Laurie S. Swaim

Knowledge and attitiudes of pregnant women and their providers towards recommendations for immunization during pregnancy.

OBJECTIVES Tetanus, diphtheria and acellular pertussis (Tdap) and influenza vaccination is recommended during each pregnancy but uptake is suboptimal. We evaluated knowledge and acceptance of vaccination recommendations among pregnant women. METHODS Prospective, convenience survey of pregnant women presenting for antenatal care at the Pavilion for Women, Texas Childrens Hospital, Houston, and their healthcare providers. RESULTS 796 of 825 (96.5%) of women and 63 of 87 (72.4%) providers completed surveys. Mean age of pregnant women was 30.2 (18-45) years. Self-identified race/ethnicity was 45% white, 26% Hispanic, 13% black, 12% Asian and 4% other. Most women had college degrees (84%) and private health insurance (83%). Mean gestation was 28.5 weeks with 4.8%, 37.8% and 57.4%, in the 1st, 2nd and 3rd trimesters, respectively. Women used various sources for pregnancy information (personal contacts, providers, print, audiovisual and online media) but 89.1% cited a provider as their most trusted source, predominantly (85.8%) their physician. 668 (84%) knew vaccines are recommended during pregnancy, specifically influenza (77%) and Tdap (61%) vaccines. 659 (83%) were willing to receive vaccines if recommended by their physician. Factors impacting vaccination decisions included safety for baby, safety for mother and sufficient information, scoring 4.7, 4.5 and 4.2, respectively, on a 5-point scale; less important were additional visit time (2.6), cost (1.9) or needle phobia (1). Women surveyed in the 3rd trimester showed greater acceptance than those earlier in gestation (87% vs 78%; P0.003). Maternal education, ethnicity, insurance, multiple gestation or history of serious illness in a prior infant did not affect willingness to receive vaccines. CONCLUSIONS Pregnant women are willing to accept vaccination in pregnancy if recommended by their physician and if sufficient discussion of safety and rationale occurs. Strong physician recommendation, as reported for pediatric vaccination, is essential to optimizing uptake of vaccines during pregnancy.

Incidence of Methicillin-Resistant Staphylococcus aureus in Postpartum Breast Abscesses

OBJECTIVE The study objective is to determine the incidence of methicillin-resistant Staphylococcus aureus (MRSA) in postpartum breast abscesses in two Houston, TX, area hospitals. STUDY DESIGN AND METHODS This is a retrospective chart review of women hospitalized for postpartum breast abscesses at Womans Hospital of Texas and Memorial Hermann Hospital between January 1, 2000 and December 31, 2006. Patients were identified by searching admission records for ICD-9 codes related to breast abscesses. Demographic characteristics, medical history, culture results, and pertinent procedures were recorded. Statistical analyses included the Fisher exact test for categorical data and Students test for continuous variables. RESULTS Thirty-three postpartum abscesses were identified: 19 from Memorial Hermann Hospital and 14 from Womans Hospital. MRSA and S. aureus were the only causative bacteria identified. Twelve of the 19 abscesses from Hermann Hospital were MRSA positive (63%), and nine of the 14 from Womans Hospital were MRSA positive (64%). There were no statistically significant differences among women with MRSA abscesses versus those with S. aureus abscesses in terms of ethnicity, age, time to presentation, parity, insurance, or mode of delivery. Susceptibility patterns were consistent with community-acquired MRSA. CONCLUSIONS MRSA is a significant pathogen in postpartum breast abscesses in our population, and a high level of suspicion is warranted. Local susceptibility patterns should guide treatment. Empirical treatment of breast abscesses without first obtaining cultures should be discouraged.

Prevention and management of hysterectomy complications.

Hysterectomy is the most common gynecologic surgical procedure performed in the United States. Although most hysterectomies proceed without incident, complications with serious consequences may occur. This chapter reviews the incidence, predisposing factors, intraoperative risk, diagnosis, and management and prevention of complications of hysterectomy. These include hemorrhage, infection, thromboembolism, injury to viscera, and neuropathy. The prepared surgeon is familiar with anatomy, surgical risk factors, current recommendations for prophylaxis and prevention, as well as modern management of complications of hysterectomy.

Hysteroscopic Sterilization in the Office Setting

Hysteroscopic sterilization is growing in popularity. Nearly 500,000 women have been sterilized using this method, and an increasing number of physicians are now performing this procedure in the office setting. The office setting can provide a cost-effective, convenient, and safe environment for hysteroscopic sterilization. Patients may benefit from avoiding hospital preoperative visits, excessive laboratory evaluation, operating room wait times, and expense associated with hospital care. Physicians may improve productivity through remaining in their office or avoiding operating room delays. This article reviews office-hysteroscopic sterilization with the Essure microinsert system.

The Role of Obstetrics/Gynecology Hospitalists in Reducing Maternal Mortality

The United States experienced a 6.1% annual increase in the maternal death rate from 2000 to 2013. Maternal deaths from hemorrhage and complications of preeclampsia are significant contributors to the maternal death rate. Many of these deaths are preventable. By virtue of their continuous care of laboring patients, active involvement in hospital safety initiatives, and immediate availability, obstetric hospitalists are uniquely positioned to evaluate patients, initiate care, and coordinate a multidisciplinary effort. In cases of significant maternal hemorrhage, hypertensive crisis, and acute pulmonary edema, the availability of an obstetrics hospitalist may facilitate improved patient safety and fewer maternal deaths.

Prevalence of Vaccine Hesitancy Among Expectant Mothers in Houston, Texas

OBJECTIVE Nonmedical exemptions continue to rise because of increasing proportions of vaccine-hesitant parents. The proportion of expectant parents who are vaccine-hesitant is currently unknown. We assessed the prevalence of vaccine hesitancy among expectant parents receiving care at an obstetrics clinic in Houston, Texas. METHODS We conducted a cross-sectional survey of expectant parents between 12 and 31 weeks gestation who received care at Texas Childrens Pavilion for Women between July 2014 and September 2015. Using convenience sampling, participants completed a questionnaire that included questions on demographic items, self-assessed pregnancy risk, receipt of annual influenza vaccine, and the 15-item Parents Attitudes About Childhood Vaccines survey, a validated tool to identify vaccine-hesitant parents. We used multivariable logistic regression to determine the association of demographic characteristics, pregnancy risk, and influenza vaccine receipt with vaccine hesitancy after controlling for variables significant in univariable analyses. RESULTS Six hundred ten expectant mothers and 38 expectant fathers completed the Parents Attitudes About Childhood Vaccines survey. Overall, 50 of 610 expectant mothers (8.2%; 95% confidence interval [CI], 6.1%-10.7%) were vaccine-hesitant. Expectant mothers were primarily non-Hispanic white, 30 years old or older, and married. The odds of being vaccine-hesitant were 2.2 times greater (95% CI, 1.2-4.1) among expectant mothers with a college level of education or less compared with those with more than a 4-year degree. The odds of being vaccine-hesitant were 7.4 times greater (95% CI, 3.9-14.0) among expectant mothers who do not receive an annual influenza vaccine compared with those who do. CONCLUSIONS Our findings suggest the need to identify and address vaccine hesitancy among expectant parents before birth.

Association Between Third-Trimester Tdap Immunization and Neonatal Pertussis Antibody Concentration

Importance Immunization with tetanus, diphtheria, and acellular pertussis (Tdap) vaccine is recommended in the United States during weeks 27 through 36 of pregnancy to prevent life-threatening infant pertussis. The optimal gestation for immunization to maximize concentrations of neonatal pertussis toxin antibodies is unknown. Objective To determine pertussis toxin antibody concentrations in cord blood from neonates born to women immunized and unimmunized with Tdap vaccine in pregnancy and optimal gestational age for immunization to maximize concentrations of neonatal antibodies. Design, Setting, and Participants Prospective, observational, cohort study of term neonates in Houston, Texas (December 2013-March 2014). Exposures Tdap immunization during weeks 27 through 36 of pregnancy or no Tdap immunization. Main Outcomes and Measures Primary outcome was geometric mean concentrations (GMCs) of pertussis toxin antibodies in cord blood of Tdap-exposed and Tdap-unexposed neonates and proportions of Tdap-exposed and Tdap-unexposed neonates with pertussis toxin antibody concentrations of 15 IU/mL or higher, 30 IU/mL or higher, and 40 IU/mL or higher, cutoffs representing quantifiable antibodies or levels that may be protective until the infant immunization series begins. Secondary outcome was the optimal gestation for immunization to achieve maximum pertussis toxin antibodies. Results Six hundred twenty-six pregnancies (mean maternal age, 29.7 years; 41% white, 27% Hispanic, 26% black, 5% Asian, 1% other; mean gestation, 39.4 weeks) were included. Three hundred twelve women received Tdap vaccine at a mean gestation of 31.2 weeks (range, 27.3-36.4); 314 were unimmunized. GMC of neonatal cord pertussis toxin antibodies from the Tdap-exposed group was 47.3 IU/mL (95% CI, 42.1-53.2) compared with 12.9 IU/mL (95% CI, 11.7-14.3) in the Tdap-unexposed group, for a GMC ratio of 3.6 (95% CI, 3.1-4.2; P < .001). More Tdap-exposed than Tdap-unexposed neonates had pertussis toxin antibody concentrations of 15 IU/mL or higher (86% vs 37%; difference, 49% [95% CI, 42%-55%]), 30 IU/mL or higher (72% vs 17%; difference, 55% [95% CI, 49%-61%]), and 40 IU/mL or higher (59% vs 12%; difference, 47% [95% CI, 41%-54%]); P < .001 for each analysis. GMCs of pertussis toxin antibodies were highest when Tdap vaccine was administered during weeks 27 through 30 and declined thereafter, reaching a peak at week 30 (57.3 IU/mL [95% CI, 44.0-74.6]). Conclusions and Relevance Immunization with Tdap vaccine during the third trimester of pregnancy, compared with no immunization, was associated with higher neonatal concentrations of pertussis toxin antibodies. Immunization early in the third trimester was associated with the highest concentrations.