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Occupancy monitoring in smart buildings has great potential to improve their operational performance. One of the most common applications concerns the dynamic adaptation of indoor conditions accord...

A retrospective, case-control study was performed to determine whether pregnant women using cocaine had an increase in maternal infectious morbidity. Seventy-six women with urine drug screens positive for cocaine on admission to the labor and delivery unit were compared to 134 women who had negative urine drug screens. Patients were matched for risk factors associated with the development of intraamniotic infection and endometritis, such as parity, length of labor and length of membrane rupture. There was no significant difference in the incidence of intraamniotic infection or endometritis between the two groups. Thus, cocaine does not appear to increase the risk of peripartum infectious morbidity after controlling for well-established risk factors.

To determine whether there is a relation between lecture attendance and factual knowledge of obstetrics and gynecology, as measured by the National Board of Medical Examiners (NBME) clinical science subject examination.We analyzed data on 197 students completing 8-week obstetrics and gynecology rotations from July 1, 1991 to June 30, 1992. Each student was expected to attend a weekly lecture series, and each completed the NBME clinical science subject examination at the end of the clerkship. Student attendance and board scores were correlated at the end of the academic year overall and by subgroups. Scores in the top and bottom 15% were defined as good and poor performance, respectively.A negative correlation (r = -0.1738, P = .0146) was found between percent absence and examination score. The odds ratio for poor performance was 5.48 (95% confidence interval 1.3-26.5; P = .015) for the subgroup of students with more than 30% absence compared to those without absences. Odds ratios for scoring in the upper 15th percentile were not significant.The negative correlation and the high odds ratio for poor performance suggest the value of monitoring attendance and identifying students at risk for poor performance (more than 30% absence). Lower absence rates did not predict performance.

Septic pelvic thrombophlebitis is a major complication of endometritis. The thrombi commonly occur in the uterine and/or ovarian veins and may extend into the inferior vena cava.Following vaginal delivery, a 19-year-old woman, gravida 2, developed postpartum septic pelvic thrombophlebitis extending from the right ovarian vein up to the diaphragm and down to the femoral vein. The patient was treated successfully with heparin and antibiotics, and eventually was discharged on oral anticoagulants for an extended period. Follow-up revealed complete resolution of the thrombus.Septic pelvic thrombophlebitis is not limited to the pelvis and lower abdominal vessels.

To determine the accuracy of visually versus digitally determined cervical dilation.We studied 64 pregnant women with rupture of the amniotic membranes. One of two residents performed a speculum examination, estimated the dilation and effacement visually, and noted whether fetal parts or amniotic membranes were present. The same examiner then determined digitally the cervical dilation and effacement and station of the presenting part.There was a statistically significant correlation between visually and digitally determined cervical dilation (r = 0.78, P.001).Visual estimation of cervical dilation correlates well with digital examination.

To determine the carriage rate of enterococcus in the lower genital tract of women having a cesarean delivery and to determine whether a single 2-g intraoperative dose of ampicillin eradicates enterococcus from the lower genital tract.Lower genital tract cultures were taken in 84 women who were in labor or had ruptured membranes and who were about to have an indicated cesarean delivery. The subjects were randomized to receive either a single 2-g dose of ampicillin or a cephalosporin as prophylaxis. Cultures were repeated 24 hours postpartum.Enterococcus was isolated preoperatively in 33 subjects (39.3%) and postoperatively in 36 (42.9%). The enterococcus was eradicated in five of 17 women (29.5%) who received ampicillin.These results suggest that a single 2-g dose of ampicillin does not eradicate enterococcus from the lower genital tract.

Roseola infantum (exanthem subitum) was first described as a specific syndrome by Zahorsky in 1913. It is a benign disease that occurs almost exclusively in infants and young children (six months to three years of age). We report a case of roseola in a pregnant woman. We were unable to find any prior reports of roseola in pregnancy. The classic presentation of roseola is characterized by high temperatures (103-105 degrees F) that last 3-5 days and resolve by crisis followed by the appearance of a morbilliform rash that lasts a few hours to a few days. The infectious agent is human herpesvirus-6. We recommend the addition of roseola to the differential diagnosis of rashes that occur in pregnancy. The potential danger to the fetus from this virus is unknown.

The extended-spectrum cephalosporins provide better activity against gram-negative bacilli and anaerobes than first-generation agents. Cefoxitin and cefotetan (second-generation) and ceftriaxone (third-generation) have excellent activity against B. fragilis and are useful in the treatment of postoperative infections and pelvic inflammatory disease. The extended-spectrum cephalosporins are as efficacious as first-generation agents for prophylaxis of cesarean section and hysterectomy. The first-generation drugs, such as cefazolin, are considerably less expensive than these newer compounds, however, making first-generation agents the drugs of choice when used for prophylaxis. The majority of the third-generation agents should be reserved for the treatment of meningitis and resistant nosocomial infections.

From February 1988 to April 1990, we collected blood for hepatitis B surface antigen (HBsAg) from all women coming to the Texas Tech University Health Science Center in Lubbock for prenatal care. These patients were from rural western Texas and eastern New Mexico. They were also screened for hepatitis B risk factors, as outlined by the Centers for Disease Control. We reviewed the prenatal records of all HBsAg-positive women. Six of 4452 women (0.13%) had a positive HBsAg test. Four of the six women had identifiable risk factors and two did not; two were non-Hispanic caucasian (Anglo), two were Hispanic, and two were black. Anglos comprised 49.5% of the rural population, Hispanics 34.9%, blacks 12.8%, and Asians 2.8%. No Asian women were positive for HBsAg. The prevalence of HBsAg positivity was lower in this rural population than in previously reported urban populations. While the prevalence in the studied blacks and Hispanics was similar to that in previous reports, the prevalence in the rural Anglos was lower.

Some obstetricians recommend the Zavanelli maneuver to resolve shoulder dystocia. Descriptions in the literature report an almost automatic ease in performance of the maneuver. We report a case of severe shoulder dystocia in which management with the Zavanelli maneuver and immediate cesarean was extremely difficult. The procedure involved exact reversal of all the cardinal movements of labor, and the delivery required terbutaline, general anesthesia, and added personnel to ensure successful extraction of the fetus. A delivery requiring the Zavanelli maneuver can be difficult to perform and may be worsened by insufficient personnel and inexact reversal of all the cardinal movements of labor.

Although the most common definition of a reactive nonstress test is an acceleration in the fetal heart rate of 15 beats per minute (bpm) for 15 seconds, some investigators require that the fetal heart rate acceleration be maintained at 15 bpm above the baseline for the entire 15 seconds (long criterion), and others require simply that the acceleration be 15 seconds from the beginning until the return to the baseline (short criterion). In 1,241 nonstress tests (NSTs) there was a statistically significant difference in the number of reactive tests between the short and long criteria (1,108 [89%] vs. 985 [79%], P less than .001). This difference in percentage of reactivity may be important when comparing studies performed by various investigators. In comparing cesarean section deliveries for fetal distress we were unable to find a difference in the ability to predict a poor outcome between use of the short and long criteria. However, a type II error is possible since the number of poor outcomes was small. We now use the short criterion for NST interpretation.

Chlamydia causes many human infections and should be treated aggressively. Tetracycline or doxycycline are the drugs of choice, but erythromycin can be used if a drug allergy is present or if tetracyclines are contraindicated. In the pregnant woman, aggressive treatment can improve neonatal outcome. In the United States, each year 155,000 infants are exposed to Chlamydia trachomatis during the birth process, and more than 100,000 will be infected. Of these, 75,000 will get conjunctivitis, and 30,000 will get pneumonia. In pregnancy, erythromycin is the drug of choice, with treatment recommended after initial culture and at term if repeat cultures are positive. If erythromycin is not tolerated, or the patient has an allergy to it, ampicillin or clindamycin may be effective alternatives.

The authors reviewed all documented cases of bacteremia in obstetric patients between 1975 and 1979, with emphasis on the clinical course. The incidence of bacteremia was 7.5:1000 obstetric admissions and 9.7% of those patients sampled. One hundred seventy-six bacteremic obstetric patients had the following diagnoses: endoparametritis (123), pyelonephritis (29), chorioamnionitis (14), and other (10). No deaths, clinical evidence of septic shock, or cases of postinfection endocarditis were found. The most common bloodstream isolates were Escherichia coli (57), group B streptococcus (28), and Bacteroides sp (26). The patients with endoparametritis had a fever index of 86.2 +/- 47.1F-hours, an average hospital stay of 6.5 +/- 3.1 days, a 7.3% rate of complications, and a 19.5% rate of failure of primary antibiotics. The patients with chorioamnionitis had a fever index of 32.7 +/- 48.9F-hours and an average hospital stay of 4.8 +/- 2.3 days. These clinical measures are comparable with those in the general population with the same diagnoses at the authors' hospital. In this obstetric population, prompt, vigorous treatment rendered the clinical course of bacteremic patients with genital infections remarkably similar to that of nonbacteremic patients with the same kinds of infection.

A study was undertaken to evaluate the postoperative morbidity of classical cesarean section (CCS). Eighty-nine such procedures, performed between 1970 and 1977, were reviewed. All cases in which prophylactic antibiotics were used were excluded from the study. Forty-seven patients (53%) developed standard morbidity, and 46 patients (52%) had a clinical diagnosis of infection. Of these, 30 patients (34%) had endoparametritis, 5 patients (6%) had abdominal wound infection, and 11 patients (12%) had urinary tract or pulmonary infection. Two patients (2%) had pelvic thrombophlebitis, but no patient was found to have an abscess or pelvic hematoma. In comparison with matched patients who had a low cervical transverse cesarean section (LCTCS) performed during the same time, patients with a CCS had a comparable incidence of standard morbidity and operative site infection. These infections responded promptly to vigorous antibiotic therapy with no apparent increased risk of amjor postoperative complications in the population studied.

During a 4-year period, 48 obstetric patients with aerobic streptococcal bacteremia were identified. The isolates were group B (31); group D, enterococci (5); group A (4); group D, not enterococci (3); Streptococcus pneumoniae (3); and viridans streptococci (2). The most common diagnoses were endometritis (36) and chorioamnionitis (8). For all streptococcal genital infections, the clinical presentation included early-onset fever, often with few localizing signs. Only one patient had a chronic debilitating disease. There was an excellent correlation between genital and bloodstream isolates (36 of 42). Maternal response to therapy was good, with no deaths nor episodes of septic shock. Possible infectious complications developed in two fetuses and four neonates. The microbiologic and clinical features of aerobic streptococci were reviewed, and the outcome in obstetric patients and that in other adults were compared.

The authors studied the levels of immunoglobulins (Ig) in the amniotic fluid of 46 patients with intraamniotic infection and of 46 matched controls. Amniotic fluid was collected through a transcervical intrauterine catheter. All infected patients had clinical signs of intraamniotic infection and at least 10(2) colony-forming units/milliliter of a high-virulence organism. None of the controls became infected. The matching criteria were gestational age, labor, interval from rupture of the membranes to delivery, and interval from rupture of the membranes to amniotic fluid collection. The authors tested each amniotic fluid sample for immunoglobulins G, M, and A by a single radial immunodiffusion technique. The mean IgG level in amniotic fluid for the intraamniotic infection group was 33.9 +/- 38.5 mg/dl, and the mean level for the control group was 17.9 +/- 11.1 mg/dl. The authors concluded that the mean IgG level in amniotic fluid from patients with intraamniotic infection is significantly higher than in controls (P less than .02).

Four techniques for obtaining endometrial cultures in puerperal patients were compared in 18 uninfected women undergoing postpartum tubal ligation. Four culture specimens were obtained from each patient in the following sequence: transfundal aspiration, transcervical brush biopsy of the endometrium through a double-lumen catheter, transcervical lavage of the endometrial cavity through a double-lumen catheter, and aspiration of the secretions from the lower uterine segment through a single-lumen catheter. Quantitative cultures for aerobic and anaerobic bacteria were performed on all specimens. Cultures from the single-lumen aspirate had the greatest variety of different organisms and the highest colony counts of individual organisms. The brush and lavage techniques were equally effective in reducing, but not eliminating, contamination of endometrial specimens with cervical organisms. The authors conclude that, of the techniques evaluated in these uninfected patients, the most satisfactory procedure for routinely obtaining endometrial cultures is brush biopsy or lavage through a double-lumen catheter.

Serum gentamicin levels were measured by agar diffusion bioassay in 38 patients undergoing treatment with clindamycin-gentamicin for post-cesarean endomyometritis. Patients received intravenous gentamicin in a dose of 1 mg/kg actual body weight every eight hours. All trough levels were less than 1 microgram/ml. The mean 30-minute postinfusion level was 5.78 +/- 2.43 micrograms/ml (mean +/- SD). The range of postinfusion concentrations was 1 to 12 micrograms/ml. Postinfusion concentrations were less than 5 micrograms/ml in 13 patients, but none of these individuals experienced a clinical failure of antimicrobial therapy. There were no statistically significant differences in mean age, weight, hematocrit, serum creatinine, estimated creatinine clearance, or administered dose in patients with therapeutic gentamicin levels and patients with apparent subtherapeutic levels. The authors conclude that postinfusion gentamicin concentrations fluctuate widely in obstetric patients receiving 1 mg/kg/dose and that apparent subtherapeutic postinfusion levels still may be clinically efficacious, depending upon the antimicrobial susceptibility of the infecting microorganisms.

A retrospective, case-control study was performed to determine risk factors for, and complications of, wound abscess after cesarean delivery. The records of 64 patients with abscess and 64 controls were examined. The following variables were significantly associated with wound abscess: labor duration, interval from rupture of membranes to delivery, number of vaginal examinations, duration of internal fetal monitoring, operating time, and estimated blood loss. Also strongly associated were presence of endometritis or chorioamnionitis, fever in labor, and an indication of dystocia. The mean hospital stay was six days longer in patients with wound abscess. Fascial dehiscence requiring repair was present in 4.7%.

Ceftazidime in the breast milk of 11 puerperal women were determined by bioassay. Each patient received 2 g of ceftazidime intravenously every 8 h for 5 days. The mean (+/- standard deviation) ceftazidime concentrations in the milk were: 3.8 +/- 2.0 (before the next dose), 5.2 +/- 3.0 (1 h after), and 4.5 +/- 1.7 micrograms/ml (3 h after). Ceftazidime was excreted in breast milk at relatively constant levels between days 2 and 4 of therapy.