Bruce W. Kovacs

Clinical significance of prenatal ultrasonographic intestinal dilatation in fetuses with gastroschisis

OBJECTIVE Our purpose was to evaluate the clinical significance of intestinal dilatation detected by prenatal ultrasonographic examination in fetuses with gastroschisis. STUDY DESIGN A retrospective chart review was performed of all patients cared for at Los Angeles County/University of Southern California Womens and Childrens Hospital with the prenatal diagnosis of gastroschisis over a 7-year period (1988 through 1995). Patients were divided into two groups on the basis of the presence or absence of ultrasonographically measured fetal bowel diameter of > or = 17 mm. Neonatal outcomes of the two groups were compared. RESULTS Twenty-one patients met the entry criteria during the study period. Fetuses with maximal bowel diameter of > or = 17 mm did not have a longer time to full oral feeding, a longer initial hospital stay, or a greater need for bowel resection when compared with fetuses with a bowel diameter < 17 mm. Two newborns underwent bowel resection because of intestinal atresia. Prenatal ultrasonographic examination failed to show significant bowel dilatation in either infant. CONCLUSION Our data suggest that prenatal evidence of intestinal dilatation in fetuses with gastroschisis does not predict immediate neonatal outcome. Thus this finding is not an appropriate indication for preterm delivery in the absence of other evidence of fetal compromise.

Vaginal delivery of the nonvertex second twin

OBJECTIVE The purpose of our study was to test the hypothesis that there is no increased morbidity or mortality associated with vaginal delivery of the nonvertex second twin. STUDY DESIGN The medical records of 781 consecutive twin gestations achieving a gestational age > or = 20 weeks and delivering between Jan. 1, 1985, and Dec. 31, 1988, were reviewed. All live-born, vaginally delivered second twins were identified, grouped by presentation, and compared with respect to 5-minute Apgar scores, length of neonatal hospital stay, neonatal intensive care unit admissions, and neonatal deaths. RESULTS Of the 390 live-born, vaginally delivered second twins, 207 were delivered as vertex and 183 were delivered as breech. Ninety-five percent of the breech deliveries were total breech extractions. There were no statistically significant differences between the vaginal breech and vaginal vertex deliveries in any of the neonatal outcome measures studied even when stratified by birth weight. CONCLUSIONS These results support the null hypothesis and suggest that vaginal delivery of the nonvertex second twin is a safe intrapartum management option, although no conclusion can be reached in infants weighing < 1500 gm. We found no evidence of excessive morbidity or mortality associated with total breech extraction of the second twin.

Prenatal diagnosis of human parvovirus B19 in nonimmune hydrops fetalis by polymerase chain reaction

OBJECTIVE Nonimmune hydrops fetalis is a potentially lethal condition reflecting the clinical manifestation of several pathologic processes. Recently maternal infection by human parvovirus B19 has been reported to result in nonimmune fetal hydrops. We sought to develop a rapid and sensitive test to detect the presence of this agent in utero. STUDY DESIGN Using a cloned isolate of the virus, we developed an assay based on enzymatic amplification of a segment of the human parvovirus B19 genome that allows direct detection of this agent in samples of fetal blood and amniotic fluid. RESULTS The method detected as few as 100,000 genome equivalences and was specific for the viral genome alone. We used this assay to evaluate nine fetuses initially seen with nonimmune hydrops. Three cases were found to be positive for the human parvovirus B19 genome. CONCLUSION The method is powerful in that it is rapid, sensitive, and simple. This assay may have general applicability in evaluation of nonimmune hydrops and in documentation of the natural history of fetal human parvovirus infections.

Ultrasonographic measurement of amniotic fluid volume in normal diamniotic twin pregnancies

OBJECTIVE Our purpose was to determine the amniotic fluid volume in normal diamniotic twins. STUDY DESIGN The single amniotic fluid index for both twin members, the maximum depth and width of each twins largest pocket, were measured every 4 to 6 weeks between 15 and 40 weeks in 91 normal diamniotic twin gestations. The two-diameter pocket in each twin was determined as its largest pockets depth multiplied by its width. Normal twin gestations were defined as those with <20% birth weight discordance, appropriate for gestational age, no fetal anomalies, delivery at > or = 37 weeks, and normal newborns. Amniotic fluid index values, depths, and two-diameter pockets were stratified into 2-week intervals and transformed into base 10 logarithms because of their nongaussian distributions. The correlations of these measurement with gestational age were evaluated. Their means and 90%, 95%, and 98% confidence intervals were determined. RESULTS The amniotic fluid index changed significantly with gestational age. However, depths and two-diameter pockets did not. The amniotic fluid index rose from 15 to 24 weeks, plateaued until 36 weeks, and then declined. The 90%, 95%, and 98% confidence intervals for each twins depth were 2.4 to 7.9, 2.1 to 8.8, and 1.9 to 10 cm, respectively (mean 4.3 cm). These respective confidence intervals for each twins two-diameter pocket were 8 to 44, 7 to 52, and 5 to 63 cm2 (mean 19 cm2). The amniotic fluid index confidence interval curves were plotted from the log (amniotic fluid index)=0.8276 + 0.01675x-0.0000001900x4, R2=0.78, p=0.002 (where x is gestational age). CONCLUSION The amniotic fluid volume in normal diamniotic twin pregnancies was established ultrasonographically. Only the amniotic fluid index changed significantly with gestational age. These findings may have significance in the clinical management of twin gestation.

A dopamine D3 receptor genotype is associated with hyperandrogenic chronic anovulation and resistant to ovulation induction with clomiphene citrate in female Hispanics.

OBJECTIVE To determine if dopamine (D3) receptor genotypes are associated with anovulation and response to ovulation induction with clomiphene citrate. DESIGN Clinical and laboratory characteristics of anovulatory patients and ovulatory controls were compared with findings at the DNA level. SETTING An outpatient clinic at an university medical center. PATIENTS One hundred eighty human Hispanic female volunteers (130 of these with documented ovulatory status) were studied. INTERVENTIONS Genomic DNAs were extracted from each patient. Polymerase chain reaction with subsequent restriction digest was performed to analyze the D3 receptor allele status (two possible alleles). MAIN OUTCOME MEASURES Menstrual history, serum T, and midluteal serum Ps from spontaneous and clomiphene cycles were correlated with D3 receptor genotype. RESULTS Hispanic females with the 22 genotype compared with the other genotypes (11 and 12) were more likely to have irregular menses, an elevated serum T (> or = 70 ng/dL [conversion factor to SI unit, 3.467]), and hyperandrogenic chronic anovulation. These patients tended to be resistant to ovulation induction requiring a significantly higher dose of clomiphene to achieve an ovulatory response (22 genotype [mean +/- SEM] [140.0 +/- 19.0 mg] versus 11 [77.1 +/- 17.5 mg] or 12 [69.2 +/- 13.1 mg]). This effect was independent of patient age, weight, or serum T level. CONCLUSIONS Hyperandrogenic chronic anovulation may have a genetic component. Genetic analysis may be useful in predicting resistance to ovulation induction with clomiphene.

Detection of hyperdiploid malignant cells in body cavity effusions by fluorescence in Situ hybridization on thinPrep slides

Benign body cavity effusions sometimes cannot be distinguished from malignant ones by conventional cytology. The authors performed fluorescence in situ hybridization (FISH) on ThinPrep slides using chromosome specific probes to see if hyperdiploid malignant cells could be detected in 20 body cavity effusions. The results were then compared with those of conventional cytology.

EP3-2 receptor mRNA expression is reduced and EP3-6 receptor mRNA expression is increased in gravid human myometrium.

Objective: To assess relative expression levels of mRNA for EP3 isoforms EP3-2, EP3-3, and EP3-6 in human myometrium in various physiologic states. Methods: Using semiquantitative reverse transcriptase-polymerase chain reaction, we analyzed myometrial samples from 46 women (ten menopausal, ten nongravid premenopausal, 19 gravidas, seven premenopausal misoprostol-treated nongravid women) for the specific expression of mRNA messages for the EP3 receptor isoforms EP3-2, EP3-3, and EP3-6. Results: We found that the expression of EP3-2 was significantly lower in gravid than nongravid myometrium (P < .0001). Levels of the EP3-6 message were higher in gravid samples than in nongravid specimens (P < .02). EP3-3 mRNA was present in higher levels in menopausal samples compared with the other groups. Conclusions: The selective fluctuation of mRNA expression of the different EP3 isoforms suggests the possibility of an important regulatory role for these receptors in myometrial contractility. Additional studies are necessary to evaluate the exact mechanism of action of EP3 receptor isoforms in human myometrium.

Studies of human germinal mutations by deoxyribonucleic acid hybridization.

Spontaneous mutations that occur in human germ cells contribute significantly to clinical disorders and result in premature mortality, incurable morbidity, mental handicap, and infertility. We have used molecular analysis of deoxyribonucleic acid to study the occurrence of spontaneous human germinal mutations. We examined 458 offspring and parents in 60 multigeneration human families. Probes for hypervariable loci were dispersed throughout all chromosomes to note the occurrence of new mutations. We found that both point mutations and insertion-deletion mutations occur frequently enough to be directly quantitated. The rates of occurrence detected at the molecular level are much greater than the rates detected with other modalities. The mutational rates at some loci approach 1% in live-born children. Such mutations appear to be sequence specific and related to the processes of meiosis or mitosis as they occur in the production of human gametes.

Expression of the Oxytocin and V1a Vasopressin Receptors in Human Myometrium in Differing Physiologic States and following Misoprostol Administration

Objective: To assess relative expression levels of mRNA for the oxytocin receptor (OTR) and the V1a vasopressin receptor (V1aR) in human myometrium in various physiologic states and to determine if misoprostol exposure affects the expression of mRNA for these receptors. Study Design: Using semiquantitative reverse transcription-polymerase chain reaction, we analyzed myometrial samples from 37 women (10 menopausal, 10 nongravid premenopausal, 10 gravidae, 7 premenopausal misoprostol-treated nongravid women) for the specific expression of mRNA messages for OTR and V1aR. The presence of the OTR and V1aR protein was confirmed by immunohistochemistry. Results: We found that the expression of OTR was significantly higher in gravid compared to premenopausal nongravid (p < 0.0001), misoprostol-treated (p < 0.001) and menopausal myometrium (p < 0.0001). Differences in V1aR expression were not statistically significant among the four study groups. Conclusion: The expression of OTR mRNA in myometrium is markedly increased during late gestation. V1aR expression is present in all physiologic states, and does not appear to be altered by the presence or absence of labor. Misoprostol administration does not appear to have an effect on OTR and V1aR mRNA receptor expression.

Associations Between the Endothelial Nitric Oxide Synthase Gene (NOS3), Reproductive Behaviors, and Twinning

Fertility decline in industrialized nations, fuelled by increased educational opportunity and delayed marriage/childbearing, is a driving force in reshaping contemporary population structure. These same forces have contributed to an increase in twinning, due to fertility drugs, but a possible decline in natural dizygotic twinning. Twinning has been linked to elevations in testosterone and age-related increases in follicle-stimulating hormone. Using data from 473 females, we examined the role of the regulatory gene for nitric oxide synthase (NOS3) in fertility-related events and in the vulnerability to preeclampsia, or pregnancy-induced hypertension (PIH). We found that the 2-allele of a biallelic marker for this gene was associated with increased risk of PIH, with testosterone, with LH/FSH ratio, and with earlier age at menarche. Subsequent studies of the mothers of twins revealed that the NOS3 2-allele was associated with earlier maternal age at the birth of the twins, less education, and increased monozygotic twinning rate among females with birth ages <30. Additionally, 2-allele carriers evaluated by the multiphasic personality questionnaire had elevated scores for aggression and decreased scores for achievement orientation. These data suggest that, other events equal, the NOS3 2-allele carriers would outproduce NOS3 1-allele carriers, eventually threatening the viability of the 1-allele. However, prior to recent advances in medicine, preeclampsia, linked to the 2-allele, is thought to have had a roughly 40% rate of maternal/fetal mortality, balancing the selective advantages otherwise conferred upon the 2-allele.