Vaginal matrix metalloproteinase-9 (MMP-9) as a potential early predictor of preterm birth.

OBJECTIVES: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Vestibulodynia and the Vaginal Microbiome: A Case-Control Study.

BACKGROUND: Recent studies of the vaginal microbiome have led to a better understanding of the microbiota and interactions with the host environment, however the role of the vaginal microbiome in vestibulodynia remains unclear. AIM: This study aims to investigate and examine differences in the bacterial and fungal microbiome among patients with vestibulodynia and healthy controls. METHODS: A case-control study was conducted examining the vaginal microbiome of 29 patients with vestibulodynia and 26 controls through Stony Brook University Obstetrics and Gynecology ambulatory clinic. Exclusion criteria included a diagnosis of vaginal infection at the time of presentation, a prior diagnosis of vulvodynia or receipt of treatment, immunosuppression, and receipt of steroid or antibiotic therapy. Vaginal swab samples were obtained from participants. DNA was extracted and sent for diversity assay of 16S rRNA for prokaryotic species and internal transcribed spacers (ITS) for fungi. Demographic characteristics for both cases and controls were obtained through a retrospective chart review. OUTCOME MEASURE: Principal component analysis (PCA) and linear discriminant analysis effect size (LefSe) were used to identify differences in relative abundance of operational taxonomic units (OTUs) for the vaginal microbiome between vestibulodynia patients and controls. RESULTS: Lactobacillus species were dominant amongst both cases and controls. PCA of 16S and ITS OTUs did not show significant differences in microbiome composition between vestibulodynia patients and controls. LefSe demonstrated higher abundance of Bifidobacterium longum, the Genus Sneathia, and the Family Leptotrichiaceae, in controls compared to vestibulodynia samples. For ITS, Aspergillus spp. was significantly more prevalent in controls than in vestibulodynia cases. CLINICAL IMPLICATIONS: Additional studies are needed to further assess the clinical significance of these findings. STRENGTHS AND LIMITATIONS: Strengths of this study include ITS amplicon sequence analysis for fungal species diversity. Limitations of this study include small sample size and lack of racial diversity. CONCLUSIONS: Our study did not find significant differences in composition or diversity between the vaginal microbiomes of cases of vestibulodynia and controls; however, the data suggests differences in abundance of biota requiring further research for biological and clinical significance. Panzarella DA, Peresleni T, Collier JL, et al. Vestibulodynia and the Vaginal Microbiome: A Case-Control Study. J Sex Med 2022;19:1451-1462.

Saving time, signaling trust: Using the PROMOTE self-report screening instrument to enhance prenatal care quality and therapeutic relationships.

Objectives: Comprehensive screening of psychosocial vulnerabilities and substance use in prenatal care is critical to promote the health and well-being of pregnant patients. Effective implementation of new screening procedures and instruments should be accompanied by an in-depth investigation to assess their feasibility and impact on care delivery. Methods: In 2020, following implementation of the Profile for Maternal and Obstetric Treatment Effectiveness (PROMOTE) an innovative self-report screening instrument developed for outpatient prenatal clinics in the U.S., we conducted individual interviews and focus groups with twenty-two midwives, nurse practitioners, and obstetric residents focused on the PROMOTE and its impacts on care delivery. We used interpretive description for the qualitative analysis of the interviews. Results: Five themes were identified: Guiding Time Efficiently: "The Time I Don't Have," Preventing Missed Care, Signaling Trustworthiness, Establishing Trauma-Informed Foundations, and Promoting "Honest" Patient Disclosure. Conclusion: Interviews suggest that patient completion of the PROMOTE before the medical encounter helps reduce previously reported barriers, is more time-effective, and makes history-taking easier. It also facilitates the patient-provider relationship. Innovation: Findings offer insight into the breadth and depth of clinical impact resulting from the PROMOTE, and provide guidance for the implementation of such tools to optimize health outcomes.

Pregnancy-specific coping and changes in emotional distress from mid- to late pregnancy.

Objective: To examine whether pregnancy-specific coping predicts changes in emotional distress from mid- to late pregnancy. Background: There is a need to identify ways of coping that reduce or elevate emotional distress in pregnant women as such distress increases the risk of adverse birth outcomes. Methods: 132 women receiving prenatal care from a university hospital midwifery practice were recruited prior to 25 weeks gestation (M = 19.58, SD = 5.14). The state anxiety version of the State-Trait Personality Inventory (STPI) and the Revised Prenatal Distress Questionnaire (NuPDQ) were administered in mid- (M = 25.7 weeks, SD = 4.55) and late (M = 33.4 weeks, SD = 4.18) pregnancy and the Revised Prenatal Coping Inventory (NuPCI) at the latter timepoint. Results: Factor analysis of the NuPCI identified five distinct, conceptually interpretable types of coping: Prayer/Spirituality, Receiving Social Support, Planning/Preparation, Positive Appraisal, and Avoidant Coping. Avoidant Coping was used least frequently and Positive Appraisal was used most. The STPI and NuPDQ were aggregated to create a measure of emotional distress. After controlling for mid-pregnancy distress, Avoidant Coping predicted greater emotional distress in late pregnancy (ß = .18, R2 = .61, p < .01) and Positive Appraisal predicted lower late pregnancy distress (ß = -.15, R2 = .60, p < .01). Conclusion: This is one of the first studies to demonstrate that specific ways of coping with stress during pregnancy predict changes in pregnant women's emotional distress. The NuPCI is a psychometrically sound self-report instrument to examine coping and its association with emotional distress.

Progesterone effects on vaginal cytokines in women with a history of preterm birth.

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.

Patient-provider communication, maternal anxiety, and self-care in pregnancy.

RATIONALE: Favorable relationships with health care providers predict greater patient satisfaction and adherence to provider recommendations. However, the specific components of patient-provider relationships that account for these benefits have not been identified. The potential benefits of strong patient-provider relationships in pregnancy may be especially important, as care providers have frequent, intimate interactions with pregnant women that can affect their emotions and behaviors. In turn, prenatal emotions and health behaviors have potent effects on birth outcomes. OBJECTIVE: This study investigated whether pregnant women's relationships with their midwives predicted better self-care. Specific components of the patient-provider relationship (communication, integration, collaboration, and empowerment) were examined. We also investigated a mechanism through which these relationship components may be associated with salutary health behaviors: by alleviating women's anxiety. METHODS: In total, 139 low-risk patients of a university-affiliated midwifery practice in the northeastern United States completed well-validated measures assessing their relationship with midwives, state anxiety, and prenatal health behaviors in late pregnancy; state anxiety was also assessed in mid-pregnancy. RESULTS: Women's perceptions of better communication, collaboration, and empowerment from their midwives were associated with more frequent salutary health behavior practices in late pregnancy. Controlling for mid-pregnancy anxiety, lower anxiety in late pregnancy mediated associations of communication and collaboration with health behavior practices, indicating that these associations were attributable to reductions in anxiety from mid- to late pregnancy. CONCLUSION: Results substantiate that benefits of patient-provider relationships in pregnancy may extend beyond providing medical expertise. Some aspects of patient-provider relationships may offer direct benefits to pregnant women in promoting better health practices; other aspects of these relationships may indirectly contribute to better health practices by alleviating negative emotions. The benefits of strong midwife relationships may derive from the reassurance, comfort, and warmth these relationships offer, as well as the information and education that midwives provide to their patients.

Psychometric properties of the Prenatal Health Behavior Scale in mid- and late pregnancy.

INTRODUCTION: Psychometrically sound self-report measures are important tools to advance research on health behaviors in pregnancy. The Prenatal Health Behavior Scale (PHBS) has been used in prior studies to quantify health behaviors and examine their associations with relevant variables, but its psychometric properties have not been carefully investigated. METHODS: In a sample of low-risk women, we examined the factor structure, reliability, and validity of the PHBS at mid- (N = 138) and late (N = 102) pregnancy. RESULTS: In confirmatory factor analysis, items on the PHBS loaded onto a single reliable factor, but separating health-promoting and health-impairing behavior into two factors had better model fit. The scales defined by these two factors had good internal consistency in mid- and late pregnancy, were only moderately correlated, and were predicted by somewhat different sets of sociodemographic and psychological variables. Pregnancy-specific stress was a robust predictor of health-promoting and health-impairing behavior across time. DISCUSSION: Results bolster confidence in the reliability and validity of the PHBS and its appropriateness as a self-report tool for investigation of health behaviors among pregnant women. This study is one of the first investigations to examine patterns and predictors of health behavior practices at two time periods of pregnancy.