Is preterm delivery indicated in fetuses with gastroschisis and antenatally detected bowel dilation?

INTRODUCTION

Due to the controversy surrounding diagnostic ultrasound evaluations and elective preterm delivery of fetuses with gastroschisis, we sought to calculate the predictive value of bowel dilation in fetuses with gastroschisis and evaluate the effect of preterm delivery on neonatal outcomes.

MATERIALS AND METHODS

Ultrasounds and medical records of 103 mother-infant pairs with fetal gastroschisis were reviewed. Eighty-nine pairs met the criteria. Intestinal complications, gestational age at delivery, birth weight, and number of abdominal surgeries were documented.

RESULTS

Forty-eight fetuses (54%) had bowel dilation and 41 (46%) did not. The positive predictive value of bowel dilation for complicated gastroschisis was 21%. There were 50 (56%) preterm and 39 (44%) term deliveries. The mean birth weight was 2,114 g (SD = 507) and 2,659 g (SD = 687), p = 0.001. For infants delivered preterm, the mean number of postnatal abdominal surgeries was 2.1 (SD = 1.1) as compared to 1.3 (SD = 0.5) surgical procedures for those infants delivered at term gestation. This was not statistically significant. With respect to hospital stay for each group, the mean length of neonatal intensive care unit admission was 48 days (SD = 33) in the preterm group and 35 days (SD = 50) in the term group, which was not statistically significant.

DISCUSSION

Ultrasound-detected bowel dilation was not predictive of important intestinal complications. Our data did not substantiate any benefit for elective preterm delivery of neonates with gastroschisis.

Predictors of successful labor induction with oral or vaginal misoprostol

OBJECTIVE

To identify independent predictors of successful labor induction with oral or vaginal misoprostol.

METHODS

Women enrolled in four previous randomized trials involving oral or vaginal misoprostol for cervical ripening and labor induction were included in the present cohort study, with dosing of 25-50 microg every 4 to 6 h vaginally (n = 574) or 50 microg every 4 h orally (n = 207). Multiple logistic regression was performed to identify factors independently associated with successful labor induction -- defined as vaginal delivery within 12 h, vaginal delivery within 24 h and spontaneous vaginal delivery. Predictors of Cesarean birth and the need for only one dose of misoprostol were also identified. Variables included in the models were maternal age, weight, height, parity, gravidity, membrane status, route of misoprostol, gestational age, birth weight, and Bishop score and its individual components.

RESULTS

Maternal age, height, weight, parity, birth weight, dilatation, effacement and cervical station were associated with vaginal delivery within 24 h of induction. Maternal age, height, weight, nulliparity, birth weight and route of misoprostol were associated with Cesarean birth, with oral misoprostol being associated with a lower rate of Cesarean birth. The need for only one dose of misoprostol was predicted by maternal height, weight, parity, gestational age, Bishop score and route of misoprostol.

CONCLUSION

Characteristics of the woman (height, weight, parity), the fetus (birth weight) and some of the individual components of the Bishop score, were associated with successful labor induction, with oral misoprostol being associated with a lower rate of Cesarean birth.

First trimester ultrasound screening is effective in reducing postterm labor induction rates: a randomized controlled trial

OBJECTIVE

This study was designed to test the null hypothesis that first trimester ultrasound crown-rump length measurement for gestational age determination will result in no difference in the rate of induction of labor for postterm pregnancy, compared with second trimester biometry alone.

STUDY DESIGN

Two hundred eighteen women were randomly assigned to receive either first trimester ultrasound screening or second trimester ultrasound screening to establish the expected date of confinement. Sample size was calculated by using a 2-tailed alpha=.05 and power (1-beta)=80%. Data were analyzed with chi(2) and Fisher exact tests.

RESULTS

Of 104 women randomly assigned to the first trimester screening group, 41.3% had their gestational age adjusted on the basis of the crown-rump length measurement. Of 92 women randomly assigned to the second trimester screening group, 10.9% were corrected as a result of biometry (P <.001, relative risk=0.26, 95% CI=0.15-0.46). Five women in the first trimester screening group and 12 women in the second trimester screening group had labor induced for postterm pregnancy (P=0.04, relative risk=0.37, 95% CI=0.14-0.96).

CONCLUSION

The application of a program of first trimester ultrasound screening to a low-risk obstetric population results in a significant reduction in the rate of labor induction for postterm pregnancy.

Excessive uterine activity accompanying induced labor

OBJECTIVE

To estimate the incidence and timing of excessive uterine activity accompanying induction of labor with misoprostol using different routes (oral or vaginal) and forms (intact tablet or crushed) and to compare these with dinoprostone gel, oxytocin, and spontaneous labor.

METHODS

This retrospective cohort study included 519 women at term who had labor induced and 86 women at term in spontaneous labor. Induction agents included misoprostol, dinoprostone, or oxytocin. Fetal heart rate and uterine activity tracings were analyzed independently by three maternal-fetal medicine physicians. The diagnosis of tachysystole or hyperstimulation required the agreement of two or more reviewers.

RESULTS

The incidence of tachysystole was highest with misoprostol administered by vaginal tablet (misoprostol vaginal tablet 50 microg every 4 hours, 48.6%; vaginal tablet crushed 50 microg and suspended in hydroxyethyl gel every 4 hours, 30.7%, P =.009; oral tablet 50 microg every 4 hours, 22.2%, P =.001; oral tablet crushed 50 microg every 4 hours, 15.5%, P <.001; dinoprostone gel, 33.0%, P =.022; intravenous oxytocin, 30.2%, P =.027; and spontaneous onset of labor, 23.3%, P <.001). Hyperstimulation occurred more often with dinoprostone gel (16.5%) than with other forms of induction or spontaneous labor. Hyperstimulation occurred significantly more often with vaginal misoprostol crushed tablet (7.9%) and vaginal misoprostol intact tablet (7.6%) than with crushed oral misoprostol (1.0%) (P =.016 and.018, respectively). There was a shorter time to tachysystole with increasing doses of vaginal misoprostol tablet (P =.01).

CONCLUSION

The incidence of tachysystole and hyperstimulation, and time to tachysystole, varied depending on the route and form of misoprostol given.

Pregnancy with cytochrome oxidase-deficient mitochondrial myopathy

BACKGROUND

Cytochrome oxidase-deficient mitochondrial myopathies represent a heterogeneous group of muscle disorders. Physical stress can cause life-threatening risks related to rhabdomyolysis or respiratory compromise.

CASE

A 21-year-old primigravida with cytochrome C oxidase-deficient mitochondrial myopathy who presented for obstetric care at 8 weeks' gestation complained of muscle fatigue and spasm after exertion. The increased metabolic demands of pregnancy led to worsening pain, muscle fatigue, and ultimately complete immobility.

CONCLUSION

Cytochrome oxidase-deficient mitochondrial myopathies are rare but serious complications of pregnancy.

Diurnal and seasonal variations in the duration and depth of the longest dives in southern elephant seals (Mirounga leonina): possible physiological and behavioural constraints

This study seeks to understand how the physiological constraints of diving may change on a daily and seasonal basis. Dive data were obtained from southern elephant seals (Mirounga leonina) from South Georgia using satellite relay data loggers. We analysed the longest (95th percentile) dive durations as proxies for physiological dive limits. A strong, significant relationship existed between the duration of these dives and the time of day and week of year in which they were performed. The depth of the deepest dives also showed a significant, but far less consistent, relationship with local time of day and season. Changes in the duration of the longest dives occurred irrespective of their depth. Dives were longest in the morning (04:00-12:00 h) and shortest in the evening (16:00-00:00 h). The size of the fluctuation varied among animals from 4.0 to 20.0 min. The daily pattern in dive depth was phase-shifted in relation to the diurnal rhythm in dive duration. Dives were deeper at midday and shallower around midnight. Greater daily changes in duration occurred in seals feeding in the open ocean than in those foraging on the continental shelf. The seasonal peak in the duration of the longest dives coincided with austral midwinter. The size of the increase in dive duration from autumn/spring to winter ranged from 11.5 to 30.0 min. Changes in depth of the longest dives were not consistently associated with particular times of year. The substantial diurnal and seasonal fluctuations in maximum dive duration may be a result of changes in the physiological capacity to remain submerged, in addition to temporal changes in the ecological constraints on dive behaviour. We speculate about the role of melatonin as a hormonal mediator of diving capability.

A META-ANALYSIS OF CONTROLLED-RELEASE PROSTAGLANDIN FOR CERVICAL RIPENING AND LABOUR INDUCTION

OBJECTIVES: to examine the effectiveness and safety of controlled-release prostaglandin for cervical ripening. DATA SOURCES: we conducted a computerized search of Medline using the keywords "Cervidil"; or "Propess"; or "prostaglandin/dinoprostone" and "pessary"; or "prostaglandin/dinoprostone" and "controlled" and "release"; or "prostaglandin/dinoprostone" and "vaginal" and "insert"; identifying studies in the English literature published between January 1980 and December 1999. STUDY SELECTION: we included all randomized trials that compared controlled-release vaginal prostaglandin with a retrieval string with any other method of cervical ripening or with a placebo. Nine studies were identified.TABULATION, INTERACTION, AND RESULTS: the two coauthors independently abstracted the data and evaluated the studies for methodologic quality, blinded to each other's results. Homogeneity of results was evaluated, and if present, the summary odds ratio and 95 percent confidence intervals were determined. Compared with placebo, controlled-release prostaglandin resulted in cervical change (summary odds ratio [OR] = 3.99, 95% confidence interval [CI] = 2.71-5.86), a higher rate of vaginal delivery in 12 hours (OR = 29.01, 95% CI = 7.08-118.87), less need for oxytocin (OR = 0.14, 95% CI = 0.06-0.32), but a higher incidence of excessive uterine activity (P<0.0001) and hyperstimulation (P = 0.004). When compared with Prepidil, there was a higher rate of excessive uterine activity with controlled-release prostaglandin (P = 0.03), but less need for oxytocin (OR = 0.09, 95% CI = 0.01-0.53). When compared with Prepidil/immediate oxytocin, there was a lower rate of active labour in 12 hours with controlled-release prostaglandin (OR = 0.27, 95% CI = 0.10-0.72). There was a lower rate of vaginal delivery in 12 hours and higher incidence of oxytocin use with controlled-release prostaglandin as compared with misoprostol (OR = 0.53, 95% CI = 0.34-0.83 and OR = 1.58, 95% CI = 1.08-2.32 respectively). The induction to delivery interval was shorter with controlled-release prostaglandin than with placebo or Prepidil, but longer than with Prepidil/immediate oxytocin, or misoprostol. Although no differences were seen with maternal morbidity (such as Caesarean delivery) or neonatal outcomes, the sample size was not adequate to evaluate these outcomes. CONCLUSION: controlled-release prostaglandin appears to be an effective cervical ripening agent as compared with Prepidil, but may result in an increased incidence of excessive uterine activity. Controlled-release prostaglandin may not be as effective as misoprostol or Prepidil/immediate oxytocin. Further randomized trials with larger sample sizes are needed to evaluate maternal morbidity and neonatal outcomes.

Sexuality and sexual activity in pregnancy

OBJECTIVES

To evaluate women's sexual experience in pregnancy, and to describe their sources of information regarding sexuality during this period.

DESIGN

Cross-sectional study.

SETTING

The offices of obstetricians providing obstetric care in a tertiary care university hospital in St. John's, Newfoundland, Canada.

POPULATION

One hundred and forty-one pregnant women.

METHODS

Pregnant women anonymously completed self-administered questionnaires regarding sexuality and sexual activity during pregnancy. Responses were summarised using descriptive statistics, and comparisons were made between the trimesters of pregnancy. Multiple logistic regression was performed to assess the influences of a variety of factors on sexual activity.

RESULTS

Vaginal intercourse and sexual activity overall decreased throughout pregnancy (P = 0.004 and 0.05, respectively) with the trimester of pregnancy being the only independent predictor. Most women reported a decrease in sexual desire (58%). Overall, 49% of women worried that sexual intercourse may harm the pregnancy. Concerns regarding sexual activity leading to preterm labour or premature rupture of membranes increased as the pregnancy progressed (P < 0-001 and P = 0-001, respectively). Only 29% of women discussed sexual activity in pregnancy with their doctor and 49% of these women raised the issue first, with 34% feeling uncomfortable in bringing up the topic themselves. Most women (76%) who had not discussed these issues with their doctor felt they should be discussed.

CONCLUSIONS

A reduction in sexual activity, vaginal intercourse and sexual desire occurs in many women as pregnancy progresses. Both the woman and her partner have concerns regarding complications in the pregnancy as a result of sexual intercourse. The majority of women wish to discuss these issues with their doctor, but are not always comfortable raising the topic themselves.

Randomized comparison of oral misoprostol and oxytocin for labor induction in term prelabor membrane rupture

OBJECTIVES

To compare labor induction intervals between oral misoprostol and intravenous oxytocin in women who present at term with premature rupture of membranes.

METHODS

One hundred eight women were randomly assigned to misoprostol 50 microg orally every 4 hours as needed or intravenous oxytocin. The primary outcome measure was time from induction to vaginal delivery. Sample size was calculated using a two-tailed alpha of 0.05 and power of 80%.

RESULTS

Baseline demographic data, including maternal age, gestation, parity, Bishop score, birth weight, and group B streptococcal status, were similar. The mean time +/-standard deviation to vaginal birth with oral misoprostol was 720+/-382 minutes compared with 501+/-389 minutes with oxytocin (P = .007). The durations of the first, second, and third stages of labor were similar. There were no differences in maternal secondary outcomes, including cesarean birth (eight and seven, respectively), infection, maternal satisfaction with labor, epidural use, perineal trauma, manual placental removal, or gastrointestinal side effects. Neonatal outcomes including cord pH, Apgar scores, infection, and admission to neonatal intensive care unit were not different.

CONCLUSION

Although labor induction with oral misoprostol was effective, oxytocin resulted in a shorter induction-to-delivery interval. Active labor intervals and other maternal and neonatal outcomes were similar.

A masked randomized comparison of oral and vaginal administration of misoprostol for labor induction

OBJECTIVE

To test the null hypothesis that administering misoprostol orally or vaginally will result in no difference in time to vaginal birth, and to determine whether different frequencies of tachysystole and hyperstimulation are associated with route of administration.

METHODS

Two hundred six women after 37 completed weeks' gestation who presented with an indication for induction were randomly assigned to receive misoprostol (50 microg) either orally or vaginally every 4 hours as needed to induce labor. Placebo use and allocation concealment accomplished blinding until data analysis was completed. Sample size was calculated to allow a two-tailed alpha of .05 and power (1-beta) of 80%. All fetal heart rate and uterine activity graphs were classified according to Curtis' criteria before induction groups were unmasked.

RESULTS

Analysis involved 104 women in the oral group and 102 in the vaginal group. The mean time (+/-standard deviation) to vaginal birth with oral misoprostol was 1072 (+/-593) minutes compared with 846 (+/-385) minutes with the vaginal protocol (P=.004). There were no significant differences in cesarean rate, epidural use, or neonatal outcomes. More frequent tachysystole for 20 minutes (P < .01) and hyperstimulation (P < .04) were observed with vaginal misoprostol. No neonatal asphyxia occurred in either group.

CONCLUSION

Misoprostol effectively induces labor, given orally or vaginally. There is a shorter interval to vaginal birth with vaginal application; however, the more frequent occurrence of fetal heart rate graph abnormalities in this group suggests that, until the optimal dosing interval for vaginal use is determined, the preferred route of misoprostol administration might be oral.

Direct genetic selection of two classes of R17/MS2 coat proteins with altered capsid assembly properties and expanded RNA-binding activities

RNA challenge phages are derivatives of bacteriophage P22 that enable direct genetic selection for a specific RNA-protein interaction. The bacteriophage P22 R17 encodes a wild-type R17 operator site and undergoes lysogenic development following infection of susceptible bacterial strains that express the R17/MS2 coat protein. A P22 R17 derivative with an OcRNA site (P22 R17 [A(-10)U]) develops lytically following infection of these strains. RNA challenge phages can be used to isolate second-site coat protein suppressors that recognize an OcRNA sequence by selecting for lysogens with a P22 R17 [Oc] phage derivative. The bacteriophage derivative P22 R17 [A(-10)U] was used in one such scheme to isolate two classes of genes that encode R17 coat proteins with altered capsid assembly properties and expanded RNA-binding characteristics. These mutations map outside the RNA-binding surface and include amino acid substitutions that interfere with interactions between coat protein dimers in the formation of the stable phage capsid. One class of mutants encodes substitutions at the highly conserved first and second positions of the mature coat protein. N-terminal sequence analysis of these mutants reveals that coat proteins with substitutions only at position 1 are defective in post-translational processing of the initiator methionine. All selected proteins possess expanded RNA-binding properties since they direct efficient lysogen formation for P22 R17 and P22 R17 [A(-10)U]; however, bacterial strains that express the protein mutants remain sensitive to lytic infection by other P22 R17 [Oc] bacteriophages. The described selection strategy provides a novel genetic approach to dissecting protein structure within RNA-binding proteins.

The influence of fixed rotational deformities of the femur on the patellofemoral contact pressures in human cadaver knees

Patellofemoral contact pressures resulting from fixed rotational deformities of the femur were studied in human cadaver knees. The increase in the degree of fixed rotational deformities of the femur results in a nonlinear increase in patellofemoral contact pressures on the contralateral facets of the patella (i.e., external rotational deformity resulted in a contact pressure increase on the medial facet, and internal rotational deformity resulted in a contact pressure increase on the lateral facet of the patella). With the initial isometric tension of 200 N in the quadriceps tendon for 30 degrees, 60 degrees, 90 degrees, and 120 degrees knee flexion, the peak contact pressure showed no significant differences between the medial and lateral facets of the patella in its anatomic position. At 20 degrees of rotational deformity of the femur, only a slight increase was noted for the tension in the quadriceps tendon and the patellofemoral contact pressures on the contralateral facets of the patella. However, at 30 degrees rotational deformity of the femur, both the external and internal rotational deformity of the femur showed a significant increase in the tension of the quadriceps tendon and the patellofemoral contact pressures on contralateral facets of the patella. The greatest increase in patellofemoral contact pressures was observed at 30 degrees and 60 degrees knee flexion for both the external and internal rotational deformity of the femur. The external rotational deformity of the femur for all knee flexion angles showed significantly higher peak patellofemoral contact pressure increases on the medial facet of the patella as compared with the lateral patellofemoral contact pressure increase resulting from internal rotational deformity of the femur.

Acute effects of parenteral beta-blockade on regional ventricular function of infarct and noninfarct zones after reperfusion therapy in humans

Although the mechanism is unknown, clinical trials have suggested that intravenous beta-adrenergic blockade may prevent early cardiac rupture after myocardial infarction. Previous studies have examined effects of beta-blockers on global left ventricular function after myocardial infarction; however, few data exist regarding their immediate effects on regional function or in patients after successful reperfusion. Therefore, 65 patients in whom thrombolysis with or without coronary angioplasty achieved reperfusion at 4.6 +/- 1.7 h from symptom onset were studied. Low osmolarity contrast ventriculograms were obtained immediately before and after administration of 15 mg of intravenous metoprolol (n = 54) or placebo (n = 11). Intravenous metoprolol immediately decreased heart rate (from 92 to 76 beats/min, p less than 0.0001), increased left ventricular diastolic volume (from 150 to 163 ml, p less than 0.001) and systolic volume (from 72 to 77 ml, p less than 0.0005) but did not change systolic and diastolic pressures. Although there was no difference in ejection fraction after metoprolol, centerline chord analysis revealed reduced noninfarct zone motion (from 0.41 to 0.12 SD/chord, p less than 0.05), improved infarct zone motion (from -3.1 to -2.9 SD/chord, p less than 0.01) and smaller circumferential extent of hypokinesia (from 30 to 27 chords, p less than 0.05). Patients with dyskinesia of the infarct zone had the most striking improvement in infarct zone wall motion. Because these changes occurred immediately after beta-blockade, they could not be attributed to myocardial salvage. No significant changes in heart rate, left ventricular volumes or regional wall motion were apparent in the control group.(ABSTRACT TRUNCATED AT 250 WORDS)

Determination of sex from arm bone measurements

Discriminant function analysis has been applied to numerous dimensions of the cranial and postcranial skeleton for sex determination of U.S. blacks and whites and is extended here to five measurements of the arm and wrist. These include maximum lengths of the long arm bones in addition to two measurements that reflect wrist breadth. Our results indicate that whites are more accurately classified than blacks, but seven of the 31 possible measurement combinations common to both groups yield functions with sex prediction accuracies comparable to most, but not all, functions based on other parts of the skeleton.

Mechanism of acute myocardial infarction in patients with prior coronary artery bypass grafting and therapeutic implications

Although acute myocardial infarction (AMI) is usually due to thrombotic occlusion when involving a native coronary artery, the mechanism responsible for AMI in patients with previous coronary artery bypass grafting (CABG) is not well understood. Since knowledge of pathophysiology of AMI may alter subsequent management, angiograms obtained between 1 hour and 7 days of AMI (median 1 day) were reviewed in 50 patients greater than 1 year after CABG. The culprit vessel was identified by the presence of residual stenosis and/or thrombus in the vessel supplying the infarct zone or by reviewing previous angiograms. The infarct vessel was identified as a vein graft in 38 (76%) patients, the native vessel in 8 patients (16%) and could not be accurately determined in 4 patients (8%). Among the 38 vein grafts suspected as the infarct vessel, unequivocal angiographic evidence of residual thrombus (filling defect/persistent staining) was present in 31 (82%) and was greater than 2 cm in length in 15 patients. Successful reperfusion occurred in only 2 of 8 (25%) grafts after intravenous thrombolytic therapy. Intragraft thrombolysis with or without additional angioplasty was successful at restoring flow in 8 of 10 (80%) grafts. Data indicate that in patients who have undergone previous CABG, AMI is usually caused by thrombotic occlusion of a saphenous vein graft and that conventional intravenous thrombolytic therapy may be inadequate to restore flow. The large mass of thrombus and absent flow in the graft may require subselective drug infusion, a higher thrombolytic dose or a mechanical means of recanalization.

A new thrombolytic regimen for acute myocardial infarction using combination half dose tissue-type plasminogen activator with full dose streptokinase: a pilot study. KAMIT Study Group

Because a previous study utilizing a combination of recombinant tissue-type plasminogen activator (rt-PA) and urokinase demonstrated reduced reocclusion rates compared with rates obtained with rt-PA alone, this study was conducted to determine whether the combination of rt-PA and streptokinase might achieve similar results at reduced cost. Forty patients with acute myocardial infarction were treated with a 1 h infusion of rt-PA (50 mg) and streptokinase (1.5 million U) administered within 6 h (mean 3.6 +/- 1.2) of symptom onset. Emergency coronary arteriography revealed patency of the infarct-related artery in 30 (75%) of 40 patients. With the addition of coronary angioplasty in those who had unsuccessful thrombolytic reperfusion, the early patency rate was increased to 98%. In-hospital mortality rate (2.5%) and the incidence of significant bleeding requiring transfusion (15%) were low. Angiographically documented reocclusion of the infarct vessel occurred in 3 (8%) of 37 patients by day 7. Regional wall motion of the infarct zone improved by 0.9 +/- 0.9 SD/chord (p less than 0.0005), and ejection fraction increased 3.6 +/- 8% units (p less than 0.05) between immediate and day 7 studies. In contrast to the price of full dose rt-PA ($2,300) or rt-PA with urokinase ($3,500), the cost of this regimen was $1,230. This pilot study demonstrates that at half the cost, a combination of half dose rt-PA with full dose streptokinase offers high infarct vessel patency, recovery of ventricular function, a low rate of reocclusion and few bleeding complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Fluctuating asymmetry in fetuses of diabetic rhesus macaques

This study examines dental fluctuating asymmetry (FA) in two samples of fetal rhesus monkeys, one composed of 19 fetuses from diabetic mothers (FDM) and the other of 20 fetuses from nondiabetic mothers. Seventeen measurements were taken on the deciduous dentition of right and left mandibles. The degree of FA was assessed by comparing FDM to fetuses of normal mothers by correlation between right and left sides, and analysis of variation differences between right and left sides. Significant FA was found for three traits based on the correlation between right and left sides and for seven traits by the between-treatment ratio of variance between sides. Distal teeth, both within and outside of a morphologic field, exhibit significantly greater FA than mesial teeth. Our results support the hypothesis that developmental instability is detectable by dental FA.