Hepatitis E-Associated Hospitalizations in the United States: 2010-2015 and 2015-2017.

Hepatitis E is considered rare in the United States (US) despite its widespread occurrence in Asian and African countries. The objective of this study was to describe the characteristics of hepatitis E-related pregnancies and acute-on-chronic liver failure and analyse trends for hepatitis E diagnosis among hospitalized patients in the US. We examined data from the 2010-2017 National Inpatient Sample from Healthcare Cost and Utilization Project to determine mortality, morbidity, pregnancy diagnoses, chronic liver disease diagnoses, and other conditions during hospitalization. Data were extracted for hospitalizations with hepatitis E as defined by ICD-9 codes 070.43 and 070.53 and ICD-10 code B17.2. Of 208,462,242 hospitalizations from 2010-2015, we identified 960 hepatitis E hospitalizations. The hospitalization rate of hepatitis E was 3.7 per 10 million in 2010 and 6.4 per 10 million in 2015 (ß = 0.60, p = 0.011). From 2015 to 2017, the hospitalization appeared to increase with slope (ß) of 0.50. Among those hospitalizations, 34 (4%) died and 85 (9%) had acute-on-chronic liver failure. Ninety-five (10%) had a diagnosis of pregnancy, there were no reports of maternal or foetus/neonate deaths, but there was a high proportion of adverse events for both during hospitalization. Having a chronic liver disease was associated with hepatic coma diagnosis (OR = 10.94, p = 0.002). Although the hospitalization rate of hepatitis E in the US is low, it appears to be increasing over time. Further studies are necessary in order to conclude a causal association of hepatitis E with adverse events and mortalities in pregnancy and chronic liver disease in the US.

Infections complicating cesarean delivery.

PURPOSE OF REVIEW: Cesarean sections are common surgical procedures performed in a healthy population and are unique because of a relatively high rate of postoperative infection. There have been many important advances in understanding the pathogenesis of infection and evaluation of interventions to prevent post cesarean section infections in the last few years. Our purpose in this review is to analyze these new data, discuss unanswered questions, and propose changes in standard of care. RECENT FINDINGS: Wound closure techniques including subcuticular sutures and subcutaneous suturing have been shown to be effective at reducing surgical site infections. Wound dressings including negative pressure dressings likely do not decrease infection rates. The type, timing, and duration of preoperative prophylactic antibiotics, including adjunctive azithromycin for laboring women and multidose antibiotics in obese women, have also yielded mixed results. Our understanding of normal uterine microbiome and the impact of intrapartum antibiotics on the newborn is emerging. SUMMARY: The pathogenesis of surgical site infections after Cesarean section is complex and multifactorial. Many interventions to reduce infections have been studied with varying degrees of effectiveness. Despite advances in the area, important questions remain unanswered.

Early skin-to-skin contact for healthy full-term infants after vaginal and caesarean delivery: a qualitative study on clinician perspectives.

AIMS AND OBJECTIVES: This study aims to provide insight into key factors from a clinician's perspective that influence uninterrupted early skin-to-skin contact after vaginal and caesarean delivery of healthy full-term infants. BACKGROUND: Early skin-to-skin contact of healthy full-term infants ideally begins immediately after birth and continues for the first hour or the first breastfeed as recommended by the Baby Friendly Hospital Initiative. However, adoption of early skin-to-skin contact is low in many settings and the barriers that hinder its universal use are not well understood. DESIGN: An exploratory qualitative research design using semi-structured interviews. METHODS: Eleven clinicians were interviewed, including five registered nurses and one medical doctor from the obstetrics and gynaecology unit as well as four registered nurses and one medical doctor from the neonatal intensive care unit. Core topics that were discussed included perceptions on early skin-to-skin contact and facilitating factors and barriers to early skin-to-skin contact after vaginal and caesarean delivery. Interview sessions were recorded, transcribed and analysed using a thematic analysis approach. A coding framework was developed from which subthemes emerged. The overall themes were adopted from Lee et al.'s thematic framework to categorise factors into institutional, familial-level and implementation factors. FINDINGS: Critical institutional factors included inadequate staffing and education of clinicians on early skin-to-skin contact. On a familial level, parental education and motivation were identified as important factors. Barriers to implementation included the absence of a clinical algorithm and unclear definitions for eligible mothers and infants. CONCLUSIONS: Various facilitating factors and barriers to early skin-to-skin contact of healthy full-term infants born via vaginal and caesarean delivery were identified. RELEVANCE TO CLINICAL PRACTICE: Addressing these factors can help to provide a better understanding of clinician perspectives on early skin-to-skin contact and help guide its implementation as standard of care for healthy full-term infants.

Association between depression and nonadherence to antiretroviral therapy in pregnant women with perinatally acquired HIV.

Women with perinatally acquired HIV (PAH) face unique psychosocial challenges due to the presence of a lifelong chronic illness and often unstable living situations. With advances in HIV treatment, an increasing number of those with PAH are reaching childbearing age and becoming pregnant. Depression may be an important and common factor that complicates both treatment and pregnancy outcomes in this group. We conducted a retrospective cohort study in pregnant patients with PAH to determine if history of depression is associated with nonadherence to antiretroviral therapy (ART). We reviewed charts of women with PAH receiving prenatal care at a single institution from March 1995 to December 2012. ART nonadherence was measured by patient self-report of any missed doses in the third trimester. Demographic, obstetric, and HIV infection characteristics of patients with a history of depression (dPAH) were compared to patients without a history of depression. Nine pregnancies among 6 dPAH women and 14 pregnancies among 12 PAH women without a history of depression were identified. None of the dPAH women reported 100% adherence to ART in the third trimester while 57% of women without a history of depression reported strict adherence (p = 0.04). The mean HIV RNA level at delivery was higher among dPAH women (17,399 vs. 2966 copies/Ml; p = 0.03) and fewer reached an undetectable HIV RNA level (<400 copies/mL) at delivery (p = 0.03). We concluded that a history of depression may contribute to poor medication adherence and treatment outcomes among pregnant women with PAH. Focused attention on diagnosis and treatment of depression in the preconception period may lead to more optimal medication adherence.

Women Living with Human Immunodeficiency Virus with Intended and Unintended Pregnancy: Characteristics and Patient Outcomes.

Background: Rates of unintended pregnancy may be higher in women living with human immunodeficiency virus (WLWH) than in the general population, and it is unclear how populations of WLWH with intended and unintended pregnancy differ. We compared baseline characteristics and outcomes between WLWH with intended and unintended pregnancy. Materials and Methods: We conducted a retrospective analysis of WLWH enrolled in a human immunodeficiency virus (HIV) and Pregnancy clinic from 2003 to 2014. Data were analyzed using descriptive statistics, chi-square test, Student's t-test, one-way analysis of variance, and linear and logistic regression analysis. Two-tailed p-value <0.05 was considered significant. The study was approved by the Johns Hopkins University School of Medicine Institutional Review Board. Results: Sixty-nine (27.1%) of 255 women reported an intended pregnancy. Women with intended pregnancy (WWIP) were more likely to be older, White, married, privately insured, and college educated. WWIP were less likely to use tobacco (15.9% vs. 44.2%, p < 0.001), alcohol (2.9% vs. 11.1%, p = 0.041), opiates (0.0% vs. 19.3%, p < 0.001), or cocaine (2.9% vs. 21.0%, p < 0.001) during pregnancy, more likely to disclose their HIV status to the father of the baby by delivery (100.0% vs. 15.8%, p < 0.001), and more likely to receive less effective contraception at delivery (condoms 14.9% vs. 4.8%, p = 0.024; sterilization 11.9% vs. 22.1%, p = 0.028). In multivariate regression analysis, pregnancy intendedness was an important predictor of nondetectable viral load at pregnancy entry but not at delivery. Conclusions: WLWH vary in their baseline characteristics and pregnancy outcomes depending on pregnancy intendedness, highlighting the need to improve pregnancy timing in WLWH and intensify interventions for women with unintended pregnancy.

Ondansetron to reduce neonatal opioid withdrawal severity a randomized clinical trial.

OBJECTIVE: To determine if treatment with a 5-HT3 antagonist (ondansetron) reduces need for opioid therapy in infants at risk for neonatal opioid withdrawal syndrome (NOWS). STUDY DESIGN: A multicenter, randomized, placebo controlled, double blind clinical trial of ninety (90) infants. The intervention arms were intravenous ondansetron or placebo during labor followed by a daily dose of ondansetron or placebo in infants for five days. RESULTS: Twenty-two (49%) ondansetron-treated and 26 (63%) placebo-treated infants required pharmacologic treatment (p > 0.05). The Finnegan score was lower in the ondansetron-treated group (4.6 vs. 5.6, p = 0.02). A non-significant trend was noted for the duration of hospitalization. There was no difference in need for phenobarbital or clonidine therapy, or total dose of morphine in the first 15 days of NOWS treatment. CONCLUSIONS: Ondansetron treatment reduced the severity of NOWS symptoms; and there was an indication that it could reduce the length of stay. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov NCT01965704.

The case for simulation as part of a comprehensive patient safety program.

Simulation in obstetrics allows us to practice in a safe environment. Simulations can improve the performance of individuals and obstetric teams. The evidence is overwhelming that, with simulated practice, obstetricians improve their technical and communication skills. Evidence is emerging that simulation ultimately may improve clinical outcomes. It stands to reason that simulation in obstetrics should be incorporated into comprehensive patient safety programs.

Pregnancy in an Urban Cohort of Adolescents Living with Human Immunodeficiency Virus: Characteristics and Outcomes in Comparison to Adults.

Adolescents (13-24 years of age) account for more than one-fifth of new HIV diagnoses yearly, and the United States has one of the highest rates of adolescent pregnancy among high resource countries. However, there is limited information on the characteristics and outcomes of adolescents living with HIV (ALWHIV) during pregnancy and differences with pregnancy in adults living with HIV. We performed a retrospective cohort study to compare demographic characteristics, HIV viral suppression, and pregnancy outcomes in adolescents (n = 90) as compared with adults (n = 250) in an urban HIV pregnancy clinic from 2003 to 2015. Seventy-one women overall were diagnosed with HIV during pregnancy (adolescents, 25/90; adults, 46/250). One-fifth of adolescents acquired HIV perinatally. Adolescents were more likely than adults to have unintended pregnancy (83.6% vs. 68.7%, p = 0.016) and were less likely to be virally suppressed at delivery (50.0% vs. 69.7% overall, p = 0.001; 48.0% vs. 78.2% in postuniversal antiretroviral therapy era, p = 0.007%). Over one-third of adolescents reported a history of any illicit substance use, and adolescents were more likely than adults to use marijuana during pregnancy (29.2% vs. 16.9%, p = 0.013). Adolescents were less likely to experience preterm labor (11.0% vs. 24.1%, p = 0.012) or preterm premature rupture of membranes (3.7% vs. 16.7%, p = 0.003). There was one case of maternal-fetal transmission, which occurred in an adult pregnancy. Despite the high rate of unintended pregnancy, one-third of adolescents were discharged without an identified contraception plan. We identify several opportunities for intervention to improve reproductive health outcomes in ALWHIV.

Preterm Parturient with Polyhydramnios and Pancreatitis: Primary Presentation of Hyperparathyroidism.

OBJECTIVE: To report a case of severe hypercalcemia secondary to primary hyperparathyroidism in a late-preterm pregnant patient and review medical and surgical treatments as well as obstetric and neonatal outcomes. BACKGROUND: Diagnosis of parathyroid disease during pregnancy can be difficult due to nonspecific presentation. Management decisions are complex and require multidisciplinary collaboration. CASE: A 29-year-old G2P1001 woman at 35 weeks and 3 days' gestation presented with preterm contractions, polyhydramnios, pancreatitis, and severe hypercalcemia. Work-up revealed primary hyperparathyroidism with multiple thyroid nodules. Patient history, presentation, and biopsy were suspicious for parathyroid carcinoma. Despite severe hypercalcemia, both patient and fetus remained stable and medical management was pursued in an attempt to optimize mother and fetus prior to delivery. Due to recalcitrant hypercalcemia, surgical resection was ultimately required. She was subsequently delivered in the setting of preterm labor. Final pathology revealed parathyroid adenoma with atypia and occult papillary thyroid carcinoma. CONCLUSION: Symptoms of hypercalcemia can mimic those of a normal third trimester pregnancy and can have serious maternal and fetal effects if left untreated. A coordinated, multidisciplinary approach to these patients is necessary.

Severe Maternal Morbidity at Delivery and Risk of Hospital Encounters Within 6 Weeks and 1 Year Postpartum.

BACKGROUND: Little is known about the impact of severe maternal morbidity (SMM) after delivery. We examined the risk of rehospitalization in the first year postpartum among deliveries to women with and without SMM. MATERIALS AND METHODS: We used the Pregnancy to Early Life Longitudinal data system, in which vital birth/fetal death records were linked with hospital delivery discharge data and subsequent nondelivery hospitalization data, including observational stays (OSs) and in-patient stays (hospital discharge [HD]) for Massachusetts residents during 2002-2011. We excluded deliveries to women with preexisting chronic conditions: hypertension, diabetes, asthma, and autoimmune conditions for a final sample of 685,228 deliveries. Multivariable log binomial regression with generalized estimating equations modeled the relative risk (RR) of hospital encounters 6 weeks and 1 year postpartum. RESULTS: The rate of SMM was 99 per 10,000 deliveries. In the first year postpartum, 2.8% of deliveries to women without chronic medical conditions experienced at least one HD encounter and 1.0% at least one OS encounter. The adjusted relative risk (aRR) of any HD encounter for deliveries with SMM was 2.48 (95% confidence interval [CI]: 2.20-2.80) within 6 weeks postpartum and 2.04 (95% CI: 1.87-2.23) within 1 year. For OS encounters, aRRs among deliveries with SMM at delivery were 2.47 (95% CI: 1.94-3.14) in the first 6 weeks and 1.69 (95% CI: 1.43-2.01) in 1 year. CONCLUSIONS: In Massachusetts, SMM increased the risk of rehospitalization in the first year postpartum among deliveries to women without chronic medical conditions.

Acute Cardiac Effects of Severe Pre-Eclampsia.

BACKGROUND: Pre-eclampsia with severe features (PEC) is a pregnancy-specific syndrome characterized by severe hypertension and end-organ dysfunction, and is associated with short-term adverse cardiovascular events, including heart failure, pulmonary edema, and stroke. OBJECTIVES: The authors aimed to characterize the short-term echocardiographic, clinical, and laboratory changes in women with PEC, focusing on right ventricular (RV) systolic pressure (RVSP) and echocardiographic-derived diastolic, systolic, and speckle tracking parameters. METHODS: In this prospective observational study, the authors recruited 63 women with PEC and 36 pregnant control patients. RESULTS: The PEC cohort had higher RVSP (31.0 ± 7.9 mm Hg vs. 22.5 ± 6.1 mm Hg; p < 0.001) and decreased global RV longitudinal systolic strain (RVLSS) (-19.6 ± 3.2% vs. -23.8 ± 2.9% [p < 0.0001]) when compared with the control cohort. For left-sided cardiac parameters, there were differences (p < 0.001) in mitral septal e' velocity (9.6 ± 2.4 cm/s vs. 11.6 ± 1.9 cm/s), septal E/e' ratio (10.8 ± 2.8 vs. 7.4 ± 1.6), left atrial area size (20.1 ± 3.8 cm2 vs. 17.3 ± 2.9 cm2), and posterior and septal wall thickness (median [interquartile range]: 1.0 cm [0.9 to 1.1 cm] vs. 0.8 cm [0.7 to 0.9 cm], and 1.0 cm [0.8 to 1.2 cm] vs. 0.8 cm [0.7 to 0.9 cm]). Eight women (12.7%) with PEC had grade II diastolic dysfunction, and 6 women (9.5%) had peripartum pulmonary edema. CONCLUSIONS: Women with PEC have higher RVSP, higher rates of abnormal diastolic function, decreased global RVLSS, increased left-sided chamber remodeling, and higher rates of peripartum pulmonary edema, when compared with healthy pregnant women.

Pseudo-outbreak of Penicillium in an outpatient obstetrics and gynecology clinic.

We report an unusual pseudo-outbreak of Penicillium that occurred in patients seen in an outpatient obstetrics and gynecology clinic. The pseudo-outbreak was detected in late 2012, when the microbiology department reported a series of vaginal cultures positive for Penicillium spp. Our investigation found Penicillium spp in both patient and environmental samples and was potentially associated with the practice of wetting gloves with tap water by a health care worker prior to patient examination.

Mathematical Modeling of the Biomarker Milieu to Characterize Preterm Birth and Predict Adverse Neonatal Outcomes.

PROBLEM: To identify preterm neonates at risk for adverse neonatal outcomes. METHOD OF STUDY: A nested case-control study from the prospectively followed Boston Birth Cohort of mother-neonate pairs was performed. A classification model for preterm-born neonates was derived from 27 cord blood biomarkers using orthogonal projections to latent structures discriminant analysis. Predictive relationships were made between biomarkers and adverse outcomes using logistic regression. RESULTS: From 926 births (53% of which were preterm), using weighted values for 27 biomarkers, a score was created that classified 73% of preterm deliveries. Soluble TNF-R1, NT-3, MCP-1, BDNF, IL-4, MMP-9, TREM-1, TNF-α, IL-5 and IL-10 were most influential. Our model was more sensitive for birth <34 weeks (sensitivity 89.5%, specificity 76.9%). IL-10, TNF-α, BDNF, NT-3, MMP-9, sTNF-R1 and MCP-1 were significantly predictive of NEC, IVH, sepsis and infections. CONCLUSION: We developed a novel mathematical model of 27 biomarkers associated with adverse neonatal outcomes in neonates born preterm.

Herpes Simplex Virus Cervicitis Mimicking Preterm Premature Rupture of Membranes.

BACKGROUND: The diagnosis of preterm premature rupture of membranes (PROM) is based on pooling, ferning, and Nitrazine tests; definitive diagnosis is made with a blue dye test. CASE: A 21-year-old woman, gravida 1 para 0, at 25 5/7 weeks of gestation was admitted for preterm PROM with positive findings of pooling, Nitrazine, and ferning. Her cervix was bluish with white plaques. Amniotic fluid volume was normal. On hospital day 8, her discharge ceased; examination was negative for pooling, Nitrazine, and ferning. A blue dye tampon test was negative. A Pap test result from her hospitalization returned consistent with herpes infection. CONCLUSION: The diagnosis of preterm PROM should be constantly reevaluated in the setting of a normal amniotic fluid volume.

A subset of nondescript axillary lymph node inclusions have the immunophenotype of endosalpingiosis.

We report 2 cases of bland, otherwise nondescript axillary lymph node inclusions that have the immunophenotype of endosalpingiosis in patients with concurrent invasive breast carcinomas. Neither inclusion demonstrated the classic morphology of endosalpingiosis with admixed ciliated and secretory cells. Rather, both cases were composed of nondescript cuboidal to columnar bland epithelial cells situated within the lymph node capsule. Whereas both inclusions labeled diffusely for estrogen receptor and lacked evidence of a myoepithelial component, both labeled diffusely for PAX8 and WT-1, which distinguished them from their corresponding concurrent primary mammary carcinomas. These findings suggest that a subset of otherwise nondescript axillary lymph node inclusions represent endosalpingiosis and highlight the utility of PAX8 and WT-1 immunohistochemistry in distinguishing these from metastatic well-differentiated ductal carcinoma.

Periventricular leukomalacia and placental histopathologic abnormalities.

OBJECTIVE: To estimate whether there are placental histopathologic abnormalities associated with neonatal periventricular leukomalacia (PVL), a major precursor of cerebral palsy. METHODS: This is a case-control study of 167 neonates born between 23 and 34 weeks of gestation diagnosed with PVL by head ultrasonography within 6 weeks of birth, and 167 control neonates without neurologic morbidity matched by gestational age. Placentas for both case neonates and control neonates were reviewed by two perinatal pathologists who were blinded to neonatal course. RESULTS: Neonates with PVL were significantly more likely to have positive neonatal blood (28.7%, 16.8%, P=.001) and cerebrospinal fluid (14.4%, 4.8%, P=.007) cultures. The ratio of placental weight to birth weight did not differ between groups, but neonates with PVL had significantly more chronic diffuse capsular deciduitis (20.4%, 10.8%, P=.02) and capsular decidual plasma cells (8.4%, 2.4%, P=.02). Conditional logistic regression adjusting for birth weight and the presence of multiple gestation in the identification of PVL showed a significant increase for diffuse capsular deciduitis (P=.02) and capsular decidual plasma cells (P=.03). CONCLUSION: Periventricular leukomalacia has a significant but weak association with chronic diffuse capsular deciduitis and the presence of capsular decidual plasma cells, evidence of chronic infection but not histologic acute chorioamnionitis. LEVEL OF EVIDENCE: II.