The Perinatal Birth Environment: Communication Strategies and Processes for Adherence to a Standardized Guideline in Women Undergoing Second-Stage Labor With Epidural Anesthesia.

Key to any perinatal safety initiative is buy-in and strong leadership from obstetric and pediatric providers, advanced practice nurses, and labor and delivery nurses in collaboration with ancillary staff. In the fall of 2007, executives of a large Midwestern hospital system created the Zero Birth Injury Initiative. This multidisciplinary group sought to eliminate birth injury using the Institute of Healthcare Improvement Perinatal Bundles. Concurrently, the team implemented a standardized second-stage labor guideline for women who choose epidural analgesia for pain management to continue the work of eliminating birth injuries in second-stage labor. The purpose of this article was to describe the process of the modification and adaptation of a standardized second-stage labor guideline, as well as adherence rates of these guidelines into clinical practice. Prior to implementation, a Web-based needs assessment survey of providers was conducted. Most (77% of 180 respondents) believed there was a need for an evidence-based guideline to manage the second stage of labor. The guideline was implemented at 5 community hospitals and 1 academic health center. Data were prospectively collected during a 3-month period for adherence assessment at 1 community hospital and 1 academic health center. Providers adhered to the guideline in about 57% of births. Of patients whose provider followed the guideline, 75% of women were encouraged to delay pushing compared with only 28% of patients delayed pushing when the provider did not follow the guideline.

A perinatal care quality and safety initiative: are there financial rewards for improved quality?

BACKGROUND: Although costs of providing care may decrease with hospital initiatives to improve obstetric and neonatal outcomes, the accompanying reduced adverse outcomes may negatively affect hospital revenues. METHODS: In 2008 a Minnesota-based hospital system (Fairview Health Services) launched the Zero Birth Injury (ZBI) initiative, which used evidence-based care bundles to guide management of obstetric services. A pre-post analysis of financial impacts of ZBI was conducted by using hospital administrative records to measure costs and revenues associated with changes in maternal and neonatal birth injuries before (2008) and after (2009-2011) the initiative. RESULTS: For the Fairview Health Services hospitals, after adjusting for relevant covariates, implementation of ZBI was associated with a mean 11% decrease in the rate of maternal and neonatal adverse outcomes between 2008 and 2011 (adjusted odds ratio [AOR] = 0.89, p = .076). As a result of the adverse events avoided, the hospital system saved $284,985 in costs but earned $324,333 less revenue, which produced a net financial decrease of $39,348 (or a $305 net financial loss per adverse event avoided) in 2011, compared with 2008. CONCLUSIONS: Adoption of a perinatal quality and safety initiative that reduced birth injuries had little net financial impact on the hospital. ZBI produced better clinical results at a lower cost, which represents potential savings for payers, but the hospital system offering improved quality reaped no clear financial rewards. These results highlight the important role for shared-savings collaborations (among patients, providers, government and third-party payers, and employers) to incentivize QI. Widespread adoption of perinatal safety initiatives combined with innovative payment models may contribute to better health at reduced cost.

High rate of severe fetal outcomes associated with maternal parvovirus b19 infection in pregnancy.

OBJECTIVE: To augment the understanding of parvovirus B19 infection in pregnancy with respect to maternal characteristics and their corresponding fetal outcomes. STUDY DESIGN: Retrospective case-series of all women referred to Magee-Women_s Hospital with serologically-documented parvovirus B19 infection during pregnancy from 1998-2001. RESULTS: All 25 cases that are available for analysis occurred from January through June. The frequency of cases varied substantially from year to year, with 14 cases in 1998, 0 cases in 1999 and 2000, and 11 cases in 2001. In contrast to previous reports, the minority of women [4/25(16%)] experienced symptoms attributable to parvovirus B-19 infection although 3 of 25 (12%) fetuses developed hydrops fetalis and 4/25 (16%) suffered an intrauterine of fetal death. CONCLUSIONS: These findings suggest that parvovirus B19 infection in pregnancy follows seasonal and annual trend variation, may produce a lower frequency of maternal symptoms and a higher fetal loss rate than previously reported. Synopsis. Maternal parvovirus B19 infection follows seasonal and annual variation is often asymptomatic and may have higher fetal loss rates than previously reported. Continued surveillance is warranted.

Host immune consequences of asymptomatic Trichomonas vaginalis infection in pregnancy.

OBJECTIVE: The purpose of this study was to define the impact of asymptomatic trichomoniasis on lower genital tract neutrophil activation in pregnancy. STUDY DESIGN: In this nested cohort study, pelvic examination was performed on 65 asymptomatic pregnant women between 7 and 22 weeks' with vaginal pH > 4.4. Concentrations of cervical interleukin-8 and alpha-defensin were determined using enzyme-linked immunosorbent assay (ELISA). Trichomonas vaginalis was detected by culture. RESULTS: Median concentrations of vaginal fluid neutrophil defensins and cervical interleukin-8 were significantly greater among women with asymptomatic trichomoniasis (median defensins 18,622 ng/mL, median IL-8 9244 pg/mL) than their uninfected counterparts (median defensins 5144 ng/mL, median IL-8 2044 pg/mL) (P < .001). All women with asymptomatic trichomoniasis had detectable defensin and interleukin-8 concentrations. CONCLUSION: Asymptomatic trichomoniasis in pregnancy is accompanied by a state of neutrophil activation.

Premature rupture of the fetal membranes: is the amnion the major determinant?

OBJECTIVE: The objective of the study was to evaluate the relative contributions of amnion and chorion to the strength of fetal membranes and to correlate these findings with gestational age. STUDY DESIGN: Fetal membranes from 78 pregnancies were tested for biaxial puncture force using a blunt, instrumented probe with a low-force load cell connected through a load cell conditioner to an oscilloscope. The average of 2 to 4 tests performed on independent regions of the membrane was recorded. Means and SDs were calculated through the gestational age ranges of less than 32, 32 to 36, or 37 weeks or longer. Linear regression analysis was performed across gestational age after grouping data by labor and mode of delivery. RESULTS: There were trends toward decreasing puncture force with gestational age for both chorioamnion and amnion for both vaginal deliveries and cesarean sections. The trends were significant by linear regression for labored deliveries but not unlabored cesarean sections for both chorioamnion and amnion alone. There was no trend in chorion puncture force with either gestational age or delivery mode and the mean puncture force values were, on average, half those for the amnion. CONCLUSION: The amnion is significantly stronger than the chorion when subjected to biaxial strength testing. The amnion but not the chorion is significantly affected by the chemical and mechanical changes during gestation and the labor process. These data will help direct future studies on the effects of clinical and molecular modulators of inflammation on membrane rupture thresholds with special emphasis on the biochemical and structural changes in the amnion.

Vaginal breech deliveries selected using computed tomographic pelvimetry may be associated with fewer adverse outcomes.

OBJECTIVE: Vaginal breech (VB) delivery at term remains controversial. Our objective was to compare neonatal and maternal outcomes in VB deliveries selected using computed tomographic (CT) pelvimetry to those selected clinically. METHODS: A retrospective cohort study of singleton, term, VB deliveries with adequate clinical pelvimetry and estimated fetal weight of 3,850 g was performed. Women in the CT group had adequate pelvimetry by CT measurements. Neonatal and maternal outcomes were recorded. RESULTS: Of the VB deliveries, 58 women had adequate CT pelvimetry and 37 women were selected using clinical criteria alone. There were no perinatal deaths. Neonatal morbidity was significantly lower in VB deliveries selected using CT criteria at 0% versus 10.8% in the clinically selected group (p=0.02). CONCLUSION: VB deliveries selected using CT pelvimetry may be associated with fewer adverse neonatal outcomes than those selected using only clinical criteria. Therefore, it is inappropriate, without CT pelvimetry and strict selection criteria, to conclude that VB deliveries are unsafe. Our experience suggests that there may be a population in which VB delivery is a safe alternative if selected using a combination of specific clinical, sonographic, and CT criteria.

Predictive value of the clinical diagnosis of lower genital tract infection in women.

OBJECTIVE: We hypothesized that diagnostic approaches to lower genital tract infections are inaccurate and proposed this study to evaluate typical approaches. STUDY DESIGN: Clinical diagnoses were made with symptoms, direct observation, wet mount, vaginal pH, and amines in 598 women with genital complaints. Laboratory testing for N gonorrhoeae, yeast, T vaginalis, C trachomatis, and bacterial vaginosis by Gram stain. RESULTS: The most frequent symptoms were vaginal discharge (64%), change in discharge (53%), malodor (48%), and pruritus (32%). The infection rates were 46% bacterial vaginosis, 29% yeast, 12% trichomoniasis, 11% chlamydia or gonorrhea; 21% of the patients had no infection. The symptoms did not predict laboratory diagnosis. Clinical signs and symptoms with office-based tests and microscopy improved the accuracy of diagnoses. Amsel's clinical diagnosis of bacterial vaginosis was the most sensitive at 92%. The sensitivity of wet mount diagnosis of trichomoniasis was 62%, of yeast by microscopy was 22%, and of mucopus for the prediction of gonorrhea and/or chlamydia was 30%. CONCLUSION: Symptoms alone should not be used to direct treatment in instances in which resources permit more complete evaluation with office-based testing that includes microscopy. Treatment failures or diagnostic uncertainty should prompt specific laboratory testing.

Improving universal prenatal screening for human immunodeficiency virus.

OBJECTIVE: To evaluate the effect of implementation of a human immunodeficiency virus (HIV) educational intervention on universal screening for HIV in a prenatal clinic setting. METHODS: In this retrospective cohort study, frequencies of offering and acceptance of HIV testing were compared before and after an educational intervention performed by an HIV-focused nurse. The records of 293 women seeking prenatal care before the intervention and 206 women seeking prenatal care after the intervention were reviewed for offering and acceptance of HIV testing. Fisher's exact test and logistic regression were used to evaluate the relationship between the educational intervention and the offering and acceptance of HIV testing. RESULTS: The frequency of HIV test offering at first visit and test acceptance before the educational intervention were 96.5% and 74.8%, respectively, and after the intervention were 99.5% and 84.3%, respectively. This improvement in offering (3% change) and acceptance (9.5% change) was statistically significant (offering at first visit: OR = 7.27, 95% CI = 1.02 to 316.9; test acceptance: OR = 1.82, 95% CI = 1.14 to 2.88). Test acceptance was statistically significantly improved in the post-intervention group after controlling for confounding variables (OR = 2.02, 95% CI = 1.2 to 3.39). CONCLUSION: The addition of an HIV-focused nurse to a clinic setting improved the frequency of test offering at first visit and of acceptance of HIV testing by pregnant women.

Multiple-marker screening in human immunodeficiency virus-positive pregnant women: Screen positivity rates with the triple and quad screens.

OBJECTIVE: The study was undertaken to determine the screen-positive rates of multiple-marker screening tests in pregnant women who are positive for human immunodeficiency virus (HIV) at our institution for open neural tube defects and aneuploidy, for both triple (alpha-fetoprotein, human chorionic gonadotropin [hCG], unconjugated estriol) and quad (alpha-fetoprotein, hCG, unconjugated estriol, inhibin A) screens, and to compare these rates with a matched control group. STUDY DESIGN: A 1:1 matched case-control study was performed comparing multiple marker screening test results in 34 HIV-positive women with age- and race-matched HIV-negative controls. Individual serum markers and screen positive rates for both the triple and quad screens were compared among the cases and controls. RESULTS: In each group, there were 19 women with triple screens and 15 with quad screens. Serum hCG multiples of the median were significantly higher in the HIV-positive compared with the HIV-negative women (P=.033). There was no difference in screen positive rates between the cases and controls using the triple screen, but there was a significantly higher overall screen positive rate in the HIV-positive group when the quad screen was used (33% vs 7%, P=.046). CONCLUSION: There is a significantly higher rate of overall quad screen positivity on multiple-marker screening among HIV-positive women compared with a matched control group.

Decreased cervical proinflammatory cytokines permit subsequent upper genital tract infection during pregnancy.

OBJECTIVE: The purpose of this study was to test the hypothesis that suppressed immune function in the lower genital tract, as represented by decreased concentrations of cervical proinflammatory cytokines early in pregnancy, is a risk factor for clinical chorioamnionitis. STUDY DESIGN: Interleukin-1beta, interleukin-6, and interleukin-8 were measured by enzyme-linked immunosorbent assay in cervical fluid from a cohort of 403 women at 8 to 20 weeks of gestation. RESULTS: Of the 88 women with one low cytokine concentration, 8.0% of the women had clinical chorioamnionitis compared with 4.4% among the 228 women with no low cytokines (adjusted odds ratio, 2.0; 95% CI, 0.7-5.8). Clinical chorioamnionitis occurred in 15 of the 87 women (17.2%), with two or three depressed cytokine concentrations compared with women with no low cytokines (adjusted odds ratio, 5.1; 95% CI, 2.0-13.0). CONCLUSION: Genital tract immune hyporesponsiveness, as represented by low cervical concentrations of multiple cytokines, permits subsequent clinical chorioamnionitis.

Clinical and cervical cytokine response to treatment with oral or vaginal metronidazole for bacterial vaginosis during pregnancy: a randomized trial.

OBJECTIVE: To compare the efficacy of oral versus vaginal metronidazole treatment in pregnant women with bacterial vaginosis, and to compare cytokine profiles (interleukin-1beta, -6, and -8) in the cervical secretions of these women before and after treatment. METHODS: Pregnant women with bacterial vaginosis diagnosed both by Gram stain and clinical criteria were randomized to receive oral (n=52) or vaginal (n=50) metronidazole therapy. Cervical specimens for cytokine analysis and vaginal fluid for evaluation of bacterial vaginosis were obtained at baseline and 4 weeks after treatment. RESULTS: There was no significant difference in therapeutic cure rates (defined as a Gram stain score of 0-3 and the absence of all four clinical signs of bacterial vaginosis) between the two groups (71% and 70% for the oral and vaginal groups, respectively, P=1.0). Cervical levels of interleukin-1beta, -6, and -8 were significantly lower after treatment among the 72 women cured of bacterial vaginosis (P<.001, P=.001, and P=.02, respectively) but not among women who failed to respond to therapy. For interleukin-1beta and -6, a significant decrease in cytokine level was observed in both the oral and vaginal treatment groups. CONCLUSION: One week of oral metronidazole and 5 days of intravaginal metronidazole are equally efficacious for treatment of bacterial vaginosis during pregnancy. The decrease in cervical interleukin-1beta, -6, and -8 levels among women who established a normal flora after treatment but not among those with persistent bacterial vaginosis suggests a direct linkage between vaginal flora abnormalities and elevated cervical levels of interleukin-1beta, -6, and -8.

Detection of Chlamydia trachomatis and Neisseria gonorrhoeae by strand displacement amplification and relevance of the amplification control for use with vaginal swab specimens.

Vaginal swab specimens may be preferable to cervical swab or urine specimens for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae because of the ease of specimen collection and transport. The purpose of this study was to evaluate whether vaginal swab specimens are equivalent to cervical swab specimens for the detection of N. gonorrhoeae and C. trachomatis by the Becton Dickinson strand displacement amplification assay (SDA) with the BDProbeTec ET instrument and then to evaluate the use of the amplification control in a clinical research setting. In the first phase, vaginal and cervical swab specimens were obtained from 455 symptomatic women aged 18 to 40 attending primary health care and sexually transmitted disease clinics. Thirty-nine specimens (8.6%) had true-positive results for N. gonorrhoeae and 37 specimens (8.1%) had true-positive results for C. trachomatis. The sensitivity of SDA was superior to that of culture for the detection of N. gonorrhoeae with vaginal swab specimens and equivalent to that of the Roche PCR for the detection of C. trachomatis with cervical swab specimens. In the second phase of the study, 1,411 consecutively collected vaginal swab specimens were evaluated, with 357 (25.3%) specimens giving indeterminate readings on the basis of the result for the amplification control. The prevalences of sexually transmitted pathogens in vaginal swab specimens with and without use of the amplification control were 6.0 and 5.8%, respectively, for C. trachomatis and 3.1 and 3.0%, respectively, for N. gonorrhoeae. Although, vaginal swab specimens were equivalent to cervical swab specimens for the detection of N. gonorrhoeae and C. trachomatis by SDA with respect to sensitivity, one in four vaginal swab specimens yielded an indeterminate result when the amplification control was used. The amplification control has limited value for use with vaginal swab specimens.

Bacterial vaginosis is a strong predictor of Neisseria gonorrhoeae and Chlamydia trachomatis infection.

To evaluate whether bacterial vaginosis predicts the acquisition of sexually transmitted diseases (STDs), we studied 255 nonpregnant female subjects aged 15-30 who reported recent sexual contact with a male partner in whom either gonococcal or chlamydial urethritis or nongonococcal urethritis was diagnosed. Compared to subjects with normal vaginal flora, subjects with bacterial vaginosis were more likely to test positive for Neisseria gonorrhoeae (odds ratio [OR], 4.1; 95% confidence interval [CI], 1.7-9.7) and Chlamydia trachomatis (OR, 3.4; 95% CI, 1.5-7.8). Subjects colonized vaginally by hydrogen peroxide-producing lactobacilli were less likely to receive a diagnosis of chlamydial infection or gonorrhea than subjects without such lactobacilli. Bacterial vaginosis was a strong predictor of gonorrhea and chlamydial infection among subjects who reported recent exposure to a male partner with urethritis. These data support the importance of vaginal flora in the defense against STD acquisition.

Aumento da replicação do vírus da imunodeficiência humana tipo 1 induzida por Neisseria gonorhoeae na presença de leucócitos polimorfonucleares / Enhancement of human immunodeficiency virus tipe 1 replication induced by neisseria gonorrhoeae in presence of polymorphonuclear leukocytes

Determina a influência da NG associada a leucócitos polimorfonucleares - PMNsobre a replicação do HIV I. Para análise da replicação viral foram utilizadas células monocíticas pré-infectadas pelo HIV I. Para o ensaio bacteriano utilizou-se uma cepa de NG classificada como PorB3 serovar, pilli e opa positivas. A NG , isoladamente ou em associação ao PMN, aumentou significativamente a replicação in vitro do HIV I

Memory CD4(+) T cells are the earliest detectable human immunodeficiency virus type 1 (HIV-1)-infected cells in the female genital mucosal tissue during HIV-1 transmission in an organ culture system.

The virologic and cellular factors that are involved in transmission of human immunodeficiency virus type 1 (HIV-1) across the female genital tissue are poorly understood. We have recently developed a human cervical tissue-derived organ culture model to study heterosexual transmission of HIV-1 that mimics the in vivo situation. Using this model we investigated the role of phenotypic characteristics of HIV-1 and identified the cell types that are first infected during transmission. Our data indicate that the cell-free R5 HIV-1 was more efficiently transmitted than cell-free X4 HIV-1. Cell-free and cell-associated HIV-1 had comparable transmission efficiency regardless of whether the virus was of R5 or X4 type. We have demonstrated that memory CD4(+) T cells and not Langerhans cells were the first HIV-1 RNA-positive cells detected at the epithelial-submucosal junction 6 h after virus exposure. Multicolor laser confocal microscopy demonstrated a globular distribution of HIV-1 gag-pol mRNA in the cytoplasm, and the distribution of CD4 and the CD45RO isoform was irregular on the cellular membrane. At 96 h postinoculation, in addition to memory CD4(+) T cells, HIV-1 RNA-positive Langerhans cells and macrophages were also detected. The identification of CD4(+) T cells in the tissue at 6 h was confirmed by flow cytometric simultaneous immunophenotyping and ultrasensitive fluorescence in situ hybridization assay on immune cells isolated from disaggregated tissue. Furthermore, PMPA [9-[2-(phosphonomethoxy)propyl] adenine], an antiretroviral compound, and UC781, a microbicide, inhibited HIV-1 transmission across the mucosa, indicating the utility of the organ culture to screen topical microbicides for their ability to block sexual transmission of HIV-1.

Lower genital tract infection and endometritis: insight into subclinical pelvic inflammatory disease.

OBJECTIVE: To investigate the association between lower genital tract infections and subclinical PID. Fallopian tube damage is a common complication of acute symptomatic pelvic inflammatory disease (PID), yet most women with tubal factor infertility do not have a history of acute PID. Subclinical PID is believed to be an important cause of tubal factor infertility. METHODS: We conducted a cross-sectional study among women attending a sexually transmitted diseases or ambulatory gynecology clinic. A convenience sample of 556 women with bacterial vaginosis, gonorrhea, or chlamydia, or women at risk for gonorrhea or chlamydia were enrolled. Women diagnosed with acute PID were not eligible to participate. The main outcome was subclinical PID, as defined by the presence of histologic endometritis. RESULTS: Subclinical PID was more common in women with lower genital tract infection than in uninfected women. Subclinical PID was present in 27% of women with Chlamydia trachomatis (odds ratio 3.4; 95% confidence interval [CI] 1.8, 6.3) and in 26% of women infected with Neisseria gonorrhoeae (odds ratio 2.4; 95% CI 1.1, 5.1). Among women with bacterial vaginosis, 15% had endometritis (odds ratio 2.7; 95% CI 1.02, 7.2). CONCLUSION: Subclinical PID is common among women with lower genital tract infections. Additional prospective studies are necessary to determine the reproductive impact of these asymptomatic upper genital tract infections.