Use of abnormalities in the Friedman curve as a predictor of operative delivery in macrosomic babies.

OBJECTIVE: To assess the use of the Friedman labor curve as a predictor of operative delivery in macrosomic pregnancies. STUDY DESIGN: Medical records of 1141 patients who had delivered babies > or =4000 gm (group 1) were reviewed and were compared with the results of the next mother who delivered a neonate with birth weight <4000 gm (group 2). The variables studied were progress of labor as denoted on the Friedman curve, oxytocin use, and need for operative delivery. RESULTS: In the 1141 patients with neonatal birth weights > or =4000 gm, there was a trend toward a longer second stage, arrest disorder, and operative delivery but this did not reach statistical significance. CONCLUSION: Abnormalities in the Friedman curve were not useful as a predictor for operative delivery in pregnancies complicated by fetal macrosomia. There were no statistically significant differences between the two groups in terms of the variables studied.

Amniotic fluid granulocyte colony stimulating factor levels: a rapid marker for diagnosing chorioamnionitis.

PROBLEM: To assess the usefulness of amniotic fluid (AF) granulocyte colony stimulating factor (G-CSF) levels as a rapid marker for diagnosing chorioamnionitis. METHOD OF STUDY: AF levels were obtained from term and preterm patients with and without chorioamnionitis (CAM). Patients with urinary tract, respiratory tract, and other infections were excluded. Results obtained from the AF G-CSF assays were compared with those from other parameters used for diagnosing CAM: maternal fever, leukocytosis, tachycardia, fetal tachycardia, AF glucose levels, white blood cell count, Gram stain, and aerobic and anaerobic cultures. The sensitivity, specificity, and predictive values were calculated. RESULTS: In the uninfected AF samples, G-CSF levels were present but low, ranging from 400 to 1600 pg/ml. Levels in the infected samples, however, were markedly increased, ranging from 1600 to 14,000 pg/ml; P < 0.05. When a cutoff of 2000 pg/ml was used as a clear marker for CAM, the sensitivity was 67%, the specificity was 100%, and the positive and negative predictive values were 100% and 86%, respectively. The comparison of the other AF G-CSF laboratory parameters also revealed high sensitivity, specificity, and predictive values for detecting CAM. CONCLUSION: (i) AF G-CSF levels are elevated in CAM. (ii) An AF G-CSF level > 2000 pg/ ml is a strong positive predictor of CAM. (iii) Elevated AF G-CSF levels appear to be more reliable in predicting CAM than any other single test currently used in clinical practice.

Amniotic fluid granulocyte colony stimulating factor levels in chorioamnionitis do not predict neonatal sepsis.

PROBLEM: To assess the usefulness of amniotic fluid (AF) granulocyte colony-stimulating factor levels (G-CSF) in chorioamnionitis (CAM) to predict neonatal sepsis. METHOD OF STUDY: AF samples were obtained from term and preterm patients with (Group I) and without (Group II) CAM and were assayed for G-CSF levels. Patients with other infections were excluded. All AF samples were also tested for gram stain and cultures. The sensitivity, specificity, and predictive values of these parameters for diagnosing neonatal sepsis were assessed. RESULTS: Positive AF cultures were the best predictors of neonatal sepsis in CAM, with a sensitivity of 67% and a positive predictive value (PPV) of 80%. Elevated AF G-CSF levels (> 1,000 pg/ml) were poor predictors of neonatal sepsis with a sensitivity of 29% and PPV of 39%. CONCLUSION: Even though AF G-CSF levels were markedly elevated in patients with CAM, they were poor predictors of subsequent neonatal sepsis.

Correlation between maximum cervical dilatation at cesarean delivery and subsequent vaginal birth after cesarean delivery.

OBJECTIVE: To determine whether the extent of cervical dilatation at cesarean delivery affects the subsequent vaginal birth after cesarean (VBAC) rate. METHODS: Relevant records of the index pregnancy (group I) were reviewed for cervical dilatation at cesarean delivery, oxytocin use, indication, neonatal weight, and epidural use. The records of the subsequent pregnancy (group II) were reviewed for successful VBAC rates, neonatal weight, oxytocin, and epidural use. RESULTS: There were 1917 patients in the study. The indications for cesarean in group I were malpresentation (5.1%), fetal distress (14.9%), and arrest disorders (80%). In group II, the VBAC success rates were 73% for previous malpresentation and 68% for previous fetal distress. In those with previous cesarean deliveries for arrest disorders with cervical dilatation at 5 cm or less, the VBAC success rate was 67%. It was 73% for 6-9 cm dilatation and 13% for the fully dilated group (P < .05). CONCLUSIONS: Patients who attempt a VBAC may be counseled that a cesarean delivery at full dilatation is associated with a reduced chance of a subsequent successful VBAC.

Identification of restriction barriers in Pasteurella multocida.

Several naturally occurring antibiotic resistance plasmids were isolated from Pasteurella multocida type D strains. One plasmid, pPM1, was used to study transfer of DNA among P. multocida strains, and could be transferred into Escherichia coli and some P. multocida isolates. However, pPM1 could only be transferred into the toxigenic P. multocida LFB3 at very low frequency. Plasmid recovered from the electrotransformants could be transferred to LFB3 at high frequency. These plasmid DNAs were resistant to PstI, and sensitive to DpnI digestion. Sensitivity to DpnI was common to all the P. multocida DNAs, but resistance to PstI was confined to LFB3. Plasmid pPM1 treated with PstI methylase was able to transform LFB3 at an increased frequency compared to unmethylated DNA, suggesting that LFB3 has a restriction system which cleaves at or near PstI sites.

Constitutive expression of Pasteurella multocida toxin.

The expression of the Pasteurella multocida toxin (PMT) gene toxA was investigated. Growth in vitro at 30 degrees C or added iron caused less than 4-fold repression of toxA expression. The putative repressor TxaR was expressed in Escherichia coli but deletion and frameshift mutations abolishing TxaR production had no effect on toxA expression. Naturally occurring non-toxigenic mutants which contained the toxA gene had no large rearrangements near toxA or changes in toxA promoter structure. Thus PMT is constitutively expressed and is only regulated in a minor way.

Expression of the 3-phosphoglycerate kinase gene (pgkA) of Penicillium chrysogenum.

The sequence of the Penicillium chrysogenum pgkA gene promoter was determined up to 952 nucleotides (nt) 5' to the major transcriptional start point (position +1), and contains a 38 bp pyrimidine-rich region within which transcription initiates at this and two minor sites (-11, -23). A 21 bp segment (-99 to -79) closely matches a region which is essential for the expression of the Aspergillus nidulans pgkA gene. A further region was found with similarity to sequences in other A. nidulans promoters possibly effecting response to carbon source. The terminator region of the P. chrysogenum pgkA gene was sequenced as far as 192 nt 3' to the stop codon and three polyadenylation sites were found at 94, 103 and 107 nt from this point, the first preceded by a possible polyadenylation signal. No transcription termination signal was found but several regions potentially forming stem-loop-structures were noted. A single 1.3 kb pgkA mRNA was readily detected by Northern blot analysis of total cellular RNA. Steady-state levels of pgkA mRNA were 1.5 to 2.0 times greater in mycelium harvested at similar stages of growth from medium containing the carbon sources acetate or quinate compared to glucose. A transformed strain of P. chrysogenum containing a fusion of the pgkA promoter to the Escherichia coli lacZ reporter gene integrated at the oliC locus was constructed, and beta-galactosidase activity monitored during growth of batch cultures in defined media. The pgkA promoter activity increased during exponential growth and was 2-3 times greater and increased most rapidly in mycelium grown on quinate or acetate compared to glucose.(ABSTRACT TRUNCATED AT 250 WORDS)

Fetal cardiac effects of oral ritodrine tocolysis.

The beta-sympathomimetic oral tocolytic ritodrine can cause maternal tachycardia and hypotension, and may cross the placenta. A new echocardiographic technique has been developed to explore fetal and placental ritodrine effects. Values in 76 healthy historic controls were compared to 18 studies in 16 patients performed while receiving stable oral ritodrine therapy, measured both at baseline and 30 minutes after a dose. Data collected included maternal pulse and blood pressure (BP), fetal cerebral and umbilical Doppler waveforms, and fetal heart rate. A new index of fetal myocardial contractility, combined ventricular shortening fraction, was derived from two-dimensionally directed M-mode. Maternal pulse and BP, fetal heart rate and heart size, and all Doppler indices were normal, without demonstrable dose-response effects. In the control subjects, combined ventricular shortening fraction fell with increasing gestational age (combined ventricular shortening fraction = -0.27 estimated gestational age + 49; r = 0.27; P < or = 0.02; standard error of the estimate, 11%). However, combined ventricular shortening fraction in ritodrine patients was abnormally decreased in 72% of cases. The mean index in normal subjects was 43 +/- 5%, but in ritodrine patients it was only 31%. We conclude that a history of premature labor or oral ritodrine, or both, is associated with reduced shortening fraction. Since there was no change in placental resistance, cerebral hypoxia, fetal heart rate, or heart size (preload), then low shortening fraction may be due to increased fetal systemic vascular resistance (BP) or decreased myocardial contractility.

Ex vivo expansion of cord blood-derived stem cells and progenitors.

Cord blood-derived CD34+ cells have proved superior to adult marrow or elicited peripheral blood in ex vivo cell and progenitor expansion. In addition, cord blood-derived cells with a phenotype and function of early stem cells (e.g., long-term culture-initiating cells) can be expanded in vitro in the presence of a combination of cytokines by 15- to 20-fold over 7-14 days. These observations suggest that ex vivo expansion of cord blood CD34+ cells will permit improved engraftment of adults and will prove effective in retroviral-mediated gene transfection of early stem cell populations.

First trimester disulfiram exposure: report of two cases.

Disulfiram has been used effectively to deter alcohol consumption in patients with a history of alcohol abuse. Its use in reproductive age women has become increasingly common in recent years, intensifying the risk of fetal exposure. Nonspecific but significant abnormalities have been described in the infants of women treated with disulfiram in the first trimester of their pregnancies. Based on these data, authors have previously exposure is confirmed despite a lack of any pattern to the defects reported. We report the outcomes of two pregnancies with first trimester disulfiram exposure. In both cases, the timing and dose of disulfiram was known. In one case, disulfiram was the only potential teratogen exposed to the fetus. Both neonates were normal at birth and have shown subsequent normal development. This report suggests that the poor prognosis previously given to fetuses exposed to disulfiram in the first trimester may not be warranted.

Use of esterase inhibitors and zone electrophoresis to define bacterial esterases in amniotic fluid.

OBJECTIVE: The purpose of our study was to define further the role of bacterial esterases in amniotic fluid obtained from women with chorioamnionitis. STUDY DESIGN: Amniotic fluid samples from 39 patients with chorioamnionitis were submitted for bacterial cultures and in vitro assay. Esterase inhibitors diisopropyl fluorophosphate and iodoacetic acid were added and the degree of inhibition calculated. These results were compared with the amniotic fluid culture results. Chi square analysis was performed to compare the results of the esterase assay and the inhibition assay between the uninfected and infected amniotic fluid samples. RESULTS: Thirty-one patients had positive bacterial cultures, with 21 being infected with gram-negative organisms. All samples showed significant inhibition (range 55% to 82%) with diisopropyl fluorophosphate. There was partial inhibition with iodoacetic acid (range 10% to 30%) in the gram-negative samples but no inhibition in the gram-positive and uninfected samples. Six infected and two uninfected samples were analyzed by using zone electrophoresis with human plasma as a control. Minimal esterase motility was noted in the amniotic fluid samples as compared with that in plasma. CONCLUSION: The esterases in amniotic fluid appeared to be of bacterial, not human, origin. Furthermore, different groups of bacteria appeared to produce different esterases in infected amniotic fluid.

Amniotic fluid index: correlation with amniotic fluid volume.

We calculated the amniotic fluid indexes (AFIs) of 310 women on 459 occasions. Normative data were analyzed and compared with data in several high-risk groups. In the normal gestations there was a progressive increase in AFI with advancing gestation until 32 weeks, after which there was a decline. The mean AFIs in abnormal gestations varied with the clinical diagnoses. These values were compared to those obtained by assessing amniotic fluid volume (AFV), that is a pocket more than 2 cm. There were 51 patients with abnormal AFVs. Forty-two had decreased fluid, six also had decreased AFIs; nine had increased AFVs and five (all with diabetes) also had increased AFIs. Thus, AFIs in normal pregnancies showed an orderly pattern of change with gestational age, and there was no accurate correlation between AFI and AFV. Thus, using AFV alone may lead to false interpretations of amniotic fluid status.

Surgical treatment of incompetent cervix.

A comparison of multiple factors in the surgical management of cervical incompetence was carried out in 114 procedures. Factors examined included training level of the operator, gestational age, cervical effacement and dilation at the time of operation, diagnostic evaluation, Shirodkar or McDonald procedure, year of the procedure, and tocolytic therapy. The endpoint for successful outcome was defined as 37 weeks or newborn weighing over 2500 gm rather than neonatal survival, thus differing from previous studies. All patients were delivered vaginally unless there was an obstetric indication for cesarean delivery. The most important determinants of a term birth in patients with incompetent cervix were operator experience and the use of a Shirodkar procedure.

Developmental pattern of muscarinic receptors in normal and Down's syndrome fetal brain--an autoradiographic study.

The ontogeny of muscarinic cholinergic receptors in developing human brain was analyzed by in vitro receptor autoradiography with [3H]Quinuclidinyl Benzilate. It was found that muscarinic receptors develop relatively early; the levels at 24 weeks of gestation were comparable or even higher then the values in the adult brain, and that the levels of both M1 and M2 receptors increase with age. M1 receptors were concentrated mainly in forebrain regions while M2 receptors dominated in the thalamus. Scatchard analysis revealed Kd and Bmax values which are comparable to the adult values. Three brains of aborted Down's syndrome fetuses were examined in parallel and exhibited comparable levels and similar distribution to normal non-Down fetuses except for a modest increase of receptor levels which was observed in the striatum.

Variable decelerations in reactive nonstress tests with decreased amniotic fluid index predict fetal compromise.

A total of 3158 patients at greater than or equal to 34 weeks' gestation undergoing nonstress tests and amniotic fluid index determinations were divided into six groups according to the amniotic fluid index and the nature of the decelerations. Fetuses with antepartum decelerations had statistically significantly increased incidences of intrapartum decelerations and operative deliveries because of intrapartum "distress," regardless of the amniotic fluid index. They also had significantly increased rates of neonatal acidosis and low Apgar scores when there were "severe" decelerations and an amniotic fluid index less than 5 in the antepartum period. Thus spontaneous decelerations in reactive nonstress tests with an amniotic fluid index less than 5 may predict fetal compromise.