Sexual Abuse as a Risk Factor for Opioid Misuse in Pregnancy.

The purpose of this study was to identify a potential relationship between childhood sexual abuse and opioid misuse in pregnancy and to illustrate the need for better integration and collaboration between the medical and psychological disciplines to combat the opioid crisis. We sampled 93 pregnant women at a high-risk pregnancy clinic within a university medical center who were in their second trimester or beyond. Fifty-five women were considered high-risk due to opioid misuse and 38 women were considered high-risk due to medical reasons other than drug use. Our findings reveal both presence of and severity of sexual abuse were significantly associated with opioid misuse in pregnancy, while physical abuse, emotional abuse, and neglect were not. While childhood sexual abuse is a significant risk factor for opioid misuse in pregnancy, most doctors do not feel comfortable asking about trauma history. A public health approach to opioid misuse in pregnancy must consider how "diseases of despair" disproportionately impact women with limited access to adequate psychological and medical care. A preventative model of care, which targets screenings for ACEs in primary care and gynecological visits may help decrease the impact of sexual abuse.

Using a consumer-based wearable activity tracker for physical activity goal setting and measuring steps in pregnant women with gestational diabetes mellitus: exploring acceptance and validity.

BACKGROUND: Activity monitoring devices may be used to facilitate goal-setting, self-monitoring, and feedback towards a step-based physical activity (PA) goal. This study examined the performance of the wrist-worn Fitbit Charge 3™ (FC3) and sought opinions on walking and stepping-in-place from women with gestational diabetes (GDM). METHODS: Participants completed six 2-min metronome-assisted over ground bouts that varied by cadence (67, 84, or 100 steps per minute) and mode (walking or stepping-in-place; N = 15), with the sequence randomized. Steps were estimated by FC3 and measured, in duplicate, by direct observation (hand-tally device, criterion). Equivalence testing by the two one-sided tests (TOST) method assessed agreement within ± 15%. Mean absolute percent error (MAPE) of steps were compared to 10%, the accuracy standard of the Consumer Technology Association (CTA)™. A subset (n = 10) completed a timed, 200-m self-paced walk to assess natural walking pace and cadence. All participants completed semi-structured interviews, which were transcribed and analyzed using descriptive and interpretive coding. RESULTS: Mean age was 27.0 years (SD 4.2), prepregnancy BMI 29.4 kg/m2 (8.3), and gestational age 32.8 weeks (SD 2.6). The FC3 was equivalent to hand-tally for bouts of metronome-assisted walking and stepping-in-place at 84 and 100 steps per minute (i.e., P < .05), although walking at 100 steps per minute (P = .01) was no longer equivalent upon adjustment for multiple comparisons (i.e., at P < .007). The FC3 was equivalent to hand-tally during the 200-m walk (i.e., P < .001), in which mean pace was 68.2 m per minute (SD 10.7), or 2.5 miles per hour, and mean cadence 108.5 steps per minute (SD 6.5). For walking at 84 and 100 steps per minute, stepping-in-place at 100 steps per minute, and the 200-m walk, MAPE was within 10%, the accuracy standard of the CTA™. Interviews revealed motivation for PA, that stepping-in-place was an acceptable alternative to walking, and competing responsibilities made it difficult to find time for PA. CONCLUSIONS: The FC3 appears to be a valid step counter during the third trimester, particularly when walking or stepping-in-place at or close to women's preferred cadence.

High prevalence of Group B Streptococcus colonization among pregnant women in Amman, Jordan.

BACKGROUND: Little is known of the burden of Group B Streptococcus (GBS) colonization among pregnant women in Jordan. We conducted a pilot study to determine the prevalence of GBS among pregnant women in Amman, Jordan, where GBS testing is not routine. We also explored GBS serotypes and the performance of a rapid GBS antigen diagnostic test. METHODS: We collected vaginal-rectal swabs from women who presented for labor and delivery at Al-Bashir Hospital. Three methods were used to identify GBS: Strep B Rapid Test (Creative Diagnostics), blood agar media (Remel) with confirmed with BBL Streptocard acid latex test (Becton Dickinson), and CHROMagar StrepB (Remel). Results were read by a senior microbiologist. We defined our gold standard for GBS-positive as a positive blood agar culture confirmed by latex agglutination and positive CHROMagar. PCR testing determined serotype information. Demographic and clinical data were also collected. RESULTS: In April and May 2015, 200 women were enrolled with a median age of 27 years (IQR: 23-32); 89.0% were Jordanian nationals and 71.9% completed secondary school. Median gestational age was 38 weeks (IQR: 37-40); most women reported prenatal care (median 9 visits; IQR: 8-12). Median parity was 2 births (IQR: 1-3). Pre-pregnancy median BMI was 24.1 (IQR: 21.5-28.0) and 14.5% reported an underlying medical condition. Obstetric complications included gestational hypertension (9.5%), gestational diabetes (6.0%), and UTI (53.5%), of which 84.5% reported treatment. Overall, 39 (19.5%) of women were GBS-positive on blood agar media and CHROMagar, while 67 (33.5%) were positive by rapid test (36% sensitivity, 67% specificity). Serotype information was available for 25 (64%) isolates: III (48%), Ia (24%), II (20%), and V (8%). No demographic or clinical differences were noted between GBS+ and GBS-negative women. CONCLUSIONS: Nearly one in five women presenting for labor in Jordan was colonized with GBS, with serotype group III as the most common. The rapid GBS antigen diagnostic had low sensitivity and specificity. These results support expanded research in the region, including defining GBS resistance patterns, serotyping information, and risk factors. It also emphasizes the need for routine GBS testing and improved rapid GBS diagnostics for developing world settings.

Maternal immunization: opportunities for scientific advancement.

Maternal immunization is an effective strategy to prevent and/or minimize the severity of infectious diseases in pregnant women and their infants. Based on the success of vaccination programs to prevent maternal and neonatal tetanus, maternal immunization has been well received in the United States and globally as a promising strategy for the prevention of other vaccine-preventable diseases that threaten pregnant women and infants, such as influenza and pertussis. Given the promise for reducing the burden of infectious conditions of perinatal significance through the development of vaccines against relevant pathogens, the Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH) sponsored a series of meetings to foster progress toward clinical development of vaccines for use in pregnancy. A multidisciplinary group of stakeholders convened at the NIH in December 2013 to identify potential barriers and opportunities for scientific advancement in maternal immunization.

Vaccine Hesitancy in Women's Health.

The development of vaccines is considered one of the greatest breakthroughs of modern medicine, saving millions of lives around the world each year. Despite vaccines' proven success, vaccine hesitancy remains a major issue affecting vaccine uptake. Common themes exist in patients' apprehension to receive vaccines. Women's health providers possess an important role in addressing these concerns and dispelling common misconceptions that may increase vaccine hesitancy thereby reduce vaccine uptake. This review aims to explore many of these topics as they are related to women's health and provide strategies for providers to implement which may reduce vaccine hesitancy among our patients.

Individual-level determinants of COVID-19 vaccination in pregnant people in East Tennessee.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) infection during pregnancy increases the risk of severe illness and death. This study describes individual-level determinants of COVID-19 vaccination among pregnant people in East Tennessee. METHODS: Advertisements for the online Moms and Vaccines survey were placed in prenatal clinics in Knoxville, Tennessee. Determinants were compared between unvaccinated individuals and those partially or fully vaccinated for COVID-19. RESULTS: Wave 1 of the Moms and Vaccines study included 99 pregnant people: 21 (21.2%) were unvaccinated and 78 (78.8%) were partially or fully vaccinated. Compared with the unvaccinated individuals, the partially or fully vaccinated patients more often obtained information about COVID-19 from their prenatal care provider (8 [38.1%] vs. 55 [70.5%], P = 0.006) and indicated higher levels of trust in that information (4 [19.1] vs. 69 [88.5%], P < 0.0001). Misinformation was higher in the unvaccinated group overall, although there was no difference in concern for the severity of COVID-19 infection during pregnancy by vaccination status (1 [5.0%] of the unvaccinated vs. 16 [20.8%] of the partially or fully vaccinated, P = 0.183). CONCLUSION: Strategies to counter misinformation are of the utmost importance, particularly pregnancy- and reproductive health-related misinformation, because of the increased risk of severe disease faced by unvaccinated pregnant individuals.

Association of cord blood methylation fractions at imprinted insulin-like growth factor 2 (IGF2), plasma IGF2, and birth weight.

PURPOSE: Altered methylation at Insulin-like Growth Factor 2 (IGF2) regulatory regions has previously been associated with obesity, and several malignancies including colon, esophageal, and prostate adenocarcinomas, presumably via changes in expression and/or loss of imprinting, but the functional significance of these DNA methylation marks have not been demonstrated in humans. We examined associations among DNA methylation at IGF2 differentially methylated regions (DMRs), circulating IGF2 protein concentrations in umbilical cord blood (UCB) and birth weight in newborns. METHODS: Questionnaire data were obtained from 300 pregnant women recruited between 2005 and 2009. UCB DNA methylation was measured by bisulfite pyrosequencing. UCB plasma concentrations of soluble IGF2 were measured by ELISA assays. Generalized linear regression models were used to examine the relationship between DMR methylation and IGF2 levels. RESULTS: Lower IGF2 DMR methylation was associated with elevated plasma IGF2 protein concentrations (ß = -9.87, p < 0.01); an association that was stronger in infants born to obese women (pre-pregnancy BMI > 30 kg/m(2), ß = -20.21, p < 0.0001). Elevated IGF2 concentrations were associated with higher birth weight (p < 0.0001) after adjusting for maternal race/ethnicity, pre-pregnancy BMI, cigarette smoking, gestational diabetes, and infant sex. These patterns of association were not apparent at the H19 DMR. CONCLUSION: Our data suggest that variation in IGF2 DMR methylation is an important mechanism by which circulating IGF2 concentrations, a putative risk factor for obesity and cancers of the colon, esophagus, and prostate, are modulated; associations that may depend on pre-pregnancy obesity.

To Be Active or to Stop? A Cross-Sectional Retrospective Study Exploring Provider Advice and Patient Fears Surrounding Physical Activity in Pregnancies Complicated by Fetal Growth Restriction.

Exercise guidance for women with pregnancies complicated by fetal growth restriction (FGR) is vague, despite the fact that physical activity during pregnancy improves placental development, placental blood flow, and encourages healthy fetal growth. The goal of this study is to test the hypothesis that women with pregnancies complicated by FGR are fearful of physical activity and are being given unclear or limited advice from healthcare providers. Participants (N = 78) (women who delivered an infant diagnosed with FGR within the past 5 years) took an electronic survey including demographic information, pregnancy information, provider advice recall, and other health-related information relevant to growth-restricted pregnancies. Quantitative and qualitative (post-positivism paradigm) methods were employed to analyze the data. When asked specifically about how the FGR diagnosis impacted their activity levels, nearly 50% of participants said the diagnosis led them to decrease their activity levels. Participants reported that healthcare providers who do discuss activity with pregnant patients with FGR suggest low-intensity activities or ceasing activity, although the majority of providers did not discuss activity at all. More fears surrounding physical activity were reported post-FGR diagnosis, including worrying about fetal growth and development and causing fetal harm when engaging in physical activity.

Physical activity for blood glucose control in gestational diabetes mellitus: rationale and recommendations for translational behavioral interventions.

Gestational Diabetes Mellitus (GDM) is associated with adverse health outcomes during pregnancy and beyond. Previous randomized controlled trials of exercise interventions have demonstrated that exercise, conducted primarily during supervised sessions, improves maternal glycemic control in women with GDM. However, additional research is needed to develop physical activity interventions that are easily implemented in healthcare settings (e.g., recommendations and strategies to increase non-supervised physical activity). This narrative review presents: current physical activity recommendations for pregnancy and women with GDM; the scientific literature to date on physical activity, particularly walking, and blood glucose control in GDM; rationale for physical activity interventions targeting women with GDM that are appropriate for translation to the clinical setting (e.g., lifestyle interventions that include behavioral counseling with a health coach); and the strategies employed by previous, successful lifestyle interventions for pregnant and postpartum women that were based in clinical settings.Most previous exercise interventions for blood glucose control in women with GDM have included supervised exercise sessions, and will thus be difficult to translate to the health care system. However, lifestyle interventions for weight maintenance (i.e., healthy diet and physical activity) set in the health care system and delivered by health coaches have been successfully implemented in pregnant and postpartum populations. Therefore, we suggest that future trials examine lifestyle interventions that promote unsupervised walking with evidence-based behavioral strategies (e.g., goal setting, monitoring, and feedback) and consider incorporating the use of physical activity tracking devices to support these strategies.

Metabolic Flexibility and Weight Status May Contribute to Inter-Individual Changes in Breastmilk Lipid Content in Response to an Acute Bout of Exercise: Preliminary Findings from a Pilot Study.

The purposes of this pilot study were to describe changes in breastmilk lipid content in response to an acute bout of moderate intensity exercise and to explore maternal metabolic health factors, including metabolic flexibility, which may impact this change. A cross-sectional, observational, pilot study design was performed in 14 women between 4 and 6 months postpartum. Whole body fasting lipid oxidation was assessed, a standardized high-fat breakfast was consumed, and lipid oxidation was again measured 120-minutes post-meal. Metabolic flexibility was determined by comparing the change in lipid oxidation before and after the meal. Women completed 30-minutes of moderate intensity treadmill walking 150-minutes post-meal. Breastmilk was expressed and analyzed for lipid content before and after exercise. Overall, there was no significant difference between pre- and post-exercise breastmilk lipid content (pre-exercise 59.4±36.1 g/L vs. post-exercise 52.5±20.7 g/L, p=0.26). However, five (36%) women had an increase in breastmilk lipid content in response to the exercise bout, compared to nine (64%) that had a decrease in breastmilk lipid content suggesting inter-individual variability. The change in breastmilk lipid content from pre- to post-exercise was positively correlated to metabolic flexibility (r=0.595, p=0.03). Additionally, post-exercise lipid content was positively correlated with body mass index (BMI), body composition, and postpartum weight retention. Preliminary findings from this pilot study suggest that metabolic flexibility and maternal weight status may help explain the inter-individual changes in breastmilk lipid content in response to an acute bout of moderate intensity exercise.

Opioid use in pregnancy: Borderline features and Hepatitis C virus.

This study examined the relationship between borderline personality disorder assessed as self-reported borderline features (Morey, 1991), opioid use, and Hepatitis C virus (HCV) in pregnant women. There were 55 women in the opioid use group and 38 in the comparison group who were at high risk due to medical issues that did not include drug use. Women were in their 2nd or 3rd trimester. All women received Medicaid and were racially representative of the geographic area (84% White). We assessed opioid use severity from medical records based on urine assays and prescriptions for opioids. The results revealed that women who scored in the clinical range of total borderline features, which is associated with a diagnosis of borderline personality disorder (Trull, 1995), had 2.83 greater odds of being opioid users (prescribed and nonprescribed) than had individuals below the cutoff. The borderline features of affective instability, identity disturbance, negative relationships, and self-harm/impulsivity were significantly correlated with opioid use severity. Negative relationships and self-harm/impulsivity contributed significant variance in opioid use severity over and above affective instability and identity disturbance. Women in the clinical range of borderline features were more likely to have HCV than were women below the cutoff, and the borderline feature of negative relationships specifically was associated with HCV. We discuss implications for interventions to address negative relationships and self-harm/impulsivity and interventions to help prevent opioid misuse in women before they become pregnant. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Medication-assisted treatment vs. detoxification for women who misuse opioids in pregnancy: Associations with dropout, relapse, neonatal opioid withdrawal syndrome (NOWS), and childhood sexual abuse.

The American College of Obstetricians and Gynecologists recommends medication-assisted treatment (MAT) for pregnant women who misuse opioids rather than detoxification because of possible relapse and dropout from treatment (ACOG, 2017). In a prospective study, fifty-five pregnant women with an opioid use disorder were offered a choice of MAT or detoxification. Ethical concerns precluded random assignment. We assessed dropout, treatment outcome, relapse, other illicit drug use, infant neonatal opioid withdrawal syndrome (NOWS), and childhood sexual abuse. Of 55 women, 13 initially chose MAT and 42 women chose detoxification. All women received behavioral support. No one dropped out of treatment prior to delivery. All women who chose MAT initially remained on MAT. Of women who chose detoxification, 23% switched to MAT, 30% tapered below initial MAT doses, and 45% fully detoxified by delivery. There was a significant difference in opioid relapse between women on MAT (26%) and those who detoxified (0%), but no differences for other illicit drug use. Infants of women on MAT were more likely to have neonatal NOWS (91%) than infants of women who tapered below initial MAT doses but did not fully detoxify (62%). Infants of mothers who tapered (62%) were more likely to have NOWS than infants of women who fully detoxified (0%). Women on MAT reported significantly lower sexual abuse severity than did women who tapered or detoxified. It is critical to replicate the current findings and to follow up with mothers and their infants postpartum to ascertain the long-term impact of tapering or detoxification during pregnancy.

Pregnant women's history of childhood maltreatment and current opioid use: The mediating role of reflective functioning.

There is an association between the experience of childhood maltreatment and opioid misuse in adults, especially for women. However, we know little about this association in pregnancy, and less about processes that could be the target of interventions to help women better parent their infants. We examined reflective functioning as a putative process. Reflective functioning is the ability to interpret one's own and others' behavior in terms of underlying mental states, e.g., emotions, motivations, and beliefs. We sampled 55 pregnant women who misused opioids and 38 women at high risk due to medical factors, e.g., heart disease. We assessed maltreatment with the Maltreatment and Abuse Chronology of Exposure (MACE; Teicher & Parigger, 2015), and reflective functioning with the Reflective Functioning Questionnaire (RFQ; Fonagy et al., 2016). Maltreatment variables included the sum of severity across all subtypes, number of subtypes experienced, and severity of sexual, physical, and emotional abuse, and of neglect. We created a categorical opioid user group variable: women who used opioids in pregnancy vs. high-risk medical comparisons. We found that women who used opioids in pregnancy had poorer reflective functioning than did high-risk medical comparisons. We also created an opioid use severity scale (ranging from 0 to 3) from urine assays and history of prescribed opioids from medical records. Using Hayes (2012)'s bootstrapping PROCESS macro, we found that reflective functioning mediated the association between all maltreatment variables and opioid use severity. We discuss the results in terms of how best to intervene to improve women's reflective functioning, which may help their ability to parent.

Infant follow-up postdelivery from a hepatitis C viral load positive mother.

Objective: The primary current recommendation for infant follow-up postdelivery from a hepatitis C virus (HCV) viral load positive mother is to evaluate for the presence of antibody at or after 18 months of age. Our study objective was to analyze compliance with this recommendation for postdelivery infant HCV screening at our institution among a cohort of infants delivered from HCV viral load positive mothers. Methods: Starting 1 January, 2015, a prospective database was developed for all pregnancies that involved mothers with a positive HCV viral load during pregnancy. This short report describes the infant follow-up for deliveries through 30 June, 2016. At hospital discharge, all neonates were given follow-up pediatric appointments and mothers were supplied the date and time of the appointment along with the pediatric group name, office directions, and phone number. Statistics involved simple percentages with Poisson binomial 95% confidence intervals. Results: A total of 127 newborns were delivered of HCV viral load positive mothers during the study period and 55 (43%, 95% CI 35-52%) attended their pediatric appointments and were still in follow-up. Regarding the 72 cases (57%, 95% CI 48-65%) not in follow-up, 24 (19%, 95% CI 13-27%) never presented to care and 48 (38%, 95% CI 29-47%) came to one or two visits shortly after delivery but were absent for further follow-up. Conclusions: These data demonstrate that follow-up at 18 months postdelivery from an HCV viral load positive mother occurs in less than half of the cases and alternative screening strategies should be evaluated.

Neonatal Head Circumference in Newborns With Neonatal Abstinence Syndrome.

OBJECTIVES: To compare head circumference (HC) in neonates treated for neonatal abstinence syndrome (NAS) with control neonates without antenatal opioid exposure. METHODS: Our prospective cohort study ran from April 1, 2014, through December 31, 2016. Newborns treated for NAS delivered from well-dated pregnancies ≥34 weeks' gestation were compared with newborns who were nonopioid exposed and matched for race, parity, mode of delivery, and gestational age. All mothers underwent serial antenatal urine drug testing. A minimum of 754 study participants were needed (377 in each group) to demonstrate an increase in the proportion of newborns with HCs less than or equal to the 10th percentile from 10% in controls to a minimum of 20% in NAS newborns with 90% power. RESULTS: A total of 858 neonates were enrolled (429 NAS cases and 429 controls). Mean HC for cases was 33.04 cm (±1.9 cm) compared with 33.99 cm (±2.0 cm) for controls (P < .0001). Among the 429 NAS cases, the mothers of 372 (87%) were on opioid medication-assisted treatment. For NAS cases, 30.1% (95% confidence interval: 25.8%-34.7%) had an HC less than or equal to the 10th percentile (129 of 429 neonates), and 8.2% (95% confidence interval: 5.8%-11.2%) had an HC less than or equal to the third percentile (35 of 429 neonates). Multivariate analysis was used and determined that only chronic opioid use during gestation resulting in a neonate who was NAS treated was a significant risk factor for the observed smaller HC. CONCLUSIONS: Chronic opioid use during pregnancy sufficient to cause NAS was associated with smaller HCs at birth. Most mothers were on opioid agonist medication-assisted treatment, which is currently the recommended treatment option during pregnancy.

Dyspnea in Pregnancy: A Case Report of a Third Trimester Mediastinal Mass in Pregnancy.

BACKGROUND Dyspnea in pregnancy is common and attributable to a variety of etiologies including normal physiology. The obstetric provider is challenged with distinguishing between physiologic versus pathologic dyspnea. CASE REPORT A 31-year-old G2 P1001 female at 34 weeks gestation presented with dyspnea, tachycardia, and inability to lie supine. Imaging revealed a large heterogeneous anterior mediastinal mass (14.8×11.5 cm). Multidisciplinary coordinated care led to diagnosis of B cell lymphoma, delivery via cesarean section under regional anesthesia in steep Trendelenberg position, followed by chemotherapy postpartum. CONCLUSIONS Dyspnea in pregnancy is common but might represent underlying pathology. While an obstetrician is knowledgeable of physiologic pregnancy changes, he or she should remain vigilant for underlying pathologic causes of dyspnea, including malignancy. Anterior mediastinal masses propose unique anesthetic challenges including respiratory impairment and cardiopulmonary collapse requiring collaborative care and planning.

Infections in Pregnancy and the Role of Vaccines.

Pregnant women are at risk for infection and may have significant morbidity or mortality. Influenza, pertussis, zika, and cytomegalovirus produce mild or asymptomatic illness in the mother, but have profound implications for her fetus. Maternal immunization can prevent or mitigate infections in pregnant women and their infants. The Advisory Committee of Immunization Practices recommends 2 vaccines during pregnancy: inactivated influenza, and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis during pregnancy. The benefits of MMR, varicella, and other vaccines are reviewed. Novel vaccine studies for use during pregnancy for prevention of illness are explored.

Empirical Studies Addressing the Opioid Epidemic: An Urgent Call for Research.

Opioid misuse has become one of the most pressing public health problems facing the country. In this article, we briefly review literature regarding the opioid epidemic in the United States and the negative consequences of opioid use disorder. We provide information regarding treatment and relapse using a variety of intervention approaches. We call for research on people with opioid use disorder that can contribute to a variety of areas: improving medication-assisted treatment, addressing chronic pain, examination of adjunctive behavioral interventions, overdose, high risk behaviors and infections, pregnancy, diverse populations, and other psychological factors. Collectively addressing these crucial areas of research will advance the field and help alleviate suffering and prevent death from opioid use disorder.