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1.  Ovarian Abscess Following Therapeutic Insemination 
Background: Artificial insemination is a commonly performed procedure for the treatment of various forms of infertility. Infectious complications have only rarely been noted as a complication of intrauterine insemination (IUI).
Case: In this presentation, we report the first case of an ovarian abscess following IUI with the husband's semen. Despite treatment with triple antibiotics, an oophorectomy was required. Surgical as well as pathological evaluation confirmed the diagnosis of an ovarian abscess. Following surgery, the patient responded well to antibiotic therapy.
Conclusion: Since pelvic infections are ascending processes, the violation of the natural cervical barrier with IUI can theoretically place the patient at increased risk for this complication. While few advocate routine cultures of semen samples, the clinician must be acutely alert to potential infectious morbidity following this procedure. Early diagnosis and intervention are necessary to minimize morbidity and optimize treatment.
PMCID: PMC2366148  PMID: 18472883
2.  Effect of Resident Physician Education Regarding Selective Chemoprophylaxis for the Prevention of Early Onset Group B Streptococcal Sepsis: An Outcome Study 
Objective: The aim of this study was to evaluate the effect of a voluntary protocol for selective intrapartum chemoprophylaxis on the incidence of early onset group B streptococcal sepsis (GBS EOS).
Methods: Cases of GBS EOS were defined as a positive GBS culture from a normally sterile fluid obtained during the first 7 days of life. All cases of GBS EOS at an urban, university-affiliated community hospital were reviewed during 2 time periods. The 2-year period before instituting a resident education program to promote selective chemoprophylaxis (1988–89) was retrospectively reviewed; the 2-year period after the education program was introduced (1990–91) was prospectively recorded. The outcome measure was the incidence of GBS EOS.
Results: The rate of GBS EOS was 7/14,335 deliveries (0.05%) before and 9/13,999 (0.064%) after the introduction of the education program (observed difference between proportions 0.016%, 95% confidence interval [CI] for the difference between the proportions –0.071% to 0.04%, P = not significant [NS]). The rate of GBS EOS in preterm infants was 5/1,331 (0.376%) before and 3/1,297 (0.23%) afterward (observed difference between proportions 0.14%, 95% CI –0.28% to 0.56%, P = NS). The incidence of GBS EOS did not decrease during the latter period due to failure of antepartum cultures to predict intrapartum GBS colonization (2 cases); non-compliance with voluntary recommendations to administer chemoprophylaxis (2 cases); failure of chemoprophylaxis or therapy for intraamniotic infection to prevent neonatal infection (3 cases); and occurrence of GBS EOS in infants without risk factors (2 cases).
Conclusions: An education program for resident physicians regarding chemoprophylaxis for GBS EOS did not significantly reduce the absolute incidence of disease. Alternative strategies are needed that redress the causes of failure inherent in the current guidelines. Some cases of GBS EOS are not preventable because the parturient does not have risk factors that indicate chemoprophylaxis.
PMCID: PMC2366147  PMID: 18472876
3.  Group A Streptococcal Puerperal Sepsis: Historical Review and 1990s Resurgence 
There appears to be a resurgence of puerperal sepsis due to a historically important pathogen, group A β-hemolytic streptococcus.
PMCID: PMC2366146  PMID: 18472884
4.  Immunizations During Pregnancy 
PMCID: PMC2366145  PMID: 18472875
5.  Pregnancy Outcome in Swiss-Webster Mice Infected With Chlamydia trachomatis  
Objective: The objective of this study was to observe pregnancy outcomes in mice infected transvaginally with Chlamydia trachomatis.
Methods: Pregnant mice were inoculated transvaginally with either C. trachomatis (CT) or sterile calf serum (CON) on pregnancy day 4. Pregnancy outcomes as well as genital tract histology and culture were compared. Statistical analysis was performed using Fisher's exact test and Student's t-test.
Results: Twenty-four of 26 CT mice had positive uterine cultures for C. trachomatis. Inflammation occurred in 9 (34.6%) (P = 0.002, 95% confidence interval = 1.7–3.5) and intrauterine fetal demise occurred in 5 (19.2%) (P = 0.05, 95% confidence interval = 1.6–2.9) of CT mice. No mice in the CON group (0/24) had positive uterine cultures, developed inflammation, or experienced intrauterine fetal demise.
Conclusions: Lower genital tract chlamydial infection is associated with intrauterine fetal demise in Swiss-Webster mice.
PMCID: PMC2366144  PMID: 18472881
6.  Randomized Trial of Antibiotics in Addition to Tocolytic Therapy to Treat Preterm Labor 
Objective: The objective of this study was to assess whether antibiotic therapy plus tocolysis given to women in preterm labor would prolong pregnancy compared with tocolysis alone.
Methods: A randomized, double-blind trial of intravenous mezlocillin and oral erythromycin therapy vs. placebo was used in addition to tocolysis among women in preterm labor ≤34 weeks gestation with intact membranes. Amniocentesis was performed, and chorioamnionic membranes were examined histologically and cultured for microorganisms after delivery.
Results: Clinical characteristics including gestational age at enrollment, frequency of contractions, cervical Bishop's score, and white blood cell count on admission were similar in the 2 groups. Antibiotic therapy was well tolerated. No significant differences in the interval to delivery, birth weight, and neonatal outcomes were observed between the 2 groups. Women in the antibiotic group had a significantly lower incidence of postpartum infections compared with women in the placebo group. Patients with evidence of upper genital tract infection in either group had a significantly shorter interval to delivery, lower gestational age at delivery, lower mean birth weight, and increased neonatal hospitalization time.
Conclusions: Lack of an antibiotic effect on the gestational age at delivery may be due to the low prevalence of upper genital tract infection among unselected women in preterm labor, to advanced preterm labor unresponsive to antibiotic therapy, or to an inability of antibiotics given alone to inhibit the cytokine response. Further work is needed to identify markers of upper genital tract infection among women in preterm labor and to evaluate other potential therapeutic interventions.
PMCID: PMC2366143  PMID: 18472878
7.  Epidemiology of Sexually Transmitted Diseases Among Pregnant Adolescents 
Objective: The purpose of this study was to determine the epidemiology of sexually transmitted diseases (STDs) among pregnant adolescents.
Methods: Charts of all patients (n = 735) who attended the Maternal and Infant Care Clinic at University Hospital, Newark, NJ, between July 1, 1991, and June 30, 1992, were reviewed for STDs which included gonorrhea, chlamydia, syphilis, and human immunodeficiency virus (HIV). At the first prenatal visit, each registrant had endocervical specimens obtained to detect gonorrhea and chlamydia. A serum sample was obtained for syphilis screening. HIV testing was made available to all patients and testing was done on a voluntary basis. The same STD screening that was done at the initial visit was repeated at 28 and 36 weeks.
Results: Twenty-five percent of patients tested positive for one or more STDs. The mean patient age was 17.3 years. The mean gestational age at first visit was 19.5 weeks. The mean number of visits was 7.3. The following STDs were identified: 4.8% of patients tested positive for gonorrhea, 20.9% tested positive for chlamydia, and 1.7% tested positive for syphilis. Twenty-one percent of patients had a positive STD diagnosed at the initial visit. Another 4.8% of patients had an STD diagnosed at some time after the initial visit when the initial screen was negative for STDs. An additional 1% of patients who initially tested positive for an STD had subsequent screening which revealed another STD (different organism). Seven patients tested HIV positive. Sixty-one percent of patients with STDs agreed to HIV testing. One patient had HIV coexistent with another STD.
Conclusions: Pregnant adolescents are at risk for multiple STDs. HIV testing should be offered. STD screening should be repeated in the third trimester in adolescent patients.
PMCID: PMC2366142  PMID: 18472877
8.  Trichomonas vaginalis: Diagnosis and Clinical Characteristics in Pregnancy 
Objective: The objectives of this study were to 1) determine the prevalance and characterize the symptomatology of Trichomonas vaginalis (TV) infection in pregnant women on entry into prenatal care in an inner-city population; 2) compare conventional microscopic methods vs. culture techniques in diagnosing TV in both symptomatic and asymptomatic pregnant patients; and 3) correlate wet mount microscopic and microbiologic characteristics of varying manifestations of trichomoniasis.
Methods: One thousand two hundred sixty patients in an inner-city population were tested at entry into prenatal care for TV by saline wet mount and culture techniques. Other tests for lower genital tract infection were also performed. Vaginal symptoms were ascertained through standardized questioning prior to examination. Standard microscopic and microbiologic data were also obtained for analysis. Wet mounts were systematically examined and considered negative if no TV was identified in 10 high powerfields (HPFs). Cultures were inspected from days 4 to 7 or until positive results were obtained. Results were analyzed using McNemar's test for correlated proportions, chi-squared test, or Fisher exact test where appropriate.
Results: Culture and wet mount results were available in 1,175 patients. TV infection was documented by one or both techniques in 110/1,175 (9.4%). Culture methods detected 105/110 (94.5%) of all patients while wet mount detected 90/110 (73%) (P <0.001). Vaginal symptoms were present in only 20/110 patents (18.2%). Among asymptomatic patients, culture detected 94% while wet mount detected 70% (P < 0.001). Among symptomatic patients, wet mount and culture were both effective and diagnosed 85% and 95% of infections, respectively (P = not significant). Patients with TV were more likely to have increased vaginal fluid wlaite blood cells (WBCs) and more severe vaginal flora disruption than uninfected controls. Subgroup analysis revealed wet mount-positive/culture-positive patients were more likely to have vaginal flora disruption, as evidenced by decreased lactobacilli and elevated vaginal pH, than wet mount-negative/culture-positive subjects. Coexistent infection rates were similar regardless of wet mount status. Elevated vaginal fluid WBCs were more common among patients with symptoms.
Conclusions: 1) Screening pregnant women for TV based solely on symptomatology is ineffective in this population; 2) culture techniques detected more infections than conventional microscopic evaluation; and 3) significant increases in vaginal fluid WBCs and altered vaginal flora are found in both symptomatic and asymptomatic TV, suggesting that both infestations have the potential to adversely affect pregnancy outcome. Studies on the influence of TV on pregnancy outcomes are ongoing.
PMCID: PMC2366141  PMID: 18472879
9.  Fatal Herpetic Hepatitis in Pregnancy 
Background: Disseminated herpetic infections during pregnancy have been reported in the literature.
Case: This case presentation describes a pregnant patient who presented with fever, elevated liver enzymes, and upper abdominal tenderness and succumbed from fulminant herpetic hepatitis.
Conclusion: Early diagnosis and treatment are essential because of the high mortality rate.
PMCID: PMC2366140  PMID: 18472882
10.  Human Papillomaviruses and Papillomatosis Lesions of the Female Lower Genital Tract 
Objective: The objective of this study was to determine whether human papillomavirus (HPV) infections are involved in the development of papillomatosis lesions of the lower female genital tract.
Methods: A total of 616 biopsy specimens of genital papillomatous lesions (307 nodular and 309 papular types) from 598 patients were anaylyzed for the presence of HPV DNA sequences by polymerase chain reaction (PCR). These specimens were also examined by histopathological assessment for characteristic HPV-associated cytological changes, by immunohistochemical staining for HPV-associated antigen, and by electron microscopy for the presence of virions.
Results: HPV DNA sequences were found in 97.9% (140 of 143 cases) and 1.1% (1 of 91 cases) of the nodular and papular papillomatosis cases tested, respectively. In 18 patients who had both types of papillomatosis lesions, HPV DNA was invariably found only in nodular tissues. HPV-associated antigen, koilocytosis, and virions were found in 53.6% (98 of 183 cases), 70.5% (129 of 183 cases), and 5.9% (5 of 85 cases) of nodular papillomatosis lesions tested, respectively.
Conclusions: These data suggest that nodular papillomatosis was closely associated with HPV infection, but that papular papillomatosis of the lower female genital tract may have an etiology other than HPV infection,
PMCID: PMC2366139  PMID: 18472880
11.  Case-control Analysis of Clostridium difficile—Associated Diarrhea on a Gynecologic Oncology Service 
Objective: The incidence, morbidity, and risk factors associated with Clostridium difficile-associated diarrhea (CDAD) were studied in a group of gynecologic oncology patients.
Methods: A case-control analysis of gynecologic oncology patients with CDAD was carried out from August 1986 through January 1989 in a university medical center.
Results: One hundred twenty-three stool samples were tested for C. difficile using the CDT latex agglutination test (Marion Diagnostics, Kansas City, MO). Thirty episodes of CDAD developed in 23 patients. From August 1986 through July 1988, the incidence was stable at 1.5 episodes/100 admissions. From August 1988 through January 1989, the incidence increased to 9.9 episodes/100 admissions (P = 0.005). Compared with patients with nonspecific antibiotic-associated diarrhea, the study patients were hospitalized longer prior to the development of symptoms (mean 15.2 vs. 9.2 days, P = 0.006) and were admitted more frequently with diarrhea (37% vs. 11%, P = 0.015). The rates of surgery, chemotherapy, and radiation therapy were similar. Fever (57% vs. 14%, P < 0.001), abdominal pain (40% vs. 6%, P < 0.001), bloody stools (27% vs. 3%, P = 0.006), and leukocytosis (64% vs. 26%, P = 0.011) were more common among the study cases. The duration, indication, and number of antibiotics administered were similar, though once started, the mean time to symptoms was longer in the study cases (13.7 vs. 6.1 days, P = 0.004). Seven relapses, 1 death, and 1 unplanned colostomy occurred among women with CDAD.
Conclusions: C. difficile is a serious cause of nosocomial morbidity in gynecologic oncology patients. Diarrhea developing after antibiotic exposure is more likely to be associated with C. difficile in patients whose symptoms develop several days after completing antibiotics and in patients with a history of CDAD.
PMCID: PMC2364387  PMID: 18475384
12.  To Vaccinate or Not to Vaccinate 
PMCID: PMC2364386  PMID: 18475383
13.  Novel Family of Gynecologic Cancer Antigens Detected by Anti-HIV Antibody 
Objective: The reactivity of gynecologic cancer proteins with monoclonal antibody (MAb) directed against the human immunodeficiency virus I (HIV-I) was tested.
Methods: Cytoplasmic and nuclear proteins, extracted from a broad range of gynecologic cancers obtained during standard surgical procedures, were tested in Western blotting with MAb 5023 developed against the amino acid sequences 308–322 of the envelope protein gp120 of HIV-I.
Results: Three cell membrane proteins, Mrl20,000 (p120), Mr41,000 (p41), and Mr24,000 (p24), and one chromatin protein, Mr24,000 (p24), were detected by MAb 5023 in invasive, poorly differentiated cervical squamous-cell carcinoma; ovarian serous cystadenocarcinoma; poorly and well-differentiated endometrial carcinoma; vulvar squamous-cell carcinoma; and malignant mixed müllerian tumor. The same antigens were identified in cervical carcinoma cell line SiHa. Neither p120 nor p24 was recognized by other MAbs directed against the variable loop of gp120. Antigens p120 and p41 were undetectable in normal ovarian tissue and in biopsy samples of normal vaginal and rectal mucosa. Rectosigmoid cancer as well as colon carcinoma, lung carcinoma, and melanoma cell lines all tested negative.
Conclusions: The identified antigens may represent either the products of human genes (proto-onc-ogenes) or, more likely, the products of an unknown virus specifically expressed in female cancer.
PMCID: PMC2364385  PMID: 18475387
14.  Chorioamnionitis: Association of Nonreassuring Fetal Heart-rate Patterns and Interval From Diagnosis to Delivery on Neonatal Outcome 
Objective: The purpose of this study was to determine whether selected fetal heart-rate (FHR) patterns and the interval from diagnosis to delivery in pregnancies complicated by chorioamnionitis could predict neonatal outcome.
Methods: During a 6-month period, 217 consecutive patients with acute chorioamnionitis were prospectively identified in labor. Following delivery, the fetal monitor strips and hospital courses were reviewed for both the mother and neonate. Multiple logistic regression was used to analyze the presence of a nonreassuring FHR pattern and the effect on neonatal outcome. Fisher exact tests were used to analyze the time intervals from the diagnosis of chorioamnionitis to delivery and their significance on neonatal outcome parameters.
Results: The overall incidence of chorioamnionitis in our population was 2.3%. None of the independent variables analyzed following the diagnosis of chorioamnionitis until delivery were significantly associated with an umbilical artery (Ua) pH < 7.20. There were no differences in cord pH, Apgar scores, sepsis, admission to special-care nursery, and oxygen requirements in neonates based on the duration of time from the diagnosis of chorioamnionitis to delivery in our study. None of the newborns had pathologic fetal acidemia (Ua pH < 7.00). None of the FHR patterns we identified after the diagnosis of acute chorioamnionitis were significantly associated with neonates with a Ua pH < 7.20.
Conclusions: An interval from diagnosis to delivery of up to 12 h plays little if any role in neonatal outcome.
PMCID: PMC2364384  PMID: 18475385
15.  Septic Shock and Sepsis Syndrome in Obstetric Patients 
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.
PMCID: PMC2364383  PMID: 18475391
16.  Evidence for In Utero Hematogenous Transmission of Group B β-hemolytic Streptococcus 
Background: The presumed ascending route of group B β-hemolytic streptococcus (GBS) infection from the colonized maternal genital tract is well accepted. This case report proposes a hematogenous, selective infection of one unruptured amniotic sac over the other ruptured amniotic sac in a twin gestation in a patient with known GBS vaginal colonization.
Case: This is a case report of GBS sepsis in twin B with intact membranes. Twin A, with 28 h of ruptured membranes, failed to show any signs of infection. The pathology of the placenta confirmed chorioamnionitis in twin B and the absence of infection in twin A.
Conclusion: The presence of culture-positive GBS sepsis in the twin with the unruptured amniotic sac, as well as the absence of GBS infection in the twin with the ruptured sac, suggests an alternative means of infection for GBS infection, such as hematogenous transplacental transmission.
PMCID: PMC2364382  PMID: 18475389
17.  Human Papillomavirus DNA in LEEP Plume 
Objective: This study was undertaken to determine the prevalence of human papillomavirus (HPV) in loop electrosurgical excision procedure (LEEP) plumes.
Methods: Forty-nine consecutive patients with colposcopic and cytologic evidence of cervical intraepithelial neoplasia (CIN) were tested. Smoke plumes were collected through a filter placed in the suction tubing. DNA was harvested by proteinase K digest of the filters and prepared for polymerase chain reaction (PCR) by L1 consensus primers.
Results: Thirty-nine (80%) tissue samples were positive for HPV, with types 6/11 in 4, 16/18 in 19, 31/33/35 in 2, and other types in 6 patients. The tissue sample was inadequate for typing in 8 patients. HPV DNA was detected in 18 (37%) filters.
Conclusions: Although the consequences of HPV in LEEP plume are unknown, it would be prudent to adopt stringent control procedures.
PMCID: PMC2364381  PMID: 18475386
18.  Role of Bacterial Vaginosis in Peripartum Infections 
Objective: The purpose of this prospective investigation was to determine if the presence of bacterial vaginosis (BV) at the time of delivery was associated with the development of maternal and neonatal infection.
Methods: Vaginal fluid was collected from 390 laboring patients. Smears of the vaginal secretions were gram stained, and slides were scored and interpreted as normal, intermediate, and BV based on Gram's stain criteria. Results of the Gram's stains were correlated with the clinical diagnoses of chorioamnionitis, endometritis, and neonatal sepsis.
Results: Eighty-eight percent of patients were term and 12% were preterm. The overall prevalence of BV was 30%. The frequency of BV was similar in both term and preterm women. BV was significantly more prevalent among nonwhites than whites (37% vs. 25%, P = 0.005). Maternal characteristics such as mean age, parity, status of the membranes, mean duration of labor, mean duration of ruptured membranes, mean length of fetal monitoring, mean number of vaginal examinations, and mode of delivery were similar in patients with BV, intermediate, and normal Gram's stains. Forty-seven (12%) women developed peripartum infection. The frequencies of chorioamnionitis or endometritis in women with BV or intermediate Gram's stains were 19/116 (16.4%) and 11/63 (17.5%), respectively. The frequency in each of the 2 groups was significantly increased compared with the rate in women with normal Gram's stains: 17/211 (8.1%), [P = 0.034, OR = 2.0 (95% CI, 1.07–3.73) for BV and P = 0.054, OR = 2.1 (95% CI, 1.12–3.94) for intermediate Gram's stain]. The incidence of suspected or confirmed neonatal infection was significantly higher in mothers with intermediate Gram's stains compared with mothers with normal Gram's stains (P = 0.02, OR = 2.18, 95% CI, 1.12–3.94), while no difference in incidence was observed between mothers with BV and normal Gram's stains (P > 0.05). The rate of neonatal infection directly correlated with maternal group B streptococcal colonization rather than with BV.
Conclusions: In this population, patients with BV and intermediate Gram's stains had an increased frequency of peripartum infection.
PMCID: PMC2364380  PMID: 18475388
19.  Salmonella typhi and Pregnancy: A Case Report 
Background: Salmonella typhi may be a cause of significant morbidity and mortality in both the mother and fetus. Febrile illness during pregnancy, especially that associated with hemolysis, is associated with chorioamnionitis, pyelonephritis, or viral syndrome. As such, S. typhi should be considered when a patient presents with a fever and hemolysis. We present a case of S. typhi complicating pregnancy.
Case: A primigravida at 26 weeks gestation presented with persistent spiking temperature and severe hemolysis. Her presenting signs and symptoms included fever, vomiting, cough, earache, jaundice, dark urine, and anemia. After 4 units of blood, her posttransfusion hematocrit was 29%. Hemolysis was evident on a peripheral blood smear. Total bilirubin was 2.5 mg/dl and direct bilirubin was 1.2 mg/dl. Gentamicin and clindamycin were administered empirically. Stool, blood, and urine cultures were obtained. Blood cultures were positive for S. typhi. Antibiotic coverage was changed to gentamicin and ceftriaxone. She defervesced on the 5th day and had no further problems. A healthy male infant was delivered vaginally at term.
Conclusion: Typhoid fever is a serious infection, and special concern arises when S. typhi complicates pregnancy. The diagnosis of S. typhi should be considered in a gravida presenting with fever with prompt institution of antibiotic therapy. Appropriate cultures are essential for confirming the diagnosis.
PMCID: PMC2364379  PMID: 18475390
20.  Assessment of the Value of Routine Blood Cultures in the Evaluation and Treatment of Patients With Chorioamnionitis 
Objective: The objective of this investigation was to determine the usefulness of blood cultures in evaluating patients with chorioamnionitis who were treated in accordance with a specific antibiotic protocol.
Methods: We reviewed the records of 539 patients with chorioamnionitis who delivered at our facility over a 3 year period (July 1, 1989–June 30, 1992). Patients had one set of aerobic and anaerobic blood cultures at the time of their initial assessment. They were treated initially with ampicillin or vancomycin plus gentamicin. Those who required cesarean delivery also received clindamycin postoperatively. Patients who had a poor initial response to therapy were treated empirically with selected antibiotics targeted against likely resistant organisms until the results of bacteriologic cultures were available. Bacteremic patients had repeat blood cultures while on therapy. We analyzed the medical records to determine the frequency with which blood culture results led to meaningful changes in patient management. We also compared the duration of febrile morbidity in bacteremic vs. nonbacteremic patients.
Results: Thirty-nine of 538 patients (7.2%, 95% confidence interval [CI] 5.2–9.2%) had positive blood cultures. In only one patient did the result of the blood culture definitively alter therapy. This patient had a fever of unknown origin, and the finding of a positive blood culture ultimately led to the diagnosis of chorioamnionitis. The mean duration of febrile morbidity was not significantly different in bacteremic vs. nonbacteremic patients (2.03 vs. 1.74 days). None of the repeat blood cultures was positive. The cost of blood cultures in the study population was $72,759.00.
Conclusions: The routine use of blood Cultures in the assessment of patients with chorioamnionitis rarely provides information that justifies a change in clinical management when patients are treated in accordance with the specific antibiotic protocol outlined in this investigation.
PMCID: PMC2364378  PMID: 18475375
22.  Comparison of Culture and Rapid Enzyme Immunoassay for the Detection of Group B Streptococcus in High-Risk Pregnancies 
Objective: The purpose of this study was to evaluate the Equate Strep B® test for clinical use in patients at high risk for complications from group B streptococcus (GBS) disease.
Methods: Vaginoperineal swabs were obtained from patients with preterm premature rupture of the membranes and/or preterm labor and semiquantitative GBS cultures and Equate® assay were performed.
Results: From May 14, 1990, to April 30, 1992, 650 patients were enrolled; 626 had both culture and Equate® results available, of whom 24% were colonized with GBS. The sensitivity, specificity, positive predictive value, and negative predictive value of the rapid assay were 28%, 84%, 35%, and 79%, respectively. Although the prevalence of GBS was higher in patients with ruptured membranes compared with those with intact membranes, rupture of membranes did not affect test sensitivity or specificity.
Conclusions: We conclude that the Equate® rapid assay is not a sensitive method of GBS detection in high-risk patients.
PMCID: PMC2364376  PMID: 18475376
23.  Cytomegalovirus Infection in Pregnancy 
Cytomegalovirus (CMV) infection is of great importance to obstetrician-gynecologists because maternal infection is relatively common and can result in severe injury to the fetus. The greatest risk to the fetus occurs when the mother develops a primary CMV infection in the first trimester. Forty to 50% of infants delivered to mothers with primary CMV infections will have congenital infections. Of these neonates, 5–18% will be overtly symptomatic at birth. Approximately 30% of severely infected infants die, and 80% have severe neurologic morbidity. Eighty-five to 90% of infants will be asymptomatic, and 10–15% of these babies subsequently have sequelae such as visual and auditory defects. If the mother develops a recurrent or reactivated CMV infection during pregnancy, the risk of a severe congenital infection is very low. Perinatal infection, as opposed to congenital infection, may result from exposure to the virus during delivery or lactation and rarely leads to serious sequelae. Antimicrobial therapy and immunotherapy for CMV are, at present, unsatisfactory. Therefore, all patients, pregnant women in particular, must be educated about preventive measures.
PMCID: PMC2364375  PMID: 18475382
24.  Propensity of Tampons and Barrier Contraceptives to Amplify Staphylococcus aureusToxic Shock Syndrome Toxin-I 
Objective: Although the incidence of reported cases of toxic shock syndrome (TSS) has declined in recent years, the disease continues to occur in menstruating women using the newer, less-absorbent tampons or barrier contraceptives. Extant tampons and other vaginal devices were tested for the ability to induce TSS toxin-1 (TSST-1) by a TSS strain of Staphylococcus aureus MN8, a known high-toxin producer. Tested for the first time were 20 varieties of tampons, including 2 all-cotton brands newly introduced in the United States, a polyurethane contraceptive sponge, a latex diaphragm, and a polymer menstrual collection cup.
Methods: All products were washed in sterile distilled water prior to use to reduce the effect of leachable chemicals. Duplicate experiments with unwashed products were also performed. Entire tampons and other test products were immersed in brain heart infusion broth plus yeast extract (BHIY) and inoculated with S. aureus MN8, a known TSST-1 producer. After incubation, the culture supernatants were assayed for TSST-1 by gel immunodiffusion.
Results: Except for all-cotton tampons, greater amounts of TSST-1 were detected in the supernatant fluid of washed tampons than detected in those which were not washed. While TSST-1 levels in unwashed non-cotton tampons ranged from 0.5 to 8 μg/ml, when these products were washed, TSST-1 levels increased to 2–32 μg/ml. In all-cotton tampons, whether washed or not, there was no detectable TSST-1.
Conclusions: The propensity for all-cotton tampons not to amplify TSST-1 in vitro suggests they would lower the risk for tampon-associated TSS.
PMCID: PMC2364374  PMID: 18475381
25.  Occult Intraamniotic Infection at the Time of Midtrimester Genetic Amniocentesis: A Reassessment 
Objective: The objective of this study was to reevaluate the incidence of occult early midtrimester intraamniotic infection in asymptomatic patients at the time of genetic amniocentesis.
Methods: A total of 177 amniotic fluid (AF) specimens from patients referred for genetic amniocentesis between 15 and 20 postmenstrual weeks were evaluated for the presence of bacteria by detailed light microscopy, after Gram and Wright stain, and by cultures for aerobic and anaerobic baceria, Mycoplasma sp., and Ureaplasma urealyticum. Seventy-seven AF specimens were also tested for the presence of bioactive leukoattractants by a leukotaxis bioassay.
Results: All fluids were negative for bacteria and bioactive leukoattractants [95% confidence interval (CI), 0–1.9%; 99% CI, 0–2.9%]. This is significantly less than a recently reported incidence of 5.09% (P = 0.002). Incidentally, artifacts with light microscopic morphology consistent with spermatozoa were found during the detailed light microscopic evaluation of AF Gram stains from 2 (1.1%) AF samples in otherwise uneventful pregnancies, a previously unreported finding. Scanning electron microscopy was used to confirm the light microscopic findings.
Conclusions: Occult intraamniotic infection in the second trimester is not as high as recently reported. AF culture in all cases of second-trimester amniocentesis is not necessary. The identification of spermatozoa on Gram stain of second-trimester AF specimens needs further confirmation.
PMCID: PMC2364373  PMID: 18475380

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