Differences in pregnancy and perinatal outcomes among symptomatic versus asymptomatic COVID-19-infected pregnant women: a systematic review and meta-analysis

BACKGROUND

There is dearth of information on COVID-19's impact on pregnant women. However, literature reported trends of COVID-19 differ, depending on the presence of clinical features upon presentation.

OBJECTIVE

This systematic review aimed to assess differences in risk factors, management, complications, and pregnancy and perinatal outcomes in symptomatic vs. asymptomatic pregnant women with confirmed SARS-CoV-2 infection.

METHODS

A search was run on electronic databases to identify studies reporting COVID-19 in pregnancy. Meta-analysis was performed and odds ratios and mean difference with 95% confidence intervals were calculated using Review Manager 5.4. Review Prospero registration number CRD42020204662.

RESULTS

We included ten articles reporting data from 3158 pregnancies; with 1900 symptomatic and 1258 asymptomatic pregnant women. There was no significant difference in the mean age, gestational age, and body mass index between the two groups. The meta-analysis suggested that pregnant women who were obese (OR:1.37;95%CI:1.15 to 1.62), hypertensive (OR:2.07;95%CI:1.38 to 3.10) or had a respiratory disorder (OR:1.64;95%CI:1.25 to 2.16), were more likely to be symptomatic when infected with SARS-CoV-2. Pregnant women with Black (OR:1.48;95%CI:1.19 to 1.85) or Asian (OR:1.64;95%CI:1.23 to 2.18) ethnicity were more likely to be symptomatic while those with White ethnicity (OR:0.63;95%CI:0.52 to 0.76) were more likely to be asymptomatic. Cesarean-section delivery (OR:1.40;95%CI:1.17 to 1.67) was more likely amongst symptomatic pregnant women. The mean birthweight(g) (MD:240.51;95%CI:188.42 to 293.51), was significantly lower, while the odds of low birthweight (OR:1.85;95%CI:1.06 to 3.24) and preterm birth (< 37 weeks) (OR:2.10;95%CI:1.04 to 4.23) was higher amongst symptomatic pregnant women. Symptomatic pregnant women had a greater requirement for maternal ICU admission (OR:13.25;95%CI:5.60 to 31.34) and mechanical ventilation (OR:15.56;95%CI:2.96 to 81.70) while their neonates had a higher likelihood for Neonatal Intensive Care Unit admission (OR:1.96;95%CI:1.59 to 2.43). The management strategies in the included studies were poorly discussed, hence could not be analyzed.

CONCLUSION

The evidence suggests that the presence of risk factors (co-morbidities and ethnicity) increased the likelihood of pregnant women being symptomatic. Higher odds of complications were also observed amongst symptomatic pregnant women. However, more adequately conducted studies with adjusted analysis and parallel comparison groups are required to reach conclusive findings.

Insaka: mobile phone support groups for adolescent pregnant women living with HIV

BACKGROUND

Mobile phone-based interventions have been demonstrated in different settings to overcome barriers to accessing critical psychosocial support. In this study, we aimed to assess the acceptability and feasibility of a phone-based, peer-to-peer support group intervention for adolescent pregnant women aged 15-24 years living with HIV in Zambia.

METHODS

Sixty-one consenting participants were recruited from Antenatal Clinics of two large urban communities in Lusaka. They were invited to participate in the mobile phone-based intervention that allowed them to anonymously communicate in a small group led by a facilitator for 4 months. A mixed methods approach was used to assess acceptability and feasibility, including a focus group discussion, pre- and post-intervention interview and analysis of the content of the text message data generated.

RESULTS

Participants reported finding the platform "not hard to use" and enjoyed the anonymity of the groups. Seventy-one percent of participants (n = 43) participated in the groups, meaning they sent text messages to their groups. Approximately 12,000 text messages were sent by participants (an average of 169 messages/user and 6 mentors in 6 groups. Topics discussed were related to social support and relationships, stigma, HIV knowledge and medication adherence.

CONCLUSION

The study showed that the intervention was acceptable and feasible, and highlighted the potential of the model for overcoming existing barriers to provision of psychosocial support to this population.

Changes in awareness and knowledge concerning mother-to-child infections among Japanese pregnant women between 2012 and 2018

This study aimed to investigate the long-term changes in awareness of and knowledge about mother-to-child infections across 6 years in Japan. A questionnaire survey was conducted at our facility from October 2012 to January 2018, and the study periods were divided into 4 phases comprising 16 months each. A multiple-choice questionnaire assessed participants’ awareness of the following 13 pathogens of mother-to-child infections: cytomegalovirus (CMV), Toxoplasma gondii (T. gondii), hepatitis B virus, rubella virus, herpes simplex virus, parvovirus B19, hepatitis C virus, human immunodeficiency virus, human T cell leukemia virus type-1, measles virus, varicella-zoster virus, Chlamydia trachomatis, and Treponema pallidum. For the selected four pathogens (i.e., CMV, rubella virus, T. gondii, and parvovirus B19), the questionnaire also evaluated participants’ knowledge of transmission routes, the most susceptible time of infection that could yield severe fetal disease during pregnancy, the maximum frequency of fetal infection in cases of maternal infection, and methods to prevent maternal infection. In total, 1433 pregnant Japanese women were included in this study. There was no secular change in awareness of the pathogens concerning mother-to-child infections over time, and we also clarified that the detailed knowledge of the four pathogens of typical mother-to-child infections did not improve. Since knowledge about methods to prevent maternal infection is still insufficient for all pathogens, further advocacy is required to prevent mother-to-child infections.

Pregnancy and Postpartum Challenges During COVID-19 for African-African Women

The purpose of this article is to discern and examine causative factors that are likely to influence the higher consequences of health disparities experienced by pregnant and postpartum African-American women with COVID-19. Although understudied, pregnancy in the presence of COVID-19 increases the risk for illness severity. Data suggest that pregnant women with COVID-19 are more likely to be hospitalized, to be admitted to the intensive care unit, and to require life support. Similarly, COVID-19 poses significant challenges to maternal and obstetric care during the postpartum recovery period. African- American women bear a disproportionately higher morbidity and mortality burden for diseases such as diabetes, obesity, and hypertension. Pre-existing chronic health conditions may place pregnant and postpartum women at a higher risk for developing severe health consequences from COVID-19 before, during, and after delivery. In addition, social determinants of health are hypothesized to modulate the deleterious impact of COVID-19 among pregnant and postpartum African-American women.

Persistence of group B Streptococcus vaginal colonization and prevalence of hypervirulent CC-17 clone correlate with the country of birth: a prospective 3-month follow-up cohort study

To identify factors associated with vaginal colonization and persistence by group B Streptococcus (GBS) and by the hypervirulent neonatal CC-17 clone in late pregnancy and after delivery, a multicentre prospective observational cohort with 3-month follow-up was established in two university hospitals, Paris area, France. Pregnant women were recruited when antenatal screening for GBS vaginal colonization at 34-38 weeks of gestational age was positive. Vaginal samples were analysed by conventional culture methods at antenatal screening, delivery, and 21 and 60 days following delivery. Identification of the hypervirulent neonatal GBS CC-17 was performed. Colonization was defined as persistent when all vaginal samples were positive for GBS. A total of 754 women were included. GBS vaginal colonization was persistent in 63% of the cases (95% CI 59%-67%). Persistent colonization was more likely in women born in Sub-Saharan Africa compared with women born in France (OR = 1.88, 95% CI 1.05-3.52), and GBS CC-17 was overrepresented in women born in Sub-Saharan Africa (OR = 2.09, 95% CI 1.20-3.57). Women born in Sub-Saharan Africa are at higher risk for GBS vaginal persistence than women born in France. This observation correlates with an increased prevalence of the hypervirulent GBS CC-17 in the former group, which likely reflect variations linked to ethnicity and vaginal community-state types and might account for the increased susceptibility of black neonates to GBS infections.

Trends and Characteristics of Sexually Transmitted Infections During Pregnancy: United States, 2016-2018

Objectives-This report presents data on recent trends for three sexually transmitted infections (STIs)-chlamydia, gonorrhea, and syphilis-reported among women giving birth in the United States from 2016 through 2018, and rates by selected characteristics for 2018. Methods-Data are from birth certificates and are based on 100% of births registered in the United States for 2016, 2017, and 2018. Birth certificate data on infections during pregnancy are recommended to be collected from the mother's medical records (1). Mothers are to be reported as having an infection if there is a confirmed diagnosis or documented treatment for the infection in their medical record (2). Results-Among women giving birth in 2018, the overall rates of chlamydia, gonorrhea, and syphilis were 1,843.9, 310.2, and 116.7 per 100,000 births, respectively. The rates for these STIs increased 2% (chlamydia), 16% (gonorrhea), and 34% (syphilis) from 2016 through 2018. In 2018, rates of chlamydia and gonorrhea decreased with advancing maternal age, whereas those for syphilis decreased with maternal age through 30-34 years and then increased for women aged 35 and over. In 2018, rates of all three STIs were highest for non-Hispanic black women, women who smoked during pregnancy, women who received late or no prenatal care, and women for whom Medicaid was the principal source of payment for the delivery. Among women aged 25 and over, rates of each of the STIs decreased with increasing maternal education.

Stillbirth Associated With Infection in a Diverse U.S. Cohort

OBJECTIVE

To better characterize infection-related stillbirth in terms of pathogenesis and microbiology.

METHODS

We conducted a secondary analysis of 512 stillbirths in a prospective, multisite, geographically, racially and ethnically diverse, population-based study of stillbirth in the United States. Cases underwent evaluation that included maternal interview, chart abstraction, biospecimen collection, fetal autopsy, and placental pathology. Recommended evaluations included syphilis and parvovirus serology. Each case was assigned probable and possible causes of death using the INCODE Stillbirth Classification System. Cases where infection was assigned as a probable or possible cause of death were reviewed. For these cases, clinical scenario, autopsy, maternal serology, culture results, and placental pathology were evaluated.

RESULTS

For 66 (12.9%) cases of stillbirth, infection was identified as a probable or possible cause of death. Of these, 36% (95% CI 35-38%) were categorized as a probable and 64% (95% CI 62-65%) as a possible cause of death. Infection-related stillbirth occurred earlier than non-infection-related stillbirth (median gestational age 22 vs 28 weeks, P=.001). Fetal bacterial culture results were available in 47 cases (71%), of which 35 (53%) grew identifiable organisms. The predominant species were Escherichia coli (19, 29%), group B streptococcus (GBS) (8, 12%), and enterococcus species (8, 12%). Placental pathology revealed chorioamnionitis in 50 (76%), funisitis in 27 (41%), villitis in 11 (17%), deciduitis in 35 (53%), necrosis in 27 (41%), and viral staining in seven (11%) cases. Placental pathology found inflammation or evidence of infection in 65 (99%) cases and fetal autopsy in 26 (39%) cases. In infection-related stillbirth cases, the likely causative nonbacterial organisms identified were parvovirus in two (3%) cases, syphilis in one (2%) case, cytomegalovirus (CMV) in five (8%) cases, and herpes in one (2%) case.

CONCLUSION

Of infection-related stillbirth cases in a large U.S. cohort, E coli, GBS, and enterococcus species were the most common bacterial pathogens and CMV the most common viral pathogen.

Self-Reported Long-Term Antiretroviral Adherence: A Longitudinal Study Among HIV Infected Pregnant Women in Mpumalanga, South Africa

We evaluate the impact of a multi-session cognitive behavioral prevention of mother to child transmission (PMTCT) intervention on antiretroviral therapy (ART) adherence. A total of 683 women were enrolled into a randomized control trial conducted at twelve community health centres (CHCs) in Mpumalanga Province. Participants were randomized to Standard Care or Enhanced PMTCT Intervention (EI). EI received three group and three individual intervention sessions. EI impact was ascertained on ART adherence (baseline vs 12 months post-partum). Women in the intervention groups were less likely to remain stable with regards to ART adherence over time compared to the control groups. In predicting if women become adherent over time, the intervention condition had no impact. However, the intervention condition was significantly positively associated with change to non-adherence. The enhanced cognitive-behavioral PMTCT intervention did not show any improvement in relation to maternal ART adherence relative to standard PMTCT care.Trial registration Clinicaltrials.gov: number NCT02085356.

Racial disparities in intrapartum group B Streptococcus colonization: a higher incidence of conversion in African American women

OBJECTIVE

To compare the incidence of group B Streptococcus (GBS) conversion from a negative antepartum to a positive intrapartum culture among women who self-identify as non-Hispanic black, Hispanic, or non-Hispanic white.

STUDY DESIGN

This was a prospective cohort study of women with a negative rectovaginal GBS culture obtained within 35 days of enrollment. An intrapartum rectovaginal swab was collected and cultured for GBS. Data were compared with chi-square, Fisher's exact, or Wilcoxon rank-sum test. Modified Poisson regression was used.

RESULTS

We enrolled 737 women; 75.4% were non-Hispanic white, 17.6% were non-Hispanic black, and 6.9% were Hispanic. Non-Hispanic black women were more likely to convert to GBS positive than non-Hispanic white women, 9.2% as compared to 5.3% (RR: 2.0; 95% CI: 1.02-3.8).

CONCLUSION

The increased incidence of positive intrapartum GBS cultures among non-Hispanic black women suggests that non-Hispanic black race is a risk factor for GBS conversion in the late third trimester.

Hepatitis C infection among pregnant women in central Poland: Significance of epidemiological anamnesis and impact of screening tests to detect infection

BACKGROUND

Mother-to-child transmission is one of the main sources of hepatitis C virus (HCV) infection in children. However, because of the asymptomatic course of the illness, certain women may not be aware of their infection.

OBJECTIVES

The aim of this study was to estimate the significance of epidemiological anamnesis in diagnoses of HCV infection in women of reproductive age and to evaluate how screening among pregnant women impacts the detection of HCV infection.

MATERIAL AND METHODS

Epidemiological interviews of 432 mothers infected with HCV (but free of human immunodeficiency virus (HIV)) were conducted in the Warsaw Hospital for Infectious Diseases (Poland) from 1998 to 2012.

RESULTS

Complaints or abnormalities in laboratory tests were the reasons for anti-HCV antibody testing in 28.2% of mothers, whereas specific interview responses or occupational health care services group affiliation were the reasons for testing in 35.6%. However, in a large group of women, infection was only detected because of screening examinations. The introduction of routine screening for pregnant women (since 2010 in Poland) has led to the increased detection of HCV infection in women who did not present with infection risk factors (9.9% before 2010 vs 46.1% after 2010). This practice has also led to an increase in the percentage of women diagnosed during pregnancy (21.5% before 2010 vs 30.8% after 2010).

CONCLUSIONS

Establishing HCV infection risk factors during the interview process is the most common indicator for serological testing; however, not all infected cases can be diagnosed in this manner. Screening for anti-HCV antibodies in pregnant women increases the detection of HCV infection in this group.

Awareness and Utilization: Prevention of Mother-to-Child Transmission (PMTCT) Services among Primigravid Women attending Primary Health Care Facilities in Zaria, North-Western Nigeria

BACKGROUND

Nigeria with an estimated population of 193 million is Second to South Africa in the number of people living with Human Immune Deficiency Virus and Acquired Immune Deficiency Syndrome (HIV/AIDS) worldwide, representing 9% of the global burden of the disease. The objective of this study is to determine the awareness, knowledge and utilization of PMTCT services before first pregnancy in the study population, which is a critical prong 1 PMTCT strategy to prevent and control the vertical transmission of this pandemic infection.

METHODS

An analytical cross-sectional study conducted in February-April 2016 among 300 Primigravid women selected by the cluster sampling technique from six Primary Health Care (PHC) facilities that offered PMTCT services out of a list of 25 PHC facilities in Zaria LGA at the time of the survey. Data were collected using interviewer administered, closed ended questionnaire. Bivariate and multivariate logistic regression analyses were done using the IBM SPSS version 20 and the Stata Corp STATA SE 14 to determine variables that were significantly associated with respondents' utilization of the PMTCT services. The level of significance was set at p<0.05.

RESULTS

The mean age of the respondents and mean gestational age at booking were 21.1+3.54 years and 21.68 + 6.74 weeks, respectively. One-fifth of the respondents were not aware of any HIV preventive method, 81(27%) did not know that HIV can be transmitted from the mother to the fetus, 83 (27.7%) believed that transmission was by witchcraft, while 76%, 64% and 45% opined that use of condom, faithfulness to an HIV negative sexual partner and abstinence respectively were protective measures. Only 62(20.7%) were ever tested for HIV infection and 7(2.3%) of these were HIV positive. There were significant association between respondent age, awareness, perception and knowledge of MTCT, gestational age at booking, family setting and the prior utilization of PMTCT services (p<0.05).

CONCLUSION

The awareness and utilization of PMTCT services before pregnancy was poor. There was a need to scale up programmes to improve the uptake of PMTCT services before pregnancy toward attaining the sustainable development goal 3.3.

Heterogeneity of Hepatitis B Infection Among Pregnant Asian American and Pacific Islander Women

INTRODUCTION

Perinatal transmission of hepatitis B virus among Asian Americans and Pacific Islanders is a key driver of racial health disparities in liver cancer and mortality in the U.S. This study documents the prevalence of hepatitis B virus infection among pregnant women across racial/ethnic groups and among Asian Americans and Pacific Islanders to assess the need for intervention, and then identifies the individual correlates of hepatitis B virus infection among Asian American and Pacific Islander pregnant women.

METHODS

Using the 2014-2015U.S. birth rate population data, this study estimates a series of logistic regression models to examine the associations between individual-level correlates and hepatitis B virus infection among Asian American and Pacific Islanders pregnant women. Data were analyzed in July 2017.

RESULTS

Among Asian American and Pacific Islander pregnant women, Chinese American mothers are ten times more likely to experience hepatitis B virus infection than are Asian Indian and Japanese American mothers. Foreign-born mothers are significantly more likely to experience hepatitis B virus infection during pregnancy than those of their U.S.-born counterparts. Maternal SES characteristics are important correlates of hepatitis B virus infection among pregnant women.

CONCLUSIONS

Studies must disaggregate the pan-ethnic Asian American and Pacific Islander category to examine the health and health disparities of Asian Americans and Pacific Islanders. Given the heterogeneity of hepatitis B virus infection prevalence among Asian American and Pacific Islander pregnant women, the effectiveness of prevention and intervention programs depends on careful consideration of ethnicity in conjunction with group-specific factors.

Geography of Microcephaly in the Zika Era: A Study of Newborn Distribution and Socio-environmental Indicators in Recife, Brazil, 2015-2016

OBJECTIVES

We assessed sociodemographic and health care factors of mothers and newborns during a 2015-2016 outbreak of microcephaly in Recife, Brazil, and we analyzed the spatial distribution and incidence risk of newborns with microcephaly in relation to socio-environmental indicators.

METHODS

We collected data from August 2015 through May 2016 from Brazil's Live Birth Information System and Bulletin of Microcephaly Notification, and we geocoded the data by maternal residence. We constructed thematic maps of districts, according to socio-environmental and vector indicators. We identified spatial aggregates of newborns with microcephaly by using the Bernoulli model. We performed logistic regression analyses to compare the incidence risk of microcephaly within socio-environmental indicator groups.

RESULTS

We geocoded 17 990 of 19 554 (92.0%) live births in Recife, of which 202 (1.1%) newborns were classified as having microcephaly, based on a head circumference of ≥2 standard deviations below the mean. Larger proportions of newborns with microcephaly (compared with newborns without microcephaly) were born to mothers who delivered in a public hospital, did not attend college, were aged ≤19, or were black or mixed race. A higher risk of microcephaly (incidence rate ratio [IRR] = 3.90; 95% confidence interval [CI], 1.88-8.06) occurred in districts with the lowest (vs highest) Municipal Human Development Index (ie, an index that assesses longevity, education, and income). The risk of microcephaly was significantly higher where rates of larvae density (IRR = 2.31; 95% CI, 1.19-4.50) and larvae detection (IRR = 2.04; 95% CI, 1.05-4.00) were higher and rates of sewage system (IRR = 2.20; 95% CI, 1.16-4.18) and garbage collection (IRR = 1.96; 95% CI, 0.99-3.88) were lower. Newborns with microcephaly lived predominantly in the poorest areas and in a high-risk cluster (relative risk = 1.89, P = .01) in the north.

CONCLUSIONS

The disproportionate incidence of microcephaly in newborns in poor areas of Recife reinforces the need for government and public health authorities to formulate policies that promote social equity and support for families and their children with microcephaly.

Serum Retinol Levels in Pregnant Adolescents and Their Relationship with Habitual Food Intake, Infection and Obstetric, Nutritional and Socioeconomic Variables

Globally, vitamin A deficiency (VAD) affects about 19.1 million pregnant women. Its occurrence is classically associated with inadequate food intake and may also be associated with socioeconomic factors and the presence of infection. The aim of this study was to determine the factors related to serum retinol levels among pregnant teenagers. The sample consisted of 89 pregnant adolescents, from whom socioeconomic, obstetric, anthropometric, and food consumption data were collected. Serum concentrations of retinol and the supposed presence of infection were determined by high-performance liquid chromatography and C-reactive protein quantification, respectively. The serum retinol concentrations were classified according to the criteria of the World Health Organization. We adopted a 5% significance level for all statistical tests. Serum retinol levels were significantly and positively associated with sanitation (p = 0.008) and pre-gestational nutritional status (p = 0.002), and negatively with the trimester (p = 0.001). The appropriate sanitation conditions and pre-pregnancy body mass index (BMI) were shown to have a protective effect against VAD. Conversely, serum retinol levels were reduced with trimester progression, favoring VAD occurrence.

Characteristics of Pregnant Women With Hepatitis B Virus Infection in 5 US Public Health Jurisdictions, 2008-2012

OBJECTIVE

We estimated the prevalence of hepatitis B surface antigen (HBsAg), a serologic marker of active hepatitis B virus (HBV) infection, among pregnant women, and estimated the proportion HBsAg-positive pregnant women who had received additional recommended testing.

METHODS

From 2008 through 2012, Perinatal Hepatitis B Prevention Programs (PHBPPs) in Florida, Michigan, Minnesota, New York City, and Texas prospectively collected data on demographic characteristics of HBsAg-positive pregnant women. We estimated the prevalence of HBsAg positivity among pregnant women by demographic characteristics using natality data. PHBPPs (excluding Texas) collected additional recommended testing (for hepatitis B e antigen [HBeAg] and/or HBV deoxyribonucleic acid [DNA]) among HBsAg-positive pregnant women to measure levels of viremia.

RESULTS

During the study period, 15,205 HBsAg-positive women were case-managed. The median age of HBsAg-positive women was 29 years; prenatal HBsAg screening was at a median of 27 weeks pre-delivery. Of 15,205 HBsAg-positive women, 11,293 (74.3%) were foreign-born. In four PHBPPs with 14,098 pregnancies among 12,214 HBsAg-positive women, HBeAg and/or HBV DNA testing was documented for 2,794 (19.8%) pregnancies. The estimated prevalence of HBsAg positivity among pregnant women was 0.38% (17,023 of 4,468,773). HBsAg prevalence was highest among foreign-born women from most regions in Asia (2.0% to 8.7%; with the exception of South Asia, 0.4%) and Africa (3.4%).

CONCLUSION

One-fifth of HBsAg-positive pregnant women had documentation for HBeAg and/or HBV DNA, and about one-third reported receiving care for HBV infection during a case-managed pregnancy. Greater emphasis is needed on prenatal evaluation for HBV liver disease care and treatment among pregnant women with HBV infection.

[BRUCELLA MELITENSIS (BM) BACTEREMIA IN HOSPITALIZED ADULT PATIENTS IN SOUTHERN ISRAEL]

BACKGROUND

Southern Israel is endemic for Brucella melitensis (BM) infection.

AIMS

This study aims to describe clinical manifestations and laboratory abnormalities in hospitalized adults with BM-bacteremia and to assess the relationship between various laboratory parameters, outcomes and complications of brucellosis.

METHODS

This is a retrospective study. All BM bacteremic patients hospitalized in the Soroka University Medical Center (SUMC) during 2006-2011 were included. Demographic, clinical data and laboratory results were collected from the medical records.

RESULTS

A total of 114 patients were included in the study, mostly of Bedouin-Arab origin (92%). The average age was 44 years (±18.4) and included 62 females (54%) of whom 11 were pregnant. Most of the subjects were exposed to sheep or their milk or meat products. The main symptoms included fever, arthralgia, myalgia, headache, and low back pain. Complications were present in 22 patients (19%): arthritis and osteomyelitis (59%), spontaneous abortion (36% of pregnant woman), endocarditis and epididymitis. The incidence of complications was correlated to anemia and leukopenia (p=0.03) and to a low neutrophil count (p=0.009). A decrease of albumin by one unit correlated with an increased hospitalization length by 1.9 days; older age also correlated with a prolonged stay. Complications were present in 45% of pregnant women vs. 10% in non-pregnant women (p=0.011. Relapse occurred in nine patients (8%); only one of these received adequate antibiotic treatment.

CONCLUSIONS

MB-bacteremia in southern Israel occurs mainly in Bedouin-Arabs after exposure to sheep or their products. Older age and low albumin levels increase hospitalization. Leukopenia, mainly low neutrophil count, and low thrombocyte count can predict complications. Pregnant women have a higher incidence of complications. Relapse is rare under adequate antibiotic treatment.

Increase in incidence of congenital syphilis - United States, 2012-2014

Congenital syphilis (CS) occurs when a mother infected with syphilis transmits the infection to her child during pregnancy. CS can cause severe illness, miscarriage, stillbirth, and early infant death. However, among pregnant women with syphilis who deliver after 20 weeks gestation, maternal treatment with penicillin is 98% effective at preventing CS (1). In the United States, the rate of CS decreased during 1991–2005 but increased slightly during 2005–2008 (2). To assess recent trends in CS, CDC analyzed national surveillance data reported during 2008–2014, calculated rates, and described selected characteristics of infants with CS and their mothers. The overall rate of reported CS decreased from 10.5 to 8.4 cases per 100,000 live births during 2008–2012, and then increased to 11.6 cases per 100,000 live births in 2014, the highest CS rate reported since 2001. From 2012 to 2014, reported cases and rates of CS increased across all regions of the United States. To reduce CS, the timely identification of and response to increases in syphilis among women of reproductive age and men who have sex with women are essential. All women should have access to quality prenatal care, including syphilis screening and adequate treatment, during pregnancy (3).

Racial and ethnic disparities in maternal morbidity and obstetric care

OBJECTIVE

To evaluate whether racial and ethnic disparities exist in obstetric care and adverse outcomes.

METHODS

We analyzed data from a cohort of women who delivered at 25 hospitals across the United States over a 3-year period. Race and ethnicity was categorized as non-Hispanic white, non-Hispanic black, Hispanic, or Asian. Associations between race and ethnicity and severe postpartum hemorrhage, peripartum infection, and severe perineal laceration at spontaneous vaginal delivery as well as between race and ethnicity and obstetric care (eg, episiotomy) relevant to the adverse outcomes were estimated by univariable analysis and multivariable logistic regression.

RESULTS

Of 115,502 studied women, 95% were classified by one of the race and ethnicity categories. Non-Hispanic white women were significantly less likely to experience severe postpartum hemorrhage (1.6% non-Hispanic white compared with 3.0% non-Hispanic black compared with 3.1% Hispanic compared with 2.2% Asian) and peripartum infection (4.1% non-Hispanic white compared with 4.9% non-Hispanic black compared with 6.4% Hispanic compared with 6.2% Asian) than others (P<.001 for both). Severe perineal laceration at spontaneous vaginal delivery was significantly more likely in Asian women (2.5% non-Hispanic white compared with 1.2% non-Hispanic black compared with 1.5% Hispanic compared with 5.5% Asian; P<.001). These disparities persisted in multivariable analysis. Many types of obstetric care examined also were significantly different according to race and ethnicity in both univariable and multivariable analysis. There were no significant interactions between race and ethnicity and hospital of delivery.

CONCLUSION

Racial and ethnic disparities exist for multiple adverse obstetric outcomes and types of obstetric care and do not appear to be explained by differences in patient characteristics or by delivery hospital.

LEVEL OF EVIDENCE

II.

Factors associated with lack of viral suppression at delivery among highly active antiretroviral therapy-naive women with HIV: a cohort study

BACKGROUND

A high delivery maternal plasma HIV-1 RNA level (viral load [VL]) is a risk factor for mother-to-child transmission and poor maternal health.

OBJECTIVE

To identify factors associated with detectable VL at delivery despite initiation of highly active antiretroviral therapy (HAART) during pregnancy.

DESIGN

Multicenter observational study. (ClinicalTrial.gov: NCT00028145).

SETTING

67 U.S. AIDS clinical research sites.

PATIENTS

Pregnant women with HIV who initiated HAART during pregnancy.

MEASUREMENTS

Descriptive summaries and associations among sociodemographic, HIV disease, and treatment characteristics; pregnancy-related risk factors; and detectable VL (>400 copies/mL) at delivery.

RESULTS

Between 2002 and 2011, 671 women met inclusion criteria and 13.1% had detectable VL at delivery. Factors associated with detectable VL included multiparity (16.4% vs. 8.0% nulliparity; P = 0.002), black ethnicity (17.6% vs. 6.6% Hispanic and 6.6% white; P < 0.001), 11th grade education or less (17.6% vs. 12.1% had a high school diploma; P = 0.013), initiation of HAART in the third trimester (23.9% vs. 12.3% and 8.6% in the second and trimesters, respectively; P = 0.003), having an HIV diagnosis before the current pregnancy (16.1% vs. 11.0% during the current pregnancy; P = 0.051), and having the first prenatal visit in the third trimester (33.3% vs. 14.3% and 10.5% in the second and third trimesters, respectively; P = 0.002). Women who had treatment interruptions or reported poor medication adherence were more likely to have detectable VL at delivery.

LIMITATION

Data on many covariates were incomplete because women entered the study at varying times during pregnancy.

CONCLUSION

A total of 13.1% of women who initiated HAART during pregnancy had detectable VL at delivery. The timing of HAART initiation and prenatal care, along with medication adherence during pregnancy, were associated with detectable VL at delivery. Social factors, including ethnicity and education, may help identify women who could benefit from focused efforts to promote early HAART initiation and adherence.

PRIMARY FUNDING SOURCE

U.S. Department of Health and Human Services.

Pregnant women's knowledge and attitude to mother to child transmission of human immuno-deficiency virus in a rural community in Northwest Nigeria

BACKGROUND

The high seroprevalence of HIV in Nigeria contributing to a huge burden of paediatric infection and with wide disparities in the various zones of the country needs to be addressed. The main strategy involves the prevention of mother to child transmission (MTCT) of HIV which remains the cornerstone of preventing the next generation from acquiring HIV.

OBJECTIVES

To ascertain the knowledge and attitude of pregnant women in Northwest Nigeria to HIV and MTCT despite the low literacy level in the rural community.

METHODS

This was a cross sectional study in which 450 pregnant women attending the booking clinic of a tertiary institution were recruited and interviewed using an interviewer administered semi-structured pre-tested questionnaires. The questionnaire assessed the pregnant women's knowledge related to HIV, MTCT of HIV, its prevention and respondents' attitude towards it.

RESULTS

Of the 450 respondents, majority (96.2%) were aware of HIV. Most of them (78%) had adequate knowledge of MTCT of HIV. About half of the respondents knew that MTCT of HIV could be prevented by not breastfeeding, few agreed with taking of antiretroviral during pregnancy (28%) and giving new born antiretroviral (20.2%) as ways of preventing MTCT.

CONCLUSION

The respondents in this study had a high level of awareness of HIV/AIDS, a good general knowledge of MTCT and attitude towards PMTCT but a below average knowledge of specific interventions on prevention of MTCT of HIV.

Pregnancy, obstetric and neonatal outcomes in HIV positive Nigerian women

While the effect of HIV infection on some maternal outcomes is well established, for some others there is conflicting information on possible association with HIV. In this study we investigated pregnancy and neonatal outcome of HIV positive women in large HIV treatment centre over a period of 84 months. They were managed according to the Nigerian PMTCT protocol. Adverse obstetric and neonatal outcome were observed in 48.3% HIV positives compared 30.3% to the negatives (OR: 2.08; CI: 1.84-2.34). Low birth weight ( OR:2.95; CI:1.95-3.1), preterm delivery (OR:2.05; CI:1.3-3.1), perinatal death (OR:1.9;CI:1.3-3.2), and spontaneous abortion (OR:1.37; CI:1.1-2.3) were factors found to be independently associated with HIV. Low CD4 count (OR: 2.45; CI: 1.34- 4.56) and opportunistic infections (OR: 2.11; CI: 1.56-3.45) were to be associated with adverse obstetric and neonatal outcome. This study confirms the association of HIV, severe immunosuppression and opportunistic infection and adverse obstetric and neonatal outcome.

Reducing Alaska Native paediatric oral health disparities: a systematic review of oral health interventions and a case study on multilevel strategies to reduce sugar-sweetened beverage intake

BACKGROUND

Tooth decay is the most common paediatric disease and there is a serious paediatric tooth decay epidemic in Alaska Native communities. When untreated, tooth decay can lead to pain, infection, systemic health problems, hospitalisations and in rare cases death, as well as school absenteeism, poor grades and low quality-of-life. The extent to which population-based oral health interventions have been conducted in Alaska Native paediatric populations is unknown.

OBJECTIVE

To conduct a systematic review of oral health interventions aimed at Alaska Native children below age 18 and to present a case study and conceptual model on multilevel intervention strategies aimed at reducing sugar-sweetened beverage (SSB) intake among Alaska Native children.

DESIGN

Based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Statement, the terms "Alaska Native", "children" and "oral health" were used to search Medline, Embase, Web of Science, GoogleScholar and health foundation websites (1970-2012) for relevant clinical trials and evaluation studies.

RESULTS

Eighty-five studies were found in Medline, Embase and Web of Science databases and there were 663 hits in GoogleScholar. A total of 9 publications were included in the qualitative review. These publications describe 3 interventions that focused on: reducing paediatric tooth decay by educating families and communities; providing dental chemotherapeutics to pregnant women; and training mid-level dental care providers. While these approaches have the potential to improve the oral health of Alaska Native children, there are unique challenges regarding intervention acceptability, reach and sustainability. A case study and conceptual model are presented on multilevel strategies to reduce SSB intake among Alaska Native children.

CONCLUSIONS

Few oral health interventions have been tested within Alaska Native communities. Community-centred multilevel interventions are promising approaches to improve the oral and systemic health of Alaska Native children. Future investigators should evaluate the feasibility of implementing multilevel interventions and policies within Alaska Native communities as a way to reduce children's health disparities.

The continuum of maternal sepsis severity: incidence and risk factors in a population-based cohort study

OBJECTIVE

To investigate the incidence and risk factors associated with uncomplicated maternal sepsis and progression to severe sepsis in a large population-based birth cohort.

METHODS

This retrospective cohort study used linked hospital discharge and vital statistics records data for 1,622,474 live births in California during 2005-2007. Demographic and clinical factors were adjusted using multivariable logistic regression with robust standard errors.

RESULTS

1598 mothers developed sepsis; incidence of all sepsis was 10 per 10,000 live births (95% CI = 9.4-10.3). Women had significantly increased adjusted odds (aOR) of developing sepsis if they were older (25-34 years: aOR = 1.29; ≥35 years: aOR = 1.41), had ≤high-school education (aOR = 1.63), public/no-insurance (aOR = 1.22) or a cesarean section (primary: aOR = 1.99; repeat: aOR = 1.25). 791 women progressed to severe sepsis; incidence of severe sepsis was 4.9 per 10,000 live births (95% CI = 4.5-5.2). Women had significantly increased adjusted odds of progressing to severe sepsis if they were Black (aOR = 2.09), Asian (aOR = 1.59), Hispanic (aOR = 1.42), had public/no-insurance (aOR = 1.52), delivered in hospitals with <1,000 births/year (aOR = 1.93), were primiparous (aOR = 2.03), had a multiple birth (aOR = 3.5), diabetes (aOR = 1.47), or chronic hypertension (aOR = 8.51). Preeclampsia and postpartum hemorrhage were also significantly associated with progression to severe sepsis (aOR = 3.72; aOR = 4.18). For every cumulative factor, risk of uncomplicated sepsis increased by 25% (95% CI = 17.4-32.3) and risk of progression to severe sepsis/septic shock increased by 57% (95% CI = 40.8-74.4).

CONCLUSIONS

The rate of severe sepsis was approximately twice the 1991-2003 national estimate. Risk factors identified are relevant to obstetric practice given their cumulative risk effect and the apparent increase in severe sepsis incidence.

Differences in hepatitis B infection rate between ethnic groups in antenatal women in Birmingham, United Kingdom, May 2004 to December 2008

Hepatitis B virus (HBV) is a major cause of morbidity and mortality worldwide. Although the United Kingdom (UK) prevalence of HBV is low, it is increasing. There is some evidence that the rate of infection is much higher in some populations living in Britain of non-white ethnicity or who were not born in Britain, compared with the British-born white population. We examined the prevalence of HBV infection in pregnant women through hepatitis B surface antigen (HBsAg) or e-antigen (HBeAg) in Birmingham UK between May 2004 and December 2008 and the effect of ethnicity on the relative risk of infection. There was a significant increase in the number of antenatal HBV infections detected over the study period from 106 cases in 2005 to 161 cases in 2008 (p=0.037). Women who define themselves as of black African, non-British white and Pakistani ethnicity had a markedly elevated rate of HBV infection (relative risk (RR): 11.25, 5.87 and 2.33 respectively) compared to the England average. Health organisations that serve populations with a high or increasing proportion of women originating from intermediate and high HBV prevalence areas of the world such as Africa, some parts of Europe and Asia, should anticipate a need for perinatal and postnatal prophylaxis to children born to HBV infected mothers.

The burden of invasive early-onset neonatal sepsis in the United States, 2005-2008

BACKGROUND

Sepsis in the first 3 days of life is a leading cause of morbidity and mortality among infants. Group B Streptococcus (GBS), historically the primary cause of early-onset sepsis (EOS), has declined through widespread use of intrapartum chemoprophylaxis. We estimated the national burden of invasive EOS cases and deaths in the era of GBS prevention.

METHODS

Population-based surveillance for invasive EOS was conducted in 4 of the Centers for Disease Control and Prevention's Active Bacterial Core surveillance sites from 2005 to 2008. We calculated incidence using state and national live birth files. Estimates of the national number of cases and deaths were calculated, standardizing by race and gestational age.

RESULTS

Active Bacterial Core surveillance identified 658 cases of EOS; 72 (10.9%) were fatal. Overall incidence remained stable during the 3 years (2005: 0.77 cases/1000 live births; 2008: 0.76 cases/1000 live births). GBS (∼ 38%) was the most commonly reported pathogen followed by Escherichia coli (∼ 24%). Black preterm infants had the highest incidence (5.14 cases/1000 live births) and case fatality (24.4%). Nonblack term infants had the lowest incidence (0.40 cases/1000 live births) and case fatality (1.6%). The estimated national annual burden of EOS was approximately 3320 cases (95% confidence interval [CI]: 3060-3580), including 390 deaths (95% CI: 300-490). Among preterm infants, 1570 cases (95% CI: 1400-1770; 47.3% of the overall) and 360 deaths (95% CI: 280-460; 92.3% of the overall) occurred annually.

CONCLUSIONS

The burden of invasive EOS remains substantial in the era of GBS prevention and disproportionately affects preterm and black infants. Identification of strategies to prevent preterm births is needed to reduce the neonatal sepsis burden.

Vigilance must be a priority: maternal genital tract sepsis

Although very rare in the UK, sepsis was the leading cause of direct maternal deaths during 2006-2008, with an increase in community acquired Group A streptococcal infection (CMACE 2011). Most deaths occurred in the postnatal period and were often preceded by a sore throat or other upper respiratory infection, with a clear seasonal pattern. An associated factor was women of BME origin (black or minority ethnic origin). More than half of the deaths followed birth by caesarean section. All antenatal and postnatal women should be offered advice on the signs and symptoms of life threatening conditions, including sepsis. Information should include the importance of good hand and perineal hygiene and of the need to seek immediate medical care if feeling unwell. Relevant NICE guidance should be disseminated and implemented as widely as possible. Greater priority should be given to ensuring all women, particularly those in the most vulnerable groups, are aware of how to access timely and appropriate care.

HIV and pregnancy: challenges in practice

Midwives face great challenges in practice in caring for women with multiple medical, social and psychological needs. This article highlights the issues such as extreme grief reaction, fear of abandonment and stigma and prejudice that women face when they are diagnosed HIV positive during pregnancy. The article also discusses the importance of communication and a multi-agency approach in providing safe antenatal care for vulnerable women and their families.

Pregnancy-specific association of vitamin D deficiency and bacterial vaginosis

OBJECTIVE

Recent data suggest vitamin D deficiency (VDD) is associated with bacterial vaginosis (BV) during pregnancy. We hypothesized that VDD is a risk factor for BV in nonpregnant women.

STUDY DESIGN

Using National Health and Nutrition Examination Survey data, we conducted multivariable logistic regression analyses stratified by pregnancy.

RESULTS

VDD was associated with BV only in pregnant women (adjusted odds ratio [AOR], 2.87; 95% confidence interval [CI], 1.13-7.28). Among nonpregnant women, douching (AOR, 1.72; 95% CI, 1.25-2.37), smoking (AOR, 1.66; 95% CI, 1.23-2.24), and black race (AOR, 2.41; 95% CI, 1.67-3.47) were associated with BV; oral contraceptive use was inversely associated with BV (AOR, 0.60; 95% CI, 0.40-0.90). VDD moderated the association between smoking and BV in nonpregnant women.

CONCLUSION

Risk factors for BV differ by pregnancy status. VDD was a modifiable risk factor for BV among pregnant women; evaluation of vitamin D supplementation for prevention or adjunct therapy of BV in pregnancy is warranted.

Screening for infectious diseases in pregnant, foreign-born women from multiple global areas

OBJECTIVE

To describe and compare infectious diseases commonly screened for during pregnancy among pregnant immigrant women from multiple global regions.

STUDY DESIGN

We retrospectively reviewed the charts of all women born outside the United States who delivered at Vanderbilt University Medical Center during 2003-2006. These women were identified through the birth certificate applications for their children. The primary outcomes were prevalence of positive tests for tuberculosis, HIV, hepatitis B, gonorrhea and Chlamydia, rubella immunity and syphilis.

RESULTS

During the years 2003-2006, 1,767 immigrant women gave birth at Vanderbilt University Medical Center. The women were from Africa (17%), Asia (25%), Europe (11%), Latin America (26%), Middle East (18%), North America (2%) and Oceana (1%). There were no statistically significant differences in prevalence among immigrant groups for positive purified protein derivatives (PPDs), rubella titers, rapid plasma reagin (syphilis) and gonorrhea. Significantly more women from Asia and Africa had positive hepatitis B surface antigen. Asian women were less likely than other immigrant groups to be positive for HIV. Significant differences were also noted among groups for Chlamydia. Screening rates differed by immigrant groups and were related to mode of testing.

CONCLUSION

Our data reinforce the importance of screening for diseases for which vaccinations are available, especially for hepatitis B and rubella. The data also show the importance of following up positive PPDs, particularly among pregnant immigrant women. Screening differences among groups may exist, and further research is needed to examine causal factors.

Rethinking HIV/AID disclosure among women within the context of motherhood in South Africa

This qualitative study explored whether motherhood plays a role in influencing decisions to conceal or reveal knowledge of seropositive status among women living with HIV/AIDS in 2 South African communities: Gugulethu and Mitchell's Plain. Using the PEN-3 cultural model, we explored how HIV-positive women disclose their status to their mothers and how HIV-positive mothers make decisions about disclosure of their seropositive status. Our findings revealed 3 themes: the positive consequences of disclosing to mothers, how being a mother influences disclosure (existential role of motherhood), and the cost of disclosing to mothers (negative consequences). The findings highlight the importance of motherhood in shaping decisions to reveal or conceal knowledge of seropositive status. Implications for interventions on HIV/AIDS prevention, care, and support are discussed.

Quantifying the risk of pandemic influenza in pregnancy and indigenous people in Australia in 2009

An increased relative risk of infection with the 2009 pandemic H1N1 influenza virus associated with pregnancy and Indigenous status has been a common finding in many countries. Using publicly available data from May to October 2009 in Australia, we estimated the relative risk of hospitalisation, admission to intensive care unit and death as 5.2, 6.5 and 1.4 respectively for pregnant women, and as 6.6, 6.2 and 5.2, respectively for Indigenous Australians. Pregnancy and Indigenous status were associated with severe influenza. More complete analyses of risks in these groups are required to understand and prevent influenza morbidity and mortality.

Living with a killer: HIV/AIDS infect thousands of Texans

Tens of thousands of Texans go about their everyday lives infected with HIV and AIDS. Many of them are children infected at birth. Two bills in this year's Texas legislative session sought to reduce the devastation wrought by the disease.

Cervical cytokine network patterns during pregnancy: the role of bacterial vaginosis and geographic ancestry

Few studies have examined the coordinated regulation of the extensive network of cytokines, chemokines, and growth factors involved in the immune response to bacterial vaginosis (BV) during pregnancy. We compared these patterns between women with (BV(+)) and without (BV(-)) bacterial vaginosis and between women of African and of European ancestry. This cohort included 83 Whites (28 BV(+) and 55 BV(-)) and 80 Blacks (41 BV(+) and 39 BV(-)). Pairwise correlations were determined for 28 factors that included cytokines, chemokines, and growth factors. In Whites, there were significantly more correlations involving immunoregulatory cytokines in BV(-) compared with BV(+) women. In Blacks, there were no significant differences in the correlation patterns between BV(+) and BV(-) women. Overall, in BV(-) women, there were no significant differences in the correlation patterns between Whites and Blacks. Conversely, in BV(+) women, Blacks have a stronger correlated response to infection than Whites. This indicates that Whites and Blacks have different correlated immune responses to BV that may at least partially explain the disparity observed in the prevalence of this disease.

Levels and patterns of HIV RNA viral load in untreated pregnant women

OBJECTIVE

To assess pregnancy levels and patterns of HIV RNA in the absence of antiretroviral therapy, while appropriately adjusting for potential confounders, including maternal immune status and race.

METHODS

Data on > or = 1 antenatal HIV RNA measurements were available for 333 untreated HIV-infected pregnant women enrolled in the European Collaborative Study. CD4 counts and HIV RNA measurements were routinely collected from 1992 and 1998, respectively. Linear mixed effects models based on 246 women for whom complete data were available examined changes in HIV RNA levels over pregnancy, with a nested random effects term accounting for measurement variability within women and period of sample collection.

RESULTS

The change in HIV RNA over pregnancy varied significantly by race (p=0.005): from the second trimester until delivery, HIV RNA decreased significantly by an estimated 0.019 log(10) copies/ml/week in white women (95% CI -0.03, -0.007); in black women the estimated 0.016 log(10) copies/ml/week increase (95% CI -0.005, 0.037) was not statistically significant. At delivery, HIV RNA levels in black women were 0.45 log(10) copies/ml higher (95% CI 0.08, 0.83) than in white women.

CONCLUSIONS

Our findings suggest that HIV RNA dynamics over pregnancy differ by race, although other interpretations cannot be excluded, due to potential for unmeasured confounding.

Perinatal HIV transmission and pregnancy outcomes in indigenous women in Western Australia

BACKGROUND

Implementation of obstetric and neonatal interventions has reduced mother to child transmission of HIV. Health outcomes for Aboriginal people are often worse than for non-Aboriginal people; was this the case for HIV infection in pregnancy?

AIMS

To compare the management and outcomes of pregnancy in Aboriginal and non-Aboriginal HIV-positive women in Western Australia (WA).

METHODS

A retrospective study of all pregnancies delivered in WA to HIV-infected women from 1991 until 2005. Managed pregnancies were compared in Aboriginal and non-Aboriginal women. Outcome measures were HIV status of the babies, birthweight, rates of caesarean delivery and perinatal mortality.

RESULTS

Fifty-six pregnancies occurred in 41 HIV-infected women resulting in 54 live births. Of the 41 women, 16 (39%) were Aboriginal. In regard to birthweight, perinatal mortality, rates of caesarean section and rates of HIV perinatal transmission, there was no significant difference between babies born to Aboriginal and those born to non-Aboriginal mothers. In contrast, of the eight pregnancies, with no contact with the multidisciplinary team, five babies (63%) were infected with HIV (2% vs 63%P = 0.001). There was no case of perinatal HIV infection in 22 pregnancies of the Aboriginal women that received care through the multidisciplinary team; perinatally acquired HIV occurred in the first pregnancy of one of these women before she was aware of her status when she was not managed by the team.

CONCLUSIONS

Similar outcomes can be achieved in both HIV-positive Aboriginal and non-Aboriginal women, through intensive, culturally appropriate, multidisciplinary care and without elective caesarean delivery.

Pregnancy and oral health: utilisation of dental services during pregnancy in northern Greece

BACKGROUND

Recent studies have shown that gingivitis and periodontal infection during pregnancy represent an independent risk factor for pre-term birth. However, little is known about the prevalence and correlates of dental attendance during pregnancy.

METHODS

During the first 3 days postpartum, an anonymous questionnaire was administered to 425 women in order to explore their dental condition and utilisation of dental health services during pregnancy, as well as their perceptions on the potential associations between dental care during pregnancy and pregnancy outcomes.

RESULTS

Almost half of the respondents (46.8%) reported symptoms of gingivitis during their pregnancy. Pregnancy gingivitis was independently associated with non-Greek ethnicity (p=0.008), multiparity versus primiparity (p<0.005), lower economic class versus middle and upper classes (p=0.001), and the lack of routine primary dental care (p=0.005). Some 27.3% reported a visit to the dentist during their pregnancy. The majority (72.2%) believed that dental treatment during pregnancy might have a negative affect on pregnancy outcome. The presence of pregnancy gingivitis and the belief that dental treatment during pregnancy is safe were both independently associated with visiting a dentist during pregnancy (p<0.0005 for both).

CONCLUSIONS

Despite the increased prevalence of dental problems among pregnant women, few women seek dental services in this population, which can be primarily attributed to women's erroneous beliefs regarding the safety of dental examination. Therefore, there is an imperative need to offer oral health education and develop preventive programs for women of reproductive age.

Patterns of antibiotic resistance among group B streptococcus isolates: 2001-2004

The objectives were to determine the prevalence of group B streptococcus (GBS) and to characterize antibiotic resistance patterns. All pregnant women presenting to the triage units at two urban hospitals during three intervals from 2001 to 2004 were included. Each interval lasted approximately four weeks. Swabs were inoculated into selective broth and cultured on tryptic soy agar with 5% sheep blood. GBS was identified using the StrepTex latex agglutination system. GBS positive cultures were tested for their resistance to ampicillin, erythromycin, clindamycin, and cefazolin. GBS was isolated from 154 (12.2%) of 1264 swabs collected during the study period. African-American women were more likely to be colonized with GBS than Caucasians and Hispanics. Resistance to routinely administered antibiotics was common, but there were no statistically significant increases in resistance to antibiotics over the study period. Ongoing surveillance of antibiotic resistance patterns is important in determining optimal prophylaxis and therapy.

Racial disparity in risk of preterm birth associated with lower genital tract infection

The objective of this study was to examine the associations between lower genital tract infection, racial group and preterm birth in the Vaginal Infections and Prematurity Study, a large prospective cohort study conducted between 1984 and 1989. This analysis included 11 910 women enrolled at 23-26 weeks' gestation with equal representation from self-identified African American, Hispanic and white women. Subjects were screened for Chlamydia trachomatis, Trichomonas vaginalis and bacterial vaginosis at study entry, and their pregnancy outcomes were ascertained after delivery. The primary outcome of interest was preterm delivery of a low-birthweight infant (<37 weeks and <2500 g). The associations between lower genital tract infection and preterm delivery of a low-birthweight infant were examined within each racial group, with adjustment for potential confounders using multivariable logistic regression. In this cohort, 6.4% of African Americans, 3.8% of Hispanics, and 4.4% of whites had a preterm delivery of a low-birthweight infant (P < 0.001). Lower genital tract infection was significantly associated with preterm delivery of a low-birthweight infant among African Americans, but not among other racial groups. The proportion of preterm birth associated with lower genital tract infection was 21% among African Americans and 5% among whites. The increase in infection-associated preterm birth among African Americans appears to be related both to an increased prevalence of lower genital tract infection, and also to an increased risk of preterm delivery of a low-birthweight infant in the context of lower genital tract infection.

Pregnancy outcomes and antiretroviral treatment in a national cohort of pregnant women with HIV: overall rates and differences according to nationality

We used data from the main surveillance study of HIV and pregnancy in Italy to evaluate possible differences in pregnancy care and outcomes according to nationality. Among 960 women followed in 2001-06, 33.5% were of foreign nationality, mostly from African countries. Foreign women had lower rates of preconception counselling and planning of pregnancy. They had more frequently HIV diagnosed during pregnancy, with a later start of antiretroviral treatment and lower treatment rates at all trimesters but not when the entire pregnancy, including delivery, was considered. No differences were observed between the two groups in ultrasonography assessments, hospitalisations, AIDS events, intrauterine or neonatal deaths, and mode and complications of delivery. Foreign women had a slightly lower occurrence of preterm delivery and infants with low birthweight. The results indicate good standards of care and low rates of adverse outcomes in pregnant women with HIV in Italy, irrespective of nationality. Specific interventions, however, are needed to increase the rates of counselling and HIV testing before pregnancy in foreign women.

Fetal Fibronectin and Adverse Infant Outcomes in a Predominantly Human Immunodeficiency Virus–Infected African Population

OBJECTIVE

To evaluate the relationship between fetal fibronectin and preterm birth and maternal-to-child transmission of human immunodeficiency virus (HIV) in an African population of predominantly HIV-infected women.

METHODS

During a trial of second trimester and intrapartum antibiotics compared with placebo to prevent chorioamnionitis and reduce preterm birth and mother-to-child transmission of HIV, vaginal fluid was collected before antibiotics (20-24 weeks) and after treatment at 28 weeks and assayed for fetal fibronectin. Pregnancy outcomes of 2,353 women delivering liveborn singleton infants are presented.

RESULTS

Positive fetal fibronectin assays (50 ng/mL or more) were detected in 4.2% and 4.9% of samples at 20-24 weeks and 28 weeks. Positive fetal fibronectin assays at 28 weeks but not at 20-24 weeks were associated with lower mean birthweight (199 g, P<.001); lower mean gestational age (2 weeks, P<.001); six-fold higher rate of preterm birth less than 32 weeks (10.8% compared with 1.9%, odds ratio 6.3, 95% confidence interval 3.2-12.3) and a two-fold higher rate of preterm birth less than 37 weeks (38.7 compared with 22.0%, odds ratio 2.3, 95% confidence interval 1.5-3.3). Also, at 28 weeks, as the fetal fibronectin values increased, each of the outcomes worsened, and every test of trend was significant. An association between elevated fetal fibronectin levels and mother-to-child transmission of HIV was present at 20 to 24 weeks but not at 28 weeks. Antibiotic treatment at 20 to 24 weeks was not associated with fetal fibronectin levels at 28 weeks.

CONCLUSION

In a population of predominantly HIV- infected African women, fetal fibronectin concentrations at 28 but not at 20-24 weeks were associated with increased risk of preterm birth. The associations were stronger for early preterm birth and when fetal fibronectin levels were higher. High levels of fetal fibronectin were positively associated with mother-to-child transmission of HIV at 20 -24 but not at 28 weeks. Antibiotic treatment did not influence fetal fibronectin levels.

CLINICAL TRIAL REGISTRATION

www.clinicalTrials.gov, NCT00021671

LEVEL OF EVIDENCE

I.

Management of advanced HIV disease with no other complications in women and in Africans

The number of patients who present with advanced human immunodeficiency virus (HIV) disease [defined as a helper lymphocyte (CD4) count <50 cells/mm3 or the presence of an acquired immunodeficiency syndrome (AIDS)-defining illness] is increasing. In the USA during 1994-1999, a relatively stable proportion of 43% of people diagnosed with HIV infection were tested late in the infection (had AIDS diagnosed within 1 year of diagnosis). A recent review of newly diagnosed infections in 2003 found that 301/977 (31%) of patients in the UK and Ireland presented late (<200 CD4 cells/mm3). Before a diagnosis is made, patients with advanced disease do not benefit from antiretroviral therapy and may continue to transmit the infection to others. Furthermore, when antiretroviral therapy is initiated in patients with CD4 counts of 201-350 cells/mm(3), the risk of death is lower than when treatment is started at lower CD4 cell counts. With the increasing prevalence of HIV in women and African immigrants, some doctors are concerned that different management approaches need to be used in these groups. This article reviews the evidence and some clinical scenarios for patients with advanced disease without complications and women and Africans who may present with advanced HIV disease. The aim is to offer practical advice on therapeutic options for treatment-naïve patients who present with advanced HIV disease on the basis of available clinical evidence.

Barriers and incentives to HIV treatment uptake among Aboriginal people in Western Australia

OBJECTIVE

To examine the barriers and incentives to HIV treatment uptake among Aboriginal people in Western Australia.

METHODS

In-depth, semi-structured interviews were conducted between February and September 2003 with 20 Aboriginal people who were HIV-positive; almost half the total number of Aboriginal people known to be living with HIV in Western Australia at that time.

RESULTS

Despite having access to treatments in both urban and rural areas, only 11 of the 20 participants were on antiretroviral treatment at the time of interview. Four of the women had been prescribed treatment during pregnancy only. The main barriers to treatment uptake were fear of disclosure and discrimination, heavy alcohol consumption and poverty. The incentives were pregnancy and access to services whose approach can be described as broad-based and holistic, i.e. supporting people in the context of their everyday lives by providing psychosocial and welfare support as well as healthcare.

CONCLUSION

For many Aboriginal people, maintaining social relationships, everyday routines and the respect of friends, families and community is a greater priority than individual health per se. Treatment regimens must be tailored to fit the logistical, social and cultural context of everyday life, and be delivered within the context of broad-based health services, in order to be feasible and sustainable.

Prenatal syphilis infection is a possible cause of preterm delivery among immigrant women from eastern Europe

OBJECTIVE

to evaluate the prevalence of maternal syphilis at delivery and neonatal syphilis infection in an Italian urban area, in connection with the increased flow of immigration.

STUDY DESIGN

A prospective surveillance study was carried out in Bologna, Italy, from November 2000 to March 2006. All pregnant women were screened for syphilis at delivery. Infants born to seropositive mothers were enrolled in a prospective follow-up.

RESULTS

During the study period 19,205 women gave birth to 19,548 infants. A total of 85 women were seropositive for syphilis at delivery. The overall syphilis seroprevalence in pregnant women was 0.44%, but it was 4.3% in women from eastern Europe and 5.8% in women from Central-South America. Ten women were first found positive at delivery, as they did not receive any prenatal care. Nine of these were from eastern Europe. All their infants were asymptomatic, but six had both reactive immunoglobulin (Ig)M western blot and rapid plasma reagin tests and were considered prenatally infected. Three of six were preterm (gestational age <37 weeks).

CONCLUSIONS

In Italy, congenital syphilis infection is strictly related to immigration from eastern Europe. Although it is asymptomatic, it could cause premature delivery. Therefore, it is necessary to perform serological tests during the third trimester in mothers coming from endemic areas to adequately treat syphilis in pregnancy and prevent congenital infection. If the mother's test results are not available at delivery, it is necessary to investigate the newborn, especially if it is born prematurely.

Serological and virological profile of chronic HBV infected women at reproductive age in Greece. A two-year single center study

OBJECTIVE

Seroprevalence of HBsAg in 26,746 women at reproductive age in Greece and evaluation of HBeAg/anti-HBe serological status as well as serum HBV-DNA levels in a subgroup of HBsAg(+) women at labor.

STUDY DESIGN

Serological markers were detected using enzyme immunoassays. Serum HBV-DNA was calculated using a sensitive quantitative PCR assay, with a lower limit of quantification of 200 copies/ml.

RESULTS

Overall, 1.53% of women were HBsAg(+) and the majority of them (64.96%) were Albanian. Among Albanian women the mean prevalence of HBsAg was 4.9%, 5.57% among Asian women, and 1.29% among women from Eastern European countries. The prevalence of HBsAg among African (0.29%) and Greek women (0.57%) was very low and significantly lower in comparison with the mean value of the studied population. Only 2.67% of HBsAg(+) women were HBeAg(+). Of a subgroup of women in labor with available serum samples 28.6% had undetectable levels of viremia (<200 copies/ml) and 15.9% had extremely low levels of viral replication (<400 copies/ml). Only 12.7% of pregnant women evaluated at labor exhibited extremely high serum HBV-DNA levels (>10,000,000 copies/ml) whereas 42.8% of them exhibited HBV-DNA levels between 1500 and 40,000 copies/ml.

CONCLUSIONS

The overall prevalence of HBsAg is relatively low among women at reproductive age in Greece but is higher among specific ethnic populations (Asian, Albanian). The HBeAg(-)/antiHBe(+) serological status is a finding observed in the vast majority of HBsAg(+) women of our study population, and a significant percentage of them (approximately 44.5%) exhibit extremely low or even undetectable levels of viral replication at labor, suggesting possibly that only a proportion of HBsAg(+) women in Greece exhibit an extremely high risk of vertical transmission of the infection.