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2.
Contraception ; 100(2): 101-105, 2019 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-31108053

RESUMEN

OBJECTIVES: To compare the expulsion rate at 6 months after postplacental insertion by intrauterine device (IUD) type. STUDY DESIGN: This prospective cohort included participants with a postplacental IUD inserted after vaginal or cesarean delivery, aged 18-45 and ≥24 weeks' gestation. Study enrollment took place after IUD selection and insertion. Participants returned for a postpartum visit and received a short message service survey regarding IUD expulsion, removal, vaginal bleeding and breastfeeding weekly from weeks 0 to 5 and on weeks 12 and 24 postpartum. Multivariable logistic regression examined 6-month expulsion rate by IUD type adjusting for variables that differed between the groups at baseline and in the bivariate analyses. RESULTS: Of 114 participants, 75 (65.8%) chose a levonorgestrel 52-mg IUD and 39 (34.2%) chose a copper IUD; 58 (50.9%) had a vaginal delivery, and 56 (49.1%) had a cesarean delivery. Groups were similar except that copper IUD users had a higher median parity (3 vs. 2, p=.03) and a higher proportion of senior residents compared to junior residents had performed insertion (46.2% vs. 22.7%, p=.02). The expulsion rate at 6 months was similar between the levonorgestrel and copper groups (26.7% and 20.5%, respectively; p=.38). Multivariable logistic regression also demonstrated that the odds of expulsion did not differ by IUD type (adjusted odds ratio 0.98, 95% confidence interval 0.22-4.48). CONCLUSION: The expulsion rate at 6 months after postplacental insertion did not differ between the levonorgestrel and copper IUD type. IMPLICATIONS: Prior studies demonstrate a wide range of expulsion after postplacental insertion, and recent data suggest a higher expulsion rate for the levonorgestrel compared to the copper intrauterine device. However, many studies did not control for patient-level factors or delivery route. We found that when controlling for these confounding variables, the expulsion rate at 6 months postpartum did not differ by intrauterine device type.

3.
Obstet Gynecol ; 133(4): 803-809, 2019 04.
Artículo en Inglés | MEDLINE | ID: mdl-30870277

RESUMEN

This article describes the Engage, Motivate, Protect, Organize, self-Worth, Educate, Respect (EMPOWER) Clinic for Survivors of Sex Trafficking and Sexual Violence located at Gouverneur Health in New York, New York, as a model for integrated gynecologic and psychiatric care of survivors of sexual and gender-based violence. Although patients with a history of sexual trauma often have critical health needs that persist long after the traumatic event, most existing services for survivors of sexual violence focus solely on the provision of acute care immediately after the violence has occurred. There are very few clinics in the United States dedicated to managing the significant long-term medical consequences and sequelae of sexual violence in a trauma-informed setting. We report on best practices for the provision of trauma-sensitive medical care to this patient population based on those employed at the EMPOWER Clinic. In particular, we outline some of the unique considerations for treating survivors relating to taking a patient history, conducting the physical and gynecologic examinations, ensuring confidentiality, and managing legal issues. Finally, we reflect on the challenges faced in sustaining the EMPOWER Clinic and the importance of the existence of a clinic dedicated to this specific population.


Asunto(s)
Instituciones de Atención Ambulatoria/organización & administración , Participación del Paciente , Guías de Práctica Clínica como Asunto , Delitos Sexuales/estadística & datos numéricos , Trastornos por Estrés Postraumático/terapia , Sobrevivientes/estadística & datos numéricos , Adulto , Prestación de Atención de Salud/organización & administración , Femenino , Trata de Personas/psicología , Trata de Personas/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Modelos Organizacionales , Ciudad de Nueva York , Educación del Paciente como Asunto/organización & administración , Delitos Sexuales/psicología , Trastornos por Estrés Postraumático/etiología , Sobrevivientes/psicología , Poblaciones Vulnerables/psicología , Poblaciones Vulnerables/estadística & datos numéricos , Adulto Joven
4.
J Bioeth Inq ; 15(4): 549-555, 2018 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-30117063

RESUMEN

According to the World Health Organization, female genital cutting affects millions of girls and women worldwide, particularly on the African continent and in the Middle East. This paper presents a plausible, albeit hypothetical, clinical vignette and then explores the legal landscape as well as the ethical landscape physicians should use to evaluate the adult patient who requests re-infibulation. The principles of non-maleficence, beneficence, justice, and autonomy are considered for guidance, and physician conscientious objection to this procedure is discussed as well. Analyses of law and predominant principles of bioethics fail to yield a clear answer regarding performing female genital cutting or re-infibulation on an adult in the United States. Physicians should consider the patient's physical, mental, and social health when thinking about female genital cutting and should understand the deep-rooted cultural significance of the practice.


Asunto(s)
Discusiones Bioéticas , Circuncisión Femenina/ética , Obstetricia , Prioridad del Paciente/etnología , Mujeres Embarazadas/etnología , Salud de la Mujer/etnología , Adulto , Actitud del Personal de Salud , Características Culturales , Toma de Decisiones/ética , Grupos Étnicos , Femenino , Conocimientos, Actitudes y Práctica en Salud , Humanos , Obstetricia/ética , Embarazo
7.
Contraception ; 96(4): 261, 2017 10.
Artículo en Inglés | MEDLINE | ID: mdl-28716468
8.
Fam Syst Health ; 35(3): 360-372, 2017 09.
Artículo en Inglés | MEDLINE | ID: mdl-28414479

RESUMEN

INTRODUCTION: The impact of sexual violence (SV) on mental health, self-care, and interpersonal relationships is profound and poses special challenges to health care delivery. Reproductive health care merits special attention because the care required may be linked to reminders of past abuse. We explored facilitators and barriers affecting the use of reproductive health services among women veterans with a history of SV. METHOD: Between June and September 2015, we conducted 2 focus groups and 3 general education sessions with 27 female veterans with a history of SV at 1 medical center. We analyzed transcripts according to applied thematic analysis and used Nvivo software for data management and retrieval. RESULTS: Three main themes emerged from the focus groups and education sessions. PARTICIPANTS: (a) expressed a desire for greater agency in relation to the control they have over their bodies and medical care; (b) described how posttraumatic stress symptoms are retriggered during medical care; and (c) expressed needs for additional education, peer and provider support within the medical system. DISCUSSION: For women with a history of SV, multiple individual and systemic barriers complicate how they utilize reproductive health services. Group education sessions were an effective mode of support, information and connection to other women within the Veterans Health Administration. (PsycINFO Database Record


Asunto(s)
Grupos Focales/métodos , Delitos Sexuales/psicología , Enseñanza/normas , Adulto , Anciano , Femenino , Grupos Focales/normas , Humanos , Persona de Mediana Edad , Investigación Cualitativa , Servicios de Salud Reproductiva/normas , Autocuidado/métodos , Autocuidado/psicología , Estados Unidos , United States Department of Veterans Affairs/organización & administración , Veteranos/psicología
10.
Contraception ; 95(2): 190-197, 2017 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-27621043

RESUMEN

OBJECTIVES: Clinicians and researchers need an accurate tool assessing contraceptive knowledge in order to understand the effectiveness of teaching efforts. However, most widely used indices are outdated. The objective of this study is to create an evidence-based assessment tool and determine its validity and reliability for measuring contraceptive knowledge. STUDY DESIGN: The study team developed the 25-question multiple-choice tool entitled the Contraceptive Knowledge Assessment (CKA). Expert reviewers examined content validity and semistructured patient interviews acquired feedback on subject matter and comprehension. A two-tiered approach explored criterion validity via (1) comparison with the gold standard (Contraceptive Knowledge Inventory) and (2) comparison between groups with lower and higher contraceptive knowledge. Repeat testing after 2-4 weeks evaluated test-retest reliability. RESULTS: Six experts and seven patients provided feedback on the initial CKA. One hundred two reproductive-aged male and female patients and 27 medical students completed the final CKA with an overall mean patient score of 9/25 (36%). The mean score on the CKA was higher than the mean score on the gold standard (9.1 vs. 5.8, p<.001). Patients scored lower on the CKA than did medical students (9.1 [36.4%] vs.19.4 [77.6%], p<.005). There were no differences within patients' results with repeat testing over time (p=.667). CONCLUSIONS: The CKA is a valid and reliable tool to measure a patient's level of knowledge regarding contraception. This research tool may allow for the assessment of baseline knowledge, educational gaps, and improvement after an intervention. Knowledge may be lower than previous studies suggest, signifying need for improved education on contraception and better understanding of the relationship between knowledge and behavior change. IMPLICATIONS: The CKA provides an evidence-based, reliable, and validated assessment of contraceptive knowledge. This modern tool may help to determine the effectiveness of interventions to improve education on contraception.


Asunto(s)
Anticoncepción , Evaluación Educacional/métodos , Conocimientos, Actitudes y Práctica en Salud , Adolescente , Adulto , Anticoncepción/métodos , Conducta Anticonceptiva , Femenino , Humanos , Masculino , Persona de Mediana Edad , Educación del Paciente como Asunto/métodos , Encuestas y Cuestionarios , Adulto Joven
11.
Clin Infect Dis ; 62(3): 323-333, 2016 Feb 01.
Artículo en Inglés | MEDLINE | ID: mdl-26486699

RESUMEN

BACKGROUND: Owing to increasing sulfadoxine-pyrimethamine (SP) resistance in sub-Saharan Africa, monitoring the effectiveness of intermittent preventive therapy in pregnancy (IPTp) with SP is crucial. METHODS: Between 2009 and 2013, both the efficacy of IPTp-SP at clearing existing peripheral malaria infections and the effectiveness of IPTp-SP at reducing low birth weight (LBW) were assessed among human immunodeficiency virus-uninfected participants in 8 sites in 6 countries. Sites were classified as high, medium, or low resistance after measuring parasite mutations conferring SP resistance. An individual-level prospective pooled analysis was conducted. RESULTS: Among 1222 parasitemic pregnant women, overall polymerase chain reaction-uncorrected and -corrected failure rates by day 42 were 21.3% and 10.0%, respectively (39.7% and 21.1% in high-resistance areas; 4.9% and 1.1% in low-resistance areas). Median time to recurrence decreased with increasing prevalence of Pfdhps-K540E. Among 6099 women at delivery, IPTp-SP was associated with a 22% reduction in the risk of LBW (prevalence ratio [PR], 0.78; 95% confidence interval [CI], .69-.88; P < .001). This association was not modified by insecticide-treated net use or gravidity, and remained significant in areas with high SP resistance (PR, 0.81; 95% CI, .67-.97; P = .02). CONCLUSIONS: The efficacy of SP to clear peripheral parasites and prevent new infections during pregnancy is compromised in areas with >90% prevalence of Pfdhps-K540E. Nevertheless, in these high-resistance areas, IPTp-SP use remains associated with increases in birth weight and maternal hemoglobin. The effectiveness of IPTp in eastern and southern Africa is threatened by further increases in SP resistance and reinforces the need to evaluate alternative drugs and strategies for the control of malaria in pregnancy.


Asunto(s)
Antimaláricos/farmacología , Resistencia a Medicamentos , Recién Nacido de Bajo Peso , Malaria/prevención & control , Complicaciones Infecciosas del Embarazo/prevención & control , Pirimetamina/farmacología , Sulfadoxina/farmacología , Adulto , África del Sur del Sahara/epidemiología , Sustitución de Aminoácidos , Antimaláricos/administración & dosificación , Dihidropteroato Sintasa/genética , Combinación de Medicamentos , Quimioterapia/métodos , Femenino , Humanos , Recién Nacido , Malaria/complicaciones , Proteínas Mutantes/genética , Plasmodium falciparum/enzimología , Embarazo , Estudios Prospectivos , Pirimetamina/administración & dosificación , Sulfadoxina/administración & dosificación , Resultado del Tratamiento , Adulto Joven
12.
AIDS ; 29(2): 183-91, 2015 Jan 14.
Artículo en Inglés | MEDLINE | ID: mdl-25426808

RESUMEN

OBJECTIVE: Combination antiretroviral therapy (ART) is now the global standard for HIV-infected pregnant and breastfeeding women at all CD4⁺ cell counts. We compared the efficacy and safety of an efavirenz versus lopinavir/ritonavir regimen for HIV-infected pregnant women initiating ART in rural Uganda. DESIGN: Randomized clinical trial. METHODS: We performed a planned secondary analysis comparing viral load suppression (HIV-1 RNA ≤400 copies/ml), safety, and HIV transmission to infants in a trial designed to test the hypothesis that lopinavir/ritonavir versus efavirenz-based ART would reduce placental malaria (PROMOTE, ClinicalTrials.gov, NCT00993031). HIV-infected, ART-naive pregnant women at 12-28 weeks gestation and any CD4⁺ cell count were randomized. ART was provided and participants were counseled to breastfeed for 1 year postpartum. RESULTS: The median age of the 389 study participants was 29 years; median CD4⁺ cell count was 370 cells/µl. At delivery, virologic suppression was 97.6% in the efavirenz arm and 86.0% in the lopinavir/ritonavir arm (P < 0.001). At 48 weeks postpartum, 91.0% of women on efavirenz and 88.4% on lopinavir/ritonavir had viral suppression (P = 0.49). Grade 1 or 2 gastrointestinal adverse events were higher among women on lopinavir/ritonavir versus efavirenz. Only two infants acquired HIV (both in the lopinavir/ritonavir arm), and HIV-free infant survival was similar between study arms: 92.9% (lopinavir/ritonavir) versus 97.2% (efavirenz) (P = 0.10). CONCLUSION: Virologic suppression at delivery was higher with an efavirenz versus lopinavir/ritonavir-based regimen. However, women in both arms achieved high levels of virologic suppression through 1 year postpartum and the risk of transmission to infants was low.


Asunto(s)
Fármacos Anti-VIH/uso terapéutico , Benzoxazinas/uso terapéutico , Infecciones por VIH/tratamiento farmacológico , Lopinavir/uso terapéutico , Complicaciones Infecciosas del Embarazo/tratamiento farmacológico , Ritonavir/uso terapéutico , Adulto , Terapia Antirretroviral Altamente Activa , Lactancia Materna , Recuento de Linfocito CD4 , Femenino , VIH-1/genética , Humanos , Lactante , Recién Nacido , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Malaria/tratamiento farmacológico , Embarazo , Complicaciones Infecciosas del Embarazo/virología , Uganda , Carga Viral
13.
J Acquir Immune Defic Syndr ; 67(2): 128-35, 2014 Oct 01.
Artículo en Inglés | MEDLINE | ID: mdl-25072616

RESUMEN

BACKGROUND: Protease inhibitor-based antiretroviral therapy (ART) has been associated with preterm birth in some studies. We examined risk factors for preterm birth among women randomized to lopinavir/ritonavir (LPV/r)- or efavirenz (EFV)-based ART. METHODS: This was a planned secondary analysis of the PROMOTE-Pregnant Women and Infants Study, an open-label, randomized controlled trial comparing the risk of placental malaria among HIV-infected, ART-naive pregnant Ugandan women assigned to initiate LPV/r- or EFV-based ART at 12-28 weeks gestation. Gestational age was determined based on last menstrual period and ultrasound biometry. All women received bednets and trimethoprim-sulfamethoxazole. Stillbirths, spontaneous abortions, and multiple gestations were excluded from the primary analysis. Potential risk factors for preterm birth (<37 weeks gestation) were evaluated by univariate and multivariate logistic regression. RESULTS: Three hundred fifty-six women were included in this analysis. At enrollment, median gestational age was 21 weeks and median CD4 cell count was 368 cells per cubic millimeter. 14.7% of deliveries in the EFV arm and 16.2% in the LPV/r arm were preterm. Preterm birth was associated with gestational weight gain below 0.1 kg/week versus 0.1 kg/week or more [odds ratio (OR) = 2.49; 95% confidence interval (CI): 1.38 to 4.47; P = 0.003]. Neither ART regimen of LPV/r versus EFV (OR = 1.12; 95% CI: 0.63 to 2.00; P = 0.69) nor placental malaria (OR = 0.74; 95% CI: 0.38 to 1.44; P = 0.37) was associated with preterm birth. CONCLUSIONS: LPV/r was not associated with an increased risk of preterm birth compared with EFV. However, interventions are needed to address modifiable risk factors for preterm birth, such as nutritional status (ClinicalTrials.gov, NCT00993031).


Asunto(s)
Fármacos Anti-VIH/efectos adversos , Fármacos Anti-VIH/uso terapéutico , Terapia Antirretroviral Altamente Activa/efectos adversos , Terapia Antirretroviral Altamente Activa/métodos , Infecciones por VIH/complicaciones , Infecciones por VIH/tratamiento farmacológico , Nacimiento Prematuro/epidemiología , Adolescente , Adulto , Benzoxazinas/efectos adversos , Benzoxazinas/uso terapéutico , Femenino , Humanos , Recién Nacido , Lopinavir/efectos adversos , Lopinavir/uso terapéutico , Masculino , Embarazo , Factores de Riesgo , Ritonavir/efectos adversos , Ritonavir/uso terapéutico , Uganda/epidemiología , Adulto Joven
14.
J Infect Dis ; 210(12): 1938-45, 2014 Dec 15.
Artículo en Inglés | MEDLINE | ID: mdl-24958908

RESUMEN

BACKGROUND: Human immunodeficiency virus (HIV)-infected pregnant women are at increased risk of malaria and its complications. In vitro and in vivo data suggest that the HIV protease inhibitors lopinavir/ritonavir may have potent antimalarial activity. We sought to evaluate whether lopinavir/ritonavir-based antiretroviral therapy (ART) reduced the risk of placental malaria. METHODS: HIV-infected, ART-naive pregnant women were enrolled between gestational weeks 12 and 28 and randomly assigned to receive lopinavir/ritonavir-based or efavirenz-based ART. Women received daily trimethoprim-sulfamethoxazole prophylaxis and insecticide-treated bed nets at enrollment and were followed up to 1 year after delivery. The primary outcome was placental malaria, defined by the detection of malaria parasites, using microscopy or polymerase chain reaction (PCR) analysis of placental blood specimens. Secondary outcomes included placental malaria, defined by histopathologic results; adverse birth outcomes; incidence of malaria; and prevalence of asymptomatic parasitemia. Analyses were done using an intention-to-treat approach. RESULTS: Of 389 subjects randomly assigned to a treatment group, 377 were followed through to delivery. There was no significant difference in the risk of placental malaria, as defined by thick smear or PCR findings, between the lopinavir/ritonavir-based and efavirenz-based ART arms (7.4% vs 9.8%; P = .45). Similarly, there were no differences in secondary outcomes between the 2 treatment arms. CONCLUSIONS: Lopinavir/ritonavir-based ART did not reduce the risk of placental or maternal malaria or improve birth outcomes, compared with efavirenz-based ART. CLINICAL TRIALS REGISTRATION: NCT00993031.


Asunto(s)
Fármacos Anti-VIH/uso terapéutico , Antimaláricos/uso terapéutico , Terapia Antirretroviral Altamente Activa/métodos , Infecciones por VIH/complicaciones , Infecciones por VIH/tratamiento farmacológico , Malaria/prevención & control , Adolescente , Adulto , Benzoxazinas/uso terapéutico , Femenino , Humanos , Recién Nacido , Lopinavir/uso terapéutico , Embarazo , Complicaciones Infecciosas del Embarazo/tratamiento farmacológico , Complicaciones Infecciosas del Embarazo/prevención & control , Ritonavir/uso terapéutico , Resultado del Tratamiento , Combinación Trimetoprim y Sulfametoxazol/uso terapéutico , Adulto Joven
15.
Matern Child Health J ; 18(9): 2044-53, 2014 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-24585398

RESUMEN

Household food insecurity (HHFI) may be a barrier to both optimal maternal nutritional status and infant feeding practices, but few studies have tested this relationship quantitatively, and never among HIV-infected individuals. We therefore described the prevalence of HHFI and explored if it was associated with poorer maternal nutritional status, shorter duration of exclusive breastfeeding (EBF) and fewer animal-source complementary foods. We assessed these outcomes using bivariate and multivariate analyses among 178 HIV-infected pregnant and breastfeeding (BF) women receiving combination antiretroviral therapy in the PROMOTE trial (NCT00993031), a prospective, longitudinal cohort study in Tororo, Uganda. HHFI was common; the prevalence of severe, moderate, and little to no household hunger was 7.3, 39.9, and 52.8 %, respectively. Poor maternal nutritional status was common and women in households experiencing moderate to severe household hunger (MSHH) had statistically significantly lower body mass index (BMIs) at enrollment (21.3 vs. 22.5, p < 0.01) and prior to delivery (22.6 vs. 23.8, p < 0.01). BMI across time during pregnancy, but not gestational weight gain, was significantly lower for MSHH [adjusted beta (95 % CI) -0.79 (-1.56, -0.02), p = 0.04; -2.06 (-4.31, 0.19), p = 0.07], respectively. The prevalence (95 % CI) of EBF at 6 months was 67.2 % (59.7-73.5 %), and the proportion of women BF at 12 months was 80.4 % (73.3-85.7 %). MSHH was not associated with prevalence of EBF at 6 months or BF at 12 months. However, among those women still EBF at 4 months (81.4 % of population), those experiencing MSHH were significantly more likely to cease EBF between 4 and 6 months (aHR 2.38, 95 % CI 1.02-5.58). The prevalence of HHFI, maternal malnutrition, and suboptimal infant feeding practices are high and the causal relationships among these phenomena must be further explored.


Asunto(s)
Lactancia Materna/estadística & datos numéricos , Abastecimiento de Alimentos/estadística & datos numéricos , Infecciones por VIH/complicaciones , Fenómenos Fisiologicos Nutricionales Maternos , Estado Nutricional , Complicaciones Infecciosas del Embarazo , Adulto , Análisis de Varianza , Fármacos Anti-VIH/uso terapéutico , Índice de Masa Corporal , Distribución de Chi-Cuadrado , Depresión/etiología , Quimioterapia Combinada , Composición Familiar , Femenino , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/psicología , Humanos , Lactante , Recién Nacido , Embarazo , Prevalencia , Ensayos Clínicos Controlados Aleatorios como Asunto , Clase Social , Estrés Psicológico/etiología , Factores de Tiempo , Uganda/epidemiología , Aumento de Peso
16.
J Acquir Immune Defic Syndr ; 63(5): 578-84, 2013 Aug 15.
Artículo en Inglés | MEDLINE | ID: mdl-24135775

RESUMEN

BACKGROUND: As efforts intensify to eliminate perinatal HIV transmission, understanding kinetics of maternal-to-child transfer of antiretrovirals during pregnancy and breastfeeding is critical. Antiretroviral levels in plasma, cord blood, and breastmilk reflect exposure over short intervals. Hair concentrations reflect cumulative exposure and can uniquely quantify in utero transfer of maternal medications to infants. We measured plasma and hair antiretroviral levels in HIV-infected Ugandan mothers and their infants at delivery and during breastfeeding to assess transfer. METHODS: HIV-infected pregnant women were randomized to lopinavir/ritonavir- or efavirenz-based therapy in a larger trial (the Prevention of Malaria and HIV disease in Tororo, PROMOTE). At 0, 8, and 12 weeks postpartum, plasma antiretroviral levels were measured in 117 mother-infant pairs; hair levels were assayed at 12 weeks. Ratios and correlations of infant:maternal concentrations were calculated. RESULTS: By 12 weeks, 90.4% of mothers reported exclusive breastfeeding. Hair and plasma levels over time suggest moderate (47%) to extensive (87%) in utero transfer of lopinavir and ritonavir, respectively, but negligible transfer of either via breastfeeding. Moderate transfer of efavirenz occurs during pregnancy and breastfeeding (40% cumulative; 15% during breastfeeding). Despite differences in exposure, no infant seroconversions or correlations between infant hair/plasma antiretroviral levels and adverse effects were observed. CONCLUSIONS: Using a unique approach combining hair and plasma data, we found that different antiretrovirals have distinct kinetics of mother-to-infant transfer. Efavirenz transfers during both pregnancy and breastfeeding, whereas lopinavir and ritonavir transfer only in utero. Further study of the degree and timing of maternal-to-child transfer by antiretroviral will help optimize strategies that protect infants and minimize toxicities during periods of risk.


Asunto(s)
Fármacos Anti-VIH/farmacocinética , Benzoxazinas/farmacocinética , Cabello/química , Lopinavir/farmacocinética , Leche Humana/química , Plasma/química , Ritonavir/farmacocinética , Fármacos Anti-VIH/administración & dosificación , Benzoxazinas/administración & dosificación , Femenino , Infecciones por VIH/tratamiento farmacológico , Humanos , Lactante , Recién Nacido , Lopinavir/administración & dosificación , Embarazo , Complicaciones Infecciosas del Embarazo/tratamiento farmacológico , Ritonavir/administración & dosificación , Uganda
17.
PLoS One ; 8(9): e73073, 2013.
Artículo en Inglés | MEDLINE | ID: mdl-24023811

RESUMEN

BACKGROUND: Intermittent preventive treatment during pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is widely recommended in sub-Saharan Africa to reduce the risk of malaria and improve birth outcomes. However, there are reports that the efficacy of IPTp with SP is waning, especially in parts of Africa where antimalarial resistance to this drug has become widespread. METHODOLOGY/PRINCIPAL FINDINGS: We conducted a cross-sectional study of 565 HIV-uninfected women giving birth at Tororo District Hospital in southeastern Uganda. The primary objective of the study was to measure associations between use of SP during pregnancy from antenatal records and the risk of adverse outcomes including placental malaria, low birth weight, maternal parasitemia and maternal anemia. The proportion of women who reported taking 0, 1, 2, and 3 doses of SP during pregnancy was 5.7%, 35.8%, 56.6% and 2.0% respectively. Overall, the prevalence of placental malaria was 17.5%, 28.1%, and 66.2% by placental smear, PCR, and histopathology, respectively. In multivariate analyses controlling for potential confounders, ≥ 2 doses of SP was associated with non-significant trends towards lower odds of placental malaria by placental smear (OR = 0.75, p = 0.25), placental malaria by PCR (OR = 0.93, p = 0.71), placental malaria by histopathology (OR = 0.75, p = 0.16), low birth weight (OR = 0.63, p = 0.11), maternal parasitemia (OR = 0.88, p = 0.60) and maternal anemia (OR = 0.88, p = 0.48). Using a composite outcome, ≥ 2 doses of SP was associated with a significantly lower odds of placental malaria, low birth weight, maternal parasitemia, or maternal anemia (OR = 0.52, p = 0.01). CONCLUSIONS/SIGNIFICANCE: In this area of Uganda with intense malaria transmission, the prevalence of placental malaria by histopathology was high even among women who reported taking at least 2 doses of SP during pregnancy. The reported use of ≥ 2 doses of SP was not associated with protection against individual birth and maternal outcome measures but did protect against a composite measure of any adverse outcome.


Asunto(s)
Malaria/epidemiología , Malaria/prevención & control , Complicaciones del Embarazo/epidemiología , Complicaciones del Embarazo/prevención & control , Pirimetamina/farmacología , Sulfadoxina/farmacología , Adulto , Estudios Transversales , Dihidropteroato Sintasa/genética , Documentación , Combinación de Medicamentos , Resistencia a Medicamentos , Femenino , Humanos , Malaria/genética , Malaria/transmisión , Mutación , Parto , Embarazo , Complicaciones del Embarazo/genética , Tetrahidrofolato Deshidrogenasa/genética , Uganda/epidemiología , Adulto Joven
19.
J Trop Pediatr ; 59(6): 441-6, 2013 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-23764539

RESUMEN

As human immunodeficiency virus (HIV)-infected women gain access to combination antiretroviral therapy throughout sub-Saharan Africa, a growing number of infants are being born HIV-exposed but uninfected. Data about neonatal mortality and the impact of premature delivery, in this population are limited. We describe the 28-day mortality outcomes in a cohort of HIV-exposed infants who had ultrasound-confirmed gestational age in rural Uganda. There were 13 deaths among 351 infants, including 9 deaths in the perinatal period. Premature delivery was a strong predictor of mortality. The prevention of HIV transmission to infants is now possible in rural low-resource settings but the frequency of neonatal death among HIV-exposed infants remains extremely high, calling for new comprehensive interventions to reduce mortality in this growing population.


Asunto(s)
Antirretrovirales/efectos adversos , Terapia Antirretroviral Altamente Activa/efectos adversos , Infecciones por VIH/tratamiento farmacológico , Mortalidad Infantil , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Complicaciones Infecciosas del Embarazo/tratamiento farmacológico , Adulto , Antirretrovirales/uso terapéutico , Femenino , Estudios de Seguimiento , Edad Gestacional , Infecciones por VIH/diagnóstico , Infecciones por VIH/prevención & control , Infecciones por VIH/transmisión , VIH-1 , Humanos , Lactante , Recien Nacido Prematuro , Masculino , Embarazo , Complicaciones Infecciosas del Embarazo/diagnóstico , Resultado del Embarazo , Nacimiento Prematuro , Estudios Prospectivos , Población Rural/estadística & datos numéricos , Análisis de Supervivencia , Resultado del Tratamiento , Uganda/epidemiología
20.
PLoS One ; 7(8): e41934, 2012.
Artículo en Inglés | MEDLINE | ID: mdl-22879899

RESUMEN

OBJECTIVE: Maternal nutritional status is an important predictor of birth outcomes, yet little is known about the nutritional status of HIV-infected pregnant women treated with combination antiretroviral therapy (cART). We therefore examined the relationship between maternal BMI at study enrollment, gestational weight gain (GWG), and hemoglobin concentration (Hb) among 166 women initiating cART in rural Uganda. DESIGN: Prospective cohort. METHODS: HIV-infected, ART-naïve pregnant women were enrolled between 12 and 28 weeks gestation and treated with a protease inhibitor or non-nucleoside reverse transcriptase inhibitor-based combination regimen. Nutritional status was assessed monthly. Neonatal anthropometry was examined at birth. Outcomes were evaluated using multivariate analysis. RESULTS: Mean GWG was 0.17 kg/week, 14.6% of women experienced weight loss during pregnancy, and 44.9% were anemic. Adverse fetal outcomes included low birth weight (LBW) (19.6%), preterm delivery (17.7%), fetal death (3.9%), stunting (21.1%), small-for-gestational age (15.1%), and head-sparing growth restriction (26%). No infants were HIV-infected. Gaining <0.1 kg/week was associated with LBW, preterm delivery, and a composite adverse obstetric/fetal outcome. Maternal weight at 7 months gestation predicted LBW. For each g/dL higher mean Hb, the odds of small-for-gestational age decreased by 52%. CONCLUSIONS: In our cohort of HIV-infected women initiating cART during pregnancy, grossly inadequate GWG was common. Infants whose mothers gained <0.1 kg/week were at increased risk for LBW, preterm delivery, and composite adverse birth outcomes. cART by itself may not be sufficient for decreasing the burden of adverse birth outcomes among HIV-infected women. TRIAL REGISTRATION: Clinicaltrials.gov NCT00993031.


Asunto(s)
Fármacos Anti-VIH/uso terapéutico , Terapia Antirretroviral Altamente Activa , Infecciones por VIH/tratamiento farmacológico , Fenómenos Fisiologicos Nutricionales Maternos , Estado Nutricional , Resultado del Embarazo , Población Rural , Adulto , Fármacos Anti-VIH/farmacología , Femenino , Retardo del Crecimiento Fetal/patología , Feto/efectos de los fármacos , Humanos , Recién Nacido de Bajo Peso , Recién Nacido , Recién Nacido Pequeño para la Edad Gestacional , Fenómenos Fisiologicos Nutricionales Maternos/efectos de los fármacos , Análisis Multivariante , Estado Nutricional/efectos de los fármacos , Embarazo , Factores de Riesgo , Uganda , Aumento de Peso/efectos de los fármacos
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