Candidiasis during pregnancy may result from isogenic commensal strains.

OBJECTIVE: Our laboratory previously demonstrated that asymptomatic vaginal colonization during pregnancy is a factor predisposing patients to subsequent symptomatic vulvovaginal candidiasis. It is unknown whether symptoms result from strain replacement or a change in host relationship to the original colonizing strain. This study was undertaken to determine whether Candida albicans isolates from asymptomatic women could be responsible for subsequent symptomatic vaginitis. METHODS: We retained isolates of C. albicans from women followed longitudinally through pregnancy, and identified six pairs of cultures from women who were colonized without symptoms and who later became symptomatic (average time 14 weeks). We used a random amplification of polymorphic DNA (RAPD) analysis to determine whether isolates from our study patients were genetically similar or dissimilar. RESULTS: Analysis of these pairs of yeast strains by RAPD revealed that five of the six women had symptoms apparently due to the same yeast strain that was found initially as a commensal strain. To increase the power of these observations, we also performed RAPD analysis on six randomly selected yeast strains from other women in this study who had not become symptomatic to determine whether any of these unrelated strains matched strains from those women who became symptomatic. CONCLUSION: Symptomatic yeast vaginitis is usually due to strains of C. albicans already carried in the lower genital tract, underscoring the need to understand regulation of growth and virulence of the organism in vivo.

Glutathione S-transferase in human endometrium: quantitation and interindividual variability in isoform content.

OBJECTIVES: The goals of the present study were to determine whether human endometrium contains glutathione S-transferases (GSTs), to identify the isoforms present (if any) and to assess the causes of any intersubject variability which was observed. METHOD: Hysterectomy patients (n = 32, 13 with endometrial carcinoma) were examined in the core study. The ability of cytosol from these endometria to conjugate 1-chloro-2,4-dinitrobenzene was measured. Additional studies with chemical inhibitors and monoclonal antibodies to GSTpi were also performed. RESULTS: The pattern of inhibition caused by ethacrynic acid and cibacron blue strongly suggests substantial interindividual variability in type (alpha and pi dominant) and amount ( approximately 10-fold) of this important group of enzymes. Significantly lower GST activity was seen in cancer patients who were smokers when compared with all other subjects (p < 0.05). CONCLUSION: There are substantial interindividual differences in the GST content of human endometrium. Furthermore, lower GST activity in tissues from endometrial carcinoma patients with a history of smoking may have contributed to the neoplastic transformation of this tissue.

Serum erythromycin levels in pregnancy.

Erythromycin is the recommended therapy for pregnant women with chlamydial infection. Despite the fact that this drug has been available since 1952, relatively little is known about its pharmacokinetic behavior in pregnant women, and no investigations have been conducted in women who were in the third trimester of pregnancy. In this study, 10 women were treated with erythromycin for chlamydial infection during pregnancy; 7 of these women were in the third trimester of pregnancy, and 3 were in the second trimester. Serum samples were obtained at 0.5, 1, 2, 3, and 4 hours after a 500-mg oral dose of erythromycin base and were analyzed to determine absorption and peak serum levels of erythromycin. Results indicated that absorption was delayed and serum levels were diminished in comparison with values reported in the literature for patients in the second trimester of pregnancy. In 2 women, erythromycin serum levels were not detectable at any time during the 4 hours of the study; these 2 women also experienced the most severe gastrointestinal symptoms. Although the size of our study population was small and certainly not definitive, the data suggest that in patients in the third trimester of pregnancy, severe adverse gastrointestinal events may forewarn of subtherapeutic plasma concentrations of erythromycin, which could have consequences for the treatment outcome.

Effects of gestational and overt diabetes on human placental cytochromes P450 and glutathione S-transferase.

The placenta possesses the ability to metabolize a number of xenobiotics and endogenous compounds by processes similar to those seen in the liver. Animal and in vivo studies have observed that the presence of diabetes alters the expression of hepatic metabolizing enzymes (cytochrome P450 and glutathione S-transferase); however, it is unknown whether similar alterations occur in the human placenta. To evaluate whether diabetes has any effect of placental xenobiotic metabolizing activity, the catalytic activities of 7-ethoxyresorufin O-deethylation (EROD, CYP1A1), chlorzoxazone 6-hydroxylation (CYP2E1), dextromethorphan N-demethylation (CYP3A4), dextromethorphan O-demethylation (CYP2D6), and 1-chloro-2, 4-dinitrobenzene (CDNB) conjugation with glutathione (glutathione S-transferase, GST) from placentas of diet (class A1) and insulin-dependent (class A2) gestational diabetics and overt diabetics were compared with matched controls. EROD activity (CYP1A1) ranged from 0.29 to 2.67 pmol/min/mg protein. However, no differences were observed among overt or gestational diabetics and their respective matched controls. CDNB conjugation (GST) ranged from 0.275 to 1.65 units/min/mg protein. In contrast to that observed with CYP1A1, a small but statistically significant reduction in GST activity was noted in overt diabetics as compared with their matched controls and gestational diabetics. CYP2E1, 2D6, and 3A4 enzymatic activities were not detected in human placental tissue. GST protein was detectable in all tissues studied, but no CYP protein could be detected in any of the tissues. Thus, it seems that pregnant women with overt diabetes have reduced GST activity in the placenta, which could potentially result in the exposure of the fetus to harmful electrophiles. However, the full clinical significance of this finding remains to be elucidated.

Regiospecific expression of cytochrome P4501A1 and 1B1 in human uterine tissue.

The goal of this study was to investigate the expression of these isoforms in different regions of the human uterus. Expression was determined in the endometrium (ENDO), endocervix (CERV) and squamous region (SR) from six non-smoking women by using RT-PCR. The transcripts encoding for CYP1A1 were significantly higher (P < 0.05) in the SR compared to the other areas. However, the expression of CYP1B1 was significantly higher (P < 0.05) in the ENDO. CYP1B1 expression appeared to be extremely low in a woman in the secretory stage of the menstrual phase, relative to the ENDO of the other patients who were all in the proliferative stage at hysterectomy. CYP1B1 mRNA was expressed in only two out of six patients in the SR and in three out of five patients in the CERV. CYP1A1 was also uniformly expressed in the ENDO of all except one patient, whereas expression was minimal in the other regions. It is likely that variability in the expression of these isoforms may be responsible for the differential susceptibility to cancer in women.

Longitudinal investigation of candida vaginitis in pregnancy: role of superimposed antibiotic use.

OBJECTIVE: To evaluate the purported association of antibiotic use and subsequent symptomatic Candida vaginitis among pregnant women. METHODS: Two hundred fifty obstetric patients were followed in a prospective, culture-based, longitudinal, and observational study from the first antepartum appointment through the postpartum visit at 6 weeks. All patients were cultured for yeast (Nickerson agar) initially. Patients with symptoms and microscopic evidence of vaginitis at the initial visit were followed through pregnancy but were not analyzed with asymptomatic individuals who had vaginal cultures for Candida at the first visit and at subsequent visits if they developed vulvovaginal symptoms. Patients were categorized as colonized or uncolonized on the basis of initial cultures and were evaluated at least monthly for antibiotic use and vaginal complaints. In addition, hospital records were reviewed after the final visit to document antibiotic use or vaginal infection. RESULTS: Asymptomatically colonized patients were at a threefold greater risk of developing symptoms than were uncolonized patients (P < .001). Among women receiving antibiotics during pregnancy, 6.1% developed symptoms of Candida vaginitis compared with 15.6% of women who did not receive antibiotics. For the entire study population, 46% of the patients received at least one course of antibiotic therapy and 21% had multiple courses. Only three of the seven who became symptomatic with yeast vaginitis did so within 4 weeks of treatment. Many of the antibiotic regimens were prescribed by providers other than the obstetrician. CONCLUSION: Antibiotic treatment during pregnancy was frequent in the study population, but was not associated with a significant risk of developing Candida vaginitis.

The effects of diabetes on placental aromatase activity.

Diabetes complicates 2-3% of all pregnancies and is associated with an increase in both perinatal morbidity and mortality, though reasons for these adverse outcomes are unknown. Estrogen biosynthesis is a critical factor during pregnancy and is carried out in the placenta via aromatase (cytochrome P450 19A1), which catalyzes the conversion of C-19 androgens to C-18 estrogens. Previous studies have shown that hormones such as insulin-like growth factors and insulin regulate aromatase activity when studied in vitro. Interestingly, levels of these hormones are altered in patients with diabetes. Thus, we hypothesized that the presence of maternal diabetes may alter placental aromatase activity and thus estrogen biosynthesis, possibly serving as one factor in the adverse outcomes of babies born to mothers with diabetes. To this end, we measured the production of 19-hydroxyandrostenedione, 19-oxoadrostenedione and estrone in 30 placental tissues from diabetic patients, using [7-3H]androst-4-ene-3,17-dione as a model substrate for aromatase (P450 19A1). A statistical difference was detected in the percentage of 19-oxoandrostenedione formed between the overt and control groups (P < 0.05). Additionally, NADPH P450-reductase levels were measured in these same tissues to determine whether alterations in this enzyme necessary for aromatase activity could be affected by diabetes. No differences in reductase levels were detected among the patient groups. However, a statistical correlation was found between NADPH P450-reductase activity and the formation velocities of all three estrogen products (P < 0.05). Thus, it appears that the presence of diabetes does not affect placental aromatase activity.

Ampicillin vs. Penicillin for in utero therapy.

The pharmacokinetics of penicillin G and ampicillin are reviewed as they pertain to their potential use in in vitro therapy.

Regiospecificity of placental metabolism by cytochromes P450 and glutathione S-transferase.

The placenta possesses the ability to metabolize numerous xenobiotics and endogenous steroids. However, it is unknown whether regional differences in these enzymatic reactions exist in the human placenta. To this end, we undertook a study of four regions of the placenta, the chorionic plate, maternal surface, placental margin and whole tissue, to assess the activities of cytochrome P450 1A1 and 19A1 (aromatase) and glutathione S-stransferase in these fractions. No differences in either P450 1A1 or glutathione S-transferase activities were noted among any of the placental fractions. However, with respect to P450 19A1 activity, the placental margin differed significantly from all other fractions (p < 0.05). This study demonstrates that whole tissue samples of the human placenta are adequate for placental cytochrome P450 and glutathione S-transferase metabolism studies.

In situ mycotoxin production by Candida albicans in women with vaginitis.

The virulence attributes of Candida albicans in cases of mucocutaneous disease have not been identified. Based on the recent finding that C. albicans is able to produce an immunosuppressive mycotoxin, gliotoxin, we analyzed vaginal samples of 3 women severely symptomatic for vaginal candidiasis and found that they contained significant levels of gliotoxin. Three control women who were not colonized with C. albicans showed no gliotoxin in vaginal samples. These findings raise the possibility that gliotoxin may play a role in the virulence of C. albicans.

Chlamydia trachomatis antigen prevalence among pregnant women in West Virginia.

During 1990, more than 2,100 women who received prenatal care at one of four clinics which serve 11 West Virginia counties, were screened for chlamydial antigen. Overall, 5.6 percent of the women screened had positive antigen tests and 90 percent of these individuals were under the age of 25. The prevalence of chlamydia was different at three geographic sites with the highest rate of positive antigen test being 9.4 percent at one site. These findings led to a careful analysis of the prevalence of this disease among women who lived in rural areas versus those who lived in urban areas. This detailed analysis involved only patients seen in the Grafton and Morgantown clinics, and revealed a tendency for most positive antigen tests to occur among women with urban addresses. Our study indicates that a substantial chlamydial problem exists among pregnant women of young age. Although screening all pregnant women for chlamydia may not be cost effective, knowing which individuals are at highest risk may help target limited screening for these patients.

High performance ion exclusion chromatographic characterization of the vaginal organic acids in women with bacterial vaginosis.

Vaginal organic acids have previously been detected by gas-liquid chromatography, but we have applied an ion exclusion high performance liquid chromatographic procedure to the analysis of vaginal discharge samples. This procedure has the advantage of not requiring derivitization of non-volatile acids and provides the convenience of a technique which does not require the use of flammable gasses, while allowing the identification of at least 18 different acids from the same chromatographic analysis. Vaginal discharge from women with symptoms of bacterial vaginosis was collected on weighed swabs and analysed for the presence of organic acids. The results were compared to the organic acid content of samples obtained from the same cohort of women after treatment with metronidazole. In addition, samples were obtained from asymptomatic women and these samples were analysed in the same manner. The number of organic acids present in samples from women with bacterial vaginosis was greater than the number found after treatment or among asymptomatic women. Succinic acid appeared to be inversely related to lactate concentration and succinate:lactate ratios were greater among women with bacterial vaginosis before treatment than after treatment. Liquid chromatography has proven useful as a means of evaluating the metabolic end-products of vaginal microorganisms in situ.

The transport barrier of epithelia: a comparative study on membrane permeability and charge selectivity in the rabbit.

The transport barrier of the epithelial presents one of the major problems limiting the effective use of these tissues as alternate delivery routes for macromolecules such as peptides and proteins. In the present study, two membrane transport properties, namely, the permeability and permselectivity of the shunt pathway, were investigated and compared in various tissues including the nasal, tracheal, bronchial, buccal, rectal, vaginal, corneal, epidermal, duodenal, jejunal, ileal, and colonic epithelia. Membrane permeability was evaluated using a combined method based on electrical conductance and flux measurements of a hydrophilic fluorescent probe, 6-carboxy fluorescein (CF). Membrane permselectivity or the charge discriminating ability of the membrane was evaluated by KCl diffusion potential measurements. The results indicate that all epithelia under investigation possess a relatively high degree of permeation barrier and are highly selective for the absorption of positively charged solutes. Shunt path permeability was found to vary greatly among tissues from different epithelia, whereas membrane charge selectivity was relatively constant in these tissues. A good correlation was observed between membrane electrical conductance and steady-state flux of CF, indicating a paracellular transport of the compound. The rank order of the intrinsic membrane permeability was as follows: intestinal approximately nasal greater than or equal to bronchial greater than or equal to tracheal greater than vaginal greater than or equal to rectal greater than corneal greater than buccal greater than skin. Membrane permselectivity, expressed as the ratio of transport number (positive over negative), ranges from 1.78 for the buccal to 1.33 for the rectal epithelium.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of vaginal malodor and efficacy of treatment by high performance ion exchange chromatography.

High performance ion exchange chromatography was employed to evaluate the presence of short chain organic acids in the vaginal fluid of a woman troubled by persistent foul vaginal odor, but who did not have typical bacterial vaginosis. The vaginal secretions from this patient were collected on a weighed cotton swab and eluted into water and extracted by acidified ether. Salts of the acids were back-extracted into aqueous solution and chromatographed on an H-form resin column and compared to commercially available standards. A strikingly large amount of caproic acid was found. The caproic acid disappeared after metronidazole therapy, and a subsequent follow-up chromatogram showed a predominance of lactic acid. The success of this technique in evaluating the present case suggests that such a method may prove useful in other types of vaginal infection.

Implications of metronidazole pharmacodynamics for therapy of trichomoniasis.

A liquid chromatographic technique for the detection of metronidazole (MDZ) and its major metabolites, combined with a vaginal sampling technique employing extraction of drug from vaginal swabs, was used to evaluate the concentration of MDZ in the vaginal fluid during therapy. Wide variation in the absolute concentration of unchanged drug was noted, although the average vaginal levels were about half the serum concentration 2 h after treatment had been initiated and comparable to the serum levels 6 and 24 h after treatment. Oral administration of MDZ invariably resulted in the presence of the drug in the serum and urine but the drug was not always detected in the vaginal secretions. The presence of the relatively inactive acetyl metabolite in the vaginal fluid of patients who failed to respond to therapy for trichomoniasis suggested the possible role of drug modification as a contributing factor in the lack of therapeutic success. The presence of MDZ in women in whom the cervix had previously been surgically removed attests to the transport or transudation of the drug across the vaginal epithelium without involvement of the secretory activity of the cervix.

Interstitial pregnancy. A case report.

Interstitial pregnancy is uncommon, and the correct diagnosis requires awareness of this form of ectopic pregnancy.

Diagnostic considerations in intra-amniotic syphilis.

Amniotic fluid is rarely used in the evaluation of syphilis during pregnancy but was available from a woman with positive serologic tests in the 30th week of gestation. Nonmotile intra-amniotic spirochetes were seen by dark-field microscopy 20 hr after treatment with benzathine penicillin G. The identity of the organism in amniotic fluid was confirmed by immunofluorescent staining. Less than 0.5 units/ml of penicillin was present in the amniotic fluid at this time. The amniotic fluid was positive in the Venereal Disease Research Laboratory (VDRL; Atlanta, GA) test, and the concentration of IgM was elevated as was the ratio of lecithin to sphyngomyelin. Phosphatidyl inositol and phosphatidyl glycerol were also present in the amniotic fluid. After treatment the lecithin-sphyngomyelin ratio declined; phosphatidyl glycerol disappeared, whereas phosphatidyl inositol was still present. Despite evidence of intrauterine growth retardation at 30 weeks, the infant born at 37 weeks was of normal weight and length; however, the head circumference was below the tenth percentile. These studies suggest that analysis of amniotic fluid may provide new insights into the biology of syphilis in pregnancy, but does not constitute a recommendation for routine examination of the amniotic fluid in mothers with reactive serologic tests for syphilis.