Antimicrobial resistance in colonizing group B Streptococci before the implementation of a Swedish intrapartum antibiotic prophylaxis program.

The prevalence of antibiotic resistance and their genetic determinants in colonizing group B streptococci (GBS) sampled in a Swedish nationwide survey was examined. In five GBS isolates (1.3%), kanamycin/amikacin resistance and the presence of the aphA-3 gene was identified. Three of these isolates carried the aad-6 gene and were streptomycin-resistant. Screening with kanamycin and streptomycin 1,000-µg disks enabled a rapid and easy detection of these isolates. In all, 312/396 (79%) GBS were tetracycline-resistant and 95% of the examined isolates harbored the tetM gene. Among the 22 (5.5%) GBS resistant to erythromycin and/or clindamycin, the ermB gene was detected in nine isolates (41%) and erm(A/TR) in ten isolates (45%). A high level of erythromycin and clindamycin resistance with minimum inhibitory concentrations (MICs) >256 mg/L was found in four serotype V isolates that harbored ermB. The erythromycin/clindamycin resistance was distributed among all of the common serotypes Ia, Ib, II, III, IV, and V, but was not present in any of the 44 serotype III isolates associated to clonal complex 17. Screening for penicillin resistance with 1-µg oxacillin disks showed a homogenous population with a mean inhibition zone of 20 mm. A change in the present oxacillin breakpoints for GBS is suggested.

Manual acupuncture reduces hyperemesis gravidarum: a placebo-controlled, randomized, single-blind, crossover study.

Hyperemesis gravidarum, severe vomiting, develops in about 1-2% of all pregnancies. Acupuncture on the point PC6 above the wrist on the palmar side has been found to prevent some types of nausea and vomiting. The purpose of the present study was to see if acupuncture, in addition to standard treatment, could hasten the improvement of hyperemesis gravidarum. Thirty-three women with hyperemesis were evaluated in a randomized, single-blind, crossover comparison of two methods of acupuncture, active (deep) PC6 acupuncture or placebo (superficial) acupuncture. The women estimated their degree of nausea on a visual analogue scale (VAS). The daily number of emesis episodes were documented. Crossover analyses showed that there was a significantly faster reduction of nausea VAS and more women who stopped vomiting after active acupuncture than after placebo acupuncture. This study suggests that active PC6 acupuncture, in combination with standard treatment, could make women with hyperemesis gravidarum better faster than placebo acupuncture.

Intravenous nitroglycerin for rapid uterine relaxation.

BACKGROUND: To investigate the effect of nitroglycerin in vitro and in vivo on human uterine contractile activity. METHODS: In vitro myometrial strips were obtained from six pregnant women at term who underwent elective cesarean section. The biopsies were mounted in tissue baths. After spontaneous or oxytocin-induced activity had been accomplished, nitroglycerin in various concentrations was added to the baths and the effects were continuously registered. In vivo, in an open study nitroglycerin was administered as a bolus injection of 100-200 micrograms intravenously to 32 women at cesarean section when uterine relaxation was urgently needed; to 22 other women after vaginal delivery for facilitation of manual removal of retained placentas, and to one patient at vaginal delivery of premature twins. RESULTS: In vitro nitroglycerin induced a dose-dependent inhibition of spontaneous as well as oxytocin-induced myometrial contractile activity. Complete muscular relaxation was obtained at a concentration of 25-50 micrograms/ml. In vivo all patients had rapid effective uterine relaxation after intravenous injection of 100-200 micrograms nitroglycerin. CONCLUSION: Nitroglycerin administered intravenously seems to be a rapid and effective uterine muscle relaxant agent without overt adverse effects on mother or fetus.

Amniotic fluid interleukins in Swedish and Mozambican pregnant women.

The aim of the study was to investigate inflammatory cytokines, interleukin-1 beta (IL-1 beta), interleukin-1 receptor antagonist (IL-1ra), IL-6, IL-8 in amniotic fluid, in a cohort of Swedish pregnant women from early to late pregnancy and Mozambican late pregnant women with and without signs of histologic chorioamnionitis. Eleven Swedish women were studied from early pregnancy (week 16-17) to late pregnancy (week 37-38). Amniotic fluid was collected via amniocentesis in early pregnancy and also in late pregnancy during elective Caesarean section. From Mozambican women, amniotic fluid was harvested transmurally through the uterus wall during elective Caesarean section. Half of the group of 30 women showed histological signs of chorioamnionitis and half of the group did not show such signs. A statistical, significant increase in IL-1ra, Il-6 and IL-8 values from early to late pregnancy was seen in the Swedish pregnant women. Among the Mozambican women, no statistically significant increase in the above-mentioned interleukins was observed when comparing women with and without histological signs of chorioamnionitis. Term Swedish and Mozambican women did not show differences in cytokine levels. There were no detectable values of IL-1 beta in either Swedish or Mozambican women. IL-1ra, IL-6 and IL-8 increased in amniotic fluid from the second to the third trimester in the Swedish cohort. No correlation was found between histological chorioamnionitis and elevated cytokine levels of amniotic fluid in term pregnant women not in labour. An equally good cytokine response was found among Swedish and Mozambican third-trimester non-labouring women.

Amniotic fluid antibacterial activity and nutritional parameters in term Mozambican and Swedish pregnant women.

Randomly selected parturients with term singleton pregnancies from two different settings, 83 from Mozambique and 90 from Sweden, entered the study. All of them underwent elective cesarean section, which enabled sterile harvesting of amniotic fluid (AF). AF samples were then tested for antibacterial activity (ABA). Background data and nutritional status were compared. Average age was 32.7 and 30.7 years (n.s.), average parity 6.6 and 1.6 (p < 0.0001), average number of antenatal visits 4.9 and 11.6 (p < 0.0001), and average birthweight 3,194 and 3,688 g (p < 0.01), respectively. Body mass index, mid-upper-arm circumference and hemoglobin did not show any significant differences. The average ABA of AF was more than 50% higher in Swedish than in Mozambican specimens (p < 0.0001). Less than one-sixth of MoZambican women reached the average ABA of AF from Swedish women. Bacterial outgrowth delay equal to or above 3 h was encountered in 13% of Mozambican AF as against 61% of Swedish AF (OR 0.10; 95% CI 0.05-0.19). Histopathological examinations of the placenta, nonplacental membranes and umbilical cord showed inflammatory lesions in 29% of the Mozambican parturients and in 13% of Swedish parurients (OR 2.65; 95% 1.00-6.98). It is probable that the lower antibacterial activity in Mozambican AFs reflects an increased vulnerability to ascending genital infections during late pregnancy.

The use of intravenous nitroglycerin for emergency cervico-uterine relaxation.

A patient with a twin pregnancy was in preterm labour after 25 gestational weeks when, during vaginal delivery of the second twin, severe spasm of the cervix and fetal bradycardia ensued. Induction of general anesthesia did not relax the cervix. After bolus doses of nitroglycerin 100 + 50 micrograms i.v., prompt cervico-uterine relaxation was obtained allowing manual extraction of the baby. A short review of the literature and a summary of our experience in the administration of nitroglycerin i.v. in obstetrics are presented.

Aetiology of late fetal death in Maputo.

BACKGROUND: To study the etiology of late fetal death in Maputo. PATIENTS: Stillbirths (n = 163) in Maputo were compared to 207 live births. RESULTS: A probable cause of fetal death could be determined in 112 cases (69%). Hypertension was the most common factor associated with stillbirth and occurred in 14% of the fetal deaths, followed by abruption of the placenta (13%), syphilis (8%), clinical intra-uterine infection (6%), malaria (4%), fetal malformation (4%), umbilical cord complications (4%) and anaemia (4%). Mothers of stillborns and referent mothers differed in the following parameters: fetal weight, gestational age, numbers of previous stillbirths, haemoglobin, packed cell volume (p < 0.001), age, number of pregnancies (p < 0.01), parity, number of live children and skinfold thickness (p < 0.05). In the stillborn cases where no probable cause of fetal death was established, newborn weight was significantly lower and estimated gestational age significantly shorter (p < 0.001), number of previous pregnancies and number of previous stillbirths were significantly larger (p < 0.05) than in the referent group, but otherwise no significant differences were found. In two randomly selected sub-groups, 28 mothers with stillbirth without probable diagnoses, and in 24 referent mothers, selected serum proteins and acute-phase reactants were determined. There were no statistically significant differences in the mean values of haptoglobin, pre-albumin, retinol-binding protein and alpha 1-antitrypsin in the two subgroups. The stillbirth subgroup had significantly higher mean values of C-reactive protein and serum orosomucoid than the referent group (p < 0.01). CONCLUSION: Signs of maternal illness were present in one third of the mothers with stillbirth, and half of them required medical care. In one third there was no final diagnosis, but these mothers showed significantly higher mean values of acute phase reactants, suggesting low-grade infection.

Intrauterine infections and their association with stillbirth and preterm birth in Maputo, Mozambique.

Subclinical intrauterine infections during pregnancy in Mozambican women were studied in an attempt to elucidate their potential association with adverse pregnancy outcome, particularly stillbirth and preterm birth. A total of 39 stillbirths and 21 preterm live births were compared with 121 term live births. Extraplacental membranes and amniotic fluid were studied to ascertain the presence or absence of chorioamnionitis and of antibacterial activity in amniotic fluid. It was found that signs of maternal subclinical disease in extraplacental membranes in combination with an absence of antibacterial activity in amniotic fluid was overrepresented in stillbirths and preterm births in relation to term live births. A tentative conclusion is that a lack of antibacterial activity in amniotic fluid and established chorioamnionitis represent a vicious combination with strongly negative significance for the fetal outcome.

IgM-antibodies against T. pallidum detected in sera from mothers of stillborn babies in Mozambique by the solid-phase haemadsorption assay (SPHA).

Serum samples taken at the delivery from 27 syphilitic mothers in Mozambique, 16 with stillborn babies and 11 with healthy babies were tested upon presence of IgM antibodies against T. pallidum by the solid-phase haemadsorption assay (SPHA). Fourteen out of the 16 serum samples from mothers with stillborn babies but only one out of the 11 samples from mothers with healthy babies were found positive by the SPHA test. Clinical signs indicative of syphilis are difficult to find in the Maputo area as there were more than 40,000 annual births and only five obstetricians when the study was carried out. It is believed that the findings may indicate those mothers who were serologically positive with the SPHA test had clinically active syphilis and that syphilis might be the cause or a contributory cause of death in 14 of the stillborn babies. The SPHA test was easy to perform and we recommend its adoption by laboratories with facilities to perform the TPHA test.

PIP: Serum samples taken at delivery from 27 syphilitic mothers in Mozambique, 16 with stillborn babies and 11 with healthy babies, were tested for the presence of IgM antibodies against T. pallidum by the solid-phase hemadsorption assay (SPHA). 14 of 16 serum samples from mothers with stillborn babies but only 1 of 11 samples from mothers with healthy babies were found positive by the SPHA test. Clinical signs indicative of syphilis are difficult to find in the Maputo area, as there were more than 40,000 annual births and only 5 obstetricians when the study was conducted. It is believed that the findings may indicate that those mothers who were serologically positive with the SPHA test had clinically active syphilis and that syphilis may have been the cause or a contributory factor in the death of 14 of the stillborn babies. The SPHA test was easy to perform and the authors recommend its adoption by laboratories with facilities to perform the TPHA test.

Parity-related prevalence of rhesus antigens among Mozambican parturients.

The potential risk of rhesus alloimmunization and the ensuing risk of fetal death with increasing parity were investigated in two groups of parturients; primiparous and grand multiparous (para > or = 5) women with liveborns. It was hypothesized that significantly fewer women of the latter than of the former group would be rhesus negative, since grand multiparity would be expected to be associated with an increased risk of late fetal death in rhesus-negative parturients. Primiparous (n = 390) and grand multiparous (n = 755) parturients with liveborns were studied in order to identify D- and Du-negative individuals. Sixteen out of 390 primiparas (4.10%) and 28/755 (3.71%) grand multiparas were D and Du negative. The difference did not reach statistical significance. It appears that being a D- and Du-negative grand multiparous parturient, in the absence of anti-D prophylaxis, is not a significant reproductive disadvantage to being primipara in terms of an increased risk of having stillborn babies.

Streptococcal types in impetigo and acute glomerulonephritis among children in Addis Ababa.

Studies on the streptococcal epidemiology of impetigo in children below 12 years of age in Addis Ababa indicated that most streptococci isolated belonged to the classic serological impetigo strains. Streptococcal type 9 seemed to be a new impetigo strain. Several cases of severe acute glomerulonephritis on impetigo basis were observed during the study.