J.M. Ernest

Amniotic fluid interleukin-6 levels correlate with histologic chorioamnionitis and amniotic fluid cultures in patients in premature labor with intact membranes

OBJECTIVES Our purpose was (1) to determine the frequency of intraamniotic and extraamniotic intrauterine infection in patients with premature labor and intact membranes and (2) to determine if intrauterine infection is associated with elevated amniotic fluid interleukin-6 levels. STUDY DESIGN Amniocentesis was performed on 57 patients in preterm labor and 201 controls at various gestational ages without labor and at term with labor. The amniotic fluid was evaluated with gram stain, cultures, and an enzyme-linked immunosorbent assay specific for interleukin-6. Placentas from study patients (n = 52) and term controls (n = 120) were analyzed. RESULTS The frequency of positive amniotic fluid cultures (intraamniotic intrauterine infection) was 10 of 57 (18%) in the preterm labor group and zero of 201 for controls. Histologic chorioamnionitis (extraamniotic intrauterine infection) was present in 21 of 24 (88%) of patients in preterm labor that failed tocolysis and 28 of 120 (23%) of term laboring controls. An amniotic fluid interleukin-6 level of > or = 600 pg/ml was 100% sensitive and 89% specific (positive predictive value 85%, negative predictive value 100%) for the identification of intrauterine infection. CONCLUSION Interleukin-6 is a sensitive and specific marker for the identification of both intraamniotic and extraamniotic intrauterine infection in patients in preterm labor with intact membranes.

Causes of low birth weight births in public and private patients

This examination of the cause of low birth weight births in two model populations, one of public and one of private patients, finds significant differences in the reasons for low birth weight births in the two groups. Idiopathic premature labor was related to 47.1% of private low birth weight births, but only 24.8% of public births; low birth weight term (26.7%) and premature rupture of fetal membranes (33.7%) were more common in public low birth weight births than in private births (13.8% and 23.0%, respectively). Medical problems were related to 16.1% of private and 14.9% of public low birth weight births. Since current prematurity prevention methods are most likely to prevent low birth weight births related to idiopathic premature labor, the relative success of such programs in reducing the rate of low birth weight births is likely to depend on the characteristics of the patient population to which the programs are directed.

Risk Factors and Outcome of Varicella-Zoster Virus Pneumonia in Pregnant Women

To determine the factors associated with an increased risk of developing varicella-zoster virus (VZV) pneumonia during pregnancy, a case-control analysis was done in which 18 pregnant women with VZV pneumonia were compared with 72 matched control subjects. VZV infection was identified clinically, and VZV pneumonia was diagnosed by dyspnea and findings on chest radiographs. Of 347 pregnant women with VZV infection, 18 (5.2%) had pneumonia treated with acyclovir, and none died. Mean gestational age at rash onset was 25.8 plus minus 8.8 weeks for patients with pneumonia and 17.7 +/- 10.3 weeks for control subjects, which was not significant in the multivariable model. Women with VZV pneumonia were significantly more likely to be current smokers (odds ratio [OR], 5.1; 95% confidence interval [CI], 1.6-16.7) and to have > or = 100 skin lesions (OR, 15.9; 95% CI, 1.9-130.2). Pregnant women with VZV infection may be more likely to develop varicella pneumonia if they are smokers or manifest > or = 100 skin lesions.

Chlamydia in pregnancy : A randomized trial of azithromycin and erythromycin

Objective To determine side effect profiles and cure rates of azithromycin compared with erythromycin in the treatment of chlamydial cervicitis complicating pregnancy. Methods Pregnant patients with positive DNA antigen assays for Chlamydia trachomatis were randomized to either azithromycin, 1 g oral slurry in a single dose, or erythromycin, 500 mg every 6 hours for 7 days. Repeat assays were planned for 3 weeks after therapy. Side effects, compliance, and treatment efficacy were assessed. Results One hundred six women were enrolled, and eighty-five women completed the protocol. Significantly fewer gastrointestinal side effects were noted in the azithromycin group than in the erythromycin group (11.9% versus 58.1%, P ≤ .01). Enhanced compliance was noted with azithromycin, because it was given in a single observed dose. Similar treatment efficacy was noted between azithromycin and erythromycin (88.1% versus 93.0%, P > .05). Conclusion Compared with erythromycin, azithromycin is associated with significantly fewer gastrointestinal side effects in pregnancy. This association, along with the ease of administration and similar efficacy, suggests that azithromycin should be considered for the initial treatment of chlamydial cervicitis in pregnancy.

Regional program for prevention of premature birth in northwestern North Carolina

We present our experience with introducing and implementing a prematurity prevention program in a 20-county region in northwest North Carolina. The program is based on the risk assessment and educational model. In the first 25 months of results available, 17,370 births occurred in women enrolled in the project. During 1985, 42.5% of all births in the region occurred in the project. During the time span examined, a downward trend was seen for rates of low birth weight births in public and private patients and for very low birth weight births in private patients. During 1985, private births in the project were significantly less likely to be low birth weight or very low birth weight than private births to women not in the project. These results suggest that regional implementation of prematurity prevention programs is feasible and that such programs are particularly appropriate for private patients.

Elevated endoxin-like factor complicating a multifetal second trimester pregnancy: treatment with digoxin-binding immunoglobulin.

We report a case of a second trimester multifetal pregnancy with preeclampsia associated with an elevated digoxin-like immune factor. Due to the remoteness from viability the patient was offered therapy with digoxin-binding immunoglobulin. No untoward maternal effects were noted.

Do U.S. Medical Licensure Examination Step 1 Scores Correlate with Council on Resident Education in Obstetrics and Gynecology In-Training Examination Scores and American Board of Obstetrics and Gynecology Written Examination Performance?

OBJECTIVE The purpose of this study was to assess the possible association between scores of >200 on U.S. Medical Licensure Examination (USMLE) step 1 and the Council on Resident Education in Obstetrics and Gynecology (CREOG) in-training examinations and the pass rate on the American Board of Obstetrics and Gynecology (ABOG) written examination. METHODS The USMLE step 1 and postgraduate year 1 to 4 CREOG in-training examination scores for the graduating chief residents in eight accredited obstetrics and gynecology residency programs were obtained. Performance on USMLE step 1 was correlated with ABOG examination performance and CREOG in-training examination scores. The correlations between USMLE step 1 and CREOG in-training examination scores and ABOG examination performance were analyzed by using the Spearman correlation coefficient. RESULTS USMLE step 1 scores were significantly correlated with CREOG in-training examination scores (p < 0.000). None of the residents who scored >200 on USMLE step 1 and a mean of >200 on the CREOG in-training examinations failed the ABOG written examination. CONCLUSION Program directors have used USMLE step 1 to identify trainees who are likely to perform well on the CREOG in-training examination. The CREOG in-training examination has been used to identify residents who are likely to pass the ABOG written examination. The results of this study document the strength of these associations.

A comparison of risk assessment models for term and preterm low birthweight

BACKGROUND Most epidemiological research dealing with the assessment of risk for low birthweight has focused on all low birthweight births. Studies that have attempted to distinguish between term and preterm low birthweights have tended to examine preterm low birthweight, since the risk of perinatal mortality and morbidity is greatest for this group of infants. METHOD This study uses data from 25,408 singleton births in a 20-county region in North Carolina to identify and compare risk factors for term and preterm low birthweights, and also examines the usefulness of separate multivariate risk assessment systems for term and preterm low birthweights that could be used in the clinical setting. RESULTS Risk factors that overlap as significant predictors of both types of low birthweight include race, no previous live births, smoking, weight under 100 lb, and previous preterm or low birthweight birth. Age also is a significant predictor of both types of low birthweight, but in opposite directions. Younger age is associated with reduced risk of term low birthweight and increased risk of pattern low birthweight. CONCLUSION Comparison of all risk factors indicates that different multivariate models are needed to understand the epidemiology of preterm and term low birthweights. In terms of clinical value, a general risk assessment model that combines all low birthweight births is as effective as the separate models.

Meconium-stained amniotic fluid-associated infectious morbidity : A randomized, double-blind trial of ampicillin-sulbactam prophylaxis

Objective To evaluate the efficacy of intrapartum prophylactic administration of ampicillin-sulbactam in reducing intraamniotic infection and postpartum endometritis in patients with meconium-stained amniotic fluid (AF). Methods Patients with intrapartum meconium-stained AF were randomized to receive either ampicillin-sulbactam or normal saline (placebo) intravenously at the time of diagnosis of meconium and every 6 hours until delivery. The outcomes of the two groups were compared with respect to intra-amniotic infection and postpartum endometritis. Results During the study period, 332 patients with meconium-stained AF were approached for participation, and 120 patients met inclusion criteria and were enrolled. Patient demographics, labor, and delivery characteristics were similar. Ampicillin-sulbactam reduced the incidence of intraamniotic infection from 23.3 to 6.7%, (P = .02; relative risk [RR] 0.48, 95% confidence interval [CI] 0.22–0.98). The incidence of postpartum endometritis was also reduced, but the difference was statistically nonsignificant (8.3 versus 16.7%, P = .16; RR 0.64, 95% CI 0.30–1.33). Conclusion Prophylactic intravenous ampicillin-sulbactam significantly reduces intra-amniotic infection in patients with meconium-stained AF.

Low amniotic fluid glucose levels are a specific but not a sensitive marker for subclinical intrauterine infections in patients in preterm labor with intact membranes

OBJECTIVE The purpose of this study was to evaluate the ability of a low amniotic fluid glucose level, as defined by previously published thresholds, to identify a subclinical intrauterine infection in women in preterm labor with intact membranes. STUDY DESIGN Amniotic fluid glucose levels, amniotic fluid cultures, and placental histologic characteristics were determined in women with preterm labor (n = 55) and in preterm controls (n = 58). These amniotic fluid glucose levels were compared between women with and without intrauterine infection using the Mann-Whitney U test. The sensitivity, specificity, and positive and negative predictive values for the identification of an intrauterine infection were determined with four different previously published amniotic fluid glucose threshold levels and the threshold from receiver-operator characteristic curve analysis of the study data. RESULTS The median amniotic fluid glucose level was significantly lower in patients with positive amniotic fluid cultures (intraamniotic infection group) but was not lower in the group of patients with only histologic chorioamnionitis (extra-amniotic infection group), compared with noninfected controls. The sensitivity of a low amniotic fluid glucose level to detect both types of intrauterine infection ranged from 41% to 55%, depending on the threshold used. The specificity of a low amniotic fluid glucose level to detect an intrauterine infection ranged from 94% to 100%, the positive predictive value ranged from 86% to 100%, and the negative predictive value ranged from 70% to 80% with the same thresholds. CONCLUSION Low amniotic fluid glucose levels are a specific but not a sensitive marker for either intraamniotic or extra-amniotic intrauterine infections in patients with preterm labor.