Antiretroviral therapy during pregnancy. Beyond AZT (ZDV)

Although zidovudine (ZDV) monotherapy remains the standard for the prevention of mother-to-child transmission, it may now be inadequate therapy for treatment of the mother. The safety and efficacy of the newer therapeutic agents have yet to be established during pregnancy; however, the need to maintain maternal health mandates that clinicians understand the benefits and limitations of antiretroviral therapy beyond ZDV.

Pitfalls in the diagnosis of nonconjoined monoamniotic twins

The morbidity and mortality of monoamniotic twins are high. Despite recent advances in imaging, the definitive diagnosis of monoamniotic twins remains elusive. When monoamniotic twins are suspected, the optimal antepartum management is uncertain. A false-positive diagnosis of monoamniotic twins by computed tomographic amniography was investigated. By a Medline search the literature on monoamnionicity from 1966 to January 1994 was reviewed. All reports including diagnostic methods and management of monoamniotic twins were reviewed. All five previous case reports of computed tomographic amniography correctly identified amnionicity in cases in which amnionicity was unclear. Four cases confirmed monoamnionicity and one case excluded monoamnionicity. Four recent series that used ultrasonography revealed a low predictive accuracy (9% to 25%) for the establishment of monoamnionicity when intervening membranes were absent. One recent prospective series revealed a positive predictive value of 80% among five monoamniotic twin pairs with the use of first-trimester ultrasonography. The methods available to diagnose monoamniotic twins are improving. The complications that result from a false-positive diagnosis are discussed and the management and diagnosis of monoamniotic twins are reviewed.

Parturients infected with human immunodeficiency virus and regional anesthesia. Clinical and immunologic response

BACKGROUND

It is estimated that 1.5 million Americans are infected with the human immunodeficiency virus (HIV-1), and the consequences of HIV infection are a leading cause of death in women aged 15-44 yr. Thus, HIV-1 disease, or acquired immunodeficiency syndrome, occurs with increasing frequency in the parturient, and there is little information concerning the risks of regional anesthesia. Fear of spreading infection to the central nervous system or adverse neurologic sequelae have led some clinicians to advise against regional anesthesia. Thus, this study was undertaken to evaluate the possible problems or risks associated with regional anesthesia in parturients infected with HIV-1 and to determine whether anesthesia affected the clinical course of the disease.

METHODS

The clinical course and immunologic function of 30 parturients infected with HIV-1 were evaluated prospectively. Extensive medical and laboratory evaluation before delivery and 4-6 months postpartum was undertaken. Medical problems related to HIV-1 disease and use of antiviral drugs also were monitored. The anesthetic management was dictated by the clinical situation and the patient's wishes were careful postpartum follow-up to evaluate possible neurologic changes or infection.

RESULTS

Regional anesthesia was administered in 18 parturients, and 12 received small doses of opioids or no analgesia. There were no changes in the immunologic parameters studied (CD4+, p24, beta 2 microglobulins), and HIV-1 disease remained stable in the peripartum period. There were no infections, complications, or neurologic changes in the peripartum period. Sixty-eight percent of the infants were HIV-1-negative and, in 21% of infants, the HIV-1 status was indeterminate (probably negative).

CONCLUSIONS

This prospective study of parturients infected with HIV-1 demonstrated that regional anesthesia can be performed without adverse sequelae. There were no neurologic or infectious complications related to the obstetric or anesthetic course. The immune function of the parturient was stable in the peripartum period. Although the number of patients studied was small, with careful medical evaluation, regional anesthesia is an acceptable choice in the parturient infected with HIV-1.

AIDS (HIV) risk assessment in an inner-city women's clinic

Risk assessment and antibody testing are potential modalities through which interventions to reduce heterosexual and perinatal transmission of human immunodeficiency virus (HIV) can occur. More than 98% of women attending inner-city adult gynecology, adult contraception and teen family planning clinics successfully completed self-administered HIV (AIDS) risk assessment questionnaires and received individual counseling, risk-reduction education and referral for antibody testing. Fourteen percent of the women (671/4,802) reported at least one HIV risk factor. Multiple sexual partners and intravenous drug use were the most commonly reported HIV risk factors in this population.

Substance abuse in pregnancy

The number of women who abuse drugs during pregnancy is unknown, but as many as 375,000 infants may be affected. Although some substances appear to result in less damage than others, it is impossible to differentiate individual effects because of the common use of multiple substances. The potential for synergy among substances with similar physiologic effect is an additional factor. The immediate perinatal effects of substance abuse are often obvious; it is the long-term effects that we have only recently begun to examine. These long-term effects will involve both the individual and society.

Seroprevalence and epidemiologic correlates of human immunodeficiency virus infection in women with acute pelvic inflammatory disease

As the number of women with acquired immunodeficiency syndrome (AIDS) continues to rise in the United States, it becomes important to target preventive interventions as effectively as possible toward those groups at highest risk of acquiring human immunodeficiency virus (HIV) infection. We analyzed the prevalence of serum antibody to HIV in 333 women admitted to the Gynecology Service at San Francisco General Hospital with acute pelvic inflammatory disease in the years 1985-1988. The proportion of women with HIV infection in our sample rose incrementally over this 4-year period, from 0 to 6.7%. A history of intravenous (IV) drug use conferred a 23-fold risk of HIV seropositivity. In contrast, markers of the level of sexual activity did not correlate significantly with the presence of HIV infection, although the power to detect such an association was limited by the small sample size. An intensification of educational efforts directed at IV drug-using women in San Francisco is necessary to prevent further increases in the rate of HIV infection and further spread into the heterosexual population.

Isolation of Chlamydia trachomatis from sexually abused female adolescents

Cultures for Chlamydia trachomatis were obtained from 127 female adolescents (13-17 years of age) evaluated for reported sexual abuse. The rate of positive cultures for C trachomatis in this population was 14% (18 of 127). Neisseria gonorrhoeae was found in 12% (15 of 127) of these patients. All but two of the culture-positive patients admitted sexual activity before the abuse, and it is likely that most of the infections were acquired during this previous sexual activity. Concomitant infection with N gonorrhoeae was found in seven adolescents positive for C trachomatis. No adolescents in this study exhibited a positive VDRL. Victims of abuse should be tested for both gonococcal and chlamydial infection. These data show that if antibiotic prophylaxis is used for the sexually abused adolescent, it should be directed against both C trachomatis and N gonorrhoeae.

Management of twin pregnancy: the vaginal route is still safe

To investigate the effect of method of delivery on the outcome of twin pregnancies, we reviewed all deliveries at our institution over the 10 years from 1976 to 1985. Two hundred six pairs were delivered, with a mean gestational age of 34 weeks (range 20 to 43 weeks) and a mean weight of 2116 gm (range 220 to 3800 gm). The mean gestational age at diagnosis of the twin pregnancy was 23 weeks. Nineteen (4.6%) infants were stillborn, and 36 (8.7%) died in the neonatal period. Cesarean section was used to deliver both twins in 66 cases. The method of delivery for the remaining 142 cases was vaginal-vertex, 85 (61%), vaginal-breech, 40 (29%), cesarean section, 13 (9%), and version and extraction, 2 (1%). The four most common indications for cesarean section for both twins were previous cesarean section, breech presentation, abnormal labor, and fetal distress. The indications for the 13 cesarean sections after vaginal delivery of twin A were fetal distress, cord prolapse, high presenting part, and footling breech. The impact of the method of delivery was investigated by comparing outcome variables between twin pairs. No significant differences were noted for perinatal mortality, need for resuscitation, duration of newborn hospital stay, and trauma. There were significant differences in the 1- and 5-minute Apgar scores in the vaginal delivery group. These differences were clinically minor, tending toward mild acidemia, and were unaffected by route or method of delivery.

Management of the pregnant woman infected with the human immunodeficiency virus

A significant number of the one to two million adults in the United States infected with the human immunodeficiency virus (HIV) are women of childbearing age. It is estimated that approximately 50% of HIV-infected pregnant women will transmit the virus to their fetuses or neonates. Obstetricians and gynecologists must be prepared to care for HIV-infected pregnant women. Comprehensive management includes clinical and psychosocial care in the antepartum, intrapartum, and postpartum periods. Referrals and/or consultations with other providers are often appropriate. Infection control policies must be uniform for all patients because not all HIV-infected patients will be so identified.

Beta-adrenergic receptors and cyclic adenosine monophosphate generation in human fetal lung

We designed experiments to determine whether beta-adrenergic receptors are present and functional in human fetal lung during the 2nd trimester of gestation. To determine the presence of beta receptors, characterize their binding sites, and assess changes in receptor with gestational age, we performed radioligand binding assays with the specific, high-affinity beta antagonist, 125I-iodocyanopindolol, in membrane particulates from the lungs of 2nd trimester abortuses (15-23 wk). Binding of 125I-iodocyanopindolol was saturable and of high affinity (dissociation constant = 40 pM). Binding was stereoselective as determined by competition studies with (-) and (+) stereoisomers of propranolol. Agonist affinities (isoproterenol greater than epinephrine much greater than norepinephrine) were consistent with a predominance of beta-2 receptors; this predominance was confirmed by competition studies with the specific beta-2 receptor antagonist ICI 118-551 (75% beta-2, 25% beta-1). The concentration of beta-adrenergic receptors increased with gestational age. To assess the functional coupling of the beta receptors, we tested the ability of receptor occupancy to activate adenylate cyclase. For this assay, we incubated minced human fetal lung with beta agonists and determined the amount of cAMP generated. beta Agonists stimulated cAMP generation more than 2-fold. We conclude that beta-adrenergic receptors are present and functional in human fetal lung as early as the 2nd trimester.

Failure to demonstrate decreased beta-adrenergic receptor concentration or decreased agonist efficacy in term or preterm human parturition

Iodine 125-labeled iodocyanopindolol, a radioactive beta-adrenergic antagonist, bound to particulate preparations of pregnant human myometrium in a manner compatible with binding to the beta-adrenergic receptor. Studies with a specific beta 2-antagonist, IPS 339, indicated that 72% of receptors present were of the beta 2-subtype. Quantitative studies of beta-receptor concentrations in myometrium from women at term indicated no change in receptor concentration during labor. Similarly, there was no difference in beta-receptor concentration in myometrium from women in labor or before labor between 28 and 34 weeks of gestation. Concentrations of the beta-receptor were not different at any stage of gestation assayed. Isoproterenol competition for iodocyanopindolol binding was used to examine efficacy of receptor agonist interactions in myometrium from women at term, in labor, or before labor and from women in preterm labor. There was no difference in high-affinity binding, an index of efficacy, in any of the groups examined.

Glycosylated hemoglobin as a screening test for carbohydrate intolerance in pregnancy

The usefulness of glycosylated hemoglobin as a prenatal screening test for carbohydrate intolerance was studied in 806 consecutive subjects by correlating glycosylated hemoglobin to 1-hour post-50 gm Glucola plasma glucose (1 degree G) levels, and 3-hour oral glucose tolerance tests (3 degrees GTT). Sixty-seven subjects whose 1 degree G greater than or equal to 150 mg/100 ml received a 3 degrees GTT; 12 were diagnostic of carbohydrate intolerance. Compared to carbohydrate-tolerant controls, carbohydrate-intolerant gravid patients had higher 1 degree G (p less than 0.001) and glycosylated hemoglobin (p less than 0.05) levels. Linear regression analysis of 1 degree G and glycosylated hemoglobin demonstrated r = 0.35 (p less than 0.0001). Compared to the glycosylated hemoglobin test, the 1 degree G screening test has greater specificity, sensitivity, and predictive value for a positive diagnosis. Consequently, the 1 degree G is a better routine screening test for carbohydrate intolerance than is glycosylated hemoglobin.