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Objective: This study aimed to determine the accuracy and feasibility of self-sampling in patients suspected of having recurrent vulvovaginal candidosis (RVC)., Materials and Methods: Of 441 patients with symptoms suggestive of RVC presenting during an 8-year period (January 2000 to December 2007) at a dermatology clinic, 277 were instructed to perform weekly vaginal self-sampling for a period of up to 8 weeks. Demographic charactervistics, medical history, physical examination, culture results, and therapeutic efficacy were analyzed with Fisher exact, χ test, or Student t test., Results: When only considering the results of the culture taken at consultation, 17.1% (20/117) of RVC cases could be confirmed. Positive cultures from self-sampling confirmed another 97 cases of RVC (82.9%). The sensitivity of a single Candida culture ranged from 18% to 53%, depending on the cutoff level of growth intensity of the yeast recovered. Specificity ranged from 97% to 100%, and the positive predictive value ranged from 92% to 100%. The number of positive cultures obtained was not associated with the duration of earlier vaginal complaints or with the efficacy of prophylactic treatment. Prophylactic treatment was equally effective in patients taking fluconazole once (8/13, 61.5%) or twice (48/74, 64.9%) a month, but treatment regimes were not randomized., Conclusions: The diagnosis of RVC can be improved dramatically by self-sampling, enabling a sooner start of adequate treatment. Multiple positive cultures were not associated with disease of longer duration or more severe disease and did not influence the response to prophylactic treatment.

Urogenital diseases, especially infection and cancer, are major causes of death and morbidity in females. Yet, millions of women in the developing world have no access to basic urogynecological care, and the diagnosis and treatment of widespread aberrant bacterial conditions (bacterial vaginosis [BV] and aerobic vaginitis [AV]) remain suboptimal the world over. Samples from women living in resource-disadvantaged and developed countries have been analyzed by high-throughput sequencing to reveal the diversity of bacteria in the vagina, how rapidly the bacterial population fluctuates over time, and how rapidly the switch occurs between healthy and aberrant conditions. Unfortunately, clinical diagnostic methods are inefficient and too often outdated therapies are administered. The net result is suboptimal care and recurrent disease that adversely affects the quality of life. This viewpoint outlines a scientific and translational road map designed to improve the cervicovaginal health and treatment of disease. This comprises (1) improving education of women and physicians on the vaginal microbiota; (2) having agencies target funding for research to improve diagnosis and test new therapies; and (3) making sure that new approaches are accessible in developing countries, empowering to women, and are acceptable and appropriate for different populations.

Bacterial vaginosis (BV) is a common vaginal disorder characterized by an alteration of the vaginal bacterial morphotypes, associated with sexually transmitted infections and adverse pregnancy outcomes. The purpose of the present study was to evaluate the impact of different doses of rifaximin vaginal tablets (100 mg/day for 5 days, 25 mg/day for 5 days, and 100 mg/day for 2 days) on the vaginal microbiota of 102 European patients with BV enrolled in a multicenter, double-blind, randomized, placebo-controlled study. An integrated molecular approach based on quantitative PCR (qPCR) and PCR-denaturing gradient gel electrophoresis (PCR-DGGE) was used to investigate the effects of vaginal tablets containing the antibiotic. An increase in members of the genus Lactobacillus and a decrease in the BV-related bacterial groups after the antibiotic treatment were demonstrated by qPCR. PCR-DGGE profiles confirmed the capability of rifaximin to modulate the composition of the vaginal microbial communities and to reduce their complexity. This molecular analysis supported the clinical observation that rifaximin at 25 mg/day for 5 days represents an effective treatment to be used in future pivotal studies for the treatment of BV.

Aims: To investigate if vaginal application of dequalinium chloride (DQC, Fluomizin®) is as effective as vaginal clindamycin (CLM) in the treatment of bacterial vaginosis (BV)., Methods: This was a multinational, multicenter, single-blind, randomized trial in 15 centers, including 321 women. They were randomized to either vaginal DQC tablets or vaginal CLM cream. Follow-up visits were 1 week and 1 month after treatment. Clinical cure based on Amsel's criteria was the primary outcome. Secondary outcomes were rate of treatment failures and recurrences, incidence of post-treatment vulvovaginal candidosis (VVC), lactobacillary grade (LBG), total symptom score (TSC), and safety., Results: Cure rates with DQC (C1: 81.5%, C2: 79.5%) were as high as with CLM (C1: 78.4%, C2: 77.6%). Thus, the treatment with DQC had equal efficacy as CLM cream. A trend to less common post-treatment VVC in the DQC-treated women was observed (DQC: 2.5%, CLM: 7.7%; p = 0.06). Both treatments were well tolerated with no serious adverse events occurring., Conclusion: Vaginal DQC has been shown to be equally effective as CLM cream, to be well tolerated with no systemic safety concerns, and is therefore a valid alternative therapy for women with BV [ClinicalTrials.gov, Med380104, NCT01125410]., (Copyright © 2011 S. Karger AG, Basel.)

To maintain a healthy vaginal ecosystem or to restore any disturbance, sufficient estrogen levels, an intact mature vaginal epithelium, and physiological lactobacillary microflora are essential. Thus, a combination of beneficial lactobacilli and estrogen is an appealing treatment option. This article reviews the published data on the use of viable Lactobacillus acidophilus KS400 and a low dose of estriol (0.03 mg E3) in the form of vaginal tablets (Gynoflor®). In vitro studies demonstrated that L. acidophilus KS400 produces lactic acid and hydrogen peroxide (H2O2), inhibits the growth of relevant vaginal pathogens, and inhibits adherence of pathogens to epithelial cells. Topical administration of E3 for treatment of vaginal diseases is generally preferred, as this route of application of hormones produces a more significant local proliferative response and has no stimulating effect on the endometrium. Overall, 16 clinical studies have been published with the combination of L. acidophilus KS400 and 0.03 mg E3. The results of these trials have demonstrated that the combination improves the vaginal epithelium and the restoration of the lactobacillary microflora with an excellent safety profile, even during pregnancy. The combination can be used in pre- and postmenopausal women for the restoration of the vaginal flora after anti-infective therapy, for treatment of symptomatic vaginal atrophy, and for abnormal vaginal flora therapy. It can be also considered in repetitive therapy courses for the long-term prevention of recurrences of bacterial vaginosis, even though further clinical studies are needed to substantiate the benefit of this application.

Aerobic vaginitis (AV) is an alteration in vaginal bacterial flora that differs from bacterial vaginosis (BV). AV is characterised by an abnormal vaginal microflora accompanied by an increased localised inflammatory reaction and immune response, as opposed to the suppressed immune response that is characteristic of BV. Given the increased local production of interleukin (IL)-1, IL-6 and IL-8 associated with AV during pregnancy, not surprisingly AV is associated with an increased risk of preterm delivery, chorioamnionitis and funisitis of the fetus. There is no consensus on the optimal treatment for AV in pregnant or non-pregnant women, but a broader spectrum drug such as clindamycin is preferred above metronidazole to prevent infection-related preterm birth. The exact role of AV in pregnancy, the potential benefit of screening, and the use of newer local antibiotics, disinfectants, probiotics and immune modulators need further study., (© 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2011 RCOG.)

Objective: To assess different bacterial and epidemiological factors associations with increased vaginal pH in the pregnant women population during the first trimester., Design: A cross-sectional, observational study., Setting: Three outpatient clinics in Riga., Population: From July 2009 until January 2010, 139 unselected consecutive pregnant women at the first prenatal visit., Methods: Pregnant women were submitted to an interview, vaginal examination and vaginal specimen collection for pH measurement and native microscopy., Main Outcome Measures: Vaginal pH ≥4.5 was considered as elevated. Abnormal bacterial microflora was classified according to Donders., Results: Elevated vaginal pH was significantly associated with bacterial vaginosis (p < 0.001), aerobic vaginitis (p < 0.001) and mixed aerobic vaginitis and bacterial vaginosis flora (p < 0.001) and presence of sperm cells in the smears (p= 0.024). Most cases with sperm were associated with abnormal vaginal flora. Normal lactobacillary morphotypes were more often found in the pH ≤4.4 group (p < 0.001), while leptosomic and short types were found more frequently with increased pH., Conclusions: Elevated vaginal pH is associated with different types of abnormal vaginal flora and the presence of sperm cells., (© 2010 The Authors Acta Obstetricia et Gynecologica Scandinavica© 2010 Nordic Federation of Societies of Obstetrics and Gynecology.)

Objective: Study the reproducibility of wet smear interpretation of clue cells, lactobacillary grades and leukocyte dominance with conventional bright light and phase contrast microscopy., Study Design: Sets of vaginal specimens were taken from unselected consecutive women attending an outpatient gynaecology clinic. Air-dried vaginal fluid on a microscope slide was rehydrated with isotonic saline before examination by six independent international investigators. Some investigators initially used a conventional bright light microscope, followed by phase contrast technique., Results: Using phase contrast microscopy, an excellent inter-observer agreement was obtained among all investigators for clue cells detection (Kappa values from 0.69 to 0.94) and lactobacillary grades (Kappa 0.73-0.93). When conventional light microscopes were used, poor agreement was obtained for these criteria (Kappa index 0.37-0.72 and 0.80, respectively), but switching to phase contrast microscopy by the same investigators, improved Kappa to 0.83-0.85 and 0.88, respectively. The inter-observer agreement for estimation of the leukocyte/epithelial cell ratio (Kappa index 0.17-0.67) was poor, irrespective of the type of microscopy applied. Intra-observer agreement of clue cell detection and lactobacillary grading was also found to be excellent if phase contrast microscopy was used (Kappa 0.87-0.93), and poor with conventional bright light microscopy (Kappa 0.45-0.66)., Conclusion: Clue cells and the lactobacillary grades are reliably identified by phase contrast microscopy in wet smears, with excellent intra- and inter-observer reproducibility agreement, and better than when simple bright light microscopy was used. Evaluation of leukocyte grading, on the other hand, was inconsistent among the different microscopists, irrespective of the type of microscope used. We propose to grade the leukocytes in a different way than searching for leukocyte dominance over epithelial cells, namely by counting them per high power field and per epithelial cell.

Animal and 'in vitro' experiences learned that human chorionic gonadotropin (hCG) is capable to protect from breast cancer. Receptors for hCG/luteinizing hormone (LH) are present on human female and male breast cancer cells. hCG decreases proliferation and invasion of breast cancer MCF-7 cells by inhibiting NF-kappa B, AP-1 activation and other genes. Doxorubicin toxicity is enhanced by conjugation with beta-hCG in MCF-7 cells. All these pieces of evidence suggest that hCG is active in human breast cancer. Direct proof however is missing. We performed a pilot study phase I trial for testing the inhibitory effects or recombinant hCG (rhCG) on primary breast cancer. Twenty-five postmenopausal women with newly diagnosed breast cancers of more than 1.5 cm were biopsied before randomization to receive either 500 microg rhCG (n=20) or placebo. After 2 weeks, surgery was done and tissues were analysed with regard to morphological, immunohistochemical and biochemical changes in tissues and plasma. rhCG reduces significantly the proliferative index and the expression of both the oestrogen receptor and progesterone receptor. rhCG does not modify the hormonal level of estradiol, progesterone, inhibin and follicle stimulating hormone (FSH) but increases significantly the level of LH. In a second pilot study, we tested the clinical efficacy through an open-label single centre study in 13 postmenopausal women with metastatic breast cancer. A 500 microg rhCG once every 2 days shows activity in postmenopausal metastatic breast cancer. The time to progression is relatively short. Response to previous hormonal treatment is indicative for rhCG activity. Given the data in primary and metastatic breast cancer rhCG further large scale investigation is highly warranted. rhCG can be an realistic option in (chemo-) prevention trials.

Objectives: The aim of this study was to examine the accuracy of the presence of high-risk human papillomavirus (HR-HPV) DNA (HR-HPV DNA test) postconisation as prediction of recurrent or residual cervical intraepithelial neoplasia (CIN) after treatment of high-grade cervical intraepithelial lesions (CIN2+) in a prospective study and to compare this with follow-up cytology and the marginal status of the excised tissue., Design: Prospective follow-up study., Setting: Unselected women presenting at colposcopy clinic of University Hospital Gasthuisberg, Leuven., Population: Seventy-two women treated with conisation for CIN2 or CIN3., Methods: Women were followed by HR-HPV DNA test (Hybrid Capture II test of Digene) every 3 to 6 months. The same vial was used for cytology and the HR-HPV DNA test (SurePath). All women were further followed by colposcopy and cytology for 24 months at 6-month intervals. The outcome of the study was presence of >CIN2, proven with colposcopy-directed biopsy occurring within 24 months after treatment. HR-HPV status was correlated with recurrent or residual CIN2+., Main Outcome Measures: Sensitivity, specificity, predictive values and diagnostic odds ratios to predict treatment failure or cure were computed for HR-HPV testing, marginal status and follow-up cytology. HR-HPV status was also correlated with section margins postconisation and with the first cervical smear., Results: In 6 of the 72 treated women (8%), residual or recurrent CIN occurred. Women with recurrence were significantly older than women without a recurrence (51.5 +/- 9.6 versus 39.8 +/- 12.2 years, P= 0.007). All six women with recurrence were HR-HPV positive, four had a positive follow-up smear (>or=atypical squamous cells of uncertain significance = ASCUS+) and only two had involved section margins. Among the 66 cured women, 15 were HR-HPV positive, 6 had an abnormal smear and 12 had positive section margins. Sensitivity of cytology, positive section margins and HR-HPV DNA positivity was 66.7, 33.3 and 100% to predict treatment failure. Specificity of the three tests was, respectively, 90.9, 81.8 and 77.3%. Women with HR-HPV DNA at 3 to 6 months showed recurrent or residual CIN in 15% (2/13) if they had normal follow-up Pap smears and in 50% (4/8) if they had abnormal Pap smears. Margin status was not statistically significantly associated with human papillomavirus status., Conclusion: Persistence or clearance of HR-HPV DNA is an early valid prognostic marker of failure or cure after treatment for CIN2+ and is more accurate than cytology or section margin status at the time of conisation. The absence of HR-HPV DNA has a 100% negative predictive value. Higher age at conisation may be a previously unrecognised risk factor for recurrence.

Objective: This study was undertaken to investigate a possible link between first-trimester diagnosis of bacterial vaginosis and cessation of pregnancy at < or =20 weeks' gestation., Study Design: Women (n = 228) who received routine prenatal care in Flanders, Belgium, during the first trimester (14 weeks' gestation) and had a living singleton fetus were examined for microbiologic flora of the vagina. Bacterial vaginosis was assessed either clinically (Amsel et al criteria), microscopically (clue cells), or by culture of bacterial vaginosis-associated bacteria. Data were analyzed univariately (relative risk) and multivariately., Results: The presence of bacterial vaginosis at the first prenatal visit was strongly associated with subsequent early pregnancy loss (relative risk, 5.4; 95% confidence interval, 2.5-11). After multivariate analysis bacterial vaginosis, Mycoplasma hominis, and Ureaplasma urealyticum but not other microorganisms remained associated with an increased risk of miscarriage., Conclusion: Bacterial vaginosis and mycoplasmas may play causative roles in spontaneous abortion and early pregnancy loss.

We reviewed the frequency of umbilical endometriosis after laparoscopic-assisted subtotal hysterectomy with unprotected removal of uterine segments through the umbilical incision. Retrospective analysis of surgical records was followed by recall and clinical examination of 10 patients. Two women developed umbilical endometriosis. One was the only patient operated during menstruation. The other was one of two women operated in the late luteal phase and with subsequent adequate exposure to endogenous or exogenous estrogens. From 1976-1997, 22 reports of umbilical endometriosis were published: 18 cases were spontaneous, 2 occurred after ring sterilization, and 2 after diagnostic laparoscopy. These data lend support to the concept that implantation and the potential development of menstrual endometrium are increased after surgery. It is speculated that procedures that expose menstrual endometrial cells to nonepithelialized areas could be associated with an increased risk of endometriosis.

Testing for and treating sexually transmitted diseases (STDs) in pregnant women deserves special attention. Treatment possibilities are limited because of potential risks for the developing fetus, and because effects can differ in pregnant compared with non-pregnant women, re-infection may be missed because of the intrinsic delicacy of contact-tracing during pregnancy and because pregnant women are more reluctant to take the prescribed medication in its full dose, if at all. However, the devastating effects of some of these genital infections far outweigh any potential adverse effects of treatment. Although active syphilis has become a rarity in most Western countries, it is still prevalent in South America, Africa and South-East Asia. Benzathine benzylpenicillin (2.4 million units once or, safer, twice 7 days apart) is the treatment of choice, although patients with syphilis of longer standing require 3 weekly injections as well as extensive investigation into whether there has been any damage due to tertiary syphilis. Despite declining rates of gonorrhea, the relative rate of penicillinase-producing strains is increasing, especially in South-East Asia. The recommended treatment is intramuscular ceftriaxone (125 or 250 mg) or oral cefixime 400 mg. Despite good safety records after accidental use, fluoroquinolones are contraindicated during pregnancy. An alternative to a fluoroquinolone in pregnant women with combined gonorrhea and chlamydial infection is oral azithromycin 1 or 2 g. Azithromycin as a single 1 g dose is also preferable to a 7 day course of erythromycin 500 mg 4 times a day for patients with chlamydial infection. Eradication of Haemophilus ducreyi in patients with chancroid can also be achieved with these regimens or intramuscular ceftriaxone 250 mg. Trichomonas vaginalis, which is often seen as a co-infection, has been linked to an increased risk of preterm birth. Patients infected with this parasite should therefore received metronidazole 500 mg twice daily for 7 days as earlier fears of teratogenesis in humans have not been confirmed by recent data. Bacterial vaginosis is also associated with preterm delivery in certain risk groups, such as women with a history of preterm birth or of low maternal weight. Such an association is yet to be convincingly proven in other women. The current advice is to treat only women diagnosed with bacterial vaginosis who also present other risk factors for preterm delivery. The treatment of choice is oral metronidazole 1 g/day for 5 days. The possible reduction of preterm birth by vaginally applied metronidazole or clindamycin is still under investigation. In general, both test of cure and re-testing after several weeks are advisable in most pregnant patients with STDs, because partner notification and treatment are likely to be less efficient than outside pregnancy and the impact of inadequately treated or recurrent disease is greater because of the added risk to the fetus. Every diagnosis of an STD warrants a full screen for concomitant genital disease. Most ulcerative genital infections, as well as abnormal vaginal flora and bacterial vaginosis, increase the sexual transmission efficiency of HIV, necessitating even more stringent screening for and treating of STD during pregnancy.

Objective: To test the sensitivity of the rapid group B streptococci (GBS) antigen test ICONR and compare its accuracy in women with vaginal enterococci or with non-specific disturbance of the lactobacillary flora., Study Design: The ICONR, aerobic culture and a microscopic wet mount evaluation were done on a vaginal sample in 254 unselected women presenting for routine gynecologic care in an academic hospital in Flanders, Belgium and tested by Chi2 [diagnostic odds ratio (DOR) and its 95 percent confidence limits]., Results: Sensitivity of the test was 70%, specificity 99.5%. Prevalence of GBS was 10.6% overall, 23% in the group with abnormal vaginal flora and 7% in the normal group (p=0.002). Accuracy of the ICONR was not affected by abnormal vaginal flora, but was significantly lower in the presence of enterococci: the DOR decreased from 490 to 58, and the positive predictive value from 94 to 80%., Conclusion: With a sensitivity of 70% the enzyme immunoassay ICONR does not appear to be suitable as a practical screening tool for detecting GBS carriage in normal or preterm laboring women. In the presence of enterococci the test performed less well, with a DOR falling by 8 to 9 fold. We presume this is due to lower specificity in vivo in the presence of enterococci, as non-specific disturbance of the lactobacillary flora did not interfere with test results.

Background: Syphilis remains a major cause of premature birth, fetal and perinatal death, and congenital syphilis in South Africa, despite systematic antenatal screening by rapid plasma reagin and treatment with 2.4 million U of benzathine penicillin G., Goal: To determine whether one injection of 2.4 million of U of benzathine penicillin G, as recommended by the 1993 Centers for Disease Control and Prevention guidelines, is sufficient treatment for early syphilis during pregnancy., Study Design: Outcome of pregnancy was prospectively analyzed after zero to three weekly intramuscular injections of benzathine penicillin G in 180 of 212 human immunodeficiency virus-seronegative black urban women with syphilis in Pretoria, South Africa., Results: One hundred eight women receiving two or three weekly intra-gluteal injections of benzathine penicillin G had a favorable pregnancy outcome. However, after only one injection, lower birth weight, increased immaturity, prematurity, and total preterm birth rate resulted. Total pregnancy loss and perinatal mortality were also increased. After exclusion of patients treated with oral penicillin derivatives and adjustment for the estimated duration of treponemicidal levels at 3 weeks after injection, the perinatal outcome was reanalyzed. Treponemicidal coverage of 3 weeks or less resulted in decreased birth weight (2,748 vs. 3,130 g, P = 0.004) compared with treponemicidal coverage lasting longer than 3 weeks. In addition, the relative risks for prematurity (relative risk [RR], 8.5; 95% confidence interval [CI95], 2.5-28), perinatal mortality (RR, 20.5; CI95, 2.3-184), and congenital syphilis (RR 2.0; CI95-0.6-6.8) were increased when coverage was less then 3 weeks. These results were comparable to those obtained when no treatment was given. Most of the incompletely treated women delivered at less than 4 weeks after they received their injection. These also had the worst neonatal outcome. Impaired outcome due to short treatment clustered in early attenders of prenatal care (before the 28th week of gestation) and when the initial rapid plasma reagin titer was higher than 16. Although numbers were small for a firm conclusion, incompletely treated and untreated women who had taken intercurrent oral ampicillin had an improved birth weight, lower prematurity rate, and lower fetal rate., Conclusions: One intramuscular injection of 2.4 million U benzathine penicillin G or treponemicidal concentrations lasting 3 weeks or less is not sufficient therapy for pregnant women with syphilis. Although fetal outcome is clearly improved at birth with more than one injection, without follow-up of the neonates, complete cure cannot be predicted from these data. To obtain treponemicidal activity for longer than 3 weeks, the authors recommend administration of two injections of 2.4 million U benzathine penicillin at least 1 week apart, if possible at 4 weeks or more before delivery. This therapy is especially important for patients who attend prenatal care before 28 weeks of pregnancy or when the rapid plasma reagin titer is higher than 16.

A IVF twin pregnancy in a patient who had previously undergone a myomectomy ended in a intrauterine infection, placental abruption and fetal losses at 21 weeks. Intrauterine Candidiasis may have played a role in the pathogenesis of the unsuccessful outcome.

We studied the accuracy of the rapid antigen detection tests Gonozyme and Chlamydiazyme in high-risk women in an outpatient prenatal clinic, Kalafong University Hospital, Pretoria, South Africa. Women (n = 433) presenting with uneventful pregnancy (n = 324), unavoidable miscarriage (n = 41) or infertility of 1 year's duration (n = 68) had a Pap smear for lactobacillary grading and detection of pathogens like Candida albicans or Trichomonas vaginalis, a swab for culture of Neisseria gonorrhoeae, and a swab for Gonozyme, Chlamydiazyme and Chlamydia immunofluorescence collected from the endocervix. Specificities of both antigen tests were high, but sensitivities and positive predictive values were disappointingly low. Chlamydial antigen was recovered in only 37% of samples with positive immunofluorescence, gonococcal antigen was detected in only 50% of samples with positive culture for N. gonorrhoeae. Although prevalence of N. gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis was higher in women with disturbed lactobacillary grades on the Pap smears, sensitivities of the antigen tests were lower in this group. We conclude that detection of endocervical antigens of C. trachomatis and N. gonorrhoeae lacked sensitivity in pregnant and infertile women living in an area with high prevalence of chlamydial cervicitis, gonorrhoea and Trichomonas vaginitis. Furthermore, the rapid antigen tests lack accuracy when the lactobacillary flora is disturbed and are, therefore, not suitable for detection of C. trachomatis or N. gonorrhoeae in pre-screened patients.

Papanicolaou (Pap) smears taken at the first antenatal visit of black African women were examined for lactobacillary expression and its correlation with the prevalence of genital infections and with the outcome of pregnancy. Lactobacillary morphotypes were absent (grade III) in 52% of 256 women. Trichomonas, Chlamydia, gonococci, or syphilis was identified in 54% of grade III women, and in 17% of grade I + II women (p < 0.0001). There were partially independent positive associations of Trichomonas, Chlamydia, and gonococci and a negative association of Candida morphotypes with grade III. Absence of lactobacilli, whether or not in the context of bacterial vaginosis, is an indicator for the presence of other genital infections. Birthweight was 2000 gm or less in 5% of 82 children of grade I + II mothers, and in 16% of 83 children of grade III mothers (p = 0.02). Thus, there are populations in whom the grading of lactobacilli in routine Pap smears helps to direct further investigations and to predict the outcome of pregnancy.

In anticipation of systematic prenatal screening at the antenatal clinic of Gasthuisberg University Hospital, Leuven, Belgium, the attitude of 500 successive pregnant women towards testing for rubella, toxoplasmosis, hepatitis B virus, HIV and syphilis was studied by means of written questionnaires. All tests were well accepted, toxoplasmosis and rubella being most (92 and 91%), syphilis and HIV being least (79 and 82%) favoured. Refusal was generally associated with lower education, but refusal for syphilis and HIV was associated with high education. Ninety-four percent wanted to be informed of the results of the tests. Only one woman (0.2%) of those who agreed with testing did not want to know her HIV test result. Pregnant doctors were more reluctant about screening, in particular for sexually transmitted diseases, whereas nurses were in favour of it. Written information failed to increase the acceptance rate, but lowered the number of women without an opinion.

In a prospective study of 124 urban black pregnant women, 43% had Candida isolated from endocervical cultures and 20% had Candida cell forms on cytological Pap-stained cervical specimens. The presence of Candida cell forms on Pap smears had a better correlation with Candida colonisation when normal lactobacillary flora was present, when Trichomonas vaginalis parasites were absent and when the infecting Candida species was C. albicans. Positive cultures were strongly related to a number of clinical signs and symptoms, but Pap smears were not. Neither Candida culture nor Candida cells in Pap smear revealed an association with premature delivery, birth weight, severe neonatal morbidity or mortality. We confirm that the routine cervical Pap smear is not a sensitive method for diagnosing symptomatic fungal infection. More specifically, some of the Pap smear characteristics, such as disturbed lactobacillary flora or co-infection with T. vaginalis, interfere with accurate diagnosis.

Although Candida albicans is a frequent inhabitant of the female genital tract, chorioamnionitis is rarely caused by this fungal organism. In this report we present two cases with manifest Candida chorioamnionitis. The first case is a twin pregnancy with premature delivery and survival of both twins. The second case is a pregnancy with intra-uterine contraceptive device in situ ending in a midtrimester abortion, followed by the next pregnancy also ending in an abortion in the second trimester. Possible triggers responsible for the increased invasiveness of otherwise benign Candida vaginitis are discussed. Foreign intra-uterine bodies such as contraceptive devices and cerclage sutures necessitate repetitive search for Candida species infection, and prompt adequate antifungal treatment in cases of documented infection. Both cases of the present report add further substantial evidence to the hypothesis of amniotic infection by ascending transcervical infection. The frequent concomitant cervical infections with other infectious agents as well as antibiotherapy influencing the normal Lactobacillary defence mechanisms are both likely to increase the risk. Systemic debilitating diseases that promote invasiveness are briefly discussed.

In a prospective study on genital infections, the influence of Chlamydial cervicitis on pregnancy outcome was evaluated. In eleven women with Chlamydial cervicitis perinatal outcome was recorded, the placenta was examined and the newborns were screened for Chlamydial conjunctivitis. They were compared with 13 women who were negative for Chlamydia and were delivered immediately after a Chlamydia positive woman. Compared to negative women, women with Chlamydia cervicitis were younger and presented for antenatal care at a later gestational age (difference not significant) and started having sexual intercourse at an earlier age (P less than 0.02). There was a significant association between Chlamydial infection and chorioamnionitis, lower birth weight and severe neonatal infection (P less than 0.05); but a contribution from concomitant genital pathogens could not be completely ruled out. Therefore a screening program for Chlamydia should include screening for other genital infections. While almost all cases of Chlamydia could have been suspected by this technique, a screening based on lactobacillary grades in Pap smears might be helpful for this purpose, even more so because it also facilitates tracing other genital pathogens. Detection of Chlamydial antigen from conjunctival swabs taken immediately after birth did not adequately reflect the risks of neonatal infection in this small group.

Two families with X-linked recessive centro-nuclear myopathy (XLR-CNM) are described. Evidence is accumulating that XLR-CNM forms a distinct entity, in contrast to the commoner later-onset forms. Family history often provides a clue to the diagnosis. Pregnancy is very often complicated by hydramnios and reduced fetal movements. We describe two families with five affected male babies who all died. An isolated case with severe fetal brady-arrhythmias in combination with acute increase in polyhydramnios is mentioned. The neonatal mortality in all recorded cases is 80 percent, with respiratory insufficiency as the cause of death. An attempt is made to establish early prenatal diagnosis and the possibility of carrier detection is briefly discussed.

A study was performed to determine the effect of preoperative irradiation on microvascular arterial anastomoses. The study focused on microthrombi and epithelial regeneration. Using scanning electron microscopy (SEM), a clear difference was seen comparing nonirradiated to irradiated vessels. No difference was found between short- and long-term effects of irradiation.

A newborn with Down's syndrome complicated by complete atrioventricular (AV) block, despite normal cardiac anatomy, is described. The congenital AV block was diagnosed in utero, and the characteristics of Down's syndrome were recognised after birth. Pitfalls in antenatal diagnosis and management of complete AV block in the fetus are briefly outlined. Identification of fetal karyotype in case of isolated congenital AV block is recommended.