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Bone marrow transplantation provides successful treatment for many diseases of the immune and hematopoietic systems. The main therapeutic ingredient in this procedure is stem cells collected from the bone marrow. Recently, it has been demonstrated that stem cells from human umbilical cord blood can serve as an alternative to bone marrow transplantation in children. Although cord blood transplantation in adults has not yet been attempted, it appears that there are enough stem cells present in cord blood for successful engraftment in adults. Obstetric health care providers should be aware that many familial conditions are treatable by cord blood stem cell transplantation in children. Obstetric health care providers caring for patients with familial disorders should consider counseling such patients regarding the collection and storage of cord blood for potential future uses in autologous or allogeneic transplantation.

Objective: To assess the antenatal ultrasonic diagnosis of the twin transfusion syndrome, an enigmatic disorder that results in an imbalance in the blood flow between monochorionic twins., Study Design: Retrospective review of 16 cases of twin transfusion syndrome confirmed by placental pathology and neonatal data., Results: A disparity in antenatal fetal weights, size difference between the two amniotic sacs and a single placenta were present in 81% (13/16) of confirmed cases. The finding of two separate umbilical cords with a disparity in the size or number of vessels was rare. Evidence of hydrops in either fetus or findings of congestive cardiac failure in the recipient twin were uncommon., Conclusion: Our data strongly suggest that the twin transfusion syndrome can be diagnosed in a significant number (81%) of cases. The syndrome is variable, and it is rare to observe all the diagnostic criteria in one case.

Despite advances in maternal fetal medicine, the management of severe twin-to-twin transfusion syndrome in the second trimester presents a significant challenge. Presently, there is no uniformly accepted management protocol that is available for the treatment of this syndrome. We report the use of indomethacin in three cases of severe twin-to-twin transfusion syndrome in the second trimester. In the three cases of severe twin-to-twin transfusion syndrome no reduction of amniotic fluid in either sac was demonstrated. Two cases were complicated by single intrauterine fetal death within 72 hours of initiating indomethacin therapy. Because of our experience with these three cases, we conclude that indomethacin does not prevent perinatal mortality in patients with severe twin-to-twin transfusion syndrome.

A rapid bedside test has been devised that enables an untrained observer to predict (p less than 0.001) when amniotic fluid will be greater than or equal to 0.15 at an optical density of 650 nm, lecithin/sphingomyelin ratio will be greater than or equal to 2.0, or when phosphatidylglycerol will be present. By a visual comparison of the turbidity of unspun amniotic fluid against positive (mature) or negative (immature) controls, technicians and resident physicians who had had no special training were able to classify correctly 87.2% (82/94) of unknown amniotic fluid samples. The sensitivity of the new test is 90.8% (58/65); the specificity is 70.3% (23/29). Thus, when more sophisticated methods are not readily available, we believe that this easily performed and accurate test can provide supplemental or preliminary data for patient management. In remote geographic areas our method could serve as the primary source of information about fetal lung maturity.

A 26-year-old white woman had premature rupture of membranes at 35 weeks' gestation. Cervical specimens initially demonstrated group B streptococci and Chlamydia trachomatis. Amniocentesis was performed and the amniotic fluid was positive for chlamydia by direct fluorescent antibody stain. The Gram stain was negative. The patient had an elevated white blood cell count. Labor was induced because of suspected chorioamnionitis. A 2120-g female infant was delivered with an Apgar score of 9 at 1 and 5 minutes. The infant's eye and nasopharyngeal specimens were positive for chlamydia by direct fluorescent antibody stain. After delivery, both Ureaplasma urealyticum and C trachomatis were isolated from the amniotic fluid and fetal membranes. This is the first reported case of chlamydial isolation in amniotic fluid.

Twin gestation is now an area of vital concern to the perinatologist. Within the last decade a substantial reduction in perinatal mortality has been achieved, largely through advances in neonatal intensive care. However, preterm birth and its consequences remain the most important causes of perinatal morbidity and mortality. Twin pregnancy accounts for approximately 10% of all premature deliveries. From the data currently available, there is no justification for the routine use of hospital bedrest, prophylactic tocolytic agents, or elective cerclage in the management of twin pregnancy. Programs directed at the prevention of perterm delivery in twin pregnancy will be the focus of more scientific research. The use of ultrasound and antepartum testing in the form of the nonstress test, the biophysical profile, and Doppler ultrasound may lead to major advances in the diagnosis of intrauterine growth retardation and the twin-to-twin transfusion syndrome in twins. Therefore, it is reasonable to expect that fetal death and neonatal death from intrauterine growth retardation can be prevented.

A test that circumvents the complex methodology needed for the determination of L/S ratios has been developed. It has been observed that the optical density, measured at 400 nm, of supernatants collected from fresh amniotic fluids centrifuged at 2000 g for 10 minutes correlates with L/S ratios.

Bacteria preincubated with myeloperoxidase (MPO) are more readily killed upon the addition of H2O2 and Cl- than controls not subject to prior incubation. This effect was evidenced by decreased requirements of MPO and H2O2 (to approximately 33%) for equivalent bactericidal activity. MPO adsorbed onto the bacterial surface is not accessible to other competing substrates such as guaiacol and [1(-14)C] alanine. It appears that when MPO is adsorbed to the bacteria, it carries out a coupled reaction in which the activated chlorine directly attacks the bacterial cell surface.

The influence of pregnancy, pregnancy plasma, and pregnancy-associated lhormones on the response of peripheral blood lymphocytes to two phytomitogens (PHS and PWM) was examined in a group of 17 healthy women during pregnancy and the postpartum period. No consistent disparity between pregnancy, postpartum, and control tests was noted in either intrinsic lymphocyte responsiveness or in the effect of autologous plasma or four pregnancy-associated hormones (estriol, progesterone, hPL, and estradiol-17 beta) on lymphocyte responsiveness.

Amniotic fluids obtained by amniocentesis at 16 weeks to term were examined for the presence of Chlamydia trachomatis, Mycoplasma hominis, and Ureaplasma urealyticum. Of 140 fluids tested, none harbored chlamydiae, and only one harbored mycoplasma, M. hominis. A number of amniotic fluids were subsequently tested for their ability to inhibit the growth of these microorganisms. Amniotic fluids and chlamydial suspensions in a 2:1 ratio were incubated 30 to 90 minutes before their inoculation in McCoy cells. Procedures were followed for chlamydial isolation. Genital mycoplasmas were incubated with amniotic fluid samples for 24 or 48 hours at 35 degrees C. Growth in amniotic fluid specimens was compared with growth in pseudoamniotic fluid and broth controls. Fourteen amniotic fluid specimens collected from gestations of 16 to 40 weeks, were found to be inhibitory to the formation of inclusions of C. trachomatis in McCoy cells. Ten amniotic fluid specimens (16 to 39 weeks, gestation) demonstrated various degrees of inhibition against M. hominis, and three fluids were inhibitory to the growth of Ureaplasma. The inhibitor was heat and protease resistant and activity was proportional to concentration. The molecular weight of the inhibitor was probably greater than 10,000 daltons, and pH, although perhaps a contributing factor, was not the cause of the inhibition.

Analysis of 150 patients at term (greater than 36 weeks) with premature rupture of the membranes (PROM) was made. In the group followed conservatively, 87.5% (98 of 112) began labor within 48 hours, and only 3.6% (4 of 112) had a latent period of greater than seven days. The incidence of cesarean section in patients with induced and spontaneous labors was compared in corrected groups. The induced group had a 39% (15 of 38) cesarean section rate as compared to 12% (11 of 91) in the spontaneous labor group (p = less than 0.01). None of the patients in the study showed signs of sepsis by central cultures, and only 12.7% (19 of 150) showed febrile morbidity. A conservative approach to term patients with PROM and an unfavorable cervix for induction seems to decrease the incidence of cesarean section.

By mounting a layer of chorioamniotic membrane on a specially designed reaction vessel, we studied the effect of Escherichia coli and/or group B streptococcus growing on the decidual surface of the membranes in tissue culture or bacteriologic medium. The organisms grew equally well in either medium. When growing in tissue culture medium, either organism significantly weakened the membranes as compared with controls (membranes incubated in the absence of either organism). Membranes derived from pregnancies delivered vaginally or abdominally responded similarly. When organisms were grown in bacteriologic medium, bursting pressures did not decrease. Addition of bacteriologic medium (20-60%) to tissue culture medium did not affect bacterial growth, but inhibited significantly the lowering of bursting pressures. Bacteriologic medium also inhibited the peroxidase-H2O2-halide system in vitro. Heat-killed bacteria and/or supernatants of culture medium previously inoculated with bacteria were not effective in weakening membranes. The results suggest that live bacteria in conjunction with active membrane metabolism lead to a weakening and eventual rupture of the membranes.

In this study, we have attempted to correlate optical density measurements of amniotic fluids with L/S ratios. We may conclude, with over a 98 per cent accuracy, that fluids having optical density readings of 0.15 and above, at 650 nm. will have an L/S ratio over 2.0. Fluids having optical density readings up to 0.05 will have L/S ratios of about 1.3. Finally, amniotic fluids having optical densities greater than 0.05 and less than 0.15 will have L/S ratios of approximately 1.5.

A 20,000 g pellet obtained from the homogenate of CD1 mouse spleen cells has measurable peroxidase and bactericidal activities. Whole body x-irradiation stimulates the in vitro peroxidative and bactericidal activities of the spleen cells. These cells do not phagocytize. However, addition of polystyrene latex particles to spleen cells from non- or x-irradiated mice, increases glucose oxidation. The extent of this stimulation (three- to fourfold) is less than that of PMN (six- to tenfold). Interaction between particles and lymphocyte surface may be the cause of this stimulation. The increased bactericidal activity due to x-ray is attributed mainly to an increase in the peroxidase activity of the lymphocytes. Surface (membrane) action rather than phagocytosis may be involved in the bactericidal process. The spleen lymphocyte peroxidase is distinct from myeloperoxidase in several respects.

Optical density readings of amniotic fluids of 0.15 or greater at 650 nm have been noted to correlate with fetal pulmonary maturity. The amniotic fluid absorbance has been shown to be due not only to lecithin and sphingomyelin but also to other surfactants, including phosphatidyl glycerol and inositol. The addition of lecithin and sphingomyelin to previously centrifuged amniotic fluid (i.e., optical) density less than 0.001: L/S ratio, nondetectable) results in an increase in absorbance. At any simulated L/S ratio, the addition of phosphatidyl glycerol and/or phosphatidyl inositol results in a further increase in optical density. It is suggested that optical density readings represent more closely the surfactant composition of amniotic fluid than L/S ratios; therefore, it appears that optical density measurements are a better predictor of fetal pulmonary development than are L/S ratios.

A simple, rapid, economical, and accurate test to assess fetal pulmonary maturity on a 24-hour basis, 7 days a week, is urgently needed. A 15-minute test has been developed that correlates well with fetal pulmonary maturity. Optical density (OD) readings at 650 nm of greater than or equal to 0.15 in pigment-free, centrifuged (2000 Xg, 10 minutes) amniotic fluids obtained from gestations of 33 to 42 weeks correlate with fetal pulmonary maturity (131 of 131, 100%). When OD readings are less than 0.15 in fluids from gestations of 24 to 40 weeks, and antepartum steroids are utilized, the incidence of respiratory distress syndrome (RDS) is 8.3% (14 of 169). The true false-negative rate in this group is therefore unknown.

A simple and rapid test that correlates with L/S ratios has been developed. By centrifuging fresh, unfrozen amniotic fluids at 200g for 10 minutes and measuring the optical density at at 650 nm, correlation with L/S ratios is obtained. Optical density readings of 0.15 or greater correlate 100% with L/S ratios of 2.0 or greater. Optical readings below 0.15 correlate 94% with L/S ratios below 2.0.

Fetal pulmonary maturity is generally determined by analyzing amniotic fluid for surfactants. This task is accomplished by lipid extraction of the fluid and resolution, identification and quantitation of the isolated lipids with thin-layer chromatography. These methods are lengthy, cumbersome and often not available on demand. A quick, simple, reliable and economical test therefore would be highly desirable. We have been able to correlate an optical density (OD) reading of amniotic fluid at 650 nm greater than or equal to 0.15 with the absence of hyaline membrane disease (HMD). For 428 fluids in which an OD reading of greater than or equal to 0.15 was found and delivery occurred within 48 hours, HMD was present in only two infants. The accuracy of the test was 99.53% , with a false-positive rate of 0.47%. With the use of this simple and accurate test one can satisfy the requirement of an on-demand test to determine fetal pulmonary maturity.

Previous investigators have demonstrated that polymorphonuclear neutrophils exhibit intense chemiluminescence (CL) during phagocytosis and the CL response can be used to study the cellular and humoral aspects of the phagocytic process. A microtechnique that used 10 microliters of whole blood as a source of phagocytes was developed and used to measure the phagocytic CL response during pregnancy. Increased sensitivity was achieved by the use of a high concentration of luminol (0.5 mM), prepared by sonication, as a CL amplifier. The high intensity of CL produced with luminol permitted the use of a scintillation counter in the IN coincidence mode, avoiding the necessity of dark-adapting the counting vials and reagents and working under subdued red light. The CL response was dose dependent on the number of phagocytes and/or particles (polystyrene spherules, opsonized zymosan, and E coli). The CL response was decreased by inhibitors that prevent particle uptake (iodoacetate and fluoride), inhibitors that prevent free-radical production (sodium benzoate and superoxide dismutase), and by inhibitors that inactivate myeloperoxidase (cyanide and azide). Results suggested that the phagocytic CL response in our assay system was dependent on O2 activation followed by the activated O2 species reacting with myeloperoxidase and chloride. The new technique was used to demonstrate a progressive increase with gestation in the phagocytic CL response in pregnancy and a rapid decrease to normal values at 1 week postpartum.

The antimicrobial activities of the myeloperoxidase-H(2)O(2)-halide system have received considerable attention recently. The precise mechanism by which this system exerts its lethal activity is presently not clear. In an effort to learn more regarding a possible mechanism of action, the susceptibility of protein-bound amino acids to enzymatic attack by myeloperoxidase (MPO) in the presence of chloride ions was investigated. [1, 7-(14)C]diaminopimelic acid (DAP) was incorporated into Escherichia coli W-7 proteins with little randomization of the radioactivity. Under appropriate conditions, it was observed that the MPO-H(2)O(2)-halide system released approximately 94% of the radioactivity from labeled bacteria. This would indicate that, in addition to decarboxylation, peptide bonds are also split during this reaction. The oxidative decarboxylation of DAP-labeled bacteria by MPO (i) is Cl(-) dependent, (ii) has an acid pH optimum, (iii) requires a specific concentration of H(2)O(2) for activity, (iv) reaches a plateau by 25 min, and (v) is markedly inhibited by taurine. These properties are similar to those observed with free amino acids. It appears from these data that MPO can not only decarboxylate free and bound amino acids, yielding aldehydes, but also it can actively participate in oxidative peptide cleavage. Both of those activities may play a critical role in the microbicidal action of the leukocyte.

A conservative approach was followed in 188 patients with premature rupture of the membranes (PROM) over a 2 year period. There were no neonatal deaths from sepsis, and only one infant showed a positive central bacteriologic culture. Fifty-seven percent of all patients less than 37 weeks' gestation had a latent period of 24 hours and 19% went beyond 7 days before labor began. Patients less than 34 weeks' gestation who received antepartum steroids for lung maturation showed no increased infectious morbidity or mortality. A conservative approach to patients with PROM seems reasonable when either prematurity and/or a cervix unfavorable for induction further complicates the pregnancy.

Free-flowing amniotic fluid collected vaginally can be used in a reliable way for determination of fetal pulmonary maturity. Lavaging the vaginal/cervical area with sterile saline and examining the lavage fluid for lecithin/sphingomyelin (L/S) spots showed no detectable spots in the supernatants (one exception) and barely detectable L/S spots in the sediment. Vaginal-cervical saline-wash fluids did not affect fluid L/S ratios. Lavaging the vaginal-cervical area with abdominal amniotic fluid did not affect the L/S ratio of the original amniotic fluid.

An in vitro experimental model has been developed which allows the study of amnion lysosomal enzyme release under controlled conditions. Briefly, a layer of human amnion membrane mounted on a specially designed reaction vessel serves as the reaction surface. We have noted that the addition of particulate material to these membranes incubating in pseudoamniotic fluid results in an increased release of the lysosomal marker enzyme N-acetylglucosaminidase when compared to the release in the absence of particles. This release is completely inhibited by iodoacetate and slightly by azide. A similar increased release is also noted with the use of term amniotic fluid as incubation medium when compared to centrifuged (30,000 g/20 min) amniotic fluid. Lecithin and lysolecithin were effective in releasing increasing amounts of enzyme. This increased release was noted only from membranes of placentas collected from subjects who had undergone cesarean section prior to labor. Membranes collected from vaginal deliveries after labor showed a baseline increased release but no further stimulation upon the addition of any of the substances. These results suggest that the release of lysosomal enzymes from amnion membranes is brought about by substance(s) present in amniotic fluid. Very probably, these are surfactants. The interaction of these substances with amnion cells would eventually result in an exponential burst of prostaglandin synthesis, which would result in labor.

The following perinatal intensive care management protocol is suggested to minimize morbidity and mortality in multiple pregnancy. 1. Early diagnosis is essential, with ultrasound examination regarding as invaluable for all pregnant patients. If ultrasound examination has not been done, multiple pregnancy should be suspected in all patients who have a family history of dizygotic births, are large for dates or anemic, or have a low-grade preeclampsia. 2. Maternal care should be provided at a tertiary care (level III) perinatatl center, which is more fully equipped to manage multiple gestation. 3. Bed rest, if instituted early enough (26-29 weeks) appears to be of value, especially in promoting increased birth weight. 4. A liberal approach to performing cesarean birth is suggested when any abnormal presentation exists. 5. Aggressive management, using tocolytic agents to delay premature labor and steroids to accelerate pulmonary maturity, should be strongly considered. 6. The personnel of a neonatal intensive care unit should employ a team approach to the preparation for and management of multiple preterm births.

The concept that premature rupture of the membranes is due to an infectious process is well accepted. However, no definitive data implicating a particular microorganism or a mechanism of action have been advanced. By the use of our recently developed experimental in vitro amnion-chorion reaction vessel model we have studied the effect of the peroxidase-hydrogen peroxide-halide antimicrobial system on these membranes. We have noted that amnion, chorion, decidua, and placental macrophages all possess peroxidase activity. Tissues collected from deliveries following labor (vaginal) are significantly higher in activity than those collected from deliveries with no labor (cesarean section). A mobilization of enzyme from macrophages to amnion appears to occur in the laboring patient. Increased protein hydrolysis is noted in membranes collected from patients without labor subjected to the peroxidase-hydrogen peroxide-halide cytotoxic system when compared with membranes from laboring patients. Bursting pressures of membranes collected from patients without labor are shown to be decreased when the membranes were incubated in the presence of lysolecithin or in the presence of amniotic fluid and phospholipase A2.

Pregnancy in a renal homograft recipient resulted in the delivery of a 2770-g male fetus by classic cesarean section. Renal function remained stable throughout the gestation. The fetoplacental unit was monitored by the concurrent assay of 24-hour urinary estrogen excretion and human placental lactogen (hPL) in light of the spuriously low estrogen levels often found in these patients on chronic glucocorticoid immunosuppression.

1. MPO, H2O2 and C1- form a complex that undergoes intramolecular rearrangement yielding the chlorinium ion. 2. The chlorinium ion can interact with MPO, bacteria and amino acids. 3. The reaction can occur at a wide range of pH, H2O2 concentration and C1- concentration. 4. The chlorinium ion can attack different protein molecules to cause structural changes. 5. Preincubation of MPO with bacteria results in greater bactericidal activity. 6. Diffusible bactericidal agents are also produced by the MPO-H2O2-C1- system.

A total of 489 consecutive 24-hour urine collection from 162 patients were analyzed for creatinine excretion. The 24-hour creatinine excretion increased with the urine volume. Creatinine excretions in 24-hour urine collections were not statistically different between in- and out-patients. The results indicate that the mean urine creatinine per 24 hours is 1.08 g for 24-hour urine volumes between 500 and 1500 ml. For urine volumes greater than 1500 ml it is 1.22 g. For 24-hour urine volumes less than 500 ml, the mean creatinine is 0.63 g.

In this study we have attempted to correlate amniotic fluid optical density measurements and lecithin/sphingomyelin (L/S) ratios with the presence of phosphatidylglycerol. An 85% correlation (126 of 148) of all three parameters was noted. When the assumption was made that phosphatidylglycerol is indicative of fetal pulmonary maturity, 93 of 94 fluid samples having an optical density at 650 nm greater than or equal to 0.15 had demonstrable phosphatidylglycerol for a 1% false positive rate. In 53 fluid samples having an optical density at 650 nm less than 0.15, phosphatidylglycerol was present in 11 and absent in 42, a 21% false negative rate. The same analyses with lecithin/sphingomyelin ratios showed a 5% false positive rate and a 31% false negative rate.