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Evidence of the impact of maternal nutritional status on pregnancy outcome is increasing. However, reference values for vitamin and homocysteine concentrations in maternal blood during normal pregnancy are scarce, and are lacking for the preconceptional period and early pregnancy. Thus, in a longitudinal study we evaluated vitamin and homocysteine concentrations in 102 nulliparous women with an uneventful singleton pregnancy and normal outcome not using supplements. The physiological changes in vitamin and homocysteine concentrations in blood were determined from the preconceptional period throughout pregnancy until 6 weeks post-partum. The vitamins evaluated comprised retinol, thiamin, riboflavin, pyridoxal 5'-phosphate, folate in serum and erythrocytes, vitamin B12 and alpha-tocopherol. The plasma homocysteine concentration was also measured, considering the essential roles of folate, vitamin B6 and vitamin B12 in homocysteine metabolism. The concentrations of retinol, thiamin, pyridoxal 5'-phosphate serum folate and vitamin B12 decreased during pregnancy. In contrast, the concentrations of riboflavin, alpha-tocopherol, and folate in erythrocytes increased or showed only minor changes. Homocysteine concentrations also remained approximately constant during pregnancy. These observations emphasize the importance of preconceptional and post-partum concentrations of vitamins in the evaluation of pregnancy-induced changes. These data have provided valuable reference values for vitamins and homocysteine before, during and after pregnancy in order to contribute to better diagnosis of maternal deficiencies and to study further the relationship between maternal vitamin status and adverse course and outcome of pregnancy.

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OBJECTIVE: Assessment of anxiety levels in women and men before and after preconception counseling and during the first trimester of pregnancy. METHODS: Couples were recruited from the fertility clinic of the University Medical Center Nijmegen, the Netherlands. Anxiety was assessed using the 40-item Spielberger State-Trait Anxiety Inventory (STAI). RESULTS: 53 women and 51 men (74%) completed the STAI both before and after counseling. Anxiety levels did not change significantly after counseling or during the first trimester of pregnancy. 83.4% would recommend preconception counseling to others. CONCLUSION: Preconception counseling is valued by the majority of women and men and does not lead to adverse psychological effects.

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OBJECTIVE: To compare the endocrine changes in the follicular phase in infertile patients with polycystic ovary syndrome (PCOS) treated with either pulsatile IV GnRH after GnRH-agonist (GnRH-a) down-regulation or clomiphene citrate (CC). DESIGN: Subgroup analysis within a randomized, controlled, multicenter study. SETTING: Women referred to the Infertility Clinic, Catharina Hospital Eindhoven, The Netherlands. PATIENT(S): Twenty-eight infertile patients with PCOS. INTERVENTIONs): Patients were randomly assigned to pulsatile IV GnRH (10-20 microgram/90 min) after GnRH-a down-regulation or CC (50-150 mg; cycle days 3-7). Patients were monitored on alternate days with ovarian sonography and serum concentrations of E(2), LH, and FSH. Serum P and sonography confirmed ovulation. MAIN OUTCOME MEASURE(S): Serum concentrations of E(2), LH, and FSH were assessed before treatment was started and after each ovarian sonography. RESULT(S): In ovulatory cycles, no statistically significant differences were observed during the follicular phase comparing serum concentrations of E(2), LH, and FSH between the treatments. However, a significant increase in LH occurred in the GnRH group. CONCLUSION(S): No significant endocrine differences were observed between GnRH and CC treatment. However, there was a significant increase in the serum LH concentration during the follicular phase in the GnRH group. Increments of LH in the GnRH group may be due to recovery of endogenous LH secretion.

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OBJECTIVE: To assess the awareness, opinions on desirability and preconditions such as special knowledge with regard to the concept of preconceptional health counselling among general practitioners. DESIGN: Descriptive. SETTING: General practices in the Groot Gelre district of the Dutch General Practitioners Society. METHOD: A representative sample of 100 general practitioners were asked by phone for permission to send a questionnaire; 89 out of the 94 general practitioners who were sent a questionnaire replied (response: 89%). RESULTS: Almost all general practitioners (88%) knew about the concept of preconceptional health counselling and most of them already gave some kind of preconceptional advice. 93% considered preconceptional health counselling part of their job responsibility and 91% were prepared to give more preconceptional health care in the future. 53% of all general practitioners, however, indicated that they lacked sufficient knowledge to give adequate advice. The advantages of preconceptional health care were considered to outweigh possible disadvantages such as medicalization of pregnancy. CONCLUSION: The general practitioners knew about preconceptional health care and considered it part of their job. Many already provided preconceptional health care, although not in a structured way. General practitioners appeared to lack time and appropriate knowledge, which indicates a need for postgraduate training.

PIP: In April and May 1997, a total of 100 general practitioners (GPs) in the Groot Gelre district of the Dutch General Practitioners Society were surveyed by phone for permission to send a questionnaire. 89 of 94 GPs who were sent a questionnaire replied, yielding a response rate of 89%. 78 of 89 GPs (88%) knew about the concept of pre-pregnancy health (PH) counseling and most of them already gave some kind of preconceptional advice (98% about folic acid, 93% about smoking, 88% about alcohol, 94% about various other substances, and 73% about the prevention of infections--toxoplasmosis, rubella). 87% of GPs questioned the patients about hereditary/congenital diseases that the child might inherit, 76% about hereditary diseases in the family, and 62% about diabetes. Less frequently occurring hereditary diseases were much less often asked about, such as Huntington's disease (14%), cystic fibrosis (19%), and hemophilia (14%). If the woman expressed the desire to have a child, 25% of GPs took an expanded case history. If a GP indicated a risk factor with regard to a potential pregnancy, 75% of them identified the possible consequences and informed the patient about them. 93% considered PH counseling part of their job responsibility and 91% were prepared to provide more PH care in the future. 53% of all GPs, however, indicated that they lacked sufficient knowledge to give adequate advice. The advantages of PH care were considered to outweigh possible disadvantages, such as medicalization of pregnancy, according to 74% of GPs. GPs appeared to lack time and appropriate knowledge, which indicates a need for postgraduate training.

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Endosonography (ES) was used for the preoperative TNM (1987) staging of tumors in 43 patients with pancreatic cancer and 24 patients with ampullary carcinomas. These results were correlated with the histologic findings of resected specimens. Early-stage tumors could be distinguished from advanced stages of cancer with ES. Detailed images of ductular and parenchymal abnormalities allowed distinction between pancreatic and ampullary carcinomas based on anatomic location. The overall accuracy of ES in the assessment of tumor classification in pancreatic and ampullary carcinoma was 92% and 88%, respectively. In diagnosing regional lymph nodes in pancreatic and ampullary tumors the accuracy of ES was 74% and 54%, respectively. For diagnosing metastatic lymph nodes in pancreatic and ampullary carcinoma the accuracy of ES was 91% and 80%, respectively. The prevalence of lymph node metastases in T1 pancreatic cancers and T1 ampullary carcinomas was 40% and 0%, respectively. Discrimination between inflammation and metastases was difficult with ES. ES was not accurate in assessing distant metastases because of the limited penetration depth of ultrasound.

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Prospectively, 72 patients with a gastric carcinoma were studied endosonographically before surgery. The results were correlated with those obtained with the histology of resected specimens according to the new (1987) TNM classification. Endoscopic ultrasonography (EUS) was accurate in assessing the extent and depth of tumor infiltration. Early gastric carcinoma could readily be distinguished from advanced carcinoma. The overall accuracy of EUS was 84.7%. Occasionally, overstaging and understaging occurred. Stenosis was a factor limiting accurate staging. EUS was reasonably accurate in the assessment of lymph node metastasis. The overall accuracy was 81.0%. In non-metastatic lymph nodes, however, the accuracy was only 50%. Difficulties occurred in distinguishing granulomatous lymph nodes and small micrometastatic lymph node involvement. EUS was not accurate in diagnosing distant metastasis, due to the limited depth of penetration of ultrasound. Technical improvements such as a reduction in the diameter of the echoprobe, and the use of the biopsy channel for EUS-guided cytological puncture will further enhance the accuracy of EUS.

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