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Background:In March 2017, the New Jersey Department of Health received reports of 3 patients who developed septic arthritis after receiving intra-articular injections for osteoarthritis knee pain at the same private outpatient facility in New Jersey. The risk of septic arthritis resulting from intra-articular injection is low. However, outbreaks of septic arthritis associated with unsafe injection practices in outpatient settings have been reported.Methods:An infection prevention assessment of the implicated facility’s practices was conducted because of the ongoing risk to public health. The assessment included an environmental inspection of the facility, staff interviews, infection prevention practice observations, and a medical record and office document review. A call for cases was disseminated to healthcare providers in New Jersey to identify patients treated at the facility who developed septic arthritis after receiving intra-articular injections.Results:We identified 41 patients with septic arthritis associated with intra-articular injections. Cultures of synovial fluid or tissue from 15 of these 41 case patients (37%) recovered bacteria consistent with oral flora. The infection prevention assessment of facility practices identified multiple breaches of recommended infection prevention practices, including inadequate hand hygiene, unsafe injection practices, and poor cleaning and disinfection practices. No additional cases were identified after infection prevention recommendations were implemented by the facility.Discussion:Aseptic technique is imperative when handling, preparing, and administering injectable medications to prevent microbial contamination.Conclusions:This investigation highlights the importance of adhering to infection prevention recommendations. All healthcare personnel who prepare, handle, and administer injectable medications should be trained in infection prevention and safe injection practices.

Background: Pregnant women and infants

Objective: Ascertain predictors of inactivated influenza vaccine (IIV) uptake in pregnancy in mother–infant pairs from six Australian sites over four consecutive influenza seasons (2012–2015). Methods: Prospective observational cohort study calculating proportions of unvaccinated and vaccinated pregnancies. Multivariable logistic regression calculating adjusted odds ratios (aOR) and 95% confidence intervals (95%CI) to determine demographic, pregnancy and birth characteristics as predictors of IIV uptake in pregnancy. Results: Uptake of IIV was 36% (n=3,651/9,878) with only 3–4% during the first trimester. Validation of IIV receipt was obtained for 77% of vaccinated participants. Predictors of IIV uptake in pregnancy were: healthcare provider recommendation to have IIV during pregnancy (aOR 7.04 [95%CI 5.83‐8.50]): GP (aOR 4.12 [95%CI 3.43‐4.98]), obstetrician (aOR 4.41 [95%CI 3.45‐5.64]), midwife (aOR 1.88 [95%CI 1.51‐2.36]); previous IIV within 12 months of their current pregnancy (aOR 2.87 [95%CI 2.36‐3.50]); and pertussis vaccination during the current pregnancy (aOR 4.88 [95%CI 4.08‐5.83]). Conclusions and implications for public health: Healthcare provider discussions with pregnant women about the risks associated with influenza infection during pregnancy and early infancy and evidence about the safety and effectiveness of IIV are required. Recommending and offering IIV in pregnancy needs to be included in these discussions to improve uptake.

Background During the 2014-2015 US influenza season, 320 cases of non-mumps parotitis (NMP) among residents of 21 states were reported to the Centers for Disease Control and Prevention (CDC). We conducted an epidemiologic and laboratory investigation to determine viral etiologies and clinical features of NMP during this unusually large occurrence. Methods NMP was defined as acute parotitis or other salivary gland swelling of >2 days duration in a person with a mumps- negative laboratory result. Using a standardized questionnaire, we collected demographic and clinical information. Buccal samples were tested at the CDC for selected viruses, including mumps, influenza, human parainfluenza viruses (HPIVs) 1-4, adenoviruses, cytomegalovirus, Epstein-Barr virus (EBV), herpes simplex viruses (HSVs) 1 and 2, and human herpes viruses (HHVs) 6A and 6B. Results Among the 320 patients, 65% were male, median age was 14.5 years (range, 0-90), and 67% reported unilateral parotitis. Commonly reported symptoms included sore throat (55%) and fever (48%). Viruses were detected in 210 (71%) of 294 NMP patients with adequate samples for testing, ≥2 viruses were detected in 37 samples, and 248 total virus detections were made among all samples. These included 156 influenza A(H3N2), 42 HHV6B, 32 EBV, 8 HPIV2, 2 HPIV3, 3 adenovirus, 4 HSV-1, and 1 HSV-2. Influenza A(H3N2), HHV6B, and EBV were the most frequently codetected viruses. Conclusions Our findings suggest that, in addition to mumps, clinicians should consider respiratory viral (influenza) and herpes viral etiologies for parotitis, particularly among patients without epidemiologic links to mumps cases or outbreaks.

Background: The burden of acute lower respiratory infection (ALRI) in Indigenous children of Australia's Northern Territory is among the highest globally. No published data exists on the effect of pneumococcal conjugate vaccine (PCV) introduction on ALRIs in this population beyond 2005. The aim of this study was to describe the rates of ALRI admissions to hospital in Indigenous infants in the Northern Territory from 2006 to 2015, across three periods of different PCV use. We hypothesised that broader valency PCVs would be more effective against hospitalisations for pneumonia. Methods: We did a retrospective population-based cohort study of Indigenous infants born in the Northern Territory followed up until age 12 months. Data were from administrative hospital and perinatal datasets. International classification of diseases codes (tenth revision, Australian modification; ICD-10AM) were used to identify respiratory hospitalisations of interest: all-cause ALRI, all-cause pneumonia, bacterial pneumonia, viral pneumonia, influenza-like illness (ILI), respiratory syncytial virus ALRI (RSV-ALRI), and pneumococcal ALRI. Incidence rates were compared between PCV eras (7-valent PCV [PCV7], 2006–09; 10-valent PCV [PCV10], 2009–11; and 13-valent PCV [PCV13], 2011–15) using interrupted time trend analysis and negative binomial regression. Findings: For children born between Jan 1, 2006, and Dec 31, 2015, 4138 ALRI episodes (31% of all hospitalisations) occurred among 2888 (20%) of the 14 594 infants. The overall ALRI hospitalisation rate was 29·7 episodes per 100 child-years. Prominent risk factors associated with ALRI hospitalisation were living in a remote community or the Central desert region, being born preterm or with low birthweight. ALRI rates were lowest in the PCV13 era, in association with a significant reduction in bacterial pneumonia hospitalisations in the PCV13 era compared with the PCV10 (incidence rate ratio 0·68, 95% CI 0·57–0·81) and PCV7 (0·70, 0·60–0·81) eras. In contrast, RSV-ALRI rates were 4·9 episodes per 100 child-years in each era. Interpretation: A 30% reduction in bacterial-coded pneumonia hospitalisations in the Northern Territory during the era of PCV13 immunisation supports its ongoing use in the region. Despite the reduction, one in five Indigenous infants born in the region continue to be hospitalised with an ALRI in their first year of life. Future gains require multifaceted environmental and biomedical approaches. Funding: National Health and Medical Research Council of Australia.

Influenza and pertussis infections are disproportionately higher among Aboriginal and Torres Strait Islander women and their infants compared to other Australians. These infections are potentially preventable through vaccination in pregnancy; however, there is a lack of systematic monitoring and therefore knowledge of vaccine uptake, safety and effectiveness in Australia, and specifically among Aboriginal and Torres Strait Islander women. The limited data available suggest there is a lower uptake of maternal vaccination among Aboriginal and Torres Strait Islander women compared to non-Aboriginal and Torres Strait Islander women, and this review seeks to explore potential reasons and the knowledge gaps in this regard. Other key gaps include the equitable access to quality antenatal care for Aboriginal and Torres Strait Islander women; and pregnancy loss

Remote-living Aboriginal and Torres Strait Islander women experience a higher burden of influenza infection during pregnancy than any other Australian women. Despite recommendations of inactivated influenza vaccination (IIV) in pregnancy, uptake and safety data are scarce for this population. We examined uptake of IIV in pregnancy and report adverse birth outcomes amongst a predominantly unvaccinated group of remote-living Aboriginal and Torres Strait Islander women from the Northern Territory (NT), using data from the 1+1 Healthy Start to Life study. Data were deterministically linked with the NT Immunisation Register to ascertain IIV exposure in pregnant women during 2003–2006 and 2009–2011 inclusive. Overall, IIV uptake in pregnancy was 3% (n=20/697 pregnancies); 0% (0/414) pre-influenza A(H1N1)pdm09 and 7% (20/293) post-influenza A(H1N1)pdm09 (2009–2011). Vaccine uptake was poor in this cohort and it is unclear at what stage this policy failure occurred. Women with known comorbidities and/or high risk factors were not targeted for vaccination. Much larger study participant numbers are required to validate between group comparisons but there was no clinically nor statistically significant difference in median gestational ages (38 weeks for both groups), mean infant birthweights (3,001 g unvaccinated vs 3,175 g IIV vaccinated), nor birth outcomes between the few women who received IIV in pregnancy and those who did not. There were no stillbirths in women who received an IIV in pregnancy.

We conducted probabilistic data linkage of three population datasets for the Northern Territory (NT), Australia, to describe the incidence of preterm births, stillbirths, low birthweight and small for gestational age (SGA) per 1000 NT births; and influenza and pertussis hospitalisations per 1 00 000 NT births in infants vs. 64.7); stillbirths 2.3 (AR 10.8 vs. 4.6); low birthweight 2.9 (AR 54 vs. 19); and SGA 1.7 (AR 187 vs. 111). Hospitalisation (2000–2015) and Immunisation Register datasets (1994–2015), showed that influenza hospitalisations (n = 53) and rates were 42.3 times higher in Aboriginal infants (AR 254 vs. 6); and that pertussis hospitalisations (n = 37) were 7.1 times higher in Aboriginal infants (AR 142.5 vs. 20.2) compared to non-Aboriginal infants. These baseline data are essential to assess the safety and effectiveness of influenza and pertussis vaccinations in pregnant women from the NT. Remote living Aboriginal women and infants stand to benefit the most from these vaccines.

Background:­­­­ For Indigenous infants living in Australia’s Northern Territory (NT) acute lower respiratory infections (ALRIs) are a leading cause of hospitalisation and preventable mortality. The study describes the burden of ALRI hospitalisation in this population from 2006 to 2015 with contrast between three periods of different pneumococcal conjugate vaccine (PCV) use. Methods: We conducted a historical cohort study of NT Indigenous infants born between 1st January 2006 and 31st December 2015 and followed until age 12 months. Data were from administrative hospital and perinatal datasets. International classification of diseases codes were used to identify respiratory hospitalisations of interest: all cause ALRI, all cause pneumonia, bacterial pneumonia, viral pneumonia, influenza-like illness (ILI), respiratory syncytial virus ALRI (RSV-ALRI) and pneumococcal ALRI. Incidence rates were compared between PCV eras (7-valent PCV-PCV7, 2006-2009; PCV10, 2009-2011; PCV13, 2011-2015) using interrupted time trend analysis and negative binomial regression. Findings: Over the study period 4138 ALRI episodes (31% of all hospitalisations) occurred among 2888 of the 14594 infants (20% of the cohort). The overall ALRI hospitalisation rate was 29.7 episodes per 100 child-years. Prominent risk factors associated with ALRI hospitalisation were living in a remote community or the Central desert region, being born preterm or with low birth weight. ALRI rates were lowest in the PCV13 era in association with a significant reduction in bacterial pneumonia hospitalisations in the PCV13 relative to the PCV10 (IRR 0∙68, 95% CI 0∙57-0∙81) and PCV7 (IRR 0∙70, 95% CI 0∙60-0∙81) eras. In contrast, RSV-ALRI rates were 4∙9 episodes per 100 child-years in each era. Interpretation: We found a 30% reduction in bacterial-coded pneumonia hospitalisation episodes during the era of PCV13 use. Despite this, one in five NT Indigenous infants continue to be hospitalised with an ALRI in their first year of life. RSV associated ALRI rates were high and remained unchanged over a decade. Funding Statement: This work was supported by the National Health and Medical Research Council (NHMRC) of Australia. MJB was funded by an NHMRC Early Career Fellowship (1088733) and NHMRC-funded `Hot North - Improving Health Outcomes in the Tropical North’ Fellowship (1131932). JB is supported by a NHMRC scholarship (1150901) and a NHMRC-funded Centre of Research Excellence in Ear and Hearing Health of Aboriginal and Torres Strait Islander children scholarship (1078557). VMO none. SJP was supported by a NHMRC Peter Doherty Early Career Fellowship (1113302). AJL was supported by NHMRC Fellowship (1020561), the NHMRC-funded Centre of Research Excellence in Ear and Hearing Health of Aboriginal and Torres Strait Islander Children (1078557), The Balnaves Foundation, the Northern Territory Government and the Australian Government. PSM none. RMA none. LM was supported by an Australian Postgraduate Award through Charles Darwin University and an Enhanced Living scholarship through Menzies School of Health Research towards a Doctor of Philosophy degree. RW none. ABC is supported by Australia’s NHMRC Practitioner Fellowship (1058213) and a Children’s Hospital Foundation Fellowship, Queensland (50286). Declaration of Interests: The authors stated: "None exist." Ethics Approval Statement: This project was approved by the Human Research Ethics Committee of the NT Department of Health and Menzies School of Health Research (HREC 2015-2406).

Background During the 2014-2015 influenza season in the United States, 256 cases of influenza-associated parotitis were reported from 27 states. We conducted a case-control study and laboratory investigation to further describe this rare clinical manifestation of influenza. Methods During February 2015-April 2015, we interviewed 50 cases (with parotitis) and 124 ill controls (without parotitis) with laboratory-confirmed influenza; participants resided in 11 states and were matched by age, state, hospital admission status, and specimen collection date. Influenza viruses were characterized using real-time polymerase chain reaction and next-generation sequencing. We compared cases and controls using conditional logistic regression. Specimens from additional reported cases were also analyzed. Results Cases, 73% of whom were aged

Background: Inactivated influenza vaccine (IIV) and pertussis vaccination are recommended in pregnancy. Limited safety data exist for women who received IIV vaccine during the first trimester of pregnancy or received both vaccines in pregnancy. We assessed adverse birth outcomes between vaccinated and unvaccinated pregnancies. Methods: Among prospectively enrolled Australian "FluMum" participants (2012-2015), primary exposure was receipt and timing of IIV during pregnancy. Primary outcomes included preterm birth, low birthweight at term (LBWT), and small for gestational age (SGA). We compared birth outcomes for IIV in pregnancy with women unvaccinated in pregnancy using Cox proportional hazard ratios (HRs) with 95% confidence intervals (CIs). Adjusted HRs (aHRs) controlled for potential confounding variables. Sensitivity analyses were conducted in a subgroup of women who received pertussis vaccination during pregnancy to assess whether associations between IIV and adverse outcomes were maintained after adjusting for pertussis vaccination. Results: Among 8827 participants in our study, women who received IIV in pregnancy did not have an elevated risk of an adverse birth outcome compared with unvaccinated pregnant women: preterm births (HR, 1.10 [95% CI, .92-1.31]; P = .28); LBWT (HR, 1.05 [95% CI, .76-1.44]; P = .77); or SGA (HR, 0.99 [95% CI, .86-1.15]; P = .94). Adjustment for pertussis vaccination during pregnancy yielded similar results: preterm births (aHR, 1.05 [95% CI, .82-1.34]; P = .69); LBWT (aHR, 0.81 [95% CI, .50-1.29]; P = .37); SGA (aHR, 0.92 [95% CI, .74-1.14]; P = .43). There was no evidence of elevated risk by trimester of IIV. Conclusions: No significant associations were found between maternal IIV or pertussis vaccination in pregnancy and adverse birth outcomes, regardless of the trimester of pregnancy a vaccination was given compared to unvaccinated pregnancies.

SUMMARYPertussis morbidity is highest in infants too young to be fully protected by routine vaccination schedules. Alternate vaccine strategies are required to maximise protection in this age-group. To understand baseline pertussis epidemiology prior to the introduction of the maternal pertussis vaccination program in 2014, we conducted a retrospective case series analyses of 53 901 notifications and temporal trends from 1997 to 2014. Notifications were highest in infants younger than 4 months of age and highest annual notification rates in infants younger than 1 month of age (308/100 000 per year). Amongst Aboriginal and Torres Strait Islander infants aged younger than 1 month, this rate was 576/100 000 per year. Notification rates were 40% higher amongst women 15–44 years, 62·4/100 000 population compared with men (44·5/100 000) and 90% higher in Aboriginal and Torres Strait Islander women of the same age (38·2/100 000) compared with men (19·7/100 000). Six infant deaths were identified, all younger than 2 months of age. Monitoring epidemiology in at-risk groups – infants too young to be vaccinated, women of childbearing age and Aboriginal and Torres Strait Islander peoples – following implementation of the maternal pertussis vaccination program will be important to assess its impact and safety.

Background Botulism is a paralytic disease caused by the neurotoxin produced by Clostridium botulinum. The majority of cases are due to ingestion or injection drug use. Wound botulism from traumatic injury is exceedingly rare, with only one to two cases reported each year in the United States. Case Report A 27-year-old man presented to the Emergency Department with diplopia, dysphagia, and progressive weakness 10 days after sustaining a gunshot wound to his right lower leg. He had been evaluated for the same complaints at a different facility the day prior and was discharged. His wound appeared well-healing, but a high suspicion for wound botulism led to rapid consultation with the state Poison Control Center and the Centers for Disease Control and Prevention. The patient developed worsening respiratory insufficiency and required mechanical ventilation. Expeditious treatment with equine heptavalent botulinum antitoxin resulted in significant recovery of strength in 4 days. Serum toxin bioassay tested positive for botulinum neurotoxin type A. Why Should an Emergency Physician be Aware of This? Wound botulism now accounts for the majority of adult botulism in the United States. It should be considered in any patient with signs of neuromuscular disease and a recent injury, even if the wound appears uninfected.

Introduction In Australia, influenza vaccination is recommended for all women who will be pregnant during the influenza season. Vaccine safety and effectiveness are key concerns and influencers of uptake for both vaccine providers and families. We assessed the safety of receiving an influenza vaccination during any trimester of pregnancy with respect to preterm births and infant birthweight. Methods We conducted a nested retrospective cohort study of ‘FluMum’ participants (2012–2014). Our primary exposure of interest was influenza vaccination during pregnancy. The primary outcomes of interest were infant birthweight and weeks’ gestation at birth for live singleton infants. Analyses included comparisons of these birth outcomes by vaccination status and trimester of pregnancy an influenza vaccine was given. We calculated means, proportions, and relative risks and performed multivariable logistic regression for potential confounding factors. Results In the 7126 mother-infant pairs enrolled in this study, mean maternal age at infant birth was 31.7 years. Influenza vaccine uptake in pregnancy was 34%. Most mothers with a known date of vaccination received a vaccine in the second trimester (51%). Those mothers with a co-morbidity or risk factor were 13% more likely to have influenza vaccine during pregnancy compared to other mothers (RR 1.13, 95% CI 1.04–1.24, p = 0.007). Mean weeks’ gestation at birth was 38.7 for the vaccinated and 38.8 for the unvaccinated group (p = 0.051). Infants in the vaccinated group weighed 15 g less in birthweight compared to the unvaccinated infants (95% CI −12.8 to 42.2, p = 0.29). Conclusion Results arising from this large Australian cohort study are reassuring with respect to two critical safety outcomes; preterm births and low infant birthweights. Studies examining a broader range of birth outcomes following influenza vaccination during pregnancy are required, particularly now that maternal vaccination in pregnancy has expanded to include pertussis as well as influenza.

During the spring of 2009, pandemic influenza A (H1N1) virus (pH1N1) was recognized and rapidly spread worldwide. To describe the geographic distribution and patient characteristics of pH1N1-associated deaths in the United States, the Centers for Disease Control and Prevention requested information from health departments on all laboratory-confirmed pH1N1 deaths reported from 17 April through 23 July 2009. Data were collected using medical charts, medical examiner reports, and death certificates. A total of 377 pH1N1-associated deaths were identified, for a mortality rate of .12 deaths per 100,000 population. Activity was geographically localized, with the highest mortality rates in Hawaii, New York, and Utah. Seventy-six percent of deaths occurred in persons aged 18-65 years, and 9% occurred in persons aged ≥ 65 years. Underlying medical conditions were reported for 78% of deaths: chronic lung disease among adults (39%) and neurologic disease among children (54%). Overall mortality associated with pH1N1 was low; however, the majority of deaths occurred in persons aged

On March 6, 2017, the New Jersey Department of Health (NJDOH) was notified of three cases of septic arthritis in patients who had received intra-articular injections for osteoarthritic knee pain at a private outpatient practice. The practice voluntarily closed the next day. NJDOH, in conjunction with the local health department and the New Jersey Board of Medical Examiners, conducted an investigation and identified 41 cases of septic arthritis associated with intra-articular injections administered during 250 patient visits at the same practice, including 30 (73%) patients who required surgery. Bacterial cultures of synovial fluid or tissue from 15 (37%) patients were positive; all recovered organisms were oral flora. An infection prevention assessment of the practice identified multiple breaches of recommended infection prevention practices, including inadequate hand hygiene, inappropriate use of pharmacy bulk packaged (PBP) products as multiple-dose containers and handling PBP products outside of required pharmacy conditions, and preparation of syringes up to 4 days in advance of their intended use. No additional septic arthritis cases were identified after infection prevention recommendations were implemented within the practice.

Background Influenza infection during pregnancy causes significant morbidity and mortality. Immunisation against influenza is recommended during pregnancy in several countries however, there are limited data on vaccine uptake, and the determinants of vaccination, in pregnant Australian Aboriginal and/or Torres Islander women. This study aimed to collect pilot data on vaccine uptake and attitudes towards, and perceptions of, maternal influenza vaccination in this population in order to inform the development of larger studies. Methods A mixed-methods study comprised of a cross-sectional survey and yarning circles (focus groups) amongst Aboriginal and Torres Strait Islander women attending two primary health care services. The women were between 28 weeks gestation and less than 16 weeks post-birth. These data were supplemented by data collected in an ongoing national Australian study of maternal influenza vaccination. Aboriginal research officers collected community data and data from the yarning circles which were based on a narrative enquiry framework. Descriptive statistics were used to analyse quantitative data and thematic analyses were applied to qualitative data. Results Quantitative data were available for 53 women and seven of these women participated in the yarning circles. The proportion of women who reported receipt of an influenza vaccine during their pregnancy was 9/53. Less than half of the participants (21/53) reported they had been offered the vaccine in pregnancy. Forty-three percent reported they would get a vaccine if they became pregnant again. Qualitative data suggested perceived benefits to themselves and their infants were important factors in the decision to be vaccinated but there was insufficient information available to women to make that choice. Conclusions The rates of influenza immunisation may continue to remain low for Aboriginal and/or Torres Strait Islander women during pregnancy. Access to services and recommendations by a health care worker may be factors in the lower rates. Our findings support the need for larger studies directed at monitoring and understanding the determinants of maternal influenza vaccine uptake during pregnancy in Australian Aboriginal and Torres Strait Islander women. This research will best be achieved using methods that account for the social and cultural contexts of Aboriginal and Torres Strait Islander communities in Australia.

This oral presentation will describe the surveillance planning and activities for a large-scale event (Super Bowl XLVIII) using New Jersey syndromic surveillance system (EpiCenter).

In 2008, the New Jersey Department of Health (NJDOH) identified a 21.1% increase in reported invasive pneumococcal disease (IPD). In 2009, NJDOH piloted nucleic acid-based serotyping to characterize serotypes causing IPD. From April through September, NJDOH received specimens from 149 of 302 (49%) case patients meeting our case definition. An uncommon serotype, 10A, accounted for 25.2% of IPD overall and was identified in 12 counties, but it was associated with one county (rate ratio = 5.4, 95% confidence interval [CI] 2.1, 11.8). NJDOH subsequently conducted a case-control study to assess the presentation of and clinical risk factors for 10A IPD. Case patients with 10A IPD were more likely to have had immunosuppression, asthma, and multiple chronic medical conditions than control subjects had (odds ratio [OR] = 2.6, 95% CI 1.1, 6.3; OR=4.7, 95% CI 1.7, 13.2; and OR=2.3, 95% CI 1.0, 5.2, respectively). State-based pneumococcal serotype testing identified an uncommon serotype in New Jersey. Continued pneumococcal serotype surveillance might help the NJDOH identify and respond to future serotype-specific increases.

Objective: To identify parameters that may assist clinicians in predicting which women will develop preeclampsia (PE) after initially presenting with gestational hypertension (GH). Methods: 118 women were recruited to the study with GH or PE. They were divided into three groups based on their diagnosis at delivery- (1) GH, (2) PE from the time of presentation, (3) those with an initial diagnosis of GH who progressed to PE. Women underwent 24 hour ambulatory blood pressure monitoring (ABPM) and had serum estrogen, progesterone, β-HCG, leptin and adiponectin measured as possible predictors of transformation of GH to PE. Results: Women who presented with GH, and progressed to PE, presented four weeks earlier (33 vs 37 weeks, p < 0.001) than those who did not progress. Women with PE, either as their initial diagnosis or after progression from GH, were delivered earlier (p < 0.001) and had more small for gestational age (SGA) babies than women with GH at delivery (p < 0.05). Those who developed PE after presenting with GH generally had higher blood pressures than those who remained as GH, significant for awake and 24 hour systolic blood pressures (p < 0.05). β-HCG, estrogen, progesterone or leptin values were similar across the groups. Adiponectin was higher in women with established PE at presentation compared to women with GH (p = 0.02) but adiponectin failed to discriminate those women with an initial diagnosis of GH who progressed to PE. Conclusion: 24 hr ABPM may provide a non-invasive method of identifying this 'at risk' GH population, particularly in the case of early presentation.

Objective: To determine whether self-initiated and recorded automated blood pressure measurement can provide an accurate estimate of ambulatory blood pressure in pregnant women suspected of having 'white coat hypertension'. Design: A prospective observational study. Setting: Women's and Children's Health Unit, St George Hospital, a teaching hospital of the University of New South Wales. Population: Pregnant women being assessed for possible 'white-coat hypertension'. Methods: Sixty-six pregnant women who were undergoing 24 hour ambulatory blood pressure monitoring (ABPM) in their home or work environment also measured their blood pressure six times during this interval using a self-initiated automated blood pressure recorder (Omron HEM 705CP). Agreement between awake ABPM and Omron recorded blood pressures was tested by Bland-Altman analysis. Main outcome measure: Limits of agreement between blood pressures measured by each device. Results: Average blood pressures obtained by the two devices were identical (125/77 mmHg) but limits of agreement were wide, -20 to +23 mmHg for systolic blood pressure and -9 to +15 mmHg for diastolic blood pressure. Conclusion: The Omron HEM 705CP is a useful device for measuring group average blood pressures in pregnant women suspected of having white coat hypertension but cannot reliably replace ABPM for clinical management of individual pregnant women.

Objective To determine (a) the prevalence of hypertension during sleep in pre-eclampsia and gestational hypertension, and (b) whether women with hypertension during sleep have worse pregnancy outcomes than hypertensive pregnant women with controlled (normal) blood pressure (BP) during sleep. Design Prospective double-blind cohort study. Setting Inpatients and outpatients managed in a day assessment unit (DAU) at St George Hospital, Sydney, Australia. Participants A total of 186 hypertensive pregnant women, 158 of whom had successful 24 h BP monitoring; 40% had proteinuric pre-eclampsia (PE), 43% gestational hypertension (GH) and 17% essential hypertension (EH). Interventions Blood pressure, 24 h non-invasive, monitoring (Spacelabs 90207) was undertaken successfully in 158 women with PE, GH or EH, whether or not they were receiving antihypertensives. Women and clinicians were blinded to results of these BP monitors. Sleep hypertension was defined as BP > 117/68 mmHg at 26-30 weeks or < 123/72 mmHg after 30 weeks gestation. Main outcome measures Maternal and fetal outcomes were compared between women with and without sleep hypertension and the prevalence of sleep hypertension was determined. Results Sleep hypertension was present in 59%, more commonly in PE (79%) than GH/EH (45%), P