Jan Hart

Behaviors and perceptions regarding seasonal and H1N1 influenza vaccination during pregnancy.

We examined vaccination rates during pregnancy against both seasonal and pandemic H1N1 influenza and reasons for nonadherence to recommended guidelines during the 2009 through 2010 influenza season. Demographic and vaccination data were collected using a cross-sectional approach. Among 813 postpartum women, 520 (64%) reported receiving the seasonal influenza vaccination and 439 (54%) reported receiving the H1N1 influenza vaccination during pregnancy. Most received vaccinations at their obstetricians office. Major reasons for not receiving vaccination were: not knowledgeable about the vaccine importance (25%), concerns for effects on fetal and maternal health (18% and 9%, respectively), and not knowledgeable about where to obtain vaccination (9%). Reported H1N1 influenza vaccination rates were significantly lower in blacks (37%) compared with non-Hispanic whites, Hispanics, and Asian/other (57%, 59%, and 58%, respectively; P < .0001). Subsequent campaigns for improving vaccination rates in pregnancy should focus on educating patients about vaccine importance and safety.

Pandemic Influenza A H1N1 2009 Infection versus Vaccination: A Cohort Study Comparing Immune Responses in Pregnancy

Background With the emergence of H1N1 pandemic (pH1N1) influenza, the CDC recommended that pregnant women be one of five initial target groups to receive the 2009 monovalent H1N1 vaccine, regardless of prior infection with this influenza strain. We sought to compare the immune response of pregnant women to H1N1 infection versus vaccination and to determine the extent of passive immunity conferred to the newborn. Methods/Findings During the 2009-2010 influenza season, we enrolled a cohort of women who either had confirmed pH1N1 infection during pregnancy, did not have pH1N1 during pregnancy but were vaccinated against pH1N1, or did not have illness or vaccination. Maternal and umbilical cord venous blood samples were collected at delivery. Hemagglutination inhibition assays (HAI) for pH1N1 were performed. Data were analyzed using linear regression analyses. HAIs were performed for matched maternal/cord blood pairs for 16 women with confirmed pH1N1 infection, 14 women vaccinated against pH1N1, and 10 women without infection or vaccination. We found that pH1N1 vaccination and wild-type infection during pregnancy did not differ with respect to (1) HAI titers at delivery, (2) HAI antibody decay slopes over time, and (3) HAI titers in the cord blood. Conclusions Vaccination against pH1N1 confers a similar HAI antibody response as compared to pH1N1 infection during pregnancy, both in quantity and quality. Illness or vaccination during pregnancy confers passive immunity to the newborn.

Rate of Change in Cervical Length in Women With Vaginal Bleeding During Pregnancy

OBJECTIVE: To evaluate whether women with known risk factors for preterm birth will manifest different rates of cervical shortening preceding a spontaneous preterm birth. METHODS: We conducted a secondary analysis of data from the Maternal--Fetal Medicine Units Network Preterm Prediction Study. Known risk factors for preterm birth were recorded. Cervical lengths were measured between 22+0 weeks and 24+6 weeks, and again 4 weeks later. Cervical slope was defined as the change in cervical length between these visits divided by time (millimeters per week). Preterm birth was defined as preterm premature rupture of membranes or spontaneous preterm labor leading to delivery before 37 weeks of gestation. We analyzed the data for 2,584 women using logistic regression and tested for interaction between risk factors in the model to determine whether cervical shortening preceded preterm births in all variable groups. RESULTS: Cervical slope was not significantly associated with preterm birth (P=.9) in women with vaginal bleeding. Cervical slope was significantly associated with preterm birth in women without a history of vaginal bleeding (odds ratio 1.2, 95% confidence interval 1.1–1.4). CONCLUSIONS: Pregnancies without vaginal bleeding have a 20% increase in the risk of preterm birth for each additional millimeter per week increase in cervical slope. Pregnancies with vaginal bleeding are at risk for preterm birth but do not appear to undergo progressive cervical shortening. This suggests that women with vaginal bleeding undergo a different mechanism leading to preterm birth. LEVEL OF EVIDENCE: II

Intrapartum management of premature rupture of membranes: effect on cesarean delivery rate.

OBJECTIVE: To estimate whether it is possible to define clinically a subgroup of women who have so high a cesarean delivery rate as to avoid spontaneous onset of labor or induced labor. METHODS: We conducted a retrospective cohort study (October 2005 to January 2010) on a data set of women who had premature rupture of membranes (PROM) at greater than 24 weeks of gestation, a singleton pregnancy, and a viable fetus without congenital anomalies. Patients were treated in a common way regarding indications for delivery. The primary outcome was cesarean delivery. RESULTS: We identified 1,026 women (comprising 7.9% of all deliveries) who had PROM and met the inclusion criteria. There were 404 with preterm deliveries. One hundred thirty-seven (13.4%) had a contraindication to either labor or vaginal delivery. For women with induction (n=355), vaginal delivery occurred in 82%, whereas for those with spontaneous labor (n=534), vaginal delivery occurred in 87% (P=.03). No clinically defined subgroup had an observed cesarean delivery rate greater than 27%, and in most subgroups, it was lower, even when we built in multiple risk factors, including gestational age less than 34 weeks, chorioamnionitis, abruption, and nulliparity. CONCLUSION: In the absence of a contraindication to labor or to vaginal delivery, the likelihood of vaginal delivery after PROM, with either spontaneous or induced labor, is high, even when we included multiple risk factors for cesarean delivery. LEVEL OF EVIDENCE: II

Development and psychometric properties of a violence screening tool for primary care.

PURPOSE The aim of this study was to develop and validate a screening tool to detect youth at risk for future violence perpetration for primary care. METHODS Youth (n = 165) aged 11-17 years enrolled during a primary care appointment. Two clinics served as study sites. Youth filled out questionnaires confidentially at baseline and at 1-year follow-up. Primary outcome was violent behavior during the preceding year. At baseline, youth answered 18 risk and protective factor questions that predicted future violence involvement. Additional violence scales were asked for a total of 47 questions. Item analysis determined which combination best predicted future violence involvement. Psychometric properties, including internal consistency, test-retest reliability, convergent validity, and predictive validity, were analyzed. RESULTS A total of 101 youth (61%) completed 1-year follow-up: 16% reported violent behavior with no difference between gender or race/ethnicity. Twenty-five baseline questions correlated with violence involvement 1 year later. After item analysis, 14 questions demonstrated the strongest psychometric functioning with Cronbachs α = .77. External validity was strong, with the 14 item violence injury protection and risk screen correlating with the aggression (.74) and victimization (.54) scales, the Strength and Difficulties Questionnaire (.39), and current violence involvement (.78). For youth aged 14-17 years, predictive validity was strongly correlated (.78) with future violence perpetration. A score of 5.0 for males and 6.0 for females revealed a sensitivity of 77%, a specificity of 98%, and a positive predictive value of 91%. Seventeen percent of youth aged 14-17 screened positive using these cutpoints. CONCLUSION A brief, 14-item questionnaire demonstrated strong psychometric functioning and performed well as a screening tool to predict future violence perpetration for youth aged 14-17.

Prevalence and descriptive analysis of congenital heart disease in parturients: obstetric, neonatal, and anesthetic outcomes ☆

STUDY OBJECTIVE The study objectives are to (1) assess prevalence of congenital heart disease (CHD), (2) describe outcomes of pregnancies in women with CHD, (3) compare outcomes in women with and without CHD, and (4) characterize neonatal outcomes in pregnancies complicated by CHD. DESIGN This was a retrospective cohort study of women who delivered at the University of Colorado Hospital. Diagnosis of CHD was identified based on history of cardiac disease, pulmonary disease, or subacute bacterial endocarditis prophylaxis during labor and confirmed with echocardiogram when available. Comprehensive retrospective review of anesthetic, obstetric, and neonatal outcomes was performed. SETTING University of Colorado Hospital. PATIENTS 18,226 women. INTERVENTIONS Medical record review. MEASUREMENTS Valvular abnormalities, New York Heart Failure Association classification scores, types of CHD, maternal age, race, gravidity, parity, maternal prepregnancy body mass index, cigarette use, type of delivery, type of analgesia used, early initiation of neuraxial analgesia, arrhythmias, need for peripartum diuretics, prolonged maternal hospital stay, preterm birth, small for gestational age, neonatal CHD, neonatal or maternal intensive care unit (ICU) admissions, and maternal or neonatal death. MAIN RESULTS We identified 117 pregnancies in 110 women with CHD. Parturients with CHD were more likely to have operative vaginal delivery (P < .0001), neonatal ICU admissions (P = .003), and had prolonged hospital stays. Occurrence of CHD in neonates was 6%. Moderate-to-severe valvular disease was associated with increased rates of operative vaginal delivery, early initiation of neuraxial labor analgesia, cardiac complications (including arrhythmia and use of diuretics), prolonged hospital stay, and maternal ICU admission. However, most deliveries and births were uncomplicated; and there were one case each of maternal mortality and fetal death after birth. CONCLUSION Operative abdominal deliveries and neonatal ICU admissions are more common in women with CHD, but these pregnancies are generally well tolerated with low mortality rates.