Clinical problem of preterm labor.
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Congresses as Topic↗
Biomedical subjects
J D Blanco
Publications and source records attributed to J D Blanco.
Pathophysiology, diagnosis, and management of intraamniotic infection.
Intraamniotic infection (IAI) is a term used to describe a clinically diagnosed infection of the contents of the uterus. It is found most often after rupture of the membranes. The most useful diagnostic tests are physical examination, amniotic fluid glucose determination, and amniotic fluid Gram's stain. There is no clearly established means for the prevention of IAI, but cervical examinations and cervical manipulation can increase the risk, so caution with their use is still warranted. Treatment for this infection should be initiated when the diagnosis is made to provide the lowest risk of neonatal and maternal complications. Ampicillin or penicillin plus gentamicin are the most extensively tested antibiotics for treatment before delivery. Clindamycin or metronidazole should be added if a cesarean section is performed. As a general rule, antibiotics should be continued postpartum until the patient has been afebrile and asymptomatic for a minimum of 24 hours. Neonatal complications of IAI may be substantial especially for the premature fetus. Women with this infection have a greater risk for dysfunctional labor and cesarean section.
Amnion↗
Declines in patient volume: an obstetrics and gynecology teaching program's response.
Historically, University teaching hospitals have been the primary providers of health care to the indigent population. With the advent of managed health-care plans, the university hospitals have seen a rapid decline in their obstetrical patient populations. This decrease is reflected in the numbers of deliveries and gynecological surgeries. From 1990 to 1995, these changes resulted in a significant decline in deliveries at our hospital, the Lyndon B. Johnson General Hospital. To reverse this ominous trend, we instituted a variety of changes resulting in a more patient-centered system and found an improvement in the numbers of obstetrical patients. In the following report, we describe these changes and the subsequent outcome.
Delivery, Obstetric↗
Chlorhexidine versus sterile water vaginal wash during labor to prevent peripartum infection.
OBJECTIVE: Our purpose was to determine whether a dilute solution of chlorhexidine used as a one-time vaginal wash intrapartum can reduce the incidence of intraamniotic infection or endometritis in laboring pregnant women. STUDY DESIGN: Term pregnant women in labor were prospectively randomized to receive either 20 ml of 0.4% chlorhexidine (n = 481) or 20 ml of sterile water (n = 466) placebo. All patients were monitored for risk factors associated with intraamniotic infection. Continuous variables were compared with the Mann-Whitney U test and discrete variables were compared with Fisher's exact test. RESULTS: No significant differences in infection were found between the chlorhexidine and placebo groups. During the study period 21 of 466 women (4.5%) had intraamniotic infection in the control group compared with 25 of 481 women (5.2%) receiving chlorhexidine (p = 0.65, 95% confidence interval 0.82 to 1.41). Nine women in the placebo group (1.9%) and 9 women in the chlorhexidine group (1.9%) had endometritis (p = 1.0, 95% confidence interval 0.62 to 1.56). CONCLUSIONS: Our findings suggest that a one-time 0.4% chlorhexidine vaginal wash does not decrease the incidence of infectious morbidity in parturients, compared with the use of sterile water.
Adult↗
Prolonged prior infection with Chlamydia prevents adverse pregnancy outcome in a murine model.
OBJECTIVE: Our purpose was to compare the rate of adverse pregnancy outcome in pregnant mice with lower genital tract chlamydial infection who had a prior short chlamydial infection versus a prior long-term infection. STUDY DESIGN: A total of 127 female mice were divided into short-term and long-term infection groups. We infected the lower genital tracts with Chlamydia trachomatis. After 7 days in the short-term infection group and 30 days in the long-term infection group, we treated the mice with tetracycline-impregnated chow. After documentation of cure, the mice were mated and transvaginally reinfected with Chlamydia trachomatis. Forty-one of the 127 (32%) mice became pregnant. We noted the number of mice with fetal death and the number of pups present. We cultured the lower uterine segment and the pups for Chlamydia. RESULTS: Seven of 21 (33%) mice in the short-term infection group had fetal deaths compared with 1 of 20 (5%) in the long-term infection group (p < 0.05). In the short-term infection group 21 of 21 (100%) mice had positive transvaginal chlamydial cultures after reinoculation compared with only 7 of 20 (35%) in the long-term infection group (p < 0.000004). Seventeen of 21 (81 %) mice in the short-term infection group had positive chlamydial cultures from the lower uterine segment versus 1 of 20 (5%) in the long-term infection group (p < 0.000001). Sixty-five percent of pups in the short-term infection group and none (0%) of the pups in the long-term infection group were positive for Chlamydia (p < 0.00001). CONCLUSIONS: We conclude that in this murine model a prior 30-day genital tract infection with Chlamydia protects pregnant mice from subsequent reinfection and adverse pregnancy outcomes.
Animals↗
Food and Drug Administration meeting and the Collaborative Home Uterine Monitoring Study.
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Controlled Clinical Trials as Topic↗
The rate of severe preeclampsia is increased in triplet as compared to twin gestations.
The objective of this study was to determine if the rate of preeclampsia is increased in triplet as compared to twin gestations. Fifty-three triplet pregnancies between 1986 and 1993 at The New York Hospital-Cornell Medical Center were reviewed. These were matched for maternal age, parity, and race to twin gestations (N = 53) from the same population. Severe preeclampsia was defined by standard criteria. Student's t-test, Fisher exact test, and Chi-square were used for statistical analysis. The rate of severe preeclampsia was increased significantly in the triplet group 12 of 53 (22.6%) as compared with the twin group 3 of 53 (5.7%) (OR = 4.9, 95% CI 1.2-23.5, p = 0.02). The rate of overall preeclampsia was not significantly different in the triplet 18 of 53 (33.96%) or twin 12 of 53 (22.6%) groups. In this retrospective, case-controlled study, the rate of severe pre-eclampsia was significantly increased in triplet gestations as compared to twins although the overall rate of preeclampsia was not. This information may be useful in counseling patients with high order multifetal gestations.
Adult↗
The effect of cocaine on mitogen-induced lymphyocyte proliferation in pregnant women.
Cocaine use during pregnancy is associated with increased risk of sexually transmitted diseases, including syphilis and HIV. Many sociological and economic factors related to cocaine use have been shown to contribute to this increased risk. Cocaine may also affect immunological function thereby increasing risk for sexually transmitted diseases. The objective of this study was to determine if cocaine suppresses mitogen-induced lymphocyte proliferation in pregnant women. Peripheral blood mononuclear cells were obtained from 39 pregnant women. Lymphocyte proliferation was stimulated with concanavalin A (conA, 1 microg/mL). Cocaine was added at time zero to one set of cultures and at 0, 24, and 48 hr to a second set of cultures (to correct for cocaine degradation in culture). Three doses of cocaine were used: 0.1, 1 and 10 microg/mL. The cells were pulsed with 1 microCi 3H thymidine at 72 hr and harvested 19 hr after addition of the isotope. Lymphocyte proliferation, as determined by radioactivity (cpm) was assessed. Cocaine had no statistically significant effect on conA-stimulated lymphocyte proliferation when added at time = 0 or when added daily. Cocaine, in concentrations similar to those found in clinical experiments with drug users, does not suppress in vitro concanavalin A-induced lymphocyte proliferation in cells obtained from pregnant women.
Cell Division↗
Ineffectiveness of latex condoms in preventing contamination of the transvaginal ultrasound transducer head.
The efficacy of condoms in preventing contamination of the transvaginal ultrasound transducer head and possible transmission of blood-borne pathogens is unknown. Our objective was to determine the rate of contamination of the transvaginal ultrasound probe after use in the emergency department. After indicated transvaginal ultrasound scans, the latex condom was removed and the transducer head was inspected for contamination. The presence of vaginal bleeding and the duration of the ultrasound scan were noted. Ten milliliters of hydrogen peroxide (H2O2) was placed in the condom. Bubbling, which occurs in the presence of blood or cervicovaginal secretions, was considered a positive test. Exposure of a clean condom or coupling gel to H2O2 did not cause bubbling. Two-tailed Fisher's Exact and Student's t tests were used for statistical analysis. Of 173 cases, 8 (5%) had a positive H2O2 test for contamination. In only 3 of these 8 cases was gross contamination seen. Latex condoms are ineffective in preventing contamination of the transvaginal ultrasound transducer head. Visual inspection of the transducer head often fails to identify the presence of blood or body fluids. This suggests that additional measures should be taken to prevent transmission of blood-borne pathogens.
Condoms↗
Microbiologic assessment of the transabdominal ultrasound transducer head.
The objectives of this study were to determine (1) the rate of bacterial isolation from the abdomen of women having obstetric ultrasonography, (2) the rate of bacterial transmission to the transducer head, and (3) the eradication rate after routine wiping of the transducer head. A total of 191 obstetric patients participated in this study. At the start of each day, the transducer head and the coupling gel were cultured. Aerobic cultures were obtained from each patient's periumbilical and suprapubic areas before the transabdominal scan and from the transducer head before and after wiping off the gel with a dry cloth. Daily transducer head and gel cultures were negative. Of the abdominal skin cultures, 175 (92%) were positive; 35 (18%) were positive for serious organisms, and 140 (74%) were positive for organisms of low virulence. Sixty percent of the transducer head cultures from women with abdominal skin pathogens were positive before the gel was wiped off. None of the cultures from the transducer head were positive after removal of the gel. We conclude that many women carry potentially virulent pathogens on the abdominal skin and that transmission of these organisms to the transducer head commonly occurs. Physical removal of the gel from the transducer head effectively eradicates these microorganisms, minimizing patient-to-patient transmission.
Abdomen↗
A randomized trial of prophylactic doxycycline for curettage in incomplete abortion.
OBJECTIVE: To determine whether prophylactic doxycycline at suction curettage for incomplete abortion decreases the rate of postoperative pelvic infection. METHODS: We randomized 240 patients to receive intravenous doxycycline or placebo at curettage. Cervical specimens for gonorrhea and chlamydia were obtained preoperatively. Two weeks post-procedure, we evaluated all patients for infectious morbidity and repeated gonorrhea and chlamydia cultures. Statistical analysis used Mann-Whitney U test, McNemar test, or Fisher exact test, as appropriate. RESULTS: There were no statistically significant differences in age, parity, gestational age, history of sexually transmitted disease, pelvic inflammatory disease, or multiple sex partners between the doxycycline and placebo groups. Preoperative gonorrhea or chlamydia isolates were positive in five (4.2%) and six (5%) of 120 doxycycline patients and four (3.3%) and eight (6.6%) of 120 controls (not significant). All preoperative gonorrhea isolates remained positive postoperatively. Seven (5.8%) controls had positive postoperative chlamydia isolates, as did one (0.8%) in the doxycycline group (P = .06). We diagnosed eight (6.6%) of 120 doxycycline patients and seven (5.8%) of 120 controls with infectious morbidity (not significant). CONCLUSION: In our population of patients with incomplete abortion, the prevalence of gonorrhea and chlamydia was low, and prophylactic doxycycline did not decrease the rate of postoperative febrile morbidity.
Abortion, Incomplete↗
Coagulation studies in patients with marked thrombocytopenia due to severe preeclampsia.
From July 1, 1990, to July 1, 1993, we analyzed the results of fibrinogen levels, prothrombin time, and partial thromboplastin time in patients with severe preeclampsia, at least one platelet count less than 100,000/microL, and no signs of abruption or hemorrhage. Analysis was by Pearson's correlation coefficient and Wald's sequential analysis. We analyzed 162 blood collections from 48 patients. There was no correlation between the level of thrombocytopenia and the levels of prothrombin time, partial thromboplastin time, or fibrinogen. None of the samples from any of the preeclamptic patients demonstrated an abnormal prothrombin time or partial thromboplastin time.
Blood Coagulation↗
Cocaine use in pregnancy and the risk of intraamniotic infection.
A retrospective, case-control study was performed to determine whether pregnant women using cocaine had an increase in maternal infectious morbidity. Seventy-six women with urine drug screens positive for cocaine on admission to the labor and delivery unit were compared to 134 women who had negative urine drug screens. Patients were matched for risk factors associated with the development of intraamniotic infection and endometritis, such as parity, length of labor and length of membrane rupture. There was no significant difference in the incidence of intraamniotic infection or endometritis between the two groups. Thus, cocaine does not appear to increase the risk of peripartum infectious morbidity after controlling for well-established risk factors.
Adult↗
Endometritis after cesarean: the effect of age.
In this study, we compared the rate of endometritis after cesarean section in two age groups. The first group consisted of patients who were 17 years old or younger (teenage group) and the second group of patients were 35 years of age or older (advanced maternal age group). Patients in each group were matched for length of labor, length of rupture of membranes, and the use of prophylactic antibiotics. In the teenage group, 18 of 41 (43.9%) developed endometritis compared with 6 of 41 (14.6%) in the advanced maternal age group (P < 0.003). This study supports the concept that young age is a risk factor for endometritis after cesarean section.
Adolescent↗
Gentamicin levels in pregnant women with pyelonephritis.
This study was performed at University Medical Center, Lubbock, Texas, from July 1989 to June 1990. We obtained serum gentamicin peak and trough levels in 23 pregnant women with pyelonephritis. The patients were given a loading dose of 2 mg/kg gentamicin, followed by 1.5 mg/kg gentamicin adjusted for obesity every 8 hours. Peak levels were obtained 1 hour after the fifth dose and trough levels were drawn 30 minutes before the sixth dose. Statistical analysis was performed using chi 2 analysis. The mean (+/- SD) peak gentamicin level was 2.7 +/- 1.4 micrograms/mL and the mean trough level was 0.5 +/- 0.3 micrograms/mL. Twenty-two of 23 (96%) patients had peak levels 5 micrograms/mL and 1 of 23 (4%) patients had peak levels between 5 and 10 micrograms/mL. The mean peak gentamicin level in pregnancy is significantly less than in puerperal women (2.70 versus 5.78; P < 0.000001). We conclude that the majority of pregnant women treated for pyelonephritis with standard doses of gentamicin do not achieve therapeutic levels. Also, peak gentamicin levels are significantly below that reported for puerperal women.
Adult↗
Is there a relation between student lecture attendance and clinical science subject examination score?
OBJECTIVE: To determine whether there is a relation between lecture attendance and factual knowledge of obstetrics and gynecology, as measured by the National Board of Medical Examiners (NBME) clinical science subject examination. METHODS: We analyzed data on 197 students completing 8-week obstetrics and gynecology rotations from July 1, 1991 to June 30, 1992. Each student was expected to attend a weekly lecture series, and each completed the NBME clinical science subject examination at the end of the clerkship. Student attendance and board scores were correlated at the end of the academic year overall and by subgroups. Scores in the top and bottom 15% were defined as good and poor performance, respectively. RESULTS: A negative correlation (r = -0.1738, P = .0146) was found between percent absence and examination score. The odds ratio for poor performance was 5.48 (95% confidence interval 1.3-26.5; P = .015) for the subgroup of students with more than 30% absence compared to those without absences. Odds ratios for scoring in the upper 15th percentile were not significant. CONCLUSIONS: The negative correlation and the high odds ratio for poor performance suggest the value of monitoring attendance and identifying students at risk for poor performance (more than 30% absence). Lower absence rates did not predict performance.
Clinical Clerkship↗
Endotoxin, interleukin-1 beta, interleukin-6, or tumor necrosis factor-alpha do not acutely stimulate isolated murine myometrial contractile activity.
OBJECTIVES: Endotoxin, interleukin-1 beta, interleukin-6, and tumor necrosis factor-alpha have been implicated in the pathogenesis of preterm labor, but their acute effect on myometrial contractile activity is unknown. The objective of this study was to determine their effect on isolated pregnant murine myometrial contractile activity. STUDY DESIGN: Isometric contractions were measured in myometrium isolated from pregnancy day 18 Swiss-Webster mice. Frequency, duration, amplitude, and integrated area were compared before and after the addition of endotoxin (10(3) and 10(4) ng/ml) (n = 6), interleukin-1 beta (10 and 10 ng/ml) (n = 6), interleukin-6 (1 and 10 ng/ml) (n = 6), and tumor necrosis factor-alpha (1 and 10 ng/ml) (n = 6). Results were analyzed with the Wilcoxon rank-sum test. RESULTS: The addition of endotoxin, interleukin-1 beta, interleukin-6, or tumor necrosis factor-alpha did not result in a change in the contractile activity of isolated pregnant murine myometrium compared with control. CONCLUSION: Endotoxin, interleukin-1 beta, interleukin-6, and tumor necrosis factor-alpha do not acutely increase isolated murine myometrial contractile activity.
Animals↗
Uterine contractions after antibiotic therapy for pyelonephritis in pregnancy.
OBJECTIVE: The purpose of our study was to investigate the pathogenesis of preterm labor in pyelonephritis, we determined the number of uterine contractions occurring in patients with pyelonephritis before and after antibiotic therapy. STUDY DESIGN: We recorded the uterine contractions before and after antibiotic administration in 30 patients with acute pyelonephritis at Lyndon B. Johnson Hospital in Houston. Exclusion criteria were cervical dilatation > or = 4 cm, < 26 weeks' gestation, antibiotics within 7 days, clinical intraamniotic infection, rupture of membranes, or other maternal infection. Statistical analysis was by Kruskal-Wallis analysis of variance and Wilcoxon rank sum tests. RESULTS: The patients averaged eight contractions per hour on admission. The contraction rate significantly increased in hours +1 to +4 after antibiotic administration. The increase in uterine contractility occurred in patients with urinary tract gram-negative isolates. CONCLUSIONS: Pregnant women with pyelonephritis resulting from gram-negative bacteria increase their rate of uterine contractility after antibiotic treatment. This observation may be important in understanding the pathogenesis of preterm labor in pyelonephritis.
Adult↗