ABSTRACT Intrauterine infection is a recognized cause of preterm birth. The infectious organisms are believed to originate primarily from the vaginal tract and secondarily from other parts of the body. It is plausible that microbes in the oral cavity can be transmitted to the pregnant uterus. However, direct evidence supporting such a transmission is lacking. In this study, amniotic fluids of 34 pregnant women were examined by PCR using 16S and 23S rRNA universally conserved primers. Bacterial DNA was amplified from the only patient with clinical intrauterine infection and histologic necrotizing acute and chronic chorioamnionitis. One strain, Bergeyella sp. clone AF14, was detected and was 99.7% identical to a previously reported uncultivated oral Bergeyella strain, clone AK152, at the 16S rRNA level. The same strain was detected in the subgingival plaque of the patient but not in her vaginal tract. The 16S-23S rRNA sequence of clone AF14 matched exactly with the sequences amplified from the patient's subgingival plaque. These observations suggest that the Bergeyella strain identified in the patient's intrauterine infection originated from the oral cavity. This is the first direct evidence of oral-utero microbial transmission. The patient's periodontal health during pregnancy was unclear. She did not have detectable periodontal disease during postpartum examination. Bergeyella spp. had not been previously associated with preterm birth and were detected in subgingival plaque of women without clinical levels of intrauterine infection. Uncultivated species may be overlooked opportunistic pathogens in preterm birth. This study sheds new light on the implication of oral bacteria in preterm birth.

To critically examine the causes and potential prevention of maternal death in the United States since 2000. We examined medical records from all maternal deaths among 1.24 million births occurring between from 2000-2005 in the nation's largest healthcare system. We assessed the causal relationship between route of delivery and death and determined whether such deaths were potentially preventable. 78 maternal deaths occurred in 1,239,385 deliveries (6.3/100,000 births.) For women undergoing cesarean delivery, the rate was 13.2/100,000 cesareans and for those undergoing vaginal birth, 1.5/100,000 vaginal births. Leading causes of death were: Amniotic fluid embolism −15%, complications of preeclampsia −15%, pulmonary thromboembolism −13%, cardiac disease −11%, obstetric hemorrhage −9%, non-OB infection −8%, accident/suicide 7%. In only 4 cases of cesarean section was death caused by complications of the operation itself rather than by the indication for the cesarean. All of these cases were deemed potentially preventable. Cesarean section may have contributed to death in 9 additional cases of pulmonary thromboembolism. There was only 1 fatal pulmonary embolism among the women delivering vaginally. In 10 cases, (13%) death was attributable to medical provider error. In 10 cases, (13%) death was attributable to the actions of the patient or another non-medical provider. Most maternal deaths are not currently preventable. Although cesarean section is associated with a higher mortality rate than vaginal delivery, it is only uncommonly causative. Deaths causally linked to cesarean were, in our series, all potentially preventable. Given the diversity of causes of maternal death, significant reductions in the maternal mortality rate in the United States will only come from improved understanding of the nature and prevention of preeclampsia and amniotic fluid embolism or universal thromboprophylaxis for all women undergoing cesarean section.

ObjectiveTo identify factors affecting the success of a free Smoking Cessation in Pregnancy (SCIP) program for uninsured and low income patients in a High-Risk pregnancy clinic (29% smoking, 1 in 6 low birth-weight).Study designThe study design was that of a prospective longitudinal observational clinical study. One-on-one counseling for SCIP was provided at prenatal/postnatal visits by part-time nurse coordinators using American Cancer Society's Fresh Start smoking cessation protocols. Information obtained (risk factors, smoking status, counseling level, surveys, carbon monoxide sensor readings) was recorded in the EPIC electronic record. Incentives were Babies R' Us $10 gift certificates, Panera Bread and Bonnie Bell.Results443 patients (including smoked in past year) were counseled and 288 (65%) were smokers during the current pregnancy. The age for starting smoking (mean 16.0, SD 3.6) ranged from 8 to 29 with 35.8% smoking by age 15, 52.8% from 16 to 20, 7.8% 21 to 25, and only 2.8% after age 25. 76% smoked 10 or more cigarettes prior to entering the SCIP program. 77% of smokers had 12 years or less of education. 76% of smokers were exposed to second hand household smoke. 54/79 (68.4%) of the smokers who quit prior to their first visit in SCIP were followed and of them 50/54 (92.3%) remained quit in SCIP. 131/209 (62.7%) of ongoing smokers were followed and of them 44 (21.0%) quit smoking, 50 (23.9%) cut back, 23 (11.0%) showed no change and 14 (6.7%) smoked more. Overall smoking reduction with SCIP was significant to P < .0001. The presence of 2 or more household members smoking (P = .013) or with friends smoking (P = .001) was associated with increased smoking in SCIP. Primary care physicians warning against prenatal smoking was associated with improved smoking reduction in SCIP (P < .006).ConclusionSCIP success was associated with supportive physicians and decreased with smoking family or close friends. Future SCIP programs may benefit by behavior modification of clinicians and patient family/friends. Funded by Ohio Chapter of the March of Dimes 2003 and 2004. ObjectiveTo identify factors affecting the success of a free Smoking Cessation in Pregnancy (SCIP) program for uninsured and low income patients in a High-Risk pregnancy clinic (29% smoking, 1 in 6 low birth-weight). To identify factors affecting the success of a free Smoking Cessation in Pregnancy (SCIP) program for uninsured and low income patients in a High-Risk pregnancy clinic (29% smoking, 1 in 6 low birth-weight). Study designThe study design was that of a prospective longitudinal observational clinical study. One-on-one counseling for SCIP was provided at prenatal/postnatal visits by part-time nurse coordinators using American Cancer Society's Fresh Start smoking cessation protocols. Information obtained (risk factors, smoking status, counseling level, surveys, carbon monoxide sensor readings) was recorded in the EPIC electronic record. Incentives were Babies R' Us $10 gift certificates, Panera Bread and Bonnie Bell. The study design was that of a prospective longitudinal observational clinical study. One-on-one counseling for SCIP was provided at prenatal/postnatal visits by part-time nurse coordinators using American Cancer Society's Fresh Start smoking cessation protocols. Information obtained (risk factors, smoking status, counseling level, surveys, carbon monoxide sensor readings) was recorded in the EPIC electronic record. Incentives were Babies R' Us $10 gift certificates, Panera Bread and Bonnie Bell. Results443 patients (including smoked in past year) were counseled and 288 (65%) were smokers during the current pregnancy. The age for starting smoking (mean 16.0, SD 3.6) ranged from 8 to 29 with 35.8% smoking by age 15, 52.8% from 16 to 20, 7.8% 21 to 25, and only 2.8% after age 25. 76% smoked 10 or more cigarettes prior to entering the SCIP program. 77% of smokers had 12 years or less of education. 76% of smokers were exposed to second hand household smoke. 54/79 (68.4%) of the smokers who quit prior to their first visit in SCIP were followed and of them 50/54 (92.3%) remained quit in SCIP. 131/209 (62.7%) of ongoing smokers were followed and of them 44 (21.0%) quit smoking, 50 (23.9%) cut back, 23 (11.0%) showed no change and 14 (6.7%) smoked more. Overall smoking reduction with SCIP was significant to P < .0001. The presence of 2 or more household members smoking (P = .013) or with friends smoking (P = .001) was associated with increased smoking in SCIP. Primary care physicians warning against prenatal smoking was associated with improved smoking reduction in SCIP (P < .006). 443 patients (including smoked in past year) were counseled and 288 (65%) were smokers during the current pregnancy. The age for starting smoking (mean 16.0, SD 3.6) ranged from 8 to 29 with 35.8% smoking by age 15, 52.8% from 16 to 20, 7.8% 21 to 25, and only 2.8% after age 25. 76% smoked 10 or more cigarettes prior to entering the SCIP program. 77% of smokers had 12 years or less of education. 76% of smokers were exposed to second hand household smoke. 54/79 (68.4%) of the smokers who quit prior to their first visit in SCIP were followed and of them 50/54 (92.3%) remained quit in SCIP. 131/209 (62.7%) of ongoing smokers were followed and of them 44 (21.0%) quit smoking, 50 (23.9%) cut back, 23 (11.0%) showed no change and 14 (6.7%) smoked more. Overall smoking reduction with SCIP was significant to P < .0001. The presence of 2 or more household members smoking (P = .013) or with friends smoking (P = .001) was associated with increased smoking in SCIP. Primary care physicians warning against prenatal smoking was associated with improved smoking reduction in SCIP (P < .006). ConclusionSCIP success was associated with supportive physicians and decreased with smoking family or close friends. Future SCIP programs may benefit by behavior modification of clinicians and patient family/friends. Funded by Ohio Chapter of the March of Dimes 2003 and 2004. SCIP success was associated with supportive physicians and decreased with smoking family or close friends. Future SCIP programs may benefit by behavior modification of clinicians and patient family/friends. Funded by Ohio Chapter of the March of Dimes 2003 and 2004.

Journal of Ultrasound in MedicineVolume 23, Issue 4 p. 565-568 Case Report Fetal Bladder Outlet Obstruction Due to Ureterocele In Utero “Colander” Therapy Graham G. Ashmead MD, Corresponding Author Graham G. Ashmead MD gashmead@metrohealth.org Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio USAAddress correspondence and reprint requests to Graham G. Ashmead, MD, Case Western Reserve University, MetroHealth Medical Center, 2500 MetroHealth Dr, Cleveland, OH 44109.Search for more papers by this authorBrian Mercer MD, Brian Mercer MD Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio USASearch for more papers by this authorMelissa Herbst MD, Melissa Herbst MD Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio USASearch for more papers by this authorJules Moodley MD, Jules Moodley MD Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio USASearch for more papers by this authorAnca Bota RDMS, Anca Bota RDMS Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio USASearch for more papers by this authorJack S. Elder MD, Jack S. Elder MD Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio USASearch for more papers by this author Graham G. Ashmead MD, Corresponding Author Graham G. Ashmead MD gashmead@metrohealth.org Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio USAAddress correspondence and reprint requests to Graham G. Ashmead, MD, Case Western Reserve University, MetroHealth Medical Center, 2500 MetroHealth Dr, Cleveland, OH 44109.Search for more papers by this authorBrian Mercer MD, Brian Mercer MD Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio USASearch for more papers by this authorMelissa Herbst MD, Melissa Herbst MD Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio USASearch for more papers by this authorJules Moodley MD, Jules Moodley MD Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio USASearch for more papers by this authorAnca Bota RDMS, Anca Bota RDMS Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio USASearch for more papers by this authorJack S. Elder MD, Jack S. Elder MD Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio USASearch for more papers by this author First published: 01 April 2004 https://doi.org/10.7863/jum.2004.23.4.565Citations: 12Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume23, Issue4April 2004Pages 565-568 RelatedInformation

Induction of labor is associated with the risk of cesarean delivery and its' associated morbidities. However, when indicated, several cervical ripening protocols are available to the caregiver. These have shown some elevation in cesarean delivery risk, but may shorten labor duration. We performed a cost analysis to evaluate which of cervical ripening protocol results in the greatest cost savings. Using decision analysis techniques, we compared 4 strategies for induction of labor at term: (1) Transcervical Foley bulb with concurrent oxytocin infusion, (FOL); (2) Misoprostol 25 μg vaginal suppository every four hours up to six doses followed by oxytocin infusion as needed when favorable cervix achieved (MISO); (3) Cervidil 10 mg transvaginal insert with oxytocin infusion if needed after 12 hours, (CER); and (4) Prepidil 0.5 mg vaginal gel every six hours up to three doses with oxytocin infusion if needed six hours after last dose (PREP). Baseline assumptions: Probability (prob) of oxytocin infusion in FOL .994, MIS .58, CER .85, PREP .970, prob of cesarean delivery in FOL .29, MISO .257, CER .160, PREP .204, cost of VD $3397, cesarean delivery with labor $6500, misoprostol $7.11, Cervidil $168, Prepidil $203, Foley $13.00, Oxytocin $1.05/10 mU. Sensitivity analyses were performed. Under baseline assumptions for a term pregnancy FOL is the preferred strategy at a cost savings of $4297 per delivery, compared to MISO: $4194, CER: $3893, and PREP: $4030. The choice of a cervical ripening method for induction at term which results in the least cost expenditure without impacting outcomes is highly desired. Our analysis suggests transcervical Foley bulb with concurrent oxytocin infusion is the most cost saving approach to this issue.

Suspected macrosomia (SM) is often an indication for labor induction. We sought to determine the impact of suspected macrosomia on labor course and outcome in women induced for this indication. Women with intact membranes and no contractions who were induced between 1/97 and 6/03 were identified from the perinatal database of this urban tertiary care center. Those delivering before 37 weeks, with multifetal gestations, prior cesarean delivery (CD), fetal demise, malpresentation, or a contraindication to labor/vaginal delivery were excluded. Clinical characteristics and delivery outcomes of those with and without SM were compared. We performed similar analyses for those undergoing labor induction for SM only and those with no evident medical indication ("social" induction, N = 313). P < 0.05 was considered significant. 144 SM and 2564 non-SM women met inclusion criteria. SM women were more likely to have gestational diabetes (18% vs 9%) and less likely to have preeclampsia (3% vs 14%) or be induced ≤41 weeks (15% vs 44%), P < 0.02 for each. Cervical dilation, effacement, and station were similar between the two groups (P > 0.30 for each). CD was more common (38% vs 21%), and estimated blood loss, greater with SM (EBL: 504 vs 408 mL), P < 0.0001 for each. For those delivering vaginally, the SM group had longer 2nd stages (57 vs 35 min) and larger infants (3891 vs 3345 g), P ≤ 0.0001 for each, but not more shoulder dystocia (5.5% vs 2.8%, P = 0.18). Compared with "social" induction, SM had larger infants (3955 vs 3310 g), longer admission to delivery time (14.5 vs 12.7 hr) and 2nd stages (49 vs 29 min), and more CDs (34.9% vs 15.8%) and EBL (464 vs 376 mL), P < 0.03 for each. SM is associated with an increased risk of CD, longer second stage of labor, and more blood loss when compared with all other inductions and inductions for no evident medical indication at term.

There are conflicting reports as to whether preeclampsia (PET) shortens or prolongs labor. We sought to determine the impact of PET on labor course and outcome in women induced for this indication. Women with intact membranes and no contractions who were induced between 1/97 and 6/03 were identified from the perinatal database of this urban tertiary care center. Those delivering before 37 weeks, with multifetal gestations, prior cesarean delivery (CD), fetal demise, malpresentation, or a contraindication to labor or vaginal delivery were excluded. Clinical characteristics and delivery outcomes of those with and without PET were compared. Labor course was evaluated by multivariate analysis adjusting for age, weight, nulliparity, gestational age, cervical dilation, effacement, station, and infant weight. P<0.05 was considered significant. 367 PET and 2341 non-PET women met inclusion criteria. PET women were more likely primigravid (47% vs 34%), less likely to smoke (9% vs 20%), and presented at an earlier gestation (39.1 vs 40.2 wk), with smaller infants (3200 vs 3400 g), P<0.05 for each. Those with PET had statistically but not clinically less dilated cervixes (median 2.0 for each, P<0.02). CD was more common (26% vs 21%) and estimated blood loss greater (460 vs 410 mL) with PET, P<0.04. For those delivering vaginally, the PET group had longer times to onset of regular contractions (6.6 vs 4.8 hr) to membrane rupture (ROM: 9.0 vs 7.5 hr), lengths of 1st stage (9.2 vs 8.1 hr) and 2nd stage (42.3 vs 35.4 min), duration of ROM (7.1 vs 5.9 hr), and admission to delivery time (16.1 vs 13.3 hr), P<0.04 for each, after controlling for other factors. PET is associated with an increased risk of CD after induction at term and with a prolongation of each phase of labor after controlling for other factors.

To provide prenatal health smoking cessation in pregnancy (SCIP) services for uninsured or low-income patients in a high-risk pregnancy clinic with a high incidence of smoking (29%) and low birthweight (1 in 6 babies). The goal was to create a successful model SCIP program for implementation in other pregnancy clinics in the greater Cleveland community. The study design was that of a prospective longitudinal observational clinical study. The SCIP program was based on one-on-one counseling at prenatal visits by nurse coordinators implementing American Cancer Society smoking cessation protocols using the Fresh Start model. Information was obtained at each prenatal and postnatal visit including risk factors, smoking status, and level of counseling. Gift certificates were provided as incentives. Extensive surveys were obtained initially and 6 weeks post partum. SCIP information was recorded utilizing the EPIC patient electronic medical record. 114 patients were counseled and 76 (67%) were smokers during the current pregnancy. The age for starting smoking (mean 16.3, SD 3.9) ranged from 8 to 29, with 13.7% smoking by age 12, 45.2% by age 15, 53.4% by age 16, 67.1% by age 17, and 83.6% by age 18. 85.1% smoked 10 cigarettes or more prior to entering the SCIP program. 83.1% of the smokers had 12 years or less of education. 86.8% were exposed to secondhand smoke. 15 of the smokers (19.7%) had quit smoking before their first visit in SCIP, and of these, 8 continued not to smoke and 7 were lost to follow-up. Of the 61 ongoing smokers, 24 (39.3%) were lost to follow-up, 18 (29.5%) cut back on smoking (10 setting a quit date), 9 quit smoking (14.7%), 8 (13.1%) showed no change, and 2 (3.3%) increased slightly. The decreased smoking with the SCIP program was significant to P

We used a randomized trial to compare two polio vaccine pamphlets written on a sixth grade level – the vaccine information statement prepared by the Centers for Disease Control (CDC) and an easy-to-read pamphlet we developed (LSU) – for reading ability, comprehension and preference among 610 parents with a broad range of demographic characteristics. Parents at all reading levels and incomes preferred LSU (76% vs. 21%, P<0.001). Although readers of LSU achieved significantly higher comprehension (65% vs. 60%, P<0.05) this difference may not be clinically significant. The information items presented with instructional graphics were the only items on which differences in comprehension levels achieved both clinical and statistical significance. Comprehension was lowest for the CDC mandated information on risks and the National Injury Compensation. Our findings demonstrate that simplifying written immunization material and making it more suitable will increase appeal, but such modification may not raise comprehension to an acceptable level without use of instructional graphics. Health education materials intended for general parent populations, which are written on a sixth grade reading level, may not adequately educate parents or prepare them for a discussion with their physicians.