Asem A. Moussa, MD

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Pre-eclampsia first  described more than hundred years ago, remains a leading cause of  maternal and fetal morbidity and mortality.  Despite extensive  researches, our knowledge of the aetiology and pathophysiology is still  limited (Chappel & Bewley, 1998).
 
 	Recently, there has been interest in the role of vascular endothelial  damage in the pathogenesis of this disorder.  It has been proposed that  endothelial activation is the primary event in the multisystem disorder  of pre-eclampsia.  Evidence of endothelial involvement in this condition  abounds. It is now known that endothelial activation contributes to the  coagulation abnormalities observed in this disease (Dekker and Sibai,  1998).
 
 	In women  with severe pre-eclampsia serum thrombomodulin (TM) was found to be  significantly elevated indicating its circulatory release by damaged  endothelium (Hsu et al., 1995).  Also a low level of Antithrombin III  has been reported in pre-eclamptic women (Verduzco & Gonzmlez,  1998).
 
 

To study the changes of two natural  anticoagulant factors, circulating thrombomodulin level (TM) and  anti-thrombin III (AT III) activity in both maternal and fetal cord  plasma of women with pre-eclampsia and its correlation with fetal  morbidity and postpartum regression of pre-eclampsia.
 
 

 This study was conducted on 60 pregnant  women, attending the obstetric clinics for follow up, at Ghamra  Military Hospital during the period between September 1998 and May 1999.   Subjects were all primigravidae with Singleton pregnancy in the third  trimester.  Their ages ranged from 25 – 35 years old.  All of them  signed informed consent for inclusion in the study.
 
 	These cases were divided into two main groups; the first comprised a  control group of 20 healthy normal pregnant women and the second  comprised a study group of 40 cases having pre-eclampsia.  The  pre-eclampsia group was further subdivided into mild pre-eclamptics (20  patients) and severe pre-eclamptics (20 patients).The criteria of severe pre-eclampsia were:

Diastolic blood pressure of 110 mmHg or higher.

Presence of proteinuria of 2+ or more or total proteins of 4-5 gm/litre/24hours.

Presence of symptoms, specifically haedache, visual disturbances&upper abdominal pains.

A full obstetric sheet planned for this work  was fulfilled for every case. Thorough physical examination and  laboratory investigations, as full blood picture, serum urea,  creatinine, uric acid, serum transaminases (ALT, AST) total bilirubin  and qualitative assessment of protein in urine with reagent paper strips  were carried out.
 A blood sample was taken from each subject on two occasions (before  delivery and within 48 hours of delivery). Before delivery venous blood  samples were obtained at the same gestational age in both the  pre-eclampsia and the control group (34.4 + 1.9 weeks’ gestation) In  pre-eclampsia blood samples were taken at diagnosis.  Cord blood samples  of about 5 ml. were also obtained at the time of delivery from the  fetal side.  Fetal birthright and Apgar score at one and five minutes  were recorded.
 
 	Plasma was prepared from all samples by collection into glass tubes  containing 0.109-M trisodium citrate 9 parts blood, 1 part  anticoagulant).  The samples were then centrifuged for 15 min. at 3000  rpm.  Aliquots of plasma were stored at 80C until the assay was  performed.  Plasma specimens were tabled with only the date of sampling  and the patient’s identification number.
 
 

The current study was conducted to understand the  relevance of the endothelium to subsequent activation of the coagulation  cascade and to determine the changes of two natural anticoagulant  factors, circulating TM levels and AT-III activity, in pre-eclamptic  pregnancies.  Moreover, this study aims to determine whether changes in  plasma levels of TM and AT-III would correlate with maternal and fetal  morbidity and with the postpartum regression of pre-eclampsia.
 
 	In this study, it was found that antepartum TM levels were  significantly higher in pre-eclamptic women as compared with those of  their matched controls.  Also, this study correlated the severity of  pre-eclampsia with TM levels.  It compared the maternal plasma  antepartum TM in different groups.  The results showed that antepartum  TM levels increase with the increase in the severity of pre-eclampsia  (severe pre-eclampsia 76.50 + 6.50 ng/ml. mild pre-eclampsia 54.84 +  3.11 ng/ml, and control 41.83 + 4.01 ng/ml).  The statistical difference  between severe pre-eclampsia and control groups, mild pre-eclampsia and  control groups, severe pre-eclampsia and mild pre-eclampsia were  significant (P  < 0.005).
 
 	In contrast to TM, it was found that antepartum plasma AT-III  activities were significantly lower in both severely and mildly  pre-eclamptic pregnancies.  Moreover, we found that AT-III activities  were inversely correlated with TM levels in severely pre-eclamptic  pregnancies, but not in mild pre-eclamptic pregnancies (r = -0.633, P =  0.003).
 
 	The study at hand speculates that this may reflect a different degree  of vascular endothelial damage and subsequent activation of the  coagulation cascade between women with severe and mild pre-eclampsia.   Consequently, there is an increase in the shedding of TM antigen into  the blood of pre-eclamptic women and decreased availability of binding  sites for thrombin and subsequently decreases circulating AT-III levels.   Thus, increased unbound thrombin in pre-eclampsia subsequently  enhances the consumption of AT-III and increases thrombin-AT-III complex  levels (Reinthaller et al., 1990).  In addition, injured endothelial  cells could also lead to decreased secretion of heparin sulfate  proteoglycan and impede the activity of AT-III on thrombin (Galstian et  al., 1992).  Thus, decreased AT-III levels may in part reflect the  binding of AT-III to denuded areas of injured endothelium and  subsequently shorten the activity elimination half-life (Weiner et al.,  1990). 
 
 	These results are in agreement with the results of Minakami et al.,  (1993) and Bontis et al., (1995).  However Hsu et al., (1993) and Hsu et  al., (1995) found that the severely, but not mildly, pre-eclamptic  women had significantly higher circulating TM levels, than those in  their matched controls did.  They concluded that this might indicate a  different mechanism of disease entity in severely versus mildly  pre-eclamptic pregnancies.  In women with mild pre-eclampsia they  speculated that perturbation of the endothelium might not be severe  enough to increase the circulating TM levels and decrease the secretion  of heparin sulfate proteoglycan.  However, a functional change of TM  conformation might decrease the activation of the TM-protein C  anticoagulant pathway, which eventually increases unbound thrombin and  subsequently decreases circulating AT-III levels.
 
 	This study compared the cord plasma TM and plasma AT III in different  pre-eclamptic groups.  It was found that the cord plasma TM levels were  significantly higher in severely (P = 0.03), but not mildly (P = 0.13),  pre-eclamptic women as compared with those of their matched controls.   In contrast to TM, we found that cord plasma At-III levels were  significantly lower in severely (P = 0.00), but not mildly (P = 0.43)  pre-eclamptic women as compared with those of their matched controls.
 
 	The explanation of this can possibly be that, the high cord plasma TM  and the low cord plasma AT-III may be originated from the maternal side  and cross the placental barrier.  In this study, there was a significant  positive correlation between antepartum plasma TM level and cord plasma  TM in the severely (r=0.678), but not mildly (r 0.109) pre-eclamptic  groups.  However, there was no significant correlation between  antepartum AT-III level and cord plasma AT-III in the control (r=0.020)  as well as in the pre-eclamptic groups.  Further researches on the  placental role in transferring TM and AT-III may be of benefit.
 
 	Another explanation of this could be that it might come from the fetal  side affected by the severity of pre-eclampsia.  One of the main  complications of pre-eclampsia is fetal hypoxia.  In this study, there  was a significant negative correlation between cord plasma TM and Apgar  score at l-min in mildly (r = 0.847) and severely (r =0.822)  pre-eclamptic groups.  However, there was a significant positive  correlation between cord plasma AT-III and Apgar score at l-min. in  mildly (r=0.818) and severely (r =0.961) pre-eclamptic groups.
 
 	Nako et al., (1997) concluded that hypoxia would injury vascular  endothelial cells and consequently raised plasma TM levels in  asphyxiated infants.  They studied the plasma TM concentration at birth  in 11 asphyxiated infants was significantly elevated compared with that  in 48 infants without asphyxia (38.1 Vs 27.0 ug/l, P <0.0001).
 
 	Thus, the present study demonstrated the role of antepartum plasma TM  and cord plasma TM in the prediction of fetal outcome in pre-eclamptic  pregnancies and in reflecting the state of uteroplacental insufficiency,  resulting in antepartum or intrapartum apoxia and also intrauterine  fetal growth restriction.  SO, the elevated levels of antepartum plasma  TM and cord plasma TM, either done by cordocentesis or after delivery of  the fetus should alert the clinician to the possibility of fetal  jeopardy and the need for immediate interference.
 
 	Should elevated levels of antepartum plasma TM be used as an indicator  for impairment of uteroplacental circulation and consequently poor fetal  outcome necessitating termination of pregnancy is still subjected to  further studies.

Table (1): Clinical Data in Severely and Mildly         Pre-Eclamptic Groups

Table (2): Lab Data in Severely and Mildly Pre-Eclamptic         Groups


    
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    Bontis, J., Vavilis, D., Agorastos, T. et al., (1995):    Maternal plasma level of thrombomodulin is increased in mild pre-eclampsia. Eur. J. Obstet. Gynaecol. 60: 139: 141.

    Chappell, L. and Bewley, S. (1998):    Pre-eclamptic toxaemia: the role of uterine artery Doppler. Br. J. Obstet. Gynaecol. 105: 379-382.

    Dekker, G.A., Sibai, B.M. (1998):    Etiology and pathogenesis of pre-eclampsia: Current concepts. Am. J. Obstet. Gynaecol. 179: 1359 â 1375.

    Hsu, C.D.; Iriye, B.; Johnson, T.R.B. et al., (1993):    Elevated circulating thrombomodulin levels in severe pre-eclampsia. Am. J. Obstet. Gynaecol. 169:148-149.

    Hsu, C.D.; Johnson, T.R.B., Hong, S.F. et al., (1995):    Altered circulating thrombomodulin and antithrombin III activities as evidence for varied activation of the coagulation cascade in severe versus mild pre-eclampsia. J. Matern. Fetal Invest. 5: 140-143.

    Galstian, A., Beer, A.E.; Roberts, J. M. et al., (1992):    Immunology of pre-eclampsia. In: Coulam, C.B., Faulk, W.P. McIntyre, J.A. edit. Immunological Obstetrics. New York: W.W. Norton and Company Inc. 502 â 516.

    Minakami, H.; Takahashi, T.; Izumi, A. et al., (1993):    Increased levels of plasma thrombomodulin in pre-eclampsia. Gynaecol. Obstet. Invest. 36: 208-210.

    Nako, Y.; Tomomasa, T.; Morikawa, A. (1997):    Plasma thrombomodulin level in newborn infants with and without perinatal asphyxia. Acta Paediatr. 86:91-95.

    Reinthaller, A.; Mursch-Edlmayr, G.; Tatra, G. (1990):    Thrombin-antithrombin III complex levels in normal pregnancy and hypertensive disorders and after delivery. Br. J. Obstet. Gynaecol. 97:506-510.

    Verduzco, R.L.; Gonzmlez, P.E. (1998):    Antithrombin III in pre-eclampsia-eclampsia. Gynaecol. Obstet. Mex. 66: 343-346.

    Weiner, C.P.; Herrig, J.E., Peizer, G.D. et al., (1990):    Elimination of antithrombin III concentrate in healthy pregnant and pre-eclamptic women with an acquired antithrombin III deficiency. Thromb. Res. 58:395-401.

Articles

Pre-eclampsia first described more than hundred years ago, remains a leading cause of maternal and fetal morbidity and mortality. Despite extensive researches, our knowledge of the aetiology and pathophysiology is still limited (Chappel & Bewley, 1998).

Thrombomodulin and Antithrombin-III as Evidence for Varied Activation of the Coagulation Cascade

 To compare pregnancy rate in women with polycystic ovary syndrome(PCOS) resistant to clomiphene citrate, using different methods of treatment.
 
 

 One hundred infertile women known to have PCOS and failed to conceive with one-year clomiphene citrate treatment.
 
 

 Women randomly classified into 5 groups, each comprised 20 cases. Group (1) received clomiphene citrate plus human menopausal gonadotrophines (HMG) plus human chorionic gonadotrophins(HCG). Group (II) received HMG + HCG. Group (III) received pure FSH plus HCG. Group (IV) received LHRHa plus HMG. Group (V) subjected to laparoscopic ovarian drilling using diathermy.
 
 

 In group (I) four out of 20 women (20%) responded to treatment and became pregnant in 60 treatment cycles (6.66%). In Group (II) six women (30%) had pregnancy in 60 cycles of treatment (10%). In the third group pregnancy occurred in 3 women (15%) with 60 treatment cycles (5%). In the fourth group eleven women became pregnant (55%) during the same treatment cycles (18%), this was statistically significant when compared to group I and III. In the laparoscopic group 9 (45%) women had pregnancy during three months after ovarian drilling.
 
 

 Several alternative ovulation induction methods are available, the use of LHRH analogue combined with HMG/HCG had better results and laparoscopic diathermy can be the second in rank in the selection of treatment.


 Polycystic ovary syndrome is characterized by enlarged ovaries, multiple peripherally arranged cysts and increased stromal density(1). Polycystic ovary syndrome is responsible for approximately 25-30% of infertility

  in women, which is mainly anovulatory(2). Ovulation can be induced with antiesterogens in many women but a proportion fail to respond and even  in those who ovulate, the pregnancy rate is often low and the miscarriage rate is high. However, treatment with  human menopausal gonadotrophins may be successful but extremely demanding for women and for the clinic, and there is a  significant risk of hyperstimulation and multiple pregnancy even with intensive monitoring(3). Pulsatile luteinizing  hormone releasing hormone (LHRH) therapy has been used but the results have been disappointing and miscarriage rate is high(4).  However, the use of LHRHa in down regulation mechanism (pituitary  desensitization) gave a rather good results with entire elimination of premature  luteinization and higher pregnancy rate(5).
 
 Wedge resection of the ovaries was used successfully in the management  of women with PCOS prior to the availability of anti-estrogens in the 1960, this treatment resulted in a high rate of  ovulation but was followed by significant formation of adhesions that prevented pregnancy from a few months after  the procedure was performed(6). Recently laparoscopic diathermy has been introduced as an alternative to wedge resection(7-10). The  advantages of this form of treatment are that it entails laparoscopy  rather than laparotomy and the scars are small. Ovulation has been found to  occur post operatively in more than 80% of women(7).
 
 These alternative methods of management of PCOS cases resistant to clomiphene citrate provoked us to study pregnancy rate with different methods of treatment.
 
 


 One hundred women with primary infertility and ultrasonic features of  polycystic ovaries(1) were selected for this prospective study. All had  oligomenorrhoea with or without hirsutism. Biochemically, all had an Lh/FSH ratio >3.
 
 All patients failed to conceive after one year of treatment with clomid. In all, fallopian tubes were patent, proved by HSG and laparoscopy, their husbands had normal semen analysis and no obvious cause of infertility apart from anovulation was found.
 
 All patients signed a consent to be involved in the study and they were randomly classified into 5 groups.
 
 Group I comprised 20 patients, received Clomid in a dose of 150 mg/day from day 3 through day 7 of the menstrual cycle

, human menopausal gonadotrophins (Pergonal, serono) started with an initial dose of 150 IU given I.M at day 5 of the menstrual cycle and the dose was adjusted according to ovarian response with the intention to obtain one or more mature follicles with follicular diameter greater than 17 mm and estradiol (E2) level >800 pg/ml. Treatment was monitored by ultrasound and serum assay for estradiol. Ultrasound was performed twice usually at day 10 and day 13, E2 estimation was performed at days 11,12, and 13. HCG injection (Profasi, serono) was given in a dose of 10,000 IU IM when we reached our criteria of ovulation and timed intercourse was requested post HCG by 24-36 hours.
 
 Group II comprised 20 patients who received Pergonal initially in 2 amps dose (300IU) and adjusted according to the ovarian response. Treatment started on day 3 of the menstrual cycle and the criteria and monitoring of ovulation followed the same protocol as in group I. Timed intercourse was requested 24-36 hours after HCG (10,000IU) injection.
 
 Group III also comprised 20 patients, received pure FSH (metrodin, 75 IU) started on day 3 of the menstrual cycle in dose of 2 amps which was increased or decreased according to the ovarian response. The same criteria and monitoring of ovulation were used in this group as previous groups. Timed intercourse was requested 24-36 hours after 10,000 IU injection of         HCG.
 
 Group IV included 20 patients, received LHRH agonist (superfact, Hoechst hounslow, uk). Nasal spray started on day 24 of the preceding cycle with one puff per nostril every 6 hours to deliver 100 ug. The drug was continued till day O (day of HCG administration). Pergonal was given on day 3 of the menstrual cycle with initial dose of 2 amps and the dose was adjusted according to the ovarian response. The same criteria and monitoring of ovulation was as previous and timed intercourse advised 24-36 hours post HCG injection (10,000IU).
 
 Group V Twenty patients had laparoscopic ovarian drilling using diathermy during the proliferative phase of the menstrual period. Diathermy was applied to each ovary for 4-6 seconds at a time in 4-8 separate places according to the ovarian size. All patients were followed for 3 months with no further treatment.
 
 


 A semi quantitative urinary test was performed 10 days after the expected date of next period or 24 days post HCG injection.
 
 


 Blood samples were collected in a dry plastic disposable syringe on heparinized tubes and then centrifuged. Plasma was taken for determination of E2, FSH and LH.
 
 E2 was measured by RIA using the method of Schmidt et al(11). LH was  determined by the heterologus ovine double antibody radioimmunoassay according to the method used by loudon et al(12). FSH was measured in  duplicate in single assay using an ovine radioimmunoassay method described by McNatty et al(13).
 
 
 


 All patients had primary infertility, where the duration of infertility is shown in table (1), in terms of mean and standard deviation, group V had a longer duration of infertility (10.2 ±5.3 years).
 
 The mean age and SD of the studied groups was also compared in table (1), group IV had the oldest patient with mean age and SD (36.4 ±1.9). None of these are statistically significant.
 
 The pretreatment hormonal levels of both the LH and FSH showed the characteristic feature of         PCO, where as seen in table (1) the LH is higher than the FSH by two or three times.
 
 In group I four out of the 20 cases (20%) responded to the treatment and became pregnant in a total of 60 treatment cycles (6.66%). In group II six women (30%) had pregnancy out of 20 women in 60 treatment cycles (10%). In the third group pregnancy was achieved in 3 out of 20 cases (15%) over 60 treatment cycles (5%). In group IV, 11 women became pregnant (55%) out of 20 women over 60 treatment cycles (18%), this was statistically significant (p<0.05) when compared to group I and also when compared with group II (p<0.02).
 
 In the fifth group nine women became pregnant (45%) over 3 months (60 cycles, 15%).


 Several alternative ovulation induction methods are available to women with clomiphene resistant anovulation associated with polycystic ovary

 syndrome (PCOS) but there are no accepted guide lines on the choice of treatment. 
 
 The use of HMG with clomiphene citrate to enhance follicular growth and increase its efficacy as in group I of this study is a known method. It is less expensive than the others but the pregnancy rate per cycle is and the use of LHRHa combined with HMG is statistically significant p<0.05 when both regimes were compared.
 
 The pregnancy rate in the second group (HMG+HCG) regime was 10% (pregnancy per treatment cycle) these results are less than the result of Farhi et al. 1993. When the pregnancy in this group compared with the other groups no statistically significance was found.
 
 The third group received FSH, there results as a pregnancy per treatment cycle was 5%, which is less than the pregnancy rate obtained by the Farhi et al, 1993, where they reported pregnancy rate 23%. However, this group results were significant when compared to group IV, (p<0.02).
 
 The fourth group LHRHa combined with HMG/HCG, gave a better results regarding pregnancy rate which might be explained because of the elimination of premature luteinization and prevention of the interference and interplay of the high LH which is a dominant feature in PCOS. Our results were similar to Farhi et al, 1993; and Wada et al, 1993. The results of the LHRHa group had a statistical significance when compared with group I and group III.
 
 The last group, where the laparoscopic drill was offered as a surgical line of treatment the current study results were less in terms of pregnancy per treatment cycles than the results of Armar and Lachalin, 1993 and Gjonneses, 1994.
 
 The laparoscopy group when compared to other groups no statistical significance was found but apparently the laparoscopy carries advantages over the other lines of treatment as the chance of recurrent spontaneous ovulation and repeated pregnancy allowing the women to lead a normal life with the stress of frequent hospital visits and no risk of         hyperstimulation.
 
 
         


 In conclusion we have shown that women with PCOS resistant to clomiphene citrate have had several alternative ovulation induction. The use of LHRHa combined with HMG/HCG has better results and laparoscopic diathermy can be the second in rank in the selection of the treatment.

1-Adams Frants,S, and Polson,DW. Multifollicular ovaries, clinical and endocrine features and response to pulsatile gonadotrphine releasing hormone. Lancet II, 1985, 1375-1378.

2-Clayton RN, Ogden V, and Hodgkinsonc. How common are polycystic ovaries in normal women and what is their significance for the fertility of populations. Clin.Endocrinol,1992, 39:623-632.

3-Amrar,NA, and Lacheline,GL. Laparoscopic ovarian diathermy: an effective treatment for antiestrogen resistant anovulatory infertility in women with polycystic ovary syndrome. Br. J. Obst.Gyn,1993, 100:161-164.

4-Eshel A, Abdal Wahib N, Armar NA, Abdams JM, Jacobs HS. Pulsatile luteinizing hormone releasing hormone therapy in women with polycystic ovary syndrome. Fertil. Steril, 1988, 49:956-960.

5-Farhi J, Homburg R, Lerner A, Ben Rafeal Z. The choice of treatment for anovulation associated with polycystic ovary syndrome following failure to conceive with clomiphene. Hum.reprod.,1993, 8:1369-1371.

6-Adashi EY, Rock JA, Guzick D, Went ZA, Jone GR, Joes HW. Fertility following bilateral ovarian wedge resection, a critical analysis of 90 consecutive cases of polycystic ovary syndrome. Fertil. Steril. 1981,36:320-325.

7-Gjnnaess,H. Ovarian electrocautery in treatment of women with polycystic ovary syndrome(PCOS): Factors affecting the results. Acta Obstet. Gynecol. Scand. 1994, 73:407-412.

8-Kovacs G, Buckler H, Bangah M. Treatment of anovulation due to polycystic ovarian syndrome by laparoscopic ovarian electrocautery. Br. J. Obst. Gyn. 1991,98:30-35.

9-Wada I, Matson PL, Tromp, SA and Berman BA. Assisted conception using buserelin and human menopausal gonadotrophins in women with polycystic ovary syndrome. Br. J. Obst.Gyn. 1993, 100:365-369.

10-Schmidt AM, Nadal Schmidt MJ, and Beamer NB. Serum concentration of oestradiol and progesterone during the normal oestrous cycle and early pregnancy in the loin. Journal of reproduction and fertility,1979,57:267-272.

11-Loudon AS, McLeod BJ, and Curleuris JD. Pulsatile secretion of LH during the preovulatory and luteal phases of oestrous cycle pero daird's deer kind. Journal of reproduction and fertility,1990, 89:663-670.

12-McNatty KP, Fisher M, Collins, Hudson NL, Heath DA, and Henderson KM. Differences in the plasma concentration of FSH and LH in ovarectomized Barooth FF and EWES. Journal of reproduction and fertility,1989, 85:705-713.

Polycystic ovary syndrome is characterized by enlarged ovaries, multiple peripherally arranged cysts and increased stromal density(1). Polycystic ovary syndrome is responsible for approximately 25-30% of infertility in women, which is mainly anovulatory(2). Ovulation can be induced with antiesterogens in many women but a proportion fail to respond and even in those who ovulate, the pregnancy rate is often low and the miscarriage rate is high.

Conception Rate in Polycystic Ovary Syndrome

Vitamin E (alpha-tocopherol) is  thought to play a role in several stages of carcinogenesis through its  contribution to immunocomptence, inhibition of mutation formation and  repair of membranes and DNA.

To evaluate the efficacy of vitamin E in treatment of cervical cancer precursor (Cervical Intraepithelial Lesion, CIN)

Prospective double-blind placebo controlled clinical trial.

Al-Hussein University Hospital, El-Darassa, Cairo.

The target population  was 100 women with biopsy confirmed Cervical Intraepithelial Neoplasia  I&II (CIN I & II). All women were from the same catchment     area (El-Darassa) with similar socioeconomic status. Patients signed  informed consent and serum was taken for vitamin E assay using high  pressure liquid chromatography, serum vitamin E measured at the start of  the study and at 6 months. Patients were randomly divided into four  groups. First group (group I) comprised 25 patients, received vitamin E  injection,100mg (0.33cc) intralesion every month under colposcopic  guidance. Second group (group     II, 25 patients) received placebo (o.33cc sterile saline)  Intralesion every month under colposcopic guidance. Third group (Group  III, 25 patients) received oral vitamin E 400mg daily for 6 months.  Fourth group (Group IV,25 patients) received oral placebo daily for 6  months.

Response rates were determined at 0, 3, 6, 9 and 12 months with cytology, colposcopy and/or biopsies.

Complete regression of CIN observed  in 44% (11/25) in group I, while in group II regression rate was     16% (4/25) which is statistically significant (P<0.05). Also the  duration taken for complete response was significantly higher in group I  than in group II (5.57

Regression rates in group III were higher 24% (6/25) than that in group         IV12% (3/25), but was not statistically significant.

Lesions with diameter <100mm2 showed  significant regression rates than those with diameters<100mm2. Serum  vitamin E was low in all groups and remained low except in group III it  was significantly higher than other groups after 6 months of treatment.

Injection of vitamin E locally in  Cases with CIN I & II gave good response rates and further studies  with larger and frequent doses are recommended.

Worldwide cervical cancer is second only to breast cancer as the most common malignancy in both incidence and mortality

The cervix is an ideal model for the study of  chemoprevention in humans. The evidence is strong that normal cervical  epithelium proceeds through a precancerous stage (Cervical  Intraepithelial Neoplasia) prior to the development of invasive cancer.
 
 Vitamin E is thought to play a role in several stages of carcinogensis  through its contribution to immunocomptence, inhibition of mutagen  formation and repair of membranes and DNA. The question as to whether  vitamin E can prevent or slow down carcinogensis has interested a number  of researchers during the past few years 

. It has been hypothesized that free  radical-initiated cell damage and particularly DNA damage, is involved  in the etiology of cancer, and that vitamin E, because of its properties  as an antioxidant and free radical scavenger, may play a role in the  prevention of cancer 

. Vitamin E is also thought to have other anticancer  effects. Animal and invitro studies suggest that vitamin E decreases  tissue susceptibility to malignancies in several stages of carcinogensis  by a number of ubiquitous mechanisms. These include inhibition or  blockage of formation of nitrosamines 

 or other mutagens or carcinogens from precursors via direct chemical interaction.

It has also been suggested that vitamin E inhibits  mutagens or carcinogens from reaching or reacting with target sites by  scavenging mutagens or by enhancing detoxification process. Furthermore,  the vitamin may prevent cancer progression by enhancing the immune  response to developing cancer cells and may cause tumor regression by  direct action on the cancer cells 

The aim of this study was to evaluate the efficacy of vitamin E in treatment of Cervical Intraepithelial Neoplasia.
 
 


 
 Hundred patients with cervical intraepithelial neoplasia I & II (CIN  I& II) included in this prospective study. All patients were  monogamy of similar socioeconomic background living in the same  catchment area (El-Darassa, Cairo).

Diagnosis of CIN was based upon cytology and confirmed  by colposcopically directed biopsies. For all patients colposcopic  examination was satisfactory with negative endocervical cytology and no  evidence of extension of the lesion into the vagina. All patients did  not receive therapeutic doses of vitamin E during the  previous 6 months  before start of study, they all signed informed consent and all had  Depo-Provera as a method for contraception during the study period.
 Serum was collected at the start of study and after 6 months to measure vitamin E using high pressure liquid chromatography

.
 Patients randomly divided into 4 groups:

Group I: (25 patients) received vitamin E injection  100mg into the lesion (0.33cc Vol., Kahira Pharmaceuticals &  Chemical Industries Co) monthly for 6 months using insulin syringe.

Group II: (25 patients) received warm saline  injection (0.33cc Vol.) into the lesion every month for 6 months using  insulin syringe.

Group III: (25 patients) received oral vitamin E 400IU/day (Kahira Pharmaceuticals & Chemical Industries Co) for 6 months.

Group IV: (25 patients) received oral placebo daily for 6 months.

Cervical lesion was mapped before, during and after the  study and data were recorded on modified colposcopic sheet. The diameter  of the lesion was measured by means of plastic ruler 2cm length glutted  perpendicular on the tip of a uterine sound.

Complete response was defined as complete regression of  the lesion on colposcopy and absence of dyskaryotic cells on cervical  smear as well as absence of residual CIN on biopsy at 12th. month.  Partial response referred to regression of the lesion by >50% as  measured by the product of the two largest perpendicular diameters of  the lesion and continued presence of dyskaryotic cells on smear. Lesion  showing reduction of <50% of diameter was considered stable.
 
 Clinical and laboratory data were tabulated and analyzed statistically  using IBM personal computer with statistical program Epi.Info.version  6.02. t-test used to compare means, chi-square to compare different  groups and Z-test to compare percentages with a significant level set at  P<0.05.
 
 


 
 Age of patients were comparable in all groups, with mean age (

The mean age ( SD) at first intercourse was comparable  in all groups with no statistical difference between groups, it was 17.8  (

1.8) years in groups I; II; II; and IV respectively.

No statistical difference between groups with regard to mean number of deliveries and mean duration of marriage. (

)
 
 The number of cases with CIN I were 16, 15, 13, and 14 in groups I, II,  II and IV respectively while the numbers of cases with CIN II were 9,  10, 12, and 11 in groups I, II, II, and IV respectively. Acetowhite  epithelium present in majority of cases with punctations and mosaic  blood vessels in some cases. (

)
 
 Complete regression of the lesion was seen in 44% (11/25) in group I, which was significant than group II, 16% (4/25) P<0.05.

Complete regression of the lesion was 24% (6/25) in group III while in group IV it was 12% (3/25), this was not significant (

).
 
 The duration for complete regression was significantly less in group I than in group II (5.75

The duration to achieve complete regression was  comparable in group III and IV (6.5 1.04 months vz 7 2.3 months  respectively). The duration to achieve partial response was comparable  in all groups. (

One patients in group I upstaged from CIN I to CIN II  and two patients from the control groups upstaged to CIN II and III  during the study period.
 
 Lesions with diameter <100mm2 significantly regressed completely than lesions with diameter>100mm2.(

Serum levels of vitamin E were low in all groups at the start of the study and showed significant rise in group III only after 6 months. (


 
 The association between vitamin E status and the risk of different sites  of cancer has been widely studied epidemiologically in the past 10  years. Most of the studies have concerned all sites of cancer or some of  the most incident cancer sites 

 (12, 13, 14, 15, 16, 17, 18, 19 ,20, 21, 22, 23)

Studies on cervical carcinoma have ,with few exceptions 

 revealed lower dietary intake of serum levels of vitamin E among cases of cervical dysplasia and cervical cancer 

Evidence from culture studies, animal models and  observational epidemiological studies that vitamin E may provide  protection against cancer has led to several clinical intervention  trials being set up. Based on limited number of patients with mammary  dysplasia, a number of trials suggested that the risk of breast cancer  may be reduced by vitamin E supplementation 

. Larger trials on benign breast disease, however, failed to confirm these results 

Vitamin E supplement was shown to reduce prostate cancer incidence and mortality by one-third in men who smoke 

. The simultaneous addition of lycopen together with  alpha-tochopherol resulted in a strong inhibitory effect of prostate  carcinoma cell proliferation

. Also oral administration of  alpha-tochopherol resulted in both clinical and histopathological  responses in oral premalignant leukoplakia lesions 

In the present study, the group received local injection  of vitamin E showed significantly complete response rates in a  significantly shorter duration than the control group, although serum  vitamin E levels were consistently low in both groups.

Patients received oral vitamin E supplementation showed  no significant response compared to the placebo group, although serum  vitamin E levels were significantly higher in patients receiving vitamin  E than in patients receiving placebo after 6 months of supplementation.

This could be explained by the possibility that the  amount of vitamin E that accumulated in the cervix may not be high  enough when administered orally for a short period. It is also possible  that the timing of the dose may affect the results.

In the present study it was observed that small lesions  <100mm2 responded significantly than larger lesions >100mm2, which  indicates that tissue levels of vitamin E is more important than serum  levels in predicting the response rate.
 
 


 
 Vitamin E injected into the lesion in cases with CIN give significant  response rates, and smaller lesions tend to respond more significantly  than larger lesions.
 Further studies with larger and more frequent local doses of with measuring tissue levels of vitamin E is recommended. 

Table II: Colposcopic findings in all groups

Table III: Response rate among all groups

Table V: Relation between size of lesion and response rate in patients treated by vitamin E (group I & III)

Table VI: Serum vitamin E levels at the start and after  6 months of study

1-National Institute of Health,Consensus Development Conference Statement: Cervical Cancer. NIH Census Statement 1996 April,1-3;14(1):1-38.

2-Birt DF . Update on the effects of vitamins A,C and E and selenium on carcinogenesis. Proc.Soc.Exp.Biol.Med.,1986,183:311-320(abstr.)

3-Chen LH; Biossonneault GA; and Glauert HP. Vitamin C, Vitamin E and cancer . Anticancer Res.,1988,8:739-748 (review).

Vitamin E (alpha-tocopherol) is thought to play a role in several stages of carcinogenesis through its contribution to immunocomptence, inhibition of mutation formation and repair of membranes and DNA.

Alpha-Tochopherol in Treatment of Cervical Cancer Precursor

 
 This study compared the maternal blood and fetal outcome in women with pregnancy-induced hypertension who received epidural and other anaesthesia. Spanning a period of three years, 234 pregnant women were analyzed in the study. All had pregnancy-induced hypertension with diastolic blood pressure readings of > 95 mmHg and proteinuria > 300 mg. Epidural analgesia was given to 160 patients, 46 received general anesthesia, and 28 had local anesthesia. The maternal blood pressure was assessed before and after anesthesia was administered, and the fetal outcome was assessed by Apgar Score and Cord pH.
 
 
 


 Pre-eclampsia is the most common life-threatening complication in pregnant women, although the safety of general anesthesia for delivery of patients with pregnancy-induced hypertension (PIH) has been established (Clark & Cotton, 1988).
 
 The use of epidural anesthesia for pain relief in such patients has remained controversial. Large numbers of trained and practicing obstetricians believe that regional anesthesia is dangerous for patients with PIH because severe hypotension, necessitating the use of vasopressors and large infusion of intravenous fluids can often lead to increased fetal and maternal morbidity and mortality (

). Experience, however, has proven that continuous lumber epidural analgesia is acceptable, as long as: the coagulation profile is acceptable; circulating volume is adequately maintained; maternal arterial blood pressure is pharmacologically controlled; and aorta cavil compression is avoided (

).
 
 This controversy motivated us to study the effect of epidural anesthesia on PIH patients
 
 
 


 Our aim was to elucidate the effect of epidural anesthesia in patients with PIH, and also to compare the fetal and maternal outcome among patients delivered with either epidural, general or local anesthesia.
 
 
 


 This study was carried out from March, 1992, to June, 1995. The 234 patients chosen for the study were suffering from PIH. 160 patients were admitted early in labor and were given epidural analgesia. The 28 patients who

went into labor and arrived at the hospital too late for regional anesthesia served as the control group to vaginally delivered patients. 46 patients had elective Caesarean section (C.S.) deliveries under general anesthesia, and out of the 160 patients who received epidural anesthesia, 20 cases delivered by C.S. Out of 234 patients overall, a total of 66 patients delivered by C.S..
 
 

 Patients 	and infants delivered vaginally with epidural analgesia (140 patients).

 Patients 	and infants delivered vaginally with local anesthesia (28 patients).

 Patients 	and infants delivered by C.S. with epidural anesthesia (20 patients).

 Patients 	and infants delivered by C.S. with general anesthesia (46 patients).


 Before an epidural was given, the procedure was explained to each patient and consent was obtained. An intravenous infusion was sited before insertion of the epidural, and the circulation was preloaded with 500 ml of crystalloid to decrease incidence of hypotension. A 17-gauge epidural needle was inserted into the second or third lumber epidural space by loss of resistance to saline technique under complete asepsis. A 20-gauge teflon catheter was then threaded to 5 cm cephalad while ensuring the absence of blood, C.S.F. or paraesthesia. Following careful inspection of the catheter after aspiration failed to reveal C.S.F. or blood, a test dose of 3 ml 0.25% bupivacaine was injected between contractions to decrease false negative. This was done to exclude intrathecal or intravenous placement Following assessment of the test dose, 10 ml 0.25% of bupivicaine was profressively injected with careful haemodynamic and fetal monitoring.
 
 Each patient was instructed to lie on her side to prevent supine hypotension. Arterial blood pressure was monitored every 2 min. for the first 10 min, and then every 10 min. When unilateral analgesia occurred, the patient was turned on her other side and more local anesthesia (5-10 ml) was injected.
 
 


 This group received general anesthesia with labetalol pretreatment as 20 mg, initially followed by of 10 mg increments every 3 min., but not exceeding 1 mg/kgm of body weight.
 
 
 


 The age of patients who received epidural analgesia ranged from 20-31 years, with a mean of 26.9 +/- 5.4. The mean age of patients who received the local anesthesia was 24.61 +/- 4.6 years, and those who received general anesthesia for C.S. had a mean age of 23.6 +/- 3.9 years.
 
 The parity for group I was 70% primigravida, 80% primigravida for group II, 60% primigravida for group III and 70% primigravida for group IV. The duration of second-stage labor was 1.2 hours in group I and 0.7 hours for group II, with statistical significance (P. 0.001). [

] The maternal blood pressure was 170/95 +/- 18/13 mmHg in group I, and 175/110 +/- 22/12 mmHg in group II. There was significant statistical difference, as the blood pressure of group I was greatly reduced to level 130/85 +/- 20/18 mmHg, with P. Value of 0.01. [

]
 
 The neonatal outcome for group I and group II regarding the Apgar Score, the birth weight and abnormal heart rate was not statistically significant. [Table 2] The maternal blood pressure before anesthesia was 160/95 +/- 17/12 mmHg in group III, and 170/110 +/- 24/13 mmHg in group IV. There was significant statistical difference. The blood pressure of group III was greatly lowered to the level of 130/90 +/- 20/16 mmHg (p value < 0.01). [Table 3] The neonatal outcome for group III and group IV regarding Apgar Score after 1 min was statistically significant, but not significant after 5 min. [

Table (1): Maternal Outcome with Group I & II

Table (2): Maternal and Neonatal Outcome with Vaginal 			Delivery Group I & II

Table (3): Maternal and Neonatal Outcome with Group 			III & IV (deliveries C.S.)

Patients with mild PIH generally only require caution during anesthesia. However, patients with severe PIH are critically ill and require stabilization prior to any anaesthetic.
 
 We studied maternal and fetal outcome following delivery with continuous epidural anesthesia in patients with PIH. It was found that epidural anesthesia is an effective and safe method for pain relief during labor. The elimination of labor pain and allaying of anxiety in patients during labor subsequently reduces the sympathetic activity, causing vasodilatation and dropping of the blood pressure
 
 In our study, the drop in blood pressure was significant in the group that delivered vaginally with epidural analgesia and the maternal and fetal outcomes were similar to the deliveries with local perineal infiltration. Therefore, the maternal and fetal morbidity were not increased when epidural analgesia was administrated to patients with PIH. 

 said that with epidural analgesia, the maternal and fetal outcomes were similar to deliveries with local perineal infiltration; thus, the maternal and fetal morbidity are not increased when epidural analgesia is administrated to patients with PIH. 

) also said that epidural analgesia does not alter the cardiac output of pre-eclamptic, as long as the patient is adequately hydrated. After adequate intravascular volume expansion and maintenance of uterine displacement, lumber epidural analgesia actually increases uterine artery (Ramos-Santos et al., 1991) and mean intervillous blood flow (Joupilla et al., 1982). Furthermore, there were no cases of fetal heart abnormalities nor material hypertension when the above regiment was followed.
 
 

In group IV, we found that there was a significant increase in blood pressure and maternal heart rate in comparison with group III, in which patients were well hydrated and aorto-caval compression was avoided.

said that induction of general anesthesia and tracheal intubation carry the risk of sudden maternal hypertension, perhaps beyond the limits of cerebral blood autoregulation. Although this is a danger of general anesthesia, some centres will not use epidural block for Caesarean delivery of pre-eclamptic parturients for fear of sudden and refractory hypotension, leading to profound uteroplacental insufficiency in an already-compressed gestation

Others confirm that in cases of epidural anesthesia without hypotension, the conditions of newborns at birth are better, even if uterine delivery time is prolonged

In our study there was a prolongation of the second stage of labor in patients receiving epidural analgesia. The possible cause of this prolongation could be lumbosacral neuromotor blockade with epidural analgesia, which may reduce the effectiveness of uterine contractions, plus abolish bearing power.

) said that the second stage of labor may be prolonged during epidural analgesia as a result of the loss of the bearing down reflex and reduce the efficacy of maternal explosive effort. It is no longer considered necessary to terminate the second stage of labor after a set time (1-2 hours), provided there is no evidence of fetal distress.
 
 


 Continued lumber epidural anesthesia is the best technique for managing patients with PIH. Epidural anesthesia should not be used to correct hypertension, but it has many advantages over other anaesthetic techniques, as it produces complete pain relief and negates the need for maternal narcotics which depress ventilation and have adverse effects on preterm babies. On the other hand, it prevents the increase in blood pressure associated with bearing down, avoiding increased cerebral spinal pressure, and it is also more effective than general anesthesia in controlling the blood pressure and avoiding the swings in blood pressure due to tracheal intubation in C.S. deliveries. It is also abolishes the neurally imposed vasoconstrictor and reduces the circulating catecholamines that occur with anxiety and labor pains.
 
 Thus, in the absence of coagulopathy, continuous epidural anesthesia is the anesthetic of choice for most patients with PIH during labor, regardless of vaginal or Caesarean section delivery.

1.    Andrew M., Molinow M.D.: Pre-eclampsia and eclampsia: Anaesthetic management. Annual refresher course lectures, 421 - 1991.

2.    Clark SL, and Cotton D.D.: Clinical indications for pulmonary artery catheterization in patient with severe pre-eclampsia. Am. J. Of Obstet Gynaecol 1988, 158.453.

3.    Graham C., Goldstein A.: Epidural analgesia and cardiac output in severe pre-eclamptics. Anesthesia 35:709-1980.

4.    Hodgkinson R.; Husain F.J. and Hayash H.: Systemic and pulmonary blood pressure during C.S. in patients with gestational hypertension. Can J. anesthesia 27:389, 1980.

5.    Joupilla P.; Joupilla R. and Hollmen A. et al.,: Lumber epidural analgesia to improve inter villus blood flow during labour in severe-pre-eclampsia. Obstet & Gynaecol 59:158, 1982.

6.    Lindheimer M.D., Katz A.I.: Hypertension in pregnancy. N. Engl. J. Med. 313 : 675, 1985.

7.    Miller A.C., Devore J.S., Eisler E.A.: Effects of anesthesia on uterine activity and labor. Anesthesia for obstetrics 3rd ed. 53-69, 1993.

8.    Moore TR.; Key T.C. and Reisner L.S. et al.,: Elevation of the use of continuous lumber epidural anesthesia for the hypertensive pregnant woman in labor A.J. Obstet & Gynaecol 152: 404, 1985.

9.    Ramos - Santos E., Devoe L.D. Wakefield M. et al.,: The effects of epidural anesthesia on the Doppler velocimetry of umbilical and uterine arteries in normal and hypertensive patients during active term labor Obstet & Gynaecol 17-20, 1991.

10.    Stoetting R.K. Miller R.D.: Basics of anesthesia PP 363-387 New York Churchill Living stone 1984. 

Comparative Study BetweenEpidural Analgesia vs. Other Anaesthetic Techniques on the Maternal Blood Pressure and Foetal Outcome in Pregnancy Induced Hypertension (PIH)

Author | Asem A. Moussa, MD

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