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To establish the role of clinical chorioamnionitis as an independent risk factor for recurrence in a subsequent pregnancy.This was a historical cohort study of pregnant women who had their first and second deliveries at our institution between January 1988 and May 2005. The index pregnancy was restricted to those who delivered vaginally. Data were collected from a continuously updated obstetric database and included demographic and labor characteristics and neonatal outcomes. Chorioamnionitis was diagnosed clinically.The study population consisted of 23,397 women. During the index pregnancy, 10% of women developed chorioamnionitis. This group was significantly different from the rest of the cohort in terms of age, ethnicity, length of labor, epidural analgesia, use of internal monitors, and incidence of prolonged rupture of membranes. In the second pregnancy, 6% of those women again developed chorioamnionitis compared with 2% of women who did not have chorioamnionitis in the first pregnancy (odds ratio 2.93, 95% confidence interval 2.40-3.57). After adjusting for the above confounders, the increased risk of recurrence persisted (odds ratio 1.85, 95% confidence interval 1.49-2.30).Women delivering vaginally who were diagnosed with chorioamnionitis during their first pregnancy are at increased risk for chorioamnionitis in a subsequent pregnancy. This supports the concept that there may be a predisposition to chorioamnionitis that should be further investigated.II-2.

Respiratory infections that complicate pregnancy are encountered frequently, and they encompass a broad range of disorders. Although respiratory infections usually are not seen more commonly in pregnancy, they often result in greater morbidity and mortality secondary to the physiologic adaptations that occur during pregnancy. Pregnant patients who have one of these disorders require a higher level of surveillance and intervention.

The objective of this study was to review the presentation and management of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) in pregnant women.This was a chart review of pregnant patients who were diagnosed with MRSA between January 1, 2000, and July 30, 2004. Data collected included demographic characteristics, clinical presentation, culture results, and pathogen susceptibilities. Patients' pregnancy outcomes were compared with the general obstetric population during the study period.Fifty-seven charts were available for review. There were 2 cases in 2000, 4 in 2001, 11 in 2002, 23 in 2003, and 17 through July of 2004. Comorbid conditions included human immunodeficiency virus and acquired immunodeficiency syndrome (13%), asthma (11%), and diabetes (9%). Diagnostic culture was most commonly obtained in the second trimester (46%); however 18% of cases occurred in the postpartum period. Skin and soft tissue infections accounted for 96% of cases. The most common site for a lesion was the extremities (44%), followed by the buttocks (25%), and breast (mastitis) (23%). Fifty-eight percent of patients had recurrent episodes. Sixty-three percent of patients required inpatient treatment. All MRSA isolates were sensitive to trimethoprim-sulfamethoxazole, vancomycin, and rifampin. Other antibiotics to which the isolates were susceptible included gentamicin (98%) and levofloxacin (84%). In comparison with the general obstetric population, patients with MRSA were more likely to be multiparous and to have had a cesarean delivery.Community-acquired MRSA is an emerging problem in our obstetric population. Most commonly, it presents as a skin or soft tissue infection that involves multiple sites. Recurrent skin abscesses during pregnancy should raise prompt investigation for MRSA.II-3.

Influenza is a significant cause of morbidity and mortality from febrile respiratory illness worldwide. Influenza in pregnant women has historically been associated with a higher rate of morbidity and mortality. Pneumonia is the sixth leading cause of death in the United States, and it is the number one cause of death from an infectious disease. Although pregnant women do not get pneumonia more often than nonpregnant women, it can result in greater morbidity and mortality because of the physiologic adaptations of pregnancy. Pregnant patients who have either of these conditions require a higher level of surveillance and intervention.

There were approximately 2 million deaths worldwide from tuberculosis in 1997, 98% of them in developing countries. Factors implicated in the resurgence of tuberculosis in the United States in the late 80s and early 90s included increased immigration from countries with high prevalence, HIV infection, emergence of resistant strains, poverty, homelessness, drug abuse, and a decline in tuberculosis-related health services. With better control programs, cases began to decrease in 1993. In 1998, 18,361 cases of tuberculosis (6.8 per 100,000 population) were reported to the US Centers for Disease Control and Prevention (CDC), a 31% decrease from 1992. Pregnancy is not thought to change the course of tuberculosis; however, tuberculosis poses a risk to the pregnant woman and her fetus.

OBJECTIVE: To estimate the incidence of puerperal mastitis requiring hospital admission and to describe demographic and obstetric risk factors for this condition. We also sought to identify trends in bacteriology among isolates obtained from breast abscesses and breast-milk aspirates, with a focus on treatment strategies used for community-acquired methicillin-resistant Staphylococcus aureus (MRSA). METHODS: Patients with puerperal mastitis who were admitted to a county-based teaching hospital between January 1997 and December 2005 were identified by International Classification of Diseases, 9th Revision, codes (675.1, 675.2). Data collected included demographic characteristics, clinical presentation, treatment, duration of admission, premorbid antibiotic exposure, and bacteriology. Demographic variables and obstetric outcomes were compared with all other pregnant women delivered at our hospital. RESULTS: One hundred twenty-seven of 136,459 women delivered at our teaching hospital were admitted for puerperal mastitis (9.3 [95% confidence interval (Cl) 7.8-11.1] per 10,000 deliveries). The incidence of mastitis only during the study period was 6.7 (95% Cl 5.4-8.3) per 10,000 deliveries, and the incidence of mastitis with breast abscess was 2.6 (95% Cl 1.8-3.6) per 10,000 deliveries. Puerperal mastitis was significantly associated with younger women (23.4 years compared with 25.1 years, P

Objective To measure the efficacy of valacyclovir suppression in late pregnancy to reduce the incidence of recurrent genital herpes in labor and subsequent cesarean delivery. Methods A total of 350 pregnant women with a history of genital herpes were assigned randomly to oral valacyclovir 500 mg twice a day or an identical placebo from 36 weeks of gestation until delivery. In labor, vulvovaginal herpes simplex virus (HSV) culture and polymerase chain reaction (PCR) specimens were collected. Vaginal delivery was permitted if no clinical recurrence or prodromal symptoms were present. Neonatal HSV cultures and laboratory tests were obtained, and infants were followed up for 1 month after delivery. Data were analyzed using chi2 and Student t tests. Results One hundred seventy women treated with valacyclovir and 168 women treated with placebo were evaluated. Eighty-two percent of the women had recurrent genital herpes; 12% had first episode, nonprimary genital herpes; and 6% had first episode, primary genital herpes. At delivery, 28 women (8%) had recurrent genital herpes requiring cesarean delivery: 4% in the valacyclovir group and 13% in the placebo group (P = .009). Herpes simplex virus was detected by culture in 2% of the valacyclovir group and 9% [corrected] of the placebo group (P =.02). No infants were diagnosed with neonatal HSV, and there were no significant differences in neonatal complications. There were no significant differences in maternal or obstetric complications in either group. Conclusion Valacyclovir suppression after 36 weeks of gestation significantly reduces HSV shedding and recurrent genital herpes requiring cesarean delivery. Level of evidence I.

The purpose of this study was to estimate whether universal influenza vaccination of pregnant women was cost-effective in the management of influenza-like illness during influenza season.A decision analysis model was developed to investigate the cost-effectiveness of providing inactivated trivalent influenza vaccine to all pregnant women. This scenario was compared with providing supportive care only on a case-by-case basis to the unvaccinated pregnant population.Vaccination of 100% of pregnant women would save approximately 50 dollars per woman, resulting in a net gain of approximately 45 quality-adjusted hours relative to providing supportive care only.Universal vaccination with inactivated trivalent influenza vaccine is cost-saving relative to providing supportive care alone in the pregnant population.III.

To determine if protease inhibitor use was associated with increased glucose intolerance in our population of pregnant women infected with the human immunodeficiency virus (HIV).Women who were infected with HIV from January 1, 1998, to January 8, 2004, and who had a 1-hour and 3-hour glucola test were identified. Medical records were reviewed to obtain demographic characteristics and obstetric and laboratory data. Drug regimens at the time of glucola testing were determined. Human immunodeficiency virus-infected women were then matched 1:3 to HIV-noninfected gravidas by race, age, and year of delivery.One hundred seventy-one HIV-infected women had glucola results available. Twelve percent had an abnormal 1-hour glucola result and 3% had an abnormal 3-hour result. This was similar to the HIV-noninfected population. Forty-five percent of the HIV-infected cohort was on a protease inhibitor at the time of glucola testing. Protease inhibitor exposure had no effect on glucola test results. HIV infection itself also did not increase abnormal glucola test results.Glucose intolerance in this obstetric population was not associated with the diagnosis of HIV or with the use of protease inhibitors. Protease inhibitors should continue to be an option for the treatment of HIV in pregnancy.

To test the hypothesis that high (or =20.7 ng/mL) pretreatment serum folic acid level increases the failure of single-dose methotrexate for ectopic pregnancy.Twenty patients with ectopic pregnancy and measured pretreatment folic acid levels were divided into 2 groups based on pretreatment serum folic acid level (oror =20.7 ng/mL). All patients were candidates for single-dose methotrexate treatment. Variables analyzed in the 2 groups were pretreatment folic acid level, initial P-human chorionic gonadotropin (hCG) level, size of the ectopic mass, presence of fetal heart tones and clinical outcomes.Eleven patients had serum folic acid levelsand 9or =20.7 ng/mL. The mean (+/- SD) folic acid level was 13.4 ng/mL (+/- 3.2) in the group with folic acid levels20.7 ng/mL, significantly lower than in the group with folic acid levels20.7 ng/mL (p0.001). The 2 groups were similar in initial hCG level, size of the ectopic mass and presence of fetal heart tones. The failure rate was significantly higher in the group with pretreatment serum folic acid levelsor = 20.7 ng/mL as compared to the group below (n = 4, 44%, vs. n = 0, 0%; p = 0.02).High pretreatment folic acid levels increase the risk of treatment failure with single-dose methotrexate.

Objective The incidence of perinatal transmission of neonatal herpes infection has recently been reported at 1 in 3200 births. The main objective of this study was to determine a population-based incidence of neonatal herpes simplex virus infection. Study Design This was a retrospective chart review of newborn infants presenting with herpes infection established by cerebrospinal fluid polymerase chain reaction or lesion culture between 1999 and 2003. Only infants delivered at our institution were considered to establish a population-based incidence. Results Four cases of neonatal herpes infection were identified based on polymerase chain reaction and culture diagnosis. During the study period 78,115 infants were delivered at our institution yielding an incidence of 1 in 20,000 live births. Conclusion The incidence of neonatal herpes infection at our institution is lower than reported elsewhere. A national surveillance program of neonatal herpes is needed to measure the burden of disease across the United States.

205 THE EFFICACY AND SAFETY OF INFLUENZA VACCINATION IN PREGNANCY JEANNE SHEFFIELD, VANESSA LAIBL, SCOTT ROBERTS, MARY LORIMER, BRIAN CASEY, DON MCINTIRE, GEORGE D. WENDEL JR, University of Texas Southwestern Medical Center at Dallas, Obstetrics and Gynecology, Dallas, Texas OBJECTIVE: Limited data are available about the efficacy of influenza vaccination in pregnant women. We sought to measure the efficacy and safety of the inactivated influenza vaccine in pregnant women during the 2003-2004 influenza season. STUDY DESIGN: Pregnant women R20 weeks gestation from our prenatal clinics were offered the inactived influenza vaccine during the 2003-2004 influenza season. Data prospectively were collected on vaccinated women and a matched control group receiving prenatal care during the influenza season at the same gestational age who did not get vaccinated. Student t-test and chisquare analysis were performed to compare the two groups. RESULTS: During the 2003-2004 influenza season, 2889 pregnant women received the inactive influenza vaccine. To date, 2352 (81%) of these women have delivered, and the analysis is limited to this subset. The comparison group includes 1988 women. There were no significant differences in demographic characteristics between the 2 groups.The mean EGA at vaccination was 30.0 G 5.9 weeks. The vaccinated group was less likely to deliver an infant !36 weeks (3% versus 5%, P = .02) and less likely to have a newborn NICU admission (P = .04). All other obstetric and neonatal complications were similar in the 2 groups, including neonatal infection and malformation rates. Overall, 6 women (2.6 per 1000) in the vaccinated group developed laboratory confirmed influenza and 13 women (6.5 per 1000) developed infection in the non-vaccinated group (P = .047). When restricting the analysis to those women developing influenza >2 weeks after vaccination, the time required to develop immunity, there was 1 case (0.4 per 1000) of influenza (P ! .001: RR = 15.5 (2.02,118.4)). CONCLUSION: The influenza vaccine efficacy rate during the 2003-2004 season in our pregnant population was >99%. Significantly fewer women developed influenza after the vaccine, and it reduced the rate of influenza 15 fold when given over 2 weeks before exposure. The inactivated influenza vaccine is very effective and safe for women in the second half of prenancy. S66 SMFM Abstracts