Essure microinserts corroborates the irreversibility and the reliability of the fibrotic reaction that ensured tubal occlusion after devices placement.

Hypoxia and preeclampsia: increased expression of urocortin 2 and urocortin 3.

OBJECTIVE: Urocortin 2 (Ucn2) and urocortin 3 (Ucn3) are new members of the corticotrophin-releasing hormone (CRH) family of peptides expressed and localized in human placenta. In the current study, we aimed to asses whether hypoxia affects placental Ucn2/Ucn3 messenger RNA (mRNA) expression and protein localization in physiological or pathological hypoxia and to evaluate whether the effect is modulated by the hypoxia-inducible factor 1alpha (HIF-1alpha). METHODS: Early first-trimester placental specimens from elective termination of pregnancy were used for villous explants and term placental tissue were used for primary cell cultures. The samples were incubated under different oxygen conditions; parallel sets exposed to hypoxia re-oxygenation (HR). Dimethyloxalylglycine (DMOG), an HIF-1alpha stabilizer, was used to mimic the effects of hypoxia in villous explants. Real-time polymerase chain reaction (PCR) and immunohystochemistry were performed on early pregnancy and preeclamptic (PE) placentae. mRNA levels were measured on villous explants and cell cultures incubated under different oxygen and reagent conditions. RESULTS: Both Ucn2 and Ucn3 mRNA expression was significantly higher at 6 to 9 weeks of gestation than 10 to 12 wks and in primary trophoblast cell cultures and explants exposed to low O(2) tension (3%) compared to 20% O(2). Strong Ucn2/Ucn3 immunoreactivity was present in trophoblast villi from 6 weeks placentae. Ucn2 immunostaining was stronger in early PE (E-PE) samples relative to controls whereas Ucn3 showed stronger immunoreactivity in late-PE (L-PE) placentae. Only Ucn2 transcript levels increased in HR explants. Ucn2 and Ucn3 expression by first-trimester explants was significantly greater in the presence of DMOG. All PE placentae expressed significantly higher Ucn2 and Ucn3 mRNA compared to controls. DISCUSSION: Placental Ucn2 and Ucn3 expression is sensitive to O(2) tensions and mediated by HIF-1alpha. During early pregnancy, Ucn2/Ucn3 may influence trophoblast proliferation and establishment of pregnancy. In PE placentae, the increased expression of both peptides may reflect a response to the oxidative stress.

Neuroendocrine mechanisms in pregnancy and parturition.

The complex mechanisms controlling human parturition involves mother, fetus, and placenta, and stress is a key element activating a series of physiological adaptive responses. Preterm birth is a clinical syndrome that shares several characteristics with term birth. A major role for the neuroendocrine mechanisms has been proposed, and placenta/membranes are sources for neurohormones and peptides. Oxytocin (OT) is the neurohormone whose major target is uterine contractility and placenta represents a novel source that contributes to the mechanisms of parturition. The CRH/urocortin (Ucn) family is another important neuroendocrine pathway involved in term and preterm birth. The CRH/Ucn family consists of four ligands: CRH, Ucn, Ucn2, and Ucn3. These peptides have a pleyotropic function and are expressed by human placenta and fetal membranes. Uterine contractility, blood vessel tone, and immune function are influenced by CRH/Ucns during pregnancy and undergo major changes at parturition. Among the others, neurohormones, relaxin, parathyroid hormone-related protein, opioids, neurosteroids, and monoamines are expressed and secreted from placental tissues at parturition. Preterm birth is the consequence of a premature and sustained activation of endocrine and immune responses. A preterm birth evidence for a premature activation of OT secretion as well as increased maternal plasma CRH levels suggests a pathogenic role of these neurohormones. A decrease of maternal serum CRH-binding protein is a concurrent event. At midgestation, placental hypersecretion of CRH or Ucn has been proposed as a predictive marker of subsequent preterm delivery. While placenta represents the major source for CRH, fetus abundantly secretes Ucn and adrenal dehydroepiandrosterone in women with preterm birth. The relevant role of neuroendocrine mechanisms in preterm birth is sustained by basic and clinic implications.

The use of nomegestrol acetate in rapid preparation of endometrium before operative hysteroscopy in pre-menopausal women.

The presence of a thin endometrium has an important role in allowing the best conditions for hysteroscopic surgery. Here, we explored the efficacy of a 14-day administration of nomegestrol acetate, a progestogen with high progestogen potency effects, in rapid endometrial preparation to operative hysteroscopy. A total of 86 fertile women selected for operative hysteroscopy received for 14 days either 5mgday(-1) of nomegestrol acetate (n=43; group A) or 4mgday(-1) of folic acid (n=43; group B), starting on day 1 of the subsequent menstrual cycle. Before treatments on days 12-14 of the menstrual cycle, all patients underwent endometrial thickness measurement; ultrasonography of the ovaries to measure the appearance of a dominant follicle; diagnostic hysteroscopy with endometrial biopsy; plasma estradiol (E2), progesterone (P), luteinising hormone (LH) and follicle-stimulating hormone (FSH) levels measurements. On the day of surgery, patients repeated endometrial and ovarian ultrasonography and, E2, P, LH and FSH measurement. At enrolment, endometrial thickness, mean follicular diameter and E2, P, LH and FSH concentrations did not differ between groups. At the time of operative hysteroscopy (i.e., after 14 days' treatment) group A, but not group B, showed significant (all P<0.001) reduction of endometrial thickness, mean diameter of dominant follicle, E2, P and LH concentrations. Endometrial preparation was judged more effective in group A than B, since the endometrial mucosa in all of the women of group A appeared to be very thin, hypotrophic, regular and pale. In conclusion, administration of nomegestrol acetate was effective in reducing endometrial thickness, also acting on the hypothalamus-pituitary-ovarian axis, thus allowing highly favourable operative hysteroscopic conditions.

Urocortin increases IL-4 and IL-10 secretion and reverses LPS-induced TNF-alpha release from human trophoblast primary cells.

PROBLEM: As urocortin (Ucn) is a placental peptide belonging to the corticotrophin-releasing hormone (CRH) family that modulates immune function in other biological models, this study evaluated Ucn effects on cytokines secretion from cultured human trophoblast cells. METHOD OF STUDY: Placentas were collected from normal term pregnancies after elective caesarean section, and primary trophoblast culture was prepared followed by the treatment of Ucn and/or CRH selective antagonists, antalarmin and astressin 2b. The anti-inflammatory cytokines IL-4 and IL-10 and the pro-inflammatory cytokine TNF-alpha were measured by ELISA. RESULTS: Urocortin treatment induced a significant and dose-dependent increase of IL-4 and IL-10, whereas it did not affect TNF-alpha secretion. When incubated in the presence of LPS, Ucn reversed LPS-induced TNF-alpha release from cultured trophoblast cells, an effect that was blocked by the CRH-R2 selective antagonist, astressin 2b. CONCLUSION: Urocortin stimulates IL-4 and IL-10 secretion and reverses LPS-induced TNF-alpha release from trophoblast cells through action on CRH-R2 receptors, suggesting that this peptide may play a possible role as an anti-inflammatory agent.

Urocortin 2 stimulates estradiol secretion from cultured human placental cells: an effect mediated by the type 2 corticotrophin-releasing hormone (CRH) receptor.

Estrogens produced by the placenta are pivotal in human pregnancy and parturition. Several hormones are involved in regulating estrogen production. Recently, the corticotrophin releasing hormone family of peptides has expanded and among the new members, urocortin 2 is expressed from human placenta. The aim of the current study was to determine urocortin 2 effects on estradiol secretion and cytochrome P450 aromatase mRNA levels and protein expression from cultured human trophoblast cells. Trophoblast cell cultures were treated with urocortin 2 and for comparison, corticotrophin releasing hormone, or urocortin 1 in the presence of estrogen precursors dehydroepiandrosterone-sulfate, androstenedione, and testosterone. Estradiol output was measured using enzyme-linked immunosorbent assay. Cytochrome P450 aromatase mRNA levels and protein expression were evaluated using reverse transcriptase-polymerase chain reaction and Western blot. Trophoblast cell cultures treated with increasing amounts of corticotrophin releasing hormone and urocortin 1 showed increased secretion of E2 in the presence of androstenedione. In the presence of urocortin 2, E2 output in cultures treated with dehydroepiandrosterone, androstenedione, and testosterone was consistently raised in a time and dose-dependent manner to maximum values at 24 hours. P450 aromatase mRNA levels and protein expression were upregulated by urocortin 2 in the presence of C19 precursors. The addition of antisauvagine-30, a corticotrophin releasing hormone-receptor-2 antagonist, significantly reversed urocortin 2 effects on E2 secretion and P450 aromatase expression. Our results suggest that urocortin 2 may play a role in the regulation of E2 production throughout pregnancy, thereby contributing to the placental regulation of key reproductive events in pregnancy maintenance and parturition.

Prediction of preterm delivery based on maternal plasma urocortin.

CONTEXT: Preterm birth still remains a significant management problem, and a large number of markers of the disease have been investigated. OBJECTIVE: We measured plasma levels of urocortin, a neuropeptide expressed by gestational tissues, in women with threatened preterm labor (TPTL) to evaluate whether the measurement may predict preterm delivery (PTD). DESIGN: We studied patients as part of an open observational study. SETTING: The study was conducted at a tertiary referral center for obstetric care. PATIENTS: Eighty-five women with singleton pregnancies between 28 and 34 completed gestational weeks with TPTL participated in the study. INTERVENTIONS: Interventions included clinical examination and urocortin measurement. MAIN OUTCOME MEASURES: Pregnancy outcome and evaluation of sensitivity, specificity, and predictive values of urocortin as diagnostic test for PTD were measured. RESULTS: Thirty of 85 patients (35.3%) had PTD: 23 of 30 delivered within 7 d from admission (delivery time interval: 2.91 +/- 1.62 d; gestational weeks at delivery: 32.12 +/- 1.7); the remaining delivered later (delivery time interval: 11.71 +/- 4.27 d; gestational weeks at delivery: 33.5 +/- 2.18). Urocortin was significantly higher in women who delivered preterm (median 131.2 pg/ml, interquartile interval 115.1-139.4 pg/ml) than in those who progressed to term delivery [95.4 (69.9-101.3) pg/ml, P < 0.0001] and still higher in those delivering within 7 d from admission [137.7 (124.8-141.2) pg/ml]. Receiver operating characteristic curve analysis revealed that urocortin at the cutoff of 113.9 pg/ml had sensitivity of 80%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 90% as a marker for PTD. CONCLUSIONS: Maternal plasma urocortin concentration is increased in patients with TPTL who have PTD, and its measurement may be a promising new biochemical marker of PTD.

Labor (term and preterm) is associated with changes in the placental mRNA expression of corticotrophin-releasing factor.

Because maternal plasma corticotrophin-releasing factor (CRF) levels increase during the last weeks of pregnancy and at parturition, the present study evaluated whether placental mRNA expression of CRF and CRF-binding protein (CRF-BP) are modified in preterm delivery. A group of 30 women with singleton pregnancies were enrolled in the study. A placental tissue specimen was collected from pregnant women (1) at term after cesarean delivery (39.3 +/- 0.1 gestational weeks; n = 10), (2) at term after spontaneous vaginal delivery (40.1 +/- 0.2 gestational weeks; n = 10), or (3) at preterm delivery (32.4 +/- 0.4 gestational weeks; n = 10). Changes of placental mRNA expression were evaluated by real-time quantitative reverse transcriptase polymerase chain reaction analysis. Placental CRF mRNA expression at term (P < .001) and preterm delivery (P < .001) was significantly higher than in cesarean delivery and highest in preterm placentas. With respect to CRF-BP, no significant difference in placental mRNA expression was observed among samples collected after term or preterm delivery and cesarean delivery. The present study showed for the first time that both term and preterm labor are associated with increased expression of placental CRF but not CRF-BP mRNA.

Urocortin 2 and urocortin 3 are expressed by the human placenta, deciduas, and fetal membranes.

OBJECTIVE: Urocortin 2 (UCN2) and urocortin 3 (UCN 3) are recently identified neuropeptides showing homology to corticotropin-releasing factor (CRF). In the present study, we evaluated their expression and localization in gestational tissues (placenta, decidua, fetal membranes), and their effect on placental adrenocorticotropic hormone secretion. STUDY DESIGN: The study was performed in a tertiary clinical care center. Tissues were obtained at first (n = 8; 8-11 weeks of pregnancy) and third (n = 8; 38-40 gestational weeks) trimester. The mRNA expression was evaluated by semiquantitative reverse transcription-polymerase chain reaction (RT-PCR); the cellular localization by immunohistochemistry; ACTH levels were measured in media collected from cultured placental villi. RESULTS: All tissues analyzed expressed UCN2 and UCN3 mRNA. UCN2 and UCN3 were localized in cytotrophoblast and syncytiotrophoblast cells; UCN2 was present in maternal and fetal vessels and in amniotic cells, while UCN3 was absent. Finally, UCN2 and UCN3 did not stimulate ACTH secretion. CONCLUSION: Gestational tissues differentially express UCN2 and UCN3 and, despite their homology to CRF, they did not stimulate placental ACTH secretion.