Ms. Hester is Content Specialist with Contemporary OB/GYN and Contemporary Pediatrics.

Miranda Hester

	New data on persistence of Zika virus in some infected individuals has led The Centers for Disease Control and Prevention (CDC) to issue an update on testing of asymptomatic pregnant women. The 

 builds on interim guidance for health care providers that was published by CDC in July 2016.

	Emerging epidemiologic and laboratory data, said CDC, indicate that Zika virus IgM can persist beyond 12 weeks in a subset of infected people. As a result, IgM detection may not always indicate a recent infection. A Puerto Rican study of symptomatic patients with nucleic acid test (NAT)-confirmed Zika shows persistence of the virus IgM in 100% of participants at 8 to 15 days after symptom onset and in 87% at more than 60 days after symptom onset. Median time to first negative Zika virus IgM was 4 months (range 8-210 days) according to unpublished data from the ongoing study.

	CDC noted that while IgM persistence could affect test interpretation in all patients infected with Zika, it would have the greatest effect on clinical management of pregnant women with a history of living in or traveling to areas with Zika virus transmission before conception. Pregnant women who test positive for IgM antibody may have been infected with the virus and developed the response before conception.

	CDC’s recommendations for testing symptomatic pregnant women are unchanged. For asymptomatic pregnancy women who live in or frequently travel to areas with Zika virus transmission with CDC Zika Travel Notices, the agency recommends:

	·       Screening for risk of Zika exposure and symptoms, with prompt NAT testing if symptoms develop during pregnancy or a sexual partner tests positive for Zika;

	·       Consideration of NAT testing at least once per trimester, unless a previous test has been positive;

	·       Consideration of NAT testing of amniocentesis specimens if the test is performed for other reasons;

	·       Patient counseling each trimester on limitations of IgM and NAT testing; and

	·       Consideration of IgM testing to determine baseline Zika virus IgM levels as part of preconception counseling.

NEXT: Can corticosteroids be effective hours before delivery?

	Can corticosteroids be effective hours before delivery?

	Administering antenatal corticosteroids only hours prior to delivery may improve survival in very preterm infants, according to results of a Swedish study published in 

	Researchers used data from the Effective Perinatal Intensive Care in Europe study, which gathered information from 19 regions across 11 European countries from 2011 to 2013. The cohort included 4594 singleton infants with a gestational age range of 24 to 31 weeks. The infants did not have severe anomalies and were not otherwise exposed to multiple courses of antenatal corticosteroids. The authors studied 3 outcomes: severe neonatal brain injury, which was defined as an intraventricular hemorrhage grade 3 or greater or cystic periventricular leukomalacia; composite of mortality or severe neonatal morbidity, which was defined as an intraventricular hemorrhage grade of 3 or greater, cystic periventricular leukomalacia, surgical necrotizing enterocolitis, or stage 3 or greater retinopathy of prematurity; and in-hospital mortality.

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	Of the infants in the cohort, 2496 were boys. The average gestational age was 28.5 weeks and the average birth weight was 1213 g. Among the 662 infants unexposed to antenatal corticosteroids, the mortality rate was 20.6% (136 of 661). Administering antenatal corticosteroids was linked with a rapid and immediate decline in mortality, which plateaued with over 50% risk reduction where administration-to-birth interval was 18 to 36 hours. A similar pattern was seen for composite mortality or morbidity outcome. An administration-to-birth interval of more than 48 hours was linked with a significant reduction in the risk of severe neonatal brain injury. The risk reduction association was antenatal corticosteroids was transient and an administration-to-birth interval exceeding 1 week was associated with increasing mortality and risk of severe neonatal brain injury.

	Based on the assumption that a causal relationship existed between mortality and timing of antenatal corticosteroids, the researchers performed a simulation which demonstrated that administering the drugs 3 hours before delivery to infants who had no previous exposure was associated with an estimated decline in mortality of 26%. They concluded that, contrary to previous hypotheses, administration of antenatal corticosteroids in a few hours prior to delivery may prove effective for improving survival and decreasing neonatal morbidity in very preterm infants.

NEXT: Is hepatitis C on the rise in pregnant women?

	Is hepatitis C on the rise in pregnant women?

Centers for Disease Control and Prevention

, the rate of hepatitis C is on the rise in the United States among women giving birth.

	Investigators used US birth certificate data to examine trends and geographic differences in the rates of hepatitis C infection among women who gave birth between 2009 and 2014. They used Tennessee birth certificates to examine individual characteristics and outcomes linked with a hepatitis C infection and a multivariable model to calculated adjusted odds. The data were collected from the National Vital Statistics System and Tennessee Department of Health vital records.

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	During the study period, presence of a hepatitis C infection at time of delivery from states reporting such infections on birth certificates increased by 89%, from 1.8 to 3.4 per 1000 live births. The highest infection rate in 2014 was found in West Virginia, at 22.6 per 1000 live births, while Hawaii had the lowest rate at 0.7 per 1000 live births. In the adjusted analyses of Tennessee births, where the rate is 10.1 per 1000 live births, the odds of having a hepatitis C infection were roughly 3-fold higher among women who lived in rural counties than in those who lived in urban counties. In women who smoked cigarettes while pregnant, the odds of an infection were 4.5-fold higher, and among women who had a concurrent hepatitis B infection, the odds were 17-fold higher.

	The implications for public health practice from these data are that screening for hepatitis C in women who are of childbearing age and providing treatment may help reduce perinatal transmission of the disease. Monitoring infants who are exposed to hepatitis C also could aid in identifying these infections.

Articles

The latest on testing guidelines for Zika from the CDC. Plus: Are corticosteroids effective when administered only hours before delivery? Also, a look at the prevalence of hepatitis C among pregnancy women in the United States.

CDC issues advisory on Zika testing

	Postmenopausal women who use ospemifene, a selective estrogen receptor modulator, may experience an increase in vasomotor symptoms during their first 4 weeks on the drug, according to results of a pooled analysis of Phase II and Phase III randomized trials published in 

	The researchers compiled the incidence of vasomotor symptoms treatment-emergent adverse events (TEAEs) from 5 randomized, placebo-controlled clinical studies and baseline parameters associated with vasomotor symptom incidence. Data from a previously unpublished, 6-week placebo-controlled study evaluating ospemifene’s effects on the frequency and severity of vasomotor syndromes were used as well.

	An analysis of pooled vasomotor symptom TEAE data for 2166 women showed an 8.5% incidence of vasomotor symptoms for ospemifene and 3.2% for placebo (

 < 0.0001). The first 4 weeks of ospemifene treatment saw the highest frequency of vasomotor symptoms and the frequency decreased thereafter. An increased incidence of hot flashes was more likely in women who had taken hormone therapy within 6 months before study start (

 = 0.0234), had more vasomotor symptom days per month at baseline (

 = 0.0313), and took the study treatment for a longer period of time (

 = 0.0234), according to results of logistic regression analysis. In the unpublished study of 198 postmenopausal women who experienced moderate to severe vasomotor symptoms, ospemifene 60 mg/d did not worsen the severity and frequency of existing vasomotor symptoms.

	The researchers concluded that vasomotor symptom TEAEs were more frequent with ospemifene 60 mg/d than with placebo, especially in women who had previously used hormone therapy. The vasomotor symptoms lessened at 4 weeks and ospemifene did not worsen existing vasomotor symptoms in women who were experiencing moderate to severe hot flashes.

NEXT: Cerclage suture linked with preterm birth

Cerclage suture linked with preterm birth

	A study by British researchers suggests that cerclages done with braided sutures are more likely to end in preterm birth (PTB) or a nonviable pregnancy than are those done with monofilament sutures. The braided material, say the authors, appears to promote vaginal bacterial dysbiosis, which in turn results in local tissue inflammation and premature cervical remodeling.

, the findings are from a retrospective analysis and the researchers see an urgent need for clinical trials, powered for the outcomes of PTB, neonatal morbidity, and mortality, to assess the impact of cerclage suture material.

	The authors assessed birth outcomes in a cohort of 678 women who received cervical cerclages at five UK university hospitals over a 10-year period. Half of the procedures were done with braided suture material and half with monofilament suture. The women in whom the braided suture was used had higher rates of nonviable births (delivery <24 weeks or intrauterine death) compared to those in whom the monofilament suture was used (15% versus 5%; 

<0.0001). The braided suture also was associated with an increased rate of PTB at 24 to 37 weeks’ gestation: 28% versus 17% for monofilament; 

	Although a history of PTB contributed significantly to the nonviable births, the researchers said the braided suture was the “primary driver” of that observed outcome irrespective of potential confounders including maternal age, ethnicity, and parity. It was also the major variable influencing risk of PTB, independent of maternal age, ethnicity, parity, and history of previous PTB. Distribution of cervical length was similar between the braided and monofilament suture groups.

	The braided material, the authors found, caused a “marked shift toward dysbiosis” 4 weeks after cerclage and that change persisted until 16 weeks after the procedure. The material was also associated with an increasing proportion of women with reduced levels of 

 spp and increased diversity of anaerobic bacteria. In contrast, the women who had cerclages with monofilament suture maintained high levels of 

 spp, which remained stable. The researchers also noted that the braided material was associated with increased release of inflammatory cytokines-including interleukin (IL)-1β, IL-6, IL-8, and tumor necrosis factor-α-into cervicovaginal fluid.

	“We estimate that a global shift to monofilament suture use for cervical cerclage would prevent 170,000 PTBs [number needed to treat (NNT), 9.4; 95% confidence interval (CI), 5.9 to 22.6] and 172,000 fetal losses [NNT, 9.3; 95% CI, 6.6 t 16.0) per annum worldwide,” said the authors. 

NEXT: How delaying pregnancy can decrease risk of microcephaly from Zika virus

	How delaying pregnancy can decrease risk of microcephaly from Zika virus

	Strategic delays when planning pregnancy may help mitigate birth defects caused by the Zika virus, according to results of an epidemiologic study published in 

	Researchers used a vector-borne Zika virus transmission model fitted to the epidemiologic data derived from 2015 to 2016 in Colombia. The intervention was recommendations to delay pregnancy by 3, 6, 9, 12, or 24 months, at different levels of adherence. Weekly and cumulative incidence of prenatal infections and microcephaly cases were measured.

	The authors found that with 50% adherence to the recommendations to delay pregnancy by 9 to 24 months, the cumulative incidence of prenatal Zika virus infection was likely to decrease by 17% to 44%, whereas recommendations to delay pregnancy by 6 months or less were likely to increase prenatal infections by 2% to 7%. Researchers noted that delaying pregnancy could lead to women becoming pregnant during the peak of a Zika virus outbreak.

	It was noted that sexual transmission of Zika virus was not explicitly accounted for in the model due to limited data, but it would be implicit in the overall transmission rate.

	The investigators concluded that delaying pregnancy can have a substantial effect on reducing cases of microencephaly but it can exacerbate Zika outbreaks if the duration of the delay is insufficient. Several factors need to be carefully considered when promoting strategic delays, including the timing of initiation of the intervention, duration of the delay, and population adherence. “In the absence of a vaccine or therapeutic drugs for Zika virus infection,” the authors said, “a combination of mass and individual pregnancy-delay strategies with effective vector-control measures is needed to curtail the spread and burden of the ongoing outbreak in the Americas.”

A study examines if ospemifene is linked to increased hot flashes. Plus: Do certain cerclage sutures increase the risk of preterm birth? Also, do pregnancy delays actually decrease the risk of microcephaly as a result of congenital Zika infection?

Does ospemifene increase vasomotor symptoms?

	Women who undergo an ovary-sparing hysterectomy may be at a greater risk of early onset of menopause, according to a secondary analysis from the Prospective Research on Ovarian Function study

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, the findings are based on a comparison of baseline antimullerian hormone levels and absolute change and percentage change in levels of the hormone from baseline to 1 year follow-up in premenopausal women who underwent ovary-sparing hysterectomy for benign indications versus a cohort of similar age but with intact reproductive organs.  Overall, the women who underwent hysterectomy but retained their ovaries entered menopause 1.9 years earlier than the reference cohort. Baseline median antimullerian hormone levels were similar in the referent group (n = 172) and the hysterectomy group (n = 148).

	A year later, the hysterectomized women had a much greater median percentage decrease (-40.7% compared with -20.9%; 

<.001). A higher proportion of this group also had undetectable antimullerian hormone (12.8% compared with 4.7%; P=.02), and their antimullerian hormone levels averaged 0.77 that in the reference cohort (

=.001). The differences were attenuated among white women, but were still significant among black women. Comparisons between women with a low ovarian reserve at baseline and women with a high ovarian reserve at baseline showed similar findings.

	The researchers concluded that while women who underwent ovary-sparing hysterectomy had similar levels of antimullerian hormone levels at baseline, they experienced a greater percentage decrease in those levels after 1 year than the reference cohort. That suggests, the authors said, that hysterectomy may lead to ovarian damage that is unrelated to a woman’s baseline ovarian reserve.

NEXT: Betamethasone and respiratory compliations in preemies

Betamethasone and respiratory complications in preemies

	Babies born at in the late preterm period whose mothers received betamethasone may have less respiratory complications, according to results of a recent multicenter study. The findings, by investigators from the Eunice Kenney Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network, were published in 

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	For the multicenter trial, women with a singleton pregnancy at 34 weeks 0 days to 36 weeks 5 days’ gestation who were at high risk of delivery before 36 weeks 0 day were randomized to two injections of betamethasone or matching placebo 24 hours apart. The investigators assessed neonatal composite of treatment in the first 72 hours (use of continuous positive airway pressure or high-flow nasal cannula for at least 2 hours, supplemental oxygen with a fraction of inspired oxygen of at least 0.30 for ≥4 hours, extracorporeal membrane oxygenation or mechanical ventilation) or stillbirth or neonatal death within 72 hours after delivery.

	A total of 2827 infants were born to the women who participated in the study. Of the 1427 infants whose mothers received betamethasone, 165 (11.6%) experienced respiratory complications versus 202 (14.4%) of the 1400 infants whose mothers received placebo (relative risk in the betamethasone group 0.80; 95% confidence interval [CI], 0.66 to 0.97, 

=0.02). In the betamethasone group, severe respiratory complications, transient tachypnea of the newborn, surfactant use, and bronchopulmonary dysplasia also were significantly less frequent.

	Incidence of chorioamnionitis and neonatal sepsis did not differ between the groups. Neonatal hypoglycemia was more common in the betamethasone group than in the placebo group (24.0% vs. 15.0%; relative risk, 1.60; 95% CI, 1.37 to 1.87; 

NEXT: Preterm birth and the vaginal microbiome

	In women with a short cervix, the vaginal microbiome may influence risk of preterm birth. That was the conclusion drawn by researchers based on results of a cohort study, which were presented at the Society for Reproductive Investigation 63

 Annual Scientific Meeting in Montreal, Canada.

	The data are from 131 women, 59 of whom were in their first pregnancy following cervical conization and 72 of whom who were pregnant and had a history of previous preterm birth. Investigators from Imperial College, London, compared the vaginal microbiome and cervical length and volume in the two groups to determine whether the composition of their vaginal microbiomes was associated with the likelihood of delivering preterm.

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	Follow up on all of the women was at 22 and 28 weeks’ gestation, with high vaginal swabs and measurement of transvaginal cervical length and volume. Of the women studied, 23% went on to deliver preterm (<37 weeks’ gestation). Compared with the women whose pregnancies went to full term, their vaginal microbiomes at 12 weeks were dominated by 

<0.05), equating to 67% sensitivity and 75% specificity for preterm birth. 

 dominance at the same time point was strongly associated with term delivery (95%, 51/56; 

	Rates of preterm birth were lower in the women with a history of conization than in those with a prior preterm birth (10% vs 33%, 

<0.01) and they had persistently shorter cervical length and volume throughout their pregnancies (

<0.05). Those findings were associated with more abundant 

<0.001) at 16 weeks’ gestation. Results were similar through pregnancy until 28 weeks’ gestation.

	The data, the authors said, suggest that a vaginal microbiome dominated by 

 may be protective against PTB in high-risk pregnancy while prevalence of 

 may be risk factors. That may account for the lower PTB rates in pregnancy post-conization despite reduced cervical length and volume.  

	Kindlinger L, MacIntyre D, Lee Y, et al. Identification of vaginal microbial communities associated with specific etiologies of preterm birth. Abstract O-022 presented at:  Society for Reproductive Investigation; March 19, 2016; Montreal, Canada. 

A new study looks at whether ovary-sparing hysterectomies can lead to early menopause. Plus: Does betamethasone reduce respiratory complications in preterm infants? Also, the impact of the vaginal microbiome on preterm birth.

Do ovary-sparing hysterectomies lead to early menopause?

The American Journal of Obstetrics & Gynecology 

suggests that allowing women more time in the prolonged second stage of labor could drastically reduce the cesarean rate.

	Researchers at the Sidney Kimmel College of Medicine at Thomas Jefferson University in Philadelphia, Pennsylvania assessed data on nulliparous women with singleton pregnancies at 36 0/7 to 41 6/7 weeks’ gestation. All of them reached the American College of Obstetricians and Gynecologists definition of prolonged second stage of labor: either 3 hours with epidural anesthesia or 2 hours without epidural anesthesia.

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	Randomization was to either extension of labor by 1 additional hour or to the usual labor, defined as expedited delivery either via cesarean delivery or operative vaginal delivery. Exclusion criteria included intrauterine fetal death, age < 18 years, planned cesarean delivery, and suspected major fetal anomaly.

	Overall 78 women were assigned randomly and all of the women had epidural anesthesia. The demographics of the women in the two study arms were not significantly different. In the extended labor group, the rate of cesarean delivery was 19.5% or 8 out of 41 births. In the usual labor group, the rate of cesarean delivery was 43.2% or 16 out of 17 births (relative risk, 0.45; 95% confidence interval, 0.22–0.93). The number needed-to-treat to prevent 1 cesarean delivery was 4.2. No statistically significant differences were seen in maternal or neonatal morbidity outcomes between the 2 groups.

	The researchers concluded that extending labor in nulliparous women with a singleton pregnancy, under epidural anesthesia, and in a prolonged second stage seemed to decrease the rate of cesarean delivery by a little more than 50%. They pointed out that the study was underpowered in its ability to detect small differences, which could have some clinical importance.

NEXT: Can a cervical pessary help prevent preterm birth?

Can a cervical pessary help prevent preterm birth?

	Research to date on use of a silicone pessary around the cervix to prevent preterm birth has produced contradictory results. Adding to those data are outcomes from a new randomized controlled trial, which cast doubt on the value of the devices. 

, the findings are from a multicenter comparison of pessary placement and expectant management by researchers from UK. The participants were 930 women aged ≥16 with singleton pregnancies and cervical lengths ≤25 mm at 20 weeks 0 days to 24 weeks 6 days gestation.

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	Half the participants received cervical pessaries and half were followed expectantly. Vaginal progesterone was administered to 423 woman with a cervical length ≤15 mm at randomization or on a subsequent visit. Antibiotics were administered to 267 of the women who had positive vaginal cultures and cervical cerclages were placed in 7 women with very short cervixes.

	The primary outcome of the study was spontaneous delivery before 34 weeks’ gestation, which occurred in 55 (12.0%) of the women who had pessaries and 50 (10.8%) of the women in the control group (odds ratio in the pessary group 1.12; 95% confidence interval [CI] 0.75 to 1.69; 

=0.57). No significant difference was seen between the pessary and expectant management groups in percentage of women who did not give birth spontaneously before 34 weeks (hazard ratio in the pessary group 1.13; 95% CI 0.77 to 1.65;

=0.54). Adjustment for cervical length, progesterone use, and antibiotic treatment did not change the results.

	Looking at adverse events, the investigators found that pessary placement did not affect rates of perinatal death, adverse neonatal outcomes, or need for neonatal special care. The women who received the devices did have more vaginal discharge than those in the control group (10.5% vs. 6.2%; 

NEXT: Why do teen LARC users not use condoms?

shows that high school girls who use recommended long-acting reversible contraceptives (LARC) may be more likely to not use condoms during sexual intercourse than their peers who use oral contraceptives (OCs).

	For the study, the researchers used data from the 2013 national Youth Risk Behavior Survey, a nationally representative sample of US students in grades 9 to 12. Descriptive analyses were performed with sexually active female students (n = 2288) while logistic regression analyses were limited to sexually active female users of LARC (intrauterine devices and implants) and moderately effective contraceptives (n = 619).

	Among the 2288 participants (56.7% were white and 33.6% were in 12

 grade), 1.8% used LARC; 5.7% used Depo-Provera, patch, or ring; 22.4% used OCs; 40.8% used condoms; 11.8% used withdrawal or some other method; 15.6 used no contraceptive method; and 1.9% were not sure about the method they used. Following an adjust analysis, LARC users were roughly 60% less likely to use condoms than were OC users (adjusted prevalence ratio [aPR], 0.42; 95% CI, 0.21-0.84). There was no significant difference in condom use between LARC users and those who used Depo-Provera, patch, or the ring (aPR, 0.57; 95% CI, 0.26-1.25). The study also raised the concern that LARC users had nearly double the chance of having 2 or more recent sexual partners in comparison to OC users (aPR, 2.61; 95% CI, 1.75-3.90) and Depo-Provera, patch, or ring users (aPR, 2.58; 95% CI, 1.17-5.67).

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	Researchers were quick to point out that some limitations should be taken into account when interpreting the findings. The survey data used are based on self-report, allowing for misreported behaviors. In addition, the survey only asked about the primary contraceptive method used when a girl last engaged in sexual intercourse, which could mean that some teens polled used condoms in addition to their primary contraceptive choice, but only listed the primary method. Important information not included in the data involved duration of contraceptive use; whether the contraceptive was correctly and consistently; and information about the girls’ partners.

	The researchers concluded that girls who use LARCs are far more likely to not use condoms while engaging in sexual intercourse than their peers who use OCs. They speculate that this could be because teens believe that condoms are for backup pregnancy prevention. Given the highly effective nature of LARCs, some girls may not perceive that they are at risk of sexually transmitted infections (STIs). This cognitive disconnect indicates a clear need to emphasize the STI prevention capabilities of condoms.

A new study wonders if allowing a longer labor could help reduce rates of cesarean delivery. Plus: Does placing a cervical pessary prevent preterm birth? Also, a look at why teenaged LARC users aren't using condoms for STI prevention.

Miranda Hester

Articles

CDC issues advisory on Zika testing

Does ospemifene increase vasomotor symptoms?

Do ovary-sparing hysterectomies lead to early menopause?

Why a longer labor could cut cesarean delivery rates