Operative laparoscopy in pregnancy

OBJECTIVE

We compared the surgical outcomes of pregnant women undergoing laparotomy in the first 2 trimesters of pregnancy with those undergoing laparoscopy for the management of acute pelvic pain.

METHODS

We performed a systematic retrospective chart review of patients whose discharge diagnosis included intrauterine pregnancy with exploratory laparotomy or laparoscopy from August 1, 1993 to October 31, 1999. The following factors were assessed: preoperative diagnosis, postoperative diagnosis, gestational age at the time of surgery, operative time, hospital stay, pathology, gestational age at delivery, complications, and outcome of the pregnancy in both groups.

RESULTS

Sixteen pregnant patients underwent surgery during the study period. All but one had abdominopelvic pain, and all patients had an associated adnexal mass. The mean gestation age at the time of surgery was 15+/-6 weeks versus 13+/-4 weeks in the laparoscopic and laparotomy groups, respectively (P=NS). All patients undergoing laparoscopy remained in the hospital for one day compared with a mean of 4.4+/-1.1 days in the laparotomy group (P<0.0001). Pregnancy outcomes were similar and uniformly good.

CONCLUSION

Laparotomy can be avoided and pregnant patients managed safely by operative laparoscopy, with shorter hospital stays.

Can known risk factors explain racial differences in the occurrence of bacterial vaginosis?

BACKGROUND

Black women are more likely to have bacterial vaginosis (BV) than are non-Hispanic white women. We examined whether this disparity can be explained by racial differences in known BV risk factors.

METHODS

Nine hundred black and 235 white women were enrolled from five US sites. At baseline, structured interviews were conducted and vaginal swabs self-collected for Gram-stain and culture.

RESULTS

Black women were more likely than white women to have BV/intermediate vaginal flora. They also were more likely to be older, have lower educational attainment and family incomes, have a history of a sexually transmitted disease, and douche. After adjustment for demographic and lifestyle factors, blacks remained at elevated risk for BV/intermediate flora (OR 2.2, 95% CI 1.5-3.1). Blacks also were more likely to have specific BV-related vaginal microflora, as well as gonococcal or chlamydial cervicitis (OR 2.2, 95% CI 1.2-3.8) after adjustment for known BV risk factors.

CONCLUSION

Risk factor differences did not explain the observed racial disparity in the occurrence of BV, BV-related microflora, or gonococcal or chlamydial cervicitis. These findings highlight our limited understanding of the factors accounting for the occurrence of bacterial vaginosis and cervicitis among black and white women.

Why women douche and why they may or may not stop

BACKGROUND

Although douching is common, it is a potentially harmful habit.

GOAL

We studied attitudes and knowledge around the behavior of douching.

STUDY DESIGN

Of 1,200 women enrolled in this multisite study, 532 douched and answered questions on a structured interview regarding douching behaviors.

RESULTS

Over half had douched for 5 or more years. Douching was most often initiated on the recommendation of female relatives and practiced for reasons of hygiene. Half of women considered douching to be healthy. Those who considered douching to be unhealthy reported that douching may disrupt vaginal flora but did not cite more serious risks. Nonetheless, women who had been advised by a health professional to stop douching were less likely to consider douching healthful and were more likely to have tried to stop.

CONCLUSION

Women had a limited understanding of potential adverse health consequences associated with douching. Targeted health messages may influence women to initiate douching cessation.

Endometritis does not predict reproductive morbidity after pelvic inflammatory disease

OBJECTIVE

We investigated the association between endometritis and reproductive morbidity.

STUDY DESIGN

Participants were 614 women in the PID Evaluation and Clinical Health (PEACH) Study with pelvic pain, pelvic organ tenderness, and leukorrhea, mucopurulent cervicitis, or untreated cervicitis. We compared women with endometritis (>or=5 neutrophils or >or=2 plasma cells), Neisseria gonorrhoeae or Chlamydia trachomatis upper genital tract infection (UGTI) or both to women without endometritis/UGTI for outcomes of pregnancy, infertility, recurrent pelvic inflammatory disease (PID), and chronic pelvic pain (CPP), adjusting for age, race, education, PID history, and baseline infertility.

RESULTS

Endometritis/UGTI was not associated with reduced pregnancy (odds ratio [OR] 0.8, 95% CI 0.6-1.2) or elevated infertility (OR 1.0, 95% CI 0.6-1.6), recurrent PID (OR 0.6, 95% CI 0.4-0.9), or CPP (OR 0.6, 95% CI 0.4-0.9). PEACH participants with and without endometritis/UGTI had higher age- and race-specific pregnancy rates than 1997 national rates.

CONCLUSION

Among women with clinically suspected mild-to-moderate PID treated with standard antibiotics, endometritis/UGTI was not associated with reproductive morbidity.

Douching in relation to bacterial vaginosis, lactobacilli, and facultative bacteria in the vagina

OBJECTIVE

To study how frequency, recentness, and reason for douching impact bacterial vaginosis-related vaginal microflora and the occurrence of cervical pathogens. Douching has been linked to bacterial vaginosis as well as to chlamydial cervicitis in some, but not all, studies.

METHODS

A total of 1200 women at high risk for sexually transmitted infections were enrolled from five clinical sites around the United States. Cross-sectional, structured interviews were conducted and vaginal swabs were self-obtained for Gram stain, culture, and DNA amplification tests for Neisseria gonorrhoeae and Chlamydia trachomatis.

RESULTS

Douching at least once per month was associated with an increased frequency of bacterial vaginosis. Those who douched recently (within 7 days) were at highest risk [odds ratio (OR) 2.1, 95% confidence interval (CI) 1.3, 3.1]. Douching for symptoms (OR 1.7, 95% CI 1.1, 2.6) and for hygiene (OR 1.3, 95% CI 1.0, 1.9) both related to bacterial vaginosis risk. The associations between douching and Gardnerella vaginalis, Mycoplasma hominis, and lack of hydrogen peroxide-producing lactobacilli were similar to those between douching and bacterial vaginosis. Gonococcal or chlamydial cervicitis was not associated with douching.

CONCLUSION

Douching for symptoms or hygiene, particularly frequent or recent douching, was associated with bacterial vaginosis and bacterial vaginosis-associated vaginal microflora, but not with gonococcal or chlamydial cervicitis.

Preterm premature rupture of the membranes is associated with a reduction in neonatal respiratory distress syndrome

OBJECTIVE

The purpose of this study was to evaluate the effect of preterm premature rupture of the membranes on the frequency of respiratory distress syndrome among singleton pregnancies that are complicated with preterm delivery.

STUDY DESIGN

We performed a retrospective analysis of singleton pregnancies that were delivered between 24 and 34 weeks of gestation. Patients were categorized on the basis of membrane integrity into two groups: ruptured versus intact. All patients received prophylactic antibiotics and a single course of antenatal betamethasone. Data were analyzed with the Student t test, the chi(2) test, and the Fisher exact test. Multiple logistic regression analysis was performed to examine the effect of possible confounding variables that were considered risk factors for respiratory distress syndrome. Probability values of <.05 for all two-tailed tests were considered significant.

RESULTS

A total of 366 patients were included (99 patients in the preterm premature rupture of the membranes group and 267 patients in the intact membranes group). Patients were delivered at 30.7 +/- 2.9 and 30.1 +/- 2.7 (mean +/- SD) weeks of gestation, with birth weights of 1620 +/- 594 and 1417 +/- 501 g, respectively. The frequency of respiratory distress syndrome in the neonate was significantly lower in the preterm premature rupture of the membranes group than in their intact counterparts (17% vs 39%, P <.001). Multiple logistic regression analysis confirmed that preterm premature rupture of the membranes (odds ratio, 0.16; 95% CI, 0.08-0.34) was independently associated with a reduction in the frequency of respiratory distress syndrome.

CONCLUSION

In the clinical setting of delivery before 34 weeks of gestation, preterm premature rupture of the membranes is associated with a significant decrease in the frequency of neonatal respiratory distress syndrome.

Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial

OBJECTIVE

Pelvic inflammatory disease (PID) is a common and morbid intraperitoneal infection. Although most women with pelvic inflammatory disease are treated as outpatients, the effectiveness of this strategy remains unproven.

STUDY DESIGN

We enrolled 831 women with clinical signs and symptoms of mild-to-moderate pelvic inflammatory disease into a multicenter randomized clinical trial of inpatient treatment initiated by intravenous cefoxitin and doxycycline versus outpatient treatment that consisted of a single intramuscular injection of cefoxitin and oral doxycycline. Long-term outcomes were pregnancy rate, time to pregnancy, recurrence of pelvic inflammatory disease, chronic pelvic pain, and ectopic pregnancy.

RESULTS

Short-term clinical and microbiologic improvement were similar between women randomized to the inpatient and outpatient groups. After a mean follow-up period of 35 months, pregnancy rates were nearly equal (42.0% for outpatients and 41.7% for inpatients). There were also no statistically significant differences between outpatient and inpatient groups in the outcome of time to pregnancy or in the proportion of women with pelvic inflammatory disease recurrence, chronic pelvic pain, or ectopic pregnancy.

CONCLUSION

Among women with mild-to-moderate pelvic inflammatory disease, there was no difference in reproductive outcomes between women randomized to inpatient treatment and those randomized to outpatient treatment.

Effectiveness of a rescue dose of antenatal betamethasone after an initial single course

OBJECTIVE

To evaluate the effects of a single rescue dose of antenatal betamethasone after an initial single course on the frequency of neonatal respiratory distress syndrome and perinatal infectious morbidity in pregnancies complicated with preterm labor and delivery.

STUDY DESIGN

We performed a cohort analysis of singleton pregnancies for which delivery occurred between 28 and 34 weeks' gestation after a single course of betamethasone administered before 28 weeks' gestation. Patients were then segregated into the following 2 groups on the basis of betamethasone exposure at the delivery admission: (1) a single 12-mg injection (rescue group) and (2) observation only (observation group). Patients who delivered infants within 24 hours of the rescue dose were excluded, as were those who had ruptured membranes for longer than 24 hours before delivery, those with diabetes that required insulin, and those with exposure to repeated doses of betamethasone before admission. Data were analyzed by use of the Student t test, chi2 test, and Fisher exact test. Multiple logistic regression was performed to examine the effect of each steroid dosing regimen on respiratory distress syndrome. Two-tailed P values <.05 were considered to be significant.

RESULTS

A total of 152 patients were included, with 89 in the rescue group and 63 in the observation group. Both groups were similar with respect to maternal demographics, mean gestational age at the initial single course and at delivery, mode of delivery, and mean birth weights. Rescue administration was significantly associated with a reduction in the frequency of respiratory distress syndrome (odds ratio, 0.44; 95% confidence interval, 0.2 to 0.9) and mean ventilator days (odds ratio, 0.44; 95% confidence interval, 0.2 to 0.8) compared with observation alone. All other studied perinatal outcomes analyzed were similar between the groups. Multiple logistic regression confirmed an independent association between a single rescue dose and a reduction in the frequency of respiratory distress syndrome (odds ratio, 0.40; 95% confidence interval, 0.2 to 0.9).

CONCLUSIONS

A single rescue dose of betamethasone is associated with a reduction in the frequency of respiratory distress syndrome without an apparent increase in perinatal infectious disease.

Scheduled cesarean delivery and the prevention of human immunodeficiency virus transmission: a survey of practicing obstetricians

OBJECTIVE

To characterize practice patterns among obstetrician-gynecologists with respect to delivery for human immunodeficiency virus (HIV)-seropositive women, following publication of the 1999 American College of Obstetricians and Gynecologists (ACOG) Committee Opinion regarding scheduled cesarean delivery for HIV-infected patients.

METHODS

A 25-question, multiple-choice survey was mailed to 2000 randomly selected obstetrician-gynecologists: 1000 maternal-fetal medicine specialists and 1000 general obstetrician-gynecologists. Mailing addresses were obtained from the 1999-2000 editions of the Society for Maternal-Fetal Medicine (SMFM) and ACOG membership directories. Information was requested about general perceptions of the 1999 ACOG Committee Opinion and about practice patterns with respect to management of HIV disease in pregnancy. Data were analyzed by using descriptive statistics and the chi-square test. Any P values <.05 were considered significant.

RESULTS

After a single mailing we received 512 responses (25.6%), including 433 (43%) from SMFM members and 79 (8%) from ACOG members. Among the respondents, 47% disagreed with the current scientific validity of the 1999 ACOG Committee Opinion recommendation to offer cesarean delivery to all HIV-seropositive pregnant women. No statistically significant differences were detected in the demographic profiles, years of experience, or practice settings of participants who agreed with the scientific validity when compared to those who did not. Most respondents used viral load detection (87%) monitored on a trimester basis (67%) for clinical management decisions. Most practitioners (72%) do not recommend cesarean delivery for women who are compliant with antiretroviral therapy and who have undetectable viral loads regardless of CD4 counts. However, most practitioners (67%) do recommend cesarean delivery for those compliant women with detectable viral loads, irrespective of CD4 counts (67%).

CONCLUSIONS

There is considerable disagreement among practicing obstetricians with respect to the 1999 ACOG Committee Opinion recommendation to offer cesarean delivery to all HIV-seropositive women. Most physicians use viral load detection to assist with the counseling in delivery options for HIV-infected pregnant women.

Hormonal and barrier contraception and risk of upper genital tract disease in the PID Evaluation and Clinical Health (PEACH) study

OBJECTIVE

Among women diagnosed with pelvic inflammatory disease, we examined the associations between hormonal or barrier methods of contraception and upper genital tract infection or inflammation.

METHODS

Participants were 563 patients from a treatment trial for pelvic inflammatory disease. All had pelvic pain; pelvic organ tenderness; and leukorrhea, mucopurulent cervicitis, or untreated cervicitis. Contraceptive use within the prior 4 weeks was compared among women with baseline upper genital tract gonorrhea or chlamydia, women with endometritis without upper genital tract gonorrhea or chlamydia, and women with neither upper genital tract gonorrhea or chlamydia nor endometritis.

RESULTS

Inconsistent condom use was significantly and independently associated with a 2 to 3 times elevated risk for upper genital tract infection. Upper genital tract gonorrhea or chlamydia was not significantly associated with use of oral contraceptives, use of medroxyprogesterone, condoms used consistently, nor other barrier methods.

CONCLUSION

No hormonal or barrier contraceptive method was related to a reduction in upper genital tract disease among women with clinical pelvic inflammatory diseases.

Antibiotic resistance patterns of group B streptococci in late third-trimester rectovaginal cultures

OBJECTIVE

Our purpose was to determine the antibiotic sensitivity patterns of rectovaginal group B streptococcal isolates obtained from a heterogeneous obstetric population in the late third trimester.

STUDY DESIGN

We performed a prospective observational study of rectovaginal group B streptococcal isolates obtained in the late third trimester during routine screening over a 12-month period. All cultures were prepared in a selective broth medium for 18 to 24 hours before plating onto sheep blood agar. Susceptibility testing of all isolates was performed for ampicillin, cefazolin, clindamycin, erythromycin, penicillin G, and vancomycin with the E-test method.

RESULTS

A total of 2111 consecutive rectovaginal cultures were performed in which group B streptococci were isolated from 574 (27.2%) different patients. The "antibiogram" of the susceptible percentage is as follows: vancomycin, 100%; ampicillin, 98.2%; penicillin G, 98.2%; cefazolin, 98.1%; clindamycin, 92%; erythromycin, 81%. Ten isolates (1.8%) demonstrated intermediate susceptibility to both ampicillin and penicillin G.

CONCLUSION

Routine susceptibility testing of group B streptococcal isolates collected during pregnancy should be considered because of the emergence of antibiotic resistance among group B streptococcal strains.

Douching and endometritis: results from the PID evaluation and clinical health (PEACH) study

BACKGROUND

Douching has been related to risk of pelvic inflammatory disease (PID).

GOAL

To examine the association between douching and PID in a large, multicenter, clinical trial of PID after adjustment for race/ethnicity.

STUDY DESIGN

Interviews were conducted with 654 women who had signs and symptoms of PID. Vaginal Gram stains and upper genital tract pathology/cultures were obtained from all the women. Women with evidence of plasma cell endometritis and/or gonococcal or chlamydial upper genital tract infections were compared with women who had neither endometritis nor upper genital tract infection.

RESULTS

Women with endometritis or upper genital tract infection were more likely to have douched more than once a month or within 6 days of enrollment than women who never douched. These associations remained after adjustment for confounding factors, after analysis of black women only; and among women with normal or intermediate vaginal flora but not bacterial vaginosis.

CONCLUSION

Among a predominantly black group of women with clinical PID, frequent and recent douching was associated with endometritis and upper genital tract infection.

Clinical predictors of endometritis in women with symptoms and signs of pelvic inflammatory disease

OBJECTIVE

Careful detection and treatment of pelvic inflammatory disease are essential for the prevention of adverse sequelae. The purpose of this study was to evaluate the diagnostic test characteristics of clinical criteria for the diagnosis of pelvic inflammatory disease.

STUDY DESIGN

We performed a cross-sectional analysis of the baseline characteristics of 651 patients enrolled in a multicenter randomized treatment trial for pelvic inflammatory disease. Clinical and laboratory findings were recorded for all patients, and endometrial sampling was performed. We calculated sensitivity and specificity and performed receiver operating characteristic curve analysis and multivariate logistic regression, using histologic endometritis as the criterion standard.

RESULTS

The minimal criteria for pelvic inflammatory disease, as recommended by the Centers for Disease Control and Prevention, had a sensitivity of 83%, in comparison with a 95% sensitivity for adnexal tenderness (P =.001). Of the supportive clinical criteria, the finding most highly associated with endometritis was a positive test result for Chlamydia trachomatis or Neisseria gonorrhoeae (adjusted odds ratio, 4.3; 95% confidence interval, 2.89--6.63). A multivariate logistic regression model indicated that combinations of criteria significantly improve the prediction of endometritis.

CONCLUSION

Sensitivity can be maximized by using the presence of adnexal tenderness as a minimal criterion for the diagnosis of pelvic inflammatory disease, and supportive criteria are helpful in estimating the probability of endometritis.

Is betamethasone effective longer than 7 days after treatment?

OBJECTIVE

To determine whether perinatal outcomes are influenced by the interval between antenatal betamethasone administration and delivery.

METHODS

We did a retrospective cohort analysis of live-born singleton neonates born between 28 and 34 weeks' gestation after a single course of betamethasone, defined as two 12-mg doses over 24 hours. Subjects were grouped according to length of interval between initial betamethasone dose and delivery (1-2 days, 3-7 days, and 8-14 days). We excluded women who had membranes ruptured for longer than 24 hours before delivery, delivery before the second dose of betamethasone, or more than two doses of betamethasone. Data were analyzed by Student t test, chi(2) test, or Fisher exact test. Multiple logistic regression analyses were done using suspected risk factors for respiratory distress syndrome (RDS) and intraventricular hemorrhage (IVH). We calculated that a sample of 200 women would provide more than 80% power to detect a 50% reduction in incidence of RDS for a two-sided test of significance at a critical level of.05.

RESULTS

Among 216 women, 97 delivered in 1-2 days, 78 in 3-7 days, and 41 in 8-14 days after a single course of betamethasone. Groups were similar in selected demographics, tocolytic exposure, gestational age at delivery, modes of delivery, and mean birth weights. There were no significant differences in frequencies of RDS (39.2%, 41.1%, and 36.6%, respectively) or grades 3-4 IVH (1.1%, 1.3%, and 0%, respectively) between groups. Frequencies of selected perinatal infectious outcomes also were similar between groups. Multiple logistic regression analyses found no association between RDS or IVH and delivery more than 7 days from betamethasone therapy.

CONCLUSION

There were no differences in perinatal outcomes in pregnancies delivered 8-14 days after antenatal exposure to betamethasone compared with those delivered within 7 days of exposure.

Urinalysis and urinary tract infection: update for clinicians

Dysuria is a common presenting complaint of women and urinalysis is a valuable tool in the initial evaluation of this presentation. Clinicians need to be aware that pyuria is the best determinate of bacteriuria requiring therapy and that values significant for infection differ depending on the method of analysis. A hemocytometer yields a value of > or = 10 WBC/mm3 significant for bacteriuria, while manual microscopy studies show > or = 8 WBC/high-power field reliably predicts a positive urine culture. In cases of uncomplicated symptomatic urinary tract infection, a positive value for nitrites and leukocyte esterase by urine dipstick can be treated without the need for a urine culture. Automated urinalysis used widely in large volume laboratories provides more sensitive detection of leukocytes and bacteria in the urine. With automated microscopy, a value of > 2 WBC/hpf is significant pyuria indicative of inflammation of the urinary tract. In complicated cases such as pregnancy, recurrent infection or renal involvement, further evaluation is necessary including manual microscopy and urine culture with sensitivities.

Effectiveness of antenatal corticosteroid administration after preterm premature rupture of the membranes

OBJECTIVE

This study was undertaken to determine the effect of antenatal betamethasone administration on the incidences of respiratory distress syndrome, intraventricular hemorrhage, and perinatal infectious morbidity in the setting of preterm premature rupture of membranes.

STUDY DESIGN

We performed a nonconcurrent prospective analysis of women with singleton pregnancies who were delivered between 24 and 32 weeks' gestation after preterm premature rupture of membranes. Patients were subdivided into 2 groups according to betamethasone exposure: (1) none (control group) and (2) two 12-mg doses in a 24-hour interval on admission (single-course group). Patients who received >2 doses of betamethasone were excluded. All patients received broad-spectrum prophylactic antibiotics. Data were analyzed with the Student t test, the chi(2) test, and the Fisher exact test. Multiple logistic regression analyses incorporated multiple variables considered risk factors for respiratory distress syndrome and intraventricular hemorrhage. P <.05 for all 2-tailed tests was considered significant.

RESULTS

A total of 362 patients were included, with 203 in the control group and 159 in the single-course group. Patients in these groups were delivered at 31.0 +/- 3.0 and 30.2 +/- 2.7 (mean +/- SD) weeks' gestation, respectively. The groups were similar with respect to selected demographic characteristics, latency until delivery, mode of delivery, birth weight, and maternal group B streptococcal colonization status. Univariate analysis demonstrated significant decreases in the frequencies of both respiratory distress syndrome (odds ratio, 0.31; 95% confidence interval, 0.2-0.5) and grade III/IV intraventricular hemorrhage (odds ratio, 0.14; 95% confidence interval, 0.1-0.6) in the single-course group. The frequencies of early neonatal sepsis, chorioamnionitis, endometritis, and neonatal death were similar between groups. Multiple logistic regression analyses determined that a single course of betamethasone was independently associated with reductions in the frequencies of both respiratory distress syndrome (odds ratio, 0.16; 95% confidence interval, 0.1-0.4) and grade III/IV intraventricular hemorrhage (odds ratio, 0.18; 95% confidence interval, 0.1-0.4).

CONCLUSIONS

A single course of betamethasone administered antenatally to patients with preterm premature rupture of membranes was associated with decreases in the frequencies of both respiratory distress syndrome and advanced grades of intraventricular hemorrhage without any increase in perinatal infectious morbidity.

Neonatal sepsis and death after multiple courses of antenatal betamethasone therapy

OBJECTIVE

This study was undertaken to compare the effects of single versus multiple courses of betamethasone therapy on the frequencies of neonatal outcomes and perinatal infectious morbidity among singleton pregnancies complicated by preterm delivery.

STUDY DESIGN

We performed a nonconcurrent prospective analysis of singleton pregnancies delivered between 24 and 34 weeks' gestation after antenatal betamethasone exposure. Patients were categorized into two groups according to betamethasone exposure: (1) two 12-mg doses in a 24-hour interval on admission (single-course group) and (2) repeated dosing after the initial single course (multiple-course group). All patients received prophylactic antibiotics for group B streptococci. Any patients with ruptured membranes for >24 hours before delivery were excluded. Data were analyzed with the Student t test, the chi(2) test, and the Fisher exact test. Multiple logistic regression analyses were performed to examine the effect of each steroid dosing regimen on early-onset neonatal sepsis and neonatal death. P <.05 was considered significant for all 2-tailed tests.

RESULTS

A total of 453 patients were included, with 267 in the single-course group and 186 in the multiple-course group. The two groups were similar with respect to maternal demographic characteristics, gestational age at delivery, mode of delivery, birth weight, and maternal group B streptococcal colonization. Multiple courses were significantly associated with early-onset neonatal sepsis (odds ratio, 5.00; 95% confidence interval, 1.3-23. 2), chorioamnionitis (odds ratio, 9.96; 95% confidence interval, 2. 1-64.6), endometritis (odds ratio, 3.61; 95% confidence interval, 1. 7-8.1), and neonatal death (odds ratio, 2.92; 95% confidence interval, 1.3-6.9). The frequencies of the other neonatal outcomes analyzed, including respiratory distress syndrome and grade III or IV intraventricular hemorrhage, were similar between the 2 groups. Multiple logistic regression analyses confirmed that multiple courses of antenatal betamethasone were independently associated with early-onset neonatal sepsis (odds ratio, 1.25; 95% confidence interval, 1.1-1.9) and neonatal death (odds ratio, 1.70; 95% confidence interval, 1.1-1.9).

CONCLUSIONS

Multiple courses of antenatal betamethasone are associated with increased risks of perinatal infectious morbidity and neonatal death.

Amniotic fluid index values after preterm premature rupture of the membranes and subsequent perinatal infection

OBJECTIVE

Our purpose was to determine whether an amniotic fluid index (AFI) <5 cm after preterm premature rupture of the membranes is associated with an increased risk of perinatal infection.

STUDY DESIGN

We performed a nonconcurrent prospective analysis of 225 singleton pregnancies complicated by preterm premature rupture of the membranes, with delivery between 24 and 32 weeks' gestation. All included patients received 2 doses of betamethasone antenatally, in the first 24 hours after admission, and broad-spectrum antibiotic prophylaxis. Patients were categorized into 2 groups on the basis of a 4-quadrant AFI <5 cm (n = 131) or > or =5 cm (n = 94). Perinatal outcomes analyzed included latency until delivery, mode of delivery, and frequencies of clinical chorioamnionitis, postpartum endometritis, and culture-proved early neonatal sepsis. Continuous data were evaluated for normal distribution and tested for significance with the Student t test. Categoric data were tested with the chi(2) and Fisher exact tests. Multiple logistic regression analyses were performed with chorioamnionitis, endometritis, and early-onset neonatal sepsis each as the dependent variable in separate analyses. All 2-sided P values <.05 were considered significant.

RESULTS

Both groups were similar with respect to selected demographics, gestational age at rupture of the membranes, birth weight, and maternal group B streptococcal colonization. Patients with an AFI <5 cm demonstrated a shorter mean latency until delivery (5.5 +/- 4.0 vs 14.1 +/- 5.2) (mean +/- SD) days (P =.02), greater frequency of amnioinfusion therapy (23.6% vs 5.3%) (P <.001), and cesarean delivery for nonreassuring fetal testing (18.3% vs 4. 3%) (P =.01). Multiple logistic regression analysis showed that an AFI <5 cm was the only significant risk factor independently associated with early-onset neonatal sepsis (P =.004) and chorioamnionitis (P =.024).

CONCLUSIONS

An AFI <5 cm after preterm premature rupture of the membranes between 24 and 32 weeks' gestation is associated with an increased risk of perinatal infection and a shorter latency preceding delivery.

Late third-trimester treatment of rectovaginal group B streptococci with benzathine penicillin G

OBJECTIVE

We sought to determine the efficacy of late third-trimester benzathine penicillin G administration in eradicating maternal group B streptococcal colonization at delivery.

STUDY DESIGN

We performed a prospective trial of late third-trimester treatment with benzathine penicillin G versus observation in 78 obstetric patients colonized with group B streptococci. Patients were screened by use of rectovaginal swabs cultured in selective media between 34 and 37 completed weeks' gestation. Patients with positive cultures were offered antepartum treatment with 4.8 million units of intramuscular benzathine penicillin G or observation. Participants in both groups were recultured at their delivery admission before receiving standard intrapartum therapy. The primary outcome was the frequency of persistent maternal group B streptococcal colonization at the delivery admission. Other outcome variables included semiquantitative growth characteristics of all group B streptococcal cultures, the frequency of neonatal sepsis, and adverse maternal effects. Data were analyzed by the Student t test for continuous variables and the chi(2) or Fisher exact test for categoric variables, with significance established at P <.05.

RESULTS

Both groups were similar with respect to selected demographics, gestational age at delivery, and frequency of heavy group B streptococcal growth in initial screening cultures. The mean interval from treatment until delivery was 19.4 +/- 7.5 days (mean +/- SD). There were no cases of neonatal sepsis in either group or any adverse maternal effects attributed to the treatment. Group B streptococcal culture characteristics at delivery admission were as follows. Positive results for group B streptococci were found in 7 (25%) treated patients and 41 (82%) patients under observation (relative risk, 0.30; 95% confidence interval, 0.16-0.59; P <.0001). Positive results for heavy growth of group B streptococci were found in 0 (0%) treated patients and 31 (62%) patients under observation (relative risk, 0.01; 95% confidence interval, 0.00-0.12; P <.0001).

CONCLUSIONS

Treating group B streptococci carriers with benzathine penicillin G in the late third trimester eradicates or significantly reduces maternal group B streptococcal colonization at delivery. This may provide an adjuvant therapy to those mothers at risk for receiving inadequate intrapartum antibiotic prophylaxis against group B streptococci.

Wound infection after cesarean: effect of subcutaneous tissue thickness

OBJECTIVE

To estimate the effect of the thickness of subcutaneous tissue at the surgery site on abdominal wound infection after cesarean delivery.

METHODS

We measured the maximum vertical depths of subcutaneous incisions of women who had cesarean deliveries. The surgical technique for closure was standardized and drains were not used. Abdominal wound infection was defined by standard criteria and limited to the first 6 postoperative weeks. Additional demographic, intrapartum, and perioperative data previously associated with wound infection also were collected. Data were analyzed by Student t test, chi(2) test, and multiple logistic regression.

RESULTS

Wound infection occurred in 11 of 140 women (7.8%) who delivered by cesarean. Risk factors identified as significantly associated with wound infection by univariate analysis were thickness of subcutaneous tissue, maternal weight, and body mass index. Multiple logistic regression analysis confirmed subcutaneous tissue thickness as the only significant risk factor for wound infection, with a relative risk of 2.8 (95% confidence interval 1.3, 5.9). There were no significant differences between women who developed wound infections and those without infections in terms of selected demographics, duration of ruptured membranes, number of vaginal examinations, chorioamnionitis, type of skin incision, or duration of surgery.

CONCLUSION

Thickness of subcutaneous tissue appears to be the only significant risk factor associated with abdominal wound infection after cesarean delivery.

Adolescents and sexually transmissible diseases

Sexually transmitted infections are alarmingly common among adolescents in the United States. Behavioral, biologic, and health care access factors place adolescent girls at high risk for many common infections. This population also experiences a disproportionate burden related to the sequelae of STDs. The costs are high for the individual adolescent and for society. Clinicians treating adolescent girls should address the general lack of knowledge about the risks and consequences of STDs. They should be prepared to offer confidential and comprehensive counseling, screening, and treatment according to established guidelines. Office policies that protect adolescent confidentiality are an important component in providing effective care. Adolescence is a period during which lifelong health behaviors are established. It provides a critical opportunity for promoting responsible behaviors and reducing risks through health promotion and prevention strategies.

Association of lower genital tract inflammation with objective evidence of endometritis

The purpose of this report is to evaluate the association between lower genital tract inflammation and objectively diagnosed endometritis. We analyzed the first 157 patients enrolled in the PEACH study, a multicenter randomized clinical trial designed to compare the effectiveness of outpatient and inpatient therapy for PID. Women less than 38 years of age, who presented with a history of pelvic discomfort for 30 days or less and who were found to have pelvic organ tenderness (uterine or adnexal tenderness) on bimanual examination, were initially invited to participate. After recruitment of the first 58 patients (group 1) we added the presence of leukorrhea, mucopurulent cervicitis, or untreated positive test for N. gonorrhoeae or C. trachomatis to the inclusion criteria (group 2, N = 99). We compared rates of endometritis in the two groups and calculated the sensitivity, specificity, and predicted values of the presence of white blood cells in the vaginal wet preparation. The rate of upper genital tract infection in group 1 was 46.5% (27/58) compared to 49.5% (49/99) in group 2. Microbiologic evidence of either N. gonorrhoeae or C. trachomatis increased from 22.4% in group 1 to 38.3% in group 2. The presence of vaginal white blood cells or mucopus has a high sensitivity (88.9%), but a low specificity (19.4%) for the diagnosis of upper genital-tract infection. Assessment of the lower genital tract for evidence of infection or inflammation is a valuable component of the diagnostic evaluation of pelvic inflammatory disease. The presence of either mucopus or vaginal white blood cells is a highly sensitive test for endometritis in patients with pelvic pain and tenderness.

Association of lower genital tract inflammation with objective evidence of endometritis

The purpose of this report is to evaluate the association between lower genital tract inflammation and objectively diagnosed endometritis. We analyzed the first 157 patients enrolled in the PEACH study, a multicenter randomized clinical trial designed to compare the effectiveness of outpatient and inpatient therapy for PID. Women less than 38 years of age, who presented with a history of pelvic discomfort for 30 days or less and who were found to have pelvic organ tenderness (uterine or adnexal tenderness) on bimanual examination, were initially invited to participate. After recruitment of the first 58 patients (group 1) we added the presence of leukorrhea, mucopurulent cervicitis, or untreated positive test for N. gonorrhoeae or C. trachomatis to the inclusion criteria (group 2, N = 99). We compared rates of endometritis in the two groups and calculated the sensitivity, specificity, and predicted values of the presence of white blood cells in the vaginal wet preparation. The rate of upper genital tract infection in group 1 was 46.5% (27/58) compared to 49.5% (49/99) in group 2. Microbiologic evidence of either N. gonorrhoeae or C. trachomatis increased from 22.4% in group 1 to 38.3% in group 2. The presence of vaginal white blood cells or mucopus has a high sensitivity (88.9%), but a low specificity (19.4%) for the diagnosis of upper genital-tract infection. Assessment of the lower genital tract for evidence of infection or inflammation is a valuable component of the diagnostic evaluation of pelvic inflammatory disease. The presence of either mucopus or vaginal white blood cells is a highly sensitive test for endometritis in patients with pelvic pain and tenderness.