Objective: The purpose of this study was to determine if bacterial growth occurred in the amniotic
fluid of laboring women. Twenty patients who required an intrauterine pressure catheter (IUPC)
during labor were studied. Amniotic fluid samples were aspirated during labor and at the time of
Methods: IUPCs were placed in laboring patients for a variety of reasons. Cervical cultures were
taken prior to insertion of an IUPC. After the IUPC was placed, amniotic fluid cultures were taken
both at the time of placement and 30 minutes prior to delivery. These cultures were sent for aerobic,
anaerobic, Mycoplasma, and Ureaplasma cultures.
Results: The increase in bacterial concentration from the initial sample to the final sample was
statistically significant (P < 0.01) for both aerobes and anaerobes. Amniotic fluid samples demonstrated
a median of 0 bacterial species per patient on initial collection and 2 bacterial species per
patient in final collection. The mean count of cfu for erobes in the initial amniotic samples was
3.5 × 104, compared to that of the second samples, which was 1.4 × 105. The mean count of cfu for
anaerobes in the initial amniotic fluid samples,.was 4.1 × 102, compared to that of the second
samples, which was 8.0 × 103. Only 3 of 20 patients developed chorioamnionitis, with only 1 patient
having an increased number ofbacterial species significantly higher than the median. Although 80%
of patients had a colony count ≥ 102 cfu/cc, only 19% of this group developed chorioamnionitis.
Conclusions: The number of bacterial species and colony counts increased significantly during
labor, but this factor alone was not enough to cause chorioamnionitis in a significant number of
Chlamydia trachomatis is the most common reportable sexually transmitted disease (STD) in the
United States. In the 1980s, rapid diagnostic tests for chlamydia began to replace more cumbersome
tissue culture methods. Current data on rapid antigen detection assays demonstrate acceptable
sensitivity, specificity, and predictive values in populations with a high prevalence of chlamydia.
Few studies report the performance of these assays in a low-prevalence obstetric and gynecologic
(Ob/Gyn) population, This study compares the most commonly used direct fluorescent antibody
(DFA) assay (Syva Microtrak) with tissue culture (TC) in a low-prevalence population. Endocervical
specimens (775) were tested from women at risk for chlamydia infection, and the prevalence
was found to be 7.7%. The DFA assay demonstrated a sensitivity of 80% and a specificity of 97%
compared with TC. The positive and negative predictive values were 72% and 98%, respectively.
The results of this study indicate that the Syva DFA assay lacks the sensitivity and positive
predictive value for routine use in Ob/Gyn populations with a lowprevalence of C. trachomatis.
The purpose of this study was to evaluate the relationship between postoperative abdominal incision
problems and opening subcutaneous tissues with electrocautery or scalpel. Women scheduled for
elective abdominal hysterectomy who gave informed consent were randomly assigned to subcutaneous
abdominal wall tissue incision by electrocautery or scalpel. Postoperative abdominal wound
problem diagnoses included seroma, hematoma, infection, or dehiscence without identifiable etiology.
Fifteen of 380 women (3.9%) developed a wound problem; six had scalpel and nine had
electrosurgical subcutaneous incisions (P = 0.4). Thicker subcutaneous tissues (P = 0.04) and concurrent
pelvic infection (P < 0.001) were significant risk factors for postoperative wound problems.
Only two women (0.5%) developed an infection. We conclude that the method of subcutaneous
tissue incision was unrelated to the development of postoperative abdominal incision problems in
380 women undergoing elective abdominal hysterectomy.
The introduction of silver nitrate for prophylaxis of gonococcal ophthalmia neonatorum is one of the
milestones of preventive medicine. However, in our time an increasing necessity to review Credé's
prophylaxis from both a human rights and a medical standpoint is required. The chairmen of the
obstetrics and gynecology departments of the German university hospitals were questioned to learn
about their policy and experience. Data were provided by 22 of 28 consulted institutions, representing
31,700 annual deliveries seen over a mean period of 5.5 years. Ocular prophylaxis was in use in
16 (73%) of the reporting hospitals (1% silver nitrate in 14 and gentamicin in 2). A nonspecific
conjunctival reaction occurred in 5–10% of the newborns, but no major side effects were seen.
Non-gonococcal ophthalmia neonatorum was observed in less than 0.1%; however, institutions
without a preventive policy reported up to a 5% incidence of neonatal conjunctivitis, mostly due to
Staphylococcus aureus, as well as Neisseria gonorrhoeae in two newborns. Application of silver nitrate
is considered a necessary prophylactic measure and safe if it is properly administered. However,
major efforts should be directed toward its replacement by alternative antiseptic substances as well
as toward chlamydial screening and therapy in pregnancy.
Several descriptions of hydrostatic injuries while water-skilng have been described, including lacerations
of the perineum, vagina, and cervix. Salpingitis or pelvic abscess resulting from water-skiing
injuries are rare but important complications. A case of a pelvic abscess following a fall while
water-skiing is described. The abscess was drained laparoscopically, resulting in a good clinical
outcome. The mechanism of injury and recommendations for prevention are also presented. Upper
genital tract infection may result from water-skiing injuries due to hydrostatic pressure forcing
bacteria and water through the vagina and cervix into the endometrium, fallopian tube, and peritoneal
cavity. While an uncommon complication, physicians and other practitioners caring for women
should be aware of this potential complication from water-skiing.
Penicillin class antibiotics have demonstrated varying degrees of in vivo and in vitro success when
tested against Chlamydia trachomatis. The activity of ampicillin-sulbactam, an agent commonly
utilized in the treatment of pelvic infections, was tested to ascertain if any antichlamydial activity is
present. Up to six endocervical isolates of C. trachomatis were tested against each of five antibiotics
including doxycycline, erythromycin, clindamycin, ampicillin/sulbactam, and sulbactam alone. McCoy cell monolayers were inoculated with high inclusion counts of 10,000–30,000 inclusion-forming
units (IFU) per coverslip, and exposed to each antibiotic. Up to nine subsequent antibiotic free
culture passes were performed to assess the viability of abnormal inclusions. Doxycycline, erythromycin,
and clindamycin achieved 100% eradication of inclusions at concentrations of 4.0, 2.0, and
1.0 µg/mL. Exposure to ampicillin/sulbactam resulted in a greater than 99% reduction in the inclusion
count at 32.0 µg/mL, while sulbactam by itself demonstrated considerably less activity. Abnormal
inclusions were noted only in the ampicillin/sulbactam exposed cells, and these, plus all inclusions
remaining following sublethal exposure to the other antibiotics, resulted in regrowth to control
levels in subsequent passes. Doxycycline and erythromycin demonstrated excellent activity. Clindamycin
and ampicillin/sulbactam also significantly reduced inclusion formation, and therefore may
provide adequate C. trachomatis coverage in patients receiving these antibiotics for pelvic infections.
Maternal and neonatal infections with Salmonella typhi have been well documented. There are only
two previous case reports of intrauterine infection with non-typhoidal species. This paper presents a
third case of maternal septicemia followed by neonatal sepsis with Salmonella heidelberg.
To determine whether a previous pelvic infection has an effect on the outcome of a subsequent
pregnancy, we identified women with a diagnosis of pelvic inflammatory disease (PID), amnionitis,
and postpartum or postabortal endometritis-salpingitis by a retrospective chart review of all patients
admitted to the Department of Obstetrics and Gynecology at The New York Hospital-Cornell
Medical Center between 1975 and 1977 and between 1985 and 1988. Antimicrobial regimens
effective against Chlamydia trachomatis were initiated in 1985. Controls were randomly selected
patients presenting during the same time period for routine examinations who had normal Pap
smears and no infections. Both groups were comparable for age, race, gravity, and parity. Differences
were evaluated by chi square analysis, using the Yates correction factor. We identified 183
women with a history of the above infections who subsequently conceived, and 82 controls. There
were no differences in outcome between the two index groups. Term vaginal deliveries occurred in
14.2% of the women with a prior pelvic infection and in 56% of the controls (P < 0.001). Among the
97 women who had had PID, 21 (21.6%) had a spontaneous abortion in the subsequent pregnancy,
as opposed to 6 (7.3%) of the controls (P = 0.013). In addition, eight of the women with PID (but no
controls) went into preterm labor (P = 0.021). An increased incidence of preterm labor (P = 0.001)
was also observed in women with a history of amnionitis. A history of endometritis was not
associated with an increased prevalence of abnormal outcome in subsequent pregnancies. PID and
amnionitis may adversely affect the outcome of subsequent pregnancies.
Necrotizing fasciitis is a severe, life-threatening soft tissue infection that results in rapid and progressive
destruction of the superficial fascia and subcutaneous tissue. Because of its varied clinical
presentation and bacteriological make-up, it has been labelled with many other names such as acute
streptococcal gangrene, gangrenous erysipelas, necrotizing erysipelas, hospital gangrene, and acute
dermal gangrene. Although described by Hippocrates and Galen, it has received increasing attention
in obstetrical and gynecological literature only within the last 20 years. This review includes two
recent cases successfully managed at Parkland Memorial Hospital, Dallas, Texas. The first patient
was a 50 year old, morbidly obese, diabetic woman who presented with a small, painful lesion on the
vulva. After failing triple antibiotic therapy with ampicillin, clindamycin, and gentamicin, the diagnosis
of necrotizing fasciitis of the vulva was made, and she was taken to the operating room for
extensive excision. She was discharged home on hospital day 29. The second patient was a 65 year
old, obese, diabetic woman with risk factors for atherosclerosis who had a wound separation after an
abdominal hysterectomy. Two days later a loss of resistance to probing was noted in the subcutaneous
tissue. Necrotizing fasciitis was suspected, and she was taken to the operating room for resection.
The patient was discharged home on hospital day 27. The mortality rate after diagnosis of
necrotizing fasciitis has been reported to be 30% to 60%. We review the literature and outline the
guidelines used in a large Ob/Gyn teaching hospital to minimize the adverse outcome. Lectures on
soft-tissue infections are included on a regular basis. The high-risk factors of age over 50, diabetes,
and atherosclerosis are emphasized. The need for early diagnosis and surgical treatment within 48
hours is stressed, and any suspicious lesions or wound complications are reported to experienced
senior house officers and staff. We use two recent cases to highlight the diagnostic clues and
management strategies for this often fatal polymicrobial infection.
Objective: This study evaluated the blood and uterine tissue concentration of mezlocillin, a broadspectrum
Methods: We adapted a liquid chromatographic method to measure mezlocillin in serum and
tissue. Mezlocillin reference standard was diluted in water, chromatographed on a reversed phase
C18 column eluted at 1.5 ml/min with acetonitrile and phosphate buffer (1:3 v:v), and detected
spectrophotometrically at 210 nm. Mezlocillin was administered to 14 premenopausal women scheduled
to undergo vaginal hysterectomy. Each patient received a 4 g IV infusion of the drug 30 to 60
min prior to surgery. During surgery, tissue was removed from the uterine cervix and blood was
obtained for assay of mezlocillin content.
Results: Chromatography of the mezlocillin standard furnished a discrete peak with a retention
time of 2.4 min. The sensitivity of the assay was 0.1 µg/ml with a linear response up to 100 µg/ml.
The correlation coefficient for the standard curve was 0.9997. When reference standard was diluted
in pooled human serum, the assay was complicated by interfering compounds. These were removed
by ether extraction. The sensitivity of the assay performed in serum was 3 µg/ml. Serum samples
contained from 81.2 to 358 µg of mezlocillin/ml with an average serum concentration of 207.5 µg/ml.
When serum containing a known amount of mezlocillin was homogenized for a period of time
similar to that required to homogenize tissue samples, a deteatable loss of drug was observed and
was applied as a correction factor to the measured tisulevels. After correction, the average tissue
level was 117.2 µg/ml and ranged from 27% to 98% of the serum levels.
Conclusions: The serum concentration of mezlocillin after IV infusion of 4 g was greater than that
required to inhibit the majority of the most significant organisms responsible for post-hysterectomy
sepsis. Although tissue levels appeared to be consistently lower than serum levels, they could be
expected to provide an inhibitory effect against many of the bacterial strains that contaminate the
Objective: his investigation was undertaken to evaluate the relationship between postcesarean endometritis
and (1) method of placental removal and (2) site for uterine repair.
Methods: This prospective, randomized study included 120 patients who underwent primary or
repeat abdominal delivery for arrest of progress in labor, fetal distress, or breech presentation.
Parturients were divided into four groups: I—spontaneous placental detachment, in situ uterine
repair; II—spontaneous placental detachment, exteriorized uterine repair; III—manual placental
removal, in situ uterine repair; and IV—manual placental removal, exteriorized uterine repair.
Prophylactic antibiotics were not used.
Results: Endometritis was significantly increased in the manual removal/exteriorized uterine
repair group versus all the other groups including the spontaneous removal in situ (group I,
P = 0.012), the spontaneous removal/exteriorized repair group (group II, P = 0.034), and the manual
removal/in situ repair group (group III, P = 0.043). Comparison of group IV (manual removal/
exteriorized repair) with the combined groups I, II, and III (spontaneous removal/in situ repair,
spontaneous removal/exteriorized repair, and manual removal/in situ repair) was significantly different
(P = 0.005). Prior to delivery, use of an internal monitoring system, skill of the operating
surgeon, and type of anesthesia were similar among groups.
Conclusions: The findings of this investigation suggest that; when other known causes of infectious
morbidity are constant, manual placental remvol in association with exteriorization for
uterine repair significantly increases postcesarean endometritis.
A 21 year old woman (G2 P0101)
of 24 weeks gestation presented with syphilis of unknown duration.
Sonography revealed fetal hydrops and placental thickening. Weekly intramuscular injections of 2.4
million U Bicillin for 3 weeks was initiated as recommended by the Centers for Disease Control.
Repeat sonogram 1 week after starting treatment revealed increased ascites and a new pericardial
effusion. Due to the worsening fetal condition, therapy was altered and the patient was admitted for
IV penicillin. She received a continuous infusion of 18 million U penicillin G daily for 10 days. Serial
sonograms showed improvement offetal ascites and pericardial effusion with 10 days of IV therapy,
and complete resolution of hydrops was noted within 3 weeks. The fetus was born at term with no
stigmata of congenital syphilis on newborn exam, and laboratory tests suggested adequate treatment
Asymptomatic infection appears to be a common cause of fallopian tube damage resulting in ectopic pregnancy or infertility.
The purpose of this prospective investigation was to compare two methods for sheathing of the
endovaginal ultrasound-probe. The study was conducted over a 7-month period in 1991–1992. In the
first half of the investigation, latex examination gloves were used to sheath the endovaginal probe;
during the second half of the investigation, latex condoms were used. Following the ultrasound
examination, the probes were inspected for gross contamination by the ultrasonographer. The
sheaths were then tested for perforations by filling them with water to twice their usual volume and
observing for leaks. Fifty unused gloves and condoms were similarly tested to determine the prevalence
of preexisting defects. One hundred twenty-eight gloves and 102 condoms from patients were
tested. Four gloves (3.1%, 95% C.I. 1.6–4.6%) and seven condoms (6.9%, 95% C.I. 4.4–9.4%) had
perforations (NS). When the probe was covered by a glove, one instance of visible contamination
occurred (0.78%, 95% C.I. 0–1.6%) compared with eight instances when the probe was covered with
a condom (7.8%, 95% C.I. 5.2–10.4%, P < .007). The prevalance of preexisting defects in the 50
unused gloves was 2%, which is not significantly different from the prevalence in used gloves. There
were no defects in the 50 unused condoms compared with 7 in the used condoms (P = .057). Visible
contamination of the endovaginal probe with blood or genital tract secretions is more likely when
condoms are used as sheaths. However, even gloves provide imperfect coverage of the probe,
illustrating the need for thorough decontamination of the endovaginal instrument after each use.
Five different antibiotic susceptibility methods were utilized to test the effectiveness of cefotetan
against 200 anaerobic bacteria recovered from patients with obstetrical or gynecological infections.
The object of this study was to determine if a more economical and rapid method for anaerobic
susceptibility testing was as acceptable as the reference agar dilution method. The five methods
were: 1) broth disk elution, 2) microbroth technique, 3) a commercially available microbroth technique,
4) a commercially available spiral gradient technique, and 5) reference agar dilution. The
minimal inhibitory concentrations (MICs) calculated from the spiral gradient technique were equal
to or within one doubling dilution of the reference system in 99.5% of cases, while the percentage for
the commercially available microbroth system was 96.8%, very similar to the microbroth technique
used in our laboratory that yielded a percentage of 96.3. The disk elution method correlated to the
reference agar dilution method in 95.3% cases. While the overall agreement between these techniques
is good, especially for the spiral gradient system, clustering of certain organisms near the
breakpoint of the antibiotic tested results in variability in the labeling of these organisms as susceptible
or resistant. This problem appears to be particularly significant for the disk elution method.
Therefore, further refinements in these methods of suscleptibility testing are needed in order to
provide a more clinically useful assessment of the susceptibility or resistance of certain bacterial
Adisruption of the dynamic equilibrium of the healthy vagina may have significant sequelae,
leading to chronic or serious conditions. Therefore, all cases of vaginitis should be
accurately diagnosed and appropriately treated.
Background: Disseminated coccidiomycosis during pregnancy can lead
to both maternal and neonatal mortality. Placentitis is an uncommon sequelae and its effect
on placental function remains speculative. The present report describes our management of
such a case and describes serial umbilical artery velocimetry of an affected placenta.
Case: A pregnant woman with coccidioidal placentitis confirmed
histologically was treated with systemic and intrathecal amphotericin B starting at 28 weeks
gestation. Serial umbilical artery velocimetry revealed that all systolic/diastolic ratios
remained normal, and a normal infant was delivered at term.
Conclusion: Coccidioidal placentitis was successfully treated with
amphotericin B; serial umbilical artery velocimetry monitoring exhibited no abnormalities
and, along with other reassuring fetal parameters, allowed continuation of the pregnancy to
Objective: The objective of this study was to develop a reproducible
method of establishing the concentration of yeast cells per milliliter of solution.
Methods: Three methods of determining the number of yeast cells in
solution were compared: Neubauer's counting chamber, spectrophotometry, and
Results: All three methods were comparable and reproducible.
The following formulas were highly effective in determining the number of yeast cells in
solution: chamber (× 103/ ml) 64.3 + 8,206 × spectrophotometry (absorbance); and chamber
/ml) –0.2 + 64 × nephelometry (volt).
Conclusions: Utilization of spectrophotometry or nephelometry
and the appropriate formula allow for the precise determination, which is easily reproducible,
of the concentration of yeast cells in solution. This will facilitate experimentation involving
precise inocula or requirement for specific concentrations of yeast cells for various
Objective: To assess various methods of management of
actinomyces-like organisms associated with intrauterine devices.
Methods: A retrospective chart review of 173 patients with intrauterine
device-associated actinomyces- like organisms detected on Pap smear was performed.
The patients were managed by IUD removal with or without antibiotic therapy, antibiotic
therapy alone, or no treatment at all.
Results: The success rate as reflected in negative follow-up smear was
100% for IUD removal combined with antibiotics, 97.4% for IUD removal alone, and 36.8% for
antibiotics therapy alone.
Conclusions: The best way to manage intrauterine device-associated
actinomyces-like organisms is removal of the device with or without antibiotics.
Objective: The amount, origin, and resources of infectious disease
knowledge in the field ofobstetrics and gynecology were investigated. If this knowledge is
lacking, the exact length of the specific infectious disease training during residency should
be defined to meet the ever-increasing knowledge required in training.
Methods: A 50-question test was developed by one faculty member
utilizing questions that incorporated the basic sciences of microbiology and pharmacology
and clinical knowledge of infectious diseases in the area of obstetrics and gynecology.
Multiple choice and matching questions were structured so as to ascertain the source of the
knowledge, including medical school curriculum, recent journal articles, and clinical
Results: The test was given yearly to all students and residents on the
Obstetric and Gynecology Service over a period of 2 year's. The questions were the same for
each group, but were reshuffled each exam period. Three hundred and seven tests were
properly administered and recorded. There was no statistical improvement in any successive
year’s scores unless specific infectious disease training occurred. Increasing improvement in
scores was noted, with an increasing duration of infectious disease training specific for
obstetrics and gynecology, beginning at 2 weeks (22% improvement), 4 weeks (30%
improvement), and 6 weeks (31% improvement) (P = .05–.001). Basic science questions were
most frequently answered correctly by medical students and early residents, while correctly
answered clinical questions correlated with increasing clinical experience except in
the area of ambulatory care.
Conclusions: The infectious disease knowledge of residents in
obstetrics and gynecology can be improved with 4 weeks of intensive training.
Re-exposure to basic science knowledge and improved training in ambulatory care in this
resident group appear to be necessary. This test or similar tests can be helpful in defining
areas of deficiencies and their possible remedies.
Objective: Ampicillin plus sulbactam, an irreversible
β-lactamase inhibitor, was compared to cefoxitin
in the treatment of women with acute pelvic inflammatory disease (PID) with and without
Methods: Participation in an open, prospective, randomized clinical trial was
offered to all women given the clinical diagnosis of acute PID who required inpatient therapy.
Neisseria gonorrhoeae and Chlamydia trachomatis were sought in cervical and endometrial
samples and aerobic and anaerobic species were sought in endometrial samples prior to
treatment initiation. Treatment was given on at least 4 days and until women were afebrile for at
least 48 h. Daily examinations were performed to assess response to therapy and safety. Only
women in whom C. trachomatis was identified were discharged from the hospital on oral
doxycycline to be taken for 10–14 days.
Results: One hundred twenty-four women were evaluated for safety;
117 (94%) were evaluated for efficacy. Demographic characteristics were similar for women in
each treatment group. N. gonorrhoeae was recovered from 59% and C. trachomatis was
recovered from 42% of study subjects. Inflammatory masses were identified in 35/76 (46%)
women given ampicillin/sulbactam and 17/41 (41%) women given cefoxitin. Ampicillin/sulbactam
cured 75 ,of 76 women (98.7%) [95% confidence interval (CI) 92.9–100.0%] and cefoxitin cured 37
of,41,omen (90.2%) (95% CI 76.9–97.3%) in that treatment regimen.
Conclusions: Overall ampicillin/sulbactam was more effective (P = 0.05) than
cefoxitin, due to superior efficacy in infection complicated by inflammatory mass(es).35/35 vs.
12/17 cured; P = 0.007).
Background: Nausea and vomiting are common during the
first half of pregnancy and usually require only supportive measures. When symptoms
are progressive and weight loss occurs, treatable causes should be sought by means of
upper gastrointestinal endoscopy. We report a case of an immunocompetent gravida with
invasive Candida albicans esophagitis.
Case: The immunocompetent primigravida developed progressive
nausea, vomiting, epigastric pain, and a 4.1 kg weight loss during the second trimester
of pregnancy. Treatment with metoclopramide and cimetidine for presumed gastroesophageal
reflux was not effective. The patient had normal T-cell CD4 and CD8 subsets and was human
immunodeficiency virus (HIV) antibody negative. Upper gastrointestinal endoscopy
revealed C. albicans esophagitis which was treated with oral nystatin. The esophagitis had
resolved completely when reassessed postpartum. The use of histamine2 blockers is
associated with an increased risk for fungal esophagitis and may have been a
contributing cause in this case.
Conclusion: Pregnant patients with persistent nausea, vomiting,
and weight loss should be evaluated by endoscopy for fungal esophagitis.