An adaptation of a radioimmunoassay for plasma oestriol for assaying urine oestriol is presented. The method has been shown to be precise, reliable, and directly comparable with the manual spectrophotometric technique for urine oestriol.

The determination of serum oestriol is known to be a useful parameter of the function of the feto-placental unit. In order to derive the normal range on application of the radioimmunoassay technique, the serum oestriol level was determined in 242 gravidae during the second half of pregnancy. The pregnancies were all uncomplicated and ended with the delivery of a healthy baby at term. The statistical mean and 4 confidence intervals were calculated for each gestational week individually. During the second half of pregnancy there was a continuous gradual increase in serum oestriol; between the 34th and 38th gestational week there was a further steep increase, followed by a decrease from the 39th gestational week onwards. The usefulness of this method is illustrated on the basis of case reports of 10 high-risk pregnancies in which oestriol determination is compared with the clinical findings and HPL determination.

This paper is the first of a series concerning the follow-up of children whose mothers had subnormal oestriol excretion during pregnancy. The incidences of still births, neonatal deaths, dysmaturity and major and minor congenital malformations were significantly increased in pregnancies complicated by one or more subnormal oestriol value. Growth parameters and developmental progress were measured of 136 infants who attained the age of one year, and it was encouraging to find that no gross departures from normal were observed.

Calculations to define the distribution of normal urinary oestriol excretion values during pregnancy are presented. The values had a normal distribution, uniform variance and increased linearly with time after logarithmic conversion. The variance could, therefore, be partitioned and a control chart constructed.

We compared the medical and financial cost-effectiveness of prenatal serum screening for Down's syndrome using maternal age, serum alpha-fetoprotein and human chorionic gonadotrophin with and without the use of unconjugated oestriol. The use of unconjugated oestriol is medically more cost-effective than screening without it at all levels of detection. The actual performance depends on whether gestational age is estimated using 'dates' or an ultrasound scan. At a detection rate of 60 per cent, the proportion of unaffected fetal losses per case diagnosed at amniocentesis is about 22 per cent less if gestational age is estimated using dates (time since the first day of the last menstrual period) and about 47 per cent less if it is based on an ultrasound scan examination. At this detection rate, the inclusion of unconjugated oestriol increases costs by about 2k pounds per case diagnosed (36k pounds instead of 34k pounds) if gestational age is estimated using dates, but it is no more expensive if gestational age is measured from an ultrasound scan examination (indeed, it is more cost-effective at detection rates above 60 per cent). Since there is little change in the financial cost with the inclusion of unconjugated oestriol, for the improved medical performance of screening, it is worthwhile including it in the screening test.

In order to evaluate the possible underlying factors for the increase in red cell 2,3-diphosphoglycerate content observed in late diabetic pregnancy, its relationship with serum unconjugated oestriol, human placental lactogen, haemoglobin and hydrogen ion concentrations was investigated in 42 pregnant diabetic women. A significant correlation was found between red cell 2,3-diphosphoglycerate and serum unconjugated oestriol (r = 0.54, p less than 0.001), whereas no correlation was present between 2,3-diphosphoglycerate and the following variables: arterial pH, haemoglobin concentration and human placental lactogen. The content of 2,3-diphosphoglycerate correlated significantly with haemoglobin-oxygen affinity expressed as P50 at pH 7.4 (r = 0.34, p less than 0.05). The results of this study indicate that serum unconjugated oestriol may participate in the regulation of red cell 2,3-diphosphoglycerate content and thereby of the maternal blood oxygen release to the fetus.

The effects of repetitive administration of 50 micrograms of LRH and 100 micrograms of TRH in a single bolus at 0, 90 and 180 min on Prl, TSH, FSH, beta-hCG and oestriol were tested in 11 healthy pregnant women in their third trimester of pregnancy. Basal hormonal levels were in agreement with previous reports. The Prl and TSH peaks after each injection of LRH/TRH were similar for each hormone. No significant changes in serum FSH, beta-hCG and oestriol were detected after repetitive administration of LRH/TRH. Thus, the responsiveness of lactotroph and thyrotroph cells to pulsatile stimulation with LRH/TRH is not altered during the last trimester of pregnancy, and FSH, beta-hCG and oestriol levels remain constant during the period of sampling.

OBJECTIVE

Evaluation of the oestriol pharmacokinetics, pharmacodynamics and safety in healthy, postmenopausal women under treatment with a vaginal ring with continuous delivery rates of 0.125 (Test 1), 0.250 (Test 2) or 0.500 mg/day (Test 3) for 21 days.

METHODS

Thirty-one subjects received a single application of Test 1, 2 or 3. The oestriol plasma concentration was determined by LC-MS/MS. The FSH, LH and SHBG serum concentrations, maturation value (MV) and vaginal pH were assessed to describe the pharmacodynamics. Adverse events, local tolerability and endometrial thickness (ET) were evaluated to determine safety.

RESULTS

The 90% CI of the coefficient/slope β was 0.5997 %-1.174 % for AUC0-tlast , 0.5838 %-1.115 % for AUC0-∞ and 0.2408 %-0.943 % for Cmax . Dose-proportionality could not be rejected for AUC, but a deviation from proportionality was statistically significant for Cmax . The FSH and LH curves showed a decrease that was more pronounced with higher delivery rates; however, SHBG did not presented this behavior. A treatment effect on MV and vaginal pH was comparable for all formulations. All products showed increase in MV (70-80%) and the distribution of parabasal, intermediate and superficial cells showed a shift towards superficial cells. The vaginal pH values markedly decreased under treatment. The effect on ET was no dose-dependent.

CONCLUSIONS

All formulations released sufficient amounts of oestriol to trigger the maximum local effect. However, there was no difference between formulations regarding surrogate parameters for clinical efficacy. A dose-dependency; however, was clearly demonstrated for FSH and LH. The product was well tolerated and safe.

Maternal serum screening for alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG) increases the detection rate of Down's syndrome (DS) pregnancies. To estimate the risk of a DS pregnancy for a particular woman, Wald et al. combine a trivariate function of AFP, hCG, and unconjugated oestriol with age-specific risk. Calculation of independent likelihood ratios (LRs) for AFP and hCG has allowed us to examine the predictive value of each test alone and the combination. AFP and hCG were measured in stored serum samples from 672 normal, 8 trisomy 21 (DS), 9 trisomy 18, and 2 trisomy 13 pregnancies. AFP and hCG multiples of the median (MOM) were calculated for each sample. The LRs for AFP MOM and hCG MOM were calculated and combined with age-specific risk. Of eight DS pregnancies, six had increased risk based on age and AFP. Addition of hCG detected two additional DS pregnancies. Of nine trisomy 18 pregnancies, four (44 per cent) had hCG MOM under 0.25. Three out of nine would have been classified as high risk by AFP, but none by combined AFP and hCG. Amniocentesis would have been recommended in 74 per cent of aneuploid pregnancies if both age and serum screening were used. Abandonment of amniocentesis based on age alone would have excluded two abnormal pregnancies from detection. Screening programmes should note that combined risk figures are specific for DS and do not include other trisomies. Detection of other trisomies requires inclusion of low hCG level as a discriminator and continuation of age-based testing.

Second trimester maternal serum screening for fetal Down's syndrome (DS), using the AFP (alpha-fetoprotein), hCG (human chorionic gonadotrophin) and uE3 (unconjugated oestriol) triple test, is as well documented procedure associated with a DS-detection rate of about 70 per cent, for an amniocentesis rate of about 7 per cent. The triple test is relatively little used in the Nordic countries, though its wider use would result in more efficient diagnosis of DS and various fetal malformtions. The maternal age indication currently used leaves gravidae under 35 years of age without prenatal diagnostics, although it is in just this age group that the majority (70 per cent) of cases of fetal DS occur. In Denmark, where 12 per cent of gravidae undergo invasive diagnostic procedures, the proportion of induced abortions due to the procedures is far too high, in relation to the DS detection rates obtained. Maternal serum screening yields a much better ratio between the risk of abortion after amniocentesis and the likelihood of DS detection than does maternal age alone. Maternal serum screening at 7-14 weeks of gestation, using pregnancy-associated plasma protein A and free hCG beta subunit concentrations, will become available within the next few years, thus reducing the incidence of some of the psychological and technical problems associated with second trimester screening, especially that of third trimester abortion. Irrespective of whether it is performed in the first or the second trimester, maternal serum screening will be the cornerstone of prenatal DS diagnosis in the future.

BACKGROUND

Fetal abnormalities are the most common cause of perinatal and postnatal death and infant handicap. For this reason prenatal screening (for fetal malformation) has become a routine part of obstetric care in many countries. Most often used are biochemical tests and continuously developing ultrasound diagnostics which makes possible precise analysis of the fetal morphology. There is interesting to establish a noninvasive test for the early detection of fetal malformation in pregnancy which is based on ultrasound examination (NT measurement from the 10th to the 19th weeks, presence of nasal bone in the first trimester ultrasound), correlated with serum concentration of AFP, beta-HCG and oestriol in the second trimester of pregnancy (triple test). The main aim of the study was to establish a diagnostic schema for detection of fetal malformations based on NT measurement in the first and second trimester coupled with triple test performed in the second trimester.

METHODS

A group of 775 pregnant women from the 10-th week of pregnancy until childbirth has been put under examination. Between the 10th and the 14th and than between 15th and 19th week of pregnancy ultrasound examination with fetal biometry and NT measurement was done. NT measurements have been performed in accordance with the standards worked out by professor K. Nicolaides. At the first ultrasound examination the presence of the nasal bone was observed. The next step was performing the triple test between the 15th and 19th week of pregnancy. On the same day as second ultrasound examination blood was taken to determine the results of the triple test (ELISA method). The obtained results have undergone statistical analysis.

RESULTS

The age of women qualified for the examination oscillated between 15 and 45 (over 35 -9.4%). There were 8 fetal malformations recognized all connected with the chromosomal anomalies, namely, 4 Downs syndrome, 2 fetuses with trisomy of the 18th pair of chromosomes and 2 with triploidy. At all physiologic pregnancies nasal bone was seen during first ultrasound examination. The obtained results of nuchal fold measurements and concentrations for the parameters of the triple test have been the basis to calculate medians in the particular weeks of pregnancy. In all the cases of genetic malformations the widening of the nuchal fold above 99 percentile (MoM NT) has been observed. Fetal nasal bone were absent in 62.5% first trimester ultrasound examinations. The risk of the occurrence of a genetic malformation resulting from the mother's age combined with the risk connected with the NT measurements and the results of the triple test for the cut-off point 1:250 (which seems to be the best for this population) gave 100% sensitivity, 0.6% % of false positive results and the positive predictive value of 80%. The above mentioned results are better than the ones which were obtained within the triple test only, where for the previously fixed cut-off point 1:250 sensitivity reached 63%, positive predictive value 25% and 4.4% false positive rate. Performing the so-called integrated test in which the risk of the occurrence of any malformation is estimated on the basis of the NT measurement in the first and the second term of pregnancy seems to be far more useful.

CONCLUSIONS

Diagnostic schema for detection of fetal malformations in the first half of pregnancy which is based on ultrasound examination (NT measurement from the 10th to the 19th weeks), correlated with serum concentration of AFP, beta-HCG and oestriol in the second trimester of pregnancy (triple test) is very sensitive and safe method of the prenatal diagnosis leading to significant decrease of the invasive procedures (amniocentesis).

The present study compares the negative feed back action of cortisol and cortison on oestriol production in late human pregnancy. 10 women from the 38th to 40th week of gestation volunteered in this study. All had uncomplicated courses of pregnancy and delivered healthy babies at term. 5 patients received a continuous infusion of 100 mg Cortisol from 10 a.m. to 12 a.m. To the other 5 patients 100 mg Cortison were infused during the same period. Blood specimens (5 ml) were drawn in 60 and 30 minutes intervals from 8 a.m. to 5 p.m. Plasma levels of unconjugated oestriol were measured by radioimmunoassay. The suppression of oestriol levels was nearly identical in both groups: After Cortisol oestriol concentrations decreased from 17.1 +/- 9.1 ng/ml to 6.0 +/- 1.2 ng/ml (p less than 0.001) and after Cortison from 15.5 +/- 5.8 ng/ml to 5.9 +/- 1.8 ng/ml (p less than 0.001), respectively. According to these results the placental metabolism of maternal cortisol to cortison does not impair the negative feed back action of this hormone on the foetal hypothalamus-hypophysis-system.

Rates of reaction of different oestrogens in Kober reagent vary greatly. Rate constants were measured between 100 degrees C and 150 degrees C. Oestradiol, oestrone, 16-oxo-oestradiol, 16 alpha hydroxyoestrone, 16-epioestriol and urine pool show two sequential first order reactions at 100 degrees C; oestriol and its conjugates give a single reaction (slower than the other oestrogens except for the very slow oestretrol). Above 120 degrees C differences decrease, all oestrogens having one rate for Kober product formation: the decay reaction, which is also first order, becomes significant. Oestriol and its conjugates have relatively high apparent activation energies in the Kober reaction (120-138 kJmol-1) compared to other oestrogens studied (105-124 kJmol-1). The apparent activation energy for the decay reaction is the same within experimental error (115 +/- 3 kJmol-1). This is consistent with a common product formed from oestrogen reacting with Kober reagent. Analytical methods must respond similarly to major urinary oestrogens. Appropriate conditions include 100 degrees C for at least 20 min or 135 degrees C for 3 to 4 minutes.

We studied the plasma oestriol concentration during increasing gestation in 192 normal pregnancies and 96 pregnancies complicated by diabetes mellitus. Among the 96 patients there were 16 established, 32 gestational, 29 'persistent' gestational and 19 either gestational or 'persistent' gestational diabetic pregnancies. Serial blood samples were collected and their concentrations of oestriol (total oestriol) determined by radioimmunoassay. The distribution of birthweights and placental weights around each gestational period was skewed to the right. Therefore, the 5th and 95th percentiles were obtained after computing a logarithmic transformation of the data. The incidence of big and small babies in all diabetic groups, except that in the gestational diabetic group, was significantly higher than that in the group of normal pregnant women. The distribution of oestriol concentrations was also skewed to the right and had to be normalized by logarithmic transformation. The oestriol profile in normal pregnancies had a wide scatter, especially after the 37th week. Serial measurements with reference to the normal oestriol profile showed a detection rate of approximately 85% for both normal and abnormal foetal outcome. There were 15% of false negative and 16% of false positive results. Results in this study indicate that serial blood oestriol measurement may be a useful additional index for foetal monitoring in pregnancies in diabetic women. Furthermore, if large scale screenings using a single estimation are performed, it is best carried out between the 33rd and 34th week of gestation.

OBJECTIVE

Our aim was to investigate whether the maternal serum concentrations of first and second trimester serum analytes are altered in familial Mediterranean fever (FMF) pregnancies.

METHODS

The screening tests were compared in a series of 16 serum samples from FMF pregnancies and in a cohort of 48 pregnant women with normal pregnancy. Serum samples were obtained between 11 and 13 weeks; 16 and 18 weeks gestation.

RESULTS

Serum pregnancy-associated plasma protein-A (PAPP-A) levels, expressed as multiples of the median (0.9 ± 0.45 MoM) in the control group, were significantly higher than FMF patients (0.6 ± 0.3 MoM) (p = 0.027). Analyses of alpha-fetoprotein, human chorionic gonadotropin and oestriol levels showed no significant differences between FMF and normal pregnancies.

CONCLUSIONS

Our study revealed that low levels of PAPP-A are associated with FMF.

An improved method is described for the determination of oestriol concentrations in urines of pregnant women. Oestriol is detected as a derivate of 1-dimethylaminonaphtalene-5-sulphonylchloride (DANSYLchloride). The method has the following characteristics: 1. The recovery of oestriol-16-glucuronide is 94%. 2. For the interpretation of the results obtained with this method mean values and 95% probability bounds of urinary oestriol excretion for each week of the last three months of pregnancy are given. (e.g. 49--125 mumol/24 h at 32 weeks of gestation, 108--238 mumol/24 h at 40 weeks). 3. The coefficient of variation of the method is 4% (from day to day). 4. The lowest detectable concentration is 3 mumol/l. 5. Influence of glucose can be eliminated. 6. Other urinary compounds have no influence on the determination.

The renal clearance of unconjugated oestriol, oestriol glucosiduronate and oestriol sulphate by the kidney in late human pregnancy has been compared with simultaneous measurements of inulin clearance. The results for the fractions not bound to protein indicate that after glomerular filtration, unconjugated oestriol is completely reabsorbed, oestriol glucosiduronate is both filtered and excreted actively by the tubules, and that oestriol sulphate is filtered but not excreted or absorbed by the tubules; the administration of probenecid confirms these observations on tubular handling. The possibility of using endogenous oestril sulphate as a means of measuring the glomerular filtration rate in pregnancy is suggested.

OBJECTIVE

To evaluate the effect of adjuvants during intensive vaginal dilator therapy for functional and anatomical neovagina creation in women with Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH).

METHODS

This retrospective cohort study included 75 women with MRKH undergoing intensive vaginal dilator treatment between 2000 and 2014. One specialist nurse performed non-surgical vaginal dilation aided by adjuvants, during inpatient admissions for several dilation sessions per day. Following discharge, women continued dilation at home and were advised to attend fortnightly follow-up appointments.

RESULTS

Outcomes from 68 women were analysed. The median age of starting treatment was 18 years (range: 13-36). There was a mean of 3 days per admission (range 1-5) with a median of 10 dilation sessions per admission. Adjuvant treatment was used by 48/68 (71%) women: oestriol cream 29/68 (43%), 50:50 nitrous oxide and oxygen 44/68 (65%), diazepam 8/68 (12%), lidocaine ointment 26/68 (39%), paracetamol 35/68 (51%) and naproxen 2/68 (3%). There were no statistically significant differences for changes in vaginal parameters. Women receiving adjuvants had a median increase of 4.5 cm (0.5-7 cm) in neovaginal length compared with women not receiving adjuvants who had a median increase of 3.25 cm (0-7 cm) during intensive treatment. Women who received adjuvants tolerated more dilation sessions per day (10 vs 6.5 median sessions respectively) than those who did not (P < 0.001). Of those with documented length at discharge, 42/56 (75%) women had an anatomical neovagina of 7 cm or greater length.

CONCLUSIONS

Vaginal dilation delivered by intensive treatment and supplemented by adjuvant treatments in a multi-disciplinary centre is a rapid and effective method for creation of a neovagina in women with MRKH.

OBJECTIVE

Prenatal screening was set up to identify patients at high-risk of chromosome 21 trisomy based on maternal serum markers measurement. However, the risk of trisomy 21 should not be the only result considered by obstetricians. In fact, abnormal marker values can be associated with other fetal diseases and used to improve maternal and fetal follow-up. Our objective was therefore to study other predictive values of maternal serum markers.

UNASSIGNED

A search through publications was conducted using the PubMed® or Cochrane® databases.

RESULTS

In case of high PAPP-A there is no link with any complications. Second trimester high hCG or first trimester low hCG are associated with an increased vascular risk. High α-fetoprotein level is a marker of neural tube defects or abdominal wall defect. Persistence of high α-fetoprotein with normal echography can suggest other rare fetal diseases. Low maternal serum markers suggests 18 trisomy. Oestriol reflects the fetal hypothalamo-hypophyseal axis and can be used as a diagnosis tool.

CONCLUSIONS

Serum markers could be interesting tools for the identification of high-risk pregnancy and the prevention of neonatal complications. They also appear as a potential help to diagnose certain congenital malformations.

Authors have studied plasma human placental lactogen (HPL) an oestriol levels in 37 pregnant women affected by severe hypertensive disorders, diabetes mellitus, bad obstetric history, intrauterine growth retardation. They point out validity of associated and seriated dosages of these hormones because they are expression of foetus wellbeing and of placental function to survey high risk pregnancies.

The use of maternal age alone to identify pregnant mothers at risk of a fetus with Down's syndrome has recently been supplemented by maternal serum screening using biochemical markers such as alpha-protein, human chorionic gonadotrophin and oestriol. These tests have been reported to increase the sensitivity of antenatal detection of such fetuses from 35% to 67% with a false positive rate of 5%. However, these maternal serum markers may be affected by maternal weight, the smoking history of mothers and diabetes mellitus. Furthermore, such sensitivities are achieved only when gestational age is assessed accurately by ultrasound. Many further studies need to be carried out before the introduction of maternal serum screening into routine obstetric practice in Singapore. These include studies on the incidence of Down's syndrome in the local population, studies on the distribution of these serum markers in the second trimester of pregnancy, sensitivities and positive predictive values of such a test in the local population as well as the socio-economic implications of implementing such a screening test in the local obstetric population.