Coronavirus Disease 2019 in Pregnancy: The Experience at an Urban Safety Net Hospital.

Shortly after the identification of a novel coronavirus, the coronavirus disease 2019, or COVID-19, a global pandemic was declared. There have been conflicting data about the severity of COVID-19 disease course in pregnant women, with most US data suggesting an increase in severity and increased need for hospitalization and intubation in obstetric patients. In the general population, the disease is more common among racial and ethnic minority populations, and severity is increased with comorbid conditions and obesity. The purpose of this study is to characterize COVID-19 infection in pregnancy in a population of women getting prenatal care at an urban safety-net hospital. Beginning in April, 2020, all women were tested at admission for delivery, and additionally as an outpatient if presenting with COVID-19 symptoms. In three months, there were 208 discrete women tested and 23 (11.1%) who were positive for COVID-19. The incidence of COVID-19 was 5.1% in asymptomatic women being screened upon admission to the hospital. There was a high prevalence of obesity (68.2%) and other comorbid conditions (43.5%) in this population, and all patients were racial/ethnic minorities. Despite these risk factors, the patients uniformly had either mild or asymptomatic disease. No symptomatic patients required hospitalization for their infection. In this population of pregnant women at high risk for severe COVID-19 infection, only mild disease was observed.

Predictors of Persistent or Recurrent Disease After Loop Electrosurgical Excision Procedure.

OBJECTIVE: Follow-up recommendations after an excisional procedure vary depending on whether or not there is a positive ectocervical or endocervical margin or endocervical curettage (ECC). The purpose of this study was to evaluate the importance of these findings in predicting recurrent/persistent (r/p) disease in a sample of human immunodeficiency virus (HIV)-seropositive and -negative patients. MATERIALS AND METHODS: Loop electrosurgical excision procedures with a concurrent ECC performed at the Cook County ambulatory clinic between September 29, 2008, and April 15, 2014 were included in this study. Chart review was performed to collect demographic data, pathology results, and all subsequent cytology or histology. We examined the association of these factors with r/p disease using χ and Fisher exact tests as well as log-binomial regression. RESULTS: There were 242 women included for analysis. Of these, 9 LEEP specimens showed invasive cancer or adenocarcinoma in situ, and 15.7% were HIV positive. Mean follow-up was 16.4 months. On bivariate analysis, HIV serostatus, LEEP histology, ectocervical margin, endocervical margin, and ECC were all associated with r/p disease. On multivariate regression, only HIV serostatus and ECC were associated with r/p disease. Among women with either a positive endocervical or ectocervical margin or ECC, the prevalence of r/p disease is 29% if they are HIV negative, and 75% if they are positive. CONCLUSIONS: In our study, ECC seems more predictive of r/p disease than margin status. Most HIV-positive women with positive margins or ECC have r/p disease, whereas most HIV-negative women do not. One should consider HIV serostatus when deciding whether or not to perform repeat excision.

The Effects of Viral Load Burden on Pregnancy Loss among HIV-Infected Women in the United States.

BACKGROUND: To evaluate the effects of HIV viral load, measured cross-sectionally and cumulatively, on the risk of miscarriage or stillbirth (pregnancy loss) among HIV-infected women enrolled in the Women's Interagency HIV Study between 1994 and 2013. METHODS: We assessed three exposures: most recent viral load measure before the pregnancy ended, log10 copy-years viremia from initiation of antiretroviral therapy (ART) to conception, and log10 copy-years viremia in the two years before conception. RESULTS: The risk of pregnancy loss for those with log10 viral load >4.00 before pregnancy ended was 1.59 (95% confidence interval (CI): 0.99, 2.56) times as high as the risk for women whose log10 viral load was ≤1.60. There was not a meaningful impact of log10 copy-years viremia since ART or log10 copy-years viremia in the two years before conception on pregnancy loss (adjusted risk ratios (aRRs): 0.80 (95% CI: 0.69, 0.92) and 1.00 (95% CI: 0.90, 1.11), resp.). CONCLUSIONS: Cumulative viral load burden does not appear to be an informative measure for pregnancy loss risk, but the extent of HIV replication during pregnancy, as represented by plasma HIV RNA viral load, predicted loss versus live birth in this ethnically diverse cohort of HIV-infected US women.

A County Hospital Experience with Reproductive Travelers to the United States for Obstetric Care: Maternal and Neonatal Outcomes.

Objective: To describe the maternal and neonatal outcomes, health care utilization, and cost to reproductive travelers for obstetric care (RTOC) at a single institution. Materials and Methods: A retrospective chart review was conducted of women identified as reproductive travelers who delivered at Stroger Hospital in Chicago, IL when a self-pay package of obstetrical services was offered. Data included maternal characteristics and obstetric and neonatal outcomes. Results: A total of 413 reproductive travelers delivered during the study period. The majority (88%) was of Nigerian citizenship. The median gestational age at first prenatal visit was 35 weeks with a median of three prenatal visits. The patients were in good health with a high prevalence of infectious disease and a low prevalence of chronic disease. Women had complex obstetric histories, and 28.6% had cesarean delivery, with the most common indication being prior uterine surgery. Severe maternal morbidity occurred in 4.1% of the women and admission to the neonatal intensive care unit (NICU) in 16.3% of the babies. Extra charges beyond those covered by the financial package were incurred by 230 (55.7%) of the women. Conclusion: Reproductive travelers have better obstetric outcomes and fewer NICU admissions than non-travelers who delivered at the same institution. However, the care of RTOC in this manner is fraught with challenges, including late presentation for care, lack of medical records, providers at times managing unfamiliar conditions, and unforeseen financial obligations assumed by patients.

Factors influencing persistence or recurrence of cervical intraepithelial neoplasia after loop electrosurgical excision procedure.

OBJECTIVE: The purpose of this study was to determine the predictors of persistent or recurrent cervical intraepithelial neoplasia (CIN) after a loop electrosurgical excision procedure (LEEP) procedure in an urban population of low socioeconomic status. METHODS: A database was created using information about LEEPs done between October 2004 and December 2008 at John H. Stroger Jr. Hospital, Cook County. This information was then analyzed using χ2 test to determine the predictors of persistent or recurrent CIN. RESULTS: A total of 769 LEEPs were performed during the study period, and 52 were excluded secondary to ineligible entries, index cytology report not recorded, or incorrect medical record numbers. Persistent or recurrent disease was defined as cytology of atypical squamous cells cannot rule out high grade lesion (ASC-H) or worse without a histology, or histology of CIN 1 or worse, at any time after the LEEP was performed. Of our study population, 64.7% had a follow-up cytology or biopsy performed. Of these women, 24.7% had persistent or recurrent disease. The preoperative factors, namely positive human immunodeficiency virus serostatus (p < .0001) and a preoperative endocervical curettage that was positive for neoplasia (p < .0001), and postoperative factors, namely positive margin status (p < .0001) and high-grade pathology on the LEEP specimen (p < .0001), were significantly associated with persistent or recurrent disease. A high-grade preoperative cytology, a high-grade preoperative cervical biopsy, or the type of procedure performed (single specimen or separate endocervical pass) was not significantly associated with persistent or recurrent disease. CONCLUSIONS: In our population, adherence with follow-up was poor, and the rate of persistence or recurrence was high. In a limited resource setting such as ours, patients with significant predictors of persistence/recurrence such as human immunodeficiency virus seropositivity, endocervical disease, and high-grade pathology or positive margins on LEEP specimens should be targeted for closer surveillance.

Histology of loop electrosurgical excision procedures performed on women younger than 21 years and 65 years or older.

OBJECTIVE: To examine the prevalence and histology of loop electrosurgical excision procedures (LEEPs) done on women who are outside the age limits of the updated guidelines for cervical cytologic screening. MATERIALS AND METHODS: A database of all LEEPs performed between October 2004 and November 2009 was created. All data on age, human immunodeficiency virus status, cytology and histology before the procedure, and histology of the LEEP specimen were collected. RESULTS: There were 939 LEEPs performed during the study period, and data on 64 cases were excluded because of inadequate information. Fifty-four LEEPs were performed on women who were either younger than 21 years and those 65 years or older. All LEEPs were performed under traditionally accepted indications, except for 1 LEEP, which was excluded. None of the women gave a history of human immunodeficiency virus infection, and none of the older women had a history of abnormal cervical cytologic result before the index case. Of the procedures performed on the adolescents, 24 demonstrated high-grade lesions on LEEP (51.1%). Of the 6 procedures performed on older women, 4 LEEP specimens demonstrated high-grade lesions (66.7%). There were no cancers. CONCLUSIONS: We treated many women with LEEP excision who would not have been screened using current 2009 guidelines. Most of these women had high-grade lesions. The new guidelines may not be applicable to all population groups.

A comparison of loop electrosurgical excision procedures between human immunodeficiency virus-seropositive and -seronegative women.

OBJECTIVE: The purpose of this study was to compare preoperative and postoperative factors between human immunodeficiency virus (HIV)-seropositive and -seronegative women having a loop electrosurgical excision procedure (LEEP). Our hypothesis is that cervical intraepithelial neoplasia (CIN) presents differently in immunocompromised women. MATERIALS AND METHODS: A database of LEEPs performed from October 2004 to November 2009 at John H. Stroger Jr. Hospital, Cook County, Illinois, was created. Patients were considered to have persistent/recurrent disease if they had a cytological diagnosis of atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion, or worse with no histology or a histological diagnosis of CIN 1 or worse at any time after their LEEP. χ2 Analysis was performed to evaluate differences between HIV-seropositive and -seronegative women. RESULTS: There were 886 LEEPs performed during the study period, 92 among HIV-seropositive and 794 among HIV-seronegative women. Overall, 64.7% had any cytology or histology performed after their procedure, and seropositive women were more likely to follow up (p = .004). Preoperative cytological and cervical histological diagnoses were not different between seropositive and negative women; however, a preoperative endocervical curettage, which was positive, was more common among seropositive women (p < .0001). Human immunodeficiency virus-seropositive women were more likely to have CIN on LEEP histology (p = .04), and more likely to have positive margins (p < .0001) and recurrent/persistent disease (p < .0001). CONCLUSIONS: The spectrum of cervical disease was very different between HIV-seropositive and -negative women having LEEPs in our study. Practitioners managing HIV-infected women should be aware of these differences and counsel and follow up appropriately.

Prevalence of Inadequate Cervical Cancer Screening in Low-Income Older Women.

Objective: At age 65 years, cervical cancer screening is not recommended in women with an adequate history of negative screening tests in the previous 10 years if they do not have other high-risk factors for cervical cancer. The purpose of this study was to assess the proportion of older low-income women at a safety net urban hospital system without other risk factors for cervical cancer who should have cervical cancer screening because of an inadequate screening history, and to evaluate if they were triaged appropriately. Materials and Methods: Medical records from 200 women 65 years and older at the Gynecology clinic of John H. Stroger Hospital of Cook County were evaluated for adequate cervical cancer screening or hysterectomy to see if they could stop screening. Charts were reviewed to see if a screen was performed, and the results of that test and associated biopsies. Data using cytology alone and the cytology/human papillomavirus cotest were compared. Chi-square test was used. Results: Of 200 women included, the median age was 68.5 years, range 65-93 years. Of these women, 81 (40.5%) did not need testing because of adequate screening or hysterectomy for benign indications. There were 119 (59.5%) women who needed to continue testing because of inadequate screening. Of these women, 46 (38.7%) did not have appropriate testing carried out. Of 73 correctly screened women, 16 (21.9%) required biopsies, of which 11 demonstrated high-grade lesions or cancers. Conclusions: Many older women, especially low-income women, need to continue screening for cervical cancer because of inadequate screening histories. This is a group at increased risk for cervical cancer, and it is imperative that clinicians evaluate previous test results before exiting a woman from screening at age 65 years.

Gynecologic issues in the HIV-infected woman.

In this article, gynecologic conditions of increased importance in the HIV-infected woman are discussed. Women living with HIV may have an increase in menstrual disorders, lower genital tract neoplasias, gynecologic surgery, and sexually transmitted infections. The literature relevant to choosing a method of contraception for HIV-positive women is also discussed. With the advent of HAART, seropositive women are now facing issues around longevity, such as menopause and disorders of bone mineral density, as well as those associated with fertility.

Prolonged Amenorrhea and Resumption of Menses in Women with HIV.

OBJECTIVE: To compare etiologies of prolonged amenorrhea in a cohort of HIV-infected women with a cohort of similar uninfected at-risk women. MATERIALS AND METHODS: Women from the Women's Interagency HIV Study were seen every 6 months, and completed surveys including questions about their menstruation. Those who reported no vaginal bleeding for at least 1 year ("prolonged amenorrhea") with subsequent resumption of bleeding were compared with women in whom bleeding had stopped permanently ("menopause"). Characteristics associated with reversible prolonged amenorrhea were ascertained. RESULTS: Of 828 women with prolonged amenorrhea, 37.6% had reversible amenorrhea and 62.4% never resumed menses. HIV-seropositive women with prolonged amenorrhea were significantly younger at cessation of menses than HIV-negative women (p < 0.0001). Of those with reversible prolonged amenorrhea, approximately half were taking medications associated with amenorrhea, including 95 (30.6%) hormonal contraception, 80 (25.7%) opiates/stimulants, 16 (5.1%) psychotropic medications, and 6 (1.9%) chemotherapy. HIV-seropositive women were less likely to have medications as a cause of amenorrhea than seronegative women (p = 0.02). In multivariable analysis, women with reversible prolonged amenorrhea of unknown etiology were younger (p < 0.0001), more often obese (p = 0.03), and less educated (p = 0.01) than those with permanent amenorrhea. Among HIV-seropositive women, markers of severe immunosuppression were not associated with prolonged amenorrhea. CONCLUSION: Women with HIV infection have unexplained prolonged amenorrhea more often than at-risk seronegative women. This is especially common among obese, less-educated women. Prolonged amenorrhea in the HIV-seropositive women should be evaluated and not be presumed to be to the result of menopause.

Effects of human immunodeficiency virus on protracted amenorrhea and ovarian dysfunction.

OBJECTIVE: To characterize ovarian failure and prolonged amenorrhea from other causes in women who are both human immunodeficiency virus (HIV) seropositive and seronegative. METHODS: This was a cohort study nested in the Women's Interagency HIV Study, a multicenter U.S. study of HIV infection in women. Prolonged amenorrhea was defined as no vaginal bleeding for at least 1 year. A serum follicle stimulating hormone more than 25 milli-International Units/mL and prolonged amenorrhea were used to define ovarian failure. Logistic regressions, chi2, and t tests were performed to estimate relationships between HIV-infection and cofactors with both ovarian failure and amenorrhea from other causes. RESULTS: Results were available for 1,431 women (1,139 HIV seropositive and 292 seronegative). More than one half of the HIV positive women with prolonged amenorrhea of at least 1 year did not have ovarian failure. When adjusted for age, HIV seropositive women were about three times more likely than seronegative women to have prolonged amenorrhea without ovarian failure. Body mass index, serum albumin, and parity were all negatively associated with ovarian failure in HIV seropositive women. CONCLUSION: HIV serostatus is associated with prolonged amenorrhea. It is difficult to ascertain whether the cause of prolonged amenorrhea is ovarian in HIV-infected women without additional testing. LEVEL OF EVIDENCE: II-2.

Effect of hormonal contraceptive use on plasma HIV-1-RNA levels among HIV-infected women.

We compared the HIV-1-RNA and CD4 lymphocyte counts from users and non-users of hormonal contraception cross-sectionally upon entry into the Women's Interagency HIV Study, and again longitudinally. There did not appear to be an association between hormonal contraception use and HIV-1-RNA levels in our study. There was a small increase in CD4 cell counts among hormonal users of doubtful clinical significance.

Gynecologic issues in the HIV-infected woman.

Science has made great strides in understanding the management of the many gynecologic conditions that affect HIV-positive women with an increased frequency. As HIV-infected women's life expectancy continues to lengthen, new treatments are necessary for recurring conditions, such as lower genital tract neoplasias. The medical field has much to learn about the interaction between sex steroids, HIV-infection, and the immune system. As knowledge grows, clinicians will be better equipped to counsel women about contraceptive issues, pregnancy, and menopause.

Hysterectomy among women with HIV: indications and incidence.

OBJECTIVE: To describe hysterectomy rates and indications among women with HIV and to compare them with at-risk HIV-seronegative women. METHODS: Reports of hysterectomy were collected from 3752 participants in a prospective cohort study of women with HIV and comparison uninfected women. Available operative notes were retrieved and abstracted. Comparisons were made using the Fisher exact, chi, Wilcoxon 2-sample, and Student's t tests. RESULTS: Incident hysterectomy was performed for 106 (4.5%) of 2361 HIV-seropositive women, most often for cervical neoplasia, and for 24 (2.9%) of 837 HIV-seronegative women (P = 0.04). The incidence of hysterectomy was 7.7 per 1000 person-years for HIV-seropositive women and 5.3 per 1000 person-years for HIV-seronegative women (P = 0.09). HIV-seropositive and HIV-seronegative women undergoing incident hysterectomy were similar, except for a higher likelihood of an abnormal preoperative Papanicolaou test result in the former (P = 0.001). Surgical indications did not differ by serostatus. CONCLUSION: Women with HIV are more likely than uninfected women to require a hysterectomy, most often for cervical neoplasia.

Risk of high-grade cervical intraepithelial neoplasia among young women with abnormal screening cytology.

OBJECTIVE: To estimate the risk of high-grade cervical disease among teenage women with abnormal cytology. METHODS: Retrospective analysis of a prospectively collected database of females undergoing colposcopy for abnormal screening cytology in an urban dysplasia clinic. RESULTS: Among 211 eligible teens, high-grade squamous intraepithelial lesions were found in 17 (8%) on referral cytology and 4 (2%) on repeat cytology. High-grade cervical intraepithelial neoplasia was found in colposcopic biopsy specimens 30 (15%) of young women; no patient had cancer. Age, referral Pap, ethnicity, parity, HIV serostatus, history of other sexually transmitted infections, smoking, oral contraceptive use condom use, use of medroxyprogesterone, age at first intercourse, and the number of years since first intercourse did not predict increasing risk of high-grade cervical intraepithelial neoplasia (CIN). In logistic regression, both number of partners > or = 5 (p = 0.003) and a finding of any squamous intraepithelial lesion in a Pap test repeated at colposcopy (p = 0.025) were significant predictors of CIN 2,3, though the predictive value of the model was weak (R = 0.12). CONCLUSION: Only 15% of teens with abnormal cytology have high-grade CIN. Colposcopy may be most appropriate for those with multiple partners and squamous intraepithelial lesions on repeat Pap.

Histologic findings after a colposcopic biopsy showing CIN2.

OBJECTIVE: To determine the risk of CIN3 and cancer in subsequent specimens among women with colposcopic biopsy showing CIN2. METHODS: A retrospective review of demographic and medical information collected at colposcopy. Patient records were again reviewed 8 to 26 months later for information on procedures and histology results. RESULTS: Histologic evaluation of specimens showed no lesions in 14, atypia or koilocytosis in 21, CIN1 in 25, CIN2 in 26, CIN 3 in 27, ungraded CIN in 3, and cancer in 3. No cancers were found in women at or below the median age of 33 years or those with satisfactory colposcopy. However, cancers were found in women with negative repeat cytology and negative colposcopic impression. CONCLUSION: Observation may be an option for young women with CIN2 on colposcopic biopsy if they are reliable for follow up and the entire squamocolumnar junction is seen.

Histologic findings from the cervix among older women with abnormal cervical cytology.

OBJECTIVE: The aim of this study was to determine rates of cervical neoplasia among women at least 50 years of age referred for colposcopy after abnormal cytology and to compare these to younger women. METHODS: From a prospectively accrued database of 2825 women undergoing colposcopy in the gynecology clinic of an urban public hospital, women at least 50 years of age with a known cytologic abnormality were selected for retrospective analysis. Demographic and medical information collected at colposcopy and subsequent histology was reviewed. Cytology results were based on the Bethesda system, and histology was reported as grades of cervical intraepithelial neoplasia (CIN). Statistical analysis was by t test, chi(2) test, and Mann-Whitney U test. RESULTS: Among 325 women at least age 50, cervical histologic results were benign or atypical for 147 (45%), CIN1 for 28 (9%), CIN2 for 21 (6%), CIN3 for 49 (15%), cancer for 11 (3%), and ungraded dysplasia for 7 (2%), with no biopsy performed for 62 (19%) women. Symptoms were more common among women with cancer (6/11 or 55%) than those without (62/263 or 21%, P = 0.01). Negative histology (80/231 or 35%), CIN3 (49/231 or 21%), and cancer (9/231 or 4%) were more common among older than younger women (287/1403 or 20%, 199/1403 or 14%, and 11/1403 or 1%, respectively), while atypia (438/1403 or 31%), CIN1 (321/1403 or 23%), and CIN2 (147/1403 or 10%) were more common among younger than older women (53/231 or 23%, 23/231 or 10%, and 17/231 or 7%, respectively, P < 0.04). Differences in the distribution of cervical histology results remained significant among women with ASCUS (P = 0.001) but not those with LSIL (P > 0.9), HSIL (P > 0.07), or cancer (P > 0.4). CONCLUSIONS: Most older women are referred for colposcopy with lesser grades of abnormality, but cervical cancers are found across all cytologic grades and were more common in symptomatic women. Compared to younger women with abnormal cytology, women at least 50 years of age with ASCUS had higher rates of negative evaluations and high grade but not low- or mid-grade lesions.