Prevalence of hepatitis C among pregnant women in an Appalachian population.

The opioid crisis has adversely affected West Virginia's pregnant and infant populations. With high rates of opioid use disorder and neonatal abstinence syndrome, West Virginia has the highest rates of Hepatitis C (HCV) acute infection among pregnant women. To better understand how HCV impacts an already high-risk population, the study purpose was to (1) describe its prevalence among women receiving prenatal care at a single tertiary care clinic in Appalachia and compare with state and national rates, and (2) determine whether it is associated with preterm birth (gestation <37 weeks). Data were collected on a retrospective cohort of pregnant patients universally screened for HCV between 2017 and 2021. The study cohort had an HCV infection rate of 119/988 = 11.94% or 119.4 per 1000. This is five times the rate of 22.6 per 1000 live births in West Virginia in 2014 and 35 times the national rate of 3.4 per 1000 live births (MMWR Morb Mortal Wkly Rep 66, 2017 and 470). Viral loads were detected in 63 (6.38%) of patients. The study cohort with birth outcome data had high rates of tobacco use (326/720; 45.3%) and substance abuse (209/720; 29.0%). The preterm birth rate was 17.8% (128/720), almost double the national average (10.09%) (Natl Vital Stat Rep 70, 2021 and 1). There was no statistically significant difference in preterm birth between HCV-positive (15/92; 16.3%) and HCV-negative (113/628; 18.0%) patients. HCV infection in our population presents a significant public health issue and missed opportunity for treatment in a population with continuity of care challenges. These findings could be used to justify a pilot program for early postpartum referral for treatment.

Predicting perinatal outcomes with an obstructive sleep apnea screening tool.

The objective was to determine if a screening tool for obstructive sleep apnea could be used to predict adverse perinatal outcomes. This was a prospective observational study of patients receiving prenatal care and universally screened for obstructive sleep apnea with the STOP Questionnaire (four questions related to Snoring, Tiredness during daytime, Observed apnea, and high blood Pressure). Confounding variables were included in a backwards logistic regression model to predict adverse perinatal outcomes. The study population of 442 women had positive STOP screens (64; 14.5%) associated with preterm delivery and neonatal intensive care unit admissions. For preterm delivery, history of preterm delivery was the strongest predictor with odds ratios of 4.2 (95% confidence interval 2.0-8.8; p < 0.001), followed by STOP, odds ratios 2.8 (95% confidence interval 1.4-5.8; p = 0.004) and nulliparity, odds ratios 2.3 (95% confidence interval 1.2-4.4; p = 0.013). A positive STOP was the only significant predictor for neonatal intensive care unit admissions, odds ratios 2.5 (95% confidence interval 1.1-5.7; p = 0.036). STOP screening test performance indicated low sensitivity but high specificity: preterm delivery (28.3%, 87.4%), neonatal intensive care unit admissions (27.3%, 86.6%), low birth weight (25.0%, 86.9%), and preeclampsia (16.7%, 85.6%). As a stand-alone tool, the STOP Questionnaire has limited performance, but could be explored in combination with other factors that might increase sensitivity to predict preterm delivery and neonatal intensive care unit admission.

Improving screening for alcohol consumption during pregnancy with phosphatidylethanol.

OBJECTIVE: The study objective was to compare rates of alcohol use between urine ethanol testing and self- reporting (Method: 1) and Phosphatidylethanol (PEth) dried blood spot testing and self-reporting (Method: 2). METHODS: This was a prospective observational study in an obstetric clinic with universal alcohol screening. RESULTS: Method: 1 identified 11 patients with alcohol use (5 urine and 6 self-reported); Method: 2 identified 28 (22 PEth and 6 self-reported) out of 315 patients (one patient positive for both urine and PEth). The six patients with self-reported use had negative urine and PEth testing. We had fair agreement between the two methods (282 negative and 7 positive; 289/314=92.0%; Kappa 0.32, p<0.001); method 2 identified significantly more women (McNemar, p<0.001). Combining methods: resulted in an alcohol detection rate of 10.2% (32/314). CONCLUSION: Method: 2 identified more alcohol users than Method: 1. Combining both methods: identified the most alcohol consumption.

Use of Sperm Parameters to Predict Clinical Pregnancy with Intrauterine Insemination.

OBJECTIVE: To test the hypothesis that morphology is the best predictor of clinical pregnancy (CP) when employing intrauterine insemination (IUI). STUDY DESIGN: We retrospectively reviewed a registry of 527 couples who collectively underwent 1,027 IUI cycles, testing sperm parameters and other variables with univariate and multivariate analyses for association with CP. With the literature scant regarding the impact of sperm morphology on IUI outcome, we determined semen parameter threshold values in our patient population and compared them to published reference range values. A logistic regression model was used to determine predictors of CP. RESULTS: Fecundity was 12.9% per cycle and fertility was 23.3% by the third attempted cycle. Morphology was the most significant parameter predicting CP with IUI. Motility was also significant when employing our new threshold values. Using receiver operator characteristic curve analysis, values 16% morphology and 69% motility were found to be the optimal threshold values for achieving CP. CONCLUSION: Morphology was the best predictor of CP. When considering IUI, the best chance of clinical pregnancy occurs when both motility and morphology values are above normal thresholds.

Relationship Between Methadone, Selective Serotonin Reuptake Inhibitors, and Neonatal Abstinence Syndrome.

OBJECTIVE: To compare incidence and severity of neo- natal abstinence syndrome (NAS) in neonates exposed to methadone and selective serotonin reuptake inhibitors (SSRIs) with neonates ex- posed to methadone alone. STUDY DESIGN: Retro- spective cohort study of women on methadone main- tenance with live births be- tween January 1, 2003, and December 31, 2009, at a tertiary care hospital. Data were abstracted from electronic medical records, exclud- ing cases of multiple gestations and lack of neonatal abstinence score documentation. Data analysis included Mann-Whitney U, Fisher's exact test, a receiver operat- ing characteristic curve, and a scatter diagram. RESULTS: A total of 91 cases comprised our study population, with 85 (93.4%) assigned to the methadone- only group and 6 (6.6%) assigned to the methadone and SSRIs group. NAS incidence was not significantly different between the methadone/SSRI group and the methadone group (5/6 [83.3%] vs. 43/85 [50.6%], p=0.21). However, severity of NAS (median 14.0 vs. 10.0, p=0.04) and neonatal intensive care unit stay were significantly higher and longer in the methadone/ SSRI group. CONCLUSION: While currently neonates exposed to SSRIs are not screened for NAS, health care providers may need to pay closer attention to the effects of SSRIs on neonates.

Transvaginal cervical length and tobacco use in Appalachian women: association with increased risk for spontaneous preterm birth.

Currently ACOG recommends that a mid-term screening strategy may be considered to identify short cervix in low risk populations in an effort to prevent preterm birth. Vaginal progesterone is recommended for women with a cervical length ≤20 mm. Cerclage is recommended for women with prior spontaneous preterm birth who are already receiving progesterone supplementition and CL is <25 mm. This study examined risk factors for spontaneous preterm birth (SPB) <35 weeks among a general obstetrical population prior to these ACOG recommendations. However, cervical cerclage was a possible intervention. Study population included 1,074 patients from 1 Jan 2007-30 Jun 2008 receiving mid-trimester transvaginal ultrasounds during prenatal care at a tertiary medical center clinic. Receiver operator characteristic (ROC) curve cutoff optimal value was ≤34 mm, (n=224), corresponding to 8.9% SPB with shortened cervices compared to 1.4% in patients with normal cervices (>34 mm; n=850; p<0.001 (Area Under the Curve (AUC) 76.6, p<0.001). Cervical lengths <30 mm had 12 times the risk of SPB (p<0.001) while 30-34 mm had 5 times (p=0.005). Tobacco use (≥10 cigarettes per day), p=0.030, and low BMI, p=0.034, had additive effect. Shortened cervical length during routine screening independently predicted SPB while heavy smoking with shortened cervix during pregnancy doubled risk compared to shortened cervix alone.

Intraoperative utilization of dexamethasone/bupivacaine/gentamicin solution in laparoscopic assisted vaginal hysterectomy and pain management.

Adequately controlling pain is a key component of postoperative care after a hysterectomy. The purpose of this study was to evaluate the effects of two intraperitoneal (IP) administered solutions during Laparoscopic Assisted Vaginal Hysterectomy (LAVH), on the amount of postoperative self-administered morphine. In this prospective, randomized, double blinded study, twenty women undergoing LAVH randomly distributed to two treatment groups: (1) 100 ml dexamethasone/ bupivacaine/ gentamicin (DMG) solution: 60 cc injected vaginally at cuff and 40 cc placed topically via laparoscopy over intra-peritoneal postoperative surfaces (IP) and 5 ml bupivacaine or 5 ml saline injected at the laparoscopic incision sites, (2) 100 ml saline solution: 60 cc injected vaginally at cuff and 40 cc placed topically via laparoscopy over intra-peritoneal postoperative surfaces (IP) and 5 ml bupivacaine or 5 ml saline injected at the laparoscopic incision sites. The amount of morphine utilized by the patients was documented from their patient controlled anesthesia (PCA) pump. Patient parameters recorded included perceived pain score, height, weight, age, race, reason for surgery, pre-surgery medications, American Society of Anesthesiologist (ASA) classification, length of the surgery and estimated blood loss (EBL). Age, EBL, length of surgery, and ASA classification were not significantly different between the groups. The postoperative amount of morphine utilized was higher at 4 (p=.02) and 16 hours (p = .04) and tended to be higher at 8, 12 hours (p=.06), and 24 hours (p=.09) in the saline IP group. Overall the saline IP group (n=10) used (median; range) 21.5; 8-82 mg of morphine while the DMG IP group (n=10) used 10.5; 1-23 mg. No participants reported a postoperative infection. This study demonstrates that intraoperative utilization of DMG solution during LAVH enables patients clinically to have less perceived pain and subsequently tend to utilize about half the amount of morphine, helping to avoid the potential harmful side effects and adverse reactions of morphine.

The 80-hour work week for residents: views from obstetric and gynecology program directors.

In 2003, the Accreditation Council for Graduate Medical Education mandated an 80-hour work week restriction for residency programs. We examined program directors' views on how this mandate affects the education of Obstetrics and Gynecology residents. A 25 question survey was administered via Survey Monkey to Obstetrics and Gynecology program directors in the United States over three months in 2011. Fifty program directors (response rate of 28%) completed it with more men (62%) than women (38%) respondents. Overall, only 28% (14/50) responded that the program had improved, with significantly fewer men (5/14; 16.1%) than women (47.4% 9/19; p < 0.0169) directors reporting this. There was little perceived improvement in any of the six core ACGME performance objectives and in the CREOG scores, with the improvement ranging from 8% to 12%. In fact, while we observed the percentage of women directors reporting improvement in patient care and interpersonal and communication skills significantly higher compared with their male counterparts, the majority of women still reported either no improvement or a decline in these areas. Though our sample size was small, we found some significant difference between the views of male and female program directors. Both groups nonetheless responded with the majority with a decline or no change rather than a perceived improvement in any of the educational endeavors studied.

Serum anti-endometrial antibodies and first trimester pregnancy loss.

Serum anti-endometrial antibodies (AEA) have been studied as a marker for endometriosis and implantation failure. We sought to determine if the presence of AEA in the serum of pregnant patients is associated with first trimester pregnancy loss including complete abortion. This is a prospective pilot case control study of 30 patients presenting with first trimester pregnancy loss compared to a control group of 30 first trimester pregnant patients with a normal course for the presence of serum AEA. The control group was selected using propensity matching of patient characteristics. AEA assays were performed by a single operator blinded to clinical status of patients. The mean maternal age in the study and control groups was not statistically significant (26.1 +/- 5.7 vs. 24.2 +/- 4.5 years, p < 0.155). A history of pregnancy loss was not significantly greater in the study group (12/30 = 40.0%) as compared to the control group (8/30 = 26.7%, p < 0.412). In both study and control groups, 40% of the samples tested positive for AEA; therefore, we found no evidence of an association between the presence of AEA and pregnancy loss. These findings in our pilot study suggest that presence of serum AEA does not appear to be a marker for early pregnancy loss.

Smoking in pregnancy in West Virginia: does cessation/reduction improve perinatal outcomes?

To determine if pregnant women decreasing/quitting tobacco use will have improved fetal outcomes. Retrospective analysis of pregnant smokers from 6/1/2006-12/31/2007 who received prenatal care and delivered at a tertiary medical care center in West Virginia. Variables analyzed included birth certificate data linked to intervention program survey data. Patients were divided into four study groups: <8 cigarettes/day-no reduction, <8 cigarettes/day-reduction, ≥8 cigarettes/day-no reduction, and ≥8 cigarettes/day-reduction. Analysis performed using ANOVA one-way test for continuous variables and Chi-square for categorical variables. Inclusion criteria met by 250 patients. Twelve women (4.8%) quit smoking; 150 (60%) reduced; 27 (10.8%) increased; and 61 (24.4%) had no change. Comparing the four study groups for pre-term births (<37 weeks), 25% percent occurred in ≥8 no reduction group while 10% occurred in ≥8 with reduction group (P = 0.026). The high rate of preterm birth (25%) in the non-reducing group depended on 2 factors: (1) ≥8 cigarettes/day at beginning and (2) no reduction by the end of prenatal care. Finally, there was a statistically significant difference in birth weights between the two groups: ≥8 cigarettes/day with no reduction (2,872.6 g) versus <8 cigarettes/day with reduction (3,212.4 g) (P = 0.028). Smoking reduction/cessation lowered risk of pre-term delivery (<37 weeks) twofold. Encouraging patients who smoke ≥8 cigarettes/day during pregnancy to decrease/quit prior to delivery provides significant clinical benefit by decreasing the likelihood of preterm birth. These findings support tobacco cessation efforts as a means to improve birth outcome.

Prenatal diagnosis of spontaneous bladder rupture in a female fetus.

Spontaneous bladder rupture is a rare condition, with diagnosis more rare in the prenatal than postnatal period. To our knowledge, there have been 7 cases of prenatally diagnosed bladder ruptures and all have been males. We report the first case of prenatal diagnosis of spontaneous bladder rupture in a female fetus. After a primary Cesarean-section birth, a tear in the newborn infant bladder dome was identified and repaired in 2 layers. The cause of the bladder rupture remains unknown.

Endometriosis-associated infertility: double intrauterine insemination improves fecundity in patients positive for antiendometrial antibodies.

PROBLEM: Prospective registry study evaluating effects of endometriosis (E) and serum antiendometrial antibodies (AEA) on fecundity in intrauterine insemination (IUI) cycles. METHOD OF STUDY: AEA assays on 572 consecutive women receiving 969 single and 274 double IUI cycles. Logistic regression was utilized. RESULTS: Fecundity was 11.5% (143/1243 cycles). Double IUI improved fecundity with significance achieved in certain study groups. Compared to the AEA- subgroup, all study groups except for the E+ AEA- group had significantly lower fecundity. Two study groups receiving double IUI had significantly increased fecundity, E- AEA+ (OR: 5.1, CI: 1.1-22.7, P=0.032) and E+ AEA+ (OR: 4.1, CI: 1.2-14.0, P=0.025) and significant predictors of pregnancy (E- AEA+, OR: 7.8, CI: 1.7-36.2, P=0.009 and E+ AEA+, OR: 4.2, CI: 1.2-15.1, P=0.026). CONCLUSION: Double IUI improves fecundity in AEA+ patients. E-associated infertility is better diagnosed by the AEA assay than by surgery. Double IUI should be attempted prior to assisted reproductive technologies in AEA+ patients with normal fallopian tubes.

The ability of the quadruple test to predict adverse perinatal outcomes in a high-risk obstetric population.

OBJECTIVE: To determine the ability of the quadruple Down's syndrome screening test (quad screen) to predict other adverse perinatal outcomes (APO) in a high-risk obstetric population. SETTING: A tertiary medical centre in West Virginia. METHODS: We retrospectively reviewed 342 obstetric patients with quad screen data from a single clinic. The quad screen included maternal serum levels of alphafetoprotein (AFP), human chorionic gonadotrophin (hCG), uncongjugated oestriol (uE(3)), and inhibin A. The risk of APO was compared between patients with at least one abnormal marker versus no abnormal markers and >or=2 abnormal markers versus <2 abnormal markers. Abnormal markers were determined by cut-off values produced by Receiver Operator Characteristic (ROC) curves and the FASTER trial. Unadjusted and adjusted effects were estimated using logistic regression analysis. RESULTS: The risk of having an APO increased significantly for patients with abnormal markers by about three-fold using ROC and two-fold using FASTER trial thresholds. CONCLUSIONS: The quad screen shows value in predicting risk of APO in high-risk patients.