Obstetric clavicular fracture: the enigma of normal birth.

OBJECTIVE: To determine the main risk factors involved in neonatal clavicular fracture, the most common injury to the neonate. METHODS: Two hundred fifteen cases of clavicular fracture of 65,091 vaginal deliveries (0.4%) occurring between January 1983 and December 1988 were pair-matched with controls based on mode and date of delivery, race, and maternal age. Incidences, odds ratios, and stratified analysis were used to identify and control for confounding between risk factors. RESULTS: Shoulder dystocia, increasing birth weight, and increasing gestational age were identified as risk factors. Within the range of normal birth weights, there is a biologic gradient of increasing risk for clavicular fracture. Although shoulder dystocia is the strongest risk factor identified, the magnitude of its point estimate is probably affected to a large extent by differential ascertainment. The use of forceps, prolonged second stage of labor, and nulliparity status were not significantly associated with neonatal clavicular fracture. CONCLUSIONS: Neonatal clavicular fracture occurs commonly in an obstetric population. Obstetric clavicular fracture is an unpredictable, unavoidable complication of normal birth.

The correlation between transperineal sonography and digital examination in the evaluation of the third-trimester cervix.

OBJECTIVE: To determine the correlation between transperineal or translabial ultrasound and digital examination of the cervix in the third trimester in women presenting to the obstetrical triage area complaining of uterine contractions and/or rupture of membranes. METHOD: One hundred women were evaluated initially with an ultrasound unit using a 5-MHz glove-covered curvilinear transducer applied to the perineum in the sagittal plane. Immediately after the ultrasound evaluation, another examiner assessed the cervix digitally, blinded to the sonographic results. Cervical dilatation, length, and station were assessed. RESULTS: Transperineal ultrasound correlated (P < .001) with digital cervical examination in the assessment of dilatation (Pearson correlation coefficient 0.87), length (Pearson correlation coefficient 0.80), and corrected station (Pearson correlation coefficient 0.69). CONCLUSION: There is a statistically significant correlation between the digital cervical examination and the sonographic assessment of cervical dilatation, length, and station by the transperineal approach.

Markers of acute and chronic asphyxia in infants with meconium-stained amniotic fluid.

OBJECTIVE: Cord blood pH, lactate, hypoxanthine, and erythropoietin levels have all been used as markers of either acute or chronic asphyxia. We sought to determine whether these index values were significantly different in infants with or without meconium-stained amniotic fluid. STUDY DESIGN: Fifty-six pregnant women in spontaneous labor at term were divided into two groups on the basis of the presence or absence of meconium-stained amniotic fluid. All meconium-stained fluid was centrifuged, and the volume percentage of particulate matter (i.e., meconium) was recorded. Umbilical artery blood and mixed arterial and venous cord blood were obtained at each delivery. Lactate, hypoxanthine, and erythropoietin levels were measured. Statistical analysis included Student t test and rank sum statistics where appropriate. Normal and Spearman correlation coefficients were also used. RESULTS: There were no significant differences in mean umbilical artery pH (7.26 +/- 0.06 vs 7.25 +/- 0.10), lactate levels (32.8 +/- 10 mg/dl vs 30.4 +/- 14.2 mg/dl), and hypoxanthine levels (13.4 +/- 6.7 mumol/L vs 14.0 +/- 6.0 mumol/L) in newborns with meconium (n = 28) compared with controls (n = 28). Erythropoietin levels were significantly greater in newborns with meconium (median 39.5 mIU/ml vs 26.8 mIU/ml, p = 0.039). There was no correlation between the amount of particulate matter and any marker of asphyxia. CONCLUSIONS: There was no correlation between markers of acute asphyxia (i.e., umbilical artery blood pH, lactate, or hypoxanthine) and meconium. However, erythropoietin levels were significantly elevated in newborns with meconium-stained amniotic fluid. This latter marker may better correlate with chronic asphyxia.

Genital herpes during pregnancy: no lesions, no cesarean.

OBJECTIVE: To determine the effects at our hospital of adoption of the 1988 guidelines recommended by ACOG for management of genital herpes infections during pregnancy. METHODS: Between 1984-1986, 96 pregnancies complicated by active genital herpes were delivered at Parkland Hospital. The outcome of these pregnancies were compared with 217 similar pregnancies managed after implementation of the 1988 ACOG herpes guidelines. RESULTS: Adoption of the 1988 ACOG herpes guidelines resulted in a 37% decrease in the use of cesarean delivery for women with genital herpes infections at our hospital. Most of this decrease was because the new guidelines eliminated the need for a confirmatory negative herpes culture before permitting vaginal delivery. No neonatal herpes infections occurred as a result of implementing the ACOG recommendations. CONCLUSION: The rate of cesarean delivery for women with genital herpes infections during pregnancy declined significantly at our hospital as a result of the adoption of ACOG herpes guidelines, and there were no neonatal consequences, such as increased incidence of neonatal herpes simplex virus infection.

Fetal acidemia associated with regional anesthesia for elective cesarean delivery.

OBJECTIVE: To determine the prevalence, magnitude, and type of fetal acidemia associated with contemporary obstetric anesthetic techniques. METHODS: Umbilical artery blood gases were obtained in 1601 singleton pregnancies delivered by elective cesarean. RESULTS: General anesthesia was used in 371 (23%) women, epidural in 286 (18%), combined spinal-epidural in 659 (41%), and spinal in 231 (14%). Approximately 18% of infants exposed to regional anesthetics had umbilical artery blood pH values 7.19 or less, 42 (3%) infants had pH values less than 7.10, and nine (1%) had values 6.99 or less. The incidence of fetal acidemia was greater in spinal and combined spinal-epidural procedures compared to epidural anesthetics. Fetal acidemia was predominantly respiratory in type because carbon dioxide pressure was abnormally increased when fetal acidemia was diagnosed. CONCLUSIONS: Regional anesthesia is associated with fetal acidemia, occasionally severe, and has features of an acute respiratory type of acidemia. Fetal acidemia is less frequent with epidural anesthesia compared to subarachnoid techniques.

Evaluating the effects of elevated levels of atmospheric trace gases on herbs and shrubs: a prototype dual array field exposure system.

In the context of global climate change, an understanding of the long-term effects of increasing concentrations of atmospheric trace gases (carbon dioxide, CO(2), ozone, O(3), oxides of nitrogen, NO(x) etc.) on both cultivated and native vegetation is of utmost importance. Over the years, under field conditions, various trace gas-vegetation exposure methodologies with differing advantages and disadvantages have been used. Because of these variable criteria, with elevated O(3) or CO(2) levels, at the present time the approach of free-air experimental-release of the gas into study plots is attracting much attention. However, in the case of CO(2), this approach (using 15 m diameter study plot with a single circular array of vent pipes) has proven to be cost prohibitive (about 59000-98000 dollars/year/replicate) due to the consumption of significant quantities of the gas to perform the experiment (CO(2) level elevated to 400 ppm above the ambient). Therefore, in this paper, we present a new approach consisting of a dual, concentric exposure array of vertical risers or vent pipes. The purpose of the outer array (17 m diameter) is to vent ambient air outward and toward the incoming wind, thus providing an air curtain to reduce the velocity of that incoming wind to simulate the mode or the most frequently occurring wind speed at the study site. The inner array (15 m diameter) vents the required elevated levels of trace gases (CO(2), O(3), etc.) into the study plot. This dual array system is designed to provide spatial homogeneity (shown through diffusion modeling) of the desired trace-gas levels within the study plot and to also reduce its consumption. As an example, while in the single-array free-air CO(2)-release system the consumption of CO(2) to elevate its ambient concentration by 400 ppm is calculated to be about 980 tons/year/replicate, it is estimated that in the dual array system it would be approximately 590 tons/year/replicate. Thus, the dual array system may provide substantial cost savings (24000-39000 dollars/year/replicate) in the CO(2) consumption (60-100 dollars/ton of CO(2)) alone. Similarly, benefits in the requirements of other trace gases (O(3), NO(x), etc.) are expected, in future multivariate studies on global climate change.

Pneumonia complicating pregnancy.

OBJECTIVE: To determine the clinical course and perinatal outcomes of women with pneumonia complicating pregnancy. METHODS: Between 1989 and 1993, we admitted 71 pregnant women for treatment of community-acquired pneumonia. Exposure and outcome variables as well as characteristics of their clinical course were identified and analyzed. Two-sample Wilcoxon rank-sum and Fisher exact tests were used for statistical analyses. RESULTS: Five women had adverse pregnancy outcomes related to pneumonia: two maternal-fetal deaths, one preterm delivery, one fetal death, and one early abortion. Compared with women whose pregnancies went to term, these five women had a significantly lower mean oxygen pressure on admission (68 versus 83 mmHg). Other risk factors for adverse outcome included diffuse radiologic pulmonary involvement and current smoking of more than ten cigarettes per day. Neither illicit drug use nor anemia were risk factors. Although 31 of these 71 women had underlying chronic diseases, these were not associated with negative outcomes. CONCLUSIONS: Despite prompt hospitalization and treatment, antepartum pneumonia is potentially serious, even in young, otherwise healthy women. Although underlying maternal disease appears to be related to the development of antepartum pneumonia, we did not confirm previous reports that suggested its relation to adverse pregnancy outcome.

The transfer of the nucleoside analog ganciclovir across the perfused human placenta.

OBJECTIVE: The purpose of this study was to compare the maternal-fetal placental transfer of the antiviral nucleoside analog ganciclovir to that of acyclovir and to investigate the mechanism of transport. STUDY DESIGN: The ex vivo human placental cotyledon model was used. Carbon 14-labeled antipyrine was used as the reference compound to determine the clearance index of both antiviral agents. Dinitrobenzylthioinosine was used as a nucleoside transport inhibitor to help determine the transfer mechanism of each agent. RESULTS: The clearance index for ganciclovir was 0.17 +/- 0.08 and 0.20 +/- 0.10 at 1 and 10 micrograms/ml maternal concentrations. This was similar to the clearance index for acyclovir, which was 0.17 +/- 0.06 and 0.18 +/- 0.12, respectively. The clearance index for ganciclovir was not significantly affected by the addition of 5 mumol/L dinitrobenzylthionosine to the perfusate (0.25 +/- 0.09 vs 0.20 +/- 0.05). The same was true for acyclovir (0.29 +/- 0.06 vs 0.22 +/- 0.07). When the closed system and maternal ganciclovir concentrations of 1.0, 10.0, and 100 micrograms/ml were used, the percent fetal levels compared with maternal levels at 1 hour were 17.2%, 19.2%, and 17.3%, respectively. For acyclovir the fetal levels were 15.6%, 9.1%, and 8.9% compared with maternal levels. CONCLUSION: The antiviral agents ganciclovir and acyclovir appear to cross the placenta by simple diffusion, at least at therapeutic levels, and this transfer is not affected by the nucleoside transport inhibitor dinitrobenzylthioinosine.

Chorioamnionitis: association of nonreassuring fetal heart-rate patterns and interval from diagnosis to delivery on neonatal outcome.

OBJECTIVE: The purpose of this study was to determine whether selected fetal heart-rate (FHR) patterns and the interval from diagnosis to delivery in pregnancies complicated by chorioamnionitis could predict neonatal outcome. METHODS: During a 6-month period, 217 consecutive patients with acute chorioamnionitis were prospectively identified in labor. Following delivery, the fetal monitor strips and hospital courses were reviewed for both the mother and neonate. Multiple logistic regression was used to analyze the presence of a nonreassuring FHR pattern and the effect on neonatal outcome. Fisher exact tests were used to analyze the time intervals from the diagnosis of chorioamnionitis to delivery and their significance on neonatal outcome parameters. RESULTS: The overall incidence of chorioamnionitis in our population was 2.3%. None of the independent variables analyzed following the diagnosis of chorioamnionitis until delivery were significantly associated with an umbilical artery (Ua) pH < 7.20. There were no differences in cord pH, Apgar scores, sepsis, admission to special-care nursery, and oxygen requirements in neonates based on the duration of time from the diagnosis of chorioamnionitis to delivery in our study. None of the newborns had pathologic fetal acidemia (Ua pH < 7.00). None of the FHR patterns we identified after the diagnosis of acute chorioamnionitis were significantly associated with neonates with a Ua pH < 7.20. CONCLUSIONS: An interval from diagnosis to delivery of up to 12 h plays little if any role in neonatal outcome.

Physiological adjustment of two full-sib families of ponderosa pine to elevated CO(2).

Seeds from two full-sib families of ponderosa pine (Pinus ponderosa) with known differences in growth rates were germinated and grown in an ambient (350 micro l l(-1)) or elevated (700 micro l l(-1)) CO(2) concentration. Gas exchange at both ambient and elevated CO(2) concentrations was measured 1, 6, 39, and 112 days after the seed coat was shed. Initial stimulation of CO(2) exchange rate (CER) by elevated CO(2) was large (> 100%). On Day 1, CER of seedlings grown in elevated CO(2) and measured at ambient CO(2) was significantly lower than the CER of seedlings grown and measured at ambient CO(2), indicating physiological adjustment of the seedlings exposed to elevated CO(2). Physiological acclimation to elevated CO(2) was complete by Day 39 when there was no significant difference in CER between seedlings grown and measured at ambient CO(2) and seedlings grown and measured at elevated CO(2). After 4 months, the light response of seedlings in the two treatments was determined at both ambient and elevated CO(2). Light compensation point, CER at light saturation, and apparent quantum efficiency of seedlings grown and measured at ambient CO(2) were not significantly different from those of seedlings grown and measured at elevated CO(2). With a short-term increase in CO(2), CER at light saturation (5.16 +/- 0.52 versus 3.13 +/- 0.30 micro mol CO(2) m(-2) s(-1)) and apparent quantum efficiency (0.082 +/- 0.011 versus 0.045 +/- 0.003 micro mol CO(2) micro mol(-1) quanta) were significantly increased. Leaf C/N ratio was significantly increased in the elevated CO(2) treatment. There were few significant differences between families for any response to elevated CO(2). Under the experimental conditions, high growth rate was not correlated with a greater response to elevated CO(2).

pK1' and bicarbonate concentration in plasma.

Values for pK1' were determined from pH measured at 37 degrees C with three blood-gas analyzers and from calculated pco2 values in 443 freshly separated plasmas, tonometered at 37 degrees C. Plasma was taken from healthy volunteers, seriously ill patients, and hyponatremic patients. pK1' values varied by considerably more than 0.06 in healthy volunteers as well as in very ill patients, and bicarbonate concentrations ([HCO3]p) calculated by blood-gas analyzers based on the pK1' value of 6.1 could be in error by some +/- 60%. pK1' was similarly determined for tonometered (37 degrees C) replicate dilutions of plasma samples. By adding weighed amounts of dry NaCl and NaHCO3 to the diluted samples we increased the Na+ concentration to approximately 150 mmol/L and bicarbonate concentrations to values ranging from approximately 2.5 to approximately 52.5 mmol/L. pK1' values decreased when [HCO3]p was increased in dilutions of plasma kept at constant ionic strength. At any given [HCO3]p, pK1' values were higher at high than at low values of pco2.

In Situ Estimates of Variable Plant Resistance to Water Flux in Ilex opaca Ait.

Xylem pressure potentials and stomatal diffusion resistances were measured in the field in Ilex opaca Ait. during days which differed in temperature and vapor pressure deficit. Water flux into leaves was calculated by combining the field data with laboratory determinations of the relation between tissue water deficit and water potential. Estimates of apparent plant resistance were then calculated from fluxes and differences between soil water potential and xylem tension. The resistance depended strongly on water flux, dropping by a factor of over 7 from low to high water flow rates. This extends the generality of variable plant resistances measured in controlled environment studies to I. opaca as it occurs naturally in the field. The relation of apparent plant resistance to water flux as estimated in this study can be useful in simulation models which calculate water uptake to leaves as a flux driven by a difference in soil and leaf water potentials across a resistance between the bulk soil and the leaf.

Components of water potential estimated from xylem pressure measurements in five tree species.

Pressure volume curves were measured with a pressure bomb in leaves collected in the field from Ilex opaca, Acer rubrum, Liquidambar styraciflua, Liriodendron tulipifera and Cornus florida. Water potential components were calculated from the curves. The species differed in the relationships measured. In all species the trends from summer to fall were toward lower (more negative) osmotic potentials, lower matric potentials more rapid loss of turgor with increasing leaf water deficit, and the occurrence of incipient plasmolysis at lower values of leaf water deficit. Initial osmotic potentials ranged from-14.8 to-19.8 bars, similar to values reported in the literature for other mesophytic plants. These values, however, were much higher than those reported for halophytes and xerophytes. The fraction of leaf water which contributes to the osmotic potential ranged from 0.74 to 0.98 in this study. Values reported for other mesophytes and for halophytes and xerophytes all fall well within this range. Patterns of component water potentials are discussed in relation to potential growth rates and water flow in the total plant system.