Premature rupture of membranes at term: a medical and economic rationale for active management.
Explore the source record for details and available documents.
Australia↗
Biomedical subjects
P Duff
Publications and source records attributed to P Duff.
Acute inhalant toxicoses of cagebirds.
Explore the source record for details and available documents.
Air Pollution, Indoor↗
Correlation between cervical cytologic results and Gram stain as diagnostic tests for bacterial vaginosis.
OBJECTIVE: Our purpose was to determine the reliability of the Papanicolaou smear in making the diagnosis of bacterial vaginosis with the vaginal Gram stain used as the diagnostic standard. STUDY DESIGN: We conducted a prospective, blinded, cross-sectional study of 210 consecutive patients referred to the Colposcopy Clinic for evaluation of abnormal cervical cytologic results. Each patient had a standard Papanicolaou smear and Gram stain of vaginal discharge. The sensitivity, specificity, positive predictive value, and negative predictive value of the Papanicolaou smear were determined with the Gram stain used as the standard for diagnosis of bacterial vaginosis. RESULTS: Of the 210 patients, 80 (38.1%) had Gram stains that were positive for bacterial vaginosis and 118 (56.2%) had negative Gram stains. Twelve (5.7%) had intermediate Gram stains that were also considered negative. Of the 80 patients with positive Gram stains, 44 had cervical smears consistent with bacterial vaginosis and 36 had negative smears. Of the 130 patients with negative Gram stains, two had a positive cervical smear. Therefore, compared to the Gram stain, cervical cytologic test results had a sensitivity of 55% and a specificity of 98%. The respective positive predictive and negative predictive values were 96% and 78%. CONCLUSION: Compared to Gram stain of vaginal secretions, the cervical Papanicolaou smear has fair sensitivity (55%) and excellent positive predictive value (96%) in diagnosing bacterial vaginosis.
Bacteria, Anaerobic↗
The effect of placental removal method on the incidence of postcesarean infections.
OBJECTIVE: Our purpose was to determine whether the incidence of postoperative endometritis and wound infection is associated with the method of placental removal at the time of cesarean section. STUDY DESIGN: Parturients undergoing cesarean delivery were prospectively randomized to have the placenta removed manually or spontaneously. Patients were excluded from participation if they had received intrapartum prophylactic antibiotics or had been determined to have chorioamnionitis. After delivery of the infant women in the manual group had the placenta extracted by the primary surgeon, whereas women in the spontaneous group had the placenta delivered by gentle traction on the umbilical cord. All study subjects received perioperative prophylactic antibiotics. The primary outcome variable was a postcesarean infection, defined as postecsarean endometritis or wound cellulitis requiring drainage and antibiotic therapy. RESULTS: A total of 333 women were enrolled in the investigation, with 165 assigned to the manual removal group and 168 allocated to have spontaneous removal. There were no statistically significant differences in mean gestational age, frequency or duration of ruptured membranes, frequency or duration of labor, or mean number of vaginal examinations between the two study groups. Postoperative infections occurred in 25 of 168 (15%) women in the spontaneous delivery group compared with 44 of 165 (27%) women in which the placenta was manually extracted (relative risk 0.6, 95% confidence interval 0.4 to 0.9, p = 0.01). Subset analysis of patients delivered with ruptured membranes similarly demonstrated a statistically significant reduction in the incidence of postoperative infections with spontaneous placental removal compared with manual extraction (20% vs. 38%, relative risk 0.5, 95% confidence interval 0.3 to 0.9, p = 0.02). There was a similar trend toward a reduction in postdelivery infections associated with spontaneous placental removal in women with intact membranes; however, this difference did not attain statistical significance. CONCLUSIONS: Spontaneous delivery of the placenta after cesarean delivery is associated with a decrease in the incidence of postcesarean infections.
Cesarean Section↗
Statistics for the Residency Review Committee: a clear windows approach.
Because the reporting requirements imposed by the Residency Review Committee (RRC) for Obstetrics and Gynecology have become more extensive, we sought to develop a Microsoft Windows 3.1 (Microsoft Corp., Redmond, WA)-based computer program for maintaining an on-line record of resident surgical experience. Data input for our program occurs in two stages. All residents are responsible for maintaining separate obstetrics and gynecology-primary care statistical booklets. Each booklet consists of individual perforated data sheets. The front of the obstetrics data sheets is a replica of the bottom portion of RRC S Form Obstetrics. The reverse side is a replica of the top half of S Form Obstetrics, listing all "accountable" obstetric procedures, coded by level of operator responsibility. The front of the gynecology data sheet replicates the S Form Primary and Preventive Ambulatory Medicine. The reverse of this sheet is a replica of S Form Gynecology and lists all "accountable" gynecologic procedures, again coded by level of operator responsibility. Residents submit data sheets on a daily basis to the residency program coordinator, who then enters each patient encounter into a user-friendly data base program. Data entry screens are essentially identical to the individual encounter forms, and input requires fewer than 30 seconds per form. Once the individual patient's data is entered on the screen, the computer program automatically updates the resident's cumulative surgical experience and stratifies experience by year of training. At any time, program administrators have on-line access to a comprehensive record of an individual resident's or group of residents' clinical experience.
Gynecology↗
Antibiotic selection in obstetric patients.
Penicillin and ampicillin are valuable antibiotics in obstetrics because of their excellent activity against group A and group B streptococci. In addition, ampicillin is the treatment of choice for enterococcal infections, particularly urinary tract infections. Limited spectrum cephalosporins are of primary value as prophylactic agents. Ceftriaxone, an intermediate spectrum agent, is an excellent drug for treatment of infections caused by N. gonorrhoeae. Extended spectrum cephalosporins, penicillins, and carbapenems provide sufficient coverage against pathogenic organisms to be used as single agents for treatment of polymicrobial infections such as chorioamnionitis and puerperal endometritis. Alternatively, combination regimens such as clindamycin or metronidazole plus an aminoglycoside or aztreonam are also highly effective in this clinical situation. Erythromycin and azithromycin have value primarily for treatment of endocervical chlamydial infections and mycoplasma pneumonia in obstetric patients and for intrapartum prophylaxis against group B streptococcal infection in patients who are allergic to beta-lactam antibiotics.
Anti-Bacterial Agents↗
Premature rupture of the membranes at term.
Explore the source record for details and available documents.
Dinoprostone↗
Risk factors for neonatal sepsis.
OBJECTIVE: To determine the associations between maternal characteristics, intrapartum events, and neonatal sepsis by multivariate analysis. METHODS: We enrolled 823 women from a high-risk population and analyzed maternal and neonatal demographic and outcome variables with univariate analysis and multivariate logistic modeling. RESULTS: Two-hundred sixteen women (26%) were colonized with group B streptococci, 82 (10%) developed chorioamnionitis, and 141 (17%) delivered prematurely. Culture-proven neonatal sepsis or meningitis was found in 15 of 833 (1.8%) neonates, and 101 of the remaining 818 (12.3%) infants were suspected to have sepsis or pneumonia. Multivariate analysis of risk factors for proven neonatal sepsis demonstrated a statistically significant association with decreasing gestational age, duration of internal monitoring for more than 12 hours (odds ratio [OR] 7.2, 95% confidence interval [CI] 1.6-32.2), maternal group B streptococcal infection (OR 4.2, 95% CI 1.4-13.1), chorioamnionitis (OR 4.4, 95% CI 1.2-16.1), and endometritis (OR 6.4, 95% CI 1.2-34.2). CONCLUSION: Through the use of multivariate modeling, we determined that chorioamnionitis or endometritis, preterm delivery, group B streptococcal colonization, and a prolonged duration of internal monitoring are independent risk factors for neonatal sepsis. We postulate that the presence of a foreign body that traverses the birth canal may facilitate ascending peripartal infection.
Confidence Intervals↗
Premature rupture of the membranes in term patients.
Premature rupture of the membranes (PROM) occurs in 5-10% of pregnancies. Approximately 60% of cases are in term patients. Infection of the lower genital tract and/or amniotic cavity is one of the most important etiologies of PROM. The diagnosis is usually established by direct observation of pooling of amniotic fluid in the vaginal vault. In problematic cases, the nitrazine and fern tests can be used to confirm the diagnosis. Term patients with PROM and favorable cervices should undergo induction of labor with oxytocin. Patients with unfavorable cervices probably are best managed by induction of labor with prostaglandin compounds, although, in highly selected cases, expectant management may be considered. During induction of labor, long latent phases should be anticipated, and vaginal examinations should be minimized. Patients should receive prophylactic antibiotics, if indicated, for prevention of group B streptococcal infection and should be observed carefully for early signs of chorioamnionitis.
Cervix Uteri↗
Inhibition of neutrophil oxidative burst and phagocytosis by meconium.
OBJECTIVE: Meconium in amniotic fluid has been associated with an increased prevalence of chorioamnionitis. In an effort to delineate the mechanism of this association, we determined the effect of meconium on the neutrophil's capacity for phagocytosis and microbial killing by oxidative burst in vitro. STUDY DESIGN: Sterile meconium samples were obtained from four fetuses at the time of breech delivery and were then pooled and lyophilized. Neutrophils were purified from whole blood of each of 13 pregnant nonlaboring patients. Phagocytosis and the oxidative burst of neutrophils in the presence and absence of meconium were assessed by single-cell analysis with flow cytometry. Phagocytosis was measured as the mean fluorescence intensity produced after 30 minutes of incubation with fluorescein-labeled Escherichia coli. Oxidative burst was measured as the mean fluorescence intensity resulting from the oxidation of internalized reduced dichlorodihydrofluorescein after 15 minutes of stimulation with phorbol myristate acetate. Oxidative burst was expressed as the neutrophil oxidative index and the net fluorescence intensity. Neutrophil oxidative index was equivalent to the quotient of the mean fluorescence intensity for phorbol myristate acetate-stimulated and unstimulated cells. Net fluorescence intensity was equivalent to the absolute difference between stimulated and unstimulated cells. RESULTS: Exposure of neutrophils to light and very light meconium each resulted in significantly lower mean neutrophil oxidative index compared with unexposed controls (3.2 +/- 4.9 and 4.2 +/- 5.9 vs 16.2 +/- 7.5, p = 0.00002 and p = 0.0007, respectively) and significantly lower mean net fluorescence intensity than that of control cells (112 +/- 220 and 188 +/- 294 vs 613 +/- 328, p = 0.0001 and p = 0.005, respectively). Phagocytosis was significantly impaired in the presence of moderate meconium compared with control cells (2239 +/- 393 vs 4645 +/- 2071, p = 0.0001). Light meconium did not significantly affect phagocytosis. CONCLUSION: Meconium has significant effects on neutrophil function in vitro. Both light and very light meconium inhibit the oxidative burst. Moderate meconium inhibits phagocytosis.
Chorioamnionitis↗
Development of a guidebook for senior students applying for residency training in obstetrics and gynecology.
This article describes a detailed residency guidebook that I developed over the course of 4 years based on interaction with 42 student advisees. Questions most frequently asked by the students were recorded, and comprehensive written responses were prepared that addressed their specific concerns. The completed guidebook contains several major sections. The introductory portion provides a general description of the discipline of obstetrics and gynecology, outlines the format of residency training programs, and assesses the competitiveness of residencies in obstetrics and gynecology compared with other disciplines. The second section lists deadlines for completing various tasks, such as selecting an adviser, planning the senior curriculum, requesting and submitting applications, preparing the curriculum vitae and personal statement, and soliciting letters of recommendation. The next section of the guidebook provides suggestions for the senior curriculum and specifically addresses the issue of "audition electives" in obstetrics and gynecology. The next two sections present formats for the student's personal statement and curriculum vitae. Next, guidelines for requesting letters of recommendation are presented. Thereafter, information is provided to help students determine the number of applications they should submit, and training programs targeted by the student are classified by size, type, and competitiveness. Finally, the guidebook addresses questions related to scheduling and preparing for interviews.
Gynecology↗
Performance of a new DNA probe for the detection of group B streptococcal colonization of the genital tract.
OBJECTIVE: To test the performance characteristics of a new DNA probe designed for the rapid identification of heavy colonization of the genital tract with group B streptococci. METHODS: Vaginal and combined vaginal-perianal samples were collected from 193 pregnant women and cultured on colistin-nalidixic acid agar plates. Bacterial growth was classified semiquantitatively. Specimens were also tested by a new DNA probe in two formats: a direct assay performed on the swabs soon after collection and an assay performed after the swabs were incubated for 24 hours in an enriched culture medium. RESULTS: The agar cultures were positive in 36 of 193 patients (18.6%, 95% confidence interval 13.2-24). Nineteen women were lightly colonized, and 17 were heavily colonized (at least 10(4) colonies/mL). The combined vaginal-perianal swabs yielded positive results more often than the vaginal swabs alone (26 versus 16, chi 2 = 24, P < .01). In its direct form, the assay had only 8.3% sensitivity in identifying colonized women. In heavily colonized women, the sensitivity of the assay increased slightly to 12%. After a 16-24-hour incubation, the sensitivity of the assay was 81%. CONCLUSION: The direct assay is insufficiently sensitive for clinical use. The delayed assay offers no advantage over standard cultures.
DNA Probes↗
Acute hypotension related to sepsis in the obstetric patient.
While infections are a common complication of pregnancy, bacteremia and septic shock are relatively rare. Efforts to prevent serious bacterial infections are the most effective means of minimizing maternal and fetal morbidity. Screening for first trimester asymptomatic bacteriuria, prompt and thorough evaluation of suspected bacterial infections, and conscientious intrapartum assessment can have a significant impact in decreasing localized bacterial infections. The prompt recognition and institution of antimicrobial therapy in women suspected of having systemic infections is of paramount importance in reducing the incidence of serious maternal morbidity and mortality. Initial efforts in the treatment of sepsis should be directed at intravascular volume expansion in an effort to improve myocardial performance and tissue oxygenation. Inotropic agents occasionally may be necessary; however, they should be used with caution and only after adequate volume expansion has been provided. Adequate antimicrobial therapy requires treatment with multiagent therapy, providing coverage for the wide variety of genital tract pathogens.
Acute Disease↗
The frequency of glove contamination during cesarean delivery.
OBJECTIVE: To determine the frequency of glove contamination associated with fetal extraction during cesarean delivery. METHODS: The study was performed in 25 women having scheduled or unscheduled cesarean delivery. Surgeons double-gloved for all procedures. Immediately before and after delivery of the fetus, the dorsal aspect of the fingers and hand of the surgeon's outer glove was swabbed with cotton-tip applicators and cultured for aerobic and anaerobic organisms. Only the glove from the hand that was used to deliver the infant was cultured. RESULTS: Nine of 25 cultures (36%, 95% confidence interval [CI] 17-55) performed immediately before fetal extraction were positive for staphylococci. No other organisms were isolated. Cultures performed following fetal extraction showed non-staphylococcal bacteria in 11 of 14 (79%, 95% CI 58-100) laboring women and one of 11 (9%, 95% CI 0-26) nonlaboring women, a statistically significant difference (P < .01). In the laboring patients, non-staphylococcal bacteria were isolated with similar frequency from the dorsal aspect of the hand (seven of 14, 50%, 95% CI 24-76) and the fingers (ten of 14, 71%, 95% CI 47-95). These cultures yielded mostly bacterial species from the Enterobacteriaceae family. CONCLUSION: In laboring patients with ruptured membranes, delivery of the fetal head frequently results in contamination of the surgeon's glove with pathogenic bacteria. This finding may partially explain the increased frequency of post-cesarean endometritis associated with manual extraction of the placenta.
Bacteria↗
Peripartum infection associated with vaginal group B streptococcal colonization.
OBJECTIVE: To determine the frequency of peripartum infection in parturients colonized with group B streptococci. METHODS: We screened 915 obstetric patients for group B streptococcal colonization using selective broth media; 823 had vaginal cultures performed within 2 weeks preceding delivery and received complete follow-up. Vaginal group B streptococcal colonization and other risk factors for peripartum maternal infection were assessed using univariate and multivariate logistic modeling. RESULTS: Two hundred sixteen women (26%, 95% confidence interval [CI] 23-29) were colonized with group B streptococci. Chorioamnionitis or endometritis occurred in 45 of 216 colonized women (21%, 95% CI 15.6-26.4) and 72 of 607 women who were not colonized (12%, 95% CI 9-15; P < .01). When confounding variables were controlled in a multivariate analysis, the association between group B streptococcal colonization and chorioamnionitis, but not endometritis, was confirmed (odds ratio 3.6, 95% CI 2.1-6.2). The risk of chorioamnionitis increased in a stepwise fashion with light (odds ratio 1.9, 95% CI 1.0-3.7), moderate (odds ratio 2.6, 95% CI 1.3-5.2), and heavy (odds ratio 3.2, 95% CI 1.5-6.6) colonization. CONCLUSION: Intrapartum vaginal colonization with group B streptococci is an important independent risk factor for chorioamnionitis.
Chorioamnionitis↗
Recurrence of Treacher Collins' syndrome with sonographic findings.
Treacher Collins' syndrome, or mandibulofacial dysostosis, is a rare, autosomal-dominant disorder. We describe the recurrence of this anomaly in the fetus of a patient who previously had delivered a severely affected infant. The ultrasonographic findings of hydramnios, absence of fetal swallowing movements, and poor growth of the biparietal diameter and head circumference permitted us to suggest the diagnosis antenatally of another affected child.
Adult↗
An analysis of the cost-effectiveness of selected protocols for the prevention of neonatal group B streptococcal infection.
OBJECTIVE: To determine the expected neonatal outcome in a hypothetical obstetric population with various screening and intrapartum management protocols for the prevention of neonatal group B streptococcal infections. METHODS: We used decision analysis to investigate the performance of various antenatal and intrapartum group B streptococcal screening protocols combined with selective or universal intrapartum antibiotic prophylaxis in preventing neonatal early-onset group B streptococcal disease. Population characteristics, screening test performance, and treatment efficacy profiles were abstracted from previous investigations. RESULTS: In the absence of screening or treatment, the estimated neonatal attack rate and mortality rate were 3.6 and 0.60 cases per 1000 neonates, respectively. Universal antenatal screening at 26-28 weeks' gestation and selective intrapartum prophylaxis (treatment of colonized women with risk factors) or nonselective prophylaxis (treatment of all colonized women) had attack rates of 1.64 and 1.08 and mortality rates of 0.21 and 0.18 cases per 1000 neonates, respectively. Rapid intrapartum screening and selective prophylaxis had an estimated attack rate of 1.92-2.58 and a mortality rate of 0.26-0.40 cases per 1000 neonates, with results dependent upon the time required to attain test results. Similarly, rapid intrapartum screening and nonselective prophylaxis had an attack rate of 1.44-2.30 and a mortality rate of 0.24-0.38 cases per 1000 neonates. Empirical prophylaxis of all women delivering prematurely, regardless of culture status, had an attack rate of 2.40 and mortality rate of 0.36 cases per 1000 neonates. CONCLUSIONS: Under ideal circumstances, antenatal group B streptococcal screening at 26-28 weeks' gestation with vaginal-rectal cultures and subsequent intrapartum prophylaxis is associated with lower projected neonatal attack and mortality rates than protocols using rapid intrapartum screening methods. However, in a non-research population, difficulties frequently encountered with antenatal screening procedures may minimize these differences.
Clinical Protocols↗
An orientation program for new residents in obstetrics and gynecology.
OBJECTIVE: To describe a comprehensive orientation program for new medical school graduates beginning residency training in obstetrics and gynecology. METHODS: A three-phase orientation program was developed and administered over 5 days before the start of formal residency training. The first phase provided instruction in basic cardiac life support and neonatal resuscitation. In the second phase, a mini-core curriculum was presented through interactive small-group seminars. Seminar topics included prenatal care, fetal heart rate monitoring, labor and vaginal delivery, cesarean delivery, intrapartum and puerperal infection, antibiotic selection, ectopic pregnancy, and pelvic inflammatory disease. In the final phase of the program, the new graduates participated in five practical exercises designed to teach basic examination and surgical techniques. RESULTS: Two groups of five new graduates completed the orientation program. All rated the program as excellent and recommended that it be made a permanent part of the curriculum. The overall cost of the program was less than $300 per trainee. CONCLUSION: A comprehensive orientation program emphasizing acquisition of practical clinical and surgical skills was successful in facilitating the transition from medical school to residency training in obstetrics and gynecology.
Curriculum↗