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Rates of opioid use disorder (OUD) among pregnant women are increasing precipitously. Much attention is being devoted to the biomedical mechanisms underlying harmful maternal and child outcomes of opioid-exposed pregnancies. Yet, despite the documented vulnerability of these women and the treatment barriers they face, little research and clinical attention are being directed toward the life-context factors that affect their health. We describe how life context affects pregnant women with OUD and explain that a socioecological, woman-centered research and practice approach that includes systematic assessment of life context is necessary to improve the health and well-being of this population. [ABSTRACT FROM AUTHOR]

We respond to four commentaries (Beatty, 2020; Knight, 2020; Premkumar, 2020; Roberts, 2020) on our article (Preis et al., 2020). These commentaries extended our focus on life context and prenatal care of opioid using women to other vital topics, including the legacy and continuing impact of societal and institutional racism and other forms of discrimination against substance-using and/or pregnant women of color and the need to evaluate the impact of new assessment approaches and policies before they are recommended for wide use. We highlight these critical issues and the ways that we have attempted to address them to improve research and care for pregnant women with opioid use disorder (OUD). [ABSTRACT FROM AUTHOR]

Objective: To determine the effect of intramuscular progesterone on the vaginal immune response of pregnant women with a history of prior preterm birth. Methods: A prospective, cohort study of women at 11–16 weeks gestation, ≥18 years of age, and carrying a singleton pregnancy was conducted from June 2016 to August 2017 after IRB approval. Women in the progesterone arm had a history of preterm birth and received weekly intramuscular 17-hydroxyprogesterone caproate. Controls comprised of women with healthy, uncomplicated pregnancies. Excluded were women with vaginitis, diabetes mellitus, hypertension, or other chronic diseases affecting the immune response. A vaginal wash was performed at enrollment, at 26–28 weeks, and at 35–36 weeks gestation. Samples underwent semi-quantitative detection of human inflammatory markers. Immunofluorescence pixel density data was analyzed and a P value <0.05 was considered significant. Results: There were 39 women included, 10 with a prior preterm birth and 29 controls. The baseline demographics and pregnancy outcomes for both groups were similar in age, parity, race, BMI, gestational age at delivery, mode of delivery, and birth weight. Enrollment cytokines in women with a prior preterm birth, including IL-1 alpha (39.2±25.1% versus 26.1±13.2%; P = 0.04), IL-1 beta (47.9±26.4% versus 24.9±17%; P<0.01), IL-2 (16.7±9.3% versus 11.3±6.3%; P = 0.03), and IL-13 (16.9±12.4% versus 8.2±7.4%; P = 0.01) were significantly elevated compared to controls. In the third trimester the cytokine densities for IL-1 alpha (26.0±18.2% versus 22.3±12.0%; P = 0.49), IL-1 beta (31.8±15.9% versus 33.1±16.8%; P = 0.84), IL-2 (10.0±8.4% versus 10.9±5.9%; P = 0.71), and IL-13 (9.1±5.9% versus 10.0±6.5%; P = 0.71) were all statistically similar between the progesterone arm and controls, respectively. Conclusion: There is an increased cytokine presence in vaginal washings of women at risk for preterm birth which appears to be modified following the administration of 17- hydroxyprogesterone caproate to levels similar to healthy controls. [ABSTRACT FROM AUTHOR]

Objective. This study was performed to review the clinical utility of commercial laboratory Toxoplasmosis -specific IgM testing during pregnancy and outcomes of the gestation at our institution. Methods. A retrospective review of all women referred for suspected acute Toxoplasma gondii infection during pregnancy from 1984 through 2004 was performed. Women were diagnosed with suspected acute toxoplasmosis based on commercial laboratory serologic antibody testing. All women had blood sent to a recognized reference laboratory for antibody testing within 2 weeks of the commercial laboratory results. The study protocol was approved by the Institutional Review Board. Chi-square analysis were used with a significance of P < .05. Results. A total of 130 women were evaluated during the study period with 116 IgM positive results from the commercial laboratories. The commercial laboratory antibodies were as follows: IgM positive with IgG negative ( n = 20), IgM positive with IgG positive ( n = 96), and IgM negative with IgG positive ( n = 14). There was a significant reduction in the IgM positive results when comparing commercial laboratory ( n = 116) with the reference laboratory results ( n = 28; p < .001). Acute toxoplasmosis infection was diagnosed in 7 (5%) of the women. All cases of acute toxoplasmosis infection had a positive commercial laboratory IgM result. The false positive rate for the commercial laboratory IgM was 88.6% and the diagnostic indices were sensitivity 100%, specificity 11.4%, positive predictive value 6% and negative predictive value 100%. Conclusion. Commercial laboratory Toxoplasmosis -specific IgM is associated with a high false positive rate. The commercial and reference laboratory IgM results identified all cases of acute toxoplasmosis infection. Commercial laboratories reflexively obtaining reference laboratory confirmation of positive results could reduce costs associated with testing, referrals, retesting, and invasive procedures. [ABSTRACT FROM AUTHOR]

To evaluate the differences in vaginal matrix metalloproteinases (MMP) and tissue inhibitors of metalloproteinases (TIMPs) in pregnant patients with a history of prior preterm birth compared with controls. A prospective cohort pilot study recruited patients during prenatal care with history of prior spontaneous preterm birth (high-risk group) or no history of preterm birth (low-risk/controls). Inclusion criteria were singleton gestation at 11–16 weeks and between 18 and 55 years of age. Exclusion criteria were diabetes mellitus, hypertension, diseases affecting the immune response or acute vaginitis. A vaginal wash was performed at time of enrollment, and patients were followed through delivery. Samples were analyzed using semi-quantitative analysis of MMPS and TIMPS. The study was approved by the IRB and a p-value <0.05 was considered significant. A total of 48 pregnant patients were recruited: 16 with a history of preterm birth (high-risk group) and 32 with no history of preterm birth (low-risk group/controls). Groups were similar in age, race, BMI, and delivery mode. The high-risk group had more multiparous women (100 vs. 68.8 %; p=0.02), a greater preterm birth rate (31.2 vs. 6.3 %; p=0.02), and a lower birth weight (2,885 ± 898 g vs. 3,480 ± 473 g; p=0.02). Levels of vaginal MMP-9 were greater in high-risk patients than low-risk patients (74.9 % ± 27.0 vs. 49.4 % ± 31.1; p=0.01). When dividing the cohort into patients that had a spontaneous preterm birth (7/48, 14.6 %) vs. those with a term delivery (41/48, 85.4 %), the vaginal MMP-9 remained elevated in the cohort that experienced a preterm birth (85.46 %+19.79 vs. 53.20 %+31.47; p=0.01). There were no differences in the other MMPS and in TIMPs between high and low-risk groups. There was an increase in vaginal MMP-9 during early pregnancy in those at high risk for preterm birth and in those who delivered preterm, regardless of prior pregnancy outcome. Vaginal MMP-9 may have potential as a marker of increased risk of preterm birth. [ABSTRACT FROM AUTHOR]

Background. Policies for sponge count are not routine practice in most labor and delivery rooms. Ignored or hidden retained vaginal foreign bodies has potentially significant health care morbidity. Case. This was a case of a retained vaginal sponge following an uncomplicated spontaneous vaginal delivery. Delivery room policy resulted in the discovery of the sponge on X-ray when an incorrect sponge count occurred and physical exam did not find the sponge. Conclusion. This emphasizes the use of protocols to enhance patient safety and prevent medical error. [ABSTRACT FROM AUTHOR]

Background. Policies for sponge count are not routine practice in most labor and delivery rooms. Ignored or hidden retained vaginal foreign bodies has potentially significant health care morbidity. Case. This was a case of a retained vaginal sponge following an uncomplicated spontaneous vaginal delivery. Delivery room policy resulted in the discovery of the sponge on X-ray when an incorrect sponge count occurred and physical exam did not find the sponge. Conclusion. This emphasizes the use of protocols to enhance patient safety and prevent medical error. [ABSTRACT FROM AUTHOR]

Psychosocial vulnerabilities (e.g. inadequate social support, financial insecurity, stress) and substance use elevate risks for adverse perinatal outcomes and maternal mental health morbidities. However, various barriers, including paucity of validated, simple and usable comprehensive instruments, impede execution of the recommendations to screen for such vulnerabilities in the first antenatal care visit. The current study presents findings from a newly implemented self-report tool created to overcome screening barriers in outpatient antenatal clinics. This was a retrospective chart-review of 904 women who completed the Profile for Maternal & Obstetric Treatment Effectiveness (PROMOTE) during their first antenatal visit between June and December 2019. The PROMOTE includes the 4-item NIDA Quick Screen and 15 additional items that each assess a different psychosocial vulnerability. Statistical analysis included evaluation of missing data, and exploration of missing data patterns using univariate correlations and hierarchical clustering. Three quarters of women (70.0%) had no missing items. In the entire sample, all but four PROMOTE items (opioid use, planned pregnancy, educational level, and financial state) had < 5% missing values, suggesting good acceptability and feasibility. Several respondent-related characteristics such as lower education, less family support, and greater stress were associated with greater likelihood of missing items. Instrument-related characteristics associated with missing values were completing the PROMOTE in Spanish or question positioning at the end of the instrument. Conducting a comprehensive screening of theoretically and clinically meaningful vulnerabilities in an outpatient setting is feasible. Study findings will inform modifications of the PROMOTE and subsequent digitisation. [ABSTRACT FROM AUTHOR]

We utilized machine learning (ML) methods on data from the PROMOTE, a novel psychosocial screening tool, to quantify risk for prenatal depression for individual patients and identify contributing factors that impart greater risk for depression. Random forest algorithms were used to predict likelihood for being at high risk for prenatal depression (Edinburgh Postnatal Depression Scale; EPDS ≥ 13 and/or positive self-injury item) using data from 1715 patients who completed the PROMOTE. Performance matrices were calculated to assess the ability of the PROMOTE to accurately classify patients. Probability for depression was calculated for individual patients. Finally, recursive feature elimination was used to evaluate the importance of each PROMOTE item in the classification of depression risk. PROMOTE data were successfully used to predict depression with acceptable performance matrices (accuracy = 0.80; sensitivity = 0.75; specificity = 0.81; positive predictive value = 0.79; negative predictive value = 0.97). Perceived stress, emotional problems, family support, age, major life events, partner support, unplanned pregnancy, current employment, lifetime abuse, and financial state were the most important PROMOTE items in the classification of depression risk. Results affirm the value of the PROMOTE as a psychosocial screening tool for prenatal depression and the benefit of using it in conjunction with ML methods. Using such methods can help detect underreported outcomes and identify what in patients' lives makes them more vulnerable, thus paving the way for effective individually tailored precision medicine. [ABSTRACT FROM AUTHOR]

Introduction. To compare the effects of medication-assisted treatment on the placenta in pregnant women with opioid use disorder and uncomplicated pregnancies. Methods. This is a case-controlled study of pregnant women utilizing medication-assisted treatment, buprenorphine or methadone, which were matched to healthy uncomplicated controls by gestational age. Placental evaluations and neonatal outcomes were evaluated. Data analysis performed standard statistics and relative risk analysis with a p < 0.05 considered significant. Results. There were 143 women who met the inclusion criteria: 103 utilizing MAT, 41 buprenorphine and 62 methadone, and 40 uncomplicated matched healthy controls. The incidence of delayed villous maturation was 36% in the medication-assisted group compared with 10% in controls (RR 3.6: 95% CI 1.37-9.43; p < 0.01). The placental weight was greater (541 ± 117 g versus 491 ± 117 g; p = 0.02), and the fetoplacental weight ratio was lower (5.70 ± 1.1 versus 7.13 ± 1.4 ; p < 0.01) in the medication-exposed pregnancies compared with controls. The mean birth weight of the MAT newborns was significantly lower than that of the healthy controls (3018 ± 536 g versus 3380 ± 492 g; p < 0.01). When evaluating the subgroups of the MAT newborns, the birth weight of the methadone-exposed newborns (2886 ± 514 g) was significantly lower than that of the buprenorphine-exposed newborns (3218 ± 512 g; p < 0.01). Conclusion. Medication-exposed pregnancies have a greater incidence of delayed villous maturation, a larger placental size, and a decreased fetoplacental weight ratio compared to the healthy controls. Larger long-term follow-up studies to evaluate outcomes with the presence of delayed villous maturation are needed. [ABSTRACT FROM AUTHOR]

Objectives: Assisted reproductive technologies (ART) may be associated with placental abnormalities including placenta previa, umbilical cord abnormalities, and placental abruption. Our study evaluates the relationship between ART and placental abnormalities compared with spontaneously conceived controls. Methods: An IRB-approved cohort study was conducted including women who delivered between January 2013 and December 2018. We excluded delivery prior to 23 weeks and known fetal anomalies. Patients were matched with controls (2:1) for parity, age, and mode of delivery. Controls were women who had spontaneously conceived and delivered immediately preceding and following the index delivery. The primary outcome was placental abnormalities found on both antenatal ultrasound and pathology in ART gestations compared with spontaneously conceived gestations. Results: There were 120 ART pregnancies and 240 matched control pregnancies identified. The groups were similar for parity, BMI, comorbidities, number of multiples, mode of delivery, and female newborns. The ART group had a higher maternal age (37.1±5 y vs. 30.0±5 y; p<0.001), greater preterm birth (29 vs. 6%; p<0.001), and lower BW (2,928±803 g vs. 3,273±586 g; p<0.001). The ART group had a higher incidence of placenta previa on ultrasound (4.0 vs. 0.4%, p=0.01), adherent placentas at delivery (3 vs. 0% p=0.014), placental abruption (2 vs. 0%; p=0.04), as well as an increased rate of velamentous cord insertion (12 vs. 3%, p<0.001) and marginal cord insertion (28 vs. 15%, p=0.002). ART demonstrated a two-fold likelihood of abnormal placental pathology. Conclusions: ART is associated with increased rate of placental abnormalities, including abnormal umbilical cord insertion and increased rates of adherent placentation. This information may be beneficial in planning and surveillance in patients with ART pregnancies. [ABSTRACT FROM AUTHOR]

Objective: To compare the rate of wound complications among women who underwent cesarean delivery through a Pfannenstiel skin incision followed by subcuticular closure with either poliglecaprone 25 suture or polyglactin 910 suture.Methods: Patients undergoing nonemergent cesarean delivery at or beyond 37 weeks of gestation were randomized to undergo subcuticular skin closure with either poliglecaprone 25 or polyglactin 910. The primary outcome was a wound composite outcome of one or more of the following: surgical site infection, wound separation, hematoma, or seroma within the first 30 days postpartum. To detect a reduction in the primary outcome rate from 12% to 4%, with a power of 0.90 and a two-tailed α of 0.05, 237 women per study group were required. Analysis was performed according to the intent-to-treat principle.Results: From May 28, 2015, to August 5, 2016, 275 women were randomized to poliglecaprone 25 and 275 to polyglactin 910, of whom 520 (95%) were included in the final analysis: 263 in the poliglecaprone 25 group [of whom 231 (88%) actually underwent poliglecaprone 25 closure) and 257 in the polyglactin 910 group [of whom 209 (81%) actually underwent polyglactin 910 closure]. The groups were similar in demographic characteristics, medical comorbidities, and perioperative characteristics. Poliglecaprone 25 was associated with a significantly decreased rate of overall wound complications when compared with polyglactin 910, 8.8% compared with 14.4% (relative risk 0.61, 95% CI 0.37-0.99; P=.04).Conclusion: Closure of the skin after cesarean delivery with poliglecaprone 25 suture decreases the rate of wound complications compared with polyglactin 910 suture.Clinical Trial Registration: ClinicalTrials.gov, NCT02459093. [ABSTRACT FROM AUTHOR]

Objective: To compare chlorhexidine with alcohol, povidone-iodine with alcohol, and both applied sequentially to estimate their relative effectiveness in prevention of surgical site infections after cesarean delivery.Methods: Women undergoing nonemergent cesarean birth at greater than 37 0/7 weeks of gestation were randomly allocated to one of three antiseptic skin preparations: povidone-iodine with alcohol, chlorhexidine with alcohol, or the sequential combination of both solutions. The primary outcome was surgical site infection reported within the first 30 days postpartum. Based on a surgical site infection rate of 12%, an anticipated 50% reduction for the combination group relative to either single skin preparation group, with a power of 0.90 and an α of 0.05, 430 women per group were needed to detect a difference.Results: From January 2013 to July 2014, 1,404 women were randomly assigned to one of three groups: povidone-iodine with alcohol (n=463), chlorhexidine with alcohol (n=474), or both (n=467). The groups were similar with respect to demographics, medical disorders, indication for cesarean delivery, operative time, and blood loss. The overall rate of surgical site infection-4.3%-was lower than anticipated. The skin preparation groups had similar surgical site infection rates: povidone-iodine 4.6%, chlorhexidine with alcohol 4.5%, and sequential 3.9% (P=.85).Conclusion: The skin preparation techniques resulted in similar rates of surgical site infections. Our study provides no support for any particular method of skin preparation before cesarean delivery.Clinical Trial Registration: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01870583.Level Of Evidence: I. [ABSTRACT FROM AUTHOR]

Abstract: Objective : To determine predictors of treatment failure and recurrence after surgical excisional procedures for CIN in HIV-infected women. Methods : A retrospective cohort study was conducted in which 136 eligible HIV-infected women treated for CIN between 1999 and 2005 were included. Data were abstracted from charts and computer databases. Treatment failures were defined as the presence of CIN 1+ at initial follow-up. Recurrences were defined as the presence of CIN 1+ subsequent to initial normal follow-up. Results : Treatment failure at initial follow-up was common, occurring in 51% of CIN 1 and 55% of CIN 2+. Most lesions detected at treatment failure were high grade (>70%), regardless of the grade of initial lesion. Significant risk factors for treatment failure were loop electrosurgical excision procedure (LEEP) compared to cold knife conization (RR=1.76; 95% CI: 1.15–2.64), and low CD4+ count (p =0.04). Among those with an initial normal clinical evaluation, 55% eventually recurred. As with treatment failure, most lesions detected at recurrence were high grade. Risk factors for recurrence included use of LEEP (hazard ratio [HR]=3.38; 95% CI: 1.55–7.39), higher HIV RNA level, and the presence of positive margins at treatment (HR=6.12; 95% CI: 1.90–19.73). Conclusions : Most CIN treatment of HIV-infected women studied either failed or resulted in recurrence. Of particular concern, many of these subsequent lesions were high grade. Conization, however, was associated with significantly less failure/recurrence than LEEP. Clinicians treating CIN in HIV-infected women should avoid raising expectations of cure and instead focus on the achievable goal of cancer prevention until there are better therapies for this patient population. [Copyright &y& Elsevier]

BACKGROUND: Strongyloides stercoralis is a common human parasite worldwide and has been associated with severe infection in immunosuppressed patients. High mortality rates have accompanied this severe disseminated infection. There is a scarcity of literature surrounding severe Strongyloides infection in pregnancy. CASE: A 30-year-old primigravid Haitian woman at 25 weeks of gestation presented with acute abdominal pain and an abnormal fetal heart tracing. Mild anemia and eosinophilia were laboratory abnormalities on admission. She received corticosteroids for the fetus and subsequently developed septic shock. Sputum and stool were positive for S stercoralis larvae. Hyperinfection was diagnosed, stillbirth occurred, and the patient died. CONCLUSION: A more global awareness and education surrounding helminth infection during pregnancy may improve response, reduce delay in diagnosis, and potentially improve outcome. [ABSTRACT FROM AUTHOR]