Gustavo Vilchez

Brucellosis in pregnancy: clinical aspects and obstetric outcomes

OBJECTIVE Brucellosis is a zoonosis with high morbidity in humans. This disease has gained interest recently due to its re-emergence and potential for weaponization. Pregnant women with this disease can develop severe complications. Its association with adverse obstetric outcomes is not clearly understood. The objective of this study was to describe the obstetric outcomes of brucellosis in pregnancy. METHODS Cases of pregnant women with active brucellosis seen at the Hospital Nacional Cayetano Heredia from 1970 to 2012 were reviewed. Diagnostic criteria were a positive agglutination test and/or positive blood/bone marrow culture. Presentation and outcomes data were collected. The Chi-square test was used for nominal variables. A p-value of <0.05 indicated significance. RESULTS One hundred and one cases were included; 27.7% had a threatened abortion/preterm labor, 12.8% experienced spontaneous abortion, 13.9% preterm delivery, 8.1% fetal death, and 1.1% congenital malformations. There was one maternal death secondary to severe sepsis. After delivery, neonatal death occurred in 8.1%, low birth weight in 14.5%, and congenital brucellosis in 6.4%. The most common treatment was aminoglycosides plus rifampicin (42.2% of cases). Complication rates decreased if treatment was started within 2 weeks of presentation (p < 0.001). CONCLUSIONS This is the largest series of brucellosis in pregnancy reported in the literature. Brucella presents adverse obstetric outcomes including fetal and maternal/neonatal death. Cases with unexplained spontaneous abortion should be investigated for brucellosis. Prompt treatment is paramount to decrease the devastating outcomes.

Physicians' responsibility for antibiotic use in infants from periurban Lima, Peru

OBJECTIVE To describe the use of antibiotics in Peruvian children under 1 year in a setting where they are available without a prescription. METHODS Data were analyzed from a cohort study between September 2006 and December 2007 of 1 023 children < 2 months old in periurban Lima, Peru, followed until they were 1 year old. RESULTS Seven hundred seventy of 1 023 (75.3%) children took 2 085 courses of antibiotics. There were two courses per child per year (range 0-12). Higher rates of antibiotic use were found in children 3-6 months old (37.2%). Antibiotics were given to children for 8.2% of common colds, 58.6% of all pharyngitis, 66.0% of bronchitis, 40.7% of diarrheas, 22.8% of dermatitis, and 12.0% of bronchial obstructions. A physicians prescription was the most common reason for antibiotic use (90.8%). Medication use without a prescription was found in 6.9% of children, and in 63.9% of them it was preceded by a physicians prescription. CONCLUSIONS Infants are often exposed to antibiotics in this setting. Overuse of antibiotics is common for diagnoses such as pharyngitis, bronchitis, bronchial obstruction, and diarrhea but is typically inappropriate (83.1% of courses) based on the most common etiologies for this age group. Interventions to improve the use of antibiotics should focus on physicians, since a physicians prescription was the most common reason for antibiotic use.

Maternal race and neonatal outcomes after elective repeat cesarean delivery

Abstract Objective: To determine the effect of race in the risks of prematurity-related complications (PRC) after elective repeat cesarean delivery (ERCD). Methods: The NCHS-CDC Database for the U.S. (2004–2008) was used. ERCD cases were included. Exclusion criteria were multiple gestation, trial of labor, fetal anomalies, history of diabetes and/or hypertension. PRC analyzed were: Apgar score, assisted ventilation, intensive care admission, surfactant use, antibiotic use, seizures. Regression analysis was performed to calculate the odds ratio (OR) of these variables. Deliveries at 36–40 weeks were studied with 40 weeks as reference. Results: Totally, 785 340 ERCDs were performed between 36 and 40 weeks. For the overall population, there was not difference in adverse outcomes between 39 and 40 weeks. The rates of PRC were significantly higher in newborns at 38 compared to 39 weeks, with similar findings in sub-analysis of whites. For African-Americans, the rate of PRC was not significantly different at 38 compared to 39 weeks. Conclusions: We report increased rates of PRC after ERCD before 39 weeks, similar findings from smaller hospital-based studies. For African-American newborns, there was no further decrease in PRC after 38 weeks suggesting earlier maturation of these fetuses. The study does not propose changing the current 39 weeks threshold for ERCD.

Racial disparities in the optimal for induction of labor in low-risk term pregnancies: a national population-based study

Abstract Objective: The recommendation for elective induction of labor (IOL) is to await ≥39 weeks. Studies show earlier maturity of Blacks compared to Whites. The objective was to examine the effect of the Black race on the risk of intrapartum and neonatal complications after IOL. Methods: Black women with non-indicated IOL at 37–42 weeks were selected from the CDC-Birth Cohorts 2007–2010. Congenital anomalies, hypertension/diabetes, low-birth weight, breech presentation, previous cesarean and premature rupture of membranes were excluded. Intrapartum/neonatal complications were analyzed. Logistic regression was used to calculate adjusted odds ratios, using 39 weeks as reference. Results: 311 264 black were compared with 2 451 774 deliveries of other races. For Blacks, the risks of cesarean delivery and intrapartum complications were lower at 38 weeks. Chance of vaginal delivery was greater at 38 weeks. Risks of neonatal complications was not increased at 38 compared to 39 weeks. Conclusions: Intrapartum complications were lower at 38 than at 39 weeks in Blacks with no increased risk of neonatal complications. Meconium staining and fetal distress were higher as early as at 40 weeks, perhaps due to accelerated maturation. While a 39-week goal is simple and benefits many patients, a more “personalized medicine” approach may benefit even more mothers and babies.

Labor and neonatal outcomes after term induction of labor in gestational diabetes.

Objective:To identify the optimal gestational age (GA) for induction of labor (IOL) at term among patients with gestational diabetes (GDMA) according to perinatal outcomes.Study Design:The US Natality Database from 2007 to 2010 was reviewed. Inclusion criteria were singleton delivery, IOL at 37 to 42 weeks and GDMA. Exclusion criteria included congenital anomalies, pre-gestational diabetes, hypertensive disorders, previous cesarean, breech presentation and rupture of membranes. Controls were non-GDMA cases delivered in geographic and temporal proximity. Delivery mode, macrosomia and perinatal complications were analyzed. Logistic regression adjusted for confounders was used to calculate odds ratios by GA using 39 weeks non-GDMA as reference.Results:In all, 96 964 cases and 176 079 controls were included. Increased risk for all adverse outcomes among GDMA cases was found. The nadir for intrapartum and neonatal complications was 38 and 40 weeks, respectively, whereas for cesarean and macrosomia was 39 weeks.Conclusion:The optimal timing for IOL at term in GDMA appears to be 39 to 40 weeks.

Intrapartum mean platelet volume is not a useful predictor of new‐onset delayed postpartum pre‐eclampsia

To determine whether intrapartum mean platelet volume (MPV) can predict new‐onset delayed postpartum pre‐eclampsia.

Differences in clinical presentation and pregnancy outcomes in antepartum preeclampsia and new-onset postpartum preeclampsia: Are these the same disorder?

Objective New-onset postpartum preeclampsia is a poorly defined condition that accounts for a significant percentage of eclampsia cases. It is unclear whether new-onset postpartum preeclampsia is a different disorder from or belongs to the same spectrum of classic antepartum preeclampsia. The objective of this study was to compare the clinical presentation and pregnancy outcomes of antepartum preeclampsia and new-onset postpartum preeclampsia. Methods A retrospective study including 92 patients with antepartum preeclampsia and 92 patients with new-onset postpartum preeclampsia was performed. Clinical presentation and pregnancy outcomes were compared. Chi-square test was used to analyze categorical variables, and independent t-test and Mann-Whitney U-test for numerical variables. P-values of <0.05 were used to indicate statistical signifi cance. Results Patients with antepartum preeclampsia and new-onset postpartum preeclampsia differ significantly in profile, symptoms at presentation, laboratory markers and pregnancy outcomes. Conclusion New-onset postpartum preeclampsia has a distinct patient profile and clinical presentation than antepartum preeclampsia, suggesting they may represent different disorders. Characterization of a patient profile with increased risk of developing this condition will help clinicians to identify patients at risk and provide early and targeted interventions to decrease the morbidity associated with this condition.

Decreased risk of prematurity after elective repeat cesarean delivery in Hispanics

Abstract Background: The current recommendation is to delay elective repeat cesarean deliveries (ERCD) until 39 weeks to decrease prematurity risks. Prior reports suggest accelerated maturity of fetuses according to race (African-Americans and Asians). Objective: To analyze the effect of the Hispanic ethnicity on the prematurity risk after ERCD. Methods: The US Natality Database from 2004 to 2008 was reviewed. Inclusion criteria were singleton delivery, no trial of labor, repeat cesarean. Exclusion criteria were fetal anomalies, history of diabetes/hypertension related disorders. Outcomes analyzed were Apgar score, assisted ventilation, intensive care admission, surfactant/antibiotic use and seizures. Two groups were identified: non-Hispanic Whites (NHW) and Hispanic Whites (HW). Regression analysis was performed to calculate adjusted odds ratios. Deliveries at 36–40 weeks were studied with 40 weeks as the reference group. Results: A total of 930 421 ERCDs were identified, 396 823 NHW and 236 733 HW. For NHW, the risk of prematurity was lower at 39 weeks. For HW, there was no difference in the risks of prematurity at/beyond 38 weeks. Conclusion: There appears to be accelerated maturity with no increase in prematurity risk at 38 weeks in HW delivered by ERCD. Ethnicity can be considered for patient counseling and decision making regarding optimal timing of elective interventions.

Optimal Timing for Term Delivery of Twin Pregnancies: A Population-Based Study

OBJECTIVE The objective of this study was to examine the risk of adverse neonatal outcomes after twin delivery according to gestational age. MATERIALS AND METHODS The U.S. Natality Database from 2007 to 2010 was reviewed. Inclusion criteria were twin deliveries and gestational age of 37 to 42 weeks. Exclusion criteria were congenital anomalies and missing/incomplete data. Cases were subdivided by gestational age into early term, term, and late term. Singleton pregnancies matched by delivery time and location were selected as controls. Outcome variables included were low Apgar score, assisted ventilation, neonatal intensive care unit admission, surfactant/antibiotic use, seizures, and birth injury. Logistic regression analysis was used to calculate adjusted odds ratios according to gestational age and plurality, using singleton term as reference. RESULTS A total of 220,169 twin and 270,540 singleton deliveries were identified. The risk of adverse neonatal outcomes for twins was higher than for singletons. For twins, the distribution of the risks of the composite of adverse neonatal outcomes was linear, being the lowest at early term and the highest at late term, whereas the distribution for singletons was u-shaped being lowest at term compared with early and late term. CONCLUSIONS Twins are at higher risk of suboptimal neonatal outcomes than singletons, but do better when delivered at early term rather than term or late term.

Maternal side effects & fetal neuroprotection according to body mass index after magnesium sulfate in a multicenter randomized controlled trial

Abstract Objective: Evidence supports the need of dose-adjustment of several drugs according to body mass index (BMI) to prevent toxicity in the underweight, and ensure efficacy in obese women. However, for MgSO4 neuroprotection, the effect of BMI on maternal toxicity and fetal neuroprotection is understudied. We analyze the effect of BMI on maternal/infant outcomes after MgSO4. Methods: Secondary analysis of a clinical trial that studied MgSO4 neuroprotection. Maternal side effects, magnesium cord levels, and offspring cerebral palsy/death were analyzed along BMI strata using ANOVA and chi-square test. Logistic regression was used to calculate adjusted odds ratios according to the treatment and BMI, using nonobese that received placebo as reference. Interaction analyses were performed to validate differential efficacy of BMI. Results: From 2241 women, more side effects and higher magnesium cord levels were seen in underweight women (p = 0.05). MgSO4 neuroprotection was effective in the non-obese (p = 0.02), but not in obese women (p = 1.00). In multivariate analyses, MgSO4 significantly reduced cerebral palsy only in nonobese women. Interaction analyses showed the moderator effect of BMI (p = 0.169). Increasing MgSO4 dose in obese mothers may ensure neuroprotective efficacy without representing increased maternal risks. Considering costs of studying this association, current analysis may form the basis for reasonable practice.