Telerehabilitation for pelvic girdle dysfunction in pregnancy during COVID-19 pandemic crisis: A case report.

BACKGROUND: Pelvic girdle dysfunction is a common musculoskeletal disorder among pregnant women. It is a disabling condition affecting the ability of a pregnant woman to perform her daily functional activities. The scope of digital health in delivering rehabilitation services is growing exponentially, especially in the present COVID -19 pandemic crisis. CASE DESCRIPTION: A 29-year-old primigravida, at 32 weeks of gestation with severe pelvic girdle pain during bed transitions, sought physiotherapy consultation via video call, as she expressed difficulty in accessing Physiotherapy services due to the present pandemic crisis. Physiotherapy consultation was provided in 4 weekly sessions using a real-time video-based telerehabilitation program and the patient performed unsupervised exercise sessions for 30 minutes for 5 days per week for 4 weeks. The plan of care included muscle energy techniques, pelvic cloth belt, strengthening, stabilization exercises and stretching. OUTCOMES: The patient completed four sessions including evaluation and treatment and there was a reduction of pain scores for bed transitions from NPRS 8/10 during session one to NPRS 0/10 during session four. The Pelvic girdle dysfunction questionnaire showed a decrease in percentage scores from 54.6 to 4 at the end of physiotherapy sessions. CONCLUSION: Telerehabilitation was successfully used to manage a pregnant woman with pelvic girdle dysfunction.

Racial inequity in methadone dose at delivery in pregnant women with opioid use disorder.

BACKGROUND: Medications for opioid use disorder, including methadone, combined with comprehensive wraparound services, are the gold standard for treatment in pregnancy. Higher methadone doses are associated with treatment retention in pregnancy and relapse prevention. Given known inequities where individuals of color tend to be prescribed lower doses of opioids for other conditions, the purpose of this study was to determine whether there is racial inequity in methadone dose at delivery in pregnant women with opioid use disorder. METHODS: Retrospective review of medical charts identified pregnant women (N = 339) treated with methadone for opioid use disorder during pregnancy at one center from 2012 to 2017. Variables extracted from medical records included race, demographic and relevant clinical information (e.g., methadone dose at delivery, height, weight, etc.). Analyses used simple and multiple linear regressions to determine associations between these characteristics and methadone dose at delivery. RESULTS: The mean methadone doses at delivery among women of color and white women were 105.8 mg and 144.9 mg, respectively (p < .0001). After adjusting for maternal age, gestational age at delivery, body mass index, type of opioid used, and parity, race was significantly and independently associated with methadone dose at delivery, with women of color receiving 36.2 mg less than white women (p = .0003). CONCLUSIONS: Pregnant women of color with opioid use disorder received 67% of the dose of methadone at delivery that white women received. Antiracist responses to prevent provider bias in evaluating dose needs are needed to correct this inequity and prevent undertreatment of opioid use disorder among women of color.

Pharmacokinetics of buprenorphine in pregnant sheep after intravenous injection.

Buprenorphine is a semi-synthetic opioid, widely used in the maintenance treatment for opioid-dependent pregnant women. Limited data exist on the pharmacokinetics of buprenorphine in pregnancy. We conducted a pharmacokinetic study to determine the pharmacokinetics of intravenous buprenorphine in pregnant sheep. Fourteen pregnant sheep in late gestation received 10 µg/kg of buprenorphine as an intravenous bolus injection. Plasma samples were collected up to 48 h after administration. Buprenorphine and its metabolite, norbuprenorphine, were quantified from plasma using a LC/MS/MS method, with lower limits of quantification of 0.01 µg/L and 0.04 µg/L for buprenorphine and norbuprenorphine, respectively. The pharmacokinetic parameters were calculated using noncompartmental analysis. The pharmacokinetic parameters, median (minimum-maximum), were Cmax 4.31 µg/L (1.93-15.5), AUCinf 2.89 h*µg/L (1.72-40.2), CL 3.39 L/h/kg (0.25-6.02), terminal t½ 1.75 h (1.07-31.0), Vss 8.04 L/kg (1.05-49.3). Norbuprenorphine was undetected in all plasma samples. The median clearance in pregnant sheep was higher than previously reported for nonpregnant sheep and human (male) subjects. Our sensitive analytical method was able to detect long terminal half-lives for six subjects, and a wide between-subject variability in the study population. Significance statement: Buprenorphine is widely used for the treatment of opioid use disorder in pregnancy. However, limited data exist on the pharmacokinetics of buprenorphine during pregnancy. As this type of study cannot be done in humans due to ethical reasons, we conducted a study in pregnant sheep. This study provides pharmacokinetic data on buprenorphine in pregnant sheep and helps us to understand the pharmacokinetics of the drug in humans.

Maintenance agonist treatments for opiate-dependent pregnant women.

BACKGROUND: The prevalence of opiate use among pregnant women can range from 1% to 2% to as high as 21%. Just in the United States alone, among pregnant women with hospital delivery, a fourfold increase in opioid use is reported from 1999 to 2014 (Haight 2018). Heroin crosses the placenta, and pregnant, opiate-dependent women experience a six-fold increase in maternal obstetric complications such as low birth weight, toxaemia, third trimester bleeding, malpresentation, puerperal morbidity, fetal distress and meconium aspiration. Neonatal complications include narcotic withdrawal, postnatal growth deficiency, microcephaly, neuro-behavioural problems, increased neonatal mortality and a 74-fold increase in sudden infant death syndrome. This is an updated version of the original Cochrane Review first published in 2008 and last updated in 2013. OBJECTIVES: To assess the effectiveness of any maintenance treatment alone or in combination with a psychosocial intervention compared to no intervention, other pharmacological intervention or psychosocial interventions alone for child health status, neonatal mortality, retaining pregnant women in treatment, and reducing the use of substances. SEARCH METHODS: We updated our searches of the following databases to February 2020: the Cochrane Drugs and Alcohol Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science. We also searched two trials registers and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). SELECTION CRITERIA: Randomised controlled trials which assessed the efficacy of any pharmacological maintenance treatment for opiate-dependent pregnant women. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. MAIN RESULTS: We found four trials with 271 pregnant women. Three compared methadone with buprenorphine and one methadone with oral slow-release morphine. Three out of four studies had adequate allocation concealment and were double-blind. The major flaw in the included studies was attrition bias: three out of four had a high dropout rate (30% to 40%), and this was unbalanced between groups. Methadone versus buprenorphine: There was probably no evidence of a difference in the dropout rate from treatment (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.37 to 1.20, three studies, 223 participants, moderate-quality evidence). There may be no evidence of a difference in the use of primary substances between methadone and buprenorphine (RR 1.81, 95% CI 0.70 to 4.68, two studies, 151 participants, low-quality evidence). Birth weight may be higher in the buprenorphine group in the two trials that reported data MD;-530.00 g, 95%CI -662.78 to -397.22 (one study, 19 particpants) and MD: -215.00 g, 95%CI -238.93 to -191.07 (one study, 131 participants) although the results could not be pooled due to very high heterogeneity (very low-quality of evidence). The third study reported that there was no evidence of a difference. We found there may be no evidence of a difference in the APGAR score (MD: 0.00, 95% CI -0.03 to 0.03, two studies,163 participants, low-quality evidence). Many measures were used in the studies to assess neonatal abstinence syndrome. The number of newborns treated for neonatal abstinence syndrome, which is the most critical outcome, may not differ between groups (RR 1.19, 95% CI 0.87 to1.63, three studies, 166 participants, low-quality evidence). Only one study which compared methadone with buprenorphine reported side effects. We found there may be no evidence of a difference in the number of mothers with serious adverse events (AEs) (RR 1.69, 95% CI 0.75 to 3.83, 175 participants, low-quality evidence) and we found there may be no difference in the numbers of newborns with serious AEs (RR 4.77, 95% CI 0.59, 38.49,131 participants, low-quality evidence). Methadone versus slow-release morphine: There were no dropouts in either treatment group. Oral slow-release morphine may be superior to methadone for abstinence from heroin use during pregnancy (RR 2.40, 95% CI 1.00 to 5.77, one study, 48 participants, low-quality evidence). In the comparison between methadone and slow-release morphine, no side effects were reported for the mother. In contrast, one child in the methadone group had central apnoea, and one child in the morphine group had obstructive apnoea (low-quality evidence). AUTHORS' CONCLUSIONS: Methadone and buprenorphine may be similar in efficacy and safety for the treatment of opioid-dependent pregnant women and their babies. There is not enough evidence to make conclusions for the comparison between methadone and slow-release morphine. Overall, the body of evidence is too small to make firm conclusions about the equivalence of the treatments compared. There is still a need for randomised controlled trials of adequate sample size comparing different maintenance treatments.

El ejercicio físico en el embarazo y/o el posparto frente a la fatiga percibida / Physical exercise in pregnancy and / or postpartum in the face of perceived fatigue

Se realizó un análisis de la literatura cuyo objetivo principal fue evaluar cómo repercute la actividad física realizada por la mujer en la fatiga posparto. Se llevó a cabo una revisión sistemática de estudios de investigación cumpliendo con los criterios del protocolo de revisión Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). Se realizaron búsquedas aplicando los criterios de inclusión en las siguientes bases de datos electrónicas; Web of Science, Scopus, PubMed, Cuiden; y en el motor de búsqueda Google Académico; también se han realizado búsquedas inversas realizadas a través de la bibliografía procedente de los artículos encontrados. Se identificaron 2460 artículos que cumplían los criterios de inclusión. Al realizar una criba por duplicados, lectura de título y abstract de los artículos identificados, y posteriormente una lectura en profundidad de los artículos, se incluyeron en la presente revisión sistemática 13 artículos. Una vez analizados los artículos se observa en los resultados de los mismos que se pone de manifiesto la relación positiva que existe entre realizar actividad física durante el embarazo o el posparto y la reducción de los niveles de Fatiga Posparto

An analysis of the literature whose main objective was to evaluate how the physical activity carried out by women in postpartum fatigue was carried out. A systematic review of research studies was carried out, fulfilling the criteria of the review protocol Preferred Reporting Items for Systematic reviews and Meta-Analyzes (PRISMA). We searched by applying the inclusion criteria in the following electronic databases; Web of Science, Scopus, PubMed, Cuiden; and in the Google Scholar search engine; Inverse searches have also been carried out through the bibliography from the articles found. We identified 2460 articles that met the inclusion criteria. When carrying out a screening in duplicates, reading the title and abstract of the identified articles, and subsequently an in-depth reading of the articles, 13 articles were included in the present systematic review. Once the articles have been analyzed, the results show that there is a positive relationship between physical activity during pregnancy or postpartum and the reduction of Postpartum Fatigue levels

Effectiveness of home exercise in pregnant women with carpal tunnel syndrome: Randomized Control Trial.

OBJECTIVE: To evaluate the effectiveness of a home exercise programme in pregnant patients with carpal tunnel syndrome. METHODS: The randomised, single-blind, controlled clinical study was conducted at Vakif University School of Medicine, Istanbul, Turkey, From December 2017 to June 2018 and comprised pregnant women with carpal tunnel syndrome (CTS) . Clinical evaluation of each patient was performed by a blind researcher and (EMG) Electromyography measurements were performed by another blind researcher. Patients were divided into two groups with normal and (mild or moderate) CTS based on EMG results and clinical examination. Patients with symptoms, clinical signs and CTS in EMG were included in group 1, while patients whose symptoms and clinical evaluation (such as Tinel, Phalen, Reverse Phalen and Durkan's test) were positive but not CTS in EMG were included in group 2. Exercise forms were given to both groups and they were asked to perform the exercises stated in the form in 3 sets each day and 10 repetitions in each set. The Sick Boston Carpal Tunnel Syndrome Questionnaire was administered face-to-face to collect data which was analysed using SPSS 22. RESULTS: Of the 33 subjects, 19(57.6%) were in patient group 1 and 14(42.4%) in control group 2. The overall mean age of the sample was 28.84±3.62 years. There were no significant differences between the groups in terms of symptoms and clinical tests (p>0.05). The symptom severity scale between the groups was significantly high in group 1 (p<0.05). Patients receiving treatment showed a decrease in symptom severity and functional capacity, but only the former showed a significant decrease in group 2 (p>0.05). CONCLUSIONS: Nerve and tendon slip exercises for patients with mild to moderate carpal tunnel syndrome symptoms were found to be simple and reliable methods that could be applied to patients to increase their functionality and to reduce the severity of the disease.

Effects of lumbar stabilization and muscular stretching on pain, disabilities, postural control and muscle activation in pregnant woman with low back pain.

BACKGROUND: Low back pain is common during pregnancy. Lumbar stabilization and stretching exercises are recommended to treat low back pain in the general population. However, few studies have applied the effects of these two interventions in pregnant women with low back pain. AIM: To compare the effects of lumbar stabilization and stretching exercises for the treatment of gestational low back pain. DESIGN: A pilot randomized clinical trial. SETTING: Laboratory of Functional Evaluation and Human Motor Performance and physical therapy clinics. POPULATION: Initially, 30 pregnant women with low back pain were recruited, of which 24 met the following inclusion criteria: being between 19-29 weeks of gestation; being in prenatal clinical follow-up; having nonspecific mechanical low back pain started in pregnancy; not participating in specific low back pain treatment in the last 3 months. A total of 20 women completed the study (10 each group). METHODS: The main outcome measures were clinical (pain by Visual Analogue Scale (VAS) and McGill Pain Questionnaire and disability by Roland Morris Questionnaire), and secondary outcome measures were: postural balance (force platform); muscle activation level of multifidus, iliocostalis lumborum, rectus abdominis and external abdominal oblique (electromyography). The women were randomized into two groups for 6 weeks of intervention twice a week for a 50-minute treatment: 1) lumbar stabilization exercise protocol and 2) stretching exercise protocol. RESULTS: There was a significant reduction (P=0.03) in pain (1.68 in VAS and 4.81 for McGill questionnaire) for both interventions, but no change in disability score. In addition, both interventions were comparable for a significant improvement in postural stability (in mean d=0.77) for the velocity sway parameter, and significantly increased activation (P>0.05) of the external abdominal oblique muscle after intervention. CONCLUSIONS: Both modalities (lumbar stabilization and stretching) were efficient for pain reduction, improving balance and increasing one trunk activity muscle after 6 weeks of intervention in pregnant women with low back pain. CLINICAL REHABILITATION IMPACT: The present study has implications, especially for clinical decision-making with regard to therapy choice in pregnant women with LBP to reduce pain and improve trunk function as measured through balance performance.

Trajectories of Fetal Adipose Tissue Thickness in Pregnancies After Gastric Bypass Surgery.

PURPOSE: Recent studies showed that women after surgery are at higher risk of delivering small-for-gestational infants. Thus, this study aims to investigate longitudinal changes of fetal subcutaneous adipose tissue thickness (FSCTT) of fetuses conceived after gastric bypass surgery as compared to BMI-matched controls. METHODS: Retrospective cohort study measuring ultrasound-derived longitudinal trajectories of abdominal FSCTT in 41 singleton pregnancies after gastric bypass surgery compared to 41 BMI-matched controls and 64 obese mothers. RESULTS: FSCTT was significantly lower in fetuses of women after GB as compared to BMI-matched controls in the second (mean difference 1.38 mm, p < 0.001) and third trimester of gestation (mean difference 3.37 mm, p < 0.001). Longitudinal analysis revealed significant differences in mean FSCTT trajectories between offspring's in GB mothers, BMI-matched, or obese controls. The ratio of FSCTT and abdominal circumference remained constant in the BMI-matched control group whereas it significantly decreased in fetuses of women after GB. Despite remarkable differences were observed in longitudinally assessed FSCTT, further analyses in the GB subgroup revealed that FSCTT were not influenced by OGTT mean or 120 min glucose values, biochemically hypoglycemia, time since bariatric surgery, or weight loss since surgery. CONCLUSION: In fetuses of mothers with history of bariatric surgery, abdominal FSCTT was markedly reduced. While the underlying mechanisms are not fully understood, a multifactorial genesis including nutritional deficiencies and altered metabolism after bariatric surgery is assumed.

Peer support specialists and perinatal opioid use disorder: Someone that's been there, lived it, seen it.

Perinatal opioid use disorder (OUD) has increased drastically since 2000 and is associated with myriad adverse outcomes. The Substance Abuse and Mental Health Services Administration (SAMHSA) recommends using peer support services to promote sustained remission from substance use disorders (SUDs). Integrating peer support specialists into perinatal OUD treatment has the potential to improve maternal and child health. However, there is limited published research on the experiences of pregnant and parenting women with peer support specialists during SUD treatment. The purpose of this study was to: (1) describe experiences of perinatal women undergoing OUD treatment with peer support specialists; (2) describe recommendations for improving or enhancing peer support services. For this qualitative descriptive study, we conducted two focus groups in a private location in a clinic that serves postpartum women with OUD (N = 9) who were parenting a child under the age of 5. The focus groups were voice recorded, professionally transcribed, and analyzed in MAXQDA using content analysis. Four themes emerged from the data: Feeling Supported by Peer Support Specialists, Qualities of an 'Ideal' Peer Support Specialist, Strategies to Improve Interactions with Peer Support Specialists, and Importance of Communication Across the Perinatal Period. Participants reported that PSSs had a strong, positive impact on their recovery. Postpartum women report overall positive experiences receiving peer support services during their pregnancy and postpartum period. However, participants offered suggestions to improve their interactions with PSSs, such as clarifying the boundaries between peer supporters and clients. Pregnant and postpartum women in OUD treatment have the potential to benefit from access to PSS throughout their perinatal period. Future research is needed to determine the impact of PSS on sustained recovery for perinatal women with OUD.

Effect of pelvic floor muscle training on postpartum sexual function and quality of life: A systematic review and meta-analysis of clinical trials.

There are a weakness and laxity in pubourethral and external urethral ligaments during postpartum which has an important role in the females' sexual function and quality of life. Some evidences showed that pelvic floor muscle training can strength pelvic muscles and prevent sexual dysfunction. Therefore, current study aimed to review the effect of pelvic floor exercise on female sexual function and quality of life in the postpartum period. PubMed, CINAHL, Medline, Scopus, Google scholar citations, Persian databases including SID and Iran Medex were searched using MeSH-based keywords to find published articles. Experimental and quasi-experimental studies in Persian and English were included. Data extracted was done in pre-defined checklist by two independent researchers. Risk of bias was assessed using the Cochrane Risk of Bias tool. Meta-Analysis of the data was carried out by "Comprehensive Meta-analysis Version 2" (CAM). The search resulted in 347 titles and abstracts, which were narrowed down to 12 potentially eligible articles. Pooled standardized differences in means (SMD) of sexual function in both pelvic floor exercise and control group were 0.462 [0.117 to 0.806], p = 0.009. The pooled SMD was 1.294 [0.926 to 1.663], p < 0001 for sexual quality of life. The pooled SMD was 0.232 [0.038-0.426], p = 0.019 for general quality of life. Evidences showed that pelvic floor muscle training in primi or multi-parous women can boost sexual function and quality of life in postpartum. Although the majority of studies and the result of meta-analysis reported positive results, more high-quality RCTs are needed in this area. One limitation of our study is significant heterogeneity because of different intervention method.

[What is the best exercise for rehabilitation of abdominal diastasis rehabilitation?] / ¿Cuál es el mejor ejercicio para la rehabilitación de la diástasis abdominal?

The aim of this study was to analyse the scientific literature to identify the different types of exercises that influence inter-rectus distance with a view to subsequently including them in the treatment of diastasis rectus abdominis. A search made in the CINHAL, PEDRo, Pubmed, and Scopus databases. Fourteen valid articles were included in the analysis. The articles were divided into 2 groups: those analysing exercise with an immediate effect and those presenting an exercise programme with a delayed effect (long term); the most commonly used exercise was the curl-up. There is a lack of consensus on the effects of the different types of exercises evaluated on inter-rectus distance. However, curl ups decrease inter-rectus distance when it is checked immediately. Abdominal muscle training through an exercise programme helps to reduce inter-rectus distance but the optimal exercises to include in an exercise programme remain to be elucidated.

Medication-Assisted Treatment Use Among Pregnant Women With Opioid Use Disorder.

OBJECTIVE: To evaluate temporal trends in medication-assisted treatment use among pregnant women with opioid use disorder. METHODS: We conducted a retrospective cohort study using Pennsylvania Medicaid administrative data. Trends in medication-assisted treatment use, opioid pharmacotherapy (methadone and buprenorphine) and behavioral health counselling, were calculated using pharmacy records and procedure codes. Cochrane-Armitage tests evaluated linear trends in characteristics of pregnant women using methadone compared with buprenorphine. RESULTS: In total, we evaluated 12,587 pregnancies among 10,741 women with opioid use disorder who had a live birth between 2009 and 2015. Across all years, 44.1% of pregnant women received no opioid pharmacotherapy, 27.1% used buprenorphine, and 28.8% methadone. Fewer than half of women had any behavioral health counseling during pregnancy. The adjusted prevalence of methadone use declined from 31.6% (95% CI 29.3-33.9%) in 2009 to 25.2% (95% CI 23.3-27.1%) in 2015, whereas the adjusted prevalence of buprenorphine use increased from 15.8% (95% CI 13.9-17.8%) to 30.9% (95% CI 28.8-33.0%). Greater increases in buprenorphine use were found in geographic regions with large metropolitan centers, such as the Southwest (plus 24.9%) and the Southeast (plus 12.0%), compared with largely rural regions, such as the New West (plus 5.2%). In 2015, the adjusted number of behavioral health counseling visits during pregnancy was 3.4 (95% CI 2.6-4.1) among women using buprenorphine, 4.0 (95% CI 3.3-4.7) among women who did not use pharmacotherapy, and 6.4 (95% CI 4.9-7.9) among women using methadone. CONCLUSION: Buprenorphine use among Medicaid-enrolled pregnant women with opioid use disorder increased significantly over time, with a small concurrent decline in methadone use. Behavioral health counseling use was low, but highest among women using methadone.

Diagnosis and rehabilitation of a pregnant woman with spinal cord disorder due to spinal cord tumor.

Introduction: Spinal cord tumors are a rare cause of spinal cord disorder (SCD). Early diagnosis can be challenging, especially in patient populations with other potential etiologies for back pain, such as pregnant women. Case presentation: A 28-year-old female presented at 8 weeks gestation with thoracic back pain initially diagnosed as gestational low back pain. Her symptoms progressed to lower extremity weakness. After diagnosis and resection of a spinal cord ependymoma, we collaborated with the inpatient interdisciplinary team to devise a rehabilitation program focused on minimizing pregnancy-related complications and optimizing care of a newborn in the setting of a new paraplegia. Discussion: Providers should not assume all pregnant women with low back pain have gestational back pain, as it can be due to more insidious causes. The rehabilitation course for women who develop an SCD during gestation should be carefully tailored toward their pre- and post-natal care and with the education of how the disorder can affect pregnancy and parenting.

Juggling identities of rheumatoid arthritis, motherhood and paid work - a grounded theory study.

PURPOSE: To explore how women with rheumatoid arthritis manage their illness, motherhood, and work life. METHODS: A constructivist, grounded theory approach based on individual interviews and participant observations with 20 women with rheumatoid arthritis who participated in work life and had children living at home or were pregnant. After initial and focused coding Goffman's concepts of social identity were applied. RESULTS: A core category: "Juggling meaningful identities" and three conceptual categories were developed: (1) Work life as the strongest identity marker; (2) Motherhood: a two-sided act; (3) Living with rheumatoid arthritis as an identity? Paid work, motherhood, and illness are linked to the women's social identities. The women construct and change their identities in interactions with children, partners, other parents, colleagues, and employers. CONCLUSION: The women attribute the highest priority to their professional identity, spending the majority of their time and energy in an effort to appear as "good stable workers". The disease is seen as a hindrance in this regard, and the illness identity is almost completely rejected. In motherhood, the women prioritize close interaction with their children, and deprioritize external activities. Extended outbreaks of the disease and issues regarding the children force the women to deprioritize working life. Implications for rehabilitation Juggling meaningful identities of rheumatoid arthritis, motherhood, and paid work challenge women in managing their everyday lives. Therefore, rehabilitation professionals should support individuals to develop new strategies to manage the challenges they experience regarding juggling motherhood and work ability. Work is a dominant identity marker for women with rheumatoid arthritis therefore, rehabilitation professionals have an important role to play in investigating possible ways for the individual to maintain employment or return to work. Living with rheumatoid arthritis and being a paid worker challenge women's role performance and thereby their identification as mothers. Therefore, rehabilitation professionals have to support the women and their families.

Adherence trajectories of buprenorphine therapy among pregnant women in a large state Medicaid program in the United States.

PURPOSE: Little is known about the longitudinal patterns of buprenorphine adherence among pregnant women with opioid use disorder, especially when late initiation, nonadherence, or early discontinuation of buprenorphine during pregnancy may increase the risk of adverse outcomes. We aimed to identify distinct trajectories of buprenorphine use during pregnancy, and factors associated with these trajectories in Medicaid-enrolled pregnant women. METHODS: A retrospective cohort study included 2361 Pennsylvania Medicaid enrollees aged 15 to 46 having buprenorphine therapy during pregnancy and a live birth between 2008 and 2015. We used group-based trajectory models to identify buprenorphine use patterns in the 40 weeks prior to delivery and 12 weeks postdelivery. Multivariable multinomial logistic regression models were used to identify factors associated with specific trajectories. RESULTS: Six distinct trajectories were identified. Four groups initiated buprenorphine during the first trimester of the pregnancy (early initiators): 31.6% with persistently high adherence, 15.1% with moderate-to-high adherence, 10.5% with declining adherence, and 16.7% with early discontinuation. Two groups did not initiate buprenorphine until midsecond or third trimester (late initiators): 13.5% had moderate-to-high adherence and 12.6% had low-to-moderate adherence. Factors significantly associated with late initiation and discontinuation were younger age, non-white race, residents of rural counties, fewer outpatient visits, more frequent emergency department visits and hospitalizations, and lower buprenorphine daily dose. CONCLUSIONS: Six buprenorphine treatment trajectories during pregnancy were identified in this population-based Medicaid cohort, with 25% of women initiating buprenorphine late during pregnancy. Understanding trajectories of buprenorphine use and factors associated with discontinuation/nonadherence may guide integration of behavioral treatment with obstetrical/gynecological care to improve buprenorphine treatment during pregnancy.

Use of Kratom, an Opioid-like Traditional Herb, in Pregnancy.

BACKGROUND: Kratom (Mitragyna speciosa) is an herbal preparation with opioid-like effects made from a tree native to Southeast Asia and the Pacific Islands. Increasingly, kratom is used for self-treatment of opioid use disorder and recently has been associated with a multistate outbreak of salmonellosis. Few data are available on the clinical outcomes of kratom use in pregnancy. CASES: We present two cases of pregnant women presenting with kratom dependence. Both women presented with symptoms consistent with opioid withdrawal. Both women were initiated on opioid replacement, with successful treatment of symptoms. CONCLUSIONS: Kratom is an emerging self-treatment for opioid use disorder in the obstetric population. Obstetric care providers should be aware of kratom and consider opioid replacement for pregnant women with kratom dependence.

Pregnancy and Naltrexone Pharmacotherapy.

A 25-year-old woman, gravida 3 para 2 at 12 weeks of gestation, with two prior cesarean deliveries, presents for prenatal care. She is in treatment for opioid use disorder on extended-release naltrexone injection, with a history of opioid overdose, relapse, and poor treatment adherence on methadone and buprenorphine. She asks, "Is it safe for my baby if I continue on this medication? How will you manage my postoperative pain?"

Determining the Initiation of Opiate Misuse Resulting in Opioid Use Disorder in Pregnant Women.

The aim of this study was to explore the "opiate misuse footprint" made by obstetrics and gynecology physicians in prescribing opioid medications for postpartum pain control that led to opioid misuse and opioid use disorder. Data were collected using intake information and anonymous surveys administered to pregnant women at local methadone clinics in Indianapolis, Indiana, in 2016-2017. Results from this study revealed that 40% of the 33 participants stated that the first drug they became addicted to was prescription opioids; 71% stated that the first opiate they became addicted to was a prescription pain medication. Prescription opioids were mainly obtained from emergency medicine physicians and friends. Reported use of opioids within the past four months was high, with the most commonly used drugs being methadone (57.6%) and heroin (42.4%). A majority of participants also endorsed a history of sexual and physical abuse, recent incarceration, and mental health disorders. As a large number of pregnant women with opioid use disorder reported their initial drug of misuse as prescription pain medications, it is important to avoid overprescribing opioids in reproductive-age women.

"People in regular society don't think you can be a good mother and have a substance use problem": Participatory action research with women with substance use in pregnancy.

OBJECTIVE: To work collaboratively with women accessing an integrated program for women with substance use in pregnancy to learn how services can be improved. DESIGN: Qualitative design using focus groups within a participatory action framework. SETTING: Sheway, a program located in the Downtown Eastside of Vancouver, BC. PARTICIPANTS: A total of 21 co-researchers who were women who had accessed Sheway services. METHODS: Semistructured focus groups were recorded and transcribed. Data analysis was iterative and reviewed weekly with focus group members. Themes were member checked and reviewed with co-researchers. The action phase of the project involved the co-researchers presenting their main findings to the Sheway staff members. The staff and women worked collaboratively to implement client-directed changes to the program. MAIN FINDINGS: Co-researchers described Sheway as family. They expressed concern about transitioning from the program to other community services and identified stereotypes and negative treatment by health care providers as barriers to their transition out of the program. One action project developed by the co-researchers was a "transition group" where women could connect to current and former Sheway clients. The women could retain the social support they gained through Sheway while learning about other resources. The co-researchers also prioritized developing peer-to-peer mentorship to support new clients. The findings of the research were disseminated to Sheway staff, the Department of Family Practice at the University of British Columbia, and local family medicine maternity care providers with the hope of improving care for women with substance use in pregnancy. CONCLUSION: A participatory action framework allowed women to engage as co-researchers. The co-researchers emphasized the importance of relationships and a sense of family with other women as well as providers as positive aspects of their care. Women involved in this project identified negative attitudes of health care providers toward substance use in pregnancy as barriers. Co-researchers proposed transition support and peer-to-peer networking as action projects to improve their care.