Quality predictors of abdominal fetal electrocardiography recording in antenatal ambulatory and bedside settings

Background: Fetal electrocardiography using an abdominal monitor (Monica AN24™) could increase the diagnostic use of fetal heart rate (fHR) variability measurements. However, signal quality may depend on factors such as maternal physical activity, posture, and bedside versus ambulatory setting. Methods: Sixty-three healthy women wore the monitor at home and 42 women during a hospital stay. All women underwent a posture experiment, and all home and 13 hospital participants wore the monitor during daytime and nighttime. The success rate (SR) of fHR detection was analyzed in relation to maternal physical activity, posture, daytime versus nighttime, and other maternal and fetal predictors. Results: Ambulatorily, the SR was 86.8% for nighttime and 40.2% for daytime. The low daytime SR was largely due to effects of maternal physical activity and posture. The in-hospital SR was lower during nighttime (71.1%) and similar during daytime (43.3%). SR was related to gestational age, but not affected by pre-pregnancy and current body mass index or fetal growth restriction. Conclusions: The success of beat-to-beat fHR detection strongly depends on the home/hospital setting and predictors such as time of recording, activity levels, and maternal posture. Its clinical utility may be limited in periods of unsupervised recording with physical activity or posture shifts

Obstetric gel shortens second stage of labor and prevents perineal trauma in nulliparous women : a randomized controlled trial on labor facilitation

Abstract Objective: To determine whether the obstetric gel shortens the second stage of labor and exerts a protective effect on the perineum. Method: A total of 251 nulliparous women with singleton low-risk pregnancies in vertex position at term were recruited. A total of 228 eligible women were randomly assigned to Group A, without obstetric gel use, or to Group B, obstetric gel use, i.e., intermittent application into the birth canal during vaginal examinations, starting at the early first stage of labor (prior to 4 cm dilation) and ending with delivery. Results: A total of 183 cases were analyzed. For vaginal deliveries without interventions, such as C-section, vaginal operative procedure or Kristeller maneuver, obstetric gel use significantly shortened the second stage of labor by 26 min (30%) (P=0.026), and significantly reduced perineal tears (P=0.024). First stage of labor and total labor duration were also shortened, but not significantly. Results did not show a significant change in secondary outcome parameters, such as intervention rates or maternal and newborn outcomes. No side effects were observed with obstetric gel use. Conclusion: Systematic vaginal application of obstetric gel showed a significant reduction in the second stage of labor and a significant increase in perineal integrity. Future studies should further investigate the effect on intervention rates and maternal and neonatal outcome parameters

Postnatal retention in HIV care: insight from the Swiss HIV Cohort Study over a 15-year observational period

OBJECTIVES: The aim of this study was to quantify loss to follow-up (LTFU) in HIV care after delivery and to identify risk factors for LTFU, and implications for HIV disease progression and subsequent pregnancies. METHODS: We used data on pregnancies within the Swiss HIV Cohort Study from 1996 to 2011. A delayed clinical visit was defined as > 180 days and LTFU as no visit for > 365 days after delivery. Logistic regression analysis was used to identify risk factors for LTFU. RESULTS: A total of 695 pregnancies in 580 women were included in the study, of which 115 (17%) were subsequent pregnancies. Median maternal age was 32 years (IQR 28-36 years) and 104 (15%) women reported any history of injecting drug use (IDU). Overall, 233 of 695 (34%) women had a delayed visit in the year after delivery and 84 (12%) women were lost to follow-up. Being lost to follow-up was significantly associated with a history of IDU [adjusted odds ratio (aOR) 2.79; 95% confidence interval (CI) 1.32-5.88; P = 0.007] and not achieving an undetectable HIV viral load (VL) at delivery (aOR 2.42; 95% CI 1.21-4.85; P = 0.017) after adjusting for maternal age, ethnicity and being on antiretroviral therapy (ART) at conception. Forty-three of 84 (55%) women returned to care after LTFU. Half of them (20 of 41) with available CD4 had a CD4 count < 350 cells/μL and 15% (six of 41) a CD4 count < 200 cells/μL at their return. CONCLUSIONS: A history of IDU and detectable HIV VL at delivery were associated with LTFU. Effective strategies are warranted to retain women in care beyond pregnancy and to avoid CD4 cell count decline. ART continuation should be advised especially if a subsequent pregnancy is planned

Postnatal retention in HIV care: insight from the Swiss HIV Cohort Study over a 15-year observational period*

Objectives The aim of this study was to quantify loss to follow-up (LTFU) in HIV care after delivery and to identify risk factors for LTFU, and implications for HIV disease progression and subsequent pregnancies. Methods We used data on pregnancies within the Swiss HIV Cohort Study from 1996 to 2011. A delayed clinical visit was defined as &gt; 180 days and LTFU as no visit for &gt; 365 days after delivery. Logistic regression analysis was used to identify risk factors for LTFU. Results A total of 695 pregnancies in 580 women were included in the study, of which 115 (17%) were subsequent pregnancies. Median maternal age was 32 years (IQR 28-36 years) and 104 (15%) women reported any history of injecting drug use (IDU). Overall, 233 of 695 (34%) women had a delayed visit in the year after delivery and 84 (12%) women were lost to follow-up. Being lost to follow-up was significantly associated with a history of IDU [adjusted odds ratio (aOR) 2.79; 95% confidence interval (CI) 1.32-5.88; P = 0.007] and not achieving an undetectable HIV viral load (VL) at delivery (aOR 2.42; 95% CI 1.21-4.85; P = 0.017) after adjusting for maternal age, ethnicity and being on antiretroviral therapy (ART) at conception. Forty-three of 84 (55%) women returned to care after LTFU. Half of them (20 of 41) with available CD4 had a CD4 count &lt; 350 cells/μL and 15% (six of 41) a CD4 count &lt; 200 cells/μL at their return. Conclusions A history of IDU and detectable HIV VL at delivery were associated with LTFU. Effective strategies are warranted to retain women in care beyond pregnancy and to avoid CD4 cell count decline. ART continuation should be advised especially if a subsequent pregnancy is planned. Correspondence: Dr Karoline Aebi-Popp, Department of Infectious Diseases, University Hospital Bern, CH-3010 Bern, Switzerland. Tel: +41 0 31 632 2745; fax: +41 0 31 632 31 76; e-mail: [email protected] *The data in this article were presented, in part, at the International Congress on Drug Therapy in HIV Infection, 2-6 November 2014, Glasgow, UK. † See Appendix. DOI: 10.1111/hiv.12299 © 2015 British HIV Association HIV Medicine (2015 ORIGINAL RESEARCH Introduction Prevention of mother to child transmission (PMTCT) of HIV is the &apos;gateway&apos; to HIV treatment and care for pregnant women newly diagnosed with HIV infection and a chance to re-engage for those who have previously lost contact with HIV services. The majority of women living with HIV are of childbearing age The aim of this study was to evaluate the proportion of women in the Swiss HIV Cohort Study (SHCS) who were lost to follow-up in HIV care after pregnancy and delivery. Secondary aims were to analyse risk factors and possible reasons for not attending specialized HIV services after having a baby and the impact of being lost to follow-up on viral load (VL) and CD4 cell count development in the mother. Methods Study population and data collection The SHCS is a multicentre observational study for interdisciplinary HIV research in Switzerland. Since 1988, HIVpositive adults have prospectively and continuously been enrolled and followed at seven cohort centres, affiliated hospitals and private practices collaborating with the centres. Over 18 000 HIV-infected individuals have been included since, corresponding to approximately 70% of all HIV-infected individuals in Switzerland (for more details, consult http://www.shcs.ch). At a semi-annual follow-up structured anamnestic, clinical and laboratory data are obtained. Clinicians or study nurses collect data on sociodemographic and clinical characteristics, ART, comorbidities including injecting drug use (IDU) and noninjecting drug use and comedications based on a predefined questionnaire. Results for CD4 cell count and HIV VL tests, performed at routine follow-up visits, are collected at least every 6 months. Patients who do not attend follow-up visits are actively traced and re-invited to attend by letter. The cohort study has been approved by all local ethical committees and written informed consent was obtained from all participants. The Swiss Mother and Child HIV Cohort Study (MoCHiV) contains detailed information about pregnancy, delivery and the newborn and is fully integrated in the SHCS. In contrast to most national HIV pregnancy cohorts, longitudinal data for the postpartum period are therefore available. We included all deliveries between 1 January 1996 and 31 December 2011 for which information about medical follow-up after delivery was available. Outcome variables and definitions CD4 cell count was categorized as &lt; 200, 200-349, 350-499, ≧ 500 cells/μL. The last VL obtained during pregnancy and within 8 weeks prior to delivery was considered as the VL at delivery. Gestational age was reported to the nearest completed week based on ultrasound or last menstrual period. The first trimester was defined as 1-12 weeks, the second trimester as 13-27 HIV Medicine Statistical methods We analysed data for women with intervals of &gt;180 or 365 days between clinical visits during the first year after delivery. Women who re-presented to services after an LTFU period of &gt; 365 days were included in the analysis as a subgroup to identify reasons for their re-presentation and to assess their clinical status. We assessed factors associated with an LTFU event with univariable and multivariable logistic regression. These models were also used to assess time trends in retention in care by including calendar year as a covariate. The factors affecting CD4 values at a subsequent pregnancy (such as ART between pregnancies, time between pregnancies, and CD4 count at first pregnancy) were assessed using univariable and multivariable linear regression models. A P-value of &lt; 0.05 was considered to represent a statistically significant difference. We used STATA version 13.1 (StataCorp, College Station, TX) for data management and analyses. Results Characteristics of pregnancies in HIV-infected women There were 738 deliveries reported, of which 43 were excluded because the delivery took place outside the time of SHCS participation. Clinical and demographic characteristics for 695 pregnancies in 580 women included in this study are presented in Among women diagnosed before pregnancy, the percentage on ART at conception increased over time from 48% for the years 1996-1999 to 60% for 2000-2003, 64% for 2004-2007 and 74% for 2008-2011 (P trend The sequence of HIV-related care Figure 1 summarizes data on clinical visits for deliveries between 1996 and 2011, from HIV diagnosis to retention in care after delivery. The last HIV-related clinical visit prior to conception of known HIV-positive women took place during the last 3 months before conception in two-thirds (357 of 524; 69%) of women. However, 62 (12%) of them had their last HIV visit more than 6 months before becom- 2008-2011 196 (32) 14 Retention in care of HIV-infected women after delivery 3 © 2015 British HIV Association HIV Medicine Factors associated with loss to follow-up Overall, there were 233 of 695 (33.5%) births with an interval to the first follow-up visit after delivery of &gt; 180 days in the year after delivery, including 84 (12.1% of total) who were lost to follow-up for &gt; 365 days. Clinical, immunological and virological characteristics of women re-presenting to care after being lost to follow-up Forty-six (55%) of 84 women who were lost to follow-up subsequently returned to clinical care (median time interval 688 days; IQR 476-1309 days). There was no association between being completely lost to follow-up (as opposed to returning after &gt; 365 days) and ethnicity, maternal age, CD4 cell count at delivery, VL at delivery, time of HIV diagnosis or report of IDU (data not shown). Among those who did not return, 16 women (42.1%) did not respond to invitations, eight (21.1%) had emigrated, five had stopped participation in the SHCS, four had changed clinic/physician and three had died within 1 year after delivery (the reason for no return in two cases was unknown). The three deaths occurred in the years 1999, 2001 and 2004: one was attributable to end-stage AIDS, one to pneumonia and one to unknown circumstances. Half of the women with a documented CD4 cell count at their return after LTFU (20 of 41) had CD4 counts &lt; 350 cells/μL and 15% (six of 41) had CD4 counts &lt; 200 cells/μL. The median difference between CD4 cell counts at delivery and at return after LTFU was a loss of 80 cells/μL (IQR −230 to 30) Subsequent pregnancies A total of 115 subsequent pregnancies (115 of 695; 17%) were reported overall in this cohort. There was no difference in the proportion of women with undetectable VL at the subsequent delivery between women with delayed follow-up and those with continuous follow-up after pregnancy (data not shown). However, while 9% (nine of 105) of the women with regular follow-up after their first pregnancy were lost to follow-up after their subsequent pregnancy, the number increased to 40% (four of 10) in the case of LTFU after the first pregnancy (P = 0.014). The median inter-pregnancy interval was 990 days (IQR 693-1455 days). Women who had stopped ART after delivery had a mean CD4 count decline of 170 cells/μL at their first measurement during the subsequent pregnancy compared with the last measurement in the index pregnancy. In contrast, women continuing ART postpartum had a mean increase in CD4 count of 58 cells/μL compared with the last measured CD4 count around delivery of the index pregnancy (P &lt; 0.001). Discussion In Europe, the unproblematic access to drugs for effective control of HIV infection, resulting in a nearly normal life expectancy and very low rates of MTCT of HIV under optimal circumstances, encourages HIV-infected women to have children. However, our study demonstrates that follow-up of women with HIV infection is insufficient after delivery. We found that 34% of women had a delayed clinical visit in HIV care of &gt; 180 days and 12% were lost to follow-up in HIV care for more than 1 year after delivery. In our analysis of data for childbearing women, a history of IDU and a failure to suppress viral replication by delivery were associated with an increased risk of dropping out of HIV care. This reflects an increased disengagement of women with greater social vulnerability and of those who were less adherent to ART during pregnancy and/or presented late during pregnancy with delays in combination antiretroviral therapy (cART) initiation. Interestingly, ethnicity was not associated with higher rates of LTFU. Women who started ART during pregnancy were also more likely to disengage from postnatal HIV care compared with women who were on ART before pregnancy. The last finding is consistent with results of a South African study, where LTFU was associated with initiation of ART during pregnancy Higher rates of postnatal LTFU have been described in African countries: a study from South Africa In our cohort, one-quarter of women stopped their ART after delivery. In Europe, repeated pregnancies in HIVinfected women after diagnosis are common, and monitored within well-established PMTCT programmes. Data from the UK and Ireland showed that the proportion of subsequent pregnancies increased from 20.3% (32 of 158) in 1997 to 38.6% (565 of 1465) in 2009 (P &lt; 0.001) Another important finding in our study was that half of our patients who returned after LTFU after delivery for &gt; 1 year had a CD4 count &lt; 350 cells/μL. This shows that women with LTFU after delivery are at an increased risk with respect to their own health as they miss regular monitoring to ensure that treatment is started in a timely manner once it is indicated by reaching the CD4 threshold or because of HIV-associated diseases even at high CD4 counts. The UK and Ireland National Study of HIV in Pregnancy and Childhood showed that nearly 40% of women had an immunological indication for ART at the start of their second pregnancy, of whom nearly half had reported CD4 counts ≥ 350 cells/μL at their first pregnanc