Mark A. Turrentine

Use of Thrombolytics for the Treatment of Thromboembolic Disease During Pregnancy

The incidence of thromboembolic disease is increased during pregnancy. Prevention and treatment of thromboembolic disease can have a significant impact on the morbidity and mortality of pregnant women. Anticoagulation with heparin is the treatment of choice; however, in some instances this is inadequate or contraindicated. In the nonpregnant patient, alternative therapies have included surgical intervention or fibrinolytic agents. Traditionally, thrombolytic therapy has been considered a relative contraindication during pregnancy due to the maternal and fetal risk of hemorrhagic complications. Hence, no controlled trials of agents such as streptokinase, urokinase, or tissue plasminogen activator for the treatment of thromboembolic events during pregnancy, have been performed, or are currently feasible. Since 1961, 36 reports have been published describing the use of thrombolytic agents during pregnancy. In a review of the worlds literature, 172 pregnant women affected with thromboembolic conditions were treated with thrombolytic medications. A maternal mortality rate of 1.2 percent was observed. Approximately 10 pregnancy losses were noted (5.8 percent). Hemorrhagic complications were reported in 8.1 percent of patients. We summarize the published literature on the use of thrombolytic agents during pregnancy and discuss the treatment success and reported complications.

Recurrence of group B streptococci colonization in subsequent pregnancy.

OBJECTIVE: To estimate the prevalence of group B streptococci (GBS) colonization in a subsequent pregnancy in women with and without GBS colonization in an index pregnancy. METHODS: A retrospective cohort study of women who had two consecutive deliveries with the availability of GBS culture result at 35 to 37 weeks of gestation or the diagnosis of GBS colonization by urine culture for both pregnancies was undertaken. Women in the index pregnancy with GBS genitourinary tract colonization were compared by culture date with the next woman that screened negative for GBS colonization. To detect a doubling of GBS colonization from 20% to 40% would require 91 women in each arm at P<.05 with a power of 80%. Risk factors for GBS colonization were ascertained. Univariable and conditional logistic regression analyses were performed. P<.05 was considered statistically significant. RESULTS: A total of 102 women positive for GBS genitourinary colonization were compared with controls. The rate of recurrence for GBS colonization (53%) was significantly higher when judged against women GBS negative in their index pregnancy (15%) (adjusted odds ratio 11.7, 95% confidence interval 3.5–38.9, P<.01). Women who were GBS positive in the index pregnancy were more often of African-American race and less likely to be nulliparous or smoke tobacco. CONCLUSION: Women with GBS colonization are at increased risk of GBS colonization in a subsequent pregnancy. Prior GBS colonization should be considered in the algorithm to treat unknown GBS status during term labor. LEVEL OF EVIDENCE: II

Duration of Intrapartum Antibiotics for Group B Streptococcus on the Diagnosis of Clinical Neonatal Sepsis

Background. Infants born to mothers who are colonized with group B streptococcus (GBS) but received <4 hours of intrapartum antibiotic prophylaxis (IAP) are at-risk for presenting later with sepsis. We assessed if <4 hours of maternal IAP for GBS are associated with an increased incidence of clinical neonatal sepsis. Materials and Methods. A retrospective cohort study of women-infant dyads undergoing IAP for GBS at ≥37-week gestation who presented in labor from January 1, 2003 through December 31, 2007 was performed. Infants diagnosed with clinical sepsis by the duration of maternal IAP received (< or ≥4-hours duration) were determined. Results. More infants whose mothers received <4 hours of IAP were diagnosed with clinical sepsis, 13 of 1,149 (1.1%) versus 15 of 3,633 (0.4%), P = .03. Multivariate logistic regression analysis showed that treatment with ≥4 hours of IAP reduced the risk of infants being diagnosed with clinical sepsis by 65%, adjusted relative risk 0.35, CI 0.16–0.79, and P = .01. Conclusion. The rate of neonatal clinical sepsis is increased in newborns of GBS colonized mothers who receive <4 hours compared to ≥4 hours of IAP.

Screening for Group B Streptococcus: A Private Hospital's Experience

Objective. To assess the effect of universal screening and administration of intrapartum antibiotic prophylaxis to prevent early-onset neonatal GBS sepsis at a private tertiary care hospital since issuance of the 2002 CDC guidelines for preventing perinatal GBS disease. Methods. Retrospective analysis of women delivering between January 1, 2003 and December 31, 2004 at a private tertiary care hospital in Houston, Texas. The percentage of women screened, GBS positive women receiving intrapartum antibiotic prophylaxis, and infants developing early-onset GBS sepsis were determined. Results. 2,108 women delivered 2,135 infants with 1,874 (89%) screened for GBS. Of those screened, 1,322 (71%) tested negative and 552 (29%) tested positive for GBS. In this analysis of 2,135 infants, 3 (0.94 cases/1,000 live births) were diagnosed with invasive GBS sepsis. Conclusion. High rates of screening of pregnant women for GBS colonization and use of intrapartum antibiotic prophylaxis for GBS carriers can be achieved in a private tertiary care hospital setting. “Synopsis: High screening rates for group B streptococcus in a private tertiary care hospital reduce the incidence of maternal and early onset neonatal GBS infection.”

Single-dose fluconazole for vulvovaginal candidiasis : Impact on prothrombin time in women taking warfarin

OBJECTIVE: To estimate the effect of a single oral 150-mg dose of fluconazole on the prothrombin time of women on long-term warfarin therapy. METHODS: Women on warfarin therapy for 6 months or more with no change in dose within 4 weeks of the study, and a prothrombin time (PT) with an International Normalized Ratio (INR) between 2 and 3 were invited to participate. Two consecutive baseline PTs were obtained (days –1 and 0), and women were given 150 mg of fluconazole. Prothrombin times were measured on days 2, 5, and 8 of the study. The change in PT was calculated from the difference between the baseline PT on day 0 and the PT during the study period. To detect a 10% difference in a PT (approximately 2.1 seconds) of a patient with an INR of 2.0, at P < .05 and a power of 90%, 5 subjects are required. RESULTS: Six women participated. The mean (± standard deviation) PT for day 0 was 27.7 ± 4.1 seconds or INR 2.6 ± 0.4. The PT increased 11% at day 2, 34% at day 5, and 2% at day 8; these differences were not statistically significant. However, one half of the women had either a clinically relevant increase of the INR greater than 4, or bleeding that required their dosage of warfarin to be decreased. CONCLUSION: A single 150-mg oral dose of fluconazole may increase the PT to a clinically relevant level in a woman on chronic warfarin therapy. Clinicians should monitor the PT carefully after a single dose of fluconazole. LEVEL OF EVIDENCE: II-2

Intrapartum antibiotic prophylaxis for Group B Streptococcus: has the time come to wait more than 4 hours?

Despite progress in preventing infant group B streptococcal disease, group B streptococcus remains the leading cause of early-onset neonatal sepsis in the United States. Fortunately, most women who are colonized with group B streptococcus receive therapy and antibiotic prophylaxis is effective. However, the only factor associated with missed chemoprophylaxis is the short duration of time between hospital admission and delivery. Although antibiotic prophylaxis given for at least 2 hours shows some pharmacological benefit, the most effective method of preventing early-onset group B streptococcus disease is 4 hours of therapy. Intrapartum management strategies might be modified to improve the efficacy of antibiotic exposure. Obstetricians should consider strengthening the beneficial effect of intrapartum antibiotic prophylaxis for infants exposed to group B streptococcus by providing at least 4 hours of treatment coverage.

Cost-Effectiveness of Universal Prophylaxis in Pregnancy with Prior Group B Streptococci Colonization

Objective. To estimate the costs and outcomes of rescreening for group B streptococci (GBS) compared to universal treatment of term women with history of GBS colonization in a previous pregnancy. Study Design. A decision analysis model was used to compare costs and outcomes. Total cost included the costs of screening, intrapartum antibiotic prophylaxis (IAP), treatment for maternal anaphylaxis and death, evaluation of well infants whose mothers received IAP, and total costs for treatment of term neonatal early onset GBS sepsis. Results. When compared to screening and treating, universal treatment results in more women treated per GBS case prevented (155 versus 67) and prevents more cases of early onset GBS (1732 versus 1700) and neonatal deaths (52 versus 51) at a lower cost per case prevented (

Randomized prospective study comparing erythromycin, amoxicillin, and clindamycin for the treatment of chlamydia trachomatis in pregnancy.

8 805 versus

Use of the cervical cerclage: comparison of a community and university hospital setting.

12 710). Conclusion. Universal treatment of term pregnancies with a history of previous GBS colonization is more cost-effective than the strategy of screening and treating based on positive culture results.

Influenza Vaccination among Pregnant Women: Patient Beliefs and Medical Provider Practices

Objective: The purpose of this study was to compare the efficacy and side effects of erythromycin, amoxicillin, and clindamycin in eradicating Chlamydia trachomatis from the lower genital tract of pregnant women. Methods: A total of 174 women at <36 weeks gestation with positive cervical cultures for C. trachomatis were enrolled. Patients were assigned in a randomized prospective fashion to either erythromycin (500 mg q.i.d, for 7 days), amoxicillin (500 mg t.i.d, for 7 days), or clindamycin (600 mg t.i.d, for 10 days). Six women elected not to participate and 8 patients were lost to follow-up, leaving 53 patients in the erythromycin group, 55 patients in the amoxicillin group, and 52 patients in the clindamycin group. All sexual partners of the enrolled women were offered doxycycline (100 mg b.i.d. for 7 days) and patients were instructed to use barrier contraception until treatment was complete. Results: All 3 medications were effective agents for the treatment of antenatal C. trachomatis infection with treatment efficacies of 96%, 94%, and 98% for the erythromycin, amoxicillin, and clindamycin groups, respectively. When the antibiotic groups were compared, no statistically significant differences were noted in intolerance. However, the differences in the incidence of gastrointestinal symptoms between erythromycin and amoxicillin and/or clindamycin were significant (P < 0.05). Conclusions: These findings suggest that 1) all 3 antibiotic regimens are efficacious, 2) erythromycin has a higher incidence of side effects, and 3) amoxicillin or clindamycin are reasonable alternatives for the treatment of C. trachomatis in pregnant patients unable to tolerate erythromycin.