Search

Background: Hypertensive disorders of pregnancy (HDP) cause substantial preventable maternal morbidity and mortality. Postpartum hypertension that worsens after women are discharged is particularly...

Background Factors that influence breastfeeding initiation and duration have been well established; however, there is limited understanding of in-hospital exclusive breastfeeding (EBF), which is critical for establishing breastfeeding. Grady Memorial Hospital, which serves a high proportion of participants receiving Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and racial/ethnic minorities, had an in-hospital EBF rate in 2018 by the Joint Commission’s definition of 29% and sought contextualized evidence on how to best support breastfeeding mothers. Objective The objectives were to (1) identify facilitators and barriers to in-hospital EBF and (2) explore breastfeeding support available from key stakeholders across the social-ecological model. Design In-depth, semistructured interviews were conducted and analyzed using thematic analysis. Participants The sample included a total of 38 purposively sampled participants from Grady Memorial Hospital (10 EBF mothers, 10 non-EBF, and 18 key stakeholders such as clinicians, community organizations’ staff, and administrators). Results Key themes included that maternal perception of inadequate milk supply was a barrier to in-hospital EBF at the intrapersonal level. At the interpersonal level, a personable and individualized approach to breastfeeding counseling may be most effective in supporting EBF. At the institutional level, key determinants of EBF were gaps in prenatal breastfeeding education, limited time to provide comprehensive prenatal education to high-risk patients, and practical help with latching and positioning. Community-level WIC services were perceived as a facilitator due to the additional benefits provided for EBF mothers; however, the distribution of WIC vouchers for formula to mothers while they are in the hospital undermines the promotion of EBF. Cultural norms and a diverse patient population were reported as barriers to providing support at the macrosystem level. Conclusion Multipronged approaches that span the social-ecological model may be required to support early EBF in hospital settings.

Despite the strong link between cardiometabolic pregnancy complications and future heart disease, there are documented gaps in engaging those who experience such conditions in recommended postpartum follow-up and preventive care. The goal of our study was to understand how people in a Medicaid-insured population perceive and manage risks during and after pregnancy related to an ongoing cardiometabolic disorder.We conducted in-depth qualitative interviews with postpartum participants who had a cardiometabolic conditions during pregnancy (chronic or gestational diabetes, chronic or gestational hypertension, or preeclampsia). We recruited postpartum participants from a single safety-net hospital system in Atlanta, Georgia, and conducted virtual interviews during January through May 2021. We conducted a content analysis guided by the Health Belief Model and present themes related to risk management.From the 28 interviews we conducted, we found that during pregnancy, advice and intervention by the clinical care team facilitated management behaviors for high-risk conditions. However, participants described limited understanding of how pregnancy complications might affect future outcomes, and few described engaging in postpartum management behaviors.Improving continuity and content of care during postpartum may improve uptake of preventive behaviors among postpartum patients at risk of heart disease.

Underserved subgroups are less likely to have optimal health prior to pregnancy. We describe preconception health indicators (behavior, pregnancy intention, and obesity) among pregnant Latina women with and without chronic stress in metro Atlanta. We surveyed 110 pregnant Latina women enrolled in prenatal care at three clinics in Atlanta. The survey assessed chronic stress, pregnancy intention, preconception behavior changes (taking folic acid or prenatal vitamins, seeking healthcare advice, any reduction in smoking or drinking), and previous trauma. Specific behaviors to improve health prior to pregnancy were uncommon (e.g., taking vitamins (25.5%) or improving nutrition (20.9%)). Just under half of women were experiencing a chronic stressor at the time of conception (49.5%). Chronically stressed women were more likely to be obese (aOR: 3.0 (1.2, 7.4)), less likely to intend their pregnancy (aOR: 0.3 (0.1, 0.7)), and possibly less likely to report any PHB (45.5% vs. 57.4%; aOR: 0.5 (0.2–1.1)). Chronically stress women were less likely to enter prenatal care with optimal health. However, preconception behaviors were uncommon overall.

Congenital transmission is the most important mode of transmission of Chagas disease (CD) in non-endemic countries. Identifying CD in reproductive-aged women is essential to reduce the risk of transmitting the disease to their children and offer treatment to women and their children, which could cure the disease. We evaluated the use of point-of-care (POC) testing for CD in postpartum patients. In our patient population, 16.7% (23/138) tested positive by POC testing, but confirmatory testing was negative for all patients. Among those considered high risk, 30% declined participation. Our results suggest limited utility of the point-of-care test used in our study and identify an opportunity for improvement to broaden diagnostic testing options. Our study also highlights the need to develop strategies to increase subject participation in future research.

Zika virus was first identified in Uganda in 1947 but received little attention until 2015 when a large outbreak of Zika virus illness followed by an increased number of babies born with microcephaly occurred in Brazil. Zika virus spread rapidly throughout the Americas, and in 2016 was identified as a cause of microcephaly and other serious birth defects. Since that time, much has been learned about the Zika virus. The virus is primarily spread by the bite of Aedes species mosquitoes; however, other forms of transmission (e.g., sexual and intrauterine) have been recognized. Although postnatal Zika virus infection typically causes mild or no symptoms, effects on infants born to prenatally infected mothers can be severe and include structural birth defects and neurodevelopmental effects. The risk of a structural birth defect among infants born to mothers with confirmed or suspected Zika virus infection during pregnancy has ranged from 5 to 10%. The timing of Zika infection during pregnancy affects risk, with higher risks with the first-trimester infection. Neurodevelopmental effects are seen even in infants who appear normal in the newborn period. Although cases of Zika virus infection have fallen in the Americas, the Zika virus remains an active threat in some regions of the world. The development of a Zika vaccine will require continued focus and investment. Until a Zika vaccine is available, prevention efforts for pregnant women include avoidance of travel to areas with active Zika transmission, avoidance of mosquito bites for those living in or traveling to areas with Zika transmission, and protection against sexual transmission.

BACKGROUND: In 2015 and 2016, Colombia had a widespread outbreak of Zika virus. Data from two national population-based surveillance systems for symptomatic Zika virus disease (ZVD) and birth defects provided complementary information on the effect of the Zika virus outbreak on pregnancies and infant outcomes. METHODS: We collected national surveillance data regarding cases of pregnant women with ZVD that were reported during the period from June 2015 through July 2016. The presence of Zika virus RNA was identified in a subgroup of these women on real-time reverse-transcriptase–polymerase-chain-reaction (rRT-PCR) assay. Brain or eye defects in infants and fetuses and other adverse pregnancy outcomes were identified among the women who had laboratory-confirmed ZVD and for whom data were available regarding pregnancy outcomes. We compared the nationwide prevalence of brain and eye defects during the outbreak with the prevalence both before and after the outbreak period. RESULTS: Of 18,117 pregnant women with ZVD, the presence of Zika virus was confirmed in 5926 (33%) on rRT-PCR. Of the 5673 pregnancies with laboratory-confirmed ZVD for which outcomes had been reported, 93 infants or fetuses (2%) had brain or eye defects. The incidence of brain or eye defects was higher among pregnancies in which the mother had an onset of ZVD symptoms in the first trimester than in those with an onset during the second or third trimester (3% vs. 1%). A total of 172 of 5673 pregnancies (3%) resulted in pregnancy loss; after the exclusion of pregnancies affected by birth defects, 409 of 5426 (8%) resulted in preterm birth and 333 of 5426 (6%) in low birth weight. The prevalence of brain or eye defects during the outbreak was 13 per 10,000 live births, as compared with a prevalence of 8 per 10,000 live births before the outbreak and 11 per 10,000 live births after the outbreak. CONCLUSIONS: In pregnant women with laboratory-confirmed ZVD, brain or eye defects in infants or fetuses were more common during the Zika virus outbreak than during the periods immediately before and after the outbreak. The frequency of such defects was increased among women with a symptom onset early in pregnancy. (Funded by the Colombian Instituto Nacional de Salud and the Centers for Disease Control and Prevention.)

Background Yersinia pestis continues to cause sporadic cases and outbreaks of plague worldwide and is considered a tier 1 bioterrorism select agent due to its potential for intentional use. Knowledge about the clinical manifestations of plague during pregnancy, specifically the maternal, fetal, and neonatal risks, is very limited. Methods We searched 12 literature databases, performed hand searches, and consulted plague experts to identify publications on plague during pregnancy. Articles were included if they reported a case of plague during pregnancy and at least 1 maternal or fetal outcome. Results Our search identified 6425 articles, of which 59 were eligible for inclusion and described 160 cases of plague among pregnant women. Most published cases occurred during the preantibiotic era. Among those treated with antimicrobials, the most commonly used were sulfonamides (75%) and streptomycin (54%). Among cases treated with antimicrobials, maternal mortality and fetal fatality were 29% and 62%, respectively; for untreated cases, maternal mortality and fetal fatality were 67% and 74%, respectively. Five cases demonstrated evidence of Y. pestis in fetal or neonatal tissues. Conclusions Untreated Y. pestis infection during pregnancy is associated with a high risk of maternal mortality and pregnancy loss. Appropriate antimicrobial treatment can improve maternal survival, although even with antimicrobial treatment, there remains a high risk of pregnancy loss. Limited evidence suggests that maternal-fetal transmission of Y. pestis is possible, particularly in the absence of antimicrobial treatment. These results emphasize the need to treat or prophylax pregnant women with suspected plague with highly effective antimicrobials as quickly as possible.

We conducted a cohort study to determine sociodemographic risk factors for severe acute respiratory syndrome coronavirus 2 infection among obstetric patients in 2 urban hospitals in Atlanta, Georgia, USA. Prevalence of infection was highest among women who were Hispanic, were uninsured, or lived in high-density neighborhoods.

Objective Pregnant African American women living in low-income urban communities have high rates of trauma exposure and elevated risk for the development of trauma-related disorders, including posttraumatic stress disorder (PTSD) and depression. Yet, engagement in behavioral health services is lower for African American women than Caucasian women. Limited attention has been given to identifying trauma exposure and PTSD, especially within at-risk communities. The present study examined rates of trauma exposure, PTSD, depression, and behavioral health treatment engagement in an obstetrics/gynecology (OB/GYN) clinic within an urban hospital. Method The study included 633 pregnant African American women screened within the OB/GYN clinic waiting room; 55 of the women also participated in a subsequent detailed clinical assessment based on eligibility for a separate study of intergenerational risk for trauma and PTSD in African American mother-child dyads. Results Overall, 98% reported trauma exposure, approximately one third met criteria for probable current PTSD, and one third endorsed moderate-or-severe depression based on self-report measures. Similar levels were found based on clinical assessments in the subsample. While 18% endorsed depression treatment, only 6% received treatment for PTSD. In a subsample of women with whom chart reviews were conducted (n = 358), 15% endorsed a past psychiatric diagnosis but none shared their PTSD diagnosis with their OB/GYN provider. Conclusion Results of the current study highlight elevated levels of trauma exposure, PTSD, and depression in low-income, African American pregnant women served by this urban clinic, and demonstrate the need for better identification of trauma-related disorders and appropriate linkage to culturally responsive care especially for PTSD. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Objective To evaluate predictors of vaccination among women who received tetanus, diphtheria, and acellular pertussis vaccination (Tdap), influenza vaccination, and Tdap and influenza vaccinations. Study Design In a retrospective cohort study of all full-term (≥37 weeks gestation) deliveries between July 1, 2016 and June 30, 2018 at a single, safety-net institution, we used multinomial logistic regression models to compare predictors of vaccination among women who received Tdap only, influenza only, and both Tdap and influenza vaccines. Results Among 3132 full-term deliveries, women were primarily non-Hispanic black (67.5%), between the ages of 21–34 (65.3%), and multiparous (76.0%). The rates of only influenza or Tdap vaccination were 10.3% and 21.6%, respectively; 43.3% of women received both vaccines, and 24.9% of women did not receive either vaccine. In the adjusted models, Hispanic ethnicity was positively associated with receipt of all types of vaccination and non-Spanish language interpreter use was positively associated with receipt of Tdap vaccination and Tdap and influenza vaccination. A parity of greater than three and inadequate and unknown prenatal care adequacy were negative predictors of all types of vaccination. Pre-existing hypertension was negatively associated with Tdap vaccination, and HIV-positive status was negatively associated with influenza vaccination and Tdap and influenza vaccination. Conclusion Compared to the national rate of both Tdap and influenza vaccination (32.8%), a higher proportion of women received both vaccines in our study population. Vaccine uptake may be affected by race/ethnicity, use of interpreter services, parity, pre-existing comorbidities, and prenatal care adequacy. The lower rate of influenza vaccination compared to Tdap vaccination suggests that other factors, such as vaccine hesitancy and mistrust, may be differentially impacting influenza vaccination uptake in our predominantly minority population. Future provider and public health approaches to vaccine promotion should incorporate culturally appropriate strategies that address vaccine-related beliefs and misconceptions.

Concentration of antiretroviral (ARV) drug found in plasma, and amounts of drug excreted into breastmilk, may affect HIV viral load and potentially perinatal HIV transmission.In this cohort study with 2-phase sampling, we included mothers randomized to postpartum maternal ARVs or daily infant nevirapine during 28 weeks of breastfeeding in the Breastfeeding, Antiretrovirals, and Nutrition study. Among these, we included all mothers who transmitted HIV to their infants between 2 and 28 weeks and 15% of mothers who did not (n = 27 and 227, respectively). Spearman correlation coefficients (r) were used to assess the correlation between maternal plasma and breastmilk ARV concentration. Associations between the median effective drug concentration (EC50) and detectable maternal viral load (plasma:40 copies per milliliter, breastmilk:56 copies per milliliter) were assessed using mixed-effects models. Cox models were used to estimate the association between maternal or infant plasma drug concentration and breastmilk HIV transmission from 2 to 28 weeks.All ARV compounds exhibited substantial correlations between maternal plasma and breastmilk concentrations (r: 0.85-0.98, P-value0.0001). Having plasma drug concentration above the EC50 was associated with lower odds of having detectable HIV RNA [maternal plasma odds ratio (OR) 0.64, 95% confidence interval (CI): 0.45 to 0.91; breastmilk OR 0.22, 95% CI: 0.14 to 0.35] and a reduced rate of breastmilk HIV transmission (hazard ratio 0.40, 95% CI: 0.18 to 0.93). Having breastmilk drug concentration above the EC50 was also associated with lower odds of having detectable maternal HIV RNA (plasma OR 0.62, 95% CI: 0.45 to 0.85; breastmilk OR 0.42, 95% CI: 0.29 to 0.59).Ensuring adequate drug concentration is important for viral suppression and preventing breastmilk HIV transmission.

BACKGROUND: Smoking near conception has adverse effects on pregnancy outcomes. We estimated the proportion of assisted reproductive technology (ART) cycles with smoking reported and associated clinical outcomes. METHODS: We used a retrospective cohort study (2009–2013) using national data of ART cycles in the United States. We compared patient characteristics, infertility diagnoses, and treatment procedures by self-reported smoking in the 3 months before treatment. Using multivariable logistic regression accounting for clustering by state, clinic, and patient, we assessed adjusted odds ratios (aOR) and 95% confidence intervals (CI) between smoking and clinical outcomes: cycle cancellations among all cycles (cycle stopped before retrieval of eggs or transfer of embryos), treatment outcomes (implantation, ectopic pregnancy, intrauterine pregnancy, and live birth) among cycles with ≥1 fresh embryo transferred, and pregnancy outcomes (miscarriage, stillbirth, and live birth) among intrauterine pregnancies. RESULTS: Smoking was reported in 1.9% of cycles. Higher proportions of cycles among smokers versus non-smokers were younger, non-Hispanic White, multigravida women and had tubal factor and male factor infertility diagnoses; lower proportions had diagnoses of diminished ovarian reserve and unexplained infertility, and used donor eggs. Smoking was associated with higher adjusted odds of cycle cancellation with no embryo transfer (aOR: 1.10; 95% CI: 1.00–1.21) and cancellations before fresh oocyte retrieval or frozen embryo transfer (1.11; 1.02–1.21). Associations between other clinical outcomes were nonsignificant. CONCLUSIONS: Over 12,000 ART cycles in the United States were exposed to smoking during 2009–2013; smoking increased the odds of cycle cancellation. Providers should encourage women to quit smoking before ART treatments.

Underserved subgroups are less likely to have optimal health prior to pregnancy. We describe preconception health indicators (behavior, pregnancy intention, and obesity) among pregnant Latina women with and without chronic stress in metro Atlanta.We surveyed 110 pregnant Latina women enrolled in prenatal care at three clinics in Atlanta. The survey assessed chronic stress, pregnancy intention, preconception behavior changes (taking folic acid or prenatal vitamins, seeking healthcare advice, any reduction in smoking or drinking), and previous trauma.Specific behaviors to improve health prior to pregnancy were uncommon (e.g., taking vitamins (25.5%) or improving nutrition (20.9%)). Just under half of women were experiencing a chronic stressor at the time of conception (49.5%). Chronically stressed women were more likely to be obese (aOR: 3.0 (1.2, 7.4)), less likely to intend their pregnancy (aOR: 0.3 (0.1, 0.7)), and possibly less likely to report any PHB (45.5% vs. 57.4%; aOR: 0.5 (0.2-1.1)).Chronically stress women were less likely to enter prenatal care with optimal health. However, preconception behaviors were uncommon overall.

Delaying Pregnancy during a Public Health Crisis Whether public health agencies should recommend that women avoid becoming pregnant during public health crises like Covid-19 because of potential ri...

Objectives We aimed to examine the extent to which health plan expenditures for infertility services differed by whether women resided in states with mandates requiring coverage of such services and by whether coverage was provided through a self-insured plan subject to state mandates versus fully-insured health plans subject only to federal regulation. Methods This retrospective cohort study used individual-level, de-identified health insurance claims data. We included women 19-45 years of age who were continuously enrolled during 2011 and classified them into three mutually exclusive groups based on highest treatment intensity: in vitro fertilization (IVF), intrauterine insemination (IUI), or ovulation-inducing (OI) medications. Using generalized linear models, we estimated adjusted annual mean, aggregate, and per member per month (PMPM) expenditures among women in states with an infertility insurance mandate and those in states without a mandate, stratified by enrollment in a fully-insured or self-insured health plan. Results Of the 6,006,017 women continuously enrolled during 2011, 9199 (0.15%) had claims for IVF, 10,112 (0.17%) had claims for IUI, and 23,739 (0.40%) had claims for OI medications. Among women enrolled in fully insured plans, PMPM expenditures for infertility treatment were 3.1 times higher for those living in states with a mandate compared with states without a mandate. Among women enrolled in self-insured plans, PMPM infertility treatment expenditures were 1.2 times higher for mandate versus non-mandate states. Conclusions for Practice Recorded infertility treatment expenditures were higher in states with insurance reimbursement mandates versus those without mandates, with most of the difference in expenditures incurred by fully-insured plans.

The 2014 to 2016 Ebola outbreak, primarily based in 3 West African countries, had far-reaching global effects. Importantly, the crisis highlighted large gaps in reproductive health services in affected countries and inadequate health care system preparedness for obstetrical patients in the setting of highly contagious infectious diseases. We aim to review Ebola virus effects with a focus on the obstetrical implications in the context of this recent Ebola outbreak, discuss the lessons learned following this outbreak and propose current measures specific to obstetrics that should be considered in preparation for the next concerning emergent infectious disease.

Previous outbreaks suggest that pregnant women with Ebola virus disease (EVD) are at increased risk for severe disease and death. Healthcare workers who treat pregnant women with EVD are at increased risk of body fluid exposure. Despite the absence of pregnant women with EVD in the United States, CDC activated the Maternal Health Team (MHT), a functional unit dedicated to emergency preparedness and response issues, on October 18, 2014. We describe major activities of the MHT. A high-priority MHT activity was to publish guiding principles early in the response. The MHT also prepared guidance documents, provided guidance and technical support for hospital preparedness, and addressed inquiries. We analyzed maternal health inquiries received through CDC-INFO, MHT, and CDC’s Medical Investigations Team from August 2014 to December 2015. Internal call logs used to capture, monitor, and track inquiries for the three data sources were merged. Inquiries not related to maternal health issues and duplicates were removed. Each inquiry was categorized by route (email/phone), inquirer type, and topic. In total, 201 inquiries were received from clinicians, public health professionals, and the public. The predominant topic was related to infection control for high-risk situations such as labor and delivery. During the Ebola response, most inquiries were received via email rather than telephone, a notable shift compared to the H1N1 emergency response. Lessons learned during the H1N1 and Ebola responses are currently informing CDC’s Zika Response, an unprecedented emergency response primarily focused on reproductive health issues.

Intentional release of infectious agents and biological weapons to cause illness and death has the potential to greatly impact pregnant women and their fetuses. We review what is known about the maternal and fetal effects of seven biological threats: Bacillus anthracis (anthrax); variola virus (smallpox); Clostridium botulinum toxin (botulism); Burkholderia mallei (glanders) and Burkholderia pseudomallei (melioidosis); Yersinia pestis (plague); Francisella tularensis (tularemia); and Rickettsia prowazekii (typhus). Evaluating the potential maternal, fetal, and infant consequences of an intentional release of an infectious agent requires an assessment of several key issues: (1) are pregnant women more susceptible to infection or illness compared to the general population?; (2) are pregnant women at increased risk for severe illness, morbidity, and mortality compared to the general population?; (3) does infection or illness during pregnancy place women, the fetus, or the infant at increased risk for adverse outcomes and how does this affect clinical management?; and (4) are the medical countermeasures recommended for the general population safe and effective during pregnancy? These issues help frame national guidance for the care of pregnant women during an intentional release of a biological threat. Birth Defects Research 109:391-398, 2017.© 2017 Wiley Periodicals, Inc.

Emerging infections have the potential to produce adverse effects on the pregnant woman or her fetus; however, studying these effects is often challenging. We review our experiences with investigating the prenatal effects of two mosquito-borne infections that emerged in the past 2 decades, West Nile virus (WNV) and Zika virus. Concerns regarding teratogenicity were raised about both viruses; Zika virus has been confirmed to be teratogenic, while WNV appears not to increase the risk for adverse outcomes, although teratogenicity has not been excluded. Study designs used to examine the effects of both viruses include case reports and series, pregnancy registries, and cohort studies. Case-control studies and birth defects surveillance systems are being used to study the effects during pregnancy of Zika virus, but not the effects of WNV, because a specific phenotype was observed among infants with congenital Zika infection, but not among infants with congenital WNV infection. Experimental data that demonstrated that Zika virus was neurotropic have also been useful because they provided biologic plausibility for Zika virus's teratogenic effects: these findings were consistent with observations in congenitally infected infants. Challenges encountered with studies to evaluate the effects of these infections include the broad range of possible adverse outcomes, the inability to include all infected pregnant women in studies because many infections are asymptomatic, and the difficulty with interpretation of diagnostic testing of infants (WNV and Zika) and pregnant women (Zika). This review might be helpful to guide future studies of the effects of emerging infections during pregnancy. Birth Defects Research 109:363-371, 2017. © 2017 Wiley Periodicals, Inc.

Background Zika virus is a newly recognized human teratogen; monitoring its impact on the birth prevalence of microcephaly and other adverse pregnancy outcomes will continue to be an urgent need in the United States and worldwide. Methods When the Centers for Disease Control and Prevention (CDC) activated the Emergency Operations Center for the Zika virus outbreak response in January of 2016, public health leadership recognized that a joint, coordinated effort was required between activities focused on the effects of the infection among pregnant women and those focused on birth defects in fetuses and infants. Before the introduction of Zika virus in the Americas, population-based birth defects surveillance occurred independently of pregnancy surveillance activities. Results The coordination of pregnancy surveillance and birth defects surveillance implemented through the CDC Zika virus response represents a paradigm shift. Conclusion Coordination of these surveillance systems provides an opportunity to capture information from both a prospective and retrospective approach. This relatively modest investment in the public health infrastructure can continue to protect pregnant women and their infants during the ongoing response to Zika virus and in the next emergent threat to maternal and child health. Birth Defects Research 109:372–378, 2017. © 2017 Wiley Periodicals, Inc.

We modeled the potential cost-effectiveness of increasing access to contraception in Puerto Rico during a Zika virus outbreak. The intervention is projected to cost an additional $33.5 million in family planning services and is likely to be cost-saving for the healthcare system overall. It could reduce Zika virus-related costs by $65.2 million ($2.8 million from less Zika virus testing and monitoring and $62.3 million from avoided costs of Zika virus-associated microcephaly [ZAM]). The estimates are influenced by the contraception methods used, the frequency of ZAM, and the lifetime incremental cost of ZAM. Accounting for unwanted pregnancies that are prevented, irrespective of Zika virus infection, an additional $40.4 million in medical costs would be avoided through the intervention. Increasing contraceptive access for women who want to delay or avoid pregnancy in Puerto Rico during a Zika virus outbreak can substantially reduce the number of cases of ZAM and healthcare costs.

BACKGROUND Antiretroviral (ARV) interventions are used to reduce HIV viral replication and prevent mother-to-child transmission. Viral suppression relies on adherence to ARVs. METHODS A 2-phase study was conducted using data from the Breastfeeding, Antiretrovirals, and Nutrition study. We included mothers randomized to 28 weeks of postpartum ARVs with ≥1 plasma or breastmilk specimen. All mothers who transmitted HIV to their infants from 2-28 weeks (n = 31) and 15% of mothers who did not (n = 232) were included. Adherence was measured by pill count [categorized as poor (0%-80%), partial (81%-98%), and near perfect (>98%)]. Associations between adherence and breastmilk RNA were assessed using mixed-effects models. Cox models were used to estimate associations between breastmilk RNA and HIV transmission. Using Monte Carlo simulation, we estimated the number of transmissions that would occur had everyone randomized to maternal ARVs been 90% and 100% adherent. RESULTS Partial or near perfect ARV adherence significantly reduced the odds of having detectable (≥40 copies/mL) breastmilk RNA, compared with poor adherence (Odds Ratio (OR) 0.23, 95% CI: 0.08 to 0.67; OR 0.36, 95% CI: 0.16 to 0.81, respectively). Detectable breastmilk RNA was associated with increased breastmilk transmission compared with undetectable breastmilk RNA (hazard ratio 3.8, 95% CI: 1.2 to 12.1). All transmitting mothers had ≥1 plasma viral load specimen >100 copies per milliliter. An estimated similar number of transmissions would occur with 90% adherence compared with 100%. CONCLUSIONS Helping patients adhere to ARVs throughout breastfeeding is important for realizing the full potential of recommended ARV interventions to prevent mother-to-child HIV transmission. Maintaining plasma viral load

The aim of this study was to identify factors associated with double embryo implantation following double embryo transfer (DET) during assisted reproductive technology (ART) procedures and to evaluate the implications of findings in selecting candidates for elective single embryo transfer (eSET).Factors predicting double embryo implantation, defined as embryo transfers with two or more heartbeats on 6-week ultrasound following DET, were assessed using the US National ART Surveillance System data from 2000 to 2012 (n = 1,793,067 fresh, autologous transfers). Adjusted risk ratios (aRRs) were estimated after stratifying by prognosis. Favorable prognosis was defined as first-time ART with supernumerary embryo(s) cryopreserved. Average prognosis was defined as first-time ART without supernumerary embryo(s) cryopreserved, prior unsuccessful ART with supernumerary embryo(s) cryopreserved, or prior ART with previous birth(s) conceived with ART or naturally. Rates and factors associated with double embryo implantation were compared with single embryo implantation following DET among both prognosis groups.Double embryo implantation was positively associated with blastocyst (versus cleavage) transfer in favorable (aRR = 1.58 (1.51-1.65)) and average (aRR = 1.67 (1.60-1.75)) prognosis groups and negatively associated with age35 years in both prognosis groups. For average prognosis patients, double embryo implantation was associated with retrieving10 oocytes (aRR = 1.22 (1.18-1.24)).Regardless of prognosis, patients aged35 years with blastocyst-stage embryos and average prognosis patients from whom10 oocytes were retrieved may be good candidates for eSET. Physicians may consider using these data to counsel patients on eSET, which would reduce multiple gestations and associated complications.

Objective To compare the risk of preeclampsia among spontaneously conceived pregnancies to those after hyperestrogenic ovarian stimulation (hyperestrogenic OS) with and without assisted reproductive technology (ART), and stimulation with non-hyperestrogenic aromatase inhibitor stimulation (non-hyperestrogenic OS). Methods Live-born singleton deliveries among women 20-49 years were identified in the 2004-2012 Truven Health MarketScan Commercial Claims and Encounters Databases using ICD-9 and CPT codes. Maternal characteristics were compared using Chi squared and Fisher exact tests. We performed multilevel multivariable logistic regression, controlling for maternal age, parity, comorbid conditions, and region of delivery, and calculated adjusted odds ratios (aOR) and 95 % confidence intervals for mild and severe preeclampsia. Results 1,014,526 spontaneously conceived, 6881 hyperestrogenic OS with ART, 27,516 hyperestrogenic OS without ART, and 2117 non-hyperestrogenic OS pregnancies were identified. The adjusted odds of developing preeclampsia were increased for deliveries after hyperestrogenic OS with ART (mild preeclampsia aOR 1.42, 1.24-1.62; severe preeclampsia aOR 1.83, 1.59-2.11) and without ART (mild preeclampsia aOR 1.32, 1.24-1.42; severe preeclampsia aOR 1.53, 1.41-1.66). Adjusted odds of preeclampsia were similar between spontaneously conceived and non-hyperestrogenic OS pregnancies. Conclusions for Practice Risk of preeclampsia after ART may in part be related to supraphysiologic estrogen associated with hyperestrogenic OS.

Infants born to HIV-1-infected mothers in resource-limited areas where replacement feeding is unsafe and impractical are repeatedly exposed to HIV-1 throughout breastfeeding. Despite this, the majority of infants do not contract HIV-1 postnatally, even in the absence of maternal antiretroviral therapy. This suggests that immune factors in breast milk of HIV-1-infected mothers help to limit vertical transmission. We compared the HIV-1 envelope-specific breast milk and plasma antibody responses of clade C HIV-1-infected postnatally transmitting and nontransmitting mothers in the control arm of the Malawi-based Breastfeeding Antiretrovirals and Nutrition Study using multivariable logistic regression modeling. We found no association between milk or plasma neutralization activity, antibody-dependent cell-mediated cytotoxicity, or HIV-1 envelope-specific IgG responses and postnatal transmission risk. While the envelope-specific breast milk and plasma IgA responses also did not reach significance in predicting postnatal transmission risk in the primary model after correction for multiple comparisons, subsequent exploratory analysis using two distinct assay methodologies demonstrated that the magnitudes of breast milk total and secretory IgA responses against a consensus HIV-1 envelope gp140 (B.con env03) were associated with reduced postnatal transmission risk. These results suggest a protective role for mucosal HIV-1 envelope-specific IgA responses in the context of postnatal virus transmission. This finding supports further investigations into the mechanisms by which mucosal IgA reduces risk of HIV-1 transmission via breast milk and into immune interventions aimed at enhancing this response. IMPORTANCE Infants born to HIV-1-infected mothers are repeatedly exposed to the virus in breast milk. Remarkably, the transmission rate is low, suggesting that immune factors in the breast milk of HIV-1-infected mothers help to limit transmission. We compared the antibody responses in plasma and breast milk of HIV-1-transmitting and -nontransmitting mothers to identify responses that correlated with reduced risk of postnatal HIV-1 transmission. We found that neither plasma nor breast milk IgG antibody responses were associated with risk of HIV-1 transmission. In contrast, the magnitudes of the breast milk IgA and secretory IgA responses against HIV-1 envelope proteins were associated with reduced risk of postnatal HIV-1 transmission. The results of this study support further investigations of the mechanisms by which mucosal IgA may reduce the risk of HIV-1 transmission via breastfeeding and the development of strategies to enhance milk envelope-specific IgA responses to reduce mother-to-child HIV transmission and promote an HIV-free generation.

Objectives. We explored how changes in insurance coverage contributed to recent nationwide decreases in newborn circumcision. Methods. Hospital discharge data from the 2000–2010 Nationwide Inpatient Sample were analyzed to assess trends in circumcision incidence among male newborn birth hospitalizations covered by private insurance or Medicaid. We examined the impact of insurance coverage on circumcision incidence. Results. Overall, circumcision incidence decreased significantly from 61.3% in 2000 to 56.9% in 2010 in unadjusted analyses (P for trend = .008), but not in analyses adjusted for insurance status (P for trend = .46) and other predictors (P for trend = .55). Significant decreases were observed only in the South, where adjusted analyses revealed decreases in circumcision overall (P for trend = .007) and among hospitalizations with Medicaid (P for trend = .005) but not those with private insurance (P for trend = .13). Newborn male birth hospitalizations covered by Medicaid increased from 36.0% (2000) to 50.1% (2010; P for trend Conclusions. Shifts in insurance coverage, particularly toward Medicaid, likely contributed to decreases in newborn circumcision nationwide and in the South. Barriers to the availability of circumcision should be revisited, particularly for families who desire but have less financial access to the procedure.

Objective To estimate the burden of pregnancy-related mortality resulting from influenza A (H1N1)pdm09 virus infection during the 2009-2010 pandemic influenza season. Methods Data from the Centers for Disease Control and Prevention's Pregnancy Mortality Surveillance System were used to identify women whose death during or shortly after pregnancy was attributed or likely attributed to the influenza A (H1N1)pdm09 virus from April 15, 2009, through June 30, 2010. We report the characteristics of these women and enumerate cases resulting in death as the pandemic began, peaked, and resolved. Results During the pandemic season, we identified 915 pregnancy-related deaths and 4,911,297 live births. Seventy-five (8.2%) women died as a result of confirmed influenza A (H1N1)pdm09 infection deaths and 34 (3.7%) women as a result of possible influenza A (H1N1)pdm09 infection deaths. The pregnancy-related mortality ratio for confirmed and possible (combined) influenza A (H1N1)pdm09 infection deaths was 2.2 per 100,000 live births. Most deaths occurred during the 2009 calendar year with the peak of the distribution of deaths over time occurring in October 2009. Conclusion Twelve percent of pregnancy-related deaths were attributed to confirmed or possible influenza A (H1N1)pdm09 infection during the 2009-2010 pandemic season. Because prediction of pandemics is difficult, planning for prevention of influenza and care for those women affected are critical for preventing associated severe maternal morbidity and mortality. Level of evidence III.

Background: Little is known about the influence of antiretroviral therapy with or without micronutrient supplementation on the micronutrient concentrations of HIV-infected lactating women in resource-constrained settings. Objective: We examined associations of highly active antiretroviral therapy (HAART) and lipid-based nutrient supplements (LNS) with concentrations of selected micronutrients in HIV-infected Malawian women at 24 wk postpartum. Methods:Plasma micronutrient concentrations were measured in a subsample (n = 690) of Breastfeeding, Antiretrovirals, and Nutrition (BAN) study participants who were randomly assigned at delivery to receive HAART, LNS, HAART+LNS, or no HAART/no LNS (control). HAART consisted of protease inhibitor‐based triple therapy. LNS (140 g/d) met energy and micronutrient requirements of lactation. Multivariable linear regression tested the association of HAART and LNS, plus their interaction, with micronutrient concentrations, controlling for season, baseline viral load, and baseline CD4 count. Results: We found significant HAART by LNS interactions for folate (P = 0.051), vitamin B-12 (P < 0.001), and transferrin receptors (TfRs) (P = 0.085). HAART was associated with lower folate (with LNS: 227%, P < 0.001; without LNS: 212%, P = 0.040) and higher TfR concentrations (with LNS: +14%, P = 0.004; without LNS: +28%, P < 0.001), indicating iron deficiency. LNS increased folate (with HAART: +17%, P = 0.037; without HAART: +39%, P < 0.001) and decreased TfR concentrations (with HAART only: 212%, P = 0.023). HAART was associated with lower vitamin B-12 concentrations only when LNS was present (218%, P = 0.001), whereas LNS increased vitamin B-12 only when no HAART was present (+27%, P < 0.001). HAART, but not LNS, was associated with higher retinol-binding protein (RBP; +10%, P = 0.007). We detected no association of HAART or LNS with selenium, ferritin, or hemoglobin. Conclusion: The association of HAART with lower folate, iron deficiency, and higher RBP plus the attenuation of LNS effects on folate and vitamin B-12 when combined with HAART has implications for the health of lactating HIV-infected women taking HAART in prevention of mother-to-child transmission programs. This trial was registered at clinicaltrials.gov as NCT00164736. J Nutr doi: 10.3945/jn.115.212290.

OBJECTIVE:To examine characteristics and causes of legal induced abortion–related deaths in the United States between 1998 and 2010.METHODS:Abortion-related deaths were identified through the national Pregnancy Mortality Surveillance System with enhanced case-finding. We calculated the abortion mort

From January 1 to April 3, 2015, 159 people from 18 states and the District of Columbia were reported as having measles. Most cases are part of an outbreak linked to a California amusement park. Because measles was eliminated in the United States in 2000, most U.S. clinicians are unfamiliar with the condition. We reviewed information on the current outbreak, measles manifestations, diagnostic methods, treatment, and infection-control recommendations. To identify information on measles and pregnancy, we reviewed reports with 20 or more measles cases during pregnancy that included data on effects on pregnant women or pregnancy outcomes. These reports were identified through MEDLINE from inception through February 2015 using the following strategy: (((pregnan*) AND measles) AND English[Language]) NOT review[Publication Type]. Reference lists also were reviewed to identify additional articles. Pregnant women infected with measles are more likely to be hospitalized, develop pneumonia, and die than nonpregnant women. Adverse pregnancy outcomes, including pregnancy loss, preterm birth, and low birth weight, are associated with maternal measles; however, the risk of congenital defects does not appear to be increased. No antiviral therapy is available; treatment is supportive. Early identification of possible cases is needed so that appropriate infection control can be instituted promptly. The recent measles outbreak highlights the role that obstetric health care providers play in vaccine-preventable illnesses; obstetrician-gynecologists should ensure that patients are up to date on all vaccines, including measles-containing vaccines, and should recommend and ideally offer a measles-containing vaccine to women without evidence of measles immunity before or after pregnancy.