Implementation of guidelines for preventing early onset group B streptococcal infection.

Early onset Group B Streptococcus (EOGBS) disease, defined by an onset within the first 72 hours of life, occurs in 1.3 to 3.7 per 1,000 live births. The authors sought to determine the impact of the new CDC/AAP/ACOG guidelines on the prepartum screening practice, intrapartum management, incidence of EOGBS infection, and evaluation of neonates born to GBS colonized women at University Macdonald Women's Hospital (Cleveland, OH). A retrospective analysis by chart review was conducted from January 1, 1995 to December 31, 1997 of women identified as GBS colonized during prenatal screening. These women were then divided into 2 groups: period I, women who delivered January 1, 1995 to June 30, 1996 (before institutional implementation of the guidelines for management of GBS colonization]; and period II, women who delivered July 1, 1996 to December 31, 1997 after implementation of the guidelines. A chart review was conducted for infants 72 hours old, and GBS culture positive (blood or CSF) for the same time period. In complying with the new screening and treatment guidelines, there was a significant increase in the number of mothers screened and the detection of maternal colonization, plus a 63% reduction in EOGBS. There was also a substantial reduction in the number of invasive procedures on the neonates. The authors conclude that the new guidelines are both medically and economically effective.

Subclavian deep vein thrombosis associated with the use of recombinant follicle-stimulating hormone (Gonal-F) complicating mild ovarian hyperstimulation syndrome.

OBJECTIVE: To describe two cases of subclavian deep vein thrombosis (DVT) associated with the use of recombinant gonadotropins and mild ovarian hyperstimulation syndrome (OHSS) and review the literature associated with this condition. DESIGN: Retrospective study (case report). SETTING: Tertiary academic IVF program. PATIENT(S): Two women undergoing IVF with intracytoplasmic sperm injection due to male factor infertility. INTERVENTION(S): Ovaluation induction with recombinant FSH, IVF, and therapeutic heparinization. MAIN OUTCOME MEASURE(S): Coagulation studies, resolution of DVT, delivery at term. RESULT(S): Mild OHSS with left subclavian thrombosis occurred in two patients. Laboratory evaluation revealed normal protein C, protein S, antinuclear antibodies (ANA), and absence of antiphospholipid (APA) and anticardiolipin antibodies (ACA). Antithrombin III levels and coagulation studies were also within normal limits. Both patients tested negative for a factor V Leiden mutation and delivered healthy infants at term. CONCLUSION(S): Arm swelling associated with the use of gonadotropins during controlled ovarian hyperstimulation should be promptly evaluated and treated. Subclavian vein thrombosis is a rare complication of ovulation induction, and the possibility that recombinant gonadotropins increase the risk for this complication should be further studied.

Neonatal morbidity after elective repeat cesarean section and trial of labor.

OBJECTIVE: To evaluate neonatal outcomes after an elective repeat cesarean section (ERCS) compared with a trial of labor (TOL). POPULATION AND METHOD: All mothers who underwent previous cesarean section and delivered singleton infants at term gestation were identified during a 1-year period. Neonatal outcomes were compared between infants delivered by ERCS (n = 497) and those delivered by TOL (n = 492), and between infants delivered by a successful (n = 336) and a failed (n = 156) TOL. A cohort of mothers and their term infants delivered by routine vaginal delivery were also identified. RESULTS: Infants delivered by ERCS had an increased rate of transient tachypnea compared with infants born by TOL (6% vs 3%). Compared with routine vaginal deliveries, the adjusted odds ratio of developing any respiratory problem after an ERCS was 2.3 (95% confidence interval [CI]: 1.4, 3.8), and for developing transient tachypnea was 2.6 (CI: 1.5, 4.5). In addition, two infants delivered by ERCS developed respiratory distress syndrome. Infants delivered after a TOL had increased rates of suspected and proven sepsis (5% vs 2% and 1% vs 0.1%, respectively). Compared with a successful TOL, the infants delivered by cesarean section after a failed TOL had more neonatal morbidity and had a longer hospital stay (4.8 +/- 2 vs 3.1 +/- 2 days). The odds ratio for developing any respiratory illness after a failed TOL was 2.1 (95% CI: 1.1, 4.1), for suspected sepsis was 4.8 (95% CI: 2.6, 9.0), and for proven sepsis was 19.3 (95% CI: 2.0, 187). Neonatal outcomes after a successful TOL were similar to routine vaginal births. CONCLUSION: Infants born by ERCS are at increased risk for developing respiratory problems compared with those born by TOL. However, TOL is associated with increased rates of suspected and proven sepsis. This appears to be limited to infants delivered by cesarean section after a failed TOL.

Relation of maternal cocaine use to the risks of prematurity and low birth weight.

To determine whether maternal cocaine use at the time of delivery of the infant is an independent risk factor for low birth weight or prematurity, we performed a prospective anonymous urine toxicology screening study among 425 women in a large urban university-based maternity hospital. The data were subjected to univariate analysis with the Fisher Exact Test and odds ratio determination, and to multivariate analyses by logistic regression. Of 11 variables analyzed, cocaine use near delivery, no prenatal care, marijuana and cigarette use, black race, a previous preterm infant, and staff service were significantly associated with premature birth by univariate analysis. No prenatal care (odds ratio, 9.89; 95% confidence intervals, 3.74 to 26.17) and cocaine use (odds ratio, 7.31; 95% confidence intervals, 2.87 to 18.61) demonstrated the greatest risk associated with premature birth by univariate prediction. After analysis by multivariate logistic modeling, only cocaine use detected at birth remained a significant predictor of prematurity (odds ratio, 13.4; 95% confidence intervals, 1.23 to 145.0). Staff service, black race, cocaine use near the time of delivery, marijuana and cigarette use, a previous preterm infant, and no prenatal care were significant univariate predictors of low birth weight. Cocaine use (odds ratio, 4.14; 95% confidence intervals, 1.18 to 14.56) and marijuana use (odds ratio, 4.52; 95% confidence intervals, 1.42 to 14.39) were the strongest univariate factors. After analysis by multivariate logistic modeling, cocaine use near the time of delivery demonstrated the highest odds ratio (9.90) for predicting low birth weight, but the 95% confidence intervals included 1 (0.53 to 184.0). We conclude that independent of potentially interrelated covariables, a positive result on a cocaine urine toxicology test at the time of delivery is the most dominant factor that was tested to predict prematurity and possibly low birth weight. The effect of cocaine on the duration of gestation or fetal growth may be due to its pharmacologic properties, or cocaine use during pregnancy may identify a subgroup of women whose risk is due to as-yet-unidentifiable socioeconomic or cultural characteristics.

Preliminary experience with in vitro fertilization-surrogate gestational pregnancy.

This report documents the medical details and 3-year follow-up evaluation of the infertile and surrogate couples involved in the first successful in vitro fertilization gestational surrogate pregnancy and summarizes clinical experience and outcome of all patients treated to date. Results of the first 28 couples treated are presented. The pregnancy rate for 39 cycles reaching attempts at oocyte retrieval is 18%. The procedural aspects, ethical issues, legal issues, and subsequent program development are summarized. Recommendations are of a similar program. There are numerous potential pitfalls and traps for the unwary, but our experience has thus far been gratifyingly positive, and we endorse the further provision, observation, and documentation of this controversial approach to the care of the infertile couple.

In vitro fertilization (IVF)-surrogacy: application of IVF to women without functional uteri.

Women with absent or dysfunctional uteri consented to controlled ovarian stimulation, ovum aspiration, in vitro fertilization, and embryo culture. Cleaving preembryos were transferred to recipient (surrogate) women whose menstrual cycles were in approximate synchrony with the ovum donor. None of the embryo recipients received medication. Six cases are described, resulting in one spontaneous loss at 6 weeks, four full-term deliveries, and one ongoing pregnancy. HLA typing demonstrated all babies to be genotypic offspring of the gamete donors.

Dynamic incompetent cervix uteri. Sonographic observations.

In 15 of 56 patients with incompetent cervix, rapid changes in the degree of dilatation of the cervical canal were observed during sonographic examination, with the same degree of bladder distension. In ten of those 15 patients, the canal was seen to be completely closed at some point during the examination. Because of these rapid dynamic changes in the dilatation of the cervical canal, it is necessary to observe the cervical portion of the uterus several times during the sonographic examination, especially in patients suspected to have incompetent cervix. It is possible for the cervical canal to remain closed for several minutes during the examination. Incompetent cervix can go undetected if the cervix is not observed frequently throughout the sonographic examination.

Determination of the elastic properties of the cervix.

The elastance of the uterine cervix of nonpregnant women was measured by placing a 3- or 4-cm compliant balloon in the cervical canal and determining its pressure-volume characteristic while filling with up to 5 mL of sterile water at a rate of 12 mL/minute. The mean elastance for 247 patients who had previously suffered either one or more spontaneous midterm pregnancy losses, preterm birth, or three or more early spontaneous abortions was significantly lower than that of 42 controls who did not meet these criteria. Elastances were significantly lower in groups having a clinically observed patulous cervix or laceration, or a clinically diagnosed incompetent cervix, than in the normal cervix group. No significant difference was found between the follicular and luteal phases for 64 regularly cycling women. Values were significantly reduced in women showing a widened cervix on a hysterosalpingogram when compared with those with a normal-appearing cervix. When larger Hegar dilators were passed without resistance, the elastance was generally lower, although there was not always good correlation between the largest dilator passed and elastance.

Ultrasound evaluation of sutures following cervical cerclage for incompetent cervix uteri.

This prospective study was designed to determine whether it is possible to visualize cerclage suture material by ultrasound and to evaluate the clinical usefulness of ultrasound examination after cervical cerclage during pregnancy. Ultrasound examinations demonstrated suture material in all patients in this study. The 5-mm-wide Mersiline tape suture, used in the Shirodkar procedure, was easier to visualize by ultrasound than the no. 2 nylon suture used in the McDonald procedure. Ultrasound examination can be helpful in evaluating the location and effectiveness of the sutures and in detecting protrusion of the membranes beyond the sutures before it is clinically apparent. The sonographic demonstration of the relationship of the protruding membranes to the level of the sutures can be valuable in patient management.