Placental malaria and mother-to-child transmission of human immunodeficiency virus-1

There are few studies of the association between placental malaria (PM) and mother-to-child transmission (MTCT) of human immunodeficiency virus-1 (HIV-1), and the results of published studies are inconsistent. To determine the association between PM and MTCT of HIV-1, we performed a secondary analysis of data from a clinical trial of antibiotics to reduce chorioamnionitis. Data regarding 1,662 HIV-1-infected women with live born singleton and first-born twin infants with information regarding PM and infant HIV-1 infection status at birth were analyzed. At the time of the study, women did not have access to antiretroviral drugs for treatment of acquired immunodeficiency syndrome but had received nevirapine prophylaxis to reduce the risk of MTCT of HIV-1. Placental malaria was not associated with the infant HIV-1 infection status at birth (P = 0.67). Adjustment for maternal plasma viral load and CD4+ cell count did not change these results (odds ratio = 1.06, 95% confidence interval = 0.51-2.20, P = 0.87). Placental malaria was more likely to be related to HIV-1 infection at birth among women with low viral load at baseline (P for interaction = 0.08). In conclusion, PM was not associated with infant HIV-1 infection status at birth. The interaction of maternal plasma viral load, PM, and MTCT of HIV-1 warrants further studies.

Evidence-based anesthesia: fever of unknown origin in parturients and neuraxial anesthesia

The safety of neuraxial analgesia in febrile patients is controversial. We performed an evidenced-based project in an effort to establish a guideline for our active obstetric clinical practice. Neuraxial anesthesia is generally safe for parturients, and complications are rare; however, serious adverse outcomes can result. Because of the devastating nature of the morbidity, the decision to proceed with a neuraxial anesthetic in the face of infection may be contentious. Fever and sepsis are considered relative contraindications to regional anesthesia; however, epidural anesthesia is a superior method of management of pain during labor. One must also consider that 30% to 40% of patients with chorioamnionitis require cesarean delivery. Because of the increased morbidity and mortality of general anesthesia in this population, it may be reasonable to proceed with regional anesthesia. Based on a review of the literature, it is difficult to estimate the risk of an infrequently occurring event. We recommend evaluation of each individual to determine the risks and benefits of the anesthetic. However, it is prudent to administer antibiotics before the regional anesthetic and adhere to strict aseptic technique. Postprocedure monitoring is essential for early detection and treatment of complications.

A retrospective review of ampicillin-sulbactam and amoxicillin + clavulanate vs cefazolin/cephalexin and erythromycin in the setting of preterm premature rupture of membranes: maternal and neonatal outcomes

OBJECTIVE

The purpose of this study was to compare the efficacy and outcomes of 2 different antibiotic regimens that are used to prolong latency in preterm premature rupture of membranes. The primary objective was to determine whether the use of ampicillin-sulbactam/amoxicillin + clavulanate was associated with an increased risk of necrotizing enterocolitis.

STUDY DESIGN

A retrospective review of pregnancies that were complicated by preterm premature rupture of membranes from 1999-2006 at 2 institutions was performed. Outcomes were compared between subjects who received parenteral ampicillin-sulbactam followed by oral amoxicillin + clavulanate (protocol A) and subjects who received parenteral cefazolin and erythromycin followed by oral cephalexin and erythromycin (protocol B).

RESULTS

There were 147 women who were evaluated; 88 women received protocol A, and 59 women received protocol B. There were no differences in latency period, gestational age at delivery, or route of delivery. The incidence of necrotizing enterocolitis was 8.0% and 10.2% for protocol A and protocol B, respectively (P = .64).

CONCLUSION

Ampicillin-sulbactam/amoxicillin + clavulanate was not associated with an increase in neonatal necrotizing enterocolitis. Erythromycin in combination with cefazolin and cephalexin is an effective latency antibiotic regimen.

A phase III clinical trial of antibiotics to reduce chorioamnionitis-related perinatal HIV-1 transmission

OBJECTIVE

A multisite study was conducted in Africa to assess the efficacy of antibiotics to reduce mother-to-child transmission (MTCT) of HIV-1.

DESIGN

A randomized, double-blinded, placebo-controlled, phase III clinical trial.

METHODS

HIV-1-infected women were randomly assigned at 20-24 weeks' gestation to receive either antibiotics (metronidazole plus erythromycin antenatally and metronidazole plus ampicillin intrapartum) or placebo. Maternal study procedures were performed at 20-24, 26-30, and 36 weeks antenatally, and at labor/delivery. Infants were seen at birth, 4-6 weeks, and 3, 6, 9 and 12 months. The primary efficacy endpoints were overall infant HIV-1 infection and HIV-1-free survival at 4-6 weeks. All women and infants received single-dose nevirapine prophylaxis in this study.

RESULTS

A total of 1510 live-born infants were included in the primary analysis. The proportions of HIV-1-infected infants at birth were similar (antibiotics 7.1%; placebo 8.3%; P = 0.41). Likewise, there were no statistically significant differences at 4-6 weeks in the overall risk of MTCT of HIV-1 (antibiotics 16.2%; placebo 15.8%; P = 0.89) or HIV-1-free survival (79.4% in each study arm). Post-randomization, the proportion of women with bacterial vaginosis at the second antenatal visit was significantly lower in the antibiotics arm compared with the placebo arm (23.8 versus 39.7%; P < 0.001), but the frequency of histological chorioamnionitis was not different (antibiotics 36.9%; placebo 39.7%; P = 0.30). Adverse events in mothers and their infants did not differ by randomization arm.

CONCLUSION

This simple antepartum and peripartum antibiotic regimen did not reduce the risk of MTCT of HIV-1.

The HPTN 024 Study: the efficacy of antibiotics to prevent chorioamnionitis and preterm birth

OBJECTIVE

The use of antibiotics to prevent preterm birth has achieved mixed results. Our goal in this study was to determine if antibiotics given prenatally and during labor reduce the incidence of preterm birth and histologic chorioamnionitis.

STUDY DESIGN

A double-blind randomized placebo-controlled trial of antibiotics to reduce preterm birth was conducted in 4 African sites. Both HIV-infected and uninfected pregnant women were given 2 courses of antibiotics, prenatally at 24 weeks (metronidazole 250 mg and erythromycin 250 mg tid orally for 7 days), and during labor (metronidazole 250 mg and ampicillin 500 mg q 4 hours) or identically appearing placebos. Two thousand ninety-eight HIV-infected and 335 HIV-uninfected women had evaluable end points, including gestational age determined by both obstetric and pediatric criteria and birth weight (BWT). Pre- and post-treatment rates of various sexually transmitted infections (STI) were determined and placentas were evaluated for histologic chorioamnionitis.

RESULTS

Comparing antibiotic versus placebo treated HIV-infected and uninfected women, there were few differences in mean gestational age at delivery, the percent of preterm births, the time between randomization and delivery, or BWT. Four weeks after the 24-week antibiotic/placebo course, bacterial vaginosis, and trichomoniasis were reduced by 49% to 61% in the antibiotic groups compared with the placebo groups. However, in both the HIV-infected and uninfected groups, the placentas showed no difference in the rate of histologic chorioamnionitis. There were significant differences between HIV-infected and uninfected women, with the former having less education, a history of more stillbirths, more STIs, and in this pregnancy, a lower BWT (2949 vs 3100 g, P < .0001).

CONCLUSION

Despite reducing the rate of vaginal infections, the antibiotic regimen used in this study did not reduce the rate of preterm birth, increase the time to delivery, or increase BWT. Failure of this regimen to reduce the rate of histologic chorioamnionitis may explain the reason the antibiotics failed to reduce preterm birth.

Chorioamnionitis and neonatal encephalopathy in term infants with fetal acidemia: histopathologic correlations

The aim of this study was to determine whether the presence or severity of histologic abnormalities of infection/inflammation such as chorioamnionitis, vasculitis, or funisitis confers an additional risk for neonatal encephalopathy in term infants delivered in the presence of severe fetal acidosis. The medical records as well as placental pathology of term infants (n = 51) born with a cord umbilical arterial pH <7.00 were reviewed. Abnormal outcome was predefined as Sarnat stage 2 or 3 neonatal encephalopathy in the first week of life or neonatal death as a consequence of severe brain injury. Consistent with prior data, the presence of severe fetal acidemia, a low 5-minute Apgar score, and need for cardiopulmonary resuscitation were significantly associated with neonatal encephalopathy. However, the presence of histologic chorioamnionitis had a poor predictive value and did not confer additional risk for the subsequent development of neonatal encephalopathy.

Vitamins C and E in the latency period in women with preterm premature rupture of membranes

OBJECTIVE

To determine whether supplementation with vitamins C and E after preterm premature rupture of membranes (PPROM) is associated with an increased latency period.

METHODS

In this double-blind, randomized, controlled trial, 60 women with singleton pregnancies of 26 to 34 weeks' duration and PPROM were randomly assigned to vitamin C (500 mg/day) and vitamin E (400 IU/day) or placebo until delivery. All women received 2 doses of betamethasone in the first 24 h after admission as well as broad-spectrum antibiotic prophylaxis.

RESULTS

Important demographic, as well as clinical characteristics such as number of cases of chorioamnionitis, early neonatal sepsis, and respiratory distress syndrome, were similar in the 2 groups. A statically significant difference in the mean+/-S.D. number of days of latency was found between the groups (10.5+/-5.2 days vs. 3.5+/-4.0 days (P = 0.03).

CONCLUSION

Vitamins C and E supplementation of after PPROM is associated with a longer latency before delivery.

Antenatal steroids may reduce adverse neurological outcome following chorioamnionitis: neurodevelopmental outcome and chorioamnionitis in premature infants

OBJECTIVE

To examine the effect of antenatal steroid exposure and in utero inflammation on the development of severe intraventricular haemorrhage, periventricular leukomalacia and long-term neurological outcome in infants less than 30 completed weeks gestation.

METHOD

Infants less than 30 completed weeks gestation from January 1996 to July 2001 were identified from a prospectively managed database. Placental pathology was reviewed for the presence or absence of chorioamnionitis and funisitis. Infants were divided into three groups depending on the degree of exposure to fetal inflammation (no inflammation, chorioamnionitis only and chorioamnionitis and funisitis). Data relating to gestational age, birthweight, sex, antenatal steroid exposure, surfactant treatment, days of positive pressure ventilation and days of oxygen requirement were collected. Cerebral ultrasound studies were examined for evidence of intraventricular or intraparenchymal echodensity and periventricular leukomalacia. Long-term neurological outcome was assessed by neurological examination for cerebral palsy and by Griffiths Mental Developmental Assessment for general developmental quotient.

RESULTS

Two hundred and twenty infants were identified. The mean gestational age was 27.7 weeks and the mean birthweight 1092 g. Seventy-two per cent of mothers had received a complete course of antenatal steroids. The risk of Grade III intraventricular haemorrhage or intraparenchymal echodensity was associated with exposure to in utero inflammation if a complete course of antenatal steroids had not been received (P = 0.002). This association did not exist if a complete course of antenatal steroids was given (P = 0.62). Fourteen infants had cerebral palsy (7%). The presence of cerebral palsy was also associated with in utero inflammation in the absence of complete antenatal steroid cover (P = 0.03) and not in the presence of complete cover (P = 0.59). The mean general developmental quotient on Griffiths Mental Developmental Assessment at 12 months or 3 years was not affected by exposure to in utero inflammation regardless of antenatal steroid exposure.

CONCLUSION

Risk of intraventricular haemorrhage or intraparenchymal echodensity and cerebral palsy was associated with in utero inflammation in the absence of a complete course of antenatal steroids. A complete course of antenatal steroids appeared to extinguish any association between in utero inflammation and adverse neurological outcome.

Outcome of neonates less than 30 weeks gestation with histologic chorioamnionitis

The purpose of this study was to determine the short-term outcome of newborns less than 30 weeks gestation when there is definite placental histologic chorioamnionitis. A retrospective analysis was performed of records of all neonates delivered at our institution from January 1989 through January 1999. This information was retrieved from our perinatal database and pathology database. The population was stratified according to the presence or absence of histologic chorioamnionitis. Statistical analysis was performed using student t-test and Mann-Whitney method. Logistic regression was used to control for potential confounding variables. There were 392 neonates less than 30 weeks gestation delivered during this time period. Complete placental histology was available for 342 patients (87.4%). Histologic chorioamnionitis was identified in 140 (40.9%) cases. Those with histologic chorioamnionitis delivered sooner (26.3 versus 27.5 weeks), were of lower birth weight (920.1 versus 1029.8 g), and had lower 5-minute Apgarscores. Neonatal septicaemia and pneumonia were strongly associated with underlying histologic chorioamnionitis. There was a significant reduction in the incidence of respiratory distress syndrome (RDS) when histologic chorioamnionitis was present. Severe histologic chorioamnionitis increases the risk of premature delivery and is strongly associated with neonatal sepsis. There is a significant reduction in the incidence of RDS and neonatal mortality.

Vaginal chlorhexidine during labour for preventing maternal and neonatal infections (excluding Group B Streptococcal and HIV)

BACKGROUND

The incidence of chlorioamnionitis occurs in between 8 to 12 women for every 1000 live births and 96% of the cases of chlorioamnionitis are due to ascending infection. Following spontaneous vaginal delivery, 1% to 4% of women develop postpartum endometritis. The incidence of neonatal sepsis is 0.5% to 1% of all infants born. Maternal vaginal bacteria are the main agents for these infections. It is reasonable to speculate that prevention of maternal and neonatal infections might be possible by washing the vagina and cervix with an antibacterial agent for all women during labour. Chlorhexidine belongs to the class of compounds known as the bis-biguanides. Chlorhexidine has antibacterial action against a wide range of aerobic and anaerobic bacteria, including those implicated in peripartal infections.

OBJECTIVES

To evaluate the effectiveness and side-effects of chlorhexidine vaginal douching during labour in reducing maternal and neonatal infections (excluding Group B Streptococcal and HIV).

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (July 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2002), MEDLINE (from 1966 to 2002), EMBASE (from 1980 to 2002), CINAHL (from 1982 to 2002) and LILACS (from 1982 to 2002).

SELECTION CRITERIA

Randomized or quasi-randomized trials comparing chlorhexidine vaginal douching during labour with placebo or other vaginal disinfectant to prevent (reduce) maternal and neonatal infections (excluding Group B Streptococcal and HIV).

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial eligibility and quality, extracted and entered the data into the RevMan software and interpreted the data. A third reviewer analysed and interpreted the data. The fourth reviewer also interpreted the data.

MAIN RESULTS

Three studies (3012 participants) were included. There was no evidence of an effect of vaginal chlorhexidine during labour in preventing maternal and neonatal infections. Although the data suggest a trend in reducing postpartum endometritis, the difference was not statistically significant (relative risk 0.83; 95% confidence interval 0.61 to 1.13).

REVIEWERS' CONCLUSIONS

There is no evidence to support the use of vaginal chlorhexidine during labour in preventing maternal and neonatal infections. There is a need for a well-designed randomized controlled trial using appropriate concentration and volume of vaginal chlorhexidine irrigation solution and with adequate sample size.

Antenatal corticosteroid therapy in premature infants

OBJECTIVE

The objective was to examine the effect of antenatal corticosteroid treatment on premature infants, with special attention to any possible adverse effects on neonatal outcome.

METHODS

A retrospective chart review of all singleton and multiple pregnancies delivered in our perinatal center between 1991 and 1999, who had a birth weight of < or =1,500 g and who were subsequently admitted to our neonatal intensive care unit. Three hundred and sixty-five infants were included in the study and divided into two groups. One group had a gestational age below 28 weeks (< or =196 days) and one group was 28 weeks (>196 days) onward.

RESULTS

Antenatal corticosteroid therapy reduced the duration of mechanical ventilation, the need for supplementary oxygen, and the need for exogenous surfactant in neonates born at >196 days's gestation (p<0.05). Corticosteroid treatment seemed to benefit the respiratory distress syndrome (RDS; p=0.051) in this group. There were less cases of necrotizing enterocolitis and neonatal death in the group with corticosteroid treatment (p<0.05). Before 28 weeks' gestation, all parameters that were examined (e.g., duration of mechanical ventilation, need for supplemental oxygen, need for exogenous surfactant, RDS) showed no significant differences between those pregnancies pre-treated with corticosteroids or those not treated with corticosteroids. There was no adverse effect of corticosteroids on chorioamnionitis and early onset sepsis in pregnancies with a premature rupture of the membranes. Repeated corticosteroid treatment had no effect on birth weight, but did not improve neonatal outcome either. The interval between last corticosteroid treatment and delivery had no influence on RDS. There was no effect of corticosteroids on periventricular leukomalacia and intraventricular hemorrhage. Regression analysis showed a higher risk of severe RDS in multiple gestations.

CONCLUSION

Antenatal betamethasone treatment reduces perinatal morbidity and mortality after 28 weeks' gestation. We found no adverse effects and also no benefit of repetitive corticosteroid treatment. The interval between last corticosteroid treatment and delivery did not influence the incidence of RDS. Dose, timing, and rate of antenatal corticosteroids should be reconsidered in multiple gestations.

Chorioamnionitis: a risk factor for fetal and neonatal morbidity

Despite widespread use of drugs to arrest preterm labor, there has been no decrease in the numbers of low-birth-weight or preterm infants in the last 20 years. Evidence from many sources links preterm birth to symptomatic and subclinical infections. Recently, an increasing body of evidence has suggested that not only is subclinical infection responsible for preterm birth but also for many serious neonatal sequelae, including periventricular leukomalacia, cerebral palsy, respiratory distress and even bronchopulmonary dysplasia and necrotizing enterocolitis. Proxies of intrauterine infection include clinical chorioamnionitis, histological chorioamnionitis and intraamniotic increase in cytokines, which have been found to be associated with acute neonatal morbidity and mortality and, at least to some degree, with neurological impairment, chronic lung disease and thymus involution in the preterm infant. The infectious/inflammatory mechanisms involved are not fully understood, and the types of microbes and genetic features of host adaptive and innate immune responses need to be better characterized.

Maternal epidural analgesia and rates of maternal antibiotic treatment in a low-risk nulliparous population

BACKGROUND

Epidural analgesia is associated with an increased rate of fever in prospective randomized trials. While the evidence suggests that epidural fever is not infectious, epidural analgesia has been associated with increased rates of antibiotic use, the indications that prompt treatment have not been examined.

METHODS

We analyzed 1235 nulliparous women with singleton term pregnancies presenting in labor with a temperature of < 99.5 degrees F. Antibiotic use during labor was categorized by indication.

RESULTS

A total of 59.6% of women received epidural analgesia. The rate of antibiotic use was significantly higher in women receiving epidural analgesia (28 vs 10.8%). After adjusting for confounders using logistic regression, epidural analgesia was associated with a relative risk of 2.6 (95% CI 2.0, 3.4) for antibiotic treatment. The majority of the increased risk was due to significantly higher rates of antibiotic treatment for presumed chorioamnionitis (9.0 vs 0.4%) in the epidural analgesia group.

CONCLUSION

Epidural-related fever results in excess maternal antibiotic treatment for presumed chorioamnionitis.

Chorioamnionitis and brain injury

The limited available evidence supports a strong association of chorioamnionitis with neonatal encephalopathy and CP in the term infant. The association of chorioamnionitis with depressed Apgar scores or neonatal seizures and with CP is equivocal in the preterm infant. Different study results may be related to differences in study populations, perhaps specifically to differences in susceptibility by stages of neurologic development as well as differences in gene frequencies associated with inflammation and thrombophilia. We require further understanding of the normal roles of cytokines in brain development, pregnancy, and inflammatory homeostasis before clinical interventions directed at cytokines, their receptors, or the inflammatory process are considered.

Antibiotic administration in patients with preterm premature rupture of membranes reduces the rate of histological chorioamnionitis: a prospective, randomized, controlled study

OBJECTIVE

To determine whether antibiotic administration in patients with preterm premature rupture of membranes is associated with a reduction in the rate of histological chorioamnionitis and funisitis.

METHODS

One hundred consecutive patients with preterm premature rupture of membranes and no labor between 24 and 34 weeks were invited to participate in this study. Eligible patients randomly received either clindamycin-gentamicin for 7 days or placebo, and were managed expectantly until 35 weeks unless fetal or maternal indications developed. Microbial invasion of the amniotic cavity was defined as the presence of a positive amniotic fluid culture obtained by transabdominal amniocentesis. Cervicovaginal infection was diagnosed when bacterial vaginosis or a positive culture for cervicovaginal pathogens or facultative bacteria associated with a significant increase in the white blood cell count were found. Histological chorioamnionitis was based on the observation of polymorphonuclear leukocyte infiltration of the chorionic plate or the extraplacental fetal membranes. Funisitis was diagnosed in the presence of polymorphonuclear leukocyte infiltration into the umbilical vessel walls or Wharton jelly. Statistics were performed using contingency tables.

RESULTS

Seventy-one patients with available histological study of the placenta were included. Thirty-five women received antibiotics and 36 were given placebo. Patients who received antibiotics had a significantly lower rate of histological chorioamnionitis than patients who received placebo (46% (16/35) vs. 69% (25/36), respectively; p < 0.05). This effect was more pronounced among women with microbial invasion of the amniotic cavity and/or cervicovaginal infection (58% vs. 89%, respectively; p < 0.01). Antibiotic therapy was associated with an increase in the frequency of placentas without histological abnormalities (29% vs. 6%; p < 0.01). The frequency of funisitis was not different between groups.

CONCLUSION

Administration of antibiotics in patients with preterm premature rupture of membranes is associated with a significant reduction in the incidence of histological chorioamnionitis but it does not modify the frequency of funisitis.

The Northwestern Twin Chorionicity Study: I. Discordant inflammatory findings that are related to chorionicity in presenting versus nonpresenting twins

OBJECTIVE

The purpose of this study was to evaluate the association between chorionicity and discordant chorioamnionitis and funisitis in twin gestations.

STUDY DESIGN

This was a retrospective analysis of 1156 twin placentas with a standardized diagnosis of chorionicity, chorioamnionitis, and funisitis for comparison between presenting and nonpresenting twins with dichorionic-separate, dichorionic-fused, and monochorionic placentas.

RESULTS

Frequencies of chorioamnionitis in the nonpresenting twin were significantly lower in dichorionic placentas (odds ratio, 0.4; 95% CI, 0.3, 0.6, in dichorionic-separate placentas; odds ratio, 0.5; 95% CI, 0.3, 0.8, in dichorionic-fused placentas) compared with monochorionic placentas. The frequency of advanced inflammation (ie, chorioamnionitis with funisitis) was significantly lower in the nonpresenting twin than in the presenting twin, but only in dichorionic-separate placentas (odds ratio, 0.2; 95% CI, 0.1, 0.4).

CONCLUSION

Dichorionic placentas confer significant protection against the spread of chorioamnionitis from the presenting to the nonpresenting gestational sac. In the more advanced process that involves the umbilical cord, only the subset of separate dichorionic placentas confers this protective effect against the spread of inflammation.

Indications for and questions about antenatal steroids

Antenatal glucocorticoid treatment of women at risk of preterm delivery between 24 and 34 weeks' gestation has been the standard of care since 1994. Recent information supports its use with preterm prolonged rupture of membranes, in very early gestations in which neonatal survival will be attempted, and in women with preeclampsia. Many women who deliver before 30 weeks' gestation have chronic silent chorioamnionitis, which does not seem to be a contraindication to antenatal glucocorticoid therapy. The preferred antenatal treatment is a short- and long-acting betamethasone combination given as 12-mg maternal injections at the identification of preterm labor and 24 hours later. Repeated courses of antenatal glucocorticoids given at 7- to 10-day intervals if preterm delivery does not occur are not indicated. Antenatal glucocorticoid therapy is very effective, and no adverse effects of a single treatment course have been identified.

[Sialic acid of glycoconjugates in amniotic fluid]

OBJECTIVES

Sialic acid is a negatively charged monosaccharide attached to non-reducing end of N- and O-linked carbohydrate chains of glycoconjugates. The claimed biological functions of sialic acid include its participation in cell to cell recognition and interaction as well as affecting the function of receptors by providing binding sites for ligand. Increased sialic acid concentration have been observed in several diseases e.g. malignancies, diabetes, inflammatory disorders, rheumatoid arthritis and alcoholism.

DESIGN

The aim of the present work was to determine if the amount of sialic acid attached to glycoconjugates of amniotic fluid changes during pregnancy.

MATERIALS AND METHODS

The sialic acid content in 47 samples of amniotic fluid derived from pregnant women with gestational age between 13 and 42 was studied by sialic acid specific lectins immunosorbent assay. The patient samples were divided into seven groups.

RESULTS

Time dependent changes in the degree of sialylation of glycoconjugates in amniotic fluid during pregnancy, particularly in advanced pregnancy were observed. Moreover, the highest sialic acid content on glycoconjugates in pregnancies complicated by premature rupture of membranes and is prolonged pregnancy were also detected.

CONCLUSIONS

Sialic acid content determination in amniotic fluid could be a potentially useful marker of inflammation process of amniochorion during pregnancy.

Preventing recurrent second trimester group B streptococcus chorioamnionitis by intermittent prophylactic ampicillin

BACKGROUND

Whereas carrying group B streptococcus during pregnancy is common, second trimester group B streptococcus chorioamnionitis with intact membranes is rare, and recurrence of the latter problem even more so.

CASE

A 38-year-old multipara with a history of recurrent second trimester group B streptococcus chorioamnionitis resulting in pregnancy loss was treated, beginning at 14 weeks' gestation, with monthly prophylactic ampicillin therapy throughout pregnancy and delivered a healthy male infant at term.

CONCLUSION

In women with recurrent pregnancy loss due to second trimester group B streptococcus chorioamnionitis, an intermittent prophylactic antibiotic regimen throughout pregnancy might increase the probability of successful pregnancy.

Premature rupture of the membranes: an evidence-based approach to clinical care

Management of the patient with premature rupture of membranes is a relatively common but often perplexing problem frequently faced by the obstetrician. Despite the recent advances in perinatal care, premature membrane rupture, especially in the preterm patient, remains a potentially serious complication with important maternal and fetal implications. This review will address the important questions concerning the management of premature rupture of membranes and will attempt to provide comprehensive answers as they appear in the medical literature.

Association between funisitis and elevated interleukin-6 in cord blood

OBJECTIVE

[corrected] To determine whether elevated plasma interleukin-6 (IL-6) in umbilical venous cord blood at delivery is associated with funisitis and whether IL-6 can be used to screen for funisitis in preterm neonates.

METHODS

At the time of delivery, umbilical venous cord blood samples were collected from 92 infants for whom placental pathology results were also available. Interleukin-6 concentrations in the umbilical venous cord blood plasma were measured by immunoassay. Histologic examinations of the placenta and umbilical cord were done to determine the presence or absence of funisitis and chorioamnionitis. For a power of 90% with an alpha of.05, 12 subjects were required in each group.

RESULTS

We found a significant association between the presence of histologic funisitis and elevated umbilical venous cord blood plasma IL-6 concentrations (defined as 10 pg/mL or greater). Of 15 infants whose umbilical cords showed funisitis, 93% (14 of 15) had elevated umbilical venous cord blood plasma IL-6 concentrations. Of 77 infants without funisitis, 32% (25 of 77) had elevated IL-6 concentrations in their cords (P <.001, two-sided Fisher exact test). The negative predictive value of IL-6 as a screening test for funisitis was 98%.

CONCLUSION

In preterm neonates, screening for funisitis by using the immunoassay for IL-6 appears to be valid. In the near future, elevated umbilical venous cord blood IL-6 concentrations at delivery could be clinically useful to identify children who might benefit from early treatment for systemic fetal inflammatory syndrome.

Antibiotics and preterm labor

In summary, a definite association has been demonstrated between preterm labor and genital tract infection. Conclusions regarding the true benefits of antibiotics as adjunctive therapy in treatment of preterm labor are inconsistent. Whereas some of the studies were able to demonstrate significant prolongation of pregnancy, no consistent reduction in either maternal or neonatal morbidity has been demonstrated. However, because the actual incidental morbidity rate is low in the populations studied, the power of this finding is also low. The potential risks for using antimicrobials has yet to be adequately addressed. It has been shown that bacterial resistance can develop when antibiotics are used without specific aim or when a specific bacteria is undertreated. It has been recently shown that prenatal and intrapartum antibiotic use is associated with an increased risk for antibiotic resistant neonatal sepsis if infection occurs. Because of these reasons, we discourage the administration of antibiotic treatment to women in preterm labor for the purpose of pregnancy prolongations. Treatment should be directed towards those with specific indications for treatment (e.g., intrapartum, group B streptococci prophylaxis, urinary tract infection, etc). The primary flaw in these many evaluations of preterm labor is the true incidence of preterm birth. The clinical diagnosis of preterm labor is a difficult one. Approximately one-half of those individuals with preterm contractions will not deliver until term. So, the use of antibiotics for all women in idiopathic preterm labor is destined to treat many women who are unlikely to benefit. If we were able to truly identify those who were in "true" labor, perhaps we could be more selective in determining who may benefit from antibiotics. Biochemical markers such as onco-fetal fibronectin could well-be a helpful marker. Goldberg et al evaluated FFN in vaginal and cervical secretions while attempting to better-predict who would have upper genital tract infection. In this large, multicenter trial, patients were tested for FFN every 2 weeks from 23 to 30 weeks gestation. In those patients who proceeded to deliver before 32 weeks gestation, increased levels of cervical FFN (> 50 ng/ml) were identified in approximately one-quarter. Fetal fibronectin was positive in 4% of their samples and was found to be twice as likely in one with bacterial vaginosis. They showed that the presence of increased FFN was associated with upper genital tract infection (clinical and histologic chorioamnionitis) as a main reason for preterm labor and delivery (increased risk 16-20-fold). Those with increased FFN levels were also shown to have an increased incidence of neonatal sepsis as well. Peaceman et al used FFN to attempt to identify those at risk for preterm delivery among women with contractions between 24 and 34 6/7 weeks gestation. Those with negative FFN were less likely to deliver within 7 days of the test. The negative predictive value was 99.7%, suggesting that this test may be helpful in identifying women who would not benefit from antibiotic treatment. However, if in the absence of prospective clinical trials demonstrating the efficacy of this approach, we discourage the use of FFN screening for this indication.