OBJECTIVE: To assess the prevalence and potential risk factors associated with human papillomavirus (HPV) cervical infection among women residing in a region of northeastern Argentina with a high incidence of cervical cancer. METHODS: A case-control study of 330 women participating in a cervical cytological screening program conducted in Posadas city, Misiones, Argentina, from February 1997 to November 1998 was carried out. Standardized questionnaires were administered, and clinical examination including colposcopy was performed. Fresh endocervical specimens for HPV DNA detection by generic polymerase chain reaction were collected and the products typed by dot-blot hybridization. RESULTS: Human papillomavirus DNA was found in 61% of samples analyzed (185/301). Samples with normal cytology had a 43% infection rate (85/199), while those classified as low-grade squamous intraepithelial lesion, high-grade squamous intraepithelial lesion, and invasive cervical carcinoma had an infection rate of 96% (53/55), 100% (29/29), and 100% (18/18), respectively. Human papillomavirus typing showed a 64% (118/185) prevalence of type 16 among all the infected population analyzed; type 16 was detected among 49% (42/85) of infected samples with normal cytology and in an average of 74% (74/100) with abnormal cytology. Sexual behavior, residence in southern Paraguay, and history of a previous sexually transmitted diseases were the main risk factors associated with high-grade cervical lesions. CONCLUSIONS: An elevated prevalence of HPV infection was detected in this population, which also has a high incidence of cervical cancer. The broad distribution of high-risk HPV type 16 in women with normal cytology and colposcopy suggests that viral infection is an important determinant of regional cancer incidence.
OBJECTIVE: To measure the risk of perinatal transmission of HBV in chronic carriers who undergo amniocentesis. METHODS: This was a prospective, longitudinal study from 1990 to 1995 of women who were HBV carriers and underwent amniocentesis. The infants of these women were followed from birth to one year of age. Maternal data examined included HBV antigen and antibody status, liver function tests (LFTs) and the amniocentesis report. RESULTS: Twenty-eight women were identified. Two of 28 neonates were stillborn unrelated to hepatitis. Five infants were lost to follow-up leaving 21 mother-child pairs to evaluate. All 21 women were chronic HBV carriers at the time of amniocentesis for delivery. No mother had abnormal LFTs, and only one of 21 women was positive for hepatitis B e antigen (HBeAg). Thirteen amniocenteses were for advanced maternal age, and four were for abnormal maternal serum alphafetoprotein (MSAFP) screening. None of the amniocenteses were recorded as bloody, and the placenta was anterior in 6 of 21 procedures. None of the 21 infants (95% CI: 0-16.8%) were positive for HbsAg during the first month of life or at 12 months of age. All infants received HBV vaccine and HBIG immunoprophylaxis. CONCLUSION: The risk of transmission of HBV to the fetus after amniocentesis in women who are HBV carriers is low. Immunoprophylaxis in these infants was successful.
OBJECTIVE: Aims of this study were to determine the IgG and IgM seropositivity to parvovirus B19 during the three trimesters of pregnancy. METHODS: Initially, a total of 1,047 pregnant women were included in a prospective study. Blood samples were obtained from 343, 406 and 298 cases in the first, second and third trimesters, respectively. To study the incidence of seroconversion, a second sample of blood was obtained 2-4 weeks later from the first 100 cases, who were IgG and IgM negative in the first trimester. RESULTS: The seroprevalence of parvovirus B19 IgG and IgM was 53.3% and 2.2%, respectively. The incidence of seroconversion was 16.5%. The rate of fetal loss was 15.4% in patients with acute infection, all of which occurred in the first two trimesters. CONCLUSIONS: The percentage of IgG positive cases is significantly higher in first and second trimesters compared to the third trimester. The seroconversion rate was 16.5%.
OBJECTIVE: To determine the demographic and clinical variables characteristic of non-epidemic intrapartum or puerperal group A streptococcal (GAS) infection. METHODS: The records of 47 patients diagnosed with intrapartum or puerperal GAS infection over a 6 1/2 year period at Hadassah-University Hospital-Mt. Scopus, Jerusalem were reviewed. Data regarding 25,811 women, the general population of women that delivered during that period, were obtained from their computerized medical records. Frequency distributions, t-test, chi-square, and Spearman's Rank Correlation were used, as appropriate, to analyze and compare demographic and clinical variables associated with development of GAS infection, its clinical course and subsequent development of septic shock. RESULTS: Mean age of mothers with GAS infection was higher than that of our general pregnant population (30.4 versus 27.4 years, P = 0.0019), and a higher proportion of GAS infected patients (30% versus 12%, P < 0.005) experienced PROM. Thirty-one (66%) women had fever as their sole presenting symptom, eight (17%) had fever and abdominal pain, seven (15%) had fever and abnormal vaginal bleeding, and one patient (2%) presented with a rash. Three patients (6%) developed a septic shock. Two of these patients presented with symptoms more than 14 days after delivery. CONCLUSIONS: We describe the characteristics of non-epidemic intrapartum or puerperal GAS infection. Data from our study and review of the literature suggest that some patients who develop septic shock may present later in the puerperium than patients with an uncomplicated GAS infection.
OBJECTIVE: Group B streptococcal (GBS) vulvovaginitis is a poorly-delineated clinical entity. The purpose of this study is to report semiquantitative data from four cases of GBS vulvovaginitis and to comment on their significance in terms of the in vitro inhibitory capabilities of GBS. METHODOLOGY: Four patients whose clinical presentations were consistent with GBS vulvovaginitis, from whom GBS was isolated and for whom semi-quantitative as well as qualitative microbiologic data existed, were identified. RESULTS: To produce vulvovaginitis, GBS must be at a high multiplicity (10(8) CFU/g of vaginal fluid). Single coisolates were identified in three of the four cases (two cases of Escherichia coli and one case of Staphylococcus aureus). Group B streptococcus does not inhibit either of these bacteria in vitro. CONCLUSION: When the growth requirements for the demonstration of in vitro inhibition for GBS or lack thereof are met in vivo, the in vivo observations are consistent with those projected from the in vitro data.
OBJECTIVE: Review available literature on pelvic inflammatory disease in postmenopausal women. DESIGN: MEDLINE literature review from 1966 to 1999. RESULTS: Pelvic inflammatory disease is uncommon in postmenopausal women. It is polymicrobial, often is concurrent with tuboovarian abscess formation, and is often associated with other diagnoses. CONCLUSION: Postmenopausal women with pelvic inflammatory disease are best treated with inpatient parenteral antimicrobials and appropriate imaging studies. Failure to respond to antibiotics should yield a low threshold for surgery, and consideration of alternative diagnoses should be entertained.
OBJECTIVE: To assess the utility of a less invasive approach to the care of women with a pelvic abscess, we retrospectively reviewed the outcome of women with pelvic abscesses managed by transvaginal ultrasound-guided aspiration. METHODS: A retrospective analysis of 27 pelvic abscesses in 22 consecutive women undergoing transvaginal drainage, including 13 tuboovarian abscesses (TOAs) and 14 postoperative abscesses (POAs). All patients received broad-spectrum intravenous antibiotics from the time infection was diagnosed to resolution of signs and symptoms. Chart review and examination of ultrasound files were utilized to extract demographic clinical, laboratory, and outcome data. RESULTS: The mean age for the study group was 30 years old. Mean duration from diagnosis to drainage was 5.6 days (TOA) and 2.0 days (POA), P < 0.01. The mean diameter of the abscesses was 86 mm. The volume of purulent material drained ranged from 70-750 mL. Perceived adequacy of drainage was correlated with lack of abscess septation. Cultures for aerobic and anaerobic pathogens were positive in 51% of cases (79% POA versus 23% TOA, P < 0.05) with 1.9 organisms/ positive culture. Transvaginal drainage was successful in 25 of 27 abscesses. No complications were reported. CONCLUSION: In skilled hands, transvaginal guided aspiration of pelvic abscess is a highly successful technique with minimal risk to the patient. Follow-up studies are needed to assess the long-term sequelae, such as frequency of infertility, ectopic pregnancy, and chronic pelvic pain.
OBJECTIVE: To examine antenatal screening as a predictor of intrapartum shedding of herpes simplex virus (HSV) and to determine its usefulness in guiding the appropriate route of delivery for patients with recurrent HSV in pregnancy. METHODS: A population of 198 pregnant women with a history of recurrent genital HSV were cultured in the last weeks of their pregnancy by specially-trained personnel and intrapartum by their delivering attendants. RESULTS: Of cultures from a total of 906 antenatal visits, 17% were culture positive, with an asymptomatic shedding rate of 3.4%. Asymptomatic shedding occurred in 12.6% of women. Over the 8-week antepartum period, viral culture-positivity rates for each visit ranged from 11% to 19.5%. This provided an expected delivery culture-positivity rate of 15.3%. However, actual intrapartum viral culture positivity occurred in only three of 191 women (1.5%; P < 0.001). Because previous studies have suggested antepartum culture positivity fails to predict intrapartum viral shedding, evaluations, including cultures, as well as predictive values for subsequent culture positivities, were determined under the supervision of an infectious disease specialist. Under these conditions, positive predictive values were 59% when the interval between visits was 2 days, but only 19% when days between visits were >2 (P < 0.0001). No cases of neonatal herpes were seen in this population, although cesarean deliveries were performed in 31% of the patient population, with genital herpes as the indication for 56% of those. CONCLUSIONS: Antepartum serial screening by viral culture is not predictive of an infant's risk of intrapartum viral exposure when conducted at weekly intervals. However, more frequent assessments of patients can be predictive of an infant's exposure risk to HSV; for patients with frequent recurrent disease near term or primary infection in pregnancy, frequent late antepartum screening may be appropriate.
Hydrophobic interaction is generally considered to play an important role in the adherence of microorganisms to eukaryotic cells and also to certain inert surfaces. Using a microbe adhesion assay to hydrocarbons (n-hexadecane), 68 strains of Candida albicans and 30 non-albicans strains were studied. Influence of source of isolate, age of the culture, and percentage of germ tube formation on adhesion were studied. C. albicans blastoconidia were found to be hydrophilic; conversely, blastoconidia of non-albicans strains were slightly more hydrophobic. Germ tube formation was associated with a significant rise in cell surface hydrophobicity.
BACKGROUND: Extrapulmonary tuberculosis has vague symptoms and few signs. It is essential to recognize and diagnose this curable disease prior to performing definitive surgery. Newer tests such as DNA or RNA amplification allow for early diagnosis but have limitations. CASE: We report a case of peritoneal tuberculosis in an immigrant woman. She had vague symptoms of low-grade fever, mild abdominal pain, obstipation, and bloating. Diagnostic laparoscopy was performed to establish the diagnosis. Tuberculosis was confirmed by DNA extraction from the frozen section specimen with subsequent analysis using polymerase chain reaction. CONCLUSION: Peritoneal tuberculosis is a disease that often simulates malignancies. With the increasing prevalence of human immunodeficiency virus in developed countries, tuberculosis is also on the rise and should be considered in the differential diagnosis of a patient with an abdominal/pelvic mass and ascites.
Lymphogranuloma venereum (LGV) is a rare form of the sexually transmitted disease caused by Chlamydia trachomatis. In the United States, there are fewer than 350 cases per year. In a review of the world's literature, there has not been a case reported in the last thirty years of a case of LGV presenting as a rectovaginal fistula. We present a case of an otherwise healthy American woman who presented with a rectovaginal fistula. Although uncommon, LGV does occur in developed countries and may have devastating tissue destruction if not recognized and treated before the tertiary stage.
OBJECTIVE: To compare intravaginal 5-fluorouracil (5-FU) and placebo for the treatment of cervical and/or vaginal human papillomavirus (HPV). METHODS: A randomized, placebo-controlled trial was performed. Women with HPV detected visually or by Papanicolaou (Pap) test and confirmed by colposcopic biopsy were randomized to receive either intravaginal 5-FU cream or an intravaginal placebo cream. Women with cervical or vaginal intraepithelial neoplasia were excluded. The primary outcome measure was cytologic regression of HPV as determined by Pap test screening 4 to 6 months after treatment. The secondary outcome was cytologic evidence of disease progression at both the 4-6-month and 12-month follow-up evaluations. Data were analyzed using the Chi square test with significance established at P < 0.05. RESULTS: A total of forty patients were randomized, and thirty patients had a follow-up Pap test 4 to 6 months after treatment. Of those patients treated with 5-FU, 28% demonstrated regression of HPV on cytologic evaluation, compared with 69% of those treated with placebo (P < 0.05). Twelve-month follow-up cytology was available from 18 of the study participants. There were no significant differences in the frequency of cytologic progression or regression between groups at 12 months. CONCLUSION: Four to six months post treatment, the use of intravaginal 5-FU for the treatment of cervical or vaginal HPV is associated with a lower rate of regression than the use of placebo.
BACKGROUND: Maternal cervicovaginal colonization with Lancefield group B streptococci (GBS) is an important risk factor for neonatal morbidity and mortality. About 15% of women are carriers of GBS. Usually, they are asymptomatic. CASES: We describe two patients with symptomatic vaginitis for which no apparent cause was found. Both patients were heavily colonized with GBS. After antibiotic treatment, both became asymptomatic and culture negative, but after recolonization with GBS, symptoms resumed. This phenomenon was repeatedly observed. After emergence of resistance to antibiotics, local application of chlorhexidine appeared to be the only useful treatment. CONCLUSION: We hypothesize that GBS-vaginitis may be a possible disease entity. Although at present it is not clear why some patients become symptomatic, we speculate that the immunologic response is somehow selectively hampered in such patients.
OBJECTIVE: Helicobacter pylori plays a major role in abdominal symptoms and gastroduodenal pathology, including gastric cancer. Pregnancy has been associated with changes in both humoral and cell-mediated immunity. These changes include alterations in the various classes of antibodies during different gestational periods. It has been previously suggested that these alterations may expose pregnant women to an increased risk of infection with this microorganism. METHODS: To further investigate this hypothesis, we assayed sera from 229 asymptomatic pregnant women for the presence of H.-pylori-specific immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies by means of a commercially available serum ELISA test (Malakit, Biolab, Belgium). Both tests were previously validated in large series of H.-pylori-positive and -negative subjects. While the presence of H.-pylori-specific IgG antibodies is only a marker for a "chronic" infection with this bacterium and therefore no indicator of the time of acquisition of the infection, specific IgM antibodies are a more specific marker for a recently acquired infection with H. pylori. Results were compared with those previously obtained in asymptomatic, healthy, nonpregnant individuals. RESULTS: One hundred twenty of 229 women (52.4%) and 55/118 nonpregnant subjects (46.6%) were seropositive for H.-pylori-specific IgG antibodies (P > 0.3). Out of these 120 IgG-antibody-positive women, 36 (30%) were positive for H.-pylori-specific IgM antibodies, as were 25/109 (22.9%) in the IgG-antibody-negative group (P > 0.3). Overall, 61/229 (26.6%) of the pregnant women had recently been infected with H. pylori, compared with 11% of the healthy, nonpregnant population (P > 0.01). CONCLUSIONS: Our observations confirm the possibility of an increased susceptibility to H. pylori infection in pregnancy. Additional studies are necessary to further understand the immune response to H. pylori in pregnancy.
OBJECTIVE: The relationship between pregnancy outcome and expression of the heat shock proteins (hsps) or hsp-antibody complexes of 60kD (hsp60), 70kD (hsp70), and 90kD (hsp90) in placental tissue and circulating antibodies to hsps was evaluated. METHOD: Expression of hsp60, hsp70, and hsp90 in placentae from 12 women with preterm birth, eight with intrauterine growth restriction (IUGR), and 10 with term birth, as well as the presence of the corresponding antibodies, was investigated by a new carbocyanine double fluorescence technique. Results were compared with microbiological findings and circulating antibodies to hsps in sera. RESULTS: In each placental specimen examined, hsp60, hsp70, and hsp90 were identified. However, hsp70-antibody complexes were detected in only four of the preterm labor cases. Similarly, hsp60-antibody complexes were detected in only five preterm labor patients and in one patient with IUGR. None of the placentae contained hsp90-antibody complexes. In the preterm birth group, all patients with hsp60-antibody complexes were also positive for circulating antibodies to hsp60. The presence of hsp70-antibody complexes also correlated with hsp70 antibody in sera. CONCLUSIONS: Formation of hsp60- and hsp70-antibody complexes in the placenta may contribute to the induction of preterm birth. Women sensitized to these antibodies may be at increased risk for adverse pregnancy outcome.
OBJECTIVE: This study evaluated the accuracy of the commercial product Strep B OIA (optical immunoassay) compared to the standard agar and broth culture methods for detecting vaginal colonization with group B streptococcus (GBS). METHODS: Preoperative vaginal cultures were obtained from 141 nonpregnant gynecological patients undergoing major gynecologic surgery. Major gynecologic surgery was defined as benign gynecologic, gyne-oncology, and urogynecologic procedures. The results of the Strep B OIA test were compared to the results obtained from SXT agar (selective for GBS), colistin-nalidixic acid ((CNA) agar, and Todd-Hewitt broth cultures. RESULTS: The prevalence of vaginal GBS colonization in this population was 20.6%. The sample sensitivity and specificity of the OIA method were 58.6% and 85.7%, respectively. These values are lower than the sensitivity and specificity of 85.4% and 91.5%, respectively, given in the OIA package insert. Although the sample negative predictive value was fairly high (88.9%), the positive predictive value was low (51.5%). CONCLUSION: Although a previous study stated that the product Strep B OIA reduces the time required to obtain results (30 minutes versus days) and can, therefore, function as a useful diagnostic tool in the management of early-onset GBS disease, the present study's finding of low sensitivity and low positive predictive value indicates that this test may have very limited clinical value.
OBJECTIVE: The aim of this study is to describe the bacterial flora of women in preterm labor with or without premature rupture of membranes. METHODS: Retrospective studies of 239 patients with preterm labor were performed. RESULTS: One hundred and twenty-three of 239 patients with preterm labor (51.5%) had bacterial vaginosis. Seventy of the 239 patients with preterm labor (29.3%) developed premature rupture of the membranes (preterm PROM). Of the 70 patients with preterm PROM, 51 (72.9%) had bacterial vaginosis. Therefore, 51 of the 123 patients with bacterial vaginosis (41.5%) developed preterm PROM. An increased number of organisms detected from the vaginal discharge in patients with preterm labor was associated with preterm PROM by Cochran-Armitage test. An increased number of organisms detected from the vaginal discharge in patients with preterm labor complicated with bacterial vaginosis was significantly associated with preterm PROM by Cochran-Armitage test. CONCLUSIONS: In preterm labor, the number of different species detected in the vagina provide sensitive and specific prediction of preterm PROM in patients with preterm labor.
OBJECTIVE: To investigate the influence of the increased use of intrapartum chemoprophylaxis on the incidence of vertically transmitted neonatal sepsis. METHODS: Multiple institutional databases were queried for the number of cases in which intrapartum antibiotics were used, the obstetric risk factors that were present, and the number of resultant cases of neonatal sepsis that occurred for deliveries from 1992 through 1997. Intrapartum antibiotic use was compared between the first and fourth quarter of 1997. Comparisons were made between the years 1992-1996 and 1997 for the incidence of the various pathogens causing neonatal sepsis; group B streptococcus (GBS), gram-negative sepsis, and others. RESULTS: We found a significant increase in intrapartum chemoprophylaxis between the first and fourth quarters of 1997 corresponding to the increased physician awareness of published guidelines. As expected, the incidence of neonatal GBS sepsis was drastically reduced (from 1.7/1000 live births to 0 in 3730 births, P = 0.02). Unfortunately, there was a concomitant increase in the incidence of gram-negative sepsis (0.29/1000 vs. 1.3/1000, P = .02). The overall incidence of neonatal sepsis remained unchanged (2.7/1000 vs. 2.1/1000, P = .69). CONCLUSIONS: Published guidelines have encouraged physicians to increase the use of intrapartum chemoprophylaxis to reduce vertical transmission of GBS. This study confirms the efficacy of this approach. Unfortunately, this reduction comes at the cost of increasing the incidence of ampicillin-resistant gram-negative neonatal sepsis with a resultant increased mortality. These data provide compelling evidence that the policy of providing ampicillin chemoprophylaxis in selected patients needs to be reconsidered.
OBJECTIVE: To evaluate the safety and efficacy of intravenous and oral ofloxacin monotherapy in the treatment of laparoscopically documented acute pelvic inflammatory disease (PID). METHODS: This study was conducted as an open-label, phase-III, uncontrolled, multicenter study. Patients identified with laparoscopic findings of salpingitis were treated with 400 mg of intravenous ofloxacin every 12 hours followed by 400 mg of oral ofloxacin every 12 hours for 10 to 14 days. Patients were evaluated five times for clinical and microbial efficacy. Since laparoscopy was performed only at admission, pathogens identified laparoscopically were presumed eradicated if they were present on the laparoscopic culture and the patient was clinically cured or improved at final evaluation. RESULTS: Of the 70 patients evaluable for safety (intent-to-treat population), the mean age was 25.6 years. Sixty-one of 70 patients (87%) were cured, one improved, one did not improve, and seven were unevaluable because they discontinued study participation. Fifty-one were evaluable for clinical efficacy: 50 (98%) were cured and one did not improve. Sixteen were evaluable for expanded microbiological efficacy: three had documented Neisseria gonorrhoeae; 12, Chlamydia trachomatis; and one, a mixed infection of both organisms. All cervical, laparoscopic, and endometrial cultured pathogens, including N. gonorrhoeae and C. trachomatis, were eradicated or presumed eradicated at the posttherapy visit. No serious or unexpected adverse events occurred. CONCLUSIONS: Ofloxacin monotherapy was effective and well tolerated in the treatment of laparoscopically proven PID in a geographically diverse population. Future studies are necessary to evaluate long-term outcomes and sequelae of PID treatment with single agent therapy.