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Kleinmann W, Zofkie AC, McIntire DD, Adhikari EH. A prospective study of lactate levels in uncomplicated spontaneous and induced labor. Am J Perinatol 2024. [PMID: 38593986 DOI: 10.1055/a-2302-8828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
OBJECTIVE Maternal pushing can yield lactate levels that are above the normal range for nonpregnant individuals. Many hospitals require lactate levels as part of sepsis bundles, and this can confuse the clinicians when measured during labor. The objective of this study was to observe lactate levels in uncomplicated labor. STUDY DESIGN This was a prospective study of patients presenting to Labor & Delivery in early labor. Patients met inclusion criteria if they presented at 37 weeks' gestation or greater and were either 3-4 centimeters dilated, in early labor with rupture of membranes less than 12 hours or were being induced for oligohydramnios or postdates gestation. A baseline maternal lactate level was collected at enrollment. Further levels were collected at complete cervical dilation and every 30 minutes during the second stage of labor up to 3 hours or until delivery. RESULTS From January 7, 2021 through December 30, 2021, a total of 148 screened patients met inclusion criteria and 38 were enrolled. Eight (21%) patients withdrew after baseline lactate level was drawn. Twenty-three (61%) patients had a level drawn at complete dilation. Of the 12 (32%) patients with a lactate level drawn at complete and after thirty minutes of pushing, the mean change in lactate level was 2.0±1.8 mmol/L or 0.07±0.06 mmol/L/min (p < 0.01). This change is more pronounced in the second stage of labor for patients with chorioamnionitis (2.6 mmol/L), although this difference is not statistically significant (p = 0.41). CONCLUSIONS Lactate levels increase significantly once a patient reaches complete cervical dilation within thirty minutes of pushing. This increase is more pronounced, although significantly, in patients with chorioamnionitis. As sepsis is one of the leading causes of maternal morbidity and mortality, this pilot study is relevant for providers to see the natural course of lactate levels in labor.
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Affiliation(s)
- Whitney Kleinmann
- Obstetrics & Gynecology, UT Southwestern Medical Center, Dallas, United States
| | - Amanda C Zofkie
- Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, United States
| | | | - Emily H Adhikari
- Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, United States
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Adhikari EH. Update on syphilis in pregnancy: marrying basic science advances and clinical perseverance to solve an ancient public health problem. Curr Opin Obstet Gynecol 2024; 36:67-74. [PMID: 38205786 DOI: 10.1097/gco.0000000000000939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
PURPOSE OF REVIEW While the clinical disease of syphilis, its consequences in pregnancy, and its sensitivity to penicillin treatment have remained relatively unchanged for a century or more, new technologies and basic discoveries in syphilis research have translated into tangible advances in clinical diagnosis, treatment, and prevention. The purpose of this review is to help the reader understand some of the recent relevant scientific publications on syphilis and its causative organism in a clinical obstetric context. RECENT FINDINGS Rates of adult and congenital syphilis have risen dramatically in the last decade despite public health efforts. Penicillin shortages and lack of screening or adequate treatment have all contributed to global disease burden. Advances in genomic and microbiological characterization of this spirochete have led to new developments in serologic and molecular diagnosis as well as evaluation of potential vaccine candidates. Until a syphilis vaccine is available, substance use disorders and lack of screening in pregnancy are associated with increased congenital syphilis, and these challenges will require novel solutions to fully address this public health crisis. SUMMARY Addressing the burden of congenital syphilis demands that obstetricians stay well informed of new tools and resources for diagnosis, treatment, and prevention of syphilis now and in the future.
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Affiliation(s)
- Emily H Adhikari
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Chan CS, Kong JY, Sultana R, Mundra V, Babata KL, Mazzarella K, Adhikari EH, Yeo KT, Hascoët JM, Brion LP. Optimal Delivery Management for the Prevention of Early Neonatal SARS-CoV-2 Infection: Systematic Review and Meta-analysis. Am J Perinatol 2024. [PMID: 38267002 DOI: 10.1055/a-2253-5665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
OBJECTIVE Delivery management interventions (DMIs) were recommended to prevent delivery-associated transmission of maternal SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) to infants without evidence of effect on early neonatal SARS-CoV-2 infection (ENI) and neonatal death <28 days of life (ND). This systematic review describes different DMI combinations and the frequency of ENI and ND. STUDY DESIGN Individual patient data were collected from articles published from January 1, 2020 to December 31, 2021 from Cochrane review databases, Medline, and Google Scholar. Article inclusion criteria were: documented maternal SARS-CoV-2 polymerase chain reaction (PCR)-positive status 10 days before delivery or symptomatic at delivery with a positive test within 48 hours, known delivery method, and known infant SARS-CoV-2 PCR result. Primary outcomes were ENI (positive PCR at 12 hours to 10 days) and ND. All characteristics were pooled using the DerSimonian-Laird inverse variance method. Primary outcome analyses were performed using logit transformation and random effect. Pooled results were expressed as percentages (95% confidence intervals). Continuity correction was applied for all pooled results if any included study has 0 event. RESULTS A total of 11,075 publications were screened. 117 publications representing 244 infants and 230 mothers were included. All publications were case reports. ENI and ND were reported in 23.4% (18.2-29.18) and 2.1% (0.67-4.72) of cases, respectively. Among cases with available information, DMIs were reported for physical environment (85-100%), delivery-specific interventions (47-100%), and infant care practices (80-100%). No significant comparisons could be performed between different DMI combinations due to small sample size. CONCLUSION The evidence supporting any DMI in SARS-CoV-2-infected mothers to prevent ENI or ND is extremely limited. Limitations of this meta-analysis include high risk of bias, small sample size, and large confidence intervals. This identifies the need for multinational database generation and specific studies designed to provide evidence of DMI guidelines best suited to prevent transmission from mother to neonate. KEY POINTS · In this review we analyzed 2 years of maternal SARS-CoV-2 published cases.. · We assessed association of delivery management interventions with infant SARS-CoV-2 infection.. · We found no evidence supporting any DMI for that purpose..
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Affiliation(s)
- Christina S Chan
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas, Southwestern Medical Center, Dallas, Texas
| | - Juin Yee Kong
- Department of Neonatology, Kandang Kerbau Women's and Children's Hospital, Singapore
| | - Rehena Sultana
- Department of Quantitative Medicine, Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Vatsala Mundra
- School of Medicine, University of Texas, Southwestern Medical Center, Dallas, Texas
| | - Kikelomo L Babata
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas, Southwestern Medical Center, Dallas, Texas
| | - Kelly Mazzarella
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas, Southwestern Medical Center, Dallas, Texas
| | - Emily H Adhikari
- Department of Obstetrics and Gynecology, University of Texas, Southwestern Medical Center, Dallas, Texas
| | - Kee Thai Yeo
- Department of Neonatology, Kandang Kerbau Women's and Children's Hospital, Singapore
| | - Jean-Michel Hascoët
- Department of Pediatrics, Division of Neonatology, Lorraine University, DevAH, CHRU-Nancy, France
| | - Luc P Brion
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas, Southwestern Medical Center, Dallas, Texas
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Adhikari EH, Lu P, Kang YJ, McDonald AR, Pruszynski JE, Bates TA, McBride SK, Trank-Greene M, Tafesse FG, Lu LL. Diverging Maternal and Cord Antibody Functions From SARS-CoV-2 Infection and Vaccination in Pregnancy. J Infect Dis 2024; 229:462-472. [PMID: 37815524 PMCID: PMC10873180 DOI: 10.1093/infdis/jiad421] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/27/2023] [Accepted: 09/29/2023] [Indexed: 10/11/2023] Open
Abstract
Maternal immunity impacts the infant, but how is unclear. To understand the implications of the immune exposures of vaccination and infection in pregnancy for neonatal immunity, we evaluated antibody functions in paired peripheral maternal and cord blood. We compared those who in pregnancy received mRNA coronavirus disease 2019 (COVID-19) vaccine, were infected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the combination. We found that vaccination enriched a subset of neutralizing activities and Fc effector functions that was driven by IgG1 and was minimally impacted by antibody glycosylation in maternal blood. In paired cord blood, maternal vaccination also enhanced IgG1. However, Fc effector functions compared to neutralizing activities were preferentially transferred. Moreover, changes in IgG posttranslational glycosylation contributed more to cord than peripheral maternal blood antibody functional potency. These differences were enhanced with the combination of vaccination and infection as compared to either alone. Thus, Fc effector functions and antibody glycosylation highlight underexplored maternal opportunities to safeguard newborns.
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Affiliation(s)
- Emily H Adhikari
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Parkland Health, Dallas Texas, USA
| | - Pei Lu
- Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ye Jin Kang
- Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ann R McDonald
- Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jessica E Pruszynski
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Timothy A Bates
- Department of Microbiology and Immunology, Oregon Health and Science University, Portland, Oregon, USA
| | - Savannah K McBride
- Department of Microbiology and Immunology, Oregon Health and Science University, Portland, Oregon, USA
| | - Mila Trank-Greene
- Department of Microbiology and Immunology, Oregon Health and Science University, Portland, Oregon, USA
| | - Fikadu G Tafesse
- Department of Microbiology and Immunology, Oregon Health and Science University, Portland, Oregon, USA
| | - Lenette L Lu
- Parkland Health, Dallas Texas, USA
- Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Immunology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Adhikari EH, McGuire J, Lo J, McIntire DD, Spong CY, Nelson DB. Vaginal Compared With Oral Misoprostol Induction at Term: A Cluster Randomized Controlled Trial. Obstet Gynecol 2024; 143:256-264. [PMID: 37989142 DOI: 10.1097/aog.0000000000005464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 10/12/2023] [Indexed: 11/23/2023]
Abstract
OBJECTIVE To evaluate efficacy in achieving vaginal delivery with a standardized vaginal compared with oral misoprostol regimen for labor induction at term. METHODS In this single-center, cluster randomized trial, we randomized induction method by week among individuals with gestational age of 37 weeks or more, cervical dilation of 2 cm or less, intact membranes, and indication for delivery to either oral (100 micrograms every 4 hours for up to two doses), or vaginal (25 micrograms every 3 hours for up to five doses) misoprostol regimens, followed by a standardized oxytocin protocol. Individuals with an antepartum stillbirth, major fetal anomalies, malpresentation, ruptured membranes, nonreassuring fetal status, or contraindication to prostaglandin were excluded. The primary outcome was vaginal delivery at first induction attempt. Secondary outcomes included time to delivery, need for oxytocin, chorioamnionitis, and adverse maternal and neonatal outcomes. Outcomes were recorded at the individual level and adjusted for clustering, with analysis by intention to treat. RESULTS Between May 24, 2021, to September 19, 2022, 1,322 women were randomized to vaginal misoprostol in 33 clusters and 1,224 to oral misoprostol in 37 clusters. Demographic characteristics or initial cervical dilation did not differ between groups. The primary outcome did not differ between induction regimens and occurred in 1,032 (78.1%) of the vaginal misoprostol arm and 945 (77.2%) of the oral misoprostol arm (adjusted relative risk [RR] 1.01, 95% CI, 0.97-1.05). Tachysystole with fetal heart rate changes occurred less frequently with vaginal compared with oral misoprostol (3.5% vs 5.9%, adjusted RR 0.59, 95% CI, 0.40-0.87). Time to delivery did not differ between groups. Oxytocin was less frequently required before delivery in the vaginal misoprostol group (68.8% vs 78.4%, adjusted RR 0.88, 95% CI, 0.84-0.92). CONCLUSION Induction of labor with vaginal compared with oral misoprostol protocols did not increase the frequency of vaginal delivery at term but did reduce the need for oxytocin use before delivery. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT04755218.
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Affiliation(s)
- Emily H Adhikari
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, and Parkland Health, Dallas, Texas
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Faucher MA, Morillos S, Cordova P, McNeil-Santiel J, Onisko N, Adhikari EH, Nelson DB. Kratom (Mitragyna speciosa): A Case Review of Use Before and During Pregnancy. J Midwifery Womens Health 2024; 69:144-149. [PMID: 37679866 DOI: 10.1111/jmwh.13558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
Kratom (Mitragyna speciosa) is a plant-based substance with psychoactive properties similar to opioids but is not currently classified as an opioid. One of its more prevalent uses is to treat opioid dependency and withdrawal symptoms. Opioid use disorder is a leading cause of pregnancy-associated maternal mortality, and pregnant women may be using kratom as a substitute or alternative to opioids. Prevalence of kratom use is increasing rapidly, but scientific evidence specific to therapeutic and adverse effects is lacking overall, and the implications of its use in pregnancy and on the fetus-newborn are limited to a few case reports. Kratom is a legal substance by federal law, although some states have banned its use. The lack of regulation is concerning. Significant illness and associated deaths have been reported with kratom use. Lack of disclosure by people using kratom and limited laboratory testing options are major challenges for health care providers and public health.
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Affiliation(s)
- Mary Ann Faucher
- Women & Infants Specialty Health, Parkland Health, Dallas, Texas
| | | | - Polly Cordova
- Women & Infants Specialty Health, Parkland Health, Dallas, Texas
| | | | - Nancy Onisko
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Emily H Adhikari
- Department of Obstetrics & Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - David B Nelson
- Department of Obstetrics & Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
- Division of Maternal-Fetal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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Kleinmann WN, Pruszynski JE, Adhikari EH. Use of integrase inhibitors vs protease inhibitors is associated with improved HIV viral suppression. Am J Obstet Gynecol MFM 2023; 5:101151. [PMID: 37689245 DOI: 10.1016/j.ajogmf.2023.101151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/22/2023] [Accepted: 09/02/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Current guidelines for antiretroviral therapy in pregnancy include the use of a dual-nucleoside reverse transcriptase inhibitor with either an integrase strand transfer inhibitor or a ritonavir-boosted protease inhibitor, although there is no designation of which is the preferred option. OBJECTIVE This study aimed to compare viral suppression at delivery among patients on dual-nucleoside reverse transcriptase inhibitors combined with either an integrase strand transfer inhibitor or a protease inhibitor. A hypothesis was made that the incidence of viral suppression is higher with the use of a dual-nucleoside reverse transcriptase inhibitor backbone combined with an integrase strand transfer inhibitor than with the use of a dual-nucleoside reverse transcriptase inhibitor backbone combined with a protease inhibitor. STUDY DESIGN This study was an observational study of pregnant patients living with HIV who received prenatal care and delivered after 20 weeks of gestation at an urban safety net hospital. All pregnant patients with HIV were referred to a centralized clinic for HIV counseling, medication management, and prenatal care. Antiretroviral therapy was continued or initiated according to protocols based on national guidance. Among patients on a dual-nucleoside reverse transcriptase inhibitor backbone combined with integrase strand transfer inhibitor vs protease inhibitor at delivery, we compared the demographics and HIV disease characteristics, including year of diagnosis, viral load, and antiretroviral therapy class. The outcome of interest was viral suppression at delivery, defined as a viral load of <50 copies/mL. RESULTS From January 2011 to December 2021, 604 patients on dual-nucleoside reverse transcriptase inhibitor met the inclusion criteria, including 411 patients (68%) on protease inhibitor and 193 patients (32%) on integrase strand transfer inhibitor at delivery. Demographic distribution was similar, and prenatal care was initiated at 12 weeks of gestation. Among the integrase strand transfer inhibitor group, 101 (17%) were on antiretroviral therapy at initiation of prenatal care compared with 169 (28%) in the protease inhibitor group. At delivery, the frequency of viral load suppression was higher among those on an integrase strand transfer inhibitor (147/193 [76%]) than among those on a protease inhibitor (275/411 [67%]) (odds ratio, 1.59; 95% confidence interval, 1.08-2.33). Among those with a detectable virus, quantitative viral load was not different. During the study period, the use of a protease inhibitor decreased, whereas the use of an integrase strand transfer inhibitor increased. CONCLUSION Among pregnant patients living with HIV, viral suppression was more common among those on a dual-nucleoside reverse transcriptase inhibitor backbone combined with integrase strand transfer inhibitor than among those on a dual-nucleoside reverse transcriptase inhibitor backbone protease inhibitor at delivery. Our results support the use of dual-nucleoside reverse transcriptase inhibitor with integrase strand transfer inhibitor as a first-line antiretroviral therapy regimen in pregnancy.
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Affiliation(s)
- Whitney N Kleinmann
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas and Parkland Health, Dallas, TX.
| | - Jessica E Pruszynski
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas and Parkland Health, Dallas, TX
| | - Emily H Adhikari
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas and Parkland Health, Dallas, TX
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Adhikari EH, Lu P, Kang YJ, McDonald AR, Pruszynski JE, Bates TA, McBride SK, Trank-Greene M, Tafesse FG, Lu LL. Diverging maternal and infant cord antibody functions from SARS-CoV-2 infection and vaccination in pregnancy. bioRxiv 2023:2023.05.01.538955. [PMID: 37205338 PMCID: PMC10187183 DOI: 10.1101/2023.05.01.538955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Immunization in pregnancy is a critical tool that can be leveraged to protect the infant with an immature immune system but how vaccine-induced antibodies transfer to the placenta and protect the maternal-fetal dyad remains unclear. Here, we compare matched maternal-infant cord blood from individuals who in pregnancy received mRNA COVID-19 vaccine, were infected by SARS-CoV-2, or had the combination of these two immune exposures. We find that some but not all antibody neutralizing activities and Fc effector functions are enriched with vaccination compared to infection. Preferential transport to the fetus of Fc functions and not neutralization is observed. Immunization compared to infection enriches IgG1-mediated antibody functions with changes in antibody post-translational sialylation and fucosylation that impact fetal more than maternal antibody functional potency. Thus, vaccine enhanced antibody functional magnitude, potency and breadth in the fetus are driven more by antibody glycosylation and Fc effector functions compared to maternal responses, highlighting prenatal opportunities to safeguard newborns as SARS-CoV-2 becomes endemic.
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Affiliation(s)
- Emily H. Adhikari
- Division of Maternal-Fetal Medicine and Department of Obstetrics and Gynecology, UTSW Medical Center, Dallas, TX
- Parkland Health, Dallas TX
| | - Pei Lu
- Division of Infectious Diseases and Geographic Medicine and Department of Internal Medicine, UTSW Medical Center, Dallas, TX
| | - Ye jin Kang
- Division of Infectious Diseases and Geographic Medicine and Department of Internal Medicine, UTSW Medical Center, Dallas, TX
| | - Ann R. McDonald
- Division of Infectious Diseases and Geographic Medicine and Department of Internal Medicine, UTSW Medical Center, Dallas, TX
| | - Jessica E. Pruszynski
- Division of Maternal-Fetal Medicine and Department of Obstetrics and Gynecology, UTSW Medical Center, Dallas, TX
| | - Timothy A. Bates
- Department of Microbiology and Immunology, Oregon Health and Science University, Portland, OR
| | - Savannah K. McBride
- Department of Microbiology and Immunology, Oregon Health and Science University, Portland, OR
| | - Mila Trank-Greene
- Department of Microbiology and Immunology, Oregon Health and Science University, Portland, OR
| | - Fikadu G. Tafesse
- Department of Microbiology and Immunology, Oregon Health and Science University, Portland, OR
| | - Lenette L. Lu
- Parkland Health, Dallas TX
- Division of Infectious Diseases and Geographic Medicine and Department of Internal Medicine, UTSW Medical Center, Dallas, TX
- Department of Immunology, UTSW Medical Center, Dallas, TX
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Byrne JJ, Shamshirsaz AA, Cahill AG, Turrentine MA, Seasely AR, Eid J, Rouse CE, Richley M, Raghuraman N, Naqvi M, El-Sayed YY, Badell ML, Cheng C, Liu J, Adhikari EH, Patel SS, O'Neil ER, Ramsey PS. Outcomes Following Extracorporeal Membrane Oxygenation for Severe COVID-19 in Pregnancy or Post Partum. JAMA Netw Open 2023; 6:e2314678. [PMID: 37213099 DOI: 10.1001/jamanetworkopen.2023.14678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2023] Open
Abstract
Importance Existing reports of pregnant patients with COVID-19 disease who require extracorporeal membrane oxygenation (ECMO) are limited, with variable outcomes noted for the maternal-fetal dyad. Objective To examine maternal and perinatal outcomes associated with ECMO used for COVID-19 with respiratory failure during pregnancy. Design, Setting, and Participants This retrospective multicenter cohort study examined pregnant and postpartum patients who required ECMO for COVID-19 respiratory failure at 25 hospitals across the US. Eligible patients included individuals who received care at one of the study sites, were diagnosed with SARS-CoV-2 infection during pregnancy or up to 6 weeks post partum by positive nucleic acid or antigen test, and for whom ECMO was initiated for respiratory failure from March 1, 2020, to October 1, 2022. Exposures ECMO in the setting of COVID-19 respiratory failure. Main outcome and measures The primary outcome was maternal mortality. Secondary outcomes included serious maternal morbidity, obstetrical outcomes, and neonatal outcomes. Outcomes were compared by timing of infection during pregnancy or post partum, timing of ECMO initiation during pregnancy or post partum, and periods of circulation of SARS-CoV-2 variants. Results From March 1, 2020, to October 1, 2022, 100 pregnant or postpartum individuals were started on ECMO (29 [29.0%] Hispanic, 25 [25.0%] non-Hispanic Black, 34 [34.0%] non-Hispanic White; mean [SD] age: 31.1 [5.5] years), including 47 (47.0%) during pregnancy, 21 (21.0%) within 24 hours post partum, and 32 (32.0%) between 24 hours and 6 weeks post partum; 79 (79.0%) had obesity, 61 (61.0%) had public or no insurance, and 67 (67.0%) did not have an immunocompromising condition. The median (IQR) ECMO run was 20 (9-49) days. There were 16 maternal deaths (16.0%; 95% CI, 8.2%-23.8%) in the study cohort, and 76 patients (76.0%; 95% CI, 58.9%-93.1%) had 1 or more serious maternal morbidity events. The largest serious maternal morbidity was venous thromboembolism and occurred in 39 patients (39.0%), which was similar across ECMO timing (40.4% pregnant [19 of 47] vs 38.1% [8 of 21] immediately postpartum vs 37.5% postpartum [12 of 32]; P > .99). Conclusions and Relevance In this multicenter US cohort study of pregnant and postpartum patients who required ECMO for COVID-19-associated respiratory failure, most survived but experienced a high frequency of serious maternal morbidity.
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Affiliation(s)
- John J Byrne
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Health Science Center in San Antonio, San Antonio
| | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Alison G Cahill
- Department of Obstetrics and Gynecology, University of Texas at Austin, Dell Medical School, Austin
| | - Mark A Turrentine
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Angela R Seasely
- Center for Women's Reproductive Health, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham
| | - Joe Eid
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus
| | - Caroline E Rouse
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Indiana University School of Medicine, Indianapolis
| | - Michael Richley
- Department of Obstetrics and Gynecology, University of California, Los Angeles
| | - Nandini Raghuraman
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Mariam Naqvi
- Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, California
| | - Yasser Y El-Sayed
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Obstetrics, Stanford University, Palo Alto, California
| | - Martina L Badell
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - CeCe Cheng
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Health Science Center in San Antonio, San Antonio
- Department of Obstetrics and Gynecology, Methodist Hospital, San Antonio, Texas
| | - James Liu
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Emily H Adhikari
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Soha S Patel
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Erika R O'Neil
- Department of Pediatrics, Brooke Army Medical Center, San Antonio, Texas
| | - Patrick S Ramsey
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Health Science Center in San Antonio, San Antonio
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Ogunkua OT, Adhikari EH, Gasanova I, Jalloh MN, Syed SS, Pruszynski JE, Spong CY. Neuraxial Anesthesia during the COVID-19 Pandemic: Report from a Large Academic Medical Center. Am J Perinatol 2023. [PMID: 36603831 DOI: 10.1055/a-2008-2600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Three primary neuraxial techniques reduce labor pain: epidural, dural puncture epidural (DPE), and combined spinal-epidural (CSE). This study aims to determine whether neuraxial analgesia techniques changed after the onset of the coronavirus disease 2019 (COVID-19) pandemic. Given that a dural puncture confirms neuraxial placement, we hypothesized that DPE was more frequent in women with concerns for COVID-19. STUDY DESIGN A single-center retrospective cohort study comparing neuraxial analgesia techniques for labor and delivery pain management before and after the onset of the COVID-19 pandemic and in patients with and without SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) at a maternity hospital in Dallas, Texas, with a large delivery service. Statistical analyses included the Chi-square test for categorical and Kruskal-Wallis test for nonparametric ordinal comparisons. The Cochran-Mantel-Haenszel test was used to assess the association between neuraxial technique and accidental dural puncture or postdural puncture headache. RESULTS Of 10,971 patients who received neuraxial analgesia for labor, 5,528 were delivered in 2019 and 5,443 in 2020. Epidural analgesia was the most common neuraxial technique for labor pain in 2019 and 2020. There was no difference in the frequency of neuraxial analgesia techniques or the rates of accidental dural puncture or postdural puncture headaches comparing all deliveries in 2019 to 2020. Despite a significant increase in DPEs relative to epidurals in the SARS-CoV-2-positive group compared with the SARS-CoV-2-negative group in 2020, there was no significant difference in postdural puncture headaches or accidental dural punctures. CONCLUSION The advantages of a DPE, specifically the ability to confirm epidural placement using a small gauge spinal needle, likely led to an increase in the placement of this neuraxial in SARS-CoV-2-positive patients. There was no effect on the frequency of postdural puncture headaches or accidental dural punctures within the same period. KEY POINTS · Epidural analgesia was the most common neuraxial technique for labor pain management.. · Dural puncture epidural placements increased in SARS-CoV-2-positive patients.. · Rates of postdural puncture headaches and accidental dural puncture after neuraxial placement did not change..
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Affiliation(s)
- Olutoyosi T Ogunkua
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Emily H Adhikari
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Irina Gasanova
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Miakka N Jalloh
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sannoor S Syed
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jessica E Pruszynski
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Catherine Y Spong
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
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11
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Ambia AM, Faucher MA, Cordova PB, McNeil-Santiel J, Morillos S, Adhikari EH, Wells C, Roberts SW, Herrera CL, Kleinschmidt K, Onisko NS, Kern J, Andino A, Nelson DB. Perinatal opioid use prevention and treatment at a public, inner-city hospital system. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.1032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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12
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Kleinmann W, Zofkie AC, McIntire DD, Adhikari EH. Lactate levels increase significantly in the second stage of spontaneous and induced labor. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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13
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Kleinmann W, Pruszynski JE, Adhikari EH. HIV viral suppression in sequential pregnancies with and without changing antiretroviral therapy class. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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14
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Schell RC, Macias DA, Garner WH, White AM, McIntire DD, Pruszynski J, Adhikari EH. Examining the impact of trimester of diagnosis on COVID-19 disease progression in pregnancy. Am J Obstet Gynecol MFM 2022; 4:100728. [PMID: 35995369 PMCID: PMC9391234 DOI: 10.1016/j.ajogmf.2022.100728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/02/2022] [Accepted: 08/15/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND COVID-19 infection is associated with increased morbidity in pregnancy and adverse maternal and neonatal outcomes. Little is currently known about how the timing of infection during pregnancy affects these outcomes. OBJECTIVE This study aimed to evaluate the effect of trimester of COVID-19 infection on disease progression and severity in pregnant patients. STUDY DESIGN This was a prospective cohort study of pregnant patients diagnosed with COVID-19 infection who delivered at a single urban hospital. Universal testing for SARS-CoV-2 was performed at hospital admission and for symptomatic patients in inpatient, emergency department, and outpatient settings. Disease severity was defined as asymptomatic, mild, moderate, severe, or critical on the basis of National Institutes of Health criteria. We evaluated disease progression from asymptomatic to symptomatic infection and from asymptomatic or mild infection to moderate, severe, or critical illness, and stratified by trimester of COVID-19 diagnosis. Primary outcomes included progression of COVID-19 disease severity and a composite obstetrical outcome, which included delivery at <37 weeks, preeclampsia with severe features, abruption, excess blood loss at delivery (>500 mL for vaginal or >1000 mL for cesarean delivery), and stillbirth. RESULTS From March 18, 2020 to September 30, 2021, 1326 pregnant patients were diagnosed with COVID-19 and delivered at our institution, including 103 (8%) first-, 355 (27%) second-, and 868 (65%) third-trimester patients. First-trimester patients were older and had more medical comorbidities; 86% of patients in all trimesters were Hispanic. Among patients admitted within 14 days of a positive test, 3 of 18 (17%) first-trimester, 20 of 47 (43%) second-trimester, and 34 of 574 (6%) third-trimester patients were admitted for the indication of COVID-19 illness. Across all trimesters, 1195 (90%) of 1326 COVID-19 infections were asymptomatic or mild, and 45 (10%) of 436 initially asymptomatic patients developed symptoms. Of patients with asymptomatic or mild symptoms at diagnosis, 4 (4%) of 93 first-, 18 (5%) of 337 second-, and 49 (6%) of 836 third-trimester patients developed moderate, severe, or critical illness (P=.80). There was no significant difference in composite obstetrical outcome with respect to trimester of COVID-19 diagnosis (24% first-trimester, 28% second-trimester, 28% third-trimester patients; P=.69). CONCLUSION Moderate, severe, or critical illness develops in almost 10% of pregnant patients. The frequency of COVID-19 disease progression in pregnancy does not differ by trimester of diagnosis.
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Affiliation(s)
- Rachel C Schell
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX (Drs Schell, Macias, White, McIntire, Pruszynski, and Adhikari); Parkland Health, Dallas, TX (Drs Schell, Macias, White, and Adhikari).
| | - Devin A Macias
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX (Drs Schell, Macias, White, McIntire, Pruszynski, and Adhikari); Parkland Health, Dallas, TX (Drs Schell, Macias, White, and Adhikari)
| | - W Holt Garner
- School of Medicine, The University of Texas Southwestern Medical Center, Dallas, TX (Mr Garner)
| | - Alesha M White
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX (Drs Schell, Macias, White, McIntire, Pruszynski, and Adhikari); Parkland Health, Dallas, TX (Drs Schell, Macias, White, and Adhikari)
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX (Drs Schell, Macias, White, McIntire, Pruszynski, and Adhikari)
| | - Jessica Pruszynski
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX (Drs Schell, Macias, White, McIntire, Pruszynski, and Adhikari)
| | - Emily H Adhikari
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX (Drs Schell, Macias, White, McIntire, Pruszynski, and Adhikari); Parkland Health, Dallas, TX (Drs Schell, Macias, White, and Adhikari)
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15
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Adhikari EH, Spong CY. Understanding Acute Obstetric Morbidity Associated With SARS-CoV-2 Variants-Unwrapping the Layers of an Onion. JAMA Netw Open 2022; 5:e2226444. [PMID: 35960525 DOI: 10.1001/jamanetworkopen.2022.26444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Emily H Adhikari
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas
- Parkland Health and Hospital System, Dallas, Texas
| | - Catherine Y Spong
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas
- Parkland Health and Hospital System, Dallas, Texas
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16
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Adhikari EH, Spong CY. Pregnancy is not a disability: including pregnant healthcare workers in COVID-19 vaccine mandates. Am J Obstet Gynecol 2022; 226:757-759. [PMID: 34902322 PMCID: PMC8660659 DOI: 10.1016/j.ajog.2021.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 12/07/2021] [Indexed: 11/11/2022]
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17
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Adhikari EH, MacDonald L, SoRelle JA, Morse J, Pruszynski J, Spong CY. COVID-19 Cases and Disease Severity in Pregnancy and Neonatal Positivity Associated With Delta (B.1.617.2) and Omicron (B.1.1.529) Variant Predominance. JAMA 2022; 327:1500-1502. [PMID: 35325015 PMCID: PMC8949750 DOI: 10.1001/jama.2022.4356] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This study examines infections, illness severity, vaccinations, and early neonatal infections among obstetric patients during the pre-Delta, Delta, and Omicron periods of the COVID-19 pandemic.
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Affiliation(s)
- Emily H. Adhikari
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas
| | | | - Jeffrey A. SoRelle
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas
| | - Jessica Morse
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Jessica Pruszynski
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas
| | - Catherine Y. Spong
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas
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18
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Macias DA, Adhikari EH, Eddins M, Nelson DB, McIntire DD, Duryea EL. A comparison of acute pain management strategies after cesarean delivery. Am J Obstet Gynecol 2022; 226:407.e1-407.e7. [PMID: 34534504 DOI: 10.1016/j.ajog.2021.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/01/2021] [Accepted: 09/08/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND There are approximately 1.2 million cesarean deliveries performed each year in the United States alone. While traditional postoperative pain management strategies previously relied heavily on opioids, practitioners are now moving toward opioid-sparing protocols using multiple classes of nonnarcotic analgesics. Multimodal pain management systems have been adopted by other surgical specialties including gynecology, although the data regarding their use for postoperative cesarean delivery pain management remain limited. OBJECTIVE To determine if a multimodal pain management regimen after cesarean delivery reduces the required number of morphine milligram equivalents (a unit of measurement for opioids) compared with traditional morphine patient-controlled analgesia while adequately controlling postoperative pain. STUDY DESIGN This was a prospective cohort study of postoperative pain management for women undergoing cesarean delivery at a large county hospital. It was conducted during a transition from a traditional morphine patient-controlled analgesia regimen to a multimodal regimen that included scheduled nonsteroidal anti-inflammatory drugs and acetaminophen, with opioids used as needed. The data were collected for a 6-week period before and after the transition. The primary outcome was postoperative opioid use defined as morphine milligram equivalents in the first 48 hours. The secondary outcomes included serial pain scores, time to discharge, and exclusive breastfeeding rates. Women who required general anesthesia or had a history of substance abuse disorder were excluded. The statistical analyses included the Student t test, Wilcoxon rank-sum, and Hodges-Lehman shift, with a P value <.05 being considered significant. RESULTS During the study period, 877 women underwent cesarean delivery and 778 met the inclusion criteria-378 received the traditional morphine patient-controlled analgesia and 400 received the multimodal regimen. The implementation of a multimodal regimen resulted in a significant reduction in the morphine milligram equivalent use in the first 48 hours (28 [14-41] morphine milligram equivalents vs 128 [86-174] morphine milligram equivalents; P<.001). Compared with the traditional group, more women in the multimodal group reported a pain score ≤4 by 48 hours (88% vs 77%; P<.001). There was no difference in the time to discharge (P=.32). Of the women who exclusively planned to breastfeed, fewer used formula before discharge in the multimodal group than in the traditional group (9% vs 12%; P<.001). CONCLUSION Transition to a multimodal pain management regimen for women undergoing cesarean delivery resulted in a decrease in opioid use while adequately controlling postoperative pain. A multimodal regimen was associated with early successful exclusive breastfeeding.
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Affiliation(s)
- Devin A Macias
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX.
| | - Emily H Adhikari
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Michelle Eddins
- Department of Anesthesiology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - David B Nelson
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Don D McIntire
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Elaine L Duryea
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX
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19
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Adhikari EH, SoRelle JA, McIntire DD, Spong CY. Increasing severity of COVID-19 in pregnancy with Delta (B.1.617.2) variant surge. Am J Obstet Gynecol 2022; 226:149-151. [PMID: 34529957 PMCID: PMC8437765 DOI: 10.1016/j.ajog.2021.09.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/08/2021] [Accepted: 09/09/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Emily H Adhikari
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390.
| | - Jeffrey A SoRelle
- Department of Pathology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Catherine Y Spong
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX
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20
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Adhikari EH, Roberts S. Sexually Transmitted Infections and Preterm Birth-Attempting to Pin Down Targets for Intervention From Population-Level Observational Data. JAMA Netw Open 2021; 4:e2134459. [PMID: 34842929 DOI: 10.1001/jamanetworkopen.2021.34459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Scott Roberts
- University of Texas Southwestern Medical Center, Dallas
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21
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Zofkie AC, Fomina YY, Roberts SW, McIntire DD, Nelson DB, Adhikari EH. Effectiveness of Chlamydia trachomatis expedited partner therapy in pregnancy. Am J Obstet Gynecol 2021; 225:325.e1-325.e7. [PMID: 33894150 DOI: 10.1016/j.ajog.2021.04.238] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/12/2021] [Accepted: 04/15/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Expedited partner therapy for Chlamydia trachomatis has had mixed efficacy in different populations, but limited data exist on the efficacy of the therapy in a pregnant population. OBJECTIVE This study aimed to evaluate the real-world effectiveness of establishing a prenatal expedited partner therapy program in eradicating chlamydia before delivery and to examine the maternal and neonatal outcomes between women who received expedited partner therapy for chlamydia and women who received standard partner referral testing and treatment during pregnancy. STUDY DESIGN An expedited partner therapy program was implemented on August 21, 2019, at a public hospital in a county with high chlamydia prevalence. Pregnant women were provided with single-dose packets of azithromycin to treat partners following a diagnosis of chlamydia infection. We prospectively observed pregnant women treated in the expedited partner therapy program who delivered at our institution in the same year and compared the outcomes with a historic cohort from the previous year that had traditional partner referral testing and treatment. We excluded women with concurrent gonorrhea, HIV, syphilis, or current intimate partner violence. The primary outcome was chlamydia reinfection or no-cure rates at repeat testing in 4 to 6 weeks following treatment or at the 36-week prenatal care screening. Secondary outcomes included obstetrical, maternal, and neonatal outcomes, including premature rupture of membranes, chorioamnionitis, endometritis, neonatal intensive care unit admission, neonatal sepsis, pneumonia, and conjunctivitis. RESULTS The rate of chlamydia infection was 3.6% over a 2-year period in our delivered population. In the year following the implementation of the expedited partner therapy, compared with 419 women (mean±standard deviation, 23.4±5.5 years) who were diagnosed with chlamydia infection in the previous year, 471 women (mean±standard deviation age, 23.8±5.3 years) who delivered at our institution were diagnosed with chlamydia infection. There was no difference in race, parity, prenatal care attendance, or concomitant sexually transmitted infections. Compared with the pre-expedited partner therapy group, the rate of reinfection in the post-expedited partner therapy group was not statistically different (60/471 [13%] vs 61/419 [15%]; odds ratio, 0.86 [95% confidence interval 0.58-1.26]). In a per-protocol analysis, 72 women (17%) in the pre-expedited partner therapy group and 389 women (83%) in post-expedited partner therapy group received expedited partner therapy; reinfection was not statistically different between groups (P=.47). There was no difference in secondary outcomes, although a trend toward improved rates of endometritis was noted in the post-expedited partner therapy group (odds ratio, 0.13; 95% confidence interval, 0.02-1.02). CONCLUSION The implementation of a prenatal expedited partner therapy program did not affect the rate of chlamydia reinfection before delivery. Treatment of chlamydia in an inner-city population has multiple factors that lead to successful treatment. Future efforts to reduce sexually transmitted infection and chlamydia reinfection rates in an at-risk population should include exploring patient education and safe sex practices beyond expedited partner therapy alone during pregnancy.
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Affiliation(s)
- Amanda C Zofkie
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX; Department of Obstetrics and Gynecology, Parkland Health and Hospital Systems, Dallas, TX.
| | - Yevgenia Y Fomina
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX; Department of Obstetrics and Gynecology, Parkland Health and Hospital Systems, Dallas, TX
| | - Scott W Roberts
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX; Department of Obstetrics and Gynecology, Parkland Health and Hospital Systems, Dallas, TX
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - David B Nelson
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX; Department of Obstetrics and Gynecology, Parkland Health and Hospital Systems, Dallas, TX
| | - Emily H Adhikari
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX; Department of Obstetrics and Gynecology, Parkland Health and Hospital Systems, Dallas, TX
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22
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Chan CS, Kong JY, Babata KL, Mazzarella K, Adhikari EH, Yeo KT, Hascoët JM, Brion LP. Optimal delivery management for the prevention of early neonatal SARS-CoV-2 infection. Hippokratia 2021. [DOI: 10.1002/14651858.cd013689.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Christina S Chan
- Pediatrics / Div. Neonatal-Perinatal Medicine; University of Texas, Southwestern Medical Center; Dallas Texas USA
| | - Juin Yee Kong
- Department of Neonatology; KK Women's and Children's Hospital; Singapore Singapore
| | - Kikelomo L Babata
- Pediatrics / Div. Neonatal-Perinatal Medicine; University of Texas, Southwestern Medical Center; Dallas Texas USA
| | - Kelly Mazzarella
- Pediatrics / Neonatal-Perinatal Medicine; University of Texas, Southwestern Medical Center; Dallas Texas USA
| | - Emily H Adhikari
- Department of Obstetrics and Gynecology; University of Texas, Southwestern Medical Center; Dallas Texas USA
| | - Kee Thai Yeo
- Department of Neonatology; KK Women's and Children's Hospital; Singapore Singapore
| | | | - Luc P Brion
- Division of Neonatal-Perinatal Medicine; University of Texas Southwestern at Dallas; Dallas Texas USA
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23
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Babata KL, Yeo KT, Chan CS, Mazzarella K, Adhikari EH, Kong JY, Hascoët JM, Brion LP. Feeding strategies to prevent neonatal SARS-CoV-2 infection in term or late preterm babies born to mothers with confirmed COVID-19. Hippokratia 2021. [DOI: 10.1002/14651858.cd013691.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Kikelomo L Babata
- Pediatrics / Div. Neonatal-Perinatal Medicine; University of Texas, Southwestern Medical Center; Dallas Texas USA
| | - Kee Thai Yeo
- Department of Neonatology; KK Women's and Children's Hospital; Singapore Singapore
| | - Christina S Chan
- Pediatrics / Div. Neonatal-Perinatal Medicine; University of Texas, Southwestern Medical Center; Dallas Texas USA
| | - Kelly Mazzarella
- Pediatrics / Neonatal-Perinatal Medicine; University of Texas, Southwestern Medical Center; Dallas Texas USA
| | - Emily H Adhikari
- Department of Obstetrics and Gynecology; University of Texas, Southwestern Medical Center; Dallas Texas USA
| | - Juin Yee Kong
- Department of Neonatology; KK Women's and Children's Hospital; Singapore Singapore
| | | | - Luc P Brion
- Division of Neonatal-Perinatal Medicine; University of Texas Southwestern at Dallas; Dallas Texas USA
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Abstract
IMPORTANCE Ensuring access to prenatal care services in the US is challenging, and implementation of telehealth options was limited before the COVID-19 pandemic, especially in vulnerable populations, given the regulatory requirements for video visit technology. OBJECTIVE To explore the association of audio-only virtual prenatal care with perinatal outcomes. DESIGN, SETTING, AND PARTICIPANTS This cohort study compared perinatal outcomes of women who delivered between May 1 and October 31, 2019 (n = 6559), and received in-person prenatal visits only with those who delivered between May 1 and October 31, 2020 (n = 6048), when audio-only virtual visits were integrated into prenatal care during the COVID-19 pandemic, as feasible based on pregnancy complications. Parkland Health and Hospital System in Dallas, Texas, provides care to the vulnerable obstetric population of the county via a high-volume prenatal clinic system and public maternity hospital. All deliveries of infants weighing more than 500 g, whether live or stillborn, were included. EXPOSURES Prenatal care incorporating audio-only prenatal care visits. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of placental abruption, stillbirth, neonatal intensive care unit admission in a full-term (≥37 weeks) infant, and umbilical cord blood pH less than 7.0. Visit data, maternal characteristics, and other perinatal outcomes were also examined. RESULTS The mean (SD) age of the 6559 women who delivered in 2019 was 27.8 (6.4) years, and the age of the 6048 women who delivered in 2020 was 27.7 (6.5) years (P = .38). Of women delivering in 2020, 1090 (18.0%) were non-Hispanic Black compared with 1067 (16.3%) in 2019 (P = .04). In the 2020 cohort, 4067 women (67.2%) attended at least 1 and 1216 women (20.1%) attended at least 3 audio-only virtual prenatal visits. Women who delivered in 2020 attended a greater mean (SD) number of prenatal visits compared with women who delivered in 2019 (9.8 [3.4] vs 9.4 [3.8] visits; P < .001). In the 2020 cohort, 173 women (2.9%) experienced the composite outcome, which was not significantly different than the 195 women (3.0%) in 2019 (P = .71). In addition, the rate of the composite outcome did not differ substantially when examined according to the number of audio-only virtual visits attended. CONCLUSIONS AND RELEVANCE Implementation of audio-only virtual prenatal visits was not associated with changes in perinatal outcomes and increased prenatal visit attendance in a vulnerable population during the COVID-19 pandemic when used in a risk-appropriate model.
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Affiliation(s)
- Elaine L. Duryea
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas
- Department of Obstetrics and Gynecology, Parkland Health and Hospital System, Dallas, Texas
| | - Emily H. Adhikari
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas
- Department of Obstetrics and Gynecology, Parkland Health and Hospital System, Dallas, Texas
| | - Anne Ambia
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas
- Department of Obstetrics and Gynecology, Parkland Health and Hospital System, Dallas, Texas
| | - Catherine Spong
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas
- Department of Obstetrics and Gynecology, Parkland Health and Hospital System, Dallas, Texas
| | - Donald McIntire
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas
| | - David B. Nelson
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas
- Department of Obstetrics and Gynecology, Parkland Health and Hospital System, Dallas, Texas
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Affiliation(s)
- Emily H Adhikari
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas
- Parkland Health and Hospital System, Dallas, Texas
| | - Catherine Y Spong
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas
- Parkland Health and Hospital System, Dallas, Texas
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Macias DA, Adhikari EH, Eddins M, Nelson DB, McIntire DD, Duryea EL. 843 A comparison of acute pain management strategies after cesarean delivery. Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2020.12.866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Zofkie AC, Fomina YY, Roberts SW, Rogers V, McIntire DD, Nelson DB, Adhikari EH. 1020 Effectiveness of chlamydia expedited partner therapy in pregnancy. Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2020.12.1045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Adhikari EH, Moreno W, Zofkie AC, MacDonald L, McIntire DD, Collins RRJ, Spong CY. Pregnancy Outcomes Among Women With and Without Severe Acute Respiratory Syndrome Coronavirus 2 Infection. JAMA Netw Open 2020; 3:e2029256. [PMID: 33211113 PMCID: PMC7677755 DOI: 10.1001/jamanetworkopen.2020.29256] [Citation(s) in RCA: 148] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
IMPORTANCE Published data suggest that there are increased hospitalizations, placental abnormalities, and rare neonatal transmission among pregnant women with coronavirus disease 2019 (COVID-19). OBJECTIVES To evaluate adverse outcomes associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pregnancy and to describe clinical management, disease progression, hospital admission, placental abnormalities, and neonatal outcomes. DESIGN, SETTING, AND PARTICIPANTS This observational cohort study of maternal and neonatal outcomes among delivered women with and without SARS-CoV-2 during pregnancy was conducted from March 18 through August 22, 2020, at Parkland Health and Hospital System (Dallas, Texas), a high-volume prenatal clinic system and public maternity hospital with widespread access to SARS-CoV-2 testing in outpatient, emergency department, and inpatient settings. Women were included if they were tested for SARS-CoV-2 during pregnancy and delivered. For placental analysis, the pathologist was blinded to illness severity. EXPOSURES SARS-CoV-2 infection during pregnancy. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of preterm birth, preeclampsia with severe features, or cesarean delivery for abnormal fetal heart rate among women delivered after 20 weeks of gestation. Maternal illness severity, neonatal infection, and placental abnormalities were described. RESULTS From March 18 through August 22, 2020, 3374 pregnant women (mean [SD] age, 27.6 [6] years) tested for SARS-CoV-2 were delivered, including 252 who tested positive for SARS-CoV-2 and 3122 who tested negative. The cohort included 2520 Hispanic (75%), 619 Black (18%), and 125 White (4%) women. There were no differences in age, parity, body mass index, or diabetes among women with or without SARS-CoV-2. SARS-CoV-2 positivity was more common among Hispanic women (230 [91%] positive vs 2290 [73%] negative; difference, 17.9%; 95% CI, 12.3%-23.5%; P < .001). There was no difference in the composite primary outcome (52 women [21%] vs 684 women [23%]; relative risk, 0.94; 95% CI, 0.73-1.21; P = .64). Early neonatal SARS-CoV-2 infection occurred in 6 of 188 tested infants (3%), primarily born to asymptomatic or mildly symptomatic women. There were no placental pathologic differences by illness severity. Maternal illness at initial presentation was asymptomatic or mild in 239 women (95%), and 6 of those women (3%) developed severe or critical illness. Fourteen women (6%) were hospitalized for the indication of COVID-19. CONCLUSIONS AND RELEVANCE In a large, single-institution cohort study, SARS-CoV-2 infection during pregnancy was not associated with adverse pregnancy outcomes. Neonatal infection may be as high as 3% and may occur predominantly among asymptomatic or mildly symptomatic women. Placental abnormalities were not associated with disease severity, and hospitalization frequency was similar to rates among nonpregnant women.
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Affiliation(s)
- Emily H. Adhikari
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas
- Women and Infants Specialty Health, Parkland Health and Hospital System, Dallas, Texas
| | - Wilmer Moreno
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas
- Women and Infants Specialty Health, Parkland Health and Hospital System, Dallas, Texas
| | - Amanda C. Zofkie
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas
- Women and Infants Specialty Health, Parkland Health and Hospital System, Dallas, Texas
| | - Lorre MacDonald
- Women and Infants Specialty Health, Parkland Health and Hospital System, Dallas, Texas
| | - Donald D. McIntire
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas
| | - Rebecca R. J. Collins
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas
| | - Catherine Y. Spong
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas
- Women and Infants Specialty Health, Parkland Health and Hospital System, Dallas, Texas
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Babata KL, Yeo KT, Chan CS, Mazzarella K, Adhikari EH, Kong JY, Hascoët JM, Brion LP. Feeding strategies to prevent neonatal SARS-CoV-2 infection in term or late preterm babies born to mothers with confirmed COVID-19. Hippokratia 2020. [DOI: 10.1002/14651858.cd013691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Kikelomo L Babata
- Pediatrics / Div. Neonatal-Perinatal Medicine; University of Texas, Southwestern Medical Center; Dallas Texas USA
| | - Kee Thai Yeo
- Department of Neonatology; KK Women's and Children's Hospital; Singapore Singapore
| | - Christina S Chan
- Pediatrics / Div. Neonatal-Perinatal Medicine; University of Texas, Southwestern Medical Center; Dallas Texas USA
| | - Kelly Mazzarella
- Pediatrics / Neonatal-Perinatal Medicine; University of Texas, Southwestern Medical Center; Dallas Texas USA
| | - Emily H Adhikari
- Department of Obstetrics and Gynecology; University of Texas, Southwestern Medical Center; Dallas Texas USA
| | - Juin Yee Kong
- Department of Neonatology; KK Women's and Children's Hospital; Singapore Singapore
| | | | - Luc P Brion
- Division of Neonatal-Perinatal Medicine; University of Texas Southwestern at Dallas; Dallas Texas USA
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Chan CS, Kong JY, Babata KL, Mazzarella K, Adhikari EH, Yeo KT, Hascoët JM, Brion LP. Optimal delivery management for the prevention of early neonatal SARS-CoV-2 infection. Hippokratia 2020. [DOI: 10.1002/14651858.cd013689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Christina S Chan
- Pediatrics / Div. Neonatal-Perinatal Medicine; University of Texas, Southwestern Medical Center; Dallas Texas USA
| | - Juin Yee Kong
- Department of Neonatology; KK Women's and Children's Hospital; Singapore Singapore
| | - Kikelomo L Babata
- Pediatrics / Div. Neonatal-Perinatal Medicine; University of Texas, Southwestern Medical Center; Dallas Texas USA
| | - Kelly Mazzarella
- Pediatrics / Neonatal-Perinatal Medicine; University of Texas, Southwestern Medical Center; Dallas Texas USA
| | - Emily H Adhikari
- Department of Obstetrics and Gynecology; University of Texas, Southwestern Medical Center; Dallas Texas USA
| | - Kee Thai Yeo
- Department of Neonatology; KK Women's and Children's Hospital; Singapore Singapore
| | | | - Luc P Brion
- Division of Neonatal-Perinatal Medicine; University of Texas Southwestern at Dallas; Dallas Texas USA
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Zofkie AC, Seasely AR, Gaffney D, Rogers VL, Mcintire DD, Roberts SW, Adhikari EH. Syphilis Immunoassay Signal Strength Correlates with Active Infection in Pregnant Women. Am J Perinatol 2020; 37:671-678. [PMID: 31910464 DOI: 10.1055/s-0039-3402748] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This study aimed to evaluate the association of ARCHITECT chemiluminescent immunoassay (CIA) signal strength (signal-to-cutoff [S/CO] ratio), with maternal syphilis stage, rapid plasma reagin (RPR) reactivity, and congenital syphilis. STUDY DESIGN A prospective observational study of reverse syphilis screening was conducted. Pregnant women were screened with CIA. Reactive CIA was reflexed to RPR; particle agglutination test (Treponema pallidum particle agglutination [TPPA]) was performed for CIA+/RPR- results. Clinical staging with history and physical was performed, and disease stage was determined. Prior treatment was confirmed. We compared S/CO ratio and neonatal outcomes among the following groups: Group 1: CIA+/RPR+/TPPA+ or CIA+/RPR-/TPPA+ with active syphilis; Group 2: CIA+/RPR-/TPPA+ or CIA+/serofast RPR/TPPA+, previously treated; Group 3: CIA+/RPR-/TPPA+, no history of treatment or active disease; Group 4: CIA+/RPR-/TPPA-, false-positive CIA. RESULTS A total of 144 women delivered with reactive CIA: 38 (26%) in Group 1, 69 (48%) in Group 2, 20 (14%) in Group 3, and 17 (12%) in Group 4. Mean (±standard deviation) S/CO ratio was 18.3 ± 5.4, 12.1 ± 5.3, 9.1 ± 4.6, and 1.9 ± 0.8, respectively (p < 0.001). Neonates with overt congenital syphilis occurred exclusively in Group 1. CONCLUSION Women with active syphilis based on treatment history, clinical staging, and laboratory indices have higher CIA S/CO ratio and are more likely to deliver neonates with overt evidence of congenital syphilis.
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Affiliation(s)
- Amanda C Zofkie
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center, Dallas, Texas
| | - Angela R Seasely
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center, Dallas, Texas
| | - Donna Gaffney
- Microbiology Laboratory, Parkland Health and Hospital System, Dallas, Texas
| | - Vanessa L Rogers
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center, Dallas, Texas
| | - Donald D Mcintire
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center, Dallas, Texas
| | - Scott W Roberts
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center, Dallas, Texas
| | - Emily H Adhikari
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center, Dallas, Texas
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Adhikari EH, Nelson DB, Kelly MA, Moseley L, Wafford M, Cox A, McIntire DD, Leveno KJ. 31: Labor induction with combined foley bulb plus oral misoprostol versus misoprostol alone: a cluster-randomized trial. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Adhikari EH, Knypinski J, Gaffney D, McIntire DD, Rogers V. 320: Physiologic parameters and sepsis bundle failures during the 2017-2018 influenza season. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Adhikari EH, Frame IJ, Hill E, Fatabhoy R, Strickland AL, Cavuoti D, McIntire DD, Hollaway RM. Abbott ARCHITECT Syphilis TP Chemiluminescent Immunoassay Accurately Diagnoses Past or Current Syphilis in Pregnancy. Am J Perinatol 2020; 37:112-118. [PMID: 31905408 DOI: 10.1055/s-0039-3400994] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We evaluate diagnostic accuracy of the ARCHITECT chemiluminescent immunoassay (CIA) screening test in pregnancy, and evaluate pregnancy outcomes among screen-positive women. STUDY DESIGN Samples from routine prenatal rapid plasma reagin (RPR) tests were collected between June 22 and August 18, 2017 and frozen. Samples were batch-tested with the Abbott ARCHITECT syphilis TP immunoassay (CIA, index test). We calculated sensitivity, specificity, predictive value, and false positivity. We compared pregnancy and neonatal outcomes among screen-positive women. RESULTS Of 1,602 specimens, 35 (2.2%) were RPR + ; of those, 24 (69%) were CIA +/Treponema pallidum particle agglutination assay (TPPA)+ and 11 (31%) were CIA-/TPPA-. Of 1,567 RPR- specimens, 14 (0.9%) were CIA + ; of those, 13 (93%) were TPPA + , and one (7%) had a false positive CIA test. Sensitivity of the CIA (95% CI) was 100% (90.5-100%), specificity 99.9% (99.6-100%), positive predictive value 97.4% (86.2-99.9%), and false positive rate 0.06% (0.002-0.4%) for current or past syphilis. Among 37 CIA +/TPPA+ women, seven (19%) had RPR-negative status (Group 1), 11 (30%) had previously treated syphilis (Group 2), and 19 (51%) had active infection (Group 3). One stillbirth occurred in a woman with early, active syphilis identified at delivery; no adverse perinatal outcomes occurred among women in Groups 1 or 2. CONCLUSION The ARCHITECT syphilis TP immunoassay accurately diagnoses current or past syphilis in pregnancy. Clinical history and staging remain essential using a reverse algorithm.
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Affiliation(s)
- Emily H Adhikari
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ithiel J Frame
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Pathology, Parkland Health and Hospital System, Dallas, Texas
| | - Emilie Hill
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Pathology, Parkland Health and Hospital System, Dallas, Texas
| | - Rizwana Fatabhoy
- Department of Pathology, Parkland Health and Hospital System, Dallas, Texas
| | - Amanda L Strickland
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Pathology, Parkland Health and Hospital System, Dallas, Texas
| | - Dominick Cavuoti
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rita M Hollaway
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas
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Adhikari EH, Schell RC, Seasely AR, Zofkie AC, McIntire DD, Roberts SW, Rogers V. 1072: Evaluating the clinical impact of implementing reverse syphilis screening at a large public hospital. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.1085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Adhikari EH, Frame I, Hill E, Fatabhoy R, Cavuoti D, McIntire D, Holloway R. 700: Diagnostic accuracy of Abbott ARCHITECT Syphilis TP chemiluminescent immunoassay in pregnant women. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Adhikari EH, Yule CS, Roberts SW, Rogers VL, Sheffield JS, Kelly MA, McIntire DD, Barnes A. Factors Associated with Postpartum Loss to Follow-Up and Detectable Viremia After Delivery Among Pregnant Women Living with HIV. AIDS Patient Care STDS 2019; 33:14-20. [PMID: 30601060 DOI: 10.1089/apc.2018.0117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Pregnant women living with HIV are at risk for loss to follow-up and viral rebound after delivery. We conducted a retrospective cohort study of women with HIV who delivered at Parkland Hospital, Dallas, to identify factors associated with postpartum loss to HIV care 1 year after delivery. Logistic regression was used to identify factors predicting loss to follow-up. For a subset of women, we compared odds of viremia detectable at delivery and postpartum among women with higher versus lower pill burden regimens. We included 604 women with HIV who delivered between 2005 and 2015. Three hundred ninety-one (65%) women completed at least one visit with an HIV provider within 1 year of delivery. The follow-up rate among black, non-Hispanic women was 65%; 57% for white, non-Hispanic women; and 78% for Hispanic women. Women without follow-up presented for prenatal care later (17 vs. 11 weeks, p < 0.001), and were less likely to be on antiretroviral therapy at initial prenatal visit (29% vs. 49%, p < 0.001). Factors predicting loss to follow-up in multivariate analysis included low-level viremia at delivery [adjusted odds ratio (aOR) = 2.85, 95% confidence interval (CI) = 1.73-4.71] and failure to return for a postpartum visit (aOR = 3.19, 95% CI = 2.07-4.94). High antiretroviral pill burden (≥6 pills daily) was associated with viremia (>1000 copies/mL) at the first prenatal visit (OR = 8.7, 95% CI = 4.6-16.6) through 1 year postpartum (OR = 2.3, 95% CI = 1.2-4.4). Viremia at delivery, failure to return for a postpartum visit, and high pill burden during pregnancy are predictors of postpartum loss to HIV care.
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Affiliation(s)
- Emily H. Adhikari
- Department of Obstetrics and Gynecology and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Casey S. Yule
- Department of Obstetrics and Gynecology and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Scott W. Roberts
- Department of Obstetrics and Gynecology and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Vanessa L. Rogers
- Department of Obstetrics and Gynecology and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jeanne S. Sheffield
- Department of Obstetrics and Gynecology and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mary Ann Kelly
- Department of Obstetrics and Gynecology and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Donald D. McIntire
- Department of Obstetrics and Gynecology and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Arti Barnes
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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Adhikari EH, Macias D, Gaffney D, White S, Rogers VL, McIntire DD, Roberts SW. Diagnostic accuracy of fourth-generation ARCHITECT HIV Ag/Ab Combo assay and utility of signal-to-cutoff ratio to predict false-positive HIV tests in pregnancy. Am J Obstet Gynecol 2018; 219:408.e1-408.e9. [PMID: 29913173 DOI: 10.1016/j.ajog.2018.06.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/04/2018] [Accepted: 06/09/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND False-positive HIV screening tests in pregnancy may lead to unnecessary interventions in labor. In 2014, the Centers for Disease Control and Prevention released a new algorithm for HIV diagnosis using a fourth-generation screening test, which detects antibodies to HIV as well as p24 antigen and has a shorter window period compared with prior generations. A reactive screen requires a differentiation assay, and supplemental qualitative RNA testing is necessary for nonreactive differentiation assay. One screening test, the ARCHITECT Ag/Ab Combo assay, is described to have 100% sensitivity and >99% specificity in nonpregnant populations; however, its clinical performance in pregnancy has not been well described. OBJECTIVE The objective of the study was to determine the performance of the ARCHITECT assay among pregnant women at a large county hospital and to assess whether the relative signal-to-cutoff ratio can be used to differentiate between false-positive vs confirmed HIV infections in women with a nonreactive differentiation assay. STUDY DESIGN This is a retrospective review of fourth-generation HIV testing in pregnant women at Parkland Hospital between June 1, 2015, and Jan. 31, 2017. We identified gravidas screened using the ARCHITECT Ag/Ab Combo assay (index test), with reflex to differentiation assay. Women with reactive ARCHITECT and nonreactive differentiation assay were evaluated with a qualitative RNA assay (reference standard). We calculated sensitivity, specificity, predictive value, and false-positive rate of the ARCHITECT screening assay in our population and described characteristics of women with false-positive HIV testing vs confirmed infection. Among women with a nonreactive differentiation assay, we compared interventions among women with and without a qualitative RNA assay result available at delivery and examined relative signal-to-cutoff ratios of the ARCHITECT assay in women with false-positive vs confirmed HIV infection. RESULTS A total of 21,163 pregnant women were screened using the ARCHITECT assay, and 190 tested positive. Of these, 33 of 190 (17%) women had false-positive HIV screening tests (28 deliveries available for analysis), and 157 of 190 (83%) had confirmed HIV-1 infection (140 available for analysis). Diagnostic accuracy of the ARCHITECT HIV Ag/Ab Combo assay in our prenatal population (with 95% confidence interval) was as follows: sensitivity, 100% (97.7-100%); specificity, 99.8% (99.8-99.9%); positive likelihood ratio, 636 (453-895); negative likelihood ratio, 0.0 (NA); positive predictive value, 83% (77-88%); and false positive rate, 0.16% (0.11-0.22%), with a prevalence of 7 per 1000. Women with false-positive HIV testing were younger and more likely of Hispanic ethnicity. A qualitative RNA assay (reference standard) was performed prenatally in 24 (86%) and quantitative viral load in 22 (92%). Interventions occurred more frequently in women without a qualitative RNA assay result available at delivery, including intrapartum zidovudine (75% vs 4%, P = .002), breastfeeding delay (75% vs 8%, P = .001), and neonatal zidovudine initiation (75% vs 4%, P = .002). The ARCHITECT signal-to-cutoff ratio was significantly lower for women with false-positive HIV tests compared with those with established HIV infection (1.89 [1.27, 2.73] vs 533.65 [391.12, 737.22], respectively, P < .001). CONCLUSION While the performance of the fourth-generation ARCHITECT HIV Ag/Ab Combo assay among pregnant women is comparable with that reported in nonpregnant populations, clinical implications of using a screening test with a positive predictive value of 83% in pregnancy are significant. When the qualitative RNA assay result is unavailable, absence of risk factors in combination with an ARCHITECT HIV Ag/Ab assay S/Co ratio <5 and nonreactive differentiation assay provide sufficient evidence to support deferral of unnecessary intrapartum interventions while awaiting qualitative RNA results.
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Affiliation(s)
- Emily H Adhikari
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX.
| | - Devin Macias
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Donna Gaffney
- Clinical Microbiology Laboratory, Parkland Health and Hospital System, Dallas, TX
| | - Sarah White
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Vanessa L Rogers
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Scott W Roberts
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
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Adhikari EH, Rodriguez AN, Nelson DB, Rogers VL, Roberts SW, McIntire DD, Casey BM. 861: Increasing numbers of false positive Zika tests during pregnancy. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.11.398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Adhikari EH, McKiever M, Nelson DB, Johnson KA, Stocks ME, Rogers VL, Roberts SW, McIntire DD, Casey BM. 860: Neonatal surveillance among asymptomatic Zika-exposed infants through 6 months of life. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.11.397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Adhikari EH, Macias D, Hill E, White S, Rogers VL, McIntire DD, Roberts SW. 859: 4 th generation HIV testing in pregnancy: How sure is sure? Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.11.396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Adhikari EH, Nelson DB. Reply. Am J Obstet Gynecol 2017; 217:92. [PMID: 28268198 DOI: 10.1016/j.ajog.2017.02.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 02/25/2017] [Indexed: 11/15/2022]
Affiliation(s)
- Emily H Adhikari
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX 75390-9049.
| | - David B Nelson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX 75390-9049
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Adhikari EH, Nelson DB, Johnson KA, Jacobs S, Rogers VL, Roberts SW, Sexton T, McIntire DD, Casey BM. Infant outcomes among women with Zika virus infection during pregnancy: results of a large prenatal Zika screening program. Am J Obstet Gynecol 2017; 216:292.e1-292.e8. [PMID: 28153665 DOI: 10.1016/j.ajog.2017.01.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 12/21/2016] [Accepted: 01/13/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Zika virus infection during pregnancy is a known cause of congenital microcephaly and other neurologic morbidities. OBJECTIVE We present the results of a large-scale prenatal screening program in place at a single-center health care system since March 14, 2016. Our aims were to report the baseline prevalence of travel-associated Zika infection in our pregnant population, determine travel characteristics of women with evidence of Zika infection, and evaluate maternal and neonatal outcomes compared to women without evidence of Zika infection. STUDY DESIGN This is a prospective, observational study of prenatal Zika virus screening in our health care system. We screened all pregnant women for recent travel to a Zika-affected area, and the serum was tested for those considered at risk for infection. We compared maternal demographic and travel characteristics and perinatal outcomes among women with positive and negative Zika virus tests during pregnancy. Comprehensive neurologic evaluation was performed on all infants delivered of women with evidence of possible Zika virus infection during pregnancy. Head circumference percentiles by gestational age were compared for infants delivered of women with positive and negative Zika virus test results. RESULTS From March 14 through Oct. 1, 2016, a total of 14,161 pregnant women were screened for travel to a Zika-affected country. A total of 610 (4.3%) women reported travel, and test results were available in 547. Of these, evidence of possible Zika virus infection was found in 29 (5.3%). In our population, the prevalence of asymptomatic or symptomatic Zika virus infection among pregnant women was 2/1000. Women with evidence of Zika virus infection were more likely to have traveled from Central or South America (97% vs 12%, P < .001). There were 391 deliveries available for analysis. There was no significant difference in obstetric or neonatal morbidities among women with or without evidence of possible Zika virus infection. Additionally, there was no difference in mean head circumference of infants born to women with positive vs negative Zika virus testing. No microcephalic infants born to women with Zika infection were identified, although 1 infant with hydranencephaly was born to a woman with unconfirmed possible Zika disease. Long-term outcomes for infants exposed to maternal Zika infection during pregnancy are yet unknown. CONCLUSION Based on a large-scale prenatal Zika screening program in an area with a predominantly Hispanic population, we identified that 4% were at risk from reported travel with only 2/1000 infected. Women traveling from heavily affected areas were most at risk for infection. Neonatal head circumference percentiles among infants born to women with evidence of possible Zika virus infection during pregnancy were not reduced when compared to infants born to women without infection.
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Adhikari EH, Jacobs SO, Rogers VL, Roberts SW, Nelson DB, Casey BM. 584: A county hospital-based prenatal screening program for Zika virus infection. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Adhikari EH, Jacobs SO, Johnson K, Rogers VL, Roberts SW, Nelson DB, Casey BM. 77: Frontal occipital circumference percentiles of infants delivered to mothers with zika infection during pregnancy. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Stewart RD, Nelson DB, Adhikari EH, McIntire DD, Roberts SW, Dashe JS, Sheffield JS. The obstetrical and neonatal impact of maternal opioid detoxification in pregnancy. Am J Obstet Gynecol 2013; 209:267.e1-5. [PMID: 23727040 DOI: 10.1016/j.ajog.2013.05.026] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 04/23/2013] [Accepted: 05/13/2013] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The purpose of this study was to analyze the obstetric and neonatal impact of an opioid detoxification program during pregnancy, as well as to examine variables associated with successful opioid detoxification. STUDY DESIGN This is a retrospective cohort study of women electing inpatient detoxification and subsequently delivering at our hospital from Jan. 1, 2006, through Dec. 31, 2011. Detoxification was considered successful if women had no illicit drug supplementation at the time of delivery. Maternal characteristics were ascertained by chart review and analyzed for variables associated with success. Obstetric and neonatal outcomes were also assessed based on maternal success at delivery. RESULTS Of the 95 women during the study period with complete data, 53 (56%) were successful. There were no demographic or social risk factors identified associated with success. Women with successful detoxification at delivery had longer inpatient detoxification admissions (median 25 vs 15 days, P < .001) and were less likely to leave prior to completion of the program than women who had relapsed at delivery (9% vs 33%, respectively, P < .001). Infants of mothers who were successfully detoxified had shorter hospitalizations (median 3 vs 22 days, P < .001), lower maximum neonatal abstinence syndrome scores (0 vs 8.3, P < .001), and were less likely to be treated for withdrawal (10% vs 80%, P < .001). CONCLUSION Opiate detoxification in pregnancy requires a significant time commitment and extended treatment, however, can be successfully achieved in compliant parturients. Importantly, maternal demographics and drug histories do not portend success, supporting continued opiate detoxification being offered to all women expressing intent.
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Affiliation(s)
- Robert D Stewart
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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