Postpartum Opioid Use among Military Health System Beneficiaries.

OBJECTIVE: The aim of the study is to evaluate the prevalence and factors associated with opioid prescriptions to postpartum patients among TRICARE beneficiaries receiving care in the civilian health care system versus a military health care facility. STUDY DESIGN: We evaluated postpartum opioid prescriptions filled at discharge among patients insured by TRICARE Prime/Prime Plus using the Military Health System Data Repository between fiscal years 2010 to 2015. We included women aged 15 to 49 years old and excluded abortive pregnancy outcomes and incomplete datasets. The primary outcome investigated mode of delivery and demographics for those filling an opioid prescription. Secondary outcomes compared prevalence of filled opioid prescription at discharge for postpartum patients within civilian care and military care. RESULTS: Of a total of 508,258 postpartum beneficiaries, those in civilian health care were more likely to fill a discharge opioid prescription compared with those in military health care (OR 3.9, 95% CI 3.8-3.99). Cesarean deliveries occurred less frequently in military care (26%) compared with civilian care (30%), and forceps deliveries occurred more frequently in military care (1.38%) compared with civilian care (0.75%). Women identified as Asian race were least likely to fill an opioid prescription postpartum (OR 0.79, 95% CI 0.75-0.83). Women aged 15 to 19 years had a lower odds of filling an opioid prescription (OR 0.83, 95% CI 0.80-0.86). Women associated with a senior officer rank were less likely to fill an opioid prescription postpartum (OR 0.83, 95% CI 0.73-0.91), while those associated with warrant officer rank were more likely to fill an opioid prescription (OR 1.14, 95% CI 1.06-1.23). CONCLUSION: Our data indicates that women who received care in civilian facilities were more likely to fill an opioid prescription at discharge when compared with military facilities. Factors such as race and age were associated with opioid prescription at discharge. This study highlights areas for improvement for potential further studies. KEY POINTS: · Opioid prescription patterns for postpartum women may vary across the country.. · Our study indicates postpartum patients in civilian care are more likely to fill opioids postpartum.. · This study highlights a population which may have an improved opioid prescribing pattern..

Comparing Compensation of U.S. Military Physicians and Civilian Physicians in Residency Training and Beyond.

Introduction  Resident physicians have a professional degree but are compensated less than other recently graduated professionals such as lawyers or nurse practitioners. The U.S. Military Healthcare System differs from the civilian setting in that physicians' salaries are based primarily on military rank. We compared military and civilian physician salaries across various specialties to determine if the increased military pay during residency compensates for military attending physicians' lower income as compared to their civilian counterparts. Methods This cross-sectional study compares military and civilian pay for resident and attending physicians in the fields of Obstetrics & Gynecology (OB/GYN), Family Medicine, and General Surgery. Military pay was obtained from 2018 Defense Finance and Accounting Service (DFAS) data. Civilian salaries were obtained from the Medscape 2018 Residents Salary & Debt Report, Medical Group Management Association (MGMA) 2018 Provider Compensation Report, and 2017-2018 Association of American Medical Colleges (AAMC) Faculty Salary Report. Results Military resident physicians earned 53% more than civilian residents while military attending physicians earned 32%-58% less (after taxes) than their civilian counterparts, varying by specialty. Military attending physicians' negative pay differential occurred in both academic and non-academic practice environments through MGMA data. Discussion The positive pay differential in military residency does not compensate for the negative pay differential of military attending physicians face as compared to their civilian counterparts. This negative pay differential persisted when comparing post-tax pay. Some military service benefits, such as decreased educational debt, are challenging to quantify and vary considerably between individuals. As the military seeks to reshape its healthcare force, military and civilian compensation differences should be considered.

Does Universal Coverage Mitigate Racial Disparities in Potentially Avoidable Maternal Complications?

OBJECTIVE: Potentially avoidable maternity complications (PAMCs) have been validated as an indicator of access to quality prenatal care. African-American mothers have exhibited a higher incidence of PAMCs, which has been attributed to unequal health coverage. The objective of this study was to assess if racial disparities in the incidence of PAMCs exist in a universally insured population. STUDY DESIGN: PAMCs in each racial group were compared relative to White mothers using multivariate logistic regression. Stratified subanalyses assessed for adjusted differences in the odds of PAMCs for each racial group within direct versus purchased care. RESULTS: A total of 675,553 deliveries were included. Among them, 428,320 (63%) mothers were White, 112,170 (17%) African-American, 37,151 (6%) Asian/Pacific Islanders, and 97,912 (15%) others. African-American women (adjusted odds ratio [aOR]: 1.05, 95% CI: 1.02-1.08) were more likely to have PAMCs compared with White women, and Asian women (aOR: 0.92, 95% CI: 0.89-0.95) were significantly less likely to have PAMCs compared with White women. On stratified analysis according to the system of care, equal odds of PAMCs among African-American women compared with White women were realized within direct care (aOR: 1.03, 95% CI: 1.00-1.07), whereas slightly higher odds among African-American persisted in purchased (aOR: 1.05, 95% CI: 1.01-1.10). CONCLUSION: Higher occurrence of PAMCs among minority women sponsored by a universal health coverage was mitigated compared with White women. Protocol-based care as in the direct care system may help overcome health disparities.

An alternative to cesarean: a description of external cephalic version in noncephalic presenting twin.

Objective: External cephalic version (ECV) is utilized in breech presenting singleton gestations but ECV of the noncephalic presenting twin has been considered technically unfeasible. We have successfully performed ECVs of the noncephalic presenting twin. Our objective is to describe our experience with this technique.Study design: This is a descriptive case series of our attempted ECVs in twin pregnancies and their outcomes.Results: Of 19 twin A ECV attempts, 10 cases were successful. The overall vaginal delivery rate was 42% (8/19 cases). There were no emergent cesarean deliveries required, and no neonatal injuries were observed.Conclusions: ECV can be achieved in pregnancies complicated by a noncephalic presenting twin. Further study is necessary to assess the safety and generalizability of our finding.

SMFM Special Statement: Operative vaginal delivery: checklists for performance and documentation.

The frequency of operative vaginal delivery has been declining, even though it can be an attractive alternative to cesarean delivery in selected cases. Performance of operative vaginal delivery required consideration of many indications, contraindications, and prerequisites. Optimal documentation of operative vaginal delivery requires the recording of several specific elements that are unique to forceps or vacuum delivery. A cognitive aid such as a checklist is well suited to this situation in which there are numerous elements to consider, a low frequency of performance, and teams with variable expertise. We propose 2 checklists to help ensure that all relevant elements are considered for every operative vaginal delivery: (1) a checklist for preparation and performance of the procedure and (2) a checklist for documentation. We suggest practical tips to help facilities adapt these checklists to their own circumstances and implement them on their units.

Variations in prenatal screening in a US federal healthcare system: Same coverage, different options.

The Military Health System (MHS) is a federally funded organization that provides care to active duty service members and their beneficiaries. Our objective was to determine what methods of prenatal screening are used by military treatment facilities (MTFs), assess variations between institutions, and determine how practice patterns align with national recommendations. We surveyed all MTFs offering comprehensive prenatal care (n = 49). Departments were asked about aneuploidy screening options, availability of diagnostic testing, and carrier screening. In all, 43 MTFs (88%) completed the survey. Most (39/43) patients were stratified based on risk (predominantly maternal age at delivery and history). The most commonly offered test was combined 1st/2nd trimester screening (59%). Sixty percent routinely offered diagnostic testing, though less than half routinely offered microarrays. The majority offered universal carrier screening for cystic fibrosis (98%) and complete blood count with screening for thalassemias and hemoglobinopathies (88%). At the time of data collection, only five facilities (12%) had implemented spinal muscular atrophy carrier screening. Considerable heterogeneity exists in prenatal aneuploidy testing and carrier screening within the MHS. Standardized guidelines, protocols, and laboratory support would improve processes across the system. Additional resources including genetic counseling support and provider education are needed.

Reducing Perineal Lacerations Through Team-Based Simulation.

INTRODUCTION: Vaginal deliveries that result in perineal trauma involve significant morbidity to women. Multiple strategies have been identified to reduce the risk of severe perineal lacerations. The objective of this study was to evaluate the effectiveness of an interprofessional simulation-based teams-training program aimed at reducing severe perineal lacerations during childbirth. METHODS: A quasi-experimental pre-post single-group design was used to examine the performance of labor and delivery personnel at a large multihospital system after participating in a mixed-modality simulation program for reducing perineal lacerations. Multiple educational strategies aimed at management of second stage of labor (including laboring down, warm compresses, coaching, positioning, perineal support, controlled delivery of fetal head, and mediolateral episiotomy techniques) were taught using patients, task trainers, and a standardized curriculum during interprofessional educational sessions. Primary study outcomes were as follows: (a) pre-post differences in knowledge; (b) pre-post differences in team performance assessments; and (c) pre-post differences in safety culture. Secondary outcomes were severe perineal laceration rates. RESULTS: During an 18-month period, 675 personnel in 4 hospitals participated in the program. Significant improvement was noted in pre-post scores of knowledge (59.86%, 93.87%, P < 0.0001), performance (36.54%, 93.45%, P < 0.0001), and safety culture (3.24, 1.45, 1 = high, 5 = low, P < 0.0001). Severe perineal laceration rates decreased by 33.38% since initiation. Rates fluctuated with the addition of new personnel and renewed educational programs. CONCLUSIONS: A multimodal interprofessional simulation program of strategies to prevent severe perineal lacerations significantly improved knowledge, skills, and attitudes in labor and delivery personnel within a healthcare system. Severe perineal laceration rates were reduced.

A Case of Intertwin Membrane Hemorrhage with Spontaneous Resolution.

Vaginal bleeding during pregnancy places women at increased risk of spontaneous abortion. Etiologies for threatened and spontaneous abortions have been well studied, but there is little information on intertwin membrane hemorrhage. We present a patient with a multiple gestation pregnancy who experienced first trimester vaginal bleeding with visualization and subsequent rapid resolution of an intertwin membrane hemorrhage. The patient had an otherwise normal pregnancy until the third trimester when she developed preeclampsia with severe features and elected for a primary cesarean section at 35 + 5 weeks. The implications of an intertwin membrane hemorrhage are not well understood, although there could be a possible correlation between the hemorrhage and the ultimate progression to preeclampsia with severe features. Despite the final diagnosis, the patient did not have any noticeable complications due to the hemorrhage both when it was discovered and in the weeks following its discovery.

Visual Estimation of Force Applied During Simulated Deliveries Complicated by Shoulder Dystocia.

Background Shoulder dystocia occurs when the fetal head delivers, but the shoulder is lodged behind the pubic symphysis. Training for these emergency deliveries is not optimized, and litigation can occur around a shoulder dystocia delivery. Objective Evaluate the ability of an outside observer to visually estimate the amount of traction applied to the fetal head during simulated deliveries complicated by shoulder dystocia. Study Design Simulated deliveries with an objective measurement of traction were randomly organized for estimation of traction applied. Videos show providers applying a "normal" (75 N) and "excessive" (150 N) amount of force in both a "calm" and "stressed" delivery. Results Fifty participants rated the amount of force applied. Observers estimated traction, on a scale from 1 to 5, higher in the 150-N deliveries as compared with 75-N deliveries ("calm" environment: 3.1 vs. 2.8, p < 0.001; and "stressed" environment: 3.2 vs. 2.8, p < 0.001). Only 15% of observers rated force "above average" or "excessive" in a "calm" environment, as opposed to 30% of observers in the "stressed" environment. Conclusion Observers are not able to determine when "excessive force" is used and are twice as likely to overestimate the force applied to a fetal head when an average amount of force is used and the delivery environment is stressful. Precis Observers are unable to determine when excessive traction is applied to the fetal head during simulated deliveries complicated by shoulder dystocia.

Pregnancy-associated breast cancer.

Breast cancer is the second most common malignancy affecting pregnancy. Pregnancy-associated breast cancer (PABC) is defined as breast cancer diagnosed during pregnancy or in the first postpartum year. Because PABC is a relatively rare event surrounded by multiple variables, few studies address the best management and treatment options. We present a case of PABC to illustrate and highlight some of the recommendations for treatment, obstetric care, delivery management, and cancer surveillance.

Peripartum cardiomyopathy and acute fatty liver of pregnancy: one patient with two zebras.

OBJECTIVE: Peripartum cardiomyopathy (PPCM) and acute fatty liver of pregnancy (AFLP) are rare complications of pregnancy affecting approximately 1/10,000 pregnancies each. We describe a patient who had biopsy-proven AFLP complicated by PPCM. METHODS: Chart review and literature search. RESULTS: The patient is a 22-year-old G5P1213 obese African-American female who presented at 30 weeks gestation with abdominal pain. She had normal blood pressures and mildly elevated liver enzymes. After completion of a 24 hour urine protein collection that was consistent with pre-eclampsia, an induction of labor with uncomplicated vaginal delivery was accomplished. Following delivery, a computed tomography scan of the abdomen revealed significant cardiomegaly. An echocardiogram revealed global dysfunction with an ejection fraction of 10%. Liver biopsy showed AFLP. Attempts to establish a unifying etiology were unrevealing. The PPCM was treated with diuretics and intravenous immunoglobulin. The patient's clinical status deteriorated, eventually requiring continuous dialysis, intubation, pharmacologic and mechanical inotropic support, and a feeding tube. The patient was discharged to a long-term care facility where she subsequently passed away from multiorgan failure. CONCLUSION: AFLP and PPCM are rare complications of pregnancy. We present a patient who had both. Both diseases carry a high mortality rate, and together, are likely fatal.

Transplacental supply of mannose and inositol in uncomplicated pregnancies using stable isotopes.

OBJECTIVE: The aim of this study was to determine relative contributions of transplacental flux vs. fetal production for inositol and mannose in normal term pregnancies. STUDY DESIGN: Seven term uncomplicated pregnancies undergoing cesarean section were infused with (13)C- and (2)H-labeled isotopes of glucose, inositol, and mannose until a steady state was achieved. Maternal and fetal concentrations of labeled and unlabeled glucose, mannose, and inositol were measured using gas chromatography/mass spectroscopy. The fetomaternal molar percentage excess ratio was calculated for each glucose, mannose, and inositol. RESULTS: The fetomaternal molar percentage excess ratio of mannose in the fetal artery (F(artery)/M) was 0.99 [97.5% confidence interval (CI), 0.91-1.07] and in the fetal vein (F(vein)/M), 1.02 (97.5% CI, 0.95-1.10). Both were not significantly different from 1.0, consistent with transplacental supply. The fetomaternal ratios for glucose were similar to mannose (fetal artery, 0.95; 97.5% CI, 0.84-1.15; and fetal vein, 0.96; 97.5% CI, 0.85-1.07). The fetomaternal ratio for inositol was significantly less than 1.0 (fetal artery, 0.08; 97.5% CI, 0.05-0.12; fetal vein, 0.12; 97.5% CI, 0.06-0.18), indicating little transplacental flux and significant fetal production. CONCLUSION: In normal term pregnancies, fetal mannose and glucose concentrations are dependent upon maternal transplacental supply. Fetal inositol is not dependent upon transplacental supply.

The intrauterine growth-restricted fetus and placenta evaluation.

Evaluation of the placenta is extremely important in attempting to understand the pathophysiology of intrauterine growth restriction. Only with careful gross and microscopic evaluation, along with clinical pathologic correlation can the underlying cause(s) and recurrence risks be understood.

May-Thurner Syndrome resulting in acute iliofemoral deep vein thrombosis in the postpartum period.

BACKGROUND: May-Thurner Syndrome is a congenital anomaly of the right iliac artery, which causes an acquired narrowing defect in the left iliac vein. The artery abnormally compresses the vein causing intraluminal collagen deposition and sluggish venous flow. This syndrome places patients at increased risk of proximal deep venous thrombosis. CASES: We describe three postpartum patients with May-Thurner Syndrome complicated by iliofemoral deep vein thrombosis and their management. There was no evidence of underlying thrombophilia, yet these women had large proximal thrombi. They were treated with anticoagulation followed by thrombolysis and, in one case, stent placement. CONCLUSION: May-Thurner syndrome can predispose postpartum patients to large, proximal thrombi and may be treated effectively with a combination of thrombolysis and stent placement. May-Thurner Syndrome should be considered in the differential diagnosis of pelvic thrombosis, especially when thrombophilias are excluded.