This study aimed to evaluate predictors of umbilical artery acidemia in term neonates with low 5-minute Apgar scores. The researchers analyzed data from over 27,000 term singleton births over a 13-year period. They identified 94 neonates with 5-minute Apgar scores under 7, of which 33 showed evidence of umbilical artery acidemia. Logistic regression found that intrauterine vascular disease was independently associated with umbilical artery acidemia, whereas intrauterine infection and acute intrapartum events were not significantly associated. Umbilical artery acidemia was present in 38% of term babies with low Apgar scores, and was predominantly linked to chronic antepartum vascular problems
Magnesium Prevents the Cerebral Palsy Precursor in Premature InfantsRoss Finesmith M.D.
To determine if magnesium sulfate has an effect on the development of cystic
periventricular leukomalacia in preterm infants, this retrospective case control study
was conducted. There were 23,382 infants born at three teaching hospitals in the metropolitan New York area from January 1992 to December 1994. Four hundred ninety-two infants met our entrance criteria. Criteria included a birth weight less than 750 g, survival to at least 7 days of life and at least one cranial ultrasound after 7 days of life.
Infants exposed to magnesium sulfate in utero were less likely to develop periventricular
leukomalacia. Two of 18 (11%) infants with periventricular leukomalacia were
exposed to magnesium sulfate in-utero compared to 14 of 36 controls (39%) (p =
0.035) (OR = 0.196, 95% Cl = 0.039-0.988). Pre-eclampsia as an independent factor
was not associated with a reduced risk (p = 0.251) (OR = 0.294, 95% Cl =
0.033-2.65). Preterm infants exposed to antenatal magnesium sulfate were found to
have a reduced risk of developing cystic periventricular leukomalacia.
Magnesium Prevents the Cerebral Palsy Precursor in Premature InfantsRoss Finesmith M.D.
To determine if magnesium sulfate has an effect on the development of cystic
periventricular leukomalacia in preterm infants, this retrospective case control study
was conducted. There were 23,382 infants born at three teaching hospitals in the metropolitan New York area from January 1992 to December 1994. Four hundred ninety-two infants met our entrance criteria. Criteria included a birth weight less than 750 g, survival to at least 7 days of life and at least one cranial ultrasound after 7 days of life.
Infants exposed to magnesium sulfate in utero were less likely to develop periventricular
leukomalacia. Two of 18 (11%) infants with periventricular leukomalacia were
exposed to magnesium sulfate in-utero compared to 14 of 36 controls (39%) (p =
0.035) (OR = 0.196, 95% Cl = 0.039-0.988). Pre-eclampsia as an independent factor
was not associated with a reduced risk (p = 0.251) (OR = 0.294, 95% Cl =
0.033-2.65). Preterm infants exposed to antenatal magnesium sulfate were found to
have a reduced risk of developing cystic periventricular leukomalacia.
Diagnostic approach and management of extrauterine pregnancyRustem Celami
An ectopic pregnancy is a pregnancy that develops outside a woman's uterus. This happens when the fertilized egg from the ovary does not reach or implant itself normally in the uterus. Instead, the egg develops somewhere else in the abdomen. The products of this conception are abnormal and cannot develop into fetuses. Urine pregnancy test is often done by women itself once amenorrhea is present about 2 weeks of expected menstrual period, however, pregnancy blood test such Beta – human Chorionic Gonadotropin (BhCG) and ultrasound examination are the best tool of diagnosis. The most common place that ectopic pregnancy occurs is in one of the fallopian tubes, a so-called tubal pregnancy. These are the tubes that transport the egg from the ovary to the uterus. Ectopic pregnancies also can be found on the outside of the uterus, on the ovaries, or attached to the bowel. Most serious complication of an ectopic pregnancy is intra-abdominal hemorrhage. In the case of a tubal pregnancy, for example, as the products of conception continue to grow in the fallopian tube, the tube expands and eventually ruptures. This can be very dangerous because a large artery runs on the outside of each Fallopian tube. If the artery ruptures, the woman can bleed severely. Ectopic pregnancy is usually found in the first 5-10 weeks of pregnancy and is the leading cause of pregnancy-related deaths in the first trimester of pregnancy in the USA. In Albania, we face difficulties not only in application of high technology of ultrasound machine in public health sector but unfortunately we are unable to perform BhCG in public health sector laboratories, such making not only challenge and even delay but an expensive process of diagnosis of this medical problem. In conclusion, since ectopic pregnancy is an abnormal pregnancy, and comes with high risk of serious complication, early diagnosis of pregnancy location and its management is crucial in preventing medical complication.
International Journal of Pharmaceutical Science Invention (IJPSI) inventionjournals
International Journal of Pharmaceutical Science Invention (IJPSI) is an international journal intended for professionals and researchers in all fields of Pahrmaceutical Science. IJPSI publishes research articles and reviews within the whole field Pharmacy and Pharmaceutical Science, new teaching methods, assessment, validation and the impact of new technologies and it will continue to provide information on the latest trends and developments in this ever-expanding subject. The publications of papers are selected through double peer reviewed to ensure originality, relevance, and readability. The articles published in our journal can be accessed online
Reproductive Genetics: Introduction to Genetic Testing Optionskanew396
GenomeSmart can help you navigate the different reproductive genetic testing options to allow you to make informed decisions for the health of yourself and your family.
How to choose between drugs: efficacy / safety and cost effectiveness. In IVF, we have GnRHagonist and antagonists: how to choose based on best available evidence. This talk may help to answer this question
widespread epidemic of Zika virus (ZIKV) infection was reported in 2015 in South and Central America and the Caribbean. A major concern associated with this infection is the apparent increased incidence of microcephaly in fetuses born to mothers infected with ZIKV. In this report, we describe the case of an expectant mother who had a febrile illness with rash at the end of the first trimester of pregnancy while she was living in Brazil. Ultrasonography performed at 29 weeks of gestation revealed microcephaly with calcifications in the fetal brain and pla-centa. After the mother requested termination of the pregnancy, a fetal autopsy was performed. Micrencephaly (an abnormally small brain) was observed, with almost complete agyria, hydrocephalus, and multifocal dystrophic calcifications in the cortex and subcortical white matter, with associated cortical displacement and mild focal inf lammation. ZIKV was found in the fetal brain tissue on reverse-transcriptase–polymerase-chain-reaction (RT-PCR) assay, with consistent findings on electron microscopy. The complete genome of ZIKV was recovered from the fetal brain
Diagnostic approach and management of extrauterine pregnancyRustem Celami
An ectopic pregnancy is a pregnancy that develops outside a woman's uterus. This happens when the fertilized egg from the ovary does not reach or implant itself normally in the uterus. Instead, the egg develops somewhere else in the abdomen. The products of this conception are abnormal and cannot develop into fetuses. Urine pregnancy test is often done by women itself once amenorrhea is present about 2 weeks of expected menstrual period, however, pregnancy blood test such Beta – human Chorionic Gonadotropin (BhCG) and ultrasound examination are the best tool of diagnosis. The most common place that ectopic pregnancy occurs is in one of the fallopian tubes, a so-called tubal pregnancy. These are the tubes that transport the egg from the ovary to the uterus. Ectopic pregnancies also can be found on the outside of the uterus, on the ovaries, or attached to the bowel. Most serious complication of an ectopic pregnancy is intra-abdominal hemorrhage. In the case of a tubal pregnancy, for example, as the products of conception continue to grow in the fallopian tube, the tube expands and eventually ruptures. This can be very dangerous because a large artery runs on the outside of each Fallopian tube. If the artery ruptures, the woman can bleed severely. Ectopic pregnancy is usually found in the first 5-10 weeks of pregnancy and is the leading cause of pregnancy-related deaths in the first trimester of pregnancy in the USA. In Albania, we face difficulties not only in application of high technology of ultrasound machine in public health sector but unfortunately we are unable to perform BhCG in public health sector laboratories, such making not only challenge and even delay but an expensive process of diagnosis of this medical problem. In conclusion, since ectopic pregnancy is an abnormal pregnancy, and comes with high risk of serious complication, early diagnosis of pregnancy location and its management is crucial in preventing medical complication.
International Journal of Pharmaceutical Science Invention (IJPSI) inventionjournals
International Journal of Pharmaceutical Science Invention (IJPSI) is an international journal intended for professionals and researchers in all fields of Pahrmaceutical Science. IJPSI publishes research articles and reviews within the whole field Pharmacy and Pharmaceutical Science, new teaching methods, assessment, validation and the impact of new technologies and it will continue to provide information on the latest trends and developments in this ever-expanding subject. The publications of papers are selected through double peer reviewed to ensure originality, relevance, and readability. The articles published in our journal can be accessed online
Reproductive Genetics: Introduction to Genetic Testing Optionskanew396
GenomeSmart can help you navigate the different reproductive genetic testing options to allow you to make informed decisions for the health of yourself and your family.
How to choose between drugs: efficacy / safety and cost effectiveness. In IVF, we have GnRHagonist and antagonists: how to choose based on best available evidence. This talk may help to answer this question
widespread epidemic of Zika virus (ZIKV) infection was reported in 2015 in South and Central America and the Caribbean. A major concern associated with this infection is the apparent increased incidence of microcephaly in fetuses born to mothers infected with ZIKV. In this report, we describe the case of an expectant mother who had a febrile illness with rash at the end of the first trimester of pregnancy while she was living in Brazil. Ultrasonography performed at 29 weeks of gestation revealed microcephaly with calcifications in the fetal brain and pla-centa. After the mother requested termination of the pregnancy, a fetal autopsy was performed. Micrencephaly (an abnormally small brain) was observed, with almost complete agyria, hydrocephalus, and multifocal dystrophic calcifications in the cortex and subcortical white matter, with associated cortical displacement and mild focal inf lammation. ZIKV was found in the fetal brain tissue on reverse-transcriptase–polymerase-chain-reaction (RT-PCR) assay, with consistent findings on electron microscopy. The complete genome of ZIKV was recovered from the fetal brain
Objective: To investigate the immunohistochemical staining of hypoxia-inducible factor 1-alpha (HIF-1α) and Ki-67 expression in the placenta of pregnant women with placenta previa and placenta accreta.
Study Design: Thirty placentas (10 normotensive, 10 placenta previa, and 10 placenta accreta) were processed for routine histological tissue processing. The biochemical parameters of patients were recorded. Placentas were stained with hematoxylin-eosin and HIF-1α and Ki-67 immunostaining.
Results: Normal histology was observed in placentas of normotensive pregnant women. Placenta previa sections showed increased syncytial knots, intervillous hemorrhage, fibrin accumulation, and hyalinization. In placenta accreta sections, increased syncytial nodes, vascular dilation/congestion, fibrin accumulation, and hyalinization were observed. Normotensive placentas showed no HIF-1α expression. In placenta previa tissues, high HIF-1α expression was observed in vascular endothelial cells, villous stromal cells, and syncytial knots. High HIF-1α expression was recorded in villous stromal cells and cytotrophoblast cells in placenta accreta. In normotensive placental tissues, no Ki-67 expression was observed. In placenta previa sections, high Ki-67 expression was observed mostly in root villi stromal cells and some endothelial cells. High Ki-67 expression was observed mostly in villi stromal cells of placenta accreta.
Conclusion: It is thought that HIF-1α is an important regulatory gene in the development of villus in trophoblast invasion such as placenta accreta and previa, while Ki-67 will play a key role in the development of abnormal placenta with its stimulating effect on inflammatory cell development and angiogenesis in accreta and preeclampsia.
“A Study on Coagulation Profile in Pregnancy Induced Hypertension Cases”iosrjce
IOSR Journal of Biotechnology and Biochemistry (IOSR-JBB) covers studies of the chemical processes in living organisms, structure and function of cellular components such as proteins, carbohydrates, lipids, nucleic acids and other biomolecules, chemical properties of important biological molecules, like proteins, in particular the chemistry of enzyme-catalyzed reactions, genetic code (DNA, RNA), protein synthesis, cell membrane transport, and signal transduction. IOSR-JBB is privileged to focus on a wide range of biotechnology as well as high quality articles on genetic engineering, cell and tissue culture technologies, genetics, microbiology, molecular biology, biochemistry, embryology, cell biology, chemical engineering, bioprocess engineering, information technology, biorobotics.
— This study was conducted to find out if AFI ≤ 5 cms has any clinical significance in identifying the subsequent fetal distress & associated maternal & perinatal outcomes, in pregnancies beyond 37 weeks. Methodology: This is a prospective case control study done from July 2010 to July 2012 (24 months) at Dr Vasantrao Pawar Medical College, Hospital and Research Center. Adgaon, Nashik. It study the pregnancy outcome comparison of 58 Anenatal Cases(ANCs)as Study Group with diangosis of oligohydramnios (AFI ≤ 5 cms) by ultrasound after 37 completed weeks of gestation w e r e compared with 58 ANCs (Control Group) with no oligohydramnios (AFI > 5 cms). These two groups were matched for other variables like age, parity, gestational age and any pregnancy complication. Results: There was significant difference between two groups. Hypertension and Preeclampsia were found significantly more in ANCs with oligohydramnios. FHR deceleration was also significantly higher in women with oligohydramnios. Women require LSCS were also significantly more in women with oligohydramnios. Newborn borned by women with oligohydramnios had significantly more chances to admit in NICU than in newborn born by women without oligohydramnios. Conclusion: It can be concluded from this study that women with oligohydramnios poor pregancy outcomes. Determination of AFI can be used as an adjunct to other fetal surveillance methods. Determination of AFI can be used as valuable screening test for predicting fetal distress in labour, requiring caesarean section.
Study of Neonatal Outcome with Low Apgar Score in Term Neonatesiosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Can we use NNT (neonatal thrombocytopenia) as a screening tool in at risk neo...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
In developed countries aseptic delivery techniques, hygienic cord care and prompt antimicrobial therapy have decreased the occurrence as well as the severity of Omphalitis. However, the condition remains a significant cause of morbidity and mortality in the developing country. The objective is the risk factors, clinical and bacteriological profile of neonates with Omphalitis in Iraq. Regarding the patients sixty-four neonatal Omphalitis admitted at the Neonatal Intensive Care Units of Children Welfare Teaching Hospital and Neonatal Intensive Care Units of Al-elwya Teaching Hospital in Baghdad Iraq, during 8 months from October 2011 to May 2012. The risk factors and clinical, bacteriologic and relevant investigational profiles and outcomes were studied in neonates with Omphalitis. For the study purpose Omphalitis was classified into four categories based on severity. The result was show that the incidence of Omphalitis was higher in home births and in neonates with low birth weight. Staphylococcus aureus was the most common pathogen isolated from umbilical swabs followed by Escherichia coli. Regarding conclusion low birth weight and home delivery are considered as risk factors for Omphalitis in Iraq. The treatment should be received for Gram-positive and Gram-negative microorganism because of the predominance of Gram-negative microorganisms in neonatal infant with Omphalitis.
ABSTRACT- Placenta is the mirror of fetomaternal status. The effect of anemia in pregnancy can be diverse and detrimental to the mother and the fetus. This prompted us to carry out the present study, which aimed to observe and compare the morphological features of placenta at term in anemic and non-anemic mothers of North Bengal and to find out the clinical relevance of such structural changes. Total 30 placentas were collected from each group of selected patients after delivery at labor room. Examination of placenta was conducted according to proforma. A general survey of umbilical cord, membranes, fetal surface, and maternal surface was carried out. The diameters were measured, area was estimated, and shape was noted. Placenta and fetus was weighed in the same scale. The volume was estimated by water displacement method. In anemic mothers, mean baby birth weight was found to be significantly less than that of control group. The mean placental weight in test group was significantly increased in comparison to controls. The mean placental volume and mean placental area in case of test group were significantly increased. Occurrence of morphological features, like subchorionic fibrosis; retroplacental clot, gross calcification, or placental infarction etc were found to be significantly higher in anemic mothers in comparison to non-anemic group. In the present study, it was proved that placenta has considerable functional reserve capacity. It tends to limit the ill-effects of tissue injury and of unfavorable maternal milieu like anemia. Our findings were in accordance with the previous studies in this field. Key-words- Placenta, Maternal anaemia, Morphological changes, Placental weight
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
1. EURO-6277; No of Pages 5
European Journal of Obstetrics & Gynecology and
Reproductive Biology xxx (2008) xxx–xxx
www.elsevier.com/locate/ejogrb
Factors associated with umbilical artery acidemia in term
infants with low Apgar scores at 5 min
Anna Locatelli a,*, Maddalena Incerti a, Alessandro Ghidini a,
Massimiliano Greco a, Elisabetta Villa b, Giuseppe Paterlini b
a
Department of Obstetrics and Gynecology, San Gerardo Hospital, University of Milano-Bicocca, Via Solferino 16, 20052 Monza (MI), Italy
b
Department of Neonatology, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
Received 13 June 2007; received in revised form 3 December 2007; accepted 9 January 2008
Abstract
Objective: To evaluate predictors of umbilical artery acidemia in term neonates with low Apgar score.
Study design: From a cohort of term singleton deliveries over a 13-year period, we selected neonates with 5-min Apgar score <7. Acidemia
was defined as umbilical artery pH < 7.00 or base excess (BE) À12 mmol/L. Three pathogenic processes of neonatal acidemia were
evaluated: (1) intrauterine vascular disease, defined as preeclampsia, clinical diagnosis of placental abruption, birth weight <10th centile, or
histologic evidence of placental infarction or severe vascular pathology, (2) intrauterine infection, defined as clinical chorioamnionitis,
histologic chorioamnionitis, or early neonatal sepsis, and (3) acute intrapartum events, which included cases of cord prolapse, amniotic fluid
embolism, uterine rupture, sudden and sustained fetal bradycardia or absence of FHR variability with a previously normal pattern, shoulder
dystocia or complicated breech extraction. The associations of such processes with umbilical artery evidence of acidemia were tested using
x2, Fisher’s exact test, Student’s t-test, and logistic regression, with P < 0.05 or odds ratio (OR) with 95% confidence interval (CI) not
inclusive of the unity considered significant.
Results: Among the 27,395 neonates in the cohort, an Apgar score at 5 min <7 was recorded in 94 (0.32%) and it was associated with
umbilical artery acidemia in 33 cases. Logistic regression analysis showed that intrauterine vascular disease was independently associated
with umbilical cord acidemia (P = 0.035, OR = 3.2, 95% CI = 1.1–9.7) whereas intrauterine infection (OR = 1.1, 95% CI 0.4–3.4) and acute
intrapartum events (OR = 2.1 95% CI 0.6–7.0) were not.
Conclusions: Umbilical artery evidence of acidemia is present in 38% of term babies with low Apgar score and it is predominantly associated
with chronic antepartum vascular disease. Neither intrauterine infection nor acute intrapartum events are significantly associated with
umbilical artery acidemia.
# 2008 Elsevier Ireland Ltd. All rights reserved.
Keywords: Low Apgar score; Umbilical artery acidemia; Term pregnancy
Because metabolic acidosis signals greater risk of
1. Introduction
subsequent neurologic injury and multiorgan dysfunction
In 1952, Virginia Apgar proposed her score as a means of [4], measurement of umbilical artery pH has been widely
evaluating the physical condition of infants shortly after adopted as an adjunct to the Apgar score for assessing the
delivery and of predicting neonatal survival [1,2]. A low condition of newborn infants. Indeed, results of cord blood
Apgar score at 5 min at term is commonly indicative of a gas analysis provide a more precise assessment of the
neonate at greater risk of death [3]. newborn than Apgar scores alone [5]. Whereas respiratory
acidosis is usually due to intrapartum events and is not
associated with adverse neonatal outcome [6], metabolic
acidosis can portend greater risks of neonatal asphyxia,
* Corresponding author. Tel.: +39 039 233 4720; fax: +39 039 233 3820.
encephalopathy and cerebral palsy [7]. An umbilical artery
E-mail address: anna.locatelli@unimib.it (A. Locatelli).
0301-2115/$ – see front matter # 2008 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejogrb.2008.01.003
Please cite this article in press as: Locatelli A, et al., Factors associated with umbilical artery acidemia in term infants with low Apgar
scores at 5 min, Eur. J. Obstet. Gynecol (2008), doi:10.1016/j.ejogrb.2008.01.003
2. EURO-6277; No of Pages 5
2 A. Locatelli et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology xxx (2008) xxx–xxx
pH < 7 and a BE À12 mmol/L have been suggested as Meconium was graded as thin or thick, the latter being
optimal cut-offs to define fetal metabolic acidosis [8]. greenish, opaque and non-watery. Only thick meconium was
Although the Apgar score provides a convenient short- considered for the purpose of the statistical analysis. Blood
hand for the status of the newborn, it is often incorrectly used samples from umbilical arteries were routinely obtained
as a correlate of neonatal acidosis. In fact, only a minority of immediately after delivery on all infants deemed to be
neonates with low Apgar scores at 5 min have cord evidence viable. The samples were placed in ice and blood gas
of metabolic acidosis [9]. We have examined the prenatal analysis, inclusive of pH and base excess (BE), was usually
characteristics of term infants with low Apgar scores at performed within 15 min of delivery (Blood Gas Analyzer
5 min to evaluate predictors of cord blood gas evidence of OMNI 3 e OMNI S Roche, Basel; Switzerland). Small-for-
gestational age was defined as a birth weight <10th centile
metabolic acidosis.
adjusted for gender and gestational age according to Italian
standards [11].
Placentas were collected and examined in high-risk
2. Materials and methods
pregnancies or in the presence of perinatal complications.
We have accessed a prospectively collected database of Histopathologic findings were classified according to
neonates born at 37.0 weeks or greater at our institution from standard published protocols [12]. Acute inflammatory
1/1993 to 12/2005. The computerized obstetric and neonatal lesions in the amnion, umbilical and chorionic vessels, and
databases of S. Gerardo Hospital, Monza, Italy, provide choriodecidua were classified as present or absent indepen-
information on all births occurring at the hospital. Data dently from the severity or extent of the lesions.
concerning labor and delivery are abstracted and recorded Uteroplacental vascular pathology was defined as evidence
within 24 h of delivery. The hospital is a tertiary care facility of absent or incomplete conversion of the basal spiral
and serves as referral center for a vast area north-east of arteries, placental abruption, villous infarcts and fibrosis,
Milan. Strict and consistent diagnostic and clinical manage- fibrinoid necrosis, atherosis, increased syncythial knotting,
ment algorithms were implemented in labor and delivery and X-cell proliferation. Neonatal outcome variables
during the study period for term deliveries. Such algorithms considered were hypoxic–ischemic encephalopathy [13];
differed for pregnancies classified as low risk or high risk. multiorgan dysfunction (defined as involvement of one or
The study fulfilled the exemption criteria from submission to more organ system, lung, kidneys, heart, and intestines); and
the Institutional Review Board because it involved existing neonatal death [14].
Statistical analysis included x2 or Fisher’s exact test for
data and the information was recorded by the investigator in
such a manner that individual subjects could not be categorical variables, Student’s t-test for continuous vari-
ables, and logistic regression with a two-tailed P < 0.05 or
identified, directly or through identifiers linked to the
subjects. an odds ratio (OR) with 95% confidence interval (CI) not
Included in the present study were all singleton, liveborn inclusive of unity considered significant. Perinatal variables
neonates without major congenital anomalies and with a 5- were evaluated in reference to umbilical artery evidence of
acidemia, defined as pH < 7.0 and/or BE À12 mmol/L
min Apgar score <7. The attending obstetric and/or
pediatric personnel were responsible for assignment of [8]. In addition to the information recorded in the database,
the Apgar scores. Gestational age was based on the date of we have computed the following three composite variables
the last menstrual period and prenatal ultrasound examina- to shed light onto the processes underlying cord blood
tion before 22 weeks, which is routinely done at our acidemia: (1) intrauterine vascular disease, defined as
preeclampsia (blood pressure >140/90 mmHg with protei-
institution.
nuria >300 mg/24 h or >100 mg/dl in two specimens
Fetal heart rate (FHR) monitoring pattern on admission or
collected >6 h apart), clinical diagnosis of placental
during labor was interpreted according to the Boylan
abruption, birth weight <10th centile, or histologic evidence
classification [10]. FHR was monitored intermittently
during the first and second stage of labor by certified nurse of placental infarction or severe vascular pathology [15]. (2)
midwives. Continuous electronic monitoring was imple- Intrauterine infection, defined as clinical chorioamnionitis
mented in the presence of obstetric or medical risk factors, or (diagnosed in the presence of two or more of the following:
temperature elevation to at least 38 8C, white blood cell
if the FHR was non-reassuring at intermittent auscultation.
A tracing was considered non-reassuring if it presented any count at least 15,000 cells/mm, uterine tenderness and foul-
of the following characteristics: persistent tachycardia smelling amniotic fluid); histologic chorioamnionitis; or
>180 beats/min, reduced or absent variability (<5 bpm); early neonatal sepsis (diagnosed in the presence of positive
bradycardia <100 beats/min lasting longer than 10 min; blood cultures within 72 h of birth). (3) Acute intrapartum
repetitive late decelerations or severe variable decelerations. events, defined as cases of cord prolapse, amniotic fluid
All tracings within 1 h of birth were reviewed to confirm embolism, uterine rupture, sudden and sustained fetal
appropriate classification. Amniotic fluid characteristics bradycardia or absence of FHR variability with pattern
(including subjective assessment of amniotic fluid volume at previously normal, shoulder dystocia, or complicated breech
membrane rupture and fluid color) were also recorded. extraction [4,8,16].
Please cite this article in press as: Locatelli A, et al., Factors associated with umbilical artery acidemia in term infants with low Apgar
scores at 5 min, Eur. J. Obstet. Gynecol (2008), doi:10.1016/j.ejogrb.2008.01.003
3. EURO-6277; No of Pages 5
A. Locatelli et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology xxx (2008) xxx–xxx 3
Table 1
Demographic and antepartum characteristic of gestations resulting in neonates with 5-min Apgar score <7
À12, N = 33 pH ! 7 and/or BE > À12, N = 53
pH < 7 and/or BE
Variable P-value
32.6 Æ 4.2 32.7 Æ 4.7
Maternal age (years) 0.91
Caucasian ethnicity 30 (90.9%) 47 (88.6%) 1
Nulliparity 25 (75.7%) 35 (66.0%) 0.47
39.7 Æ 1.4 40 Æ 1.1
Gestational age at delivery (weeks) 0.60
Premature rupture of membranes 11 (33.3%) 16 (30.1%) 0.94
Diabetes 0 (0%) 5 (9.4%) 0.17
Preeclampsia 3 (9.0%) 0 (0%) 0.053
Data are expressed as no. (%), or mean Æ S.D. BE: base excess, expressed in mmol/L.
Placental information was available in 56/86 (65%)
3. Results
cases. No significant differences were observed in the rates
A cohort of 29,395 consecutive pregnancies fulfilled the of placental diagnoses of inflammatory or vascular lesions
study inclusion criteria. A 5-min Apgar score <7 was (Table 2).
reported in 94 cases (0.32%) and a score <3 in 9 cases We then evaluated two composite variables that reflect
(0.03%). Cord gas analysis was obtained in 86/94 cases with intrauterine processes antedating labor and which are often
5-min Apgar score <7 (in 8 cases gas analysis was not implicated in the causation of low Apgar scores and fetal
performed), which constitute the study population. Umbi- acidemia: intrauterine infection and vascular disease.
lical artery evidence of acidemia was present in 33/86 Neonates with low Apgar score and umbilical artery
(38%). The range of umbilical artery BE of cases with acidemia had higher rates of intrauterine vascular disease
umbilical artery acidemia was À25; À11, while in cases (preeclampsia, abruptio placentae, birth weight <10th
without acidemia was À11.5; À0.1. When we compared centile and placental vascular pathology) than those non-
prenatal variables in cases of low Apgar scores with acidemic (12/33 or 36% vs. 7/53 or 13%, P = 0.012;
umbilical artery acidemia and those without, only maternal OR = 3.7, 95% CI 1.3–10.6), whereas rates of intrauterine
preeclampsia approached statistical significance (Table 1). infection (clinical chorioamnionitis, histologic chorioam-
Table 2 displays the obstetric characteristics of the two nionitis and early neonatal sepsis) were similarly repre-
groups; abruptio placentae was the only event more frequent sented in the two groups (8/33 or 24% vs. 12/53 or 23%,
in acidemic babies. A non-reassuring FHR tracing obtained P = 0.9; OR = 1.1, 95% CI 0.4–2.9). Of interest the
antepartum or intrapartum was observed in 27/33 or 82% of significant association between non-reassuring FHR tracing
cases with umbilical artery acidemia and in 30/53 or 57% of and umbilical artery acidemia observed at univariate
those without acidemia (P = 0.04; OR 2.8, 95% CI 1.1, 7.5). analysis lost significance after taking into account intrau-
In all cases in which FHR tracing was the main indication for terine vascular disease using logistic regression analysis
operative delivery, the baby was born within 30 min of the (P = 0.1, OR = 2.4, 95% CI = 0.8–6.6), suggesting that non-
decision to intervene. In 2 cases of acidemic babies (6%) reassuring FHR tracings reflect in part an underlying
FHR was monitored during labor with intermittent intrauterine vascular disease. In 6 cases (4 in acidemic and 2
auscultation rather than continuously. in non-acidemic neonates) a sudden and sustained fetal
Table 2
Obstetric and histologic characteristics of gestations resulting in neonates with 5-min Apgar score <7
À12, N = 33 pH ! 7 and/or BE > À12, N = 53
pH < 7 and/or BE
Variable P-value
Induction of labor 9/22 (57.9%) 17/42 (43.2%) 0.97
Clinical chorioamnionitis 3 (9.0%) 8 (15.1%) 0.51
Cord prolapse 1 (3.0%) 0 (0%) 0.38
Abruptio placentae 4 (12.1%) 1 (1.8%) 0.07
Oxytocin use 11/22 (50%) 22/42 (52.3%) 0.85
Thick meconium-stained amniotic fluid 13 (39.3%) 24 (45.2%) 0.59
Amniotic fluid embolism 1 (3.0%) 0 (0%) 0.38
Oligohydramnios 2 (6.0%) 8 (15.1%) 0.30
Polyhydramnios 2 (6.0%) 4 (7.5%) 1
Cesarean delivery 20 (60.6%) 30 (56.6%) 0.71
Operative vaginal delivery 4 (12.1%) 2 (3.7%) 0.19
Shoulder dystocia 1 (3.0%) 3 (5.6%) 1
Breech extraction 0 (0%) 1 (1.8%) 1
Uterine rupture 0 (0%) 0 (0%) 1
Acute placental inflammatory lesions 5/21 (23.8%) 9/35 (25.7%) 1
Uteroplacental vascular lesion 6/21 (28.5%) 4/35 (11.4%) 0.20
Data are expressed as no. (%), or mean Æ S.D. BE: base excess, expressed in mmol/L.
Please cite this article in press as: Locatelli A, et al., Factors associated with umbilical artery acidemia in term infants with low Apgar
scores at 5 min, Eur. J. Obstet. Gynecol (2008), doi:10.1016/j.ejogrb.2008.01.003
4. EURO-6277; No of Pages 5
4 A. Locatelli et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology xxx (2008) xxx–xxx
Table 3
Logistic regression analysis of predictors of neonatal acidosis
P-value Odds ratio 95% confidence interval
Intrauterine vascular disease 0.01 4.10 1.37–12.2
Intrauterine infection 0.84 1.10 0.37–3.37
Acute intrapartum events 0.24 2.07 0.61–7.01
Table 4
Characteristics and outcome of neonates with 5-min Apgar score <7 according to umbilical artery evidence of acidosis
À12, N = 33 pH ! 7 and/or BE > À12, N = 53
pH < 7 and/or BE
Variable P-value
Apgar score 3 at 5 min 6 (18.1%) 3 (5.6%) 0.08
Female sex 12 (36.3%) 22 (41.5%) 0.63
3284 Æ 591 3312 Æ 453
Birth weight (g) 0.79
47.6 Æ 32.3 46.8 Æ 30.9
Birth weight centile 0.91
Birth weight 10th centile 5 (15.1%) 3 (5.6%) 0.25
Early neonatal sepsis 0 (0%) 0 (0%) 1
Data are expressed as no. (%), or mean Æ S.D. BE: base excess, expressed in mmol/L.
bradycardia or absence of FHR variability was recorded, neonatal muscular, neurologic or cardiovascular diseases
with a previously normal pattern. FHR monitoring was [4]. Conversely, we have observed that intrapartum events
continued until delivery in 5/6 cases, in the remaining one leading to low Apgar scores can be severe enough to cause
the tracing was discontinued 10 min before delivery. Rates permanent neurologic damage without causing acidemia
of acute intrapartum events (cord prolapse, amniotic fluid (for example, trauma at delivery from shoulder dystocia).
The strengths of our study include a rate of Apgar score <7
embolism, uterine rupture, sudden occurrence of non-
reassuring FHR tracing, shoulder dystocia, and complicated in our population (0.3%) consistent with that reported in the
breech extraction) were not significantly associated with recent literature (0.4%) [3]; umbilical artery gas analysis
umbilical artery acidemia (7/33 or 21% vs. 7/53 or 13%, performed in 90% of cases; data collected prospectively, and
P = 0.33; OR = 1.8, 95% CI 0.6–5.4), even after controlling management of labor and delivery following specific and
for the other two composite variables using logistic consistent protocols. Thus we feel that our analysis is based on
regression (P = 0.24) (Table 3). data largely free from selection biases. A limitation of our
As shown in Table 4, there were no significant differences study is that data were not always available in every case; in
in the characteristics of neonates with 5-min Apgar score <7 particular, placental information was missing in 35% of cases.
according to umbilical artery acidemia. Babies with low A pathologic antepartum or intrapartum FHR tracing in
Apgar score and cord acidemia had a neonatal course more neonates with low Apgar scores is associated with a higher
frequently complicated by hypoxic–ischemic encephalopathy probability of metabolic acidosis. As previously reported,
(19/33 or 57.6% vs. 8/53 or 15.1%, P < 0.01; OR = 7.9, 95% however, abnormal FHR tracings have a high false positive
CI 2.4–26.1) or multiorgan dysfunction (9/31 or 29.0% vs. 4/ rate in the prediction of acidosis (in our series of neonates with
48 or 8.3%, P = 0.03; OR = 7.6, 95% CI 2.6–24.3). In the low 5-min Apgar scores it was 57%). Predictive fetal heart rate
acidemic group there were 2 (7%) neonatal deaths, while none patterns demonstrate good sensitivity but poor specificity with
occurred among non-acidemic babies (P = 0.14). Three of the many false positives for intrapartum fetal asphyxia [17]. On
surviving infants developed cerebral palsy, two in the the other hand, in nearly 1 out of 5 (21%) neonates with low
acidemic group and one in the non-acidemic group. Apgar scores at 5 min and acidemia the FHR tracing did not
provide clues of the impending outcome.
In an attempt to understand whether events leading to
umbilical cord acidosis are acute or chronic in nature, we
4. Discussion
grouped together acute intrapartum hypoxic events accord-
ing to an established classification [4,8,16]. No significant
Although low Apgar scores are often considered as
correlates of neonatal acidosis, in our series umbilical artery difference was present in rates of acute events between cases
evidence of acidemia is present only in 38% of babies with with vs. without acidemia. This finding is in line with what
Apgar scores <7 at 5 min. This finding underscores the has been reported in two series evaluating predictors of
importance of obtaining umbilical artery gas analysis in the hypoxic–ischemic encephalopathy [4,18]. We have explored
presence of any depressed neonate, and of not equating low chronic processes which are prevalent in the pregnant
Apgar scores to intrapartum asphyxia. Indeed, factors other population and may lead to acidemia: intrauterine vascular
than acidosis are at play in the majority of neonates with low pathology and intrauterine infection. We integrated placen-
tal pathology findings, which were available in 63% of cases,
Apgar scores, such as maternal sedation, infection, or
Please cite this article in press as: Locatelli A, et al., Factors associated with umbilical artery acidemia in term infants with low Apgar
scores at 5 min, Eur. J. Obstet. Gynecol (2008), doi:10.1016/j.ejogrb.2008.01.003
5. EURO-6277; No of Pages 5
A. Locatelli et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology xxx (2008) xxx–xxx 5
[4] American College of Obstetricians and Gynecologists, American
with clinical correlates of similar underlying processes.
Academy of Pediatrics. Neonatal encephalopathy and cerebral palsy:
Thus we considered placental vascular lesions and their
defining the pathogenesis and pathophysiology. Washington, DC:
clinical correlates of preeclampsia, placental abruption and ACOG; 2003.
low birth weight centiles [19–22], as manifestations of an [5] ACOG Committee on Obstetric Practice, American Academy of
intrauterine vascular disease, whereas we considered Pediatrics Committee on Fetus and Newborn. Use and abuse of the
Apgar score. Compendium of selected publications, no. 174. Washing-
chorioamnionitis, early neonatal sepsis, or histologic
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Please cite this article in press as: Locatelli A, et al., Factors associated with umbilical artery acidemia in term infants with low Apgar
scores at 5 min, Eur. J. Obstet. Gynecol (2008), doi:10.1016/j.ejogrb.2008.01.003