Folic acid supplementation--when and how.

The periconceptional intake of 400 micrograms of folic acid can prevent 50-70% of neural tube defects. It is difficult to achieve this intake with diet alone, even with the recently approved levels for grain-food fortification. Therefore, a daily multivitamin with folic acid is recommended for all women of childbearing potential. Obstetrician-gynecologists should exercise every opportunity to educate their patients to this end. Although raised as a concern, the potential of masking the megaloblastic anemia of pernicious anemia is unlikely with these levels of supplementation, and considering the rarity of the disease in women of reproductive age.

Human immunodeficiency virus infection and pregnancy.

The human immunodeficiency virus (HIV) epidemic is clearly one of the most serious health-care crises in the professional lives of contemporary physicians. It cannot be regarded as a curiosity to be dealt with by inner-city infectious-disease experts, but rather must be considered a problem for all health-care providers and a problem in which the obstetrician-gynecologist has a special role to play.

The physician and the social contract.

Expenditures for health care are growing at a staggering rate, yet over 30 million Americans lack access to care. A growing population with needs, increasing administrative costs, expanding biomedical technology, and the ever-increasing expectations of patients are among the explanations for this cost. To resolve the problem, we must establish priorities, evaluate technology more carefully before application, reassess our fees as they relate to effort, and evaluate what we do for our patients as it relates to society generally. Many of the problems in health care are societal problems, but physicians as a particularly responsible and knowledgeable part of society must take the lead in finding and implementing the solutions.

Pneumococcal polysaccharide antibody levels in patients with term and preterm pregnancies.

Serum antibody levels against 12 serotypes of pneumococcal polysaccharide were assessed in pregnant women as well as in cord bloods of their infants. Twelve women were evaluated during the first trimester, second trimester, and in labor at term, and eight women were assessed in the first trimester and in preterm labor. Antibody levels significantly decreased from the first trimester to delivery both in patients with term (339 versus 281 ng AbN/mL; P less than .001), and preterm (448 versus 299 ng AbN/mL; P less than .001) deliveries. There was no significant difference in mean antibody levels or their rate of decline between term and preterm pregnancies.

Relation of private or clinic care to the cesarean birth rate.

The rising rate of cesarean births in the United States has been the focus of academic attention as well as attention from the media during the past decade. Although there is a consensus about the indications for cesarean delivery that have led to the increased rate (dystocia, malpresentation, fetal distress, and previous cesarean delivery), the influence of other key factors, such as whether the patient received care from a private physician or through a hospital clinic, has not been established. In a review of 65,647 deliveries in four Brooklyn hospitals between 1977 and 1982, we found that private physicians performed significantly more cesarean sections than house officers and attending physicians. Private patients giving birth to their first child were significantly more likely than clinic patients to undergo cesarean delivery if dystocia, malpresentation, or fetal distress was diagnosed, and private patients with one or more previous deliveries were significantly more likely to undergo cesarean delivery if dystocia or malpresentation was diagnosed. Private patients had fewer perinatal deaths, which were concentrated among infants with birth weights under 2000 g, but the infants of private patients had a significantly higher rate of low Apgar scores and birth injuries than the infants of clinic patients.

Relationship of vaginitis to the sex of conceptuses.

The relative viability of X-bearing and Y-bearing spermatozoa is influenced by factors in the vagina such as pH. The vaginal environment, in turn, is influenced by its flora. This study examined the relationship of the vaginal flora to the sex of conceptuses. It was found that women who carried Trichomonas vaginalis or Bacteroides sp or who had nonspecific vaginitis at first prenatal visit were significantly more likely to deliver females than women who carried none of these organisms (54 versus 37%, P less than .02).

Risk factors for prematurity and premature rupture of membranes: a prospective study of the vaginal flora in pregnancy.

Prematurity remains a major cause of perinatal mortality in the United States. Some research has indicated that infectious agents play a role in either initiating preterm labor, causing premature rupture of the membranes, or preventing tocolysis. This study attempted to determine if the presence of various vaginal pathogens in early pregnancy was associated with the subsequent development of premature rupture of membranes or preterm labor. We found that among 233 evaluable patients those with Trichomonas vaginalis were significantly more likely to have premature rupture of the membranes (p less than 0.03), and those with Bacteroides sp. were more likely to be delivered of their infants before 37 weeks (p less than 0.03) and to have infants weighing less than 2500 gm (p less than 0.05). Those with Ureaplasma urealyticum more frequently began preterm labor (p less than 0.05). Preterm premature rupture of the membranes was found significantly more often among patients with Bacteroides sp. Stepwise multiple logistic regression analysis indicated that those associations were not related to the number of previous abortions, deliveries, or preterm deliveries or to maternal age. We conclude that microbiologic screening in early pregnancy may aid in the assessment of patient risk for preterm delivery.

The relationship of maternal antibody levels to post-cesarean section endometritis.

One hundred eight pneumococcal polysaccharide antibody levels were determined by radioimmunoassay preoperatively in 18 patients who underwent elective repeat cesarean section. Eight patients developed post-cesarean section endometritis, and 10 did not. The endometritis group did not vary significantly from the noninfected group in preoperative hematocrit, social status, number of previous pregnancies, maternal and newborn weights, length of operation, and Apgar scores. Mean antibody levels in the endometritis group were significantly lower than those in the control group (49 versus 103 ng/ml; p less than 0.05). Mean antibody levels for the six serotypes in the endometritis group were significantly lower than those in the control group (p less than 0.05). This study indicated that a healthy maternal immune system may play an important role in preventing post-cesarean section morbidity. Pneumococcal polysaccharide antibody levels may be used in pregnancy to assess the risk for post-cesarean section infections.

Cervical cerclage: an aggressive approach to threatened or recurrent pregnancy wastage.

Patients at high risk for recurrent pregnancy wastage may not always provide a typical history of cervical incompetence. Seventy-five pregnancies were managed with a cervical cerclage, with tocolytic agents used adjunctively in some. The pregnancies were divided into three groups on the basis of past obstetric history and statistically analyzed with respect to outcome. Patients in categories 1 and 2 showed significant improvement in mean birth weight and maximum gestational age attained with a shift in the ratio of term to premature births after intervention. In category 3, a trend of improvement in mean birth weight and maximum gestational age was seen but fetal salvage was not improved. Maternal morbidity was low with a cerclage-related cesarean section rate of 6.8% and only 8% infectious morbidity. It is concluded that cervical cerclage should be considered in the management of recurrent pregnancy wastage even if the obstetric history is atypical.

Chancroid and granuloma inguinale.

PIP: Chancroid, also known as soft chancre, is seen infrequently and is manifested locally rather than systemically. The causative organism, Hemophilus ducreyi, is a short nonmotile bacillus, non-acid-fast, and usually gram-negative. Culture of the organism is difficult because contamination by other organisms inhibits the growth of H. ducreyi. Chancroid is relatively rare in the US but is more common in developing countries. It is a disease of the sexually promiscuous and is associated with poor hygiene. The lesions are usually obvious in the male but may be undetected in women. The incubation period is 3-5 days and the typical lesion is a soft nonindurated ulcer with a dirty exudate at the base, which is painful and exquisitely tender to palpation. Bubo formation is common and about half suppurate. Diagnosis depends on differentiation from other genital ulcers. The characteristics of the lesions and the nature of lymph node involvement are diagnostic features; smears and cultures are also involved but the organism may be difficult to isolate and the diagnosis must often be established on clinical grounds alone. In many instances no specific therapy other than cleansing with soap and water may be required. The sulfonamides, tetracycline, or a combination may be utilized. Prevention is usually a function of hygiene; condoms offer good protection. Granuloma inguinale, a disease of tropical and subtropical countries, is caused by the gram-negative, pleomorphic and microaerophilic bacterium Calymmatobacterium granulomatis. The mode of transmission is probably sexual but sexual transmission has been questioned on the basis that the disease is not very contagious. It is likely that a break in the skin or mucosa is necessary for the disease to become established. Lesions occur a few days to 3 months after inoculation in the form of 1 or more indurated papules which gradually break down to form ulcers. The ulceration may spread to the entire genitocrural area if untreated, but systemic disease is very rare. The diagnosis is usually suggested by the history and physical findings but confirmation can be obtained by smears of biopsy and histologic examination. The condition is responsive to a wide variety of antibiotics. Personal hygiene is the most effective means of prevention.^ieng

The relationship of amniotic fluid phosphate-to-zinc ratios to post-cesarean section infection.

Although many reports concerning risk factors for post-cesarean section febrile morbidity have been published, few have considered the antibacterial activity of amniotic fluid. This study, in which the amniotic fluid phosphate-to-zinc ratios were used as a reflection of antibacterial activity, demonstrates that, among 85 patients who underwent elective repeat cesarean sections, less febrile morbidity was present when the patient's amniotic fluid had greater antibacterial activity. There was less standard fever, use of antibiotics, and endometritis among patients whose amniotic fluid had lower phosphate-to-zinc ratios.

Vaginal colonization with Group B beta-hemolytic streptococcus as a risk factor for post-cesarean section febrile morbidity.

Vaginal colonization of mothers with Group B beta-hemolytic streptococcus (GBS) has been recognized as a risk factor for neonatal morbidity. The relationship of GBS colonization to risks for the mother who undergoes cesarean section has not been defined. In this study, we found that, among patients who underwent cesarean section, the 19% of them who were colonized with GBS had a higher incidence of standard fever (66.6% vs. 30.5%), clinical diagnosis of endomyometritis (61.1% vs. 12.5%), and use of antibiotics (61.1% vs. 26.3%) in relationship to a significantly increased frequency of premature rupture of the membranes (50.0% vs. 14.8%). Reasons for the association between vaginal colonization and increased morbidity are discussed.