An epidemic of parvovirus B19 in a population of 3,596 pregnant women: a study of sociodemographic and medical risk factors.

OBJECTIVES: To estimate the incidence of human parvovirus B19 among pregnant women before and during an epidemic, to elucidate possible sociodemographic and medical risk factors during pregnancy and to estimate the association between parvovirus B19 infection and negative pregnancy outcome. DESIGN: Prospective study among pregnant women followed from their first antenatal visit before 24 full weeks of gestation until delivery. SETTING: Department of Obstetrics and Gynaecology, Odense University Hospital, Denmark, November 1992 to February 1994. METHODS: 3,596 pregnant women were invited to participate. The women were examined at first antenatal visit in the period from November 1992 to February 1994 and at delivery. The last delivery was in August 1994 and samples were thus collected before and during a large parvovirus B19 epidemic in Denmark January to September 1994. A blood sample for parvovirus B19 serology was taken at enrollment and from the umbilical cord at delivery. Three questionnaires were completed during 2nd and 3rd trimesters and a registration form at delivery. In total, 3,174 (87.6%) were enrolled and 79.5% completed the study. RESULTS: The prevalence of B19 IgG seropositivity at the first antenatal visit before 24 full weeks of gestation was 66% . The cumulative prevalence proportion of acute parvovirus B19 infection during pregnancy among IgG negative women was found to be 10.3% (IgM seropositivity and/or IgG seroconversion). The IgG seroconversion incidence increased significantly from 1.0% to 13.5% among 932 seronegative pregnant women before and during the epidemic, respectively (P < 0.001). Independent risk factors related to increased risk of B19 infection during pregnancy, adjusted for other sociodemographic and medical factors, were: children at home (adjusted OR 2.1, 95% CI 1.3-3.2); serious medical disease (adjusted OR 3.0, 95% CI 1.0-8.5); and a stressful job (adjusted OR 1.8, 95% CI 1.0-3.3). Parvovirus B 19 IgM seropositivity was associated with events of late spontaneous abortions and stillbirths (crude OR 9.9; 95% CI 3.3-29.4). CONCLUSION: Before and during an epidemic of acute B19 infection incidences were measured among pregnant women to be 1.0% and 13.5%, respectively. Three factors, significantly increasing the risk of acute B19, were identified as: having children at home; suffering from serious medical diseases; and having a stressful job. IgM positivity for parvovirus B19 was associated with negative outcome of pregnancy.

Few microorganisms associated with bacterial vaginosis may constitute the pathologic core: a population-based microbiologic study among 3596 pregnant women.

OBJECTIVE: To evaluate the association between various microorganisms isolated from the genital tract in pregnant women with bacterial vaginosis. STUDY DESIGN: A cross-sectional population-based study among pregnant women addressed at their first antenatal visit before 24 full gestational weeks from the referring area of the Department of Obstetrics and Gynecology at Odense University Hospital, Denmark, from November 1992 to February 1994. The main outcome measures were prevalence of various microorganisms and statistical estimates of interactions (crude, adjusted, and relative odds ratios) between the microorganisms isolated from the lower genital tract in pregnant women with and without clinical diagnosis of bacterial vaginosis. RESULTS: Three thousand five hundred ninety-six (3596) pregnant women were asked to participate. Of the 3596 pregnant women 3174 (88.4%) agreed to participate before 24 full gestational weeks. After controlling for the presence of other microorganisms, strong associations between Gardnerella vaginalis, anaerobic bacteria, Mycoplasma hominis, and present bacterial vaginosis were found. Similarly Lactobacillus spp. were found to be associated with the absence of bacterial vaginosis. The combination of G. vaginalis and anaerobic bacteria and/or M. hominis was found in 59.6% of the cases with bacterial vaginosis and in 3.9% of the cases without bacterial vaginosis (odds ratio 36.4, 95% confidence interval 27.8 to 47.8). The crude odds ratio was found to be as high as 74.8 (95% confidence interval 32.3 to 174.1) when the combination of G. vaginalis, M. hominis, anaerobic bacteria, and no Lactobacillus spp. was associated with bacterial vaginosis. CONCLUSION: There is a microbial foundation for bacterial vaginosis, and it is possibly due to an intermicrobial interaction in which the microorganisms G. vaginalis, anaerobic bacteria, and M. hominis are dominating, indicating that these constitute the pathologic core of bacterial vaginosis.

[Endometrial resection. Peroperative complications and postoperative course]. / Endometrieresektion. Peroperative komplikationer og postoperativt forløb.

The effectiveness of transcervical resection of the uterine endometrium was assessed in 106 consecutive women admitted for surgical treatment for menstrual disorders, suitable for treatment with endometrial resection. No hormonal pretreatment was given. Amenorrhoea occurred in about 25%; 80% were satisfied after the initial treatment and 86% were satisfied if the procedure was repeated after at least one year postoperatively. The results were the same in 34 (32%) who had fibroids or polyps in the uterine cavity. No serious operative or postoperative complications appeared. Seven patients (6.6%) required temporary tamponade to control bleeding. It is concluded that endometrial resection is an advance in the management of menstrual disorders. The satisfaction in the patients is high and the complication rate low.

[Prevalence of Chlamydia trachomatis among conscripts. A comparative study of urine samples and urethral swabs]. / Forekomst af Chlamydia trachomatis hos vaernepligtige, En sammenlignende undersøgelse of urinprøve og urethrapodning.

The purpose of the investigation was 1) to determine the prevalence of C. trachomatis among young men and women enrolled in military service, 2) to compare enzyme-immunoassay (EIA) of a urethral swab with a sample of first voided morning urine, 3) to determine frequency of earlier venereal diseases (VD) and actual symptoms of urethritis and cervicitis. EIA positive specimens were confirmed by immunofluorescent microscopy. The investigation comprised 831 men and 80 women (17-26 years). The prevalence was 5.7% (95% confidence limits 4.2-7.4%) and 15% (8-25%) for men and women, respectively (p < 0.005, chi 2). The agreement between the results of the urethral swab and the urine sample was low. Sensitivity and positive predictive value for urethral swab was better than for urine. The handling of urine specimens was more laborious and confirmation more difficult. The percentage of actual symptoms among Chlamydia positive men was 6. The frequency of earlier VD was 7.5% and 10% among men and women, respectively. Treatment with tetracycline was effective, which makes control of eradication unnecessary. We conclude that genital chlamydial infection among young asymptomatic people is common and screening would be desirable. We still recommend urethral swabbing as the routine method until simpler and/or more reliable assays for urine specimens are developed.

Sterility of the uterine cavity.

In a prospective open study the sterility of the uterine cavity was evaluated in 99 women admitted for hysterectomy. The indications for hysterectomy were in most cases persistent irregular vaginal bleeding and fibromyomas of the uterus. Samples for both aerobic and anaerobic bacteria, Chlamydia trachomatis, yeasts and viruses were taken preoperatively from the apex of the vagina and cervical os. Immediately after hysterectomy the uterus was opened under sterile conditions and samples obtained from the isthmus and fundus of the uterine cavity for microbiological examination. Wet smears were taken from the same sites. Nearly a quarter of all the patients harbored one or more microorganisms in the uterus, mostly Gardnerella vaginalis, Enterobacter and Streptococcus agalactiae. We found that in a significant number of cases, the uterine cavity is colonized with potentially pathogenic organisms which may play a causative role in endometritis. The results indicate that inflammation of the uterine cavity should be evaluated by hysteroscopic examination before hysterectomy is undertaken in patients with persistent irregular vaginal bleeding.

[Herpes simplex infection in pregnant women and newborn infants]. / Herpes simplex-infektion hos gravide og nyfødte.

The incidence of genital herpes infection is increasing. About 50% of infections in women are asymptomatic. Neonatal infection is the most serious complication of genital HSV-infection, the mortality being 70% if untreated. The incidence of asymptomatic HSV-infection in pregnant women at the time of giving birth is 0.2%. These women cannot be identified on the basis of clinical symptoms and medical history, and the diagnostic methods currently in use are not sufficiently sensitive for the screening of low risk groups. Pregnant women with primary HSV-infection shed larger quantities of virus than women with recurrent infection, furthermore the foetus has not received passive immunisation by maternal antibody transfer. There is an increased risk of miscarriage, intrauterine infection and premature birth in connection with primary HSV-infection in pregnancy. Almost 50% of children born to mothers with primary HSV-infection at the time of birth become infected neonatally, compared with only 2-5% of children born to mothers with active recurrent HSV-infection. Recommendations are given for monitoring primary HSV-infection in the third trimester with viral cultures, monitoring recurrent HSV-infections clinically and indications for when delivery should be by caesarean section. Children born to women with active primary HSV-infection should be treated with antiviral agents. Children born to women with recurrent infection should have their secretions cultured for HSV.

A randomised controlled trial of prophylaxis of post-abortal infection: ceftriaxone versus placebo.

OBJECTIVE: To investigate the incidence of post-operative infection after first trimester abortion in women treated with a long-acting cephalosporin (ceftriaxone) compared with low risk patients receiving no treatment and with high risk patients receiving our standard treatment of ampicillin/pivampicillin and metronidazole. DESIGN: A prospective, randomised controlled trial. SETTING: Department of Obstetrics and Gynaecology, Rigshospitalet, University of Copenhagen, Denmark. SUBJECTS: Nine hundred and ninety-six women, admitted on an outpatient basis for legal termination of pregnancy at 12 weeks or less of gestation, were included in the study after giving informed consent. The women were divided into high risk and low risk categories and allocated either to treatment with ceftriaxone or to standard treatment. For high risk patients the standard treatment was initiated by a peroperative injection of ampicillin and metronidazole, followed by oral doses of metronidazole and pivampicillin three times daily for four days. No prophylactic antibiotics were given to the women randomised to standard treatment in the low risk group. INTERVENTIONS: All women were kept under observation, and, between six and 14 days postoperatively, underwent pelvic examination. Clinical endpoints were noted. MAIN OUTCOME MEASURES: Post-operative pelvic inflammatory disease in women applying for legal first trimester abortion. RESULTS: Seven hundred and eighty-six women fulfilled the criteria for evaluation. A tendency toward a prophylactic effect of ceftriaxone was observed in most clinical findings. A significant prophylactic effect of ceftriaxone was found in the low risk group. CONCLUSIONS: This study demonstrated a significant reduction in post-operative pelvic inflammatory disease in low risk patients, who were applying for legal first trimester abortion, treated peroperatively with ceftriaxone. No significant difference was demonstrated between high risk patients treated with ceftriaxone or ampicillin/pivampicillin and metronidazole.

[Complete invasive mole in a 50-year old woman]. / Komplet invasiv mola hos en 50-årig kvinde.

A 50-year-old woman was admitted for hysterectomy due to persistent vaginal bleeding and enlargement of the uterus. Before operation a significant increased beta-HCG was measured. Histologic examination of uterine contents obtained by aspiration showed trophoblastic disease. An decrease in beta-HCG was registered postoperatively. However, two weeks later it rose again and the patient started treatment with methotrexate. It is recommended that the treatment of patients with invasive gestational trophoblastic disease is centralized.

A prospective randomized double-blind trial of ceftriaxone versus no treatment for abdominal hysterectomy.

The value of preoperative prophylactic parenteral treatment with ceftriaxone at elective abdominal hysterectomy was investigated in a prospective, randomized, double-blind study, in which 157 women participated, 77 in the antibiotic group and 80 in the control group. Increased febrile morbidity and a significant preponderance of women with urinary tract infections were observed in the untreated group, whereas there was no significant difference between the two groups regarding wound infections or infiltration at the top of the vagina. We find no indication for routine prophylactic use of antibiotics at elective abdominal hysterectomy.

[The venereological profile in Godthab District Venereal Clinic, Nuuk, Grønland. A 3-month study in 1991]. / Den venerologiske profil i Godthåb Distrikts Venereaklinik, Nuuk, Grønland. En tre måneders undersøgelse i 1991.

A total of 803 patients participated in a consecutive review of the disease pattern concerning venereal diseases. The investigation took place in the Clinic for Venereal Diseases in Nuuk/Godthåb during a period of three months. Less than half of the contacts were on account of symptoms of genital infection. One fifth of the patients had been summoned for partner control. A corresponding proportion felt well and had not been exposed to any known risk of infection. Chlamydia trachomatis was demonstrated in 19% and gonorrhoea in 10%. Among the asymptomatic persons, 16% were found to be Chlamydia positive and 0.6% gonococcal positive. Syphilis was demonstrated in one man and one woman. One man was known to be HIV-positive and two contacts of this patient were found to be negative but seroconversion occurred subsequently in both cases. Vaginitis and bacterial vaginosis were found in 38% of the women. In over one third (39%), no clinical or microbiological evidence of genital infection was found. Early diagnosis, treatment, information and tracing of contacts are still the cardinal principles in the combat of venereal diseases in Greenland.

Survival of chlamydiae in human semen prepared for artificial insemination by donor.

Semen specimens from 21 men with urethral infection with Chlamydia trachomatis were tested for the presence of the organism before and after cryopreservation for 3 weeks of storage at -196 degrees C. Five specimens were chlamydia-positive before preservation and four of them were still positive after storage when examined by enzyme immunoassay (Chlamydiazyme). When examined by cell culture, four proved chlamydia- positive before storage and two afterwards. The results indicate that testing for C. trachomatis has to be performed from the urethra of all donors of semen used for artificial insemination before the inoculation takes place.

Detection of Chlamydia trachomatis in formalin-fixed endometrial tissue.

Formalin-fixed tissue biopsies from 29 women with the histological diagnosis of severe endometritis were examined for chlamydial antigen by fluorescein-conjugated monoclonal chlamydial antibodies (SYVA) technique; 15 (52%) were positive. In nine patients also samples for isolation of Chlamydia trachomatis by cell-culture technique were obtained peroperatively; seven were culture-positive. In all these patients fluorescent chlamydial antigen was detected, whereas the two culture-negative patients had no such antigen. The technique presented makes it possible to examine series of formalin-fixed endometrical biopsies to evaluate the significance of C. trachomatis being etiologic agent in endometritis in females.

Gardnerella vaginalis in posthysterectomy infection.

Eighty-six women were admitted for abdominal hysterectomy. Preoperatively, 43 women were culture-positive for Gardnerella vaginalis from the cervical os, and 43 women were culture-negative. Postoperatively, 18 patients developed inflammation; among those 14 patients from the culture-positive group were infected, whereas only 4 patients from the culture-negative group developed inflammation. The difference between occurrence of G. vaginalis and the absence of the bacteria in patients with postoperative infection is highly significant. No such increased risk of postoperative infection was correlated to the isolation of any other microorganism looked for viz. aerobic and anaerobic bacteria, yeasts, viruses or chlamydiae. G. vaginalis may play a causative role in the development of posthysterectomy infection.

Occurrence of Ureaplasma urealyticus and Mycoplasma hominis in non-gonococcal urethritis before and after treatment in a double-blind trial of ofloxacin versus erythromycin.

The efficacy of ofloxacin, a new quinolone derivate, was tested against that of erythromycin in a prospective double-blind trial in patients with non-gonococcal urethritis (NGU) with special reference to the occurrence of Mycoplasma hominis and Ureaplasma urealyticum. 188 male NGU patients were randomized to treatment with either ofloxacin 200 mg b.i.d. or erythromycin 500 mg b.i.d. for seven days. Before treatment eight (4.3%) patients, five in the erythromycin group and three in the ofloxacin group, were M. hominis positive. At follow-up day 8 and 15 after start of treatment all five in the erythromycin group and two in the ofloxacin group were still positive. U. urealyticum was recovered in 16 patients (8.5%) before treatment. One patient was still positive in the erythromycin group when examined day 15, whereas all patients were negative in the ofloxacin group at both follow-up controls. Clinically, the efficacy of treatment day 15 was 77.4% in the erythromycin group and 84.3% in the ofloxacin group. The difference was not significant. Side-effects occurred in 38.5% in the erythromycin group and in 21.3% in the ofloxacin group. This difference is significant. Ofloxacin is effective in the treatment of NGU in males and is an alternative to conventional antibiotic treatment.