Application of a Proposed Algorithm to Cesarean Deliveries for Nonreassuring Fetal Heart Rate Tracing.

OBJECTIVES: The aim of the study is to evaluate how current management of Category II fetal heart rate tracings compares with that suggested by a published algorithm and whether these differences lead to disparate neonatal outcomes. STUDY DESIGN: This is a retrospective observational study from the resident service at an academic-community tertiary care center from 2013 to 2018. We reviewed archived fetal heart rate tracings from patients with cesarean delivery performed for nonreassuring fetal heart rate tracing and interpreted tracings against the algorithm. We assigned tracings to one of three categories: Group A-consistent; Group B-inconsistent too early (algorithm permits the patient to labor longer); Group C-inconsistent too late (algorithm suggests performing the cesarean delivery sooner). Maternal demographics, features of labor, and neonatal outcomes were compared. RESULTS: Of the 110 cases, 27 (24.5%) had a cesarean delivery performed in group A, 49 (44.5%) in group B, and 34 (30.9%) in group C. Baseline characteristics were similar. Of the 49 in group B, 46 (93.9%) violated the algorithm at the same branchpoint. In group C, cesarean deliveries would have been performed on average 244 minutes earlier had the algorithm been used. Neonatal outcomes were not significantly different among the groups, including 5-minute Apgar <7, pH <7.1, and NICU admit. CONCLUSION: Our retrospective application of the algorithm showed that 44.5% of patients who have cesarean delivery for nonreassuring fetal heart rate tracing may be able to labor longer and that violation at a common decision point on the algorithm (moderate variability or accelerations, but a lack of recurrent decelerations) is responsible for nearly all such cesarean deliveries. More studies are needed to evaluate if cesarean delivery rates for nonreassuring fetal heart rate tracing can be reduced without impacting neonatal outcomes using the algorithm. KEY POINTS: · There is a potential to further standardize management of Category II fetal heart rate tracings.. · In our practice, 25% of cesareans performed for fetal distress were consistent with the algorithm.. · A subset of patients (45%) with cesarean for fetal distress may have been able to labor longer..

Mapping spatial approximations between the amino terminus of secretin and each of the extracellular loops of its receptor using cysteine trapping.

While it is evident that the carboxyl-terminal region of natural peptide ligands bind to the amino-terminal domain of class B GPCRs, how their biologically critical amino-terminal regions dock to the receptor is unclear. We utilize cysteine trapping to systematically explore spatial approximations among residues in the first five positions of secretin and in every position within the receptor extracellular loops (ECLs). Only Cys(2) and Cys(5) secretin analogues exhibited full activity and retained moderate binding affinity (IC(50): 92±4 and 83±1 nM, respectively). When these peptides probed 61 human secretin receptor cysteine-replacement mutants, a broad network of receptor residues could form disulfide bonds consistent with a dynamic ligand-receptor interface. Two distinct patterns of disulfide bond formation were observed: Cys(2) predominantly labeled residues in the amino terminus of ECL2 and ECL3 (relative labeling intensity: Ser(340), 94±7%; Pro(341), 84±9%; Phe(258), 73±5%; Trp(274) 62±8%), and Cys(5) labeled those in the carboxyl terminus of ECL2 and ECL3 (Gln(348), 100%; Ile(347), 73±12%; Glu(342), 59±10%; Phe(351), 58±11%). These constraints were utilized in molecular modeling, providing improved understanding of the structure of the transmembrane bundle and interconnecting loops, the orientation between receptor domains, and the molecular basis of ligand docking. Key spatial approximations between peptide and receptor predicted by this model (H(1)-W(274), D(3)-N(268), G(4)-F(258)) were supported by mutagenesis and residue-residue complementation studies.

ERα/ERß-directed CBS transcription mediates E2ß-stimulated hUAEC H2S production.

Elevated endogenous estrogens stimulate human uterine artery endothelial cell (hUAEC) hydrogen sulfide (H2S) production by selectively upregulating the expression of H2S synthesizing enzyme cystathionine ß-synthase (CBS), but the underlying mechanisms are underdetermined. We hypothesized that CBS transcription mediates estrogen-stimulated pregnancy-dependent hUAEC H2S production. Estradiol-17ß (E2ß) stimulated CBS but not cystathionine γ-lyase (CSE) expression in pregnant human uterine artery ex vivo, which was attenuated by the estrogen receptor (ER) antagonist ICI 182,780. E2ß stimulated CBS mRNA/protein and H2S production in primary hUAEC from nonpregnant and pregnant women, but with greater responses in pregnant state; all were blocked by ICI 182,780. Human CBS promoter contains multiple estrogen-responsive elements (EREs), including one ERE preferentially binding ERα (αERE) and three EREs preferentially binding ERß (ßERE), and one full ERE (α/ßERE) and one half ERE (½α/ßERE) binding both ERα and ERß. Luciferase assays using reporter genes driven by human CBS promoter with a series of 5'-deletions identified the α/ßEREs binding both ERα and ERß (α/ßERE and ½α/ßERE) to be important for baseline and E2ß-stimulated CBS promoter activation. E2ß stimulated ERα/ERß heterodimerization by recruiting ERα to α/ßEREs and ßERE, and ERß to ßERE, α/ßEREs, and αERE. ERα or ERß agonist alone trans-activated CBS promoter, stimulated CBS mRNA/protein and H2S production to levels comparable to that of E2ß-stimulated, while ERα or ERß antagonist alone abrogated E2ß-stimulated responses. E2ß did not change human CSE promoter activity and CSE mRNA/protein in hUAEC. Altogether, estrogen-stimulated pregnancy-dependent hUAEC H2S production occurs by selectively upregulating CBS expression via ERα/ERß-directed gene transcription.

Antepartum vaginal bleeding: characteristics associated with delivery within seven days.

Objective: To identify maternal and/or fetal characteristics associated with delivery within seven days for patients who present with vaginal bleeding in the antepartum period.Methods: This is a retrospective chart review performed at a community-academic tertiary care center. Three hundred and twenty-two consecutive charts associated with admission for vaginal bleeding during pregnancy between January 2015 and May 2020 were reviewed. One hundred and twenty-six women were included based on singleton gestation, gestational age 24 0/7 - 36 6/7 weeks, self-limited vaginal bleeding, vital sign stability (blood pressure >100/60 mmHg, heart rate >60 beats per minute, respiratory rate <20 breaths per minute), absence of signs of labor, no known placenta previa/accreta, recent vaginal intercourse, or trauma. Patient demographic and clinical characteristics were compared using Fisher's exact and two-sample t-tests tests when appropriate. Univariate and multivariate logistic regression models were fitted to predict delivery within 7 days.Results: Thirty-four percent of women who presented with light vaginal bleeding delivered within seven days, with a mean of 2.6 days (n = 44/126). Patients without evidence of labor but with sterile vaginal exam (SVE) >2 cm on admission were 14 times more likely to deliver within 7 days than SVE ≤ 2 cm (AOR 14.49, 95% CI 3.33-63.03); however, 35.2% of women with SVE ≤ 2 cm still delivered in this timeframe (n = 12/34). Of the 59 patients who had cervical lengths (CL) performed, those with CL ≤2.5 cm were 4.22 times more likely to deliver within 7 days (OR 4.22, 95% CI 1.10-16.20). Seventy-eight percent of the patients who had CL >2.5 cm and SVE 0-1 cm went on to deliver >14 days from their initial bleeds (n = 18/23).Conclusion: Patients who present with self-limited vaginal bleeding and SVE > 2 cm should be admitted for antenatal steroids. Prolonged inpatient observation beyond the typical steroid window of 48-72 h should be dependent on the individual patient. Given that CL ≤2.5 cm and regular contractions are known risk factors for preterm delivery, these characteristics alone may also warrant extended inpatient observation, though even in conjunction with vaginal bleeding, neither was a significant predictor for delivery in our study. In contrast, the majority of patients with vaginal bleeding and SVE <2 cm delivered >14 days after their initial bleeds and are likely eligible for shorter periods of observation.

Profile of Reported Alcohol, Tobacco, and Recreational Drug Use in Nulliparous Women.

OBJECTIVE: To estimate alcohol, tobacco, and recreational drug use during pregnancy among nulliparous women. METHODS: In a cohort of nulliparous women followed through pregnancy from the first-trimester nuMoM2b (Nulliparous Outcomes in Pregnancy: Monitoring Mothers to be) study, self-reported use of alcohol, tobacco, and drugs was chronicled longitudinally at four study visits in this secondary analysis. Rates of use before pregnancy, in each trimester (visit 1, visit 2, visit 3, approximating each trimester), and at the time of delivery (visit 4) were recorded. The amount of alcohol, tobacco, and drug exposure were recorded using validated measures, and trends across pregnancy were analyzed. RESULTS: Of the 10,038 study participants, 10,028 had information regarding alcohol, tobacco, and drug use at visit 1, 9,412 at visit 2, 9,217 at visit 3, and 7,167 at visit 4. The rates of drinking alcohol, which had been 64.6% in the 3 months before pregnancy, were lower in pregnancy (3.9% at visit 1, 5.6% at visit 2, 7.0% at visit 3, and 6.1% at visit 4, P<.001 for all). Rates later in pregnancy were all greater than in the first trimester (P<.01). The rate of smoking in the 3 months before pregnancy, which was 17.8%, also declined at visit 1 (5.9%), and continued to decline through pregnancy (5.3% at visit 2, 4.7% at visit 3, and 3.9% at visit 4, with all rates lower than that of visit 1 [P<.01]). Although recreational drug use was relatively common in the months before pregnancy (33.8%), it also declined during pregnancy (1.1% at visit 2, 0.7% at visit 3, 0.4% at visit 4). CONCLUSIONS: In this geographically and ethnically diverse cohort of nulliparous women, rates of self-reported alcohol, smoking, and recreational drug use were all significantly lower during than before pregnancy. Nonetheless, rates of alcohol use rose as pregnancy progressed, highlighting the need for continued counseling throughout all trimesters of pregnancy. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT01322529.

Direct inhibition of hypoxia-inducible transcription factor complex with designed dimeric epidithiodiketopiperazine.

Selective blockade of hypoxia-inducible gene expression by designed small molecules would prove valuable in suppressing tumor angiogenesis, metastasis and altered energy metabolism. We report the design, synthesis, and biological evaluation of a dimeric epidithiodiketopiperazine (ETP) small molecule transcriptional antagonist targeting the interaction of the p300/CBP coactivator with the transcription factor HIF-1alpha. Our results indicate that disrupting this interaction results in rapid downregulation of hypoxia-inducible genes critical for cancer progression. The observed effects are compound-specific and dose-dependent. Controlling gene expression with designed small molecules targeting the transcription factor-coactivator interface may represent a new approach for arresting tumor growth.