Jan M. Kriebs

Understanding Herpes Simplex Virus: Transmission, Diagnosis, and Considerations in Pregnancy Management

Genital herpes simplex virus (HSV) infections are frequently asymptomatic or undiagnosed, but more than half the US population is seropositive for HSV, and about one-fifth are positive for HSV-2. These two factors contribute to the risk for sexual transmission and therefore to the risk of late-pregnancy acquisition of HSV. Most neonatal herpes infections are the result of undiagnosed, new-onset HSV infection in the mother. This article reviews the epidemiology of HSV, risks of transmission, and testing and management of HSV during pregnancy. Options for evaluation and management are presented.

Predictors of fetal growth in maternal HIV disease

We sought to determine predictors of fetal growth restriction in maternal HIV disease. Pregnant HIV-positive women on antiretroviral therapy were monitored with serial viral load and CD4 counts. Individualized growth potential (GP) percentile was calculated for birth weight (BW). BW <10th GP percentile defined fetal growth restriction (FGR). Multiple medical and social factors, CD4 count, viral load, and antiretroviral therapy were tested for impact on fetal growth using chi-square and multiple regression analysis. Two hundred eleven women were studied. CD4 count <200 in the first trimester was strongly associated with FGR (odds ratio 8.75, 95% confidence interval 2.88 to 26.52). Maternal age ( P = 0.02) and smoking ( P = 0.03) were independent cofactors for FGR (Nagelkerke R(2) = 0.33). No other factors demonstrated an independent effect. Severity of maternal HIV disease as indicated by the CD4 count, rather than placental exposure to viral load, predicts FGR. Smoking has an independent detrimental effect on fetal growth.

Obesity as a complication of pregnancy and labor.

Over the last 40 years, there have been significant increases in the rates of overweight and obesity in childbearing women. There has been a parallel increase in the rates of pregnancy complications including hypertension, diabetes, fetal macrosomia, and complications of delivery. Caregivers can focus on appropriate interventions during pregnancy and childbirth to improve outcomes and prevent harm.

Obesity in pregnancy: addressing risks to improve outcomes.

The rapidly increasing rates of obesity among women of childbearing age, not only in the United States but also across the globe, contribute to increased risks during pregnancy and childbirth. Overweight and obesity are quantified by body mass index (BMI) for clinical purposes. In 2010, 31.9% of US women aged 20 to 39 years met the definition of obesity, a BMI of 30 kg/m2 or greater. Across the life span, obesity is associated with increased risks of hypertension, cardiovascular disease, diabetes, sleep apnea, and other diseases. During pregnancy, increasing levels of prepregnancy BMI are associated with increases in both maternal and fetal/neonatal risks. This article reviews current knowledge about obesity in pregnancy and health risks related to increased maternal BMI, addresses weight stigma as a barrier to care and interventions that have evidence of benefit, and discusses the development of policies and guidelines to improve care.

Methicillin-resistant Staphylococcus aureus infection in the obstetric setting.

Methicillin-resistant Staphylococcus aureus (MRSA) is an increasingly prevalent pathogen, both in the community and in hospitalized patients. The virulence of MRSA, coupled with its resistance to many frequently prescribed antibiotics, requires increased vigilance in the assessment and diagnosis of skin and soft tissue infections. This article reviews the epidemiology of MRSA and focuses on treatment of MRSA when it is diagnosed during pregnancy.

The global reach of HIV: preventing mother-to-child transmission.

This article focuses on the effects of the worldwide human immunodeficiency virus (HIV) epidemic on the lives of pregnant women and their infants in the developing world. It discusses the natural history of mother-to-child transmission (MTCT) in HIV, including the role of breastfeeding and the effectiveness of various treatment/prevention schemes in resource-poor communities. Although the treatment schemes are not the same as those used in North America, the underlying principles of transmission are the same. Understanding the mechanisms of MTCT and recognizing the benefits of even short-term therapies can promote appropriate interventions when complete perinatal antiretroviral therapy is impossible.

Staphylococcus Infections in Pregnancy: Maternal and Neonatal Risks.

Staphylococcus aureus is carried by up to one third of the general population; about 2% are carriers for methicillin-resistant S. aureus (MRSA). Infections caused by the antibiotic-resistant form include skin and soft tissue infections, as well as pneumonia, sepsis, and wound infections. Although the risks of hospital-associated systemic infections have decreased with attention to infection control procedures, serious obstetric illness remains a concern. This article describes the range of MRSA infection in the setting of pregnancy and discusses risks to both mother and newborn associated with active MRSA infection during pregnancy and childbirth. Methicillin-resistant S. aureus remains a risk to mothers and newborns, requiring prompt identification and appropriate management.

Infectious diseases in pregnancy: issues of screening, prevention, and treatment.

Infectious disease recommendations that play a part in care during birth, or among hospitalized antepartum women, are updated with new information as evidence becomes available. At the time of hospitalization during pregnancy, attention to testing and treatment can prevent the transmission of infections to the newborn, can improve the management of the mothers health, and is an increasingly important aspect of patient safety initiatives. Obstetric and perinatal nurses who are aware of current recommendations play a critical role in disease prevention. This article discusses issues that are relevant for maternal child healthcare practitioners. Examples are used to illustrate concerns of particular importance during pregnancy, such as antibiotic-resistant infections, vaccine-preventable illness, and testing for infectious diseases.

Patient safety during induction of labor.

Rates of induction of labor have risen rapidly since 1990, from 9.6% in that year to a peak of 23.8% of the 2010 singleton births in the United States. Even as the definition of term pregnancy has been refined to reflect the continuing maturation needs of the fetus, and mothers have been encouraged to “go the full forty,” management strategies for pregnancy conditions that increase risk have included early induction. Labor induction should only be undertaken when there are specific indications for interrupting the normal processes of pregnancy. These indications may relate to maternal, fetal, or placental conditions or simply reflect the understanding that in all pregnancies, the placenta will eventually lose its ability to adequately provide oxygen, nutrition, and waste removal for the fetus. Patient safety—for both the mother and the child—can be improved when clinicians practice within clinical guidelines that follow the best available evidence and women are able to make informed decisions regarding plans for labor.

Protease inhibitor therapy and fetal growth potential in HIV-positive women

Our objective was to test if protease inhibitors (PIs) increase the incidence of fetal growth restriction (FGR). Human immunodeficiency (HIV)-seropositive women were studied. At birth the neonatal weight percentile was assigned by predicted growth potential (GP), accounting for race, parity, weight, height, gestational age, birthweight, and gender (Gardosi, 1992). FGR was defined as GP < 10% percentile. Maternal age, CD4 count, viral load, weight gain, prenatal care, tobacco, alcohol, substance abuse, and PI use were related to FGR using chi-square and multiple regression analysis. Ninety-three of 191 women received PI. In these, FGR occurred in 27 (29%) compared with 15 (15.3%) in the non-PI group ( P = 0.02). Maternal CD4 count ( P < 0.0001) was the primary determinant, and smoking ( P = 0.037) was an independent cofactor for FGR (Nagelkerke r2 = 0.24). Twenty-six of 82 (31.7%) smokers had FGR, versus 16 of 109 (14.7%) of nonsmokers (odds ratio, 2.69; 95% confidence interval, 1.33 to 5.46; P = 0.005). After exclusion of the CD4 count, PI became a cofactor for FGR ( P = 0.021 and Nagelkerke r2 = 0.104). We concluded that maternal HIV status and smoking determine the risk for FGR. Although PIs increase the risk for FGR, this effect appears to depend on maternal disease severity.