Kimberly Fortner

Bacteria Localization and Chorion Thinning among Preterm Premature Rupture of Membranes

Objective Bacterial colonization of the fetal membranes and its role in pathogenesis of membrane rupture is poorly understood. Prior retrospective work revealed chorion layer thinning in preterm premature rupture of membranes (PPROM) subjects. Our objective was to prospectively examine fetal membrane chorion thinning and to correlate to bacterial presence in PPROM, preterm, and term subjects. Study Design Paired membrane samples (membrane rupture and membrane distant) were prospectively collected from: PPROM = 14, preterm labor (PTL = 8), preterm no labor (PTNL = 8), term labor (TL = 10), and term no labor (TNL = 8), subjects. Sections were probed with cytokeratin to identify fetal trophoblast layer of the chorion using immunohistochemistry. Fluorescence in situ hybridization was performed using broad range 16 s ribosomal RNA probe. Images were evaluated, chorion and choriodecidua were measured, and bacterial fluorescence scored. Chorion thinning and bacterial presence were compared among and between groups using Students t-test, linear mixed effect model, and Poisson regression model (SAS Cary, NC). Results In all groups, the fetal chorion cellular layer was thinner at rupture compared to distant site (147.2 vs. 253.7 µm, p<0.0001). Further, chorion thinning was greatest among PPROM subjects compared to all other groups combined, regardless of site sampled [PPROM(114.9) vs. PTL(246.0) vs. PTNL(200.8) vs. TL(217.9) vs. TNL(246.5)]. Bacteria counts were highest among PPROM subjects compared to all other groups regardless of site sampled or histologic infection [PPROM(31) vs. PTL(9) vs. PTNL(7) vs. TL(7) vs. TNL(6)]. Among all subjects at both sites, bacterial counts were inversely correlated with chorion thinning, even excluding histologic chorioamnionitis (p<0.0001 and p = 0.05). Conclusions Fetal chorion was uniformly thinner at rupture site compared to distant sites. In PPROM fetal chorion, we demonstrated pronounced global thinning. Although cause or consequence is uncertain, bacterial presence is greatest and inversely correlated with chorion thinning among PPROM subjects.

Maternal Immunization: Opportunities for Scientific Advancement

Maternal immunization is an effective strategy to prevent and/or minimize the severity of infectious diseases in pregnant women and their infants. Based on the success of vaccination programs to prevent maternal and neonatal tetanus, maternal immunization has been well received in the United States and globally as a promising strategy for the prevention of other vaccine-preventable diseases that threaten pregnant women and infants, such as influenza and pertussis. Given the promise for reducing the burden of infectious conditions of perinatal significance through the development of vaccines against relevant pathogens, the Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH) sponsored a series of meetings to foster progress toward clinical development of vaccines for use in pregnancy. A multidisciplinary group of stakeholders convened at the NIH in December 2013 to identify potential barriers and opportunities for scientific advancement in maternal immunization.

Influenza and tetanus, diphtheria, and acellular pertussis vaccinations during pregnancy

&NA; Vaccinations in pregnancy are an important aspect of prenatal care and of improving not only maternal health but also neonatal outcomes. Only 2 vaccines are specifically recommended during pregnancy: influenza and tetanus, diphtheria, and acellular pertussis (Tdap). &NA; Because influenza illness disproportionately affects pregnant women compared with other populations, annual prevention of influenza illness is recommended for all women who will be pregnant during influenza season (October to May). Influenza vaccination has been recently reported to also result in decreased febrile respiratory illnesses in the newborn, likely through passive antibody transfer. &NA; Pertussis infection rates are rising in the United States as vaccine-induced immunity wanes, with the mortality burden primarily seen in infants aged <6 months. Pertussis immunization with Tdap is now recommended for all pregnant women during the late second (>20 weeks) or third trimester with the intent to both protect the pregnant woman and provide passive antibody to the infant before vaccination at 2 months of age. &NA; Provider support for these recommendations regarding both annual influenza vaccination and postpartum Tdap vaccination during pregnancy is critical to ensuring vaccine delivery and improving both maternal and fetal health. The article reviews the epidemiology and clinical aspects of influenza and pertussis infection with particular attention to pregnancy and recommendations for vaccination in these women. Target Audience: Obstetricians and gynecologists, ophthalmologists, neurologists, family physicians, emergency room physicians Learning Objectives: After completing this CME activity, obstetricians and gynecologists should be better able to analyze how influenza infection disproportionally affects pregnant women. Assess how influenza vaccination improves maternal and likely neonatal outcomes. Evaluate pertussis infection and immunity in adults, and counsel pregnant women as to the benefits of Tdap vaccination, particularly for the infant.

Cervical dilation as a predictor of pregnancy outcome following emergency cerclage

Objective: To determine whether cervical dilation at the time of physical examination indicated cerclage placement can predicts latency and gestational age at delivery. Methods: A retrospective cohort study of all women who underwent physical examination indicated cerclage placement from 1996 to 2011 at Duke University Hospital (DUH) was performed. Physical examination indicated cerclage was defined as cerclage placement after 16 weeks in women with a cervical length of less than 2.5 cm and/or cervical dilation greater than or equal to 1 cm at time of procedure. Subjects were divided into two groups depending on cervical dilation at time of procedure (≥2 cm, <2 cm) for comparison. A multivariate linear regression model for the outcome gestational age of delivery was constructed, controlling for confounding variables. Results: A total of 110 women with complete data were available for analysis. Median gestational age at cerclage placement was similar between the two groups (20.3 vs. 20.3 weeks, p = 0.8). Women with cervical dilatation ≥2 cm dilation delivered at an earlier median gestational age than women with cervical dilation <2 cm (27.0 vs. 35.6 weeks, p < 0.001). Cervical dilation at the time of cerclage placement independently predicted gestational age at delivery while controlling for use of intracervical Foley balloon catheter for membrane reduction, cerclage suture type, history of prior preterm birth, race, insurance status, and tobacco use. Conclusions: Women who receive a rescue cerclage are more likely to deliver at an earlier gestational age when cervical dilation is ≥2 cm at the time of procedure.

Maternal BMI, IGF-I Levels, and Birth Weight in African American and White Infants.

At birth, elevated IGF-I levels have been linked to birth weight extremes; high birth weight and low birth weight are risk factors for adult-onset chronic diseases including obesity, cardiovascular disease, and type 2 diabetes. We examined associations between plasma IGF-I levels and birth weight among infants born to African American and White obese and nonobese women. Prepregnancy weight and height were assessed among 251 pregnant women and anthropometric measurements of full term infants (≥37 weeks of gestation) were taken at birth. Circulating IGF-I was measured by ELISA in umbilical cord blood plasma. Linear regression models were utilized to examine associations between birth weight and high IGF-I, using the bottom two tertiles as referents. Compared with infants with lower IGF-I levels (≤3rd tertile), those with higher IGF-I levels (>3rd tertile) were 130 g heavier at birth, (β-coefficient = 230, se = 58.0, P = 0.0001), after adjusting for gender, race/ethnicity, gestational age, delivery route, maternal BMI and smoking. Stratified analyses suggested that these associations are more pronounced in infants born to African American women and women with BMI ≥30 kg/m2; the cross product term for IGF-I and maternal BMI was statistically significant (P ≤ 0.0004). Our findings suggest that the association between IGF-I levels and birth weight depends more on maternal obesity than African American race/ethnicity.

Infant follow-up postdelivery from a hepatitis C viral load positive mother

Abstract Objective: The primary current recommendation for infant follow-up postdelivery from a hepatitis C virus (HCV) viral load positive mother is to evaluate for the presence of antibody at or after 18 months of age. Our study objective was to analyze compliance with this recommendation for postdelivery infant HCV screening at our institution among a cohort of infants delivered from HCV viral load positive mothers. Methods: Starting 1 January, 2015, a prospective database was developed for all pregnancies that involved mothers with a positive HCV viral load during pregnancy. This short report describes the infant follow-up for deliveries through 30 June, 2016. At hospital discharge, all neonates were given follow-up pediatric appointments and mothers were supplied the date and time of the appointment along with the pediatric group name, office directions, and phone number. Statistics involved simple percentages with Poisson binomial 95% confidence intervals. Results: A total of 127 newborns were delivered of HCV viral load positive mothers during the study period and 55 (43%, 95% CI 35–52%) attended their pediatric appointments and were still in follow-up. Regarding the 72 cases (57%, 95% CI 48–65%) not in follow-up, 24 (19%, 95% CI 13–27%) never presented to care and 48 (38%, 95% CI 29–47%) came to one or two visits shortly after delivery but were absent for further follow-up. Conclusions: These data demonstrate that follow-up at 18 months postdelivery from an HCV viral load positive mother occurs in less than half of the cases and alternative screening strategies should be evaluated.

Empirical Studies Addressing the Opioid Epidemic: An Urgent Call for Research

Opioid misuse has become one of the most pressing public health problems facing the country. In this article, we briefly review literature regarding the opioid epidemic in the United States and the negative consequences of opioid use disorder. We provide information regarding treatment and relapse using a variety of intervention approaches. We call for research on people with opioid use disorder that can contribute to a variety of areas: improving medication-assisted treatment, addressing chronic pain, examination of adjunctive behavioral interventions, overdose, high risk behaviors and infections, pregnancy, diverse populations, and other psychological factors. Collectively addressing these crucial areas of research will advance the field and help alleviate suffering and prevent death from opioid use disorder.

Infections in Pregnancy and the Role of Vaccines

Pregnant women are at risk for infection and may have significant morbidity or mortality. Influenza, pertussis, zika, and cytomegalovirus produce mild or asymptomatic illness in the mother, but have profound implications for her fetus. Maternal immunization can prevent or mitigate infections in pregnant women and their infants. The Advisory Committee of Immunization Practices recommends 2 vaccines during pregnancy: inactivated influenza, and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis during pregnancy. The benefits of MMR, varicella, and other vaccines are reviewed. Novel vaccine studies for use during pregnancy for prevention of illness are explored.

Rate of histologic chorioamnionitis among parturients with intrapartum fever

to better understand care and referral of pregnant women with suspected and confirmed ZIKV infection. CONCLUSIONS: Tools are currently in use in five countries and results will inform recommended referral pathways for pregnant women with suspected and confirmed cases of ZIKV infection. Surveys will continue to be updated based on user experience as part of ongoing QI programs. Ultimately, these tools will be available in a variety of settings for use by Ministries of Health and/or Social Welfare for adaptation as a supervision checklist and use outside of this program.

High prevalence of Group B Streptococcus colonization among pregnant women in amman, jordan

14 High prevalence of Group B Streptococcus colonization among pregnant women in amman, jordan Kate Clouse, Asem Shehabi, Abel Mani Suleimat, Samir Faouri, Najwa Khuri-Bulos, James Chappell, Kimberly B. Fortner, David M. Aronoff, Natasha Halasa Vanderbilt University Department of Medicine, Division of Infectious Diseases, Nashville, TN, University of Jordan, Amman, Jordan, Al-Bashir Hospital, Amman, Jordan, Vanderbilt University Department of Pathology, Nashville, TN, Vanderbilt University Department of Obstetrics and Gynecology, Nashville, TN, Vanderbilt University Department of Pediatrics, Nashville, TN OBJECTIVES: To conduct a pilot study to determine the prevalence of GBS among pregnant women in Amman, Jordan, where Group B Streptococcus (GBS) testing is not routine. METHODS: We collected rectal/vaginal swabs from women who presented in labor at Al-Bashir Hospital, a large government-run hospital in Amman, Jordan. Three methods were used to identify GBS: Strep B Rapid Test (Creative Diagnostics), blood agar media (Remel) with confirmed with BBL Streptocard acid latex test (Becton Dickinson), and CHROMagar StrepB (Remel). Results were read by a local microbiologist. We defined gold standard for GBS+ as a positive blood agar culture confirmed by latex agglutination and positive CHROMagar. Demographic and clinical data were also collected. We present proportions for categorical variables and medians and interquartile ranges (IQR) for continuous variables. RESULTS: In April and May 2015, 200 women were enrolled at a median age of 27 years (IQR: 23-32); 88.9% were Jordanian nationals and 71.9% completed secondary school. Median gestational age was 38 weeks (IQR: 37-40) and nearly all women reported prenatal care (median 9 visits; IQR: 8-12). Pre-pregnancy median BMI was 24.1 (IQR: 21.5-28.0) and 15.5% reported an underlying medical condition. Median gravidity was 3 pregnancies (IQR: 2-5) and parity was 2 births (IQR: 1-3). Obstetric complications included gestational hypertension (9.5%), gestational diabetes (6.0%), and UTI (53.5%), of which 84.5% reported treatment. Overall, 39 (19.5%) of women were positive for GBS on blood agar media and CHROMagar, while 67 (33.5%) were positive by rapid test (36% sensitivity, 67% specificity). No demographic or clinical differences were noted between GBS+ and GBS-negative women. Penicillin allergy was reported in 5.0%. CONCLUSIONS: A high proportion of women presenting for labor at Al-Bashir were colonized with GBS. The rapid diagnostic was less sensitive and specific than culture. These results support expanded research in the region, including defining the GBS resistance patterns, serotyping information, and risk factors. It also emphasizes the need for improved rapid GBS diagnostics for developing world settings.