Infection and preterm labour

Diversity and stability of cultured vaginal lactobacilli in pregnant women from a multi-ethnic urban UK population

AIM

To determine the diversity and stability of cultured vaginal lactobacilli in a multi-ethnic population of pregnant women.

METHODS AND RESULTS

A single-centre, prospective, cohort study was performed in a tertiary perinatal centre in East London, UK. Self-collected vaginal swabs at 13 and 20 weeks gestation were obtained from women attending for routine antenatal care and cultured for lactobacilli. In women who provided both swabs, 37 of 203 (18%) had no lactobacilli cultured at either time. Only 53 (26%) had the same species at both times. Black women were less likely to have lactobacilli cultured at 13 weeks (P = 0·014), and Black and Asian women were less likely to have lactobacilli cultured at 20 weeks (P = 0·002) compared with those in the White and Other groups.

CONCLUSIONS

Significant differences exist between ethnic groups in the carriage and stability of vaginal lactobacilli.

SIGNIFICANCE AND IMPACT OF THE STUDY

These differences have implications for the design of interventions aimed at normalizing the vaginal microbiota in pregnant women.

HIV transmission to extremely low birth weight infants

BACKGROUND

Prematurity increases the perinatal HIV transmission rate compared with term infants. There is sparse literature documenting the risk of transmission of HIV to extremely low birth weight (ELBW) infants.

OBJECTIVE

To determine the risk of perinatal transmission of HIV to ELBW infants in a tertiary neonatal unit in South Africa.

METHODS

A prospective database was maintained on all inborn ELBW infants over a 1-year period from March 2010 to February 2011. Survival and DNA HIV polymerase chain reaction results at 6 weeks were recorded.

RESULTS

Of the 180 ELBW infants, 51 (28%) of these babies were HIV exposed. Of these 51 infants, 37 survived until 6 weeks of age. Polymerase chain reaction testing revealed 1 HIV-positive infant for a rate of 2.7% (95% confidence interval: 0.7-14.1%). Twenty-six (72%) of the 36 mothers received antiretroviral drugs, but only 16 (44%) had been treated for more than 1 month.

CONCLUSIONS

The rate of HIV transmission in this cohort of ELBW infants is very low despite only 44% of the mothers receiving adequate antiretroviral drugs. We postulate that this is due to our high (89%) cesarean section rate, universal (100%) infant prophylactic antiretroviral drugs and the use of pasteurized breast milk.

The INIS Study. International Neonatal Immunotherapy Study: non-specific intravenous immunoglobulin therapy for suspected or proven neonatal sepsis: an international, placebo controlled, multicentre randomised trial

BACKGROUND

Sepsis is an important cause of neonatal death and perinatal brain damage, particularly in preterm infants. While effective antibiotic treatment is essential treatment for sepsis, resistance to antibiotics is increasing. Adjuvant therapies, such as intravenous immunoglobulin, therefore offer an important additional strategy. Three Cochrane systematic reviews of randomised controlled trials in nearly 6,000 patients suggest that non-specific, polyclonal intravenous immunoglobulin is safe and reduces sepsis by about 15% when used as prophylaxis but does not reduce mortality in this situation. When intravenous immunoglobulin is used in the acute treatment of neonatal sepsis, however, there is a suggestion that it may reduce mortality by 45%. However, the existing trials of treatment were small and lacked long-term follow-up data.This study will assess reliably whether treatment of neonatal sepsis with intravenous immunoglobulin reduces mortality and adverse neuro-developmental outcome.

METHODS AND DESIGN

A randomised, placebo controlled, double blind trial. Babies with suspected or proven neonatal sepsis will be randomised to receive intravenous immunoglobulin therapy or placebo.

ELIGIBILITY CRITERIA

Babies must be receiving antibiotics and have proven or suspected serious infection AND have at least one of the following: birthweight less than 1500 g OR evidence of infection in blood culture, cerebrospinal fluid or usually sterile body fluid OR be receiving respiratory support via an endotracheal tube AND there is substantial uncertainty that intravenous immunoglobulin is indicated.

EXCLUSION CRITERIA

Babies are excluded if intravenous immunoglobulin has already been given OR intravenous immunoglobulin is thought to be needed OR contra-indicated. Trial treatment: Babies will be given either 10 ml/kg of intravenous immunoglobulin or identical placebo solution over 4-6 hours, repeated 48 hours later.

PRIMARY OUTCOME

Mortality or major disability at two years, corrected for gestational age.

DATA COLLECTION

Data will be collected at discharge from hospital and at 2 years of age (corrected for gestation) using a parental questionnaire and a health status questionnaire completed during a face-to-face follow-up appointment with the child's paediatrician.

TRIAL REGISTRATION

Current Controlled Trials ISCRTN94984750.

Risk factors for preterm, low birth weight and small for gestational age birth in urban Aboriginal and Torres Strait Islander women in Townsville

OBJECTIVES

To assess the characteristics of Indigenous births and to examine the risk factors for preterm (<37 weeks), low birth weight (<2,500 g) and small for gestational age (SGA) births in a remote urban setting.

DESIGN

Prospective cohort of singleton births to women attending Townsville Aboriginal and Islander Health Services (TAIHS) for shared antenatal care between 1 January 2000 and 31 December 2003.

MAIN OUTCOME MEASURES

Demographic, obstetric, and antenatal care characteristics are described. Risk factors for preterm birth, low birth weight and SGA births are assessed.

RESULTS

The mean age of the mothers was 25.0 years (95% CI 24.5-25.5), 15.8% reported hazardous or harmful alcohol use, 15.1% domestic violence, 30% had an inter-pregnancy interval of less than 12 months and 9.2% an unwanted pregnancy. The prevalence of infection was 50.2%. Predictors of preterm birth were a previous preterm birth, low body mass index (BMI) and inadequate antenatal care, with the subgroup at greatest risk of preterm birth being women with a previous preterm birth and infection in the current pregnancy. Predictors of a low birth weight birth were a previous stillbirth, low BMI and an interaction of urine infection and non-Townsville residence; predictors of an SGA birth were tobacco use, pregnancy-induced hypertension and interaction of urine infection and harmful alcohol use.

CONCLUSION

The prevalence of demographic and clinical risk factors is high in this group of urban Indigenous women. Strategies addressing potentially modifiable risk factors should be an important focus of antenatal care delivery to Indigenous women and may represent an opportunity to improve perinatal outcome in Indigenous communities in Australia.

Maternal periodontal disease and preterm low birthweight: case-control study

Periodontal disease has been suggested to be an important risk factor for preterm low birthweight (PLBW). Here we report a case-control study of 236 cases (infants < 37 wks and weighing < 2499 g) and a daily random sample of 507 controls (> or = 38 wks and weighing > or = 2500 g). Clinical periodontal indices were measured on the labor wards. Associated risk factors for periodontal disease and PLBW were ascertained by means of a structured questionnaire and maternity notes. The risk for PLBW decreased with increasing pocket depth (odds ratio [OR] 0.83, 95% confidence interval [CI] 0.68 to 1.00). After adjustment for maternal age, ethnicity, maternal education, smoking, alcohol consumption, infections, and hypertension during pregnancy, this decreased further (OR 0.78, 95% CI 0.64 to 0.99). We found no evidence for an association between PLBW and periodontal disease. Our results do not support a specific drive to improve periodontal health of pregnant women as a means of improving pregnancy outcomes.

Risk adjusted and population based studies of the outcome for high risk infants in Scotland and Australia. International Neonatal Network, Scottish Neonatal Consultants, Nurses Collaborative Study Group

OBJECTIVES

To compare outcomes of care in selected neonatal intensive care units (NICUs) for very low birthweight (VLBW) or preterm infants in Scotland and Australia (study 1) and perinatal care for all VLBW infants in both countries (study 2).

DESIGN

Study 1: risk adjusted cohort study; study 2: population based cohort study.

SUBJECTS

Study 1: all 2621 infants of < 1500 g birth weight or < 31 weeks' gestation admitted to a volunteer sample of hospitals comprising eight of all 17 Scottish NICUs and six of all 12 tertiary NICUs in New South Wales and Queensland in 1993-1994; study 2: all 5986 infants of 500-1499 g birth weight registered as live born in Scotland and Australia in 1993-1994.

MAIN OUTCOMES

Study 1: (a) hospital death; (b) death or cerebral damage, each adjusted for gestation and CRIB (clinical risk index for babies); study 2: neonatal (28 day) mortality.

RESULTS

Study 1. Data were obtained for 1628 admissions in six Australian NICUs, 775 in five Scottish tertiary NICUs, and 148 in three Scottish non-tertiary NICUs. Crude hospital death rates were 13%, 22%, and 22% respectively. Risk adjusted hospital mortality was about 50% higher in Scottish than in Australian NICUs (adjusted mortality ratio 1.46, 95% confidence interval (CI) 1.29 to 1.63, p < 0.001). There was no difference in risk adjusted outcomes between Scottish tertiary and non-tertiary NICUs. After risk adjustment, death or cerebral damage was more common in Scottish than Australian NICUs (odds ratio 1.9, 95% CI 1.5 to 2.5). Both these risk adjusted adverse outcomes remained more common in Scottish than Australian NICUs after excluding all infants < 28 weeks' gestation from the comparison. Study 2. Population based neonatal mortality in infants of 500-1499 g was higher in Scotland (20.3%) than Australia (16.6%) (relative risk 1.22, 95% CI 1.08 to 1. 39, p = 0.002). In a post hoc analysis, neonatal mortality was also higher in England and Wales than in Australia.

CONCLUSIONS

Study 1: outcome was better in the Australian NICUs. Study 2: perinatal outcome was better in Australia. Both results may be consistent, at least in part, with differences in the organisation and implementation of neonatal care.

Use of antibiotics during pregnancy

OBJECTIVE

To describe the occurrence and distribution of antibiotic treatments, in addition their indications in control pregnant women in the population-based large dataset of the Hungarian Case-Control Surveillance of Congenital Abnormalities, 1980-1996.

RESULTS

Of 38 151 control pregnant women who delivered later newborn infants without congenital abnormality, 6554 (17.2%) were treated by antibiotics. Most women (14.5%) had penicillin, while 1.2% and 0.7% of pregnant women were treated by cephalosporins and tetracyclines, respectively. More than 100 pregnant women used the following antibiotics: ampicillin (6.9%), penamecillin (5.9%), cefalexin (1.0%), phenoxymethylpenicillin (0.6%), oxytetracycline (0.5%), erythromycin (0.45%), benzylpenicillin-procain (0.4%) and benzylpenicillin+benzylpenicillin-procain (0.3%). Different antibiotics had different indications for treatment. The mean birth weight was significantly lower in the treated group compared to the untreated group.

PRACTICAL IMPLICATIONS

Different antibiotics have different chemical structures and indications for treatment. Therefore it is not appropriate to evaluate their teratogenic potential of combined antibiotic groups. There may be many interactions between underlying maternal diseases, other drug uses, further confounding factors and antibiotics studied, thus adequate controls are needed to estimate the adjusted teratogenic odds-risk ratios. European countries have different spectrum of antibiotic use. It would be necessary to know these baseline data of different populations. The anxiety and fear created by the notion that nearly all drugs cause congenital abnormalities may be more harmful than some proven human teratogenic drugs themselves. Thus a better risk-benefit estimation for antibiotic uses during pregnancy is an urgent and important task.