Failed vaginal birth after a cesarean section: how risky is it? I. Maternal morbidity

OBJECTIVE

Our purpose was to determine the maternal risks associated with failed attempt at vaginal birth after cesarean compared with elective repeat cesarean delivery or successful vaginal birth after cesarean.

STUDY DESIGN

From 1989 to 1998 all patients attempting vaginal birth after cesarean and all patients undergoing repeat cesarean deliveries were reviewed. Data were extracted from a computerized obstetric database and from medical charts. The following three groups were defined: women who had successful vaginal birth after cesarean, women who had failed vaginal birth after cesarean, and women who underwent elective repeat cesarean. Criteria for the elective repeat cesarean group included no more than two previous low transverse or vertical incisions, fetus in cephalic or breech presentation, no previous uterine surgery, no active herpes, and adequate pelvis. Predictor variables included age, parity, type and number of previous incisions, reasons for repeat cesarean delivery, gestational age, and infant weight. Outcome variables included uterine rupture or dehiscence, hemorrhage >1000 mL, hemorrhage >2000 mL, need for transfusion, chorioamnionitis, endometritis, and length of hospital stay. The Student t test and the chi(2) test were used to compare categoric variables and means; maternal complications and factors associated with successful vaginal birth after cesarean were analyzed with multivariate logistic regression, allowing odds ratios, adjusted odds ratios, 95% confidence intervals, and P values to be calculated.

RESULTS

A total of 29,255 patients were delivered during the study period, with 2450 having previously had cesarean delivery. Repeat cesarean deliveries were performed in 1461 women (5.0%), and 989 successful vaginal births after cesarean delivery occurred (3.4%). Charts were reviewed for 97.6% of all women who underwent repeat cesarean delivery and for 93% of all women who had vaginal birth after cesarean. Vaginal birth after cesarean was attempted by 1344 patients or 75% of all appropriate candidates. Vaginal birth after cesarean was successful in 921 women (69%) and unsuccessful in 424 women. Four hundred fifty-one patients undergoing cesarean delivery were deemed appropriate for vaginal birth after cesarean. Multiple gestations were excluded from analysis. Final groups included 431 repeat cesarean deliveries and 1324 attempted vaginal births after cesarean; in the latter group 908 were successful and 416 failed. The overall rate of uterine disruption was 1.1% of all women attempting labor; the rate of true rupture was 0.8%; and the rate of hysterectomy was 0.5%. Blood loss was lower (odds ratio, 0.5%; 95% confidence interval, 0.3-0.9) and chorioamnionitis was higher (odds ratio, 3.8%; 95% confidence interval, 2.3-6.4) in women who attempted vaginal births after cesarean. Compared with women who had successful vaginal births after cesarean, women who experienced failed vaginal births after cesarean had a rate of uterine rupture that was 8.9% (95% confidence interval, 1.9-42) higher, a rate of transfusion that was 3.9% (95% confidence interval, 1.1-13.3) higher, a rate of chorioamnionitis that was 1.5% (95% confidence interval, 1.1-2.1) higher, and a rate of endometritis that was 6.4% (95% confidence interval, 4.1-9.8) higher.

CONCLUSION

Patients who experience failed vaginal birth after cesarean have higher risks of uterine disruption and infectious morbidity compared with patients who have successful vaginal birth after cesarean or elective repeat cesarean delivery. Because actual numbers of morbid events are small, caution should be exercised in interpreting results and counseling patients. More accurate prediction for safe, successful vaginal birth after cesarean delivery is needed.

Preliminary surveys of outdoor and indoor aeromycobiota in Uganda

This investigation was conducted during the period of March through June 1998 to trap, enumerate and identify the different airborne fungi in a variety of microhabitats of outdoor and indoor environments in different localities of Uganda. The settle plate method was used and Czapek-Dox agar was the isolation medium. A total of 47 genera and 61 species in addition to some other unidentified airborne fungi were trapped from all exposures at outdoor (39 genera and 52 species) and indoor (35 and 49) environments. The total fungal catches of outdoor airspora obtained from all exposures (and even in most individual exposures) were more than twice (5222 colonies) of that of the indoor ones (4361) when the exposure periods are taken into consideration. It is worth mentioning that the most highly polluted sites were either parks, forests or river banks for outdoor exposures, or teaching laboratory, library, laterines or bathrooms for indoor exposures. The most prevalent fungi from both outdoor and indoor microhabitats being species of Mycosphaerella, Yeasts, Penicillium, Fusarium, Aspergillus, Cochliobolus and Alternaria. However, several others were trapped frequently from either outdoor or indoor environments. On the other hand, several others were trapped only, but not frequently (in low or rare instances) from either outdoor or indoor microhabitats. The implications of these airborne spores are also discussed.

Evaluation of the mycological status of luncheon meat with special reference to aflatoxigenic moulds and aflatoxin residues

The luncheon meat samples analyzed, which were produced locally by the two main luncheon meat producing companies in Egypt were relatively highly contaminated either by moulds and yeasts in general, aflatoxigenic species and aflatoxin residues in particular. The most frequently encountered fungi from the samples were yeasts, Aspergillus niger, A. flavus, Penicillium chrysogenum, Rhizopus stolonifer, Mucor circinelloides. Less common were Cladosporium sphaerospermum, Alternaria alternata, Mycosphaerella tassiana, P. aurantiogriseum and P. oxalicum. The most important aflatoxigenic species, A. flavus, was isolated frequently. It was 10% of the total fungal isolates from both samples of the two companies. Seven luncheon meat samples out of 50 analyzed were positive for aflatoxin B1 or B1 and G1, while all samples were negative for aflatoxins B2, G2, M1 and M2. Aflatoxin B1 was detected only in 4 and 3 samples out of 25 analyzed from each of company A and B, respectively. The highest detectable level, 11.1 ppb, was recorded in a sample from company B and the least, 0.5 ppb, in a sample from company A. Aflatoxin G1, at concentration of 3.2 ppb, was detected in only one sample of the aflatoxin B1--contaminated 3 samples of company B: this sample also had the highest level of aflatoxin B1. Some luncheon meat samples had higher numbers of aflatoxigenic A. flavus than others, however these samples were negative for aflatoxins. The hazardous potential of such contamination will be discussed.

The use of colchicine in treatment of experimental toxoplasmosis

Colchicine was given in 2 doses (3 and 15 micrograms/mouse) at the time of infection or 48 hours late. It proved effective in both doses, but better results were obtained with early treatment. The mortality rates were 30% & 30%, and Toxoplasma carriers among the surviving mice was 28.6% and 42.9% with high and low doses respectively. When the treatment was given 48 hours after infection, the mortality rates were 50% and 60%, Toxoplasma carriers were 40% and 50% with high and low doses respectively.

Comparison of vaginal and cesarean section delivery for fetuses in breech presentation

OBJECTIVES

Our purpose was to evaluate the perinatal mortality and morbidity of deliveries with fetuses presenting by the breech comparing outcomes of two groups according to mode of delivery: vaginal and cesarean section.

RESULTS

Of 756 fetuses studied, 271 were delivered vaginally and 485 by cesarean section. In infants weighing > or = 1500 grams, "further corrected" mortality and morbidity rates were low and similar for both delivery routes: one neonatal death (NNM) in each. Among very low birth weight (VLBW) infants (< 1500 grams) the "further corrected" mortality rate was higher in the vaginal group: 57.4%, and 18.0% in abdominal deliveries (odds ratio [OR] = 6.1, 95% CI: 3.1 to 12.1). Likewise, rate of depression at five minutes were higher in the vaginal group (p < 0.001). However, the average fetal weight among the vaginal deliveries VLBW (787 grams) was 250 grams less than in the cesarean section group (1040 grams). After adjustment for fetal weight, gestational age, and other prognostic variables the odds ratio for neonatal death was no longer statistically significant (adjusted OR = 2.1, 95% CI: 0.9 to 5.2, p = 0.105). Comparison of planned vaginal delivery with elective cesarean section yielded smaller differences (adjusted OR for neonatal death = 1.3, 95% CI: 0.6 to 2.9, p = 0.525).

CONCLUSION

The poor perinatal outcomes of breech delivered infants are due primarily to VLBW, congenital malformations, and premature labor. Although abdominal delivery had a lower NNM rate than vaginal delivery, the difference was not significant after adjustment for confounding factors. The results confirm the findings of a previously analyzed similar series delivered at our institution between 1980 and 1987. They suggest that, with appropriate technique, abdominal delivery is not mandatory in breech presentation.

Microbial populations, ammonification and nitrification in soil treated with urea and inorganic salts

Soil fertilization with urea at rates of 0.2 and 0.5 mg N/g soil was toxic for total counts of bacteria and fungi except with cellulolytic fungi where growth was promoted by addition of urea after 90-d incubation. Also, the population numbers of both bacteria and fungi were significantly decreased when soil was amended with CaCl2 and K2SO4 applied at two levels (50 and 100 mumol/g soil). Some alleviation of the toxic effect of either urea or the inorganic salts was observed when they were applied in combination. Fungal species composition was found to be affected in the treated soil. The most tolerant fungi were Alternaria alternata, Aspergillus flavus, A. fumigatus, A. niger, A. terreus, Eurotium amstelodami, E. chevalieri, Nectria haematococca, Paecilomyces variotii and Stachybotrys chartarum. Other species of fungi were either sensitive to all treatments or sensitive to some and tolerant to others. Ammonium nitrogen was found to be more accumulated in soil treated with urea mixed with inorganic salts compared with soil treated only with urea whereas NO3(-)-N (and NO2(-)-N) was decreased. The overall effect of the addition of inorganic salts on total mineralized nitrogen, however was promotive. Soil pH was increased in urea-treated soil but was depressed by application of CaCl2 or K2SO4 to values lower than that of untreated soil. The results may be of agronomical interest in overcoming problems encountered with urea application as N fertilizer.

Massive bleeding from colonic diverticular disease with NSAID use

Non-steriodal anti-inflammatory drugs (NSAID) are not only associated with bleeding in the stomach and duodenum, but can also complicate pre-existing diverticular disease of the colon. Here, a 58 year-old male with severe per rectal bleeding is presented and the role of NSAID as a causative factor of his problem is discussed.

Spectroscopic studies of 9-hydroxyellipticine binding to DNA

The binding of 9-hydroxyellipticine to calf thymus DNA, poly[d(A-T)]2, and poly[d(G-C)]2 has been studied in detail by means of CD, linear dichroism, resonance light scattering, and molecular dynamics. The transition moment polarizations of 9-hydroxyellipticine were determined in polyvinyl alcohol stretched film. Spectroscopic solution studies of the DNA/drug complex are combined with theoretical CD calculations using the final 50 ps of a series of molecular dynamics simulations as input. The spectroscopic data shows 9-hydroxyellipticine to adopt two main binding modes, one intercalative and the other a stacked binding mode involving the formation of drug oligomers in the DNA major groove. Analysis of the intercalated binding mode in poly[d(A-T)]2 suggests the 9-hydroxyellipticine hydroxyl group lies in the minor groove and hydrogen bonds to water with the pyridine ring protruding into the major groove. The stacked binding mode was examined using resonance light scattering and it was concluded that the drug was forming small oligomer stacks rather than extended aggregates. Reduced linear dichroism measurements suggested a binding geometry that precluded a minor groove binding mode where the plane of the drug makes a 45 degrees angle with the plane of the bases. Thus it was concluded that the drug stacks in the major groove. No obvious differences in the mode of binding of 9-hydroxyellipticine were observed between different DNA sequences; however, the stacked binding mode appeared to be more favorable for calf thymus DNA and poly[d(G-C)]2 than for poly[d(A-T)]2, an observation that could be explained by the slightly greater steric hindrance of the poly[d(A-T)]2 major groove. A strong concentration dependence was observed for the two binding modes where intercalation is favored at very low drug load, with stacking interactions becoming more prominent as the drug concentration is increased. Even at DNA: drug mixing ratios of 70:1 the stacked binding mode was still important for GC-rich DNAs.

1,3-Dimethylpyrimidoheterocycles as antibacterial agents

1,3-Dimethylbarbituric acid was used as a versatile precursor for the preparation of annelated pyranopyrimidines 2 and 3a-c besides pyrrolopyrimidine 12. The isolated pyrazolopyrimidines 8a-c and 10 and fused pyrazolopyrimidines 14a-d were also synthesized. In addition the new obtained pyrimidoheterocycles were subjected to bacterial testings.

Based on biochemical and physiological behavior, where is Aspergillus egyptiacus better placed?

Physiological and biochemical properties were tested in 45 isolates of Aspergillus egyptiacus (16 isolates), Emericella nidulans (16) and Aspergillus versicolor (13). The three fungal species exhibited common and similar features. The big similarity between A. egyptiacus and E. nidulans was greater than between A. egyptiacus and A. versicolor. It included the inability to produce base either from sodium citrate or lactic acid media, growth at 45 degrees C (thermophilicity), and production of very similar pigmentations on Aspergillus flavus and parasiticus agar. A. egyptiacus is therefore better placed in the Aspergillus nidulans-Emericella assemblage.

CA-125 in peritoneal fluid from patients with nonmalignant gynecologic disorders

To assess the diagnostic value of measuring CA-125 levels in peritoneal fluid from women with nonmalignant gynecologic disorders, we determined CA-125 levels in peritoneal fluid and in serum collected simultaneously from 46 women undergoing gynecologic surgery. Patients with benign ovarian disease, non-ovarian gynecologic pathology and severe endometriosis had, on average, higher CA-125 levels in peritoneal fluid than did patients with a normal pelvis and those with mild endometriosis. There was no obvious correlation between peritoneal fluid and serum levels of CA-125. Our data show that (1) measurement of serum CA-125 levels is not useful for distinguishing between different benign gynecologic disorders, and (2) levels of CA-125 in peritoneal fluid in benign gynecologic disorders are comparable to the reported lower range of levels observed in women with intraperitoneal malignancies.

Mycoflora inhabiting water closet environments

Sixty-six fungal species in addition to two species varieties belonging to 31 genera were isolated during the current study from water closet (WC) sewage samples (39 species and two varieties in 20 genera) and WC air (53 species and two varieties in 25 genera). There were more fungi in the WC air than in sewage. The most prevalent fungi in WC sewage and air were members of the genera Aspergillus, Cladosporium and Penicillium. Acremonium, Alternaria, Emericella, Mycosphaerella and Pleospora were dominant only in WC air. Some species of these genera are considered to be true or opportunistic pathogens. The pollution level due to the bacterial flora either in the air or in the sewage of WCs was relatively higher than that of the fungal flora. Testing the capability to produce urease, nearly all fungal isolates (65 out of 67) and bacteria tested (35 out of 36) proved to be good urease producers.

Significance of positive cervical cultures for Chlamydia trachomatis in patients with preterm premature rupture of membranes

We tested the hypothesis that in patients with preterm premature rupture of membranes the presence of Chlamydia trachomatis in the cervix shortens the latent period (time from rupture of membranes to delivery) and increases the incidence of chorioamnionitis and early endometritis. A total of 178 conservatively managed patients with PROM between 22 and 35 weeks' gestation had cervical cultures for chlamydia, group B Streptococcus (GBS) and Neisseria gonorrhoeae performed at the time of rupture. Patients with GBS and gonorrhea were treated at the time the culture results were available and excluded from analysis. The remaining patients were divided into group 1: 26 patients (14.6%) positive for only chlamydia (and not treated until discharge from the hospital); group 2: 120 patients (67.4%) negative for all three organisms. The two groups did not differ in cesarean rate, duration of conservative management, hospital stay, or birthweight. Furthermore, the rates of chorioamnionitis (30.8% group 1; 38.3% group 2) or early endometritis (11.5% group 1; 20.8% group 2) were similar. We conclude that in patients with preterm premature rupture of membranes, the presence of chlamydia in the cervix appears to neither decrease the latent period nor increase the incidence of chorioamnionitis and early endometritis.

Use of the drop volume of amniotic fluid in predicting fetal lung maturity. Clinical experience

Respiratory distress syndrome (RDS), resulting from inadequate amounts of alveolar surfactant, is a leading cause of neonatal mortality. This study analyzed the drop volume for predicting the risk of neonatal RDS by evaluating the surface tension of amniotic fluid. The drop-volume method quantifies the surface tension of amniotic fluid using the fact that the volume of a falling drop of liquid is proportional to the quantity of surface-active substances (surfactant) in the solution. Distilled water is used as a reference solution. The test is simple to perform and requires only two minutes and 2 mL of amniotic fluid. Amniotic fluid was obtained by amniocentesis from 120 pregnancies, ranging from 24 to 42 weeks of gestation, within four days of delivery. Specimens contaminated with meconium or hemolyzed blood or from patients with clinical chorioamnionitis were not used. The lecithin:sphingomyelin ratio and phosphatidylglycerol tests were also determined for 54 of the study cases. A mature drop-volume test result was associated with a healthy infant with no RDS 95% of the time (negative predictive value). Fifty-two percent of the healthy infants in the study were predicted by an arbitrary unit of time (S) value of less than or equal to 85.0 (specificity). Thirteen of the 16 infants who developed RDS (81%) were predicted by an S value of greater than or equal to 85.1 (sensitivity). Of those infants with an S value of greater than or equal to 85.1, 21% developed RDS (positive predictive value).

The effect of filtration of amniotic fluid on the growth of Chlamydia trachomatis and Escherichia coli

There is increasing concern about Chlamydia trachomatis infection during pregnancy, because of reports of increased maternal, fetal, and neonatal risks. Amniotic fluid is known to possess antibacterial activity and has recently been shown to inhibit formation of chlamydial inclusions in McCoy cell culture. To further characterize the anti-chlamydial factor, we investigated the effect of filtering the fluid (0.45 microns pores) prior to incubation. Amniotic fluid was obtained from 12 women at term gestation, either by amniocentesis, or at cesarean section, Chlamydial inclusion formation was studied in McCoy cell cultures, and Escherichia coli growth was studied by a plate-count method. Filtered amniotic fluid had significantly less inhibitory activity against chlamydial inclusion formation than nonfiltered fluid did. Both filtered and nonfiltered amniotic fluid were equally effective in inhibiting E. coli colony growth. These data suggest that the chlamydial inhibitor in amniotic fluid does not pass through 0.45 microns pores and is larger than the bacterial inhibitor that was reported to be a peptide of low molecular weight.

Keratinophilic and other fungi isolated from combine harvester wheat and sorghum dusts and from the atmosphere of winnow sites in Egypt

Three methods were used for the isolation of fungi in the present investigation: the dilution-plate method, hair-baiting technique with horse hairs and the "exposed plate" method. Sabouraud's glucose agar at 28 degrees C was also used as isolation medium. 102 species and 2 species varieties belonging to 36 genera were collected from combine harvester wheat and sorghum dusts and from the atmosphere of hay or winnow sites. Chrysosporium was represented by 6 species: C. asperatum, C. indicum, C. keratinophilum, C. merdarium, C. pannorum and C. tropicum. Several filamentous fungi tolerating high levels of cycloheximide and other moulds were frequently encountered in the two types of dusts and in the two atmospheres, such as members of Acremonium, Alternaria, Aspergillus, Cladosporium, Emericella, Eupenicillium, Fusarium, Paecilomyces, Penicillium, Piedraia, Rhizopus, Scopulariopsis and others.

Cardiac echinococcosis: the diagnostic value of computed tomography scanning

The diagnosis of cardiac hydatid disease is a difficult one. Conventional and specific cardiac investigations are not pathognomonic of this disease. In this report, the diagnostic value of computed tomography (CT) scanning was prospectively investigated in seven patients. In five patients, the diagnosis was confirmed surgically. The CT-information obtained correlated accurately to the operative findings. In all the patients, CT-densities of the lesions were measured and were found to coincide with values of mean CT-densities of hydatid cysts elsewhere in the body. The capability of measuring tissue densities is unique to CT-scanning and have been emphasized in this report.

Selective effect of cefoxitin prophylaxis on post-cesarean-section microbial flora

A double-blind study was done to test the efficacy of cefoxitin in the prevention of post-cesarean-section infection. The antibiotic was given in three 2-g doses; the initial dose was given immediately after the cord was clamped, and subsequent doses were given four and eight hours later. Cefoxitin prophylaxis significantly reduced morbidity serious enough to require therapeutic antibiotics or to prolong the hospital stay and led to an overall reduction in the anaerobic microbial flora of the endocervix. However, the antibiotic was selective for the overgrowth of enterococci, which were present in nearly half the postoperative cultures of patients who had received the drug. Enterococcal sepsis occurred in one patient, and three other patients had significant bacteriuria and/or urinary tract infections from enterococci. No cefoxitin-resistant strains of Enterobacteriaceae, among species normally sensitive to the drug, were isolated from the stool samples after prophylaxis. The risk of enterococcal colonization and superinfection must be weighted against the benefits of reduction of the infection risk when deciding upon routine antibiotic prophylaxis for cesarean section.

Unique anomalies in cephalothoracopagus janiceps conjoined twins with implications for multiple mechanisms in the abnormal embryogenesis

The anatomic features of female conjoined twins with the Janiceps type of cephalothoracopagus are described. Abnormalities included bilateral clefts of the alveolar arches, shared rudimentary mandible, high, arched clavicles, multiple rib deformities, single shared foregut and small intestine, absent large intestines, omphalocele, multicystic kidneys, hypoplastic lungs, interconnected aortas and neck vessels, single ovary with elongated uterus in each twin, displaced labia, abnormal segmentation of the vertebrae, spinal dysraphism, diastasis of the symphysis pubis, malrotated lower extremity, bilateral posterior dislocation of the hips, and club feet. There were two hearts with internal anomalies. Both spinal cords had a myelocele in the lumbar region. The abnormalities noted in previous reports of conjoined twins of this type are reviewed and compared. We propose that factors associated with conjoining, dysgenetic (developmental) defects, and deformations resulting from crowding in utero all may have been important in the abnormal development in this case.

Fungal flora associated with combine harvester wheat and sorghum dusts from Egypt

107 species and 8 species varieties belonging to 44 genera were collected from combine harvester wheat and sorghum dusts (35 genera and 91 species + 4 varieties) and from the atmosphere of their hay sites (26 genera and 69 species + 4 varieties) on glucose- and cellulose-Czapek's Dox agar at 28 degrees C and 45 degrees C. The mycoflora of wheat and sorghum dusts were basically similar on the two types of media and the most common fungi were: Alternaria alternata, Aspergillus flavus, A. fumigatus, A. niger, A. ochraceus, A. sydowii, A. terreus, Cochliobolus spicifer, Emericella nidulans, Fusarium moniliforme, Penicillium chrysogenum, P. duclauxii, P. funiculosum and P. oxalicum. Truly thermophilic species were frequently encountered from the two substrates: Chaetomium thermophilum, Humicola grisea var. thermoidae, H. insolens, Malbranchea pulchella var., sulphurea, Rhizomucor pusillus, Sporotrichum thermophilum, Talaromyces thermophilus, Thermoascus thermophilus and Thermomyces lanuginosus. The airborne fungi in the two atmospheres were basically similar and the most prevalent species were members of Alternaria (1 species), Aspergillus (18 species + 2 varieties), Chaetomium (2 species), Cochliobolus(3 species), Emericella (3 species + 2 varieties), Fusarium (3 species), Mucor (1 species), Penicillium (14 species) and Stachybotrys (1 species).

Fetal urinary tract obstruction and trisomy 18 mosaicism. A case report

Routine ultrasound examination has led increasingly to antepartum detection of fetal anomalies. Management decisions remain difficult, however, because information on the presence of other anomalies is frequently unobtainable. A case of fetal urinary tract obstruction, although apparently an isolated defect, proved to be associated with a lethal chromosome abnormality, trisomy 18 mosaicism.

A comparison of cefonicid and cefoxitin for preventing infections after vaginal hysterectomy

One hundred women who underwent vaginal hysterectomy were randomly and prospectively divided into two study groups, one to receive a single, 1-g preoperative dose of cefonicid and the other to receive 2 g of cefoxitin preoperatively and postoperatively for a total of four doses. There were no differences between the two groups in the rates of febrile morbidity, urinary tract infection, serious infection, noninfectious morbidity or duration of hospitalization. Both cefonicid and cefoxitin were equally effective in preventing postoperative infectious morbidity and demonstrated little difference in side effects. The single-dose regimen of cefonicid provides the advantages of decreased cost and prolonged therapeutic tissue levels when compared to cefoxitin. Perioperative antimicrobial prophylaxis with this single-dose cephalosporin provides a cost-effective regimen that is both safe and prophylactically effective.

N-nitrosoephedrine and N-nitrosopseudoephedrine: their dissolution, absorption, blood clearance and elimination studies

Dissolution and absorption rates (in vitro); clearance from blood and elimination rates of N-nitrosoephedrine (NEP) and N-nitrosopseudophedrine (NPEP) in mice were determined. The two isomers obeyed first-order kinetics and from the slope of the regression line, the rate constant for each study was obtained. These constants were 0.023, 0.038 min-1 (dissolution); 0.192, 0.225 h-1 (stomach absorption); 2.898, 1.980 h-1 (intestinal absorption); 0.33, 0.55 h-1 (blood clearance) and 0.373, 0.393 h-1 (elimination from whole animal) of NEP and NPEP, respectively, and were tested by Student's t-test. Significant differences in the dissolution, absorption and blood clearance rates of NPEP from those of NEP have been observed (P less than 0.05-0.01). These differences are expected to exert their influence on the metabolic rates and the carcinogenic and/or spectral properties of NEP and NPEP, in a related pattern.

Use of C-reactive protein to predict the outcome of medical management of tuboovarian abscesses

Medical management of tuboovarian abscesses (TOAs) has been shown to be successful. However, the ability to predict which patients with TOA would respond to antibiotic therapy could shorten the hospital stay and decrease treatment costs. C-reactive protein (CRP), an acute-phase-reactant protein with a short half-life, was investigated as a possible predictor of response by TOA patients to medical therapy. Twenty-two patients with TOAs were admitted prospectively into this study, which included daily quantitative determinations of CRP. The patients had either resolution of the mass and symptoms (responders), increased evidence of systemic sepsis and acute peritonitis requiring surgery (failures) or continuation of the tender adnexal mass without evidence of peritoneal irritation (persisters). Twelve patients classified as responders showed a continued daily decrease in quantitative CRP levels of at least 20% per day below the previous day's value until the return to normal levels. The five failures showed a progressive rise in CRP levels as well as evidence of systemic sepsis. Persisters showed an initial decrease in the CRP level followed by a leveling off of the value to a decrease of less than 20% per day. The rate at which daily CRP determinations decline may be a useful predictor of the response to antibiotic therapy.

Surgical approaches to pelvic infections in women

Pelvic abscess is a complication of gynecologic disease or obstetric surgery. Tuboovarian complex is differentiated from abscesses because of the absence of a true abscess wall; treatment of a tuboovarian complex is conservative. The diagnosis of tuboovarian complex is made by history, pelvic examination and ultrasonography. Tuboovarian abscesses (TOAs) are sequelae of surgical procedures. Both conventional and novel surgical techniques can be used to manage them. Pelvic thrombophlebitis and ovarian vein thrombosis are late complications of pelvic infections that may be associated with significant morbidity and mortality.

Role of Chlamydia trachomatis in postpartum endometritis

To investigate the role of Chlamydia trachomatis in puerperal endometritis, 72 patients with endometritis following vaginal or cesarean section delivery were studied. Blood, urine and endometrial cultures for aerobic and anaerobic bacteria and for C trachomatis were performed for all patients. C trachomatis was isolated in 25% of patients with endometritis. Patients with post-vaginal-delivery endometritis and a positive C trachomatis culture had a later onset of infection as well as a favorable clinical response to treatment despite persistence of C trachomatis in their endometrial cultures at the end of therapy. Cephalosporins failed to eradicate C trachomatis from endometrial cultures after five days of intravenous therapy.

Ureteral stent placement for recurrent hydronephrosis in pregnancy. A case report

Conservative management of recurrent hydronephrosis in pregnancy is an alternative to surgical intervention and placement of a ureteral stent during the second trimester.

On the local optimality of the fuzzy isodata clustering algorithm

The convergence of the fuzzy ISODATA clustering algorithm was proved by Bezdek [3]. Two sets of conditions were derived and it was conjectured that they are necessary and sufficient for a local minimum point. In this paper, we address this conjecture and explore the properties of the underlying optimization problem. The notions of reduced objective function and improving and feasible directions are used to examine this conjecture. Finally, based on the derived properties of the problem, a new stopping criterion for the fuzzy ISODATA algorithm is proposed.

Clostridium difficile-associated diarrhea follows perioperative prophylaxis with cefoxitin

Clostridium difficile-associated diarrhea during prolonged therapy of obstetric and gynecologic infections is known to occur with use of all classes of antibiotics except vancomycin and the aminoglycosides. We present 11 cases of C. difficile-associated diarrhea which followed a short course of perioperative prophylaxis with cefoxitin during a 1-year period. Nine of the cases of C. difficile-associated diarrhea were among 162 women who received cefoxitin perioperative prophylaxis for cesarean section or hysterectomy, but none occurred in 85 women who received one of four other antibiotics for perioperative prophylaxis (p = 0.024, Fisher's exact test). The two other occurrences of C. difficile-associated diarrhea following perioperative prophylaxis with cefoxitin were in women who underwent exploratory laparotomy. We conclude that C. difficile-associated diarrhea is related to perioperative prophylaxis with cefoxitin.

Immunoglobulins in prolonged ruptured membranes

Concentrations of immunoglobulins G, M, and A were studied in maternal and cord serum of patients with prolonged premature rupture of membranes, as well as in properly matched control patients. None of the patients studied showed any evidence of clinical chorioamnionitis or other prenatal infections. Cases were divided into term premature rupture of membranes and term controls and preterm (less than 34 gestational weeks) premature rupture of membranes and preterm controls. In the term group, with 12 to 24 hours of premature rupture of membranes, maternal immunoglobulins M and A, and cord immunoglobulin A were significantly increased. With a duration of premature rupture of membranes of more than 24 hours, levels of immunoglobulins M and A in maternal serum and levels of immunoglobulins G and A in cord serum showed significant elevations. Levels of cord immunoglobulin M from both subgroups of patients with premature rupture of membranes showed a trend upward but were not significantly higher than those in control patients. In the preterm group, with 12 to 24 hours of premature rupture of membranes, only cord immunoglobulin A was significantly increased. With premature rupture of membranes of greater than or equal to 72 hours, only maternal immunoglobulin G increased significantly and remained elevated; immunoglobulins M and A in cord serum were also significantly increased. The significant rise in immunoglobulins in patients with premature rupture of membranes may indicate subclinical maternal and fetal infection. This suggests the possibility that subclinical infections may play a role in the etiology of premature rupture of membranes.

Persistent Müllerian duct syndrome. Review and report of 3 cases

Three cases of persistent Müllerian duct syndrome are reported. All were phenotypically and karyotypically male but with persistent duct remnants. Problems encountered in management and surgery are discussed.

Chlamydial colonization of the cervix in pregnant adolescents

We studied the incidence of Chlamydia trachomatis colonization of the cervix in pregnant adolescents and analyzed the effect of such colonization on pre-, intra-and postpartum events. A significant increase in post-vaginal-delivery endometritis as well as an increase in other sexually transmitted diseases occurred in patients colonized by C. trachomatis.

The significance of C-reactive protein levels in women with premature rupture of membranes

In a prospective study of 100 patients with preterm premature rupture of membranes, clinical chorioamnionitis was present in 18 and histologic chorioamnionitis was present in 63. Patients who were managed conservatively for premature rupture of membranes were monitored by C-reactive protein determination, white blood cell and differential counts, maternal temperature, and fetal heart tone. C-reactive protein was measured nephelometrically (Immuno-chemistry Analyzer II, Beckman). Elevated C-reactive protein levels correlated well with both the pathologic and the clinical diagnosis of chorioamnionitis. Elevated C-reactive protein levels (at least 12 to 24 hours before delivery) were more sensitive than other standard laboratory or clinical tests in predicting chorioamnionitis both by clinical and pathologic criteria. When C-reactive protein values were normal, clinical chorioamnionitis was rarely found, whereas pathologically diagnosed chorioamnionitis was found half of the time. We conclude that although the C-reactive protein level is a very sensitive predictor of infectious morbidity in premature rupture of membranes, its specificity is not high.

K-means-type algorithms: a generalized convergence theorem and characterization of local optimality

The K-means algorithm is a commonly used technique in cluster analysis. In this paper, several questions about the algorithm are addressed. The clustering problem is first cast as a nonconvex mathematical program. Then, a rigorous proof of the finite convergence of the K-means-type algorithm is given for any metric. It is shown that under certain conditions the algorithm may fail to converge to a local minimum, and that it converges under differentiability conditions to a Kuhn-Tucker point. Finally, a method for obtaining a local-minimum solution is given.

Disseminated blastomycosis in a pregnant woman: review of amphotericin B usage during pregnancy

Disseminated blastomycosis was diagnosed in a 27-yr-old woman during her twenty-eighth week of pregnancy. Her skin lesions resolved promptly on treatment with amphotericin B. At full-term delivery when the mother had already received 1,536 mg of amphotericin B, the infant was normal and the placenta showed no evidence of blastomycotic infection. After administration of 16 mg of amphotericin B over 140 min, at delivery the concentrations of amphotericin B in serum of blood samples from the mother and the cord were 0.32 and 0.12 micrograms/ml, respectively. The published experience with systemic mycoses and amphotericin B treatment in pregnant women is reviewed. There is no evidence of teratogenesis or persistent toxic side effects in infants delivered from mothers treated with this drug during pregnancy.

Synthesis and biological activity of certain derivatives of 2,4-dioxo-1,2,3,4-tetrahydroquinazoline. Part 2

The synthesis of 6-bromo-1-ethyl-2,4-dioxo-1,2,3,4-tetrahydroquinazoline, its benzoyl and its benzyl derivatives is described. The unreported 5-bromo-N-phenyl-anthranilic acid was synthesized from anthranilic acid adopting a procedure, which involved a novel synthesis of 2,5-dibromobenzoic acid. Direct bromination of N-phenylanthranilic acid and N-p-tolyl-anthranilic acid afforded the tribromo-and dibromoderivatives respectively.

The effect of mebendazole on sheep hydatid cysts as demonstrated by electron microscopy

The ultrastructural changes induced in hydatid cysts from lungs of sheep after medication with one or two courses of mebendazole (Ovitelmin), each lasting 3 wk, are described. The hydatid germinal membrane tissue collected from the treated sheep showed complete degeneration of the tegumental and subtegumental structures and minor degree of calcification. Lung hydatid cysts of the untreated sheep presented normal ultrastructural configurations.

Clostridium perfringens septicemia following cesarean section

A Clostridium perfringens infection is described in an 18-year-old primigravida following cesarean section at 43 weeks' gestation. Despite the ubiquitous distribution of these organisms, such infections are rarely encountered in obstetrics. Characteristics of these bacteria and appropriate diagnostic and therapeutic procedures are presented. Despite the infrequency of this potentially lethal complication, survival depends on early diagnosis and aggressive treatment.

Reduced urinary estriol levels with erythromycin therapy

Several pharmacologic agents are known to interfere with urinary estriol levels in pregnancy. This report implicates erythromycin as yet another agent responsible for such interference.