Carolyn Gardella

Lead exposure in pregnancy: a review of the literature and argument for routine prenatal screening.

Despite a steady decline in average blood lead levels in the U.S. population, approximately 0.5% of women of childbearing age may have blood levels exceeding 10 &mgr;g/dl. Strong correlations between maternal and umbilical cord blood lead levels demonstrate that lead is transferred from the mother to the fetus. High lead levels are known to cause neurobehavioral effects in infants and children, and the cumulative effects of low levels of lead exposure in utero and after birth can have similar detrimental effects. Modern sources of exposure include occupational exposure during automotive or aircraft paint manufacturing, lead production or smeltering, exposure to stained glass soder, and environmental exposure during home renovation. Prenatal screening for lead exposure may include use of a five-item questionnaire similar to the pediatric questionnaire. Management of prenatal lead exposure focuses on removal of the lead source. Rarely, highly toxic chelation therapy is needed for maternal indications. Recognition and removal of lead sources during the prenatal period can prevent maternal and neonatal morbidity. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader will be able to list the potential sources of lead intoxication in our society, to describe the effects of low level exposure in utero, and to outline the management strategy of the lead exposed pregnant patient.

Pregnancy Complications Associated with Hepatitis C: Data from a 2003–2005 Washington State Birth Cohort

OBJECTIVE The objective of the study was to determine the effect of hepatitis C virus (HCV) on selected maternal and infant birth outcomes. STUDY DESIGN This population-based cohort study using Washington state birth records from 2003 to 2005 compared a cohort of pregnant women identified as HCV positive from birth certificate data (n = 506) to randomly selected HCV-negative mothers (n = 2022) and drug-using HCV-negative mothers (n = 1439). RESULTS Infants of HCV-positive mothers were more likely to be low birthweight (odds ratio [OR], 2.17; 95% confidence interval [CI] 1.24, 3.80), to be small for gestational age (OR, 1.46; 95% CI, 1.00, 2.13), to need assisted ventilation (OR, 2.37; 95% CI, 1.46, 3.85), and to require neonatal intensive car unit (NICU) admission (OR, 2.91; 95% CI, 1.86, 4.55). HCV-positive mothers with excess weight gain also had a greater risk of gestational diabetes (OR, 2.51; 95% CI, 1.04, 6.03). Compared with the drug-using cohort, NICU admission and the need for assisted ventilation remained associated with HCV. CONCLUSION HCV-positive pregnant women appear to be at risk for adverse neonatal and maternal outcomes.

High-concentration supplemental perioperative oxygen to reduce the incidence of postcesarean surgical site infection: a randomized controlled trial.

OBJECTIVE: Most postcesarean infections are caused by anaerobic bacteria. Oxidative killing, an important defense against surgical infections, depends on the oxygen level in contaminated tissue. Among patients undergoing colorectal surgery, perioperative supplemental oxygen decreased infection rates by 50%. We tested the hypothesis that high-concentration inspired oxygen decreases the incidence of surgical site infection in women undergoing cesarean delivery. METHODS: Using a double blind technique, 143 women undergoing cesarean delivery under regional anesthesia after the onset of labor were randomly assigned to receive low- or high-concentration inspired oxygen via nonrebreathing mask during the operation and for 2 hours after. Surgical site infection was defined clinically as administration of antibiotics for postpartum endometritis or wound infection during the initial hospital stay or within 14 days of surgery. Interim statistical analysis was performed after 25% of the planned sample size (143 of 550) accrued using intention-to-treat principle. The stopping rule P value for futility was P>.11 with two planned interim analyses. RESULTS: Postcesarean infection occurred in 17 (25%, 95% confidence interval [CI] 15–35%) of 69 women assigned to high-concentration oxygen compared with 10 (14%, 95% CI 6–22%) of 74 women assigned to low-concentration inspired oxygen (relative risk 1.8, 95% CI 0.9–3.7, P=.13). The P value exceeded the P value for futility, suggesting these differences were unlikely to reach statistical significance with continued recruitment. CONCLUSION: High-concentration perioperative oxygen delivered through a nonrebreathing mask did not decrease the risk of postcesarean surgical site infection. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00670020 LEVEL OF EVIDENCE: I

Risk factors for group B streptococcal genitourinary tract colonization in pregnant women

OBJECTIVE: To identify risk factors for group B streptococcus (GBS) colonization in pregnancy, hypothesizing that health care workers may have increased risk. METHODS: Population-based, case-control study comparing 40,459 cases of GBS colonization, identified from Washington State birth certificate data linked to hospital discharge data for live births between 1997 and 2002, with 84,268 controls matched by year of delivery by multivariable logistic regression. RESULTS: After adjustment for confounders, the following characteristics were independently associated with increased maternal GBS colonization: health care occupation (odds ratio [OR] 1.22, 95% confidence interval [CI] 1.07–1.38), black race (OR 1.54, 95% CI 1.36–1.74), overweight (OR 1.07, 95% CI 1.01–1.12), obesity (OR 1.20, 95% CI 1.13–1.28), severe obesity (OR 1.45, 95% CI 1.28–1.63), median income greater than lowest quintile (OR 1.29, 95% CI 1.20–1.39 for fifth versus first quintile), some high school education (OR 1.21, 95% CI 1.05–1.40), high school graduate (OR 1.35, 95% CI 1.16–1.56), and adequate prenatal care (OR 1.14, 95% CI 1.06–1.24). Hispanic women (OR 0.88, 95% CI 0.80–0.96) and smokers (OR for 1–10 cigarettes per day 0.90, 95% CI 0.83–0.97) had a decreased odds of colonization. CONCLUSION: Health care workers, black women, and women with high body mass index may be at greater risk of GBS colonization in pregnancy. However, any increases in risk are modest and the association between a health care occupation and GBS colonization needs to be investigated further. LEVEL OF EVIDENCE: II-2

Long-term Effect of Depot Medroxyprogesterone Acetate on Vaginal Microbiota, Epithelial Thickness and HIV Target Cells

BACKGROUND Depot medroxyprogesterone acetate (DMPA) has been linked to human immunodeficiency virus type 1 (HIV-1) acquisition. METHODS Vaginal microbiota of women using DMPA for up to 2 years were cultured. Mucosal immune cell populations were measured by immunohistological staining. RESULTS Over 12 months, the proportion with H2O2-positive lactobacilli decreased (n = 32; 53% vs 27%; P = .03). Median vaginal CD3(+) cells also decreased (n = 15; 355 vs 237 cells/mm(2); P = .03), as did CD3(+)CCR5(+) cells (195 vs 128 cells/mm(2); P = .04), HLA-DR(+) cells (130 vs 96 cells/mm(2); P = .27), and HLA-DR(+)CCR5(+) cells (18 vs 10 cells/mm(2); P = .33). CONCLUSIONS DMPA contraception does not increase vaginal mucosal CCR5(+) HIV target cells but does decrease CD3(+) T lymphocytes and vaginal H2O2-producing lactobacilli.

Frequency of Mastalgia Among Women Veterans

AbstractOBJECTIVE: To determine the prevalence and frequency of mastalgia and its association with psychiatric conditions and unexplained pain syndromes. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional mailed survey completed by 1,219 female veterans enrolled at the VA Puget Sound Health Care System in 1998. MEASUREMENTS: Breast pain in the past year, unrelated to pregnancy, was categorized as infrequent (≤ monthly) or frequent (≥ weekly) mastalgia. Surveys assessed posttraumatic stress disorder (PTSD), depression, panic disorder, and alcohol misuse with validated screening tests, as well as self-reported past-year chronic pelvic pain, fibromyalgia, and irritable bowel syndrome. RESULTS: The response rate was 63%. Fifty-five percent of the respondents reported past-year mastalgia. Of these, 15% reported frequent mastalgia. Compared to women without mastalgia, women reporting frequent mastalgia were more likely to screen positive for PTSD (odds ratio [OR] 5.2, 95% confidence interval [CI] 3.2 to 8.4), major depression (OR 4.2, 2.6 to 6.9), panic disorder (OR 7.1, 3.9 to 12.8), eating disorder (OR 2.6, 1.5 to 4.7), alcohol misuse (OR 1.8, 1.1 to 2.8), or domestic violence (OR 3.1, 1.9 to 5.0), and to report fibromyalgia (OR 3.9, 2.1 to 7.4), chronic pelvic pain (OR 5.4, 2.7 to 10.5), or irritable bowel syndrome (OR 2.8, 1.6 to 4.8). Women with infrequent mastalgia were also more likely than women without mastalgia to screen positive for PTSD, depression, or panic disorder, or report pelvic pain or irritable bowel syndrome, although associations were weaker than with frequent mastalgia. CONCLUSIONS: Like other unexplained pain syndromes, frequent mastalgia is strongly associated with PTSD and other psychiatric conditions. Clinicians seeing patients with frequent mastalgia should inquire about anxiety, depression, alcohol misuse, and trauma history.

Effect of maternal herpes simplex virus (HSV) serostatus and HSV type on risk of neonatal herpes

Background. Neonatal herpes simplex virus (HSV) is a rare but devastating disease. We have conducted pooled analyses of data from 3 cohorts to evaluate the effects of maternal HSV serostatus and HSV type on risk of neonatal HSV acquisition and severity. Methods. Data from cohorts in Seattle, WA, and Stanford, CA, USA, and Stockholm, Sweden were pooled using Mantel–Haenszel methods. Results. Seventy‐eight infants with documented neonatal HSV and known maternal HSV serostatus were included. The risk of neonatal HSV‐2 infection was similar in infants born to HSV seronegative women compared with HSV‐1 seropositive women (pooled OR: 1.6; 95% CI: 0.6–4.0). The odds of neonatal HSV infection was increased in the presence of exposure to maternal HSV‐1 versus HSV‐2 (adjusted pooled OR: 19.2; 95% CI: 5.8–63.6). An elevated odds of disseminated HSV in infants born to women with newly acquired genital herpes was observed in Stockholm (OR = 13.5; 95% CI: 1.4–630), but not in Seattle or Stanford. Conclusion. Our results suggest that maternal HSV‐1 antibody offers little, if any, protection against neonatal HSV‐2 infection. During reactivation, HSV‐1 appears more readily transmissible to the neonate than HSV‐2, a concerning finding given the rising frequency of genital HSV‐1 infection.

Induction of labor in the absence of standard medical indications: incidence and correlates.

Background: Induction of labor is an increasingly common obstetrical procedure, with approximately 20–34% of women undergoing labor induction in the United States annually. Objective: To determine the extent of labor induction in the absence of standard medical indications and to assess possible associations with maternal and infant characteristics and hospital factors. Methods: We ascertained induction of labor and associated details as part of a medical record validation study of 4541 women with live, singleton births in 2000 in Washington State using medical record, birth certificate, and hospital discharge data. In this analysis, we report findings for the 1473 women (33% of original cohort) whose medical records indicated that their labors were induced. Results: Among women with induced labor, 7.9% had no clinical information providing an indication for the induction, and 6.4% had only “nonstandard” indications recorded. Compared with women delivering in moderate volume hospitals, women who delivered at lower volume (odds ratios [OR] 3.9; 95% confidence intervals [CI] 1.8–8.6) or higher volume hospitals (OR 4.2; 95% CI 2.4–7.2) had significantly increased risk for undocumented indication of labor. Women who had undocumented indication for induction were at significantly decreased risk of giving birth at a teaching hospital and a public nonfederally owned hospital, and were at greater risk to give birth at a private religious hospital. Factors that remained independently associated with nonstandard indication for induction of labor were primiparas (OR 2.4; 95% CI 1.3–4.2); multiparas (OR 4.3; 95% CI 2.5–7.4), pregnancy-induced hypertension (OR 0.2; 95% CI 0.1–0.4), hospital volume ≥2000 births annually (OR 19.9; 95% CI 6.7–58.6), primary (OR 11.7; 95% CI 4.1–33.6), and tertiary level hospital (OR 0.4; 95% CI 0.2–0.7). Conclusions: Our findings suggest that nearly 15% of inductions either were not clinically indicated according to standard protocols or indications were incompletely documented. At minimum, further studies are needed to explore how best to improve documentation of indications of labor because accurately describing, among other things, the process of labor induction, is a basic benchmark of care.

Rapid polymerase chain reaction assay to detect herpes simplex virus in the genital tract of women in labor.

OBJECTIVE: To develop a rapid quantitative real-time polymerase chain reaction (PCR) to detect herpes simplex virus (HSV) in the genital secretions of women that may be used in labor. METHODS: Samples of genital secretions from women in labor, swabs of active genital lesions, and swabs of buffer solution were analyzed using a newly developed rapid HSV PCR assay to detect HSV glycoprotein B gene and quantitate virion copy number. A previously validated TaqMan PCR to detect HSV glycoprotein B gene was performed as the comparator gold standard. Positivity determination that optimized sensitivity and specificity was determined with receiver operating characteristic curves. RESULTS: The median time to result for rapid HSV PCR was 2 hours (range 1.5–3.5 hours). A positivity determination rule that required both wells of the rapid test to detect 150 copies or greater of HSV per milliliter maximized specificity (96.7%) without appreciable loss of sensitivity (99.6%). Among positive samples, the correlation between the rapid test and TaqMan for the quantity of HSV isolated was excellent (R=0.96, P<.001). The rapid test had a positive predictive value of 96.7% and a negative predictive value of 99.6% in a population with HSV shedding prevalence of 10.8%, based on the prevalence of genital HSV previously found among HSV-2 seropositive women in labor. CONCLUSION: Rapid HSV PCR provides results with excellent sensitivity and specificity within a timeframe that could inform clinical decision making for identifying neonates at risk of neonatal HSV infection. LEVEL OF EVIDENCE: II

Persons with Early Syphilis Identified through Blood or Plasma Donation Screening in the United States

The number of persons with early syphilis who donated blood between 1995 and 2000 in the United States was estimated using data collected in the National Electronic Telecommunication System for Surveillance (NETSS). To distinguish paid from volunteer donors, cases reported in 2000 were analyzed. For the 6 years, 22 primary, 81 secondary, and 413 early latent syphilis cases were identified through donation screening. In 2000, 69 cases of early syphilis were identified through donation screening in 16 states. In 6 states that reported 53 of these cases, 31 case subjects (58%) were volunteer donors and 22 (42%) were paid donors. Eighty-one percent of volunteer donors and 64% of paid donors reported no risk factors for syphilis. After adjustment for variation in NETSS use, it was estimated that, over the 6 years, approximately 1200 cases of early syphilis were detected nationally through donation screening, and 58% of the case subjects were volunteer donors.