Perspective on women's health: editors' 1997-1998 year in review

Heart disease, breast cancer, and hormone therapy were top clinical concerns in women's health in 1997. One of the major reports on heart disease confirmed that women are no different from men in terms of early infarct-related artery patency rates, reocclusion after thrombolytic therapy, and ventricular functional response to injury/reperfusion; nevertheless, women have 3 times the mortality of men in the first 30 days after an acute myocardial infarction. Research brought only modest gains in the understanding of breast cancer etiology in 1997, but engendered major debate on whether women younger than 50 years should have mammograms every 1 to 2 years. A National Institutes of Health consensus conference said no, but the National Cancer Institute's National Cancer Advisory Board said yes. Evidence of estrogen benefits and risks mounted: One report added to the data suggesting that estrogen may retard age-related memory loss, while another study reported that the risk of breast cancer significantly increased with long-term use of estrogens. The interest in selective estrogen receptor modulators (SERMs), also called "designer estrogens," grew. Efforts to develop pharmacologic treatment for obesity suffered a setback in 1997 when a team reported that 1 in 3 patients who used d-fenfluramine developed abnormal valvular thickening, with the most severe cases needing valve replacement. One of the most promising events in colorectal cancer, the third most common cancer in women, was the set of screening guidelines issued by the Agency for Health Care Policy and Research. The year ended with major ethical debates about multiple gestation and cloning.

Trichomonas vaginalis associated with low birth weight and preterm delivery. The Vaginal Infections and Prematurity Study Group

BACKGROUND

Several studies have suggested that pregnant women infected with Trichomonas vaginalis may be at increased risk of an adverse outcome.

GOAL

To evaluate prospectively the association between T. vaginalis and risk of adverse pregnancy outcome in a large cohort of ethnically diverse women.

STUDY DESIGN

At University-affiliated hospitals and antepartum clinics in five United States cities, 13,816 women (5,241 black, 4,226 Hispanic, and 4,349 white women) were enrolled at mid-gestation, tested for T. vaginalis by culture, and followed up until delivery.

RESULTS

The prevalence of T. vaginalis infection at enrollment was 12.6%. Race-specific prevalence rates were 22.8% for black, 6.6% for Hispanic, and 6.1% for white women. After multivariate analysis, vaginal infection with T. vaginalis at mid-gestation was significantly associated with low birth weight (odds ratio 1.3; 95% confidence interval 1.1 to 1.5), preterm delivery (odds ratio 1.3; 95% confidence interval 1.1 to 1.4), and preterm delivery of a low birth weight infant (odds ratio 1.4; 95% confidence interval 1.1 to 1.6). The attributable risk of T. vaginalis infection associated with low birth weight weight in blacks was 11% compared with 1.6% in Hispanics and 1.5% in whites.

CONCLUSIONS

After considering other recognized risk factors including co-infections, pregnant women infected with T. vaginalis at mid-gestation were statistically significantly more likely to have a low birth weight infant, to deliver preterm, and to have a preterm low birth weight infant. Compared with whites and Hispanics, T. vaginalis infection accounts for a disproportionately larger share of the low birth weight rate in blacks.

Tuberculosis skin testing in pregnancy: trends in a population

BACKGROUND

A change has recently been noted in the epidemiology of tuberculosis in the United States. Multiple factors, including human immunodeficiency virus (HIV) infection, increases in the homeless population, and immigration, are cited as causes for an increased prevalence. The population of pregnant women in New Orleans exhibits several of these risk factors and may be compared with a previous description of this group reported in 1983.

METHODS

All patients requesting obstetric care at the Medical Center of Louisiana at New Orleans from January 1994 to April 1995, were offered tuberculosis skin testing during their initial outpatient clinic visit. A skin test was considered positive if there was 10 mm of induration (5 mm in HIV-positive patients) at 48 hours. Other information collected included HIV status and ethnic group. This group was compared with a group of patients tested in 1981 and 1982.

RESULTS

The study included 1621 patients, who underwent testing and had available results. The only significant risk factor for a positive skin test in 1994 was Hispanic ethnicity. Hispanics are the most recent immigrants to the New Orleans area. In 1983 Asians were at highest risk and were the newest immigrants to the city. HIV status was insignificant as a predictor of skin test conversion.

CONCLUSIONS

Pregnant women at highest risk for tuberculosis in this urban center are recent immigrants to the United States. This is consistent with data reported by the Centers for Disease Control and Prevention from other locales. Efforts should be made to ensure that recently immigrated pregnant women receive skin testing as part of their obstetric care.

Elective versus emergency cesarean hysterectomy on a teaching service--1981 to 1991

We compared the differences in morbidity of elective and emergency cesarean hysterectomy (CH) in a training program. Records of patients who had elective or emergency CH were reviewed for information reflecting perioperative morbidity and fetal outcome. Eighty-eight CHs were elective and 18 were emergencies. Compared to emergency CHs, operative time for elective CHs was 30 minutes less, intraoperative blood loss was 700 mL lower, less postoperative blood replacement was needed, and hospital stay was 3.5 days shorter. Emergency CH had nearly twice the frequency of postoperative febrile morbidity and a three-times-higher rate of morbidity due to other causes. CHs were done at a gestational age of 36 or more weeks in 81.6% of elective cases, compared to only 50% of emergency cases. Mean birth weight of newborns delivered electively was 900 g higher, and Apgar scores were better. These data show that CHs done by house staff in training have a significantly lower complication rate when the operations are elective rather than emergent.

Clinical and microbiological correlates of vaginal trichomoniasis during pregnancy. The Vaginal Infections and Prematurity Study Group

Colonization with Trichomonas vaginalis is a possible cause of poor pregnancy outcome. To facilitate the diagnosis of this condition during pregnancy, we conducted a prospective, multicenter study of 13,816 gravid women who were between 23rd and 26th week of gestation. Findings significantly associated with T. vaginalis colonization included a yellow, green, or bloody discharge from the vagina or cervix; abnormal odor after KOH was added to a vaginal specimen; a vaginal pH of > 5.0; and cervical friability. The amount of vaginal discharge and abnormal consistency of the discharge were also associated with T. vaginalis colonization. These findings (except for cervical bleeding and odor after the addition of KOH to a vaginal specimen, which may be influenced by the presence of other flora) are consistent with those reported elsewhere. The clinical usefulness of these features is minimal, and it is more significant that other microorganisms are makers for trichomoniasis; therefore, controlling for other flora is important in the investigation of T. vaginalis colonization.

Association between bacterial vaginosis and preterm delivery of a low-birth-weight infant. The Vaginal Infections and Prematurity Study Group

BACKGROUND

Bacterial vaginosis is believed to be a risk factor for preterm delivery. We undertook a study of the association between bacterial vaginosis and the preterm delivery of infants with low birth weight after accounting for other known risk factors.

METHODS

In this cohort study, we enrolled 10,397 pregnant women from seven medical centers who had no known medical risk factors for preterm delivery. At 23 to 26 weeks' gestation, bacterial vaginosis was determined to be present or absent on the basis of the vaginal pH and the results of Gram's staining. The principal outcome variable was the delivery at less than 37 weeks' gestation of an infant with a birth weight below 2500 g.

RESULTS

Bacterial vaginosis was detected in 16 percent of the 10,397 women. The women with bacterial vaginosis were more likely to be unmarried, to be black, to have low incomes, and to have previously delivered low-birth-weight infants. In a multivariate analysis, the presence of bacterial vaginosis was related to preterm delivery of a low-birth-weight infant (odds ratio, 1.4; 95 percent confidence interval, 1.1 to 1.8). Other risk factors that were significantly associated with such a delivery in this population were the previous delivery of a low-birth-weight infant (odds ratio, 6.2; 95 percent confidence interval, 4.6 to 8.4), the loss of an earlier pregnancy (odds ratio, 1.7; 1.3 to 2.2), primigravidity (odds ratio, 1.6; 1.1 to 1.9), smoking (odds ratio, 1.4; 1.1 to 1.7); and black race (odds ratio, 1.4; 1.1 to 1.7). Among women with bacterial vaginosis, the highest risk of preterm delivery of a low-birth-weight infant was found among those with both vaginal bacteroides and Mycoplasma hominis (odds ratio, 2.1; 95 percent confidence interval, 1.5 to 3.0).

CONCLUSIONS

Bacterial vaginosis was associated with the preterm delivery of low-birth-weight infants independently of other recognized risk factors.

Outcome of the Vaginal Infections and Prematurity Study: results of a clinical trial of erythromycin among pregnant women colonized with group B streptococci

OBJECTIVE

Our purpose was to determine whether erythromycin treatment of pregnant women colonized with group B streptococci would reduce the occurrence of low birth weight (< 2500 gm) and preterm (< 37 completed weeks) birth.

STUDY DESIGN

In a double-blind clinical trial, 938 carriers of group B streptococci were randomized to receive erythromycin base (333 mg three times a day) or matching placebo beginning during the third trimester and before 30 weeks and continuing for 10 weeks or until 35 weeks 6 days of pregnancy.

RESULTS

Pregnancy outcomes were available for 97% of randomized women; 14% of subjects withdrew from the trial. Birth weight < 2500 gm occurred in 8.6% of the erythromycin and 6.1% of the placebo recipients (relative risk 1.4, 0.9 to 2.2, p = 0.16). Preterm delivery occurred in 11.4% of women randomized to erythromycin and in 12.3% randomized to placebo (relative risk 0.9, 95% confidence limits 0.6 to 1.3, p = 0.65). Greater benefit of erythromycin in reducing these outcomes was not observed among women reporting the best compliance.

CONCLUSIONS

In this study of pregnant women colonized with group B streptococci treatment with erythromycin was not shown to be effective at prolonging gestation or reducing low birth weight. Greater than anticipated complicating factors, including spontaneous clearance of the organism, use of nontrial antibiotics, and density of colonization, may have resulted in population sizes too small to detect a benefit of treatment. Future studies should take these factors into account in determining sample sizes.

Comparison of three regimens recommended by the Centers for Disease Control and Prevention for the treatment of women hospitalized with acute pelvic inflammatory disease

This six-center, prospective, open-label clinical trial compared the efficacy and safety of three regimens recommended by the Centers for Disease Control and Prevention (CDC) for the treatment of women hospitalized for acute pelvic inflammatory disease (PID). The study focused on the response to inpatient therapy, not on long-term prevention of sequelae. A severity score was used for objective comparison of the degree of illness before and after therapy. Women were randomly assigned (in a 1:1:1 ratio) to treatment with cefoxitin plus doxycycline, clindamycin plus gentamicin, or cefotetan plus doxycycline. Two hundred seventy-five (94.2%) of 292 evaluable women required no alteration in therapeutic regimen. The three regimens produced almost identical cure rates. No serious adverse clinical or laboratory events were observed. In short, the three regimens recommended by the CDC for inpatient therapy of acute PID were similarly effective and safe.

Episiotomy repair: chromic versus polyglycolic acid suture

The use of an episiotomy for vaginal delivery is a controversial topic in modern obstetrics. If one is done, however, correct technique and appropriate suture material are important. On the LSU Obstetrics Service, the usual midline episiotomy has traditionally been closed with 2-0 chromic suture. Theoretically, the use of a less reactive material, eg, polyglycolic acid (Dexon), may be beneficial in terms of acute postpartum discomfort and healing. As a comparison of healing and patient comfort parameters between 2-0 chromic and 2-0 polyglycolic acid suture used for episiotomy repair after delivery, two consecutive months' worth of parturients at Medical Center of Louisiana/Charity Hospital had episiotomy repair, with either chromic or polyglycolic acid suture, by junior house officers routinely attending delivery. Patients had follow-up during hospital stay, and when examined at 6 weeks for evidence of suture line healing, they were also asked about comfort and resumption of sexual activity. Of 48 patients who had repair with 2-0 chromic suture, 6 were lost to follow-up. Of 44 gravidas who had repair with 2-0 polyglycolic acid suture, 7 were lost to follow-up. At the 6-week postpartum examination, patients with polyglycolic acid sutures had significantly better healing. A noticeable scar was present in 42 of 42 patients with chromic sutures versus 21 of 37 in the polyglycolic acid group, a scar with granulation tissue in 16 of 42 versus 3 of 37, and a gaping scar in 9 of 42 and 0 of 37, respectively. Recovery of function, measured by resumption of sexual activity by 6 weeks, was demonstrated in 1 of 42 patients who had chromic sutures versus 19 of 37 patients who had polyglycolic acid sutures. Episiotomy repair with 2-0 polyglycolic acid (Dexon) offers significant advantages over traditional 2-0 chromic suture, both in terms of wound healing and resumption of normal patient activity, including sexual activity.

Randomized comparative study of cefepime and cefotaxime in the treatment of acute obstetric and gynaecological infections

Patients with presumed acute gynaecological infections were randomized (2:1) to receive cefepime 2 g every 12 h (n = 159) or cefotaxime 2 g every 8 h (n = 72), both im or by a 30-min i.v. infusion. For evaluation of efficacy, patients were required to have a bacteriologically documented infection, with at least one pathogen isolated susceptible to both drugs. Duration of treatment was 2-8 days in the 95 cefepime-treated patients and 3-10 days in the 36 cefotaxime-treated patients with evaluable infections; approximately three-quarters of the patients in each group were treated for 4-5 days. Clinical response was satisfactory in 81/95 (85%) of the evaluable cefepime recipients and 30/36 (83%) of the evaluable cefotaxime recipients (P = 0.802). In total, 211 (85%) of the 247 pathogens isolated from evaluable cefepime recipients were eradicated, compared with 98 (90%) of 109 pathogens isolated from evaluable cefotaxime recipients. All pathogens were eradicated in 77 (81%) cefepime-treated patients and in 31 (86%) cefotaxime-treated patients (P = 0.379). Overall response to treatment, calculated by combining clinical response and individual patient bacteriological response, was considered effective, partially effective or ineffective in 77%, 13% and 11% of cefepime-treated patients respectively and in 75%, 19% and 6% of cefotaxime-treated patients respectively (P = 0.932 for effective response). Adverse clinical events were reported by 68 (43%) of 159 cefepime recipients and by 26 (36%) of 72 cefotaxime recipients (P = 0.342); adverse events were deemed drug-related in 6% of cefepime recipients (diarrhoea, rash and headache) and in 1% of cefotaxime recipients (diarrhoea, pruritus and rash). Treatment was discontinued prematurely due to adverse events in five cefepime-treated patients and in one cefotaxime-treated patient (P = 0.476). Local intolerance was reported by 33 (21%) of the 159 cefepime-treated patients and by 14 (19%) of the 72 cefotaxime-treated patients receiving drug via the iv route alone; none of the patients discontinued treatment because of local intolerance. Laboratory test abnormalities were observed in a small number of patients in each group (1-8%), but none warranted discontinuation of treatment. Cefepime 2 g bd appears to have efficacy and safety comparable to that of cefotaxime 2 g tid in the treatment of acute obstetric and gynaecological infections.

Comparison of morbidity in cesarean section hysterectomy versus cesarean section tubal ligation

This study was undertaken to compare the morbidity of cesarean section hysterectomy (C-HYST) and cesarean section bilateral tubal ligation (C-BTL) in a nonemergency or elective environment. Charts were reviewed for patients who underwent elective C-HYST or elective C-BTL before the onset of labor, without the use of antibiotics. Demographics, maternal morbidity, operative difficulties and postoperative complications were compared. Statistically significant differences in patient demographics include a higher maternal age in the C-HYST group than for those in the C-BTL group (31.0 +/- 5.8 versus 27.7 +/- 5.4 years; p = 0.002). C-BTL patients had higher gestational ages (39.4 +/- 1.6 versus 38.7 +/- 1.3 years; p = 0.0017). The C-HYST group had a higher estimated blood loss (1,201 +/- 472 versus 718 +/- 364 milliliters; p = 0.001), change in hematocrit level (6.0 +/- 4.4 percent versus 4.5 +/- 3.4 percent; p = 0.013) and operating time (115 +/- 37 versus 74 +/- 26 minutes; p = 0.0001). Blood transfusion was similar in both groups. Febrile morbidity was higher in the C-BTL group (68.0 percent versus 50.0 percent; p = 0.01). Endometritis was the significant determinant of febrile morbidity for the C-BTL group (41.7%) and cuff cellulitis in the C-HYST group (25.6 percent). Intraoperative and postoperative complications between the two groups were rare and not statistically different. Clinical morbidity for C-HYST is not significantly different than C-BTL. Elective C-HYST may be used in place of C-BTL when indications for hysterectomy are present.

Group B streptococcal colonization in the diabetic gravida patient

Previous reports have suggested that pregnant diabetic patients have higher carriage rates of group B Streptococcus (GBS) than nondiabetic gravidas. In order to evaluate this in our population, we cultured the posterior pharynx, endocervix, vagina, and rectum of 101 diabetic pregnant women and 100 nondiabetic gravida patients. The colonization rate of GBS was higher in the diabetic population, 31.7%, than in the nondiabetic group 19.0%, (p < 0.039). The vagina was the site most often positive in both diabetic and nondiabetic populations (23.8% and 17.0%, respectively, p = NS). The second site to culture positive overall and the only individual site that was positive significantly more often in diabetics was the rectum (16.9% versus 7.0%, p < 0.05). Differences in colonization rates were not evident when insulin requirement and diabetic classes were considered.

Demographic and behavioral predictors of Trichomonas vaginalis infection among pregnant women. The Vaginal Infections and Prematurity Study Group

There is little available information on the demographic and behavioral factors associated with Trichomonas vaginalis in pregnant women. Among 13,816 women from six urban clinic centers, the prevalence rate by culture at mid-pregnancy was 12.6%. Women colonized with T vaginalis were significantly more likely to be black, cigarette smokers, unmarried, and less educated (all P less than .01). Several behavioral factors associated with T vaginalis included greater numbers of sexual partners both lifetime and in the last year, 5 years or more of sexual activity, and a history of gonorrhea (all P less than .01). Trichomonas vaginalis-colonized women were less sexually active in the preceding month compared with uncolonized women (P less than .01). Women using either barrier or oral contraception in the 6 months before becoming pregnant were far less likely to be colonized (P less than .01). Other factors such as age, gravidity, income level, age at first coitus, and use of antibiotics, alcohol, or douche during pregnancy were not independently associated with T vaginalis colonization. Because many of the factors predictive of increased risk of colonization have also been shown to be associated with adverse pregnancy outcome, they should be considered in assessing the association of T vaginalis with adverse pregnancy outcome.

Antibiotic therapy for postcesarean endomyometritis

Puerperal uterine infection, or endomyometritis, occurs more commonly after cesarean section than after vaginal birth. With the rate of cesarean delivery almost 25% of all births in this country, such infection is relatively common. The classic therapy for postcesarean endomyometritis is the combination of clindamycin and an aminoglycoside, usually gentamicin or tobramycin. This regimen has requisite antimicrobial activity against the aerobes and anaerobes of the cervicovaginal flora that usually cause this illness. In the last decade, however, the availability of broad-spectrum beta-lactam antibiotics has enabled the clinician to combat postcesarean infection with single-agent antimicrobial chemotherapy, or monotherapy. "Higher-generation" cephalosporins such as cefoxitin, cefotetan, and moxalactam, as well as the semisynthetic penicillins ticarcillin, piperacillin, and mezlocillin, have all been used alone in the therapy for postpartum infection. The addition of a beta-lactamase inhibitor to this class of drugs now offers a further resource to the practitioner if beta-lactamase-mediated antibiotic resistance arises in the patient population being treated.

A randomized placebo-controlled trial of erythromycin for the treatment of Ureaplasma urealyticum to prevent premature delivery. The Vaginal Infections and Prematurity Study Group

Ureaplasma urealyticum has been associated with low birth weight and histologic chorioamnionitis and it is a frequent isolate from the chorioamnion of patients who are delivered prematurely. In prior clinical trials using antibiotics active against U. urealyticum, antibiotic treatment was associated with reduced prematurity and increased mean birth weight. In this multicenter, randomized, double-blind clinical trial, pregnant women with U. urealyticum were treated with 333 mg of erythromycin base or placebo three times daily, starting between 26 and 30 weeks' gestation and continuing through 35 completed weeks of pregnancy. Women with urinary tract infection or Neisseria gonorrhoeae infection were excluded from the trial, and women with Chlamydia trachomatis or group B streptococci were excluded from these analyses. Erythromycin did not eliminate U. urealyticum from the lower genital tract. There were no significant differences between erythromycin- and placebo-treated women in infant birth weight or gestational age at delivery, in frequency of premature rupture of membranes, or in neonatal outcome.

Temporary gastrostomy tubes in major gynecologic surgery

Prophylactic, temporary tube gastrostomy was done in 39 patients having major gynecologic surgery. Patients who were thought to be at high risk for postoperative ileus had a Foley catheter inserted intraoperatively through the greater curvature of the stomach. The procedure was found to be technically easy, well tolerated by the patients, and clinically useful, since postsurgical ileus was prevented or treated without the local and respiratory ill effects of the commonly used nasogastric tube.

Antibiotic therapy for pelvic inflammatory disease

Pelvic inflammatory disease (PID) is a serious illness with important medical and economic consequences, especially for young women. To make a significant impact on the acute and chronic morbidity associated with PID, experts currently recommend aggressive hospitalization and parenteral antimicrobial therapy. Antibiotic therapy, in the 1989 recommendations of the Centers for Disease Control, includes broad-spectrum cephalosporins active against penicillinase-producing Neisseria gonorrhoeae and the mixed aerobic and anaerobic genital flora, with concomitant administration of doxycycline for possible or proven infection with Chlamydia trachomatis. An alternative regimen consists of the "gold standard" combination of clindamycin plus an aminoglycoside. However, with the availability of beta-lactam/beta-lactamase-inhibitor combinations, such as ticarcillin/clavulanate and ampicillin/sulbactam, which have modest to very good activity against all these classes of bacteria, the gynecologist has the capability to utilize single-agent antibiotic regimens to adequately treat this potentially devastating sexually transmitted disease.

Hepatitis B

Hepatitis B virus is an important sexually transmitted organism that causes not only disease in sexual partners but important perinatal illness as well. The obstetrician-gynecologist must be aware of the epidemiology and the pathophysiology of HBV infections, as well as strategies for treatment and prevention. Physicians must first realize that their profession places them in a high-risk group by definition; therefore pre-exposure prophylaxis (that is, vaccination) is a logical step to take early in a medical career. Moreover, familiarity with guidelines for global HBsAg screening of pregnant women to prevent the serious pediatric hepatic morbidity that results from perinatal transmission of the virus is of paramount importance.

Listeriosis as an obstetric complication in an immunocompromised patient

We have reported a case of maternal death associated with Listeria monocytogenes septicemia in a woman who was being treated with immunosuppressive drugs for lupus nephritis. This report, coupled with a previous case of L monocytogenes sepsis in a pregnant patient with AIDS, emphasizes that L monocytogenes infection may be an important, unrecognized pathogen in pregnant women with impaired immunity.

Pelvic inflammatory disease and tubo-ovarian abscess

Pelvic inflammatory disease is a disease that has reached nearly epidemic proportions in the United States. The gold standard of diagnosis remains laparoscopy, and treatment is usually with broad-spectrum antibiotics and surgery.

Surgical sterilization at the time of cesarean delivery

The cesarean section operation has been recognized for more than a century as an ideal time for the obstetrician to effect sterilization, usually with minimal morbidity, by way of one of the methods of tubal ligation. The physician must choose between simple, quick methods such as the Pomeroy or Parkland, with their slightly higher but acceptable failure rates, or the more elaborate and foolproof methods that involve burial of the tubal ends, such as the Irving or Uchida, which are technically more difficult and time consuming. The authors stress that whichever procedure is utilized, the surgeon must resist the desire to elaborate on proven techniques; otherwise, higher than published failure rates may result. It is important for the patient to understand the risks, both of immediate morbidity and remote failure, and to give her informed consent. Attentive presterilization counseling may identify the patient who will regret the loss of her fertility.

Single-dose antimicrobial prophylaxis at abdominal hysterectomy. Cefamandole vs. cefotaxime

Two hundred twenty-three women were given a single, 1-g, intravenous dose of cefamandole or cefotaxime at elective abdominal hysterectomy in a multicenter, prospective, randomized, blind clinical trial of efficacy and safety. The demographic, surgical, efficacy and safety variables were statistically similar. Prior to discharge from the hospital, 12 women (5.3%) developed major postoperative pelvic infections that required parenteral antimicrobial therapy; no wound infections occurred. There was no correlation between a depressed antimicrobial development of significant postoperative infection. An expanded spectrum of antibacterial activity and a longer serum half-life did not improve clinical efficacy, and single-dose intravenous cephalosporin prophylaxis before abdominal hysterectomy was associated with a low incidence of pelvic infection.

Fine-tuning the fluorescent antibody test for chlamydial infections in pregnancy

Endocervical specimens from 168 asymptomatic women in the second trimester of pregnancy were screened for Chlamydia trachomatis infection with both standard tissue culture methods and a direct fluorescein-conjugated monoclonal antibody assay (MicroTrak). Based on tissue culture results, the prevalence of Chlamydia trachomatis was 26.2% in this population. Compared with tissue culture, the monoclonal antibody assay's sensitivity, specificity, and positive predictive value varied depending upon how many elementary bodies were used to define a positive test. Specifically, if a cutoff of ten elementary bodies was used (as per the manufacturer's instructions), the sensitivity, specificity, and positive predictive value of this test were 86.3, 98.4, and 95.0%, respectively. At the other extreme, a cutoff of one elementary body produced a more sensitive but less specific test, with parameters of 93.2, 89.5, and 75.9%, respectively. Based on these data and operating characteristic analysis, the cutoff value defining a positive test was appropriately set at two or more elementary bodies, at least for this study population. This resulted in a sensitivity, specificity, and positive predictive value of 93.2, 95.2, and 87.2%, respectively. This monoclonal antibody assay appears to be a reasonable substitute for cell culture for Chlamydia trachomatis. However, because of varying magnitudes and implications of false-positive and false-negative tests, clinicians are urged to determine the appropriate breakpoint for their individual laboratories and patient populations before substituting the direct fluorescent antibody test for tissue culture.

Ultrasonographic identification of the macrosomic fetus

Ultrasonographically determined biparietal diameter, femur length, abdominal circumference, and estimated fetal weight were analyzed with regard to their ability to predict the macrosomic newborn. Receiver operating characteristic curves were plotted for each of these variables. Estimated fetal weight was superior to biparietal diameter or femur length measurements in the identification of the overgrown fetus. Because of limitations of positive predictive values and sensitivities, application of these observations varies with the clinical setting in which they are used.

Production of a phosphatidylglycerol-like substance by genital flora bacteria

Bacteria contaminating amniotic fluid have anecdotally been shown to produce a phosphatidylglycerol-like substance, thus giving false positive tests for phosphatidylglycerol in vaginal pool fluid from patients with premature rupture of the membranes. Isolates of Escherichia coli, Proteus mirabilis, Acinetobacter calcoaceticus, Klebsiella pneumoniae, Staphylococcus aureus, coagulase-negative Staphylococcus, Streptococcus faecalis, and Streptococcus agalactiae (group B streptococcus) were grown in broth and analyzed for the presence of phosphatidylglycerol-like material by one-dimensional thin-layer chromatography and also by a polyclonal, immunologic slide agglutination test (Amniostat-FLM). All species demonstrated a positive test result for phosphatidylglycerol by either thin-layer chromatography, slide agglutination, or both. The material migrated separately from cardiolipin and phosphatidylethanolamine as determined by chromatography, but identically with the phosphatidylglycerol control. Gram-negative species were more strongly positive than gram-positive organisms. Colony counts on the order of 10(8) colony-forming units per milliliter were necessary to give positive test results for phosphatidylglycerol. The possible clinical implications of these findings are discussed.

Ticarcillin disodium and clavulanate potassium in the treatment of post-cesarean-section endomyometritis

The combination of ticarcillin disodium/clavulanate potassium is a potent, irreversible inhibitor of beta-lactamase that is active against a broad spectrum of gram-positive and -negative bacteria, which often are found in the polymicrobial infection of postcesarean endomyometritis. Eighty-four randomly chosen women with postcesarean endomyometritis received 3 g ticarcillin disodium plus 100 mg clavulanate potassium intravenously every six hours. The drug was discontinued after patients were afebrile and asymptomatic for 72 hours. The mean duration of therapy was 4.7 days. A clinical cure was achieved in 56 of the 70 evaluable patients (80%); 14 were clinical failures. Six of the 70 patients (9%) were bacteremic. One hundred eighty-five aerobic bacteria and 109 anaerobic bacteria were isolated. Of the 96 aerobic isolates tested, 75 (78%) were beta-lactamase positive, as were 68 of the 78 anaerobic isolates (87%).

Comparative effectiveness and safety of cefotetan and cefoxitin as prophylactic agents in patients undergoing abdominal or vaginal hysterectomy

In a multicenter, randomized clinical trial, 282 women who underwent abdominal or vaginal hysterectomy were given a single preoperative 2 g dose of cefotetan (171 evaluable patients) or three perioperative 2 g doses of cefoxitin (84 evaluable patients) as antibiotic prophylaxis. A successful clinical response occurred in 92 percent of those receiving cefotetan and 90 percent of those receiving cefoxitin who underwent abdominal hysterectomy, and in 94 percent of those receiving cefotetan and 93 percent of those receiving cefoxitin who underwent vaginal hysterectomy. The incidence of vaginal cuff cellulitis was 3.4 percent and 5 percent for cefotetan and cefoxitin patients, respectively, who underwent abdominal hysterectomy, and 4.8 percent and 4.5 percent, respectively, for those who underwent vaginal hysterectomy. The incidence of major wound infection was 3.4 percent and 2.5 percent for cefotetan and cefoxitin, respectively, in the abdominal hysterectomy group. Postoperative changes in oral body temperature, duration of hospitalization, and postoperative grading of surgical wounds were similar. Both drugs were well tolerated. These results suggest that a single dose of cefotetan is equally effective and as safe as multiple-dose cefoxitin for prophylaxis in patients undergoing hysterectomy.

Randomized double-blind comparison of mezlocillin versus cefoxitin prophylaxis for vaginal hysterectomy

One hundred patients undergoing vaginal hysterectomy were enrolled in a randomized double-blind comparative antibiotic prophylaxis study. Forty-six patients received mezlocillin and 54 patients received cefoxitin. No significant difference was found among patients who developed febrile morbidity. Failure rate for mezlocillin was 17 per cent and for cefoxitin, 15 per cent. There was an increase in colonization of Streptococcus faecalis and Enterobacter species in patients receiving three doses of cefoxitin prophylaxis.

The effect of hepatitis B antigenemia on pregnancy outcome

Sixty patients documented to have hepatitis B antigenemia during pregnancy were identified retrospectively and compared with an equal number of matched control patients. Maternal and newborn infant parameters were examined. No statistically significant differences were noted between the two groups, except for an increase in infant birth weight in the group showing antigen-positive test results, specifically in infants born to Oriental mothers. It is concluded that infants born to women testing positive for hepatitis B surface antigen represent normal infants eminently suitable for peripartal preventive immunotherapy.

Pelvic inflammatory disease during pregnancy

Pelvic inflammatory disease associated with pregnancy is not commonly reported. We present three illustrative cases at ten, 13, and 26 weeks of gestation. Unlike pelvic abscess, which may be discovered at any stage of gestation, acute salpingitis during pregnancy occurs more commonly in the first trimester. Both processes are associated with substantial fetal wastage. Diagnosis may be difficult if the obstetrician is not aware that these infections can occur during pregnancy. The diagnosis is often made at laparotomy by a physician expecting appendicitis or another inflammatory condition. Since salpingitis during pregnancy, like salpingitis generally, is amenable to antibiotic therapy, surgery may be avoided if appropriate antibiotic therapy is quickly instituted. The pregnant patient and her fetus may be spared general anesthesia and the attendant risks of abdominal surgery.

Acute pyelonephritis in pregnancy

There were 107 episodes of pyelonephritis associated with pregnancy or the early puerperium occurring in 103 gravidas investigated retrospectively for information concerning prematurity, low birthweight, and antibiotic susceptibility patterns in the recovered microorganisms. No difference was found in the incidence of prematurity on low birthweight between that group and a control group of gravidas from the same population. Members of the Enterobacteriaceae genus were the most common bacterial isolates from the urine, with a large portion of E. coli being resistant to both ampicillin (33%) and cephalothin (13%). Treated pyelonephritis associated with pregnancy does not appear to predispose to prematurity or low birthweight in this population. Also, initial therapy with a first-generation cephalosporin may no longer be appropriate, because a significant number of isolates (11%) were resistant to cephalothin.

Moxalactam versus clindamycin plus tobramycin for the treatment of puerperal infections

Sixty women with the diagnosis of puerperal endometritis were randomized to receive either moxalactam (n = 29) or the combination of clindamycin and tobramycin (n = 31) as therapy for their infection. Endometrial bacteriology consisted of mixed flora, both aerobic and anaerobic gram-positive and gram-negative organisms. Clinical cure was achieved in 27 (93%) of the moxalactam-treated patients and 28 (90%) of those given combination therapy. The two failures of moxalactam therapy were associated with enterococcal infection. Failures of clindamycin/tobramycin therapy were due to enterococcal infection, abscess formation, and moderately severe diarrhea. This study indicates that moxalactam is as effective and safe as the combination of clindamycin/tobramycin for the treatment of postpartum endometritis.

Tobramycin dosing in the puerperal patient

Serum levels of tobramycin were determined with an enzyme immunoassay technique in 20 puerperal women with postcesarean endometritis who were being treated with metronidazole-tobramycin. Ideal dosing was then calculated to attempt to provide peak serum levels between 5 and 8 micrograms/mL and trough serum levels less than 2 micrograms/mL. In eight patients, therapeutic serum levels could not be attained even at doses greater than the package-insert recommendation of 3 mg/kg/d. Therapeutic levels were achieved in five patients with doses between 3 and 5 mg/kg/d and in seven patients only at doses above the maximum recommended daily dose of 5 mg/kg. The puerperal patient appears to usually require much higher dosages of tobramycin than usual, and serum levels must be monitored for therapeutic reasons rather than for toxicity.

The pregnant hepatitis B carrier: evidence favoring comprehensive antepartum screening

The prevalence of hepatitis B surface antigen among 15,399 gravidas screened in the prenatal clinic at Charity Hospital of Louisiana in New Orleans was 0.88%. The race-specific prevalence was 0.56% for whites, 0.62% for blacks, and 8.8% for Orientals. Identifiable risk factors could not be found for approximately half of the hepatitis B surface antigen-positive women. Comprehensive antepartum hepatitis B screening is recommended, based upon the significant risk of perinatal transmission to the neonate and upon the failure of selective screening to identify the majority of maternal hepatitis B surface antigen carriers in our population. The cost-effectiveness of general antepartum screening compares favorably with current blood bank hepatitis screening costs.

Severe uterine hemorrhage from blastomycosis of the endometrium. A case report

A 32-year-old black woman presented in the emergency room with vaginal bleeding. Physical examination revealed a granulomatous lesion on the thigh and a breast abscess. Histopathologic examination and culture of an endometrial biopsy revealed Blastomyces dermatitidis. The breast abscess and thigh lesion were found to contain B. dermatitidis as well.

The microbiology of premature rupture of the membranes

The foregoing discussions bring to mind several salient facts: Although numerous barriers to infection exist, this aspect is understood incompletely. Conclusions on the pathogenicity or nonpathogenicity of certain organisms are often made from studies with very small numbers of patients, or in very specific patient populations. When such entities as low birth weight, premature labor, and PROM, which are all obviously related to some extent, are studied, very complicated analyses on large numbers of patients are required. Most of the organisms discussed are considered to be sexually transmitted. Because STDs are generally recognized to travel together in the same patient populations, the statistics necessary to separate one organism from another are complex indeed. The previous discussion notwithstanding, it is extremely difficult to form a solid conclusion about relation of these organisms to PROM with confidence. Many more patients need to be studied through many more pregnancies. In addition, differences among population subgroups make extrapolation extremely difficult. Currently the Louisiana State University is participating in a large, multicenter, collaborative study under the auspices of the National Institutes of Health. This study should provide an adequate data base concerning most of the isolates discussed and potential adverse outcomes of pregnancy. Then definitive statements may be made regarding both the screening of pregnant women and initiation of selective therapy. Specific management recommendations are discussed by Nagey and Saller in this symposium.

In-vitro and in-vivo activity of parenterally administered beta-lactam antibiotics against Chlamydia trachomatis

The extended-spectrum penicillins ticarcillin, mezlocillin, and piperacillin might be useful as single agents for the treatment of pelvic infections in women if it could be shown that these drugs are active against Chlamydia trachomatis. We found that the MIC90 (concentration at which 90% of strains are inhibited) values of ticarcillin, mezlocillin, and piperacillin were 16, 16, and 64 micrograms/ml, respectively. Several cephalosporins were found to have MICs for C. trachomatis of greater than 200 micrograms/ml. Ten women with postpartum endometritis who were colonized with C. trachomatis had repeated chlamydial cultures following treatment with beta-lactam antibiotics. All seven cases treated with ticarcillin plus clavulanic acid (a beta-lactamase inhibitor) or piperacillin alone had C. trachomatis-negative cultures after treatment. Three of four of these women had negative cultures at a second follow-up visit. In contrast, the three women treated with a cephalosporin were culture-positive at their first follow-up clinic visit. These data suggest that there is a correlation between the in-vitro measurement of beta-lactam antibiotic activity against C. trachomatis and the microbiologic outcome of treatment. We conclude that the extended-spectrum penicillins deserve further evaluation as single agents for the treatment of pelvic infections in women at high risk for C. trachomatis infections.

Comparison of ticarcillin plus clavulanic acid with cefoxitin in the treatment of female pelvic infection

Ninety-three female patients with post-cesarean endometritis, post-hysterectomy pelvic cellulitis, and other miscellaneous moderately severe pelvic soft-tissue infections were treated in a randomized fashion with either ticarcillin plus clavulanic acid or cefoxitin. Of the 47 patients treated with ticarcillin plus clavulanic acid, 38 had clinical cures, four showed improvement, therapy failed in three, and two were nonevaluable, for a failure rate of 6.7 percent. Of the 46 patients treated with cefoxitin, 33 had clinical cures, five showed improvement, therapy failed in seven, and one was nonevaluable, for a failure rate of 15.6 percent. Bacteriologically, the addition of clavulanic acid to ticarcillin was found to broaden the antibacterial spectrum to include some Escherichia coli, most Klebsiella, many coagulase-negative staphylococci, and all isolates of Staphylococcus aureus. Adverse reactions were few, with only one patient having therapy with cefoxitin discontinued because of side effects. It is concluded that ticarcillin plus clavulanic acid is quite suitable for antibiotic therapy of female pelvic soft-tissue infection, based on the (expanded) coverage of both aerobic and anaerobic bacterial species.