Eva Lathrop

Update: Interim Guidance for Health Care Providers Caring for Pregnant Women with Possible Zika Virus Exposure - United States (Including U.S. Territories), July 2017.

CDC has updated the interim guidance for U.S. health care providers caring for pregnant women with possible Zika virus exposure in response to 1) declining prevalence of Zika virus disease in the World Health Organizations Region of the Americas (Americas) and 2) emerging evidence indicating prolonged detection of Zika virus immunoglobulin M (IgM) antibodies. Zika virus cases were first reported in the Americas during 2015-2016; however, the incidence of Zika virus disease has since declined. As the prevalence of Zika virus disease declines, the likelihood of false-positive test results increases. In addition, emerging epidemiologic and laboratory data indicate that, as is the case with other flaviviruses, Zika virus IgM antibodies can persist beyond 12 weeks after infection. Therefore, IgM test results cannot always reliably distinguish between an infection that occurred during the current pregnancy and one that occurred before the current pregnancy, particularly for women with possible Zika virus exposure before the current pregnancy. These limitations should be considered when counseling pregnant women about the risks and benefits of testing for Zika virus infection during pregnancy. This updated guidance emphasizes a shared decision-making model for testing and screening pregnant women, one in which patients and providers work together to make decisions about testing and care plans based on patient preferences and values, clinical judgment, and a balanced assessment of risks and expected outcomes.

Self-administration of misoprostol prior to intrauterine device insertion among nulliparous women: a randomized controlled trial.

BACKGROUND Barriers to intrauterine device (IUD) use in nulliparous women include fear of pain with insertion and provider perception of difficulty with insertion. The goal of this study was to evaluate whether misoprostol prior to IUD insertion in nulliparous women eased insertion and decreased pain. STUDY DESIGN This was a double-blinded, randomized, controlled trial. Nulliparous women requesting an IUD were randomized to buccal placement of 400-mcg misoprostol or placebo. Provider ease of insertion and patient-reported pain were measured using a 100-mm visual analogue scale. RESULTS Seventy-three subjects completed the study. Baseline characteristics were similar between groups. Provider perception of ease of insertion was not different between study and control groups (28.97 mm, 22.33 mm, p=.18). Pain immediately prior to IUD insertion (10.84 vs. 2.11; p=.003) and after IUD insertion (46.50 vs. 35.14; p=.040) was higher for those in the study group compared to the control group. CONCLUSION This study demonstrates that it is not helpful to provide misoprostol for cervical ripening prior to insertion of IUDs as it does not improve ease of insertion for provider or decrease reported pain for the woman, and it may increase womens pain experience with insertion. IMPLICATION STATEMENT Our study demonstrates that providers do not perceive nulliparous IUD insertion as difficult; women do experience pain with insertion but find the experience acceptable. The addition of misoprostol for cervical ripening prior to insertion does not ease insertion for providers and increases the pain level experienced by women.

Reproductive Healthcare Needs and Desires in a Cohort of HIV-Positive Women

Background. The aim of this study was to determine current contraceptive use, contraceptive desires and knowledge, future fertility desires, and sterilization regret in a cohort of HIV-positive women. Study Design. 127 HIV-positive women receiving care at an urban infectious disease clinic completed a survey addressing their contraceptive and reproductive histories as well as their future contraceptive and fertility desires. Results. The most common forms of contraception used were sterilization (44.4%) and condoms (41.3%). Less than 1% used a long-term reversible method of contraception (LARC) despite these being the methods that best fit their desired attributes of a contraceptive method. Overall, 29.4% desired future fertility. Only 50.6% of those sexually active had spoken with a provider within the last year regarding their contraceptive plans. There was a high degree of sterilization regret (36.4%), and 18.2% of sterilized women desired future fertility. Multivariate analysis found women in a monogamous relationship had a statistically increased rate of regret compared to women who were not sexually active (OR 13.8, 95% CI 1.6–119, P = 0.17). Conclusion. Given the diversity in contraceptive and fertility desires, coupled with a higher rate of sterilization regret than is seen in the general population, integration of comprehensive family planning services into HIV care via increased contraceptive education and access is imperative.

Contraceptive Use Among Nonpregnant and Postpartum Women at Risk for Unintended Pregnancy, and Female High School Students, in the Context of Zika Preparedness — United States, 2011–2013 and 2015

Zika virus infection during pregnancy can cause congenital microcephaly and brain abnormalities (1,2). Since 2015, Zika virus has been spreading through much of the World Health Organizations Region of the Americas, including U.S. territories. Zika virus is spread through the bite of Aedes aegypti or Aedes albopictus mosquitoes, by sex with an infected partner, or from a pregnant woman to her fetus during pregnancy.* CDC estimates that 41 states are in the potential range of Aedes aegypti or Aedes albopictus mosquitoes (3), and on July 29, 2016, the Florida Department of Health identified an area in one neighborhood of Miami where Zika virus infections in multiple persons are being spread by bites of local mosquitoes. These are the first known cases of local mosquito-borne Zika virus transmission in the continental United States.(†) CDC prevention efforts include mosquito surveillance and control, targeted education about Zika virus and condom use to prevent sexual transmission, and guidance for providers on contraceptive counseling to reduce unintended pregnancy. To estimate the prevalence of contraceptive use among nonpregnant and postpartum women at risk for unintended pregnancy and sexually active female high school students living in the 41 states where mosquito-borne transmission might be possible, CDC used 2011-2013 and 2015 survey data from four state-based surveillance systems: the Behavioral Risk Factor Surveillance System (BRFSS, 2011-2013), which surveys adult women; the Pregnancy Risk Assessment Monitoring System (PRAMS, 2013) and the Maternal and Infant Health Assessment (MIHA, 2013), which surveys women with a recent live birth; and the Youth Risk Behavior Survey (YRBS, 2015), which surveys students in grades 9-12. CDC defines an unintended pregnancy as one that is either unwanted (i.e., the pregnancy occurred when no children, or no more children, were desired) or mistimed (i.e., the pregnancy occurred earlier than desired). The proportion of women at risk for unintended pregnancy who used a highly effective reversible method, known as long-acting reversible contraception (LARC), ranged from 5.5% to 18.9% for BRFSS-surveyed women and 6.9% to 30.5% for PRAMS/MIHA-surveyed women. The proportion of women not using any contraception ranged from 12.3% to 34.3% (BRFSS) and from 3.5% to 15.3% (PRAMS/MIHA). YRBS data indicated that among sexually active female high school students, use of LARC at last intercourse ranged from 1.7% to 8.4%, and use of no contraception ranged from 7.3% to 22.8%. In the context of Zika preparedness, the full range of contraceptive methods approved by the Food and Drug Administration (FDA), including LARC, should be readily available and accessible for women who want to avoid or delay pregnancy. Given low rates of LARC use, states can implement strategies to remove barriers to the access and availability of LARC including high device costs, limited provider reimbursement, lack of training for providers serving women and adolescents on insertion and removal of LARC, provider lack of knowledge and misperceptions about LARC, limited availability of youth-friendly services that address adolescent confidentiality concerns, inadequate client-centered counseling, and low consumer awareness of the range of contraceptive methods available.

HIV and maternal mortality

The majority of the 17 million women globally that are estimated to be infected with HIV live in Sub‐Saharan Africa. Worldwide, HIV‐related causes contributed to 19 000–56 000 maternal deaths in 2011 (6%–20% of maternal deaths). HIV‐infected pregnant women have two to 10 times the risk of dying during pregnancy and the postpartum period compared with uninfected pregnant women. Many of these deaths can be prevented with the implementation of high‐quality obstetric care, prevention and treatment of common co‐infections, and treatment of HIV with ART. The paper summarizes what is known about HIV disease progression in pregnancy, specific causes of HIV‐related maternal deaths, and the potential impact of treatment with antiretroviral therapy on maternal mortality. Recommendations are proposed for improving maternal health and decreasing maternal mortality among HIV‐infected women based on existing evidence.

Postpartum contraceptive needs in northern Haiti

To assess the knowledge of, attitudes toward, and practices regarding postpartum contraception among healthcare providers and postpartum women in northern Haiti.

Eliminating Preventable HIV-Related Maternal Mortality in Sub-Saharan Africa: What Do We Need to Know?

Introduction:HIV makes a significant contribution to maternal mortality, and women living in sub-Saharan Africa are most affected. International commitments to eliminate preventable maternal mortality and reduce HIV-related deaths among pregnant and postpartum women by 50% will not be achieved without a better understanding of the links between HIV and poor maternal health outcomes and improved health services for the care of women living with HIV (WLWH) during pregnancy, childbirth, and postpartum. Methods:This article summarizes priorities for research and evaluation identified through consultation with 30 international researchers and policymakers with experience in maternal health and HIV in sub-Saharan Africa and a review of the published literature. Results:Priorities for improving the evidence about effective interventions to reduce maternal mortality and improve maternal health among WLWH include better quality data about causes of maternal death among WLWH, enhanced and harmonized program monitoring, and research and evaluation that contributes to improving: (1) clinical management of pregnant and postpartum WLWH, including assessment of the impact of expanded antiretroviral therapy on maternal mortality and morbidity, (2) integrated service delivery models, and (3) interventions to create an enabling social environment for women to begin and remain in care. Conclusions:As the global community evaluates progress and prepares for new maternal mortality and HIV targets, addressing the needs of WLWH must be a priority now and after 2015. Research and evaluation on maternal health and HIV can increase collaboration on these 2 global priorities, strengthen political constituencies and communities of practice, and accelerate progress toward achievement of goals in both areas.

Pediatric condyloma acuminata.

BACKGROUND Condyloma acuminata are caused by human papilloma virus (HPV) 6 and 11 and most commonly present in the anogenital region. Most transmission among adults is via sexual transmission, but HPV and resulting anogenital warts in pediatric populations may be a result of perinatal vertical transmission, indirect transmission through contaminated objects or surfaces, autoinoculation, or sexual transmission. CASE A 9-year-old premenarchal female presented with multiple perianal warts. She had no significant medical history, and denied history of any sexual contact, including sexual abuse. The external examination revealed multiple warts in the perianal region, but no lesions, discharge, inflammation, or external signs of trauma were visible. Tests for sexually transmitted infections were all negative. The warts were diagnosed as condyloma acuminata, and were subsequently treated with trichloroacetic acid 80% (TCA) in the providers office. TCA was applied on 3 separate occasions 2 weeks apart, showing marked improvement at each visit. SUMMARY/DISCUSSION While both sexual and nonsexual means of transmission are possible, sexual abuse must always be considered in pediatric cases. It is recommended that investigators proceed delicately, because the investigation can be psychologically damaging for patients and their families. Treatment methods are a unique consideration for pediatric patients, as most options are painful and require multiple office visits. The benefits of self-administration at home must be weighed with the likelihood of patient compliance and need for ongoing evaluation by the provider.

The methodology for developing a prospective meta-analysis in the family planning community

BackgroundProspective meta-analysis (PMA) is a collaborative research design in which individual sites perform randomized controlled trials (RCTs) and pool the data for meta-analysis. Members of the PMA collaboration agree upon specific research interventions and outcome measures, ideally before initiation but at least prior to any individual trial publishing results. This allows for uniform reporting of primary and secondary outcomes. With this approach, heterogeneity among trials contributing data for the final meta-analysis is minimized while each site maintains the freedom to design a specific trial. This paper describes the process of creating a PMA collaboration to evaluate the impact of misoprostol on ease of intrauterine device (IUD) insertion in nulliparous women.MethodsAfter the principal investigator developed a preliminary PMA protocol, he identified potential collaborating investigators at other sites. One site already had a trial underway and another site was in the planning stages of a trial meeting PMA requirements. Investigators at six sites joined the PMA collaborative. Each site committed to enroll subjects to meet a pre-determined total sample size. A final common research plan and site responsibilities were developed and agreed upon through email and face-to-face meetings. Each site committed to contribute individual patient data to the PMA collaboration, and these data will be analyzed and prepared as a multi-site publication. Individual sites retain the ability to analyze and publish their sites independent findings.ResultsAll six sites have obtained Institutional Review Board approval and each has obtained individual funding to meet the needs of that sites study. Sites have shared resources including study protocols and consents to decrease costs and improve study flow. This PMA protocol is registered with the Cochrane Collaboration and data will be analyzed according to Cochrane standards for meta-analysis.ConclusionsPMA is a novel research method that improves meta-analysis by including several study sites, establishing uniform reporting of specific outcomes, and yet allowing some independence on the part of individual sites with respect to the conduct of research. The inclusion of several sites increases statistical power to address important clinical questions. Compared to multi-center trials, PMA methodology encourages collaboration, aids in the development of new investigators, decreases study costs, and decreases time to publication.Trial RegistrationClinicalTrials.gov: NCT00613366, NCT00886834, NCT01001897, NCT01147497 and NCT01307111

Knowledge and use of and opportunities for emergency contraception in Northern Haiti.

To evaluate the knowledge and experience of, and desire for, emergency contraception (EC) in postpartum women in Haiti, and to determine the knowledge and practices of EC providers.