Brain proton magnetic resonance spectroscopy in children exposed to methamphetamine in utero.

OBJECTIVE: To examine the possible neurotoxic effects of prenatal methamphetamine exposure on the developing brain using 1H-MRS. METHODS: Methamphetamine-exposed children (n = 12) and age-matched unexposed control subjects (n = 14) were evaluated with MRI, localized 1H-MRS, and a Child Behavior Checklist. Metabolite concentrations of N-acetyl-containing compounds (NA), total creatine (Cr), choline-containing compounds, myoinositol, and glutamate + glutamine were measured in the frontal white matter and striatum. RESULTS: Despite an absence of visible structural abnormalities in either group, children exposed to methamphetamine in utero had higher [Cr] (+10%, p = 0.02) in the striatum. [NA], primarily a measure of N-acetylaspartate, was normal in both regions, which suggests no significant neuronal loss or damage in the two brain regions examined. There were no differences in reported behavior problems among the methamphetamine-exposed children relative to the unexposed group. CONCLUSIONS: The authors found increased [Cr] in the striatum with relatively normal [NA] in children exposed to methamphetamine. These findings suggest an abnormality in energy metabolism in the brains of children exposed to methamphetamine in utero.

Risk factors for postcesarean endomyometritis.

Postcesarean endomyometritis is the most common nosocomial infection treated by obstetrician-gynecologists. One important prevention strategy is the use of perioperative antibiotic prophylaxis initiated after occlusion of the umbilical cord for parturient patients with a high risk of this infection. However, the identification of these high risk patients remains problematic. Numerous clinical risk factors have been identified in the literature. Important intrinsic risk factors include indigent socioeconomic status, anemia, and preterm gestational age at the time of cesarean section. The three most consistently identified extrinsic risk factors include labor prior to cesarean section, the duration of ruptured chorioamniotic membranes, and the number of preoperative vaginal examinations. Alternatively, many investigators have attempted to define high-risk patients utilizing various laboratory tests, such as Gram staining or bacterial culture of amniotic fluid, chorioamniotic membranes, or endometrial biopsy specimens; although specific, these tests have not been sufficiently sensitive predictors of infection. Currently, assessment of the duration of ruptured membranes and length of labor remain the most sensitive, readily available, and therefore clinically useful predictors of postcesarean endomyometritis.

Epidemic perinatal listeriosis at autopsy.

Seven cases of listeriosis identified at perinatal autopsy are described. The cases occurred during the time of a 1985 Los Angeles, California, epidemic of listeriosis from suspected food contamination by Listeria monocytogenes. In only one of seven cases were gross pathologic lesions encountered. Microscopic lesions in six cases consisted of rare, localized microabscesses or granuloma-like lesions in multiple organs and contained histiocytes, monocytes, lymphocytes, and polymorphonuclear leukocytes with variable necrosis. One case had no gross or microscopic findings. Organomegaly was uncommon. The diagnosis was confirmed in three cases by postmortem blood culture. Complete perinatal autopsy is important for confirmation of listeriosis when microbiologic, gross, or microscopic findings alone may not yield characteristic features.

Clinical manifestations of epidemic neonatal listeriosis.

We report the broad spectrum of clinical manifestations in 23 infants with positive cultures for Listeria monocytogenes who were treated in our hospital during a recent epidemic. The majority of infants (70%) were preterm and none was small for gestational age. Thirteen (56%) had respiratory distress at birth with evidence of congenital pneumonia. Four of the 5 deaths occurred among these infants. Four infants considered healthy after resuscitation developed fever and lethargy within 36 hours after birth. Only one of these infants had evidence of pneumonia. We conclude that congenital pneumonia with respiratory distress at birth is the major cause of mortality and morbidity from L. monocytogenes infection in the neonate.

Perinatal listeriosis (early-onset): correlation of antenatal manifestations and neonatal outcome.

Listeria monocytogenes is an underdiagnosed and underreported cause of congenital sepsis. Twenty mother/infant pairs from whom Listeria was isolated were studied at the University of Southern California School of Medicine and Women's Hospital during the last ten years to delineate antepartum factors indicative of a fetus at high risk for perinatal Listeria sepsis. The combination of high maternal leukocyte count, fetal tachycardia, decreased fetal heart rate variability, and, especially, the absence of intrapartum fetal heart rate accelerations was associated with a complicated course for the neonate with congenital Listeria sepsis. Intrapartum administration of antibiotics decreased fetal morbidity and mortality but did not impair recovery of the organism.

Cervical ripening with prostaglandin E2 vaginal suppositories.

A prospective, randomized, double-blind, placebo-controlled study was undertaken to evaluate the safety and efficacy of a 3-mg prostaglandin E2 (PGE2) vaginal suppository for the initiation of cervical ripening before the induction of labor. All patients were required to have an initial Bishop score of 4 or les. The 3-mg PGE2 vaginal suppository was found to be an effective method of both cervical ripening and labor induction. Its use resulted in a highly significant improvement in the mean Bishop score compared with the placebo group (2.67 versus 0.55 points, P less than .00005). Its use also resulted in a significant reduction in the number of failed inductions (5 versus 23%, P less than .0005). Moreover, 68% of the patients treated with PGE2 labored after initial suppository placement, and 42% of these patients never required oxytocin augmentation of labor. However, there were three instances of uterine hyperstimulation/hypertonus following placement of the 3-mg PGE2 suppository, suggesting that perhaps a lower dose of PGE2 would improve its safety as a ripening agent without affecting its efficacy.

Induction of labor with prostaglandin E2 vaginal suppositories.

A prospective randomized study of 85 parturients was undertaken comparing the safety and efficacy of a 3-mg prostaglandin E2 vaginal suppository with intravenous oxytocin for the induction of labor. All patients were required to have a Bishop's score of 5 or higher. Labor was successfully induced in 98% of the patients in both groups by their respective methods. Sixty-four percent of the patients receiving a 3-mg prostaglandin E2 suppository required no intravenous oxytocin. More specifically, 82% (23/28) of the parous patients but only 29% (5/17) of the nulliparous patients who received a single 3-mg prostaglandin E2 suppository for labor induction did not require oxytocin augmentation (P less than .005). The first and second stages of labor were not significantly different for the two groups, and there was no significant difference in the incidence of cesarean section. A 3-mg prostaglandin E2 vaginal suppository may be a useful alternative to oxytocin for the induction of labor in carefully selected patients.

Bacteremia in post-Cesarean section endomyometritis: differential response to therapy.

Presented are blood culture results obtained from 200 patients with post-cesarean section endomyometritis treated with either penicillin-gentamicin or clindamycin-gentamicin. Their clinical course is correlated to their blood culture results by the fever index. Fifty-three percent of the 60 organisms isolated from 48 patients were anaerobic bacteria. Patients from whose blood cultures anaerobic bacteria were recovered had higher fever indexes than did those with aerobic isolates (P less than .05). Clindamycin-gentamicin patients from whose blood cultures anaerobic organisms were isolated had less febrile morbidity than did comparable penicillin-gentamicin patients. Patients with Bacteroides fragilis bacteremia had the highest fever indexes overall. Therefore, patients with post-cesarean section endomyometritis have less febrile morbidity if they are initially treated with a drug effective against anaerobic bacteria, especially B fragilis.

Human immunodeficiency virus-1 seroprevalence among parturients in Los Angeles County public hospitals.

To estimate the prevalence of human immunodeficiency virus type 1 (HIV-1) among parturients in an area with a high cumulative incidence of AIDS, an HIV seroprevalence study was conducted in 1988 in Los Angeles County. Test results were available from 8485 (86.1%) of the 9860 women delivering at four public hospitals. The test results were linked to demographic and medical information available from routinely collected delivery records. Three specimens were HIV-positive, for a seroprevalence of 3.5 per 10,000. The seropositive women were all Latina. The prevalence of HIV among women delivering at all hospitals in Los Angeles County has been shown to be relatively low compared with that of other metropolitan areas with a high number of AIDS cases, such as New York city, but appears to be even lower among women delivering at public hospitals during this time period. This low prevalence is attributed to the predominance of Latinas, who may have lower levels of infection, among public hospital parturients. The relatively low prevalence of HIV among injection drug users in Los Angeles County may contribute to the overall lower prevalence among women in Los Angeles County compared with those in New York city. This study supplements county-specific data obtained from statewide blinded neonatal testing by providing details on HIV seroprevalence among the catchment populations of public hospitals in Los Angeles County.

An intravaginal controlled-release prostaglandin E2 pessary for cervical ripening and initiation of labor at term.

The purpose of this randomized, double-blind study was to evaluate the efficacy and safety of a new controlled-release hydrogel pessary for ripening the cervix and initiating labor. Subjects had an entry Bishop score of 4 or less and gestational age of 37 or more weeks. One hundred fourteen women received a placebo pessary and 101 received the hydrogel pessary, containing 10 mg of prostaglandin (PG) E2. Compared with the placebo group, those given the PGE2 pessary were more likely to have an increase in Bishop score of 3 or more (60 or 59% versus 21 or 18%; P less than .0001), change to a Bishop score of 6 or higher (59 or 58% versus 18 or 16%; P less than .0001), and active labor (68 or 67% versus 15 or 13%; P less than .0001). Including the crossover study, uterine hyperstimulation (28 of 182, 15%) and fetal heart rate abnormalities (18 of 182, 10%) in PGE2-treated subjects were reversed on removal of the pessary with no apparent harm to the mother or fetus. These temporary adverse effects appeared while the pessary was in place and after the onset of active labor. Oxytocin was unnecessary in 89 of 182 (49%) of the PGE2-treated cases and was used more often to augment than to induce labor. We conclude that the described controlled-release PGE2 vaginal pessary induces appreciable cervical ripening and frequently initiates active labor with little or no need for oxytocin. The pessary may cause uterine hyperstimulation or fetal heart rate abnormalities, but these would be expected to reverse on removal of the pessary.

Serologic evidence of prior chlamydial infection in patients with tubal ectopic pregnancy and contralateral tubal disease.

Oviductal damage from infectious salpingitis is a principle cause of ectopic pregnancy. To examine the role of Chlamydia trachomatis in patients with ectopic pregnancy, 24 patients undergoing laparotomy for ectopic pregnancy were evaluated by assessment of chlamydial serology and chlamydial cultures of tubal biopsy specimens. The patients were divided into two groups based on the presence or absence of gross abnormalities in the fallopian tube contralateral to the ectopic gestation. Ten patients in group I showed gross evidence of chronic salpingitis in the contralateral tube; 14 patients in group II had normal-appearing contralateral tubes. Chlamydial cultures were negative in both groups. Chlamydial immunoglobulin M antibodies assayed by indirect microimmunofluorescence were negative in both groups (less than or equal to 1:32). Mean geometric immunoglobulin G titers for C. trachomatis were significantly higher in the patients with evidence of contralateral chronic salpingitis (78.9 versus 13.1). These findings suggest that C. trachomatis may be a major cause of oviductal damage, which predisposes to ectopic pregnancy.

Chlamydia trachomatis is not an important cause of abnormal postcoital tests in ovulating patients.

To examine the role of Chlamydia trachomatis infections of the cervix and abnormal postcoital tests (PCT) in a general infertility clinic, 63 consecutive patients undergoing a midcycle PCT during a routine infertility workup underwent endocervical curettage, and a 10-ml blood sample was obtained. The endocervical tissue was cultured for C. trachomatis; the serum sample was analyzed for chlamydial IgG and IgM antibodies using an indirect microimmunofluorescence assay. A negative titer was considered to be less than or equal to 1:8 dilution for IgG antibodies and less than or equal to 1:32 dilution for IgM antibodies. A good PCT was defined as greater than or equal to 5 motile sperm per high power field (HPF). A poor PCT was defined as less than 2 motile sperm/HPF, and a fair PCT was defined as 2 to 4 motile sperm/HPF. Of the 63 PCTs done, 27 (42.9%) were good, 14 (22.2%) were fair, and 22 (34.9%) were poor. All endocervical tissue cultures for C. trachomatis obtained during PCTs were negative. All IgM chlamydial antibody titers were negative (less than or equal to 1:32 dilution), 55 (87.3%) of the patients having a zero titer. Eleven (17.5%) of the patients had negative IgG chlamydial antibody titers (less than or equal to 1:8 dilution), none of the patients had a 1:16 dilution, and 52 (82.5%) had positive IgG chlamydial antibody titers (greater than or equal to 1:32 dilution). Thus, chlamydial infections of the endocervix are rare and not commonly associated with poor PCTs in this patient population.

The treatment of endomyometritis.

The mainstay of treatment for postpartum endometritis is a combination of antibiotics, such as clindamycin plus an aminoglycoside. In an effort to save time and reduce the cost of treating this infection, researchers have investigated monotherapy with a beta-lactam antibiotic. Twenty-five patients with postcesarean endometritis and three with postpartum endometritis were studied at two sites for the effectiveness of 3.1 g ticarcillin disodium/clavulanate potassium administered every four or six hours for a minimum of four days. Eighteen of the 25 postcesarean endometritis patients (72%) were judged clinical cures, 6 (24%) were clinical failures, and 1 had therapy discontinued because of diarrhea. In the postpartum course of all the patients there were no wound infections and three (12%) instances of bacteremia. The majority of the enterococci were sensitive to ticarcillin disodium/clavulanate potassium, as were all of the Escherichia coli, Klebsiella pneumoniae, Bacteroides bivius, Bacteroides fragilis and other Bacteroides species.

Treatment of postcesarean endomyometritis.

Improved understanding of the microbiology of postcesarean endometritis has dramatically changed the approach to its antibiotic therapy. Initial therapy should include broad-spectrum anaerobic coverage, including against all Bacteroides species, as well as gram-positive and gram-negative aerobic coverage. Moreover, ideally initial therapy should also include coverage of Chlamydia trachomatis. Furthermore, although the use of antibiotic prophylaxis for high-risk patients undergoing cesarean section has significantly decreased their incidence of febrile morbidity, one must remember that prophylactic antibiotics have important bacteriologic effects that may limit the efficacy of monotherapy for the treatment of endometritis in prophylaxis failures.

The use of prophylactic antibiotics in patients undergoing emergency primary cesarean section.

The use of short-course (24-hour) prophylactic antibiotics was studied in 84 consecutive afebrile patients who underwent emergency primary cesarean section. There was a significant reduction in the incidence of postoperative endomyometritis in the group prophylactic antibiotics (12/45, 26.7%) compared to the control group not given prophylactic antibiotics (20/39, 51.3%), p less than 0.05. The duration of hospital stay was also significantly reduced by the use of prophylactic antibiotics (4.3 +/- 0.6 days versus 5.1 +/- 1.3 days, p less than 0.05). Other identified advantages that resulted from the use of prophylactic antibiotics included a shorter duration of treatment required for postoperative endomyometritis in the group given prophylactic antibiotics and an increased likelihood of being cured by initial therapy for endomyometritis in the group given prophylactic antibiotics (100% versus 70%). When taken together, these results indicate that the urgency of operation is a unique risk factor for postoperative infectious morbidity, and suggest that patients who undergo emergency primary cesarean section benefit from a short course of prophylactic antibiotics.

Listeria meningitis during pregnancy.

Meningitis is the major pathologic manifestation of Listeria monocytogenes in the United States. Despite the fact that this organism has a well-known predilection for individuals who are pregnant or immunocompromised, to date, maternal listeric meningitis remains an unreported entity in the English literature. The authors report two cases of this disease and review the diagnosis and treatment of meningitis in general and, more specifically, of listeric meningitis in pregnancy. It is recommended that the initial treatment of bacterial meningitis during pregnancy should be a combination of ampicillin and gentamicin pending definitive identification of the causative organism and its antibiotic sensitivity pattern.

Nonstress testing.

Physiologic considerations on regulation of the fetal heart rate are reviewed. The types of fetal heart rate acceleration are classified and illustrated. Data from 509 patients undergoing 1,281 nonstress tests are presented, with emphasis on indications, technique, and interpretation. The nonstress test had a false negative rate lower than that of the contraction stress test. Since the false positive rate is high, a nonreactive test requires further evaluation. Progressive loss of baseline variability and decreasing frequency of accelerations appear to be early signs of fetal compromise.

The role of anaerobic bacteria in postpartum endomyometritis.

To evaluate the role of anaerobic bacteria in postpartum endomyometritis, intravenous metronidazole was used as the sole initial therapy in 25 women with clinical signs of infection. This agent has not been shown to have activity against aerobic pathogens in soft tissue pelvic infections. A clinical cure was obtained in 21 of 25 (84%) with oral metronidazole utilized after the patient had been afebrile for at least 24 hours. The mean fever index of the 21 successfully treated women was 35.9 degree hours with a SD of +/-30 hours. The four patients with treatment failure required alternate antibiotics and the mean fever index of these patients was 138.0 degree hours. Transcervical endometrial cultures were obtained prior to therapy in 24 women. Anaerobes were recovered in every instance with a total of 67 isolates, a mean of 2.8 per patient. The most common isolates were peptococcus and Bacteroides species. A culdocentesis was performed concurrently in 23 women. Anaerobes were recovered in 20 (87%) with a total of 55 isolates. The most frequent isolates were peptococcus and Bacteroides fragilis. In 23 women in whom paired transcervical endometrial and cul-de-sac cultures were obtained, at least one common organism was isolated in 18 (78%). Both the successful clinical response to metronidazole and the paired culture results suggest that anaerobic organisms have an important role in endomyometritis following vaginal delivery.

Perinatal outcome associated with PCP versus cocaine use.

Phencyclidine (PCP) remains a widely used illicit drug, especially among adolescents and young adults. The pharmacologic effects of PCP are similar to those of cocaine; therefore, in this retrospective study 37 PCP-intoxicated parturients were matched for ethnicity, tobacco use, age, gravidity, and degree of prenatal care with 37 cocaine-intoxicated parturients. Infants exposed to PCP in utero, like those exposed to cocaine, had a high incidence of intrauterine growth retardation (32 vs 19%, N.S.), precipitate labor (43 vs 27%, N.S.), symptoms of neonatal drug withdrawal/intoxication, and prolonged neonatal hospitalizations. Moreover, they were more likely to have meconium-stained amniotic fluid (30 vs 19%, p = .05) and less likely to be born prematurely as cocaine-exposed infants. The comparison between the long-term developmental outcome of these groups awaits further study.

Preinduction cervical priming with PGE2 intracervical gel.

A prospective, randomized, controlled clinical trial was conducted to evaluate the safety and efficacy of a single, 0.5-mg dose of prostaglandin E2 gel in a shelf-stable triacetin base administered intracervically in patients with an unfavorable cervix (Bishop score less than or equal to 4) 12 hours prior to oxytocin-induction of labor. forty-eight evaluable patients were enrolled, 25 in the PGE2 group and 23 in the control group. PGE2 gel treatment resulted in a significant improvement in the mean Bishop score compared to control (3.14 versus 0.70, P less than .00005). Sixty-four percent of the patients treated with PGE2 had regular uterine contractions during the 12-hour preinduction period beginning 2.18 +/- 2.0 hours after gel insertion, compared to 9% in the control group, P = .0001. Moreover, 12% (3/25) of the patients receiving PGE2 progressed into active labor and delivered during the preinduction period. The duration of oxytocin infusion required for the induction or augmentation of labor was significantly shorter for patients who received intracervical PGE2 gel compared to the control group (13.1 +/- 8.1 versus 19.0 +/- 8.7, P less than .05). However, there was no significant difference in the incidence of cesarean section between the two study groups (40 and 22% in the PGE2 and control groups, respectively). No episodes of uterine hypertonus or hyperstimulation or gastrointestinal side effects occurred as a result of PGE2 gel treatment.(ABSTRACT TRUNCATED AT 250 WORDS)