A Framework for Coordination between Obstetric and Pediatric Providers in Public Health Emergencies: Lessons Learned from the Zika Outbreak in the United States, 2015 to 2017.

Emergency response to emerging threats with the potential for vertical transmission, such as the 2015 to 2017 response to Zika virus, presents unique clinical challenges that underscore the need for better communication and care coordination between obstetric and pediatric providers to promote optimal health for women and infants. Published guidelines for routine maternal-infant care during the perinatal period, and models for transitions of care in various health care settings are available, but no broad framework has addressed coordinated multidisciplinary care of the maternal-infant dyad during emergency response. We present a novel framework and strategies to improve care coordination and communication during an emergency response. The proposed framework includes (1) identification and collection of critical information to inform care, (2) key health care touchpoints for the maternal-infant dyad, and (3) primary pathways of communication and modes of transfer across touchpoints, as well as practical strategies. This framework and associated strategies can be modified to address the care coordination needs of pregnant women and their infants with possible exposure to other emerging infectious and noninfectious congenital threats that may require long-term, multidisciplinary management. KEY POINTS: · Emerging congential threats present unique coordination challenges for obstetric and pediatric clinicians during emergency response.. · We present a framework to help coodinate care of pregnant women/infants exposed to congenital threats.. · The framework identifies critical information to inform care, health care touchpoints, and communication/information transfer pathways..

Female Pelvic Conditions: Chronic Pelvic Pain.

Chronic pelvic pain (CPP) is defined as at least 6 months of pain originating from the lower abdomen or pelvis that is not associated with pregnancy. Symptoms include abdominal bloating, low back pain, and dyspareunia. CPP is considered a symptom and not a diagnosis. The etiology may involve a specific organ or condition (eg, endometriosis, adhesions). The most common associated conditions are endometriosis, interstitial cystitis, irritable bowel syndrome, and depression. The history and physical examination are essential in the evaluation. A comprehensive history that encompasses the gynecologic, obstetric, surgical, and psychosocial histories is key. The psychosocial history should include screening for depression, anxiety, posttraumatic stress disorder, and physical and sexual abuse because of their association with CPP. The physical examination should include musculoskeletal, abdominal, and gynecologic examinations. The choice of laboratory tests and imaging studies should be guided by the history and physical examination findings. Management is multimodal and involves management of associated conditions, pharmacotherapy, surgeries and procedures, physical therapy, and behavior and lifestyle therapies. The multidisciplinary care team typically consists of the primary care physician, subspecialty physicians (eg, gynecology, pain management, psychiatry, gastroenterology, urology), a physical therapist, and a behavioral health subspecialist.

Female Pelvic Conditions: Abnormal Uterine Bleeding.

Abnormal uterine bleeding (AUB) is the term used to describe uterine bleeding that varies from the normal parameters of menstruation. This term replaces several previously used terms with less clear or conflicting definitions, including dysfunctional uterine bleeding, irregular menstrual bleeding, and menorrhagia. PALM-COEIN is a classification system for the etiologies of AUB in nongravid menstruating women. PALM refers to discrete structural entities (ie, polyp, adenomyosis, leiomyoma, malignancy and hyperplasia); COEIN refers to nonstructural etiologies (ie, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified). The prevalence of AUB is estimated to be 35% or higher. The history and physical examination are key in the evaluation of patients with AUB. Patients with symptomatic acute blood loss require urgent evaluation for potential hemodynamic instability. For women 45 years and younger with AUB, endometrial biopsy is indicated if specific risk factors for endometrial cancer are present. Endometrial biopsy is indicated for all patients with AUB who are older than 45 years or have postmenopausal bleeding. Management of AUB is determined by its etiology, and typically consists of medical therapy (ie, combination oral contraceptives, progestin-containing intrauterine devices, tranexamic acid, nonsteroidal anti-inflammatory drugs). Patients with structural lesions may require surgical procedures. Management should be individualized and patient desire for current or future fertility should be considered.

Female Pelvic Conditions: Polycystic Ovary Syndrome.

It is estimated that polycystic ovary syndrome (PCOS) affects about 10% of women of reproductive age in the United States. Principal risk factors include obesity and a family history of PCOS. A diagnosis of PCOS should be considered in women with irregular or absent menstrual cycles, issues related to hyperandrogenism, or infertility. The Rotterdam diagnostic criteria require two of the following three factors: oligo- or anovulation, clinical and/or biochemical signs of hyperandrogenism, and polycystic ovaries identified on ultrasonography. Laboratory tests are recommended to rule out other conditions and factors, including thyroid conditions, hyperprolactinemia, atypical congenital adrenal hyperplasia, and tumors. The mainstays of treatment are lifestyle changes to achieve weight loss and combination oral contraceptives (COCs). (PCOS is an off-label use of COCs.) A weight loss of 5% to 10% has been shown to decrease PCOS symptoms. Medical or surgical management of obesity may be indicated. COCs provide endometrial protection and help manage acne and hirsutism. (Hirsutism is an off-label use of COCs. Acne is an off-label use of some COCs.) Routine acne treatments also are used. Hirsutism may improve with topical cosmetic treatments, spironolactone, or finasteride. (Hirsutism is an off-label use of spironolactone and finasteride.) Infertility is a common issue in patients with PCOS. The aromatase inhibitor letrozole is the first-line treatment for PCOS-related anovulation. Gonadotropin-releasing hormone analogues also are used to induce ovulation. (This is an off-label use of letrozole and gonadotropin-releasing hormone analogues.).

Female Pelvic Conditions: Genitourinary Syndrome of Menopause.

Genitourinary syndrome of menopause (GSM) is a term that describes the genital, urinary, and sexual changes that occur in women because of a lack of estrogen. This most commonly is because of menopause, but can be because of a hypoestrogenic state caused by hyperprolactinemia, oophorectomy, premature ovarian failure, chemotherapy, or radiation. GSM describes a group of signs and symptoms that affect quality of life and progress over time, including vaginal dryness, dyspareunia, dysuria, urinary urgency, and frequent urinary tract infections. GSM is underdiagnosed. It affects 65% of women 1 year after the onset of menopause, and 84% of women 6 years after menopause. Physicians routinely should ask all perimenopausal and postmenopausal women about GSM symptoms. The diagnosis is made clinically, based on the history and physical examination. Use of nonhormonal lubricants and vaginal moisturizers should be recommended as first-line therapies. Vaginal estrogen is the most effective treatment. Other therapies include vaginal dehydroepiandrosterone (DHEA), ospemifene, systemic estrogen therapy, and pelvic floor physical therapy.

Protecting newborns by immunizing family members in a hospital-based vaccine clinic: a successful Tdap cocooning program during the 2010 California pertussis epidemic.

OBJECTIVE: Infants are at greatest risk for mortality from pertussis infection. Since 2005, the Advisory Committee on Immunization Practices has recommended a cocooning strategy of vaccinating all close contacts of infants with tetanus, diptheria, and acellular pertussis (Tdap) vaccine to reduce the risk of transmitting pertussis. Difficulties in establishing a complete cocoon have been reported in the literature. We determined whether families of newborns could be fully immunized against pertussis, thereby providing a complete cocoon of protection. METHODS: Tdap vaccine was offered during visiting hours to contacts aged 7 years and older and to postpartum patients who had not received Tdap vaccine during pregnancy. We then conducted retrospective phone interviews with randomly selected mothers (or other family members) to assess vaccination rates. We compared household vaccination rates during intervention and control periods and the demographic factors associated with Tdap vaccination of all members within the households. RESULTS: During the intervention period, 243 postpartum patients and 1,287 other family members of newborns were immunized, with 84.8% of all family members receiving Tdap vaccination. Seventy-six percent of households reported a complete cocoon. In the control group, 52.2% of all family members received Tdap vaccination, and 29.3% of households had a complete cocoon. In the control group, fewer family members completed Tdap vaccination in the larger households than in the smaller households (p=0.008). CONCLUSION: A cocooning strategy can be successfully implemented, such that the majority of newborns leave the hospital with their families fully immunized against pertussis.

Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis.

This guideline is a revision of the clinical practice guideline, "Diagnosis and Management of Bronchiolitis," published by the American Academy of Pediatrics in 2006. The guideline applies to children from 1 through 23 months of age. Other exclusions are noted. Each key action statement indicates level of evidence, benefit-harm relationship, and level of recommendation. Key action statements are as follows: