Sarah K. Dotters-Katz

Maternal Effects of Respiratory Syncytial Virus Infection during Pregnancy.

Clarifying these effects could show potential benefits of RSV vaccination of pregnant women.

Use of a thrombopoietin mimetic for chronic immune thrombocytopenic purpura in pregnancy.

BACKGROUND: Romiplostim, a thrombopoietin mimetic, is a novel therapeutic option for patients with chronic immune thrombocytopenic purpura. We report on the effects of romiplostim use throughout pregnancy. CASE: A 28-year-old primigravid woman with chronic immune thrombocytopenic purpura initiated a planned pregnancy on romiplostim. The second and third trimesters were marked by a cyclic pattern of thrombocytopenia requiring supplemental corticosteroids or intravenous immunoglobulin and resultant thrombocytosis. Increased romiplostim doses and daily corticosteroids stabilized the platelet count before induction of labor at 33 weeks of gestation. The newborn manifested intraventricular hemorrhage at birth, although no developmental delay was present on follow-up at 10 months of age. CONCLUSION: The decreased efficacy of romiplostim monotherapy is attributed to increased target-mediated drug disposition and the physiologic changes of pregnancy. Safety concerns still exist for the developmental effects of romiplostim on the fetus.

Chikungunya Fever: Obstetric Considerations on an Emerging Virus.

&NA; Chikungunya fever is an increasingly common viral infection transmitted to humans by species of the Aedes mosquitoes. Characterized by fevers, myalgias, arthralgias, headache, and rash, the infection is endemic to tropical areas. However, identification of disease vectors to Europe and the Americas has raised concern for possible spread of chikungunya to these areas. More recently, these concerns have become a reality; with more than 500,000 new cases in the Western hemisphere in the last 2 years, questions have arisen about the implications of infection during pregnancy and delivery. A literature review was performed using MEDLINE in order to gather information regarding the obstetric implications of this infection. It appears that although this virus can cross the placenta in the first and second trimester leading to fetal infection and miscarriage, this is a very rare occurrence. In contrast, active maternal infection within 4 days of delivery conveys a high risk of vertical transmission. Maternal infection during pregnancy does not appear to be more severe than infection on the nonpregnant female. Given the increasing incidence of chikungunya, obstetric providers should be aware of the disease and its implication for the gravid female. Target Audience Obstetricians and gynecologists, family physicians, emergency medicine physicians, nurse midwives Learning Objectives After completing this activity, the learner should be better able to: describe the presentation, symptoms, and diagnosis of chikungunya fever; describe the risks of chikungunya fever to fetus and to the mother in each trimester and at the time of delivery; and outline the management considerations for pregnant women with active chikungunya infection.

Postpartum wound and bleeding complications in women who received peripartum anticoagulation

INTRODUCTION The objective of this study was to compare wound and bleeding complications between women who received anticoagulation after cesarean delivery due to history of prior venous thromboembolic disease, arterial disease, or being a thrombophilia carrier with adverse pregnancy outcome, to women not receiving anticoagulation. METHODS Women in the Duke Thrombosis Center Registry who underwent cesarean delivery during 2003-2011 and received postpartum anticoagulation (anticoagulation group, n=77), were compared with a subset of women who delivered during the same time period, but did not receive anticoagulation (no anticoagulation group, n=77). The no anticoagulation group comprised women who were matched to the anticoagulation group by age, body mass index, type of cesarean (no labor vs. labor), and date of delivery. Bleeding and wound complications were compared between the two groups. A multivariable logistic regression model was constructed to determine if anticoagulation was an independent predictor of wound complication. RESULTS Women who received anticoagulation during pregnancy had a greater incidence of wound complications compared to those who did not (30% vs. 8%, p<0.001). Using multivariable logistic regression, while controlling for race, diabetes, chorioamnionitis, and aspirin use, anticoagulation predicted the development of any wound complication (OR 5.8, 95% CI 2.2, 17.6), but there were no differences in the mean estimated blood loss at delivery (782 vs. 778 ml, p=0.91), change in postpartum hematocrit (5.4 vs. 5.2%, p=0.772), or percent of women receiving blood products (6.5 vs. 1.3%, p=0.209) between the two groups. CONCLUSIONS Anticoagulation following cesarean delivery is associated with an increased risk of post-cesarean wound complications, but not other postpartum bleeding complications.

Medical and Infectious Complications Associated with Pyelonephritis among Pregnant Women at Delivery

Objective. Pyelonephritis is a common cause of antepartum admission and maternal morbidity. Medical complications associated with pyelonephritis during delivery are not well described; thus the objective of this study was to estimate medical, infectious, and obstetric complications associated with pyelonephritis during the delivery admission. Study Design. We conducted a retrospective cohort study using the Nationwide Inpatient Sample (NIS) for the years 2008–2010. The NIS was queried for all delivery-related discharges. During the delivery admission, the ICD-9-CM codes for pyelonephritis were used to identify cases and were compared to women without pyelonephritis. A multivariable logistic regression model was constructed for various medical, infectious, and obstetric complications among women with pyelonephritis compared to women without, while controlling for preexisting medical conditions and demographics. Results. During the years 2008–2010, there were 26,397 records with a diagnosis of pyelonephritis during the delivery admission, for a rate of 2.1 per 1000 deliveries. Women with pyelonephritis had increased associated risks for transfusion, need for mechanical ventilation, acute heart failure, pneumonia, pulmonary edema, acute respiratory distress syndrome, sepsis, acute renal failure, preterm labor, and chorioamnionitis, while controlling for preexisting medical conditions. Conclusions. Pyelonephritis at delivery admissions is associated with significant medical and infectious morbidity.

Parasitic infections in pregnancy.

Parasitic infections affect tens of millions of pregnant women worldwide. These infections lead directly and indirectly to a spectrum of adverse maternal and fetal/placental effects. With the increase in global travel, healthcare providers will care for women who have recently moved from or traveled to areas where these infections are endemic. We reviewed the literature, assessing case reports, case series, and prospective and retrospective trials, to provide guidelines for management of common parasitic infections in pregnancy. Parasitic infections tend to preferentially affect 1 part of the maternal-fetal unit. Thus, we categorize parasitic infections into those that preferentially cause harm to the mother, preferentially affect the fetus, and preferentially affect the placenta. Target Audience: Obstetricians and Gynecologists, Family Physicians, and Nurse Midwives. Learning Objectives: After completing this CME activity, physicians should be better able to differentiate immune modulators associated with parasitic infection and their relationship to adverse pregnancy outcomes; assess the specific effects of certain parasitic infections on the gravid female, her placenta, and her fetus; and in addition, design a treatment regimen for pregnant women presenting with a parasitic infection.

The impact of familial Mediterranean fever on women's health.

&NA; Familial Mediterranean fever (FMF) is the most common hereditary recurrent febrile disorder, characterized by the sudden onset of high fever and severe abdominal pain. The implications of this disorder on a womans health are significant and not well known among obstetrician/gynecologists. The goal of this review is to familiarize providers caring for women on the ramifications of FMF on different aspects of a womans life, including puberty, fertility, pregnancy, and menopause, as well as to help them to diagnose and manage FMF when these patients become pregnant. Target Audience: Obstetricians and Gynecologists, Family Physicians, Nurse Midwives, Emergency Room Physicians, Internists. Learning Objectives: After participating in this activity, physicians should be better able to evaluate the implications of familial Mediterranean fever on puberty, menstruation, and contraceptive options. Manage uncomplicated and complicated familial Mediterranean fever in pregnancy. Diagnose familial Mediterranean fever in the emergency/urgent setting.

Risk factors for post-operative wound infection in the setting of chorioamnionitis and cesarean delivery

Abstract Objective: The objective of this study was to identify factors associated with an increased risk of post-operative wound infection in women with chorioamnionitis who undergo cesarean delivery. Methods: We conducted a retrospective cohort study of women with clinical chorioamnionitis who underwent cesarean delivery at a tertiary-care center between June 2010 and May 2013. Demographic data, labor and delivery details and post-operative outcomes were collected. Women with and without post-operative wound infections were compared. Results: Of 213 women with clinical chorioamnionitis who underwent cesarean delivery, 32 (15%) developed wound infections. Women with wound infection were more likely to have a body mass index (BMI) greater than or equal to 40 (p = 0.04), chronic hypertension (p = 0.03), leukocytosis on presentation (p = 0.046) or use tobacco (p = 0.002). Women who received ertapenem postpartum were less likely to develop wound infection than those who did not receive antibiotics (p = 0.02) or those that received ampicillin, gentamicin and clindamycin (p = 0.005). Conclusions: Elevated BMI, tobacco use, chronic hypertension and leukocytosis at admission were associated with an increased risk of wound infection. Ertapenem appeared to reduce the risk of post-operative wound infections in women who had chorioamnionitis and underwent cesarean delivery. This could be considered as a treatment option for this high-risk population.

Gastroschisis: A Review of Management and Outcomes.

We performed an evidence-based review of the obstetrical management of gastroschisis. Gastroschisis is an abdominal wall defect, which has increased in frequency in recent decades. There is variation of prevalence by ethnicity and several known maternal risk factors. Herniated intestinal loops lacking a covering membrane can be identified with prenatal ultrasonography, and maternal serum &agr;-fetoprotein level is commonly elevated. Because of the increased risk for growth restriction, amniotic fluid abnormalities, and fetal demise, antenatal testing is generally recommended. While many studies have aimed to identify antenatal predictors of neonatal outcome, accurate prognosis remains challenging. Delivery by 37 weeks appears reasonable, with cesarean delivery reserved for obstetric indications. Postnatal surgical management includes primary surgical closure, staged reduction with silo, or sutureless umbilical closure. Overall prognosis is good with low long-term morbidity in the majority of cases, but approximately 15% of cases are very complex with complicated hospital course, extensive intestinal loss, and early childhood death. Target Audience Obstetricians, Maternal Fetal Medicine Providers, Certified Nurse Midwives, and Family Medicine Providers. Learning Objectives After participating in this activity, the reader should be able to describe common pregnancy complications associated with gastroschisis; discuss options for prenatal and antenatal fetal surveillance; counsel parents regarding prenatal predictors of neonatal outcome and long-term prognosis; and describe the evidence-based recommendations for timing and mode of delivery.

Gestational age at initiation of 17-alpha hydroxyprogesterone caproate and recurrent preterm birth

Background Preterm birth is the leading cause of neonatal morbidity and mortality in nonanomalous neonates in the United States. Women with a previous early spontaneous preterm birth are at highest risk for recurrence. Weekly intramuscular 17‐alpha hydroxyprogesterone caproate reduces the risk of recurrent prematurity. Although current guidelines recommend 17‐alpha hydroxyprogesterone caproate initiation between 16 and 20 weeks, in clinical practice, 17‐alpha hydroxyprogesterone caproate is started across a spectrum of gestational ages. Objective The objective of the study was to examine the relationship between the gestational age at 17‐alpha hydroxyprogesterone caproate initiation and recurrent preterm birth among women with a prior spontaneous preterm birth 16–28 weeks’ gestation. Study Design This was a retrospective cohort study of women from a single tertiary care center, 2005–2016. All women with ≥1 singleton preterm births because of a spontaneous onset of contractions, preterm prelabor rupture of membranes, or painless cervical dilation between 16 and 28 weeks followed by a subsequent singleton pregnancy treated with 17‐alpha hydroxyprogesterone caproate were included. Women were grouped based on quartiles of gestational age of 17‐alpha hydroxyprogesterone caproate initiation (quartile 1, 140/7 to 161/7; quartile 2, 162/7 to 170/7; quartile 3, 171/7 to 186/7; and quartile 4, 190/7 to 275/7). Women with a gestational age of 17‐alpha hydroxyprogesterone caproate initiation in quartiles 1 and 2 were considered to have early‐start 17‐alpha hydroxyprogesterone caproate; those in quartiles 3 and 4 were considered to have late‐start 17‐alpha hydroxyprogesterone caproate. The primary outcome was recurrent preterm birth <37 weeks’ gestation. Secondary outcomes included recurrent preterm birth <34 and <28 weeks’ gestation and composite major neonatal morbidity (diagnosis of grade III or IV intraventricular hemorrhage, periventricular leukomalacia, bronchopulmonary dysplasia, necrotizing enterocolitis stage II or III, or death). Gestational age at delivery was compared by quartile of 17‐alpha hydroxyprogesterone caproate initiation using Kaplan‐Meier survival curves and the log‐rank test. Logistic regression models estimated odds ratios for the association between gestational age at 17‐alpha hydroxyprogesterone caproate initiation and preterm birth <37 weeks’ gestation, adjusting for demographics, prior pregnancy and antenatal characteristics. Results A total of 132 women met inclusion criteria; 52 (39.6%) experienced recurrent preterm birth <37 weeks in the studied pregnancy. 17‐Alpha hydroxyprogesterone caproate was initiated at a mean 176/7 ± 2.5 weeks. Demographic and baseline characteristics were similar between women with early‐start 17‐alpha hydroxyprogesterone caproate (quartiles 1 and 2) compared with those with late‐start 17‐alpha hydroxyprogesterone caproate (quartiles 3 and 4). Women with early‐start 17‐alpha hydroxyprogesterone caproate trended toward lower rates of recurrent preterm birth <37 weeks compared with those with late‐start 17‐alpha hydroxyprogesterone caproate (41.3% vs 57.7%, P = .065). Delivery gestational age was inversely proportional to gestational age at 17‐alpha hydroxyprogesterone caproate initiation (quartile 1, 374/7 weeks vs quartile 2, 365/7 vs quartile 3, 361/7 weeks vs quartile 4, 340/7, P = .007). In Kaplan‐Meier survival analyses, these differences in delivery gestational age by 17‐alpha hydroxyprogesterone caproate initiation quartile persisted across pregnancy (log‐rank P < .001). In regression models, later initiation of 17‐alpha hydroxyprogesterone caproate was significantly associated with increased odds of preterm birth <37 weeks. Women with early 17‐alpha hydroxyprogesterone caproate initiation also had lower rates of major neonatal morbidity than those with later 17‐alpha hydroxyprogesterone caproate initiation (1.5% vs 14.3%, P = .005). Conclusion Rates of recurrent preterm birth among women with a prior spontaneous preterm birth 16–28 weeks are high. Women beginning 17‐alpha hydroxyprogesterone caproate early deliver later and have improved neonatal outcomes. Clinicians should make every effort to facilitate 17‐alpha hydroxyprogesterone caproate initiation at 16 weeks.