Hepatitis C Prevalence and Birth Outcomes among Pregnant Women in the United States: A 2010-2020 Population Study.

BACKGROUND: The rates of hepatitis C virus (HCV) infection have increased in the pregnant population. We aim to describe the age-stratified clinical outcomes and trends for inpatient pregnant women with HCV in the U.S. METHODS: We utilized hospitalization data from the 2010-2020 National Inpatient Sample. Pregnancy and HCV were identified according to their ICD-9/ICD-10 codes. Demographic and clinical data including cirrhosis, mortality, preterm birth, and stillbirth were extracted. The age groups were defined as ≤18, 19-25, 26-34, and ≥35 years. RESULTS: We identified 195,852 inpatient pregnant women with HCV, among whom 0.7% were ≤18, 26.7% were 19-25, 57.9% were 26-34, and 14.8% were ≥35 years of age. The hospitalization rates of pregnant women with HCV increased overall between 2010 and 2020, with the highest velocity in the 26-34 age group. The 26-34 age group had the highest HCV burden, with an age-standardized hospitalization rate of 660 per 100,000 in 2020. The rates of mortality and cirrhosis were significantly higher in the HCV cohort and increased further with age (p < 0.05). Among the HCV pregnant cohort, 151,017 (77.1%) delivered during hospitalization. Preterm births and stillbirths were significantly higher in the HCV pregnant cohort compared to the controls across multiple age groups (p < 0.05). Minority race/ethnicity was associated with increased mortality, cirrhosis, preterm birth, and stillbirth (p < 0.001). HIV co-infection, hepatitis B co-infection, and diabetes increased the odds of cirrhosis (p < 0.001). CONCLUSIONS: Hospitalizations of pregnant women with HCV are escalating, and these women are at increased risk of mortality, cirrhosis, preterm birth, and stillbirth with modifying factors, exacerbating risks further.

A Composite Score for Predicting Vertical Transmission of Hepatitis C: A Multicenter Study.

BACKGROUND: Prevention of the vertical transmission of the hepatitis C virus (HCV) presents an obstetric challenge. There are no approved antiviral medications for the treatment or prevention of HCV for pregnant patients. OBJECTIVE: We aimed to create a composite score to accurately identify a population of pregnant patients with HCV who have high potential for vertical transmission. STUDY DESIGN: In a retrospective, multicenter cohort study, we identified pregnant patients with hepatitis C with linked data to their infants who have had HCV RNA or HCV antibody testing. Demographic data, including age and race/ethnicity, as well as clinical and laboratory data, including tobacco/alcohol use, infections, liver function tests, the HCV RNA titer, HCV antibody, HCV genotype, absolute lymphocyte count, and platelet count, were collected. Data were analyzed using logistic regression and receiver operating characteristics (ROCs) and internally validated using the forward selection bootstrap method. RESULTS: We identified 157 pregnant patients and 163 corresponding infants. The median maternal delivery age was 29 (IQR: 25-33) years, and the majority (141, or 89.8%) were White. A high HCV RNA titer, high absolute lymphocyte count, and high platelet count were associated with vertical transmission. A high HCV RNA titer had an AUROC of 0.815 with sensitivity, specificity, a positive predictive value, and a negative predictive value of 100.0%, 59.1%, 17.6%, and 100.0%, respectively. A composite score combining the three risk factors had an AUROC of 0.902 (95% CI = 0.840-0.964) but with a risk of overfitting. CONCLUSIONS: An HCV RNA titer alone or a composite score combining the risk factors for HCV vertical transmission can potentially identify a population of pregnant patients where the rate of vertical transmission is high, allowing for potential interventions during antepartum care.

Acceptability of an mHealth App for Monitoring Perinatal and Postpartum Mental Health: Qualitative Study With Women and Providers.

BACKGROUND: Up to 15% of pregnant and postpartum women commonly experience undiagnosed and untreated mental health conditions, such as depression and anxiety, which may result in serious health complications. Mobile health (mHealth) apps related to mental health have been previously used for early diagnosis and intervention but not among pregnant and postpartum women. OBJECTIVE: This study aims to assess the acceptability of using mHealth to monitor and assess perinatal and postpartum depression and anxiety. METHODS: Focus group discussions with pregnant and postpartum women (n=20) and individual interviews with health care providers (n=8) were conducted to inform the acceptability of mHealth and determine its utility for assessing perinatal and postpartum mood symptoms. Participants were recruited via purposive sampling from obstetric clinics and the surrounding community. A semistructured interview guide was developed by an epidemiologist with qualitative research training in consultation with an obstetrician. The first author conducted all focus group discussions and provider interviews either in person or via Zoom (Zoom Video Communications, Inc) depending on the COVID-19 protocol that was in place during the study period. All interviews were audio recorded with consent; transcribed; and uploaded for coding to ATLAS.ti 8 (ATLAS.ti Scientific Software Development Gmb H), a qualitative data analysis and retrieval software. Data were analyzed using the deductive content analysis method using a set of a priori codes developed based on the interview guide. Methodological rigor and quality were ensured by adopting a systematic approach during the implementation, data collection, data analysis, and reporting of the data. RESULTS: Almost all women and providers had downloaded and used at least 1 health app. The respondents suggested offering short questions in layperson language that could be understood by women of all educational levels and offering no more than 2 to 3 assessments per day at preferred timings decided by the women themselves. They also suggested that the women themselves receive the alerts first, with other options being family members, spouses, or friends if the women themselves did not respond within 24 to 72 hours. Customization and snooze features were strongly endorsed by women and providers to improve acceptability and utility. Women mentioned competing demands on their time during the postpartum period, fatigue, privacy, and the security of mental health data as concerns. Health care professionals highlighted the long-term sustainability of app-based mood assessment and monitoring as an important challenge. CONCLUSIONS: The findings from this study show that mHealth would be acceptable to pregnant and postpartum women for monitoring mood symptoms. This could inform the development of clinically meaningful and inexpensive tools for facilitating the continuous monitoring of, the early diagnosis of, and an early intervention for mood disorders in this vulnerable population.

Performance of a Multianalyte 'Rule-Out' Assay in Pregnant Individuals With Suspected Preeclampsia.

BACKGROUND: The ability to diagnose preeclampsia clinically is suboptimal. Our objective was to validate a novel multianalyte assay and characterize its performance, when intended for use as an aid to rule-out preeclampsia. METHODS: Prospective, multicenter cohort study of pregnant individuals presenting between 280/7 and 366/7 weeks' with preeclampsia-associated signs and symptoms. Individuals not diagnosed with preeclampsia after baseline evaluation were enrolled in the study cohort, with those who later developed preeclampsia, classified as cases and compared with a negative control group who did not develop preeclampsia. Individuals with assay values at time of enrollment ≥0.0325, determined using a previously developed algorithm, considered at risk. The primary analysis was the time to develop preeclampsia assessed using a multivariate Cox regression model. RESULTS: One thousand thirty-six pregnant individuals were enrolled in the study cohort with an incidence of preeclampsia of 30.3% (27.6%-33.2%). The time to develop preeclampsia was shorter for those with an at-risk compared with negative assay result (log-rank P<0.0001; adjusted hazard ratio of 4.81 [3.69-6.27, P<0.0001]). The performance metrics for the assay to rule-out preeclampsia within 7 days of enrollment showed a sensitivity 76.4% (67.5%-83.5%), negative predictive value 95.0% (92.8%-96.6%), and negative likelihood ratio 0.46 (0.32-0.65). Assay performance improved if delivery occurred <37 weeks and for individuals enrolled between 28 and 35 weeks. CONCLUSIONS: We confirmed that a novel multianalyte assay was associated with the time to develop preeclampsia and has a moderate sensitivity and negative likelihood ratio but high negative predictive value when assessed as an aid to rule out preeclampsia within 7 days of enrollment. REGISTRATION: The study was registered on Clinicaltrials.gov (Identifier NCT02780414).

PM2.5 Constituents and Onset of Gestational Diabetes Mellitus: Identifying Susceptible Exposure Windows.

Fine particulate matter (PM2.5) has been linked to gestational diabetes mellitus (GDM). However, PM2.5 is a complex mixture with large spatiotemporal heterogeneities, and women with early-onset GDM (i.e., diagnosed before 24th gestation week) have distinct maternal characteristics and a higher risk of worse health outcomes compared with those with late-onset GDM (i.e., diagnosed in or after 24th gestation week). We aimed to examine differential impacts of PM2.5 and its constituents on early- vs. late-onset GDM, and to identify corresponding susceptible exposure windows. We leveraged statewide linked electronic health records and birth records data in Florida in 2012-2017. Exposures to PM2.5 and its constituents (i.e., sulfate [SO4 2-], ammonium [NH4 +], nitrate [NO3 -], organic matter [OM], black carbon [BC], mineral dust [DUST], and sea-salt [SS]) were spatiotemporally linked to pregnant women based on their residential histories. Cox proportional hazards models and multinomial logistic regression were used to examine the associations of PM2.5 and its constituents with GDM and its onsets. Distributed non-linear lag models were implemented to identify susceptible exposure windows. Exposures to PM2.5, SO4 2-, NH4 +, and BC were statistically significantly associated with higher hazards of GDM. Exposures to PM2.5 during weeks 1-12 of gestation were positively associated with GDM. Associations of early-onset GDM with PM2.5 in the 1st and 2nd trimesters, SO4 2- in the 1st and 2nd trimesters, and NO3 - in the preconception and 1st trimester were considerably stronger than observations for late-onset GDM. Our findings suggest there are differential associations of PM2.5 and its constituents with early- vs. late-onset GDM, with different susceptible exposure windows. This study helps better understand the impacts of air pollution on GDM accounting for its physiological heterogeneity.

Age at menarche and cardiovascular health: results from the NHANES 1999-2016.

OBJECTIVE: Cardiovascular disease is the leading cause of death among women. Early menarche has been associated with many cardiovascular disease risk factors, but little is known about its associations with cardiovascular health (CVH) as defined by Life's Simple 7 (LS7). We aim to examine the associations between age at menarche and CVH. METHODS: Data were obtained from the 1999-2016 National Health and Nutrition Examinations Survey (NHANES). CVH was assessed according to LS7 (ideal CVH: > 4 ideal CVH metrics, CVH score: ranging from 0 to 14). Weighted logistic regression was used after adjusting for sociodemographic factors. The interaction between age at menarche and age was also examined. RESULTS: Among the 20,447 women included, 2,292 (11.2%) had ideal CVH. After adjusting for age, race/ethnicity, education, poverty income ratio, marital status, and birth year, significantly worse CVH was observed among women with early menarche (OR: 0.70, 95% CI: 0.60-0.82), and higher odds of ideal CVH were observed among those with late menarche (OR: 1.40, 95% CI: 1.21-1.62). Consistent results were observed for CVH score. Age significantly modifies the associations between age at menarche and CVH. Late menarche was significantly associated with ideal CVH among those aged 25-34 (OR: 1.64, 95% CI: 1.27-2.11) or 35-44 (OR: 1.73, 95% CI: 1.31-2.30), while the associations for early menarche were observed only among those aged 25-34 years (OR: 0.72, 95% CI: 0.53-0.97). CONCLUSIONS: Our findings suggested that early menarche is associated with worse CVH, especially among young women. Further efforts are warranted to confirm these findings.

Video Summary:http://links.lww.com/MENO/A643.

Coronavirus Disease 2019 (COVID-19) and pregnancy: what obstetricians need to know.

Coronavirus disease 2019 is an emerging disease with a rapid increase in cases and deaths since its first identification in Wuhan, China, in December 2019. Limited data are available about coronavirus disease 2019 during pregnancy; however, information on illnesses associated with other highly pathogenic coronaviruses (ie, severe acute respiratory syndrome and the Middle East respiratory syndrome) might provide insights into coronavirus disease 2019's effects during pregnancy. Coronaviruses cause illness ranging in severity from the common cold to severe respiratory illness and death. Currently the primary epidemiologic risk factors for coronavirus disease 2019 include travel from mainland China (especially Hubei Province) or close contact with infected individuals within 14 days of symptom onset. Data suggest an incubation period of ∼5 days (range, 2-14 days). Average age of hospitalized patients has been 49-56 years, with a third to half with an underlying illness. Children have been rarely reported. Men were more frequent among hospitalized cases (54-73%). Frequent manifestations include fever, cough, myalgia, headache, and diarrhea. Abnormal testing includes abnormalities on chest radiographic imaging, lymphopenia, leukopenia, and thrombocytopenia. Initial reports suggest that acute respiratory distress syndrome develops in 17-29% of hospitalized patients. Overall case fatality rate appears to be ∼1%; however, early data may overestimate this rate. In 2 reports describing 18 pregnancies with coronavirus disease 2019, all were infected in the third trimester, and clinical findings were similar to those in nonpregnant adults. Fetal distress and preterm delivery were seen in some cases. All but 2 pregnancies were cesarean deliveries and no evidence of in utero transmission was seen. Data on severe acute respiratory syndrome and Middle East respiratory syndrome in pregnancy are sparse. For severe acute respiratory syndrome, the largest series of 12 pregnancies had a case-fatality rate of 25%. Complications included acute respiratory distress syndrome in 4, disseminated intravascular coagulopathy in 3, renal failure in 3, secondary bacterial pneumonia in 2, and sepsis in 2 patients. Mechanical ventilation was 3 times more likely among pregnant compared with nonpregnant women. Among 7 first-trimester infections, 4 ended in spontaneous abortion. Four of 5 women with severe acute respiratory syndrome after 24 weeks' gestation delivered preterm. For Middle East respiratory syndrome, there were 13 case reports in pregnant women, of which 2 were asymptomatic, identified as part of a contact investigation; 3 patients (23%) died. Two pregnancies ended in fetal demise and 2 were born preterm. No evidence of in utero transmission was seen in severe acute respiratory syndrome or Middle East respiratory syndrome. Currently no coronavirus-specific treatments have been approved by the US Food and Drug Administration. Because coronavirus disease 2019 might increase the risk for pregnancy complications, management should optimally be in a health care facility with close maternal and fetal monitoring. Principles of management of coronavirus disease 2019 in pregnancy include early isolation, aggressive infection control procedures, oxygen therapy, avoidance of fluid overload, consideration of empiric antibiotics (secondary to bacterial infection risk), laboratory testing for the virus and coinfection, fetal and uterine contraction monitoring, early mechanical ventilation for progressive respiratory failure, individualized delivery planning, and a team-based approach with multispecialty consultations. Information on coronavirus disease 2019 is increasing rapidly. Clinicians should continue to follow the Centers for Disease Control and Prevention website to stay up to date with the latest information (https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html).

Medicolegal Review of Methotrexate Administration to Viable Intrauterine Pregnancies.

Objective: To examine 3 legal cases in which physicians prescribed methotrexate to women with a viable intrauterine pregnancy, presumed to be ectopic, resulting in adverse fetal outcomes. Study Design: We conducted an electronic literature search for legal cases using the keywords "methotrexate" and "pregnancy" in the LexisNexis legal research engine as well as an Internet-wide search using the additional keyword "verdict." We manually searched the resultant list of identified cases and categorized the studies identified in the search by verdict, award amount, and outcome of the embryo exposed to methotrexate. Results: The monetary awards are typically greater when the embryo exposed to methotrexate lives and requires continuous medical and custodial care as compared to when the fetus dies in utero or shortly after birth. Conclusion: Physicians who, with all good intentions, prescribe methotrexate to women with a viable pregnancy, presumed to be ectopic, could find them-selves liable for an adverse fetal outcome. For the benefit of patients, their unborn offspring, and the liability exposure of the physician, it is important to be very cautious when prescribing methotrexate.

Zika Virus and Pregnancy: A Review of the Literature and Clinical Considerations.

The latest Zika virus (ZIKV) outbreak has reached epidemic proportions as it spreads throughout South and Central America. In November 2015, the Brazilian Ministry of Health reported a 20-fold increase in the number of cases of neonatal microcephaly, which corresponds geographically and temporally to the ZIKV outbreak. Case reports have provided some evidence of a causal link between maternal ZIKV infection, fetal microcephaly, and intracranial calcifications. The sparse data regarding ZIKV in pregnancy come solely from case reports and personal communications, and recommendations for management of ZIKV exposure during pregnancy are rapidly evolving. Our objective is to review and synthesize the current literature regarding ZIKV as it pertains to pregnancy and provide some assistance to clinicians who may have to manage a pregnant patient with potential exposure to ZIKV. We will also explore certain aspects of related viruses in pregnancy in hopes to shed light on this little-known topic.

Early versus Late Feeding after Cesarean Delivery: A Randomized Controlled Trial.

OBJECTIVE: This study aims to evaluate whether early feeding after cesarean delivery (CD) shortens the time to pass flatus and bowel movement. METHODS: Women at term undergoing CD were randomly assigned to start oral intake either within 6 hours (early feeding) or after 12 hours (late feeding) from surgery completion. Women with preeclampsia, or requiring emergent CD, additional bowel surgery, or the use of general anesthesia were excluded. Our primary outcome was time of passing first flatus following surgery completion. Secondary outcomes included time of first bowel sounds, time of first bowel movement, nausea/vomiting, and length of maternal hospital stay (clinicaltrials.gov identifier NCT02396485). RESULTS: A total of 177 women were randomized to early (n = 85) or late feeding (n = 82). There was no loss to follow-up, and outcomes were available for all patients. There were no differences in baseline characteristics between the two groups. Early feeding resulted in shorter time to pass flatus (median [interquartile range], 715 [485-1,208] minutes vs. 1,300 [820-1,760] minutes; p < 0.001) and to have bowel sounds (232 [168-537.8] minutes vs. 554.5 [202-706] minutes; p = 0.001). Time to pass bowel movement was shorter in the early-feeding group, but did not reach significance. The groups did not differ in length of stay or in rates of nausea, vomiting, or ileus. CONCLUSION: In women undergoing CD, early oral intake is well tolerated and results in earlier return of bowel function.

Fetal assessment near the limits of viability.

Assessments of gestational age are critical in dealing with the pregnancy at the limits of viability, 22-25-weeks gestation, where neonatal outcomes reveal very significant differences from week to week. The obstetrical team can estimate gestational age within a window of 7-10 days during this critical threshold at the window of viability via determination of last menstrual period, bimanual exam, early pregnancy test, and/or ultrasound. One must also take into account the impact of maternal disease processes, congenital abnormalities, number of fetus(es), and/or fetal growth restriction, along with ongoing evaluation and parental involvement in this decision-making process during the peri-viability period.

Timing of perioperative antibiotics for cesarean delivery: a metaanalysis.

OBJECTIVE: The purpose of this study was to summarize the available evidence on timing of perioperative antibiotics for cesarean delivery. STUDY DESIGN: We searched the literature for studies that compare prophylactic antibiotics for cesarean delivery that are given before the procedure vs at cord clamping. Only randomized controlled trials were included. RESULTS: Preoperative administration significantly reduced the risk of postpartum endometritis (relative risk [RR], 0.47; 95% CI, 0.26-0.85; P = .012) and total infectious morbidity (RR, 0.50; 95% CI, 0.33-0.78; P = .002). There was a trend toward lower risk of wound infection (RR, 0.60; 95% CI, 0.30-1.21; P = .15). Preoperative administration of antibiotics did not significantly affect suspected neonatal sepsis that requires a workup (RR, 1; 95% CI, 0.70-1.42), proven sepsis (RR, 0.93; 95% CI, 0.45-1.96), or neonatal intensive care unit admissions (RR, 1.07 95% CI, 0.51-2.24). There was no significant heterogeneity between the randomized controlled trials. CONCLUSION: There is strong evidence that antibiotic prophylaxis for cesarean delivery that is given before skin incision, rather than after cord clamping, decreases the incidence of postpartum endometritis and total infectious morbidities, without affecting neonatal outcomes.

The validity of cervical dilation as an indication of true labor between 32 and 36 weeks 6 days of gestation.

OBJECTIVE: Cervical dilation with regular contraction traditionally has been used to differentiate between true and false labor. This diagnostic criterion has not been tested as most patients receive tocolytics. Our objective was to determine the time from admission to delivery in women with preterm contractions and advanced cervical dilation without tocolytics. STUDY DESIGN: We reviewed the records of patients with preterm labor on the basis of regular contractions and cervical dilation > or = 3 cm between 32 and 36 weeks 6 days of gestation. Chi-square analysis was performed for delivery at > 1 week. RESULTS: In the records, 68.8% of the patients remained pregnant at > 1 week without tocolysis. Between 32 and 34 weeks of gestation, the use of tocolysis did not help to prolong pregnancy > 1 week (81% vs 88%; alpha = .05; power = 0.65). CONCLUSION: Cervical dilation with preterm contraction cannot be used as an indication of true labor. More accurate methods to diagnose true preterm labor and direct management decisions are needed.

An unusual presentation of congenital heart disease.

We describe an unusual presentation of congenital heart disease mimicking preeclampsia in a young, gravid girl. The diagnosis of Shone's complex was confirmed by echocardiography. This complex is manifested by multiple levels of obstruction involving the left side of the heart and the systemic circulation. It is extremely rare, especially in pregnant adolescents. We briefly describe the patient's clinical history, physical examination, and treatment, as well as our clinical decisions regarding her case. The discussion focuses on the spectrum of findings in Shone's complex and the physiologic impact of therapy on this patient.