Book Review

Infections in Pregnancy

N Engl J Med 1997; 337:1701December 4, 1997

Article

Infections in Pregnancy
Second edition. By Larry C. Gilstrap, III, and Sebastian Faro. 345 pp., illustrated. New York, John Wiley, 1997. $79.95. ISBN: 0-471-11699-8

Infection is the most common problem encountered by obstetricians. Some infections, such as asymptomatic bacteriuria and postpartum endometritis, occur frequently, affect primarily the mother, are easily recognized, and typically respond promptly to antibiotic therapy. Others, such as chorioamnionitis, hepatitis B, syphilis, human immunodeficiency virus (HIV) infection, primary herpes simplex, and varicella, pose a considerable threat to the well-being of both the mother and the fetus and neonate. Still others, such as cytomegalovirus infection, toxoplasmosis, rubella, and parvovirus infection, present little risk to an immunologically competent pregnant woman but may cause severe injury to a developing fetus. In these circumstances, considerable expertise is required to accurately identify and treat the affected fetus.

The second edition of Infections in Pregnancy by Gilstrap and Faro is a valuable reference for clinicians who seek to understand the consequences of these varied infections for the mother and the fetus. The book is particularly appropriate for residents in obstetrics and gynecology and family practice, fellows in maternal–fetal medicine, medical infectious-disease consultants, and obstetrical nurse-practitioners.

The first edition was a multiauthored textbook. The second edition has been entirely rewritten by two physicians with unique perspectives. Dr. Faro is both a generalist clinician and an experienced research microbiologist. His influence is most evident in the clearly written descriptions of the microbiology, epidemiology, and pathophysiology of obstetrical infections. Dr. Gilstrap is an accomplished clinical investigator and an expert in the care of women with high-risk pregnancies. His effect on the narrative is most apparent in the thoughtful and carefully reasoned, evidence-based recommendations for treatment.

Infections in Pregnancy has several strengths. First, it is well organized and well written; the new format smooths out some of the irregularities inherent in any multiauthored textbook. Second, the book is comprehensive without being ponderous. It provides an excellent overview of maternal infections ranging from relatively uncomplicated vaginal and endocervical infections to life-threatening disorders such as septic shock, necrotizing fasciitis, and HIV infection. It also presents clear, concise reviews of the major perinatally transmitted infections, including rubella, varicella, syphilis, and toxoplasmosis and those due to parvovirus, hepatitis B, and cytomegalovirus. In recognition of the ever increasing frequency of international travel, the authors have also included a chapter on unusual parasitic diseases, such as babesiosis, trypanosomiasis, and leishmaniasis, which pose major threats to pregnant women who travel to or reside in areas of the world where these diseases are endemic. Third, the textbook is very well illustrated, especially the chapters on syphilis and protozoan infections. Fourth, the authors have provided exceptionally good diagnostic and management algorithms. These easy-to-follow diagrams are particularly helpful in understanding the more complicated maternal and fetal infections. The clarity of the algorithms is complemented by concise summaries of salient points at the end of each chapter.

The weak points of the book are few. As with any textbook that takes months to prepare, new developments have supplanted some of the authors' recommendations. For example, the diagnosis of congenital toxoplasmosis can now be made by applying DNA probes to fetal cells obtained by amniocentesis, thus making the more dangerous procedure of umbilical-blood sampling unnecessary. In addition, the Centers for Disease Control and Prevention has now published new recommendations for antibiotic prophylaxis against opportunistic infections in HIV-infected patients that differ slightly from those of the authors.

The authors might also have devoted more attention to the issue of cost-effective selection of antibiotics. They do not address the newer pharmacokinetic data showing improved efficacy, a lower risk of toxicity, and a lower cost with single daily dosing of aminoglycosides, as compared with multidose regimens. They also do not specifically consider cost comparisons between single-agent therapy with the newer extended-spectrum penicillins, cephalosporins, and carbapenems and older combination regimens such as clindamycin, penicillin, and gentamicin.

However, in the final analysis, these criticisms are minor and in no way detract from the authors' substantial contribution to the infectious-diseases literature. For clinicians, both generalists and specialists, this textbook is an excellent reference, providing a thoughtful synthesis of basic-science material and practical clinical guidelines. It merits a place in the libraries of all providers concerned with the care and well-being of obstetrical patients.

Patrick Duff, M.D.
University of Florida College of Medicine, Gainesville, FL 32610