Obstetrical factors and the transmission of human immunodeficiency virus type 1 from mother to child

Citationsfrom

the literature /International

Journal of Gynecology & Obstetrics 55 (1996) 313-321

ment to the trial was stopped early (November, 1995) by the trial steering committee on the advice of the independent data-monitoring committee, because the data accumulated showed a clear advantage with ECMO. 124 children were enrolled before December, 1994; those who survived to 1 year of age have undergone neurological assessmentat that age (by one of three developmental paediatricians unaware of treatment allocation). Findings: Overall, 81 (44%) infants died before leaving hospital, and two are known to have died later. Death rates differed between the two trial groups; 30 of 93 infants allocated ECMO died compared with 54 of 92 allocated conventional care. The relative risk was 0.55 (95% CI 0.39-0.77; P= O.OOOS), which is equivalent to one extra survivor for every 3-4 infants allocated ECMO. The difference in survival applied irrespective of the primaty diagnosis, disease severity, and type of referral centre. The benefit of ECMO was also found for the primary outcome measure of death or disability at 1 year (among 124 children enrolled before December, 1994). One child in each group has severe disability (overall Griffiths’ developmental quotient < SO, or untestable), and 16 (ten ECMO, six conventional management) have impairments with a lesser degree of disability. Interpretation: These preliminary results demonstrate the clinical effectiveness of a well-staffed and organised neonatal ECMO service. ECMO support should be actively considered for neonates with severe but potentially reversible respiratory failure. The effects of S-nitrosoglutathione on platelet activation, hypertension, and uterine and fetal Doppler in severe preeclampsia Lees C.; Langford E.; Brown AS.; De Belder A.; Pickles A.; Martin J.F.; Campbell S. GBR

OBSTET GYNECOL 1996 88/l (14-19) Objective: To determine the effects of the platelet-specific nitric oxide donor S-nitrosoglutathione on women with severe preeclampsia. Methods: Ten women with severe preeclampsia or preeclampsia with severe fetal compromise at 21-33 weeks gestation each received a 60-90-min intravenous infusion of 50-250 Pbpg/min of S-nitrosoglutathione. Each was hypertensive, despite conventional oral antihypertensive therapy in eight. Maternal blood pressure, heart rate, platelet activation, uterine artery, and fetal Doppler indices were measured during the infusion. Results: A dose-dependent reduction in mean arterial pressure from 125 mmHg (95% confidence interval (Cl) 117-133) to 103.5 (95% CI 97-111) (P < 0.005) and an increase in pulse rate from 73.7 beats per min (95% CI 64.3-84.5) to 89.1(95% Cl 81.2-97.8) (P < 0.02) was observed during the infusion. Mean uterine artery resistance index fell from 0.76 (95% CI 0.73-0.81) to 0.70 (95% CI 0.65-0.75) (P < 0.009). Platelet activation measured by P-selectin expression was reduced from 3.02% (95% CI 2.09-4.36) to 1.22% (95% CI 0.94-1.58) (P < 0.01). Fetal Doppler indices (umhilical artery, middle cerebral artery, and thoracic aorta) showed no significant changes during the infusion. Conclusion: S-nitrosoglutathione infusion reduced maternal mean

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arterial pressure, platelet activation, and uterine artery resistance without further compromising fetal Doppler indices. This study suggests that platelet-specific nitric oxide donors may prove beneficial in the management of severe preeclampsia. Obstetrical factors and the transmission of human immunodeficiency virus type 1 from mother to child Landesman S.H.; Kalish L.A.; Burns D.N.; Minkoff H.; Fox H.E.; Zorrilla C.; Garcia P.; Fowler M.G.; Mofenson L.; Tromala R. USA

N ENGL J MED 1996 334/25 (1617-1623) Background. A substantial proportion of perinatally acquired infections with the human immunodeficiency virus type 1 (HIV-l) occur at or near delivery, which suggests that obstetrical factors may have an important influence on transmission. We evaluated the relation of such factors and other variables to the perinatal transmission of HIV-l. Methods. The Women and Infants transmission Study is a prospective, observational study of HIV-l-infected women who were enrolled during pregnancy and followed with their infants for 3 years after delivery. We studied obstetrical, clinical, immunologic, and virologic data on 525 women who delivered live singleton infants whose HIV-l-infection status was known as of August 31, 1994. Results. Among mothers with membranes that ruptured more than 4 h before delivery, the rate of transmission of HIV-l to the infants was ZS%, as compared with 14% among mothers with membranes that ruptured 4 h or less before delivery. In a multivariate analysis, the presence of ruptured membranes for more than 4 h nearly doubled the risk of transmission (odds ratio, 1.82; 95% confidence interval, 1.10-3.00; P= 0.02), regardless of the mode of delivery. The other maternal factors independently associated with transmission were illicit-drug use during pregnancy (odds ratio, 1.90; 95% confidence interval, 1.14-3.16; P = O.Ol), low antenatal Cd4 + lymphocyte count (< 29% of total lymphocytes) (odds ratio, 2.82; 1.67-4.76; P < O.OOl), and birth weight < 2500 g (odds ratio, I .86; 1.03-3.34; P = 0.04). Conclusions. The risk of transmission of HIV-l from mother to infant increases when the fetal membranes rupture more than 4 h before delivery. Outcome of twin gestations complicated by a single anomalous fetus Malone F.D.; Craig0 S.D.; Chelmow D.; D’Alton M.E. USA

OBSTET GYNECOL 1996 88/l (l-5) Objective: To compare the outcome of twin gestations complicated by a single anomalous fetus with twin gestations with no fetal anomalies. Methods: The study included all patients with twin gestations diagnosed with a fetal anomaly in one fetus during 1990-1994, and excluded twin gestations with anomalies in both fetuses. The control twin group was composed of all other normal twin pregnancies followed and delivered at our center in the preceding 2 years. Results: We reviewed 24 twin