Bartholin's, vulval and perineal abscesses

Perineal infections are a common presenting complaint in women attending acutely to a gynaecology department. The mainstay of treatment of Bartholin's abscesses is incision and drainage; however, newer conservative methods are replacing the need for hospital admission and surgery, with similar long-term outcome and patient satisfaction. Carcinoma should be considered if the appearance of any vulval lesion is atypical; under these circumstances, biopsy and histological analysis are mandatory. If the origin of a labial or perineal infection or abscess is indistinct, an opinion from surgical colleagues should be sought in order to provide the optimal method of treatment.

• Bartholin's abcesses is a common gynaecological complaint for women presenting to an emergency department.

• The mainstay of treatment of Bartholin's abcesses is incision and drainage. There is no place for antibiotics in the management of these infections unless cellulitis is present.

• The outpatient management of Bartholin's abscesses by use of conservative procedures may be an effective alternative to surgical treatment.

• Other perineal abscesses are often found to represent anterior extensions of Bartholin's abscesses.

• Communication with general surgical colleagues is important if the origin of a perineal infection is indistinct.

• A randomised trial of the usage of the Word catheter versus marsupialisation will demonstrate whether there is a difference in healing, recurrence rates and patient satisfaction.

Intrapartum factors in early-onset group B streptococcal sepsis in term neonates: A case-control study

OBJECTIVE: A case-control study was used to (1) examine the intrapartum characteristics of term neonates with early-onset group B streptococcal sepsis and (2) determine what percentage of patients meet The American College of Obstetricians and Gynecologists guideline for intrapartum administration of antibiotics. STUDY DESIGN: Twenty-one women delivered of term neonates who contracted early-onset group B streptococcal sepsis were matched with 63 mothers who were colonized with group B streptococci. The women were matched for race, age, parity, and gestational age. A Student t test and χ² analysis were performed. Significance was defined as p < 005. RESULTS: The attack rate was 2.1 instances of sepsis per 1000 live births. For both groups, the maternal demographics and the actual birth weights were similar. Case mothers compared with controls had longer labor (11.4 ± 6.9 vs 5.8 ± 4.3 hours, p < 0.0001), had longer time elapsed between rupture of membranes and delivery (10.3 ± 6.4 vs 3.2 ± 3.6 hours, p < 0.0001); required oxytocin more often (76% vs 32%, p < 0.001); required more pelvic examinations (6 or more; 71% vs 46%, p < 005); and had a significantly higher cesarean section rate (33% vs 3%; p < 0.001). Only 10% (2 of 21) of case mothers met The American College of Obstetricians and Gynecologists guideline for chemoprophylaxis. CONCLUSION: The American College of Obstetricians and Gynecologists guideline for chemoprophylaxis identifies only 10% of women whose term newborns contract early-onset group B streptococcal sepsis. (Am J Obstet Gynecol 1996;174:1934-40.)     

The impact of contraceptive methods on the onset of symptomatic vulvovaginal candidiasis within the menstrual cycle

OBJECTIVE: Vulvovaginal candidiasis is the second most common cause of vaginal discharge. Low-dose oral contraceptives are no longer thought to increase the absolute risk of episodic vulvovaginal candidiasis. This study investigates the possible impact that hormonal contraception may have on the timing of onset of symptoms within the menstrual cycle.STUDY DESIGN: In a retrospective chart review of reproductive-aged women seen at the Women's Health Care Clinic at Harbor-University of California, Los Angeles, Medical Center, data from the records of 448 symptomatic women who had 507 episodes of vulvovaginal candidiasis were extracted and analyzed for timing of onset of symptoms within the menstrual cycle. Diagnosis was based on symptoms, physical findings, and microscopy. Onset was divided into five physiologic ranges within an idealized 28-day menstrual cycle. Comparisons among groups were made with use of χ² and p < 0.05 thresholds for statistical significance.RESULTS: No differences were found in the onset of symptoms within the idealized menstrual cycle ranges between women using hormonal birth control methods and those using nonhormonal ones. The distribution was remarkably uniform throughout the cycle with the exception of the first few days (during menses).CONCLUSION: The timing of onset of symptoms of vulvovaginal candidiasis within a woman's menstrual cycle is not affected by her method of birth control. (Am J Obstet Gynecol 1997;176:1376-80.)     

HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome versus severe preeclampsia: Onset at ≤28.0 weeks’ gestation

Objective: Our purpose was to determine whether the onset of the HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome in women at ≤28.0 weeks’ gestation is associated with an increased risk of adverse maternal and perinatal outcomes in comparison with the risk for women with severe preeclampsia but without the HELLP syndrome at a similar gestational age. Study Design: Sixty-four patients with either the HELLP syndrome (n = 32) or severe preeclampsia but absent HELLP syndrome laboratory test results (n = 32), admitted at ≤28.0 weeks’ gestation between July 1, 1992, and April 30, 1999, were studied. Maternal and perinatal outcomes were compared between the 2 groups. Statistical analysis was performed by the Student t test and the Fisher exact test. Results: There were no significant differences between the 2 groups regarding African-American race (59% vs 75%), nulliparity (50% vs 56%), or the use of corticosteroids (59% vs 78%). There were no maternal deaths. One woman with the HELLP syndrome had a liver hematoma. The rate at which transfusion of blood products was required was significantly greater in women with the HELLP syndrome than in those with severe preeclampsia only (25% vs 3%; P < .05). There were no significant differences between the 2 groups with respect to eclampsia (16% vs 13%), abruptio placentae (6% vs 9%), disseminated intravascular coagulopathy (13% vs 0%), pulmonary edema (13% vs 6%), acute renal failure (3% vs 0%), pleural effusion (3% vs 3%), or ascites (6% vs 16%). No significant differences were found between the 2 groups with respect to neonatal death (11% vs 17%), respiratory distress syndrome (78% vs 86%), or composite neonatal morbidity. Conclusions: Except for the need for transfusion of blood products in women with the HELLP syndrome, onset at ≤28.0 weeks’ gestation is not associated with an increased risk of adverse maternal or neonatal outcomes in comparison with the risk for women with severe preeclampsia but without the HELLP syndrome at a similar gestational age. (Am J Obstet Gynecol 2000;183:1475-9.)     

Misoprostol: An effective agent for cervical ripening and labor induction

Objective: Our purpose was to compare the safety and efficacy of intravaginal misoprostol versus intracervical prostaglandin E₂ gel (dinoprostone) for preinduction cervical ripening and induction of labor.Study design: Two hundred seventy-six patients with indications for induction of labor and unfavorable cervices were randomly assigned to receive either intravaginal misoprostol or intracervical dinoprostone. Twenty-five micrograms of misoprostol were placed in the posterior vaginal fornix every 3 hours, with a potential maximum of eight doses. Prostaglandin E₂ in gel form, 0.5 mg, was placed in the endocervix every 6 hours, with a maximum of three doses. Further medication was withheld with the occurence of spontaneous rupture of membranes, entry into active phase of labor, or a “prolonged contraction response.”Results: Among those evaluated, 138 received misoprostol and 137 received dinoprostone. The average interval from start of induction to vaginal delivery was shorter in the misprostal group (1323.0 ± 844.4 minutes) than in the dinoprostone group (1532.4 ± 706.5 minutes) (p < 0.05). Need for oxytocin augmentation of labor occurred more commonly in the dinoprostone group (72.6%) than in the misprostol group (45.7%) (p < 0.0001). There were no significant differences in the routes of delivery. Twenty-eight of the misoprostol-treated patients (20.3%) and thirty-eight of the dinoprostone-treated patients (27.7%) required abdominal delivery. Complications such as uterine lachysystole and thick meconium passage occurred with similar frequency in the two treatment groups.Conclusions: Intravaginal administration of misoprostol appears to be as effective as intracervical dinoprostone for cervical ripening and labor induction. Complications associated with prostaglandin administration were not statistically different between the two treatment groups. The cost of misoprostol ($0.36/100μg) is much less than that of dinoprostone ($75/0.5mg).     

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.     

Vaginal hysterectomy for the woman with a moderately enlarged uterus weighing 200 to 700 grams

Objectives: The purpose of this study was to compare the surgical outcomes of women with moderately enlarged uteri undergoing vaginal hysterectomy with those of women with uteri of normal size undergoing vaginal hysterectomy. A secondary objective was to investigate the roles of uterine morcellation and laparoscopically assisted vaginal hysterectomy in the treatment of these women. Study Design: Thirty consecutive women during a 2-year period with uterine enlargement to a weight of between 200 and 700 g underwent vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy limited to lysis of adhesions or adnexectomy. These patients with uterine enlargement (group 1) were compared with 160 women with uteri weighing <200 g who also underwent vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy during the same interval (group 2). The 2 groups were compared for total complications, operative time, hospital stay, perioperative hemoglobin concentration change, and use of vaginal uterine morcellation and laparoscopically assisted vaginal hysterectomy. Results: Operative time for vaginal hysterectomy was significantly longer for women in group 1 than for women in group 2 (66.6 ± 26.2 minutes vs 53.0 ± 25.5 minutes, P = .008). There was a linear relationship between uterine weight and operative time: Operative time = 47.156 + 0.056 × Uterine weight (r = 0.20, F = 7.66, degrees of freedom 1, 188, P = .006). Vaginal morcellation of the uterus was needed in 80.0% of the women in group 1 and in 10.0% of the women in group 2 (P < .001). Two women in group 1 (6.7%) and 9 women (5.6%) in group 2 had laparoscopically assisted procedures for lysis of adhesions, adnexectomy, or both, unrelated to uterine size (P = .69). There were no significant differences between the 2 groups with respect to perioperative hemoglobin concentration change or hospital stay. Finally, the rates of major surgical complications were similar in the 2 groups (3.3% in group 1 vs 4.3% in group 2, P > .99, 95% confidence interval –8.1% to 5.9%). Conclusions: Although vaginal hysterectomy requires a modest increase in operative time, it is as safe and effective for the woman with a moderately enlarged uterus as for the woman with a uterus of normal size. Vaginal uterine morcellation is the key to a successful operation and obviates the need for either abdominal or laparoscopically assisted hysterectomy solely to deal with moderate uterine enlargement. (Am J Obstet Gynecol 1999;180:1337-44.)     

Effect of magnesium prophylaxis and preeclampsia on the duration of labor

Objective: Our goals were to compare duration of labor at term for (1) women with preeclampsia versus normotensive nulliparous women and (2) nulliparous women with preeclampsia who received magnesium for seizure prophylaxis versus those who did not. Study Design: We performed a retrospective cohort study of all nulliparous, term vaginal deliveries from 1989 through 1995 at University of California, San Francisco. The perinatal database and medical records were reviewed for information on duration of labor, maternal and labor characteristics, and neonatal outcomes. The χ² odds ratio, and Student t tests were used to compare categoric and continuous variables between women with preeclampsia and control women and between women with preeclampsia who did and those who did not receive magnesium. Logistic regression was used to evaluate variables predictive of labor duration. Results: Our study subjects were 4083 normotensive nulliparous women and 154 women with preeclampsia. A sample size calculation revealed that 1764 normotensive control subjects were needed to show a 10% difference in labor duration with 80% power and alpha of 0.05. Among women with preeclampsia, 93 (60%) were treated with magnesium and 61 (40%) were not. More women with preeclampsia than normotensive women had induction of labor and received epidural anesthesia, prostaglandin gel, and oxytocin (P < .003). Total labor duration did not differ between women with preeclampsia and normotensive women (P = .15) or between women with preeclampsia who received magnesium and those who did not (P = .09). In comparison with normotensive women, those with preeclampsia had a higher rate of postpartum hemorrhage (31% vs 22%, P = .005), and the rate was even higher among preeclamptic women treated with magnesium versus those who received no magnesium (34% vs 26%, P = .002). Logistic regression, with prolonged first stage of labor (>12 hours) used as the outcome variable, indicated that epidural anesthesia (odds ratio 2.3, 95% confidence interval 1.9-2.6), oxytocin (odds ratio 1.8, 95% confidence interval 1.6-2.2), and persistent occipitoposterior presentation (odds ratio 1.6, 95% confidence interval 1.1-2.4) were associated with prolonged labor, whereas preeclampsia (odds ratio 0.9, 95% confidence interval 0.7-1.1) and treatment with magnesium were not (odds ratio 1.1, 95% confidence interval 0.9-1.4). Induction (odds ratio 0.5, 95% confidence interval 0.4-0.6) and birth weight <2500 g (odds ratio 0.5, 95% confidence interval 0.4-0.8) were associated with faster labor. Conclusions: In term nulliparous women, neither preeclampsia nor magnesium prophylaxis affected labor duration. (Am J Obstet Gynecol 1999;180:1475-9.)     

Human Papillomavirus DNA Detection in Cervical Specimens by Hybrid Capture: Correlation with Cytologic and Histologic Diagnoses of Squamous Intraepithelial Lesions of the Cervix

Human papillomavirus (HPV) DNA detection in cervical specimens was correlated with cytologic and histologic diagnoses for 151 women who were referred to the Johns Hopkins Hospital colposcopy clinic for evaluation of an abnormal Pap smear. HPVs were identified as “high-risk” or “low-risk” by Hybrid Capture. The final disease status was categorized as high-grade squamous intraepithelial lesion (HSIL) by histology (n= 26), low-grade squamous intraepithelial lesion (LSIL) by histology (n= 43), equivocal [histology negative, cytology atypical squamous cells of undetermined significance (ASCUS) or higher,n= 42], and negative (both histology and cytology negative,n= 40). Thirty-five percent of disease-negative women and 84% of the women with biopsy-proven or equivocal disease were HPV-positive. Ninety-two percent of the HPV-positive women harbored high-risk HPVs, either high-risk HPVs alone (77%) or high-risk HPVs along with low-risk HPVs (15%). High-risk HPVs predominated in disease-negative as well as disease-positive women. Collection of specimens with a cytobrush was more efficient for HPV DNA detection than collection by cervicovaginal lavage. Large amounts of HPV DNA correlated with presence of HSIL or LSIL. For detection of HSIL, considering only brush samples, the sensitivities of abnormal cytology (ASCUS or higher), of high-risk HPVs, and of the two combined were, respectively, 87, 93, and 100%; the corresponding specificities were 30, 30, and 20%. HPV DNA detection may be most beneficial in populations with low HPV prevalence.     

Cost and quality-of-life analyses of surgery for early endometrial cancer: Laparotomy versus laparoscopy

OBJECTIVE: The purpose of this study was to determine whether the cost or quality of life associated with surgical treatment of presumed early-stage endometrial cancer differed on the basis of the surgical approach. STUDY DESIGN: A retrospective analysis was performed on a consecutive series of women with presumed early-stage endometrial cancer treated at the Women's Cancer Center of Northern California. The senior author was the surgeon, cosurgeon, or assistant on all cases. The women comprise two groups with different surgical approaches. The first group of 17 women underwent exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic and aortic lymphadenectomy. The second group of 13 women underwent the same surgery by laparoscopy. The two groups were compared with a two-tailed Student t test. Variables analyzed included age, height, weight, Quetelet index, and predisposing medical problems. Lymph node counts were compiled. Hospital costs were broken down into four cost categories: (1) operating room, (2) hospital bed, (3) pharmacy, and (4) anesthesia. A two-tailed Student t test was also used in this analysis. Issues examined regarding quality of life included (1) average hospital stay, (2) complications, and (3) time to return to normal activity. RESULTS: The patient population differed significantly (p < 005) with regard to weight and Quetelet index. The laparotomy group required significantly longer hospitalization than the laparoscopy group (6.3 vs 2.4 days, p < 0.001), resulting in higher overall hospital costs ($19,158 vs $13,988, p < 005). Similarly, patients undergoing laparotomy took longer to return to normal activity (5.3 weeks vs 2.4 weeks, p < 0.0001). CONCLUSION: Laparoscopic management of endometrial cancer may result in significant cost savings and improved quality of life as demonstrated by shortened hospital stays and an earlier return to normal activity. (Am J Obstet Gynecol 1996;174:1795-800.)     

Perinatal risks associated with borderline amniotic fluid index

Objective: Our purpose was to determine whether a borderline amniotic fluid index observed during antepartum testing confers a significant risk of adverse perinatal outcome. Study Design: We conducted a retrospective review of all patients entering antepartum testing at Los Angeles County–University of Southern California Women’s and Children’s Hospital during a 4-month period beginning January 1, 1996. Women with singleton pregnancies who underwent antepartum testing within 1 week of delivery and who were delivered at our institution were identified for our study. An amniotic fluid index >5 and <10 cm was defined as “borderline” and an amniotic fluid index of 10 to 24 cm was considered normal. Markers of adverse perinatal outcome included intrapartum fetal distress, 5-minute Apgar score <7, meconium-stained amniotic fluid, and intrauterine growth restriction. Results: There was a 2-fold increase in the incidence of adverse perinatal outcome among the women with borderline amniotic fluid index in comparison with control subjects with normal amniotic fluid volume. This difference reflected a 4-fold increase in the incidence of fetal growth restriction among women with a borderline amniotic fluid index. Conclusions: A borderline amniotic fluid index observed in antepartum testing is associated with an increased risk of intrauterine growth restriction and overall adverse perinatal outcome. These observations suggest that borderline amniotic fluid index merits twice-weekly antepartum testing. (Am J Obstet Gynecol 1999;180:1461-3.)     

Long-term outcome of nonconservative surgery (hysterectomy) for endometriosis-associated pain in women <30 years old

Objective: This study was undertaken to evaluate the effect that a patient’s age at the time of hysterectomy for endometriosis-associated pain has on long-term improvement in symptoms. Study Design: An investigation of women who underwent hysterectomy for pelvic pain and endometriosis at <30 or >40 years of age was performed by means of medical records review and mailed questionnaires. Participants were asked to complete 2 standardized surveys, the Disruption of Functioning Index and the Beck Depression Inventory. Results: Sixteen women in the study group (<30 years old) and 27 women in the control group returned completed questionnaires. Although similar proportions reported overall alleviation of pain, the study group was significantly more likely to report residual symptoms, such as dyspareunia and dysuria. This younger group also more often reported a sense of loss after hysterectomy and reported more overall disruption in different aspects of life. Conclusion: Women who undergo hysterectomy for pelvic pain and endometriosis at <30 years old are more likely than older women to have residual symptoms, to report a sense of loss, and to report more disruption from pain in different aspects of their lives. (Am J Obstet Gynecol 1999;180:1360-3.)     

Preterm delivery in women with pregestational diabetes mellitus or chronic hypertension relative to women with uncomplicated pregnancies

Objective: The purpose of this study was to compare the rates of indicated and spontaneous preterm delivery among women with chronic hypertension or pregestational diabetes mellitus with the rates among healthy women. Study Design: This was a secondary analysis of data from healthy women with singleton gestations enrolled in a prospective observational study for prediction of preterm delivery (control group, N = 2738), women with pregestational diabetes mellitus requiring insulin therapy (n = 461), and women with chronic hypertension (n = 761). The two latter groups were enrolled in a randomized multicenter trial for prevention of preeclampsia. The main outcome measures were rates of preterm delivery, either spontaneous (preterm labor or rupture of membranes) or indicated (for maternal or fetal reasons), and neonatal outcomes. Results: The overall rates of preterm delivery were significantly higher among women with diabetes mellitus (38%) and hypertension (33.1%) than among control women (13.9%). Rates were also significantly higher for delivery at <35 weeks’ gestation. Women with diabetes mellitus had significantly higher rates of both indicated preterm delivery (21.9% vs 3.4%; odds ratio, 8.1; 95% confidence interval, 6.0-10.9) and spontaneous preterm delivery (16.1% vs 10.5%; odds ratio, 1.6; 95% confidence interval, 1.2-2.2) than did women in the control group. In addition, they had significantly higher rates of both indicated preterm delivery (odds ratio, 4.8; 95% confidence interval, 3.0-7.5) and spontaneous preterm delivery (odds ratio, 2.1; 95% confidence interval, 1.4-3.0) at <35 weeks’ gestation than did control women. Compared with control women those with chronic hypertension had higher rates of indicated preterm delivery at both <37 weeks’ gestation (21.9% vs 3.4%; odds ratio, 8.1; 95% confidence interval, 6.2-10.6) and at <35 weeks’ gestation (12.1% vs 1.6%; odds ratio, 8.2; 95% confidence interval, 5.7-11.9), but there were no differences in rates of spontaneous preterm delivery. Conclusion: The increased rate of preterm delivery among women with chronic hypertension relative to control women was primarily an increase in indicated preterm delivery, whereas the rates of both spontaneous and indicated preterm delivery were increased among women with pregestational diabetes mellitus. (Am J Obstet Gynecol 2000;183:1520-4.)     

Placenta previa: A 22-year analysis

Objective: Our purpose was to identify what anesthetic method is safer for women with a placenta previa. Study Design: We retrospectively reviewed all women with placenta previa who underwent cesarean delivery during the period January 1, 1976–December 31, 1997 at Northwestern Memorial Hospital. Results: Of 93,384 deliveries, placenta previa was found in 514 women. Identifiable trends with time included an increasing incidence of placenta previa (r = 0.54, P < .01); cesarean hysterectomy (r = 0.54, P < .01); placenta accreta (r = 0.45, P < .03); and regional anesthesia (r = 0.84, P < .0001). The mean gestational age at delivery was 35.3 ± 3.4 weeks and did not change with time. General anesthesia was used for delivery in 380 women and regional anesthesia was used for 134 women. Prior cesarean delivery and general anesthesia were independent predictors of the need for blood transfusion, but only prior cesarean delivery was a predictor of the need for hysterectomy. General anesthesia increased the estimated blood loss, was associated with a lower postoperative hemoglobin concentration, and increased the need for blood transfusion. Elective and emergent deliveries did not differ in estimated blood loss, in postoperative hemoglobin concentrations, or in the incidence of intraoperative and anesthesia complications. Regional and general anesthesia did not differ in the incidence of intraoperative and anesthesia complications. Conclusions: In women with placenta previa, general anesthesia increased intraoperative blood loss and the need for blood transfusion. Regional anesthesia appears to be a safe alternative. (Am J Obstet Gynecol 1999;180:1432-7.)     

Local and distant skin flaps in the reconstruction of vulvar deformities

OBJECTIVES: The purpose of this study was to evaluate the safety and efficacy of skin flaps in vulvar reconstructive surgery. STUDY DESIGN: A retrospective review was performed on 207 consecutive flaps on 191 assessable women referred between 1992 and 1996. Outcome measures were wound closure, healing, restoration of coital function, and final result after any secondary revision. RESULTS: Primary closure without tension was possible in all but one instance, and 186 (89.9%) wounds healed by primary intention. Of 146 contractures, 95.8% were reparable by simple sliding flaps (YV advancement or “maple leaf”). Conversely, all the 99 tissue deficits required a pivoting design (random transposition, Martius, pudendal thigh, and gracilis or gluteus myocutaneous flaps). Primary success rates decreased sharply with worsening deformity, underlying disease, and complexity of flap design. There were 65 complications among 42 individuals, and 21 women required subsequent Z plasty or a second flap. Nonetheless, disease was cured and function restored in 178 (93.2%) patients. CONCLUSIONS: Sliding or pivoting vulvar flaps are generally reliable. Complex flaps are more difficult, but there are seldom any simpler surgical options.(Am J Obstet Gynecol 1997;177:1372-84)     

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.     

A prospective cohort study of women after primary repair of obstetric anal sphincter laceration

Objective: This study was undertaken to prospectively assess subjective anorectal symptoms by questionnaire and to prospectively assess the integrity of the anal sphincter by physical and ultrasonographic examination in women with and without obstetric anal sphincter laceration. Study Design: Fifteen subjects who sustained obstetric anal sphincter lacerations at the time of vaginal delivery were matched with 15 control subjects and followed up prospectively. Women underwent physical and ultrasonographic evaluations and answered questionnaires regarding anorectal symptoms at 6 weeks and at 4 months post partum. Data were evaluated with the Fisher exact test, the Wilcoxon exact and signed rank tests, and the McNemar test. Results: On postpartum examination the subjects with lacerations had more separated sphincters and decreased anal resting and squeeze tones with respect to control subjects (P < .05). According to ultrasonographic evaluation the anal sphincters were more commonly disrupted in the laceration group than in the control group (external anal sphincter, 40% vs 20%; P = .43; and internal anal sphincter, 47% vs 7%; P = .035). Subjective rating of fecal incontinence was significantly greater in the laceration group than in the control group (P < .05). There was no correlation between fecal incontinence symptoms and the integrity of the external anal sphincter. At the 4-month visit, fecal incontinence was resolved in 36% of subjects; however, continued anorectal dysfunction was reported by 43% of subjects in the laceration group versus only 7% of the control subjects (P = .08). Conclusion: Reports of fecal incontinence were significantly greater among women with a history of primarily repaired obstetric anal sphincter lacerations than among control subjects. Ultrasonographic examination revealed separated anal sphincters in 40% of the women with obstetric anal sphincter lacerations, despite repair at the time of delivery. (Am J Obstet Gynecol 1999;181:1317-23.)     

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.)     

Calciuria in symptom-free primigravid women remote from term: Is the response to an oral calcium challenge predictable?

Objective: This study was undertaken to compare the calciuric response in symptom-free primigravid women to an oral calcium load between those with normal urinary calcium excretions and those with relatively low urinary calcium excretions. Study Design: This was a prospective clinical trial. Eligible primigravid women between 16 and 20 weeks’ gestation provided a 24-hour urine sample for determination of urinary calcium/urinary creatinine ratio. On the basis of these results the patients were divided into 2 groups: a relatively hypocalciuric group, in which the urinary calcium excretion was ≤3.4 mg · kg^–1 · 24 h^–1, and a normocalciuric group, in which the urinary calcium excretion was >3.4 mg · kg^–1 · 24 h^–1. All participants undertook a 3-day low calcium dietary regimen. On the fourth day women underwent an oral calcium challenge. A 2-hour urine sample was collected before ingestion of 1 g calcium carbonate (preload). One hour after ingestion the women again collected a 2-hour urine sample (postload). The urinary calcium/urinary creatinine ratios in the preload and postload samples were determined and compared within and between the groups. Results: The mean change (±SD) between the preload and postload urinary calcium/urinary creatinine ratios in the relatively hypocalciuric group was 0.60 ± 1.44 (P = .04); that in the normocalciuric group was 3.09 ± 2.26 (P = .11 ). There was a 5-fold difference in the response to calcium load between the hypocalciuric women and the normocalciuric women (0.60 vs 3.09), although this difference was not statistically significant (P = .20). Conclusions: Both hypocalciuric and normocalciuric women responded to an oral calcium challenge by an increase in the calcium excretion. The cause of the hypocalciuria in women at increased risk for preeclampsia is therefore not simply poor absorption of calcium. (Am J Obstet Gynecol 1999;180:1419-21.)     

Candidal renal and urinary tract infection in neonates

Candida species are a common cause of urinary tract infection in newborns requiring intensive care. Renal candidiasis is frequently associated with these urinary tract infections and is manifest by “fungus balls” or renal parenchymal infiltration. Candidal urinary tract infections in high-risk newborns are often associated with candidemia, thereby warranting systemic antifungal therapy. Sonography is useful in diagnosing renal candidiasis, obstruction from “fungus balls,” and abscesses. The sonographic appearance of “fungus balls” may persist long after clinical resolution of Candida infection in neonates and should not affect duration of antifungal therapy. Amphotericin B is currently the drug of choice for neonates with renal candidiasis and candidal urinary tract infection. Surgical management should be reserved for decompression of obstructive candidiasis and drainage of abscesses.