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Objective: Testing hemoglobin and hematocrit values in labor and delivery at term is a routine practice at many centers. This necessity was evaluated by comparing values obtained at 26-28 weeks versus those obtained at term., Materials: This is a prospective, observational study. All patients at least 37 weeks presenting to labor and delivery were evaluated during the study period. Enrollment criteria included having either a hemoglobin or hematocrit between 26 and 28 weeks and again on admission with term labor. Deliveries at less than 37 weeks and pregnancies complicated by multiple gestations, hemoglobinopathies, and hypertensive disorders were excluded. The World Health Organization (WHO) definition of anemia was used as well as an operationally defined threshold, below which local practitioners would change management (hemoglobin 8 g/dL, hematocrit 25%). The compliance of patients to any form of iron therapy was evaluated by questioning patients on admission., Results: One hundred and one patients met enrollment criteria. At 26-28 weeks, 20 patients were anemic by WHO criteria. On admission to labor and delivery at term, relative to 26-28-week values, hemoglobin had increased from 11.1 g/dL to 11.6 g/dL (P <.01), and hematocrit increased from 31.5-34.3% (P <.01). Eleven patients had term values that were lower than 26-28-week values. Of these, five patients met WHO criteria at 26-28 weeks. However, no value at term was below the operationally defined value., Conclusion: The frequency of anemia fell from 20% at 26-28 weeks to 11% at term. The mild anemia at term did not change local management in any patient. Thus, if the value obtained at 26-28 weeks is acceptable (non-anemic by WHO criteria), the routine testing of these values at term can be avoided, resulting in significant cost savings.

Objective: To compare wet smear and Gram stain diagnoses of bacterial vaginosis among asymptomatic pregnant women., Methods: Between November 1, 1996 and December 31, 1997, asymptomatic women who initiated prenatal care in our obstetric clinics were invited to participate. Exclusion criteria included antimicrobial use within 2 weeks, cervical cerclage, vaginal bleeding, placenta previa, spermicide use, douching, or intercourse within 8 hours. Clinical diagnosis that required two of three positive criteria for bacterial vaginosis (vaginal pH, whiff test, and clue cells on wet smear) was compared with Gram stain diagnosis (Bacterial vaginosis score 7-10 by Nugent criteria)., Results: Population characteristics (n = 69) included an average (+/- standard deviation [SD]) maternal age of 27. 3 +/- 6.6 years, 26 nulliparas (38%), 28 black women (41%), 23 white women (38%), 15 Hispanic women (22%), and three Asian women (4%). The mean (+/-SD) gestational age at entry was 15.6 +/- 7.6 weeks. Twenty-seven percent (18 of 67) of the study population was diagnosed with bacterial vaginosis by definitive Gram stain. Two slides were lost or were of poor quality and not included. Using Gram stain diagnosis of bacterial vaginosis as the standard, clinical diagnosis had sensitivity of 56% (95% confidence interval [CI] 32%, 78%), a specificity of 96% (95% CI 90%, 100%), a positive predictive value of 83%, and a negative predictive value of 85%., Conclusion: In asymptomatic pregnant women, bacterial vaginosis can be diagnosed reliably by Gram stain.

Objective: To test the hypothesis that the presence of meconium-stained amniotic fluid (AF) is associated with maternal and neonatal infection, both before and after delivery., Methods: Nine hundred thirty-six laboring women were analyzed for the presence of meconium in amniotic fluid and occurrence of peripartum infection. Meconium was assessed clinically as thin, moderate, or thick. Intra-amniotic infection and endometritis were diagnosed by standard definitions. All patients were tested for vaginal group B streptococcus, bacterial vaginosis, and other aerobic organisms., Results: Meconium-stained AF was present in 28% of the study participants (9% thin, 12% moderate, 7% thick). The presence of meconium was associated with increased intra-amniotic fluid (17% versus 9%, relative risk [RRI 1.98, 95% confidence interval [CI] 1.3, 3.1), endometritis (10% versus 5%, RR 2.38, 95% CI 1.3, 4.4), and total infection (25% versus 13%, RR 2.19, 95% CI 1.5, 3.2). Thick meconium had higher infection rates than clear AF (44% versus 13%, RR 5.18, 95% CI 2.9, 9.3). Meconium was associated independently with peripartum infection by multiple logistic regression (RR 1.28, 95% CI 1.1, 1.6)., Conclusion: Meconium-stained AF is associated with increased peripartum infection, independent of other risk factors for infection. Thick meconium, in particular, is associated with a marked increase in peripartum infectious morbidity.

Objective: To test the hypothesis that sexual behaviors predict colonization of the vagina by group B streptococcus among minority women., Methods: We conducted a prospective, descriptive study of 192 consecutive African-American (37%) and Hispanic women (63%). Each woman underwent a detailed interview concerning sexual behavior. Separate specimens were taken from the endocervix, upper vagina, lower vagina, and anorectum and placed in selective broth media for isolation of group B streptococcus. Significant behavioral predictors of vaginal group B streptococcus colonization and heavy (3-4+) colonization were identified using stepwise logistic regression., Results: The incidence of vaginal colonization was 39% and heavy colonization was 35%. Nineteen percent reported anal intercourse, 46% reported sex at least two times per week, and 21% reported more than one partner in the previous 30 days. The significant predictors of vaginal group B streptococcal infection were: African-American ethnicity, adjusted odds ratio (OR) 6.1 (95% confidence interval [CI] 2.5-15.1); presence of rectal group B streptococcus, adjusted OR 100.6 (95% CI 26.7-379.3); nulliparous, adjusted OR 3.6 (95% CI 1.4-9.5); and nonpregnant status, adjusted OR 3.9 (95% CI 1.3-12.2). The significant predictors of heavy colonization were: more than one partner in the last 30 days, adjusted OR 2.6 (95% CI 1.2-5.6); and African-American ethnicity, adjusted OR 2.3 (95% CI 1.2-4.5). Anal intercourse was associated with a reduced likelihood of vaginal group B streptococcal infection, adjusted OR 0.34 (95% CI 0.12-0.91)., Conclusion: Sexual behavior, especially anal intercourse, does not predict vaginal colonization by group B streptococcus. African-American women are more likely to have vaginal and heavy group B streptococcus colonization. Heavy vaginal colonization is associated with multiple partners in African-American women.

Objective: To determine whether continuous epidural analgesia with bupivacaine and fentanyl affects the rate of cervical dilation and myometrial contractility., Methods: In a 5-week period, 62 consecutive women who received standardized epidural analgesia were matched with the next two groups of 124 consecutive women of the same parity who did not receive epidural analgesia. The outcome variables were uterine activity, rate of cervical dilation, oxytocin therapy, and operative deliveries., Results: Continuous epidural analgesia with bupivacaine and fentanyl did not result in a change in myometrial contractility in the first hour after the initiation of analgesia. However, despite more oxytocin therapy, the rate of cervical dilation was significantly lower in the epidural group than in the nonepidural group (1.9 versus 5.6 cm/hour, P < .001). Operative deliveries were more common in patients with epidural analgesia than in those without it (12 of 62 versus two of 124, P < .001)., Conclusion: After epidural analgesia, myometrial contractility is maintained with oxytocin, but the ability of the uterus to dilate the cervix is reduced significantly.

Objective: To evaluate the efficacy and safety of ampicillin-sulbactam (3 g every 6 hours) in patients with pelvic inflammatory disease or postpartum endometritis using a randomized, comparative, multicenter study of parallel design., Methods: Eligible patients with pelvic inflammatory disease were randomized to receive either ampicillin-sulbactam or cefoxitin (2 g every 6 hours) plus doxycycline (100 mg every 12 hours). Those with endometritis were randomized to ampicillin-sulbactam or clindamycin (900 mg every 8 hours) plus gentamicin (1.5 mg/kg every 8 hours). In the ampicillin-sulbactam group, chlamydia-positive patients also received oral doxycycline., Results: For pelvic inflammatory disease, the clinical response rates (cure or improvement) were 85.5% (47 of 55) and 89.6% (43 of 48) in the ampicillin-sulbactam and cefoxitin and doxycycline groups, respectively (chi 2 = 0.10, P = .76). For endometritis, the clinical response rates were 88.7% (141 of 159) and 90.8% (139 of 153) in the ampicillin-sulbactam and clindamycin and gentamicin groups, respectively (chi 2 = 0.15, P = .70). The percentages of patients with pelvic inflammatory disease who had adverse experiences were not significantly different in the cefoxitin and doxycycline group (47% [29 of 62]) than in those receiving ampicillin-sulbactam (33% [22 of 66]) (P = .12). These adverse effects were mostly mild or moderate. In the endometritis subjects, the incidence of adverse experiences in the ampicillin-sulbactam group (11% [20 of 179]) was comparable to that during treatment with clindamycin and gentamicin (12% [22 of 180]). These adverse experiences were also mostly mild to moderate., Conclusion: Ampicillin-sulbactam is as effective and well tolerated as combination regimens using cefoxitin plus doxycycline and clindamycin plus-gentamicin for the treatment of pelvic inflammatory disease or endometritis, respectively.

Despite the use of prophylactic antibiotics, endometritis occurs in 1-31% of patients after cesarean delivery. We sought to identify predictors of prophylactic antibiotic failure. In a retrospective review of 1800 cesarean deliveries, 766 patients had either ampicillin or cefazolin prophylaxis; 240 (31.3%) developed endometritis. Stepwise logistic regression identified the number of vaginal examinations (P less than .001), nulliparity (P = .001), low gestational age (P = .033), and cefazolin use (P = .002) as predictors of endometritis. One in two women with six or more vaginal examinations before cesarean delivery will have prophylactic failure. In preterm gestations (N = 177), the number of vaginal examinations was the single predictor of prophylactic antibiotic failure (P = .002). The number of vaginal examinations can be used to design new strategies to prevent a high rate of prophylactic failure.

Perforation of surgical gloves places the obstetrician at risk for blood-borne infectious diseases. Seven hundred fifty-four surgical gloves used in vaginal and cesarean deliveries and postpartum tubal ligations were examined for evidence of perforation by the air inflation-water submersion technique. The overall glove perforation rate was 13.3%, with 62% of the perforations remaining unrecognized during the surgical procedure. The majority of perforations occurred on the fingers of the nondominant hand. Multivariate analysis with logistic regression indicated that cesarean delivery (odds ratio 3.52), any vaginal laceration or episiotomy (odds ratio 4.95), and chief resident status (odds ratio 3.00) were the major risk factors for surgical glove perforation. Surgical technique by assistants, especially in complex cases, is as important as that of the primary surgeon in regard to glove perforations.

One hundred thirty-six patients were enrolled in a randomized, double-blind, placebo-controlled trial of oral antibiotic therapy (amoxicillin) versus placebo following successful intravenous (IV) antibiotic therapy for postpartum endometritis. No subjects were readmitted to the hospital for recurrent endometritis and there were no wound infections or recurrent fevers. Minor side effects were seen in 10% of those taking amoxicillin and 14% of those taking placebo. Compliance was fair; only 52% of those taking amoxicillin and 65% of those taking placebo completed therapy. The lack of infectious complications in this high-risk population suggests that oral antibiotic therapy is unnecessary after successful IV antibiotic therapy for endometritis.

Predictors of postpartum endometritis were identified in 607 asymptomatic, laboring women. One hundred (16.5%) developed postpartum endometritis. Multivariate analysis using stepwise logistic regression identified cesarean delivery (relative risk 12.8; P less than .0001) as the dominant overall predictor. In patients with cesarean delivery (N = 124), prophylactic antibiotics (relative risk 0.54; P less than .0002) and high-virulence bacteria or Mycoplasma hominis (relative risk 1.4; P less than .01) predicted the incidence of endometritis, and in patients with vaginal delivery (N = 483), "bacterial vaginosis organisms" (relative risk 14.2; P less than .001) and aerobic gram-negative rods (relative risk 4.2; P less than .01) predicted endometritis. Despite significant associations found on univariate analysis, clinical variables such as duration of labor, rupture of membranes, and internal monitoring were not predictive of endometritis in the multivariate analysis. Our findings show that cesarean delivery and certain organisms, such as bacterial vaginosis or high-virulence organisms, predict endometritis, and that clinical variables may be facilitators rather than predictors of endometritis.

A pregnancy after an orthotopic liver transplantation was associated with abruptio placentae and preterm delivery at 27.5 weeks. The mother's immediate postpartum period was complicated by a midgut volvulus through a mesenteric defect in the Roux-en-Y loop. Both mother and infant survived after prolonged hospitalization.

The effect of mode of delivery on the mortality and morbidity of 26- to 32-week neonates was studied. Five hundred six consecutive deliveries at 26 to 32 weeks' gestation were reviewed. The populations were divided into high-risk and low-risk neonates by evaluation of antepartum variables known to increase neonatal risk, ie, abruptio placenta. One hundred ninety-six infants were classified as low risk. In this group, 124 vaginal and 72 cesarean section deliveries were compared using demographic, peripartum, and neonatal variables. Cesarean delivery was associated with highly significant maternal morbidity, including a 30% incidence of vertical uterine incision. No difference in neonatal mortality was shown. Cesarean delivery was associated with lower one-minute Apgar scores and a greater incidence and severity of hyaline membrane disease. No neonatal differences were shown in the incidence of trauma, intraventricular hemorrhage, or seizures. This study does not support cesarean delivery of all tiny neonates.

Because subclinical genital tract infection may play a major role in preterm birth, the efficacy of adjunctive antibiotic therapy in combination with standard parenteral tocolysis was examined in a randomized, blinded study of patients with idiopathic preterm labor. Labor was documented by three contractions in 20 minutes, cervical dilation of 1 cm or more, and the need for parenteral tocolysis. Enrollment was restricted to patients with intact membranes and without known causes for preterm labor. One hundred three patients at 24-34 weeks' gestation were randomized to intravenous ampicillin plus oral erythromycin or corresponding placebos. Compared with the placebo group, the adjunctive antibiotic group had a similar frequency of preterm birth (38 versus 44%), time to delivery (34 versus 34 days), birth weight (2847 versus 2855 g), and episodes of recurrent labor requiring parenteral tocolysis (0.43 versus 0.49). In our population, we found no benefit to the adjunctive use of ampicillin plus erythromycin. Significant differences in genital microflora between our patients and those of other studies may explain our results.

A randomized trial of intrapartum versus postpartum antibiotic treatment of women with intra-amniotic infection was conducted. Intra-amniotic infection was treated with ampicillin and gentamicin during labor (at the time of diagnosis) in 26 women and immediately after umbilical cord clamping in 19 women. Intrapartum treatment led to a lower incidence of neonatal sepsis (0 versus 21%; P = .03) and a shorter neonatal hospital stay (3.8 versus 5.7 days; P = .02) when compared with postpartum treatment. There were no significant differences in the microbiologic results, the gestational age, or the birth weight between the groups. Intrapartum-treated mothers had a shorter mean postpartum stay, a lower mean number of febrile days, and a lower mean peak postpartum temperature than did postpartum-treated mothers; these differences were all statistically significant (P = .05). The treatment of clinical intra-amniotic infection during labor results in improved outcome.

A case of congenital neuroblastoma is presented. The interesting features are maternal symptomatology consistent with fetal production of catecholamines and the dilemmas of differential diagnosis. Observations are made on the frequency and diagnosis of fetal neoplasia. Antepartum detection of catecholamine metabolites may be the basis for the diagnosis of fetal neuroblastoma.

The identification of risk factors for intra-amniotic infection may allow changes in obstetric management and reduce complications. In a pilot study, stepwise logistic regression identified duration of ruptured membranes and duration of interval monitoring as significant risk factors for intra-amniotic infection. Using the preliminary regression equation, we established critical durations (risk criteria) to predict a 20% or greater probability of intra-amniotic infection. Subsequently, 2908 patients were screened prospectively for risk criteria and/or the presence of intra-amniotic infection. Seven hundred five patients of the 2908 (24%) met the risk criteria, and 107 of 124 cases of intra-amniotic infection (86%) met the risk criteria. In patients meeting the risk criteria, the relative risk of intra-amniotic infection was 19.7. In addition, 81 of 705 (12%) of mothers developed endometritis. Ten neonates of mothers with criteria developed sepsis or pneumonia. A stepwise logistic regression performed on the prospectively gathered data showed that among patients meeting risk criteria, parity, duration of internal monitoring, and duration of membrane rupture were the significant risk factors for intra-amniotic infection.

The effect of cervical group B streptococcus on the conservative management of preterm premature rupture of membranes was examined in 140 consecutive patients. Upon the patient's admission, we obtained cervical cultures for group B streptococcus, genital mycoplasmas, and chlamydia. Patients with and without group B streptococcus were compared. Group B streptococcus patients had earlier rupture of membranes (30.7 versus 31.6 weeks) and shorter latent periods (76.8 versus 138.5 hours). Intra-amniotic infection (six of 16 versus 26 of 120) and endometritis (four of ten versus three of 94) were significantly more common in group B streptococcus patients. Neonates of mothers positive for group B streptococcus were smaller (1749 +/- 844 versus 2100 +/- 779 g) and more likely to have infectious complications (eight of 16 versus 29 of 120; P less than .01). Control for the presence of mycoplasmas, chlamydia, listeria, or gonorrhea failed to change the significance of these results. The usual policy was to use intrapartum ampicillin prophylaxis in asymptomatic group B streptococcus patients. However, only four of 16 remained asymptomatic and had latent periods long enough for the results of cultures obtained on admission to be available. We conclude that group B streptococcus significantly complicates the conservative management of preterm premature rupture of membranes and that the effectiveness of intrapartum prophylactic ampicillin may be compromised by awaiting the results of conventional cultures to define colonized patients.