Longitudinal profiles of the vaginal microbiota of pre-, peri-, and postmenopausal women: preliminary insights from a secondary data analysis

OBJECTIVE

Menopause is often accompanied by lowered Lactobacillus spp. relative abundance and increased abundance of diverse anaerobic/aerobic bacteria in the vaginal microbiota due in part to declines in estrogen. These microbiota are associated with urogenital symptoms and infections. In premenopause, vaginal microbiota can fluctuate rapidly, particularly with menstrual cycles and sexual activity; however, the longitudinal dynamics of vaginal microbiota are understudied in peri- and postmenopause. We described vaginal community stability across reproductive stages.

METHODS

Pre- (n = 83), peri- (n = 8), and postmenopausal (n = 11) participants provided twice-weekly mid-vaginal samples (total, 1,556; average, 15 per participant) over 8 weeks in an observational study. Composition of the vaginal microbiota was characterized by 16S rRNA gene amplicon sequencing, and a community state type (CST) was assigned to each sample. Clustering of longitudinal CST profiles, CST transition rates, duration of low-Lactobacillus/high bacterial diversity CSTs, and other metrics of bacterial community dynamics were assessed across reproductive stages.

RESULTS

The proportion of participants with longitudinal CST profiles characterized by low-Lactobacillus CSTs was similar among pre- (38.6%), peri- (37.5%), and postmenopausal (36.4%) participants (P = 0.69). CST transition rates between consecutive samples were 21.1%, 16.7%, and 14.6% for pre-, peri-, and postmenopausal participants, respectively (P = 0.49). Low-Lactobacillus CST tended to persist for at least 4 weeks, irrespective of reproductive stage.

CONCLUSIONS

Findings from this small yet frequently sampled cohort revealed vaginal bacterial fluctuations over 8 weeks that were similar across reproductive stages. Larger and longer-term studies based on these preliminary data could provide insights into the influence of microbiota dynamics on urogenital outcomes during menopause.

Maternal and infant cannabis testing and associated birth outcomes

OBJECTIVES

The objective of the study was to determine any identifiable clinical utility of the practice of universal maternal and infant tetrahydrocannabinol (THC) testing at the time of birth.

METHODS

This was cross-sectional, retrospective cohort study comparing the following birth outcomes in relation to maternal and infant tetrahydrocannabinol (THC): APGAR scores, cord gases, NICU admission and need for immediate resuscitation. All births at the University of Maryland Medical Center between January 1, 2018 and December 31, 2020 were reviewed. Those that had either maternal or infant test results missing were excluded. Statistical analysis was performed using STATA v27. Birth outcomes were adjusted for gestational age at delivery and tobacco use. Infant resuscitation was considered the need for any respiratory support.

RESULTS

A total of 4260 maternal/infant pairs were included. Of these, 314 (7.4%) birthing parents and 161 (3.8%) of infants tested positive for THC. Of the birth parents who tested positive for THC, 51.3% of their infants also tested positive for THC. Maternal/infant pairs that both tested positive for THC had the lowest need for immediate resuscitation and Neonatal Intensive Care Unit admission. Cord gases and APGAR scores were similar between the groups. Birth parents who tested positive for THC delivered infants at an earlier gestational age (37w6d v 38w5d, p = 0.001) and lower mean birth weight (2690gm v 3061gm, p = 0.001) than those who tested negative even after adjusting for confounders. When limited to only term births and broken down by weeks completed gestation, the mean birth weights were lower for every week in those who tested positive for THC versus those who tested negative.

CONCLUSIONS

Our study shows that maternal and neonatal testing for THC at the time of birth is not predictive of important neonatal outcome parameters. Therefore, even though it is likely that there are some effects of in utero THC exposure on the neonate, we did not find any clinical benefits that would justify routine maternal and/or infant testing for THC at the time of birth.

Low-dose Induction of Buprenorphine in Pregnancy: A Case Series

BACKGROUND

Because of a risk of precipitated withdrawal occurring from buprenorphine induction in people who use fentanyl, low-dose inductions are becoming increasingly common. However, little evidence exists on the use of this method in pregnant people.

METHODS

We conducted a case series of all pregnant people treated for opioid use disorder with low-dose buprenorphine induction at the University of Maryland Medical Center between January 1, 2021, and August 22, 2022. Primary outcome was completion of induction regimen. Secondary outcomes were self-report of withdrawal, continuation of buprenorphine until delivery, and return to or continuation of illicit opioid use.

RESULTS

Six pregnant people were prescribed a total of 10 buprenorphine inductions. Five of the 6 pregnant people (83.3%) completed at least 1 induction, none of whom experienced precipitated withdrawal. Two of 6 (33.3%) continued buprenorphine until the time of delivery, and 1 of 6 (16.7%) abstained from illicit opioid use.

CONCLUSIONS

The low-dose buprenorphine induction regimen described was successful in 5 of 6 pregnant individuals. Further research, particularly regarding continuation rates, is needed.

Predicting Maternal and Infant Tetrahydrocannabinol Exposure in Lactating Cannabis Users: A Physiologically Based Pharmacokinetic Modeling Approach

A knowledge gap exists in infant tetrahydrocannabinol (THC) data to guide breastfeeding recommendations for mothers who use cannabis. In the present study, a paired lactation and infant physiologically based pharmacokinetic (PBPK) model was developed and verified. The verified model was used to simulate one hundred virtual lactating mothers (mean age: 28 years, body weight: 78 kg) who smoked 0.32 g of cannabis containing 14.14% THC, either once or multiple times. The simulated breastfeeding conditions included one-hour post smoking and subsequently every three hours. The mean peak concentration (Cmax) and area under the concentration-time curve (AUC(0-24 h)) for breastmilk were higher than in plasma (Cmax: 155 vs. 69.9 ng/mL; AUC(0-24 h): 924.9 vs. 273.4 ng·hr/mL) with a milk-to-plasma AUC ratio of 3.3. The predicted relative infant dose ranged from 0.34% to 0.88% for infants consuming THC-containing breastmilk between birth and 12 months. However, the mother-to-infant plasma AUC(0-24 h) ratio increased up to three-fold (3.4-3.6) with increased maternal cannabis smoking up to six times. Our study demonstrated the successful development and application of a lactation and infant PBPK model for exploring THC exposure in infants, and the results can potentially inform breastfeeding recommendations.

Reported Reasons for Cannabis Use Before and After Pregnancy Recognition

OBJECTIVES

Cannabis use is cautioned against during pregnancy, yet many pregnant people continue to use. This study aimed to evaluate the patterns and reasons for cannabis use before and after conception in pregnant people who screened positive for cannabis use at initiation of prenatal care.

METHODS

Pregnant patients at 1 prenatal practice in Baltimore, MD, who either self-reported cannabis use or tested positive on urine toxicology were approached for enrollment. Those who consented were given an anonymous survey with multiple choice questions regarding frequency and reasons for use before and after pregnancy recognition. Fisher exact, χ 2 test, and analysis of variance were used for analysis.

RESULTS

Of 117 pregnant people approached, 105 enrolled in the study. Of the 105 respondents, 40 (38.1%) reported complete abstinence after pregnancy recognition, whereas 65 (61.9%) reported continued use. Of the respondents who continued cannabis use, 35 (53.8%) had decreased frequency of use or quit, 26 (40%) reported no change in frequency of use, and 4 (6.2%) reported increase in frequency of use. Those who considered their use medical or mixed before pregnancy were 4 times as likely to continue use compared with those who considered their use nonmedical (66.7% vs 33.3%; odds ratio, 4.0; 95% confidence interval, 1.3-12.8). Respondents who continued use after pregnancy recognition were significantly more likely to discuss their use with their obstetrician (89.2% vs 50%, P < 0.001).

CONCLUSIONS

Reasons for use frequently changed after recognition of pregnancy. Most people who continued use during pregnancy reported that their reasons were for symptom control.

Limited Utility of Toxicology Testing at Delivery for Perinatal Cannabis Use

OBJECTIVES

To describe the characteristics of individuals undergoing toxicology testing at delivery for a sole indication of cannabis use and to evaluate the rate of unexpected positive toxicology testing results among this cohort.

METHODS

This retrospective cohort study included dyads with a maternal history of cannabis use who underwent peripartum toxicology testing between 2016 and 2020 at 5 birthing hospitals in Massachusetts. We collected information on maternal demographic characteristics and toxicology test results and reviewed records of dyads with unexpected positive results to identify additional social risk factors and clinical outcomes.

RESULTS

Of 60 608 live births reviewed, 1924 dyads underwent toxicology testing, including 614 (31.9%) for a sole indication of cannabis use. Significantly greater percentages of patients in the cannabis cohort were <25 years old (32.4% vs 6.1% of the birthing population, P <.001), non-Hispanic Black (32.4% vs 8.1%, P < .001), Hispanic or Latino (30.5% vs 15.5%), American Indian/Alaskan (0.7% vs 0.1%), and publicly insured (39.9% vs 15.6%, P <.001). Eight of the 614 dyads (1.3%) had an unexpected positive toxicology test result, including 2 (0.3%) unexpectedly positive for opioids. Seven dyads (1.1%) had false positive test results for unexpected substances. Only 1 test result changed clinical management; a urine test positive for opioids prompted monitoring (but not medication) for neonatal opioid withdrawal syndrome.

CONCLUSIONS

Toxicology testing of patients for a sole indication of cannabis use, without other risk factors, may be of limited utility in elucidating other substance use and may exacerbate existing disparities in perinatal outcomes.

Effect of maternal adverse childhood experiences (ACE) and cannabis use on pregnancy outcomes

This study aimed to characterize the relationship between cannabis use, ACE score, and pregnancy outcomes. Pregnant patients in Baltimore, MD, completed the 17-point ACE checklist. Charts of the birth parent and neonate were reviewed for urine toxicology testing at initiation of care and delivery, prenatal care metrics, and birth statistics. Multivariable logistic regression analysis was performed to assess the relationship between ACE score, cannabis use, and pregnancy outcomes. Of 256 birth parents, 87 (34.0%) tested positive for cannabis at initial visit and 39 (15.2%) tested positive for cannabis at delivery. Testing positive for cannabis at initial visit or delivery was associated with higher ACE score (15.1 vs 13.7, p = 0.04; 16.2 vs 13.8, p = 0.01). Of those who tested positive for cannabis at initial visit, 39/87 (45.0%) tested positive at delivery. Continued cannabis use at delivery was associated with lower maternal weight gain (7.9 kg vs 13.3 kg, p = 0.003), fewer prenatal visits (7 vs 8, p = 0.010), and numerically higher mean ACE score. Cannabis use at delivery was associated with 10% lower birthweight (2665 g vs 3014 g p < 0.05) but not with pre-term birth. Total ACE score was not significantly associated with any birth outcome. Worse pregnancy outcomes were associated with cannabis use throughout pregnancy but not with cannabis use at prenatal care initiation. The interplay of ACE and continued cannabis use during pregnancy warrants further research on the physiologic effects of cannabis and interventions to decrease substance use during pregnancy.

Serum antibodies to surface proteins of Chlamydia trachomatis as candidate biomarkers of disease: results from the Baltimore Chlamydia Adolescent/Young Adult Reproductive Management (CHARM) cohort

We previously observed that the nine-member family of autotransported polymorphic membrane proteins (Pmps) of Chlamydia trachomatis is variably expressed in cell culture. Additionally, C. trachomatis-infected patients display variable Pmp-specific serum antibody profiles indirectly suggesting expression of unique Pmp profiles is an adaptive response to host-specific stimuli during infection. Here, we propose that the host response to Pmps and other outer surface proteins may correlate with disease severity.

This study tests this hypothesis using an ELISA that measures serum IgG antibodies specific for the nine C. trachomatis Pmp subtypes and four immunodominant antigens (MOMP, OmcB, Hsp60, ClpP) in 265 participants of the Chlamydia Adolescent/Young Adult Reproductive Management (CHARM) cohort.

More C. trachomatis-infected females displayed high Pmp-specific antibody levels (cut-off Indexes) than males (35.9–40.7% of females vs. 24.2–30.0% of males), with statistical significance for PmpC, F and H (P&lt;0.05). Differences in Pmp-specific antibody profiles were not observed between C. trachomatis-infected females with a clinical diagnosis of pelvic inflammatory disease (PID) and those without. However, a statistically significant association between high levels of OmcB-specific antibody and a PID diagnosis (P&lt;0.05) was observed.

Using antibody levels as an indirect measure of antigen expression, our results suggest that gender- and/or site-specific (cervix in females vs. urethra in males) stimuli may control pmp expression in infected patients. They also support the possible existence of immune biomarkers of chlamydial infection associated with disease and underline the need for high resolution screening in human serum.

Association between continued cannabis use during pregnancy and symptoms of anxiety and depression

Cannabis use in pregnancy is common, as are mental health disorders, but the association between the two is not well established. This study is a single-site retrospective cohort. Urine testing for cannabis was evaluated at two-time points to categorize women as having never used, quit or continued to use. Edinburgh Postnatal Depression Scale (EPDS) and Generalized Anxiety Disorder (GAD) screen results were compared across groups using multinomial logistic regression. In addition, EPDS and GAD change scores between initiation of care and delivery were analyzed. 604 women were included, 221 (36.3%) with positive toxicology testing for cannabis at the initiation of care. Women who continued cannabis use were significantly more likely to have elevated GAD and EPDS scores (2.55 [1.31, 4.99]) and EPDS score (2.75 [1.43, 5.28]), respectively as compared to those with no use. No significant differences were found between groups in GAD or EPDS change scores t women with higher depression scores on the EPDS had 2.70 times the odds of being in the continuous use group compared to the quit using group (aOR = 2.70, 95% CI = [1.30, 5.88]). Both anxiety and depression symptoms were found to be associated with cannabis use and continued use during pregnancy.

Observational cohort study of the effect of a single lubricant exposure during transvaginal ultrasound on cell-shedding from the vaginal epithelium

The outer layers of the vaginal epithelium (VE) are important because they accumulate glycogen which, under optimal conditions, Lactobacillus spp. consume to grow and acidify the vaginal microenvironment with lactic acid. We hypothesized that exposure to lubricant, for example in the conduct of a transvaginal ultrasound (TVUS), may contribute to the shedding of mature epithelial cells, exposing immature cells. Cervicovaginal fluid (CVF) was sampled at four time points by menstrual cup (Softdisc™) from 50 women referred for TVUS, during which a controlled volume of lubricant was applied to the TVUS wand. Samples were collected (1) immediately before TVUS and (2) 6-12 hours, (3) within one week, and (4) two weeks after TVUS. Clinical vaginal lubricants are similar to commercial lubricants, and often have a high osmolality or pH, and contain bactericides such as methylparaben and propylparaben. The number and maturity of epithelial cells in each CVF sample were measured by quantitative and differential fluorimetry (maturity index, MI). Comparisons of cell-counts and maturity were made by paired Wilcoxon signed-rank tests. Among women with a high pre-TVUS MI (> 3), there was a decrease in median cell-count and mean MI in the sample collected 6-12 hours after TVUS (p<0.001, n = 26 and p < 0.001, n = 26, respectively). For these women, cell-count and MI remained lower in the sample collected within the subsequent week (p<0.001, n = 29 and p<0.01, n = 29, respectively), and MI remained lower in the sample collected within two weeks of TVUS (p<0.01, n = 25), compared to the pre-TVUS sample. Among participants with a low pre-TVUS MI (< 3), cell-count was higher in the sample collected within two weeks of TVUS compared to the pre-TVUS sample (p = 0.03, n = 15), but no significant changes in MI were observed. Results were similar when restricted to reproductive-age women. This preliminary data indicates hypertonic vaginal lubricants may increase vaginal epithelial cell shedding.

Concordance and discordance between maternal and newborn drug test results

BACKGROUND

Screening for substance use is recommended during pregnancy, and many clinicians rely on urine drug screening to identify newborns at potential risk for withdrawal.

OBJECTIVE

This study aimed to determine the concordance and discordance rates between maternal and neonatal drug testing at or near the time of delivery.

STUDY DESIGN

This retrospective chart review was performed at a single institution that employs universal testing for those who consent. Results of maternal and neonatal urine drug testing via immunoassay at delivery were compared.

RESULTS

Of 1573 singleton pregnancies, 233 mothers (14.8%) had a positive test result for any substance and 102 of their newborns (43.8%) had concordant positive test results. Of the 285 positive maternal test results for individual substances, 133 (46.7%) were concordant with newborn test results. After removing iatrogenic positives, there were 84 truly discordant pairs representing 5.9% of the total cohort of test pairs, but 29.5% of the pairs with maternal positive test results. When considering the outcome of a newborn positive test result, the overall sensitivity and specificity for the maternal test were 21.1% and 85.8%, respectively. The positive and negative predictive values were 46.7% and 96.4%, respectively. After excluding iatrogenic positive test results, the sensitivity and specificity for maternal testing were 97.8% and 99.4%, respectively, and the negative predictive value of maternal testing for all substances approached 100%. A total of 11 pairs of twins had at least 1 twin with a positive drug test result, and of these, 6 twin pairs (54.5%) had drug test results that were discordant from each other.

CONCLUSION

There is a high rate of iatrogenic discrepancy in maternal and neonatal drug testing. After adjusting for iatrogenic positive test results, the negative predictive value of maternal testing is high. Many discrepancies, such as those in twins, remained unexplained by medication administration, and potential reasons for these discrepancies warrant further investigation.

Abortion in women with severe preeclampsia and eclampsia prior to 24 weeks gestation

OBJECTIVE

Due to poor prognosis, obstetric care providers often recommend abortion for women diagnosed with severe preeclampsia prior to fetal viability. However, there is limited available evidence to guide the counseling regarding risks.

STUDY DESIGN

This study is a retrospective case series that describes outcomes of all women who underwent abortions with the diagnosis of severe preeclampsia or eclampsia prior to 24 weeks gestation.

RESULTS

This case series describes 11 women who underwent abortion prior to 24 weeks gestation due to severe preeclampsia or eclampsia, 9 by dilation and evacuation and 2 by labor induction. The majority of women underwent dilation and evacuation and no women undergoing either induction of labor or dilation and evacuation had severe complications directly related to the abortion.

CONCLUSIONS

This case series provides information on the safety of abortion procedures in women with severe preeclampsia and eclampsia syndrome.

Interaction with the justice system and other factors associated with pregnant women's self-report and continuation of use of marijuana

BACKGROUND

Marijuana use in pregnancy is common and self-report of use to healthcare providers is variable. This study evaluates the relationship between prior interaction with the justice system as well as other factors associated with self-report and continuation of use of marijuana in pregnancy.

METHODS

This retrospective cohort study included women with a positive urine toxicology test for marijuana at their initial prenatal visit. Prior interaction with the judicial system was determined by querying a publicly available database. Those who did and did not self-report use were compared using chi square and Fisher's exact test for analysis of categorical variables and t test for comparison of means. A logistic regression was performed to determine factors related to remaining positive at the time of birth.

RESULTS

Of 597 women included in analysis, 308 (51.6%) self-reported use. African American women were more likely to self-report use (p = 0.02). Interaction with the justice system was not statistically predictive of self-report. Of 483 (80.9%) who had birth outcome data available, 117 (24.2%) had positive marijuana tests at the time of delivery. Women who tested positive at birth were older (27.3 v 25, p < 0.01), more likely to present later for care (p = 0.02) and more likely to have self-reported their use at their initial visit (p = 0.03).

DISCUSSION

Discrepancies exist between pregnant women's self-report of marijuana use and biologic testing results. Women with positive toxicology testing who self-report use may do so due to more problematic use and may benefit from enhanced interventions.

Cannabis Use as Determined by Biologic Testing in Maternal and Newborn Urines during a Period of Drug Liberalization

Introduction: Cannabis use is common in pregnancy and prevalence of reported past month use have been increasing despite recommendations of abstinence. Our study aimed to evaluate the prevalence of cannabis use in pregnancy using urine drug screens obtained at the time of admission to Labor and Delivery. Methods: De-identified laboratory data from three birthing hospitals located in Maryland were used to determine the percentage of cannabis positive urine toxicology tests among women admitted to Labor and Delivery. Data were collected at each site starting the year that universal urine cannabis testing was instituted. One hospital also performed universal testing of newborns which was contrasted with maternal data there. Results: Overall, 5.7% of the 22,435 maternal and 3.4% of the 8,346 newborn urine toxicology tests and were positive for cannabis. Trends varied between institutions. When all three institutions were combined, the percent of positive urine toxicology tests was unchanged between 2016 and 2018. At Site 1 between 2014 and 2018, the percentage of cannabis positive urine toxicology tests increased from 5.7% to 9.9% and newborn tests increased from 1.7% to 3.4%. Only 27.7% of the neonates born to women with positive screens also had a positive screen at the time of birth. Conclusions: Prevalence of cannabis use until the time of delivery vary by location but were largely unchanged over a period of drug liberalization.

An investigation of putative exposure of staff to novel psychoactive substances in a prison

Issue

In a prison in Scotland, an increasing number of incidents occurred where staff became unwell secondary to potential exposure to novel psychoactive substances (NPS) smoked by prisoners. There were high levels of concern for the safety of individual staff, and for establishment staffing. NPS use is a significant problem in custodial settings, and impacts individuals and establishments.

Methods

HMP and HPT led an incident response: HMP focused on prevention and direct management of incidents; HPT focused on exposure circumstances, clinical presentation and toxicological testing of symptomatic staff. A protocol was agreed between all agencies involved. Over 8 months, all incidents’ initial assessment and any subsequent clinical and toxicological results were collated and analysed by HPT.

Results

There were 19 incidents involving 16 staff members. Cases presented in clusters, in one instance 13 people presented over 5 days. Five presented in early 2018.

Individuals reported a wide range of non-specific physical and psychological effects; some cases experienced severe impairment of day-to-day function. The most common effects were headache and fatigue but some reported sleep disturbance and confusion lasting up to 72 hrs. There were no significant clinical observations at hospital, and the 3 tests for toxicology were negative.

Lessons

The individuals affected by these incidents experienced physical and psychological distress, and impairment of daily functioning which impacted on the safe function of the establishment. It is unlikely staff presentations were due to toxicological effects from substances used by prisoners. It is possible their symptoms were psychosomatic. This could be further investigated, and consideration given to supportive intervention for staff affected by exposure to NPS. The investigation demonstrated excellent collaborative work between the prison, health services, and forensic laboratories in a novel investigation into NPS exposure in prisons.

Key messages

NPS use, and subsequent exposure to staff, is a growing issue in custodial settings. A combination of supportive interventions for staff, including reduction and mitigation of risk of exposure to NPS, plus control of substances use in prisons can help.

Prenatal Substance Use and Perceptions of Parent and Partner Use Using the 4P's Plus Screener

Background Prenatal substance use screening is recommended. The 4 P's Plus screener includes questions on perceived problematic substance use in parents and partner that are not considered in risk stratification. Objectives This research examined the: (1) prevalence of self-reported problematic parental and partner substance use and associations with biochemically-verified prenatal substance use; (2) utility of self-reported perceptions of parent/partner substance use as proxies for prenatal substance use; and (3) degree to which the sensitivity of the 4P's Plus can be augmented with consideration of parent/partner questions in risk stratification. Methods A convenience sample of 500 pregnant women was recruited between January 2017 and January 2018. Participants completed the 4P's Plus and provided urine for drug testing. Diagnostic utility of problematic parent/partner substance use questions was assessed, then compared to the 4P's Plus used as designed, and to the 4P's Plus used with these 2 questions included in risk stratification. Results Half (51%) of respondents reported either partner or parental problematic substance use. When partner or parent problematic substance use were considered as proxies for prenatal substance use, sensitivity was 65% and specificity was 55%. When used as intended, sensitivity was 94% and specificity was 29%. Including partner/parent questions increased sensitivity to 96% but lowered specificity (19%). Partner substance use and combined partner/parent use were associated with prenatal substance use [adjusted odds ratio (aOR): 2.0 (1.2, 2.4; p = 0.006); aOR = 1.6 (1.1, 2.5, p = 0.04)]. Conclusions for Practice Sensitivity of the 4P's Plus may improve with inclusion of self-reported problematic partner/parent substance use items in risk stratification.

Pregnancy outcomes after removal of osmotic dilators in patients who presented for second-trimester abortion

OBJECTIVE

The objective was to report pregnancy outcomes and potentially related complications among 13 patients who had osmotic dilators placed for second-trimester dilation and evacuation (D&E) followed by subsequent removal with the intention to continue their pregnancies.

STUDY DESIGN

We reviewed billing and scheduling data between 2005 and 2017 to identify the total number of women seen for D&E and to identify the individuals who had dilators placed without a subsequent scheduled dilation and evacuation. We then performed chart reviews to determine pregnancy outcomes.

RESULTS

Between 2005 and 2017, we treated 2532 patients who presented for second-trimester abortions by D&E and received osmotic dilators for cervical preparation. Twenty (0.8%) of these women had cervical dilators removed with the intention of continuing their pregnancies. We could obtain outcome data for 13 of these pregnancies; one of these women ultimately elected to have an abortion. Eight of the remaining 12 women (66%) experienced complications which included premature preterm rupture of membranes, preterm delivery, maternal infection and hemorrhage. Six (50%) pregnancies ended in spontaneous abortion or fetal or neonatal death.

CONCLUSION

Continuation of pregnancy after placement and removal of osmotic dilators may increase the risk of adverse pregnancy outcomes.

IMPLICATIONS

Of the women who had outcome data available, 50% who had cervical dilators removed experienced spontaneous abortion or fetal or neonatal death. Conservatively assuming that all women lost to follow-up had healthy pregnancies, 30% of women experienced fetal or neonatal death and 40% had an adverse pregnancy outcome.

Should prenatal care providers offer pregnancy options counseling?

BACKGROUND

Professional guidelines indicate that pregnancy options counseling should be offered to pregnant women, in particular those experiencing an unintended pregnancy. However, research on whether pregnancy options counseling would benefit women as they enter prenatal care is limited. This study examines which women might benefit from options counseling during early prenatal care and whether women are interested in receiving counseling from their prenatal care provider.

METHODS

At four prenatal care facilities in Louisiana and Maryland, women entering prenatal care completed a self-administered survey and brief structured interview (N = 586). Data were analyzed through descriptive statistics, bivariate analyses, multivariate multinomial logistic regression, and coding of open-ended responses.

RESULTS

At entry into prenatal care, most women reported that they planned to continue their pregnancy and raise the child. A subset (3%) scored as having low certainty about their decision on the validated Decision Conflict Scale, indicating need for counseling. In addition, 9% of women stated that they would be interested in discussing their pregnancy options with their prenatal care provider. Regression analyses indicated some sociodemographic differences among women who are in need of or interested in options counseling. Notably, women who reported food insecurity in the prior year were found to be significantly more likely to be in need of options counseling (RRR = 3.20, p < 0.001) and interested in options counseling (RRR = 5.48, p < 0.001) than those who were food secure. Most women were open to discussing with their provider if their pregnancy was planned (88%) or if they had considered abortion (81%). More than 95% stated they would be honest with their provider if asked about these topics.

CONCLUSIONS

Most women are certain of their decision to continue their pregnancy at the initiation of prenatal care. However, there is a subset of women who, despite entering prenatal care, are uncertain of their decision and wish to discuss their options with their health care provider. Screening tools and/or probing questions are needed to support prenatal care providers in identifying these women and ensuring unbiased, non-directive counseling on all pregnancy options.

Prevalence and associated birth outcomes of co-use of Cannabis and tobacco cigarettes during pregnancy

Use of Cannabis and use of tobacco overlap, and co-use of Cannabis and tobacco has increased over the past decade among adults. The current study aims to document the prevalence and correlates of co-use of Cannabis and tobacco cigarettes among adult pregnant women utilizing secondary data from a larger study that compared and validated screeners for illicit and prescription drug use during pregnancy. Pregnant women (N = 500; 71% African American; 65% never married, average age of 28 years) were recruited from two urban University obstetric clinics between January and December 2017. Participants self-reported demographic, Cannabis, and tobacco cigarette use characteristics, and provided urine and hair samples for drug testing. Within two weeks after due date, research staff reviewed participants' electronic medical records to collect birth outcome data. Results showed that 9.0% reported co-use of Cannabis and tobacco, 12.1% reported Cannabis only use, 7.8% reported tobacco cigarette only use, and 71.1% reported no Cannabis or tobacco cigarette use in the past month. The birth outcomes to emerge as significant correlates of co-use of Cannabis and tobacco cigarettes were small head circumference, and the occurrence of birth defects, with the co-use group having the highest odds of a small head circumference [aOR: 5.7 (1.1-28.9)] and birth defects [aOR: 3.1 (1.2-8.3)] compared with other use groups. The Cannabis only group had 12 times higher odds of a stillbirth or miscarriage (aOR = 12.1). Screening and interventions to address concurrent Cannabis and tobacco use during pregnancy are needed, particularly among subpopulations with higher co-use rates. It is imperative to further explore and highlight the possible health implications of maternal co-use given the high prevalence rates found in this study sample.

Risk-Based Hepatitis C Screening in Pregnancy Is Less Reliable Than Universal Screening: A Retrospective Chart Review

Current guidelines recommend only hepatitis C virus (HCV) risk-based screening during pregnancy. We examined screening practices at a major medical center and found inconsistent risk-based screening and the presence of HCV among women with no known risk factors. We make a case for the implementation of universal HCV screening during pregnancy.

Comparison and validation of screening tools for substance use in pregnancy: a cross-sectional study conducted in Maryland prenatal clinics

INTRODUCTION

Prescription-drug use in the USA has increased by more than 60% in the last three decades. Prevalence of prescription-drug use among pregnant women is currently estimated around 50%. Prevalence of illicit drug use in the USA is 14.6% among pregnant adolescents, 8.6% among pregnant young adults and 3.2% among pregnant adults. The first step in identifying problematic drug use during pregnancy is screening; however, no specific substance-use screener has been universally recommended for use with pregnant women to identify illicit or prescription-drug use. This study compares and validates three existing substance-use screeners for pregnancy-4 P's Plus, National Institute on Drug Abuse (NIDA) Quick Screen/Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) and the Substance Use Risk Profile-Pregnancy (SURP-P) scale.

METHODS AND ANALYSIS

This is a cross-sectional study designed to evaluate the sensitivity, specificity and usability of existing substance-use screeners. Recruitment occurs at two obstetrics clinics in Baltimore, Maryland, USA. We are recruiting 500 participants to complete a demographic questionnaire, NIDA Quick Screen/ASSIST, 4 P's Plus and SURP-P (ordered randomly) during their regularly scheduled prenatal appointment, then again 1 week later by telephone. Participants consent to multidrug urine testing, hair drug testing and allowing access to prescription drug and birth outcome data from electronic medical records. For each screener, reliability and validity will be assessed. Test-retest reliability analysis will be conducted by examining the results of repeated screener administrations within 1 week of original screener administrations for consistency via correlation analysis. Furthermore, we will assess if there are differences in the validity of each screener by age, race and trimester.

ETHICS AND DISSEMINATION

This study is approved by the Institutional Review Board of the University of Maryland (HP-00072042), Baltimore, and Battelle Memorial Institute (0619-100106433). All participants are required to give their informed consent prior to any study procedure.

Cannabis and pregnancy: Maternal child health implications during a period of drug policy liberalization

Cannabis use is common and increasing among women in the United States. State policies are changing with a movement towards decriminalization and legalization. We explore the implications of cannabis liberalization for maternal and child health. Most women who use cannabis quit or cut back during pregnancy. Although women are concerned about the possible health effects of cannabis, providers do a poor job of counseling. There is a theoretical potential for cannabis to interfere with neurodevelopment, however human data have not identified any long-term or long lasting meaningful differences between children exposed in utero to cannabis and those not. Scientifically accurate dissemination of cannabis outcomes data is necessary. Risks should be neither overstated nor minimized, and the legal status of a substance should not be equated with safety. Decreasing or stopping use of all recreational drugs should be encouraged during pregnancy. Providers must recognize that even in environments where cannabis is legal, pregnant women may end up involved with Child Protective Services. In states where substance use is considered child abuse this may be especially catastrophic. Above all, care for pregnant women who use cannabis should be non-punitive and grounded in respect for patient autonomy.

Prognostic utility of neuroinjury biomarkers in post out-of-hospital cardiac arrest (OHCA) patient management

Despite aggressive intervention, patients who survive an out-of-hospital cardiac arrest (OHCA) generally have very poor prognoses, with nationwide survival rates of approximately 10-20%. Approximately 90% of survivors will have moderate to severe neurological injury ranging from moderate cognitive impairment to brain death. Currently, few early prognostic indicators are considered reliable enough to support patients' families and clinicians' in their decisions regarding medical futility. Blood biomarkers of neurological injury after OHCA may be of prognostic value in these cases. When most bodily tissues are oxygen-deprived, cellular metabolism switches from aerobic to anaerobic respiration. Neurons are a notable exception, however, being dependent solely upon aerobic respiration. Thus, after several minutes without circulating oxygen, neurons sustain irreversible damage, and certain measurable biomarkers are released into the circulation. Prior studies have demonstrated value in blood biomarkers in prediction of survival and neurologic impairment after OHCA. We hypothesize that understanding peptide biomarker kinetics in the early return of spontaneous circulation (ROSC) period, especially in the setting of refractory cardiac arrest, may assist clinicians in determining prognosis earlier in acute resuscitation. Specifically, during and after immediate resuscitation and return of ROSC, clinicians and families face a series of important questions regarding patient prognosis, futility of care and allocation of scarce resources such as the early initiation of extracorporeal cardiopulmonary resuscitation (ECPR). The ability to provide early prognostic information in this setting is highly valuable. Currently available, as well as potential biomarkers that could be good candidates in prognostication of neurological outcomes after OHCA or in the setting of refractory cardiac arrest will be reviewed and discussed.

Marijuana use and pregnancy: prevalence, associated characteristics, and birth outcomes

This study examines the prevalence, behaviors, and birth outcomes associated with marijuana use in pregnancy. This was a retrospective cohort from a university-based prenatal care clinic from July 1, 2009 to June 30, 2010. The primary exposure was marijuana use, defined by self-report or urine toxicology. Demographic and outcome data were determined by chart review and analyzed by chi-square test, Fisher's exact test, ANOVA, and logistic regression. Three hundred and ninety-six patients initiated prenatal care during this time frame; 116 (29.3 %) of whom screened positive for marijuana at initial visit. Patients who used marijuana were less likely to have graduated high school (p = 0.016) or be employed (p = 0.015); they were more likely to use tobacco (p < 0.001) or alcohol (p = 0.032) and report a history of abuse (p = 0.010) or depressed mood (p = 0.023). When analyzed via logistic regression, only tobacco use remained associated with marijuana use (adjusted odds ratio (OR) = 3.3; 95 % confidence interval (CI): 1.9-5.9). Birth outcomes were available for 170 (43.0 %) patients. Only 3 (1.9 %) tested positive for marijuana at the time of delivery. Marijuana use was not related to incidence of low birth weight (13.8 % vs 14.0 %, p = 1.00), preterm delivery (17.7 % vs 12.0 %, p = 0.325), or NICU admissions (25.5 % vs 15.8 %, p = 0.139). Prenatal care utilization was equal between marijuana users and non-users. Although marijuana is common among obstetric patients at prenatal care initiation, most cease use by delivery. Marijuana is strongly correlated with cigarette use. We found no differences in birth outcomes or utilization of prenatal care by marijuana exposure.

[Asylum seekers and refugees in the medical polyclinic: a comparison between the Basel, Bern and Geneva polyclinics]

This cross-sectional study describes the state of health of asylum seekers and refugees and the health services provided to them by the medical outpatient departments of three major Swiss university hospitals, Basel, Berne and Geneva. The comparison of outpatient departments differing in organisational structure facilitated the identification of positive and negative determinants of health service provision. Questionnaires have been filled in by all physicians of the three medical outpatient departments (Basel: 10, Berne: 1, Geneva: 36). All consultations of asylum seekers and refugees have been recorded during the study period (Basel: 42, Berne: 93, Geneva: 187). Interviews have been done with the physicians who coordinated the study. During the study period the majority of the patients originated from former Yugoslavia, Turkey, Sri Lanka, Somalia, Angola and Zaire. One of the most prominent features of the population investigated has been its diversity in respect to countries of origin, languages, ability to communicate and education. Diversity and low consultation rates per physician could explain many of the problems which have been observed, e.g. the lack of experience in specific approaches to these patients or difficulties to provide interpreters. To improve the health care for this group of patients in medical outpatient departments small teams of physicians should be selected. By these means adequate levels of experience could be achieved and organizational problems could be dealt with more effectively. In addition, the relationship between specific problems of asylum seekers and refugees and more general issues of the interaction between physicians and patients are discussed in view of tasks in research and training.

Rapid HIV testing and counseling for voluntary testing centers in Africa

OBJECTIVE

Voluntary HIV testing and counseling (VTC) has been shown to reduce the incidence of HIV in cohabiting couples who now represent the majority of new infections in many African cities. Community and client perceptions of a 1-day voluntary testing and counseling program in Lusaka, Zambia, were assessed, and a rapid HIV-testing algorithm was evaluated for VTC centers.

METHODS AND DESIGN

Between May 1995 and June 1996, outreach workers distributed written invitations door to door. The 1-day program was held 6 days/week including weekends. Transport, child care and lunch were provided. Community and client surveys followed in July 1996.

RESULTS

Over 3500 couples married for a median of 4-5 years requested testing: 23% were HIV+/+, 57% were HIV-/- and 20% were discordant with one HIV+ and one HIV- partner. Sixty-eight per cent of couples surveyed had made the decision to be tested before attending the 1-day program and 80% had not previously known where to obtain HIV testing. Knowledge that couples could show discordant results rose from 29 before to 88% after pretest counseling. Clients reported high levels of satisfaction with the services and 90 out of 99 (92%) preferred to receive their results the same day. Clients at another center who waited 10 days for their results reported more fear, and 19 out of 31 (61%) would have preferred to get their results the same day. Over 99% of those who attended the program thought active promotion of voluntary HIV testing in the community was a positive thing, as did 90% of those who were invited but did not attend. Sensitivity and specificity of the rapid test algorithm were both 99.4% in this setting.

CONCLUSIONS

Active promotion of voluntary HIV testing and counseling in couples is needed to reduce the spread of HIV in high-prevalence areas. The use of rapid, on-site HIV testing allows clients to receive result-specific counseling in a single visit. Ongoing quality control of a subset of samples at an outside laboratory is essential.

Hyperkalaemia associated with haemorrhagic shock in rabbits: modification by succinylcholine, vecuronium and blood transfusion

In haemorrhagic patients, hyperkalaemia may occur after succinylcholine administration. We investigated in haemorrhagic rabbits whether vecuronium caused hyperkalaemia and if blood transfusion prevented succinylcholine-induced hyperkalaemia. Rabbits were lightly anaesthetized with halothane/N2O and 30-35 ml/kg blood were withdrawn to cause arterial pH to decrease to approximately 7.0-7.1. Group C (n = 12) received 3 ml saline, Group S (n = 13) received succinylcholine 1 mg/kg, Group V (n = 7) received vecuronium 0.25 mg/kg and Group T (n = 9) was transfused with 10 ml/kg blood 10 min prior to receiving succinylcholine 1 mg/kg. K+ analysis was repeated at 5 min, and at 10 min in most animals. Haemorrhage increased K+ (nmol.1-1, mean +/- SD): Group C, 3.4 +/- 0.3 to 6.8 +/- 1.8; Group S, 3.8 +/- 0.5 to 6.9 +/- 2.3; Group V, 3.8 +/- 0.3 to 7.1 +/- 1.9; Group T, 3.6 +/- 0.5 to 7.6 +/- 2.9. K+ decreased in Group T (to 5.4 +/- 1.8) after blood transfusion. K+ increased at 5 min in Group S (to 8.7 +/- 2.6) and at 10 min for Group C (to 8.4 +/- 1.7) and Group T (to 7.2 +/- 2.3). The K+ increase at 5 min for Group S (1.8 +/- 0.8) was significantly higher than those for Group C (1.0 +/- 0.6) or Group V (0.9 +/- 0.4), but was not different from that of Group T (1.5 +/- 0.7). We conclude that haemorrhage and succinylcholine cause hyperkalaemia in rabbits. Muscle relaxation itself does not appear to be a factor, but transfusion may lessen the hyperkalaemia.

Isolation of a laminin-binding protein from muscle cell membranes

Skeletal muscle myofibers are each ensheathed by a continuous basal lamina consisting predominantly of type IV collagen, laminin and heparan sulfate proteoglycan. In order to identify laminin-binding components in the muscle cell surface, plasma membranes from mouse thigh muscle and from rat L6 myoblasts were separated by polyacrylamide gel electrophoresis and transferred to nitrocellulose paper by electroblotting. Incubation of the transferred samples with I-labelled laminin revealed a prominent band of approximate mol. wt. 68 000. A protein of this mol. wt. was isolated by affinity chromatography of muscle cell plasma membranes on laminin-Sepharose. The hydrophobic protein has an apparent mol. wt. of 68 000 and has a high content of serine, glycine and acidic amino acids. After detergent solubilization the purified protein binds to laminin-coated Sepharose beads at a higher rate than to beads coated with either fibronectin or collagen types I and IV. The interaction of the protein, called LB 68, with laminin was also studied after incorporation into synthetic lecithin vesicles. While detergent-solubilized LB 68 bound to I-labeled laminin only at lower than physiological ionic strength, liposome-incorporated LB 68 bound to laminin in the absence of detergents under physiological conditions. We propose that this protein is involved in the interaction of myoblasts with laminin substrates and thus may participate in the anchorage of the basal lamina in the plasmalemma of myotubes.

The depression of endolysin synthesis in bacteria infected with high multiplicities of phage lambda

The effect of multiplicity of infection was studied in Escherichia coli with lambda phage, using phage endolysin as an example of a late gene product. A very sensitive endolysin assay method was used so that the initiation time of endolysin synthesis could be more accurately determined. It was observed that high multiplicity of infection (1) increases the rate of lysogenization, (2) progressively delays lysis time, and (3) significantly delays and reduces the synthesis of endolysin in lamdacIII+ cII+ -infected cells. The extent of delay and reduction in endolysin synthesis increases with increasing multiplicity. In contrast, lamdacIII67cII68-infected cells show no delay in endolysin synthesis at high multiplicity of infection when compared with the lamdacIII+ cII+ -infected cells. The results suggest that (1) the expression of cIII and cII genes is multiplicity dependent, (2) high multiplicity of infection enhances the expression of the cIII and cII genes, and (3) the expression of the cIII and cII genes interferes with the expression of the late genes. A model to explain how the expression of the cIII and cII genes interferes with the expression of the late genes is proposed.