Nonsteroidal anti-inflammatory drug "allergy" labeling is associated with increased postpartum opioid utilization.

BACKGROUND: Current guidelines recommend a stepwise approach to postpartum pain management, beginning with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), with opioids added only if needed. Report of a prior NSAID-induced adverse drug reaction (ADR) may preclude use of first-line analgesics, despite evidence that many patients with this allergy label may safely tolerate NSAIDs. OBJECTIVE: We assessed the association between reported NSAID ADRs and postpartum opioid utilization. METHODS: We performed a retrospective cohort study of birthing people who delivered within an integrated health system (January 1, 2017, to December 31, 2020). Study outcomes were postpartum inpatient opioid administrations and opioid prescriptions at discharge. Statistical analysis was performed on a propensity score-matched sample, which was generated with the goal of matching to the covariate distributions from individuals with NSAID ADRs. RESULTS: Of 38,927 eligible participants, there were 883 (2.3%) with an NSAID ADR. Among individuals with reported NSAID ADRs, 49.5% received inpatient opioids in the postpartum period, compared to 34.5% of those with no NSAID ADRs (difference = 15.0%, 95% confidence interval 11.4-18.6%). For patients who received postpartum inpatient opioids, those with NSAID ADRs received a higher total cumulative dose between delivery and hospital discharge (median 30.0 vs 22.5 morphine milligram equivalents [MME] for vaginal deliveries; median 104.4 vs 75.0 MME for cesarean deliveries). The overall proportion of patients receiving an opioid prescription at the time of hospital discharge was higher for patients with NSAID ADRs compared to patients with no NSAID ADRs (39.3% vs 27.2%; difference = 12.1%, 95% confidence interval 8.6-15.6%). CONCLUSION: Patients with reported NSAID ADRs had higher postpartum inpatient opioid utilization and more frequently received opioid prescriptions at hospital discharge compared to those without NSAID ADRs, regardless of mode of delivery.

Human Papillomavirus Inpatient Postpartum Vaccination: Clinical Guideline Implementation.

OBJECTIVE: The nine-valent human papillomavirus (9vHPV) vaccine is highly effective at preventing cervical cancer, yet U.S. vaccination rates remain low. The objective of this study was to evaluate integration of 9vHPV inpatient vaccination into routine postpartum care. METHODS: Obstetrics professionals at an academic urban referral center received an emailed protocol outlining a novel 9vHPV vaccination program of postpartum inpatients aged 26 years or younger. A retrospective evaluation from March 2021 to March 2022 was conducted to evaluate implementation. Characteristics of patients vaccinated before pregnancy compared with vaccine-eligible patients (none, unknown, or partially vaccinated status) were compared by the use of χ2, analysis of variance, and multivariable logistic regression. Similarly, analyses were performed comparing vaccine-eligible patients who did with those who did not receive an inpatient 9vHPV vaccination. RESULTS: Of 569 postpartum inpatients, 370 (65.0%) were already vaccinated, 70 (34.2%) were never vaccinated, 49 (24.6%) were partially vaccinated, and 80 (14.1%) had unknown status. Of vaccine-eligible patients, 46 (23.1%) received 9vHPV vaccination as an inpatient. In multivariable analysis, race and ethnicity, marital status, and primary language were significant predictors of vaccination before pregnancy. Among vaccine-eligible patients, inpatient vaccination recipients were primarily Hispanic, Spanish speaking, and publicly insured. In multivariable analysis of vaccine-eligible patients, receiving care from the certified nurse midwifery practice was the only independent predictor of vaccination (odds ratio 2.4, 95% CI 1.02-5.74, P=.04). CONCLUSION: Non-Hispanic White, Spanish-speaking, and married patients were disproportionally undervaccinated in our baseline population, but about one quarter of vaccine-eligible patients received 9vHPV vaccination postpartum. Inpatient postpartum 9vHPV vaccination may help narrow disparities in vaccination.

Disparities in Maternal-Infant Drug Testing, Social Work Assessment, and Custody at 5 Hospitals.

OBJECTIVE: To evaluate for disparities in peripartum toxicology testing among maternal-infant dyads across a hospital network and subsequent child protective services (CPS) involvement. METHODS: Retrospective chart review of 59,425 deliveries at 5 hospitals in Massachusetts between 2016 and 2020. We evaluated associations between maternal characteristics, toxicology testing, and child welfare involvement with disproportionality risk ratios and hierarchical logistical regression. RESULTS: Toxicology testing was performed on 1959 (3.3%) dyads. Younger individuals and individuals of color were more likely to be tested for cannabis use or maternal medical complications compared to white non-Hispanic individuals. Among those without a substance use disorder, age <25 (adjusted odds ratio [aOR] 2.81; 95% confidence interval [CI], 2.43-3.26), race and ethnicity (non-Hispanic Black (aOR 1.80; 95% CI, 1.52-2.13), Hispanic (aOR 1.23; 95% CI, 1.05-1.45), mixed race/other (aOR 1.40; 95% CI, 1.04, 1.87), unavailable race (aOR 1.92; 95% CI, 1.32-2.79), and public insurance (Medicaid [aOR 2.61; 95% CI, 2.27-3.00], Medicare [aOR 13.76; 95% CI, 9.99-18.91]) had increased odds of toxicology testing compared to older, white non-Hispanic, and privately insured individuals. The disproportionality ratios in testing were greater than 1.0 for individuals under 25 years old (3.8), Hispanic individuals (1.6), non-Hispanic Black individuals (1.8), individuals of other race (1.2), unavailable race (1.8), and individuals with public insurance (Medicaid 2.6; Medicare 10.6). Among dyads tested, race and ethnicity was not associated with CPS involvement. CONCLUSIONS: Peripartum toxicology testing is disproportionately performed on non-white, younger, and poorer individuals and their infants, with cannabis use and medical complications prompting testing more often for patients of color than for white non-Hispanic individuals.

Informed consent is poorly documented when obtaining toxicology testing at delivery in a Massachusetts cohort.

BACKGROUND: Positive toxicology testing at delivery can have enormous consequences for birthing persons and their families, including charges of child abuse or neglect and potential loss of custody for the birthing parent. Therefore state and national guidelines stipulate that, clinicians must obtain consent before toxicology testing at delivery. OBJECTIVE: This study aimed (1) to determine clinician documentation of patient consent for peripartum toxicology testing and (2) to characterize the extent to which patient and hospital characteristics were associated with documented consent. STUDY DESIGN: This was a retrospective cohort of individuals who underwent toxicology testing within 96 hours of delivery between April 2016 and April 2020 at 5 affiliated hospitals across Massachusetts. Medical records were reviewed for documentation of clinician intent to obtain maternal toxicology, testing indication, verbal consent to testing, and child protective services involvement. Hierarchical multivariable logistic regression was used to examine the association between patient and hospital characteristics and documentation of verbal consent. RESULTS: Among 60,718 deliveries, 1562 maternal toxicology tests were obtained. Verbal consent for testing was documented in 466 cases (29.8%). Documented consent was lacking across most demographic groups. Consent was no more likely to be documented when a report was filed with child protective services and less likely in cases where the birthing parent lost custody before discharge (P=.003). In our multivariable model, consent was least likely to be documented when a maternal complication (abruption, hypertension, preterm labor, preterm premature rupture of membranes, or intrauterine fetal demise) was the indication for testing (adjusted odds ratio, 0.46; 95% confidence interval, 0.28-0.76). Verbal consent was twice as likely to be documented in delivery hospitals with established consent policies (adjusted odds ratio, 2.10; 95% confidence interval, 1.01-4.37). CONCLUSION: Consent for toxicology testing at delivery seemed to be infrequently obtained on the basis of clinician documentation. Provider education and hospital policies for obtaining informed consent are needed to protect the rights of birthing individuals.

Mode of Delivery and Unplanned Cesarean: Differences in Rates and Indication by Race, Ethnicity, and Sociodemographic Characteristics.

OBJECTIVE: We aimed to examine the relationship of sociodemographic variables with racial/ethnic disparities in unplanned cesarean births in a large academic hospital system. Secondarily, we investigated the relationship of these variables with differences in cesarean delivery indication, cesarean delivery timing, length of second stage and operative delivery. STUDY DESIGN: We conducted a retrospective cohort study of births >34 weeks between 2017 and 2019. Our primary outcome was unplanned cesarean delivery after a trial of labor. Multiple gestations, vaginal birth after cesarean, elective repeat or primary cesarean delivery, and contraindications for vaginal delivery were excluded. Associations between mode of delivery and patient characteristics were assessed using Chi-square, Fisher exact tests, or t-tests. Odds ratios were estimated by multivariate logistic regression. Goodness of fit was assessed with Hosmer Lemeshow test. RESULTS: Among 18,946 deliveries, the rate of cesarean delivery was 14.8% overall and 21.3% in nulliparous patients. After adjustment for age, body mass index (BMI), and parity, women of Black and Asian races had significantly increased odds of unplanned cesarean delivery; 1.69 (95% CI: 1.45,1.96) and 1.23 (1.08, 1.40), respectively. Single Hispanic women had adjusted odds of 1.65 (1.08, 2.54). Single women had increased adjusted odds of cesarean delivery of 1.18, (1.05, 1.31). Fetal intolerance was the indication for 39% (613) of cesarean deliveries among White women as compared to 63% (231) of Black women and 49% (71) of Hispanic women (p <0.001). CONCLUSION: Rates of unplanned cesarean delivery were significantly higher in Black and Asian compared to White women, even after adjustment for age, BMI, parity, and zip code income strata, and rates of unplanned cesarean delivery were higher for Hispanic women self-identifying as single. Racial and ethnic differences were seen in cesarean delivery indications and operative vaginal deliveries. Future work is urgently needed to better understand differences in provider care or patient attributes, and potential provider bias, that may contribute to these findings. KEY POINTS: · Racial, ethnic, and socioeconomic differences exist in the odds of unplanned cesarean.. · Indications for unplanned cesarean delivery differed significantly among racial and ethnic groups.. · There may be unmeasured provider level factors which contribute to disparities in cesarean rates..

Racial differences in indications for obstetrical toxicology testing and relationship of indications to test results.

BACKGROUND: Despite illicit substance use in pregnancy occurring across all demographic groups, minority pregnant and delivering patients with a low income tend to undergo testing at a higher rate than their counterparts. National guidelines for indications do not exist and ordering of toxicology testing may be applied inequitably. OBJECTIVE: This study aimed to evaluate whether any documented indications in a large cohort of patients were associated with a positive toxicology test and whether indications for urine toxicology testing were applied consistently to different demographic groups. STUDY DESIGN: This was a retrospective cohort study reviewing pregnant and delivering patients who underwent toxicology testing on obstetrical units at 1 institution from May 30, 2015, to December 31, 2018. Age, race, marital status, median income of residential ZIP code, indications for testing, and test results were collected for each patient by individual chart review. Indications included preterm complications (preterm prelabor rupture of membranes or preterm labor), abruption or hypertension, reported substance use, fetal complications, maternal complications, and none. Multivariate logistic regression models were analyzed for the association between indication and test result and the likelihood of marijuana as the sole positive test result. Logistic regression was used to evaluate the relationship of indication for testing with maternal race. RESULTS: Among 20,274 births, 551 patients underwent toxicology testing during the study period. No indication for drug toxicology testing was associated with a positive result, except reported current or previous substance use. Compared with White patients, Black and Hispanic women were 4.26 times (95% confidence interval, 2.55-7.09) and 5.75 times (95% confidence interval, 2.89-11.43) more likely to have toxicology testing for an indication other than reported substance use, respectively. Of all patients with positive test results (n=194), 48% tested positive for marijuana only. CONCLUSION: Compared with their White counterparts, Black and Hispanic pregnant and delivering patients may be more frequently toxicology tested for indications less clearly associated with illicit substance use. The absence of evidence-based guidelines for toxicology testing on obstetrical units risks inequitable care and stigmatization of patient groups.

Results of a Statewide Survey of Obstetric Clinician Depression Practices.

Purpose: Perinatal depression affects upwards of one in seven women and is associated with significant negative maternal and child consequences. Despite this, it remains under-detected and under-treated. We sought to identify clinician practices, self-efficacy, and remaining barriers to comprehensively addressing perinatal depression care. Materials and Methods: Surveys were administered to obstetric clinicians in Massachusetts that queried frequency of depression screening and Likert questions about subsequent depression management. Results: Approximately 79.0% of clinicians approached completed the survey. Whereas most clinicians (93.5%) screened for perinatal depression at 6 weeks postpartum, fewer clinicians (66.1%) screened during pregnancy. Most reported they were comfortable providing support to their patients (98.4%), but fewer endorsed being able to treat them on their own (43.0%). Most noted an ability to treat with antidepressants (77.9%); however, fewer endorsed adequate access to nonmedication treatment (45.5%). Conclusions: The majority of surveyed clinicians screen for depression consistent with guidelines. However, efforts are focused on the postpartum period, despite literature citing two-thirds of patients experiencing onset before or during pregnancy. Respondents indicated an ability to treat with medication management, while noting greater challenge with referral. These findings describe the challenges of interdisciplinary coordination as a barrier to comprehensive perinatal mental health care. Clinical Trial Registration Number: NCT02760004.

Toxicology Testing in a Newborn ICU: Does Social Profiling Play a Role?

OBJECTIVE: A rising incidence in maternal drug use during pregnancy has led to a concomitant rise in neonatal opioid withdrawal syndrome. Despite evidence that drug use during pregnancy affects all demographic groups equally, authors of recent studies have suggested that minority women are tested for drug use more than their counterparts. In this study, we aimed to assess whether toxicology testing of neonates was associated with maternal characteristics. METHODS: Retrospective cohort study reviewing charts of neonates born at an urban academic center between January 1, 2018, and December 31, 2018, who underwent toxicology testing. Demographics from tested neonates were taken from mothers' self-reported data and compared with sociodemographics of all mothers with deliveries in 2018, including age, race, marital status, and zip code. Indication for toxicology testing as recorded by ordering clinician was also collected. There were no standardized guidelines for toxicology testing during this study period. RESULTS: Of 6438 births in 2018, toxicology testing was sent on 86 neonates (1.3%). Mothers of neonates with testing were younger (P < .0001), less likely to be white (P < .0001), self-reported "single" (P < .0001), and lived in lowest income zip codes (P < .0001). Indications for testing were varied, with the most common indications including maternal substance use disorder (37%) and marijuana use (26%). CONCLUSION: Maternal age, race, marital, and socioeconomic status were associated with toxicology testing on neonates, although data suggest that drug use affects all demographic groups. Current practice at our institution may overtest some groups. Evidence-based, standardized guidelines are urgently needed to reduce bias and repercussions of toxicology testing of neonates.

Safety and Tolerability of Repetitive Transcranial Magnetic Stimulation During Pregnancy: A Case Report and Literature Review.

Patients with neuropsychiatric disease may benefit from repetitive transcranial magnetic stimulation as a nonpharmacologic alternative to relieve symptoms of major depression, obsessive compulsive disorder, and perhaps other syndromes such as epilepsy. We present a case of repetitive transcranial magnetic stimulation treatment as an adjunct therapy for a patient experiencing refractory epileptic seizures during the third trimester of pregnancy. Notably, the patient tolerated repetitive transcranial magnetic stimulation well, without adverse events, and delivered a healthy child. We also summarize the current literature pertaining to therapeutic repetitive transcranial magnetic stimulation use during pregnancy.

Association of Antenatal Depression with Clinical Subtypes of Preterm Birth.

OBJECTIVE: To estimate the association between antenatal depression and spontaneous preterm birth (SPTB) relative to medically indicated preterm birth (MPTB). STUDY DESIGN: This was a secondary analysis of a nested case-control study of preterm birth (PTB). The exposure was a clinical diagnosis of antenatal depression. The outcome was PTB at <37 weeks classified as SPTB (spontaneous labor, preterm premature rupture of membranes, placental abruption, and cervical shortening); and MPTB (preeclampsia and intrauterine growth restriction). Multinomial logistic regression models compared women without PTB versus MPTB and SPTB, adjusting for age, race, parity, tobacco use, insurance status, and prepregnancy body mass index, and history of PTB for SPTB. RESULTS: Among 443 pregnant women, 15.6% had an SPTB and 8.6% had an MPTB, and 16% were diagnosed with antenatal depression. Women with an SPTB were three times more likely to have antenatal depression compared with women without an SPTB (adjusted odds ratio [AOR]: 2.81; 95% confidence interval [CI]: 1.40-5.63). No significant association was identified between antenatal depression and MPTB (AOR: 1.77; 95% CI: 0.67-4.62). The association between antenatal depression and SPTB did not change after adjusting the aforementioned model for a history of PTB and antidepressant use. CONCLUSION: Antenatal depression may differentially affect the risk of PTB through an increase in the odds of SPTB. These results have implications for future studies on prevention and treatment options for depression and PTB.

Is There an Association between Body Mass Index and Cervical Length? Implications for Obesity and Cervical Length Management in Pregnancy.

Objective Obesity and cervical insufficiency are leading causes of morbidity in pregnancy. We assess the relationship between maternal body mass index (BMI) and second-trimester cervical length. Methods A secondary analysis of a nested case-control study of women with singleton gestations enrolled from 2006 to 2008. The primary exposure was first-trimester BMI, categorized per World Health Organization criteria: normal (18.5 to ≤ 25 kg/m2), overweight (25 to ≤ 30 kg/m2), and obese (> 30 kg/m2). The primary outcome was cervical length > 75th percentile. Results Among 391 pregnant women observed, the median cervical length was 3.6 cm, and the median BMI was 24.8 kg/m2. In multivariable analyses, after adjusting for BMI, age, race, parity, smoking, and gestational age at delivery, women who were overweight (adjusted odds ratio [AOR]: 2.18; 95% CI: 1.20-3.96) and obese (AOR: 2.83; 95% CI: 1.47-5.43) were more than two times more likely to have a cervical length > 75th percentile. When cervical length and BMI were assessed linearly, for each 1.0 kg/m2 increase in BMI, cervical length increased by 0.25 mm. These results were robust to utilizing different cutoffs of cervical length and pre-pregnancy BMI. Conclusion This study demonstrates a relationship between BMI and cervical length suggesting that obesity may be associated with longer cervical length. These results will need to be replicated in larger cohorts undergoing universal cervical length assessment.

Utilizing Longitudinal Measures of Fetal Growth to Create a Standard Method to Assess the Impacts of Maternal Disease and Environmental Exposure.

Impaired or suboptimal fetal growth is associated with an increased risk of perinatal morbidity and mortality. By utilizing readily available clinical data on the relative size of the fetus at multiple points in pregnancy, including delivery, future epidemiological research can improve our understanding of the impacts of maternal, fetal, and environmental factors on fetal growth at different windows during pregnancy. This study presents mean and standard deviation ultrasound measurements from a clinically representative US population that can be utilized for creating Z-scores to this end. Between 2006 and 2012, 18, 904 non-anomalous pregnancies that received prenatal care, first and second trimester ultrasound evaluations, and ultimately delivered singleton newborns at Brigham and Women's hospital in Boston were used to create the standard population. To illustrate the utility of this standard, we created Z-scores for ultrasound and delivery measurements for a cohort study population and examined associations with factors known to be associated with fetal growth. In addition to cross-sectional regression models, we created linear mixed models and generalized additive mixed models to illustrate how these scores can be utilized longitudinally and for the identification of windows of susceptibility. After adjustment for a priori confounders, maternal BMI was positively associated with increased fetal size beginning in the second trimester in cross-sectional models. Female infants and maternal smoking were associated with consistently reduced fetal size in the longitudinal models. Maternal age had a non-significant association with increased size in the first trimester that was attenuated as gestation progressed. As the growth measurements examined here are widely available in contemporary obstetrical practice, these data may be abstracted from medical records by investigators and standardized with the population means presented here. This will enable easy extension of clinical data to epidemiologic studies investigating novel maternal, fetal, and environmental factors that may impact fetal growth.

Evaluation of the sealing capability of implants to titanium and zirconia abutments against Porphyromonas gingivalis, Prevotella intermedia, and Fusobacterium nucleatum under different screw torque values.

STATEMENT OF PROBLEM: When evaluating long-term implant success, clinicians have always been concerned with the gap at the implant-abutment junction, where bacteria can accumulate and cause marginal bone loss. However, little information regarding bacterial leakage at the implant-abutment junction, or microgap, is available. PURPOSE: The purpose of this study was to evaluate sealing at 2 different implant-abutment interfaces under different screw torque values. MATERIAL AND METHODS: Twenty sterile zirconia abutments and 20 sterile titanium abutments were screwed into 40 sterile implants and placed in test tubes. The ability of a bacterial mixture of Prevotella intermedia, Porphyromonas gingivalis, and Fusobacterium nucleatum to leak through an implant-titanium abutment seal under 20 and 35 Ncm torque values and an implant-zirconia abutment seal under 20 and 35 Ncm torque values was evaluated daily until leakage was noted. Once a unit demonstrated leakage, a specimen was plated. After 4 days, the number of colonies on each plate was counted with an electronic colony counter. Plating was used to verify whether or not bacterial leakage occurred and when leakage first occurred. The implant-abutment units were removed and rinsed with phosphate buffered saline solution and evaluated with a stereomicroscope. The marginal gap between the implant and the abutment was measured and correlated with the amount of bacterial leakage. The data were analyzed with ANOVA. RESULTS: Bacterial leakage was noted in all specimens, regardless of material or screw torque value. With titanium abutments, changing the screw torque value from 20 to 35 Ncm did not significantly affect the amount of bacterial leakage. However, with zirconia abutments, changing the screw torque value from 20 to 35 Ncm was statistically significant (P<.017). Overall, the marginal gap noted was larger at the zirconia-abutment interface (5.25 ±1.99 µm) than the titanium-abutment interface (12.38 ±3.73 µm), irrespective of the screw torque value. Stereomicroscopy revealed a nonuniform marginal gap in all specimens. CONCLUSION: The results of this study showed that, over time, bacteria will leak through the implant-abutment microgap at the implant-abutment interface. Implants with a titanium abutment demonstrate a smaller microgap than implants with a zirconia abutment. Tightening the zirconia abutment screw from 20 to 35 Ncm decreases the size of the microgap, which suggests a more intimate fit between the implant and the abutment.

Estimated fetal weight by ultrasound: a modifiable risk factor for cesarean delivery?

OBJECTIVE: The purpose of this study was to investigate whether knowledge of ultrasound-obtained estimated fetal weight (US-EFW) is a risk factor for cesarean delivery (CD). STUDY DESIGN: Retrospective cohort from a single center in 2009-2010 of singleton, term live births. CD rates were compared for women with and without US-EFW within 1 month of delivery and adjusted for potential confounders. RESULTS: Of the 2329 women in our cohort, 50.2% had US-EFW within 1 month of delivery. CD was significantly more common for women with US-EFW (15.7% vs 10.2%; P < .001); after we controlled for confounders, US-EFW remained an independent risk factor for CD (odds ratio, 1.44; 95% confidence interval, 1.1-1.9). The risk increased when US-EFW was >3500 g (odds ratio, 1.8; 95% confidence interval, 1.3-2.7). CONCLUSION: Knowledge of US-EFW, above and beyond the impact of fetal size itself, increases the risk of CD. Acquisition of US-EFW near term appears to be an independent and potentially modifiable risk factor for CD.

Fetal bisphenol A exposure: concentration of conjugated and unconjugated bisphenol A in amniotic fluid in the second and third trimesters.

Bisphenol A (BPA) is an estrogenic compound widely used in polycarbonate plastics. The placental enzyme ß-glucuronidase may deconjugate BPA into its "free" active form. We sought to quantify levels of conjugated and free BPA in second and third trimester amniotic fluid. Liquid chromatography coupled with mass spectrometry was used to measure BPA concentrations in 20 second trimester and 20 third trimester amniotic fluid specimens. Total BPA was detected in 16/20 second trimester samples; levels ranged from non-detectable to 0.75ng/mL (median 0.47ng/mL). Free BPA was detected in 9/20 second trimester samples; levels ranged from 0.31 to 0.43ng/mL (median 0.38ng/mL). Total BPA was detected in 2/20 third trimester samples. Free BPA was detected in 1/20 (0.42ng/mL). When detected, free BPA comprised 83% and 91% of total BPA in second and third trimester amniotic fluid, respectively. Placental ß-glucuronidase may deconjugate BPA, increasing fetal exposure to free BPA.