OBJECTIVE: To compare the incidence of hypertensive disorders of pregnancy among women living with human immunodeficiency virus (HIV) on combination antiretroviral therapy (ART) to women without HIV, and to evaluate the association of hypertensive disorders of pregnancy with ART regimens or timing of ART initiation. METHODS: We conducted a retrospective cohort study among two overlapping pregnancy cohorts using preexisting databases at a single tertiary care hospital: all pregnant women who delivered during years 2016–2018 (cohort 1) and all women living with HIV who delivered during years 2011–2018 (cohort 2). The primary outcome for both cohorts was any hypertensive disorder of pregnancy; gestational hypertension and preeclampsia were also examined separately. The primary exposure variables were HIV status for cohort 1 and ART regimen (integrase strand transfer inhibitor–containing, protease inhibitor–containing, or non-nucleoside reverse transcriptase inhibitor–containing) for cohort 2. For estimation of risk ratios (RRs), we used a modified Poisson regression with robust error variances. Multivariate models among the women living with HIV in cohort 2 were tested for a statistical interaction between ART regimen and timing of initiation. RESULTS: In cohort 1, among 80 women living with HIV compared with 3,464 women without HIV, there was no difference in the risk of hypertensive disorders of pregnancy (29% in women living with HIV vs 30% in women without HIV, adjusted RR 0.9, 95% CI 0.6–1.3). In cohort 2, among 265 women living with HIV, integrase strand transfer inhibitor–containing regimens were associated with an increased risk for any hypertensive disorder of pregnancy (25% among integrase strand transfer inhibitor vs 10% among protease inhibitor, adjusted RR 2.8, 95% CI 1.5–5.1) and gestational hypertension (20% among integrase strand transfer inhibitor vs 8% among protease inhibitor, adjusted RR 2.8, 95% CI 1.3–5.9) compared with protease inhibitor–containing regimens. Timing of ART initiation was not associated with hypertensive disorders of pregnancy, nor did it significantly alter the associations between ART regimen and hypertensive disorders of pregnancy outcomes. CONCLUSION: Overall the risk of hypertensive disorders of pregnancy was similar among women living with HIV on ART and women without HIV. With greater integrase strand transfer inhibitor use, the greater frequency of hypertensive disorders of pregnancy with these regimens compared with protease inhibitor–containing regimens warrants future evaluation using cohorts with greater sample size.
Influenza infection in pregnant women is associated with increased risk of morbidity and mortality. Despite recommendations for all women to receive the seasonal influenza vaccine during pregnancy, vaccination rates among pregnant women in the U.S. have remained around 50%. The objective of this study was to evaluate clinical and demographic factors associated with antenatal influenza vaccination in a medically underserved population of women. We conducted a retrospective cohort study at Grady Memorial Hospital, a large safety-net hospital in Atlanta, Georgia, from July 1, 2016, to June 30, 2018. Demographic and clinical characteristics were abstracted from the electronic medical record. The Kotelchuck index was used to assess prenatal care adequacy. Relative risks and 95% confidence intervals for associations between receipt of influenza vaccine and prenatal care adequacy, demographic characteristics, and clinical characteristics were calculated using multivariable log-binominal models. Among 3723 pregnant women with deliveries, women were primarily non-Hispanic black (68.4%) and had Medicaid as their primary insurance type (87.9%). The overall vaccination rate was 49.8% (1853/3723). Inadequate prenatal care adequacy was associated with a lower antenatal influenza vaccination rate (43.5%), while intermediate and higher levels of prenatal care adequacy were associated with higher vaccination rates (66.9–68.3%). Hispanic ethnicity, non-Hispanic other race/ethnicity, interpreter use for a language other than Spanish, and preexisting diabetes mellitus were associated with higher vaccination coverage in multivariable analyses. Among medically underserved pregnant women, inadequate prenatal care utilization was associated with a lower rate of antenatal influenza vaccination. Socially disadvantaged women may face individual and structural barriers when accessing prenatal care, suggesting that evidenced-based, tailored approaches may be needed to improve prenatal care utilization and antenatal influenza vaccination rates.
What are the novel findings of this work?The majority of cases of prenatal urinary tract dilation (UTD) diagnosed in the second trimester did not persist in the third trimester and more than half of the cases of persistent UTD in the third trimester did not result in postnatal UTD. The majority of infants with postnatal UTD were managed expectantly, with only 2% requiring surgery within 6 months after birth. What are the clinical implications of this work?The current prenatal risk stratification system by UTD grade (A1 vs A2-3), based on the 2014 UTD consensus classification developed in the USA, can be used to predict postnatal UTD with fair accuracy. Further research is needed to determine whether the predictive performance of this system can be further improved by incorporating additional clinical and sonographic risk factors in order to further reduce the need for repeat third-trimester evaluation and postnatal follow-up.
Background: The prevalence of moderate or complex (moderate-complex) congenital heart defects (CHDs) among adults is increasing due to improved survival, but many patients experience lapses in specialty care or their CHDs are undocumented in the medical system. There is, to date, no efficient approach to identify this population. Objective: To develop and assess the performance of a risk score to identify adults aged 20-60 years with undocumented specific moderate-complex CHDs from electronic health records (EHR). Methods: We used a case-control study (596 adults with specific moderate-complex CHDs and 2384 controls). We extracted age, race/ethnicity, electrocardiogram (EKG), and blood tests from routine outpatient visits (1/ 2009 through 12/2012). We used multivariable logistic regression models and a split-sample (4: 1 ratio) approach to develop and internally validate the risk score, respectively. We generated receiver operating characteristic (ROC) c-statistics and Brier scores to assess the ability of models to predict the presence of specific moderate-complex CHDs. Results: Out of six models, the non-blood biomarker model that included age, sex, and EKG parameters offered a high ROC c-statistic of 0.96 [95% confidence interval: 0.95, 0.97] and low Brier score (0.05) relative to the other models. The adult moderate-complex congenital heart defect risk score demonstrated good accuracy with 96.4% sensitivity and 80.0% specificity at a threshold score of 10. Conclusions: A simple risk score based on age, sex, and EKG parameters offers early proof of concept and may help accurately identify adults with specific moderate-complex CHDs from routine EHR systems who may benefit from specialty care.
INTRODUCTION: Uptake of seasonal influenza vaccination among pregnant women remains low despite recommendations supporting routine vaccination in this population at high risk for severe morbidity. We evaluated predictors of antenatal influenza vaccination in an underserved patient population. METHODS: We conducted a retrospective cohort study of all women with deliveries to Emory healthcare providers at Grady Memorial Hospital, a large safety-net hospital, between July 1, 2016 and June 30, 2018. Demographic and clinical characteristics were abstracted from electronic medical records. The Kotelchuk Index was used to assess prenatal care adequacy. Adjusted relative risks (aRRs) and 95% confidence intervals (CIs) for associations between demographic and clinical characteristics and receipt of influenza vaccine were calculated using multivariable log-binomial models. IRB approval was obtained for this study. RESULTS: Among 3,727 women with deliveries, most were non-Hispanic black (68.60%) and had Medicaid as their primary insurer for delivery (87.93%). The overall vaccination rate was 49.80% (1,856/3,727). Characteristics significantly associated with influenza vaccination in multivariable models were Hispanic ethnicity (aRR 1.44, 95% CI 1.11-1.88), transferring care between institutions (aRR 0.34, 95% CI, 0.29-0.41), and inadequate prenatal care (aRR 0.70, 95% CI, 0.64-0.75). CONCLUSION: Women with inadequate or discontinuous prenatal care were less likely than women with adequate prenatal care to receive a seasonal influenza vaccine. Hispanic ethnicity was associated with increased rates of influenza vaccination, even after controlling for interpretive language services. These findings highlight the importance of continuous, regular prenatal care in recommending and offering antenatal vaccinations to pregnant patients while supporting possible cultural differences in vaccine acceptance.
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