Chorionic Villus Sampling: Clinical and Cytogenetic Study of the First 1,058 Cases in YUMC from 1984 to 2004 years

Objective: This study was performed to evaluate the feasibility, accuracy and safety of Chorionic Villus Sampling (CVS). Methods: We analyzed the outcome of 1,058 cases of CVS performed for prenatal genetic diagnosis between 7 and 12 weeks of gestation in the outpatient prenatal genetic clinic in Yonsei University Medical Center (1,030 cases by trans-cervical method and 28 cases by trans-abdominal). Fetal Karyotyping was obtained by direct or indirect culture methods using Gimsa and Gimsa-Banding. Results: Advanced maternal age was the most common indication for CVS (34.7%). The overall sampling success rate was 98% (1040/ 1,058), representing 92.5% in 7 to 8 weeks, 98.0% in 9 to 10 weeks, and 98.9% in 11 to 12weeks of gestation. The majority of cases (94.6%) required one or two aspirations. Cytogenetic analysis routinely included direct overnight and long-term culture methods, which revealed 27 chromosomal abnormalities (2.6%). Of 1,040 cases in which CVS were successful, 989 delivered normal baby, 23 resulted in fetal loss, 25 had therapeutic termination (24 with chromosome abnormalities and 1 with normal chromosome with huge myoma), and 3 with chromosome abnormalities were loss to follow up. The overall fetal loss rate was 2.2% (23/1,058). No congenital anomalies were found to be related to CVS in these series. Conclusion: When performed by experienced operators and cytogeneticists beyond 9 weeks of gestation, CVS is a feasible, accurate and safe method for prenatal genetic diagnosis capable of replacing genetic amniocentesis.ope

Clinical and Cytogenetic study on 3,672 Genetic Amniocentesis: YUMC 20 years experience from 1985 to 2004 years

Objective: To systematic analyze the change of the annual distribution and indications, age distribution of the patients and chromosomal results according to patient’s age and indications in midtrimester genetic amniocentesis Methods: This study conducted between 1985 and 2004 collected 3,672 amniocenteses procedure which were done at College of Medicine, after prenatal genetic counceling for mothers who have high risk for carrying chromosomally abnormal babies. Results: 1. The incidence of amniocentesis had been in gradual increase since the 1980’’s, however, the number has increased sharply for the patiences in mid 1990’s. 2. Of the 3,672 amniocentesis cases, 32.2% was maternal age 30 to 34 which was most common age group and followed by age 35 to 39 was 29.9% and age 25 to 29 was 27.8%. 3. The indications for amniocentesis were advanced maternal age (36.1%), abnormal maternal serum markers (31.7%) and abnormal ultrasonographic findings which implies chromosomal abnormality (9.6%). In the 1980’s, amniocentesis had earlier been used primarily for those in advanced maternal age groups, at least 35 years older. Recently maternal serum markers and ultrasonography play an important role as an indicator for the amniocentesis. 4. From the 3,672 cases, 3,556 cases showed normal diploidy and 116 cases abnormal karyotype which consisted 3.16%. In autosomal disorders, 36 Down syndrome, 15 Edward syndrome, 2 Patau syndrome were diagnosed. In Sex chromosomal anomaly, 5 Turner syndrome, 6 47XYY, and 2 Klinefelter syndrome. Add to that 31 translocation including 21 Reciprocal translocation and 10 Robertsonian translocation, and 8 deletions and 4 mosaicisms were diagnosed. Of the 354 cases with abnormal ultrasonic findings, 19 (5.4%) resulted in chromosomal anomaly. Of the 1,164 casaes with positive maternal serum markers, 42 (3.6%) resulted in chromosomal anomaly. Those who had abnormal ultrasonographic findings implying chromosomal abnormality were found to have correlation with chromosomal abnomality than other indications. Conclusion: Midtrimester genetic amniocentesis is an important diagnostic tool in prenatal diagnosis, of which the annual incidence has been recently increased abruptly. Not only maternal age, but the maternal serum markers and ultrasonograms should be considered in prenatal counseling. Amniocentesis should be well informed to the general population.ope

Cyclic Expression of Cyclooxygenase-1 and -2 in Human Endometrium

Cyclooxygenase (COX) is an enzyme involved in the conversion of arachidonic acid to prostaglandins (PGs), and exists in two forms, COX-1 and COX-2. COX has been reported to be involved in early implantation by secretion of PGs which causes permeability of vessels and reaction of decidual cells around the implantation site. Recently, in mice and sheep studies, COX-1 and COX-2 expression in the endometrium has been reported to be different according to implantation and stages of the estrous cycle, but expression of COX-1 and COX-2 in human endometrium during the menstrual cycle has not yet been established. The purpose of this study was to observe the variances of COX-1 and COX-2 expression by immunohistochemical staining in endometrial samples obtained from human hysterectomy specimens and biopsies of women of reproductive age according to different stages of the menstrual cycle. Also, we attempted to observe COX-1 and COX-2 expression in the epithelial and stromal cells of the endometrium obtained during the mid-secretory phase, which were cultured separately. COX-2 showed a cyclic pattern of expression according to the different stages of the menstrual cycle and was strongly expressed particularly at the mid-secretory phase which corresponds to the time of implantation. However, COX-1 tended to be increased in the early proliferative, and mid- and late secretory phases, but was also expressed in the whole menstrual cycle showing no particular pattern. In the separately cultured cells COX-1 was expressed in epithilial cells and COX-2 in the stromal cells. The above results suggest that since COX-2 is expressed at the same time as implantation and cultured cells display a specific secretory pattern, COX-2 has inductive endocrine enzyme properties and has an important effect on endometrial cells during implantation. Also, COX-2 expression in endometrial cells may be utilized as a useful marker of endometrial maturation.ope

Establishment of Three Dimensional in-vitro Culture System with Human Endometrial Cells : Induction of Differentiation by Sex Steroid Hormone & Characterization

Objective : The aim of this study was to establish three-dimensionally cultured endometrial cell model containing endometrial stromal cell (ESC), endometrial epithelial cell (EEC) and extracellular matrix (ECM) and to compare the morphological and biomolecular expression patterns of this model with mid-luteal endometrium in vivo. Materials and Methods : The EEC and ESC was obtained from hysterectomy specimen and cultured separately. The EEC was overlayered in Matrigel layer on ESC embedded in collagen. The model had been cultured for 48 h in DMEM medium containing estrogen and progesterone. The ultrastructure was evaluated by electron microscopy. The expression of integrins, cyclooxygenases and matrix metalloproteinases were examined by immunohistochemistry and zymography. Results : EEC in three-dimensional culture model grew with polarity and tight junction and desmosome between cells were found. The formation of pinopodes was also detected. In three-dimensionally cultured endometrial cell model, the expression of integrin α1, α4, β3, MMP-1, -2, -3 and 9 was detected which was not expressed in monolayer culture of EEC, ESC or ESC embedded in collagen. Conclusion : The three-dimensionally cultured endometrial cell model possessed the morphological and biomolecular characteristics of in vivo endometrium of implantation period. These characteristics could be achieved by paracrine interactions between ESC and EEC. This model may contribute to the studies of differentiation of endometrium, process of implantation and pathophysiology of implantation-related diseases.ope

Expression of Estrogen Receptor and Telomerase Activity in Chorionic Villi and Decidua of Early Human Gestation

Objective : To investigate whether there is any differences between normal pregnancy (NP) and spontaneous abortion (SAB) regarding estrogen receptor (ER) expression and telomerase activity (TA) in the chorionic villi and decidual tissues. Methods : Chorionic villi and decidual tissues were obtained between 6 and 9 weeks' gestation from 14 patients with SAB and 17 normal pregnant women who have undergone an elective abortion. All tissue samples were assayed for ER with enzyme immunoassay and also TA was analysed using telomeric repeat amplication protocol. Results : A significant decrease in ER expression (2.81±2.77 fmol/mg of protein; p<.001) was demonstrated in SAB group compared to that of NP group (4.56±1.85 fmol/mg) in decidua. However, no significant difference in ER expression in chorionic villi was found between the two groups. SAB group showed significantly lower levels of TA than that of NP group in both chorionic villi (21.4% vs. 82.4%; p=.002) and deciduas (7.1% vs. 52.9%; p=.009). Conclusion : Our results suggest that decreased level of ER expression in deciduas might cause decidual senescence and eventually, spontaneous abortion.ope

Effect of Hypoxia on Telomerase Activity in Placental Tissue in Pregnancies with Fetal Growth Restriction

Objective : To observe the difference in telomerase activity (TA) expression in the placenta between fetal growth restriction (FGR) with preeclampsia and those without and to evaluate the effect of oxygen concentration on the TA expression in the trophoblastic cells. Methods : Telomerase activity was measured in 48 (normal pregnancies, 16; preeclampsia with FGR, 15; normotensive FGR, 17) placentas which were obtained between 32 and 41 weeks' gestations. Trophoblastic cells were extracted from 8 chorionic villi samples obtained from 8-10 weeks' placenta and were cultured in either 2%, 8%, and 20% oxygen atmosphere. Then TA was examined by using telomeric repeat amplification protocol (TRAP) assay. Results : During 3rd trimester of pregnancy, exhibited TA expression in normal pregnancy, FGR complicated by preeclampsia, and normotensive FGR groups were 11 of 16 (68.8%), 4 of 15 (26.7%), and 4 of 17 (23.5%), respectively. Significantly lower level of TA was detected in the FGR group compared to the normal pregnancies (p=0.009), whereas within FGR pregnancies, presence of preeclampsia did not seem to have statistically significant effect on TA expression. TA expression levels were measured by optical density in trophoblasts cultured under various oxygen concentration which revealed that significantly higher TA was exhibited in the cells cultured in 2% oxygen compared to 8% and 20% (p<0.001). However no significant difference was noted in TA between cells cultured in 8% and 20% oxygen. Conclusion : Decreased TA in the placenta from pregnancies with FGR was noted regardless of presence of preeclampsia indicating a probable correlation between FGR and placental senescence. Since increased TA was noted in trophoblastic cells that were cultured in hypoxic condition, we could speculate that the intervillous oxygen tension during early-stage placental development plays a certain role in the placental degeneration in pregnancies complicated by FGR and preeclampsia.ope

A Case of Full Term Delivery of a Child with 47 , XYY Subsequent to Prenatal Diagnosis at Midtrimester

47,XYY is a rare sex chromosomal disorder. Approximately 1.45 per 1,000 live births have on XYY chromosome pattern. The extra Y chromosome is paternal in origin and results from nondisjunction in the second meiotic division. Although the phenotype is normal on the newborn, an increased incidence of minor anomalies has been reported. Recently, a 37-year-old primigravid woman received amniocentesis at 17 weeks gestation at a private clinic and was diagnosed as having a fetus with 47,XYY. We performed amniocentesis again at 20 weeks of pregnancy and confirmed fetal karyotype to be 47,XYY using the conventional cytogenetics and fluorescence in situ hybridization (FISH) techniques. As she did not want to terminate her pregnancy, she was put under antenatal care but ended up in vaginal delivery in 40 weeks. As a result of physical examination, the neonate showed a normal phenotype except for a mild hypospadia and a simian crease.ope

Correlation between Steroid Hormone Metabolites and Leiomyomas of Uterus

Objective: To elucidate 1) whether there are any differences in the urine concentrations of steroid hormone metabolites between patients with leiomyoma and normal controls 2) the correlation between urinary profiles of steroid hormones and leiomyomas of the uterus according to their type, location, volume, and weight. Materials of Methods: The study population consisted of 37 premenopausal patients with uterine leiomyoma and the control group consisted of 25 premenopausal normal volunteer women without uterine leiomyoma. Confirmation of the existence of uterine leiomyoma was done by ultrasonography and histopathological examination after surgery. The volume of the leiomyoma was estimated by trans-abdominal and/or trans-vaginal ultrasonography. The Leiomyomas were divided into 3 types (subserosal, intramural and submucosal). Seventeen patients had subserosal type of leiomyoma, 10 with the intramural type and 10 with the submucosal type. The locations of the leiomyoma were also divided into 3 groups (fundus, body and isthmus). Seventeen patients showed a fundus location, 10 in body, and 10 in isthmus. We compared urinary profiles of the endogenous steroids between patients with leiomyomas and normal controls, and also investigated the relationship between urinary profiles of the endogenous steroids and leiomyomas according to their type, location, volume and weight by using highly sensitive Gas Chromatography-Mass Spectrometry (GC-MS) system. Results: The mean ages of the patients with leiomyomas and the control group were 43.1 ±5.6 and 40.6 ±7.2 years, the weights were 63.4 ±7.3 and 59.4 ±8.1 ㎏, and their heights were 155.4 ±4.8 and 159.3 ±4.8 cm respectively. Seventeen patients had subserosal, 10 had intramural, and 10 had submucosal leiomyomas. There were 17 patients with leiomyoma located in fundus, 10 in body and 10 in isthmus. 17ß-estradiol, 5-AT, 11-keto ET, 11ß-hydroxy An, 11ß-hydroxy Et, THS, THA, THE, a-cortolone, a-cortol, ß-cortol, 11ß-OH Et/11ß-OH An and E2/E1 were significantly increased in patients with leiomyoma than in the control group. 17ß-estradiol was significantly increased in the intramural and the submucosal types than in the subserosal type. There was no significant difference in the concentrations of urinary steroids according to the locations of leiomyomas. There was no significant relationship between the concentration of urinary steroids and the volume of the leiomyomas. 17ß-estradiol significantly decreased as the weight of uterus increased (r=-0.322, p=0.04). Conclusion: The concentrations of steroid hormone metabolites were generally increased in patients with leiomyoma but were not significantly related to the volume and weight of the leiomyomas. Our study suggests that steroid hormones may be involved in the initiation of leiomyomas but may not be involved in their progression. In addition, the concentrations of steroid hormone metabolites are not related to the leiomyoma type and location.ope

Pregnancy Outcomes in Women with Unexplained Elevation of Maternal Serum Human Chorionic Gonadotropin Levels at Midtrimester

Objective : Our purpose was to determine the association between unexplained elevation of maternal serum human chorionic gonadotropin (hCG) in the second trimester and adverse pregnancy outcomes. Material and methods : Between February 1995 and July 1999, we evaluated 1566 pregnant women who have underwent second trimester triple marker screening tests (alpha-fetoprotein, unconjugated estriol, human chorionic gonadotropin) and delivered at Severance Hospital, Yonsei Medical Center. Multiple pregnancies, abnormal fetal karyotypes, fetal anomalies, and abortions were excluded from the study. One hundred twenty-one women with hCG levels greater than 2.0 multiples of the median (MoM) were included in the study group while 1389 women with hCG levels less than 2.0 MoM served as the control group. Pregnancy outcomes were obtained from the delivery and neonatal records in our institution. Adverse pregnancy outcomes between the two groups were compared using chi-square test and Fisher's exact test. Results : Women with unexplained elevation of human chorionic gonadotropin levels were associated with statistically significant increased risks for preeclampsia, preterm delivery, and low birth weight (p<0.05). However, there were no significant differences between the study and control groups with respect to preterm premature rupture of membranes, abnormal fetal heart rate tracing, abruptio placentae, intrauterine fetal death, and neonatal death. Conclusion : An unexplained elevation in human chorionic gonadotropin level in the second trimester may increase the risk for preeclampsia, preterm delivery, and low birth weight but not for other adverse pregnancy outcomes such as preterm premature rupture of membranes, abnormal fetal heart rate tracing, intrauterine fetal death, or neonatal death.ope

The prognostic value of serum CA 125 in endometrial cancer

Objective : The prognostic value of serum CA 125 sampled before the staging operation and the right CA 125 cut-off level in endometrial cancer was evaluated. Methods : Medical charts of 119 endometrial cancer patients diagnosed and surgically treated at the Department of Obstetrics and Gynecology, Yonsei University College of Medicine from March 1995 to March 2001 were reviewed. The prognostic value of CA 125 was evaluated by comparing it to other established prognostic factors of endometrial cancer such as myometrial invasion, cervix extension, tumor size, and grossly invasive disease. Enzyme immunoassay (Elecsys 2010; Roche Ltd., Basel, Switzerland) was used for the measurement of serum CA 125. Results : The level of presurgically taken serum CA 125 level correlated well with the established prognostic factors of endometrial cancer. CA 125 was one of the information that could be obtained prior to the surgical staging for predicting extensive endometrial cancer, and it could be correlated with the 5 year survival. CA 125≥20 U/ml had a higher sensitivity and lower false negative rate in predicting extensive endometrial cancer compared to the conventionally used level of CA 125≥35 U/ml. Conclusion : CA 125 has a prognostic value in predicting the extensive endometrial cancer needing lymphadenectomy, therefore it might be included in the baseline study of endometrial cancer for predicting the prognosis and individualizing the treatment modality. CA 125≥20 U/ml might be considered as the cut-off level in endometrial cancer for a better sensitivity and false negative rate.ope