Suture type for hysterotomy closure: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Recent randomized controlled trials have demonstrated an association between uterine closure technique at the time of cesarean delivery and short- and long-term operative outcomes with varied results. This systematic review and meta-analysis aimed to examine types of suture material used for cesarean delivery.

DATA SOURCES

Scopus, PubMed, Cochrane Central Register of Controlled Trials, Ovid, and ClinicalTrials.gov were searched from inception of each database to October 2021.

STUDY ELIGIBILITY CRITERIA

All randomized controlled trials that compared types of suture materials used for hysterotomy closure during low-transverse cesarean delivery at ≥24 weeks' gestation and examined maternal outcomes were included for this review. The primary outcome was estimated blood loss. Secondary outcomes included additional surgical complications.

METHODS

Results were summarized as mean difference or risk ratio with associated 95% confidence intervals. The quality of studies was evaluated with the Cochrane Handbook for Systematic Reviews of Interventions for judging risk of bias. Heterogeneity was measured using I-squared (Higgins I2).

RESULTS

This review included 7 randomized controlled trials, of which 3 compared multifilament with barbed suture (136 vs 136 participants), 3 compared multifilament with conventional monofilament suture (245 vs 244 participants), and 1 trial compared multifilament with chromic suture (4590 vs 4595 participants). Primary analysis showed no difference in estimated blood loss between the multifilament and the barbed suture group (mean difference, 46.2 mL; 95% confidence interval, -13.6 to 105.9), nor in change in hemoglobin concentration between the multifilament and the conventional monofilament group (mean difference, -0.1%; 95% confidence interval, -0.5 to 0.3). Secondary outcomes showed a reduction in operative time with barbed vs multifilament suture (mean difference, 1.9 minutes; 95% confidence interval, 0.03-3.8). Analysis also demonstrated an increased uterine scar thickness with use of conventional monofilament vs multifilament suture (mean difference, -1.05 mm; 95% confidence interval, -1.9 to -0.2).

CONCLUSION

This meta-analysis does not support a specific type of suture material for uterine closure at cesarean delivery because of insufficient data. Although barbed suture was associated with an overall decrease in operative time, and use of conventional monofilament suture was associated with an increase in uterine scar thickness, the clinical utility of these differences is not clear. Further adequate randomized controlled trials are warranted for evaluation of different suture materials for hysterotomy closure.

A novel extended prophylactic antibiotic regimen in preterm pre-labor rupture of membranes: A randomized trial

OBJECTIVES

Prophylactic antibiotic use in preterm pre-labor rupture of membranes (PPROM) is associated with a significant reduction in intra-amniotic infection and improved neonatal outcome. However, data is insufficient to determine the optimal antibiotic regimen. Considering the rise in Escherichia coli and Klebsiella pneumonia early-onset sepsis rate and the emergence of ampicillin resistance, our aim is to compare the efficiency of two antibiotic regimens in prolonging pregnancy and reducing infectious morbidity.

DESIGN

This multicenter randomized unblinded controlled prospective trial compared two antibiotic prophylactic protocols in PPROM: ampicillin + roxithromycin vs. cefuroxime + roxithromycin in 84 women with PPROM, from 12/2015-12/2019.

RESULTS

The median latency period was significantly longer (p = 0.039) in the cefuroxime + roxithromycin group (4.63 [0.59-50.18] days) than in the ampicillin + roxithromycin group (2.3 [0.15-58.3] days). Neonatal admission to neonatal intensive care unit rate, hospitalization length, neonatal respiratory distress syndrome, neonatal fever, and need for respiratory support or mechanical ventilation, were similar between the groups. K. pneumonia cultures were significantly more frequent in the ampicillin + roxithromycin group. None of the cultures were group B Streptococcus positive.

CONCLUSIONS

To prolong latency period and reduce gram-negative early-onset sepsis, cefuroxime + roxithromycin is recommended as the first-line protocol in PPROM.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02819570.

Elites in social networks: An axiomatic approach to power balance and Price's square root law

A common two-tier structure for social networks is based on partitioning society into two parts, referred to as the elite and the periphery, where the "elite" is the relatively small but well-connected and highly influential group of powerful individuals around which the society is centered, and the "periphery" consists of the rest of society. It is observed that the relative sizes of economic and social elites in various societies appear to be continually declining. One possible explanation is that this is a natural social phenomenon, resembling Price's "square root" law for the fraction of good scientists in the scientific community. We try to assess the validity of this explanation by studying the elite-periphery structure via introducing a novel axiom-based model for representing and measuring the influence between the elite and the periphery. The model is accompanied by a set of axioms that capture the elite's dominance, robustness and density, as well as a compactness property. Relying on the model and the accompanying axioms, we are able to draw a number of insightful conclusions about the elite-periphery structure. In particular, we show that in social networks that respect our axioms, the size of a compact elite is sublinear in the network size. This agrees with Price's principle but appears to contradict the common belief that the elite size tends to a linear fraction of society (recently claimed to be around 1%). We propose a natural method to create partitions with nice properties, based on the key observation that an elite-periphery partition is at what we call a 'balance point', where the elite and the periphery maintain a balance of powers. Our method is based on setting the elite to be the k most influential nodes in the network and suggest the balance point as a tool for choosing k and therefore the size of the elite. When using nodes degrees to order the nodes, the resulting k-rich club at the balance point is the elite of a partition we refer to as the balanced edge-based partition. We accompany these findings with an empirical study on 32 real-world social networks, which provides evidence that balanced edge-based partitions which satisfying our axioms commonly exist.

The History of the Low Transverse Cesarean Section: The Pivotal Role of Munro Kerr

Cesarean section has undergone a transformation that has radically changed the prognosis of both the pregnant woman and her unborn child. The attributed mortality rate of Cesarean section during the 19th century was over 50% worldwide. Today, mortality from Cesarean delivery is rare. However, the technique of transversely incising the uterus in its lower uterine segment, although less than a century old, is passed on from instructor to apprentice, often without either of them being aware of its noble history. In this brief review, we discuss the reported history regarding this incision and the significant role played by John Munro Kerr.

Isolated polyhydramnios in the third trimester: is a gestational diabetes evaluation of value?. Gynecol Endocrinol 2017;33:849-852. [PMID: 28488900 DOI: 10.1080/09513590.2017.1323857]

We evaluated implications of testing for gestational diabetes mellitus (GDM) in pregnancies complicated by third trimester isolated polyhydramnios with previous negative diabetes screening test. In this retrospective cohort study of 104 pregnant women with polyhydramnios between 2005 and 2013, all had normal first trimester fasting glucose and normal glucose challenge test (GCT < 140 mg/dL). Late onset GDM was diagnosed in five women (4.8%) with isolated polyhydramnios, one abnormal value in the oral glucose tolerance test (OGTT) was identified in four additional women (3.8%). No significant differences were found in risk factors for GDM, mean second trimester GCT (117.5 vs. 107.2 mg/dL, p = 0.38) or fasting glucose values (82 vs. 86 mg/dL, p = 0.29) between women in the polyhydramnios group with and without late GDM diagnosis. Moreover, no significant difference was found in relation to the mode of delivery or birth weight between the studied groups (3437 ± 611 vs. 3331 ± 515 g, p = 0.63). Diagnosis of third trimester polyhydramnios was not associated with increased risk for GDM or neonatal complications.

Correlation between changes in liver stiffness and preeclampsia as shown by transient elastography

OBJECTIVE

The aim of this study was to evaluate the use of Fibroscan as a measure of liver transient elastography in women with preeclampsia and compare the results with a group of normotensive controls.

MATERIALS AND METHODS

In this prospective observational case-control study, women at 24-41 weeks gestation who were diagnosed with preeclampsia using standard criteria, between January 2012 and December 2013, were included. The Fibroscan test was performed by a hepatologist 1-7 days postpartum. A control group consisted of low-risk women with normal pregnancy outcomes.

RESULTS

Fibroscan results for fibrosis were significantly higher in the 32 preeclamptic women compared to the 16 normotensive women (mean 4.57 kPa vs. 3.66 kPa respectively, P = 0.01). There was no difference in liver steatosis between women with preeclampsia and normotensive women (226 vs. 225 kPa, respectively, P = 0.442) Conclusions: Fibroscan results for fibrosis were significantly higher in postpartum preeclamptic women (although within the normal range). Further studies are required in order to evaluate the usefulness of Fibroscan as an additional test in the evaluation and management of preeclampsia.

Reconsidering the Current Preterm Premature Rupture of Membranes Antibiotic Prophylactic Protocol

OBJECTIVE

The purpose of our study was to determine whether the current antibiotic regimen for preterm premature rupture of membranes (PPROM) is adequate for covering the current causative agents and sensitivities of chorioamnionitis and early-onset neonatal sepsis.

STUDY DESIGN

During a 3-year period, we retrieved the results from placental and amniotic membrane cultures obtained at delivery in cases of maternal fever, chorioamnionitis, and PPROM, and from blood cultures obtained from neonates with early-onset sepsis (EOS) in three participating hospitals. Sensitivity of pathogens to antimicrobial agents was performed using routine microbiologic techniques.

RESULTS

There were 1,133 positive placental or amniotic cultures, 740 (65.3%) were from gram-negative Enterobacteriaceae. There were 27 neonates diagnosed with EOS with positive blood cultures. Aerobic Enterobacteriaceae accounted for 14 cases (52%) and group B streptococcus for 7 cases (26%). Of the Escherichia coli and Klebsiella sp., only 38% were sensitive to ampicillin.

CONCLUSION

Local pathogens and their antibiotic sensitivity profiles should be explored every few years and an effective antibiotic protocol chosen to cover the main pathogens causing chorioamnionitis and EOS. Consideration should be made for changing ampicillin in women with PPROM to a regimen with better coverage of gram-negative Enterobacteriaceae.

Counseling for fetal macrosomia: an estimated fetal weight of 4,000 g is excessively low

OBJECTIVE

Because of the known complications of fetal macrosomia, our hospital's policy has been to discuss the risks of shoulder dystocia and cesarean section (CS) in mothers with a sonographic estimated fetal weight (SEFW) ≥ 4,000 g at term. The present study was performed to determine the effect of this policy on CS rates and pregnancy outcome.

STUDY DESIGN

We examined the pregnancy outcomes of the macrosomic (≥ 4,000 g) neonates in two cohorts of nondiabetic low risk women at term without preexisting indications for cesarean: (1) SEFW ≥ 4,000 g (correctly suspected macrosomia) and (2) SEFW < 4,000 g (unsuspected macrosomia).

RESULTS

There were 238 neonates in the correctly suspected group and 205 neonates in the unsuspected macrosomia group, respectively. Vaginal delivery was accomplished in 52.1% of the suspected group and 90.7% of the unsuspected group, respectively, p < 0.001. There was no difference in the rates of shoulder dystocia. The odds ratio for CS was 9.0 (95% confidence interval, 5.3-15.4) when macrosomia was correctly suspected.

CONCLUSION

The policy of discussing the risk of macrosomia with SEFW ≥ 4,000 g to women is not justified. A higher SEFW to trigger counseling for shoulder dystocia and CS, more consistent with American College of Obstetrics and Gynecology (ACOG) guidelines, should be considered.

Uptake of noninvasive prenatal testing at a large academic referral center

OBJECTIVE

Noninvasive prenatal testing (NIPT) is a recently developed risk-assessment technique with high sensitivity and specificity for fetal aneuploidy. The effect NIPT has had on traditional screening and diagnostic testing has not been clearly demonstrated. In this study, NIPT uptake and subsequent changes in the utilization of first-trimester screen (FTS), chorionic villus sampling (CVS), and amniocentesis in a single referral center is reported.

STUDY DESIGN

Monthly numbers of NIPT (in high-risk patients), FTS, CVS, and amniocentesis were compared between a 35-month baseline period (April 2009 through February 2012) before introduction of NIPT, and the initial 16 months following NIPT introduction divided in 4-month quarters beginning in March 2012 through June 2013.

RESULTS

A total of 1265 NIPT, 6637 FTS, 251 CVS, and 1134 amniocentesis were recorded over the 51-month study period in singleton pregnancies of women who desired prenatal screening and diagnostic testing. NIPT became the predominant FTS method by the second quarter following its introduction, increasing by 55.0% over the course of the study period. Total first-trimester risk assessments (NIPT+FTS) were not statistically different following NIPT (P = .312), but average monthly FTS procedures significantly decreased following NIPT introduction, decreasing by 48.7% over the course of the study period. Average monthly CVS and amniocentesis procedures significantly decreased following NIPT introduction, representing a 77.2% and 52.5% decrease in testing, respectively. Screening and testing per 100 morphological ultrasounds followed a similar trend.

CONCLUSION

NIPT was quickly adopted by our high-risk patient population, and significantly decreased alternate prenatal screening and diagnostic testing in a short period of time.

Removal of an intraabdominal levonorgestrel-releasing intrauterine device during pregnancy

A woman with a viable intrauterine 12-week pregnancy and an intraabdominal levonorgestrel-releasing intrauterine device had the device successfully removed under local anesthesia. The pregnancy continued without complication. The decision to remove an intraabdominal levonorgestrel-releasing intrauterine device during pregnancy remains controversial.

Management of meconium-stained neonates

We examined the use of a new scoring system for the meconium-stained infant, which was designed to help the neonatologist decide on the appropriate therapeutic approach in the delivery room. Eighty meconium-stained infants were scored for: presence of fetal distress; meconium quality; performance of nasopharyngeal suctioning before the first breath and clinical condition in the first minute of life. Management consisted of gentle oropharyngeal suctioning or intubation and tracheal suctioning. Clinical outcome was compared with that of 100 meconium-stained infants born a year earlier. All babies in the control group underwent laryngoscopy and 30% were subsequently intubated. Universal laryngoscopy was not performed in the study group, and only 22.5% of these infants were intubated. The clinical outcome of the studied babies was identical to that of the newborns treated by the standard procedure. The use of the meconium intubation score eliminated the need for universal delivery room laryngoscopy for meconium-stained infants and significantly reduced the number of intubations performed.

Reducing human interactions in Web directory searches

Consider a website containing a collection of webpages with data such as in Yahoo or the Open Directory project. Each page is associated with a weight representing the frequency with which that page is accessed by users. In the tree hierarchy representation, accessing each page requires the user to travel along the path leading to it from the root. By enhancing the index tree with additional edges (hotlinks) one may reduce the access cost of the system. In other words, the hotlinks reduce the expected number of steps needed to reach a leaf page from the tree root, assuming that the user knows which hotlinks to take. The hotlink enhancement problem involves finding a set of hotlinks minimizing this cost.

This article proposes the first exact algorithm for the hotlink enhancement problem. This algorithm runs in polynomial time for trees with logarithmic depth. Experiments conducted with real data show that significant improvement in the expected number of accesses per search can be achieved in websites using this algorithm. These experiments also suggest that the simple and much faster heuristic proposed previously by Czyzowicz et al. [2003] creates hotlinks that are nearly optimal in the time savings they provide to the user.

The version of the hotlink enhancement problem in which the weight distribution on the leaves is unknown is discussed as well. We present a polynomial-time algorithm that is optimal for any tree for any depth.

Interleukin 1beta in serum of women with preterm uterine contractions

Preterm delivery is a major obstetric and public health problem, accounting for 50-70% of all perinatal deaths. An enzyme-linked immunoassay (ELISA) test was used to determine serum interleukin 1b (IL-1b) levels in 32 women with preterm contractions compared with 26 women in term labour and 11 normal preterm pregnant women. Women with preterm contractions (with or without treatment) had significantly lower mean serum levels of IL-1b (23.5 pgr/ml) compared with women in term labour (218 +/- 57 pgr/ml), but similar levels to pregnant women not in labour at the same weeks of gestation.

Evaluation of fetal cardiac contractility by two-dimensional ultrasonography

OBJECTIVE

Evaluation of fetal cardiac contractility by two-dimensional ultrasonography and construction of nomograms of area shortening fraction, end-diastolic area and end-systolic area of fetal cardiac ventricles during uncomplicated pregnancy.

MATERIALS AND METHODS

Fetal echocardiography was performed on 160 pregnant women between 14 and 28 weeks' gestation. Measurements were taken on the four-chamber view. The area of each ventricle was measured by tracing the endocardium at the end of systole and at the end of diastole. Area shortening fraction was calculated by the following formula: SF = (Ad - As)/Ad (SF--area shortening fraction, Ad--end-diastolic ventricular area, As--end-systolic ventricular area).

RESULTS

A statistically significant increase in normal fetal area shortening fraction, end-diastolic area and end-systolic area of both ventricles with advancing gestational age was established. There were no significant differences in the area shortening fraction between right and left ventricles.

CONCLUSIONS

Area shortening fraction shows good correlation with gestational age. Nomogram of area shortening fraction, end-diastolic area and end-systolic area of both ventricles can be used as the reference for evaluation of ventricle size and cardiac contractility in normal and pathological cases.

In-utero development of the fetal colon and rectum: sonographic evaluation

OBJECTIVE

To construct a normal range for the internal diameter of the fetal descending colon and rectum during gestation.

SUBJECTS AND METHODS

This was a prospective, cross-sectional study including 379 healthy pregnant women with normal singleton pregnancies at 19-40 weeks of gestation. Measurements of the fetal descending colon (maximum internal diameter) and the fetal rectum (at the level of the bladder, measuring the anteroposterior diameter), were performed by high-resolution transabdominal sonography.

RESULTS

Adequate bowel measurements were obtained in all 379 fetuses. The diameter of the descending colon and rectum plotted as a function of gestational age had a sigmoid curve; the curve estimation was expressed by a cubic regression equation with R(2) of 0.848 and 0.831, respectively (P < 0.0001). The normal mean and the 95% prediction limits were defined.

CONCLUSION

The present data provide a normal range of fetal bowel (descending colon and rectum) diameters from the early second trimester of pregnancy onwards. They may allow intrauterine assessment of the development of the fetal colon and may serve as reference values in the detection of anomalies of the fetal bowel.

The relationship between maternal serum thyroid-stimulating immunoglobulin and fetal and neonatal thyrotoxicosis

OBJECTIVE

To estimate whether the risk of neonatal thyrotoxicosis was related to the value of maternal thyroid-stimulating immunoglobulin in women with Graves disease.

METHODS

The records of pregnant women undergoing testing for thyroid-stimulating immunoglobulin over a 10-year period were analyzed. Neonatal thyrotoxicosis was defined as the presence of tachycardia, goiter, hydrops, tremulousness, voracious appetite, irritability, cardiomegaly, or congestive heart failure, with elevated thyroid hormone levels. The relationship between maternal thyroid-stimulating immunoglobulin values and the development of thyrotoxicosis was examined. The sensitivity, specificity, and positive and negative predictive values were calculated using an arbitrarily chosen cutoff for thyroid-stimulating immunoglobulin.

RESULTS

Twenty-nine women with a history of Graves disease and positive thyroid-stimulating immunoglobulin values were available for analysis. Of the 35 live births, there were six cases of neonatal thyrotoxicosis (17.1%). A maternal thyroid-stimulating immunoglobulin value at least 5 index units predicted neonatal thyrotoxicosis with a sensitivity of 100%, specificity of 76.0%, positive predictive value of 40.0%, and negative predictive value of 100%.

CONCLUSION

Pregnancies complicated by high values of maternal thyroid-stimulating immunoglobulin appear to be at risk of developing neonatal thyrotoxicosis.

Nuchal fold thickness at 14-16 weeks' gestation as measured by transvaginal sonography

OBJECTIVE

To establish normal values of fetal nuchal fold thick-ness at 14-16 weeks of gestation by transvaginal sonography.

METHODS

Transvaginal sonography was used to measure nuchal fold thickness in 182 normal pregnancies at 14-16 weeks of gestation. Nuchal fold thickness was measured as the distance from the outer skull bone to the outer skin surface in the transverse axial image in the suboccipital-bregmatic plane of the head.

RESULTS

There was no significant association between nuchal fold thickness and gestational age (r = 0.084; P = 0.258). The mean (standard deviation) was 2.2 (0.5) mm and the 95th centile was 3.0 mm.

CONCLUSIONS

The 95th centile of nuchal fold thickness measured by transvaginal sonography at 14-16 weeks is 3.0 mm.

Normal cardiac flow velocities at 14-16 weeks of gestation measured by transvaginal ultrasound

OBJECTIVE

Doppler ultrasound has been used to study the flow velocities through the valves and arteries of the fetal heart. Using transvaginal sonography, we sought to determine normal values for flow velocities through the fetal heart valves at 14-16 weeks of gestation.

METHODS

Eighty-seven normal fetuses were examined. The flow velocity waveforms were visualized using Doppler ultrasound with the sample volume calipers placed just distally to the four fetal valves. Peak E- and A-wave velocities were recorded for the tricuspid and mitral valves and peak systolic flow velocities were recorded for the ascending aorta and pulmonary arteries. Linear regression for comparison of flow velocities with gestational age was performed.

RESULTS

There was no significant correlation between any of the velocities and gestational age.

CONCLUSIONS

Flow velocities through the fetal cardiac valves remain unchanged at 14-16 weeks of gestation as measured by transvaginal Doppler sonography.

Hospitalization for early bonding of the genetic mother after a surrogate pregnancy: report of two cases

BACKGROUND

In surrogate pregnancies the genetic parents have little opportunity for early bonding to their infant, either prenatally (in utero) or in the immediate postnatal period. The purpose of this article is to describe a new method for encouraging early parent-infant bonding after surrogate pregnancy by hospitalizing the genetic mother in the maternity ward immediately after the delivery.

METHODS

Two genetic mothers were hospitalized in the maternity ward (rooming-in system) at the Rabin Medical Center in Israel immediately after delivery of their infants by surrogate arrangement. The first birth was a singleton pregnancy with vaginal delivery and the second, a twin pregnancy with delivery by cesarean section. The genetic parents were counseled by a social worker from the adoption agency, starting 3 months before the estimated date of delivery. The parents were referred to the hospital social worker before the delivery. To assess attachment, we observed the parents' behavior toward their children during two daily 15-minute periods of free, unstructured interaction.

RESULTS

The parents showed good primary caregiving functions and established affective verbal and physical contact with the infants. They began to recognize the infants' needs and temperament, and exhibited an aura of self-confidence during their interactions. All expressed satisfaction with the method at discharge and reported on reduction of their fears about returning home with the infants.

CONCLUSIONS

We believe that early hospitalization of the genetic mother in a surrogate delivery may be desirable to establish good and safe early mother-infant bonding, and that it should be considered for adoption as regular hospital policy. Further randomized studies with larger samples over the long term are warranted.

Cerebral lateral ventricular atrial diameter of male and female fetuses at 20-24 weeks' gestation

OBJECTIVE

To determine if the lateral ventricular atrial diameter differs between male and female fetuses at 20-24 weeks' gestation.

DESIGN

Prospective study.

METHODS

The transverse diameter of the ventricular atrium was measured from inner wall to inner wall for a total of 202 pregnant women with 105 male fetuses and 97 female fetuses.

RESULTS

The mean diameter of the ventricular atrium for the 202 fetuses was 4.96 +/- 0.96 mm (range, 2.1-8.4 mm). The 105 males had a mean diameter of 4.95 +/- 0.98 mm and the 97 females a mean diameter of 4.97 +/- 0.94 mm. There was no statistical difference between the sexes.

CONCLUSIONS

In our population, there was no difference between ventricular atrial diameter in male and female fetuses at 20-24 weeks' gestation.

Interindividual variability in sensitivity to warfarin--Nature or nurture?

BACKGROUND

Interindividual variability in responses to warfarin is attributed to dietary vitamin K, drug interactions, age, or genetic polymorphism in the cytochrome P4502C9 enzyme (CYP2C9) (allelic variants 2C9*2 and 2C9*3 ) linked with impaired metabolism of the potent enantiomere S-warfarin.

PATIENTS AND METHODS

We quantified the relative effects of age and of simultaneously determined CYP2C9 genotype, plasma warfarin and vitamin K concentrations, and concurrent medications on warfarin maintenance doses in 156 patients at optimized stable anticoagulation.

RESULTS

Allele frequencies for CYP2C9*1, CYP2C9*2, and CYP2C9*3 were 0.84, 0.10, and 0.06. Warfarin doses were 6.5 +/- 3.2, 5.2 +/- 2.4, and 3.3 +/- 2.0 mg/d in the 3 genotype groups (P < .0001). Warfarin doses decreased with age as follows: 7.7 +/- 3.7 versus 4.9 +/- 2.9 mg/d at < 50 years and >66 years (P < .001), mainly as a result of decreased plasma warfarin clearance (2.8 +/- 1.4 mL/min versus 1.9 +/- 0.8 mL/min; P < .001). Vitamin K (1.6 +/- 1.1 ng/mL) did not differ among the age or genotype groups. Patients >or=66 years old with the CYP2C9*3 allele required only 2.2 +/- 1.2 mg/d compared with 7.9 +/- 3.7 mg/d in those <or=65 years old bearing the CYP2C9*1 allele (P < .001). On multiple regression, warfarin maintenance doses were independently associated with plasma warfarin (reflecting its metabolic clearance) (r (2) = 0.26), age (possibly reflecting increased intrinsic sensitivity) (r (2) = 0.12), and genotype (reflecting S-warfarin levels) (r (2) = 0.10) but not with plasma vitamin K.

CONCLUSIONS

At optimized steady state, individual sensitivity to warfarin is determined by CYP2C9 genotype and age with no effect of vitamin K. Prospective studies will determine the impact of these findings in clinical practice.

Expanded Möbius syndrome

A woman presented at 33 weeks gestation with reduced fetal movements and a nonreactive nonstress test. Fetal ultrasound examination revealed a peculiar unilateral arm tremor. At emergency cesarean section, performed for fetal indications, a 1,672-gm male infant was delivered requiring intubation for feeble respiratory effort. After delivery the neonate was transiently hypertonic and later hypotonic. Continuing ventilatory support at minimal settings was necessary. The work-up for aneuploidy, metabolic disorders, and infection was negative. The infant died after being removed from ventilatory support on day 22. Postmortem examination revealed extensive bilateral brain gliosis and mineralization without evidence of inflammation, partial absence of cranial nerve nuclei III-XI, and a total absence of cranial nerve roots VI-XI. Together these finding are compatible with a diagnosis of expanded Möbius syndrome.

Immunodetection of living trophoblast

BACKGROUND

Human chorionic gonadotropin, the pregnancy hormone, is synthesized by trophoblast cells which make up the placenta.

OBJECTIVE

To determine whether antibody to hCG can be used to specifically detect living trophoblast in vitro by binding to the external membrane.

METHODS

Trophoblast was isolated from fresh placentas of women undergoing termination of pregnancy in the first trimester and incubated with monoclonal antibody to hCG. Anti-mouse immunoglobulin G with a fluorescent marker was then added.

RESULTS

Syncytiotrophoblast stained positive on the external surface of the cell, while controls of leukocytes, endometrial cells and hepatocytes were negative.

CONCLUSION

The hCG monoclonal antibody may be used to specifically detect hCG on the surface of living trophoblast in vitro.

Does female age affect embryo morphology?

Deteriorating oocyte quality is commonly believed to be the primary determinant of the decreased implantation potential in older women. We assessed the influence of age on embryo morphology in standard in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) modalities. All 6350 consecutive embryos (2990 IVF, 3360 ICSI) obtained in our Assisted Reproductive Technology Unit from January 1996 through June 1997 were included. High quality embryos were defined as those with equal-sized blastomeres and < 10% fragmentations and a cleavage rate of four cells on day 2 or eight cells on day 3 transfers. The results were analyzed for the standard IVF group, the ICSI group, and the ICSI subgroup with severe male factor infertility (< or = 1 x 10(6) total motile spermatozoa in the ejaculate). For standard IVF, a positive association was observed between female age and increased proportion of good quality embryos. No such association was detected for the ICSI cycles (whole group or subgroup). We conclude that in standard IVF, embryo quality, as reflected by embryo morphology, does not deteriorate with increased maternal age.