Clinical Review Recent advances


BMJ 2000; 321 doi: (Published 01 July 2000) Cite this as: BMJ 2000;321:33
  1. James M Roberts (, vice president
  1. Magee-Womens ResearchInstitute, 204 Craft Avenue, Pittsburgh, PA 15213-3054, USA

    Important concepts in obstetrics and their clinical implications are increasingly guided by evidence and in many cases by the gold standard—randomised clinical trials. This article focuses on key areas of changing practice chosen because they represent important changes in approach and demonstrate the increasing use of evidence in obstetrics.


    The information I selected for this article was chosen on the basis of a poll I made of the 12 practitioners in maternal fetal medicine at the University of Pittsburgh and from conversations with colleagues from around the United States.

    Fig 1.

    Incidence of early onset neonatal infection with group B streptococci. This decreased 60% between 1993, when preventive antibiotic treatment was advocated, and 1998 in surveillance areas of more than 12 million births. (Adapted from Schrag et al1)

    Infections in obstetrics

    Group B streptococcal infections are a major source of morbidity for full term and preterm infants.1 Neonatal infection is caused by pathogens passed from the mother by vertical transmission. These organisms are exquisitely sensitive to penicillin. These observations have prompted several strategies to treat mothers during childbirth. The approach currently recommended by the American College of Obstetrics and Gynecology is intrapartum treatment with intravenous benzylpenicillin (5 million units, then 2.5 million units every 4 hours) or ampicillin (2 g, then 1 g every 4 hours) until delivery, based on either intrapartum risk (fever, prolonged rupture of membranes, or imminent preterm delivery) or screening for carriage of streptococci at 35–37 weeks' gestation. A recent survey indicates that intrapartum antibiotic treatment guided by this identification of risk has reduced the incidence of early onset neonatal infection with group B streptococci by 65% (figure).1 This is projected to prevent 200 neonatal deaths a year in the United States.1 Thus, a major educational effort can modify obstetric practice and save lives. The implications …

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