Mandated preterm delivery: its prevalence and impact at a tertiary referral center.

OBJECTIVE: To determine the prevalence and impact of mandated preterm deliveries at a tertiary referral center. METHODS: A chart review was conducted at our institution on all livebirths from 24 weeks to completion of 37 weeks' gestation between 1 January 1998 and 31 December 1999. Mandated delivery was defined as intentional intervention because of a deteriorating maternal or fetal condition. Reasons for intervention and intrapartum courses were compared with two other preterm groups (premature ruptured membranes, spontaneous labor) delivering during the same period. Statistical analyses included the Student t test, univariate ANOVA, X2 test and Mann-Whitney test. RESULTS: A total of 894 pregnancies delivered preterm, with 132 (14.8%) being mandated. Primary reasons for mandated delivery included severe pre-eclampsia (69.0%), vaginal bleeding (11.4%), deteriorating maternal illness (10.6%), worsening fetal growth restriction (6.1%) or major fetal malformation (3.0%). Delivery at less than 34 weeks was more common in the mandated group (68.9%) than in the ruptured membranes group (41.2%, p < 0.005) or in the spontaneous labor group (46.5%; p < 0.01). Cesarean section rates were higher in the mandated group (69.7%) than in the ruptured membranes group (18.3%; p <0.001) or in the spontaneous labor group (21.5%; p < 0.001). The presence of an unfavorable cervix, unsuccessful trial of labor, non-cephalic fetal presentation, or fetal intolerance of labor explained the high rate of surgery. CONCLUSIONS: Conditions mandating delivery accounted for 14.8% of all preterm births. Mandated delivery is associated with a greater need for delivery before 34 weeks, often by Cesarean section.

Is high-dose misoprostol able to lower the incidence of cesarean section? A randomized controlled trial.

OBJECTIVE: To determine whether high-dose (100 microg) misoprostol was able to increase the rate of successful labor induction and lower the incidence of Cesarean section without adverse fetal effects. METHODS: A total of 360 women were randomized to receive either oxytocin (n = 192) by intravenous infusion, or misoprostol (n = 168) 100 microg intravaginally every 4 h. The Cesarean section rate was the primary end-point. Incidences of uterine and fetal heart rate abnormalities during labor and adverse neonatal outcomes were assessed as secondary end-points. RESULTS: Compared with those women receiving oxytocin, patients given misoprostol had a significantly shortened labor (10.7+/-6.0 vs. 15.4+/-10.4 h, p < 0.001). The Cesarean section rate did not differ between patients receiving misoprostol or oxytocin (36 (21.4%) vs. 38 (19.8%), p = 0.79) despite a sample size adequate to detect a 13 percentage point difference in this outcome. Patients receiving misoprostol had a higher incidence of the hyperstimulation syndrome (27 (16.1%) vs. 9 (4.7%), p < 0.001), and of fetal intolerance of labor as an indication for Cesarean delivery (23 (63.9%) vs. 15 (39.5%), p = 0.06), and had a greater number of umbilical artery cord blood pH findings of< 7.20 (20 (43.5%) vs. 6 (17.1%), p = 0.02). These worrisome trends on interim analysis resulted in our prematurely terminating the study. CONCLUSION: High-dose intravaginal misoprostol did not reduce the Cesarean section rate and was associated with a greater hazard of fetal intolerance of labor.

Prevention of group B streptococcus early-onset neonatal sepsis: comparison of the Center for Disease Control and prevention screening-based protocol to a risk-based protocol in infants at greater than 37 weeks' gestation.

OBJECTIVE: To compare the Center for Disease Control consensus guidelines' screening-based strategy to a risk-based strategy as regards the incidence of early-onset group B streptococcus (GBS) infection among term infants. STUDY DESIGN: A cohort of university hospital prenatal clinic mother-infant pairs who were screened for GBS at 35 to 37 weeks' gestation were compared to a matched control group of unscreened mother-infant pairs from the outreach satellite prenatal clinics who delivered at the same institution during the same time period. GBS screening was carried out with rectovaginal cultures plated on selective media. GBS-positive women received antimicrobial prophylaxis in labor whereas women of unknown GBS status were only treated intrapartum if they had a risk factor for GBS infection. Principal outcome variables included incidence of cases of neonatal early-onset GBS sepsis (blood, urine, or cerebrospinal fluid positive for GBS), incidence of cases of strongly suspected GBS sepsis (culture negative), and incidence of neonatal sepsis with non-GBS organisms. RESULTS: There were 3164 screened mother-infant pairs who were compared to 2684 unscreened pairs. The incidence of GBS carriage was 13.3%. A random sample of 420 screened women were compared to a matched sample of 407 women of unknown GBS carrier status for characterization of demographics and risk factors. No cases of documented GBS sepsis occurred in the infants of the screened women, but four cases occurred among the infants of the women who did not undergo screening (incidence 1.5/1000) (p = 0.04), only one of whom had a risk factor for GBS infection. Cases of suspected but culture negative sepsis were not more common in the screened population when compared to the unscreened. There was one case of Escherichia coli sepsis in an infant of a mother in the unscreened group. CONCLUSIONS: GBS screening at 35 to 37 weeks, with intrapartum antimicrobial prophylaxis of carriers, decreased the incidence of neonatal early-onset GBS sepsis and appears to have advantages over treatment based on risk factors alone in term infants.

Assessing clinical competence of medical students in women's health care: use of the objective structured clinical examination.

OBJECTIVE: To assess clinical competency of third-year medical students completing a problem-oriented, primary care emphasis clerkship in obstetrics and gynecology using an objective structured clinical examination, and to determine the feasibility of implementing the objective structured clinical examination in the curriculum. METHODS: Sixteen groups of third-year medical students were evaluated prospectively on their exit performances with a six-station objective structured clinical examination designed to test clinical competency in basic primary care obstetrics-gynecology. Consistency of scores across stations, differences in performance for separate groups, and relationship of objective structured clinical examination scores compared with other indicators of medical proficiency, such as written examinations and faculty evaluations, were assessed. RESULTS: One hundred ninety-eight students were evaluated over 25 months. Test reliability across stations revealed alpha values ranging between .50 and .56. Correlations between performance on the objective structured clinical examination and the written test (r = .10) were low, demonstrating that the objective structured clinical examination clearly tests a separate domain of student capability. Cost of the objective structured clinical examination was $81.66 per student. CONCLUSION: The objective structured clinical examination is a reliable and valid test of the clinical competence of medical students in the primary health care of women. It provides information that is not obtained by more traditional assessment modalities at a reasonable cost.

Is amniotic fluid analysis the key to preterm labor? A model using interleukin-6 for predicting rapid delivery.

OBJECTIVE: Our purpose was to create a model for predicting amnionitis and rapid delivery in preterm labor patients by use of amniotic fluid interleukin-6 and clinical parameters. STUDY DESIGN: Amniotic fluid was cultured and analyzed, and a clinical score (incorporating gestational age, amniotic fluid Gram stain, glucose, leukocyte esterase, and maternal serum C-reactive protein) was determined in 111 patients diagnosed with preterm labor. Statistical analysis involved t tests, chi2, logarithmic regression, and multivariate regression analysis (P < or = .05). RESULTS: The incidence of positive amniotic fluid cultures was 8.7% (9 of 103 patients). Patients with positive cultures of the amniotic fluid had a shorter delivery interval (4.8 +/- 7.5 vs 28.9 +/- 25.4 days, P < .001). Patients with elevated amniotic fluid interleukin-6 (> or = 7586 pg/ml) were more likely to have a positive amniotic fluid culture (relative risk = 8.8, 95% confidence interval = 1.6 to 47.4, P < .001) and to be delivered within 2 days (relative risk = 16.8, 95% confidence interval = 4.5 to 62.7, P < .001). Stepwise multivariate regression analysis yielded a model using interleukin-6, cervical dilatation, and gestational age (r2 = 0.63, P < .001) with a specificity of 100% for predicting delivery within 2 days of amniocentesis. CONCLUSIONS: A mathematical model using maternal amniotic fluid interleukin-6 seems to be a useful clinical tool for quantifying the interval to preterm birth for patients in preterm labor.

Does labetalol predispose to pulmonary edema in severe pregnancy-induced hypertensive disease?

We investigated whether use of labetalol, a beta adrenoreceptor blocking antihypertensive agent commonly employed as an alternative to hydralazine, is independently associated with pulmonary edema in women with severe preeclampsia. We retrospectively evaluated women with severe preeclampsia who were given labetalol by intravenous bolus for MAP > 120 mm Hg. Outcome variables included: achieving MAP < 120 mm Hg with < 300 mg of labetalol, incidence of adverse effects of the drug, including pulmonary edema, hypotension, and maternal bradycardia. Total intravenous fluid intake exceeding output (+ delta I/O) and presence or absence of preeclamptic liver involvement were noted. Statistical analysis included unpaired t-tests and Fisher's exact test. Fifty-one women were studied, 7 (13.7%) of whom developed pulmonary edema. Demographic and pregnancy characteristics were not different between patients who did or did not develop pulmonary edema. No patient had detectable underlying heart disease. Patients with or without pulmonary edema did not differ as regards entry MAP (130 +/- 14 vs. 129 +/- 18 mm Hg), total dose of labetalol (209 +/- 83 vs. 193 +/- 39 mg/24 hours), incidence of bradycardia or hypotension (0/7 vs. 8/44), or presence of hepatic involvement (1/7 vs. 9/44). However, there was a significant difference in degree of positive fluid balance. Patients developing pulmonary edema had a net gain of 1,466 +/- 429 mL of fluid in the 24 hours in which they received labetalol than those who did not (659 +/- 1152 mL, P = .003). Initial central hemodynamic monitoring data revealed no impairment of cardiac performance (mean cardiac output 7.7 +/- 1.8 L/min, cardiac index 4.0 +/- 0.8 L/min/m2, left ventricular stroke work index 73 +/- 9 g.m.m-2) despite high pulmonary capillary wedge pressures (22 +/- 4 mm Hg). We conclude that the incidence of pulmonary edema in patients with severe preeclampsia who are treated with labetalol appears to be a result of an increase in third space fluid accumulation as a manifestation of the severity of their disease, not a direct effect of the drug on cardiac performance.

Active management of labor: does it make a difference?

OBJECTIVE: Our goal was to evaluate whether active management of labor lowers cesarean section rates, shortens the length of labor, and overcomes any negative effects of epidural analgesia on nulliparous labor. STUDY DESIGN: We randomly assigned 405 low-risk term nulliparous patients to either an active management of labor (n = 200) or our usual care control protocol (n = 205). Patients who were undergoing active management of labor were diagnosed as being in labor on the basis of having painful palpable contractions accompanied by 80% cervical effacement, underwent early amniotomy, and were treated with high-dose oxytocin for failure to progress adequately in labor. RESULTS: The cesarean section rate in the active management of labor group was lower than that of controls but not significantly so (active management, 7.5%; controls, 11.7%; p = 0.36). The length of labor in the active management group was shortened by 1.7 hours (from 11.4 to 9.7 hours, p = 0.001). Fifty-five percent of patients received epidural analgesics; a reduction in length of labor persisted despite the use of epidural analgesics (active management 11.2 hours vs control 13.3 hours, p = 0.001). A significantly greater proportion of active management patients were delivered by 12 hours compared with controls (75% vs 58%, p = 0.01); this difference also persisted despite the use of epidural analgesics (66% vs 51%, p = 0.03). CONCLUSIONS: Patients undergoing active management had shortened labors and were more likely to be delivered within 12 hours, differences that persisted despite the use of epidural analgesics. There was a trend toward a reduced rate of cesarean section.

Changes in hemodynamics, ventricular remodeling, and ventricular contractility during normal pregnancy: a longitudinal study.

OBJECTIVE: To investigate the hemodynamic changes occurring in normal pregnancy and to see if these changes were associated with an increase in myocardial contractility. METHODS: In a longitudinal study, primigravidas were studied with echocardiography in early (15 +/- 1.8 weeks), mid (26 +/- 1.2 weeks), and late (36 +/- 1.0 weeks) gestation, as well as at 6 weeks postpartum. Cardiac dimensions were measured with two-dimensional and M-mode echocardiography and hemodynamic indices were calculated. All measurements were made with subjects in the left lateral decubitus position. Statistical analysis was performed with repeated measures analysis of variance. RESULTS: Seventy-six women with normal pregnancy outcomes completed all four studies. From the baseline study to late gestation, an increase in cardiac output of 27% (from [mean +/- standard error] 4.2 +/- 0.1 to 5.8 +/- 0.2 L/min, P = .001), and a decrease in total peripheral resistance of 33% (from 1356 +/- 69 to 941 +/- 37 dynes/second cm-5, P = .001) occurred. Over this same time period, left ventricular function, while demonstrating a small and non-significant increase in velocity of circumferential fiber shortening (from 1.25 +/- 0.02 to 1.27 +/- 0.02 cm/second), revealed a 12% decrease in wall stress (from 36.3 +/- 1.0 to 31.9 +/- 1.0 g/cm2, P = .001) and a 13% decrease in the load-independent wall stress to velocity of circumferential fiber shortening ratio (from 30.0 +/- 1.2 to 26.1 +/- 1.0, P = .01), implying enhanced intrinsic myocardial contractility. CONCLUSION: Normal pregnancy is characterized by enhanced myocardial performance.

Digoxin-like immunoreactive substance and sodium-potassium-adenosine triphosphatase inhibition in normal pregnancy: a longitudinal study.

OBJECTIVE: To measure the levels of digoxin-like immunoreactive substance and digitalis-like factor bioactivity as manifested by sodium-potassium-adenosine triphosphatase (ATPase) inhibition throughout pregnancy. METHODS: Serum samples were collected from primigravidas in early (15 +/- 1.8 weeks), mid (26 +/- 1.2 weeks), and late (36 +/- 1.1 weeks) gestation, as well as at 6 +/- 1.1 weeks postpartum (mean +/- standard error). Digoxin-like immunoreactive substance levels were determined by radioimmunoassay and digitalis-like factor bioactivity was determined by inhibition of ATPase. Data were analyzed by means of repeated measures analysis of variance. RESULTS: In 41 women with normal pregnancy outcomes, levels of digoxin-like immunoreactive substance rose progressively and significantly (P < .001) throughout pregnancy and returned to normal levels postpartum. Inhibition of ATPase activity also rose significantly (P < .004), but not as dramatically, during pregnancy and remained elevated 6 weeks postpartum. CONCLUSION: Although digoxin-like immunoreactive substance levels rise in pregnancy, functional digitalis-like factor activity, as manifested by inhibition of ATPase, does not parallel this rise strictly, implying that digoxin-like immunoreactive substance receptors may be reset during normal pregnancy. The enhanced cardiac performance that occurs in normal pregnancy may be mediated in part by increased digitalis-like factor activity.

"Preeclamptic labs" for evaluating hypertension in pregnancy.

OBJECTIVE: To determine the utility of evaluating coagulation function in patients with chronic hypertension, transient hypertension, preeclampsia, eclampsia and the HELLP syndrome. STUDY DESIGN: We retrospectively reviewed the charts of 244 patients who delivered between March 1992 and March 1994 at the University of New Mexico with a discharge diagnosis of either hypertension, preeclampsia or eclampsia. RESULTS: Nine patients were thrombocytopenic on admission, as defined by a platelet count of < 100,000/mm3. Three of the 244 patients had mild prolongation of the partial thromboplastin time, and none had prolongation of the prothrombin time. Two of the patients with prolongation of the partial thromboplastin time were thrombocytopenic on admission, and the last had elevation of liver enzymes. No patient had clinical evidence of coagulopathy. CONCLUSION: Measurement of the partial thromboplastin time and prothrombin time in the evaluation of preeclampsia/eclampsia can be avoided if the platelet count and liver enzymes are normal. This results in a decrease in hospital charges and no compromise in patient safety.

Relative effects of antepartum and intrapartum maternal blood glucose levels on incidence of neonatal hypoglycemia.

OBJECTIVE: The objective of this study was to compare the relative effects of both antepartum and intrapartum maternal plasma glucose concentrations on neonatal plasma glucose levels. STUDY DESIGN: This was a prospective, nonrandomized study. Two hundred thirty-three pregnant insulin-requiring patients with diabetes received intensive diabetic treatment aimed at maintaining the 2-hour postprandial plasma glucose level < 150 mg/dl and the intrapartum plasma glucose level < 100 mg/dl. The neonatal plasma glucose level was monitored during the first 48 hours of life and the incidence of neonatal hypoglycemia was compared with the average antepartum and intrapartum maternal plasma glucose concentrations. RESULTS: The lowest incidence of neonatal hypoglycemia occurred, as expected, among infants of patients who had the lowest mean antepartum and intrapartum plasma glucose levels. However, the intrapartum plasma glucose concentration had a stronger association with decreased neonatal hypoglycemia than the antepartum plasma glucose levels. CONCLUSIONS: Even in the presence of poor antepartum diabetic control tight regulation of the intrapartum plasma glucose levels will significantly reduce the incidence of neonatal hypoglycemia.

A randomized trial of misoprostol and oxytocin for induction of labor: safety and efficacy.

OBJECTIVE: To compare the safety and efficacy of misoprostol and oxytocin for induction of labor. METHODS: One hundred thirty women requiring induction of labor were randomized to receive either intravenous oxytocin or 100 micrograms misoprostol, administered intravaginally every 4 hours until labor was established. RESULTS: Compared with women receiving oxytocin, a greater percentage of women in the misoprostol group had Bishop scores of 3 or less (58 versus 38%, P < .05). Nonetheless, the median induction-to-delivery interval was significantly shorter (585 versus 885 minutes, P < .001) in the misoprostol group. Women in the misoprostol group were more likely to deliver vaginally within 24 hours of the start of induction (77 versus 55%, P < .002). Epidural analgesia was used more frequently in women receiving oxytocin than in those receiving misoprostol (73 versus 50%, P = .025). The total percentage of cesarean deliveries was not significantly different, although the percentage of cesarean deliveries for dystocia was lower in the misoprostol group (8 versus 21%, P = .02). Uterine tachysystole was significantly more common (70 versus 11%, P < .001) and hospital charges significantly less with misoprostol. CONCLUSION: Compared with oxytocin for labor induction, misoprostol results in a shorter induction-to-delivery interval, a reduction in the rate of cesarean delivery for dystocia, and a decreased use of epidural analgesia. Uterine tachysystole is significantly more common with the use of misoprostol.

A comparison of the 3 H glucose tolerance test and the 2 H value in identifying risk for excessive fetal growth.

The objective of this study was to determine if the 2 h value of the glucose tolerance test (GTT) is as reliable as the complete GTT in identifying risk for excessive fetal growth. Five hundred eighty-eight patients underwent a 3 h oral GTT at 26-28 weeks' gestation. The 2 h value of the test was compared to the results of the GTT. The incidence of large for gestational age (LGA) infants was compared for patients who had an abnormal GTT or an abnormal 2 h value only. A normal 2 h value was associated with a normal GTT in 98.5% of cases, while an abnormal 2 h value was associated with an abnormal GTT in 70% of cases. An abnormal GTT was associated with a 22% incidence of LGA, while a 2 h value > or = 165 mgm/dl was associated with a 20% incidence of LGA. This difference was not statistically significant. A single 2 h value GTT is more cost-effective and as predictive as a complete 3 h GTT in identifying risk for excessive fetal growth.

Systemic lupus erythematosus in pregnancy.

For the pregnant woman with systemic lupus erythematosus (SLE), there is a potential for profound effects on perinatal outcome. Because SLE is a multisystem disease, there are numerous effects on and nursing implications for the mother, the fetus, and the newborn that require individual case management. The article discusses SLE in pregnancy as well as appropriate clinical management and therapeutic intervention to assist the perinatal and neonatal nurse in caring for the mother, fetus, and neonate.

A prospective randomized evaluation of a hygroscopic cervical dilator, Dilapan, in the preinduction ripening of patients undergoing induction of labor.

OBJECTIVE: Our purpose was to investigate the safety and efficacy of a synthetic intracervical hygroscopic dilator, Dilapan (Gynotech, Inc., Middlesex, N.J.), on ripening the cervix before medically indicated induction of labor. STUDY DESIGN: Two hundred forty patients with a Bishop score of < or = 4 were prospectively randomized to receive either preinduction synthetic hygroscopic dilators (n = 112) or no pretreatment (n = 128) before oxytocin induction. RESULTS: Compared with controls, the dilator group exhibited a significant change in median Bishop score, but there was no significant difference in length of labor (dilator 18.8 +/- 12.8 hours vs control 21.7 +/- 14.8 hours) or in the cesarean section rate (dilator 41/112 [36.6%] vs control 49/128 [38.3%]). Relative proportions of nulliparous and multiparous patients, infant weights, and cervical dilation at the time of cesarean section were not significantly different between groups. No adverse maternal or fetal effects could be attributed to use of the device. CONCLUSIONS: Preinduction cervical ripening with hygroscopic dilators does not shorten the length of labor or lower the cesarean section rate in patients undergoing induction of labor.

Comparison of absorbable uterine staples and traditional hysterotomy during cesarean delivery.

OBJECTIVE: To evaluate the use of the Auto Suture Poly CS-57 disposable surgical stapler to determine if the device offers any advantages over suture closure of the uterus. METHODS: A matched case-control study design was used. Operative time, estimated blood loss, change in hematocrit, incidence of postoperative endometritis, length of stay, and total patient costs were compared. Patients were recruited from a university hospital setting and a private practice. RESULTS: There were 288 patients in the study, 144 in the staple group and 144 matched patients in the standard hysterotomy control group. Patients did not differ in age, parity, gestational age, number of primary or repeat operations, anesthesia, infant weights, or outcomes. Comparing the patients in the staple group and the control group, there was no significant difference in operative time (63.7 +/- 22.9 versus 62.0 +/- 22.3 minutes, staple group versus controls, respectively), estimated blood loss (822 +/- 338 versus 879 +/- 318 mL), change in hematocrit (-5.9 versus -6.5 volume percent), incidence of postoperative endometritis (15 versus 20%), length of stay (4.1 +/-1.3 versus 4.0 +/- 2.2 days), or total cost ($4490 +/- 1544 versus $3997 +/- 1117). Comparing patients operated upon by residents in the university to those operated upon by the private attending physicians, there were no significant differences noted in the above-mentioned variables between stapled and sutured patients. CONCLUSION: Compared with the usual suture technique for cesarean delivery, the uterine stapling device used in this study was not associated with a significant decrease in the incidence of postoperative anemia, infection, length of hospital stay, or cost. This device appears to offer no advantage over traditional hysterotomy and repair.

Chagas disease in pregnancy.

BACKGROUND: Chagas disease is a tropical disease now making its appearance in the United States as more immigration from Latin America occurs. Pregnant women with chronic infection with Trypanosoma cruzi may present with cardiac or gastrointestinal symptoms and transmit the infection to their fetuses. CASE: A 32-year-old Mexican woman presented with cardiac symptoms at 16 weeks' gestation. She was found to have a left anterior hemiblock on her electrocardiogram. Her indirect immunofluorescent antibody titer for T cruzi was positive at greater than 1:2048. Subsequently, she had a normal pregnancy and delivery. The infant's T cruzi immunofluorescent antibody titer was 1:256 at birth and had not declined at his 6-week follow-up. CONCLUSION: Obstetric care providers in the United States need to be familiar with American trypanosomiasis because it may present during pregnancy. Serious maternal disease is possible, and perinatal transmission may be seen in 2-10% of cases.

Acute spinal cord injury and neurogenic shock in pregnancy.

A case of a pregnant woman with a subluxation of C-6 on C-7 with acute quadriplegia and sensory loss to the T-10 dermatome is described. Hemodynamic and fetal monitoring during the 3-week period of neurogenic shock resulted in good maternal and fetal outcomes. Pulmonary complications and anesthetic issues are important aspects of the care of these critically ill patients. Major trauma is a common cause of death and disability in young adults and may contribute to as much as 15 percent of nonobstetric maternal deaths. Spinal cord injuries involve young women in 15 percent of cases. The literature is replete with information on the obstetric management of patients with preexisting spinal cord injury (1-4) but there is little on the management and special problems of the pregnant patient with acute spinal cord trauma. We report here the management of a case of acute cord transection accompanied by spinal shock and discuss the specific maternal as well as fetal considerations in this syndrome.

Increased recovery of group B Streptococcus by the inclusion of rectal culturing and enrichment.

Detection of intrapartum carriage of group B streptococcus (GBS) and subsequent antibiotic prophylaxis may prevent GBS infections in neonates. Because the gastrointestinal tract is the primary source of this organism, detection of carrier status requires both rectal and vaginal swabs. Vaginal swabs from 651 obstetric outpatients were plated onto 5% sheep blood agar. A second vaginal and a rectal swab were collected and incubated overnight in an enrichment medium of Todd-Hewitt broth containing antibiotics. By at least one method, 110 (16.9%) patients were positive for GBS. Only 31.8% of these positive patients were detected by direct culture of vaginal swabs. The use of vaginal swabs directly plated onto blood agar identified only three carriers not detected by another method. Inoculation of an enrichment broth with the vaginal swab and subsequent subculture detected 70.9% of the total. The use of both vaginal and rectal swabs with enrichment detected 97.3% of total GBS carriers. A subset of enrichment broths inoculated with vaginal and rectal specimens from 279 patients was tested for GBS by direct latex agglutination (Streptex; Murex Diagnostics, Inc., Norcross, GA, USA). Of the 90 broths that grew GBS on subculture, only 59 (65.6%) were positive by the direct agglutination method. The use of this method, although reducing processing time by 1 day, gave false-negative results for one-third of the GBS-positive broths. An accurate detection of the GBS carrier state can only be achieved by a combination of vaginal and rectal swabs incubated in enrichment broth and subcultured on blood agar.

Hantavirus pulmonary syndrome complicating pregnancy.

OBJECTIVE: The purpose of this report is to bring to the attention of obstetric care providers the occurrence in pregnancy of a threatening pulmonary syndrome caused by hantavirus infection. STUDY DESIGN: Two recent cases of hantavirus pneumonitis in pregnancy, one complicated by adult respiratory distress syndrome, are presented. The clinical characteristics and epidemiology of the illness, which has now been reported in 12 western states, are detailed. RESULTS: Hantavirus pulmonary syndrome is characterized by pneumonitis, often progressing to adult respiratory distress syndrome, which is accompanied by thrombocytopenia, lactacidemia, and leukocytosis with a marked left shift. Severe hypoxemia and lactacidemia were associated with a poor perinatal outcome. CONCLUSION: The hantavirus pulmonary syndrome occurring during pregnancy may be life-threatening and may result in fetal hypoxemic damage.