Saliva steroid levels reflect the unbound unconjugated (free, biologically active) plasma hormone levels. Saliva oestriol (E3), oestradiol (E2), oestrone (E1) and progesterone levels were estimated by radioimmunoassay in saliva samples obtained twice a week from 18 weeks gestation until 38 days before delivery and then daily until the spontaneous onset of labour at term from 20 normal pregnant women. The overall percentage increases in the median concentrations of E3, E2, E1 and progesterone were 718, 370, 80 and 214%, respectively, in the last 20 weeks and 149, 82, 24 and 41%, respectively, in the last 6 weeks of pregnancy. The median E3:progesterone ratio rose slowly from 0.65 at 20 weeks before delivery to 1.0 at 5 weeks before delivery and then rapidly to 1.65 one day before the spontaneous onset of labour. There was an increase in the E3:progesterone ratio from less than 1 to greater than 1 before labour in every subject.

The hypoestrogenic state induced by gonadotrophin-releasing hormone agonist (GnRHa) has been shown to be effective in the treatment of oestrogen-dependent disorders but to induce bone loss. Adding back low doses of oestrogen in GnRHa therapy has been proposed to prevent bone loss. The purpose of this study is to assess the efficacy of add-back therapy with different natural oestrogens such as oestrone (OE(1)), oestradiol (OE(2)) and oestriol (OE(3)). Three-month-old female rats (250 g) were subcutaneously administered microcapsules of leuprorelin acetate in doses of 1 mg/kg of body weight every 4 weeks. GnRHa therapy lasted 16 weeks, and pellets of OE(1), OE(2) or OE(3) (0.5 mg/pellet, 60 day release), as an add-back agent, were implanted at 8 weeks of treatment. At the end of treatment, GnRHa alone decreased bone mineral density of the femur and lumbar vertebrae, and increased serum levels of bone metabolic markers such as alkaline phosphatase and osteocalcin levels. As for cancellous bone histomorphometry, GnRHa decreased bone volume while it increased osteoid volume, osteoid surface, eroded surface, mineral apposition rate and bone formation rate. All the oestrogens tested prevented these changes caused by GnRHa therapy. GnRHa induced a significant increase in body weight and a marked reduction in uterine weight, which was not observed in OE(1) or OE(2) add-back group. Body weight and uterine weight of the OE(3) add-back group were the same as those of the GnRHa group. These findings indicate that GnRHa induces high turnover bone loss which can be prevented by concomitant administration of natural oestrogens such as OE(1), OE(2) and OE(3) to the same extent. In addition, OE(3) is unique in that it is much less effective than OE(1) and OE(2) in blocking body weight gain and in promoting growth of uterine tissues. Because of its tissue-selective actions, OE(3) could be considered as one of the most appropriate oestrogens used for GnRHa add-back therapy.

OBJECTIVE

To evaluate the introduction to two health districts of an antenatal serum screening programme for Down's syndrome using the triple test-measurement of alpha fetoprotein, unconjugated oestriol, and human chorionic gonadotrophin concentrations in second trimester serum samples.

METHODS

All women delivering at the main maternity units in both districts were eligible for the screening programme. A serum sample was taken between 15 and 22 weeks' gestation, confirmed by ultrasound scan. An estimated risk of 1 in 250 or greater was considered to be a screen positive result and further diagnostic tests were offered. As far as possible the outcome of all screened pregnancies was recorded, and babies with Down's syndrome born to women who declined serum screening were also identified.

RESULTS

6990 singleton pregnancies were screened over a two year period, representing an estimated uptake of 67% (6990/ 10,443). After a screen positive result 80% of women (168/211; 95% confidence interval 74.2 to 85.1%) opted for amniocentesis. The false positive rate was 2.9% (203/6979; 95% confidence interval 2.5 to 3.3%). The detection rate in the screened population was 73% (8/11). The estimated cost of identifying one Down's syndrome affected pregnancy was about 31,000 pounds.

CONCLUSIONS

Successful introduction of the triple test to health districts where there is no established serum screening programme for neural tube defects is possible. The programme seems to be acceptable to most of those screened. Uptake of the programme is sufficient to make it more effective than a policy for Down's syndrome screening dependent on age only.

We conducted a study to investigate the effect of parity on the following six serum markers used in screening for Down's syndrome, after adjusting them for ethnic group and maternal weight: alpha-fetoprotein (AFP), unconjugated oestriol (uE3), total human chorionic gonadotrophin (hCG), free alpha-hCG, free beta-hCG, and dimeric inhibin A. We aimed to estimate the effect of adjusting for any differences found on the screening performance. AFP, uE3, and hCG concentrations were available from 16,666 women with singleton pregnancies without Down's syndrome or neural tube defects and without insulin-dependent diabetes mellitus, who were screened between 15 and 22 weeks' gestational age. Stored serum samples were available on a subset of 1347 women and these were used to measure free alpha-hCG, free beta-hCG, and inhibin A. Serum concentrations were expressed as multiples of the median (MOM) for women of the same gestational age, weight, and ethnic group. Of the six markers, only hCG levels were affected by parity; hCG levels decreased by 3.1 per cent per previous birth (95 per cent confidence interval 2.2-4.0 per cent); there was no significant relationship between the number of previous abortions and hCG level after adjustment for the number of previous births. The effect of previous births on hCG was not due to maternal age. Only AFP was affected by maternal age, but the effect was small; levels increased by 4.4 per cent per 10 years of age (3.2-5.7 per cent). It is not worthwhile adjusting serum markers for parity or for maternal age in prenatal screening for Down's syndrome because their effect on the performance of screening is negligible.

Two receptor systems for oestrogens have been demonstrated in the uterus: the cytosol-nuclear receptor system and the eosinophil receptor system. It has been proposed that the cytosol-nuclear receptor system mediates the genomic response to oestrogens in the uterus, while the eosinophil receptor system is thought to mediate the uterine edema and other early oestrogenic responses in the uterus. Cortisol is known to decrease drastically the number of eosinophils in the blood and therefore to limit their availability for migration to the uterus. The present results show that cortisol also drastically reduces both the oestrogen-induced uterine eosinophilia and the uterine wet weight responses, but does not interfere with the oestrogen-induced uterine RNA and protein increases. Oestradiol-17 beta has a higher affinity than oestriol for the cytosol-nuclear receptors and is now found to be the more potent oestrogen in inducing the genomic activation in the uterus. Estriol has a higher affinity than oestradiol-17 beta for the eosinophil receptors, and therefore, oestriol is the stronger oestrogen in inducing those oestrogenic effects which are mediated by the eosinophil receptor system. We conclude that the eosinophil receptor system for oestrogens is a new system, independent of Jensen's cytosol-nuclear receptor system, and this eosinophil receptor system is involved in the mechanism of oestrogen action in the uterus.

The glucuronic acid adducts of 1-naphthol, 2-naphthol and 4-methylumbelliferone activate microsomal UDP-glucuronyltransferase (EC 2.4.1.17) when the enzyme is assayed with p-nitrophenol as aglycone. Phenyl glucuronide and oestriol 3beta-glucuronide also activate UDP-glucuronyltransferase. but to a lesser extent. Activation by glucuronides is not dependent on metal ions, but is blocked by prior treatment of microsomal fractions with p-chloromercuribenzoate. The kinetic mechanism of activation is concluded to be an increase in the affinity of the enzyme for UDP-glucuronic acid. Activation by 1-naphthyl glucuronide, at high concentrations of p-nitrophenol, is not affected by 1-naphthol. Apparently 1-naphthyl glucuronide activates the preparation by binding at a site that is separate from the site of glucuronidation of 1-naphthol. Further evidence for the existence of distinct effector sites for the glucuronides was provided by the finding that activation by glucuronides is inhibited competitively by aglycone glucosides. These glucosides do not inhibit the rate of glucuronidation of p-nitrophenol in the absence of glucuronide adducts, nor do they alter the rate of glucuronidation of 1-naphthol. When UDP-glucuronyltransferase is assayed with 1-naphthol as aglycone it is activated by p-nitrophenyl glucuronide, 4-methyl-umbelliferyl glucuronide and under appropriate conditions by its own glucuronide. These activations are similarly inhibited by aglycone glucosides. p-Nitrophenyl glucuronide also stimulates the rate of glucuronidation of o-aminophenol, o-aminobenzoate and bilirubin.

Thirty-four postmenopausal stress incontinence patients were divided in two groups: 17 were treated with 0.5 mg oestriol vaginal cream for 90 days, 17 controls were treated with moisturizing cream. All had low urethral pressures and dystrophy. Treated patients showed improvement of maximum urethral pressure, urethral closure pressure, and volume at first sensation of fullness. Dystrophy was cured in most patients; in 17% incontinence was cured and in 41% subjectively improved.

25 women aged 53--78 years with at least two years menopause were divided in three groups receiving one of the following oral treatments for three weeks: 2 mg oestradiol-17 beta plus 1 mg oestriol, 4 mg oestradiol-17 beta plus 2 mg oestriol or 50 micrograms ethinyloestradiol daily. Blood samples were collected before, during and after the treatment and the effect on the serum concentration of prolactin, oestradiol-17 beta, follicle-stimulating hormone and luteinizing hormonee was evaluated. During treatment with natural human oestrogens serum oestradiol-17 beta levels were significantly higher than before treatment. The serum concentration of prolactin was unchanged in patients receiving 2 mg oestradiol-17 beta plus 1 mg oestriol but increased in patients receiving 4 mg oestradiol-17 beta plus 2 mg oestriol or 50 micrograms ethinyl-oestradiol, thus indicating dose-dependence for natural human oestrogens. However, the increase was moderate, and these higher levels were not significantly different from levels of prolactin in serum found in 16 younger women. Concentrations of follicle-stimulating hormone and luteinizing hormon were depressed during treatment, the former to significantly lower levels when higher doses of oestrogens were used.

The effects of adrenocortical and gonadal steroids on the secretion in vitro of ACTH by adenohypophysial segments and corticotrophin releasing factor (CRF) by isolated hypothalami were studied in the rat. Corticosterone (1.25 X 10(-6) mol/l), betamethasone (2.5 X 10(-8) mol/l) and progesterone (2.5 X 10(-7) mol/l) reduced the hypothalamic extract-induced secretion of ACTH by pituitary tissue in vitro but aldosterone (2 X 10(-7) mol/l), testosterone, androsterone, androstenedione (2 x 10(-7) mol/l), oestradiol, oestriol, and oestrone (10(-6) mol/l) did not. Corticosterone (2.5 +/- 10(-9) mol/l), aldosterone (2 X 10(-8) mol/l) and betamethasone (2 X 10(-10) mol/l) inhibited and oestradiol, oestriol and oestrone (10(-8) - 10(-6) mol/l) potentiated the production of CRF by isolated hypothalami which occurred when acetylcholine or 5-hydroxytryptamine were added to the incubation medium but progesterone (2.5 X 10(-7) mol/l), testosterone, androsterone and androstenedione (2 X 10(-7) mol/l) had no effects. The results indicate that hypothalamo-pituitary-adrenocorticotrophic activity may be modified not only by glucocorticoids but also by other steroids.

The development of a sensitive radioimmunoassay has enabled measurements of pregnancy-associated plasma protein-A (PAPP-A) to be performed from early pregnancy. The present paper compares the plasma concentrations of PAPP-A with the levels of two trophoblastic proteins, human placental lactogen (hPL) and the beta-subunit of human chorionic gonadotrophin (beta-hCG), with a steroid of fetoplacental origin, total oestriol (total E3), and with a fetal protein, alpha-fetoprotein (AFP). PAPP-A was also measured in amniotic fluid and in maternal urine. In contrast with the secretion of the other substances studied, which either reach a plateau or even decrease during the last 4 weeks of pregnancy, PAPP-A steadily increased in the maternal circulation from 7 to 40 weeks gestation. It is proposed that PAPP-A production is either not related to placental mass or that PAPP-A is not of trophoblastic origin. The increase of PAPP-A in amniotic fluids parallels the increase in maternal blood; virtually no PAPP-A is excreted in urine.

A method for determining whether a pregnant woman with an extremely low serum oestriol (ELSE) measurement of mid-trimester is carrying a fetus with steroid sulphatase deficiency or another more serious disorder is described. We undertook GC/MS analysis of steroids in random maternal urine samples and quantified oestriol, oestriol precursors (dehydroepiandrosterone (DHEA), 5-androstene-3 beta, 17 beta-diol, 16 alpha-hydroxy-dehydroepiandrosterone and 5-androstene-3 beta, 16 alpha, 17 beta-triol), pregnanediol, and five other steroids largely unaffected by pregnancy (androsterone, etiocholanolone, tetrahydrocortisol, 5 alpha-tetrahydrocortisol and tetrahydrocortisone). Thirty-two samples collected from seven normal pregnant women between the 7th and 27th week of pregnancy and 22 from individuals with ELSE were analysed. Diagnostic ratios of excreted products were developed. These included ratios of oestriol and oestriol precursors to the cumulative value for the five non-pregnancy-related steroids and ratios of oestriol and oestriol precursors to pregnanediol and to each other. Our data demonstrated high 3 beta-hydroxy-5-ene steroid excretion in all ELSE patients together with low urinary oestriol excretion, a situation only consistent with deficiency of steroid sulphatase. The normal individuals had high oestriol and low excretion of oestriol precursors. No patient in our series showed the low oestriol levels and low oestriol precursor values that would indicate a fetal adrenal abnormality as the underlying defect.

BACKGROUND

Until the publication of the Serum Urine and Ultrasound Screening Study (SURUSS) report, it was difficult to compare the different antenatal screening tests for Down's Syndrome because of variations in study designs. We here present the main results from SURUSS, updated to take account of recent information on nuchal translucency in Down's Syndrome pregnancies, and discuss their implications.

METHODS

SURUSS was a prospective study of 47,053 singleton pregnancies (including 101 pregnancies with Down's Syndrome) conducted in 25 maternity units. Nuchal translucency measurements were taken. Serum and urine samples collected between 9 and 13 weeks, and again between 14 and 20 weeks of pregnancy were stored. Samples from each affected pregnancy and five matched controls were tested for currently used or suggested biochemical Down's Syndrome screening markers. Pregnancies were followed up to determine the presence or absence of Down's Syndrome. For an 85% Down's Syndrome detection rate, the false-positive rate for the Integrated test (nuchal translucency and pregnancy associated plasma protein-A [PAPP-A] at 11 completed weeks of pregnancy, and alpha-fetoprotein, unconjugated oestriol [uE3], free beta or total human chorionic gonadotrophin (hCG) and inhibin-A in the early second trimester) was 0.9%, the Serum integrated test (without nuchal translucency) 2.7%, the Combined test (nuchal translucency with free beta-hCG and PAPP-A at 11 weeks) 4.3%, the Quadruple test (alpha-fetoprotein, uE3, free beta or total hCG and inhibin-A) 6.2%, and nuchal translucency at 11 weeks, 15.2%. All tests included maternal age. Using the Integrated test at an 85% detection rate, there would be six diagnostic procedure-related unaffected fetal losses following amniocentesis per 100,000 women screened compared with 35 using the Combined test or 45 with the Quadruple test.

CONCLUSIONS

The Integrated test offers the most effective and safe method of screening for women who attend in the first trimester. The next best test is the Serum integrated test. The Quadruple test is the best test for women who first attend in the second trimester. There is no justification for retaining the Double (alpha-fetoprotein and hCG) or Triple (alpha-fetoprotein, uE3, and hCG) tests, or nuchal translucency alone (with or without maternal age) in antenatal screening for Down's Syndrome.

Blood was collected from 12 women following Caesarean section or normal delivery at term. The decline in plasma concentration of total oestriol, oestriol sulphate, oestriol glucosiduronate, unconjugated oestriol, human placental lactogen and pregnancy specific beta1 glycoprotein following delivery of the placenta was studied for 120 hours. The steroids and human placental lactogen fell very rapidly but pregnancy specific beta1 glycoprotein declined much more slowly. Analysis of the curves of puerperal decline suggests that the oestriol moieties are distributed in many compartments of the mother but that the proteins penetrate only to the plasma and the interstitial fluid.

In order to trace the passage of steroids and proteins from the placenta to the maternal peripheral blood, samples of retroplacental blood, uterine vein blood and peripheral blood were taken from women undergoing Caesarean section at term. The concentration of unconjugated oestriol, total oestriol, human placental lactogen and pregnancy specific beta1 glycoprotein was measured. The oestrogen concentration in the uterine vein was higher than the peripheral blood, the placental lactogen was slightly higher and the pregnancy specific beta1 glycoprotein was the same in the uterine vein and the peripheral veins. In keeping with this, the retroplacental blood had a high concentration of oestrogen, moderately raised placental lactogen and a low pregnancy specific glycoprotein concentration. It is concluded that there is a rapid secretion of oestriol from placenta to the mother; a slower secretion of placental lactogen and no clear evidence of a flow of pregnancy specific glycoprotein from the placenta.

OBJECTIVE 1. To characterise the forearm vascular reactivity of women with pre-eclampsia in the third trimester of pregnancy and compare it with that in normal or gestational hypertensive pregnancies. 2. To document female sex steroid (oestradiol, progesterone, oestriol and betahCG) levels in the three groups of women.

METHODS

Forearm blood flow was measured by venous occlusion plethysmography during intra-arterial infusion of saline and vasoactive substances: angiotensin II, sodium nitroprusside, acetylcholine and N(G)-monomethyl-L-arginine (L-NMMA).

METHODS

Research laboratory at St George Hospital, Kogarah, Sydney, Australia.

METHODS

Fifteen non-pregnant women in the follicular phase of the menstrual cycle, 15 third trimester normal pregnant women, 13 women in the third trimester with gestational hypertension and 15 women with pre-eclampsia.

METHODS

Changes in forearm blood flow in response to vasoactive substances.

RESULTS

Normal pregnant women had higher baseline forearm blood flow than non-pregnant women, decreased vasodilator responses to sodium nitroprusside and reduced vasoconstrictor responses to angiotensin II. No difference in response to angiotensin II, sodium nitroprusside or L-NMMA was found among normal pregnant, pre-eclampsia or gestational hypertension women, but vasodilatory responses of pre-eclamptic women to acetylcholine were reduced compared with normal pregnant women. Higher serum progesterone levels were found in women with pre-eclampsia and gestational hypertension than in normal pregnancy.

CONCLUSIONS

The hyperdynamic circulation of normal pregnancy is characterised by refractoriness to angiotensin II but this is not altered in pre-eclampsia. Pre-eclamptic women demonstrate a reduced vasodilator response to acetylcholine which, in the absence of any alteration in response to L-NMMA, implies that factors other than nitric oxide deficiency mediate the vasoconstriction of pre-eclampsia.

In order to clarify the mechanism of retarded foetal growth in smoking pregnant women, foeto-placental function and maternal nutritional condition were assessed. Dehydroepiandrosterone sulfate (DHAS) loading test, measurement of cotinine which is a major metabolite of nicotine and pathohistological examination of placental villi were also made to know the effect of smoking on utero-placental circulation. In heavy smokers, urinary oestriol and serum hPL levels were lower than those in non-smokers while the maternal nutritional condition was not different from that in non-smokers. In the DHAS loading test, heavy smokers showed lower conversion of DHAS to oestradiol. In the non-stress test (NST), bradycardia and/or loss of variability of baseline foetal heart rate were noted after smoking. Levels of cotinine in maternal blood and umbilical cord blood in heavy smokers were markedly higher than those in non-smokers. Microscopic examination showed atrophic and hypovascular changes of placental villi obtained from smoking mothers. These results suggest that the retarded fetal growth in heavy smokers is due to the impairment of utero-placental circulation as a result of the vasoconstricting effect of nicotine.