628: Upper respiratory tract infection during pregnancy: is it associated with adverse perinatal outcome?

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www.AJOG.org 625 Novel influenza A (H1N1) virus infection and pregnancy outcomes in an inner city hospital: a case series Scott A. Shainker1, Jodi F. Abbott1 1

Boston Medical Center, Boston University School of Medicine, Department of Obstetrics and Gynecology, Boston, Massachusetts

OBJECTIVE: In the spring of 2009, the World Health Organization declared a novel influenza A (H1N1) virus pandemic. Despite the high level of global awareness, there has been a paucity of reported pregnancy outcomes in the H1N1 population. This case series reviews pregnancy outcomes in women hospitalized with confirmed H1N1 viral infection. It is the belief of the authors that sharing our experiences in managing pregnancies complicated by H1N1 viral infection will assist obstetricians with future encounters. STUDY DESIGN: This study is a retrospective chart review. RESULTS: 6 pregnancies to date have been complicated by H1N1 virus in our population; 5 singletons, one twin gestation. Of these, 5 out of the 6 have delivered, 3 out of the 5 resulted in delivery at term, the other 2 were delivered at 31wks (twin) and 32wks, respectively. 4 out of the 5 deliveries resulted in cesarean sections. Gestational age at delivery ranged from 31 1/7wks to 40 4/7 wks. Apgar scores ranged from 0 to 9 and 5 to 9, for one and five minutes, respectively. The one minute apgar of zero was the result of a teen pregnancy complicated by severe pre-eclampsia, who delivered via emergent cesarean section for a category III fetal heart tracing. Fetal weights ranged from 1520g to 4570g. There was no pathologic evidence of placental involvement in any of our cases. One patient did have underlying lung disease, no patients required admission to the ICU or mechanical ventilation. CONCLUSION: Historically, novel influenza A has shown to carry a high morbidity and mortality in the pregnant population. The current H1N1 virus pandemic contributes to the morbidity of pregnancy. Although 3 out of the 5 cases resulted in delivery at term, our experience does support the notion H1N1 viral infection can exacerbate underlying pulmonary disease, and is associated with preterm delivery. This is the largest case series reviewing pregnancy outcomes in the current H1N1 virus pandemic to date, and the only reported case of H1N1 virus infection complicating a multiple gestation pregnancy. 0002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.490

626 Longitudinal variation in group B streptococcal status in preterm patients Matthew Mingione1, John Kowalczyk2, Daniel Grace3 1

Riverside Methodist Hospital, Obstetrics and Gynecology, Columbus, Ohio, 2University of Rochester, College of Medicine, Rochester, New York, 3University of Rochester, Department of Obstetrics and Gynecology, Rochester, New York

OBJECTIVE: Prior studies of term gestations revealed 96% concordance between a negative Group B Streptococcus (GBS) culture obtained within 4 weeks of delivery and culture status at the time of delivery. The concordance of GBS cultures for patients at risk of preterm birth has not been established. A pilot study at our institution revealed 4 of 19 patients with symptomatic preterm labor (PTL) or preterm rupture of membranes (PPROM) converted from negative GBS status to positive GBS status within 2 weeks. Additionally, we observed a decreased period of latency for subjects that converted. We sought to establish the longitudinal concordance of Group B Streptococcus (GBS) cultures in patients with PTL/PPROM compared to term and preterm controls. Our secondary aim was to quantify the impact of converion on the period of latency. STUDY DESIGN: Weekly rectovaginal GBS cultures were obtained from patients admitted for PTL or PPROM. These were compared to weekly GBS cultures from asymptomatic preterm and term controls. RESULTS: Conversion from a negative to positive GBS culture within 4 weeks occurred in 6 of 50 PTL/PPROM patients (12%), 10 of 52 (19.2%) term controls and 4 of 26 (15.4%) preterm controls. There was no significant difference in conversion rate for the three groups (P value⫽ 0.603) . Mean interval to conversion was 12.8 days for PTL/

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PPROM cases, 10.4 days for term controls and 24 days for preterm controls. There was no difference in the latency between converters and non-converters in the PTL/PPROM cases. CONCLUSION: There was no difference in conversion to positive GBS culture between PTL/PPROM patients and term and preterm controls. However the conversion rate is approximately 5 times higher than prior reports. Conversion to GBS positive status did not affect latency. These results call into question the reliability of GBS cultures obtained even 2 weeks prior to delivery. 0002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.491

627 Fetal cerebral periventricular halo at mid gestation: an ultrasound finding suggestive of fetal CMV infection Giuliana Simonazzi1, Brunella Guerra2, Paola Bonasoni3, GianluigI Pilu2, Tiziana Lazzarotto4, Donatella Santini5, Nicola Rizzo2 1 University of Bologna, Department of Obstetrics and Gynecology, St. Orsola Malpighi Hospital, Bologna, Italy, 2University of Bologna, Department of Obstetrics and Gynecology, St. Orsola Malpighi Hospital, Italy, 3 Department of Pathology, Arcispedale S.Maria Nuova, Reggio Emiliai, Italy, 4 University of Bologna, Department of Clinical and Experimental Medicine (Section of Microbiology), St. Orsola Malpighi Hospital, Italy, 5University of Bologna, Department of Pathology, St. Orsola Malpighi Hospital, Italy

OBJECTIVE: To identify a cerebral ultrasound finding indicative of fetal

CMV infection at mid gestation. STUDY DESIGN: All fetuses of patients referred to our Maternal-Fetal

Medicine Unit for primary CMV infection between January 2007 and December 2008 underwent prospective transvaginal neurosonographic examination at 20-22 weeks’ gestation. RESULTS: Transvaginal sonography identified a periventricular echogenic halo with well-defined borders in six foetuses at a mean gestational age of 20.5 weeks (range, 20-22 weeks) out of 218 women with primary CMV infection. The hyperechogenicity surrounding the ventricular margins was particularly evident in the coronal section of the fetal brain, especially at the level of the frontal horns of the lateral ventricles. Transabdominal axial views of the fetal head were normal in all cases except for a small biparietal diameter and head circumference in three foetuses. Ventriculomegaly was not observed in any case. Amniocentesis was performed in all cases for viral assessment at 20-22 week’s gestation, and all samples were found by virus isolation and polymerase chain reaction to be positive for CMV infection. All patients opted for termination of pregnancy given the result of prenatal investigations. Four women declined post-mortem examination. A complete autopsy was performed in two fetuses and microscopic examination showed changes compatible with subacute white matter injury resembling telencephalic leukomalacia. The sonographic and pathologic findings were compared in these two cases. The macroscopic examination showed an excellent correlation with the ultrasonographic findings in one of the two cases (case 1); in the other the hemispheres did not appear abnormal macroscopically, but only at microscopic examination (case 2). CONCLUSION: A fetal cerebral periventricular halo in pregnant patients at mid gestation with recent CMV infection is suggestive of fetal infection and is associated with white matter lesions. This finding can only be demonstrated clearly using a transvaginal approach. 0002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.492

628 Upper respiratory tract infection during pregnancy: is it associated with adverse perinatal outcome? Liran Stiller-Timor1, Amalia Levy2, Gershon Holcberg1, Eyal Sheiner1 1 Soroka University Medical Center, Ob/Gyn, Beer Sheva, Israel, 2Ben Gurion University of the Negev, Epidemiology, Beer-Sheva, Israel

OBJECTIVE: To determine whether there is an association between up-

per respiratory tract infection (URTI) requiring hospitalization during pregnancy, and adverse perinatal complications.

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STUDY DESIGN: A retrospective population-based study comparing all singleton pregnancies of patients with and without URTI requiring hospitalization was performed. Multiple logistic regression models were performed to control for confounders. RESULTS: Out of 186,373 deliveries, 0.13% (n⫽246) required hospitalization due to URTI during pregnancy. URTI was significantly associated with preterm deliveries (15.9% vs. 7.9%; p⬍0.001), lower birth weight (3082⫾624 vs. 3183⫾546 grams; p⬍0.001) and higher rate of cesarean deliveries (CD; 20.3% vs. 13.2%; p⬍0.001) as compared to the comparison group. Even after controlling for possible confounders such as maternal age and parity, using multivariable analyses, the significant association between URTI and preterm delivery (weighted OR⫽2.2; 95% CI 1.6-3.1; p⬍0.001), as well as CD (weighted OR⫽1.5; 95% CI 1.1-2.2; p⫽0.020) persisted. In contrast, no significant association was documented between URTI and premature rapture of membranes (PROM; 4.9% vs.6.9%; p⫽0.212), low Apgar scores (⬍7) at 5 minutes (0.4% vs.0.6%; p⫽0.761) and perinatal mortality (0-4% vs.1.3 %; p⫽0.223). CONCLUSION: Maternal URTI is an independent risk factor for preterm delivery and cesarean delivery. 0002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.493

629 Comparison of bactericidal properties of alcohol-based chlorhexidine versus povidone-iodine prior to amniocentesis Kristin Brigger1, Joan Mastrobattista2, Karen Bishop3

www.AJOG.org aim was to characterize pregnancy related LM morbidity,risk factors and molecular epidemiology. STUDY DESIGN: A nationwide retrospective cohort study encompassing 10 years surveillance of all Israeli cases of pregnancy related listeriosis. Cases were identified from records of all hospital-based clinical microbiology laboratories and the national reference laboratory. Clinical data were obtained from patient records. Mother and infant were counted as a single case. RESULTS: Between January 1998 and December 2007 166 pregnancy related cases were identified, representing yearly incidence rates of 5-25 cases/100,000 births. Most cases occurred in the 2nd and 3rd trimester. Maternal symptoms and fetal survival by trimester are shown in table 1. The calculated perinatal case fatality rate was 47% comprising a fetal loss rate of 38.2% and additional 7.9% neonatal mortality. Fetal survival improved significantly (P value⬍ 0.05) as pregnancy age advanced: for each sequential week of pregnancy survival rose by 30% (OR 1.3, CI 1.18-1.45). A single case of maternal mortality was recorded. No correlation was found between LM serotype and pregnancy outcome, age or any other clinical parameter. Molecular analysis of LM isolates showed that approximately a third of the cases were caused by a single LM clone. CONCLUSION: This study emphasizes the profound impact of LM as a pathogen in the vulnerable pregnant population in Israel. The molecular epidemiology findings make closer surveillance, identification and control of sources of LM mandatory.

1

University of Texas Health Science Center at Houston, Houston, Texas, University of Texas M.D. Anderson Cancer Center, Houston, Texas, 3 University of Texas Health Science Center at Houston, Obstetrics, Gynecology and Reproductive Sciences, Houston, Texas 2

Clinical Presentation and Fetal/Neonatal Survival

OBJECTIVE: To compare the bactericidal properties of povidone-io-

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dine versus alcohol-based chlorhexidine solution for cleansing the gravid abdomen prior to amniocentesis. STUDY DESIGN: 50 study participants were recruited from the University of Texas Women’s Clinic in Houston, Texas. Two baseline swabs of the patient’s abdomen were obtained to assess bacterial flora prior to treatment. A 10% povidone-iodine solution and 2% Chlorhexidine gluconate with 70% isopropyl alcohol solution (CHG/IPA) in a 3 milliliter pre-filled applicator (Chloro-prep) were then used on different sides of the abdomen. After 30 seconds time, cultures were obtained and plated on Trypticase Soy with Sheep’s Blood Agar for aerobic flora. Plates were incubated at 37 degrees Celsius for 48 hours for aerobic flora. Colony forming units (CFU) were counted and recorded. RESULTS: There was no statistically significant difference between baseline colony counts on each subject when looking at the right and the left side of the patients abdomen. (p value 0.33). The post-cleansing colony counts were next compared yielding a statistically significant (p-value of ⬍0.001), favoring Chlorhexidine as the better cleanser. CONCLUSION: 2% Chlorhexidine with 70% isopropyl alcohol demonstrated excellent bactericidal efficacy and was superior to povidoneiodine regimen for cleansing the maternal abdomen. 0002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.494

630 Listeriosis affecting pregnancy: 10 year analysis Anat Hershko-Klement1, Hila Elinav2, Lea Valinsky3, Eyal Braun4, Yossi Paitan5, Moshe D Fejgin6, Colin S Block2, Ran Nir-Paz2 1

Meir Medical Center, Department of Obstetrics and Gynecology, Kfar-Saba, Israel, 2Hadassah Hebrew University Medical Center, Deprtment of Clinical Microbiology and Infectious Diseases, Jerusalem, Israel, 3Israel Ministry of Health, Central Laboratories, Jerusalem, Israel, 4Rambam medical center, The Unit of Infectious Diseases, Haifa, Israel, 5Meir Medical Center, Clinical microbiology, Kfar-Saba, Israel, 6Meir Medical Center, Tel Aviv University, Obstetrics and Gynecology, Kfar-Saba, Israel

OBJECTIVE: Listeria monocytogenes(LM) is a foodborne pathogen that causes life threatening infections. In pregnancy it may cause fetal loss and preterm delivery. Neonates are prone to sepsis and death. Our

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Fever, Contractions, Abdominal pain, reduced movements

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Neonatal 116/126 .......................................................................................................................................................................................... 0002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.495

631 Prevalence of Epstein-Barr virus reactivation in pregnancy Sina Haeri1, Arthur Baker1, Kim Boggess1 1 University of North Carolina at Chapel Hill, Obstetrics & Gynecology, Chapel Hill, North Carolina

OBJECTIVE: Recent evidence suggests a link between Epstein-Barr vi-

rus (EBV) reactivation and chronic stress, due decreased cellular immune responses in the adult non-pregnant population. Our objective was to determine the prevalence of EBV reactivation in a diverse cohort of pregnant women. STUDY DESIGN: In this cross-sectional study, we evaluated mid-pregnancy serum specimens from 64 healthy pregnant women for presence of EBV Viral Capsid Antigen (VCA), EBV Nuclear Antigen (NA), and EBV Early Antigen (EA). EBV primary infection was defined by the presence of EBV VCA IgM with absence of EBV NA IgM. EBV reactivation will be defined by the presence EBV VCA IgM or EBV EA IgG with presence of EBV NA IgM or EBV VCA IgG. Data was analyzed using Chi-square and student t-test. RESULTS: In our pregnant cohort, 63 (98%) of the 64 women were EBV (seropositive). Among these seropositive women, 22 (35%) women demonstrated EBV reactivation in pregnancy. EBV reactivation was not associated with maternal age, race, parity, or insurance type. CONCLUSION: In our diverse pregnant cohort, 98% of women analyzed were EBV seropositive with 35% demonstrating EBV reactivation in the pregnancy. The pathophysiology & clinical implications of EBV reactivation during pregnancy need further study. 0002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.496

American Journal of Obstetrics & Gynecology Supplement to DECEMBER 2009