In a multicenter, randomized, invesgtigator-blind, parallel study, 398 patients were dispensed topical
butoconazole nitrate 2% cream for 3 days (n = 199) or miconazole nitrate 2% cream for 7 days (n =
199) for vaginal use. Efficacy analyses included 254 patients with culture-confirmed Candida (119
butoconazole and 135 miconazole users). Of the 398 patients issued study medication, 9 were lost
to follow-up. Therefore, safety analyses included 389 patients (197 butoconazole and 192 miconazole
users). Evaluations upon admission and approximately 8 and 30 days post-treatment included
Candida cultures, potassium hydroxide (KOH) wet mounts, and vulvovaginal examinations, with
rating of vulvovaginal signs and symptoms using a 4-point scale. Rates of clinical cure (based on
sign/symptom scores), microbiologic cure (based on cultures and wet mounts), and therapeutic cure
(both clinical and microbiologic cures) were assessed and were to be similar between the regimens.
Therapeutic cure rates were 57.8% and 61.4% for butoconazole and miconazole, respectively.
Three-day butoconazole treatment was as safe and effective as 7-day miconazole therapy in treating
Objective: The purpose of this study was to determine if the prevalence of neonatal and maternal
infectious morbidity in patients with preterm premature rupture of membranes (PROM) who
received ampicillin prophylaxis for presemptive group B streptococcal colonization is increased
compared to those who received no prophylaxis.
Methods: The charts of all patients with preterm PROM who delivered between January 1988
and December 1993 were retrospectively reviewed. The routine use of ampicillin prophylaxis was
initiated in January 1991. Patients with singleton gestations were included in the analysis only if
chorioamnionitis was excluded on admission. Variables used in the final analysis included gestational
age at the time of preterm PROM, gestational age at delivery, duration of rupture of membranes,
birth weight, method of delivery, use of steroids, tocolytics, or antibiotics for group B
streptococcus prophylaxis, neonatal sepsis, neonatal mortality, and postpartum endomyometritis.
Data were analyzed using Student's t-test, chi-square test, Fisher's exact test, and stepwise logistic
regression analysis to evaluate the effect of chemoprophylaxis for group B streptococcus on the
incidence of neonatal sepsis and maternal postpartum endomyometritis. A two-tailed P < 0.05 was
used to denote statistical significance.
Results: The charts of 206 patients were reviewed; 146 patients received ampicillin for group B
streptococcal prophylaxis and 60 patients did not. There was a significantly higher incidence of
postpartum endomyometritis among the patients who received ampicillin (62% vs. 22%; P < 0.01).
The association between postpartum endomyometritis and chemoprophylaxis remained significant
even after controlling for other confounding variables. There was no significant difference in the
incidence of neonatal sepsis (5% vs. 7%; P = 0.7) or death
(5% vs. 3%; P = 0.9) between both groups.
Conclusions: Group B streptococcal prophylaxis with a short course of intravenous ampicillin
increases the risk of postpartum endomyometritis in patients with premature PROM.
Objective: The purpose of this study was to examine the role of the genital mycoplasmas
Mycoplasma hominis and Ureaplasma urealyticum as causes of bacteremia in a tertiary referral obstetrical, gynecological,
and neonatal intensive care facility, over a period of 12 years from 1983 to 1994 inclusively.
Methods: All clinically significant blood cultures were reviewed and the percentage of septicemic
episodes for genital mycoplasmas was compared to the total isolation rate, including conventional
Results: The overall positivity rate for all pathogenic organisms isolated from the blood cultures
of infants ranged from 4.5% to 7.7% per annum. U. urealyticum represented 0.8% of these positive
isolates and M. hominis 0.4%. For adults, the overall positivity rate from blood cultures ranged from
6.5% to 13.5%, with U. urealyticum representing 9.6% of these positive isolates and M. hominis 9.9%.
Conclusions: With M. hominis having an established role in such clinical entities as postabortal and
postpartum fever and U. urealyticum strongly implicated with chronic lung disease in low birth
weight infants, it is appropriate to examine blood cultures for genital mycoplasmas in an obstetric
Objective: The purpose of this study was to determine the ex vivo human placental transfer of
rifampin and rifabutin.
Methods: Seven placentas from uncomplicated term vaginal or cesarean deliveries were studied
utilizing the ex vivo single cotyledon perfusion system. Antipyrine was used for the reference
compound in the determination of the clearance indices of rifampin and rifabutin.
Results: The clearance indices of rifampin at maternal concentrations of 1.0 and 10.0 μg/ml were
0.12 ± 0.05 and 0.12 ± 0.11, respectively. The clearance indices of rifabutin at maternal concentrations
of 1.0 and 10.0 μg/ml were 0.44 ± 0.11 and 0.37 ± 0.15, respectively.
Conclusions: Because of its greater lipophilicity, rifabutin was found to have a greater clearance
than rifampin. However, because of rifabutin's trend toward greater deposition in tissue, there was
proportionately less accumulation of rifabutin in the fetal circulation when compared to rifampin.
Background: Pneumonia is the most common complication of varicella-zoster infection in adults and
has potentially devastating effects when complicating pregnancy. Due to the significant morbidity
and mortality associated with this complication during pregnancy and the small number of reported
cases in the literature, we present this report to help educate physicians who care for pregnant
Cases: Seven patients are presented in this report. These patients presented at various stages in
pregnancy, from 17 to 31 weeks of gestation. Three of the patients had unremarkable hospital
courses. Three of the patients had hospital stays over 21 days in duration. One patient died from
complications of varicella pneumonia after 31 days of hospitalization. The obstetric outcomes of the
7 patients described include 1 non-viable delivery at 20 weeks gestation, 3 term deliveries, 2 preterm
deliveries, and 1 patient who has not yet delivered. All of the patients presented were treated with
intravenous acyclovir therapy. Of the patients described, 3 required intubation and ventilatory
support. Other complications encountered include disseminated intravascular coagulation (DIC),
adult respiratory distress syndrome (ARDS), metabolic encephalopathy, pneumothorax, superimposed
bacterial pneumonia, and sepsis.
Conclusion: The course and treatment of varicella pneumonia complicating pregnancy are discussed.
Current recommendations regarding the use of varicella-zoster immune globulin (VZIG)
are also reviewed.
Objective: The purpose of this study was to prospectively test the null hypothesis that there is no
difference in the clinical effectiveness of azithromycin and erythromycin for the treatment of chlamydia
cervicitis in pregnancy.
Methods: All antepartum obstetrical patients underwent routine screening for chlamydia cervicitis
using a DNA probe assay (Gen-Probe Pace, San Diego, CA). Women who tested positive for
chlamydia cervicitis were prospectively randomized to receive either azithromycin 1 g orally at
enrollment, or erythromycin 500 mg orally 4 times a day for 7 days. Sexual partners were referred
to the county health department for evaluation and treatment. A test of cure was repeated in 2
weeks. Results were analyzed by chi-square analysis and Fisher's exact test when indicated.
Results: One hundred forty women tested positive for chlamydia cervicitis and agreed to randomization.
There were 4 (6.2%) treatment failures in the azithromycin group and 18 (27.7%) in
the erythromycin group (P = 0.005). Gastrointestinal side effects were reported by 42 (65.5%) of the
women taking erythromycin, but only 12 (19.4%) of those taking azithromycin (P < 0.002). Gastrointestinal
side effects and resultant noncompliance were significantly related to treatment failure
Conclusions: The findings of this study support the conclusion that a single dose of azithromycin
is a significantly more effective and better tolerated treatment regimen for chlamydia cervicitis in
pregnancy than erythromycin which is currently recommended.
Objective: This study aims to determine the pathophysiology of vulvar vestibulitis and to evaluate
currently used treatment options.
Methods: Two hundred twenty women with vulvar vestibulitis were seen between October 1987
and March 1995. Every patient had vulvar pain when they attempted intercourse, 75% had excessive
vaginal discharge, 36.4% had constant or recurring vulvar burning, and 10.9% had symptoms
suggestive of cystitis. All were cultured for the presence of Candida albicans. One hundred sixty-one
(73.2%) were also tested for vaginal IgE and prostaglandin E2 (PGE2); 72 (32.7%) had a vulvar biopsy performed as well.
Results: A wide range of variants were noted: 53 (24.1%) had a human papilloma virus (HPV)
infection, 25 (11.4%) had a Candida vulvovaginitis, 43 (19.5%) had a vaginal allergy, 15 (6.8%) had
vaginal PGE2 present, 14 (6.4%) had elevated urinary oxalate excretion, and 29 (13.2%) had a
variety of diagnosed variants. In 81 (36.8%) no underlying diagnosis was made. This understates
the numbers and varieties of vulvar vaginal diagnoses, for not all patients received a vaginal fluid
analysis, a vulvar biopsy, or a 24 h urine screen for oxalates. A variety of medical and operative
interventions was used. Symptoms were relieved in 65.9% of patients. The degree of sueeess varied.
Successful outcomes were achieved in 14.3% of patients using a low oxalate diet and calcium citrate
supplementation, 16% with anti-Candida treatment, 48.1% with antihistamines, 77% with vulvar
injection of interferon, 83% with operative removal of inflamed vulvar tissue, and a posterior
colporrhaphy used to cover the cutaneous defect.
Conclusions: The diagnosis of vulvar vestibulitis is easy to make. An etiology for this chronic
condition will not be achieved in every patient. A majority of patients can get relief by a variety of
medical and operative interventions.
Background: Capnocytophaga species are common oral pathogens and infrequent causes of systemic
infection in patients with compromised host. The isolation of this organism suggests an oral source
Case: A 32-year-old woman was admitted at 23 weeks gestation in preterm premature rupture
of the membranes. She subsequently developed signs of clinical intra-amniotic infection, including
fever, fetal tachycardia, and uterine tenderness. Bacteriologic studies of the amniotic fluid by trans-abdominal
amniocentesis and subchorionic placental cultures yielded Capnocytophaga species. On
review of the patient's history, a temporal relation was noted between orogenital contact and onset
of clinical infection. Thorough evaluation of the patient, including dental examination with periodontal
cultures, did not reveal an obvious source of infection. However, significant periodontal
disease was identified in her partner and Capnocytophaga species were isolated from her partner.
Conclusion: This case suggests that intra-amniotic infection may have been due to an ascending
infection after orogenital contact.
Background: Increasing reports of intrauterine device (IUD)-related abdominopelvic actinomycosis
have been described recently. Surgical therapy has been the usual treatment when tubo-ovarian
abscess is identified.
Case: A 38-year-old woman suffering from Actinomyces pelvic abscess unresponsive to medical
treatment underwent transvaginal ultrasound-guided needle aspiration. It resulted in marked improvement
and avoided surgical treatment.
Conclusion: Transvaginal needle aspiration of Actinomyces pelvic abscess may be an alternative to
surgical therapy, thereby allowing the preservation of pelvic organs.
Objective: This report evaluates the acceptance, results, and predictors of human immunodeficiency
virus (HIV) infection in inner city women referred to a colposcopy clinic for abnormal cervical
Methods: HIV testing results of 1,908 inner city women referred for abnormal cervical cytology
were analyzed retrospectively with respect to acceptance, race, ethnicity, Pap smear results, sexually
transmitted diseases (STDs), HIV exposures, and final histologic findings.
Results: HIV testing was accepted by 50.4% of patients. Women who agreed to screening were
significantly more likely to admit exposure to HIV or to be Hispanic, foreign-born, or have a history
of multiple STDs. Of those screened, 3.3% were found to be HIV seropositive. Although higher
grades of referral Pap smears were noted in the women found to be HIV seropositive, final histologic
findings were not different. The only predictors of unknown HIV seropositivity were admitted
HIV exposure and external condyloma.
Conclusions: Fifty percent of inner city women of unknown HIV status referred for abnormal
cervical cytology will accept HIV serotesting and 3.3% are found to be positive. Most HIV-seropositive
women can be detected based on either a history of exposure to HIV or the presence
of external condyloma.
Objective: We analyzed the histologic and immunohistochemical changes in the endometrial leukocytic
subpopulations to determine which of them are characteristic of chronic endometritis.
Results: Endometrial biopsies from 25 cases of chronic endometritis and 35 controls were studied.
Characteristic morphologic findings included the presence of a plasma cell infiltrate, and a prominent,
albeit non-specific, lymphocytic infiltrate in all patients with endometritis. A neutrophilic
infiltrate was also noted in 90% of the patients. Other non-specific histologic findings included
occasional prominent lymphoid aggregates, stromal edema, hemorrhage, and necrosis and cystic
dilation of some glands in endometria of patients with chronic endometritis. Endometrial immune
cells were investigated immunohistochemically using antibodies to CD3 (pan-T), CD20 (pan-B,
L26), and Ham-56 (macrophage). In control patients, endometrial immune cells were predominantly
composed of CD3 and Ham-56 positive cells. CD20 positive cells comprised <2% of immune
cells in control patients [mean: <2 cells/high power field (HPF)]. Large numbers of CD20 and CD3
lymphocytes were seen in endometria of patients with chronic endometritis. A semiquantitative
analysis showed that the numbers of CD20 and CD3 positive cells in patients with chronic endometritis
were increased 50- and 3-fold, respectively, when compared to those of control patients
(mean B cells: 49 vs. 2 cells/HPF; mean T cells: 149 vs. 45 cells/HPF). CD20 positive cells were
predominantly seen in subepithelial and periglandular aggregates. CD3 positive cells had a predominant
stromal distribution and an occasional intra- or subepithelial localization. There was no
difference in the number and distribution of Ham-56 positive cells in patients with or without
Conclusions: These findings suggest that CD20 cells may have a significant role in the pathogenesis
of chronic endometritis and that immunostaining for B and T lymphocytes could be used in
confirming the diagnosis of endometritis or in diagnosing subclinical or progressing endometritis in
which plasma cells could not be detected or are rarely identified.
Biliary tract disease is a relatively uncommon, heterogenous disease in pregnancy. Specifically,
acute cholecystitis can be especially difficult to recognize in pregnancy. However, once diagnosed,
the initial management plan should be conservative and include antibiotic therapy. Subsequent
management depends on the gestational age at diagnosis. Surgical therapy, when indicated,
should not be delayed and a planned intervention during the second trimester appears to offer a
better outcome than surgery performed under emergent conditions.
Objective: The purpose of this study was to evaluate the benefits achievable by Amplicor polymerase
chain reaction (PCR) (F. Hoffmann-LaRoche Ltd., Basel, Switzerland) with urine specimens
in addition to PACE 2 (Gen-Probe, Inc., San Diego, California) assay with cervical swab specimens
in the diagnosis of Chlamydia trachomatis in women.
Methods: Cervical and urine specimens from 286 women were tested for C. trachomatis by PACE
2 and Amplicor PCR, respectively. All urine specimens were analyzed undiluted and diluted 1:10
to detect and eliminate possible PCR inhibition. A confirmatory PCR assay using major outer
membrane protein-based primers (MOMP-PCR) was used on urine specimens that were positive
by PCR from women who were negative by PACE 2 with cervical swab specimens.
Results: Of the endocervical specimens, 26 were positive by the PACE 2 assay. The PCR with
urine was positive in 21 of these patients. When the urine specimens were analyzed diluted 1:10, 4
of the 5 PCR-negative specimens from PACE 2-positive patients turned positive by the PCR.
Additionally, 4 urine specimens from PACE 2-negative women were positive by the PCR with
urine, and 3 of them could be confirmed by MOMP-PCR. Altogether, 29 women were found to be
positive for C. trachomatis by either of the two assays.
Conclusions: By using the PCR with urine specimens, an 11% increase in sensitivity could be
achieved in addition to that obtained by PACE 2 assay with cervical swab specimens. In the present
material, however, the increased sensitivity was reversed by the presence of PCR inhibitors in 14%
of the female urine specimens. Amplicor PCR with urine specimens can undoubtedly be recommended
for the diagnosis of chlamydial infections in women. However, constant monitoring of the
PCR inhibition seems highly advisable to obtain full benefit of the sensitivity of the PCR.
Objective: Our objective was to determine the role of Mycoplasma hominis
and Ureaplasma urealyticum in pelvic inflammatory disease (PID).
Methods: The clinical and microbiologic variables in 114 patients with a clinical diagnosis of PID
were compared prospectively according to the isolation of M. hominis and U. urealyticum from their
Results: The groups were epidemiologically well matched. Clinical parameters such as temperature,
leukocyte count, erythrocyte count, and C-reactive protein on admission and length of hospital
stay were similar in the patients, regardless of their mycoplasma status. A significant percentage of
the patients either continued or started to harbor genital mycoplasmas after the resolution of PID
without any significant clinical sequelae.
Conclusions: The presence of genital mycoplasmas does not change the clinical presentation and
course of PID. Both M. hominis and U. urealyticum can persist or colonize the endometrium after
complete recovery from PID. Therefore, the genital mycoplasmas do not seem to have a dominant
pathogenic role in PID.
Objective: The aim of this study was to prospectively evaluate the efficacy of a therapeutic course
of intravenous antibiotics followed by oral antibiotics vs. intravenous antibiotics alone to prevent
recurrent urinary tract infection.
Methods: Pyelonephritis was documented by strict criteria in 67 pregnant women who were then
treated with appropriate intravenous antibiotics until afebrile and asymptomatic for 48 h. Women
were then randomized to completion of a 10-day course of oral nitrofurantoin 100 mg qid or no
further antibiotic therapy. Urine cultures (UC) were obtained 2 and 6 weeks after discharge, and
at delivery. A positive UC or readmission for pyelonephritis was considered endpoints for participation
in the study. Antibiotic suppression was not used.
Results: Readmission for pyelonephritis prior to the 2-week follow-up visit occurred in 2/36
(5.6%) women randomized to the oral therapy group compared to 4/31 (12.9%) in the no oral
treatment group (P = 0.29). At the 2-week follow-up visit, 6/31 (19.4%) women had a positive UC
in the oral therapy compared to 8/26 (30.1%) in the no oral treatment group but this difference was
not statistically significant (P = 0.31).
Conclusions: Completion of 10 days of antibiotic therapy with oral medication does not significantly
reduce the risk of recurrent pyelonephritis immediately post-parenteral treatment. Women in
the no oral treatment group had a non-significant increase in positive UC at the 2-week follow-up
visit. The high rates of recurrent urinary tract infection during pregnancy in both groups underscore
the need for regular UC and for the possible role of oral antibiotic suppression.
Objective: According to unsatisfactory therapeutic results in patients with chronically recurrent
vaginal candidosis, we investigated if immunologic patient factors could be found and treated.
Methods: In 42 women with chronically recurrent and 20 women with acute Candida albicans
vulvovaginitis, as well as 14 women with C. glabrata vaginitis, the following investigations were
carried out: identification of yeast species; quantification of T lymphocytes and their subpopulations
in sera; proliferation tests of T lymphocytes in vitro; treatment of 18 patients with chronically
recurrent vaginal candidosis with the synthetic T-lymphocyte- stimulator thymopentin; and, finally,
control of the above-mentioned parameters in the clinical course.
Results: Women with C. albicans vulvovaginitis showed fewer T lymphocytes and subpopulations
in the peripheral blood than healthy women. Only the number of non-specific killer (NK) cells,
however, was significantly lower in cases of acute C. albicans vulvovaginitis.
In women with C. glabrata vaginitis, the number of T lymphocytes in the blood was within the normal range. In vitro
proliferation tests using mitogens, bacterial antigens, and commercially available candida antigens
with and without addition of thymopentin were carried out on the T lymphocytes of women with
chronically recurrent C. albicans vulvovaginitis. These tests revealed no significant differences
compared with the other patients with C. albicans infections. The patients were treated with thymopentin.
Those women who revealed an increase of initially low numbers of T-helper cells recovered from vaginal candidosis after thymopentin treatment.
Conclusions: The peripheral T lymphocytes may be diminished in patients with chronically recurrent
C. albicans vaginitis, and immunologic treatment can reduce the relapse rate.
Background: Eczema herpeticum is an uncommon manifestation of an infection with herpes simplex
virus (HSV). The disease is primarily seen in patients with histories of atopic eczema. Eczema
herpeticum may be a life-threatening illness, but the mortality is felt to be <10% with modern
antiviral and antibacterial agents. The use of acyclovir for other viral infections secondary to
herpesvirus in pregnancy has been well documented. The authors now present a case report of
eczema herpeticum treated with acyclovir during pregnancy.
Case: A patient with a history of eczema herpeticum presented in pregnancy with a recurrence.
She was successfully treated with intravenous (IV) acyclovir with good maternal and fetal outcome.
Conclusion: Acyclovir may be utilized in pregnancy for several manifestations of HSV including
Azithromycin (Zithromax®, Pfizer, Inc., New York, NY) is a 15-membered-ring macrolide and
the first azalide antibiotic. It is distinguished from other macrolides by its rapid and extensive
penetration into intracellular and interstitial tissue compartments, accompanied by prolonged
tissue and serum half-lives. Azithromycin shares the gram-positive activity of erythromycin but
is more potent against gram-negative organisms. For urethritis and cervicitis caused by
Chlamydia trachomatis, azithromycin is effective and well tolerated in a single dose of 1 g, a regimen
recommended by the CDC. A 5-day dosage regimen is available for the treatment of community-acquired
respiratory-tract and skin and skin-structure infections caused by susceptible organisms.
Azithromycin provides short-duration, high-compliance, cost-effective regimens that should improve