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Preeclampsia represents one of the most frequent complications of pregnancy, however, little is known about its aetiology. Damage of the endothelial layer lining the blood vessel wall is thought to play an important role in the pathophysiology of preeclampsia, accordingly, mild hyperhomocysteinaemia has been reported to be more prevalent among preeclamptic women. Therefore, we investigated the role of hyperhomocysteinaemia in preeclampsia by measuring plasma levels of homocysteine and studying the prevalence of the 677(C-->T) polymorphism in the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene, which may lead to reduced MTHFR enzyme activity and subsequently to higher plasma homocysteine levels. Plasma samples of 10 healthy non-pregnant women, 10 normotensive pregnant women, and 20 women with preeclampsia were analysed for total homocysteine levels by high performance liquid chromatography. Furthermore, 167 Dutch non-pregnant women previously hospitalised for preeclampsia and 403 population-based controls were analysed for the 677(C-->T) polymorphism by polymerase chain reaction followed by restriction fragment length polymorphism analysis (PCR/RFLP). In normotensive pregnancy homocysteine levels were lower compared with levels in healthy non-pregnant controls (8.4 versus 13.7micromol/l, P<0.001). Women with preeclampsia showed higher concentrations than women during normotensive pregnancy (13.3 versus 8.4micromol/l, P<0.02). However, levels of homocysteine in preeclampsia were comparable to those found in healthy non-pregnant women. PCR/RFLP showed no significant difference in the incidence of the 677(C-->T) polymorphism in the MTHFR gene between preeclamptic women with or without HELLP syndrome and controls (13 and 9% homozygous for the less common T-allele, respectively; OR 1.5, 95% CI 0.8-2.6, P=0.17). In contrast with previous reports, we cannot confirm that mild hyperhomocysteinaemia is a risk factor for preeclampsia. Pregnancy induced hyperhomocysteinaemia found in preeclampsia might better be explained by fluctuations in plasma volume than by the presence of the 677(C-->T) polymorphism in the MTHFR gene.

Objective: Microsomal epoxide hydrolase is an important enzyme involved in the metabolism of endogenous and exogenous toxicants. Polymorphic variants of the human epoxide hydrolase gene vary in enzyme activity. We determined whether genetic variability in the gene encoding for microsomal epoxide hydrolase contributes to individual differences in susceptibility to the development of pre-eclampsia with or without the syndrome of Haemolysis, Elevated Liver enzymes, and Low Platelets (HELLP)., Methods: A total of 183 non-pregnant women with a history of pre-eclampsia, 96 of whom had concurrently developed the HELLP syndrome, and 151 healthy female controls were genotyped for the 113Tyr-->His polymorphism in exon 3 and the 139His-->Arg polymorphism in exon 4 of the epoxide hydrolase gene by a polymerase chain reaction-restriction fragment length polymorphism assay. Chi-square analysis was used for statistical evaluation of differences in polymorphic rates., Results: In pre-eclampsia a higher frequency (29%) of the high activity genotype Tyr113 Tyr113 in exon 3 was found as compared to controls (16%, OR 2.0, 95% CI 1.2-3.7). There was no difference between groups for the 139His-->Arg polymorphism. In women with a history of pre-eclampsia, no difference in epoxide hydrolase genotypes was found between women who either did or did not develop the HELLP syndrome. In addition, a significant association was found between predicted EPHX activity and pre-eclampsia., Conclusions: Women with the high activity genotype in exon 3, which could reflect differences in metabolic activation of endogenous or exogenous toxic compounds, may have enhanced susceptibility to pre-eclampsia. However, polymorphisms in the epoxide hydrolase gene do not seem to influence the risk for concurrent development of the HELLP syndrome.

Enhanced levels of reactive oxygen species (ROS) and decreased levels of antioxidants may contribute to the development of pre-eclampsia. Protein carbonyls may be sensitive biomarkers for ROS-mediated protein damage, whereas the ferric reducing ability of plasma (FRAP) value may serve as marker for antioxidant capacity.Twenty-two healthy pregnant women and 50 patients with severe pre-eclampsia, 25 of whom with concurrent (haemolysis, elevated liver enzymes, low platelets) HELLP syndrome were investigated prospectively with respect to placental and decidual levels of protein carbonyls and FRAP antioxidant capacity. Measurements were evaluated using the Kruskal-Wallis or Mann-Whitney U -tests for comparison between groups, and the Wilcoxon signed-rank test for comparison within groups. Spearman's correlation tests were used for correlation analyses. Placental and decidual protein carbonyl levels were higher in pre-eclampsia with HELLP than in healthy pregnancy, whereas FRAP levels were lower. Differences between pre-eclampsia and healthy pregnancy showed the same trend, but did not reach statistical significance. In pre-eclampsia with HELLP syndrome carbonyl levels as well as FRAP levels were significantly higher in placenta as compared with decidua.Higher levels of protein carbonyls and lower antioxidant capacity in both placenta and decidua in pre-eclampsia with concurrent HELLP syndrome as compared to healthy pregnancy may indicate that considerable ROS-mediated damage occurs in this disorder., (Copyright 2001 Harcourt Publishers Ltd.)

Evidence of the impact of maternal nutritional status on pregnancy outcome is increasing. However, reference values for vitamin and homocysteine concentrations in maternal blood during normal pregnancy are scarce, and are lacking for the preconceptional period and early pregnancy. Thus, in a longitudinal study we evaluated vitamin and homocysteine concentrations in 102 nulliparous women with an uneventful singleton pregnancy and normal outcome not using supplements. The physiological changes in vitamin and homocysteine concentrations in blood were determined from the preconceptional period throughout pregnancy until 6 weeks post-partum. The vitamins evaluated comprised retinol, thiamin, riboflavin, pyridoxal 5'-phosphate, folate in serum and erythrocytes, vitamin B12 and alpha-tocopherol. The plasma homocysteine concentration was also measured, considering the essential roles of folate, vitamin B6 and vitamin B12 in homocysteine metabolism. The concentrations of retinol, thiamin, pyridoxal 5'-phosphate serum folate and vitamin B12 decreased during pregnancy. In contrast, the concentrations of riboflavin, alpha-tocopherol, and folate in erythrocytes increased or showed only minor changes. Homocysteine concentrations also remained approximately constant during pregnancy. These observations emphasize the importance of preconceptional and post-partum concentrations of vitamins in the evaluation of pregnancy-induced changes. These data have provided valuable reference values for vitamins and homocysteine before, during and after pregnancy in order to contribute to better diagnosis of maternal deficiencies and to study further the relationship between maternal vitamin status and adverse course and outcome of pregnancy.

Purpose: The purpose of the present study was to determine the gluthathione S-transferases (GST) P1-1 and A1-1 levels in cyst fluid from malignant, borderline, and benign ovarian tumors. The clinical relevance of these enzymes in cyst fluid was investigated, including the possible relation with resistance to chemotherapy., Methods: A total of 90 ovarian cysts were punctured for cyst fluid collection. GSTP1-1 and GSTA1-1 concentrations were determined by ELISA in cyst fluid from 23 malignant, 9 borderline, and 51 benign primary ovarian tumors, and levels were correlated with histopathological data., Results: Significantly higher GSTP1-I concentrations were found in cyst fluid from malignant (median: 477 ng/ml), compared with benign (median: 52 ng/ml) ovarian cysts (p < 0.0001), as well as in fluid from borderline (median: 366 ng/ml) compared with benign cysts (p < 0.0001). No significant differences were found in cyst fluid GSTA1-1 concentrations between the histologic subgroups. In cyst fluid from malignant tumors higher GSTPI-1 and lower GSTAI-1 concentrations were found in patients with worse prognostic factors: FIGO II-III-IV, grade 2-3, residual tumor > 2 cm, presence of ascites, patients with recurrent disease, and survival, but differences were not significant. In the subgroup of patients that received cisplatin-based chemotherapy (n = 14) significantly higher GSTP1-1 (p = 0.01) concentrations were found in patients with recurrence compared with patients without recurrence. Considering only FIGO stage I patients, a differentiation could be made between patients with or without recurrence based on cyst fluid GSTP I - I concentrations., Conclusions: Determination of glutathione S-transferases P 1-1 in cyst fluid samples from ovarian tumors can be of additiona] value in the differentiation between histologic subgroups. In case of possible low malignant potential cysts where sampling of the most representative tissue can be an issue, determination of GSTP- I concentrations in cyst fluid may optimise histopathologic classification. Cyst fluid GSTP1-1 seems to be a good marker for aggressiveness of the ovarian tumor, and it may predict response to chemotherapy.

Objective: Assessment of anxiety levels in women and men before and after preconception counseling and during the first trimester of pregnancy., Methods: Couples were recruited from the fertility clinic of the University Medical Center Nijmegen, the Netherlands. Anxiety was assessed using the 40-item Spielberger State-Trait Anxiety Inventory (STAI)., Results: 53 women and 51 men (74%) completed the STAI both before and after counseling. Anxiety levels did not change significantly after counseling or during the first trimester of pregnancy. 83.4% would recommend preconception counseling to others., Conclusion: Preconception counseling is valued by the majority of women and men and does not lead to adverse psychological effects.

Effects of folate deficiency on the rate of apoptosis in human cytotrophoblastic cells has been investigated. Apoptosis was determined in cytotrophoblastic cells after culture in 1. control medium, 2. folate-free medium and 3. folate-free medium plus 10% fetal calf serum. Apoptosis rates in cells cultured in mediums 2 and 3 were significantly higher than those cultured in the control medium (P<0.02 and P<0.03, respectively). In conclusion, human cytotrophoblastic cells show a significantly increased rate of apoptosis in vitro after culture in a folate-free medium. Possible explanations for the association between folate deficiency and pregnancy complications are suggested.

An imbalance between oxidative stress and maternal detoxification or antioxidant capacity may explain the symptoms of preeclampsia and the haemolysis-elevated liver enzymes-low platelets (HELLP) syndrome. Oxidative stress is known to induce damage of the endothelium, which is one of the pathophysiological features of preeclampsia and the HELLP syndrome. Administration of N-acetylcysteine, an antioxidant itself and a precursor of the endogenous antioxidant glutathione, might stabilize or even partly recover the process of endothelial damage and may lead to prolongation of pregnancy.

Increased reactive oxygen species (ROS) and lipid peroxidation may be implicated in the pathogenesis of preeclampsia by causing cell (membrane) damage and impaired endothelial function. Carbonyl derivatives of proteins, or protein carbonyls, may be sensitive biomarkers of ROS-mediated damage. The aim of the study was to compare levels of protein carbonyls in plasma of preeclamptic, healthy pregnant and healthy nonpregnant women. Plasma protein carbonyls were measured in 47 preeclamptic, 45 healthy pregnant and 22 healthy nonpregnant women by using a sensitive ELISA-method. ANOVA, the unpaired t-test and Pearson's correlation were used for statistical analysis. Preeclamptic women had significantly higher plasma protein carbonyl levels than healthy pregnant women (P < 0.0001). Healthy pregnant women showed significantly higher protein carbonyl levels (P < 0.001) as compared to nonpregnant controls. The higher levels of protein carbonyls as compared to nonpregnant controls suggest that increased oxygen free radical damage occurs in normal pregnancy and to a much higher extent in preeclampsia.

Introduction: Dietary sodium restriction results in activation of the renin-angiotensin-aldosterone-system. In the non-pregnant situation renin release in response to a low sodium diet is mediated by prostaglandins. We studied the effect of dietary sodium restriction on urinary prostaglandin metabolism in pregnancy., Patients and Methods: In a randomized, longitudinal study the excretion of urinary metabolites of prostacyclin (6-keto-PGF(1 alpha)and 2,3-dinor-6-keto-PGF(1 alpha)) and thromboxane A(2)(TxB(2)and 2,3-dinor-TxB(2)) was determined throughout pregnancy and post partum in 12 women on a low sodium diet and in 12 controls., Results: In pregnancy the excretion of all urinary prostaglandins is increased. The 6-keto-PGF(1 alpha)/ TxB(2)-ratio as well as the 2, 3-dinor-6-keto-PGF(1 alpha)/ 2,3-dinor-TxB(2)-ratio did not significantly change in pregnancy. CONCLUISION Prostacyclin and thromboxane do not seem to play an important role in sodium balance during pregnancy., (Copyright 2000 Harcourt Publishers Ltd.)

Objective: Investigation of the incidence of neonatal herpes in the Netherlands between 1992 and 1998., Design: Inventory questionnaire survey., Methods: All virological laboratories in the Netherlands were sent a questionnaire on the number of culture proven cases of neonatal herpes recorded between 1992 and 1998 and on the type of herpes simplex virus (HSV-1 or HSV-2). The gynaecological and paediatric departments of all university hospitals and of half of the general hospitals were sent questionnaires as well. Gynaecologists were asked how often caesarean section was performed in order to prevent neonatal herpes and how frequently pregnant women were seen with genital herpes. Paediatricians were asked how often they observed neonatal herpes, the type of HSV and the possible transmission route. Based on these data the figures for the whole of the Netherlands were estimated., Results: The incidence of neonatal herpes in the Netherlands in the period 1992 to 1998 was 2.4 per 100,000 neonates. HSV-1 was the cause of neonatal herpes in 73%, HSV-2 in 9%, and in 18% of the cases the type of infection was not recorded. The number of pregnant women with genital herpes had increased, but, in agreement with a consensus statement, the gynaecologists hardly performed caesarean sections any more to prevent neonatal herpes (2 per year)., Conclusions: The incidence of neonatal herpes in the Netherlands had not increased. There was no predominant role of HSV type 2 causing neonatal herpes.

Objective: To study the influence of chronic dietary sodium restriction on uteroplacental circulation., Methods: In a randomized trial, Doppler flow velocity waveforms of the uterine and umbilical artery were studied at monthly intervals during pregnancy in 59 women on a low-sodium diet and in 68 controls., Results: Pulsatility index (PI), resistance index (RI), and A/B ratio of the uterine artery were significantly lower during sodium restriction, whereas PI, RI, and A/B ratio of the umbilical artery were significantly higher., Conclusions: The lower resistance indices of the uterine artery during sodium restriction might reflect an increase in pulse pressure/impedance ratio as a result of activation of the renin-angiotensin system. The increase in umbilical artery resistance indices supports the hypothesis that fetal circulation might be altered by chronic dietary sodium restriction.

Objective: To determine whether genetic variability in biotransformation enzymes contributes to individual differences in susceptibility to preeclampsia or the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP)., Methods: Polymorphisms in the genes of glutathione S-transferases and cytochrome P-450 1A1 were assessed by polymerase chain reaction in 170 nonpregnant women with a history of preeclampsia, 90 of whom had HELLP syndrome, and 109 healthy control women with an uncomplicated obstetric history. chi(2) analysis was used for statistical evaluation of differences in polymorphism rates., Results: A higher frequency of the glutathione S-transferase P1b-1b genotype was observed in preeclamptic women than in controls (14% in preeclampsia and 5% in controls; odds ratio 3.4, 95% confidence interval 1.2, 10. 6, P =.02). Genetic polymorphisms in other glutathione S-transferases and cytochrome P-450 1A1 genes occurred equally frequently in cases and controls. In women with a history of preeclampsia, there were no differences in the occurrence of the genetic polymorphisms investigated in women who either did or did not develop the HELLP syndrome., Conclusion: Women with the glutathione S-transferase P1b-1b genotype, which could result in lower glutathione S-transferase detoxification capacity, might have higher susceptibility to preeclampsia. However, polymorphisms in glutathione S-transferase genes do not seem to be a risk factor for development of the HELLP syndrome.

An imbalance between phase I drug metabolizing enzymes and phase II detoxification enzymes may contribute to the development of pre-eclampsia. Polymorphic variants in the phase I enzyme, cytochrome P450 genes may lead to increased toxification, whereas polymorphisms in the phase II enzyme, glutathione S-transferase genes may result in impaired detoxification. Most abundant in placenta and decidua is glutathione S-transferase P1-1, which may therefore be of particular importance in reproduction. We studied the frequencies of polymorphic variants in those enzymes in 187 women with recurrent early pregnancy loss and in 109 women with an uncomplicated obstetric history. DNA was extracted and subsequently polymerase chain reaction based genotyping assays were used. chi(2)-Analysis and Fisher's exact test were used for statistical evaluation. The glutathione S-transferase P1b-1b genotype was found significantly more often in women with recurrent early pregnancy loss than in controls (12% versus 5%, P = 0.03), in particular in those who consumed coffee (P = 0.02) or smoked cigarettes (P = 0.04). Polymorphisms in other glutathione S-transferase and cytochrome P450 genes occurred equally frequently in cases and controls. In conclusion, the occurrence of the glutathione S-transferase P1b-1b genotype, leading to lower glutathione S-transferase Pi enzyme activity and consequently to impaired placental detoxification, may represent a risk factor for recurrent early pregnancy loss.

Objective: To estimate the relative risk of recurrent early pregnancy loss for different total plasma homocysteine and serum folate concentrations., Methods: In a case-control study, we measured homocysteine (fasting and afterload), folate (serum and red cells), pyridoxal 5'-phosphate, and cobalamin concentrations in 123 women who had at least two consecutive spontaneous early pregnancy losses each and compared concentrations with those of 104 healthy controls., Results: Women with recurrent early pregnancy losses had significantly lower serum folate concentrations than controls, whereas the other measurements were similar to those of controls. Elevated homocysteine, fasting greater than 18.3 micromol/L and afterload greater than 61.5 micromol/L, was a risk factor for recurrent early pregnancy loss, with odds ratios (ORs) and 95% confidence intervals (95% CIs) of 3.6 (1.2, 12.7) and 2.7 (0.9, 8.8) in the group with recurrent miscarriages: 6.4 (1.9, 24.3) and 4.3 (1. 2, 17.3) in primary aborters, and 4.2 (1.3, 15.4) and 3.4 (1.0, 12. 8) in those with three or more miscarriages. The ORs (95% CIs) in the same study populations for serum folate concentrations less than 8.4 nmol/L were 2.1 (0.9, 4.8), 2.7 (1.0, 7.8), and 3.2 (1.3, 8.1), respectively. A significant dose-response relationship between serum folate concentrations and risk of recurrent early pregnancy loss suggested a protective effect by high serum folate concentrations., Conclusion: Elevated homocysteine and reduced serum folate concentrations were risk factors for recurrent spontaneous early pregnancy losses. Folic acid supplementation might be beneficial in women with histories of early pregnancy loss.

Objective: To investigate the prevalence of the 677 (C --> T) and 1298 (A --> C) polymorphisms in the methylenetetrahydrofolate reductase (MTHFR) gene in our preeclamptic population. For a summary estimation of the risk of the 677 (C --> T) polymorphism for preeclampsia, we also performed a meta-analysis on four previously published case-control studies to which our results were added., Methods: Genotypes were analyzed by polymerase chain reaction followed by restriction enzyme analysis. The results of 176 nonpregnant women, previously hospitalized for preeclampsia in a tertiary care center, were compared with 403 Dutch population-based controls. Results were statistically analyzed with a chi-square test., Mean Outcome Measures: The incidence of the 677 (C --> T) and 1298 (A --> C) polymorphisms in the MTHFR gene., Results: The incidence of both MTHFR missense polymorphisms was not significantly different between cases and controls. We found an odds ratio (OR) of 1.5 [95% confidence interval (CI) 0.8-2.6, p = 0.17] and an OR of 1.0 (95% CI 0.6-1.9, p = 0.23) for the 677 (C --> T) and the 1298 (A --> C) polymorphism, respectively, in cases comparing the prevalence of the homozygous genotype versus the other two genotypes. The meta-analysis resulted in a significant OR of 2.0 (95% CI 1.4-2.9)., Conclusions: In contrast to four previous studies, we were neither able to confirm an increased risk for preeclampsia to the 677 (C --> T) polymorphism nor did we find an increased risk for preeclampsia to the 1298 (A --> C) polymorphism. From the meta-analysis, however, we conclude that it cannot be ruled out that the homozygous 677TT genotype is a modest but significant risk factor for preeclampsia.

Methionine loading tests and folate, vitamin B(6), and vitamin B(12) analyses were performed in 27 mothers of children with congenital heart defects. Median fasting plasma homocysteine concentrations were significantly higher in the study group as compared with 56 control subjects (P =.0001). Maternal hyperhomocysteinemia may be a risk factor for congenital heart defects.

Maternal folic acid supplementation has been suggested to play a role in the prevention of nonsyndromic orofacial clefts, i.e., cleft lip +/- cleft palate. Using a case-control design, we investigated vitamin-dependent homocysteine metabolism in 35 mothers with nonsyndromic orofacial cleft offspring and 56 control mothers with nonmalformed offspring. A standardized oral methionine loading test was performed, in which fasting and afterload plasma total homocysteine, serum and red-cell folate, serum vitamin B12, and whole-blood vitamin B6 levels were determined. We found that both fasting (P < 0.01) as well as afterload (P < 0.05) homocysteine concentrations were significantly higher in cases compared to controls. Hyperhomocysteinemia, defined by a fasting and/or afterload homocysteine concentration above the 97.5th percentile, was present in 15.6% of the cases and in 3.6% of controls (odds ratio, 5.3 (1.1-24.2)). The median concentrations of serum (P < 0. 01) and red-cell (P < 0.05) folate were significantly higher, and vitamin B6 concentrations appeared to be significantly lower (P < 0. 05), in cases compared with controls. No significant difference was observed between groups for vitamin B12. These preliminary data offer evidence that maternal hyperhomocysteinemia may be a risk factor for having nonsyndromic orofacial cleft offspring., (Copyright 1999 Wiley-Liss, Inc.)

International studies have yielded contradictory results on efficacy of a sodium-restricted diet during pregnancy in preventing and curing hypertension of pregnancy. In the Netherlands three studies have been performed to investigate the value of dietary sodium restriction in pregnancy; they concerned epidemiology, prevention and treatment. Midwives often prescribed this dietary intervention. Urinary sodium excretion was not related to blood pressure changes in pregnancy. Dietary sodium restriction from the third month of pregnancy onwards did not reduce the incidence of pregnancy-induced hypertension. Maternal side effects were a decreased intake of nutrients, decreased maternal weight gain, lowered plasma volume and stimulation of the renin-angiotensin-aldosterone system. A dietary sodium restriction in women with early symptoms of pregnancy-induced hypertension showed no therapeutic effect on blood pressure. There is no place for dietary sodium restriction in the prevention or treatment of hypertension in pregnancy.

Pre-eclampsia is a major complication of pregnancy with high morbidity and mortality rates. The aetiology is still unclear but impaired detoxification or enhanced levels of reactive (oxygen) metabolites may contribute to the development or maintenance of pre-eclampsia. Glutathione and glutathione-related enzymes, as one of the major detoxificating and free-radical scavenging systems, may play a role in controlling the disease. Seventeen normotensive pregnant women and 24 pre-eclamptic women were investigated prospectively with respect to placental and decidual levels of total glutathione (GSH), glutathione S-transferase activity (GST), selenium-dependent glutathione peroxidase (SeGPX) and total glutathione peroxidase activity (TGPX, both selenium- and non-selenium-dependent GPX). Decidual levels of glutathione and related enzymes were compared with placental levels, and the investigated parameters in pre-eclampsia were compared with those in normotensive pregnancy by the Mann-Whitney U -test. Clinical data were correlated with biochemical parameters by Spearman's correlation test. Glutathione levels were significantly higher in decidua as compared with placenta. Glutathione levels were elevated in pre-eclampsia and HELLP (haemolysis, elevated liver enzymes, low platelets) as compared to normotensive pregnancy for decidua and in the placenta of patients with pre-eclampsia only. Glutathione S-transferase activity was not different between the two groups. In the placenta of patients with pre-eclampsia+HELLP, total glutathione peroxidase activity was elevated versus controls. Selenium-dependent glutathione peroxidase activity was higher in decidua versus placenta and in decidua of pre-eclamptic versus control subjects. Enhanced glutathione concentrations and glutathione peroxidase activities were often found in placenta and decidua in pre-eclampsia, probably as a compensatory mechanism to prevent further damage by peroxides, (oxygen) radicals or other toxins in the placenta or in the feto-placental interface., (Copyright 1999 Harcourt Publishers Ltd.)

Glutathione and glutathione-related enzymes are pivotal for the normal functioning of several important biological processes in humans. Glutathione and glutathione-related enzymes are involved in the metabolism and detoxification of cytotoxic and carcinogenic compounds as well as reactive oxygen species. The role of reactive oxygen species in reproduction was the subject of many investigations, and there is compelling evidence for the involvement of these species in the physiology and pathology of both male and female reproductive systems. The glutathione/glutathione-related enzyme system was extensively studied in gynaecological oncology, but to a lesser extent in other topics related to reproduction. In this paper a review is provided on the glutathione/glutathione-related enzyme system in reproduction. Attention is given to its role as a detoxicating system, and as an early marker for disease.

Purpose: We evaluated new intervention techniques and surgical instruments in a fetal monkey model to determine improvements that would be useful for early intrauterine intervention. Our findings may be helpful in the future for treating select cases of severe prenatal obstructive uropathology., Materials and Methods: In a series of experiments on 18 pregnant rhesus monkeys (Macaca mulatta) at mid trimester we assessed various endoscopic intra-amniotic access techniques as well as morbidity, mortality and possibilities for fetoscopy., Results: In all 18 fetuses adequate fetoscopy was possible with no maternal mortality. Of the 18 pregnancies 14 went to term with no early or late postoperative complications. Technical improvements changed the intrauterine access technique from open placement of trocars to the use of the Seldinger technique, gun introduction of needles with small caliber sheets and small caliber introduction trocars, resulting in minimal amniotic membrane separation. Various rigid and flexible endoscopes were evaluated for fetoscopy and up to 3 cannulas were placed. No change in the fetal growth pattern was observed on postoperative ultrasound. Subsequent pregnancies occurred during this study period, and there were no acceptance problems of the newborns by the mothers., Conclusions: New techniques have led to improved intrauterine fetal access. Morbidity mainly depends on the disruption of amniotic membranes, which has an important preterm role. Adapted endoscopes and other instruments offer new possibilities for fetal diagnosis and therapy in the future. Our primate model seems to be suitable for evaluating these new techniques before they are used in a clinical setting.

Objective: In the case of a monochorionic multiple pregnancy with one non-viable fetus who compromises its co-twin, fetoscopic cord ligation may be performed. We describe our fetoscopic cord ligation technique and discuss the efficacy of cord ligation for salvaging the co-twin, based on available data., Study Design: Descriptive case series of four cases and review of the cases published up to 1996., Results: We performed four successful ligations. Of the 23 reported cases, which include the present series, two ligations failed. Four fetuses died in utero, and 17 were born alive at a mean of 8 weeks following the procedure. Two babies died in the perinatal period, a third after 60 days. Preterm uterine contractions do not seem to be a clinical problem. Preterm prelabour rupture of the membranes (PPROM) complicates about 40% of cases, the majority occurring prior to 32 weeks., Conclusion: Fetoscopic cord ligation is a feasible procedure with a 71% survival rate and a high risk for PPROM.

Serum levels of aminotransferases, lactate dehydrogenase, gammaglutamyl transferase, alkaline phosphatase, albumin and conjugated bilirubin, measured in 54 women at a median of 31 months (range 3-101) after pregnancies complicated by the HELLP syndrome, were not elevated. Total bilirubin levels, however, were elevated in 20% of these women; this represents a significant difference from the prevalence in 151 women with a previous normal pregnancy (chi2 = 12.23, P < 0.001), or in the normal female population (chi2 = 22.34, P < 0.00001). This raises the possibility that a dysfunction of the bilirubin-conjugating mechanism represents a risk factor for the development of the HELLP syndrome.

Objective: To assess the awareness, opinions on desirability and preconditions such as special knowledge with regard to the concept of preconceptional health counselling among general practitioners., Design: Descriptive., Setting: General practices in the Groot Gelre district of the Dutch General Practitioners Society., Method: A representative sample of 100 general practitioners were asked by phone for permission to send a questionnaire; 89 out of the 94 general practitioners who were sent a questionnaire replied (response: 89%)., Results: Almost all general practitioners (88%) knew about the concept of preconceptional health counselling and most of them already gave some kind of preconceptional advice. 93% considered preconceptional health counselling part of their job responsibility and 91% were prepared to give more preconceptional health care in the future. 53% of all general practitioners, however, indicated that they lacked sufficient knowledge to give adequate advice. The advantages of preconceptional health care were considered to outweigh possible disadvantages such as medicalization of pregnancy., Conclusion: The general practitioners knew about preconceptional health care and considered it part of their job. Many already provided preconceptional health care, although not in a structured way. General practitioners appeared to lack time and appropriate knowledge, which indicates a need for postgraduate training.

Glutathione S-transferases (GST) are a family of enzymes involved in the detoxification of xenobiotics. In humans, GST are divided into four different classes, alpha, mu, pi and theta, with partly overlapping substrate specificity and a tissue-specific expression pattern. We studied the cellular distribution of GST alpha and pi in a variety of human embryonic organs obtained from an extra-uterine monozygotic twin pregnancy at 8 weeks' gestational age. Tissues were fixed in 4% paraformaldehyde and embedded in paraffin. Three 4 microm thick sections were used, one for routine haematein and eosin staining, the others for immunohistochemical determination using monoclonal and polyclonal antibodies against GST alpha and pi, respectively. Both GST alpha and pi were present in hepatocytes, gastrointestinal epithelium, adrenal gland medulla, and tela chorioidea in the telencephalon. GST pi, but not alpha, was found in the epithelium of pancreatic and pulmonary glands, trachea, nephrons and urinary collecting ducts, as well as in the pia mater of the telencephalon and in developing nerve tissue in the gastrointestinal muscularis mucosae. In summary, we have demonstrated that immunoreactive protein for both GST alpha and pi is expressed in the human embryo at 8 weeks' gestational age. The early expression of GST alpha and pi in the epithelia of the urinary and digestive tracts and the respiratory system supports the importance of GST in the detoxification of potentially toxic or carcinogenic compounds. Our results suggest that the embryo itself is capable of detoxifying noxious compounds that are generated intracellularly or that cross the trophoblastic tissue.

We report a disseminated intrauterine Pasteurella multocida infection in a puerperal woman who could not remember any traumatic exposure to her cat. An oral swab taken from the cat, just 2 days after the patient's admission, grew Pasteurella multocida, with an PCR-fingerprinting pattern identical to the patient's isolate. Hand-washing after every contact with cats and dogs and if feasible separation of in-house pets from mother and infant should be applied to prevent this uncommon but serious occurrence of post-partum infections. To our knowledge this is the first case of Pasteurella multocida 'child-bed fever', with a genotypically identical strain isolated from the in-house cat.

Endoscopic surgery may in the future become an attractive alternative to open fetal surgery. Herein, we present our evolving experience with minimal access techniques in sheep and nonhuman primate models. Fifty-two pregnant sheep (term = 145 d) were used. All underwent laparotomy. Cannulas were 5 mm diameter with balloon fixation device. In group I (95-105 d, n = 22, and 70-74 d, n = 19), a total of 119 cannulas were placed by open hysterotomy and pursestring suture through myometrium and membranes. In group II (n = 11), access was obtained by Seldinger guidewire technique. Eight cannulas were introduced over a dilator and 7 were radially expanding endoscopic cannulas. Fifteen cannulas were also placed in 5 pregnant Rhesus monkeys using Seldinger and radially expanding techniques. Cannula removal was followed by insertion of a collagen sponge plug and oversewing of the myometrium. Mini-hysterotomies with purse-stringing provided excellent access to the amniotic cavity, without dissection of the membranes. Classic Seldinger technique with forward dilatation was equally effective, but caused stretching of membranes. In sheep and in primates, Seldinger technique with radial dilatation allowed safe access without membrane separation. Leak-proof removal of the cannulas was achieved in all primates. Open hysterotomy with purse-string and balloon-tipped cannula provides efficient and safe access to the gravid sheep uterus. Seldinger technique allows equally secure access, and alleviates the need for hysterotomies. Radial dilatation of the porthole eliminates forward dissection of the membranes, both in sheep and primate models. This method, and collagen plug insertion upon completion of the endoscopic procedure, may provide a truly minimally invasive approach to in-utero surgery.

Neurohypophysial hormones are thought to be involved in alterations in fluid balance during pregnancy and delivery. In the course of normal pregnancy intravascular volume is increased whereas sodium restriction is thought to reduce plasma volume and cardiac output. In the present study, we measured the effect of long-term severe sodium restriction on vasopressin (AVP) and oxytocin (OT) levels during normal pregnancy and after delivery. Fifty-nine healthy nulliparous women were randomized either for a low sodium diet (20 mmol sodium daily) or for a normal diet from week 12 of pregnancy onwards. Circulating plasma levels and urinary excretion of AVP and OT, their neurophysins (Np-AVP and Np-OT) and AVP bound to platelets were determined at regular intervals during pregnancy and after delivery. After completion of the study, women on a sodium-restricted diet were compared with control women on a normal diet using repeated measurement ANOVA with adjustment for potentially confounding variables. After randomization, a reduction in urinary sodium excretion of, on average, 40-82% was found. In general, no effect of sodium restriction could be demonstrated on the various parameters (0.53 < P < 0.98) with the exception of a significantly lower 24-h urinary AVP excretion by non-smokers with sodium restriction compared with non-smokers having a normal diet (P = 0.018). For all parameters, clear changes were found in the course of pregnancy and puerperium (P < 0.0001 to P < 0.005). Platelet-bound AVP decreased and Np-OT increased during pregnancy. After birth, free plasma AVP, platelet-bound AVP, OT, osmolality, sodium and potassium increased, while Np-AVP and Np-OT decreased. Although elevated Np-AVP and Np-OT levels during pregnancy seem to indicate increased release of neurohypophysial hormones, pregnancy up to 36 weeks of gestation is accompanied by low circulating AVP and OT levels. Long-term severe sodium restriction diminishes urinary AVP excretion in (non-smoking) pregnant women, without changing circulating levels of AVP and OT, despite the known reduction in circulating volume. The reduced circulating (platelet-bound) AVP levels during pregnancy, whether or not in combination with severe sodium restriction, support the absence of significant non-osmotic stimulation of AVP during pregnancy.

Objectives: Prenatal ultrasonographic investigations have led to an increasing number of prenatally detected abnormalities, of which a large number involves the urogenital tract. This study was performed to evaluate if endoscopic intra-amniotic access is possible in primates., Methods: In 10 midtrimester rhesus monkeys (Macaca mulatta), endoscopic intrauterine fetoscopy was performed with three access cannulas. Using a Seldinger technique, a vascular access system, and a pediatric laparoscopy set, intra-amniotic inspection was attempted. Fetal growth throughout pregnancy was monitored by ultrasonographic measurements of fetal biometry., Results: Intrauterine access could successfully be achieved in 10 rhesus monkeys with three cannulas. After partial amniotic fluid exchange, adequate fetoscopy was always possible. Two monkeys aborted on the second and sixth postoperative days. Serial ultrasonographic investigations for fetal biometry showed no disturbance of the intrauterine growth patterns in the remaining 8 monkeys., Conclusions: We currently conclude that the rhesus monkey model for experimental intrauterine endoscopic surgery may be suitable for study of the developmental abnormalities of the genitourinary tract.

Dietary sodium restriction is used in the Netherlands in the prophylaxis of preeclampsia. To study the effects of long-term sodium restriction on the intake of other nutrients and the outcome of pregnancy, 68 healthy nulliparous pregnant women were randomly assigned to either a low-sodium diet (20 mmol/24 h) or an unrestricted diet. The diet was consumed between week 14 of gestation and delivery. The dietary intakes of energy, fat, protein, carbohydrate, sodium, potassium, and calcium were estimated with the dietary-history technique. A low-sodium diet reduced the intake of protein (by approximately 15 g/24 h), fat (by 20 g/24 h), and calcium (by 350 mg/24 h) and tended to decrease the energy intake (by approximately 0.7 MJ/24 h). The intakes of carbohydrate and potassium did not differ between the groups. The maternal weight gain was less in the low-sodium group (6.0 +/- 3.7 compared with 11.7 +/- 4.7 kg). Mean birth weight was not significantly different (3.2 +/- 0.5 compared with 3.4 +/- 0.5 kg).

Background: Most laboratory parameters change during pregnancy. A serial study of a large number of routine haematological and biochemical blood parameters and biochemical urine parameters was conducted in a group of 66 healthy nulliparous pregnant women, who had an uncomplicated pregnancy., Methods: Blood samples and 24-h urine samples were obtained at four weeks intervals during pregnancy and at 1 (1P) and 6 (6P) weeks after delivery., Results: During pregnancy, haemoglobin concentration, haematocrit and erythrocyte count were lower, mean cell volume was not different, and mean cell haemoglobin and mean cell haemoglobin concentration were enhanced. The platelet count during pregnancy was not different from the level at 6P but increased 60% at 1P. Serum ferritin decreased 50% whereas plasma fibrinogen increased 100%. Serum creatinine (-28%), uric acid (-35%) and urea (-40%) concentrations were reduced during pregnancy. The serum concentrations of sodium (-4 mmol/l) and potassium (-0.2 mmol/l) were lower, but serum chloride was unaltered. Serum protein and albumen concentrations declined by 7.8 and 9.4 g/l respectively. The serum concentrations of bilirubin, ALAT, ASAT and gamma-GT remained unaltered. Serum LDH was 30% above normal non-pregnant values at 1P. The heat-stable alkaline phosphatase level increased in the third trimester. Heat-stable and heat-labile fractions were both elevated at 1P. The serum osmolality was 9 mosmol/kg lower and urine volume was about 25% higher during pregnancy. The creatinine excretion was unaltered but creatinine clearance increased by 25%., Conclusions: The concentrations of most components change during pregnancy. The interpretation of results of laboratory tests in pregnant women should be made with caution.

Objective: To study the presence of homocysteine, methionine and the vitamins folate, B12, and B6 in human ovarian follicular fluid (FF)., Design: Measurement of homocysteine, methionine, folate, and vitamins B12 and B6 in ovarian FF and blood., Setting: Academic Department of Obstetrics and Gynecology at St. Radboud Hospital, Nijmegen, The Netherlands., Participants: Fourteen healthy women undergoing an IVF program., Results: Detectable amounts of homocysteine and methionine were found in FF. Homocysteine concentrations were similar to those in serum. Methionine concentrations proved to be slightly but significantly lower than in corresponding serum samples. Concentrations of vitamins B12 and B6 were significantly lower in FF than in serum, whereas folate concentrations were not significantly different. A statistically significant correlation between corresponding serum and FF concentrations of homocysteine, folate, and vitamin B12 could be established., Conclusions: These data support the hypothesis that the ovum might be exposed to high homocysteine or low methionine concentrations, or both, and a lack of vitamins, which might be important in fertilization and early embryogenesis.

Objective: To study the possible pathophysiological implications of long continued dietary sodium restriction in pregnancy., Design: Longitudinal prospective randomized study of the effects of a low sodium diet compared with unrestricted sodium intake in pregnancy., Setting: Academic Department of Obstetrics and Gynaecology at Sint Radboud Hospital, Nijmegen, The Netherlands., Subjects: 42 healthy nulliparous women., Intervention: A low sodium diet (20 mmol sodium daily) started in the 14th week of pregnancy and stopped after delivery., Main Outcome Measures: Maternal weight gain, food intake, blood pressure, cardiac output, systemic vascular resistance, haematocrit and birthweight., Results: Total maternal weight gain and dietary energy intake during pregnancy and weight at 1 and 6 weeks postpartum were significantly lower in the low sodium group. Blood pressure during pregnancy did not show major differences. Stroke volume and cardiac output during pregnancy were significantly lower in the low sodium group whereas systemic vascular resistance was significantly higher. Haematocrit values in the low sodium group tended to be lower during pregnancy, but were significantly lower at 1 and 6 weeks postpartum than in the unrestricted group. Placental and birthweights were not significantly different between the two groups., Conclusions: Chronic dietary sodium restriction during pregnancy is characterized by a diminished body fat accumulation and a reduction in circulating volume, due to a decrease in both plasma and red cell volume, in combination with a high systemic vascular resistance without major effects on blood pressure and birthweight.

This article reviews the major milestones in obstetric research in the past 90 years, which have lead to the wide-spread use of salt restriction during pregnancy. Possibly the most ardent advocate of the view that salt plays a crucial role in eclampsia was De Snoo (1877-1949), a Dutch obstetrician. However, despite many enthusiastic clinical reports, no convincing evidence has ever been produced that salt restriction helps in the prevention of hypertension during pregnancy.

During oral supplementation of 5 mg folic acid and 1 microgram vitamin B12, the daily folate levels in plasma, red cells and midtrimester amniotic fluid were significantly higher in ten pregnant women during the 15th-18th week of menstrual age as compared to ten non-supplemented women serving as controls. In the control group as well as in the supplemented group, the folate concentrations in amniotic fluid were found to be lower than in the corresponding maternal plasma and red cells. Of all women investigated there was a significant positive correlation between maternal plasma folate concentrations and amniotic fluid levels (r = 0.72, p less than 0.001) and no correlation between red cell folate concentrations and amniotic fluid levels (r = 0.30, p = 0.22). Oral supplementation of vitamin B12 did not elevate maternal blood concentrations and amniotic fluid levels. Vitamin B12 levels in amniotic fluid in this group and controls were always higher than in plasma. These data suggest that the orally administrated dosages of folic acid unlike those of vitamin B12 augment both plasma, red cells and amniotic fluid levels.