The proform of eosinophil major basic protein (proMBP), the most abundant protein in the eosinophil specific granule, is synthesized by the placenta and secreted into the maternal circulation, where it is found complex-bound to pregnancy-associated plasma protein-A (PAPP-A) and other proteins. We examined the potential of proMBP as a maternal serum marker for fetal Down syndrome (DS) by determining its maternal serum concentration (MSpMBP) in 25 Down syndrome (DS) pregnancies and 152 control pregnancies in the first trimester, and in 105 DS pregnancies and 156 control pregnancies in the second trimester. The median (95 per cent confidence interval) MSpMBP MoM in DS pregnancies (n=15) was 0.66 (0.49-0.79) in gestational weeks 5-9; 1.06 (0.71-1.97) in weeks 10-12 (n=10) and 1.62 (1.18-1.98) in weeks 14-20 (n=105). Using parameterized receiver operator characteristics analysis for proMBP as a single marker for DS, detection rates (DRs) of 22 per cent and 38 per cent, for false-positive rates (FPRs) of 5 per cent, were found in weeks 5-9 (using MSpMBP</=cut-off) and weeks 14-20 (using MSpMBP>/=cut-off), respectively. When age and MSpMBP were used as markers in combination, a DR of 36.8 per cent for an FPR of 5.5 per cent was obtained in weeks 5-9 using a risk cut-off of 1:250. In weeks 14-20 the DR was 48.4 per cent for an FPR of 5.3 per cent using the same risk cut-off. This makes proMBP a marker comparable in diagnostic efficiency to human chorionic gonadotrophin (hCG), and exceeding that of alpha-fetoprotein (AFP) and unconjugated <em>oestriol</em> (uE3), in the second trimester.

A cytogenetically normal male fetus was subsequently found to have female external genitalia, a cardiac malformation and mid-trimester intra-uterine growth retardation by ultrasound examination. The maternal serum oestriol level was low. The combination of low oestriol and sonographic findings suggested Smith Lemli Opitz syndrome (SLO), which was confirmed by a markedly increased amniotic fluid level of 7-dehydrocholesterol. We review the differential diagnosis of apparent sex reversal in a fetus and low maternal serum oestriol level. To further examine the specificity of low maternal oestriol level as a marker for SLO a follow-up study of 12141 pregnancies screened for Down syndrome using three biochemical markers: alpha-fetoprotein, beta-human chorionic gonadotrophin and oestriol was performed. 26 pregnancies had an oestriol level that was 0.25 MoM or less. SLO was not diagnosed clinically in any of the liveborn children ascertained through a low maternal oestriol level. Nine of the pregnancies ended in spontaneous miscarriage. Although the frequency of SLO in pregnancies with low maternal oestriol levels or sex-reversed fetuses is unknown, the diagnosis of SLO should, nevertheless, be considered in both clinical settings.

In 32 subjects with histologically and/or cytologically verified prostatic cancer the hormonal pattern was studied by assaying 18 plasma and urinary hormones or groups of hormones and relating the values to the response to endocrine treatment. Total orchidectomy (orchiepididymectomy) was performed on 9 patients, subcapsular orchidectomy on 13 patients and oestrogen therapy with Estradurin was given in 4 patients. Six patients had total orchidectomy followed by estrogen therapy. With few exceptions all values were within the normal range. The only significant exceptions were the high urinary oestrogen values and the low urinary oestrone + oestradiol/oestriol ratio observed as compared to healthy males working in a factory. No urinary hormone values or ratios of hormone values could be used for the prediction of prognosis in prostatic carcinoma patients. However, the ratios of plasma testosterone/oestradiol (T/Oe2) and testosterone/prolactin (T/Prl) were found to give good information with regard to the response to endocrine treatment. High values for one or both of these ratios meant a good response to treatment in all subjects without exception in this material. Subjects with both ratios low had a good response to endocrine treatment in 50% of the cases. No other plasma hormones measured were of any help prognostically. It is concluded that by measuring the T/Oe2 and T/Prl ratios it seems possible to select a group of patients with favourable primary response to endocrine treatment.

The serum level of unconjugated 17 beta-oestradiol (E2) and oestriol (E3) in the maternal vein (MV), the umbilical vein (UV) and artery (UA) immediately after term (n = 34) and preterm (n = 74) labour was measured to clarify the hormonal changes that occur between the maternal and fetal compartments. The following results were found. (1) The level of E2 and E3 increased equally in the MV, UV and UA serum from the 28th-32nd week to the 33rd-36th week of pregnancy. From the 33rd-36th week to the 40th week there was no change in the MV, but the value of E2 and E3 decreased significantly in the UV and UA serum. (2) The serum level of E2 in the MV was significantly higher than that in the UV and UA during every gestational period. In contrast, the serum concentration of E3 in the MV was significantly lower than that in the UV and UA. (3) The value of 'UA/UV X 100' of E2 and E3 was about 30% during the 28th-40th week. (4) A weak correlation was found between the MV serum level of E2 and E3 and UA serum concentrations. A strong correlation was found between the UV and UA serum levels of E2 and E3. The authors suggest that though there is a close connection between the fetal and the maternal organism, the fetus is still capable of maintaining its hormonal environment independently.

Relationship between concentrations of serum oestrogens, plasma renin substrate and plasma renin activity were studied in six women throughout pregnancy. There was a significant positive correlation between serum oestradiol-17 beta and plasma renin substrate concentrations (r=0.60). Serum oestriol concentrations also correlated significantly with plasma renin substrate concentrations (r = 0.68). Correlation coefficients calculated separately for each subject throughout pregnancy were higher than those for the whole group. Also, there was much individual variation in dose-response of serum oestrogens to plasma renin substrate concentrations. There was no significant correlation between serum oestrogens and plasma renin activity. Our results support the view that oestrogens cause the increase in plasma renin substrate concentration during pregnancy, and emphasize the individual variation in response of renin substrate concentration to serum level of oestrogens.

The excretion of twelve oestrogens in urine, pooled daily from a group of pregnant women, was determined before, during and after ampicillin administration (2 g/day, for 3 days). On the second day of ampicillin administration total oestrogen excretion fell to 67% of the mean control value, oestriol excretion to 69% and that of the other eleven individual oestrogens to an average of 62% of the mean control values. In general, on the third day of treatment and on the two post-treatment days this decrease tended to be corrected. The patterns of change in the urinary levels of the individual metabolites provided no clear lead to the basic mechanism of ampicillin impairment of oestrogen excretion. However, as the drug affected all their excretion in more or less the same way as it did that of oestriol, it is possible that ampicillin interferes primarily with their enterohepatic circulation in the mother as has been established with reasonable certainty in the case of oestriol.

1. The separation of the oestrogen conjugates in late-pregnancy urine into two groups, peaks I and II, by gel filtration on Sephadex G-25 (Beling, 1963) has been shown to be affected by the presence of urate, which delays the elution of peak II conjugates. 2. By reapplication to a Sephadex column, peak I conjugates have been further separated into two groups (peaks IA and IB) and the metabolites in urine effecting this separation have been studied. 3. Further analysis of the mixed conjugates in the main groups IA, IB and II by ion-exchange and partition chromatography has led to the identification of some of the conjugates present. 4. Oestriol 3-sulphate 16alpha-glucuronide and 16alpha-hydroxyoestrone 3-sulphate 16alpha-glucuronide have been identified in peak IA. 5. The main components of peak IB have been identified as oestrone 3-glucuronide and oestriol 3-glucuronide. 6. The major conjugate in peak II was oestriol 16alpha-glucuronide and no oestriol 17beta-glucuronide was found; small amounts of the ring-d monoglucuronides oestradiol 17beta-glucuronide, 16-epioestriol 16beta-glucuronide and 16alpha-hydroxyoestrone 16alpha-glucuronide were found in this fraction. 7. The behaviour of synthetic oestrogen monoglucuronides has been used as a guide in separation.

Conjugated and unconjugated oestrone, oestradiol and oestriol were measured in simultaneous milk and plasma samples obtained from 21 women in the early post-partum period. Conjugated oestrogens comprised more than 90% of the total oestrogen content of both milk and plasma. Oestrone glucosiduronate was the major oestrogen metabolite in milk (33%), the levels being significantly higher (P less than 0.01) than in plasma. Oestriol glucosiduronates were the predominant oestrogen metabolites (63%) in plasma.

A series of preparations containing 17-beta-oestradiol and oestriol in a proportion of 2 : 1 was studied with respect to their effects and side effects in 352 women in the menopause and postmenopause in a total of 2 101 woman months. In certain of the treated groups it was considered of value to produce regular bleeding, and in these patients the oestrogen therapy was complemented with noretisterone acetate during short periods. Both the subjective and the objective effects of the treatment were excellent. Side effects were rare and the treatment seems to have advantages over other oestrogenic compounds. No signs of disturbance of the liver function were observed. In contrast to the alkyl substituted steroids the natural oestrogens seem to have a normalising effect on the blood lipids.

Constant-release implants filled with oestradiol-17 beta induced sexual receptivity in ovariectomized rats in response to progesterone treatment if they were implanted 32 h before behavioural testing. A 20 h period of exposure to oestradiol, by implantation 32 h before testing and removal of the implants 20 h later, was sufficient for induction of the behaviour. The exposure time necessary for behavioural responses could be further reduced to two 4 h periods, between 32 and 28 h and between 16 and 12 h, before testing. Serum levels of oestradiol were raised within 1 h of oestradiol implantation and declined rapidly after implant removal. A single injection of oestradiol benzoate was much more potent than a single injection of oestradiol in inducing sexual receptivity in ovariectomized rats, but this difference in potency was reversed if two appropriately timed injections were given. Oestrone- or oestriol-filled implants were relatively ineffective in inducing sexual receptivity. It is suggested that oestradiol has to be present at crucial time points to prepare an ovariectomized rat to respond behaviourally to progesterone treatment and that oestradiol is the principal oestrogen in the stimulation of sexual behaviour in female rats.

A convenient solid phase method for extracting and fractionating steroid hormones from serum or urine is presented. The influence of the solvent used for extraction, of the body fluid to be extracted, and of the degree of sample dilution on the efficiency of extraction was studied for progesterone and cortisol. The potency of fractionation was demonstrated by the separation of the steroid pairs, deoxycortisol--cortisol and oestradiol--oestriol, from a urine sample. Influence of ionic strength, pH and temperature on the reproducibility was assessed for deoxycortisol in undiluted urine. With respect to practicability and efficiency, this method has proved to be considerably superior to conventional liquid-liquid techniques.

Mestranol, the three-methyl ether form of ethinyloestradiol and one of the two oestrogens used in oral contraceptive steroids, was administered in a dose of 0.02 mg daily for 120 days to 25 oophorectomized women.Urinary oestriol and pregnanediol excretions were unaffected by the mestranol treatment but there was a shift of the maturation index of the vaginal smear to the right, indicating a correction of the pretreatment oestrogen deficiency. No significant change in the blood pressure or electrocardiograph recordings occurred during this relatively short period of administration. A significant rise in the serum protein-bound iodine, which might be regarded as an undesirable effect of mestranol on a long-term basis, occurred. Hepatic function as measured by bromsulphthalein was not impaired by the treatment. Mestranol had no effect on the total body water or on the total exchangeable potassium of the women. Its two most serious adverse effects were impairment of glucose tolerance and a high incidence (16%) of venous thrombo-embolic disease.The gravity of the adverse effects far outweighs any beneficial ones and precludes the use of mestranol alone for long-term hormone replacement therapy in postmenopausal women.

The urinary excretion of magnesium was studied in two groups of healthy women just after menopause. The women in group I were randomly allocated to receive either placebo or 4, 2 or 1 mg 17 beta-oestradiol in cyclical combination with 1 mg norethisterone acetate (a progestational agent). Oestradiol was given, in the above-mentioned doses, from days 1 to 22, and 1, 1 or 0 mg oestradiol was given from days 23 to 28, in combination with norethisterone acetate from days 13 to 22 and oestriol 2, 1 or 0.5 mg from days 1 to 23 and 0.5, 0.5 or 0 mg from days 23 to 28. The women in group II were allocated to receive either placebo, 2 mg oestradiol valerate in cyclical combination with 1 mg cyproterone acetate (oestradiol valerate from days 1 to 21 and cyproterone acetate from days 12 to 21) with 1,000 mg of calcium per day or oestradiol valerate + cyproterone acetate without calcium. Oestrogen and progesterone therapy decreased the urinary magnesium excretion significantly when compared to the placebo group. The effect was related to the dose of oestrogen. Furthermore, our results indicate that calcium supplementation influences the urinary excretion of magnesium in a two-phase paradoxical manner.

BACKGROUND

Adjusting maternal serum markers for maternal weight is considered to be a standard practice when screening for pregnancies associated with Down's syndrome. The choice of model for taking maternal weight into account is, however, rarely explicitly evaluated.

METHODS

The relationship between the maternal serum markers alphafetoprotein (AFP), human chorionic gonadotropin (HCG) and unconjugated oestriol (uE3), determined with the Beckman Coulter access reagents and maternal weight was investigated in a cohort of 752 Belgian women being screened for pregnancy associated with Down's syndrome. Two different models (the log-linear equation and the linear-reciprocal equation) were used to determine the relationship between the serum markers and maternal weight.

RESULTS

A significant relationship between log(10) multiples of median (MoM) values and weight (kg) was obtained for all markers, and the log-linear model had higher coefficients of determination (r(2)) when compared with the linear-reciprocal model. Weight correction with either method achieved the optimum effect that the correction factor for a woman with a population median weight of 65.5 kg was not significantly different from 1. Simulated weight-corrected MoM values with the two approaches were compared and variation was estimated. The mean difference between the weight-corrected MoM values calculated by the two methods was 7.8% (SD 4.3%) for AFP, 14.0% (4.4%) for HCG and 5.9% (3.2%) for uE3. This resulted in a difference in risk estimate of 1.66-5.34% for Down's syndrome owing to weight correction algorithm differences in women of median weight.

CONCLUSIONS

The log-linear weight correction approach was shown to be marginally more effective by a goodness-of-fit analysis. Differences in weight-corrected MoM values estimated with the two approaches are highly significant (p<0.0001, Wilcoxon's paired sample test), but the effect on risk calculation was not significant. It was observed that the changes in risk became significant the more the MoM correction factors deviated from 1.

A total of 132 twin pregnancies in black African women were studied prospectively after 30 weeks gestation. Delivery occurred before 37 weeks in 32%. There was a trend (0.1 greater than P greater than 0.05) towards a higher preterm delivery rate in nullipara (57%), in women under the age of 20 years (60%) and in those with a height/weight ratio of greater than 2.5 (50%). The cervix was assessed with a score based on the length of the canal minus the dilatation of the internal os. In both term and preterm labour there was a significant relation between a cervical score of 0 or a decrease in cervical score and the onset of labour within the subsequent 14 days (P less than 0.001). By these criteria to predict impending labour, 60% of all labours that ensured within 14 days of the assessment would have been predicted with a 20% false positive rate. When nulliparae were excluded the predictive value of cervical assessment for preterm labour was 80% with a false positive rate of less than 5%. Plasma oestriol levels were significantly higher in the preterm labour group but had no clinical prognostic value.

OBJECTIVE

To investigate the effect of different oestrogens and progestogens, at various concentrations, on the oxidation of low density lipoproteins (LDL) in vitro.

METHODS

Oestradiol, oestrone, oestriol and equilin, as well as medroxyprogesterone acetate, norgestrel and norethisterone, were added to isolated male LDL, before it was oxidised in the presence of copper ions at 37 degrees C. The oxidation process was monitored spectrophotometrically by the production of conjugated dienes. The lag time to oxidation and the maximum rate of propagation of the reaction were used as measures of the resistance and susceptibility of the LDL to oxidation respectively.

RESULTS

The lag time was increased from 43.7 +/- 1.5 min (mean +/- SEM) for LDL without any added hormone, to 81.2 +/- 1.0 min by 1 microM oestradiol (P < 0.01), 77.9 +/- 4.6 min by 1 microM oestrone (P < 0.01), 67.6 +/- 6.2 min by 1 microM equilin (P < 0.01), and 51.8 +/- 2.8 min by 1 microM oestriol (P < 0.05). The maximum rate of propagation of the reaction was decreased from 0.23 +/- 0.01 nmol conjugated dienes/mg LDL-protein/min (mean +/- SEM) (control LDL) to 0.14 +/- 0.006 nmol/mg/min by oestradiol (P < 0.01), 0.15 +/- 0.009nmol/mg/min by oestrone (P < 0.01), 0.17 +/- 0.012 nmol/mg/min by equilin (P < 0.01) and 0.19 +/- 0.014 nmol/mg/min (P < 0.05) by oestriol. The progestogens alone had no antioxidant effect, nor did their addition to the oestrogens influence their antioxidant activity.

CONCLUSIONS

These results demonstrate that all oestrogens investigated have an inhibitory effect on LDL oxidation in vitro. The magnitude of this effect varied, being of the order oestradiol>> oestrone>> equilin>> oestriol.

BACKGROUND

Down's syndrome occurs when a person has three, rather than two copies of chromosome 21; or the specific area of chromosome 21 implicated in causing Down's syndrome. It is the commonest congenital cause of mental disability and also leads to numerous metabolic and structural problems. It can be life-threatening, or lead to considerable ill health, although some individuals have only mild problems and can lead relatively normal lives. Having a baby with Down's syndrome is likely to have a significant impact on family life.Non-invasive screening based on biochemical analysis of maternal serum or urine, or fetal ultrasound measurements, allows estimates of the risk of a pregnancy being affected and provides information to guide decisions about definitive testing.Before agreeing to screening tests, parents need to be fully informed about the risks, benefits and possible consequences of such a test. This includes subsequent choices for further tests they may face, and the implications of both false positive and false negative screening tests (i.e. invasive diagnostic testing, and the possibility that a miscarried fetus may be chromosomally normal). The decisions that may be faced by expectant parents inevitably engender a high level of anxiety at all stages of the screening process, and the outcomes of screening can be associated with considerable physical and psychological morbidity. No screening test can predict the severity of problems a person with Down's syndrome will have.

OBJECTIVE

To estimate and compare the accuracy of first trimester ultrasound markers alone, and in combination with first trimester serum tests for the detection of Down's syndrome.

METHODS

We carried out extensive literature searches including MEDLINE (1980 to 25 August 2011), Embase (1980 to 25 August 2011), BIOSIS via EDINA (1985 to 25 August 2011), CINAHL via OVID (1982 to 25 August 2011), and The Database of Abstracts of Reviews of Effects (the Cochrane Library 2011, Issue 7). We checked reference lists and published review articles for additional potentially relevant studies.

METHODS

Studies evaluating tests of first trimester ultrasound screening, alone or in combination with first trimester serum tests (up to 14 weeks' gestation) for Down's syndrome, compared with a reference standard, either chromosomal verification or macroscopic postnatal inspection.

METHODS

Data were extracted as test positive/test negative results for Down's and non-Down's pregnancies allowing estimation of detection rates (sensitivity) and false positive rates (1-specificity). We performed quality assessment according to QUADAS criteria. We used hierarchical summary ROC meta-analytical methods to analyse test performance and compare test accuracy. Analysis of studies allowing direct comparison between tests was undertaken. We investigated the impact of maternal age on test performance in subgroup analyses.

RESULTS

We included 126 studies (152 publications) involving 1,604,040 fetuses (including 8454 Down's syndrome cases). Studies were generally good quality, although differential verification was common with invasive testing of only high-risk pregnancies. Sixty test combinations were evaluated formed from combinations of 11 different ultrasound markers (nuchal translucency (NT), nasal bone, ductus venosus Doppler, maxillary bone length, fetal heart rate, aberrant right subclavian artery, frontomaxillary facial angle, presence of mitral gap, tricuspid regurgitation, tricuspid blood flow and iliac angle 90 degrees); 12 serum tests (inhibin A, alpha-fetoprotein (AFP), free beta human chorionic gonadotrophin (ßhCG), total hCG, pregnancy-associated plasma protein A (PAPP-A), unconjugated oestriol (uE3), disintegrin and metalloprotease 12 (ADAM 12), placental growth factor (PlGF), placental growth hormone (PGH), invasive trophoblast antigen (ITA) (synonymous with hyperglycosylated hCG), growth hormone binding protein (GHBP) and placental protein 13 (PP13)); and maternal age. The most frequently evaluated serum markers in combination with ultrasound markers were PAPP-A and free ßhCG.Comparisons of the 10 most frequently evaluated test strategies showed that a combined NT, PAPP-A, free ßhCG and maternal age test strategy significantly outperformed ultrasound markers alone (with or without maternal age) except nasal bone, detecting about nine out of every 10 Down's syndrome pregnancies at a 5% false positive rate (FPR). In both direct and indirect comparisons, the combined NT, PAPP-A, free ßhCG and maternal age test strategy showed superior diagnostic accuracy to an NT and maternal age test strategy (P < 0.0001). Based on the indirect comparison of all available studies for the two tests, the sensitivity (95% confidence interval) estimated at a 5% FPR for the combined NT, PAPP-A, free ßhCG and maternal age test strategy (69 studies; 1,173,853 fetuses including 6010 with Down's syndrome) was 87% (86 to 89) and for the NT and maternal age test strategy (50 studies; 530,874 fetuses including 2701 Down's syndrome pregnancies) was 71% (66 to 75). Combinations of NT with other ultrasound markers, PAPP-A and free ßhCG were evaluated in one or two studies and showed sensitivities of more than 90% and specificities of more than 95%.High-risk populations (defined before screening was done, mainly due to advanced maternal age of 35 years or more, or previous pregnancies affected with Down's syndrome) showed lower detection rates compared to routine screening populations at a 5% FPR. Women who miscarried in the over 35 group were more likely to have been offered an invasive test to verify a negative screening results, whereas those under 35 were usually not offered invasive testing for a negative screening result. Pregnancy loss in women under 35 therefore leads to under-ascertainment of screening results, potentially missing a proportion of affected pregnancies and affecting test sensitivity. Conversely, for the NT, PAPP-A, free ßhCG and maternal age test strategy, detection rates and false positive rates increased with maternal age in the five studies that provided data separately for the subset of women aged 35 years or more.

CONCLUSIONS

Test strategies that combine ultrasound markers with serum markers, especially PAPP-A and free ßhCG, and maternal age were significantly better than those involving only ultrasound markers (with or without maternal age) except nasal bone. They detect about nine out of 10 Down's affected pregnancies for a fixed 5% FPR. Although the absence of nasal bone appeared to have a high diagnostic accuracy, only five out of 10 affected Down's pregnancies were detected at a 1% FPR.