Retrospective Cohort Study of Syphilis-Related Stillbirths in Winnipeg, Manitoba From 2017-2020.

OBJECTIVE: Syphilis-related stillbirths (SRSBs) disproportionately affect marginalized women with 11% of all local stillbirths having maternal syphilis as a contributory factor in 2020. This study describes the incidence and perinatal factors associated with SRSB. METHODS: This was a retrospective cohort study of all stillbirths occurring from 1 January 2017 to 31 December 2020, at a single tertiary-level referral hospital in Winnipeg, Manitoba. Cases that met criteria for SRSB were identified from hospital records and included in the final analysis. Maternal demographics, comorbidities, prenatal care attendance, sexually transmitted infection testing, treatment, and diagnostic investigations at time of stillbirth were collected from hospital charts using a standardized data collection form. Descriptive statistics were performed to present the results. RESULTS: The proportion of SRSB increased over the period of study from 0%-11%. Eleven cases were identified as SRSB, with diagnosis occurring intrapartum in 7 cases and antenatally in 4 cases. Of the 4 antenatal cases, only 2 had identifiable treatment responses indicated by microbiological and pathology workup. Commonly identified risk factors for SRSB were homelessness, mental illness, substance use, sexually transmitted co-infections, and lack of prenatal care. CONCLUSIONS: Cases of SRSB are rising in Winnipeg with 11% of all stillbirths having maternal syphilis as a contributory factor by 2020. SRSBs disproportionately affect marginalized women. The dramatic and rapid changes in the epidemiology of syphilis in Winnipeg are likely shared by other Canadian regions and warrant increased prevention strategies to improve outcomes.

Pertussis Non-Vaccination During Pregnancy Despite Advice From Prenatal Care Providers.

OBJECTIVE: The purpose of this study was to measure the proportion of non-vaccination for pertussis in mothers in Canada who had been advised by their prenatal care provider to get vaccinated, and to identify sociodemographic factors and beliefs associated with non-vaccination. METHODS: The Survey on Vaccination during Pregnancy (part of childhood National Immunization Coverage Survey) included biological mothers of children born from September 2018 to March 2019. This analysis was restricted to 2657 mothers who had been advised by their prenatal care provider to get vaccinated against pertussis during pregnancy and knew whether or not they had been vaccinated. RESULTS: Of those who had been advised to get vaccinated against pertussis, 21% were not. This rate varied across provinces and territories, ranging from 9% in Prince Edward Island to 32% in Newfoundland and Labrador. Factors independently associated with pertussis non-vaccination included lower household income, having had past live births, and having received prenatal care from an obstetrician-gynecologist or a midwife compared to a family doctor. The risk of pertussis non-vaccination despite prenatal care advice was higher for those who disagreed that the baby would be at greater risk of pertussis if the mother did not get vaccinated. It was also higher for those who disagreed with statements regarding perceived benefits of vaccination. Conversely, disagreement with statements on perceived barriers was negatively associated with pertussis non-vaccination. CONCLUSION: These findings highlight the underlying factors associated with non-vaccination against pertussis despite prenatal care provider recommendation. Some inaccurate beliefs about pertussis and vaccination during pregnancy persist, leading to non-vaccination.

Vaginal microbiome-hormonal contraceptive interactions associate with the mucosal proteome and HIV acquisition.

Alterations to the mucosal environment of the female genital tract, such as genital inflammation, have been associated with increased HIV acquisition in women. As the microbiome and hormonal contraceptives can affect vaginal mucosal immunity, we hypothesized these components may interact in the context of HIV susceptibility. Using previously published microbiome data from 685 women in the CAPRISA-004 trial, we compared relative risk of HIV acquisition in this cohort who were using injectable depot medroxyprogesterone acetate (DMPA), norethisterone enanthate (NET-EN), and combined oral contraceptives (COC). In women who were Lactobacillus-dominant, HIV acquisition was 3-fold higher in women using DMPA relative to women using NET-EN or COC (OR: 3.27; 95% CI: 1.24-11.24, P = 0.0305). This was not observed in non-Lactobacillus-dominant women (OR: 0.95, 95% CI: 0.44-2.15, P = 0.895) (interaction P = 0.0686). Higher serum MPA levels associated with increased molecular pathways of inflammation in the vaginal mucosal fluid of Lactobacillus-dominant women, but no differences were seen in non-Lactobacillus dominant women. This study provides data suggesting an interaction between the microbiome, hormonal contraceptives, and HIV susceptibility.

Pertussis Vaccination in Canadian Pregnant Women, 2018-2019.

OBJECTIVE: This study was undertaken to measure the uptake of pertussis vaccination during pregnancy in Canada and to identify sociodemographic factors associated with non-vaccination. METHODS: A total of 5091 biological mothers of children born between September 2, 2018, and March 1, 2019, were interviewed about pertussis vaccination during their pregnancy. RESULTS: Among 4607 mothers who recalled whether they had been vaccinated for pertussis, 43% had been vaccinated and 57% had not. The main reason given by mothers for not having been vaccinated was not being aware that pertussis vaccination was recommended. Factors independently associated with non-vaccination were being born outside Canada, lower household income, living in a province or territory where pertussis vaccination was not provided free of charge, having had previous live births, and having received maternity care from a midwife. CONCLUSION: Advice from the maternity care provider is an important driver of pertussis vaccination during pregnancy.

Knowledge of Congenital CMV, Risk Behaviours for CMV Acquisition, and Acceptance of an Educational Infographic Among Postpartum Women: A Pilot Study.

Congenital cytomegalovirus (cCMV) infection in the newborn can present with sensorineural hearing loss and microcephaly. The objectives of this study were to determine baseline knowledge of cCMV and the acceptability of an infographic about cCMV among a group of postpartum women. Participants completed a questionnaire assessing their perceptions of an infographic as well as their knowledge and risk behaviours for acquisition of CMV. Of all 140 respondents, 119 (85%) had no prior knowledge of cCMV, and all 12 women (8.6%) who viewed the infographic indicated that it was helpful. Our study also demonstrated that passive dissemination of an infographic in clinics results in limited viewership.

Association of SARS-CoV-2 Infection During Pregnancy With Maternal and Perinatal Outcomes.

Importance: There are limited high-quality, population-level data about the effect of SARS-CoV-2 infection on pregnancy using contemporaneous comparator cohorts. Objectives: To describe maternal and perinatal outcomes associated with SARS-CoV-2 infection in pregnancy and to assess variables associated with severe disease in the pregnant population. Design, Setting, and Participants: CANCOVID-Preg is an observational surveillance program for SARS-CoV-2-affected pregnancies in Canada. This analysis presents exploratory, population-level data from 6 Canadian provinces for the period of March 1, 2020, to October 31, 2021. A total of 6012 pregnant persons with a positive SARS-CoV-2 polymerase chain reaction test result at any time in pregnancy (primarily due to symptomatic presentation) were included and compared with 2 contemporaneous groups including age-matched female individuals with SARS-CoV-2 and unaffected pregnant persons from the pandemic time period. Exposure: SARS-CoV-2 infection during pregnancy. Incident infections in pregnancy were reported to CANCOVID-Preg by participating provinces/territories. Main Outcomes and Measures: Maternal and perinatal outcomes associated with SARS-CoV-2 infection as well as risk factors for severe disease (ie, disease requiring hospitalization, admission to an intensive care unit/critical care unit, and/or oxygen therapy). Results: Among 6012 pregnant individuals with SARS-CoV-2 in Canada (median age, 31 [IQR, 28-35] years), the greatest proportion of cases were diagnosed at 28 to 37 weeks' gestation (35.7%). Non-White individuals were disproportionately represented. Being pregnant was associated with a significantly increased risk of SARS-CoV-2-related hospitalization compared with SARS-CoV-2 cases among all women aged 20 to 49 years in the general population of Canada (7.75% vs 2.93%; relative risk, 2.65 [95% CI, 2.41-2.88]) as well as an increased risk of intensive care unit/critical care unit admission (2.01% vs 0.37%; relative risk, 5.46 [95% CI, 4.50-6.53]). Increasing age, preexisting hypertension, and greater gestational age at diagnosis were significantly associated with worse maternal outcomes. The risk of preterm birth was significantly elevated among SARS-CoV-2-affected pregnancies (11.05% vs 6.76%; relative risk, 1.63 [95% CI, 1.52-1.76]), even in cases of milder disease not requiring hospitalization, compared with unaffected pregnancies during the same time period. Conclusions and Relevance: In this exploratory surveillance study conducted in Canada from March 2020 to October 2021, SARS-CoV-2 infection during pregnancy was significantly associated with increased risk of adverse maternal outcomes and preterm birth.

Guideline No. 420: Cytomegalovirus Infection in Pregnancy.

OBJECTIVE: To provide an update on current recommendations for cytomegalovirus (CMV) infection during pregnancy. The objectives of this guideline are: TARGET POPULATION: Patients of child-bearing age, pregnant patients, and patients planning a pregnancy. BENEFITS, HARMS, AND COSTS: The patient partners urged us to make awareness of preventive strategies a high priority, despite concern that discussing CMV with patients could cause unnecessary anxiety. CMV educational interventions have shown benefits from increased awareness of cCMV prevalence and preventive strategies among providers, patients, and families. EVIDENCE: We searched MEDLINE, EMBASE, and CENTRAL databases for CMV in pregnancy. The search terms were developed using MeSH terms and keywords (Appendix). The results were filtered for articles published between January 2010 and October 2020 and systematic reviews, meta-analyses, clinical trials, and observational studies. The main inclusion criteria were pregnant patients and infants, as the target population, and CMV infection, as the diagnosis of interest. Recommendations are graded according to the U.S. Preventive Services Task Force grade of recommendations and level of certainty. VALIDATION METHODS: We collaborated with patient partners, including members of CMV Canada (cmvcanada.com). In formulating our recommendations, we included patients' voices to add a unique and valuable perspective, thus ensuring that our recommendations are relevant to the patient-provider partnership. INTENDED AUDIENCE: All perinatal health care providers. RECOMMENDATIONS (GRADE AND LEVEL OF CERTAINTY IN PARENTHESES).

A Retrospective Study of Clinical Encounters for Pelvic Inflammatory Disease: Missed Opportunities to Screen for Syphilis and HIV?

OBJECTIVE: Missed screening opportunities may contribute to the rising rates of sexually transmitted and blood borne infections (STBBIs) in Manitoba. This study sought to determine the proportion of women who are screened for syphilis and human immunodeficiency virus (HIV) when admitted with pelvic inflammatory disease (PID). METHODS: We performed a retrospective analysis of all inpatient admissions for PID over 3 discrete years (fiscal years 2007, 2012, 2017) at a single tertiary care centre. Data extracted from medical records included STBBI screening performed, clinical signs at presentation, and history of PID or STBBI. To improve the accuracy of our estimates, we complemented the records data with population data from Manitoba. We evaluated predictive factors influencing any or concurrent STBBI screening using bivariate analysis for significance (P < 0.05). RESULTS: One hundred and five admissions met inclusion criteria. Syphilis and HIV screening was ordered concurrently with chlamydia and gonorrhoea screening in 6 (6%) of encounters and was ordered at any point during admission for PID in 28 (27%). A history of substance abuse (odds ratio [OR] 4.94 [95% CI 1.62-15.05] for syphilis screening and OR 6.94 [95% CI 2.38-20.23] for HIV screening) and a positive gonorrhea result while admitted (OR 3.40 [95% CI 1.06-10.88] for syphilis screening) were strongly associated with receiving any screening. Reporting multiple sexual partners was also strongly associated with receiving any STBBI screening while admitted (OR 19.44 [95% CI 2.01-187.92] and OR 15.00 [95% CI 1.58-142.70] for syphilis and HIV screening, respectively). CONCLUSION: A minority of patients were screened for syphilis and HIV while admitted for PID. This study highlights a missed opportunity to screen for STBBI among sexually active women.

The Canadian HIV Pregnancy Planning Guidelines: What Pregnancy Care Providers Need to Know About HIV Transmission and Pre-Conception Considerations.

Today, under ideal conditions with combination antiretroviral therapy (cART), HIV is a chronic illness with a normal life expectancy. As such, people with HIV are pursuing experiences that once escaped them, such as parenthood. One of the most important factors in reducing perinatal HIV transmission was, and still is, adequate planning. And pregnancy planning has a few additional implications for people affected by HIV, not unlike for people with other chronic illnesses. In 2018, the updated Canadian HIV Pregnancy Planning Guidelines (CHPPGs) were published with 36 recommendations. To help pregnancy care providers use the CHPPGs in pregnancy planning counselling for people living with HIV and their partners, this paper summarizes 5 key considerations in the modern era of HIV management.

The Risk of Postoperative Infectious Complications Following Massive Intraoperative Blood Loss During Gynaecologic Laparotomy: Retrospective Cohort Study.

PURPOSE: To determine whether massive intraoperative blood loss (MIBL) was independently associated with postoperative infectious complications after gynaecologic laparotomy. METHODS: We conducted a retrospective cohort study of patients undergoing gynaecologic laparotomy who were exposed or not exposed to MIBL. The outcome of interest was composite postoperative febrile morbidity. Multiple logistic regression was used to determine the association between exposure and outcome while controlling for measured covariates. RESULTS: The primary outcome was identified to have occurred in 48% (144 of 298) of surgeries with MIBL compared with 12% (51 of 413) of surgeries without MIBL (P < 0.0001). MIBL was found to be strongly and independently associated with primary outcome (adjusted odds ratio 7.04; 95% confidence interval 4.62-10.74; P < 0.0001) after adjusting for age, body mass index, diabetes, immunosuppression, type of procedure, incision type, drains left in situ, and bowel complications. CONCLUSION: MIBL is strongly and independently associated with postoperative febrile morbidity after gynaecologic laparotomy.

Penicillin Skin Testing, Challenge, and Desensitization in Pregnancy: A Systematic Review.

OBJECTIVE: This study sought to evaluate available evidence of the safety of penicillin skin testing (PST), challenge, and desensitization in pregnancy, with efforts to improve perinatal care for patients with a penicillin allergy history and mitigate the negative sequelae of unverified penicillin allergy labels. METHODS: A systematic review of studies was conducted using Cochrane Library, Medline, EMBASE, and International Pharmaceutical Abstracts. Included were peer-reviewed studies without date restrictions, published in English or French, relating to PST, challenge, or desensitization in pregnancy. Editorials, opinion pieces, and letters were excluded. Review authors independently screened citations and full-text articles, extracted data, and conducted quality assessment. Given the heterogeneity of study designs, a narrative synthesis was conducted. RESULTS: The search identified 1195 references, of which 18 studies met inclusion criteria. In total there were 231 patients with varying histories of penicillin allergy, the majority requiring treatment for syphilis or group B streptococcal (GBS) disease during pregnancy. Of the 203 participants who underwent PST, 83.7% had negative test results. Allergy-related reactions were rare in PST (1.5%) and challenge (0%), and although these reactions were more common in desensitization (19.7%), most were benign. Among the 231 cases, only one adverse pregnancy outcome was reported (0.4%). CONCLUSION: This review demonstrates that the known prevalence of true penicillin allergy extends to pregnant women. PST and desensitization can be safely applied during pregnancy and are tools that should be used more frequently. Further data on the safety of challenge during pregnancy are recommended.

A Systematic Review of Barriers to Vaccination During Pregnancy in the Canadian Context.

OBJECTIVE: Although vaccination in pregnancy has the potential to affect maternal and infant morbidity and mortality dramatically, uptake of recommended vaccinations in pregnancy remains low. The objective of this study was to identify barriers and facilitators of vaccination during pregnancy in Canada. METHODS: The Medline database and the tables of contents of four relevant Canadian journals were screened to identify all studies that considered barriers and/or facilitators to vaccination during pregnancy, specifically in Canadian settings. Citations were screened, and a narrative synthesis of findings was undertaken given the heterogeneity of study design. RESULTS: In total, 17 studies met inclusion criteria, most with a focus on the seasonal and pandemic influenza vaccines. Facilitators and barriers were identified at the level of the patient and the provider. At both levels, knowledge was an important facilitator of vaccine acceptance during pregnancy and was notably improved in studies following the 2009 pandemic H1N1 influenza outbreak compared with earlier studies. Vaccine endorsement by a prenatal care provider and clear messages of safety for the fetus emerged as key motivators. Few studies addressed system-level barriers or interventions for improving vaccine uptake during pregnancy in the Canadian setting. CONCLUSION: Common themes have emerged from the Canadian literature addressing barriers and facilitators of vaccination during pregnancy. However, there is a paucity of literature to suggest strategies to improve the uptake of vaccination during pregnancy in Canadian settings. Further research is urgently needed given the expanding role of vaccination during routine prenatal care.

No. 357-Immunization in Pregnancy.

OBJECTIVE: To review the evidence and provide recommendations on immunization in pregnancy. OUTCOMES: Outcomes evaluated include effectiveness of immunization and risks and benefits for mother and fetus. EVIDENCE: The Medline and Cochrane databases were searched for articles published up to January 2017 on the topic of immunization in pregnancy. VALUES: The evidence obtained was reviewed and evaluated by the Infectious Diseases Committee of the SOGC under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS: Implementation of the recommendations in this guideline should result in more appropriate immunization of pregnant and breastfeeding women, decreased risk of contraindicated immunization, and better disease prevention.

No. 354-Canadian HIV Pregnancy Planning Guidelines.

OBJECTIVE: The objective of the Canadian HIV Pregnancy Planning Guidelines is to provide clinical information and recommendations for health care providers to assist Canadians affected by HIV with their fertility, preconception, and pregnancy planning decisions. These guidelines are evidence- and community-based and flexible and take into account diverse and intersecting local/population needs based on the social determinants of health. INTENDED OUTCOMES: EVIDENCE: Literature searches were conducted by a librarian using the Medline, Cochrane Central Register of Controlled Trials (CENTRAL), and Embase databases for published articles in English and French related to HIV and pregnancy and HIV and pregnancy planning for each section of the guidelines. The full search strategy is available upon request. VALUES: The evidence obtained was reviewed and evaluated by the Infectious Diseases Committee of the SOGC under the leadership of the principal authors, and recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care and through use of the Appraisal of Guidelines Research and Evaluation instrument for the development of clinical guidelines. BENEFITS, HARMS, AND COSTS: Guideline implementation should assist the practitioner in developing an evidence-based approach for the prevention of unplanned pregnancy, preconception, fertility, and pregnancy planning counselling in the context of HIV infection. VALIDATION: These guidelines have been reviewed and approved by the Infectious Disease Committee and the Executive and Council of the SOGC. SPONSOR: Canadian Institutes of Health Research Grant Planning and Dissemination grant (Funding Reference # 137186), which funded a Development Team meeting in 2016.