Salih Yasin

Influence of human immunodeficiency virus infection on pelvic inflammatory disease.

Objective To examine the influence of human immunodeficiency virus (HIV) infection on clinical and microbiologic characteristics of pelvic inflammatory disease (PID). Methods Forty-four HIV-infected women and 163 HIV noninfected women diagnosed with PID by standard case definition were evaluated by using clinical severity scores, transabdominal sonograms, and endometrial biopsies. After testing for bacterial infections, patients were prescribed antibiotics as recommended by the Centers for Disease Control and Prevention (CDC). Results Symptoms of PID and analgesic use before enrollment did not differ by HIV serostatus. More HIV-infected women had received antibiotics before enrollment (40.9% versus 27.2%, P = .08), a factor associated with milder signs regardless of serostatus. More HIV-infected women had sonographically diagnosed adnexal masses at enrollment (45.8% versus 27.1%, P = .08), a difference that yielded higher median severity scores (17.5 of 42 points versus 15 of 42 points, P = .07). However, those differences were not significant at the P < .05 level. Mycoplasma (50% versus 22%, P < .05) and streptococcus species (34% versus 17%, P < .05) were isolated more commonly from biopsies of HIV-infected women. Within 30 days after enrollment, HIV-infected women generally responded as well to therapy as HIV-noninfected women did, regardless of initial CD4 T-lymphocyte percentage. Conclusion Among women with acute PID, HIV infection was associated with more sonographically diagnosed adnexal masses. Clinical response to CDC-recommended antibiotics did not differ appreciably by serostatus. Mycoplasmas and streptococci were isolated more commonly from HIV-infected women, but those organisms also might be associated with PID in immunocompetent women.

Pharmacokinetics and Safety of Stavudine in HIV-Infected Pregnant Women and Their Infants: Pediatric AIDS Clinical Trials Group Protocol 332

This study evaluates the safety, tolerance, and pharmacokinetics of stavudine (d4T) in human immunodeficiency virus (HIV)-infected zidovudine (ZDV)-intolerant/refusing pregnant women and of single-dose d4T in their infants. Women received d4T and lamivudine (3TC) from enrollment until labor. During labor, women received oral 3TC and either intravenous or oral d4T. Infants received ZDV and 3TC for 6 weeks and a single dose of oral d4T at weeks 1 and 6. Mean maternal antenatal d4T pharmacokinetics (terminal plasma half-life [T1/2], 83.5+/-16.8 min; area under the plasma-concentration time curve [AUC0-infinity), 81.6+/-22.0 microg.min/mL; n=6) were not significantly different from those during labor (T(1/2), 87.3+/-24.7 min; AUC0-infinity, 88.1+/-16.6 microg.min/mL; n=6). Umbilical-cord and maternal plasma concentrations were not significantly different from one another. The oral clearance of d4T in infants was significantly greater at week 6 versus week 1 (6.8+/-1.0 vs. 5.6+/-1.2 mL/min/kg). There were no toxicities, in women or infants, that required discontinuation or modification of the study drug. No infants had positive HIV viral diagnostic tests. d4T with or without 3TC is a potential alternative to ZDV for HIV-infected pregnant women.

Prenatal care in cocaine-exposed pregnancies

Objective To examine the effect of prenatal care with and without drug rehabilitation on perinatal outcome in cocaine-using women. Methods Cocaine-exposed pregnancies of 905 human immunodeficiency virus (HIV)-negative women were frequency matched (ratio 6:1) and compared with 150 nonusers. Cocaine subgroups consisted of 278 women who received prenatal care and drug rehabilitation (“comprehensive care”), 206 women who received prenatal care only, and 421 who received neither. Maternal and fetal complications, drug screening, and attendance were recorded. Pregnancy rates and HIV seroconversion were determined over the year following delivery. Results The groups were similar in age, race, education and poverty level. Linear trends of increasing incidence of maternal complications were seen across the four groups. Comparing nonusers with cocaine users, the odds ratios, with 95% confidence intervals were: 28.0 (4.2, 103.2) for both anemia and weight under 100 lb; 2.4 (1.8, 5.0) for urinary tract infections; 15 (4.6, 36.1) for syphilis; and 11.2 (4.0, 35.8) for other sexually transmitted diseases. Perinatal outcome measures were similar for nonusers and “comprehensive care” groups but significantly worse for the other two groups. Four maternal deaths and two myocardial infarctions occurred with no care. Positive toxicology at delivery was 1.5 and 4.3 times more likely for the two groups without drug treatment, than for “comprehensive care.” Congenital anomalies and HIV seroconversion increased in cocaine users. Repeat pregnancy was less likely and more often drug free with “comprehensive care.” Conclusion “Comprehensive care” of the cocaine-using gravida increases the likelihood of carrying to term, having fewer complications, being drug free at delivery, and having fewer exposed repeat pregnancies.

Use of adenosine for pharmacological cardioversion of SVT in pregnancy.

Objective: To evaluate the success and safety of adenosine use in treating maternal supraventricular tachycardia (SVT) in pregnancy.Methods: Hemodynamically stable pregnant women diagnosed with supraventricular tachycardia admitted to Jackson Memorial hospital from 1990 to 1995 and treated with adenosine were included in the study. Adenosine was given intravenously with an initial dose of 6 mg, followed by two 12 mg doses as needed. Mothers and fetuses were followed prospectively to assess short-term and long-term effects of the treatment.Results: A total of four pregnant patients were treated with adenosine for medical cardioversion of SVT. All patients were hemodynamically stable upon arrival to the maternity ward and were successfully treated with adenosine. Both mothers and fetuses were monitored during treatment. Adenosine successfully converted the SVT to sinus rhythm, in all four patients. One patient was treated successfully twice, at 15 weeks and subsequently at 24 weeks. No complications occurred to either the mothers or the fetuses during the treatment. Five and ten minute APGAR scores at birth were greater than seven. Mothers and babies were followed from 1 month to 5 years after treatment and no contributory deleterious effects have been found. One patient was lost to follow-up.Conclusion: Our four patient cases, added to the limited published cases in the literature, support adenosines safety and efficacy for the medical treatment of supraventricular tachycardia in the hemodynamically stable pregnant woman.

Conservative management of a 20-week cervical ectopic pregnancy with placenta percreta

Cervical pregnancy is a rare form of ectopic pregnancy representing less than 1 % of all ectopic pregnancies. The implantation occurs in the cervical stroma below the level of the internal os. Failure to diagnose early, with continued progression of cervical ectopic pregnancy is associated with unpredictable occurrence of uncontrollable hemorrhage [1]. Early diagnosis is essential as it allows treatment with minimal intervention and reduction in overall morbidity and mortality. Different approaches have been described for conservative management of cervical ectopic pregnancy aimed at preserving future fertility. These include systemic or local methotrexate injection with intra-amniotic needle aspiration of fluid, local potassium chloride injection, dilatation and curettage, amputation of the cervix or partial trachelectomy [2]. Interventions employed in conservative management to decrease hemorrhage are intra-cervical tamponade with a Foley catheter, angiographic uterine artery occlusion, internal iliac artery ligation and cervical cerclage. However, there is still the potential for conservative management to fail and result in severe hemorrhage warranting surgical management such as definitive hysterectomy. Due to the rarity of cervical ectopic pregnancies and advanced cervical ectopic pregnancies historically being managed surgically, there is a lack of information in the literature on conservative management of advanced cervical ectopic pregnancies. At our institution, we successfully managed conservatively a second trimester cervical ectopic pregnancy at 15 weeks gestation [3]. We describe in this case report our experience on conservative management of a cervical ectopic pregnancy at 20 weeks gestation. To the best of our knowledge, this is the first case of a 20-week cervical ectopic pregnancy successfully managed conservatively followed by a subsequent live term uncomplicated delivery.

Exit Procedure for Fetal Mediastinal Teratoma with Large Pericardial Effusion: A Case Report with Review of Literature

Abstract Background: Large mediastinal teratomas in the fetus are rare and can present with direct compression of intrathoracic structures as well as pericardial and pleural effusions. Mediastinal fetal teratoma may be detected as a mass in the chest during a routine prenatal ultrasound. Because of the pressure on mediastinal structures it may result in non-immune fetal hydrops (NIFH) and polyhydramnios. The development of hydrops may lead to fetal demise. Timely obstetric and/or surgical intervention is important to improve survival in this patient population. Case review: We report a case of a large mediastinal teratoma in a fetus who presented with a large pericardial effusion at 28 weeks gestation. The fetus developed NIFH at 31 weeks gestation. The fetus was successfully managed with an ex utero intrapartum therapy (EXIT) procedure which involved pericardiocentesis and surgical resection of the large teratoma. Histological examination revealed an encapsulated immature teratoma. Discussion: Mediastinal teratomas are usually detected by routine second- and third-trimester ultrasound. Large teratomas have been described to present with airway compromise and NIFH. Some cases have been managed by postnatal surgery and rare cases by EXIT procedure. Conclusions: This is the first reported case of a fetal mediastinal teratoma and severe pericardial effusion who developed NIFH, in whom EXIT procedure was successfully employed to simultaneously drain the effusion and resect the tumor.

Predictive Value of Amniotic Fluid Gram Stain in Postcesarean Endomyometritis

The objective of this prospective study was to determine the value of the amniotic fluid Gram stain in identifying patients at high risk for postcesarean endomyometritis. Intraoperative samples of amniotic fluid were obtained from 151 patients undergoing nonelective cesarean section. Gram stains were performed and analyzed for the presence of bacteria and white blood cells (WBCs). Endomyometritis occurred in 55/151 (36%) of patients. Positive Gram stain, defined as the presence of any bacteria in any high power field, occurred in 29/55 (53%) of patients with endomyometritis as compared to 4/96 (4.2%) of patients without endomyometritis (P < 0.001). The amniotic fluid Gram stain showed a sensitivity of 53%, specificity of 96%, a negative predictive value of 78%, and a positive predictive value of endomyometritis of 88%, which was higher than other clinical determinants evaluated. A positive test can therefore be used in clinical management by starting antibiotic treatment at the time of cesarean delivery. ...