Laura E. Riley

The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries.

BACKGROUND: In this study, we sought to (1) define trends in the incidence of postpartum hemorrhage (PPH), and (2) elucidate the contemporary epidemiology of PPH focusing on risk factors and maternal outcomes related to this delivery complication. METHODS: Hospital admissions for delivery were extracted from the Nationwide Inpatient Sample, the largest discharge dataset in the United States. Using International Classification of Diseases, Clinical Modification (ninth revision) codes, deliveries complicated by PPH were identified, as were comorbid conditions that may be risk factors for PPH. Temporal trends in the incidence of PPH from 1995 to 2004 were assessed. Logistic regression was used to identify risk factors for the most common etiology of PPH—uterine atony. RESULTS: In 2004, PPH complicated 2.9% of all deliveries; uterine atony accounted for 79% of the cases of PPH. PPH was associated with 19.1% of all in-hospital deaths after delivery. The overall rate of PPH increased 27.5% from 1995 to 2004, primarily because of an increase in the incidence of uterine atony; the rates of PPH from other causes including retained placenta and coagulopathy remained relatively stable during the study period. Logistic regression modeling identified age <20 or ≥40 years, cesarean delivery, hypertensive diseases of pregnancy, polyhydramnios, chorioamnionitis, multiple gestation, retained placenta, and antepartum hemorrhage as independent risk factors for PPH from uterine atony that resulted in transfusion. Excluding maternal age and cesarean delivery, one or more of these risk factors were present in only 38.8% of these patients. CONCLUSION: PPH is a relatively common complication of delivery and is associated with substantial maternal morbidity and mortality. It is increasing in frequency in the United States. PPH caused by uterine atony resulting in transfusion often occurs in the absence of recognized risk factors.

Addressing Obesity in Pregnancy: What Do Obstetric Providers Recommend?

OBJECTIVE Maternal obesity is associated with adverse pregnancy outcomes. To improve outcomes, obstetric providers must effectively evaluate and manage their obese pregnant patients. We sought to determine the knowledge, attitudes, and practice patterns of obstetric providers regarding obesity in pregnancy. METHODS In 2007-2008, we surveyed 58 practicing obstetricians, nurse practitioners, and certified nurse-midwives at a multispecialty practice in Massachusetts. We administered a 26-item questionnaire that included provider self-reported weight, sociodemographic characteristics, knowledge, attitudes, and management practices. We created an 8-point score for adherence to 8 practices recommended by the American College of Obstetricians and Gynecologists (ACOG) for the management of obese pregnant women. RESULTS Among the respondents, 37% did not correctly report the minimum body mass index (BMI) for diagnosing obesity, and most reported advising gestational weight gains that were discordant with 1990 Institute of Medicine (IOM) guidelines, especially for obese women (71%). The majority of respondents almost always recommended a range of weight gain (74%), advised regular physical activity (74%), or discussed diet (64%) with obese mothers, but few routinely ordered glucose tolerance testing during the first trimester (26%), planned anesthesia referrals (3%), or referred patients to a nutritionist (14%). Mean guideline adherence score was 3.4 (SD 1.9, range 0-8). Provider confidence (beta = 1.0, p = 0.05) and body satisfaction (beta = 1.5, p = 0.02) were independent predictors of higher guideline adherence scores. CONCLUSIONS Few obstetric providers were fully compliant with clinical practice recommendations, defined obesity correctly, or recommended weight gains concordant with IOM guidelines. Provider personal factors were the strongest correlates of self-reported management practices. Our findings suggest a need for more education around BMI definitions and weight gain guidelines, along with strategies to address provider personal factors, such as confidence and body satisfaction, that may be important predictors of adherence to recommendations for managing obese pregnant women.

Putting the “M” back in maternal–fetal medicine

Although maternal death remains rare in the United States, the rate has not decreased for 3 decades. The rate of severe maternal morbidity, a more prevalent problem, is also rising. Rise in maternal age, in rates of obesity, and in cesarean deliveries as well as more pregnant women with chronic medical conditions all contribute to maternal mortality and morbidity in the United States. We believe it is the responsibility of maternal-fetal medicine (MFM) subspecialists to lead a national effort to decrease maternal mortality and morbidity. In doing so, we hope to reestablish the vital role of MFM subspecialists to take the lead in the performance and coordination of care in complicated obstetrical cases. This article will summarize our initial recommendations to enhance MFM education and training, to establish national standards to improve maternal care and management, and to address critical research gaps in maternal medicine.

Acute Histologic Chorioamnionitis at Term: Nearly Always Noninfectious

Background The link between histologic acute chorioamnionitis and infection is well established in preterm deliveries, but less well-studied in term pregnancies, where infection is much less common. Methodology/Principal Findings We conducted a secondary analysis among 195 low-risk women with term pregnancies enrolled in a randomized trial. Histologic and microbiologic evaluation of placentas included anaerobic and aerobic cultures (including mycoplasma/ureaplasma species) as well as PCR. Infection was defined as ≥1,000 cfu of a single known pathogen or a ≥2 log difference in counts for a known pathogen versus other organisms in a mixed culture. Placental membranes were scored and categorized as: no chorioamnionitis, Grade 1 (subchorionitis and patchy acute chorioamnionitis), or Grade 2 (severe, confluent chorioamnionitis). Grade 1 or grade 2 histologic chorioamnionitis was present in 34% of placentas (67/195), but infection was present in only 4% (8/195). Histologic chorioamnionitis was strongly associated with intrapartum fever >38°C [69% (25/36) fever, 26% (42/159) afebrile, P<.0001]. Fever occurred in 18% (n = 36) of women. Most febrile women [92% (33/36)] had received epidural for pain relief, though the association with fever was present with and without epidural. The association remained significant in a logistic regression controlling for potential confounders (OR = 5.8, 95% CI = 2.2,15.0). Histologic chorioamnionitis was also associated with elevated serum levels of interleukin-8 (median = 1.3 pg/mL no histologic chorioamnionitis, 1.5 pg/mL Grade 1, 2.1 pg/mL Grade 2, P = 0.05) and interleukin-6 (median levels = 2.2 pg/mL no chorioamnionitis, 5.3 pg/mL Grade 1, 24.5 pg/mL Grade 2, P = 0.02) at admission for delivery as well as higher admission WBC counts (mean = 12,000cells/mm3 no chorioamnionitis, 13,400cells/mm3 Grade 1, 15,700cells/mm3 Grade 2, P = 0.0005). Conclusion/Significance Our results suggest histologic chorioamnionitis at term most often results from a noninfectious inflammatory process. It was strongly associated with fever, most of which was related to epidural used for pain relief. A more ‘activated’ maternal immune system at admission was also associated with histologic chorioamnionitis.

Uptake of influenza vaccine in pregnant women during the 2009 H1N1 influenza pandemic

The goals of this study were to define the uptake of H1N1 and seasonal influenza vaccination during pregnancy among women delivering during the 2009 H1N1 pandemic and explore barriers to vaccination. All postpartum women at the Massachusetts General Hospital from January 2010 through March 2010 were invited to complete an anonymous questionnaire about demographics, vaccination status, and attitudes about vaccination during pregnancy. Among 370 participants (53% response rate), 81% accepted both the H1N1 and seasonal influenza vaccines during pregnancy. Patients who declined one or both vaccines cited concerns over safety as a major deterrent. Of the 36% of participants who reported having flu-like symptoms during this pregnancy only 8.6% took oseltamivir. While a high vaccination rate was identified in this study, further education is needed to reassure patients regarding vaccine safety. Education for providers and patients emphasizing the benefits of early treatment of pregnant women with flu-like symptoms should be a priority.

Association of epidural-related fever and noninfectious inflammation in term labor.

OBJECTIVE: To investigate the role of infection and noninfectious inflammation in epidural analgesia-related fever. METHODS: This was an observational analysis of placental cultures and serum admission and postpartum cytokine levels obtained from 200 women at low risk recruited during the prenatal period. RESULTS: Women receiving labor epidural analgesia had fever develop more frequently (22.7% compared with 6% no epidural; P=.009) but were not more likely to have placental infection (4.7% epidural, 4.0% no epidural; P>.99). Infection was similar regardless of maternal fever (5.4% febrile, 4.3% afebrile; P=.7). Median admission interleukin (IL)-6 levels did not differ according to later epidural (3.2 pg/mL compared with 1.6 pg/mL no epidural; P=.2), but admission IL-6 levels greater than 11 pg/mL were associated with an increase in fever among epidural users (36.4% compared with 15.7% for 11 pg/mL or less; P=.008). At delivery, both febrile and afebrile women receiving epidural had higher IL-6 levels than women not receiving analgesia. CONCLUSION: Epidural-related fever is rarely attributable to infection but is associated with an inflammatory state. LEVEL OF EVIDENCE: II

Herpes Simplex Virus

Herpes simplex virus (HSV) infection is prevalent worldwide. Herpes labialis, caused predominantly by HSV-1, and herpes vulvovaginitis, caused predominantly by HSV-2, may result in significant morbidity and mortality for infected neonates exposed during delivery. The diagnosis of HSV infection is made by serological testing, viral culture, or polymerase chain reaction. Women with primary herpes vulvovaginitis exhibit a painful vesicular rash which is self-limited but may be followed by multiple recurrences. Women at greatest risk to transmit HSV to their neonates are those who experience their first episode of HSV during the latter stage of pregnancy. If infected, their neonates may have localized skin, eye and mucosal lesions, invasive central nervous system infection, or disseminated disease. Because of the potentially devastating outcome for a baby infected with HSV, pregnant women with active HSV lesions at delivery should be offered a cesarean section. Still, many neonates who are infected with HSV are born to women with asymptomatic HSV shedding. Therefore, prevention of HSV during pregnancy is exceedingly important.

ISUOG Interim Guidance on ultrasound for Zika virus infection in pregnancy: information for healthcare professionals

In response to the World Health Organization (WHO) statements and international concerns regarding the Zika virus (ZIKV) outbreak, ISUOG is publishing the following guidance for ultrasound during pregnancy. With the current uncertainty regarding many aspects of the diagnosis and clinical course of ZIKV infection in pregnancy, potentially valuable information may be obtained by ultrasound practitioners that may help in counseling pregnant women and further improve our understanding of the pathophysiology of ZIKV infection in pregnancy. This statement is not intended to replace previously published interim guidance on evaluation and management of ZIKV-exposed pregnant women. It should therefore be considered in conjunction with other relevant advice from organizations such as:

Ensuring the Safe and Effective Use of Medications During Pregnancy: Planning and Prevention Through Preconception Care

Whether to use a medication during pregnancy can be a concern for both women and health care providers. It has been estimated that up to 10% of congenital anomalies may be caused by environmental exposures–that is, exposures to medications, alcohol, or other exogenous factors that have adverse effects on the developing embryo or fetus [1]. Avoiding all potentially adverse exposures can prevent these adverse effects. However, it is not always possible to avoid taking medications during pregnancy. Women who are pregnant continue to experience short-term and long-term health conditions that must be managed. Discontinuing treatment of a serious condition when a woman becomes pregnant can have profound, long-term implications both for her health and that of her baby. In a retrospective study from eight health maintenance organizations, researchers estimated that approximately 59% of pregnant women were prescribed a medication other than a vitamin or mineral supplement at some time during pregnancy [2]. Use of over-the-counter medications during pregnancy may be even higher, and many women take a dietary or herbal supplement other than multivitamins or folic acid while pregnant [3, 4]. Preconception care provides the opportunity to optimize a woman’s use of medications in preparation for pregnancy. Such care includes identifying patterns of medication use before pregnancy occurs; adjusting those patterns to avoid the use of nonessential medications; minimizing exposure to medications known to be harmful to the embryo or fetus; and adjusting the dose, route of administration, and timing of essential treatments to optimize maternal health at each stage of pregnancy while safeguarding the embryo, fetus, and infant. In this paper, we summarize the basic principles of teratology and the current state of knowledge about the effects of medication use during pregnancy; outline basic components of preconception care that can help minimize the risk of birth defects; and provide examples of approaches to planning for the safe and effective use of medications during pregnancy through preconception care.

Use of the combined tetanus-diphtheria and pertussis vaccine during pregnancy.

OBJECTIVE A recent increase in pertussis cases prompted the Advisory Committee on Immunization Practices to recommend administering the perinatal tetanus, diphtheria, and pertussis (Tdap) vaccine during each pregnancy. We sought to describe uptake of Tdap and identify predictors of vaccination in pregnancy. STUDY DESIGN We conducted a retrospective study of all women delivering at a university hospital between February and June 2013. Demographic, pregnancy, and vaccination data were abstracted from the medical record. The relationship between maternal age, parity, gestational age, race/ethnicity, marital status, prenatal provider/site, insurance, influenza vaccination status, and Tdap vaccine was described by univariate analysis. Independent predictors were identified by multivariable logistic regression. RESULTS In our cohort of 1467 women, 1194 (81.6%) received a Tdap vaccine. After adjusting for potential confounders, 3 factors were found to be independent predictors of receiving the vaccine. Patients were more likely to receive Tdap if they had been vaccinated against influenza during this pregnancy (adjusted odds ratio [aOR], 1.7; 95% confidence interval [CI], 1.4-2.3). Black women were less likely to receive Tdap when compared with other women (aOR, 0.42; 95% CI, 0.27-0.67). Also, women who delivered preterm were less likely to receive the Tdap vaccine (aOR, 0.33; 95% CI, 0.22-0.48). CONCLUSION A high overall Tdap vaccination rate was observed following implementation of the Advisory Committee on Immunization Practices guidelines. Black women, however, had significantly lower vaccine uptake than other women. Further research is needed to understand and minimize this disparity. Women who delivered prematurely also had a decreased rate of Tdap vaccination; vaccinating earlier should be considered to better capture this population.