Euan M Wallace

Abstract: Subgaleal hemorrhage in the newborn is a serious adverse event that is often unrecognized and under-appreciated. This retrospective case series aimed to determine perinatal factors associated with subgaleal hemorrhage and subsequent neonatal outcomes. Obstetric and neonatal details of 21 infants with subgaleal hemorrhage over a 10-year period were collected. The mother was primiparous in 95% cases, 48% had a prolonged second stage (>120 minutes) and 43% had prolonged rupture of membranes (>12 hours). Thirteen infants (62%) were born by instrumental vaginal delivery. Ten infants (48%) required resuscitation at delivery. The severity of subgaleal hemorrhage was mild in four infants (19%), moderate in 10 (48%) and severe in seven (33%). Hypovolemic shock developed in 10 infants (48%), encephalopathy in 13 (62%) and coagulopathy was present in five infants (24%). There were three (14%) deaths. Long-term outcomes were good in the surviving infants.

Abstract: Perinatal morbidity and mortality are significantly higher in pregnancies complicated by chronic hypoxia and intrauterine growth restriction (IUGR). Clinically, placental insufficiency and IUGR are strongly associated with a fetoplacental inflammatory response. To explore this further, hypoxia was induced in one fetus in twin-bearing pregnant sheep (n=9) by performing single umbilical artery ligation (SUAL) at 110 days gestation. Five ewes were administered the anti-inflammatory drug sulfasalazine (SSZ) daily, beginning 24h before surgery. Fetal blood gases and inflammatory markers were examined. In both SSZ- and placebo-treated ewes, SUAL fetuses were hypoxic and growth-restricted at 1 week (P<0.05). A fetoplacental inflammatory response was observed in SUAL pregnancies, with elevated pro-inflammatory cytokines, activin A and prostaglandin E(2). SSZ did not mitigate this inflammatory response. It is concluded that SUAL induces fetal hypoxia and a fetoplacental inflammatory response and that SSZ does not improve oxygenation or reduce inflammation. Further studies to explore whether alternative anti-inflammatory treatments may improve IUGR outcomes are warranted.

Abstract: Within-pair comparison of monozygotic (MZ) twins provides an ideal model for studying factors that regulate epigenetic profile, by controlling for genetic variation. Previous reports have demonstrated epigenetic variability within MZ pairs, but the contribution of early life exposures to this variation remains unclear. As epigenetic marks govern gene expression, we have used gene expression discordance as a proxy measure of epigenetic discordance in MZ twins at birth in two cell types. We found strong evidence of expression discordance at birth in both cell types and some evidence for higher discordance in twin pairs with separate placentas. Genes previously defined as being involved in response to the external environment showed the most variable expression within pairs, independent of cell type, supporting the idea that even slight differences in intrauterine environment can influence expression profile. Focusing on birthweight, previously identified as a predisposing factor for cardiovascular, metabolic and other complex diseases, and using a statistical model that estimated association based on within-pair variation of expression and birthweight, we found some association between birthweight and expression of genes involved in metabolism and cardiovascular function. This study is the first to examine expression discordance in newborn twins. It provides evidence of a link between birthweight and activity of specific cellular pathways and, as evidence points to gene expression profiles being maintained through cell division by epigenetic factors, provides a plausible biological mechanism for the previously described link between low birthweight and increased risk of later complex disease.

Abstract: Recent evidence has shown the importance of ensuring that all pregnancies with gestational diabetes mellitus (GDM) are identified and managed appropriately. However, there remains a lack of consensus as to how to best identify these women.

Abstract: The pathogenic origin of preeclampsia is defective placental development (placentation) and function. Preeclampsia is not diagnosed until later in pregnancy, and reliable early detection is highly desirable. HtrA3 is a recently cloned gene with high expression during placentation in the mouse, rhesus monkey, and human.

Abstract: This literature review summarises the history of patient safety initiatives in health-care systems around the world. The need to improve patient safety is commonly called for following interrogation of data captured as a measure of patient safety including audit, clinical indicator reporting and evaluation methods. Many such reports exist for maternity services. Recommendations for improvement identified after review may be taken up, but there is little in the literature that demonstrates how clinicians consider such recommendations, implement improvement strategies and assess their impact. The authors of this paper concur with other authors who call for more research in this regard.

Abstract: Monash Medical Centre (MMC) is a university-affiliated tertiary referral hospital in Melbourne, Victoria, Australia. The hospital has a large obstetric service and is the only quarternary obstetric unit in Victoria. The intensive care unit (ICU) is a busy 21-bed general unit with a broad casemix. While there is no designated state service obstetric ICU in Victoria, MMC ICU has increasingly tried to accept all obstetric patients referred, from both MMC and externally.

Abstract: To assess maternal serum activin A, an early phase response protein in systemic infection, as an early marker of intrauterine infection in women with preterm prelabour rupture of membranes (PPROM).

Abstract: The use of oxytocin to prevent postpartum haemorrhage at elective caesarean section is largely based on evidence derived from vaginal births. Overseas studies indicate wide variation in practice with regard to specific doses of oxytocin administered at caesarean section. No such surveys have been undertaken in Australia or New Zealand.

Abstract: Chronic lung disease characterized by loss of lung tissue, inflammation, and fibrosis represents a major global health burden. Cellular therapies that could restore pneumocytes and reduce inflammation and fibrosis would be a major advance in management.

Abstract: Prelabour rupture of membranes (PROM), whether at term or preterm, can be a difficult diagnosis to confirm. Clinician uncertainty often leads to unnecessary intervention for risk management reasons. Amnisure® is a bedside immunoassay for placental alpha macroglobulin-1 (PAMG-1), which has been shown to have high sensitivity and specificity in the diagnosis of PROM. However, whether the use of Amnisure® alters clinical management remains untested. The objective of this study was to assess the clinical utility of Amnisure®.

Abstract: Catabolism of tryptophan via the kynurenine pathway is up-regulated in the human placenta by infection, resulting in the release of pro-inflammatory and neuroactive metabolites into the fetal circulation. In this study we determined if activation of NFκB is involved in the inflammation-induced increase of kynurenine pathway activity in the human placenta. Placentae obtained after elective caesarian section at 37-40 weeks gestation (n=8), and explants (35-40 mg) prepared from terminal villi were incubated under standard conditions in the presence of 10 μg/ml LPS for 24 or 48 h; duplicates of each explant were incubated either with or without 5mM sulfasalazine added to the medium. Expression of mRNAs for key kynurenine-forming enzymes, indoleamine 2,3-dioxygrenase (IDO) and tryptophan 2,3-doalxygenase (TDO) and the inflammatory cytokines TNFα and IL6 was studied by RT-PCR. Kynurenine output by explants was measured in samples in the incubation medium by absorbance at 363nm after separation from other metabolites using an HPLC technique. Expression of IDO, TDO, TNFα and IL6 mRNAs was increased with LPS treatment, a response mitigated by the presence of sulfasalazine (P<0.01, P<0.01, P=0.03 &P=0.04). Kynurenine output into the culture medium increased with LPS treatment but this was also prevented by sulfasalazine at 24h (mean ± SEM; 412.1 ± 40 vs. 147.7 ± 48.9 nM/mg, P=0.01) and 48 h (636 ± 39.1 vs. 135.5 ± 29.8 nM/mg, P=0.001, respectively). Sulfasalazine inhibited the LPS induction of both the kynurenine pathway and pro-inflammatory cytokines in the placenta, implicating NFκB in the LPS effect. Direct measurement of NFκB activity showed that sulfasalazine decreased NFκB activation under both control and LPS-treated conditions. These observations show that kynurenine pathway activity in the human placenta is increased by a NFκB dependent pathway, and suggests a new therapeutic strategy for the management of pregnancies with in utero infection.

Abstract: In pregnancy, untreated chlamydia infection has been associated with adverse outcomes for both mother and infant. Like most women, pregnant women infected with chlamydia do not report genital symptoms, and are therefore unlikely to be aware of their infection. The aim of this study was to determine the acceptability of screening pregnant women aged 16-25 years for chlamydia as part of routine antenatal care.

Abstract: Human amnion epithelial cells (hAECs) are a heterologous population positive for stem cell markers; they display multilineage differentiation potential, differentiating into cells of the endoderm (liver, lung epithelium), mesoderm (bone, fat), and ectoderm (neural cells). They have a low immunogenic profile and possess potent immunosuppressive properties. Hence, hAECs may be a valuable source of cells for cell therapy. This unit describes an efficient and effective method of hAEC isolation, culture, and cryopreservation that is animal product-free and in accordance with current guidelines on preparation of cells for clinical use. Cells isolated using this method were characterized after 5 passages by analysis of karyotype, cell cycle distribution, and changes in telomere length. The differentiation potential of hAECs isolated using this animal product-free method was demonstrated by differentiation into lineages of the three primary germ layers and expression of lineage-specific markers analyzed by PCR, immunocytochemistry, and histology.

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Abstract: BACKGROUND: It is widely recognised that deficiencies in fetal surveillance practice continue to contribute significantly to the burden of adverse outcomes. This has prompted the development of evidence-based clinical practice guidelines by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists and an associated Fetal Surveillance Education Program to deliver the associated learning. This article describes initial steps in the validation of a corresponding multiple-choice assessment of the relevant educational outcomes through a combination of item response modelling and expert judgement. METHODS: The Rasch item response model was employed for item and test analysis and to empirically derive the substantive interpretation of the assessment variable. This interpretation was then compared to the hierarchy of competencies specified a priori by a team of eight subject-matter experts. Classical Test Theory analyses were also conducted. RESULTS: A high level of agreement between the hypothesised and derived variable provided evidence of construct validity. Item and test indices from Rasch analysis and Classical Test Theory analysis suggested that the current test form was of moderate quality. However, the analyses made clear the required steps for establishing a valid assessment of sufficient psychometric quality. These steps included: increasing the number of items from 40 to 50 in the first instance, reviewing ineffective items, targeting new items to specific content and difficulty gaps, and formalising the assessment blueprint in light of empirical information relating item structure to item difficulty. CONCLUSION: The application of the Rasch model for criterion-referenced assessment validation with an expert stakeholder group is herein described. Recommendations for subsequent item and test construction are also outlined in this article.

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Abstract: The objective was to characterize the effect of glucocorticoid treatment on fetal organ blood flow and regional cerebral blood flow in normally grown fetuses and fetuses with intrauterine fetal growth restriction (IUGR).

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Abstract: OBJECTIVES: To determine the risk factors associated with chlamydial infection in pregnancy and the sensitivity and specificity of these when used for selective screening. METHODS: A prospective, cross-sectional study of pregnant women aged 16-25 years attending four major public antenatal services across Melbourne, Australia. Between October 2006 and July 2007, women were approached consecutively and asked to complete a questionnaire and to provide a first-pass urine specimen for Chlamydia trachomatis testing using polymerase chain reaction. RESULTS: Of 1180 eligible women, 1087 were approached and 1044 (88%) consented to participate. Among the 987 women for whom a questionnaire and a definitive diagnostic assay were available, the prevalence of chlamydia was 3.2% (95% CI: 1.8-5.9). In a multiple logistic regression model, younger age (</=20 years) (adjusted odds ratio (AOR): 2.1 (95% CI: 0.6, 7.9)) and reporting more than one sex partner in the prior 12 months (AOR: 11.5 (95% CI: 7.1, 18.5)) were each associated with chlamydia infection. The use of any antibiotic within 3 months (AOR: 0.2 (95% CI: 0.1, 0.6)) was associated with reduced odds for infection. Screening restricted to women who reported more than one sex partner in the prior 12 months would have detected 44% of infections in women aged 16-25 years, with only 7% of women being screened. The addition of women aged 20 and under would have detected 72% of infections, requiring 27% of women to be screened. CONCLUSIONS: Selective chlamydia screening of pregnant women based on risk factors can improve the yield from screening. However, the potential harm of missed infections among excluded women would need to be considered.

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Abstract: After a 'needs assessment', in 2004 the Royal Australian and New Zealand College of Obstetricians and Gynaecologists developed and introduced the Fetal Surveillance Education Program (FSEP) to provide high quality education to all clinicians caring for labouring women in Australia and New Zealand. A formal evaluation of the program was planned from the inception of FSEP. We report here the participant feedback from the first 4439 participants in 2004-2006. Overall, FSEP was considered a high quality resource, rated equally well by midwives and obstetricians. This is the first large-scale evaluation to be reported for any fetal surveillance education program.

Abstract: Recent studies report an association between maternal thyroid auto-antibodies and preterm birth. None have made the important distinction between spontaneous and iatrogenic preterm birth. We investigated the association between spontaneous preterm birth before 35-week gestation and both thyroid function and auto-antibody status.

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Abstract: Circulating levels of activin A are significantly increased in women with preeclampsia when compared with those with a normal pregnancy. The mechanisms underlying these increased levels are unknown. We undertook these studies to explore whether oxidative stress might be the mechanism. We exposed trophoblast explants, human umbilical vein endothelial cells (HUVECs) and peripheral blood monocytes to oxidative stress in vitro using xanthine/xanthine oxidase (X/XO), measuring activin A and isoprostane in conditioned media and mRNA for activin beta(A) in explants and HUVECs. We also measured isoprostane and activin A in serum from 21 women with preeclampsia and from 20 women with a normal pregnancy. Treatment with X/XO significantly increased 8-isoprostane production from placental explants, HUVECs and monocytes, indicative of oxidative stress, and significantly increased activin A output from placental explants (139.1 +/- 27.4 per mg wet weight vs 322.9 +/- 89.7 pg/ml per mg wet weight, P = 0.02) and from HUVECs (1.2 +/- 0.2 vs 3.2 +/- 1.8 ng/ml, P = 0.04). There was no effect on activin A output from monocytes. X/XO significantly increased beta(A) mRNA in placental explants but not in HUVECs. Maternal plasma levels of 8-isoprostane and activin A were significantly higher in women with preeclampsia when compared with controls (333.8 +/- 70 vs 176.3 +/- 26.2 pg/ml, P = 0.04 and 49.5 +/- 7 vs 13.1 +/- 1.2 ng/ml, P < 0.001 respectively). In the women with preeclampsia, but not in those with a normal pregnancy, circulating levels of 8-isoprostane and activin A were significantly and positively correlated (r(2) = 0.72; P < 0.001). These data suggest that oxidative stress may be one of the mechanisms underlying increased circulating activin A in preeclampsia.

Abstract: Intrauterine growth restriction (IUGR) is associated with altered fetal cardiovascular function to ensure adequate perfusion of essential organs. IUGR fetuses are at risk of preterm delivery and so are likely to receive antenatal glucocorticoids to promote lung maturation. Because glucocorticoids alter vascular tone, we questioned whether such treatment may induce fetal cardiovascular alterations. Using pregnant sheep carrying twins, we induced IUGR at approximately 0.7 gestation by single umbilical artery ligation in one twin, using the other twin as a control. In each fetus, we monitored carotid blood flow and arterial blood gases. We administered 11.4 mg betamethasone (n = 5) or vehicle (n = 4) to the ewe on d 5 (BM1) and 6 (BM2) postsurgery. On d 7, fetal brains were collected for immunohistochemistry. In control fetuses, carotid blood flow decreased 3.5 h post-BM1 by 24% (P < 0.001), returning to baseline at 5.5 h. In IUGR fetuses, carotid flow decreased 2.5 h post-BM1 by 27% and then increased by 25% over baseline, peaking at 11 h (P < 0.001). Compared to control + saline, we observed a significant increase in oxidative damage (4-hydroxynonenal-positive cells) in the fetal hippocampus and subcallosal area of all treatment groups (IUGR + BM > IUGR + saline = control + BM). There was a significant correlation between carotid blood flow reperfusion after betamethasone and the number of 4-hydroxynonenal-positive cells in the cortex and hippocampus. These data suggest that antenatal betamethasone may induce brain injury in the IUGR fetus but not in the normally grown fetus.

Abstract: BACKGROUND: The administration of antenatal corticosteroids to women at risk of preterm birth is an important component of care for such women. However, inevitably, attempts to maximise the number of women who receive corticosteroids ahead of preterm birth will also expose women perceived at risk who subsequently deliver at term. These women have not been previously quantified. AIMS: To describe antenatal corticosteroid prescribing practices at a single institution over a seven-year period. METHODS: Interrogation of an electronic birthing outcome system supplemented by hand-searching of medical records, recording all women birthing before 34 weeks and all women with a hospital admission before 34 weeks but birthing after 34 weeks. The number of women receiving antenatal corticosteroids in each of these groups was recorded, and trends between groups and over time were analysed using logistic regression. RESULTS: While the total number of women receiving antenatal corticosteroids in our institution has risen over the last seven years, the proportion of women receiving antenatal corticosteroids who deliver between 24 and 35 weeks has increased inconsistently and modestly (average increase 12% per year (95% CI: 6-19%, P < 0.001). In contrast, the number of women receiving antenatal corticosteroids who subsequently deliver after 34 weeks has increased consistently, with an average increase rate of 21% per year (95% CI: 16-25%, P < 0.001). CONCLUSIONS: Increasing numbers of women birthing after 34 weeks in our hospital are receiving antenatal corticosteroids before 34 weeks. The long-term implications of this are not currently clear.

Abstract: BACKGROUND: The inappropriate use or interpretation of intrapartum fetal surveillance (IFS) continues to be a major contributor to adverse obstetric outcomes, suggesting that training in IFS is deficient. What professional education in intrapartum fetal surveillance currently exists in Victorian public hospitals is unknown. AIMS: To map the current formal IFS education and competency assessment practices in Victorian public hospitals. METHODS: A structured survey comprising 25 questions was developed and mailed to both a senior obstetric and a midwifery manager in all public maternity hospitals in Victoria. Non-respondents were followed up at 2 months. RESULTS: One hundred and twenty surveys were sent to 60 hospitals, of which 103 replies from 58 hospitals were received, representing a 97% hospital response rate. Only 19 (33%) of respondent hospitals had an existing education program. Hospitals with > 2000 births per annum were more likely to have a program than those with < 1000 births per annum (86% vs 23%, P=0.004). Of the 19 existing education programs, only nine contained any fetal physiology. All respondents thought that IFS education should be compulsory for relevant staff. Only six (10%) of the hospitals had any assessment of competency but 90% of respondents thought that such an assessment should be compulsory. CONCLUSIONS: These data reveal important deficiencies in the provision and quality of current IFS education practices in Victoria, particularly in smaller and rural hospitals. However, these deficiencies seem to reflect a lack of opportunity rather than a lack of interest.

Abstract: The aim of this study was to investigate whether maternal serum levels of angiopoietin-2 (Ang-2) and pregnancy-associated plasma protein A (PAPP-A) are associated with subsequent intrauterine growth restriction (IUGR). Ang-2 was measured in 29 nonpregnant and 44 pregnant women at 10-13 weeks of gestation. The median concentration of Ang-2 was 26.61 ng/ml in normal pregnant women compared with 1.71 ng/ml in nonpregnant controls (P < 0.01). Women who subsequently developed severe IUGR had lower levels of Ang-2 compared with normal pregnant controls (P < 0.01). PAPP-A levels were similar in all pregnant groups. These findings suggest that Ang-2 should be evaluated for its ability to predict pregnancies that later are affected by IUGR.

Abstract: The amnion is the inner of two membranes surrounding the fetus. That it arises from embryonic epiblast cells prior to gastrulation suggests that it may retain a reservoir of stem cells throughout pregnancy. We found that human amniotic epithelial cells (hAECs) harvested from term-delivered fetal membranes express mRNA and proteins present in human embryonic stem cells (hESCs), including POU domain, class 5, transcription factor 1; Nanog homeobox; SRY-box 2; and stage-specific embryonic antigen-4. In keeping with possible stem cell-like activity, hAECs were also clonogenic, and primary hAEC cultures could be induced to differentiate into cardiomyocytic, myocytic, osteocytic, adipocytic (mesodermal), pancreatic, hepatic (endodermal), neural, and astrocytic (neuroectodermal) cells in vitro, as defined by phenotypic, mRNA expression, immunocytochemical, and/or ultrastructural characteristics. However, unlike hESCs, hAECs did not form teratomas upon transplantation into severe combined immunodeficiency mice testes. Last, using flow cytometry we have shown that only a very small proportion of primary hAECs contain class IA and class II human leukocyte antigens (HLAs), consistent with a low risk of tissue rejection. However, following differentiation into hepatic and pancreatic lineages, significant proportions of cells contained class IA, but not class II, HLAs. These observations suggest that the term amnion, an abundant and easily accessible tissue, may be a useful source of multipotent stem cells that possess a degree of immune privilege.

Abstract: Trophoblast growth and invasion of the uterine endometrium are critical events during placentation and are tightly regulated by factors produced within the trophoblast-endometrial microenvironment. Deficiencies in placentation can result in early miscarriage or preeclampsia and intrauterine growth restriction, leading to impaired fetal health. The latter has been linked to major adult health disorders. IL-11 is essential for blastocyst implantation in mice. In humans, IL-11 and its receptor IL-11 receptor alpha (IL-11Ralpha) are maximally expressed in the decidua and chorionic villi during early pregnancy; however, the role of IL-11 in trophoblast function is unknown. Therefore, we examined whether IL-11Ralpha is expressed in human first trimester implantation sites, and whether IL-11 influences proliferation and migration of a human extravillous trophoblast (EVT)-hybridoma cell line and primary EVT cells, used as models for EVT. Immunoreactive IL-11Ralpha localized to subpopulations of interstitial and endovascular EVT cells in vivo. In EVT cells in vitro, IL-11: 1) stimulated phosphorylation of signal transducer and activator of transcription-3; 2) was without effect on EVT cell proliferation; and 3) stimulated significant migration of EVT-hybridoma cells (no endogenous IL-11), whereas in primary EVT, blocking endogenous IL-11 inhibited EVT migration by 30-40%. These data demonstrate that IL-11 stimulates human EVT migration, but not proliferation, likely via signal transducer and activator of transcription-3, indicating an important role for IL-11 in placentation.

Abstract: BACKGROUND: Pro-alphaC inhibins are luteal derived analytes peaking in the maternal serum as early as Day 16 after conception. We set out to verify a previous post hoc analysis which suggested that pro-alphaC levels measured this early are extremely sensitive in predicting clinical pregnancy success after unstimulated IVF with ovulatory cycles. METHODS: Prospective observational study of 246 women undergoing frozen embryo transfer with ovulatory cycles. Serum pro-alphaC and beta-HCG levels at 14-17 days after conception were measured by enzyme-linked immunosorbent assay and grouped according to whether a clinical pregnancy occurred (demonstrable cardiac activity at > or =6 weeks' gestation). RESULTS: Of 34 (13.8%) women who achieved a clinical pregnancy, median (25th-75th centile) Days 14-17 pro-alphaC levels were 995 pg/ml (758-1463), 6- to 7-fold higher than levels observed in the remainder who did not fall pregnant (112.8 pg/ml (104-121); P < 0.0001). At a fixed 95% specificity, pro-alphaC was 100% sensitive in predicting clinical pregnancy. The best specificities achieved at 100% sensitivity were; 94.8% for pro-alphaC, 96.7% for beta-HCG and 98.1% when both analytes were combined. CONCLUSIONS: Clinical pregnancy is always associated with a release of luteal derived pro-alphaC 14-17 days after conception. Pro-alphaC may play a possible biological role and be a useful clinical biomarker of luteal health.

Abstract: Mammalian embryos cannot survive without the placenta. Development of the human placenta requires trophoblast proliferation, differentiation, and invasion as well as highly coordinated modulation of the maternal uterus. HtrA1 is a member of the recently identified mammalian HtrA (high temperature requirement factor A) serine protease family with a high level of expression in the placenta. In this study, we examined whether HtrA1 expression (mRNA and protein) is associated with placental development in the human. HtrA1 is up-regulated in both endometrial glands and decidual cells during endometrial preparation for embryo implantation and during first-trimester pregnancy at placentation. HtrA1 expression was also detected in certain trophoblast subtypes during early pregnancy. The villous syncytiotrophoblast and cytotrophoblast showed the strongest expression while the interstitial extravillous trophoblast showed the lowest or no expression of HtrA1. The distinct distribution of HtrA1 at the maternal-trophoblast interface suggests that HtrA1 may play a role in placental development.

Abstract: AIM: The US Centre for Disease Control (CDC) recently amended their guidelines for the prevention of early-onset group B streptococcal disease (EOGBSD) of the newborn to recommend bacteriological screening, rather than risk factor-based screening, as the preferred method of identifying 'at risk' mother-infant pairs. This recommendation was derived from population data suggesting that the effectiveness of bacteriological screening was superior to a risk-factor approach because antibiotic compliance was better with the former. Whether poor compliance and therefore impaired prevention is inherent in risk-factor screening has not been widely tested. METHODS: For a 6-month period we audited compliance with an established risk-factor EOGBSD prophylaxis program. RESULTS: During the audit period, 1243 women delivered, of whom 287 (23%) had at least one risk factor. Of these women, 193 (67%), representing 15% of all women giving birth, received antibiotics. Thus, there were 94 women who were eligible for antibiotics but did not receive prophylaxis. There were sound clinical reasons for withholding antibiotics in 68 of these. Therefore, the corrected compliance rate within our program was 73%. CONCLUSION: This compares favourably with published compliance rates with bacteriological-based programs, but we have suggested mechanisms to improve compliance further.

Abstract: Copper is an essential trace element necessary for normal growth and development. During pregnancy, copper is transported from the maternal circulation to the fetus by mechanisms which have not been clearly elucidated. The copper uptake protein, hCTR1 is predicted to play a role in copper transport in human placental cells. This study has examined the expression and localisation of hCTR1 in human placental tissue and Jeg-3 cells. In term placental tissue the hCTR1 protein was detected as a 105 kDa protein, consistent with the size of a trimer which may represent the functional protein. A 95 kDa band, possibly representing the glycosylated protein, was also detected. hCTR1 was localised within the syncytiotrophoblast layer and the fetal vascular endothelial cells in the placental villi and interestingly was found to be localised toward the basal plasma membrane. It did not co-localise with either the Menkes or the Wilson copper transporting ATPases. Using the placental cell line Jeg-3, it was shown that the 35 kDa monomer was absent in the extracts of cells exposed to insulin, estrogen or progesterone and in cells treated with estrogen an additional 65 kDa band was detected which may correspond to a dimeric form of the protein. The 95 kDa band was not detected in the cultured cells. These results provide novel insights indicating that hormones have a role in the formation of the active hCTR1 protein. Furthermore, insulin altered the intracellular localisation of hCTR1, suggesting a previously undescribed role of this hormone in regulating copper uptake through the endocytic pathway.

Abstract: HTRA3 is a newly identified serine peptidase of the mammalian HTRA (high-temperature requirement factor A) family, that is upregulated dramatically during mouse placental development. The current study determined whether HTRA3 was involved in human placentation. During the menstrual cycle, HTRA3 was expressed primarily in the endometrial glands, being significantly upregulated toward the mid- to late secretory phases; prominent expression in the stroma detected only in the decidual cells in the late secretory phase. Thus, overall endometrial HTRA3 expression was highest in the late secretory phase, when the endometrium is prepared for maternal-trophoblast interaction. During the first trimester of pregnancy, both glandular and decidual HTRA3 expression increased further with the decidual upregulation being highly significant. The strong link between HTRA3 expression and endometrial stromal cell decidualization was further established in an in vitro model using primary endometrial stromal cells. HTRA3 was also expressed by certain trophoblast subtypes in the first-trimester placenta: strongly in the villous syncytiotrophoblast, trophoblast shell, and endovascular trophoblast and weakly in the distal portion of the trophoblast cell columns but not in villous cytotrophoblast, the proximal region of the cell columns, or interstitial trophoblast. Upregulation of HTRA3 expression in association with placental development was revealed by a significant elevation of this protein in the maternal serum during the first trimester. We thus propose that HTRA3 is a previously unrecognized factor closely associated with and potentially important for human placentation. This study established crucial groundwork for future investigations toward establishing the physiological roles of HTRA3 in human placentation.

Abstract: Embryo implantation and trophoblast invasion are tightly regulated processes, involving sophisticated communication between maternal decidual and fetal trophoblast cells. Decidualization is a prerequisite for successful implantation and is promoted by a number of paracrine agents, including activin A. To understand the downstream mechanisms of activin-promoted decidualization, the effects of activin on matrix metalloproteinases (MMPs) (important mediators of decidualization) were investigated. Activin A stimulated endometrial production of proMMPs-2, -3, -7, -9, and active MMP-2. In contrast, inhibin A was a potent inhibitor of proMMP-2, and antagonized the effect of activin on MMPs. Activin is up-regulated with decidualization, and MMPs-2, -3, and -9 increase in parallel. Furthermore, proMMP-2 production is stimulated when decidualization is accelerated with activin, and suppressed when activin is neutralized, attenuating decidualization. These data support that activin A promotes decidualization through up-regulating MMPs. Previous in vitro evidence proposes further roles for activin and MMPs in promoting trophoblast invasion; therefore, we examined their interrelationships in early human implantation sites. MMPs-7 and -9 were produced by static cytotrophoblast subpopulations, whereas MMP-2 was strikingly up-regulated in invasive extravillous cytotrophoblasts (EVT). Maternal decidua is the primary source of activin, where a role in stimulating MMP-2 in iEVTs can be envisaged. Inhibin was absent from cytotrophoblast populations, except for a dramatic up-regulation in endovascular EVT plugs, coinciding with a down-regulation of MMP-2. This suggests that inhibin may have a role in the cessation of vascular invasion. These data support that activin, via effects on MMPs, is an important factor in the maternal-fetal dialog regulating implantation.

Abstract: OBJECTIVE: To determine whether activin A concentrations are altered in chronic fetal hypoxemia and intrauterine fetal growth restriction (IUGR). DESIGN: In vivo animal experimental model. SETTING: Department of Physiology, Monash University. POPULATION: Chronically catherised fetal sheep in late pregnancy. METHODS: Chronic fetal hypoxia and IUGR were experimentally induced by single umbilical artery ligation (SUAL) in catheterised fetal sheep. Maternal and fetal blood samples and amniotic fluid (AF) samples were collected during surgery and thereafter on alternate days, until the time of delivery for analyte measurement. Fetal blood gas parameters were measured daily. MAIN OUTCOME MEASURES: Plasma and AF was used to analyse activin A, prostaglandin E2 (PGE2) and cortisol and fetal blood gas analysis was undertaken in whole blood. RESULTS: SUAL produced asymmetric IUGR and non-acidaemic chronic fetal hypoxia and resulted in preterm labour (129 [3] days). AF activin A concentrations were 10-fold higher in the SUAL group than in controls whereas levels in the fetal and maternal circulations were similar between groups. CONCLUSIONS: SUAL-induced IUGR and fetal hypoxaemia increases AF activin A. This may be an important adaptive or protective response to IUGR.

Abstract: OBJECTIVE: To investigate an association between low human chorionic gonadotrophin (hCG) levels at the end of the first week of implantation and later clinical miscarriage occurring after ultrasound confirmation of a live pregnancy. METHODS: This was an observational retrospective study of 1,054 women who underwent in vitro fertilization and achieved an ultrasound-confirmed live singleton pregnancy with cardiac activity. The incidence of miscarriage diagnosed at 8-19 weeks +6 days of gestation was estimated in these 3 subgroups according to their hCG concentrations at day 16 after conception: less than the 25th, 25th-75th, and more than the 75th percentiles. RESULTS: The overall incidence of miscarriage was 11.1% (117/1,054), and the median gestational age at diagnosis was 10 weeks and 4 days. The median (95% confidence interval) day 16 hCG level in the miscarriage group was 182 mIU/mL (157-211), significantly lower than the median level in those who had an ongoing pregnancy (223 mIU/mL [213-233], P < .003). There was an increasing risk of miscarriage associated with decreased hCG levels (8.0% at > 75th percentile; 9.9% at 25th-75th percentiles; 16.7% at < 25th percentile; P = .003). CONCLUSION: Low hCG levels in very early pregnancy are associated with an increased risk of miscarriage occurring after the clinical recognition of pregnancy. The mechanisms underlying late first-trimester and second-trimester miscarriages may have begun as early as the first week of implantation. LEVEL OF EVIDENCE: III.

Abstract: BACKGROUND: Differentiating between the small healthy fetus and the high risk growth restricted fetus remains a significant obstetric challenge. It has been previously shown that maternal activin A levels are increased in association with fetal growth restriction. AIM: To evaluate maternal serum activin A as a marker of fetal growth restriction. METHODS: Prospective cohort study of 62 women referred for fetal assessment because of a clinical suspicion of a small for gestation fetus. Maternal serum levels of activin A were measured with an ELISA. RESULTS: Activin A levels, expressed as median (95% CI) MoMs, were similar in the women with a normal-sized fetus and in those with a healthy small for gestational age fetus, 1.14 (95% CI 1.0-1.5) and 1.31 (95% CI 0.8-2.1), respectively (P = 0.97). Compared to the women with a normal-sized fetus or a healthy small fetus, activin A levels were significantly elevated in the women who had an intrauterine fetal growth restriction fetus 2.37 (95% CI 1.6-3.7; P = 0.01 compared to normal and P = 0.04 compared to healthy small). CONCLUSIONS: These data confirm that circulating activin A is increased in association with fetal growth restriction. However, a single blood sample for activin A will not efficiently discern between healthy and compromised small fetuses.

Abstract: It has been shown previously that the absolute measurement of nuchal translucency (NT) thickness, one of the most effective screening tests for fetal Down syndrome, significantly decreases with increasing image size. We undertook a prospective study to assess whether this effect materially alters the NT-derived risk estimation for fetal Down syndrome. In 350 women, NT was measured at both 100 and 200% image sizes. The median NT measurement at 200% was 8% smaller than at 100%. The screen-positive rates at 100 and 200% image sizes were 5.1% (18/350) and 2.3% (8/350), respectively (P= 0.048). Altering the image magnification settings is likely to decrease the sensitivity of NT-derived Down syndrome risk estimation. Further study is required to test the effect of our finding on the sensitivity of NT screening and to assess whether adjustments in gain settings mitigate the effect.

Abstract:

Abstract: OBJECTIVE: The purpose of this study was to determine whether placental-derived kynurenines (neuroactive metabolites that are derived from tryptophan) contributes to infection-mediated fetal cerebral injury. STUDY DESIGN: Placentae and cord blood were obtained from term deliveries (n = 16) and preterm deliveries with or without intrauterine bacterial infection (n = 8 per group). We investigated whether the placenta expressed messenger RNAs of kynurenine metabolite-forming enzymes, the effects of infection in vivo on the expression of these enzymes by the placenta, the in vitro effects of bacterial endotoxin lipopolysaccharide on expression and kynurenine metabolite output by the placenta, and the kynurenine metabolite levels in umbilical cord blood. RESULTS: Placentae expressed messenger RNA of tryptophan-degrading enzymes and synthesized several compounds. The expression of several enzymes increased significantly in placentae that were exposed to infection and/or lipopolysaccharide. Lipopolysaccharide also induced significant increases in placental kynurenine and quinolinic acid output. Kynurenine and quinolinic acid in cord blood of fetuses who were exposed to infection were elevated significantly. CONCLUSION: Inflammatory mediated release of kynurenines from placentae exposes the fetus to significant amounts of potentially neurotoxic substances.

Abstract: For over 30 years, antenatal diagnosis of Down syndrome has been offered on the basis of advanced maternal age. While this was appropriate in the 1970s, developments in antenatal screening have rendered this a most inefficient strategy that is associated with excessive costs and procedure-related pregnancy losses. In this article we argue for a review of how we test for Down syndrome in the older woman.

Abstract: AIM: The aim of this study is to review the clinical usefulness of Doppler velocimetry of the uterine artery for the detection of adverse obstetric outcome in a population of women with elevated mid-trimester serum beta-human chorionic gonadotrophin (betahCG). METHODS: Women with an unexplained elevated mid-trimester betahCG level (> or = 4.0 multiples of the median) are offered uterine artery Doppler assessment at 22-24 weeks of gestation. We have audited the clinical usefulness of this practice by reviewing the prevalence of the adverse outcomes of gestational hypertension, intrauterine growth restriction (IUGR) and preterm birth and the predictive capacity of the test when applied to this subgroup of high-risk patients. RESULTS: Sixty-two women had an elevated serum betahCG and underwent Doppler study of uterine artery flow velocity waveform. Notching afforded better predictive utility for any outcome than the resistance index alone or in combination with notching. For a composite adverse outcome of any or all of gestational hypertension, birthweight < or = 10th centile, and preterm delivery, the presence of a uterine notch alone had sensitivity of 30.7% and specificity of 93.8%. For the identification of severe fetal growth restriction (< 5th centile) and/or preeclampsia, the presence of a notch offered a sensitivity of 50%, specificity of 96.3%, a positive likelihood ratio of 13.5, and a negative likelihood ratio of 0.5. CONCLUSIONS: The identification of uterine artery notching by means of Doppler ultrasound as a component of the surveillance of women with unexplained elevated betahCG levels significantly improves the prediction of preeclampsia and/or severe IUGR, although the low prevalence of 13% of these adverse outcomes limits the usefulness of the test in routine clinical practice.

Abstract: Indoleamine 2,3-dioxygenase (IDO) has been implicated in contributing to immunotolerance in early pregnancy, but the presence in the term placenta of mRNAs for enzymes that produce other biologically active kynurenine end-products suggests other functions for kynurenine pathway metabolites. The aim of this study was to investigate the localisation of two key enzymes - IDO and kynurenine hydroxylase (KYN-OHase) - in first trimester decidua and in the human placenta across pregnancy. Using immunocytochemistry, it was shown that there was strong expression of IDO and KYN-OHase in stromal and glandular epithelial cells of first trimester decidua. In first and second trimester placenta, IDO and KYN-OHase were localised to the syncytiotrophoblast, stroma and macrophages. IDO and KYN-OHase mRNAs were also identified, and the enzymes appear to be functional because kynurenine and 3-hydroxy-anthranilic acid (respective products of the activity of these enzyme) were released into the medium when first trimester placental explants were maintained in culture for 48h. In term placenta, both IDO and KYN-OHase immunoreactivities were confined mainly to vascular endothelial cells of villous blood vessels, and to macrophages within the fetal villus, whereas syncytial staining was very weak or absent. The shift of expression of these enzymes away from the syncytiotrophoblast to fetal endothelial cells in terminal villi suggests that the function of the enzymes may change from a role in immunosuppression at the maternal-fetal interface in early pregnancy, to one associated with regulation of fetoplacental blood flow or placental metabolism in late gestation.

Abstract: The iodine status of pregnant women from different ethnic groups in an Australian population was determined by measuring urinary iodine concentration (UIC) from stored spot urine samples. Study subjects were selected from pregnant women participating in a Down Syndrome screening study at Monash Medical Centre in Melbourne, Australia. In total, 263 Vietnamese, 262 Indian/Sri Lankan (ISL) and 277 Caucasian women were included. The median UIC of Caucasian women (52 microg/L) was significantly lower than that of both Vietnamese women (58 microg/L, P <0.01) and ISL women (61 microg/L, P = 0.03). The proportion of women who had a UIC below 50 microg/L was 48.4% of the Caucasian women, 38.4% of the Vietnamese women and 40.8% of the ISL women. These data are consistent with mild iodine deficiency for each of the groups of pregnant women. The evidence for mild iodine deficiency in these groups of pregnant women is consistent with recent Australian studies in pregnant and non-pregnant individuals. The association of ethnicity with iodine status is most likely due to differences in dietary behaviours. Understanding the factors that influence iodine nutrition in a multiethnic population will be important for identifying the most useful approaches to improving iodine status, evaluating different strategies and the development of appropriate monitoring programs. Action to improve iodine status in the Australian population should include consideration of ethnic differences in diet.

Abstract: Copper is an essential trace element necessary for normal growth and development. During pregnancy, copper is transported from the maternal circulation to the fetus by mechanisms which have not been clearly elucidated. Two copper transporting ATPases, Menkes (ATP7A; MNK) and Wilson (ATP7B; WND) are known to be expressed in the placenta and are thought to have a role in copper transport to the fetus. In this study, the expression and localization of the MNK and WND proteins in the human placenta were investigated in detail using immunoperoxidase and double-label immunohistochemistry. MNK and WND are differentially localized within the placenta. MNK is present in the syncytiotrophoblast, the cytotrophoblast and the fetal vascular endothelial cells whereas WND is only in the syncytiotrophoblast. Placental levels of both proteins, measured by Western blot analysis, did not change across pregnancy. These data offer some insights into possible roles for MNK and WND within the placenta.

Abstract: In early pregnancy, serum levels of the luteal-derived hormone pro-alphaC inhibin peak by the second week after conception. Whether this early rise is biologically important and a consistent feature of only successful pregnancy is unknown. We undertook a prospective cross-sectional study to determine whether serum pro-alphaC inhibin levels at d 15-17 are predictive of a successful clinical in vitro fertilization pregnancy and compared levels between fresh embryo transfer (ET) and frozen-thawed ET. Median (95% confidence interval) pro-alphaC inhibin levels were 68 (57-76) pg/ml in 204 women who did not become clinically pregnant after ET, significantly lower than in either 90 women who became clinically pregnant after fresh ET and who had 3139 (1684-4220) pg/ml or in 39 women with a successful frozen ET who had 877 (678-1111) pg/ml. Pro-alphaC was highly sensitive and specific in predicting clinical pregnancy success but did not improve on the performance of human chorionic gonadotropin. Pro-alphaC inhibin levels were not correlated with progesterone or human chorionic gonadotropin. Levels were no higher in singleton compared with multiple pregnancies and did not increase across gestation, suggestive of a luteal source. The increase in circulating pro-alphaC inhibin in very early pregnancy is highly specific to clinical pregnancy, suggesting a possible biological role in early gestation.

Abstract: In an asymptomatic cohort, serum pregnancy-associated protein-A (PAPP-A) levels among women destined to miscarry were 14% of those seen with ongoing pregnancies. Levels were as low 3 weeks before diagnosis as on the day of diagnosis, suggesting that PAPP-A levels might predict future miscarriage.

Abstract: OBJECTIVE: To determine whether activin A levels reflect oxygen availability in basal and hypoxic conditions in the late pregnant fetus and newborn lamb. DESIGN: In vivo animal experimental study. SETTING: Department of Physiology, Monash University. POPULATION: Chronically catheterised fetal sheep in late gestation. METHODS: Fetal hypoxia was induced at 125 (n = 4), 135 (n = 4) or 145 days ('term'; n = 3) gestational age by maternal nitrogen exposure, for 4 hours, during which maternal and fetal arterial, and amniotic fluid samples were collected. Lambs (age one, five and eight days; n = 3) were exposed to 1 hour of hypoxia via nitrogen exposure. MAIN OUTCOME MEASURES: Activin A, prostaglandin E2 (PGE2) and cortisol were analysed in plasma and amniotic fluid, and whole blood was used to determine Pao2, Paco2, %O2, lactate and pH. RESULTS :Basal activin A concentrations in the fetal arterial circulation remained unchanged between 125 days (0.230 [0.10] ng/mL) and term (0.28 [0.10] ng/mL), as did fetal oxygen saturation (59.11% [4.74%] to 52.25% [4.84%]) and pH (7.35 [0.02] to 7.37 [0.02]). Moderate fetal hypoxia (50% fall in fetal arterial %O2) produced a significant increase in circulating activin A (2.05 [0.67] ng/mL) and a significant decrease in pH (7.27 [0.03]) at 125 days of gestation, however, at 135 and 145 days, activin A and pH remained unchanged. Fetal activin A concentration was significantly correlated with pH (P = 0.036) but not %O2 (P = 0.072). Hypoxia in the lambs did not alter circulating activin A. CONCLUSIONS: In response to hypoxia, activin A is increased in the circulation of 125-day-old fetuses, but not in older fetuses. Fetal arterial activin A levels sensitively reflect pH but not oxygen saturation, with increasing activin A in conditions of metabolic acidosis.

Abstract: The aim of the present study was to determine whether activin A concentrations are dependent on feto-placental oxygen availability and to investigate the temporal relationship of activin A with prostaglandin (PG) E(2) and cortisol. Nine fetal sheep (six hypoxic and three control) were instrumented and catheterised at 0.8 gestation. Reduced uterine blood flow was used to achieve three levels of hypoxia (mild = fetal SaO(2) 40-50%; moderate = fetal SaO(2) 30-40%; severe = fetal SaO(2) 20-30%), for 4 h on 3 consecutive days. Activin A, PGE(2) and cortisol levels were determined in maternal and fetal blood and amniotic fluid. Moderate and severe hypoxia produced a significant (P < 0.05) increase in fetal plasma activin A concentrations. The amniotic fluid activin A concentrations were 15-fold higher than those in the fetal circulation, but were unchanged by hypoxia. The fetal PGE(2) response reflected the degree of hypoxia over the 3 days, with moderate and severe hypoxia producing a significant (P < 0.05) increase in PGE(2) concentrations. Fetal plasma cortisol concentrations were increased ( P < 0.05) during all levels of hypoxia. Fetal arterial activin A was increased in response to moderate and severe hypoxia, but levels were not maintained over the hypoxic period. The increases in activin A and cortisol concentrations preceded the increase in PGE(2).

Abstract: BACKGROUND: To provide current data on maternal and neonatal outcomes in triplet pregnancies in an Australian population. METHODS: Retrospective case note review of all triplet pregnancies managed within a single Australian tertiary centre. RESULTS: Fifty-four sets of triplets were managed from January 1996 to October 2002. A total of 59% resulted from the use of assisted reproductive technologies. The median gestation at delivery was 32.5 weeks (range: 21-36 weeks); 14% delivered prior to 28 weeks and 43% delivered before 32 weeks. Preterm labour and preterm rupture of membranes were the most common antenatal complications occurring in 57 and 22% of pregnancies, respectively. A total of 93% of pregnancies were delivered by Caesarean section and 37% of mothers experienced at least one post-partum complication. A total of 96% of neonates were liveborn, with a median birthweight of 1644 g (range: 165-2888 g). The two most common neonatal complications were jaundice and hypoglycaemia in 52 and 43% of liveborn neonates, respectively. A total of 28% of neonates were below the 10th centile for gestational age and sex. A total of 8% of neonates demonstrated congenital anomalies. The perinatal mortality at a gestational age of 20-24 weeks was 100%, 22% at 25-28 weeks and zero for those babies born at 29 weeks or beyond. CONCLUSION: Assisted reproductive technologies contribute significantly to the incidence of triplet pregnancies. Gestational age at delivery and perinatal mortality is comparable to published international data. Triplets born in a tertiary centre beyond 28 weeks gestation have a very favourable prognosis in the newborn period.

Abstract: OBJECTIVES: To measure maternal serum and amniotic fluid levels of macrophage inhibitory cytokine-1 (MIC-1) in Down syndrome and normal pregnancies, assessing the utility of MIC-1 as a prenatal marker of Down syndrome. METHODS: Stored serum from 64 Down syndrome and 399 control pregnancies, collected at 8 to 17 weeks of pregnancy, and stored amniotic fluid from 17 Down syndrome and 53 controls, collected at 15 to 19 weeks of pregnancy, were retrieved for analysis. MIC-1 was measured using an established in-house ELISA, blinded to sample type. RESULTS: In maternal serum, MIC-1 levels are not altered in Down syndrome in either the first or second trimester. Levels, expressed as median (95% CI) multiples of the median (MoM), in the Down syndrome cases and controls were 1.07 (0.9-1.1) MoM and 1.0 (0.95-1.03) MoM respectively. In amniotic fluid, MIC-1 levels were significantly decreased compared to controls, 0.52 (0.44-0.64) MoM versus 1.0 (0.85-1.08) MoM (p < 0.0001). CONCLUSION: MIC-1 is decreased in amniotic fluid but not in maternal serum in Down syndrome pregnancies. MIC-1 will not be useful as a prenatal marker of Down syndrome.

Abstract: Macrophage inhibitory cytokine 1 (MIC 1) is thought to have immunomodulatory actions favouring fetal viability. We measured serum concentrations of MIC 1 in asymptomatic women at 6-13 weeks' gestation who subsequently miscarried or who had already miscarried. MIC 1 concentrations in the miscarriage cohort (n=100), were a third of those who had ongoing pregnancies (n=197). Multiples of the median for miscarriage was 0.32 (95% CI 0.23-0.32) versus 1.00 (0.93-1.06) for ongoing pregnancies; p<0.0001. Concentrations were just as low 3 weeks before diagnosis as on the day of diagnosis. That MIC 1 serum concentrations seem to be low weeks before miscarriage suggests possible predictive and causative roles, as well as therapeutic potential.

Abstract: OBJECTIVE: To define the ontogeny of umbilical artery activin A at term and to evaluate activin A as a potential marker of perinatal hypoxia. DESIGN: A cohort study. SETTING: A university teaching hospital delivery suite. POPULATION: A convenience sample of 141 term pregnancies. METHODS: At delivery, umbilical artery and vein bloods were collected for blood gas measurements and subsequent measurement of activin A. Activin A levels were correlated with blood gas measurements and with labour and neonatal outcomes. MAIN OUTCOME MEASURES: Umbilical arterial activin A and pH. RESULTS: The median (95% CI) umbilical arterial activin A level at delivery was 1.38 (1.34-1.70) ng/mL. Levels varied significantly across gestation (P= 0.03), increasing from 36 to 38 weeks, thereafter decreasing to a nadir at 41 weeks. In 60 matched samples, the median (95% CI) venous and arterial activin A levels were 0.89 (0.81-1.06) ng/mL and 1.38 (1.21-1.61) ng/mL, respectively (P < 0.0001). Mean umbilical arterial pH was 7.20 (7.06-7.38; 5-95th centiles) and was not significantly correlated with log10 activin A (r=- 0.01; P= 0.68). Compared with healthy controls, there was no difference in arterial activin A in neonates identified as having suffered significant intrapartum asphyxia (P= 0.96). Fetal activin A levels were significantly lower in cases delivered by emergency caesarean section for complications during the first stage of labour compared with cases delivered vaginally (P= 0.003). CONCLUSIONS: Umbilical artery activin A does not appear to be a sensitive marker of fetal oxygenation or of risk of hypoxic-ischaemic encephalopathy.

Abstract: OBJECTIVE: Miscarriage is the commonest complication of human pregnancy. We undertook this study to assess whether inhibin A, pro-alphaC inhibin and/or activin A, products of the corpus luteum and placenta, might be useful in either the prediction or diagnosis of miscarriage. DESIGN: Case-control study. PATIENTS: Ninety-eight asymptomatic women at 6-13 weeks gestation who subsequently had a miscarriage and 198 gestation-matched women with a normal singleton pregnancy. MEASUREMENTS: Maternal serum levels of inhibin A, pro-alphaC inhibin, activin A and human chorionic gonadotrophin (hCG) were measured. RESULTS: Inhibin A, pro-alphaC and hCG, expressed as multiples of the normal median (MoM; +/-95% confidence intervals) in the miscarriage cases were significantly lower than in the viable controls, 0.56 (0.48-0.69) MoM vs. 1.00 (0.98-1.13) MoM, 0.55 (0.51-0.84) MoM vs. 1.0 (0.86-1.22) MoM and 0.34 (0.23-0.36) MoM vs. 1.00 (0.94-1.08) MoM, respectively (P < 0.0001 for all). Of the three analytes, hCG was the most discriminating between cases and controls. Levels of activin A in the miscarriage cases were not significantly different from controls, 0.96 (0.86-1.07) vs. 1.0 (0.95-1.08). CONCLUSIONS: These data suggest that inhibin A, pro-alphaC inhibin and activin A will not be useful in either the prediction or diagnosis of early pregnancy miscarriage.

Abstract: OBJECTIVE: We examined whether estrogen action in human parturition is regulated by an intracrine mechanism mediated by target tissue expression of specific 17beta-hydroxysteroid dehydrogenase (17betaHSD) isozymes that interconvert estrone (E1) and estradiol (E2), such that the onset of labor is associated with an increase in local E2 bioavailability. METHODS: The extent of 17betaHSD-1, -2, -3, -4, -5, and -7 expression (measured by quantitative reverse transcriptase polymerase chain reaction) and the capacity to interconvert E1 and E2 were compared in amnion, chorion, placenta, decidua, and myometrium obtained from women at term before (n = 6) and after (n = 6) the onset of labor. RESULTS: In chorion, abundance of 17betaHSD-1 (converts E1 to E2) mRNA decreased 2.7-fold (P <.05) in association with labor onset. In myometrium, 17betaHSD-1 and 17betaHSD-4 (converts E2 to E1) mRNAs increased two-fold and five-fold, respectively, with the onset of labor (P <.05 for each). No other statistically significant labor-associated change in 17betaHSD expression was observed. In chorion, 17betaHSD oxidative (E2 to E1) and reductive (E1 to E2) activities and the net E2 synthetic capacity increased with labor. In decidua, both activities decreased with the onset of labor, but there was no change in net E2 synthetic capacity. The capacity to interconvert E1 and E2 did not change in the other tissues. CONCLUSION: The increase in E2 synthetic capacity in the chorion might contribute to an increase in local estrogen bioactivity in association with the onset of labor. However, it cannot be explained by changes in 17betaHSD isozyme expression and is unlikely to account for the increased estrogen action at parturition. These data show that intracrine mechanisms based on 17betaHSD isozyme expression play a minor role, if any, in controlling estrogen action in gestational tissues during human parturition.

Abstract: OBJECTIVE: To assess the level of knowledge about Down syndrome screening among a sample of health professionals providing antenatal care. DESIGN: A structured questionnaire-based survey. SETTING: Health professionals allied to a tertiary level maternity hospital in metropolitan Melbourne. METHODS: A self-administered questionnaire was given or posted to 166 health care providers to assess their knowledge of prenatal Down syndrome screening. RESULTS: A total of 140 completed surveys were returned (83% response rate), including 70 from general practitioners, 34 from midwives, 33 from obstetricians and three from geneticists. Of these, 130 confirmed that they regularly counsel women about prenatal screening for Down syndrome. Sixteen per cent of those indicated that they only offered testing to selected 'high risk' women rather than all women. Overall, there was a high level of awareness regarding the gestations at which the commonly used screening tests are offered but a poor appreciation of the relative performances of those tests. Seventy-eight (60%) of those counselling indicated that they discussed detection and screen positive rates specific for the age of the woman. However, less than 10% were able to provide those rates. CONCLUSION: Knowledge of Down syndrome screening was variable among those who regularly counsel women about these tests. The results of the present survey highlight the need for professional education about prenatal screening.

Abstract: OBJECTIVE: To assess whether women have a preference for Down syndrome screening test performance. METHODS: A structured questionnaire exploring women's preferences for screening test performance was administered to women attending their first prenatal visit who wished to have Down syndrome screening performed. RESULTS: One hundred and twenty women were interviewed. The majority of women (n=80) chose a screening test with a low screen-positive rate rather than the highest detection rate. The reasons given for this preference were a desire to minimise the risk of miscarriage of a normal baby and a belief that a detection rate of 80 to 90% was acceptable. However, older women (>37 years) chose a test with the highest detection rate possible, regardless of the higher screen-positive rate, preferring to miscarry a normal baby as a result of a diagnostic test rather than miss the detection of a baby with Down syndrome. Preferences were not influenced by previous screening experience. CONCLUSIONS: Women express different preferences for screening test performance. Maternal age rather than previous screening experiences appears to be the major influence in these choices.

Abstract: OBJECTIVES: To assess the effect of altering image size on the absolute nuchal translucency (NT) measurement. METHODS: NT was measured at three image magnifications (60%, 100% and 200%) in 120 singleton pregnancies. RESULTS: The mean +/- SD NT measurements were 1.52 +/- 0.57 mm, 1.35 +/- 0.53 mm and 1.18 +/- 0.48 mm at 60%, 100% and 200% magnification, respectively (p = 0.00001). CONCLUSIONS: The measurement of NT decreases significantly with increasing image size. Optimisation of NT as a method of screening will require agreed standardisation of image magnification.

Abstract: OBJECTIVES: It has been previously shown that glucocorticoids alter umbilical artery flow velocity waveforms in singleton pregnancies complicated by umbilical artery absent end diastolic flow. Whether similar effects are evident in multiple pregnancies where one fetus has umbilical artery absent end diastolic flow is not known. METHODS: Women with a twin or triplet pregnancy complicated by umbilical artery absent end diastolic flow in one fetus were admitted to hospital for intensive fetal surveillance including daily umbilical artery flow velocity waveform studies, as per hospital protocol. All women received prophylactic betamethasone (11.4 mg x 2, 24 h apart) in anticipation of preterm delivery. RESULTS: Between October 1996 and February 2002, 24 women with a multiple pregnancy complicated by umbilical artery absent end diastolic flow were cared for. Of these, six had a pregnancy with feto-fetal transfusion and excluded from further analysis. Of the remaining 18 women, eight had monochorionic diamniotic twins, eight had dichorionic twins, and two had trichorionic, triamniotic triplets. The median (range) gestation at diagnosis of umbilical artery absent end diastolic flow was 210.5 days (173-241). In nine (50%) of the 18 pregnancies the administration of betamethasone was associated with return of umbilical artery end diastolic flow for a median of 5 days. There was no association between this effect and chorionicity. The median (range) interval from diagnosis of umbilical artery absent end diastolic flow to delivery was 11 days (1-46). CONCLUSIONS: As previously reported in singleton pregnancies, the maternal administration of betamethasone in multiple pregnancies with umbilical artery absent end diastolic flow is associated with a transient return of end diastolic flow.

Abstract: Background - Iodine deficiency is re-emerging as a potential public health problem in Australia. Poor iodine status in pregnancy is associated with impaired fetal development, both mental and physical. Furthermore, there may be significant ethnic variation in maternal iodine status. Objective - To describe maternal iodine status in a multiethnic Australian population. Design - Cross-sectional. Urinary iodine (UI) concentration was measured in spot urine samples, collected in early pregnancy, from Vietnamese, Indian/Sri Lankan and Caucasian women who participated in a Downs Syndrome Screening Program over 1999-2001 in Melbourne. Outcomes - WHO Iodine Status: Caucasian (n=178): 49.0 UImicrog/L (Median); 50.6 (%UI below 50micro/L); moderate iodine deficiency. Vietnamese (n=200): 56.5(1); UImicrog/L (Median); 38.5 (%UI below 50micro/L); mild iodine deficiency; Indian/Sri Lankan (n=181): 53.0(2) UImicrog/L (Median); 47.0 (%UI below 50micro/L); mild iodine deficiency. P=0.003 cf Caucasian; (2);P=0.15 cf Caucasian). Conclusions - Consistent with recent studies in non-pregnant individuals, these women were mildly to moderately iodine deficient according to World Health Organisation (WHO) criteria. The findings may have implications for fetal development and for public health advice.

Abstract: Intra-amniotic bacterial infection is a major risk factor for cerebral impairment in infants that are born pre-term however, the causal pathways are largely unknown. Whether placental derived, neuroactive kynurenine metabolites play any role in fetal cerebral damage during episodes of intra-amniotic infection is presently unknown. In this preliminary study, we explored if kynurenine metabolites may be involved, examining if mRNAs of enzymes involved in tryptophan catabolism through the kynurenine pathway (KP) were expressed in the placenta and if their expression was co-ordinately altered with exposure to bacterial infection. We found that placentae from healthy women at term and those with clinical signs of amniotic fluid bacterial infection pre-term expressed mRNAs of the KP enzymes, with higher expression overall in the infected group. Significant increases in indoleamine 2,3-dioxygenase (IDO), tryptophan dioxygenase (TDO) and kynureninase (KYNase) expression were detected in association with infection. These findings suggest that tryptophan may be constitutively degraded through the KP in the human placenta. Whether higher concentrations of placental derived kynurenine metabolites enter the fetus during episodes of infection and their physiological roles if any remains to be elucidated.

Abstract: Previous studies have identified the presence of unidentified small molecular weight (mol wt) forms of inhibin and the pro-alphaC region of the inhibin alpha subunit in serum from women during late pregnancy. The aim of this study was to investigate if these gestational-related changes in mol wt forms arose from changing placental production. Pooled placental extracts, derived from normal healthy singleton pregnancies in the 1st, 2nd and 3rd trimesters of pregnancy, were fractionated by a combined immunoaffinity chromatography, preparative PAGE and electroelution procedure. Inhibin A, inhibin B and the pro-alphaC region of the inhibin alpha subunit were determined in the eluted fractions by specific ELISAs, with the profiles of immunoactivity characterized in terms of molecular size and percentage recovery. Inhibin B was undetectable in all samples. Mol wt peaks of 36k, 75K and 97K for inhibin A and 29k, 55K and 97K for pro-alphaC were detected in placental extracts across all three trimesters. The relative abundancy of small mol wt inhibin A forms (<30K) present in the placenta increased significantly in the third trimester placenta, increasing from 0.3 per cent in the first trimesters to 6 per cent in the third trimester (P=0.01, chi-squared test). The relative abundances of various mol wt forms of pro-alphaC was similar at all three gestations (P=0.67). In serum, small mol wt inhibin A and pro-alphaC forms accounted for 23.4 per cent and 37.4 per cent of inhibins, respectively, in the third trimester.These data suggest that the presence of small mol wt forms of both inhibin A and pro-alphaC in maternal serum is only partially attributed to placental production and/or secretion. We conclude that inhibin A and pro-alphaC inhibins in maternal serum are processed in late pregnancy by more than one mechanism to form low mol wt circulating forms of, as yet, undetermined structure.

Abstract: OBJECTIVE: To assess maternal serum activin A as a potential marker of fetal growth restriction. DESIGN: A cohort study. SETTING: A maternal-fetal medicine unit, university teaching hospital. POPULATION: Fifty-seven women with a small fetus (less than 10th centile for gestation) referred for assessment of fetal size by ultrasound biometry. METHODS: At the time of presentation for fetal biometry, maternal blood was collected for activin A measurement. The case records of each woman were independently reviewed after delivery and the pregnancy grouped into one of three groups: constitutionally small fetus, intrauterine growth restricted (IUGR) fetus or IUGR fetus and maternal pre-eclampsia (IUGR-pre-eclampsia). Activin A levels in the three groups were compared. MAIN OUTCOME MEASURES: Maternal serum activin A levels. RESULTS: Sixteen of the 57 pregnancies were classified as constitutionally small, 17 as IUGR and 24 as IUGR-pre-eclampsia. Expressed as multiples of a normal median (MoMs), the median (95% CI) activin A level in the constitutionally small pregnancies was 1.12 (0.72-1.39) MoMs significantly lower than the level in both the IUGR pregnancies, 3.00 (1.84-4.11) MoMs, and the IUGR-pre-eclampsia pregnancies, 7.96 (5.73-10.62) MoMs (P = 0.002 and 0.0001 for IUGR vs constitutionally small and IUGR-pre-eclampsia vs constitutionally small, respectively). CONCLUSIONS: Maternal serum activin A may be useful in the assessment of the small for gestational age fetus.

Abstract: In a retrospective cohort study we have previously shown that administration of betamethasone to women with a pregnancy complicated by absent end-diastolic flow in the umbilical artery (UA) is associated with altered UA flow velocity waveforms. To examine this phenomenon further we undertook a prospective study of 30 similar singleton pregnancies. Umbilical artery FVWs were recorded before and after betamethasone administration using real-time pulsed wave colour flow Doppler. The results of this prospective cohort were similar to those of the retrospective study allowing pooling of the data. Of the 55 total pregnancies with umbilical artery AEDF studied betamethasone administration was associated with the return of end-diastolic flow in 39 (71 per cent; 95 per centCI: 59-83 per cent). The median (range) duration of this change was 3 (1-10) days. There is no evidence that this change has either a beneficial or detrimental effect on foetal health. Administration of betamethasone to women with a pregnancy complicated by umbilical artery AEDF is associated with the transient return of end-diastolic flow in most cases. While the mechanisms underlying this effect are yet to be fully elucidated it has implications for foetal surveillance in these high-risk pregnancies.

Abstract: Embryo implantation, endometrial stromal cell decidualization and formation of a functional placenta are critical processes in the establishment and maintenance of pregnancy. Interleukin (IL)-11 signalling is essential for adequate decidualization in the mouse uterus and IL-11 promotes decidualization in the human. IL-11 action is mediated via binding to the specific IL-11 receptor alpha (IL-11Ralpha). The present study examined immunoreactive IL-11 and IL-11Ralpha in cycling rhesus monkey endometrium, at implantation sites in cynomolgus and rhesus monkeys and in human first trimester decidua and defined distinct spatial and temporal patterns. In cycling rhesus monkey endometrium, IL-11 and IL-11Ralpha increased in both basalis and functionalis regions during the secretory compared with the proliferative phase, with changing cellular locations in luminal and glandular epithelium and stroma. The patterns were similar overall to those previously described in human endometrium. Differences were seen in immunostaining during implantation in cynomologus and rhesus monkey. In the cynomolgus, very little staining for IL-11 or IL-11Ralpha was seen in syncytio- and cyto-trophoblast cells in the villi between days 12 and 150 of pregnancy although there was moderate staining in cytotrophoblast in the shell between days 12 and 17 and in subpopulations of cytotrophoblast cells invading the arteries at day 17. By contrast in the rhesus monkey between days 24 and 35 of pregnancy and in human first trimester placenta, cyto- and syncytio-trophoblast in the villi but not cytotrophoblast in the shell were positively stained. The most intense staining for both IL-11 and IL-11Ralpha was present within the decidua in the maternal component of implantation sites in all three primates but moderate staining was also present in maternal vascular smooth muscle and glands perivascular cells and epithelial plaques. These results are consistent with a role for IL-11 both during decidualization and placentation in primates.

Abstract: Placental activin A and inhibin A output is increased in pre-eclampsia, a condition characterized by placental hypoxaemia, whereas follistatin secretion is unaltered. We investigated whether hypoxia was the basis for elevated placental activin A and inhibin A output. First trimester and term placental explants were grown in 5-6% dissolved O(2) (n=10/trimester) and 200 microM cobalt chloride (CoCl(2),n =6/trimester) to simulate environmental and cellular hypoxia respectively, for up to 72 h. Activin A, inhibin A and follistatin production were compared with control cultures grown in standard media at 20% O(2). In first trimester and term placenta, activin A output declined significantly under 5-6% O(2) (P=0.006 and 0.001 after 48 h respectively). Inhibin A declined significantly under 5-6% O(2), mainly in first trimester placenta (P=0.03, 24h). CoCl(2) significantly elevated activin A production in term placenta (P=0.003, 48 h), whereas inhibin A output was unaffected. Neither low O(2) or CoCl(2) altered follistatin output from first trimester or term placenta. These findings suggest that there may be novel O(2) sensing mechanism/s that down regulate activin A and inhibin A in the placenta and that low O(2) is not the mechanism behind increased placental inhibin A or activin A output in pre-eclampsia.

Abstract: Macrophage inhibitory cytokine-1 (MIC-1), a divergent member of transforming growth factor-beta superfamily, has been recently shown to be produced by the human placenta with detectable levels in maternal serum. In this study, using immunohistochemistry, we have localized MIC-1 in placenta, decidua and foetal membranes across pregnancy and, using an enzyme-linked immunoassay, measured MIC-1 in maternal serum in normal pregnancy, in association with labour and pre-eclampsia. In the placenta MIC-1 was principally localized to the syncytiotrophoblast while in the foetal membranes MIC-1 was present in the amniotic epithelium, chorionic trophoblasts and adherent decidual cells. There were no differences in MIC-1 staining distribution or intensity in the placentae between women in labour and not in labour, or between healthy and pre-eclamptic pregnancies. MIC-1 staining in the foetal membranes was slightly stronger after a labour and delivery compared to those delivered by elective Caesarean section. MIC-1 levels in the maternal serum increased with advancing gestation but there were no significant differences in maternal serum levels associated with either labour or pre-eclampsia.These observations would be consistent with MIC-1 having roles at the maternal-foetal interface, perhaps in the establishment and/or maintenance of pregnancy. Our data argue against MIC-1 having a significant role in the regulation of labour or in the pathophysiology of pre-eclampsia.

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Abstract: A number of studies demonstrate that both long-term and short-term exposure to glucocorticoids alters vascular function. We have examined whether the short-term administration of glucocorticoids into the human fetal-placental circulation affects placental arterial pressure and alters vascular responses to vasoconstrictive and vasodilator agents. Single lobules of term human placentae were bilaterally perfused in vitro with Krebs' solution (maternal and fetal, 5 ml/min Krebs, 95% O2, 5% CO2, 37 C, pH 7.3), and changes in fetal-placental arterial perfusion pressure were measured. Dexamethasone (100 nM) infusion for 1 h into the fetal-placental circulation caused a significant decrease in basal arterial pressure (n = 19, t test, P < 0.05). Continuous dexamethasone infusion (100 nM) did not alter vasoconstrictive responses to PGF(2alpha) (0.5-120 pM, n = 12, ANOVA, P > 0.05) or potassium chloride (5-600 mM, n = 12, ANOVA, P > 0.05) or vasodilator responses to CRH (53-7400 pM, n = 13, ANOVA, P > 0.05). However when fetal-placental vessels were submaximally preconstricted and then infused with dexamethasone alone (40 nM-10 microM), there was a dose-dependent decrease in arterial pressure (n = 8). Dexamethasone-induced dilation was not inhibited by blocking nitric oxide synthase or cyclo-oxygenase activity. These data suggest that dexamethasone can cause dilation in the fetal-placental circulation, possibly via an endothelium-independent pathway.

Abstract: This study was undertaken to compare placental levels of 2,3-Dioxygenase (IDO), a free radical scavenger, and 4-Hydroxynonenal (4-HNE), a major by-product of lipid peroxidation, in normal and pre-eclamptic pregnancies. Placentae were collected at caesarean section from women with a term, normal singleton pregnancy (37-40 weeks' gestation, n=10) and women with a term singleton pregnancy complicated by pre-eclampsia (n=10). IDO and 4-HNE localization and intensity was studied by semi-quantitative immunohistochemistry and differences between groups were analysed using the Mann-Whitney U test. Immunostaining for IDO was located primarily in endothelial cell nuclei, with a reduced level of staining in the cytoplasm, in most capillaries from all placentae examined. A significantly higher level of IDO immunostaining was observed in normal placentae compared to pre-eclamptic placentae (P=0.008). 4-HNE was located mainly in the cytoplasm of syncytiotrophoblast cells of all placentae examined. There were no significant differences in the pattern or intensity of 4-HNE immunostaining levels between normal and pre-eclamptic pregnancies (P=0.684). Our IDO results support the hypothesis of decreased anti-oxidative capability in the placenta and the possibility of an ineffective compensatory mechanism against increased oxidative stress in the fetus.

Abstract: OBJECTIVE: To determine the timing of the onset of the umbilical artery flow velocity waveform changes following maternal administration of betamethasone in pregnancies complicated by umbilical artery absent end-diastolic flow, and to explore whether these changes are associated with flow velocity waveform changes in other fetoplacental vessels. SUBJECTS AND METHODS: This was a prospective study of 12 women with pregnancies complicated by umbilical artery absent end-diastolic flow. Flow velocity waveforms were recorded from the umbilical artery, fetal middle cerebral artery, renal artery, aorta and ductus venosus, before and after maternal betamethasone administration, using real-time pulsed wave Doppler. RESULTS: In all 12 pregnancies, the administration of maternal betamethasone was followed by the return of end-diastolic flow within 24 h. End-diastolic flow was first observed at 4 h and was present in all women studied at 8 h. In addition, there was a statistically significant decrease in the pulsatility index in the fetal aorta at 8 h and the middle cerebral artery at 24 h. No change was observed in the ductus venosus or the renal artery flow velocity waveforms. CONCLUSION: The findings suggest that, in pregnancies complicated by absent end-diastolic flow in the umbilical artery, maternally administered betamethasone induces a return in umbilical artery end-diastolic flow as early as 4 h, along with widespread vasodilatation throughout the fetoplacental vasculature.

Abstract: It appears from current evidence that the most effective screening strategy for Down syndrome will involve a combination of first trimester nuchal translucency and serum biochemistry, whether performed in the first or second trimester. The aim of this study was to determine the optimum gestation based upon menstrual dates at which to schedule nuchal translucency (NT) measurement for the evaluation of fetal Down syndrome risk. Five thousand eight hundred and thirty-five pregnancies had an ultrasound scan scheduled between 11 and 14 completed weeks of gestation based upon either the last menstrual period (n = 3199) or a prior ultrasound scan (n = 2636). For last menstrual period-based ultrasound scans, with advancing gestation the frequency of missed miscarriage significantly decreased (p = 0.009, chi squared test), as did the need to reschedule a further scan because the gestation of the scheduled scan was too early to measure NT (p < 0.0001, Chi-squared test). In contrast, with advancing gestation the rate of unsuccessful NT measurement because the crown-rump length (CRL) was greater than 84 mm significantly increased (p < 0.0001, Chi-squared test). Of the women who had had an earlier ultrasound, 42 (1.6%) had a missed miscarriage and 9 (0.3%) were over gestation at the time of the NT scan. These data suggest that when only the last menstrual period is known the optimum time to schedule a nuchal translucency measurement is at 12 to 13 weeks' gestation.

Abstract: The aim of this study was to investigate localization and content of activin beta A-subunit and activin receptors in gestational tissues throughout pregnancy and in association with term labour. Placenta and fetal membranes were collected from women undergoing first and second trimester terminations and from women before and after term labour. Activin beta A-subunit and activin receptors IA, IB, IIA and IIB were studied by immunohistochemistry. Term tissues were analysed for activin A and follistatin content by ELISA and the presence of receptor proteins was assessed by Western hybridization. Activin beta A-subunit was localized to the syncytiotrophoblast and cytotrophoblast in placentae from all gestational ages, and to the amniotic epithelial and chorionic trophoblast layer at term. In placentae of first and second trimester, receptor proteins were localized to the syncytium, whereas at term, the distribution was confined predominantly to vascular endothelial cells of villous blood vessels. Receptor proteins in amnion were localized to some epithelial cells, mesenchyme and chorionic trophoblast. These findings suggest that activin A is secreted by and targets the placental syncytium and amniotic epithelium in early pregnancy, but at term targets the vascular endothelium of placenta and the fetal membranes. There were no differences with labour onset.

Abstract: In pregnancy the feto-placental unit is the major source of activin A. However, the role(s) of activin A in late pregnancy remain uncertain and controversial. In particular, whether activin A levels alter in association with labour is unclear. In a cross-sectional cohort study, maternal serum samples were collected from women at term prior to elective Caesarean section (n=11), during labour prior to a spontaneous vaginal delivery (n=31), an instrumental vaginal delivery (n=16) or an emergent Caesarean section (n=7). Umbilical artery blood samples were collected from 75 pregnancies, after an elective Caesarean section (n=9), a normal vaginal delivery (n=37), an instrumental vaginal delivery (n=15) or an emergent Caesarean section (n=14). Levels of activin A were measured and compared according to modes of delivery.Maternal, but not foetal, serum activin A was increased significantly in women who were delivered by an intrapartum Caesarean section compared to other modes of delivery. Foetal, but not maternal, serum activin A was significantly correlated with umbilical artery pH. Maternal serum activin A is increased in women undergoing an intrapartum Caesarean section compared to either a vaginal delivery or an elective Caesarean section. The mechanism(s) underlying this observation are not clear.

Abstract: OBJECTIVE: The aim of this study was to determine whether women prefer the results of screening for Down syndrome tests to be reported as the risk of Down syndrome in early pregnancy at the time of the screening test or the risk at delivery (which takes into account the number of Down syndrome pregnancies that will be spontaneously lost before birth). DESIGN: A structured questionnaire. SETTING: A tertiary hospital antenatal clinic. SAMPLE: One hundred and fifteen English-speaking women who expressed an interest in having screening tests for Down syndrome performed. METHODS: A structured questionnaire exploring women's preferences for risk reporting was self administered by women attending for their first antenatal visit. MAIN OUTCOME MEASURES: Women's preference for reporting of screening test results as risk at time of test, risk at birth or both, and the reasons for this preference. RESULTS: The majority (n = 82) of women preferred to have both the risk of Down syndrome at the time of screening and at the time of birth reported. The most common reason (n = 60) given for this preference was a desire to have as much information available as possible so that an informed decision regarding further investigations could be made. CONCLUSIONS: The majority of women prefer to receive Down syndrome screening results as both the risk at the time of the test and the risk at birth.

Abstract: BACKGROUND: Inhibin A, an established prenatal marker of Down syndrome (DS), exists in the maternal circulation in a number of isoforms. The present study explored whether specific inhibin A isoforms may be selectively increased in DS, offering the prospect of improved marker performance. METHODS: Second trimester maternal serum, placental extracts and amniotic fluid (AF) pools from both normal and DS pregnancies were fractionated by a combined immunoaffinity (IA) chromatography, preparative polyacrylamide gel electrophoresis (Prep-PAGE) and electroelution procedure. Inhibins A, B and pro-alphaC were determined in the eluted fractions by specific enzyme-linked immunosorbent assays (ELISAs) and the profiles of immunoactivity (IA) characterized in terms of molecular weight (MW) and percentage recovery. RESULTS: The MW patterns of inhibin A and pro-alphaC in maternal serum and AF were similar between DS and control pregnancies, both showing peaks between 25-40 k and approximately 65 k. AF contained, in addition, a higher proportion of <30 k inhibins A and B, and <25 k pro-alphaC forms. There were large differences in the inhibin forms present in DS placentae, with more 70 k and less 30-40 k inhibin A than in controls. CONCLUSIONS: The present data suggest that the processing, cleavage or secretion of inhibin MW forms by the DS placenta differs from normal. However, these differences are not reflected in maternal serum and so improvements in serum screening will not be afforded by measuring specific inhibin A isoforms.

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Abstract: The literature suggests that up to 19% of umbilical cord blood samples are invalid. Accordingly, it has been proposed that blood should be universally collected from both vessels. We prospectively collected paired arterial and venous blood to examine whether our centre, where staff were experienced in single vessel collection, was more accurate. Of 289 paired samples, 53 (18.3%) were considered invalid. Despite this significant error rate, we propose that routinely, only arterial sampling is needed and that an additional venous sample need only be taken to validate samples in cases of pH < 7.15, a difficult delivery or a non-vigorous baby.

Abstract: In pregnancy the feto-placental unit is the major source of activin A. However, the role(s) of activin A in late pregnancy remain uncertain and controversial. In particular, whether activin A levels alter in association with labour is unclear. In a cross-sectional cohort study, maternal serum samples were collected from women at term prior to elective Caesarean section (n=11), during labour prior to a spontaneous vaginal delivery (n=31), an instrumental vaginal delivery (n=16) or an emergent Caesarean section (n=7). Umbilical artery blood samples were collected from 75 pregnancies, after an elective Caesarean section (n=9), a normal vaginal delivery (n=37), an instrumental vaginal delivery (n=15) or an emergent Caesarean section (n=14). Levels of activin A were measured and compared according to modes of delivery. Maternal, but not foetal, serum activin A was increased significantly in women who were delivered by an intrapartum Caesarean section compared to other modes of delivery. Foetal, but not maternal, serum activin A was significantly correlated with umbilical artery pH. Maternal serum activin A is increased in women undergoing an intrapartum Caesarean section compared to either a vaginal delivery or an elective Caesarean section. The mechanism(s) underlying this observation are not clear.

Abstract: Unexplained fetal death in utero in late pregnancy represents an increasing proportion of perinatal deaths. It has been assumed that critical hypoxia is the likely mechanism underlying these losses, but the lack of a physiological marker has hampered both confirmation and prediction which could lead to timely intervention. In this paper, we report studies on hypoxia that we have performed in chronically cannulated late pregnant sheep, complemented by parallel investigations undertaken in human pregnancies. Our initial studies were directed towards determining activin secretion in the fetus and mother during late gestation, and immediately after fetal surgery using a sheep model. This led us to propose that there may be a relationship between hypoxia and activin A, follistatin and prostaglandin (PG) release from the feto-placental unit. Subsequent studies have been directed towards examining this potential relationship in sheep and in humans with compromised pregnancies. As a result of these studies, we have identified a potential mechanism by which activin A may be involved in regulating the response of the fetus to hypoxic insult. Activin A and follistatin concentrations increased in late gestation in ovine maternal plasma and in fetal fluids. Feto-placental hypoxemia or maternal isocapnic hypoxemia, leading to fetal hypoxia, were specific triggers for an acute increase in fetal activin A and follistatin concentrations during late gestation. The source and secretion of activin A, follistatin, and the associated release of PGE(2,) from within the feto-placental unit varied according to the site of the insult. The concomitant secretion of activin A and PGE(2) into the fetal circulation and amniotic fluid during reduced uterine blood flow provides an insight into the physiological regulatory mechanisms that might be involved. Changes observed in maternal activin A concentrations in mid and late gestation in the human may also be associated with fetal compromise. In human pregnancies, elevated activin A concentrations were observed in maternal plasma in mid and late gestation, in association with severe pre-eclampsia and with severe fetal growth restriction, compared to those observed in pregnancies with constitutionally small, healthy fetuses. Activin A was also elevated in maternal and arterial cord plasma in women at term during labour and immediately prior to undergoing emergency Caesarean section for failure to progress. These findings offer exciting new possibilities to gain insights into the mechanisms that underlie the maintenance of fetal wellbeing and provide a rationale for the potential that activin A may prove to be a useful clinical marker of fetal distress.

Abstract: Maternal serum pools obtained from healthy women throughout normal pregnancy were fractionated by a combined immunoaffinity chromatography, preparative PAGE, and electroelution procedure. Inhibin A and the pro-alpha C region of the inhibin alpha-subunit were determined in the eluted fractions by specific ELISAs, and the profiles of immunoactivity characterized in terms of molecular weight and percent recovery. The molecular weight patterns of inhibin A and pro-alpha C in serum during early pregnancy (<19 wk gestation) showed peaks between 25-40K and approximately 60K, consistent with the presence of known mature and larger precursor inhibin forms. However, during late pregnancy (>19 wk gestation), an increase in the proportion of smaller molecular weight forms (from 2% to approximately 25%) of inhibin A and pro-alpha C of unknown structure were observed in the less than 30K and less than 25K regions, respectively. To assess whether this change in molecular weight distribution in late pregnancy was related to the method of serum collection, serum and plasma from women during early and late pregnancy were collected and snap-frozen. Three pools [one from early pregnancy (12-15 wk), two from late pregnancy (28-39 wk)] of serum and plasma were then fractionated as described above. No differences in molecular weight patterns of inhibin A and pro-alpha C were observed between serum and plasma pools obtained in early pregnancy. However, in late pregnancy there was a reduction in the proportion of low molecular weight forms between serum (25% inhibin A, 35% pro-alpha C) and plasma (12% and 17%, respectively), but not to the low levels seen in early pregnancy. Incubation of iodinated 30K human inhibin A with serum or plasma obtained from early or late pregnancy showed no evidence of cleavage, suggesting that 30K inhibin A is not the cleavage precursor. It is speculated that the formation of small molecular weight forms of both inhibin A and pro-alpha C is attributed to proteolytic changes, in part induced in the circulation during late gestation and in part by the placenta before secretion. It is concluded that inhibin A and pro-alpha C are processed in late pregnancy by more than one mechanism to form low molecular weight circulating forms of unknown structure.

Abstract: The attitudes of Australian obstetricians to the resuscitation of extremely premature infants are reported. A structured questionnaire including questions regarding antenatal parent counselling, resuscitation practices, survival rates and personal attitudes about life support was distributed to obstetricians working in Australian hospitals with a Level 3 nursery Eighty-nine (48% response rate) replies were received from 12 units located in seven major cities. Obstetricians are more likely to discuss resuscitation with prospective parents with increasing gestation with a major shift occurring at 23-24 weeks' gestation. They strive for consensus with parents regarding resuscitation options and they act upon the opinion of both the prospective parents and their paediatric colleagues. Threat of litigation rarely influences the decision to limit resuscitation of an extremely preterm infant. Obstetricians may underestimate the prognosis for extremely preterm infants. The data presented offer useful insights into current attitudes and practice of tertiary hospital obstetricians.

Abstract: The evaluation of the role of critical hypoxia in unexplained fetal death in utero has been hampered by the lack of a physiological marker. Here we report the novel observation that feto-placental hypoxemia is an acute trigger for increased activin secretion from the feto-placental unit in late pregnancy. Hypoxemia was induced in chronically cannulated late pregnant fetal sheep by restricting blood flow through the maternal uterine arteries. Using maternal and fetal blood samples and amniotic fluid obtained via chronically implanted catheters, fetal blood gas parameters, plasma and amniotic fluid concentrations of activin A, prostaglandin (PG) E(2) and PGFM, the circulating metabolite of PGF(2alpha), were determined before, during and after a ten hour period of fetal hypoxemia. Hypoxemia acutely increased activin A and PGE(2) levels in both amniotic fluid and the fetal circulation with values rapidly returning to baseline with normoxemia. PGFM also increased in both compartments with a relatively delayed time frame compared to that of activin A and PGE(2). The increase in activin A and PGE(2) induced by hypoxemia may be a mechanism to regulate feto-placental blood flow during fetal compromise and also offers the possibility that activin A represents a useful marker of feto-placental hypoxemia.

Abstract: Maternal serum activin A levels are elevated in women with preeclampsia. To explore whether this could be due, at least in part, to increased production by the gestational tissues, we have measured activin A in the serum of women with (n=23) or without preeclampsia (n=62) at 29-40 weeks of gestation and in placenta and fetal membranes from preterm preeclamptic (PT-PE, n=8), term preeclamptic (T-PE, n=10) and healthy term controls (T-C, n=10). We have also explored if there are associated changes in activin receptor Alk2, ActRII and ActRIIB in these tissues. The relative amounts of receptor proteins were measured by densitometry on Western blots and receptors and activin beta(A) subunit localised by immunohistochemistry in PT-PE, T-PE and T-C gestational tissues (n=8-10/group). Maternal serum activin A levels were significantly elevated in women with preeclampsia (multiples of the normal median (MoM)=3.5, P<0.0001, Mann-Whitney U test) compared with healthy women (median MoM=1.0). Compared with control tissues, the activin A content was significantly higher in preeclamptic placentae (P=0.001 and P=0.0005 for PT-PE and T-PE respectively, Mann-Whitney U test), but significantly lower in the amnion (P=0.005 and P=0.014 for PT-PE and T-PE respectively) and choriodecidua (P=0.009 for T-PE). The maternal serum activin A level in women with preeclampsia was significantly correlated with elevated placental production (P=0.01, Pearson's correlation). Receptor Alk2 protein levels were significantly elevated in T-PE placentae (P=0.0006, Mann-Whitney U test), ActRIIB levels were significantly lower in PT-PE placentae (P=0.01) and ActRII levels were significantly lower in PT-PE choriodecidua (P=0.0002) compared with controls. There were no apparent differences in the distribution of the beta(A) subunit and receptors Alk2, ActRII and ActRIIB between control and preeclamptic tissues. These findings suggest that elevated levels of activin A in the maternal circulation in association with preeclampsia are due, at least in part, to increased placental production, and that the regulation of activin synthesis in placenta and fetal membranes is differentially regulated. Further, the differences in activin receptor protein levels between preeclamptic and control placenta and choriodecidua suggest that activin A-induced regulation may be altered in preeclampsia.

Abstract: OBJECTIVE: To explore whether abnormalities in growth hormone binding protein (GHBP) may underlie the growth restriction associated with fetal aneuploidy. DESIGN: A retrospective casecontrol study. SETTING: Monash Medical Centre. Clayton, Victoria, Australia. POPULATION: Twenty-one trisomy 18, and 30 trisomy 21 pregnancies, and 170 chromosomally normal pregnancies at 15-18 weeks of gestation representing three to five controls per case matched for source, gestation and duration of storage. METHODS: GHBP was measured using a ligand immunofunctional assay RESULTS: In the chromosomally normal pregnancies GHBP levels decreased slightly but significantly across the narrow gestational window studied. Compared with controls, levels of GHBP, expressed as median (95% CI) multiples of the median (MoM). in the trisomy 21 pregnancies were similar, 1.0 (0.92-1.39) MoM and 1.27 (1.04-1.50) MoM, respectively; P = 0.061 (Mann-Whitney U test) but were significantly reduced in the trisomy 18 pregnancies, 0.68 (0.5 1-0.84) MoM: P = 0.0014 (Mann-Whitney U test). CONCLUSIONS: These data suggest that decreased levels of maternal growth hormone binding protein, and by implication growth hormone receptor complement, may underlie the early severe growth restriction that is characteristic of trisomy 18.

Abstract: OBJECTIVE: To pilot a protocol for a national multicentre randomised trial in which a low molecular weight heparin will be compared with placebo for prevention of venous thrombotic events occurring within six weeks after caesarean section. DESIGN: Double-blind randomised controlled trial. SETTING: Tertiary care centre. PARTICIPANTS: Seventy-six women having had a caesarean section, 37 in the control group and 39 in the Dalteparin group. METHODS: Consenting patients having had an emergency or elective caesarean section were commenced on study medication 6-24 hours post-operatively. The study medication, dalteparin 2,500 iu or saline, was given subcutaneously once daily for four or five days post-operatively depending on the patient's length of stay. Patients were reviewed in hospital for operative outcomes and contacted at two and six weeks post-operatively. RESULTS: Of the 141 women given information about the trial, 76 (54%) consented to participate. Follow up to six weeks was achieved in all women who were recruited. More women in the placebo arm had general anaesthesia, but otherwise the two groups had similar characteristics at randomisation. There was only one occurrence of a deep vein thrombosis during the study. This patient was in the treatment arm and the thrombosis occurred between two and six weeks post-operatively. All other outcomes were similar in the two groups. CONCLUSION: Our experience of a 26% recruitment rate, the thrombosis rate of 1.3% (95% CI 0.03-7.1%) and the contactability of all participants two and six weeks post-operatively, indicates that this study is feasible.

Abstract: At their first hospital antenatal visit, 209 women were interviewed to explore their level of knowledge of Down syndrome and the available prenatal tests. Overall, the women had limited knowledge. Non-Caucasian women had less knowledge of Down syndrome, available prenatal tests and the association of Down syndrome with advanced maternal age than Caucasian women. Women with a history of a previous pregnancy and women over 35 years of age were not more aware of Down syndrome or the available tests than other women. These findings have significant implications for antenatal education and the implementation of screening programs for Down syndrome.

Abstract: OBJECTIVE: To measure activin A content and to localise and semi-quantitate activin receptors in human myometrium at term and during labour. DESIGN: Myometrium was collected from non-pregnant women (n = 6), pregnant women at term not in labour (n = 6) and at term in labour (n = 6). SETTING: Monash Medical Centre, Melbourne, Australia. MAIN OUTCOME MEASURES: Tissue lysates of myometrium were analysed for activin A content using an enzyme-linked immunosorbent assay and activin receptor proteins IA, IIA and IIB using Western hybridisation. Activin betaA-subunit and activin receptors were localised in myometrium by immunohistochemistry. RESULTS: Activin A was detected by ELISA in non-pregnant, pregnant and labouring myometrium. Levels were significantly higher in labouring myometrium. The three activin receptors IA, IIA and IIB were detected in all myometrial samples by Western hybridisation. Receptor IA was expressed in significantly higher levels in pregnant myometrium. Receptor IIA was very weakly expressed throughout. The expression of receptor IIB was similar in all three groups. Activin betaA-subunit and all three receptors were localised to the endothelial cells of myometrial blood vessels. Neither activin betaA-subunit nor any of the three activin receptors were immunolocalised to myometrial smooth muscle cells in the three groups. This result was confirmed by Western blotting for expression of activin receptors in isolated myometrial smooth muscle and microvascular endothelial cells. CONCLUSION: The myometrium is not a target for activin A during late pregnancy or labour. However, activin A may have a role in the regulation of microvascular endothelial cell function in the myometrium.

Abstract: Inhibin A is a useful prenatal marker of Down syndrome. Currently, the available enzyme-linked immunosorbent assays (ELISAs) for inhibin A are based upon the same paired monoclonal antibodies. In the present study we have confirmed for one of those ELISAs that short-term sample storage as whole blood leads to a significant decline in detectable inhibin A and that this is most likely due to erythrocyte catalase interference with a critical oxidation step in the assay. While this interference can be eliminated by heating the samples pre-assay, this process is labour intensive. In the present study we have demonstrated that the addition of 3-amino-1,2,4-triazole (AT), a catalase 'suicide' inhibitor, also prevents the decline of inhibin A levels in samples stored as whole blood. We suggest that the addition of AT to samples prior to assay is a simple modification to the inhibin A ELISA that affords optimum performance.

Abstract: It has been previously shown that the uptake of prenatal diagnosis by Victorian women of a non-English speaking background is significantly lower than that of comparable English speaking women. To explore this further we have examined the uptake of Down syndrome screening and diagnosis by Vietnamese women attending a community-based antenatal clinic in metropolitan Melbourne over a two year period. Of the 207 women studied, 161 (78%) were offered screening or diagnosis and of these women 139 (86%, 95%CI 81-92%) accepted the offer, representing 67% (95%CI 61-74%) of the entire population. Of the 127 women who had screening, rather than diagnosis, 12 (9%) had an 'increased risk' result. Eleven of these women accepted diagnosis. We also explored the reasons why 45 (22%) of women were not offered screening. Almost half (44%) of these women first attended the clinic at a too advanced stage of gestation but in 25 women there were no obvious reasons. These results are discussed in the context of current prenatal screening and diagnostic practice in Victoria and simple recommendations made.

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Abstract: OBJECTIVES: To survey clinical protocols for prevention of early-onset group B streptococcal disease (EOGBSD) of the newborn in public maternity hospitals. DESIGN: Postal questionnaire with telephone follow-up when required. SETTING: All hospitals that undertook deliveries in public patients in the State of Victoria, November 1997 to January 1998. RESULTS: The survey was sent to 84 hospitals: 71 responded and 64 met the criteria and provided usable data (76% response rate). These 64 represented 42,784 births (68% of births in Victoria in 1996). Most hospitals (62; 97%) undertook actions that would identify and treat pregnant women at risk of EOGBSD. 48 (75%) performed bacteriological screening for maternal GBS carriage, but only 20 of these had a unified protocol. Screening was mostly by low vaginal swab (15 hospitals) and before 30 weeks' gestation (12 hospitals). Low vaginal swab plus anal swab was used in only one hospital. Bacteriological screening was significantly more common in metropolitan hospitals than in rural hospitals (100% versus 67%; P = 0.007, Fisher's exact test). Targeting of prophylaxis by recognised risk factors was reported by 59 (92%) hospitals, 45 of which also undertook screening. There was considerable variation in the specific risk factors used. CONCLUSIONS: While there was clearly widespread awareness of EOGBSD in Victorian public hospitals, prevention programs varied considerably. The development of consensus practice guidelines might improve EOGBSD prevention, reducing morbidity, mortality and costs.

Abstract: Activin A levels are elevated in maternal serum of pregnant women with hypertensive disturbances. Because follistatin is a circulating binding protein for activin A, the present study was designed to evaluate whether serum follistatin and activin A levels also change in patients with hypertensive disorders in the last gestational trimester. The study design was a controlled survey performed in the setting of an academic prenatal care unit. Healthy pregnant women (controls, n=38) were compared with patients suffering from pregnancy-induced hypertension (PIH, n=18) or pre-eclampsia (n=16). In addition, the study included a subset of patients with pre-eclampsia associated with intrauterine growth restriction (IUGR, n=5). Maternal blood samples were withdrawn at the time of diagnosis (patients) or in a random prenatal visit (controls), and serum was assayed for follistatin and activin A levels using specific enzyme immunoassays. Hormone concentrations were corrected for gestational age by conversion to multiples of median (MoM) of the healthy controls of the same gestational age. Follistatin levels were not different between controls and patients, while activin A levels were significantly increased in patients with PIH (1.8 MoM), pre-eclampsia (4.6 MoM), and pre-eclampsia+IUGR (3.2 MoM, P<0.01, ANOVA). The ratio between activin A and follistatin was significantly increased in patients with PIH (1.5 MoM) and was further increased in patients with pre-eclampsia (4.5 MoM) and in the group with pre-eclampsia+IUGR (2.6 MoM). Follistatin levels were positively correlated with gestational age in control subjects (r=0. 36, P<0.05) and in patients with PIH (r=0.46, P<0.05) or pre-eclampsia (r=0.61, P<0.01), while activin A correlated with gestational age only in the healthy control group (r=0.69, P<0.0001). The finding of apparently normal follistatin and high activin A levels in patients with PIH and pre-eclampsia suggests that unbound, biologically active, activin A is increased in women with these gestational diseases.

Abstract: OBJECTIVE: To examine changes in maternal serum levels of activin A and follistatin during pregnancy and labour. DESIGN: In three cross sectional and three longitudinal studies venous blood was collected from women during pregnancy, spontaneous labour, labour induction and prior to elective caesarean section for the measurement of activin A and follistatin. SETTING: Monash Medical Centre, Clayton, Victoria, Australia. POPULATION: One hundred and twenty-three women participated in a cross sectional study in pregnancy, 18 women in two longitudinal pregnancy studies, 36 women in a cross sectional labour study, nine women in a longitudinal study of labour induction. Ten women undergoing elective caesarean section were also studied. METHODS: Activin A and follistatin were measured using two sensitive and specific enzyme-linked immunosorbent assays. RESULTS: In the cross sectional study of pregnancy, mean (SEM) maternal serum activin A and follistatin levels increased towards term (2.4 ng/mL (0.3) and 1.8 ng/mL (0.3) in first trimester to 18.9 ng/mL (3.8) and 5.3 ng/mL (0.9) at term, respectively), but the longitudinal study revealed that levels plateau in the last three weeks of pregnancy (16.0 ng/mL (2.6) and 6.2 ng/mL (1.4) at 37 weeks and 16.6 ng/mL (3.5) and 6.2 ng/mL (0.5) before labour for activin A and follistatin, respectively). There was no difference in levels of activin A and follistatin between women delivered by caesarean section and labouring women at term (14.9 ng/mL (2.8) vs 11.0 ng/mL (0.93) and 5.95 ng/mL (0.67) vs 5.71 ng/mL (0.63), respectively) and levels of both proteins did not alter throughout spontaneous or induced labour. CONCLUSIONS: We believe that these data argue against activin A playing an acute role in the initiation or regulation of human parturition.

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Abstract: Severe placental dysfunction is much more common in pregnancies with a male than with a female fetus. Furthermore, the birthweight/placental weight ratio is increased in these pregnancies, consistent with fetal growth restriction, and is higher with a male fetus than with a female fetus. These observations of placental insufficiency may underlie the increased in-utero loss rate of male fetuses.

Abstract: A sample of 6,038 obstetric ultrasound referrals and reports between January 1993 and June 1999 in a single Melbourne private ultrasound practice was reviewed to determine whether the referral and reporting pattern for nuchal translucency (NT) measurement has changed. The proportion of both 10-14 week ultrasound scans and mid trimester fetal anatomy scan referrals increased significantly over the study period (p < 0.001 and p < 0.001, respectively). There was also a significant increase in NT reporting and the number of specific referrals for an NT measurement over the study period (p = 0.01 and p < 0.001, respectively). If current trends continue it is likely that the 10-14 week scan for NT measurement will become a routine component of antenatal care. Therefore, as a matter of urgency, it is imperative that the best and most cost-effective screening strategy for Down syndrome in an Australian population is defined.

Abstract: Macrophage inhibitory cytokine-1 (MIC-1) is a recently described divergent member of the transforming growth factor-ss superfamily. MIC-1 transcription up-regulation is associated with macrophage activation, and this observation led to its cloning. Northern blots indicate that MIC-1 is also present in human placenta. A sensitive sandwich enzyme-linked immunosorbent assay for the quantification of MIC-1 was developed and used to examine the role of this cytokine in pregnancy. High levels of MIC-1 are present in the sera of pregnant women. The level rises substantially with progress of gestation. MIC-1 can also be detected, in large amounts, in amniotic fluid and placental extracts. In addition, the BeWo placental trophoblastic cell line was found to constitutively express the MIC-1 transcript and secrete large amounts of MIC-1. These findings suggest that the placental trophoblast is a major source of the MIC-1 present in maternal serum and amniotic fluid. We suggest that MIC-1 may promote fetal survival by suppressing the production of maternally derived proinflammatory cytokines within the uterus.

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Abstract: Maternal serum inhibin A and free beta human chorionic gonadotrophin (beta-hCG) were measured in 759 chromosomally normal, pregnant women at 10-14 weeks of gestation. There were nine who subsequently developed pre-eclampsia and in these women the maternal serum inhibin A concentration was significantly higher than in the normotensive controls.

Abstract: One hundred women were interviewed at their first hospital antenatal visit to assess their knowledge of, and attitudes to, first versus second trimester screening for Down's syndrome. Overall, the women had limited knowledge of Down's syndrome, and the prenatal screening and diagnostic tests that are available. However, when informed, the majority of women expressed a clear preference for first trimester screening tests for Down's syndrome, regardless of the rate of miscarriage of Down's syndrome pregnancies between 10 and 15 weeks of gestation. These findings have implications for the planning of prenatal Down's syndrome screening programmes.

Abstract: We report a rare case of large bilateral phaeochromocytomas in pregnancy, found coincidentally by ultrasonography at 26 weeks' gestation, in a woman with a family history of Von Hippel Lindau syndrome. Further, we report maternal and fetal serum and amniotic fluid phenoxybenzamine levels from this case.

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Abstract: BACKGROUND: High placental vascular resistance is an important cause of fetal growth restriction and subsequent perinatal mortality. Identification of affected pregnancies allows appropriate fetal surveillance and delivery, but there are no known therapeutic strategies to decrease resistance and improve blood flow. However, placental corticotropin-releasing hormone (CRH) is thought to be a potent fetoplacental vasodilator, and exogenous corticosteroids can increase placental CRH secretion. Therefore, we examined whether corticosteroids could improve fetoplacental blood flow in pregnancies with increased vascular resistance. METHODS: A retrospective review of umbilical-artery flow-velocity waveforms (FVWs) before and after betamethasone administration was undertaken in pregnancies with increased placental vascular resistance, as shown by umbilical-artery absent end-diastolic flow (AEDF). FVWs were obtained by pulsed-wave doppler ultrasonography. We studied all 28 pregnancies monitored at the maternal-fetal medicine unit of a university teaching hospital since 1995. FINDINGS: The median duration of gestation at presentation with AEDF was 27 weeks (range 23-33). In 19 (68% [95% CI 49-86]) pregnancies, umbilical-artery diastolic flow returned within 24 h after betamethasone administration, consistent with decreased resistance. The median duration of this effect was 3 days (range 2-7). There were no differences in duration of gestation at diagnosis or delivery, or in birthweight between fetuses showing a return of flow after betamethasone and those not showing a return of flow. INTERPRETATION: In pregnancies with umbilical-artery AEDF, betamethasone treatment is associated with decreased placental vascular resistance, possibly induced via increased placental CRH secretion. This study does not provide insights into whether this effect would be beneficial or harmful to the fetus.

Abstract: OBJECTIVE: In the second trimester of pregnancy, inhibin A is significantly increased in maternal serum and decreased in amniotic fluid in Down's syndrome pregnancies compared to normal. We wished to further evaluate the levels of inhibin A, inhibin B, pro-alpha C inhibin, activin A and the binding protein follistatin in amniotic fluid in Down's syndrome and control pregnancies. DESIGN: Case-matched control study. PATIENTS: 29 Down's syndrome and 290 chromosomally normal control pregnancies were identified from records and amniotic fluid, collected at second trimester amniocentesis, retrieved from routine storage for analysis. MEASUREMENTS: Inhibin A, inhibin B, pro-alpha C inhibin, total activin A and follistatin were measured using sensitive and specific enzyme linked immunosorbent assays. RESULTS: The median (10th-90th percentiles) amniotic fluid inhibin A level in the control pregnancies increased from 334 (122-553) ng/l at 14 weeks' to 695 (316-1475) ng/l at 19 weeks' gestation. The corresponding figures for inhibin B and the alpha-subunit precursor inhibin pro-alpha C were 632 (185-1354) and 2062 (1237-3381) ng/l, respectively at 14 weeks' and 2439 (748-5307) and 3115 (2021-6567) ng/l, respectively at 19 weeks' gestation. Total activin A increased from 3795 (1554-5296) at 14 weeks' to 5086 (3059-8224) at 18 weeks' gestation. Expressed as multiples of the median (MoM) the median (95% CI) amniotic fluid levels of inhibin A, inhibin B, pro-alpha C inhibin and acitivin A in the Down's syndrome samples were 0.77 (0.59-0.85), 0.94 (0.63-1.23), 0.77 (0.49-0.84) and 0.77 (0.53-0.87), respectively. Compared to controls the levels of inhibin A, pro-alpha C inhibin and activin A were significantly lower in Down's syndrome pregnancies (P < 0.01, Mann-Whitney U test). Follistatin levels in the controls declined slightly from 2106 (1421-3538) ng/l at 14 weeks' to 1600 (1281-2543) ng/l at 18 weeks' gestation. Levels in the Downs' syndrome pregnancies were similar to controls. CONCLUSIONS: The data suggest that the production, secretion or metabolism of the inhibin alpha- and beta A-subunits is altered in Down's syndrome pregnancies in the second trimester.

Abstract: Follistatin is a specific binding protein which controls bioavailability of activins and inhibins which have an important role in fetal development. In the first trimester of pregnancy bioactive dimeric inhibins are found at high concentrations in the extra-embryonic coelomic fluid, but the distribution of follistatin and activins is not known. We have used recently developed immunoassays for follistatin, activin A and activin AB to determine their presence in the intrauterine compartments during early pregnancy. Follistatin was present in highest concentrations in the extra-embryonic coelomic fluid (11.72 +/- 1.70 ng/ml; median +/- SEM), with less in maternal serum (6.35 +/- 4.58) and lowest amounts in amniotic fluid (0.97 +/- 0.52). Follistatin concentrations in extra-embryonic coelomic fluid were highly correlated with both dimeric inhibin isoforms. Activin A was present in only barely detectable amounts in some samples of extra-embryonic coelomic fluid (41% of samples) and maternal serum (26%) and was undetectable in all amniotic fluid samples. Activin AB was undetectable in all compartments. The presence of follistatin in the amniotic and extra-embryonic coelomic fluids may regulate the availability of bioactive activins and inhibins which are released into the intrauterine compartments during the development of the fetus and placenta in early pregnancy.

Abstract: Eating disorders and the associated behavioural problems and drug abuse are uncommon in pregnancy. When they do occur they are often unrecognized because of denial but when significant may pose a risk to both the mother and her fetus. This case illustrates a number of problems that may be encountered in women with eating disorders in pregnancy, including prolonged and recurrent metabolic disturbances and diuretic abuse. In particular it illustrates the derangements of thyroid function seen in pregnant women with eating disorders and reminds us that when a cause for thyrotoxicosis remains obscure, thyroxine abuse should be considered and explored.

Abstract: In second-trimester Down syndrome pregnancies, levels of inhibin-A (the alpha-betaA dimer) in maternal serum and amniotic fluid (AF) are significantly higher and lower than in normal pregnancy, respectively. Since AF also contains inhibin-B (the alpha-betaB dimer) and precursor inhibins, we have examined whether the secretion of these inhibin isoforms may also be altered in association with Down syndrome. AF from 45 Down syndrome and 150 chromosomally normal pregnancies between 16 and 19 weeks' gestation were analysed, blinded to whether the sample was from a Down syndrome or a normal pregnancy. The median (10th-90th percentiles) inhibin-B level in the control pregnancies increased from 310.0 (80.8-1112.5) pg/ml at 16 weeks to 459.5 (193.7-1386.8) pg/ml at 19 weeks' gestation. The corresponding figures for precursor inhibins (pro-alphaC inhibins) were 541.8 (206.9-1322.8) pg/ml at 16 weeks and 1391.8 (433.3-2652.6) pg/ml at 19 weeks. Expressed as multiples of the median (MOM), the levels of inhibin-B and pro-alphaC inhibins in the Down syndrome samples were 0.85 and 0.79, respectively. Neither was significantly different from the controls. These data suggest that, of the three inhibin subunits, abnormal production or secretion of the inhibin betaA-subunit may underlie the decreased inhibin-A levels previously observed in Down syndrome. Confirmation of this by quantitative assessment of the inhibin subunit messenger ribonucleic acids would now be useful.

Abstract: Using two enzyme-linked immunosorbent assays specific for inhibin A and pro-alpha C inhibin, levels of the two proteins were assessed in maternal serum from 43 Down syndrome and 300 chromosomally normal pregnancies at 15-17 weeks' gestation. Compared to the control pregnancies, both inhibin A and pro-alpha C inhibin were significantly elevated in the Down syndrome pregnancies with median levels, expressed as multiples of the normal median, of 1.53 MoM and 1.34 MoM, respectively (P < 0.001 and P = 0.046 compared to controls). Levels of inhibin A and pro-alpha C inhibin were weakly but significantly correlated in both the control and the Down syndrome sera (r = 0.25, P < 0.0001; r = 0.4, P = 0.008, respectively). These data suggest that the mechanism(s) underlying the elevated inhibin levels observed in Down syndrome may affect the regulation of both the inhibin alpha- and beta A-subunits.

Abstract: Tubal pregnancy is now commonly managed by laparoscopic salpingostomy or systemic methotrexate. A disadvantage of such conservative management is the need for appropriate follow-up, with serial measurement of serum concentrations of human chorionic gonadotrophin (HCG), to exclude persistent ectopic pregnancy (PEP). Concentrations of inhibin A, also a placental product, are significantly increased during pregnancy and the half-life of inhibin A is significantly shorter than that of HCG. To assess the suitability of inhibin A as a marker of PEP, we studied 16 women who had undergone surgery for a tubal pregnancy, measuring HCG and inhibin during follow-up. The mean +/- SEM time taken to achieve non-pregnant concentrations of inhibin A was significantly shorter than for HCG (4.2 +/- 0.8 days versus 21.6 +/- 4.4 days respectively; P < 0.001 Wilcoxon signed rank test). However, in all women the inhibin A concentration increased rapidly after reaching a nadir, reflecting the return of ovarian function, complicating the interpretation of results. In four women inhibin A was almost undetectable preoperatively, while the corresponding HCG concentration was high. These data suggest that inhibin A will not be a useful marker for PEP but that it may provide a more accurate preoperative assessment of trophoblast viability than HCG, thereby improving management.

Abstract: The development of a sensitive and specific enzyme-linked immunoassay (ELISA) for inhibin A stimulated the observation that inhibin A was a useful prenatal marker of Down's syndrome. Modifications of that ELISA, in terms of preassay sample treatment, detection methods and standard preparation, were subsequently introduced to improve assay performance and reduce costs. These modified formats have been validated and reported. We describe the modifications in detail, explaining the rationale for each, and report the results of a study directly comparing the various ELISA formats in terms of assay performance when applied to clinical samples and ability to differentiate between normal and Down's syndrome pregnancies. A format involving sample pretreatment with sodium dodecylsulphate at 100 degrees C was found to give better assay performance and a modest improvement in discrimination between Down's syndrome samples and controls, and we recommend this format for use by other investigators.

Abstract: The development of a sensitive and specific enzyme-linked immunoassay (ELISA) for inhibin A stimulated the observation that inhibin A was a useful prenatal marker of Down's syndrome. Modifications of that ELISA, in terms of preassay sample treatment, detection methods and standard preparation, were subsequently introduced to improve assay performance and reduce costs. These modified formats have been validated and reported. We describe the modifications in detail, explaining the rationale for each, and report the results of a study directly comparing the various ELISA formats in terms of assay performance when applied to clinical samples and ability to differentiate between normal and Down's syndrome pregnancies. A format involving sample pretreatment with sodium dodecylsulphate at 100 degrees C was found to give better assay performance and a modest improvement in discrimination between Down's syndrome samples and controls, and we recommend this format for use by other investigators.

Abstract: It is often accepted that fibroids cause a variety of female reproductive problems, such as menorrhagia, pain, infertility, pregnancy loss and pregnancy complications. Understandably, therefore, many 'successful' medical or surgical interventions have been proposed. However, while fibroids are certainly commonly associated with these conditions, it remains unclear whether this is coincidental, because of the high prevalence of fibroids, or causal. In particular, this chapter explores the roles of fibroids in menorrhagia, discussing possible pathophysiological mechanisms and the utility of medical and surgical management. Similarly, the relationship between fibroids and infertility is examined, concluding that fibroids are not causative in the vast majority of cases and thereby questioning the effectiveness of myomectomy as a treatment for infertility. The use of hormone replacement therapy in post-menopausal women with existing fibroids is also discussed, concluding that this is generally safe and appropriate. In pregnancy, it is a commonly held tenet that uterine fibroids enlarge and that they are associated with various adverse outcomes such as miscarriage, placental abruption, fetal growth retardation and Caesarean section. This chapter evaluates the available evidence for this and concludes that, as with infertility, the role of fibroids has been exaggerated. Nonetheless, pregnancy management options are discussed.

Abstract: To assess the maternal haematological effects of betamethasone administered in late pregnancy, an automated full blood count was performed before and daily for 5 days after betamethasone in 25 women with a singleton pregnancy between 23 and 33 weeks' gestation. From a mean (+/- SD) baseline level of 11.0+/-2.2 x 10(9)/L, the total white cell count increased significantly to 13.2+/-2.9 x 10(9)/L and 13.5+/-3.1 x 10(9)/L on the first and second day after treatment respectively, returning to baseline on day 3 (p<0.0001, ANOVA). These changes represented a mean increase in the neutrophil count of 35% and a mean decrease in the lymphocyte count of 23%. While there was considerable intersubject variation in the extent of the changes, this study has quantified the leucocytosis induced by betamethasone in late pregnancy, information that may assist with the clinical evaluation of a woman at risk of preterm delivery.

Abstract: OBJECTIVE: To determine the relation between maternal serum inhibin-A and free beta-hCG concentrations in chromosomally normal pregnancies and to compare the two biochemical markers for their sensitivity in identifying trisomy 21 pregnancies. SAMPLE: Inhibin-A and free beta-hCG were measured in maternal serum samples from 800 chromosomally normal singleton pregnancies at 10 to 14 weeks of gestation and 76 singleton pregnancies with fetal trisomy 21. RESULTS: In the normal group maternal serum inhibin-A was significantly associated with both maternal weight and gestational age (F = 11.2, P < 0.0001). In pregnancies with trisomy 21 the maternal serum inhibin-A and free beta-hCG concentrations were significantly increased (mean difference inhibin = 0.51 SD, F = 18, P < 0.0001 and mean difference free beta-hCG = 1.13 SD, F = 80, P < 0.0001). For a 5% false positive rate, the sensitivity of maternal serum free beta-hCG in identifying pregnancies with trisomy 21 was 28.9% compared with 12.8% for maternal serum inhibin-A. Delta inhibin-A was significantly associated with delta-free beta-hCG (r = 0.345, P < 0.01) and the deviation from the normal mean for free beta-hCG was significantly greater than the deviation for inhibin-A (t = 4.0, P < 0.0001). For a 5% false positive rate, the sensitivity achieved by combining information from delta inhibin-A and delta free beta-hCG was similar to the sensitivity of free beta-hCG alone (30.3% compared with 28.9%). CONCLUSION: At 10 to 14 weeks of gestation fetal trisomy 21 is associated with increased maternal serum inhibin-A and free beta-hCG levels. However, the degree of elevation of inhibin-A is less than that of free beta-hCG, and there is a significant association between levels of the two proteins. The sensitivity for trisomy 21 achieved with the combination of maternal serum inhibin-A and free beta-hCG is not significantly different from that achieved with maternal serum free beta-hCG alone.

Abstract: Using new specific and sensitive enzyme-linked immunosorbent assays for inhibin A and inhibin B, we measured these proteins in amniotic fluid (AF), maternal serum (MS), and umbilical cord serum in normal pregnancies. Inhibin A levels in AF rose from a median (10-90th percentile) level of 615 (158.2-1124.6) pg/mL at 14 weeks to 1336.0 (489.4-2084.1) pg/mL at 20 weeks, and inhibin B rose from 216.6 (67.4-554.6) to 1078.2 (439.3-2482.2) pg/mL over the same period. In MS, inhibin A levels fell from a median (10-90th percentile) level of 177.5 (101.4-290.7) pg/mL at 10 weeks to a nadir of 111.9 (59.5-200.3) pg/mL at 17 weeks, rising again to 180.3 (74.1-327.2) pg/mL at 20 weeks. No inhibin B was detectable in MS. In 47 pairs of matched samples (14-16 weeks gestation) there was no correlation of inhibin A levels in AF with those in MS (r = 0.19; P > 0.05). In 45 term umbilical cord serum samples, no dimeric inhibin was detectable in serum from female babies, but inhibin B was detectable in male sera; the median (10-90th percentile) concentration was 167.4 (111.2-224.8) pg/mL. These data suggest that for the gestation periods studied, although the placenta secretes inhibin A, another source, probably the fetal membranes, secretes both inhibin A and inhibin B. Further, the presence of inhibin B in male fetuses is consistent with a testicular origin, suggesting that inhibin B may be important in the development of the fetal hypothalamo-pituitary-testicular axis.

Abstract: Inhibin has been postulated to be secreted by Sertoli cells in response to follicle stimulating hormone (FSH) and in turn to exert an inhibitory effect on FSH production. We have investigated this relationship using an assay specific for dimeric inhibin B. A total of 56 normal men received 200 mg testosterone enanthate (TE) i.m. weekly, for 65 +/- 1 weeks in a trial of hormonal male contraception. Before treatment a significant negative correlation between inhibin B and FSH concentration (r = 0.49, P < 0.001) was observed. During TE treatment, luteinizing hormone (LH) and FSH were rapidly suppressed. This was followed by a parallel decline in inhibin B and sperm concentration. During the early recovery phase, inhibin B concentrations remained suppressed in men who showed a delay in resumption of spermatogenesis, despite higher FSH concentrations. Inhibin B returned to pretreatment concentrations after 24 weeks recovery, when the inverse relationship with FSH was restored. Our results showed the expected inverse physiological relationship between inhibin B and FSH in normal men, with a decline during TE treatment and alpha subsequent resumption of the inverse relationship during recovery. These data clearly support the hypothesis that inhibin B plays a physiological role in the feedback control of FSH secretion, and reflects FSH-stimulated Sertoli cell function.

Abstract: Recently, inhibin-A has been shown to be a useful new prenatal marker of Down's syndrome, significantly increasing detection rates. While the placenta is believed to be the major source of inhibin in pregnancy, there are actually very limited data available on specific inhibin dimers in pregnancy. Using a sensitive and specific ELISA we have measured the inhibin-A content of amniotic fluid (AF) to investigate further the biology of inhibin-A in chromosomally normal and abnormal pregnancies. AF from 51 Down's syndrome and 161 chromosomally normal pregnancies between 16 and 19 weeks of gestation were analysed, blinded as to whether the sample was from a Down's syndrome or normal pregnancy. There were no sex differences in inhibin-A content in either the control or Down's syndrome pregnancies. The median (10-90th percentiles) inhibin-A level in the control pregnancies increased from 339.6 (175.2-649.1) pg/ml at 16 weeks to 592.9 (256.4-1027.3) pg/ml at 19 weeks of gestation. The median (95% confidence interval) inhibin-A in the Down's syndrome pregnancies, expressed as multiples of the median (MoM) to correct for gestation, was 0.77 (0.68-0.89) MoM, significantly lower than the controls (P < 0.001, Mann-Whitney U test). We believe that these data are compatible with more than one source of inhibin-A in pregnancy and suggest that the fetal membranes may be contributing significantly to AF inhibin-A content. Further, our data would suggest that the endocrine function of the placenta and the other inhibin source(s) are differentially regulated.

Abstract: We have examined whether insulin dependent diabetes mellitus (IDDM) affects maternal serum levels of inhibin-A, a recently described prenatal marker of Down's syndrome, by comparing levels in 169 women with IDDM with levels in 432 nondiabetic pregnant women between 15 and 20 weeks of gestation. There was a small but significant increase in the inhibin-A level in the diabetic women only when levels were corrected for maternal weight: median MoM 1.17 (P < 0.01 vs controls, Student's t test). The underlying mechanism for this elevation in pregnancies complicated by IDDM currently remains obscure.

Abstract: To investigate the role of inhibin in the control of follicle-stimulating hormone (FSH) secretion, we have measured levels of immunoreactive inhibin (ir-inhibin), inhibin B, Pro-alpha C containing inhibins, FSH, luteinizing hormone (LH), and testosterone in twelve men with hematological malignancies before, during, and after chemotherapy. Inhibin B levels fell significantly by 1 month from a mean +/- SE baseline level of 273.2 +/- 32.8 pg/mL, reaching a nadir of 52.6 +/- 15.3 pg/mL at 4 months (P < 0.0001). FSH levels increased within the first month from a baseline level of 3.9 +/- 0.6 IU/L, reaching a peak level of 22.4 +/- 3.3 IU/L at 4 months (P < 0.0001). FSH and inhibin B were significantly and inversely correlated (r = 0.69, P < 0.0001). Pro-alpha C containing inhibin levels increased significantly (P < 0.05) at 3 months and were significantly and positively correlated with FSH (r = 0.38, P = 0.002). LH levels increased significantly but to a much lesser extent than FSH, the increase becoming evident only 4 months after treatment commenced (P < 0.03). Levels of ir-inhibin and testosterone remained unchanged throughout the study. These data provide strong support to the hypothesis that inhibin B is the physiologically important form of inhibin in men, negatively regulating FSH secretion at the pituitary. Furthermore, they suggest that FSH stimulates inhibin alpha-subunit secretion by the testis.

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Abstract: OBJECTIVE: Despite widespread recognition that prenatal administration of corticosteroids dramatically reduces perinatal mortality and morbidity, clinical practice in this area remains less than ideal. We therefore reviewed our practice to identify reasons for this and to determine attainable standards of care. DESIGN: Retrospective case record review. SETTING: Level three maternity unit in Edinburgh, UK. POPULATION: All women admitted at gestations of 24 to 34 weeks and 6 days inclusive, and all women receiving corticosteroids in one institution, over a 10-month period. MAIN OUTCOME MEASURES: The number and clinical features of women delivering before and after 35 weeks of pregnancy who had received corticosteroids. RESULTS: Seven hundred and two women were admitted during the study period; case records were available for 688 of these. One hundred and ninety-two women (28%) delivered before 35 weeks of gestation, of whom 123 (64%) had received dexamethasone. Of 69 women who received no steroids 30 (43%) were in hospital for more than 24 hours before delivery. Overall, 29% of women receiving dexamethasone delivered after 35 weeks of gestation and 42 (24%) women treated with dexamethasone received more than one course. While the grade of admitting doctor did not affect prescribing, there were other significant differences that may help guide future practice. CONCLUSIONS: This study provides some guidance for optimising corticosteroid prescribing and for the development of clinical practice guidelines. Approximately 80% of women should be able to receive at least some corticosteroids prior to delivery before 35 completed weeks of pregnancy.

Abstract: The effect of intramuscular dexamethasone administration in late pregnancy on the maternal peripheral white cell count was examined in 20 women. The mean total white cell count increased from a baseline of 11.3 x 10(9)/L (SD 2.3) to 16.2 x 10(9)/L (SD 4.6) on day 1, normalising thereafter. This 43% increase represented composite changes in the neutrophil and lymphocyte counts which, on average, increased by 62% and decreased by 22%, respectively. It is concluded that prenatal dexamethasone induces a significant neutrophilia on the first day following administration. This information may be helpful when monitoring for infection.

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Abstract: BACKGROUND: To compare the pharmacokinetics of orally administered dexamethasone with intramuscular administration in antenatal patients at risk of preterm delivery. METHOD: Ten antenatal patients at risk for preterm delivery were given two intramuscular and then one oral dose of dexamethasone. Plasma which was collected at set intervals following the first intramuscular dose and the oral dose was assayed for dexamenthasone. The results were analyzed using pharmacokinetic data-fitting software and pharMacokinetic parameters calculated. RESULTS: After oral adminIstration of dexamethasone the mean maximum plasma concentration obtained was 65% that of the intramuscular dose and the bioavailability of the oral route was calculated as 72% of the intramuscular route. The terminal half-lives of dexamethasone were similar for both routes. CONCLUSIONS: These limited data would suggest that if dexamethasone is to be administered orally, which would be both preferable to patients and more economic, then a proportionately increased dose of oral dexamethasone would be required to provide similar maternal plasma pharmacokinetics to the intramuscular dose in current use. Further, larger studies are now required to confirm this.

Abstract: BACKGROUND AND OBJECTIVE: Prenatal maternal serum screening for Down's syndrome has become an important and established part of modern antenatal care. Previously it has been reported that non-specific immunoreactive inhibin may be useful in this context. Using a novel assay we have evaluated dimeric inhibin A as a possible second trimester marker of Down's syndrome. METHODS: From 1992-1993 records, stored sera from women with Down's affected pregnancies and chromosomally normal control pregnancies were identified and retrieved for analysis. These sera had been prospectively collected at 15, 16 and 17 weeks gestation. SUBJECTS: Records revealed 21 women who had had a Down's syndrome pregnancy and who also had serum available for analysis. Sera from 150 chromosomally normal controls, matched for gestation and duration of storage, were also retrieved. MEASUREMENTS: Dimeric inhibin A was measured using a recently developed two-site enzyme-linked immunoassay. This employs a capture anti inhibin beta A-subunit monoclonal antibody, covalently bound to a microtitre plate and a second anti inhibin alpha-subunit antibody conjugated to alkaline phosphatase, allowing detection. RESULTS: The mean (95% CI) maternal serum dimeric inhibin A in the samples from control pregnancies was 237 (201.5-273.4) ng/l, 266.9 (235.4-298.5) ng/l and 207.2 (178.5-235.9) ng/l at 15, 16 and 17 weeks gestation respectively. Expressing the results from the Down's samples as multiples of the normal median (MoM), the median (95% CI) MoM was 2.6 (2.25-3.57), significantly higher than the controls (P < 0.0001, Mann-Whitney U-test). In the sample set tested, for a given false positive rate of 5.3% inhibin A alone afforded a detection rate of 62%, detecting cases previously undetected by routine screening. CONCLUSIONS: Dimeric inhibin A appears to be a promising new marker for the prenatal detection of Down's syndrome. Further prospective evaluation and assessment with other established markers would now be merited.

Abstract: Initial studies of immunoreactive inhibin using a commercial assay have shown levels to be increased in three second-trimester series of maternal samples from Down's syndrome-affected pregnancies. This assay detected non-specifically all forms of circulating inhibin, dimeric and free alpha subunits, whether fully or partially processed. More recently, a new specific assay for dimeric inhibin-A has shown elevated results in both a first-trimester and a second-trimester series of cases. In order to assess the value of dimeric inhibin-A as a potential marker in the second trimester, we have analysed 157 Down's syndrome cases and used 367 unaffected cases across the gestational range 14-20 weeks to establish control medians and population parameters. In our series, the median MOM in Down's cases was 1.77, significantly higher than in the controls. At a 5 per cent false-positive rate, dimeric inhibin-A alone identified 37 per cent of cases. When used in conjunction with maternal age and other marker combinations, mathematical modelling showed detection rates rising from 48 per cent (inhibin-A plus age) to 61 per cent (inhibin-A, free beta hCG, age) and 68 per cent (inhibin-A, AFP, free beta hCG, age). Our data suggest that dimeric inhibin-A may have greater potential earlier in gestation when median levels at 14-16 weeks are 1.92 compared with 1.46 at 17-23 weeks. Dimeric inhibin-A may be a valuable addition to screening protocols, particularly in early gestations.

Abstract: BACKGROUND. In screening for Down's syndrome in the second trimester of pregnancy, the concentrations of alpha-fetoprotein, the beta subunit of human chorionic gonadotropin, and intact human chorionic gonadotropin in material serum are widely used markers. We investigated a new marker, dimeric inhibin A, and compared its predictive value with that of the established markers. METHODS. Serum samples were obtained at 7 to 18 weeks of gestation from 58 women whose fetuses were known to be affected by Down's syndrome, 32 whose fetuses were affected by trisomy 18, and 438 whose fetuses were normal, and the samples were analyzed for each marker. Individual serum concentrations of each marker were converted to multiples of the median value at the appropriate length of gestation in the women with normal pregnancies, and rates of detection of Down's syndrome by screening for inhibin A in various combinations with the other markers were estimated by multivariate analysis. RESULTS. In the women with fetuses affected by Down's syndrome, the serum inhibin A concentrations were 2.06 times the median value in the women with normal pregnancies (P < 0.001). This compared with 2.00 times the median for the beta subunit of human chorionic gonadotropin, 1.82 times the median for intact human chorionic gonadotropin, and 0.72 for alpha-fetoprotein. The serum concentrations of inhibin A in the women with fetuses affected by Down's syndrome did not appear to be significantly elevated above normal until the end of the first trimester and were not significantly different from normal in the women with fetuses affected by trisomy 18 (P = 0.17). The rate of detection of Down's syndrome was 53 percent and the false positive rate was 5 percent when alpha-fetoprotein, the beta subunit of human chorionic gonadotropin, the maternal age were used together as predictors. The detection rate increased to 75 percent when inhibin A was added (P = 0.002). CONCLUSIONS. In the second trimester of pregnancy, measuring inhibin A in maternal serum, in combination with measurements of alpha-fetoprotein and beta subunit of human chorionic gonadotropin, significantly improved the rate of detection of Down's syndrome.

Abstract: OBJECTIVE: To review the outcome of pregnancies complicated by placenta praevia over a three-year period (1991-1993) and to describe in detail the antenatal course and the events leading to delivery, assessing retrospectively whether there are clinical features predictive of outcome and whether outpatient management would be reasonable. DESIGN: A retrospective review of the case records of women with a pregnancy complicated by placenta praevia. SETTING: A tertiary referral teaching hospital in Edinburgh. RESULTS: There were 15,930 deliveries in the study period. Fifty-eight women (0.4%) had a placenta praevia in the third trimester, 42 of whom (72%) had at least one episode of bleeding. Overall, 62% of the women had a major praevia with no differences in the grade of praevia between those women who did or did not have bleeding. Both diagnosis and delivery occurred significantly earlier in women with antepartum bleeding than in those without (median gestation at diagnosis 28.6 weeks versus 33.3 weeks (P < 0.01) and at delivery 36.0 weeks versus 37.1 weeks (P = 0.04), respectively). Delivery by emergency caesarean section was more common in women with bleeding (62% versus 38%). An increasing number of bleeding episodes experienced by individuals was not associated with significant differences in outcomes. Rapid emergency delivery for bleeding was necessary for three women, in none of whom could the bleeding have been predicted. CONCLUSIONS: The clinical outcomes of placenta praevia are highly variable and cannot be predicted confidently from antenatal events. Nonetheless, in the majority of cases with or without bleeding and irrespective of the degree of praevia, outpatient management would appear safe and appropriate.

Abstract: To assess the value of inhibin A as an additional second-trimester maternal serum marker of Down's syndrome we studied 56 affected and 280 unaffected pregnancies matched for gestational age. The median level in the cases was 1.62 multiples of the gestation-specific median (MOM) in the controls, with 95 per cent confidence limits of 1.34-1.96. The distribution of inhibin levels in affected and unaffected pregnancies was approximately log Gaussian, with means about 1 standard deviation apart. This degree of separation was similar to that for human chorionic gonadotropin (hCG), free beta-hCG, and unconjugated oestriol (uE3), but about double that of alpha-fetoprotein (AFP) measured in the same samples. Inhibin was largely uncorrelated with AFP and uE3, whereas the log correlation coefficient with hCG was 0.29 (P = 0.19) for Down's syndrome and 0.41 (P < 0.0001) for unaffected pregnancies; with free beta-hCG, it was 0.18 (P = 0.38) and 0.38 (P < 0.0001), respectively. On the basis of these results and other published studies, we estimate that measuring inhibin A in addition to AFP and hCG or free beta-hCG (with or without uE3) will increase the detection rate for a fixed 5 per cent false-positive rate by about 7 per cent.

Abstract:

Abstract: Initial studies of immunoreactive inhibin using a commercial assay have shown levels to be increased in three second-trimester series of maternal samples from Down's syndrome-affected pregnancies. This assay detected non-specifically all forms of circulating inhibin, dimeric and free alpha subunits, whether fully or partially processed. More recently, a new specific assay for dimeric inhibin-A has shown elevated results in both a first-trimester and a second-trimester series of cases. In order to assess the value of dimeric inhibin-A as a potential marker in the second trimester, we have analysed 157 Down's syndrome cases and used 367 unaffected cases across the gestational range 14-20 weeks to establish control medians and population parameters. In our series, the median MOM in Down's cases was 1.77, significantly higher than in the controls. At a 5 per cent false-positive rate, dimeric inhibin-A alone identified 37 per cent of cases. When used in conjunction with maternal age and other marker combinations, mathematical modelling showed detection rates rising from 48 per cent (inhibin-A plus age) to 61 per cent (inhibin-A, free beta hCG, age) and 68 per cent (inhibin-A, AFP, free beta hCG, age). Our data suggest that dimeric inhibin-A may have greater potential earlier in gestation when median levels at 14-16 weeks are 1.92 compared with 1.46 at 17-23 weeks. Dimeric inhibin-A may be a valuable addition to screening protocols, particularly in early gestations.

Abstract: Inhibins are present in maternal serum during pregnancy. However, the presence of inhibins in the compartments surrounding the fetus in early pregnancy is not well defined. Using novel specific enzyme-linked immunosorbent assays we have demonstrated that the bioactive dimeric inhibin forms, inhibin-A and inhibin-B, and the immunoreactive inhibin forms containing pro- and alpha C sequences are present in different amounts in the extra-embryonic coelomic and amniotic fluids and maternal serum between 8-11 weeks gestation. Of the bioactive dimeric inhibins, both inhibin. A (mean +/- SEM 236.0 +/- 24.8 pg/ml) and inhibin-B (62.0 +/- 8.6 pg/ml) are present in extra-embryonic coelom whereas no dimeric inhibin is present in the amniotic fluid and only inhibin-A (360.2 +/- 32.9 pg/ml) is present in maternal serum. Furthermore, pro-alpha C-related immunoreactivity is present at high concentrations in the extra-embryonic coelom (591.7 +/- 60.5 pg/ml), amniotic fluid (452.4 +/- 76.8 pg/ml) and maternal serum (539.4 +/- 39.5 pg/ml). These findings would indicate that at this stage of gestation inhibin-A, inhibin-B and immunoreactive pro- alpha C-containing inhibin production are likely to arise from different sources including the fetus, placenta and fetal membranes and maternal sources including the ovary. Inhibins may be important regulators of fetal and placental development and involved in the establishment of pregnancy.

Abstract: OBJECTIVE: To identify factors differentiating men becoming azoospermic from those remaining oligozoospermic within 6 months of T treatment. DESIGN: Prospective, open, noncomparative contraceptive efficacy study. SETTING: International multicenter study of 271 men in 10 centers in seven countries. PATIENTS: Data from 157 achieving azoospermia and 68 remaining oligozoospermic after 6 months of treatment were analyzed. The remaining 46 men were excluded as having unclassifiable suppression status due to discontinuation before completion of suppression. INTERVENTIONS: Weekly IM injections of 200 mg T enanthate. MAIN OUTCOME MEASURES: Anthropometric, seminal, hormonal, and biochemical data obtained before, during, and after treatment as potential predictors of consistent azoospermia. RESULTS: Azoospermic men had [1] faster rates of fall in sperm output and, after a delay of 75 +/- 4 days (mean +/- SE) for sperm to reappear in the ejaculate, exhibited a faster rate of recovery of sperm output; [2] higher pretreatment levels of FSH (mean +/- SE; 3.7 +/- 0.3 versus 2.7 +/- 0.4 mIU/mL [conversion factor to SI units, 1.00]); and [3] (if treated for > 15 months) a prolonged after treatment rebound in gonadotropins compared with nonazoospermic men. There were no other differences in pretreatment variables or plasma T levels and changes in androgen-sensitive markers during treatment. None of the variables explained the higher rates of azoospermia among men in Chinese (91%, n = 3) compared with non-Chinese centers (60%, n = 7). CONCLUSION: Nonuniformity of T-induced azoospermia among healthy fertile men is not due to anthropometric or ethnic differences, to variations in androgen effects, or to poor compliance with treatment. The heterogeneity in individual susceptibility to T-induced azoospermia is most consistent with quantitative differences in the hormonal regulation of spermatogenesis and is likely to be evident with other hormonal methods for male contraception.

Abstract:

Abstract: Sixty-three normal Caucasian men were administered intramuscular testosterone enanthate (TE) 200 mg i.m. weekly for 12 months as part of a male contraceptive trial. This dose of TE caused a 2.5-fold increase in trough serum testosterone concentrations. High density lipoprotein cholesterol (HDL-C) was significantly depressed from pretreatment concentration of 1.19 +/- 0.04 nmol/l to 1.03 +/- 0.04 mmol/l after 12 weeks of treatment, and remained suppressed for the duration of treatment (p < 0.001). There were no changes in serum concentration of total cholesterol (TC), low density lipoprotein cholesterol (LDL-C) or triglycerides (TG) during treatment, but the concentrations of TC and LDL-C were depressed at three months post-treatment. There was a sustained elevation in LDL-C:HDL-C ratio during TE treatment (p < 0.005), from 3.41 +/- 0.15 pretreatment to 3.88 +/- 0.19 after 12 weeks of TE treatment. Sex hormone binding globulin (SHBG), but not testosterone (T) or estradiol (E2), was significantly associated with HDL-C (r = 0.83, p = 0.001). Lipoprotein (a) (Lp(a)) was measured in a subgroup of 33 men: serum concentration fell from 187 +/- 45 mg/l pretreatment to 140 +/- 35 mg/l after 16 weeks of TE treatment (p < 0.01).

Abstract: Intracranial neoplasms presenting during pregnancy are uncommon. We report the case of a woman with a giant acoustic neuroma, presenting with hyperemesis gravidarum, and detail the surgical excision of the tumour during the third trimester. The case illustrates the unusual presentation and that such surgery can be performed safely without detriment to mother or fetus.

Abstract: While second-trimester prenatal screening programmes for Down's syndrome have become established in prenatal care, it would be advantageous to be able to offer screening in earlier pregnancy. To this end, we have evaluated a new potential maternal serum marker, dimeric inhibin A, as a possible first-trimester marker. Dimeric inhibin A was measured in prospectively collected maternal serum from 23 cases of Down's syndrome and matched chromosomally normal controls, at 11-13 weeks' gestation. Levels of this protein were significantly elevated in the Down's pregnancies compared with the control pregnancies. The median multiple of the normal median (MOM) for the Down's samples was 2.46 (95 per cent confidence interval: 2.11-3.26, P < 0.0001 vs. controls). These results suggest that dimeric inhibin A is a useful discriminator of Down's-affected pregnancies from normal pregnancies in the first trimester and that sensitive screening in combination with maternal age and other possible markers may be practicable in the first trimester.

Abstract: BACKGROUND AND OBJECTIVE: Maternal serum immunoreactive inhibin has been shown to be significantly elevated in Down's affected pregnancies in the second trimester, suggesting that it may be useful in prenatal diagnosis. We have investigated whether it is similarly elevated in the first trimester. DESIGN: Stored maternal sera from women with Down's affected pregnancies and chromosomally normal control pregnancies were retrieved for analysis. These sera had been collected prospectively at either 11 or 12 weeks gestation as a routine antenatal booking procedure. SUBJECTS: From records, 11 women were identified as having had a Down's pregnancy. For each of these, 4 controls matched for gestation and duration-of-storage were also identified. MEASUREMENTS: Two different inhibin immunoassays were evaluated, one using an antibody raised against 31 kDa bovine inhibin and the other, a commercial two-site assay, using two antibodies directed against two distinct alpha-subunit epitopes. RESULTS: Neither assay detected a significant effect of gestation on serum inhibin levels. After combining the data from both gestations, no significant difference between the Down's samples and controls for either assay was detected. However, analysis of the data for each gestation separately revealed that one assay detected a significant difference in inhibin levels between Down's affected and unaffected pregnancies at 11 weeks gestation (mean +/- SEM 3186 +/- 195 vs 2020 +/- 172 ng/l, P < 0.01) but not at 12 weeks. The other, commercial, assay did not detect a significant difference at either gestation. In addition, there was poor association between the results of the two assays. CONCLUSIONS: These data suggest that immunoreactive inhibin, as detected by these assays, will not be useful as a late first trimester marker for Down's syndrome and also that these two assays detect different inhibin species in pregnancy serum.

Abstract: Sex-steroid based male contraceptive regimes induce azoospermia in only 40-70% of Caucasian men. The reason(s) why the remainder maintains a low level of spermatogenesis (oligozoospermia) despite gonadotrophin suppression is unclear. In order to improve our understanding of this phenomenon, we examined the changes in sperm density and plasma LH, FSH, testosterone (T), oestradiol (E2), and inhibin (IN) in 28 normal men who received 200 mg testosterone enanthate (TE) im weekly during a male contraceptive efficacy trial. Gonadotrophins were measured by an ultrasensitive time-resolved immunofluorometric assay (DELFIA) with a sensitivity of 0.04 U/L, to determine the adequacy of suppression. Seventeen of the 28 men achieved azoospermia; the other 11 remained oligozoospermic (sperm density 3.3-4.7 x 10(6)/mL) after 6 months of TE exposure. Azoospermic subjects displayed a more rapid decline in sperm density, a significant difference being apparent by 5 weeks after starting TE. During TE treatment, both LH and FSH were consistently suppressed to below the limits of detection, whereas there was a 2.5-fold rise in T and E2 with a similar decrease in IN. There were no consistent differences in any of these hormone concentrations between the azoospermic and oligozoospermic groups. Recovery of sperm density to baseline levels or above 20 x 10(6)/mL was significantly slower in the azoospermic group. During the recovery phase, the azoospermic men exhibited significantly higher LH and FSH levels compared to baseline and to the oligozoospermic subjects even though no differences in circulating T, E2, or IN were observed. We conclude that incomplete gonadotrophin suppression or differences in sex steroid or inhibin levels are unlikely to be responsible for the maintenance of minor degrees of spermatogenesis in some men during TE administration. The rebound rise in gonadotrophins in azoospermic but not oligozoospermic responders during recovery may reflect a more profound degree of spermatogenic suppression in the former group.

Abstract: Steroid regimens containing androgens are being evaluated currently as hormonal contraceptives for men. The possible non-reproductive effects of such treatment were assessed during an efficacy trial using a prototype regime of 200 mg testosterone enanthate i.m. weekly. Prostatic function and size were monitored by regular rectal examination, blood levels of prostate-specific androgen (PSA) were measured in 30 men and prostatic size was measured by trans-rectal ultrasound imaging in a representative subgroup of five subjects for 12 months and for a further 6 months after discontinuation. Despite the sustained rise in serum levels of testosterone, oestradiol and dihydrotestosterone during treatment, there was no detectable increase in prostatic size on rectal examination or any significant change in blood concentrations of PSA. A small but significant increase (14.3 +/- 2.0%) in maximal prostate transverse area was observed in four men while the remaining one showed no change. Our preliminary data demonstrate the feasibility and importance of monitoring prostatic function in the development of androgen-containing male hormonal contraceptives.

Abstract: To investigate the fertility of men who remain oligozoospermic despite sex steroid suppression, the in-vitro fertilizing capacity of residual spermatozoa was assessed in 30 men receiving intramuscular testosterone enanthate (TE). Spermatozoa were prepared by either Percoll or repetitive centrifugation/washing. Although the mean (+/- SEM) pretreatment zona-free hamster oocyte penetration (HOP) rates were similar (59.4 +/- 10.1 and 63.8 +/- 10.8%), following the induction of oligozoospermia the Percoll-prepared spermatozoa exhibited a penetration rate (26.9 +/- 10.2%) which was markedly greater than that obtained for sperm prepared by repetitive washing (0 +/- 0%). In addition, the partners of two men exhibiting a HOP test with Percoll-prepared spermatozoa, conceived despite a sperm concentration of 3 x 10(6) ml-1 and a negative HOP test with spermatozoa prepared by repetitive washing. These results suggest that Percoll preparation optimizes the assessment of in-vitro sperm function and that the fertility of men with TE-induced severe oligozoospermia is suppressed but not abolished.

Abstract: The potential importance of GnRH pulse frequency modulation and steroid or inhibin negative feedback in the selective control of pituitary FSH secretion was investigated in 5 adult men with idiopathic hypogonadotropic hypogonadism in whom plasma testosterone has been previously normalized by pulsatile GnRH therapy. The effects of decreasing frequency of pulsatile iv GnRH administration from 2- to 4-hourly for 7 days were examined at constant GnRH bolus dose or constant daily dose and also with interrupted gonadal steroid feedback using a combination of an anti-androgen (flutamide 250 mg t.i.d.) and an aromatase inhibitor (aminogluthetimide 125 mg b.d.) orally for a further 7 days. Slowing GnRH pulse frequency from 2- to 4-hourly did not alter mean plasma FSH at constant bolus dose or constant total daily doses of GnRH. In two subjects with subnormal but not in another two with normal testicular volumes, FSH rise was observed when the 4-hourly GnRH pulse frequency was combined with the interruption of steroid feedback. These results are not compatible with a major role for GnRH pulse frequency modulation in the regulation of pituitary FSH secretion in the presence of normal gonadal steroid feedback. Irrespective of FSH concentrations, plasma inhibin immunoactivity did not change significantly with the alteration in GnRH pulse frequency. The role of inhibin in the control of FSH therefore remains undefined in men.

Abstract: Human seminal plasma has uniquely high concentrations of PGE and 19-hydroxy PGE but the function of these PGs has not been elucidated. PGs of the E series have been shown to be paracrine and autocrine regulators of the function of immune cells and high levels of PGE have been shown consistently to suppress function in such cells. Human seminal plasma has a potent immunosuppressive effect and evidence is accumulating that this is largely due to PG components. In this study the effects of human seminal plasma on the killing activity of natural killer (NK) cells as judged by 51Cr release from K562 cells have been studied in groups of fertile and infertile men. Although there was no significant difference in the PGE, 19-hydroxy PGE or the NK cell inhibitory activity in the two groups, the inhibition of NK cell activity was closely correlated with the PGE and the 19-OH PGE content of the seminal plasma in the fertile group. This finding is further evidence that the major contribution to the immunosuppressive properties of human semen is provide by the high concentration of PGs of the E series in this fluid.

Abstract: Ten normal men were given three monthly intramuscular injections of 200mg of depot medroxyprogesterone acetate (DMPA) and 250mg of testosterone oenanthate (TE) as part of a male contraceptive trial. During the three months of treatment, serum high density lipoprotein cholesterol (HDL-C) and the HDL-C:LDL-C (low density lipoprotein cholesterol) ratio were significantly depressed compared to baseline. Although the long-term effect of this alteration in lipoprotein cholesterol metabolism in normolipidaemic men is currently uncertain, these results suggest that the potential cardiovascular risks of progestagen-containing regimens for male contraception will have to be seriously considered.