Maternal immunization with pneumococcal polysaccharide vaccine in the third trimester of gestation.

In a randomized, double blinded study, 23-valent pneumococcal polysaccharide vaccine (PSV) or conjugate Haemophilus influenzae type b (HbOC) vaccine was administered to 60 healthy women in the third trimester of gestation. Total IgG, IgG1, and IgG2 antibodies to pneumococcal serotypes 6B, 14, 19F and 23F were measured by ELISA in mothers prior to immunization, at delivery and 7 months after delivery, and in infants at birth (cord blood), 2 and 7 months after delivery. IgA was evaluated in breast milk at 2 and 7 months, and opsonophagocytic activity in cord blood. PSV was safe and immunogenic in pregnant women. Transplacental transmission of vaccine-specific antibodies was efficient. Maternal immunization with PSV resulted in significantly higher concentrations of pneumococcal antibodies in infants at birth and at 2 months of age, and greater functional opsonophagocytic activity of passively acquired IgG antibody.

Preterm labor and maternal hypoxia in patients with community-acquired pneumonia.

OBJECTIVE: We sought to determine if preterm labor is associated with the degree of maternal hypoxia in pregnant women with community-acquired pneumonia but no other maternal diseases. METHODS: We retrospectively reviewed the medical records of all antepartum patients admitted with a diagnosis of community-acquired pneumonia to an inner-city university hospital between 1983 and 1987. Included in this review were only the patients with radiologically confirmed diagnose of pneumonia and documented arterial blood gases on room air at the time of admission, but no other maternal diseases. RESULTS: A total of 22 cases were identified. There was no maternal mortality, but there were 2 patients (9%) who developed respiratory failure requiring mechanical ventilation. Bacteremia with Streptococcus pneumoniae was documented in 1 patient (5%). Preterm labor complicated 5 cases (23%) and led to preterm delivery in 3 patients (14%). Terbutaline tocolysis was instituted in 3 patients, but was discontinued in 1 patient who was allowed to deliver because of her worsening condition. Preterm labor was associated with the WBC count on admission, usually > 18,000/mm3, but no statistically significant correlation with the severity of maternal hypoxia was noted. Five patients (23%) were incorrectly diagnosed at the time of admission, 4 with an initial diagnosis of pyelonephritis and 1 with an initial diagnosis of cholecystitis. CONCLUSIONS: Community-acquired pneumonia in the antepartum period is responsible for significant maternal and fetal complications even in the absence of other maternal diseases. Preterm labor and delivery remain frequent, and tocolysis should be used cautiously. At the time of admission, the diagnosis may be difficult. The degree of maternal hypoxia on admission does not correlate with the presence of preterm labor.

Ectopic pregnancy with undetectable serum and urine beta-hCG levels and detection of beta-hCG in the ectopic trophoblast by immunocytochemical evaluation.

BACKGROUND: Ectopic pregnancies associated with negative urine or serum pregnancy test by radioimmunoassay usually demonstrate either nonviable trophoblast or absent production of beta-hCG by the ectopic pregnancy. CASE: We report a patient with intra-abdominal hemorrhage caused by a ruptured ampullary ectopic pregnancy who had undetectable serum and urine beta-hCG levels (less than 5 mIU/mL). Immunoperoxidase staining of the ectopic trophoblastic tissue obtained at surgery revealed both beta-hCG and placental alkaline phosphatase. CONCLUSION: Negative serum and urine pregnancy tests can occur even though beta-hCG produced by the viable ectopic trophoblastic tissue can be demonstrated by immunoperoxidase staining.

Treatment of cervical chlamydial infection with amoxicillin/clavulanate potassium.

OBJECTIVE: To determine if amoxicillin/clavulanate potassium is effective in the treatment of Chlamydia trachomatis endocervicitis. METHODS: Thirty-two patients with culture-proven endocervical infection were treated with amoxicillin/clavulanate potassium, 500 mg orally 3 times a day for 10 days. Post-treatment endocervical specimens were obtained at 2, 4, and 6 weeks for culture of C. trachomatis. Male partners were treated with doxycycline, 100 mg orally twice daily for 10 days. The couples were provided condoms and asked to use them throughout the duration of the study. RESULTS: All patients treated with amoxicillin/clavulanate potassium were cured of signs of cervicitis. All were found to be free of C. trachomatis at their follow-up visits. CONCLUSIONS: Amoxicillin/clavulanate potassium is effective in eradicating C. trachomatis.

Herpes genitalis.

In conclusion, herpes genitalis has become one of the most common sexually transmitted diseases and has reached epidemic proportions. It presents a grave risk to immunocompromised patients and to newborns. The advent of effective therapy with acyclovir has dramatically modified the morbidity and mortality of disseminated herpesvirus infection and has helped in the therapy of primary and recurrent herpes genitalis. Current work has indicated that the disease can be transmitted by asymptomatic patients who are shedding the virus in the absence of visible lesions, which presents a diagnostic and therapeutic problem, especially significant for the pregnant patient, because infection of the neonate leads to serious consequences. Close follow-up of the pregnant woman with genital herpes therefore is imperative to minimize the risk to the newborn. At this time, no vaccines have been demonstrated to be safe and effective; therefore, prevention is of the utmost importance.

Fungal vulvovaginitis.

Fungal vulvovaginitis remains one of the most frequent conditions affecting the lower genital tract. Recent advances in the understanding of the pathophysiology of the condition have improved our ability to treat recurrent or persistent cases. More clinical data have become available on the optimal duration of treatment with some of the newer antifungal agents.

PIP: Actual incidence of vulvovaginitis is unknown, but apparently about 75% of women experience at least 1 episode of yeast vulvovaginitis during their reproductive years. Candida species causes almost all cases, e.g., Candida albicans causes about 90% of cases. Other species include C. glabrata and C. tropicalis. The spore form of C. albicans spreads the infection and is asymptomatic. The mycelia form induces symptoms. Neither C. glabrata nor C. tropicalis produce mycelia. The 1st step in establishing an infection is bonding to the vaginal mucosa. C. albicans adheres better than do the other 2 species. Proteolytic enzymes help the fungus bind to the mucosa. Research indicates that differences in the composition of normal vaginal bacteria, dearths in site functions that are specific for Candida, or prostaglandin or IgE interference with the cellular mediated immune response specific to Candida may be responsible for recurrent infections. The signs and symptoms of yeast vulvovaginitis are not clear cut so clinicians need to request laboratory tests on samples to confirm diagnosis. The most common symptom is considerable itching. Antifungal medicine is either topical or systemic. The most common yet oldest antifungal agent is 0.5-1% gentian violet applied topically to the affected mucous membranes. There is dome evidence, however, that it causes chromosome damage in some mammal cells. No reported cases of cancer in humans exist though. Imidazoles and polyene compounds constitute the mainstays of candidiasis treatment. Oral ketoconazole has shown promise in preventing recurrence. Colonization and symptomatic vaginitis rates rise during pregnancy. Symptomatic vaginitis is most common during the 3rd trimester. Diabetes mellitus also predisposes women to vaginitis. Women who use high dose oral contraceptives, the contraceptive sponge, and antibiotics also face increased risk of colonization and symptomatic vaginitis. Vaginitis is common among women with AIDS.

Ciprofloxacin versus gentamicin/clindamycin for postpartum endometritis.

An open, randomized, comparative study of intravenous ciprofloxacin versus gentamicin and clindamycin was performed on women with postpartum endometritis. Ciprofloxacin alone successfully eradicated the infections in 35 of 49 patients (71%), while the combination of gentamicin/clindamycin cured 41 of 48 (85%) (P = .15). The microbiology and antibiotic sensitivity of the endometrial isolates confirmed the poor activity of ciprofloxacin against anaerobic bacteria and less-than-optimal activity against Streptococcus faecalis. Ciprofloxacin, when used alone, may not be suitable for the treatment of postpartum endometritis.

Serous surface carcinoma of the peritoneum: a clinicopathologic study of 22 cases.

Serous surface carcinoma (SSC) of the peritoneum is defined as a primary tumor histologically indistinguishable from serous carcinoma of the ovary, diffusely involving the peritoneal surface but sparing or only superficially invading the ovaries. In this study of 22 cases of SSC, it was found that the main clinical manifestations of SSC were abdominal pain and enlargement. In most cases, SSC evenly involved the entire mesothelial surface but rarely was predominant in or even limited to the pelvis. It frequently invaded the submesothelium, but deep invasion into abdominal and pelvic organs or local metastasis was rare, and distant metastasis was not seen at presentation. Microscopically, SSC was a high-grade tumor frequently showing high mitotic rate, psammomas bodies, and necrosis. The tumor was usually contiguous with hyperplastic mesothelium on either ovarian surface or other locations. Tumor cells in all cases except one showed cytoplasmic or surface neutral or acidic mucin or both. Tumor cells stained positive for keratin (100% of cases), epithelial membrane antigen (100%), Leu-M1 (45%), B72.3 (85%), vimentin (35%), and carcinoembryonic antigen (25%). Electron microscopic studies of six cases showed epithelial differentiation in each. Seven patients (32%) were alive with no clinical disease at 3 to 31 months, one patient (4%) was alive with extensive local disease at 24 months, 11 patients (50%) died almost exclusively of local recurrence at 1 to 70 months, and three patients (14%) died of operative complications. It is concluded that SSC arises from peritoneal mesothelium but has epithelial phenotype. It can be morphologically differentiated from other conditions with similar laparotomy findings, such as malignant mesothelioma, benign papillary mesothelioma, cystic mesothelioma, and benign or borderline peritoneal serous tumors. The prognosis of SSC is poor, and most patients die of uncontrollable local disease.

Pneumonia and pulmonary tuberculosis in pregnancy.

Successful treatment of pneumonia in pregnancy requires aggressive supportive therapy and effective antibiotic coverage. Prevention is crucial in dealing with aspiration pneumonia. A high index of suspicion should be maintained for pulmonary tuberculosis in the obstetrical population.