Premature rupture of membranes and preterm labor: neonatal infection and perinatal mortality risks

The purpose of this study was to analyze neonatal infection rates and perinatal mortality in births complicated by premature rupture of membranes (PROM) and spontaneous labor before term (less than 37 weeks' gestation). Neonatal infection occurred more commonly in preterm compared with term infants. The risk of infection due solely to PROM was insignificant compared with the risk attributable to preterm birth. Perinatal mortality and cause-specific mortality varied inversely with gestational age. These rates were not significantly different between groups with or without PROM or with or without associated development of maternal endometritis. Although the mortality due to infection was higher in preterm compared with term groups, most preterm deaths were attributed to other factors, particularly anoxia and respiratory causes. The diverse fetal risks associated with PROM and the associated maternal infection risks analyzed support expectant management when PROM occurs preterm.

Gestational age assessment. II. Prediction from combined clinical observations

Accurate assessment of the estimated date of confinement is a cornerstone of obstetric care. In an earlier report, we examined the time of occurrence of various historical and clinical estimators of gestational age in relation to the date of delivery. We now examine the possibility of combining multiple clinical estimators to improve the prediction of delivery date. Formulas for predicting delivery date from multiple clinical estimators were developed in a group of 418 patients who were delivered of infants weighing greater than or equal to 3,000 gm, after spontaneous onset of labor. These formulas were tested in a separate group of 107 patients who fulfilled similar criteria. In patients with a known last menstrual period, additional clinical information did not improve the prediction of delivery date; however, if the last menstrual period was uncertain or unknown, averaging the predicted delivery dates by several clinical examinations provided a prediction of delivery date as precise as if the last menstrual period were known.

Premature rupture of the membranes and prolonged latency

The aim of this retrospective study in 8320 patients with premature rupture of the membranes (PROM) was to determine the consequences of prolongation of the latent period. Among patients with pregnancies of more than 37 weeks' duration, those with PROM and latent periods of more than 1 day demonstrated an increased incidence of intrapartum fever (IPF), whereas those with latent periods of more than 3 days demonstrated a marked increase in fetal (but not neonatal) deaths. Although IPF and perinatal mortality were more common in preterm pregnancies, neither was found to increase or decrease with prolonged latency, provided differences in gestational ages and race were taken into account. In the absence of chorioamnionitis, there appears to be no benefit to delivery before 37 weeks' gestation.

Limited wrist arthrodesis. Part II: Intercarpal and radiocarpal combinations

Fusion of selected bones of the carpus, occasionally combined with the radius or metacarpal bases, has been used to treat a wide variety of serious pathologic conditions of the wrist. Indications include severe localized degenerative arthritis and posttraumatic changes secondary to subluxation, dislocation, or residual instability resulting in significant pain. The procedure was performed on 28 wrists in 26 patients. There were three failures to obtain union initially, two of which united after secondary grafting procedures. All patients had less pain and most had functional, though limited, ranges of wrist motion. Limited wrist arthrodesis provides a workable alternative to complete wrist fusion and Silastic wrist arthroplasty for many wrists with localized destruction.

Significance of the sinusoidal fetal heart rate pattern

The sinusoidal fetal heart rate pattern has been reported to be an indication of fetal compromise. In this review of 31 cases, drawn from a total of 559 monitored cases of normal and at-risk women, only one resulted in poor outcome, and this was attributable to a difficult breech delivery. An association with administration of analgesics is confirmed. The sinusoidal fetal heart rate pattern does not appear to be uniformly associated with fetal distress. Its presence should be an indication for meticulous assessment of other electrocardiographic, biochemical, or clinical evidence of fetal status.

Gestational age assessment. I. analysis of individual clinical observations

Accurate assessment of the estimated date of confinement is a cornerstone of obstetric care. Traditionally this date has been predicted from historical and clinical examinations; however, there have been few studies of the accuracy of such predictions. Multiple estimators of gestational age were examined in 418 patients who were delivered of infants weighting larger than or equal to 3,000 gm, following spontaneous onset of labor. Mean intervals from an event to delivery were calculated for last menstrual period (284.2 days), quickening (156.3 days), first audible fetal heart tones (136.2 days), uterine fundus at the umbilicus (140.8 days), and measurements of the fundal height. The variability in each of these estimators was examined and compared. The last menstrual period, if known with certainty, is the most accurate estimator, followed by the uterus at the umbilicus, first heard fetal heart tones, fundal height, and quickening.

The histopathology of the developing tubal ectopic pregnancy

Examination of histopathologic sections taken of tubal ectopic pregnancies and gross dissections of these specimens suggest that, in the majority of cases, the growth of the developing trophoblast takes place in a largely extratubal site and that the common clinical impression that the mass associated with the tubal ectopic pregnancy is a dilated fallopian tube is largely erroneous.

Plasma estriol in the evaluation of third-trimester gestational age

This study attempts to confirm previous reports of a clinically useful serum unconjugated estriol surge at 36 weeks' gestation. Although an apparently physiologic estriol surge occurred at 36 +/- 2.1 weeks in 25 of 32 patients, clinical reality makes weekly plasma sampling difficult. In individual cases, use of the "surge point" predicted gestational age within a 4-week range with only 66% accuracy, and potentially serious errors in dating occurred. Other biochemical (lecithin:sphingomyelin, phosphatidylglycerol) and sonographic methods are superior in resolving problems with dating gestational age in the third trimester.

Adult respiratory distress syndrome in obstetrics and gynecology

The diagnosis, pathophysiology, and treatment of adult respiratory distress syndrome (ARDS) are discussed and 2 cases are presented. ARDS has varied etiology but common clinical, roentgenographic, and pathologic findings; it has been increasingly recognized as an important cause of morbidity and mortality in seriously ill patients. The obstetrician-gynecologist must be aware of this condition, for survival depends upon prompt diagnosis and meticulous therapy of the condition and its underlying cause.

Paraneoplastic hypercalcemia in ovarian tumors

Two cases of paraneoplastic hypercalcemia secondary to ovarian tumors are presented. Both cases were secondary to ectopic parathormone (PTH) production. Other mediators postulated to cause this syndrome are prostaglandins, vitamin D-like sterols, non-vitamin D sterols, vitamin A, cortisol, and "osteoclast-activating factor.' The key treatment modalities for acute hypercalcemia are hydration and diuresis with furosemide; phosphates, steroids, antiprostaglandins, and hemodialysis may also be of value. Calcitonin is theoretically the most attractive treatment modality, but the rapid development of resistance limits its use to acute management. Mithramycin is most effective for long-term palliation of hypercalcemia if tumor-directed therapy is unsuccessful. Review of the literature confirms the previously made observation that mesonephromas are disproportionaately represented in association with this syndrome.

A dynamic graph for documentation of gestational age

A graphic format is presented for the display and storage of data relating to gestational age. The graph permits rapid retrieval and synthesis of often confusion information and is thereby useful in the management of complicated pregnancies.

Benign gestational trophoblastic disease metastatic to pleura: unusual cause of hemothorax

A unique case of hemothorax caused by proven pleural involvement with benign gestational trophoblastic disease and anticoagulation is presented. The pulmonary manifestations of gestational trophoblastic disease are reviewed. It is stressed that these may be associated with histologically benign as well as frankly malignant disease, and that the clinician must be alert for them in managing all patients with known or suspected gestational trophoblastic disease.

Progesterone binding by human endometrial tissue during the proliferative and secretory phases of the menstrual cycle and by hyperplastic and carcinomatous endometrium

Cytosol receptors for progesterone were assayed in human endometrial tissue during the proliferative and secretory phases of the menstrual cycle and in the hyperplastic and carcinomatous endometrium. The assays were performed utilizing a technique involving prior treatment of the cytosol extract with dextran-coated charcoal to remove endogenous progesterone. The results showed that the progesterone receptor activity was higher during the later proliferative and early secretory phases of the menstrual cycle. Hyperplastic and carcinomatous endometrium also contained specific cytosol receptor for progesterone, and the binding activity of the hyperplastic endometria and endometrial polyps was comparable to that found during the later proliferative phase of the menstrual cycle. No apparent correlation between the progesterone receptor level and the morphologic degree of differentiation in Grades 1 and 2 adenocarcinomas of the endometrium was observed.

Anterior subluxation of the lateral tibial plateau. A diagnostic test and operative repair

Recurrent anterior subluxation of the lateral tibial plateau is a common type of chronic knee instability resulting from trauma. It can be reproduced by the clinical test described and corrected by a surgical procedure called the sling and reef operation, in which a strip of iliotibial tract is used to create a sling and to reef the posterolateral capsule. From 1971 to 1978, eighty-four patients were operated on, of whom fifty had been evaluated at one to six and one-half years after operation. The results were: forty-one good, six fair, and three poor. The lesions found in the thirty-seven knees in which arthrotomy was performed included a tear of the anterior cruciate in every case, a tear of the medial meniscus in fifteen and of the lateral meniscus in eleven, a notch in the articular surface of the lateral femoral condyle in fifteen, and a lateral marginal tibial (Segond) fracture in three. No definite lateral capsular tears were visualized--only stretching comparable to that seen in recurrent dislocation of the shoulder.

Ribosome processing in HeLa cells. Studies on structural aspects of precursor and mature ribosomes

Mature ribosomes, their subunits, and their ribonucleoprotein precursors were extracted from HeLa cells and prepared for electron microscopy by a method based on adsorption of nucleic acid to a charged grid. Images so obtained revealed the presence of two types of ribonuclease-sensitive fibrils of consistent morphology. One of these types of fibril is present on the 80S and 55S nucleolar ribonucleoprotein precursors and the mature 60S subunit. The other type is restricted to the 80S precursor. The morphology of the fibrils and their distribution in the various preparations suggest identification with known secondary structural features of isolated pre-rRNA.

Sheared DNA fragment sizing: comparison of techniques

DNA fragmented by conventional French press shearing procedures (30,000 lbs/in2) has a number-average fragment size of 230 base pairs. This is considerably smaller than the 450 base pairs typically reported for DNA sheared by this method. Comparison of 5 sizing techniques indicates that sheared DNA fragment size is overestimated by either measurement of velocity sedimentation or Kleinschmidt Electron Microscopic visualization. Both adsorption grid electron microscopic visualization and gel electrophoresis yield the most reliable estimates of the mean size of small DNA fragment populations. In addition, the assessment of fragment size distribution (not possible from sedimentation analysis) potentially allows more critical evaluation of DNA hybridization and reassociation kinetic and measurement parameters.