Relationship of gestational age and cervical dilation to the timing of delivery

OBJECTIVE

To determine the effect of gestational age and cervical dilation on pregnancy continuation in women with idiopathic preterm labor who were treated with parenteral tocolysis.

METHOD

A total of 950 women with singleton gestations, intact membranes and preterm labor treated with tocolysis prior to 34 weeks' gestation were retrospectively studied. These women were identified from the March of Dimes prematurity prevention program database. For analysis, women were categorized into five gestational age groups and three cervical dilation groups. The primary outcomes measured were the percentage of women who remained undelivered at 48 h and at 14 days post-initiation of therapy.

RESULT

Overall, 82% of women remained undelivered after 48 h and 65% remained undelivered at 14 days. As cervical dilation advanced, the number of women remaining undelivered at 48 h and 14 days significantly decreased. However, even at > or = 4 cm, 52% of women remained undelivered at 48 h. If the cervix was dilated < 2 cm, gestational age did not influence the number of days gained prior to delivery. However, if the cervix was dilated > or = 2 cm, women at < 25 weeks' gestation were more likely to deliver compared to women at the same dilation but with more advanced gestational ages.

CONCLUSION

Overall, 82% of women in preterm labor and 52% of those presenting with > or = 4-cm cervical dilation, delivered after 48 h. Therefore there appears to be ample opportunity for most women in preterm labor with intact membranes, even those at advanced dilations, to receive a complete course of corticosteroid therapy.

Active-phase labor arrest: oxytocin augmentation for at least 4 hours

OBJECTIVE

To assess a labor-management protocol that mandated at least 4 hours of oxytocin augmentation before cesarean delivery for active-phase labor arrest.

METHODS

We prospectively evaluated term gravidas in spontaneous labor with active-phase labor arrest (cervix at least 4 cm dilated and 1 cm or less of cervical progress in 2 hours). Exclusion criteria included nonvertex presentation, previous cesarean, multiple gestation, and a nonreassuring fetal heart rate tracing or chorioamnionitis at the time of labor arrest. After the diagnosis of active-phase arrest, oxytocin was initiated with an intent to achieve a sustained uterine contraction pattern of greater than 200 Montevideo units. Cesarean delivery was not performed for labor arrest until at least 4 hours of a sustained uterine contraction pattern of greater than 200 Montevideo units, or a minimum of 6 hours of oxytocin augmentation if this contraction pattern could not be achieved.

RESULTS

Five hundred forty-two women were managed by the protocol, and 92% delivered vaginally. The subsequent vaginal delivery rate for parous women who had not progressed (1 cm of cervical dilation or less) despite 2 hours of oxytocin augmentation was 91%, and it was 74% for nulliparas. With no labor progress after 4 hours of oxytocin augmentation, the subsequent vaginal delivery rates were 88% for parous women and 56% for nulliparas. There were no severe maternal complications. One neonate had persistent fetal circulation and one had a positive blood culture, but both did well.

CONCLUSION

Extending the minimum period of oxytocin augmentation for active-phase labor arrest from 2 to at least 4 hours was effective and safe.

Patterns of radiotherapy practice for patients with squamous carcinoma of the uterine cervix: patterns of care study

PURPOSE

To determine the impact of research findings and evolving technology on the patterns of radiotherapy practice for patients with carcinoma of the uterine cervix.

METHODS AND MATERIALS

Sixty-two radiation therapy facilities participated in the study after having been selected from a random sample, proportionally stratified according to practice type, of all United States facilities. Each facility submitted a list of patients treated during 1992-1994 with radiation for squamous carcinoma of the cervix. Cases for review were randomly selected from each institution after excluding those of patients who had distant metastases or initial hysterectomy. A total of 471 patients' records were reviewed in the treating institutions to obtain information about patients' characteristics, diagnostic evaluation, tumor extent, treatment approach, and radiotherapy techniques.

RESULTS

Of the 61 facilities that treated eligible cases of intact cervical cancer during the 3-year survey period, 35 (57%) treated fewer than three eligible patients per year. Thirty-four (83%) of 41 non-academic facilities vs. 1 (5%) of 20 academic facilities treated fewer than three patients per year. FIGO stages were I, II, III, and IV in 32%, 40%, 24%, and 3% of patients, respectively. Computed tomography (CT) was the most common method of lymph node evaluation, but surgical evaluation, which was performed in 76 (16%) patients, had increased from previous surveys. Fields were designed using a dedicated simulator in 95% of patients; a dedicated CT unit was used for treatment planning in 119 (30%) cases. External beam irradiation was most often given using a four-field technique at 180 cGy per day on a 10-20 MV linear accelerator. The average daily fraction size had decreased from previous surveys, and 13% of patients were treated with daily doses of 170 cGy or less. Most patients were treated with a combination of external beam and low dose-rate (LDR) intracavitary irradiation. Of 425 patients who had treatment with curative intent that included brachytherapy, 362 (85%) had LDR brachytherapy, 45 (11%) had high dose-rate (HDR) brachytherapy, 3 had a combination of HDR and LDR, and 15 had incomplete information about the brachytherapy dose-rate. Forty-six (23%) of 197 patients with Stages I-IIA disease were treated with radiation followed by extrafascial hysterectomy. Of 111 patients treated with curative intent for Stage III-IV disease, 72 (65%) had a combination of external beam and intracavitary radiation therapy, 22 (20%) had external beam plus interstitial brachytherapy, and 17 (15%) were treated with external beam irradiation only. For patients who completed treatment with curative intent and did not have adjuvant hysterectomy or HDR brachytherapy, the median total dose at point A was 82.5 Gy. For all patients who completed treatment with radiation alone, the median total duration of treatment was 63 days; more than 70 days were taken to complete treatment in 33% of cases. Twenty-nine percent of patients received chemotherapy, usually concurrent with their radiation therapy. Only 27% of these patients were on investigational protocols.

CONCLUSIONS

Greater participation in well-designed prospective trials might help clinicians address important clinical questions and reduce current inconsistencies in the use of adjuvant treatments. Radiation oncologists should take steps to avoid unnecessary treatment protraction and to improve patient compliance. Future studies will be needed to determine whether the small number of cases being treated in most nonacademic facilities will influence the outcome for patients with invasive cervical carcinoma.

Mimicry profiles are affected by human-induced habitat changes

Mimicry theory predicts that mimics in a Batesian mimicry complex evolve to resemble models closely, and that there is a limit on the numbers of mimics relative to models. For hoverflies (Diptera: Syrphidae), supposed mimics of social wasps (Hymenoptera: Vespidae, neither of these is true; many mimics are imperfect and in the UK and Europe they outnumber their models manifold. We hypothesized that the high abundance of mimics relative to models in the UK may be the result not just of mimic model dynamics, but of habitat changes caused by humans. Most of the larvae of poor mimics are aphidophagous, and changes from ancient forest to agricultural and/or urban habitats may have vastly augmented aphid numbers. Using new and literature data, we compared mimicry profiles of habitats differing in their degree of habitat disturbance. In both cases more highly disturbed habitats had proportionally more poor mimics and fewer high-fidelity mimics than less disturbed habitats. This supports the hypothesis that habitat change has an effect on model to mimic ratios.

Orgaran during rotational atherectomy in the setting of heparin-induced thrombocytopenia

Heparin is considered necessary during percutaneous coronary interventions; however, heparin is contraindicated in patients with heparin-induced thrombocytopenia and/or heparin antibodies. We describe the successful use of the heparinoid Orgaran (danaparoid sodium) in addition to abciximab (ReoPro) in a patient with heparin antibodies who required rotational atherectomy.

Combination of fosinopril and pravastatin decreases platelet response to thrombin receptor agonist in monkeys

Both angiotensin-converting enzyme (ACE) inhibitors and 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors have been shown to decrease cardiovascular morbidity and mortality. Results from clinical trials have suggested that HMG-CoA reductase inhibition might exert a beneficial effect independent of its lipid-lowering effect, and ACE inhibition may exert a benefit independent of blood-pressure lowering. To test the hypothesis that such an effect might be mediated by alteration in platelet reactivity, we studied 55 monkeys receiving both, 1, or neither of the ACE inhibitor fosinopril and the HMG-CoA reductase inhibitor pravastatin. Platelet responsiveness to collagen and to the thrombin receptor agonist (TRA) SFLRRN-NH2 was determined by aggregometry. For each agonist, the maximum rate and extent of aggregation were measured for each dose, and the concentration required for half-maximal response (C50) was determined. Each drug, when given alone, slightly decreased the dose of agonist required to produce 50% response in the rate and extent of platelet aggregation relative to control. The combination of the 2 drugs, however, produced a significant increase in the dose of TRA required to produce 50% response in the rate and extent of aggregation relative to either drug alone or the control group. This was not true for collagen. The magnitude of the change relative to the control group, 47% for rate and 30% for extent of aggregation, could confer considerable protection by changing the threshold for thrombin-induced platelet aggregation and, thus, decrease thrombosis.

Terbutaline pump maintenance therapy for prevention of preterm delivery: a double-blind trial

OBJECTIVE

This study's aim was to determine whether maintenance therapy with terbutaline administered by pump prolongs gestation in women after treatment with intravenous magnesium sulfate tocolysis for suspected preterm labor.

STUDY DESIGN

Consenting women with a singleton gestation and intact membranes who had uterine contractions and >1 cm cervical dilation, 80% effacement, or progressive cervical change and whose contractions were successfully arrested with intravenous magnesium were randomly assigned to receive either terbutaline or normal saline solution placebo by subcutaneous infusion pump. Pump therapy was administered with a standardized protocol. Pump therapy was discontinued and parenteral magnesium was resumed if recurrent preterm labor developed while women were on the therapeutic regimen at <34 weeks' gestation and no contraindication for tocolysis existed. If recurrent labor was arrested, pump therapy was restarted according to the original treatment group. A sample size of 48 women was required to detect a 2-week intergroup difference in mean time to delivery. Analyses were based on intent to treat.

RESULTS

Fifty-two women received terbutaline (n = 24) or placebo (n = 28). At random assignment the groups were similar with respect to age, race, parity, previous preterm delivery, gestational age, and cervical examination. Overall there was a 1-day difference in mean time to delivery between the groups (terbutaline 29 +/- 22 days and placebo 28 +/- 23 days, P = .78). There were no differences in the rates of preterm delivery at <34 and <37 weeks' gestation. Neonatal outcomes were similar.

CONCLUSIONS

Maintenance terbutaline therapy administered by pump does not prolong gestation in women successfully treated for suspected preterm labor.

Maternal serum alpha-fetoprotein and dimeric inhibin A detect aneuploidies other than Down syndrome

OBJECTIVE

Our purpose was to determine whether the combination of maternal serum alpha-fetoprotein, free human chorionic gonadotropin-beta, dimeric inhibin A, and maternal age detects aneuploidies other than Down syndrome.

STUDY DESIGN

We retrieved stored serum from pregnancies complicated by aneuploidies other than Down syndrome from 1988 to 1997 (n = 55, mean maternal age 35.2 +/- 5.6 years). Alpha-fetoprotein levels were obtained from our database, and free human chorionic gonadotropin-beta and dimeric inhibin A levels were measured in the thawed serum with use of commercial assays. Analyte values were used in both 3-analyte and 2-analyte multiple-marker screening tests; detection rates were determined at several different Down syndrome risk-positive cutoff values.

RESULTS

In the 3-analyte test 58% (32/55) of all aneuploidies were detected with use of both the Down syndrome protocol at a screen-positive risk cutoff value of 1:300 (false-positive rate 17%) and a novel trisomy 18 screening algorithm. However, 67% (37/55) detection was obtained with use of the 2-analyte combination of alpha-fetoprotein and dimeric inhibin A, with both the Down syndrome protocol (screen positive cutoff value 1:300) and the trisomy 18 algorithm: 12 of 13 trisomy 18 (92%), 9 of 17 Turner's syndrome (53%), 10 of 17 other sex chromosome aneuploidies (59%), 1 of 1 trisomy 22 (100%), and 5 of 7 trisomy 13 (71%).

CONCLUSIONS

The combination of maternal serum alpha-fetoprotein, dimeric inhibin A, and maternal age detects autosomal trisomies other than Down syndrome at a rate superior to that of the traditional analyte combination.

Routine maternal platelet count: an assessment of a technologically driven screening practice

Because automated blood cell counters are now widely used in many clinical settings, an assessment of hemoglobin concentration or hematocrit is invariably accompanied by a platelet count. Thus many asymptomatic pregnant women are being screened for thrombocytopenia. The objective of a good screening program is to reduce morbidity and mortality and thereby improve the quality of life; criteria for the evaluation of proposed or ongoing screening programs are well established. However, the screening of pregnant women for thrombocytopenia seems to have been both technologically mandated and passively accepted. Therefore we systematically evaluated the current de facto screening of asymptomatic pregnant patients for thrombocytopenia in the context of well-explained, desirable characteristics for a successful screening program. We conclude that screening for thrombocytopenia in pregnancy fails to meet established criteria, may actually be harmful (by placing unaffected fetuses of thrombocytopenic women, and the women themselves, at risk from invasive procedures), and should therefore be discontinued.

Patterns of care study decision tree and management guidelines for esophageal cancer. American College of Radiology

PURPOSE

The Patterns of Care Study (PCS) of the American College of Radiology periodically develops a decision tree and current management guidelines for major malignancies where radiation has an important role. The decision tree is a framework which depicts the division of patients into treatment groups. The treatment guidelines are useful in management and also serve as a starting point for quality assessment. For the first time, PCS decided to develop consensus management guidelines for esophageal cancer.

MATERIALS AND METHODS

A consensus panel was convened to define the key issues and develop guidelines for esophageal cancer management. A modified Delphi process was used to achieve consensus.

RESULTS

The consensus panel developed guidelines for the management of patients with adenocarcinoma or squamous cell carcinoma of the esophagus with a Karnofsky performance status of over 50. Patients with clinical stage I or II esophageal cancer can be treated with curative intent using either a primary surgical or primary chemoradiation approach. For patients with clinical stage III malignancy, where the most common approaches are palliative, surgical resection is generally not recommended and chemoradiation is the preferred treatment.

CONCLUSION

The PCS has developed treatment guidelines for esophageal cancer based on consensus committee deliberations. These guidelines can be useful for those who manage esophageal cancer.

Radiation therapy for rectosigmoid and rectal cancer: results of the 1992-1994 Patterns of Care process survey

PURPOSE

To determine the US national practice standards for patients with adenocarcinoma of the rectum treated in radiation oncology facilities.

MATERIALS AND METHODS

A national survey of 57 institutions identified 507 eligible patients who received radiation therapy as a component of their treatment for rectal cancer. A stratified two-stage cluster sampling with simple random sampling at each stage for each stratum was used and on-site surveys were performed.

RESULTS

Of the 507 patients, 378 (75%) received postoperative therapy, 110 (22%) received preoperative therapy, 17 (2%) received both preoperative and postoperative therapy, and less than 0.5% received intraoperative radiation alone. To more accurately assess the utilization of modern radiation techniques as well as recommendations of the National Cancer Institute (NCI)-sponsored, randomized, postoperative, adjuvant combined modality therapy rectal cancer trials into current practice, the analysis was limited to the 243 (48%) patients with tumor, node, and metastasis staging system classification T3 and/or N1-2M0 disease who underwent conventional surgery with negative margins. Although only 7% were treated on a clinical trial, 90% received chemotherapy for a median of 21 weeks. Most were treated with modern radiation treatment techniques. In contrast, techniques to identify and help exclude the small bowel from the radiation field were not routinely used.

CONCLUSION

Despite the fact that only 7% of patients with T3 and/or N1-2M0 disease were treated on a clinical trial, such trials appear to have resulted in a positive influence on the standard of practice within the oncology community. Although there are still some deficiencies, the majority of these patients received combined modality therapy and were treated with modern radiation therapy techniques.

Pregnancy outcomes following sonographic nonvisualization of the fetal stomach

OBJECTIVE

To review pregnancy outcomes when two or more ultrasound scans persistently fail to visualize the fetal stomach.

METHODS

A computerized ultrasound database was used to identify all fetuses in which two or more serial ultrasound examinations failed to visualize the fetal stomach. Sonographic images were reviewed retrospectively, with the reviewer blinded to outcome data, to confirm persistent nonvisualization. Pregnancy outcome data were obtained from hospital charts and physicians' office records. Fetal karyotypes, when performed, were obtained from amniotic fluid (AF) culture. The ultrasound findings then were compared with fetal karyotype results and pregnancy outcome data.

RESULTS

Of 35,569 ultrasound scans performed during 1991-1996, 26 fetuses (0.07%) with persistently nonvisualized stomachs were identified. Structural defects were detected in 17 fetuses (65%), most often involving the cardiothoracic (n = 5), genitourinary (n = 4), and central nervous systems (n = 4). Karyotypes were obtained in 12 fetuses, and four of them were abnormal. Only five of 17 fetuses (29%) with a structural defect survived. In nine of 26 fetuses (35%) with persistently nonvisualized stomachs, no structural defect was identified. Each of these nine fetuses had abnormal AF volume in its surrounding sac, and the overall perinatal survival in fetuses without a structural defect was only 50%.

CONCLUSION

Fetuses with persistently nonvisualized stomachs have an increased incidence of structural defects and AF abnormalities and are more likely to have a poor outcome. A detailed ultrasound examination and fetal karyotype analysis should be performed to evaluate fetuses with persistently nonvisualized stomachs.

A randomized trial of misoprostol and extra-amniotic saline infusion for cervical ripening and labor induction

OBJECTIVE

To compare the cesarean rates in women undergoing induction of labor with unfavorable cervices who receive either misoprostol or extra-amniotic saline infusion.

METHODS

We assigned 250 women undergoing indicated induction of labor randomly to misoprostol (50 microg every 4 hours for three doses with or without oxytocin) or extra-amniotic saline infusion and oxytocin. Each eligible subject had a singleton gestation, vertex presentation, intact membranes, cervical dilation no more than 2 cm, and effacement no more than 50%.

RESULTS

Two hundred forty-eight women were studied after two exclusions; 120 were assigned to misoprostol, and 128 to extra-amniotic saline infusion. This sample size ensured an 80% chance of detecting an intergroup difference in cesarean rates of at least two-fold. The groups were similar in age, race, parity, indication for induction, and gestational age. The extra-amniotic saline infusion group had a significantly lower median initial dilation; however, at 12 hours, this group was significantly more dilated. The groups also were similar in epidural use, chorioamnionitis rates, endometritis rates, birth weights, and neonatal outcomes. Overall, 23% of women underwent cesarean deliveries, 18% and 27% for the misoprostol and extra-amniotic saline infusion groups, respectively (P = .12). There were no significant differences in the median time to either vaginal or cesarean delivery between the two groups. Eighty-one percent of women were delivered in less than 24 hours from initiation of induction; 78% in the misoprostol group, and 84% in the extra-amniotic saline infusion group (P = .19).

CONCLUSION

Both methods of labor induction appear to be equally effective in this group of women at high risk for cesarean delivery and prolonged induction of labor.

Intraoperative hypothermia and post-cesarean wound infection

OBJECTIVE

To determine whether intraoperative hypothermia during cesarean delivery is a risk factor for wound infection.

METHODS

Eighteen cases with wound infection and 18 controls matched for age, weight, presence of gestational hypertension, and surgery length were selected from a cohort of 900 women who underwent cesarean delivery and who were assessed for wound infection according to strict criteria. Because immediate postoperative temperatures reflect intraoperative temperature nadir accurately and were available universally, we compared the mean immediate postoperative temperatures between cases and controls.

RESULTS

In addition to the intentionally matched factors, the groups were well-matched for race, parity, presence of labor, presence of meconium, and duration of membrane rupture. The mean initial postoperative temperatures were similar between the two groups (36.3+/-0.9C versus 36.6+/-1.0C, respectively; P=.8). This study had a power of 90% to detect an intergroup difference of 1C.

CONCLUSION

In this case-control study of cesarean delivery, intraoperative hypothermia was not a risk factor for wound infection.

Treatment systems guidelines for primary rectal cancer from the 1996 Patterns of Care Study

PURPOSE

The Patterns of Care Rectal Cancer Committee was formed to develop consensus recommendations for patients with adenocarcinoma of the rectum limited to the pelvis.

METHODS AND MATERIALS

The Committee was composed of a multidisciplinary group of oncologists, and clinical scenarios were chosen to address most of the major treatment controversies in the combined modality treatment of rectal cancer. A literature search was then conducted and the major articles were identified. A modified Delphi technique was used to arrive at consensus. Serial surveys were conducted by distributing questionnaires to the Committee members to consolidate expert opinion. Voting was conducted using a scoring system and opinions were unified to the highest degree possible.

RESULTS

Consensus voting was performed for 4 clinical scenarios. Acceptability ratings for treatment were grouped into 3 broad categories: not acceptable, acceptable, and most acceptable. Based on the treatment options, a decision tree was developed that reflects the consensus of the committee.

CONCLUSION

These options may help guide treatment decisions in rectal cancer.

Does a high carbohydrate preparatory diet affect the 3-hour oral glucose tolerance test in pregnancy?

The aim of this study was to determine the effect of a high carbohydrate preparatory diet on the performance of the 3-hour oral glucose tolerance test (GTT) in pregnancy. This prospective clinical trial was performed at a university hospital outpatient obstetric clinic. Gravidas who had an abnormal blood sugar screening test were asked to ingest one of two preparatory diets: > or = 150g/day of carbohydrate for 3 days (Carbo) or six Snickers candy bars per day for 3 days (Candy), or to remain on their usual diet (Ad lib) prior to the GTT. A 100g oral GTT was performed after an overnight fast, and blood glucose values were determined at 1, 2, and 3 hours. Patients with either a fasting whole blood glucose > 120 mg/dl or > or = two abnormal values on the GTT were considered to have gestational diabetes mellitus and received diet therapy. Women who failed diet therapy also received insulin. Our primary outcome parameter was the intergroup incidence of gestational diabetes mellitus. Other parameters included the mean 1-, 2-, and 3-hour glucose values and the rates of both cesarean delivery and large-for-gestational age infants. Of the 354 women studied, 108 entered the Carbo group, 105 entered the Candy group, and 141 comprised the Ad Lib group. The three groups were comparable with regard to historic and demographic risk factors for gestational diabetes mellitus. After the GTT, 29% of the Carbo group were considered to have gestational diabetes mellitus vs. 28% in both the Ad lib and Candy groups (P = 0.98). Additionally, both the mean intergroup fasting, 1-hour, 2-hour, and 3-hour whole blood glucose values and selected clinical outcomes were similar (P = 0.35-0.99). Compared to usual dietary intake, recommending a high carbohydrate diet had a negligible effect on the 100g oral GTT in pregnancy.

Alopecia universalis associated with a mutation in the human hairless gene

There are several forms of hereditary human hair loss, known collectively as alopecias, the molecular bases of which are entirely unknown. A kindred with a rare, recessively inherited type of alopecia universalis was used to search for a locus by homozygosity mapping, and linkage was established in a 6-centimorgan interval on chromosome 8p12 (the logarithm of the odds favoring linkage score was 6.19). The human homolog of a murine gene, hairless, was localized in this interval by radiation hybrid mapping, and a missense mutation was found in affected individuals. Human hairless encodes a putative single zinc finger transcription factor protein with restricted expression in the brain and skin.

Significance of a false-positive trisomy 18 multiple-marker screening test

OBJECTIVE

To determine if a false-positive trisomy 18 multiple-marker screening test (all three analytes low: maternal serum alpha-fetoprotein [AFP] at most 0.75 multiples of the median [MoM], unconjugated estriol at most 0.60 MoM, and hCG at most 0.55 MoM) indicates increased risk for obstetric complications or is related to maternal weight.

METHODS

We accessed our genetic database to obtain multiple-marker screening test results, fetal karyotypes, and pregnancy outcomes from all patients with a normal multiple-marker screening test (n = 3900) and from all patients with a positive trisomy 18 screening test (n = 103) seen in the prenatal diagnosis clinic from 1992 to 1996. During this period, only maternal serum AFP was adjusted for maternal weight.

RESULTS

A positive trisomy 18 screen identified five of 12 trisomy 18 fetuses. Women with a false-positive trisomy 18 screen were heavier (175.6 +/- 43.8 lb versus 159.9 +/- 37.9 lb, P < .001) and younger (29.7 +/- 6.5 years versus 32.3 +/- 6.5 years, P < .001) than women with a normal multiple-marker screening test, but were not at increased risk for pregnancy complications. Weight-adjusting all three analytes reduced the false-positive trisomy 18 screen rate by 42% (from 1.9% to 1.1%) but did not change the trisomy 18 detection rate.

CONCLUSION

A false-positive trisomy 18 screening test does not indicate increased risk to develop pregnancy complications and may be related to inadequate correction for increased maternal weight.

Elevated second-trimester dimeric inhibin A levels identify Down syndrome pregnancies

OBJECTIVE

Our purpose was to determine whether second-trimester dimeric inhibin A levels distinguish Down syndrome pregnancies from euploid pregnancies.

STUDY DESIGN

With use of a commercially available enzyme-linked immunosorbent assay (Serotec, Oxford) inhibin A medians were established in stored sera from 40 to 50 euploid pregnancies at each week of gestation from 14 to 20 weeks and from 33 Down syndrome pregnancies. Maternal serum alpha-fetoprotein, unconjugated estriol, and human chorionic gonadotropin levels measured in each sample before storage were retrieved. The performance of inhibin A in the multiple-marker screening test was evaluated.

RESULTS

The mean inhibin A multiple of the median was significantly higher in the Down syndrome group than in the euploid group (2.84 +/- 2.0 vs 1.22 +/- 1.0, p = 0.0001). An inhibin A level > or = 1.6 multiples of the median identified 70% of all Down syndrome pregnancies at a false-positive rate of 22%. Replacing estriol with inhibin A in the multiple-marker screening test resulted in a higher Down syndrome detection rate at a lower screen-positive rate.

CONCLUSION

Elevated second-trimester maternal serum inhibin A levels identify Down syndrome pregnancies; replacing estriol with inhibin A in the multiple-marker screening test improves test performance.

Alpha-fetoprotein, free beta-human chorionic gonadotropin, and dimeric inhibin A produce the best results in a three-analyte, multiple-marker screening test for fetal Down syndrome

OBJECTIVE

The purpose of this study was to determine, among six second-trimester maternal serum analytes, the best three-analyte combination for fetal Down syndrome detection.

STUDY DESIGN

With use of commercially available assay kits, medians for free beta-human chorionic gonadotropin, CA 125, and dimeric inhibin A were established in stored sera from 45 to 50 euploid pregnancies at each week of gestation from 14 to 22 weeks and from 33 Down syndrome pregnancies. Maternal serum alpha-fetoprotein, unconjugated estriol, and intact human chorionic gonadotropin levels measured in each sample before storage were retrieved. All 20 possible three-analyte combinations were evaluated in the multiple-marker screening test for Down syndrome.

RESULTS

The mean maternal age of the study population was 35.6 +/- 5.3 years. The best three-analyte combination was maternal serum alpha-fetoprotein, free beta-human chorionic gonadotropin, and dimeric inhibin A: 97% of Down syndrome cases were detected at a false-positive rate of 16%. At a slightly higher false-positive rate (18%) maternal serum alpha-fetoprotein, estriol, and intact human chorionic gonadotropin detected only 79% of cases.

CONCLUSIONS

Of six second-trimester maternal serum analytes, the best three-analyte combination for fetal Down syndrome detection was maternal serum alpha-fetoprotein, free beta-human chorionic gonadotropin, and dimeric inhibin A. This retrospective analysis should now be confirmed prospectively.

Randomized trial of single-dose versus multiple-dose cefotetan for the postpartum treatment of intrapartum chorioamnionitis

OBJECTIVE

Our purpose was to determine whether a single postpartum dose of a cephalosporin would effectively treat women with intrapartum chorioamnionitis and decrease the length of hospitalization.

STUDY DESIGN

After vaginal delivery consenting women who had received antibiotics for chorioamnionitis were assigned to postpartum treatment with either a single 2 gm intravenous dose of cefotetan or to cefotetan 2 gm given intravenously every 12 hours for a minimum of 48 hours. Chorioamnionitis was defined as an intrapartum temperature of > or = 100.4 degrees F and maternal or fetal tachycardia, maternal leukocytosis, or uterine tenderness. Patients were discharged when they had received their assigned dosage of cefotetan, were afebrile (temperature < 100.4 degrees F) and > or = 24 hours from delivery.

RESULTS

We studied 109 women (55 single dose, 54 multiple dose) with chorioamnionitis. The two groups were similar with regard to demographic and intrapartum characteristics. The median (range) interval from delivery to discharge was 24 hours lower in the single-dose group (33 [16 to 190] vs 57 [36 to 190] hours, p = 0.0001). The incidence of failed therapy was similar (single dose: 6/55, 11%, vs multiple dose: 2/54, 3.7%, p = 0.27).

CONCLUSIONS

A single postpartum dose of cefotetan appears to be effective treatment for intrapartum chorioamnionitis after a vaginal delivery and decreases the length of hospital stay.