Perspective on women's health: editors' 1997-1998 year in review.

Heart disease, breast cancer, and hormone therapy were top clinical concerns in women's health in 1997. One of the major reports on heart disease confirmed that women are no different from men in terms of early infarct-related artery patency rates, reocclusion after thrombolytic therapy, and ventricular functional response to injury/reperfusion; nevertheless, women have 3 times the mortality of men in the first 30 days after an acute myocardial infarction. Research brought only modest gains in the understanding of breast cancer etiology in 1997, but engendered major debate on whether women younger than 50 years should have mammograms every 1 to 2 years. A National Institutes of Health consensus conference said no, but the National Cancer Institute's National Cancer Advisory Board said yes. Evidence of estrogen benefits and risks mounted: One report added to the data suggesting that estrogen may retard age-related memory loss, while another study reported that the risk of breast cancer significantly increased with long-term use of estrogens. The interest in selective estrogen receptor modulators (SERMs), also called "designer estrogens," grew. Efforts to develop pharmacologic treatment for obesity suffered a setback in 1997 when a team reported that 1 in 3 patients who used d-fenfluramine developed abnormal valvular thickening, with the most severe cases needing valve replacement. One of the most promising events in colorectal cancer, the third most common cancer in women, was the set of screening guidelines issued by the Agency for Health Care Policy and Research. The year ended with major ethical debates about multiple gestation and cloning.

Trichomonas vaginalis associated with low birth weight and preterm delivery. The Vaginal Infections and Prematurity Study Group.

BACKGROUND: Several studies have suggested that pregnant women infected with Trichomonas vaginalis may be at increased risk of an adverse outcome. GOAL: To evaluate prospectively the association between T. vaginalis and risk of adverse pregnancy outcome in a large cohort of ethnically diverse women. STUDY DESIGN: At University-affiliated hospitals and antepartum clinics in five United States cities, 13,816 women (5,241 black, 4,226 Hispanic, and 4,349 white women) were enrolled at mid-gestation, tested for T. vaginalis by culture, and followed up until delivery. RESULTS: The prevalence of T. vaginalis infection at enrollment was 12.6%. Race-specific prevalence rates were 22.8% for black, 6.6% for Hispanic, and 6.1% for white women. After multivariate analysis, vaginal infection with T. vaginalis at mid-gestation was significantly associated with low birth weight (odds ratio 1.3; 95% confidence interval 1.1 to 1.5), preterm delivery (odds ratio 1.3; 95% confidence interval 1.1 to 1.4), and preterm delivery of a low birth weight infant (odds ratio 1.4; 95% confidence interval 1.1 to 1.6). The attributable risk of T. vaginalis infection associated with low birth weight weight in blacks was 11% compared with 1.6% in Hispanics and 1.5% in whites. CONCLUSIONS: After considering other recognized risk factors including co-infections, pregnant women infected with T. vaginalis at mid-gestation were statistically significantly more likely to have a low birth weight infant, to deliver preterm, and to have a preterm low birth weight infant. Compared with whites and Hispanics, T. vaginalis infection accounts for a disproportionately larger share of the low birth weight rate in blacks.

Tuberculosis skin testing in pregnancy: trends in a population.

BACKGROUND: A change has recently been noted in the epidemiology of tuberculosis in the United States. Multiple factors, including human immunodeficiency virus (HIV) infection, increases in the homeless population, and immigration, are cited as causes for an increased prevalence. The population of pregnant women in New Orleans exhibits several of these risk factors and may be compared with a previous description of this group reported in 1983. METHODS: All patients requesting obstetric care at the Medical Center of Louisiana at New Orleans from January 1994 to April 1995, were offered tuberculosis skin testing during their initial outpatient clinic visit. A skin test was considered positive if there was 10 mm of induration (5 mm in HIV-positive patients) at 48 hours. Other information collected included HIV status and ethnic group. This group was compared with a group of patients tested in 1981 and 1982. RESULTS: The study included 1621 patients, who underwent testing and had available results. The only significant risk factor for a positive skin test in 1994 was Hispanic ethnicity. Hispanics are the most recent immigrants to the New Orleans area. In 1983 Asians were at highest risk and were the newest immigrants to the city. HIV status was insignificant as a predictor of skin test conversion. CONCLUSIONS: Pregnant women at highest risk for tuberculosis in this urban center are recent immigrants to the United States. This is consistent with data reported by the Centers for Disease Control and Prevention from other locales. Efforts should be made to ensure that recently immigrated pregnant women receive skin testing as part of their obstetric care.

Elective versus emergency cesarean hysterectomy on a teaching service--1981 to 1991.

We compared the differences in morbidity of elective and emergency cesarean hysterectomy (CH) in a training program. Records of patients who had elective or emergency CH were reviewed for information reflecting perioperative morbidity and fetal outcome. Eighty-eight CHs were elective and 18 were emergencies. Compared to emergency CHs, operative time for elective CHs was 30 minutes less, intraoperative blood loss was 700 mL lower, less postoperative blood replacement was needed, and hospital stay was 3.5 days shorter. Emergency CH had nearly twice the frequency of postoperative febrile morbidity and a three-times-higher rate of morbidity due to other causes. CHs were done at a gestational age of 36 or more weeks in 81.6% of elective cases, compared to only 50% of emergency cases. Mean birth weight of newborns delivered electively was 900 g higher, and Apgar scores were better. These data show that CHs done by house staff in training have a significantly lower complication rate when the operations are elective rather than emergent.

Clinical and microbiological correlates of vaginal trichomoniasis during pregnancy. The Vaginal Infections and Prematurity Study Group.

Colonization with Trichomonas vaginalis is a possible cause of poor pregnancy outcome. To facilitate the diagnosis of this condition during pregnancy, we conducted a prospective, multicenter study of 13,816 gravid women who were between 23rd and 26th week of gestation. Findings significantly associated with T. vaginalis colonization included a yellow, green, or bloody discharge from the vagina or cervix; abnormal odor after KOH was added to a vaginal specimen; a vaginal pH of > 5.0; and cervical friability. The amount of vaginal discharge and abnormal consistency of the discharge were also associated with T. vaginalis colonization. These findings (except for cervical bleeding and odor after the addition of KOH to a vaginal specimen, which may be influenced by the presence of other flora) are consistent with those reported elsewhere. The clinical usefulness of these features is minimal, and it is more significant that other microorganisms are makers for trichomoniasis; therefore, controlling for other flora is important in the investigation of T. vaginalis colonization.

Association between bacterial vaginosis and preterm delivery of a low-birth-weight infant. The Vaginal Infections and Prematurity Study Group.

BACKGROUND: Bacterial vaginosis is believed to be a risk factor for preterm delivery. We undertook a study of the association between bacterial vaginosis and the preterm delivery of infants with low birth weight after accounting for other known risk factors. METHODS: In this cohort study, we enrolled 10,397 pregnant women from seven medical centers who had no known medical risk factors for preterm delivery. At 23 to 26 weeks' gestation, bacterial vaginosis was determined to be present or absent on the basis of the vaginal pH and the results of Gram's staining. The principal outcome variable was the delivery at less than 37 weeks' gestation of an infant with a birth weight below 2500 g. RESULTS: Bacterial vaginosis was detected in 16 percent of the 10,397 women. The women with bacterial vaginosis were more likely to be unmarried, to be black, to have low incomes, and to have previously delivered low-birth-weight infants. In a multivariate analysis, the presence of bacterial vaginosis was related to preterm delivery of a low-birth-weight infant (odds ratio, 1.4; 95 percent confidence interval, 1.1 to 1.8). Other risk factors that were significantly associated with such a delivery in this population were the previous delivery of a low-birth-weight infant (odds ratio, 6.2; 95 percent confidence interval, 4.6 to 8.4), the loss of an earlier pregnancy (odds ratio, 1.7; 1.3 to 2.2), primigravidity (odds ratio, 1.6; 1.1 to 1.9), smoking (odds ratio, 1.4; 1.1 to 1.7); and black race (odds ratio, 1.4; 1.1 to 1.7). Among women with bacterial vaginosis, the highest risk of preterm delivery of a low-birth-weight infant was found among those with both vaginal bacteroides and Mycoplasma hominis (odds ratio, 2.1; 95 percent confidence interval, 1.5 to 3.0). CONCLUSIONS: Bacterial vaginosis was associated with the preterm delivery of low-birth-weight infants independently of other recognized risk factors.

Outcome of the Vaginal Infections and Prematurity Study: results of a clinical trial of erythromycin among pregnant women colonized with group B streptococci.

OBJECTIVE: Our purpose was to determine whether erythromycin treatment of pregnant women colonized with group B streptococci would reduce the occurrence of low birth weight (< 2500 gm) and preterm (< 37 completed weeks) birth. STUDY DESIGN: In a double-blind clinical trial, 938 carriers of group B streptococci were randomized to receive erythromycin base (333 mg three times a day) or matching placebo beginning during the third trimester and before 30 weeks and continuing for 10 weeks or until 35 weeks 6 days of pregnancy. RESULTS: Pregnancy outcomes were available for 97% of randomized women; 14% of subjects withdrew from the trial. Birth weight < 2500 gm occurred in 8.6% of the erythromycin and 6.1% of the placebo recipients (relative risk 1.4, 0.9 to 2.2, p = 0.16). Preterm delivery occurred in 11.4% of women randomized to erythromycin and in 12.3% randomized to placebo (relative risk 0.9, 95% confidence limits 0.6 to 1.3, p = 0.65). Greater benefit of erythromycin in reducing these outcomes was not observed among women reporting the best compliance. CONCLUSIONS: In this study of pregnant women colonized with group B streptococci treatment with erythromycin was not shown to be effective at prolonging gestation or reducing low birth weight. Greater than anticipated complicating factors, including spontaneous clearance of the organism, use of nontrial antibiotics, and density of colonization, may have resulted in population sizes too small to detect a benefit of treatment. Future studies should take these factors into account in determining sample sizes.

Comparison of three regimens recommended by the Centers for Disease Control and Prevention for the treatment of women hospitalized with acute pelvic inflammatory disease.

This six-center, prospective, open-label clinical trial compared the efficacy and safety of three regimens recommended by the Centers for Disease Control and Prevention (CDC) for the treatment of women hospitalized for acute pelvic inflammatory disease (PID). The study focused on the response to inpatient therapy, not on long-term prevention of sequelae. A severity score was used for objective comparison of the degree of illness before and after therapy. Women were randomly assigned (in a 1:1:1 ratio) to treatment with cefoxitin plus doxycycline, clindamycin plus gentamicin, or cefotetan plus doxycycline. Two hundred seventy-five (94.2%) of 292 evaluable women required no alteration in therapeutic regimen. The three regimens produced almost identical cure rates. No serious adverse clinical or laboratory events were observed. In short, the three regimens recommended by the CDC for inpatient therapy of acute PID were similarly effective and safe.

Episiotomy repair: chromic versus polyglycolic acid suture.

The use of an episiotomy for vaginal delivery is a controversial topic in modern obstetrics. If one is done, however, correct technique and appropriate suture material are important. On the LSU Obstetrics Service, the usual midline episiotomy has traditionally been closed with 2-0 chromic suture. Theoretically, the use of a less reactive material, eg, polyglycolic acid (Dexon), may be beneficial in terms of acute postpartum discomfort and healing. As a comparison of healing and patient comfort parameters between 2-0 chromic and 2-0 polyglycolic acid suture used for episiotomy repair after delivery, two consecutive months' worth of parturients at Medical Center of Louisiana/Charity Hospital had episiotomy repair, with either chromic or polyglycolic acid suture, by junior house officers routinely attending delivery. Patients had follow-up during hospital stay, and when examined at 6 weeks for evidence of suture line healing, they were also asked about comfort and resumption of sexual activity. Of 48 patients who had repair with 2-0 chromic suture, 6 were lost to follow-up. Of 44 gravidas who had repair with 2-0 polyglycolic acid suture, 7 were lost to follow-up. At the 6-week postpartum examination, patients with polyglycolic acid sutures had significantly better healing. A noticeable scar was present in 42 of 42 patients with chromic sutures versus 21 of 37 in the polyglycolic acid group, a scar with granulation tissue in 16 of 42 versus 3 of 37, and a gaping scar in 9 of 42 and 0 of 37, respectively. Recovery of function, measured by resumption of sexual activity by 6 weeks, was demonstrated in 1 of 42 patients who had chromic sutures versus 19 of 37 patients who had polyglycolic acid sutures. Episiotomy repair with 2-0 polyglycolic acid (Dexon) offers significant advantages over traditional 2-0 chromic suture, both in terms of wound healing and resumption of normal patient activity, including sexual activity.

Randomized comparative study of cefepime and cefotaxime in the treatment of acute obstetric and gynaecological infections.

Patients with presumed acute gynaecological infections were randomized (2:1) to receive cefepime 2 g every 12 h (n = 159) or cefotaxime 2 g every 8 h (n = 72), both im or by a 30-min i.v. infusion. For evaluation of efficacy, patients were required to have a bacteriologically documented infection, with at least one pathogen isolated susceptible to both drugs. Duration of treatment was 2-8 days in the 95 cefepime-treated patients and 3-10 days in the 36 cefotaxime-treated patients with evaluable infections; approximately three-quarters of the patients in each group were treated for 4-5 days. Clinical response was satisfactory in 81/95 (85%) of the evaluable cefepime recipients and 30/36 (83%) of the evaluable cefotaxime recipients (P = 0.802). In total, 211 (85%) of the 247 pathogens isolated from evaluable cefepime recipients were eradicated, compared with 98 (90%) of 109 pathogens isolated from evaluable cefotaxime recipients. All pathogens were eradicated in 77 (81%) cefepime-treated patients and in 31 (86%) cefotaxime-treated patients (P = 0.379). Overall response to treatment, calculated by combining clinical response and individual patient bacteriological response, was considered effective, partially effective or ineffective in 77%, 13% and 11% of cefepime-treated patients respectively and in 75%, 19% and 6% of cefotaxime-treated patients respectively (P = 0.932 for effective response). Adverse clinical events were reported by 68 (43%) of 159 cefepime recipients and by 26 (36%) of 72 cefotaxime recipients (P = 0.342); adverse events were deemed drug-related in 6% of cefepime recipients (diarrhoea, rash and headache) and in 1% of cefotaxime recipients (diarrhoea, pruritus and rash). Treatment was discontinued prematurely due to adverse events in five cefepime-treated patients and in one cefotaxime-treated patient (P = 0.476). Local intolerance was reported by 33 (21%) of the 159 cefepime-treated patients and by 14 (19%) of the 72 cefotaxime-treated patients receiving drug via the iv route alone; none of the patients discontinued treatment because of local intolerance. Laboratory test abnormalities were observed in a small number of patients in each group (1-8%), but none warranted discontinuation of treatment. Cefepime 2 g bd appears to have efficacy and safety comparable to that of cefotaxime 2 g tid in the treatment of acute obstetric and gynaecological infections.

Comparison of morbidity in cesarean section hysterectomy versus cesarean section tubal ligation.

This study was undertaken to compare the morbidity of cesarean section hysterectomy (C-HYST) and cesarean section bilateral tubal ligation (C-BTL) in a nonemergency or elective environment. Charts were reviewed for patients who underwent elective C-HYST or elective C-BTL before the onset of labor, without the use of antibiotics. Demographics, maternal morbidity, operative difficulties and postoperative complications were compared. Statistically significant differences in patient demographics include a higher maternal age in the C-HYST group than for those in the C-BTL group (31.0 +/- 5.8 versus 27.7 +/- 5.4 years; p = 0.002). C-BTL patients had higher gestational ages (39.4 +/- 1.6 versus 38.7 +/- 1.3 years; p = 0.0017). The C-HYST group had a higher estimated blood loss (1,201 +/- 472 versus 718 +/- 364 milliliters; p = 0.001), change in hematocrit level (6.0 +/- 4.4 percent versus 4.5 +/- 3.4 percent; p = 0.013) and operating time (115 +/- 37 versus 74 +/- 26 minutes; p = 0.0001). Blood transfusion was similar in both groups. Febrile morbidity was higher in the C-BTL group (68.0 percent versus 50.0 percent; p = 0.01). Endometritis was the significant determinant of febrile morbidity for the C-BTL group (41.7%) and cuff cellulitis in the C-HYST group (25.6 percent). Intraoperative and postoperative complications between the two groups were rare and not statistically different. Clinical morbidity for C-HYST is not significantly different than C-BTL. Elective C-HYST may be used in place of C-BTL when indications for hysterectomy are present.

Group B streptococcal colonization in the diabetic gravida patient.

Previous reports have suggested that pregnant diabetic patients have higher carriage rates of group B Streptococcus (GBS) than nondiabetic gravidas. In order to evaluate this in our population, we cultured the posterior pharynx, endocervix, vagina, and rectum of 101 diabetic pregnant women and 100 nondiabetic gravida patients. The colonization rate of GBS was higher in the diabetic population, 31.7%, than in the nondiabetic group 19.0%, (p < 0.039). The vagina was the site most often positive in both diabetic and nondiabetic populations (23.8% and 17.0%, respectively, p = NS). The second site to culture positive overall and the only individual site that was positive significantly more often in diabetics was the rectum (16.9% versus 7.0%, p < 0.05). Differences in colonization rates were not evident when insulin requirement and diabetic classes were considered.

Demographic and behavioral predictors of Trichomonas vaginalis infection among pregnant women. The Vaginal Infections and Prematurity Study Group.

There is little available information on the demographic and behavioral factors associated with Trichomonas vaginalis in pregnant women. Among 13,816 women from six urban clinic centers, the prevalence rate by culture at mid-pregnancy was 12.6%. Women colonized with T vaginalis were significantly more likely to be black, cigarette smokers, unmarried, and less educated (all P less than .01). Several behavioral factors associated with T vaginalis included greater numbers of sexual partners both lifetime and in the last year, 5 years or more of sexual activity, and a history of gonorrhea (all P less than .01). Trichomonas vaginalis-colonized women were less sexually active in the preceding month compared with uncolonized women (P less than .01). Women using either barrier or oral contraception in the 6 months before becoming pregnant were far less likely to be colonized (P less than .01). Other factors such as age, gravidity, income level, age at first coitus, and use of antibiotics, alcohol, or douche during pregnancy were not independently associated with T vaginalis colonization. Because many of the factors predictive of increased risk of colonization have also been shown to be associated with adverse pregnancy outcome, they should be considered in assessing the association of T vaginalis with adverse pregnancy outcome.