Epidemiologic factors and urogenital infections associated with preterm birth in a midwestern U.S. population.

OBJECTIVE: To correlate epidemiologic factors with urogenital infections associated with preterm birth. METHODS: Pregnant women were sequentially included from four Wisconsin cohorts: large urban, midsize urban, small city, and rural city. Demographic, clinical, and current pregnancy data were collected. Cervical and urine specimens were analyzed by microscopy, culture, and polymerase chain reaction for potential pathogens. RESULTS: Six hundred seventy-six women were evaluated. Fifty-four (8.0%) had preterm birth: 12.1% (19/157) large urban, 8.8% (15/170) midsize urban, 9.4% (16/171) small city, and 2.3% (4/178) rural city. Associated host factors and infections varied significantly among sites. Urogenital infection rates, especially Mycoplasma hominis and Ureaplasma parvum, were highest at the large urban site. Large urban site, minority ethnicity, multiple infections, and certain historical factors were associated with preterm birth by univariable analysis. By multivariable analysis, preterm birth was associated with prior preterm birth (adjusted odds ratio [aOR] 2.76, 95% confidence interval [CI] 1.27-6.02) and urinary tract infection (aOR 2.62, 95% CI 1.32-519), and negatively associated with provider-assessed good health (aOR 0.42, 95% CI 0.23-0.76) and group B streptococcal infection treatment (surrogate for health care use) (aOR 0.38, 95% CI 0.15-.99). Risk and protective factors were similar for women with birth at less than 35 weeks, and additionally associated with M hominis (aOR 3.6, 95% CI 1.4-9.7). CONCLUSION: These measured differences among sites are consistent with observations that link epidemiologic factors, both environmental and genetic, with minimally pathogenic vaginal bacteria, inducing preterm birth, especially at less than 35 weeks of gestation.

Outcomes in gestations between 20 and 25 weeks with preterm premature rupture of membranes.

BACKGROUND: Preterm deliveries complicate 11% of all births within the United States. In the urban inner city population, this figure approaches approximately 18%. In one quarter to one third of these deliveries, preterm premature rupture of the membranes (PPROM) has been a causative factor. OBJECTIVE: The purpose of this study was to evaluate outcomes of pregnancies complicated by preterm premature rupture of membranes at less than or equal to 24 weeks gestation at our institution. METHODS: A retrospective review of 300 charts was performed on patients delivered at our institution from December 2003 to December 2004. Patients with gestational ages between 20 and 24 weeks with ruptured membranes were included in the study. Maternal, fetal, placental, and neonatal characteristics were reviewed. RESULTS: A total of 16 infants were delivered. Seven infants were live born. The latency period was 4 days. The mean gestational age was 22 1/7 weeks. The average life span of the live born infants was noted to be 20 days. Chorioamnionitis was demonstrated in 85% of the placental specimens; in 57% of these specimens, group B streptococcus was noted to be the etiologic agent. Of the 16 infants delivered, only one infant is still alive and neurologically intact. CONCLUSION: Various pathogens have been associated with PPROM and subsequent preterm delivery. The findings of this study suggest that within our population, group B streptococcus appears to be the primary causal agent associated with PPROM. Prevention of infection by early surveillance and patient education may help to decrease the incidence, but further investigation is warranted.

Fertility outcomes following myomectomy in an urban hospital setting.

OBJECTIVE: Infertility is rarely a consequence of myomas. However, a causal relationship may be suspected when other causes of infertility have been excluded. Uterine myomas have been reported in 27% of infertile women; 50% of women with unexplained infertility become pregnant after myomectomy. The objective of this study was to establish the impact of the surgical removal of myomas on fertility outcomes in women experiencing recurrent pregnancy loss or unexplained infertility. Fallopian tube, anovulatory disorders and male fertility factors had been appropriately excluded. DESIGN: This was a retrospective study in which we compiled data from the medical records of eight patients from 2003-2004 who underwent abdominal myomectomy for infertility or recurrent pregnancy loss. We calculated rates for subsequent spontaneous abortion, preterm delivery, cesarean delivery, malpresentation and postpartum hemorrhage. RESULTS: There were two patients who were nulliparous premyomectomy, and six had recurrent pregnancy losses. There was a cumulative success rate of 75% (six live births in eight patients) following myomectomy. One had two subsequent pregnancies. There were no spontaneous abortions. Three (37.5%) patients failed to conceive postmyomectomy, one of which was found to have bilateral tubal occlusion. Of the six pregnancies achieved, two (33%, 95% CI 2.06, 3.14) were preterm deliveries, six (100%, 95% CI 1.74, 3.50) were delivered by cesarean section and three (50%, 95% CI 3.50, 1.73) were malpresentations (two breech, one transverse lie). One patient (16%, 95% CI 2.06, 3.30) had abruptio placentae and two patients (33%, 95% CI 2.06, 3.14) experienced postpartum hemorrhage. CONCLUSION: This study suggests that there may be a beneficial effect of surgical removal of myomas on enhancing fertility and successful pregnancy outcome. However, the sample was too small to achieve statistical significance.

Pregnancy complicated by emphysematous pyonephrosis.

Emphysematous pyonephrosis is a rare, rapidly progressive infection characterized by the presence of exudative material and fermentative gases within a dilated renal collecting system. This unusual clinical entity is noted almost exclusively in diabetic patients, often in conjunction with chronic urinary tract infection and obstruction. In most instances, E. coli is the etiologic agent; however other enterobacteriaceae may be isolated. High fever, leukocytosis, renal parenchymal necrosis and the accumulation of gases in the kidney and perinephric tissues are the hallmark of this condition. Surgical resection of the involved tissue and systemic antibiotic administration are among the primary mainstays of therapy. We present a unique case of a pregnant patient with fulminant emphysematous pyonephrosis and the successful treatment rendered.

Postpartum pyomyoma.

Leiomyomata are common benign tumors of the uterus and female pelvis. Myomas have been reported in 25% of Caucasian American women and 50% of African-American women. The true incidence is unknown, but descriptions of 50% have been found at postmortem examinations. Considering the high incidence of uterine myomata in women of reproductive age, they are reported as complications in only 2% of pregnancies. Pyomyoma (suppurative leiomyoma) a rare complication results from infarction and infection of a leiomyoma. Without a strong clinical suspicion and surgical intervention, fatalities may occur. Since 1945, only 15 cases have been described in the literature, mostly in pregnant or postmenopausal women after ascending infection. This report documents a pyomyoma that presented as a postpartum enlargement of a previously known leiomyoma. This case is unique because the patient did not undergo a hysterectomy at the time of exploratory laparotomy. Six months after the procedure, normal cyclic bleeding was noted.

Pulmonary alveolar hemorrhage in a pregnancy complicated by systemic lupus erythematosus.

We present a case of a pregnant patient with fulminant systemic lupus erythematosus complicated by alveolar hemorrhage, a rare and potentially fatal manifestation of lupus. It typically presents in the context of a pulmonary-renal syndrome. Active lupus nephritis with hypoalbuminemia is a major risk factor for alveolar hemorrhage. Treatment with high-dose corticosteroids is the mainstay of therapy.

Red degeneration of a leiomyoma masquerading as retained products of conception.

BACKGROUND: The incidence of leiomyomas in pregnancy is approximately 1%. Their presence has been linked to spontaneous abortion, premature labor, soft tissue dystocia, uterine inertia, fetopelvic disproportion, malposition of the fetus, retention of the placenta, and postpartum hemorrhage. CASE: This case report documents a seldom-described event of a submucous leiomyoma masquerading as retained products of conception. The patient presented 4 weeks postpartum with complaints of urinary retention and heavy bleeding with cramping. Examination revealed a large mass resembling placental tissue filling the vaginal vault. The necrotic mass was removed with blunt and sharp dissection. The final pathology report revealed a degenerating leiomyoma. CONCLUSION: Complicating factors associated with this fibroid included a history of spontaneous abortion and preterm labor, as well as fetal malpresentation and carneous degeneration of the leiomyoma. Gestational myomas, although rare, can have an unusual appearance that may be misinterpreted.