How does uterine contractile activity affect the success of trial of labour after caesarean section, and the risk of uterine rupture? An exploratory, blinded analysis of a cohort from a randomised controlled trial.

OBJECTIVE: To investigate the impact of uterine contractile activity on the outcome of trial of labour after caesarean section (TOLAC). DESIGN: Secondary, blinded analyses of a prospective TOLAC cohort. SETTING: Two labour wards, one in a university tertiary hospital and the other in a central hospital. POPULATION: A total of 194 TOLAC parturients with intrauterine tocodynamometry during labour. METHODS: Analysis of intrauterine pressure, frequency of contractions and baseline tonus of uterine muscle in 30-minute periods for 4 hours before birth. MAIN OUTCOME MEASURES: Primary outcome: uterine contractile activity during TOLAC. Secondary aims: contributors associated with failed TOLAC and uterine rupture. RESULTS: TOLAC succeeded in 74% of cases. Uterine contractile activity, expressed as intrauterine pressure, was significantly higher in successful TOLAC compared with failed TOLAC (210 versus 170 Montevideo units). The statistically significant risk factors of failed TOLAC, after multivariate regression analysis, were prolonged gestational age, reduced cervical dilatation at admission and lower mean intrauterine pressure. In cases of uterine rupture, contractile activity did not differ from that in failed TOLAC. Cervical ripening with a Foley catheter appeared to be a risk factor for uterine rupture, as well as cervical dilatation <3 cm at admission. The incidence of total uterine rupture was 2.6% (n = 5). CONCLUSIONS: Women with successful vaginal birth had higher uterine contractile activity than those experiencing failed TOLAC or uterine rupture despite similar use of oxytocin. Induction of labour with a Foley catheter turned out to be a risk factor for uterine rupture during TOLAC among parturients with no previous vaginal delivery. TWEETABLE ABSTRACT: During VBAC the response to oxytocin, assessed as intrauterine pressure, is greater and adequate, in contrast to failed TOLAC.

Intrauterine versus external tocodynamometry in monitoring labour: a randomised controlled clinical trial.

OBJECTIVE: To investigate whether the use of intrauterine tocodynamometry versus external tocodynamometry (IT versus ET) during labour reduces operative deliveries and improves newborn outcome. As IT provides more accurate information on labour contractions, the hypothesis was that it may more appropriately guide oxytocin use than ET. DESIGN: Randomised controlled trial. SETTING: Two labour wards, in a university tertiary hospital and a central hospital. POPULATION: A total of 1504 parturients with singleton pregnancies, gestational age ≥37 weeks and fetus in cephalic position: 269 women with uterine scars, 889 nulliparas and 346 parous women with oxytocin augmentation. METHODS: Participants underwent IT (n = 736) or ET (n = 768) during the active first stage of labour. MAIN OUTCOME MEASURES: Primary outcome: rate of operative deliveries. SECONDARY OUTCOMES: duration of labour, amount of oxytocin given, adverse neonatal outcomes. RESULTS: Operative delivery rates were 26.9% (IT) and 25.9% (ET) (odds ratio 1.05, 95% CI 0.84-1.32, P = 0.663). The ET to IT conversion rate was 31%. We found no differences in secondary outcomes (IT versus ET). IT reduced oxytocin use during labours with signs of fetal distress, and trial of labour after caesarean section. CONCLUSIONS: IT did not reduce the rate of operative deliveries, use of oxytocin, or adverse neonatal outcomes, and it did not shorten labour duration. TWEETABLE ABSTRACT: IT (versus ET) reduced oxytocin use in high-risk labours but did not influence operative delivery rate or adverse neonatal outcomes.

Maternal and neonatal characteristics in obstetric intensive care unit admissions.

BACKGROUND: The objective of this study was to evaluate the course of pregnancy and delivery of obstetric patients admitted for intensive care, and determine the health status of their infants. METHODS: This was a retrospective register-based study. Four university hospitals in Finland participated. Obstetric patients admitted to the intensive care unit in any trimester of pregnancy, during delivery or up to 42 days post partum were identified from clinical information systems over a five-year study period. Parturient and infant data were collected from the Medical Birth Register. RESULTS: During the study period (2007-2011), 283 obstetric patients were identified from the clinical information system. The most common reason for admission was hypertensive complications (58%), followed by obstetric haemorrhage (25.1%). Advanced maternal age, nulliparity and multiple pregnancies were associated with obstetric intensive care unit admissions. Of patients admitted to intensive care, 68.9% delivered by unscheduled caesarean section. Nearly 60% of neonates were born preterm, 56.1% needed treatment in a neonatal intensive care unit or an observation unit and 4.6% died within one week. CONCLUSION: Advanced maternal age, nulliparity and multiple pregnancy were more common among intensive care unit-admitted women than in the general obstetric population. The main causes for admission were hypertensive complications and obstetric haemorrhage. Compared with the general obstetric population, neonates of intensive care unit-admitted mothers were eight times more likely to require treatment on a neonatal ward and their risk of neonatal death was also eight times greater.

Prevalence and Clinical Significance of Streptococcus dysgalactiae subspecies equisimilis (Groups C or G Streptococci) Colonization in Pregnant Women: A Retrospective Cohort Study.

Objectives: Little is known about the significance of Streptococcus G or C colonization in pregnant women. The objective of this study was to assess whether vaginal Streptococcus group G or C colonization detected in late pregnancy increases the infectious morbidity of the mother or newborn. Methods: A total of 15,114 rectovaginal cultures taken at 35-37 weeks of pregnancy were analyzed at Tampere University Hospital, Finland, between 2012 and 2014. From this laboratory data, all Streptococcus G or C-positive cultures were included to study maternal and neonatal infectious morbidity after delivery. This study population was compared to women with a positive Streptococcus B culture and to women with a negative culture. Results: The prevalence of Streptococcus G or C colonization was 2.9%. Significantly more postpartum endometritis was found in this study group. No association was found between colonization and neonatal bacteremia. Conclusions: Streptococcus G or C colonization is associated with postpartum endometritis. More research is needed to clarify if antibiotic prophylaxis is reasonable for this group during delivery.

Outcomes of primary anal sphincter repair after obstetric injury and evaluation of a novel three-choice assessment.

BACKGROUND: The aim of the present study was to evaluate the subjective outcome of primary repair of obstetric anal sphincter injury (OASIS) at 6 months, the factors associated with the symptoms of anal incontinence (AI), and the role of a simple survey consisting in one question with three answer choices, combined with the Wexner incontinence score for the assessment of this patient population. METHODS: A retrospective cohort study was conducted on patients with third- or fourth-degree OASIS operated on between January 2007 and December 2013 inclusive at Tampere University Hospital, Finland. At 6 months, the patients were asked to report their Wexner's score as well as the three-choice assessment regarding AI symptoms. Based on this assessment, the patients were divided into three groups: those, asymptomatic, those with mild symptoms who did not want further treatment and those with severe symptoms who were willing to undergo further evaluation and treatment. RESULTS: There were 325 patients (median age 30 years). A total of 310 patients answered the questionnaire. Of which, one hundred and ninety-eight (63.9%) patients were asymptomatic, 85 (27.4%) had mild AI, and 27 (8.7%) experienced severe symptoms. There was no statistical difference in the results between the two techniques used (overlapping vs. end-to-end), or the stage of specialization of the operating physician. Persistent symptoms were associated with instrumental vaginal delivery (OR 2.12, 95% CI 1.32-3.41), severity of the injury (OR 1.64, 95% CI 1.20-2.25), and increased maternal age (OR 1.07, 95% CI 1.02-1.13). The correlation between the three-choice symptom evaluation and the Wexner score was good (Spearman's rho 0.82). CONCLUSIONS: After 6 months, severe symptoms after OASIS repair were present in 9% of women and were more frequent in older women, women with high-degree tears and after instrumental vaginal delivery. A three-choice assessment of AI symptoms correlated well with the Wexner score and might be useful to triage patients who need further evaluation.

Obstetric parameters and Doppler findings in cerebral circulation as predictors of 1 year neurodevelopmental outcome in asphyxiated infants.

OBJECTIVE: To establish the association of cardiotocography (CTG) and other obstetric parameters with pulsed Doppler findings in cerebral arteries during the first day of life, and to compare the cerebral artery Doppler with other determinants of asphyxia in predicting 1-year neurological outcome in asphyxiated full-term infants. STUDY DESIGN: Cerebral blood flow velocity (CBFV) were measured from the anterior cerebral (ACA) and basilar (BA) arteries in 30 asphyxiated and 30 healthy-term infants using pulsed Doppler ultrasonography at approximately 24 h of age. CTG, cord artery pH, Apgar scores, biochemical asphyxia markers and symptoms of hypoxic-ischemic encephalopathy (HIE) were compared with the Doppler findings in respect of the ability to predict the outcome, defined by death or impaired neurological performance at 1 year of age. RESULT: In all, 20% of the asphyxiated infants but none in the control group had increased peak systolic CBFVs (mean+3 s.d.) in the ACA or BA. The sensitivity of increased systolic CBFV to predict abnormal outcome in the asphyxia group was 83%, specificity 95% and the sensitivity of the combination of HIE grade from 2 to 3 and increased systolic CBFV in the ACA or BA was 100% and specificity was 95%, respectively. Pathological CTG and low cord artery pH or low Apgar scores showed low predictive power. CONCLUSION: Grade from 2 to 3 HIE and the systolic CBFV (mean+3 s.d.) in the ACA or BA by Doppler ultrasound seemed to predict the outcome in asphyxiated infants at 1 year of age better than CTG, acid basement status, Apgar scores or asphyxia markers. If an increase of more than +3 s.d. in the systolic CBFV does not occur within the first 24 h of life, a good 1-year neurological outcome may be anticipated.

Spontaneous bleeding from the uterine arteries during pregnancy--problems in diagnosis and therapy--bleeding from uterine arteries during pregnancy.

Arterial bleeding, initially negative on MRI, ultrasonography and radiographic angiography, complicated the course of pregnancy with severe and recurrent vaginal and pelvic haemorrhage in the second trimester. Bleeding from the left uterine artery was successfully terminated by angiographic embolisation. No harmful effects on the fetal well-being were recorded after the embolisation. Massive haemorrhage, most probably from the right uterine artery, recurred some days later, and Caesarean section was performed. At postpartal ultrasonography and catheter angiography, massive arterial bleeding from a pseudoaneurysmatic vessel was clearly imaged on the right side of the cervical myometrium and could successfully be treated by radiographic embolisation. Though the primary aetiology of bleeding remains uncertain, it is possible that cervical endometriosis could have been associated with this complication.

Biodegradation of methyl tert-butyl ether by cold-adapted mixed and pure bacterial cultures.

An aerobic mixed bacterial culture (CL-EMC-1) capable of utilizing methyl tert-butyl ether (MTBE) as the sole source of carbon and energy with a growth temperature range of 3 to 30 degrees C and optimum of 18 to 22 degrees C was enriched from activated sludge. Transient accumulation of tert-butanol (TBA) occurred during utilization of MTBE at temperatures from 3 degrees C to 14 degrees C, but TBA did not accumulate above 18 degrees C. The culture utilized MTBE at a concentration of up to 1.5 g l(-1) and TBA of up to 7 g l(-1). The culture grew on MTBE at a pH range of 5 to 9, with an optimum pH of 6.5 to 7.1. The specific growth rate of the CL-EMC-1 culture on 0.1 g l(-1) of MTBE at 22 degrees C and pH 7.1 was 0.012 h(-1), and the growth yield was 0.64 g (dry weight) g(-1). A new MTBE-utilizing bacterium, Variovorax paradoxus strain CL-8, isolated from the mixed culture utilized MTBE, TBA, 2-hydroxy isobutyrate, lactate, methacrylate, and acetate as sole sources of carbon and energy but not 2-propanol, acetone, methanol, formaldehyde, or formate. Two other isolates, Hyphomicrobium facilis strain CL-2 and Methylobacterium extorquens strain CL-4, isolated from the mixed culture were able to grow on C(1) compounds. The combined consortium could thus utilize all of the carbon of MTBE.

Maternal haemodynamics in pre-eclampsia compared with normal pregnancy during caesarean delivery.

OBJECTIVE: To determine how pre-eclampsia modifies maternal haemodynamics during caesarean delivery. DESIGN: Prospective study. SETTING: Tampere University Hospital, Finland. POPULATION: Ten pre-eclamptic parturients and ten healthy parturients with uncomplicated pregnancies scheduled for elective caesarean section under spinal anaesthesia. METHODS: Haemodynamic parameters were assessed by whole-body impedance cardiography noninvasively. MAIN OUTCOME MEASURES: Stroke index (SI), heart rate (HR), cardiac index (CI), systemic vascular resistance index (SVRI) and mean arterial pressure (MAP) were recorded before operation, continuously during caesarean section, during the period of dissipation of anaesthesia and on the second to fifth postpartum day. RESULTS: Baseline haemodynamics in women with pre-eclampsia differed significantly from healthy women in higher SVRI and MAP and lower SI and CI. In women with pre-eclampsia, preload infusion increased both SI and HR, causing a significant rise in CI, while in healthy parturients, only HR rose. In both the groups, spinal blockade reduced SVRI but CI remained stable. At the moment of delivery, CI increased in both groups. In uncomplicated pregnancies, both SI and HR increased, but in women with pre-eclampsia, SI was not altered and the rise in CI was due to an increase in HR only. After the reversal of anaesthesia, haemodynamics in the control group returned to baseline values, whereas in women with pre-eclampsia, SI and CI fell to levels that were significantly lower than the levels observed before surgery. CONCLUSIONS: In women with pre-eclampsia, inability to increase SI at the moment of delivery may suggest dysfunction of the left ventricle to adapt to volume load caused by delivery and prompts concern for the increased risk of pulmonary oedema.

Macrocephaly-cutis marmorata telangiectatica congenita syndrome--prenatal signs in ultrasonography.

A new case of macrocephaly-cutis marmorata telangiectatica congenita (M-CMTC) syndrome is described. The patient presented typical congenital findings in utero, although the syndrome was diagnosed postnatally. The M-CMTC syndrome should be considered when there is a marked fetal overgrowth and progressive macrocephaly with no indications of maternal hyperglycemia or fetal hyperinsulinism. Our patient also had unilateral pleural effusion, curved femur and frontal bossing.

Massive multicystic dilatation of the uterine wall with myometrial venous thrombosis during pregnancy.

We present a pregnancy complicated by multicystic dilatation of the uterine wall during the second trimester, leading to massive uterine distension, anemia and preterm Cesarean section. The cystic changes detected by ultrasound and magnetic resonance imaging involved the whole uterine wall surrounding the entire amniotic cavity. Histopathological examination revealed the benign nature of the cystic changes, which represented dilated and thrombosed venous lacunae. Disturbed venous drainage, combined with local thrombosis, was likely to have led to the collection of a large volume of blood in the uterine wall and the subsequent multicystic change of the myometrium.

Inhibition by nitric oxide-releasing compounds of E-selectin expression in and neutrophil adhesion to human endothelial cells.

The effects of two chemically unrelated nitric oxide (NO)-releasing compounds were studied on adhesion molecule expression in and neutrophil adhesion to human umbilical vein endothelial cells. Incubation of confluent monolayers of endothelial cells with increasing concentrations of lipopolysaccharide stimulated the adhesion of polymorphonuclear leukocytes to endothelial cells. Flow cytometric analysis showed that lipopolysaccharide treatment upregulated the expression of adhesion molecules E-selectin and intercellular adhesion molecule-1 (ICAM-1) in human umbilical vein endothelial cells. A novel NO-releasing compound GEA 3175 (1,2,3, 4-oxatriazolium, -3-(3-chloro-2-methylphenyl)-5-[[(4-methylphenyl)sulfonyl]amino]-, hydroxide inner salt) inhibited lipopolysaccharide-induced adhesion being more potent than the earlier known NO donor S-nitroso-N-acetylpenicillamine. The increased E-selectin expression induced by lipopolysaccharide was significantly attenuated by the two NO donors tested whereas ICAM-1 expression remained unaltered. The present data show that NO donors inhibit E-selectin expression in and neutrophil adhesion to lipopolysaccharide-stimulated vascular endothelial cells. Thus, by inhibiting leukocyte adhesion NO donors may reduce leukocyte infiltration and leukocyte-mediated tissue injury in inflammation and ischemia-reperfusion injury.

Magnetic resonance imaging compared to ultrasonography in fetal weight and volume estimation in diabetic and normal pregnancy.

OBJECTIVE: To estimate fetal volume and weight in diabetic and normal pregnancy using high-resolution magnetic resonance imaging. METHODS: T1-weighted magnetic resonance imaging was combined with semiautomatic segmentation technique. The accuracy of fetal volume estimations thus obtained was compared with conventional ultrasound-based weight estimations in ten pregnant women with insulin-dependent diabetes mellitus and ten women with normal pregnancy. Examinations were made within 48 hours before delivery. RESULTS: Ultrasound-based estimations of fetal weight showed a correlation rate of r=0.77 with the actual birth weights in the whole material, while volume determinations based on magnetic resonance imaging showed a significantly better correlation rate of r=0.95. Diabetic women did not differ from the normal pregnancy group with regard to birth weight or the accuracy of weight estimations. CONCLUSIONS: High-resolution magnetic resonance imaging combined with semiautomatic segmentation software was found to be accurate in determining fetal volume and, consequently, better than conventional ultrasound-based techniques in estimating fetal weight. The use of magnetic resonance imaging in fetal weight estimation may be recommended for clinical situations where an accurate weight estimate is considered essential.

Acute intrapartum fetoplacental transfusion in monochorionic twin pregnancy.

BACKGROUND: The risk of antenatal fetofetal transfusion in monochorionic twin pregnancies has been noted, but possible acute intrapartum transfusion has not been studied extensively. Acute fetoplacental transfusion after the birth of the first twin can be disastrous to the second twin, so it deserves description. CASES: We present three cases of acute intrapartum fetoplacental transfusion after successful deliveries of first twins. After the births of their cotwins, the second twins rapidly deteriorated and were born severely hypovolemic and anemic. CONCLUSION: The risk of acute intrapartum transfusion should be kept in mind when planning delivery of monochorionic twins.

Structure of the Microbial Communities in Coniferous Forest Soils in Relation to Site Fertility and Stand Development Stage.

> Abstract The structure, biomass, and activity of the microbial community in the humus layer of boreal coniferous forest stands of different fertility were studied. The Scots pine dominated CT (Calluna vulgaris type) represented the lowest fertility, while VT (Vaccinium vitis-idaéa type), MT (Vaccinium myrtillus type), and OMT (Oxalis acetocella-Vaccinium myrtillus type) following this order, were more fertile types. The microbial community was studied more closely by sampling a succession gradient (from a treeless area to a 180-years-old Norway spruce stand) at the MT type site. The phospholipid fatty acid (PLFA) analysis revealed a gradual shift in the structure of the microbial community along the fertility gradient even though the total microbial biomass and respiration rate remained unchanged. The relative abundance of fungi decreased and that of bacteria increased with increasing fertility. The structure of the bacterial community also changed along the fertility gradient. Irrespective of a decrease in fungal biomass and change in bacterial community structure after clear-cutting, the PLFA analysis did not show strong differences in the microbial communities in the stands of different age growing on the MT type site. The spatial variation in the structure of the microbial community was studied at a MT type site. Semivariograms indicated that the bacterial biomass, the ratio between the fungal and bacterial biomasses, and the relative amount of PLFA 16:1omega5 were spatially autocorrelated within distances around 3 to 4 m. The total microbial and fungal biomasses were autocorrelated only up to 1 m. The spatial distribution of the humus microbial community was correlated mainly with the location of the trees, and consequently, with the forest floor vegetation.http://link.springer-ny.com/link/service/journals/00248/bibs/38n2p168.html

Antibodies against copper-oxidised and malondialdehyde-modified low density lipoproteins in pre-eclampsia pregnancies.

OBJECTIVE: To measure auto-antibodies against oxidatively modified low density lipoprotein (LDL) in pre-eclamptic pregnancies using two different techniques. DESIGN: Clinical study comparing pre-eclamptic and normal pregnancies. SETTING: Tampere University Hospital, Finland. POPULATION: Twenty-one primigravidae with pre-eclampsia and 13 healthy, normotensive primigravidae as controls. METHODS: The serum titers of antibodies against both malondialdehyde-modified and copper-oxidised LDL (MDA-LDL and copper-ox LDL) were analysed and related to parameters reflecting the severity of pre-eclampsia. RESULTS: There was a positive correlation (r = 0.58) between antibodies against MDA-LDL and copper-ox LDL in women with pre-eclampsia but not in healthy pregnant controls. The antibody levels against copper-ox LDL, but not against MDA-LDL, were higher in women with pre-eclampsia than in women with a normal pregnancy (P < 0.01). While the antibody titers against copper-ox LDL did not correlate with any parameter reflecting the severity of pre-eclampsia, those against MDA-LDL showed a positive correlation with the level of diastolic blood pressure (r = 0.54) and a negative correlation with platelet count (r = -0.61) in women with pre-eclampsia. CONCLUSION: There are increased titers of serum autoantibodies against copper-oxidised LDL in pre-eclampsia, which may reflect enhanced lipid peroxidation involving circulating lipoproteins.

New aerobic ammonium-dependent obligately oxalotrophic bacteria: description of Ammoniphilus oxalaticus gen. nov., sp. nov. and Ammoniphilus oxalivorans gen. nov., sp. nov.

The genus Ammoniphilus is proposed for aerobic endospore-forming Gram-variable rod-shaped bacteria, which are ammonium-dependent, obligately oxalotrophic and haloalkalitolerant, oxidase- and catalase-positive, mesophilic and motile by peritrichous flagella. Cell wall contained two electron-dense layers. The external layer consists of a chain of electron-dense granules morphologically resembling the cellulosomes of Clostridium thermocellum. Two species are described, Ammoniphilus oxalaticus gen. nov., sp. nov. and Ammoniphilus oxalivorans gen. nov., sp. nov. The type strains of these species are strains RAOx-1 (= DSM 11538) and RAOx-FS (= DSM 11537), respectively. Ammoniphilus strains were isolated from the rhizosphere of sorrel (Rumex acetosa) and from decaying wood. The strains require a high concentration of ammonium ions and use oxalate as the sole organic source of carbon and energy for growth; no growth factors were required. Growth occurred at pH 6.8-9.5. The optimum temperature and pH for growth were 28-30 degrees C and 8.0-8.5. All strains grew in a saturated solution of ammonium oxalate, and tolerated 3% NaCl. Whole-cell hydrolysates contain meso-diaminopimelic acid and glucose. The menaquinone of the strains was MK 7, and the major cellular fatty acids were 12-methyl tetradecanoic, cis-hexadec-9-enoic and hexadecanoic acids. The G + C content of the DNA was 45-46 mol% for A. oxalaticus and 42 mol% for A. oxalivorans. The almost complete 16S rDNA sequence of three strains of the two species of Ammoniphilus shows that the genus falls into the radiation of the Clostridium-Bacillus subphylum of Gram-positive bacteria. The closest phylogenetic neighbour of Ammoniphilus is Oxalophagus oxalicus. The DNA-DNA hybridization value between strains RAOx-1 and RAOx-FS was 39.7%.

Evaluation of a rapid strip test for insulin-like growth factor binding protein-1 in the diagnosis of ruptured fetal membranes.

We evaluated the clinical usefulness of a new bedside test (PROM TEST) for insulin-like growth factor binding protein-1 (IGFBP-1) in the detection of ruptured fetal membranes (ROM). Cervicovaginal secretion was sampled between 15 and 37 weeks of gestation from asymptomatic women with apparently intact membranes and from women with clinically confirmed ROM, as well as from symptomatic women with suspected ROM based on history. IGFBP-1 in samples was detected with a dipstick based on immunochromatography. The test result was positive in 100% of cases with unequivocal ROM and in 5.3% of cases with apparently intact membranes. Furthermore, the PROM TEST was positive in 64 of 181 patients evaluated for suspected ROM based on history, but in whom the diagnosis could not be clinically confirmed at the initial evaluation. Fifty of the 64 women (78.1%) were delivered prematurely (< 37 weeks). Five of the 117 PROM-negative patients had elective cesarean section for reasons unrelated to ROM before 37 weeks and 10 of the remaining 112 patients (8.9%) had preterm delivery. Women with equivocal ROM and a positive test result had a 6.9-fold increased relative risk (95% confidence interval 4.2-11.4) of preterm delivery compared with women who had a negative result at the time of evaluation. Multiple logistic regression including PROM TEST result, contractions, vaginal bleeding and cervical changes indicated that a positive PROM TEST result was an independent predictor of preterm delivery (P = 0.0001). In summary, a positive PROM TEST result identifies ROM with high sensitivity and a negative result effectively excludes those with intact membranes. In patients with suspected but clinically unconfirmed ROM, the positive test result is associated with increased risk of preterm delivery, suggesting that microruptures of fetal membranes can also be detected by the PROM TEST.