Receiving gestational weight gain recommendations and associated risks: A qualitative study among low-income women.

Appropriate weight gain goals promote healthy gestational weight gain (GWG). Despite receiving recommendations from their providers, most women do not know how much weight they should gain during pregnancy. This study sought to describe the experiences of pregnant women when given GWG recommendations. The research proceeded using a phenomenological approach. With Institutional Review Board approval, primigravida women with a healthy singleton pregnancy at 8-20 weeks gestation were recruited from the community and purposively from a low-income obstetrics clinic. Within 60-minutes, trained interviewers 1) presented GWG recommendations and associated risks; and 2) interviewed participants using a semi-structured guide. Participants received a $40 gift card. Interviews were recorded and transcribed. Two trained coders used Braun and Clarke's (2020) reflexive thematic analysis procedures. When presented with GWG information, participants (n = 29, Mage = 25.5, 4.7 SD) proceeded to: 1) make sense of the information, 2) evaluate the credibility of the information, 3) weigh the importance of the information, 4) predict likely outcomes, and 5) plan behaviors. Participants who were able to understand the information, found it to be credible and important, and who predicted adverse outcomes for failing to adhere to recommendations reported intentions for health promoting behaviors. Future research should test GWG counseling methods based on these cognitive processes. Clinicians should consider these 5 cognitive processes when providing initial GWG counseling.

Characterization of urinary concentrations of heavy metals among socioeconomically disadvantaged black pregnant women.

The objective of this study was to characterize exposures to metals using biological samples collected on socioeconomically disadvantaged black pregnant women. We obtained 131 anonymous urine samples provided by black pregnant women visiting a Medicaid-serving prenatal clinic in Houston, TX, from March 27, 2017 to April 11, 2017. We analyzed urine samples for 15 metals including cadmium (Cd), arsenic (As), lead (Pb), and nickel (Ni) and for creatinine and cotinine. We found that median concentrations of zinc (Zn), selenium (Se), and aluminum (Al) among black pregnant women in this study were 1.5 to 3 times higher than levels reported among a cohort of well-educated non-Hispanic white pregnancy planners. We also observed elevated levels of urinary Cd and antimony (Sb) as compared with those reported for a nationally representative sample of adult women in the USA. Based on the results of an exploratory factor analysis, potential sources of metal exposures in this population may arise in home environments or be due to diet, industrial and natural sources, or traffic.

A comparison of common practices for identifying substance use during pregnancy in obstetric clinics.

BACKGROUND: Substance use during pregnancy has been linked to adverse birth and other outcomes. Screening and intervention in the prenatal clinic are recommended, and reliance on patient reports or selective urine drug screening is inadequate. The aim of this prospective project was to determine substance use identification rates associated with common screening practices, compared to universal screening, among pregnant women seeking care at an urban, academic obstetric clinic. METHODS: Women attending their first prenatal visit (N = 275) completed a self-report questionnaire on lifetime and current substance use. A urine drug screening was also conducted, the results of which were not reported to providers. Participants' charts were reviewed to obtain the results of provider-ordered screens. RESULTS: The sample was primarily African-American and Latino, with Medicaid insurance. Ten women (4.6%) reported current marijuana use, while more than double that number (n = 27; 11.6%) screened positive for marijuana via universal screening. The majority of women who screened positive via universal screening did not have a provider-ordered urine drug screening, and less than one-third (29.3%) of clinician-ordered screens were positive for at least one substance. Finally, 90% of women who reported they were using marijuana were not selected by providers for a screen. DISCUSSION: Data demonstrate the high proportion of women using marijuana and the limitations of patient self-report and selective, nonroutine screening to identify substance use during pregnancy. Effective, standardized, clinic-wide strategies are needed to support providers in identifying pregnant women who use substances in order to increase the frequency of education and intervention.

Randomized Quality Improvement Trial of Opting-In Versus Opting-Out to Increase Influenza Vaccination Rates during Pregnancy.

Introduction Despite strong recommendations, only 40.6% of pregnant women attending two prenatal clinics were vaccinated against influenza during the 2009 pandemic. We tested whether an opting-out approach would improve vaccine uptake. Methods We conducted a randomized quality improvement (QI) trial to compare opting-out with conventional opting-in consent for influenza immunization. Women age ≥ 18 years attending the University of Texas Health Science Center at Houston (UTHealth) or UT-Medical Branch (UTMB) prenatal clinics during the 2010-2011 influenza season, were eligible. Results We enrolled 280 women (140 UTHealth, 140 UTMB). Both groups had similar mean age (26.0 ± 5.5 years), mean gestational age (19.4 ± 9.5 weeks), and percent with underlying health conditions (20.7%). Vaccination rates with opting-in and opting-out were similar among all (83 vs. 84%), UTHealth (87 vs. 93%), and UTMB patients (79 vs.76%) ( p > 0.05). In subsamples of patients assessed, consent strategy did not significantly affect maternal recall of information provided. Conclusion While prenatal influenza vaccination uptake doubled from the 2009-2010 influenza season, opting-out did not perform better than opting-in, a conclusion opposite that we would have reached had this been a nonconcurrent trial. Vaccination rates dropped posttrial; hence, continued research is needed to increase the prenatal influenza immunizations.

Quality Improvement to Demonstrate the Lack of Reliability of the Human Papillomavirus mRNA Assay to Identify Women With Latent Human Papillomavirus Infections.

OBJECTIVE: To assess the consistency between human papillomavirus (HPV) mRNA testing in women with a history of previous HPV infections diagnosed by HPV DNA assay and the potential effects on follow-up HPV screening. METHODS: This was a quality improvement study that used data from a pathology laboratory software database reviewed from November 2014 to June 2016 to identify female patients aged 30 years or older with greater than one HPV-positive result, including one or more HPV mRNA assay results and one or more documented HPV DNA assay results for comparison. Previous correlative cytology and colposcopic histopathology were also documented. American College of Obstetricians and Gynecologists' cervical cancer screening guidelines were used to compare potential differences in follow-up recommendations. RESULTS: Four hundred twenty-five charts for female patients 30 years of age or older were identified with one or more prior high-risk HPV infections by DNA assay. There was a 69.3% difference in HPV mRNA results compared with previous HPV DNA-positive results. There was a potential change in follow-up for 71.7% of patients with one prior high-risk-HPV-positive result and 60.0% of patients with two or more prior high-risk HPV-positive results. There were 231 colposcopy reports evaluated in this study. Of these, 62 (26.8%) were abnormal colposcopy reports, including 45 low-grade squamous intraepithelial lesions, 15 high-grade squamous intraepithelial lesions, and two cancers. Twenty-five (40.3%) abnormal colposcopy findings were in patients with a history of at least than two prior HPV DNA-positive results and a report of currently being HPV-negative with the mRNA assay. CONCLUSION: The HPV mRNA assays are less sensitive for detection of latent HPV infections compared with HPV DNA assays. Based on these data and the potential change in follow-up care, the HPV mRNA assay should not be used for a primary screening tool for cervical cancer. Many pathology laboratories have shifted to using the HPV mRNA assay without clear discussion with gynecologists about the effects on patient follow-up. The type of HPV assay being used should be documented and any HPV mRNA result confirmed by HPV DNA assay.

Association Between Health Beliefs and Gestational Weight Gain.

BACKGROUND: The Institute of Medicine (IOM) provides recommendations for optimal weight gain during pregnancy to minimize complications associated with obesity and excessive weight gain. The Health Belief Model and prior research suggest knowledge of health recommendations and associated risks motivate health behaviors. This study determined whether knowledge of maternal and infant obesity risks during pregnancy (ORDP) and knowledge of IOM gestational weight gain (GWG) recommendations were associated with total GWG and likelihood of adhering to IOM recommendations. MATERIALS AND METHODS: In this prospective survey study, healthy women with a singleton pregnancy were recruited from prenatal clinic waiting rooms of a university medical center to complete a one-time survey of prepregnancy weight and height, demographic variables, knowledge of infant-related ORDP (e.g., large for gestational age), knowledge of maternal-related ORDP (e.g., Cesarean delivery), and knowledge of IOM GWG recommendations. Total GWG was obtained from clinic medical records. Logistic and multiple regression analyses were performed. RESULTS: The sample consisted of 159 women with average age of 25 and prepregnancy body mass index of 28. Women in the sample were predominantly African American (57%) and from low socioeconomic conditions. Results showed (1) knowledge of GWG recommendations was inversely related to total GWG among normal and underweight women and (2) knowledge of infant-related ORDP was positively related to total GWG among overweight and obese women and the likelihood of exceeding recommendations among normal and underweight women. Knowledge of maternal-related ORDP was not related to GWG. CONCLUSION: As the Health Belief Model suggests, knowledge appears to be a modifiable factor in preventing excess GWG. However, there may be misinformation regarding how to adhere to clinical recommendations.

Potential of Metformin to Improve Cardiac Risk in Postpartum Women with Gestational Diabetes.

OBJECTIVE: Pregnancy is associated with an increase in total cholesterol, high density lipoproteins (HDL), and low-density lipoproteins (LDL). Postpartum, HDL and LDL decrease over the first 12 weeks postpartum. Oxidized LDL (ox-LDL) is a marker of oxidative stress-related inflammation, which is associated with obesity and also with development of cardiovascular disease. Cardiovascular protection and weight loss are benefits from metformin, especially in women with diabetes. The objective of this study was to compare changes in lipid profiles and biomarkers for obesity during the initial 6 weeks postpartum between women with gestational diabetes mellitus (GDM) treated with metformin versus placebo. METHODS: This was a planned ancillary study of a randomized controlled trial compares metformin versus placebo in women with GDM for postpartum weight loss. Two 3 mL blood samples were collected within 24 h of delivery and 6 weeks postpartum immediately processed after collection then stored at -20°C until completion of clinical trial prior to analysis. Change in the median plasma concentrations of total cholesterol, HDL, ox-LDL, glucose, insulin, leptin, and unacylated ghrelin were compared between study groups. RESULTS: Of the 77 postpartum women were included, 35 received metformin and 42 received placebo. There was less of a reduction in HDL in the metformin group compared to placebo (-2.3 versus -7.5 mg/dL, p = 0.019). In addition, there was a greater reduction in ox-LDL in those receiving metformin (-12.2 versus -3.8 mg/dL, p = 0.038). No other differences were observed in the selected biomarkers evaluated. CONCLUSION: Biomarker levels of HDL and ox-LDL were positively affected during the initial 6 weeks postpartum in GDM women treated with metformin. Additional studies with a longer duration of metformin treatment in the postpartum period are warranted to evaluate long-term potential benefits.

Accessing Disadvantaged Pregnant Women in Houston, Texas, and Characterizing Biomarkers of Metal Exposure: A Feasibility Study.

Abstract: Communities of color or low socioeconomic status are disproportionately affected by metal exposure given spatial variability of the ambient levels of these contaminants. Despite this, there is little research characterizing metal concentrations in blood among disadvantaged populations in the U.S., especially among pregnant women who are particularly vulnerable and difficult to access. Thus, we conducted a pilot study among disadvantaged pregnant women in Houston, Texas to assess willingness to participate in key activities of an epidemiologic study and characterize exposures to 16 metals. Thirty-one women attending a Medicaid-serving prenatal clinic were included in this pilot study and completed an interviewer-administered questionnaire. We obtained and measured metal compounds in whole blood samples for 22 of these women during third-trimester prenatal visits. Median whole blood concentrations of Ni, As, Cd, and Pb were 27, 1.4, 0.6, and 6.3 µg/L, respectively. Most women were willing to participate in critical aspects of a research study, including wearing a personal air-sampling badge for 2-3 days (87.1%), receiving ultrasounds (83.9%), and providing blood draws (64.5%). Despite the small sample, our results provide evidence of women's metal exposure and their willingness to participate in future research studies to elucidate exposure pathways and explore related health effects experienced among this population of disadvantaged pregnant women.

Breast Pain: Engorgement, Nipple Pain, and Mastitis.

This review explores current concepts surrounding breastfeeding complications including nipple pain and trauma, breast engorgement, mastitis, and breast abscess. The review discusses possible etiologies, risk factors, incidence, differential diagnosis, and suggested treatment strategies. The evidence that supports these management options is discussed.

Factors associated with knowledge of personal gestational weight gain recommendations.

OBJECTIVES: Excess adiposity (obesity and excess gestational weight gain, GWG) during pregnancy (EADP) increases risk for gestational diabetes, preeclampsia, and child and maternal obesity. Personal GWG goals predict total GWG. Some estimates suggest only 30% of pregnant women have personal GWG goals that are congruent with Institute of Medicine GWG recommendations. The primary purpose of this study was to determine the extent to which perceived pre-pregnancy weight status, healthcare provider advice, knowledge of EADP risks, and value for healthy GWG predicted knowledge of GWG recommendations. The secondary purpose was to determine sources of GWG information among pregnant women. METHODS: Pregnant women with a confirmed singleton pregnancy completed a one-time survey in obstetric clinic waiting rooms. Logistic regression analysis was used. RESULTS: 246 predominantly African American, low income, overweight/obese women completed surveys. Average age was 25 (SD 5.3) and gestation age ranged from 7 to 40 weeks. Knowledge of pre-pregnancy weight status was the only unique predictor of GWG recommendation knowledge (B = .642, p = .03). The top three sources of GWG information were physicians, internet, and books. The least frequently reported sources of GWG information were other healthcare providers, community programs, and television. CONCLUSION: In low income diverse overweight/obese pregnant women, accurate pre-pregnancy weight status perception was the only significant unique predictor of knowledge of GWG recommendations. Physicians were the preferred source of GWG information. Clinicians should have frequent, ongoing conversations about weight status with women before, during, and after pregnancy.

Evaluating the potential effect on fetal tissue after exposure to granisetron during pregnancy.

The objective of this study was to elucidate the possible toxic effects on the fetal tissues after exposure to two clinically relevant concentrations of granisetron. Primary cells were isolated from human fetal organs of 16-19 weeks gestational age and treated with 3 ng/mL or 30 ng/mL of granisetron. Cell cycle progression was evaluated by flow cytometry. ELISA was used to detect alterations in major apoptotic proteins. Up to 10% apoptosis in cardiac tissue was observed following treatment with 30 ng/mL granisetron. Neither concentration of granisetron caused alteration in cell cycle progression or alterations in apoptotic proteins in any of the other tissues. At 30 ng/mL granisetron concentration had the potential to induce up to 10% apoptosis in cardiac tissue; clinical significance needs further evaluation. At granisetron 3 ng/mL there was no detectable toxicity or on any fetal tissue in this study. Further research is needed to confirm these preliminary findings and determine if clinically significant.

Evaluation of the maternal-fetal transfer of granisetron in an ex vivo placenta perfusion model.

The objective of this study was to estimate maternal-fetal transplacental passage of granisetron in an ex vivo placental perfusion model. Term human placentas (N=8) were collected immediately after delivery. A single cotyledon from each placenta was perfused granisetron concentration to mimic systemic maternal peak plasma concentrations following either IV (50ng/mL) or transdermal administration (5ng/mL). To assess drug transfer and accumulation, samples were collected from maternal and fetal compartments. In the 50ng/mL open model, the mean transport fraction was 0.21±0.08 with clearance index of 0.53±0.66. Fetal peak concentrations achieved was 5.6±6.6ng/mL with mean accumulation of 5.35±6.4ng/mL. No drug was detected in the fetal compartment with the 5ng/mL models. Transplacental passage of granisetron was inconsistent at the 50ng/mL concentration that achieved with IV dosing. However, there consistently was no detectable passage in all the placentas evaluated of the granisetron at 5ng/mL concentration that would be achieved after transdermal patch administration.

Nitrate and nitrite content of human, formula, bovine, and soy milks: implications for dietary nitrite and nitrate recommendations.

BACKGROUND: Estimation of nitrate and nitrite concentrations of milk sources may provide insight into potential health risks and benefits of these food sources for infants, children, and adults. The World Health Organization and American Academy of Pediatrics recommends exclusive consumption of human milk for the first 6 months of life. Human milk is known to confer significant nutritional and immunological benefits for the infant. Consumption of formula, cow's, and soy milk may be used as alternatives to human milk for infants. METHODS: We sought to estimate potential exposure to nitrate and nitrite in human, formula, bovine, and soy milk to inform total dietary exposure estimates and recommendations. Using sensitive quantitative methodologies, nitrite and nitrate were analyzed in different samples of milk. RESULTS: Human milk concentrations of colostrum (expressed days 1-3 postpartum; n=12), transition milk (expressed days 3-7 postpartum; n=17), and mature milk (expressed >7 days postpartum; n=50) were 0.08 mg/100 mL nitrite and 0.19 mg/100 mL nitrate, 0.001 mg/100 mL nitrite and 0.52 mg/100 mL nitrate, and 0.001 mg/100 mL nitrite and 0.3 mg/100 mL nitrate, respectively, revealing that the absolute amounts of these anions change as the composition of milk changes. When expressed as a percentage of the World Health Organization's Acceptable Daily Intake limits, Silk® Soy Vanilla (WhiteWave Foods, Broomfield, CO) intake could result in high nitrate intakes (104% of this standard), while intake of Bright Beginnings Soy Pediatric® formula (PBM Nutritionals, Georgia, VT) could result in the highest nitrite intakes (383% of this standard). CONCLUSIONS: The temporal relationship between the provision of nitrite in human milk and the development of commensal microbiota capable of reducing dietary nitrate to nitrite supports a hypothesis that humans are adapted to provide nitrite to the gastrointestinal tract from birth. These data support the hypothesis that the high concentrations of breastmilk nitrite and nitrate are evidence for a physiologic requirement to support gastrointestinal and immune homeostasis in the neonate.

Survey of obstetrics and gynecology residents' training and opinions on robotic surgery.

To investigate obstetrics and gynecology residents' access to training in robotics and their opinions of its utility and future in gynecologic surgery a 31-item questionnaire was developed and distributed to Ob/Gyn residents in the United States via email. Results were tabulated via SurveyMonkey.com(©). A total of 470 residents representative of all ACOG districts and PGY levels responded. A total of 72% of residents reported ≥3 staff surgeons performing robotic gynecologic surgery at their institution and 70% had participated in robotic surgery in the past 12 months. Robotic hysterectomy (81%) and oncologic surgery (76%) were the most frequently performed procedures. A total of 79% believe their institution should provide formal training in robotics, but only 38% report access to it. A total of 23% have operated at the surgeon console, and 44% plan to incorporate robotic surgery into their practice after completing residency. A total of 3.6% feel equipped to perform robotic surgery without additional training. A total of 63% believe robotic surgery in gynecology will continue to increase in popularity. Exposure to gynecologic robotic procedures during residency is increasing. Although residents believe robotics has a place in gynecology, many feel formalized training has not been successfully implemented into their residency. Development of a structured program for training residents in robotics merits further investigation.

The absence of Candida albicans in milk samples of women with clinical symptoms of ductal candidiasis.

OBJECTIVE: The objective of this prospective study was to determine if Candida albicans is present in the milk of women suffering from symptoms of severe nipple and deep breast pain. STUDY DESIGN: The symptomatic group included women who reported sore, inflamed, or traumatized nipples or intense stabbing or burning pain. The control group included breastfeeding women without symptoms. The skin of the nipple and areola were washed with detergent and thoroughly rinsed. Milk samples were analyzed for (1 --> 3)-beta-D-glucan and grown on Candida growth medium. RESULTS: There was no significant difference in (1 --> 3)-beta-D-glucan levels between the control and symptomatic group. No Candida species were culturable either before or after the addition of iron to stimulate growth, with the exception of one patient. The addition of pure C. albicans to milk samples suggested that milk does not inhibit Candida growth. CONCLUSION: These data suggest that C. albicans is not present in milk ducts and may not be associated with this syndrome.