A non-inflatable anti-shock garment for obstetric hemorrhage.

OBJECTIVES: Maternal death from hemorrhage in low resource settings is frequently due to long delays in transportation to referral centers and/or in obtaining blood and surgical interventions. This case series was designed to demonstrate the feasibility, efficacy and safety of the non-inflatable anti-shock garment (NI-ASG) for resuscitation and hemostasis in the initial management of obstetric hemorrhage and shock. METHODS: Fourteen cases of obstetric hemorrhage and hypovolemic shock at Memorial Christian Hospital, Sialkot, Pakistan were managed with a specific clinical protocol based on using NI-ASG as the primary intervention. RESULTS: The NI-ASG was used to resuscitate and stabilize women with hypovolemic shock from 18 to 57 h. Thirteen patients survived without evidence of morbidity, but one had prolonged shock followed by multiple organ failure and death. CONCLUSIONS: This study confirmed that the NI-ASG quickly restored the vital signs of most women in severe hemorrhagic shock and stabilized them while awaiting blood transfusion.

Genital herpes during pregnancy: inability to distinguish primary and recurrent infections clinically.

OBJECTIVE: To determine if the signs and symptoms of genital herpes in pregnancy accurately identify primary genital herpes infections using serologic testing for final classification. METHODS: Twenty-three women with clinical signs and symptoms suggestive of primary genital herpes infections in the second and third trimesters of pregnancy were subsequently cultured and tested serologically (for herpes simplex virus type 1 and herpes simplex virus type 2 antibodies) and classified as having true primary (no herpes simplex virus type 1 or type 2 antibodies), nonprimary (heterologous herpes simplex virus antibodies present), or recurrent (homologous antibodies present) infections. RESULTS: Only one of 23 women with clinical illnesses consistent with primary genital herpes virus simplex infections had serologically-verified primary infection. This primary infection was caused by herpes simplex virus type 1. Three women had nonprimary type 2 infections, and 19 women had recurrent infections. Among culture-proven recurrent infections, 12 were caused by herpes simplex virus type 2 and three by herpes simplex virus type 1. Only one infant was born preterm, and no clinically significant perinatal morbidity was observed. CONCLUSION: Correct classification of gestational genital herpes infections can be accomplished only when clinical evaluation is correlated with viral isolation and serologic testing using a type-specific assay. Severe first episodes of genital herpes infections among women in the second and third trimesters of pregnancy are not usually primary infections and are not commonly associated with perinatal morbidity.

The Zavanelli maneuver for relief of abdominal dystocia associated with gastroschisis.

A patient with acute hydramnios and advanced preterm labor at 34 weeks was seen after gastroschisis had been diagnosed by second-trimester fetal ultrasonography. The fetus also had meconium peritonitis and acute ascites. The distended abdomen did not decompress spontaneously during the second stage of labor. Severe abdominal dystocia was resolved with the Zavanelli maneuver (cephalic replacement) and cesarean delivery. This is the first reported use of the Zavanelli maneuver for abdominal dystocia.

The management of pregnancies complicated by genital infections with herpes simplex virus.

In this review we summarize current knowledge related to the identification of pregnancies that may be complicated by genital herpes and describe the consequences of maternal infections with genital herpes. We address the implications of this information for the management of genital herpes during pregnancy and at delivery and for the care of neonates exposed to herpes simplex virus at delivery. On the basis of the current data, we cannot make specific recommendations concerning many of the clinical problems that are caused by herpes simplex virus infections in pregnant women. We identify and discuss unresolved questions about optimal management.

Pharmacokinetics of acyclovir in the term human pregnancy and neonate.

Concern about neonatal herpes often leads to cesarean delivery of infants in women with a history of genital herpes. The antiviral drug acyclovir has been used effectively to suppress genital herpes simplex virus recurrences in nonpregnant adults. Its administration to pregnant women with recurrent genital herpes may reduce herpes simplex virus recurrences and thus may decrease the cesarean section rate among this population. To study the pharmacokinetics, safety, and patient tolerance of suppressive oral acyclovir, either 200 mg (n = 7) or 400 mg (n = 8) was administered orally every 8 hours to pregnant women with a history of recurrent herpes simplex virus, from 38 weeks' gestation until delivery. The mean +/- SD plasma levels for the 200 and 400 mg groups, respectively, were: first dose peak, 1.7 +/- 0.6 and 2.3 +/- 1.0 mumol/L; steady-state trough, 0.7 +/- 0.3 and 0.8 +/- 0.6 mumol/L; steady-state peak, 1.9 +/- 1.0 and 3.3 +/- 1.0 mumol/L. In late gestation maternal acyclovir pharmacokinetics were similar to those of nonpregnant adults from other studies. Acyclovir was concentrated in the amniotic fluid; however, there was no accumulation in the fetus (mean maternal/infant plasma ratio at delivery was 1.3). Acyclovir was well tolerated, and no toxicity was seen in the mothers or infants. The administration of acyclovir, 400 mg every 8 hours, appears appropriate for use in an efficacy and safety study regarding suppression of herpes simplex virus recurrences during the last weeks of pregnancy.

Use of polymerase chain reaction for successful identification of asymptomatic genital infection with herpes simplex virus in pregnant women at delivery.

The polymerase chain reaction was adapted to the amplification of a herpes simplex virus (HSV) DNA sequence, common to HSV types 1 and 2 (HSV-1, HSV-2). The amplified product was detectable by ethidium-bromide staining or Southern hybridization of gels and by dot hybridization. The HSV polymerase chain reaction detected HSV DNA in samples obtained from eight patients with genital lesions from which HSV-2 was isolated in tissue culture and from four patients with labial lesions from which HSV-1 was isolated. The HSV polymerase chain reaction identified HSV in clinical specimens obtained from 11 women who had asymptomatic genital HSV infections at delivery. None of 11 samples obtained at delivery from women who had antibodies to HSV-2, but whose delivery cultures were negative, were positive by polymerase chain reaction and no false-positive reactions were obtained when the reaction mixture contained human cell DNA or varicella-zoster virus, cytomegalovirus, Epstein-Barr virus, or human papillomavirus DNA.

A prospective evaluation of primary genital herpes simplex virus type 2 infections acquired during pregnancy.

In order to study the epidemiology of herpes simplex type 2 (HSV-2) infections during pregnancy, we used an enzyme immunoassay to detect type-specific antibodies to HSV-2 glycoprotein G in serial blood samples obtained from a cohort of 1891 pregnant women. Blood samples obtained at about 17 and 32 weeks of gestation and at the time of delivery were assessed for antibody to HSV-2 glycoprotein G in order to evaluate the prevalence of past infections with HSV-2 and the rate of acquisition of HSV-2 infection during pregnancy. Three hundred eleven pregnant women (16.5%) were found to have had past infections with HSV-2. Four of the 1580 women who were initially seronegative developed antibodies to HSV-2 during pregnancy. The annualized rate of acquisition of HSV-2 infection in pregnant women was 0.58%. Three of four women had asymptomatic primary infections; all of the women had preexisting HSV-1 immunity. None of the women or their infants experienced any adverse consequences of gestational herpes. Based upon our very limited number of observations to date, asymptomatic primary episodes occurring in women with previous HSV-1 immunity may be of less consequence to the fetus and neonate than symptomatic true primary HSV-2 infections.

Initiation of prenatal care by adolescents. Associations with social support, stress, and Hispanic ethnicity.

The purpose of this study was to determine the social factors associated with initiation of prenatal care by adolescents. Eighty-one postpartum adolescents aged 17 years and under were interviewed within 24 hours of delivery about background factors, living situation, experiences, and behaviors during pregnancy. Of the adolescents, 58 were of Hispanic (Mexican) origin; the remainder were non-Hispanic whites. The first prenatal visit occurred at a mean of 4.04 months' gestation for Hispanics and 4.39 months' gestation for the non-Hispanics, one month after the pregnancy test. Differences between the ethnic groups were not significant. Controlling for ethnicity, both age and social support from the partner and his family were associated with initiation of care (P less than .01). In a separate analysis, age and partner-family support were unaffected by the introduction of stress and parental support (P less than .01). These findings highlight the importance of the partner and his family as a source of support to pregnant adolescents. To whom and when the adolescent communicates about the pregnancy may be the key linking social support to initiation of prenatal care. Providers who work with sexually active adolescents should emphasize the importance of early communication with partners and with family members if a pregnancy is suspected.

Use of routine viral cultures at delivery to identify neonates exposed to herpes simplex virus.

We obtained specimens for viral culture from mothers, infants, or both at the time of 6904 deliveries, without regard to the mothers' history of genital herpes. Herpes simplex virus (HSV) was recovered in cultured specimens from 14 of the 6904 deliveries (0.20 percent); all 14 mothers were asymptomatic. All viral isolates were herpes simplex virus type 2 (HSV-2). Only 1 of the 14 women (7 percent) had a history of genital herpes, whereas 12 (86 percent) had serologic evidence of a previous infection with HSV-2. None of the infants born to these 12 women contracted neonatal herpes. However, one of the two infants born to women with serologic evidence of a primary HSV infection at the time of delivery contracted neonatal herpes. Our findings show that most infants at risk of exposure to HSV at delivery will not be identified if concern about asymptomatic shedding of virus is limited to women with a history of genital herpes infection. Most neonatal exposure to an asymptomatic maternal HSV infection at delivery is not predictable or preventable. Therefore, physicians caring for newborns need to consider neonatal herpes in the differential diagnosis when infants become ill during the first weeks of life, regardless of the presence or absence of identifiable risk factors for HSV infection.

Type-specific antibodies to herpes simplex virus type 2 (HSV-2) glycoprotein G in pregnant women, infants exposed to maternal HSV-2 infection at delivery, and infants with neonatal herpes.

We used a murine monoclonal antibody to herpes simplex virus (HSV) type 2 (HSV-2) glycoprotein G (gG) to develop an enzyme immunoassay that detected HSV-2 type-specific antibodies in human sera. Antibodies to HSV-2 gG were detected in 98 (96%) of 102 sera from pregnant women with culture-proved HSV-2 infection. Sixty-five percent of the women had serological evidence of past HSV-2 infection by the Rawls index, based on titers of neutralizing antibody to HSV type 1 and HSV-2. Thirty (88%) of 34 infants exposed to maternal HSV infection at delivery had antibodies to HSV-2 gG and remained well. One infant exposed to primary maternal HSV-2 infection lacked antibodies to HSV-2 gG and developed neonatal HSV-2 infection. The mean +/- SD optical density by HSV-2 gG enzyme-linked immunosorbent assay for sera obtained from 17 infants within one week after onset of neonatal HSV-2 infection was 0.25 +/- 0.12, compared with 1.15 +/- 0.34 in cord blood sera from exposed infants who did not develop symptoms (P less than .0001 by t test).

Substance use by hispanic and white non-hispanic pregnant adolescents: A preliminary survey.

White non-Hispanic and Hispanic adolescents aged 17 years and under n= 81) who delivered in San Jose, California area hospitals during a 6-week period were interviewed within 24 hours concerning their use of cigarettes, marijuana, and alcohol during pregnancy, and a number of background, social support, and psychosocial factors. Before 12-16 weeks of pregnancy, each of the substances studied was used by over 50% of this population, with 53% smoking cigarettes, 51% smoking marijuana, and 58% consuming beer or wine. Most substance use ceased after 12-16 weeks of pregnancy. There were no significant differences between ethnic groups in substance use. Multiple regression analyses showed that cigarette smoking decreased when social support was provided by the adolescent's partner and it was higher if parents smoked and/or used alcohol p<.001. Parental substance use, combined with lack of social support, was also associated significantly with marijuana use p<.001, explaining 30% of the variance. Use of birth control prior to pregnancy was related to beer and wine consumption p<.05, explaining 16% of the variance. Active inclusion of members of the adolescent's support network in pregnancy care, and initiative by educators and clinicians in discussing substance use, may accelerate its cessation. Ethnicityrelated behavior change strategies may be of little relevance to adolescent substance use during pregnancy.

Adjunctive magnesium sulfate infusion does not alter metabolic changes associated with ritodrine tocolysis.

Magnesium sulfate, an agent whose cellular actions might cause metabolic disturbances, has been used concomitantly with ritodrine hydrochloride for preterm labor tocolysis. Although the profound metabolic effects of beta-adrenergic agents have been well described, the possibility that adjunctive magnesium might cause further or unexpected alterations in maternal metabolic parameters has not been fully evaluated. To investigate this question, we prospectively randomized patients, in a blinded fashion, to receive ritodrine plus placebo or ritodrine plus adjunctive magnesium sulfate for preterm labor tocolysis. Serial measurements of potassium, glucose, blood urea nitrogen, and hematocrit were obtained and compared between tocolytic treatment groups. The metabolic changes found were similar in each group and appear to result predominantly from beta-adrenergic stimulation with no apparent perturbations caused by the direct cellular actions of magnesium sulfate. From the metabolic standpoint, it appears that the clinician may use adjunctive magnesium sulfate without fear of accentuating or obscuring the expected beta-adrenergic-induced alterations in the above-mentioned maternal metabolic parameters.

Failure of antepartum maternal cultures to predict the infant's risk of exposure to herpes simplex virus at delivery.

In 414 pregnant women with a history of recurrent genital herpes simplex infection, we studied the correlation between asymptomatic viral shedding in late pregnancy and at the time of delivery. Antepartum cultures for asymptomatic reactivation of herpes simplex virus were positive in 17 of the 414 women (4.1 percent). None of these women had positive cultures at the time of delivery. Cultures of specimens obtained at delivery from 5 of 354 asymptomatic mother-infant pairs (1.4 percent) were positive for asymptomatic excretion of herpes simplex virus. None of these women had had antepartum cultures that documented asymptomatic excretion of herpes simplex virus, despite the fact that culturing was repeatedly performed during the four weeks before delivery. Asymptomatic shedding of herpes simplex virus occurred with the same frequency at delivery, whether or not any episodes of symptomatic recurrence were noted during the pregnancy (1.4 vs. 1.3 percent). We conclude that antepartum maternal cultures do not predict the infant's risk of exposure to herpes simplex virus at delivery.

Perinatal events and cerebral palsy.

This review highlights recent studies that refute the following hypothesis on the genesis of cerebral palsy: The risk factors that cause death are also risk factors for brain damage resulting in cerebral palsy, if they occur at lower intensity, less frequently, or for a shorter duration. Untested, unproved, and invalid theories that emerged in the 1950s stimulated the assembly of much data that are at odds with the notion that the pathways of causation for cerebral palsy and perinatal mortality are identical.

Asymptomatic shedding of herpes simplex virus from the cervix and lesion site during pregnancy. Correlation of antepartum shedding with shedding at delivery.

Asymptomatic shedding of herpes simplex virus (HSV) was detected in 0.83% of 955 cultures obtained from pregnant women with culture-proved recurrent genital HSV infections during pregnancy; seven (2.3%) of 299 women had asymptomatic shedding. In addition, one (2.3%) of 42 pregnant women with recurrent genital infection in the past but no attacks during pregnancy shed HSV when asymptomatic. Shedding occurred more frequently from the usual lesion site than from the cervix. The virus was not isolated at delivery from women with asymptomatic antepartum shedding. When an active lesion was present, concomitant shedding of HSV from the cervix occurred in seven (3.6%) of 193 pregnant women with vulvar lesions and in one (2.1%) of 47 women with lesions remote from the vulva. Ninety-two percent of the latter lesions were caused by type 2 HSV. In women who have had recurrent genital HSV infections in the past, asymptomatic shedding occurs in those with active attacks during pregnancy as well as in those asymptomatic throughout pregnancy; however, asymptomatic shedding during the antepartum period does not predict asymptomatic shedding at delivery.