Benzodiazepines in Pregnancy.

Benzodiazepine use and dependence are on the rise as well as the number of deaths attributable to the combination of opioids and benzodiazepines. Anxiety, the most frequent condition for which benzodiazepines are prescribed, occurs commonly, and is increasingly noted to coincide with pregnancy. Use of both benzodiazepine anxiolytics and anxiety in pregnancy is associated with preterm delivery and low birth weight. Short-term neonatal effects of hypotonia, depression, and withdrawal are described but long-term sequelae, if any, are poorly understood. Benzodiazepines are associated with physical dependence and withdrawal symptoms which can be serious. To avoid withdrawal, tapering off these medications is recommended. What is known about the pharmacology and pharmacokinetics, pregnancy implications, tapering schedules, and alternative strategies for anxiety are discussed.

Buprenorphine Versus Methadone for Opioid Dependence in Pregnancy.

OBJECTIVE: To evaluate maternal and neonatal safety outcomes for methadone and buprenorphine in the obstetric population. DATA SOURCES: A literature search of PubMed (1966 to March 2016) and EMBASE (1973 to March 2016) was completed using the search terms buprenorphine, methadone, pregnancy, opioid, and neonatal abstinence syndrome Priority was given to randomized controlled trials and trials directly comparing buprenorphine and methadone during pregnancy. The bibliographies were reviewed for other relevant articles. STUDY SELECTION AND DATA EXTRACTION: All human studies published in English, that compared methadone and buprenorphine use in pregnancy were evaluated. Because of the limited number of obstetric studies, only 5 critical studies were found. DATA SYNTHESIS: Buprenorphine significantly improved or had similar outcomes to methadone for development of neonatal abstinence syndrome (NAS), percentage of infants requiring treatment for NAS (20%-47% vs 45.5%-57%, respectively), total amount of morphine used to treat NAS (0.472-3.4 vs 1.862-10.4 mg, respectively), duration of NAS (4.1-5.6 vs 5.3-9.9 days, respectively), peak NAS (3.9-11 vs 4.9-12.8 score, respectively), infant hospital stay (6.8-10.6 vs 8.1-17.5 days, respectively), and gestational age at delivery (38.8-39.7 vs 37.9-38.8 weeks, respectively). No difference was found with other neonatal or maternal outcomes. CONCLUSIONS: Both methadone and buprenorphine are effective agents, with improved safety compared with continued nonmedical opioid use during pregnancy. There is evidence to suggest that buprenorphine should be considered as an equivalent option to methadone for use in pregnancy; however, larger studies are still needed to fully evaluate buprenorphine safety and advantages over methadone in the obstetric population.

Yoga in Pregnancy.

Yoga is a mind-body practice that encompasses a system of postures (asana), deep breathing (pranayama), and meditation. Over 36 million Americans practice yoga of which the majority are reproductive-aged women. Literature to support this practice is limited, albeit on the rise. A prenatal yoga practice has been shown to benefit women who suffer from anxiety, depression, stress, low back pain, and sleep disturbances. A small number of studies have been performed in high-risk pregnancies that also demonstrate an improvement in outcomes. The safety of performing yoga for the first time in pregnancy and fetal tolerance has been demonstrated.

Transvaginal cervical length and amniotic fluid index: can it predict delivery latency following preterm premature rupture of membranes?

OBJECTIVE: We sought to determine whether transvaginal cervical length (TVCL), amniotic fluid index (AFI), or a combination of both can predict delivery latency within 7 days in women presenting with preterm premature rupture of membranes (PPROM). STUDY DESIGN: This was a prospective observational study of TVCL measurements in 106 singleton pregnancies with PPROM between 23-33 weeks. Delivery latency was defined as the period (in days) from the initial TVCL after PPROM to delivery of the infant, with our primary outcome being delivery within 7 days of TVCL. The independent predictability of significant characteristics for delivery within 7 days was determined using multiple logistic regression. Sensitivity, specificity, and predictive values were used to examine whether the presence of a short TVCL, AFI, or a combination of both affected the risk of delivery within 7 days. RESULTS: Delivery within 7 days occurred in 51/106 (48%) of pregnancies. Median duration (interquartile range) from PPROM to delivery and TVCL to delivery was 8 days (4.0-16.0) and 8 days (3.0-15.0), respectively. Using multiple regression TVCL as a continuous variable (odds ratio, 0.65; 95% confidence interval, 0.44-0.97; P < .05), AFI ≤5 cm (odds ratio, 4.69; 95% confidence interval, 1.58-13.93; P < .01) were determined to be independent predictors of delivery within 7 days. In all, 42 women (40%) had a TVCL ≤2 cm, while 62 (59%) had AFI ≤5 cm. A total of 26 women (25%) had a combination of both TVCL ≤2 cm and AFI ≤5 cm, while 28 women (27%) had neither characteristic. The predictive value of delivery within 7 days for a TVCL ≤2 cm was 62%, and for an AFI ≤5 cm was 58%. Having a combination of low TVCL and low AFI did not increase the predictive value of delivery within 7 days (58%). In contrast, only 3 of 27 women (11%) with neither characteristic delivered within 7 days. The predictive value of delivery >7 days for TVCL >2 cm alone was 61%. This predictive value changed when analyzed in conjunction with an AFI ≤5 cm and >5 cm at 42% and 89%, respectively. CONCLUSION: A shorter TVCL and an AFI ≤5 cm independently predict delivery within 7 days in women presenting with PPROM. The combination of an AFI >5 cm and TVCL >2 cm greatly improved the potential to remain undelivered at 7 days following cervical length assessment. These findings may be helpful for counseling and optimizing maternal and neonatal care in women with PPROM.

Reduction of opioid utilization after vaginal delivery with an electronic health record intervention.

BACKGROUND: The national epidemic of opioid misuse has focused its attention on postpartum analgesic usage. Adequate pain control achieved with nonopioid pain medications and conservative measures could reduce the number of opioid pain medications available for misuse and diversion. Interventions that decrease inpatient opioid use after delivery could reduce the potential for chronic dependence in postpartum women. Modification of preloaded electronic order sets to decrease opioid administration has successfully reduced opioid use following a major abdominal surgery, including cesarean delivery. However, interventions to reduce opioid use following vaginal delivery are not well described. OBJECTIVE: We aimed to evaluate the effect of removing opioid medications from postpartum order sets on medication usage following vaginal delivery. STUDY DESIGN: We performed a retrospective cohort study of women undergoing a singleton vaginal delivery at an academic tertiary care center. Our institution removed opioid medications from postpartum order sets in April 2018. We compared the following 2 delivery cohorts: the "preintervention" cohort (April 2016-March 2018) and the "postintervention" cohort (June 2018-July 2018). The primary outcome was postpartum opioid use. The secondary outcomes were nonopioid analgesic use and discharge with an opioid prescription. We compared the demographic and obstetrical data, self-reported pain scores, and postpartum analgesic usage between groups. We determined that a minimum of 138 patients would be needed in each group to identify a 20% decrease in opioid usage (α=.05; ß=.2). RESULTS: We analyzed 276 subjects: 138 in the preintervention group and 138 in the postintervention group. The postintervention group was older and more likely to have an operative vaginal delivery. Otherwise, groups had similar demographic and obstetrical characteristics. Postpartum opioid use decreased from 56% in the preintervention group to 16% in the postintervention group, a 71% reduction (P<.001). The incidence of severe pain score (>7) was similar between groups with a median occurrence of 1 (interquartile range, 0-4) for both (P=.7). The number of opioid discharge prescriptions among those receiving inpatient opioids was significantly lower in the postintervention group than in the preintervention group (18% vs 38%, respectively), a 53% decrease (P<.001). CONCLUSION: Removal of opioids from the postpartum order set was associated with lower rates of opiate usage following vaginal delivery in a single center without changing the frequency of severe pain scores. This simple intervention has the potential to reduce opioid exposure.

Recurrent preeclampsia: the effect of weight change between pregnancies.

OBJECTIVE: To estimate whether the risk of recurrent preeclampsia is affected by interpregnancy change in body mass index (BMI). METHODS: We conducted a population-based cohort study using Missouri maternally linked birth certificates for 17,773 women whose first pregnancies were complicated by preeclampsia. The women were placed into three groups: those who decreased their BMIs, those who maintained their BMIs, and those who increased their BMIs between their first two pregnancies. The primary outcome was recurrent preeclampsia in the second pregnancy. Adjusted risk ratios and 95% confidence intervals were calculated using Poisson regression analysis. RESULTS: The overall rate of recurrent preeclampsia in women who decreased their BMIs between pregnancies was 12.8% (risk ratio 0.70, confidence interval 0.60-0.81) compared with 14.8% if BMI was maintained and 18.5% in those who increased their BMIs (risk ratio 1.29, confidence interval 1.20-1.38). Within the normal weight, overweight, and obese weight categories, women who decreased BMI between pregnancies were less likely to experience recurrent preeclampsia. Women in all weight categories who increased their BMIs between pregnancies were more likely to experience recurrent preeclampsia. CONCLUSION: Interpregnancy weight reduction decreases the risk of recurrent preeclampsia and should be encouraged in women who experience preeclampsia. LEVEL OF EVIDENCE: II.

The combined effect of maternal smoking and obesity on the risk of preeclampsia.

AIMS: Cigarette smoking during pregnancy is associated with a lower risk of preeclampsia, whereas obesity increases the risk of preeclampsia. We sought to assess the combined effect of smoking and obesity on the risk of preeclampsia. METHODS: We conducted a population-based cohort study of 129,674 women who delivered singleton infants during 2000-2001. Data for cigarette use, pre-pregnancy body mass index (BMI), preeclampsia, and potential confounders were obtained from birth certificate files. Mantel-Haenszel stratified analysis and logistic regression were used to analyze the data. RESULTS: The preeclampsia risk was 3.1, 4.5, 7.6 and 8.8% for normal weight (BMI 18.5-24.9), overweight (25.0-29.9), obese (30.0-39.9) and morbidly obese (>or=40.0 kg/m2) women, respectively, who smoked cigarettes while pregnant. The preeclampsia risk was 3.9, 6.2, 9.0 and 12.3% for the same groups of women, respectively, who did not smoke during their pregnancy. Compared to non-smokers, the relative risk of preeclampsia for women who smoked cigarettes was 0.78 (95% confidence interval 0.73-0.83) before and after adjusting for pre-pregnancy BMI and other factors associated with preeclampsia. CONCLUSION: The risk of preeclampsia is lower for women who smoke cigarettes while pregnant regardless of their pre-pregnancy BMI.

Visual attention in preschool children prenatally exposed to cocaine: implications for behavioral regulation.

The presence of cocaine during the prenatal period disrupts the development of neural systems involved in mediating visual attention; therefore, it is possible that prenatal cocaine exposure results in impairments in visual attention in early childhood. In the current study we hypothesized that preschool children with prenatal cocaine exposure would exhibit difficulties in the disengagement operation of visual attention and in sustaining attention, particularly for targets presented in the right visual field. Fourteen cocaine-exposed children and 20 control children between 14 and 60 months of age were assessed on measures of visual attention, cognition, and behavior. Cocaine-exposed children had slower reaction times on disengagement trials in the second half of our attention task, supporting our hypotheses that impairments in disengagement and sustained attention are associated with prenatal cocaine exposure. There was a trend for slower reaction times to targets presented in the right visual field, but not to targets presented in the left visual field. Cocaine-exposed children also exhibited greater difficulties in behavioral regulation. Overall, our findings suggest that children with prenatal cocaine exposure demonstrate specific impairments in visual attention and behavioral regulation.