Naltrexone Compared With Buprenorphine or Methadone in Pregnancy: A Systematic Review.

OBJECTIVE: Although naltrexone is an evidence-based medication for opioid use disorder (MOUD), few data are available with use in pregnancy. Our objective was to assess outcomes of pregnant individuals with opioid use disorder (OUD) taking naltrexone compared with those taking methadone or buprenorphine. DATA SOURCES: We undertook a systematic review using electronic database search (PubMed, CINAHL, EMBASE, PsycInfo), conference proceedings, and trial registries including ClinicalTrials.gov . METHODS OF STUDY SELECTION: We conducted an electronic search of research articles through May 2023 for randomized controlled trials, prospective cohort, and retrospective cohort studies of naltrexone (oral, implant, or extended release) compared with methadone or buprenorphine (sublingual or extended release) among pregnant individuals with OUD. After double review of all articles, we abstracted obstetric (primary outcome: gestational age at delivery), neonatal (primary outcome: neonatal abstinence syndrome [NAS]), and substance use outcomes. TABULATION, INTEGRATION, AND RESULTS: Five studies met eligibility criteria; four were retrospective cohort studies, and one was a prospective cohort study. Four studies included data on gestational age at delivery (weeks) with no difference detected between the two groups in any study (mean difference ranging -0.20, 95% CI, -1.49-1.09 to 0.8, 95% CI, -0.15 to 1.75). Three studies included data on NAS with all studies detecting a lower risk in the naltrexone group compared with methadone or buprenorphine (relative risk ranging from 0.08, 95% CI, 0.01-1.16 to 0.15, 95% CI, 0.06-0.36). Most studies (four of five) had a moderate or high potential for selection bias primarily driven by small sample size and lack of controlling for confounders. CONCLUSION: Although the evidence base is limited, available data suggest that naltrexone use in pregnancy is a reasonable MOUD option with reassuring perinatal outcomes. To enhance confidence in this conclusion and to assess substance use outcomes, further comparative studies of pregnant people with OUD taking naltrexone and other MOUD types are needed. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, 42017074249.

Continuation in Treatment and Maintenance of Custody of Newborns After Delivery in Women With Opioid Use Disorder.

OBJECTIVE: To identify variables associated with continuation in treatment and maintenance of custody after pregnancies in women with opioid use disorder (OUD). METHODS: The medical records of pregnant women with documented OUD from 2011 to 2018 and with at least 6 months follow-up postpartum were retrospectively reviewed. RESULTS: Via multivariate analysis, women on opioid maintenance therapy (OMT) were more likely to continue in treatment and maintain custody, whereas women enrolled in a residential treatment program during pregnancy were less likely to continue in treatment or maintain custody. Women who continued in treatment were significantly more likely to maintain custody of their children than those who did not. CONCLUSIONS: Continuation in treatment and maintenance of custody were closely related. Care providers should attempt to improve both outcomes.

Opioid prescribing trends in postpartum women: a multicenter study.

BACKGROUND: The postpartum period can be a particularly vulnerable time for exposure to opioid medications, and there are currently no consensus guidelines for physicians to follow regarding opioid prescribing during this period. OBJECTIVE: The purpose of this study was to evaluate inter- and intrahospital variability in opioid prescribing patterns in postpartum women and better understand the role of clinical variables in prescribing. STUDY DESIGN: Data were extracted from electronic medical records on 4248 patients who delivered at 6 hospitals across the United States from January 2016 through March 2016. The primary outcome of the study was postpartum opioid prescription at the time of hospital discharge. Age, parity, route of delivery, and hospital were analyzed individually and with multivariate analyses to minimize confounding factors. Statistical methods included χ2 to analyze frequency of opioid prescription by hospital, parity, tobacco use, delivery method, and laceration type. An analysis of variance was used to analyze morphine equivalent dose by hospital. RESULTS: The percentage of women prescribed postpartum opioids varied significantly by hospital, ranging from 27.6% to 70.9% (P <0.001). Oxycodone-acetaminophen was the most commonly prescribed medication (50.3%) with each hospital having its preferred opioid type. Median number of tablets prescribed ranged from 20 to 40 (P < .0001). Primiparous women were more likely to receive opioids than multiparous women when broken down by a parity of 1, 2, 3, 4, and ≥5 (52.8%, 48.0%, 47.6%, 40.1%, and 45.8%, respectively, P = .0005). Among women who had vaginal deliveries, opioid prescription rates were higher in women who experienced either a second-degree laceration (35.5%, P = .0002) or a third-/fourth-degree laceration (59.3%, P < .001). CONCLUSION: Postpartum opioid prescription rates vary widely among hospitals, but providers within the same hospital tend to follow similar prescribing trends. The variation in prescribing found in our study illustrates the need for clear consensus guidelines for postpartum pain management.

Prevalence of illicit drug use in pregnant women in a Wisconsin private practice setting.

OBJECTIVE: We sought to measure the prevalence of illicit drug use in our obstetric population, to identify the drugs being used, and to determine whether a modified version of the 4Ps Plus screening tool could serve as an initial screen. STUDY DESIGN: In this prospective study, urine samples of 200 unselected patients presenting for initiation of prenatal care in a Wisconsin private practice were analyzed for evidence of the use of illicit drugs. RESULTS: Of 200 patients, 26 (13%) had evidence of drugs of abuse in their urine samples. Marijuana (7%) and opioids (6.5%) were the most commonly identified drugs. Adding 5 questions about drug or alcohol use to the obstetric intake questionnaire proved sensitive in identifying patients with high risks of having a positive drug screen. CONCLUSION: The rate of drug use in our low-risk population was higher than expected and may reflect increasing rates of drug use across the United States. Enhanced screening should be performed to identify patients using illicit drugs in pregnancy to improve their care. Medical centers and communities may benefit from periodic testing of their community prevalence rates to aid in appropriate care planning.

Predictors of obesity in childhood, adolescence, and adulthood in a birth cohort.

To determine how characteristics of pregnancy, birth, and early infancy are related to offspring obesity at three critical developmental periods. Mothers were followed through pregnancy and 10-15 years after. Offspring data were obtained through medical record review. Maternal and offspring characteristics were examined to predict obesity in childhood (ages 4-5 years), adolescence (ages 9-14 years), and early adulthood (ages 19-20 years). The original cohort included 802 children born to 795 women. Children who were twins, who had died, or whose mothers had died were excluded (n=25). Medical records of 68.5% of the remaining 777 children documented a height and weight at childhood, adolescence, or early adulthood. Relative risks (RRs) to predict obesity at early adulthood were 12.3 for childhood and 45.1 at adolescence. RRs were also significant to predict obesity at early adulthood between the mother's obesity at prepregnancy (RR=6.4), 4-5 years postpregnancy (RR=6.3), and 10-15 years postpregnancy (RR=6.2). Excluding these variables from the multivariate models and adjusting by gender, birth insurance, and mother's marital status at delivery, the best model to predict obesity at childhood included birth weight, weight gain in infancy, and delivery type. At adolescence, it included maternal pregnancy smoking status, gestational weight gain, and weight gain in infancy, and in early adulthood, included maternal pregnancy smoking status, gestational weight gain, and birth weight. Maternal pregnancy smoking status, gestational weight gain, and weight gain in infancy have long-term effects on offspring. Maternal obesity is the strongest predictor of obesity at all times studied.

Telephone-based management of lactation mastitis.

OBJECTIVE: To evaluate the quality of care for mastitis managed by telephone without an office or emergency room visit. STUDY DESIGN: A word search of electronic medical records allowed for identification of patients managed with a mastitis clinical practice guideline. Comparisons of outcomes were made to a group of patients who received care in the clinic, urgent care or emergency room. RESULTS: Rates of successful resolution with 1 encounter were 86% for telephone-based care and 82% for visit-based care (p = 0.550). Antibiotic selection was enhanced by use of the standing order. CONCLUSION: Telephone-based management of mastitis may be safe, effective, and efficient.

Emergency cesarean section and the 30-minute rule: definitions.

We explored the role that lack of a standard definition and heterogeneity in patient selection criteria in the literature might have on the apparent inability to routinely begin an emergency cesarean section in less than 30 minutes. A review of the literature on emergency cesarean delivery was performed. Although there are some similarities in definitions and the criteria used for patient selection in multiple studies, the variability in the definitions could be responsible for some of the apparent timeliness performance deficiency in the literature. A standard definition and directions for future research are suggested.

Acute cystitis in women: experience with a telephone-based algorithm.

OBJECTIVE: This paper evaluates short-term (60-day) outcomes for women with symptoms of acute cystitis evaluated and treated with a telephone-based protocol. METHODS: We used a retrospective analysis of medical records of patients evaluated and treated according to a guideline-based algorithm for symptoms of acute cystitis. RESULTS: The algorithm was utilized in the care of 273 women reporting symptoms of urinary tract infection (UTI), with 75.4% being treated without urinalysis or cultures. Over the next 60 days, 46 (16.8%) were seen or made phone contact for recurrent or persistent urinary tract symptoms, with 6 patients (2.2%) diagnosed with pyelonephritis. No other adverse events were identified in the 60 days after use of the protocol. CONCLUSIONS: A telephone-based nurse evaluation and treatment algorithm can allow for successful management of the majority of women identifying symptoms of uncomplicated lower UTIs.

On call: a survey of Wisconsin obstetric groups.

OBJECTIVE: The purpose of this study was to identify patterns of obstetric call in order to identify areas of focus for future evaluation of "best practices." STUDY DESIGN: A telephone survey of obstetricians in Wisconsin was conducted, attempting to sample 1 physician from each group or call pool in every hospital in the state. RESULTS: Sixty-six physicians responded to this survey. The range in size of call pools was 1 to 11, with the median being 5. The duration of call is usually 24 hours. All have other nondelivery responsibilities while on call. In-house call is almost always limited to hospitals with residencies (6/8). Twenty-three percent of groups have formalized back-up systems, and 26% of groups have recovery provisions after call. CONCLUSION: There is no standard call system. Practicing obstetricians are commonly on call for longer hours and have less time off after call than is now mandated for obstetric residents, though work intensity may vary.

Implementing patient safety practices in small ambulatory care settings.

BACKGROUND: Improving patient safety in the outpatient setting poses unique challenges for patient safety leaders in clinics and hospitals. Even though ambulatory care may be less technologically complex than inpatient care, it is often more complex logistically. METHODS AND MATERIALS: From October 2002 to May 2003, Gundersen Lutheran Medical Center developed a tool kit of best practices and conducted a collaborative to institute these best practices within a regional health care network. All clinics evaluated patient safety standards and enhanced medication-related practices. RESULTS: Improvements were demonstrated in medication list accuracy. A number of policies were instituted, and medical and nursing staffs were educated in patient safety issues. Improvements were sustained after one year. DISCUSSION: The collaborative model of improvement efforts was an effective model for improving patient safety in small group practices. Structural and process changes often do not require major changes in workflow or large technology installations. Many of the projects allowed for, or required, local assessment and management. However, within a large system of clinics, some of the improvements in this study--verbal order policy, methodology and/or technology for assessment of medication and allergy list accuracy, warfarin care--required systemwide efforts. The degree of difficulty of achieving improvements was surprisingly low and barriers were minimal.

Preventing early-onset group B streptococcal sepsis: efforts to measure and improve compliance with guidelines.

OBJECTIVES: We describe strategies employed in achieving a high level of compliance with Centers for Disease Control and Prevention guidelines for the prevention of early-onset Group B streptococcal neonatal sepsis. METHODS: This is a retrospective review of all deliveries at or beyond 37 weeks gestation at Gundersen Lutheran Medical Center to determine (1) whether and when cultures were obtained for group B Streptococcus, (2) whether antibiotics were administered, and (3) the timing of antibiotic treatment relative to delivery, following educational efforts to an integrated medical center's departments of Obstetrics and Gynecology and Family Practice. Changes were made in prenatal records and admission order forms to facilitate compliance. RESULTS: Cultures were obtained antenatally from 946 (99.0%) of the 956 women, with 87.4% (827) of these obtained between 35 and 37 weeks gestation. One hundred eighty-two (19.2%) of the women were colonized with group B Streptococcus. One hundred sixty of the 173 patients eligible for antibiotic prophylaxis (92.5%) received it. DISCUSSION: Our rates of antenatal culturing and prophylactic antibiotic administration compared favorably with those previously reported. Our strategies for achieving high compliance with group B Streptococcus prevention protocols include educating and obtaining consensus from individuals providing obstetrical care and building reminders into physician and nurse workflows.

Impact of perinatal weight change on long-term obesity and obesity-related illnesses.

OBJECTIVE: To estimate the impact of perinatal weight change on obesity, weight gain, and development of obesity-related illnesses 15 years after pregnancy. METHODS: Pregnancy-related factors and weights of 795 women were recorded at first prenatal visit and 6 months postpartum and were available through medical record review at 4, 10, and 15 years. Obesity-related illnesses were recorded 15 years later. RESULTS: A total of 484 (61%) original cohort members were available for follow-up. Weight gain during pregnancy, weight loss by 6 months postpartum, and baseline body mass index (BMI) were all related to current BMI and weight gain at follow-up. Women who breastfed beyond 12 weeks and participated in postpartum aerobic exercise had lower BMI and weight gain 15 years later. By follow-up, 13% had developed diabetes or prediabetes. Thirty percent had developed heart disease, hypertension, or dyslipidemia. Baseline BMI and weight change over 15 years were significant predictors of both diseases. Smoking status at last follow-up was also a significant predictor of heart disease or pre-heart disease. CONCLUSION: Excess pregnancy weight gain and failure to lose weight in an appreciable time are indicators of obesity in midlife. Excess weight gain and obesity status are predictors of diabetes and heart disease, although pregnancy-related weight changes alone are not directly related.

Ultrasound assessment of first-trimester bleeding.

OBJECTIVE: To assess the outcome (to the end of the first trimester) of pregnancies with vaginal bleeding and the influence of ultrasound-acquired information on care and cost of care. METHODS: A chart review was performed of 1,240 patients receiving care at an integrated medical center for threatened abortion from 1998-2000. Records from 715 patients with adequate follow-up data were reviewed and outcomes studied. Charges for outpatient and inpatient care were obtained from the data warehouse. RESULTS: Main findings include that on endovaginal ultrasonography, 44% of the pregnancies were viable, of which 86% continued to the end of the first trimester and that of the 33% of pregnancies that were nonviable, 74% successfully miscarried without intervention. Charges for the care varied significantly, based on outcome and choice of site of care. CONCLUSION: Endovaginal ultrasonography for the evaluation of early pregnancy bleeding has a significant effect on care decisions and costs. LEVEL OF EVIDENCE: II-3.

Excess pregnancy weight gain and long-term obesity: one decade later.

OBJECTIVE: To estimate the impact of excess pregnancy weight gain and failure to lose weight by 6 months postpartum on excess weight 8-10 years later. METHODS: Seven hundred ninety-five women were observed through pregnancy and 6 months postpartum to examine factors that affect weight loss. Weight was recorded 10 years later through a medical record review to examine the impact of retained weight on long-term obesity. Overall weight change at last follow-up and body mass index (BMI) were examined by pregnancy weight gain appropriateness according to the Institute of Medicine guidelines for weight gain during pregnancy. RESULTS: Of the original cohort, 540 women had a documented weight beyond 5 years (mean = 8.5 years). The average weight gain from prepregnancy to follow-up was 6.3 kg. There was no difference in weight gain by prepregnancy BMI. Women who gained less than the recommended amount during their pregnancy were 4.1 kg heavier at follow-up, those gaining the recommended amount were 6.5 kg heavier, and those gaining more than recommended were 8.4 kg heavier (P =.01). Women who lost all pregnancy weight by 6 months postpartum were 2.4 kg heavier at follow-up than women with retained weight, who weighed 8.3 kg more at follow-up (P =.01). Women who breast-fed and women who participated in aerobic exercise also had significantly lower weight gains. CONCLUSION: Excess weight gain and failure to lose weight after pregnancy are important and identifiable predictors of long-term obesity. Breast-feeding and exercise may be beneficial to control long-term weight.