Myeloperoxidase in the plasma and placenta of normal pregnant women and women with pregnancies complicated by preeclampsia and intrauterine growth restriction.

Myeloperoxidase (MPO) is a heme protein produced and released by activated neutrophils and monocytes, and increased MPO is considered important in the pathophysiology of cardiovascular diseases (CVD). Accumulating evidence suggests that preeclampsia (PE), idiopathic intrauterine growth restriction (IUGR), and CVD share many similar metabolic disturbances, including an enhanced systemic inflammatory response and endothelial dysfunction. We hypothesized that MPO plays an important role in the development of PE and IUGR. Plasma samples were collected mid-gestation and at delivery from women with normal pregnancies (n = 40) and those who subsequently developed PE (n = 20), IUGR (n = 11) or both (PE + IUGR, n = 8). Placental samples were obtained immediately after delivery from 22 women with normal pregnancies, 19 women with PE, 14 women with IUGR, and 14 women with PE + IUGR. The MPO concentrations were measured using ELISA. Women with PE + IUGR had significantly higher plasma MPO before delivery than normal pregnant women. There was no difference in plasma levels at mid-gestation or the placental concentrations between women with normal pregnancies and those who developed PE, IUGR, or PE + IUGR. Using explants prepared from the placentas of 8 women with normal pregnancies and 8 women with PE, we found no difference in the levels of MPO in the tissue homogenates and culture media between these two groups of women. Together, these results indicate that increased maternal circulating MPO in women with PE + IUGR is likely a result of enhanced systemic inflammation caused by the established disease rather than a primary pathophysiological factor.

Risk factors for pre-eclampsia in an Asian population.

OBJECTIVE: To identify the risk factors for pre-eclampsia in an Asian population. METHOD: We conducted a retrospective cohort study involving 29375 Taiwanese women who delivered between July 1990 and September 1998, excluding pregnancies complicated by chronic hypertension or fetal malformations. RESULT: Four hundred and fifteen women had pre-eclampsia (1.4%). Women who had a history of pre-eclampsia (OR 6.3, 95% CI 4.4, 9.2), multiple gestation (OR 3.6, 95% CI 2.4, 5.5), a prepregnancy BMI > 24.2 kg/m(2) (OR 2.4, 95% CI 1. 8, 3.1), were > 34 years of age (OR 1.8, 95% CI 1.4, 2.4), nulliparous (OR 1.3, 95% CI 1.2, 1.5), had urinary tract infection (OR 4.8, 95% CI 1.5, 15.8), or worked during pregnancy (OR 1.9, 95% CI 1.4, 2.4) were at increased risk of pre-eclampsia. CONCLUSION: Some of the risk factors for pre-eclampsia among Asian women are the same as those of other ethnic groups, whereas some of the risk factors are different.

Maternal urine alpha-fetoprotein concentrations between 14 and 21 weeks of gestation.

BACKGROUND: The aim of this study was to ascertain the normal range of the midtrimester maternal urine alpha-fetoprotein (AFP) concentrations in Taiwanese pregnancies. METHODS: AFP was measured in the urine samples, obtained before genetic amniocentesis, from 268 women with normal singleton pregnancies between 14 and 21 weeks of gestation. Week-specific median values for urine AFP/creatinine (Cr) were calculated by weighted linear regression after log transformation and the data were converted to units in the multiple of the median (MoM). The gestational age in all cases was determined by ultrasound parameters. RESULTS: The levels of urine AFP and AFP/Cr increased gradually with advancing gestational age. The AFP/Cr MoM values of singleton pregnancies after log transformation showed a normal distribution with a mean (standard deviation) of 0.0071 (0.3228). The median, 10th and 90th centiles of AFP/Cr were 0.98, 0.43 and 3.61 MoM, respectively. Of the pregnant Taiwanese women studied, 4.9% (13/268) and 16% (43/268) had urine AFP/Cr MoM levels less than 0.31 MoM and 0.5 MoM respectively. CONCLUSION: The establishment of a reference range which allows for gestational differences in AFP/Cr levels is essential for further antenatal testing.

Delivery of a severely anaemic fetus after partial molar pregnancy: clinical and ultrasonographic findings.

The incidence of a normal live fetus and a partial molar placenta is extremely rare. Although triploidy is the most frequent association, a fetus with normal karyotype can survive in cases of partial molar pregnancy. We report a case of partial molar placenta in which a live female baby was delivered at 32 weeks gestation by a 30-year-old woman. At the 18th week, ultrasonographic examination revealed a normal fetus with a huge, multicystic placenta. Chromosomal evaluation by amniocentesis revealed a normal female karyotype (46,XX), and serial biometric measurement of the fetus showed normal growth during pregnancy. There were no obstetric complications until the 32nd gestational week when preterm rupture of the membranes occurred. The electronic fetal heart beat tracing showed a repeated sinusoid pattern and late deceleration after admission. The patient underwent emergency Caesarean section and delivered a 1551-g, anaemic female baby with an Apgar score of 1, 4 and 6 at 1, 5 and 10 min, respectively. The baby recovered within 2 weeks after respiratory support and transfusion of packed red blood cells. Although anaemia is one of the risk factors that jeopardize the fetus in the case of partial molar pregnancy, termination is not indicated when the fetus is normal and no complications have occurred.

Perinatal outcome of oligohydramnios without associated premature rupture of membranes and fetal anomalies.

To investigate the perinatal outcome of patients with oligohydramnios (amniotic fluid index < or = 5 cm), but without premature rupture of membranes and fetal congenital anomalies, data from 245 singleton pregnancies were analyzed and compared to those with normal amniotic fluid volumes (5 < amniotic fluid index < 24 cm, n=27,261). Significantly higher incidences of primiparity, pregnancy-induced hypertension, premature separation of placenta, past history of intrauterine fetal death, past history of preterm delivery, postterm pregnancy, and advanced maternal age were noted to be associated with the occurrence of oligohydramnios. Pregnancies complicated by a markedly diminished amniotic fluid volume assessed antenatally by ultrasound were significantly more frequently associated with adverse perinatal outcomes such as preterm delivery, low or very low birth weight, low Apgar scores, intrauterine fetal death, small-for-gestational-age newborns, meconium staining, cesarean delivery, neonatal intensive care, and neonatal death.

Midtrimester human chorionic gonadotropin levels: normal reference values in Chinese pregnant women.

In order to establish normative median values of maternal serum total human chorionic gonadotropin (hCG) at our own laboratory, 2711 normal sera were collected from uncomplicated, singleton Chinese pregnant women, including 1705 samples measured by radioimmunoassay (RIA) between 13 and 24 weeks' gestation and 1006 samples measured by enzyme immunoassay (EIA) between 14 and 20 weeks' gestation. The hCG secretion pattern throughout midtrimester measured by RIA is similar to that of measured by both RIA and EIA have a steep drop initially and then steadily decline from 17 weeks of gestation. The total (hCG levels measured by RIA and EIA showed different normative median values and distribution. If it was measured by RIA between 14 and 20 week's gestation, there were 3.7% and 17.8% of pregnancies with serum total hCG levels less than 0.25 multiple of the median (MoM) and 0.5 MoM, retrospectively, and 11.6% and 5.5% among them with serum levels above 2.0 MoM and 2.5 MoM, respectively. When it was measured by EIA, there were 0.7% and 9.2% of pregnancies with serum total hCG levels less than 0.25 MoM and 0.5 MoM, respectively, and 8.9% and 3.7% among them with serum levels above 2.0 MoM and 2.5 MoM, respectively. Accurate and satisfactory interpretation of maternal serum screening for Down syndrome depends on establishment of a well-developed normative median value for each week of gestation. Any laboratory intends to provide hCG for maternal serum screening should have its own reference data by its own immunoassay method.

Congenital malformation in newborns. Analysis of 501 cases.

Over a 14-year period in Chang Gung Memorial Hospital, 510 out of 44, 362 newborns were found to have birth defects. Maternal age, gestational age, parity, infant sex and birth weight were analyzed for each anomaly and compared to normal newborns. The average maternal age and parity for newborns with congenital anomalies were not significantly different from normal newborns. Mothers giving birth to babies with chromosomal aberrations, however, had a significantly older maternal age than the normal population. The gestational age at delivery was significantly shorter for all except craniofacial anomaly. In addition, there was a high percentage of intrauterine growth retardation in congenital anomalies. The central nervous system, the musculoskeletal system and craniofacial systems were the most commonly involved. The leading anomalies included cleft lip, cleft palate, anencephaly, polydactyly, hydrops fetalis, trisomy 21 and cystic hygroma. With improved ultrasound equipment and other prenatal diagnostic procedures, many defects of the fetus can now be identified. If the fetus is diagnosed with a surgically correctable lesion like cleft lip, it can be kept to term, delivered, then managed postnatally. If life-incompatible malformations have been detected before the 24th week, physicians are in a good position to counsel the parents. After the 24th week termination is proscribed by law. Therefore, physicians must take special care to detect fetal abnormalities early.

Meconium peritonitis-antenatal diagnosis by ultrasound.

Meconium peritonitis is usually the result of prenatal bowel obstruction with subsequent perforation, then the contents spread into the peritoneal cavity, which results in a sterile inflammatory reaction. The incidence ranges from 1/1500 to 1/2000, if without prenatal diagnosis and planned postnatal treatment, the mortality rate is as high as 62%. We describe three children, two with surgically, one with autoptically confirmed meconium peritonitis. All had abnormally prenatal ultrasonographic examinations. The first fetus showed a large 10 x 11 cm intra-abdominal mass with floating echogenic substances inside and with an echogenic rim. The second showed increased echogenicity with dilated bowel in abdominal cavity in one of the twin, and the third had an intra-abdominal cyst with several echogenic bands inside, fetal ascites was also noted. It is remarkable that the ultrasonographic findings were different in the three children. Two of the three children survived postoperation, one died 3 hours later after induction out at 31 weeks of gestational age due to multiple congenital anomalies.

Non-mosaic trisomy 20 in cultures of amniotic fluid from a fetus with serious congenital malformation.

We present a case of non-mosaic trisomy 20 in amniotic fluid associated with major congenital anomalies. A detailed prenatal ultrasonic examination was performed, and revealed dilatation of the cisterna magna and the fourth ventricle with hypoplasia of the vermis of the cerebellum. Fetal echocardiography showed overriding aorta and ventricular septal defects with pulmonary atresia. However, the karyotype of the lymphocyte in the cord blood was normal female 46, XX. The occurrence of the Dandy-Walker malformation in non-mosaic trisomy 20 has not been reported before, and the clinical significance of this major defect for prenatal diagnosis is discussed.

[Emergency obstetric hysterectomy: report of fifteen cases].

From June 1978 to June 1990, there were 41,989 deliveries, 13,396 cesarean sections and 15 emergency obstetric hysterectomies at Taipei Chang Gung Memorial Hospital. The incidence of emergency obstetric hysterectomy is 36/100,000 deliveries. The mean age of patients is 31.7 years old. The indications for hysterectomy were placental disorder (60.0%), uterine atony (26.7%), and uterine rupture (13.3%). The present series showed that 14 cases had total abdominal hysterectomy, while only one case had a subtotal hysterectomy. Total hysterectomy should generally be performed unless maternal instability mandates a more expeditious subtotal hysterectomy. The most common postoperative complication included unknown fever and urinary tract infection. For those four cases of post-cesarean hysterectomy, conservative treatment was tried but failed. All cases presented with hypotension (less than 80/60 mmHg), tachycardia (greater than 100 times/min) and with a mean hemoglobin of 9 mg% during the observation period. In these patients, blood loss, operating time and length of hospitalization was increased when compared with a group of 7 patients undergoing cesarean hysterectomy. In patients with placenta accreta, who are candidates for cesarean hysterectomy, initial hypotension, tachycardia and shock developed during cesarean section. It must be emphasized that conservative aggressive measures to control obstetric hemorrhage remain the mainstay of therapy, but emergency hysterectomy played the life-saving role with which every practitioner of obstetrics must be familiar and keep in mind.

Analysis of birth weight and gestational age in Taiwan.

Appropriate interpretation of monitored fetal growth throughout pregnancy in individual patients and populations is dependent upon the availability of adequate standards. Previously published standards either were based on small samples, data decades old or were characteristic of foreign subpopulations. We have reviewed the data on a series of 46,575 singleton live births at Chang Gung Memorial Hospital from 1979 to 1989. The ratio of males to females was 1.08. The fetal growth pattern in the third trimester of pregnancy approximates a sigmoid curve. Fetal growth was most rapid from the 32nd to the 37th week of gestation with an average increase of 240 g per week. The birth weight declined beyond 42 weeks' gestation. There were significantly greater weight gains amongst male fetuses as compared to female fetuses from the 34th to the 42nd week of gestation. The mean birth weight recorded at 40 weeks' gestation in male and female newborns was 3,381 g and 3,262 g, respectively. Comparing the birth weight of term pregnancies using our data, with those of a previous, two-decade old report (1945-1967) by Chen, we found that birth weight were slightly higher in this study. The derived fetal growth curves are useful for clinical, public health, and investigational purposes.

The value of cordocentesis in management of patients with severe preeclampsia.

Severe preeclampsia affects placental function and causes fetal compromise. It is necessary to deliver the fetus at an appropriate time in order to minimize fetal mortality and morbidity. Cordocentesis was performed in 9 patients with severe preeclampsia (group 1) and 10 patients with other pregnancy complications (group 2). Intrauterine growth retardation occurred in 5 patients in group 1 and in only one patient in group 2. Blood gas parameters including pH, pO2 and O2 saturation were significantly lower for group 1, while pCO2 was significantly higher, as compared to group 2. For patients in group 1, non-invasive fetal surveillance successfully identified 5 patients with fetal compromise, who required immediate termination of pregnancy. All 5 of these patients had abnormal fetal blood gas analyses by cordocentesis. Fetal blood gas analysis was abnormal in 2 additional fetuses among the remaining 4 patients who exhibited normal findings by non-invasive methods of fetal surveillance. These results suggest that cordocentesis is useful in identifying fetal compromise (fetal hypoxia/acidosis) prior to the onset of labor in high-risk patients, such as preeclampsia associated with intrauterine growth retardation.

Perinatal outcome of chorionic villus sampling versus amniocentesis.

This study assesses the relative risks of first trimester transcervical chorionic villus sampling (CVS) versus midtrimester amniocentesis performed between April 1986 and March 1988. The most common indication for prenatal diagnosis was advanced maternal age. We discovered 5.1% chromosomal aberrations in CVS compared to 1.0% in amniocentesis. Bleeding was the most frequent early complication, and only 1 case had major hemorrhage with subsequent spontaneous abortion. The fetal loss rate (gestational age less than 28 weeks) was 4.5% in CVS versus 1.2% in amniocentesis, which was not significantly different from the background fetal loss rate reported in normal pregnancies after an 8-week gestational age. Three cases of fetal loss after CVS were probably procedure-related; 1 case had spontaneous abortion and 2 cases had chorioamnionitis. Therefore, we considered that the causal relationship between CVS and the infection was highly probable. The clinical pregnancy outcome indicated that there were no differences in overall perinatal mortality, Apgar score, body weight, body length, gestational age at delivery, intrauterine growth retardation, placenta weight and placental disorders between the CVS group and the amniocentesis group. The pregnancies did not reveal any specific effects of the prenatal diagnostic procedure, but a long-term pediatric follow-up is needed.

Syndrome of hemolysis, elevated liver enzymes, and low platelet count: report of 4 cases.

Four cases of severe preeclamptic patients with the findings of hemolysis (H), elevated liver enzymes (EL) and a low platelet count (LP) were presented. Maternal mortality occurred in two of the four cases with one experiencing liver rupture. Intrauterine fetal death occurred in 3 cases. The entity has been termed the HELLP syndrome. The high maternal and perinatal mortality of our cases was mainly due to the severe coagulopathy associated with the HELLP syndrome. The practicing obstetrician must be knowledgeable about this severe consequence of toxemia in pregnancy and aggressive management is essential to improve maternal and perinatal outcome.