ArticlePDF Available

Estudio prospectivo aleatorio controlado de un programa de tamizaje de infecciones para reducir la tasa de partos prematuros

Authors:

Abstract

Objetivo: Evaluar si un programa de tamizaje durante el embarazo reduce la tasa de partos prematuros en una población general de gestantes. Diseño: Estudio multicéntrico, prospectivo, aleatorio y controlado. Lugar: Clínicas prenatales no establecidas en hospitales. Material y métodos: Se realizó una coloración de Grama 4.429 gestantes durante sus consultas preparto de rutina, en el segundo trimestre del embarazo, con el objetivo de detectar infecciones vaginales asintomáticas. En el grupo de estudio, los obstetras recibieron los resultados de las pruebas y se les brindó a las pacientes el tratamiento y el seguimiento habitual para la infección detectada. En el grupo de control, no se revelaron los resultados de los frotis vaginales a los profesionales. Principales variables de resultados: La principal variable de los resultados fue el parto prematuro antes de las 37semanas. Las variables secundarias fueron el parto prematuro antes de las 37 semanas en combinación con diferentes categorías de peso al nacer iguales o menores a 2.500 g, y la tasa de muertes fetales (¿abortos tardíos¿). Resultados: Se obtuvieron datos sobre los resultados correspondientes a 2.058 mujeres del grupo de intervención y a 2.097 mujeres del grupo de control. En el grupo de estudio, el número de partos prematuros fue significativamente inferior al grupo de control (3% vs. 5,3%; intervalo de confianza al 95% de la diferencia 1,2 - 3,6, p=0,0001). La cantidad de partos prematuros también fue significativamente menor en las categorías de peso inferiores antes de las 37 semanas y ≤ 2.500 g. En el grupo de estudio se registraron 8 abortos tardíos y en el grupo de control 15. Conclusión: La integración de un programa simple de tamizaje de infecciones en los cuidados prenatales de rutina se asocia con una disminución significativa de la cantidad de partos prematuros y reduce la proporción de abortos tardíos en una población general de gestantes.
A preview of the PDF is not available
ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
The purpose of the study was to examine intercenter variability in the interpretation of Gram-stained vaginal smears from pregnant women. The intercenter reliability of individual morphotypes identified on the vaginal smear was evaluated by comparing them with those obtained at a standard center. A new scoring system that uses the most reliable morphotypes from the vaginal smear was proposed for diagnosing bacterial vaginosis. This scoring system was compared with the Spiegel criteria for diagnosing bacterial vaginosis. The scoring system (0 to 10) was described as a weighted combination of the following morphotypes: lactobacilli, Gardnerella vaginalis or bacteroides (small gram-variable rods or gram-negative rods), and curved gram-variable rods. By using the Spearman rank correlation to determine intercenter variability, gram-positive cocci had poor agreement (0.23); lactobacilli (0.65), G. vaginalis (0.69), and bacteroides (0.57) had moderate agreement; and small (0.74) and curved (0.85) gram-variable rods had good agreement. The reliability of the 0 to 10 scoring system was maximized by not using gram-positive cocci, combining G. vaginalis and bacteroides morphotypes, and weighting more heavily curved gram-variable rods. For comparison with the Spiegel criteria, a score of 7 or higher was considered indicative of bacterial vaginosis. The standardized score had improved intercenter reliability (r = 0.82) compared with the Spiegel criteria (r = 0.61). The standardized score also facilitates future research concerning bacterial vaginosis because it provides gradations of the disturbance of vaginal flora which may be associated with different levels of risk for pregnancy complications.
Article
Objective: We sought to evaluate the association between prior spontaneous preterm delivery and subsequent pregnancy outcome. Study Design: A total of 1711 multiparous women with singleton gestations were prospectively evaluated at 23 to 24 weeks’ gestation. Prior pregnancies were coded for the presence or absence of a prior spontaneous preterm delivery. If a prior spontaneous preterm delivery had occurred, the gestation of the earliest prior delivery (13-22, 23-27, 28-34, and 35-36 weeks’ gestation) was recorded. Current gestations were categorized as spontaneous preterm delivery at
Article
Objective: Our purpose was to determine the risk factors, physical findings, microflora, and pregnancy outcome among pregnant women with moderate to heavy vaginal growth of Candida albicans and other Candida species. Study design: A multicenter cohort of 13,914 women were enrolled between 23 and 26 weeks' gestation. Women completed a questionnaire, underwent a physical examination, and had genital specimens taken for culture. A subset of 1459 women were reexamined during the third trimester. Pregnancy outcomes were recorded at delivery. Results: The prevalence of moderate to heavy Candida colonization at midgestation was 10%. Colonized women, 83% of whom carried C. albicans, were more likely to be black or Hispanic, unmarried, a previous oral contraceptive user, and to manifest clinical signs indicative of Candida carriage. Candida colonization was positively associated with Trichomonas vaginalis, group B streptococci, and aerobic Lactobacillus and was not associated with adverse pregnancy outcome. Conclusion: These results suggest that Candida colonization is not associated with low birth weight or preterm delivery.
Article
In zwei prospektiven Erhebungen wurde die Effektivität der von Saling entwickelten Selbstvorsorge-Aktion zur Frühgeburtenvermeidung untersucht. In 16 der insgesamt 29 Erfurter Frauenarztpraxen erhielten interessierte Schwangere Informationsmaterial sowie eine Messausstattung (Careplan VpH-Handschuhe). Die Frauen wurden angeleitet, vaginale pH-Messungen 2 × wöchentlich selbst vorzunehmen. Die Schwangeren waren dahingehend aufgeklärt, bei erhöht gemessenen pH-Werten (≥ 4,7) oder anderen Auffälligkeiten ihren betreuenden Arzt umgehend zu konsultieren, um sich gegebenenfalls mit Laktobazillus-Präparaten oder bei gesicherter Bakterieller Vaginose mit Clindamycin-Creme i.vag. behandeln zu lassen. In der Erfurter Untersuchung wurden 73 von 381 Frauen in der Interventionsgruppe als risikobelastet identifiziert. 58 von ihnen wurden mit der Laktobazillus-Zubereitung behandelt, 24 z. T. darüber hinaus mit Clindamycin-Creme. 3 Schwangere entzogen sich der Therapie. Die Frühgeburtenrate betrug 8,1 % unter pH-Selbstmessung bzw. Intervention vs. 12,3 % in der Kontrollgruppe (p < 0,05, n = 2341). 0,3 % vs. 3,3 % der Neugeborenen zählten zur Gruppe der frühen Frühgeborenen mit < 32 + 0 Schwangerschaftswochen (p < 0,01). Ein vorzeitiger Blasensprung trat in 22,8 % vs. 30,8 % (p < 0,001) auf. In der zweiten Erhebung wurde versucht, beginnend mit März 2000, sämtliche Schwangeren im Land Thüringen über die betreuenden Frauenärzte mit dem Messhandschuh auszurüsten. Als Hypothese für den Erfolg dieser Aktion gilt die Annahme, dass die Frühgeburtlichkeit beginnend mit Juli 2000 einen deutlichen Abfall aufweisen muss, was über die Perinatalerhebung des Landes zu bewerten ist. Die Resultate der Aktion im Raum Erfurt zeigen u. a. einen Rückgang der Frühgeburtlichkeit von 7,68 auf 6,81 % bzw. einen Rückgang der frühen Frühgeburten von 3,22 auf 2,39 %, jeweils auf das erste bzw. zweite Halbjahr bezogen (n = 1600). Besonders auffällig ist die Tatsache, dass bei den frühen Frühgeburten 19 vs. 0 vorzeitige Blasensprünge auftraten. Auf der Basis der Auswertung vom November 2001 für das Land Thüringen, die alle über die Perinatalerhebung erfassten Entbindungen (n = 16 276) einbezieht, ist ebenfalls ein klares Resultat abzulesen: Sowohl die Gesamtzahl der frühen Frühgeburten (1,58 vs. 0,99 %, p < 0,001) als auch der untergewichtigen Kinder war im zweiten Halbjahr entsprechend der im Ansatz formulierten Hypothese signifikant geringer. Die dargestellten Zahlen der Perinatalerhebung 2000 des Landes sprechen aus unserer Sicht für die Ausweitung der Aktion auf die Bundesrepublik Deutschland.
Article
Purpose: The purpose of this study was to evaluate the outcome of infants born between 22 and 28 completed weeks of gestational age. A gestational age of 24 weeks, regarded in the relevant literature as the limit of viability, was the focus of particular interest. Study Design: Prenatal data were collected retrospectively from the maternal records. Neonatal mortality, early morbidity, as well as the disability rate in the first year of follow-up at corrected age of prematurity were determined and correlated with gestational age. Results: 60 infants were included in the study. Intact survival improved with increasing gestational age. None of the infants born prior to 24 weeks showed intact survival until discharge compared to 74% of the infants born at 24 weeks or later. Gestational age had a major influence on severe handicap (p < 0.03). 50% of the infants prior 24 weeks showed a severe handicap compared to 24 % at 24 weeks or older. There was a marked improvement in the outcome at 25 weeks of gestation (p < 0.01). Conclusion: Viability of fetuses at 23 and 24 weeks of gestation remains ethically and clinically controversial. In our opinion, fetuses at 23 weeks or younger should not be considered viable at this time. On the other hand we continue to treat fetuses at 24 weeks or older as viable. Aggressive obstetric management, especially Caesarean section, should nevertheless only be considered from a gestational age of 25 weeks onward.
Article
Premature birth causes high rates of neonatal morbidity and mortality. There are multiple causes of preterm birth. This article reviews the evidence linking subclinical infection and premature birth. Although maternal genital tract colonization with specific organisms has been inconsistently associated with preterm birth and/or premature rupture of membranes, some infections have been consistently associated with preterm delivery. The association of histologic chorioamnionitis with prematurity is a consistent finding, but the mechanisms require further study. The relationship between histologic chorioamnionitis infection and the chorioamnionitis of prematurity requires additional research. A varying number of patients in "idiopathic" preterm labor have positive amniotic fluid cultures (0% to 30%), but it is not clear whether infection preceded labor or occurred as a result of labor. Evidence of subclinical infection as a cause of preterm labor is raised by finding elevated maternal serum C-reactive protein and abnormal amniotic fluid organic acid levels in some patients in preterm labor. Biochemical mechanisms for preterm labor in the setting of infection are suggested by both in vitro and in vivo studies of prostaglandins and their metabolites, endotoxin and cytokines. Some, but by no means all, antibiotic trials conducted to date have reported decreases in prematurity. These results support the hypothesis that premature birth results in part from infection caused by genital tract bacteria. In the next few years, research efforts must be prioritized to determine the role of infection and the appropriate prevention of this cause of prematurity.
Article
The etiology of vaginitis can be difficult to prove. To determine the relationship between clinical criteria (symptoms and signs) and three causes of vaginitis, we prospectively evaluated 22 criteria in 123 unselected symptomatic patients. Diagnoses of Candida albicans and Trichomonas vaginalis infection were based on culture. Bacterial vaginosis was defined by the presence of 3 of 4 clinical criteria. Only 49% of our patients received diagnoses, and itching was the only symptom more frequently noted among those with diagnoses. Symptoms did not differ among the three infections, and lack of vaginal odor in yeast infection was the only significantly different physical sign. Yeast and trichomonads were seen on microscopy in 63% and 75% of culture-positive specimens. Bacterial vaginosis had no significant clinical criteria beyond those that defined the diagnosis. We conclude that presenting symptoms and signs in vaginitis evaluation have limited value, and that half of the women with vaginitis may lack a microbiologic diagnosis.
Article
To study the role of infection in prematurity, we studied the demographic and obstetrical characteristics, chorioamnionic cultures, and placental histologic features of women who delivered prematurely and compared these findings with those in women who delivered at term. Microorganisms were isolated from the area between the chorion and the amnion (chorioamnion) in 23 of 38 placentas (61 percent) from women with preterm labor who delivered before 37 weeks' gestation and in 12 (21 percent) of 56 placentas from women without preterm labor who delivered at term (odds ratio, 5.6; 95 percent confidence interval, 2.1 to 15.6). The most frequent isolates from the placentas of those whose infants were delivered prematurely were Ureaplasma urealyticum (47 percent) and Gardnerella vaginalis (26 percent). The recovery of any organism from the chorioamnion was strongly associated with histologic chorioamnionitis (odds ratio, 7.2; 95 percent confidence interval, 2.7 to 19.5) and with bacterial vaginosis (odds ratio, 3.2; 95 percent confidence interval, 1.1 to 6.6). When multiple logistic regression was used to control for demographic and obstetrical variables, premature delivery was still related to the recovery of organisms from the chorioamnion (odds ratio, 3.8; 95 percent confidence interval, 1.5 to 9.9) and with chorioamnionitis (odds ratio, 5.0; 95 percent confidence interval, 1.6 to 15.3). The proportion of placentas with evidence of infection was highest among those who delivered at the lowest gestational age. We conclude that infection of the chorioamnion is strongly related to histologic chorioamnionitis and may be a cause of premature birth.
Article
We prospectively studied the relationship of pregnancy outcome to bacterial vaginosis, an anaerobic vaginal condition, and to other selected genital pathogens among 534 gravid women. Bacterial vaginosis was presumptively diagnosed by gas-liquid chromatographic identification of microbial organic acid metabolites in 102 women (19%), and cervical infection with Chlamydia trachomatis was found in 47 (9%) of the women. Although women with and without bacterial vaginosis had similar demographic and obstetric factors, neonates born to women with bacterial vaginosis had lower mean birth weight than did neonates born to women without bacterial vaginosis (2960±847 g vs 3184 ±758 g). Bacterial vaginosis was significantly associated with preterm premature rupture of the membranes (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.1 to 3.7), preterm labor (OR, 2.0; CI, 1.1 to 3.5), and amniotic fluid infection (OR, 2.7; CI, 1.1 to 6.1), but not with birth weight below 2500 g (OR, 1.5; CI, 0.8 to 2.0). Cervical infection with C trachomatis was independently associated with preterm premature rupture of the membranes, preterm labor, and low birth weight (OR, 1.5; CI, 0.8 to 2.0). (JAMA 1986;256:1899-1903)