Treatment interruption after pregnancy: effects on disease progression and laboratory findings.

OBJECTIVE: To assess clinical progression and inflammatory markers among women stopping or continuing antiretroviral therapy (ART) after pregnancy. METHODS: ART-naïve women with CD4+ lymphocyte counts >350 cells/uL initiating ART during pregnancy had clinical events and laboratory markers compared over one year postpartum between those stopping (n = 59) or continuing (n = 147) ART. RESULTS: Slopes in CD4 count and HIV RNA did not differ between groups overall and in subsets of ZDV or combination therapy. The hazard ratio (HR) of a new class B event was 2.09 (95% CI 0.79-5.58) among women stopping ART, 1.24 (0.31-4.95) in those stopping ZDV, and 2.93 (0.64-13.36) among those stopping combination therapy. Women stopping ART had increased immune activation. No significant differences were seen in C-reactive protein, lipids, leptin, or interleukin-6. CONCLUSIONS: While changes in CD4 and HIV RNA levels over one year were similar between women stopping or continuing ART postpartum, higher immune activation among women stopping therapy requires further study.

No increase in rates of early-onset neonatal sepsis by non-group B Streptococcus or ampicillin-resistant organisms.

OBJECTIVE: We assessed the impact of a risk-based approach to group B Streptococcus (GBS) prophylaxis on the rates of early-onset neonatal sepsis (EONS). STUDY DESIGN: A retrospective cohort study of neonates born at a tertiary-care hospital from 1990 to 1996 was performed. Cases of EONS were identified among neonates born in a period without GBS prophylaxis (1990-1992) and compared with those born in a period with GBS prophylaxis (1993-1996). The antibiotic susceptibility data on each organism isolated in the blood culture were obtained. RESULTS: In the period without prophylaxis, 99 cases of EONS were identified among 25,934 neonates for a rate of 3.8 per 1000 births. In the period with prophylaxis, 90 cases of EONS occurred among 34,262 neonates for a rate of 2.6 per 1000. The rate of GBS-EONS significantly decreased between the 2 periods (from 1.9 to 1.1, P =.01). There was a trend toward a decrease in the rate of EONS caused by non-GBS gram-positive organisms (from 1.2 to 0.7, P =.06). There was no significant increase in the rate of EONS caused by gram-negative or ampicillin-resistant organisms. CONCLUSIONS: A risk-based approach to GBS prophylaxis reduced the incidence of GBS-EONS at a tertiary-care hospital. This decrease was not accompanied by an increase in the incidence of EONS by non-GBS or ampicillin-resistant organisms.

Cost-effectiveness of elective cesarean delivery in human immunodeficiency virus-infected women(1).

OBJECTIVE: To evaluate the cost-effectiveness of an elective cesarean delivery strategy in human immunodeficiency virus (HIV)-infected women receiving zidovudine therapy to prevent perinatal transmission. METHODS: A decision-analysis model was constructed to compare two delivery strategies in HIV-infected women: usual care and recommendation for elective cesarean delivery. The model followed a hypothetical cohort of 7000 HIV-infected pregnant women in the United States who were receiving zidovudine therapy for 1 year. The third-party payer perspective was taken. Cost of delivery method with and without complications and lifetime medical care cost for pediatric HIV infection were considered. The main outcome measure was cases of perinatal HIV transmission prevented. RESULTS: Compared with the usual care strategy, the elective cesarean delivery strategy resulted in an additional 3486 cesarean deliveries each year, prevented 142 cases (52.4%) of perinatal HIV transmission, and resulted in incremental overall cost savings to society of $5.3 million per year ($37,284 saved per case of perinatal transmission prevented). With other estimates held constant, the elective cesarean delivery strategy would not be cost saving when the baseline perinatal HIV transmission rates were all reduced by 43.3%. CONCLUSIONS: Elective cesarean delivery in HIV-infected women receiving zidovudine is one management strategy for prevention of perinatal HIV transmission and can be cost saving. However, if other strategies, such as use of combination antiretroviral therapy and/or measurement of viral load, result in at least 50% reduction of the baseline perinatal HIV transmission rates, elective cesarean delivery will not be cost saving.

Genital tract human immunodeficiency virus type 1 (HIV-1) shedding and inflammation and HIV-1 env diversity in perinatal HIV-1 transmission.

This study sought to identify genital tract characteristics associated with vertical transmission of human immunodeficiency virus type 1 (HIV-1). HIV-1 DNA and RNA, HIV-1 env diversity, and inflammatory cells were quantified in cervicovaginal lavages (CVLs) of 24 women enrolled in the Women and Infants Transmission Study; 7 women transmitted HIV-1 perinatally. Vaginal candidiasis, HIV-1 culture positivity, levels of HIV-1 DNA and cell-free RNA, and HIV-1 env diversity were significantly higher in the CVLs of transmitters. CVL HIV-1 DNA levels correlated with higher levels of inflammatory cells and cell-free HIV-1 RNA. Of subjects with paired blood and CVL specimens, there was more HIV-1 env heterogeneity between blood and CVLs in transmitters than in nontransmitters. In summary, increased HIV-1 shedding is correlated with a more complex population of HIV-1 quasispecies in the genital tracts of parturient women, which may increase the probability that a fetotropic strain is transmitted.

Obstetric and newborn outcomes in a cohort of HIV-infected pregnant women: a report of the women and infants transmission study.

OBJECTIVE: To determine obstetric and neonatal outcomes in a cohort of HIV-infected pregnant women and to assess whether HIV-related immunosuppression increases the risk of adverse outcomes of pregnancy. METHODS: Between 1989 and 1994, interview, physical examination, laboratory, and medical record data were prospectively collected from HIV-infected pregnant women and on their newborns. Factors associated with adverse pregnancy outcome and HIV disease status were correlated with pregnancy outcome using logistic regression analysis. RESULTS: 634 women delivered after 24 weeks of gestation. Preterm birth, low birth weight, and small-for-gestational-age neonates occurred in 20.5%, 18.9%, and 24.0% of pregnancies, respectively. Factors associated with low birth weight were CD4 percentage <14%, history of adverse pregnancy outcome, pediatric HIV infection, bleeding during pregnancy, and Trichomonas infection. Preterm birth was associated with CD4 percentage <14%, a history of adverse pregnancy outcome, and bleeding during pregnancy. Being small for gestational age was associated with maternal hard drug use during pregnancy, Trichomonas infection, history of adverse pregnancy outcome, and hypertension. CONCLUSIONS: Adverse pregnancy outcomes are common for HIV-infected women and are associated with low maternal CD4 percentage and pediatric HIV infection. Preterm birth, low birth weight, and small-for-gestational-age ranking, however, are also associated with previously recognized sociodemographic and obstetric factors that are not unique to HIV infection.

Changes in total, CD4+, and CD8+ lymphocytes during pregnancy and 1 year postpartum in human immunodeficiency virus-infected women. The Women and Infants Transmission Study.

OBJECTIVE: To assess changes in lymphocyte subsets during pregnancy and 1 year postpartum in human immunodeficiency virus (HIV)-infected women. METHODS: Changes in CD4+ and CD8+ cell counts, CD4 and CD8 percent, CD4/CD8 ratio, and total lymphocyte count and percent were assessed in each of 226 HIV-infected women followed during pregnancy and 1 year postpartum, and for each of 100 nonpregnant HIV-infected woman during 1 year. Trends over time were compared between pregnant women with and without several covariates. Postpartum changes over a 1-year period were compared to a 1-year period in the nonpregnant cohort. RESULTS: There was a mean increase of 2.76 per week in the CD4+ cell count during pregnancy (P = .04). No other characteristics changed significantly during pregnancy. The mean CD4+ and CD8+ cell counts, the CD8 percent, and the total lymphocyte count and percent increased immediately postdelivery. During the first postpartum year, there were statistically significant declines in the absolute CD4+ and CD8+ cell counts, the relative CD4 and CD8 percentages, and the total lymphocyte count and percentage. The rate of change for CD4+ and CD8+ counts, but not for CD4 percent, was less during 1 year in the nonpregnant cohort than in the first postpartum year, and the CD8 percent increased in the nonpregnant women. A wide variability in trends of all measurements during pregnancy was seen. CONCLUSION: During pregnancy, CD4 and CD8 percentages remain stable. There are no clinically significant changes during pregnancy or postpartum in any lymphocyte parameter we assessed. Postpartum changes in lymphocytes and lymphocyte subsets most likely represent a return to baseline from the physiologic changes of pregnancy and the immediate postpartum period.

Prevention of transmission. Pharmaceutical and obstetric approaches.

An increasing body of information regarding risk factors for perinatal HIV transmission suggests the use of logical management strategies during the prenatal period and parturition directed at maximizing maternal health and minimizing perinatal transmission. This article reviews the recommendations for pharmacologic therapy and rational obstetric management strategies to decrease perinatal HIV transmission based on published clinical trials and a review of data relevant to transmission.

Low risk of post-cesarean section infection in insulin-requiring diabetic women.

OBJECTIVE: The purpose of this study was to determine if insulin-requiring diabetic women undergoing nonelective cesarean section are at higher risk for postoperative infection than nondiabetic women. RESEARCH DESIGN AND METHODS: Medical records of a cohort of insulin-requiring diabetic women who underwent cesarean section after labor or rupture of membranes and nondiabetic control subjects matched for age and insurance status were retrospectively reviewed. Data abstracted included maternal characteristics, antepartum, intrapartum, and postpartum events. RESULTS: Post-cesarean section infection including endometritis, wound infection, and septic pelvic thrombophlebitis occurred in 10.2% of 205 diabetic women and 12.1% of control subjects, in whom antibiotic prophylaxis was used in 79% of diabetic women and 84% of control subjects. Duration of rupture of membranes was a significant risk factor for post-cesarean section infection in both groups. CONCLUSIONS: Insulin-requiring diabetic women undergoing nonelective cesarean section with antimicrobial prophylaxis have a rate of postoperative infection similar to that for nondiabetic women.

Transmission of human immunodeficiency virus infection presumed to have occurred via female homosexual contact.

We describe a 24-year-old woman infected with the human immunodeficiency virus (HIV) whose sole risk behavior was prior sexual contact with an HIV-infected woman. Our patient's clinical course suggests that viral transmission occurred during the beginning of their sexual relationship. Our case, combined with those previously reported, provides evidence that female homosexual activity can be a risk behavior for acquisition of HIV infection. Seroprevalence studies, however, have not provided evidence for transmission of HIV by this behavior. These studies, combined with the sparse number of individual case reports, suggest that female homosexual activity is an inefficient mechanism of HIV transmission.

Bacillary angiomatosis in a pregnant patient with acquired immunodeficiency syndrome.

Bacillary angiomatosis, a cutaneous lesion newly recognized to affect patients with AIDS, may resemble Kaposi sarcoma. It is presumed to be an infectious process caused by the gram-negative bacilli associated with cat-scratch fever. We present a case of bacillary angiomatosis in a pregnant AIDS patient.

The effect of cigarette smoking, Chlamydia trachomatis infection, and vaginal douching on ectopic pregnancy.

We conducted a case-control study of the relation between ectopic pregnancy and three exposures of interest: cigarette smoking, previous chlamydial infection, and vaginal douching. Cases were women with surgically confirmed tubal ectopic pregnancy; controls were women with intrauterine pregnancy at 14 weeks' gestation or less. All women were between the ages of 18-40 and were cared for at the same hospital. Sixty-nine case women and 101 controls were interviewed and underwent serologic tests for Chlamydia trachomatis exposure. Cases were more likely than controls to be nulliparous, non-white, and unmarried and to report a high school education or less (P less than .05). The proportions of cases and controls who reported smoking during the month of conception were 51 and 20%, respectively. The adjusted odds ratio for smoking was 2.4 (95% confidence interval 1.2-5.1) when current smokers were compared with former smokers and women who had never smoked. The proportions of women who had previous chlamydial infection (immunoglobulin G [IgG] greater than 1:64) among cases and controls were 35 and 20% (adjusted odds ratio 1.3, 95% confidence interval 0.6-3.0). Overall, 28% of cases and 19% of controls douched once or more per month (adjusted odds ratio 0.8, 95% confidence interval 0.3-2.2). We conclude that current cigarette smoking may be associated independently with ectopic pregnancy and that smoking cessation before the month of conception may reduce this risk. For these women, previous chlamydial infection and vaginal douching did not appear to increase significantly the risk of ectopic pregnancy.

Risk factors for preterm premature rupture of fetal membranes: a multicenter case-control study.

To assess the association between women with preterm premature rupture of membranes and 41 potential risk factors, we conducted a case-control study in six United States tertiary perinatal centers. The study involved completion of a comprehensive questionnaire for 341 women with preterm premature rupture of membranes in singleton pregnancies from 20 to 36 weeks' gestation and 253 control women matched for maternal age, gestational age, parity, clinic or private patient status, and previous vaginal or cesarean delivery. Univariate analysis revealed 11 variables associated with a significantly (p less than 0.05) increased risk of preterm premature rupture of membranes. After multiple logistic regression analysis, three variables remained in the model as independent risk factors: antepartum vaginal bleeding in more than one trimester (odds ratio 7.4; 95% confidence interval, 2.2, 25.6), current cigarette smoking (odds ratio, 2.1; 95% confidence interval, 1.4, 3.1), and previous preterm delivery (odds ratio, 2.5; 95% confidence interval, 1.4, 2.5). Cessation of cigarette smoking by pregnant women may reduce the risk of preterm premature rupture of membranes. Further study is necessary to determine the nature of the relationship between antepartum vaginal bleeding and preterm premature rupture of membranes.

Pregnancy outcome after premature rupture of the membranes at or before 26 weeks' gestation.

Pregnancy outcome was examined in 59 clinically stable patients with rupture of the membranes at or before 26 weeks' gestation. The mean gestational age at rupture of the membranes was 23.2 weeks, and the mean latent period was 21.5 days. Delivery occurred within 7 days in 29 patients (49.2%), chorioamnionitis developed in 27 patients (45.8%), and operative delivery was required in 24 patients (40.7%). Sixty-three infants were delivered, with a perinatal mortality rate of 49.1%. Among survivors, 84% required newborn intensive care during the initial hospitalization, 77% were discharged with minor to moderate reversible sequelae, and 16% were discharged with sequelae that were likely to be of long-term duration. Obstetric factors present at rupture of the membranes were evaluated for their ability to predict maternal and neonatal morbid outcomes; obstetric interventions were evaluated for their ability to modify outcomes. These data suggest that outcomes in this subset of patients may not be uniformly dismal, and support clinical decision-making on an individualized basis.

Plasma and tissue concentrations of ceforanide and cefazolin in women undergoing hysterectomy.

Thirty-four women who underwent vaginal hysterectomy received either ceforanide or cefazolin as perioperative antimicrobial prophylaxis. Samples of plasma, myometrium, endometrium and fallopian tubes were obtained at various intervals after injection and were assayed for cephalosporin concentration. Following intramuscular injection approximately 1 h prior to surgery, both drugs provided adequate tissue levels at the time of the procedure. Although both antimicrobials achieved similar tissue concentrations, all tissue samples for ceforanide exceeded the MIC90 for Escherichia coli while in the cefazolin group 9/18 myometrial samples and 10/15 endometrial samples fell below the MIC90 for this organism.

Single-dose antibiotic prophylaxis in high-risk patients undergoing cesarean section. A comparative trial.

A prospective, double-blind study was performed to evaluate the comparative efficacy of single- and multiple-dose antimicrobial prophylaxis for preventing infection in high-risk patients undergoing cesarean section. One hundred fifty-eight patients were randomly assigned to receive either a single perioperative dose of mezlocillin, three doses of mezlocillin or three doses of cefoxitin. The incidence of endometritis was 5.9%, 4.0% and 4.0%, respectively. The incidence of febrile morbidity was 5.9%, 2.0% and 6.1%, respectively. These differences are not statistically significant. The single perioperative dose of mezlocillin was as effective as the three-dose regimen of either mezlocillin or cefoxitin.

Actinomycotic pelvic inflammatory disease simulating malignancy.

The protean and indolent nature of pelvic actinomycosis combined with the rarity of the disease poses a diagnostic dilemma. Woody induration and pelvic fibrosis may be present to such a degree that a diagnosis of pelvic malignancy is entertained. Early diagnosis and aggressive antibiotic therapy prior to definitive surgical management, even in the face of extensive anatomic changes, may enable the surgeon to perform relatively conservative surgery, obviating the need for procedures usually reserved for malignant disease.

A comparative trial of cefazolin and moxalactam as prophylaxis for preventing infection after abdominal hysterectomy.

In a randomized, double-blind clinical trial, 208 women who underwent abdominal hysterectomy received either cefazolin (N = 108) or moxalactam (N = 100) as perioperative antimicrobial prophylaxis. There were no differences between the two groups in rates of serious infection, minor wound infection, standard febrile morbidity, duration of hospitalization, proportion receiving other postoperative antibiotics, or rates of rehospitalization. Women who received moxalactam had significantly more urinary tract infections, 87% of which were caused by the enterococcus. It is concluded that perioperative prophylaxis with third-generation cephalosporins is not justified at this time.