Neonatal sepsis after betamethasone administration to patients with preterm premature rupture of membranes

OBJECTIVE

We sought to determine the effect of antenatal betamethasone exposure on the incidence of early onset neonatal sepsis in patients with preterm premature rupture of membranes.

STUDY DESIGN

We performed a nonconcurrent prospective analysis of infants delivered between 24 and 34 weeks' gestation after preterm premature rupture of membranes. Patients with preterm premature rupture of membranes were categorized into 3 groups on the basis of the following betamethasone exposures: (1) none (control subjects), (2) two 12-mg doses in a 24-hour interval on admission (single course), and (3) weekly administration after the initial single course (multiple courses). All included patients received prophylactic antibiotics for group B streptococci. Discrete data were tested for significance with the chi(2) test. Continuous data were tested for significance with an analysis of variance. Multiple logistic regression analysis was performed to determine the confounding effect of the multiple variables that were considered risk factors for early-onset neonatal sepsis. All P values of <.05 were considered significant.

RESULTS

Three hundred seventy-four patients with preterm premature rupture of membranes were included, 203 of whom were evaluated in the control group, 99 in the single-course group, and 72 in the group receiving multiple courses of betamethasone. Early-onset neonatal sepsis was significantly associated with multiple courses of corticosteroids (P <.001) and gestational age (P =.002). Multiple courses of antenatal betamethasone were significantly associated with chorioamnionitis (P =.004) and endometritis (P =.004). Single-course corticosteroid administration was not significantly associated with any maternal or neonatal infectious complications.

CONCLUSIONS

Multiple courses of antenatal betamethasone administered to patients with preterm premature rupture of membranes is associated with an increased risk of early-onset neonatal sepsis development.

Comparison of once-daily and twice-daily dosing of 0.75% metronidazole gel in the treatment of bacterial vaginosis

BACKGROUND AND OBJECTIVES

Bacterial vaginosis is the most common cause of vaginal symptoms in women and has potential complications. Efforts to improve treatment of this disease process are warranted.

GOAL OF THIS STUDY

The goal of this study was to compare the safety and efficacy of once-daily intravaginal administration of 0.75% metronidazole gel for 5 days to the established twice-daily regimen in the treatment of bacterial vaginosis.

STUDY DESIGN

Nonpregnant women with bacterial vaginosis diagnosed by accepted clinical criteria at 14 geographically diverse general gynecology clinics were enrolled in this prospective, randomized, investigator-blind, parallel study. They were treated with either once-daily or twice-daily 0.75% metronidazole gel 5 g intravaginally for 5 days and were reevaluated at 7 to 12 days and 28 to 35 days after completing treatment. Efficacy was determined by clinical criteria. Adverse drug reactions were monitored.

RESULTS

Of the 514 evaluable women enrolled, bacterial vaginosis was cured at the first return visit among evaluable patients in 153 of 199 (77%) of those who received the once-daily and in 157 of 196 (80%) of those who received the twice-daily administration. Bacterial vaginosis was cured among evaluable patients at the final visit in 104 of 180 (58%) of those who received once-daily and 109 of 178 (61%) of those who received the twice-daily regimen. Intent-to-treat analysis showed cure at 1 month in 118 of 207 (57%) of those treated once daily and 129 of 209 (62%) of those treated twice daily. Side effects were mild, and none caused treatment discontinuation.

CONCLUSIONS

Once-daily dosing of 0.75% metronidazole gel 5 g for 5 days yields efficacy, safety, and tolerance equivalent to the currently used twice-daily dosing in the treatment of bacterial vaginosis, adding another competitive choice to the available therapeutic options for this condition.

Pelvic inflammatory disease in the postmenopausal woman

OBJECTIVE

Review available literature on pelvic inflammatory disease in postmenopausal women.

DESIGN

MEDLINE literature review from 1966 to 1999.

RESULTS

Pelvic inflammatory disease is uncommon in postmenopausal women. It is polymicrobial, often is concurrent with tuboovarian abscess formation, and is often associated with other diagnoses.

CONCLUSION

Postmenopausal women with pelvic inflammatory disease are best treated with inpatient parenteral antimicrobials and appropriate imaging studies. Failure to respond to antibiotics should yield a low threshold for surgery, and consideration of alternative diagnoses should be entertained.

Pelvic inflammatory disease in the postmenopausal woman

OBJECTIVE

Review available literature on pelvic inflammatory disease in postmenopausal women.

DESIGN

MEDLINE literature review from 1966 to 1999.

RESULTS

Pelvic inflammatory disease is uncommon in postmenopausal women. It is polymicrobial, often is concurrent with tuboovarian abscess formation, and is often associated with other diagnoses.

CONCLUSION

Postmenopausal women with pelvic inflammatory disease are best treated with inpatient parenteral antimicrobials and appropriate imaging studies. Failure to respond to antibiotics should yield a low threshold for surgery, and consideration of alternative diagnoses should be entertained.

Factors predicting upper genital tract inflammation among women with lower genital tract infection

We sought to identify factors that discriminate between women with a lower genital tract infection and women with a lower genital tract infection and endometritis. This study enrolled women at risk for or having a lower genital tract infection with Chlamydia trachomatis or Neisseria gonorrhoeae and measured behavioral and clinical factors. Women were identified through contact tracing of male partners, presentation with cervicitis, or presentation with symptoms of pelvic inflammatory disease and classified as (1) having a lower genital tract infection without endometritis, (2) having a lower genital tract infection with endometritis, (3) having no lower genital tract infection with endometritis, and (4) having neither a lower genital tract infection nor endometritis. The primary comparison was between women having a lower genital tract infection without endometritis to women having a lower genital tract infection and endometritis. Women with a lower genital tract infection and endometritis were older and reported a history of more sexually transmitted diseases (70.0% vs. 56.7%), abdominal pain (82.2% vs. 60.0%), and use of barrier methods of contraception (28.9% vs. 8.6%) than women with a lower genital tract infection alone. The regression model found that women with a lower genital tract infection and endometritis were 7.1 times (95% CI = 2.2-23.0) more likely to report abdominal pain and 4.6 times (95% CI = 1.5-14.9) more likely to use barrier methods of contraception than women with a lower genital tract infection alone. These results suggest that behavioral factors, in addition to symptoms, can be used to identify women with and without upper genital tract involvement.

Design of the PID Evaluation and Clinical Health (PEACH) Study

This paper describes the PID Evaluation and Clinical Health Study (PEACH), a multicenter, randomized clinical trial designed to compare treatment with outpatient and inpatient antimicrobial regimens among women with pelvic inflammatory disease (PID). PEACH is the first trial to evaluate the effectiveness and cost-effectiveness of currently recommended antibiotic combinations in preventing infertility, ectopic pregnancy, chronic pelvic pain, recurrent PID, and other health outcomes. It is also the largest prospective study of PID ever conducted in North America. We describe the PEACH study's specific aims, study organization, patient selection criteria, conditions for exclusion, data collected upon entry, randomization and treatment, adherence measures, follow-up activities, quality-of-life measures, outcomes, and statistical analyses. In the first 11 months of enrollment (March 1996-January 1997), 312 women were randomized. Of eligible women, 59% consented to enroll. Participating women are primarily black (72%) and young (mean age 24 years). After a median of 5.5 months of follow-up, we were in contact with 95% of study participants. The PEACH study will provide a rationale for selecting between inpatient and outpatient antibiotic treatment, the two most common treatment strategies, for PID.

Clinical utility of CA125 levels in predicting laparoscopically confirmed salpingitis in patients with clinically diagnosed pelvic inflammatory disease

OBJECTIVE

The purpose of this study was to determine the utility of serum CA125 determinations in diagnosing acute salpingitis.

METHODS

CA125 levels were determined for 34 women with the clinical diagnosis of pelvic inflammatory disease (PID). Acute salpingitis was confirmed laparoscopically in 28 women (82.3%).

RESULTS

Twenty patients (71.4%) with laparoscopically confirmed acute salpingitis had CA125 levels greater than 7.5 units, compared with no patients (0/6) with laparoscopically normal tubes (P = 0.002). The degree of elevation of CA125 levels correlated with the severity of tubal inflammation noted at laparoscopy. All patients with levels above 16 units had laparoscopically severe salpingitis.

CONCLUSIONS

We conclude that while CA125 levels above 7.5 units may modestly improve the ability of the clinical diagnosis of PID to accurately reflect visually confirmed acute salpingitis, limitations of the test make its clinical utility questionable.

Clinical utility of CA125 levels in predicting laparoscopically confirmed salpingitis in patients with clinically diagnosed pelvic inflammatory disease

OBJECTIVE

The purpose of this study was to determine the utility of serum CA125 determinations in diagnosing acute salpingitis.

METHODS

CA125 levels were determined for 34 women with the clinical diagnosis of pelvic inflammatory disease (PID). Acute salpingitis was confirmed laparoscopically in 28 women (82.3%).

RESULTS

Twenty patients (71.4%) with laparoscopically confirmed acute salpingitis had CA125 levels greater than 7.5 units, compared with no patients (0/6) with laparoscopically normal tubes (P = 0.002). The degree of elevation of CA125 levels correlated with the severity of tubal inflammation noted at laparoscopy. All patients with levels above 16 units had laparoscopically severe salpingitis.

CONCLUSIONS

We conclude that while CA125 levels above 7.5 units may modestly improve the ability of the clinical diagnosis of PID to accurately reflect visually confirmed acute salpingitis, limitations of the test make its clinical utility questionable.

Sexually transmitted diseases in pregnancy

Sexually transmitted diseases are common complications of pregnancy and may have significant maternal/fetal effects. Knowledge of the symptoms and physical examination features, methods of diagnosis, indications for screening, and appropriate treatment options are essential for obstetric/gynecologic health care providers.

Oral contraception and the recognition of endometritis

OBJECTIVE

Oral contraceptive use has been associated with a lower risk of symptomatic pelvic inflammatory disease but a higher risk of chlamydial cervicitis. To explain these seemingly contradictory findings, we asked whether oral contraceptive use was more common among women with unrecognized endometritis than among women with recognized endometritis.

STUDY DESIGN

A multicenter case-control study was performed. Women without signs of pelvic inflammatory disease were ascertained through contact tracing of partners with sexually transmitted diseases or through presentation with cervicitis. Women with symptomatic pelvic inflammatory disease met a set of standard clinical criteria. We compared the 43 cases without signs of pelvic inflammatory disease but with endometritis ("unrecognized endometritis") with the 111 controls with recognized pelvic inflammatory disease and endometritis ("recognized endometritis").

RESULTS

Women with unrecognized endometritis were 4.3 times (95% confidence interval 1.6 to 11.7) more likely than women with recognized endometritis to use oral contraceptives.

CONCLUSION

Future studies need to fully characterize the risks and benefits of oral contraceptives in relation to sexually transmitted diseases.