Herbert Kiss

Prospective randomised controlled trial of an infection screening programme to reduce the rate of preterm delivery

Abstract Objective To evaluate whether a screening strategy in pregnancy lowers the rate of preterm delivery in a general population of pregnant women. Design Multicentre, prospective, randomised controlled trial. Setting Non-hospital based antenatal clinics. Participants 4429 pregnant women presenting for their routine prenatal visits early in the second trimester were screened by Gram stain for asymptomatic vaginal infection. In the intervention group, the womens obstetricians received the test results and women received standard treatment and follow up for any detected infection. In the control group, the results of the vaginal smears were not revealed to the caregivers. Main outcome measures The primary outcome variable was preterm delivery at less than 37 weeks. Secondary outcome variables were preterm delivery at less than 37 weeks combined with different birth weight categories equal to or below 2500 g and the rate of late miscarriage. Results Outcome data were available for 2058 women in the intervention group and 2097 women in the control group. In the intervention group, the number of preterm births was significantly lower than in the control group (3.0% v 5.3%, 95% confidence interval 1.2 to 3.6; P = 0.0001). Preterm births were also significantly reduced in lower weight categories at less than 37 weeks and ≤ 2500 g. Eight late miscarriages occurred in the intervention group and 15 in the control group. Conclusion Integrating a simple infection screening programme into routine antenatal care leads to a significant reduction in preterm births and reduces the rate of late miscarriage in a general population of pregnant women.

Increased Risk of Mother-to-Infant Transmission of Hepatitis C Virus by Intrapartum Infantile Exposure to Maternal Blood

Virological and clinical data from 73 hepatitis C virus (HCV)-infected pregnant women who gave birth to 75 children were merged retrospectively, by logistic regression analysis, to investigate risk factors for vertical transmission of HCV. Eighty-two percent of the HCV-infected mothers were HCV-RNA-positive during pregnancy, and 10% were coinfected with human immunodeficiency virus (HIV). Nine children were HCV infected, 1 was HIV infected, but none was HIV-HCV coinfected. Among vaginal deliveries, the mean HCV load of mothers who transmitted HCV to their infants was higher than that of those who did not (8.1 x 10(5) vs. 1.4 x 10(4) copies/mL; P=.056). A reduction in umbilical cord-blood pH (relative risk, 3.9; P=.04) or the occurrence of perineal or vaginal laceration (relative risk, 6.4; P=.028) during vaginal delivery significantly increased the risk of vertical HCV transmission. In conclusion, high maternal viremia, infantile hypoxia, and intrapartum exposure to virus-contaminated maternal blood increased the risk of HCV transmission during vaginal deliveries. Consequently, cesarean section may reduce the risk of vertical HCV transmission in selected cases.

Randomized, double-blind, placebo-controlled study of oral lactobacilli to improve the vaginal flora of postmenopausal women.

OBJECTIVE The purpose of this randomized, double-blind, placebo-controlled study was to evaluate the influence of the orally administered probiotic strains Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14 on the quality of the vaginal flora in postmenopausal women. STUDY DESIGN Postmenopausal women with Nugent scores between 4 and 6 in initial vaginal swab, were randomized into two groups. Women in the intervention group received probiotic capsules containing 2.5x10(9)CFU (colony forming units) each of lyophilized L. rhamnosus GR-1 and L. reuteri RC-14 and women in the control group received an oral placebo once daily, in both groups for 14 days. Final vaginal swabs were taken 1 day after the last administration of the medication. The primary efficacy variable was a change in the Nugent score between baseline and the end of the study of at least two grades in each individual patient. RESULTS Seventy two women were recruited in the study, 35 assigned to the intervention group and 37 to the control group. Twenty-one of the 35 subjects (60%) in the intervention group and 6 of the 37 subjects (16%) in the control group showed a reduction in the Nugent score by at least two grades. The difference in the number of patients with improvement was highly significant (p=0.0001). The median difference in Nugent scores between baseline and the end of the study was 3 in the intervention group and 0 in the control group (p=0.0001). CONCLUSION Our results provide evidence for an alternative modality to restore the normal vaginal flora using specific probiotic strains administered orally.

Characterisation of the vaginal Lactobacillus microbiota associated with preterm delivery

The presence of an abnormal vaginal microflora in early pregnancy is a risk factor for preterm delivery. There is no investigation on vaginal flora dominated by lactic acid bacteria and possible association with preterm delivery. We assessed the dominant vaginal Lactobacillus species in healthy pregnant women in early pregnancy in relation to pregnancy outcome. We observed 111 low risk pregnant women with a normal vaginal microflora 11 + 0 to 14 + 0 weeks of pregnancy without subjective complaints. Vaginal smears were taken for the identification of lactobacilli using denaturing gradient gel electrophoresis (DGGE). Pregnancy outcome was recorded as term or preterm delivery (limit 36 + 6 weeks of gestation). The diversity of Lactobacillus species in term vs. preterm was the main outcome measure. L. iners alone was detected in 11 from 13 (85%) women who delivered preterm. By contrast, L. iners alone was detected in only 16 from 98 (16%) women who delivered at term (p < 0.001). Fifty six percent women that delivered at term and 8% women that delivered preterm had two or more vaginal Lactobacillus spp. at the same time. This study suggests that dominating L. iners alone detected in vaginal smears of healthy women in early pregnancy might be associated with preterm delivery.

Vaginal Lactobacillus microbiota of healthy women in the late first trimester of pregnancy

Objective  This study was undertaken to characterise the dominant species of Lactobacillus colonising the vagina of healthy pregnant women, to examine some of their phenotypic and genotypic properties, and to gain a better understanding of the potential role of species, which might be associated with infection‐free status.

Fetal fibronectin as a selection criterion for induction of term labor

OBJECTIVE We examined whether the presence of fetal fibronectin in cervicovaginal secretions can be used as a selection criterion for induction of labor at term. STUDY DESIGN Cervicovaginal secretions of 64 women who were scheduled for induction of labor were examined for fetal fibronectin and divided into group A (positive for fibronectin) and group B (negative for fibronectin). Both groups were examined for Bishop score, the number of prostaglandin tablets administered, and the interval between induction of labor and delivery. RESULTS In group A the interval between induction of labor and delivery was significantly shorter (p < 0.0001) than in group B. The number of prostaglandin tablets administered to group A was likewise significantly lower (p < 0.0001). Unsuccessful induction of labor only occurred in women with fibronectin-negative cervicovaginal secretions. CONCLUSION The assessment of the fibronectin content of cervicovaginal secretions constitutes a viable instrument in the decision-making process preceding induction of labor.

Fetal fibronectin as a marker to predict the onset of term labor and delivery

OBJECTIVE We examined whether the presence of fetal fibronectin in cervicovaginal secretions may be a marker to predict the onset of term labor and delivery. STUDY DESIGN A prospective study was performed in 100 primiparous and multiparous women having reached their expected date of confinement. Fetal fibronectin was assayed by taking samples of both the cervical and vaginal mucus with two different fetal fibronectin tests. The study population was divided into women delivering within 48 hours and women giving birth > 48 hours after sampling. RESULTS Seven patients had to be excluded from evaluation. Of the remaining 93 women, 37 were delivered within 48 hours; fetal fibronectin was detected in 30. Fifty-six women were delivered later than 48 hours; 51 of them had negative results for fetal fibronectin (positive accuracy 86%, negative accuracy 88%, p < 0.0001). CONCLUSION Fetal fibronectin in the cervicovaginal secretions of women who have reached their expected date of confinement is a useful predictor of the onset of term labor and delivery.

The transfer of interleukin-8 across the human placenta perfused in vitro.

Objective To assess the placental transfer of interleukin (IL)-8 in vitro. Methods Eighteen placentas obtained immediately after delivery were perfused with a mixture of 125I-Iabeled IL-8 (IL-8*) and unlabeled IL-8 in two different concentrations. Antipyrine was coinfused in all experiments as a reference compound. Fetal-to-maternal and maternal-to-fetal perfusions were performed. Radioactivity was measured in a gamma counter at the end of each perfusions experiment. In four experiments, unlabeled IL-8 was analyzed in addition to labeled IL-8 to exclude a change in the IL-8/IL8* ratio resulting from membrane transfer. Results Two of the 18 experiments had to be discarded because of poor transfer of antipyrine. There was only faint accumulation of radioactivity in the transplacental compartment, regardless of whether the test substance was added maternally or fetally. Because measurement of unlabeled IL-8 yielded negative results, the radioactivity is clearly attributable to free iodine 125, which is generated during IL radiolabeling or which disassociates from IL-8 in small amounts after radiolabeling. Conclusion Interleukin-8 does not appear to cross the placenta by simple diffusion, regardless of the concentration or the perfusion rate. The impermeability of the placenta to the diffusion of IL-8 might explain why there is insufficient correlation between serum and amniotic fluid cytokine concentration of pregnant women and the presence of the amnion infection syndrome.

Characterisation of the oral, vaginal and rectal Lactobacillus flora in healthy pregnant and postmenopausal women

OBJECTIVE To investigate the hypothesis that the rectum may be an important reservoir for vaginal colonisation by Lactobacillus species. STUDY DESIGN We included 60 pregnant women aged 18-35 years and 80 postmenopausal women aged 55-65 years in this cross-sectional observational study. Participants had to be without clinical signs of vaginal infection and without hormone replacement therapy. Only women with normal vaginal microflora (Nugent scores 0-3) were included in the evaluation. The first oral, vaginal, and rectal smears were taken for the enumeration of lactobacilli by cultural methods and identification of dominating lactobacilli based on multiplex polymerase chain reaction (PCR). The second oral, vaginal, and rectal smears were taken for molecular lactobacilli profiling using PCR denaturing gradient gel electrophoresis (DGGE). RESULTS 30 pregnant and 30 postmenopausal women were evaluated. On multiplex PCR, 99 colonies isolated from 30 pregnant women and 37 colonies isolated from 30 postmenopausal women were identified as being members of the genus Lactobacillus: 50% of pregnant and 33% of postmenopausal women had one or more Lactobacillus spp. recovered from their oral specimens. Around 80% of pregnant and 40% of postmenopausal women harboured one or more Lactobacillus spp. in the vagina and rectum. On PCR-DGGE, 80% of pregnant and 40% of postmenopausal women harboured the same lactobacilli isolates in both the vagina and rectum. CONCLUSION This study supports the hypothesis that the rectum may play an important role as a reservoir for some strains of lactobacilli that colonise the vagina.

DNA Hybridization Test: Rapid Diagnostic Tool for Excluding Bacterial Vaginosis in Pregnant Women with Symptoms Suggestive of Infection

ABSTRACT This prospective comparative study evaluated a DNA hybridization test (Affirm VPIII) as an alternative to Gram stain for the diagnosis of bacterial vaginosis. We examined vaginal smears from 1,725 pregnant women between the 12th and 36th weeks of gestation with clinical signs of vaginal infection. The DNA hybridization test compared well with Gram stain and can be used as a rapid diagnostic tool to exclude bacterial vaginosis.