Maternal and infant cannabis testing and associated birth outcomes.

OBJECTIVES: The objective of the study was to determine any identifiable clinical utility of the practice of universal maternal and infant tetrahydrocannabinol (THC) testing at the time of birth. METHODS: This was cross-sectional, retrospective cohort study comparing the following birth outcomes in relation to maternal and infant tetrahydrocannabinol (THC): APGAR scores, cord gases, NICU admission and need for immediate resuscitation. All births at the University of Maryland Medical Center between January 1, 2018 and December 31, 2020 were reviewed. Those that had either maternal or infant test results missing were excluded. Statistical analysis was performed using STATA v27. Birth outcomes were adjusted for gestational age at delivery and tobacco use. Infant resuscitation was considered the need for any respiratory support. RESULTS: A total of 4260 maternal/infant pairs were included. Of these, 314 (7.4%) birthing parents and 161 (3.8%) of infants tested positive for THC. Of the birth parents who tested positive for THC, 51.3% of their infants also tested positive for THC. Maternal/infant pairs that both tested positive for THC had the lowest need for immediate resuscitation and Neonatal Intensive Care Unit admission. Cord gases and APGAR scores were similar between the groups. Birth parents who tested positive for THC delivered infants at an earlier gestational age (37w6d v 38w5d, p = 0.001) and lower mean birth weight (2690gm v 3061gm, p = 0.001) than those who tested negative even after adjusting for confounders. When limited to only term births and broken down by weeks completed gestation, the mean birth weights were lower for every week in those who tested positive for THC versus those who tested negative. CONCLUSIONS: Our study shows that maternal and neonatal testing for THC at the time of birth is not predictive of important neonatal outcome parameters. Therefore, even though it is likely that there are some effects of in utero THC exposure on the neonate, we did not find any clinical benefits that would justify routine maternal and/or infant testing for THC at the time of birth.

Comparison of Computer-Assisted Self-Interview Versus Clinician Interview for Self-Reported Vulvovaginal Symptoms.

ABSTRACT: This secondary analysis (N = 43) compared computer-assisted self-interview (CASI) to clinician interview for self-report of 8 vulvovaginal symptoms. Concordance was moderate between interview modes (range, 70-86%) with itching and odor having highest agreement. Although prior reports suggest more responses on CASI, we found CASI did not significantly increase self-report of symptoms over clinician interview.

Effect of maternal adverse childhood experiences (ACE) and cannabis use on pregnancy outcomes.

This study aimed to characterize the relationship between cannabis use, ACE score, and pregnancy outcomes. Pregnant patients in Baltimore, MD, completed the 17-point ACE checklist. Charts of the birth parent and neonate were reviewed for urine toxicology testing at initiation of care and delivery, prenatal care metrics, and birth statistics. Multivariable logistic regression analysis was performed to assess the relationship between ACE score, cannabis use, and pregnancy outcomes. Of 256 birth parents, 87 (34.0%) tested positive for cannabis at initial visit and 39 (15.2%) tested positive for cannabis at delivery. Testing positive for cannabis at initial visit or delivery was associated with higher ACE score (15.1 vs 13.7, p = 0.04; 16.2 vs 13.8, p = 0.01). Of those who tested positive for cannabis at initial visit, 39/87 (45.0%) tested positive at delivery. Continued cannabis use at delivery was associated with lower maternal weight gain (7.9 kg vs 13.3 kg, p = 0.003), fewer prenatal visits (7 vs 8, p = 0.010), and numerically higher mean ACE score. Cannabis use at delivery was associated with 10% lower birthweight (2665 g vs 3014 g p < 0.05) but not with pre-term birth. Total ACE score was not significantly associated with any birth outcome. Worse pregnancy outcomes were associated with cannabis use throughout pregnancy but not with cannabis use at prenatal care initiation. The interplay of ACE and continued cannabis use during pregnancy warrants further research on the physiologic effects of cannabis and interventions to decrease substance use during pregnancy.

Patient Perceptions of Three Substance Use Screening Tools for Use During Pregnancy.

OBJECTIVES: The purpose of this study was to understand pregnant women's perceptions of three validated substance use screening tools and identify a preferred tool for use during pregnancy. The three screening tools studied included the 4P's Plus, the NIDA Quick Screen/ NIDA-Modified Alcohol, Smoking and Substance Involvement Screening Test, and the Substance Use Risk Profile-Pregnancy Scale. METHODS: A total of 493 cognitive interviews were completed with a diverse sample of pregnant women presenting to two obstetrics practices in Baltimore, MD from January 2017 to January 2018. This study served as a qualitative companion to a larger study comparing the accuracy and acceptability of substance use screening tools in prenatal care. After completing each screening tool, participants were asked their perceptions of the tool and to choose their preferred tool. Interviews were recorded, transcribed verbatim, coded, and analyzed using NVivo software. RESULTS: The plurality of participants (43.4%) reported they preferred the 4P's Plus. Fewer participants preferred the NIDA Quick Screen (32.5%) and the SURP-P (24.1%). Participants felt that the 4P's Plus was both comprehensive and concise. While many participants felt that disclosure of substance use would vary by individual, participants also suggested that when screening is confidential, includes questions about a patient's background, and administered by a non-judgmental provider, pregnant people may be more likely to answer honestly. CONCLUSIONS FOR PRACTICE: The 4P's Plus is a promising and acceptable substance use screening tool for use in prenatal care. Clinicians can use several methods to increase acceptability of substance use screening and encourage disclosure of prenatal substance use.

Association between continued cannabis use during pregnancy and symptoms of anxiety and depression.

Cannabis use in pregnancy is common, as are mental health disorders, but the association between the two is not well established. This study is a single-site retrospective cohort. Urine testing for cannabis was evaluated at two-time points to categorize women as having never used, quit or continued to use. Edinburgh Postnatal Depression Scale (EPDS) and Generalized Anxiety Disorder (GAD) screen results were compared across groups using multinomial logistic regression. In addition, EPDS and GAD change scores between initiation of care and delivery were analyzed. 604 women were included, 221 (36.3%) with positive toxicology testing for cannabis at the initiation of care. Women who continued cannabis use were significantly more likely to have elevated GAD and EPDS scores (2.55 [1.31, 4.99]) and EPDS score (2.75 [1.43, 5.28]), respectively as compared to those with no use. No significant differences were found between groups in GAD or EPDS change scores t women with higher depression scores on the EPDS had 2.70 times the odds of being in the continuous use group compared to the quit using group (aOR = 2.70, 95% CI = [1.30, 5.88]). Both anxiety and depression symptoms were found to be associated with cannabis use and continued use during pregnancy.

Opioid prescription-use after cesarean delivery: an observational cohort study.

OBJECTIVE: To evaluate current opioid prescription practices following a cesarean delivery. METHODS: Women were asked to participate in a prospective observational cohort study following a cesarean delivery. Participants were asked about their opioid use after discharge, amount leftover, subjective pain score, and satisfaction. RESULTS: A total of 344 women had cesarean deliveries during the study period, 242 were approached, 171 met eligibility criteria, and 109 were included in the analysis. Women in our study were predominantly African American (66.1%), high school graduates (32.1%), publicly insured (65.1%), single (55%) working mothers (68.8%). Most had been previously prescribed opioids (70.6%), of which 58.4% had a prior cesarean delivery. Only 78.8% of study participants took their opioid prescriptions, and 89.6% had an average of 17 pills leftover. The number of pills taken correlated with those prescribed in the study. Improved satisfaction in pain control with opioid and non-opioid alternatives was associated with a decrease in opioids used. Similarly, the participants' perception of their abundant prescription quantity was associated with a decrease in prescription taken. CONCLUSION: Women were prescribed excess opioids. Excess opioids accounted for 63.3% of all pills filled, a total of 1670 pills leftover, most of which were stored in an unlocked location (75.6%). Our data showed a discrepancy of pills prescribed (24) compared to those used (10), which was also perceived as enough or too many by our participants. Our study demonstrates that women would benefit from fewer opioid pills and a discussion based on their pain perception.

Nonoptimal Vaginal Microbiota After Azithromycin Treatment for Chlamydia trachomatis Infection.

We characterized the composition and structure of the vaginal microbiota in a cohort of 149 women with genital Chlamydia trachomatis infection at baseline who were followed quarterly for 9 months after antibiotic treatment. At time of diagnosis, the vaginal microbiota was dominated by Lactobacillus iners or a diverse array of bacterial vaginosis-associated bacteria including Gardnerella vaginalis. Interestingly, L. iners-dominated communities were most common after azithromycin treatment (1 g monodose), consistent with the observed relative resistance of L. iners to azithromycin. Lactobacillus iners-dominated communities have been associated with increased risk of C. trachomatis infection, suggesting that the impact of antibiotic treatment on the vaginal microbiota could favor reinfections. These results provide support for the dual need to account for the potential perturbing effect(s) of antibiotic treatment on the vaginal microbiota, and to develop strategies to protect and restore optimal vaginal microbiota.

Has a critical mass of women resulted in gender equity in gynecologic surgery?

Gender equity in medicine and surgery has recently received widespread attention. Unlike surgical specialties that remain predominantly male, the majority of obstetrician-gynecologists have been women for nearly a decade, and women have composed the majority of trainees since the 1990s. Despite a critical mass of women, biases related to gender persist in the field. Professional and behavioral expectations of men and women gynecologists remain different for patients and workplace colleagues. Gender discrimination and sexual harassment are still experienced at high rates by both trainees and obstetrician-gynecologists in practice. In addition, in other surgical fields, women gynecologic surgeons face a gender wage gap that is unexplained by differences in experience, hours worked, or subspecialty training. Academic advancement and the attainment of leadership positions remain a challenge for many women. Policies related to pregnancy and parenting may disproportionately affect the careers of women gynecologists. This article presents peer-reviewed evidence relevant to gender equity in the workplace and suggests proactive interventions to ensure diversity and inclusion for gynecologic surgeons.

Cannabis Use as Determined by Biologic Testing in Maternal and Newborn Urines during a Period of Drug Liberalization.

Introduction: Cannabis use is common in pregnancy and prevalence of reported past month use have been increasing despite recommendations of abstinence. Our study aimed to evaluate the prevalence of cannabis use in pregnancy using urine drug screens obtained at the time of admission to Labor and Delivery. Methods: De-identified laboratory data from three birthing hospitals located in Maryland were used to determine the percentage of cannabis positive urine toxicology tests among women admitted to Labor and Delivery. Data were collected at each site starting the year that universal urine cannabis testing was instituted. One hospital also performed universal testing of newborns which was contrasted with maternal data there. Results: Overall, 5.7% of the 22,435 maternal and 3.4% of the 8,346 newborn urine toxicology tests and were positive for cannabis. Trends varied between institutions. When all three institutions were combined, the percent of positive urine toxicology tests was unchanged between 2016 and 2018. At Site 1 between 2014 and 2018, the percentage of cannabis positive urine toxicology tests increased from 5.7% to 9.9% and newborn tests increased from 1.7% to 3.4%. Only 27.7% of the neonates born to women with positive screens also had a positive screen at the time of birth. Conclusions: Prevalence of cannabis use until the time of delivery vary by location but were largely unchanged over a period of drug liberalization.

Patterns in On-time, Daily Submission of a Short Web-Based Personal Behavior Survey in a Longitudinal Women's Health Study.

We evaluated compliance with submitting a short Web-based personal behavior survey daily during a 10-week study (n = 52 women/3419 diaries). Time-stamped forms revealed that 50% of diaries were submitted within 24 hours of the email prompt, and 19% were missing or submitted more than 3 days late. Late submissions may affect data quality.

The Vaginal Microbiota and Behavioral Factors Associated With Genital Candida albicans Detection in Reproductive-Age Women.

BACKGROUND: Vulvovaginal candidiasis is commonly diagnosed and has been associated in prospective studies with the acquisition of HIV. Little data is available on how the composition of the vaginal microbiota, and other risk factors, are associated with the molecular detection of Candida albicans-a common cause of vulvovaginal candidiasis. METHODS: In a cross-sectional study, self-collected vaginal swabs were obtained from 394 nonpregnant, reproductive-age women. C. albicans was detected using polymerase chain reaction targeting C. albicans ITS1/2 region. Vaginal microbiota was characterized by 16S rRNA gene amplicon sequencing of the V3 to V4 hypervariable regions and clustered into community state types (CSTs). Multiple logistic regression identified factors associated with C. albicans detection. RESULTS: Twenty-one percent had C. albicans detected and 46% reported vaginal symptoms in the prior 60 days. There was a 2-fold increase in the odds of C. albicans if a woman was in a L. crispatus-dominated CST compared to CSTs with low-Lactobacillus levels (adjusted odds ratio, 2.05; 95% confidence interval, 0.97-4.37). History of self-treatment with antifungals, L. crispatus relative abundance, and receptive oral sex were also significantly associated with C. albicans detection. CONCLUSIONS: A L. crispatus-dominated vaginal microbiota is thought to protect women from both development of bacterial vaginosis and incidence of sexually transmitted infections; however, our data suggest that L. crispatus is associated with increased C. albicans detection. Receptive oral sex may also be a risk factor for vaginal C. albicans colonization.

Prenatal Substance Use and Perceptions of Parent and Partner Use Using the 4P's Plus Screener.

Background Prenatal substance use screening is recommended. The 4 P's Plus screener includes questions on perceived problematic substance use in parents and partner that are not considered in risk stratification. Objectives This research examined the: (1) prevalence of self-reported problematic parental and partner substance use and associations with biochemically-verified prenatal substance use; (2) utility of self-reported perceptions of parent/partner substance use as proxies for prenatal substance use; and (3) degree to which the sensitivity of the 4P's Plus can be augmented with consideration of parent/partner questions in risk stratification. Methods A convenience sample of 500 pregnant women was recruited between January 2017 and January 2018. Participants completed the 4P's Plus and provided urine for drug testing. Diagnostic utility of problematic parent/partner substance use questions was assessed, then compared to the 4P's Plus used as designed, and to the 4P's Plus used with these 2 questions included in risk stratification. Results Half (51%) of respondents reported either partner or parental problematic substance use. When partner or parent problematic substance use were considered as proxies for prenatal substance use, sensitivity was 65% and specificity was 55%. When used as intended, sensitivity was 94% and specificity was 29%. Including partner/parent questions increased sensitivity to 96% but lowered specificity (19%). Partner substance use and combined partner/parent use were associated with prenatal substance use [adjusted odds ratio (aOR): 2.0 (1.2, 2.4; p = 0.006); aOR = 1.6 (1.1, 2.5, p = 0.04)]. Conclusions for Practice Sensitivity of the 4P's Plus may improve with inclusion of self-reported problematic partner/parent substance use items in risk stratification.

Rates of regression of cervical dysplasia between initial biopsy and excisional procedure in routine clinical practice.

PURPOSE: To determine rates and factors associated with regression of cervical intraepithelial neoplasia (CIN) 2 + between colposcopic biopsy and therapeutic excisional procedure in standard practice. METHODS: A retrospective chart review was performed for women undergoing a cervical excisional procedure for CIN 2 + at clinics at three academic institutions over a 3-year period. Cytology, histology, patient age and time-to-excision were analyzed to determine factors influencing rates of regression. RESULTS: Of 356 women undergoing excision for CIN 2 + on colposcopic biopsy, 91 (25.3%) of final pathology diagnoses displayed clinically significant regression. Age and time-to-excision were not associated with regression, but referral cytology and severity of initial biopsy histology were, with ASC-H (aOR 0.1, CI 0.03, 0.8) and CIN 3/AIS (aOR 0.4, CI 0.2, 0.7) being less likely to regress than less severe lesions. CONCLUSIONS: Disease severity by referral cytology or diagnostic biopsy, as opposed to age or length of time-to-excision, is likely the most relevant factor in determination of regression for cervical intraepithelial neoplasia in women undergoing excisional treatment for biopsy-confirmed CIN2 +.

Risk of complication during surgical abortion in obese women.

BACKGROUND: Surgical abortion is a generally safe procedure. Obesity is a known risk factor for complications in other surgical procedures, but insufficient information exists to determine the effects of increasing body mass index on the risk of surgical abortions. OBJECTIVE: The purpose of this study was to determine whether obesity is a risk factor for major complications in surgical abortions. METHODS: A quality control database from a single outpatient center was analyzed to determine rates of major complications during surgical abortions in relation to obesity class. Complications included hemorrhage, need for repeat evacuation, uterine perforation, cervical laceration, medication reaction, unexpected surgery, or unplanned admission to the hospital. Chi-squared and analysis of variance were used for analysis. RESULTS: We included 2468 procedures: 1475 procedures (59.8%) in the first trimester and 993 procedures (40.2%) in the second trimester. The overall complications rate was 2.2%. Second-trimester procedures were more likely than those in the first trimester to have complications (3.1% vs 1.6%; P=.009). Overall, 39.6% of the women were obese, and 9.6% of them met criteria for class 3 obesity (body mass index, >40 kg/m2). Women who underwent second-trimester abortions with class 3 obesity had a rate of complication of 8.7%, which was significantly more than normal weight women (odds ratio, 5.90; 95% confidence interval, 1.93-8.07; P<.001). COMMENT: Surgical abortions are overall safe procedures, but class 3 obesity increases the rate of complication in second-trimester procedures.

Should prenatal care providers offer pregnancy options counseling?

BACKGROUND: Professional guidelines indicate that pregnancy options counseling should be offered to pregnant women, in particular those experiencing an unintended pregnancy. However, research on whether pregnancy options counseling would benefit women as they enter prenatal care is limited. This study examines which women might benefit from options counseling during early prenatal care and whether women are interested in receiving counseling from their prenatal care provider. METHODS: At four prenatal care facilities in Louisiana and Maryland, women entering prenatal care completed a self-administered survey and brief structured interview (N = 586). Data were analyzed through descriptive statistics, bivariate analyses, multivariate multinomial logistic regression, and coding of open-ended responses. RESULTS: At entry into prenatal care, most women reported that they planned to continue their pregnancy and raise the child. A subset (3%) scored as having low certainty about their decision on the validated Decision Conflict Scale, indicating need for counseling. In addition, 9% of women stated that they would be interested in discussing their pregnancy options with their prenatal care provider. Regression analyses indicated some sociodemographic differences among women who are in need of or interested in options counseling. Notably, women who reported food insecurity in the prior year were found to be significantly more likely to be in need of options counseling (RRR = 3.20, p < 0.001) and interested in options counseling (RRR = 5.48, p < 0.001) than those who were food secure. Most women were open to discussing with their provider if their pregnancy was planned (88%) or if they had considered abortion (81%). More than 95% stated they would be honest with their provider if asked about these topics. CONCLUSIONS: Most women are certain of their decision to continue their pregnancy at the initiation of prenatal care. However, there is a subset of women who, despite entering prenatal care, are uncertain of their decision and wish to discuss their options with their health care provider. Screening tools and/or probing questions are needed to support prenatal care providers in identifying these women and ensuring unbiased, non-directive counseling on all pregnancy options.

Cigarette Smoking Status and Substance Use in Pregnancy.

Objectives Substance use during pregnancy is a significant public health issue. Prenatal substance use increased in the past decade while prenatal cigarette smoking has remained stable. Co-use of tobacco and other drugs is a concern because of potential additive risks. This study aims to describe the prevalence rates of substance use among pregnant women and examine the association between smoking status (nonsmoker, recent quitter and current smoker) and other drug use. Methods In this cross-sectional study, pregnant women (n = 500) were recruited from two obstetric practices to complete three substance use screeners and have their urine tested for 12 different drug classes, including cannabis, opioids and cocaine. Participants were divided into three groups based on survey responses: nonsmokers, recent quitters (smoked in the month prior to pregnancy but not past month) and current smokers (past-month). Results Approximately 29% of participants reported smoking in the month before pregnancy. During pregnancy, 17, 12 and 71% were current smokers, recent quitters and nonsmokers respectively. Overall prevalence of illicit or prescription drug use in pregnancy was 27%. Cannabis was the most common drug used in pregnancy with prevalence of 22%, followed by opioids (4%), cocaine (1%), tricyclic antidepressants (TCAs) (1%), amphetamines (1%), and benzodiazepines (1%). On multivariable logistic regression, smoking in pregnancy was associated with a positive urine drug screen; with adjusted odds ratio (aOR) 4.7 (95% CI 2.6-8.3) for current smokers and 1.6 (95% CI 0.8-3.3) for recent quitters. Factors negatively associated with positive drug screen were second and third trimester pregnancies, 0.5 (0.3-0.9) and 0.3 (0.2-0.6) respectively; and employment, 0.5 (0.3-0.8). Conclusions for Practice Co-use of tobacco and illicit drugs, particularly cannabis, is relatively high during pregnancy. Additional research is needed to understand the health implications of co-use versus use of tobacco only. Given the strong association between smoking and other drug use, clinicians should routinely assess for illicit drug use in women who smoke during pregnancy.

Cannabis and pregnancy: Maternal child health implications during a period of drug policy liberalization.

Cannabis use is common and increasing among women in the United States. State policies are changing with a movement towards decriminalization and legalization. We explore the implications of cannabis liberalization for maternal and child health. Most women who use cannabis quit or cut back during pregnancy. Although women are concerned about the possible health effects of cannabis, providers do a poor job of counseling. There is a theoretical potential for cannabis to interfere with neurodevelopment, however human data have not identified any long-term or long lasting meaningful differences between children exposed in utero to cannabis and those not. Scientifically accurate dissemination of cannabis outcomes data is necessary. Risks should be neither overstated nor minimized, and the legal status of a substance should not be equated with safety. Decreasing or stopping use of all recreational drugs should be encouraged during pregnancy. Providers must recognize that even in environments where cannabis is legal, pregnant women may end up involved with Child Protective Services. In states where substance use is considered child abuse this may be especially catastrophic. Above all, care for pregnant women who use cannabis should be non-punitive and grounded in respect for patient autonomy.

Primary Placement of Incisional Negative Pressure Wound Therapy at Time of Laparotomy for Gynecologic Malignancies.

OBJECTIVE: Wound complications are an important cause of postoperative morbidity amongst patient with gynecologic malignancies. We evaluated whether the placement of prophylactic negative pressure wound therapy (NPWT) at the time of laparotomy for gynecologic cancer surgery reduces wound complication rates. METHODS: A retrospective analysis of patients undergoing laparotomy with primary wound closure performed by a gynecologic oncologist at a single academic institution over a 5-year study period was performed. Patients who had placement of prophylactic NPWT dressing were compared with patients with a standard closure. Postoperative outcomes were examined. RESULTS: A total of 230 patients were identified: 208 women received standard wound care, 22 received NPWT. Groups were similar in age, prevalence of diabetes, tobacco use, and number of previous abdominal procedures. Intraoperative factors including length of procedure and transfusion requirements were similar. Body mass index for patients receiving standard treatment was 30.67 compared with 41.29 for NPWT group (P < 0.001). Incidence of all wound complications was 19.7% for those receiving standard treatment versus 27.3% for NPWT group (P = 0.40). Length of hospital stay was similar between the 2 groups (5.25 vs 6.22 days, P = 0.20). There were 3 hospital readmissions for wound complications-none occurred in women with a prophylactic NPWT dressing. CONCLUSIONS: Despite significantly higher obesity rates, patients with prophylactic NPWT dressing placement had similar rates of wound complications. Our findings suggest a potential therapeutic benefit in the use of prophylactic NPWT for the reduction of wound complications in this high-risk gynecologic oncology patient population.