Human Papillomavirus Inpatient Postpartum Vaccination: Clinical Guideline Implementation.

OBJECTIVE: The nine-valent human papillomavirus (9vHPV) vaccine is highly effective at preventing cervical cancer, yet U.S. vaccination rates remain low. The objective of this study was to evaluate integration of 9vHPV inpatient vaccination into routine postpartum care. METHODS: Obstetrics professionals at an academic urban referral center received an emailed protocol outlining a novel 9vHPV vaccination program of postpartum inpatients aged 26 years or younger. A retrospective evaluation from March 2021 to March 2022 was conducted to evaluate implementation. Characteristics of patients vaccinated before pregnancy compared with vaccine-eligible patients (none, unknown, or partially vaccinated status) were compared by the use of χ2, analysis of variance, and multivariable logistic regression. Similarly, analyses were performed comparing vaccine-eligible patients who did with those who did not receive an inpatient 9vHPV vaccination. RESULTS: Of 569 postpartum inpatients, 370 (65.0%) were already vaccinated, 70 (34.2%) were never vaccinated, 49 (24.6%) were partially vaccinated, and 80 (14.1%) had unknown status. Of vaccine-eligible patients, 46 (23.1%) received 9vHPV vaccination as an inpatient. In multivariable analysis, race and ethnicity, marital status, and primary language were significant predictors of vaccination before pregnancy. Among vaccine-eligible patients, inpatient vaccination recipients were primarily Hispanic, Spanish speaking, and publicly insured. In multivariable analysis of vaccine-eligible patients, receiving care from the certified nurse midwifery practice was the only independent predictor of vaccination (odds ratio 2.4, 95% CI 1.02-5.74, P=.04). CONCLUSION: Non-Hispanic White, Spanish-speaking, and married patients were disproportionally undervaccinated in our baseline population, but about one quarter of vaccine-eligible patients received 9vHPV vaccination postpartum. Inpatient postpartum 9vHPV vaccination may help narrow disparities in vaccination.

Association of Antenatal Depression with Clinical Subtypes of Preterm Birth.

OBJECTIVE: To estimate the association between antenatal depression and spontaneous preterm birth (SPTB) relative to medically indicated preterm birth (MPTB). STUDY DESIGN: This was a secondary analysis of a nested case-control study of preterm birth (PTB). The exposure was a clinical diagnosis of antenatal depression. The outcome was PTB at <37 weeks classified as SPTB (spontaneous labor, preterm premature rupture of membranes, placental abruption, and cervical shortening); and MPTB (preeclampsia and intrauterine growth restriction). Multinomial logistic regression models compared women without PTB versus MPTB and SPTB, adjusting for age, race, parity, tobacco use, insurance status, and prepregnancy body mass index, and history of PTB for SPTB. RESULTS: Among 443 pregnant women, 15.6% had an SPTB and 8.6% had an MPTB, and 16% were diagnosed with antenatal depression. Women with an SPTB were three times more likely to have antenatal depression compared with women without an SPTB (adjusted odds ratio [AOR]: 2.81; 95% confidence interval [CI]: 1.40-5.63). No significant association was identified between antenatal depression and MPTB (AOR: 1.77; 95% CI: 0.67-4.62). The association between antenatal depression and SPTB did not change after adjusting the aforementioned model for a history of PTB and antidepressant use. CONCLUSION: Antenatal depression may differentially affect the risk of PTB through an increase in the odds of SPTB. These results have implications for future studies on prevention and treatment options for depression and PTB.

Is There an Association between Body Mass Index and Cervical Length? Implications for Obesity and Cervical Length Management in Pregnancy.

Objective Obesity and cervical insufficiency are leading causes of morbidity in pregnancy. We assess the relationship between maternal body mass index (BMI) and second-trimester cervical length. Methods A secondary analysis of a nested case-control study of women with singleton gestations enrolled from 2006 to 2008. The primary exposure was first-trimester BMI, categorized per World Health Organization criteria: normal (18.5 to ≤ 25 kg/m2), overweight (25 to ≤ 30 kg/m2), and obese (> 30 kg/m2). The primary outcome was cervical length > 75th percentile. Results Among 391 pregnant women observed, the median cervical length was 3.6 cm, and the median BMI was 24.8 kg/m2. In multivariable analyses, after adjusting for BMI, age, race, parity, smoking, and gestational age at delivery, women who were overweight (adjusted odds ratio [AOR]: 2.18; 95% CI: 1.20-3.96) and obese (AOR: 2.83; 95% CI: 1.47-5.43) were more than two times more likely to have a cervical length > 75th percentile. When cervical length and BMI were assessed linearly, for each 1.0 kg/m2 increase in BMI, cervical length increased by 0.25 mm. These results were robust to utilizing different cutoffs of cervical length and pre-pregnancy BMI. Conclusion This study demonstrates a relationship between BMI and cervical length suggesting that obesity may be associated with longer cervical length. These results will need to be replicated in larger cohorts undergoing universal cervical length assessment.

Utilizing Longitudinal Measures of Fetal Growth to Create a Standard Method to Assess the Impacts of Maternal Disease and Environmental Exposure.

Impaired or suboptimal fetal growth is associated with an increased risk of perinatal morbidity and mortality. By utilizing readily available clinical data on the relative size of the fetus at multiple points in pregnancy, including delivery, future epidemiological research can improve our understanding of the impacts of maternal, fetal, and environmental factors on fetal growth at different windows during pregnancy. This study presents mean and standard deviation ultrasound measurements from a clinically representative US population that can be utilized for creating Z-scores to this end. Between 2006 and 2012, 18, 904 non-anomalous pregnancies that received prenatal care, first and second trimester ultrasound evaluations, and ultimately delivered singleton newborns at Brigham and Women's hospital in Boston were used to create the standard population. To illustrate the utility of this standard, we created Z-scores for ultrasound and delivery measurements for a cohort study population and examined associations with factors known to be associated with fetal growth. In addition to cross-sectional regression models, we created linear mixed models and generalized additive mixed models to illustrate how these scores can be utilized longitudinally and for the identification of windows of susceptibility. After adjustment for a priori confounders, maternal BMI was positively associated with increased fetal size beginning in the second trimester in cross-sectional models. Female infants and maternal smoking were associated with consistently reduced fetal size in the longitudinal models. Maternal age had a non-significant association with increased size in the first trimester that was attenuated as gestation progressed. As the growth measurements examined here are widely available in contemporary obstetrical practice, these data may be abstracted from medical records by investigators and standardized with the population means presented here. This will enable easy extension of clinical data to epidemiologic studies investigating novel maternal, fetal, and environmental factors that may impact fetal growth.

Hematologic disease in pregnancy: the obstetrician's perspective.

Pregnancy can be a time of significantly increased morbidity and mortality in women with hematologic disease. With careful planning and preparation, most women can be cared for safely, resulting in a healthy mother and child. Management concerns in each trimester are reviewed, with a particular focus on labor and delivery planning and common obstetric complications. Diagnostic testing and the use of medications in pregnancy and lactation are discussed in detail.

Protein:creatinine ratio in uncomplicated twin pregnancy.

OBJECTIVE: Women with twin pregnancies may have higher rates of isolated proteinuria than do those with singletons. We compared protein-to-creatinine (P:C) ratios longitudinally through gestation in uncomplicated twin and singleton pregnancies. STUDY DESIGN: P:C ratios were compared at 3 times points in 102 (51 twins, 51 singletons) healthy gravid patients who did not have preeclampsia develop, using linear and logistic regression techniques. RESULTS: P:C ratio increased significantly over gestation in all patients. This increase was significantly greater in twins than in singletons. The odds of P:C ratio >0.19 was 3.5 times higher in twins between 34 and 38 weeks. CONCLUSION: Women with uncomplicated twin pregnancies have greater protein excretion as measured by P:C ratios than do those with singletons. In early pregnancy, protein excretion is similar, but it diverges significantly by the latter third trimester. We suggest that normal values for proteinuria in twins may differ from those in singletons, and warrant further evaluation.

Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome: management and follow-up.

OBJECTIVE: To review the experience at two large referral centers with the syndrome of obstructed hemivagina and ipsilateral renal anomaly (OHVIRA), and to review the risks, benefits, and complications of surgical management options. DESIGN: Retrospective case series. SETTING: Children's Hospital Boston and Brigham and Women's Hospital, Boston, Massachusetts. PATIENT(S): Twenty-seven cases of obstructed hemivagina over a 12-year period. MAIN OUTCOME MEASURE(S): For each patient who presented symptoms, diagnostic studies, anatomic findings, surgical management, outcomes, and complications were reviewed. RESULT(S): The mean age of diagnosis was 14 years. Twenty-three patients had ipsilateral renal anomalies, including 20 patients who had renal agenesis. Two had dysplastic ipsilateral kidneys requiring nephrectomy in infancy. Twenty-six patients underwent vaginal reconstruction, and eight of those additionally underwent laparoscopy for clarification of diagnosis. Six required a two-stage vaginoplasty because of incomplete previous resection (n = 1), infection or anatomic distortion (n = 4), or restenosis (n = 2). Vaginal septum adenosis was seen in eight patients. CONCLUSION(S): Most patients with OHVIRA syndrome can be treated solely with single-stage vaginoplasty. Routine laparoscopy is not essential to management. Vaginal stenosis is a postoperative possibility, and may be associated with vaginal adenosis.