Impact of endocrine disruptor chemicals in gynaecology.

The potential hazardous effects that estrogen- and androgen-like chemicals may have both on wildlife and human health have attracted much attention from the scientific community. Endocrine disruptors (EDCs) are chemicals that have the capacity to interfere with normal signalling systems. EDCs may mimic, block or modulate the synthesis, release, transport, metabolism and binding or elimination of natural hormones. Even though potential EDCs may be present in the environment at only very low levels, they may still cause harmful effects, especially when several different compounds act on one target. EDCs include persistent pollutants, agrochemicals and widespread industrial compounds. Not all EDCs are man-made compounds; many plants produce substances (phytoestrogens) that can have different endocrine effects either adverse or beneficial in certain circumstances. Natural substances such as sex hormones from urban or farm wastes can become concentrated in industrial, agricultural and urban areas; thus, such wastes may be considered potential 'EDCs' for humans and/or wildlife. Much attention has focussed on changing trends in male reproductive parameters in relation to EDC exposure; however, studies on the female reproductive system have been less comprehensive. We have focussed this article on four major aspects of female reproductive health: fertility and fecundability, endometriosis, precocious puberty and breast and endometrial cancer.

The policy of antenatal corticosteroid administration in Italy vs. other European countries.

OBJECTIVE: To describe antenatal corticosteroid policies in Italy in comparison with other European countries, as inferred by the published data of the EURAIL Study Group (1999). METHODS: The results of a mail survey of departmental policies in Italy and Europe were compared. RESULTS: The survey response rate was similar in Italy and Europe (86% and 81%, respectively); 70.7% of the respondents in Italy and 84% in Europe started antenatal corticosteroids from 24 to 28 weeks' gestation; however, 5% of respondents in Italy started at a gestational age of >34 weeks. The use of multiple antenatal corticosteroid courses was observed in 81% of the units in Italy and 87% in Europe. Betamethasone was the more frequently used drug in Italy. CONCLUSIONS: Antenatal corticosteroids are used frequently in Italy and Europe in accordance with international recommendations, although many differences exist in the mode of administration. In 1999 almost all units used multiple courses, although this may not represent the rule 5 years later, following the publication of a prospective randomized trial that questioned the benefits of multiple courses of antenatal corticosteroids.

Foscarnet therapy for congenital cytomegalovirus liver fibrosis following prenatal ascites.

We report on an infant with multi-system disease including liver fibrosis, right microphthalmia with cataract, interstitial pneumonitis, and hyperechoic lesions in the basal ganglia and in the periventricular and thalamic regions. Prenatal ascites with hepatomegaly concomitantly with detection of cytomegalovirus (CMV) DNA in the amniotic fluid, following recurrent maternal CMV infection, had been shown. Although CMV culture and DNA detection were negative in the urine, the infant was given foscarnet because CMV infection was demonstrated in the liver by DNA detection and immunohistochemical staining. Favorable clinical outcome and absence of CMV in the liver were subsequently shown. Our case suggests that congenital CMV disease following maternal recurrence may not be associated with disseminated infection but only with intracellular infection. The diagnosis should therefore be based on CMV detection in the involved organs. Moreover, this is the first report on the possible efficacy and safety of foscarnet for therapy of immunocompetent infants with congenital CMV disease.

The combination of computerized cardiotocography and amniotic fluid index for the prediction of neonatal acidemia at birth: a modified biophysical profile.

OBJECTIVE: To study the combination of computerized cardiotocography (cCTG) and the amniotic fluid index (AFI) in the prediction of neonatal acidemia at birth. METHODS: A total of 89 singleton third-trimester high-risk pregnancies delivered by Cesarean section, with an AFI evaluated within 24 h from birth, and an antepartum cCTG performed within 6 h from delivery, were studied. The score was the sum of values for AFI (oligo/anhydramnios = 1, normal = 0) and cCTG (Dawes-Redman criteria, not met = 1, met = 0). The endpoint was to predict an abnormal neonatal outcome as defined by an umbilical artery pH of < or = 7.2. RESULTS: Fifteen neonates had an umbilical artery pH of < 7.2. The combination of cCTG + AFI score was able to predict pH values (< or = 7.20) with an OR = 2.83 (p < 0.02). The diagnostic accuracy of the combination of cCTG + AFI was as follows: sensitivity 80%, specificity 58%, positive predictive value 28%, negative predictive value 83%. COMMENT: We suggest that the cCTG + AFI score may be of value in the prediction of neonatal acidemia and help in the management of third-trimester high-risk pregnancies.

Effect of antenatal betamethasone therapy on maternal-fetal Doppler velocimetry.

BACKGROUND: The effect of antenatal betamethasone on fetal parameters includes a transient reduction of FHR variation and of fetal body movements. An effect on maternal-fetal blood flow has also been shown, with non-univocal results. AIMS: To evaluate the effect of antenatal betamethasone in third trimester singleton high-risk pregnancies by Doppler technology. SUBJECTS AND METHODS: Thirty-six pregnant women who received a full course of betamethasone (12 mg i.m. two times, 24 h apart) were studied. The Doppler examination included the assessment of the pulsatility index (PI) of the umbilical artery (UA PI), the middle cerebral artery (MCA PI) and of resistance index of uterine arteries (Ut RI) before treatment, and 48 and 96 h after second dose of betamethasone. RESULTS: No significant variation was noted in UA PI through betamethasone therapy. MCA PI decreased significantly 48 h from the last injection of betamethasone (P=0.002), and returned to basal values at 96 h. No difference was found for the other Doppler parameters examined. When serial Doppler studies were analyzed according to the gestational age, in the group <32 weeks' gestation, MCA PI decreased significantly after 48 h (P<0.006) and returned to pre-treatment values after 96 h from the last betamethasone dose. Conversely, no difference was found in Doppler serial measurements in any of the analyzed districts in the subgroup > or =32 weeks. CONCLUSION: Betamethasone treatment is associated with a significant, although transient, reduction of MCA PI, especially at gestational ages <32 weeks'.

The biophysical/biochemical test. A new marker of fetal lung maturity in borderline cases.

OBJECTIVE: To assess the diagnostic accuracy of the combination of a biophysical (lamellar body count [LB]) with a biochemical test lecithin/sphingomyelin ratio (L/S) for the evaluation of fetal lung maturity (FLM) in cases of intermediate-borderline pulmonary maturity. STUDY DESIGN: We studied 105 cases with one or both intermediate (2.1-2.4:1 for L/S and/or 15,000-19,000/microL for LB) or borderline (2.5:1 for L/S and/or 20,000/microL for LB count) FLM indices and no phosphatidylglycerol who delivered within 72 hours of amniocentesis, excluding multiple gestation and contaminated amniotic fluid samples. The biophysical x biochemical marker (B x B) was calculated by multiplying L/S by the corresponding LB, then dividing by 10(3). By using the ROC curve, a cutoff of 50 was found. RESULTS: B x B values were lower in respiratory distress syndrome (RDS) than in the non-RDS group (30 [23-41] vs. 52 [50-70], P < .001; median, 25-75%). All RDS cases had a B x B value < 50. Diagnostic accuracy for B x B was: sensitivity, 100%; specificity, 83%; positive predictive value, 61%; negative predictive value, 100%. Sensitivity and positive predictive values were higher for B x B than L/S. CONCLUSION: B x B may be a useful tool for cases with borderline FLM.

Fetal lung maturity in pregnancies complicated by insulin-dependent and gestational diabetes: a matched cohort study.

OBJECTIVE: To study fetal lung maturity (FLM) as determined by amniotic fluid (AF) tests in diabetic pregnancies (DP) under euglycemic metabolic control, in comparison with matched controls (C). PATIENTS AND METHODS: From 514 consecutive pregnancies where amniocentesis was performed for FLM assessment, we selected 45 glycemic controlled DP. Nineteen DP were Type I (IDDM) and 26 pregnancies were diagnosed Type III (GDM). Cases were matched to C by therapy with corticosteroids, gestational age at amniocentesis, pregnancy complications other than diabetes and gender. FLM was determined by the shake test and lamellar bodies (LB) count, lecithin/sphingomyelin (L/S) ratio (planimetric and stechiometric) and phosphatidylglycerol presence (PG). DP were further sub-divided according to gestational age period at amniocentesis, type of diabetes, associated therapy and fetal malformations. RESULTS: RDS (n=2) and neonatal wet lung (n=5) were diagnosed in neonates from diabetic mothers. We found no statistical difference when comparing FLM indices between DP and C groups: shake test 3.1:1+/-1.2 vs. 2.7:1+/-1.2, P<0.40; planimetric L/S 3.4+/-1.4 vs. 3.1+/-2.0, P<0.27; stechiometric L/S 8.2+/-7.4 vs. 7.1+/-6.1, P<0.54; percentage of PG positivity 57% vs. 46%, P<0.13; lamellar bodies count (X10(3)/microl) 42.8+/-36.9 vs. 41.5+/-30.4, P<0.72. No differences were found between DP and controls for subgroups according to gestational age, type of Diabetes (IDDM or GDM), congenital lesions and associated therapy. CONCLUSIONS: In euglycemic, metabolically controlled diabetic patients FLM is not delayed, however an increased risk for neonatal wet lung should be considered.

The effect of glucocorticoid therapy on fetal lung maturity indices in hypertensive pregnancies.

OBJECTIVE: To assess fetal lung maturity tests in hypertensive pregnancies and to examine the effect of glucocorticoid therapy. METHODS: In a cohort study involving 68 pregnant women with hypertension, 34 received antenatal betamethasone before amniocentesis and 34 did not. Controls were 68 women with uncomplicated pregnancies, matched for gestational age at amniocentesis and fetal gender. Amniotic fluid (AF) samples were analyzed by lamellar body count, planimetric and stechiometric lecithin-sphingomyelin ratio (L/S), and presence of phosphatidylglycerol. RESULTS: Fetal lung maturity, as determined by lamellar body counts and by planimetric L/S, was lower in hypertensive pregnancies not treated with steroids than in controls (19,600 +/- 14,500 versus 39,800 +/- 22,700, P < .009, and 1.9 +/- 0.6 versus 3.9 +/- 1.8, P < .01, respectively). In the period of 24 to 33 weeks' gestation, the percentage of untreated pregnancies with mature lamellar body counts and mature L/S was significantly lower than that of controls (13% versus 33%, P < .001; 6% versus 40%, P < .002 and P < .003, respectively). In contrast, in patients treated with betamethasone, the percentage of cases with mature indices for both tests was not significantly different from that of controls, but was higher than that of untreated hypertensive patients (40% versus 13%, P < .001; 33% versus 6%, P < .001). Phosphatidylglycerol did not differ among groups. From 34 to 38 weeks, no difference was found in the percentage of mature cases for lamellar bodies in pregnant women with hypertension not treated with steroids in comparison with controls (68% versus 84%), nor between cases treated and controls (74% versus 84%). In the same period, no difference in L/S values was found among groups, and the percentage of cases positive for phosphatidylglycerol was lower in hypertensive pregnancies than in controls (47% versus 95%, P < .001) and was not affected by steroid treatment (37% versus 95%, P < .001). CONCLUSION: Fetal lung maturity, as reflected in AF tests, is delayed in hypertensive pregnant patients, and steroids increase all lung maturity indices except phosphatidylglycerol between 24 and 33 weeks' gestation.

The effect of polyhydramnios and oligohydramnios on fetal lung maturity indexes.

The influence of amniotic fluid (AF) volume on common fetal lung maturity (FLM) indices was evaluated. Cases diagnosed with altered AF volume as estimated by ultrasound (n = 71; polyhydramnios = 33, oligohydramnios = 38) were matched to controls by: gestational age (GA) at amniocentesis, GA at delivery, neonatal weight, sex, and pregnancy complication. FLM was assessed on AF specimens obtained by transabdominal amniocentesis by planimetric and stechiometric L/S, phosphatidylglycerol (PG), and lamellar bodies counts (LB). In cases with polyhydramnios, L/S ratios (planimetric and stechiometric) were statistically lower in cases with respect to controls (2.1 +/- 0.9 vs. 2.8 +/- 1.0, p = 0.007, and 4.8 +/- 2.4 vs. 5.9 +/- 2.7, p < 0.04; respectively). Absence of PG was more frequent in (70.8% vs. 50%, p = 0.02). LB counts were lower in cases than in controls (15.5 +/- 12.1 x 10(3)/microL vs. 21.9 +/- 14.3 x 10(3)/microL, p < 0.05). In cases with oligohydramnios, no difference was found for planimetric and stechiometric L/S in comparison to controls (2.6 +/- 1.2 vs. 2.6 +/- 1.0, N.S. and 4.9 +/- 2.1 vs. 4.6 +/- 1.8, N.S.; respectively), absence of PG (62.5% vs. 50%, N.S.), and LB counts (27.2 x 10(3)/microL +/- 12.8 x 10(3)/microL vs. 28.6 x 10(3)/microL +/- 24.1 x 10(3)/microL, N.S.). In conclusion, oligohydramnios was not associated with altered FLM indices; in cases with polyhydramnios all FLM indices were significantly lower.