Biomedical subjects
Publications and source records attributed to W N Spellacy.
This article is a review of the various factors relating to fetal and neonatal mortality in infants of a particular birth weight. Factors influencing survival positively also are considered, including various presentations and some specific maternal factors.
Using a 1982-4 computerized data base from a perinatal network, 511 pregnancies in women whose age was 40 or more years at delivery were studied. The oldest woman was 52 years of age. This represented 1.2% of the 41,335 women delivering. Their pregnancy outcomes were compared with those in 26,759 whose age at delivery was 20 to 30 years. The older women were more parous and had higher weights. There was also an increased frequency of hypertension, diabetes mellitus, and placenta previa in the older women. These changes had a significant impact on the fetus for the older women had an increase in infant macrosomia, male sex, stillbirths, and low Apgar scores. They also had a higher incidence of cesarean section and fewer forcep deliveries. The older women whose weight was less than 67.5 kg at delivery did not show any difference in hypertension, fetal macrosomia, fetal death rates, or low infant Apgar scores. Also older of low parity did not have an increase in placenta previa. The older women of normal weight and low parity showed a higher frequency of diabetes mellitus and cesarean section delivery, but their infant outcomes were not different from the control groups. Thus older women of low parity and normal weight managed by modern obstetric methods can expect a good pregnancy outcome.
Appendectomy was performed on 40 consecutive consenting patients undergoing elective cesarean section in a clinic population. The control group consisted of all other patients undergoing elective cesarean section during the period of study. The populations were similar. Clinical infection, blood loss, gastrointestinal tract recovery rates were equal in both groups. Appendectomy added 15 minutes to the operation time and extended the hospital stay by about one-half day. There were no wound infections or serious morbidity. A fifth of the appendixes removed were abnormal, including two with inflammation and one with a carcinoid tumor. Prophylactic appendectomy does not seem to add to the risk of elective cesarean section.
The performance of 29 residents in obstetrics and gynecology on parts 1 and 2 of the national board examinations, which they had taken to graduate from medical school, was compared to their performance on the Council on Resident Education in Obstetrics and Gynecology in-training examination taken during the third year of residency. There was a statistically significant correlation between results of part 1 of the national board and results of the Council on Resident Education examination (r = 0.45, p less than 0.05) and between part 2 of the national board and results of the Council on Resident Education examination (r = 0.67, p less than 0.001). Those scoring "low" (less than fiftieth percentile) on the Council on Resident Education test all had scores less than 500 on part 2 of the national board, whereas those scoring "high" on the Council on Resident Education test (greater than ninetieth percentile) scored about 600 or higher on part 2 of the national board. These data suggest that results of part 2 of the national board can be useful in the resident selection process and that the performance of residents on in-training examinations relates more to resident selection than to the residency educational programs.
The distribution of receptors for insulin and epidermal growth factor along the longitudinal axis of the uterine cavity was studied in 28 uteri obtained from women of reproductive age undergoing hysterectomy for benign conditions. Insulin binding to crude plasma membranes was higher (p less than 0.05) in the secretory than in the proliferative phase of the menstrual cycle in all uterine segments (fundus to cervix). Epidermal growth factor binding did not change during the menstrual cycle but the number of epidermal growth factor binding sites was higher in the cervix than in the fundus (p less than 0.05). Scatchard plots of binding data, obtained with crude plasma membranes from pooled uteri, were curvilinear; the high-affinity sites had dissociation constants of 1 to 4 nmol/L and receptor concentrations of 100 to 300 fmol/mg of protein, for both iodine 125-labeled insulin and 125I-labeled epidermal growth factor. In plasma membranes, obtained from another 15 uteri, mouse nerve growth factor (3.3 micrograms/ml) decreased the binding of insulin by an average of 17% (p less than 0.005); in the decidua of a pregnant uterus at 12 weeks Scatchard analysis showed that nerve growth factor decreased the affinity but not the number of insulin-binding sites. Nerve growth factor had no effect on epidermal growth factor binding. Human prolactin (2 micrograms/ml) also decreased insulin binding by an average of 18% (n = 5, p less than 0.025) but had no effect on epidermal growth factor binding. These "baseline" data will be useful in further studies of the possible interactions between (1) receptors for various peptide growth factors and (2) sex steroid hormones, in normal and neoplastic endometrium and cervix.
Initial instruction in the pelvic examination in the United States and Canada was reviewed by questionnaire. Seventy-two percent of the 116 responding medical schools taught this material in the second year, two-thirds with a specific course devoted to the subject. Ninety-three percent used "live models" or "teaching associates" in place of, or in addition to, traditional methods such as the examination of clinic patients. The use of teaching associates was uniformly rated as an extremely effective educational method. A continued trend toward use of an educational methodology that emphasizes communication as well as psychomotor skill instruction is identified.
Human ovarian tissue samples were obtained at the time of laparotomy, and plasma membrane fractions were prepared and used in receptor assays. Incubations of the membrane fraction were performed with [125I]insulin (porcine), and Scatchard analysis of binding showed biphasic curves. The high affinity sites had an average concentration of 57.4 +/- 7.9 (+/- SEM) fmol/mg protein and a dissociation constant of 3.5 +/- 0.9 nM (n = 9). Neither affinity nor number of binding sites changed significantly during the menstrual cycle. We conclude that there is high affinity binding of [125I]insulin to human ovarian plasma membranes.
Thirty-one normal women were studied daily in 41 cycles. Venous blood samples were taken for measurements of luteinizing hormone (LH), estradiol (E2), and progesterone (P), and vaginal examinations were done to obtain cervical mucus and vaginal fluid. The specific activity of guaiacol peroxidase (GP), extracted from cervicovaginal secretions with 0.5 M CaCl2, was determined in the vaginal samples. In the follicular phase, from day -7 to day 0 (the LH +1 day, when ovulation presumably occurred), there was a strong negative correlation between GP and the rising E2 (r = -0.94). On days 1 to 10 after ovulation, there was a strong positive correlation between GP and P (r = 0.84). In nine ovulatory cycles in which P levels did not exceed 8 ng/ml on any day, indicating possible luteal phase inadequacy, there were significantly lower GP levels than in another 32 ovulatory cycles with higher P (P = 0.04). These results suggest that (1) at midcycle, E2 seems to "down-regulate" the GP specific activity; and (2) in the luteal phase, serum P levels parallel those of GP activity, even in the presence of high luteal E2. GP activity profiles during the menstrual cycle can be used to define the fertile period, may prove useful in diagnosing pregnancy, and may be a simple, convenient test for an inadequate corpus luteum.
A prospective randomized study was performed to determine the usefulness of x-ray pelvimetry before oxytocin induction or augmentation. Two hundred primiparous women were entered into this study. Agreement on pelvic size by the clinical and radiologic assessment occurred in 76.5% of the cases. When the total groups were compared, there were no differences in pregnancy outcome. In the induction of labor subgroups there were less forcep deliveries and lower five-minute Apgar scores in the pelvimetry group. In the augmentation subgroups there were no differences. The subgroup of patients diagnosed clinically to have a borderline pelvis, had a higher incidence of cesarean section (P less than .05) if they had x-ray pelvimetry. These results suggest that the elimination of x-ray pelvimetry in primigravida women does not lead to a compromise in infant outcome when electronic fetal monitoring is used.
Using a 1982 to 1983 regional network data bank of 33,545 delivered infants, a study was conducted comparing 574 macrosomic infants weighing greater than 4500 g to a control group of 18,739 infants whose birth weights were 2500 to 3499 g. Macrosomic infants occurred in 1.7% of the deliveries. Women delivering macrosomic infants were significantly older, of higher parity, more obese (greater than 90 kg), and more frequently diabetic and postmature (longer than 42 weeks) than the controls. The women having macrosomic infants had a higher frequency of cesarean deliveries. The macrosomic infants were more often male and had more birth trauma and shoulder dystocia, higher death rates, and lower Apgar scores. Five-minute Apgar scores were lowest in the very macrosomic subgroup (greater than 5000 g). The high-risk group triad included obesity, diabetes, and post-dates and had a macrosomia frequency of 5 to 14%. Macrosomic infants delivered by cesarean section had significantly fewer birth injuries. Because of these serious perinatal problems, women at risk should be screened for macrosomic infants, and if found, they should be delivered electively by cesarean section.
The effects of prolactin and relaxin on insulin binding by isolated human adipocytes from women at term gestation were studied in vitro. It was found that prolactin decreases, and relaxin increases, insulin binding to the adipocytes. Both changes appear to be due to alterations in the affinity of the insulin receptors. These effects seem to be mediated through specific prolactin and relaxin receptors of the adipocyte and require the presence of an intact cellular cytoskeleton. This suggests that one hormone, for example, prolactin, can interact with its own specific receptor and thereby after the affinity of a heterologous receptor for its hormone (insulin). Heterologous hormone-receptor complex interactions ("cross-talk") may be widespread and could represent a fundamental mechanism in the functioning of the endocrine system.
The vaginal secretions of 20 normal control subjects and 21 patients with motile, curved anaerobic rods were cultured for aerobic and anaerobic bacteria, Chlamydia trachomatis, herpes simplex virus, and Trichomonas vaginalis. Extensive histories and physical examinations of the patients and microscopic appearance and gas-liquid chromatography patterns of vaginal secretions were compared between the two groups. The patients who had motile rods in their vaginal secretions more frequently presented with a history of complaints about foul-smelling discharge (18 [86%] of 21); discharge noted during physical examination at their introitus (15 [71%] of 21); a vaginal pH greater than 4.5 (21 [100%] of 21); and a highly specific microscopic appearance of their secretions. The secretions were characterized by the absence of lactobacilli, the presence of highly motile, curved bacilli, and an increased number of background bacteria when compared with normal patients. Patients had more frequent anaerobic isolates than did controls (P less than .001), with increased numbers of Peptococcus, Peptostreptococcus, Propionibacterium, and Bacteroides species. All patients with motile bacteria in their secretions met the criteria of the syndrome of nonspecific vaginosis that has been previously described.
A Tutor Programme was created in a third-year clerkship in obstetrics and gynaecology to remedy a student complaint of insufficient contact with teaching staff. Data obtained through the use of observational methodologies were integrated with data from questionnaires and student/teacher interviews to assess programme content, its contribution to student education, and the characteristics of student-teacher interactions. Teachers and students both expressed satisfaction at this opportunity to 'get to know each other'. A unique contribution of the programme was the discussion of a set of topics categorized as 'Medicine as a Career and Lifestyle', e.g. how to make career decisions, residency selection, etc.). These topics were not addressed elsewhere in the curriculum yet were of great importance to the students. The value of observational methods in comprehensive programme evaluation was reaffirmed.
A selective and differential agar for optimal growth of the large curved motile anaerobic rods isolated from patients having non-specific vaginosis (NSV) was developed. A basal medium of Columbia CNA agar was used with colony growth found to be optimal by the addition of 7% fetal calf serum and 5% rabbit blood (CNARS). Beta-Haemolysis was found to be demonstrated most readily on a bilayer plate with a basal layer consisting of CNA agar with fetal calf serum, overlaid with a layer of CNA agar containing fetal calf serum and rabbit blood. Optimal growth was found by anaerobic incubation at 37 degrees C, after 5 days.
The potential usefulness of a Family Planning Risk Scoring Sheet was studied in 1720 consecutive women who completed a family planning visit and were prescribed a specific contraceptive method. The results demonstrated that many women had relative or absolute contraindications to their prescribed method that were detected later by the Family Planning Risk Scoring Sheet. There were 29 women in the oral contraceptive and intrauterine device groups who had absolute contraindications detected (2.8 and 2.4%, respectively). The nurse practitioners tended to have fewer unrecognized problems in their groups than did the physicians. The usefulness of the Family Planning Risk Scoring Sheet was demonstrated and its routine use in a busy family planning unit is recommended.
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The effect of estradiol, progesterone and norgestrel on serum insulin and glucose levels and on insulin binding to adipocytes, hepatocytes and diaphragm muscle cell membranes has been evaluated in castrated male rats. Estradiol administration (5 micrograms/day X 6) significantly increased basal plasma insulin levels and the amount of insulin bound to fat and liver cells as well as muscle cell membranes. Progesterone treatment (5 mg/day X 6) caused a slight increase of basal insulin levels and a decrease of insulin binding to fat cells. Norgestrel treatment (5 mg/day X 6) decreased both insulin levels and the amount of insulin bound to adipocytes; a much lower dose of norgestrel, 6 micrograms/day X 7, also caused a decline in adipocyte insulin binding due to an apparent increase in the dissociation constant of the high affinity binding sites. These studies demonstrate that ovarian sex steroids have a significant effect on insulin binding to target cells. This animal model would assist in determining the mechanisms involved in changes of carbohydrate metabolism which occur during the menstrual cycle, pregnancy, the menopausal state and with the use of oral contraceptives.