摘要:

ObjectiveTo describe the safety, efficacy, and perinatal transmission rates of human immunodeficiency virus (HIV) with combination antiretroviral therapy in pregnancy.MethodsRetrospective study of all HIV-infected pregnant women treated with combination antiretroviral therapy after September 1, 1996, and who delivered by September 1, 1998, at Bronx-Lebanon Hospital Center.ResultsThirty women received combination therapy, 13 with protease inhibitor. Median baseline CD4 was 285 cells/mm3; 16 (53%) had AIDS, 20 (67%) were antiretroviral-experienced, and 11 (37%) were illicit substance users. Fourteen were receiving antiretroviral therapy (eight with protease inhibitor) during the first trimester. Combination therapy was prescribed for a median of 26 weeks during pregnancy. One third changed antiretroviral therapy, and nearly half (47%) were nonadherent. Twenty-four women had a successful viral load and/or CD4 response. The median (range) delivery gestation was 39 (32–42) weeks, and the median (range) birth weight was 2892 (1430–3863) g. Adverse outcomes included one stillbirth; one case of microcephaly; and five infants less than 2500 g, two of which were under 36 weeks' gestation. Median birth weight did not differ with maternal protease exposure. None of the 26 infants studied for at least 4 months had HIV infection. Associated maternal complications were four cases of pregnancy-induced hypertension, one of gestational diabetes, and one exacerbation of hepatitis C virus.ConclusionCombination antiretroviral therapy in pregnancy was efficacious in reducing viral load, increasing CD4, and preventing vertical HIV transmission in women with advanced HIV disease, extensive antiretroviral experience, prior history of vertical transmission, and/or substance abuse. The findings are promising in this preliminary report that combination antiretroviral therapy may not be related to major infant toxicity, but further study is warranted.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo report the experience with state-mandated voluntary newborn human immunodeficiency virus (HIV) screening in a large university hospital.MethodsRetrospective analysis of delivery records and newborn HIV screening data for infants born between May 4, 1996, and January 31, 1997.ResultsOf 3111 women, 40% had HIV testing during pregnancy, 28% had testing before pregnancy, 30% never had testing, and 2% gave no information. Most (91%) consented to postpartum newborn HIV testing, although rates varied by HIV counselor (range 81–96%,P< .001) and maternal HIV testing history (range 72–94%,P< .001). Maternal antepartum HIV testing rates varied by delivering physician (range 8–100%,P< .001) and by antepartum care site (clinics, 83%; faculty practices, 72%; private practices, 57%;P< .001). Fourteen HIV-exposed infants (0.46% of infants tested) were identified, 13 of whom were born to women known to be HIV positive before delivery. These women had received zidovudine prophylaxis according to Adult AIDS Clinical Trials Group 076 guidelines. All 14 infants subsequently tested negative for HIV. Human immunodeficiency virus–positive women were more likely than HIV-negative women to have received antepartum care in clinics (93% compared with 11%), have care paid by Medicaid (93% compared with 28%), and reside in high-risk areas (72% compared with 11%) (P< .001).ConclusionNewborn HIV screening has little incremental impact in settings with aggressive antepartum screening and/or low HIV infection rates. Interventions to increase antepartum HIV screening in the private sector should be implemented.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo determine the seroprevalence of and risk factors for human papillomavirus (HPV) type 16 capsid antibodies in a large cohort of pregnant women.MethodsAntibodies against in vitro produced HPV-16 capsids were measured in stored sera from 2597 pregnant women enrolled from 1984 through 1989 in the Vaginal Infection and Prematurity Study, New Orleans site.ResultsWomen in this study were primarily black (83.4%) with a mean age of 23.4 years (standard deviation [SD], 5.1), mean number of sexual partners in lifetime was 3.3 (SD, 6.6), and the mean age at sexual debut was 16.7 years (SD, 2.2). Overall, 28.0% (n= 727) of these women were positive for HPV-16 capsid antibodies. In bivariate analysis, the presence of antibodies against HPV-16 was correlated with numerous demographic characteristics as well as history of various sexually transmitted diseases. However, neither current cervical or vaginal infection nor adverse obstetric outcome was associated with increased detection of HPV-16 antibodies. In multivariate logistic regression analysis, factors predictive of HPV-16 seropositivity were: more than five lifetime sexual partners (odds ratio [OR], 1.80; 95% confidence interval [CI], 1.28, 2.52), 6 or more years of sexual activity (OR, 1.84; 95% CI, 1.22, 2.78), level of education (OR, 1.26; 95% CI, 1.03, 1.55), and history ofNeisseria gonorrhoeaeinfection (OR, 1.53; 95% CI, 1.20, 1.96).ConclusionHPV-16 seropositivity correlates with measures of sexual activity, confirming its role as a sexually transmitted disease, and its prevalence is similar to that in nonpregnant populations. HPV-16 seropositivity does not predict an adverse obstetric outcome

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo describe characteristics of United States female obstetrician-gynecologists, a large and growing group, and to contrast them with other female physicians.MethodsWe contrasted data from 313 obstetrician-gynecologists to data from 4132 other female physician respondents to the Women Physicians' Health Study, a national questionnaire-based study.ResultsObstetrician-gynecologists assumed fewer domestic responsibilities, reported higher personal and household incomes, and were more likely to be in a group practice than other female physicians. Female obstetrician-gynecologists' personal health behaviors and other personal characteristics, career satisfaction, and desire to remain in their specialty were similar to those of other female physicians. Obstetrician-gynecologists did more counseling and screening than primary care physicians (family and general practitioners and internists) with respect to breast cancer and hormone replacement therapy (HRT). Obstetrician-gynecologists performed equivalently to primary care physicians with respect to human immunodeficiency virus (HIV), colorectal cancer, blood pressure, weight, exercise, and smoking, performed like other specialists with respect to cholesterol, skin cancer, and flu vaccine, and between these two groups with respect to nutrition and alcohol. Obstetrician-gynecologists' perceived relevance of, training in, and confidence regarding counseling were higher for HRT and breast cancer compared with other physicians.ConclusionObstetrician-gynecologists have many similarities with other female physicians, including level of career satisfaction, but earned more and assumed fewer domestic responsibilities. Although obstetrician-gynecologists counseled more than other specialists, with the increasing role of obstetrician-gynecologists as primary care doctors, it is noteworthy that female obstetrician-gynecologists frequently provide gynecologic-specific preventive care, but are less likely to address other nonobstetric-gynecologic areas of prevention. This finding could be transformed by continued changes in the education of residents and practicing physicians.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveLittle is known about female physicians' personal contraceptive use, and such usage could influence their prescribing patterns.MethodsWe used data from the Women Physicians' Health Study, a large (n= 4501) national study, administered in 1993–1994, on characteristics of female physicians in the United States.ResultsThese female physicians (ages 30–44 years) were more likely to use contraception than women in the general population (ages 15–44 years); this was true even when the physicians were compared with only other women of high socioeconomic status and when stratified by ethnicity, age, and number of children. Physicians were also more likely to use intrauterine devices, diaphragms, or condoms, and less likely to use female or male sterilization than were other women. Younger female physicians were especially unlikely to use permanent methods, particularly when compared with their age-matched counterparts in the general population. One fifth of contracepting physicians used more than one type of contraceptive; the most frequently used combination was spermicide with a barrier method.ConclusionFemale physicians contracept differently than do women in the general population, in ways consistent with delaying and reducing total fertility. Physicians' personal characteristics have been shown to influence their patient counseling practices, including their contraception-related attitudes and practices. Although female physicians' clinical advice might differ from their personal practices, as women physicians become more prevalent, their contraceptive choices could influence those of their patients.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo assess physicians' knowledge and practices of modern methods of natural family planning.MethodsA questionnaire was mailed to 840 physicians selected randomly from Missouri state licensing records for obstetrics-gynecology, family practice, general practice, and general internal medicine.ResultsThe response rate was 65%. A total of 375 physicians (69% of respondents) saw women for reproductive issues. About half (46%) of physicians reported that they mentioned natural family planning to at least some women when discussing family planning issues. Observing vaginal discharge of cervical mucus was discussed by 40% of physicians in the context of avoiding pregnancy and by 36% of physicians in the context of helping a couple achieve pregnancy. Twenty-two percent of physicians estimated the best possible effectiveness of natural family planning to avoid pregnancy to be greater than 90%, and 35% estimated the actual effectiveness to avoid pregnancy to be greater than 70%. (The threshold rates of 90% best possible effectiveness and 70% actual effectiveness were chosen to be somewhat less than those reported in medical literature.) Physicians who gave higher estimates of effectiveness of natural family planning and physicians who were aware of an instructor in their community were more likely to provide women with relevant information about natural family planning.ConclusionMost physicians, especially those unaware of availability of instructors in their areas, underestimate the effectiveness of natural family planning and do not give information about modern methods to women

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo identify factors associated with fear of childbirth during and after first labor.MethodsWe analyzed first deliveries of 100 primiparas who reported severe fear of vaginal childbirth during their second pregnancies and 200 age- and parity-matched controls who reported no later fear of delivery. The main outcome measures were previous miscarriages, participation in birth-education classes, support during labor, length of first delivery, pain relief, obstetric complications, welfare of the newborn, and time between deliveries.ResultsThe prevalence of emergency cesarean (adjusted odds ratio [OR] 26.9, confidence interval [CI] 11.9, 61.1) and vacuum extraction (adjusted OR 4.5, CI 2.2, 9.3) during first delivery was much higher in subjects than controls. Labor lasted longer in cases than in controls during the first (10.5 hours versus 7.8 hours,P= .016) and second stages (62 minutes versus 47 minutes,P= .002). They received epidural analgesia more often, but its timing and the amount used were not different between groups. Of the group with fear, 44% could not define any specific cause for fear and regarded the entire delivery as frightening.ConclusionEmergency cesarean and vacuum extraction during first deliveries were associated with secondary fear of delivery. Emergency obstetric procedures cannot be avoided, so prevention of fear might require more education on causes and consequences of cesarean or vacuum extraction, eg, in birth classes and at postpartum visits.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo compare outpatient to inpatient management of acute pyelonephritis in pregnancy beyond 24 weeks' gestation.MethodsNinety-two gravidas past 24 weeks' gestation, randomized to outpatient or inpatient therapy, received two 1-g doses of intramuscular ceftriaxone at 24-hour intervals while hospitalized, then were discharged and reevaluated within 48–72 hours or remained hospitalized until afebrile for 48 hours. Subjects received oral cephalexin after initial treatment. Urine cultures were done on admission and 5–14 days after therapy. Surveillance continued until delivery. We anticipated that 15% of outpatients and 0.01% of inpatients would require changes in antibiotic therapy.ResultsTwenty-one percent of women evaluated were excluded. Thirteen of 46 (28%) outpatients' hospitalization exceeded 24 hours. Six outpatients (13.0%) and one inpatient did not respond to initial therapy and were treatment failures (relative risk [RR] 1.82, 95% confidence interval [CI] 1.00, 3.31). Within 2 weeks of initial therapy, seven of 81 (8.6%) subjects had positive urine cultures, four outpatients versus three inpatients (P> .999). Eleven of 84 (13.1%) deliveries for which birth data were available occurred preterm (six of 41 outpatients versus five of 43 inpatients) (RR 1.14, 95% CI 0.61, 2.11).ConclusionThere were no significant differences in clinical responses or birth outcomes of inpatients or outpatients treated for acute pyelonephritis after 24 weeks' gestation if they completed their assigned protocols. Thirty percent of outpatients were unable to, and most women with acute pyelonephritis in the third trimester were not candidates for outpatient therapy.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo investigate the effect of pregnancy and delivery on continence and to assess whether physical markers of collagen weakness can predict postpartum urinary and fecal incontinence (including incontinence of flatus).MethodsIn a prospective, longitudinal study in a London teaching hospital, 549 nulliparas were interviewed after 34 weeks' gestation and again 3 months postpartum regarding urinary and fecal symptoms before and during pregnancy and after delivery. Family histories of incontinence, prolapse, and collagen abnormalities were recorded also. Physical examination was done to assess markers of collagen weakness such as striae, hernia, varicose veins, and joint mobility.ResultsThe prevalence of urinary incontinence before, during, and after pregnancy was 3.6%, 43.7%, and 14.6%, and rates of fecal incontinence were 0.7%, 6.0%, and 5.5%, respectively. Fecal urgency was more common in women who had spontaneous and instrument-assisted vaginal deliveries (n= 413) compared with cesareans (n= 131) (7.3% versus 3.1%;P= .046). Postnatal urinary or fecal dysfunction was not related to antenatal body mass index, smoking, race, striae, varicose veins, hemorrhoids, or family history of incontinence. Higher joint-mobility scores were associated with incontinence of flatus (P= .021) but not with other urinary or fecal symptoms.ConclusionAlthough collagen weakness was previously implicated in the pathogenesis of incontinence, physical markers in this study could not predict postpartum urinary and fecal incontinence. Either those markers were not representative of collagen weakness, or a larger study with longer follow-up is necessary.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

ObjectiveTo determine whether regional differences exist in uterine and systemic hemodynamic responses to the menstrual cycle, whether the hormonal environment correlates with the changes, and whether uterine artery hemodynamic adaptation depends on the side of ovulation.MethodsTwenty nulliparas had transvaginal Doppler ultrasonographic assessment of the uterine and upper-extremity radial arteries at three time points in each of two menstrual cycles. Doppler indices (peak systolic velocity, end-diastolic velocity, time-averaged maximum velocity, resistance index [RI], and blood flow) were measured in the radial and uterine arteries. Women were examined in the menstrual (cycle day 2–3), follicular (cycle day 9–10), and luteal phases (cycle day LH surge plus 9–10). At each time, serum estradiol (E2) and progesterone were measured by radioimmunoassay. Statistical analyses were repeated-measures analysis of variance and the Fisher least significant difference procedure.ResultsThirty-four nonconception ovulatory cycles were evaluated. Blood flow in each uterine artery increased significantly from a mean (± standard deviation) of 22.4 ± 7.3 mL/minute in the follicular phase to 30.7 ± 13.7 mL/minute in the luteal phase, which coincided with a reduction in the RI. The changes were independent of the side of ovulation. The radial artery did not parallel these changes (follicular blood flow of 27.2 ± 13.9 mL/minute; luteal blood flow of 24.7 ± 10.5 mL/minute). We did not identify any significant correlation between these changes and serum E2 or progesterone concentrations.ConclusionWe identified differences in the hemodynamic responses of the uterine artery compared with the radial artery during the menstrual cycle. We believe the difference indicates distinct regional control of vascular response during the menstrual cycle.

ISSN:0029-7844    

出版商:OVID    

年代:1999

数据来源: OVID