In utero progression of mild fetal ventriculomegaly.

OBJECTIVE: To evaluate the progression in utero of mild isolated fetal ventriculomegaly (defined as a transverse diameter of the atrium of the lateral ventricle measuring between 10 and 15 mm), and to estimate the proportion of fetuses that normalize (diameter decreasing to less than 10mm), stabilize (remaining between 10 and 15 mm), or progress to more severe ventriculomegaly (becoming greater than 15 mm). METHODS: The obstetric databases of 3 institutions were queried for any studies mentioning ventriculomegaly or hydrocephalus. Reports and original images were reviewed to verify cases of isolated mild ventriculomegaly, with no other anomalies on comprehensive ultrasonographic examination. Fetuses that had 2 or more evaluations more than 3 weeks apart were included. RESULTS: A total of 63 fetuses met the criteria for isolated mild ventriculomegaly. The mean gestational age and ventricular measurements were 24.7+/-3.7 weeks and 11.8+/-1.1mm, respectively, at the initial scan and 34+/-2.9 weeks and 12.1 +/-3.8mm, respectively, at the final scan. The mean number of scans was 3.75 per fetus (range, 2-6). Amniocentesis revealed the deletion of 5p, which causes the cri du chat, in 1 of 21 fetuses; 26 fetuses (41%) showed normalization of the lateral ventricles; 10 fetuses (16%) showed progression; and 27 (43%) appeared stable. shows the statistics of the individual groups. Three of the fetuses that "stabilized" improved from 15 mm to 11, 11.5, and 11.7 mm, respectively. Two worsened from 10.2 to 14 mm and from 11.4 to 13 mm. CONCLUSIONS: More than 40% of the cases of mild isolated fetal ventriculomegaly resolved in utero. The significant overlap in measurements for the different groups precludes prediction in individual cases. However, of the 13 cases where the transverse diameter measured 13 mm or more, only 1 normalized, while 9 of the remaining 12 cases stabilized and 3 progressed.

Preventable risk factors for the delivery of very low birth weight infants in Richmond, Virginia.

Our aim was to identify preventable risk factors for very low birth weight (VLBW) in our urban patient population in order to target intervention programs toward those areas. Retrospective chart review was performed on all patients who delivered VLBW infants between March 1, 1995 and February 28, 1996 at the Medical College of Virginia Hospitals. VLBW patients were then compared with mothers who delivered infants >1,500 g during the same period. Chi-square and Fisher's exact test were used for statistical analysis. P value <.05 was considered significant. Of the 77 study patients identified as having delivered VLBW infants, 42% had a preventable risk factor for VLBW. 31% were smokers, 14% were cocaine users, and 10% had no prenatal care. Cigarette smoking and substance abuse are major preventable risk factors for VLBW in our patient population. Efforts to reduce VLBW in our community should focus on reducing tobacco and illicit substance use.

Increased circulating lipid peroxides in severe preeclampsia activate NF-kappaB and upregulate ICAM-1 in vascular endothelial cells.

Preeclampsia is a systemic disease of pregnancy characterized by maternal hypertension, proteinuria, and edema. These clinical pathological findings may be attributed to abnormalities in vascular endothelial activation secondary to increased oxidative stress. To test the hypothesis that increased circulating lipid peroxides in preeclamptic women activate vascular endothelial cells, we determined NF-kappaB transcriptional activity and ICAM-1 expression in human umbilical vein endothelial cells (HUVEC) cultured with plasma from women with severe preeclampsia (preeclamptic plasma, N = 12) or plasma from normal pregnancies (normal plasma, N = 12). Preeclamptic women had increased circulating lipid peroxides compared with normal pregnant women, as demonstrated by a 4.5-fold higher concentration of plasma malondialdehyde (PkB luciferase reporter construct transfected into HUVEC, preeclamptic plasma was found to up-regulate HUVEC NF-kappaB activity by 2.5-fold when compared with normal plasma (PkB activation in response to preeclamptic-plasma by 77% (PkB activation and ICAM-1 expression on HUVEC, which can be inhibited by vitamin E and N-acetyl-cysteine.

Hepatitis C in pregnancy.

In epidemiologic studies done primarily in Europe and in the United States, antibody to hepatitis C has been present in approximately 1% to 4% of pregnant women. Although close to 50% of infected women have no known risk factors for infection, routine screening of pregnant women is not currently recommended. Hepatitis C virus (HCV) may be transmitted to the newborn at a rate of approximately 5%; it is not clear whether this occurs in utero, intrapartum, or both. Factors that increase the risk of vertical transmission include concomitant HIV infection and a high maternal HCV viral load. Breast feeding does not appear to significantly increase the risk of neonatal HCV infection. There is currently no treatment for HCV infection that is approved for use in pregnancy or for use in the neonate.

Risk factors and opportunities for prevention of early-onset neonatal sepsis: a multicenter case-control study.

BACKGROUND: Early-onset group B streptococcal (GBS) prevention efforts are based on targeted use of intrapartum antibiotic prophylaxis (IAP); applicability of these prevention efforts to infections caused by other organisms is not clear. METHODS: Multicenter surveillance during 1995 to 1996 for culture-confirmed, early-onset sepsis in an aggregate of 52 406 births; matched case-control study of risk factors for GBS and other sepsis. RESULTS: Early-onset disease occurred in 188 infants (3.5 cases per 1000 live births). GBS (1.4 cases per 1000 births) and Escherichia coli (0.6 cases per 1000 births) caused most infections. GBS sepsis less often occurred in preterm deliveries compared with other sepsis. Compared with gestation-matched controls without documented sepsis, GBS disease was associated with intrapartum fever (matched OR, 4.1; CI, 1.2-13.4) and frequent vaginal exams (matched OR, 2.9; CI, 1.1-8. 0). An obstetric risk factor-preterm delivery, intrapartum fever, or membrane rupture >/=18 hours-was found in 49% of GBS cases and 79% of other sepsis. IAP had an adjusted efficacy of 68.2% against any early-onset sepsis. Ampicillin resistance was evident in 69% of E coli infections. No deaths occurred among susceptible E coli infections, whereas 41% of ampicillin-resistant E coli infections were fatal. Ninety-one percent of infants who developed ampicillin-resistant E coli infections were preterm, and 59% of these infants were born to mothers who had received IAP. CONCLUSIONS: Either prenatal GBS screening or a risk-based strategy could potentially prevent a substantial portion of GBS cases. Sepsis caused by other organisms is more often a disease of prematurity. IAP seemed efficacious against early-onset sepsis. However, the severity of ampicillin-resistant E coli sepsis and its occurrence after maternal antibiotics suggest caution regarding use of ampicillin instead of penicillin for GBS prophylaxis.

Hepatitis in the obstetric patient.

The six agents identified thus far that cause viral hepatitis are reviewed, and their impact upon pregnancy is described. Although it is the most common cause of jaundice during pregnancy, viral hepatitis does not generally increase the risk of pregnancy complications, nor is it teratogenic. Vertical transmission of some types of viral hepatitis does occur, however.

Autologous blood donation with placenta previa: is it feasible?

Autologous blood donation has been recommended for patients with placenta previa. We hypothesized that premature delivery, preexisting anemia, and bleeding would limit its utilization. We reviewed the charts of all patients admitted with placenta previa between July 1, 1989, and April 30, 1992. To be eligible for autologous donation we assumed that the patient would need to be asymptomatic with a hematocrit 34% or higher at 32 weeks' gestation. Eighty-eight patients were admitted with placenta previa, 12 (14%) of whom were eligible for autologous donation. Two eligible patients required transfusion at delivery and four delivered prior to 34 weeks. Few patients with placenta previa are eligible for autologous donation and although two would have used their autologous units, twice as many may have been compromised by recent autologous donation. We conclude that autologous donation is not feasible in a majority of patients with placenta previa and is of limited usefulness in its management.

Cervicitis as a clinical indicator of gonococcal and chlamydial infections in pregnancy.

OBJECTIVE: We undertook the present study to attempt to apply clinical indicators predictive of cervical infection in nongravid populations with either Neisseria gonorrhoeae or Chlamydia trachomatis to our pregnant population and to determine the significance of the clinical diagnosis of "cervicitis." METHODS: A retrospective chart review of all pregnant women with a final diagnosis of cervicitis who were seen in the Medical College of Virginia obstetrical emergency room was performed during the period of September 1991 to December 1992. RESULTS: Given the diagnosis of cervicitis in our emergency department, we found that the clinical examination predicted cervical infection with N. gonorrhoeae or C. trachomatis in only 20% of the pregnant women. Gravidas with chlamydial infections were younger (20.1 +/- 3.7 years) compared with gravidas not infected (23.2 +/- 5.4 years) (P < 0.0001). They were also more likely to have a diagnosis of lower urinary-tract infection [relative risk (RR) 2.89, 95% confidence interval (CI) 1.42-5.85]. CONCLUSIONS: The clinical indicators of cervical infection with C. trachomatis and N. gonorrhoeae were unreliable.

Preterm rupture of the membranes associated with recent cocaine use.

OBJECTIVE: We postulated that recent cocaine use is common among patients with preterm (< 37 weeks) rupture of the membranes and that cocaine users have shorter latency periods before the onset of labor and delivery compared with those without recent cocaine use. STUDY DESIGN: A urine toxicologic screen was performed on all patients admitted with preterm rupture of the membranes. Patients were managed expectantly, without tocolytics, antibiotics, or steroids. RESULTS: One hundred three patients were enrolled; 71 had negative screens and 19 were positive for cocaine alone. Cocaine-positive women were significantly older and had more advanced cervical dilatation at admission and a significantly shorter latency period from rupture of membranes to labor and delivery. CONCLUSION: Preterm rupture of the membranes associated with recent cocaine use is characterized by advanced cervical dilatation at admission and a shorter latency period to labor and delivery.

HIV infection and pregnancy.

The epidemiology, management, and outcome of pregnancy complicated by HIV infection are discussed. Although lymphocyte counts may drop during pregnancy, HIV infection does not appear to increase the risk of obstetric complications and poor pregnancy outcome. Although most pregnant women with HIV are asymptomatic, progression of disease, including the development of opportunistic infections, may occur during gestation. Serious bacterial infections are not common unless the CD4 count is less than 300 cells/mm3. Transmission of HIV to the neonate complicates approximately 30% of affected pregnancies.

Comparison of culture and rapid enzyme immunoassay for the detection of group B streptococcus in high-risk pregnancies.

OBJECTIVE: The purpose of this study was to evaluate the Equate Strep B(R) test for clinical use in patients at high risk for complications from group B streptococcus (GBS) disease. METHODS: Vaginoperineal swabs were obtained from patients with preterm premature rupture of the membranes and/or preterm labor and semiquantitative GBS cultures and Equate(R) assay were performed. RESULTS: From May 14, 1990, to April 30, 1992, 650 patients were enrolled; 626 had both culture and Equate(R) results available, of whom 24% were colonized with GBS. The sensitivity, specificity, positive predictive value, and negative predictive value of the rapid assay were 28%, 84%, 35%, and 79%, respectively. Although the prevalence of GBS was higher in patients with ruptured membranes compared with those with intact membranes, rupture of membranes did not affect test sensitivity or specificity. CONCLUSIONS: We conclude that the Equate(R) rapid assay is not a sensitive method of GBS detection in high-risk patients.

Changes in T-lymphocyte subpopulations during pregnancy complicated by human immunodeficiency virus infection.

OBJECTIVE: We describe changes in T-lymphocyte subpopulations in pregnancies complicated by human immunodeficiency virus infection. STUDY DESIGN: T-lymphocyte counts were performed every trimester and post partum on all patients with human immunodeficiency virus infection. Patients with a CD4 count < 500 cells/mm3 were offered zidovudine after the first trimester. We performed a regression analysis of repeated measures on the total lymphocyte, CD4, and CD8 counts. RESULTS: Twenty-three patients were studied, 10 (43%) of whom took zidovudine. CD4, CD8, and total lymphocyte counts decreased in patients not taking zidovudine but remained stable in patients receiving zidovudine. The differences were not statistically significant. CONCLUSIONS: CD4 and CD8 counts may decrease during pregnancies complicated by human immunodeficiency virus infection, primarily because of decreases in the total lymphocyte count. The use of zidovudine may prevent this decline. The clinical use of absolute CD4 counts during pregnancy requires further study.

Comparison of questionnaire screening and urine toxicology for detection of pregnancy complicated by substance use.

OBJECTIVES: To compare the efficacy of structured questionnaire screening and prenatal urine toxicology for the detection of substance use by pregnant women, and to describe substance use patterns in a group of women presenting to a university-based obstetric clinic. METHODS: All patients presenting to our obstetric clinic for their first prenatal visit were evaluated for evidence of current use of alcohol or any illicit substances. Nursing personnel administered an extensive questionnaire, which included detailed questions about past and current substance use patterns. Urine samples were examined by a commercial laboratory for alcohol and a number of illicit substances. Current users were defined as those who admitted use within the past 30 days or who had positive urine toxicology. RESULTS: Fifty-eight of 302 patients (19.2%) were identified as current users of alcohol or illicit substances. Only 17 of 41 women (41.5%) with toxicologic evidence of recent use admitted to current use. Only 17 of 34 (50.0%) admitting to current use had toxicology positive for any substance. Patients with a history of multiple past substance use were significantly more likely to have positive urine toxicology than those without such a history (26.1 versus 7.4%; P < .005). Among current users, multiple substance use (34.5%) and cigarette smoking (52%) were common. CONCLUSION: A screening combination of structured questionnaire and universal urine toxicology identifies more current users than either technique alone, and neither is clearly superior to the other. A history of multiple substance use may be an important indicator of current use.

Imipenem-cilastatin.

Imipenem-cilastatin, with its broad spectrum of activity and relative safety, offers an excellent alternative for the treatment of many obstetric and gynecologic infections. In addition, the possibilities for intramuscular administration give clinicians additional treatment options. Because of the relatively high cost of imipenem-cilastatin, it should not be considered "first-line" therapy for most obstetric and gynecologic infections at present. Misuse and overuse of imipenem-cilastatin will result in the further development of resistant organisms, as has already been seen with many other antibiotics, and continued monitoring of susceptibility patterns is necessary.

Red blood cell transfusion and cesarean section.

OBJECTIVE: Our objective was to determine the incidence of blood transfusion in patients delivered by cesarean section and to identify factors predictive of the need for transfusion. STUDY DESIGN: A chart review was performed on cesarean patients receiving blood transfusion over a year at the Medical College of Virginia Hospital and an equal number of randomly selected cesarean patients. RESULTS: Sixty-one (6.8%) patients received a packed red blood cell transfusion intraoperatively or postoperatively. Transfusion was associated with lower gestational ages, antepartum bleeding, arrest of descent, and longer postoperative stays. After stepwise logistic regression analysis, only antepartum bleeding and preoperative hemoglobin were significant independent predictors of the need for blood transfusion. CONCLUSION: Transfusion with cesarean section is common and is associated with antepartum bleeding and other primarily intrapartum and unpredictable factors.

Obstetric and neonatal infection.

Recent advances in prevention, diagnosis, and treatment of infection-associated preterm labor are discussed. This includes antepartum treatment of vaginal infections, amniocentesis for culture and glucose levels, and adjunctive antibiotic treatment of preterm labor and preterm premature rupture of the membranes. Risk factors for neonatal group B streptococcus sepsis are described and testing for rapid detection of maternal group B streptococcus colonization is discussed, as are recent prospective studies of pregnancy outcome following human parvovirus B19 infection. Studies quantifying the transmission of herpes simplex virus to neonates following vaginal delivery to mothers with recurrent infections are discussed, as well as the results of several studies using rapid detection kits for the virus.

A randomized, double-blind, placebo-controlled trial of oral antibiotic therapy following intravenous antibiotic therapy for postpartum endometritis.

One hundred thirty-six patients were enrolled in a randomized, double-blind, placebo-controlled trial of oral antibiotic therapy (amoxicillin) versus placebo following successful intravenous (IV) antibiotic therapy for postpartum endometritis. No subjects were readmitted to the hospital for recurrent endometritis and there were no wound infections or recurrent fevers. Minor side effects were seen in 10% of those taking amoxicillin and 14% of those taking placebo. Compliance was fair; only 52% of those taking amoxicillin and 65% of those taking placebo completed therapy. The lack of infectious complications in this high-risk population suggests that oral antibiotic therapy is unnecessary after successful IV antibiotic therapy for endometritis.

Prevalence of asymptomatic hepatitis B infection in pregnant Mexican-American women.

Recent reports document high rates of asymptomatic hepatitis B virus infection in pregnant Hispanic women of Caribbean and Latin American origin, frequently in the absence of identifiable risk factors. We hypothesized that the prevalence of asymptomatic hepatitis B virus infection in Mexican-American women was much lower and that most belonged to established risk groups. Three thousand seven hundred eight-nine pregnant women, 77% of whom had Hispanic surnames, were screened for hepatitis B surface antigen upon admission in labor to Medical Center Hospital in San Antonio. Twelve women, six of whom had Hispanic surnames, were found to have asymptomatic hepatitis B infections. The prevalence of asymptomatic infections was 3.2 per 1000 (95% confidence interval 1.6-5.5) in the total population, 2.0 per 1000 (95% confidence interval 0.7-4.5) in those with Hispanic surnames, and 7.0 per 1000 (95% confidence interval 2.5-15.0) in those with non-Hispanic surnames. Risk factors, as defined by the Centers for Disease Control, were found in five (42%) of the positive patients overall and in only one (17%) of the positive patients with an Hispanic surname. We conclude that, although asymptomatic hepatitis B infection is uncommon in these pregnant Mexican-American women, the absence of identifiable risk factors in the majority of those infected suggests that routine screening in this population is justified.

Protein banding patterns of the outer membrane-enriched fraction of Bacteroides bivius.

Bacteroides bivius is a common anaerobe in female genital infections. Although protein banding patterns of outer membrane (OM) preparations of Bacteroides fragilis are well described and are homologous within the species, similar work has not been done with B. bivius. Our aims were to (i) characterize the OM banding patterns of B. bivius and compare them with those of other Bacteroides species and (ii) test clinical isolates of B. bivius against anti-B. bivius and anti-B. fragilis sera to identify different serogroups that might also exhibit different OM banding patterns. OM-enriched fractions of 27 clinical strains of B. bivius, 6 Bacteroides disiens strains, 10 B. fragilis strains, and 12 other Bacteroides strains were prepared, and sodium dodecyl sulfate-polyacrylamide gel electrophoresis was performed. Antisera to B. bivius ATCC 29303 and B. fragilis ATCC 25285 were raised in rabbits and tested against Bacteroides strains in an indirect enzyme-linked immunosorbent assay. All 27 B. bivius strains contained protein bands at 32, 27, 25, and 23 kilodaltons. This pattern was present in only 2 of 28 other strains; both of these were B. disiens. All B. bivius strains were reactive with the anti-B. bivius serum, while only 6 of 39 other strains (2 of 6 B. disiens) were reactive. Non-B. fragilis Bacteroides strains did not react with the anti-B. fragilis serum. Although there was marked homogeneity in the OM banding patterns of B. bivius, some B. disiens strains exhibited similar OM banding patterns. There appears to be some antigenic cross-reactivity between strains of B. bivius and B. disiens and very little with other Bacteroides species. These results may ultimately allow the development of rapid diagnostic tests for the B. bivius-B. disiens group.t

A randomized, blinded, placebo-controlled trial of antibiotics in idiopathic preterm labor.

Because subclinical genital tract infection may play a major role in preterm birth, the efficacy of adjunctive antibiotic therapy in combination with standard parenteral tocolysis was examined in a randomized, blinded study of patients with idiopathic preterm labor. Labor was documented by three contractions in 20 minutes, cervical dilation of 1 cm or more, and the need for parenteral tocolysis. Enrollment was restricted to patients with intact membranes and without known causes for preterm labor. One hundred three patients at 24-34 weeks' gestation were randomized to intravenous ampicillin plus oral erythromycin or corresponding placebos. Compared with the placebo group, the adjunctive antibiotic group had a similar frequency of preterm birth (38 versus 44%), time to delivery (34 versus 34 days), birth weight (2847 versus 2855 g), and episodes of recurrent labor requiring parenteral tocolysis (0.43 versus 0.49). In our population, we found no benefit to the adjunctive use of ampicillin plus erythromycin. Significant differences in genital microflora between our patients and those of other studies may explain our results.