Sleep-disordered breathing in high-risk pregnancies is associated with elevated arterial stiffness and increased risk for preeclampsia.

BACKGROUND: Impaired vascular function is a central feature of pathologic processes preceding the onset of preeclampsia. Arterial stiffness, a composite indicator of vascular health and an important vascular biomarker, has been found to be increased throughout pregnancy in those who develop preeclampsia and at the time of preeclampsia diagnosis. Although sleep-disordered breathing in pregnancy has been associated with increased risk for preeclampsia, it is unknown if sleep-disordered breathing is associated with elevated arterial stiffness in pregnancy. OBJECTIVE: This prospective observational cohort study aimed to evaluate arterial stiffness in pregnant women, with and without sleep-disordered breathing and assess the interaction between arterial stiffness, sleep-disordered breathing, and preeclampsia risk. STUDY DESIGN: Women with high-risk singleton pregnancies were enrolled at 10 to 13 weeks' gestation and completed the Epworth Sleepiness Score, Pittsburgh Sleep Quality Index, and Restless Legs Syndrome questionnaires at each trimester. Sleep-disordered breathing was defined as loud snoring or witnessed apneas (≥3 times per week). Central arterial stiffness (carotid-femoral pulse wave velocity, the gold standard measure of arterial stiffness), peripheral arterial stiffness (carotid-radial pulse wave velocity), wave reflection (augmentation index, time to wave reflection), and hemodynamics (central blood pressures, pulse pressure amplification) were assessed noninvasively using applanation tonometry at recruitment and every 4 weeks from recruitment until delivery. RESULTS: High-risk pregnant women (n=181) were included in the study. Women with sleep-disordered breathing (n=41; 23%) had increased carotid-femoral pulse wave velocity throughout gestation independent of blood pressure and body mass index (P=.042). Differences observed in other vascular measures were not maintained after adjustment for confounders. Excessive daytime sleepiness, defined by Epworth Sleepiness Score >10, was associated with increased carotid-femoral pulse wave velocity only in women with sleep-disordered breathing (Pinteraction=.001). Midgestation (first or second trimester) sleep-disordered breathing was associated with an odds ratio of 3.4 (0.9-12.9) for preeclampsia, which increased to 5.7 (1.1-26.0) in women with sleep-disordered breathing and hypersomnolence, whereas late (third-trimester) sleep-disordered breathing was associated with an odds ratio of 8.2 (1.5-39.5) for preeclampsia. CONCLUSION: High-risk pregnant women with midgestational sleep-disordered breathing had greater arterial stiffness throughout gestation than those without. Sleep-disordered breathing at any time during pregnancy was also associated with increased preeclampsia risk, and this effect was amplified by hypersomnolence.

A retrospective study comparing postoperative opioid prescribing practices in an academic medical centre.

Background: In the midst of the North American opioid crisis, identifying and intervening on drivers of high-risk opioid prescriptions is an important step towards reducing iatrogenic harm. Objectives: We aimed to identify factors associated with variations in high-risk opioid discharge prescriptions, following select surgical procedures, to guide future quality improvement initiatives. Methods: This retrospective cohort study analyzed 1322 patients who underwent select open pelvic and open abdominal surgeries between January 1 and December 31, 2017, in a tertiary health care centre in Montreal. Results: Patients who underwent open abdominal surgeries were prescribed significantly higher daily doses of morphine milligram equivalents (MME) (45 mg; interquartile range, 30-60), than patients who underwent either a caesarean delivery (20 mg, 20-20) or a hysterectomy (30 mg, 22-30). After adjustment for multiple potential confounders, abdominal surgery was associated with 4 times the odds of receiving more than 50 MME at hospital discharge compared with pelvic surgeries (odds ratio, 3.96; 95% confidence interval, 1.31-11.97). The availability of postoperative preprinted order sets with fixed high doses of opioids was also highly associated with the outcome. Conclusion: In our institution, some surgeries were more likely to receive high-risk opioid prescriptions at discharge. Efforts to optimize safer prescribing practices should address the creation and/or updating of preprinted order sets to reflect current best practice guidelines. This initiative could be overseen by hospital pharmacy and therapeutics committees.

Obstetrical and Newborn Outcomes Among Patients With SARS-CoV-2 During Pregnancy.

We report on the perinatal outcomes of pregnant patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from 2 hospitals in Montréal, Québec. Outcomes of 45 patients with SARS-CoV-2 during pregnancy were compared with those of 225 patients without infection. Sixteen percent of patients with SARS-CoV-2 delivered preterm, compared with 9% of patients without (P = 0.28). Median gestational age at delivery (39.3 (interquartile range [IQR] 37.7-40.4) wk vs. 39.1 [IQR 38.3-40.1] wk) and median birth weight (3250 [IQR 2780-3530] g vs. 3340 [IQR 3025-3665] g) were similar between groups. The rate of cesarean delivery was 29% for patients with SARS-CoV-2. Therefore, we did not find important differences in outcomes associated with SARS-CoV-2. Our findings may be limited to women with mild COVID-19 diagnosed in the third trimester.

Postpartum Analgesia in New Mothers (PAIN) Study: A Survey of Canadian Obstetricians' Post-Delivery Opioid-Prescribing Practices.

OBJECTIVE: We aimed to describe opioid prescribing practices after obstetric delivery and to evaluate how these practices compare with national opioid prescribing guidelines. METHODS: A closed survey was developed, evaluated for validity and reliability, and distributed by email to obstetrician members of the Society of Obstetricians and Gynaecologists of Canada (SOGC) in December 2018. Descriptive statistics were used to summarize respondent demographics, pharmaceutical pain management strategies, and opioid prescribing practices. Logistic regression was used to measure associations between respondent characteristics and high-risk opioid prescribing practices (e.g., prescribing >50 mg morphine equivalent dose per day, prescribing >5 days, not screening for substance/opioid use disorder before prescribing). RESULTS: Our survey had high content validity (content validity index 0.89; 95% CI 0.78-1.00) and adequate reliability (Kappa 0.70; 95% CI 0.63-0.84 and intraclass correlation coefficient 0.70; 95% CI 0.67-0.81). Of the 1019 SOGC members reached, 243 initiated the survey (response rate, 24%). Among respondents, 235 (92%) completed the survey. Among opioid prescribers, 47% reported at least 1 high-risk opioid prescribing practice, the most frequent being a lack of substance/opioid use disorder screening. In the adjusted logistic regression model, being in practice more than 20 years (adjusted odds ratio [aOR] 0.53; 95% CI 0.29-0.93) and practising in a non-central area of Canada (aOR 0.49; 95% CI 0.28-0.84) reduced the odds of high-risk prescribing. CONCLUSION: Further research on barriers to screening are needed to support and enhance safer opioid prescribing practices among Canadian obstetricians.

Recommendation Patterns among Gynaecologists and Radiologists for Adnexal Masses on Ultrasound.

OBJECTIVE: Ultrasound is the primary modality used to evaluate adnexal lesions. Follow-up recommendations for ovarian cysts remain controversial between gynaecologists and radiologists. The objective of this study was to compare practice patterns for adnexal masses described on ultrasound on the basis of the interpreter's field of specialty. METHODS: This study was conducted within the McGill University Hospital Network at two hospitals that differ in the department of interpretation of pelvic ultrasounds. In one hospital, all studies are reported by gynaecologists, and in the other, by radiologists. The study investigators collected data from pelvic ultrasounds of newly diagnosed ovarian lesions performed from May to June 2014. Multivariate logistic regression analyses were used to compare recommendation patterns between the two groups. RESULTS: A total of 201 of 1110 pelvic ultrasound studies performed met our inclusion criteria. Gynaecologists interpreted 69 (34%) pelvic ultrasounds, and radiologists reported on 132 (66%). Reported adnexal mass types were not significantly different between the two groups. As compared with gynaecologists, radiologists were more likely to recommend MRI or CT scans (OR 11.76; 95% CI 1.17-117.78), as well as follow-up ultrasound studies (OR 4.67; 95% CI 1.66-13.1), and they were less likely to recommend no further imaging (OR 0.18; 95% CI 0.07-0.45). Groups did not differ in recommendation patterns for referral to a specialist. CONCLUSION: There are significant differences in recommendation patterns between gynaecologists and radiologists in evaluating new adnexal masses on ultrasound. This difference can have important effects on resource use and patients' concerns.

Evaluation of management and surgical outcomes in pregnancies complicated by acute cholecystitis.

OBJECTIVE: To evaluate the management of pregnancies complicated by acute cholecystitis (AC) and determine whether pregnant women are more likely to have medical and surgical complications. METHODS: We carried out a population-based matched cohort study using the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample from 2003 to 2011. Pregnant women with AC were age matched to non-pregnant women with AC on a 1:5 ratio. Management and outcomes were compared using descriptive analysis and conditional logistic regression. RESULTS: There were 11,835 pregnant women admitted with AC who were age matched to 59,175 non-pregnant women. As compared to non-pregnant women, women with AC were more commonly managed conservatively, odds ratio (OR) 6.1 (5.8-6.4). As compared to non-pregnant women, pregnant women with AC more commonly developed sepsis [OR 1.4 (1.0-1.9)], developed venous thromboembolism [OR 8.7 (4.3-17.8)] and had bowel obstruction [OR 1.3 (1.1-1.6)]. Among pregnant women with AC, surgical management was associated with a small but significant increased risk of septic shock and bile leak. CONCLUSION: AC, in the context of pregnancy, is associated with an increased risk of adverse outcomes. Although the literature favors early surgical intervention, pregnancies with AC appear to be more commonly managed conservatively with overall comparable outcomes to surgically managed AC. Conservative management may have a role in select pregnant women with AC.

Medical and obstetric outcomes among pregnant women with tuberculosis: a population-based study of 7.8 million births.

BACKGROUND: Worldwide, tuberculosis remains a major health concern, with an estimated 9.6 million people infected in the year 2014, of which one-third were women. Tuberculosis is estimated to be even more prevalent in pregnant women than the general population. To date there has been conflicting evidence on the maternal and neonatal complications of tuberculosis in pregnancy. OBJECTIVE: We sought to determine trends in the incidence of tuberculosis in pregnancy and to examine the associations between tuberculosis in pregnancy and maternal and fetal complications. STUDY DESIGN: We conducted a retrospective cohort study using the 2003 through 2011 Healthcare Cost and Utilization Project Nationwide Inpatient Sample. We identified hospital admissions during which women with and without tuberculosis delivered. The temporal patterns in incidence of tuberculosis were estimated, as were the rates of pulmonary and nonpulmonary tuberculosis. Multivariate logistic regression was used to examine the adjusted effects of tuberculosis on maternal and neonatal outcomes. RESULTS: During the study period, there were 7,772,999 births, of which 2064 were to women with tuberculosis, for an overall incidence of 26.6 per 100,000 births. From 2003 through 2011, there was an upward trend in the incidence of tuberculosis from 1.92-4.06 per 10,000 births (P < .0001), mostly due to increasing numbers of nonpulmonary tuberculosis. Compared with noncases, tuberculosis occurred with greater frequency in women who were 25-34 years of age and of Hispanic ethnicity. Significantly more women with tuberculosis had concurrent HIV. In addition, delivery hospitalizations with tuberculosis compared with those without tuberculosis were more likely to experience chorioamnionitis, preterm labor, postpartum anemia, blood transfusion, pneumonia, acute respiratory distress syndrome, and mechanical ventilation. Maternal mortality was significantly increased in women with tuberculosis. Congenital anomalies were higher among babies delivered to women with tuberculosis. CONCLUSION: The rate of tuberculosis in pregnancy is rising in the United States. Although this increase appears to be mostly due to nonpulmonary disease, there was also a high incidence of maternal respiratory complications, mortality, and postpartum obstetric morbidity.

Incidence and outcomes of women with Hodgkin's lymphoma in pregnancy: a population-based study on 7.9 million births.

OBJECTIVE: The purpose of our study was to estimate the incidence and maternal and fetal outcomes of Hodgkin's lymphoma (HL) in pregnancy. METHODS: We carried out a population-based cohort study on all births identified in the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample from 2003 to 2011. We calculated disease incidence and used logistic regression analysis to estimate the adjusted effect of HL on maternal and neonatal outcomes. RESULTS: There were 638 cases of HL in pregnancy among 7,916,388 births, for an overall incidence of 8.06 per 100,000 births, with no perceivable trend over the 8-year study period. Relative to controls, HL in pregnancy was more common among Caucasians and women aged 25-34 years. After adjusting for baseline characteristics, women with HL in pregnancy were more likely to have preterm births, odds ratio (OR) 1.93 (1.53, 2.42) require postpartum blood transfusion, OR 1.38 (1.05, 1.82), and have venous thromboembolism (VTE), OR 7.93 (2.97, 21.22). CONCLUSION: The incidence of HL in pregnancy appears to be higher than previously reported with no temporal trend over an 8-year period. Although there is a greater risk of preterm birth and maternal postpartum blood transfusion and VTE, overall maternal and neonatal major morbidity and mortality does not appear to be increased.

Incidence and outcomes of women with non-Hodgkin's lymphoma in pregnancy: a population-based study on 7.9 million births.

AIM: Non-Hodgkin's lymphoma (NHL) is a rare malignancy that can affect women of all ages. The purpose of our study was to estimate the incidence, maternal and fetal outcomes of pregnancy-associated non-Hodgkin's lymphoma (PANHL). MATERIAL AND METHODS: We conducted a population-based cohort study on all births identified in the Healthcare Cost and Utilization Project - Nationwide Inpatient Sample from 2003 to 2011. Disease incidence was calculated and logistic regression was used to estimate the adjusted effect of NHL on maternal and fetal outcomes. RESULTS: Of 7,917,453 births, there were 427 cases of PANHL for an overall incidence of 5.39 per 100,000 births, increasing from 4.44 per 100,000 births to 7.17 per 100,000 births over the 9-year period. Relative to controls, PANHL was more common among Caucasians and women aged 25-34 years. Non-specified PANHL was most commonly coded in >81% of cases, with mycosis fungoides and Burkitt's lymphoma being the other two most common. After adjusting for baseline characteristics, women with PANHL were more likely to have pre-eclampsia, odds ratio (OR) 1.57 (95% confidence interval [CI] 1.06-2.32), cesarean section, OR 1.37 (95%CI 1.13-1.67), preterm births OR 2.50 (95%CI 1.94-3.22), postpartum blood transfusions, OR 2.73 (2.10-3.55), and infectious morbidity, OR 2.81 (95%CI 1.16-6.79). Maternal and fetal mortality rates were significantly increased among women with PANHL. CONCLUSION: The incidence of PANHL is increasing and is associated with an increased risk of maternal and neonatal morbidity and mortality, and as such, women with PANHL may best be managed in specialized centers.