Early pregnancy termination with vaginal misoprostol before and after 42 days gestation.

BACKGROUND: Misoprostol is a prostaglandin E(1) analogue that has been used for medical abortion. We conducted this prospective study to compare the efficacy of vaginal misoprostol for abortion in women at a gestational age of <42 days and in women at a gestational age of 42-56 days. METHODS: A total of 160 women seeking medical termination of a pregnancy of <56 days were enrolled in the study. Medical termination was performed using 800 micro g of vaginal misoprostol, repeated every 24 h for a maximum of three doses. RESULTS: The overall complete abortion rate was 91.3%. In group A (gestation <42 days) complete abortion occurred in 96.3% of women, whereas in group B (gestation = 42-56 days) complete abortion occurred in 86.3% of women (P < 0.025). The two groups did not differ significantly with respect to side-effects (incidence of pain, bleeding, nausea, diarrhoea, fever and headache). Women who had aborted successfully were significantly more satisfied with the method compared with women who did not (P < 0.001). CONCLUSIONS: The vaginal misoprostol-alone regimen is highly effective for women seeking medical abortion of pregnancies of

A case of partial mole and atypical type I triploidy associated with severe HELLP syndrome at 18 weeks' gestation.

Partial mole is a rare complication of pregnancy and 90% of cases are associated with triploidy. HELLP syndrome is also a rare and life-threatening condition that occurs after 20 weeks' gestation. We report a case presenting with a combination of severe HELLP syndrome, partial mole, triploidy type I and fetal growth restriction at 18 weeks' gestation. Partial mole and any type of triploidy must be considered in cases of hydrocephalus and severe growth restriction in the second trimester of pregnancy. Our case highlights the fact that growth restriction can be associated with type I triploidy and that severe HELLP syndrome can develop in such cases even before 20 weeks' gestation.

Severe nonimmune hydrops fetalis and congenital corneal opacification secondary to human parvovirus B19 infection. A case report.

BACKGROUND: In parvovirus infections in animals, congenital anomalies are seen, but the teratogenic potential in humans seems fairly low. CASE: A fetus with hydrops, ascites and pleural effusion was seen at a prenatal ultrasound examination. Fetal cordocentesis was performed, and fetal blood was positive for parvovirus antibodies. Intravascular fetal blood transfusion was given at 21 and 23 weeks of gestation. At 39 weeks labor started spontaneously, and a 2,960-g, female infant was delivered. The newborn had bilateral opacification of the cornea. CONCLUSION: In this case a combination of fetal parvovirus B19 infection and congenital corneal opacification was seen. This case also demonstrates that blood transfusions in hydropic fetuses may reverse the hydrops and prevent intrauterine death.

Routine obstetrical ultrasound at 18-22 weeks: our experience on 7,236 fetuses.

OBJECTIVE: This study aimed at examining the detection rate of congenital abnormalities by using routine ultrasonography at 18-22 weeks of gestation. METHODS: The sample included 7,236 fetuses. A detailed sonographic examination was performed in each fetus and a neonatal evaluation or pathology examination was made to confirm the prenatal findings. RESULTS: The total prevalence of fetal abnormalities in our sample was 2.24% (162/7,236). There were 29/162 (17.9%) fetuses with CNS abnormalities, 27/162 (16.7%) fetuses with gastrointestinal abnormalities, and 28/162 (17.3%) fetuses with urinary tract abnormalities. There were also 31/162 (19.1%) fetuses with cardiovascular abnormalities, 26/162 (16.0%) with malformation of the limbs and musculoskeletal system, and 21/162 (13%) fetuses with other various abnormalities. The overall sensitivity in detecting fetuses with congenital abnormalities was 80.25% (130/162). The sensitivity per system was 93.1% (27/29) for CNS, 45.2% (14/31) for cardiovascular system, 85.2% (23/27) for gastrointestinal system, 85.7% (24/28) for urinary system, 84.6% (22/26) for musculoskeletal system, and 95.2% (20/21) for the rest of the abnormalities detected. We performed 40 pregnancy terminations in the group of malformed fetuses. Among the fetuses considered as normal, 1.7% had chromosomal abnormalities. CONCLUSIONS: The results indicate that routine sonographic examination at 18-22 weeks of gestation can detect the majority of congenital abnormalities. More experience is needed for the examination of the cardiovascular system, where the sensitivity was particularly low (14/31 or 45.2%).

Evaluation of first-trimester screening by fetal nuchal translucency and maternal age.

The aim of this screening study was to evaluate first-trimester screening for chromosomal defects by fetal nuchal translucency thickness at 10-14 weeks of gestation in four Fetal Medicine Units in Greece. Estimates of the risk for trisomy 21 were calculated taking into account fetal nuchal translucency thickness and maternal age. There were 3550 cases; the median maternal age was 29 years (range 16-48 years); and 277 (7.8 per cent) were over 37 years. The median crown rump length was 60 mm (range 38-85 mm) and the fetal nuchal translucency thickness increased with crown rump length and measurements were above the 95th centile in 101 (2.9 per cent) of the cases. The adjusted risk was 1 in 300 or more in 172 (4.9 per cent) of the cases and the high-risk group contained ten of the 11 (91 per cent) fetuses with trisomy 21 and all 11 fetuses with other chromosomal defects. The findings of this study provide further evidence for the high efficacy of screening for chromosomal abnormalities by fetal nuchal translucency and maternal age.

Facial nerve palsy during pregnancy.

The aim of this prospective study was to investigate whether pregnancy predisposes to facial nerve palsy and what the specific properties of facial nerve palsy are during this period. Eight cases of idiopathic facial nerve palsy occurring during the last trimester of pregnancy are presented. Out of 50 women with idiopathic facial nerve palsy, 15 were in childbearing age; eight presented a facial nerve palsy during pregnancy of which 6 during the last trimester of pregnancy. The electrodiagnostic tests indicated nerve degeneration in two of the eight cases; they were treated with corticosteroids. In the other six patients, no nerve degeneration was observed, and therefore, no treatment was given. These data suggest that pregnancy is probably associated with an increased predisposition to facial nerve palsy.

Neutrophil and monocyte beta 2-integrin expression in trisomic fetuses.

Flow cytometry was used to measure neutrophil and monocyte beta 2-integrin expression in fetuses with trisomy 18 (n = 7) and trisomy 21 (n = 7) at 20-25 weeks' gestation. The values were compared with those of 112 chromosomally normal fetuses. There were no significant differences in beta 2-integrin expression between normal and aneuploid fetuses. These findings demonstrate that in trisomies 21 and 18, alteration in beta 2-integrin expression is unlikely to contribute to the pathogenesis of immunological deficiencies that have been observed in these aneuploidies both prenatally and postnatally.

Neutrophil and monocyte beta 2-integrin expression in maternal and fetal blood.

OBJECTIVE: The aim of this study was to investigate fetal and maternal leukocyte beta 2-integrin expression throughout pregnancy. STUDY DESIGN: In a cross-sectional study of 173 fetuses at 18 to 40 weeks' gestation, 114 women with normal singleton pregnancies at 6 to 40 weeks, and 25 adult volunteers, flow cytometry was used to determine neutrophil and monocyte expression of beta 2-integrins. RESULTS: The surface density of beta 2-integrins on fetal neutrophils and monocytes increased significantly with gestation, except for the expression of fetal monocyte CD11b, which did not change. There were no significant changes in maternal beta 2-integrin expression with gestation. During the third trimester fetal expression of CD18, CD11b, and CD11c on neutrophils and CD11b on monocytes was lower, and maternal expression of CD11a on neutrophils and CD18, CD11a and CD11c on monocytes was higher than were the control adult values. CONCLUSIONS: These data demonstrate that pregnancy is associated with changes in the expression of maternal beta 2-integrins and illustrate the pattern of immunophenotypic maturation of fetal beta 2-integrins on neutrophils and monocytes.

Maternal peripheral blood lymphocyte subpopulations in normal and pathological pregnancies.

Flow cytometry was used to determine lymphocyte subpopulations in maternal blood from 143 pathological pregnancies: 50 with fetal aneuploidy; 32 with missed abortions; 12 with ectopic pregnancies; 20 with multi-fetal pregnancies, and 29 with pregnancies complicated by intrauterine growth retardation (IUGR). The values were compared to those of 240 women with normal singleton pregnancies at 8-40 weeks of gestation and 20 non-pregnant controls. In early pregnancy (8-10 weeks), compared to non-pregnant values, there was a decrease in the percentage of CD4+ cells and CD4+ to CD8+ ratio and an increase in the percentage of CD8+ cells. In later pregnancy, the CD4+ cell percentage and CD4+ to CD8+ ratio increased and the CD8+ cell percentage decreased to reach non-pregnant values at term. The percentage of natural killer (CD3- and CD16/56+) cells decreased with gestation, while the percentage of B (CD19+) cells did not change significantly. In IUGR, the percentage of CD4+ cells and CD4+ to CD8+ ratio were decreased, while the percentage of CD8+ cells was increased. In contrast, in the groups of missed abortions and ectopic pregnancies, the CD4+ to CD8+ ratio was increased. In multifetal pregnancies and those with fetal aneuploidies there were no significant differences in maternal lymphocyte subpopulations from normals.

Fetal immunological and haematological changes in intrauterine infection.

OBJECTIVE: To study fetal immunological and haematological changes to intrauterine infection. DESIGN: In 37 pregnancies at risk of intrauterine infection, fetal blood obtained by cordocentesis at 20 to 36 weeks gestation was used for differential leucocyte counts, platelet count, enumeration of lymphocyte subpopulations, and neutrophil adhesion receptor expression. SETTING: Harris Birthright Research Centre for Fetal Medicine, London. RESULTS: All four fetuses with viral infections had platelet counts below the 5th centile and three had natural killer (NK) cell counts greater than the 95th centile of the normal range. Similarly, all five fetuses with bacterial or candidal infection had neutrophil counts greater than the 95th centile of the normal range; lymphocyte subpopulations were normal. CONCLUSIONS: In pregnancies complicated by intrauterine infection, fetuses exhibit NK cell lymphocytosis and thrombocytopenia in response to viraemia, and neutrophilia in response to bacteraemia from at least 21 weeks gestation.

Abnormal immunological development in fetuses with trisomy 18.

Flow cytometry was used to enumerate the lymphocyte subpopulations in fetal blood obtained by cordocentesis from eight trisomy 18 fetuses at 20-36 weeks' gestation. Compared with values in chromosomally normal fetuses, in trisomy 18 the mean T- and natural killer (NK) cell counts were significantly lower (t = -7.63, P < 0.001 and t = -3.58, P < 0.01, respectively); the mean B-cell count was not significantly different (t = -1.32). These findings demonstrate that in trisomy 18 there is abnormal intrauterine development of the immune system.

Fetal lymphocyte subpopulations in red blood cell iso-immunised pregnancies.

OBJECTIVE: To study the association between fetal anaemia and alterations in lymphocyte subpopulations. DESIGN: Cross-sectional study. SETTING: The Harris Birthright Research Centre for Fetal Medicine, King's College Hospital Medical School, London. SUBJECTS: Forty-three red blood cell iso-immunised pregnancies undergoing cordocentesis at 19 to 38 weeks gestation. MAIN OUTCOME MEASURES: Fetal blood haemoglobin concentration, erythroblast count and lymphocyte subpopulations. RESULTS: The mean T (CD3+), B (CD19+), T-helper (CD4+), T-suppressor/cytotoxic (CD8+) and natural killer (NK: CD16+/CD56+) cell counts in the anaemic fetuses were significantly lower than the appropriate normal mean for gestation (CD3+: t = -3.25, P < 0.01; CD19+: t = -2.14, P < 0.05; CD4+: t -4.03, P < 0.001; CD8+: t = -3.39, P < 0.01 and CD16+/CD56+: t = -3.49, P < 0.01). Furthermore, there was a significant association between the decrease in T lymphocyte number and the degree of fetal anaemia (r = 0.342, P < 0.05). CONCLUSIONS: Fetuses from red blood cell iso-immunised pregnancies exhibit nonselective lymphopenia that is proportional to the degree of anaemia.

Fetal blood mononuclear cell division in normal and pathological pregnancies.

Fetal blood mononuclear cell division was measured using flow cytometry in 53 normal pregnancies and 51 pathological pregnancies complicated either by anaemia due to red blood cell isoimmunisation (RCI: n = 21), intrauterine growth retardation (SGA: n = 13) or abnormal karyotype (n = 17). In normal pregnancy, mononuclear cell division rates decreased with gestational age from a mean of 1.8% at 18 weeks to 1% at 40 weeks. Furthermore, there was a significant association between cell division and erythroblast count. The rates of cell division and erythroblast count were significantly increased in the chromosomally abnormal fetuses, and significantly decreased in the transfused RCI fetuses compared to the controls. Although the erythroblast count was elevated in the SGA fetuses, the mononuclear cell division was not significantly different from the controls. Fetal blood mononuclear cell division is elevated in early pregnancy and in chromosomally abnormal fetuses, probably as a consequence of increased numbers of circulating haemopoietic precursors. Mononuclear cell division is decreased in transfused RCI fetuses as a consequence of suppressed erythropoiesis. In SGA fetuses, despite the increased erythropoietic stimulation and erythroblastosis, cell division is not increased.

Fetal immunodeficiency: a consequence of placental insufficiency.

OBJECTIVE: To study the effect of placental insufficiency on fetal lymphocyte subpopulations. STUDY DESIGN: Cross sectional study of 19 growth retarded fetuses undergoing cordocentesis at 24 to 37 weeks gestation. Flow cytometry was used to enumerate fetal blood lymphocyte subpopulations. RESULTS: The mean T (CD3+), B (CD19+), T-helper (CD4+), T-suppressor/cytotoxic (CD8+) cell counts and the CD4 to CD8 ratio in the growth retarded fetuses were significantly lower than respective normal mean for gestation (CD3+: z = 3.66, P < 0.001; CD19+: z = 2.18, P < 0.05; CD4+: z = 3.76, P < 0.001; CD8+: z = 2.26, P < 0.05; and CD4/CD8: z = 2.27, P < 0.05). There were significant associations between the decrease in the T lymphocyte subpopulations and the degree of fetal acidaemia. CONCLUSIONS: Growth retarded fetuses demonstrate immune abnormalities that could be attributed to intrauterine starvation.