Peripheral arterial disease in HIV-infected and uninfected women.

OBJECTIVE: Although HIV infection has been associated with increased risk of subclinical atherosclerosis and cardiovascular events, peripheral arterial disease (PAD) has not been assessed in HIV-infected patients. The objective of this study was to determine the prevalence of, and risk factors for, PAD using ankle-brachial index (ABI) measurement in HIV-infected and uninfected women. METHODS: ABI was determined for 335 participants in the Women's Interagency HIV Study (WIHS). A cross-sectional analysis was conducted to determine factors associated with high (>or=1.40) ABI. RESULTS: The prevalence of low ABI (or=1.40) was 6.9% (n=23). The prevalence of low ABI was too low to allow risk factor analysis. On multivariate analysis, factors associated with high ABI were current cigarette smoking [adjusted odds ratio (OR(adj)) 2.53, 95% confidence interval (CI) 0.99-6.43], being underweight (OR(adj) 11.0, 95% CI 1.61-75.63) and being overweight (OR(adj) 5.40, 95% CI 1.13-25.89). CONCLUSIONS: Although the prevalence of ABI or=1.40 was unexpectedly high. Further studies are indicated to determine the clinical significance of high ABI and its relation to the risk of cardiovascular events in HIV-infected women.

Epidemiology and natural history of ligase chain reaction detected chlamydial and gonococcal infections.

OBJECTIVES: Ligase chain reaction (LCR) technology has dramatically increased the sensitivity of tests for sexually transmitted infections (STIs). It is unknown whether low copy infections (LCR positive, culture negative) have any clinical consequences. We assessed the clinical significance of untreated low copy Chlamydia trachomatis and Neisseria gonorrhoeae infections in a cohort of sexually active women. METHODS: We studied a cohort of sexually active women followed at 6 month intervals for up to 3 years. Frozen urine specimens from 181 women with negative cultures for C. trachomatis and N. gonorrhoeae who were 'high risk' (defined as being less than 40 years old at baseline, and having either Trichomonas vaginalis at baseline or a history of more than one sexual partner during the 12 months before baseline) were tested for C. trachomatis and N. gonorrhoeae by LCR (Abbott Laboratories, Abbott Park, IL, USA). The specimens from all visits for each person were pooled and LCR was performed on the pool. Laboratory results were linked to clinical information. We also tested all urine samples obtained from patients with a positive culture. RESULTS: 10 additional infections (nine C. trachomatis and one N. gonorrhoeae) were detected with LCR technique. None of the women with low copy infection had evidence of subsequent pelvic inflammatory disease or ectopic pregnancy. Pooling of urine samples resulted in a 47% decline in the number of tests performed. CONCLUSIONS: Additional STIs can be identified when using LCR. Pooling of urine specimens is a cost saving technique for C. trachomatis and N. gonorrhoeae testing.

Acute bowel perforation in a fetus with gastroschisis.

Gastroschisis is a congenital anomaly with a reported incidence of 1 in 10,000 live births. Although prenatal diagnosis is more common with the widespread use of biochemical markers and obstetric ultrasound, the role of ultrasound in the identification of the fetus that might need early intervention has not been established. Acute bowel perforation was diagnosed by ultrasound at 34 weeks gestation in a fetus with gastroschisis. An immediate Cesarean section was performed, followed by repair with primary closure. The neonatal outcome was favorable. The post-partum findings, including bowel pathology, confirmed the antenatal diagnosis. Acute bowel perforation can be diagnosed antenatally. Immediate intervention, before further bowel injury occurs, might enhance the ability of the surgeon to perform primary closure and obtain a favorable outcome.

Predictors and risk-taking consequences of drug use among HIV-infected women.

OBJECTIVE: To determine rates of drug use among women with HIV, and to examine associations between drug use, health, risk behavior, and sexually transmitted diseases (STD). DESIGN: A longitudinal cohort study of 260 women with confirmed HIV-positive serostatus. METHODS: Each participant contributed a self-report interview, a clinical examination, laboratory testing of cultures for Trichomonas vaginalis, Chlamydia trachomatis, Neisseria gonorrhoeae, and urinalysis for the presence of metabolites of cocaine and opiates. Data were examined on 140 women at 1-year follow-up. Women were defined as drug users if they reported crack, cocaine, or heroin use in the 6 months before the interview or if they had a positive toxicologic test result for cocaine or opiates. RESULTS: 34% of those in the sample were classified as positive for drug use. Drug use was associated with the number of sexual partners, age at first intercourse, prevalence of STDs, and lower quality of life. STDs were present at baseline in 33.7% and 15.5% of drug users and nonusers, respectively. Drug use among this population was also associated at both baseline and follow-up with the likelihood of having a Karnofsky score below 80, and with overall perceived general health. CONCLUSIONS: Drug users in this cohort were more likely to engage in behaviors that place them at risk for STDs, to have elevated STD prevalence, and to have lower perceived health across several indices. Identification of drug use and treatment for it need to be a central component of HIV care for women.

Prevalence and incidence of gynecologic disorders among women infected with human immunodeficiency virus.

OBJECTIVE: Our purpose was to ascertain the prevalence, incidence, and predictors of gynecologic disorders among women infected with human immunodeficiency virus. STUDY DESIGN: We serially assessed 292 women infected with human immunodeficiency virus and 681 uninfected women. Outcomes were incidence and prevalence of sexually transmitted diseases, viral shedding, findings of Papanicolaou smears, fungal infections, and menstrual disorders. RESULTS: Women infected with the virus were more likely to have prevalent vulvovaginal candidiasis (odds ratio 1.80, 95% confidence interval 1. 0-3.25, P =.05), oncogenic human papillomavirus (odds ratio 3.79, 95% confidence interval 2.43-5.91, P =.001), abnormal Papanicolaou smears (odds ratio 5.40, 95% confidence interval 3.35-8.78, P =.001), amenorrhea (4.8% vs 0%, P =.05), positive results on Treponema pallidum hemagglutination assay (odds ratio 1.83, 95% confidence interval 1.16-2.88, P =.01), infection with cytomegalovirus (odds ratio 4.2, 95% confidence interval 1.82-10.62, P =.001), and genital warts (odds ratio 6.93, 95% confidence interval 3.16-16.30, P =.001) but were less likely to have Chlamydia trachomatis infection (odds ratio 0.28, 95% confidence interval 0.10-0.66, P =.01). Annual incidence rates among women infected with human immunodeficiency virus were 4.0% for candidiasis, 22.0% for oncogenic human papillomavirus, 11.4% for genital warts, 1.7% for infection with C trachomatis, 1.7% for infection with Neisseria gonorrhoeae, 10.3% for Trichomonas vaginalis, 1.1% for positive results on T pallidum hemagglutination assay, 7.4% for an abnormal Papanicolaou smear, and 10.9% for infection with herpes simplex virus. Overall, 46.9% had at least 1 incident condition. Women infected with human immunodeficiency virus were more likely to have incident oncogenic human papillomavirus infection (odds ratio 2.0, 95% confidence interval 1.01-3.8), abnormal Papanicolaou smears (odds ratio 7.76, 95% confidence interval 2.08-42.8), and genital warts (odds ratio 9. 32, 95% confidence interval 3.04-38.0). Incidence and prevalence of sexually transmitted diseases and oncogenic human papillomavirus infection increased with increased CD4(+) cell counts. CONCLUSIONS: Women infected with the human immunodeficiency virus are significantly more likely to have prevalent and incident gynecologic disorders but not disorders related to risk taking (eg, incident sexually transmitted diseases). The latter disorders increased in women with CD4(+) cell counts >500 cells/mm3. Clinicians should be aware of these patterns so that they can provide appropriate evaluation and treatment of gynecologic disorders.

Human immunodeficiency virus infection in pregnancy.

The pace at which our knowledge and treatment of the human immunodeficiency virus (HIV) has advanced has been staggering. A disease that was unknown two decades ago, that was untreatable only a decade ago, and whose rate of mother-to-child transmission was immutable just 5 years ago, is now readily diagnosed, treated with increasing effectiveness, and blocked from transmission in the large majority of cases. None of these advances can be provided to patients unless their physicians actively screen patients and, for those identified as HIV infected, assure them of access to the latest therapies. This article is a primer for those obstetricians who would engage in such efforts. The data that form the basis of therapy are provided as well as clinical guidelines for the care of the pregnant woman infected with HIV.

Hepatitis C virus infection in the mothers and infants cohort study.

OBJECTIVES: To estimate the hepatitis C virus (HCV) vertical transmission rate, the effect of potential risk factors, and the pattern of HCV antibody response and viremia in HCV-infected infants. STUDY DESIGN: The Mothers and Infants Cohort Study enrolled both human immunodeficiency virus (HIV)-seropositive and HIV-seronegative pregnant women at five obstetric clinics in New York City in a prospective cohort study between January 1986 and January 1991. HCV-infected mothers and their 122 offspring were followed-up for a minimum of 12 months for evidence of HCV infection as determined by persistent HCV antibodies or detection of HCV RNA by reverse transcription polymerase chain reaction. Comparisons among groups for categorical variables were performed using the Fisher's exact test. RESULTS: Seven (6%; 95% confidence interval, 2%-11%) of the 122 infants were HCV-infected. There was a tendency for increased risk of transmission with maternal viral and obstetrical factors, such as coinfection with HIV (7% vs 4%), high HIV viral load (13% vs 6%), HCV viremia (8% vs 3%), vaginal delivery (6% vs 0%), and female gender of offspring (8% vs 3%), although none of the associations reached statistical significance. After loss of maternal antibody, HCV antibody seroconversion occurred at a mean age of 26 months in 3 HIV-coinfected infants compared with 7 months of age in 4 HCV-infected HIV-uninfected infants. Serial samples showed that HCV RNA persisted in 6 infants for at least 18 to 54 months. CONCLUSIONS: Our study is in accordance with other studies that have shown low overall HCV vertical transmission risk and a trend toward higher risk with maternal risk factors such as HIV-coinfection or HCV viremia. A delay in infant HCV antibody response may be associated with HIV coinfection although larger studies are needed to confirm these findings.

Neurobehavioral and pregnancy effects of prenatal zidovudine exposure in Sprague-Dawley rats: preliminary findings.

In 1994, the Public Health Service made prenatal zidovudine (ZDV, AZT) the standard of care to prevent mother-to-child transmission of HIV. The current study was undertaken to determine if prenatal exposure to ZDV has an impact on pregnancy outcomes, birth anomalies, or offspring behavior in an animal model using Sprague-Dawley (SD) rats. Thirty-one virgin female SD rats were mated and randomly assigned to receive either ZDV at 150 mg/kg/day or vehicle via gastric intubation for 22 days starting on gestation day (G) 1. On G 22, teratologic examination of 12 litters showed no gross structural malformations. There were no significant differences between the groups for maternal food and water consumption or maternal weight gain across pregnancy. However, ZDV treatment significantly reduced litter size and increased birth weights for both male and female pups. One developmental milestone, pinna detachment, occurred significantly earlier in the ZDV-exposed male pups compared to the vehicle-intubated male controls. On day 21-22 of life, pups in each litter were injected with one of four doses of amphetamine and were observed for behavioral activity in a photobeam-based activity monitor for 1 h. Overall amphetamine increased activity and decreased thigmotaxis or wall-hugging behavior. ZDV treatment increased the locomotor response to amphetamine in females only and dampened the action of amphetamine to decrease thigmotaxis in both genders. Further studies are warranted to determine the threshold dose at which these changes occur, the duration of the effects, as well as the neurochemical system(s) responsible for the altered amphetamine responses.

An association between the heat-humidity index and preterm labor and delivery: a preliminary analysis.

OBJECTIVES: The goal of this study was to determine whether a relationship exists between heat-humidity indexes and rates of preterm labor and preterm delivery. METHODS: Preterm labor and delivery rates were compared during the 2 summer and 2 winter weeks with the highest and lowest heat-humidity indexes for each season. RESULTS: The rate of preterm labor increased consistently from 1.23% to 3.00% as the heat-humidity index rose. When preterm births were examined, the trend was similar but not statistically significant. CONCLUSIONS: Given the public health import of preterm labor and the frequency with which pregnant women may be exposed to extremes of heat, studies designed to confirm or refuse our preliminary observations are warranted.

Antiretroviral therapy in the pregnant woman.

The use of antiretroviral agents to treat patients infected with HIV has become increasingly complex. Obstetricians caring for the pregnant woman infected with HIV must, no less than the HIV specialist, be familiar with the various medications now available. This article profiles each of the antiretroviral agents currently available, with a focus on issues relevant to the pregnant patient. Strategies for treating the nonpregnant patient and considerations for the use of these strategies in pregnancy also are discussed. Additional information about prophylaxis for common opportunistic infections is included.

Changes in perinatal cocaine use in an inner-city hospital, 1988 to 1992.

Temporal trends in perinatal drug use among parturients at an inner-city hospital were assessed in a cohort study of 1300 parturients in 1991 through 1992 and 1111 parturients in 1988 through 1989. Toxicology results were coupled to data sheets containing demographic and obstetrical information. A decrease was noted between 1988 and 1992 in the prevalence of cocaine metabolites, independent of the utilization of prenatal services. An increase in marijuana use and no change in opiate use were seen. When adjusted for ethnicity and receipt of care, a 50% decline in the odds ratio (OR) of cocaine use was noted between 1988 and 1992 (OR = 0.55; 95% confidence interval = 0.39, 0.79).

The effect of recent cocaine use on the progress of labor.

OBJECTIVE: This study was undertaken to determine whether peripartum cocaine use shortens labor. STUDY DESIGN: A total of 1220 gravidas delivering at an urban county hospital (November 1991 through April 1992) had urine specimens sent for toxicology studies. Cervical dilatation on admission and time intervals during the course of labor were recorded. Analysis of covariance and exact tests for multiple contingency tables were used to compare duration of labor by cocaine use after we adjusted for other factors. RESULTS: Compared with nonusers, women who had positive test results for cocaine were older, were of greater parity, and were admitted to the hospital at greater cervical dilatation (4.63 cm vs 3.96 cm, p < 0.05). The duration of labor from admission to birth was also shorter (336 vs 565 minutes, p < 0.001). After we controlled for type of delivery, parity, birth weight, and prenatal care, there was no significant difference in labor duration in any stage. CONCLUSIONS: There is no difference in duration of any stage of labor related to cocaine use after patients' obstetric characteristics are controlled for.

Resurgence of active tuberculosis among pregnant women.

OBJECTIVE: To determine the frequency of active tuberculosis during pregnancy in two hospitals located in an area where tuberculosis is epidemic and to describe its course and association with human immunodeficiency virus (HIV) infection. METHODS: We reviewed and analyzed the medical records of 16 pregnant women diagnosed with tuberculosis between 1985-1992 at Kings County Hospital (n = 12) and Saint Vincent's Hospital (n = 4) in New York City. RESULTS: Ten of the 16 pregnant women with proven active tuberculosis had pulmonary tuberculosis, two had tuberculous meningitis, and one each had mediastinal, renal, gastrointestinal, and pleural tuberculosis. Eleven were tested for HIV, and seven were seropositive. One HIV-infected patient with pulmonary tuberculosis died of respiratory failure. In the 6 years between 1985-1990, five cases of active tuberculosis during pregnancy were identified (12.4 per 100,000 deliveries). During the 2 years of 1991-1992, 11 cases were recorded (94.8 per 100,000 deliveries). CONCLUSION: Cases of active tuberculosis are increasing among pregnant women in epidemic communities and are associated with HIV infection. Early tuberculin skin test screening with appropriate preventive therapy should reduce morbidity due to tuberculosis in HIV-infected women of reproductive age. Identification of pregnant women with tuberculosis requires a high index of suspicion.

The impact of human immunodeficiency virus serostatus on reproductive decisions of women.

Each year in the United States, several thousand women infected with the human immunodeficiency virus (HIV) become pregnant. The scope of the pediatric HIV epidemic will be determined by the reproductive decisions of these women. Although initial studies have not documented an effect of serostatus on reproductive choice, these studies have been limited to single-risk groups (eg, drug users) and have had small numbers of participants. We studied 108 HIV-seronegative women and 98 seropositive women through an index pregnancy and for an average of 1.5 years postpartum. Thirty-four of the seronegative women (31%) and 32 of the seropositive women (33%) learned their serostatus early enough in pregnancy to have the option to undergo abortion. One of the 34 seronegative women (2.9%) and six of the 32 seropositive women (18.8%) chose abortion (P less than .05). During follow-up, we found no significant differences in the numbers of pregnancies or live births between seropositive and seronegative women, or between drug-using and non-drug-using women. Among those who developed AIDS (N = 10), no live births occurred during followup. Although positive HIV status did correlate with the decision to terminate pregnancies, it did not correlate with subsequent fertility.

Predictors of cocaine use in pregnancy.

Several hundred thousand infants are exposed to cocaine in utero every year in the United States. In an attempt to provide services for women abusing drugs, various programs have been proposed for prenatal drug testing. This study was conducted to assess the sensitivity, specificity, and predictive values of screening programs based on a variety of clinical and historical factors. Between October 1988 and March 1989, 1111 parturients who delivered at an inner-city hospital had urine samples and data collected. The urine, linked by code number to the data, which contained no identifiers, was tested anonymously for illicit drugs. We then assessed the associations of a variety of historical and clinical variables with positive toxicologies. An acknowledged history of drug use or a combination of no prenatal care and cigarette use provided the most valid prediction of cocaine use, with a 59.8% sensitivity, 97.5% specificity, 70% positive predictive value, and 94.9% negative predictive value for positive urine toxicologic examinations. The addition of clinical data such as low birth weight did not improve predictive values significantly. Although the use of easily available historical data allowed correct identification of 60% of parturients who used cocaine, no combination of factors could detect all users. If it is considered beneficial to identify all users at a given point, then urine toxicology screening would be more appropriate than sole reliance on patient history.

Foot necrosis in a surviving fetus associated with twin-twin transfusion syndrome and monochorionic placenta.

Twin gestations with diamniotic monochorionic placentas have increased perinatal morbidity. We report a case in which, following the death of one member of a set of twins, absent end-diastolic flow was noted. At delivery, we noted thrombosis of placental vessels and vascular connections between the placental vessels of the larger and the smaller twins. The surviving twin was also noted to have necrosis of the right foot, consistent with a thromboembolic phenomenon.