Search

The purpose of this pilot study was to examine possible neurotoxic effects of prenatal methamphetamine (Meth) exposure on the developing brain and on cognition. Meth-exposed children (n=13) and unexposed control subjects (n=15) were evaluated with MRI. Global brain volumes and regional brain structures were quantified. Ten Meth-exposed and nine unexposed children also completed neurocognitive assessments. Meth-exposed children scored lower on measures of visual motor integration, attention, verbal memory and long-term spatial memory. There were no differences among the groups in motor skills, short delay spatial memory or measures of non-verbal intelligence. Despite comparable whole brain volumes in each group, the Meth-exposed children had smaller putamen bilaterally (-17.7%), smaller globus pallidus (left: -27%, right: 30%), smaller hippocampus volumes (left: -19%, right: -20%) and a trend for a smaller caudate bilaterally (-13%). The reduction in these brain structures correlated with poorer performance on sustained attention and delayed verbal memory. No group differences in volumes were noted in the thalamus, midbrain or the cerebellum. In summary, compared with the control group, children exposed to Meth prenatally exhibit smaller subcortical volumes and associated neurocognitive deficits. These preliminary findings suggest prenatal Meth exposure may be neurotoxic to the developing brain.

To determine fetal growth and the incidence of withdrawal symptoms in term infants exposed to methamphetamine in utero, we retrospectively identified neonates whose mothers used methamphetamine during pregnancy and matched them to unexposed newborns. Exclusion criteria included multiple and preterm gestations. Although there were no differences in infant growth parameters between the methamphetamine-exposed and methamphetamine-unexposed neonates, methamphetamine exposure throughout gestation was associated with decreased growth relative to infants exposed only for the first two trimesters. In addition, there were significantly more small for gestational age infants in the methamphetamine group compared with the unexposed group. Methamphetamine-exposed infants whose mothers smoked had significantly decreased growth relative to infants exposed to methamphetamine alone. Withdrawal symptoms (as determined by a previously reported scoring system) requiring pharmacologic intervention were observed in 4% of methamphetamine-exposed infants. These preliminary findings indicate that methamphetamine use is associated with growth restriction in infants born at term.

Objective: The effects of prenatal cocaine exposure have been examined using neurobehavioral and brain structural evaluations; however, no study has examined the effects of prenatal cocaine on brain metabolism. Proton magnetic resonance spectroscopy ((1)H-MRS) is a noninvasive method to examine the biochemistry of various brain regions. The purpose of this study was to examine the possible neurotoxic effects of prenatal cocaine exposure on the developing brain using (1)H-MRS., Methods: Cocaine-exposed children (n = 14) and age-matched unexposed control participants (n = 12) were evaluated with MRI and localized (1)H-MRS. Metabolite concentrations of N-acetyl-containing compounds (NA), total creatine (Cr), choline-containing compounds, myoinositol, and glutamate + glutamine were measured in the frontal white matter and striatum., Results: Despite an absence of structural abnormalities in either group, children exposed to cocaine in utero had significantly higher Cr (+13%) in the frontal white matter. NA, primarily a measure of N-acetyl aspartate and neuronal content, was normal in both regions examined by (1)H-MRS. Normal NA suggests no significant neuronal loss or damage in the 2 brain regions examined in children exposed to cocaine prenatally., Conclusions: Consistent with findings in abstinent adult cocaine users, we found increased Cr in the frontal white matter, with normal NA in children exposed to cocaine. These findings suggest the need to investigate further possible abnormalities of energy metabolism in the brain of children exposed to cocaine in utero. In addition, this study demonstrates the feasibility of using (1)H-MRS to investigate the effects of prenatal drug exposure on the developing brain.

To estimate the prevalence of human immunodeficiency virus type 1 (HIV-1) among parturients in an area with a high cumulative incidence of AIDS, an HIV seroprevalence study was conducted in 1988 in Los Angeles County. Test results were available from 8485 (86.1%) of the 9860 women delivering at four public hospitals. The test results were linked to demographic and medical information available from routinely collected delivery records. Three specimens were HIV-positive, for a seroprevalence of 3.5 per 10,000. The seropositive women were all Latina. The prevalence of HIV among women delivering at all hospitals in Los Angeles County has been shown to be relatively low compared with that of other metropolitan areas with a high number of AIDS cases, such as New York city, but appears to be even lower among women delivering at public hospitals during this time period. This low prevalence is attributed to the predominance of Latinas, who may have lower levels of infection, among public hospital parturients. The relatively low prevalence of HIV among injection drug users in Los Angeles County may contribute to the overall lower prevalence among women in Los Angeles County compared with those in New York city. This study supplements county-specific data obtained from statewide blinded neonatal testing by providing details on HIV seroprevalence among the catchment populations of public hospitals in Los Angeles County.

The purpose of this randomized, double-blind study was to evaluate the efficacy and safety of a new controlled-release hydrogel pessary for ripening the cervix and initiating labor. Subjects had an entry Bishop score of 4 or less and gestational age of 37 or more weeks. One hundred fourteen women received a placebo pessary and 101 received the hydrogel pessary, containing 10 mg of prostaglandin (PG) E2. Compared with the placebo group, those given the PGE2 pessary were more likely to have an increase in Bishop score of 3 or more (60 or 59% versus 21 or 18%; P less than .0001), change to a Bishop score of 6 or higher (59 or 58% versus 18 or 16%; P less than .0001), and active labor (68 or 67% versus 15 or 13%; P less than .0001). Including the crossover study, uterine hyperstimulation (28 of 182, 15%) and fetal heart rate abnormalities (18 of 182, 10%) in PGE2-treated subjects were reversed on removal of the pessary with no apparent harm to the mother or fetus. These temporary adverse effects appeared while the pessary was in place and after the onset of active labor. Oxytocin was unnecessary in 89 of 182 (49%) of the PGE2-treated cases and was used more often to augment than to induce labor. We conclude that the described controlled-release PGE2 vaginal pessary induces appreciable cervical ripening and frequently initiates active labor with little or no need for oxytocin. The pessary may cause uterine hyperstimulation or fetal heart rate abnormalities, but these would be expected to reverse on removal of the pessary.

Fetal heart rate tracings of pregnancies complicated by cocaine use were analyzed to evaluate the effects of subacute maternal cocaine use on the fetus. Nonstress tests were performed twice weekly on patients from the perinatal substance abuse clinic with screening of maternal urine samples for cocaine, amphetamines, phencyclidine, and opiates at the time of each examination. Nonstress tests performed when the urine toxicology screen was positive for cocaine alone (positive cocaine nonstress tests) were paired with those from the same patient but performed when the screen was negative (negative cocaine nonstress tests). The nonstress tests were analyzed with the Lyons scoring system, which evaluates the baseline heart rate, the oscillatory amplitude of the baseline, the oscillatory frequency, decelerations, and accelerations. Twenty pairs of nonstress tests from 20 patients were analyzed. The total score was higher on the negative cocaine nonstress test in 70% of the pairs and equal in the remaining 30% (p less than 0.001). Significant differences occurred in the oscillatory amplitude (p less than 0.001), frequency (p = 0.002), and acceleration scores (p = 0.03) but not the fetal heart rate baseline or the deceleration scores. The observed changes may reflect alterations in fetal central nervous system neurotransmitters and fetal state regulation, which may affect the developing central nervous system of cocaine-exposed fetuses and in turn play a role in the developmental and behavioral abnormalities observed in cocaine-exposed infants.

We performed a case-control study of the association of past exposure to Chlamydia trachomatis and ectopic pregnancy with 306 case patients with an ectopic pregnancy and 266 pregnant patients who served as controls. The geometric mean antichlamydial antibody titer among cases was 75 +/- 10.2 vs 13 +/- 11.0 among controls. The matched-pair odds ratio for ectopic pregnancy and IgG titer of 1:64 or greater to C trachomatis was 3.0 (95% confidence interval, 2.1 to 4.4). Adjusting for age at first intercourse, total lifetime partners, douching, history of infertility, and parity yielded a relative risk of 2.4 (95% confidence interval, 1.5 to 3.3). Current douching remained an independent risk factor after controlling for chlamydial exposure, with an adjusted relative risk of 2.1 (95% confidence interval, 1.3 to 3.5). The population attributable fraction for chlamydial infection was 0.47 and that for douching was 0.45. The results stress the need for control of C trachomatis infections and for further study of specific douching behaviors as risk factors for ectopic pregnancy.

Phencyclidine (PCP) remains a widely used illicit drug, especially among adolescents and young adults. The pharmacologic effects of PCP are similar to those of cocaine; therefore, in this retrospective study 37 PCP-intoxicated parturients were matched for ethnicity, tobacco use, age, gravidity, and degree of prenatal care with 37 cocaine-intoxicated parturients. Infants exposed to PCP in utero, like those exposed to cocaine, had a high incidence of intrauterine growth retardation (32 vs 19%, N.S.), precipitate labor (43 vs 27%, N.S.), symptoms of neonatal drug withdrawal/intoxication, and prolonged neonatal hospitalizations. Moreover, they were more likely to have meconium-stained amniotic fluid (30 vs 19%, p = .05) and less likely to be born prematurely as cocaine-exposed infants. The comparison between the long-term developmental outcome of these groups awaits further study.

In Los Angeles County, California, 142 cases of human listeriosis were reported from January 1 through August 15, 1985. Ninety-three cases (65.5 percent) occurred in pregnant women or their offspring, and 49 (34.5 percent) in nonpregnant adults. There were 48 deaths: 20 fetuses, 10 neonates, and 18 nonpregnant adults. Of the nonpregnant adults, 98 percent (48 of 49) had a known predisposing condition. Eighty-seven percent (81 of 93) of the maternal/neonatal cases were Hispanic. Of the Listeria monocytogenes isolates available for study, 82 percent (86 of 105) were serotype 4b, of which 63 of 86 (73 percent) were the same phage type. A case-control study implicated Mexican-style soft cheese (odds ratio, 5.5; 95 percent confidence interval, 1.2 to 24.8) as the vehicle of infection; a second case-control study showed an association with one brand (Brand A) of Mexican-style soft cheese (odds ratio, 8.5; 95 percent confidence interval, 2.4 to 26.2). Laboratory study confirmed the presence of L. monocytogenes serogroup 4b of the epidemic phage type in Brand A Mexican-style cheese. In mid-June, all Brand A cheese was recalled and the factory was closed. An investigation of the cheese plant suggested that the cheese was commonly contaminated with unpasteurized milk. We conclude that the epidemic of listeriosis was caused by ingestion of Brand A cheese contaminated by one phage type of L. monocytogenes serotype 4b.

A prospective randomized study of 85 parturients was undertaken comparing the safety and efficacy of a 3-mg prostaglandin E2 vaginal suppository with intravenous oxytocin for the induction of labor. All patients were required to have a Bishop's score of 5 or higher. Labor was successfully induced in 98% of the patients in both groups by their respective methods. Sixty-four percent of the patients receiving a 3-mg prostaglandin E2 suppository required no intravenous oxytocin. More specifically, 82% (23/28) of the parous patients but only 29% (5/17) of the nulliparous patients who received a single 3-mg prostaglandin E2 suppository for labor induction did not require oxytocin augmentation (P less than .005). The first and second stages of labor were not significantly different for the two groups, and there was no significant difference in the incidence of cesarean section. A 3-mg prostaglandin E2 vaginal suppository may be a useful alternative to oxytocin for the induction of labor in carefully selected patients.

We report the broad spectrum of clinical manifestations in 23 infants with positive cultures for Listeria monocytogenes who were treated in our hospital during a recent epidemic. The majority of infants (70%) were preterm and none was small for gestational age. Thirteen (56%) had respiratory distress at birth with evidence of congenital pneumonia. Four of the 5 deaths occurred among these infants. Four infants considered healthy after resuscitation developed fever and lethargy within 36 hours after birth. Only one of these infants had evidence of pneumonia. We conclude that congenital pneumonia with respiratory distress at birth is the major cause of mortality and morbidity from L. monocytogenes infection in the neonate.

To examine the role of Chlamydia trachomatis infections of the cervix and abnormal postcoital tests (PCT) in a general infertility clinic, 63 consecutive patients undergoing a midcycle PCT during a routine infertility workup underwent endocervical curettage, and a 10-ml blood sample was obtained. The endocervical tissue was cultured for C. trachomatis; the serum sample was analyzed for chlamydial IgG and IgM antibodies using an indirect microimmunofluorescence assay. A negative titer was considered to be less than or equal to 1:8 dilution for IgG antibodies and less than or equal to 1:32 dilution for IgM antibodies. A good PCT was defined as greater than or equal to 5 motile sperm per high power field (HPF). A poor PCT was defined as less than 2 motile sperm/HPF, and a fair PCT was defined as 2 to 4 motile sperm/HPF. Of the 63 PCTs done, 27 (42.9%) were good, 14 (22.2%) were fair, and 22 (34.9%) were poor. All endocervical tissue cultures for C. trachomatis obtained during PCTs were negative. All IgM chlamydial antibody titers were negative (less than or equal to 1:32 dilution), 55 (87.3%) of the patients having a zero titer. Eleven (17.5%) of the patients had negative IgG chlamydial antibody titers (less than or equal to 1:8 dilution), none of the patients had a 1:16 dilution, and 52 (82.5%) had positive IgG chlamydial antibody titers (greater than or equal to 1:32 dilution). Thus, chlamydial infections of the endocervix are rare and not commonly associated with poor PCTs in this patient population.

To evaluate the role of anaerobic bacteria in postpartum endomyometritis, intravenous metronidazole was used as the sole initial therapy in 25 women with clinical signs of infection. This agent has not been shown to have activity against aerobic pathogens in soft tissue pelvic infections. A clinical cure was obtained in 21 of 25 (84%) with oral metronidazole utilized after the patient had been afebrile for at least 24 hours. The mean fever index of the 21 successfully treated women was 35.9 degree hours with a SD of +/-30 hours. The four patients with treatment failure required alternate antibiotics and the mean fever index of these patients was 138.0 degree hours. Transcervical endometrial cultures were obtained prior to therapy in 24 women. Anaerobes were recovered in every instance with a total of 67 isolates, a mean of 2.8 per patient. The most common isolates were peptococcus and Bacteroides species. A culdocentesis was performed concurrently in 23 women. Anaerobes were recovered in 20 (87%) with a total of 55 isolates. The most frequent isolates were peptococcus and Bacteroides fragilis. In 23 women in whom paired transcervical endometrial and cul-de-sac cultures were obtained, at least one common organism was isolated in 18 (78%). Both the successful clinical response to metronidazole and the paired culture results suggest that anaerobic organisms have an important role in endomyometritis following vaginal delivery.

Circulating levels of inactive renin, that is, prorenin, are increased in normal pregnant women. To determine whether the uteroplacental unit secretes prorenin into the maternal circulation, we measured enzymatically active and inactive renin in plasma simultaneously obtained from the radial artery and uterine vein of 12 normotensive, nonlaboring patients undergoing elective cesarean section at term. We also measured these forms of renin in the umbilical arterial and venous blood of these patients. Our data reveal that the levels of inactive renin in both arterial and uterine venous blood of normal pregnant women are significantly higher than in peripheral venous blood of nonpregnant, normotensive control subjects; normotensive term patients have a ratio of plasma inactive to active renin of 9:1 in contrast to the 1:1 ratio in normotensive nonpregnant subjects; there is a significant uterine arteriovenous difference of prorenin (66.2 +/- 24.4 ng/ml/hr, p less than 0.05) but not of active renin (1.8 +/- 1.5 ng/ml/hr, not significant). These results suggest that the uteroplacental unit contributes to the elevated prorenin levels at term pregnancy.

Seven cases of listeriosis identified at perinatal autopsy are described. The cases occurred during the time of a 1985 Los Angeles, California, epidemic of listeriosis from suspected food contamination by Listeria monocytogenes. In only one of seven cases were gross pathologic lesions encountered. Microscopic lesions in six cases consisted of rare, localized microabscesses or granuloma-like lesions in multiple organs and contained histiocytes, monocytes, lymphocytes, and polymorphonuclear leukocytes with variable necrosis. One case had no gross or microscopic findings. Organomegaly was uncommon. The diagnosis was confirmed in three cases by postmortem blood culture. Complete perinatal autopsy is important for confirmation of listeriosis when microbiologic, gross, or microscopic findings alone may not yield characteristic features.

Listeria monocytogenes is an underdiagnosed and underreported cause of congenital sepsis. Twenty mother/infant pairs from whom Listeria was isolated were studied at the University of Southern California School of Medicine and Women's Hospital during the last ten years to delineate antepartum factors indicative of a fetus at high risk for perinatal Listeria sepsis. The combination of high maternal leukocyte count, fetal tachycardia, decreased fetal heart rate variability, and, especially, the absence of intrapartum fetal heart rate accelerations was associated with a complicated course for the neonate with congenital Listeria sepsis. Intrapartum administration of antibiotics decreased fetal morbidity and mortality but did not impair recovery of the organism.

Major advances have been made in the identification and prevention of perinatal factors that lead to long-term handicap or neurologic deficits. When the infant or child exhibits a major handicap, scrutiny of the pregnancy management often occurs in an attempt to define the causal factors. The medical goal of this inquiry is to prevent injuries and, when possible, to eliminate these factors. In the litigious sense, any deviation from optimal, ideal care or any unusual observations, such as unusual or atypical fetal heart rate patterns, are often causally linked to the adverse outcome. There are at least four categories of major fetal injury that probably occur prior to labor. An awareness of, and a diligent search for, details will no doubt clarify the legitimate origins of many so-called birth injuries. Hence the common tendency to fixate on minor deviations and/or deficiencies of labor and delivery management as causing catastrophic injuries will be successfully challenged.

The loss of a child in utero can be a tragic experience. The purpose of the present study was to examine some patient characteristics that may predict which women are likely to have problems in adjusting to the loss and to examine the effectiveness of interventions by care providers in facilitating emotional recovery. Twenty-eight women who were no more than 4 weeks post partum from a fetal death were interviewed while waiting to see their physicians at the fetal demise clinic at Los Angeles County Women's Hospital. It was found that women were less depressed after the loss if they already had children, if they did not blame themselves for the death, and if they received a picture of the infant or were allowed to see the infant. Women benefited from sympathy from the medical personnel and being kept informed of problems as they developed.

The mainstay of treatment for postpartum endometritis is a combination of antibiotics, such as clindamycin plus an aminoglycoside. In an effort to save time and reduce the cost of treating this infection, researchers have investigated monotherapy with a beta-lactam antibiotic. Twenty-five patients with postcesarean endometritis and three with postpartum endometritis were studied at two sites for the effectiveness of 3.1 g ticarcillin disodium/clavulanate potassium administered every four or six hours for a minimum of four days. Eighteen of the 25 postcesarean endometritis patients (72%) were judged clinical cures, 6 (24%) were clinical failures, and 1 had therapy discontinued because of diarrhea. In the postpartum course of all the patients there were no wound infections and three (12%) instances of bacteremia. The majority of the enterococci were sensitive to ticarcillin disodium/clavulanate potassium, as were all of the Escherichia coli, Klebsiella pneumoniae, Bacteroides bivius, Bacteroides fragilis and other Bacteroides species.

The use of short-course (24-hour) prophylactic antibiotics was studied in 84 consecutive afebrile patients who underwent emergency primary cesarean section. There was a significant reduction in the incidence of postoperative endomyometritis in the group prophylactic antibiotics (12/45, 26.7%) compared to the control group not given prophylactic antibiotics (20/39, 51.3%), p less than 0.05. The duration of hospital stay was also significantly reduced by the use of prophylactic antibiotics (4.3 +/- 0.6 days versus 5.1 +/- 1.3 days, p less than 0.05). Other identified advantages that resulted from the use of prophylactic antibiotics included a shorter duration of treatment required for postoperative endomyometritis in the group given prophylactic antibiotics and an increased likelihood of being cured by initial therapy for endomyometritis in the group given prophylactic antibiotics (100% versus 70%). When taken together, these results indicate that the urgency of operation is a unique risk factor for postoperative infectious morbidity, and suggest that patients who undergo emergency primary cesarean section benefit from a short course of prophylactic antibiotics.

Blood levels of ketamine, measured in both mother (1,230 ng/ml at 1 minute) and fetus (470 ng/ml at 1 minute) illustrate not only rapidly decreasing levels of the drug after its intravenous administration but also its transplacental passage. Concentrations of norepinephrine, epinephrine, and dopamine did not change in the mother or fetus after ketamine, with the exception of maternal levels of epinephrine, which were significantly higher at 45 minutes than control values (p less than 0.05). Maternal effects of ketamine consisted of increases in mean arterial pressure (7% p less than 0.05), cardiac output (16% p less than 0.01), and respiratory acidosis, all of which were slight and transitory. Although resting uterine tone increased (39% p less than 0.01), the uterine blood flow remained constant. None of the physiologic alterations could be correlated with changes in catecholamine levels. Therefore, the cardiovascular and uterine stimulating properties of ketamine at a dose of 0.7 mg/kg are small and are not the result of increased catecholamine levels in plasma. Further studies are necessary to elucidate the mechanism.

This study assesses (1) the relationship between the bacteriology of amniotic-membrane cultures (AMCs) obtained at the time of primary cesarean section and the subsequent postoperative course of afebrile, laboring patients whose membranes ruptured greater than or equal to 4 hr before delivery and (2) the impact of perioperative antibiotics on this relationship. Therapy with perioperative antibiotics was begun after the cord was clamped and the membrane specimen was obtained for culture. Specimens for AMC were obtained from 127 patients; 62 received placebo and 65 received perioperative antibiotics. In spite of the homogeneity of the patients' clinical risk factors, their AMCs demonstrated considerable variation in the degree of bacterial contamination present at the time of cesarean section. The presence of no growth or of low-virulence isolates only in the AMC usually was associated with a benign postoperative course, and therapy with perioperative antibiotics did not significantly decrease the incidence of endometritis associated with these AMC patterns. On the other hand, the presence of a mixture of high- and low-virulence organisms in the AMC or of high-virulence anaerobes only--more specifically, gram-negative anaerobes--was predictive of subsequent postcesarean endometritis only for patients who did not receive perioperative antibiotics, and therapy significantly decreased the incidence of endometritis associated with these AMC patterns. In conclusion, the correlation between specific bacteriologic patterns found in the AMC and the subsequent development of endometritis for patients who did not receive prophylactic antibiotics was better than the correlation based on clinical risk factors alone.

Meningitis is the major pathologic manifestation of Listeria monocytogenes in the United States. Despite the fact that this organism has a well-known predilection for individuals who are pregnant or immunocompromised, to date, maternal listeric meningitis remains an unreported entity in the English literature. The authors report two cases of this disease and review the diagnosis and treatment of meningitis in general and, more specifically, of listeric meningitis in pregnancy. It is recommended that the initial treatment of bacterial meningitis during pregnancy should be a combination of ampicillin and gentamicin pending definitive identification of the causative organism and its antibiotic sensitivity pattern.

Pseudomonads are common causes of nosocomial infections but are rarely implicated in perinatal disease. In a retrospective autopsy study we found that 9% of all acute congenital bacterial infections were due to Pseudomonas species. Premature rupture of membranes occurred in half the cases and clinical maternal amnionitis in two-thirds. One case was apparently nosocomial in origin. No known risk factors were implicated in any other case. Seven infants were stillborn and two died within a few hours. Congenital pneumonia, funisitis, and chorioamnionitis were found at autopsy. Intrauterine infection due to the pseudomonads poses a serious problem that has not been previously recognized.

Improved understanding of the microbiology of postcesarean endometritis has dramatically changed the approach to its antibiotic therapy. Initial therapy should include broad-spectrum anaerobic coverage, including against all Bacteroides species, as well as gram-positive and gram-negative aerobic coverage. Moreover, ideally initial therapy should also include coverage of Chlamydia trachomatis. Furthermore, although the use of antibiotic prophylaxis for high-risk patients undergoing cesarean section has significantly decreased their incidence of febrile morbidity, one must remember that prophylactic antibiotics have important bacteriologic effects that may limit the efficacy of monotherapy for the treatment of endometritis in prophylaxis failures.

The suggestion that extraperitoneal cesarean section might be a useful method of preventing postoperative infectious complications prompted a prospective study of 91 primary extraperitoneal cesarean sections on afebrile laboring patients with ruptured membranes longer than 4 hours. Fifty of 91 patients having extraperitoneal cesarean sections (group A) were compared with 36 patients having low cervical transperitoneal primary cesarean sections (control group) meeting the same entry criteria in a prospective randomized fashion. The other 41 patients (group B = 25 of 41, group C = 16 of 41) were selected from qualifying high-risk patients depending on the availability of an experienced operator with group C receiving perioperative prophylactic antibiotics. The only significant difference in outcome was: four of 16 (25%) patients in group C (extraperitoneal cesarean section plus prophylactic antibiotics) developed postoperative endomyometritis versus 20 of 36 (56%), 28 of 50 (56%), and 12 of 25 (48%) patients in the transperitoneal primary cesarean section control group and extraperitoneal cesarean section group A and B, respectively (p less than 0.05). There was a trend toward enhanced postoperative recovery in all extraperitoneal cesarean section groups compared with the transperitoneal primary cesarean section control group. Thus, the technique of extraperitoneal cesarean section apparently offers no significant advantage in the prevention of postcesarean endomyometritis, but the use of perioperative prophylactic antibiotics apparently has significant impact.

Obstetrical situations in which endogenous or exogenous vasoactive amines precipitously increase maternal blood pressure and decrease uterine blood flow may be associated with increased maternal morbidity and mortality and with development of fetal acidosis and distress. We examined the effectiveness of nitroglycerin in lowering maternal blood pressure and increasing uterine blood flow during the infusion of the alpha-adrenergic agent phenylephrine. During the phenylephrine infusion maternal blood pressure increased 20%, cardiac output decreased 25%, total peripheral vascular resistance increased 60%, pulmonary arterial pressure increased 40%, uterine blood flow decreased 50%, and fetal arterial pH decreased from 7.37 to 7.30 (p less than 0.05). While maintaining the phenylephrine infusion at a constant rate, the infusion of nitroglycerin rapidly returned maternal systemic pressure and pulmonary arterial pressure to control values, decreased total peripheral resistance to 18% above control, increased cardiac output to 12% below control, increased uterine artery blood flow to 30% below control, and increased the fetal arterial pH from 7.30 to 7.35 (p less than 0.05). It is concluded that maternal hypertension resulting from intense alpha-adrenergic stimulation may be treated rapidly and effectively by the intravenous infusion of nitroglycerin with a partial restoration (20%) of uterine artery blood flow toward control.

Oviductal damage from infectious salpingitis is a principle cause of ectopic pregnancy. To examine the role of Chlamydia trachomatis in patients with ectopic pregnancy, 24 patients undergoing laparotomy for ectopic pregnancy were evaluated by assessment of chlamydial serology and chlamydial cultures of tubal biopsy specimens. The patients were divided into two groups based on the presence or absence of gross abnormalities in the fallopian tube contralateral to the ectopic gestation. Ten patients in group I showed gross evidence of chronic salpingitis in the contralateral tube; 14 patients in group II had normal-appearing contralateral tubes. Chlamydial cultures were negative in both groups. Chlamydial immunoglobulin M antibodies assayed by indirect microimmunofluorescence were negative in both groups (less than or equal to 1:32). Mean geometric immunoglobulin G titers for C. trachomatis were significantly higher in the patients with evidence of contralateral chronic salpingitis (78.9 versus 13.1). These findings suggest that C. trachomatis may be a major cause of oviductal damage, which predisposes to ectopic pregnancy.

A prospective, randomized, controlled clinical trial was conducted to evaluate the safety and efficacy of a single, 0.5-mg dose of prostaglandin E2 gel in a shelf-stable triacetin base administered intracervically in patients with an unfavorable cervix (Bishop score less than or equal to 4) 12 hours prior to oxytocin-induction of labor. forty-eight evaluable patients were enrolled, 25 in the PGE2 group and 23 in the control group. PGE2 gel treatment resulted in a significant improvement in the mean Bishop score compared to control (3.14 versus 0.70, P less than .00005). Sixty-four percent of the patients treated with PGE2 had regular uterine contractions during the 12-hour preinduction period beginning 2.18 +/- 2.0 hours after gel insertion, compared to 9% in the control group, P = .0001. Moreover, 12% (3/25) of the patients receiving PGE2 progressed into active labor and delivered during the preinduction period. The duration of oxytocin infusion required for the induction or augmentation of labor was significantly shorter for patients who received intracervical PGE2 gel compared to the control group (13.1 +/- 8.1 versus 19.0 +/- 8.7, P less than .05). However, there was no significant difference in the incidence of cesarean section between the two study groups (40 and 22% in the PGE2 and control groups, respectively). No episodes of uterine hypertonus or hyperstimulation or gastrointestinal side effects occurred as a result of PGE2 gel treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Postcesarean endomyometritis is the most common nosocomial infection treated by obstetrician-gynecologists. One important prevention strategy is the use of perioperative antibiotic prophylaxis initiated after occlusion of the umbilical cord for parturient patients with a high risk of this infection. However, the identification of these high risk patients remains problematic. Numerous clinical risk factors have been identified in the literature. Important intrinsic risk factors include indigent socioeconomic status, anemia, and preterm gestational age at the time of cesarean section. The three most consistently identified extrinsic risk factors include labor prior to cesarean section, the duration of ruptured chorioamniotic membranes, and the number of preoperative vaginal examinations. Alternatively, many investigators have attempted to define high-risk patients utilizing various laboratory tests, such as Gram staining or bacterial culture of amniotic fluid, chorioamniotic membranes, or endometrial biopsy specimens; although specific, these tests have not been sufficiently sensitive predictors of infection. Currently, assessment of the duration of ruptured membranes and length of labor remain the most sensitive, readily available, and therefore clinically useful predictors of postcesarean endomyometritis.

Physiologic considerations on regulation of the fetal heart rate are reviewed. The types of fetal heart rate acceleration are classified and illustrated. Data from 509 patients undergoing 1,281 nonstress tests are presented, with emphasis on indications, technique, and interpretation. The nonstress test had a false negative rate lower than that of the contraction stress test. Since the false positive rate is high, a nonreactive test requires further evaluation. Progressive loss of baseline variability and decreasing frequency of accelerations appear to be early signs of fetal compromise.

Presented are blood culture results obtained from 200 patients with post-cesarean section endomyometritis treated with either penicillin-gentamicin or clindamycin-gentamicin. Their clinical course is correlated to their blood culture results by the fever index. Fifty-three percent of the 60 organisms isolated from 48 patients were anaerobic bacteria. Patients from whose blood cultures anaerobic bacteria were recovered had higher fever indexes than did those with aerobic isolates (P less than .05). Clindamycin-gentamicin patients from whose blood cultures anaerobic organisms were isolated had less febrile morbidity than did comparable penicillin-gentamicin patients. Patients with Bacteroides fragilis bacteremia had the highest fever indexes overall. Therefore, patients with post-cesarean section endomyometritis have less febrile morbidity if they are initially treated with a drug effective against anaerobic bacteria, especially B fragilis.

A prospective, randomized, double-blind, placebo-controlled study was undertaken to evaluate the safety and efficacy of a 3-mg prostaglandin E2 (PGE2) vaginal suppository for the initiation of cervical ripening before the induction of labor. All patients were required to have an initial Bishop score of 4 or les. The 3-mg PGE2 vaginal suppository was found to be an effective method of both cervical ripening and labor induction. Its use resulted in a highly significant improvement in the mean Bishop score compared with the placebo group (2.67 versus 0.55 points, P less than .00005). Its use also resulted in a significant reduction in the number of failed inductions (5 versus 23%, P less than .0005). Moreover, 68% of the patients treated with PGE2 labored after initial suppository placement, and 42% of these patients never required oxytocin augmentation of labor. However, there were three instances of uterine hyperstimulation/hypertonus following placement of the 3-mg PGE2 suppository, suggesting that perhaps a lower dose of PGE2 would improve its safety as a ripening agent without affecting its efficacy.