Urine drug screening on labor and delivery.

BACKGROUND: Substance use including opioids, methamphetamines, benzodiazepines, and barbiturates during pregnancy is harmful for the pregnant person and the fetus. Routine screening using validated questionnaires is recommended, but often biologic sampling is done instead. There is often bias in urine drug screening on labor and delivery units. OBJECTIVE: This study aimed to compare characteristics of people who did and did not receive urine drug screening during labor and delivery and to examine the relationship of maternal results to neonatal results. STUDY DESIGN: This was a retrospective chart review examining all people in 2017 who delivered in the labor and delivery unit at our institution. We collected urine drug screening result information, maternal demographic data, follow-up after positive maternal tests, and neonatal test results. Individual characteristics and obstetrical outcomes were analyzed. RESULTS: Of 6265 deliveries, 297 urine drug screening tests were ordered. People who were tested identified most commonly as Native Hawaiian or Pacific Islander (P<.0001). The most common indications for ordering tests were a history of substance use and insufficient prenatal care (P<.0001). People who tested positive were more likely to self-identify as White (P=.03) and have history of substance use (P<.0001). Among the positive test results, 24 (24%) were caused by a provider-ordered medication. Self-identification as Native Hawaiian or Pacific Islander was not predictive of a positive result. Of the tested people, 36% (108/297) had a positive result on preliminary testing, and 33% (98/295) on confirmatory testing. CONCLUSION: Native Hawaiians and Pacific Islanders were more likely to undergo testing, whereas White people were more likely to have a positive result. Maternal results were not reliable for predicting neonatal drug test results and vice versa. With rising rates of substance use disorders in the pregnant and reproductive-age population, standardized unbiased race-neutral guidelines for urine drug screening should be implemented using laboratory test results that include preliminary and reflex confirmatory results.

Transcutaneous Electrical Nerve Stimulation for Post-Cesarean Birth Pain Control: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether transcutaneous electrical nerve stimulation (TENS) reduces opioid use after cesarean birth. METHODS: We conducted a randomized, double-blind, placebo-controlled trial of TENS after cesarean birth, with the primary outcome of opioid use during the first 60 hours postoperatively. Secondary outcomes included pain scores and satisfaction with pain control on each postoperative day, duration of postoperative hospitalization, and adverse effects of TENS. We estimated 60 patients in each arm for 80% power to detect a 25% decrease in opioid use, assuming 10% attrition. To assess for a placebo effect, an additional 60 patients were randomized to no TENS during recruitment for secondary analyses comparing opioid use, pain scores, and pain control satisfaction between no TENS and placebo TENS. Analysis was by intention-to-treat. RESULTS: From January 2020 through March 2021, we enrolled 180 participants-60 per group. Baseline characteristics were similar across groups. Median (interquartile range) opioid consumption in the first 60 hours postoperatively, in morphine milligram equivalents, was 7.5 (0-30) with active TENS and 0 (0-22.5) with placebo TENS (P=.31). There were no significant differences in pain scores, satisfaction with pain control, or postoperative length of stay. In the no TENS group, median (interquartile range) opioid consumption in the first 60 hours postoperatively was 7.5 (0-21.9), similar to that in the placebo group (P=.57). There were also no significant differences in pain scores or pain control satisfaction between participants allocated to no TENS and those allocated to placebo TENS. CONCLUSION: Use of TENS after cesarean birth did not change hospital opioid consumption, pain scores, or length of postoperative stay. There was no evidence for a placebo effect of TENS on opioid use or pain scores. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov: NCT04399707. FUNDING SOURCE: Cardinal Health.

Aortic aneurysm and dissection in pregnancy: A case report.

We describe a 24-year-old pregnant woman at 34 weeks of gestation who presented to a community hospital with sharp chest pain radiating to her back. She was found to have a 6 cm ascending aortic aneurysm despite not having any established risk factors. She was transported by air ambulance to a tertiary-care hospital. She delivered a live female neonate via cesarean delivery. Her postpartum course was notable for multiple episodes of chest pain and multiple imaging studies that were read as negative for aortic dissection. Definitive valve surgery was postponed by the cardiothoracic surgeons to allow for recovery from severe preeclampsia, treatment of endometritis, and due to concerns for uterine bleeding while on anticoagulation during cardiopulmonary bypass. She was eventually transferred to another hospital in another state for valve-sparing surgery. During transport, she developed a pulmonary embolism, and after arrival an aortic dissection was confirmed. She received a mechanical aortic valve replacement and the aneurysm was repaired. She returned home and recovered without complication. A gene panel revealed a heterozygous pathogenic variant of the Filamin A gene. Aortic aneurysms during pregnancy are rare, and aortic dissections are more rare. We recommend expeditious surgical treatment, a heightened index of suspicion, and testing for a genetic cause of aneurysm when diagnosed in a pregnant or postpartum woman with no known risk factors.

Methamphetamine Use in Pregnant Women in Hawai'i: A Case Series.

Methamphetamine use is widespread among pregnant and reproductive-aged women in Hawai'i. Women who use methamphetamine require comprehensive care that is gender specific and tailored to their needs. In Hawai'i, more services are needed to solve this serious public health problem. The authors present three cases of methamphetamine use with negative maternal and fetal outcomes. The first case describes a pregnant woman with daily methamphetamine use who experienced cardiac arrest with subsequent preterm delivery and maternal death due to global anoxic brain injury. The second case describes a pregnant woman with daily methamphetamine use which exacerbated her chronic hypertension and led to intrauterine fetal demise. The third case describes a pregnant woman with current methamphetamine use who experienced preeclampsia and a cerebrovascular accident necessitating preterm delivery. Methamphetamine remains a serious public health concern for the United States and especially in the state of Hawai'i.