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Obstetrician & Gynecologist (OB/GYN)
34 years of experience
Accepting new patients

Credentials

Education ?

Medical School Score
Saint Louis University (1978)
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Awards & Distinctions ?

Awards  
One of America's Leading Experts on:
Pregnancy Complications (Infectious)
Syphilis
Syphilis (Congenital Syphilis)
Associations
American Congress of Obstetricians and Gynecologists
American Board of Obstetrics and Gynecology

Affiliations ?

Dr. Wendel is affiliated with 9 hospitals.

Hospital Affiliations

Score

Rankings

  • UT Southwestern University Hospital - Zale Lipshy
    5151 Harry Hines Blvd, Dallas, TX 75235
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    Top 25%
  • UT Southwestern University Hospital - St. Paul
    5909 Harry Hines Blvd, Dallas, TX 75235
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    Top 25%
  • Parkland Health & Hospital System
    5201 Harry Hines Blvd, Dallas, TX 75235
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  • Dallas County Hospital District
  • Parkland Hospital
  • UT Southwestern Zale Lipshy Hospital
  • UT Southwestern Medical Center at Dallas
  • St Paul Med Ctr
  • UT Southwestern St Paul Hospital
  • Publications & Research

    Dr. Wendel has contributed to 102 publications.
    Title Maternal Human Immunodeficiency Virus Infection and Congenital Transmission of Cytomegalovirus.
    Date February 2011
    Journal The Pediatric Infectious Disease Journal
    Excerpt

    To determine the frequency of congenital cytomegalovirus (CMV) infection in infants born to human immunodeficiency virus (HIV)-infected mothers and assess risk factors that may facilitate intrauterine transmission of CMV, including the role of perinatal HIV infection.

    Title Jarisch-herxheimer Reaction Triggered by Group B Streptococcus Intrapartum Antibiotic Prophylaxis.
    Date August 2010
    Journal Obstetrics and Gynecology
    Excerpt

    The Jarisch-Herxheimer reaction is an acute systemic event that can occur during the treatment of spirochetal infections. During pregnancy, it can cause signs and symptoms in both the mother and fetus, including fever, tachycardia, uterine contractions, and fetal heart rate pattern changes.

    Title Effectiveness of an Instructional Dvd on Third- and Fourth-degree Laceration Repair for Obstetrics and Gynecology Postgraduate Trainees.
    Date May 2010
    Journal International Journal of Gynaecology and Obstetrics: the Official Organ of the International Federation of Gynaecology and Obstetrics
    Excerpt

    To assess the effectiveness of an instructional DVD on the anatomy and repair of anal sphincter lacerations to improve postgraduate trainees' understanding.

    Title Presentation of Seasonal Influenza A in Pregnancy: 2003-2004 Influenza Season.
    Date May 2010
    Journal Obstetrics and Gynecology
    Excerpt

    To describe the clinical course of influenza in pregnant women followed at our institution during the 2003-2004 influenza season.

    Title Maternal and Neonatal Outcomes After Antepartum Treatment of Influenza with Antiviral Medications.
    Date May 2010
    Journal Obstetrics and Gynecology
    Excerpt

    To review the maternal and neonatal outcomes after antepartum exposure to M2 ion channel inhibitors or oseltamivir to provide some guidance on the risk, if any, of antiviral medication during pregnancy.

    Title The Effect of Progesterone Levels and Pregnancy on Hiv-1 Coreceptor Expression.
    Date March 2009
    Journal Reproductive Sciences (thousand Oaks, Calif.)
    Excerpt

    The upregulation of HIV-1 co-receptor expression during certain clinical settings may explain the predisposition of individuals to enhanced HIV-1 acquisition. We sought to determine the effect of estrogen and progesterone on the HIV-1 coreceptors, CCR5 and CXCR4. Co-receptor expression on CD3- and CD14-positive cells obtained systemically and locally (genital tissue in women) was determined in men, pre- and post-menopausal women, pregnant women in each trimester and in labor. CCR5 on both CD3- and CD14-positive cells was highest in pregnant women, and increased as gestation advanced ( P < .01 and P < .001, respectively). Progesterone levels were significantly associated with CCR5 expression on PBMCs ( P < .03 for CD3-positive, and P < .002 for CD14-positive cells) and from cells isolated from tissue ( P < .001).CCR5 mRNA expression correlated with the cell surface marker expression from blood and tissue. These findings suggest that pregnancy and other high progesterone states may predispose women to HIV-1 acquisition.

    Title Ampicillin Resistance and Outcome Differences in Acute Antepartum Pyelonephritis.
    Date November 2008
    Journal Infectious Diseases in Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To measure the incidence of ampicillin-resistant uropathogens in acute antepartum pyelonephritis and to determine if patients with resistant organisms had different clinical outcomes. STUDY DESIGN: This was a secondary analysis of a prospective cohort study of pregnant women admitted with pyelonephritis, diagnosed by standard clinical and laboratory criteria. All patients received ampicillin and gentamicin. RESULTS: We identified 440 cases of acute pyelonephritis. Seventy-two percent (316 cases) had urine cultures with identification of organism and antibiotic sensitivities. Fifty-one percent of uropathogens were ampicillin resistant. The patients with ampicillin-resistant organisms were more likely to be older and multiparous. There were no significant differences in hospital course (length of stay, days of antibiotics, ECU admission, or readmission). Patients with ampicillin-resistant organisms did not have higher complication rates (anemia, renal dysfunction, respiratory insufficiency, or preterm birth). CONCLUSION: A majority of uropathogens were ampicillin resistant, but no differences in outcomes were observed in these patients.

    Title Third Trimester Antiviral Prophylaxis for Preventing Maternal Genital Herpes Simplex Virus (hsv) Recurrences and Neonatal Infection.
    Date April 2008
    Journal Cochrane Database of Systematic Reviews (online)
    Excerpt

    BACKGROUND: Genital herpes simplex virus (HSV) infection is one of the most common viral sexually transmitted infections. The majority of women with genital herpes will have a recurrence during pregnancy. Transmission of the virus from mother to fetus typically occurs by direct contact with virus in the genital tract during birth. OBJECTIVES: To assess the effectiveness of antenatal antiviral prophylaxis for recurrent genital herpes on neonatal herpes and maternal recurrences at delivery. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 4), MEDLINE (January 1966 to February 2007) and EMBASE (January 1974 to February 2007; handsearched conference proceedings; reviewed bibliographies of all relevant articles for further references; and contacted experts in the field. SELECTION CRITERIA: Randomized controlled trials which assessed the effectiveness of antivirals compared to placebo or no therapy, on neonatal herpes and maternal disease endpoints among pregnant women with genital herpes. DATA COLLECTION AND ANALYSIS: Two authors independently applied study selection criteria and extracted data. MAIN RESULTS: Seven randomized controlled trials (1249 participants) which met our inclusion criteria compared acyclovir to placebo or no treatment (five trials) and valacyclovir to placebo (two trials). The effect of antepartum antiviral prophylaxis on neonatal herpes could not be estimated. There were no cases of symptomatic neonatal herpes in the included studies in either the treatment or placebo groups. Women who received antiviral prophylaxis were significantly less likely to have a recurrence of genital herpes at delivery (relative risk (RR) 0.28, 95% confidence interval (CI) 0.18 to 0.43, I(2 )= 0%). Women who received antiviral prophylaxis were also significantly less likely to have a cesarean delivery for genital herpes (RR 0.30, 95% CI 0.20 to 0.45, I(2) = 27.3%). Women who received antiviral prophylaxis were significantly less likely to have HSV detected at delivery (RR 0.14, 95% CI 0.05 to 0.39, I(2) = 0%). AUTHORS' CONCLUSIONS: Women with recurrent genital herpes simplex virus should be informed that the risk of neonatal herpes is low. There is insufficient evidence to determine if antiviral prophylaxis reduces the incidence of neonatal herpes. Antenatal antiviral prophylaxis reduces viral shedding and recurrences at delivery and reduces the need for cesarean delivery for genital herpes. Limited information exists regarding the neonatal safety of prophylaxis. The risks, benefits, and alternatives to antenatal prophylaxis should be discussed with women who have a history and prophylaxis initiated for women who desire intervention.

    Title Effect of Genital Ulcer Disease on Hiv-1 Coreceptor Expression in the Female Genital Tract.
    Date January 2008
    Journal The Journal of Infectious Diseases
    Excerpt

    OBJECTIVE: To examine the expression of human immunodeficiency virus type 1 (HIV-1) coreceptors (CCR5 and CXCR4) by monocytic cells within human genital ulcers. METHODS: Women with primary or secondary syphilis, herpes simplex virus type 1 (HSV-1) or HSV-2 infection, or noninfectious abrasions had a biopsy sample taken from the lesion and contralateral vulva. HIV-1 coreceptor expression on CD3(+) and CD14(+) cells was analyzed by flow cytometry. Real-time reverse-transcriptase polymerase chain reaction was used to assess levels of coreceptor mRNA expression. RESULTS: Women with primary or secondary syphilis or with HSV-1 or HSV-2 infection had significantly increased numbers of CD14(+) cells expressing CCR5 within the genital ulcer. This increase was also noted in the nonulcerated tissue isolated from women with syphilis and in peripheral blood mononuclear cells from women with secondary syphilis. CCR5 mRNA expression was increased in tissue obtained from syphilis lesions. CONCLUSIONS: Monocytes recruited to genital ulcer disease (GUD) sites express increased levels of CCR5. This increased expression could account, at least in part, for enhanced HIV-1 transmission in the setting of GUD.

    Title The Incidence of Neonatal Herpes Infection.
    Date May 2007
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The incidence of perinatal transmission of neonatal herpes infection has recently been reported at 1 in 3200 births. The main objective of this study was to determine a population-based incidence of neonatal herpes simplex virus infection. STUDY DESIGN: This was a retrospective chart review of newborn infants presenting with herpes infection established by cerebrospinal fluid polymerase chain reaction or lesion culture between 1999 and 2003. Only infants delivered at our institution were considered to establish a population-based incidence. RESULTS: Four cases of neonatal herpes infection were identified based on polymerase chain reaction and culture diagnosis. During the study period 78,115 infants were delivered at our institution yielding an incidence of 1 in 20,000 live births. CONCLUSION: The incidence of neonatal herpes infection at our institution is lower than reported elsewhere. A national surveillance program of neonatal herpes is needed to measure the burden of disease across the United States.

    Title Recurrence of Clinical Chorioamnionitis in Subsequent Pregnancies.
    Date January 2007
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To establish the role of clinical chorioamnionitis as an independent risk factor for recurrence in a subsequent pregnancy. METHOD: This was a historical cohort study of pregnant women who had their first and second deliveries at our institution between January 1988 and May 2005. The index pregnancy was restricted to those who delivered vaginally. Data were collected from a continuously updated obstetric database and included demographic and labor characteristics and neonatal outcomes. Chorioamnionitis was diagnosed clinically. RESULTS: The study population consisted of 23,397 women. During the index pregnancy, 10% of women developed chorioamnionitis. This group was significantly different from the rest of the cohort in terms of age, ethnicity, length of labor, epidural analgesia, use of internal monitors, and incidence of prolonged rupture of membranes. In the second pregnancy, 6% of those women again developed chorioamnionitis compared with 2% of women who did not have chorioamnionitis in the first pregnancy (odds ratio 2.93, 95% confidence interval 2.40-3.57). After adjusting for the above confounders, the increased risk of recurrence persisted (odds ratio 1.85, 95% confidence interval 1.49-2.30). CONCLUSION: Women delivering vaginally who were diagnosed with chorioamnionitis during their first pregnancy are at increased risk for chorioamnionitis in a subsequent pregnancy. This supports the concept that there may be a predisposition to chorioamnionitis that should be further investigated. LEVEL OF EVIDENCE: II-2.

    Title A Comparison of an Interactive Computer-based Method with a Conventional Reading Approach for Learning Pelvic Anatomy.
    Date December 2006
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: This study was undertaken to assess the impact of interactive, computer-based versus conventional, paper-based format in student, resident, and fellow learning and retention of anatomy knowledge. STUDY DESIGN: Randomized longitudinal cohort design with scores repeated as pre-, post-, and follow-up tests. Subjects were randomly assigned to an anatomy module in computer-based (CD-ROM) format and 1 in paper-based format. A follow-up examination was administered 3 weeks after the posttest to evaluate retention of knowledge. Tests results were analyzed by using Student t tests and analysis of variance. RESULTS: Thirty-nine subjects completed all testing. Regardless of instructional method, pretest to posttest scores improved (P < .01), and posttest to follow-up test scores decreased among all levels of training (P < .01). Student satisfaction was highest with CD-ROM format. CONCLUSION: Improvement and retention of anatomy knowledge was not significantly different when comparing a new CD-ROM interactive approach with a traditional paper-based method.

    Title Valacyclovir Prophylaxis to Prevent Recurrent Herpes at Delivery: a Randomized Clinical Trial.
    Date August 2006
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To measure the efficacy of valacyclovir suppression in late pregnancy to reduce the incidence of recurrent genital herpes in labor and subsequent cesarean delivery. METHODS: A total of 350 pregnant women with a history of genital herpes were assigned randomly to oral valacyclovir 500 mg twice a day or an identical placebo from 36 weeks of gestation until delivery. In labor, vulvovaginal herpes simplex virus (HSV) culture and polymerase chain reaction (PCR) specimens were collected. Vaginal delivery was permitted if no clinical recurrence or prodromal symptoms were present. Neonatal HSV cultures and laboratory tests were obtained, and infants were followed up for 1 month after delivery. Data were analyzed using chi2 and Student t tests. RESULTS: One hundred seventy women treated with valacyclovir and 168 women treated with placebo were evaluated. Eighty-two percent of the women had recurrent genital herpes; 12% had first episode, nonprimary genital herpes; and 6% had first episode, primary genital herpes. At delivery, 28 women (8%) had recurrent genital herpes requiring cesarean delivery: 4% in the valacyclovir group and 13% in the placebo group (P = .009). Herpes simplex virus was detected by culture in 2% of the valacyclovir group and 9% [corrected] of the placebo group (P =.02). No infants were diagnosed with neonatal HSV, and there were no significant differences in neonatal complications. There were no significant differences in maternal or obstetric complications in either group. CONCLUSION: Valacyclovir suppression after 36 weeks of gestation significantly reduces HSV shedding and recurrent genital herpes requiring cesarean delivery. LEVEL OF EVIDENCE: I.

    Title Cost-effectiveness of Universal Influenza Vaccination in a Pregnant Population.
    Date July 2006
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The purpose of this study was to estimate whether universal influenza vaccination of pregnant women was cost-effective in the management of influenza-like illness during influenza season. METHODS: A decision analysis model was developed to investigate the cost-effectiveness of providing inactivated trivalent influenza vaccine to all pregnant women. This scenario was compared with providing supportive care only on a case-by-case basis to the unvaccinated pregnant population. RESULTS: Vaccination of 100% of pregnant women would save approximately 50 dollars per woman, resulting in a net gain of approximately 45 quality-adjusted hours relative to providing supportive care only. CONCLUSION: Universal vaccination with inactivated trivalent influenza vaccine is cost-saving relative to providing supportive care alone in the pregnant population. LEVEL OF EVIDENCE: III.

    Title Effect of Protease Inhibitor Therapy on Glucose Intolerance in Pregnancy.
    Date June 2006
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To determine if protease inhibitor use was associated with increased glucose intolerance in our population of pregnant women infected with the human immunodeficiency virus (HIV). METHODS: Women who were infected with HIV from January 1, 1998, to January 8, 2004, and who had a 1-hour and 3-hour glucola test were identified. Medical records were reviewed to obtain demographic characteristics and obstetric and laboratory data. Drug regimens at the time of glucola testing were determined. Human immunodeficiency virus-infected women were then matched 1:3 to HIV-noninfected gravidas by race, age, and year of delivery. RESULTS: One hundred seventy-one HIV-infected women had glucola results available. Twelve percent had an abnormal 1-hour glucola result and 3% had an abnormal 3-hour result. This was similar to the HIV-noninfected population. Forty-five percent of the HIV-infected cohort was on a protease inhibitor at the time of glucola testing. Protease inhibitor exposure had no effect on glucola test results. HIV infection itself also did not increase abnormal glucola test results. CONCLUSION: Glucose intolerance in this obstetric population was not associated with the diagnosis of HIV or with the use of protease inhibitors. Protease inhibitors should continue to be an option for the treatment of HIV in pregnancy.

    Title Postpartum Sterilization Choices Made by Hiv-infected Women.
    Date February 2006
    Journal Infectious Diseases in Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To assess if HIV-infected women made different choices for postpartum sterilization after implementation of the Pediatric AIDS Clinical Trials Group protocol 076 (November 1, 1994) compared to before implementation. STUDY DESIGN: A retrospective cohort study in which medical records were reviewed to obtain demographic, obstetric and HIV-related data from January 1993 through December 2002. HIV-infected women who completed a pregnancy by birth or abortion were divided into two comparison groups: "Pre-076" and "Post-076". The primary outcome was sterilization by postpartum tubal ligation.Results. Forty-two women (74%) in the Pre-076 group chose sterilization compared to 139 of 310 women (45%) in the Post-076 group (unadjusted OR 3.44, 95% CI 1.83, 6.47). Seventy-one percent of women younger than 21 years of age in the Pre-076 Group chose sterilization compared with only 35% of women younger than 21 years in the Post-076 group (p = 0.0136). Similarly, 78% of primiparous women chose sterilization after their first pregnancy in the Pre-076 group, compared to 14% in the Post-076 group (p < 0.001). CONCLUSIONS: Since the implementation of PACTG 076 protocol in November 1994, fewer HIV-infected women chose postpartum sterilization. The typical woman who now chooses postpartum sterilization is less likely to be young or primiparous than those who chose sterilization before PACTG Protocol 076 implementation.

    Title Clinical Presentation of Community-acquired Methicillin-resistant Staphylococcus Aureus in Pregnancy.
    Date November 2005
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The objective of this study was to review the presentation and management of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) in pregnant women. METHODS: This was a chart review of pregnant patients who were diagnosed with MRSA between January 1, 2000, and July 30, 2004. Data collected included demographic characteristics, clinical presentation, culture results, and pathogen susceptibilities. Patients' pregnancy outcomes were compared with the general obstetric population during the study period. RESULTS: Fifty-seven charts were available for review. There were 2 cases in 2000, 4 in 2001, 11 in 2002, 23 in 2003, and 17 through July of 2004. Comorbid conditions included human immunodeficiency virus and acquired immunodeficiency syndrome (13%), asthma (11%), and diabetes (9%). Diagnostic culture was most commonly obtained in the second trimester (46%); however 18% of cases occurred in the postpartum period. Skin and soft tissue infections accounted for 96% of cases. The most common site for a lesion was the extremities (44%), followed by the buttocks (25%), and breast (mastitis) (23%). Fifty-eight percent of patients had recurrent episodes. Sixty-three percent of patients required inpatient treatment. All MRSA isolates were sensitive to trimethoprim-sulfamethoxazole, vancomycin, and rifampin. Other antibiotics to which the isolates were susceptible included gentamicin (98%) and levofloxacin (84%). In comparison with the general obstetric population, patients with MRSA were more likely to be multiparous and to have had a cesarean delivery. CONCLUSION: Community-acquired MRSA is an emerging problem in our obstetric population. Most commonly, it presents as a skin or soft tissue infection that involves multiple sites. Recurrent skin abscesses during pregnancy should raise prompt investigation for MRSA. LEVEL OF EVIDENCE: II-3.

    Title Prevalence of Hepatitis B and C in Pregnant Women Who Are Infected with Human Immunodeficiency Virus.
    Date October 2005
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The purpose of this study was to evaluate the prevalence of hepatitis B and hepatitis C virus co-infection among pregnant women who are infected by human immunodeficiency virus and who attend an obstetric complications prenatal clinic. STUDY DESIGN: A de-identified research obstetric human immunodeficiency virus database was reviewed regarding patient demographic characteristics, risk factors for infection, history of sexually transmitted diseases, and initial CD4 count. RESULTS: Four hundred fifty-five women who are infected with human immunodeficiency virus with 572 pregnancies were delivered over 11 years. The overall prevalence of human immunodeficiency virus and hepatitis B or C virus co-infection in our population was 6.3%. More specifically, 1.5% was co-infected with hepatitis B virus, and 4.9% was co-infected with hepatitis C virus. Patients with hepatitis virus were more likely to use intravenous drugs (52% vs 18%; P < .01) and alcohol (38% vs 5%; P < .01). Co-infected patients were older (28 vs 25.6 years; P=.04), but there were no racial differences. Median baseline CD4 counts in hepatitis B virus co-infected patients were significantly lower (310 cells/mm3) than those in either hepatitis C virus co-infected patients (453 cells/mm3) or patients who were not co-infected with human immunodeficiency virus (414 cells/mm3). CONCLUSION: One of 16 pregnant women who were infected with human immunodeficiency virus was co-infected with hepatitis B or hepatitis C virus. Hepatitis B co-infections appear to be associated with more compromised immune status in our cohort.

    Title Transplacental Passage of Vancomycin in the Ex Vivo Human Perfusion Model.
    Date March 2005
    Journal Infectious Diseases in Obstetrics and Gynecology
    Excerpt

    OBJECTIVES: To determine maternal-fetal transplacental passage of vancomycin in the ex vivo human placental perfusion model. METHODS: Six term placentas were collected immediately after delivery and perfused with physiologic medium using the single cotyledon perfusion system. Vancomycin was added to the maternal medium and perfused through the maternal circulation of the cotyledon. Over a 1-h period in an open system, samples of the perfusate were collected at defined intervals from the fetal venous catheter and from the maternal effluence to assess vancomycin transfer. Thereafter, the system was closed for 1-5 h to establish accumulation. Transport fraction and clearance indexes were calculated by perfusing antipyrine 14C (positive control). Vancomycin was estimated by high pressure liquid chromatography and antipyrine 14C concentration was determined by liquid scintillation. RESULTS: Mean vancomycin maternal peak and trough concentrations ranged from 30.0 to 51.5 microg/ml and 7.7 to 16.4 microg/ml, respectively. Clearance indexes were minimal with a mean peak range of 0.000-0.080 and a mean trough range of 0.00-0.17. For each placenta, transport fraction for antipyrine 14C was > 1.85 with a single pass of > 40%. No accumulation of vancomycin was noted when the system was closed for 1-5 h. The mean peak clearance index was zero after perfusing the placenta for up to 5 h with 35.8 microg/ml of vancomycin. CONCLUSION: Transplacental passage of vancomycin was minimal in the ex vivo human placental perfusion model, with no detectable accumulation.

    Title False Positive Results for the Auszyme Monoclonal Test.
    Date March 2005
    Journal Obstetrics and Gynecology
    Title Acute Pyelonephritis in Pregnancy.
    Date February 2005
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To examine the incidence of pyelonephritis and the incidence of risk factors, microbial pathogens, and obstetric complications in women with acute antepartum pyelonephritis. METHODS: For 2 years, information on pregnant women with acute pyelonephritis was collected in a longitudinal study. All women were admitted to the hospital and treated with intravenous antimicrobial agents. We compared the pregnancy outcomes of these women with those of the general obstetric population received at our hospital during the same time period. RESULTS: Four hundred forty cases of acute antepartum pyelonephritis were identified during the study period (incidence 1.4%). Although there were no significant differences in ethnicity, pyelonephritis was associated with nulliparity (44% versus 37%, P = .003) and young age (P = .003). Thirteen percent of the women had a known risk factor for pyelonephritis. Acute pyelonephritis occurred more often in the second trimester (53%), and the predominant uropathogens were Escherichia coli (70%) and gram-positive organisms, including group B beta Streptococcus (10%). Complications included anemia (23%), septicemia (17%), transient renal dysfunction (2%), and pulmonary insufficiency (7%). CONCLUSION: The incidence of pyelonephritis has remained low in the era of routine prenatal screening for asymptomatic bacteriuria. First-trimester pyelonephritis accounts for over 1 in 5 antepartum cases. Gram-positive uropathogens are found more commonly as pregnancy progresses. Maternal complications continue, but poor obstetrical outcomes are rare.

    Title Cost-effectiveness of Herpes Simplex Virus Type 2 Serologic Testing and Antiviral Therapy in Pregnancy.
    Date January 2005
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The purpose of this study was to determine whether serologic testing for herpes simplex virus type 2 (HSV-2) in pregnant women and their partners is cost-effective. STUDY DESIGN: A decision analysis model was developed to investigate the cost-effectiveness of providing type-specific serologic testing at week 15 of pregnancy for all women unaware of their HSV-2 status, and offering antiviral suppressive therapy from week 36 until delivery to all seropositive women. This scenario was compared with current care, in which only a minority of women diagnosed with genital herpes (GH) receives antiviral suppressive therapy (AST). In a third scenario, testing is offered to partners of pregnant women who test seronegative, and antiviral suppressive therapy is offered to the partners who test seropositive. RESULTS: Compared with current care, offering testing and antiviral suppressive therapy to 100,000 pregnant women resulted in an incremental cost of $3.1 million, 15.7 fewer cases of neonatal herpes, 186 fewer cesarean deliveries, and an incremental cost per quality-adjusted life- year gained (QALY) of $18,680. Offering testing and suppressive therapy to both the pregnant women and their partners resulted in an increased cost of $8.6 million, 16.8 fewer cases of neonatal herpes, 192 fewer cesarean deliveries, and an incremental cost per QALY of $48,946 compared with no testing. CONCLUSION: Compared with commonly accepted benchmarks for cost-effectiveness (<$50,000/QALY), type-specific HSV-2 serologic testing of pregnant women may be a cost-effective strategy.

    Title Morbidity That is Associated with Curettage for the Management of Spontaneous and Induced Abortion in Women Who Are Infected with Hiv.
    Date November 2004
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The purpose of this study was to determine the morbidity that is associated with curettage for the management of abortions in women who were infected with human immunodeficiency virus compared with women who were not infected with human immunodeficiency virus. STUDY DESIGN: Women who were infected with human immunodeficiency virus (cases) and who underwent curettage for the management of scheduled and unscheduled abortions in the first half of pregnancy between January 1, 1993, and December 31, 2002, were identified. Women who were not infected with human immunodeficiency virus (control subjects) were matched 3:1 to cases for gestational age, type of abortion, and year of procedure. Medical records were reviewed to obtain demographic characteristics, gestational age, abortion characteristics, and procedure-related complications. Chi-squared test, Student t test, and Wilcoxon rank-sum test were used to determine statistical significance. RESULTS: Seventy-one women who were infected with human immunodeficiency virus (cases) and 213 women who were not infected with human immunodeficiency virus (control subjects) who underwent curettage during the study period were evaluated. Forty-eight cases (68%) and 146 control subjects (69%) underwent a scheduled curettage. Twenty-three cases (32%) and 66 control subjects (31%) underwent an unscheduled curettage for spontaneous or incomplete abortion. No significant differences were seen in age, gravidity, or parity. There were significantly more black women in the HIV-infected cohort (P < .001), which was representative of our human immunodeficiency virus population. The mean gestational age in the cases was greater than in the control subjects (10.9 +/- 4.2 weeks of gestation vs 9.2 +/- 3.1 weeks of gestation; P = .004). Procedure-related complications occurred in 10 of the women (14%) who were infected with human immunodeficiency virus who underwent curettage, compared with 9 of the women (4%) who were not infected with human immunodeficiency virus (P = .004). With the use of logistic regression, complication rates were unaffected by the difference in gestational age. Infectious complications did not differ between the 2 groups (P = .435). CONCLUSION: There was a higher rate of procedure-related complications among women who were infected with human immunodeficiency virus and who underwent curettage for management of spontaneous and induced abortions. There was no increase in infectious morbidity in the women who were infected with human immunodeficiency virus.

    Title Improving the Management of Opioid-dependent Pregnancies.
    Date August 2004
    Journal American Journal of Obstetrics and Gynecology
    Title Acyclovir Prophylaxis to Prevent Herpes Simplex Virus Recurrence at Delivery: a Systematic Review.
    Date January 2004
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: Genital herpes simplex virus (HSV) infection is one of the most common viral sexually transmitted diseases in the United States. Perinatal transmission of the virus to the fetus or neonate is a major concern in affected pregnancies. Our objective was to systematically review published data to estimate the effect of prophylactic acyclovir provided to pregnant women near term on the rate of recurrent genital herpes at delivery; the number of cesarean deliveries performed for clinical HSV recurrences or prodromal symptoms; and the prevalence of HSV virologic detection at delivery. DATA SOURCES: Our search included MEDLINE (1966-March 2003), LILACS, EMBASE, conference proceedings, abstracts from scientific forums and bibliographies of published articles with the following medical headings: acyclovir, pregnancy, Herpes viridae, and Herpesviridae. METHODS OF STUDY SELECTION: Prospectively designed criteria included randomized, clinical trials detailing the use of acyclovir in pregnancy for women with HSV published in either abstract or article form. Five trials with a total enrollment of 799 patients were included in the analysis. TABULATION, INTEGRATION, AND RESULTS: The studies were reviewed independently by three of the authors. With RevMan software, a fixed-effects model was used to calculate a summary odds ratio (OR) comparing the effect of treatment with placebo. Acyclovir prophylaxis beginning at 36 weeks' gestation was effective in reducing clinical HSV recurrences at the time of delivery (OR 0.25; 95% confidence interval [95% CI] 0.15, 0.40), cesarean deliveries for clinical recurrence genital herpes (OR 0.30; 95% CI 0.13, 0.67), total HSV detection at delivery (OR 0.11; 95% CI 0.04, 0.31), and asymptomatic HSV shedding at delivery (OR 0.09; 95% CI 0.02, 0.39). CONCLUSION: The results of this meta-analysis indicate that prophylactic acyclovir beginning at 36 weeks' gestation reduces the risk of clinical HSV recurrence at delivery, cesarean delivery for recurrent genital herpes, and the risk of HSV viral shedding at delivery.

    Title State Laws Regarding Prenatal Syphilis Screening in the United States.
    Date December 2003
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The purpose of this study was to assess the frequency and pattern of state laws or regulations regarding prenatal syphilis serologic screening in the United States in 2001. STUDY DESIGN: We surveyed the United States for existing laws and regulations regarding serologic screening for syphilis during pregnancy. Testing was compared with 2000 state rates of syphilis in women and newborn infants, with states that had syphilis high morbidity areas, and with national 2000 and 2010 objectives for rates of syphilis. RESULTS: Forty-six of the 50 states (90%) and the District of Columbia have laws regarding antenatal syphilis screening. Thirty-four of the 46 statutes (76%) mandate one prenatal test, usually at the first prenatal visit or early in pregnancy. Twelve laws (26%) include third-trimester testing for all or high-risk women. The presence of high morbidity areas, incidence of early syphilis in women, and rates of congenital syphilis are associated with increasing frequency of legislated antepartum screening. CONCLUSION: Only 90% of states have statutes that require antepartum syphilis screening, and there is variation in the content of the statutes about the number and timing of tests. States with a heavy burden of infectious syphilis in women tend to require more prenatal testing.

    Title Early-onset Group B Streptococcal Infection After a Combined Maternal and Neonatal Group B Streptococcal Chemoprophylaxis Strategy.
    Date June 2003
    Journal Pediatrics
    Excerpt

    OBJECTIVE: In January 1995, a combined maternal and neonatal protocol for prevention of early-onset group B streptococcal (GBS) infection was implemented that consisted of a risk factor-based approach for maternal intrapartum chemoprophylaxis using ampicillin combined with a single intramuscular dose of penicillin given to all newborns within 1 hour of delivery. The objective of this study was to review the cases of early-onset GBS infections that occurred from 1995 to 1999 to identify factors associated with their continued occurrence despite implementation of a GBS chemoprophylaxis protocol. METHODS: Infants <or=72 hours of age with early-onset GBS infection born at Parkland Memorial Hospital in Dallas from January 1995 to December 1999 were identified through a prospective laboratory-based surveillance system. Maternal and infant medical records were reviewed for clinical and demographic data. RESULTS: There were 32 cases (0.47/1000 live births) of early-onset GBS infection for the 5-year period. This represented a 76% reduction compared with the rate from 1986 to 1994 (1.95/1000), when there was no protocol for GBS chemoprophylaxis. Thirteen cases (41%) did not have any identifiable maternal risk factor. Of the 19 cases (59%) with risk factors, maternal intrapartum fever was the most frequent (15 [79%]), followed by prematurity (6 [32%]) and prolonged rupture of membranes (6 [32%]). Among the 19 mothers with risk factors, 15 (79%) mothers received intrapartum chemoprophylaxis, and 12 (80%) of the 15 mothers had intrapartum fever. Only 33% of mothers with risk factors received >or=2 doses of intrapartum chemoprophylaxis, and among those with intrapartum fever, 25% received >or=2 doses. None of the 32 infants with early-onset GBS infection received the combination of intrapartum ampicillin and postnatal penicillin. CONCLUSIONS: A combined obstetric and neonatal chemoprophylaxis protocol significantly reduced early-onset GBS infection. Maternal intrapartum fever was the most frequent risk factor associated with failure of chemoprophylaxis.

    Title A Blueprint for Obstetric Critical Care.
    Date March 2003
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The purpose of this study was to describe our 2-year experience with 483 critically ill peripartum women and to propose a blueprint for obstetric critical care. STUDY DESIGN: This was a prospective study to evaluate all admissions to the Obstetric Intermediate Care Unit and obstetric admissions to medical/surgical intensive care units. Our findings are followed by general recommendations for the organization of obstetric critical care. RESULTS: Almost two thirds of the women had obstetric complications that included pregnancy-associated hypertension and obstetric hemorrhage. Medical disorders were most common in the other one third of the women. CONCLUSION: An Obstetric Intermediate Care Unit allows for the continuation of care by obstetricians and results in fewer transfers to medical/surgical intensive care units. Patient treatment depends on hospital size and available resources. In most tertiary centers, the critically ill pregnant woman is best cared for by obstetricians in an Obstetric Intermediate Care Unit. In smaller hospitals, transfer to a medical or surgical intensive care unit may be preferable.

    Title Acyclovir Suppression to Prevent Recurrent Genital Herpes at Delivery.
    Date February 2003
    Journal Infectious Diseases in Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To determine if suppressive acyclovir near term decreased the frequency of clinical recurrences at delivery in women with recurrent genital herpes simplex virus (HSV) infection. METHODS: We conducted a prospective, double-blind, randomized trial in 234 women with recurrent genital herpes. Women with genital infection of any frequency were enrolled. Patients received either suppressive oral acyclovir 400 mg three times daily or an identical placebo after 36 weeks' gestation. Clinical lesions were identified, and HSV cultures were obtained at delivery. The frequencies of clinical and subclinical HSV recurrences at delivery were evaluated. RESULTS: Six percent of patients treated with acyclovir, and 14% of patients treated with placebo had clinical HSV at delivery (p = 0.046). No patients in the acyclovir group had positive HSV cultures, compared with 6% of placebo-treated patients (p = 0.029). There was no significant difference in subclinical HSV shedding in the acyclovir group (0%) compared with the placebo-treated group (3%) (p = 0.102). CONCLUSIONS: Suppressive acyclovir therapy significantly decreased the incidence of clinical genital herpes and the overall incidence of HSV excretion at delivery in patients with previous herpes infection.

    Title Relationship Between Maternal Methadone Dosage and Neonatal Withdrawal.
    Date January 2003
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To determine whether maternal methadone dosage affects duration and degree of neonatal narcotic withdrawal. METHODS: This was a retrospective cohort study of pregnant women with opioid addiction who delivered live-born singletons between April 1990 and April 2001. Inpatient detoxification or outpatient methadone maintenance therapy was offered. Women who had a positive drug screen or whose neonate tested positive for opioids were considered to be supplementing. We evaluated indices of neonatal withdrawal according to the maximum daily methadone dosage in the last week of pregnancy. RESULTS: Seventy women with opioid addiction were followed. Median methadone dosage was 20 mg (range 0-150 mg), and 32 infants (46%) were treated for narcotic withdrawal. Among women who received less than 20 mg per day, 20-39 mg per day, and at least 40 mg per day of methadone, treatment for withdrawal occurred in 12%, 44%, and 90% of infants, respectively (P < 0.02). Methadone dosage was also correlated with both duration of neonatal hospitalization and neonatal abstinence score (r(s) =.70 and.73 respectively, both P <.001). Neonates were more likely to experience withdrawal if their mothers were supplementing with heroin, 68% versus 35% (P =.01). Regardless of supplementation, there was a significant relationship between methadone dosage and neonatal withdrawal (P <.05). CONCLUSION: Maternal methadone dosage was associated with duration of neonatal hospitalization, neonatal abstinence score, and treatment for withdrawal. Heroin supplementation did not alter this dose-response relationship. In selected pregnancies, lowering the maternal methadone dosage was associated with both decreased incidence and severity of neonatal withdrawal.

    Title Acute Renal Failure in Association with Severe Hyperemesis Gravidarum.
    Date November 2002
    Journal Obstetrics and Gynecology
    Excerpt

    BACKGROUND: Severe hyperemesis gravidarum is a rare but potentially devastating complication of pregnancy. Among its many potential complications are dehydration, electrolyte imbalance, malnutrition, Wernicke encephalopathy, and compromised renal function. CASE: We report the case of a 21-year-old woman at 15 weeks' gestation presenting to the emergency department with severe hyperemesis gravidarum associated with acute renal failure. Her initial serum creatinine and blood urea nitrogen were 10.7 mg/dL and 171 mg/dL, respectively. The patient underwent daily hemodialysis for 5 days with subsequent return of renal function to normal. CONCLUSION: Women with severe hyperemesis gravidarum may be at risk for acute renal failure caused by severe intravascular volume depletion.

    Title Treatment of Syphilis in Pregnancy and Prevention of Congenital Syphilis.
    Date October 2002
    Journal Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America
    Excerpt

    Studies about the management of syphilis during pregnancy were reviewed. They lacked uniformity in diagnostic criteria and study design. Currently recommended doses of benzathine penicillin G are effective in preventing congenital syphilis in most settings, although studies are needed regarding increased dosing regimens. Azithromycin and ceftriaxone offer potential alternatives for penicillin-allergic women, but insufficient data on efficacy limit their use in pregnancy. Ultrasonography provides a noninvasive means to examine pregnant women for signs of fetal syphilis, and abnormal findings indicate a risk for obstetric complications and fetal treatment failure. Ultrasonography should precede antepartum treatment during the latter half of pregnancy to gauge severity of fetal infection. However, optimal management of the affected fetus has not been established; collaborative management with a specialist is recommended. Antepartum screening remains a critical component of congenital syphilis prevention, even in the era of syphilis elimination.

    Title Placental Histopathology of Congenital Syphilis.
    Date August 2002
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To evaluate the contribution of placental histopathology to the diagnosis of congenital syphilis. METHODS: From January 1, 1986, through December 31, 1998, all pregnant women presenting to a large, urban Dallas County labor and delivery unit with untreated syphilis at delivery and who had placental evaluation performed were identified. Women were clinically staged, and the infants were evaluated for congenital syphilis using a standard protocol. Each placenta was evaluated by two independent pathologists. Histologic characteristics of the placenta related to congenital syphilis in live-born and stillborn infants were then analyzed. RESULTS: Sixty-seven women met the study criteria: 33 (49%) stillborn and 18 (27%) live-born infants with congenital syphilis, 15 (22%) uninfected live-born infants, and one uninfected stillborn fetus diagnosed by current criteria. There were no differences between the groups with regard to demographic characteristics, prenatal care, or stage of syphilis. Stillborn infants were more likely to deliver preterm (P <.001). Controlling for gestational age, histopathology revealed necrotizing funisitis, villous enlargement, and acute villitis associated with congenital syphilis. Erythroblastosis was more common in stillborn infants with congenital syphilis than all live-born infants (odds ratio 16, 95% confidence interval 1, 370). The addition of histologic evaluation to conventional diagnostic evaluations improved the detection rate for congenital syphilis from 67% to 89% in live-born infants, and 91% to 97% in stillborn infants. CONCLUSION: Our results show that histopathologic examination of the placenta is a valuable adjunct to the contemporary diagnostic criteria used to diagnose congenital syphilis.

    Title Risk of Hepatitis B Transmission in Breast-fed Infants of Chronic Hepatitis B Carriers.
    Date June 2002
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To measure the rate of hepatitis B (HBV) transmission from chronic HBV carriers to breast-fed infants after immunoprophylaxis. METHODS: Since 1992, information on women with HBV during pregnancy has been collected in a prospective longitudinal study. Those HBV carriers and their infants participating in a county HBV immunoprophylaxis program were identified. Infants were followed for up to 15 months and examined for hepatitis B infection by hepatitis B surface antigen (HBsAg). RESULTS: A total of 369 infants born to women with chronic HBV met the inclusion criteria and received hepatitis B immune globulin at birth and the full course of the hepatitis B vaccine series. We compared 101 breast-fed infants with 268 formula-fed infants. There was no significant difference between the two groups with respect to the number of women who were positive for hepatitis B e antigen (HBeAg) (22% versus 26%, P =.51). Three women in the breast-feeding group had liver transaminase abnormalities, compared with six women in the formula-feeding group (P =.29). Overall, there were nine cases of HBV infection transmission (2.4%). None of the 101 breast-fed infants and nine formula-fed infants (3%) were positive for HBsAg after the initial vaccination series (P =.063). The mean length of time for breast-feeding was 4.9 months (range 2 weeks to 1 year). CONCLUSION: With appropriate immunoprophylaxis, including hepatitis B immune globulin and hepatitis B vaccine, breast-feeding of infants of chronic HBV carriers poses no additional risk for the transmission of the hepatitis B virus.

    Title Central Nervous System Infection in Congenital Syphilis.
    Date June 2002
    Journal The New England Journal of Medicine
    Excerpt

    BACKGROUND: Identification of infants with Treponema pallidum infection of the central nervous system remains challenging. METHODS: We used rabbit-infectivity testing of the cerebrospinal fluid to detect T. pallidum infection of the central nervous system in infants born to mothers with syphilis. The results were compared with those of clinical, radiographic, and conventional laboratory evaluations; IgM immunoblotting of serum and cerebrospinal fluid; polymerase-chain-reaction (PCR) assay testing of serum or blood and cerebrospinal fluid; and rabbit-infectivity testing of serum or blood. RESULTS: Spirochetes were detected in the cerebrospinal fluid of 19 of 148 infants by rabbit-infectivity testing. Exposure of the infant to antibiotics before cerebrospinal fluid was obtained for rabbit-infectivity testing was associated with a negative test result (P=0.001). Spirochetes were detected in the cerebrospinal fluid in 17 of 76 infants (22 percent) who had no prior antibiotic exposure. These 17 infants included 41 percent (16 of 39) of those with some abnormality on clinical, laboratory, or radiographic evaluation; 60 percent (15 of 25) of those with abnormal findings on physical examination that were consistent with congenital syphilis; and 41 percent (17 of 41) of those with a positive result on IgM immunoblotting or PCR testing of serum, blood, or cerebrospinal fluid, or a positive result on rabbit-infectivity testing of serum or blood. Only one infant who had normal findings on clinical evaluation had a positive cerebrospinal fluid rabbit-infectivity test. Overall, central nervous system infection was best predicted by IgM immunoblotting of serum or PCR assay of serum or blood. CONCLUSIONS: Most infants with T. pallidum infection of the central nervous system can be identified by physical examination, conventional laboratory tests, and radiographic studies. However, the identification of all such infants requires the use of additional tests, including IgM immunoblotting and PCR assay.

    Title Prevention of Neonatal Group B Streptococcal Disease: A Combined Intrapartum and Neonatal Protocol.
    Date June 2002
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: We sought to assess the efficacy of a clinical protocol to reduce the incidence of early-onset neonatal group B Streptococcus (GBS) infection. STUDY DESIGN: We assessed neonatal sepsis from GBS and other organisms with use of a before-after study design to evaluate the effects of implementation of combined intrapartum antimicrobial prophylaxis given selectively to mothers with GBS risks and penicillin G given to all neonates. RESULTS: In 1994, early-onset GBS infection developed in 31 of 13,887 live births (2.2/1000), 13 preterm and 18 term cases. After implementation of the prophylaxis protocol (1995), 6 of 13,527 live births had early-onset GBS (0.4/1000) (P <.001). There were no preterm (P =.0004) and 6 term GBS cases (P =.02). The efficacy continued through 1999 (0.5/1000) without an increase in neonatal infections from other bacteria. CONCLUSION: Combined maternal and infant antimicrobial prophylaxis can significantly and safely reduce rates of early-onset GBS infection in both preterm and term infants.

    Title Congenital Syphilis After Maternal Treatment for Syphilis During Pregnancy.
    Date April 2002
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The purpose of this study was to characterize pregnancies that were complicated by maternal syphilis that had been treated before delivery in which the newborn infant was diagnosed with congenital syphilis. STUDY DESIGN: Prospective surveillance from January 1, 1982, to December 31, 1998, involved women who received antenatal treatment for syphilis. Infants who were born with congenital syphilis were identified by clinical or laboratory criteria. Antepartum factors such as gestational age, time to delivery and VDRL titers were then analyzed and compared with those of women who had been treated and who were delivered of an uninfected infant. The 1:1 match was based on the stage of syphilis and the gestational age at treatment. RESULTS: Forty-three women who received antepartum therapy for syphilis were delivered of an infant with congenital syphilis. Most of the women had been treated for early syphilis; the mean gestational age at treatment was 30.3 weeks. Thirty-five percent of the women were treated >30 days before delivery. Fifty-six percent of the infants were preterm. The 1:1 match revealed that treatment and delivery high VDRL titers, prematurity, and a short interval from treatment to delivery were significantly different in those infants who were diagnosed with congenital syphilis. CONCLUSION: High VDRL titers at treatment and delivery, earlier maternal stage of syphilis, the interval from treatment to delivery, and delivery of an infant at < or =36 weeks' gestation are associated with the delivery of a congenitally infected neonate after adequate treatment for maternal syphilis.

    Title Acyclovir Concentrations in Human Breast Milk After Valaciclovir Administration.
    Date February 2002
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The purpose of this study was to determine the valaciclovir and acyclovir pharmacokinetic profiles in serum and breast milk after valaciclovir administration to women after delivery. STUDY DESIGN: Valaciclovir (500 mg twice daily for 7 days) was given to 5 women after delivery who were breast-feeding healthy term infants. Matched serum and breast milk samples were obtained after the initial dose, on day 5 and 24 hours after the drug was discontinued. Infant urine was obtained on day 5. RESULTS: Valaciclovir was rapidly converted to acyclovir. The peak serum acyclovir concentration occurred 3 hours before the peak breast milk concentration (2.7 microg/mL at 1 hour vs 4.2 microg/mL at 4 hours). The serum acyclovir elimination half-life was 2.3 hours. The ratio of breast milk to serum acyclovir concentration was highest 4 hours after the initial dose at 3.4 and reached steady state ratio at 1.85. The median infant urine acyclovir concentration at steady state was 0.74 microg/mL. CONCLUSION: Valaciclovir is rapidly converted to acyclovir and concentrates in breast milk. However, the amount of acyclovir in breast milk after valaciclovir administration is considerably less (2%) than that used in therapeutic dosing of neonates.

    Title Effect of a Resident-created Study Guide on Examination Scores.
    Date January 2002
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To evaluate the effect of a resident-created study guide on Council on Resident Education in Obstetrics and Gynecology (CREOG) In-Training and American Board of Obstetrics and Gynecology (ABOG) written examination scores. METHODS: In 1995, a group of residents at the University of Texas Southwestern Medical Center began creating an annual study guide based on the CREOG Test Item Summary Booklet. Individual, program, and national scores for 3 years before the intervention were compared with scores for 3 years after the intervention. A four-way analysis of variance was used to evaluate the effect of the intervention accounting for sex, Alpha Omega Alpha Medical Honor Society (AOA) status, and calendar year. A random effects model was also used to adjust for confounders. Categoric variables were compared using Mantel-Haenszel chi(2). Program failure rates for the ABOG written examination before and after the intervention were compared with relative risks. RESULTS: After introduction of the study guide, the annual difference between our program and the national percent correct increased significantly (2.1% versus 4.8%, P <.001), after adjustment for AOA status and calendar year. The improvement was distributed among resident levels 2-4 (all P <.02) and for non-AOA residents (P < or = .001). The relative risk of failure of the written ABOG examination before the study guide was 3.5 (95% confidence interval 0.77, 15.9). CONCLUSION: These findings demonstrate an important cooperative use of the Test Item Summary Booklet as an educational resource.

    Title Acyclovir Suppression to Prevent Clinical Recurrences at Delivery After First Episode Genital Herpes in Pregnancy: an Open-label Trial.
    Date December 2001
    Journal Infectious Diseases in Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To continue evaluation of the use of acyclovir suppression in late pregnancy after first episode genital herpes simplex virus (HSV) infection, using an open-label study design. METHODS: Ninety-six women diagnosed with genital herpes for the first time in the index pregnancy were prescribed suppressive acyclovir 400 mg orally three times daily from 36 weeks until delivery in an open-label fashion. Herpes cultures were obtained when patients presented for delivery. Vaginal delivery was permitted if no clinical recurrence was present; otherwise a Cesarean delivery was performed. Neonatal HSV cultures were obtained and infants were followed clinically. Rates of clinical and asymptomatic genital herpes recurrences and Cesarean delivery for genital herpes were measured, and 95% confidence intervals were calculated. RESULTS: In 82 patients (85%) compliant with therapy, only 1% had clinical HSV recurrences at delivery. In an intent to treat analysis of the entire cohort, 4% had clinical recurrences (compared with 18-37% in historical controls). Asymptomatic shedding occurred in 1% of women without lesions at delivery. Two of the four clinical recurrences were HSV-culture positive. No significant maternal or fetal side-effects were observed. CONCLUSIONS: In clinical practice the majority of patients are compliant with acyclovir suppression at term. The therapy appears to be effective at reducing clinical recurrences after a first episode of genital herpes complicating a pregnancy.

    Title Hepatotoxicity with Antiretroviral Treatment of Pregnant Women.
    Date December 2001
    Journal Obstetrics and Gynecology
    Excerpt

    BACKGROUND: Hepatotoxicity in adults with human immunodeficiency virus (HIV) infection has been associated with all classes of antiretroviral drugs and coinfection with hepatitis B and C virus. We treated two HIV-infected pregnant women in whom hepatotoxicity developed after initiating antiretroviral therapy. CASES: The first woman developed icterus, jaundice, hyperbilirubinemia, and elevated serum aminotransferase levels approximately 5 months after beginning combination antiretroviral therapy with zidovudine, lamivudine, and efavirenz. Serum aminotransferase abnormalities improved after discontinuation of antiretroviral medications. The second woman had similar symptoms and laboratory abnormalities 3 months after initiation of zidovudine, lamivudine, and nelfinavir. Despite initial improvement after discontinuing her antiretroviral medications, fulminant hepatic failure developed and she died. Both patients tested negative for hepatitis A, B, and C; Epstein-Barr virus; and cytomegalovirus. There was no history of illicit drug use, alcohol use, or blood transfusions in either case. CONCLUSION: We emphasize the need for careful monitoring for hepatotoxicity after initiation of antiretroviral therapy.

    Title A Randomized Trial That Compared Oral Cefixime and Intramuscular Ceftriaxone for the Treatment of Gonorrhea in Pregnancy.
    Date October 2001
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The purpose of this study was to evaluate prospectively the Centers for Disease Control recommendations for the treatment of gonococcal infection in pregnancy. STUDY DESIGN: One hundred sixty-one women who were referred with probable endocervical gonorrhea underwent pretreatment endocervical, anal, and oral cultures for Neisseria gonorrhoeae. The women were randomly assigned to receive ceftriaxone 125 mg intramuscularly or cefixime 400 mg orally. Treatment was open and in a 1:1 distribution. There were 95 evaluable patients. The tests of cure cultures were performed 4 to 10 days after treatment. RESULTS: Eighty-six women (91%) had endocervical infection; 39 women (41%) had anal infection, and 11 women (12%) had pharyngeal infection. Fifty of 95 women (53%) had concomitant endocervical chlamydial infection. The overall efficacy was 91 of 95 subjects (95.8%; 95% CI, 89.6%-98.8%). Ceftriaxone was effective in 41 of 43 cases (95%; 95% CI, 84.2%-99.4%), and cefixime was effective in 50 of 52 cases (96%; 95% CI, 86.8%-99.5%). No significant difference was noted in the overall efficacy or by site of infection. Three of the 4 women who experienced treatment failures admitted to unprotected intercourse before their test of cure culture. CONCLUSION: Both intramuscular ceftriaxone 125 mg and oral cefixime 400 mg appear to be effective for the treatment of gonococcal infection in pregnancy.

    Title Fetal Syphilis: Clinical and Laboratory Characteristics.
    Date June 2001
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To examine the pathophysiology of fetal syphilis and correlate hematologic, immunologic, and sonographic findings. METHODS: Twenty-four women with untreated syphilis during pregnancy were prospectively identified. Sonography with amniocentesis and percutaneous umbilical blood sampling were performed. Darkfield examination, rabbit infectivity testing, and polymerase chain reaction for detection of Treponema pallidum were performed on amniotic fluid. Hematologic and chemical testing of fetal blood was performed using standard techniques. Fetal antitreponemal IgM was detected by Western blot assay. Maternal syphilis was treated with 2.4 to 4.8 million units of benzathine penicillin G intramuscularly. Neonatal outcomes and signs of congenital syphilis were recorded. RESULTS: Six women had primary, 12 had secondary, and six had early latent syphilis. Sixty-six percent of fetuses (95% confidence interval [CI] 47%, 82%) had either congenital syphilis or detection of Treponema pallidum in amniotic fluid. Sixty-six percent had hepatomegaly, including three fetuses (12.5%, 95% CI 4%, 31%) with ascites. Fetal antitreponemal IgM was detected in three cases. Abnormal liver transaminases were found in 88% (CI 69%, 96%), anemia in 26% (CI 13%, 47%), and thrombocytopenia in 35% (CI 19%, 55%). Maternal treatment was successful in 83% (CI 64%, 93%). Risk of treatment failure was significantly increased when hepatomegaly and ascites were present (P =.01). CONCLUSION: Findings with fetal syphilis are similar to those of neonatal syphilis. We hypothesize that fetal transaminase elevation occurs early in the course of infection; hematologic abnormalities and hydrops occur later. Severity of disease may be associated with risk of treatment failure.

    Title In Vitro Selection of Lentivirus Vector-transduced Human Cd34+ Cells.
    Date October 2000
    Journal Human Gene Therapy
    Excerpt

    Human CD34(+) cells with in vivo repopulating potential hold much promise as a target for corrective gene transfer for numerous hematopoietic disorders. However, the efficient introduction of exogenous genes into this small, quiescent population of cells continues to present a significant challenge. To circumvent the need for high initial transduction efficiency of human hematopoietic cells, we investigated a dominant selection strategy using a variant of the DHFR gene (DHFR(L22Y)). For this purpose, we constructed a lentivirus-based bicistronic vector expressing EGFP and DHFR(L22Y). Here we demonstrate efficient in vitro selection and enrichment of lentivirus vector-transduced human CD34(+) hematopoietic cells from fetal liver, umbilical cord blood, bone marrow, and peripheral blood after cytokine mobilization. Growth of transduced human CD34(+) cells in semisolid culture under selective pressure resulted in enrichment of transduced progenitor cells to 99.5% (n = 14). Selection for DHFR(L22Y)(+) cells after expansion of transduced progenitors in liquid culture resulted in a 7- to 13-fold increase in the percentage of marked cells. Thus we have shown that transduced human hematopoietic cells may be effectively enriched in vitro by dominant selection, suggesting that development of such strategies holds promise for future in vivo application.

    Title Reducing Neonatal Group B Streptococcal Disease.
    Date May 2000
    Journal The New England Journal of Medicine
    Title Risk of Hepatitis B Transmission After Amniocentesis in Chronic Hepatitis B Carriers.
    Date January 2000
    Journal Infectious Diseases in Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To measure the risk of perinatal transmission of HBV in chronic carriers who undergo amniocentesis. METHODS: This was a prospective, longitudinal study from 1990 to 1995 of women who were HBV carriers and underwent amniocentesis. The infants of these women were followed from birth to one year of age. Maternal data examined included HBV antigen and antibody status, liver function tests (LFTs) and the amniocentesis report. RESULTS: Twenty-eight women were identified. Two of 28 neonates were stillborn unrelated to hepatitis. Five infants were lost to follow-up leaving 21 mother-child pairs to evaluate. All 21 women were chronic HBV carriers at the time of amniocentesis for delivery. No mother had abnormal LFTs, and only one of 21 women was positive for hepatitis B e antigen (HBeAg). Thirteen amniocenteses were for advanced maternal age, and four were for abnormal maternal serum alphafetoprotein (MSAFP) screening. None of the amniocenteses were recorded as bloody, and the placenta was anterior in 6 of 21 procedures. None of the 21 infants (95% CI: 0-16.8%) were positive for HbsAg during the first month of life or at 12 months of age. All infants received HBV vaccine and HBIG immunoprophylaxis. CONCLUSION: The risk of transmission of HBV to the fetus after amniocentesis in women who are HBV carriers is low. Immunoprophylaxis in these infants was successful.

    Title Pituitary Gland Gumma in Congenital Syphilis After Failed Maternal Treatment: a Case Report.
    Date July 1999
    Journal Pediatrics
    Excerpt

    A preterm, very low birth weight infant was born to a mother with early latent syphilis who was treated 10 days and 3 days before delivery with 2.4 mU of benzathine penicillin. The infant had clinical, laboratory, and radiographic abnormalities consistent with congenital syphilis, ie, a Venereal Disease Research Laboratory test titer that was fourfold greater than was the maternal titer, hepatosplenomegaly, abnormal liver function tests, pneumonitis, osteochondritis of the long bones, and cerebrospinal fluid (CSF) examination showing a reactive Venereal Disease Research Laboratory test, pleocytosis, and elevated protein content. The infant died on the third day of life, and an autopsy revealed an evolving gumma of the anterior pituitary. Immunoglobulin M immunoblotting of serum and CSF was positive, and polymerase chain reaction detected Treponema pallidum DNA in endotracheal aspirate and CSF. This case highlights the pathologic abnormalities observed in congenital syphilis and focuses on the rare finding of an evolving anterior pituitary gumma. Furthermore, it documents the failure of maternal syphilis treatment during the last 4 weeks of pregnancy to cure fetal infection and supports the recommendation that all infants born to mothers with syphilis treated during the last 4 weeks of pregnancy should receive penicillin therapy.

    Title Syphilis in Pregnancy.
    Date April 1999
    Journal Clinical Obstetrics and Gynecology
    Title Efficacy of Treatment for Syphilis in Pregnancy.
    Date February 1999
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To evaluate prospectively the Centers for Disease Control and Prevention (CDC) recommended regimens for the treatment of antepartum syphilis and prevention of congenital syphilis. METHODS: This was a prospective evaluation of recommended syphilis treatment regimens from September 1, 1987, to August 31, 1989, at Parkland Memorial Hospital, Dallas, Texas. Women with syphilis were staged and treated according to CDC recommendations. Treatment included 2.4 million units of intramuscular (IM) benzathine penicillin G for primary, secondary, or early latent (less than 1 year) syphilis. Women with late latent (uncertain or longer than 1 year) syphilis were treated with 7.2 million units of benzathine penicillin G IM over 3 weeks. RESULTS: During the study period, 448 of 28,552 women (1.6%) delivered were diagnosed with syphilis. One hundred eight were diagnosed at delivery and treated postpartum. The remaining 340 (75.9%) gravidas with untreated syphilis attending prenatal clinic comprised the study group. The success of therapy in preventing congenital syphilis was as follows: primary syphilis, 27 of 27; secondary syphilis, 71 of 75; early latent syphilis, 100 of 102; and late latent syphilis, 136 of 136. The success rate for all stages of syphilis was 334 of 340 (98.2%). The success rate of therapy in secondary syphilis was significantly different from that of the other groups (P = .03). Two of the six fetal treatment failures produced preterm stillborns. Only one maternal treatment failure occurred, in a human immunodeficiency virus-infected woman. CONCLUSION: The CDC-recommended regimens for the prevention of congenital syphilis and treatment of maternal infection are effective, but the highest risk of fetal treatment failure exists with maternal secondary syphilis.

    Title Opioid Detoxification in Pregnancy.
    Date November 1998
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: Opioid withdrawal has been associated with poor fetal growth, preterm delivery, and fetal death. We sought to evaluate the safety of antepartum opioid detoxification in selected gravidas. METHODS: Between 1990 and 1996, women with singleton gestations who reported opioid use were offered inpatient detoxification. Predetoxification sonography was performed to confirm gestational age and to exclude fetuses with growth restriction and oligohydramnios. Women with mild withdrawal symptoms were given clonidine initially, and methadone was substituted if symptoms persisted. Objective signs of withdrawal were treated with methadone from the outset. Antenatal testing was performed once gestations reached 24 weeks. Newborns were observed for signs of neonatal abstinence syndrome and were treated as necessary. Obstetric and neonatal outcome data were collected. RESULTS: Thirty-four gravidas elected to undergo opioid detoxification at a mean gestational age of 24 weeks. The median maximum dose of methadone was 20 mg per day (range 10-85 mg), and the median time to detoxification was 12 days (range 3-39 days). Overall, 20 women (59%) successfully underwent detoxification and did not relapse, ten (29%) resumed antenatal opioid use, and four (12%) did not complete detoxification and opted for methadone maintenance. There was no evidence of fetal distress during detoxification, no fetal death, and no delivery before 36 weeks. Fifteen percent of neonates were treated for narcotic withdrawal. CONCLUSION: In selected patients, opioid detoxification can be accomplished safely during pregnancy.

    Title A Randomized Placebo-controlled Evaluation of Terbutaline for External Cephalic Version.
    Date November 1997
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To evaluate the efficacy of subcutaneous terbutaline therapy on the success rate of external cephalic version in term gestation. METHODS: Women with singleton noncephalic gestations were assigned randomly to receive either terbutaline (0.25 mg) or placebo. Physicians were blinded to the assignment. Fifteen to 30 minutes after the study drug was administered, external cephalic version was attempted. It was discontinued after three attempts, for patient discomfort, for fetal heart rate decelerations, or when successful. Patients were discharged home after the procedure and allowed to enter spontaneous labor. Primary outcomes evaluated included initial success of version, presentation in labor, and route of delivery. RESULTS: One hundred three women were enrolled in the study between January 1994 and June 1995, of whom 52 were assigned to terbutaline and 51 to placebo. External cephalic version was successful in 27 of 52 (52%) women receiving terbutaline compared with 14 of 51 (27%) of those receiving placebo (P = .019). This comparison yielded a relative risk (RR) of 1.9 (95% confidence interval [CI] 1.3, 6.5). Four of the 27 (15%) successful versions in the terbutaline group and three of the 14 (21%) successful versions in the placebo group spontaneously reverted to breech presentation. Ultimately, in labor there were 24 (46%) cephalic presentations in the terbutaline group and 13 (25%) in the placebo group (P = .048, RR 1.84, 95% CI 1.1, 5.8). Cesarean delivery rates were 11 of 41 (27%) for women with successful versions and 58 of 62 (94%) among those with failed versions (P < .001). CONCLUSION: Terbutaline (0.25 mg) administered subcutaneously before an attempted version in women at term with noncephalic presentations significantly increased the initial success rate of version and the rate of cephalic presentations in labor while decreasing the rate of cesarean delivery.

    Title Syphilis in Pregnancy.
    Date June 1997
    Journal Clinics in Perinatology
    Excerpt

    Syphilis in pregnancy remains a problem despite the availability of adequate diagnostic tests and years of penicillin therapy. During pregnancy, syphilis is compounded by its occurrence among populations that under-use the health care system and by its association with cocaine use and infection with HIV. The potentially devastating effect of syphilis on the fetus and attendant adverse outcomes on the pregnancy continue to make syphilis a global problem of major medical and public health consequences.

    Title Postpartum Endometritis Caused by Herpes Simplex Virus.
    Date June 1997
    Journal Obstetrics and Gynecology
    Excerpt

    BACKGROUND: Herpes simplex virus (HSV) is rarely the causative agent of endometritis and is usually found in association with pelvic inflammatory disease. Only one case of postpartum HSV endometritis has been reported. CASES: We describe two cases of herpes simplex postpartum endometritis. Neither patient had genital HSV lesions noted at the time of delivery. The first case developed after a preterm cesarean delivery in an 18-year-old primipara. She had persistent puerperal fever despite broad-spectrum anti-microbial treatment. The second case was a 16-year-old primipara whose vaginal delivery was complicated by severe postpartum endometritis. Vulvar and endometrial cultures were positive for HSV alone in both patients. Both infants died from disseminated HSV infection. CONCLUSION: Herpes simplex virus can cause clinical postpartum endometritis.

    Title In Utero Infection with Treponema Pallidum in Early Pregnancy.
    Date May 1997
    Journal Prenatal Diagnosis
    Excerpt

    Amniocentesis was performed under sonographic guidance in gravidas (< 20 weeks' gestation) with untreated syphilis. Five to ten millilitres of amniotic fluid from each patient was used for rabbit infectivity testing (RIT) and polymerase chain reaction (PCR) to detect amniotic fluid infection with Treponema pallidum. Gravidas were treated with benzathine penicillin G. Newborns were examined for clinical and laboratory signs of congenital syphilis including immunoglobulin M (IgM) antibody to T. pallidum by Western blotting (immunoblotting). Eleven patients were enrolled at a mean gestational age of 16.8 weeks. T. pallidum was recovered from amniotic fluid by RIT in four cases (36 per cent), and PCR was positive in three of the amniotic fluid specimens (27 per cent). There were no false-positive PCR results. None of the newborns had clinical evidence of congenital syphilis and their sera lacked IgM reactivity to T. pallidum antigens by immunoblotting. These findings confirm in utero infection with T. pallidum in continuing early pregnancy and indicate that in utero treponemal infection can be eradicated by maternal treatment.

    Title Comparison of Azithromycin and Ceftriaxone for the Treatment of Chancroid.
    Date March 1996
    Journal Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America
    Excerpt

    We conducted a randomized, unblinded, prospective study designed to determine the efficacy of single-dose azithromycin for the treatment of chancroid. Men and women 16 years of age and older who had darkfield-negative genital ulcers that were clinically suspected to be caused by Haemophilus ducreyi and who attended urban sexually transmitted disease clinics or presented to hospital emergency departments were enrolled in the study. Patients were randomized to receive 250 mg of ceftriaxone im or 1 g of azithromycin orally, both given as a single dose. They were followed for up to 23 days after treatment. For 65 patients, cultures were positive for H. ducreyi; there were 68 patients whose cultures were negative for both H. ducreyi and herpes simplex virus and who had no evidence of syphilis. All 133 patients returned for at least one follow-up visit. At the time of the last follow-up visit, all 32 patients whose cultures were positive for H. ducreyi and who were treated with azithromycin were clinically cured. In all 33 culture-positive cases in which ceftriaxone was used, there was either clinical improvement or cure at the time of the patient's last follow-up visit. In addition, azithromycin and ceftriaxone were equally effective in healing ulcers for which cultures were negative. We conclude that a single 1-g oral dose of azithromycin is as effective as a 250-mg im dose of ceftriaxone for the treatment of chancroid.

    Title Acyclovir Suppression to Prevent Cesarean Delivery After First-episode Genital Herpes.
    Date January 1996
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To determine if suppressive acyclovir therapy given to term gravidas experiencing a first episode of genital herpes simplex virus (HSV)-infection during pregnancy decreases the need for cesarean delivery for that indication. METHODS: Forty-six pregnant women with first episodes of genital herpes during pregnancy were randomly assigned to receive oral acyclovir 400 mg or placebo, three times per day, from 36 weeks' gestation until delivery as part of a prospective, double-blind trial. Herpes simplex virus cultures were obtained when patients presented for delivery. Vaginal delivery was permitted if no clinical recurrence was present; otherwise, a cesarean was performed. Neonatal HSV cultures were obtained and infants were followed-up clinically. RESULTS: None of the 21 patients treated with acyclovir and nine of 25 (36%) treated with placebo had clinical evidence of recurrent genital herpes at delivery (odds ratio [OR] 0.04, 95% confidence interval [CI] 0.002-0.745; P = .002). No woman treated with acyclovir had a cesarean for herpes, compared with nine of 25 (36%) of those treated with placebo (OR 0.04, CI 0.002-0.745; P = .002). No patient in either treatment group experienced asymptomatic genital viral shedding at delivery. No neonate had evidence of herpes infection or adverse effects from acyclovir. CONCLUSION: Suppressive acyclovir therapy reduced the need for cesarean for recurrent herpes in women whose first clinical episode of genital HSV occurred during pregnancy. Suppressive acyclovir treatment did not increase asymptomatic viral shedding and was not harmful to the term fetus.

    Title Obstetric Clavicular Fracture: the Enigma of Normal Birth.
    Date January 1996
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To determine the main risk factors involved in neonatal clavicular fracture, the most common injury to the neonate. METHODS: Two hundred fifteen cases of clavicular fracture of 65,091 vaginal deliveries (0.4%) occurring between January 1983 and December 1988 were pair-matched with controls based on mode and date of delivery, race, and maternal age. Incidences, odds ratios, and stratified analysis were used to identify and control for confounding between risk factors. RESULTS: Shoulder dystocia, increasing birth weight, and increasing gestational age were identified as risk factors. Within the range of normal birth weights, there is a biologic gradient of increasing risk for clavicular fracture. Although shoulder dystocia is the strongest risk factor identified, the magnitude of its point estimate is probably affected to a large extent by differential ascertainment. The use of forceps, prolonged second stage of labor, and nulliparity status were not significantly associated with neonatal clavicular fracture. CONCLUSIONS: Neonatal clavicular fracture occurs commonly in an obstetric population. Obstetric clavicular fracture is an unpredictable, unavoidable complication of normal birth.

    Title Common Bacterial Sexually Transmitted Diseases in Pregnancy.
    Date September 1995
    Journal The Journal of the Arkansas Medical Society
    Title Genital Herpes During Pregnancy: No Lesions, No Cesarean.
    Date February 1995
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To determine the effects at our hospital of adoption of the 1988 guidelines recommended by ACOG for management of genital herpes infections during pregnancy. METHODS: Between 1984-1986, 96 pregnancies complicated by active genital herpes were delivered at Parkland Hospital. The outcome of these pregnancies were compared with 217 similar pregnancies managed after implementation of the 1988 ACOG herpes guidelines. RESULTS: Adoption of the 1988 ACOG herpes guidelines resulted in a 37% decrease in the use of cesarean delivery for women with genital herpes infections at our hospital. Most of this decrease was because the new guidelines eliminated the need for a confirmatory negative herpes culture before permitting vaginal delivery. No neonatal herpes infections occurred as a result of implementing the ACOG recommendations. CONCLUSION: The rate of cesarean delivery for women with genital herpes infections during pregnancy declined significantly at our hospital as a result of the adoption of ACOG herpes guidelines, and there were no neonatal consequences, such as increased incidence of neonatal herpes simplex virus infection.

    Title Sexually Transmitted Diseases in Pregnancy.
    Date May 1994
    Journal Seminars in Perinatology
    Title Multicenter, Comparative Study of Cefotaxime and Ceftriaxone for Treatment of Uncomplicated Gonorrhea.
    Date November 1993
    Journal Sexually Transmitted Diseases
    Excerpt

    BACKGROUND AND OBJECTIVES: Cefotaxime is a third-generation cephalosporin that has in vitro activity against Neisseria gonorrhoeae, including beta-lactamase-producing strains. A single 1-g intramuscular dose is effective and is recommended by the Centers for Disease Control and Prevention as an alternative treatment for uncomplicated gonorrhea. GOAL OF THIS STUDY: This study was conducted to evaluate the efficacy and safety of a lower 500-mg dose of cefotaxime in the treatment of uncomplicated gonococcal infections. STUDY DESIGN: In a randomized multicenter study, patients who had uncomplicated gonorrhea were treated with 500 mg of cefotaxime or 250 mg of ceftriaxone. Both antibiotics were given intramuscularly. Efficacy and safety were assessed four to seven days following treatment. RESULTS: Six hundred thirteen patients were enrolled. Bacteriologic eradication rates for anogenital infection were 97.7% of the patients (213/218) in the cefotaxime group and 99.1% of the patients (221/223) in the ceftriaxone group (P = 0.243). Adverse events occurred in 4.2% and 7.5% of patients in the two groups, respectively. CONCLUSION: Cefotaxime 500 mg appears to be a safe and cost-effective alternative to ceftriaxone 250 mg for the treatment of uncomplicated gonorrhea.

    Title Thyrotoxic Hypokalemic Periodic Paralysis Following Second-trimester Prostaglandin-induced Abortion.
    Date October 1993
    Journal Obstetrics and Gynecology
    Excerpt

    BACKGROUND: Hypokalemic periodic paralysis with thyrotoxicosis has never been described in pregnancy or the puerperium. CASE: A 31-year-old Hispanic woman underwent three prostaglandin inductions for a second-trimester missed abortion. Her management was complicated by hyperthermia, nausea, vomiting, and diarrhea. She developed isolated proximal muscle paralysis and sensory loss on the first post-abortion day. Her serum potassium was 1.5 mEq/L. The serum free thyroxine index exceeded 25 and TSH was below 0.03 microIU/mL, leading to a diagnosis of thyrotoxic hypokalemic periodic paralysis. Oral and parenteral potassium repletion restored full neurologic function, and propylthiouracil treatment was initiated until thyroid ablation could be performed. CONCLUSION: Gastrointestinal potassium loss during prostaglandin-induced abortion may unmask previously undiagnosed periodic paralysis.

    Title Penicillin Levels Following the Administration of Benzathine Penicillin G in Pregnancy.
    Date September 1993
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To investigate the distribution of penicillin in the maternal-placental-fetal unit at term gestation. METHODS: Twenty-five healthy gravidas at 38-39 weeks' gestation scheduled for elective repeat cesarean delivery under spinal anesthesia received benzathine penicillin G, 2.4 million units intramuscularly (IM) preoperatively. Ten women delivered 1 day after injection, five delivered 2-3 days after, and ten delivered 7 days after. We collected maternal serum and cerebrospinal fluid, amniotic fluid (AF), and cord serum at delivery. Penicillin levels were measured using a validated agar disc diffusion method (sensitivity 0.006 micrograms/mL) with Micrococcus lutea as the test organism. RESULTS: There was no significant difference in mean penicillin levels at day 1, day 2-3, or day 7 for maternal serum, maternal cerebrospinal fluid, cord serum, or AF. The mean (+/- standard error) penicillin concentration (range 0.005-0.59 micrograms/mL) in maternal serum declined from 0.14 +/- 0.04 micrograms/mL 1 day after injection to 0.08 +/- 0.06 micrograms/mL 7 days after injection. The proportion of patients with a penicillin concentration at or above 0.018 micrograms/mL in the maternal serum declined significantly from day 1 to day 7 (P = .03). Overall, nine of 25 women (36%) had serum penicillin levels that were less than 0.018 micrograms/mL. CONCLUSION: A wide range of penicillin levels were observed in gravidas at term in the maternal serum, cerebrospinal fluid, umbilical cord serum, and AF within 1 week after 2.4 million units of benzathine penicillin G IM. We speculate that altered pharmacokinetics may affect the efficacy of this drug for prevention of congenital syphilis in the near-term gestation.

    Title Fetal Syphilis: Correlation of Sonographic Findings and Rabbit Infectivity Testing of Amniotic Fluid.
    Date May 1993
    Journal Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine
    Excerpt

    Fetal syphilis is the presumed diagnosis when the sonographic findings of fetal hydrops are found in the presence of maternal syphilis. In the absence of fetal hydrops, the diagnosis of fetal infection is difficult. We hypothesized that intra-amniotic infection would be accompanied by anatomic placental and fetal abnormalities that could be detected by ultrasonography. Rabbit infectivity testing (RIT), intratesticular inoculation of rabbits with amniotic fluid, can be used to confirm intra-amniotic infection with Treponema pallidum. Twenty-one gravidas with untreated early (primary, secondary, and early latent) syphilis underwent sonography and amniocentesis for RIT at 24 weeks of gestation or later. Antenatal sonographic findings were compared to their amniotic fluid RIT results. Hepatomegaly was significantly (P < 0.01) associated with amniotic fluid infection detected by RIT. Antenatal detection of hepatomegaly, which is probably the initial sonographic manifestation of hydrops fetalis, may ultimately identify the fetus affected with congenital syphilis.

    Title Postpartum Perineal Morbidity After Fourth-degree Perineal Repair.
    Date March 1993
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: We attempted to determine the frequency of postpartum perineal morbidity (dehiscence, infection, and rectovaginal fistula) in women after fourth-degree perineal repair. STUDY DESIGN: The medical records of 390 women at Parkland Memorial Hospital with fourth-degree perineal repair during 1989 and 1990 were retrospectively reviewed in a case-cohort study. Statistical analysis included chi 2 contingency tables, Fisher exact test, Mann-Whitney test, and analysis of variance. RESULTS: Twenty-one of 390 women (5.4%) had postpartum perineal morbidity. Seven (1.8%) had dehiscence alone, 11 (2.8%) had infection and dehiscence, and 3 (0.8%) had infection alone. Overall there were 18 dehiscences (4.6%) and 14 infections (3.6%) in the total group with perineal morbidity. Two high rectovaginal fistulas were concomitantly detected in women with perineal dehiscence. Only shoulder dystocia, metritis, and postpartum fever occurred significantly more frequently in patients with postpartum perineal morbidity than in women without perineal morbidity. Smoking and human papillomavirus infection were not associated with perineal repair morbidity. CONCLUSIONS: Postpartum perineal morbidity after fourth-degree perineal repair is an uncommon event. It is not predicted by readily preventable antepartum or intrapartum factors.

    Title Evaluation of Molecular Methodologies and Rabbit Infectivity Testing for the Diagnosis of Congenital Syphilis and Neonatal Central Nervous System Invasion by Treponema Pallidum.
    Date February 1993
    Journal The Journal of Infectious Diseases
    Excerpt

    IgM immunoblotting and polymerase chain reaction (PCR) were evaluated for use in diagnosing congenital syphilis, and the prevalence of central nervous system (CNS) invasion by Treponema pallidum during congenital infection was examined. The results of rabbit infectivity testing (RIT) on serum and cerebrospinal fluid (CSF) of 19 infants born to mothers with untreated early syphilis were compared with results of PCR and IgM immunoblotting. Seven infants had clinical evidence of congenital syphilis supported by positive serum IgM immunoblot (7/7), PCR (6/7), and RIT (3/3). Six symptomatic infants (86%) had T. pallidum isolated from CSF by RIT; 5 of 6 RIT-positive CSF samples were positive by PCR, and 2 also were reactive by IgM immunoblot. In 12 asymptomatic infants, 5 (42%) had a reactive serum IgM immunoblot and in 4 of these IgM reactivity was the only evidence of congenital infection. CNS invasion by T. pallidum was uncommon among asymptomatic infants; only 1 (8%) was positive by CSF RIT. The excellent agreement between RIT and PCR further substantiates the use of PCR as a surrogate for RIT. Our data indicate that the diagnosis of asymptomatically infected neonates will require a comprehensive approach using assays for both specific neonatal IgM and T. pallidum DNA in serum and CSF.

    Title Treatment of Gonorrhea in Pregnancy.
    Date January 1993
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To evaluate prospectively the 1989 Centers for Disease Control recommendations for treatment of gonorrhea in pregnancy. METHODS: Two hundred fifty-two women referred with probable endocervical gonorrhea had pre-treatment endocervical, rectal, and oral cultures for Neisseria gonorrhoeae and direct fluorescent antibody testing for Chlamydia trachomatis. They were assigned randomly to receive ceftriaxone 250 mg intramuscularly (IM), spectinomycin 2 g IM, or amoxicillin 3 g orally plus probenecid 1 g orally. Treatment was unblinded and in a 1:1:1 distribution. RESULTS: Two hundred forty-five women (97%) had endocervical infection, 68 (27%) had rectal infection, and 17 (7%) had pharyngeal infection. One hundred two of 252 women (40%) had concomitant endocervical C trachomatis. The overall efficacy was 235 of 252 subjects (93%) (95% confidence interval [CI] 90.1-96.4%). Ceftriaxone was effective in 80 of 84 cases (95%) (95% CI 90.6-99.9%), amoxicillin with probenecid was effective in 75 of 84 cases (89%) (95% CI 82.5-96%), and spectinomycin was effective in 80 of 84 cases (95%) (95% CI 90.6-99.9%). No significant difference was noted in overall efficacy or by site of infection. There was no increased incidence of congenital malformations in the offspring spring of any treatment group. CONCLUSIONS: Ceftriaxone and spectinomycin are safe and effective for the treatment of gonorrhea in pregnancy. Amoxicillin with probenecid has lower efficacy and is not recommended for treatment of gonococcal infection in pregnancy.

    Title The Prevalence of Sexual Assault: a Survey of 2404 Puerperal Women.
    Date November 1992
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The purpose of this investigation was to determine the prevalence of sexual assault, to characterize pregnancy complications, and to report pregnancy outcomes of assault victims. STUDY DESIGN: Puerperal women (n = 2404) were interviewed regarding a history of forced sexual contact. Obstetric, medical, and forensic records were reviewed. Statistical analysis was performed by Student t test, chi 2 test, or Fisher's exact test. RESULTS: The lifetime prevalence of sexual assault in this obstetric population was 5% (n = 120). Rape victims had a higher incidence of sexually transmitted diseases (9% vs 4%, p < 0.01), urinary tract infections or vaginitis (32% vs 21%, p = 0.02), drug use (9% vs 2%, p < 0.001), and multiple hospitalizations during the index pregnancy (15% vs 8%, p < 0.01). There was no difference between victims and nonvictims in neonatal outcome as reflected by umbilical artery blood pH, gestational age, or birth weight. CONCLUSIONS: A history of sexual assault is common in an urban indigent obstetric population. These women have more frequent pregnancy complications but achieve normal pregnancy outcomes.

    Title Sexual Assault in Postmenopausal Women.
    Date November 1992
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To examine patient characteristics, patterns of injury, forensic evidence, and the frequency of sexual assault in postmenopausal rape victims from 1986-1991. METHODS: Medical and forensic records were reviewed from 129 postmenopausal women (50 years of age or older) and 129 women from a comparison group (14-49 years of age) who reported having been sexually assaulted. Statistical analysis was performed by Student t test, chi 2, multiple logistic regression, or Fisher exact test. RESULTS: Postmenopausal women represented 2.2% of women reporting sexual assault in Dallas County. The postmenopausal victim was more often white (64%), whereas the younger victim was more often black (53%). Drug or alcohol use within the previous 24 hours was more common in the younger group. Trauma, in general, was common, occurring in 67% of the postmenopausal women and 71% of the younger group (P = not significant). Genital trauma was more common in the postmenopausal group (43 versus 18%; P < .001). Nearly one in three postmenopausal women had genital abrasions or edema. Almost one in five older women had genital lacerations, with one in four severe enough to require surgical repair. In contrast, the frequency of extragenital trauma was more common in younger victims (66 versus 49%; P < .01). Forensic findings were similar in both groups; however, in postmenopausal women motile spermatozoa were seen only in those examined within 6 hours of the assault. CONCLUSION: Postmenopausal women who have been sexually assaulted are more likely to sustain genital trauma than younger victims.

    Title Igm Antibody to Treponema Pallidum in Cerebrospinal Fluid of Infants with Congenital Syphilis.
    Date October 1992
    Journal American Journal of Diseases of Children (1960)
    Excerpt

    OBJECTIVES--To characterize the neonatal IgG and IgM response to specific Treponema pallidum antigens in the cerebrospinal fluid (CSF) of infants with congenital syphilis. DESIGN--Cross-sectional survey. SETTING--Newborn nursery and neonatal intensive care unit of a county hospital in Dallas, Tex. PARTICIPANTS--Twenty-one infants born to mothers with reactive serologic tests for syphilis were enrolled. Group 1 consisted of six infants with clinical and laboratory evidence of congenital syphilis; group 2, six asymptomatic infants born to mothers with untreated syphilis; and group 3, nine asymptomatic infants whose mothers were treated for syphilis before delivery. SELECTION PROCEDURES--Random sample. MEASUREMENTS AND RESULTS--Immunoblotting was used to examine the IgM and IgG reactivities of neonatal serum and CSF against T pallidum antigens. Among serum samples of all group 1 infants, a specific IgM response to T pallidum antigens with apparent molecular masses of 47, 45, and 17 kd was observed. Cerebrospinal fluid IgM reactivity to a 47-kd antigen of T pallidum was seen in four group 1 infants. Serum samples from two group 2 and three group 3 infants demonstrated IgM reactivity against the 47-kd antigen and, in some cases, against the 45-kd antigen of T pallidum. None of 15 group 2 and 3 infants had a positive CSF IgM immunoblot result. The IgG reactivity in CSF was similar in the three groups and was directed against T pallidum antigens with apparent molecular masses of 72, 59, 47, 45, 42, 37, 34, 17, and 15 kd. CONCLUSIONS--A specific IgM response to T pallidum antigens, particularly the 47-kd antigen, was detected in the CSF of some infants with clinical and laboratory evidence of congenital syphilis. The potential usefulness of this test for the diagnosis of congenital neurosyphilis merits further study.

    Title Seroprevalence and Risk Factors for Hepatitis C Virus Antibody in Pregnant Women.
    Date October 1992
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To better understand hepatitis C viropathies and seroprevalence by performing an epidemiologic analysis of pregnant women seropositive for antibody against hepatitis C. METHODS: We studied 1013 consecutive obstetric patients at Parkland Memorial Hospital who gave informed consent for detailed interviews and serotesting. Sera were analyzed for antibody to the hepatitis C virus using both C100-3 and RIBA-4 assays. Neonatal assessment was carried out in the immediate postpartum period. RESULTS: Hepatitis C antibody was detected in 2.28% (N = 23) of the 1005 women in whom analysis was completed. Factors associated with seropositivity included intravenous (IV) drug use, sexually transmitted diseases, hepatitis B infection, maternal age greater than 22.5 years, increased parity (eg, greater than 2.1), history of transfusion, and three or more different lifetime sexual partners or a sexual partner who used IV drugs. Maternal and neonatal outcome was not different between hepatitis C antibody-positive and -negative groups. CONCLUSIONS: Epidemiologic data are consistent with sexual and parenteral modes of transmission. Women with hepatitis C antibody did not have excessive perinatal complications compared with antibody-negative women. A model protocol and cost analysis for screening pregnant women for hepatitis C infection are presented. However, routine screening for hepatitis C is not advocated.

    Title Randomized Comparison of Cefotaxime and Ceftriaxone in Patients with Uncomplicated Gonorrhea.
    Date April 1992
    Journal Clinical Therapeutics
    Excerpt

    Cefotaxime is a third-generation cephalosporin with excellent in vitro antimicrobial activity against Neisseria gonorrhoeae, including beta-lactamase-producing strains. A single, 1-gm, intramuscular dose has previously been shown to be effective in the treatment of uncomplicated gonorrhea. A randomized, multicenter study was conducted to evaluate the efficacy and safety of a lower, 500-mg dose of cefotaxime in comparison with ceftriaxone 250 mg, the standard treatment for uncomplicated gonorrhea. One hundred forty-two patients were enrolled and 115 were evaluable. Bacteriologic eradication rates were 95% in the cefotaxime group and 100% in the ceftriaxone group (P = 0.119). Adverse events that were possibly related to the study drug occurred in 3% and 8% of patients in the cefotaxime and ceftriaxone groups, respectively. Cefotaxime 500 mg appears to be a safe and cost-effective alternative to ceftriaxone 250 mg for the treatment of uncomplicated gonorrhea.

    Title Congenital Syphilis Associated with Dilation of Fetal Small Bowel. A Case Report.
    Date March 1992
    Journal Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine
    Title Use of Polymerase Chain Reaction and Rabbit Infectivity Testing to Detect Treponema Pallidum in Amniotic Fluid, Fetal and Neonatal Sera, and Cerebrospinal Fluid.
    Date February 1992
    Journal Journal of Clinical Microbiology
    Excerpt

    The diagnosis of congenital syphilis continues to pose a difficult clinical challenge. Because the serodiagnosis of congenital syphilis has significant limitations, the direct detection of Treponema pallidum in suspect neonatal tissues or body fluids represents a desirable alternate diagnostic strategy. We developed and applied the polymerase chain reaction (PCR) for the detection of T. pallidum in clinical material relevant to the diagnosis of congenital syphilis but which typically contain factors inhibitory for the PCR. Four methods of specimen processing were examined to circumvent PCR inhibition; clinical materials included amniotic fluids, neonatal sera, and neonatal cerebrospinal fluids. The PCR was 100% specific for T. T. pallidum compared with the sensitive rabbit infectivity test (RIT) for all clinical materials tested. For amniotic fluids, the PCR was 100% sensitive when correlated with the RIT but had a lesser sensitivity when applied to sera or cerebrospinal fluids, which typically contain few treponemes. The combined sensitivity of the PCR for all clinical samples was 78%. Positive PCR results also were obtained among some clinical specimens for which RIT was not performed; these results correlated well with either stigmata or risk factors for congenital syphilis. The combined results suggest that the PCR can be a useful adjunct to the diagnosis and clinical management of congenital syphilis and that it will provide a valuable tool for investigations of the pathogenesis of the disorder.

    Title Identification of Treponema Pallidum in Amniotic Fluid and Fetal Blood from Pregnancies Complicated by Congenital Syphilis.
    Date November 1991
    Journal Obstetrics and Gynecology
    Excerpt

    Two pregnant women with secondary syphilis underwent amniocentesis and evaluation for fetal syphilis. In both cases, motile spirochetes, typical of Treponema pallidum, were observed during dark-field microscopic examination of the amniotic fluid. The presence of T pallidum was confirmed by antitreponemal monoclonal antibody immunofluorescence assays and by rabbit infectivity tests using the amniotic fluid. In the first case, an infant at 35 weeks' gestation delivered within 24 hours of amniocentesis had hepatosplenomegaly, osteochondritis, and neurosyphilis. In the second case, a fetus at 24 weeks' gestation was hydropic and a fetal blood sample showed anemia, thrombocytopenia, and elevated liver enzymes. Fetal syphilis was confirmed by rabbit infectivity testing using fetal blood obtained by funipuncture. This is the first report of the diagnosis of fetal syphilis by funipuncture and confirmation of the presence of virulent T pallidum in the blood of a human fetus. The mother was treated for secondary syphilis, but the infant had residual signs of congenital infection at birth 14 weeks later. Neonatal serum from the first case and fetal serum from the second case showed specific immunoglobulin M reactivity with the 47-kd antigen of T pallidum by Western blot assays. A new wild-type strain of T pallidum, designated DAL-1, was isolated from the amniotic fluid of the first case and is available for future studies. We conclude that the presence of T pallidum in amniotic fluid or fetal blood indicates fetal-placental infection. Further investigation is necessary to determine the pathogenesis of amniotic fluid infection and its role in the prenatal diagnosis of congenital syphilis.

    Title Congenital Syphilis Associated with Negative Results of Maternal Serologic Tests at Delivery.
    Date September 1991
    Journal American Journal of Diseases of Children (1960)
    Title Hiv Prevalence in Pregnant Intravenous Drug Users in Dallas, Texas.
    Date June 1991
    Journal Texas Medicine
    Excerpt

    Information available regarding the prevalence of human immunodeficiency virus (HIV) in pregnant women indicates that the primary risk factor for infection is intravenous drug use. At Parkland Memorial Hospital in Dallas, Texas, approximately 4.7% of pregnant women reported using intravenous drugs. The estimated prevalence of HIV infection among pregnant intravenous drug users at this hospital was 3.3%. This is similar to the HIV infection rates reported for nonpregnant parenteral drug-using populations in other areas of the southwestern United States, suggesting that there may be a lower rate of endemic infection in this region of the country.

    Title A Randomized Trial of Ofloxacin Versus Cefoxitin and Doxycycline in the Outpatient Treatment of Acute Salpingitis.
    Date June 1991
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    The object of this randomized study was to compare the safety and efficacy of oral ofloxacin, 400 mg twice daily for 10 days, versus intramuscular cefoxitin, 2 gm, plus oral probenecid, 1 gm, followed by oral doxycycline, 100 mg twice daily for 10 days, in the outpatient treatment of uncomplicated acute salpingitis. Thirty-eight women (53%) had Neisseria gonorrhoeae from their pretreatment endocervical or endometrial cultures, and 18 had Chlamydia trachomatis (25%). Thirty-five of 37 women (95%) treated with the ofloxacin regimen were clinically cured, and 34 of 35 (97%) were cured with the cefoxitin-doxycycline regimen (p = 0.52). One clinical failure occurred in each group with N. gonorrhoeae infection, and one failure occurred in the ofloxacin group because of side effects. The bacteriologic response for N. gonorrhoeae in both groups was 100%. The eradication of C. trachomatis was 100% (10/10) for the cefoxitin/doxycycline group and 86% (6/7) for ofloxacin. The side effects were similar in both groups of subjects. In this study both regimens were effective for the outpatient treatment of uncomplicated acute salpingitis.

    Title Sexual Assault in Pregnancy.
    Date May 1991
    Journal Obstetrics and Gynecology
    Excerpt

    Little is known about the acute effects of sexual assault on pregnant victims and the outcome of their gestations. A retrospective review of sexual assault victims in Dallas County from 1983-1988 revealed that 114 of 5734 (2%) were pregnant. There were 0.55 and 0.75 gravid sexual assault victims per 1000 deliveries for Dallas County and Parkland Memorial Hospital, respectively. The purposes of this study were to examine patient demographics, forensic evidence and patterns of injury in pregnant victims compared with 114 matched nonpregnant sexual assault victims, and to compare pregnancy outcome with that of the Parkland Memorial Hospital obstetric population. The typical victim was a black, parous gravida in her twenties at a mean gestational age of 15 weeks, without previous prenatal care. Vulvar (95%), oral (27%), and anal (6%) penetration were reported with similar frequency in both groups. The detection of whole and motile sperm from the vaginal specimens was similar in pregnant and nonpregnant women. Physical trauma was more common in nonpregnant victims (63 versus 43%; P less than .004), especially genital trauma (21 versus 5%; P less than .001). Injury was more common to the head and neck or extremities than to the abdomen, chest, or back in both groups. There was no difference in the pattern of trauma by gestational age, but there were no truncal injuries in women at 20 weeks' gestation or greater. There were no spontaneous abortions or deliveries within 4 weeks of the assault, but low birth weight delivery (24%) and preterm delivery (16%) were common.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Doppler Systolic-diastolic Ratios in Pregnancies Complicated by Syphilis.
    Date February 1991
    Journal Obstetrics and Gynecology
    Excerpt

    Maternal infection with syphilis can result in focal areas of vasculitis and, similarly, placental villitis and obliterative arteritis. We hypothesized that Doppler systolic-diastolic ratios (S/Ds) in pregnancies complicated by maternal syphilis infection might reflect an increased resistance to placental perfusion. Doppler velocity waveform analysis was used to study the uterine and umbilical arteries in third-trimester pregnancies complicated by maternal syphilis infection. A control group of similarly studied normal pregnancies was used for comparison. Statistically significant increases were found in the mean S/Ds of both the uterine and umbilical arteries in the syphilis group compared with the normal group, indicating an increased resistance to perfusion of the placenta in pregnancies complicated by syphilis. This difference was even greater in association with the identification of spirochetes in the amniotic fluid by dark-field microscopy, indicating that the S/D results are related to the presence of intrauterine infection. Serial S/Ds in a small subgroup of patients correlated with the clinical courses, including an apparent acute vascular-resistance change associated with treatment, probably due to the Jarisch-Herxheimer reaction. Because of these post-treatment vascular events, the pre-treatment S/D alone may have a limited clinical predictive value for treatment efficacy in congenital syphilis.

    Title Shoulder Dystocia.
    Date December 1990
    Journal Clinical Obstetrics and Gynecology
    Title Sexually Transmitted Diseases in Pregnancy.
    Date June 1990
    Journal Seminars in Perinatology
    Excerpt

    STDs can be one of the most common antepartum complications in high-risk gravidas. Screening for gonorrhea, syphilis, HPV, and possibly hepatitis B and chlamydial infection, should be considered in most, if not all, pregnant women. Familiarity with the common clinical presentations and treatment of bacterial STDs will prevent untoward maternal and neonatal outcome. Recognition of viral STDs, followed by appropriate counseling and management, will avoid most neonatal viral infection.

    Title The Jarisch-herxheimer Reaction Complicating Syphilotherapy in Pregnancy.
    Date March 1990
    Journal Obstetrics and Gynecology
    Excerpt

    Thirty-three gravidas with syphilis were monitored with hourly vital signs and examinations for 24 hours after treatment with benzathine penicillin G. Fifteen (45%) of the subjects had a Jarisch-Herxheimer reaction, including all three, 12 of 20 (60%), and none of ten of those with primary, secondary, and latent syphilis, respectively. The most common symptoms were fever (73%), uterine contractions (67%), and decreased fetal movement (67%). The signs or symptoms began 2-8 hours after treatment; fevers peaked at 6-12 hours post-therapy and the events usually abated by 16-24 hours after treatment. Uterine contractions and decreased fetal activity began concurrent with maternal fever in eight of ten women reporting contractions. Transient late decelerations were detected in three of 11 monitored patients. Three of the women with Jarisch-Herxheimer reactions delivered infants with congenital syphilis, including one stillbirth, but none of those without a detectable reaction had fetal treatment failures. Prostaglandin F2 alpha and prostacyclin metabolites were elevated transiently in the one subject studied, suggesting their role in mediating the cardiovascular and uterine events in the post-treatment period. The Jarisch-Herxheimer reaction in pregnancy is similar in frequency, character, and intensity to that in nonpregnant adults, but gravidas may have increase uterine activity and transient alterations in fetal well-being. The pregnant patient with a severely affected fetus with congenital syphilis may experience preterm labor, preterm delivery, or fetal death in association with the Jarisch-Herxheimer reaction.

    Title Early and Congenital Syphilis.
    Date January 1990
    Journal Obstetrics and Gynecology Clinics of North America
    Excerpt

    The incidence of infectious syphilis is increasing in the United States, particularly among women. Not surprisingly, congenital syphilis rates have also risen. These have led to a rekindling of interest in the manifestations and treatment of primary, secondary, and latent syphilis. Coinfection with human immunodeficiency virus may alter clinical presentations and response to therapy.

    Title Examination of Amniotic Fluid in Diagnosing Congenital Syphilis with Fetal Death.
    Date December 1989
    Journal Obstetrics and Gynecology
    Excerpt

    The diagnosis of congenital syphilis is difficult, particularly in stillborn fetuses, who are often macerated and have undergone autolysis. These changes can obscure both syphilitic histologic findings and special stains for spirochetes in tissue specimens used to confirm the diagnosis of congenital syphilis. Five gravidas with untreated syphilis and fetal deaths underwent sonographic examination and amniocentesis. In all five cases, dark-field microscopic examination of the amniotic fluid showed spirochetes with morphology and motility characteristic of Treponema pallidum. Organisms were infrequent, but easily identified at 400x magnification and confirmed using an oil-immersion objective yielding a 900x magnification. After delivery, fetal-placental examination and autopsy showed clinical findings typical of congenital syphilis in all five cases. Histologic changes compatible with syphilis were found in all four autopsied fetuses. Silver impregnation stains were positive in two of five tissue specimens, and anti-treponemal monoclonal antibody immunofluorescence assays were positive in one of three amniotic fluid specimens examined retrospectively, further strengthening the specificity of the dark-field microscopic identification of spirochetes. This technique, which can make the diagnosis of congenital syphilis, is recommended for women with syphilis and a fetal death, especially if sonographic hydrops and/or edema is present or if an autopsy will not be performed.

    Title Concomitant Infection with Neisseria Gonorrhoeae and Chlamydia Trachomatis in Pregnancy.
    Date September 1989
    Journal Obstetrics and Gynecology
    Excerpt

    Gonorrhea is an important marker for endocervical chlamydial infections in nonpregnant women. Concomitant infection rates as high as 50% have been reported. There are few data on concomitant infection rates in pregnant patients. The purpose of this study was to examine the prevalence of endocervical chlamydial infections in pregnant women with gonorrhea. Patients with cervical cultures positive for Neisseria gonorrhoeae at their initial prenatal visit had endocervical specimens for Chlamydia trachomatis culture obtained before anti-gonorrheal therapy. Control patients were selected at random from the same prenatal population. The prevalence of C trachomatis in patients with gonorrhea was significantly greater than that in the control population (46 versus 5%; P less than .001). Patients with gonorrhea were younger, less often married, and more often black than the control population, but these demographic differences did not account for the large difference in the chlamydial prevalence. Erythromycin 500 mg four times daily provided an excellent cure rate without intolerable side effects. Pregnant patients being evaluated or treated for gonorrhea should also be considered at high risk for concomitant cervical chlamydial infection.

    Title Cardiac Arrhythmias During Pregnancy.
    Date August 1989
    Journal Clinical Obstetrics and Gynecology
    Excerpt

    Arrhythmias of the pregnant patient are rare. In most cases, the therapeutic agent chosen should be much the same as that in the nonpregnant patient, and an understanding of the pharmacology of the antiarrhythmic agents is necessary for rational use in the pregnant patient with an arrhythmia. Substantial experience has been accumulated using some of the older agents for treatment of arrhythmias in pregnancy. As newer agents become available, there may be indications for their use in pregnancy; however, we recommend initially using well-known drugs until more experience is gained with the newer ones. The choice of an agent should be made only after thorough evaluation of the patient's symptoms, accurate diagnosis and an analysis of potential benefit versus potential risk to the mother or fetus.

    Title Molecular Analysis of the Fetal Igm Response to Treponema Pallidum Antigens: Implications for Improved Serodiagnosis of Congenital Syphilis.
    Date March 1989
    Journal The Journal of Infectious Diseases
    Excerpt

    Western blot analysis of the fetal IgM response to Treponema pallidum antigens was examined among 39 pairs of maternal/infant sera; this included 12 mothers and infants with active syphilis (group I), 9 mothers with active syphilis and their infants with uncertain infection (group II), and 18 mothers treated for syphilis before delivery and their asymptomatic infants (group III). A fetal IgM response to T. pallidum antigens with apparent molecular masses of 72, 47, 45, 42, 37, 17, and 15 kDa was observed among sera of infants with congenital syphilis. Fractionation of sera into IgM and IgG components by high performance liquid chromatography confirmed that fetal IgM antibodies in every case were directed specifically against a 47-kDa antigen. Two asymptomatic infants from group II also showed serum IgM reactivities with the 47-kDa antigen, thereby appearing to confirm in utero infection. The combined data suggest that fetal serum IgM reactivity with the 47-kDa antigen of T. pallidum can be used as an important molecular marker for the diagnosis of congenital syphilis.

    Title The Effects of Syphilis on Endocrine Function of the Fetoplacental Unit.
    Date January 1989
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    Several pregnancy complications that are thought to cause chronic intrauterine stress have been found to lead to inappropriate fetal development and reductions in estrogen production. In the current study we sought to evaluate the fetoplacental unit in pregnancies complicated by maternal syphilis (n = 37), with and without fetal infection. Maternal 17 beta-estradiol and estriol levels were reduced during the third trimester in women with syphilis when compared with those in women with uncomplicated pregnancies. Serum progesterone levels were within normal limits or else were increased in women with syphilis. When compared with data in age- and weight-matched control infants of women having no pregnancy complications, umbilical cord serum levels of dehydroepiandrosterone sulfate, the major fetal adrenal precursor of placental estrogens, were subnormal (897 +/- 597 ng/ml, mean +/- SD) in 12 newborn infants with congenital syphilis (33.9 +/- 4.2 weeks' gestation, birth weight 2020 +/- 719 gm); such infants also had excessive serum levels of cholesterol (103 +/- 37 mg/dl). Dehydroepiandrosterone sulfate (1883 +/- 907 ng/ml) and cholesterol (58.1 +/- 13.9 mg/dl) levels were within normal limits in 19 uninfected infants of women with syphilis (38.6 +/- 2.4 weeks' gestation, birth weight 2861 +/- 660 gm). Cortisol levels were increased and estriol levels were decreased in both groups of neonates of women with syphilis compared with those in control neonates. These findings are suggestive that estrogen production often is reduced in pregnancies complicated by syphilis; the reduction in estriol appears to be largely due to reduced fetal adrenal dehydroepiandrosterone sulfate production. The reduction in 17 beta-estradiol levels may be due to alterations in maternal precursor synthesis. Although placental progesterone formation appears to be normal in women with syphilis, a deficiency in placental aromatase activity also is possible.

    Title Gestational and Congenital Syphilis.
    Date July 1988
    Journal Clinics in Perinatology
    Excerpt

    The frequency of congenital syphilis continues to increase throughout the United States during the 1980s. Untreated maternal infection can lead to stillbirth, premature labor, congenital infection, and neonatal death. Preventive measures, based on control of early syphilis in women, prenatal care, improved diagnosis and diligent followup, can help to decrease the incidence of congenital syphilis. The clinical presentation and recommended regimens for therapy of the gravida with syphilis and neonates with suspected congenital syphilis are reviewed.

    Title Multicenter Comparison of Cefotetan and Cefoxitin in the Treatment of Acute Obstetric and Gynecologic Infections.
    Date May 1988
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    Two hundred eighty-seven women were treated in a multicenter, randomized, comparative study to compare the safety and efficacy of cefotetan every 12 hours with that of cefoxitin every 6 or 8 hours in the treatment of acute obstetric and gynecologic pelvic infections. The most frequent primary diagnoses in both groups were endometritis and pelvic inflammatory disease; 24 of these patients were also bacteremic. The mean duration of treatment was 5.2 and 5.4 days for the cefotetan and cefoxitin groups, respectively, and the total doses administered were 18.1 and 32.1 gm, respectively. The rate of clinical failure for the cefotetan group was 8.5% and 12.2% for the cefoxitin group. Laboratory and clinical adverse reactions were infrequent and none was serious; both antimicrobials were well tolerated. These results suggest the administration of cefotetan provided adequate clinical and bacteriologic effectiveness in the treatment of hospital- and community-acquired, polymicrobial obstetric and gynecologic pelvic infections.

    Title Oral Desensitization for Penicillin Sensitivity.
    Date April 1987
    Journal Jama : the Journal of the American Medical Association
    Title Trophoblastic Embolization During Molar Evacuation: Central Hemodynamic Observations.
    Date March 1987
    Journal Obstetrics and Gynecology
    Excerpt

    We evaluated prospectively the extent of trophoblastic embolization and its central hemodynamic effects during and after evacuation of large molar pregnancies in six women. A pulmonary artery catheter was inserted to obtain hemodynamic measurements as well as to obtain blood samples to identify trophoblasts before, during, and six hours after evacuation. Small numbers of both multinucleated giant cells and of large mononuclear cells with abundant cytoplasm were identified in the buffy coat of blood, aspirated in two cases before evacuation and for all six cases, during evacuation. There were no significant changes in heart rate or mean systemic arterial, pulmonary arterial, central venous, and pulmonary capillary wedge pressures; or cardiac output, stroke volume, and pulmonary or systemic vascular resistance when preevacuation preanesthetic values were compared with those six hours after evacuation. However, significant decreases in heart rate, mean arterial pressure, and pulmonary vascular resistance were observed during evacuation, which returned to preevacuation levels by completion of anesthesia.

    Title Penicillin Allergy and Desensitization in Serious Infections During Pregnancy.
    Date May 1985
    Journal The New England Journal of Medicine
    Excerpt

    Penicillin allergy presents a major obstacle to the successful management of some antepartum infections. We studied 15 pregnant women with histories of penicillin allergy confirmed by positive immediate wheal-and-flare skin tests. Thirteen had syphilis, one listeria sepsis, and one Streptococcus viridans endocarditis. Each patient was desensitized over four to six hours by oral administration of increasing doses of penicillin V. At the completion of the procedure, full-dose parenteral therapy with penicillin G or ampicillin was instituted. No extracutaneous reactions were detected. Five of the subjects (33 per cent) experienced pruritus (three) or urticaria (two), but no interruption of desensitization or therapy was necessary. All clinically apparent maternal infections were cured. The pregnancy complicated by listeriosis aborted in the first trimester. The 11 neonates delivered to date are normal. These results indicate that oral desensitization is an acceptably safe approach to therapy in pregnant women who are allergic to penicillin and have infections that require beta-lactam drugs.

    Title Myocardial Infarction During Pregnancy: a Review.
    Date January 1985
    Journal Obstetrics and Gynecology
    Excerpt

    In the present review the world literature on pregnancy complicated by myocardial infarction is summarized, and two additional cases are presented. It is apparent that the majority of pregnant women who have died after myocardial infarction did so at the time of initial infarction, and maternal mortality was greatest if the infarction was late in pregnancy. Moreover, delivery within two weeks of infarction was associated with increased mortality as was reinfarction during labor. These results suggest that the increasing cardiovascular stresses of late pregnancy, especially when intensified by parturition, seriously compromise women with ischemic heart disease. Efforts should therefore be made to limit myocardial oxygen demand/consumption throughout pregnancy, and particularly during parturition. Although principles of management can be generalized, these high risk patients require individualization of care by a multidisciplinary team of cardiologists, anesthesiologists, and obstetricians.

    Title Longitudinal Evaluation of Hemodynamic Changes in Eclampsia.
    Date December 1984
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    Eight primigravid women with eclampsia underwent invasive hemodynamic monitoring shortly after admission and showed initial low right and left ventricular filling pressures, hyperdynamic left ventricular function, and elevated systemic vascular resistance. These findings persisted throughout 12 postpartum hours, with management that consisted of restriction of fluid, magnesium sulfate, and intermittent hydralazine for severe hypertension. Thereafter, those women without spontaneous diuresis had elevated pulmonary capillary wedge pressures despite hyperdynamic ventricular function. We hypothesize that this phenomenon was due to mobilization of extracellular extravascular fluid prior to diuresis. Comparison of these women with those with severe preeclampsia previously reported by others suggests that their hemodynamic status is significantly influenced by differences in fluid management.

    Title Sustaining the Prolife Momentum: Legal and Political Strategies.
    Date January 1983
    Journal Hospital Progress
    Title Inpatient Treatment for Uncomplicated and Complicated Acute Pelvic Inflammatory Disease: Ampicillin/sulbactam Vs. Cefoxitin.
    Date
    Journal Infectious Diseases in Obstetrics and Gynecology
    Excerpt

    Objective: Ampicillin plus sulbactam, an irreversible beta-lactamase inhibitor, was compared to cefoxitin in the treatment of women with acute pelvic inflammatory disease (PID) with and without inflammatory mass(es).Methods: Participation in an open, prospective, randomized clinical trial was offered to all women given the clinical diagnosis of acute PID who required inpatient therapy. Neisseria gonorrhoeae and Chlamydia trachomatis were sought in cervical and endometrial samples and aerobic and anaerobic species were sought in endometrial samples prior to treatment initiation. Treatment was given on at least 4 days and until women were afebrile for at least 48 h. Daily examinations were performed to assess response to therapy and safety. Only women in whom C. trachomatis was identified were discharged from the hospital on oral doxycycline to be taken for 10-14 days.Results: One hundred twenty-four women were evaluated for safety; 117 (94%) were evaluated for efficacy. Demographic characteristics were similar for women in each treatment group. N. gonorrhoeae was recovered from 59% and C. trachomatis was recovered from 42% of study subjects. Inflammatory masses were identified in 35/76 (46%) women given ampicillin/sulbactam and 17/41 (41%) women given cefoxitin. Ampicillin/sulbactam cured 75 ,of 76 women (98.7%) [95% confidence interval (CI) 92.9-100.0%] and cefoxitin cured 37 of,41,omen (90.2%) (95% CI 76.9-97.3%) in that treatment regimen.Conclusions: Overall ampicillin/sulbactam was more effective (P = 0.05) than cefoxitin, due to superior efficacy in infection complicated by inflammatory mass(es).35/35 vs. 12/17 cured; P = 0.007).

    Title Acute Obstructive Hydrocephalus Due to Cysticercosis During Pregnancy.
    Date
    Journal Infectious Diseases in Obstetrics and Gynecology
    Excerpt

    Background: Cysticercosis, due to the parasite Taenia solium, can involve any organ. When central nervous system infection occurs, signs and symptoms depend on the location of the cerebral lesions. Most patients develop seizures, focal symptoms, or headaches with nausea and vomiting.Case: A case of extraparenchymal (intraventricular) cysticercosis was diagnosed in a patient at term who presented with acute alteration in mental status. Ventriculostomy was performed because of acute obstructive hydrocephalus. Labor ensued and was augmented with oxytocin. Intrapartum management included magnesium sulfate seizure prophylaxis and corticosteroids. Intracranial pressures ranged between 4 and 12 cm H(2)O peripartum with approximately 300 mL of cerebrospinal fluid drained over the first 24 hours. Postpartum management included craniotomy with resection of a larval cyst and oral praziquantel therapy.Conclusion: This case describes an uncommon presentation of neurocysticercosis that should be considered in gravidas with acute mental status changes.

    Title Infectious Diseases Are Important Worldwide Causes of Morbidity and Mortality in Women. Preface.
    Date
    Journal Infectious Disease Clinics of North America
    Title Rapid Diagnostic Methods in Sexually Transmitted Infections.
    Date
    Journal Infectious Disease Clinics of North America
    Excerpt

    Sexually transmitted infections (STIs) are common infections throughout the developed and the developing world. It is estimated that worldwide there are 1 million new cases per day of curable bacterial STIs. As part of the World Health Organization 2001 Sexually Transmitted Diseases Diagnostics Initiative, the organization explored the need for simple, affordable, point-of-care STI testing for curable bacterial STIs. This article reviews the evidence supporting the implementation of currently available rapid tests for five common STIs: syphilis, gonorrhea, chlamydia, HIV, and herpes.

    Title Efficacy of an Accelerated Hepatitis B Vaccination Program During Pregnancy.
    Date
    Journal Obstetrics and Gynecology
    Excerpt

    To estimate the feasibility and immunogenicity of an accelerated hepatitis B vaccination schedule of 0, 1, and 4 months in high-risk pregnant women.

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