Management of Isolated Fever in Labour Compared with Clinical Chorioamnionitis in a Quaternary Centre.

OBJECTIVES: To investigate treatment patterns of women with isolated fever in labour and evaluate if variables in the sepsis in obstetrics score (SOS) or fetal tachycardia are associated with treatment differences. Our secondary objective was to compare women with isolated fever in labour with women with clinical chorioamnionitis to identify any clinicodemographic differences. METHODS: A retrospective cohort study of 473 patients at BC Women's Hospital who presented with isolated fever in labour between January 2011 and April 2016 compared with a dataset of 1135 women with clinical chorioamnionitis from 2011 to 2016 in the same institution. RESULTS: In our cohort of isolated fever in labour, antibiotics were given 74.2 % of the time, and the majority received cefazolin and metronidazole (80.9%, of those who received antibiotics). Higher maternal temperature and heart rate at time of first fever and fetal tachycardia were associated with more antibiotic use. Slightly higher maternal temperature was associated with use of a saline bolus and blood cultures. The proportion of women with a SOS greater than 5 increased 4.5-fold from time of first fever to time of maximum SOS. There were fewer cesarean deliveries in the isolated fever in labour group compared with the clinical chorioamnionitis group (22.4% vs. 54.0%; P < 0.0001). CONCLUSIONS: Slightly higher maternal temperature was associated with increased treatment, including antibiotic use, saline bolus administration, and blood cultures. As evidenced by the higher proportion of women with an SOS over 5, women with isolated fever in labour may have a propensity to deteriorate clinically.

A Survey on Variation in Diagnosis and Treatment of Chorioamnionitis in Tertiary Centres in Canada.

OBJECTIVE: Clinical detection and management of chorioamnionitis is challenging given the gold-standard for diagnosis remains placental pathology, the results of which are only available after delivery. Moreover, recommended diagnostic criteria for clinical chorioamnionitis have evolved over time. The goal of this study was to describe trends and differences in chorioamnionitis diagnostic and management practices in Canada. METHODS: We surveyed obstetric care providers participating in the Canadian Preterm Birth Network. Questionnaires were distributed electronically to all 29 sites and completed by 1 maternal-fetal medicine investigator at each site. RESULTS: The response rate was 82.8% (n = 24). There was considerable variation in the clinical criteria used to diagnose chorioamnionitis with 9 of 22 sites stating this occurs "frequently" or "very frequently." Isolated fever was "always" or "most of the time" used as an indication to start empiric antibiotic therapy in 14 of 24 sites, and 21 of 23 sites used the same diagnostic criteria for term and preterm deliveries. Placental histology (15 sites) and white blood cell count (14 sites) were the most common clinical tests performed to confirm chorioamnionitis. A combination of ampicillin and aminoglycoside antibiotics was used at 12 sites. Another frequently used antibiotic therapy was cefazolin and metronidazole (4 sites). CONCLUSION: There is a wide variation in practices for the diagnosis and management of chorioamnionitis across Canada. The results of this study will guide efforts to improve and standardize the management of this condition.

Dynamics of leukocyte telomere length in pregnant women living with HIV, and HIV-negative pregnant women: A longitudinal observational study.

BACKGROUND: HIV-mediated inflammation and immune activation can accelerate telomere attrition. In addition, antiretrovirals can inhibit telomerase, possibly shortening telomeres. We examined the longitudinal dynamics of leukocyte telomere length (LTL) during pregnancy in a unique cohort of women living with HIV (WLWH) treated with combination antiretroviral therapy (cART), and HIV-negative control women. METHODS: Blood was collected at three visits during pregnancy, at 13-23, >23-30, and >30-40 weeks of gestation, and for WLWH only, at 6 weeks post-partum. LTL was measured by qPCR and both cross-sectional and longitudinal (MANOVA) models were used to examine possible predictors of LTL among participants who attended all three visits during pregnancy. RESULTS: Among WLWH (n = 64) and HIV-negative women (n = 41), within participant LTL were correlated throughout pregnancy (p<0.001). LTL was shorter among WLWH at first visit, but this difference waned by the second visit. WLWH who discontinued cART post-partum experienced a decrease in LTL. Longitudinally, LTL was similar in both groups and increased as gestation progressed, a change that was more pronounced among women under 35 years. Among WLWH, both smoking throughout pregnancy (p = 0.04) and receiving a ritonavir-boosted protease inhibitor-based regimen (p = 0.03) were independently associated with shorter LTL. CONCLUSIONS: LTL increases as pregnancy progresses; the reasons for this are unknown but may relate to changes in blood volume, hormones, and/or cell subset distribution. While our observations need confirmation in an independent cohort, our data suggest that although some cART regimens may influence LTL, being on cART appears overall protective and that stopping cART post-partum may negatively impact LTL. The effect of smoking on LTL is clearly negative, stressing the importance of smoking cessation.

Exploring the live birth rates of women living with HIV in British Columbia, Canada.

OBJECTIVE: To evaluate the birth rates of women living with HIV (WLWH) compared to the general population in British Columbia (BC), Canada. METHODS: We retrospectively reviewed clinical and population level surveillance data from 1997 to 2015. Live birth rates from 1997 to 2015 among WLWH aged 15-49 years were compared with those of all BC women. Next, the number of live births among WLWH with a live birth between 1997-2012 and HIV-negative controls matched 1:3 by geocode were compared. RESULTS: WLWH had a lower birth rate compared to all BC women [31.4 (95%CI, 28.6-34.3) vs. 40.0 (39.3-40.1)/1000 person years]. Stratified by age, WLWH aged 15-24 years had a higher birth rate while WLWH aged 25-49 years had a lower birth rate than BC women (p<0.01). Between 1997 and 2015, birth rates for both populations decreased among women aged 15-24 years, and increased among women aged 25-49 years, most strikingly among WLWH 35-49 years (p<0.01). When comparing WLWH with a live birth to HIV-negative geocode matched controls, WLWH aged 15-24 years (p = 0.03) and aged 25-34 years (p<0.01) had more live births than controls while WLWH aged 35-49 years did not (p = 0.06). CONCLUSIONS: On a population level, WLWH have lower birth rates than the general population. However, this is not observed among WLWH who have ever given birth compared with matched controls, suggesting that sociodemographic factors may play an important role. WLWH are increasingly giving birth in their later reproductive years. Taken together, our data supports the integration of reproductive health and HIV care.

Stability of hepatitis B viral load during pregnancy and implications for antepartum prophylaxis: A prospective cohort study.

BACKGROUND: We examined changes in hepatitis B virus (HBV) viral loads (VLs) in pregnancy, their association with hepatitis B e antigen (HBeAg), and the associated infant outcomes. METHODS: We prospectively followed 132 mothers positive for hepatitis B surface antigen (HBsAg) and their 135 infants from 2011 to 2015 in Vancouver, British Columbia. Outcome measures included association between maternal HBeAg and high (>200,000 IU/mL) or low (≤200,000 IU/mL) HBV VL, changes in HBV VL through pregnancy, infant HBsAg status, and infant completion of the HBV vaccination series. RESULTS: f the 91 participants with an available HBV VL, 13 (14.3%) had an HBV VL of more than 200,000 IU/mL. Of 59 participants with paired HBeAg and HBV VL in pregnancy, 6 had an HBV VL of more than 200,000 IU/mL; of interest, 2 of the 6 (33.3%) were HBeAg-negative. Thirty-eight participants had HBV VL results at both mid-trimester and delivery. For these 38 participants, Wilcoxon signed-ranks test for paired data found that an HBV VL remained stable (p = .58). We observed no perinatal transmissions. However, 20.7% of infants did not have a documented complete HBV vaccination series, 20.0% did not have post-vaccination HBsAg testing completed, and 18% did not have anti-HBs titres measured by age 12 months. CONCLUSIONS: Our study demonstrates that HBeAg and HBV VL are not reliably predictive of each other. This supports the improved predictive value of VL measurement in pregnancy to risk stratify pregnant patients to offer antiviral treatment when indicated and further minimize the risk of perinatal transmission.

Assessing Maternity Care Providers' Knowledge of the Management of Hepatitis B in Pregnancy.

OBJECTIVE: This study sought to evaluate maternity care providers' knowledge of the management of hepatitis B virus (HBV) in pregnancy. METHODS: A total of 71 maternity care providers from obstetrics, family practice, and midwifery who were practicing at a tertiary women's hospital in Canada completed a survey assessing their demographics and knowledge of the management of HBV in pregnancy. Descriptive statistics were used to assess the survey responses. RESULTS: Of 71 participants, 28% were obstetricians, 35% were family doctors, and 37% were midwives. Most participants (72%) had seen fewer than six pregnant patients with HBV in the last 2years. Correctly, 100% of participants indicated that all pregnant patients should be screened for HBV in pregnancy, and 99% indicated that infants should receive post-exposure prophylaxis. Incorrectly, 25.4% of participants indicated that pregnancy is a contraindication to HBV immunization, 90.1% indicated the recommended timeline for infant serological follow-up, and participants were largely divided on which investigations were needed for a pregnant patient with HBV. Only 23.9% of participants indicated the current recommended viral load for consideration of antiviral treatment in pregnancy. CONCLUSION: Maternity care providers in our cohort had a strong understanding of the fundamentals of caring for pregnant patients with HBV. Continuing education should emphasize the safety of HBV vaccination in pregnancy, novel investigations in pregnancy, current evidence on the use of antivirals in pregnancy, and appropriate timelines for infant serological follow-up.

An Evaluation of Introduction of Rapid HIV Testing in a Perinatal Program.

OBJECTIVE: This study was conducted to evaluate the roll-out of rapid HIV testing as part of an emergency Prevention of Perinatal HIV Transmission Program. Specifically, HIV prevalence in this population, the reason(s) for performing the rapid HIV test, and compliance with recommendations for antiretroviral prophylaxis were assessed. METHODS: Since November 2011, all women presenting to a tertiary labour and delivery unit with unknown HIV status or with ongoing risk of HIV infection since their last HIV test were offered rapid HIV testing. Through retrospective chart review, demographic data, HIV risk and prior testing history, and antiretroviral prophylaxis, data were collected and descriptive statistics were performed. RESULTS: One hundred fourteen rapid HIV tests were conducted and there were two preliminary reactive rapid results (one true positive, one false positive). None of the infants was HIV infected. Sixty-three percent of women had multiple risk factors for HIV acquisition, most commonly intravenous drug use (54%). Forty-four percent of women were within the 4-week seroconversion window at the time of delivery; 25% of these women and 52% of their infants received prophylactic drug therapy. CONCLUSION: Rapid HIV testing identified a high-risk cohort and enabled aggressive management of a newly diagnosed HIV-positive pregnancy, successfully preventing perinatal HIV transmission. Risk factors for HIV acquisition were ongoing within the seroconversion window for over half of the women, impacting the utility of the test in eliminating unnecessary antiretroviral prophylaxis in this population because prophylaxis is recommended despite a negative rapid HIV test in these cases.