Beáta Hargitai

Placental protein 13 (galectin-13) has decreased placental expression but increased shedding and maternal serum concentrations in patients presenting with preterm pre-eclampsia and HELLP syndrome

Placental protein 13 (PP13) is a galectin expressed by the syncytiotrophoblast. Women who subsequently develop preterm pre-eclampsia have low first trimester maternal serum PP13 concentrations. This study revealed that third trimester maternal serum PP13 concentration increased with gestational age in normal pregnancies (p < 0.0001), and it was significantly higher in women presenting with preterm pre-eclampsia (p = 0.02) and hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome (p = 0.01) than in preterm controls. Conversely, placental PP13 mRNA (p = 0.03) and protein, as well as cytoplasmic PP13 staining of the syncytiotrophoblast (p < 0.05) was decreased in these pathological pregnancies compared to controls. No differences in placental expression and serum concentrations of PP13 were found at term between patients with pre-eclampsia and control women. In contrast, the immunoreactivity of the syncytiotrophoblast microvillous membrane was stronger in both term and preterm pre-eclampsia and HELLP syndrome than in controls. Moreover, large syncytial cytoplasm protrusions, membrane blebs and shed microparticles strongly stained for PP13 in pre-eclampsia and HELLP syndrome. In conclusion, parallel to its decreased placental expression, an augmented membrane shedding of PP13 contributes to the increased third trimester maternal serum PP13 concentrations in women with preterm pre-eclampsia and HELLP syndrome.

Rare Case of Exomphalos Complicated with Umbilical Cord Teratoma in a Fetus with Trisomy 13

An exomphalos containing unusual solid and cystic mass was diagnosed during a routine ultrasound examination in the 17th week of gestation. Further investigations were planned but the pregnancy was terminated. The fetopathological examination revealed an umbilical cord teratoma. Although this entity is very rare it should be emphasized as a possible differential diagnosis when cystic lesion of the cord is detected. Large teratomas associated with abdominal wall defect may have poor fetal outcome and can be associated with structural and chromosomal abnormalities. In our case trisomy 13 was diagnosed.

Marked chromogranin A elevation in a patient with bilateral adrenal incidentalomas, and its rapid normalization after discontinuation of proton pump inhibitor therapy

Chromogranin A (CgA) is a well-recognized tumour marker for various neuroendocrine tumours. 1 In their recent article Grossrubatscher et al. demonstrate the utility of CgA in the diagnosis and follow-up of phaeochromocytoma. 2 As the secretory activity of these tumours can be episodic, CgA measurement is of great value in cases where urinary catecholamines are negative. False-positive elevated CgA, however, can be related to various conditions, 1 including proton pump inhibitor (PPI) and steroid therapy, or be associated with impaired renal function and type A gastritis, and can lead to serious differential diagnostic problems in patients with adrenal tumours. Here, we report a case of highly elevated serum CgA level in a patient with bilateral adrenal adenomas, that was clearly associated with proton pump inhibitor therapy. As the patient also suffered from hypertension, the possibility of phaeochromocytoma had to be excluded. Discontinuation of PPI intake for 5 days normalized serum CgA, indicating that even a short interruption of PPI therapy can solve the differential diagnostic dilemma. A 73-year-old woman with a history of hypertension and gastrooesophageal reflux disease was examined for bilateral adrenal incidentalomas revealed by ultrasonography and subsequent computed tomography (CT). Although the clinical picture did not clearly suggest endocrine disease, routine endocrinological examination was undertaken. Hypercortisolism and primary aldosteronism were excluded. Serum CgA determined by radioimmunoassay (CISBio International, Gil-Sur-Yvette, France), however, was highly elevated (728 ng/ml, normal range 18–98·1 ng/ml). By contrast, urinary catecholamine metabolites (vanillylmandelic acid, normetanephrine, metanephrine, homovanillic acid) were normal, and 131 I-metaiodobenzylguanidine (MIBG) scintigraphy was also negative. Abdominal MRI showed that the signal intensities of bilateral adrenal tumours were different from those seen in phaeochromocytomas. 3 Serum creatinine and blood urea nitrogen were normal. As the patient had been treated with PPI for at least 8 years (omeprazole, and presently lansoprazole in a daily dose of 2 × 30 mg), iatrogenic elevation of CgA was suspected. To solve the serious differential diagnostic problem, we decided to suspend PPI therapy and replace it with sucralphate (4 × 1 g/day). Serum CgA returned to normal within 5 days (Fig. 1), and after a single dose (30 mg) of lansoprazole it increased again above the upper normal limit (132·4 ng/ml). Immunohistochemical analysis for CgA in mucosal biopsy samples from the gastric corpus indicated mild, simple (diffuse), enterochromaffin cell-like (ECL) hyperplasia. Although our patient did not present symptoms characteristic of phaeochromocytoma, suspicion was raised because of the highly elevated CgA together with the history of hypertension. As all other diagnostic examinations characteristic of phaeochromocytoma were negative, the possibility of PPI-related CgA elevation was raised. Short-, mediumand long-term PPI therapy has been shown to raise serum CgA. 4,5 Giusti et al . described the elevation of CgA in response to short-term (5–90 days) PPI therapy. 4 Our observation showing that a single dose of PPI may raise CgA above normal also supports a high sensitivity of serum CgA to PPI therapy. Elevation of CgA, however, was unusually high in the case presented. Available literature describes CgA levels up to 400 ng/ml (approx. 8 n m ), even after long-term PPI therapy. 5

Implementation and Experience of an Alternative QF-PCR and MLPA Diagnostic Strategy to Detect Chromosomal Abnormalities in Fetal and Neonatal Pathology Samples

Chromosomal abnormalities are a significant cause of pregnancy loss. Solid tissue fetal and neonatal pathology samples are routinely examined by karyotype analysis after cell culture. However, there is a high failure rate, and this approach is expensive and labor intensive. We have therefore evaluated a new molecular strategy involving quantitative fluorescent polymerase chain reaction (QF-PCR) and subtelomere multiplex ligation-dependent probe amplification (MLPA) analysis. A retrospective audit showed that less than 4% of abnormal cases may not be detected by this molecular strategy. We validated this strategy in parallel with cytogenetic analysis on 110 patient samples, which included cases of fetal loss, still birth, neonatal death, termination of pregnancy, recurrent miscarriage, and sudden unexpected death in infancy. This validation showed that 55 of the 57 samples that gave a result for both strategies were concordant. During the 1st year of diagnostic testing, we analyzed 382 samples by the molecular strategy. A 16% abnormality rate was observed. These included trisomies 13, 18, 21, monosomy X, and triploidy detected by QF-PCR (77%), and 23% were other trisomies and subtelomere imbalances detected by MLPA. This strategy had a 92% success rate in contrast to the 20%-30% failure rate observed with cell culture and cytogenetic analysis. We conclude that QF-PCR and subtelomere MLPA is a suitable strategy for analysis of the majority of fetal and neonatal pathology samples, with many advantages over conventional cytogenetic analysis.

Human brain of preterm infants after hypoxic-ischaemic injuries: no evidence of a substantial role for apoptosis by using a fine-tuned ultrasound-guided neuropathological analysis

Preterm birth may be associated with hypoxic-ischaemic encephalopathy (HIE) showing a well recognised number of patterns, including neuronal karyorrhexis/eosinophilia mostly at the diencephalon and brain stem and leukomalacia at the periventricular white matter. To investigate whether programmed cell death or apoptosis plays a role in HIE, we examined human brains of preterm infants. Brain tissue samples from 12 consecutive infants (24-34 weeks of gestation) were available at post-mortem examination (1998-2000) after approval of the Ethics Committee. Two tissue sections were stereologically localised after brain fixation, slice preparation, and comparison with ultrasound imaging. We studied the periventricular white matter and the corresponding cortical region in each brain. Conventional histological stains were used. In addition, apoptosis was detected using a neuronal-specific terminal deoxynucleotidyl transferase-mediated nick end-labelling (TUNEL) method (NeuroTACS). A semiquantitative evaluation was performed to compare regions close to brain lesions with injury-free areas. Neuronal apoptosis was low in both cortical and in periventricular regions. No glial apoptosis was detected. Apoptosis in neurones was, however, detected in preterm brains with bacterial or mycotic infection. These results point out to the ambiguity of the TUNEL-reactive neurons in the diseased premature infants using fine-tuned ultrasound-guided neuropathological analysis, support the probable coexistence of neuronal TUNEL-reactivity and infection, and suggest that the association between apoptosis and HIE should overall be viewed with more caution.

Elevated Brain Weight/Liver Weight Ratio in Normal Body Weight Centile Term Perinatal Deaths: An Indicator of Terminal Intrauterine Malnourishment:

A proportion of antepartum/intrapartum intrauterine deaths (IUDs) with normal or elevated body weight (BW) centile also show an elevated brain weight/liver weight (BLR) ratio. We postulate that this may be an indication of intrauterine malnourishment/incipient intrauterine growth restriction (IUGR), which may have a bearing on the cause of death. Searching our departmental postmortem database, we identified 331 IUD/intrapartum deaths (254; 77%) or early neonatal deaths (77; 23%), ≥37/40 weeks gestation in a 4-year period. The customized BW centile, BLR, brain weight/thymus weight ratio (BTR), fetus weight/placenta weight ratio (FPR), and maternal body mass index were calculated. A BLR >4.0 and a BTR >60 were regarded as abnormal. Of the 331 cases, the BLR was >4.0 in 71 (21.4%). Nineteen (26.7%) of the 71 had a BW above the 25th centile, and these were all IUDs. Eight deaths were explained. In the 11 unexplained deaths, the BTR was raised in 5 and FPR was elevated in 7. Three of these 11 mothers had impaired glucose tolerance, and 7 were overweight or obese. In the absence of a definitive cause, a raised BLR in an IUD with a normal BW centile is likely to indicate nutritional impairment/incipient IUGR. The majority of these deaths are associated with maternal obesity, with or without impaired glucose tolerance. Recognition of features of IUGR in IUDs of normal BW may help us understand the death. In these cases, placental growth may be insufficient to support a macrosomic fetus, leading to late nutritional impairment and death.

Prenatally diagnosed fetal brain injuries with known antenatal etiologies.

Periventricular leukomalacia of pre- or postnatal onset is responsible for severe neurological and intellectual impairment and cerebral palsy later in life. The etiology is multifactorial, involving hypoxic-ischemic insults of various origin. The disorder is characterized by multiple necrotic foci of the white matter found most frequently adjacent to the lateral ventricles. In the past, intrapartum factors were thought to be the major cause of neonatal brain damage, but recent investigations highlighted the role of antenatal risk factors. We present 4 cases of antenatally diagnosed brain injury with known and unusual etiology.