Prevalence and clinical significance of postpartum endometritis and wound infection.

OBJECTIVE: To correlate clinical variables (gestational age, severe pregnancy-induced hypertension, gestational diabetes mellitus, history of previous cesarean sections, fetal distress, perinatal mortality, postpartum anemia, Apgar score < or = 3 at 1 minute and < or = 7 at 5 minutes, and instrumental delivery) with postpartum endometritis (PPE) and wound infection. METHODS: Descriptive cross-sectional study of the outcome of 75,947 term and preterm singleton deliveries; vaginally and by cesarean section from 1989-1997. RESULTS: The prevalence of PPE after vaginal deliveries was 0.17% (120/68,273). Gestational age of less than 37 weeks, severe pregnancy-induced hypertension, fetal distress, instrumental deliveries, neonatal mortality, postpartum anemia, and Apgar scores of < 7 after 5 minutes were significantly associated with PPE. Gestational diabetes and an Apgar score of < 3 after 1 minute showed similar frequency with and without PPE. The prevalence of PPE after cesarean section was 2.63% (202/7,677). Preterm cesarean sections, history of previous cesarean sections, anemia, and low Apgar scores were seen more frequently with PPE than without. The incidence of cesarean delivery with gestational diabetes mellitus, fetal distress, and perinatal mortality was similar in presence and absence of PPE. The rate of wound infection after cesarean section was 3.97% (318/7,995). Gestational diabetes mellitus, history of previous cesarean deliveries, and low Apgar scores were significantly more frequent with than without wound infection. Gestational age, severe pregnancy-induced hypertension, fetal distress, perinatal mortality, and postpartum anemia were not associated with wound infection. CONCLUSIONS: Awareness of the aforementioned associations may prevent and shorten hospital stay by early diagnosis and appropriate treatment.

The relationship between hormones and human parturition.

The objective of the present review was to give an overview of some hormonal fluctuations observed in the setting of human term and preterm parturition. Prolactin, cortisol, estrogen, progesterone, and some of their precursors such as dehydroepiandrosterone sulfate (DHEA-S) were reviewed. Statistically significant differences were found when comparing cortisol, 17 beta-estradiol, and DHEA-S concentrations at term parturition between women in labor and those not in labor. In preterm labor, higher concentrations of cortisol, 17 beta-estradiol, and DHEA-S were found at labor than in women who after successful treatment delivered at term. No significant changes were seen in prolactin concentrations between women in labor and those not in labor, but they were higher in patients with preterm labor when compared to term labor. Progesterone concentrations showed no difference in preterm labor and term labor. However, maternal progesterone/17 beta-estradiol ratios were significantly lower in women delivered prematurely than in those delivered at term. The changes in hormonal ratios may play a more important role than changes in their absolute concentrations. Based on these observations, it seems that preterm and term parturition are two different endocrinological processes.

Meconium stained amniotic fluid in very low risk pregnancies at term gestation.

OBJECTIVE: To determine the prevalence and clinical significance of meconium stained amniotic fluid (MSAF) in a low risk population at term gestation and to investigate whether MSAF is a predictor for intrapartum and neonatal morbidity. METHODS: A very low risk population including 37 085 consecutive deliveries at term composed the study population. A cross-sectional study was conducted and two groups of patients were identified according to the presence (n=6164) or absence (n=30921) of meconium in the amniotic fluid at delivery and the outcomes of the two groups compared. RESULTS: The prevalence of MSAF was 16.6%. The incidence of cesarean section (5.6% vs 2.3% P<0.01), instrumental deliveries (3.2% vs 1.8% P<0.01), fetal distress (6.5% vs. 2.1% P<0.01), clinical chorioamnionitis (0.2% vs. 0.1% P<0.01), post-partum infection (0.5% vs. 0.2% P<0.01), 1-minute Apgar score <3 (1.9% vs. 1.1% P<0.01), small for gestational age (7.4% vs. 6.4% P<0.01). was significantly higher in the MSAF compared with the clear amniotic fluid group. Intrapartum and neonatal mortality in this low risk population was significantly higher in the MSAF group (1.7/1000) compared with women with clear AF (0.3/1000). CONCLUSIONS: MSAF in a low risk population at term gestation is a predictor for adverse perinatal outcome and peripartum complications.

A review of the role of trials of the use of antibiotics in women with preterm labor and intact membranes.

This updated review addresses the administration of antibiotics in women presenting with preterm labor and intact membranes as well as with bacterial vaginosis. 11 randomized controlled trials dealing with this question have been published since 1986. The results are disappointing. The probable reasons are the small number of patients in the different studies and universal use of antibiotics without performing amniocentesis to isolate the organisms involved.

A review of randomized clinical trials of antibiotic therapy in preterm premature rupture of the membranes.

Rupture of membranes before 37 completed weeks of gestation, and before the onset of contractions occurs among 2-3% of pregnancies, and in about 30%-40% of women who deliver preterm. It is known as preterm premature rupture of membranes (PPROM) and is associated with maternal and neonatal morbidity. It has been postulated that antibiotic therapy may significantly decrease the complications associated with infection. The aim of the present review is to summarize the available data about the value of antibiotic therapy in PPROM.

The role of antibiotic therapy in the prevention of prematurity.

Prematurity is the leading cause of perinatal morbidity and mortality in the industrial world, occurring in 4% to 9% of all deliveries, a rate that has remained unchanged during the past decades. Despite the relative minority of obstetric patients affected by this problem, prematurity is responsible for approximately 70% to 80% of perinatal morbidity and mortality corrected for congenital anomalies. To date, treatment modalities (tocolysis) that have been applied to patients who have preterm labor (PTL) and preterm premature rupture of membranes have been found to be of limited value in reducing both the rate of prematurity and of perinatal mortality and morbidity. A possible explanation for this failure in prevention of prematurity can be attributed to the poor understanding of the mechanisms of parturition in general and the pathophysiology of PTL in particular.

Association of recurrent vaginal candidiasis and secretory ABO and Lewis phenotype.

The relationship between ABO-Le secretor phenotype and susceptibility to recurrent idiopathic vulvovaginal candidiasis (RVVC) was investigated. ABO and Lewis blood typing was done for 38 women with RVVC (case-patients) and for women in 2 control groups, consisting of 58 healthy women, who were friends identified by case-patients, and 38 race-matched, healthy hospital employees. The 3 groups were similar with regard to age and race. There was no difference in the distribution of ABO phenotype between case-patients and controls. Case-patients were more likely than members of either control group to have Le(a+ b-) (nonsecretor) rather than Le(a- b+) (secretor) blood type. With combined nonsecretor Le(a+ b-) phenotype and absence of the Lewis gene Le(a- b-), the relative risk of chronic recurring vulvovaginal candidiasis was 2.41-4.39, depending on the analysis technique and control group. In conclusion, there is an increased frequency of ABO-Le nonsecretor status among women with RVVC.

Treatment of Torulopsis glabrata vaginitis: retrospective review of boric acid therapy.

The charts of all patients who were seen at a vaginitis clinic between January 1989 and December 1994 were retrospectively reviewed; 80 patients whose vaginal cultures yielded Torulopsis glabrata were identified. Sixty of these patients experienced 75 symptomatic episodes of vaginitis attributed to T. glabrata, and these patients are the subject of this review. Of the 60 symptomatic patients, 40 had uncomplicated T. glabrata infection, and 20 had mixed infection, most commonly in association with bacterial vaginosis. Evaluation of treatment of T. glabrata vaginitis with vaginal boric acid (600 mg/d for 14 days) revealed clinical improvement or cure in 21 (81%) of 26 episodes and mycological eradication in 20 (77%) of 26 episodes. One-third of the patients received maintenance therapy with boric acid. The clinical response and mycological eradication rates associated with therapy with topical and systemic azoles were <50%. The rate of therapeutic response to boric acid administered to patients with mixed T. glabrata infection remained high. In conclusion, in this series of patients with T. glabrata vaginitis, for whom repeated courses of antimycotic therapy with azoles had previously failed, boric acid emerged as a promising modality of therapy.

The relationship between bacterial vaginosis and preterm birth. A review.

Bacterial vaginosis is currently the most prevalent form of vaginal infection of reproductive age women. The etiology of bacterial vaginosis has not yet been defined. However, clear criteria for diagnosis and treatment have been established in the absence as well as in presence of pregnancy. Recent data show an association between bacterial vaginosis and preterm labor and delivery. This review outlines the role of bacterial vaginosis in preterm birth and other pregnancy complications.

Recurrent vulvovaginal candidiasis associated with long-term tamoxifen treatment in postmenopausal women.

BACKGROUND: Symptomatic vulvovaginal candidiasis is rare in postmenopausal subjects because of the estrogen-dependence of this infection. Tamoxifen, a breast-cancer cell estrogen-antagonist, has not previously been reported to predispose to vulvovaginal candidiasis. CASES: Three postmenopausal women, age range 60-81 years (mean 71), were identified with recurrent vulvovaginal candidiasis. In all three cases, new onset of recurrent vulvovaginal candidiasis followed daily tamoxifen therapy. The duration of prior tamoxifen therapy was 1-7 years (mean 3.5). One patient had diabetes mellitus, an additional risk factor for vulvovaginal candidiasis. In all three patients, Candida glabrata was identified as the causal pathogen, although in two patients symptomatic episodes caused by Candida albicans also occurred. In all cases, diagnosis was easily established using conventional investigations, and eradication of vulvovaginal candidiasis was possible without cessation of tamoxifen. CONCLUSION: Long-term tamoxifen treatment may be complicated by recurrent vulvovaginal candidiasis in postmenopausal women.

Vaginal microbiology of women with acute recurrent vulvovaginal candidiasis.

Alterations in the autochthonous vaginal microflora can predispose women to recurring attacks of Candida vaginitis. Quantitative aerobic and anaerobic cultures were obtained from 24 premenopausal women with acute recurrent vulvovaginal candidiasis and from 21 healthy asymptomatic premenopausal women. Lactobacillus species constituted the predominant flora in both groups, with a mean log10 CFU/ml of 8.7, a total isolation rate of 96%, and a mean of 1.6 Lactobacillus species isolated per patient compared with a mean log10 CFU/ml of 8.9, a total isolation rate of 90%, and a mean of 1.2 Lactobacillus species isolated per patient in the vaginitis and control groups, respectively. The results of this small study failed to provide evidence of an altered or abnormal vaginal bacterial flora in women with non-antibiotic-induced recurrent vulvovaginal candidiasis suffering from acute Candida vaginitis.

Vulvar vestibulitis subjects undergoing surgical intervention: a descriptive analysis and histopathological correlates.

OBJECTIVE: We describe here a series of selected patients from an established vaginitis research clinic diagnosed with vulvovestibulitis (VV) who underwent surgical intervention for focal disease. Long-term results of surgical correction are reported and characteristic histopathology findings associated with vulvar vestibulitis are emphasized. STUDY DESIGN: A retrospective chart review was carried out to extract relevant clinical, histologic, and outcome data. Tissue blocks of resected specimens were re-examined for specific inflammatory response. RESULTS: Complete data and long-term follow up were available in 16 patients who underwent surgical intervention. All were cared for by the same practitioner (CM). The mean (+/- S.D.) age and gravidity on presentation were 26.9 +/- 5.3 years and 0.9 +/- 1.5, respectively. All but one was caucasian, and 70% were nulliparous. Symptoms included entry dyspareunia (100%), discharge (70%), burning (66%), itching (20%) and other (30%). All patients had focal tenderness; other findings were erythema (50%), acetowhite staining (80%), edema (20%), micropapules (20%) and condyloma (10%). After diagnosis, initial duration of conservative management was 9.4 +/- 6.9 months (1-26 months). No patients received interferon therapy. Because of persistent symptoms the 16 subjects underwent targeted partial perineoplasties. Initial histopathology results revealed chronic inflammation, parakeratosis, hyperkeratosis, edema, koilocytosis and acanthosis. When tissue blocks were cut and stained with Giemsa, large numbers of mast cells were identified. Mean postoperative follow up was 42.0 +/- 22.4 months (10-70 months). Follow up after surgery showed an overall improvement in 15/16 patients (93.8%). CONCLUSIONS: VV affects primarily white, nulliparous women. In the carefully selected subject, surgical intervention has a high success rate, even on long-term follow up. Although the exact etiology for this condition has yet to be elucidated, the presence of mast cells supports an association with other genitourinary inflammatory syndromes such as interstitial cystitis; and allows for speculation about a possible role played by mast cell activation in the etiology of VV.

Maternal plasma and amniotic fluid cortisol and progesterone concentrations between women with and without term labor. A comparison.

OBJECTIVE: The purpose of the present study was to determine the amniotic fluid and maternal plasma concentrations of cortisol and progesterone in nonlaboring women at term and to compare them to those in women with active labor at term. STUDY DESIGN: A prospective, cross-sectional study. Soroka Medical Center of Kupat Holim, Faculty of Health Sciences, Ben-Gurion University of the Negro, Beer-Sheva, Israel. Thirty-five healthy women with normal term pregnancies were classified according to labor status into two groups: group A (16 women with spontaneous, active labor at term) and group B (19 women not in labor). RESULTS: We found a significant increase in the median concentration of plasma cortisol in women at term in active labor in comparison to those not in labor. In addition, the median concentration of cortisol in amniotic fluid in women in labor was also significantly higher than that in women not in labor. In contrast, no significant changes in median maternal plasma or amniotic fluid progesterone concentrations were detected between the groups. CONCLUSION: Human parturition is associated with a significant increase in the concentration of cortisol in both maternal plasma and amniotic fluid. These findings suggest that cortisol plays an important but still-undetermined role in human parturition.

Prolactin concentrations in preterm and term pregnancy and labour.

Maternal plasma and amniotic fluid (AF) were obtained for measurement of prolactin concentrations from: 1) 20 patients with preterm labor and intact membranes who delivered within one week of amniocentesis; 2) 20 patients with preterm labor who responded to tocolysis and delivered at term; 3) 20 women at term who were not in labor and 4) from 20 women in active labor at term. No significant differences were found between: 1) maternal plasma prolactin concentrations in women with preterm labor who delivered prematurely and those who delivered at term (155 ng/ml vs 176.5 ng/ml); 2) patients at term who were not in labor (188 ng/ml) and those who were in labor (155 ng/ml); 3) AF prolactin concentrations in the two preterm labor groups (1987.5 vs 1282.5 ng/ml) and 4) AF prolactin concentration in the two term groups (562 ng/ml vs 701 ng/ml). Prolactin concentrations were generally significantly higher preterm than at term. We concluded that no significant changes in maternal plasma and amniotic fluid prolactin levels were found in preterm and term parturition.

Comparative study of intravaginal metronidazole and triple-sulfa therapy for bacterial vaginosis.

OBJECTIVE: We sought to compare the efficacy of metronidazole gel vs. triple-sulfa cream in the treatment of bacterial vaginosis (BV). METHODS: In a double-blinded study, 247 women with symptomatic BV were randomly assigned to receive either 5 g of 0.75% metronidazole gel twice daily for 5 days or triple-sulfa cream twice daily for 5 days. There were 205 (96 treated with metronidazole and 109 treated with triple-sulfa) evaluable patients to compare efficacy at the final visit. Approximately 60% of these patients had been previously treated for BV, reflecting the recurrent nature of the disease in this patient population. RESULTS: At the first (12-16 days) return visit, 81/103 (79%) patients in the metronidazole group were cured compared with 80/113 (71%) patients in the triple-sulfa cream group (P = 0.333). At the final (28-35 days) return visit, 63/96 (66%) in the 96 metronidazole group remained cured compared with only 51/109 (47%) in the triple-sulfa group (P = 0.02). An intent-to-treat analysis similarly showed that the cure rate with metronidazole was superior to triple-sulfa (P < or = 0.02). The clinical diagnosis demonstrated a high correlation (88%) with the diagnosis made by an independent assessment by Gram's stain. The side effects reported by the patients using metronidazole gel were infrequent and mild and were similar to those reported with triple-sulfa. CONCLUSIONS: Metronidazole gel is a safe, effective, and well-tolerated treatment for BV.