A. Antsaklis

Fetal blood sampling--indication-related losses.

The aim of this study was to determine the fetal loss rate after fetal blood sampling (FBS) in relation to the indication. In total, 1981 FBS procedures (1878 pregnancies) were included, of which 117 were performed for the detection of congenital infection (group 1), 1437 for the detection of haemoglobinopathy (group 2), 233 for prenatal diagnosis with normal ultrasound findings (group 3), 121 for rapid karyotyping in cases with abnormal sonographic findings (group 4) and 73 for severe growth retardation (group 5). All the procedures were performed with a free‐hand technique under continuous ultrasound guidance. Pregnancy losses occurring within two weeks of FBS were considered procedure‐related losses. 343 pregnancies were terminated. Of the remaining 1535 continuing pregnancies, 73 (4·8 per cent) were lost, of which 39 (2·5 per cent) were lost within two weeks of the procedure. The procedure‐related losses were 3 in 103 (2·9 per cent), 17 in 1090 (1·6 per cent), 2 in 191 (1 per cent), 11 in 84 (13·1 per cent) and 6 in 67 (8·9 per cent) in groups 1, 2, 3, 4 and 5, respectively. The differences in procedural loss between the five groups were highly significant, suggesting that the method entails a much higher risk when the fetus is structurally abnormal, or severely growth retarded. Patients should therefore be counselled before the procedure accordingly.

Different ovarian stimulation protocols for women with diminished ovarian reserve.

PurposeTo review the available treatments for women with significantly diminished ovarian reserve and assess the efficacy of different ovarian stimulation protocols.MethodsLiterature research performed among studies that have been published in the Pubmed, in the Scopus Search Machine and in Cohrane database of systematic reviews.ResultsA lack of clear, uniform definition of the poor responders and a lack of large-scale randomized studies make data interpretation very difficult for precise conclusions. Optimistic data have been presented by the use of high doses of gonadotropins, flare up Gn RH-a protocol (standard or microdose), stop protocols, luteal onset of Gn RH-a and the short protocol. Natural cycle or a modified natural cycle seems to be an appropriate strategy. Low dose hCG in the first days of ovarian stimulation has promising results. Molecular biology tools (mutations, single nucleotide polymorphisms (SNPs)) have been also considered to assist the management of this group of patients.ConclusionsThe ideal stimulation for these patients with diminished ovarian reserve remains a great challenge for the clinician, within the limits of our pharmaceutical quiver.

Rapid clearance of fetal cells from maternal circulation after delivery

Abstract: We previously reported increased apoptosis in the maternal circulation during pregnancy, partly accounting for the presence of cell‐free fetal DNA in maternal plasma. In the current study, apoptosis was quantitated in 60 peripheral blood samples obtained from 15 women sequentially tested postpartum using the binding of annexin V. FISH with X/Y probes was performed on annexin V‐positive cells isolated by MACS in patients with male fetuses to estimate the proportion of fetal cells among the apoptotic cell population. Twenty‐four women at the thirty‐seventh to thirth‐eighth week of gestation and 35 nonpregnant females were used as controls. Apoptosis rate in the thirty‐seventh to thirty‐eighth week was 12.5% (9.2‐14.7%). At 30 minutes, 12 hours, 24 hours, and 48 hours postpartum, it was 25.1% (16.8‐28.5%), 12.5% (10.9‐14.1%), 6.1% (4.8‐7.1%), and 2.3% (1.3‐3.0%), respectively. Male apoptotic cells were identified in all cases with male fetuses at 37 to 38 weeks of gestation, and the mean proportion was 9.9% (5.9‐13.2%). The proportion of fetal cells 30 minutes after delivery was 14.8% (12.5‐25.5%) and 12 hours postpartum 2.1% (0.8–4.1%). Male fetal apoptotic cells were detected in three of eight samples collected 24 hours after delivery from women who delivered males, at frequencies of 0.10%, 0.15%, and 0.25% (mean 0.16%). There were no fetal apoptotic cells 48 hours after delivery. Apoptosis partly accounts for the clearance of fetal cells from the maternal circulation. Because it is a rapid reaction, completed within 2–3 hours, persistence of fetal cells is possibly due to apoptosis‐resistant progenitors or to defective regulation of apoptosis, leading to fetal cell microchimerism associated with autoimmune diseases.

Pregnancy and homozygous beta thalassaemia major

Nine pregnant women with homozygous β‐thalassaemia major followed a strict transfusion regimen to maintain their haemoglobin level > 10g/dl. One pregnancy was terminated because of concern about desferrioxamine teratogenicity and another ended in miscarriage at 11 weeks. All other women were delivered by elective caesarean section between 37 and 38 weeks. There were no obstetric complications or perinatal deaths.

Metformin administration was associated with a modification of LH, prolactin and insulin secretion dynamics in women with polycystic ovarian syndrome

Aim. To elucidate the dynamics of FSH, LH, prolactin (PRL), TSH and insulin secretion in women with polycystic ovarian syndrome (PCOS) treated with metformin (MET). Patients and methods. In a prospective, controlled and randomised trial, 32 women with PCOS and 32 with normal cycle were recruited to receive MET (850 mg b.i.d.) or placebo (n: 16 for each subgroup) for an average of 40 days. Pituitary function and insulin secretion were assessed before and after intervention by GnRH-TRH tests and oral glucose tolerance test induced insulin response. Results. Basal and area under the response curve (AURC) LH values were higher in PCOS than in normal controls before MET and declined following treatment in the former group (P < 0.05). Ovulatory PCOS responders had lower basal LH, AURCLH and AURCPRL values during MET than anovulatory cases (P < 0.05 for all) and AURCins was lower in ovulatory than anovulatory PCOS before and on MET (P < 0.02–P < 0.05), with a rise of QUICKY index in the former group during MET treatment (P < 0.05). FSH and TSH were similar. Conclusions. MET administration lowered LH activity in all PCOS women and in ovulatory responders and also compromised PRL stimulated secretion in the latter cases. These findings were indicative of an effect of MET on pituitary activity.

Local Application of Methotrexate for Ectopic Pregnancy with a Percutaneous Puncturing Technique

Management of ectopic pregnancy remains traditionally surgical. Early detection of unruptured ectopic pregnancies, using both ultrasound techniques and β-human chorionic gonadotropin (β-hCG) assays, allows a more conservative treatment. Twenty-six tubal pregnancies, which were managed with local methotrexate (MTX) injection, are presented. A single dose of 10–12.5 mg of MTX was percutaneously injected into the gestational sac under abdominal sonographic control. Complete resolution was obtained in all our patients. Four of them required a second percutaneous administration 4 days after the first one. Negligible serum β-hCG levels (<10 mIU/ml) were reached within 42 days after treatment. No systemic side effects were observed. Local administration of MTX under abdominal sonographic control seems to be an effective alternative for the treatment of ectopic pregnancy. The main potential advantages of the method are (1) a greater antitrophoblastic effect; (2) a shorter treatment period; (3) reduced dosage, and (4) absence of side effects.

Invasive techniques for fetal diagnosis in multiple pregnancy

During a 12‐year period, a variety of fetal diagnostic techniques were performed in 112 twin, 3 triplet and 1 quintuplet pregnancies, respectively. Tissues sampled included amniotic fluid, fetal blood and chorionic villi. Two spontaneous abortions occurred and one case of twins was stillborn. Four selective feticides were performed in twins for specific indications and four healthy surviving infants were delivered. It is concluded that fetal diagnosis in multiple pregnancy is safe and accurate without significant perinatal morbidity and mortality.

Factors affecting postoperative pregnancy rate after endoscopic management of large endometriomata

Objective: To identify factors influencing postoperative pregnancy rate in women with extensive endometriosis and large endometriomata as the only identified cause of infertility that were treated by laparoscopy. Method: Sixty‐four infertile patients with endometriomata (≥3 cm) and no other apparent cause of infertility. The latter were removed by operative laparoscopy. Life table calculations, the Students t‐test and the χ2 test were used where appropriate. Result: Thirty‐four patients (53%) became pregnant during the 2‐year follow‐up period. A significantly increased pregnancy rate was found for the first year compared to the second (76 vs. 24%). The existence of adhesions affected adversely the outcome of the operation only as far as early achievement of pregnancy is considered. The number and size of endometriomata and the existence of peritoneal implants have not been found to affect pregnancy rates. The severity of the disease did not affect pregnancy rate, but in the cases with moderate disease most of the pregnancies were achieved during the first postoperative year. The duration of infertility was significantly associated only at the 10% level with decreased pregnancy rates. Conclusion: Extensive endometriosis with large endometriomata can be safely and effectively treated with laparoscopy using the traditional laparoscopic tools providing the infertile patient with a high chance to conceive in a relatively short period of time postoperatively.

Erythromycin treatment for subclinical Ureaplasma urealyticum infection in preterm labor.

This study was undertaken to test the effects of erythromycin as an adjunct to tocolysis for preterm labor in women with vaginal cultures positive for Ureaplasma urealyticum. The study group consisted of 18 women in active preterm labor with pregnancies between 26 and 34 weeks of gestation and intact membranes who received 500 mg erythromycin orally every 8 h for 10 days. Seventeen women with similar characteristics served as controls and received no antibiotics. In all women contractions were suppressed with ritodrine. Erythromycin treatment resulted in a statistically significant greater mean delay of delivery (36.4 days) than among the control group (23.1 days). Higher proportion of term pregnancies (7 versus 3 pregnancies), higher mean birth weight (2,745 versus 2,474 g), lower neonatal morbidity (22.2 versus 42.2%) and shorter mean neonatal hospitalization time (9.6 versus 12.1 days) were observed, although these differences were not statistically significant. Adjunctive erythromycin treatment given to women treated for preterm labor with intact membranes and positive vaginal cultures for U. urealyticum appears to prolong gestation and to improve perinatal outcome.

Use of Annexin V Antibody to Identify Apoptotic Cells during Pregnancy

Abstract: In a previous study, we demonstrated that apoptosis increased according to gestational age, accounting partly for the presence of free fetal DNA in maternal plasma and serum. Using simultaneous TUNEL assay and FISH analysis, we identified the fetal origin of part of the apoptotic cell population, but very few TUNEL‐positive cells showed hybridization signals since they were in a late apoptosis stage and nuclei were destroyed. In the present study, the apoptotic cell population was identified immunocytochemically using Annexin V, a marker of cells in an early stage of apoptosis. The mean apoptosis rate in mononuclear cells isolated from the peripheral blood of 20 pregnant women in the 16th to 19th week of pregnancy with Annexin V was 6.8 ± 0.5% (range: 4.2–8.1%) compared to 6.14 ± 0.5% (range: 3.7–6.9%) obtained with ethidium bromide staining. FISH using X and Y chromosome‐specific probes was applied in 11 cases known to be carrying male fetuses. Eighty percent of Annexin V+ cells showed hybridization signals, while the proportion of apoptotic cells showing X/Y signals was 7.8% (range: 5–12%). Although our results are still preliminary, it seems that use of Annexin V antibody to detect the apoptotic cell population improves FISH analysis and allows a more accurate estimate of the proportion of fetal cells among the apoptotic cell population.