摘要:

Objective:To perform a decision analysis to understand better the implications of 19 potential group B streptococcus screening and treatment strategies.Methods:We searched the literature to locate appropriate articles from which to derive probability estimates. Using decision analysis, we determined the likely outcomes of 19 group B streptococcus screening and treatment strategies and focused on three main outcomes: 1) number of expected cases of early‐onset neonatal group B streptococcal sepsis, 2) percentage of gravidas treated with intrapartum antibiotics, and 3) total costs.Results:The strategy recently recommended by two committees of the American Academy of Pediatrics (universal 28‐week maternal rectovaginal group B streptococcal culture and treatment of culture‐positive, high‐risk patients in labor) is among the least effective at reducing neonatal sepsis and the most costly. Strategies based on the currently available rapid streptococcus identification tests are ineffective at reducing neonatal sepsis and are costly. Three strategies outperform the rest: 1) Universal intrapartum maternal antibiotic treatment is the most effective strategy in reducing early‐onset neonatal group B streptococcal sepsis (6% of expected) and is also the least costly; 2) intrapartum treatment based solely on risk factors (recently endorsed by ACOG) lowers the rate of neonatal sepsis to 31% of expected with an 18% maternal treatment rate and low total costs; and 3) universal 36‐week maternal culture, and treatment of all patients experiencing preterm birth and all culture‐positive patients results in 14% of expected neonatal sepsis, with a 27% maternal treatment rate and low total costs.Conclusion:Given the present state of knowledge, three strategies emerge from this decision analysis as most optimal for the prevention of early‐onset neonatal group B streptococcal sepsis: universal treatment, treatment based on risk factors, and treatment based on preterm delivery and 36‐week culture status.(Obstet Gynecol 1994;83:483‐94)

ISSN:0029-7844    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Objective:To study the impact of maternal human immunodeficiency virus type 1 (HIV‐1) infection on pregnancy outcome.Methods:Between January 1989 and December 1991, 406 HIV‐1‐seropositive and 407 HIV‐1‐seronegative age‐ and parity‐matched pregnant women from Nairobi, Kenya, all at less than 28 weeks' gestation, were recruited into a prospective study of HIV‐1 infection in pregnant women and their offspring. Both groups were followed until 6 weeks postpartum.Results:Three hundred fifteen HIV‐1‐seropositive women and 311 HIV‐1‐seronegative controls were followed until delivery. Seropositive women were younger at sexual debut and reported more lifetime partners and more sexually transmitted diseases (STDs) than the seronegative controls. The seropositive women had higher rates of genital ulcer disease (4.7 versus 2.0%;P= .08), genital warts (4.9 versus 2.0%;P= .03), and positive syphilis serology (7.9 versus 3.2%;P< .001), but there were no differences between the groups in isolation rates ofNeisseria gonorrhoeae(6.8 versus 7.1%) andChlamydia trachomatis(11.5 versus 9.0%). Maternal HIV‐1 infection was associated with significantly lower birth weight (2913 versus 3072 g;P= .0003) and with prematurity (21.1 versus 9.4%;P< .0001), but not with small for gestational age size (4.2 versus 3.2%;P= .7). The stillbirth rate was higher in seropositive women, yet not statistically significant (3.8 versus 1.9%;P= .2). Women with a CD4 count lower than 30% had a higher risk of preterm delivery (26.3 versus 10.1%;P< .001). Postpartum endometritis was more common in HIV‐1‐infected women than in seronegative controls (10.3 versus 4.2%;P= .01) and was inversely correlated with the CD4 percentage. No histopathologic placental abnormalities attributable to HIV‐1 were detected.Conclusion:Maternal HIV‐1 infection was significantly associated with prematurity and postpartum endometritis, but not with fetal growth retardation. There was a trend toward a higher stillbirth rate in HIV‐1‐seropositive mothers.(Obstet Gynecol 1994;83:495‐501)

ISSN:0029-7844    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Objective:To describe the clinical and neurologic findings in patients with late postpartum eclampsia (convulsions beginning more than 48 hours, but less than 4 weeks, after delivery).Methods:This study evaluated all patients with the diagnosis of late postpartum eclampsia managed at our institution between August 1977 and July 1992.Results:There were 54 cases of late postpartum eclampsia among a total of 334 cases of eclampsia during the study period. Late postpartum eclampsia constituted 56% of total postpartum eclampsia and 16% of all cases of eclampsia. Convulsions began from postpartum days 3‐23 (mean 6). Thirty women (56%) had been identified as preeclamptic before their convulsions. A history of either severe headache or visual disturbances before convulsion was elicited in 83% of the patients. During the study period, eight women not included in the study group had late postpartum seizures attributed to other causes.Conclusions:Severe headache or visual disturbance frequently antedates late postpartum eclampsia. Only eight of 62 patients with late postpartum seizures had identifiable etiologies other than eclampsia.(Obstet Gynecol 1994;83:502‐5)

ISSN:0029-7844    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Objective:To examine the cost‐effectiveness of the West Los Angeles Preterm Birth Prevention Project.Methods:Maternal and neonatal care data were collected on all preterm deliveries (150) and a random sample of term deliveries (140) from high‐risk patients at both experimental and control clinic sites. Costs were determined for prenatal care, inpatient preterm labor, delivery and postpartum care, and newborn care. Cost calculations, weighted by the actual proportions of term and preterm births, were confirmed with square‐root transformation and trimmed mean (2%) values.Results:When compared to control clinic high‐risk patients, experimental clinic high‐risk patients had an average cost savings of $2196 for newborn care (P= .02), resulting in a net savings of $1768 per high‐risk mother‐infant pair. Births before 32 weeks' gestation accounted for the greatest mean cost.Conclusion:Programs of comprehensive prenatal care and patient education may be highly cost‐effective for prevention of prematurity.(Obstet Gynecol 1994;83:506‐11)

ISSN:0029-7844    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Objective:To review outcomes and complications of pregnancies in women with transposition of the great arteries who had undergone the Mustard procedure.Methods:Four women with transposition of the great arteries who had undergone Mustard procedures in childhood received their obstetric care for five pregnancies at three institutions in the greater Philadelphia area between 1990‐1992. Pregnancy complications and outcomes were reviewed.Results:The most common maternal complication in pregnancy following performance of the Mustard procedure was cardiac arrhythmia, which required treatment in two of four patients. Late‐onset fetal growth restriction requiring induction occurred in two of five pregnancies. Third‐trimester oligohydramnios requiring induction occurred in one patient, and her second pregnancy was complicated by preterm labor and premature rupture of the membranes (PROM) at 33 weeks. One patient with a twin pregnancy developed mild preeclampsia, preterm labor, and PROM at 30 weeks. There were no neonatal or perinatal deaths or significant morbidity.Conclusion:If a patient with transposition of the great arteries who underwent the Mustard procedure is hemody‐namically stable before pregnancy, good maternal and fetal outcome can be expected.(Obstet Gynecol 1994;83:512‐6)

ISSN:0029-7844    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Objectives:To define the profile of 24‐hour uterine activity in normal pregnancy and to correlate contraction frequency with physical activity and emotional stress diaries.Methods:One hundred nine low‐risk pregnant women who delivered at term recorded uterine contractions for 24 hours twice weekly from 20‐40 weeks' gestation using an ambulatory monitor and kept a physical activity and emotional stress diary. Contractions per hour were calculated for each hour of the day and week of gestation, and related to physical activity and emotional stress.Results:We analyzed 71,683 hours. No contractions were recorded in 73% of the hours, and fewer than four contractions per hour occurred in 96%. Significant inter‐individual variability was noted. Contractions increased markedly with gestational age: The 95th percentile was 1.3 contractions per hour at 21‐24 weeks, 2.9 at 28‐32 weeks, and 4.9 at 38‐40 weeks. A strong clustering of contractions occurred at night, which became pronounced after 24 weeks (night:day ratio 2:1 at 28‐32 weeks). To adjust for the effects of gestational age and time of day, contractions per hour were converted to gestation‐ and hour‐specific percentiles (“contraction percentiles”). Rest was associated with a fall in contraction percentile by 1.25, whereas coitus increased the contraction percentile by 5.52 (P< .05). No changes were noted with emotional stress.Conclusions:This study provides normative contraction data in uncomplicated pregnancy. A strong diurnal rhythm is present from 24 weeks onward, with 67% of contractions occurring at night. Contractions per hour increase with gestational age but rarely exceed three per hour before term. Rest and sexual activity have small but measurable effects on contraction frequency.(Obstet Gynecol 1994;83:517‐23)

ISSN:0029-7844    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Objective:To compare radioimmunoassay of postpartum maternal hair samples with a structured maternal interview for the detection of cocaine use during pregnancy.Methods:Radioimmunoassay of hair samples obtained postpartum was compared with self‐report of cocaine use obtained by confidential, structured interviews of 405 postpartum women.Results:Cocaine or benzoylecgonine was detected in the hair samples of 129 of the 148 women (87%) who reported using cocaine at least once during pregnancy. Thirty‐six of 257 women (14%) who reported that they had used no cocaine during pregnancy had positive hair tests. Positive hair assay with negative self‐report was significantly more common among women who were unmarried (P= .001), African‐American (P< .001), and multiparous (P= .035).Conclusions:Hair analysis is a valuable complement to maternal self‐report by interview. The methods used together provide a useful clinical and research technique yielding a comprehensive estimate of gestational cocaine exposure. Either method alone may result in misclassification of gestational cocaine exposure.(Obstet Gynecol 1994;83:524‐31)

ISSN:0029-7844    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Objective:To determine the levels in serum of tissue inhibitor of metalloproteinases (TIMP) in pregnancy and to examine the possibility of a time course in relation to parturition, both term and preterm.Methods:Serum tissue inhibitor of metalloproteinases was measured using an enzyme‐linked immunosorbent assay. A cross‐sectional study was conducted in 333 women during pregnancy, labor, and the postpartum period and in 27 nonpregnant volunteers. Longitudinal data were obtained from 22 women who provided a sample at term, during labor, and in the postpartum period.Results:In uncomplicated pregnancies, serum TIMP levels were low from the onset of pregnancy until 37 weeks' gestation, in comparison to levels in nonpregnant women (P< .001). During the final weeks of pregnancy, levels rose and at 37‐42 weeks were similar to nonpregnant levels. The levels did not change with the onset of labor. Serum concentrations of TIMP obtained during preterm labor were elevated compared to a control group of patients at a similar gestation who subsequently delivered at term (P< .01). Serum TIMP levels were significantly higher during the postpartum period than at all other times (P< .001).Conclusions:Changes in serum TIMP levels during and after pregnancy may parallel the remodeling of the extracellular matrix that takes place throughout this period. Further work is necessary to evaluate the prognostic value of TIMP for preterm labor.(Obstet Gynecol 1994;83:532‐7)

ISSN:0029-7844    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Objective:To determine the frequency of glove contamination associated with fetal extraction during cesarean delivery.Methods:The study was performed in 25 women having scheduled or unscheduled cesarean delivery. Surgeons double‐gloved for all procedures. Immediately before and after delivery of the fetus, the dorsal aspect of the fingers and hand of the surgeon's outer glove was swabbed with cottontip applicators and cultured for aerobic and anaerobic organisms. Only the glove from the hand that was used to deliver the infant was cultured.Results:Nine of 25 cultures (36%, 95% confidence interval [CI] 17‐55) performed immediately before fetal extraction were positive for staphylococci. No other organisms were isolated. Cultures performed following fetal extraction showed non‐staphylococcal bacteria in 11 of 14 (79%, 95% CI 58‐100) laboring women and one of 11 (9%, 95% CI 0‐26) nonlaboring women, a statistically significant difference (P< .01). In the laboring patients, non‐staphylococcal bacteria were isolated with similar frequency from the dorsal aspect of the hand (seven of 14, 50%, 95% CI 24‐76) and the fingers (ten of 14, 71%, 95% CI 47‐95). These cultures yielded mostly bacterial species from the Enterobacteriaceae family.Conclusion:In laboring patients with ruptured membranes, delivery of the fetal head frequently results in contamination of the surgeon's glove with pathogenic bacteria. This finding may partially explain the increased frequency of post‐cesarean endometritis associated with manual extraction of the placenta.(Obstet Gynecol 1994;83:538‐42)

ISSN:0029-7844    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Objective:To compare our initial experiences with early amniocentesis and transabdominal chorionic villus sampling (CVS).Methods:We compared the diagnostic and pregnancy outcomes of our initial 250 patients undergoing early amniocentesis (at or before the 14th completed week of gestation) or transabdominal CVS (performed between 9.5‐12.9 weeks' gestation). In both groups, the indication for prenatal diagnosis was advanced maternal age (35 years or older at estimated date of delivery).Results:No diagnostic errors were made using either technique, and the culture failure rate for both methods was 0.8% (two of 250). Seven cytogenetic abnormalities in the early amniocentesis group and seven in the transabdominal CVS group were detected. Nine of the 250 women undergoing early amniocentesis reported spontaneous miscarriages following the procedure, compared to five in the transabdominal CVS group. The loss rates were 3.8% in the early amniocentesis group and 2.1% in the transabdominal CVS group among continuing pregnancies. Frequencies of premature delivery, small for gestational age infants, and associated structural defects in both groups were comparable.Conclusions:At this time, early amniocentesis cannot be assumed to be equal to conventional transabdominal CVS or amniocentesis with regard to safety or accuracy; only a large cohort randomized study will adequately determine the safety and efficacy of early amniocentesis.(Obstet Gynecol 1994;83:543‐8)

ISSN:0029-7844    

出版商:OVID    

年代:1994

数据来源: OVID