Racial differences in indications for obstetrical toxicology testing and relationship of indications to test results.

BACKGROUND: Despite illicit substance use in pregnancy occurring across all demographic groups, minority pregnant and delivering patients with a low income tend to undergo testing at a higher rate than their counterparts. National guidelines for indications do not exist and ordering of toxicology testing may be applied inequitably. OBJECTIVE: This study aimed to evaluate whether any documented indications in a large cohort of patients were associated with a positive toxicology test and whether indications for urine toxicology testing were applied consistently to different demographic groups. STUDY DESIGN: This was a retrospective cohort study reviewing pregnant and delivering patients who underwent toxicology testing on obstetrical units at 1 institution from May 30, 2015, to December 31, 2018. Age, race, marital status, median income of residential ZIP code, indications for testing, and test results were collected for each patient by individual chart review. Indications included preterm complications (preterm prelabor rupture of membranes or preterm labor), abruption or hypertension, reported substance use, fetal complications, maternal complications, and none. Multivariate logistic regression models were analyzed for the association between indication and test result and the likelihood of marijuana as the sole positive test result. Logistic regression was used to evaluate the relationship of indication for testing with maternal race. RESULTS: Among 20,274 births, 551 patients underwent toxicology testing during the study period. No indication for drug toxicology testing was associated with a positive result, except reported current or previous substance use. Compared with White patients, Black and Hispanic women were 4.26 times (95% confidence interval, 2.55-7.09) and 5.75 times (95% confidence interval, 2.89-11.43) more likely to have toxicology testing for an indication other than reported substance use, respectively. Of all patients with positive test results (n=194), 48% tested positive for marijuana only. CONCLUSION: Compared with their White counterparts, Black and Hispanic pregnant and delivering patients may be more frequently toxicology tested for indications less clearly associated with illicit substance use. The absence of evidence-based guidelines for toxicology testing on obstetrical units risks inequitable care and stigmatization of patient groups.

Toxicology Testing in a Newborn ICU: Does Social Profiling Play a Role?

OBJECTIVE: A rising incidence in maternal drug use during pregnancy has led to a concomitant rise in neonatal opioid withdrawal syndrome. Despite evidence that drug use during pregnancy affects all demographic groups equally, authors of recent studies have suggested that minority women are tested for drug use more than their counterparts. In this study, we aimed to assess whether toxicology testing of neonates was associated with maternal characteristics. METHODS: Retrospective cohort study reviewing charts of neonates born at an urban academic center between January 1, 2018, and December 31, 2018, who underwent toxicology testing. Demographics from tested neonates were taken from mothers' self-reported data and compared with sociodemographics of all mothers with deliveries in 2018, including age, race, marital status, and zip code. Indication for toxicology testing as recorded by ordering clinician was also collected. There were no standardized guidelines for toxicology testing during this study period. RESULTS: Of 6438 births in 2018, toxicology testing was sent on 86 neonates (1.3%). Mothers of neonates with testing were younger (P < .0001), less likely to be white (P < .0001), self-reported "single" (P < .0001), and lived in lowest income zip codes (P < .0001). Indications for testing were varied, with the most common indications including maternal substance use disorder (37%) and marijuana use (26%). CONCLUSION: Maternal age, race, marital, and socioeconomic status were associated with toxicology testing on neonates, although data suggest that drug use affects all demographic groups. Current practice at our institution may overtest some groups. Evidence-based, standardized guidelines are urgently needed to reduce bias and repercussions of toxicology testing of neonates.

Placenta Accreta Spectrum Without Placenta Previa.

OBJECTIVE: To evaluate placenta accreta spectrum with and without placenta previa with regard to risk factors, antepartum diagnosis, and maternal morbidity. METHODS: We conducted a retrospective cohort study of pathology-confirmed placenta accreta spectrum deliveries with hysterectomy from two U.S. referral centers from January 2010-June 2019. Maternal, pregnancy, and delivery characteristics were compared among placenta accreta spectrum cases with (previa PAS group) and without (nonprevia PAS group) placenta previa. Surgical outcomes and a composite of severe maternal morbidities were evaluated, including eight or more blood cell units transfused, reoperation, pulmonary edema, acute kidney injury, thromboembolism, or death. Logistic regression was used with all analyses controlled for delivery location. RESULTS: Of 351 deliveries, 106 (30%) had no placenta previa at delivery. When compared with the previa group, nonprevia placenta accreta spectrum was less likely to be identified antepartum (38%, 95% CI 28-48% vs 87%, 82-91%), less likely to receive care from a multidisciplinary team (41%, 31-51% vs 86%, 81-90%), and less likely to have invasive placenta increta or percreta (51% 41-61% vs 80%, 74-84%). The nonprevia group had more operative hysteroscopy (24%, 16-33% vs 6%, 3-9%) or in vitro fertilization (31%, 22-41% vs 9%, 6-13%) and was less likely to have had a prior cesarean delivery (64%, 54-73% vs 93%, 89-96%) compared with the previa group, though the majority in each group had a prior cesarean delivery. Rates of severe maternal morbidity were similar in the two groups, at 19% (nonprevia) and 20% (previa), even after controlling for confounders (adjusted odds ratio for the nonprevia group 0.59, 95% CI 0.30-1.17). CONCLUSION: Placenta accreta spectrum without previa is less likely to be diagnosed antepartum, potentially missing the opportunity for multidisciplinary team management. Despite the absence of placenta previa and less placental invasion, severe maternal morbidity at delivery was not lower. Broader recognition of patients at risk for placenta accreta spectrum may improve early clinical diagnosis and patient outcomes.

Retained placenta after vaginal delivery: risk factors and management.

Retained placenta after vaginal delivery is diagnosed when a placenta does not spontaneously deliver within a designated amount of time, variably defined as a period of 18-60 mins. It may also be diagnosed if a patient experiences significant hemorrhage prior to delivery of the placenta. Normal placenta delivery requires adequate uterine contractions, with shearing of the placenta and decidua from the uterine wall and expulsion of the tissue. Thus, retained placenta can occur in the setting of significant uterine atony, abnormally adherent placenta, as with placenta accreta spectrum (PAS), or closure of the cervix prior to placental expulsion. Risk factors for retained placenta parallel those for uterine atony and PAS and include prolonged oxytocin use, high parity, preterm delivery, history of uterine surgery, and IVF conceptions. History of a prior retained placenta and congenital uterine anomalies also appear to be risk factors. Management entails manual removal of the placenta with adequate analgesia, as medical intervention alone has not been proven effective. Complications can include major hemorrhage, endometritis, or retained portions of placental tissue, the latter of which can lead to delayed hemorrhage or infection. Prophylactic antibiotics can be considered with manual placenta removal, though evidence regarding effectiveness is inconsistent. If hemorrhage is encountered, deployment of a massive transfusion protocol, uterine evacuation with suction, and use of intrauterine tamponade, as with an intrauterine balloon, should be initiated immediately. When a separation plane between the placenta and uterus is particularly difficult to create, PAS should be considered, and preparations should be made for hemorrhage and hysterectomy. Patients with risk factors for retained placenta should have a laboratory sample sent for blood type and antibody screening on admission to labor and delivery, and plans should be made for appropriate analgesia and preparations for hemorrhage if a retained placenta is encountered.

Neuraxial Anesthesia During Cesarean Delivery for Placenta Previa With Suspected Morbidly Adherent Placenta: A Retrospective Analysis.

BACKGROUND: General anesthesia (GA) is often selected for cesarean deliveries (CD) with placenta previa and suspected morbidly adherent placenta (MAP) due to increased risk of hemorrhage and hysterectomy. We reviewed maternal outcomes and risk factors for conversion to GA in a cohort of patients undergoing CD and hysterectomy under neuraxial anesthesia (NA). METHODS: We performed a single-center, retrospective cohort study of parturients undergoing nonemergent CD for placenta previa with suspected MAP from 1997 to 2015. Patients were classified according to whether they received GA, NA, or intraoperative conversion from NA to GA. The primary outcome measure was postoperative acuity, defined as the need for intensive care unit admission, arterial embolization, reoperation, or ongoing transfusion with ≥3 units packed red blood cells. We additionally identified variables positively associated with intraoperative conversion from NA to GA during hysterectomy. Confounding was controlled with logistic regression models. RESULTS: Of 129 patients undergoing nonemergent CD for placenta previa with suspected MAP, 122 (95%) received NA as the primary anesthetic. NA was selected in the majority of patients with a body mass index ≥40 kg/m (9 of 10, 90%), a history of ≥3 prior CDs (18 of 20, 90%), suspected placenta increta or percreta (29 of 35, 83%), and Mallampati classification ≥3 (19 of 21, 90%). Of 72 patients with NA at the time of delivery who required hysterectomy, 15 (21%) required conversion to GA intraoperatively. Converted patients had a higher rate of major packed red blood cell transfusion (60% vs 25%; P = .01), with similar rates of massive transfusion (9% vs 7%; P = 1.0). Converted patients also had a higher incidence of postoperative acuity (47% vs 4%; P < .0001), including 5 intensive care unit admissions for airway management after large-volume resuscitation. After adjusting for multiple confounders, the only independent predictors of conversion among hysterectomy patients were longer surgical duration (adjusted odds ratio 1.54, 95% CI, 1.01-2.42) and a history of ≥3 prior CDs (adjusted odds ratio, 6.45; 95% CI, 1.12-45.03). CONCLUSIONS: NA was applied to and successfully used in the majority of patients with suspected MAP. Our findings support selective conversion to GA during hysterectomy in these patients, focusing on those with the highest levels of surgical complexity.

Patient selection for later delivery timing with suspected previa-accreta.

INTRODUCTION: We identified patients with previa and suspected accreta who are at lowest risk of unscheduled delivery or major morbidity with planned delivery beyond 34 weeks' gestation. MATERIAL AND METHODS: This was a retrospective cohort study of patients who had reached 34.0 weeks' gestational age with a suspected previa-accreta. We evaluated rates of unscheduled and emergent delivery based on known risk factors for premature birth. In a second analysis, we stratified patients based on level of preoperative morbidity concern and evaluated rates of major transfusion and Intensive Care Unit admission by delivery week (34 weeks, 35 weeks or 36 weeks and beyond). RESULTS: Of 84 available patients, we classified 31 patients as low risk for unscheduled delivery and 52 as high risk. The low risk group was scheduled later (36.6 vs. 36.0 weeks; p < 0.01), but demonstrated lower rates of unscheduled delivery prior to 36 weeks (3% vs. 19%, p = 0.05). Of the patients with no prior cesarean section, only one (7%) experienced massive blood loss even though 36% had unscheduled deliveries. We observed no significant increase in major transfusion or massive blood loss with advancing gestational age, likely due to selection of the most concerning patients for early, scheduled delivery. CONCLUSION: Patients with suspected previa-accreta and no risk factors for preterm birth are at low risk for an unscheduled delivery prior to 36 weeks. Those with no concern for percreta or increta or no prior cesarean section may also be candidates for later delivery.