Publications by authors named "Alan Tita"

281 Publications

First or second trimester SARS-CoV-2 infection and subsequent pregnancy outcomes.

Am J Obstet Gynecol 2022 Aug 12. Epub 2022 Aug 12.

University of Texas at Austin, Austin, TX.

Background: SARS-CoV2 infection during pregnancy is associated with adverse pregnancy outcomes including fetal death and preterm birth. It is not known whether that risk occurs only during the time of acute infection or whether risk persists later in pregnancy.

Objective: The goal of this analysis was to evaluate whether the risk of SARS-CoV-2 infection during pregnancy persists after acute maternal illness.

Study Design: A retrospective cohort study of pregnant patients with and without SARS-CoV2 infection delivering at 17 hospitals in the United States between March and December 2020. Patients experiencing a SARS-CoV-2 positive test at or prior to 28 weeks' gestation with a subsequent delivery hospitalization were compared with those without a positive SAR-CoV-2 test at the same hospitals with randomly selected delivery days during the same period. Deliveries occurring <20 weeks' gestation in both groups were excluded. Study outcomes included fetal or neonatal death, preterm birth less than 37 weeks' gestation and less than 34 weeks' gestation, hypertensive disorders of pregnancy, any major congenital malformation, and size for gestational age less than 5 or 10 percentiles at birth based on published standards. Hypertensive disorders of pregnancy that were collected included hypertensive disorders of pregnancy and preeclampsia with severe features, both overall and with delivery <37 weeks' gestation.

Results: Of 2,326 patients who tested positive for SARS-CoV-2 during pregnancy and were at least 20 weeks' gestation at delivery from March through December 2020, 402 patients (delivering 414 fetuses/neonates) were SARS-CoV-2 positive before 28 weeks' gestation and prior to their admission for delivery; they were compared to 11,705 patients without a positive SARS-CoV-2 test. In adjusted analyses, those with SARS-CoV-2 prior to 28 weeks' had a subsequent increased risk of fetal/neonatal death [2·9% vs 1·5%, adjusted relative risk (aRR) 1·97, 95% confidence interval (CI),1·01 - 3·85], preterm birth <37 weeks' (19·6% vs 13·8%, aRR, 1·29; 95%CI, 1·02 - 1·63) and hypertensive disorders of pregnancy with delivery less than 37 weeks' gestation (7·2% vs 4·1%, aRR 1·74, 95% CI 1·19-2·55). There were no significant differences in the rates of preterm birth <34 weeks', any major congenital malformation, size for gestational age less than the 5 or 10 percentiles. There were also no significant differences in the rate of gestational hypertension overall or in preeclampsia with severe features.

Conclusion: There is a modest increase in risk of adverse pregnancy outcomes subsequent to SARS-CoV-2 infection.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajog.2022.08.009DOI Listing
August 2022

Intrapartum Risk Factors Associated with Pelvic Organ Prolapse at Six Months Postpartum: Intrapartum Factors for Pelvic Organ Prolapse.

Am J Obstet Gynecol MFM 2022 Jul 16:100692. Epub 2022 Jul 16.

Department of Women's Health, Dell School of Medicine, University of Texas at Austin.

Background: Pregnancy and childbirth are known risk factors associated with the development of pelvic organ prolapse; specific intrapartum risk factors are not well characterized.

Objective: To determine intrapartum factors associated with increased risk of pelvic organ prolapse identified postpartum.

Study Design: A planned secondary analysis of a multicenter randomized clinical trial of delayed vs. immediate pushing among nulliparous women ≥ 37 weeks' gestation in labor with neuraxial analgesia conducted at six academic and community hospitals in the United States. Intrapartum characteristics were identified and Pelvic Organ Prolapse Quantification (POP-Q) assessments at 6 weeks and 6 months postpartum were performed. The primary outcome was pelvic organ prolapse, defined as ≥ Stage 2 by POP-Q assessment at 6 months. Multivariable logistic regression was used to refine risk estimates while adjusting for randomization group, macrosomia, and maternal age.

Results: Among the 941 women participating in the pelvic floor follow-up, 793 women had POP-Q assessments at 6 weeks with 11.5% (91/793) demonstrating ≥ Stage 2 prolapse. Of the 728 women followed to 6 months, ≥ Stage 2 prolapse was identified in 8% (58/728). Prostaglandin use for induction was associated with an increased risk at 6 months (adjusted odds ratio, 2.15; 95% confidence interval, 1.18-3.91; P<0.01). Length and type (spontaneous vs. induced) of the first stage of labor was not significantly associated with ≥ Stage 2 prolapse. Increased length of the second stage and duration of pushing as well were not associated with ≥ Stage 2 prolapse. After adjusting for confounding factors, cesarean delivery was protective of pelvic organ prolapse at 6 months (adjusted odds ratio, 0.12; 95% confidence interval, 0.02-0.90).

Conclusion: Management of the first and second stage of labor including time length were not associated with ≥ Stage 2 prolapse at 6 months. The findings that prostaglandin exposure was associated with increased risk likely is not directly impacting risk of prolapse but may be surrogates for other labor features that deserve exploration. Cesarean delivery was associated with protection from ≥ Stage 2 pelvic organ prolapse at 6 months, consistent with previous literature.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajogmf.2022.100692DOI Listing
July 2022

Maternal and Perinatal Outcomes Associated With the Omicron Variant of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection.

Obstet Gynecol 2022 Aug 18;140(2):262-265. Epub 2022 May 18.

Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, the Center for Women's Reproductive Health, the Division of Infectious Diseases, Department of Medicine, the Division of Neonatology, Department of Pediatrics, the Department of Biostatistics, School of Public Health, and the Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama.

Two years into the coronavirus disease 2019 (COVID-19) pandemic, we have now seen three main variant waves. We performed a retrospective cohort study of all pregnant patients with COVID-19 at our institution from March 22, 2020, to February 26, 2022, to evaluate disease severity and perinatal outcomes among the variants. Patients were categorized as pre-Delta (March 22, 2020-May 31, 2021), Delta (July 1, 2021-December 15, 2021), or Omicron (December 16, 2021- February 26, 2022) based on variant tracking from the Centers for Disease Control and Prevention and genotype sequencing at our institution. There were fewer cases of severe-critical disease (1.8% Omicron vs 13.3% pre-Delta and 24.1% Delta) and adverse perinatal outcomes during the Omicron wave compared with the pre-Delta and Delta waves.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/AOG.0000000000004849DOI Listing
August 2022

The association of race and ethnicity with severe maternal morbidity among individuals diagnosed with hypertensive disorders of pregnancy.

Am J Perinatol 2022 Jun 28. Epub 2022 Jun 28.

Obstetrics & Gynecology, University of Texas Health Sciences Center at Houston, Houston, United States.

Objective: To examine racial disparities in severe maternal morbidity in patients with hypertensive disorder of pregnancy (HDP).

Study Design: Secondary analysis of an observational study of 115,502 patients who had a live birth at ≥ 20 weeks in 25 hospitals in the US, 2008-2011. Only patients with HDP were included in this analysis. Race and ethnicity were categorized as non-Hispanic White (NHW), non-Hispanic Black (NHB) and Hispanic. Associations were estimated between race and ethnicity and the primary outcome of severe maternal morbidity, defined as any of the following: blood transfusion ≥4 units, unexpected surgical procedure, need for a ventilator ≥ 12 hours, intensive care unit (ICU) admission, or failure of ≥ 1 organ system, were estimated by unadjusted logistic and multivariable backward logistic regressions. Multivariable models were run classifying HDP into 3 levels: 1) gestational hypertension; 2) preeclampsia (mild, severe or superimposed); and 3) eclampsia or HELLP.

Results: A total of 9,612 individuals with HDP were included. The frequency of the primary outcome, composite severe maternal morbidity, was higher in NHB patients compared with that in NHW or Hispanic patients (11.8% vs. 4.5% in NHW and 4.8% in Hispanic, p<0.001). This was driven by a higher frequency of blood transfusions and ICU admissions among NHB individuals. After adjusting for sociodemographic and clinical factors, hospital site, and the severity of HDP, the odds ratios of composite severe maternal morbidity did not differ between the groups (adjusted OR 1.26, 95% CI 0.95, 1.67 for NHB and adjusted OR 1.29, 95% CI 0.94, 1.77 for Hispanic, compared to NHW patients).

Conclusion: NHB patients with HDP had higher rates of the composite maternal morbidity compared with NHW, driven mainly by higher frequencies of blood transfusions and ICU admissions. However, once severity and other confounding factors were taken into account, the differences did not persist.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/a-1886-5404DOI Listing
June 2022

ASSOCIATION OF MATERNAL BODY MASS INDEX AND MATERNAL MORBIDITY AND MORTALITY.

Am J Perinatol 2022 Jun 16. Epub 2022 Jun 16.

Oregon Health Sciences University, Portland, Portland, United States.

Objective: To assess the association of maternal BMI with a composite of severe maternal outcomes.

Study Design: Secondary analysis of a cohort of deliveries on randomly selected days at 25 hospitals from 2008-2011. Data on comorbid conditions, intrapartum events, and postpartum course were collected. The reference group (REF, BMI 18.5-29.9), obese (OB, BMI 30-39.9), morbidly obese (MO, BMI 40-49.9) and super morbidly obese (SMO, BMI  50) women were compared. The composite of severe maternal outcomes was defined as death, ICU admission, ventilator use, DVT/PE, sepsis, hemorrhage, DIC, unplanned operative procedure, or stroke. Patients in the REF group were matched 1:1 with those in all other obesity groups based on propensity score using the baseline characteristics of age, race-ethnicity, previous cesarean, pre-existing diabetes, chronic hypertension, parity, cigarette use, and insurance status. Multivariable Poisson regression was used to estimate adjusted relative risks (aRR) and 95% confidence intervals (CI) for the association between BMI and the composite outcome. Because cesarean delivery may be in the causal pathway between obesity and adverse maternal outcomes, models were then adjusted for mode of delivery to evaluate potential mediation.

Results: A total of 52,162 pregnant patients are included in the analysis. Risk of composite maternal outcomes was increased for SMO compared with REF, but not for OB and MO [OB aRR 1.06 95%CI (0.99-1.14); MO aRR 1.10 (95%CI 0.97-1.25); SMO aRR 1.32 95%CI (1.02-1.70)]. However, in the mediation analysis, cesarean appears to mediate 46% (95%CI 31% - 50%) of the risk of severe morbidity for SMO compared with REF.

Conclusion: Super morbid obesity is significantly associated with increased serious maternal morbidity and mortality; however, cesarean appears to mediate this association. Obesity and morbid obesity are not associated with maternal morbidity and mortality.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/a-1877-8918DOI Listing
June 2022

Timing of Adjunctive Azithromycin for Unscheduled Cesarean Delivery and Postdelivery Infection.

Obstet Gynecol 2022 06 2;139(6):1043-1049. Epub 2022 May 2.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, the Center for Women's Reproductive Health, and the Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, and Mission Hospital, Asheville, North Carolina; and the Departments of Obstetrics and Gynecology, University of Texas Medical Branch at Galveston, Galveston, Texas, Ochsner Health System, New Orleans, Louisiana, University of Utah and Intermountain Health Care, Salt Lake City, Utah, Columbia University, New York, New York, University of Mississippi, Jackson, Mississippi, University of Texas Health Sciences Center, Houston, Texas.

Objective: To estimate the association between timing of administration of adjunctive azithromycin for prophylaxis at unscheduled cesarean delivery and maternal infection and neonatal morbidity.

Methods: We conducted a secondary analysis of a randomized trial of adjunctive azithromycin prophylaxis in patients with singleton gestations who were undergoing unscheduled cesarean delivery. The primary exposure was the timing of initiation of the study drug (after skin incision or 0-30 minutes, more than 30-60 minutes, or more than 60 minutes before skin incision). The primary outcome was a composite of endometritis, wound infection, and other maternal infections occurring up to 6 weeks after cesarean delivery. Secondary outcomes included composite neonatal morbidity, neonatal intensive care unit admission for longer than 72 hours, and neonatal sepsis. The association of azithromycin with outcomes was compared within each antibiotic timing group and presented as risk ratios (RRs) with 95% CIs. A Breslow-Day homogeneity test was applied to assess differences in association by antibiotic timing.

Results: Of 2,013 participants, antibiotics were initiated after skin incision (median 3 minutes, range 0-229 minutes) in 269 (13.4%), 0-30 minutes before skin incision in 1,378 (68.5%), more than 30-60 minutes before skin incision in 270 (13.4%), and more than 60 minutes before skin incision (median 85 minutes, range 61-218 minutes) in 96 (4.8%). The RRs (95% CIs) of the infectious composite outcome for azithromycin compared with placebo were significantly lower for groups that initiated azithromycin after skin incision or within 1 hour before skin incision (after skin incision: RR 0.31, 95% CI 0.13-0.76; 0-30 minutes before: RR 0.62, 95% CI 0.44-0.89; more than 30-60 minutes before: 0.31, 95% CI 0.13-0.66). Risks were not significantly different in patients who received azithromycin more than 60 minutes before skin incision (RR 0.59, 95% CI 0.10-3.36). Results were similar when endometritis and wound infections were analyzed separately. Neonatal outcomes were not significantly different for azithromycin compared with placebo across all timing groups.

Conclusion: Adjunctive azithromycin administration up to 60 minutes before or at a median of 3 minutes after skin incision was associated with reduced risks of maternal composite postoperative infection in unscheduled cesarean deliveries.

Clinical Trial Registration: ClinicalTrials.gov, NCT01235546.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/AOG.0000000000004788DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9199590PMC
June 2022

Potential missed opportunities for antenatal corticosteroid exposure and outcomes among periviable births: observational cohort study.

BJOG 2022 May 24. Epub 2022 May 24.

Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States.

Objective: Test the hypothesis potential missed opportunities for antenatal corticosteroids increase as gestational age decreases and are associated with adverse outcomes.

Design: Observational cohort study.

Setting: 24 US centers in the Neonatal Research Network.

Population: Actively treated infants 22-25 weeks' gestation and birth weight 401-1000 grams, without major birth defects, born 2006-2018.

Methods: Potential missed opportunity was defined as no antenatal corticosteroids but did have prenatal antibiotics, and/or magnesium sulfate, and/or prolonged rupture of membranes. Poisson regression models adjusted for baseline characteristics.

Main Outcome Measures: Antenatal corticosteroid exposure, mortality, and severe intracranial hemorrhage or periventricular leukomalacia.

Results: 6966 (87.5%) were exposed to antenatal corticosteroids, 454 (5.7%) had no exposure but potential missed opportunities for antenatal corticosteroid exposure, and 537 (6.7%) had no exposure and no evidence of potential missed opportunities. Compared with infants born at 25 weeks, potential missed opportunities for antenatal corticosteroid exposure were more likely at 22 weeks (adjusted relative risk (aRR) [95% CI] 11.06 [7.52-16.27]) and 23 weeks (3.24 [2.44-4.29]) but did not differ at 24 weeks (1.08 [0.82-1.42]). Potential missed opportunities for antenatal corticosteroids decreased over time at 22-23 weeks' gestation. Antenatal corticosteroid exposed infants had lower risk of death (31.0% vs 54.8%; 0.77 [0.70-0.84]) and survivors had lower risk of severe brain injury (25.0% v 44.5%; 0.64 [0.55-0.73]) compared with infants with potential missed opportunities.

Conclusion: Potential missed opportunities for antenatal corticosteroid exposure increased with decreasing gestational age and were associated with higher rates of death and severe brain injury among actively treated periviable births.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/1471-0528.17230DOI Listing
May 2022

Association of Body Mass Index With the Use of Health Care Resources in Low-Risk Nulliparous Pregnancies After 39 Weeks of Gestation.

Obstet Gynecol 2022 05 5;139(5):866-876. Epub 2022 Apr 5.

Departments of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio, Northwestern University, Chicago, Illinois, University of Alabama at Birmingham, Birmingham, Alabama, University of Utah Health Sciences Center, Salt Lake City, Utah, Stanford University, Stanford, California, Columbia University, New York, New York, Brown University, Providence, Rhode Island, University of Texas Medical Branch, Galveston, Texas, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, Texas, MetroHealth Medical Center-Case Western Reserve University, Cleveland, Ohio, University of Texas Southwestern Medical Center, Dallas, Texas, University of Pennsylvania, Philadelphia, Pennsylvania, Duke University, Durham, North Carolina, and University of Pittsburgh, Pittsburgh, Pennsylvania; and the George Washington University Biostatistics Center, Washington, DC; and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland.

Objective: To compare health care medical resource utilization in low-risk nulliparous pregnancies according to body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) categories.

Methods: This is a secondary analysis of a multicenter randomized controlled trial of induction of labor between 39 0/7 39 and 4/7 weeks of gestation compared with expectant management in low-risk nulliparous pregnant people, defined as those without standard obstetric indications for delivery at 39 weeks. Body mass index at randomization was categorized into four groups (lower than 25, 25-29, 30-39, and 40 or higher). The primary outcome of this analysis was time spent in the labor and delivery department from admission to delivery. Secondary outcomes included length of stay (LOS) postdelivery, total hospital LOS, and antepartum, intrapartum, and postpartum resource utilization, which were defined a priori. Multivariable generalized linear modeling and logistic regressions were performed, and 99% CIs were calculated.

Results: A total of 6,058 pregnant people were included in the analysis; 640 (10.6%) had BMIs of lower than 25, 2,222 (36.7%) had BMIs between 25 and 29, 2,577 (42.5%) had BMIs of 30-39, and 619 (10.2%) had BMIs of 40 or higher. Time spent in the labor and delivery department increased from 15.1±9.2 hours for people with BMIs of lower than 25 to 23.5±13.6 hours for people with BMIs of 40 or higher, and every 5-unit increase in BMI was associated with an average 9.8% increase in time spent in the labor and delivery department (adjusted estimate per 5-unit increase in BMI 1.10, 99% CI 1.08-1.11). Increasing BMI was not associated with an increase in antepartum resource utilization, except for blood tests and urinalysis. However, increasing BMI was associated with higher odds of intrapartum resource utilization, longer total hospital LOS, and postpartum resource utilization. For example, every 5-unit increase in BMI was associated with an increase of 26.1% in the odds of antibiotic administration, 57.6% in placement of intrauterine pressure catheter, 5.1% in total inpatient LOS, 31.0 in postpartum emergency department visit, and 23.9% in postpartum hospital admission.

Conclusion: Among low-risk nulliparous people, higher BMI was associated with longer time from admission to delivery, total hospital LOS, and more frequent utilization of intrapartum and postpartum resources.

Clinical Trial Registration: ClinicalTrials.gov, NCT01990612.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/AOG.0000000000004753DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9142136PMC
May 2022

mHealth Phone Intervention to Reduce Maternal Deaths and Morbidity in Cameroon: Protocol for Translational Adaptation.

Int J Womens Health 2022 7;14:677-686. Epub 2022 May 7.

Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA.

Purpose: The purpose of this NIH-funded protocol is to adapt (Aim 1) and pilot test (Aim 2) an mHealth intervention to improve maternal and child health in Cameroon. We will adapt the 24/7 University of Alabama at Birmingham Medical Information Service via Telephone (MIST) provider support system to mMIST (mobile MIST) for peripheral providers who provide healthcare to pregnant and postpartum women and newborns in Cameroon.

Methods: In Aim 1, we apply qualitative and participatory methods (in-depth interviews and focus groups with key stakeholders) to inform the adaptation of mMIST for use in Cameroon. We use the sequential phases of the ADAPT-ITT framework to iteratively adapt mMIST incorporating qualitative findings and tailoring for local contexts. In Aim 2, we test the adapted intervention for feasibility and acceptability in Ndop, Cameroon.

Results: This study is ongoing at the time that this protocol is published.

Conclusion: The adaptation, refinement, and pilot testing of mMIST will be used to inform a larger-scale stepped wedged cluster randomized controlled effectiveness trial. If successful, this mHealth intervention could be a powerful tool enabling providers in low-resource settings to deliver improved pregnancy care, thereby reducing maternal and fetal deaths.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2147/IJWH.S353919DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9093609PMC
May 2022

Performance of a Multianalyte 'Rule-Out' Assay in Pregnant Individuals With Suspected Preeclampsia.

Hypertension 2022 07 12;79(7):1515-1524. Epub 2022 May 12.

Progenity, Inc, San Diego, CA (P.O., A.M., M.C., S.L.).

Background: The ability to diagnose preeclampsia clinically is suboptimal. Our objective was to validate a novel multianalyte assay and characterize its performance, when intended for use as an aid to rule-out preeclampsia.

Methods: Prospective, multicenter cohort study of pregnant individuals presenting between 28 and 36 weeks' with preeclampsia-associated signs and symptoms. Individuals not diagnosed with preeclampsia after baseline evaluation were enrolled in the study cohort, with those who later developed preeclampsia, classified as cases and compared with a negative control group who did not develop preeclampsia. Individuals with assay values at time of enrollment ≥0.0325, determined using a previously developed algorithm, considered at risk. The primary analysis was the time to develop preeclampsia assessed using a multivariate Cox regression model.

Results: One thousand thirty-six pregnant individuals were enrolled in the study cohort with an incidence of preeclampsia of 30.3% (27.6%-33.2%). The time to develop preeclampsia was shorter for those with an at-risk compared with negative assay result (log-rank <0.0001; adjusted hazard ratio of 4.81 [3.69-6.27, <0.0001]). The performance metrics for the assay to rule-out preeclampsia within 7 days of enrollment showed a sensitivity 76.4% (67.5%-83.5%), negative predictive value 95.0% (92.8%-96.6%), and negative likelihood ratio 0.46 (0.32-0.65). Assay performance improved if delivery occurred <37 weeks and for individuals enrolled between 28 and 35 weeks.

Conclusions: We confirmed that a novel multianalyte assay was associated with the time to develop preeclampsia and has a moderate sensitivity and negative likelihood ratio but high negative predictive value when assessed as an aid to rule out preeclampsia within 7 days of enrollment.

Registration: The study was registered on Clinicaltrials.gov (Identifier NCT02780414).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/HYPERTENSIONAHA.122.19038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9172903PMC
July 2022

Amniocentesis to diagnose congenital cytomegalovirus infection following maternal primary infection.

Am J Obstet Gynecol MFM 2022 07 6;4(4):100641. Epub 2022 May 6.

Washington University in St. Louis, MO (Dr Macones).

Background: Congenital cytomegalovirus infection following maternal primary cytomegalovirus infection affects approximately 0.4% of newborns in the United States but may be hard to diagnose prenatally.

Objective: To evaluate the current sensitivity and specificity of amniocentesis in detecting congenital cytomegalovirus infection.

Study Design: Secondary analysis of a multicenter randomized placebo-controlled trial designed to evaluate whether cytomegalovirus hyperimmune globulin reduces congenital cytomegalovirus infection in neonates of individuals diagnosed with primary cytomegalovirus infection before 24 weeks of gestation. At randomization, subjects had no clinical evidence of fetal infection. Eligible subjects were randomized to monthly infusions of cytomegalovirus hyperimmune globulin or placebo until delivery. Although not required by the trial protocol, amniocentesis following randomization was permitted. The fetuses and neonates were tested for the presence of cytomegalovirus at delivery. Comparisons were made between those with and without amniocentesis and between those with cytomegalovirus-positive and negative results, using chi-square or Fisher exact test for categorical variables and the Wilcoxon rank sum test or t test for continuous variables. A P value of <.05 was considered significant.

Results: From 2012 to 2018, 397 subjects were included, of whom 55 (14%) underwent amniocentesis. Cytomegalovirus results were available for 53 fetuses and neonates. Fourteen amniocenteses were positive (25%). Gestational age at amniocentesis was similar between those with and without cytomegalovirus present, as was the interval between maternal diagnosis and amniocentesis. The prevalence of fetal or neonatal infection was 26% (14/53). The neonates of all 12 subjects with a positive amniocentesis and available results had cytomegalovirus infection confirmed at delivery, as did 2 neonates from the group of 41 subjects with a negative amniocentesis, with a sensitivity of 86% (95% confidence interval, 57-98), specificity of 100% (95% confidence interval, 91-100), positive predictive value of 100% (95% confidence interval, 74-100), and negative predictive value of 95% (95% confidence interval, 83-99). Amniocentesis-positive pregnancies were delivered at an earlier gestational age (37.4 vs 39.6 weeks; P<.001) and had lower birthweights (2583±749 vs 3428±608 g, P=.004) than amniocentesis-negative pregnancies.

Conclusion: Amniocentesis results are an accurate predictor of congenital cytomegalovirus infection.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajogmf.2022.100641DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9167787PMC
July 2022

Prefusion F Protein-Based Respiratory Syncytial Virus Immunization in Pregnancy.

N Engl J Med 2022 04;386(17):1615-1626

From the University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (E.A.F.S.); Vaccine Research and Development, Pfizer, Pearl River, NY (K.J.C., K.A.S., D.R., S.B.M., E.G., D.A.S., K.U.J., W.C.G., P.R.D., A.C.G.); the Center for Women's Reproductive Health and the Department of Obstetrics and Gynecology, University of Alabama, Birmingham (A.T.N.T.); the Iowa Clinic, Des Moines (J.H.); and Gadolin Research, Beaumont (M.A.), and Ventavia Research Group, Plano (J.P.R.) - both in Texas.

Background: Respiratory syncytial virus (RSV), a major cause of illness and death in infants worldwide, could be prevented by vaccination during pregnancy. The efficacy, immunogenicity, and safety of a bivalent RSV prefusion F protein-based (RSVpreF) vaccine in pregnant women and their infants are uncertain.

Methods: In a phase 2b trial, we randomly assigned pregnant women, at 24 through 36 weeks' gestation, to receive either 120 or 240 μg of RSVpreF vaccine (with or without aluminum hydroxide) or placebo. The trial included safety end points and immunogenicity end points that, in this interim analysis, included 50% titers of RSV A, B, and combined A/B neutralizing antibodies in maternal serum at delivery and in umbilical-cord blood, as well as maternal-to-infant transplacental transfer ratios.

Results: This planned interim analysis included 406 women and 403 infants; 327 women (80.5%) received RSVpreF vaccine. Most postvaccination reactions were mild to moderate; the incidence of local reactions was higher among women who received RSVpreF vaccine containing aluminum hydroxide than among those who received RSVpreF vaccine without aluminum hydroxide. The incidences of adverse events in the women and infants were similar in the vaccine and placebo groups; the type and frequency of these events were consistent with the background incidences among pregnant women and infants. The geometric mean ratios of 50% neutralizing titers between the infants of vaccine recipients and those of placebo recipients ranged from 9.7 to 11.7 among those with RSV A neutralizing antibodies and from 13.6 to 16.8 among those with RSV B neutralizing antibodies. Transplacental neutralizing antibody transfer ratios ranged from 1.41 to 2.10 and were higher with nonaluminum formulations than with aluminum formulations. Across the range of assessed gestational ages, infants of women who were immunized had similar titers in umbilical-cord blood and similar transplacental transfer ratios.

Conclusions: RSVpreF vaccine elicited neutralizing antibody responses with efficient transplacental transfer and without evident safety concerns. (Funded by Pfizer; ClinicalTrials.gov number, NCT04032093.).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1056/NEJMoa2106062DOI Listing
April 2022

Factors That Influence Posthospital Infant Feeding Practices Among Women Who Deliver at a Baby Friendly Hospital in Southern United States.

Breastfeed Med 2022 07 11;17(7):584-592. Epub 2022 Apr 11.

Department of Obstetrics and Gynecology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA.

The Baby Friendly Hospital Initiative has had a positive impact on breastfeeding initiation; however, little is known about posthospital infant feeding practices among women who deliver at baby friendly hospitals. Therefore we sought to evaluate posthospital breastfeeding outcomes among women who deliver at a baby friendly hospital (BFH) by (1) estimating exclusive breastfeeding rates at the postpartum visit (PPV), (2) quantifying the exclusive breastfeeding discontinuation rate, and (3) identifying which factors are associated with breastfeeding discontinuation. This was a prospective cohort study of women aged 14 and over, who delivered at the University of Alabama at Birmingham. The primary outcome was mode of infant feeding categorized as exclusive breastfeeding (EBF), combination breastfeeding and formula feeding (CF), and exclusive formula feeding (EFF) at the PPV. Secondary outcome was EBF discontinuation rate. Patients who initiated formula and/or who stopped breastfeeding were asked what influenced their decision. At hospital discharge, 71.1% of the participants were EBF, 21.7% were CF, and 7.2% were EFF. At the PPV, the frequency of the primary outcome of EBF was 31.6% (95% confidence interval: 25.2-38.8); 34.6% (28.0-41.9) were CF, and 33.8% (27.3-41.1) were EFF. Therefore, the EBF absolute and relative discontinuation rates were 39.5% and 55.6%, respectively. No demographic factors, delivery characteristics, or maternal medical morbidities were associated with EBF in the multivariable logistic regression. However, women in the EBF group were more likely to report a workplace environment conducive to breastfeeding and partner and friend support. Significant breastfeeding discontinuation rates occur even among women who deliver at a BFH. Our findings suggest that multifactorial interventions, including a focus on the prevention of formula introduction, are needed in the early postpartum period to achieve higher EBF rates at the PPV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/bfm.2021.0324DOI Listing
July 2022

Maternal Diabetes and Intrapartum Fetal Electrocardiogram.

Am J Perinatol 2022 04 5. Epub 2022 Apr 5.

University of Pittsburgh, Pittsburgh, Pennsylvania.

Objective: Fetal electrocardiogram (ECG) ST changes are associated with fetal cardiac hypoxia. Our objective was to evaluate ST changes by maternal diabetic status and stage of labor.

Methods: This was a secondary analysis of a multicentered randomized-controlled trial in which laboring patients with singleton gestations underwent fetal ECG scalp electrode placement and were randomly assigned to masked or unmasked ST-segment readings. Our primary outcome was the frequency of fetal ECG tracings with ST changes by the stage of labor. ECG tracings were categorized into mutually exclusive groups (ST depression, ST elevation without ST depression, or no ST changes). We compared participants with DM, gestational diabetes mellitus (GDM), and no DM.

Results: Of the 5,436 eligible individuals in the first stage of labor (95 with pregestational DM and 370 with GDM), 4,427 progressed to the second stage. ST depression occurred more frequently in the first stage of labor in participants with pregestational DM (15%, adjusted odds ratio [aOR] 2.20, 95% confidence interval [CI] 1.14-4.24) and with GDM (9.5%, aOR 1.51, 95% CI 1.02-2.25) as compared with participants without DM (5.7%). The frequency of ST elevation was similar in participants with pregestational DM (33%, aOR 0.79, 95% CI 0.48-1.30) and GDM (33.2%, aOR 0.91, 95% CI 0.71-1.17) as compared with those without DM (34.2%). In the second stage, ST depression did not occur in participants with pregestational DM (0%) and occurred more frequently in participants with GDM (3.5%, aOR 2.01, 95% CI 1.02-3.98) as compared with those without DM (2.0%). ST elevation occurred more frequently in participants with pregestational DM (30%, aOR 1.81, 95% CI 1.02-3.22) but not with GDM (19.0%, aOR 1.06, 95% CI 0.77-1.47) as compared with those without DM (17.8%).

Conclusion: ST changes in fetal ECG occur more frequently in fetuses of diabetic mothers during labor.

Clinicaltrials: gov number, NCT01131260.

Precis: ST changes in fetal ECG, a marker of fetal cardiac hypoxia, occur more frequently in fetuses of diabetic parturients.

Key Points: · Fetal hypertrophic cardiomyopathy (HCM) and cardiac dysfunction occur frequently among fetuses of diabetic patients.. · Fetal ECG changes such as ST elevation and depression reflect cardiac hypoxia.. · Fetuses of diabetic patients demonstrate a higher prevalence of fetal ECG tracings with ST changes..
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/a-1817-5788DOI Listing
April 2022

Associations of Maternal Prenatal Stress and Depressive Symptoms With Childhood Neurobehavioral Outcomes in the ECHO Cohort of the NICHD Fetal Growth Studies: Fetal Growth Velocity as a Potential Mediator.

J Am Acad Child Adolesc Psychiatry 2022 Mar 30. Epub 2022 Mar 30.

Columbia University, New York.

Objective: Maternal prenatal stress and mood symptoms are associated with risk for child psychopathology. Within the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Fetal Growth Studies (ECHO-FGS), a racially and ethnically diverse cohort, we studied associations between prenatal stress and depressive symptoms with child neurobehavior, and potential mediation by fetal growth velocity (FGV) in low-risk pregnancies.

Method: For 730 mother-child pairs, we had serial ultrasound measurements, self-reports of prenatal stress and depression, observations of child executive functions and motor skills from 4 to 8 years, and maternal reports of child psychiatric problems. We tested associations between prenatal stress and depressive symptoms with child neurobehavior in regression analyses, and associations with FGV in mixed effect models. Post hoc we tested severity of prenatal symptoms; FGV at 25, 50, and 75 percentiles; and moderation by biological sex and by race and ethnicity.

Results: Prenatal stress and depressive symptoms were associated with child psychiatric problems, and prenatal depressive symptoms with decrements in executive functions and motor skills, especially in biological male children. Neither prenatal stress nor depressive symptoms were associated with FGV.

Conclusion: In one of the largest cohorts with observed child outcomes, and the first with broad representation of race and ethnicity in the United States, we found that prenatal stress and depressive symptoms were associated with greater reports of child psychiatric symptoms. Only prenatal depressive symptoms were associated with observed decrements in cognitive abilities, most significantly in biological male children. Stress during low-risk pregnancies may be less detrimental than theorized. There was no mediation by FGV. These findings support the need to attend to even small changes in prenatal distress, as these may have long-lasting implications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jaac.2022.03.021DOI Listing
March 2022

Treatment for Mild Chronic Hypertension during Pregnancy.

N Engl J Med 2022 05 2;386(19):1781-1792. Epub 2022 Apr 2.

From the Department of Obstetrics and Gynecology (A.T.T., W.W.A.), the Center for Women's Reproductive Health (A.T.T., J.M.S., N.A., S.O., G.R.C., W.W.A.), the Department of Biostatistics (J.M.S., G.R.C.), the Division of Neonatology, Department of Pediatrics (N.A.), and the Division of Cardiovascular Disease, Department of Medicine (S.O.), University of Alabama, Birmingham; the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill (K.B.), and the Department of Obstetrics and Gynecology, Duke University, Durham (B.L.H.) - both in North Carolina; the Department of Obstetrics and Gynecology, University of Pennsylvania (L.D.), and the Department of Obstetrics and Gynecology, Drexel University College of Medicine (L.P.), Philadelphia, St. Luke's University Health Network, Fountain Hill (J.B.), and the Department of Obstetrics and Gynecology, Magee Women's Hospital, University of Pittsburgh, Pittsburgh (H.N.S.) - all in Pennsylvania; the Department of Obstetrics and Gynecology, University of Texas (B.S.), and the Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston (K.A.), the Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas (B.C.), the Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston (G.R.S.), and the Department of Women's Health, University of Texas, Austin (L.H.); the Department of Obstetrics and Gynecology, Columbia University (K.L.), Weill Cornell University (P.A.), and the Department of Obstetrics and Gynecology, New York Presbyterian Queens Hospital (D.S.), New York, and the Department of Obstetrics and Gynecology, Winthrop University Hospital, Mineola (W.K.) - all in New York; the Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences, Oklahoma City (R.K.E.); MetroHealth System, Cleveland (K.G.); the Department of Obstetrics and Gynecology, Indiana University, Indianapolis (D.M.H.); the Department of Obstetrics and Gynecology, University of Utah (T.M.), and Intermountain Healthcare (S.E.), Salt Lake City; Ochsner Baptist Medical Center, New Orleans (S.L.); Christiana Care Health Services, Newark, DE (M.H.); the Department of Obstetrics and Gynecology, UnityPoint Health-Meriter Hospital/Marshfield Clinic, Madison (K.K.H.), and the Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee (A.P.); St. Peters University Hospital (J.F.) and the Department of Obstetrics and Gynecology, Robert Wood Johnson Medical School, Rutgers University (T.R.), New Brunswick, NJ; the Department of Obstetrics and Gynecology, Washington University, St. Louis (M.T.); the Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson (M.Y.O.); the Department of Obstetrics and Gynecology, Ohio State University, Columbus (H.F.); the Department of Obstetrics and Gynecology, University of South Alabama, Mobile (S.B.); the Department of Obstetrics and Gynecology, Yale University, New Haven, CT (U.M.R.); the Department of Obstetrics and Gynecology, University of Colorado, Boulder (E.S.), and the Department of Obstetrics and Gynecology, Denver Health, Denver (N.N.); the Department of Obstetrics and Gynecology, Emory University, Atlanta (I.K.); the Department of Obstetrics and Gynecology, University of California, San Francisco, and Zuckerberg San Francisco General Hospital (M.E.N.), San Francisco, the Department of Obstetrics and Gynecology, Stanford University, Stanford (Y.Y.E.-S.), and the Department of Obstetrics and Gynecology, Arrowhead Regional Medical Center, Colton (D.O.); Beaumont Hospital, Southfield, MI (D.O.); and the Division of Cardiovascular Sciences (Z.S.G.) and the Office of Biostatistics Research (N.L.G.), National Heart, Lung, and Blood Institute, Bethesda, MD.

Background: The benefits and safety of the treatment of mild chronic hypertension (blood pressure, <160/100 mm Hg) during pregnancy are uncertain. Data are needed on whether a strategy of targeting a blood pressure of less than 140/90 mm Hg reduces the incidence of adverse pregnancy outcomes without compromising fetal growth.

Methods: In this open-label, multicenter, randomized trial, we assigned pregnant women with mild chronic hypertension and singleton fetuses at a gestational age of less than 23 weeks to receive antihypertensive medications recommended for use in pregnancy (active-treatment group) or to receive no such treatment unless severe hypertension (systolic pressure, ≥160 mm Hg; or diastolic pressure, ≥105 mm Hg) developed (control group). The primary outcome was a composite of preeclampsia with severe features, medically indicated preterm birth at less than 35 weeks' gestation, placental abruption, or fetal or neonatal death. The safety outcome was small-for-gestational-age birth weight below the 10th percentile for gestational age. Secondary outcomes included composites of serious neonatal or maternal complications, preeclampsia, and preterm birth.

Results: A total of 2408 women were enrolled in the trial. The incidence of a primary-outcome event was lower in the active-treatment group than in the control group (30.2% vs. 37.0%), for an adjusted risk ratio of 0.82 (95% confidence interval [CI], 0.74 to 0.92; P<0.001). The percentage of small-for-gestational-age birth weights below the 10th percentile was 11.2% in the active-treatment group and 10.4% in the control group (adjusted risk ratio, 1.04; 95% CI, 0.82 to 1.31; P = 0.76). The incidence of serious maternal complications was 2.1% and 2.8%, respectively (risk ratio, 0.75; 95% CI, 0.45 to 1.26), and the incidence of severe neonatal complications was 2.0% and 2.6% (risk ratio, 0.77; 95% CI, 0.45 to 1.30). The incidence of any preeclampsia in the two groups was 24.4% and 31.1%, respectively (risk ratio, 0.79; 95% CI, 0.69 to 0.89), and the incidence of preterm birth was 27.5% and 31.4% (risk ratio, 0.87; 95% CI, 0.77 to 0.99).

Conclusions: In pregnant women with mild chronic hypertension, a strategy of targeting a blood pressure of less than 140/90 mm Hg was associated with better pregnancy outcomes than a strategy of reserving treatment only for severe hypertension, with no increase in the risk of small-for-gestational-age birth weight. (Funded by the National Heart, Lung, and Blood Institute; CHAP ClinicalTrials.gov number, NCT02299414.).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1056/NEJMoa2201295DOI Listing
May 2022

Euglycemia after antenatal late preterm steroids: a multicenter, randomized controlled trial.

Am J Obstet Gynecol MFM 2022 07 26;4(4):100625. Epub 2022 Mar 26.

Department of Obstetrics and Gynecology, The University of North Carolina at Chapel Hill, Chapel Hill, NC.

Background: Late preterm steroid administration can induce transient maternal and thus fetal hyperglycemia, which can increase production of fetal insulin and C-peptide. Infants delivered in this setting are subsequently at increased risk for hypoglycemia. Although maternal glycemic control before delivery is a key component of care for parturients with diabetes, this intervention has not been studied in the setting of late preterm steroid administration.

Objective: This study aimed to determine the effect of maternal screening for and treatment of hyperglycemia after late preterm steroid administration on fetal C-peptide levels and other metabolic markers.

Study Design: This was a multicenter, randomized trial (NCT03076775) of nondiabetic parturients with a singleton gestation receiving betamethasone at 34 0/7 weeks to 36 5/7 weeks for anticipated preterm birth. Participants randomized to maternal glycemic control received fasting and 1-hour postprandial or serial intrapartum capillary blood glucose screening with insulin treatment as indicated. Those randomized to expectant management did not receive any glucose screening or treatment. The primary outcome was fetal C-peptide level measured from umbilical cord blood at delivery. Secondary outcomes included other fetal metabolic markers and neonatal hypoglycemia (glucose level <40 mg/dL). Baseline characteristics and outcomes were compared between the groups. We estimated that we would need a sample size of 144 to provide >90% power to show a 1 ng/mL decrease in C-peptide concentration (±1.5 ng/mL) at ⍺=0.05 using a 2-sample t test and 1 interim analysis. After the interim analysis, the trial was stopped for futility.

Results: Of 491 screened parturients, 163 (33%) were deemed eligible and 86 (53%) were randomized to 1 of the treatment groups (June 2017 to February 2021). One person was lost to follow-up because of delivery at another hospital. Baseline characteristics were similar between groups. The median interval from betamethasone administration to delivery was 24 hours (interquartile range, 13-96 hours) and did not differ between groups (P=.82). Most (82%) randomized to maternal glycemic control had hyperglycemia: 80% had at least 1 fasting glucose level >95 mg/dL, 75% had at least one 1-hour postprandial glucose level >140 mg/dL, and 80% had at least 1 intrapartum glucose level >110 mg/dL. In addition, 15% had at least 1 glucose level >180 mg/dL. None had maternal hypoglycemia after insulin treatment. Compared with expectant management, maternal glycemic control did not affect the median fetal C-peptide level (1.02; interquartile range, 0.52-1.85 vs 1.09; interquartile range, 0.61-1.65; P=.97) or other metabolic markers. Maternal glycemic control also did not affect neonatal hypoglycemia (49% vs 51%; P=.83) or other secondary neonatal or maternal outcomes. There was no evidence of effect modification by gestational age or body mass index at randomization, indication for betamethasone, duration from betamethasone to delivery, maternal race or ethnicity, or neonatal sex. In addition, the results were unchanged in a sensitivity analysis using a per-protocol approach.

Conclusion: Maternal hyperglycemia was observed in most nondiabetic parturients after receiving late preterm betamethasone. However, there was no improvement in fetal metabolic status, neonatal hypoglycemia, or other neonatal or maternal outcomes with maternal glycemic control. Therefore, maternal glucose surveillance and treatment does not seem to be beneficial in nondiabetic parturients receiving late preterm steroids.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajogmf.2022.100625DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9195161PMC
July 2022

The association between maternal pre-pregnancy BMI, gestational weight gain and child adiposity: A racial-ethnically diverse cohort of children.

Pediatr Obes 2022 08 15;17(8):e12911. Epub 2022 Mar 15.

Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA.

Background: The prevalence of obesity in US children has more than tripled in the past 40 years; hence, it is critical to identify potentially modifiable factors that may mitigate the risk.

Objectives: To examine the association between maternal pre-pregnancy body mass index (BMI), gestational weight gain (GWG) and child adiposity as measured by BMI, waist circumference and percent body fat in a racial-ethnically diverse cohort.

Methods: In a prospective cohort study of healthy women without chronic disease, we examined the association between pre-pregnancy BMI, GWG and child adiposity. Children ages 4-8 years (n = 816) in the Environmental Influences on Child Health Outcomes-NICHD Fetal Growth Studies were assessed. Trained study staff ascertained maternal pre-pregnancy BMI, GWG and child adiposity.

Results: The odds of child obesity (≥95th BMI percentile) increased independently for each unit increase in maternal pre-pregnancy BMI [OR = 1.12 (95% CI: 1.08, 1.17)] and for each 5-kg increase in GWG [OR = 1.25 (95% CI: 1.07, 1.47)]. The odds of child waist circumference (≥85th percentile) also increased independently for pre-pregnancy BMI [OR = 1.09 (95% CI: 1.05, 1.12)] and GWG [OR = 1.18 (95% CI: 1.04, 1.34)].

Conclusions: Maternal pre-pregnancy BMI and GWG were each independently and positively associated with child obesity and high child waist circumference.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ijpo.12911DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9283205PMC
August 2022

Effect of misoprostol on type 3 transformation zone of the cervix among Cameroonian women.

Gynecol Oncol Rep 2022 Apr 1;40:100944. Epub 2022 Mar 1.

Center for Women's Reproductive Health, Department of Obstetrics & Gynecology, University of Alabama at Birmingham, 1700 6th Avenue South, Suite 10270, Birmingham, AL 35233, USA.

Background: Type 3 transformation zone (TZ) of the cervix has been shown to be associated with a four to five-fold increased risk of missed precancerous/cancerous lesions. The aim of this study was to evaluate the effect of intravaginal misoprostol on the TZ among women with Type 3 TZ in Cameroon.

Materials And Methods: A single dose of vaginal misoprostol (400 mcg or 600 mcg) was administered as part of the plan of care for women with Type 3 TZ during cervical cancer screening. The primary outcome was successful conversion from Type 3 TZ to Types 1 or 2 TZ. Descriptive analysis was performed using chi-square and Fisher's exact tests.

Results: Among the 90 of 107 (84.2%) women who returned for re-evaluation of the cervix, 43 (47.8%, 95% CI: 0.36%-0.60%) had conversion of Type 3 TZ to Types 1 or 2. Women who received misoprostol 600 mcg were more likely to have their Type 3 TZs converted to Types 1 or 2 than women receiving 400 mcg (p = 0.037).

Conclusion: Misoprostol converted approximately 50% of Type 3 TZ to Types 1 or 2 in Cameroon. Misoprostol is feasible in converting Type 3 TZ to Types 1 or 2 among Cameroonian women.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.gore.2022.100944DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8899222PMC
April 2022

Timing of Maternal Discharge after Cesarean Delivery and Risk of Maternal Readmission.

Am J Perinatol 2022 07 4;39(10):1042-1047. Epub 2022 Mar 4.

Birmingham, Alabama.

Objective: Despite legislation and hospital policies (present in some institutions) mandating a minimum length of stay in an effort to decrease the frequency of hospital readmissions, the effectiveness of this approach remains uncertain.We hypothesized that following cesarean delivery (CD), the rates of maternal readmission or unscheduled health care visits are lower in patients discharged on postoperative day (POD) 3 or ≥4 as compared with those discharged earlier on POD 2.

Methods: This is a secondary analysis of a multicenter randomized trial comparing adjunctive azithromycin for unscheduled CD to prevent infection. Groups were compared based on the duration of hospitalization measured in days from delivery (POD 0) to day of discharge and categorized as POD 2, 3, and ≥4. The primary outcome was the composite of any maternal postpartum readmission, unscheduled clinic, or emergency room (ER) visit, within 6 weeks of delivery. Secondary outcomes included components of the primary outcome and neonatal readmissions. We excluded women with hypertensive disorders of pregnancy and infections diagnosed prior to POD 2.

Results: A total of 1,391 patients were included. The rate of the primary outcome of any readmission increased with POD at discharge: 5.9% for POD 2, 9.4% for POD 3, and 10.9% for POD ≥4 group (trend for  = 0.03). The primary outcome increased with later discharge (POD ≥4 when compared with POD 2). Among components of the composite, ER and unscheduled clinic visits, but not maternal readmissions, increased with the timing of discharge for patients discharged on POD ≥4 when compared with POD 2. Using logistic regression, discharge on POD 3 and on POD ≥4 was significantly associated with the composite (adjusted odds ratios [aOR] 2.6, 95% confidence interval [CI] [1.3-5.3]; aOR 2.9, 95% CI [1.3-6.4], respectively) compared with POD 2.

Conclusion: The risk of maternal readmission composite following uncomplicated but unscheduled CD was not lower in patients discharged home on POD 3 or ≥4 compared with patients discharged earlier (POD 2).

Key Points: · Risk of maternal readmission is higher in patients discharged on POD 3 or 4 compared with POD 2.. · No significant differences by the timing of discharge were observed for any neonatal readmissions.. · Timing of discharge should include an individualized approach with the option of discharge by POD 2..
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0042-1743248DOI Listing
July 2022

Contemporary Test Performance of the Random Urine Protein-to-creatinine Ratio.

Am J Perinatol 2022 Mar 3. Epub 2022 Mar 3.

Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama.

Objective:  The random urine protein-to-creatinine ratio (UPCR) is a screening test used for predicting clinically significant proteinuria (urine protein  ≥ 300 mg) during pregnancy. No consensus exists on the optimal random UPCR cutoff for performing follow-up 24 hour urine (24H) total protein collection. We aim to evaluate the test performance of random UPCR in predicting proteinuria in a contemporary cohort.

Study Design:  This was a retrospective cohort study of pregnant patients at our institution from 2014 to 2018 with a random UPCR and follow-up 24H protein collection. The primary analysis estimated the test characteristics (sensitivity, specificity, positive and negative predictive values) of using random UPCR for the detection of proteinuria defined as urine protein ≥300 mg on 24H protein collection. UPCR cutoffs from 0.10 to 0.30 mg/dL were evaluated, receiver operator characteristic (ROC) curve was constructed, and area under the curve (AUC) was determined. A secondary analysis examined the correlation between UPCR and 24H protein using least squares regression and Pearson correlation.

Results:  Paired UPCR and 24H collection results were available for 1,120 patients. Mean gestational age at time of UPCR was 31.1 ± 5.1 weeks and 687 (61.3%) of patients had a 24H ≥300 mg. UPCR <0.10 mg/dL effectively excluded proteinuria ≥300 mg on 24H collection, while UPCR ≥0.18 mg/dL correctly classifies proteinuria with 91% sensitivity, 57% specificity, 77% positive predictive value, and 79% negative predictive value. UPCR ≥1.07 mg/dL had 100% specificity for 24 hour proteinuria. The area under ROC curve was 0.86. UPCR and 24H collection were highly correlated with a Pearson correlation coefficient of 0.85. After our institution lowered the threshold to obtain a 24H from UPCR ≥0.20 mg/dL to ≥0.10 mg/dL in May 2017, the percentage of patients meeting criteria for 24H collection increased from 57.8 to 84.4%.

Conclusion:  The AUC and Pearson correlation suggest random UPCR is a high performance test for the prediction of proteinuria on 24H. Optimal test performance is dependent upon clinical consideration and upon the implications of the disease or condition. A random UPCR screen positive threshold of 0.18 mg/dL maximizes sensitivity to identify clinically significant proteinuria.

Key Points: · Random urine protein to creatinine ratio is a high performance test for proteinuria.. · A random UPCR threshold of 0.18 mg/dL maximizes sensitivity to identify proteinuria.. · Optimal test performance is dependent on the disease or clinical condition..
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/a-1786-8847DOI Listing
March 2022

Impact of pushing timing on occult injury of levator ani: secondary analysis of a randomized trial.

Am J Obstet Gynecol 2022 05 22;226(5):718.e1-718.e10. Epub 2022 Feb 22.

Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL; Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL.

Background: Evidence of detachment of the levator ani muscle system is seen more frequently in patients with pelvic floor disorders. It has been suggested that passive descent of the fetus before pushing could be used to decrease operative vaginal delivery and levator ani muscle injury.

Objective: This planned analysis aimed to determine whether immediate or delayed pushing was associated with an increased proportion of injury to the levator ani muscle system after the first delivery among nulliparous women.

Study Design: The Optimizing Management of the Second Stage study was a multicenter randomized trial. Nulliparous women with term pregnancies and neuraxial analgesia were randomly assigned at complete cervical dilation to either immediate pushing or delayed pushing for 1 hour. A subset of participants consented to longitudinal objective pelvic floor assessments: (1) during postpartum stay (initial), (2) at 6 weeks (postpartum 1), and (3) at 6 months (postpartum 2) with transperineal 3-dimensional ultrasound. Following the completion of all visits by all subjects, saved 3-dimensional ultrasound volumes were assessed in a masked fashion. The outcome was "occult" levator ani muscle injury on the right or left, defined as a widening of the attachment of the levator ani to its origin utilizing the levator-urethra gap measurement. Measurements and proportions were compared between the 2 groups by study visit using the χ test or Fisher exact test for categorical variables and the t test or Mann-Whitney U test for continuous variables as appropriate.

Results: Here, 941 of 2414 randomized subjects (39.0%) participated in the pelvic floor assessments: 452 in the immediate pushing group and 489 in the delayed pushing group. We obtained sonograms on 67%, 83%, and 77% of the pelvic floor assessment participants at the initial, postpartum 1, and postpartum-2 visits, respectively. Demographic and labor characteristics were comparable between the 2 groups; 94% of participants were non-Hispanic, and 50% of participants were Black. Levator ani muscle injury was noted in 77 participants (13.6%) at the initial visit, 99 (13.1%) at PP1, and 72 (10.6%) at PP2. There was no difference in injury between women in the immediate pushing group and women in the delayed pushing group. These findings did not change when the threshold (sensitivity) of levator ani muscle injury was adjusted to a less conservative measure.

Conclusion: Among nulliparous women at term with neuraxial analgesia, the rates of occult levator ani muscle injury were not different between women undergoing immediate pushing and women undergoing delayed pushing in the second stage of labor. Further research efforts are needed to understand the development and potential prevention of subsequent pelvic floor disorders.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajog.2022.02.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9064971PMC
May 2022

Predictive performance of newborn small for gestational age by a United States intrauterine vs birthweight-derived standard for short-term neonatal morbidity and mortality.

Am J Obstet Gynecol MFM 2022 05 18;4(3):100599. Epub 2022 Feb 18.

Background: The use of birthweight standards to define small for gestational age may fail to identify neonates affected by poor fetal growth as they include births associated with suboptimal fetal growth.

Objective: This study aimed to compare intrauterine vs birthweight-derived standards to define newborn small for gestational age to predict neonatal morbidity and mortality.

Study Design: This was a secondary analysis of a multicenter observational study of 118,422 births. Live-born singleton, nonanomalous newborns born at 23 to 41 weeks of gestation were included. Those with missing gestational age estimation or without a first- or second-trimester ultrasound to confirm dating, birthweight, or neonatal outcome data were excluded. Birthweight percentile was computed using an intrauterine standard (Hadlock) and a birthweight-derived standard (Olsen). We compared the test characteristics of small for gestational age (birthweight of <10th percentile) by each standard to predict a composite neonatal morbidity and mortality outcome (death before discharge, neonatal intensive care unit admission >48 hours, respiratory distress syndrome, sepsis, necrotizing enterocolitis, grade 3 or 4 intraventricular hemorrhage, or seizures). Severe composite morbidity was analyzed as a secondary outcome and was defined as death, neonatal intensive care unit admission >7 days, necrotizing enterocolitis, grade 3 or 4 intraventricular hemorrhage, or seizures. The areas under the curve using receiver-operating characteristic methodology and proportions of the primary outcome by small for gestational age status were compared by gestational age category at birth (<34, 34 0/7 to 36 6/7, ≥37 weeks).

Results: Of 115,502 mother-newborn dyads in the parent study, 78,203 (67.7%) were included, with most exclusions occurring because of missing or inadequate dating information, multiple gestations, or delivery outside the gestational age range. The primary composite outcome occurred in 9.5% (95% confidence interval, 9.3-9.7), and the severe composite outcome occurred in 5.3% (95% confidence interval, 5.1-5.4). Small for gestational age was diagnosed by intrauterine and birthweight-derived standards in 14.8% and 7.4%, respectively (P<.001). Neonates considered small for gestational age only by the intrauterine standard experienced the primary outcome more than twice as often as those considered non-small for gestational age by both standards (18.4% vs 7.9%; P<.001). For the prediction of the primary outcome, small for gestational age by the intrauterine standard had higher sensitivity (29% vs 15%; P<.001) but lower specificity (87% vs 93%; P<.001) than by the birthweight standard. Both standards had weak performance overall, although the intrauterine standard had a higher area under the curve (0.58 vs 0.53; P<.001). When subanalyzed by gestational age at birth, the difference in areas under the curve was only present among preterm deliveries 34 to 36 competed weeks. Neither standard demonstrated any discrimination for morbidity prediction among term births (area under the curve, 0.50 for both). When the prediction of severe morbidity was compared, the intrauterine still had better overall prediction than the birthweight standard (areas under the curve, 0.65 vs 0.57; P<.001), although this also varied by gestational age at birth.

Conclusion: Among nonanomalous neonates, neither intrauterine nor birthweight-derived standards for small for gestational age accurately predicted neonatal morbidity and mortality, with no discriminatory ability at term. Small for gestational age intrauterine standards performed better than birthweight standards.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajogmf.2022.100599DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9097811PMC
May 2022

Association of SARS-CoV-2 Infection With Serious Maternal Morbidity and Mortality From Obstetric Complications.

JAMA 2022 02;327(8):748-759

Department of Women's Health, University of Texas at Austin.

Importance: It remains unknown whether SARS-CoV-2 infection specifically increases the risk of serious obstetric morbidity.

Objective: To evaluate the association of SARS-CoV-2 infection with serious maternal morbidity or mortality from common obstetric complications.

Design, Setting, And Participants: Retrospective cohort study of 14 104 pregnant and postpartum patients delivered between March 1, 2020, and December 31, 2020 (with final follow-up to February 11, 2021), at 17 US hospitals participating in the Eunice Kennedy Shriver National Institute of Child Health and Human Development's Gestational Research Assessments of COVID-19 (GRAVID) Study. All patients with SARS-CoV-2 were included and compared with those without a positive SARS-CoV-2 test result who delivered on randomly selected dates over the same period.

Exposures: SARS-CoV-2 infection was based on a positive nucleic acid or antigen test result. Secondary analyses further stratified those with SARS-CoV-2 infection by disease severity.

Main Outcomes And Measures: The primary outcome was a composite of maternal death or serious morbidity related to hypertensive disorders of pregnancy, postpartum hemorrhage, or infection other than SARS-CoV-2. The main secondary outcome was cesarean birth.

Results: Of the 14 104 included patients (mean age, 29.7 years), 2352 patients had SARS-CoV-2 infection and 11 752 did not have a positive SARS-CoV-2 test result. Compared with those without a positive SARS-CoV-2 test result, SARS-CoV-2 infection was significantly associated with the primary outcome (13.4% vs 9.2%; difference, 4.2% [95% CI, 2.8%-5.6%]; adjusted relative risk [aRR], 1.41 [95% CI, 1.23-1.61]). All 5 maternal deaths were in the SARS-CoV-2 group. SARS-CoV-2 infection was not significantly associated with cesarean birth (34.7% vs 32.4%; aRR, 1.05 [95% CI, 0.99-1.11]). Compared with those without a positive SARS-CoV-2 test result, moderate or higher COVID-19 severity (n = 586) was significantly associated with the primary outcome (26.1% vs 9.2%; difference, 16.9% [95% CI, 13.3%-20.4%]; aRR, 2.06 [95% CI, 1.73-2.46]) and the major secondary outcome of cesarean birth (45.4% vs 32.4%; difference, 12.8% [95% CI, 8.7%-16.8%]; aRR, 1.17 [95% CI, 1.07-1.28]), but mild or asymptomatic infection (n = 1766) was not significantly associated with the primary outcome (9.2% vs 9.2%; difference, 0% [95% CI, -1.4% to 1.4%]; aRR, 1.11 [95% CI, 0.94-1.32]) or cesarean birth (31.2% vs 32.4%; difference, -1.4% [95% CI, -3.6% to 0.8%]; aRR, 1.00 [95% CI, 0.93-1.07]).

Conclusions And Relevance: Among pregnant and postpartum individuals at 17 US hospitals, SARS-CoV-2 infection was associated with an increased risk for a composite outcome of maternal mortality or serious morbidity from obstetric complications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jama.2022.1190DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8822445PMC
February 2022

Early Exposure to Animals and Childhood Body Mass Index Percentile and Percentage Fat Mass.

Child Adolesc Obes 2022 13;5(1):3-15. Epub 2022 Jan 13.

Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC.

Introduction: A few studies have identified childhood animal exposure as associated with adiposity, but results are inconsistent and differ in timing.

Methods: We conducted an observational cohort study of children ages 4-8 in the Environmental Influences on Child Health Outcomes [ECHO] study. The main exposure was having a dog in the home and/or regular contact with farm animals during the first year of life. Outcomes of interest were child BMI percentile (adjusted for gender and age) categorized as normal/underweight (<85 percentile), overweight (85 to <95), and obese (≥95), and percent fat mass (continuous). Associations were analyzed using multinomial logistic regression and multivariable linear regression, respectively, with and without multiple imputation.

Results: First year animal exposure occurred in 245 of 770 (31.8%) children. Children with early animal exposure had 0.53 (95% CI: 0.28, 0.997) times the odds of being in the obese BMI category compared to those exposed to animals after controlling for covariates: maternal pre-pregnancy BMI, race/ethnicity, reported child activity level, receiving food assistance, age child began daycare (<1 year vs 1+), exclusively breastfed x6 months, and NICU admission (n=721). Children with early animal exposure had, on average, 1.5% (95% CI: -3.0, -0.1) less fat mass than exposed children after adjustment for maternal BMI, race/ethnicity, activity, food assistance, breastfeeding, and maternal education (n=548). Multiple imputation did not alter either result.

Conclusion: These results provide evidence that exposure to dogs or farm animals in the first year of life is associated with lower odds of obesity and lower percent fat mass in childhood.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/2574254x.2021.2021788DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8813042PMC
January 2022

Association between Chlamydia trachomatis, Neisseria gonorrhea, Mycoplasma genitalium, and Trichomonas vaginalis and Secondary Infertility in Cameroon: A case-control study.

PLoS One 2022 4;17(2):e0263186. Epub 2022 Feb 4.

Department of Laboratory Medicines, Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon.

Objective: Data on the prevalence and etiology of infertility in Africa are limited. Secondary infertility is particularly common, defined as the inability of a woman to conceive for at least one year following a full-term pregnancy. We describe a prospective study conducted in Cameroon designed to test the hypothesis of an association between common treatable sexually transmitted infections (STI): Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Mycoplasma genitalium (MG), and Trichomonas vaginalis (TV) and secondary infertility in women.

Methods: In this case-control study, we enrolled women in Fako Division, Cameroon between November 2017 and December 2018 with secondary infertility (cases) or current pregnancy (controls). We conducted a baseline survey to collect sociodemographic, and sexual and medical history information. Nucleic acid amplification testing using Aptima (Hologic, San Diego, CA, US) was performed on endocervical swabs for CT, NG, MG, and TV. Multivariable logistic regression was used to assess the relationship between active STI and secondary infertility.

Results: A total of 416 women were enrolled: 151 cases and 265 controls. Compared to controls, cases were older (median age 32 vs 27 years) and had more lifetime sexual partners (median 4 vs 3) (p<0.001). Cases were more likely to report dyspareunia, abnormal menses, prior miscarriage, and ectopic pregnancy (all p<0.05). STI positivity was not significantly different among cases and controls (2.7% vs 5.4% for CT, 1.3% vs 2.9% for NG, 6.0% vs 7.0% for MG, respectively), with the exception of TV which was more common in pregnant controls (0.7% vs 5%; p = 0.02).

Conclusion: Study findings did not support an association between active STI and secondary infertility in Cameroon. Given high rates of pre-existing tubal damage, routine STI screening and treatment in younger women may be more impactful than costly STI testing during infertility assessments.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0263186PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8815903PMC
March 2022

Noninvasive Prediction of Congenital Cytomegalovirus Infection After Maternal Primary Infection.

Obstet Gynecol 2022 03;139(3):400-406

Departments of Obstetrics and Gynecology, Brown University, Providence, Rhode Island, University of Texas Medical Branch at Galveston, Galveston, Texas, Northwestern University, Chicago, Illinois, Columbia University, New York, New York, University of Utah Health Sciences Center, Salt Lake City, Utah, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, University of Alabama at Birmingham, Birmingham, Alabama, The Ohio State University, Columbus, Ohio, Duke University, Durham, North Carolina University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, Case Western Reserve University, Cleveland, Ohio, University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, Texas, Stanford University, Stanford, California, University of Texas Southwestern Medical Center, Dallas, Texas University of Pennsylvania, Philadelphia, Pennsylvania, University of Pittsburgh, Pittsburgh, Pennsylvania, Madigan Army Medical Center, Joint Base Lewis-McChord, Washington, and Washington University in St. Louis, St. Louis, Missouri; the Departments of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, and Duke University, Durham, North Carolina; the George Washington University Biostatistics Center, Washington, DC; and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland.

Objective: To develop and internally validate a noninvasive method for the prediction of congenital cytomegalovirus (CMV) infection after primary maternal CMV infection.

Methods: We conducted a secondary analysis of a multicenter randomized placebo-controlled trial of CMV hyperimmune globulin to prevent congenital infection. Women were eligible if they had primary CMV infection, defined as detectable plasma CMV-specific immunoglobulin (Ig)M and CMV-specific IgG with avidity less than 50% before 24 weeks of gestation or IgG seroconversion before 28 weeks, and were carrying a singleton fetus without ultrasonographic findings suggestive of CMV infection. Antibody assays were performed in a single reference laboratory. Congenital infection was defined as CMV detection in amniotic fluid, neonatal urine or saliva, or postmortem tissue. Using backward elimination, we developed logit models for prediction of congenital infection using factors known at randomization. The performance of the model was assessed using leave-one-out cross-validation (a method of internal validation).

Results: Of 399 women enrolled in the trial, 344 (86%) had informative data for this analysis. Congenital infection occurred in 68 pregnancies (20%). The best performing model included government-assisted insurance, IgM index 4.5 or higher, IgG avidity less than 32%, and whether CMV was detectable by polymerase chain reaction in maternal plasma at the time of randomization. Cross-validation showed an average area under the curve of 0.76 (95% CI 0.70-0.82), indicating moderate discriminatory ability. More parsimonious one-, two-, and three-factor models performed significantly less well than the four-factor model. Examples of prediction with the four-factor model: for a woman with government-assisted insurance, avidity less than 32%, IgM index 4.5 or higher, and detectable plasma CMV, probability of congenital infection was 0.69 (95% CI 0.53-0.82); for a woman with private insurance, avidity 32% or greater, IgM index less than 4.5, and undetectable plasma CMV, probability of infection was 0.03 (95% CI 0.02-0.07).

Conclusion: We developed models to predict congenital CMV infection in the presence of primary maternal CMV infection and absence of ultrasonographic findings suggestive of congenital infection. These models may be useful for patient counseling and decision making.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/AOG.0000000000004691DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8857032PMC
March 2022

In Reply.

Obstet Gynecol 2022 02;139(2):338-339

Center for Women's Reproductive Health and the Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/AOG.0000000000004670DOI Listing
February 2022

Misoprostol and estradiol to enhance visualization of the transformation zone during cervical cancer screening: An integrative review.

Eur J Obstet Gynecol Reprod Biol 2022 Feb 30;269:16-23. Epub 2021 Nov 30.

Center for Women's Reproductive Health, Department of Obstetrics & Gynecology, University of Alabama at Birmingham, 176F Suite 10270, 619(TH) Street South, Birmingham, AL 35249-7333, USA; Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Alabama at Birmingham, 176F Suite 10250, 1700 6(th) Avenue South, Birmingham, AL, USA.

The purpose of this integrative literature review was to appraise studies conducted worldwide using misoprostol and estradiol in converting Type 3 transformation zone (TZ) of the cervix into Types 1 or 2 and to assess which regimen could be more feasible in low-and-middle-income countries (LMICs). We reviewed the English language literature for peer-reviewed studies that evaluated strategies to convert Type 3 TZs to Types 1 or 2 for cervical cancer screening. Web of Science and PubMed searches were performed up to July 2020. Search terms included: "cervical colposcopy," "inadequate colposcopy", "cervical cancer screening", "transformation zone," "estrogen", "estradiol", and "misoprostol." Inclusion criteria were articles published in the English language, original research, and peer reviewed articles. A total of 127 articles were abstracted, 24 articles were reviewed, and 9 articles met all inclusion criteria. We found that intravaginal misoprostol, intravaginal estradiol, and oral estradiol can successfully convert Type 3 TZ to Types 1 or 2. A single dose of vaginal misoprostol had a similar maximum response rate (20-80%) to a multi-dose regimen over several days or weeks of both intravaginal estradiol (64-83%) and oral estradiol (50-70%). Misoprostol administration was associated with more side effects such as abdominal cramping and vaginal bleeding compared to estradiol, although these were generally mild. In conclusion, Oral estradiol, intravaginal estradiol, and intravaginal misoprostol can be used to convert Type 3 TZ to Types 1 or 2. Intravaginal misoprostol is well tolerated and more feasible in LMICs due to availability and shorter treatment schedule compared to oral or intravaginal estradiol.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ejogrb.2021.11.431DOI Listing
February 2022
-->