RESUMO
OBJECTIVE: To characterize breastfeeding behaviors and identify factors associated with breastfeeding initiation among people with hepatitis C virus (HCV) infection. METHODS: We conducted a secondary analysis of a multicenter observational cohort of pregnant people with singleton gestations and HCV seropositivity. This analysis includes individuals with data on breastfeeding initiation and excludes those with human immunodeficiency virus (HIV) co-infection. The primary outcome was self-reported initiation of breastfeeding or provision of expressed breast milk. Secondary outcomes included duration of breastfeeding. Demographic and obstetric characteristics were compared between those who initiated breastfeeding and those who did not to identify associated factors. Univariable and multivariable analyses were performed. RESULTS: Overall, 579 individuals (75.0% of participants in the parent study) were included. Of those, 362 (62.5%) initiated breastfeeding or provided breast milk to their infants, with a median duration of breastfeeding of 1.4 months (interquartile range 0.5-6.0). People with HCV viremia , defined as a detectable viral load at any point during pregnancy, were less likely to initiate breastfeeding than those who had an undetectable viral load (59.4 vs 71.9%, adjusted odds ratio [aOR] 0.61, 95% CI, 0.41-0.92). People with private insurance were more likely to initiate breastfeeding compared with those with public insurance or no insurance (80.0 vs 60.1%; aOR 2.43, 95% CI, 1.31-4.50). CONCLUSION: Although HCV seropositivity is not a contraindication to breastfeeding regardless of viral load, rates of breastfeeding initiation were lower among people with HCV viremia than among those with an undetectable viral load. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov , NCT01959321 .
Assuntos
Infecções por HIV , Hepatite C , Lactente , Gravidez , Feminino , Humanos , Aleitamento Materno , Hepacivirus , Viremia , Hepatite C/epidemiologia , Infecções por HIV/epidemiologiaRESUMO
OBJECTIVE: To estimate the rate of perinatal transmission of hepatitis C virus (HCV) infection, to identify risk factors for perinatal transmission of HCV infection, and to determine the viremic threshold for perinatal transmission. METHODS: This was a prospective, multicenter, observational study of pregnant individuals at less than 24 weeks of gestation screened for HCV infection from 2012 to 2018 in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Individuals found to be HCV antibody-positive were followed throughout pregnancy. Children were followed for evidence of perinatal transmission at 2-6 months (HCV RNA testing) and at 18-24 months (HCV RNA and antibody testing) of life. The primary outcome was perinatal transmission, defined as positive test results at either follow-up time point. RESULTS: A total of 109,379 individuals were screened for HCV infection. Of the 1,224 participants who screened positive, 772 (63.1%) enrolled and 432 of those 772 (56.0%) had data available to assess primary outcome. The overall rate of perinatal transmission was 6.0% (26/432, 95% CI 4.0-8.7%). All children with HCV infection were born to individuals with demonstrable viremia. In viremic participants (n=314), the perinatal transmission rate was 8.0% (95% CI 5.2-11.5%). Risk factors for perinatal transmission included HCV RNA greater than 106 international units/mL (adjusted odds ratio [aOR] 8.22, 95% CI 3.16-21.4) and vaginal bleeding reported at any time before delivery (aOR 3.26, 95% CI 1.32-8.03). A viremic threshold for perinatal transmission could not be established. CONCLUSION: Perinatal transmission of HCV infection was limited to viremic individuals. High viral loads and antepartum bleeding were associated with perinatal transmission.
Assuntos
Hepacivirus , Hepatite C , Criança , Feminino , Gravidez , Humanos , Hepacivirus/genética , Estudos Prospectivos , Hepatite C/epidemiologia , Fatores de Risco , RNA , Hemorragia UterinaRESUMO
BACKGROUND: Labor dystocia has been identified as a contributor to the rising cesarean delivery rate in the United States. Allowing more time for vaginal delivery, while being cognizant of maternal and neonatal outcomes, has been identified as a possible strategy to lower cesarean delivery rates. OBJECTIVE: This study aimed to characterize the relationship between the duration of active phase and second-stage labor and maternal and neonatal morbidity. STUDY DESIGN: We present a secondary analysis of the Consortium on Safe Labor project. From labors of 66,940 nonanomalous nulliparous term singleton vertex gestations, we excluded labors for which active phase (≥6 cm dilation) or second stage durations could not be calculated and from sites that did not report determinants of morbidity. For each duration of active phase or second stage labor (grouped in 1-hour increments), the adjusted maternal and neonatal composite morbidity was estimated by and compared with the morbidity associated with a duration <1 hour total and a duration of 1 hour shorter. RESULTS: After exclusions, 48,144 deliveries remained. In adjusted models, compared with labor durations <1 hour total, maternal composite morbidity was significantly higher across active phase and second stage durations (both P<.001); neonatal composite morbidity was higher across the second stage (P<.001), but not active phase (P=.07) duration. These relationships appear linear with no apparent inflection point, and morbidity increases more rapidly. When compared with labor durations 1 hour shorter, significant differences persisted in maternal and neonatal composite morbidity in second stage labor only through 4 and 3 hours, respectively. CONCLUSION: Maternal and neonatal composite morbidity is greater with longer durations of active and second stage labor; however, no clear cutoff point was determined to suggest truncation of either stage of labor for reasons of morbidity. In addition, incrementally higher morbidities that were noted vs duration <1 hour total were obscured when comparison was made with labors 1 hour shorter, which suggests that focusing on short differences in duration of labor may mask important underlying trends.
Assuntos
Distocia , Segunda Fase do Trabalho de Parto , Cesárea , Parto Obstétrico , Distocia/epidemiologia , Feminino , Humanos , Morbidade , Gravidez , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Current US Preventive Services Task Force and other guidelines recommend low-dose aspirin for all pregnant women with pregestational diabetes mellitus to prevent preeclampsia and small-for-gestational-age birth. The Maternal-Fetal Medicine Units High-Risk Aspirin trial did not show a reduction in either preeclampsia or small-for-gestational-age birth in diabetic women. OBJECTIVE: Our objective was to reassess the impact of aspirin on fetal growth in diabetic pregnancies overall and according to White classification. We hypothesized that aspirin improves fetal growth in pregnancies with vascular complications of diabetes at highest risk for poor fetal growth. STUDY DESIGN: We conducted secondary analysis of the cohort of diabetic women enrolled in the Maternal-Fetal Medicine Units High-Risk Aspirin trial. The impact of aspirin prophylaxis on birthweight was assessed in the overall cohort and in 2 groups categorized according to White classification as nonvascular (White class B, C, D) or vascular (White class R, F, RF). Birthweight was converted to Z-score normalized for gestational age at delivery and neonatal sex. Difference in birthweight Z-score between aspirin and placebo was tested with a 2-sample t test. The effect of vascular group, aspirin vs placebo randomization, and the interaction of the 2 on normalized birthweight percentile was estimated with linear regression with a multivariable model including covariates body mass index, tobacco use, race, and parity. The percentage of small and large-for-gestational-age newborns born to aspirin- vs placebo-treated women was compared between groups using Pearson exact χ2 analysis, and an adjusted model was estimated by logistic regression. RESULTS: All 444 women with pregestational diabetes and complete outcome data were included (53 vascular, 391 nonvascular). Aspirin was significantly associated with a higher birthweight Z-score (0.283; 95% confidence interval, 0.023-0.544) in the overall cohort (P = .03). In the adjusted model, the association of aspirin with higher birthweight Z-score was confined to neonates of women with nonvascular diabetes (0.341; 95% confidence interval, 0.677-0.006; P = .044). An opposite but nonsignificant effect was observed among neonates from women with vascular diabetes (-0.416; 95% confidence interval, -1.335 to 0.503; P = .6). This difference in the relationship of aspirin and birthweight Z-score by vascular group was significant at P = .046. Aspirin-randomized women with nonvascular diabetes had more large-for-gestational-age births than those treated with placebo (40.2 vs 26.6%; P = .005). Small-for-gestational-age births occurred at the same frequency with aspirin vs placebo randomization in the overall cohort (8% in each group) and in each vascular group. CONCLUSION: Inconsistent with our hypothesis, aspirin did not reduce small-for-gestational-age births in the overall cohort or either group. The increased incidence of large-for-gestational-age infants in aspirin-treated diabetic gestations is of potential concern given the known increased maternal and neonatal morbidity associated with macrosomia.
Assuntos
Aspirina/administração & dosagem , Peso ao Nascer , Macrossomia Fetal/epidemiologia , Gravidez em Diabéticas , Adulto , Feminino , Desenvolvimento Fetal , Humanos , Recém-Nascido , Recém-Nascido Pequeno para a Idade Gestacional , Gravidez , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: To determine if early pregnancy serum biomarkers in high-risk women who develop preeclampsia vary according to risk factor. STUDY DESIGN: We performed a secondary analysis of the Maternal-Fetal Medicine Units Network randomized controlled trial of low-dose aspirin for the prevention of preeclampsia in high-risk women. Serum biomarker levels at enrollment (before initiation of aspirin or placebo) were compared between women who did and did not develop preeclampsia, both for the group as a whole and within each of 4 high-risk groups (insulin-dependent diabetes, hypertension, multiple gestation, and previous preeclampsia) using a regression model adjusting for gestational age at collection and prepregnancy body mass index. RESULTS: 1258 women were included (233 with insulin-dependent diabetes, 387 with chronic hypertension, 315 with a multiple gestation, 323 with previous preeclampsia). Multiple early pregnancy serum biomarkers differed between women who did and did not develop preeclampsia. Each high-risk group had a unique and largely nonoverlapping pattern of biomarker abnormality. Differences between those who did and did not develop preeclampsia were noted in vascular cell adhesion molecule in the diabetes group; human chorionic gonadotropin, soluble tumor necrosis factor receptor-2, tumor necrosis factor-alpha, selectin and angiogenin in the chronic hypertension group; interleukin-6, placental growth factor, soluble fms-like tyrosine kinase plus endoglin to placental growth factor ratio in the multiple gestation group; and angiogenin in the previous preeclampsia group. CONCLUSION: Patterns of serum biomarkers vary by high-risk group. These data support the hypothesis that multiple pathogenic pathways lead to the disease recognized clinically as preeclampsia.