Intravenous Sedation Without Intubation and the Risk of Anesthesia Complications for Obese and Non-Obese Women Undergoing Surgical Abortion: A Retrospective Cohort Study.

BACKGROUND: The primary objective of this study was to assess the risk of perioperative anesthesia-related complications in a cohort of obese and non-obese women undergoing outpatient surgical abortion under IV sedation without tracheal intubation. METHODS: We performed a retrospective cohort study of all surgical abortions through 22 6/7 weeks' gestation at an outpatient clinic from 2012 to 2013. Women receiving IV sedation were included. Obesity status was defined by the World Health Organization criteria. The primary outcome was the rate of perioperative anesthesia complications defined as tracheal intubation, pulmonary aspiration, hospital transfer for an anesthesia indication, or anesthesia-related adverse events (persistent hypoxemia and allergic reaction). The use of opioid reversal (naloxone) was assessed as a secondary outcome measure. Multivariate analysis for the secondary outcome measure was performed with adjustment for confounding factors. RESULTS: During the study period, 9348 abortions were performed. Of the 5579 patients who received IV sedation, 1438 (25.8%) were obese, 1707 (30.6%) were in the second trimester, and 851 (15.3%) were ≥17 weeks' gestation. No patients experienced a primary outcome measure. Based on the upper 95% confidence interval (CI) for the sample size, the maximal risk of an anesthesia-related complication is 1 in 1860 procedures. Naloxone use occurred in 13 (0.2%) patients and was not more frequent among obese patients (0.14% vs 0.27%; 95% CI of odds ratio [OR], 0.12-2.36; P = 0.54) or procedures at ≥17 weeks' gestation (0.47% vs 0.19%; 95% CI of OR, 0.76-8.06; P = 0.12). These negative findings should be interpreted with caution, given the limitations of the sample size to assess these secondary outcome measures. Naloxone use was associated with fentanyl doses >200 µg (0.82% vs 0.13%; P = 0.002), an association that remained significant when we controlled for confounding factors (adjusted OR, 5.51; 95% CI, 1.61-18.91). Further analysis revealed that fentanyl dose >200 µg was associated with naloxone use for procedures in the first trimester (incident rate ratio, 9.02; 95% CI, 3.73-21.80) but not in the second trimester (incident rate ratio, 0.92; 95% CI, 0.23-3.70). CONCLUSIONS: Among women receiving IV sedation without tracheal intubation for surgical abortion, anesthesia complications are rare and may not be greater for obese women or procedures at gestational age ≥17 weeks. IV sedation without tracheal intubation may be considered for women undergoing first- and second-trimester surgical abortion; however, the rarity of anesthesia-related complications in our cohort precludes a definitive conclusion regarding the overall safety of IV sedation without tracheal intubation.

Obstetrician Attitudes, Experience, and Knowledge of Planned Home Birth: An Exploratory Study.

BACKGROUND: The incidence of planned home birth is increasing in the United States. The American College of Obstetricians and Gynecologists acknowledges a woman's right to make an informed choice about place of delivery, including home birth. This exploratory study measures obstetricians' attitudes, experiences, and knowledge about planned home birth, identifies associations between these factors, and compares obstetricians' responses in Ohio to those in Arizona and New Mexico. METHODS: A survey about attitudes, experiences, and knowledge of planned home birth was distributed to obstetricians in Ohio, Arizona, and New Mexico. Attitude and knowledge scores were calculated for each respondent and used to evaluate associations through linear regression. Attitude and knowledge scores in states that have regulation of direct entry midwives (Arizona and New Mexico) were compared to a state which does not (Ohio). RESULTS: Obstetricians in all three states reported little experience and knowledge of planned home birth and overall negative attitudes. Obstetricians with stronger knowledge did not differ in their attitudes from those with less knowledge. No statistically significant differences were found when comparing attitude and knowledge scores in Ohio to Arizona and New Mexico, but Ohio obstetricians responded most negatively to the attitude questions. CONCLUSIONS: Obstetricians have limited knowledge and experience and hold very negative attitudes about planned home birth. Research is necessary to determine: 1) whether negative obstetrician attitudes would be modified by exposure to home birth education and experience, and, 2) whether negative obstetrician beliefs deter safe and timely transfer from home or compromise hospital care for transferred parturients.

Cervical cancer in Indian women reveals contrasting association among common sub-family of HLA class I alleles.

We studied the relationship between human leukocyte antigen (HLA) class I alleles and cervical cancer among Indian women. Seventy-five cervical cancer cases were compared with 175 noncancer controls. Cervical biopsy tissue specimen from cancer cases and cervical swab specimen from controls were collected for HPV detection and typing. Blood was taken for HLA typing by PCR-SSOP method. The impact of HLA class I alleles on cervical cancer risk was evaluated using StatCalc program (Epi Info version 6.0.4. CDC Atlanta, GA, USA), and confirmed with Bonferroni correction. Results revealed HLA-B*37, HLA-B*58 were associated significantly with increased risk while HLA-B*40 with decreased risk for cervical cancer. At high-resolution analysis after Bonferroni correction, HLA-B*37:01 allele was associated with increased risk, whereas HLA-B*40:06 was with decreased risk for cervical cancer. HLA-B*37:01 and HLA-B*40:06 belong to the same superfamily of HLA-B44. In silico analysis revealed different binding affinities of HLA-B*37:01 and HLA-B*40:06 for the epitopes predicted for E6 and L1 proteins of HPV16. The higher binding affinity of epitopes to B*40:06, as revealed by docking studies, supports the hypothesis that this allele is able to present the antigenic peptides more efficiently than B*37:01 and thereby can protect the carriers from the risk of cervical cancer. Thus, there is a clear indication that HLA plays an important role in the development of cervical cancer in HPV-infected women. Identification of these factors in high-risk HPV-infected women may help in reducing the cervical cancer burden in India.

HPV16 E6 variants: frequency, association with HPV types and in silico analysis of the identified novel variants.

High-risk human papillomavirus (HPV) types, specifically HPV 16 E6 variants are involved in viral persistence and the development of cervical lesions. India contributes to 1/3rd of the global cervical cancer deaths; however, information on E6 variants in the Indian population is limited. Information on these variants is essential for successful implementation of cervical cancer immunization programs. The E6 variants and their possible biological implications to the outcome of infection were studied in women attending the Tata Memorial Hospital, Mumbai, India. Cervical cancer patients with HPV 16 as a single infection (n = 33), co-infection with another HPV type (n = 20) or with multiple types (n = 10) were examined for HPV16 E6 variants using PCR and sequence analysis. The variants were identified using the prototype sequence (HPV 16R) belonging to the European lineage. The results revealed that the European T350G was the most common variant (50%) followed by the European prototype (40.3%) and the North-American (N = 3; 4.8%). The European prototype was significantly more frequent in patients infected with HPV16 alone (P < 0.05, C.I. 1.2-13.6), while the European T350G variants were seen in women with co-infections. The North-American lineage was found in women infected with HPV16 and 33. Three novel variants were identified of which two were non-synonymous. Phylogenetic analysis revealed that the variant F69L + L83V is not related to any of these lineages, while the variant M137L + L83V is closely related to the North American variant. This study found a difference in the prevalence of E6 variants compared to earlier Indian studies and their association with type of infection.

Variations in immunogenetics, human papillomavirus (HPV) infection & predisposition to cervical cancer in Indian women.

BACKGROUND & OBJECTIVES: Human papillomavirus (HPV) is the main causative agent for cervical cancer. Variability in host immunogenetic factors is important in determining the overall cellular immune response to the HPV infection. This study was carried out to confirm the association between human leukocyte antigen (HLA) class II alleles and cervical cancer in HPV infected women. METHODS: Both low and high resolution methods were used to genotype HLA class II (DRB1 and DQB1) alleles in 75 women with cervical cancer (cases) and 75 HPV positive women and 100 HPV negative women with healthy cervix (controls). odds ratio and 95% confidence interval were calculated. Co-occurring HLA alleles (haplotype) across cases and controls were also studied. RESULTS: Significant association was found for HLA-DRB1*03(*13:01) and - DQB1*02(*02:01) with increased risk for cervical cancer. Also, HLA-DRB1*13(*13:01); -DQB1*06 and -DQB1*03:02 were significantly associated with decreased risk for cervical cancer. Haplotype analysis highlighted the significant association of HLA- DRB1*07:01-DQB1*02:02 and HLA DRB1*10:01-DQB1*05:01 with cervical cancer, while HLA-DRB1*14:04-DQB1*05:03 and DRB1*15:01-DQB1*06:01 conferred decreased risk for cervical cancer. Multivariate analysis highlighted the association of specific alleles with cervical cancer after adjusting for confounding factor age. INTERPRETATION & CONCLUSIONS: There were possible associations of specific HLA class II alleles either with risk of developing cervical cancer, or with its protection. Our results confirmed the assessment of DRB1*13 as a protective marker in HPV infection outcome. our study also revealed protective association of homozygous haplotype DRB1*15- DQB1*06 with cervical cancer.

Refining Trauma-Informed Perinatal Care for Urban Prenatal Care Patients with Multiple Lifetime Traumatic Exposures: A Qualitative Study.

INTRODUCTION: Because lifetime trauma exposure has been linked to multiple adverse pregnancy outcomes, there is a need for all perinatal care providers to be versed in trauma-informed care practices. However, there are few data to guide trauma-informed practice during the perinatal period. The objective of this study was to refine ongoing development of a trauma-informed care framework for perinatal care by conducting a qualitative study of all trauma experiences and preferred screening practices of pregnant patients at an urban prenatal clinic. METHODS: In this qualitative study, we conducted semistructured interviews with 30 women receiving prenatal care at an urban clinic. Participants also completed a trauma history questionnaire. Inductive coding was used to generate themes and subthemes. RESULTS: Participants described multiple lifetime traumatic exposures as well as background exposure to community violence. Not all participants desired routine trauma screening; factors limiting disclosure included fear of retraumatization and belief that prior trauma is unrelated to the current pregnancy. Strong therapeutic relationships were identified as critical to any trauma history discussion. DISCUSSION: This study supports a trauma-informed care approach to caring for pregnant women with prior traumatic exposures, including trauma screening without retraumatization and trusting patient-provider relationships.

Maternal outcomes following the initiation of an institutional delayed cord clamping protocol: an observational case-control study.

OBJECTIVE: The objective of this study is to evaluate maternal outcomes before and after implementation of an institutional delayed cord clamping (DCC) protocol. STUDY DESIGN: We performed a secondary analysis of a retrospective cohort study of deliveries occurring at <34 weeks at a tertiary care center in 2013-2014. About 139 women who underwent early cord clamping were compared with 130 women delivered after DCC protocol implementation. Maternal estimated blood loss (EBL) was the primary outcome of interest. Operative times, post-Cesarean decrease in hemoglobin (Hgb), and rates of post-partum hemorrhage and transfusion were also examined in bivariate and multivariable analyses. RESULTS: About 75% of post-guideline deliveries had actual DCC. In regression analyses, only Cesarean delivery and multifetal gestation increased EBL. No trends were identified in EBL over time. In post-hoc analysis, the study had over 80% power to detect a difference in post-partum hemorrhage rates of 20%. CONCLUSION: An institutional DCC protocol for deliveries <34 weeks was not associated with an identifiable increase in adverse maternal outcomes.

Demographic and Other Characteristics, and Rates of Sexually Transmitted Infections among Adolescents Who Underwent Multiple Abortions in 1 Year.

STUDY OBJECTIVE: To examine characteristics of adolescent patients presenting for multiple terminations within 1 year and evaluate sexually transmitted infection (STI) status at each visit. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional retrospective chart review to identify women younger than age 20 years who underwent multiple abortions during 1 year at John H. Stroger, Jr Hospital of Cook County. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Rates and results of STI testing at each abortion encounter. RESULTS: We identified 381 adolescent patients with 2 or more abortions in 1 year. Of the 285 women who received STI testing at both clinical encounters, we identified 12 women with Chlamydia trachomatis (CT)/Neisseria gonorrhoeae (GC) coinfection. Among patients who were not coinfected, 47 of 273 (17.2%) and 4 of 273 (1.5%) tested positive for CT and GC at the initial visit, respectively. Among women who were STI negative at the time of their first abortion, 25 of 226 (11.1%) were positive for CT and 1 of 269 (0.37%) was positive for GC at the time of their second termination. CONCLUSION: Young women in our study had higher baseline rates of CT and GC than rates reported by the Centers for Disease Control and Prevention for an age-matched population. High rates of positivity at the second visit might indicate a need for increased health education and/or frequency of testing in high-risk groups. In the adolescent population for whom patient encounters can be limited, the abortion care visit provides an opportunity to provide education and mitigate risk.

CTLA-4 gene polymorphism at position +49 A>G in exon 1: a risk factor for cervical cancer in Indian women.

Single nucleotide polymorphisms (SNPs) in the CTLA-4 gene exert differential effects on T-cell response to viral infection. We aimed to evaluate the association of two SNPs of the CTLA-4 gene with cervical cancer in Indian women. The two polymorphic loci, one in the promoter region -318 C>T, rs5742909 (100 cervical cancer cases and 101 controls) and the other in exon 1 +49 A>G, rs231775 (104 cervical cancer cases and 162 controls) were genotyped using polymerase chain reaction-restriction fragment length polymorphism methods. Haplotype block structure was determined using Haploview 4.2. The statistical analyses were performed using a commercially available statistical software package, whereas PyPop was used to calculate the haplotypic frequencies. In this case-control study, the A/A genotype frequency (30.76% vs. 17.6%, P = 0.01) as well as the allelic frequency for A (52.8% vs. 43.5%, P = 0.04) was significantly higher in cases compared to controls. No significant association was seen in the -318 C>T polymorphism. In forward stepwise binary logistic regression analysis considering age and parity as potential confounders, significant association was demonstrated between +49 A/A and cervical cancer. Most likely, this is the first study from India to highlight the significant association between the CTLA-4 gene +49 A/A SNP and cervical cancer, thus adding to the global knowledge of the association of this SNP with cervical cancer.