Slow Acceptance of Universal Antiretroviral Therapy (ART) Among Mothers Enrolled in IMPAACT PROMISE Studies Across the Globe.

The PROMISE trial enrolled asymptomatic HIV-infected pregnant and postpartum women not eligible for antiretroviral treatment (ART) per local guidelines and randomly assigned proven antiretroviral strategies to assess relative efficacy for perinatal prevention plus maternal/infant safety and maternal health. The START study subsequently demonstrated clear benefit in initiating ART regardless of CD4 count. Active PROMISE participants were informed of results and women not receiving ART were strongly recommended to immediately initiate treatment to optimize their own health. We recorded their decision and the primary reason given for accepting or rejecting the universal ART offer after receiving the START information. One-third of participants did not initiate ART after the initial session, wanting more time to consider. Six sessions were required to attain 95% uptake. The slow uptake of universal ART highlights the need to prepare individuals and sensitize communities regarding the personal and population benefits of the "Treat All" strategy.

Use of adenosine for pharmacological cardioversion of SVT in pregnancy.

Objective: To evaluate the success and safety of adenosine use in treating maternal supraventricular tachycardia (SVT) in pregnancy.Methods: Hemodynamically stable pregnant women diagnosed with supraventricular tachycardia admitted to Jackson Memorial hospital from 1990 to 1995 and treated with adenosine were included in the study. Adenosine was given intravenously with an initial dose of 6 mg, followed by two 12 mg doses as needed. Mothers and fetuses were followed prospectively to assess short-term and long-term effects of the treatment.Results: A total of four pregnant patients were treated with adenosine for medical cardioversion of SVT. All patients were hemodynamically stable upon arrival to the maternity ward and were successfully treated with adenosine. Both mothers and fetuses were monitored during treatment. Adenosine successfully converted the SVT to sinus rhythm, in all four patients. One patient was treated successfully twice, at 15 weeks and subsequently at 24 weeks. No complications occurred to either the mothers or the fetuses during the treatment. Five and ten minute APGAR scores at birth were greater than seven. Mothers and babies were followed from 1 month to 5 years after treatment and no contributory deleterious effects have been found. One patient was lost to follow-up.Conclusion: Our four patient cases, added to the limited published cases in the literature, support adenosine's safety and efficacy for the medical treatment of supraventricular tachycardia in the hemodynamically stable pregnant woman.

Severe preeclampsia remote from term: labor induction or elective cesarean delivery?

OBJECTIVES: The study's objectives were as follows: (1) to determine the rate of vaginal delivery after labor induction in severe preeclampsia remote from term and (2) to determine potential predictors of success. STUDY DESIGN: Retrospective chart review was conducted on live-born singleton pregnancies complicated by severe preeclampsia and delivered at 24 to 34 weeks' gestation from January 1, 1992, to December 31, 1996. Exclusion criteria included eclampsia, presence of labor or spontaneous rupture of membranes on admission, and complication of pregnancy by an ultrasonographically detected fetal congenital anomaly. Patients were divided into 3 groups: elective cesarean delivery without labor, cesarean delivery after labor induction, and vaginal delivery after labor induction. Statistical analyses included multiple logistic regression, the Student t test, the chi2 test, and the Mann-Whitney test. P 32 weeks' gestation. The most common indication for cesarean delivery after induction, in 50.7% of the cases, was nonreassuring fetal heart rate. The median Bishop score was significantly higher (3 vs 2, P =.004) and the total hospital stay was significantly shorter in the vaginal delivery after induction group than in the cesarean delivery after induction group. However, there were no significant differences between the 2 groups in use of cervical ripening agents, gestational age at delivery, birth weight, 5-minute Apgar score, or postpartum endometritis. After exclusion of cesarean deliveries performed for malpresentation, there was no statistically significant difference in classic incision rates between the elective cesarean delivery without labor and cesarean delivery after induction groups (13.6% vs 6.8%; P =.137). According to logistic regression analysis, only the Bishop score was significantly associated with a successful induction (odds ratio 1.38, 95% confidence interval 1.11-1.71). Gestational age reached marginal significance (odds ratio 1.30, 95% confidence interval 0.89-1.89). CONCLUSIONS: (1) Labor induction should be considered a reasonable option for patients with severe preeclampsia at

Choledochal cysts diagnosed in pregnancy: a case report and review of treatment options.

An 18-year-old woman at 18 weeks' gestation presented with abdominal pain and jaundice. After extensive evaluation, she was diagnosed as having a choledochal cyst. Ten days after percutaneous drainage, she underwent complete excision and Roux-en-Y hepaticojejunostomy anastomosis. At term, she delivered vaginally without complications. Although choledochal cysts are rare in pregnancy, it is important for the obstetrician to be familiar with the presentation and the best treatment modalities available. Delay in diagnosis and inappropriate treatment can result in maternal morbidity and fetal mortality.