The Mortality of Congenital Syphilis.

OBJECTIVES: To document the case-fatality rate (CFR) of congenital syphilis diagnosed by molecular tools and rabbit infectivity testing (RIT) of clinical specimens in addition to standard evaluation and to compare that with the CFR using the Centers for Disease Control and Prevention (CDC) surveillance case definition. STUDY DESIGN: Prospective, single site, cohort study of all cases of syphilis among mothers and their infants from 1984 to 2002. The diagnosis of congenital syphilis was determined using IgM immunoblotting, polymerase chain reaction, and RIT of fetal or infant specimens in addition to clinical, laboratory, and radiographic criteria. Data were retrospectively reviewed to ascertain fetal and neonatal mortality. RESULTS: During the 18-year study, there were 191 cases of congenital syphilis confirmed by abnormalities on clinical, laboratory, or radiographic evaluation and/or positive serum IgM immunoblot, blood polymerase chain reaction, or blood/cerebrospinal fluid RIT. Of the 191 cases, 59 died for a CFR of 31%. Of the 59 deaths, 53 (90%) were stillborn and 6 (10%) died in the neonatal period. The majority (74%, 39/53) of stillbirths occurred in the third trimester. The CDC surveillance case definition correctly identified all infants with congenital syphilis, but the CDC CFR was 10% which underestimated the CFR by more than 300%. CONCLUSIONS: Our findings corroborate the high sensitivity of the CDC surveillance definition for congenital syphilis but highlight its poor estimation of its associated mortality. The CFR among infected progeny of pregnant women with syphilis was 31%, due mostly to demise in the third trimester and as such highlights the need for detection and appropriate treatment of syphilis during pregnancy.

Knowledge, Judgment, and Skills in Reproductive Health Care and Abortion Are Essential to the Practice of Obstetrics and Gynecology.

A social contract exists between medicine and society. In fulfilling the social contract to our patients and society, physicians have an obligation to provide the evidence-based care that patients want and need. What do the data regarding knowledge, judgment, and skills required to practice obstetrics and gynecology show? Obstetrics and gynecology job task analyses assess the importance of knowledge, judgment, and skills through surveys asking practicing physicians about the criticality and frequency of a variety of task statements to create an importance score. Excerpts from a 2018 practice analysis survey clearly indicate that reproductive health care and abortion are important components of the knowledge, judgment, and skills to practice obstetrics and gynecology in the United States. These standards help to assure the knowledge, judgment, and skills of current and future generations of ob-gyns, so their patients and the public can be provided the comprehensive reproductive health care they want and need. It is sometimes important to restate principles and standards that have become ingrained in thoughts and practices that guide physicians and serve to protect our patients. This concept is important now, as our country, health care professionals, and patients examine the future of reproductive health care, including abortion.

The American Board of Obstetrics and Gynecology's remote certifying examination: successes and challenges.

In response to the COVID-19 pandemic, the American Board of Obstetrics and Gynecology canceled the 2020 in-person subspecialty certifying examinations and developed remote administration of 4 subspecialty certifying examinations in 2021 for both examiners and candidates. Because of the continued risks of the COVID-19 pandemic, the 2021 specialty certifying examinations and the 2022 subspecialty certifying examinations were also administered remotely for candidates. For these examinations, examiners participated remotely in 2021 and were at the American Board of Obstetrics and Gynecology testing center in 2022. Overall, the American Board of Obstetrics and Gynecology remote certifying examinations have been well-received by candidates and examiners according to posttest survey data. Candidate performance has been comparable to that observed in the previous in-person examinations. In this review, we describe our implementation, process modifications, successes, and challenges with remote testing. During this process, the American Board of Medical Specialties approval was required, and the Standards for Educational and Psychological Testing served as our testing-industry guideline to ensure valid interpretation of scores and fairness to candidates.

Putting the "M" back in maternal-fetal medicine: A 5-year report card on a collaborative effort to address maternal morbidity and mortality in the United States.

The Centers for Disease Control and Prevention have demonstrated continuous increased risk for maternal mortality and severe morbidity with racial disparities among non-Hispanic black women an important contributing factor. More than 50,000 women experienced severe maternal morbidity in 2014, with a mortality rate of 18.0 per 100,000, higher than in many other developed countries. In 2012, the first "Putting the 'M' back in Maternal-Fetal Medicine" session was held at the Society for Maternal-Fetal Medicine's (SMFM) Annual Meeting. With the realization that rising risk for severe maternal morbidity and mortality required action, the "M in MFM" meeting identified the following urgent needs: (i) to enhance education and training in maternal care for maternal-fetal medicine (MFM) fellows; (ii) to improve the medical care and management of pregnant women across the country; and (iii) to address critical research gaps in maternal medicine. Since that first meeting, a broad collaborative effort has made a number of major steps forward, including the proliferation of maternal mortality review committees, advances in research, increasing educational focus on maternal critical care, and development of comprehensive clinical strategies to reduce maternal risk. Five years later, the 2017 M in MFM meeting served as a "report card" looking back at progress made but also looking forward to what needs to be done over the next 5 years, given that too many mothers still experience preventable harm and adverse outcomes.

Maternal titers after adequate syphilotherapy during pregnancy.

BACKGROUND: We aimed to construct a timeline for nontreponemal titer decline specific to pregnancy and evaluate factors associated with inadequate decline by delivery. METHODS: This was a retrospective medical records review from September 1984 to June 2011 of women diagnosed with syphilis after 18 weeks of gestation. Women were treated according to stage of syphilis per Centers for Disease Control and Prevention guidelines. Patients with both pretreatment and delivery titers were included for data analysis. Demographics, stage of syphilis, maternal titers, delivery, and infant outcomes were recorded. Standard statistical analyses were performed for categorical and continuous data. The titer decline was analyzed using mixed-effects regression modeling. RESULTS: A total of 166 patients met inclusion criteria. Mean gestational age at treatment was 29.1 ± 5 weeks, and 93 (56%) women were diagnosed with early-stage syphilis. For all stages of syphilis, maternal titers declined after syphilotherapy. Pretreatment titers were higher and declined more rapidly in primary and secondary disease than in latent-stage disease and syphilis of unknown duration. Sixty-three (38%) patients achieved a 4-fold decline by delivery. Patients without a 4-fold decline by delivery were older (24.6 vs 21.5 years; P < .001), treated later in pregnancy (30.3 vs 27.3 weeks; P < .001), diagnosed with latent syphilis or syphilis of unknown duration, and had less time from treatment to delivery (7.8 vs 11.1 weeks; P < .001). CONCLUSIONS: Maternal serologic response during pregnancy after adequate syphilotherapy varied by stage of disease. Failure to achieve a 4-fold decline in titers by delivery is more a reflection of treatment timing than of treatment failure.

Progression of ultrasound findings of fetal syphilis after maternal treatment.

OBJECTIVE: The purpose of this study was to evaluate ultrasound findings of fetal syphilis and to describe their progression after maternal treatment. STUDY DESIGN: This was a retrospective cohort study from September 1981 to June 2011 of seropositive women after 18 weeks of gestation who had an ultrasound before treatment to evaluate for fetal syphilis. Only those women who received treatment after the initial ultrasound scan, but before delivery, were included. If the initial ultrasound scan was abnormal, serial sonography was performed until resolution of the abnormality or delivery. Patient demographics, ultrasound findings, stage of syphilis, delivery, and infant outcomes were recorded. Standard statistical analyses were performed. Kaplan-Meier estimates were constructed to estimate time to resolution. RESULTS: Two hundred thirty-five women met the inclusion criteria; 73 of them (30%) had evidence of fetal syphilis on initial ultrasound scan. Abnormalities included hepatomegaly (79%), placentomegaly (27%), polyhydramnios (12%), ascites (10%) and abnormal middle cerebral arterial Doppler assessment (33%). After treatment, middle cerebral arterial Doppler assessment abnormalities, ascites, and polyhydramnios resolved first, followed by placentomegaly and finally hepatomegaly. Infant outcomes were available for 173 deliveries; of these, 32 infants (18%) were diagnosed with congenital syphilis. Congenital syphilis was more common when antenatal ultrasound abnormalities were present (39% vs 12%; P < .001). Infant examination findings at delivery were similar between women with and without an abnormal pretreatment ultrasound scan. However, in those infants with congenital syphilis, hepatomegaly was the most frequent abnormality found, regardless of antenatal ultrasound findings. CONCLUSION: Sonographic signs of fetal syphilis confer a higher risk of congenital syphilis at delivery for all maternal stages. Hepatomegaly develops early and resolves last after antepartum treatment.

Trends in emergency peripartum hysterectomy at a single institution: 1988-2009.

OBJECTIVE: To evaluate trends of emergency peripartum hysterectomy over two decades. STUDY DESIGN: This was a retrospective cohort study of peripartum hysterectomies at one institution from 1988 to 2009. Medical records were reviewed and data from the first 11 years were compared with data from the second 11 years. RESULTS: During the study period, 558 emergent peripartum hysterectomies were performed with full records available for 553 to review: 280 in the first period, 273 in the second (p = 0.19). In the second period, prior cesarean deliveries, length of surgery, estimated blood loss, blood transfusions, and the number of units transfused were all increased (p < 0.001). Also in the second period, there were twice as many hysterectomies for suspected placental invasion, and an almost threefold increase in pathologically confirmed placental invasion (both p < 0.001). CONCLUSION: Although emergent peripartum hysterectomies are not increasing in frequency, the risk factors and morbidities have changed.

Prevention of mother-to-infant transmission of influenza during the postpartum period.

OBJECTIVES: The optimal management of infants born to mothers with peripartum influenza infection is not known. The objective of this study is to describe our experience with a practice guideline that promotes rooming-in and breast-feeding and to determine whether infants managed in this way acquire influenza infection. STUDY DESIGN: All mothers diagnosed with influenza infection within 8 days of delivery and their infants were included. Demographics, clinical characteristics, and outcome data were collected. Mothers were contacted at ~1 month after giving birth to determine if their infants had developed any signs suggestive of influenza infection. RESULTS: Forty-two women were diagnosed with peripartum influenza over the 2003 to 2005 and 2009 to 2010 seasons. Median onset of symptoms was 3 days before delivery, and median day of diagnosis was 1 day before delivery. The 42 infants had a median gestational age of 39 weeks; none were born earlier than 35 weeks. Ninety-five percent of the infants roomed-in with their mothers. Follow-up information was available on 95% of infants by 1 month; no infants had illness suggestive of influenza through the follow-up period. CONCLUSION: A guideline for the management of infants born to mothers with peripartum influenza infection, based on attention to hand hygiene, antiviral treatment for mothers, and encouragement of rooming-in and breast-feeding, was not associated with mother-to-infant influenza transmission over three separate influenza seasons.

Anthrax cases in pregnant and postpartum women: a systematic review.

OBJECTIVE: To describe the worldwide experience of Bacillus anthracis infection reported in pregnant, postpartum, and lactating women. DATA SOURCES: Studies were identified through MEDLINE, Web of Science, Embase, and Global Health databases from inception until May 2012. The key words (["anthrax" or "anthracis"] and ["pregna*" or "matern*" or "postpartum" or "puerperal" or "lact*" or "breastfed*" or "breastfeed*" or "fetal" or "fetus" or "neonate" or "newborn" or "abort*" or "uterus"]) were used. Additionally, all references from selected articles were reviewed, hand searches were conducted, and relevant authors were contacted. METHODS OF STUDY SELECTION: The inclusion criteria were: published articles referring to women diagnosed with an infection due to exposure to B anthracis during pregnancy, the postpartum period, or during lactation; any article type reporting patient-specific data; articles in any language; and nonduplicate cases. Non-English articles were professionally translated. Duplicate reports, unpublished reports, and review articles depicting previously identified cases were excluded. TABULATION, INTEGRATION, AND RESULTS: Two authors independently reviewed articles for inclusion. The primary search of the four databases yielded 1,340 articles, and the secondary crossreference search revealed 146 articles. Fourteen articles met the inclusion criteria. In total, 20 cases of B anthracis infection were found, 17 in pregnant women, two in postpartum women, and one case in a lactating woman. Among these reports, 16 women died and 12 fetal or neonatal losses were reported. Of these fatal cases, most predated the advent of antibiotics. CONCLUSIONS: Based on these case reports, B anthracis infection in pregnant and postpartum women is associated with high rates of maternal and fetal death. Evidence of possible maternal-fetal transmission of B anthracis infection was identified in early case reports.

Efficacy of maternal and neonatal chemoprophylaxis for early-onset group B streptococcal disease.

OBJECTIVE: To estimate the rate of early-onset group B streptococcal (GBS) neonatal sepsis with combined maternal and neonatal chemoprophylaxis. METHODS: Since 1995, GBS chemoprophylaxis at our institution has consisted of intrapartum antibiotic prophylaxis to all women with identified risk factors. In addition, a single dose of penicillin G was administered within 1 hour of birth to all newborns without clinical signs or symptoms of infection. All neonates born between January 1, 2000, and December 31, 2008, and who developed early-onset (occurring at 72 hours of age or younger) invasive bacterial disease were identified. Incidence rates for sepsis resulting from GBS and other organisms were estimated. Compliance with risk factor identification and appropriate treatment was also ascertained. Rates of ß-lactam resistance among cases of neonatal disease caused by Gram-negative organisms were calculated. RESULTS: Ninety-four cases of early-onset GBS sepsis were identified among 143,467 live births with a rate of 0.66 per 1,000 births (0.53-0.80 per 1,000). Of available GBS sensitivities, 8.8% demonstrated clindamycin resistance, and 26.6% were resistant to erythromycin. Thirty-four cases of non-GBS early-onset sepsis were identified for a rate of 0.24 per 1,000 live births. Of available sensitivity reports, 42.1% of Gram-negative isolates were sensitive to ß-lactams. No significant difference in rates of early-onset GBS disease was found between the years 1995 and 2008. CONCLUSION: The sustained rates in early-onset GBS sepsis from 1995 to 2008, along with the low rates of neonatal disease caused by other pathogens, confirms the continued feasibility and efficacy of a combined maternal and neonatal GBS chemoprophylaxis.

Effect of influenza vaccination in the first trimester of pregnancy.

OBJECTIVE: To estimate the effect of first-trimester influenza vaccination on fetal and neonatal outcomes. METHODS: This was a retrospective cohort study examining delivery and neonatal outcomes after antepartum exposure to the seasonal trivalent inactive influenza vaccine. Data were collected and entered into an established computerized database. Outcomes by trimester of vaccination were then compared with women who did not receive the vaccine. RESULTS: During the 5-year study period, 10,225 women received the seasonal influenza vaccine antepartum; 8,690 of these delivered at our institution, 439 in the first trimester and 8,251 in the second and third trimesters. Women vaccinated antepartum were significantly older with higher parity than women who declined vaccination. Neonates born to mothers receiving the vaccine in any trimester did not have an increase in major malformations regardless of trimester of vaccination (2% regardless of vaccination group, P=.9). Stillbirth (0.3% compared with 0.6%, P=.006), neonatal death (0.2% compared with 0.4%, P=.01), and premature delivery (5% compared with 6%, P=.004) were significantly decreased in the vaccinated group. CONCLUSION: Influenza vaccination in the first trimester was not associated with an increase in major malformation rates and was associated with a decrease in the overall stillbirth rate. This information will aid in counseling women regarding the safety of influenza vaccination in the first trimester.

Placental and uterine pathology in women undergoing peripartum hysterectomy.

OBJECTIVE: To estimate if peripartum hysterectomies performed for intractable uterine atony have pathologic findings consistent with infection more often than those hysterectomies performed for other indications. METHODS: This is a retrospective cohort study of all consecutive peripartum hysterectomies at our institution from 1988 to 2009. Scheduled cesarean hysterectomies were excluded. Maternal, fetal, and pathologic data were obtained by medical record review. Pathologic evaluation was performed for each specimen per a standardized protocol. Patients undergoing hysterectomy for uterine atony were compared with those requiring hysterectomy for another indication. Pearson's χ and Student's t test were used for analysis. RESULTS: Of 324,654 deliveries during the study period, 558 (1.7%) women underwent emergent peripartum hysterectomies; 190 (34%) were for intractable uterine atony. Those requiring hysterectomy for uterine atony were more likely to be at term (87% compared with 62%), have clinical chorioamnionitis (19% compared with 6%), and have longer labors (8 hours compared with 2.5 hours). Certain placental pathologic findings were significantly more common in the atony group, including chorioamnionitis, umbilical vasculitis, chorionic plate vasculitis, and funisitis. Acute endometritis and cervicitis were also more common in the atony group. Conversely, abnormal placental implantation (37% compared with 8%) and leiomyomas (21% compared with 8%) were significantly more common in the group requiring hysterectomy for other indications. CONCLUSION: Patients requiring emergent peripartum hysterectomies as a result of intractable uterine atony are more likely to have clinical and pathologic findings consistent with acute inflammation and infection. LEVEL OF EVIDENCE: II.

Disseminated gonococcal infection in women.

OBJECTIVE: To review the clinical presentation, complications, and response to treatment of pregnant and nonpregnant women admitted for management of disseminated gonococcal infection over a 34-year period. METHODS: This was a review of all women diagnosed with disseminated gonococcal infection who were admitted to Parkland Memorial Hospital from 1975 through 2008. Medical records were reviewed and data extracted that included demographic information, clinical and laboratory findings, and response to antimicrobial treatment. In addition to determining perinatal outcomes, the clinical findings of women in the pregnant cohort were compared with those of nonpregnant women. RESULTS: Of 112 women hospitalized for treatment during the study period, 80 (71%) were nonpregnant and 32 (29%) were pregnant. In both groups, the frequency of disseminated infections declined substantively over the last 34 years. Presenting symptoms were similar for pregnant and nonpregnant women, and with one exception, all had arthritis that involved a mean of two joints, most commonly the knee and wrist. Two notable differences between the cohorts were that pregnant women sought care a mean of 2 days after symptoms began compared with that of 5 days for nonpregnant women (P=.003). Related to this, only 50% of pregnant women had a joint effusion compared with 70% of nonpregnant women (P=.05). CONCLUSION: The frequency of disseminated gonococcal infection decreased remarkably over the 34-year study period, paralleling the decreasing prevalence of mucosal Neisseria gonorrhoeae infections reported nationwide. In women with disseminated infections, prompt recognition and antimicrobial treatment will usually result in a favorable outcome.