Risk factors for perineal injury during delivery.

OBJECTIVE: We sought to identify risk factors for anal sphincter injury during vaginal delivery. STUDY DESIGN: This was a retrospective, case-control study. We reviewed 2078 records of vaginal deliveries within a 2-year period from May 1, 1999, through April 30, 2001. Cases (n = 91) during the study period were defined as parturients who had documentation of greater than a second-degree perineal injury. Control subjects (n = 176), who were identified with the use of a blinded protocol, included women who were delivered vaginally with less than or equal to a second-degree perineal injury. For each patient, we reviewed medical and obstetrics records for the following characteristics: maternal age, race, weight, gestational age, parity, tobacco use, duration of first and second stages of labor, use of oxytocin, use of forceps or vacuum, infant birth weight, epidural use, and episiotomy use. RESULTS: Of the 2078 deliveries that were reviewed, we discovered 91 cases (4.4%) of documented anal sphincter injury. The mean maternal age of our sample was 24.9 +/- 5.9 years). Nearly two thirds (63.2%) were white; 26.7% were black, and 10.1% were of other racial backgrounds. Forceps were used in 51.6% of deliveries that resulted in tears (cases), compared to 8.6% of deliveries without significant tears (control subjects, P <.05). Using cases and control subjects with complete data (cases, 82; control subjects, 144), delivery with forceps was associated with a 10-fold increased risk of perineal injury (odds ratio, 10.8; 95% CI, 5.2-22.3) compared to noninstrumented deliveries. The association was similar after adjustment for age, race, parity, mode of delivery, tobacco use, episiotomy, duration of labor (stages 1 and 2), infant birth weight, epidural, and oxytocin use (odds ratio, 11.9; 95% CI, 4.7-30.4). Nulliparous women were at increased risk for tears (adjusted odds ratio, 10.0; 95% CI, 3.0-33.3) compared with multiparous patients, but parity did not reduce the association between forceps-assisted deliveries and anal sphincter injuries. Increasing fetal weight was also a risk factor in both unadjusted and adjusted analyses. The performance of a midline episiotomy was associated with an increased risk of anal sphincter tear compared with delivery without an episiotomy in the univariate analysis (odds ratio, 4.9; 95% CI, 2.5-9.6), but this association was reduced in the adjusted analysis (odds ratio, 2.5; 95% CI, 1.0-6.0). The increased duration of both the first and second stages of labor increased injury risk in the unadjusted, but not adjusted, analysis. No significant association was observed between case status and the use of oxytocin or epidural anesthesia. Greater, but not significant, increased risk was associated with maternal indications for operative delivery compared with fetal indications. CONCLUSION: Our results are consistent with recent reports that identify forceps delivery and nulliparity as risk factors for recognized anal sphincter injury at the time of vaginal delivery. Further investigation should focus on the determination of whether the association of injury to instrumentation is causal or, in fact, modifiable. Because of the established association between sphincteric muscular damage and anal incontinence, patients should be counseled about the risk of anal sphincter injury when operative vaginal delivery is contemplated. Such patients should be followed closely in the postpartum setting to assess for the development of potential anorectal complaints.

Deletion of the trichodiene synthase gene of Fusarium venenatum: two systems for repeated gene deletions.

The trichodiene synthase (tri5) gene of Fusarium venenatum was cloned from a genomic library. Vectors were created in which the tri5 coding sequence was replaced with the Neurospora crassa nitrate reductase (nit3) gene and with the Aspergillus nidulans acetamidase (amdS) gene flanked by direct repeats. The first vector was utilized to transform a nitrate reductase (niaD) mutant of F. venenatum to prototrophy, and the second vector was utilized to confer acetamide utilization to the wild-type strain. Several of the transformants lost the capacity to produce the trichothecene diacetoxyscirpenol and were shown by hybridization analysis to have gene replacements at the tri5 locus. The nit3 gene was removed by retransformation with a tri5 deletion fragment and selection on chlorate. The amdS gene was shown to excise spontaneously via the flanking direct repeats when spores were plated onto fluoroacetamide.

Species-specific primers resolve members of Fusarium section Fusarium. Taxonomic status of the edible "Quorn" fungus reevaluated.

Sixty-seven authentic isolates, representing six species from Fusarium section Fusarium (= section Discolor) were subjected to random amplified polymorphic DNA (RAPD) analysis and polymerase chain reaction using species-specific primers. Remarkably uniform RAPD banding patterns were obtained intraspecifically, irrespective of the geographical origin of the isolates or the host/substratum from which they were isolated. Isolates were also assessed for colony characteristics when grown on a defined minimal medium. The Quorn strain (ATCC 20334; previously considered to be F. graminearum) matched the F. venenatum strains exclusively in RAPD profile. In addition, equivalently sized DNA fragments amplified from ATCC 20334 and two authentic F. venenatum strains were identical with respect to DNA sequence. Our molecular and morphological data support the identification of the Quorn strain as F. venenatum Nirenberg (= F. sambucinum Fuckel sensu lato).