Antibiotic prophylaxis at Cesarean delivery.

OBJECTIVE: Our aim was to compare the efficacy of ampicillin, cefotetan, and ampicillin/sulbactam in the prevention of post-Cesarean endomyometritis. METHODS: Consenting patients undergoing Cesarean delivery at the University of Louisville Hospital were enrolled in a prospective, double-blinded randomization to receive either ampicillin/sulbactam (Group 1), cefotetan (Group 2), or ampicillin (Group 3) single dose antibiotic prophylaxis following umbilical cord clamping. The primary outcome variable was the frequency of endomyometritis in the respective groups. RESULTS: Among 301 randomized patients, outcome data was available for 298 patients. Fourteen patients (4.7%), all of whom underwent non-elective Cesarean delivery, developed endomyometritis. The frequency of endomyometritis was not different among groups: Group 1, 4/101 (4%); Group 2, 4/96 (4.2%); and Group 3, 6/101 (5.9%). Wound infections were infrequently observed 4/298 (1.3%) without significant differences among groups. Stepwise discriminative analysis identified only last cervical dilatation as a significant predictor of endomyometritis (P = 0.006). CONCLUSION: Post-Cesarean endomyometritis occurs infrequently following single dose antibiotic prophylaxis after umbilical cord clamping. An advantage of broader spectrum antibiotics over ampicillin was not demonstrated.

Predictive value of fetal ultrasonography in the diagnosis of a lethal skeletal dysplasia.

BACKGROUND: Certain ultrasonographic findings identified in a fetus suspected of having a skeletal dysplasia may be predictive of a lethal outcome. METHODS: We evaluated 27 fetuses suspected of having a skeletal dysplasia using targeted ultrasonography between 16 and 31 weeks' gestation. Clinical examination and skeletal radiography were done after delivery. RESULTS: A skeletal dysplasia was confirmed and a diagnosis established in all but one case. The skeletal dysplasia was lethal in 23 cases and, in each case, the outcome was accurately predicted prenatally; however, three of the infants survived several months. In 11 of the 23 cases (48%), the specific diagnosis was correctly determined before birth. Ultrasonographic findings not considered to reflect a lethal outcome, were accurately predicted in two other cases. In an additional two, sonographic examination suggested a lethal osteochondrodysplasia, though both survived. Findings consistent with a lethal skeletal dysplasia included a femur length < 1st centile, combined with either a bell-shaped thorax, decreased bone echogenicity, or both. Using these criteria provided a positive-predictive value for neonatal deaths of 80% (20/25), and 92% (23/25) if the three that died in infancy were included. CONCLUSIONS: In the fetus suspected of having a skeletal dysplasia, certain findings on targeted ultrasonography frequently are predictive of a lethal outcome; the ability to predict this appears greatest when more than one of these abnormalities is present.

Preterm premature rupture of membranes: aggressive tocolysis versus expectant management.

The objective of our study is to determine whether aggressive tocolysis in patients with preterm premature rupture of membranes between 24 and 34 weeks gestation improves neonatal outcome. Patients with documented preterm premature rupture of membranes between 24 and 34 weeks gestation were prospectively randomized to group I, aggressive tocolysis with intravenous magnesium sulfate, or to group II, no tocolysis. The lecithin/sphingomyelin ratio was determined upon hospital admission and every 48-96 hours until delivery. Both groups received weekly steroids and antibiotics pending culture results and were promptly delivered when chorioamnionitis, fetal stress, or an Lecithin/sphingomyelin ratio of > or = 2.0 occurred. The study group involved 145 patients. No statistically significant differences between groups I (n = 78) and II (n = 67) were observed regarding demographic characteristics, gestational age at enrollment or at delivery, latency, development of clinical chorioamnionitis, birth weight, number of days in neonatal intensive care unit, days on oxygen or ventilatory support, frequency of hyaline membrane disease, necrotizing enterocolitis, intraventricular hemorrhage, neonatal sepsis, or neonatal mortality. Our data suggest that tocolysis in patients with preterm premature rupture of membranes does not significantly improve perinatal outcome.

Effect of three concentrations of intracervical prostaglandin E2 gel for cervical ripening.

To evaluate the efficacy and safety of three concentrations of prostaglandin E2 (PGE2) gel for preinduction cervical ripening. Two hundred ninety-one patients with an unfavorable cervix scheduled for induction of labor were eligible to participate in a prospective, randomized, double-blind study of one or two doses of intracervical PGE2 gel. Group 1 received a dose of 0.125 mg/2 ml; group 2 received 0.25 mg/2 ml; and group 3 received 0.5 mg/2 ml. Outcome variables included change in Bishop score, uterine tachysystole, oxytocin use, route of delivery, and maternal and neonatal complications. Two hundred twenty-nine patients were included in the study, 79 in group 1, 70 in group 2, and 80 in group 3. Among the three groups, no statistically significant differences were noted for change in Bishop score, uterine tachysystole, oxytocin use, route of delivery, or incidence of maternal or neonatal complications, Subsequent labors were frequently complicated by fetal heart rate abnormalities (24.3%) and uterine tachysystole (9.6%); 84 (38.9%) patients were delivered by cesarean section. A dose-dependent influence on outcome variables was not identified. Complications from PGE2-ripening within 4 hours of gel application were not dose dependent and occurred infrequently. This study demonstrates that there is no dose in the range tested that assures an absences of tachysystole, limiting the role of outpatient cervical ripening without some period of observation.

Immune function in athletes versus nonathletes.

The purpose of this study was to compare natural killer cell cytotoxic activity (NKCA) and Con A-induced lymphocyte proliferation (T cell function) in athletes versus nonathletes, with measurement of natural killer (NK) and T cells to allow a comparison on a "per-cell" adjusted basis. Eighteen young male endurance athletes (10 runners and 8 cyclists) with a mean VO2max of 70.7 +/- 1.3 ml.kg-1.min-1 and 6.6 +/- 0.8 years of competitive experience were compared with 11 nonathletic male adults (47.6 +/- 3.1 ml.kg-1.min-1). Concentrations of circulating leukocyte and lymphocyte subsets, including NK and T cells, were not significantly different between groups. NKCA and T cell function also did not differ between groups, whether expressed unadjusted or adjusted on a per-cell basis. For all subjects combined, both NKCA and T cell function were unrelated to VO2max (r = 0.005, p = 0.98; r = 0.007, p = 0.97, respectively). These data do not support the contention that immune function, as measured in this study, is altered in endurance athletes.

Moderate exercise training and natural killer cell cytotoxic activity in breast cancer patients.

Sixteen female breast cancer patients who had been diagnosed (3.0 +/- 1.2 years previous to the study) and undergone surgery, chemotherapy, and/or radiation treatment were randomly assigned to exercise and nonexercise groups. Pre- and post-study measurements were taken for aerobic performance, leg strength, and concentrations of circulating lymphocyte subsets and natural killer cell cytotoxic activity (NKCA). Exercise training consisted of 60 minutes of supervised weight training and aerobic activity three times each week for eight weeks. Although subjects in the exercise groups demonstrated some modest improvement in the various aerobic and strength tests, NKCA and concentrations of circulating T and NK cells were not significantly altered relative to the nonexercise group. This study suggests that moderate exercise over an eight-week period has no significant effect on the function of in vitro natural killer cells in breast cancer patients.

Drug screening in newborns and mothers using meconium samples, paired urine samples, and interviews.

We evaluated the prevalence of illicit substance abuse by comparing drug screening results derived from meconium, urine pairs, and maternal interview. Mother/infant pairs (580) were entered into this blinded, prospective study. Prevalence of illicit substance abuse was 3.4%. The lack of prenatal care correlated with the use of cocaine (p < 0.001). Neonates born to cocaine-using mothers were more likely to be premature, to have a lower birth weight, decreased length, and smaller head circumference using unpaired t test (overall p < 0.05 using Bonferroni method for simultaneous inference). For mother/infant pairs who had positive drug screening for cocaine, the interview, maternal urine sample, and meconium sample showed equal sensitivity, although the newborn urine showed poor correlation. We suggest that the newborn urine sample could be deleted from newborn drug screening, and lack of perinatal care may serve as a marker of substance abuse.

Aggressive intrapartum management of lethal fetal anomalies: beyond fetal beneficence.

OBJECTIVE: To evaluate management recommendations from the current literature for patients whose fetuses are certain to have lethal anomalies or absent (or virtually absent) cognitive function. These recommendations include termination of pregnancy or, for cases in the third trimester, nonaggressive intrapartum management, avoiding cesarean delivery for fetal indications. METHODS: We report our experience with several patients who voiced opposition to nonaggressive intrapartum care and present a rationale for selectively aggressive, intrapartum management for some of these cases. RESULTS: Four women whose fetuses had lethal anomalies requested aggressive intrapartum management. For three of the four, standard aggressive management of labor resulted in vaginal delivery of live-born infants who died shortly thereafter. The patients found comfort in the live births. The fourth patient accepted a recommendation to avoid fetal monitoring during labor, and the fetus was stillborn. This patient found the intrapartum experience to be very stressful. CONCLUSION: When a patient's desire to avoid an intrapartum stillbirth is strong enough that substantial psychological harm might result from one, the physician's beneficence-based obligation to her and respect for maternal autonomy justify selectively aggressive intrapartum therapy, even if no beneficence-based obligation to the fetus exists.

Differential cyclooxygenase-1 and -2 gene expression in human myometria from preterm and term deliveries.

The expression of cyclooxygenase-1 (COX-1) and COX-2 genes in myometria from preterm and term pregnancies was investigated by in situ hybridization, immunoblotting, and immunocytochemistry. In situ hybridization revealed that myometrial smooth muscle contained both COX-1 and COX-2 messenger ribonucleic acid transcripts. Immunoblotting revealed that myometria contained 55- and 67-kilodalton COX-1 proteins as well as 72- and 56-kilodalton COX-2 proteins. Immunocytochemistry showed that COX-1 and COX-2 proteins are present in the myometrial smooth muscle. The expression of COX-1 and COX-2 genes differed in myometria. For example, although COX-1 expression was lower, COX-2 expression was higher at term compared to preterm pregnancy not in labor. In addition, although COX-1 expression was not dependent on labor, COX-2 expression was lower with labor compared to not in labor for both preterm and term pregnancy. The myometrial smooth muscle also immunostained for prostaglandin E2 (PGE2) and PGF2 alpha, suggesting that the cyclooxygenases are catalytically active. The changes in PGE2 and PGF2 alpha paralleled the changes in COX-1 enzyme in terms of being lower at term compared to preterm pregnancy and the changes in COX-2 enzyme in terms of being lower during labor at preterm and term pregnancy. In summary, our results demonstrate that pregnant human myometria express both COX-1 and COX-2 genes. The expression of these genes differed in preterm or term pregnancy myometria from in labor and not in labor.

Novel expression of functional human chorionic gonadotropin/luteinizing hormone receptor gene in human umbilical cords.

Human umbilical cord contains two arteries and a vein surrounded by Wharton's jelly with amnion covering the exterior surface. The cord blood and amniotic fluid contain human CG (hCG). Whether hCG can directly regulate cord functions is unknown. We now report that human umbilical cords contain a major 4.4-kilobase and minor 2.6- and 1.8-kilobase hCG/LH receptor messenger RNA transcripts. The cords also contain a 50-kilodalton immunoreactive receptor protein which can bind hCG and LH, but not hFSH or hTSH. Rat testis used as a positive tissue control contained the same major and minor receptor transcripts and an 80-kilodalton receptor protein which can bind [125I]hCG. Rat liver used as a negative control contained neither receptor transcripts nor receptor protein. The smooth muscle and endothelial cells of umbilical arteries and vein, umbilical amnion, and cells in Wharton's jelly contain the receptor transcripts and receptor protein which can bind [125I]hCG. The receptor expression was higher in umbilical vessels closer to the baby and decreased toward placenta, becoming barely detectable once the vessels were inside the placental tissue. In vitro treatment of umbilical cords with highly purified hCG resulted in an increase of immunoreactive cyclooxygenase-1, cyclooxygenase-2, prostacyclin synthase, and 6-keto-prostaglandin F1 alpha, little change in thromboxane A2 synthase and a decrease of prostaglandin E2 and thromboxane B2 as compared to the controls, indicating that the cord receptors are functional. In summary, these novel findings suggest that hCG present in cord blood and amniotic fluid may directly regulate the vascular tone and quite possibly other functions of human umbilical cord.