Myeloid and lymphoid dendritic cells in normal pregnancy and pre-eclampsia

The aim of our study was to estimate the populations of peripheral blood myeloid and lymphoid dendritic cells (CD1c+, BDCA-2+) and the CD1c+ : BDCA-2+ ratio in normal pregnant women and in patients with pre-eclampsia. Fifteen women in the first, second and third trimesters of normal pregnancy, and 25 patients with pre-eclampsia were included in the study. The dendritic cells were isolated from peripheral blood, stained with monoclonal antibodies against blood dendritic cell antigens (anti-CD1c, anti-BDCA-2) and estimated using the flow cytometric method. CD1c+ and BDCA-2+ dendritic cells were present in women during all trimesters of physiological pregnancy and in pre-eclamptic patients. It was observed that the numbers of dendritic cells were significantly lower in the second trimester when compared with the first and third trimesters of normal pregnancy. Furthermore, in the second trimester, CD1c+ : BDCA-2+ ratio was higher than in the other trimesters of physiological pregnancy. All populations of dendritic cells and CD1c+ : BDCA-2+ ratio did not differ in the first and third trimesters of normal pregnancy. The percentage of BDCA-2+ dendritic cells was significantly lower in pre-eclampsia in comparison with healthy women in the third trimester of physiological pregnancy, while CD1c+ : BDCA-2+ ratio was significantly higher in pre-eclamptic patients when compared with control groups. We concluded that dendritic cells may be involved in the immune regulation during physiological pregnancy. CD1c+ and BDCA-2+ cells can influence the Th2 phenomenon which is observed during physiological pregnancy. Furthermore, it seems possible that lower BDCA-2+ cells percentage and higher CD1c+ : BDCA-2+ ratio can be associated with increased Th1-type immunity in patients with pre-eclampsia.     

Reactivation of human herpesvirus 6 and 7 in pregnant women

To elucidate the roles of human herpesvirus (HHV)-6 and -7 in pregnant women, peripheral blood samples and genital tract secretions were collected serially from pregnant women, and both serological testing and polymerase chain reaction (PCR) were carried out to detect viral DNA in the secretions. HHV-6 or HHV-7 Immunoglobulin(Ig)M antibodies were not detected in 432 plasma samples collected from pregnant women and cord blood, but IgG antibodies against both viruses were detected in all plasma samples. Significant increases in HHV-6 and HHV-7 IgG antibodies were observed in two (1.6%) and three (2.4%) pregnant women respectively of a total of 123 cases. HHV-6 DNA was detected in the genital tract in three (3.7%) of 82 pregnant women at the first trimester, and in 10 (12.2%) of the same women in the third trimester. The detection rate in the third trimester was significantly higher than that in the first trimester (P = 0.043). Although HHV-7 DNA was detected in the genital tract of two (2.7%) and seven (9.6%) pregnant women of a total of 73 during the first and third trimesters respectively, there was no statistical difference in the detection rate of the viral DNA between the trimesters. Because a significant increase in HHV-6 IgG antibodies was detected in only two pregnant women, it was not possible to carry out statistical analysis to determine the relationship between HHV-6 infection and associated clinical features. Although there was a significant increase in HHV-7 antibody titers in three pregnant women, a positive correlation between the virus infection and the clinical features was not demonstrated. There was no statistical association between virus shedding in the genital tract and the clinical features examined in this study.     

Antiphospholipid Antibodies in Patients With Preeclampsia

PROBLEM: To determine the incidence of anticardiolipin and antiphosphatidylserine antibodies in women with preeclampsia. METHODS: Sera from 100 women with preeclampsia and 100 normotensive pregnant women in the third trimester were assayed for anticardiolipin and antiphosphatidylserine antibodies. RESULTS: Antiphosphatidylserine antibodies were positive for IgM in 1 patient (1%) and for IgG in 4 patients (4%). IgM antibodies to cardiolipin were positive in two patients (2%) while IgG antibodies to cardiolipin were positive in nine patients (9%). Only 3% of the control women were positive for antiphospholipid antibodies. None of the patients or controls had positive levels of IgA anticardiolipin or antiphosphatidylserine antibodies. CONCLUSIONS: Elevated levels of IgG or IgM antibodies to cardiolipin and phosphatidylserine were detected in 11/100 (11%) of women diagnosed with preeclampsia in the third trimester compared to only 3/100 (3%) positive in controls (P < 0.05). These findings suggest that antiphospholipid antibodies may play a pathogenic role in some women with preeclampsia.     

Humoral and cell-mediated immune responses to herpesvirus antigens during pregnancy—A longitudinal study

Humoral and cellular immune responses were studied during the second trimester, third trimester, and postpartum periods in 11 pregnant women and in nonpregnant control women. Complement fixing (CF) and indirect hemagglutinating antibody (IHA) titers for herpes simplex type 1 (HSV-1), herpes simplex type 2 (HSV-2), and cytomegalovirus (CMV) were determined. Cellular response was measured by [³H]thymidine uptake by stimulated lymphocytes. Phytohemagglutinin (PHA), HSV-1, HSV-2, and CMV antigens were used as stimulants. No differences in the mean titers of CF and IHA antibodies were found. The cellular response to PHA had a transient decrease (P<0.02) during the third trimester. The cellular response to CMV was significantly lower during the second and third trimesters. A diminished response to HSV-1 antigen was observed during the second and third trimesters; the cellular response to HSV-2, though reduced, was not significantly altered during pregnancy. These data indicate a suppression of cellular responses to various herpesviruses and PHA during pregnancy.     

Heterogeneity of the iron status in the woman population during the pregnancy in Côte-d'Ivoire

The iron deficiency is a major problem of public health in the African countries, particularly in pregnant women population. The aim of our study was to appreciate the iron status during the pregnancy period (first, second and three trimesters); to realize an evaluation and to characterize the biological indicators of pregnant women. Our study was carried out in four medical and urban units of Abidjan in C?te-d'Ivoire with 531 pregnant women. The biological parameters significantly reduced in the third trimester of the pregnancy. But, an enhancement of the transferrin and the total iron binding capacity was observed. Moreover, 66 % of pregnant women presented iron deficiency anaemia (p < 0.01). In conclusion, the study shows that no pregnant woman presented iron normal status in the third trimester of the pregnancy.     

Anti-Elastin Antibodies and Elastin Turnover in Normal Pregnancy and Recurrent Pregnancy Loss

Problem  The aim of this study was to investigate elastin turnover and autoimmunity in patients with a history of recurrent pregnancy loss (RPL) and during normal pregnancy.
Method of study  Anti-α-elastin and anti-tropoelastin IgG and IgM antibodies were measured by a home-made ELISA in serum samples of 60 medically and obstetrically normal pregnant women, classified to three trimester groups, 18 female patients with RPL and 18 healthy non-pregnant women with a history of successful pregnancies. One way analyses of variance and Least Significant Difference method were used for a statistical analysis.
Results  Anti-α-elastin IgG autoantibodies were significantly decreased in the third trimester pregnant women. IgM anti-α-elastin autoantibodies were significantly decreased in all pregnancy groups compared with the controls. Synthesis/degradation ratio of elastin was significantly increased in the third trimester pregnancy group, suggesting decreased elastin degradation during this period of pregnancy. Comparing the RPL patients with the healthy non-pregnant controls showed a significantly increased anti-α-elastin IgG antibody and significantly decreased synthesis/degradation ratio in the patient's group, suggesting increased elastin degradation in RPL.
Conclusion  Elastin degradation is decreased during normal pregnancy. Increased anti-elastin IgG antibodies may contribute to the pathogenesis of pregnancy losses.     

Soluble Intercellular Adhesion Molecule-1 Serum Profile in Physiologic and Preeclamptic Pregnancy

PROBLEM: The aim of this study was to determine serum levels of soluble intercellular adhesion molecule (sICAM)-1, an adhesion receptor that mediates interactions with the immune system, in physiologic and preeclamptic pregnancies. Moreover, we evaluated whether the release of sICAM-1 during pregnancy correlated to plasma fibronectin concentrations. METHOD OF STUDY: Serum was collected from 18 nonpregnant, control women, from 58 normal pregnant women during the first (n = 13), second (n = 15), and third (n = 30) trimesters, and from 25 preeclamptic patients at 27–39 weeks' gestation. All samples were assayed for sICAM-1 by a specific enzyme-linked immunoassay and for fibronectin by a nephelometric system. Serum sICAM-1 levels in preeclamptic patients were compared to those obtained from gestational-matched normal pregnant women. RESULTS: Levels of sICAM-1 were significantly elevated (P < 0.001) in each of the three trimesters of normal pregnancy (I trimester: 390.4 ± 25.7 ng/ml; II trimester: 386.3 ± 15.4 ng/ml; and III trimester: 367.3 ± 15.8 ng/ml) when compared to those of healthy nonpregnant women (263.3 ± 11.6 ng/ml). No significant difference in sICAM-1 concentrations was observed among the three trimesters. Preeclampsia was associated to a significant decrease (P < 0.01) of sICAM-1 levels (309.8 ± 11.6 ng/ml) relative to those observed in gestational-matched pregnant women (367.3 ± 15.8 ng/ml). Fibronectin and sICAM-1 levels did not correlate. CONCLUSION: The increased levels of sICAM-1 found in physiologic pregnancies and its reduction in preeclampsia may account for some of the immunologic alterations demonstrated to be associated with pregnancy.     

Soluble HLA-DR and soluble CD95 ligand levels in pregnant women with antiphospholipid syndromes

Antiphospholipid syndrome (APS) is a severe complication in pregnancy that can lead to fetal death in the second or third trimester. As soluble HLA-DR (sHLA-DR) molecules are reported to be implicated in the etiology of pregnancy disorders and of autoimmune diseases, we studied sHLA-DR plasma levels in pregnant women with APS (n = 14) and in women with normal pregnancy (n = 15), in women with high-risk pregnancies such as preeclampsia (PE; n = 20) and intrauterine growth retardation (IUGR; n = 10) and in fertile non-pregnant women (n = 29). The sHLA-DR levels of pregnant women were assessed during the third trimester, at labor, in the first week, and in the third month of puerperium. The results obtained were compared with soluble CD95 ligand (sCD95L), an important signal molecule in the apoptosis pathway. The sHLA-DR levels in pregnant women with APS were approximately three times higher (mean 1.48 +/- 0.15 microg/ml) during the whole observation period than in fertile non-pregnant women (0.54 +/-.06 microg/ml) and nearly double in women with high risk (PE, 0.91 +/- 14 microg/ml; IUGR, 0.94 +/-.21 microg/ml) and in normal pregnancies (0.74 +/- 0.13 microg/ml). Furthermore, sHLA-DR levels of pregnant women with APS were positively correlated with the serum concentration of anti-anticardiolipin immunoglobulin G antibodies. For sCD95L plasma levels, no substantial variations were found among the different groups above. In pregnant women with APS, however, sHLA-DR levels were positively correlated with sCD95L levels. Further studies should clarify the functional involvement of sHLA-DR molecules in the induction of CD95/CD95L-mediated apoptosis pathway that may play a crucial role in the pathology of pregnancies complicated by APS.     

妊娠中、晚期300例胎儿脐血染色体核型分析

目的 分析妊娠中、晚期胎儿脐血染色体核型,了解该时期异常核型出现的频率、类型及与各种产前诊断指征的关系。方法 ３００例有产前诊断指征的孕妇,在妊娠１８～３８孕周时穿刺胎儿脐带血管,帛脐箅查染色体核型。结果 发现异常核型２３例（７．７％）,其中２１三体占３９．１％（８／１２６）,Ｐ＝０．７７。三体为主要的染色体异常,占异常核型的６０．９％（１４／２３）。其中２１三体占３９．１％（９／２３）,平衡易位     

Prospective study on maternal, intrauterine, and perinatal infections with cytomegalovirus in Japan during 1976-1990.

Since 1976, sera obtained serially from 10,218 pregnant women during the first, second, and third trimesters of gestation and cord sera were tested for CMV complement-fixing (CF) and immunofluorescent (IF) antibodies. CMV IgG-IF antibody was positive in 9,735/10,218 (95%) in the first trimester, and a significant rise of CF antibodies during pregnancy was found in 70/9,206 (0.76%) of the seropositive group and in 5/438 (1.14%) of the seronegative group. IgM antibody was found in 6/9,206 (0.06%) of seropositive women during the first trimester and in 7/70 (10.0%) of seropositive mothers with CF antibody rise and in 4/5 of seroconverted mothers of the seronegative group, suggesting that the incidence of primary infection with CMV during pregnancy was approximately 1% of susceptible women. All the mothers with immune response had infants with neither viruria nor IgM antibody in the cord blood, whereas seropositive mothers without an immune response had infants with viruria (7/1,826; 0.4%) or with IgM antibody in the cord blood (6/9,136; 0.06%). None of these 13 babies, shedding CMV or with IgM IF antibody, had physical or mental retardation. CMV IgG-IF antibody was present in almost 80% of infants between 7 and 12 months of age in 1988, suggesting that perinatal or postnatal CMV infection may occur in infants born to seropositive mothers in 70-80% of pregnancies.     

The utility of screening for perinatal depression in the second trimester among Chinese: a three-wave prospective longitudinal study

This paper aims to study the pattern of perinatal depressive symptomatology and determine the predictive power of second trimester perinatal depressive symptoms for future perinatal periods. A population-based sample of 2,178 women completed the Edinburgh Postnatal Depression Scale (EPDS) in the second and third trimesters and at 6 weeks postpartum. Repeated measures ANOVAs were used to determine the EPDS scores across three stages. The predictive power of the second trimester EPDS score in identifying women with an elevated EPDS score in the third trimester and at 6 weeks postpartum were determined. The predictive power of the second trimester EPDS score was further assessed using stepwise logistic regression and receiver operator characteristic curves. EPDS scores differed significantly across three stages. The rates were 9.9%, 7.8%, and 8.7% for an EPDS score of >14 in the second and third trimesters and at 6 weeks postpartum, respectively. Using a cut-off of 14/15, the second trimester EPDS score accurately classified 89.6% of women in the third trimester and 87.2% of those at 6 weeks postpartum with or without perinatal depressive symptomatology. Women with a second trimester EPDS score >14 were 11.78 times more likely in the third trimester and 7.15 times more likely at 6 weeks postpartum to exhibit perinatal depressive symptomatology after adjustment of sociodemographic variables. The area under the curve for perinatal depressive symptomatology was 0.85 in the third trimester and 0.77 at 6 weeks postpartum. To identify women at high risk for postpartum depression, healthcare professionals could consider screening all pregnant women in the second trimester so that secondary preventive intervention may be implemented.     

Thyroid function tests in pregnancy

The recognition of abnormality in thyroid function tests during pregnancy is important for the welfare of the mother as well as fetus. The values of serum tri-iodothyronine (T3), thyroxine (T4), thyroid-stimulating hormone (TSH) in nonpregnant women are not applicable during pregnancy and also differ in iodine deficient areas. In the present study, one hundred and twenty-four apparently normal, healthy young primigravidas with no known metabolic disorders and normal carbohydrate gestational intolerance test, consecutively attending the antenatal clinic were included in the study. The serum tri-iodothyronine (T3), thyroxine (T4) and thyroid-stimulating hormone (TSH) in these women were estimated. In the first trimester, the mean T3 values were found to be 1.85 nmol/L, which increased to a mean of 2.47 nmol/L in the second trimester and declined in the third trimester to 1.82 nmo/L. Mean T4 levels were also seen to rise from 164.50 nmol/L in the first trimester to 165.80 nmol/L in the second trimester and then decreased in the third trimester to 159.90 nmol/L. Mean TSH levels were seen to rise progressively through the three trimesters of pregnancy from 1.20 microlU/ ml in the first trimester to 2.12 microlU/ml in the second trimester and further to 3.30 microlU/ml in the third trimester of pregnancy. Three asymptomatic pregnant women (2.5%) were found to have abnormal TSH values with normal T3 and T4 levels and good obstetric outcome. This pilot study also indicates the range to T3 as 1.7 - 4.3 nmol/L in second trimester and 0.4 - 3.9 nmol/L in third trimester, T4 as 92.2 - 252.8 nmol/L in second trimester and 108.2 - 219.0 nmol/ L in third trimester, and TSH as 0.1 - 5.5 microlU/ml in second trimester and 0.5- 7.6 microlU/ml in third trimester of pregnancy.     

Serum IgM to Chlamydia trachomatis in pregnancy: its usefulness for screening

Asymptomatic infection with Chlamydia trachomatis represents an important health problem. A non-invasive diagnostic test to screen pregnant women is needed that is cost effective and can be used widely, especially in developing countries. In this setting, quantitation of antichlamydial IgM antibodies may offer an additional strategy for the control of C. trachomatis infection. The aim of this prospective study is to evaluate the quantitation of serum antichlamydial IgM antibodies, based on absorbance (A) values, in pregnant women for the prediction of C. trachomatis infection. Serum samples from a cohort of 148 pregnant women (first to third trimesters; age range: 18-35 years) presenting to the antenatal department at Safdarjang Hospital were tested for IgM antibodies specific to C. trachomatis by an enzyme-linked immunosorbent assay (ELISA) kit (Novum Diagnostics, Germany). Co-infection with other STD pathogens was ruled out. In this cohort, 85 (57.4%) pregnant women were found to be positive for IgM antibodies to C. trachomatis. Based on the cut-off value of the ELISA test (calculated as 0.558), pregnant women with an A value between 0.558 and 0.999 and those with a value > 1.000 were categorised as low positive (LP, n=41) and high positive (HP, n=44), respectively. The differences in mean A values for the LP versus negative groups (0.7504 versus 0.2249, P<0.05) and the HP versus negative groups (1.5353 versus 0.2249, P<0.05) were statistically significant. Maximum seroprevalence (44.4%, P<0.05) was found among those in the HP group in the first trimester of pregnancy. Multigravidae (34.4%, P<0.5) and multiparous (34.9%, P<0.5) pregnant women in the HP group were at an increased risk of chlamydial infection. As overall results indicated that pregnant women in the HP group were at higher risk, we stress the importance of large-scale screening of pregnant women for C. trachomatis infection, particularly in developing countries where sophisticated techniques for collection/diagnosis are as yet unavailable.     

Calcium and vitamin D status of pregnant teenagers in Maiduguri, Nigeria.

This study investigates parameters related to calcium and bone metabolism by determining the concentrations of total calcium, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, parathyroid hormone, and phosphorous in young pregnant women. The patient population was 30 pregnant Nigerian teenage women grouped by trimester (10 per group), 10 women immediately following delivery, and 21 healthy age-matched controls. On the basis of serum prealbumin levels, the general nutrition of the pregnant women was found to be significantly below that of the more privileged and better-educated nonpregnant controls. The mean total calcium concentration in sera of the third-trimester women was 8.83 mg/dL, which was significantly below that of the controls (9.77 mg/dL) and the first-trimester group (9.30 mg/dL). Despite the 10% to 15% decline in the serum level of total calcium during pregnancy, the parathyroid hormone level decreased markedly from 0.60 to 0.61 ng/mL in the first and second trimesters to 0.41 ng/mL in the third trimester. Serum vitamin D and 1,25-dihydroxyvitamin D levels in the second and third trimesters were within the normal range. These data indicate that toward the end of gestation, pregnant teenagers in northern Nigeria appear to become calcium deficient and do not exhibit the expected increase in serum parathyroid hormone levels normally seen in pregnant women.     

Interleukin-2 receptor serum concentrations in normal pregnancy and pre-eclampsia

The purpose of this research was to assess interleukin-2 receptor serum levels in normal pregnancy and pre-eclampsia. Sera from 90 healthy pregnant women (30 for each trimester), 30 with pre-eclampsia and a group of 30 healthy non-pregnant were analyzed. Soluble interleukin-2 receptor was measured by specific double antibody enzymatic immunoassay (ELISA). Results were: 267.5 +/- 12.3 (mean +/- s.e.m) pg/mL in the uncomplicated first trimester sample, 300.9 +/- 14.5 pg/mL in the second trimester and 248.8 +/- 12.5 pg/mL in the third. The non-pregnant control group had 443.7 +/- 39.6 pg/mL, significantly different from normal pregnancy in all trimesters (p < 0.001). The concentration in pre-eclamptic patients was 382.2 +/- 24.2 pg/mL, with p < 0.01 with regard to the normal third trimester group. The conclusion is that interleukin-2 receptor serum levels diminish in normal pregnancy and rise in preeclampsia. The first finding seems to be a protective mechanism to the fetal allograft. The latter, point to increased cellular activity.     

Quantitative analysis of peripheral blood Th0, Th1, Th2 and the Th1:Th2 cell ratio during normal human pregnancy and preeclampsia.

We calculated the percentage of Th1, Th2, Th0 cells and the Th1:Th2 cell ratio of peripheral blood from normal pregnant subjects and preeclampsia patients using flow cytometry which can analyse both the surface marker, CD4, and intracellular cytokines, interleukin (IL)-4 and interferon (IFN)-gamma. In normal pregnancy, the percentage of Th1 cells was significantly lower in the third trimester, and the ratios of Th1:Th2 were significantly lower in the second and third trimester than in nonpregnant subjects. In contrast, the percentage of Th1 cells and the ratios of Th1:Th2 in preeclampsia were significantly higher than in normal third trimester pregnant subjects. The percentage of Th2 cells in preeclampsia was significantly lower than in third trimester of normal pregnancy. Additionally, peripheral blood mononuclear cells from these subjects and patients were cultured with phytohemagglutinin stimulation, and IL-4 and IFN-gamma concentrations were determined in the supernatant by enzymed linked immunosorbent assays. The percentage of Th1 and Th2, and the ratios of Th1:Th2 were correlated with cytokine (IFN-gamma and IL-4) secretion level. These results demonstrated that Th2 cells were predominant in the second and third trimesters of normal pregnancy, but Th1 cells predominated in preeclamptic patients.     

链置换式扩增检测羊水中巨细胞病毒DNA

目的：介绍一种简便快速准确检测羊水中ＣＭＶ－ＤＮＡ的改良ＰＣＲ－链置换式扩增用于诊断胎儿先天感染ＣＭＶ。方法，将组成套式ＰＣＲ的外内两对引物按照一定比例（外：内＝１：５０－１００）加在同一试管中一次扩增羊水和胎儿组织中ＣＭＶ－ＤＮＡ。结果：９０例异常孕产史的孕妇羊水检测ＣＭＶ－ＤＮＡ，阳性率为３８．９％（３５／９０），其中合并染色数目异常２例（４７，ＸＹＹ和４７，ＸＸ，＋２１）（已引产）核型及染色     

Persistence of IgM antibodies to cytomegalovirus-induced late antigen in pregnancy and postpartum

21 women with IgM antibodies to cytomegalovirus-induced late antigen (CMV LA) as determined in the first, second or third trimester were tested for the persistence of these antibodies during pregnancy and postpartum. Out of 21 women 16 still showed IgM antibodies against CMV LA by 6-9 months after delivery. No striking differences could be found between women with primary or recurrent CMV infections as well as those who had intrauterine infection.     

Urinary excretion of albumin and retinol-binding protein during normal pregnancy.

In a cross sectional study of 88 pregnant women urinary excretion of albumin, when expressed as a ratio to creatinine concentration, was not significantly different from that in a non-pregnant control group of similar age (p greater than 0.05) and did not change significantly during pregnancy. Only when albumin excretion was expressed as a fractional clearance was the urinary excretion significantly increased in the third trimester compared with the first trimester (p less than 0.05), although it was still not significantly different from that in the non-pregnant control group. Excretion of retinol-binding protein was significantly increased during all three trimesters of pregnancy (p less than 0.01 in each case) and more so in the second and third trimesters than in the first. It is concluded that the increased total protein excretion that has been described during pregnancy is not explained by an increased excretion of albumin which remains essentially normal. In contrast, the tubular absorption of proteins is decreased.     

Screening for lupus anticoagulant and anticardiolipin antibodies in women with fetal loss.

Sixty six women with first or second trimester fetal loss were investigated for the presence of lupus anticoagulant by routine coagulation tests and the dilute Russell's viper venom time with a platelet neutralisation procedure, and for raised anticardiolipin antibodies by an enzyme linked immunosorbent assay. Of 35 women with recurrent fetal loss, seven were positive for lupus anticoagulant and six had increased IgG anticardiolipin antibodies, while of 31 women with only one or two episodes of fetal loss, one had lupus anticoagulant and none increased IgG anticardiolipin antibodies. These findings were significantly different. There was no difference in the incidence of increased IgM anticardiolipin antibodies between the two groups (three and two cases, respectively). A further 11 women with intrauterine death in the third trimester were studied and lupus anticoagulant and raised IgM anticardiolipin antibodies were found in one case. No woman was known to have systemic lupus erythematosus. It is concluded that lupus anticoagulant and increased IgG anticardiolipin antibodies are independently associated with recurrent first and second trimester fetal loss and that such cases should be investigated, even in the presence of otherwise good health, by a comprehensive methodological approach.