Blood cultures for women hospitalized with acute pelvic inflammatory disease. Are they necessary?

OBJECTIVE: To determine the incidence of positive blood cultures and if the results affect the clinical management or the duration of hospital stay in patients with acute pelvic inflammatory disease (PID). STUDY DESIGN: Retrospective study of all patients hospitalized with a diagnosis of acute PID from January 1, 1996, to December 31, 1997. RESULTS: Of 93 patients in the study, 3 had significant bacterial growth from blood culture specimens. The results of blood culture specimens did not affect clinical management. CONCLUSION: Routine specimens for blood culture may not be needed from patients hospitalized with acute PID.

Pregnancy complicated by autoimmune polyglandular syndrome type II: a case report.

Autoimmune polyglandular syndrome may complicate pregnancy and be confused with hyperemesis gravidarum as a cause of hypoglycemia and electrolyte imbalance in the first trimester of pregnancy. Autoimmune polyglandular syndromes are uncommon disorders characterized by the development and presentation of multiple endocrine and organ dysfunction. To our knowledge, we present the first case of an autoimmune polyglandular syndrome complicating pregnancy. A 26-year-old woman, gravida 5 para 3 at 12 weeks gestation, presented with hyperemesis and signs and symptoms consistent with adrenal insufficiency and hypothyroidism. Evaluation revealed autoimmune polyglandular syndrome type II. Autoimmune polyglandular syndromes are a myriad group of diseases characterized by polyglandular dysfunction. These syndromes should be kept in mind when dealing with pregnant patients presenting with hyperemesis and an electrolyte imbalance who do not improve with the usual treatment for hyperemesis. An endocrine dysfunction such as polyglandular syndrome may exist.

Tuberculosis in pregnancy.

Tuberculosis (TB) during pregnancy and in the perinatal period was once considered to be an infrequent event in the United States. After a decade of steady decline, however, the disease has begun a resurgence. According to the CDC, a 20% increase in the number of reported cases occurred between 1985 and 1992. The factors associated with this increase are the emergence of human immunodeficiency virus (HIV) infection, the development of drug-resistant organisms, substance abuse, homelessness, and immigration. Environmental factors promoting transmission can be found in overcrowded areas such as correctional facilities, nursing homes, hospitals, and migrant-worker camps. For a large number of medically underserved women, the obstetrician is the only interface with medical care, as most of these patients do not have primary-care providers. It is important, therefore, that health-care providers recognize the clinical symptoms of TB and follow the recognized guidelines for antenatal screening for TB because the omission of these steps can lead to potentially disastrous sequelae in the fetus and neonate.

Fetal renal artery and umbilical artery Doppler flow and fetal urine output.

The object of this study was to determine if a correlation exists between the resistance index (RI) of the umbilical artery, the RI of the fetal renal artery, and hourly urine output by fetuses of normal pregnancies. Doppler flow study of the fetal renal artery and the umbilical artery was performed in 110 fetuses between 19 and 40 weeks' gestation. Color and pulse wave Doppler was used to obtain the flow velocity waveforms. The RI of the flow velocity waveforms was calculated. Fetal bladder volume was calculated by transverse, anteroposterior, and longitudinal diameters obtained from coronal and transverse sonographic images of the fetal urinary bladder. The difference in bladder volume at 30-minute intervals was used to determine hourly urine output. Gestational age has a positive linear association with fetal urine output (P < 0.01). The RI of the fetal renal artery has a negative linear association with gestational age (P < 0.05). The RI of the umbilical artery decreased with an increase in gestation age (P < 0.01). There was a significant correlation between the RI of the umbilical artery (P < 0.01) and the fetal renal artery (P < 0.05) and hourly urine output by the fetus. The RI of the fetal renal artery decreased with gestational age. Hourly urine output of the fetus increased with gestational age. The RI of the umbilical artery and the fetal renal artery had a significant correlation with fetal urine output.

Epidemiology and clinical outcome of patients hospitalized with pelvic inflammatory disease complicated by tubo-ovarian abscess.

OBJECTIVE: The purpose of this retrospective study was to compare the clinical outcome and characteristics of pelvic inflammatory disease (PID) complicated by tubo-ovarian abscess (TOA) with PID without TOA. METHODS: Chart reviews were performed for all PID admissions to the University of Medicine and Dentistry of New Jersey-University Hospital, Newark, NJ, from January 1, 1992, to December 31, 1993. RESULTS: The incidence in this study of TOA based on sonographic evidence of a complex adnexal mass was 18%. The major differences between the patients with and without TOAs were 1) history of hospitalization for PID: 68% (13/19) vs. 29% (25/85); 2) increased erythrocyte sedimentation rate: 82 vs. 41 mm/h; 3) increased WBC count on admission: 16,200 vs. 14,700/ml; 4) failure to respond to initial antibiotic therapy; and 5) longer hospital stay: 7.8 vs. 4.4 days, respectively. Surgical intervention was required in 3 patients: 2 patients who had TOAs and 1 patient who did not have a TOA by clinical examination or by ultrasound. CONCLUSIONS: Despite longer hospital stays and blood tests suggesting more severe disease processes, PID complicated by TOA is usually responsive to intravenous (IV) antibiotic therapy without the need for surgical intervention.

Effect of maternal cocaine abuse on renal arterial flow and urine output of the fetus.

OBJECTIVE: Our purpose was to study the short-term effect of maternal cocaine abuse on blood flow of the fetal kidney and the fetal hourly urine output. STUDY DESIGN: Thirty-three pregnant patients of various gestational ages with a history of cocaine abuse were studied. Patients were included if the urine specimen was positive for cocaine on the day of study. Patients were excluded if the urine specimen was positive for any other vasoactive substances or medications. Color and pulsed wave Doppler studies were used to obtain the flow velocity waveform of the fetal renal artery. The resistance index was calculated from systolic and diastolic values of flow velocity waveforms, Longitudinal, transverse, and anteroposterior diameters of the fetal urinary bladder were measured from transverse and coronal images at their maximum diameters, and the bladder volume was calculated. The hourly urine output of the fetus was measured from the difference in the bladder volume at half-hour intervals. As controls, 110 normal pregnancies between 19 and 40 weeks were similarly studied for normal values. The resistance index of the fetal renal artery and the hourly fetal urine output of the two groups were compared. RESULTS: The resistance index of the fetal renal artery of normal pregnancies had a negative association with gestational age (p < 0.05). Cocaine-exposed fetuses had a significantly higher resistance index of the renal artery (p < 0.01) than did normal fetuses of corresponding gestational ages. A decrease in the hourly urine output of cocaine-exposed fetuses was observed, compared with normal controls of corresponding gestational ages (p < 0.001). CONCLUSION: The resistance index values of fetal renal artery and fetal urine output were affected by maternal cocaine abuse.

Rates of cesarean section and perinatal outcome. Perinatal mortality.

A comparison of relevant statistics from National Maternity Hospital, Dublin, Ireland and University Hospital, Newark, New Jersey, USA, for the years 1983-1989, revealed that after removal of major confounding factors, such as a fourfold difference in < 2500 gram births and an about tenfold discrepancy in the frequency of lethal congenital defects, the perinatal survival rates in all weight categories were significantly higher in the American center. The findings suggest that optimum perinatal results could not be achieved in an American high risk center with the approximately 6% abdominal delivery rate favored in Dublin. The same data also suggest, however, that the 17.5% rate of abdominal deliveries in Newark was unnecessarily high. The favorable impact of the relatively liberal use of cesarean section might have been derived in this study from a marked reduction of in utero losses, in the absence of an identifiable effect upon the rate of neonatal mortality.

Epidemiology of sexually transmitted diseases among pregnant adolescents.

OBJECTIVE: The purpose of this study was to determine the epidemiology of sexually transmitted diseases (STDs) among pregnant adolescents. METHODS: Charts of all patients (n = 735) who attended the Maternal and Infant Care Clinic at University Hospital, Newark, NJ, between July 1, 1991, and June 30, 1992, were reviewed for STDs which included gonorrhea, chlamydia, syphilis, and human immunodeficiency virus (HIV). At the first prenatal visit, each registrant had endocervical specimens obtained to detect gonorrhea and chlamydia. A serum sample was obtained for syphilis screening. HIV testing was made available to all patients and testing was done on a voluntary basis. The same STD screening that was done at the initial visit was repeated at 28 and 36 weeks. RESULTS: Twenty-five percent of patients tested positive for one or more STDs. The mean patient age was 17.3 years. The mean gestational age at first visit was 19.5 weeks. The mean number of visits was 7.3. The following STDs were identified: 4.8% of patients tested positive for gonorrhea, 20.9% tested positive for chlamydia, and 1.7% tested positive for syphilis. Twenty-one percent of patients had a positive STD diagnosed at the initial visit. Another 4.8% of patients had an STD diagnosed at some time after the initial visit when the initial screen was negative for STDs. An additional 1% of patients who initially tested positive for an STD had subsequent screening which revealed another STD (different organism). Seven patients tested HIV positive. Sixty-one percent of patients with STDs agreed to HIV testing. One patient had HIV coexistent with another STD. CONCLUSIONS: Pregnant adolescents are at risk for multiple STDs. HIV testing should be offered. STD screening should be repeated in the third trimester in adolescent patients.

Rates of cesarean section and perinatal outcome: stillbirths.

Based on their yearly clinical statistics for 1983-1989, the cesarean section and stillbirth rates at National Maternity Hospital (Dublin), where the patients are generally white, and University Hospital (Newark), where the patients are predominantly black, were compared. After adjusting for confounding factors, such as unregistered mothers admitted subsequent to fetal demise, differing rates of < 2500 g births and lethal congenital defects, the overall rates of intrauterine fetal demise were identical. When analyzed according to birth weights, in all weight groups, the stillbirth rates were significantly lower in Newark than in Dublin. However, for every 1000 births, more < or = 2500 g fetuses died in utero in Newark than in Dublin. This trend was reversed in the > 2500 g group, where the respective rate at National Maternity Hospital exceeded that of University Hospital more than twice. The latter result largely derived from an almost 7-fold higher rate of intrapartum deaths in the > 2500 g weight group at National Maternity Hospital as compared to University Hospital. When projected against prevailing American statistics, which reflect a stillbirth rate about twice as high among blacks than among whites, the results suggest that the management patterns favored in Newark, including a relatively liberal cesarean section rate (17.5% versus 5.8%), affected the rate of in utero losses favorably.

Clinical chorioamnionitis is not predicted by umbilical artery Doppler velocimetry in patients with premature rupture of membranes.

Chorioamnionitis substantially increases fetal and neonatal morbidity. Infants born to women with chorioamnionitis have a fourfold increase in neonatal morbidity. If this condition could be predicted before the clinical manifestation and thereby treated earlier, an improved perinatal outcome might reasonably be expected. Based on the in vitro model of bacteria-induced vasoconstriction and pulmonary hypertension noted in sheep and lambs after exposure to the spent medium of a bacterial culture, we theorized that infected amniotic fluid may produce vasospasm of umbilical and placental vessels, reduce fetal perfusion, and increase perinatal asphyxia, morbidity, and mortality. Umbilical vessel vasospasm may be detected by measuring the systolic-diastolic ratio (S/D) of the umbilical artery. Continuous Doppler flow studies of the umbilical artery S/D were performed prospectively on 51 patients with premature rupture of membranes who were not in labor. The most recent test, done within 1 day of delivery, was compared with pregnancy outcome. Ten subjects developed clinical chorioamnionitis, of whom none had an abnormal S/D. Six of 41 women without clinical chorioamnionitis had abnormal S/Ds. These data do not support the use of Doppler measurement of the S/D as a predictor of clinical chorioamnionitis.

Prenatal ultrasonographic fetal iliac bone measurement. Correlation with gestational age.

The variety of circumstances under which ultrasound examinations are performed makes fetal iliac bone measurement an important indicator of gestational age. We studied 322 well-dated pregnancies from 13 to 40 weeks' gestation with sonogram measurements of the fetal iliac bone in order to examine the relationship between gestational age and bone length. The results indicate a linear relationship, as described by the equation iliac length = -0.376 + (0.0887) (gestational age). The fit of the data to a straight line was quite close (R2 = .877, P = .0001). The data were used to obtain a nomogram for growth of the fetal iliac bone.

Crouzon syndrome: prenatal ultrasound diagnosis by binocular diameters.

This is a report of second-trimester prenatal diagnosis of Crouzon syndrome suggested by binocular and interorbital diameter measurement and family history. Early prenatal diagnosis provides the option of termination or optimal postnatal management for families who choose to continue the pregnancy.

Water and salt conservation in the human fetus and newborn. I. Evidence for a role of fetal prolactin.

A study was performed on 94 women delivering at 34-44 weeks gestation, whose pregnancies were uncomplicated to determine the role of PRL in human fetal and neonatal salt and water conservation. Ultrasonic estimation of amniotic fluid (AF) volume and sampling of maternal blood, AF, cord blood, and 2-h neonatal blood were performed to analyze PRL, osmolality, sodium ion concentration ([Na]), and blood solids [hematocrit (Hct), total serum solids (tss), and total protein concentration]. In this report, which addresses the role of fetal PRL, Pearson correlations showed the following significant relationships: 1) approximation of cord serum osmolality and [Na] in cord and maternal serum, as well as parallel changes in cord blood Hct, tss, and total protein; 2) reduced estimated AF volume and increased AF osmolality in the face of elevated cord serum osmolality and [Na]; 3) a shift toward normal in cord Hct and tss over the first 2 h of neonatal life after an initially increased or decreased cord serum osmolality, [Na], Hct, or tss; and 4) relationship between fetal pituitary PRL levels of 230 micrograms/L or less and cord serum osmolality, [Na], and Hct. The entire range of cord serum PRL levels correlated with changes in AF osmolality and [Na] as well as with neonatal changes in Hct and tss. These findings support the hypotheses that osmotic equilibrium exists between maternal and fetal circulations; that disturbances in this balance lead to changes in fetal and neonatal water excretion; and that fetal PRL, stimulated by increases in cord serum osmolality and [Na], acts as an antidiuretic, leading to restoration of the offspring's extracellular fluid volume.

Comparison of parenteral ciprofloxacin with clindamycin-gentamicin in the treatment of pelvic infection.

A prospective, randomized study of intravenous followed by oral ciprofloxacin compared with the combination of intravenous clindamycin and gentamicin was conducted in 122 women hospitalized with pelvic infections. Clinical diagnoses included endometritis (97 patients) and uncomplicated pelvic inflammatory disease (25 patients). Treatment successes for endometritis included 42 of 50 (84 percent) patients treated with ciprofloxacin compared with 35 of 47 (75 percent) treated with the clindamycin-gentamicin combination. Treatment successes for acute salpingitis included 10 of 10 (100 percent) treated with ciprofloxacin and 13 of 15 (87 percent) treated with clindamycin-gentamicin. Ciprofloxacin successfully eradicated Chlamydia trachomatis in 11 of 12 patients as did clindamycin-gentamicin in six of seven patients. In this study of pelvic infection, ciprofloxacin demonstrated efficacy comparable with the combination of clindamycin and gentamicin, and is effective against C. trachomatis.

Comparison of ticarcillin plus clavulanic acid with clindamycin and gentamicin in the treatment of postcesarean endomyometritis.

The efficacy of a single antibiotic--Timentin (ticarcillin with clavulanic acid)--was compared with a standard two antibiotic regimen (clindamycin and gentamicin) for the treatment of endomyometritis after cesarean delivery. The regimens were 3 grams of ticarcillin plus 100 milligrams of clavulanic acid given intravenously every four hours, or 600 milligrams of clindamycin given intravenously every six hours plus 3 to 5 milligrams per kilogram per day of gentamicin given intramuscularly. The diagnosis of endomyometritis was based upon an oral temperature of 100.4 degrees F. or higher on any two occasions, excluding the first 24 hours post partum, uterine tenderness and the absence of another focus of infection. Ninety-one patients were treated. Treatment failure rates were three of 49 in the clindamycin and gentamicin group and four of 42 of the ticarcillin plus clavulanic acid group. Treatment failures did not appear to be different from successes demographically or in risk factors for endomyometritis. The results of this study suggest that ticarcillin with clavulanic acid is as effective in the treatment of postcesarean endomyometritis as the standard regimen of clindamycin and gentamicin.

Varicella pneumonia during pregnancy. Treatment of two cases with acyclovir.

Pneumonia is a rare but serious complication of varicella during pregnancy. Maternal mortality has been reported to be 41% with fetal and neonatal mortality at 65%. Treatment has included respiratory support and prophylactic antibiotics. Acyclovir has been prescribed with the intent to decrease the impact of the infection. It was added to the treatment protocol of two cases of varicella pneumonia in pregnancy. Despite the high maternal and perinatal mortality both pairs of patients and infants survived. Acyclovir did not appear to adversely influence the fetus, and may have contributed to the survival of mother and child.

Difficulties in the prenatal diagnosis of Jarcho-Levin syndrome.

Prenatal diagnosis of Jarcho-Levin syndrome early in pregnancy has not been previously reported. We present a case in which ultrasound examination resulted in a tentative diagnosis at 22 weeks of pregnancy. The difficulties in arriving at a definite diagnosis are presented.