A total of 132 twin pregnancies first seen at less than 36 weeks gestation were studied prospectively to determine the epidemiological and anthropomorphic factors associated with single or dual fetal growth retardation; the clinical, biochemical and ultrasound serial measurements that are predictive of single or dual fetal growth retardation, and to design scoring systems for the prediction of fetal growth retardation. A number of factors were associated with an increased risk of fetal growth retardation, but the highest risk was present when there was an abnormality in both plasma oestriol and placental lactogen, and the biparietal diameter growth rates were divergent. Scoring systems were derived using multi-variant discriminant analysis for three clinical situations: the patient seen for the first or second time; where only clinical facilities exist and the patient was seen on three or more occasions; and where facilities exist for the biochemical tests of placental function and ultrasonic measurement of the biparietal diameters. The scoring system for the last situation had the highest predictive rate and the lowest false positive rate.

Serial measurements of alpha-fetoprotein (AFP) were made in 63 normal pregnancies throughout gestation using a radioimmunoassay. Significant levels of AFP, which were detected as early as at 10 weeks gestation, showed a gradual rise until 32 weeks, after which the levels declined until term. The limits of the normal gestational pattern have been defined and the intrapatient variability of the assay was examined. A comparison of the clinical characteristics of the pregnancies with levels of AFP was made. Higher birth weights were correlated with later attainment of peak levels of AFP and peak levels were achieved earlier in gestation in female fetuses. Higher levels of AFP and lower oestriol/AFP ratios were correlated with an earlier onset of labour.

Maternal serum inhibin levels were measured in 19 second-trimester pregnancies affected by fetal Down's syndrome and 95 unaffected control pregnancies matched for gestational age. A statistically significant elevation was found in the affected pregnancies compared with the controls (Wilcoxon rank sum test: one-tail P = 0.02). The median level in the cases was 1.3 times that in the controls, with 95 per cent confidence limits of 0.9-1.9. Although the inhibin levels were unrelated to those of alpha-fetoprotein and unconjugated oestriol in the same samples, there was a statistically significant correlation with human chorionic gonadotropin. This together with the relatively small elevation in cases suggests that inhibin would be of limited value in maternal screening for Down's syndrome.

During the years 1971-1984 urinary oestriol excretion was tested in 51,427 patients (group 1). One or more low oestriol value was found in 10.7% of patients; in this group the stillbirth rate was 6.8 times higher, the neonatal death rate 3.8 times higher, and fetal growth retardation rate 3.5 times higher than in patients with normal oestriol values (all p less than 0.00001). During the years 1985-1989 a further 20,635 patients were tested (group 2) and 7.6% had one or more low oestriol value. The perinatal mortality rate in patients with normal oestriol excretion fell from 0.8% in group 1 to 0.5% in group 2 (p less than 0.005), and in patients with low oestriol excretion from 4.2% in group 1 to 2.4% in group 2 (p less than 0.002). However, patients in group 2 with low oestriol values still had significantly unfavourable results, compared to those with normal oestriol values--stillbirth rate 3.3 times higher, neonatal death rate 4.6 times higher, and fetal growth retardation rate 3.2 times higher (all p less than 0.00001). Intravenous dextrose and aminoacid infusions were given to 967 patients who had persistently low oestriol values in spite of rest in hospital, in an attempt to correct fetoplacental function; the perinatal mortality rate was 0.9% in the 660 (68.3%) who responded favourably, and 9.8% in the 307 (31.7%) who did not respond (p less than 0.0001).

Maternal hypoglycaemia (plasma glucose below 5th centile) had a highly significant association with fetal growth retardation, and perinatal mortality was significantly increased in the presence of both hypoglycaemia and hyperglycaemia (plasma glucose above 95th centile) when pregnancy outcome was analyzed in 5000 consecutive patients who had a glucose tolerance test performed during the third trimester of pregnancy. This study confirms the significance of abnormal glucose tolerance as a causative factor of feto-placental dysfunction. The flat glucose tolerance test pattern had no significance beyond the presence of associated hypoglycaemia, but reactive hypoglycaemia, and persistent abnormalities of plasma glucose levels during the test, were associated with higher incidences of complicated outcome. Hypertonic dextrose therapy administered to the patient with persistently subnormal urinary oestriol excretion was less likely to cause a favourable response in oestriol excretion if glucose tolerance was abnormal, perhaps because the adverse influences of abnormal glucose tolerance were not reversible by the third trimester of pregnancy. Hypoglycaemia and hyperglycaemia, additional to diabetes mellitus, are significant factors in the aetiology and diagnosis of abnormal pregnancy, and point to the need to investigate therapeutic measures.

Modulation of steroid status by conventional chemotherapy was studied in 31 breast cancer patients receiving CMF and in 31 age-matched breast cancer patients without any therapy, taken as controls. This was achieved through the study of oestrogen excretion profiles using previously identified parameters and referring not only to classical but also to the "other", namely catechol and unusual, oestrogen metabolites. After CMF treatment the premenopausal patients exhibit a modified excretion pattern, mainly concerning a marked and significant reduction of classical oestrogens, as shown by pattern indices. Because there is evidence that oestriol metabolism is not markedly affected by CMF treatment, such a significant decrease in classical oestrogens must be attributed to the secretory function, presumably ovarian ab origine. To the contrary, after treatment, pattern indices show significantly higher median values in postmenopausal patients. Mean oestriol ratio values also display a significant increase, thus supporting the hypothesis that conventional cytotoxic drugs may act by enhancing oestrogen metabolic rates. In fact, the postmenopausal treated subgroup proved to have significantly higher excretion levels of most of the oestrogens considered to date. Surprisingly, E1 + E1-S fractions were strongly reduced in this subgroup and this leads to the suggestion of an increased steroid metabolic rate by CMF treatment. However, comparing 9 breast cancer patients, when having had both short-term and non-short-term CMF treatment, the effects on steroid excretion patterns appear to arise at an early stage.

Serum levels of total oestriol and human placental lactogen (HPL) were measured in 360 pregnancies; in 182 there were abnormalities likely to be associated with increased fetal risk. A total of 217 estimations of oestriol and HPL were performed in 163 normal pregnancies to define the normal ranges. The value of both tests in the management of complicated pregnancies was assessed. Serum oestriol was found to be very efficient in the diagnosis of intrauterine growth retardation. In such cases, 76% of patients had unfavourable oestriol levels. Patients with mild pre-eclampsia had HPL levels similar to normal, but values decreased significantly in the presence of fetal distress. The mean serum oestriol level in patients with pre-eclampsia were lower than normal, and were further reduced in the presence of fetal distress. The importance of measuring serum oestriol levels at each antenatal visit is stressed in the detection of developing fetal complications; in such cases, 73% of patients had subnormal values. Both tests provided accurate assessments in the 8 patients with intrauterine death. Significant fetal-placental dysfunction was present in 55 patients, and 41 (75%) were predicted by serum oestriol, 23 (42%) by HPL, and 45 (82%) by the use of both tests. In the 142 complicated pregnancies that resulted in a favourable outcome, confirmation was obtained in 102 (72%) by serum oestriol and in 121 (86%) by HPL.

During the 10-year period 1 January 1979 to 31 December 1988, polyhydramnios occurred in 537 patients with singleton pregnancies delivered at the Mercy Maternity Hospital. Associated maternal and fetal complications and the perinatal outcome of these pregnancies with polyhydramnios were analysed. In 248 of the 537 pregnancies (46%) in this group there were no maternal complications or fetal malformations and the perinatal mortality (PNM) rate was 2.4%. The PNM rate increased significantly to 13.1% when there was associated pre-eclampsia, 10% with gestational diabetes, and to 7.6% with miscellaneous complications. When polyhydramnios was associated with a fetal or placental malformation the PNM rate was 61.4%. The commonest malformations were central nervous system (31%), musculoskeletal (12%) and gastrointestinal system anomalies (10%). Placental chorioangioma occurred in two patients (0.4%) and both babies died. In women with low oestriol excretion (18% of the 455 tested) the PNM rate increased five times to 22.7%.

When different bloodstains are encountered at the scene of crime, it is possible to discriminate those from a pregnant woman from others. Human chorionic gonadotrophin, human placental lactogen, total oestriol and progesterone in the stains may be determined with radioimmunoassay techniques using commercial kits. Only 1 cm2 of bloodstain is needed for the determination of all four parameters, which gives information about the state of pregnancy. More than 100 stains of blood from women in all stages of pregnancy, normal menstruating women, menopausal and post-menopausal women and male subjects, and of menstrual blood were analysed. Bloodstains from pregnant women were easy to evaluate with the four determinations, only very early pregnancies being undetected. Stains from non-pregnant women were negative or below the cut-off level. Two case examples are also described.

A study of the clinical course of severe pre-eclamptic toxemias shows that, in case of antihypertensive therapy, it is usually necessary to terminate the pregnancy in cases of foetal maldevelopment, in cases with foetal indication (if no intrauterine death of the foetus takes place), whereas if there is no maldevelopment it is usually a maternal indication that enforces before-term termination of pregnancy. In case of foetal maldevelopment, a drop in HPL and oestriol values was seen. This suggests that the foetal condition deteriorates under antihypertensive treatment. For the foetus, which is deficiently supplied by the placenta, pre-eclamptic toxaemia is a regulatory mechanism of circulation that enhances blood supply of the placenta, since the peripheral resistance in the placental circulation, which is free from vascular nerves, is lower than in the nerve-supplied circulation of the body, on which a hypertensive substance can act. The assumption that such a compensatory mechanism exists is supported by a number of clinical observations. This regulation, which is necessary for the development and perhaps also for the survival of the foetus, is disturbed by the antihypertensive therapy, which explains the deterioration in the condition of the foetus.

The purpose of these studies was to determine whether oestrogen production is a quantitatively important pathway in the hepatic microsomal metabolism of androst-4-ene-3,17-dione. The effects of the enzyme inducing agents phenobarbitone and beta-naphthoflavone on microsomal cytochrome P-450-mediated androst-4-ene-3,17-dione hydroxylation and aromatization was investigated in the rat in vitro. In microsomal fractions from untreated rats the ratio of hydroxylated products to aromatized (oestrogenic) metabolites was 33:1. Phenobarbitone pretreatment of rats increased total hydroxylation by about 20% but did not change the ratio of hydroxylated to aromatized products (27:1). In contrast, beta-naphthoflavone induction decreased total hydroxylation to about 35% of control but did not affect total aromatization. Thus the ratio of hydroxylation to aromatization was significantly lower than in control microsomes (17:1). The principal aromatized products were oestriol and 2-hydroxyoestradiol-17 beta, with oestradiol-17 beta and its 4-hydroxy metabolite as minor products; no oestrone was observed. In further studies of the microsomal metabolism of oestrone, the major product was oestradiol-17 beta whereas hydroxylated metabolites were only minor products. Oestradiol-17 beta, in contrast, was hydroxylated to a considerable extent. These findings suggest that oestrone is a better substrate for the microsomal 17 beta-oxidoreductase than it is for cytochrome P-450. It therefore appears likely that any oestrone formed from the aromatization of androst-4-ene-3,17-dione would be readily converted to oestradiol-17 beta which, in turn, is subject to cytochrome P-450-mediated hydroxylation. Although the liver is a site of C19-steroid aromatization, it appears unlikely that this organ could contribute significantly to serum oestrogen levels since microsomal hydroxylases are readily able to convert aromatized products to biologically inactive metabolites.

The effect of three years oestriol succinate therapy (2 mg/day) on the skin was studied in 20 castrated women whose average age was 48 years. A control group whose average age was also 48 years, consisted of 7 patients who did not receive any treatment after castration. There was no significant reduction in epidermal thickness during the three year course of oestriol succinate therapy. On the other hand the significant thinning of the epidermis in the control group was observed three years after oophorectomy. The difference between the 3H-thymidine labelling indices in oestrogen and control groups was not significant three years after castration.

A reliable procedure for the assay of liver microsomal 16 alpha-hydroxylation of oestrone 3-sulphate has been developed for the guinea pig. It is based on the rapid, quantitative separation of oestradiol and oestriol by Sephadex LH-20 columns after the chemical reduction and enzymic hydrolysis of the incubation products. Microsomal preparations and incubation conditions that optimized 16 alpha-hydroxylation of oestrone 3-sulphate were employed. Under these circumstances, reduction of the substrate at C-17 and hydrolysis of the sulphate were minimized. Conditions were established that yielded reaction linearity with respect to time and microsomal concentration. This hydroxylation had an absolute requirement for NADPH, which could not be satisfied by NADH. Apparent Km values for oestrone 3-sulphate and NADPH, under the conditions used, were 14 microM and 0.17 mM respectively. 16 alpha-Hydroxylase activity was present in the liver microsomal fraction from heavily pigmented, female English Shorthaired guinea pigs. Much lower activity was detected in mature pigmented males and albino females. No activity could be demonstrated in mature, albino males.

Ten women were given dexamethasone intramuscularly in order to accelerate fetal lung maturation. Amniotic fluid and maternal serum were assayed for oestrone, oestradiol-17beta, oestriol, progesterone and chorionic gonadotrophin by specific radioimmunoassays before and after the treatment. No hormonal changes were observed in amniotic fluid. The serum levels of oestrogens 2 to 5 days after treatment were not significantly different from those before treatment, indicating that the previously reported suppression of oestrogen production by glucocorticoids disappears rapidly after treatment stops.