A new tool for the validation of umbilical cord acid-base data.

OBJECTIVE: To identify the distribution of carbon dioxide tension (pCO(2) ) relative to pH in validated umbilical cord acid-base data. DESIGN: Observational study. SETTING: European hospital labour wards. POPULATION: Data for 36,432 term newborns were obtained from three sources: two trials of fetal monitoring with electrocardiography (ECG; the Swedish randomised controlled trial and the European Union Fetal ECG trial) and data from Mölndal Hospital. METHODS: From the total study population, cases with missing values or obvious typing errors were excluded. The remaining data were validated based on specified criteria. Percentiles of arterial pCO(2) by pH were calculated using multilevel regression modelling. MAIN OUTCOME MEASURES: Umbilical cord pH, pCO(2) and base deficit. RESULTS: Acid-base values were considered invalid in one out of seven cases. Percentiles for arterial pCO(2) corresponding to specified values of arterial pH were developed from the validated data of 26, 690 cases. CONCLUSIONS: Percentiles for arterial pCO(2) for a specified arterial pH can be used as a tool to identify cases with erroneously low pCO(2) values, and thus avoid an incorrect interpretation of the newborn's acid-base status.

ST analysis of the fetal electrocardiogram during labor: Nordic observational multicenter study.

OBJECTIVE: To assess the diagnostic power of cardiotocography (CTG) plus the ST interval of the electrocardiogram (ECG) clinical guidelines with combined fetal heart rate and ST waveform analysis of the fetal ECG recorded during labor, to identify an adverse labor outcome (neonatal neurological symptoms and/or metabolic acidosis). STUDY DESIGN: An observational, multicenter study was undertaken in 12 Nordic labor wards. A total of 573 women in labor were monitored using a prototype of the STAN S 21 recorder with fetal ECG data and computerized ST analysis. RESULTS: Fifteen cases of intrapartum fetal hypoxia identified from neurological neonatal symptoms and/or cord artery pH < 7.05 with base deficit in extracellular fluid > 12.0 mmol/l were recorded. All these cases were identified by CTG + ST clinical guidelines. Five developed neonatal symptoms and had ECG abnormalities during the first stage of labor and, of the remaining ten, eight showed ST changes during active pushing in the second stage. Another eight cases had acidemia only and normal neonatal outcome. Seven of these displayed CTG + ST abnormalities. The high sensitivity of CTG + ST to predict fetal acidosis was associated with a marked increase in positive predictive values compared with conventional CTG. CONCLUSION: The STAN clinical guidelines identify fetuses at risk of intrapartum asphyxia.

Cardiotocography only versus cardiotocography plus ST analysis of fetal electrocardiogram for intrapartum fetal monitoring: a Swedish randomised controlled trial.

BACKGROUND: Previous studies indicate that analysis of the ST waveform of the fetal electrocardiogram provides information on the fetal response to hypoxia. We did a multicentre randomised controlled trial to test the hypothesis that intrapartum monitoring with cardiotocography combined with automatic ST-waveform analysis results in an improved perinatal outcome compared with cardiotocography alone. METHODS: At three Swedish labour wards, 4966 women with term fetuses in the cephalic presentation entered the trial during labour after a clinical decision had been made to apply a fetal scalp electrode for internal cardiotocography. They were randomly assigned monitoring with cardiotocography plus ST analysis (CTG+ST group) or cardiotocography only (CTG group). The main outcome measure was rate of umbilical-artery metabolic acidosis (pH <7.05 and base deficit >12 mmol/L). Secondary outcomes included operative delivery for fetal distress. Results were first analysed according to intention to treat, and secondly after exclusion of cases with severe malformations or with inadequate monitoring. FINDINGS: The CTG+ST group showed significantly lower rates of umbilical-artery metabolic acidosis than the cardiotocography group (15 of 2159 [0.7%] vs 31 of 2079 [2%], relative risk 0.47 [95% CI 0.25-0.86], p=0.02) and of operative delivery for fetal distress (193 of 2519 [8%] vs 227 of 2447 [9%], 0.83 [0.69-0.99], p=0.047) when all cases were included according to intention to treat. The differences were more pronounced after exclusion of 291 in the CTG+ST group and 283 in the CTG group with malformations or inadequate recording. INTERPRETATION: Intrapartum monitoring with cardiotocography combined with automatic ST-waveform analysis increases the ability of obstetricians to identify fetal hypoxia and to intervene more appropriately, resulting in an improved perinatal outcome.

The action of vasoconstrictive agents on human tubal arteries.

The aim of this investigation was to compare the response of small arteries of the human tubo-ovarian vasculature to certain vasoactive agents. Ring preparations of the arteries were isolated and mounted in tissue chambers for isometric recording of wall tension. The arteries were exposed to the vasoactive agents adrenalin, prostaglandin F2 alpha and two vasopressin analogues. Adrenalin, prostaglandin F2 alpha, lysin-vasopressin and triglycyl-lysine-vasopressin all produced powerful vasoconstriction, the greatest efficacy being shown by and lysine-vasopressin. The maximum response occurred after addition of a third compound to a combination of two, irrespective of which combination was used. Adrenalin showed faster contraction velocity than the other agents. The results indicate that the human tubo-ovarian arteries may be constricted by a variety of physiological and pharmacological stimuli, at least partly acting via different effector mechanisms. It is proposed that these vasoconstrictive agents--alone or in combination--may be useful in conjunction with gynaecological endoscopic surgery, e.g. in tubal pregnancy or ovarian cysts.

Auxiliary photosynthetic functions of Arabidopsis thaliana--studies in vitro and in vivo.

An improved cultivation system for Arabidopsis thaliana was developed, allowing advanced biochemical studies in vitro and in vivo of this important model plant. Highly functional Arabidopsis thylakoids were isolated and used to study both basic and regulatory photosynthetic functions with the aim to create a platform for the characterization of mutants deficient in auxiliary proteins. Light-induced proteolytic degradation of the D1 protein could be followed and shown to be a subsequent event to photoinactivation of electron transport. The phosphorylation and dephosphorylation of thylakoid proteins resembled that seen in spinach leaves although phospho-CP43 revealed an unusual regulatory behavior.

Gas kinetics during nitrous oxide analgesia for labour.

Hypoxaemia may occur after hyperventilation with nitrous oxide during labour. The purpose of this study was to assess whether diffusion hypoxia is a contributory factor. Twenty-four parturients were randomly allocated to receive 50 or 70% nitrous oxide in oxygen. The median nitrous oxide inhalation time per contraction was 58 s and 33 s, respectively. The end-tidal carbon dioxide and the minute ventilation remained unchanged. The end-tidal oxygen concentration was lowest at 120 s, reaching 15.4% in both groups. The oxygen saturation did not differ between the groups with a lowest median value of 96% before the start of nitrous oxide inhalation. Two parturients had episodes of desaturation. Both had low end-tidal oxygen concentrations in association with the desaturation but, as the end-tidal nitrous oxide concentrations were low, the desaturations could not be attributed to diffusion hypoxia.

Prognostic value of DNA ploidy and S-phase fraction in endometrial cancer stage I and II: a prospective 5-year survival study.

Knowledge of reliable prognostic factors is essential in cancer treatment. Especially when intensified treatment is to be considered to improve the overall result, it is desirable to identify well-defined high-risk groups. In a prospective study DNA ploidy and S-phase fraction were measured in 88 patients with endometrial cancer stage I and II. Fresh tumor samples were analyzed using flow cytometry prior to treatment. Diploid tumors represented 84% of the cases, and aneuploid represented 16%. The mean S-phase fraction in diploid tumors was 10%, as compared with 22% in aneuploid tumors. The follow-up time was 5 years in all cases. The survival rate for patients with diploid tumors was 92% and for aneuploid tumors 36%. In the surviving patients, the mean S-phase fraction was 10.4%, a significant difference from 19.9% in the nonsurviving patients (P < 0.001). The highest mortality was found when aneuploidy was combined with an S-phase fraction over 20%, with only 11% survival for 5 years. In diploid tumors with an S-phase fraction below 20%, the survival rate was 92%. In a stepwise regression analysis, S-phase fraction was found to be of the most important prognostic value, followed by myometrial invasion and stage of the tumor and ploidy. Grade was not found to be of any important significance.

Prognostic value of steroid hormone receptors for 5-year survival in stage II endometrial cancer.

BACKGROUND AND METHODS: In a prospective study, the 5-year survival of 57 patients with Stage II endometrial cancer was correlated to the estrogen (ER) and progesterone (PR) receptor concentrations using the dextran-coated charcoal (DCC) technique. The cutoff level was 3 fmol/mg of protein for ER and 6 fmol/mg of protein for PR. RESULTS: An histopathologic examination of the tumor tissue samples before treatment demonstrated that 16% of the cases (9 patients) were well-differentiated (Grade 1), 45% (26 patients) moderately differentiated (Grade 2), and 39% (22 patients) poorly differentiated (Grade 3). Only 3 were ER negative, whereas 19 were PR negative. The mean concentrations for ER and PR were 106 and 162 fmol/mg of protein, respectively. All patients received standard treatment, including preoperative irradiation. The total 5-year survival rate was 82% (47 of 57 patients). Deep myometrial invasion was important in Grade 3, but not in Grades 1 and 2; in these two grades, all five patients with deep infiltration survived. There was a correlation between receptor concentration and grade, with a significant difference between Grades 1 and 2 versus Grade 3. All patients who were ER negative survived, as did all patients who were PR negative in Grades 1 and 2. Of the patients with Grade 3 disease who died, four of six (67%) were PR negative. Of the patients with Grade 3 disease who survived, 10 of 16 (63%) were PR negative. CONCLUSIONS: Patients who survived for 5 years did not have significantly different ER and PR concentrations than those who died. The mean ER and PR concentrations in patients who survived were 99 and 159 fmol/mg of protein, respectively, compared with 108 and 178 fmol/mg of protein, respectively, for those who died.

Colloid (3% Dextran 70) with or without ephedrine infusion for cardiovascular stability during extradural caesarean section.

Using a non-invasive cardiac output monitor (Bo-Med NCCOM 3-R7), we have compared cardiovascular responses, degree of haemodilution and incidence of nausea during extradural Caesarean section in healthy non-labouring mothers given either ephedrine 17.5 mg and 3% Dextran 70 7.5 ml kg-1 before delivery (group A) or volume loading with Dextran 15 ml kg-1 without infusion of ephedrine (group B). Smallest systolic arterial pressures before delivery were 114 (SEM 4) mm Hg (group A) and 105 (5) (group B). There were no significant differences between the groups in mean arterial pressure, heart rate, systemic vascular resistance or central venous pressure, while cardiac output increased more with the ephedrine infusion (P less than 0.05). Haemodilution was 8% in group A and 16% in group B at the time of delivery. Ephedrine infusion was associated with a smaller incidence of nausea (P less than 0.01). Umbilical arterial pH values were not different between the two groups. We conclude that infusion of ephedrine, combined with low volume colloid administration, is a safe alternative to more extensive colloid volume expansion for control of hypotension and provides effective prophylaxis against nausea during extradural Caesarean section in healthy non-labouring mothers.

Local luteolytic effect of prostaglandin F2 alpha in the human corpus luteum.

OBJECTIVE: To evaluate the effects of prostaglandin (PG)F2 alpha on human corpus luteum (CL) function in vivo. DESIGN: The effects of a single injection of PGF2 alpha into the CL was studied. SETTING: The patients underwent elective surgery at the Department of Obstetrics and Gynecology, Sahlgrenska Hospital, University of Göteborg, Sweden. PARTICIPANTS: Twenty women with regular menstrual cycles undergoing laparoscopy for legal sterilization with tubal clips volunteered for the study. INTERVENTIONS: Prostaglandin F2 alpha (3 mg) was injected through the abdominal wall into the CL. In control cases, vehicle was injected into the CL or PGF2 alpha into the contralateral ovary. MAIN OUTCOME MEASURE: After the injections, serum was analyzed for progesterone (P) and luteinizing hormone using fluoroimmunoassay and enzyme-immunoassay, respectively. Menstrual data were recorded. RESULTS: In contrast to control cases, intraluteal injection of PGF2 alpha caused both an immediate fall of greater than 30% in serum P and a shortening of the luteal phase by 2 to 5 days. Luteinizing hormone varied independently of the changes in serum P levels. CONCLUSION: The results suggest a local role for PGF2 alpha in human luteolysis.

Effects of bupivacaine and calcium antagonists on human uterine arteries in pregnant and non-pregnant women.

Bupivacaine is a local anesthetic commonly used in obstetrical practice. Although not generally constrictive, it has a constricting effect on blood vessels in clinically used doses, and when administered close to the uterine vasculature, as in a paracervical blockade, it can induce severe fetal bradycardia and thus be hazardous to the fetus. The bupivacaine-induced vasoconstriction on uterine arteries from pregnant and non-pregnant women was effectively reduced by two different calcium antagonists, verapamil and nifedipine. In non-pregnant women, nifedipine (2.9 x 10(-7) mol.l-1) administered simultaneously with bupivacaine (5.8 x 10(-4) mol.l-1) caused a 96% and verapamil (10(-5) mol.l-1) an 84% reduction as compared with the control vessel where only bupivacaine (5.8 x 10(-4) mol.l-1) was administered. In pregnant women, nifedipine 2.9 x 10(-7) mol.l-1 and 2.9 x 10(-6) mol.l-1 produced 66% and 79% reductions, respectively. It is possible that calcium antagonists administered together with bupivacaine in paracervical blockade could reduce the risk of fetal bradycardia.

Endometrial cancer stage II: 190 cases with different preoperative irradiation.

In a retrospective study, the 5-year survival in 190 patients with endometrial adenocarcinoma stage II was evaluated in relation to different preoperative radiotherapy techniques. In one group, group A, 111 patients received low dose rate radium to the cervix region and in a second group, group B, 79 patients received high dose rate 60Co treatment using the after-loading technique. Both groups received intracavitary radium using the standard Heyman technique. There were no statistically significant differences in survival, after correction for intercurrent disease, between the two groups. The overall 5-year survival corrected by intercurrent disease was 79% for group A and 80% for group B. The histological grade survival in group A was 94% in grade 1, 83% in grade 2, and 60% in grade 3 and in group B, 100% in grade 1, 80% in grade 2, and 59% in grade 3. A correlation was found between histological grade, uterine sound, and survival in both groups. Only in grade 3 was deep infiltration found to have a worse prognosis. No metastasis in regional lymph nodes was found, but distant metastasis was a problem in grade 3. A significant overrepresentation of nullipara could be found among the 190 patients and was pronounced for grade 1. Our results indicate that vaginal radium application can be replaced by high dose rate 60Co in the treatment of stage II endometrial adenocarcinoma, with no decrease in the 5-year survival rate.

Effects of bupivacaine and calcium antagonists on the rat uterine artery.

Bupivacaine is a commonly used local anesthetic in obstetrical practice, but since this compound also has a constrictor action on vascular smooth muscle it can be hazardous to the fetus. The aim of the present study was to analyze the effect of bupivacaine on the uterine vasculature using the rat uterine artery as a model. Small arterial segments were mounted in tissue chambers for isometric recording of vascular tension using a specially designed teflon-steel gauge. Bupivacaine induced marked vasoconstriction and this vasoconstriction was reduced considerably by two different Ca antagonists, verapamil and nifedipine. Verapamil (10(-5) mol.l-1) reduced bupivacaine-produced arterial contraction by a mean of 78% and nifedipine (2.9 x 10(-7) mol.l-1) reduced arterial contraction by a mean of 57%.

Endothelin--a potent constrictor of small myometrial arteries of term pregnant women.

This study was performed to evaluate the in vitro effects of a new polypeptide, endothelin-1 (ET-1) on small intramyometrial vessels in comparison with the action of noradrenalin (NA). In connection with cesarean section, myometrial biopsies were obtained and small arteries (100-500 microns in diameter) were excised. Cylindrical segments of these vessels were used for registration of contractile activity after administration of ET-1 and NA. ET produced vasoconstriction and was approximately three times as powerful and 70-fold as potent as NA. It is suggested that ET may be involved in the regulation of human utero-placental blood flow.

Influence of bupivacaine and morphine on human umbilical arteries and veins in vitro.

Strips from human umbilical arteries and veins were prepared by microdissection. The vessel strips were mounted in tissue baths for isometric recording of contractile activity. The local anesthetic drug bupivacaine induced a concentration-dependent increase of tone in both artery and vein, whereas morphine had no effect. Nor did morphine influence the increase in vessel tone induced by bupivacaine. If applicable in vivo, the results suggest that morphine has little influence on umbilical vessel tone, whereas bupivacaine may reduce the umbilical blood flow, at least when the local concentration of bupivacaine exceeds a certain critical level. The addition of morphine to local anesthetics did not increase any adverse effects on the umbilical vessels in this study.

Ovarian cancer stages I and II: predictions and 5-year survival in two decades.

Today, when all studies of treatment of ovarian cancer stages III and IV show disappointing long-term survival despite extensive surgery and chemotherapy, it is of interest to look a little further at the characteristics of early ovarian cancer to help the development of screening methods. For this purpose, stages I and II were analyzed during the periods 1969 to 1972 (group A, n = 172) and 1979 to 1982 (group B, n = 179). The total survival for stages I and II was 57% in group A and 66% in group B. In group A, survival was 74% for stage I and 41% for stage II; the corresponding data for group B were 68 and 65%. The difference between groups A and B for stage II is statistically significant. In stage I, survival was not found to be dependent on hysterectomy and bilateral salpingo-oophorectomy (SOEBH) or bilateral/unilateral salpingo-oophorectomy (SOEB/SOEU). In stage II, however, survival increased significantly after SOEBH. The best survival (80%, 28/35) occurred in group B, stage II, where high-voltage treatment was followed by melphalan for 6 months postoperatively.

A unique case of abdominal pregnancy: what are the minimal requirements for placental contact with the maternal vascular bed?

In this report we describe a case of abdominal pregnancy in which the placenta engaged part of the wall of an intra-abdominal membranous sac with only minimal vascular connection with the peritoneal surface. A male infant weighing 3150 gm was delivered at 38 weeks' gestation. We believe this case represents the first report in the literature of an abdominal pregnancy without placental attachment to the maternal viscera.

Novel variants of adrenocorticotrophic hormone in porcine anterior pituitary.

Extracts of porcine anterior pituitary contain several corticotrophic variants of ACTH 1-39. They were isolated by adsorption chromatography, ion-exchange chromatography and reverse-phase high-performance liquid chromatography. Four variants were then identified as starting and ending at positions corresponding to ACTH 1-38, 1-37, 7-39 and 7-38. Several of these fragments were recovered in chromatographically multiple forms. Although all fragments isolated had corticotrophic activity (measured on isolated rat adrenal cells) those with a shortened N-terminal region had a lower potency than those with an intact N-terminal region. Corticotrophic activity of porcine ACTH 7-38 was detected in a preparation with a beta-aspartyl shift at position 25. However, in agreement with previous studies, synthetic human ACTH 7-38, in which an intact Asn-Gly bond was structurally proven, possessed no such activity. The results indicate that position 25 as well as positions 1-6 are important for corticotrophic activity, and that a deamidative beta-aspartyl shift at position 25 can influence the activity.