Post-discharge healthcare utilization in infants with neonatal opioid withdrawal syndrome.

The opioid epidemic in the United States has led to a significant increase in the incidence of neonatal opioid withdrawal syndrome (NOWS); however, the understanding of long-term consequences of NOWS is limited. The objective of this study was to evaluate post-discharge healthcare utilization in infants with NOWS and examine the association between NOWS severity and healthcare utilization. A retrospective cohort design was used to ascertain healthcare utilization in the first year after birth-related discharge using the CERNER Health Facts® database. ICD-9/ICD-10 diagnostic codes were used to identify live births and to classify infants into two study groups: NOWS and uncomplicated births (a 25% random sample). Evaluated outcomes included rehospitalization, emergency department (ED) visits within 30-days and one-year after discharge, and a composite one-year utilization event (either hospitalization or emergency department visit during that year). NOWS severity was operationalized as pharmacologic treatment, length of hospitalization, and medical conditions often associated with NOWS. In 3,526 infants with NOWS (restricted to gestational age ≥ 33 weeks), NOWS severity was associated with an increase in composite one-year utilization (OR: 1.1; 95% CI: 1.04-1.2) after adjusting for prematurity, sepsis, jaundice, use of antibiotics, infant sex, insurance status, race, hospital bed size, year of birth, and census division. In a subset of full-term infants (3008 with NOWS and 88,452 uncomplicated births), having a NOWS diagnosis was associated with higher odds of a 30-day (OR: 1.6; 95% CI: 1.03-2.4) and one-year rehospitalization (OR: 1.6; 95% CI: 1.1-2.4) after adjusting for infant sex, race, type of medical insurance, hospital location, census division, year of primary encounter, hospital bed size, and medical conditions. This study found higher healthcare utilization during the first year of life in infants diagnosed with NOWS, especially those with severe NOWS. Findings suggest a need for closer post-discharge follow-up and management of infants with NOWS.

Alcohol and other substance use disorder recovery during pregnancy among patients with posttraumatic stress disorder symptoms: A qualitative study.

Background: About 5% of women are pregnant at substance use disorder (SUD) treatment entry, and pregnant women with SUD often belong to marginalized groups experiencing social, economic, and health care barriers associated with stigma from prenatal substance use. Pregnant women in SUD treatment have high rates of trauma and posttraumatic stress disorder (PTSD). This study sought to (1) examine the lived experiences of pregnant individuals with PTSD symptoms in SUD treatment and (2) understand the roles of systematic or contextual barriers to the pursuit of prenatal abstinence. Methods: We draw upon in-depth semi-structured interviews to examine relationships between SUD, psychological trauma/PTSD experience, social resources, and lived experiences among patients in prenatal SUD treatment with PTSD symptoms. Our sample was pregnant patients (N = 13) with prior DSM-5 Criterion A trauma and current PTSD symptoms enrolled in a comprehensive program integrating prenatal care, substance use counseling, medication for opioid use disorder and case management at three sites affiliated with an urban academic medical center in New Mexico. Results: Using thematic analysis, four main themes identified structural forces influencing alcohol and drug use: (a) lack of access or ability to obtain resources, (b) substance use to cope with negative affect, (c) social stigma, and (d) interpersonal relationships. Conclusions: Despite receiving high-quality integrated prenatal and SUD care, these pregnant patients with PTSD symptoms in SUD treatment still experienced substantial social and structural hurdles to achieving abstinence during pregnancy.

A mother's bond: An ecological momentary assessment study of posttraumatic stress disorder symptoms and substance craving during pregnancy.

Pregnant women with substance use disorder (SUD) comprise an underserved population with complex treatment needs, including complications from trauma histories and comorbid psychological disorders. Using ecological momentary assessment, we examined momentary fluctuations in posttraumatic stress disorder (PTSD) symptoms, prenatal bonding, and substance craving, among pregnant women in SUD treatment who had a history of trauma. We hypothesized that (a) PTSD symptoms and prenatal bonding would each be associated with substance craving and (b) PTSD symptoms would be negatively associated with prenatal bonding, and this would at least partially account for the association between PTSD symptoms and substance craving (i.e., indirect effect). Participants (n = 32) were on average 27.1 weeks pregnant (SD = 5.27), 27.8 years old (SD = 4.54), and predominantly Hispanic/Latina (66%). At the within subjects level, higher momentary ratings of PTSD symptoms were associated with lower quality (but not intensity of preoccupation) of prenatal bonding, which in turn was associated with greater craving. Lower quality of prenatal bonding partially mediated the positive association between PTSD symptoms and craving, which remained strong after accounting for prenatal bonding. Our results provide some preliminary support for considering interventions aimed at stabilizing or decreasing PTSD symptoms and stabilizing or increasing prenatal bonding to reduce substance craving and, thus, the risk of perinatal substance use among women with SUD and trauma histories. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Hypersynchrony in MEG spectral amplitude in prospectively-identified 6-month-old infants prenatally exposed to alcohol.

Early identification of children who experience developmental delays due to prenatal alcohol exposure (PAE) remains a challenge for individuals who do not exhibit facial dysmorphia. It is well-established that children with PAE may still exhibit the cognitive and behavioral difficulties, and individuals without facial dysmorphia make up the majority of individuals affected by PAE. This study employed a prospective cohort design to capture alcohol consumption patterns during pregnancy and then followed the infants to 6 months of age. Infants were assessed using magnetoencephalography to capture neurophysiological indicators of brain development and the Bayley Scales of Infant Development-III to measure behavioral development. To account for socioeconomic and family environmental factors, we employed a two-by-two design with pregnant women who were or were not using opioid maintenance therapy (OMT) and did or did not consume alcohol during pregnancy. Based on prior studies, we hypothesized that infants with PAE would exhibit broad increased spectral amplitude relative to non-PAE infants. We also hypothesized that the developmental shift from low to high frequency spectral amplitude would be delayed in infants with PAE relative to controls. Our results demonstrated broadband increased spectral amplitude, interpreted as hypersynchrony, in PAE infants with no significant interaction with OMT. Unlike prior EEG studies in neonates, our results indicate that this hypersynchrony was highly lateralized to left hemisphere and primarily focused in temporal/lateral frontal regions. Furthermore, there was a significant positive correlation between estimated number of drinks consumed during pregnancy and spectral amplitude revealing a dose-response effect of increased hypersynchrony corresponding to greater alcohol consumption. Contrary to our second hypothesis, we did not see a significant group difference in the contribution of low frequency to high frequency amplitude at 6 months of age. These results provide new evidence that hypersynchrony, previously observed in neonates prenatally exposed to high levels of alcohol, persists until 6 months of age and this measure is detectable with low to moderate exposure of alcohol with a dose-response effect. These results indicate that hypersynchrony may provide a sensitive early marker of prenatal alcohol exposure in infants up to 6 months of age.

Pelvic floor symptoms and quality of life changes during first pregnancy: a prospective cohort study.

INTRODUCTION AND HYPOTHESIS: We describe pelvic floor function in nulliparous pregnant women. MATERIALS AND METHODS: Nulliparous midwifery patients completed the Incontinence Severity Index (ISI), Pelvic Floor Impact Questionnaire (PFIQ-7), Wexner Fecal Incontinence Scale (W), and answered questions about sexual activity and perineal pain at baseline during the first (T1), second (T2), or third trimester (T3) and repeated in late T3. They also underwent a Pelvic Organ Prolapse Quantification (POP-Q) exam at their baseline visit. Data were compared across trimesters. Analysis of variance (ANOVA) and logistic regression accounted for repeated measures and was controlled for age and education. RESULTS: We recruited 627 women. In T1, 124 women gave baseline data and completed questionnaires; in T2, 403; and in early T3, 96 (496 repeated questionnaires in later T3). Besides an increase in genital hiatus and perineal body (all adjusted p < .05), physical exam measures did not differ between trimesters. As pregnancy progressed, urinary incontinence (UI) (T1 = 33, T2 = 44, T3 = 69% women with ISI >0, all comparisons p < .02) and Incontinence Impact Questionnaire (IIQ-7) scores increased. Fecal incontinence (FI) increased (T1 = 8, T2 = 15, T3 = 16% from T2 to T3, p = .04); the Colorectal-Anal Impact Questionnaire (CRAIQ-7) scores did not. Perineal pain increased (T1 = 17, T2 = 18 and T3 = 40%, all adjusted p < .001), and sexual activity decreased (T1 = 94, T2 = 90, T3 = 77% sexually active, T1 vs T3 and T2 vs T3, p < .001) as pregnancy progressed. CONCLUSIONS: During pregnancy, women experience worsening UI, FI, and perineal pain. UI symptoms are associated with a negative impact on quality of life (QoL). Sexual activity decreased and POP-Q stage did not change.

Planned Home VBAC in the United States, 2004-2009: Outcomes, Maternity Care Practices, and Implications for Shared Decision Making.

BACKGROUND: In the United States, the number of planned home vaginal births after cesarean (VBACs) has increased. This study describes the maternal and neonatal outcomes for women who planned a VBAC at home with midwives who were contributing data to the Midwives Alliance of North America Statistics Project 2.0 cohort during the years 2004-2009. METHOD: Two subsamples were created from the parent cohort: 12,092 multiparous women without a prior cesarean and 1,052 women with a prior cesarean. Descriptive statistics were calculated for maternal and neonatal outcomes for both groups. Sensitivity analyses comparing women with a prior vaginal birth and those who were at the lowest risk with various subgroups in the parent cohort were also conducted. RESULTS: Women with a prior cesarean had a VBAC rate of 87 percent, although transfer rates were higher compared with women without a prior cesarean (18% vs 7%, p < 0.001). The most common indication for transfer was failure to progress. Women with a prior cesarean had higher proportions of blood loss, maternal postpartum infections, uterine rupture, and neonatal intensive care unit admissions than those without a prior cesarean. Five neonatal deaths (4.75/1,000) occurred in the prior cesarean group compared with 1.24/1,000 in multiparas without a history of cesarean (p = 0.015). CONCLUSION: Although there is a high likelihood of a vaginal birth at home, women planning a home VBAC should be counseled regarding maternal transfer rates and potential for increased risk to the newborn, particularly if uterine rupture occurs in the home setting.

The relationship of 3-D translabial ultrasound anal sphincter complex measurements to postpartum anal and fecal incontinence.

INTRODUCTION AND HYPOTHESIS: We aimed to determine whether anal sphincter complex (ASC) measurements on translabial ultrasound (TL-US) were related to anal incontinence (AI) or fecal incontinence (FI) symptoms 6 months postpartum. METHODS: A prospective cohort of primiparous women underwent TL-US 6 months after a vaginal birth (VB) or cesarean delivery (CD). Muscle thickness was measured at 3, 6, 9, and 12 o'clock positions of the external anal sphincter (EAS), the same four quadrants of the internal anal sphincter (IAS) at proximal, mid, and distal levels, and at the bilateral pubovisceralis muscle (PVM). Measurements were correlated to AI and FI on the Wexner Fecal Incontinence Scale, with sub-analyses by mode of delivery. The odds ratio (OR) of symptoms was calculated for every 1 mm increase in muscle thickness (E1MIT). RESULTS: A total of 423 women (299 VB, 124 CD) had TL-US 6 months postpartum. Decreased AI risk was associated with thicker measurements at the 6 o'clock (OR 0.74 E1MIT) and 9 o'clock proximal IAS (OR 0.71 E1MIT) in the entire cohort. For CD women, thicker measurements of the 9 o'clock proximal IAS were associated with decreased risk of AI (OR 0.56 E1MIT) and thicker distal 6 o'clock IAS measurements were related to a decreased risk of FI (OR 0.37 E1MIT). For VB women, no sphincter measurements were significantly related to symptoms, but thicker PVM measurements were associated with increased risk of AI (right side OR 1.32 E1MIT; left side OR 1.21 E1MIT). CONCLUSIONS: ASC anatomy is associated with AI and FI in certain locations; these locations vary based on the patient's mode of delivery.

Anal sphincter complex: 2D and 3D endoanal and translabial ultrasound measurement variation in normal postpartum measurements.

INTRODUCTION AND HYPOTHESIS: Women may experience anal sphincter anatomy changes after vaginal birth (VB) or Cesarean delivery (CD). Therefore, accurate and acceptable imaging options to evaluate the anal sphincter complex (ASC) are needed. ASC measurements may differ between translabial (TLUS) and endoanal (EAUS) ultrasound imaging and between 2D and 3D US. The objective of this analysis was to describe measurement variation between these modalities. METHODS: Primiparous women underwent 2D and 3D TLUS imaging of the ASC 6 months after VB or CD. A subset of women also underwent EAUS measurements. Measurements included internal anal sphincter (IAS) thickness at proximal, mid, and distal levels and the external anal sphincter (EAS) at 3, 6, 9, and 12 o'clock positions, as well as bilateral thickness of the pubovisceralis muscle (PVM). RESULTS: There were 433 women presenting for US: 423 had TLUS and 64 had both TLUS and EAUS of the ASC. All IAS measurements were significantly thicker on TLUS than EAUS (all p < 0.01), while EAS measurements were significantly thicker on EAUS (p < 0.01). PVM measurements with 3D or 2D imaging were similar (p > 0.20). On both TLUS and EAUS, there were multiple sites where significant asymmetry existed in left versus right measurements. CONCLUSIONS: US modality used to image the ASC introduces small but significant changes in measurements, and the direction of the bias depends on the muscle and location being imaged.

Does a large infant head or a short perineal body increase the risk of obstetrical perineal trauma?

BACKGROUND: Perineal trauma after vaginal delivery can have significant long-term consequences. It is unknown if a larger infant head circumference or smaller maternal perineal anatomy are risk factors for perineal trauma after vaginal delivery. METHODS: We conducted a prospective cohort study of low-risk nulliparous women. Data collected included maternal characteristics, antepartum Pelvic Organ Prolapse Quantification measurements of the perineal body and genital hiatus, labor characteristics, perineal trauma, and infant head circumference. Perineal trauma was defined as trauma that extended into the muscles of the perineum (second-degree or deeper). Univariate and multivariate logistic models were created to calculate odds ratios (OR) and 95 percent confidence intervals (CI). RESULTS: We observed 448 vaginal births. Multivariate analysis demonstrated a significant association between infant head circumference at birth and perineal trauma: OR 1.22 for each increase of 1 cm in head circumference (95% CI 1.05-1.43). There was no association between perineal body or genital hiatus length and perineal trauma. CONCLUSIONS: In nulliparous low-risk women a larger infant head circumference at birth increases the likelihood of perineal trauma, although the effect is modest. Antenatal perineal body and genital hiatus measurements do not predict perineal trauma. These results do not support alteration in mode of delivery or other obstetric practices.

Postpartum translabial 2D and 3D ultrasound measurements of the anal sphincter complex in primiparous women delivering by vaginal birth versus Cesarean delivery.

INTRODUCTION AND HYPOTHESIS: Consensus on normal translabial ultrasound (TL-US) anal sphincter complex measurements for postpartum women is lacking. We aimed to evaluate normative measurements in 2D and 3D TL-US for the anal sphincter complex (ASC) at 6 months postpartum and compare these measurements in women who had a vaginal birth (VB) and in those who had a Cesarean delivery (CD). METHODS: A large, prospective cohort of primiparous women underwent 2D and 3D TL-US 6 months after their first delivery. For normative sphincter measurements, we excluded women with third- or fourth-degree lacerations or with sphincter interruption on TL-US. Measurements included the sphincter thickness at the 3, 6, 9, and 12 o'clock positions of the external anal sphincter (EAS) and the internal anal sphincter (IAS) at proximal, mid, and distal levels. We also measured the mean coronal diameter of the pubovisceralis muscle (PVM). RESULTS: 696 women consented to participate, and 433 women presented for ultrasound imaging 6 months later. Women who sustained a third- or fourth-degree laceration had significantly thicker EAS measurements at 12 o'clock. Sphincter asymmetry was common (69 %), but was not related to mode of delivery. Only IAS measurements at the proximal and distal 12 o'clock position were significantly thicker for CD patients. There were no significant differences in the EAS or PVM measurements between VB and CD women. CONCLUSIONS: There appear to be few differences in normative sphincter ultrasound measurements between primiparous patients who had VB or CD.

First-trimester surgical abortion technique.

New data have emerged to support changes in first-trimester abortion practice in regard to antibiotic prophylaxis, cervical ripening, the use of manual vacuum aspiration, and pain management. This article addresses these new recommendations and reviews techniques in performing manual and electric vacuum uterine aspiration procedures before 14 weeks' gestation, including very early abortion (<7 weeks' gestation), technically difficult abortions, management of complications, and postabortal contraception. The information discussed also applies to miscarriage management.

Diminishing availability of trial of labor after cesarean delivery in New Mexico hospitals.

OBJECTIVE: To examine the availability of trial of labor after cesarean delivery (TOLAC) in New Mexico from 1998 to 2012 and maternity care providers' perception of barriers to TOLAC. METHODS: Hospital maternity unit directors were surveyed regarding TOLAC availability from 1998 to 2012. Maternity care providers (obstetrician-gynecologists, certified nurse-midwives, and family medicine physicians) were surveyed in 2008 regarding resources and barriers to providing TOLAC and emergency cesarean delivery. RESULTS: Trial of labor after cesarean delivery was available in 100% of counties with maternity care units in 1998 (22/22); by 2008, availability decreased to 32% (7/22). After changes in national guidelines, availability increased slightly to 9 of 22 (41%) in 2012. Barriers to TOLAC included anesthesia availability (88%), hospital and medical malpractice policies (80%), malpractice cost (69%), and obstetric surgeon availability (59%). In hospitals without TOLAC services, 73% of maternity care providers indicated a surgeon could be present in the hospital within 20 minutes of the emergency delivery decision; only 43% indicated obstetric anesthesia personnel could be present within 20 minutes (P<.001). CONCLUSIONS: Availability of TOLAC in New Mexico has decreased dramatically. Policy changes are needed to support TOLAC access in rural and community hospitals. LEVEL OF EVIDENCE: III.

Sex after childbirth: postpartum sexual function.

Pregnancy and childbirth bring many changes to the health and well-being of new mothers. Postpartum sexual health is a common concern that is often not discussed during prenatal or postpartum care and has received little attention from either clinicians or researchers. In this article, we review current theories of female sexual response, the epidemiology of postpartum sexual dysfunction, and the use of screening tools to identify women with sexual health concerns. Specifically, we present a review of published data regarding the effect of mode of delivery, perineal lacerations, postpartum depression, and breastfeeding on postpartum sexual activity and function. Finally, suggestions for how to screen for and approach the treatment of postpartum sexual problems are presented.

Association between intrapartum fetal heart rate patterns and neonatal abstinence syndrome in methadone exposed neonates.

OBJECTIVE: Determine whether infants exposed to chronic maternal methadone with abnormal intrapartum fetal heart rate (FHR) patterns are more likely to require treatment for neonatal abstinence syndrome (NAS). STUDY DESIGN: Intrapartum FHR tracings analyzed in 104 pregnancies at ≥ 34 weeks gestation for FHR variability, accelerations, and decelerations. FHR patterns compared between neonates based on treatment with methadone for NAS. Secondary analysis included relation between maternal methadone dose and intrapartum FHR patterns, initiation of methadone, age at methadone initiation, and total neonatal methadone dose. Study powered to detect 30% increase in NAS incidence in neonates with abnormal FHR tracings. RESULTS: Seventy-six (73%) of 104 neonates required methadone treatment for NAS. Neonates who required methadone had higher average baseline FHR (131 vs. 126 bpm; p < 0.04) in active labor and less likely to have FHR tracings without accelerations (1.7% vs. 20.3%; p = 0.007) in latent labor. No significant associations between neonate's need for methadone and intrapartum FHR variability or FHR decelerations. No association between maternal methadone dose (range 30-280 mg) and treatment for NAS. CONCLUSION: The need for an infant to require methadone treatment for NAS was not reliably predicted by the intrapartum FHR patterns or the maternal methadone dose.

Does spontaneous genital tract trauma impact postpartum sexual function?

Changes in sexual function are common in postpartum women. In this comparative, descriptive study, a prospective cohort of midwifery patients consented to documentation of genital trauma at birth and assessment of sexual function at 3 months postpartum. The impact of spontaneous genital trauma on postpartum sexual function was the focus of the study. Trauma was categorized into minor trauma (no trauma or first-degree perineal or other trauma that was not sutured) or major trauma (second-, third-, or fourth-degree lacerations or any trauma that required suturing). Women who underwent episiotomy or operative delivery were excluded. Fifty-eight percent (326/565) of enrolled women gave sexual function data; of those, 276 (85%) reported sexual activity since delivery. Seventy percent (193) of women sustained minor trauma and 30% (83) sustained major trauma. Sexually active women completed the Intimate Relationship Scale (IRS), a 12-item questionnaire validated as a measure of postpartum sexual function. Both trauma groups were equally likely to be sexually active. Total IRS scores did not differ between trauma groups nor did complaints of dyspareunia. However, for two items, significant differences were demonstrated: women with major trauma reported less desire to be held, touched, and stroked by their partner than women with minor trauma, and women who required perineal suturing reported lower IRS scores than women who did not require suturing.

Prenatal counseling regarding cesarean delivery.

In 1970, the cesarean delivery rate in the United States was 5.5% and women receiving prenatal care only required the knowledge that cesarean delivery was an uncommon solution to dire obstetric emergencies. In 2008, when almost one in three women deliver by cesarean, counseling on cesarean delivery must be part of each woman's prenatal care. The content of that discussion varies based on the woman's obstetric history and the anticipated mode of delivery.

Does the severity of spontaneous genital tract trauma affect postpartum pelvic floor function?

We describe the impact of genital trauma on pelvic floor function in a low-risk cohort of women after vaginal birth. Questionnaires (Present Pain Intensity Scale, Incontinence Impact Questionnaire, Fecal Incontinence Score, and Intimate Relationship Scale) were completed up to 12 weeks postpartum. Severity of trauma was recorded at delivery. Overall follow-up was 444/565 (79%). Major trauma (trauma that involved perineal muscles or required suturing) occurred in 20%; 20% delivered intact. At 12 weeks, 10% complained of perineal pain; 24% reported anal (AI) and 27% urinary incontinence (UI). Women with trauma were no more likely than those intact to complain of UI or AI, sexual inactivity, or perineal pain postpartum (all P=NS). Women with major trauma had weaker pelvic floor exercise strength than those who delivered intact or with minor trauma (odds ration 3.06, 95% confidence interval 1.41-6.63). Pelvic floor complaints postpartum were common but not associated with severity of genital trauma in a cohort of low-risk women.

Do unsutured second-degree perineal lacerations affect postpartum functional outcomes?

BACKGROUND: To compare the postpartum pelvic floor function of women with sutured second-degree perineal lacerations, unsutured second-degree perineal lacerations, and intact perineums. METHODS: A prospective cohort of nurse-midwifery patients consented to mapping of genital trauma at birth and an assessment of postpartum pelvic floor outcomes. Women completed validated questionnaires for perineal pain and urinary and anal incontinence at 12 weeks postpartum and underwent physical examination to assess pelvic floor strength and anatomy at 6 weeks postpartum. RESULTS: One hundred seventy-two of 212 (80%) eligible women provided follow-up assessment data at 6 or 12 weeks postpartum. Women with an intact perineum (n=89) used fewer analgesics (P<.002) and had lower pain scores at the time of hospital discharge than women with second-degree lacerations (sutured, n=46; unsutured, n=37; intact, n=89) (P