Amoxicillin or erythromycin for the treatment of antenatal chlamydial infection: a meta-analysis.

OBJECTIVE: To compare the effectiveness of amoxicillin and erythromycin for the treatment of antenatal Chlamydia trachomatis infection by meta-analysis of available trials involving random assignment of subjects. DATA SOURCES: A computer search of English-language abstracts using MEDLINE and the Cochrane Pregnancy and Childbirth Database (medical subject heading terms: pregnancy, chlamydia, erythromycin, amoxicillin, antenatal antibiotics) was supplemented with a review of the bibliographies of the relevant articles generated by the computer search. METHODS OF STUDY SELECTION: Five trials were identified, four of which met our inclusion criteria for the meta-analysis. DATA EXTRACTION AND SYNTHESIS: Trials to be included in this meta-analysis underwent trial quality evaluation and data abstraction. An estimate of the relative risk (RR) was calculated for the dichotomous outcomes using a fixed-effects model. The pooled RR for the effectiveness of amoxicillin compared with erythromycin was 1.11 (95% confidence interval [CI] 1.05-1.18), and the pooled RR for gastrointestinal side effects of amoxicillin compared with erythromycin was 0.29 (95% CI 0.20-0.42). The pooled RR for gastrointestinal side effects that resulted in discontinuation of therapy of amoxicillin compared with erythromycin was 0.14 (95% CI 0.06-0.36). CONCLUSION: The available data suggest that amoxicillin is more effective than erythromycin for the treatment of antenatal C trachomatis infection and has fewer gastrointestinal side effects, leading to better compliance.

Adverse perinatal events and subsequent cesarean rate.

OBJECTIVE: To determine whether severe intrapartum complications resulting in poor neonatal outcome increased obstetricians' cesarean delivery rates. METHODS: From July 1996 through June 1998 we prospectively studied 3008 deliveries by 12 obstetricians. We chose adverse neonatal outcomes that would be viewed by obstetricians as anxiety-provoking experiences that are rare in obstetric practice. Index events included head entrapment of breech infants, Apgar score less than 3 at 10 minutes, shoulder dystocia resulting in persistent brachial plexus injury, and intrapartum fetal death. After an index event was identified, the obstetrician's cesarean delivery rate for the 50 deliveries before the index event was compared with the 50 deliveries after the index event. Obstetricians who had no intrapartum complication during the observational period were matched as controls. RESULTS: Six index events were identified, three cases of shoulder dystocia and three intrapartum fetal deaths. In three of these six cases, the Apgar score at 10 minutes was less than 3. Obstetricians who attended a delivery with severe intrapartum complications had an average increase in their cesarean delivery rate of 37% in the 50 deliveries after the index event (21.0% to 28.7%, P < .05). This rate was greater (P < .05) than that of matched control obstetricians observed during the same observation period (19.0% to 18.7%). CONCLUSION: Intrapartum complications such as persistent neonatal brachial plexus injury or fetal death increased the cesarean delivery rate of the obstetrician experiencing these events. Obstetricians should be aware of the effect of these adverse events on their practice of obstetrics.

Right atrial thrombus as a complication of total parenteral nutrition in pregnancy.

BACKGROUND: Right atrial thrombus, a rare but potentially fatal complication of central venous catheter use in total parenteral nutrition, has not been reported during pregnancy. CASE: A pregnant woman with persistent hyperemesis gravidarum developed a right atrial thrombus related to central venous catheter use for total parenteral nutrition. CONCLUSION: Right atrial thrombus can be treated successfully with heparin, leading to its resolution and a normal pregnancy outcome.

Use of thrombolytics for the treatment of thromboembolic disease during pregnancy.

The incidence of thromboembolic disease is increased during pregnancy. Prevention and treatment of thromboembolic disease can have a significant impact on the morbidity and mortality of pregnant women. Anticoagulation with heparin is the treatment of choice; however, in some instances this is inadequate or contraindicated. In the nonpregnant patient, alternative therapies have included surgical intervention or fibrinolytic agents. Traditionally, thrombolytic therapy has been considered a relative contraindication during pregnancy due to the maternal and fetal risk of hemorrhagic complications. Hence, no controlled trials of agents such as streptokinase, urokinase, or tissue plasminogen activator for the treatment of thromboembolic events during pregnancy, have been performed, or are currently feasible. Since 1961, 36 reports have been published describing the use of thrombolytic agents during pregnancy. In a review of the world's literature, 172 pregnant women affected with thromboembolic conditions were treated with thrombolytic medications. A maternal mortality rate of 1.2 percent was observed. Approximately 10 pregnancy losses were noted (5.8 percent). Hemorrhagic complications were reported in 8.1 percent of patients. We summarize the published literature on the use of thrombolytic agents during pregnancy and discuss the treatment success and reported complications.

von Willebrand factor in lysates of washed canine platelets.

Canine and human platelets (washed 4 times in a solution containing EDTA, prostaglandin E1, and theophylline to prevent release of alpha-granule constituents) were lysed by being frozen and thawed in the presence of detergent. Radioelectroimmunoassay for von Willebrand factor (vWf) in 5 human platelet lysates produced precipitin rockets, shaped like those produced from vWf in plasma from healthy human beings, and indicated that the mean von Willebrand factor antigen (vWf:Ag) content in platelets from healthy human being was 526 +/- 87 human U/10(12) platelets. Radioelectroimmunoassay for vWf in platelet lysates from 17 healthy dogs with normal plasma. vWf:Ag concentration produced precipitin rockets that looked different from those produced from canine plasma and indicated vWf:Ag content of 59 +/- 35 canine U/10(12) platelets. Inclusion of protease inhibitors in the lysing solution did not normalize the appearance of the precipitin rockets or substantially alter the measured platelet content of vWf:Ag. The array of vWf multimers revealed by sodium dodecyl sulfate-agarose gel electrophoresis of canine platelet lysates had a distinct appearance that differed from that of vWf in canine or human plasma and platelets; the intensity of the canine platelet vWf multimer bands was skewed, with relatively greater density in the lower molecular weight region and faint or undetectable multimer bands in the higher molecular weight region. Electrophoretograms with visible multimers in the high molecular weight region had vWf components that had higher molecular weight than did any vWf components in canine plasma. Radioelectroimmunoassay for fibronectin in these same canine platelet lysates indicated that the fibronectin content in platelets was 2.89 +/- 1.10 mg/10(12) platelets.(ABSTRACT TRUNCATED AT 250 WORDS)

Multimeric analysis of von Willebrand factor before and after desmopressin acetate (DDAVP) administration intravenously and subcutaneously in male beagle dogs.

Eight adult male Beagles were given 1 microgram of 1-deamino-8-D-arginine vasopressin (DDAVP)/kg of body weight, SC or by slow IV infusion on separate occasions. Both routes of administration induced highly significant increases (P less than 0.0001) in plasma concentrations of von Willebrand factor (vWf) antigen (Ag) and botrocetin cofactor (BCf) activity, an indication of platelet-associated vWf activity. In most instances, increases in plasma vWf:Ag and BCf values induced by SC injection were as large as or larger than those induced by slow IV infusion. With both routes of administration, BCf activity increased more than the vWf:Ag concentration, so that high BCf-to-vWf:Ag ratios were found in plasma after DDAVP administration. In plasma samples obtained before DDAVP administration, sodium dodecyl sulfate-electrophoresis resolved the vWf into a series of multimeric proteins with molecular weights similar to those of human vWf. Sodium dodecyl sulfate-electrophoresis of plasma samples obtained after DDAVP administration revealed mainly the larger molecules of vWf that were increased by DDAVP administration.

Factor VIII complex in canine plasma after submaximal treadmill exercise.

Exercise-induced changes in the plasma concentrations of coagulation factor VIII and von Willebrand factor were evaluated, using 8 random-source adult dogs that exercised on a treadmill for 5 to 10 minutes (mean running time = 8.3 minutes). Maximum treadmill speeds attained by the dogs were 11 to 18 km/hr, and the mean of the maximum individual speeds was 14.3 km/hr. Maximum heart rates of individual dogs during exercise were 190 to 250 beats/min with a mean of 218 beats/min (a 2.4-fold increase over the mean preexercise rate). Exercise did not induce significant increases in plasma concentrations of factor VIII coagulant activity, coagglutinin co-factor activity, or factor VIII-related antigen. Results indicated that submaximal exercise does not induce increases in plasma concentrations of coagulation factor VIII or von Willebrand factor in the dog.

Effect of internal hemorrhage on fibrin(ogen) degradation products in canine blood.

To determine effects of internal hemorrhage on fibrin(ogen) degradation products, blood was pumped from catheters in the jugular veins of 7 anesthetized dogs into extravascular sites in the same dogs. Blood (25 ml/kg of body weight) was transported into their peritoneal cavities (3 dogs) or into the muscle of the pelvic limbs (4 dogs). Blood samples were obtained periodically from these dogs for 4 days after the injections were given. Fibrin(ogen) degradation products (FDP) could not be detected in any of these samples by standard procedures with a commonly used clinical assay, based on the agglutination of antibody-coated latex beads. Even when the assay was modified to make it 2.5 times as sensitive, FDP was not detected. Seemingly, extravascular blood from internal hemorrhage is unlikely to supply enough FDP to the circulating blood to produce clinically important increases in FDP concentrations.

Prekallikrein deficiency in a family of miniature horses.

Two sibling miniature horses, a male and a female, had a normal 1-stage prothrombin time and a prolonged activated-partial thromboplastin time (APTT). The addition of as little as 5% of a normal equine plasma pool to the plasma samples of both horses shortened their prolonged APTT to within normal limits. Coagulation factor analysis revealed deficiencies in factor XII (12 and 13 U/dl, control population 77 to 128 U/dl), when determined with a feline factor XII-deficient plasma substrate, but normal concentrations (119 and 96 U/dl) when a human factor XII-deficient plasma substrate was used. Deficiencies of another factor, prekallikrein, were detected with a human prekallikrein-deficient plasma substrate (16 and 6 U/dl, control population 70 to 173 U/dl). Other intrinsic coagulation factors were present in normal concentrations. The APTT was measured with plasma from the 2 horses after various incubation periods (1 to 15 minutes) with a contact activator before the addition of Ca ions. With incubation times of greater than or equal to 10 minutes, the APTT of both horses were essentially the same as that of the normal equine plasma pool. Several family members of the 2 prekallikrein-deficient miniature horses appeared to be heterozygous carriers of the prekallikrein deficiency.

Buccal mucosa bleeding times of healthy dogs and of dogs in various pathologic states, including thrombocytopenia, uremia, and von Willebrand's disease.

The buccal mucosa bleeding time (BMBT; duration of hemorrhage from standardized cuts made with a spring-loaded disposable device in the mucosal surface of the upper lip) was used to evaluate the hemostatic competence of dogs. The mean (+/- SD) BMBT for 34 healthy dogs was 2.62 +/- 0.49 minutes. The BMBT of healthy dogs anesthetized with halothane or tranquilized with xylazine were not significantly different from the BMBT of healthy dogs evaluated without chemical restraint. The BMBT was significantly (P less than 0.01) prolonged 21 hours after aspirin (10 mg/kg of body weight) was administered orally to 10 healthy dogs; however, the mean aspirin-induced increase in BMBT was only 0.40 minutes. The BMBT of 28 of 30 dogs with various diseases not traditionally associated with hemostatic deficiencies were near or within the range of BMBT for healthy dogs; however, 2 dogs had BMBT of greater than 8 minutes. In contrast, BMBT were prolonged in most dogs with diseases known to induce deficient primary hemostasis; the 3 dogs with thrombocytopenia (less than or equal to 20,000 platelets/microliter), the 7 Doberman Pinschers with von Willebrand's disease (von Willebrand factor antigen; less than or equal to 18 U/dl), and 5 of the 6 dogs with severe azotemia (serum urea nitrogen; greater than or equal to 124 mg/dl) had prolonged BMBT. The BMBT of 16 dogs were determined immediately before they were subjected to various surgical procedures, and the severity of the hemorrhage encountered during these procedures was subjectively evaluated; the amount of hemorrhage from 12 of the 16 dogs was considered to be appropriate for the corresponding surgical procedures, but the remaining 4 dogs bled excessively during surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of microwave-thawed canine plasma for transfusion.

Units of fresh-frozen canine plasma were thawed rapidly in a microwave oven, using a mean of 15.4 thawing periods of 10 seconds each. The activated partial thromboplastin times, the one-stage prothrombin times, concentrations of fibrinogen, factor-VIII coagulant activity, and von Willebrand factor antigen of microwave-thawed units were not significantly different from those measured in small aliquots of the same units thawed in a warm water bath (n = 5). Five dogs were given a unit of their own microwave-thawed plasma. During the 24 hours after infusion, no significant changes were measured in temperature, heart rate, or respiration rate. In addition, significant changes in PCV, total protein concentrations, estimates of platelet numbers, total RBC counts, total WBC counts, and differential WBC counts were not measured in blood specimens obtained before infusion and 24 hours after the infusion of microwave-thawed plasma.

Canine von Willebrand's disease. A heterogeneous group of bleeding disorders.

The term "von Willebrand's disease," refers to a group of inherited bleeding disorders, all of which are caused by a deficiency of the multimeric plasma glycoprotein, von Willebrand factor. The various forms of canine von Willebrand's disease can be categorized into one of three major types: in type I canine von Willebrand's disease, all sizes of von Willebrand factor multimers can be detected in the plasma; in type II canine von Willebrand's disease, only the smaller von Willebrand factor multimers are found in the plasma (larger multimers are absent); and in type III canine von Willebrand's disease, von Willebrand factor is completely absent from the plasma or present in only trace amounts. Von Willebrand's disease is common in dogs, but some forms of the disease are so mild that they are of questionable clinical significance.

Gastrointestinal hemorrhage during pregnancy in a patient with a history of vertical-banded gastroplasty.

Pregnancy after gastric bypass for morbid obesity is well reported; however, the only maternal complications described have involved nutritional deficiencies. We report a case of gastrointestinal hemorrhage during pregnancy resulting from erosion of a synthetic graft from a vertical-banded gastroplasty performed 4 years previously.