In-vitro stress relaxation response of neonatal peripheral nerves.

Characterizing the viscoelastic behavior of neonatal peripheral nerves is critical in understanding stretch-related peripheral nerve injuries (PNIs) in neonates. This study investigated the in-vitro viscoelastic stress relaxation response of neonatal piglet brachial plexus (BP) and tibial nerves at two different strain levels (10% and 20%) and stress relaxation testing durations (90- and 300-seconds). BP and tibial nerves from 20 neonatal piglets were harvested and pre-stretched to either 10% or 20% strain at a dynamic rate of 100 mm/min to simulate conditions, such as shoulder dystocia, that may lead to stretch-related PNIs in neonates. At constant strain, the reduction in stress was recorded for 90- or 300-seconds. The biomechanical data were then fit to a viscoelastic model to acquire the short- and long-term stress relaxation time-constants. Though no significant differences in the degree of stress relaxation were found between the two tested strain levels after 90 seconds in both nerve types, reduction in stress was moderately greater (p = 0.056) at 10% strain than at 20% for BP after 300 seconds. The reduction in stress was significantly higher in nerves subjected to a 300 second testing duration than 90 second for both strain levels and nerve types. When comparing BP and tibial nerve stress relaxation response, BP nerve relaxed significantly more than tibial at both strain levels after 90 seconds, but no significant differences were observed after 300 seconds. Our results confirm that neonatal peripheral nerve tissue is highly viscoelastic. These novel biomechanical data can be incorporated into finite element and computational models studying neonatal PNIs.

Respiratory Syncytial Virus Vaccination during Pregnancy and Effects in Infants.

BACKGROUND: Respiratory syncytial virus (RSV) is the dominant cause of severe lower respiratory tract infection in infants, with the most severe cases concentrated among younger infants. METHODS: Healthy pregnant women, at 28 weeks 0 days through 36 weeks 0 days of gestation, with an expected delivery date near the start of the RSV season, were randomly assigned in an overall ratio of approximately 2:1 to receive a single intramuscular dose of RSV fusion (F) protein nanoparticle vaccine or placebo. Infants were followed for 180 days to assess outcomes related to lower respiratory tract infection and for 364 days to assess safety. The primary end point was RSV-associated, medically significant lower respiratory tract infection up to 90 days of life, and the primary analysis of vaccine efficacy against the primary end point was performed in the per-protocol population of infants (prespecified criterion for success, lower bound of the 97.52% confidence interval [CI] of ≥30%). RESULTS: A total of 4636 women underwent randomization, and there were 4579 live births. During the first 90 days of life, the percentage of infants with RSV-associated, medically significant lower respiratory tract infection was 1.5% in the vaccine group and 2.4% in the placebo group (vaccine efficacy, 39.4%; 97.52% CI, -1.0 to 63.7; 95% CI, 5.3 to 61.2). The corresponding percentages for RSV-associated lower respiratory tract infection with severe hypoxemia were 0.5% and 1.0% (vaccine efficacy, 48.3%; 95% CI, -8.2 to 75.3), and the percentages for hospitalization for RSV-associated lower respiratory tract infection were 2.1% and 3.7% (vaccine efficacy, 44.4%; 95% CI, 19.6 to 61.5). Local injection-site reactions among the women were more common with vaccine than with placebo (40.7% vs. 9.9%), but the percentages of participants who had other adverse events were similar in the two groups. CONCLUSIONS: RSV F protein nanoparticle vaccination in pregnant women did not meet the prespecified success criterion for efficacy against RSV-associated, medically significant lower respiratory tract infection in infants up to 90 days of life. The suggestion of a possible benefit with respect to other end-point events involving RSV-associated respiratory disease in infants warrants further study. (Funded by Novavax and the Bill and Melinda Gates Foundation; ClinicalTrials.gov NCT02624947.).

Cell-free DNA results lead to unexpected diagnosis.

Maternal cell-free DNA (cfDNA) results that are discordant with the diagnostic fetal karyotype should prompt further investigation. If deeper analysis of the cfDNA results demonstrates a "saw-tooth" pattern characteristic of genome-wide imbalance, maternal malignancy is suggested. Identifying the maternal malignancy can, however, be difficult.

Management of Psoriasis Herpeticum in Pregnancy: A Clinical Conundrum.

Introduction. Kaposi varicelliform eruption (KVE) is a widespread cutaneous viral infection, most commonly herpes simplex virus, which affects patients with underlying dermatosis. When KVE occurs in a patient with a history of psoriasis, it is referred to as psoriasis herpeticum, a rare subtype of KVE with only a handful of cases reported in the literature. To the authors' knowledge, we report for the first time a case of psoriasis herpeticum in pregnancy. Case Presentation. A 23-year-old woman in her third pregnancy presented at 26-week gestation with a 10-year history of psoriasis. Cutaneous examination revealed diffuse psoriatic plaques with scattered ~1 cm erosions. Punch biopsy of the skin revealed herpes simplex virus (HSV) infection within a psoriatic plaque, necessitating dermatological treatment. The patient experienced premature rupture of membranes at 37-week gestation. Pelvic exam showed no evidence of herpetic lesions. After labor augmentation, the patient delivered a healthy female infant with no evidence of HSV infection. Discussion. Psoriasis herpeticum is a rare and potentially devastating complication of an underlying dermatosis. With a paucity of data available to guide pregnancy-specific issues, the general management of this condition is controversial and requires a multidisciplinary care approach. Concerns for systemic infection in the mother and vertical transmission to the neonate are of critical importance.

Frequency of otitis media based on otoendoscopic evaluation in preterm infants.

OBJECTIVE: This study was conducted to determine the frequency of otitis media in preterm neonates using otoendoscopy and tympanometry. STUDY DESIGN: Prospective study. SETTING: Wayne State University, Hutzel Women's Hospital Neonatal Intensive Care Unit. SUBJECTS AND METHODS: Eighty-six preterm infants were included (gestational age <36 weeks). Otoendoscopy and tympanometry were performed to detect the presence of otitis media. Kappa statistic and logistic regression were used for statistical analysis. RESULTS: Otoendoscopy was performed in 85 patients. The frequency of otoendoscopy-diagnosed otitis media was 72.9% (62/85). Tympanometry could be performed on 69.76% of the ears. There was 73.5% agreement between the findings of tympanometry and those of otoendoscopy. The association between the presence of otitis media and gestational age at birth was statistically significant. The lower the gestational age, the higher the frequency of otoendoscopy-diagnosed otitis media (P = .001). CONCLUSION: Otoendoscopically diagnosed otitis media is frequent in preterm neonates. There was agreement between the results of tympanometry and those of otoendoscopy. The frequency of otitis media increased with lower gestational age.

Obstetric outcome in a primigravid patient with autosomal-recessive multiminicore myopathy.

BACKGROUND: Multiminicore disease is a congenital myopathy characterized by muscle weakness and respiratory impairment. Predilection for the development of malignant hyperthermia has been reported in select patients. Little is known about pregnancy outcomes, although patients with other neuromuscular disorders may experience a postpartum decline. CASE: We report a case of pregnancy associated with autosomal-recessive multiminicore disease. Genetic implications of this condition were addressed. Orthopedic complications were managed through physical medicine and rehabilitation consultation. Under epidural anesthesia, a healthy full-term neonate was delivered through spontaneous vaginal delivery. There was no evidence of malignant hyperthermia or functional decline in the puerperium. CONCLUSION: A successful pregnancy outcome was achieved in a patient with multiminicore myopathy by proactively addressing potential genetic, orthopedic, and anesthetic concerns associated with this condition.

Changes in and current status of obstetrician-gynecologists' knowledge, attitudes, and practice regarding immunization.

Vaccines are important tools for disease prevention and, in obstetric patients, to prevent transmission to infants. Obstetrician-gynecologists are well situated to screen for immunization status of women of child-bearing age and to provide appropriate vaccinations. A series of research investigated obstetrician-gynecologists' beliefs, practices, and knowledge regarding immunization. Surveys were sent out in 2007 to Fellows of the American College of Obstetricians and Gynecologists. Most obstetrician-gynecologists viewed screening for vaccine-preventable diseases to be within their professional role, and a majority administers at least some vaccines. Over half agreed financial factors (eg, inadequate reimbursement, cost of storing vaccines) were barriers to vaccine administration. Other perceived barriers were a concern over safety of vaccinations during pregnancy and a view that administering vaccines was not part of their usual practice. They were also concerned about their level of training. A majority believed their immunization training was less than adequate, and believed their practice would benefit from continuing medical education courses. One study identified changes in Michigan obstetrician-gynecologists' attitudes, knowledge and practices since 2000. More Michigan ob-gyns are assessing vaccination needs, viewing this as part of their professional purview, and, in general, their knowledge of vaccine recommendations has improved. Concerns over the safety of vaccines in pregnancy as well as financial burdens of immunization have increased. Immunization is an important part of women's health care and has been, at least partially, incorporated into obstetrician-gynecologist practice. Financial burdens and physician concerns over training remain barriers to vaccine administration.

Obstetrician-gynecologists' practices and perceived knowledge regarding immunization.

BACKGROUND: Obstetrician-gynecologists can play a key role in providing appropriate vaccinations to women of childbearing age. PURPOSE: This study investigated immunization knowledge and practices, and opinions concerning potential barriers to immunization, among obstetrician-gynecologists. METHODS: In 2007, surveys were sent to Collaborative Ambulatory Research Network members, a representative sample of practicing Fellows of the American College of Obstetricians and Gynecologists; 394 responded (51.2%). Data analysis was completed in 2008. RESULTS: Most responding obstetrician-gynecologists disagreed that "routine screening for vaccine-preventable diseases falls outside of the routine practice of an ob/gyn." A majority (78.7%) stock and administer at least some vaccines. Among those who stock vaccines, 91.0% stock the human papillomavirus vaccine, and 66.8% stock the influenza vaccine. All other vaccines were stocked by <30% of practices that stock vaccines. A majority of physicians agreed that financial factors (e.g., inadequate reimbursement) were barriers to vaccine administration. Most were aware that the influenza (89.8%); hepatitis B (64.0%); and tetanus, diptheria, pertussis (58.6%) vaccines are safe to administer during pregnancy, and that the measles, mumps, rubella (97.5%); and varicella (92.9%) vaccines are not. Most (84.5%) were in concordance with recommendations that all pregnant women should receive the influenza vaccine. A majority believed their immunization training was less than adequate and believed their practice would benefit from continuing medical education courses. CONCLUSIONS: Immunization is an important part of women's health care and has been, at least partially, incorporated into obstetrician-gynecologist practice. Financial burdens and knowledge regarding vaccine recommendations remain barriers to vaccine administration. Additional training and professional information may benefit obstetric-gynecologic practice.

Strategies for fostering HPV vaccine acceptance.

Vaccines that protect against infection with the types of human papillomavirus (HPV) commonly associated with cervical cancer (HPV 16 and 18) and genital warts (HPV 6 and 11) are expected to become available in the near future. Because HPV vaccines are prophylactic, they must be administered prior to exposure to the virus, ideally during preadolescence or adolescence. The young age of the target vaccination population means that physicians, parents, and patients will all be involved in the decision-making process. Research has shown that parents and patients are more likely to accept a vaccine if it is efficacious, safe, reasonably priced, and recommended by a physician. Widespread education of physicians, patients, and parents about the risks and consequences of HPV infection and the benefits of vaccination will be instrumental for fostering vaccine acceptance.

Postpartum morbidity associated with advanced HIV disease.

OBJECTIVE: To investigate the postpartum morbidity and postpartum management of febrile morbidity associated with advanced HIV infection. METHODS: A case control study of HIV infected women at a tertiary care center during January 2000-June 2005 was performed. Postpartum morbidity was defined as endometritis, blood transfusion, wound complication, readmission, infectious morbidity, or unexpected surgery. RESULTS: Women in Group 1 had AIDS (N=33), Group 2 were relatively immunocompetent HIV infected women (N=115), and Group 3 were uninfected women (N=152). Group 1 was more likely to have a postpartum morbidity (32.3 versus 19.3 and 13.2%, P=.03) and to have postpartum imaging 18.8 versus 7.9 and 2.6%, P=.002. After controlling for potential confounders, cesarean delivery (OR 6.2, 95% CI 2.1-505.5) but not advanced HIV disease was associated with an increased risk of postpartum morbidity. CONCLUSION: Cesarean delivery and not advanced HIV disease increases the risk of postpartum morbidity in women with AIDS.

The role of sonographic endometrial patterns and endometrial thickness in the differential diagnosis of ectopic pregnancy.

OBJECTIVE: The purpose of this study was to examine the usefulness of the endometrial trilaminar pattern and thickness in the diagnosis of ectopic pregnancy. STUDY DESIGN: We reviewed patient records for clinical and ultrasonographic data for patients with the suspicion of ectopic pregnancy. The trilaminar pattern and endometrial thickness were tested as predictors for the diagnosis of ectopic pregnancy. RESULTS: The trilaminar pattern had a specificity of 94% and sensitivity of 38% (n = 403 women). The mean endometrial thickness was thinner in patients with ectopic, compared with normal pregnancy (9.5 +/- 5.7 mm vs 12.4 +/- 5.9 mm; P = .035). Patients with normal pregnancy or first-trimester losses had comparable thicknesses (12.4 +/- 5.9 mm vs 12.5 +/- 8.0 mm). The receiver operator curve showed that there was no thickness value useful for the diagnosis of ectopic pregnancy. CONCLUSION: The trilaminar pattern is specific for the diagnosis of ectopic pregnancy, but it is associated with low sensitivity. The endometrial thickness tends to be thinner in patients with an ectopic pregnancy.

Screening and counseling practices reported by obstetrician-gynecologists for patients with hepatitis C virus infection.

BACKGROUND: Obstetrician-gynecologists are important providers of primary health care to women, and the hepatitis C virus (HCV) infection screening practices and recommendations provided by obstetrician-gynecologists for HCV-infected patients are unknown. METHODS: We surveyed American College of Obstetricians and Gynecologists (ACOG) Fellows, including 413 Fellows who were participating in the Collaborative Ambulatory Research Network (CARN) and 650 randomly sampled Fellows, about HCV screening and counseling practices. RESULTS: In total, 74% of CARN members and 44% of non-CARN members responded. Demographics and practice structure were similar between the two groups. More than 80% of providers routinely collected drug use and blood transfusion histories from their patients. Of the respondents, 49% always screened for HCV infection when patients had a history of injection drug use, and 35% screened all patients who had received a blood transfusion before 1992. For HCV-infected patients, 47% of the physicians always advised against breastfeeding, 70% recommended condom use with a long-term steady partner, and 64% advised against alcohol consumption. Respondents who considered themselves to be primary care providers were no more likely to screen or provide appropriate counseling messages than were other providers. CONCLUSIONS: Most obstetrician-gynecologists are routinely collecting information that can be used to assess HCV infection risk, but HCV screening practices and counseling that are provided for those with HCV infection are not always consistent with current Centers for Disease Control and Prevention and ACOG recommendations.

Vaccination and perinatal infection prevention practices among obstetrician-gynecologists.

OBJECTIVE: To assist efforts to improve adult vaccination coverage by characterizing vaccination and infectious disease screening practices of obstetrician-gynecologists. METHODS: A written survey of demographics, attitudes, and practices was mailed to 1063 American College of Obstetricians and Gynecologists Fellows, including the Collaborative Ambulatory Research Network (n = 413) and 650 randomly sampled Fellows. RESULTS: Seventy-four percent of Collaborative Ambulatory Research Network members and 44% of nonmembers responded. A majority (Collaborative Ambulatory Research Network members: 60%; nonmembers: 49%) considered themselves primary care providers. Fewer than 60% routinely obtained patient vaccination or infection histories. Most screened prenatal patients for hepatitis B surface antigen (89%) and rubella immunoglobulin G antibody (85%). Sixty-four percent worked in practices that offered at least one vaccine; the most common were rubella (52%) and influenza (50%). Ten percent worked in practices that offered all major vaccines recommended for pregnant or postpartum women. Despite recommendations to provide influenza vaccine to pregnant women during influenza season, only 44% did so; among those who did not, 14% reported a belief that pregnant women do not need influenza vaccine. Provision of vaccine was associated with working in a multispecialty practice (adjusted odds ratio [OR] 2.6, 95% confidence interval [CI] 1.6, 4.1) and identifying as a primary care provider (adjusted OR 1.9; 95% CI 1.3, 2.7). The most common reasons for not offering vaccines were cost (44%) and a belief that vaccines should be provided elsewhere (41%). CONCLUSION: The high proportion of obstetrician-gynecologists who do not offer vaccines or screen for vaccine and infection histories suggests missed opportunities for prevention of maternal and neonatal infections.

The obstetrician-gynecologist's role in adult immunization.

Vaccine-preventable diseases (VPDs) account for significant morbidities and mortalities in the United States on an annual basis. Despite generally successful childhood vaccine programs, adults remain underimmunized against a variety of common VPDs. Lack of both physician and patient awareness contribute to this deficiency. All primary care providers, including obstetrician-gynecologists, must address this need in their office practices. Clear and authoritative adult vaccine recommendations are established and easily accessible by the clinician. Pregnancy is not an absolute contraindication to vaccine administration. In fact, certain vaccines are specifically indicated during pregnancy in the interest of the mother and her unborn child. Women frequently identify gynecologists as their sole providers of care, further emphasizing the need for attention to this health maintenance activity. New vaccine initiatives, in particular those focused on early newborn infectious conditions, sexually transmitted diseases, and cancer prevention, will likely place the obstetrician-gynecologist at the forefront of this important clinical issue.