Lemierre's syndrome complicating pregnancy.

Lemierre's syndrome is an anaerobic suppurative thrombophlebitis involving the internal jugular vein secondary to oropharyngeal infection. There is only one previous case report in pregnancy which was complicated by premature delivery of an infant that suffered significant neurological damage. We present an atypical case diagnosed in the second trimester with a live birth at term. By reporting this case, we hope to increase the awareness of obstetricians to the possibility of Lemierre's syndrome when patients present with signs of unabating oropharyngeal infection and pulmonary symptoms.

Disappearance half-life times of exogenous and growth hormone-releasing factor-stimulated endogenous growth hormone in normal rats.

This study was performed to determine the disappearance half-life times of endogenous and exogenous rat GH in conscious normal rats and to compare these with the decay characteristics of GH at the end of spontaneous normal bursts. The endogenous half-life was determined in five rats by giving an i.v. injection of rat GH-releasing factor followed after 10 min by an i.v. injection of long-acting somatostatin analogue (octreotide) and taking blood samples for 85 min. The half-lives (mean +/- S.E.M.) were 3.4 +/- 0.4 min and 13.2 +/- 1.1 min for the first and second exponential respectively as determined by bi-exponential analysis. The exogenous GH half-life was determined in ten rats by giving i.v. octreotide followed after 10 min by i.v. rat GH and sampling for 85 min. The half-lives of exogenous GH were 3.3 +/- 0.2 min and 17.5 +/- 1.4 min by bi-exponential analysis and there was no significant difference between the half-lives of endogenous and exogenous GH. The half-life of the decline of GH levels at the end of spontaneous bursts in nine rats was 14.4 +/- 0.9 min, not different from the half-life of endogenous GH, the secretion of which was terminated by octreotide. This suggests that the end of spontaneous GH bursts is marked by sudden cessation of GH release and may provide an indication of the rapidity of change in the levels of the underlying hypothalamic hormones which control GH release.

Quality of life assessment in pregnant women with the human immunodeficiency virus.

OBJECTIVE: To describe the perceived quality of life and functional status of women with human immunodeficiency virus (HIV) during the antenatal, perinatal, and postpartum periods. METHODS: Medical Outcome Survey-Short Form questionnaires were completed during antenatal visits, 24 hours after delivery, and 6 months postpartum by 21 HIV-positive women and 21 HIV-negative controls matched for age, race, parity, and education. The Medical Outcome Survey-Short Form measures subject perceptions of overall health, pain, physical role, social and cognitive function, mental health, energy/fatigue, health distress, quality of life, and health transition. Median scores between 0 and 100 (with 0 indicating poorest health) were compared using the Wilcoxon signed-rank and Kruskal Wallis/Dunn tests. RESULTS: All HIV-positive patients were asymptomatic; the median CD4 count was 386 on entry into the study. Seropositive patients reported increased health distress (50.0 versus 87.5; P < .001) and worse health transition (60.0 versus 80.0; P = .01) during antenatal visits. During the perinatal period, HIV-negative patients had a decreased sense of overall health (40 versus 80; P < .001) and worse health transition (40.0 versus 60.0; P = .04). Six months postpartum, the HIV-positive women reported decreased cognitive function (41.7 versus 62.5; P < .005) and worse social function (33.3 versus 66.7; P = .02). In general, HIV-negative women reported better quality of life in the antepartum as compared with the perinatal or postpartum period. This overall trend was also seen in the HIV-positive population. CONCLUSIONS: This is the first longitudinal evaluation of perceived quality of life in HIV-positive pregnant subjects. We conclude that perceived quality of life differs between HIV-positive and HIV-negative pregnant women. These differences may not be manifest during initial antenatal visits but may develop as pregnancy, the disease process, and other life events specific to delivery and the postpartum period interact and affect overall perceived quality of life. Longitudinal evaluation of quality-of-life issues may be important in the comprehensive care of HIV-positive women during pregnancy.

A non-hemorrhagic manifestation of vasa previa: a clinicopathologic case report.

BACKGROUND: The rare entity of vasa previa occurs when fetal vessels lying between the amniotic and chorionic membranes cross the cervical os. This report presents a case that was associated with vessel compression and concomitant adverse effects on fetal hemodynamics. CASE: A 23-year-old nulliparous woman at 36 weeks' gestation developed persistent, progressive severe variable decelerations several hours after spontaneous rupture of the membranes, resulting in a decision to perform a cesarean. At delivery, fetal vessels were noted in the membranes near the cervical os, leading into a marginally inserted cord. The decelerations were attributed to compression of the unprotected umbilical arteries by the fetal head. CONCLUSION: Vasa previa often results in fetal death and may be associated with fetal hemorrhage, but lack of bleeding does not exclude the existence of vasa previa. Altered fetal hemodynamics from varying degrees of vessel compression by the presenting part during labor may result in hypoxia and acidosis. A high index of suspicion is necessary to make the diagnosis and institute proper, timely management.

Routine use of episiotomy in modern obstetrics. Should it be performed?

Episiotomy continues to be a frequently used procedure in obstetrics despite little scientific support for its routine use. Although episiotomy does decrease the occurrence of anterior lacerations, it fails to accomplish the majority of goals stated as reasons for its use. Episiotomy does not decrease damage to the perineum but rather increases it. The midline episiotomy increases the risk for third-degree and fourth-degree lacerations. Episiotomy fails to prevent the development of pelvic relaxation and its attendant complications. Rather than decreasing maternal morbidity, episiotomy increases blood loss and is related to greater initial postpartum pain and dyspareunia. It has been associated with a more difficult and lengthy repair as measured by the need for suture material and operating room time. The claims of a protective effect on the fetus in shortening the second stage of labor, improving Apgar scores, and preventing perinatal asphyxia have not been borne out. The value of episiotomy use on a routine basis bears scientific examination in prospective, randomized, controlled trials. These types of trials are certainly achievable, ethically correct, and much needed. Until these trials are completed and published, obstetricians should not routinely perform the procedure but rather determine the need for episiotomy on a case-by-case basis.

Pulmonary sequestration.

Pulmonary sequestration is a disturbance in embryonic development that results in a cystic mass of nonfunctioning lung tissue. The authors present a case of this disorder and review the pertinent literature.

Tracheoesophageal fistula secondary to esophageal carcinoma presenting with aspiration pneumonia.

Tracheoesophageal fistulas should be suspected in patients with recurring chronic aspiration pneumonitis. They are most often secondary to intrathoracic malignancies. A case report of a patient with this disorder is presented, along with a review of pertinent literature.

Ultrasound evaluation of the fetal heart: is it possible?

Ultrasound evaluation of the fetal heart can be performed. Knowledge of the embryology, anatomy, and function of the heart have led us to understand the pathophysiology of congenital heart disease. In this review we discuss the indications as well as some basic principles of fetal echocardiography.

TORCH testing in HIV-infected women.

The issue of TORCH testing in pregnant women infected with the HIV virus remains confusing, even more so than it is in the non-HIV-infected gravida. Unfortunately, the data presented in this article make the recommendations of how to test for these various infections in pregnancy that much more difficult. Patients who are newly diagnosed as being HIV-infected and referred for prenatal care or who have not had TORCH testing probably should be tested. Thus, the prenatal patient with newly diagnosed HIV infection should be tested for T. gondii IgG antibodies. If positive for IgG antibodies, IgM antibodies should be obtained in an attempt to rule out acute T. gondii infection. Patients who test negative do not require any further testing until after the pregnancy unless they are severely immunocompromised and show signs and symptoms of toxoplasmosis. Antibodies (IgG) to CMV should be obtained in the HIV-infected gravida who is at high risk for CMV disease, i.e., patients with CD4+ T cell counts less than 100/mm3. Unfortunately, the previously described problems with antibody detection make this testing less than ideal; thus, it is not routinely recommended in the HIV-infected pregnant patient who presents for prenatal care except for those at risk of disease reactivation. As for herpes simplex virus testing, there is no value in routinely testing patients prenatally for evidence of the disease. Finally, syphilis testing in the HIV-infected gravida is of major importance. Once tested, the patient who tests negative and who remains at risk for infection should probably be retested in the third trimester. Patients who are found to have the disease and who are treated need to be tested serially to rule out re-infection or treatment failure.

Cutaneous anergy in pregnant and nonpregnant women with human immunodeficiency virus.

OBJECTIVE: To determine the prevalence of cutaneous anergy in pregnant and nonpregnant women who are seropositive for human immunodeficiency virus. METHODS AND MATERIALS: The medical records of 159 women seropositive for human immunodeficiency virus were reviewed. Demographic characteristics and tuberculin skin test results were abstracted from the chart. Tuberculin skin testing was performed by the Mantoux method (5 tuberculin units of purified protein derivative injected intradermally). Anergy testing was performed using any two of the three following antigens; tetanus toxoid, mumps, or Candida skin test antigen. A positive tuberculin test was defined as induration of 5 mm or more, and a positive test for the other antigens was defined as any amount of induration over the skin test area. Anergy was defined as any amount of induration to the other antigens. A CD4+T lymphocyte count was obtained at the time of skin testing. Continuous variables were analyzed using the Mann Whitney-U test. Categorical data were analyzed with the chi-square or Fisher's exact test as appropriate. A two-tailed P value < 0.05 was considered significant. RESULTS: There were 102 nonpregnant and 57 pregnant women who returned to have their skin test results read. There was no significant difference in the prevalence of positive, negative or anergic skin test results between groups. The CD4+T lymphocyte count (mean +/- standard deviation) in patients with anergic results was similar between pregnant (375 +/- 256/mm3) and nonpregnant (358 +/- 305/mm3) women (P = 0.64). CONCLUSION: The prevalence of cutaneous anergy is similar among pregnant and nonpregnant women seropositive for human immunodeficiency virus.

Compliance with universal precautions: knowledge and behavior of residents and students in a department of obstetrics and gynecology.

OBJECTIVES: To assess the knowledge of universal precautions for the delivery and operating rooms by residents and students and to evaluate their use of universal precautions. STUDY DESIGN: Obstetrics and gynecology (ob/gyn) residents (n = 30) and students (n = 31) from an inner-city, teaching hospital were polled by anonymous questionnaire to assess their knowledge of the appropriate barrier equipment for certain ob/gyn procedures. To determine actual compliance with universal precautions, 459 ob/gyn procedures were observed. We noted the use of appropriate barrier equipment for each procedure: gloves for pelvic exam and face shields, gowns, gloves, and booties for vaginal delivery, cesarean delivery, and dilation and curettage. The True Epistat statistical software program was used to perform simple regression analysis. RESULTS: Thirty residents (100%) knew the appropriate barrier equipment required for each type of procedure performed. One student (< 1%) did not know that booties were appropriate for the surgical procedures. Rationale for lack of compliance with universal precautions elicited by the questionnaire included time constraints (64%), inconvenience (52%), and presumption that patient was not infected (34%). The observed rate of compliance with universal precautions by participants indicates that individual compliance was inversely related to the years of experience (overall compliance rate of students was 96%; for first-year residents, 92%, second-year residents, 89%, third-year residents, 84%, fourth-year residents, 78%; r = -0.9918, P = 0.0009). CONCLUSIONS: Knowledge regarding universal precautions was nearly 100%, while overall observed compliance was only 89%. Compliance with universal precautions was better among students (96%) than among residents (88%). Compliance with universal precautions was inversely related to years of experience.

Oral tocolysis with magnesium chloride: a randomized controlled prospective clinical trial.

A prospective randomized clinical trial was conducted to assess the efficacy and safety of enteric-coated magnesium chloride (SLOW MAG) as an oral tocolytic agent. Seventy-five patients between 24 and 34 weeks' gestation who were treated with intravenous magnesium sulfate for a first episode of preterm labor were enrolled. After a 12-hour contraction-free period on intravenous therapy, patients were randomized by sealed envelope to one of three groups: group 1, SLOW MAG (535 mg every 4 hours); group 2, oral ritodrine (20 mg every 4 hours); or group 3, no therapy (control). Patients receiving oral therapy were treated until delivery or completion of 36 weeks' gestation. No difference was found between groups with respect to time gained with the use of oral therapy or number completing 36 weeks' gestation. Therapy with enteric-coated magnesium chloride was associated with significantly fewer side effects (20%) as compared with ritodrine (48%) (p less than 0.01). Our results suggest that compared with ritodrine, enteric-coated magnesium chloride is as effective in prolonging pregnancy and preventing recurrent preterm labor. However, neither enteric-coated magnesium chloride nor ritodrine appeared to be any more effective in the prevention of preterm delivery than observation alone.

Vaginal infections in human immunodeficiency virus-infected women.

OBJECTIVE: This study was undertaken to compare the frequencies of vaginal infections among human immunodeficiency virus-infected women with those among human immunodeficiency virus-seronegative women. STUDY DESIGN: Human immunodeficiency virus-seropositive women attending a comprehensive care center for human immunodeficiency virus disease at the outpatient department of an inner-city hospital in Houston underwent rigorous gynecologic evaluation for sexually transmitted diseases, including evidence of vaginal infections such as bacterial vaginosis, vulvovaginal candidiasis, and trichomonal vaginitis. Demographic information was collected, as was information regarding disease classification and degree of immunosuppression. Data regarding sexually transmitted diseases, data regarding vaginal infections, and demographic information were collected from a cohort of human immunodeficiency virus-seronegative women attending a sexually transmitted disease and family planning clinic at the same institution. The two groups were compared to determine whether there were any differences between them in the frequencies of sexually transmitted diseases and vaginal infection. Data analysis used the t test for parametric data and the Fisher exact test for nonparametric data where appropriate. P <.05 was considered significant. Statistical analysis was performed with the SAS (SAS Institute, Inc, Cary, NC) statistical software package. RESULTS: There was no difference in age between the 2 groups. The human immunodeficiency virus-infected group was predominantly African American (80.5%), whereas the human immunodeficiency virus-seronegative control group was more evenly divided between African American women (45.8%) and Latinos (41.7%; P <.0001). Although there was no significant association between HIV infection and sexually transmitted diseases in general, there were significant associations between human immunodeficiency virus infection and bacterial vaginosis (P =.02), vulvovaginal candidiasis (P =.001), and trichomonal vaginitis (P =. 003). CONCLUSION: Human immunodeficiency virus-infected women had increased frequencies of vaginal infections, including bacterial vaginosis, vulvovaginal candidiasis, and trichomonal vaginitis, with respect to human immunodeficiency virus-seronegative control subjects. No differences between the 2 groups were seen in the frequencies of sexually transmitted diseases.

A study to determine the incidence and prevalence of newly discovered human immunodeficiency virus infection during the prenatal care period.

OBJECTIVES: This study asked the following questions: 1) Does HIV testing in pregnancy identify women who previously were not known to be HIV positive? 2) When in pregnancy are women identified as HIV infected? 3) Does HIV seroconversion occur during the prenatal care period? METHODS: Medical records of 97 women from two primarily indigent care hospitals in Houston, TX who were found to be HIV positive at delivery were reviewed to determine if they had tested positive during the prenatal care period. Demographics and time of gestation of the prenatal testing also were recorded. The outcome measures were: 1) number of women found positive during prenatal care; 2) week of gestation at discovery of HIV positivity; and 3) number of women seroconverting between the initiation of prenatal care and delivery. RESULTS: Thirty women were known to be HIV positive prior to pregnancy. Fifty-six women were found to be positive during prenatal care and the seropositivity of 44 was discovered before the 34th week of pregnancy. Ten women were found to be positive at their first prenatal visit, which occurred after the 34th week. Date of testing was unknown for two women. Eleven women who received no prenatal care were found to be HIV positive at delivery. There were no seroconversions while women were under prenatal care. CONCLUSIONS: HIV testing at delivery did not find any HIV-positive women who had tested negative during prenatal care. Testing is very important for women who do not receive prenatal care. Making certain that high-risk women get into prenatal care also is very important.

Appraisal of factors influencing the normal sinus node recovery time.

The normal period of depression of sinoatrial node automaticity (sinus node recovery time, SNRT) following one minute of overdrive right atrial pacing was evaluated in 34 subjects, aged 27--83 years. Specific attention was paid to the influence of the patient's heart rate, atrial pacing rate (100 and 130 bpm) and site, and of vagal and sympathetic effects, as assessed by observations following the administration of atropine, 0 . 03 mg/kg, and propranolol, 0 . 15 mg/kg. Normal SNRT was 1046 +/- 17 ms at 100 bpm and 980 +/- 19 ms at 130 bpm. Linear regression analysis showed that at pacing rates of both 100 and 130 bpm, both before and after autonomic block, a highly significant relation existed between SNRT and the stable P-P interval observed after cessation of pacing. These regression equations were used to develop a correction factor for cycle length in assessing SNRT (corrected SNRT = SNRT--0 . 86 X cycle length, where 0 . 86 was the slope of the regression equation). The mean corrected SNRT was 314 +/- 10 ms and 290 +/- 8 ms at 100 and 130 bpm, respectively. Vagal influences increased SNRT and were of greater magnitude than the decrease in SNRT due to sympathetic effects. Corrected SNRT was significantly longer following left atrial than following right atrial pacing, but in those eight patients studied, was not significantly different following right atrial or right ventricular stimulation.

Legal considerations in screening pregnant women for human immunodeficiency virus.

This article examines the legal implications of studies showing that the probability of maternal-to-infant human immunodeficiency virus transmission can be reduced by physician interventions. These interventions require knowledge of a pregnant woman's human immunodeficiency status. Hence the offering of human immunodeficiency virus testing has become a standard of care in pregnancy. This standard of care is examined with respect to the following: (1) the physician's legal duty to the infant, (2) negligence for failing to test, (3) liability when testing only reduces the probability of transmission, (4) damages, (5) informing women about the results of their testing, (6) protecting against liability, and (7) dealing with human immunodeficiency virus-infected pregnant women. It is concluded that the physicians are likely to have legal difficulties if a human immunodeficiency virus-infected baby is born to a woman who was not offered testing or if testing is done without documenting consent. Suggestions are made for reducing liability when testing is done, when patients refuse testing, and when one is caring for human immunodeficiency virus-infected women.

Venous and volume factors in women during and after normotensive pregnancy.

1. Venous compliance and plasma volume were measured in thirty-one continuously normotensive women early (11-20 weeks) and late (31-40 weeks) in pregnancy and following delivery. 2. Mathematically fitted pressure/volume curves, obtained by venous occlusion plethysmography, were analysed according to two describing functions (i) the peak of the first derivative dv/dp max and (ii) a work index, integral of 25 (10) p dv. 3. The relationship between venous/volume factors seen after delivery, was disturbed during pregnancy, at which time the work index provided evidence for decreased venous compliance. 4. Pregnancy could be regarded as a potentially hypertensive state, brought about by a vascular/volume mismatch.

Prenatal sonographic diagnosis of a third ventricle choroid plexus papilloma.

We report a case of fetal hydrocephalus secondary to a third ventricle choroid plexus papilloma detected by ultrasound at 33 weeks' gestation. The prenatal sonographic and colour flow Doppler findings of this rare fetal intracranial tumour are discussed.