A randomized, prospective study comparing once-daily gentamicin versus thrice-daily gentamicin in the treatment of puerperal infection.

OBJECTIVE: The efficacy, safety, and antibiotic-related charges for once-daily gentamicin with twice-daily clindamycin were compared with those of thrice-daily dosing of these antibiotics. STUDY DESIGN: Patients with puerperal endometritis or with chorioamnionitis in labor assessed to be at risk for endometritis were randomized to receive gentamicin 4 mg/kg intravenously every 24 hours with clindamycin 1200 mg intravenously every 12 hours (experimental arm) or gentamicin 1.33 mg/kg intravenously and clindamycin 800 mg intravenously every 8 hours (conventional dosing interval arm). Primary outcomes included cure rates, mean length of treatment, antibiotic-related charges, and nephrotoxicity. Multiple logistic regression analysis was used to control for confounding variables. RESULTS: There were 135 and 137 patients randomized to the experimental and conventional interval arms, respectively. Cures were obtained in 94.1% and 87.6% of patients in the experimental and conventional arms, respectively (p = 0.06). The experimental arm had mean antibiotic charges of $250.79 versus $442.49 in the conventional arm (p < 0.0001). There was no permanent nephrotoxicity in either group. CONCLUSIONS: Once-daily gentamicin dosing with twice-daily clindamycin dosing is as efficacious and safe as the thrice-daily dosing of gentamicin and clindamycin for peripartum uterine infection. The experimental regimen results in substantial cost savings. The incidence of nephrotoxicity is low.

Transvaginal versus transabdominal Doppler auscultation of fetal heart activity: a comparative study.

OBJECTIVE: Our purpose was to determine whether transvaginal Doppler auscultation is more sensitive than transabdominal auscultation for the detection of fetal heart rate in the first trimester of pregnancy. STUDY DESIGN: In a prospective study 141 patients between 6 weeks and 11 weeks 6 days of gestation underwent both transvaginal and transabdominal Doppler evaluation by use of continuous-wave Doppler instruments for detection of fetal heart rate. Transvaginal ultrasonography was used as the gold standard to establish fetal cardiac activity and to help assign gestational age. The two methods of auscultation were compared for accuracy in different gestational age ranges. Sensitivities and specificities were calculated, and associations were investigated with chi 2 analysis. The direction of disagreement between modalities was tested with the McNemar chi 2 test. RESULTS: Transvaginal auscultation outperformed transabdominal auscultation in every gestational age range. Transvaginal Doppler auscultation performed significantly better than transabdominal Doppler auscultation at 8 weeks to 8 weeks 6 days (p < or = 0.004) and 9 weeks to 9 weeks 6 days (p < or = 0.006). In pregnancies with cardiac activity, fetal heart rate can be successfully detected transvaginally in 60.5% of pregnancies at 8 weeks to 8 weeks 6 days and in 87.5% of pregnancies at 9 weeks to 9 weeks 6 days of gestation. This compares with successful transabdominal detection rates of 22.9% and 56% at 8 and 9 weeks, respectively. As gestational age advances both methods became increasingly sensitive for the detection of fetal heart rate. The earliest fetal heart rate detected transvaginally was at 6 weeks 0 days of gestation compared with 7 weeks 0 days transabdominally. The transvaginal Doppler method was also more successful in detecting the fetal heart rate in women with a retroverted uterus (p < or = 0.01). CONCLUSION: By use of continuous-wave Doppler instrumentation, transvaginal auscultation is significantly better than transabdominal auscultation in detecting fetal heart rate between 8 weeks to 8 weeks 6 days and 9 weeks to 9 weeks 6 days of gestation. Use of transvaginal auscultation has potential in the evaluation of first-trimester fetal cardiac activity.

Predictive factors from cold knife conization for residual cervical intraepithelial neoplasia in subsequent hysterectomy.

OBJECTIVE: The optimal management of cervical intraepithelial neoplasia after cold knife conization remains controversial. Reliable predictors of residual dysplasia in the cervix after cold knife conization have not been consistently identified. This study was initiated to examine the accuracy of the traditional factors used to predict residual dysplasia in hysterectomy specimens after cold knife conization. STUDY DESIGN: A retrospective 10-year chart review identified a cohort of 1272 patients who underwent cold knife conization, of whom 311 had a subsequent hysterectomy within 1 year of conization. Residual disease was defined as cervical intraepithelial neoplasia or cancer in the hysterectomy specimen. All cone specimens were completely submitted for pathologic examination, and the following factors were analyzed for their predictive value: degree of dysplasia, margin involvement, endocervical gland involvement, and status of the endocervical curettage. The predictive value of age, race, gravidity, parity, socioeconomic status, cigarette smoking, and marital status were also examined. The chi 2 test, t test, and logistic regression were used for statistical analysis. RESULTS: Dysplasia or cancer were identified in 1066 (84%) of the 1272 patients who underwent cold knife conization. Of the 311 patients having a subsequent hysterectomy, 106 (34%) had residual disease in their hysterectomy specimen. By multivariate analysis only increasing age and degree of dysplasia were predictive of residual disease. The odds ratio of residual disease in the hysterectomy specimen for a 25-year-old woman was 2.7 (95% confidence interval 1.6 to 4.4) compared with a 40-year-old woman whose odds ratio was 4.9 (95% confidence interval 2.2 to 10.8). The presence of dysplasia in the cold knife conization specimen conferred an odds ratio of 12.1 (95% confidence interval 2.7 to 54.5) of identifying residual disease. Dysplasia involving the ectocervical margin, endocervical margin, and endocervical glands was not predictive of disease in the hysterectomy specimens. Endocervical curettage was not performed in 44% of the patients, preventing reliable statistical evaluation. Further analysis indicated that residual disease was found in 32% of the hysterectomy specimens with negative margins, in 31% with no endocervical gland involvement, and in 23% with a negative endocervical curettage sample. CONCLUSIONS: The presence or absence of dysplasia in the cold knife conization ectocervical margin, endocervical margin, and endocervical glands was not predictive of residual dysplasia in post-cold knife conization hysterectomy specimens. Increasing age and severity of disease in the cone specimen were the only factors that accurately predicted residual dysplasia. The traditional factors used to justify hysterectomy after cold knife conization may not be valid on the basis of these results.

Including smoking status as a new vital sign: it works!

BACKGROUND: Despite the adverse health consequences of smoking, many physicians still neglect to counsel smokers to quit. This study evaluated the effect of including smoking status as a vital sign on the frequency of physician discussions with patients about smoking and physician advice to quit smoking. METHODS: A consecutive sample of adult ambulatory patients in our metropolitan family practice residency program completed exit surveys on physician and nurse counseling about smoking. Control group data were collected for 1 month before the change was made to include smoking status as a vital sign on patient charts. Charts were then marked with a stamp as a chart prompt in the vital signs section. Data were collected for 2 months after smoking status was added to the stamp. RESULTS: There were 637 individuals surveyed, of whom 179 were current smokers; 95 in the "prestamp" group and 84 in the "poststamp" group. The percentage of patient-physician encounters during which smoking was discussed increased from 47% to 86% (P < .001). Physician advice to quit increased from 50% to 80% (P < .001). Physician discussion of smoking with patients increased across all of the five stages of change but most dramatically (53% to 95%) in the "preparation" stage. Physicians were much less likely to counsel patients in the "precontemplation" stage to quit smoking. CONCLUSIONS: Including smoking as a new vital sign significantly increased the likelihood of smoking-related discussions between patients and their physicians. The stamp is inexpensive and easy to use, and because it is a one-time office system change, it is more likely to be implemented and maintained in busy practices.

The prognostic value of serum progesterone and quantitative beta-human chorionic gonadotropin in early human pregnancy.

OBJECTIVE: Our purpose was to determine whether serum progesterone, with or without quantitative beta-human chorionic gonadotropin, is predictive of pregnancy outcome within the first 8 weeks of gestation in asymptomatic women. STUDY DESIGN: Asymptomatic patients at < 8 menstrual weeks' gestation were prospectively evaluated. The enrollment protocol included history, physical examination, ultrasonographic confirmation, and blood sample collection for beta-human chorionic gonadotropin and progesterone. The association between progesterone and beta-human chorionic gonadotropin values and pregnancy outcome was determined by logistic regression analysis. A receiver-operator characteristic curve was generated on the basis of the sensitivity and specificity of progesterone results. RESULTS: Seventy-four patients were evaluated in this study. The mean serum progesterone level for viable pregnancies was 22.1 ng/ml, which was significantly greater than that for the nonviable gestations, 10.1 ng/ml (p < 0.001). A single progesterone level was predictive of pregnancy outcome (p < 0.001). The probability of an abnormal pregnancy outcome with a serum progesterone level < or = 6 ng/ml was 81%. A single beta-human chorionic gonadotropin level did not contribute to the prediction of pregnancy outcome (p = 0.59). CONCLUSIONS: Serum progesterone alone, within the first 8 weeks of gestation, is predictive of pregnancy outcome.

Alterations in maternal-fetal Doppler flow velocity waveforms in preterm labor patients undergoing magnesium sulfate tocolysis.

OBJECTIVE: To evaluate the effects of magnesium on fetal hemodynamics in mothers treated with magnesium sulfate for preterm labor. METHODS: Twenty women who presented to the Carolinas Medical Center in preterm labor between 24-35 weeks' gestation were enrolled in the study. Pulsed-wave Doppler measurements were made from the fetal middle cerebral artery, the fetal umbilical artery, and the maternal uterine arteries before the initiation of magnesium sulfate tocolysis and during its intravenous administration. Baseline measurements were compared with intra-therapy measurements using paired t tests. RESULTS: During the administration of magnesium sulfate, the fetal middle cerebral artery diastolic blood flow velocity decreased significantly (P = .05) and the maternal uterine artery diastolic blood flow velocity increased significantly (P = .01). There were no significant changes in the umbilical artery diastolic blood flow measurements. These findings remained the same after adjusting for gestational age, estimated fetal weight, frequency of contractions, serum magnesium level at the time of the intra-therapy Doppler study, and maternal blood pressure. CONCLUSION: The alterations in fetal hemodynamics during magnesium sulfate administration suggest a physiologic normalization process related to the stressed preterm infant and the preterm labor process itself.

A prospective randomized clinical trial comparing two oxytocin induction protocols.

OBJECTIVE: Our objective was to compare the safety and efficacy of two accepted oxytocin induction protocols that differ in oxytocin dose increments. STUDY DESIGN: At the Carolinas Medical Center in Charlotte, North Carolina, 151 women with indications for induction of labor were prospectively randomized into one of two oxytocin induction protocols. Safety and efficacy of the two protocols were analyzed with two-tailed t tests and chi 2. RESULTS: Time from induction to establishment of a regular labor pattern was significantly shorter in the experimental group compared with the traditional group (p = 0.03). However, no significant difference was seen from onset of induction to time of delivery. Incidences of hyperstimulation were not significantly different between the two protocols, but there was a trend toward a higher incidence of fetal heart rate changes in the experimental group (p = 0.08). CONCLUSION: These data suggest that induction with larger dose increments will shorten time to adequate labor without an associated increase in uterine hyperstimulation or poor neonatal outcome. The differences in heart rate changes are concerning and merit further investigation. If confirmed by further studies, an increased risk of cord compression could outweigh the benefit of a faster onset of contractions.

Human papillomavirus prevalence in pregnancy.

Conventional wisdom has long held that human papillomavirus (HPV) prevalence is increased in pregnancy. We examined cervical swabs of 375 women for HPV DNA using polymerase chain reaction (PCR) and ViraPap with an expanded probe range. Of this population, 115 were pregnant (42 in the first trimester, 46 in the second, and 27 in the third) and 100 were postpartum. The control population consisted of 160 women who were otherwise similar to the pregnant population but were not pregnant or postpartum. Crude associations were examined between HPV prevalence at defined high, low, and overall levels and the pregnancy status. Multivariate analysis indicated no statistically significant association between the prevalence at any level of infection and pregnancy status. As expected, associations were found between measures of HPV prevalence and both Papanicolaou smear results and warts seen on examination. No association was found for race, smoking behavior, or number of sexual partners and HPV prevalence. The estimated risk of an HPV infection decreased as the age of the women increased. We conclude that a significant relationship between pregnancy and HPV prevalence has yet to be established.

An epidemiologic study of smoking and primary infertility in women.

OBJECTIVE: To determine the relationship between cigarette smoking and primary female infertility. DESIGN: Retrospective, case-control study. SETTING: Population-based and randomly selected from eight geographic areas in the United States. PARTICIPANTS: Women, 20 to 54 years of age, who were randomly selected to serve as the control group of the Cancer and Steroid Hormone Study were used for this study. Within this group, there were 483 women who were classified as having experienced primary infertility and 2,231 women eligible to serve as controls. Primary infertility, defined as 24 consecutive months of unprotected intercourse without conception, was documented from a calendar of each women's reproductive and contraceptive history. RESULTS: Smoking one pack of cigarettes per day (odds ratio = 1.36) and starting to smoke before 18 years of age (odds ratio = 1.30) were significantly associated with increased risk of infertility. Life table and proportional hazards analysis indicated that smoking did not significantly increase the time required to conceive among infertile women. CONCLUSIONS: Number of cigarettes smoked and age when the women began smoking contributed to infertility in this study. It is reasonable, therefore, to recommend that women stop smoking when they are attempting to become pregnant.

Difference in response of vascular resistance to orthostasis in patients with borderline and sustained essential hypertension.

Changes in hemodynamic parameters following 50-degree head up tilt were studied in a population of 78 males, including 30 patients with sustained essential hypertension, 30 patients with borderline hypertension, and 18 normotensive controls of the same age. The increase in vascular resistance following tilt was significantly higher in hypertensive subjects. In patients with sustained hypertension, baseline vascular resistance was significantly higher than in normotensive controls, and it was strongly correlated with its change following orthostasis. In patients with borderline hypertension, baseline vascular resistance was similar to that of normotensive controls and did not correlate with its change following orthostasis. The latter result suggests an abnormality in the autonomic nervous control in patients with borderline hypertension, possibly mediated by cardiopulmonary mechanoreceptors in the low pressure system.

Tilt test in essential hypertension. Differential responses in heart rate and vascular resistance.

Changes in hemodynamic parameters following 50-degree head-up tilt were studied in a population of 56 men, including 35 subjects with sustained essential hypertension and 21 age-matched normotensive controls. The increase in heart rate following tilt was similar in groups and exhibited the same reduction in response with age. The increase in vascular resistance following tilt was strongly and positively correlated with both age and baseline vascular resistance. The latter finding was observed mainly in hypertensive subjects. The study provided evidence that differentiated responses of heart rate and vascular resistance may be observed following orthostasis. In both normal and hypertensive subjects, the age dependence of heart rate response possibly reflected differences in baroreceptor reflex control of parasympathetic and sympathetic activity. In hypertensive subjects, the vascular response was amplified with age and baseline vascular resistance, suggesting a role for structural changes of the vessels in the increased vascular response.

Effect of converting enzyme inhibitors on hypertensive large arteries in humans.

As demonstrated in hypertensive humans on the basis of non-invasive Doppler methods, converting enzyme inhibitors (CEI) dilate not only small arteries but also large arteries, particularly in the brachial and the carotid circulations. The dilating effect of CEI on large arteries is associated with an enhancement of systemic and brachial arterial compliance, implying a particular action of the drug on arterial smooth muscle. Converting enzyme inhibitors are thus able to reverse the reduced arterial compliance observed in patients with essential hypertension.