Mahmoud A. Ismail

Blood protein profiles of infants born before 28 weeks differ by pregnancy complication

OBJECTIVE Disorders that lead to preterm delivery influence the fetal inflammatory response. STUDY DESIGN We calculated odds ratios of elevated concentrations of 25 blood proteins on the first postnatal day in 798 infants born before the 28th week and classified by the pregnancy disorder that lead to preterm delivery. RESULTS Concentrations of cytokines (IL-1β, IL-6, TNFα), cytokine receptors (IL-6R, TNF-R1, TNF-R2), systemic inflammatory proteins (CRP, SAA, MPO), chemokines (IL-8, MCP-1, MCP-4, MIP-1β, RANTES, I-TAC), adhesion molecules (ICAM-1, ICAM-3, VCAM-1, E-selectin), and metalloproteinases (MMP-1, MMP-9) were elevated in children delivered after preterm labor, membrane rupture, abruption, and cervical insufficiency, whereas such a pattern was not seen after preeclampsia or fetal indication/growth restriction. Inflammatory profiles were also associated with maternal vaginitis. CONCLUSION The patterns of blood proteins in the newborn support the division of pregnancy disorders that lead to preterm delivery into those associated, and those not associated, with inflammation.

The significance of C-reactive protein levels in women with premature rupture of membranes☆☆☆

In a prospective study of 100 patients with preterm premature rupture of membranes, clinical chorioamnionitis was present in 18 and histologic chorioamnionitis was present in 63. Patients who were managed conservatively for premature rupture of membranes were monitored by C-reactive protein determination, white blood cell and differential counts, maternal temperature, and fetal heart tone. C-reactive protein was measured nephelometrically (Immuno-chemistry Analyzer II, Beckman). Elevated C-reactive protein levels correlated well with both the pathologic and the clinical diagnosis of chorioamnionitis. Elevated C-reactive protein levels (at least 12 to 24 hours before delivery) were more sensitive than other standard laboratory or clinical tests in predicting chorioamnionitis both by clinical and pathologic criteria. When C-reactive protein values were normal, clinical chorioamnionitis was rarely found, whereas pathologically diagnosed chorioamnionitis was found half of the time. We conclude that although the C-reactive protein level is a very sensitive predictor of infectious morbidity in premature rupture of membranes, its specificity is not high.

Clostridium difficile-associated diarrhea follows perioperative prophylaxis with cefoxitin

Clostridium difficile-associated diarrhea during prolonged therapy of obstetric and gynecologic infections is known to occur with use of all classes of antibiotics except vancomycin and the aminoglycosides. We present 11 cases of C. difficile-associated diarrhea which followed a short course of perioperative prophylaxis with cefoxitin during a 1-year period. Nine of the cases of C. difficile-associated diarrhea were among 162 women who received cefoxitin perioperative prophylaxis for cesarean section or hysterectomy, but none occurred in 85 women who received one of four other antibiotics for perioperative prophylaxis (p = 0.024, Fishers exact test). The two other occurrences of C. difficile-associated diarrhea following perioperative prophylaxis with cefoxitin were in women who underwent exploratory laparotomy. We conclude that C. difficile-associated diarrhea is related to perioperative prophylaxis with cefoxitin.

West Nile virus encephalitis during pregnancy

BACKGROUND West Nile virus is an emerging pathogen in the United States. Although most cases are subclinical, serious infection can occur in the form of fulminant meningoencephalitis. CASE We present a case of West Nile virus meningoencephalitis complicating pregnancy. The patient presented in the second trimester with fever, nuchal rigidity, and mental status changes. The diagnosis was made by demonstrating the presence of immunoglobulin M antibody to West Nile virus in the cerebrospinal fluid. Gradual clinical improvement was noted after several days of supportive care. No obvious fetal consequences of infection were noted after birth. CONCLUSION Obstetricians and health care providers need to be mindful of West Nile virus infection in pregnant women presenting with fever and neurological signs, particularly in endemic areas.

Immunoglobulins in prolonged ruptured membranes

Concentrations of immunoglobulins G, M, and A were studied in maternal and cord serum of patients with prolonged premature rupture of membranes, as well as in properly matched control patients. None of the patients studied showed any evidence of clinical chorioamnionitis or other prenatal infections. Cases were divided into term premature rupture of membranes and term controls and preterm (less than 34 gestational weeks) premature rupture of membranes and preterm controls. In the term group, with 12 to 24 hours of premature rupture of membranes, maternal immunoglobulins M and A, and cord immunoglobulin A were significantly increased. With a duration of premature rupture of membranes of more than 24 hours, levels of immunoglobulins M and A in maternal serum and levels of immunoglobulins G and A in cord serum showed significant elevations. Levels of cord immunoglobulin M from both subgroups of patients with premature rupture of membranes showed a trend upward but were not significantly higher than those in control patients. In the preterm group, with 12 to 24 hours of premature rupture of membranes, only cord immunoglobulin A was significantly increased. With premature rupture of membranes of greater than or equal to 72 hours, only maternal immunoglobulin G increased significantly and remained elevated; immunoglobulins M and A in cord serum were also significantly increased. The significant rise in immunoglobulins in patients with premature rupture of membranes may indicate subclinical maternal and fetal infection. This suggests the possibility that subclinical infections may play a role in the etiology of premature rupture of membranes.