Beth Weitz

Antepartum, intrapartum, and neonatal significance of exercise on healthy low-risk pregnant working women

OBJECTIVE To evaluate the influence of exercise on maternal and perinatal outcome in a low‐risk healthy obstetric population. METHODS We conducted a prospective observational study of low‐risk healthy women exercising during their pregnancy. An extensive questionnaire collected antepartum, intrapartum, and postpartum patient information on 750 women. The women were divided into four groups based on exercise level during pregnancy. RESULTS There were no differences among groups for maternal demographic characteristics, antenatal illnesses, stress, social support, or smoking. Heavily exercising women were older (P = .042), had higher incomes (P = .001), and were exercising more at conception (P = .001). Women who did more exercise were more likely to need an induction of labor (P = .033, relative risk 1.84, 95% confidence interval 1.05, 3.20), induction or augmentation with oxytocin (P = .015, relative risk 1.53, 95% confidence interval 1.19, 1.97), and had longer first‐stage labors (P = .032) resulting in longer total labors (P = .011). The difference in the length of first‐stage labor was even greater if the no‐exercise group was compared with the strongly exercising group (P = .009, relative risk 1.38, 95% confidence interval 0.16, 2.60). Fewer umbilical cord abnormalities (P = .034) were observed with exercise, but exercising women had more colds and flu (P = .008). Heavily exercising women had smaller infants (mean difference 86.5 g) compared with sedentary women. CONCLUSION Exercise in working women is associated with smaller babies, increased number of inductions and augmentations of labor, and longer labors. Colds and flu are more frequent in exercising women.

Transplacental passage of antimicrobial paraben preservatives.

Parabens are widely used preservatives suspected of being endocrine disruptors, with implications for human growth and development. The most common paraben found in consumer products is methylparaben. To date, no study has examined whether these substances cross the human placenta. A total of 100 study subjects (50 mother–child pairs) were enrolled at two medical institutions, serving primarily African-American and Caucasian women, respectively. A maternal blood sample was drawn on admission and a paired cord blood sample was obtained at delivery. Of the 50 mothers, 47 (94%) showed methylparaben in their blood (mean level 20.41 ng/l), and 47 in cords bloods (mean level 36.54 ng/l). There were 45 mother–child pairs where methylparaben was found in both samples. Of these, the fetal level was higher than the maternal level in 23 (51%). For butylparaben, only 4 mothers (8%) showed detectable levels (mean 40.54 ng/l), whereas 8 cord blood samples (16%) were positive (mean 32.5 ng/l). African-American mothers and infants showed higher prevalence of detectable levels (P=0.017). Methylparaben and butylparaben demonstrate transplacental passage. Additional studies are needed to examine potential differences in exposure by geography and demographics, what products are used by pregnant women that contain these preservatives, as well as any potential long-term effects in the growth and development of exposed children.

Sharing of Snorting Straws and Hepatitis C Virus Infection in Pregnant Women.

OBJECTIVE: To evaluate possible modes of hepatitis C virus (HCV) acquisition in pregnant women found to be HCV-infected in the prenatal period and to assess transmission risk factors. METHODS: This was a prospective cohort study conducted from March 2014 through June 2015 involving the distribution of an anonymous survey to HCV-infected pregnant women that assessed for numerous modes of potential HCV transmission involving, intravenous drug use, blood transfusion, organ transplant, sexual contact, tattoos, and snorting drugs with a straw. Participants were drawn from our institutional obstetric high-risk clinic. Statistical analysis involved simple percentages and &khgr;2 comparisons where appropriate; P<.05 was considered significant. To test biologic plausibility, snorting utensils confiscated by law enforcement authorities from patients not in this study were tested for the presence of human blood. RESULTS: A total of 189 HCV-infected pregnant patients completed the survey, and no approached patients declined. Of these, 136 (72%, 95% confidence interval [CI] 65–78%) admitted to intravenous drug use, of whom 89 (65%, 95% CI 57–73%) reported sharing needles. Of the 178 (94%, 95% CI 90–97%) who admitted snorting drugs, 164 (92%, 95% CI 87–96%) reported sharing straws. The difference between the proportion reporting sharing of snorting utensils compared with the proportion sharing intravenous drug use utensils was significant (P<.001). Twenty-nine patients (15%, 95% CI 11–21%) reported snorting drugs and sharing straws but denied any other risk factor except sexual contact. Of the 54 straws confiscated by law enforcement authorities, 13 (24%, 95% CI 13–38%) tested positive for the presence of human blood. CONCLUSION: Sharing snorting utensils (straws) in noninjection drug use may be an additional risk factor for HCV and other virus transmission.

Patient reaction to Tdap vaccination in pregnancy

BACKGROUND The current obstetrical recommendation is to routinely administer the tetanus, diphtheria, and acellular pertussis (Tdap) vaccination during every pregnancy regardless of a patients prior history. There are minimal data that have prospectively evaluated solicited patient response to this treatment plan. The study objective was to evaluate patient reaction following receipt of Tdap vaccination during pregnancy. METHODS This was a prospective observational study conducted from May 2014 through March 2016. The study design involved solicited patient reaction within 1-7days after the administration of the Tdap vaccine. Data collected included pain or soreness, swelling, and/or redness at the injection site, as well as, fever and generalized body aches. Statistical analysis involved simple percentages with Poisson binomial 95% confidence intervals with Chi-square and Fishers exact comparisons where appropriate. RESULTS A total of 737 patients were evaluated and 496 (67%, 95% Confidence Interval [CI] 64-71%) were found to have at least 1 reaction to the vaccination and 187 (25%, 95% CI 22-29%) had 2 reactions or more. Overall, the majority of patients stated that the vaccination was tolerated. However, 24 (3%, 95% CI 2-5%) of the study population stated that they would not accept receipt of Tdap in a subsequent pregnancy because of the response that occurred in the current pregnancy. CONCLUSION These data demonstrate that maternal reactions following receipt of Tdap are common (two-thirds of the study population). A potential concern is the finding that some patients might refuse a repeat vaccination in a subsequent pregnancy due to these reactions. If further research reveals similar findings, a pertussis only vaccine for pregnant patients might need to be evaluated.

Pyelonephritis in Pregnancy: Prediction of Prolonged Hospitalization and Maternal Morbidity using Prognostic Scoring Systems

Objective This study aims to evaluate the usefulness of prognostic scoring systems to differentiate women admitted for pyelonephritis who develop maternal morbidity and require prolonged hospitalization. Study Design Multicenter retrospective cohort study to compare the Acute Physiology and Chronic Health Evaluation II (APACHE II) and Modified Obstetric Early Warning System (MOEWS) to predict prolonged hospitalization (> 4 days) and composite maternal morbidity for all pregnant women admitted with pyelonephritis between 2012 to 2013. One‐way analysis of variance for continuous variables, Fishers exact test for categorical variables, and receiver operating characteristic curves were used. Results Among 123 pyelonephritis cases analyzed, 25 (20%) required prolonged hospitalization. Women with prolonged hospitalization had higher rates of composite maternal morbidity, required diagnostic imaging, and had delayed administration of intravenous antibiotics (292 ± 381 vs. 218 ± 233 min, p = 0.002). APACHE II and MOEWS scores calculated from data collected within the first 24 hours of admission had a modest ability to discriminate maternal morbidity (APACHE II: area under the curve [AUC], 0.72; 95% confidence interval [CI], 0.58‐0.86 and MOEWS: AUC, 0.71; 95% CI, 0.56‐0.85). Conclusion We observed that one in five pregnancies admitted for treatment of pyelonephritis requires hospitalization for over 4 days with significant maternal morbidities. Prognostic scoring systems may be useful clinical tools to assess these patients systematically and improve morbidity.

Transplacental passage of vancomycin

Abstract Objective: To evaluate a larger number of patients receiving a vancomycin-dosing regimen of 20 mg/kg IV every 8 h for Group B streptococcus (GBS) chemoprophylaxis and analyze maternal and neonatal cord blood levels at delivery. Methods: We prospectively enrolled every mother that entered labor with a positive GBS culture and a high-risk penicillin allergy with resistance to clindamycin or unknown sensitivity. Maternal and cord blood vancomycin levels were obtained at delivery. Time from last dose completion to delivery, number of doses administered and body mass index were assessed. Results: A total of 30 patients consented and 23 (77%) maternal levels and cord blood levels were therapeutic. There were eight patients where one or both maternal and/or cord blood values were non-therapeutic, but in six of these, there was a regimen violation regarding timing of the next dose or total dosage administered. Of the 24 patients where the regimen was correctly followed, 22 (92%) had therapeutic maternal and cord blood levels. Conclusions: Using a vancomycin-dosing regimen of 20 mg/kg IV every 8 h (maximum individual dose of 2 g) produces therapeutic levels in more than 75% of mother/newborn pairs and this can exceed 90% when dosing regimens are correctly followed.

Transplacental passage of clindamycin from mother to neonate

Objective:To evaluate maternal and neonatal cord blood levels at delivery in patients receiving 900 mg of clindamycin intravenous (IV) every 8 h.Study design:Prospective study consented every mother that entered labor with a positive group B streptococcal culture, a high-risk penicillin allergy, and sensitivity to clindamycin and erythromycin. Maternal and cord blood clindamycin levels were obtained at delivery. Time from last dose completion to delivery, number of doses administered and body mass index (BMI) were assessed.Results:Twenty-three patients were consented. All maternal clindamycin values were therapeutic and 22 (96%) of the 23 cord blood samples were therapeutic. The mean maternal level was of 4.46 μg ml−1 (range of 0.7 to 8.4 μg ml−1). The mean cord blood level was 3.35 μg ml−1 (range of <0.5 to 6.4 μg ml−1).Conclusion:These data show that the current dosing recommendation of 900 mg of clindamycin IV every 8 h produces therapeutic maternal and cord blood levels.

Accuracy of the lamellar body count in amniotic fluid contaminated by meconium.

Abstract Objective: To determine whether meconium-contaminated amniotic fluid falsely elevates the lamellar body count in fetal lung maturity testing. Methods: Thirty mothers undergoing amniocentesis for fetal lung maturity testing were prospectively consented. A 2 mL portion of the patient’s sample was mixed with a 10% meconium solution and the meconium-stained sample was then run in tandem with the patient’s sample used in clinical management. Pure meconium samples without amniotic fluid were also run through the cell counter for analysis. Results: Following meconium contamination, the lamellar body count value increased in 67% of the cases, decreased in 23% and remained the same in 10%. There were 13 test results that had “immature” values in the uncontaminated patient management sample group and nine of these (69%) became elevated to a “mature” level (a false elevation) following the addition of meconium. All of the 10 pure liquid meconium samples devoid of amniotic fluid processed by the cell counter identified and quantified some particle the size of platelets. Conclusions: The lamellar body count test result is not reliable in meconium-stained amniotic fluid specimens. There is some unknown particle found in meconium that is the size of platelets/lamellar bodies that can falsely elevate the test result. Currently, the only reliable fetal lung maturity test in meconium-stained amniotic fluid is the presence of phosphatidylglycerol.