What Is the Prevalence of Measles Immunity among Pregnant Women?

OBJECTIVE: This study aimed to estimate the prevalence of measles immunity in a cohort of pregnant women in New York City and determine if there is a positive correlation of measles immunity with patient demographics, rubella immunity, number of measles, mumps, and rubella vaccine (MMR) doses received, and age at last vaccination. STUDY DESIGN: This is a cross-sectional study of pregnant patients seen at a single institution from January 2019 to May 2019. Patients were classified as measles and rubella immune or nonimmune using commercial immunoglobulin G (IgG) tests. Patient characteristics were compared using t-tests, Chi-square tests, or Fisher's exact tests as appropriate. The association of age at last vaccination with immunity status was assessed using multivariable logistic regression adjusted for age at presentation. The utility of rubella IgG for distinguishing measles immunity was assessed using receiver operating characteristic curve analysis. RESULTS: Serologic immunity for measles and rubella was obtained for 1,366 patients. Of these, 1,047 (77%) were measles immune and 1,291 (95%) were rubella immune. Patients born after 1989 were less likely to be immune to measles, while multiparity and private insurance were associated with increased measles immunity. Documentation of MMR vaccination was available for 140 (10%) patients. Of these, 44 (31%) were serologically nonimmune to measles and 9 (6.4%) were nonimmune to rubella. In patients known to have received one dose of MMR, 62% (24/39) were immune to measles with an improvement to 72% (69/96) among those who received two or more doses. Age at last vaccination was not associated with measles immunity. Rubella IgG level was a poor predictor of positive measles titer (area under the curve = 0.59). CONCLUSION: Approximately one of every four pregnant patients is serologically measles nonimmune, even among women with documented MMR vaccination or documented rubella immunity. These findings raise concerns that relying on vaccination history or rubella immune status may not be sufficient to assure protection from infection with measles. If further suggests that measles serology should be added to routine prenatal laboratory testing to identify nonimmune patients that may benefit from postpartum vaccination. KEY POINTS: · Approximately one of every four pregnant patients were serologically measles nonimmune.. · Rubella immunoglobulin G was a poor predictor of measles immunity status.. · Measles serology should be added to routine prenatal laboratory testing..

Current trends in the diagnosis and management of gestational diabetes mellitus in the United States.

OBJECTIVE: To assess current practice patterns among members of the Society for Maternal-Fetal Medicine (SMFM) with respect to the diagnosis and management of gestational diabetes mellitus (GDM). METHODS: A 38 question survey on GDM diagnosis and management was distributed to SMFM members. RESULTS: 2330 SMFM members were surveyed with a 40% response rate. Overall, 90.6% of respondents recommend a 2-step (versus a 1-step) diagnostic test. Cutoff values for the 1-h-50 g glucose challenge test vary from 130-140 mg/dL, but the majority (83%) adopts Carpenter Coustan criteria for the 3-h-100 g oral glucose tolerance test. The majority recommend glucose testing four times a day, with 55% preferring post-prandial testing at 2 h. Glyburide is used by 57% as a first-line agent, while 4% use metformin. Long-acting insulin analogs (glargine and/or detemir) are used by 46% and 33.6% of respondents, respectively. Antenatal testing is recommended by 38.7% for diet-controlled GDM compared to 98.7% for pharmacologically controlled GDM, with 56% starting by 34 weeks gestation. Most respondents recommend delivery of diet-controlled GDM at 40 weeks and pharmacologically controlled GDM at 39 weeks. Most (69%) offer elective cesarean section for an estimated fetal weight of >4500 g. CONCLUSIONS: There is significant variation in the diagnosis and management of GDM among SMFM members.

Weight gain in gestational diabetes: the effect of treatment modality.

OBJECTIVE: To evaluate treatment effectiveness (diet alone, insulin or glyburide) on maternal weight gain in gestational diabetes (GDM). METHODS: GDM patients were treated with diet alone, insulin or glyburide. Weight gain was stratified into: prior to GDM diagnosis, from diagnosis to delivery and total pregnancy weight gain. Good glycemic control was defined as mean blood glucose ≤ 105 mg/dl and obesity as Body Mass Index (BMI) ≥ 30 kg/m(2), overweight BMI 25-29 kg/m(2) and normal < 25 kg/m(2). RESULTS: Total weight gain was similar in all the treatment groups. Two-thirds of weight gain occurred prior to diagnosis (diet 85%, insulin 67% and glyburide 78%). Post-diagnosis, patients on diet alone gained less weight than those on insulin or glyburide (p < 0.001); insulin-treated patients showed greater weight gain than glyburide-treated patients (p < 0.001). Patients on diet with good glycemic control showed less weight gain after diagnosis than patients on insulin or glyburide (2.8 ± 13, 6.6 ± 10, 5.2 ± 7.9 lbs, respectively, p < 0.02). Poorly-controlled patients, regardless of treatment, had similar patterns of weight gain throughout pregnancy. CONCLUSION: Patterns of maternal weight gain in GDM pregnancies are associated with treatment modality and level of glycemic control.

Randomized controlled trial of insulin detemir versus NPH for the treatment of pregnant women with diabetes.

OBJECTIVE: We sought to determine if insulin detemir (IDet) is noninferior to insulin neutral protamine Hagedorn (NPH) for the treatment of gestational diabetes mellitus (GDM) and type 2 diabetes mellitus (T2DM) in pregnancy. STUDY DESIGN: We conducted a randomized, controlled noninferiority trial of women with GDM and T2DM who entered our Diabetes in Pregnancy Program from March 2013 through October 2014. Exclusion criteria were type 1 diabetes, age <18 years, and insulin allergy. Women who failed to achieve good glycemic control (GC) (mean blood glucose [BG] <100 mg/dL) on diet and/or hypoglycemic agents were randomized to receive either IDet or NPH, with short-acting insulin aspart added as needed. Patients were instructed to test BG 4 times a day (fasting and 2-hour postprandial). Targets of GC were fasting BG <90 mg/dL and postprandial BG <120 mg/dL, and insulin was adjusted as needed to achieve the targets. The primary outcome was overall mean BG during insulin treatment; secondary outcomes included overall mean postprandial and fasting BG, median number of weeks to achieve GC, percent of patients with overall GC, maternal weight gain, perinatal/neonatal outcomes, and number of hypoglycemic events. Power analysis (90% power) determined that 88 patients would need to be randomized, assuming a maximal acceptable difference in overall mean BG of 7 mg/dL (SD ± 10 mg/dL). A per protocol analysis was performed. RESULTS: In all, 105 women were randomized. Eighteen women were excluded leaving 87 participants for analysis (45 NPH, 42 IDet). Maternal characteristics were similar in both groups. The difference in the mean BG of the groups was 2.1 mg/dL with a 1-sided upper 95% confidence limit of 5.5 mg/dL (less than the maximal acceptable difference of 7 mg/dL; P = .2937). There was no significant difference in the primary outcome when an intent-to-treat analysis was performed or when the T2DM patients were excluded. The time to achieve GC was similar in both groups. There were no differences in perinatal outcomes and maternal weight gain among the groups. There were more hypoglycemic events per patient in the NPH group. CONCLUSION: IDet is noninferior to insulin NPH for the treatment of GDM and T2DM in pregnancy.

A controlled clinical treatment trial of interpersonal psychotherapy for depressed pregnant women at 3 New York City sites.

OBJECTIVE: While treatment decisions for antepartum depression must be personalized to each woman and her illness, guidelines from the American Psychiatric Association and the American College of Obstetrics and Gynecology include the recommendation of psychotherapy for mild-to-moderate depression in pregnant women. Although we previously demonstrated the efficacy of interpersonal psychotherapy for antepartum depression in a sample of Hispanic women, this study provides a larger, more diverse sample of African American, Hispanic, and white pregnant women from 3 New York City sites in order to provide greater generalizability. METHOD: A 12-week bilingual, parallel-design, controlled clinical treatment trial compared interpersonal psychotherapy for antepartum depression to a parenting education program control group. An outpatient sample of 142 women who met DSM-IV criteria for major depressive disorder was randomly assigned to interpersonal psychotherapy or the parenting education program from September 2005 to May 2011. The 17-item Hamilton Depression Rating Scale (HDRS-17) was the primary outcome measure of mood. Other outcome scales included the Edinburgh Postnatal Depression Scale (EPDS) and the Clinical Global Impressions scale (CGI). The Maternal Fetal Attachment Scale (MFAS) assessed mother's interaction with the fetus. RESULTS: Although this study replicated previous findings that interpersonal psychotherapy is a beneficial treatment for antepartum depression, the parenting education program control condition showed equal benefit as measured by the HDRS-17, EPDS, CGI, and MFAS. CONCLUSIONS: This study supports the recommendation for the use of interpersonal psychotherapy for mild-to-moderate major depressive disorder in pregnancy. The parenting education program may be an alternative treatment that requires further study. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00251043

The effect of blinded versus nonblinded interviews in the resident selection process.

OBJECTIVE: To evaluate whether resident applicants' academic performance biases the assessment of nonacademic qualities. METHODS: In this prospective, descriptive study, 2 blinded (personal statement only) and 1 nonblinded (application) 30-minute interviews were compared for candidates ranking into Top 10, Upper Third, Middle Thirds, Lower Third, and Do Not Rank classes. RESULTS: A total of 234 candidates were interviewed from 2005 to 2007. The association between blinded interviewers for the categories was 87%, 63%, 68%, 73%, and 90% (P  =  .0000), respectively. Comparing blinded to nonblinded interviewers showed an association of 75% (63%), 71% (86%), 68% (58%), 66% (79%), and 72.7% (82%) (P  =  .0000), respectively. A strong degree of agreement (Cohen κ, 0.75) for the 2 ranking scores resulted in 90% agreement for Top 10 and Upper Third and 85% for Middle Third and Lower Third categories. No correlation was found between United States Medical Licensing Examination scores and final ranking; moderate agreement was found between ranking and deans' letters (Cohen κ, 0.59, P  =  .0000). CONCLUSION: Candidate rankings on nonacademic attributes were not affected by interview type.