bluuebunny/crossref_metadata_2025 huggingface dataset:
Declining Insulin Requirements in Late Pregnancy: A Cause for Concern? [07D]
Authors: Wilkinson Barbara E. , McDonnell Marie , Palermo Nadine , Lassey Sarah C. , Little Sarah E.
Published: April 2020

INTRODUCTION:

There is conflicting data on whether diminishing insulin requirement at the end of pregnancy is a sign of placental insufficiency. This study gathered descriptive data on women with diminishing insulin requirement and their obstetric and neonatal outcomes.

METHODS:

This was a retrospective cohort study of women who received antenatal care between November 2017 and May 2019 in a clinic of endocrinologists and obstetricians. We hypothesized that women with a declining insulin requirement would have increased rates of placental dysfunction-related complications (oligohydramnios, IUGR, abnormal dopplers, non-reassuring antepartum testing, or a cesarean delivery for non-reassuring fetal heart tracing).

RESULTS:

Our cohort consisted of 157 women: 30 Type 1, 43 Type 2 and 84 gestational diabetics. Twenty-one (13%) experienced a drop in insulin with an average decline of 28% starting at 34 weeks. There was no significant difference in complications related to placental dysfunction (33% vs 24%; P=.37). There was a significantly increased rate of polyhydramnios (43% vs. 9%; P<.01). Women who experienced a decline in insulin delivered one week earlier (median 36w4d vs. 37w4d; P<.01). NICU admissions rates were higher (62% vs. 33%; P<.01) independent of gestational age, and were secondary to respiratory distress (52% vs. 24%; P<.01) as there were no differences in rates of treated hypoglycemia.

CONCLUSION:

We found no relationship between a decline in insulin requirement and placental function-related complications. Interestingly, we found higher rates of polyhydramnios and NICU admissions for respiratory distress regardless of gestational age, suggesting a decline in insulin requirement has a greater impact on the neonate after delivery.
Macrosomia as a Marker for Adverse Perinatal Outcomes in Pregnancy Complicated by Diabetes Mellitus [24D]
Authors: Davitt Caroline , Packer Claire , Caughey Aaron B.
Published: April 2020

INTRODUCTION:

We sought to examine the strength of macrosomia as a marker for adverse perinatal outcomes associated with poor glycemic control in women with a pre-gestational diagnosis of diabetes mellitus.

METHODS:

A retrospective cohort study of 8,535 women in California with singleton, vertex, non-anomalous gestations was performed to assess prevalence of adverse perinatal outcomes in macrosomic pregnancies complicated by diabetes mellitus. Macrosomia was defined as a birth weight greater than 4000 g. Neonatal outcomes examined included respiratory distress syndrome (RDS), hypoglycemia, jaundice, neonatal death (NND) and intrauterine fetal demise (IUFD). Maternal complications included preeclampsia, post-partum hemorrhage and chorioamnionitis. Confounding variables were controlled for and Chi-squared analyses with a P-value of less than 0.05 were considered statistically significant.

RESULTS:

Overall, macrosomia in pre-gestational diabetic women proved to be a reliable marker for increased perinatal complications. Neonatal complications were most pronounced, with macrosomic neonates at a significantly increased risk for RDS (3.81% vs 1.81% P<.001), hypoglycemia (1.24% vs 0.66% P=.007), jaundice (29.09% vs 23.06% P<.001), NND (0.19% vs 0.04% P=.024) and IUFD (1.38% vs 0.43% P<.001). Macrosomia characterized by birth weight of greater than 4500 g showed similar statistical significance in increased risk of each complication. Both classifications of macrosomia showed decreased incidence of chorioamnionitis (1.38% vs 2.52% P=.002, 1.06% vs. 2.36% P=.031).

CONCLUSION:

Macrosomia in diabetic women is a reliable marker for adverse neonatal outcomes, including increased risks for IUFD and neonatal death. Women should be counseled about these risks and managed accordingly throughout their pregnancies.
Correlation Between Indication for Cesarean Delivery and Postpartum Depression [10E]
Authors: Sega Annalisa , Cozart Ashely , Reyes-Foster Beatriz
Published: April 2020

INTRODUCTION:

Postpartum depression (PPD) is the most common complication of childbearing yet has little etiological evidence. Understanding the potential connection between PPD and birth experience is essential to improving maternal health.

METHODS:

This mixed methods study compares PPD in women who underwent urgent versus elective cesarean deliveries to understand the impact of delivery on the childbirth experience. Retrospective analysis of Listening to Mothers Survey III identified connections between indication for cesarean delivery and PPD. A pre-interview survey utilizing EPDS was administered to mothers who gave birth via cesarean within 12 months. Twenty-five participants with PPD were randomly selected for interviews. Interviews included questions about birth story and postpartum experiences which provided subjective measures of maternal well-being. Interview data was subjected to thematic qualitative analysis using Grounded Theory method. Study is UCF IRB approved.

RESULTS:

Average EDPS score of urgent cesarean section participants was 10.7±6.4, with 68.5% scoring greater than 8 (n=120). Average EDPS score of elective participants was 8.96±5.7, with 52.7% greater than 8 (n=93). The difference in mean score was statistically significant (P<.05). Interview findings revealed several important themes: support, medical interaction, stress, recovery, breastfeeding and sleep. In several cases, participants with PPD were not properly screened, or responses to screening tools were ignored. Several of our study participants reported medical interactions where they felt rushed or ignored by their providers.

CONCLUSION:

The results support our hypothesis that urgent cesarean sections have higher incidence and severity of PPD. Interview analyses highlight important points for potential physician PPD guidelines.
Liposomal Bupivacaine Decreases Pain Scores and Narcotic Use After Cesarean Delivery [19E]
Authors: Kindig Marilyn , Mouch Alexandra , Adams Darren , Maxwell Rose , Yaklic Jerome
Published: April 2020

INTRODUCTION:

Liposomal bupivacaine (LB; Exparel 1.3%) is an extended-release, local anesthetic administered perioperatively for management of postoperative (PO) pain. When used as a liposomal suspension, bupivacaine has a fast onset of action with a duration up to 72 hours. This study examines patient reported pain scores (PRPain) and total morphine equivalents (ME) in patients receiving LB administration via transversus abdominis plane block (LB-TAP) or incisional infiltration (LB-II).

METHODS:

Women receiving LB-TAP (n=107) or LB-II (n=185) after cesarean delivery between January 2018 and January 2019 were included in the study. LB-TAP under ultrasound guidance and LB-II were performed by obstetrician-gynecologists. The infusion solution (80 mL, consisted of 20 ml 1.3% liposomal bupivacaine, 30 ml 1/2% bupivacaine and 30 ml injectable saline) was compounded by the pharmacy and sent to the operating room for injection. Primary endpoints are PRPain scores (10-point visual analog scale) and total PO ME used.

RESULTS:

Women receiving LB-TAP (5.5±1.6) reported higher PRPain than women receiving LB-II (4.6±1.7) on PO day 0 (P<.001). However, groups did not differ on PRPain on PO day 1 or PO day 2. Groups were similar for total ME (LB-TAP=25.18 mg ±42.2 vs LB-II=24.92 mg ±51.3; P<.97).

CONCLUSION:

Our results show that initial differences in PRPain scores on PO day 0 for women receiving LB-TAP versus LB-II were not evident on PO day 1 or PO day 2. LB-TAP and LB-II resulted in similar ME, which was noted to be much lower than a recently published narcotics reducing protocol.
Does Treatment of Antenatal Depression Reduce Postpartum Opioid Consumption? [12E]
Authors: Luck Marissa , Sakowicz Allie , Allen Emma , Daiter Maya , Miller Emily S.
Published: April 2020

INTRODUCTION:

Major depressive disorder (MDD) has been associated with increased opioid use after a cesarean section, however, it is unclear whether treatment of depressive symptoms antenatally to achieve symptom remission reduces postpartum opioid consumption or whether the history of MDD itself reflects an increased risk. We sought to determine whether there were differences in inpatient postpartum opioid use in those with active depressive symptoms proximate to delivery versus those who were euthymic in women with a history of MDD.

METHODS:

This retrospective cohort study included women who received prenatal care and delivered at an academic, single tertiary care hospital between 9/2015 and 1/2019. This project underwent a full IRB review. Women were included if they had a documented history of diagnosed or suspected MDD and had a third trimester depression screen performed. Women were characterized as having depressive symptoms proximate to delivery if their 3rd trimester PHQ9 was ≥10. The number of morphine milligram equivalents (MME) used during the postpartum hospitalization was calculated for each patient. Bivariable and multivariable analyses were performed.

RESULTS:

Of the 321 women who met inclusion criteria, 70 (22%) had depressive symptoms proximate to delivery. These women consumed significantly more opioids postpartum (44±119 vs 23±49 MME, P=.03) and opioid consumption increased with increasing third trimester PHQ9 score (β=2.6, 95% CI 1.0–4.2). These findings persisted in multivariable analyses.

CONCLUSION:

In our study, women with depressive symptoms proximate to delivery consume more opioids in the postpartum period. Targeted depression treatment efforts may help reduce postpartum opioid use.
Toxicology Testing in Pregnancy: Evaluating the Role of Social Profiling [34C]
Authors: Perlman Nicola C. , Smith Nicole A.
Published: April 2020

INTRODUCTION:

Clear guidelines for toxicology testing of pregnant women are lacking, despite significant repercussions associated with positive tests. Implicit bias may lead to inconsistent ordering of urine toxicology (UTox) in pregnancy.

METHODS:

We reviewed all births from 1/1/2015 to 12/31/2018, and identified mothers with UTox sent outside of routine prenatal care. Demographic data was compared in women with UTox and without. Sociodemographic characteristics were examined with Chi-square, fisher's exact, or Wilcoxon rank sum test; adjusted logistic regression models were used for multivariate analysis. Models were adjusted for age, race, marital status, and mean income by residential ZIP code.

RESULTS:

UTox was sent on 2.8% (574) of 20,274 mothers. Women with UTox were younger (P<.0001), more likely “single” (P<.0001), living in the lowest income ZIP code (P<.0001), and were less likely to be white (P<.0001). In multivariate analyses, increasing age and Asian race appeared protective against UTox ordering (OR 0.95 [0.93–0.97]); (OR 0.22 [0.11–0.45]), while Native American race was not (OR 4.66 [1.98–10.99]). Black race was borderline (OR 1.235 [0.981–1.555]). Income by ZIP code exhibited a dose effect, with residence in lower versus higher income ZIP codes more likely to be associated with UTox ordering (OR 2.70 [1.87–3.90] vs. OR 1.68 [1.14–2.48]).

CONCLUSION:

Maternal age, race, marital and socioeconomic status may impacted providers' decisions to order urine toxicology testing. Evidence-based guidelines for toxicology evaluation are essential to more appropriately triage women for whom testing is medically indicated, and to decrease implicit bias in decision making.
Buprenorphine-Naloxone Versus Buprenorphine for Treatment of Opioid Use Disorder in Pregnancy [07E]
Authors: Perry Briana N. , Vais Simone , Miller Melissa , Saia Kelley A.
Published: April 2020

INTRODUCTION:

Treatments for opioid use disorder (OUD) in pregnancy remain understudied. The safety and efficacy of buprenorphine (BUP), a partial opioid agonist, and methadone, a full opioid agonist, in pregnancy has been established (1). Outside of pregnancy, the combination of BUP and naloxone (BUP-NX), a partial opioid antagonist, is commonly favored due to the decreased risk of diversion (2). Historically, women on BUP-NX are transitioned to BUP in pregnancy due to concerns for fetal exposure to naloxone (3,4). Recently, several small retrospective studies explored the use of BUP-NX in pregnancy and found no adverse maternal or neonatal outcomes (5,6). This is the first study to directly compare BUP-NX and BUP use in pregnancy.

METHODS:

This single-center, retrospective cohort study assessed 33 pregnancies managed with BUP-NX and 22 managed with BUP. Maternal outcomes included demographic characteristics, gestational age at treatment initiation, number of prenatal visits, gestational age at delivery, concurrent prescribed psychiatric medications, unprescribed or illicit substance use per urine drug screening, and delivery outcomes. Infant outcomes included birth weight, Apgar scores, and neonatal abstinence syndrome outcomes (diagnosis, treatment, and length of hospital stay).

RESULTS:

There was no significant difference in prenatal care utilization, maternal substance use, delivery outcomes, or neonatal outcomes. Among a subgroup of women transitioned from BUP to BUP-NX mid-pregnancy, no incidences of treatment destabilization were observed post-transition.

CONCLUSION:

Our study finds that BUP-NX is non-inferior to BUP in the treatment of OUD in pregnancy and supports the growing body of data indicating the safety of BUP-NX use in pregnancy.
A Prospective Evaluation of Opioid Consumption Patterns Following Vaginal and Cesarean Deliveries [03E]
Authors: Saini Amanda , Holtz David
Published: April 2020

INTRODUCTION:

There has been increasing pressure placed on healthcare providers to limit excess narcotic prescription. The purpose of our study is to evaluate opioid prescription and consumption patterns following vaginal and cesarean deliveries.

METHODS:

This is an IRB-approved prospective observational study conducted at a private academically-affiliated institution. Demographic and delivery information was abstracted from the medical record. Information regarding opioid type and number of pills prescribed and used was collected via telephone survey after discharge. Results are reported as five-milligram (5mg) oxycodone pills.

RESULTS:

Postpartum opioid utilization is reported for 142 patients. One hundred and one patients received a prescription at discharge. The median number of 5 mg oxycodone pills prescribed after both vaginal and cesarean delivery was 20. The median number of pills used after vaginal and cesarean delivery was 0 and 5, respectively. Of those who filled prescriptions after discharge, the utilization rate after vaginal deliveries was 9.2% and after cesarean deliveries, 43.5%. After 101 deliveries, 1135 opiate pills were unused. There was no relationship between demographics, smoking status, depression/anxiety, use of psychoactive medication, spontaneous versus operative vaginal delivery, planned versus unplanned cesarean delivery, or primary versus repeat cesarean delivery and post-discharge opioid consumption. There were statistically significant relationships between both inpatient opiate use and insurance type with post-discharge opiate consumption.

CONCLUSION:

Postpartum patients consume 0–40% of prescribed pain medication. Predictive factors of post-discharge opiate use include inpatient consumption and insurance type. Limiting the number of pills prescribed in the postpartum period can decrease excess narcotics available for abuse or diversion.
Rate of Gestational Diabetes Between Active Duty and Non-active Duty Beneficiaries at a Military Treatment Facility [34D]
Authors: Odedokun Tolulope , Weir Larissa
Published: April 2020

INTRODUCTION:

To compare the incidence of gestation diabetes mellitus (GDM) in active duty females compared with civilian dependents.

METHODS:

This retrospective cohort analysis was performed at a military medical center with IRB approval. Active duty and dependent status women who delivered between 01 June 2014 and 30 April 2015 were identified along with incidence of GDM. Additional data collected included fetal weight, delivery route, presence of shoulder dystocia, use of diabetes medications, age, gravidity, parity, gestational age at delivery, pre and post pregnancy body mass index (BMI) and race. Chi Squared analysis was used to compare rates of GDM. Sample size calculation determined the need for 391 women in each group to identify a 5% difference in rates of GDM with a power of 80%. P-values of <.05 were considered significant.

RESULTS:

Rates of GDM were similar between the two cohorts (active duty=9.95%, dependent=9.72%, P=.91). Age, gravidity and pre-pregnancy BMI were also similar between groups. The rate of diet controlled GDM were different between the two cohorts (active duty=53.8%, dependent=34.2%, P=.02).

CONCLUSION:

This study highlights that active duty females have similar rates of GDM as dependents. GDM is known to affect short and long-term maternal and neonatal outcomes and it can also impact a soldier's readiness following the pregnancy. Further research is required to determine the long term impact of GDM in active duty females and best practices to decrease rates of GDM in the military population.
Buprenorphine Versus Methadone in Pregnant Women With Opioid Use Disorder: A Cost-Effectiveness Analysis [06E]
Authors: Robin Arianna , Hersh Alyssa R. , Caughey Aaron B.
Published: April 2020

INTRODUCTION:

Opioid use disorder (OUD) during pregnancy has increased more than fourfold since 1999. Methadone is the longstanding treatment of choice for OUD in pregnancy, but recent data demonstrate benefits of buprenorphine, as it is associated with improved neonatal outcomes despite increased drug cost and rates of discontinuation of therapy. This model compares cost-effectiveness of buprenorphine versus methadone in management of OUD during pregnancy.

METHODS:

We used a theoretical cohort of 22,400 pregnant women to approximate the number of pregnancies affected by OUD per year in the United States. Outcomes included maternal retention in maintenance treatment, maternal overdose, neonatal abstinence syndrome, preterm birth, intrauterine growth restriction, and cerebral palsy in addition to cost and quality-adjusted life-years. The cost-effectiveness threshold was set at $100,000/QALY. Model inputs were derived from the literature and varied in sensitivity analyses to assess robustness of the model.

RESULTS:

Despite lower rates of retention and higher associated overdoses, buprenorphine treatment during pregnancy saved over $102 million healthcare dollars and 563 QALYs, making it the dominant strategy over methadone treatment. In our cohort, buprenorphine treatment resulted in 2,886 fewer cases of NAS, 1,006 fewer preterm births, 299 fewer cases of IUGR, 32 fewer stillbirths, and 12 fewer cases of CP. Sensitivity analyses showed that our results were robust over a wide range of assumptions.

CONCLUSION:

Buprenorphine treatment should be considered a first-line option for opioid dependence in pregnancy, as it leads to improved neonatal outcomes compared to methadone despite increased drug cost and risk of treatment discontinuation.
Food Insecurity and Perinatal Outcomes in Gestational Diabetics [11D]
Authors: Cooper Shontreal , Graham Maura , Khangura Raminder , Schmidt Adrienne , Fang Victor , Bakaysa Stephanie
Published: April 2020

INTRODUCTION:

This study's purpose was to 1) evaluate the association between food secure (FS) and food insecure (FI) households in patients with gestational diabetes (GDM) and without gestational diabetes (NGDM), 2) evaluate if GDM in FI households had adverse maternal and neonatal outcomes.

METHODS:

This was an observational study from October 2018 until July 2019. Postpartum women, who delivered, singleton infants ≥37 weeks gestation were recruited. Participants completed a food security survey using the USDA Household Food Security Survey Module. Surveys responses were classified as: FS and FI. The primary outcome was to evaluate the rate of FS in GDM & NGDM. We also evaluated: maternal weight (BMI, total gain), birth weight, mode of delivery, and NICU admission for hypoglycemia. A logistic regression analysis was used with a P<.05 considered significant.

RESULTS:

There were 74 patients (36-GDM, 38-NGDM; P=.01). Overall, 50 (68%) had FS & 24 (32%) had FI (P=.01). Of the 36 GDM patients, 47% (n=17) reported FI, versus 18% (n=7) of NGDM patients (P=.01). Overall, 12% (n=9) of patients had a NICU admission. In GDM group, significant findings between FI vs. FS included: higher maternal weight (BMI 36 kg/m2 vs. 30 kg/m2, total weight gain of 26.7 lbs vs. 16.7 lbs, P=.01) and NICU admissions for hypoglycemia (35% vs. 5%, P=.04).

CONCLUSION:

Gestational diabetics are at increased risk of experiencing FI and will have increased maternal weight gain. Infants of GDM in FI households are at more risk of NICU admission for hypoglycemia.
Influence of Psychiatric Medications on Neonatal Abstinence Syndrome in Women Treated for Opioid Use Disorder [17E]
Authors: Staszewski Cara , Herrera Kimberly , Persad Malini D. , Garretto Diana , Davis Jay , Garry David
Published: April 2020

INTRODUCTION:

This study sought to evaluate the impact of prescribed psychiatric medications on newborn hospital stay in women undergoing treatment for opioid use disorder (OUD).

METHODS:

A cohort of women receiving either methadone or buprenorphine in management of OUD in pregnancy were identified from delivery and newborn records over a 10-year period. Women were excluded with delivery <24 weeks, multiple gestation or known anomalous fetus. Maternal demographics, medications, GA, mode of delivery, BW, NICU admission, newborn length of stay, NAS and treatment requirements for NAS were obtained. The study was IRB approved and standard statistics were used with a P-value of <0.05 considered significant.

RESULTS:

There were 180 women were identified with 101 (56%) receiving methadone and 79 (44%) receiving buprenorphine therapy. The groups were similar for age, parity, race, BMI, marital status, tobacco use, prenatal care, incidence of preterm birth, mode of delivery, and also had similar incidence of NAS (meth 91% vs bup 90%; P=.47). Buprenorphine users had a greater number of women prescribed psychiatric medications (meth 13% vs bup 35%; P<.001), higher GA at delivery (meth 37+2.8 wk vs bup 39+1.8 wk; P<.001), shorter newborn hospital stay (meth 14+10 d vs bup 9+8 d; P<.001) and fewer newborns with NAS requiring treatment (meth 56% vs bup 24%; P<.001). Psychiatric medication usage demonstrated a 4-fold likelihood of a longer newborn hospital stay (>10 d) and buprenorphine a shorter newborn stay.

CONCLUSION:

Psychiatric medication usage is an independent predictor of a longer newborn hospital stay in women undergoing treatment for opioid use disorder.
Comparison of Postoperative Opioid Use in Mothers Whose Neonates Are in Regular Nursery Versus in Neonatal Intensive Care [08E]
Authors: Mehri Sepideh , Ruggiero Lauren , Hoskins Iffath
Published: April 2020

INTRODUCTION:

Postoperative opioid use presents pain management dilemmas because mothers should be alert and engaged with their neonates. Mothers with neonates in intensive care (NICU) have additional stresses and may desire “round the clock” vs “prn” pain management. We compared post-operative opioid usage in mothers with neonates in regular nursery (“regular”) vs. NICU.

METHODS:

From January 1, 2013 through December 12, 2018, postoperative opioid use for days 0 until discharge was retrospectively reviewed. Mothers with “regular” neonates constituted Group 1, and NICU neonates were Group 2. Perioperative substance abusers or chronic opioid users were excluded.

RESULTS:

All the 8136 charts reviewed had orders for narcotic and non-narcotic analgesics. Both agents were used by 84% and only non-narcotic analgesics by 16% of mothers. None used narcotics exclusively. All received narcotic prescriptions at discharge, regardless of postoperative opioid use. Group 1 had 6509 and Group 2 had 1627 mothers. Group 2 diagnoses included prematurity (12%), sepsis (4%), neonates with life threatening anomalies requiring major surgery (3%). No differences occurred in opioid usage between the 2 Groups (43% vs 45%, POD1; 81% vs 80%, POD2; 72% vs 70%, POD3; 20% vs 23%, POD4). Significantly more opioid usage occurred in mothers of neonates with life threatening anomalies.

CONCLUSION:

Mothers with NICU neonates did not demonstrate increased postoperative opioid usage, in spite of the perceived added stresses. However, mothers with neonates having life threatening diagnoses utilized larger amounts of narcotics post-operatively. These findings may have future implications for post discharge pain management.
Infective Endocarditis in Pregnancy During the Opioid Epidemic [16E]
Authors: Brekke Emily , O'Brien John , Stromberg Arnold
Published: April 2020

INTRODUCTION:

To compare the incidence and complications of infective endocarditis among opioid-using pregnant women from 2006–08 and 2016–18.

METHODS:

We conducted a cross-sectional analysis of hospitalizations using a publicly available, all-payer inpatient database in Kentucky. Duplicate patients were identified and removed.

RESULTS:

From 2006–08, 187,178 hospitalizations involved pregnancy of which 1,311 were diagnosed with opioid dependence, use, or abuse. Three of these women had ICD codes for endocarditis (0.23%). From 2016–18, 166,756 hospitalizations involved pregnancy, of which 5,222 were diagnosed with opioid dependence, use, or abuse (+398%). Three of these patients had rheumatic disease, leaving 37 patients (0.71%) with endocarditis related to their opioid use alone, P=.047. The 2016–18 population with endocarditis were white (100%); lived primarily in metropolitan counties (61%); and 57.1% were less than 30 years old. 11% of admissions were in the 1st trimester, 16.2% in the 2nd, 43.2% in the 3rd, and 16.2% postpartum, P=.012. 14% had a spontaneous or missed abortion. The median length of stay was 22.5 days. Ten deliveries were complicated by endocarditis, six by cesarean section. Five women underwent valvular surgery in 2016–18: four valve replacements and one total valve excision. Of the hospitalizations with a maternal mortality for 2016–18, three were complicated by endocarditis.

CONCLUSION:

A four-fold increase in hospitalization complicated by opioid use was observed as well as a significant increase in the rate of infective endocarditis in this population. Endocarditis contributed to maternal mortality, life-threatening morbidities, prolonged hospital stay, and increased cost.
Incidence of Fetal Cardiac Anomalies by Maternal Body Mass Index and Diabetes Status [20D]
Authors: Thayer Sydney Marie , Owens Sarah N. , Garg Bharti , Caughey Aaron B.
Published: April 2020

INTRODUCTION:

We sought to examine the association between body mass index (BMI) and fetal cardiac anomalies (FCA) in women with pre-existing diabetes, gestational diabetes, and without diabetes.

METHODS:

This is a retrospective cohort study of women with singleton, term pregnancies between 2007 and 2011 using linked vital statistics and discharge data. Chi-square tests were used to compare rates of FCA in diabetic and non-diabetic women categorized by BMI class. Pre-pregnancy BMI was categorized into underweight, normal weight, overweight, obesity, and morbid obesity. Multivariable logistic regression was used to examine the association of BMI with FCA by diabetes classification, controlling for maternal race/ethnicity, age, parity, education, and insurance status.

RESULTS:

The cohort of 1,993,905 consisted of 392,008 (19.7%) obese pregnant women. A higher BMI class was found to be associated with increased odds of FCA, independent of diabetes status. Compared to women without diabetes, those with gestational and pre-existing diabetes have significantly increased odds of FCA (aOR 1.41, 95% CI 1.33–1.48; aOR 4.35 95% CI 4.01–4.71, respectively). A significant association was demonstrated between BMI category and FCA for women with pre-existing diabetes, gestational diabetes, and without diabetes.

CONCLUSION:

Diabetes status and higher BMI category were both found to be individually associated with increased odds of FCA. This study also demonstrated the compounding effect of diabetes status and obesity on the incidence of FCA. Obstetrical education for women in these categories should emphasize the increased potential of this pregnancy complication and the role of prenatal ultrasonography in the identification of fetal cardiac anomalies.
Reducing the Use of Opioids in the Peripartum Period—A Quality Improvement Initiative [34E]
Authors: Jones Sarah B. , Johnson Ann , Brownlow Hannah , Vest Pamela , Stinson Jeffrey
Published: April 2020

INTRODUCTION:

The aim of this quality improvement initiative was to reduce the use of oral opioids in the inpatient postpartum period.

METHODS:

A systematic approach to pain management during the postpartum hospitalization was employed. A step-wise approach was implemented that included non-pharmacologic interventions, scheduled non-opioid pain medications, and oral opioids for breakthrough pain. Outcomes for the first 8 months were compared to baseline data from all patients delivered in 2017.

RESULTS:

In the vaginal delivery group 2889 patients were evaluated. The average number of opioid tablets taken was 0.53 per patient compared to 1.64 per patient in the baseline group, a 68% reduction. The average number of patients who received any opioid during their postpartum hospitalization was 12.4% compared to 33.6% in the baseline group, a 63% reduction. In the Cesarean section group 1162 patients were evaluated. The average number of opioid tablets taken was 6.5 per patient compared to 10.2 per patient in the baseline group, a 36% reduction. The average number of patients who received any opioid during their postpartum hospitalization was 78.4% compared to 95.3% in the baseline group, an 18% reduction.

CONCLUSION:

This quality improvement project evaluated a systematic approach to pain management in the postpartum period that includes a scheduled non-opioid pharmacologic, non-pharmacologic pain interventions, and oral opioids for breakthrough pain. The results demonstrate a clear reduction in oral opioid pain medication consumption during the postpartum hospitalization.
Incidence of Fetal Anomalies by Maternal Body Composition and Diabetes Status [19D]
Authors: Owens Sarah N. , Thayer Sydney Marie , Garg Bharti , Caughey Aaron B.
Published: April 2020

INTRODUCTION:

We sought to examine the association between body mass index (BMI) and fetal anomalies (FA) in women with pre-existing diabetes, gestational diabetes, and without diabetes.

METHODS:

This is a retrospective cohort study of women with singleton, term pregnancies between 2007 and 2011 using linked vital statistics and discharge data. Chi-square tests were used to compare rates of FA in diabetic and non-diabetic women categorized by BMI. Pre-pregnancy BMI was categorized into underweight, normal weight, overweight, obesity, and morbid obesity. Multivariable logistic regression was used to examine the association of BMI with FA by diabetes classification, controlling for maternal race/ethnicity, age, parity, education, and insurance status.

RESULTS:

The cohort of 1,993,905 consisted of 392,008 (19.7%) obese pregnant women. Higher BMI was found to be associated with increased odds of FA, independent of diabetes status. Underweight pre-pregnancy BMI was associated with decreased odds of FA compared to normal-weight. Women with gestational and pre-existing diabetes have significantly increased odds of FA (aOR 1.17, 95% CI 1.14–1.19; aOR 1.82 95% CI 1.74–1.90, respectively). A significant association was demonstrated between BMI category and FA for women with pre-existing diabetes and no diabetes but this relationship was not found with gestational diabetes.

CONCLUSION:

Diabetes status and higher BMI were found to be individually associated with increased odds of FA. This study also demonstrated the compounding effect of diabetes status and obesity on the incidence of FA. Obstetrical education for these women should emphasize the increased potential of this pregnancy complication and the role of prenatal screening for FA.
To Determine If Maternal Adverse Outcomes Predicted by Obstetric Comorbidity Index (OBCMI) Varies According to Race [32C]
Authors: Ranjit Anju , Olufajo Olubode , Zogg Cheryl , Robinson Julian N. , Luo Guoyang
Published: April 2020

INTRODUCTION:

To use nationwide data to determine if including race/ethnicity to the Obstetric Co-morbidity Index (OBCMI) improves its ability to predict severe maternal morbidity/mortality.

METHODS:

The National Inpatient Database (2010–2014) was used to identify all admissions for deliveries. Patient demographics including race/ethnicity (white, black, Hispanic) and co-morbidities were extracted. Primary outcome was defined as presence of severe maternal morbidity/mortality using ICD-9 codes. Using a stepwise logistic regression model, as previously described, maternal comorbid conditions predicting the primary outcome were determined. With separate models constructed for each race/ethnicity, weights assigned to each condition were used to determine the race/ethnicity-specific OBCMI. For each group, models predicting the primary outcome by their race specific OBCMI and other races' OBCMI was compared using c-statistic.

RESULTS:

A total of 3,830,958 deliveries were identified, among which 1,867,534 (48.7%) were white, 513,412 (13.4%) were to black, and 759,906 (19.8%) were Hispanic mothers. Severe maternal morbidity/mortality was present in 79,310 (2.07%) women. For each point increase in OBCMI derived for white women, the odds ratios for the outcome were 1.30 (CI 1.29–1.30) for white, 1.31 (CI 1.30–1.31) for black and 1.34 (CI 1.33–1.35) for Hispanic women. The c-statistic for these models were 0.652, 0.651 and 0.650 for white, black and Hispanic women, respectively. The odds ratios and c-statistics for models using black and Hispanic specific OBCMI were similar when compared between races/ethnicities.

CONCLUSION:

The obstetric comorbidity index provides a simple predictive tool to determine likelihood of severe maternal morbidity at the time of delivery, and race/ethnicity does not seem to play a large role in its predictive ability.
“There is no baby”—A Case of New Onset Psychotic Denial of Pregnancy in the Third Trimester [01E]
Authors: Chase Tess , Shah Akash , Maines Jaimie
Published: April 2020

INTRODUCTION:

Psychoanalytic theory states that pregnancy denial stems from a woman's inability to adapt to her new maternal role and leads to increased morbidity and mortality of mother and neonate.

METHODS:

A 33-year-old primigravida at 37 6/7 weeks gestation presented with new onset psychotic pregnancy denial. She was previously treated for major depressive disorder and discontinued pharmacotherapy during pregnancy. She had no history of psychosis. At 37 5/7 weeks, she reported to her husband, “There is no baby.” She was admitted to the antepartum service. Followed by a team of obstetricians, Maternal Fetal Medicine specialists, and psychiatrists, it was decided to initiate antipsychotic pharmacotherapy after delivery of the fetus. She was found to have capacity for decision making and provided informed consent for a cesarean section. She delivered a male infant at 38 1/7 weeks. She was started on psychotropic medication, and showed poor response. On postpartum day six she was transferred to inpatient psychiatry and underwent 12 bilateral electroconvulsive therapy (ECT) treatments during her 4-week inpatient and 2-week outpatient partial hospitalization. She has since returned to work, follows with outpatient psychiatry, and has a healthy relationship with her neonate.

RESULTS:

Patient informed consent was obtained for submission of a case report.

CONCLUSION:

This case highlights the interplay between medical, ethical, and legal systems. It presents challenges of peripartum psychiatric care and shows successful use of ECT for psychotic denial of pregnancy. It's reasonable to deliver before 39 weeks for worsening psychiatric disease. Proper care of mother and fetus depends on interdisciplinary care.
Gestational Weight Gain Video Module Improves Patient Knowledge of Weight Gain in Pregnancy [12D]
Authors: Milone Gina F. , Tiwari Mahesh , McInerney Hailey , Franz Brynn , Potkin Katya , Persad Malini D.
Published: April 2020

INTRODUCTION:

Approximately 70% of pregnant women gain weight outside of the National Academy of Medicine's established guidelines for gestational weight gain (GWG) in pregnancy. We set out to determine if a GWG video module improves patient knowledge of GWG goals.

METHODS:

A prospective cohort study was performed from January 2019 through August 2019 with Institutional Review Board approval. Women were allocated to routine care versus a video arm after informed consent was obtained. Both arms completed a baseline GWG knowledge questionnaire. Those undergoing routine care received provider counseling. Those in the video arm underwent routine counseling and viewed a 5-minute video module based on the American College of Obstetricians and Gynecologists and National Academy of Medicine approved material on body mass index (BMI) specific GWG goals. The GWG knowledge questionnaire was repeated in 4 weeks. Maternal demographics and baseline characteristics were collected from the electronic medical record. Independent sample t-tests, chi square analyses and Fisher exact tests were used to compare arms, with a P<.05 deemed statistically significant.

RESULTS:

A total of 52 women were included in the study, 26 in the routine counseling arm and 26 in the video module arm. Maternal demographics and baseline characteristics including BMI were similar between groups. Compared to routine counseling, women in the video module arm had a statistically significant increase in GWG knowledge (10.0±2.0 versus 12.5±2.3, P<.001).

CONCLUSION:

Compared to routine provider counseling, a GWG video module significantly improves patients' knowledge of GWG goals. Utilization of a GWG video enhances provider counseling.
Falling Insulin Requirements and Adverse Pregnancy Outcomes in Women With Pre-pregnancy Diabetes [10D]
Authors: Vainder Marina , Natt Navneet , D'Souza Rohan D. , Syeda Ambreen , Mitsakakis Nicholas
Published: April 2020

INTRODUCTION:

A subset of women with pre-gestational diabetes experience a third-trimester fall in insulin requirements (IR). There is no consensus on whether this fall represents placental dysfunction or is a variant of normal third-trimester physiology. Our study sought to determine whether a third-trimester drop in IR is associated with adverse pregnancy outcomes.

METHODS:

This is a retrospective cohort study of women with type 1 and 2 diabetes. We compared outcomes in those with and without a ≥15% drop in basal IR. The primary outcome was a composite of stillbirth, spontaneous preterm birth, preterm premature rupture of membranes and iatrogenic preterm birth or emergency caesarean delivery for fetal wellbeing concerns. The results were adjusted for the effect of maternal BMI, presence of microvascular disease, and pre-pregnancy hemoglobin A1c >7. The study was approved by the research ethics board at Mount Sinai Hospital.

RESULTS:

We included 350 women (146 type 1, 204 type 2), of which 15% had a drop of ≥15% in third-trimester basal insulin requirements. There was no difference in the primary outcome between groups (aOR 0.75 [0.27, 1.81]). In isolation the sensitivity and specificity of a ≥15% drop in basal IR as a diagnostic test for the primary outcome was 13% and 85%, respectively.

CONCLUSION:

A ≥15% drop in third-trimester basal IR is not associated with and is a poor predictor of adverse pregnancy outcomes in women with pre-pregnancy diabetes. It should not be used in isolation as a sole indication for delivery.
Association of Maternal Hypoglycemia on the Glucose Challenge Test and Small for Gestational Age Infants [06D]
Authors: Stivers Stacey L. , Thomas Megan , Devaiah Ganga , Lambers Donna
Published: April 2020

INTRODUCTION:

To determine if maternal hypoglycemia on the GCT is associated with small for gestational age (SGA) infants. The hypothesis is there will be an increased incidence of SGA in pregnancies with hypoglycemia (<88 mg/dL) as compared to euglycemia (88–129 mg/dL).

METHODS:

IRB approved, retrospective cohort study of singleton pregnancies from January 2015 to December 2017 with a GCT result between 24–28 weeks and delivery information were included. Patients with GCT >129 mg/dL and those with fetal anomalies were excluded. Neonatal and maternal outcomes were collected from the medical record. Growth classification was based on infant gender and gestational age at birth. Parametric and non-parametric tests, Fisher's exact and chi-squared tests were used for statistical analysis.

RESULTS:

2386 patients were euglycemic (88–129 mg/dL) and 966 patients were hypoglycemic (<88 mg/dL) on the GCT results. The cohort gestational age at delivery was 39.1 weeks. Hypoglycemia was associated with increased risk for SGA infants (9.3% vs 7.0%, P=.027) and intrauterine growth restriction (IUGR) (7.9% vs 5.1%, P=.003) and less likely to have large for gestational age infant (5.1% vs 7.3%). Patients with hypoglycemia had a decreased incidence of gestational hypertension (4.8% vs. 6.7%, P=.039) and pre-eclampsia (0.8% vs. 2.2%, P=.006).

CONCLUSION:

Hypoglycemia (GCT level <88 mg/dL) is associated with increased risk of SGA infants and IUGR along with decreased incidence of gestational hypertension and pre-eclampsia. This information can be used to increase fetal growth surveillance by sonography in the third trimester to improve identification of SGA and IUGR.
The Association of Hospital Admission and Postpartum Depression Rates Across Racial and Ethnic Groups [31C]
Authors: Berra Alexandra , Palmer Grace , Stafford Irene A.
Published: April 2020

INTRODUCTION:

The prevalence of postpartum depression (PPD) is approximately 10% and assessed via the Edinburg Postnatal Depression Score (EPDS). According to most data, these rates do not differ by race and ethnicity. However, there is a lack of data regarding the effect of length of antenatal admission on rates of PPD across women of differing racial and ethnic strata. The aim of this study is to determine if EPDS scores differ according to race and ethnicity across varying lengths of hospital admissions prior to delivery.

METHODS:

All pregnant women admitted to the antepartum unit at our institution from September 2017 to August 2018 were identified. Women with postpartum EPDS scores greater than or equal to ten were identified as having PPD. Antepartum length of stay was recorded by weekly intervals (0–7, 8–14, 15–21, and 22–28 days). Those admitted longer than 28 days were excluded. EPDS scores were compared in each of these groups among different races and ethnicities using chi square analysis.

RESULTS:

Black women (both Hispanic and non-Hispanic) were more likely to have PPD in every time interval. This association was statistically significant for length of stay 0–7 days (P=.03). Overall, black women were 1.7 fold more likely to suffer from PPD. In addition, Hispanic women were significantly less likely to be depressed than non-Hispanic women across all intervals (P=.02).

CONCLUSION:

Demographic information should be taken into consideration when evaluating risk for PPD. While certain racial characteristics may predispose a patient to the development of PPD, others may serve as a protective factor.
Age and Body Mass Index Can Screen for VTE Risk at Labor and Delivery Admission [02D]
Authors: Francis Kim Antonia P. , Saleh Mona , Torres Anthony Melendez , Limaye Meghana , Roman Ashley
Published: April 2020

INTRODUCTION:

Pregnancy is a risk factor for venous thromboembolism (VTE). VTE risk assessment models (RAM) have been created but not validated in obstetrics. The impact of maternal age and obesity on VTE risk score calculation is unclear. Our goal was to determine how maternal age and body mass index (BMI) affect VTE RAM scores.

METHODS:

IRB approved cross-sectional study evaluating 507 deliveries during November 2018 at an urban academic center. A total of 5 VTE cases were identified from 2013–2018. 6 RAM scores (ACOG, CMQCC, ACCP, RCOG, Caprini, Padua) were calculated for all subjects before and after exclusion of maternal age and BMI. Descriptive statistics and T-tests were utilized to ascertain the relationship between maternal age, BMI and high-risk RAM score (Caprini score of 2 or higher, RCOG score of 2 or higher, Padua score 4 or higher).

RESULTS:

The Caprini score classified 60% of cases as high risk when age and BMI were excluded versus 80% when these factors were included. Similarly, RCOG identified 80% of cases as high risk when BMI and age were excluded but captured 100% of cases when age and BMI were included. Age of 30 years or more and BMI greater than 30 kg/m2 correlated with higher Caprini and RCOG scores.

CONCLUSION:

Caprini and RCOG models were most impacted by age and BMI. If the RCOG and Caprini score are used to stratify patients for VTE risk, we propose using an abbreviated assessment utilizing only age and BMI since these had the most significant impact on final score.
Inadequate Gestational Weight Gain Among Obese Women: Harmful or Protective? [17D]
Authors: Oliva Mariana , Sipe Bradley , Odibo Linda , Odibo Anthony O.
Published: April 2020

INTRODUCTION:

The risks of inadequate gestational weight gain (IWG) remain controversial, especially among obese women. We aim to compare pregnancy outcomes in this population.

METHODS:

This is a secondary analysis from a prospective study of pregnant women undergoing fetal growth assessment. Obese participants were sorted into cohorts of adequate gestational weight gain (AWG) and IWG as defined by the Institute of Medicine guidelines. The primary outcomes were abnormal fetal growth, both large for gestational age (LGA) and small for gestational age (SGA). Secondary outcomes included: hypertensive disorders of pregnancy, gestational diabetes (GDM), preterm delivery (PTD), and composite adverse neonatal outcomes (CANO, including neonatal ICU admission, neonatal death, seizures, intraventricular hemorrhage, respiratory distress syndrome, necrotizing enterocolitis, and pH<7.10). Chi-square tests were used to compare outcomes. A stratified analysis by obesity class (class 1=BMI 30–34.9, class 2=BMI 35–39.9, class 3=BMI >40) was then performed.

RESULTS:

405 obese women were identified. 81 experienced IWG and 68 experienced AWG. IWG was protective against LGA (RR 0.10, CI 0.03–0.44, P<.01) and against GDM (RR 0.44, CI 0.21–0.93, P=.03). IWG did not affect CANO (P=.63), gestational hypertension (P=.52), preeclampsia (P=.25), PTD (P=.37), and SGA (P=.15). When stratified by obesity class, protection against GDM was seen in class 3 obesity (RR 0.24, 0.07–0.82). The risk of LGA was statistically significantly decreased in class 2 and 3 obesity.

CONCLUSION:

IWG is protective against LGA for class 2 and 3 obesity and protective against GDM for class 3 obesity. IWG did not increase risks of adverse pregnancy outcomes in obese patients.