Pregnancy and Zika: The Quest for Quality Care and Reproductive Justice.

On February 1, 2016, the World Health Organization (WHO) declared the ZIKV virus outbreak a Public Health Emergency of International Concern (PHEIC). Pregnant women and their infants, are vulnerable to the impact of this vector-borne illness (mosquito) and sexually transmitted viral infection. The uncertainty surrounding the possibility of congenital anomalies due to ZIKV infection during pregnancy bring a renewed debate about the rights of women to control their reproductive decisions. Current strategies, resources and services aimed at prevention priorities fall short of responding to a clear framework regarding sexual reproductive health, rights and justice. A comprehensive approach to reproduction, in times of Zika, needs to empower women of reproductive age and their families to make decisions and to act on those decisions. This paper highlights the contributions of the Maternal-Infant Studies Center (CEMI-Spanish Acronym) in close collaboration with the Department of Obstetrics and Gynecology of the University of the Puerto Rico School of Medicine and the University Hospital in providing comprehensive health care to pregnant women with ZIKV or at risk of ZIKV, at the very onset of the epidemic. CEMI approaches the care of pregnant women from a reproductive justice perspective, integrating clinical services, education, research, and advocacy. Transformación Prenatal (Centering Group Prenatal Care, GPC) currently implemented at the Puerto Rico University Hospital High Risk Clinics has been pivotal to achieve this aim. Based on the health professionals' experiences and women's testimonies, we articulate a set of principles and key actions that would benefit women, their family and children.

The Zika Virus Infection in Pregnancy: Review and Implications for Research and Care of Women and Infants in Affected Areas.

The world has encountered a new and serious epidemic which has disproportionately affected fetuses and infants. What makes the Zika virus (ZIKV) epidemic such a threat in our times, is that a whole generation can be affected by birth defects caused by a seemingly innocuous maternal infection, which in most cases go unnoticed and undiagnosed. Spreading to over 80 countries and affecting millions, it is associated with severe birth defects known as congenital Zika syndrome (CZS), which include fetal brain development abnormalities (microcephaly and brain calcifications), retinal abnormalities, and contractures and hypertonia of the extremities. Testing strategies are challenging because of the lack of symptoms and cross reactivity with other viral infections. Obstetrical complications include fetal loss and the need for an emergency cesarean delivery. The rate of CZS has been described as ranging from 5 to 6% among cohorts in the US, reaching 11% for 1st trimester exposure. Prolonged viremia during pregnancy has been documented in a few cases, reaching 89 days after the onset of symptoms in one case and 109 days after such onset in another. If the ZIKV can infect, multiply in, and persist in diverse placental cells, then movement across the placenta, the fetal brain, and the maternal peripheral blood is possible. There is a sense of urgency, and we need safe and effective vaccines and treatments, particularly for pregnant women. If we do not expand testing and develop methods for early diagnosis and treatment, thousands of infants will be exposed to a neurotropic virus that causes severe birth defects and that could also affect the lives of those who form the next generation.

A Pilot Study of the Perceptions of Actively Practicing Obstetricians in Puerto Rico: Factors that Influence Decision Making in Cesarean Delivery.

OBJECTIVE: The reported cesarean delivery (CD) rate for 2012 in Puerto Rico was higher than that of the United States (48.5% and 32.8%, respectively). Multiple reasons for and consequences of the high rates of CD exist. The decision to perform a CD is based on multiple factors, some of which are not obstetrical. In order to better understand those factors, the pilot study described in this manuscript analyzed data collected from obstetricians themselves. METHODS: During 2011, convenience sampling was used to collect data from active obstetric practitioners attending the Caribe Gyn 2011 conference in Ponce, Puerto Rico. A self-administered survey was piloted and analyzed using formative content analysis. Obstetricians were asked to name factors that contribute to their decision to perform a CD and factors they felt influence other obstetricians to make that decision. RESULTS: In general, common maternal and fetal causes for choosing CD were noted. Hypertensive disorders (60%) and abnormal intrapartum fetal tracing (83%) were highly rated, as were non-obstetrical factors, including physician convenience (52%) and concern for medical liability for vaginal delivery (50%). CONCLUSION: According to the participating obstetricians, many factors associated with the standard practice of obstetrics influence the decision to perform a CD. However, non-obstetrical reasons were also found. Future studies using a larger sample of Puerto Rican obstetricians are required to fully understand these factors in order to both address them through educational interventions for patients, physicians, administrators, and insurers, and inform public policy.

Uterine curettage post-partum patients with severe preeclampsia: removal of trophoblastic tissue can alter the progression of this condition.

Reviewing the literature to evaluate the effect of postpartum uterine curettage in the maternal recovery time of patients with refractory severe preeclampsia determined that uterine curettage can be of benefit in select cases and should be included in hospital protocols to avoid further maternal complications.

Risk factors for hysterectomy in abnormal placentation at the University District Hospital.

UNLABELLED: The aim of this research was to study the relationship of abnormal placentation and cesarean hysterectomy risk factors at the University District Hospital. METHOD: A retrospective study was conducted using 60 medical records of patients in the University District Hospital from 2001 to 2008 with a diagnosis of abnormal placentation. Descriptive statistics and chi square for associations were used for statistical analysis. RESULTS: The mean age in our population was 29 years and mean BMI was 29.6. 45 % of the patients had a previous history of cesarean, 1.7% of placenta previa and 26.7% of uterine curettage. We found that 33.3% had a cesarean hysterectomy and 41.7% had post-partum hemorrhage. Also 51.7% received blood transfusion. The mean hospital stay was 18.1 days. The probability of cesarean hysterectomy in patients with placenta previa was eleven times higher in patients with history of previous cesarean sections (OR 11, CI: 1.29-97.9, p value=0.01). There was no statistically significant difference in cesarean hysterectomy rate between obese (BMI>30) and nonobese patients (OR 3.8 CI: 0.69-20.5, p value=0.11). CONCLUSION: The probability of cesarean hysterectomy in patients with abnormal placentation was significantly increased in patients with previous cesarean sections. By decreasing the rate of cesarean section we can decrease the incidence of cesarean hysterectomy and its comorbidities.

Naturalization of the microbiota developmental trajectory of Cesarean-born neonates after vaginal seeding.

BACKGROUND: Early microbiota perturbations are associated with disorders that involve immunological underpinnings. Cesarean section (CS)-born babies show altered microbiota development in relation to babies born vaginally. Here we present the first statistically powered longitudinal study to determine the effect of restoring exposure to maternal vaginal fluids after CS birth. METHODS: Using 16S rRNA gene sequencing, we followed the microbial trajectories of multiple body sites in 177 babies over the first year of life; 98 were born vaginally, and 79 were born by CS, of whom 30 were swabbed with a maternal vaginal gauze right after birth. FINDINGS: Compositional tensor factorization analysis confirmed that microbiota trajectories of exposed CS-born babies aligned more closely with that of vaginally born babies. Interestingly, the majority of amplicon sequence variants from maternal vaginal microbiomes on the day of birth were shared with other maternal sites, in contrast to non-pregnant women from the Human Microbiome Project (HMP) study. CONCLUSIONS: The results of this observational study prompt urgent randomized clinical trials to test whether microbial restoration reduces the increased disease risk associated with CS birth and the underlying mechanisms. It also provides evidence of the pluripotential nature of maternal vaginal fluids to provide pioneer bacterial colonizers for the newborn body sites. This is the first study showing long-term naturalization of the microbiota of CS-born infants by restoring microbial exposure at birth. FUNDING: C&D, Emch Fund, CIFAR, Chilean CONICYT and SOCHIPE, Norwegian Institute of Public Health, Emerald Foundation, NIH, National Institute of Justice, Janssen.

Partial restoration of the microbiota of cesarean-born infants via vaginal microbial transfer.

Exposure of newborns to the maternal vaginal microbiota is interrupted with cesarean birthing. Babies delivered by cesarean section (C-section) acquire a microbiota that differs from that of vaginally delivered infants, and C-section delivery has been associated with increased risk for immune and metabolic disorders. Here we conducted a pilot study in which infants delivered by C-section were exposed to maternal vaginal fluids at birth. Similarly to vaginally delivered babies, the gut, oral and skin bacterial communities of these newborns during the first 30 d of life was enriched in vaginal bacteria--which were underrepresented in unexposed C-section-delivered infants--and the microbiome similarity to those of vaginally delivered infants was greater in oral and skin samples than in anal samples. Although the long-term health consequences of restoring the microbiota of C-section-delivered infants remain unclear, our results demonstrate that vaginal microbes can be partially restored at birth in C-section-delivered babies.

The first microbial environment of infants born by C-section: the operating room microbes.

BACKGROUND: Newborns delivered by C-section acquire human skin microbes just after birth, but the sources remain unknown. We hypothesized that the operating room (OR) environment contains human skin bacteria that could be seeding C-section born infants. RESULTS: To test this hypothesis, we sampled 11 sites in four operating rooms from three hospitals in two cities. Following a C-section procedure, we swabbed OR floors, walls, ventilation grids, armrests, and lamps. We sequenced the V4 region of the 16S rRNA gene of 44 samples using Illumina MiSeq platform. Sequences were analyzed using the QIIME pipeline. Only 68 % of the samples (30/44, >1000 sequences per site) yielded sufficient DNA reads to be analyzed. The bacterial content of OR dust corresponded to human skin bacteria, with dominance of Staphylococcus and Corynebacterium. Diversity of bacteria was the highest in the ventilation grids and walls but was also present on top of the surgery lamps. Beta diversity analyses showed OR dust bacterial content clustering first by city and then by hospital (t test using unweighted UniFrac distances, p < 0.05). CONCLUSIONS: We conclude that the dust from ORs, collected right after a C-section procedure, contains deposits of human skin bacteria. The OR microbiota is the first environment for C-section newborns, and OR microbes might be seeding the microbiome in these babies. Further studies are required to identify how this OR microbiome exposure contributes to the seeding of the neonatal microbiome. The results might be relevant to infant health, if the current increase in risk of immune and metabolic diseases in industrialized societies is related to lack of natural exposure to the vaginal microbiome during labor and birth.