Abbey J. Hardy-Fairbanks

Immune responses in infants whose mothers received Tdap vaccine during pregnancy.

Background: The effect of maternal Tdap vaccination on infant immunologic responses to routine pediatric vaccines is unknown. Methods: This was a cohort study of infants whose mothers received or did not receive Tdap vaccine during pregnancy. Maternal and cord blood samples were collected at delivery; infant blood samples were collected before and after primary series and booster dose of diphtheria, tetanus, and acellular pertussis (DTaP) and other vaccines. Geometric mean antibody concentrations or titers to pertussis, hepatitis B, tetanus, diphtheria, Haemophilus influenzae type b and polio antigens were measured. Mean maternal-to-cord blood antibody ratios were calculated. Results: At delivery, maternal and cord antibody concentrations to pertussis antigens were higher in the Tdap group (n = 16) than control group (n = 54; maternal: 1.9- to 20.4-fold greater; cord: 2.7- to 35.5-fold greater). Increased antibody concentrations persisted for infants at first DTaP (3.2- to 22.8-fold greater). After primary series, antibody concentrations to pertussis antigens were lower in Tdap group (0.7- to 0.8-fold lower), except for fimbriae types 2 and 3 (FIM) (1.5-fold greater). Antibody concentrations to pertussis antigens before and after booster dose were comparable (prebooster: Tdap group 1.0- to 1.2-fold higher than controls; postbooster: 0.9- to 1.0-fold lower). Differences in FIM values at these time points are difficult to interpret, due to varying FIM content among DTaP vaccines administered to infants in both groups. Conclusions: Maternal Tdap immunization resulted in higher pertussis antibody concentrations during the period between birth and the first vaccine dose. Although slightly decreased immune responses following the primary series were seen compared with controls, differences did not persist following the booster.

Asthma in pregnancy: pathophysiology, diagnosis and management.

Asthma is a common, potentially serious, even life-threatening, chronic medical condition seen amongst nearly all groups of patients, regardless of ethnicity and socioeconomic circumstances. This article addresses the group of pregnant women with symptomatic asthma as well as those whose asthma is asymptomatic as a result of good control. The incidence, the pathophysiologic changes of pregnancy, and the interplay between these changes and asthma are reviewed in this article. The classification of these patients and appropriate management strategies are discussed.

Prophylactic negative pressure wound therapy for obese women after cesarean delivery: A systematic review and meta-analysis

OBJECTIVE To summarize available studies on wound complication outcomes after prophylactic negative pressure wound therapy for obese women (body mass index 30 or greater). DATA SOURCES We conducted a systematic review and meta-analysis using electronic database search (PubMed, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Google scholar, and Web of Science), Cochrane, and trial registries including ClinicalTrials.gov. METHODS OF STUDY SELECTION We conducted an electronic search of research articles from 1966 to January 2017 for randomized controlled trials (RCTs), prospective cohort, and retrospective cohort studies of negative pressure wound therapy compared with standard dressing after cesarean delivery among obese women. Our primary outcome was defined as a composite of wound complication, including wound or surgical site infection, cellulitis, seroma, hematoma, wound disruption, or dehiscence. For cohort studies and RCTs, we performed a descriptive systematic review. For available RCTs, we performed a meta-analysis and pooled risk ratios using a random-effects model. We assessed for heterogeneity using χ test for heterogeneity and I test. We assessed for publication bias using a funnel plot. TABULATION, INTEGRATION, AND RESULTS Of 10 studies meeting eligibility criteria, five were RCTs and five were cohort studies. Results of cohort studies were varied; however, all had a high potential for selection bias. In the meta-analysis, there was no difference in primary composite outcome among those women with negative pressure wound therapy (16.8%) compared with those who had standard dressing (17.8%) (risk ratio 0.97, 95% CI 0.63-1.49). There was no statistically significant heterogeneity (χ test 4.80, P=.31, I=17%). CONCLUSION Currently available evidence does not support negative pressure wound therapy use among obese women for cesarean wound complication prevention. SYSTEMATIC REVIEW REGISTRATION PROSPERO: International prospective register of systematic reviews, 42016033948.

Intensity and Unpleasantness of Pain Following Vaginal and Cesarean Delivery: A Prospective Evaluation

BACKGROUND To date, most studies evaluating pain associated with cesarean birth have focused on delivery procedures or postoperative pain control methods rather than on the nature or severity of the pain experience of women, despite the increasing incidence and maternal requests for cesarean delivery. The objective in this study was to evaluate sensory, affective, and laterality aspects of pain after cesarean delivery and vaginal delivery. METHODS A prospective cohort study using a seven-item visual analog scale assessed pain at rest and with activity, and the unpleasantness and location of pain on postpartum days 1 and 2. Chart review identified demographic and clinical factors influencing pain. Multivariable regression and propensity score analyses were used to evaluate patient-level outcomes. RESULTS Of 126 consenting women, 48 underwent cesarean delivery and 78 had vaginal delivery. No statistically significant differences in pain at rest and pain unpleasantness were found between groups on postpartum day 1, but women undergoing cesarean delivery reported more pain with activity than those who had a vaginal delivery (p < 0.0002). On postpartum day 2, cesarean delivery women reported significantly more pain when compared with those with a vaginal delivery (p < 0.04), and more cesarean delivery women reported lateralized pain (p < 0.0001). In multivariate regression analyses, cesarean delivery was the most significant predictor of activity-related pain on postpartum day 1 (p < 0.00001), followed by current substance abuse (p < 0.01). Women undergoing cesarean delivery required twice the dosage of analgesics on postpartum day 1 and four times greater amounts on postpartum day 2 relative to those with a vaginal delivery (p < 0.01 and p < 0.001). CONCLUSIONS Cesarean delivery was associated with higher levels of pain, more unpleasant pain, more lateralized pain, and greater narcotic use than vaginal delivery. Evaluation of factors associated with postpartum pain can help practitioners to counsel women better about their delivery alternatives and can promote improved management of women undergoing both types of delivery experiences.

Vaginal misoprostol aids in difficult intrauterine contraceptive removal: a report of three cases

BACKGROUND Intrauterine devices are the most used long-acting reversible contraceptive method worldwide. Under normal circumstances, removal of an intrauterine contraceptive (IUC) is an uncomplicated procedure requiring gentle traction on the string. STUDY DESIGN We report three cases of nonvisible IUC strings where, following use of vaginal misoprostol, the IUC strings were visualized and the IUCs were removed intact with gentle traction. CONCLUSIONS The uterotonic and uterocontractile effects following vaginal misoprostol facilitated removal in three cases of nonvisible IUC strings. We suggest that clinicians consider including vaginal misoprostol alone or prior to planned repeat office or procedure-clinic interventions for nonvisible IUC strings.

A randomized controlled trial comparing two types of retractors at caesarean delivery

Abstract The aim of this study was to determine if the use of a self-retaining, symmetrical retractor (OB/Mobius®) during caesarean delivery is associated with differences in post-operative pain experience. Consenting women undergoing caesarean delivery were randomly assigned to OB/Mobius® versus conventional retraction instruments. Women were blinded to retractor type and filled out surgical pain surveys each post-operative day. Additional outcome variables were collected through a provider survey and chart review. Of the 154 randomised women, 144 completed the study. There was no difference in the symmetry, quality or intensity of postoperative pain based on the method of retraction. The OB/Mobius® retractor did not confer an improvement in the quality or intensity of post-caesarean discomfort in the first three days following delivery. Nor did the groups differ in operative times, blood loss or pain medication usage. However, the retractor may offer improved visualisation and retraction in obese women. Impact statement Use of a plastic sheath self-retaining retractor has been minimally studied in caesarean deliveries. Recently it was found that the use of such a retractor reduced wound infection, but another study in obese women did not show improved rates of infection (Hinkson et al. 2016; Scolari Childress et al. 2016). The study of sheath self-retaining retractors to decrease post-operative pain has not been reported previously. This study offers an investigation into a generalisable population of parturients who undergo caesarean delivery and if the primary use of a self-retaining retractor versus sole use of traditional hand-held retractors decreased post-operative pain while in the hospital. Although this study did not show an improvement in post-operative pain, provider experience reports demonstrated some improvement in visualisation, particularly in the obese population with the use of this novel retractor, thus making it an option for providers who do caesarean deliveries without an assistant and find hand-held retractors inadequate.

Patient Satisfaction With Immediate Post-Delivery Long Acting Reversible Contraception Placement [1J]

INTRODUCTION: Reliance on the postpartum visit to protect women from rapid repeat unplanned pregnancy is ineffective given that 50% of women do not attend these visits and many women have had intercourse prior. Long-acting reversible contraceptive (LARC) devices, both intrauterine contraceptives (IUC) and subdermal implants, can be placed immediately following delivery. METHODS: Women who had LARCs placed immediately after vaginal or cesarean delivery from 9/2013 to 6/2015 were contacted via phone and an anonymous survey given that included questions regarding satisfaction with timing of contraception placement, pain scores for device placement, complications or issues with their chosen LARC. RESULTS: 161 of the 323 qualified women completed surveys, including 83 IUC and 78 implant placements. There was no significant difference between rates of being satisfied/highly satisfied between IUC and implant (68.7% vs 78.2%, P=.34) or in those who would recommend their procedure to a friend (70.3% vs 81.7%, P=.16). More IUC users wished they had their device placed at delayed interval (32.5% vs 16.7%, P=.03). Overall pain scores were low, however, significantly fewer women in the implant group reported low pain scores (94% vs 84.6%, P=.09). More women reported significant complications after immediate IUC insertion than implant (10.9% vs 0%, P<.001). CONCLUSION: Immediate placement of LARC is correlated with high satisfaction rates, with the majority of users recommending the procedure to a friend. Implant users were had more issues after placement resulting in removal, but IUC users reported more complications. Immediate LARC placement is a satisfying and low-pain experience for women regardless of device.

A select issue in the postpartum period: contraception

One half of pregnancies in the United States are unintended and associated with adverse pregnancy outcomes. The postpartum period is an important, yet underutilized, time to initiate contraception. The U.S. Medical Eligibility Criteria for Contraceptive Use, 2010 provides evidence-based guidelines for choosing a contraceptive method and an update in 2011 specifically addresses contraceptive method use in the puerperium. The variety of contraceptive methods include hormonal contraception, lactational amenorrhea, barrier contraception, natural family planning, and sterilization. Ideally, counseling about contraceptive choice should begin early in pregnancy care and continue postpartum; it should also include a variety of teaching modalities. Specifically we recommend LARC options such as intrauterine devices and etonorgestrel implants, postpartum tubal sterilization, and progestin-only pills for those desiring an oral method. Department of Obstetrics and Gynecology, Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, 522422 Department of Family Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242 Data from the United States reveals that of the approximately 6.6 million pregnancies per year, one-half are unintended. Of the approximately 61 million women of reproductive age in 2006-2010, 62% were using some form of contraception. 7.7% of those not using contraception had intercourse in the previous 3 months, and represent those at highest risk for unintended pregnancy. Unintended pregnancies are associated with adverse pregnancy outcomes and behaviors, including late entry into prenatal care, decreased breastfeeding, and low birth weight. Also, short interval pregnancies are at increased risk for obstetric complications, including low birth weight, preterm birth and neonatal mortality. The optimal interval between pregnancies is debated, but greater than 11-18 months has been suggested as reducing complications in the subsequent pregnancy. Postpartum contraception is vital to the reduction of short interval pregnancies, which is a significant source of neonatal Proceedings in Obstetrics and Gynecology, 2013; 3(2):1 Postpartum contraception 2 morbidity and medical care costs. The immediate puerperium is an important period to initiate contraception. Women are often motivated to prevent or delay another pregnancy, they have immediate access to health care providers, and they are known not be pregnant. Because ovulation may occur as early as 25 days postpartum among women not breastfeeding, providing an effective contraceptive method during the puerperium is vitally important in reducing unintended pregnancy. The puerperium is a unique time period in a woman’s life, resulting in unique contraception needs. Understanding and communicating the risks and benefits of the various contraceptive methods is vital, as some contraceptive forms are better suited than others for use during this time period. In 2010, the Centers for Disease Control (CDC) published U.S. Medical Eligibility Criteria for Contraceptive Use, 2010 (US MEC), providing evidence-based guidelines for choosing a contraceptive method based on the relative safety for women with certain characteristics/conditions, including those who are postpartum. A category 1 distinction indicates that there are no restrictions for the use of a particular contraceptive method. Category 2 designates that the method may be used but that individualization and careful follow-up may be required. Category 3 indicates that a certain method is generally not recommended unless other methods are unavailable or unacceptable. Category 4 notes an unacceptable health risk may be conferred with use. The CDC-MEC criteria can be used to evaluate options for women in the postpartum period with and without chronic medical conditions. Updates to the CDC-MEC recommendations specific for postpartum women were released in 2011 and will be reviewed here. Hormonal contraception Combined estrogen and progestin hormonal contraceptive agents (oral combined hormonal contraceptive pills, transdermal patch, vaginal ring) Hormonal contraceptives are among the most used methods of contraception in the United States. In fact, according to the most recent data from the National Center for Health Statistics, the oral contraceptive pill is used by 17.1% of all reproductive age women (28% of women using some form of contraception), 1.3% use the contraceptive ring, and 0.9%, the implant or transdermal patch. These methods prevent ovulation by suppressing hypothalamic gonadotropin-releasing factors, which then prevents pituitary secretion of FSH and LH. Estrogens prevent ovulation by suppressing FSH release, and also stabilize the endometrium. Progestins suppress LH, thicken cervical mucus, and render the endometrium unfavorable for implantation. Oral progestin-only options can provide contraceptive efficacy, although the estrogen component improves cycle control, unfortunately at the expense of estrogenic side effects such as nausea, breast tenderness and thromboembolic events. Progestins produce androgenic side effects such as acne, hirsutism and lipid changes. The overall side effect profile, therefore, is Proceedings in Obstetrics and Gynecology, 2013; 3(2):1 Postpartum contraception 3 dependent upon the concentration of each hormone and specific type of progestin. Combined hormonal contraceptive pills have many benefits, including familiarity with the method, effectiveness, safety, reversibility, cycle control, decrease in dysmenorrhea, decrease in days of bleeding and amount of blood loss and other, non-contraceptive benefits. Non-oral delivery methods such as the transdermal patch or vaginal ring have the additional advantage of eliminating the need for daily compliance, as well as offering a different pharmacokinetic profile. Daily intake of oral combined hormonal contraceptives creates peaks and troughs in ethinyl estradiol concentrations, whereas the ring and patch deliver more constant levels. Exposure is lowest with the ring, while the patch is associated with the greatest overall exposure. Intermenstrual bleeding, amenorrhea, breast tenderness, abdominal bloating, headache and nausea are a few of the common side effects of combined oral contraceptives. The transdermal patch has similar side effects, though breast discomfort and dysmenorrhea are significantly more common. The most frequent side effects associated with the vaginal ring are headache, leukorrhea, vaginitis, weight gain and nausea. Despite the advantages, there are several reasons why combined hormonal contraceptives are not typically used in the puerperium. The safety and timing of contraceptive initiation during lactation are subject to debate. Studies of hormonal contraceptive agents with doses of ethinyl estradiol or mestranol of 50 mcg or more have demonstrated a suppressive effect on lactation. Those with 35 mcg or less, still have some suppressive effects, and low-dose combination oral contraceptives containing 0.03 mg ethinyl estradiol and 0.15 mg levonorgestrel in women who had been nursing for one month, had a small but significant decrease in lactation performance and in weight gain of their infants or cause maternal anxiety about milk supply. This slight inhibition of lactation induced by combined oral contraceptive agents may be sufficient enough to discourage women from continuing breastfeeding, particularly in those whose desire to nurse is marginal. On the other hand, a 2003 Cochrane review concluded that there was insufficient evidence to establish the effect of combined hormonal contraceptives, if any, on milk quality or quantity and a systematic review confirmed an inconsistent effect of combined oral contraceptives on breastfeeding duration and success, and found that infant outcomes were not affected. An update to the US MEC, specifically regarding use of contraceptive methods during the postpartum period, was published in 2011. These updated recommendations describe specific guidelines stating that all postpartum women should not use combined hormonal contraceptives during the first 21 days postpartum due to significant increased risk of venous thromboembolism (VTE) (category 4). During days 21-42, non-breastfeeding women with risk factors for VTE (e.g. prior VTE, recent cesarean delivery, or smoking), should not use these methods for the same reason of increased VTE risk (category 3). Without additional risk factors for VTE, use of combined Proceedings in Obstetrics and Gynecology, 2013; 3(2):1 Postpartum contraception 4 hormonal contraceptive during days 2142 is category 2, thus acceptable. After 42 days postpartum, no exceptions apply and use of combined hormonal contraceptives for all non-breastfeeding women is category 1. In breastfeeding postpartum women, from 21 days to < 30, regardless of the presence of additional risk factors for VTE, use is category 3. Without additional risk factors for VTE, use of combined hormonal contraceptive from day 30 forward, is category 2. (see table 1) Since ovulation is unlikely in the first month after delivery, women can be provided with a prescription for combined hormonal contraception to begin at one month (30 days from delivery). Progestogen-only contraceptives (progestin-only oral contraceptive

Unintentionally Retained Foreign Objects: A Descriptive Study of 308 Sentinel Events and Contributing Factors

OBJECTIVE Unintentionally retained foreign objects (URFOs) remain the sentinel events most frequently reported to The Joint Commission. The objective of this study was to describe reports of URFOs, including the types of objects, anatomic locations, contributing factors, and harm, in order to make recommendations to improve perioperative safety. METHODS A retrospective review was undertaken of events involving URFOs reported to The Joint Commission from October 2012 through March 2018. Inclusion criteria were events meeting Joint Commission definitions of URFO and sentinel event. Exclusion criteria were sponges used intraoperatively and guidewires. Event reports included patients undergoing surgery, child birth, wound care, and other invasive procedures. RESULTS A total of 308 events involving URFOs were reported: instruments (102), catheters and drains (52), needles and blades (33), packing (30), implants (14), specimens (6), and other items (71). Many of the instruments were used in minimally invasive or orthopedic surgery. Items were most frequently retained in the abdomen or the vagina. Most URFOs occurred in the operating room. A total of 1,156 contributing factors were identified, most frequently in the categories human factors, leadership, and communication. In the majority of reports, the harm was categorized as unexpected additional care/extended stay. Five patients died as a result of the URFO. CONCLUSION We describe events involving URFOs voluntarily reported to The Joint Commission. The variety of retained items, the departments involved, and the large number of contributing factors demonstrate the complexity of patient care and the need for a multifaceted plan for prevention. We make recommendations based on these findings.

Fast versus slow tenaculum placement during office transcervical procedures

Department of Obstetrics and Gynecology, Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242 Department of Obstetrics and Gynecology, University of Kentucky Hospital, Lexington, KY University of Iowa, Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa 52242 Biostatistics Counseling Center, University of Iowa College of Public Health, Iowa City, IA, 52242