The prevalence and clinical significance of intraamniotic infection with Candida species in women with preterm labor

Summary Intraamniotic infection is considered a major etiologic factor of preterm birth. Positive amniotic fluid cultures are rarely contaminated with Candida species. The presence of this microorganism is associated with a poor pregnancy outcome. Out of 773 transabdominal amniocenteses performed in women presenting with preterm labor and intact membranes, 77 patients (9.9%) had positive amniotic fluid cultures and in 5 women (6.5%) Candida species were identified. On the other hand, 625 amniocenteses were performed in women with preterm premature rupture of membranes and 178 (28%) had positive cultures. Only in 4 patients was Candida isolated (2.2%) (P=0.13 Fisher’s exact test). The importance of early and accurate diagnosis of intraamniotic infection with Candida is pointed out. A transabdominal amniocentesis for microbiological examination is suggested for every woman presenting with preterm labor or preterm premature rupture of membranes and especially for those who conceived with a retained IUD or cervical cerclage.     

早产与羊膜腔感染

羊膜腔感染是包括羊水、胎膜(绒毛膜、羊膜)、胎盘的感染和(或)临产前、产时发生的子宫感染.约30%的早产与羊膜腔感染有关.近年研究表明,早产伴羊膜腔感染患者的胎膜、胎盘、羊水和下生殖道分泌物中前列腺素、细胞因子浓度升高,提示其可能机制为妊娠晚期微生物通过多种途径侵入羊膜腔,刺激妊娠组织产生大量细胞因子,后者又加速前列腺素的合成与释放,从而引起宫颈成熟,子宫收缩,导致早产.对确诊的羊膜腔感染或未足月胎膜早破患者给予抗生素治疗是有效的.     

宫内感染459例临床分析

目的:分析宫内感染的病因、监测手段、治疗、预后及相关因素。方法:回顾性分析1999年1月至2004年5月在我院发生宫内感染的459例病例。结果:宫内感染发生率3.85%,并呈逐年上升趋势;与早产性胎膜早破、阴道检查次数、胎粪污染、产程时限等可能有相关性;新生儿感染发生率随孕周增加显著下降(P=0.0002)。结论:在围生保健和分娩过程中加强管理,积极预防和治疗宫内感染以改善母儿预后。     

双胎伴胎膜早破36例临床分析

目的探讨双胎伴胎膜早破的临床特点和妊娠结局.方法回顾性分析双胎伴胎膜早破36例(研究组)及同期单胎伴胎膜早破61例(对照组),从胎膜早破的发生率、期待疗法的情况、新生儿预后等情况进行探讨.结果双胎妊娠时胎膜早破的发生率为31.5%,单胎妊娠的胎膜早破发生率为11.7%(P＜0.05);双胎妊娠伴胎膜早破时早产发生率为75.0%,单胎妊娠伴胎膜早破时早产的发生率为11.5%(P＜0.001),双胎妊娠伴胎膜早破时新生儿窒息、羊水粪染、新生儿硬肿症等的发生率均高于单胎妊娠伴胎膜早破(P＜0.001).结论双胎妊娠容易发生胎膜早破、早产、新生儿窒息等,双胎妊娠伴胎膜早破时期待疗法意义不大,双胎妊娠时应尽量避免胎膜早破的发生.     

Maternal plasma lipopolysaccharide binding protein (LBP) concentrations in pregnancy complicated by preterm premature rupture of membranes

Objectives

To compare maternal plasma LBP concentrations in pregnancies complicated by preterm premature rupture of membranes (pPROM), and PROM at term, with their levels in uncomplicated pregnancy, and to determine whether LBP concentrations are of value in the diagnosis of subclinical intra-amniotic infection (IAI) in the prediction of the length of the pPROM-to-delivery interval, and in the prediction of neonatal congenital infection.

Study design

Thirty-one patients with pPROM, 35 with PROM at term, 33 healthy women at preterm gestation and 35 healthy women at term were included. In the pPROM group, analysis of maternal plasma LBP concentrations with reference to leukocytosis, C-reactive protein, vaginal fluid culture, neonatal infection and pPROM-to-delivery interval was carried out.

Results

LBP concentrations in the four studied groups were comparable. Although in 58.1% of pPROM cases at least one laboratory parameter of infection was observed, the only difference concerned the subgroup with CRP above 10 mg/L, in which LBP concentrations were higher. Comparison of LBP concentrations in patients delivered within 24 and 72 h of pPROM and after these times showed no differences, or between patients who gave birth to newborns with and without congenital infection. The predictive values of these measurements were poor.

Conclusion

The predictive value of maternal LBP determinations in the diagnostics of pPROM cases suspected of IAI is unsatisfactory. LBP measurements performed shortly after pPROM, are not of value either in the prediction of newborn's infection, or in the prognosis of latency period duration.     

The Principal Pregnancy Complications Resulting in Preterm Birth in Singleton and Twin Gestations

Preterm birth is the major cause of perinatal mortality for both singleton and twin gestations in the United States; most preterm birth prevention programs are primarily structured to detect and treat preterm labor. Most of these programs have had limited success, and the preterm birth rate for twins has remained well above that for singletons. Little attention has been paid to the question of whether the frequency of conditions that result in preterm twin delivery differs from those that result in the delivery of preterm singletons. Delivery records were reviewed for all 1,976 preterm (24–36 completed gestational weeks) singleton pregnancies and 221 preterm twin pregnancies delivered at the University of Connecticut Health Center, 1980–1989, to determine the primary complication that resulted in preterm delivery. Premature rupture of membranes was responsible for 46% of these singleton preterm deliveries, while the other causes were preterm labor with intact membranes (20%), pregnancy-induced hypertension (15%), antepartum hemorrhage (9%), and other maternal-fetal indications (10%). The five groups differed significantly in maternal and neonatal characteristics. The principal pregnancy complications resulting in preterm delivery of twins were preterm rupture of membranes (42%), preterm labor (31%), antepartum hemorrhage (4%), pregnancy-induced hypertension (11%), and other maternal-fetal indications (12%). Compared to preterm singletons, the preterm twins were significantly more likely to deliver because of preterm labor and less likely to deliver because of hemorrhage. Substantial reduction in the preterm birth rate requires programs tailored to the specific population and etiologies involved and should not solely address preterm labor.     

Late miscarriage and intraamniotic candidiasis in a woman with a retained intrauterine contraceptive device

Summary We present a case of mid-pregnancy miscarriage with a retained intrauterine contraceptive device and asymptomatic intraamniotic Candida infection.     

Leukocyte Esterase Activity as a Predictor of Amniotic Fluid Cultures in Preterm Labor

Leukocyte esterase activity has been utilized as a rapid screen for urinary tract infection. The purpose of this study was to evaluate leukocyte esterase activity as a rapid predictor of amniotic fluid culture results in patients with preterm labor. Amniocentesis was performed on 121 patients ≤34 weeks estimated gestation age with preterm labor and no clinical evidence of infection. Gram stain as well as aerobic, anaerobic, and Mycoplasma cultures were performed on the amniotic fluid. Leukocyte esterase activity was determined immediately following amniocentesis with the use of a commercially available test strip. Amniotic fluid cultures were positive in 19 subjects (16%). Leukocyte esterase was significantly more sensitive than Gram stain in detecting positive amniotic fluid culture results (79% vs. 42%, respectively; P < 0.02). Tocolysis was either unsuccessful or discontinued due to a positive Gram stain significantly more often when leukocyte esterase activity was present. Leukocyte esterase activity is a rapid and simple bedside test that is useful in assessing for subclinical intraamniotic infection in preterm labor.     

286例胎膜早破性早产新生儿结局的临床分析

目的:了解产前糖皮质激素干预对胎膜早破性早产新生儿结局的影响。方法:对我院286例胎膜早破性早产病例的临床资料进行回顾性分析。结果:34~35+6周孕龄组新生儿1分钟Apgar评分<7分的发生率、窒息率及新生儿呼吸窘迫综合征(NRDS)发生率在干预组明显低于对照组,两组间比较差异有显著性(P<0.05)。36~36+6周孕龄组新生儿窒息率、缺血缺氧性脑病(HIE)发生率、NRDS发生率及其他并发症发生率在干预组明显低于对照组,两组间比较差异有显著性(P<0.05)。28~31+6周及32~33+6周孕龄组新生儿结局的各项指标在干预组与对照组间比较差异无显著性(P>0.05)。结论:34~36+6孕周胎膜早破性早产孕妇产前使用糖皮质激素干预能显著改善新生儿结局。因样本量关系,<34孕周的胎膜早破性早产孕妇产前使用糖皮质激素干预对新生儿结局有无明显改善还有待于进一步探讨。     

Idiopathic vaginal bleeding during pregnancy as the only clinical manifestation of intrauterine infection

Objective.?To determine the frequency and clinical significance of microbial invasion of the amniotic cavity (MIAC) in patients with vaginal bleeding in the absence of placenta previa, preterm labor or preterm premature rupture of membranes (PROM).

Study design.?This retrospective cohort study included patients who presented with vaginal bleeding between 18 and 35 weeks, and underwent an amniocentesis shortly after admission for the assessment of the microbiologic status of the amniotic cavity and/or fetal lung maturity. Amniotic fluid was cultured for aerobic and anaerobic bacteria, as well as genital mycoplasmas. Patients presenting with preterm labor, preterm PROM, placenta previa, overt placental abruption, and an intrauterine device in situ were excluded, as well as those with local cervical bleeding. MIAC was defined as a positive amniotic fluid culture. Analysis was conducted with non-parametric statistics.

Results.?One hundred and fourteen patients met the entry criteria. MIAC was detected in 14% of cases (16/114). Patients with vaginal bleeding and a gestational age <?28 weeks at the time of amniocentesis had a significantly higher frequency of MIAC than those with a gestational age ??28 weeks [25% (13/52) vs. 4.8% (3/62), respectively; p?<?0.01]. Ureaplasma urealyticum was the microorganism most frequently isolated from the amniotic fluid. Except for one case admitted at 33 weeks, all patients with MIAC?had an early preterm delivery ??32 weeks. Patients with vaginal bleeding and MIAC?had a shorter procedure-to-delivery interval than those without MIAC [MIAC, median survival 19 days (95% CI 10–27 days) vs. no MIAC, median survival 50 days (95% CI 37–62 days); p?<?0.0001]. Patients with vaginal bleeding and MIAC?had a significantly lower gestational age at delivery and lower birth weight than those with vaginal bleeding and negative amniotic fluid cultures (for gestational age, median 25 weeks, range 21–33 weeks vs. median 37 weeks, range 19–42 weeks, respectively; p?<?0.01, and for birth weight, median 750?grams, range 520–1820?grams vs. 2800?grams, range 520–4880?grams, respectively; p?<?0.01), as well as a higher frequency of subsequent preterm PROM [81.3% (13/16) vs. 9.2% (9/98); p?<?0.01].

Conclusions.?MIAC was detected in 14% of patients with ‘idiopathic’ vaginal bleeding and was associated with subsequent preterm PROM and early preterm delivery. Vaginal bleeding may be the only clinical manifestation of MIAC, and it predisposes to adverse outcome.     

Intraamniotic Infection with Candida tropicalis in Preterm Labor

Colonization of the amniotic cavity with Candida tropicalis was diagnosed in a woman with preterm labor and intact membranes. Treatment with ketoconazole and amphotericin B failed to eradicate the microorganism from the amniotic cavity. Tocolysis was administered and was considered successful in prolonging the pregnancy for 11 days after the initiation of treatment. There was no clinical or microbiological evidence of neonatal infection. The infant survived and was discharged home 2 months after birth.     

Amniotic fluid Interleukin-8 as a marker for intraamniotic infection

Summary We measured the amniotic fluid Interleukin-8 (AF IL-8) levels of 80 women to see whether or not AF IL-8 levels were of value in the diagnosis of intraamniotic infection. Of twelve patients developing conventional signs of infection, 9 had an AF IL-8 concentration above 10.000 pg/ml serum. In two patients, whose baby had a serious neonatal infection, AF IL-8 concentration also exceeded 10.000 pg/ml. Only one out of 66 apparently uninfected patients had an AF IL-8 level above 10.000 pg/ml. We therefore suggest that measuring the AF IL-8 levels is of value in cases of suspected intraamniotic infection.     

Intravaginal misoprostol vs. expectant management in premature rupture of membranes with low Bishop scores at term.

OBJECTIVES: To evaluate the efficacy of vaginal misoprostol for cervical ripening and labor induction in premature rupture of membranes (PROM) cases with low Bishop scores at term. METHODS: Sixty-two PROM cases who fulfilled the criteria of 36 weeks of completed gestation, not in active labor, singleton pregnancy with vertex presentation, normal fetal heart rate reactivity, amniotic fluid index >5 cm and Bishop score <5, consented to participate in the study. Thirty-one of the cases were included in study group and a 50-microg misoprostol tablet was placed in the posterior vaginal fornix. Another 31 cases were included in control group and managed expectantly. Treatment success was defined as an interval from membrane rupture to delivery of <24 h. RESULTS: The mean admittance-delivery interval was significantly shorter in the study group (8.68+/-4.40 h) compared with the control group (26.22+/-18.98 h, P=0.001) and the mean interval from membrane rupture to delivery were also significantly shorter in the study group (19.37+/-7.20 h) than the control group (33.05+/-20.85 h, P=0.001). Oxytocin necessity was significantly lower in the study group than the control group (45.2% vs. 100%, P=0.00051). Tachysystole occurred more frequently in the study group (8 cases, 25.8% vs. 2 cases, 6.5%, P=0.038). There were no difference between two groups with regard to birth weights, 1- and 5-min Apgar scores and the need for neonatal intensive care unit. CONCLUSIONS: It is effective, safe and economic to use misoprostol vaginally in PROM cases with low Bishop scores at term.     

Comparison of pregnancy outcome among nulliparas with and without microalbuminuria at the end of the second trimester

Objective

To evaluate the rate of poor pregnancy outcome among nulliparas who had microalbuminuria at the end of the second trimester of their pregnancy.

Methods

A prospective cohort study was performed on 490 nulliparous women who were at the end of the second trimester of pregnancy. Urine tests for albuminuria and creatinine measurements were performed in all women and the albumin to creatinine ratio (ACR) was calculated. The women with microalbuminuria (exposed group) and those without microalbuminuria (nonexposed group) were monitored until the end of their pregnancy and compared for pregnancy outcome.

Results

Preterm labor (57.9% versus 13.5%), preeclampsia (50.0% versus 8.6%), intrauterine growth restriction (42.1% versus 6.4%), and preterm premature rupture of membranes (31.6% versus 10.2%) were significantly more common in the exposed group. The rates of gestational diabetes did not differ significantly between the 2 groups. In multivariate logistic regression analyses, microalbuminuria increased the risks for preterm labor (adjusted OR 2.4; 95% CI 1.1-5.5, P = 0.03) and preeclampsia (adjusted OR 9.5; 95% CI 4.6-19.3, P < 0.001).

Conclusion

Microalbuminuria at the end of the second trimester of pregnancy might increase the risks of preterm labor, preeclampsia, intrauterine growth restriction, and preterm premature rupture of membranes.     

Sex steroids enhance endotoxin-stimulated phospholipase A2 activity in hum endometrial cells

Summary Growing evidence suggests an association between intra-amniotic infection and preterm labor. We recently demonstrated that some factor(s) including endotoxin produced by the organism stimulated endogenous phospholipase A₂ resulting in liberation of arachidonic acid and prostaglandin formation (Takahashi et al. 1988). The studies presented in this report were designed to evaluate whether ovarian steroids alter activity of the phospholipase A₂ responsive to endotoxin. Exposure of human endometrial proliferative- or secretory-phases epithelium to endotoxin fromEscherichia coli increased the level of lysophosphatidylcholine (lyso-PC) by 15- and 25-fold, respectively. When the endometrial cells were preincubated with progesterone alone or progesterone and estradiol-17β for 16 h, the increase of lyso-PC by endotoxin was enhanced by approximately 1.5-fold. Progesterone showed a stimulatory effect on the response of phospholipase A₂ to bacterial endotoxin in endometrial cells. These observations may explain the mechanism(s) by which preterm or term labor associated with intra-amniotic infection is initiated.     

Preterm premature rupture of membranes in pregnancies complicated by human immunodeficiency virus infection: A single center's five-year experience

Objective. The objective of this study was to describe one center's five-year experience of the management of human immunodeficiency virus (HIV) positive gravidas with preterm premature rupture of the membranes (PPROM) not in labor at ≤34 weeks of gestation.

Methods. This is a retrospective chart review of all HIV positive gravidas with PPROM at ≤34 weeks of gestation, who delivered between December 1, 2000 and December 31, 2005.

Results. We identified 228 HIV positive gravidas of whom 19 had PPROM at ≤34 weeks of gestation. Mother-to-child transmission occurred in two of 18 surviving neonates as confirmed by a follow-up visit at six months of age. No mother-to-child transmission occurred in the 10 neonates of mothers who received antenatal highly active antiretroviral therapy and intrapartum zidovudine. Eleven neonates were delivered between 30 and 33 weeks of gestation. In this group, five of 11 gravidas received antenatal corticosteroids. The mean neonatal hospital stay was 31 days with or without prophylactic treatment of the mothers with antenatal corticosteroids.

Conclusions. In this study of HIV positive patients with PPROM, the mother-to-child transmission rate of HIV did not seem to be related to the duration of rupture of membranes prior to delivery.     

Successful treatment of preterm labour by eradication of Ureaplasma urealyticum with erythromycin

Summary Ureaplasma urealyticum was detected in the amniotic cavity of a woman with premature contractions at 32 weeks of pregnancy. Treatment with Erythromycin base was instituted for a period of ten days. Amniotic fluid analysis performed 48 hours after discontinuation of antibiotic treatment revealed sterile amniotic fluid. The pregnancy continued uneventfully until 39 weeks.