Impact of Prenatal Group Healthy Relationship Education on Postpartum Contraception

Objective

We aimed to evaluate the impact of an antenatal group healthy relationship education program on the postpartum use of long-acting reversible contraception (LARC).

Materials and Methods

This is a planned subgroup analysis of a larger randomized controlled trial. Pregnant and newly parenting women were randomized to either group healthy relationship education, "MotherWise," or no additional services. An evidence-based healthy relationship education program and individual case management sessions were provided. The program did not include any prenatal care or contraception counseling. This subgroup analysis included those participants with a nonanomalous gestation randomized at <40 weeks who received care and delivered at a single safety-net hospital and were discharged home with a live infant(s).

Results

From September 2, 2016 to December 21, 2018, 953 women were randomized in the larger trial; 507 met inclusion criteria for this study; 278 randomized to program and 229 controls. Participants were mostly young, parous, Hispanic, publicly insured women. Participants randomized to program were more likely to take a prescription medicine and be delivered through cesarean; there were not any other significant differences in baseline, antenatal, or perinatal outcomes. Those randomized to program were more likely to be discharged home with immediate postpartum LARC in place (odds ratio [OR] 1.87; confidence interval [CI] 1.17-3.00), and more likely to be using LARC at the postpartum visit (OR 2.19; CI 1.34-3.56).

Conclusion

Antenatal group healthy relationship education provided separately from prenatal care is associated with a twofold increase in the use of postpartum LARC.

Clinical Trial Registration

ClinicalTrials.gov NCT02792309; https://clinicaltrials.gov/ct2/show/NCT02792309?term=NCT02792309&draw=2&rank=1.

Relationship education for women during pregnancy: The impact of MotherWise on birth outcomes

The field of relationship science has called for more research on the impact of relationship education on child outcomes, yet studies in this area remain sparse, particularly regarding maternal and infant health at birth. Research on group prenatal care demonstrates that individual-oriented group interventions have a positive impact on infant birth outcomes, suggesting the need to consider the impacts of other forms of group programming for women. The current study examined the impact of MotherWise, an individual-oriented relationship education and brief case management/coaching program for minority and low-income pregnant women, on birth outcomes. The study sample included 136 women who enrolled in a larger randomized controlled trial of MotherWise during early pregnancy. Although statistical power was limited due to the sample size and the effects were not outright significant at p < 0.05, results indicated that the effects of MotherWise on birth outcomes were small to moderate in size (0.23 for birthweight, 0.46 for preterm birth) and suggest important avenues for future tests of relationship education programs and their impacts on maternal and infant health. The current study suggests that relationship education during pregnancy could directly impact women's and infant's health.

Concordance of Desired and Administered Postpartum Contraceptives among Emergency and Full Scope Medicaid Patients

OBJECTIVE

To determine if concordance of contraceptive preference and uptake differ between postpartum recipients of emergency versus full scope Medicaid.

STUDY DESIGN

We performed a historical cohort study of patients who delivered at a safety-net hospital in Denver, Colorado in 2016. In our public system, all patients had access to immediate postpartum tubal ligation and all forms of reversible contraception in outpatient clinics. We used data from electronic health records to compare contraceptive preferences and uptake between patients with full scope and emergency Medicaid at hospital discharge and by 12 weeks postpartum. We then compared contraceptive concordance (use of the same method as desired during delivery admission) between the groups at time of postpartum discharge and by 12 weeks postpartum.

RESULTS

We examined 693 women; 349 (50.1%) had emergency Medicaid and 344 (49.9%) had full scope Medicaid. The mean age at delivery was 27.9 years, and most patients were Hispanic (74%). Women with emergency Medicaid were less likely to receive their desired method of postpartum contraception before hospital discharge (53.6% vs. 66.9%; p < .01). One-half of the patients with emergency Medicaid who did not receive their desired method of immediate postpartum contraception were unable to obtain it based on insurance ineligibility. By 12 weeks postpartum, the rates of concordance did not differ by insurance status: 52.4% of patients with emergency Medicaid and 55.2% of patients with full scope Medicaid received their desired method of contraception (p = .46).

CONCLUSIONS

Emergency Medicaid recipients, largely recent and/or unauthorized immigrants, have high demand for highly effective postpartum contraceptives. Although emergency Medicaid recipients initially had lower rates of receipt of their desired contraceptive during the hospital stay compared with those with full scope Medicaid, they ultimately had similar concordance rates by 12 weeks postpartum. We suspect this finding was in part due to free access to all methods of contraception in our outpatient clinics during the postpartum course. Systemic barriers should be reduced to ensure better access to postpartum contraceptives for all patients, regardless of insurance coverage, to improve reproductive equity.

Self-Reported Alcohol, Tobacco, and Marijuana Use in Pregnant Women with Depressive Symptomatology

OBJECTIVE

Substance use disorders often coexist with depression. The objective of this study was to establish whether pregnant women who report depressive symptomatology were more likely to report use of alcohol, tobacco, and marijuana during pregnancy.

STUDY DESIGN

This was a secondary analysis of prospectively collected data from the Maternal-Fetal Medicine Units Network Preterm Prediction Study. Self-reported history of alcohol, tobacco, and marijuana use was compared between pregnant women with and without depressive symptomatology with adjustment for demographic factors.

RESULTS

After adjustment for demographic factors, women with depressive symptomatology were more likely to report: any alcohol use (odds ratio [OR]: 1.4, 95% confidence interval [CI]: 1.1-1.8), >1 drink per week (OR: 1.3, 95% CI: 1.0-1.8), and >1 drink per day (OR: 2.2, 95% CI: 1.5-3.4). Women with depressive symptomatology were also more likely to report use of marijuana (OR: 1.8, 95% CI: 1.2-2.6) and cigarettes (OR: 1.4, 95% CI: 1.1-1.7).

CONCLUSION

Depressive symptomatology was associated with an increase in self-reported the use of alcohol, tobacco, and marijuana during pregnancy. These data reveal the importance of targeted screening of pregnant women with depressive symptomatology for substance use.

Integrated perinatal mental health care: a national model of perinatal primary care in vulnerable populations

INTRODUCTION

Perinatal mood and anxiety disorders (PMADs) are the most common complication of pregnancy and have been found to have long-term implications for both mother and child. In vulnerable patient populations such as those served at Denver Health, a federally qualified health center the prevalence of PMADs is nearly double the nationally reported rate of 15-20%. Nearly 17% of women will be diagnosed with major depression at some point in their lives and those numbers are twice as high in women who live in poverty. Women also appear to be at higher risk for depression in the child-bearing years. In order to better address these issues, an Integrated Perinatal Mental Health program was created to screen, assess, and treat PMADs in alignment with national recommendations to improve maternal-child health and wellness. This program was built upon a national model of Integrated Behavioral Health already in place at Denver Health.

METHODS

A multidisciplinary team of physicians, behavioral health providers, public health, and administrators was assembled at Denver Health, an integrated hospital and community health care system that serves as the safety net hospital to the city and county of Denver, CO. This team was brought together to create a universal screen-to-treat process for PMAD's in perinatal clinics and to adapt the existing Integrated Behavioral Health (IBH) model into a program better suited to the health system's obstetric population. Universal prenatal and postnatal depression screening was implemented at the obstetric intake visit, a third trimester prenatal care visit, and at the postpartum visit across the clinical system. At the same time, IBH services were implemented across our health system's perinatal care system in a stepwise fashion. This included our women's care clinics as well as the family medicine and pediatric clinics. These efforts occurred in tandem to support all patients and staff enabling a specially trained behavioral health provider (psychologists and L.C.S.W.'s) to respond immediately to any positive screen during or after pregnancy.

RESULTS

In August 2014 behavioral health providers were integrated into the women's care clinics. In January 2015 universal screening for PMADs was implemented throughout the perinatal care system. Screening has improved from 0% of women screened at the obstetric care intake visit in August 2014 to >75% of women screened in August 2016. IBH coverage by a licensed psychologist or licensed clinical social worker exists in 100% of perinatal clinics as of January 2016. As well, in order to gain sustainability, the ability to bill same day visits as well as to bill, and be reimbursed for screening and assessment visits, continues to improve and provide for a model that is self-sustaining for the future.

CONCLUSION

Implementation of a universal screening process for PMADs alongside the development of an IBH model in perinatal care has led to the creation of a program that is feasible and has the capacity to serve as a national model for improving perinatal mental health in vulnerable populations.

Postplacental intrauterine device expulsion by 12 weeks: a prospective cohort study

BACKGROUND

An intrauterine device placed immediately following a delivery can serve as an effective and safe contraceptive strategy in the postpartum period. There is limited evidence that the levonorgestrel intrauterine system may have a higher rate of expulsion compared to the copper intrauterine device; however, rates of expulsion for these 2 intrauterine device types have not been compared directly.

OBJECTIVE

We sought to compare expulsion rates by 12 weeks' postpartum for the levonorgestrel intrauterine system and copper intrauterine device.

STUDY DESIGN

We enrolled women who received postplacental intrauterine devices at 2 urban hospitals. Eligible women were ≥18 years old, English- or Spanish-speaking, with singleton vaginal delivery at ≥35 weeks' gestation. Intrauterine devices were inserted within 10 minutes of placental delivery by trained providers using ring forceps or the operator's hand. Intrauterine device location was evaluated via abdominal ultrasound at 24-48 hours' postpartum, and via transvaginal ultrasound 6 and 12 weeks later, categorizing position of the intrauterine device at the fundus, below the fundus but above the internal os, any part of the intrauterine device below the internal os (partial expulsion), or no intrauterine device visualized. Outcomes included intrauterine device expulsion and method continuation. We used multivariable logistic regression to identify factors associated with expulsion.

RESULTS

We enrolled 123 women ages 18-40 years. Of these, 68 (55%) initiated levonorgestrel intrauterine system and 55 (45%) initiated copper intrauterine device. Groups were similar except more copper intrauterine device users were Hispanic (66% vs 38%) and fewer were primiparous (16% vs 31%). Among the 96 (78%) with 12-week follow-up, expulsion was higher for levonorgestrel intrauterine system users (21/55 or 38%) than for copper intrauterine device users (8/41 or 20%) (odds ratio, 2.55; 95% confidence interval, 0.99-6.55; P = .05). At 24 hours' postpartum, there was no significant difference in median distance from the intrauterine device to the fundus between intrauterine device types or between those who did or did not experience expulsion. Of expulsions, 86% occurred ≤6 weeks' postpartum. All complete expulsions were clinically identified, but of the partial expulsions, only 4/10 (40%) were clinically suspected prior to ultrasound. The only independent predictor of expulsion was intrauterine device type. Including reinsertions, intrauterine device use at 12 weeks was not significantly different for levonorgestrel intrauterine system and copper intrauterine device users (80% vs 93%; P = .14).

CONCLUSION

Women initiating postplacental levonorgestrel intrauterine system are more likely to experience complete expulsion than those initiating copper intrauterine device. Using sonographic criteria results in higher expulsion rates than previously reported. It is unclear if such high expulsion rates would be identified following standard clinical practice.

Unilateral isolated extraocular muscle lymphoma

The authors would like to present an unusual case of ocular adnexal, mucosa-associated lymphoid tissue lymphoma, isolated to a single extraocular muscle. A 59-year-old woman presented with a 3-month history of slowly progressive double vision, worse on elevation, for which her optometrist had given her prisms. A swollen left upper eyelid was present for 10 days. CT scan of the brain and orbits revealed a 3 cm × 1.5 cm mass arising from the region of the left superior rectus with no signs of bone erosion. Histology showed infiltration by small lymphoid cells. Stage 1AE low-grade marginal zone B cell lymphoma was diagnosed. Possible aetiologies included Chlamydia psittaci infection and the recently recognised IgG4-related sclerosing disease. After oral doxycycline 200 mg once a day failed to show improvement, localised radiotherapy 30 Gy resulted in excellent clinical and radiological resolution of this isolated lymphoma.

Real-time polymerase chain reaction as an aid for the detection of SYT-SSX1 and SYT-SSX2 transcripts in fresh and archival pediatric synovial sarcoma specimens: report of 25 cases from St. Jude Children's Research Hospital

Synovial sarcoma is the most common nonrhabdomyosarcomatous soft tissue sarcoma in children and adolescents and is characterized by a reciprocal t(X;18)(p11;q11) which results in the fusion of the SYT gene on chromosome 18q11 to either of two closely related genes, SSX1 (Xp11.23) or SSX2 (Xp11.21). Detection of this translocation or its resultant gene fusion by molecular methods is helpful in the pathologic diagnosis of synovial sarcoma, especially in poorly differentiated tumors. This study was designed to evaluate the utility of a real-time reverse transcriptase-polymerase chain reaction (RT-PCR) assay to detect and distinguish SYT-SSX1 and SYT-SSX2 fusions in fresh and archival specimens of synovial sarcoma in pediatric patients seen at St. Jude Children's Research Hospital. In addition, the clinicopathologic features of the tumors with SYT-SSX1 vs. SYT-SSX2 fusions were compared. The 25 patients studied had a median age of 13 years 9 months (range 5 to 19 years). Estimates of survival and event-free survival at 5 years were 78.7 +/- 10.5% and 56.2 +/- 13.2%, respectively. Seventeen (68%) tumors were monophasic, eight (32%) were biphasic. Seven tumors contained poorly differentiated areas. Positive results for either SYT-SSX1 or SYT-SSX2 were obtained in 21/25 (84%) cases. Three cases did not have a detectable gene fusion and one had no amplifiable RNA. SYT-SSX1 transcripts were found in 18/24 (75%) of the tumors while SYT-SSX2 transcripts were identified in 3/24 (12.5%). All of the poorly differentiated tumors and seven out of eight tumors from patients who developed lung metastases had an SYT-SSX1 fusion transcript. Real-time PCR is useful in detecting and distinguishing SYT-SSX1 from SYT-SSX2 gene fusions in synovial sarcoma. Valuable aspects of this methodology are the applicability to both frozen and formalin-fixed samples, decreased labor costs, and the rapidity of results. In addition, distinguishing SYT-SSX1 from SYT-SSX2 fusions with these methods allow for prospective collection of information that may clarify issues of prognostic relevance.

Induction of Purkinje fiber differentiation by coronary arterialization

A synchronized heart beat is controlled by pacemaking impulses conducted through Purkinje fibers. In chicks, these impulse-conducting cells are recruited during embryogenesis from myocytes in direct association with developing coronary arteries. In culture, the vascular cytokine endothelin converts embryonic myocytes to Purkinje cells, implying that selection of conduction phenotype may be mediated by an instructive cue from arteries. To investigate this hypothesis, coronary arterial development in the chicken embryo was either inhibited by neural crest ablation or activated by ectopic expression of fibroblast growth factor (FGF). Ablation of cardiac neural crest resulted in approximately 70% reductions (P < 0.01) in the density of intramural coronary arteries and associated Purkinje fibers. Activation of coronary arterial branching was induced by retrovirus-mediated overexpression of FGF. At sites of FGF-induced hypervascularization, ectopic Purkinje fibers differentiated adjacent to newly induced coronary arteries. Our data indicate the necessity and sufficiency of developing arterial bed for converting a juxtaposed myocyte into a Purkinje fiber cell and provide evidence for an inductive function for arteriogenesis in heart development distinct from its role in establishing coronary blood circulation.

FGF1 patterns the optic vesicle by directing the placement of the neural retina domain

Patterning of the bipotential retinal primordia (the optic vesicles) into neural retina and retinal pigmented epithelium depends on its interaction with overlaying surface ectoderm. The surface ectoderm expresses FGFs and the optic vesicles express FGF receptors. Previous FGF-expression data and in vitro analyses support the hypothesis that FGF signaling plays a significant role in patterning the optic vesicle. To test this hypothesis in vivo we removed surface ectoderm, a rich source of FGFs. This ablation generated retinas in which neural and pigmented cell phenotypes were co-mingled. Two in vivo protocols were used to replace FGF secretion by surface ectoderm: (1) implantation of FGF-secreting fibroblasts, and (2) injection of replication-incompetent FGF retroviral expression vectors. The retinas in such embryos exhibited segregated neural and pigmented epithelial domains. The neural retina domains were always close to a source of FGF secretion. These results indicate that, in the absense of surface ectoderm, cells of the optic vesicles display both neural and pigmented retinal phenotypes, and that positional cues provided by FGF organize the bipotential optic vesicle into specific neural retina and pigmented epithelium domains. We conclude that FGF can mimic one of the earliest functions of surface ectoderm during eye development, namely the demarcation of neural retina from pigmented epithelium.

Retroviral techniques for studying organogenesis with a focus on heart development

The study of development has been revolutionized by the application of molecular techniques, which make it possible to identify factors involved in the developmental process. However, in order to correctly assess the contribution of these growth factors, transcription factors, receptors or signaling molecules, it is necessary to study them in the animal as a whole; it is not enough to conclude that they must be important based on their expression patterns.

Hairy function as a DNA-binding helix-loop-helix repressor of Drosophila sensory organ formation

Sensory organ formation in Drosophila is activated by proneural genes that encode basic-helix-loop-helix (bHLH) transcription factors. These genes are antagonized by hairy and other proline-bHLH proteins. hairy has not been shown to bind to DNA and has been proposed to form inactive heterodimers with proneural activator proteins. Here, we show that hairy does bind to DNA and has novel DNA-binding activity: hairy prefers a noncanonical site, CACGCG, although it also binds to related sites. Mutation of a single CACGCG site in the achaete (ac) proneural gene blocks hairy-mediated repression of ac transcription in cultured Drosophila cells. Moreover, the same CACGCG mutation in an ac minigene transformed into Drosophila creates ectopic sensory hair organs like those seen in hairy mutants. Together these results indicate that hairy represses sensory organ formation by directly repressing transcription of the ac proneural gene.