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2.
Am J Obstet Gynecol MFM ; 3(6): 100451, 2021 Jul 25.
Artigo em Inglês | MEDLINE | ID: mdl-34320429

RESUMO

Buprenorphine is 1 of 3 medications approved by the US Food and Drug Administration for the treatment of opioid use disorder, and practitioners must obtain a federal waiver to prescribe buprenorphine. Until recently, physicians and advanced practice clinicians were required to complete 8 and 24 hours of training, respectively, before applying for this waiver and to provide psychosocial services when prescribing buprenorphine to ≤30 patients. The US Department of Health and Human Services announced in April 2021 that eligible providers would be exempt from the educational requirement for certification, making the waiver more accessible for those intending to prescribe to ≤30 patients. Here, we reviewed the historic background to the exemption and provided practical guidelines to practitioners caring for obstetrical patients with opioid use disorder who are considering applying for the waiver for the first time. Because the educational requirements will no longer be required for X-waiver application, we reviewed fundamental topics and challenging scenarios that are often reviewed in certification courses.

3.
Addict Sci Clin Pract ; 16(1): 40, 2021 06 25.
Artigo em Inglês | MEDLINE | ID: mdl-34172081

RESUMO

BACKGROUND: Opioid use disorder (OUD) disproportionately impacts rural and American Indian communities and has quadrupled among pregnant individuals nationwide in the past two decades. Yet, limited data are available about access and quality of care available to pregnant individuals in rural areas, particularly among American Indians (AIs). Unannounced standardized patients (USPs), or "secret shoppers" with standardized characteristics, have been used to assess healthcare access and quality when outcomes cannot be measured by conventional methods or when differences may exist between actual versus reported care. While the USP approach has shown benefit in evaluating primary care and select specialties, its use to date for OUD and pregnancy is very limited. METHODS: We used literature review, current practice guidelines for perinatal OUD management, and stakeholder engagement to design a novel USP protocol to assess healthcare access and quality for OUD in pregnancy. We developed two USP profiles-one white and one AI-to reflect our target study area consisting of three rural, predominantly white and AI US counties. We partnered with a local community health center network providing care to a large AI population to define six priority outcomes for evaluation: (1) OUD treatment knowledge among clinical staff answering telephones; (2) primary care clinic facilitation and provision of prenatal care and buprenorphine treatment; (3) appropriate completion of evidence-based screening, symptom assessment, and initial steps in management; (4) appropriate completion of risk factor screening/probing about individual circumstances that may affect care; (5) patient-directed tone, stigma, and professionalism by clinic staff; and (6) disparities in care between whites and American Indians. DISCUSSION: The development of this USP protocol tailored to a specific environment and high-risk patient population establishes an innovative approach to evaluate healthcare access and quality for pregnant individuals with OUD. It is intended to serve as a roadmap for our own study and for future related work within the context of substance use disorders and pregnancy.

4.
Am J Perinatol ; 2021 Apr 20.
Artigo em Inglês | MEDLINE | ID: mdl-33878768

RESUMO

OBJECTIVE: The aim of the study is to examine the impact of maternal interpregnancy body mass index (BMI) change on subsequent offspring mortality risk. STUDY DESIGN: This is a retrospective cohort study of women who had two consecutive live singleton deliveries of at least 20 weeks' gestation from the Utah Population Database. Our exposure was defined as interpregnancy BMI change from the date of first delivery to the conception date of subsequent pregnancy. We categorized BMI change as: < - 1, -1 to 0, 0 to <1 (reference), 1 to 2, 2 to 4, ≥4 kg/m2. Our primary outcome was all-cause age-specific mortality during four time periods: neonatal (≤28 days), infant (29 days to <1 year old), childhood ((≥1 to <5 years old), and late childhood (5 to <18 years old). We also examined mortality specifically attributed to congenital anomalies. Analyses used Cox proportional hazard models stratified by full term (≥37 weeks) and preterm (<37 weeks) deliveries. All models were adjusted for relevant confounders. RESULTS: Of 266,752 women, among full-term deliveries, women with a BMI increase of 4 kg/m2 or more had an increased risk of neonatal mortality in their subsequent pregnancy (hazard ratio or HR1.72, 95% confidence interval or CI 1.23-2.41) Women who lost 1 kg/m2 or more between deliveries also had increased neonatal mortality (HR 1.46, 95% CI 1.04-2.05). There were no differences in infant, early, or late childhood mortality by interpregnancy BMI change. Maternal interpregnancy interval weight loss of 1 kg/m2 or more and weight gain of ≥4 kg/m2 also had increased risk of mortality associated with congenital anomalies or conditions arising during the neonatal period following their subsequent delivery. CONCLUSION: Women with significant interpregnancy weight gain and modest weight loss have a significant increased risk of neonatal mortality following their subsequent pregnancy. KEY POINTS: · Significant weight gain between deliveries increases the risk of neonatal death.. · Modest weight loss between deliveries increases the risk of neonatal death.. · This risk may be partially explained by increased risk of congenital malformations..

5.
Adv Neonatal Care ; 21(1): 32-40, 2021 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-33055519

RESUMO

BACKGROUND: As the rate of opioid use in pregnancy escalates, there are a growing number of women diagnosed with opioid use disorder (OUD) and their newborns being cared for in inpatient settings. PURPOSE: In this study, we sought to better understand the experiences of nurses and nursing assistants working with women diagnosed with OUD and their newborns. By identifying the needs of nurses and nursing assistants, the findings from this study may contribute to reductions in stigma and improved patient care. METHODS: Nurses and nursing assistants were recruited from a postpartum unit at a large urban hospital in Utah. Participants (n = 30) attended up to 4 semistructured focus groups. We utilized Braun and Clarke's 6-phase approach to thematic analysis to analyze transcribed interviews. FINDINGS/RESULTS: Themes identified during the data analysis process included negative feelings and reactions toward patients; preferential concern for the newborn over maternal well-being; and identification of organizational and training needs to overcome these challenges. IMPLICATIONS FOR PRACTICE: These findings identify strategies for addressing challenges faced by nurses and nursing assistants in caring for women diagnosed with OUD and their newborns. IMPLICATIONS FOR RESEARCH: Future research should examine the effectiveness of approaches to reduce behaviors influenced by stigma among nurses and nursing assistants working with women diagnosed with OUD and their newborns, as well as employee and patient satisfaction, and long-term health outcomes.

7.
Obstet Gynecol ; 136(6): 1095-1102, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33156199

RESUMO

OBJECTIVE: To characterize stillbirths associated with pregestational diabetes and gestational diabetes mellitus (GDM) in a large, prospective, U.S. case-control study. METHODS: A secondary analysis of stillbirths among patients enrolled in a prospective; multisite; geographically, racially, and ethnically diverse case-control study in the United States was performed. Singleton gestations with complete information regarding diabetes status and with a complete postmortem evaluation were included. A standard evaluation protocol for stillbirth cases included postmortem evaluation, placental pathology, clinical testing as performed at the discretion of the health care professional, and a recommended panel of tests. A potential cause of death was assigned to stillbirth cases using a standardized classification tool. Demographic and delivery characteristics among women with pregestational diabetes and GDM were compared with characteristics of women with no diabetes in pairwise comparisons using χ or two-sample t tests as appropriate. Sensitivity analysis was performed excluding pregnancies with genetic conditions or major fetal malformations. RESULTS: Of 455 stillbirth cases included in the primary analysis, women with stillbirth and diabetes were more likely to be older than 35 years and have a higher body mass index. They were also more likely to have a gestational hypertensive disorder than women without diabetes (28% vs 9.1%; P<.001). Women with pregestational diabetes had more large-for-gestational-age (LGA) neonates (26% vs 3.4%; P<.001). Stillbirths occurred more often at term in women with pregestational diabetes (36%) and those with GDM (52%). Maternal medical complications, including pregestational diabetes and others, were more often identified as a probable or possible cause of death among stillbirths with maternal diabetes (43% vs 4%, P<.001) as compared with stillbirths without diabetes. CONCLUSION: Compared with stillbirths in women with no diabetes, stillbirths among women with pregestational diabetes and GDM occur later in pregnancy and are associated with hypertensive disorders of pregnancy, maternal medical complications, and LGA.


Assuntos
Diabetes Gestacional/epidemiologia , Hipertensão Induzida pela Gravidez/epidemiologia , Complicações na Gravidez/epidemiologia , Gravidez em Diabéticas/epidemiologia , Natimorto/epidemiologia , Adolescente , Adulto , Estudos de Casos e Controles , Diabetes Gestacional/etnologia , Feminino , Humanos , Hipertensão Induzida pela Gravidez/etnologia , Recém-Nascido , Pessoa de Meia-Idade , Gravidez , Complicações na Gravidez/etnologia , Gravidez em Diabéticas/etnologia , Cuidado Pré-Natal , Estudos Prospectivos , Natimorto/etnologia , Estados Unidos/epidemiologia , Adulto Jovem
8.
Ann Intern Med ; 173(11 Suppl): S19-S28, 2020 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-33253018

RESUMO

BACKGROUND: Opioid and psychotropic prescriptions are common during pregnancy. Little is known about coprescriptions of both medications in this setting. OBJECTIVE: To describe opioid prescription among women who are prescribed psychotropics compared with women who are not. DESIGN: Cross-sectional study. SETTING: U.S. commercial insurance beneficiaries from MarketScan (2001 to 2015). PARTICIPANTS: Pregnant women at 22 weeks' gestation or greater who were insured continuously for 3 months or more before pregnancy through delivery. MEASUREMENTS: Opioid prescription, dosage thresholds (morphine milligram equivalents [MME] of ≥50/day and ≥90/day), number of opioid agents (≥2), and duration (≥30 days) among those with and without prescription of psychotropics, from 2011 to 2015. RESULTS: Among 958 980 pregnant women, 10% received opioids only, 6% psychotropics only, and 2% opioids with coprescription of psychotropics. Opioid prescription was higher among women prescribed psychotropics versus those who were not (26.5% vs. 10.7%). From 2001 to 2015, psychotropic prescription overall increased from 4.4% to 7.6%, opioid prescription without coprescription of psychotropics decreased from 11.9% to 8.4%, and opioids with coprescription decreased from 28.1% to 22.0%. Morphine milligram equivalents of 50 or greater per day decreased for women with and without coprescription (29.6% to 17.3% and 22.8% to 18.5%, respectively); MME of 90 or greater per day also decreased in both groups (15.0% to 4.7% and 11.5% to 4.2%, respectively). Women prescribed opioids only were more likely to have an antepartum hospitalization compared with those with neither prescription, as were women with coprescription versus those prescribed psychotropics only. Compared with those prescribed opioids only, women with coprescriptions were more likely to exceed MME of 90 or greater per day and to be prescribed 2 or more opioid agents and for 30 days or longer. Number and duration of opioids increased with benzodiazepine and gabapentin coprescription. LIMITATION: Inability to determine appropriateness of prescribing or overdose events. CONCLUSION: Opioids are frequently coprescribed with psychotropic medication during pregnancy and are associated with antepartum hospitalization. A substantial proportion of pregnant women are prescribed opioids at doses that increase overdose risk and exceed daily recommendations. PRIMARY FUNDING SOURCE: None.


Assuntos
Analgésicos Opioides/uso terapêutico , Complicações na Gravidez/tratamento farmacológico , Medicamentos sob Prescrição/uso terapêutico , Psicotrópicos/uso terapêutico , Estudos Transversais , Feminino , Humanos , Seguro Saúde/estatística & dados numéricos , Gravidez , Estados Unidos/epidemiologia
9.
Addict Sci Clin Pract ; 15(1): 33, 2020 10 31.
Artigo em Inglês | MEDLINE | ID: mdl-33129355

RESUMO

BACKGROUND: Opioid use disorder (OUD) among women delivering at a hospital has increased 400% from 1999-2014 in the United States. From the years 2007 to 2016, opioid-related mortality during pregnancy increased over 200%, and drug-overdose deaths made up nearly 10% of all pregnancy-associated mortality in 2016 in the US. Disproportionately higher rates of neonatal opioid withdrawal syndrome (NOWS) have been reported in rural areas of the country, suggesting that perinatal OUD is a pressing issue among these communities. There is an urgent need for comprehensive, evidence-based treatment services for pregnant women experiencing OUD. The purpose of this article is to describe a study protocol aimed at developing and evaluating a perinatal OUD curriculum, enhancing evidence-based perinatal OUD treatment in a rural setting, and evaluating the implementation of such collaborative care for perinatal OUD. METHODS: This two-year study employed a one group, repeated measures, hybrid type-1 effectiveness-implementation design. This study delivered interventions at 2 levels, both targeting improvement of care for pregnant women with OUD. The first area of focus was at the community healthcare provider-level, which aimed to evaluate the acceptability and feasibility of perinatal OUD education across time and to improve provider education by increasing knowledge specific to: MOUD provision; screening, brief intervention, and referral to treatment (SBIRT) utilization; and NOWS treatment. The second area of intervention focus was at the patient-level, which assessed the preliminary effect of perinatal OUD provider education in promoting illicit opioid abstinence and treatment engagement among pregnant women with OUD. We adopted constructs from the Consolidated Framework for Implementation Research (CFIR) to assess contextual factors that may influence implementation, and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model to comprehensively evaluate implementation outcomes. DISCUSSION: This article presents the protocol of an implementation study that is employing the CFIR and RE-AIM frameworks to implement and evaluate a perinatal OUD education and service coordination program in two rural counties. This protocol could serve as a model for clinicians and researchers seeking to implement improvements in perinatal care for women with OUD in other rural communities. Trial registration NCT04448015 clinicaltrials.gov.

10.
Am J Perinatol ; 2020 Sep 24.
Artigo em Inglês | MEDLINE | ID: mdl-32971561

RESUMO

OBJECTIVE: Marijuana use is associated with placenta-mediated adverse pregnancy outcomes including fetal growth restriction, but the mechanism remains uncertain. The objective was to evaluate the association between maternal marijuana use and the feto-placental weight ratio (FPR). Secondarily, we aimed to compare placental histology of women who used marijuana to those who did not. STUDY DESIGN: This was a secondary analysis of singleton pregnancies enrolled in a multicenter and case-control stillbirth study. Prior marijuana use was detected by electronic medical record abstraction or cord homogenate positive for 11-nor-delta-9-tetrahydrocannabinol-9-carboxylic acid. Prior tobacco use was detected by self-report or presence of maternal serum cotinine. Stillbirths and live births were considered separately. The primary outcome was FPR. Association of marijuana use with FPR was estimated with multivariable linear modeling adjusted for fetal sex, preterm birth, and tobacco use. Comparisons between groups for placental histology were made using Chi-square and stratified by live birth and stillbirth, term and preterm deliveries, and fetal sex. RESULTS: Of 1,027 participants, 224 were stillbirths and 803 were live births. Overall, 41 (4%) women used marijuana during the pregnancy. The FPR ratio was lower among exposed offspring but reached statistical significance only for term stillbirths (mean 6.84 with marijuana use vs. mean 7.8 without use, p < 0.001). In multivariable modeling, marijuana use was not significantly associated with FPR (p = 0.09). There were no differences in histologic placental features among those with and without marijuana use overall or in stratified analyses. CONCLUSION: Exposure to marijuana may not be associated with FPR. Similarly, there were no placental histologic features associated with marijuana exposure. Further study of the influence of maternal marijuana use on placental development and function is warranted to better understand the association between prenatal marijuana use and poor fetal growth. KEY POINTS: · Maternal marijuana exposure was not associated with the feto-placental weight ratio.. · Marijuana exposure was not associated with differences in placental histology.. · Concerning trend toward lower feto-placental weight ratios among marijuana-exposed stillbirths..

11.
Obstet Gynecol ; 136(4): 645-653, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32925616

RESUMO

OBJECTIVE: To estimate the proportion of accidental drug-related deaths and suicides classified as pregnancy-related from 2013 to 2014 (preimplementation of standardized criteria) and 2015 to 2016 (postimplementation). METHODS: Based on Centers for Disease Control and Prevention pregnancy-related death criteria, the Utah Perinatal Mortality Review Committee developed a standardized evaluation tool to assess accidental drug-related death and suicide beginning in 2015. We performed a retrospective case review of all pregnancy-associated deaths (those occurring during pregnancy or 1 year postpartum for any reason) and pregnancy-related deaths (those directly attributable to the pregnancy or postpartum events) evaluated by Utah's Perinatal Mortality Review Committee from 2013 to 2016. We compared the proportion of accidental drug-related deaths and suicides meeting pregnancy-related criteria preimplementation and postimplementation of a standardized criteria checklist tool using Fisher's exact test. We assessed the change in pregnancy-related mortality ratio in Utah from 2013 to 2014 and 2015 to 2016 using test of trend. RESULTS: From 2013 to 2016, there were 80 pregnancy-associated deaths in Utah (2013-2014: n=40; 2015-2016: n=40), and 41 (51%) were pregnancy-related (2013-2014: n=15, 2015-2016: n=26). In 2013-2014 (preimplementation), 12 women died of drug-related deaths or suicides, and only two of these deaths were deemed pregnancy-related (17%). In 2015-2016 (postimplementation), 18 women died of drug-related deaths or suicide, and 94% (n=17/18) of these deaths met one or more of the pregnancy-related criteria on the checklist (P<.001). From 2013 to 2014 to 2015-2016, Utah's overall pregnancy-related mortality ratio more than doubled, from 11.8 of 100,000 to 25.7 of 100,000 (P=.08). CONCLUSION: After application of standardized criteria, the Utah Perinatal Mortality Review Committee determined that pregnancy itself was the inciting event leading to the majority of accidental drug-related deaths or suicides among pregnant and postpartum women. Other maternal mortality review committees may consider a standardized approach to assessing perinatal suicides and accidental drug-related deaths.


Assuntos
Prevenção de Acidentes , Uso Indevido de Medicamentos , Revisão por Pares/normas , Complicações na Gravidez , Transtornos Puerperais/mortalidade , Suicídio , Adulto , Comitês Consultivos/estatística & dados numéricos , Uso Indevido de Medicamentos/mortalidade , Uso Indevido de Medicamentos/prevenção & controle , Falha da Terapia de Resgate/estatística & dados numéricos , Feminino , Humanos , Mortalidade Materna/tendências , Mortalidade , Gravidez , Complicações na Gravidez/mortalidade , Complicações na Gravidez/prevenção & controle , Suicídio/prevenção & controle , Suicídio/estatística & dados numéricos , Utah/epidemiologia
12.
Obstet Gynecol ; 136(5): 882-891, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32909970

RESUMO

OBJECTIVE: To evaluate the effectiveness and safety of an intrauterine vacuum-induced hemorrhage-control device for postpartum hemorrhage treatment. METHODS: A multicenter, prospective, single-arm treatment study of a novel intrauterine device that uses low-level vacuum to induce uterine myometrial contraction to achieve control of abnormal postpartum uterine bleeding and postpartum hemorrhage was undertaken at 12 centers in the United States. The primary effectiveness endpoint was the proportion of participants in whom use of the intrauterine vacuum-induced hemorrhage-control device controlled abnormal bleeding without requiring escalating interventions. The primary safety endpoint was the incidence, severity, and seriousness of device-related adverse events. Secondary outcomes included time to bleeding control, rate of transfusion, and device usability scored by each investigator using the device. RESULTS: Of 107 participants enrolled with primary postpartum hemorrhage or abnormal postpartum uterine bleeding, 106 received any study treatment with the device connected to vacuum, and successful treatment was observed in 94% (100/106, 95% CI 88-98%) of these participants. In those 100 participants, definitive control of abnormal bleeding was reported in a median of 3 minutes (interquartile range 2.0-5.0) after connection to vacuum. Eight adverse events deemed possibly related to the device or procedure were reported, all of which were outlined as risks in the study and all of which resolved with treatment without serious clinical sequelae. Transfusion of 1-3 units of red blood cells was required in 35 participants, and five participants required 4 or more units of red blood cells. The majority of investigators reported the intrauterine vacuum-induced hemorrhage-control device as easy to use (98%) and would recommend it (97%). CONCLUSION: Intrauterine vacuum-induced hemorrhage control may provide a new rapid and effective treatment option for abnormal postpartum uterine bleeding or postpartum hemorrhage, with the potential to prevent severe maternal morbidity and mortality. FUNDING SOURCE: Alydia Health, Inc. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02883673.


Assuntos
Hemorragia Pós-Parto/terapia , Tamponamento com Balão Uterino/instrumentação , Vácuo-Extração/efeitos adversos , Adulto , Transfusão de Sangue/estatística & dados numéricos , Feminino , Humanos , Dispositivos Intrauterinos , Hemorragia Pós-Parto/etiologia , Gravidez , Estudos Prospectivos , Resultado do Tratamento
14.
Contemp Clin Trials ; 87: 105888, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31731006

RESUMO

The opioid crisis continues to affect pregnant and postpartum women the United States, with the number of pregnant women diagnosed with opioid use disorder (OUD) quadrupling over the last decade. The associated increase in morbidity and mortality among mother and baby warrants prompt, targeted intervention efforts that improve engagement, linkage of care, and treatment retention. Patient navigation (PN) is a chronic care intervention that can directly address this need by helping women identify medical, behavioral, and psychosocial care goals. Moreover, PN can assist women in preparing for, engaging in, and maintaining patient participation in necessary services. Specifically, PN includes strengths-based case management, 1-1 clinical support, motivational interviewing, and addiction-relapse prevention programming. The objective of this article is to present the study protocol of a pilot multisite randomized clinical trial, entitled: Optimizing Pregnancy and Treatment Interventions for Moms 2.0 (OPTI-Mom 2.0; NCT03833245). In this study, we build upon a proof-of-concept study, employing evidence-informed frameworks for protocol and intervention expansion in order to construct a PN intervention tailored for pregnant women with OUD in central Utah and southwestern Pennsylvania. Our protocol provides an initial framework of a potentially impactful intervention and may guide development of future programs. Importantly, this study further establishes the evidence-base-with potential to ameliorate serious adverse opioid-related outcomes and improve health for women and their children.


Assuntos
Transtornos Relacionados ao Uso de Opioides/terapia , Navegação de Pacientes/organização & administração , Complicações na Gravidez/terapia , Cuidado Pré-Natal/organização & administração , Centros de Atenção Terciária/organização & administração , Feminino , Humanos , Entrevista Motivacional , Tratamento de Substituição de Opiáceos/métodos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Gravidez , Complicações na Gravidez/tratamento farmacológico , Prevenção Secundária/organização & administração , Estados Unidos
15.
AJP Rep ; 9(4): e361-e365, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31754549

RESUMO

Objective The purpose of this study was to determine the impact of preclinical shadowing on student interest and perceptions of obstetrics and gynecology (OBGYN). Methods We enrolled a prospective cohort of preclinical medical students who shadowed on labor and delivery (L&D). Students sent electronic surveys a week prior (presurvey), the week after (postsurvey), and three months after shadowing (far-survey). Responses compared using descriptive statistics. We analyzed common themes of free text responses. Results From July 2016 to April 2017, 41 students shadowed on L&D; 81% were female. Eighty percent responded to at least one survey, 37% completed all surveys, (presurvey: 76%, postsurvey: 51%, and far-survey: 46%). Prior to shadowing, 10% (3/31) planed a career in OBGYN compared with 24% (5/21) after shadowing ( p = 0.42). Over 50% of students described the people and procedures as altering their perceptions of OBGYN in a positive way. Common themes explaining this change included: culture ( n = 4), team interactions ( n = 4), seeing deliveries ( n = 3), and hands-on experiences ( n = 3). Three months after shadowing, 79% described the experience as very worthwhile. Eighty-nine percent would recommend the experience to a friend not interested in OBGYN and 100% stated they would shadow again. Discussion Although shadowing may not increase students' desire to pursue OBGYN, it is nearly universally felt to be worthwhile and improves perceptions of the field.

16.
Obstet Gynecol ; 133(6): 1131-1140, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31135726

RESUMO

OBJECTIVE: Drug-induced deaths, defined as intentional or unintentional consumption of illicit substances or diverted medications leading to death, are the leading cause of death for reproductive-age women in the United States. Our objective was to describe pregnancy-associated deaths attributed to drug-induced causes to identify opportunities for intervention. METHODS: Using the Utah Perinatal Morality Review Committee database, we performed a retrospective cohort study of all pregnancy-associated deaths-death of a woman during pregnancy or within 1 year from the end of pregnancy-from 2005 to 2014. We performed a detailed descriptive analysis of women with drug-induced deaths. We compared characteristics of women with drug-induced and other pregnancy-associated deaths. RESULTS: From 2005 to 2014, 136 pregnancy-associated deaths were identified. Drug-induced death was the leading cause of pregnancy-associated death (n=35, 26%) and 89% occurred in the postpartum period. More specifically, those with a drug-induced death were more likely to die in the late postpartum period, defined as death occurring within 43 days to 1 year of the end of the pregnancy, (n=28/35, 80%) compared with women whose deaths were from other pregnancy-associated causes (n=34/101, 34%) (P<.001). The majority of drug-induced deaths were attributed to opioids (n=27/35, 77%), prescription opioids (n=21/35, 60%), and polysubstance use (n=29/35, 83%). From 2005 to 2014, the pregnancy-associated mortality ratio increased 76%, from 23.3 in 2005 to 41.0 in 2014. During this same time period, the drug-induced pregnancy-associated mortality ratio increased 200%, from 3.9 in 2005 to 11.7 in 2014. CONCLUSION: Drug-induced death is the leading cause of pregnancy-associated death in Utah and occurs primarily in the late postpartum period. Interventional studies focused on identifying and treating women at risk of drug-induced death are urgently needed.


Assuntos
Analgésicos Opioides/efeitos adversos , Mortalidade Materna , Transtornos Relacionados ao Uso de Opioides/mortalidade , Gravidez/estatística & dados numéricos , Adolescente , Adulto , Bases de Dados Factuais , Feminino , Humanos , Vigilância da População/métodos , Complicações na Gravidez/mortalidade , Resultado da Gravidez , Estudos Retrospectivos , Utah/epidemiologia , Adulto Jovem
17.
Dev Psychopathol ; 31(3): 817-831, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31064587

RESUMO

The World Health Organization recently reported that maternal mental health is a major public health concern. As many as one in four women suffer from psychiatric disorders at some point during pregnancy or the first postpartum year. Furthermore, self-injurious thoughts and behaviors (SITBs) represent one of the leading causes of death among women during this time. Thus, efforts to identify women at risk for serious forms of psychopathology and especially for SITBs are of utmost importance. Despite this urgency, current single-diagnostic approaches fail to recognize a significant subset of women who are vulnerable to perinatal stress and distress. The current study was among the first to investigate emotion dysregulation-a multilevel, transdiagnostic risk factor for psychopathology-and its associations with stress, distress, and SITBs in a sample of pregnant women (26-40 weeks gestation) recruited to reflect a range of emotion dysregulation. Both self-reported emotion dysregulation and respiratory sinus arrhythmia, a biomarker of emotion dysregulation, demonstrated expected associations with measures of mental health, including depression, anxiety, borderline personality pathology, and SITBs. In addition, self-reported emotion dysregulation was associated with blunted respiratory sinus arrhythmia responsivity to an ecologically valid infant cry task. Findings add to the literature considering transdiagnostic risk during pregnancy using a multiple-levels-of-analysis approach.


Assuntos
Emoções/fisiologia , Saúde Materna , Transtornos Mentais/psicologia , Sistema Nervoso Parassimpático/fisiopatologia , Gestantes/psicologia , Comportamento Autodestrutivo/psicologia , Adolescente , Adulto , Ansiedade/fisiopatologia , Ansiedade/psicologia , Depressão/fisiopatologia , Depressão/psicologia , Feminino , Humanos , Gravidez , Arritmia Sinusal Respiratória/fisiologia , Fatores de Risco , Autorrelato , Comportamento Autodestrutivo/fisiopatologia , Adulto Jovem
18.
Clin Obstet Gynecol ; 62(1): 168-184, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30601144

RESUMO

Stimulant use, including cocaine, methamphetamines, ecstasy, and prescription stimulants, in pregnancy is increasingly common. In the United States, stimulants are the second most widely used and abused substances during pregnancy and pregnant women using stimulants in pregnancy are at increased risk of adverse perinatal, neonatal, and childhood outcomes. In this review, we describe the pharmacology, pathophysiology, and epidemiology of stimulants, summarize the maternal and neonatal effects of perinatal stimulant use, and outline treatment options for stimulant use disorders among pregnant women. Development of effective treatment strategies for stimulant use disorders identified among pregnant women are urgently needed.


Assuntos
Alcaloides/efeitos adversos , Estimulantes do Sistema Nervoso Central/efeitos adversos , Cocaína/efeitos adversos , Metanfetamina/efeitos adversos , N-Metil-3,4-Metilenodioxianfetamina/efeitos adversos , Alcaloides/farmacocinética , Estimulantes do Sistema Nervoso Central/farmacocinética , Cocaína/administração & dosagem , Cocaína/farmacologia , Feminino , Humanos , Metanfetamina/farmacologia , N-Metil-3,4-Metilenodioxianfetamina/farmacocinética , Gravidez , Resultado da Gravidez , Efeitos Tardios da Exposição Pré-Natal/etiologia , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Revisões Sistemáticas como Assunto , Estados Unidos
19.
Am J Perinatol ; 36(7): 688-694, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30336498

RESUMO

OBJECTIVE: To quantify the effects of operative blood loss during cesarean on tissue and plasma cefazolin concentrations. STUDY DESIGN: This was a prospective observational study of singleton pregnancies undergoing scheduled cesarean between 34 and 40 weeks. Cefazolin administered prior to skin incision. Maternal plasma samples were obtained (Time 1[T1]: immediately, T2: 20 minutes, T3: 40 minutes, and T4: 60 minutes after cefazolin infusion). Subcutaneous adipose tissue sampled before and after fascia. Primary outcome was subcutaneous adipose cefazolin level after fascial closure. Formal quantitative blood loss (QBL) performed. Women with higher QBL, those at/above 75% of QBL in this population, were compared with those with lower QBL (QBL below 75%). Data analyzed using bivariable statistics. RESULTS: Ninety-two women were screened, 32 were eligible, and 20 enrolled. Median QBL was 630 mL (interquartile range [IQR]: 473-818) and 1,160 mL (IQR: 1,000-1,560) in the low and high QBL groups, respectively. Demographics and operative characteristics were similar. Median adipose cefazolin level after fascial closure did not differ between the groups (3.5 vs. 3.9 µg/g, p = 0.75). No differences in maternal plasma cefazolin concentrations between the groups at any time point or in pharmacokinetic parameters were seen. CONCLUSION: Intraoperative maternal plasma concentrations and adipose levels of cefazolin are similar between women with high and low blood loss at the time of cesarean delivery.


Assuntos
Antibacterianos/sangue , Perda Sanguínea Cirúrgica , Cefazolina/sangue , Cesárea/efeitos adversos , Infecção da Ferida Cirúrgica/prevenção & controle , Tecido Adiposo/química , Antibacterianos/análise , Antibacterianos/farmacocinética , Antibacterianos/uso terapêutico , Antibioticoprofilaxia , Cefazolina/análise , Cefazolina/farmacocinética , Cefazolina/uso terapêutico , Feminino , Humanos , Estudos Prospectivos
20.
J Matern Fetal Neonatal Med ; 32(15): 2486-2492, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29415593

RESUMO

OBJECTIVE: Moderate fish intake in early pregnancy is associated with decreased risk of preterm birth (PTB). Obesity during pregnancy is characterized by inflammation and insufficiency of essential fatty acids. The objective of this study was to measure the association between fish intake during pregnancy and risk of recurrent spontaneous (s) PTB among lean, overweight, and obese women. DESIGN: This is secondary analysis of a randomized controlled trial of omega-3 fatty acid supplementation for recurrent PTB prevention, 2005-2006. The primary exposure was fish intake at time of enrollment (16-22.9-week gestation). The primary outcomes were sPTB <37 weeks and sPTB <35 weeks. Maternal prepregnancy body mass index was treated as an effect modifier. SUBJECTS: Eight hundred and fifty-two women were included, 47% were lean, 25% overweight, and 28% obese. RESULTS: In this cohort, among lean, but not overweight or obese women, ≥1 serving of fish per week was associated with decreased frequency of sPTB <37 weeks compared with <1 serving of fish per week (45.1% versus 27.5%, p = .001) and spontaneous PTB <35 (21.4% versus 11.6%, p = .01). In adjusted models, as fish intake increased, the predicted probability of sPTB decreased in lean women but increased in overweight and obese women (p for interaction < .10). CONCLUSION: Fish intake was associated with lower probability of sPTB in lean women and higher probability in obese women. These findings warrant further investigation to understand the dietary or metabolic factors associated with obesity that may modulate benefit of fish intake during pregnancy.


Assuntos
Dieta , Peixes , Obesidade/complicações , Nascimento Prematuro/prevenção & controle , Alimentos Marinhos , Adulto , Animais , Estudos de Casos e Controles , Feminino , Humanos , Gravidez , Nascimento Prematuro/etiologia , Recidiva , Prevenção Secundária , Adulto Jovem
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