ST-segment analysis of the fetal electrocardiogram improves fetal heart rate tracing interpretation and clinical decision making

INTRODUCTION

Since its introduction into clinical use, the efficacy of electronic fetal heart rate (FHR) monitoring (EFM) has been questionable. This has been due partly to the marked variation in interpretation of the FHR pattern and subsequent decisions for obstetric intervention, (e.g., the need for prompt delivery). Current application of EFM is limited to the assessment of FHR patterns and uterine contractions. Recent development of higher-order FHR analysis has yielded monitoring systems that can add automated fetal electrocardiographic ST segment analysis to the standard FHR and uterine contraction information. Our goal was to evaluate the effect of adding ST segment analysis to standard FHR information on observer agreement for clinical decision making.

METHODS

Seven practitioners who were trained and experienced in combined FHR and ST monitoring reviewed 51 fetal monitor tracings, ranging from 2 to 4 h in length. Reviews were conducted in two sessions and at different times. The first session presented only the FHR and uterine contraction information, following which the participants determined the time at which intervention (decision for operative vaginal or Cesarean section delivery) was indicated. In the second session, the participants were provided with a randomized sequence of the same tracings with the addition of ST segment information, as produced by the STAN monitor system (Neoventa Medical, Gothenburg, Sweden). Observer agreement was based on the proportion of participants who agreed on the need for an intervention, and the per cent agreement on the timing of the intervention within 20 min before or after the median time of intervention.

RESULTS

Of the 51 cases included in this study there were ten fetuses with umbilical artery (UA) pH between 7.05 and 7.14, and nine with UA pH of < 7.05. Observer agreement increased significantly for required intervention when the ST segment information was available for tracing analysis as compared with review of the standard tracing alone (0.96 vs. 0.80, p < 0.05) and the timing of intervention (0.92 vs. 0.66, respectively, p < 0.05). Similarly, correct identification for needed interventions on fetuses with abnormal outcomes increased from 86 to 93% while unneeded interventions on normal fetuses decreased from 43 to 6%.

CONCLUSION

The addition of ST analysis to standard FHR monitoring improves observer consistency in both the decision for and timing of obstetric interventions. The incorporation of ST segment data with the standard FHR tracing may reduce the number of unneeded obstetric interventions when fetal compromise is absent.

Managing nonreassuring fetal heart rate patterns before cesarean delivery. Compliance with ACOG recommendations

OBJECTIVE

To determine the rate of compliance with current American College of Obstetricians and Gynecologists (ACOG) recommendations for management of parturients undergoing cesarean delivery for persistent nonreassuring fetal heart rate (FHR) tracings.

STUDY DESIGN

We performed a retrospective chart review (July 1995-June 1998) of all parturients who underwent cesarean delivery for nonreassuring FHR tracings. Outcome measures included maneuvers for fetal assessment (scalp stimulation or scalp blood pH) and therapeutic interventions (tocolytic agents for reducing uterine activity or amnioinfusion). Patients with multiple gestations and cesarean delivery for other indications were excluded. Student's t test, chi 2 and Fisher's exact tests were used; odds ratio and 95% confidence interval were calculated. P < .05 was considered significant.

RESULTS

Cesarean delivery for persistent nonreassuring FHR patterns included 134 (3.6%) of the 3,671 deliveries during three years. Thirty patients produced intrapartum FHR tracings containing persistent variable decelerations; 12 (40%) of these patients received amnioinfusion. In only 37% (50/134) of cases was there a documented attempt at scalp or acoustic stimulation prior to delivery. Scalp pH was obtained in 15% (15/98) of patients whose cervix was at least 3 cm dilated. Tocolytic agents were used for intrauterine resuscitation in 25% (34/134) of cases; their use varied significantly (P = .006) with the type of FHR abnormality.

CONCLUSION

At our tertiary center, ACOG recommendations for management of nonreassuring intrapartum FHR tracings were used in a limited number of cases.

Cloning and functional expression of ATA1, a subtype of amino acid transporter A, from human placenta

This report describes the primary structure and functional characteristics of human ATA1, a subtype of the amino acid transport system A. The human ATA1 cDNA was isolated from a placental cDNA library. The cDNA codes for a protein of 487 amino acids with 11 putative transmembrane domains. The transporter mRNA ( approximately 9.0 kb) is expressed most prominently in the placenta and heart, but detectable level of expression is evident in other tissues including the brain. When expressed heterologously in mammalian cells, the cloned transporter mediates Na(+)-coupled transport of the system A-specific model substrate alpha-(methylamino)isobutyric acid. The transport process is saturable with a Michaelis-Menten constant of 0. 89 +/- 0.12 mM. The Na(+):amino acid stoichiometry is 1:1 as deduced from the Na(+)-activation kinetics. The transporter is specific for small short-chain neutral amino acids. The gene for the transporter is located on human chromosome 12.

Differential influence of the 4F2 heavy chain and the protein related to b(0,+) amino acid transport on substrate affinity of the heteromeric b(0,+) amino acid transporter

We provide evidence here that b(0,+) amino acid transporter (b(0, +)AT) interacts with 4F2 heavy chain (4F2hc) as well as with the protein related to b(0,+) amino acid transporter (rBAT) to constitute functionally competent b(0,+)-like amino acid transport systems. This evidence has been obtained by co-expression of b(0, +)AT and 4F2hc or b(0,+)AT and rBAT in human retinal pigment epithelial cells and in COS-1 cells. The ability to interact with 4F2hc and rBAT is demonstrable with mouse b(0,+)AT as well as with human b(0,+)AT. Even though both the 4F2hc x b(0,+)AT complex and the rBAT x b(0,+)AT complex exhibit substrate specificity that is characteristic of system b(0,+), these two complexes differ significantly in substrate affinity. The 4F2hc x b(0,+)AT complex has higher substrate affinity than the rBAT x b(0,+)AT complex. In situ hybridization studies demonstrate that the regional distribution pattern of mRNA in the kidney is identical for b(0,+)AT and 4F2hc. The pattern of rBAT mRNA expression is different from that of b(0,+)AT mRNA and 4F2hc mRNA, but there are regions in the kidney where b(0,+)AT mRNA expression overlaps with rBAT mRNA expression as well as with 4F2hc mRNA expression.

Cesarean delivery for suspected fetal distress among preterm parturients

OBJECTIVE

Among preterm parturients (< 37 weeks) who underwent cesarean delivery for suspected fetal distress, to determine the factors associated with decision-incision time (DIT) of < or = 30 minutes and to assess if umbilical arterial pH < 7.10 is more common with DIT < or = 30 or > 30 minutes.

STUDY DESIGN

The peripartum course of all patients who had cesareans for suspected fetal distress over three years was reviewed. The inclusion criteria were reliable gestational age < 37 weeks and a single indication for cesarean delivery, suspected fetal distress. Twenty antepartum and intrapartum factors were used in a univariate analysis.

RESULTS

The mean DIT among the 84 parturients was 30.5 +/- 21.2 minutes, and 63% of patients had surgery started within 30 minutes. The incidence of pH < 7.10 was 20%. Multivariate analysis indicated that the two factors significantly associated with prolonged time to surgery were tachycardia with decreased variability (odds ratio [OR] 5.9, 95% confidence interval [CI] 1.6-21.6) and use of spinal anesthesia (OR 6.2, 95% CI 1.1-35.0). Though none of the 20 variables had significant univariate associations with neonatal acidosis at alpha = .05, those with P < .20 were considered in multiple logistic regression analysis. None of the 20 factors were associated with pH < 7.10, including DIT of > or = 30 minutes (OR 0.26, 95% CI 0.06-1.03).

CONCLUSION

DIT is likely to be > 30 minutes if cesarean delivery is due to decreased fetal heart variability or if spinal anesthesia is utilized; neonatal acidosis, however, is not significantly associated with a prolonged interval.

Structure, function, and genomic organization of human Na(+)-dependent high-affinity dicarboxylate transporter

We have cloned and functionally characterized the human Na(+)-dependent high-affinity dicarboxylate transporter (hNaDC3) from placenta. The hNaDC3 cDNA codes for a protein of 602 amino acids with 12 transmembrane domains. When expressed in mammalian cells, the cloned transporter mediates the transport of succinate in the presence of Na(+) [concentration of substrate necessary for half-maximal transport (K(t)) for succinate = 20+/-1 microM]. Dimethylsuccinate also interacts with hNaDC3. The Na(+)-to-succinate stoichiometry is 3:1 and concentration of Na(+) necessary for half-maximal transport (K(Na(+))(0.5)) is 49+/-1 mM as determined by uptake studies with radiolabeled succinate. When expressed in Xenopus laevis oocytes, hNaDC3 induces Na(+)-dependent inward currents in the presence of succinate and dimethylsuccinate. At a membrane potential of -50 mV, K(Suc)(0.5) is 102+/-20 microM and K(Na(+))(0.5) is 22+/-4 mM as determined by the electrophysiological approach. Simultaneous measurements of succinate-evoked charge transfer and radiolabeled succinate uptake in hNaDC3-expressing oocytes indicate a charge-to-succinate ratio of 1:1 for the transport process, suggesting a Na(+)-to-succinate stoichiometry of 3:1. pH titration of citrate-induced currents shows that hNaDC3 accepts preferentially the divalent anionic form of citrate as a substrate. Li(+) inhibits succinate-induced currents in the presence of Na(+). Functional analysis of rat-human and human-rat NaDC3 chimeric transporters indicates that the catalytic domain of the transporter lies in the carboxy-terminal half of the protein. The human NaDC3 gene is located on chromosome 20q12-13.1, as evidenced by fluorescent in situ hybridization. The gene is >80 kbp long and consists of 13 exons and 12 introns.

Electrogenic nature of rat sodium-dependent multivitamin transport

We report on the electrogenic nature of the transport process mediated by the rat sodium-dependent multivitamin transporter. In Cos-7 cells, the relationship of Na(+) concentration versus biotin and pantothenate uptake rate was sigmoidal with a Na(+):substrate stoichiometry of 2:1. In Cos-7 cells expressing rat SMVT biotin transport was significantly higher when the membrane was hyperpolarized and considerably reduced when the membrane was depolarized. Similarly, biotin uptake in X. laevis oocytes expressing rat SMVT was inhibited with depolarized oocyte membrane by altering the K(+) permeability across the membrane. It is concluded that the transport of biotin and pantothenate mediated by rat SMVT is electrogenic with a Na(+):substrate coupling ratio of 2:1 and that the transport process is associated with the transfer of one net positive charge across the membrane per transport cycle.

Sonographic measurements of fetal parts to predict pulmonary maturity among twins and singletons

To determine if sonographic examination of fetus can be readily utilized to predict a mature lecithin/sphingomyelin (L/S) ratio among twins and singletons. Twins (n = 36) undergoing amniocentesis for assessment of pulmonary maturity were matched with singleton (1:2) for maternal demographics, gestational age (GA), and indications for procedure. At the time of amniocentesis, twins and singletons with mature L/S ratios differed significantly in mean GA (33.2 +/- 2.7 vs 34.5 +/- 4.6 wks, p = 0.01), biparietal diameter (BPD), abdominal circumference (AC), femur length (FL) and estimate of birth weight (EFW). Based on ten receiver operating characteristics curves constructed, the following diagnostic thresholds predicted a mature L/S ratio with a true positive rate of 100% among twins and singletons, respectively: 1) BPD $84 and $92 mm; 2) head circumference $315 and $320 mm; 3) AC $295 and $350 mm; or 4) FL $64 and $72 mm; or 5) EFW $2400 and $3200 g. Using any one of these five criteria correctly identified pulmonary maturity among 59% of twins and 28% of singletons (p = 0.001). Sonographic measurement of fetal parts or EFW may be a noninvasive method to predict a mature L/S ration among twins as well as singletons.

Cloning and functional characterization of a Na(+)-independent, broad-specific neutral amino acid transporter from mammalian intestine

We have isolated a cDNA from a rabbit intestinal cDNA library which, when co-expressed with the heavy chain of the human 4F2 antigen (4F2hc) in mammalian cells, induces system L-like amino acid transport activity. This protein, called LAT2, consists of 535 amino acids and is distinct from LAT1 which also interacts with 4F2hc to induce system L-like amino acid transport activity. LAT2 does not interact with rBAT, a protein with a significant structural similarity to 4F2hc. The 4F2hc/LAT2-mediated transport process differs from the 4F2hc/LAT1-mediated transport in substrate specificity, substrate affinity, tissue distribution, interaction with D-amino acids, and pH-dependence. The 4F2hc/LAT2-associated transport process has a broad specificity towards neutral amino acids with K(t) values in the range of 100-1000 microM, does not interact with D-amino acids to any significant extent, and is stimulated by acidic pH. In contrast, the 4F2hc/LAT1-associated transport process has a narrower specificity towards neutral amino acids, but with comparatively higher affinity (K(t) values in the range of 10-20 microM), interacts with some D-amino acids with high affinity, and is not influenced by pH. LAT2 is expressed primarily in the small intestine and kidney, whereas LAT1 exhibits a much broader tissue distribution.

Perinatal outcome and amniotic fluid index in the antepartum and intrapartum periods: A meta-analysis

OBJECTIVE

Our purpose was to perform a meta-analysis of studies on the risks of cesarean delivery for fetal distress, 5-minute Apgar score <7, and umbilical arterial pH <7.00 in patients with antepartum or intrapartum amniotic fluid index >5.0 or <5.0 cm.

STUDY DESIGN

Using a MEDLINE search, we reviewed all studies published between 1987 and 1997 that correlated antepartum or intrapartum amniotic fluid index with adverse peripartum outcomes. The inclusion criteria were studies in English that associated at least one of the selected adverse outcomes with an amniotic fluid index of </=5.0 cm versus >5.0 cm. Contingency tables were constructed for each study, and relative risks and standard errors of their logs were calculated. Fixed-effects pooled relative risks were calculated for groups of studies that were homogeneous, whereas random-effects pooled relative risks were calculated for significantly heterogeneous groups of studies.

RESULTS

Eighteen reports describing 10,551 patients met our inclusion criteria. An antepartum amniotic fluid index of </=5.0 cm, in comparison with >5.0 cm, is associated with an increased risk of cesarean delivery for fetal distress (pooled relative risk, 2.2; 95% confidence interval, 1.5-3.4) and an Apgar score of <7 at 5 minutes (pooled relative risk, 5.2; 95% confidence interval, 2.4-11.3). An intrapartum amniotic fluid index of </=5.0 cm is also associated with an increased risk of cesarean delivery for fetal distress (pooled relative risk, 1.7; 95% confidence interval, 1.1-2.6) and an Apgar score <7 at 5 minutes (pooled relative risk, 1.8; 95% confidence interval, 1.2-2.7). A poor correlation between the amniotic fluid index and neonatal acidosis was noted in the only study that examined this end point. More than 23,000 patients are necessary to demonstrate that the incidence of umbilical arterial pH <7.00 is 1.5 times higher among those with oligohydramnios in labor than among those with adequate amniotic fluid index (alpha = 0.05; beta = 0.2)

CONCLUSIONS

An antepartum or intrapartum amniotic fluid index of </=5.0 cm is associated with a significantly increased risk of cesarean delivery for fetal distress and a low Apgar score at 5 minutes. There are few reports linking amniotic fluid index and neonatal acidosis, the only objective assessment of fetal well-being. A multicenter study with sufficient power should be undertaken to demonstrate that a low amniotic fluid index is associated with an umbilical arterial pH <7.00.

Nonstress testing and contraction stress testing

Antepartum fetal heart rate (FHR) testing, including the nonstress test and contraction stress test, has evolved in clinical usage over the past 3 decades. Although the nonstress test has become a standard of care in high-risk pregnancy, it has been modified by the use of fetal stimulation (vibroacoustic stimulation) and the addition of automated fetal movement recording (actocardiotocography). In all of its formats, antepartum FHR testing has been associated with reduction of preventable fetal loss. More recently, there have been attempts to improve test efficacy by computer-enhanced approaches.

Human Na(+)-dependent vitamin C transporter 1 (hSVCT1): primary structure, functional characteristics and evidence for a non-functional splice variant

We report here on the cloning and functional characterization of human Na(+)-dependent vitamin C transporter 1 (SVCT1). The human SVCT1 cDNA, obtained from a Caco2 cell cDNA library, encodes a protein of 598 amino acids with 12 putative transmembrane domains. The SVCT1-specific transcript, 2.4 kb in size, is expressed in kidney, liver, small intestine, thymus and prostate. When expressed heterologously in HRPE cells, SVCT1 mediates the transport of ascorbate, the reduced form of vitamin C, in a Na(+)-dependent manner. The transporter is specific for ascorbate with a K(t) of approximately 75 microM. The relationship between the cDNA-specific uptake rate of ascorbate and Na(+) concentration is sigmoidal with a Na(+):ascorbate stoichiometry of 2:1, indicating that the transport process is electrogenic. In Caco2 cells and in normal human intestine, SVCT1 also exists as a non-functional splice variant with a four amino acid sequence inserted between E-155 and V-156. The splice variant results from the use of a donor site 12 bp downstream of the normal donor site.

Cloning of the human thiamine transporter, a member of the folate transporter family

We have isolated a cDNA from human placenta, which, when expressed heterologously in mammalian cells, mediates the transport of the water-soluble vitamin thiamine. The cDNA codes for a protein of 497 amino acids containing 12 putative transmembrane domains. Northern blot analysis indicates that this transporter is widely expressed in human tissues. When expressed in HeLa cells, the cDNA induces the transport of thiamine (K(t) = 2.5 +/- 0.6 microM) in a Na(+)-independent manner. The cDNA-mediated transport of thiamine is stimulated by an outwardly directed H(+) gradient. Substrate specificity assays indicate that the transporter is specific to thiamine. Even though thiamine is an organic cation, the cDNA-induced thiamine transport is not inhibited by other organic cations. Similarly, thiamine is not a substrate for the known members of mammalian organic cation transporter family. The thiamine transporter gene, located on human chromosome 1q24, consists of 6 exons and is most likely the gene defective in the metabolic disorder, thiamine-responsive megaloblastic anemia. At the level of amino acid sequence, the thiamine transporter is most closely related to the reduced-folate transporter and thus represents the second member of the folate transporter family.

Cloning and expression of a b(0,+)-like amino acid transporter functioning as a heterodimer with 4F2hc instead of rBAT. A new candidate gene for cystinuria

We have cloned a transporter protein from rabbit small intestine, which, when coexpressed with the 4F2 heavy chain (4F2hc) in mammalian cells, induces a b(0,+)-like amino acid transport activity. This protein (4F2-lc6 for the sixth member of the 4F2 light chain family) consists of 487 amino acids and has 12 putative transmembrane domains. At the level of amino acid sequence, 4F2-lc6 shows significant homology (44% identity) to the other five known members of the 4F2 light chain family, namely LAT1 (4F2-lc1), y(+)LAT1 (4F2-lc2), y(+)LAT2 (4F2-lc3), xCT (4F2-lc4), and LAT2 (4F2-lc5). The 4F2hc/4F2-lc6 complex-mediated transport process is Na(+)-independent and exhibits high affinity for neutral and cationic amino acids and cystine. These characteristics are similar to those of the b(0,+)-like amino acid transport activity previously shown to be associated with rBAT (protein related to b(0,+) amino acid transport system). However, the newly cloned 4F2-lc6 does not interact with rBAT. This is the first report of the existence of a b(0,+)-like amino acid transport process that is independent of rBAT. 4F2-lc6 is expressed predominantly in the small intestine and kidney. Based on the characteristics of the transport process mediated by the 4F2hc/4F2-lc6 complex and the expression pattern of 4F2-lc6 in mammalian tissues, we suggest that 4F2-lc6 is a new candidate gene for cystinuria.

Human placental sodium-dependent vitamin C transporter (SVCT2): molecular cloning and transport function

We report here on the cloning and functional characterization of human SVCT2, a sodium-dependent vitamin C (ascorbate) transporter. The hSVCT2 cDNA obtained from a human placental choriocarcinoma cell cDNA library, codes for a protein of 650 amino acids with a predicted molecular mass of 70 kDa. At the level of amino acid sequence, the human SVCT2 exhibits 95% identity to its rat homolog. When functionally expressed in mammalian cells, hSVCT2 induces the transport of ascorbic acid. The transport process induced by hSVCT2 is Na(+)-dependent and is specific for ascorbate. The Michaelis-Menton constant (K(t)) for the transport of ascorbate in cDNA-transfected cells is 69 +/- 5 microM. The relationship between the cDNA-specific uptake rate of ascorbate and Na(+) concentration is sigmoidal with a Na(+):ascorbate stoichiometry of 2:1. Northern blot analysis shows that SVCT2-specific transcripts are present in heart, brain, placenta, and liver and is absent in lung and skeletal muscle. The size of the principal transcript is approximately 7.5 kb.

Fetal acoustic stimulation in early labor and pathological fetal acidemia: a preliminary report

OBJECTIVE

To determine if a nonreactive response to fetal acoustic stimulation in early labor can predict a significantly higher risk of umbilical arterial pH <7.10 or <7.00.

METHODS

Fetal acoustic stimulation was applied to the fetuses of term parturients (gestational age > or =37 weeks) with cervical dilation of < or =5 cm. The responses to stimulation were correlated with cesarean delivery for fetal distress and umbilical arterial pH. Student's t-test, Chi-square, and Fisher exact test were used; P < 0.05 was considered significant. Relative risks (RR) and 95% confidence intervals (CI) were calculated.

RESULTS

The study population contained 271 subjects, of which 90% (244) had a reactive response following acoustic stimulation and 10% (27) a nonreactive response. The maternal demographics, time interval from stimulation to delivery (8.3 +/- 8.7 vs. 8.3 +/- 8.4 h; P = 1.00) were similar in the two groups. Compared to those with a reactive response, patients with a nonreactive response had a significantly greater risk for: 1) cesarean delivery for fetal distress (2.0% vs. 11.1%; P = 0.03, RR 4.1, 95% Cl 1.5, 60.5), 2) umbilical arterial pH <7.10 (2.0% vs. 14.8%; P = 0.007, RR 5.0, 95% CI 2.2, 11.6), and 3) umbilical arterial pH <7.00 (0.8% vs. 7%; P = 0.05, RR 5.0, 95% CI 1.8, 15.2).

CONCLUSION

A nonreactive response to fetal acoustic stimulation in early labor is associated with a significantly increased risk for cesarean delivery for fetal distress and neonatal acidosis. This finding extends the potential value of acoustic stimulation as an intrapartum admission screening test.

Cannabinoid receptors and their role in the regulation of the serotonin transporter in human placenta

OBJECTIVE

We sought to investigate the expression of cannabinoid receptors in human placenta and BeWo choriocarcinoma cells and study their role in the regulation of the serotonin transporter.

STUDY DESIGN

Expression of the 2 types of cannabinoid receptors (CB1 and CB2) in human placenta and BeWo cells was investigated by reverse transcriptase-polymerase chain reaction and Northern blot analysis. The involvement of the receptors in the regulation of the serotonin transporter expression was studied by using a cannabinoid receptor agonist (WIN 55212-2). BeWo cells were treated with the agonist in the presence or absence of forskolin, and the serotonin transporter activity was measured by assessing paroxetine-sensitive serotonin transport. Serotonin transporter density in cell membranes was monitored by measuring paroxetine-sensitive binding of RTI-55, a specific high-affinity ligand for the transporter. Agonist-induced changes in intracellular levels of cyclic adenosine monophosphate were also monitored.

RESULTS

Reverse transcriptase-polymerase chain reaction and Northern blot analysis demonstrated unequivocally that human placenta and BeWo cells express both types of cannabinoid receptors. Treatment of BeWo cells with the receptor agonist blocked the activity of the constitutive, as well as the forskolin-induced, serotonin transporter without affecting the serotonin transporter density. This effect is not mediated by alterations in intracellular cyclic adenosine monophosphate levels.

CONCLUSION

The results show that cannabinoid receptors are expressed in human placenta and BeWo cells and play a role in the regulation of the serotonin transporter activity. Human placenta is therefore a direct target for cannabinoids, and marijuana use during pregnancy is likely to affect the placental clearance of serotonin through the serotonin transporter.

Molecular and functional characterization of the intestinal Na+-dependent multivitamin transporter

We have cloned a Na+-dependent multivitamin transporter from rabbit intestine (riSMVT). The cDNA codes for a protein of 636 amino acids with 12 putative transmembrane domains. When expressed in mammalian cells, the cDNA induces Na+-dependent uptake of the vitamins pantothenate and biotin. Lipoate is also a substrate for the cDNA-induced uptake process. The affinity constant for the cDNA-specific transport of pantothenate and biotin is approximately 2 and approximately 8 microM, respectively. The Na+:vitamin stoichiometry is greater than 1, indicating that the transport process is electrogenic. The SMVT-specific transcripts of 3.2 kbp are equally distributed throughout the small intestine. We have also cloned SMVT from the human intestinal cell line Caco-2. The Caco-2 SMVT cDNA codes for a protein of 635 amino acids which is homologous to riSMVT and is identical to the SMVT expressed in the human choriocarcinoma cell line JAR. Caco-2 SMVT also catalyzes Na+-dependent uptake of pantothenate, biotin, and lipoate. In oocytes expressing Caco-2 SMVT, all three vitamins evoke inward currents, confirming the electrogenicity of the transport process.

Human placental Na+-dependent multivitamin transporter. Cloning, functional expression, gene structure, and chromosomal localization

We have cloned the human Na+-dependent multivitamin transporter (SMVT), which transports the water-soluble vitamins pantothenate, biotin, and lipoate, from a placental choriocarcinoma cell line (JAR). The cDNA codes for a protein of 635 amino acids with 12 transmembrane domains and 4 putative sites for N-linked glycosylation. The human SMVT exhibits a high degree of homology (84% identity and 89% similarity) to the rat counterpart. When expressed in HRPE cells, the cDNA-induced transport process is obligatorily dependent on Na+ and accepts pantothenate, biotin, and lipoate as substrates. The relationship between the cDNA-specific uptake rate of pantothenate or biotin and Na+ concentration is sigmoidal with a Na+:vitamin stoichiometry of 2:1. The human SMVT, when expressed in Xenopus laevis oocytes, induces inward currents in the presence of pantothenate, biotin, and lipoate in a Na+-, concentration-, and potential-dependent manner. We also report here on the structural organization and chromosomal localization of the human SMVT gene. The SMVT gene is approximately 14 kilobase pairs in length and consists of 17 exons. The SMVT gene is located on chromosome 2p23 as evidenced by somatic cell hybrid analysis and fluorescence in situ hybridization.

Risk factors associated with blood transfusion in ectopic pregnancy

OBJECTIVE

To determine the risk factors associated with blood transfusion in ectopic pregnancy.

STUDY DESIGN

A retrospective chart review of the presentation and hospital course of ectopic pregnancies managed over five years at two hospitals was undertaken. Thirty-two variables, including demographics, presenting signs and symptoms, and intraoperative findings, were examined with univariate and multivariate logistic modeling.

RESULTS

Among 185 patients with histologically confirmed ectopics who were managed surgically, 8.6% (16 women) required transfusion. Multivariate analysis of risk factors for blood transfusion demonstrated a statistically significant association with (1) initial hemoglobin < 10 g/dL (odds ratio [OR] 38.8, 95% confidence interval [CI] 6.0-356.8); (2) human chorionic gonadotropin levels > or = 6,500 mIU (OR 18.1, 95% CI 3.6-158.1); and (3) abnormal bleeding on presentation (OR 0.08, 95% CI 0.007-0.42). The presence of two of these factors had a sensitivity of 82% (95% CI 48-98%) and a positive predictive value of 33% (95% CI 16-54%). No case had all three factors.

CONCLUSION

This study was, to our knowledge, the first regression analysis of risk factors for transfusion associated with ectopic pregnancy. It demonstrated that initial hemoglobin and human chorionic gonadotropin levels as well as abnormal bleeding on presentation are independent risk factors for blood transfusion in ectopic pregnancy.

Detection of growth-restricted fetuses in preeclampsia: a case-control study

OBJECTIVE

To determine the diagnostic accuracy of detecting growth-restricted fetuses in women with and without preeclampsia.

METHODS

Over 2 years, parturients with reliable gestational ages, preeclampsia, and sonographic estimates of birth weights were matched (1:1) for gestational age with women without preeclampsia. Paired and unpaired t tests were used; P < .05 was significant. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

Two hundred eighty-seven preeclamptic women were identified and matched. In each group, mean (+/- standard deviation [SD]) gestational age was 34.9 +/- 4.2 weeks, and 166 (57.8%) infants were born preterm. Fetal growth restriction (FGR) was significantly more common among women with preeclampsia (14.9%) than among controls (5.6%; OR 2.98, 95% CI 1.64, 5.44). The percentage of sonographic estimates within 10% of actual birth weight (57.5% versus 53.6%) was similar in the two groups (OR 1.16; 95% CI 0.84,1.62). Compared with normal growth, the mean (+/- SD) standardized absolute error was significantly higher among those with FGR regardless of group (preeclampsia 109 +/- 100 versus 158 +/- 152 g/kg; P = .009; control 117 +/- 103 versus 233 +/- 206 g/kg; P < .001). Fetal growth restriction was detected more commonly among preeclamptic women than among controls (11.6% versus 0%; OR 4.74 95% CI 0.25, 90.31). The sensitivity and positive predictive value of FGR detection were 10% and 50%, respectively, among women with preeclampsia and 0% each among controls.

CONCLUSION

Although FGR was detected more frequently in fetuses of women with preeclampsia than in those of controls, the ability to predict it with sonography remained poor.

Primary structure and functional characteristics of a mammalian sodium-coupled high affinity dicarboxylate transporter

We have cloned a Na+-dependent, high affinity dicarboxylate transporter (NaDC3) from rat placenta. NaDC3 exhibits 48% identity in amino acid sequence with rat NaDC1, a Na+-dependent, low affinity dicarboxylate transporter. NaDC3-specific mRNA is detectable in kidney, brain, liver, and placenta. When expressed in mammalian cells, NaDC3 mediates Na+-dependent transport of succinate with a Kt of 2 microM. The transport function of NaDC3 shows a sigmoidal relationship with regard to Na+ concentration, with a Hill coefficient of 2.7. NaDC3 accepts a number of dicarboxylates including dimethylsuccinate as substrates and excludes monocarboxylates. Li+ inhibits NaDC3 in the presence of Na+. Transport of succinate by NaDC3 is markedly influenced by pH, the transport function gradually decreasing when pH is acidified from 8. 0 to 5.5. In contrast, the influence of pH on NaDC3-mediated transport of citrate is biphasic in which a pH change from 8.0 to 6. 5 stimulates the transport and any further acidification inhibits the transport. In addition, the potency of citrate to compete with NaDC3-mediated transport of succinate increases 25-fold when pH is changed from 7.5 to 5.5. These data show that NaDC3 interacts preferentially with the divalent anionic species of citrate. This represents the first report on the cloning and functional characterization of a mammalian Na+-dependent, high affinity dicarboxylate transporter.

Intrapartum amniotic fluid index: a poor predictor of abnormal fetal size

OBJECTIVE

Using receiver-operating characteristic (ROC) curves, we tried to determine the diagnostic threshold of amniotic fluid index (AFI) that will identify abnormal fetal size (birth weights under 2500 g or at least 4000 g) at 37 weeks or beyond.

METHODS

We analyzed prospectively over 2 years all parturients with intact membranes and known AFI in early labor. Patients with the following conditions were excluded: pregestational or gestational diabetes, known anomalies, and preterm labor. Two ROC curves were constructed, and the areas (+/- standard error of the mean [SE]) under the curves were calculated. P < .05 was considered significant.

RESULTS

Of the 1038 subjects meeting study criteria, 3.6% and 11.5% gave birth to infants who were small for gestational age (SGA) or macrosomic, respectively. Overall, 28.7% had oligohydramnios (AFI at most 5.0 cm) and 3.6% had hydramnios (AFI at least 24.0 cm). Small for gestational age was more common in patients with AFI at most 5.0 cm (6.4%) than in those with adequate fluid (AFI 5.1-23.9; 2.5%), or hydramnios (2.7%; P = .012). Macrosomic newborns were less likely to be born to women with oligohydramnios (7.7%) than to those with adequate amniotic fluid (13.1%) or hydramnios (13.5%). Areas under ROC curves are not significantly different from the area under the nondiagnostic line, indicating that AFI (0-34 cm) cannot differentiate between newborns under 2500 g and at or over 2500 g or under 4000 and at or more 4000 g.

CONCLUSION

Intraparterium AFI appears to be a poor screening test to identify risk for delivery of SGA or macrosomic fetus.

Ultrasonographic estimate of birth weight at 24 to 34 weeks: a multicenter study

OBJECTIVE

The study was intended to compare the accuracies of ultrasonographic estimates of birth weights among infants born between 24 and 34 weeks' gestation at 3 tertiary centers.

STUDY DESIGN

In this retrospective study subjects were matched for gestational age (1:1); all underwent ultrasonographic examination within 2 weeks of delivery. The estimates of birth weight were obtained according to 26 published regression equations and their accuracies were assessed with the mean standardized absolute error. For each center the equation with the lowest error was selected to generate (1) receiver-operating characteristic curves for an estimate to identify actual weight < 1500 g and (2) prediction limit calculations to determine the estimate that ensures at 70% confidence a birth weight > 1500 g.

RESULTS

One hundred seventy-one cases were analyzed at each center. Comparison of the 26 mean standardized errors at each center indicated that (1) the range was rather wide (eg, 89 +/- 87 to 365 +/- 313 g/kg) and (2) 73% (19/26) of the equations had significantly (P < .05) different accuracies. Receiver-operator characteristic curves show that fetal weight estimates of > or = 1600 g at 2 centers and > or = 1700 g at the third center are required to predict actual birth weight < 1500 g. Prediction limit calculation suggests that different fetal weight estimates (> 1600 g at center 1, > 1900 g for the center II, and > 1800 g at center III) are needed to predict actual weight > 1500 g with a 70% accuracy.

CONCLUSIONS

Ultrasonographic estimates of weight for preterm infants, as obtained from 26 equations, are characterized by a rather wide range of accuracy; for most of the equations the accuracies of estimates differ markedly among centers.

Unengaged vertex in nulliparous women in active labor. A risk factor for cesarean delivery

OBJECTIVE

To compare the route of delivery among nulliparous parturients with and without an engaged vertex in the early, active phase of labor.

METHODS

Prospectively, the position of the fetal head was ascertained among nulliparous women at 37 weeks' gestation or more in early, active labor (cervical dilation > or = 4 cm with adequate contractions). Sixteen variables, including maternal demographics, obstetric complications and intrapartum course, were examined using chi 2 and logistic regression analysis.

RESULTS

Among the 77 patients, 33 (42.8%) had an unengaged vertex and 44 (57.2%) had an engaged vertex in active labor. Of the 22 cesarean deliveries for arrest disorder, 2 were in the engaged and 20 in the unengaged group (P < .001). The mean birth weight was similar among those who had vaginal (3,211 +/- 416 g) and cesarean delivery (3,400 +/- 489 g, P = .08). Univariate analysis indicated that chorioamnionitis (relative risk [RR] 2.6, 95% confidence interval [CI] 1.4-4.9) and unengaged vertex (RR 13.3, CI 3.3-53.0) were associated with cesarean delivery for arrest disorders. When entered into a multiple logistic model, only unengagement was a risk factor for cesarean delivery. The following were not associated with cesarean delivery: maternal demographics, gestational age, estimate of fetal weight, presence or absence of meconium, preeclampsia, diabetes mellitus, private obstetric care or use of epidural anesthesia.

CONCLUSION

Among nulliparous parturients, an unengaged vertex is a significant risk factor for cesarean delivery for arrest disorders.

An analysis of risk factors associated with blood transfusion in ectopic pregnancy

Objective: To determine the risk factors associated with blood transfusion in ectopic pregnancy.Methods: A retrospective chart review of the presentation and hospital course of ectopic pregnancies managed over 5 years at two hospitals was undertaken. Thirty-two variables, including demographics, presenting signs and symptoms, and intraoperative findings, were examined in univariate and multivariate logistic modeling.Results: Among 185 patients with histologically confirmed ectopic pregnancies who were managed surgically, 8.6% or 16 women required transfusion. Multivariate analysis of risk factors for blood transfusion demonstrated a statistically significant association with 1) initial hemoglobin <10 g/dL (odds ratio [OR] 38.8, 95% confidence interval [CI] 6.0-356.8) and 2) hCG levels >/= 6500 mIU (OR 18.1, 95% CI 3.6-158.1), as well as 3) abnormal bleeding on presentation (OR 0.08, 95% CI 0.007-0.42. Presence of two of these factors has a sensitivity of 82% (95% CI 48-98%) and a positive predictive value of 33% (95% CI 16-54%). No case had all three factors present.Conclusion: This report is, to our knowledge, the first regression analysis of risk factors for transfusion associated with ectopic pregnancy. It demonstrates that initial hemoglobin and hCG levels as well as abnormal bleeding on presentation are independent risk factors for blood transfusion in ectopic pregnancy.

Cloning and functional expression of a cDNA encoding a mammalian sodium-dependent vitamin transporter mediating the uptake of pantothenate, biotin, and lipoate

Previous studies have shown that a Na+-dependent transport system is responsible for the transplacental transfer of the vitamins pantothenate and biotin and the essential metabolite lipoate. We now report the isolation of a rat placental cDNA encoding a transport protein responsible for this function. The cloned cDNA, when expressed in HeLa cells, induces Na+-dependent pantothenate and biotin transport activities. The transporter is specific for pantothenate, biotin, and lipoate. The Michaelis-Menten constant (Kt) for the transport of pantothenate and biotin in cDNA-transfected cells is 4.9 +/- 1.1 and 15.1 +/- 1.2 microM, respectively. The transport of both vitamins in cDNA-transfected cells is inhibited by lipoate with an inhibition constant (Ki) of approximately 5 microM. The nucleotide sequence of the cDNA (sodium-dependent multivitamin transporter (SMVT)) predicts a protein of 68.6 kDa with 634 amino acids and 12 potential transmembrane domains. Protein data base search indicates significant sequence similarity between SMVT and known members of the Na+-dependent glucose transporter family. Northern blot analysis shows that SMVT transcripts are present in all of the tissues that were tested. The size of the principal transcript is 3.2 kilobases. SMVT represents the first Na+-dependent vitamin transporter to be cloned from a mammalian tissue.

Bishop score: a poor diagnostic test to predict failed induction versus vaginal delivery

BACKGROUND

We evaluated the accuracy of the Bishop score in predicting the likelihood of successful labor induction (entry into active phase) in nulliparous and multiparous women.

METHODS

During an index year, all patients having induction of labor and a preinduction Bishop score were included in a standard protocol for cervical ripening and use of oxytocin. Receiver-operating characteristic (ROC) curves were constructed for Bishop scores (0 to 11) to predict abdominal delivery for failed induction (final cervical dilation <4 cm) versus vaginal delivery.

RESULTS

Parturients who had vaginal delivery (n = 253) and those in whom attempted induction failed (n = 38) did not differ significantly with respect to maternal demographics, length of gestation, Bishop score and its distribution, and infant birth weight. The area under the ROC curve did not differ significantly from the area under the nondiagnostic line.

CONCLUSION

The Bishop score appears to be a poor predictor of the outcome of labor induction.

Limitations of clinical and sonographic estimates of birth weight: experience with 1034 parturients

OBJECTIVE

To compare the accuracy of clinical and sonographic estimates of fetal weight made throughout the third trimester of pregnancy.

METHODS

Patients in early labor had fetal weight estimated by two approaches: 1) clinical evaluation and palpation followed by 2) sonographic mensuration of fetal biparietal diameter, abdominal circumference, and femur length applied to Hadlock's formula. The accuracy of these two methods of estimating fetal weight was compared using Student t test, Wilcoxon test, and chi2 tests. P < .05 was considered significant. Prediction limits (50th, 90th, and 95th percentiles) were calculated for both techniques by obtaining the range of actual weights associated for a particular estimated fetal weight (EFW).

RESULTS

We enrolled 1034 parturients whose clinical EFWs yielded significantly higher mean (+/- standard deviation) simple error (48.2 +/- 411 g) and standardized absolute error (130 +/- 122 g/kg) than were obtained by use of sonographic formulas for EFW (-6.6 +/- 381 g and 104 +/- 89 g/kg, respectively). When the population was partitioned by gestational age, we found that sonographic EFW was more accurate than clinical EFW in preterm (n = 373) but not in term (n = 460) or post-term (n = 201) pregnancies. Prediction limits indicate that for a given EFW, for example, 800 g, the 90% ranges of actual weight based on clinical and sonographic EFW are 566-1829 g and 469-1667 g, respectively.

CONCLUSION

The apparent superiority of sonographic EFW over clinical EFW applies principally to preterm pregnancies. The prediction limitation calculation suggests that either method, for any particular estimate between 500 and 4500 g, has limited value in the estimation of actual birth weight, because this outcome is highly variable and frequently lies outside of the useful bandwidth (+/- 10%) for prospective management.

Ultrasonographic assessment of amniotic fluid does not reflect actual amniotic fluid volume

OBJECTIVE

Our objective was to compare the ability of two methods of amniotic fluid assessment (two-diameter amniotic fluid pocket versus the amniotic fluid index) to predict oligohydramnios (actual amniotic fluid volume < 500 ml) or polyhydramnios (actual amniotic fluid volume > 1500 ml).

STUDY DESIGN

The amniotic fluid index and the two-diameter amniotic fluid pocket were assessed before amniocentesis and determination of amniotic fluid volume with the dye (aminohippurate sodium)-dilution technique. To assess the detection of either oligohydramnios or polyhydramnios, the areas under the receiver-operator characteristic curves (+/-SE) were estimated by the point-to-point trapezoidal method of integration. Prediction limits were calculated by regression analysis of amniotic fluid index or two-diameter amniotic fluid pocket versus actual amniotic fluid volume and determination of 95th percentile ranges for amniotic fluid volume.

RESULTS

We studied 144 patients with a mean (+/-SD) gestational age of 31.7 +/- 5.5 weeks; mean (+/-SD) amniotic fluid index and two-diameter amniotic fluid pocket were 12.6 +/- 6.1 cm and 21.2 +/- 18.4 cm2, respectively. Mean (+/-SD) actual amniotic fluid volume was 722 +/- 735 ml (range 101 to 4318 ml). The areas under the four receiver-operator characteristic curves were not significantly different from the nondiagnostic line (p < 0.05). Regression slopes (r values) for amniotic fluid index and two-diameter amniotic fluid pocket versus actual amniotic fluid volume were 0.34 and 0.23, respectively. Calculation of the prediction limit for 95% confidence that oligohydramnios is absent requires that the amniotic fluid index be 30 cm and the two-dimension amniotic fluid pocket be 90 cm2, both thresholds of which are currently considered to represent clinical polyhdramnios.

CONCLUSIONS

Both amniotic fluid index and two-dimension amniotic fluid pocket appear to be inaccurate predictors of actual oligohydramnios or polyhydramnios when compared with dye-dilution calculations of actual amniotic fluid volume.

Managed care in obstetrics

Managed care has marched relentlessly through all fields of obstetric care: individual and group practices, proprietary hospitals and academic medical centers, and public health systems. Emphasis on cost containment while preserving high quality has driven the redesign of healthcare delivery. A number of models for providing effective and less expensive obstetric care are now being examined in the USA and abroad. Increased market penetration by managed care will also exert profound and possibly harmful effects on traditional academic teaching institutions. These organizations must adapt to this new environment or face the erosion of physician support and training bases. Ultimately, significant moral and ethical dilemmas will arise when patients' best interests for care are being continually brought into conflict with the physician's need to earn a living.

Intrapartum oligohydramnios does not predict adverse peripartum outcome among high-risk parturients

OBJECTIVE

Oligohydramnios can be defined by an amniotic fluid index < 5th percentile for gestational age or an amniotic fluid index < or = 5.0 cm regardless of gestational age. The purpose of this prospective study was to determine whether oligohydramnios by either definition predicts accurately, in a high-risk population, the risks for cesarean section for fetal distress, Apgar score < 7 at 5 minutes, and neonatal acidosis.

STUDY DESIGN

An amniotic fluid index was obtained in 490 consecutive parturients with medical or obstetric complications and a reliable gestational age. After each delivery, an umbilical arterial blood gas analysis was obtained. Both measures of amniotic fluid index were rated as screening tests with use of sensitivity, specificity, predictive values, and receiver-operator characteristic curves.

RESULTS

The incidences of cesarean section for fetal distress and umbilical arterial pH < 7.00 were 14% and 1.8%, respectively. The 70 neonates delivered by cesarean section for distress, compared with the 420 without, had a significantly higher incidence of pH < 7.00 (8.5% vs 0.7%, p = 0.0004, relative risk 5.0, 95% confidence interval 2.9 to 8.4). Sensitivity and positive predictive values of an amniotic fluid index < 5th percentile for gestational age to predict pH < 7.00 were 0.8% and 22%, respectively, and for an amniotic fluid index < or = 5.0 cm, 0.5% and 11%, respectively. Receiver-operator characteristic curves indicate that an amniotic fluid index between 0 and 20 cm cannot predict accurately which parturients will have cesarean sections for distress or be delivered of a newborn with a low Apgar score at 5 minutes or a pH < 7.10.

CONCLUSION

Both criteria for oligohydramnios are poor predictors of adverse outcome for high-risk intrapartum patients.

Sonographic examination does not predict twin growth discordance accurately

OBJECTIVE

To assess the accuracy of estimating birth weight among twins with discordancy (intra-pair difference in actual birth weight of more than 25%) and to determine the relative accuracy of an intra-pair difference in abdominal circumference (delta AC) of 20 mm or more or in estimated fetal weight (delta EFW) of 25% or more for the identification of discordant growth in twins.

METHODS

Over a 6-year period, we identified all non-anomalous twin pairs with gestational ages greater than 23 weeks and sonographic examinations within 3 weeks of birth. Ultrasonographic biometry of both twins included AC, head circumference, and femur length; these indices were used to estimate fetal weight by Hadlock's formula. Likelihood ratios, receiver-operating characteristic curves, and prediction limits were applied to assess the accuracy of the two diagnostic methods to predict an abnormal outcome.

RESULTS

A total of 242 twin pairs were studied. The mean gestational age among the 21 twins with abnormal growth (30.6 +/- 4.6 weeks) was significantly less than among the 221 twins with normal growth (33.2 +/- 4.0 weeks) (P < .005). The biometric measurements of fetal parts, sonographic estimate of fetal weight, and actual birth weight for both fetuses were significantly less for discordant twin pairs (P < .05). The accuracy of predicting birth weight, as determined by mean error and percentage of the estimate within 10% of the actual weight, was similar between the groups. Receiver-operating characteristic curves showed that both diagnostic tests yielded areas under the two curves not significantly different from the area under the nondiagnostic line (P > .05). Most important, prediction limit calculations indicated that a 90% certainty that the actual birth weight discordance was at least 25% was achievable only if delta AC was 172 mm or greater or delta EFW was 112% or more.

CONCLUSION

The most popular current methods (difference in AC or EFW) for predicting discordant growth in twin gestations have limited accuracy when held to a standard for discordance that requires a birth weight difference of at least 25%.

Predicting the duration of the first stage of spontaneous labor using a neural network

To create a neural network that predicts the length of the first stage of term labor. Two hundred patients with gestations > or = 36 weeks, in spontaneous active labor are the study group: 159 for training and 41 for testing; 4 training set patients had second-stage cesarean section for obstructed labor. The network is designed with Brainmaker MacIntosh 1.0 (California Scientific Software). Inputs are uterine activity, estimated fetal weight, position, station, and gestational age; maternal parity, age, height, weight, membrane status, and cervical dilatation. Actual first stages are regressed on those predicted by the network or by a standard partogram set. Differences between actual first stage lengths and those predicted by the neural network or partogram are compared with t-tests; while the proportions of first stages accurately predicted within 1 or 2 h are compared for both methods with chi-square tests. The network trained in 4 h (1388 runs) to a 0.15 tolerance. The network predictions have significantly higher correlation (r = 0.88) than do standard partograms (r = 0.35) with actual first stage durations. Mean differences between predicted and actual first stages are significantly lower for network output than with partograms; these differences increased with first stages exceeding 3 h; 100% of trained network values are within 2 h of actual first stage length. The network performs similarly for a new set of 41 previously unseen labors. This neural network predicts the length of the first stage of spontaneous labor and uses inputs readily available to obstetricians. It outperforms typical partograms for estimating this important feature of normal labor. Future application for intrapartum prognosis could be based on this successful design.

Computerized fetal heart rate analysis and neural networks in antepartum fetal surveillance

The use of computers for analysis of fetal heart rate has developed rapidly, enabling reproducible, objective analysis of fetal heart rate patterns. The problems of observer differences in visual assessment of fetal heart rate, and the continuum of antepartum and intrapartum fetal condition can be clarified through the use of such approaches. Computerized fetal heart rate analysis presents opportunities to perform precise evaluations of the effects of environmental conditions, medications, and disease states on fetal heart rate parameters.

Antenatal assessment of twin gestation

We have identified that twin gestation presents considerable risks to the well-being of both infants that can be traced to either related maternal or intrinsic fetoplacental factors. A protocol for the assessment of twin gestation is established, beginning with a basis in ultrasound identification of twinning and correct gestational dating. Because most hazards for twins are related to abnormal growth, discrepant growth between twins, and abnormalities of placentation, the approach to assessing well-being requires good serial biometry of twins. This critical review addresses the individual and combined application of standard tests used for evaluation of intrauterine health in single pregnancies: (1) ultrasound fetal growth curves; (2) Doppler velocimetry of the umbilical artery; (3) nonstress tests; (4) amniotic fluid assessment and (5) biophysical profile testing. The best current evidence suggests that there are clear deficiencies in the basis for growth nomograms for twin gestations, and with the exception of femur length, most individual anatomic measurements start to deviate from singleton standards between 21 and 30 weeks' gestation. Regardless of formulae used, estimated fetal weight provides the best discriminator for discordant growth. Dynamic assessment of fetal well-being is best provided by a combination of Doppler velocimetry and nonstress testing. Semiquantitative amniotic fluid assessment, other than establishing pathological conditions (eg, twin transfusion syndrome), is problematic and difficult to reproduce. Inadequate data exist to establish the value of the biophysical profile in twins. Given the limitations of present knowledge, serial assessment of twins beginning in the midtrimester with ultrasound observation, and adding combinations of Doppler velocimetry and nonstress testing in the third trimester, seems to represent the most reasonable current clinical approach to twin well-being.

Neural network prediction of nonstress test results: how often should we perform nonstress tests?

OBJECTIVE

Our purpose was to predict outcomes and optimal intervals for nonstress tests of term gravid women with neural networks.

STUDY DESIGN

We studied 100 normal term patients whose 30-minute nonstress tests, performed on 5 consecutive days, were computer analyzed for the following elements: fetal heart rate baseline, variability, signal loss, accelerations (> 15 beats/min), and decelerations. The training set used 65 patients; the testing, 35 patients. Nonstress test data (days 1 to 4) were inputs; day 5 data were training patterns. Networks for each nonstress test element used Brainmaker Macintosh 1.0 (California Scientific Software, Nevada City, Calif.) trained to 0.12 tolerance. Actual fetal heart rate elements and their daily differences were compared with predictions by the networks and multiple regressions.

RESULTS

There was little difference between networks using daily or alternate-day inputs for predicting test performance on day 5; networks using test intervals > 2 days could not be trained to tolerance. Long-term fetal heart rate variation was the nonstress test element best predicted. Daily differences networks provided better prediction of all day 5 data than did actual daily values networks or multiple regression formulas.

CONCLUSIONS

Baseline long-term fetal heart rate variability seems to be the most predictable fetal heart rate element over time and should merit more consideration in overall fetal testing. Fetal heart rate elements are not easily predicted by any method for intervals longer than 2 days. Using longer test intervals might run a greater risk for unanticipated changes in nonstress test outcomes, even when fetal condition is normal.

Effect of magnesium on fetal heart rate variability using computer analysis

We studied 16 women, at 32 weeks' or more gestation who required magnesium sulfate (MgSO4) therapy for preterm labor or preeclampsia. A 60-minute Doppler fetal heart rate (FHR) tracing, analyzed by the Oxford Sonicaid System 8000, was obtained for 1 hour before and 2 hours after each patient received intravenous MgSO4 therapy. Maternal serum Mg2+ levels were obtained at the second monitoring session. Matched paired measures of FHR parameters were compared with the Student's t test. After MgSO4 administration, we noted significant falls in long-term variability, short-term variability, and total acceleration (more than 10 beats/min) counts. Reduced short-term and overall variability occurred in all cases with maternal serum Mg2+ levels more than 4.6 mg/dL. Therapeutic maternal serum Mg2+ levels are linked with decreases in long-term and short-term FHR variability and acceleration counts. These findings should be considered when evaluating resting FHR baseline of patients thus treated.

The nonstress test. Reassessment of the "gold standard"

The NST is simpler, less invasive, less time-consuming, and less expensive than its predecessor, the CST. It may be conducted in the outpatient setting with less skilled personnel. If the NST is to remain an important diagnostic modality, the issues of interpretative criteria, test conditions, and population composition must be reconsidered. In the future, authors must specify these data in detail and present their parameters of sensitivity, specificity, predictive values, and prevalence clearly. They also would be well advised to consider the value of adding other FHR information, such as baseline rate and variability to their interpretative criteria. Because clinical management--i.e., whether or not to intervene--may be influenced by or directly follow the outcome of an NST, it is even more important that such critical questions be addressed. The testing process should be cost effective, accurate, and sensitive enough to detect pregnancies at risk, yet specific enough to identify pregnancies that will have a good outcome. We believe that the issue of stand-alone NSTs should be examined for all indications and gestational ages commonly encountered. In our laboratory, current practice suggests that most conditions, at most gestational ages, benefit from an approach that combines the NST with amniotic fluid assessment and that uses age-adjusted standards to avoid misclassification of normal infants.

Automated methods of fetal assessment. The future of antenatal testing

Conventional approaches to antenatal assessment require considerable input from domain experts to provide their maximum benefit. Many of the tests commonly used suffer from inter- or intraobserver errors, lack of objectivity and reproducibility, and inappropriate application by less experienced personnel. Recent developments in computer-assisted analyses of fetal heart rate testing and biophysical testing are presented to address some of these concerns. The development and validation of expert systems which address the use of domain knowledge to improve diagnostic, prognostic, and therapeutic approaches to antenatal management are described. Future areas of investigation are suggested.

Amniotic fluid assessment. Methods and role in fetal assessment

AFV assessment by one method or another has become an adjunct to nonstress testing in most pregnancies requiring surveillance. Evaluation by nonstress test and amniotic fluid assessment for fetuses with maternal risk factors in a protocol such as that outlined by Devoe is common practice. Adaptation of that algorithm (Fig. 4) to the needs of the clinical setting are simple. Quantitative and nonquantitative methods show an increase in perinatal morbidity and mortality with abnormal values. Those trends are most evident in studies involving postdate gestations, such as those by Marks and Lagrew. The literature and its applied lessons for clinical practice are confused by the many variables considered by those investigating AFV assessment. Superiority of one method over another has not been demonstrated consistently from one study to the next. The good correlation in AFV estimated by ultrasonography and determined by dye-dilution techniques is still based on limited studies that are unlikely to be replicated soon because of the invasive nature of the test. Even in the best circumstances, errors at extremes of AFV are common with the use of ultrasonography. At present, the best recommendations from the literature seem to take two main directions. Antenatal testing of the fetus at risk should include some evaluation of AFV. The fetus with apparently abnormal AFV should be studied anatomically and considered for delivery if decreased AFV is associated with other test abnormalities--i.e., a nonreactive nonstress test.

Can fetal biophysical observations anticipate outcome in preterm labor or preterm rupture of membranes?

OBJECTIVE

To evaluate fetal biophysical testing as a predictor of preterm delivery after preterm labor or preterm rupture of the membranes (PROM).

METHODS

We studied 50 women with suspected preterm labor and intact membranes and 25 women with PROM but not in labor between 28 and 36 weeks' gestation. Before treatment, each subject had cervical Bishop scoring and 1-hour ultrasound observation of fetal heart rate, breathing, body movements, and flexion-extensions. Data were compared with t tests, chi 2 tests, or receiver operating curves.

RESULTS

The mean gestational age at entry was similar in both groups. Twenty (80%) PROM and ten (18%) preterm labor patients delivered within 72 hours of admission; two (8%) PROM and 38 (76%) preterm labor patients delivered more than 7 days after admission. Absent breathing and body movements had high positive predictive values (100%) but moderate sensitivities (less than 55%) for predicting delivery within 72 hours or 7 days in the PROM and preterm labor groups. These sensitivities increased to nearly 70% with the addition of Bishop scores. The optimal diagnostic cutoffs for delivery within 72 hours or 7 days were a breathing incidence below 1% for the PROM group and a body movement incidence below 1% for the preterm labor group, and a breathing incidence of at most 5%.

CONCLUSIONS

Complete absence of one biophysical variable confers limited sensitivity but high positive predictive value for early delivery in patients with preterm labor or PROM. The use of cutoff percentages for the incidence of individual variables improved sensitivity for both conditions. Cervical scoring added to biophysical monitoring by improving the sensitivity for early delivery of patients in preterm labor.

Effects of amniotic fluid on proteases: a possible role of amniotic fluid in fetal wound healing

Fetuses are surrounded by amniotic fluid rich in nutrients and other factors essential to fetal development and possibly to its scarless wound healing. The purpose of this study was to determine whether amniotic fluid contains factors that regulate activities of major proteases involved in the process of wound healing (e.g., collagenase, hyaluronidase, elastase, and cathepsin B). Human amniotic fluid was assayed in vitro for inhibition or stimulation of the activity of these enzymes. Our results showed that amniotic fluid enhanced collagenase activity at a concentration of 66 micrograms protein (p < 0.01), but inhibited activities of hyaluronidase (132 micrograms protein; p < 0.05), elastase (170 micrograms protein; p < 0.05), and cathepsin B (19 micrograms protein; p < 0.01). This finding suggests that amniotic fluid could have an important role in flawless fetal wound healing by regulating these matrix-degrading enzymes.

Fetal biophysical activities in third-trimester pregnancies complicated by diabetes mellitus

OBJECTIVE

Our purpose was to compare third-trimester fetal biophysical activities in normal and well-controlled insulin-dependent diabetic pregnancies.

STUDY DESIGN

We performed serial bimonthly fetal biophysical studies from 30 to 38 weeks in 18 normal and 18 well-controlled insulin-dependent diabetic pregnancies (White classes B through D). Each study contained 60 minutes of simultaneous ultrasonographic recordings of fetal breathing movements and rates, baseline heart rate, and body movements. Mean daily blood glucose levels of diabetic patients were determined from home monitors; HbA1c was determined every 6 weeks and ultrasonographic fetal growth rates every 3 weeks. Data were compared with t tests, analysis of variance with repeated measures, and chi 2 tests.

RESULTS

Women in the diabetic group maintained good glycemic control and were delivered of normal infants of weights similar to those of nondiabetic gravidas. Their fetuses had higher mean incidences of fetal breathing movement, fetal heart rates, and fetal breathing rates but lower fetal movements and fetal heart rate acceleration counts than did controls throughout the study. Neither short- nor long-term maternal glycemic levels correlated well with fetal biophysical performance.

CONCLUSIONS

In spite of good maternal glycemic control fetuses of diabetic women behaved differently from those of nondiabetic women. Modulation of their biophysical activities may be affected by maternal glycemic status before the last trimester. Different standards might need to be applied to interpret their tests.

Dicavitary uteri with twin gestation: a case following clomiphene citrate therapy and review of obstetric outcomes

We report the first case of dicavitary twin pregnancy, following clomiphene citrate therapy, in a patient with uterus bicornis bicollis and anovulation. A review of the literature is presented, and obstetric outcomes and management of these rare pregnancies are discussed.

Intrauterine pressure catheter performance in an in vitro uterine model: a stimulation of problems for intrapartum monitoring

OBJECTIVE

To compare pressure recordings from fluid-filled and sensor-tip catheters under varying intrauterine conditions in a uterine model.

METHODS

The uterine model was a 4.1-L dual-walled polyurethane bladder with ports for dual catheter insertion. "Contractions," generated by a programmable pump, were analyzed by computer. The first three experiments used an internal volume of normal saline and included either "normal" catheter placement, distal end of the catheter coated with petroleum jelly, or distal end of the catheter kinked at 150 degrees. The fourth and fifth experiments were similar to the first except that the internal volume was either pea soup or bovine blood. Each study had at least 20 consecutive pressure waveform sequences with peaks of 100, 60, and 20 mmHg, and a resting baseline of 10 mmHg. Ascent and descent phases were each 25 seconds. Peak and baseline pressure phases were each 10 seconds.

RESULTS

Each catheter generated satisfactory pressure waveforms, which were similar in all experiments except for the one involving simulated meconium. In this trial, significant waveform damping occurred when pea soup filled the fluid catheter line (P < .05, t test).

CONCLUSIONS

In most extreme experimental conditions, the catheter types behaved similarly when detecting "intrauterine" pressure. The sole exception, thick meconium simulation, suggests that fluid-filled catheters would be less reliable in this condition unless flushed continuously with saline.

A rapid test for abruptio placentae: evaluation of a D-dimer latex agglutination slide test

OBJECTIVE

Our purpose was to evaluate a rapid latex agglutination slide test for D-dimer, a byproduct of clot lysis, in the prediction of abruptio placentae.

STUDY DESIGN

Four groups were studied: (1) 15 patients with normal pregnancies at 40 weeks' gestation, (2) 17 participants with preeclamptic pregnancies, (3) 14 patients with preterm labor, and (4) 15 patients with confirmed abruptio placentae. The latex agglutination slide test was performed with positive and negative reference solutions and plasma dilutions of 1:1, 1:2, 1:4, and 1:8. A test was considered positive if, at 2 minutes, agglutination was present at dilutions of > or = 1:2 (> or = 1.0 micrograms/ml fibrin equivalent units). Test results were compared in patient groups with and without abruptio placentae by means of the chi 2 test.

RESULTS

The likelihood of a positive D-dimer test result was not significantly different among patients in the non-abruptio placentae groups (p = 0.454). Patients in the abruptio placentae group were significantly more likely to have a positive D-dimer slide test result than those in the non-abruptio placentae groups (p = 0.0001). The D-dimer test conferred sensitivity, specificity, positive predictive value, and negative predictive value of 67%, 93%, 91%, and 48%, respectively. In contrast, other laboratory measures of coagulation (e.g., platelet count, prothrombin time, partial thromboplastin time, and fibrinogen levels) yielded no better than a 20% sensitivity for abruptio placentae.

CONCLUSIONS

The D-dimer slide test may be a superior rapid method to improve early diagnosis of abruptio placentae.