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The integrase inhibitors elvitegravir (EVG) and dolutegravir (DTG) rapidly decrease the plasma HIV-1 viral load, a key factor in the prevention of maternal-to-fetal transmission of HIV-1. No data have been reported on the concentrations of these drugs in cord blood, maternal peripheral blood mononuclear cells (PBMCs), or placental tissue in pregnant women. We present in vivo pharmacokinetic data on antiretrovirals (ARV) within maternal and cord blood and within placentae from HIV-1-infected pregnant women. Maternal blood and cord blood were obtained from women receiving EVG, cobicistat, tenofovir disoproxil fumarate, and emtricitabine as a single fixed-dose combination formulation or DTG as part of a combination regimen. Plasma and PBMCs from maternal and cord blood were obtained along with villous placental samples. Drug concentrations were simultaneously determined by liquid chromatography-tandem mass spectrometry (LC-MS/MS). Utilizing medians and ranges to interpret our data, we compared the drug concentration ratios between different matrices (maternal and cord blood plasma, PBMCs, and placenta). All five agents transferred from maternal into fetal circulation via the placenta. Concentration ratios for EVG, cobicistat, tenofovir, and emtricitabine ( n = 10) and DTG ( n = 3) were determined between cord plasma and placenta, cord and maternal plasma, and cord PBMCs and maternal PBMCs. TFV moves from maternal plasma through the placenta to the cord blood and then into cord PBMCs, where it is phosphorylated into its active forms (TFV diphosphate). These five ARVs were detected in each of the compartments, highlighting transfer of these agents from the maternal into the fetal circulation., (Copyright © 2017 American Society for Microbiology.)

Linkage and retention in care for many HIV-infected women in the postpartum period is suboptimal, which compromises long-term virologic suppression and the HIV Care Continuum. Efforts are needed to improve individual outcomes by addressing transitions in care. We summarize some successful strategies to engage and retain HIV-infected women in care during the postpartum period.

Background: Minimizing time to HIV viral suppression is critical in pregnancy. Integrase strand transfer inhibitors (INSTIs), like raltegravir, are known to rapidly suppress plasma HIV RNA in nonpregnant adults. There are limited data in pregnant women., Objective: We describe time to clinically relevant reduction in HIV RNA in pregnant women using INSTI-containing and non-INSTI-containing antiretroviral therapy (ART) options., Study Design: We conducted a retrospective cohort study of pregnant HIV-infected women in the United States from 2009 through 2015. We included women who initiated ART, intensified their regimen, or switched to a new regimen due to detectable viremia (HIV RNA >40 copies/mL) at ≥20 weeks gestation. Among women with a baseline HIV RNA permitting 1-log reduction, we estimated time to 1-log RNA reduction using the Kaplan-Meier estimator comparing women starting/adding an INSTI in their regimen vs other ART. To compare groups with similar follow-up time, we also conducted a subgroup analysis limited to women with ≤14 days between baseline and follow-up RNA data., Results: This study describes 101 HIV-infected pregnant women from 11 US clinics. In all, 75% (76/101) of women were not taking ART at baseline; 24 were taking non-INSTI containing ART, and 1 received zidovudine monotherapy. In all, 39% (39/101) of women started an INSTI-containing regimen or added an INSTI to their ART regimen. Among 90 women with a baseline HIV RNA permitting 1-log reduction, the median time to 1-log RNA reduction was 8 days (interquartile range [IQR], 7-14) in the INSTI group vs 35 days (IQR, 20-53) in the non-INSTI ART group (P < .01). In a subgroup of 39 women with first and last RNA measurements ≤14 days apart, median time to 1-log reduction was 7 days (IQR, 6-10) in the INSTI group vs 11 days (IQR, 10-14) in the non-INSTI group (P < .01)., Conclusion: ART that includes INSTIs appears to induce more rapid viral suppression than other ART regimens in pregnancy. Inclusion of an INSTI may play a role in optimal reduction of HIV RNA for HIV-infected pregnant women presenting late to care or failing initial therapy. Larger studies are urgently needed to assess the safety and effectiveness of this approach., Competing Interests: The authors report no relevant financial conflicts of interest., (Copyright © 2016 Elsevier Inc. All rights reserved.)

All HIV-infected women contemplating pregnancy should initiate combination antiretroviral therapy (cART), with a goal to achieve a maternal serum HIV RNA viral load beneath the laboratory level of detection prior to conceiving, as well as throughout their pregnancy. Successfully identifying HIV infection during pregnancy through screening tests is essential in order to prevent in utero and intrapartum transmission of HIV. Perinatal HIV transmission can be less than 1% when effective cART, associated with virologic suppression of HIV, is given during the ante-, intra-, and postpartum periods. Perinatal HIV guidelines, developed by organizations such as the World Health Organization, American College of Obstetricians and Gynecologists, and the US Department of Health and Human Services, are constantly evolving, and hence the aim of our review is to provide a useful concise review for medical providers caring for HIV-infected pregnant women, summarizing the latest and current recommendations in the United States.

Objective: To estimate the maternal and fetal risks of smallpox vaccination during pregnancy., Data Sources: MEDLINE, Web of Science, EMBASE, Global Health, ClinicalTrials.gov, and CINHAL from inception to September 2014., Methods of Study Selection: We included published articles containing primary data regarding smallpox vaccination during pregnancy that reported maternal or fetal outcomes (spontaneous abortion, congenital defect, stillbirth, preterm birth, or fetal vaccinia)., Tabulations, Integration, and Results: The primary search yielded 887 articles. After hand-searching, 37 articles were included: 18 articles with fetal outcome data and 19 case reports of fetal vaccinia. Outcomes of smallpox vaccination in 12,201 pregnant women were included. Smallpox vaccination was not associated with an increased risk of spontaneous abortion (pooled relative risk [RR] 1.03, confidence interval [CI] 0.76-1.41), stillbirth (pooled RR 1.03, CI 0.75-1.40), or preterm birth (pooled RR 0.84, CI 0.62-1.15). When vaccination in any trimester was considered, smallpox vaccination was not associated with an increased risk of congenital defects (pooled RR 1.25, CI 0.99-1.56); however, first-trimester exposure was associated with an increased risk of congenital defects (2.4% compared with 1.5%, pooled RR 1.34, CI 1.02-1.77). No cases of fetal vaccinia were reported in the studies examining fetal outcomes; 21 cases of fetal vaccinia were identified in the literature, of which three neonates survived., Conclusion: The overall risk associated with maternal smallpox vaccination appears low. No association between smallpox vaccination and spontaneous abortion, preterm birth, or stillbirth was identified. First-trimester vaccination was associated with a small increase in congenital defects, but the effect size was small and based on limited data. Fetal vaccinia appears to be a rare consequence of maternal smallpox vaccination but is associated with a high rate of fetal loss.

Background. Crisscross heart (CCH) is a complex, rare, congenital, rotational, cardiac abnormality that accounts for <0.1% of congenital heart defects (CHD). CCH is characterized by the crossing of the inflow streams of the two ventricles due to an abnormal twisting of the heart. A case of maternal CCH has not been previously reported. Case. We report a case of a primigravida with a CCH, who was separated at birth from her thoracopagus conjoined twin. Pregnancy was managed by congenital cardiology, maternal-fetal medicine, anesthesiology, and obstetrics. She underwent a 39-week vaginal delivery without maternal or neonatal complication. Conclusion. A successful term pregnancy outcome was achieved in a patient with CCH using a multidisciplinary approach to address her cardiac condition.

As perinatally HIV-infected (PHIV) women reach reproductive age, there is an increasing number who become pregnant. This is a retrospective cohort study of HIV-infected women who delivered from June 2007 to July 2012 at our institution. Maternal demographics, HIV characteristics, and obstetric and neonatal outcomes were compared. 20 PHIV and 80 SHIV pregnancies were reviewed. The groups had similar CD4+ counts, prevalence of AIDS, and use of antiretrovirals (ARV) at initiation of obstetrical care. PHIV women were significantly more likely to be younger, have a detectable viral load (35% versus 74%, P < 0.01), and have HIV-genotype resistance (40% versus 12%, P < 0.01) than the SHIV women. The median gestational age at delivery (38 weeks) and rates of obstetrical and neonatal complications were similar between the groups. While the overall rate of cesarean delivery (CD) was similar, the rates for CD due to HIV were higher in the PHIV group (64% versus 22%, P < 0.01). There was one case (5.3%) of mother-to-child transmission in the PHIV group versus two cases (2.6%) in the SHIV group. In our population, PHIV pregnant women have a higher rate of HIV-genotype resistance and higher rate of detectable viral load leading to a higher rate of CD secondary to HIV.

Objective: To evaluate the current use of complementary and alternative medication (CAM) products among women in obstetrics and gynecology outpatient clinics., Study Design: This study was performed at a major academic center among patients seen at either a faculty-led private clinical practice site (n = 250) or a resident-led clinical practice site (n = 250). Patients were requested to bring a written list and the medication bottles (prescriptions, over-the-counter medications and CAM products) to the clinic, where a survey was then administered., Results: Overall, 18.6% of participants were using CAM products. Significantly more patients reported using CAM products in the faculty private practice as compared to the resident clinic practice (28.4% vs. 8.8%, respectively, p value < 0.05). Only 29.0% of CAM products users had spoken to a healthcare provider regarding CAM products. Multivariate logistic regression model determined that older age (p < 0.0001) and Caucasian ethnicity (p = 0.0245) were associated with higher rates of CAM products use., Conclusion: In this study CAM products use was not as prevalent as anticipated for this patient population, however it continues to be underreported to providers. Healthcare professionals should continue to increase their knowledge about CAM products, take a proactive role to improve documentation, and develop an open communication with patients regarding appropriate use of CAM products.

The first cases of mother to child transmission of human immunodeficiency virus (HIV) were described more than two decades ago and since then several thousands more have been reported in western countries. In the early 1980s the majority of perinatally acquired HIV children did not survive beyond childhood. However combined antiretroviral therapy (ART) for perinatally HIV-acquired children has prolonged their survival and in the past 2 decades, many have reached adulthood. As the perinatally HIV-infected females become sexually active, they are in turn at risk for pregnancy and of transmitting HIV infection to their children. A considerable proportion of this population appears to engage in unprotected sexual intercourse leading to teenage pregnancies, STDs, and abnormal cervical cytology despite frequent contact with HIV health care providers and clinics. Currently there is a paucity of data regarding pregnancy and neonatal outcomes in HIV perinatally infected women. As increasing number of pregnancies will occur among this population we must continue to monitor and focus on their reproductive health issues to improve perinatal and long-term maternal outcomes. This paper will summarize our current knowledge about reproductive health issues and identify areas for future inquiry.

Background: The aim of this study was to determine current contraceptive use, contraceptive desires and knowledge, future fertility desires, and sterilization regret in a cohort of HIV-positive women., Study Design: 127 HIV-positive women receiving care at an urban infectious disease clinic completed a survey addressing their contraceptive and reproductive histories as well as their future contraceptive and fertility desires., Results: The most common forms of contraception used were sterilization (44.4%) and condoms (41.3%). Less than 1% used a long-term reversible method of contraception (LARC) despite these being the methods that best fit their desired attributes of a contraceptive method. Overall, 29.4% desired future fertility. Only 50.6% of those sexually active had spoken with a provider within the last year regarding their contraceptive plans. There was a high degree of sterilization regret (36.4%), and 18.2% of sterilized women desired future fertility. Multivariate analysis found women in a monogamous relationship had a statistically increased rate of regret compared to women who were not sexually active (OR 13.8, 95% CI 1.6-119, P = 0.17)., Conclusion: Given the diversity in contraceptive and fertility desires, coupled with a higher rate of sterilization regret than is seen in the general population, integration of comprehensive family planning services into HIV care via increased contraceptive education and access is imperative.

Objectives: Although the reported incidence of carboplatin hypersensitivity is low, its occurrence is important to characterize because of potential fatal complications. The purpose of this study was to determine the current incidence of carboplatin hypersensitivity in the ovarian cancer patients compared to other oncology patients and identify potential risk factors that may contribute to development of carboplatin hypersensitivity reactions., Methods: This was a retrospective chart review analyzing all hospital records at an academic tertiary oncology center between July 2002 and September 2003. Data collected included patient demographics, past medical histories, and detailed carboplatin administration information. Patients that had received carboplatin were identified from pharmacy dispensing records. Positive carboplatin hypersensitivity reactions were identified from the documentation provided in the patient medical record., Results: The incidence of carboplatin hypersensitivity for all cancer patients compared to ovarian cancer patients receiving carboplatin at our institution was 2.6% and 7.9%, respectively. Statistically significant risk factors (P < 0.05) included prior carboplatin exposure and history of drug allergies. There was also a trend to suggest premedication with histamine1 (H1) and histamine(2) (H2) blocker decreases the risk of developing carboplatin hypersensitivity reactions., Conclusion: This study confirmed a similar incidence of carboplatin hypersensitivity reactions to previous reports. However, we found that the higher incidence associated with ovarian cancer patients can be attributed to the prolonged carboplatin exposure or history of drug allergies. This is the first study to observe that the administration of H1 and H2 antagonists is associated with a decrease risk of carboplatin hypersensitivity reaction.

Nausea and vomiting, common symptoms during pregnancy, often are regarded as an unpleasant but normal part of pregnancy during the first and early second trimesters. Nausea and vomiting of pregnancy (NVP) occurs in approximately 75-80% of pregnant women. The exact etiology and pathogenesis of NVP are poorly understood and are most likely multifactorial. Some theories for the etiology of NVP are psychological predisposition, evolutionary adaptation, hormonal stimuli, and Helicobacter pylori infection. Treatment ranges from dietary and lifestyle changes to vitamins, antiemetics, and hospitalization for intravenous therapy. Treatment generally begins with nonpharmacologic interventions; if symptoms do not improve, drug therapy is added. Although NVP has been associated with a positive pregnancy outcome, the symptoms can significantly affect a woman's life, both personally and professionally. Given the substantial health care costs, as well as indirect costs, and the potential decrease in quality of life due to NVP, providers need to acknowledge the impact of NVP and provide appropriate treatment.