Background. Maternal infection is associated with adverse pregnancy outcomes, and ob-gyns are in a unique position to help prevent and treat infections. Methods. This paper summarizes studies completed by the Research Department of the American College of Obstetricians and Gynecologists regarding perinatal infections that were published between 2005 and 2009. Results. Obstetrician-gynecologists are routinely screening for hepatitis B and HIV, and many counsel prenatal patients regarding hepatitis B and toxoplasmosis. However, other infections are not regularly discussed, and many cited time constraints as a barrier to counseling. A majority discusses the transmission of giardiasis and toxoplasmosis, but few knew the source of cryptosporidiosis or cyclosporiasis. Conclusions. Many of the responding ob-gyns were unaware of or not adhering to infection management guidelines. Obstetrician-gynecologists are knowledgeable regarding perinatal infections; however, guidelines must be better disseminated perhaps via a single infection management summary. This paper identified knowledge gaps and areas in which practice can be improved and importantly highlights the need for a comprehensive set of management guidelines for a host of infections, so that physicians can have an easy resource when encountering perinatal infections.

Chronic infection with hepatitis C virus (HCV) is a major cause of liver disease-related death and is also the most frequent indication for liver transplantation in USA. Infected individuals can remain asymptomatic for 20 years or more, but they remain at risk for progressive liver disease. They also represent a potential source of infection for others. For reducing the future disease burden due to HCV, obstetrician/gynecologists and primary health care practitioners should be aware of the factors that promote HCV transmission: how to provide counseling and testing, and when specialist referral is needed.

Vaccines that protect against infection with the types of human papillomavirus (HPV) commonly associated with cervical cancer (HPV 16 and 18) and genital warts (HPV 6 and 11) are expected to become available in the near future. Because HPV vaccines are prophylactic, they must be administered prior to exposure to the virus, ideally during preadolescence or adolescence. The young age of the target vaccination population means that physicians, parents, and patients will all be involved in the decision-making process. Research has shown that parents and patients are more likely to accept a vaccine if it is efficacious, safe, reasonably priced, and recommended by a physician.Widespread education of physicians, patients, and parents about the risks and consequences of HPV infection and the benefits of vaccination will be instrumental for fostering vaccine acceptance.

Detroit has recently been distinguished as having the highest congenital syphilis rate in the United States (250.3 cases per 100 000 live births in Detroit versus 10.3 in the US). However, depending on each health department's followup and CDC reporting, these data may not accurately reflect the true congenital syphilis rate. This study examines the reported cases over a three-year time period with focus on the criteria used for diagnosis. All local health department congenital syphilis CDC collection forms (form 73.126) were reviewed for the years in question. The reported congenital syphilis cases in the year 2002–2004 in Detroit were reviewed. No cases met confirmed case criteria and few probable cases were based on neonatal evaluations. The majority of “congenital syphilis” cases were established based on incomplete maternal data such as missing followup serologic titers in the absence of complete neonatal information. In conclusion, although the reported congenital syphilis rate in Detroit is alarmingly high, the true occurrence of congenital syphilis is likely to have been overstated. A health department reporting program that includes more diligent neonatal followup would allow for a more accurate representation of this public health concern.

Objective. To investigate the postpartum morbidity and postpartum management of febrile morbidity associated with advanced HIV infection. Methods. A case control study of HIV infected women at a tertiary care center during January 2000–June 2005 was performed. Postpartum morbidity was defined as endometritis, blood transfusion, wound complication, readmission, infectious morbidity, or unexpected surgery. Results. Women in Group 1 had AIDS (N = 33), Group 2 were relatively immunocompetent HIV infected women (N = 115), and Group 3 were uninfected women (N = 152). Group 1 was more likely to have a postpartum morbidity (32.3 versus 19.3 and 13.2%, P = .03) and to have postpartum imaging 18.8 versus 7.9 and 2.6%, P = .002. After controlling for potential confounders, cesarean delivery (OR 6.2, 95% CI 2.1–505.5) but not advanced HIV disease was associated with an increased risk of postpartum morbidity. Conclusion. Cesarean delivery and not advanced HIV disease increases the risk of postpartum morbidity in women with AIDS.

BACKGROUND: Pertussis is a highly communicable, vaccine-preventable respiratory disease. Although the largest number of reported cases is among young infants, the most rapidly increasing incidence in the USA is in adolescents and young adults. Importantly, adult family members are the likely major reservoir, infecting susceptible infants before completion of childhood vaccination. We studied maternal-neonatal paired blood samples for the presence of pertussis-related antibodies to assess level of immunity and passive transplacental antibody passage. METHODS. Unselected maternal-neonatal cord blood samples were collected from 101 term deliveries in a single urban uninsured/underinsured hospital setting. Sera were analyzed for anti-pertussis toxin (PT), filamentous hemagglutinin (FHA) and pertactin (PRN) IgG antibodies by enzyme-linked immunosorbent assay (ELISA). Antibody titers were calculated using reference line methodology. Antibody values were log-transformed to establish geometric mean titers (GMT) for analysis. Student's t-test, Mann-Whitney, Pearson correlation and chi square were used for statistical comparisons as appropriate. RESULTS. Mean (SD) maternal age, gestational age and birth weight were 26.8 (6.8) years, 38.9 (1.4) weeks and 3239 (501) g, respectively. Detectable maternal levels of anti-PT, FHA and PRN were found in 34.7%, 95.0% and 80.2%, respectively. Maternal GMT (SD) for PT, FHA and PRN were 4.4 (2.6), 26.6 (3.1) and 12.3 (2.9), respectively. There was no significant relationship between PT, FHA or PRN detection or antibody GMT and maternal age. Maternal anti-PT, FHA and PRN were highly correlated with neonatal cord blood values. CONCLUSION: Despite previous childhood immunization, a large number of parous women have low or undetectable pertussis-related antibody levels, suggesting susceptibility to infection. Even with efficient transplacental passage of these antibodies, neonates similarly have limited measurable protection as detected by cord blood sampling. These data support the need for adolescent or adult vaccination against Bordetella pertussis. Healthcare providers and their clients should be aware of the risk for infant infection via family member transmission.

Background: Obstetrician—gynecologists are important providers of primary health care to women, and the hepatitis C virus (HCV) infection screening practices and recommendations provided by obstetrician—gynecologists for HCV-infected patients are unknown.

Methods: We surveyed American College of Obstetricians and Gynecologists (ACOG) Fellows, including 413 Fellows who were participating in the Collaborative Ambulatory Research Network (CARN) and 650 randomly sampled Fellows, about HCV screening and counseling practices.

Results: In total, 74% of CARN members and 44% of non-CARN members responded. Demographics and practice structure were similar between the two groups. More than 80% of providers routinely collected drug use and blood transfusion histories from their patients. Of the respondents, 49% always screened for HCV infection when patients had a history of injection drug use, and 35% screened all patientswho had received a blood transfusion before 1992. For HCV-infected patients, 47% of the physicians always advised against breastfeeding, 70% recommended condom use with a long-term steady partner, and 64% advised against alcohol consumption. Respondents who considered themselves to be primary care providers were no more likely to screen or provide appropriate counseling messages than were other providers.

Conclusions: Most obstetrician—gynecologists are routinely collecting information that can be used to assess HCV infection risk, but HCV screening practices and counseling that are provided for those with HCV infection are not always consistent with current Centers for Disease Control and Prevention and ACOG recommendations.

Objective: This study was conducted to determine whether nitric oxide (NO), a potent vasodilator and inhibitor of thrombus formation, is involved in the formation and maintenance of adhesions.

Methods: Skin, subcutaneous tissues, peritoneum and adhesions were collected from surgical patients and total RNA was isolated. Quantitative reverse transcription polymerase chain reaction (QRT-PCR) was performed to quantitate endothelial nitric oxide synthase (eNOS) and β-actin mRNA levels.

Results: eNOS mRNA levels for skin, subcutaneous tissue, peritoneum and adhesions were ≤ 3.12 × 10-4, ≤ 3.12 × 10-4, 6.24 × 10-4 and 2.5 × 10-3 attomoles/μl, respectively. β-actin mRNA levels for all tissues were between 1.25 × 10-1 and 6.25 × 10-2 attomoles/μl.

Conclusion: eNOS mRNA can be identified in tissue adhesions, and may therefore play a role in adhesion formation and maintenance.

In utero infection of the fetus has become recognized as an important cause of fetal and neonatal morbidity and mortality. Since both anatomic and functional abnormalities have been described in the fetus related to various infections, ultrasonography may be a valuable diagnostic tool in this regard. A complete review of the current literature was undertaken to report available information on this topic. Common pathogens or clinical conditions were selected. The identified data were confounded by the way in which each case originally presented for study. Although certain anomalies were frequently associated with individual organisms, their incidence could not be determined, nor were most specific to that infectious agent. Representative ultrasound images are presented for common and unusual cases.

Objective: The purpose of this study was to compare the efficacy and side effects of erythromycin, amoxicillin, and clindamycin in eradicating Chlamydia trachomatis from the lower genital tract of pregnant women.

Methods: A total of 174 women at <36 weeks gestation with positive cervical cultures for C. trachomatis were enrolled. Patients were assigned in a randomized prospective fashion to either erythromycin (500 mg q.i.d, for 7 days), amoxicillin (500 mg t.i.d, for 7 days), or clindamycin (600 mg t.i.d, for 10 days). Six women elected not to participate and 8 patients were lost to follow-up, leaving 53 patients in the erythromycin group, 55 patients in the amoxicillin group, and 52 patients in the clindamycin group. All sexual partners of the enrolled women were offered doxycycline (100 mg b.i.d. for 7 days) and patients were instructed to use barrier contraception until treatment was complete.

Results: All 3 medications were effective agents for the treatment of antenatal C. trachomatis infection with treatment efficacies of 96%, 94%, and 98% for the erythromycin, amoxicillin, and clindamycin groups, respectively. When the antibiotic groups were compared, no statistically significant differences were noted in intolerance. However, the differences in the incidence of gastrointestinal symptoms between erythromycin and amoxicillin and/or clindamycin were significant (P < 0.05).

Conclusions: These findings suggest that 1) all 3 antibiotic regimens are efficacious, 2) erythromycin has a higher incidence of side effects, and 3) amoxicillin or clindamycin are reasonable alternatives for the treatment of C. trachomatis in pregnant patients unable to tolerate erythromycin.

Septic shock is a life-threatening clinical syndrome that, despite its rare occurrence in obstetrics, remains a leading cause of maternal mortality. Its pathophysiology is explained by a profound systemic response to a complex variety of host cellular and humoral mediators elaborated after exposure to microbial toxins. Early recognition, prompt diagnostic workup, and immediate initiation of therapy improve outcomes. Therefore, recent publications have popularized the concept of the “sepsis syndrome,” a preshock list of clinical criteria associated with progressive sepsis. Needed diagnostic studies should never be withheld because of “pregnancy concerns.” With critically ill patients, the risk-to-benefit ratio supports the use of these diagnostic studies in almost all circumstances. Standard therapy is directed principally at restoring tissue perfusion by intravascular volume expansion and in some instances vasoactive pharmacological intervention. Simultaneously, identification of the source of infection and commencement of appropriate empiric antibiotic treatment are critical. In some cases, surgical abscess drainage or debridement of infected necrotic tissue will need to be considered. Novel approaches to treatment that attempt to reduce the systemic response to microbial toxins are promising and under active investigation. Pregnancy-specific considerations include the following: 1) initial signs or symptoms of septic shock may be masked by normal physiologic alterations of pregnancy; 2) a mixed polymicrobial group of organisms, consistent with lower genital tract flora, should be anticipated; and 3) initial therapy should be directed at maternal concerns since adverse fetal effects are most likely the result of maternal decompensation.

Objective: Numerous studies demonstrate the efficacy of antibiotic prophylaxis for reducing postcesarean section infectious morbidity. The duration of therapy, however, remains controversial. Cost containment measures and the ease of single dosing have led to the introduction of “extended” half-life agents for cesarean-section chemoprophylaxis. We tested the hypothesis that there was no difference in efficacy between a single dose of a short half-life agent (cefoxitin) and a longer half-life agent (cefotetan).

Methods: A prospective, double-blind trial of 375 non-elective cesarean-section cases was carried out. Study antibiotics (2 g) were administered intravenously (IV) at cord clamping only.

Results: Demographic and clinical variables between the 2 study groups were similar. No significant differences were noted in major or minor morbidity or in infectious morbidities for patients receiving the 2 prophylactic regimens. The occurrence of postoperative endometritis was likewise similar for the subjects receiving cefoxitin (10%) and cefotetan (15%). When cases whose surgery lasted >60 min were evaluated separately, no differences in outcomes between the 2 groups were identified

Conclusions: These findings confirm our hypothesis that the half-life difference between these 2 agents does not impact on single-dose Prophylactic efficacy in cesarean section.

Objective: The cytokines tumor necrosis factor (TNF) and interleukin-6 (IL-6) have previously been identified in placental tissue and are known to be mediators of infection-associated induction of the host immune system. This study was undertaken to better characterize the in vitro regulation of these cytokines in cytotrophoblast cells when challenged with the bacterial product lipopolysaccharide (LPS).

Methods: Term placentas were freshly collected, digested with trypsin/DNase, and subjected to Percoll gradient centrifugation to isolate cytotrophoblasts. Either immediately or after overnight incubation, LPS (1 μg/ml) or media alone was added to the cell cultures for 0, 1, 2, 4, 8, 24, 48, and 72 h. Total cellular RNA was isolated by the guanidinium thiocyanate/cesium chloride methodology. RNA samples were run on 1% agarose-formaldehyde gels and subsequently transferred to nylon filters. Blots were hybridized with the appropriate P32-radiolabeled probe.

Results: In non-LPS-treated cells, minimal amounts of TNF mRNA could be detected at zero time, or throughout the incubation periods. Conversely, LPS exposure resulted in detectable signal starting at 1 h and peaking at 2 h after the addition of LPS. Overnight incubation gave stronger TNF signals in the LPS stimulated cells, although the kinetics of this response remained similar to zero time exposure. IL-6 was likewise minimally expressed at zero time, although non-stimulated cell cultures demonstrated progressive increases in mRNA expression which was maximal at 16 h after plating. LPS further augmented the transcription of IL-6 mRNA, with peak signals seen at 4 h after LPS stimulation. Again, overnight incubation of the cytotrophoblasts increased baseline and LPS-induced IL-6 mRNA responses. Long-term constant exposure of cells to LPS did not demonstrate any evidence of prolonged signaling. LPS did not alter mRNA expression of the placental gene H19 or the oncogene FOS.

Conclusions: These data demonstrate the induction of TNF and IL-6 mRNA in cytotrophoblast cells with LPS. These transcriptional events are kinetically distinct and short term in nature. Overnight incubation accentuates the TNF and IL-6 mRNA signal and allows for an augmented response to LPS.