Utility of third trimester sonographic measurements for predicting SGA in cases of fetal gastroschisis.

OBJECTIVE: To assess the accuracy of different sonographic estimated fetal weight (EFW) cutoffs, and combinations of EFW and biometric measurements for predicting small for gestational age (SGA) in fetal gastroschisis. STUDY DESIGN: Gastroschisis cases from two centers were included. The sensitivity, specificity, positive and negative predictive values (PPV and NPV) were calculated for different EFW cutoffs, as well as EFW and biometric measurement combinations. RESULTS: Seventy gastroschisis cases were analyzed. An EFW<10% had 94% sensitivity, 43% specificity, 33% PPV and 96% NPV for SGA at delivery. Using an EFW cutoff of <5% improved the specificity to 63% and PPV to 41%, but decreased the sensitivity to 88%. Combining an abdominal circumference (AC) or femur length (FL) z-score less than -2 with the total EFW improved the specificity and PPV but decreased the sensitivity. CONCLUSION: A combination of a small AC or FL along with EFW increases the specificity and PPV, but decreases the sensitivity of predicting SGA.

Variable effects on murine pregnancy of immunoglobulin G fractions from women with antiphospholipid antibodies.

OBJECTIVE: Initial studies showed that passive immunization with human immunoglobulin G fractions containing antiphospholipid antibodies can result in murine fetal loss. We intended to use the murine model to study mechanisms of fetal loss associated with antiphospholipid antibodies. However, we have since found variable effects of antiphospholipid antibodies on murine pregnancy. The objective of this study was to determine the consistency of murine pregnancy loss from antiphospholipid antibody containing immunoglobulin G fraction. STUDY DESIGN: Pregnant C3H/HeN (mated with C57B1/6 males) and BALB/c (mated with BALB/c males) mice were passively immunized with antiphospholipid antibody containing human immunoglobulin G fraction from 20 women with antiphospholipid syndrome. The mice received either a single dose of 10 to 30 mg on day 12 of pregnancy or 10 mg per day on days 12 to 14 of gestation. Some mice receiving each dose of immunoglobulin G fraction were bled to confirm serum levels of anticardiolipin antibodies. Mice were killed on day 15 and the fetal status was determined. RESULTS: Overall, passive immunization with individual antiphospholipid antibody containing immunoglobulin G fractions resulted in 801 live pups (75%), 232 fetal deaths (22%), and 38 resorptions (3%) in 131 mice. The effect of immunoglobulin G fractions from individual patients was highly variable. Immunoglobulin G fraction from eight women resulted in high rates of fetal loss. However, in spite of high levels of anticardiolipin antibodies, fetal outcome was normal in mice immunized with immunoglobulin G fraction from the majority of women. The rate of fetal death did not uniformly increase with increasing doses of immunoglobulin G fraction and was unrelated to the donor's medical history. Fetal outcome was similar for both C3H/HeN and BALB/c mice. CONCLUSIONS: Human antiphospholipid antibodies have variable effects on murine pregnancy outcome. Characterization of antiphospholipid antibodies that do and do not cause murine fetal loss may provide insight into epitopes relevant to fetal loss associated with antiphospholipid syndrome.

Very advanced maternal age: pregnancy after age 45.

OBJECTIVE: Our purpose was to describe the maternal and fetal outcomes of pregnancies in women > or = 45 years old at delivery. STUDY DESIGN: A retrospective review of in-hospital deliveries after 20 weeks of gestation was performed in four Utah tertiary care hospitals for the 10-year period between 1985 and 1994. RESULTS: Seventy-nine cases were identified among 126,500 births, with an incidence of 0.63 per 1000 births. Maternal ages were 45 (n = 44), 46 (n = 21), and > or = 47 (n = 14) years. Three of the conceptions were assisted, including both twin gestations. Thirty-seven (46.8%) had obstetric complications during pregnancy; the most frequent complications were gestational diabetes (12.7%) and preeclampsia (10.1%). Median (range) gestational age at delivery was 39 (22.9 to 41.7) weeks; 12 (15.2%) deliveries occurred before 37 weeks. Eight (9.9%) karyotype abnormalities were diagnosed. The cesarean section rate was 31.7%; the most frequent indications were abnormal lie (n = 9), fetal distress (n = 5), and previous cesarean delivery (n = 5). There were no maternal deaths. Median (range) birth weight was 3466 (397 to 5085) gm; 14 (17.3%) were < 2500 gm and 16 (19.8%) were > 4000 gm. Twelve (14.8%) infants were admitted to the neonatal intensive care unit. The corrected perinatal mortality rate was 1.3% (1/78). CONCLUSIONS: In women > 45 years old at delivery maternal and fetal outcomes were generally good, but there was a high incidence of pregestational (chronic hypertension, hypothyroidism) and gestational (karyotype abnormalities, gestational diabetes, cesarean section, macrosomia) complications. This information may be helpful for counseling women between 45 and 50 years old who are considering pregnancy.

Antiphospholipid antibodies and fetal death.

OBJECTIVE: To determine the type of recurrent pregnancy loss associated with antiphospholipid antibodies. METHODS: This was a retrospective analysis of women who had two or more pregnancy losses and who were tested for antiphospholipid antibodies. The specific type of pregnancy losses were determined in patients with and without antiphospholipid antibodies. RESULTS: In our highly selected referral population, 76 of 366 women (21%) tested positive for lupus anticoagulant or anticardiolipin antibodies of 20 or more immunoglobulin-G phospholipid antibody units. Pregnancy loss occurred in 280 of 333 (84%) prior pregnancies in women with and 1240 of 1479 (84%) without antiphospholipid antibodies. However, 50% of pregnancy losses in women with antiphospholipid antibodies were fetal deaths, compared with less than 15% in women who were antiphospholipid antibody-negative. More than 80% of women with antiphospholipid antibodies had at least one fetal death, compared with less than 25% of women without (P < .001). The specificity of fetal death for the presence of antiphospholipid antibodies in patients with recurrent pregnancy loss was 76%. In contrast, two or more early first-trimester losses without fetal death had a specificity of only 6% for antiphospholipid antibodies. CONCLUSION: Fetal death is more characteristic of the type of loss experienced by patients with recurrent pregnancy loss than early first-trimester pregnancy loss in women with antiphospholipid antibodies.

Pregnancy outcome in Swiss-Webster mice infected with Chlamydia trachomatis.

OBJECTIVE: The objective of this study was to observe pregnancy outcomes in mice infected transvaginally with Chlamydia trachomatis. METHODS: Pregnant mice were inoculated transvaginally with either C. trachomatis (CT) or sterile calf serum (CON) on pregnancy day 4. Pregnancy outcomes as well as genital tract histology and culture were compared. Statistical analysis was performed using Fisher's exact test and Student's t-test. RESULTS: Twenty-four of 26 CT mice had positive uterine cultures for C. trachomatis. Inflammation occurred in 9 (34.6%) (P = 0.002, 95% confidence interval = 1.7-3.5) and intrauterine fetal demise occurred in 5 (19.2%) (P = 0.05, 95% confidence interval = 1.6-2.9) of CT mice. No mice in the CON group (0/24) had positive uterine cultures, developed inflammation, or experienced intrauterine fetal demise. CONCLUSIONS: Lower genital tract chlamydial infection is associated with intrauterine fetal demise in Swiss-Webster mice.

Gentamicin levels in pregnant women with pyelonephritis.

This study was performed at University Medical Center, Lubbock, Texas, from July 1989 to June 1990. We obtained serum gentamicin peak and trough levels in 23 pregnant women with pyelonephritis. The patients were given a loading dose of 2 mg/kg gentamicin, followed by 1.5 mg/kg gentamicin adjusted for obesity every 8 hours. Peak levels were obtained 1 hour after the fifth dose and trough levels were drawn 30 minutes before the sixth dose. Statistical analysis was performed using chi 2 analysis. The mean (+/- SD) peak gentamicin level was 2.7 +/- 1.4 micrograms/mL and the mean trough level was 0.5 +/- 0.3 micrograms/mL. Twenty-two of 23 (96%) patients had peak levels 5 micrograms/mL and 1 of 23 (4%) patients had peak levels between 5 and 10 micrograms/mL. The mean peak gentamicin level in pregnancy is significantly less than in puerperal women (2.70 versus 5.78; P < 0.000001). We conclude that the majority of pregnant women treated for pyelonephritis with standard doses of gentamicin do not achieve therapeutic levels. Also, peak gentamicin levels are significantly below that reported for puerperal women.

Endotoxin, interleukin-1 beta, interleukin-6, or tumor necrosis factor-alpha do not acutely stimulate isolated murine myometrial contractile activity.

OBJECTIVES: Endotoxin, interleukin-1 beta, interleukin-6, and tumor necrosis factor-alpha have been implicated in the pathogenesis of preterm labor, but their acute effect on myometrial contractile activity is unknown. The objective of this study was to determine their effect on isolated pregnant murine myometrial contractile activity. STUDY DESIGN: Isometric contractions were measured in myometrium isolated from pregnancy day 18 Swiss-Webster mice. Frequency, duration, amplitude, and integrated area were compared before and after the addition of endotoxin (10(3) and 10(4) ng/ml) (n = 6), interleukin-1 beta (10 and 10 ng/ml) (n = 6), interleukin-6 (1 and 10 ng/ml) (n = 6), and tumor necrosis factor-alpha (1 and 10 ng/ml) (n = 6). Results were analyzed with the Wilcoxon rank-sum test. RESULTS: The addition of endotoxin, interleukin-1 beta, interleukin-6, or tumor necrosis factor-alpha did not result in a change in the contractile activity of isolated pregnant murine myometrium compared with control. CONCLUSION: Endotoxin, interleukin-1 beta, interleukin-6, and tumor necrosis factor-alpha do not acutely increase isolated murine myometrial contractile activity.

Association of clinical intra-amniotic infection and meconium.

The objective of this study was to determine the rate of intra-amniotic infection in patients with meconium-stained amniotic fluid compared to controls. With a retrospective case-controlled study design, we compared 100 pregnant women with meconium to 100 pregnant women without meconium for the development of intra-amniotic infection. Patients delivered between September 1 and December 31, 1990. Exclusion criteria were active infection prior to labor or antibiotic use within the 7 days prior to delivery. We diagnosed clinical intra-amniotic infection in patients with ruptured membranes by a maternal temperature 100.4 degrees F or higher and any two of the following: maternal or fetal tachycardia, uterine tenderness, white blood cell count 10,500 mm3 or more, or foul-smelling amniotic fluid. Demographic variables, labor characteristics, maternal infectious morbidity, and neonatal outcome were analyzed using the Wilcoxin rank test, chi-square test, or Fisher's exact test as appropriate. The rate of clinical intra-amniotic infection was significantly higher in women with meconium-stained amniotic fluid (8%) compared with women with no meconium (2%) (p = 0.05).

Disseminated herpes zoster in a pregnant woman positive for human immunodeficiency virus.

We report a case of disseminated herpes zoster in a pregnant patient positive for the human immunodeficiency virus (HIV). Disseminated zoster was the first manifestation of HIV infection in this patient. In HIV-positive patients, zoster may be complicated by cutaneous dissemination, visceral involvement, and death. Intravenous acyclovir may prevent serious sequelae in both mother and fetus.

Uterine contractions after antibiotic therapy for pyelonephritis in pregnancy.

OBJECTIVE: The purpose of our study was to investigate the pathogenesis of preterm labor in pyelonephritis, we determined the number of uterine contractions occurring in patients with pyelonephritis before and after antibiotic therapy. STUDY DESIGN: We recorded the uterine contractions before and after antibiotic administration in 30 patients with acute pyelonephritis at Lyndon B. Johnson Hospital in Houston. Exclusion criteria were cervical dilatation > or = 4 cm, < 26 weeks' gestation, antibiotics within 7 days, clinical intraamniotic infection, rupture of membranes, or other maternal infection. Statistical analysis was by Kruskal-Wallis analysis of variance and Wilcoxon rank sum tests. RESULTS: The patients averaged eight contractions per hour on admission. The contraction rate significantly increased in hours +1 to +4 after antibiotic administration. The increase in uterine contractility occurred in patients with urinary tract gram-negative isolates. CONCLUSIONS: Pregnant women with pyelonephritis resulting from gram-negative bacteria increase their rate of uterine contractility after antibiotic treatment. This observation may be important in understanding the pathogenesis of preterm labor in pyelonephritis.

Single-dose ampicillin prophylaxis does not eradicate enterococcus from the lower genital tract.

OBJECTIVES: To determine the carriage rate of enterococcus in the lower genital tract of women having a cesarean delivery and to determine whether a single 2-g intraoperative dose of ampicillin eradicates enterococcus from the lower genital tract. METHODS: Lower genital tract cultures were taken in 84 women who were in labor or had ruptured membranes and who were about to have an indicated cesarean delivery. The subjects were randomized to receive either a single 2-g dose of ampicillin or a cephalosporin as prophylaxis. Cultures were repeated 24 hours postpartum. RESULTS: Enterococcus was isolated preoperatively in 33 subjects (39.3%) and postoperatively in 36 (42.9%). The enterococcus was eradicated in five of 17 women (29.5%) who received ampicillin. CONCLUSION: These results suggest that a single 2-g dose of ampicillin does not eradicate enterococcus from the lower genital tract.

Limited-spectrum (first-generation) cephalosporins.

Except in the treatment of pyelonephritis, the first-generation cephalosporins are rarely the first line drug of choice for any suspected infection in obstetrics. Other antibiotics have a narrower spectrum of antimicrobial coverage and are cheaper. Unless culture dictates the use of cephalosporins for main-line therapy, the use of first-generation cephalosporins should be limited to the treatment of pyelonephritis in pregnancy and for prophylaxis at the time of surgery.