Prevention of early-onset invasive neonatal group B streptococcal disease in a private hospital setting: the superiority of culture-based protocols

OBJECTIVE: In a large private tertiary care hospital we compared the two different approaches to group B streptococcal screening and intrapartum chemoprophylaxis suggested by The American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the Centers for Disease Control and Prevention: risk factor-based protocol and culture-based protocol. STUDY DESIGN: A 2-year baseline period was followed by sequential prospective observational studies of the impacts of two different group B streptococcal management protocols, 3 years with the risk-based approach and 2 years with the culture-based approach of universal screening at 35 to 37 weeks' gestation. RESULTS: During the baseline period the rate of early-onset group B streptococcal infection was 1. 1 cases per 1000 births (n = 8 cases per 6829 births). With the risk-based strategy the rate was also 1.1 cases per 1000 births (15 cases/13,270 births). After we switched to the culture-based protocol for 2 years, there were no cases of early-onset group B streptococcal infections among 9304 births (P =.001; chi(2) = 10.9). There were no increases in other early-onset infections or in antibiotic resistance. CONCLUSIONS: In our setting, which included good prenatal care and good communication between laboratories and the hospital, the approach based on maternal culture at 35 to 37 weeks' gestation and treatment during labor of all patients with positive results significantly reduced early-onset group B streptococcal infections without increasing infections from resistant organisms.     

Obstetrician preferences for prenatal strategies to reduce early-onset group B streptococcal infection in neonates: a population-based survey

OBJECTIVE: In light of a recent proposal to legislate group B streptococcal prevention strategies in New Jersey, this study examined obstetrician preferences and practices toward group B streptococcal prevention strategies in neonates. STUDY DESIGN: This was a mail survey of American College of Obstetricians and Gynecologists Fellows in New Jersey. Physician characteristics, existing guideline preferences, and reported actual group B streptococcal prevention practices were measured. RESULTS: Of the 695 potential respondents, 306 responses (44.7%) were received for analysis. Respondent stated preferences were for guidelines from the Centers for Disease and Prevention (74.5%), American College of Obstetricians and Gynecologists (12.7%), American Academy of Pediatrics (9.2%), and others (3.6%). The proportions of obstetricians who actually adhere to their stated preference were 57.5%, 64.1%, and 39.3% in Centers for Disease and Prevention, American College of Obstetricians and Gynecologists, and American Academy of Pediatrics group, respectively. Only 40.7% of the obstetricians cultured the anorectal/vaginal area for group B streptococcal carriers. An overwhelming 86.7% of obstetricians do not support legislation that regulates neonatal group B streptococcal preventing practices. CONCLUSIONS: Obstetrician preferences for use of existing group B streptococcal guidelines are often not reflected by their actual stated practices. However, obstetricians do not support legislative regulation of group B streptococcal prevention practices.     

Compliance with a risk-factor-based guideline for the prevention of neonatal group B streptococcal sepsis

Objective: The purpose of this study was to determine the compliance rate with a maternal risk-factor-based guideline for the prevention of neonatal group B streptococcal (GBS) sepsis.Methods: In August 1994, a risk-factor-based guideline for selective intrapartum prophylaxis against neonatal GBS was adopted by a group model health maintenance organization. This guideline identified the following maternal risk factors for neonatal GBS sepsis: preterm delivery, rupture of membranes for >18 h, fever/chorioamnionitis, and history of a previous GBS-affected child. Patients with one or more risk factors were to receive intrapartum antibiotic prophylaxis consisting of either ampicillin, erythromycin, or clindamycin. We conducted a retrospective chart review to record risk factors and use of antibiotics. We hypothesized that >90% of patients with risk factors would receive intrapartum chemoprophylaxis.Results: A total of 805 maternal charts were reviewed. Of these, 105 (13%) were candidates for intrapartum prophylaxis. We found an overall compliance rate of 65%. Compliance rates by risk factor were preterm delivery (51%), prolonged rupture of membranes (73%), fever/chorioamnionitis (87%), and previous affected child (100%).Conclusions: Our results show unexpectedly low compliance rates with a risk-factor-based guideline for the prevention of neonatal GBS sepsis. Only 65% of women with any risk factor for neonatal GBS sepsis received intrapartum antibiotic prophylaxis appropriately. Educational efforts to improve compliance with a risk-factor-based guideline should specifically address mothers delivering at 34-36 weeks gestation and mothers with prolonged rupture of membranes.     

Low-dose versus high-dose oxytocin augmentation of labor — A randomized trial

OBJECTIVE: Our purpose was to compare the efficacy and safety of low-dose versus high-dose oxytocin regimens in the augmentation of labor.STUDY DESIGN: Three hundred ten term pregnancies requiring augmentation of labor underwent randomization to receive either a low-dose or high-dose oxytocin augmentation regimen. Maternal demographics, labor-delivery data, and neonatal outcome were compared.RESULTS: The hgih-dose oxytocin group had a significant lower cesarean section rate, regarless of parity (10.4% vs 25.7%. p < 0.001), with no differences in maternal complications and neonatal outcomes. The time needed to correct the labor abnormality as also significantly decreased (1.24 ± 1.4 hours vs 3.12 ± 1.6 hours, p < 0.001) in the high-dose group.CONCLUSIONS: The use of a high-dose oxytocin regimen benefits both nulliparous and multiparous women requiring labor augmentation by significantly lowering both the time necessary to correct the labor normality and the need for cesarean section.     

Do concepts of causes and prevention of cerebral palsy require revision?

Objective: My purpose was to explore the criteria of The American College of Obstetricians and Gynecologists (Technical Bulletin No. 163) for perinatal asphyxia to be linked to subsequent cerebral palsy.Study design: Analysis of four cases of intrapartum fetal insults with subsequent cerebral palsy and a literature review are presented.Results: All of the four cerebral palsy cases had sufficient intrapartum causes of cerebral palsy, yet none fulfilled The American College of Obstetricians and Gyneclogists' linkage criteria. Complications in the cerebral palsy cases were as follows: maternal intrapartum cardiac arrest, fetal skull fracture with brain infarct, intrapartum fetal stoke, and a newborn delivered after uterine rupture with only central nervous system defects. There are no well-done laboratory or clinical studies that unequivocally support the “criteria” that umbilical artery pH must be < 7.00 or the requirements of Apgar score < 3, hypoxic-ischemic encephalopathy, and multiple organ dysfunction. Apparent exceptions to these criteria occur.Conclusions: The American College of Obstetricians and Gynecologists Technical Bulletin's criteria for cerebral palsy linkage and the role of parturition in cerebral palsy should be reevaluated. A rebirth of obstetric enthusiasm for cerebral palsy research, teaching, and treatment needs to occur.     

Does advanced maternal age affect pregnancy outcome in women with mild hypertension remote from term?

OBJECTIVES: Our purpose was to compare maternal and perinatal outcomes of mature women with those in younger women with pregnancies complicated by mild hypertension remote from term.STUDY DESIGN: A matched cohort design was used. A total of 379 mature pregnant women (≥35 years old) with mild hypertension remote from term were matched for race, gestational age, and proteinuria status at enrollment with 379 adult controls aged 20 to 30 years also with mild hypertension remote from term. All were enrolled in an outpatient management program that included automated blood pressure measurements and daily assessment of weight, proteinuria, and fetal movement.RESULTS: The mean gestational age at enrollment was 32.7 ± 3.0 weeks for both groups (range 24 to 36 weeks). By matching 20.6% of patients in each group had ≥1+ proteinuria on urinary dipstick at enrollment, and 77.3% of patients in each group were white. Chronic hypertension was more common in the mature group (22.4% vs 14.5%, p = 0.007). The mean gestational age at delivery (37.2 ± 2.3 vs 37.2 ± 2.2 weeks), the mean pregnancy prolongation (28.1 ± 21.0 vs 28.4 ± 22.0 days), and the mean birth weights (2864 ± 770 vs 2906 ± 788 gm) were similar between the mature and younger groups (all p > 0.05). There were no differences regarding abruptio placentae (2 vs 3 cases) or thrombocytopenia or HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome (7 vs 9 cases), and there were no cases of eclampsia. There were five stillbirths in the mature group and none in the younger group (p = 0.063).CONCLUSION: Outpatient management of mild hypertension remote from term in the mature pregnant woman was associated with similar maternal outcomes but with a nonstatistically higher stillbirth rate compared with the younger pregnant woman. (Am J Obstet Gynecol 1997;176:1236-43.)     

Obstetric practice patterns in pregnancies complicated by fetal trisomy 13 or 18

Purpose: Describe practice patterns among obstetrician/gynecologists (OB/GYNs) when caring for women with pregnancy complicated by fetal trisomy 13 (T13) or 18 (T18) and compare these between maternal–fetal medicine (MFM) and non-MFM providers.

Materials and methods: We conducted an electronic survey using the American College of Obstetricians and Gynecologists database. Using simple statistics, we describe demographics and practice patterns among respondents and compare those of MFM practitioners with non-MFM providers.

Results: The survey was sent to 300 individuals, 161 individuals verified email receipt, and 105 had complete response and were included. The median age was 58 (IQR 53,62). Sixty percent were female, 69% were private practice, and 38% were MFM. All providers were more likely to offer than to recommend antenatal and intrapartum interventions. MFMs were more likely to offer growth ultrasounds and neonatal hospice consults (53% vs. 29%, p?=?.02; 88% vs. 60%, p?p?Conclusion: Many providers offer antepartum and intrapartum interventions for pregnancies complicated by T13/18. We recommend that providers elicit each woman’s goals for pregnancies complicated by T13/18 and tailor management options to meet these goals.     

Characteristics of early-onset neonatal sepsis caused by Escherichia coli

ObjectiveThis study was conducted to document the perinatal risk factors associated with early-onset neonatal Escherichia coli sepsis and adverse neonatal outcomes.Materials and MethodsA case-control study of early-onset E coli sepsis compared with that of non-E coli sepsis was conducted by a retrospective data review of all infants with a diagnosis of sepsis during the first 7 days of life from the pediatric unit of Mackay Memorial Hospital from January 2004 to October 2008. After adjustment for gestational age, each patient with E coli early-onset sepsis was further compared with two gestational age-matched uninfected controls.ResultsCompared with infants with non-E coli sepsis (n = 27), infants with E coli sepsis (n = 19) were more likely to have preterm birth, especially at less than 30 weeks of gestation (47% vs. 4%, p < 0.01), very low birth weights (<1500 g; 47% vs. 4%, p < 0.01), intrapartum fever (26% vs. 4%, p = 0.036), preterm premature rupture of membranes (PPROM; 74% vs. 11%, p < 0.01), prolonged rupture of membranes (>24 hours; 47% vs. 0%, p < 0.01), antibiotic use (63% vs. 15%, p < 0.01), and sepsis onset on the first day of life (63% vs. 15%, p < 0.01). After adjusting for gestational age, intrapartum fever (26% vs. 5%, p = 0.035) and PPROM (74% vs. 39%, p = 0.015) were more common in infants with E coli sepsis. Fifteen of the 19 E coli isolates (79%) were ampicillin-resistant, and three (16%) were gentamicin-resistant. Antepartum and intrapartum antibiotic exposure was associated with ampicillin-resistant E coli sepsis (100% vs. 43%, p < 0.01).ConclusionEarly-onset E coli sepsis is more common in premature and very low birth weight infants and is more likely associated with intrapartum fever, PPROM, and sepsis onset on the first day of life than non-E coli sepsis. Broad-spectrum, multiple antibiotics or longer duration of antibiotic exposure may be associated with antibiotic-resistant pathogen infection.     

Antepartum use of antibiotics and early-onset neonatal sepsis: the next 4 years

OBJECTIVE: The purpose of this study was to analyze the incidence of early-onset neonatal sepsis and the presence of antibiotic resistance of the isolated bacteria and its relationship to antibiotic chemoprophylaxis that occurred during the 4 years that followed the publication of the most recent group B streptococcal guidelines. STUDY DESIGN: A prospective cohort study was performed between January 1, 1997, and December 31, 2000. All cases of early-onset neonatal sepsis were gathered prospectively. Data concerning the use of antepartum antibiotics, the isolated bacteria, and the presence of drug resistance were collected. These data were analyzed separately and were combined with published data from the preceding 6 years. RESULTS: A total of 26 cases of blood culture-proved early-onset neonatal sepsis occurred during the current 4-year study period. Group B Streptococcus was responsible for 10 cases, and the remaining 16 cases were non-group B streptococcal organisms. Of these 16 cases, 11 parturients received antibiotic chemoprophylaxis, and 10 of the isolates (91%) were resistant to the drug that was administered, compared with only one resistant bacteria (20%) in the 5 parturients who did not receive treatment (P =.01). In combining these 16 cases with the cases from the preceding 6 years, a total of 43 cases of non-group B streptococcal sepsis occurred in 49,788 deliveries. Of these, 26 mothers were given antepartum antibiotics, and 23 of the bacterial isolates (88%) exhibited resistance, compared with only 3 of the 17 cases (18%) in which antibiotics were not dispensed (P <.00001). However, because the overall use of antepartum antibiotics increased over time, the attack rate for early-onset group B Streptococcus significantly decreased by 75% (P <.000001). CONCLUSION: When early-onset neonatal sepsis develops in a case in which antepartum chemoprophylaxis was used, the bacterial isolate will most likely demonstrate resistance to the antibiotic that was administered. However, the development of early-onset group B streptococcal neonatal sepsis significantly decreased as the use of antepartum antibiotics increased. Thus, the number of prevented infections from antepartum antibiotic use may still outweigh the problems that are seen when resistant bacterial infections arise. Nevertheless, based on the current protocols, a large number of parturients are candidates for antibiotic chemoprophylaxis and this, in conjunction with the global concern of bacterial drug resistance, should be motivation to examine alternative methods, such as vaginal washing or immunotherapy, for decreasing infection.     

The effects of intrapartum magnesium sulfate therapy on fetal serum interleukin-1β, interleukin-6, and tumor necrosis factor-α at delivery: A randomized, placebo-controlled trial

Objective: Elevated levels of inflammatory cytokines in the fetus have been linked to neurologic morbidities in preterm neonates. Magnesium sulfate is currently being studied in clinical trials as a potential fetal neuroprotective agent. The purpose of this study was to determine whether intrapartum magnesium sulfate therapy has an effect on the umbilical venous concentrations of interleukin-1β, interleukin-6, and tumor necrosis factor-α at delivery. Study Design: Women with singleton gestations >32 weeks with no clinical indications for magnesium sulfate therapy (preeclampsia or tocolysis) and either clinical chorioamnionitis or prolonged rupture of membranes were recruited for the study. Consenting patients were randomly assigned, in a double-blinded fashion, to receive either magnesium sulfate (6-g load then 2 g/hr) or matched volumes of lactated Ringer’s solution until delivery. Fetal blood specimens were obtained by aspiration of the umbilical vein after cord clamping but before placental separation. Umbilical cytokine levels were measured with a sensitive and specific immunoassay. Results: Twenty-two patients were randomly assigned to groups and received either magnesium sulfate (n = 11) or placebo (n = 11). There were no differences in the demographic or clinical characteristics between groups. The umbilical venous ionized magnesium concentration was significantly higher in the magnesium sulfate group (2.32 ± 0.27 mg/dL vs 1.23 ± 0.15 mg/dL; P < .001). There were no statistically significant differences between groups with respect to umbilical levels of interleukin-1β (1.5 pg/mL [1.5-58] vs 1.5 pg/mL [1.5-10]; P = .5); interleukin-6 (8.5 pg/mL [1-1000] vs 11.2 pg/mL [1-113]; P = .9); or tumor necrosis factor-α (16 pg/mL [7.6-20.3] vs 16.6 pg/mL [8.3-22.2]; P = .5). Conclusion: In this pilot study the intrapartum administration of magnesium sulfate does not appear to affect the concentration of inflammatory cytokines in fetal blood at delivery. (Am J Obstet Gynecol 2001;184:1320-4.)     

Do prostacyclin and thromboxane contribute to the “protective effect” of pregnancies with chronic hypertension? A preliminary prospective longitudinal study

OBJECTIVE: The aim of this study was to assess prospectively the urinary excretion of renal and systemic metabolites of thromboxane and prostacyclin in normotensive and chronic hypertensive pregnancies. STUDY DESIGN: Pregnant hospital employees were invited to collect 24-hour urine samples weekly from the seventh week until delivery. Concentrations of renal metabolites (thromboxane B₂, 6-keto-prostaglandin F_1α) were measured by radioimmunoassay after extraction. Systemic metabolites (2,3-dinor-thromboxane B₂, 2,3-dinor-6-keto-prostaglandin F_1α) were assessed by enzyme immunoassay after extraction and high-pressure liquid chromatographic separation. RESULTS: Thromboxane B₂ excretion was similar in normotensive and hypertensive pregnancies, whereas a twofold increase of 6-keto-prostaglandin F_1α was observed in hypertensive compared with normotensive pregnancies (7537 ± 349 vs 3857  ± 202 pg/mg creatinine, p < 0.001). During pregnancy in both conditions measurements displayed uniform excretion of thromboxane B₂ with progressively increased levels of 6-keto-prostaglandin F_1α in chronic hypertension (R² = 0.60, p < 0.005). Mean excretion of 2,3-dinor-thromboxane B₂ averaged 1208 ± 65 and 898 ± 48 pg/mg creatinine in normotensive and hypertensive pregnancies (p < 0.001), mainly due to significant decreased concentrations in hypertension in the first half of pregnancy. Conversely, 2,3-dinor-6-keto-prostaglandin F_1α levels were 845 ± 39 and 1226 ± 67 pg/mg creatinine in normotensive and hypertensive pregnancies (p < 0.001), mostly because of significantly increased production in hypertension from 22 weeks onward. Ratios of both renal and systemic metabolites favored increased prostacyclin production in chronic hypertension. CONCLUSION: In contrast to preeclampsia, uncomplicated mild to moderate chronic hypertensive pregnancies are characterized by an excess production of prostacyclin with unaltered or even lower thromboxane concentrations, which may contribute to the general favorable outcome of this hypertensive condition.(Am J Obstet Gynecol 1997;177:1483-90.)     

Neonatal outcome after preterm delivery for preeclampsia

Objective: Our purpose was to determine whether maternal preeclampsia per se has a beneficial effect on neonatal outcome after delivery before 35 weeks.Study design: A matched cohort study design was used. Two hundred twenty-three infants of strictly defined preeclampsia women were matched for gestational age, race, gender, and mode of delivery with infants of normotensive women with preterm labor and delivery. Pregnancies with multiple gestation, premature rupture of membranes, known fetal anomalies, diabetes, or maternal medical disease were excluded. Information was obtained by review of maternal and neonatal charts. Paired categoric and continuous data were compared by McNemar's test and the Wilcoxon signed-rank test, respectively.Results: There was no difference in the incidence of neonatal death (4.5% vs 4.5%, p = 0.82), respiratory distress syndrome (22.0% vs 22.0%, p = 0.88), grades 3 and 4 intraventricular hemorrhage (2.2% vs 2.2%, p = 0.72), grades 2 and 3 necrotizing enterocolitis (5.8% vs 4.0%, p = 0.48), and culture-proved sepsis (9.0% vs 9.0%, p = 0.85). Results were similar when analysis was limited to infants born at ≤ 32 weeks, infants born to mothers with severe preeclampsia, and infants with intrauterine growth restriction.Conclusion: Maternal preeclampsia per se does not have a beneficial effect on the postnatal course] of infants born at 24 to 35 weeks' gestation.     

Labor epidural analgesia is independent risk factor for neonatal pyrexia

Objective.?To explore whether epidural analgesia (EA) in labor is independent risk factor for neonatal pyrexia after controlling for intrapartum pyrexia.

Methods.?Retrospective observational study of 480 consecutive term singleton infants born to mothers who received EA in labor (EA group) and 480 term infants delivered to mothers who did not receive EA (NEA group).

Results.?Mothers in the EA group had significantly higher incidence of intrapartum pyrexia [54/480 (11%) vs. 4/480 (0.8%), OR?=?15.1, p?<?0.0001] and neonatal pyrexia [68/480 (14.2%) vs. 15/480 (3.1%), OR?=?5.1, p?<?0.0001]. Neonates in the EA group had a median duration of pyrexia of 1 h (maximum 5 h) with a peak temperature within 1 h. Stepwise logistic regression analysis showed that maternal EA was independent risk factor for neonatal pyrexia (>37.5°C) after controlling for intrapartum pyrexia (>37.9°C) and other confounders (OR?=?3.44, CI?=?1.9–6.3, p?<?0.0001). Sepsis work-up was performed significantly more frequently in infants in the EA group [11.7% vs. 2.5%, OR?=?5.2, CI?=?2.7–9.7, p?<?0.0001] with negative blood cultures.

Conclusions.?EA in labor is an independent risk factor for pyrexia in term neonates. It is unnecessary to investigate febrile offspring of mothers who have had epidurals unless pyrexia persists for longer than 5 h or other signs or risk factors for neonatal sepsis are present.     

Neonatal sepsis and death caused by resistant Escherichia coli: Possible consequences of extended maternal ampicillin administration

Objective: Our goal was to evaluate the relationship between neonatal death caused by sepsis associated with ampicillin-resistant organisms and length of antibiotic exposure. Study Design: All neonatal deaths from culture-positive sepsis over a 3-year period were examined. Infants who were delivered at either the University of Mississippi Medical Center or at Saint Barnabas Medical Center at ≥24 weeks’ gestation and died within 7 days of life were included. Information on the organism causing sepsis and its sensitivities was collected, and the number of doses of ampicillin administered to the mother before delivery was determined. Results: Of the 78 neonatal deaths, 35 met the inclusion criteria. There were 8 cases of sepsis from ampicillin-resistant Escherichia coli and 27 cases caused by other organisms. There was a statistically significant difference between the mean number of doses of ampicillin received by the ampicillin-resistant Escherichia coli group (17.6 ± 5.5) compared with the other organisms group (4.9 ± 3.6) (P < .001). Conclusion: A relationship exists between neonatal death caused by ampicillin-resistant Escherichia coli and prolonged antepartum exposure to ampicillin. (Am J Obstet Gynecol 1999;180:1345-8.)     

Antenatal testing among 1001 patients at high risk: The role of ultrasonographic estimate of amniotic fluid volume

Objective: Our goal was to compare the accuracy of the amniotic fluid index and the 2-diameter pocket technique with respect to accuracy in predicting an adverse pregnancy outcome among patients at high risk undergoing antenatal testing. Study Design: All women with high-risk pregnancies and intact membranes who underwent antenatal testing during an 18-month period were prospectively enrolled. Ultrasonographic estimates of amniotic fluid volume were performed by means of the amniotic fluid index and the 2-diameter pocket technique. Relative risks with 95% confidence intervals and receiver operator characteristic curves were calculated for patients with an ultrasonographic estimate of oligohydramnios (amniotic fluid index of ≤5 cm or 2-diameter pocket of ≤15 cm²) versus normal fluid level (amniotic fluid index of >5 cm or 2-diameter pocket of >15 cm²). Outcome variables studied were intrapartum and neonatal complications. Results: Among 1001 patients the mean (±SD) amniotic fluid index was 10.5 ± 5 cm and the mean (±SD) 2-diameter pocket was 18.7 ± 13.6 cm². Significantly more patients (46%) were considered to have oligohydramnios according to the 2-diameter pocket criteria than according to the amniotic fluid index (21%, P < .0001, relative risk 1.7, 95% confidence interval 1.5-1.8). No significant differences in the incidences of nonreactive nonstress test results, meconium-stained amniotic fluid, cesarean delivery for fetal distress, low Apgar scores, or infants with cord pH of <7.10 were observed between the oligohydramnios and normal amniotic fluid groups (P > .05) when assessed by relative risk with confidence interval and by receiver operator characteristic curves. Conclusions: Current ultrasonographic measurements with the amniotic fluid index and the 2-diameter pocket technique are poor diagnostic tests to determine whether a patient is at high risk for an adverse perinatal outcome. (Am J Obstet Gynecol 1999;180:1330-6.)     

The effect of peritoneal fluid from patients with endometriosis on human sperm function in vitro

OBJECTIVE: Our purpose was to evaluate the effect of peritoneal fluid from women with endometriosis on sperm motility and function in an in vitro model. STUDY DESIGN: Peritoneal fluid was collected at laparoscopy from patients with and without endometriosis. Human donor sperm was diluted with this fluid, and its effect on sperm function and motility was measured with the zona-free hamster egg sperm penetration assay and computer-assisted semen analysis. RESULTS: The mean number of eggs penetrated by the sperm mixed with peritoneal fluid from patients with endometriosis was significantly fewer than the number penetrated by the sperm mixed with fluid from control patients (22.9 ± 5.31 vs 44.4 ± 4.96, p < 001, Student t test, n = 20). When evaluated by computer-assisted semen analysis, sperm mixed with peritoneal fluid from patients with endometriosis showed a significant decrease in mean swimming velocity compared with sperm mixed with peritoneal fluid from control patients (54.0 ± 1.77 vs 59.2 ± 105, p = 002, Student t test, n = 20). A significant increase in the fraction of sperm swimming at slower velocities was also found. A trend toward a positive correlation between eggs penetrated and sperm velocity was seen, but statistical significance was not achieved (correlation coefficient 0.4392, p = 0053, n = 20). CONCLUSION: These data suggest that substances found in the peritoneal fluid of patients with endometriosis could contribute to infertility through impairment of both sperm function and motion kinematics. (Am J Obstet Gynecol 1996;174:1779-85.)     

Duration of intrapartum prophylaxis for neonatal group B streptococcal disease: a systematic review

OBJECTIVE: To examine published evidence regarding duration of intrapartum antibiotic prophylaxis administered to pregnant women colonized with group B Streptococcus (GBS) to reduce infant colonization with GBS and to prevent early-onset GBS sepsis. DATA SOURCES: A search was conducted in The Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2006), MEDLINE (1966 to January 2006), EMBASE (1980 to January 2006), CINAHL (1982 to January 2006), and in protocols and guidelines of the Centers for Disease Control and Prevention, American Academy of Pediatrics, and American College of Obstetrics and Gynecology. METHODS OF STUDY SELECTION: All randomized controlled trials and observational studies in which duration of intrapartum antibiotic prophylaxis is reported relative to subsequent neonatal GBS colonization or sepsis were considered. Case series and study designs using historical cohorts or controls for comparison were excluded. TABULATION, INTEGRATION, AND RESULTS: Three prospective cohort studies and one case-control study met inclusion criteria. Heterogeneity of study design and assembly of cohorts precluded meta-analysis. A systematic review of the individual studies was performed. All studies were rated as fair or poor validity with regard to their ability to evaluate duration of intrapartum prophylaxis and transmission of GBS to the newborn. All 4 studies were largely composed of women with existing risk factors for GBS disease of the newborn. One study supported more than 1 hour of prophylaxis, two studies supported more than 2 hours of prophylaxis, and one was inconclusive. CONCLUSION: Despite unequivocal clinical guidelines recommending at least 4 hours of intrapartum antibiotic prophylaxis, there are no well-designed studies examining duration of intrapartum antibiotic prophylaxis for prevention of early-onset GBS disease of the newborn. We recommend continuing to initiate intrapartum prophylaxis according to the American College of Obstetricians and Gynecologists guidelines; however, the transmission of GBS to neonates exposed to less than 4 hours of intrapartum prophylaxis and their subsequent management require further study.     

Effect of a screening-based prevention policy on prevalence of early-onset group B streptococcal sepsis

OBJECTIVE: To assess the effectiveness and feasibility of implementing the Centers for Disease Control and Prevention (CDC) screening-based guidelines for preventing early-onset group B streptococcal sepsis. METHODS: We compared prevalence of early-onset group B streptococcal sepsis after institution of the CDC screening-based protocol (October 1, 1995 through August 31, 1999) with that of historical controls (January 1, 1992 through June 30, 1995). We reviewed medical records for a cohort of deliveries of at least 23 weeks' gestation (January 1, 1996 through December 31, 1996) for group B streptococcal colonization status, risk factors, and intrapartum antibiotic prophylaxis. RESULTS: The prevalence of early-onset group B streptococcal sepsis was 1.16 per 1000 (36 of 31, 133) live births before and 0.14 per 1000 (four of 28,733) live births after institution of the CDC protocol (P <.001). Maternal colonization was known for 95.3% of the 7168 women who delivered (January 1, 1996 through December 31, 1996) at or after 37 weeks' gestation. Of 2174 women who qualified for intrapartum antibiotic prophylaxis, 1871 (86.1%) received it before delivery. There was 93. 8% compliance with intrapartum antibiotic prophylaxis for women who delivered vaginally and 53.2% compliance for women who delivered by cesarean. CONCLUSION: Institution of the CDC screening-based protocol was accomplished at a specialty women's hospital, staffed by full-time faculty and community physicians, with 93.8% compliance for vaginal deliveries, and was associated with an 88% reduction in early-onset group B streptococcal sepsis.