Rapidly progressing ascites in a pregnancy with a massive fibroid: A case report and review of pseudo-Meigs syndrome.

Meigs syndrome is a classic triad of ascites, pleural effusions, and an ovarian fibroma with resolution following excision. Pseudo-Meigs syndrome presents similarly but is caused by a pelvic mass other than an ovarian fibroma, such as a fibroid. We present a case report of a 33-year-old gravida 2 para 0-0-1-0 woman with a massive, pedunculated fibroid who developed rapid onset of ascites and edema beginning at 5 weeks of gestation. Malignant, cardiac, renal, hepatic, and rheumatologic causes were ruled out. Her symptoms resolved following myomectomy and delivery via cesarean. Pseudo-Meigs syndrome was suspected. Pseudo-Meigs syndrome is a diagnosis of exclusion and requires surgical management for resolution. Pregnancy may be an inciting factor. Myomectomy may be done safely at the time of cesarean.

Physician perceptions of barriers to infection prevention and control in labor and delivery.

OBJECTIVE: To learn about the perceptions of healthcare personnel (HCP) on the barriers they encounter when performing infection prevention and control (IPC) practices in labor and delivery to help inform future IPC resources tailored to this setting. DESIGN: Qualitative focus groups. SETTING: Labor and delivery units in acute-care settings. PARTICIPANTS: A convenience sample of labor and delivery HCP attending the Infectious Diseases Society for Obstetrics and Gynecology 2022 Annual Meeting. METHODS: Two focus groups, each lasting 45 minutes, were conducted by a team from the Centers for Disease Control and Prevention. A standardized script facilitated discussion around performing IPC practices during labor and delivery. Coding was performed by 3 reviewers using an immersion-crystallization technique. RESULTS: In total, 18 conference attendees participated in the focus groups: 67% obstetrician-gynecologists, 17% infectious disease physicians, 11% medical students, and 6% an obstetric anesthesiologist. Participants described the difficulty of consistently performing IPC practices in this setting because they often respond to emergencies, are an entry point to the hospital, and frequently encounter bodily fluids. They also described that IPC training and education is not specific to labor and delivery, and personal protective equipment is difficult to locate when needed. Participants observed a lack of standardization of IPC protocols in their setting and felt that healthcare for women and pregnant people is not prioritized on a larger scale and within their hospitals. CONCLUSIONS: This study identified barriers to consistently implementing IPC practices in the labor and delivery setting. These barriers should be addressed through targeted interventions and the development of obstetric-specific IPC resources.

Short-term impact of a neighbourhood-based intervention on mental health and self-rated health in Hamilton, Ontario, Canada.

The Hamilton Neighbourhoods Study aimed to measure the short-term impact of a neighbourhood-based intervention known as the City of Hamilton's Neighbourhood Action Strategy on health and neighbourhood outcomes. A quasi-experimental study with 881 intervention participants across six targeted neighbourhoods and 173 control participants was conducted to investigate changes in self-rated health and mental health from baseline to follow-up. There was evidence of small improvements in mental health in two neighbourhoods, but there was no change in self-rated health. Place-based interventions aimed at high poverty neighbourhoods may have only modest impacts on health in the short-term.

The association between housing cost burden and avoidable mortality in wealthy countries: cross-national analysis of social and housing policies, 2000-2017.

BACKGROUND: It has been shown that the high cost of housing can be detrimental to individual health. However, it is unknown (1) whether high housing costs pose a threat to population health and (2) whether and how social policies moderate the link between housing cost burden and mortality. This study aims to reduce these knowledge gaps. METHODS: Country-level panel data from Organisation for Economic Co-operation and Development (OECD) countries are used. Housing cost to income ratio and age-standardised mortality were obtained from the OECD database. Fixed effects models were conducted to estimate the extent to which the housing cost to income ratio was associated with preventable mortality, treatable mortality, and suicides. In order to assess the moderating effects of social and housing policies, different types of social spending per capita as well as housing policies were taken into account. RESULTS: Housing cost to income ratio was significantly associated with preventable mortality, treatable mortality, and suicide during the post-global financial crisis (2009-2017) but not during the pre-global financial crisis (2000-2008). Social spending on pensions and unemployment benefits decreased the levels of mortality rate associated with housing cost burden. In countries with higher levels of social housing stock, the link between housing cost burden and mortality was attenuated. Similar patterns were examined for countries with rent control. CONCLUSION: Our findings suggest that housing cost burden can be related to population health. Future studies should examine the role of protective measures that alleviate health problems caused by housing cost burden.

The impact of parental involvement laws on minors seeking abortion services: a systematic review.

On June 24, 2022, the US Supreme Court overturned the constitutional right to abortion in Dobbs v Jackson Women's Health Organization. Minors are a vulnerable population with a high risk of unintended pregnancy who are likely to be disproportionately affected by abortion restrictions. Examining the impact of historical abortion restrictions in minors may provide insight into the anticipated effects of the Dobbs decision. This study is a systematic review examining the impact of parental involvement (PI) laws on minors seeking abortion services. Our review suggests an association between PI laws and decreased abortion rates. Parental involvement laws also may increase pregnancy and birth rates and out-of-state travel for abortion procedures and lead to later abortions, although effects appear to be heterogenous.

Evaluating the impact of three progestin-based hormonal contraceptive methods on immunologic changes in the female genital tract and systemically (CHIME Study): a prospective cohort study protocol.

BACKGROUND: Gonadal hormones can modify immune function, which may impact susceptibility to infectious diseases, including Human Immunodeficiency Virus (HIV). There is limited knowledge about how hormonal contraceptives (HC) influence the immune response during the course of use. The CHIME study aims to evaluate the effect of long-acting progestin-based hormonal contraceptives (depot medroxyprogesterone acetate, etonogestrel implant, and levonorgestrel intrauterine device) on immunologic changes in the female genital tract (FGT) and systemic compartment. METHODS: CHIME is an observational cohort study where participants attend 2 visits prior to initiating the HC method of their choice, and then attend 6 visits over 12 months with biological sampling (vaginal swabs, cervicovaginal lavage, cytobrush and blood) for immunological, bacteriological, and virological analyses at each visit. Immune profiling will be evaluated by multi-color flow cytometry to determine how different T-cell subsets, in particular the CD4 T-cell subsets, change during the course of contraceptive use and whether they have different profiles in the FGT compared to the systemic compartment. The study aims are (1) to characterize the alterations in FGT and systemic immune profiles associated with three long-acting progestin-only HC and (2) to evaluate the vaginal microenvironment, determined by 16 s rRNA sequencing, as an individual-level risk factor and moderator of genital and systemic immune profile changes following exposure to three commonly used HC. Data collection started in March 2019 and is scheduled to be completed in October 2024. DISCUSSION: The CHIME study aims to contribute to the body of research designed to evaluate the comparative impact of three long-acting progestin-only HC on innate and adaptive immune functions to understand how immunologic effects alter STI and HIV susceptibility.

How do housing asset and income relate to mortality? A population-based cohort study of 881220 older adults in Canada.

OBJECTIVE: A growing body of research has documented a well-established link between socioeconomic conditions and mortality among older adults. This study aims to understand (a) whether housing assets and income are associated with mortality and (b) if the value of housing assets affects the relationship between income and mortality; both questions are studied among older adults aged 65 or over in Canada. METHODS: Using the population-based linked dataset (2011 Canadian Census Health and Environment Cohorts) of 881,220 older adults over six years of follow-up (2011-2017), this study uses survival analysis to estimate the link between housing assets, income level and mortality. We also assess the potential moderating effect of housing asset levels on the association between income and mortality by categorizing individuals along two dimensions: whether they are income-poor and whether they are housing assets-poor. RESULTS: The mortality rate was higher among both the lowest asset (HR = 1.346) and the lowest income group (HR = 1.203). The association is pronounced for older adults aged 65 to 74. Assets did not significantly moderate the link between income and mortality. Income-related inequalities in mortality are observed among each group of housing asset level. Compared to those who are neither income-poor nor housing assets-poor, individuals who were income poor but not housing assets-poor were more likely to die (HR = 1.067) over seven years of follow-up, and people who were housing assets-poor only were more likely to die (HR = 1.210). Being housing-assets poor and income-poor yielded a higher hazard ratio (HR = 1.291). CONCLUSIONS: Housing assets and income are associated with mortality of older adults. It is important to identify people who are assets poor and/or income poor who are at higher risks of mortality. Social policies aimed at reducing income insecurity and housing insecurity can reduce mortality inequalities.

The World Mental Health International College Student Survey in Canada: Protocol for a Mental Health and Substance Use Trend Study.

BACKGROUND: The World Health Organization World Mental Health International College Student (WMH-ICS) initiative aims to screen for mental health and substance use problems among postsecondary students on a global scale as well as to develop and evaluate evidence-based preventive and ameliorative interventions for this population. This protocol paper presents the Canadian version of the WMH-ICS survey, detailing the adapted survey instrument, the unique weekly cross-sectional administration, the multitiered recruitment strategy, and the associated risk mitigation protocols. OBJECTIVE: This paper aims to provide a methodological resource for researchers conducting cross-national comparisons of WMH-ICS data, as well as to serve as a useful guide for those interested in replicating the outlined cross-sectional methodology to better understand how mental health and substance use vary over time among university students. METHODS: The online survey is based on the WMH-ICS survey instrument, modified to the Canadian context by the addition of questions pertaining to Canadian-based guidelines and the translation of the survey to Canadian French. The survey is administered through the Qualtrics survey platform and is sent to an independent stratified random sample of 350 students per site weekly, followed by two reminder emails. Upon survey closure every week, a random subsample of 70 nonresponders are followed up with via phone or through a personal email in an effort to decrease nonresponder bias. The survey is accompanied by an extensive risk mitigation protocol that stratifies respondents by the level of need and provides tailored service recommendations, including a facilitated expedited appointment to student counseling services for those at increased risk of suicide. The anticipated sample size is approximately 5500 students per site per year. RESULTS: In February 2020, the Canadian survey was deployed at the University of British Columbia. This was followed by deployment at Simon Fraser University (November 2020), McMaster University (January 2021), and the University of Toronto (January 2022). Data collection at all 4 sites is ongoing. As of May 6, 2022, 29,503 responses have been collected. CONCLUSIONS: Based on international collaboration, the Canadian version of the WMH-ICS survey incorporates a novel methodological approach centered on the weekly administration of a comprehensive cross-sectional survey to independent stratified random samples of university students. After 27 months of consecutive survey administration, we have developed and refined a survey protocol that has proven effective in engaging students at four Canadian institutions, allowing us to track how mental health and substance use vary over time using an internationally developed university student survey based on the criteria from the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/35168.

Trichomonas vaginalis and Spontaneous Preterm Birth in a High-Risk Obstetric Cohort in Atlanta, GA.

BACKGROUND: Trichomonas vaginalis (TV) is the most prevalent nonviral sexually transmitted infection globally, but routine screening is not recommended in HIV-negative individuals. There is a significant racial/ethnic health disparity in TV infection rates. Evidence regarding the association between TV and adverse perinatal outcomes is conflicting, but a recent large meta-analysis found a modest increased risk of preterm birth with TV infection (odds ratio, 1.27; 95% confidence interval, 1.08-1.50). The current study was undertaken to evaluate whether TV infection increases the risk of spontaneous preterm birth (sPTB) in a high-risk obstetric cohort in Atlanta, GA. METHODS: We conducted a retrospective cohort study of women delivering at a safety-net hospital in Atlanta between July 2016 and June 2018. Women delivering a singleton live fetus at >20 weeks' gestation were included. The diagnosis of TV was by nucleic acid amplification testing. The outcome of interest was sPTB before 37 weeks' gestation. Multivariable Cox proportional hazards modeling was used to estimate the effect of TV on sPTB, controlling for confounding variables, including clinical and demographic characteristics. Several sensitivity analyses were undertaken. RESULTS: There were 3723 deliveries during the study period, and approximately half (46%) were screened for TV with nucleic acid amplification testing. After exclusions, the analytic cohort included 1629 women. Median age was 26 years (interquartile range, 22-31 years), and 70% of participants were listed as non-Hispanic Black in the electronic medical record. The prevalence of TV was 16% (n = 257). The sPTB rate was 7% (n = 112). In multivariable Cox proportional hazards modeling, TV infection was not associated with a statistically significantly increased risk of sPTB (hazard ratio, 1.34; 95% confidence interval, 0.84-2.13; P = 0.22). Factors associated with sPTB included history of PTB, adequate plus or transfer of prenatal care (vs. adequate/intermediate prenatal care utilization using the Kotelchuck index), recreational substance use, and Chlamydia trachomatis diagnosed during the current pregnancy. Results were not substantively different in sensitivity analyses. CONCLUSIONS: The prevalence of TV was high in this cohort. Its infection was not associated with a statistically significantly increased risk of sPTB. Nevertheless, the magnitude of effect is consistent with prior meta-analyses.

Sexually Transmitted Infections in Pregnant People With Human Immunodeficiency Virus: Temporal Trends, Demographic Correlates, and Association With Preterm Birth.

BACKGROUND: We describe trends in prevalence and identify factors associated with Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), syphilis, and Trichomonas vaginalis (TV) diagnosed in pregnancy among US people with human immunodeficiency virus (PWH) and evaluate associations of sexually transmitted infections (STIs) with preterm birth (PTB). METHODS: We included pregnant PWH enrolled in the Surveillance Monitoring for ART Toxicities dynamic cohort of the Pediatric HIV/AIDS Cohort Study network who delivered between 2010 and 2019. Multivariable log-binomial or Poisson generalized estimating equation models were used to estimate the association of calendar year with each STI, controlling for confounders; the association of demographic and clinical factors with each STI; and the association of each STI with PTB. RESULTS: The sample included 2241 pregnancies among 1821 PWH. Median age at delivery was 29.2 years; 71% of participants identified as Black or African American. STI prevalence was: CT 7.7%, NG 2.3%, syphilis 2.4%, and TV 14.5%; 30% had unknown TV status. There were no temporal changes in STI prevalence. Younger age and initial HIV viral load ≥400 copies/mL were associated with increased risk of CT, NG, and TV. Recreational substance use was a risk factor for NG, syphilis, and TV. No STI was associated with PTB. CONCLUSIONS: Unlike nationwide trends, no changes in STI prevalence during the study period were observed. The large proportion with unknown TV status underscores the need for increased adherence to screening guidelines. STIs diagnosed during pregnancy in PWH were not associated with risk of PTB.

Pelvic organ prolapse recurrence after apical prolapse repair: does obesity matter?

INTRODUCTION AND HYPOTHESIS: We hypothesized obesity increases the risk of pelvic organ prolapse recurrence (POP-R) after primary apical prolapse repair. METHODS: We conducted a retrospective cohort study of 353 women who underwent primary apical prolapse surgery from 2011 to 2016. Demographic and clinical data were abstracted from medical records. Multivariable Cox proportional hazard models were used to generate hazard ratios (HR) for association between obesity (BMI ≥ 30 kg/m2) and POP-R (leading edge > 0), adjusting for potential confounders. Given the potential for outcome ascertainment bias due to differential loss to follow-up, a sensitivity analysis was performed assuming all patients with < 6 months of follow-up developed POP-R. RESULTS: Ten percent of women developed POP-R. The median follow-up time was 7 months (range 1.4, 63.9). Twenty-four percent of patients were Black and 70% were White; 37% were obese. After controlling for confounders, obese women did not have an increased risk of POP-R (aHR 1.39; 95% CI 0.67, 2.86, p = 0.38). Although only marginally statistically significant, patients who developed POP-R were more likely to be current smokers (aHR 3.48, 95% CI 1.14, 10.67; p = 0.06) or previous smokers (aHR 1.86, 95% CI 0.82, 4.24, p = 0.06) in comparison to non-smokers. Sensitivity analysis showed loss to follow-up had the potential to influence our results. CONCLUSIONS: Obesity was not a risk factor for POP-R in our cohort. Larger, prospective studies with longer postoperative follow-up time are needed to fully elucidate the relationship between obesity and POP-R.

Association of Delayed Treatment of Chlamydial Infection and Gonorrhea in Pregnancy and Preterm Birth.

BACKGROUND: Treating chlamydia and gonorrhea in pregnancy has been shown to decrease the associated risk of preterm birth in some studies. Delayed treatment of these infections among nonpregnant patients carries known consequences. It is unclear whether delayed treatment in pregnancy similarly increases adverse outcomes. METHODS: We conducted a retrospective cohort study of women who delivered at a safety-net hospital from July 2016 to June 2018. Women with at least one visit who were tested for chlamydia and gonorrhea were included. Women diagnosed after 36 weeks (preterm analysis) or 31 weeks (early preterm analysis) were excluded. We used multivariable logistic regression to examine the association between no infection, timely treatment (<1 week), and delayed treatment (>1 week, not treated) with preterm (<37 weeks) and early preterm (<32 weeks) birth. RESULTS: Among 3154 deliveries, 389 (12%) were preterm. Among 3107 deliveries, 74 (2%) were early preterm. In adjusted models, women with timely (adjusted odds ratio [aOR]; 1.7, 95% confidence interval [CI], 1.0-2.7) and delayed (aOR, 1.7; 95% CI, 1.1-2.5) treatments had increased odds of preterm birth. Similarly, women with timely (aOR, 2.5; 95% CI, 1.0-6.2) and delayed (aOR, 2.4; 95% CI, 1.2-4.9) treatments had increased odds of early preterm birth. Among women who tested positive, multiple infections were not associated with an increase in preterm birth (preterm: 17% vs. 20%, P = 0.53; early preterm: 5% vs. 6%, P = 0.74). CONCLUSIONS: Chlamydia and gonorrhea are associated with preterm and early preterm births, regardless of time to treatment. Creative solutions are needed to improve the prevention of these infections in pregnancy.

Postpartum Contraceptive Use and Other Reproductive Health Outcomes Among CenteringPregnancy Group Prenatal Care Participants.

Background: CenteringPregnancy® is a model of group prenatal care (PNC) that reduces preterm birth and increases patient satisfaction. Less is known about postpartum outcomes. Methods: This study aimed to evaluate whether CenteringPregnancy participants have more favorable postpartum reproductive health outcomes compared with traditional PNC participants. Our primary outcome was utilization of long-acting reversible contraception (LARC). As secondary outcomes, we examined breastfeeding at the postpartum visit, follow-up at the postpartum visit, and rapid repeat pregnancy. We conducted a retrospective cohort study of 422 women who received PNC and delivered at tertiary care hospital in Atlanta, Georgia between 2011 and 2015. Participants were eligible to participate if they were enrolled in Medicaid and received at least three PNC visits with a Certified Nurse Midwife in either CenteringPregnancy (n = 248) or traditional PNC (n = 174). Demographic and clinical data were abstracted from the electronic medical record. Multivariable log binomial regression was used to compare CenteringPregnancy participants and women who received traditional PNC. Results: One quarter of women (26%) chose LARC for postpartum contraception. There was no difference in overall contraceptive uptake between CenteringPregnancy and traditional PNC groups. CenteringPregnancy participants were 70% more likely to use LARC postpartum compared with women receiving traditional PNC (adjusted relative risk [aRR] 1.76; p < 0.01). CenteringPregnancy participants were significantly more likely to initiate breastfeeding before hospital discharge (aRR 1.14, p = 0.01) and to report exclusive breastfeeding at the postpartum visit (relative risk [RR] 2.54; p < 0.01). Women in the CenteringPregnancy group were marginally more likely to report any breastfeeding at the postpartum visit and to attend the postpartum visit (RR 1.31, p = 0.05 and RR 1.17, p = 0.05 respectively), but were no less likely to have a rapid repeat pregnancy (RR 0.90, p = 0.57). Conclusion: Women in CenteringPregnancy groups had increased uptake of LARC compared with a similar cohort of women in traditional PNC. Other potential benefits of CenteringPregnancy, including breastfeeding and attendance at the postpartum visit require further study.

The Consequences of Living in Childcare Deserts: Evidence from Canada.

Our study addresses whether working parents with young children living in childcare deserts experience greater work-family conflict and psychological distress compared to those in more resourced areas. We use 2011 individual-level data from Toronto matched to census and administrative childcare data. Results suggest that mothers experience greater conflict than fathers when in high-resourced areas. Fathers who work long hours and reside in a desert report greater psychological distress than fathers in nondeserts. These patterns are contrary to the observed results for mothers' distress by childcare availability. Our study underscores the impact of childcare options and the importance of access for all.

Notre étude examine si les parents qui travaillent avec de jeunes enfants vivant dans des « déserts de garde d'enfants¼ éprouvent plus de conflits travail-famille et de détresse psychologique, par rapport à ceux vivant dans des régions avec plus de ressources. Nous utilisons les données individuelles de 2011 de Toronto appariées aux données du recensement et des services administratifs de garde d'enfants. Les résultats suggèrent que les mères vivent plus de conflits que les pères lorsqu'elles sont dans une région disposant de ressources plus importantes. Les pères qui travaillent de longues heures et résident dans un «désert de garde d'enfants¼ rapportent plus de détresse psychologique que les autres pères. Ces tendances sont contraires aux résultats observés pour les mères. Notre étude met en évidence l'impact des options de garde d'enfants et l'importance de l'accès pour tous.

Beyond adequate: Factors associated with quality of antenatal care in western Tanzania.

OBJECTIVE: To determine quality of antenatal care (ANC). Most literature focuses on ANC attendance and services. Less is known about quality of care (QoC). METHOD: Data were analyzed from the 2016 Kigoma Reproductive Health Survey, a population-based survey of reproductive-aged women. Women with singleton term live births were included and principal component analysis (PCA) was used to create an ANC quality index using linear combinations of weights of the first principal component. Nineteen variables were selected for the index. The index was then used to assign a QoC score for each woman and linear regression used to identify factors associated with receiving higher QoC. RESULTS: A total of 3178 women received some ANC. Variables that explained the most variance in the QoC index included: gave urine (0.35); gave blood (0.34); and blood pressure measured (0.30). In multivariable linear regression, factors associated with higher QoC included: ANC at a hospital (versus dispensary); older age; higher level of education; working outside the home; higher socioeconomic status; and having lower parity. CONCLUSION: Using PCA methods, several basic components of ANC including maternal physical assessment were identified as important indicators of quality. This approach provides an affordable and effective means of evaluating ANC programs.

Labor market influences on Women's fertility decisions: Longitudinal evidence from Canada.

While fertility theories suggest that insecure labor market experiences encourage women to postpone having children, few have examined whether job insecurity perceptions influence fertility in the North American context-an omission we address in the current study. Findings from event history analyses of a panel dataset of Canadian workers (Canadian Work, Stress and Health Study) reveal that perceived job insecurity is salient for women's first birth decisions but not subsequent births. Further subgroup analyses show that the association between perceived job insecurity and likelihood of a first birth is limited to college-educated women and those in low unemployment labor market regions. Among women with less than a college degree and those in high-unemployment regions, the likelihood of a first birth does not vary by respondents' perceptions of insecurity. Results suggest a more nuanced relationship between insecure work and women's childbearing decisions than predicted by traditional pro-cyclical accounts of the economy-fertility association.

Trichomonas vaginalis in Pregnancy: Patterns and Predictors of Testing, Infection, and Treatment.

OBJECTIVE: To identify factors associated with testing for and diagnosis of trichomoniasis in pregnancy and to describe patterns of treatment and tests of reinfection or persistence. METHODS: We conducted a retrospective cohort study of women who delivered from July 2016 to June 2018 at one institution. Testing for Trichomonas vaginalis infection was done by wet mount microscopy or by nucleic acid amplification testing for routine prenatal testing or symptomatic visits. Poisson regression was used to identify factors associated with testing for trichomoniasis and testing positive in pregnancy. Treatment and re-testing patterns also were assessed. RESULTS: Among 3,265 pregnant women, 2,489 (76%) were tested for T vaginalis infection. Of the total sample, 1,808 (55%) were tested by wet mount microscopy, 1,661 (51%) by nucleic acid amplification testing, and 980 (30%) by both modalities. The sensitivity for microscopy compared with nucleic acid amplification testing was 26%, with a specificity of 99%. Factors associated with increased likelihood of being tested included younger age (adjusted risk ratio [aRR] 0.99, 95% CI 0.99-1.00) and bacterial vaginosis (aRR 1.17, 95% CI 1.01-1.37). Prevalence of trichomoniasis was 15% among those tested by any modality (wet mount or nucleic acid amplification testing). Risk factors for trichomoniasis included younger age (aRR 0.97, P<.01), being of black race (aRR 2.62, P<.01), abnormal vaginal discharge (aRR 1.45, P<.01), and chlamydia during the current pregnancy (aRR 1.70, P<.01). Women diagnosed by microscopy had a shorter time to treatment compared with those diagnosed by nucleic acid amplification testing. Most (75%) women with positive infections had a test of reinfection; 29% of these were positive. Bacterial vaginosis was associated with decreased risk of a positive test of reinfection. CONCLUSION: Although testing for and treatment of trichomoniasis during pregnancy is not routinely recommended, the high burden of infection among some pregnant women demonstrates a need to further understand patterns of T vaginalis testing and infection. Opportunities exist for improving timely treatment of trichomoniasis and test of reinfection.

Patterns of Screening, Infection, and Treatment of Chlamydia trachomatis and Neisseria gonorrhea in Pregnancy.

OBJECTIVE: To describe factors associated with not being tested for Chlamydia trachomatis and Neisseria gonorrhea infection during pregnancy and for testing positive and to describe patterns of treatment and tests of reinfection. METHODS: We conducted a retrospective cohort study of women who delivered at an urban teaching hospital from July 1, 2016 to June 30, 2018. Women with at least one prenatal care or triage visit were included. The index delivery was included for women with multiple deliveries. We used logistic regression to analyze factors associated with not being tested and for testing positive for these infections in pregnancy. Cox proportional hazards models were used to examine factors associated with time to treatment and tests of reinfection. We reviewed medical records to determine reasons for delays in treatment longer than 1 week. RESULTS: Among 3,265 eligible deliveries, 3,177 (97%) women were tested during pregnancy. Of these, 370 (12%) tested positive (287 chlamydia, 35 gonorrhea, 48 both), and 15% had repeat infections. Prenatal care adequacy and insurance status were risk factors for not being tested. Age, race and ethnicity, alcohol use, and sexually transmitted infection history were associated with testing positive. Time to treatment ranged from 0 to 221 days, with the majority (55%) of patients experiencing delays of more than 1 week. Common reasons for delays included lack of clinician recognition and follow-up of abnormal results (65%) and difficulty contacting the patient (33%). CONCLUSION: Traditional risk factors are associated with increased risk of infection during pregnancy. Prenatal care adequacy and insurance status were associated with the likelihood of being tested. Delays in treatment and tests of reinfection were common. Point-of-care testing and expedited partner therapy should be explored as ways to improve the management of these infections in pregnancy.

Combination Antiretroviral Therapy and Hypertensive Disorders of Pregnancy.

OBJECTIVE: To compare the incidence of hypertensive disorders of pregnancy among women living with human immunodeficiency virus (HIV) on combination antiretroviral therapy (ART) to women without HIV, and to evaluate the association of hypertensive disorders of pregnancy with ART regimens or timing of ART initiation. METHODS: We conducted a retrospective cohort study among two overlapping pregnancy cohorts using preexisting databases at a single tertiary care hospital: all pregnant women who delivered during years 2016-2018 (cohort 1) and all women living with HIV who delivered during years 2011-2018 (cohort 2). The primary outcome for both cohorts was any hypertensive disorder of pregnancy; gestational hypertension and preeclampsia were also examined separately. The primary exposure variables were HIV status for cohort 1 and ART regimen (integrase strand transfer inhibitor-containing, protease inhibitor-containing, or non-nucleoside reverse transcriptase inhibitor-containing) for cohort 2. For estimation of risk ratios (RRs), we used a modified Poisson regression with robust error variances. Multivariate models among the women living with HIV in cohort 2 were tested for a statistical interaction between ART regimen and timing of initiation. RESULTS: In cohort 1, among 80 women living with HIV compared with 3,464 women without HIV, there was no difference in the risk of hypertensive disorders of pregnancy (29% in women living with HIV vs 30% in women without HIV, adjusted RR 0.9, 95% CI 0.6-1.3). In cohort 2, among 265 women living with HIV, integrase strand transfer inhibitor-containing regimens were associated with an increased risk for any hypertensive disorder of pregnancy (25% among integrase strand transfer inhibitor vs 10% among protease inhibitor, adjusted RR 2.8, 95% CI 1.5-5.1) and gestational hypertension (20% among integrase strand transfer inhibitor vs 8% among protease inhibitor, adjusted RR 2.8, 95% CI 1.3-5.9) compared with protease inhibitor-containing regimens. Timing of ART initiation was not associated with hypertensive disorders of pregnancy, nor did it significantly alter the associations between ART regimen and hypertensive disorders of pregnancy outcomes. CONCLUSION: Overall the risk of hypertensive disorders of pregnancy was similar among women living with HIV on ART and women without HIV. With greater integrase strand transfer inhibitor use, the greater frequency of hypertensive disorders of pregnancy with these regimens compared with protease inhibitor-containing regimens warrants future evaluation using cohorts with greater sample size.

Perceived Barriers to Antepartum HIV Medication Adherence in HIV Infected Pregnant Women.

Introduction: Although rare, perinatal HIV transmission still occurs in the United States and most transmissions are preventable. We aim to identify patient barriers to antiretroviral therapy (ART) adherence during pregnancy and assess patient understanding of perinatal transmission. Methods: This cross-sectional survey recruited HIV positive postpartum women at a large safety net hospital in Atlanta, Georgia, between January 2016 and February 2018. Survey questions included demographic characteristics, HIV history, knowledge of perinatal transmission, and ART adherence. Perinatal and HIV outcomes were assessed using chart abstraction. Results: Of the 70 HIV infected postpartum women delivered at a large safety net hospital in Atlanta, GA, 45 women were eligible and consented to participate. Participating women were aged 18 to 40 years with an average age of 29 years old, 93% of participants were African-American, and 68% had ≥3 pregnancies. The majority of participants (75%) reported daily ART adherence. "Forgetting" was the most frequent reason for missing pills (57%). Thirteen women had a detectable viral load at the time of delivery and nine of those women had a viral load greater than 1000 copies/mL. Approximately 85% of women who correctly stated ART medications decrease perinatal transmission risk reported daily adherence compared with 50% of women without that knowledge (OR 5.6, 95% CI 1.17, 26.7). Almost half of women (40%) either did not know or believed a vaginal delivery, regardless of viral load, would increase their risk of perinatal transmission. Conclusion: Overall, women who were diagnosed with HIV during the current pregnancy, those with planned pregnancies, and those who were on medications prior to pregnancy were more likely to report daily ART adherence. Detectable viral load at delivery is the greatest risk factor for perinatal transmission; therefore strategies to increase ART adherence are needed.