Cervicovaginal fibronectin and cervical length at 23 weeks of gestation: relative risk of early preterm delivery.

OBJECTIVES: To establish the prevalence of cervicovaginal fetal fibronectin positivity at 23 weeks of gestation in a routine population of singleton pregnancies and determine the relative risk of spontaneous delivery before 33 weeks in women with a fibronectin positive result. DESIGN: Prospective clinical study. SETTING: Inner city antenatal clinic. POPULATION: Singleton pregnancies attending for routine antenatal care. METHODS: Cervicovaginal fetal fibronectin and cervical length were measured at 23 weeks of gestation. The distribution of fibronectin positivity within subgroups according to maternal characteristics was calculated and the relative risk of spontaneous delivery before 33 weeks was estimated. MAIN OUTCOME MEASURES: Prevalence of a fibronectin positive result and its relation to cervical length measurement and spontaneous preterm delivery before 33 weeks. RESULTS: Of 5,146 women participating in the study, 182 (3.5%) had a fibronectin positive result and 76 (1.5%) had a cervical length of < 15 mm. Fibronectin positive women were more likely to be Afro-Caribbean in origin, to have had a previous second trimester miscarriage and to have a short cervix. In the 5,068 women who were managed expectantly, the significantly independent relative risk of spontaneous delivery at < 33 weeks was 46.2 (95% CI 18.8-113.6), for cervical length of < or = 15 mm, 8.1 (95% CI 3.8-17.5) for a fibronectin positive result, and 4.4 (95% CI 2.2-9.1) for cigarette smoking. CONCLUSION: Fibronectin positivity at 23 weeks of gestation provides useful prediction of pregnancies at risk of spontaneous preterm delivery before 33 weeks, with a relative risk that is twice as high as cigarette smoking, but is a sixth of that of cervical length.

Cervical length at 23 weeks of gestation: relation to demographic characteristics and previous obstetric history.

OBJECTIVES: To examine the feasibility of introducing routine measurement of cervical length at 23 weeks of gestation, to establish the distribution of cervical lengths in a routine population of singleton pregnancies and to examine the relation between cervical length and demographic characteristics and previous obstetric history. METHODS: Cervical length was measured by transvaginal sonography at 23 weeks of gestation in women with singleton pregnancies attending for routine antenatal care. The distribution of cervical lengths was established and the significance of differences in median cervical length between subgroups according to maternal age, ethnic origin, maternal ponderal index, cigarette smoking, alcohol drinking, drug abuse and previous obstetric history was calculated. In addition, 100 women were asked to complete a questionnaire aimed to assess the degree of discomfort, pain or embarrassment caused by the scan. In 100 pregnancies, cervical length was measured in each patient by two of four operators to determine intraobserver and interobserver variabilities. RESULTS: During the study period, 2702 (80%) of the 3358 women attending for a 23-week scan agreed to participate in the study and, in all cases, the cervical length was measured successfully. The median cervical length was 38 mm and in 1.6% of cases the length was 15 mm or less. More than 90% of the women reported that the procedure was associated with no or only mild discomfort and embarrassment, whilst 85% found the ultrasound scan to be equally or less uncomfortable than a speculum examination. Measurement of cervical length was highly reproducible and, on 95% of occasions, the difference between two measurements by the same observer and by two observers was < or = 3.5 mm and < or = 4.2 mm, respectively. Cervical length was significantly shorter in women of Afro-Caribbean origin compared to Caucasians, those aged less than 20 years, those with a low ponderal index, those with a history of previous miscarriage or preterm delivery and in drug abusers. CONCLUSIONS: Transvaginal sonographic measurement of cervical length is highly reproducible and it is associated with a minimal degree of discomfort to the patients. At 23 weeks, the median cervical length is 38 mm and, in 1.6% of the population, the length is 15 mm or less. There is an association between cervical length and demographic characteristics and previous obstetric history.

Cervical length at 23 weeks of gestation: prediction of spontaneous preterm delivery.

OBJECTIVE: To examine the potential value of routine measurement of cervical length in singleton pregnancies at 23 weeks of gestation in the prediction of the risk for early spontaneous preterm delivery. METHODS: Cervical length was measured by sonography at 23 weeks in 2567 singleton pregnancies in women attending for routine antenatal care. In 43 women, the length was < or = 15 mm and 21 of these were managed expectantly, whereas in 22 cases a cervical cerclage was placed. In the pregnancies that were managed expectantly, the relation between cervical length and preterm delivery was examined and the risk of spontaneous delivery at < or = 32 weeks was estimated. RESULTS: Cervical length at 23 weeks was < or = 15 mm in 1.7% of cases; this group contained 86%, 58% and 20% of pregnancies that delivered spontaneously at < or = 28, < or = 32 and < or = 36 weeks, respectively. The risk for delivery at < or = 32 weeks decreased from 78% at a cervical length of 5 mm to 4% at 15 mm and 0.5% at 50 mm. CONCLUSIONS: Cervical length at 23 weeks is < or = 15 mm in < 2% of the population; this group contains about 90% and 60% of the women delivering at < or = 28 and < or = 32 weeks, respectively. Measurement of cervical length provides accurate prediction of risk for early preterm delivery.

Cervical length at 23 weeks of gestation: the value of Shirodkar suture for the short cervix.

OBJECTIVE: To examine the possible benefit of cervical cerclage in women with a very short cervix identified during routine sonographic assessment of cervical length at 23 weeks of gestation. METHODS: Transvaginal sonography was used to measure cervical length at 23 weeks of gestation in 2702 women with singleton pregnancies attending for routine antenatal care. In 43 (1.6%) cases the cervical length was < or = 15 mm. The 43 women in this group were referred to their obstetricians for the further management of pregnancy; in 21 cases, the pregnancy was managed expectantly and in 22 a Shirodkar suture was inserted under spinal anesthesia. The two groups were compared in terms of patient characteristics and pregnancy outcome. RESULTS: The 22 patients that were treated with cervical cerclage were not significantly different from the 21 given expectant management in ethnic origin, ponderal index, cigarette smoking or past obstetric history. The median cervical length was 10 mm in both groups. In the cervical cerclage group, 21 delivered after 32 weeks and one (5%) had spontaneous onset of labor and delivery before 32 completed weeks; all 22 infants survived. In the expectant management group, 11 (52%) had spontaneous onset of labor and delivery before 32 weeks; 20 infants survived but one baby died in the neonatal period. CONCLUSIONS: In women with a cervical length of < or = 15 mm at 23 weeks there is a more than 50% chance of spontaneous delivery at less than 32 weeks. Insertion of a Shirodkar suture in women with a very short cervix may be associated with a ten-fold reduction in risk for such early delivery.

Hematologic evaluation of employees with leukopenia. Naval Weapons Center, China Lake, California.

Evaluation of 86 employees with a history of leukopenia at the Naval Weapons Center (NWC), China Lake, California, was done by exposure questionnaires, medical histories, physical examinations, peripheral blood smear, and bone marrow evaluations, including morphologic examination, stem cell culture, and cytogenetics. Forty-eight subjects were found to be leukopenic at the time of the study, and two subjects were found to have hairy cell leukemia. All subjects had positive exposure histories and were healthy at the time of the study. Review of peripheral smears identified the patients with marrow abnormalities. Bone marrow cultures revealed several patients with possible marrow suppression. Chromosome studies were not diagnostic. Five-year follow-up health questionnaires revealed no significant health problems; the two workers with hairy cell leukemia are alive and fully functional. Leukopenia in itself does not appear to be a risk factor for poor health, and it is unknown whether or not it may be a useful screening tool to identify workers at risk in toxic environments. Careful evaluation of blood cell counts and peripheral smears should be sufficient to identify people with potential marrow abnormalities.

Osteoarticular and pulmonary manifestations of acute leukemia. Case report and review of the literature.

Acute leukemia with bone or joint symptoms of sufficient magnitude to obscure and delay the correct diagnosis has been reported but is rarely mentioned in the recent literature, particularly in adults. The authors report an adult with rapidly fatal acute leukemia and a clinical course dominated by recurrent osteoarticular symptoms; osteoarticular symptoms preceded the diagnosis of leukemia by 3 months and delayed diagnosis and treatment. The correct diagnosis requires awareness of the osteoarticular manifestations of acute leukemia and examination of blood or bone marrow smear by an experienced observer; a biopsy specimen of bone or joint lesions or examination of cytocentrifuged synovial fluid may aid in diagnosis. The immediate cause of death in our patient was respiratory failure with prominent leukemic interstitial pulmonary infiltrates at autopsy; clinically significant leukemic pulmonary infiltrates have only rarely been reported. The authors review the literature on pulmonary and osteoarticular manifestations caused by acute leukemic infiltrates.

Congenital self-healing histiocytosis-X.

Histiocytosis-X (H-X) is heterogeneous clinically, varying from localized benign forms to disseminated fatal forms, but has a relatively uniform and specific pathologic appearance, both by light and electron microscopy. H-X localized to bone or lung has long been recognized. Much less frequent are patients with H-X localized to skin. We report two infants with congenital self-healing H-X, clinically confined to the skin. Prediction of the clinical course from the histology of a H-X lesion is unreliable, especially for cutaneous lesions. We feel that patients with localized forms of H-X should be followed closely for progression of disease but should not be treated aggressively until time is allowed for spontaneous resolution.

Juvenile fibromatosis.

Juvenile fibromatosis is a benign lesion with locally aggressive characteristics. Wide surgical excision is the treatment of choice. Radiation therapy can be used for inoperable cases or as adjunctive therapy. Steroid therapy has not been used extensively and deserves further evaluation. In the head and neck area, juvenile fibromatosis must be very carefully diagnosed and treated due to the serious consequences that result from inadequate control.

Human myeloma IgG half-molecules. Structural and antigenic analyses,.

The structure and antigenic characteristics of a human k, IgG myeloma protein that formed half-molecules were analyzed. Most of the myeloma protein found in the patient's serum and urine consisted to two chain 4.3S half-molecules. A small amount of four chain 7S myeloma protein was, however, found in the serum and was apparently formed by the same clone of tumor cells. Polyacrylamide gel electrophoresis in 8 M urea and 1% sodium dodecyl sulfate and analytical ultracentrifugation in 6 M guanidine of the fully reduced and alkylated half-molecule indicated that this myeloma protein had a heavy chain of a smaller molecular weight (approximately 45,000) than that of normal gamma chains, Except for this apparent deletion, the heavy chain resembled gamma1 chains. The amino acid composition of the peptides containing the half-cysteine residues forming the interchain disulfide bonds, the glycopeptide of the Fc fragment and the COOH-terminal structure were similar if not identical with the analogous structures of gamma1 chains. No Fc fragment could be prepared because the Fc portion of the heavy chain of the myeloma protein was extremely susceptible to degradation with papain. After mild reduction and alkylation, the 7S myeloma protein dissociated into half-molecules, indicating a lack of noncovalent interactions in the Fc fragment that are present in all classes of human immunoglogulins and are responsible for the formation ofFc dimers. The half-molecule was antigenically deficient in the Fc fragment. It failed to precipitate with anti-Fc fragment antisera in double gel diffusion tests and inhibited a Fc-anti-Fc fragment binding reaction weakly and incompletely. The half-molecule and the 7S protein had the same genetic markers on the first and second homology region of the gamma chain. The half-molecule lacked, however, the corresponding markers on the third homology region, These findings suggest that this myeloma protein had a deletion in the gamma chain which was probably located in third homology region and was likely the structural abnormality responsible for the lack of noncovalent interaction in the Fc fragment and absence of most of the antigenic determinants characteristic of gamma chains.

IgG half-molecules: clinical and immunologic features in a patient with plasma cell leukemia.

The clinical manifestations and immunologic features of a patient with plasma cell leukemia who produced k, IgG half-molecules are described. His serum contained both 7S myeloma protein and 4.3S half-molecules, whereas his urine contained predominantly half-molecules. The half-molecules were discovered because the serum and urine formed double precipitin lines when analyzed by commercially available IgG radial immunodiffusion plates that contained antibodies to determinants on both the Fab and Fc fragments. Immunoelectrophoresis also revealed double precipition lines with such antisera. In contrast, when antisera specific for the IgG Fc fragment were used, the serum showed only a single line formed by intact IgG, and the urine failed to react, indicating that the half-molecule was antigenically deficient in the Fc fragment. The half-molecule consisted of one covalently linked heavy and light chain, both having about normal molecular weights, suggesting that they did not have a large deletion which could have caused the half-molecule production. Comparison of the clinical manifestations of the patient with those of four other known patients who produced half-molecules suggested that half-molecule formation is not associated with a distinct clinical syndrome.