Attila Pajor

Pregnancy in Liver Cirrhosis

Eleven patients with liver cirrhosis who had a pregnancy between 1974 and 1992 are reported. Prior to pregnancy 2 patients were splenectomized, 1 of them also had an unsuccessful mesocaval shunt and therefore underwent sclerotherapy. Furthermore, 3 patients were managed by injection sclerotherapy, 6 patients had episodes of hepatocellular failure and 5 had signs of hypersplenism. Gastrointestinal hemorrhage associated with pregnancy was noted in 6 patients. Jaundice was encountered in 2 patients, a raised bilirubin level in 3, ascites in 3, impairment of the synthetic liver function in 5, thrombocytopenia in 8, hemorrhagic diathesis in 5, and infectious puerperal complication in 5 patients. Esophageal sclerotherapy was used in 5 and transfusion in 6 patients. Of 12 births, 6 newborns were small-for-date and 1 of them died. Three neonates were preterm. Fetal wastage did not occur. The present data suggest that gastrointestinal hemorrhage in liver cirrhosis contributes to developing fetal growth retardation; cirrhotic patients can be prepared for pregnancy and the hematemesis during pregnancy can successfully be managed by esophageal sclerotherapy.

Pregnancy and extrahepatic portal hypertension : review and report on the management

The authors report on 17 pregnancies of 7 patients with extrahepatic portal hypertension (EPH). Before conception all patients underwent splenectomy, in 5 of them portosystemic shunts were performed and 3 women received esophageal sclerotherapy as well. Three patients had esophageal varices before and throughout the pregnancy, and in 1 patient pregnancy was electively terminated on 4 occasions for previously bleeding varices; then the sclerotherapy eradicated the varices, and she had a successful pregnancy, in which the varices recurred. No gastrointestinal bleeding was seen during the pregnancies. There were toxemia in 1, edema in 2, anemia in 3, cesarean section in 10, puerperal endometritis in 4 and puerperal thrombophlebitis of the leg in 2 pregnancies. One spontaneous abortion and 12 live births among them with 3 preterm infants were encountered. All newborns were healthy and appropriate for their gestational age. The authors review the maternal as well as fetal complications and discuss the current management for pregnant women with EPH.

Gene expression patterns of the 11β-hydroxysteroid dehydrogenase 2 enzyme in human placenta from intrauterine growth restriction: the role of impaired feto-maternal glucocorticoid metabolism

OBJECTIVE To assess 11-β-hydroxysteroid dehydrogenase 2 (11β-HSD2) gene expression patterns in human placental samples from intrauterine growth restriction (IUGR) pregnancies using normal pregnancy as control. STUDY DESIGN We compared 11-β-HSD2 gene expression in placental samples from all IUGR pregnancies treated in our clinic between January 1, 2010 and January 1, 2011 vs. 140 normal pregnancy samples from the same study period. Clinical characteristics were also assessed and compared between the IUGR and normal pregnancy groups. RESULTS Mean gestational weight gain in the IUGR group was significantly lower than in the control group. Similarly, change in body mass index (BMI) was lower. Impending intrauterine fetal asphyxia was significantly more common in the IUGR group. The 11β-HSD2 gene was underexpressed compared to controls, but this underexpression was only observed after the 33rd gestational week. Within the IUGR group, in cases of impending intrauterine fetal asphyxia the 11β-HSD2 gene was underexpressed compared to both impending asphyxia in non-IUGR cases, or IUGR without impending asphyxia. CONCLUSION Low gestational weight gain appears to predict IUGR. The 11β-HSD2 gene in IUGR is underexpressed and may result in an impaired placental barrier, decreasing protection against maternal glucocorticoids, which are thought to be prominent in fetal programming. Maternal glucocorticoid exposure resulting from an impaired placental barrier may increase the risk for cardiovascular and metobolic disorders later in adult life. In IUGR, before the 33rd gestational week, the expression of the 11β-HSD2 gene remains physiological. The underexpression of this gene after the 33rd week in impending intrauterine fetal asphyxia in IUGR points to an increased sensitivity to hypoxia when impending asphyxia is present in the late phase of IUGR pregnancies.

Gene expression patterns of insulin-like growth factor 1, 2 (IGF-1, IGF-2) and insulin-like growth factor binding protein 3 (IGFBP-3) in human placenta from preterm deliveries: influence of additional factors

OBJECTIVE To compare patterns of human placental gene expression of IGF from pregnancies that ended with preterm delivery vs. full term pregnancies as controls. STUDY DESIGN Real-time PCR was used to assess gene expression of IGF in human placental samples from 104 preterm and 140 full term pregnancies. RESULTS In the preterm delivery group, the proportion of smokers was significantly higher than in the control group. A history of preterm delivery was more common in the preterm delivery group compared to the control group. In the preterm delivery group, placental samples showed an underexpression of the IGF-1 gene compared to controls. In cases of male fetal gender an overexpression of both the IGF-2 and the IGFBP-3 genes was observed. CONCLUSION Among environmental factors influencing preterm delivery, smoking was the most significant in our study. In the majority of cases, preterm delivery was induced by intrauterine infection leading to a decreased activity of the IGF system. This mechanism may also play a role in the development of neurological sequelae and in decreased tolerance to fetal distress. The overexpression of the IGF-2 gene observed in the placenta with male fetal gender can be explained by its physiological role in the development of the male phenotype.

Pregnancy in idiopathic aplastic anemia (report of 10 patients)

This paper reports on 6 patients with severe, 2 with moderate and 2 with mild aplastic anemia who had a total of 18 pregnancies after the diagnosis. All four pregnancies that occurred during the active state of severe and moderate aplastic anemias were electively terminated. Two out of 14 pregnancies that occurred during the long-term remission were electively terminated for non-medical reason, two spontaneous abortions occurred and 10 live births were seen. All offspring were healthy at follow-up. During pregnancy the circulating blood cell levels decreased in 1 out of 6 pregnancies in patients who were in remission from mild and moderate aplastic anemias, and in 4 out of 8 pregnancies in patients who were in remission from severe aplastic anemia. In all 5 cases that showed a relapse during pregnancy the remission recurred following the termination of pregnancy. The data presented suggest that aplastic anemia in long-term remission can unpredictably relapse during pregnancy, but its final outcome appears not to be affected by pregnancy. Furthermore, there is no correlation between the pre-pregnancy clinical course and the events during pregnancy. The outcome of pregnancy during the remission of aplastic anemia seems beneficial, and spontaneous delivery should be preferred.

Abnormal fetomaternal glucocorticoid metabolism in the background of premature delivery: placental expression patterns of the 11β-hydroxysteroid dehydrogenase 2 gene.

OBJECTIVE During pregnancy, 11β-hydroxysteroid dehydrogenase 2 (11β-HSD2) is involved in the development of the placental barrier, and its main function is to protect the fetus from the effects of the physiological increase of maternal glucocorticoids. We compared human placental gene expression patterns of 11β-HSD2 from pregnancies that ended with preterm delivery versus full term pregnancies as controls. STUDY DESIGN We used real-time PCR to assess the placental gene expression patterns of 11β-HSD2 in 104 preterm and 140 full term pregnancies (control group) at the time of delivery. RESULTS In the preterm delivery group, the proportion of smokers was 26.9%, significantly higher than in the control group. Preterm delivery began with premature rupture of membranes in 70.2% and spontaneous uterine activity in 29.8%. The 11β-HSD2 gene was underexpressed in the preterm delivery group compared to normal pregnancy between 28 and 36 gestational weeks, but unchanged between 24 and 28 weeks. There was no fetal gender effect on 11β-HSD2 gene expression. CONCLUSION The reduced activity of the 11β-HSD2 gene seen in the preterm delivery group may impair fetal defences against maternal glucocorticoid exposure. In cases of impending premature delivery, glucocorticoid effects, potentially including postnatal neurological abnormalities and growth restriction, may be worsened by prophylactic steroids given to accelerate fetal lung maturity. The impairment in fetal defences against maternal glucocorticoids due to reduced 11β-HSD2 enzyme activity appears to begin after gestational week 28.

Pregnancy in Cyclic Neutropenia

We present a patient with cyclic neutropenia who had two successful pregnancies during which the disease improved. Following one of the deliveries severe endometritis and wound dehiscence of the episiotomy developed and neonatal pemphigoid was seen.

May-Hegglin anomaly and pregnancy

A hypertensive patients with thrombocytopenia is reported who had two pregnancies complicated by preeclampsia and cesarean deliveries without hemorrhage. During her first pregnancy corticosteroids were given for presumed autoimmune thrombocytopenia. Thereafter she was splenectomised. Ten years later May-Hegglin anomaly and renal failure were diagnosed. One of her children had easy bruising.

A méhüreg anatómiai rendellenességei habituális vetélőkben

Absztrakt Bevezetes: A habitualis veteles a nők 1%-at erintő rendellenesseg, amelynek hattereben genetikai, endokrin, mehűri anatomiai, immunologiai, mikrobiologiai es hematologiai, valamint andrologiai zavarok mutathatok ki mint kockazati tenyezők, de az esetek feleben ismeretlen ok miatt alakul ki. Celkitűzes: A habitualis veteles kockazati tenyezőinek kutatasa soran a szerzők arra a kerdesre kerestek valaszt, vajon a magyar lakossagban milyen gyakran fordul elő a mehureget erintő anatomiai rendellenesseg. Modszer: Retrospektiv modon dolgoztak fel 152 habitualis vetelő adatait. Az esetleges mehűri elteres tisztazasara 132 betegben vagy diagnosztikus hiszteroszkopia, vagy a mehureg 3 dimenzios ultrahangvizsgalata, 16 esetben hysterosalpingographia, 4 esetben hysterosalpingo-sonographia tortent. Eredmenyek: Megallapitottak, hogy a habitualis vetelők 15,8%-aban mehűri rendellenesseg mutathato ki. A rendellenessegek kozul septum uteri 6,5%-ban, endometriumpolypus 2,6%-ban, uterus arcuatus 2%-ban, uterus bic...

Gene expression patterns of the Bcl-2 and Bax genes in preterm birth.

Objective. The apoptotic genes Bax and Bcl‐2 are both involved in the pathogenesis of preterm delivery in conjunction with additional factors. We characterized gene expression patterns of these apoptotic regulatory genes as well as relevant environmental factors. Design. A gene expression study with evaluation of clinical data. Setting. Semmelweis University, Budapest, Hungary. Sample. Human placental samples from 104 preterm and 140 full‐term pregnancies. Methods. Gene tests were performed using real‐time PCR to assess gene expression patterns of Bax and Bcl‐2 in human placental samples. Clinical data were collected from our computerized database. Main outcome measures. Apoptotic gene expression pattern and clinical information against the background of preterm delivery. Results. In placental samples from preterm delivery pregnancies, expression of the Bcl‐2 gene was unchanged, whereas the Bax gene was overexpressed. Placental gene expression of Bax in preterm delivery was dependent on gestational age with gestational weeks 28–32 and 32–36 associated with overexpression, and no overexpression in gestational weeks 24–28. Preterm delivery began with premature rupture of membranes in 70.2% and spontaneous uterine activity in 29.8%. Conclusions. The Bax gene was overexpressed in preterm delivery, whereas expression of the Bcl‐2 gene remained unchanged. After the 28th gestational week, apoptosis appears to be a key factor in the pathogenesis of preterm delivery.