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Papers by Alan Tita

Research paper thumbnail of Predictors of Infant Hepatitis B Immunization in Cameroon: Data to Inform Implementation of a Hepatitis B Birth Dose

Pediatric Infectious Disease Journal, 2018

Background-Although most African countries offer hepatitis B immunization through a 3-dose vaccin... more Background-Although most African countries offer hepatitis B immunization through a 3-dose vaccine series recommended at 6, 10, and 14 weeks of age, very few provide birth dose vaccination. In support of Cameroon's national plan to implement the birth dose vaccine in 2017, we investigated predictors of infant hepatitis B virus (HBV) vaccination under the current program. Methods-Using the 2011 Demographic Health Survey in Cameroon, we identified women with at least one living child (age 12-60 months) and information about the hepatitis B vaccine series. Vaccination rates were calculated and logistic regression modeling was used to identify factors associated with 3-dose series completion. Changes over time were assessed with linear logistic model. Results-Among 4594 mothers analyzed, 66.7% (95% CI 64.1-69.3) of infants completed the hepatitis B vaccine series; however, an average four week delay in series initiation was noted with median dose timing at 10, 14 and 19 weeks of age. Predictors of series completion included

Research paper thumbnail of HIV Status and Contraceptive Utilization among Women in Cameroon

Journal of the International Association of Providers of AIDS Care, 2019

Objective: We examined patterns of contraceptive utilization by HIV status among women in Cameroo... more Objective: We examined patterns of contraceptive utilization by HIV status among women in Cameroon, hypothesizing that women living with HIV would utilize contraception at higher rates than their HIV-negative peers. Methods: Deidentified, clinical data from the Cameroon Baptist Convention Health Services (2007-2013) were analyzed (N ¼ 8995). Frequencies compared outcomes between women living with HIV (15.1%) and uninfected women. Multivariate analyses examined associates of contraceptive utilization and desire to become pregnant. Results: Contraceptive utilization was associated with higher education, living with HIV, monogamy, and higher parity (P < .001). Women living with HIV had 66% higher odds of using contraceptives than their negative peers (odds ratio [OR]: 1.66, confidence interval [CI]: 1.45-1.91, P < .001). Polygamous women had 37% lower odds of using contraceptives compared to monogamous women (OR: 0.63, 95% CI: 0.52-0.75, P < .001). Conclusion: Increasing contraceptive utilization in resource-constrained settings should be a priority for clinicians and researchers. Doing so could improve population health by reducing HIV transmission between partners and from mother to child.

Research paper thumbnail of Predicting Postpartum Hemorrhage in Laboring Patients in Cameroon, Africa

American Journal of Obstetrics and Gynecology, 2022

Research paper thumbnail of Prevalence of group B streptococcus anogenital colonization and feasibility of an intrapartum screening and antibiotic prophylaxis protocol in Cameroon, Africa

International journal of gynaecology and obstetrics, Jun 10, 2019

Objective:To evaluate group B streptococcus (GBS) colonization prevalence and feasibility of intr... more Objective:To evaluate group B streptococcus (GBS) colonization prevalence and feasibility of intrapartum GBS screening/antibiotic prophylaxis (IAP) in Cameroon, Africa.Methods:Prospective cohort in the Cameroon Baptist Convention Health Services network. Maternity providers collected anogenital swabs from consenting term women in labor for testing by a rapid GBS-polymerase chain reaction (PCR) system. Positive tests (GBS+) resulted in initiation of intravenous ampicillin until delivery. Primary outcomes were GBS prevalence and proportion of GBS+ women receiving ampicillin before delivery and more than 4 hours before delivery.Results:A total of 219 women were enrolled from January 10 to April 27, 2017. GBS prevalence was 12.3% (95% confidence interval [CI] 7.9–16.7) with GBS+ women more likely to reside in urban areas (19.6% vs 9.7%, P=0.004). Of 27 GBS+ women, 19 (70.4%) received ampicillin before delivery and 14 (51.9%) 4 hours or longer before delivery. A median two doses of ampicillin (interquartile range [IQR] 1–5) were given and started at a median of 105 minutes (IQR 90–155) after swab collection and 20 minutes (IQR 10–45) after GBS result. Of the 8 women who did not receive ampicillin, 7 (87.5%) delivered before test results.Conclusion:A GBS IAP protocol is feasible in Cameroon and should be evaluated for widespread implementation in Cameroon and other low-income countries to decrease GBS-related morbidity.

Research paper thumbnail of 934: Prevalence, perinatal outcomes, and maternal risk factors for Group B Streptococcus colonization in a low-income country

American Journal of Obstetrics and Gynecology, 2018

regarding country of origin, time in US, insurance, education and household income. Up to 4900 ad... more regarding country of origin, time in US, insurance, education and household income. Up to 4900 additional variables were abstracted including documentation of prenatal visits (PNV), antenatal and intrapartum care & lab values. Publicly available google search trends were mined for search terms "Make America Great Again", "Mexico wall" and "Deportation" in the southern US. The time of first deviation from the mode google search popularity value for each term was ascertained (mode inflection). Perinatal data was averaged over 15 day moving windows to determine mean days from conception to 1st PNV, number of PNVs, and intrapartum nadir hemoglobin (Hgb) as a proxy for likely iron deficiency and/or PPH. Linear regression and Student's t-tests were used to determine linear trends and mean differences before and after mode inflection. RESULTS: 24,933 occurred during the study period. A mode inflection date of 7/1/2015 was extrapolated from the google search analytics (Fig 1A). Coincident with the mode inflection, there was a significant increase in days until first PNV, fewer PNVs and a decreased trend of mean Hgb nadir (Fig 1B). These observations were notably significant among gravidae of Central American and Mexican origin, but not South Americans (Fig 1C). CONCLUSION: Our findings are of likely significant public health importance, and suggest that recent political rhetoric alters timely and regular access to PNC among nearly 25,000 deliveries in Texas. We speculate that such rhetoric lends to delayed and diminished PNC in vulnerable populations, and may contribute to maternal mortality in our region. These observations are worth of future causal analysis.

Research paper thumbnail of Predicting peripartum infection in laboring patients at high risk in Cameroon, Africa

American Journal of Obstetrics and Gynecology, 2022

Research paper thumbnail of 7 Oral azithromycin ± amoxicillin to prevent peripartum infection in laboring high-risk women: A 3-Arm RCT

American Journal of Obstetrics and Gynecology, Feb 1, 2021

Research paper thumbnail of 390: Prevention of hepatitis B in sub-Saharan Africa: a decision analytic model for the birth dose vaccine

American Journal of Obstetrics and Gynecology, 2017

Of 594 eligible women, 268 (45.1%) had documented inpatient contraceptive counseling, but only 12... more Of 594 eligible women, 268 (45.1%) had documented inpatient contraceptive counseling, but only 127 (21.4%) left the hospital using a WHO tier 1 or 2 method (Figure). Women who were younger, non-Hispanic black, multiparous, and delivered at earlier gestational ages were more likely to be have counseling documented (Table). Notably, compared to women with private insurance, women with public insurance were significantly more likely to have documented counseling (23.6% vs. 87.5%, p<0.001; aOR 8.49, 95% CI 4.74-15.20) and to uptake a WHO Tier 1 or 2 method as an inpatient (5.8% vs 52.0%, p<0.001; aOR 8.89, 95% CI 4.47-17.70). Of the subgroup of 175 women with outpatient PP records available and who attended a postpartum visit, 98.3% received contraceptive counseling. However, in this subgroup, only 96 (54.9%) adopted a WHO tier 1 or tier 2 method at the postpartum visit. Public insurance and multiparity were positively associated with a WHO Tier 1 or 2 method use by the completion of postpartum care. CONCLUSION: Documented PP contraceptive counseling and effective contraceptive use among women at high risk for recurrent PTB is far from universal. It is notable that women in economically disadvantaged communities received more documented counseling and highly effective contraceptives. The reasons for such differences should be explored.

Research paper thumbnail of Relationship Between Infertility and Digital Cervicography Findings in Cameroonian Women

International journal of women's health and reproduction sciences, Mar 23, 2018

Objectives: Cervical neoplasia and some forms of infertility are caused by sexually transmitted i... more Objectives: Cervical neoplasia and some forms of infertility are caused by sexually transmitted infections. We aimed at evaluating whether positive findings on digital cervicography (DC) (performed to screen and treat cervical neoplasia) is associated with female infertility. Materials and Methods: In this cross-sectional study, women consulting for infertility underwent cervical cancer screening using DC alongside women without infertility. A total of 2128 Cameroonian women were studied. Women with infertility were subcategorized into primary and secondary infertility. Potential confounders were assessed at the screening visit and logistic regression was used to compute adjusted relative risks for the relationship between infertility and positive DC findings. Results: Among 2128 women studied, 292 (13.7%) presented due to infertility and 1836 did not; 88 (30.1%) of women with infertility had primary infertility and 204 (69.9%) had secondary infertility. Women with infertility had a positive DC prevalence rate of 15.9% compared to 13.6% for women without infertility (P = 0.31). The prevalence rates of positive DC among women with primary infertility or among those with secondary infertility respectively, did not differ from the rate in those without infertility. After multivariable adjustments relative to those without infertility, the adjusted relative risks (aRRs) (95% CI) for a positive DC were: 0.91 (0.62-1.20) for any infertility, 0.99 (0.65-1.51) for secondary infertility and 0.73 (0.38-1.41) for primary infertility. Conclusions: Results of DC were not significantly associated with infertility (and its subtypes). Further investigations are required to evaluate the association with other cervical cancer screening modalities like Pap smear and HPV DNA-testing.

Research paper thumbnail of Single Dose of Oral Azithromycin With or Without Amoxicillin to Prevent Peripartum Infection in Laboring, High-Risk Women in Cameroon

Obstetrics & Gynecology, Oct 6, 2021

OBJECTIVE: To compare the effectiveness of single-dose azithromycin, with or without amoxicillin,... more OBJECTIVE: To compare the effectiveness of single-dose azithromycin, with or without amoxicillin, with placebo to prevent peripartum infection in laboring women. METHODS: We conducted a multicenter, three-group, double-blind randomized controlled trial of women with viable term nonanomalous pregnancies with either prolonged labor of 18 hours or longer or rupture of membranes for 8 hours or longer in Cameroon. Women with chorioamnionitis before randomization, study drug contraindications, or planned cesarean births were excluded. Women were randomized to oral azithromycin 1 g–placebo (group 1), oral azithromycin 1 g–oral amoxicillin 2 g (group 2), or placebo–placebo (group 3). All groups received usual care, including antibiotics given at the health care professional's discretion. The primary outcome was a composite of maternal peripartum infection or death from any cause up to 6 weeks postpartum. Two primary comparisons (group 1 vs group 3 and group 2 vs group 3) were planned. We estimated that 241 women per group (planning for 750 total) would provide 80% power at two-sided α=0.05 (0.025 per comparison) to detect a 50% effect size assuming 20% baseline composite infection rate. RESULTS: From January 6, 2018, to May 15, 2020, 6,531 women were screened, and 756 (253 in group 1, 253 in group 2, and 250 in group 3) were randomized. Baseline characteristics (including body mass index, duration of rupture of membranes or labor, and parity) were balanced across groups, except for maternal age. More than 60% of women in each group received usual-care antibiotics: more than 90% penicillin and approximately 50% for prolonged rupture of membranes across all study groups. Composite outcome incidences were similar in antibiotic groups 1 (6%) and 2 (7%) compared with placebo group 3 (10%) (RR 0.6, 95% CI 0.3–1.2; 0.7, 95% CI 0.4–1.3, respectively). Chorioamnionitis and wound infection were significantly lower in group 2 (3.2% vs 0.4% and 4% vs 0.8% respectively, both P=.02) compared with group 3. There were no differences in other maternal or neonatal outcomes including neonatal infection. CONCLUSION: A single dose of oral azithromycin with or without amoxicillin for prolonged labor or rupture of membranes at term did not reduce maternal peripartum or neonatal infection. Observed lower than expected infection rates and frequent usual-care antibiotic use may have contributed to these findings. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03248297. FUNDING SOURCE: Merck for Mothers Investigator Studies Program grant.

Research paper thumbnail of A decision analytic model for prevention of hepatitis B virus infection in Sub-Saharan Africa using birth-dose vaccination

International journal of gynaecology and obstetrics, Jan 31, 2018

Objective-To compare prenatal maternal hepatitis B virus (HBV) screening and infant vaccination s... more Objective-To compare prenatal maternal hepatitis B virus (HBV) screening and infant vaccination strategies to inform policy on HBV prevention in Sub-Saharan Africa. Methods-A decision analytic model was created using previously published data to assess the ability of three intervention strategies to prevent HBV infection by age 10 years. Strategy 1 comprised of universal vaccination with a pentavalent vaccine (HBV, diphtheria, tetanus, pertussis, and Haemophilus influenzae) at age 6 weeks. Strategy 2 comprised of universal HBV vaccine at birth plus pentavalent vaccine. Strategy 3 comprised of maternal prenatal HBV screening and targeted HBV vaccine at birth for all exposed infants plus pentavalent vaccine. The reference strategy provided neither maternal screening nor infant vaccination. Rates of HBV infection and costs were compared. Results-The reference strategy had an HBV infection rate of 2360 per 10 000 children. The HBV infection rate for strategy 1 was 813 per 10 000 children vaccinated (1547 cases prevented). Strategies 2 and 3 prevented an additional 384 cases and 362 cases, respectively. Inclusion of HBV vaccination at birth was the preferred approach at a willingness-to-pay threshold of US$150. Conclusion-Including a birth-dose HBV vaccine in the standard schedule was both costeffective and prevented additional infections.

Research paper thumbnail of Factors Associated with PMTCT Cascade Completion in Four African Countries

Aids Research and Treatment, 2016

Background. Many countries are working to reduce or eliminate mother-to-child transmission (MTCT)... more Background. Many countries are working to reduce or eliminate mother-to-child transmission (MTCT) of HIV. Prevention efforts have been conceptualized as steps in a cascade but cascade completion rates during and after pregnancy are low. Methods. A cross-sectional survey was performed across 26 communities in Cameroon, Cote d'Ivoire, South Africa, and Zambia. Women who reported a pregnancy within two years were enrolled. Participant responses were used to construct the PMTCT cascade with all of the following steps required for completion: at least one antenatal visit, HIV testing performed, HIV testing result received, initiation of maternal prophylaxis, and initiation of infant prophylaxis. Factors associated with cascade completion were identified using multivariable logistic regression modeling. Results. Of 976 HIV-infected women, only 355 (36.4%) completed the PMTCT cascade. Although most women (69.2%) did not know their partner's HIV status; awareness of partner HIV status was associated with cascade completion (aOR 1.4, 95% CI 1.01-2.0). Completion was also associated with receiving an HIV diagnosis prior to pregnancy compared with HIV diagnosis during or after pregnancy (aOR 14.1, 95% CI 5.2-38.6). Conclusions. Pregnant women with HIV infection in Africa who were aware of their partner's HIV status and who were diagnosed with HIV before pregnancy were more likely to complete the PMTCT cascade.

Research paper thumbnail of 934: Prevalence, perinatal outcomes, and maternal risk factors for Group B Streptococcus colonization in a low-income country

American Journal of Obstetrics and Gynecology

regarding country of origin, time in US, insurance, education and household income. Up to 4900 ad... more regarding country of origin, time in US, insurance, education and household income. Up to 4900 additional variables were abstracted including documentation of prenatal visits (PNV), antenatal and intrapartum care & lab values. Publicly available google search trends were mined for search terms "Make America Great Again", "Mexico wall" and "Deportation" in the southern US. The time of first deviation from the mode google search popularity value for each term was ascertained (mode inflection). Perinatal data was averaged over 15 day moving windows to determine mean days from conception to 1st PNV, number of PNVs, and intrapartum nadir hemoglobin (Hgb) as a proxy for likely iron deficiency and/or PPH. Linear regression and Student's t-tests were used to determine linear trends and mean differences before and after mode inflection. RESULTS: 24,933 occurred during the study period. A mode inflection date of 7/1/2015 was extrapolated from the google search analytics (Fig 1A). Coincident with the mode inflection, there was a significant increase in days until first PNV, fewer PNVs and a decreased trend of mean Hgb nadir (Fig 1B). These observations were notably significant among gravidae of Central American and Mexican origin, but not South Americans (Fig 1C). CONCLUSION: Our findings are of likely significant public health importance, and suggest that recent political rhetoric alters timely and regular access to PNC among nearly 25,000 deliveries in Texas. We speculate that such rhetoric lends to delayed and diminished PNC in vulnerable populations, and may contribute to maternal mortality in our region. These observations are worth of future causal analysis.

Research paper thumbnail of Effect of Prophylactic Negative Pressure Wound Therapy vs. Standard Wound Dressing on Surgical-Site Infection in Obese Women After Cesarean Delivery

Obstetric Anesthesia Digest, 2021

(JAMA. 2020;324:1180–1189) Maternal obesity is associated with greater likelihood of cesarean del... more (JAMA. 2020;324:1180–1189) Maternal obesity is associated with greater likelihood of cesarean delivery and higher risk of surgical-site infection. While prophylactic negative pressure wound therapy using portable, single-use systems has been increasingly used following cesarean delivery, larger studies are needed to evaluate its ability to decrease infections. This study aimed to compare the effects of prophylactic negative pressure wound therapy and standard wound dressing on risk of surgical-site infections. The authors hypothesized negative pressure wound therapy would decrease infections.

Research paper thumbnail of A decision analytic model for prevention of hepatitis B virus infection in Sub-Saharan Africa using birth-dose vaccination

International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics, Jan 8, 2018

To compare prenatal maternal hepatitis B virus (HBV) screening and infant vaccination strategies ... more To compare prenatal maternal hepatitis B virus (HBV) screening and infant vaccination strategies to inform policy on HBV prevention in Sub-Saharan Africa. A decision analytic model was created using previously published data to assess the ability of three intervention strategies to prevent HBV infection by age 10 years. Strategy 1 comprised of universal vaccination with a pentavalent vaccine (HBV, diphtheria, tetanus, pertussis, and Haemophilus influenzae) at age 6 weeks. Strategy 2 comprised of universal HBV vaccine at birth plus pentavalent vaccine. Strategy 3 comprised of maternal prenatal HBV screening and targeted HBV vaccine at birth for all exposed infants plus pentavalent vaccine. The reference strategy provided neither maternal screening nor infant vaccination. Rates of HBV infection and costs were compared. The reference strategy had an HBV infection rate of 2360 per 10 000 children. The HBV infection rate for strategy 1 was 813 per 10 000 children vaccinated (1547 cases p...

Research paper thumbnail of Factors Associated with PMTCT Cascade Completion in Four African Countries

AIDS Research and Treatment, 2016

Background. Many countries are working to reduce or eliminate mother-to-child transmission (MTCT)... more Background. Many countries are working to reduce or eliminate mother-to-child transmission (MTCT) of HIV. Prevention efforts have been conceptualized as steps in a cascade but cascade completion rates during and after pregnancy are low. Methods. A cross-sectional survey was performed across 26 communities in Cameroon, Cote d’Ivoire, South Africa, and Zambia. Women who reported a pregnancy within two years were enrolled. Participant responses were used to construct the PMTCT cascade with all of the following steps required for completion: at least one antenatal visit, HIV testing performed, HIV testing result received, initiation of maternal prophylaxis, and initiation of infant prophylaxis. Factors associated with cascade completion were identified using multivariable logistic regression modeling. Results. Of 976 HIV-infected women, only 355 (36.4%) completed the PMTCT cascade. Although most women (69.2%) did not know their partner’s HIV status; awareness of partner HIV status was a...

Research paper thumbnail of Hepatitis B, HIV, and Syphilis Seroprevalence in Pregnant Women and Blood Donors in Cameroon

Infectious Diseases in Obstetrics and Gynecology, 2016

Objectives. We estimated seroprevalence and correlates of selected infections in pregnant women a... more Objectives. We estimated seroprevalence and correlates of selected infections in pregnant women and blood donors in a resource-limited setting.Methods. We performed a cross-sectional analysis of laboratory seroprevalence data from pregnant women and voluntary blood donors from facilities in Cameroon in 2014. Rapid tests were performed to detect hepatitis B surface antigen, syphilis treponemal antibodies, and HIV-1/2 antibodies. Blood donations were also tested for hepatitis C and malaria.Results. The seroprevalence rates and ranges among 7069 pregnant women were hepatitis B 4.4% (1.1–9.6%), HIV 6% (3.0–10.2%), and syphilis 1.7% (1.3–3.8%) with significant variability among the sites. Correlates of infection in pregnancy in adjusted regression models included urban residence for hepatitis B (aOR 2.9, CI 1.6–5.4) and HIV (aOR 3.5, CI 1.9–6.7). Blood donor seroprevalence rates and ranges were hepatitis B 6.8% (5.0–8.8%), HIV 2.2% (1.4–2.8%), syphilis 4% (3.3–4.5%), malaria 1.9%, and he...

Research paper thumbnail of 17‐Hydroxyprogesterone caproate in triplet pregnancy: an individual patient data meta‐analysis

BJOG: An International Journal of Obstetrics & Gynaecology, 2015

BackgroundPreterm birth complicates almost all triplet pregnancies and no preventive strategy has... more BackgroundPreterm birth complicates almost all triplet pregnancies and no preventive strategy has proven effective.ObjectiveTo determine, using individual patient data (IPD) meta‐analysis, whether the outcome of triplet pregnancy is affected by prophylactic administration of 17‐hydroxyprogesterone caproate (17OHPc).Search strategyWe searched literature databases, trial registries and references in published articles.Selection criteriaRandomised controlled trials (RCTs) of progestogens versus control that included women with triplet pregnancies.Data collection and analysisInvestigators from identified RCTs collaborated on the protocol and contributed their IPD. The primary outcome was a composite measure of adverse perinatal outcome. The secondary outcome was the rate of birth before 32 weeks of gestation. Other pre‐specified outcomes included randomisation‐to‐delivery interval and rates of birth at <24, <28 and <34 weeks of gestation.Main resultsThree RCTs of 17OHPc versus ...

Research paper thumbnail of Examining the Starting Dose of Glyburide in Gestational Diabetes

American Journal of Perinatology, 2015

OBJECTIVE-The aim of this study was to determine the impact of initial glyburide dosing on pregna... more OBJECTIVE-The aim of this study was to determine the impact of initial glyburide dosing on pregnancy outcomes. STUDY DESIGN-Retrospective cohort of singleton pregnancies complicated by gestational diabetes (GDM) from 2007-2013. Women who received glyburide were compared by initial dose: 2.5mg (n=170) versus 5mg (n=154) total daily dose. The primary maternal outcome was hypoglycemia, defined as a blood glucose <60 mg/dL. The primary neonatal outcome was birth weight. Secondary maternal outcomes included time to blood glucose control, preeclampsia, and cesarean delivery. Secondary neonatal outcomes included macrosomia (>4000g), hypoglycemia (<40 mg/dL), shoulder dystocia, and preterm delivery. RESULTS-The 5 mg/day glyburide dose did not increase maternal hypoglycemia (26% in the 2.5 mg/day group versus 27% in the 5 mg/day group, AOR 0.67 (CI 0.30-1.49)). An increase in macrosomia in the 5 mg/day group was not significant after adjusting for maternal obesity (AOR 2.16 (CI 0.96-4.88)). Differences in preterm birth and large for gestational age were not significant after adjusting for prior preterm birth and maternal obesity, respectively. CONCLUSIONS-A higher starting dose of glyburide for the management of GDM was not associated with increased maternal hypoglycemia or decreased adverse neonatal outcomes.

Research paper thumbnail of Assessing White's Classification of Pregestational Diabetes in a Contemporary Diabetic Population

Obstetrics & Gynecology, 2015

To assess the validity of White's classification, including the role of chronic hypertension, in ... more To assess the validity of White's classification, including the role of chronic hypertension, in a contemporary diabetic population. METHODS: We performed a retrospective cohort study of all singleton pregnancies with pre-existing diabetes mellitus from 2008 to 2013. Adverse outcomes were compared across classes B, C, D, and vascular disease (R, F, H) and further stratified by the presence or absence of chronic hypertension. Outcomes examined were a composite perinatal outcome (stillbirth, neonatal death, shoulder dystocia, birth injury, seizures, requiring chest compressions or intubation at delivery, blood pressure support), small for gestational age (SGA), large for gestational age (LGA), macrosomia, shoulder dystocia, preterm delivery at less than 37 weeks of gestation, preeclampsia, and cesarean delivery. RESULTS: Of the 475 patients, the 1980 White's classification was significantly associated with SGA, LGA, macrosomia, preterm delivery, preeclampsia, and cesarean delivery (P#.01). Within each White's class based on age or time since diagnosis alone, hypertension was significantly associated with a higher incidence of preeclampsia in class B (16% without hypertension compared with 32% with hypertension, P,.01) and C (22% compared with 40%, P5.04), SGA in C (4.7% compared with 21%, P,.01), preterm delivery in B (25% compared with 46%, P,.01) and C (35% compared with 58%, P5.01), and the composite neonatal outcome in B (7.9% compared with 17%, P5.03). The incidence of adverse outcomes in classes B and C with hypertension resembles the incidence of adverse outcomes in those with diabetes one class higher. CONCLUSION: The 1980 White's classification system, taking into consideration the presence of chronic hypertension, remains a useful system for counseling pregestational diabetic women regarding adverse pregnancy outcomes.

Research paper thumbnail of Predictors of Infant Hepatitis B Immunization in Cameroon: Data to Inform Implementation of a Hepatitis B Birth Dose

Pediatric Infectious Disease Journal, 2018

Background-Although most African countries offer hepatitis B immunization through a 3-dose vaccin... more Background-Although most African countries offer hepatitis B immunization through a 3-dose vaccine series recommended at 6, 10, and 14 weeks of age, very few provide birth dose vaccination. In support of Cameroon's national plan to implement the birth dose vaccine in 2017, we investigated predictors of infant hepatitis B virus (HBV) vaccination under the current program. Methods-Using the 2011 Demographic Health Survey in Cameroon, we identified women with at least one living child (age 12-60 months) and information about the hepatitis B vaccine series. Vaccination rates were calculated and logistic regression modeling was used to identify factors associated with 3-dose series completion. Changes over time were assessed with linear logistic model. Results-Among 4594 mothers analyzed, 66.7% (95% CI 64.1-69.3) of infants completed the hepatitis B vaccine series; however, an average four week delay in series initiation was noted with median dose timing at 10, 14 and 19 weeks of age. Predictors of series completion included

Research paper thumbnail of HIV Status and Contraceptive Utilization among Women in Cameroon

Journal of the International Association of Providers of AIDS Care, 2019

Objective: We examined patterns of contraceptive utilization by HIV status among women in Cameroo... more Objective: We examined patterns of contraceptive utilization by HIV status among women in Cameroon, hypothesizing that women living with HIV would utilize contraception at higher rates than their HIV-negative peers. Methods: Deidentified, clinical data from the Cameroon Baptist Convention Health Services (2007-2013) were analyzed (N ¼ 8995). Frequencies compared outcomes between women living with HIV (15.1%) and uninfected women. Multivariate analyses examined associates of contraceptive utilization and desire to become pregnant. Results: Contraceptive utilization was associated with higher education, living with HIV, monogamy, and higher parity (P < .001). Women living with HIV had 66% higher odds of using contraceptives than their negative peers (odds ratio [OR]: 1.66, confidence interval [CI]: 1.45-1.91, P < .001). Polygamous women had 37% lower odds of using contraceptives compared to monogamous women (OR: 0.63, 95% CI: 0.52-0.75, P < .001). Conclusion: Increasing contraceptive utilization in resource-constrained settings should be a priority for clinicians and researchers. Doing so could improve population health by reducing HIV transmission between partners and from mother to child.

Research paper thumbnail of Predicting Postpartum Hemorrhage in Laboring Patients in Cameroon, Africa

American Journal of Obstetrics and Gynecology, 2022

Research paper thumbnail of Prevalence of group B streptococcus anogenital colonization and feasibility of an intrapartum screening and antibiotic prophylaxis protocol in Cameroon, Africa

International journal of gynaecology and obstetrics, Jun 10, 2019

Objective:To evaluate group B streptococcus (GBS) colonization prevalence and feasibility of intr... more Objective:To evaluate group B streptococcus (GBS) colonization prevalence and feasibility of intrapartum GBS screening/antibiotic prophylaxis (IAP) in Cameroon, Africa.Methods:Prospective cohort in the Cameroon Baptist Convention Health Services network. Maternity providers collected anogenital swabs from consenting term women in labor for testing by a rapid GBS-polymerase chain reaction (PCR) system. Positive tests (GBS+) resulted in initiation of intravenous ampicillin until delivery. Primary outcomes were GBS prevalence and proportion of GBS+ women receiving ampicillin before delivery and more than 4 hours before delivery.Results:A total of 219 women were enrolled from January 10 to April 27, 2017. GBS prevalence was 12.3% (95% confidence interval [CI] 7.9–16.7) with GBS+ women more likely to reside in urban areas (19.6% vs 9.7%, P=0.004). Of 27 GBS+ women, 19 (70.4%) received ampicillin before delivery and 14 (51.9%) 4 hours or longer before delivery. A median two doses of ampicillin (interquartile range [IQR] 1–5) were given and started at a median of 105 minutes (IQR 90–155) after swab collection and 20 minutes (IQR 10–45) after GBS result. Of the 8 women who did not receive ampicillin, 7 (87.5%) delivered before test results.Conclusion:A GBS IAP protocol is feasible in Cameroon and should be evaluated for widespread implementation in Cameroon and other low-income countries to decrease GBS-related morbidity.

Research paper thumbnail of 934: Prevalence, perinatal outcomes, and maternal risk factors for Group B Streptococcus colonization in a low-income country

American Journal of Obstetrics and Gynecology, 2018

regarding country of origin, time in US, insurance, education and household income. Up to 4900 ad... more regarding country of origin, time in US, insurance, education and household income. Up to 4900 additional variables were abstracted including documentation of prenatal visits (PNV), antenatal and intrapartum care & lab values. Publicly available google search trends were mined for search terms "Make America Great Again", "Mexico wall" and "Deportation" in the southern US. The time of first deviation from the mode google search popularity value for each term was ascertained (mode inflection). Perinatal data was averaged over 15 day moving windows to determine mean days from conception to 1st PNV, number of PNVs, and intrapartum nadir hemoglobin (Hgb) as a proxy for likely iron deficiency and/or PPH. Linear regression and Student's t-tests were used to determine linear trends and mean differences before and after mode inflection. RESULTS: 24,933 occurred during the study period. A mode inflection date of 7/1/2015 was extrapolated from the google search analytics (Fig 1A). Coincident with the mode inflection, there was a significant increase in days until first PNV, fewer PNVs and a decreased trend of mean Hgb nadir (Fig 1B). These observations were notably significant among gravidae of Central American and Mexican origin, but not South Americans (Fig 1C). CONCLUSION: Our findings are of likely significant public health importance, and suggest that recent political rhetoric alters timely and regular access to PNC among nearly 25,000 deliveries in Texas. We speculate that such rhetoric lends to delayed and diminished PNC in vulnerable populations, and may contribute to maternal mortality in our region. These observations are worth of future causal analysis.

Research paper thumbnail of Predicting peripartum infection in laboring patients at high risk in Cameroon, Africa

American Journal of Obstetrics and Gynecology, 2022

Research paper thumbnail of 7 Oral azithromycin ± amoxicillin to prevent peripartum infection in laboring high-risk women: A 3-Arm RCT

American Journal of Obstetrics and Gynecology, Feb 1, 2021

Research paper thumbnail of 390: Prevention of hepatitis B in sub-Saharan Africa: a decision analytic model for the birth dose vaccine

American Journal of Obstetrics and Gynecology, 2017

Of 594 eligible women, 268 (45.1%) had documented inpatient contraceptive counseling, but only 12... more Of 594 eligible women, 268 (45.1%) had documented inpatient contraceptive counseling, but only 127 (21.4%) left the hospital using a WHO tier 1 or 2 method (Figure). Women who were younger, non-Hispanic black, multiparous, and delivered at earlier gestational ages were more likely to be have counseling documented (Table). Notably, compared to women with private insurance, women with public insurance were significantly more likely to have documented counseling (23.6% vs. 87.5%, p<0.001; aOR 8.49, 95% CI 4.74-15.20) and to uptake a WHO Tier 1 or 2 method as an inpatient (5.8% vs 52.0%, p<0.001; aOR 8.89, 95% CI 4.47-17.70). Of the subgroup of 175 women with outpatient PP records available and who attended a postpartum visit, 98.3% received contraceptive counseling. However, in this subgroup, only 96 (54.9%) adopted a WHO tier 1 or tier 2 method at the postpartum visit. Public insurance and multiparity were positively associated with a WHO Tier 1 or 2 method use by the completion of postpartum care. CONCLUSION: Documented PP contraceptive counseling and effective contraceptive use among women at high risk for recurrent PTB is far from universal. It is notable that women in economically disadvantaged communities received more documented counseling and highly effective contraceptives. The reasons for such differences should be explored.

Research paper thumbnail of Relationship Between Infertility and Digital Cervicography Findings in Cameroonian Women

International journal of women's health and reproduction sciences, Mar 23, 2018

Objectives: Cervical neoplasia and some forms of infertility are caused by sexually transmitted i... more Objectives: Cervical neoplasia and some forms of infertility are caused by sexually transmitted infections. We aimed at evaluating whether positive findings on digital cervicography (DC) (performed to screen and treat cervical neoplasia) is associated with female infertility. Materials and Methods: In this cross-sectional study, women consulting for infertility underwent cervical cancer screening using DC alongside women without infertility. A total of 2128 Cameroonian women were studied. Women with infertility were subcategorized into primary and secondary infertility. Potential confounders were assessed at the screening visit and logistic regression was used to compute adjusted relative risks for the relationship between infertility and positive DC findings. Results: Among 2128 women studied, 292 (13.7%) presented due to infertility and 1836 did not; 88 (30.1%) of women with infertility had primary infertility and 204 (69.9%) had secondary infertility. Women with infertility had a positive DC prevalence rate of 15.9% compared to 13.6% for women without infertility (P = 0.31). The prevalence rates of positive DC among women with primary infertility or among those with secondary infertility respectively, did not differ from the rate in those without infertility. After multivariable adjustments relative to those without infertility, the adjusted relative risks (aRRs) (95% CI) for a positive DC were: 0.91 (0.62-1.20) for any infertility, 0.99 (0.65-1.51) for secondary infertility and 0.73 (0.38-1.41) for primary infertility. Conclusions: Results of DC were not significantly associated with infertility (and its subtypes). Further investigations are required to evaluate the association with other cervical cancer screening modalities like Pap smear and HPV DNA-testing.

Research paper thumbnail of Single Dose of Oral Azithromycin With or Without Amoxicillin to Prevent Peripartum Infection in Laboring, High-Risk Women in Cameroon

Obstetrics & Gynecology, Oct 6, 2021

OBJECTIVE: To compare the effectiveness of single-dose azithromycin, with or without amoxicillin,... more OBJECTIVE: To compare the effectiveness of single-dose azithromycin, with or without amoxicillin, with placebo to prevent peripartum infection in laboring women. METHODS: We conducted a multicenter, three-group, double-blind randomized controlled trial of women with viable term nonanomalous pregnancies with either prolonged labor of 18 hours or longer or rupture of membranes for 8 hours or longer in Cameroon. Women with chorioamnionitis before randomization, study drug contraindications, or planned cesarean births were excluded. Women were randomized to oral azithromycin 1 g–placebo (group 1), oral azithromycin 1 g–oral amoxicillin 2 g (group 2), or placebo–placebo (group 3). All groups received usual care, including antibiotics given at the health care professional's discretion. The primary outcome was a composite of maternal peripartum infection or death from any cause up to 6 weeks postpartum. Two primary comparisons (group 1 vs group 3 and group 2 vs group 3) were planned. We estimated that 241 women per group (planning for 750 total) would provide 80% power at two-sided α=0.05 (0.025 per comparison) to detect a 50% effect size assuming 20% baseline composite infection rate. RESULTS: From January 6, 2018, to May 15, 2020, 6,531 women were screened, and 756 (253 in group 1, 253 in group 2, and 250 in group 3) were randomized. Baseline characteristics (including body mass index, duration of rupture of membranes or labor, and parity) were balanced across groups, except for maternal age. More than 60% of women in each group received usual-care antibiotics: more than 90% penicillin and approximately 50% for prolonged rupture of membranes across all study groups. Composite outcome incidences were similar in antibiotic groups 1 (6%) and 2 (7%) compared with placebo group 3 (10%) (RR 0.6, 95% CI 0.3–1.2; 0.7, 95% CI 0.4–1.3, respectively). Chorioamnionitis and wound infection were significantly lower in group 2 (3.2% vs 0.4% and 4% vs 0.8% respectively, both P=.02) compared with group 3. There were no differences in other maternal or neonatal outcomes including neonatal infection. CONCLUSION: A single dose of oral azithromycin with or without amoxicillin for prolonged labor or rupture of membranes at term did not reduce maternal peripartum or neonatal infection. Observed lower than expected infection rates and frequent usual-care antibiotic use may have contributed to these findings. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03248297. FUNDING SOURCE: Merck for Mothers Investigator Studies Program grant.

Research paper thumbnail of A decision analytic model for prevention of hepatitis B virus infection in Sub-Saharan Africa using birth-dose vaccination

International journal of gynaecology and obstetrics, Jan 31, 2018

Objective-To compare prenatal maternal hepatitis B virus (HBV) screening and infant vaccination s... more Objective-To compare prenatal maternal hepatitis B virus (HBV) screening and infant vaccination strategies to inform policy on HBV prevention in Sub-Saharan Africa. Methods-A decision analytic model was created using previously published data to assess the ability of three intervention strategies to prevent HBV infection by age 10 years. Strategy 1 comprised of universal vaccination with a pentavalent vaccine (HBV, diphtheria, tetanus, pertussis, and Haemophilus influenzae) at age 6 weeks. Strategy 2 comprised of universal HBV vaccine at birth plus pentavalent vaccine. Strategy 3 comprised of maternal prenatal HBV screening and targeted HBV vaccine at birth for all exposed infants plus pentavalent vaccine. The reference strategy provided neither maternal screening nor infant vaccination. Rates of HBV infection and costs were compared. Results-The reference strategy had an HBV infection rate of 2360 per 10 000 children. The HBV infection rate for strategy 1 was 813 per 10 000 children vaccinated (1547 cases prevented). Strategies 2 and 3 prevented an additional 384 cases and 362 cases, respectively. Inclusion of HBV vaccination at birth was the preferred approach at a willingness-to-pay threshold of US$150. Conclusion-Including a birth-dose HBV vaccine in the standard schedule was both costeffective and prevented additional infections.

Research paper thumbnail of Factors Associated with PMTCT Cascade Completion in Four African Countries

Aids Research and Treatment, 2016

Background. Many countries are working to reduce or eliminate mother-to-child transmission (MTCT)... more Background. Many countries are working to reduce or eliminate mother-to-child transmission (MTCT) of HIV. Prevention efforts have been conceptualized as steps in a cascade but cascade completion rates during and after pregnancy are low. Methods. A cross-sectional survey was performed across 26 communities in Cameroon, Cote d'Ivoire, South Africa, and Zambia. Women who reported a pregnancy within two years were enrolled. Participant responses were used to construct the PMTCT cascade with all of the following steps required for completion: at least one antenatal visit, HIV testing performed, HIV testing result received, initiation of maternal prophylaxis, and initiation of infant prophylaxis. Factors associated with cascade completion were identified using multivariable logistic regression modeling. Results. Of 976 HIV-infected women, only 355 (36.4%) completed the PMTCT cascade. Although most women (69.2%) did not know their partner's HIV status; awareness of partner HIV status was associated with cascade completion (aOR 1.4, 95% CI 1.01-2.0). Completion was also associated with receiving an HIV diagnosis prior to pregnancy compared with HIV diagnosis during or after pregnancy (aOR 14.1, 95% CI 5.2-38.6). Conclusions. Pregnant women with HIV infection in Africa who were aware of their partner's HIV status and who were diagnosed with HIV before pregnancy were more likely to complete the PMTCT cascade.

Research paper thumbnail of 934: Prevalence, perinatal outcomes, and maternal risk factors for Group B Streptococcus colonization in a low-income country

American Journal of Obstetrics and Gynecology

regarding country of origin, time in US, insurance, education and household income. Up to 4900 ad... more regarding country of origin, time in US, insurance, education and household income. Up to 4900 additional variables were abstracted including documentation of prenatal visits (PNV), antenatal and intrapartum care & lab values. Publicly available google search trends were mined for search terms "Make America Great Again", "Mexico wall" and "Deportation" in the southern US. The time of first deviation from the mode google search popularity value for each term was ascertained (mode inflection). Perinatal data was averaged over 15 day moving windows to determine mean days from conception to 1st PNV, number of PNVs, and intrapartum nadir hemoglobin (Hgb) as a proxy for likely iron deficiency and/or PPH. Linear regression and Student's t-tests were used to determine linear trends and mean differences before and after mode inflection. RESULTS: 24,933 occurred during the study period. A mode inflection date of 7/1/2015 was extrapolated from the google search analytics (Fig 1A). Coincident with the mode inflection, there was a significant increase in days until first PNV, fewer PNVs and a decreased trend of mean Hgb nadir (Fig 1B). These observations were notably significant among gravidae of Central American and Mexican origin, but not South Americans (Fig 1C). CONCLUSION: Our findings are of likely significant public health importance, and suggest that recent political rhetoric alters timely and regular access to PNC among nearly 25,000 deliveries in Texas. We speculate that such rhetoric lends to delayed and diminished PNC in vulnerable populations, and may contribute to maternal mortality in our region. These observations are worth of future causal analysis.

Research paper thumbnail of Effect of Prophylactic Negative Pressure Wound Therapy vs. Standard Wound Dressing on Surgical-Site Infection in Obese Women After Cesarean Delivery

Obstetric Anesthesia Digest, 2021

(JAMA. 2020;324:1180–1189) Maternal obesity is associated with greater likelihood of cesarean del... more (JAMA. 2020;324:1180–1189) Maternal obesity is associated with greater likelihood of cesarean delivery and higher risk of surgical-site infection. While prophylactic negative pressure wound therapy using portable, single-use systems has been increasingly used following cesarean delivery, larger studies are needed to evaluate its ability to decrease infections. This study aimed to compare the effects of prophylactic negative pressure wound therapy and standard wound dressing on risk of surgical-site infections. The authors hypothesized negative pressure wound therapy would decrease infections.

Research paper thumbnail of A decision analytic model for prevention of hepatitis B virus infection in Sub-Saharan Africa using birth-dose vaccination

International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics, Jan 8, 2018

To compare prenatal maternal hepatitis B virus (HBV) screening and infant vaccination strategies ... more To compare prenatal maternal hepatitis B virus (HBV) screening and infant vaccination strategies to inform policy on HBV prevention in Sub-Saharan Africa. A decision analytic model was created using previously published data to assess the ability of three intervention strategies to prevent HBV infection by age 10 years. Strategy 1 comprised of universal vaccination with a pentavalent vaccine (HBV, diphtheria, tetanus, pertussis, and Haemophilus influenzae) at age 6 weeks. Strategy 2 comprised of universal HBV vaccine at birth plus pentavalent vaccine. Strategy 3 comprised of maternal prenatal HBV screening and targeted HBV vaccine at birth for all exposed infants plus pentavalent vaccine. The reference strategy provided neither maternal screening nor infant vaccination. Rates of HBV infection and costs were compared. The reference strategy had an HBV infection rate of 2360 per 10 000 children. The HBV infection rate for strategy 1 was 813 per 10 000 children vaccinated (1547 cases p...

Research paper thumbnail of Factors Associated with PMTCT Cascade Completion in Four African Countries

AIDS Research and Treatment, 2016

Background. Many countries are working to reduce or eliminate mother-to-child transmission (MTCT)... more Background. Many countries are working to reduce or eliminate mother-to-child transmission (MTCT) of HIV. Prevention efforts have been conceptualized as steps in a cascade but cascade completion rates during and after pregnancy are low. Methods. A cross-sectional survey was performed across 26 communities in Cameroon, Cote d’Ivoire, South Africa, and Zambia. Women who reported a pregnancy within two years were enrolled. Participant responses were used to construct the PMTCT cascade with all of the following steps required for completion: at least one antenatal visit, HIV testing performed, HIV testing result received, initiation of maternal prophylaxis, and initiation of infant prophylaxis. Factors associated with cascade completion were identified using multivariable logistic regression modeling. Results. Of 976 HIV-infected women, only 355 (36.4%) completed the PMTCT cascade. Although most women (69.2%) did not know their partner’s HIV status; awareness of partner HIV status was a...

Research paper thumbnail of Hepatitis B, HIV, and Syphilis Seroprevalence in Pregnant Women and Blood Donors in Cameroon

Infectious Diseases in Obstetrics and Gynecology, 2016

Objectives. We estimated seroprevalence and correlates of selected infections in pregnant women a... more Objectives. We estimated seroprevalence and correlates of selected infections in pregnant women and blood donors in a resource-limited setting.Methods. We performed a cross-sectional analysis of laboratory seroprevalence data from pregnant women and voluntary blood donors from facilities in Cameroon in 2014. Rapid tests were performed to detect hepatitis B surface antigen, syphilis treponemal antibodies, and HIV-1/2 antibodies. Blood donations were also tested for hepatitis C and malaria.Results. The seroprevalence rates and ranges among 7069 pregnant women were hepatitis B 4.4% (1.1–9.6%), HIV 6% (3.0–10.2%), and syphilis 1.7% (1.3–3.8%) with significant variability among the sites. Correlates of infection in pregnancy in adjusted regression models included urban residence for hepatitis B (aOR 2.9, CI 1.6–5.4) and HIV (aOR 3.5, CI 1.9–6.7). Blood donor seroprevalence rates and ranges were hepatitis B 6.8% (5.0–8.8%), HIV 2.2% (1.4–2.8%), syphilis 4% (3.3–4.5%), malaria 1.9%, and he...

Research paper thumbnail of 17‐Hydroxyprogesterone caproate in triplet pregnancy: an individual patient data meta‐analysis

BJOG: An International Journal of Obstetrics & Gynaecology, 2015

BackgroundPreterm birth complicates almost all triplet pregnancies and no preventive strategy has... more BackgroundPreterm birth complicates almost all triplet pregnancies and no preventive strategy has proven effective.ObjectiveTo determine, using individual patient data (IPD) meta‐analysis, whether the outcome of triplet pregnancy is affected by prophylactic administration of 17‐hydroxyprogesterone caproate (17OHPc).Search strategyWe searched literature databases, trial registries and references in published articles.Selection criteriaRandomised controlled trials (RCTs) of progestogens versus control that included women with triplet pregnancies.Data collection and analysisInvestigators from identified RCTs collaborated on the protocol and contributed their IPD. The primary outcome was a composite measure of adverse perinatal outcome. The secondary outcome was the rate of birth before 32 weeks of gestation. Other pre‐specified outcomes included randomisation‐to‐delivery interval and rates of birth at <24, <28 and <34 weeks of gestation.Main resultsThree RCTs of 17OHPc versus ...

Research paper thumbnail of Examining the Starting Dose of Glyburide in Gestational Diabetes

American Journal of Perinatology, 2015

OBJECTIVE-The aim of this study was to determine the impact of initial glyburide dosing on pregna... more OBJECTIVE-The aim of this study was to determine the impact of initial glyburide dosing on pregnancy outcomes. STUDY DESIGN-Retrospective cohort of singleton pregnancies complicated by gestational diabetes (GDM) from 2007-2013. Women who received glyburide were compared by initial dose: 2.5mg (n=170) versus 5mg (n=154) total daily dose. The primary maternal outcome was hypoglycemia, defined as a blood glucose <60 mg/dL. The primary neonatal outcome was birth weight. Secondary maternal outcomes included time to blood glucose control, preeclampsia, and cesarean delivery. Secondary neonatal outcomes included macrosomia (>4000g), hypoglycemia (<40 mg/dL), shoulder dystocia, and preterm delivery. RESULTS-The 5 mg/day glyburide dose did not increase maternal hypoglycemia (26% in the 2.5 mg/day group versus 27% in the 5 mg/day group, AOR 0.67 (CI 0.30-1.49)). An increase in macrosomia in the 5 mg/day group was not significant after adjusting for maternal obesity (AOR 2.16 (CI 0.96-4.88)). Differences in preterm birth and large for gestational age were not significant after adjusting for prior preterm birth and maternal obesity, respectively. CONCLUSIONS-A higher starting dose of glyburide for the management of GDM was not associated with increased maternal hypoglycemia or decreased adverse neonatal outcomes.

Research paper thumbnail of Assessing White's Classification of Pregestational Diabetes in a Contemporary Diabetic Population

Obstetrics & Gynecology, 2015

To assess the validity of White's classification, including the role of chronic hypertension, in ... more To assess the validity of White's classification, including the role of chronic hypertension, in a contemporary diabetic population. METHODS: We performed a retrospective cohort study of all singleton pregnancies with pre-existing diabetes mellitus from 2008 to 2013. Adverse outcomes were compared across classes B, C, D, and vascular disease (R, F, H) and further stratified by the presence or absence of chronic hypertension. Outcomes examined were a composite perinatal outcome (stillbirth, neonatal death, shoulder dystocia, birth injury, seizures, requiring chest compressions or intubation at delivery, blood pressure support), small for gestational age (SGA), large for gestational age (LGA), macrosomia, shoulder dystocia, preterm delivery at less than 37 weeks of gestation, preeclampsia, and cesarean delivery. RESULTS: Of the 475 patients, the 1980 White's classification was significantly associated with SGA, LGA, macrosomia, preterm delivery, preeclampsia, and cesarean delivery (P#.01). Within each White's class based on age or time since diagnosis alone, hypertension was significantly associated with a higher incidence of preeclampsia in class B (16% without hypertension compared with 32% with hypertension, P,.01) and C (22% compared with 40%, P5.04), SGA in C (4.7% compared with 21%, P,.01), preterm delivery in B (25% compared with 46%, P,.01) and C (35% compared with 58%, P5.01), and the composite neonatal outcome in B (7.9% compared with 17%, P5.03). The incidence of adverse outcomes in classes B and C with hypertension resembles the incidence of adverse outcomes in those with diabetes one class higher. CONCLUSION: The 1980 White's classification system, taking into consideration the presence of chronic hypertension, remains a useful system for counseling pregestational diabetic women regarding adverse pregnancy outcomes.