Sara E. Mazzoni

Measures of Maternal Stress and Mood in Relation to Preterm Birth.

OBJECTIVE: To investigate the relationships between psychological and physiologic measures of stress, mood, and gestational age at delivery and preterm birth. METHODS: This prospective cohort study recruited healthy women in the early second trimester who were 18–45 years of age. Validated psychological measures of perceived stress, depressive symptoms, and anxiety were completed at 16, 22, 28, 34, and 40 weeks of gestation. Cortisol concentration was measured in maternal hair at 16, 28, and 40 weeks of gestation to approximate first-, second-, and third-trimester levels of physiologic stress. Statistical methods included: analyses of variance, t tests, &khgr;2, Pearson correlations, regression modeling, and mediation analysis as appropriate. Hair cortisol concentrations were natural log-transformed to normalize values. RESULTS: Eleven (12%) of the 90 included women had a spontaneous preterm birth or preterm premature rupture of membranes. Perceived stress at 16 weeks of gestation correlated with both second-trimester cortisol concentration (r=0.28, P=.007) and earlier gestational age at delivery (r=−0.30, P<.01). Gestational age at delivery was also negatively correlated with cortisol concentration in the second trimester (r=−0.25, P=.02) and second-trimester cortisol concentration was higher in preterm- (2.7±0.4 log-transformed pg/mg) compared with term- (2.0±0.7 log-transformed pg/mg, P<.001) delivered women. Using mediation statistics, the association between the psychological measure, the physiologic measure, and gestational age at delivery was mainly driven by increased physiologic stress (hair cortisol concentration) in the second trimester (difference in coefficients [standard error]=−0.05 [0.02]). CONCLUSION: Higher perceived stress in the second trimester is associated with both elevated second-trimester hair cortisol concentration and gestational age at delivery. Physiologic measure of stress in the second trimester appears most strongly associated with preterm birth. Identification and amelioration of early pregnancy stressors may attenuate physiologic stress and ultimately affect preterm birth.

An Audiotaped Mental Health Evaluation Tool for Hispanic Immigrants With a Range of Literacy Levels

Debilitating mental illness is treatable if found. There is no validated self-administered mental illness evaluation tool for immigrant Hispanic farm workers with variable literacy levels. This study tested sensitivity and specificity of an audiotaped survey developed for low literacy levels compared with standard interview instruments. Subjects from 11 migrant camps completed a self-administered audiotaped survey in Spanish to diagnose major depression, substance abuse, panic and generalized anxiety, and domestic violence. Primary care clinics assisted in finding camps and provided follow-up treatment. For 154 men and 156 women, the audio tool was most sensitive for major depression and specific for anxiety disorder, alcohol abuse, and domestic violence. Seventy percent of those diagnosed with major depression received appropriate treatment. This study validated an inexpensive, self-administered audio tool to evaluate the mental health of immigrant Hispanic farm workers with a wide range of literacy levels.

Group prenatal care

Patients participating in group prenatal care gather together with women of similar gestational ages and 2 providers who cofacilitate an educational session after a brief medical assessment. The model was first described in the 1990s by a midwife for low-risk patients and is now practiced by midwives and physicians for both low-risk patients and some high-risk patients, such as those with diabetes. The majority of literature on group prenatal care uses CenteringPregnancy, the most popular model. The first randomized controlled trial of CenteringPregnancy showed that it reduced the risk of preterm birth in low-risk women. However, recent meta-analyses have shown similar rates of preterm birth, low birthweight, and neonatal intensive care unit admission between women participating in group prenatal care and individual prenatal care. There may be subgroups, such as African Americans, who benefit from this type of prenatal care with significantly lower rates of preterm birth. Group prenatal care seems to result in increased patient satisfaction and knowledge and use of postpartum family planning as well as improved weight gain parameters. The literature is inconclusive regarding breast-feeding, stress, depression, and positive health behaviors, although it is theorized that group prenatal care positively affects these outcomes. It is unclear whether group prenatal care results in cost savings, although it may in large-volume practices if each group consists of approximately 8-10 women. Group prenatal care requires a significant paradigm shift. It can be difficult to implement and sustain. More randomized trials are needed to ascertain the true benefits of the model, best practices for implementation, and subgroups who may benefit most from this innovative way to provide prenatal care. In short, group prenatal care is an innovative and promising model with comparable pregnancy outcomes to individual prenatal care in the general population and improved outcomes in some demographic groups.

Influenza and Pertussis Vaccination Among Pregnant Women and Their Infants' Close Contacts: Reported Practices and Attitudes.

Background: Our objectives were to describe the receipt of influenza and tetanus-diphtheria-acellular pertussis (Tdap) vaccines among postpartum women and their close contacts and the factors associated with cocooning. Methods: A survey between February 2013 and April 2013 of 613 postpartum women from 9 obstetrics practices assessed vaccine receipt among respondents and close contacts, demographics and 5 domains of health beliefs (benefits, barriers, susceptibility, severity and social norms). Multivariable models assessed the association of these factors with Tdap or influenza ”cocooning,” defined as the mother plus at least 1 close contact of her newborn receiving the vaccine. Results: The response rate was 45%; 61% of mothers reported that they and at least 1 close contact of their newborn had received influenza vaccine, and 67% reported this for Tdap. Infants whose mothers received influenza vaccine had a mean of 2.8 close contacts who also received influenza vaccine versus a mean of 0.9 contacts for infants whose mothers did not receive influenza vaccine (P < 0.0001). Infants whose mothers received Tdap vaccine had an average of 2.4 contacts who also received it versus 0.8 for infants whose mothers did not receive Tdap (P < 0.0001). Factors associated with influenza and Tdap cocooning included obstetrician recommendation, high perceived benefits, low perceived barriers and perceived susceptibility to disease. For Tdap, race/ethnicity was associated with cocooning (Hispanic/Latino, adjusted odds ratio 0.26, 95% confidence interval: 0.10–0.64 referent to White). Conclusion: Maternal vaccination and obstetrician recommendation are associated with infant cocooning. Interventions to increase cocooning of infants should focus on encouraging strong provider recommendations, increasing maternal knowledge of disease risk and addressing identified barriers. Reasons for possible racial/ethnic differences should be further explored.

Group prenatal care for women with gestational diabetes (.).

Abstract Objective: We aimed to determine if group prenatal care affects the progression to A2 gestational diabetes mellitus (GDM) when compared with conventional care for women with GDM. Methods: Prospective observational cohort of women diagnosed with GDM who attended group visits compared with a historical control group of women who received conventional obstetrical care in the year prior but would have met inclusion criteria for group care. The primary outcome was progression to A2 GDM. Secondary outcomes included antepartum, intrapartum and postpartum maternal outcomes and neonatal outcomes. Results: A total of 165 subjects were included: 62 in group care and 103 in conventional care. Compared with patients with conventional care, group subjects were more likely to attend a postpartum visit (92% versus 66%; p = 0.002) and were almost 4 times more likely to receive recommended diabetes screening postpartum (OR 3.9, CI 1.8–8.6). Group subjects were much less likely to progress to A2 GDM (OR 0.15, CI 0.07–0.30). There were no differences in neonatal outcomes. Conclusions: Group prenatal care for women with diabetes is associated with decreased progression to A2 GDM and improved postpartum follow-up for appropriate diabetes screening without significantly affecting obstetrical or neonatal outcomes.

Facilitators and barriers to the use of standing orders for vaccination in obstetrics and gynecology settings.

BACKGROUND: Many young and middle‐aged women receive their primary health care from their obstetrician‐gynecologists. A recent change to vaccination recommendations during pregnancy has forced the integration of new clinical processes at obstetrician‐gynecology practices. Evidence‐based best practices for vaccination delivery include the establishment of vaccination standing orders. OBJECTIVES: As part of an intervention to increase adoption of evidence‐based vaccination strategies for women in safety‐net and private obstetrician‐gynecology settings, we conducted a qualitative study to identify the facilitators and barriers experienced by obstetrician‐gynecology sites when establishing vaccination standing orders. STUDY DESIGN: At 6 safety‐net and private obstetrician‐gynecology practices, 51 semistructured interviews were completed by trained qualitative researchers over 2 years with clinical staff and vaccination program personnel. Standardized qualitative research methods were used during data collection and team‐based data analysis to identify major themes and subthemes within the interview data. RESULTS: All study practices achieved partial to full implementation of vaccine standing orders for human papillomavirus, tetanus diphtheria pertussis, and influenza vaccines. Facilitating factors for vaccine standing order adoption included process standardization, acceptance of a continual modification process, and staff training. Barriers to vaccine standing order adoption included practice‐ and staff‐level competing demands, pregnant womens preference for medical providers to discuss vaccine information with them, and staff hesitation in determining HPV vaccine eligibility. CONCLUSIONS: With guidance and commitment to integration of new processes, obstetrician‐gynecology practices are able to establish vaccine standing orders for pregnant and nonpregnant women. Attention to certain process barriers can aid the adoption of processes to support the delivery of vaccinations in obstetrician‐gynecology practice setting, and provide access to preventive health care for many women.

Lack of Agreement Between Endocervical Brush and Endocervical Curettage in Women Undergoing Repeat Endocervical Sampling

Objective To evaluate agreement between an abnormal endocervical brush (ECB) collected at the time of colposcopy and subsequent endocervical curettage (ECC). Methods All women evaluated for lower genital tract disease at a single academic institution were prospectively entered into a database. The database was queried for those who had a colposcopic exam with ECB between April 1, 2013, and June 15, 2015, and who subsequently returned for an ECC to further evaluate eligibility for expectant management or ablative therapy. ECB and ECC results were divided into 2 groups: “low-grade” included low-grade squamous intraepithelial lesions (LSIL) or atypical squamous cells of undetermined significance, and “high-grade” included high-grade squamous intraepithelial lesions (HSIL) or atypical squamous cells—cannot exclude high-grade. Women with atypical glandular cells and unsatisfactory ECB results were excluded. Percent agreement between ECB and ECC was calculated based on these categories. Results Seventy-nine women were included: 54 (68%) had a low-grade ECB, and 25 (32%) had a high-grade ECB. Of those who had a low-grade ECB, 4 had a low-grade ECC, 3 had a high-grade ECC, and 47 were negative, resulting in an agreement of 7.4% (4/54). Of those who had a high-grade ECB, 1 had a low-grade ECC, 4 had a high-grade ECC, and 20 were negative, resulting in 16% (4/25) agreement. Conclusions Our data suggest that there is poor agreement between ECC and ECB in our patient population.

Adherence to Management Recommendations in Patients Diagnosed With Cervical Intraepithelial Neoplasia 2 or 3.

Objective The aim of the study was to evaluate the rate of patient adherence to provider recommendations for biopsy proven cervical intraepithelial neoplasia (CIN) 2 or 3 in an academic safety-net hospital. Materials and Methods This is a case series of patients with biopsy-proven CIN 2 or 3 identified via pathology records between January 1, 2008 to December 31, 2012 at a single academic safety-net hospital. Patients with human immunodeficiency virus, lupus, or pregnancy were excluded. Patient demographics, recommended management, and patient adherence were extracted from the patient chart. Complete adherence was defined as completion of follow-up recommendations within 6 months of the recommended follow-up date. The primary outcome was rate of complete adherence to management recommendations. Descriptive statistics, univariate analysis, and multivariable logistic regression were performed. Results Six hundred eighty-four patients met inclusion and exclusion criteria. The complete adherence rate was 89% (n = 606). In multivariable analyses, those who completed follow-up were older (mean = 31 vs 29 years; p = .031), more likely to use a long-acting reversible contraceptive or sterilization for contraception (92% vs 87%; p = .036) and more likely to have been recommended excision (90% vs 83%; p = .009). In multivariable analysis, using a long-acting reversible contraceptive or sterilization (odds ratio = 1.75; CI = 1.02–3.0) and the recommendation of any kind of treatment as opposed to expectant management (odds ratio = 3.89; CI = 1.96–7.70) remained significantly associated with complete follow-up. Conclusions Patients were overall highly adherent to management recommendations when diagnosed with CIN 2 or 3. Those patients recommended to undergo treatment as opposed to observation were more likely to follow up.

Adherence to Management Recommendations in Patients Diagnosed With High-Grade Cervical Dysplasia [7]

INTRODUCTION: The management of high-grade cervical dysplasia includes multiple options: observation, ablation, or excision. We evaluated patient adherence to health care provider management recommendations for high-grade cervical lesions in an academic safety net hospital. METHODS: This was a retrospective cohort study identifying patients with biopsy-proven high-grade cervical dysplasia (cervical intraepithelial neoplasia 2 or 3) through pathology records between January 1, 2008, and December 31, 2012. Patients with human immunodeficiency virus or lupus or who were pregnant were excluded. Patient demographics, recommended management, and patient adherence were extracted from the chart. Complete adherence was defined as completion of follow-up recommendations within 6 months of the recommended follow-up date. The primary outcome was rate of complete adherence to management recommendations. Descriptive statistics, univariate analysis, and multivariate logistic regression were performed. RESULTS: A total of 684 patients met the inclusion criteria. The complete adherence rate was 89% (n=606). Those who completed follow-up were older (31 compared with 29 years old, P=.031), more likely to use long-acting reversible contraception or sterilization for contraception (92% compared with 87%, P=.036), and more likely to have had excision recommended (90% compared with 83%, P=.009). In multivariate analysis, those patients who had observation recommended (n=46) were less likely to complete follow-up (70%, odds ratio 0.26, confidence interval 0.13–0.51). The observation group was noted to be younger (23 compared with 32 years, P<.001), with lower parity (1.4 compared with 2.1, P<.001). No variables were associated with complete adherence in the observation group. CONCLUSION: Patients were overall highly adherent with management recommendations in the setting of high-grade cervical dysplasia. Those patients recommended to undergo observation were least likely to be adherent.

Perinatal High-Grade Cervical Cytology: A Case Series From a Safety Net Institution.

Objective To describe the outcomes of women with high-grade cervical cytology in pregnancy and to identify factors that predict completion of appropriate postpartum follow-up. Methods We describe a case series of all patients with high-grade cervical cytology collected during pregnancy between 2007 and 2011 at a single institution. Patients were considered adherent with follow-up if they received any kind of postpartum evaluation or treatment for their cervical dysplasia at our institution within 9 months of delivery. Results Of 138 women with high-grade cervical cytology in pregnancy, 87 (63%) had high-grade squamous intraepithelial lesion, 47 (34%) had atypical squamous cells that cannot rule out high-grade (ASC-H), and 4 (3%) had atypical glandular cells (AGC). Most patients (81%) underwent colposcopy during pregnancy. A total of 48 patients (43%) had biopsies performed, 26 (54%) were CIN 2 or 3, and one (2%) was adenocarcinoma in situ (AIS). A total of 97 (70%) of 138 patients completed recommended postpartum follow-up, resulting in the detection of one additional case of AIS and one case of invasive adenocarcinoma. Hispanic ethnicity (odds ratio [OR], 3.6; confidence interval [CI], 1.4–9.1), being married (OR, 4.5; CI, 1.6–12.4), being employed (OR, 3.7; CI, 1.3–10.5), and CIN2 or 3 on antenatal biopsy (OR, 9.8; CI, 2.0–47.9) were all significantly associated with completion of postpartum follow-up. Conclusion Colposcopy during pregnancy resulted in the detection of one case of AIS. Postpartum evaluation and treatment detected an additional case of AIS as well as one case of invasive cervical adenocarcinoma. Whereas certain demographic characteristics were associated with completion of recommended follow-up, the strongest association is with a high-grade biopsy during pregnancy.