[Show abstract][Hide abstract] ABSTRACT: Human immunodeficiency virus (HIV) infection during pregnancy is a condition that requires multidisciplinary care. Care must be rendered that is appropriate for both the mother and the fetus. Prevention of mother-to-child transmission of HIV is of paramount concern. To prevent transmission, universal testing for HIV infection in pregnant women is ideal. In the United States and other developed countries, great strides have been made toward decreasing the risk of HIV transmission to infants to <2% with use of a combination of highly active antiretroviral therapy during the antepartum period and during labor and delivery, scheduled cesarean section when appropriate, avoidance of breast-feeding, and 6 weeks of zidovudine prophylaxis for infants. The continuation of antiretroviral therapy after delivery depends on the needs of the mother with regard to treatment of her own health. In resource-limited countries, where simplified and shortened courses of antiretroviral regimens have been used, reduction in mother-to-child transmission has also been shown, although not as effectively as that with highly active antiretroviral therapy. In these settings, exclusive breast-feeding for 6 months is recommended to reduce the risk of postnatal transmission.
[Show abstract][Hide abstract] ABSTRACT: Heterosexual spread of HIV remains the major risk factor for transmission worldwide. Genital secretions from the infected partner contain both cell-free and cell-associated virus. Although the exact mechanism of heterosexual transmission is unknown, genital virus plays an important role. Decreasing the genital shedding of HIV is an important step in slowing the spread of the disease. Recent studies have shown that antiretroviral penetration into the genital tract varies by class and that antiretroviral therapy significantly decreases HIV levels. Compartmentalization between the blood and genital tract is based on viral load levels, resistant variants, viral diversity, and coreceptor usage. HSV-2, lack of lactobacilli, and plasma cell endometritis increased HIV genital shedding. HSV-2 suppressive therapy significantly reduces plasma and genital tract viral load. Data are conflicting on the effect of hormonal contraception on HIV genital shedding. Further studies are needed to translate these findings into decreased spread on a population level.
Current Infectious Disease Reports 12/2008; 10(6):505-11.
[Show abstract][Hide abstract] ABSTRACT: The mechanism of human immunodeficiency virus (HIV) transmission via heterosexual intercourse is unknown. We sought to determine whether the presence of inflammatory cells in the vagina is associated with the presence of genital tract HIV type 1 (HIV-1) RNA.
Analysis of a longitudinal prospective cohort was performed. Women with HIV-1 infection were assessed with use of paired plasma and cervicovaginal lavage specimens. Viral load measurements were performed using nucleic acid sequence-based amplification. White blood cells found in the genital tract (GT WBCs) were quantified using a hemacytometer. Common lower genital tract infections assessed for association with viral shedding (i.e., genital tract viral load [GTVL]) included bacterial vaginosis, candidiasis, and trichomoniasis. Generalized estimating equations were used to estimate the prevalence and odds of detectable GTVL by GT WBC. The association was examined both in the presence and in the absence of lower genital tract infections.
A total of 97 women and 642 visits were included in the analysis. Median duration of follow-up was 30.4 months. Thirty women (31%) had detectable GTVL at any visit. The median CD4 cell count at baseline was 525 cells/muL. Most women were antiretroviral therapy naive at baseline. After adjustment for plasma viral load, the odds of detectable GTVL increased as GT WBC increased, with an odds ratio of 1.36 (95% confidence interval, 1.1-1.7) per 1000-cell increase in GT WBC among women without lower genital tract infections. After adjustment for plasma viral load and lower genital tract infections by incorporating them in a regression model, GT WBC remained significantly associated with GTVL, with an adjusted odds ratio of 1.22 (95% confidence interval, 1.08-1.37).
The presence of GT WBC is associated with an increased risk of detectable GTVL.
[Show abstract][Hide abstract] ABSTRACT: To determine the risk of preterm birth related to use of additional antibiotics.
Women with Group B streptococcal (GBS) bacteriuria and women with negative urine cultures in a hospital-wide research registry were included. The impact of prenatal antibiotics in addition to those used to treat GBS bacteriuria was assessed. Logistic regression was used to determine the risk of preterm birth among bacteriuric women who received "other antibiotics".
A total of 203 women with GBS bacteriuria and 220 women with negative cultures were included. The frequency of preterm birth was 16% (35/220) for women in the control group, 16% (19/120) for women with bacteriuria not receiving additional antibiotics, and 28% (23/83) for women with bacteriuria who received antibiotics for "other indications". Among women with GBS bacteriuria, the risk of preterm birth was increased with the use of "other antibiotics" (adjusted odds ratio, 2.7; 95% confidence interval, 1.2-6.1).
Among women with GBS bacteriuria, exposure to additional antibiotics is associated with an increased risk of preterm birth.
International Journal of Gynecology & Obstetrics 09/2008; 102(2):141-5. · 1.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Pregnant women are prone to complications from many infections. However, overwhelming soft tissue infections are rarely reported in pregnant women without predisposing factors. A 40-year-old multipara presented with complaints of progressively worsening spinal muscle spasm pain. Because her medical history consisted of preterm deliveries, she was receiving injections of 17-alpha-hydroxyprogesterone caproate (17P). An imaging study revealed replacement of the vertebral marrow with a homogeneous substance. A biopsy stained for gram-positive cocci. Blood culture bottles grew STAPHYLOCOCCUS AUREUS. The lesion was re-aspirated, and grew the same isolate. The patient was treated with antibiotics and had resolution of her pain. Mother and infant did well, and she completed a prolonged course of antibiotics. This study presents an unusual case of idiopathic vertebral osteomyelitis and epidural abscess during pregnancy. Potential reasons for failure to display a systemic response to this infection with associated bacteremia include an innate variation in the patient's immune system and modification in immunity from progesterone therapy. The role that 17P played in this case, if any, is unknown.
American Journal of Perinatology 07/2007; 24(6):377-9. · 1.57 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The objective of the study was to determine the frequency of adverse pregnancy outcomes in women with untreated asymptomatic group B beta-hemolytic streptococcal (GBS) bacteriuria during pregnancy.
In this retrospective cohort, all women with antepartum GBS bacteriuria in a research registry were included. Controls were women with negative urine cultures. The frequency of chorioamnionitis was compared between groups. Chorioamnionitis was defined as intrapartum fever, fetal tachycardia, and histologic inflammation of the membranes.
One hundred twenty-two women with bacteriuria (study group) and 183 women with negative antepartum cultures (controls) were included. There were no differences in demographic characteristics between the groups. Thirty-one women (10.2%) had chorioamnionitis. Untreated GBS bacteriuria was associated with chorioamnionitis after controlling for confounding variables, adjusted odds ratio 7.2 (95% confidence interval 2.4 to 21.2). There was also a significant positive rank correlation between increasing colony count of GBS bacteriuria and increasing grade of chorioamnionitis (P = .02).
Untreated antepartum GBS bacteriuria is associated with chorioamnionitis.
American journal of obstetrics and gynecology 07/2007; 196(6):524.e1-5. · 3.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The objective of this study was to characterize the systemic immune response in women with trichomoniasis in pregnancy as compared with uninfected women.
A nested case control study was performed on 195 serum samples. Serum concentrations of cytokines, chemokines, and C-reactive protein (CRP) were compared between infected and uninfected women. Cytokines and chemokines were measured using a multiplex bead assay. The CRP concentrations were determined using a standard enzyme-linked immunosorbent assay method.
The median serum concentration of granulocyte-macrophage colony-stimulating factor (GM-CSF) was significantly higher in the trichomonas-infected group compared with the uninfected group (8.9 pg/mL vs. 5.7 pg/mL; P <0.001). The mean log-transformed CRP values were higher in the infected group compared with the uninfected group (1.66 vs. 1.27; P = 0.03).
The results of this study suggest that trichomoniasis during pregnancy can lead to a systemic immune response in some women as exhibited by elevation in the serum concentrations of both GM-CSF and CRP.
Sex Transm Dis 06/2007; 34(6):392-6. · 2.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to describe the fetal and newborn safety profile of prolonged indomethacin treatment during pregnancy. A retrospective cohort of 124 pregnant women treated with indomethacin was used to assess the outcomes of oligohydramnios, constriction of the ductus arteriosus, and composite neonatal morbidity. Eight patients (6.5%) developed ductal constriction and nine patients (7.3%) developed oligohydramnios. Composite morbidity occurred in 36 neonates (29%). Ductal constriction, oligohydramnios, and composite morbidity were not associated with duration of therapy, gestational age at start or stop of therapy, time between dosing and delivery, or dose regimen. Prolonged indomethacin therapy rarely is associated with ductal constriction and oligohydramnios.
American Journal of Perinatology 05/2007; 24(4):207-13. · 1.57 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to define the impact of asymptomatic trichomoniasis on lower genital tract neutrophil activation in pregnancy.
In this nested cohort study, pelvic examination was performed on 65 asymptomatic pregnant women between 7 and 22 weeks' with vaginal pH > 4.4. Concentrations of cervical interleukin-8 and alpha-defensin were determined using enzyme-linked immunosorbent assay (ELISA). Trichomonas vaginalis was detected by culture.
Median concentrations of vaginal fluid neutrophil defensins and cervical interleukin-8 were significantly greater among women with asymptomatic trichomoniasis (median defensins 18,622 ng/mL, median IL-8 9244 pg/mL) than their uninfected counterparts (median defensins 5144 ng/mL, median IL-8 2044 pg/mL) (P < .001). All women with asymptomatic trichomoniasis had detectable defensin and interleukin-8 concentrations.
Asymptomatic trichomoniasis in pregnancy is accompanied by a state of neutrophil activation.
American journal of obstetrics and gynecology 02/2007; 196(1):59.e1-5. · 3.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to determine whether fetal echocardiographic findings are predictive of prognosis in recipient fetuses with twin-twin transfusion syndrome (TTTS).
A cohort of 30 pregnancies with TTTS between 1990 and 2001 was included. Diagnosis and staging of TTTS were made according to the Quintero system. Fetal echocardiographic findings of cardiomegaly, right ventricular hypertrophy, and tricuspid regurgitation were evaluated for relationship with fetal death. Power analysis revealed an approximately 80% power to detect a 2-fold increased risk of fetal death, with alpha = .05. Logistic regression was used to determine the relationship between echocardiographic findings and death.
Most pregnancies were Quintero stage 1, n = 13 (43%), and ranged in severity to Quintero stage 5, n = 4 (13%). Cardiac findings in the recipient fetus that were assessed for a relationship with death included cardiomegaly at the initial appearance of TTTS or at the most severe evaluation findings, right ventricular hypertrophy at initial appearance or at the most severe evaluation findings, or tricuspid regurgitation at initial appearance or at the most severe evaluation findings. Fetal or neonatal death in the recipient twin was not related to the presence of cardiac findings (odds ratio, 0.77; 95% confidence interval, 0.16-3.74).
Fetal echocardiographic findings, whether evaluated at initial appearance or over the course of serial evaluations, were not related to fetal or neonatal death in recipient twins with TTTS.
Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 05/2006; 25(4):455-9. · 1.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To evaluate the effect of implementation of a human immunodeficiency virus (HIV) educational intervention on universal screening for HIV in a prenatal clinic setting.
In this retrospective cohort study, frequencies of offering and acceptance of HIV testing were compared before and after an educational intervention performed by an HIV-focused nurse. The records of 293 women seeking prenatal care before the intervention and 206 women seeking prenatal care after the intervention were reviewed for offering and acceptance of HIV testing. Fisher's exact test and logistic regression were used to evaluate the relationship between the educational intervention and the offering and acceptance of HIV testing.
The frequency of HIV test offering at first visit and test acceptance before the educational intervention were 96.5% and 74.8%, respectively, and after the intervention were 99.5% and 84.3%, respectively. This improvement in offering (3% change) and acceptance (9.5% change) was statistically significant (offering at first visit: OR = 7.27, 95% CI = 1.02 to 316.9; test acceptance: OR = 1.82, 95% CI = 1.14 to 2.88). Test acceptance was statistically significantly improved in the post-intervention group after controlling for confounding variables (OR = 2.02, 95% CI = 1.2 to 3.39).
The addition of an HIV-focused nurse to a clinic setting improved the frequency of test offering at first visit and of acceptance of HIV testing by pregnant women.
Infectious Diseases in Obstetrics and Gynecology 01/2004; 12(3-4):115-20.