Significance of low birthweight for gestational age among very preterm infants.

OBJECTIVE: To estimate the risk of specific adverse neonatal events resulting from the combined effects of prematurity and low birthweight in very preterm infants (delivered at 24-31 weeks of gestation). DESIGN: A cohort study of specific adverse neonatal events in preterm infants born at between 24 and 31 weeks of gestation. SETTING: Pavia, Italy. POPULATION: Two hundred and thirty singleton infants with sonographically confirmed gestational age, delivered at 24 to 31 weeks of gestation. METHODS: To evaluate the impact of a lower than expected birthweight on selected neonatal events independently of gestational age, we calculated birthweight standard deviation scores (differences between actual birthweight and fitted birthweight divided by fitted standard deviation) for each week of gestation. RESULTS: After adjustment for gestational age and other confounders, there was a significant linear trend relating a decreasing birthweight SDS to an increased likelihood of neonatal death, intraventricular haemorrhage, severe respiratory distress syndrome, and acidosis. Compared with infants with SDS > or = 0 (> or = 50th centile of birthweight), infants with birthweight SDS < -1 (< 16th centile) had increased odds for neonatal death [odds ratio (OR) 3.7, 95% confidence interval (CI) 1.42-9.6], grade III-IV intraventricular haemorrhage (OR 17.5, 95% CI 4.04-75.9), and neonatal acidosis (OR 3.22, 95% CI 1.41-7.4). The significance of birthweight SDS as a predictor of neonatal outcome, however, was lower than that of gestational age. CONCLUSIONS: A lower than expected birthweight affects the likelihood of several adverse neonatal events in very preterm infants. However, a decreasing birthweight SDS affects neonatal outcome less than decreasing gestation does.

Managing recurrent vulvovaginal candidiasis. Intermittent prevention with itraconazole.

OBJECTIVE: To evaluate the efficacy of one-day, intermittent, monthly prophylaxis with 400 mg itraconazole in the management of recurrent vulvovaginal candidiasis. STUDY DESIGN: In a randomized trial, 57 patients and 57 controls with recurrent vulvovaginal candidiasis were assigned either to receive one-day monthly itraconazole prophylaxis for six months or no treatment. Clinical and mycologic evaluations were carried out 3, 6 and 12 months after enrollment. RESULTS: During the first six months of follow-up, the rate of symptomatic recurrences was 36.4% (20/55) among the treated women and 64.2% (34/53) in the controls. The mean time +/- SEM to symptomatic recurrence was 149 +/- 6 days among patients receiving prophylaxis and 120 +/- 6 days in the controls (P = .003 by log-rank test). These differences disappeared almost completely after the cessation of intermittent prophylaxis. In fact, the proportion of patients still asymptomatic after one year of follow-up was 38.9% (21/54) among treated women and 28.8% (15/53) in the controls (P = .83 by Fisher's exact test). CONCLUSION: One-day monthly, intermittent itraconazole prophylaxis reduced the rate of recurrence in patients with recurrent vulvovaginal candidiasis, but the beneficial effect of itraconazole was lost within a few months after cessation of prophylaxis.

Cervical intraepithelial neoplasia in pregnant intravenous drug users infected with human immunodeficiency virus type 1.

OBJECTIVE: The purpose of this study was to evaluate the frequency and natural history of cervical intraepithelial neoplasia (CIN) during pregnancy in past or current intravenous drug users infected with human immunodeficiency virus type 1 (HIV-1). STUDY DESIGN: We prospectively evaluated 48 pregnant HIV-1 seropositive patients and 38 HIV seronegative controls. All the subjects were current or past intravenous drug users. Follow-up visits were carried out each trimester of pregnancy and 8-12 weeks post-partum with Papanicolau smears, colposcopic examinations and, when necessary, colposcopically directed cervical biopsies. RESULTS: Thirteen of 48 HIV-seropositive women (27.1%) and three of 38 HIV-seronegative controls (7.9%) (P = 0.027 by Fisher exact test) had biopsy-proven CIN at the beginning of pregnancy. High-grade CIN was detected in 10 cases (20.8%) and in two (5.3%) controls (P = 0.058 by Fisher exact test). None of the cervical squamous intraepithelial lesions progressed throughout pregnancy, in both cases and controls. Post-partum cold-knife cervical conization was performed on seven patients with CIN III and examination of the cone biopsy specimens demonstrated persistence of CIN III. CONCLUSIONS: HIV-infected intravenous drug users are at high risk of CIN during pregnancy, thus requiring adequate screening programs. Our preliminary data suggest that the progression rate of CIN during gestation is low in this high-risk group.

The impact of oral contraception on chlamydial infection among patients with pelvic inflammatory disease.

The prevalence of oral contraceptive use in association with chlamydial pelvic inflammatory disease (PID) and the presence of anti-chlamydial IgG and IgA in a population of 144 hospitalized and outpatient subjects with a standard diagnosis of PID was studied. The rates of chlamydial PID and IgA detection were 15.3% (22/144) and 13.9% (20/144), respectively. After stratification for age, number of pregnancies, and lifetime sexual partners, the rates of chlamydial PID (odds ratio = 0.30, 95% CI = 0.10 - 0.89) and IgA detection (odds ratio = 0.23, 95% CI = 0.07 - 0.73) were lower among previous or current oral contraceptive users than in women who had never used birth control methods. Analyses of linear trend indicated a negative association between increasing duration of exposure to hormonal contraception and anti-chlamydial IgG and IgA. This study confirms that among patients with chlamydial PID, the frequency of oral contraceptive use is lower than that in patients with PID of other etiology. Serologic studies suggest a possible relationship between hormonal contraception and changes in immune response or susceptibility to chlamydial infection.

The effect of work activity in pregnancy on the risk of fetal growth retardation.

BACKGROUND: The relationship between physical activity at work and risk of fetal growth restriction is controversial. For the most part, previous studies investigated the effect of work activity on birthweight alone. We evaluated the impact of type of occupation and physical effort at work on the risk of ultrasonographically confirmed fetal growth retardation among nulliparous women. METHODS: We compared the characteristics of work and the intensity of occupational fatigue (work posture, weekly working hours, physical effort at work) in 349 patients with ultrasonographically confirmed fetal growth retardation and 698 control pregnancies with appropriate fetal growth. Physical demands at work were evaluated by interview at birth. Logistic regression analysis was used to evaluate the association of employment status, type of occupation, and intensity of occupational fatigue with the risk of fetal growth retardation, correcting for potential confounders (maternal age, pre-pregnancy body mass index, mean weight gain in pregnancy, education, partner's social status, smoking in pregnancy, alcohol use, illicit drug use, time of stopping work, and hypertension). RESULTS: After adjusting for confounding, the risk of fetal growth retardation was similar between unemployed and formally employed women at the beginning of pregnancy (OR = 1.26; 95% confidence interval = 0.86 - 1.83). However, manual workers were at slightly higher risk of IUGR than not formally employed women (OR = 1.81; 95% CI = 1.15 - 2.85). Among formally employed women, standing or walking at work, and working > or = 30 hours a week were not significantly associated with IUGR. Finally, the risk of IUGR was significantly higher (OR = 2.46; 95% CI = 1.36 - 4.21) among women reporting moderate-to-heavy as compared to light physical effort at work. CONCLUSION: Formal employment at the beginning of pregnancy is not associated with an increased risk of IUGR. However, moderate-to-heavy physical effort at work seems to increase the risk of sonographically confirmed fetal growth retardation.

Effect measures for behavioral factors adversely affecting fetal growth.

The purpose of this study was to estimate the proportion of ultrasonically diagnosed fetal growth retardation that may be attributable to potentially remediable factors (for example, cigarette smoking, alcohol use, and drug addition). We computed multivariate odds ratios for fetal growth retardation associated with cigarette smoking and alcohol and illicit drug consumption in 350 singleton pregnancies complicated by fetal growth retardation and 700 controls. The odds ratio of fetal growth retardation among women who smoked throughout pregnancy was 2.61 (95% confidence interval, 1.38 to 4.93) compared to women who claimed to have stopped smoking by the 18th week of gestation. The summary attributable risk of fetal growth retardation associated with behavioral variables measured during the first trimester and thereafter ranged from 18 to 21%. By implication, the maximum proportion of fetal growth retardation that could theoretically be prevented by eliminating these risk factors accounts for about 1% of all births. However, allowance for the limited modifiability of preventable factors and the consistent overlap between them would probably reduce such estimate to less than 1%. We conclude that only interventions to reduce the prevalence of strong risk factors (for example, preeclampsia, sociodemographic variables) may have a substantial effect on the incidence of impaired fetal growth and subsequent infant morbidity.

The effect of work activity in pregnancy on the risk of severe preeclampsia.

The aim of this study was to evaluate the impact of type of employment and level of physical activity at work on the risk of severe preeclampsia. For this purpose, we carried out a case control study of 160 nulliparous pregnant women with severe preeclampsia and 320 normotensive nulliparous controls who received prenatal care from members of one medical staff. The type of employment and the level of physical activity sustained at work were ascertained at birth through an interview based on a standard questionnaire. The degree of physical activity at work was assessed by a 4-level activity score based on type of work, physical intensity, posture at work, and weekly working hours. In logistic regression analysis, after adjustment for potential confounders (maternal age, time of stopping work, prepregnancy body mass index, social status of the partner, history of previous abortion, and prepregnancy smoking status), clerical workers had a significantly lower risk of severe preeclampsia than women who were unemployed at the beginning of pregnancy (OR 0.53, 95% CI 0.30, 0.96). In multivariate analysis, there was a significant linear trend relating the degree of physical activity at work, to the risk of preeclampsia (likelihood chi-square = 9.38, 3 df, p = 0.002). We then restricted the analysis to women who had ever worked in pregnancy (n = 339) also adjusting for confounders, and found that clerical workers were still at significantly lower risk of severe preeclampsia than women not formally employed (OR 0.2, 95% CI 0.08, 0.49). In addition, moderate/high physical activity at work was associated with a 2-fold increase in the risk of severe preeclampsia compared to mild activity (OR 2.08, 95% CI 1.11, 3.88). We conclude that moderate to high physical activity at work seems to increase the risk of severe preeclampsia.

Sociodemographic and clinical variables modifying the smoking-related risk of low birth weight.

OBJECTIVE: The purpose of the study was to evaluate the sociodemographic and clinical variables modifying the smoking-related risk of low birth weight (< 2500 g). METHOD: This case-control study included a population of 967 singleton low birth weight deliveries and 967 selected controls. Unconditional logistic regression analysis was used to test statistical significance of the interactions between smoking in pregnancy and other risk factors for low birth weight. RESULTS: Increasing maternal age and parity potentiate the smoking-related risk of a low birth weight infant. The effect of maternal smoking on the risk of low birth weight was significantly increased in patients with a history of previous spontaneous abortion (excess risk 2.30, 95% C.I. 1.24-4.27) and in patients of high compared with patients of intermediate or low social class (excess risk 1.97, 95% C.I. 1.1-3.57). Smokers with less than two prenatal visits per trimester were at significantly greater risk of delivering a low birth weight infant (excess risk 2.36, 95% C.I. 1.14-4.87) than their counterparts with more frequent prenatal visits. Among clinical variables, the effect of maternal smoking on the risk of low birth weight was significantly increased in women with a history of first trimester hemorrhage during the current pregnancy (excess risk 2.67, 95% C.I. 1.30-5.49). CONCLUSIONS: The smoking-related risk of low birth weight is very high in some subgroups of women. Identification of these subgroups could be important for prenatal counseling.

Case-control study of maternal blood group and severe pre-eclampsia.

The relation of maternal blood group to pre-eclampsia has not been adequately studied in previous research. To investigate this relation, we conducted a case-control study of primigravidae. Data on 204 consecutive severely pre-eclamptic patients delivered pre-term and 744 controls were analysed using multivariate methods. After adjustment for the confounding effects of maternal age, social class, origin, education, pre-pregnancy weight and body mass index, and weight gain in pregnancy, we found an increased risk of pre-eclampsia for mothers with blood type AB (adjusted odds ratio = 3.07; 95% confidence interval 1.48-6.36). With respect to blood group O, A, B and Rh type, no statistically significant correlation with severe pre-eclampsia was found. Although these results should be considered with caution, they support the hypothesis of a linkage mechanism involving blood group in the inheritance of susceptibility to pre-eclampsia.

Torulopsis glabrata vaginitis.

OBJECTIVE: To study the sociodemographic risk factors and clinical features of Torulopsis glabrata vaginal infection. METHODS: We evaluated the sociodemographic and clinical characteristics of 86 consecutive symptomatic women attending a vaginitis clinic and isolated T glabrata. Case patients were compared with a control group of 174 asymptomatic women with negative vaginal cultures and an additional group of 625 symptomatic women with vaginal cultures positive for Candida albicans. In addition, the sensitivity of the isolates to the more common antimycotic agents used was tested by the modified Kirby-Bauer method. RESULTS: Patients with T glabrata vaginal infection were from lower socioeconomic backgrounds and had less education. They were more likely to use vaginal tampons and to be seropositive for human immunodeficiency virus than were negative controls. Compared with C albicans infection, T glabrata was more frequent among women over 38 years of age and in those with less education and of lower social class. In logistic regression analysis, T glabrata was associated more frequently with recurrent vaginal candidiasis than was C albicans (odds ratio 2.46, 95% confidence interval 1.33-4.54; P = .004). Six of the 86 (7%) T glabrata isolates and none of the C albicans isolates (P < .001 by Fisher exact test) were resistant to the imidazole derivatives tested. CONCLUSION: Torulopsis glabrata was isolated in 10% of women with vulvovaginal candidiasis attending a vaginitis clinic. This infection was associated with recurrent vaginitis in almost one-third of case patients presenting with symptoms.

Value of antenatal corticosteroid therapy in preterm birth.

This prospective observational study was designed to evaluate the magnitude of the corticosteroid-related reduction in the risk of respiratory distress syndrome (RDS), intraventricular hemorrhage and neonatal death according to different etiologic subgroups of preterm delivery. Of 380 patients delivered before 35 weeks' gestation, 155 received a complete course of dexamethasone or betamethasone to promote fetal lung maturation. In logistic models, the steroid-related reduction of RDS was greater among patients with intact membranes as opposed to patients with premature rupture of membranes (excess risk = 0.31; 95% confidence interval (C.I.) = 0.13-0.73; P = 0.007) and in patients with spontaneous preterm labor as compared with other etiologic groups (excess risk = 0.33; 95% C.I. = 0.11-0.98, P = 0.04). On the other hand, the steroid-related reduction of severe (grade III-IV) intraventricular hemorrhage was more marked in growth retarded as opposed to well-grown fetuses (excess risk = 0.15; 95% C.I. = 0.03-0.96, P = 0.04), and in planned as compared with spontaneous preterm deliveries (excess risk = 0.15; 95% C.I. = 0.03-0.96, P = 0.04). Results show that the greatest benefit from antenatal steroids appears to be in preterm deliveries with intact membranes and in planned preterm deliveries.

The impact of oral contraception on vulvovaginal candidiasis.

To evaluate risk factors related to sociodemographic and clinical variables, oral contraception and sexual behavior of women with recurrent vulvovaginal candidiasis, we conducted a case-control study comparing 153 patients with recurrent vulvovaginal candidiasis with both asymptomatic women with negative vaginal cultures and patients with nonrecurrent symptomatic vulvovaginal candidiasis. In logistic regression analysis, patients with recurrent Candida vaginitis were more likely than negative controls to have used any contraceptive method in the year before evaluation, to have used antibiotics in the month preceding the visit, and to have a higher number of lifetime sex partners. Compared to patients with nonrecurrent Candida vaginitis, patients with recurrent infection were more likely to use oral contraception and to have a higher frequency of monthly intercourse. The proportion of recur rent disease attributable to the pill averages 11-12%. We conclude that oral contraceptives may influence the recurrence of symptomatic vulvovaginal candidiasis.

PIP: Researchers in Italy compared data on 153 patients with recurrent vulvovaginal candidiasis (cases) with data on 306 asymptomatic patients (control group A) and data on 306 patients with nonrecurrent symptomatic vulvovaginal candidiasis (control group B). They wanted to examine the sociodemographic and clinical characteristics, sexual habits, and contraceptive histories of women with recurrent vulvovaginal candidiasis. Cases were more likely than asymptomatic women to have previously used any contraceptive method (odds ratio [OR] = 2.08 for the pill, p = 0.0032; OR = 4.15 for the IUD, p = 0.0019; OR = 2.55 for barrier methods, p = 0.014). They were also more likely to have used antibiotics in the last month before the visit (OR = 2.1; p = 0.009) and to have more lifetime sexual partners than asymptomatic women (OR = 3.82 for 7 partners; p = 0.009). Patients with recurrent vulvovaginal candidiasis were more likely than those with nonrecurrent vulvovaginal candidiasis to have used low-dose oral contraceptives (OCs) (OR = 1.59; p = 0.036) and to have a higher rate of monthly intercourse in the last 6 months (OR = 2.51 for 10 times; p = 0.048). The attributable risk of OC use for recurrent vulvovaginal candidiasis was insignificant (11-12%). These results suggest that OCs may contribute to the recurrence of symptomatic vulvovaginal candidiasis.

Cigarette smoking in pregnancy and risk of pre-eclampsia.

The relationship between smoking in pregnancy and the development of pre-eclampsia has not been well studied. Smoking habits were prospectively evaluated in 117 patients with pre-eclampsia and 468 normotensive control pregnancies. Twenty cases (17.1%) and 120 controls (25.6%) reported smoking at any time during pregnancy. In stepwise multiple logistic regression analysis, smoking in pregnancy was a significant protective factor against the occurrence of pre-eclampsia (adjusted odds ratio = 0.50; 95% confidence interval 0.28-0.80, P = 0.018). On the other hand, a history of pre-eclampsia in previous pregnancies, low (< 6th grade) educational level, a body mass index > 24 and maternal blood group AB were factors independently associated with an increased risk of pre-eclampsia. In conclusion, this study confirms that smoking in pregnancy reduces the risk of pre-eclampsia. However, the harmful consequences of smoking on pregnancy outcome far outweigh this risk reduction.

Epidemiological correlates of preterm premature rupture of membranes.

OBJECTIVE: To study the clinical risk factors for preterm premature rupture of membranes (PROM). METHOD: We conducted a case-control study of 138 patients with PROM between 24 and 35 weeks' gestation and 267 control subjects. RESULTS: In stepwise multiple logistic regression models, the population of cases was more likely to be of low social class. Other risk factors for PROM were smoking in pregnancy, 1st or 2nd-3rd trimester hemorrhages, cervical incompetence and a documented cervico-vaginal infection during index pregnancy. First trimester hemorrhage and a documented cervico-vaginal infection during index pregnancy were associated with preterm PROM both in nulliparous and in multiparous women. CONCLUSION: Few potentially remediable risk factors are associated with the occurrence of preterm PROM.