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Prognosis of the surviving co-twin after intrauterine fetal demise (IUFD) in TTTS treated by laser
S160 SMFM Abstracts
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Pavilion, Reno Hilton PROGESTERONE MODULATION OF INFLAMMATORY CYTOKINE PRODUCTION IN FETOPLACENTAL ARTERIES ANDREA SHIELDS1, JAMES WRIGHT2, PATRICK MCNUTT2, JENNIFER GOTKIN1, DAMIAN PAONESSA1, BOBBY HOWARD1, NATHAN HOELDTKE3, PETER NAPOLITANO1, 1Madigan Army Medical Center, Maternal Fetal Medicine, Tacoma, Washington, 2Madigan Army Medical Center, Clinical Investigations, Tacoma, Washington, 3Tripler Army Medical Center, Maternal Fetal Medicine, Honolulu, Hawaii OBJECTIVE: To determine if there is decreased inflammatory cytokine production from fetal arteries pretreated with progesterone (P4) following lipopolysaccharide stimulation. STUDY DESIGN: Five placentas were obtained from normal pregnancies following delivery at term. Four chorionic plate arteries were dissected from each placenta and incubated for 24 hours prior to undergoing inflammatory stimulation. Control groups consisted of the following: incubation with Dulbecco’s Modified Eagles Media (DMEM) alone and incubation with DMEM followed by stimulation with lipopolysaccaride (LPS) (50 ng/mL). Treatment groups consisted of the following: incubation with DMEM + P4 (30 ng/mL) and incubation with DMEM + P4 (30 ng/mL) followed by stimulation with LPS (50 ng/mL). Samples of each tissue culture media were collected and evaluated by immunoassay for interleukin-6 (IL-6), interleukin-10 (IL-10) and tumor necrosis factor-a (TNF-a) at 0, 8, 24 and 48 hours after LPS was added. Results are reported as mean G SEM. RESULTS: Levels of IL-6, IL-10 and TNF-a in the control and P4 treated arteries not undergoing inflammatory stimulation were similar at all time points. Following LPS stimulation, there were significant differences in the level of IL-6 in control arteries compared with P4 treated arteries at 8, 24, and 48 hours (8h: 2100 G 800 ng/mg tissue vs 170 G 90 ng/mg tissue, P ! .001; 24h: 13,000 G 3600 ng/mg tissue vs 2100 G 800 ng/mg tissue, P ! .001; 48h: 20,800 G 5000 ng/mg tissue vs 6500 G 1700 ng/mg tissue, P ! .001). IL-10 and TNF-a levels were similar in controls compared with treatment groups at all times following LPS exposure. CONCLUSION: Following inflammatory stimulation with LPS, fetoplacental arteries exposed to P4 have decreased production of the proinflammatory cytokine IL-6. P4 did not appear to alter the production of IL-10 or TNFa following inflammatory stimulation with LPS in this model.
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A COMPREHENSIVE TERATOLOGICAL ASSESSMENT OF ISOSULFAN BLUE (LYMPHAZURIN 1%) IN THE PREGNANT SPRAGUE DAWLEY RAT SHANE BANKS1, QUINTESSA MILLER2, JOSEPH HARRE3, MICHAEL LILLY2, MICHAEL ROSE4, 1United States Air Force–Keesler Medical Center, Mississippi, USA, General Surgery, Ocean Springs, Mississippi, 2United States Air Force, Keesler Medical Center, MS, General Surgery, Ocean Springs, Mississippi, 3United States Army, Keesler Medical Center, MS, Clinical Research Lab, Ocean Springs, Mississippi, 4United States Air Force, Keesler Medical Center, MS, Surgical Oncology, Ocean Springs, Mississippi OBJECTIVE: No study has reported an evaluation of the teratogenicity of isosulfan blue (Lymphazurin 1%) in a developing fetus. This study evaluated the effects of isosulfan blue in fetuses of the pregnant female rat during early, middle, and late gestational stages. Isosulfan Blue (Lymphazurin 1%) is a rosaniline dye of the triphenylmethane type that is injected intraoperatively to detect sentinel lymph nodes in patients undergoing breast cancer or melanoma treatment. If isosulfan blue were found to be safe in a pregnant human patient for injection during sentinel lymph node biopsy, a full lymph node dissection could be avoided in selected cases of breast cancer or melanoma that occurs in association with pregnancy. STUDY DESIGN: Forty-seven pregnant rats received either subcutaneous injection (1.0 ml) of isosulfan blue or normal saline on one of the following gestational days: seven, fourteen, or eighteen. Each rat underwent cesarean section either the following day (24 hours post injection), or it was delayed until full-term. Amniotic fluid samples were drawn and analyzed while fetuses and maternal uterine horns were examined. Fetuses were then examined under a stereomicroscope for external malformations and processed for histological evaluation for internal organ or skeletal malformations. RESULTS: A total of 689 fetuses were harvested. Two malformations occurred in the control arm. There were 521 amniotic fluid samples collected; the average absorbance of the isosulfan blue arm was 0.01563 G 0.02, while the control average was 0.01532 G 0.03. The fetal abortion/resorption rate was equivalent in both treatment and control groups at 4.34%. The full-term average weights were not statistically different (P O .05). CONCLUSION: No statistically significant differences were found between arms with respect to: malformation rate, amniotic fluid light absorbance, fullterm fetal abortion rate, or full-term fetal weight (P O .05). isosulfan blue dye was used without an increased malformation risk and is highly unlikely to cross the placental barrier in this rat model.
PROGNOSIS OF THE SURVIVING CO-TWIN AFTER INTRAUTERINE FETAL DEMISE (IUFD) IN TTTS TREATED BY LASER OTTAVIA CAVICCHIONI1, MASAMI YAMAMOTO1, ROMAINE ROBYR1, YVES VILLE1, 1Universite´ Paris Ouest SQY-V CHI Poissy St Germain en Laye, Poissy, France OBJECTIVE: To evaluate the incidence, fetal characteristics and consequences of ntrauterine death (IUFD) of at least one twin, in TTTS treated by laser. STUDY DESIGN: Prenatal assessment and neonatal outcome of 120 cases of TTTS treated by selective laser coagulation of chorionic plate anastomoses before 26 weeks’ were reviewed. Cases with intrauterine fetal demise of one or both twins not related to preterm delivery were identified. Fetal characteristics and complications of pregnancy were analysed in relation with IUFD using univariate analysis and multiple regression. RESULTS: IUFD of one twin occurred in 40 cases (33%) 8 hours to 85 (median: 13) days post laser including 29 donors and 21 recipients. 51% and 31% of the cases were stage 2 and 3 respecyively and 77% of donors that died had severe growth restriction (IUGR). IUFD of the co-twin occurred in 5 cases (4.2%). Late miscarriage occurred in another 2 cases (5%) within 2 weeks. Neonatal death or severe morbidity of the survivors occurred in 2 (5.5%) and 2 (5.5%) respectively. The risk of IUFD decreased progressively with gestational age at laser from 60% at 15 weeks to 28% at 26 weeks (P = .023). Multivariate analysis showed that IUFD was associated with the presence of preoperative umbilical artery Doppler abnormalities (P = .001) and velamentous cord insertion (P = .038). CONCLUSION: Overall the prognosis of the surviving co-twin was poor in up to 8/40 (20%) of the cases. The majority of these unfavorable outcomes could be anticipated in utero with the possibility of terminating severely the severely affected survivors. Thus 32 of 36 (89%) liveborn babies were neurologically normal at 1 to 44 months of life. Low gestational age at diagnosis, umbilical artery Doppler abnormalities and velamentous cord insertion may be considered as risk factors for IUFD and should influence counselling both in terms of therapeutic approach and outcome.
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CLARA CELL PROTEIN 16 (CCP16) IN MID-TRIMESTER AMNIOTIC FLUID: ASSOCIATION WITH MYCOPLASMA HOMINIS DETECTION, ETHNICITY, AND A CCP16 +38 GENE POLYMORPHISM SRIRAM C. PERNI1, SANTOSH VARDHANA1, ROBIN B. KALISH1, STEPHEN T. CHASEN1, STEVEN S. WITKIN1, 1Weill Medical College of Cornell University, Obstetrics and Gynecology, New York, New York OBJECTIVE: Ethnicity, microbial infection, and carriage of distinct alleles of polymorphic genes all influence the rates of adverse pregnancy outcomes and neonatal morbidity. CCP16, a major protein secreted by lung epithelial cells, has anti-inflammatory properties and modulates immunologic responses to pulmonary infections. The aim of our study was to measure CCP16 in mid-trimester amniotic fluid in relation to mycoplasmal detection, ethnicity, and carriage of a CCP16 gene polymorphism. STUDY DESIGN: Subjects were 184 pregnant women with singleton gestations who presented for genetic amniocentesis between 15 and 20 weeks of gestation. CCP16 levels were measured by ELISA. M hominis and U urealyticum were detected by PCR-ELISA. The +38 A > G polymorphism in exon one of the CCP16 gene was determined by polymerase chain reaction. Demographic data were retrieved from medical records. Mann-Whitney U tests and linear regression analysis were used where appropriate. RESULTS: The median CCP16 concentration was higher in blacks (34.9 ng/ mL) and Hispanics (27.7 ng/mL) than in whites (17.1 ng/mL) or Asians (16.2 ng/ mL) (P ! .005). Whites positive for intraamniotic M hominis had higher median CCP16 levels (49.6 ng/ml) than did Whites negative for M hominis (16.9 ng/ml) (P = .01). There was no relationship between M hominis and CCP16 levels in non-whites or between U urealyticum detection and CCP16 levels in Whites or non-Whites. Fetuses homozygous for CCP16*G had higher median CCP16 amniotic fluid levels (18.0 ng/ml) than did fetuses who were CCP16*G/CCP16*A heterozygotes (13.0 ng/ml) or CCP16*A homozygotes (13.4 ng/ml) (P ! .05). CONCLUSION: CCP16 +38 gene polymorphism, race/ethnicity, and intraamniotic carriage of M hominis influence mid-trimester intraamniotic CCP16 levels. The influence of differential mid-trimester CCP16 production on susceptibility to neonatal lung pathology remains to be determined. Supported by NIH HD41676.
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Pavilion, Reno Hilton PROGESTERONE MODULATION OF INFLAMMATORY CYTOKINE PRODUCTION IN FETOPLACENTAL ARTERIES ANDREA SHIELDS1, JAMES WRIGHT2, PATRICK MCNUTT2, JENNIFER GOTKIN1, DAMIAN PAONESSA1, BOBBY HOWARD1, NATHAN HOELDTKE3, PETER NAPOLITANO1, 1Madigan Army Medical Center, Maternal Fetal Medicine, Tacoma, Washington, 2Madigan Army Medical Center, Clinical Investigations, Tacoma, Washington, 3Tripler Army Medical Center, Maternal Fetal Medicine, Honolulu, Hawaii OBJECTIVE: To determine if there is decreased inflammatory cytokine production from fetal arteries pretreated with progesterone (P4) following lipopolysaccharide stimulation. STUDY DESIGN: Five placentas were obtained from normal pregnancies following delivery at term. Four chorionic plate arteries were dissected from each placenta and incubated for 24 hours prior to undergoing inflammatory stimulation. Control groups consisted of the following: incubation with Dulbecco’s Modified Eagles Media (DMEM) alone and incubation with DMEM followed by stimulation with lipopolysaccaride (LPS) (50 ng/mL). Treatment groups consisted of the following: incubation with DMEM + P4 (30 ng/mL) and incubation with DMEM + P4 (30 ng/mL) followed by stimulation with LPS (50 ng/mL). Samples of each tissue culture media were collected and evaluated by immunoassay for interleukin-6 (IL-6), interleukin-10 (IL-10) and tumor necrosis factor-a (TNF-a) at 0, 8, 24 and 48 hours after LPS was added. Results are reported as mean G SEM. RESULTS: Levels of IL-6, IL-10 and TNF-a in the control and P4 treated arteries not undergoing inflammatory stimulation were similar at all time points. Following LPS stimulation, there were significant differences in the level of IL-6 in control arteries compared with P4 treated arteries at 8, 24, and 48 hours (8h: 2100 G 800 ng/mg tissue vs 170 G 90 ng/mg tissue, P ! .001; 24h: 13,000 G 3600 ng/mg tissue vs 2100 G 800 ng/mg tissue, P ! .001; 48h: 20,800 G 5000 ng/mg tissue vs 6500 G 1700 ng/mg tissue, P ! .001). IL-10 and TNF-a levels were similar in controls compared with treatment groups at all times following LPS exposure. CONCLUSION: Following inflammatory stimulation with LPS, fetoplacental arteries exposed to P4 have decreased production of the proinflammatory cytokine IL-6. P4 did not appear to alter the production of IL-10 or TNFa following inflammatory stimulation with LPS in this model.
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A COMPREHENSIVE TERATOLOGICAL ASSESSMENT OF ISOSULFAN BLUE (LYMPHAZURIN 1%) IN THE PREGNANT SPRAGUE DAWLEY RAT SHANE BANKS1, QUINTESSA MILLER2, JOSEPH HARRE3, MICHAEL LILLY2, MICHAEL ROSE4, 1United States Air Force–Keesler Medical Center, Mississippi, USA, General Surgery, Ocean Springs, Mississippi, 2United States Air Force, Keesler Medical Center, MS, General Surgery, Ocean Springs, Mississippi, 3United States Army, Keesler Medical Center, MS, Clinical Research Lab, Ocean Springs, Mississippi, 4United States Air Force, Keesler Medical Center, MS, Surgical Oncology, Ocean Springs, Mississippi OBJECTIVE: No study has reported an evaluation of the teratogenicity of isosulfan blue (Lymphazurin 1%) in a developing fetus. This study evaluated the effects of isosulfan blue in fetuses of the pregnant female rat during early, middle, and late gestational stages. Isosulfan Blue (Lymphazurin 1%) is a rosaniline dye of the triphenylmethane type that is injected intraoperatively to detect sentinel lymph nodes in patients undergoing breast cancer or melanoma treatment. If isosulfan blue were found to be safe in a pregnant human patient for injection during sentinel lymph node biopsy, a full lymph node dissection could be avoided in selected cases of breast cancer or melanoma that occurs in association with pregnancy. STUDY DESIGN: Forty-seven pregnant rats received either subcutaneous injection (1.0 ml) of isosulfan blue or normal saline on one of the following gestational days: seven, fourteen, or eighteen. Each rat underwent cesarean section either the following day (24 hours post injection), or it was delayed until full-term. Amniotic fluid samples were drawn and analyzed while fetuses and maternal uterine horns were examined. Fetuses were then examined under a stereomicroscope for external malformations and processed for histological evaluation for internal organ or skeletal malformations. RESULTS: A total of 689 fetuses were harvested. Two malformations occurred in the control arm. There were 521 amniotic fluid samples collected; the average absorbance of the isosulfan blue arm was 0.01563 G 0.02, while the control average was 0.01532 G 0.03. The fetal abortion/resorption rate was equivalent in both treatment and control groups at 4.34%. The full-term average weights were not statistically different (P O .05). CONCLUSION: No statistically significant differences were found between arms with respect to: malformation rate, amniotic fluid light absorbance, fullterm fetal abortion rate, or full-term fetal weight (P O .05). isosulfan blue dye was used without an increased malformation risk and is highly unlikely to cross the placental barrier in this rat model.
PROGNOSIS OF THE SURVIVING CO-TWIN AFTER INTRAUTERINE FETAL DEMISE (IUFD) IN TTTS TREATED BY LASER OTTAVIA CAVICCHIONI1, MASAMI YAMAMOTO1, ROMAINE ROBYR1, YVES VILLE1, 1Universite´ Paris Ouest SQY-V CHI Poissy St Germain en Laye, Poissy, France OBJECTIVE: To evaluate the incidence, fetal characteristics and consequences of ntrauterine death (IUFD) of at least one twin, in TTTS treated by laser. STUDY DESIGN: Prenatal assessment and neonatal outcome of 120 cases of TTTS treated by selective laser coagulation of chorionic plate anastomoses before 26 weeks’ were reviewed. Cases with intrauterine fetal demise of one or both twins not related to preterm delivery were identified. Fetal characteristics and complications of pregnancy were analysed in relation with IUFD using univariate analysis and multiple regression. RESULTS: IUFD of one twin occurred in 40 cases (33%) 8 hours to 85 (median: 13) days post laser including 29 donors and 21 recipients. 51% and 31% of the cases were stage 2 and 3 respecyively and 77% of donors that died had severe growth restriction (IUGR). IUFD of the co-twin occurred in 5 cases (4.2%). Late miscarriage occurred in another 2 cases (5%) within 2 weeks. Neonatal death or severe morbidity of the survivors occurred in 2 (5.5%) and 2 (5.5%) respectively. The risk of IUFD decreased progressively with gestational age at laser from 60% at 15 weeks to 28% at 26 weeks (P = .023). Multivariate analysis showed that IUFD was associated with the presence of preoperative umbilical artery Doppler abnormalities (P = .001) and velamentous cord insertion (P = .038). CONCLUSION: Overall the prognosis of the surviving co-twin was poor in up to 8/40 (20%) of the cases. The majority of these unfavorable outcomes could be anticipated in utero with the possibility of terminating severely the severely affected survivors. Thus 32 of 36 (89%) liveborn babies were neurologically normal at 1 to 44 months of life. Low gestational age at diagnosis, umbilical artery Doppler abnormalities and velamentous cord insertion may be considered as risk factors for IUFD and should influence counselling both in terms of therapeutic approach and outcome.
565
CLARA CELL PROTEIN 16 (CCP16) IN MID-TRIMESTER AMNIOTIC FLUID: ASSOCIATION WITH MYCOPLASMA HOMINIS DETECTION, ETHNICITY, AND A CCP16 +38 GENE POLYMORPHISM SRIRAM C. PERNI1, SANTOSH VARDHANA1, ROBIN B. KALISH1, STEPHEN T. CHASEN1, STEVEN S. WITKIN1, 1Weill Medical College of Cornell University, Obstetrics and Gynecology, New York, New York OBJECTIVE: Ethnicity, microbial infection, and carriage of distinct alleles of polymorphic genes all influence the rates of adverse pregnancy outcomes and neonatal morbidity. CCP16, a major protein secreted by lung epithelial cells, has anti-inflammatory properties and modulates immunologic responses to pulmonary infections. The aim of our study was to measure CCP16 in mid-trimester amniotic fluid in relation to mycoplasmal detection, ethnicity, and carriage of a CCP16 gene polymorphism. STUDY DESIGN: Subjects were 184 pregnant women with singleton gestations who presented for genetic amniocentesis between 15 and 20 weeks of gestation. CCP16 levels were measured by ELISA. M hominis and U urealyticum were detected by PCR-ELISA. The +38 A > G polymorphism in exon one of the CCP16 gene was determined by polymerase chain reaction. Demographic data were retrieved from medical records. Mann-Whitney U tests and linear regression analysis were used where appropriate. RESULTS: The median CCP16 concentration was higher in blacks (34.9 ng/ mL) and Hispanics (27.7 ng/mL) than in whites (17.1 ng/mL) or Asians (16.2 ng/ mL) (P ! .005). Whites positive for intraamniotic M hominis had higher median CCP16 levels (49.6 ng/ml) than did Whites negative for M hominis (16.9 ng/ml) (P = .01). There was no relationship between M hominis and CCP16 levels in non-whites or between U urealyticum detection and CCP16 levels in Whites or non-Whites. Fetuses homozygous for CCP16*G had higher median CCP16 amniotic fluid levels (18.0 ng/ml) than did fetuses who were CCP16*G/CCP16*A heterozygotes (13.0 ng/ml) or CCP16*A homozygotes (13.4 ng/ml) (P ! .05). CONCLUSION: CCP16 +38 gene polymorphism, race/ethnicity, and intraamniotic carriage of M hominis influence mid-trimester intraamniotic CCP16 levels. The influence of differential mid-trimester CCP16 production on susceptibility to neonatal lung pathology remains to be determined. Supported by NIH HD41676.