Highly Atherogenic Lipid Particles are Associated with Preeclampsia After Successful Fertility Treatment for Obese Women who have Unexplained Infertility.

Atherogenic dyslipidemia-before or during pregnancy-may contribute to preeclampsia and subsequent cardiovascular disease risk. We performed a nested case-control study to further understand dyslipidemia associated with preeclampsia. The cohort consisted of participants in the randomized clinical trial "Improving Reproductive Fitness Through Pretreatment with Lifestyle Modification in Obese Women with Unexplained Infertility" (FIT-PLESE). FIT-PLESE was designed to study the effect of a pre-fertility treatment 16-week randomized lifestyle intervention program (Nutrisystem diet + exercise + orlistat vs. training alone) on improvement in live birth rate among obese women with unexplained infertility. Of the 279 patients in FIT-PLESE, 80 delivered a viable infant. Maternal serum was analyzed across five visits: before and after lifestyle interventions and also at three pregnancy visits (16, 24, and 32 weeks gestation). Apolipoprotein lipids were measured in a blinded fashion using ion mobility. Cases were those who developed preeclampsia. Controls also had a live birth but did not develop preeclampsia. Generalized linear and mixed models with repeated measures were used to compare the mean lipoprotein lipid levels of the two groups across all visits. Complete data were available for 75 pregnancies, and preeclampsia developed in 14.5% of the pregnancies. Cholesterol/high-density lipoprotein (HDL) ratios (p < 0.003), triglycerides (p = 0.012), and triglyceride/HDL ratios, all adjusted for BMI, were worse in patients with preeclampsia (p < 0.001). Subclasses a, b, and c of highly atherogenic, very small, low-density lipoprotein (LDL) particles were higher during pregnancy for the preeclamptic women (p < 0.05). Very small LDL particle subclass d levels were significantly greater only at 24 weeks (p = 0.012). The role of highly atherogenic, very small LDL particle excess in the pathophysiology of preeclampsia awaits further investigation.

Foley catheter for induction of labor: potential barriers to adopting the technique.

OBJECTIVE: To evaluate if a learning curve exists for cervical Foley placement for labor induction in women with unfavorable cervices and whether labor curves differ compared with the dinoprostone insert (PGE2). STUDY DESIGN: We conducted a secondary analysis of a multicenter randomized controlled trial. RESULT: For Foley and PGE2, successful placement occurred in 157/185 (85%) and 188/191 (98%) women (P<0.001). Unsuccessful Foley placements decreased over time (P=0.005); all occurred at the site previously using PGE2 preferentially. In women with allocated agent placed successfully who achieved complete cervical dilation, median progress with Foley (n=112), compared with PGE2 (n=123), was: 1-3 cm (6.2 vs 14.1 h; P<0.001), 3-6 cm (11.1 vs 6.7 h; P<0.001) and 6-10 cm (1.9 vs 1.5 h; P=0.14). CONCLUSION: There is a learning curve for placing cervical Foley catheters. Despite faster times to delivery, Foley is associated with slower dilation from 3 to 6 cm compared with PGE2.

Blood lymphocyte chimerism associated with IVF and monochorionic dizygous twinning: case report.

We report on dizygotic (DZ) twins, conceived by IVF and ICSI with assisted hatching, who each had a mixture of 46,XX and 46,XY cells in blood lymphocytes. The female twin had mild genitalia abnormalities but further study revealed anatomically normal reproductive anatomy. Chromosome and fluorescence in situ hybridization studies of buccal, skin and ovarian tissue were normal, as were buccal tissue DNA studies. Fetal ultrasound and fetal membrane pathology were consistent with a monochorionic, diamniotic placenta (MCDAP). These twins thus have blood chimerism but are not chimeric in the other tissues studied. The mechanism for the chimerism could be due to either placental vascular anastamoses (after the development of the haematoblast stem cells) or due to an admixture of trophoblast cells during early blastocyst development. Such trophoblast cell admixtures would be restricted to the extraembryonic tissues so that general physical development in the fetus is normal and without somatic cell chimerism. This case in combination with others previously reported suggests that in IVF conceptions, the prevalence of blood chimerism associated with twinning, and the occurrence of DZ twinning associated with MCDAP, may be higher than previously thought.

Correlation of head-to-body delivery intervals in shoulder dystocia and umbilical artery acidosis.

OBJECTIVE: Our goal was to determine the effect of shoulder dystocia on umbilical artery acidosis. STUDY DESIGN: We performed a retrospective analysis of 134 mother-infant pairs of shoulder dystocia cases at our institution from January 1, 1994, through December 31, 1997. Cases were identified from the obstetric database, and charts were abstracted for demographics, head-to-body delivery interval, umbilical blood gas parameters, and neonatal outcome. Pooled student t tests were used to compare mean blood gas values with data previously reported from our patient population. Regression analysis was performed regarding head-to-body delivery interval and blood gas parameters. RESULTS: The mean umbilical artery pH of shoulder dystocia cases (7.23 +/-.082) was less than the mean arterial pH of all vaginal deliveries in our institution (7.27 +/-.069), P <.001. Head-to-body delivery intervals (available for 44 cases) were not associated with statistically significant alterations in umbilical artery pH (r(2) =.0004), PCO(2) (r(2) =.011), or base deficit (r(2) =.006). Increasing head-to-body delivery interval was also not significantly correlated with decreasing 5-minute Apgar score (r =.0278). CONCLUSION: In our study population, shoulder dystocia resulted in statistically significant but clinically insignificant reductions in mean umbilical artery blood gas parameters. No statistically significant linear relationship was identified between the head-to-body delivery interval and fetal acid-base status.

Performance characteristics of putative tests for subclinical chorioamnionitis.

OBJECTIVE: To evaluate amniotic fluid glucose, matrix metalloproteinase (MMP)-9, interleukin (IL)-6, and IL-12 for diagnosing subclinical chorioamnionitis in women with preterm labor. METHODS: Forty-four women in preterm labor at 22-35 weeks gestation with suspected subclinical chorioamnionitis underwent amniocentesis. Amniotic fluid analysis included Gram stain, culture, and determination of glucose, MMP-9, IL-6, and IL-12 concentrations. Median values of these analytes were compared using the Mann-Whitney U test. Sensitivity, specificity, and positive and negative predictive values were calculated for tests using a positive amniotic fluid culture or delivery within 24 hours as the key outcome variables. RESULTS: Amniotic fluid concentrations of glucose, MMP-9, and IL-6 correlated closely with positive culture or delivery within 24 hours. IL- 12 concentrations did not correlate with either a positive culture or delivery within 24 hours. CONCLUSIONS: Amniotic fluid glucose, MMP-9, and IL-6 reliably predict microbial invasion of the amniotic cavity or imminent delivery. IL- 12 values did not correlate with amniotic fluid culture results or imminent delivery.

Preinduction cervical assessment.

Systems of quantifying and scoring cervical factors have been sought for years to predict the duration of labor and to determine which patients may successfully and safely undergo induction of labor. Early methods of cervical assessment generally attempted to classify patients as having favorable or unfavorable cervices based on dichotomous variables. Since then, obstetricians have begun to appreciate the usefulness of having a single score derived from the degree of ripeness of several cervical characteristics. The scoring system that has become most prevalent is the Bishop score. This system and its modifications take into account the dilation, effacement, consistency, and position of the cervix in addition to the station of the presenting part. Many have evaluated and confirmed the validity of the Bishop score. Among the factors considered in assigning the score, the strongest association with successful labor seems to be with cervical dilation. The Bishop score has been criticized for not attributing more significance to cervical dilation. However, despite this criticism, none of the modifications to the original scoring system have been shown to improve predictability. More recently, the use of ultrasound assessment of the cervix has been suggested to improve prediction of the success of labor induction. However, convincing evidence that this technique provides significant additional information when compared to digital examination is lacking. The Bishop score would seem to be the best and most cost-effective method currently available to assess the cervix and predict the likelihood of success of labor induction and the duration of such an induction.

Expanded-spectrum antibiotics with preterm premature rupture of membranes.

OBJECTIVE: To compare maternal infection rates, neonatal sepsis rates, and bacterial resistance patterns in cases of neonatal sepsis for three antibiotic protocols for women with preterm premature rupture of membranes (PROM). METHODS: From January 1, 1988 to February 28, 1998, women with preterm PROM not requiring immediate delivery were treated according to one of three antibiotic protocols. During three distinct periods, patients received no antibiotics, intravenous ampicillin for 48 hours followed by oral amoxicillin, or intravenous ticarcillin-clavulanic acid for 48 hours followed by oral amoxicillin-clavulanic acid. Rates of chorioamnionitis, endometritis, and neonatal sepsis were compared, as were antimicrobial resistance patterns. Statistical analysis was done using chi(2) analysis, Fisher exact test, and the log-likelihood ratio test. The Bonferroni correction was used for multiple comparisons. RESULTS: During the three periods, preterm PROM was diagnosed in 1695 women. The incidence of endometritis was lower during the third (5.3%) compared with the first (15.1%, P <.001) and second (11.6%, P <.001) protocols. Chorioamnionitis rates were 13.6%, 12.7%, and 15.6% (P =.34) for the first, second, and third periods, respectively, and neonatal sepsis rates were 2.2%, 0.6%, and 1.1% (P =.08), respectively. Neonatal sepsis with gram-negative (P =.02) and ampicillin-resistant (P =.04) organisms was more likely when mothers received antepartum ampicillin or ticarcillin-clavulanic acid. CONCLUSION: Antibiotic therapy for patients with preterm PROM was associated with a decrease in the rate of endometritis and a trend toward less neonatal sepsis but an increase in the proportion of gram-negative and ampicillin-resistant organisms causing neonatal sepsis.

Amniotic fluid indices of fetal pulmonary maturity with preterm premature rupture of membranes.

OBJECTIVE: To evaluate the performance of the TDx/TDxFLx fetal lung maturity II assay (Abbott Laboratories; Abbott Park, IL) on amniotic fluid (AF) specimens collected vaginally from women with preterm premature rupture of membranes (PROM). METHODS: We reviewed charts of patients with preterm PROM treated at Shands Hospital at the University of Florida from January 1, 1995, to June 30, 1999. Negative predictive values (prediction of the absence of neonatal respiratory distress) of mature (at or above 55 mg/g) and borderline (40-54 mg/g) test results were calculated for 153 women. RESULTS: Respiratory distress syndrome (RDS) occurred with frequencies of one in 42 and three in 29 cases with mature and borderline test results, respectively. All cases of RDS were mild, defined as sustained tachypnea with or without need for supplemental oxygen. With an immature (less than 40 mg/g) test result, 20 of 82 infants developed RDS, and half of those cases were severe, defined as needing mechanical ventilation. Negative predictive values of mature and borderline tests were 97.6% (95% confidence interval [CI] 92.9, 100) and 89.7% (95% CI, 78.3, 100), respectively. CONCLUSION: Mature results from fetal lung maturity tests of vaginally collected AF predict the absence of RDS with a high degree of accuracy.

Effect of obstetrics-gynecology clerkship duration on medical student examination performance.

OBJECTIVE: To compare medical student performance on the obstetrics and gynecology national board subject examination during two different clerkship rotation formats. METHODS: We compared medical student performance on the National Board of Medical Examiners (NBME) subject examination in obstetrics and gynecology for 2 years before and 2 years after the length of the clerkship at the University of Florida was decreased from 8 to 6 weeks. Medical College Admission Test (MCAT) and United States Medical Licensing Examination (USMLE) step 1 and step 2 scores were used to assess comparability between groups. Student t test and chi2 analysis were used as appropriate. RESULTS: Medical school classes were similar with respect to MCAT and USMLE step 1 and step 2 scores. Collectively, 231 students who completed the 8-week clerkship scored significantly higher on the subject examination than 239 who completed the 6-week clerkship (618.6 versus 593.5, P = .001). When analyzed by semester, students who completed the clerkship in the second half of the academic year scored similarly regardless of clerkship length (630.6 versus 616.7, P = .11); however, students who completed the clerkship during the first half of the academic year scored significantly higher with the 8-week than the 6-week clerkship (607.3 versus 569.7, P < .001). Students who took the clerkship in the last half of the academic year scored higher than students who took the clerkship in the first half for both the 8-week (630.6 versus 607.3; P = .02) and 6-week (616.7 versus 569.7; P < .001) formats. Those differences persisted on examination letter grade assignment. CONCLUSION: Decreasing the duration of the obstetrics-gynecology medical student clerkship resulted in lower subject examination scores, especially for students who matriculated in the first half of the academic year.

Prophylactic cefazolin in amnioinfusions administered for meconium-stained amniotic fluid.

OBJECTIVE: To determine if amnioinfusion with an antibiotic solution decreased the rate of clinical chorioamnionitis and puerperal endometritis in patients with meconium-stained amniotic fluid. METHODS: Patients in labor at 36 weeks of gestation or greater with singleton pregnancies and meconium-stained amniotic fluid were randomized to receive either cefazolin, 1 g/1,000 mL, of normal saline (n = 90) or normal saline (n = 93) amnioinfusion. Rates of clinically diagnosed chorioamnionitis and endometritis and of suspected and culture-proven neonatal infection were determined. RESULTS: Between the study and control groups, the incidences of clinical chorioamnionitis (7.8% vs. 8.6%), endometritis (2.4% vs. 3.5%), aggregate intrauterine infection (10.0% vs. 11.8%), suspected neonatal infection (17.8% vs. 21.5%), and proven neonatal infection (0.0% vs. 2.2%) were not significantly different. CONCLUSIONS: Prophylactic use of cefazolin in amnioinfusions did not significantly reduce rates of maternal or neonatal infection in patients with meconium-stained amniotic fluid.

Unusual mechanism of Chance fracture in an adolescent.

Transverse fractures of the vertebral arch or Chance fractures are rare in children. The few cases described have been associated with lap-type seat belt use. The adolescent female reported sustained a transverse fracture of L2 from a fall. This is an unusual mechanism of injury producing a Chance-type fracture in an adolescent.