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1/734. Generalized pustular psoriasis of pregnancy (impetigo herpetiformis).

    A 17-year-old woman had a sudden eruption of pustules in her intertriginous areas as well as of erythematosquamous plaques on the scalp, elbows, palms and soles in the third trimester of her first pregnancy. Histopathological evaluation of a biopsy revealed typical changes of pustular psoriasis with parakeratosis and abscesses of neutrophils (Kogoj's spongiform pustules). The diagnosis of pustular psoriasis was established by the typical clinical and histopathological findings. Laboratory parameters showed a highly elevated blood sedimentation rate, hypoferric anemia and decreased albumin levels. serum concentrations of parathormone and its metabolites were normal. After systemic treatment with glucocorticosteroids and antibiotics, the lesions improved but did not clear. After delivery of a healthy boy, therapy was switched to retinoid photochemotherapy with isotretinoin and PUVA that resulted in rapid and complete clearing of the eruption. The coincidence of plaque-type psoriasis and a pustular eruption as described previously in impetigo herpetiformis supports the view that this dermatosis of pregnancy is a variant of generalized pustular psoriasis.
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2/734. clostridium difficile-associated disease. Implications for midwifery practice.

    clostridium difficile-associated disease (CDAD), a gastrointestinal infection with a wide range of manifestations whose primary symptom is diarrhea, occurs when antibiotic medications, or rarely other drugs or conditions, disrupt the normal colonic microflora, making it susceptible to the growth of toxigenic C difficile. It is a significant nosocomial infection and an increased incidence has been noted in recent years. Although infrequently seen in midwifery practices, it does occur and may increase with the growing usage of intrapartal antibiotics. Midwives may evaluate and treat a client with an initial episode of mild to moderate CDAD; they also may manage collaboratively or refer for medical management those clients with recurrent or severe disease. This article reviews the epidemiology, pathogenesis, clinical presentation, prevention, and midwifery management of initial and recurrent CDAD. The limitation in the use of oral vancomycin due to the emergence of vancomycin-resistant enterococcus, resulting in metronidazole becoming the primary agent for treatment of CDAD, and the implications of this in the treatment of CDAD during pregnancy and lactation are addressed.
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3/734. Fetal meconium peritonitis after maternal hepatitis A.

    hepatitis a virus has rarely been implicated in congenital infections. After maternal hepatitis A at 13 weeks' gestation, ultrasonographic examinations revealed fetal ascites (20 weeks) and meconium peritonitis (33 weeks). After delivery, a perforated distal ileum was resected. Elevated levels of hepatitis A immunoglobulin g persisted in the infant 6 months after delivery.
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4/734. prenatal diagnosis of congenital varicella syndrome and detection of varicella-zoster virus in the fetus: a case report.

    Varicella syndrome (VS) specific malformations were sonographically seen at 22 weeks and 3 days of gestation. Fetal infection was demonstrated by detection of varicella-zoster virus (VZV) dna in fetal blood and amniotic fluid by polymerase chain reaction (PCR). Following therapeutic abortion, fetal infection was confirmed by detection of VZV dna in several fetal tissues and placenta, and by histopathological findings like miliary calcified necroses in fetal organs.
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5/734. Immunizations in pregnancy. A public health perspective.

    With the successful implementation of childhood immunization programs in the united states, an increasing percentage of vaccine-preventable infections now occur in adults. By providing primary care services to adult women, midwives are in a unique position to halt the spread of these infections. Immunizations are often avoided in pregnancy and the early post partum period, however, in the mistaken belief that vaccines are harmful to the fetus or neonate. This article, the first in a two-part series on immunizations, reviews the current epidemiology of vaccine-preventable diseases, discusses the indications and precautions for vaccine usage in pregnancy and the early postpartum period, and presents the current recommendations from the American Committee on Immunization Practices for the most commonly administered adult immunizations: tetanus-diphtheria, hepatitis b, influenza, pneumococcal, measles, mumps, rubella, and varicella.
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6/734. helicobacter pylori infection and persistent hyperemesis gravidarum.

    hyperemesis gravidarum is the most severe spectrum of gastrointestinal complaints in pregnant women. Our purpose is to describe an association of helicobacter pylori with hyperemesis gravidarum. Three pregnant women are described with the working diagnoses of hyperemesis gravidarum unresponsive to standard therapy. The medical management used to treat helicobacter pylori in these women are elaborated. The persistence of the symptomatology and/or hematemesis resulted in helicobacter pylori testing of these women. A 2-week course of antibiotics and a proton pump inhibitor or H2 receptor antagonist resulted in resolution of the hyperemesis. A discussion of the incidence, diagnosis, and management of helicobacter pylori in pregnancy is described. When the symptoms of hyperemesis gravidarum are persistent into the second trimester, active peptic ulcer disease from helicobacter pylori should be included in the differential diagnoses.
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7/734. Management of cervical cerclage after preterm premature rupture of membranes.

    The optimal management of preterm premature rupture of membranes (PPROM) in a patient with a cerclage is controversial. The issues are whether the latency period between rupture of membranes and delivery is decreased if the cerclage is removed and whether there is an increased rate of maternal or neonatal infection if the cerclage is kept in place. The data are sparse in directing management of women with prophylactic cerclages placed earlier in their pregnancies who rupture membranes. Latency seems to be increased if the cerclage is kept in place, but maternal and neonatal infectious morbidity is increased also. In women at early gestational ages, keeping the cerclage in place may be warranted until labor ensues. In more advanced gestations, it seems preferable to immediately remove the cerclage upon diagnosis of PPROM.
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8/734. pituitary gland gumma in congenital syphilis after failed maternal treatment: a case report.

    A preterm, very low birth weight infant was born to a mother with early latent syphilis who was treated 10 days and 3 days before delivery with 2.4 mU of benzathine penicillin. The infant had clinical, laboratory, and radiographic abnormalities consistent with congenital syphilis, ie, a Venereal disease research Laboratory test titer that was fourfold greater than was the maternal titer, hepatosplenomegaly, abnormal liver function tests, pneumonitis, osteochondritis of the long bones, and cerebrospinal fluid (CSF) examination showing a reactive Venereal disease research Laboratory test, pleocytosis, and elevated protein content. The infant died on the third day of life, and an autopsy revealed an evolving gumma of the anterior pituitary. immunoglobulin m immunoblotting of serum and CSF was positive, and polymerase chain reaction detected treponema pallidum dna in endotracheal aspirate and CSF. This case highlights the pathologic abnormalities observed in congenital syphilis and focuses on the rare finding of an evolving anterior pituitary gumma. Furthermore, it documents the failure of maternal syphilis treatment during the last 4 weeks of pregnancy to cure fetal infection and supports the recommendation that all infants born to mothers with syphilis treated during the last 4 weeks of pregnancy should receive penicillin therapy.
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9/734. herpes simplex hepatitis in pregnancy: a case report and review of the literature.

    Fulminant hepatic dysfunction in the third trimester of pregnancy accompanied by fever may result from disseminated herpes simplex virus. Since 1969, 24 cases of herpes simplex hepatitis, including the current case, have been reported. Mucocutaneous lesions are present in only half of cases; therefore, suspicion for diagnosis of this disease is low. Twenty-five percent of cases were not diagnosed until autopsy. Maternal and perinatal mortality are high, approaching 39 percent for both mother and fetus. Early recognition with initiation of antiviral therapy appears to be most important in maximizing survival.
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10/734. Successful treatment of generalized primary herpes simplex type 2 infection during pregnancy.

    Generalized herpes simplex virus infections constitute a severe threat to mother and child during pregnancy. Before antiviral treatments were available, both mother and foetus had a high mortality rate. The following case illustrates a successful outcome after long-term antiviral treatment. It is of great importance to suspect, diagnose and treat patients with HSV 2 early, especially during pregnancy.
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