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BACKGROUND: Primary cytomegalovirus (CMV) infection during pregnancy carries a risk of congenital infection and possible severe sequelae. There is no established intervention for preventing congenital CMV infection. METHODS: In this multicenter, double-blind trial, pregnant women with primary CMV infection diagnosed before 24 weeks’ gestation were randomly assigned to receive a monthly infusion of CMV hyperimmune globulin (at a dose of 100 mg per kilogram of body weight) or matching placebo until delivery. The primary outcome was a composite of congenital CMV infection or fetal or neonatal death if CMV testing of the fetus or neonate was not performed. RESULTS: From 2012 to 2018, a total of 206,082 pregnant women were screened for primary CMV infection before 23 weeks of gestation; of the 712 participants (0.35%) who tested positive, 399 (56%) underwent randomization. The trial was stopped early for futility. Data on the primary outcome were available for 394 participants; a primary outcome event occurred in the fetus or neonate of 46 of 203 women (22.7%) in the group that received hyperimmune globulin and of 37 of 191 women (19.4%) in the placebo group (relative risk, 1.17; 95% confidence interval [CI], 0.80 to 1.72; P = 0.42). Death occurred in 4.9% of fetuses or neonates in the hyperimmune globulin group and in 2.6% in the placebo group (relative risk, 1.88; 95% CI, 0.66 to 5.41), preterm birth occurred in 12.2% and 8.3%, respectively (relative risk, 1.47; 95% CI, 0.81 to 2.67), and birth weight below the 5th percentile occurred in 10.3% and 5.4% (relative risk, 1.92; 95% CI, 0.92 to 3.99). One participant in the hyperimmune globulin group had a severe allergic reaction to the first infusion. Participants who received hyperimmune globulin had a higher incidence of headaches and shaking chills while receiving infusions than participants who received placebo. CONCLUSIONS: Among pregnant women, administration of CMV hyperimmune globulin starting before 24 weeks’ gestation did not result in a lower incidence of a composite of congenital CMV infection or perinatal death than placebo. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Center for Advancing Translational Sciences; ClinicalTrials.gov number, NCT01376778.)

Objective The objective of this study is to evaluate whether there is an association between in-utero exposure to nicotine and subsequent hearing dysfunction. Patients and Methods Secondary analysis of a multicenter randomized trial to prevent congenital cytomegalovirus (CMV) infection among gravidas with primary CMV infection was conducted. Monthly intravenous immunoglobulin hyperimmune globulin therapy did not influence the rate of congenital CMV. Dyads with missing urine, fetal or neonatal demise, infants diagnosed with a major congenital anomaly, congenital CMV infection, or with evidence of middle ear dysfunction were excluded. The primary outcome was neonatal hearing impairment in one or more ears defined as abnormal distortion product otoacoustic emissions (DPOAEs; 1 to 8 kHz) that were measured within 42 days of birth. DPOAEs were interpreted using optimized frequency-specific level criteria. Cotinine was measured via enzyme-linked immunosorbent assay kits in maternal urine collected at enrollment and in the third trimester (mean gestational age 16.0 and 36.7 weeks, respectively). Blinded personnel ran samples in duplicates. Maternal urine cotinine >5 ng/mL at either time point was defined as in-utero exposure to nicotine. Multivariable logistic regression included variables associated with the primary outcome and with the exposure (p Results Of 399 enrolled patients in the original trial, 150 were included in this analysis, of whom 46 (31%) were exposed to nicotine. The primary outcome occurred in 18 (12%) newborns and was higher in nicotine-exposed infants compared with those nonexposed (15.2 vs. 10.6%, odds ratio [OR] 1.52, 95% confidence interval [CI] 0.55–4.20), but the difference was not significantly different (adjusted odds ratio [aOR] = 1.0, 95% CI 0.30–3.31). This association was similar when exposure was stratified as heavy (>100 ng/mL, aOR 0.72, 95% CI 0.15–3.51) or mild (5–100 ng/mL, aOR 1.28, 95% CI 0.33–4.95). There was no association between nicotine exposure and frequency-specific DPOAE amplitude. Conclusion In a cohort of parturients with primary CMV infection, nicotine exposure was not associated with offspring hearing dysfunction assessed with DPOAEs. Key Points

Objective This study aimed to assess the association of maternal body mass index (BMI) with a composite of severe maternal outcomes. Study Design Secondary analysis of a cohort of deliveries on randomly selected days at 25 hospitals from 2008 to 2011. Data on comorbid conditions, intrapartum events, and postpartum course were collected. The reference group (REF, BMI: 18.5–29.9kg/m2), obese (OB; BMI: 30–39.9kg/m2), morbidly obese (MO; BMI: 40–49.9kg/m2), and super morbidly obese (SMO; BMI ≥ 50kg/m2) women were compared. The composite of severe maternal outcomes was defined as death, intensive care unit (ICU) admission, ventilator use, deep venous thrombosis/pulmonary embolus (DVT/PE), sepsis, hemorrhage, disseminated intravascular coagulation (DIC), unplanned operative procedure, or stroke. Patients in the REF group were matched 1:1 with those in all other obesity groups based on propensity score using the baseline characteristics of age, race/ethnicity, previous cesarean, preexisting diabetes, chronic hypertension, parity, cigarette use, and insurance status. Multivariable Poisson's regression was used to estimate adjusted relative risks (aRRs) and 95% confidence intervals (CIs) for the association between BMI and the composite outcome. Because cesarean delivery may be in the causal pathway between obesity and adverse maternal outcomes, models were then adjusted for mode of delivery to evaluate potential mediation. Results A total of 52,162 pregnant patients are included in the analysis. Risk of composite maternal outcomes was increased for SMO compared with REF but not for OB and MO [OB: aRR=1.06, 95% CI: 0.99–1.14; MO: aRR=1.10, 95% CI: 0.97–1.25; SMO: aRR=1.32, 95% CI: 1.02–1.70]. However, in the mediation analysis, cesarean appears to mediate 46% (95% CI: 31–50%) of the risk of severe morbidity for SMO compared with REF. Conclusion Super morbid obesity is significantly associated with increased serious maternal morbidity and mortality; however, cesarean appears to mediate this association. Obesity and morbid obesity are not associated with maternal morbidity and mortality. Key Points

To develop and internally validate a noninvasive method for the prediction of congenital cytomegalovirus (CMV) infection after primary maternal CMV infection.We conducted a secondary analysis of a multicenter randomized placebo-controlled trial of CMV hyperimmune globulin to prevent congenital infection. Women were eligible if they had primary CMV infection, defined as detectable plasma CMV-specific immunoglobulin (Ig)M and CMV-specific IgG with avidity less than 50% before 24 weeks of gestation or IgG seroconversion before 28 weeks, and were carrying a singleton fetus without ultrasonographic findings suggestive of CMV infection. Antibody assays were performed in a single reference laboratory. Congenital infection was defined as CMV detection in amniotic fluid, neonatal urine or saliva, or postmortem tissue. Using backward elimination, we developed logit models for prediction of congenital infection using factors known at randomization. The performance of the model was assessed using leave-one-out cross-validation (a method of internal validation).Of 399 women enrolled in the trial, 344 (86%) had informative data for this analysis. Congenital infection occurred in 68 pregnancies (20%). The best performing model included government-assisted insurance, IgM index 4.5 or higher, IgG avidity less than 32%, and whether CMV was detectable by polymerase chain reaction in maternal plasma at the time of randomization. Cross-validation showed an average area under the curve of 0.76 (95% CI 0.70-0.82), indicating moderate discriminatory ability. More parsimonious one-, two-, and three-factor models performed significantly less well than the four-factor model. Examples of prediction with the four-factor model: for a woman with government-assisted insurance, avidity less than 32%, IgM index 4.5 or higher, and detectable plasma CMV, probability of congenital infection was 0.69 (95% CI 0.53-0.82); for a woman with private insurance, avidity 32% or greater, IgM index less than 4.5, and undetectable plasma CMV, probability of infection was 0.03 (95% CI 0.02-0.07).We developed models to predict congenital CMV infection in the presence of primary maternal CMV infection and absence of ultrasonographic findings suggestive of congenital infection. These models may be useful for patient counseling and decision making.

To compare fetal heart rate (FHR) patterns during the last hour of labor between small-for-gestational-age (SGA; birth weight less than the 10th percentile for gestational age) and appropriate-for-gestational-age (AGA; birth weight at the 10-90th percentile) neonates at 36 weeks of gestation or greater. We also compared the rate of cesarean delivery and composite neonatal morbidity among SGA and AGA newborns.This is a secondary analysis of a randomized trial of intrapartum fetal electrocardiographic ST-segment analysis. We excluded women with chorioamnionitis, insufficient duration of FHR tracing in the hour before delivery, and anomalous newborns. Fetal heart rate patterns were categorized by computerized pattern recognition software (PeriCALM Patterns). Composite neonatal morbidity was defined as any of the following: intrapartum fetal death, Apgar score 3 or less at 5 minutes, cord artery pH 7.05 or less, base deficit 12 mmol/L or greater, neonatal seizure, intubation at delivery, neonatal encephalopathy, and neonatal death. Logistic regression was used to evaluate the association between FHR patterns and SGA adjusted for magnesium sulfate exposure and stage of labor.Of the 11,108 women randomized, 85% (n=9,402) met inclusion criteria, of whom 9% were SGA. In the last hour, the likelihood of accelerations was significantly lower among SGA than AGA neonates (72.4% vs 66.8%; P=.001). Variable decelerations lasting greater than 60 seconds, with depth greater than 60 beats per minute (bpm) or nadir less than 60 bpm, were significantly more common with SGA than AGA (all P.001). The rate of late decelerations, prolonged decelerations, or bradycardia were similar between SGA and AGA (all P.05). Cesarean delivery for fetal indications was significantly more common with SGA (7.0%) than AGA (4.0%; P.001). The composite neonatal morbidity was 1.4% among SGA and 1.0% among AGA (odds ratio 1.40, 95% CI 0.74-2.64).Although the FHR patterns in the last hour of labor differ among SGA and AGA neonates, as does the rate of cesarean delivery, the composite neonatal morbidity was similar.

Short cervix at midgestation, the presence of intraamniotic debris, and cervical funneling are risk factors for preterm birth; however, cervical length measurements and cutoffs are not well documented among pregnant patients of different gestational ages and self-reported races and ethnicities.This study aimed to describe the distribution of cervical length and frequency of funneling and debris at midgestation in nulliparous women by gestational age and race/ethnicity.This secondary analysis of screening data from a multicenter treatment trial of singleton nulliparous patients with short cervix was conducted at 14 geographically distributed, university-affiliated medical centers in the United States. Singleton nulliparous patients with no known risk factors for preterm birth were screened for trial participation and asked to undergo a transvaginal ultrasound to measure cervical length by a certified sonographer. The distribution of cervical length and the frequency of funneling and debris were assessed for each gestational age week (16-22 weeks) and stratified by self-reported race and ethnicity, which for this study were categorized as White, Black, Hispanic, and other. Patients enrolled in the randomized trial were excluded from this analysis.A total of 12,407 nulliparous patients were included in this analysis. The racial or ethnic distribution of the study participants was as follows: White, 41.6%; Black, 29.6%; Hispanic, 24.2%; and others, 4.6%. The 10th percentile cervical length for the entire cohort was 31.1 mm and, when stratified by race and ethnicity, 31.9 mm for White, 30.2 mm for Black, 31.4 mm for Hispanic, and 31.2 mm for patients of other race and ethnicity (P.001). At each gestational age, the cervical length corresponding to the tenth percentile was shorter in Black patients. The 25 mm value commonly used to define a short cervix and thought to represent the 10th percentile ranged from 1.3% to 5.4% across gestational age weeks and 1.0% to 3.8% across race and ethnicity groups. Black patients had the highest rate of funneling (2.6%), whereas Hispanic and Black patients had higher rates of intraamniotic debris than White and other patients (P.001).Black patients had shorter cervical length and higher rates of debris and funneling than White patients. The racial and ethnic disparities in sonographic midtrimester cervical findings may provide insight into the racial disparity in preterm birth rates in the United States.

The aim of the study was to evaluate associations between fetal growth and weight at 2 years in infants born preterm using a customized approach for birth weight.This is a secondary analysis of a multicenter trial that included a 2-year follow-up of children born prematurely. Customized birth weight percentiles were calculated using the Gardosi model for a U.S. population, and the relation between customized percentile and weight and height at 2 years (adjusted for gender using z-score) was determined using regression analysis and by comparing z-scores for children with birth weight10th versus ≥10th percentile.Weight z-score at 2 years was significantly lower in the10th than in the ≥10th percentile group (median [interquartile range, IQR]: -0.66 [-1.58, -0.01] vs. -0.23 [-1.05, 0.55]; p 0.001), and remained after adjusting for maternal education (p 0.001). A similar relationship was noted for height z-score between groups (median [IQR]: -0.56 [-1.29, 0.19] vs. -0.24 [-0.99, 0.37]; p 0.001). Positive relationships between customized birth weight percentile and weight and height at 2 years were noted (p 0.001 for both), but were not strong (R (2) = 0.04 and 0.02, respectively).Customized birth weight percentile is a minor determinant of weight at 2 years among children born preterm.

ObjectiveTo determine the frequency of sepsis and other adverse neonatal outcomes in women with a clinical diagnosis of chorioamnionitis.MethodsWe performed a secondary analysis of a multi-center placebo-controlled trial of vitamins C/E to prevent preeclampsia in low risk nulliparous women. Clinical chorioamnionitis was defined as either the “clinical diagnosis” of chorioamnionitis or antibiotic administration during labor because of an elevated temperature or uterine tenderness in the absence of another cause. Early-onset neonatal sepsis was categorized as “suspected” or “confirmed” based on a clinical diagnosis with negative or positive blood, urine or cerebral spinal fluid cultures, respectively, within 72 h of birth. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by logistic regression.ResultsData from 9391 mother-infant pairs were analyzed. The frequency of chorioamnionitis was 10.3%. Overall, 6.6% of the neonates were diagnosed with confirmed (0.2%) or suspected (6.4%) early-onset sepsis. Only 0.7% of infants born in the setting of chorioamnionitis had culture-proven early-onset sepsis versus 0.1% if chorioamnionitis was not present. Clinical chorioamnionitis was associated with both suspected [OR 4.01 (3.16–5.08)] and confirmed [OR 4.93 (1.65–14.74)] early-onset neonatal sepsis, a need for resuscitation within the first 30 min after birth [OR 2.10 (1.70–2.61)], respiratory distress [OR 3.14 (2.16–4.56)], 1 min Apgar score of ≤3 [OR 2.69 (2.01–3.60)] and 4–7 [OR 1.71 (1.43–2.04)] and 5 min Apgar score of 4–7 [OR 1.67 (1.17–2.37)] (vs. 8–10).ConclusionClinical chorioamnionitis is common and is associated with neonatal morbidities. However, the vast majority of exposed infants (99.3%) do not have confirmed early-onset sepsis.

Although preterm birth37 weeks' gestation is the leading cause of neonatal morbidity and mortality in the United States, the majority of data regarding preterm neonatal outcomes come from older studies, and many reports have been limited to only very preterm neonates. Delineation of neonatal outcomes by delivery gestational age is needed to further clarify the continuum of mortality and morbidity frequencies among preterm neonates.We sought to describe the contemporary frequencies of neonatal death, neonatal morbidities, and neonatal length of stay across the spectrum of preterm gestational ages.This was a secondary analysis of an obstetric cohort of 115,502 women and their neonates who were born in 25 hospitals nationwide, 2008 through 2011. All liveborn nonanomalous singleton preterm (23.0-36.9 weeks of gestation) neonates were included in this analysis. The frequency of neonatal death, major neonatal morbidity (intraventricular hemorrhage grade III/IV, seizures, hypoxic-ischemic encephalopathy, necrotizing enterocolitis stage II/III, bronchopulmonary dysplasia, persistent pulmonary hypertension), and minor neonatal morbidity (hypotension requiring treatment, intraventricular hemorrhage grade I/II, necrotizing enterocolitis stage I, respiratory distress syndrome, hyperbilirubinemia requiring treatment) were calculated by delivery gestational age; each neonate was classified once by the worst outcome for which criteria was met.In all, 8334 deliveries met inclusion criteria. There were 119 (1.4%) neonatal deaths. In all, 657 (7.9%) neonates had major morbidity, 3136 (37.6%) had minor morbidity, and 4422 (53.1%) survived without any of the studied morbidities. Deaths declined rapidly with each advancing week of gestation. This decline in death was accompanied by an increase in major neonatal morbidity, which peaked at 54.8% at 25 weeks of gestation. As frequencies of death and major neonatal morbidity fell, minor neonatal morbidity increased, peaking at 81.7% at 31 weeks of gestation. The frequency of all morbidities fell32 weeks. After 25 weeks, neonatal length of hospital stay decreased significantly with each additional completed week of pregnancy; among babies delivered from 26-32 weeks of gestation, each additional week in utero reduced the subsequent length of neonatal hospitalization by a minimum of 8 days. The median postmenstrual age at discharge nadired around 36 weeks' postmenstrual age for babies born at 31-35 weeks of gestation.Our data show that there is a continuum of outcomes, with each additional week of gestation conferring survival benefit while reducing the length of initial hospitalization. These contemporary data can be useful for patient counseling regarding preterm outcomes.

Noninvasive prenatal screening has become an increasingly prevalent choice for women who desire aneuploidy screening. Although the test characteristics are impressive, some women are at increased risk for noninvasive prenatal screen failure. The risk of test failure increases with maternal weight; thus, obese women may be at elevated risk for failure. This risk of failure may be mitigated by the addition of a paternal cheek swab and screening at a later gestational age.The purpose of this study was to evaluate the association among obesity, gestational age, and paternal cheek swab in the prevention of screening failure.A retrospective cohort study was performed for women who were ≥35 years old at delivery who underwent screening at NorthShore University HealthSystem, Evanston, IL. Maternal weight, body mass index, gestational age, and a paternal cheek swab were evaluated in univariate and multivariable logistic regression analyses to assess the association with failed screening.Five hundred sixty-five women met inclusion criteria for our study. The mean body mass index was 25.9 ± 5.1 kg/m(2); 111 women (20%) were obese (body mass index, ≥30 kg/m(2)). Forty-four women (7.8%) had a failed screen. Obese women had a failure rate of 24.3% compared with 3.8% in nonobese women (P.01). Gestational age was not associated with failure rate (mean ± standard deviation, 13 ± 3 weeks for both screen failure and nonfailure; P = .76). The addition of a paternal cheek swab reduced the failure rate from 10.2% in women with no swab to 3.8% in women with a swab (P.01). In multivariable analysis, obesity and lack of a paternal cheek swab were independent predictors of screen failure (odds ratio, 9.75; 95% confidence interval, 4.85-19.61; P.01; and odds ratio, 3.61; 95% confidence interval, 1.56-8.33; P.01, respectively).The addition of a paternal cheek swab significantly improved noninvasive prenatal screen success rates in obese women. However, delaying testing to a later gestational age did not.

Objective We sought to describe the prevalence of serious maternal complications following early preterm birth by gestational age (GA), delivery route, and type of cesarean incision. Study Design Trained personnel abstracted data from maternal and neonatal charts for all deliveries on randomly selected days representing one third of deliveries across 25 US hospitals over 3 years (n = 115,502). All women delivering nonanomalous singletons between 23-33 weeks' gestation were included. Women were excluded for antepartum stillbirth and highly morbid conditions for which route of delivery would not likely impact morbidity including nonreassuring fetal status, cord prolapse, placenta previa, placenta accreta, placental abruption, and severe and unstable maternal conditions (cardiopulmonary collapse, acute respiratory distress syndrome, seizures). Serious maternal complications were defined as: hemorrhage (blood loss ≥1500 mL, blood transfusion, or hysterectomy for hemorrhage), infection (endometritis, wound dehiscence, or wound infection requiring antibiotics, reopening, or unexpected procedure), intensive care unit admission, or death. Delivery route was categorized as classic cesarean delivery (CCD), low transverse cesarean delivery (LTCD), low vertical cesarean delivery (LVCD), and vaginal delivery. Association of delivery route with complications was estimated using multivariable regression models yielding adjusted relative risks (aRR) controlling for maternal age, race, body mass index, hypertension, diabetes, preterm premature rupture of membranes, preterm labor, GA, and hospital of delivery. Results Of 2659 women who met criteria for inclusion in this analysis, 8.6% of women experienced serious maternal complications. Complications were associated with GA and were highest between 23-27 weeks of gestation. The frequency of complications was associated with delivery route; compared with 3.5% of vaginal delivery, 23.0% of CCD (aRR, 3.54; 95% confidence interval (CI), 2.29–5.48), 12.1% of LTCD (aRR, 2.59; 95% CI, 1.77–3.77), and 10.3% of LVCD (aRR, 2.27; 95% CI, 0.68–7.55) experienced complications. There was no significant difference in complication rates between CCD and LTCD (aRR, 1.37; 95% CI, 0.95–1.97) or between CCD and LVCD (aRR, 1.56; 95% CI, 0.48–5.07). Conclusion The risk of maternal complications after early preterm delivery is substantial, particularly in women who undergo cesarean delivery. Obstetricians need to be prepared to manage potential hemorrhage, infection, and intensive care unit admission for early preterm births requiring cesarean delivery.

We sought to evaluate the frequency of, and factors associated with, the use of 3 evidence-based interventions: antenatal corticosteroids for fetal lung maturity, progesterone for prevention of recurrent preterm birth, and magnesium sulfate for fetal neuroprotection.A self-administered survey was conducted from January through May 2011 among obstetricians from 21 hospitals that included 30 questions regarding their knowledge, attitudes, and practice of the 3 evidence-based interventions and the 14-item short version of the Team Climate for Innovation survey. Frequency of use of each intervention was ascertained from an obstetrical cohort of women between January 2010 and February 2011.A total of 329 obstetricians (74% response rate) who managed 16,946 deliveries within the obstetrical cohort participated in the survey. More than 90% of obstetricians reported that they incorporated each intervention into routine practice. Actual frequency of administration in women eligible for the treatments was 93% for corticosteroids, 39% for progesterone, and 71% for magnesium sulfate. Provider satisfaction with quality of treatment evidence was 97% for corticosteroids, 82% for progesterone, and 57% for magnesium sulfate. Obstetricians perceived that barriers to treatment were most frequent for progesterone (76%), 30% for magnesium sulfate, and 17% for corticosteroids. Progesterone use was more frequent among patients whose provider reported the quality of the evidence was above average to excellent compared with poor to average (42% vs 25%, respectively; P.001), and they were satisfied with their knowledge of the intervention (41% vs 28%; P = .02), and was less common among patients whose provider reported barriers to hospital or pharmacy drug delivery (31% vs 42%; P = .01). Corticosteroid administration was more common among patients who delivered at hospitals with 24 hours a day-7 days a week maternal-fetal medicine specialist coverage (93% vs 84%; P = .046), CONCLUSION: Obstetricians in Maternal-Fetal Medicine Units Network hospitals frequently use these evidence-based interventions; however, progesterone use was found to be related to their assessment of evidence quality. Neither progesterone nor the other interventions were associated with overall climate of innovation within a hospital as measured by the Team Climate for Innovation. National Institutes of Health Consensus Conference Statements may also have an impact on use; there is such a statement for antenatal corticosteroids but not for progesterone for preterm prevention or magnesium sulfate for fetal neuroprotection.

OBJECTIVES To estimate 1) the risk of candidiasis (neonatal thrush or breast infections or both) in nursing mother-infant pairs and 2) whether receipt of intrapartum antibiotics increases this risk. METHODS Demographic and obstetric data were obtained at delivery, and telephone follow-up was obtained at 1 week and 1 and 3 months and recorded in the Lactation Services database, which was reviewed retrospectively. The diagnoses of thrush and breast candidiasis were based on symptoms and patient reports, as per standard clinical practice. For statistical analysis, chi(2) analysis and Student t test were used. A value of P < .05 was considered significant. RESULTS A total of 811 nursing mother-infant pairs were seen between February 1, 2001, and August 31, 2002. Mother-infant pairs with follow-up who nursed for 1 month or longer were included (n = 435). Of these, 173 (39.8%) received intrapartum antibiotics, most (78.6%) for group B streptococci prophylaxis. Overall, 46 mother-infant pairs (10.6%) had either thrush or breast candidiasis (32 with both) within 1 month of delivery. Mothers who were exposed to intrapartum antibiotics were significantly more likely to develop breast candidiasis (odds ratio 2.1, 95% confidence interval 1.08-4.08). Antibiotic-exposed neonates were more likely to develop thrush, although this was not statistically significant. (odds ratio 1.87, 95% confidence interval 0.97-3.63). Antibiotic-exposed infants were younger (mean +/- standard deviation, 38.5 +/- 1.9 weeks compared with 39.0 +/- 1.3 weeks; P = .002), but there were no differences in maternal age, gravity or parity, or route of delivery. CONCLUSIONS Neonatal thrush and maternal breast candidiasis are common early postnatal complications. The higher rates of thrush and breast candidiasis in antibiotic-exposed mother-infant pairs merits further study. LEVEL OF EVIDENCE II-2.

OBJECTIVE To apply published scoring systems retrospectively to patients who had undergone a trial of labor after cesarean delivery to estimate whether there was a score at which a trial of labor should be discouraged. METHODS Patients with 1 previous cesarean delivery who then delivered between January 1, 1998, and December 31, 1998, were studied. An investigator blinded to outcome assigned scores using 3 different scoring systems. Student t test, chi(2), analysis of variance, and receiver operating curve analysis were performed. P

Objective This study was undertaken to assess contemporary outcomes in pregnancies managed expectantly after extremely preterm premature (≤24 weeks) premature rupture of the membranes (EPPROM). Study design We queried antepartum and ultrasound databases for patients with EPPROM. Data on pregnancy outcome and short-term neonatal outcomes were collected. Results Forty-six patients with EPPROM were studied. Patients were hospitalized at 24 weeks' gestation and given antibiotics and antenatal steroids. Median gestational age at PPROM was 22.0 weeks (range 16.9-24 weeks); 43 (93%) elected expectant management, 2 of whom later had an intrauterine fetal death. Median latency period to delivery was 13 days (range 0-96 days), with mean gestational age at delivery of 25.8±3.4 weeks. Overall survival was 47% (27 of 57 infants), after a median hospital stay of 71 days (range 17-209 days). Ten (37%) of the survivors have serious sequelae. Conclusion Although significant pregnancy prolongation after previable PPROM occurs in many cases, neonatal outcomes remain poor.

Our aim was to identify preventable risk factors for very low birth weight (VLBW) in our urban patient population in order to target intervention programs toward those areas. Retrospective chart review was performed on all patients who delivered VLBW infants between March 1, 1995 and February 28, 1996 at the Medical College of Virginia Hospitals. VLBW patients were then compared with mothers who delivered infants1,500 g during the same period. Chi-square and Fisher's exact test were used for statistical analysis. P value.05 was considered significant. Of the 77 study patients identified as having delivered VLBW infants, 42% had a preventable risk factor for VLBW. 31% were smokers, 14% were cocaine users, and 10% had no prenatal care. Cigarette smoking and substance abuse are major preventable risk factors for VLBW in our patient population. Efforts to reduce VLBW in our community should focus on reducing tobacco and illicit substance use.

BACKGROUND: Diabetes insipidus is rare in pregnancy. It is characterized by hypoosmolar polyuria and may be central, nephrogenic, or transient in etiology; the latter is presumably related to excess placental vasopresinase production. In theory, fetal effects of this endocrine condition may include hydramnios secondary to fetal polyuria. CASE: A pregnant patient developed rapid-onset second-trimester hydramnios that prompted a thorough fetal and maternal evaluation. She ultimately was diagnosed with transient diabetes insipidus of pregnancy because of an abrupt change in her voiding pattern at 20 weeks of gestation, significant polydipsia, and laboratory studies that revealed a hypoosmolar polyuria with normal serum and urine electrolytes. Transient neonatal polyuria also was confirmed in association with this unique maternal endocrine syndrome. CONCLUSION: The most likely cause of hydramnios in this case is transient maternal diabetes insipidus of pregnancy from excessive secretion of placental vasopressinase resulting in fetal polyuria. In cases of hydramnios of unknown etiology, if a history of maternal polyuria is elicited and confirmed, diabetes insipidus of pregnancy may play a role in some cases.

Background. Early-onset group B streptococcal (GBS) prevention efforts are based on targeted use of intrapartum antibiotic prophylaxis (IAP); applicability of these prevention efforts to infections caused by other organisms is not clear. Methods. Multicenter surveillance during 1995 to 1996 for culture-confirmed, early-onset sepsis in an aggregate of 52 406 births; matched case-control study of risk factors for GBS and other sepsis. Results. Early-onset disease occurred in 188 infants (3.5 cases per 1000 live births). GBS (1.4 cases per 1000 births) andEscherichia coli (0.6 cases per 1000 births) caused most infections. GBS sepsis less often occurred in preterm deliveries compared with other sepsis. Compared with gestation-matched controls without documented sepsis, GBS disease was associated with intrapartum fever (matched OR, 4.1; CI, 1.2–13.4) and frequent vaginal exams (matched OR, 2.9; CI, 1.1–8.0). An obstetric risk factor—preterm delivery, intrapartum fever, or membrane rupture ≥18 hours—was found in 49% of GBS cases and 79% of other sepsis. IAP had an adjusted efficacy of 68.2% against any early-onset sepsis. Ampicillin resistance was evident in 69% of E coliinfections. No deaths occurred among susceptible E coliinfections, whereas 41% of ampicillin-resistant E coliinfections were fatal. Ninety-one percent of infants who developed ampicillin-resistant E coli infections were preterm, and 59% of these infants were born to mothers who had received IAP. Conclusions. Either prenatal GBS screening or a risk-based strategy could potentially prevent a substantial portion of GBS cases. Sepsis caused by other organisms is more often a disease of prematurity. IAP seemed efficacious against early-onset sepsis. However, the severity of ampicillin-resistant E colisepsis and its occurrence after maternal antibiotics suggest caution regarding use of ampicillin instead of penicillin for GBS prophylaxis.

Objective: We undertook the present study to attempt to apply clinical indicators predictive of cervical infection in nongravid populations with either Neisseria gonorrhoeae or Chlamydia trachomatis to our pregnant population and to determine the significance of the clinical diagnosis of “cervicitis.”Methods: A retrospective chart review of all pregnant women with a final diagnosis of cervicitis who were seen in the Medical College of Virginia obstetrical emergency room was performed during the period of September 1991 to December 1992.Results: Given the diagnosis of cervicitis in our emergency department, we found that the clinical examination predicted cervical infection with N. gonorrhoeae or C. trachomatis in only 20% of the pregnant women. Gravidas with chlamydial infections were younger (20.1 ± 3.7 years) compared with gravidas not infected (23.2 ± 5.4 years) (P < 0.0001). They were also more likely to have a diagnosis of lower urinary-tract infection [relative risk (RR) 2.89, 95% confidence interval (CI) 1.42–5.85].Conclusions: The clinical indicators of cervical infection with C. trachomatis and N. gonorrhoeae were unreliable.

Although coexistent HIV infection and pregnancy are still rare in most communities, as the prevalence of HIV and AIDS continues to rise, the practicing physician can expect to see this more frequently. The internist plays a crucial role in educating these patients as to the importance of "safe sex" practices and pregnancy prevention. As with any complex medical problem, once pregnant, these patients are best managed with a team approach, involving the obstetrician, internist, neonatologist, and social worker.Perinatal transmission of human immunodeficiency virus (HIV) has become an important mode of acquisition, which results in the birth of severely ill infants who succumb early to their disease and who often are abandoned in the hospital nursery for the duration of their short lifetime. Consequently, prevention of perinatal transmission is a primary goal. Several recent studies of the seroprevalence of HIV in pregnant women have shown high rates of infection. Landesman et al. report a seroprevalence of 2% when cord blood samples were tested in a blinded fashion in an inner city municipal hospital in Brooklyn, New York. At this time, there is no evidence that HIV infection or Acquired Immune Deficiency Syndrome (AIDS) adversely affects fertility. Perinatal transmission of HIV infection occurs in 33-50% of affected pregnancies. Circumstantial evidence suggest that pregnancy adversely affects the course of disease. Once pregnancy is diagnosed, the patient should be counseled, and abortion and sterilization services should be offered. A table identifies the numerous arguments both in support of and against the routine screening of pregnant women.

Objective:The purpose of this study was to evaluate the Equate Strep B® test for clinical use in patients at high risk for complications from group B streptococcus (GBS) disease.Methods:Vaginoperineal swabs were obtained from patients with preterm premature rupture of the membranes and/or preterm labor and semiquantitative GBS cultures and Equate® assay were performed.Results:From May 14, 1990, to April 30, 1992, 650 patients were enrolled; 626 had both culture and Equate® results available, of whom 24% were colonized with GBS. The sensitivity, specificity, positive predictive value, and negative predictive value of the rapid assay were 28%, 84%, 35%, and 79%, respectively. Although the prevalence of GBS was higher in patients with ruptured membranes compared with those with intact membranes, rupture of membranes did not affect test sensitivity or specificity.Conclusions:We conclude that the Equate® rapid assay is not a sensitive method of GBS detection in high-risk patients.

Objective: Our objective was to determine the incidence of blood transfusion in patients delivered by cesarean section and to identify factors predictive of the need for transfusion. Study design: A chart review was performed on cesarean patients receiving blood transfusion over a year at the Medical College of Virginia Hospital and an equal number of randomly selected cesarean patients. Results: Sixty-one (6.8%) patients received a packed red blood cell transfusion intraoperatively or postoperatively. Transfusion was associated with lower gestational ages, antepartum bleeding, arrest of descent, and longer postoperative stays. After stepwise logistic regression analysis, only antepartum bleeding and preoperative hemoglobin were significant independent predictors of the need for blood transfusion. Conclusion: Transfusion with cesarean section is common and is associated with antepartum bleeding and other primarily intrapartum and unpredictable factors.

To estimate the efficacy of antibiotic prophylaxis at the time of nonlaboring cesarean delivery in reducing postpartum infection-related complications.We performed a secondary analysis of an observational study of cesarean deliveries performed at 13 centers from 1999-2000. Patients were included if they had cesarean delivery before labor, did not have intrapartum infection, and were not given antibiotics at delivery for reasons other than prophylaxis. The occurrence of postpartum endometritis, wound infection, and other, less common infection-related complications was compared between those who did and did not receive antibiotic prophylaxis. Results were adjusted for smoking, payer status, gestational age and body mass index at delivery, race, diabetes, antepartum infections, presence of anemia, operative time, type of cesarean delivery (primary or repeat), and center.Of the 9,432 women who met study criteria, the 6,006 (64%) who received antibiotic prophylaxis were younger, heavier at delivery, and were more likely to be African American, receive public insurance, and have diabetes. Patients who received antibiotic prophylaxis were less likely to develop postpartum endometritis (121 [2.0%] compared with 88 [2.6%], adjusted odds ratio [OR] 0.40, 95% confidence interval [CI] 0.28-0.59) or wound infection (31 [0.52%] compared with 33 [0.96%], adjusted OR 0.49, 95% CI 0.28-0.86).Antibiotic prophylaxis at the time of nonlaboring cesarean delivery significantly reduces the risks of postpartum endometritis and wound infection.III.

Recent advances in prevention, diagnosis, and treatment of infection-associated preterm labor are discussed. This includes antepartum treatment of vaginal infections, amniocentesis for culture and glucose levels, and adjunctive antibiotic treatment of preterm labor and preterm premature rupture of the membranes. Risk factors for neonatal group B streptococcus sepsis are described and testing for rapid detection of maternal group B streptococcus colonization is discussed, as are recent prospective studies of pregnancy outcome following human parvovirus B19 infection. Studies quantifying the transmission of herpes simplex virus to neonates following vaginal delivery to mothers with recurrent infections are discussed, as well as the results of several studies using rapid detection kits for the virus.

Counseling for pyelectasis in the late 2nd trimester is usually based only upon assessing the antero-posterior (AP) width of the renal pelvis. We hypothesized that checking additional features would better predict postnatal outcome.Ultrasound (24 weeks gestational age (GA)) and newborn outcome data collected prospectively since 1986 were analyzed retrospectively. We determined if outcome predictions in kidneys with a sonographically evident renal pelvis (SERP), which had evaluation of additional features (e.g., renal and bladder lengths, presence of a dilated ureter or dilated calyces) are more accurate than those that did not have these features.There were 286 fetuses studied with pediatric follow-up of an average of 6.5 years. There were 338 exams providing 459 ultrasound images with SERP. Additional features were not assessed in 183 fetuses; however 103 fetuses did have evaluation of additional features. These features were categorized as abnormal (92) or as normal (11). Fetuses with SERP and abnormal additional features required extensive urological care or died 6.1 times more often than fetuses in which additional features were not examined (p0.001) and 12.9 times more often when additional features were normal (p0.001).Fetal kidneys with SERP (24 weeks GA) and an abnormal additional ultrasound feature had extensive pediatric care significantly more often than when such features were not evaluated or were normal.

Objective To evaluate the progression in utero of mild isolated fetal ventriculomegaly (defined as a transverse diameter of the atrium of the lateral ventricle measuring between 10 and 15 mm), and to estimate the proportion of fetuses that normalize (diameter decreasing to less than 10 mm), stabilize (remaining between 10 and 15 mm), or progress to more severe ventriculomegaly (becoming greater than 15 mm). Methods The obstetric databases of 3 institutions were queried for any studies mentioning ventriculomegaly or hydrocephalus. Reports and original images were reviewed to verify cases of isolated mild ventriculomegaly, with no other anomalies on comprehensive ultrasonographic examination. Fetuses that had 2 or more evaluations more than 3 weeks apart were included. Results A total of 63 fetuses met the criteria for isolated mild ventriculomegaly. The mean gestational age and ventricular measurements were 24.7 ± 3.7 weeks and 11.8 ± 1.1 mm, respectively, at the initial scan and 34 ± 2.9 weeks and 12.1 ± 3.8 mm, respectively, at the final scan. The mean number of scans was 3.75 per fetus (range, 2–6). Amniocentesis revealed the deletion of 5p, which causes the cri du chat, in 1 of 21 fetuses; 26 fetuses (41%) showed normalization of the lateral ventricles; 10 fetuses (16%) showed progression; and 27 (43%) appeared stable. Table 1 shows the statistics of the individual groups. Three of the fetuses that “stabilized” improved from 15 mm to 11, 11.5, and 11.7 mm, respectively. Two worsened from 10.2 to 14 mm and from 11.4 to 13 mm. Conclusions More than 40% of the cases of mild isolated fetal ventriculomegaly resolved in utero. The significant overlap in measurements for the different groups precludes prediction in individual cases. However, of the 13 cases where the transverse diameter measured 13 mm or more, only 1 normalized, while 9 of the remaining 12 cases stabilized and 3 progressed.

Autologous blood donation has been recommended for patients with placenta previa. We hypothesized that premature delivery, preexisting anemia, and bleeding would limit its utilization. We reviewed the charts of all patients admitted with placenta previa between July 1, 1989, and April 30, 1992. To be eligible for autologous donation we assumed that the patient would need to be asymptomatic with a hematocrit 34% or higher at 32 weeks' gestation. Eighty-eight patients were admitted with placenta previa, 12 (14%) of whom were eligible for autologous donation. Two eligible patients required transfusion at delivery and four delivered prior to 34 weeks. Few patients with placenta previa are eligible for autologous donation and although two would have used their autologous units, twice as many may have been compromised by recent autologous donation. We conclude that autologous donation is not feasible in a majority of patients with placenta previa and is of limited usefulness in its management.

We report a case of fetal urethral obstruction complicated by spontaneous rupture of the megacystic fetal bladder and rupture of the abdominal wall, resulting in the temporary resolution of oligohydramnios and creation of a secondary gastroschisis.

OBJECTIVE: We hypothesized that HIV-positive women on protease inhibitors (PIs) would be more likely to have an elevated glucola test result than those not on PIs. METHODS: We reviewed our database of all HIV-positive pregnant women seen at our hospital. Serum glucose was measured 1 hour following a 50-g glucola load, at approximately 26-28 weeks of gestation. Statistical analysis was performed using Student's t-test, Fisher's exact test, and the Mann-Whitney rank sum test. RESULTS: Forty-one HIV-infected pregnant women with glucola testing were seen between January 1, 1997 and March 1, 2000. Fourteen patients were on PIs at the time of glucola. One patient in each group had an abnormal glucola test result (glucose >/= 140 mg/dl); both had normal 3-hour glucose tolerance tests. The glucola test results were similar between the PI-exposed and unexposed, with a mean difference of 5.8 mg/dl (95% confidence interval 9.2-20.8 mg/dl). Two neonates (both exposed to PI) had hypoglycemia (glucose < 40 mg/dl). CONCLUSIONS: The use of PIs does not significantly increase the risk of an elevated glucola result, nor is the mean glucola result increased in the women on PIs. The finding of hypoglycemia in neonates exposed to PIs merits further investigation.

Preeclampsia is a systemic disease of pregnancy characterized by maternal hypertension, proteinuria, and edema. These clinical pathological findings may be attributed to abnormalities in vascular endothelial activation secondary to increased oxidative stress. To test the hypothesis that increased circulating lipid peroxides in preeclamptic women activate vascular endothelial cells, we determined NF-kappaB transcriptional activity and ICAM-1 expression in human umbilical vein endothelial cells (HUVEC) cultured with plasma from women with severe preeclampsia (preeclamptic plasma, N = 12) or plasma from normal pregnancies (normal plasma, N = 12). Preeclamptic women had increased circulating lipid peroxides compared with normal pregnant women, as demonstrated by a 4.5-fold higher concentration of plasma malondialdehyde (PkB luciferase reporter construct transfected into HUVEC, preeclamptic plasma was found to up-regulate HUVEC NF-kappaB activity by 2.5-fold when compared with normal plasma (PkB activation in response to preeclamptic-plasma by 77% (PkB activation and ICAM-1 expression on HUVEC, which can be inhibited by vitamin E and N-acetyl-cysteine.

The six agents identified thus far that cause viral hepatitis are reviewed, and their impact upon pregnancy is described. Although it is the most common cause of jaundice during pregnancy, viral hepatitis does not generally increase the risk of pregnancy complications, nor is it teratogenic. Vertical transmission of some types of viral hepatitis does occur, however.

Bacteroides bivius is a common anaerobe in female genital infections. Although protein banding patterns of outer membrane (OM) preparations of Bacteroides fragilis are well described and are homologous within the species, similar work has not been done with B. bivius. Our aims were to (i) characterize the OM banding patterns of B. bivius and compare them with those of other Bacteroides species and (ii) test clinical isolates of B. bivius against anti-B. bivius and anti-B. fragilis sera to identify different serogroups that might also exhibit different OM banding patterns. OM-enriched fractions of 27 clinical strains of B. bivius, 6 Bacteroides disiens strains, 10 B. fragilis strains, and 12 other Bacteroides strains were prepared, and sodium dodecyl sulfate-polyacrylamide gel electrophoresis was performed. Antisera to B. bivius ATCC 29303 and B. fragilis ATCC 25285 were raised in rabbits and tested against Bacteroides strains in an indirect enzyme-linked immunosorbent assay. All 27 B. bivius strains contained protein bands at 32, 27, 25, and 23 kilodaltons. This pattern was present in only 2 of 28 other strains; both of these were B. disiens. All B. bivius strains were reactive with the anti-B. bivius serum, while only 6 of 39 other strains (2 of 6 B. disiens) were reactive. Non-B. fragilis Bacteroides strains did not react with the anti-B. fragilis serum. Although there was marked homogeneity in the OM banding patterns of B. bivius, some B. disiens strains exhibited similar OM banding patterns. There appears to be some antigenic cross-reactivity between strains of B. bivius and B. disiens and very little with other Bacteroides species. These results may ultimately allow the development of rapid diagnostic tests for the B. bivius-B. disiens group.t