- Email: [email protected]
Cytogenetic analysis of first trimester pregnancy loss
BRIEF COMMUNICATIONS Table 2 Prevalence of group B streptococcus for different groups
Population Preterm birth (b 37 weeks) PROM Adolescent (b 20 years old) Maternal age N 34 years One or more risk factors for early onset neonatal sepsis a
No.
GBS prevalence No. (%)
95% Confidence Interval
300 46 54 84 26 90
52 (17.3) 11 (23.9) 9 (16.7) 20 (23.80) 5 (19.23) 15 (16.7)
13.22–21.10 11.10–36.72 0.06–26.93 14.51–33.10 2.99–35.46 8.81– 24.51
a Defined by CDC as maternal fever, prolonged rupture of membranes, previous GBS infected infant, prenatal GBS bacteriuria, and preterm birth.
that were opened at the moment of enrollment. Treating physicians were instructed to collect a specimen with one swab that collected specimens from the vagina and rectum. The swab was placed into a recommended container with adequate transport medium. As recommended by the CDC [2], the specimens were incubated in Todd-Hewitt broth supplemented with nalidixic acid and gentamicin. After 18–24 hours of incubation at 35 ± 2 °C in ambient air, specimens were subcultured onto a sheep blood agar plate, and a Granada medium plate was made and incubated at the recommended incubation conditions [3]. Observation of cultures was conducted at 24 hours and all negative culture plates were reincubated for an additional 18–24 hours and then re-examined. All GBS isolates were tested for drug susceptibility as recommended by the CDC [2], including clindamycin and erythromycin. The characteristics of the participants are shown in Table 1. The study population was similar to the population of pregnant women who had received care in the hospital during the previous year. A total of 52 pregnant women from the sample of 300 were found to be
243
colonized with GBS (17.3%; 95% CI, 13.2–21.1). This percentage was similar to that reported previously [1]. In other studies conducted in our region, a wide range of between 3% and 21% has been reported [4]. Fifteen (16.7%) of the 90 pregnant women with one or more clinical risk factors for early-onset GBS defined by the CDC were colonized by GBS; for the preterm birth group the prevalence was 23.9% (Table 2). All isolated samples were susceptible to Penicillin G (100%). It is important to highlight that 70% of the study group did not show any risk factor during labor associated with early-onset GBS disease. In conclusion, the prevalence of GBS colonization at the Pereira Rossell Hospital was 17.3%, which is similar to the figures reported for other countries in South America. All the colonized women were susceptible to Penicillin, and consequently this antibiotic should be the first line therapy to prevent early-onset GBS disease. Acknowledgments We would like to thank the sponsorship of ION Laboratories of Uruguay. C. Sosa was supported by the National Institutes of Health, FIC, R01TW7600. References [1] Heath PT, Schuchat A. Perinatal group B streptococcal disease. Best Pract Res Clin Obstet Gynaecol 2007;21(3):411–24. [2] Schrag S, Gorwitz R, Fultz-Butts K, Schuchat A. Prevention of perinatal group B streptococcal disease. Revised guidelines from CDC. MMWR Recomm Rep 2002;51 (RR-11):1–22. [3] Rosa-Fraile M, Rodriguez-Granger J, Cueto-Lopez M, Sampedro A, Gaye EB, Haro JM, et al. Use of Granada medium to detect group B streptococcal colonization in pregnant women. J Clin Microbiol 1999;37(8):2674–7. [4] Zusman AS, Baltimore RS, Fonseca SN. Prevalence of maternal group B streptococcal colonization and related risk factors in a Brazilian population. Braz J Infect Dis 2006;10(4):242–6.
0020-7292/$ – see front matter © 2008 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2008.10.020
Cytogenetic analysis of first trimester pregnancy loss Florencia Petracchi ⁎, Daniela S. Colaci, Laura Igarzabal, Enrique Gadow Genetics Section, Department of Obstetrics and Gynecology, CEMIC, Buenos Aires, Argentina
a r t i c l e
i n f o
Article history: Received 21 August 2008 Received in revised form 10 October 2008 Accepted 15 October 2008 Keywords: Cytogenetic analysis Chorionic villus sampling Dilatation and curettage First trimester Spontaneous abortion
⁎ Corresponding author. Galvan 4102, Zip code C1431, Buenos Aires, Argentina. Tel.: +54 11 4546 8248; fax: +54 11 4541 379012. E-mail address: fl[email protected] (F. Petracchi).
First trimester spontaneous abortion is the most frequent complication of early pregnancy. Almost 50%–80% of first trimester losses are reportedly due to chromosomal abnormalities [1]. The aim of the present study was to evaluate the success rate of cytogenetic culture to analyze first trimester spontaneous abortions. A total of 726 samples from first trimester spontaneous abortions submitted to our laboratory between January 2000 and July 2007 were analyzed. The samples were collected by dilatation and curettage (D&C) or chorionic villus sampling (CVS). CVS was performed once the diagnosis of embryonic or fetal death had been made. The samples were collected transabdominally with ultrasound guidance to correctly identify and reach the chorion. Cultures were considered successful when 11 or more metaphases were obtained and could be analyzed. Infected or highly degenerated cytogenetic materials were considered to be culture failures. The success of cytogenetic cultures was analyzed according to type of sample collection. Cytogenetic studies of all the specimens were analyzed by the same group of researchers. Statistical analysis was performed using the Pearson χ2 test. Results were considered significant at a 5% level (Pb 0.05).
244
BRIEF COMMUNICATIONS
Table 1 Abnormal karyotypes from the 597 successful cultures Karyotype found
No. (%) n = 267
Trisomies Monosomies Mosaicisms Triploidies Tetraploidies Structural chromosome abnormalities Complex karyotypes
149 (55.8) 38 (14.2) 21 (7.8) 34 (12.7) 9 (3.4) 13 (4.8) 3 (1.1)
Cytogenetic culture was successful in 597 of the 726 specimens studied (82.2%). Higher successful culture rates were obtained with CVS (93.9% [78/83]; 95% CI, 86.33–97.73) compared with D&C (80.7% [519/643]; 95% CI, 77.48–83.58). This difference was statistically significant (P = 0.002). Culture rate success improved over time. Between 2000 and 2003, the success rate was 77.12% (95% CI, 72.28–81.41), while between 2004 and 2007 it was 86.56% (95% CI, 82.87–89.57) (P = 0.0021). An abnormal karyotype was found in 44.7% (267/597) of the successful cultures. The prevalence of abnormal karyotypes is shown in Table 1. In the CVS group, 58.97% (46/78) were abnormal (95% CI, 47.88–69.23) compared with the D&C group where 42.58% (221/519) were abnormal (95% CI, 38.40–46.88) (P = 0.007). Of the specimens with normal karyotypes, 81.88% (224/298) of the D&C specimens (95% CI, 77.09–85.86) and 56.25% (18/32) of the CVS specimens (95% CI, 39.31–71.85) were 46,XX (P = 0.001). A karyotype of pregnancy loss was obtained in more than 8 out of 10 specimens. Samples obtained by CVS were associated with higher culture rates than those obtained by D&C. These findings could be attributed to different factors. For example, D&C samples are probably more contaminated by maternal tissue; the samples must be transported to the lab before processing (unlike with CVS where the samples are processed immediately); and D&C samples are more likely
to be infected and unsuitable for culturing since they are obtained by surgical instrumental uterine evacuation. Furthermore, D&C specimens were obtained by different operators, who are not always aware of the correct technique for cytogenetic sample collection. In contrast, CVS specimens were processed directly at our laboratory by physicians trained in cytogenetics. Successful culture rate has improved over the years, probably as a result of the advances in laboratory techniques [2]. A higher rate of chromosomal anomalies (58.97%) was observed in samples obtained through CVS, probably because these samples are more representative of the fetus, while maternal contamination is probably less frequent. Although attempts are made to separate trophoblastic tissue from maternal decidua, they are not always successful, as evidenced by the high rate of 46,XX in the D&C specimens. Moreover, no routine method is used in our laboratory to identify maternal contamination. Failure to identify confined placental mosaicism may also be an issue [3]. The prevalence of each type of chromosomal abnormality is similar to previous reports [1]. Cytogenetic analysis of the pregnancy loss is particularly useful in couples with recurrent spontaneous abortion [4]. Cytogenetic analysis of the products of conception is a valuable tool for the study of first trimester pregnancy loss, where an abnormal karyotype finding can explain the loss. Discovery of a normal karyotype, especially in couples with recurrent spontaneous abortion, encourages the search for other etiologies. In our experience, the most successful rate of cytogenetic culture to analyze first trimester spontaneous abortion was obtained using ultrasound-guided CVS. References [1] Warburton D, Fraser FC. Spontaneous Abortion Risks in Man: Data from Reproductive Histories Collected in a Medical Genetics Unit. Am J Hum Genet 1964;16:1–25. [2] Menasha J, Levy B, Hirschhorn K, Kardon NB. Incidence and spectrum of chromosome abnormalities in spontaneous abortions: new insights from a 12-year study. Genet Med 2005;7(4):251–63. [3] Philipp T, Kalousek DK. Generalized abnormal embryonic development in missed abortion: embryoscopic and cytogenetic findings. Am J Med Genet 2002;111(1):43–7. [4] Rai R, Regan L. Recurrent miscarriage. Lancet 2006;368(9535):601–11.
0020-7292/$ – see front matter © 2008 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2008.10.014
F18-fluorodeoxyglucose–positron emission tomography for diagnosis of pelvic tuberculosis mimicking peritoneal carcinomatosis Jong Ha Hwang a, Sung Eun Kim b, Jae Kwan Lee a,⁎ a b
Department of Obstetrics and Gynecology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea Department of Nuclear Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
a r t i c l e
i n f o
Article history: Received 11 September 2008 Received in revised form 10 October 2008 Accepted 14 October 2008 Keywords: FDG-PET Peritoneal tuberculosis Peritoneal Carcinomatosis
⁎ Corresponding author. Department of Obstetrics and Gynecology, Korea University Guro Hospital, Korea University College of Medicine, 80, Guro-dong, Guro-gu, Seoul, 152-703, Korea. Tel.: +82 2 2626 2519; fax: +82 2 838 1560. E-mail address: [email protected] (J.K. Lee).
Peritoneal tuberculosis is a rare and curable infectious disease, caused mainly by Mycobacterium tuberculosis. Peritoneal tuberculosis can mimic peritoneal carcinomatosis. There are no pathognomonic clinical, radiologic, or laboratory tests for peritoneal tuberculosis. A 66-year-old woman (para 4) was referred for evaluation of ascites discovered by abdominal ultrasound. The computed tomography (CT) scan showed a large accumulation of ascites with multiple areas of peritoneal thickening and peritoneal nodules; thickening and infiltration of the mesentery and greater omentum were noted. Enlarged lymph nodes were seen in the cardiophrenic angle and along the gastrohepatic ligament. Peritoneal carcinomatosis with massive ascites was suspected. The pelvic magnetic resonance image (MRI) revealed similar findings (Fig. 1). The CA 125 level was elevated at 426.4 U/mL (normal value b 35 U/mL).
Population Preterm birth (b 37 weeks) PROM Adolescent (b 20 years old) Maternal age N 34 years One or more risk factors for early onset neonatal sepsis a
No.
GBS prevalence No. (%)
95% Confidence Interval
300 46 54 84 26 90
52 (17.3) 11 (23.9) 9 (16.7) 20 (23.80) 5 (19.23) 15 (16.7)
13.22–21.10 11.10–36.72 0.06–26.93 14.51–33.10 2.99–35.46 8.81– 24.51
a Defined by CDC as maternal fever, prolonged rupture of membranes, previous GBS infected infant, prenatal GBS bacteriuria, and preterm birth.
that were opened at the moment of enrollment. Treating physicians were instructed to collect a specimen with one swab that collected specimens from the vagina and rectum. The swab was placed into a recommended container with adequate transport medium. As recommended by the CDC [2], the specimens were incubated in Todd-Hewitt broth supplemented with nalidixic acid and gentamicin. After 18–24 hours of incubation at 35 ± 2 °C in ambient air, specimens were subcultured onto a sheep blood agar plate, and a Granada medium plate was made and incubated at the recommended incubation conditions [3]. Observation of cultures was conducted at 24 hours and all negative culture plates were reincubated for an additional 18–24 hours and then re-examined. All GBS isolates were tested for drug susceptibility as recommended by the CDC [2], including clindamycin and erythromycin. The characteristics of the participants are shown in Table 1. The study population was similar to the population of pregnant women who had received care in the hospital during the previous year. A total of 52 pregnant women from the sample of 300 were found to be
243
colonized with GBS (17.3%; 95% CI, 13.2–21.1). This percentage was similar to that reported previously [1]. In other studies conducted in our region, a wide range of between 3% and 21% has been reported [4]. Fifteen (16.7%) of the 90 pregnant women with one or more clinical risk factors for early-onset GBS defined by the CDC were colonized by GBS; for the preterm birth group the prevalence was 23.9% (Table 2). All isolated samples were susceptible to Penicillin G (100%). It is important to highlight that 70% of the study group did not show any risk factor during labor associated with early-onset GBS disease. In conclusion, the prevalence of GBS colonization at the Pereira Rossell Hospital was 17.3%, which is similar to the figures reported for other countries in South America. All the colonized women were susceptible to Penicillin, and consequently this antibiotic should be the first line therapy to prevent early-onset GBS disease. Acknowledgments We would like to thank the sponsorship of ION Laboratories of Uruguay. C. Sosa was supported by the National Institutes of Health, FIC, R01TW7600. References [1] Heath PT, Schuchat A. Perinatal group B streptococcal disease. Best Pract Res Clin Obstet Gynaecol 2007;21(3):411–24. [2] Schrag S, Gorwitz R, Fultz-Butts K, Schuchat A. Prevention of perinatal group B streptococcal disease. Revised guidelines from CDC. MMWR Recomm Rep 2002;51 (RR-11):1–22. [3] Rosa-Fraile M, Rodriguez-Granger J, Cueto-Lopez M, Sampedro A, Gaye EB, Haro JM, et al. Use of Granada medium to detect group B streptococcal colonization in pregnant women. J Clin Microbiol 1999;37(8):2674–7. [4] Zusman AS, Baltimore RS, Fonseca SN. Prevalence of maternal group B streptococcal colonization and related risk factors in a Brazilian population. Braz J Infect Dis 2006;10(4):242–6.
0020-7292/$ – see front matter © 2008 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2008.10.020
Cytogenetic analysis of first trimester pregnancy loss Florencia Petracchi ⁎, Daniela S. Colaci, Laura Igarzabal, Enrique Gadow Genetics Section, Department of Obstetrics and Gynecology, CEMIC, Buenos Aires, Argentina
a r t i c l e
i n f o
Article history: Received 21 August 2008 Received in revised form 10 October 2008 Accepted 15 October 2008 Keywords: Cytogenetic analysis Chorionic villus sampling Dilatation and curettage First trimester Spontaneous abortion
⁎ Corresponding author. Galvan 4102, Zip code C1431, Buenos Aires, Argentina. Tel.: +54 11 4546 8248; fax: +54 11 4541 379012. E-mail address: fl[email protected] (F. Petracchi).
First trimester spontaneous abortion is the most frequent complication of early pregnancy. Almost 50%–80% of first trimester losses are reportedly due to chromosomal abnormalities [1]. The aim of the present study was to evaluate the success rate of cytogenetic culture to analyze first trimester spontaneous abortions. A total of 726 samples from first trimester spontaneous abortions submitted to our laboratory between January 2000 and July 2007 were analyzed. The samples were collected by dilatation and curettage (D&C) or chorionic villus sampling (CVS). CVS was performed once the diagnosis of embryonic or fetal death had been made. The samples were collected transabdominally with ultrasound guidance to correctly identify and reach the chorion. Cultures were considered successful when 11 or more metaphases were obtained and could be analyzed. Infected or highly degenerated cytogenetic materials were considered to be culture failures. The success of cytogenetic cultures was analyzed according to type of sample collection. Cytogenetic studies of all the specimens were analyzed by the same group of researchers. Statistical analysis was performed using the Pearson χ2 test. Results were considered significant at a 5% level (Pb 0.05).
244
BRIEF COMMUNICATIONS
Table 1 Abnormal karyotypes from the 597 successful cultures Karyotype found
No. (%) n = 267
Trisomies Monosomies Mosaicisms Triploidies Tetraploidies Structural chromosome abnormalities Complex karyotypes
149 (55.8) 38 (14.2) 21 (7.8) 34 (12.7) 9 (3.4) 13 (4.8) 3 (1.1)
Cytogenetic culture was successful in 597 of the 726 specimens studied (82.2%). Higher successful culture rates were obtained with CVS (93.9% [78/83]; 95% CI, 86.33–97.73) compared with D&C (80.7% [519/643]; 95% CI, 77.48–83.58). This difference was statistically significant (P = 0.002). Culture rate success improved over time. Between 2000 and 2003, the success rate was 77.12% (95% CI, 72.28–81.41), while between 2004 and 2007 it was 86.56% (95% CI, 82.87–89.57) (P = 0.0021). An abnormal karyotype was found in 44.7% (267/597) of the successful cultures. The prevalence of abnormal karyotypes is shown in Table 1. In the CVS group, 58.97% (46/78) were abnormal (95% CI, 47.88–69.23) compared with the D&C group where 42.58% (221/519) were abnormal (95% CI, 38.40–46.88) (P = 0.007). Of the specimens with normal karyotypes, 81.88% (224/298) of the D&C specimens (95% CI, 77.09–85.86) and 56.25% (18/32) of the CVS specimens (95% CI, 39.31–71.85) were 46,XX (P = 0.001). A karyotype of pregnancy loss was obtained in more than 8 out of 10 specimens. Samples obtained by CVS were associated with higher culture rates than those obtained by D&C. These findings could be attributed to different factors. For example, D&C samples are probably more contaminated by maternal tissue; the samples must be transported to the lab before processing (unlike with CVS where the samples are processed immediately); and D&C samples are more likely
to be infected and unsuitable for culturing since they are obtained by surgical instrumental uterine evacuation. Furthermore, D&C specimens were obtained by different operators, who are not always aware of the correct technique for cytogenetic sample collection. In contrast, CVS specimens were processed directly at our laboratory by physicians trained in cytogenetics. Successful culture rate has improved over the years, probably as a result of the advances in laboratory techniques [2]. A higher rate of chromosomal anomalies (58.97%) was observed in samples obtained through CVS, probably because these samples are more representative of the fetus, while maternal contamination is probably less frequent. Although attempts are made to separate trophoblastic tissue from maternal decidua, they are not always successful, as evidenced by the high rate of 46,XX in the D&C specimens. Moreover, no routine method is used in our laboratory to identify maternal contamination. Failure to identify confined placental mosaicism may also be an issue [3]. The prevalence of each type of chromosomal abnormality is similar to previous reports [1]. Cytogenetic analysis of the pregnancy loss is particularly useful in couples with recurrent spontaneous abortion [4]. Cytogenetic analysis of the products of conception is a valuable tool for the study of first trimester pregnancy loss, where an abnormal karyotype finding can explain the loss. Discovery of a normal karyotype, especially in couples with recurrent spontaneous abortion, encourages the search for other etiologies. In our experience, the most successful rate of cytogenetic culture to analyze first trimester spontaneous abortion was obtained using ultrasound-guided CVS. References [1] Warburton D, Fraser FC. Spontaneous Abortion Risks in Man: Data from Reproductive Histories Collected in a Medical Genetics Unit. Am J Hum Genet 1964;16:1–25. [2] Menasha J, Levy B, Hirschhorn K, Kardon NB. Incidence and spectrum of chromosome abnormalities in spontaneous abortions: new insights from a 12-year study. Genet Med 2005;7(4):251–63. [3] Philipp T, Kalousek DK. Generalized abnormal embryonic development in missed abortion: embryoscopic and cytogenetic findings. Am J Med Genet 2002;111(1):43–7. [4] Rai R, Regan L. Recurrent miscarriage. Lancet 2006;368(9535):601–11.
0020-7292/$ – see front matter © 2008 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2008.10.014
F18-fluorodeoxyglucose–positron emission tomography for diagnosis of pelvic tuberculosis mimicking peritoneal carcinomatosis Jong Ha Hwang a, Sung Eun Kim b, Jae Kwan Lee a,⁎ a b
Department of Obstetrics and Gynecology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea Department of Nuclear Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
a r t i c l e
i n f o
Article history: Received 11 September 2008 Received in revised form 10 October 2008 Accepted 14 October 2008 Keywords: FDG-PET Peritoneal tuberculosis Peritoneal Carcinomatosis
⁎ Corresponding author. Department of Obstetrics and Gynecology, Korea University Guro Hospital, Korea University College of Medicine, 80, Guro-dong, Guro-gu, Seoul, 152-703, Korea. Tel.: +82 2 2626 2519; fax: +82 2 838 1560. E-mail address: [email protected] (J.K. Lee).
Peritoneal tuberculosis is a rare and curable infectious disease, caused mainly by Mycobacterium tuberculosis. Peritoneal tuberculosis can mimic peritoneal carcinomatosis. There are no pathognomonic clinical, radiologic, or laboratory tests for peritoneal tuberculosis. A 66-year-old woman (para 4) was referred for evaluation of ascites discovered by abdominal ultrasound. The computed tomography (CT) scan showed a large accumulation of ascites with multiple areas of peritoneal thickening and peritoneal nodules; thickening and infiltration of the mesentery and greater omentum were noted. Enlarged lymph nodes were seen in the cardiophrenic angle and along the gastrohepatic ligament. Peritoneal carcinomatosis with massive ascites was suspected. The pelvic magnetic resonance image (MRI) revealed similar findings (Fig. 1). The CA 125 level was elevated at 426.4 U/mL (normal value b 35 U/mL).