The Mortality of Congenital Syphilis.

OBJECTIVES: To document the case-fatality rate (CFR) of congenital syphilis diagnosed by molecular tools and rabbit infectivity testing (RIT) of clinical specimens in addition to standard evaluation and to compare that with the CFR using the Centers for Disease Control and Prevention (CDC) surveillance case definition. STUDY DESIGN: Prospective, single site, cohort study of all cases of syphilis among mothers and their infants from 1984 to 2002. The diagnosis of congenital syphilis was determined using IgM immunoblotting, polymerase chain reaction, and RIT of fetal or infant specimens in addition to clinical, laboratory, and radiographic criteria. Data were retrospectively reviewed to ascertain fetal and neonatal mortality. RESULTS: During the 18-year study, there were 191 cases of congenital syphilis confirmed by abnormalities on clinical, laboratory, or radiographic evaluation and/or positive serum IgM immunoblot, blood polymerase chain reaction, or blood/cerebrospinal fluid RIT. Of the 191 cases, 59 died for a CFR of 31%. Of the 59 deaths, 53 (90%) were stillborn and 6 (10%) died in the neonatal period. The majority (74%, 39/53) of stillbirths occurred in the third trimester. The CDC surveillance case definition correctly identified all infants with congenital syphilis, but the CDC CFR was 10% which underestimated the CFR by more than 300%. CONCLUSIONS: Our findings corroborate the high sensitivity of the CDC surveillance definition for congenital syphilis but highlight its poor estimation of its associated mortality. The CFR among infected progeny of pregnant women with syphilis was 31%, due mostly to demise in the third trimester and as such highlights the need for detection and appropriate treatment of syphilis during pregnancy.

Putting the "M" back in maternal-fetal medicine: A 5-year report card on a collaborative effort to address maternal morbidity and mortality in the United States.

The Centers for Disease Control and Prevention have demonstrated continuous increased risk for maternal mortality and severe morbidity with racial disparities among non-Hispanic black women an important contributing factor. More than 50,000 women experienced severe maternal morbidity in 2014, with a mortality rate of 18.0 per 100,000, higher than in many other developed countries. In 2012, the first "Putting the 'M' back in Maternal-Fetal Medicine" session was held at the Society for Maternal-Fetal Medicine's (SMFM) Annual Meeting. With the realization that rising risk for severe maternal morbidity and mortality required action, the "M in MFM" meeting identified the following urgent needs: (i) to enhance education and training in maternal care for maternal-fetal medicine (MFM) fellows; (ii) to improve the medical care and management of pregnant women across the country; and (iii) to address critical research gaps in maternal medicine. Since that first meeting, a broad collaborative effort has made a number of major steps forward, including the proliferation of maternal mortality review committees, advances in research, increasing educational focus on maternal critical care, and development of comprehensive clinical strategies to reduce maternal risk. Five years later, the 2017 M in MFM meeting served as a "report card" looking back at progress made but also looking forward to what needs to be done over the next 5 years, given that too many mothers still experience preventable harm and adverse outcomes.

Maternal titers after adequate syphilotherapy during pregnancy.

BACKGROUND: We aimed to construct a timeline for nontreponemal titer decline specific to pregnancy and evaluate factors associated with inadequate decline by delivery. METHODS: This was a retrospective medical records review from September 1984 to June 2011 of women diagnosed with syphilis after 18 weeks of gestation. Women were treated according to stage of syphilis per Centers for Disease Control and Prevention guidelines. Patients with both pretreatment and delivery titers were included for data analysis. Demographics, stage of syphilis, maternal titers, delivery, and infant outcomes were recorded. Standard statistical analyses were performed for categorical and continuous data. The titer decline was analyzed using mixed-effects regression modeling. RESULTS: A total of 166 patients met inclusion criteria. Mean gestational age at treatment was 29.1 ± 5 weeks, and 93 (56%) women were diagnosed with early-stage syphilis. For all stages of syphilis, maternal titers declined after syphilotherapy. Pretreatment titers were higher and declined more rapidly in primary and secondary disease than in latent-stage disease and syphilis of unknown duration. Sixty-three (38%) patients achieved a 4-fold decline by delivery. Patients without a 4-fold decline by delivery were older (24.6 vs 21.5 years; P < .001), treated later in pregnancy (30.3 vs 27.3 weeks; P < .001), diagnosed with latent syphilis or syphilis of unknown duration, and had less time from treatment to delivery (7.8 vs 11.1 weeks; P < .001). CONCLUSIONS: Maternal serologic response during pregnancy after adequate syphilotherapy varied by stage of disease. Failure to achieve a 4-fold decline in titers by delivery is more a reflection of treatment timing than of treatment failure.

Progression of ultrasound findings of fetal syphilis after maternal treatment.

OBJECTIVE: The purpose of this study was to evaluate ultrasound findings of fetal syphilis and to describe their progression after maternal treatment. STUDY DESIGN: This was a retrospective cohort study from September 1981 to June 2011 of seropositive women after 18 weeks of gestation who had an ultrasound before treatment to evaluate for fetal syphilis. Only those women who received treatment after the initial ultrasound scan, but before delivery, were included. If the initial ultrasound scan was abnormal, serial sonography was performed until resolution of the abnormality or delivery. Patient demographics, ultrasound findings, stage of syphilis, delivery, and infant outcomes were recorded. Standard statistical analyses were performed. Kaplan-Meier estimates were constructed to estimate time to resolution. RESULTS: Two hundred thirty-five women met the inclusion criteria; 73 of them (30%) had evidence of fetal syphilis on initial ultrasound scan. Abnormalities included hepatomegaly (79%), placentomegaly (27%), polyhydramnios (12%), ascites (10%) and abnormal middle cerebral arterial Doppler assessment (33%). After treatment, middle cerebral arterial Doppler assessment abnormalities, ascites, and polyhydramnios resolved first, followed by placentomegaly and finally hepatomegaly. Infant outcomes were available for 173 deliveries; of these, 32 infants (18%) were diagnosed with congenital syphilis. Congenital syphilis was more common when antenatal ultrasound abnormalities were present (39% vs 12%; P < .001). Infant examination findings at delivery were similar between women with and without an abnormal pretreatment ultrasound scan. However, in those infants with congenital syphilis, hepatomegaly was the most frequent abnormality found, regardless of antenatal ultrasound findings. CONCLUSION: Sonographic signs of fetal syphilis confer a higher risk of congenital syphilis at delivery for all maternal stages. Hepatomegaly develops early and resolves last after antepartum treatment.

Trends in emergency peripartum hysterectomy at a single institution: 1988-2009.

OBJECTIVE: To evaluate trends of emergency peripartum hysterectomy over two decades. STUDY DESIGN: This was a retrospective cohort study of peripartum hysterectomies at one institution from 1988 to 2009. Medical records were reviewed and data from the first 11 years were compared with data from the second 11 years. RESULTS: During the study period, 558 emergent peripartum hysterectomies were performed with full records available for 553 to review: 280 in the first period, 273 in the second (p = 0.19). In the second period, prior cesarean deliveries, length of surgery, estimated blood loss, blood transfusions, and the number of units transfused were all increased (p < 0.001). Also in the second period, there were twice as many hysterectomies for suspected placental invasion, and an almost threefold increase in pathologically confirmed placental invasion (both p < 0.001). CONCLUSION: Although emergent peripartum hysterectomies are not increasing in frequency, the risk factors and morbidities have changed.

Prevention of mother-to-infant transmission of influenza during the postpartum period.

OBJECTIVES: The optimal management of infants born to mothers with peripartum influenza infection is not known. The objective of this study is to describe our experience with a practice guideline that promotes rooming-in and breast-feeding and to determine whether infants managed in this way acquire influenza infection. STUDY DESIGN: All mothers diagnosed with influenza infection within 8 days of delivery and their infants were included. Demographics, clinical characteristics, and outcome data were collected. Mothers were contacted at ~1 month after giving birth to determine if their infants had developed any signs suggestive of influenza infection. RESULTS: Forty-two women were diagnosed with peripartum influenza over the 2003 to 2005 and 2009 to 2010 seasons. Median onset of symptoms was 3 days before delivery, and median day of diagnosis was 1 day before delivery. The 42 infants had a median gestational age of 39 weeks; none were born earlier than 35 weeks. Ninety-five percent of the infants roomed-in with their mothers. Follow-up information was available on 95% of infants by 1 month; no infants had illness suggestive of influenza through the follow-up period. CONCLUSION: A guideline for the management of infants born to mothers with peripartum influenza infection, based on attention to hand hygiene, antiviral treatment for mothers, and encouragement of rooming-in and breast-feeding, was not associated with mother-to-infant influenza transmission over three separate influenza seasons.

Knowledge, Judgment, and Skills in Reproductive Health Care and Abortion Are Essential to the Practice of Obstetrics and Gynecology.

A social contract exists between medicine and society. In fulfilling the social contract to our patients and society, physicians have an obligation to provide the evidence-based care that patients want and need. What do the data regarding knowledge, judgment, and skills required to practice obstetrics and gynecology show? Obstetrics and gynecology job task analyses assess the importance of knowledge, judgment, and skills through surveys asking practicing physicians about the criticality and frequency of a variety of task statements to create an importance score. Excerpts from a 2018 practice analysis survey clearly indicate that reproductive health care and abortion are important components of the knowledge, judgment, and skills to practice obstetrics and gynecology in the United States. These standards help to assure the knowledge, judgment, and skills of current and future generations of ob-gyns, so their patients and the public can be provided the comprehensive reproductive health care they want and need. It is sometimes important to restate principles and standards that have become ingrained in thoughts and practices that guide physicians and serve to protect our patients. This concept is important now, as our country, health care professionals, and patients examine the future of reproductive health care, including abortion.

The American Board of Obstetrics and Gynecology's remote certifying examination: successes and challenges.

In response to the COVID-19 pandemic, the American Board of Obstetrics and Gynecology canceled the 2020 in-person subspecialty certifying examinations and developed remote administration of 4 subspecialty certifying examinations in 2021 for both examiners and candidates. Because of the continued risks of the COVID-19 pandemic, the 2021 specialty certifying examinations and the 2022 subspecialty certifying examinations were also administered remotely for candidates. For these examinations, examiners participated remotely in 2021 and were at the American Board of Obstetrics and Gynecology testing center in 2022. Overall, the American Board of Obstetrics and Gynecology remote certifying examinations have been well-received by candidates and examiners according to posttest survey data. Candidate performance has been comparable to that observed in the previous in-person examinations. In this review, we describe our implementation, process modifications, successes, and challenges with remote testing. During this process, the American Board of Medical Specialties approval was required, and the Standards for Educational and Psychological Testing served as our testing-industry guideline to ensure valid interpretation of scores and fairness to candidates.

Pharmacokinetics of oseltamivir in breast milk and maternal plasma.

OBJECTIVE: Women in the postpartum period are at high risk for complications from influenza. Pharmacokinetic data of oseltamivir phosphate in postpartum women, however, are lacking. STUDY DESIGN: Seven healthy patients within 48 hours of delivery were recruited. Each woman received 75 mg of oseltamivir phosphate. Plasma and breast milk samples were obtained at times 0, 0.5, 1, 2, 4, 8, 12, and 24 hours after the first dose. The samples were analyzed for oseltamivir and oseltamivir carboxylate levels. Using a noncompartmental model, area under the curve (AUC), maximum concentration (C(max)), time to maximum concentration, and half-life were estimated. RESULTS: Oseltamivir phosphate and oseltamivir carboxylate were found in breast milk, although later and in lower levels than that found in plasma. The C(max) and AUC 0-24 was higher for the active metabolite than for the prodrug in both plasma and breast milk. CONCLUSION: Oseltamivir carboxylate was present in breast milk but in concentrations significantly lower than considered therapeutic in infants.

Pharmacokinetics of oseltamivir according to trimester of pregnancy.

The purpose of this study was to determine pharmacokinetic parameters for oseltamivir in all trimesters of pregnancy. Thirty pregnant women, 10 per trimester, who were receiving oseltamivir phosphate (75 mg) were recruited to study first-dose pharmacokinetics. Plasma samples were obtained at 0, 0.5, 1, 2, 4, 8, and 12 hours after the first dose. Samples were analyzed for oseltamivir and oseltamivir carboxylate levels. With the use of a noncompartmental model, we estimated the area-under-the-curve, maximum concentration, time-to-maximum concentration, and half-life. There were no significant differences in the pharmacokinetics of oseltamivir by trimester, except for an increased half-life in the first trimester for oseltamivir phosphate and an increased maximum concentration in the third trimester for oseltamivir carboxylate. The levels of oseltamivir carboxylate that were observed were within the range that was needed to achieve inhibitory concentrations at 50% for pandemic H1N1. The pharmacokinetics of oseltamivir does not change significantly according to trimester of pregnancy.

Rapid diagnostic methods in sexually transmitted infections.

Sexually transmitted infections (STIs) are common infections throughout the developed and the developing world. It is estimated that worldwide there are 1 million new cases per day of curable bacterial STIs. As part of the World Health Organization 2001 Sexually Transmitted Diseases Diagnostics Initiative, the organization explored the need for simple, affordable, point-of-care STI testing for curable bacterial STIs. This article reviews the evidence supporting the implementation of currently available rapid tests for five common STIs: syphilis, gonorrhea, chlamydia, HIV, and herpes.

Ampicillin resistance and outcome differences in acute antepartum pyelonephritis.

OBJECTIVE: To measure the incidence of ampicillin-resistant uropathogens in acute antepartum pyelonephritis and to determine if patients with resistant organisms had different clinical outcomes. STUDY DESIGN: This was a secondary analysis of a prospective cohort study of pregnant women admitted with pyelonephritis, diagnosed by standard clinical and laboratory criteria. All patients received ampicillin and gentamicin. RESULTS: We identified 440 cases of acute pyelonephritis. Seventy-two percent (316 cases) had urine cultures with identification of organism and antibiotic sensitivities. Fifty-one percent of uropathogens were ampicillin resistant. The patients with ampicillin-resistant organisms were more likely to be older and multiparous. There were no significant differences in hospital course (length of stay, days of antibiotics, ECU admission, or readmission). Patients with ampicillin-resistant organisms did not have higher complication rates (anemia, renal dysfunction, respiratory insufficiency, or preterm birth). CONCLUSION: A majority of uropathogens were ampicillin resistant, but no differences in outcomes were observed in these patients.

Central nervous system infection in congenital syphilis.

BACKGROUND: Identification of infants with Treponema pallidum infection of the central nervous system remains challenging. METHODS: We used rabbit-infectivity testing of the cerebrospinal fluid to detect T. pallidum infection of the central nervous system in infants born to mothers with syphilis. The results were compared with those of clinical, radiographic, and conventional laboratory evaluations; IgM immunoblotting of serum and cerebrospinal fluid; polymerase-chain-reaction (PCR) assay testing of serum or blood and cerebrospinal fluid; and rabbit-infectivity testing of serum or blood. RESULTS: Spirochetes were detected in the cerebrospinal fluid of 19 of 148 infants by rabbit-infectivity testing. Exposure of the infant to antibiotics before cerebrospinal fluid was obtained for rabbit-infectivity testing was associated with a negative test result (P=0.001). Spirochetes were detected in the cerebrospinal fluid in 17 of 76 infants (22 percent) who had no prior antibiotic exposure. These 17 infants included 41 percent (16 of 39) of those with some abnormality on clinical, laboratory, or radiographic evaluation; 60 percent (15 of 25) of those with abnormal findings on physical examination that were consistent with congenital syphilis; and 41 percent (17 of 41) of those with a positive result on IgM immunoblotting or PCR testing of serum, blood, or cerebrospinal fluid, or a positive result on rabbit-infectivity testing of serum or blood. Only one infant who had normal findings on clinical evaluation had a positive cerebrospinal fluid rabbit-infectivity test. Overall, central nervous system infection was best predicted by IgM immunoblotting of serum or PCR assay of serum or blood. CONCLUSIONS: Most infants with T. pallidum infection of the central nervous system can be identified by physical examination, conventional laboratory tests, and radiographic studies. However, the identification of all such infants requires the use of additional tests, including IgM immunoblotting and PCR assay.

The incidence of neonatal herpes infection.

OBJECTIVE: The incidence of perinatal transmission of neonatal herpes infection has recently been reported at 1 in 3200 births. The main objective of this study was to determine a population-based incidence of neonatal herpes simplex virus infection. STUDY DESIGN: This was a retrospective chart review of newborn infants presenting with herpes infection established by cerebrospinal fluid polymerase chain reaction or lesion culture between 1999 and 2003. Only infants delivered at our institution were considered to establish a population-based incidence. RESULTS: Four cases of neonatal herpes infection were identified based on polymerase chain reaction and culture diagnosis. During the study period 78,115 infants were delivered at our institution yielding an incidence of 1 in 20,000 live births. CONCLUSION: The incidence of neonatal herpes infection at our institution is lower than reported elsewhere. A national surveillance program of neonatal herpes is needed to measure the burden of disease across the United States.

Cost-effectiveness of universal influenza vaccination in a pregnant population.

OBJECTIVE: The purpose of this study was to estimate whether universal influenza vaccination of pregnant women was cost-effective in the management of influenza-like illness during influenza season. METHODS: A decision analysis model was developed to investigate the cost-effectiveness of providing inactivated trivalent influenza vaccine to all pregnant women. This scenario was compared with providing supportive care only on a case-by-case basis to the unvaccinated pregnant population. RESULTS: Vaccination of 100% of pregnant women would save approximately 50 dollars per woman, resulting in a net gain of approximately 45 quality-adjusted hours relative to providing supportive care only. CONCLUSION: Universal vaccination with inactivated trivalent influenza vaccine is cost-saving relative to providing supportive care alone in the pregnant population. LEVEL OF EVIDENCE: III.