Rp Heine

Vaccinations for Pregnant Women

In the United States, eradication and reduction of vaccine-preventable diseases through immunization has directly increased life expectancy by reducing mortality. Although immunization is a public priority, vaccine coverage among adult Americans is inadequate. The Institute of Medicine, the Community Preventive Services Task Force, and other public health entities have called for the development of innovative programs to incorporate adult vaccination into routine clinical practice. Obstetrician–gynecologists are well suited to serve as vaccinators of women in general and more specifically pregnant women. Pregnant women are at risk for vaccine-preventable disease-related morbidity and mortality and adverse pregnancy outcomes, including congenital anomalies, spontaneous abortion, preterm birth, and low birth weight. In addition to providing direct maternal benefit, vaccination during pregnancy likely provides direct fetal and neonatal benefit through passive immunity (transplacental transfer of maternal vaccine-induced antibodies). This article reviews: 1) types of vaccines; 2) vaccines specifically recommended during pregnancy and postpartum; 3) vaccines recommended during pregnancy and postpartum based on risk factors and special circumstances; 4) vaccines currently under research and development for licensure for maternal–fetal immunization; and 5) barriers to maternal immunization and available patient and health care provider resources.

Medical and obstetric complications among pregnant women aged 45 and older.

Objective The number of women aged 45 and older who become pregnant is increasing. The objective of this study was to estimate the risk of medical and obstetric complications among women aged 45 and older. Methods The Nationwide Inpatient Sample was used to identify pregnant woman during admission for delivery. Deliveries were identified using International Classification of Diseases, Ninth Revision (ICD-9-CM) codes. Using ICD-9-CM codes, pre-existing medical conditions and medical and obstetric complications were identified in women at the time of delivery and were compared for women aged 45 years and older to women under age 35. Outcomes among women aged 35–44 were also compared to women under age 35 to determine if women in this group demonstrated intermediate risk between the older and younger groups. Logistic regression analyses were used to calculate odds ratios with 95% confidence intervals for pre-existing medical conditions and medical and obstetric complications for both older groups relative to women under 35. Multivariable logistic regression analyses were also developed for outcomes at delivery among older women, while controlling for pre-existing medical conditions, multiple gestation, and insurance status, to determine the effect of age on the studied outcomes. Results Women aged 45 and older had higher adjusted odds for death, transfusion, myocardial infarction/ischemia, cardiac arrest, acute heart failure, pulmonary embolism, deep vein thrombosis, acute renal failure, cesarean delivery, gestational diabetes, fetal demise, fetal chromosomal anomaly, and placenta previa compared to women under 35. Conclusion Pregnant women aged 45 and older experience significantly more medical and obstetric complications and are more likely to die at the time of a delivery than women under age 35, though the absolute risks are low and these events are rare. Further research is needed to determine what associated factors among pregnant women aged 45 and older may contribute to these findings.

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.

Factors associated with the change in prevalence of cardiomyopathy at delivery in the period 2000–2009: a population‐based prevalence study

Cardiomyopathy (CM) at delivery is increasing in prevalance. The objective of this study was to determine which medical conditions are attributable to this increasing prevalance.

Closed-Incision Negative-Pressure Therapy in Obese Patients Undergoing Cesarean Delivery: A Randomized Controlled Trial

Background  Postcesarean wound morbidity is a costly complication of cesarean delivery for which preventative strategies remain understudied. Objective  We compared surgical site occurrences (SSOs) in cesarean patients receiving closed-incision negative-pressure therapy (ciNPT) or standard-of-care (SOC) dressing. Study Design  A single-center randomized controlled trial compared ciNPT (5–7 days) to SOC dressing (1–2 days) in obese women (body mass index [BMI] ≥ 35), undergoing cesarean delivery between 2012 and 2014. Participants were randomized 1:1 and monitored 42 ± 10 days postoperatively. The primary outcome SSOs included unanticipated local inflammation, wound infection, seroma, hematoma, dehiscence, and need for surgical or antibiotic intervention. Results  Of the 92 randomized patients, 82 completed the study. ciNPT and SOC groups had similar baseline characteristics. Mean BMI was 46.5 ± 6.5 and no treatment-related serious adverse events. Compared with SOC, the ciNPT group had fewer SSOs (7/43 [16.3%] vs. 2/39 [5.1%], respectively; p  = 0.16); significantly fewer participants with less incisional pain both at rest (39/46 [84.8%] vs. 20/46 [43.5%]; p  < 0.001) and with incisional pressure (42/46 [91.3%] vs. 25/46 [54.3%]; p  < 0.001); and a 30% decrease in total opioid use (79.1 vs. 55.9 mg morphine equivalents, p  = 0.036). Conclusion  A trend in SSO reduction and a statistically significant reduction in postoperative pain and narcotic use was observed in women using ciNPT.

The Effects of Anemia on Pregnancy Outcome in Patients with Pyelonephritis

Objective. Pyelonephritis is a common infectious morbidity of pregnancy. Though anemia is commonly associated with pyelonephritis, there are little data describing the effect of pyelonephritis with anemia on pregnancy outcomes. The purpose of this study was to further assess the association of anemia with infectious morbidity and pregnancy complications among women with pyelonephritis. Study Design. We conducted a retrospective cohort study of pregnant women admitted to Duke University Hospital between July 2006 and May 2012 with pyelonephritis. Demographic, laboratory, and clinical data from the subjects pregnancy and hospitalizations were analyzed. Patients with pyelonephritis and anemia (a hematocrit < 32) were compared to those without anemia. Descriptive statistics were used to compare the two groups. Results. 114 pregnant women were admitted with pyelonephritis and 45 (39.5%) had anemia on admission. There was no significant difference in age, race, preexisting medical conditions, or urine bacterial species between patients with anemia and those without. Women with anemia were more likely to deliver preterm (OR 3.3 (95% CI 1.07, 11.4), P = 0.04). When controlling for race and history of preterm delivery, women with anemia continued to have increased odds of preterm birth (OR 6.0, CI 1.4, 35, P = 0.012). Conclusion. Women with pyelonephritis and anemia are at increased risk for preterm delivery.

Bleeding per vaginam is associated with funisitis in women with preterm prelabour rupture of the fetal membranes

Please cite this paper as: Grotegut C, Johnson L, Fitzpatrick C, Heine R, Swamy G, Murtha A. Bleeding per vaginam is associated with funisitis in women with preterm prelabour rupture of the fetal membranes. BJOG 2011;118:735–740.

Efficacy of non-beta lactam antibiotics for prevention of cesarean delivery wound infections

expression of CCL3 (a Th1 chemoattractant) and higher expression of CCL2 (a Th2 chemoattractant) at 1 and 2 wpi. In vitro, cervical epithelial cells infected with Ct expressed IL-1b when treated with vehicle control. P4 further increased IL-1b expression during Ct infection, while LNG decreased IL-1b expression. CONCLUSIONS: LNG appears to blunt IL-1b production in response to Ct infection in vivo and in vitro. This may interfere with downstream chemokine production (e.g. IL-8, CCL3). This potential immunomodulatory effect could impact LNG users at higher risk for STIs.

Group B strep and associated complications in cesarean delivery

1 Group B strep and associated complications in cesarean delivery A. M. Wood, B. L. Hughes, R. P. Heine, M. S. Villers Duke University Medical Center, Durham, NC OBJECTIVES: The objective of this study is to determine the effect of Group B streptococcus (GBS) on maternal infectious complications in women undergoing cesarean delivery (CD) in an era of routine GBS antibiotic prophylaxis during labor. METHODS: Retrospective cohort of women undergoing CD during labor at 37 weeks gestation or greater from January to December 2014. Intrapartum and postpartum complications were compared between women without GBS and those with a positive culture or unknown GBS status. Routine pre-operative antibiotics were used for all women. Labor at time of cesarean was documented by physician notes. Univariate analysis was performed using chi-square and Mann-Whitney U tests. A logistic regression analysis was then performed to control for potential confounders. RESULTS: 398 women had complete data and were included. 255 women (64%) were GBS negative, and 143 were GBS positive or unknown (36%). Compared to GBS negative women, GBS positive women were had a higher BMI and parity, and lower gestational age at delivery. They were less likely to have private insurance or be of white race. They had an increased incidence of gestational diabetes or hypertensive disorders of pregnancy. There were no significant differences in length of rupture of membranes, reported penicillin allergies, or surgical technique. In univariate analysis, women with GBS were noted to have a significantly lower incidence of clinical chorioamnionitis (5% vs 18%, p1⁄40.001). There were no differences in rates of endometritis or wound infection. In adjusted analysis for the outcome chorioamnionitis, women with GBS had a decreased risk of chorioamnionitis (aOR 0.17, 95% CI 0.07, 0.44). CONCLUSIONS: Within our cohort, women who were GBS positive and underwent CD in labor had a significantly lower risk of chorioamnionitis than women who were GBS negative. There were no significant differences in other postpartum infectious complications.

Correction: Medical and Obstetric Complications among Pregnant Women Aged 45 and Older

S1 Table is omitted from the Supporting Information of the published article. Please see S1 Table and its caption here.