BIRTH OUTCOMES, HIGH-RISK SEXUAL BEHAVIORS, AND CONTRACEPTION USE AMONG WOMEN
WITH PERINATAL AND BEHAVIORALLY-ACQUIRED HIV INFECTION
G.B. Lazenby MD MSCR1, B.M. Fisher MD PhD2, O. Mmeje MD MPH3, A. Weinberg MD2, E. Aaron CRNP4,
A.E. Luque MD5, D. Willers MD6, D. Cohan MD MPH2,and D. Money MD7
Medical University of South Carolina, Charleston, SC,1 University of Colorado Anschutz Medical Campus,
Aurora, CO,2 University of California, San Francisco, San Francisco, CA,3 Drexel University, Philadelphia,
PA,4 University of Rochester, Rochester, NY,5 Washington University, St Louis, MO,6 and University of
British Columbia, Vancouver, BC7
Objectives: (1) To identify differences in birth outcomes and (2) to examine patterns of high-risk sexual
behaviors among women with perinatal HIV infection (PHIV) compared to similarly-aged women with
behaviorally-acquired HIV infection (BHIV)
Methods: We conducted a multi-site retrospective cohort study of PHIV and BHIV delivering from 20002012. PHIV women were matched 1:1 with BHIV infected women of the same age. Continuous variables
were compared using Student’s t-test and Wilcoxon rank sum tests. Categorical variables were
compared using chi-square and Fisher’s exact tests.
Results: 58 (29 PHIV, 29 BHIV) women were enrolled. At prenatal care initiation and delivery, CD4 cell
counts (509 vs 348, p=0.07) and HIV RNA viral loads were similar between groups (5890 vs 2591,
p=0.88). BHIV women tended to have higher preterm birth rates (41% vs 16%, p =0.07) and lower birth
weight neonates (2431gm vs 2931gm, p =0.03). In women with known HIV before pregnancy, those with
BHIV had higher rates of preterm birth (50% vs 24%, p=0.04) and low birth weights compared to PHIV
(2931 gm vs 2316 gm, p=0.03). Perinatal HIV transmission occurred in 2 pregnancies among BHIV
women and none in PHIV women. The majority of women were in HIV-serodiscordant relationships,
which was more common among PHIV vs BHIV (1/18 vs 5/14, p=0.06). Most women reported not using
contraception prior to conception. PHIV women reported condom use during pregnancy more
frequently than did BHIV (10/29 vs 2/29, p=0.02), however postpartum condom use was low in both
groups. Depo-medroxyprogesterone acetate was the most common postpartum contraception (PHIV
8/23 vs BHIV 6/26). During pregnancy, PHIV were diagnosed less frequently than BHIV with > 1 STI (2/28
vs 9/29, p=0.04), with Chlamydia acquisition being the most common.
Conclusions: Despite life-long HIV infection among PHIV women, adverse birth outcomes, including
perinatal HIV transmission, were more common in BHIV women. During pregnancy, while the majority
of this cohort have HIV-uninfected partners, inconsistent condom use is common before, during, and
after pregnancy.
Learning Objective: Learners will be able (1) to identify differences in birth outcomes between women
with PHIV vs BHIV. Women with BHIV are at increased risk for adverse pregnancy outcomes and
perinatal HIV transmission compared to women with PHIV and (2) to identify that pregnant women with
HIV demonstrate high-risk sexual behavior and low rates of condom and hormonal contraception use.
These findings may encourage learners to increase antenatal surveillance in women with BHIV, and
create strategies to reduce HIV and other STI transmission to partners as well as prevent future
unplanned pregnancy.
ACCEPTABILITY OF A GROUP B STREPTOCOCCAL VACCINE AMONG OBSTETRICS PATIENTS
Meghan Donnelly, MD (1), Sean O'leary, MD, MPH (2,3), Jennifer Pyrzanowski, MSPH (3), Sarah
Mccauley, MPA (3), Brenda Beaty, MSPH (4), Juliana Barnard, MA (3), Sara Mazzoni, MD (5) and Amanda
Dempsey, MD, PhD, MPH (2,3)
(1)Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora,
CO, (2)Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, (3)The
Children's Outcomes Research Program, Children's Hospital Colorado, Aurora, CO, (4)Colorado Health
Outcomes Research, University of Colorado Anschutz Medical Campus, Aurora, CO, (5)Department of
Obstetrics and Gynecology, Denver Health and Hospital Authority, Denver, CO
Objectives: Group B Streptococcus (GBS) is a significant cause of infant morbidity and mortality. A
promising GBS vaccine is currently in clinical trials. Because this vaccine would be the first to specifically
target pregnant women, we sought to assess womens' attitudes regarding the acceptability of a
hypothetical GBS vaccine.
Methods: In 2013 we performed an Internet survey among women who had received prenatal care at
one of 9 private obstetrics/gynecology (OB/GYN) practices in Colorado who were currently pregnant or
recently had given birth. Respondents read a brief introduction about GBS disease and vaccines,
followed by a series of questions based on constructs drawn from validated models of health behavior
[perceived benefits, barriers, susceptibility, and severity; self-efficacy; and norms (friends, family, and
provider)]. A multivariable model assessed characteristics associated with GBS vaccine acceptability
during the current/recent pregnancy.
Results: The response rate was 52% (239/461). While 78% agreed that a GBS vaccine would be a good
way to protect newborns, 89% and 83% agreed that they worried generally about the safety and
effectiveness, respectively, of new vaccines. Moreover, 39% believed it is generally dangerous for
pregnant women to get vaccines. Despite this, 23% definitely and 57% probably would have gotten a
GBS vaccine if available in their most recent pregnancy, and nearly all reported they would do what their
OB/GYN provider recommends and that an OB/GYN office would be the best place to receive a GBS
vaccine. Factors associated with reporting ‘definitely would have gotten a GBS vaccine’ during the
current/recent pregnancy included being influenced by social norms (Adjusted Odds Ratio [AOR] 8.83,
95% Confidence Interval [CI] 3.30-23.62), perceived susceptibility to GBS (AOR 2.67, 95% CI 1.25-5.68),
and perceived barriers to vaccination (AOR 0.20, 95% CI 0.08-0.46); preliminary analyses suggest race
may also be important (AOR, non White/non Hispanic 5.60, 95% CI 1.46-21.44, referent to White).
Conclusions: A GBS vaccine may be acceptable to pregnant women but would benefit from strong
obstetrician support and education about vaccine safety and effectiveness and the risks and
consequences of GBS infection.
Learning Objective: Learners will be able to identify womens' attitudes and perceived barriers towards a
novel vaccine strategy aimed at pregnancy to prevent adverse neonatal outcomes.
RANDOMIZED CONTROLLED TRIAL OF “MEFIRST,” A TAILORED, ONLINE EDUCATIONAL INTERVENTION
TO PROMOTE HPV VACCINATION AMONG FEMALE UNIVERSITY STUDENTS
AT Bennett, DA Patel, RC Carlos, MK Zochowski, SM Pennewell, AM Chi, VK Dalton
University of Michigan Medical School, Ann Arbor, MI.
Objectives: To examine the effect of MeFirst, a tailored, online educational intervention, on human
papillomavirus (HPV) vaccine-related knowledge, vaccination intention and uptake among previously
unvaccinated female university students.
Methods: Female university students aged 18-26 who were previously unvaccinated against HPV were
invited via email to enroll. Participants completed an online survey at baseline that assessed their HPV
vaccine-related knowledge, beliefs, attitudes and vaccination intention. Participants were then
randomized to either a MeFirst educational website tailored to their survey responses, or to a CDC
information sheet on HPV vaccine (control). Immediately afterwards, subjects completed a post-test
survey. At 3 and 12 months following the intervention, HPV vaccine uptake among participants will be
assessed via additional online surveys.
Results: Of 1004 eligible females, 661 (65.8%) completed the baseline survey and were randomized to
MeFirst or control. The mean age of randomized participants was 21.3 years and the majority (70.1%)
had been sexually active. No significant differences in demographic characteristics, sexual history, or
medical history were found between study arms. At baseline, 32.7% of participants agreed or strongly
agreed that they intended to undergo HPV vaccination. Of the 661 randomized participants, 113 (17.1%)
completed the post-test survey. Immediately after the intervention, intention to undergo HPV
vaccination increased for 23.2% of participants (p<0.0001). A greater proportion of participants in the
MeFirst group reported an increase in intention compared to controls, but the difference between
groups was not statistically significant (OR = 1.46; 95% CI = 0.60, 3.52). Overall, participants correctly
answered 1.7 more post-intervention knowledge questions, out of 10, than they did at baseline
(p<0.0001). This increase was similar between study groups, except that significantly more participants
in the MeFirst group learned that HPV could be spread by contact other than sexual intercourse
(p<0.0001).
Conclusions: Both MeFirst and control interventions improved participant HPV vaccine-related
knowledge and vaccination intention. Immediately post-test, there is no evidence that MeFirst increases
intention more than control. Additional analyses of HPV vaccine uptake at 3 and 12 months following
the intervention will further examine the impact of this tailored, online educational intervention on HPV
vaccination in female university students.
Learning Objective: Learners will compare MeFirst and control intervention impacts on HPV vaccination
intentions and knowledge among female university students.
THE SEPSIS IN OBSTETRICS SCORE (SOS): A MODEL FOR PREDICTING MORBIDITY FROM SEPSIS IN
PREGNANCY
C. Albright, T. Ali, V. Lopes, D. Rouse, B. Anderson
Objectives: To design a scoring system for use in emergency departments (ED) to predict clinical
deterioration in pregnant and postpartum women with signs of sepsis.
Methods: The Sepsis in Obstetrics Score (S.O.S.) was created by modifying validated scoring systems
based on easily obtained paramaters (temperature, heart rate, blood pressure, respiratory rate, oxygen
saturation, white blood cell count, percentage of immature neutraphils, and lactic acid concentration).
Possible scores ranged from 0 to 28. The modifications were specific to the metabolic and physiologic
changes of pregnancy. The S.O.S was applied to a retrospective cohort of pregnant and postpartum
patients between February 2009 and May 2011 with clinical suspicion of sepsis, as defined by collection
of blood cultures or influenza swabs in the ED. The primary outcome was intensive care unit (ICU)
admission within 48 hours of arrival to the ED. Secondary outcomes were telemetry unit admission,
length of stay, positive blood cultures, positive flu swabs, perinatal outcome, and maternal mortality.
Receiver operating characteristic (ROC) curves were constructed to estimate the optimal value for
prediction of ICU admission. Assuming a 2% ICU admission rate, in order to detect an area under the
curve (AUC) of ≥ 0.7 with a power of 80%, 850 total patients were needed.
Results: Between February 2009 and May 2011, the medical records of 850 eligible women were handabstracted. There were 9 ICU (1.1%) and 32 telemetry (3.8%) admissions, and no maternal deaths. The
S.O.S. had an AUC of 0.97 for ICU admission. An SOS ≥ 6 had an AUC of 0.92 with a sensitivity of 88.9%, a
specificity of 95.2%, a positive predictive value of 16.7%, and a negative predictive value of 99.9% for
ICU admission, with an adjusted odds ratio of 109 (95% confidence interval: 18 – 661). Of those patients
with an SOS of ≥ 6, the most common diagnoses at presentation were pyelonephritis (25%), influenzalike illness (ILI) (25%), and endometritis (10.4%). In contrast, those with an SOS of < 6 most commonly
presented with ILI (62.6%) and non-respiratory viral syndrome (11.4%). An SOS ≥ 6 was independently
associated with increased ICU or telemetry unit admission, positive blood cultures, and fetal
tachycardia.
Conclusions: A sepsis scoring system designed specifically for an obstetric population can reliably
identify patients at high risk for transfer to the ICU within 48 hours of presentation. Prospective
validation of the S.O.S. is warranted.
Learning Objective: To identify and use appropriate criteria with which to triage pregnant women
presenting with signs of sepsis.
GEOGRAPHICAL TRENDS AND OUTCOMES OF RESPIRATORY ILLNESSES IN PREGNANCY
E. Patel, C. Grotegut, P. Heine, G. Swamy
Duke University Medical Center, Durham, NC
Objectives: Respiratory illness in pregnancy is associated with maternal morbidity and mortality. 5% of
all H1N1-related deaths were pregnant women, who comprise only 1% of the population. Little is known
about the geographical influence and outcomes of pregnant women hospitalized for respiratory illness.
We evaluated maternal-fetal outcomes associated with respiratory illness and the impact of urban
versus rural residence.
Methods: Using discharge data from The Nationwide Inpatient Sample for 2008-2010, 12,628,747
delivery discharges were identified. Delivery hospitalizations complicated by respiratory illnesses
(pneumonia, influenza, cystic fibrosis and asthma) were identified using ICD-9 codes. Logistic regression
was used to compute odds ratios (OR) and 95% confidence intervals (CI) for demographic data, comorbid illnesses, acute medical and pregnancy complications as well as geographic location for pregnant
women hospitalized with and without respiratory illness.
Results: 3.5 per 1,000 delivery hospitalizations were due to respiratory illness. Pregnant women
admitted with respiratory illness at delivery were more likely to have underlying cardiac disease (OR 4.7,
95% CI 4.4-5.0, p<0.0001], diabetes (OR 2.0, CI 2.0-2.0, p<0.0001), autoimmune disorders (OR 2.9, CI 2.62.9, p<0.0001), and use tobacco (OR 2.7, CI 2.7-2.7, p<0.0001). Controlling for underlying risk factors,
age, income, and insurance, pregnant women admitted for respiratory illness were more likely to die
(OR 6.1, CI 5.2-7.1, p<0.0001), have a thrombotic event (OR 3.8, CI 3.4-4.2, p<0.0001), have acute renal
failure (OR 2.6, CI 2.4-2.8, p<0.0001), or have preterm labor (OR 1.3, CI 1.3-1.3, p<0.0001). Among
women hospitalized with respiratory illness, those who resided in rural areas were more likely than their
urban counterparts to suffer mortality (OR 1.6, CI 1.1-2.3, p 0.006).
Conclusions: Even after controlling for demographic factors and comorbid illness, pregnant women
hospitalized for respiratory illness at delivery have higher rates of morbidity and mortality as compared
to pregnant women admitted without respiratory illnesses. Pregnant women living in rural areas are at
particular risk for mortality associated with respiratory illness. This study demonstrates the need for
heightened awareness and care of pregnant women with respiratory illness. Immunization against
influenza, pertussis and pneumococcal disease and improved asthma care are potential ways to reduce
the morbidity and mortality associated with maternal respiratory illness.
Learning Objective: Learners will be able to identify women at increased risk of respiratory illness in
pregnancy and which of those women are at highest risk of significant morbidity and mortality.
CHORIOAMNIONITIS AND TOLL-LIKE RECEPTOR 4 EXPRESSION IN FETAL MEMBRANES
J. Thompson (1), B. Antczak (1), L. Feng (1), C. Grotegut (1), P. Seed (2), A. Murtha (1)
Duke University Medical Center, Department of Obstetrics and Gynecology, Durham, NC (1) Duke
University Medical Center, Department of Pediatrics, Durham, NC (2)
Objectives: Toll-like receptors (TLR) are a transmembrane family of pattern recognition receptors which
are present in fetal membranes and whose activation through the NFκB pathway results in the
production of an inflammatory response. This inflammatory response plays a critical role in the
pathogenesis of preterm birth and preterm premature rupture of membranes. Cell response to gram
negative bacteria is mediated through TLR4. The objective of this investigation was to determine if TLR4
expression in fetal membranes varied by infection status, histological layer, proximity to rupture site and
clinical phenotype.
Methods: Fetal membrane samples were prospectively collected from the rupture site and a site distant
from rupture in subjects with preterm premature rupture of membranes (PPROM; n=10), preterm labor
(PTL; n=10), preterm-no labor (PTNL; n=10), term labor (TL; n=10) and term no labor (TNL; n=9).
Samples were formalin fixed, paraffin embedded, and probed for TLR4 using primary antibody to TLR4
(Abcam). Slides were imaged and scored on a 4 point scale for degree of intracellular staining. Ten
images were obtained per slide and scored by three independent blinded raters. Median values were
obtained for each scorer for each slide. Student’s t-test and Kruskal-Wallis tests were used for analysis.
Results: At the rupture site, subjects with chorioamnionitis had significantly lower TLR4 expression than
subjects without chorioamnionitis in the amnion (1.0 v. 1.4, p=0.03) and chorion (1.3 v. 1.8, p=0.02) but
not decidua (1.1 v. 1.5, p=0.08). No significant differences were found in TLR4 expression at sites distant
from rupture in all histologic layers. There were no significant differences in TLR4 expression based on
clinical phenotype in all histologic cell layers.
Conclusions: TLR4 expression is reduced in subjects with chorioamnionitis especially at the rupture site
in all histologic layers suggesting that infection leads to increased activation of receptors and therefore
increased consumption. Additional work is required to better understand the relationship of specific
TLR signaling, bacterial invasion and histologic chorioamnionitis.
Learning Objective: Learners will be able to identify differences of TLR4 expression in fetal membranes
based on infection status.
MEDICAL AND INFECTIOUS COMPLICATIONS ASSOCIATED WITH PYELONEPHRITIS AMONG PREGNANT
WOMEN AT DELIVERY
Sarah K Dotters-Katz MD, R Phillips Heine MD, Chad A Grotegut MD MHS
Duke University Medical Center, Durham North Carolina
Objectives: Pyelonephritis is a common cause of obstetric antepartum admission and source of maternal
morbidity. Medical complications associated with pyelonephritis at the time delivery are not well
described, thus the objective of this study was to estimate medical, infectious, and obstetric complications
associated with pyelonephritis at delivery.
Methods: The Nationwide Inpatient Sample (NIS) for the years 2008-2010 was queried for all deliveryrelated discharges. During an admission for delivery, the International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM) codes for pyelonephritis were used to identify cases and were
compared to women without pyelonephritis. A multivariable logistic regression model was constructed for
various medical, infectious, and obstetric complications among women with pyelonephritis compared to
women without, while controlling for pre-existing medical conditions.
Results: During the years 2008-2010, there were 26,397 records with a diagnosis of pyelonephritis at
delivery for a rate of 2.09 per 1000 deliveries. At an admission for delivery, multivariable logistic regression
demonstrated women with pyelonephritis had increased risk for acute heart failure, pneumonia,
pulmonary edema, acute respiratory distress syndrome, sepsis, acute renal failure, multiple gestation,
preterm labor, and chorioamnionitis while controlling for pre-exisiting medical conditions compared to
women without pyelonephritis at delivery. The prevalence of pyelonephritis at delivery has increased
significantly over the years 2000 – 2010 from a rate of 1.51 to 2.21 per 1000 deliveries in 2000 and 2010,
respectively.
Conclusions: Pyelonephritis at delivery has increased over the years 2000 to 2010 and is associated with
significant medical and infectious morbidity.
Learning Objective: Demonstrate that pyelonephritis in pregnancy has increased over the last decade and
is associated with significant maternal morbidity.
FACTORS ASSOCIATED WITH “COCOONING” NEWBORN INFANTS TO PREVENT INFLUENZA AND PERTUSSIS
Meghan Donnelly, MD (1), Sean O'leary, MD, MPH (2,3), Jennifer Pyrzanowski, MSPH (3), Sarah Mccauley,
MPA (3), Brenda Beaty, MSPH (4), Juliana Barnard, MA (3), Sara Mazzoni, MD (5) And Amanda Dempsey,
MD, PhD, MPH (2,3),
(1)Department Of Obstetrics And Gynecology, University Of Colorado Anschutz Medical Campus, Aurora,
CO, (2)Department Of Pediatrics, University Of Colorado Anschutz Medical Campus, Aurora, CO, (3)The
Children's Outcomes Research Program, Children's Hospital Colorado, Aurora, CO, (4)Colorado Health
Outcomes Research, University Of Colorado Anschutz Medical Campus, Aurora, CO, (5)Department Of
Obstetrics And Gynecology, Denver Health And Hospital Authority, Denver, CO
Objectives: Tetanus-diphtheria-acellular pertussis (Tdap) and influenza vaccines are recommended for
pregnant women and all close contacts of newborn infants (“cocooning”), yet studies show that this
happens infrequently. Our objective was to describe factors associated with Tdap and influenza vaccine
cocooning among mothers and close contacts of their newborns.
Methods: From February to March 2013 we performed a survey of 613 women who had received prenatal
care at one of 9 private obstetrics practices in Colorado and recently given birth. The survey assessed
vaccine recommendations during pregnancy, demographics, and 6 constructs drawn from validated models
of health behavior [perceived benefits, barriers, susceptibility, and severity; self-efficacy; and norms].
Multivariable models assessed the association of these factors with Tdap or Flu vaccine cocooning, defined
as both the mother and at least one close contact of her newborn infant receiving the vaccine.
Results: The response rate was 47%. Sixty-seven percent and 61% reported cocooning for Tdap or Flu
vaccines, respectively. Significant factors associated with Tdap cocooning included obstetrician
recommendation (Adjusted Odds Ratio (AOR) 3.67, 95% Confidence Interval (CI) 2.00-6.74), perceived
barriers to vaccination (AOR 0.45, 95% CI 0.27-0.76), perceived susceptibility to pertussis (AOR 1.98, 95% CI
1.19-3.29), and race/ethnicity (Hispanic/Latino, AOR 0.26, 95% CI 0.10-0.64 referent to White). Factors
significantly associated with influenza cocooning included obstetrician recommendation (AOR 1.89, CI 1.013.52), perceived benefits of immunization (AOR 2.36, 95% CI 1.38-4.04), perceived barriers to vaccination
(AOR 0.44, 95% CI 0.26-0.73), and perceived susceptibility to influenza (AOR 1.84, 95% CI 1.08-3.16).
Conclusions: Obstetrician recommendation is strongly associated with infant cocooning. Interventions to
increase cocooning of infants should focus on encouraging strong provider recommendations, increasing
maternal knowledge of influenza and pertussis infection risk, and addressing identified barriers. Reasons
for possible racial/ethnic differences should be further explored.
Learning Objective: to educate prenatal care providers on the importance of educating patients about
cocooning and recommending appropriate influenza and Tdap vaccination.
ARE INFECTIOUS COMPLICATIONS INCREASED IN WOMEN WHO ARE STREPTOCOCCUS
AGALACTIAE COLONIZED AND RECEIVE THE INTRA-CERVICAL FOLEY CATHETER FOR PREINDUCTION CERVICAL RIPENING?
S. MCCARTY-SINGLETON, A. SCISIONE
Christiana Health System, Obstetrics and Gynecology, Newark, DE
Objectives: We sought to determine whether the use of the Foley catheter for pre-induction
cervical ripening in women colonized with GBS increases the risk of chorioamnionitis or
postpartum endomyometritis.
Methods: Women who presented to our tertiary care center for pre-induction cervical ripening using
the intra-cervical Foley catheter with a viable, non-anomalous fetus between 28 0/7-42 0/7 weeks
gestational age were identified from our validated, obstetrical database from 2006 to 2012. Women
were categorized as being GBS colonized (a positive cervical culture at their 36 week prenatal visit)
and those that were negative for colonization. Patient demographic information, prenatal
complications, reason for induction of labor, mode of delivery and obstetrical outcomes were
collected. Our primary outcome was clinical chorioamnionitis and endomyometritis, of which the
diagnoses were made by the attending physician’s discharge diagnoses and ICD-9 codes. Women
were excluded with rupture of membranes, unknown GBS status or a contraindication for vaginal
delivery.
Results: 1,529 women were included in the analysis of which 1094 (71.6%) were GBS negative. Of the
GBS negative patients 713 delivered vaginally and 381 delivered by cesarean. Of the GBS positive
patients, 258 delivered vaginally and 177 delivered by cesarean. There were no cases of
chorioamnionitis or endomyometritis in the GBS positive group, and one case of endomyometritis and
no cases of chorioamnionitis in the GBS negative group.
Conclusions: There does not appear to be an increased risk for chorioamnionitis or
endomyometritis in women who are GBS positive and receive the intracervical Foley catheter for
pre-induction cervical ripening.
Learning Objective: The learner should be able to identify the potential infectious, or lack of infectious
complications to using the intracervical Foley catheter for pre-induction cervical ripening. The learner
should also be able to demonstrate the potential advantages of using the Foley catheter in women
who are GBS positive.