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Variation in Opioid Prescribing After Vaginal and Cesarean Birth: A Statewide Analysis. Womens Health Issues 2023; 33:182-190. [PMID: 36151029 DOI: 10.1016/j.whi.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 08/16/2022] [Accepted: 08/18/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Our aim was to evaluate variation in opioid prescribing rates and prescription size following childbirth across providers and hospitals. METHODS This retrospective cohort study analyzed claims data from a single-payer Preferred Provider Organization from June 2014 to May 2019 in 84 hospitals in a statewide quality collaborative. All patients aged 12-55 years, undergoing childbirth, with continuous enrollment in pregnancy were included. The primary outcome was the predicted rate of postpartum opioid fills from 7 days before birth to 3 days after discharge. Secondary outcomes included postpartum opioid prescription size in oral morphine equivalents, a standardized measure that includes the number of pills prescribed times the strength of the medication. Multilevel regression models accounted for clustering. We calculated attributable variation in opioid fills using the intraclass correlation coefficient. RESULTS Of 41,427 births, 15,459 patients (37.2%) filled a postpartum opioid prescription (vaginal, 4,624/27,536 [16.8%]; cesarean, 10,835/13,891 [78.0%]). The median postpartum prescription size was 150 oral morphine equivalents (interquartile range [IQR], 30) (vaginal, 135; [IQR, 45]; cesarean, 150 [IQR, 75]). In adjusted models, the rates of opioid prescribing after vaginal birth differed from cesarean birth (vaginal median, 12.1% [range, 1.1%-60.0%]; cesarean median, 80.4% [range, 43.6%-90.2%]). More variation in postpartum opioid fills was attributable to providers and hospitals for vaginal (provider, 29%; hospital, 24%) than cesarean birth (provider, 8%; hospital, 6%). Variation in prescription size was driven by providers for vaginal birth (provider, 27%; hospital, 6%) and providers and hospitals for cesarean birth (provider, 29%; hospital, 21%). CONCLUSIONS Across a statewide quality collaborative, variation in postpartum opioid prescribing is attributable to providers and hospitals. Future efforts at the provider and hospital levels are needed to implement best practices for postpartum opioid prescribing.
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Main EK. Measuring Severe Maternal Morbidity: Nothing Is Simple. Jt Comm J Qual Patient Saf 2023; 49:127-128. [PMID: 36717343 DOI: 10.1016/j.jcjq.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Noh Y, Jeong HE, Choi A, Choi EY, Pasternak B, Nordeng H, Bliddal M, Man KKC, Wong ICK, Yon DK, Shin JY. Prenatal and Infant Exposure to Acid-Suppressive Medications and Risk of Allergic Diseases in Children. JAMA Pediatr 2023; 177:267-277. [PMID: 36622684 PMCID: PMC9857801 DOI: 10.1001/jamapediatrics.2022.5193] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 10/15/2022] [Indexed: 01/10/2023]
Abstract
Importance Existing observational data have indicated positive associations of acid-suppressive medication (ASM) use in prenatal and early life with allergic diseases in children; however, no study to date has accounted for confounding by indication or within-familial factors. Objective To evaluate the association of prenatal or infant exposure to ASMs with risk of allergic diseases in children. Design, Setting, and Participants This nationwide, cohort study included data from South Korea's National Health Insurance Service mother-child-linked database from January 1, 2007, to December 31, 2020. Participants included mother-child pairs of neonates born from April 1, 2008, to December 31, 2019. Exposures Prenatal and infant exposure to ASMs (histamine 2 receptor antagonists [H2RAs] and proton pump inhibitors [PPIs]). Main Outcomes and Measures Composite and individual outcomes of allergic diseases (asthma, allergic rhinitis, atopic dermatitis, and food allergy) in children (followed up to 13 years of age) were assessed. The ASM-exposed individuals were compared with unexposed individuals in propensity score (PS)-matched and sibling-matched analyses to control for various potential confounders and within-familial factors. Hazard ratios (HRs) with 95% CIs were estimated using Cox proportional hazards regression models. Results The study included 4 149 257 mother-child pairs. Prenatal exposure analyses included 808 067 PS-matched pairs (763 755 received H2RAs, 36 529 received PPIs) among women with a mean (SD) age of 31.8 (4.2) years. The PS-matched HR was 1.01 (95% CI, 1.01-1.02) for allergic diseases overall (asthma: HR, 1.02 [95% CI, 1.01-1.03]; allergic rhinitis: HR, 1.02 [95% CI, 1.01-1.02]; atopic dermatitis: HR, 1.02 [95% CI, 1.01-1.02]; food allergy: HR, 1.03 [95% CI, 0.98-1.07]); in sibling-matched analyses, the HRs were similar to those of PS-matched analyses but were not significant (allergic diseases: HR, 1.01; 95% CI, 0.997-1.01). Infant exposure analyses included 84 263 PS-matched pairs (74 188 received H2RAs, 7496 received PPIs). The PS-matched HR was 1.06 (95% CI, 1.05-1.07) for allergic diseases overall (asthma: HR, 1.16 [95% CI, 1.14-1.18]; allergic rhinitis: HR, 1.02 [95% CI, 1.01-1.03]; atopic dermatitis: HR, 1.05 [95% CI, 1.02-1.08]; food allergy: HR, 1.28 [95% CI, 1.10-1.49]); asthma risk (HR, 1.13; 95% CI, 1.09-1.17) remained significantly higher among children exposed to ASMs during infancy in sibling-matched analyses. The findings were similar for H2RAs and PPIs analyzed separately and were robust across all sensitivity analyses. Conclusions and Relevance The findings of this cohort study suggest that there is no association between prenatal exposure to ASMs and allergic diseases in offspring. However, infant exposure to ASMs was associated with a higher risk of developing asthma, although the magnitude was more modest than previously reported. Clinicians should carefully weigh the benefits of prescribing ASMs to children, accompanied by subsequent close monitoring for any clinically relevant safety signals.
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Affiliation(s)
- Yunha Noh
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
| | - Han Eol Jeong
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
| | - Ahhyung Choi
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
| | - Eun-Young Choi
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
| | - Björn Pasternak
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Hedvig Nordeng
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
| | - Mette Bliddal
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Kenneth K. C. Man
- Research Department of Practice and Policy, UCL School of Pharmacy, University College London, London, England
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong
- Laboratory of Data Discovery for Health, Hong Kong Science Park, Hong Kong
| | - Ian C. K. Wong
- Research Department of Practice and Policy, UCL School of Pharmacy, University College London, London, England
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong
- Laboratory of Data Discovery for Health, Hong Kong Science Park, Hong Kong
- Aston Pharmacy School, Aston University, Birmingham, England
| | - Dong Keon Yon
- Center for Digital Health, Medical Science Research Institute, Kyung Hee University College of Medicine, Seoul, South Korea
- Department of Pediatrics, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, South Korea
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, South Korea
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Christensen JJ, Bogsrud MP, Holven KB, Retterstøl K, Veierød MB, Nordeng H. Use of statins and other lipid-modifying agents across pregnancy: A nationwide drug utilization study in Norway in 2005-2018. Atherosclerosis 2023; 368:25-34. [PMID: 36522216 DOI: 10.1016/j.atherosclerosis.2022.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 11/16/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Statins are becoming more widely used among women of reproductive age; however, nationwide data on statin use across pregnancy is scarce. We therefore aimed to describe the drug utilization patterns for statins and other lipid-modifying agents (LMAs) before, during, and after pregnancy, for all pregnancies in Norway from 2005 to 2018. METHODS We linked individual-level data from four nationwide electronic health care registries in Norway and characterized the prescription fills of statins and other LMAs across pregnancy. We also examined trends in pregnancy-related LMA use, and characterized women using statins and other LMAs on parameters of health status and co-morbidity. RESULTS In total, 822,071 pregnancies for 503,723 women were included. The number of statin prescription fills decreased rapidly during the first trimester and returned to pre-pregnancy levels about one year postpartum. Pregnancy-related statin use increased from 2005 (approx. 0.11% of all pregnancies) to 2018 (approx. 0.29% of all pregnancies); however, in total, few statin prescriptions were filled within any trimester of pregnancy (n = 331, 0.04% of all pregnancies). Statin use was more common in women with higher age, higher weight, smoking, and comorbidities such as hypertension and diabetes mellitus; also, statin users often had co-medication pertinent to these conditions. CONCLUSIONS Although statins and other LMAs were increasingly being used around the time of pregnancy among women in Norway, drug use was mostly discontinued during the first trimester. Our results suggest that pregnancy-related statin use should be monitored, and that drug safety analyses for maternal and offspring health outcomes are needed.
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Affiliation(s)
| | - Martin P Bogsrud
- Unit for Cardiac and Cardiovascular Genetics, Oslo University Hospital, Oslo, Norway
| | - Kirsten B Holven
- Department of Nutrition, University of Oslo, Oslo, Norway; Norwegian National Advisory Unit on Familial Hypercholesterolemia, Oslo University Hospital, Oslo, Norway
| | - Kjetil Retterstøl
- Department of Nutrition, University of Oslo, Oslo, Norway; The Lipid Clinic, Oslo University Hospital, Oslo, Norway
| | - Marit B Veierød
- Oslo Centre for Biostatistics and Epidemiology, Department of Biostatistics, University of Oslo, Oslo, Norway
| | - Hedvig Nordeng
- PharmacoEpidemiology and Drug Safety Research Group and PharmaTox Strategic Research Initiative, University of Oslo, Oslo, Norway; Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
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105
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Lee SI, Hope H, O'Reilly D, Kent L, Santorelli G, Subramanian A, Moss N, Azcoaga-Lorenzo A, Fagbamigbe AF, Nelson-Piercy C, Yau C, McCowan C, Kennedy JI, Phillips K, Singh M, Mhereeg M, Cockburn N, Brocklehurst P, Plachcinski R, Riley RD, Thangaratinam S, Brophy S, Hemali Sudasinghe SPB, Agrawal U, Vowles Z, Abel KM, Nirantharakumar K, Black M, Eastwood KA. Maternal and child outcomes for pregnant women with pre-existing multiple long-term conditions: protocol for an observational study in the UK. BMJ Open 2023; 13:e068718. [PMID: 36828655 PMCID: PMC9972454 DOI: 10.1136/bmjopen-2022-068718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 02/07/2023] [Indexed: 02/26/2023] Open
Abstract
INTRODUCTION One in five pregnant women has multiple pre-existing long-term conditions in the UK. Studies have shown that maternal multiple long-term conditions are associated with adverse outcomes. This observational study aims to compare maternal and child outcomes for pregnant women with multiple long-term conditions to those without multiple long-term conditions (0 or 1 long-term conditions). METHODS AND ANALYSIS Pregnant women aged 15-49 years old with a conception date between 2000 and 2019 in the UK will be included with follow-up till 2019. The data source will be routine health records from all four UK nations (Clinical Practice Research Datalink (England), Secure Anonymised Information Linkage (Wales), Scotland routine health records and Northern Ireland Maternity System) and the Born in Bradford birth cohort. The exposure of two or more pre-existing, long-term physical or mental health conditions will be defined from a list of health conditions predetermined by women and clinicians. The association of maternal multiple long-term conditions with (a) antenatal, (b) peripartum, (c) postnatal and long-term and (d) mental health outcomes, for both women and their children will be examined. Outcomes of interest will be guided by a core outcome set. Comparisons will be made between pregnant women with and without multiple long-term conditions using modified Poisson and Cox regression. Generalised estimating equation will account for the clustering effect of women who had more than one pregnancy episode. Where appropriate, multiple imputation with chained equation will be used for missing data. Federated analysis will be conducted for each dataset and results will be pooled using random-effects meta-analyses. ETHICS AND DISSEMINATION Approval has been obtained from the respective data sources in each UK nation. Study findings will be submitted for publications in peer-reviewed journals and presented at key conferences.
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Affiliation(s)
- Siang Ing Lee
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Holly Hope
- Centre for Women's Mental Health, Faculty of Biology Medicine & Health, The University of Manchester, Manchester, UK
| | - Dermot O'Reilly
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Lisa Kent
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Gillian Santorelli
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Trust, Bradford, UK
| | | | - Ngawai Moss
- Patient and Public Representative, London, UK
| | - Amaya Azcoaga-Lorenzo
- Division of Population and Behavioural Sciences, University of St Andrews School of Medicine, St Andrews, UK
- Instituto de Investigación Sanitaria Fundación Jimenez Diaz, Hospital Rey Juan Carlos, Mostoles, Spain
| | - Adeniyi Francis Fagbamigbe
- Division of Population and Behavioural Sciences, University of St Andrews School of Medicine, St Andrews, UK
- Department of Epidemiology and Medical Statistics, University of Ibadan College of Medicine, Ibadan, Nigeria
| | | | - Christopher Yau
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
- Health Data Research UK, London, UK
| | - Colin McCowan
- Division of Population and Behavioural Sciences, University of St Andrews School of Medicine, St Andrews, UK
| | | | - Katherine Phillips
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Megha Singh
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Mohamed Mhereeg
- Data Science, Medical School, Swansea University, Swansea, UK
| | - Neil Cockburn
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Peter Brocklehurst
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Richard D Riley
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Shakila Thangaratinam
- WHO Collaborating Centre for Global Women's Health, University of Birmingham Institute of Metabolism and Systems Research, Birmingham, UK
- Department of Obstetrics and Gynaecology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Sinead Brophy
- Data Science, Medical School, Swansea University, Swansea, UK
| | | | - Utkarsh Agrawal
- Division of Population and Behavioural Sciences, University of St Andrews School of Medicine, St Andrews, UK
| | - Zoe Vowles
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Kathryn Mary Abel
- Centre for Women's Mental Health, Faculty of Biology Medicine & Health, The University of Manchester, Manchester, UK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | | | - Mairead Black
- Aberdeen Centre for Women's Health Research, University of Aberdeen School of Medicine Medical Sciences and Nutrition, Aberdeen, UK
| | - Kelly-Ann Eastwood
- Centre for Public Health, Queen's University Belfast, Belfast, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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Muramatsu K, Shigemi D, Honno K, Matsuoka M, Fujino Y, Yasunaga H, Unno N, Mitsuda N, Kimura T, Matsuda S. Hospital case volume and maternal adverse events following abnormal deliveries: Analysis using a Japanese national in-patient database. Int J Gynaecol Obstet 2023. [PMID: 36808733 DOI: 10.1002/ijgo.14725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 02/06/2023] [Accepted: 02/11/2023] [Indexed: 02/20/2023]
Abstract
OBJECTIVE To clarify the relationship between the number of deliveries and maternal outcomes in Japan, considering the declining birth rate and the evidence that hospitals with few deliveries have medical safety issues. METHODS Hospitalizations for deliveries were analyzed using the Diagnosis Procedure Combination database from April 2014 to March 2019, after which maternal comorbidities, maternal end-organ injury, medical treatment during hospitalization, and hemorrhage volume during delivery were compared. Hospitals were divided into four groups based on the number of deliveries per month. RESULTS A total of 792 379 women were included in the analysis, among whom 35 152 (4.4%) received blood transfusions, with a median blood loss of 1450 mL during delivery. Regarding complications, pulmonary embolism was significantly more frequent in hospitals with the lowest number of deliveries. CONCLUSION Using a Japanese administrative database, this study suggests an association between hospital case volume and the occurrence of preventable complications, such as pulmonary embolisms.
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Affiliation(s)
- Keiji Muramatsu
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Daisuke Shigemi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Katsumi Honno
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Masumi Matsuoka
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Yoshihisa Fujino
- Department of Environmental Epidemiology, Institute of Industrial Ecological Science, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Nobuya Unno
- Department of Obstetrics and Gynecology, Kitasato University, School of Medicine, Sagamihara, Japan
| | - Nobuaki Mitsuda
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Tadashi Kimura
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Shinya Matsuda
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, Fukuoka, Japan
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Suarez EA, Nguyen M, Zhang D, Zhao Y, Stojanovic D, Munoz M, Liedtka J, Anderson A, Liu W, Dashevsky I, Cole D, DeLuccia S, Menzin T, Noble J, Maro JC. Novel methods for pregnancy drug safety surveillance in the FDA Sentinel System. Pharmacoepidemiol Drug Saf 2023; 32:126-136. [PMID: 35871766 DOI: 10.1002/pds.5512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/14/2022] [Accepted: 07/21/2022] [Indexed: 01/26/2023]
Abstract
PURPOSE It is a priority of the US Food and Drug Administration (FDA) to monitor the safety of medications used during pregnancy. Pregnancy exposure registries and cohort studies utilizing electronic health record data are primary sources of information but are limited by small sample sizes and limited outcome assessment. TreeScan™, a statistical data mining tool, can be applied within the FDA Sentinel System to simultaneously identify multiple potential adverse neonatal and infant outcomes after maternal medication exposure. METHODS We implemented TreeScan using the Sentinel analytic tools in a cohort of linked live birth deliveries and infants nested in the IBM MarketScan® Research Database. As a case study, we compared first trimester fluoroquinolone use and cephalosporin use. We used the Bernoulli and Poisson TreeScan statistics with compatible propensity score-based study designs for confounding control (matching and stratification) and used multiple propensity score models with various strategies for confounding control to inform best practices. We developed a hierarchical outcome tree including major congenital malformations and outcomes of gestational length and birth weight. RESULTS A total of 1791 fluoroquinolone-exposed and 8739 cephalosporin-exposed mother-infant pairs were eligible for analysis. Both TreeScan analysis methods resulted in single alerts that were deemed to be due to uncontrolled confounding or otherwise not warranting follow-up. CONCLUSIONS In this implementation of TreeScan using Sentinel analytic tools, we did not observe any new safety signals for fluoroquinolone use in the first trimester. TreeScan, with tailored or high-dimensional propensity scores for confounding control, is a valuable tool in addition to current safety surveillance methods for medications used during pregnancy.
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Affiliation(s)
- Elizabeth A Suarez
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Nguyen
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Di Zhang
- Office of Biostatistics, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Yueqin Zhao
- Office of Biostatistics, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Danijela Stojanovic
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Monica Munoz
- Division of Pharmacovigilance, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jane Liedtka
- Division of Pediatric and Maternal Health, Center for Drug and Evaluation Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Abby Anderson
- Division of Urology, Obstetrics and Gynecology, Center for Drug and Evaluation Research, US Food and Drug Administration, Beltsville, Maryland, USA
| | - Wei Liu
- Division of Epidemiology, Center for Drug and Evaluation Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Inna Dashevsky
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - David Cole
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Sandra DeLuccia
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Talia Menzin
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer Noble
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Judith C Maro
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
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Tangel VE, Abramovitz S, Aaronson J, Jiang SY, Pryor KO, White RS. A retrospective multicenter analysis of patient and hospital-level factors predicting the use of general anesthesia for cesarean deliveries. Int J Obstet Anesth 2023; 54:103638. [PMID: 36841063 DOI: 10.1016/j.ijoa.2023.103638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 01/04/2023] [Accepted: 01/25/2023] [Indexed: 02/04/2023]
Affiliation(s)
- V E Tangel
- Weill Cornell Medicine, Department of Anesthesiology, New York, NY, USA.
| | - S Abramovitz
- Weill Cornell Medicine, Department of Anesthesiology, New York, NY, USA
| | - J Aaronson
- Weill Cornell Medicine, Department of Anesthesiology, New York, NY, USA
| | - S Y Jiang
- Weill Cornell Medicine, Department of Anesthesiology, New York, NY, USA
| | - K O Pryor
- Weill Cornell Medicine, Department of Anesthesiology, New York, NY, USA
| | - R S White
- Weill Cornell Medicine, Department of Anesthesiology, New York, NY, USA
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Bruno AM, Horns JJ, Allshouse AA, Metz TD, Debbink ML, Smid MC. Association Between Periviable Delivery and New Onset of or Exacerbation of Existing Mental Health Disorders. Obstet Gynecol 2023; 141:395-402. [PMID: 36657144 PMCID: PMC10477003 DOI: 10.1097/aog.0000000000005050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/27/2022] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To evaluate whether there is an association between periviable delivery and new onset of or exacerbation of existing mental health disorders within 12 months postpartum. METHODS We conducted a retrospective cohort study of individuals with liveborn singleton neonates delivered at 22 or more weeks of gestation from 2008 to 2017 in the MarketScan Commercial Research Database. The exposure was periviable delivery , defined as delivery from 22 0/7 through 25 6/7 weeks of gestation. The primary outcome was a mental health morbidity composite of one or more of the following: emergency department encounter associated with depression, anxiety, psychosis, posttraumatic stress disorder, adjustment disorder, self-harm, or suicide; new psychotropic medication prescription; new behavioral therapy visit; and inpatient psychiatry admission in the 12 months postdelivery. Secondary outcomes included components of the primary composite. Those with and without periviable delivery were compared using multivariable logistic regression adjusted for clinically relevant covariates, with results reported as adjusted incident rate ratios (aIRRs). Effect modification by history of mental health diagnoses was assessed. Incidence of the primary outcome by 90-day intervals postdelivery was assessed. RESULTS Of 2,300,244 included deliveries, 16,275 (0.7%) were periviable. Individuals with periviable delivery were more likely to have a chronic health condition, to have undergone cesarean delivery, and to have experienced severe maternal morbidity. Periviable delivery was associated with a modestly increased risk of the primary composite outcome, occurring in 13.8% of individuals with periviable delivery and 11.0% of individuals without periviable delivery (aIRR 1.18, 95% CI 1.12-1.24). The highest-risk period for the composite primary outcome was the first 90 days in those with periviable delivery compared with those without periviable delivery (51.6% vs 42.4%; incident rate ratio 1.56, 95% CI 1.47-1.66). CONCLUSION Periviable delivery was associated with a modestly increased risk of mental health morbidity in the 12 months postpartum.
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Affiliation(s)
- Ann M Bruno
- University of Utah Health, Salt Lake City, and Intermountain Healthcare, Murray, Utah
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Choi EY, Jeong HE, Noh Y, Choi A, Yon DK, Han JY, Sung JH, Choe SA, Shin JY. Neonatal and maternal adverse outcomes and exposure to nonsteroidal anti-inflammatory drugs during early pregnancy in South Korea: A nationwide cohort study. PLoS Med 2023; 20:e1004183. [PMID: 36848338 PMCID: PMC9970080 DOI: 10.1371/journal.pmed.1004183] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/24/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Existing data on the use of nonsteroidal anti-inflammatory drugs (NSAIDs) during late pregnancy is well established, providing assurance. However, the use of NSAIDs during early pregnancy remains inconclusive owing to conflicting findings on adverse neonatal outcomes as well as the limited data on adverse maternal outcomes. Therefore, we sought to investigate whether early prenatal exposure to NSAIDs was associated with neonatal and maternal adverse outcomes. METHODS AND FINDINGS We conducted a nationwide, population-based cohort study using Korea's National Health Insurance Service (NHIS) database with a mother-offspring cohort constructed and validated by the NHIS to include all live births in women aged 18 to 44 years between 2010 and 2018. We defined exposure to NSAIDs as at least two records of NSAID prescriptions during early pregnancy (first 90 days of pregnancy for congenital malformations and first 19 weeks for nonmalformation outcomes) and compared against three distinct referent groups of (1) unexposed, no NSAID prescription during the 3 months before pregnancy start to end of early pregnancy; (2) acetaminophen-exposed, at least two acetaminophen prescriptions during early pregnancy (i.e., active comparator); and (3) past users, at least two NSAID prescriptions before the start of pregnancy but no relevant prescriptions during pregnancy. Outcomes of interest were adverse birth outcomes of major congenital malformations and low birth weight and adverse maternal outcomes of antepartum hemorrhage and oligohydramnios. We estimated relative risks (RRs) with 95% CIs using generalized linear models within a propensity score (PS) fine stratification weighted cohort that accounted for various potential confounders of maternal sociodemographic characteristics, comorbidities, co-medication use, and general markers of burden of illness. Of 1.8 million pregnancies in the PS weighted analyses, exposure to NSAIDs during early pregnancy was associated with slightly increased risks for neonatal outcomes of major congenital malformations (PS-adjusted RR, 1.14 [CI, 1.10 to 1.18]) and low birth weight (1.29 [1.25 to 1.33]), and for maternal outcome of oligohydramnios (1.09 [1.01 to 1.19]) but not antepartum hemorrhage (1.05 [0.99 to 1.12]). The risks of overall congenital malformations, low birth weight, and oligohydramnios remained significantly elevated despite comparing NSAIDs against acetaminophen or past users. Risks of adverse neonatal and maternal outcomes were higher with cyclooxygenase-2 selective inhibitors or use of NSAIDs for more than 10 days, whereas generally similar effects were observed across the three most frequently used individual NSAIDs. Point estimates were largely consistent across all sensitivity analyses, including the sibling-matched analysis. Main limitations of this study are residual confounding by indication and from unmeasured factors. CONCLUSIONS This large-scale, nationwide cohort study found that exposure to NSAIDs during early pregnancy was associated with slightly higher risks of neonatal and maternal adverse outcomes. Clinicians should therefore carefully weigh the benefits of prescribing NSAIDs in early pregnancy against its modest, but possible, risk of neonatal and maternal outcomes, where if possible, consider prescribing nonselective NSAIDs for <10 days, along with continued careful monitoring for any safety signals.
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Affiliation(s)
- Eun-Young Choi
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
| | - Han Eol Jeong
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
| | - Yunha Noh
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
| | - Ahhyung Choi
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
| | - Dong Keon Yon
- Department of Pediatrics, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, South Korea
- Center for Digital Health, Medical Science Research Institute, Kyung Hee University College of Medicine, Seoul, South Korea
| | - Jung Yeol Han
- Korean Mothersafe Counselling Center, Department of Obstetrics and Gynecology, Inje University Ilsan Paik Hospital, Goyang, South Korea
| | - Ji-Hee Sung
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seung-Ah Choe
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
- Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, South Korea
- * E-mail:
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111
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To Eat or Not to Eat? A Review of Current Practices Regarding Food in Labor. CURRENT ANESTHESIOLOGY REPORTS 2023. [DOI: 10.1007/s40140-023-00549-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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112
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Tucker CM, Bell N, Corbett CF, Lyndon A, Felder TM. Using medical expenditure panel survey data to explore the relationship between patient-centered medical homes and racial disparities in severe maternal morbidity outcomes. WOMEN'S HEALTH (LONDON, ENGLAND) 2023; 19:17455057221147380. [PMID: 36660909 PMCID: PMC9887166 DOI: 10.1177/17455057221147380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND There are persistent racial/ethnic disparities in the occurrence of severe maternal morbidity. Patient-centered medical home care has the potential to address disparities in maternal outcomes. OBJECTIVES To examine (1) the association between receiving patient-centered medical home care and severe maternal morbidity outcomes and (2) the interaction of race/ethnicity on patient-centered medical home status and severe maternal morbidity. DESIGN/METHODS Using 2007 to 2016 data from the Medical Expenditures Panel Survey, we conducted a cross-sectional study to estimate the association between receipt of care from a patient-centered medical home and the occurrence of severe maternal morbidity, and racial-specific (White, Black, Asian, Other) relative risks of severe maternal morbidity. Our study used race as a proxy measure for exposure racism. We identified mothers (⩾15 years) who gave birth during the study period. We identified patient-centered medical home qualities using 11 Medical Expenditures Panel Survey questions and severe maternal morbidities using medical claims, and calculated generalized estimating equation models to estimate odds ratios of severe maternal morbidity and 95% confidence intervals. RESULTS Among all mothers who gave birth (N = 2801; representing 5,362,782 US lives), only 25% received some exposure patient-centered medical home care. Two percent experienced severe maternal morbidity, and this did not differ statistically (p = 0.11) by patient-centered medical home status. However, our findings suggest a 85% decrease in the risk of severe maternal morbidity among mothers who were defined as always attending a patient-centered medical home (odds ratios: 0.15; 95% confidence interval:0.01-1.87; p = 0.14) and no difference in the risk of severe maternal morbidity among mothers who were defined as sometimes attending a patient-centered medical home (odds ratios: 1.00; 95% confidence interval:0.16-6.42; p = 1.00). There was no overall interaction effect in the model between race and patient-centered medical home groups (p = 0.82), or ethnicity and patient-centered medical home groups (p = 0.62) on the severe maternal morbidity outcome. CONCLUSION While the rate of severe maternal morbidity was similar to US rates, few mothers received care from a patient-centered medical home which may be due to underreporting. Future research should further investigate the potential for patient-centered medical home-based care to reduce odds of severe maternal morbidity across racial/ethnic groups.
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Affiliation(s)
- Curisa M Tucker
- Department of Pediatrics, Stanford
University School of Medicine, Palo Alto, CA, USA,Curisa M Tucker, Department of Pediatrics,
Stanford University School of Medicine, 3145 Porter Drive, Palo Alto, CA 94304,
USA.
| | - Nathaniel Bell
- College of Nursing, University of South
Carolina, Columbia, SC, USA
| | | | - Audrey Lyndon
- Rory Meyers College of Nursing, New
York University, New York, NY, USA
| | - Tisha M Felder
- College of Nursing, University of South
Carolina, Columbia, SC, USA
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Yang L, Friedman AM, Krenitsky NM, Wen T, D'Alton ME, Wright JD, Booker W, Huang Y. Risk for adverse maternal outcomes among women with chronic hypertension. BJOG 2023; 130:621-635. [PMID: 36655368 DOI: 10.1111/1471-0528.17382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 10/28/2022] [Accepted: 11/08/2022] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To determine whether longitudinal health data accounts for end-organ injury or death in the setting of chronic hypertension. DESIGN Cohort of 64 799 deliveries to 61 854 women. SETTING US claims data for the preiod 2008-2019. POPULATION Women with a delivery hospitalisation and chronic hypertension. METHODS Risk for a composite of acute end-organ injury or death during the delivery hospitalisation and 30 days postpartum was analysed. Adjusted logistic regression models were derived with discrimination for each model estimated by the C-statistic. Poisson regression was used to estimate adjusted risk ratios. Starting with models using data from pregnancy, further adjustment was performed accounting for healthcare use in the year prior to pregnancy, including hospitalisations, emergency department encounters, prescription medications and pre-pregnancy diagnoses. MAIN OUTCOME MEASURES Acute end-organ injury or death. RESULTS The composite outcome occurred among 5.7% of 64 799 deliveries. For patients with commercial insurance, filling non-hypertensive medications from ≥11 different classes, compared with none (adjusted risk ratio, aRR 4.07, 95% CI 2.86-5.79), three or more hospitalisations before pregnancy, compared with none (aRR 4.75, 95% CI 3.46-6.52), and chronic kidney disease diagnosed in the year before pregnancy (aRR 2.35, 95% CI 1.88, 2.94) were associated with increased risk. For pregnancies covered by commercial insurance, the C-statistic increased from 0.615 (95% CI 0.599-0.630) in the model with pregnancy data only to 0.796 (95% CI 0.783-0.808) for the model additionally including healthcare use in the year before pregnancy. Findings with Medicaid were similar. CONCLUSIONS Prepregnancy care use predicted adverse maternal outcomes. These data may be important in risk stratification.
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Affiliation(s)
- Lanbo Yang
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Nicole M Krenitsky
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Timothy Wen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California - San Francisco, San Francisco, California, USA
| | - Mary E D'Alton
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Jason D Wright
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Whitney Booker
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Yongmei Huang
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
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Choi A, Noh Y, Jeong HE, Choi EY, Man KKC, Han JY, Kim HS, Yon DK, Shin JY. Association Between Proton Pump Inhibitor Use During Early Pregnancy and Risk of Congenital Malformations. JAMA Netw Open 2023; 6:e2250366. [PMID: 36626173 PMCID: PMC9856708 DOI: 10.1001/jamanetworkopen.2022.50366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
IMPORTANCE Proton pump inhibitors (PPIs) are increasingly used during pregnancy; however, several observational studies have raised concerns about an increased risk of specific types of congenital malformations. OBJECTIVE To examine the association between PPI exposure during early pregnancy and the risk of congenital malformations. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study used data from the National Health Insurance Service-National Health Information Database of South Korea (2010-2020); sibling-controlled analyses were conducted to account for familial factors. A total of 2 696 216 pregnancies in women aged 19 to 44 years between June 1, 2011, and December 31, 2019, and their live-born infants were identified. Pregnant women who were exposed to known teratogens or who delivered infants with chromosomal abnormalities or genetic syndromes were excluded. Data on participant race and ethnicity were not collected because the National Health Information Database does not report this information. EXPOSURES Proton pump inhibitor use during the first trimester. MAIN OUTCOMES AND MEASURES Primary outcomes were major congenital malformations, congenital heart defects, cleft palate, hydrocephalus, and hypospadias. The subtypes of major congenital malformations and congenital heart defects were evaluated as exploratory outcomes. Propensity score fine stratification was used to control for potential confounders, and a weighted generalized linear model was used to estimate relative risks with 95% CIs. RESULTS Of 2 696 216 pregnancies (mean [SD] maternal age, 32.1 [4.2] years), 40 540 (1.5%; mean [SD] age, 32.4 [4.6] years) were exposed to PPIs during the first trimester. The absolute risk of major congenital malformations was 396.7 per 10 000 infants in PPI-exposed pregnancies and 323.4 per 10 000 infants in unexposed pregnancies. The propensity score-adjusted relative risks were 1.07 (95% CI, 1.02-1.13) for major congenital malformations, 1.09 (95% CI, 1.01-1.17) for congenital heart defects, 1.02 (95% CI, 0.72-1.43) for cleft palate, 0.94 (95% CI, 0.54-1.63) for hydrocephalus, and 0.77 (95% CI, 0.51-1.17) for hypospadias. In the sibling-controlled analyses, no associations were observed between PPI use and primary outcomes, including major congenital malformations (odds ratio, 1.05; 95% CI, 0.91-1.22) and congenital heart defects (odds ratio, 1.07; 95% CI, 0.88-1.30). A range of sensitivity analyses revealed results that were similar to the main findings. CONCLUSIONS AND RELEVANCE In this cohort study, the use of PPIs during early pregnancy was not associated with a substantial increase in the risk of congenital malformations, although small increased risks were observed for major congenital malformations and congenital heart defects; findings from sibling-controlled analyses revealed that PPIs were unlikely to be major teratogens. These findings may help guide clinicians and patients in decision-making about PPI use in the first trimester.
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Affiliation(s)
- Ahhyung Choi
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
| | - Yunha Noh
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
| | - Han Eol Jeong
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
| | - Eun-Young Choi
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
| | - Kenneth K. C. Man
- Research Department of Practice and Policy, University College London School of Pharmacy, London, United Kingdom
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong
| | - Jung Yeol Han
- Korean Mothersafe Counselling Center, Department of Obstetrics and Gynecology, Inje University Ilsan Paik Hospital, Goyang, South Korea
| | - Hyun-Soo Kim
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Dong Keon Yon
- Center for Digital Health, Medical Science Research Institute, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, South Korea
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
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Acute coronary syndrome during pregnancy and postpartum in France: the nationwide CONCEPTION study. Am J Obstet Gynecol MFM 2023; 5:100781. [PMID: 36273812 DOI: 10.1016/j.ajogmf.2022.100781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 10/17/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Cardiovascular diseases, including acute coronary syndromes, are the leading cause of maternal death in many developed countries. OBJECTIVE We assessed acute coronary syndrome incidences during pregnancy, peripartum, and postpartum periods. We also compared overall pregnancy (ie, covering all 3 periods) incidence with that found in nonpregnant women of childbearing age. STUDY DESIGN All women aged between 15 and 49 years without ischemic heart disease who delivered between 2010 and 2018 in France were included in the CONCEPTION cohort. Data were extracted from the French National Health Insurance Information System database. Acute coronary syndromes were defined according to the International Classification of Diseases, Tenth Revision codes recorded in the principal hospital diagnosis. We used Poisson regression to estimate crude acute coronary syndrome incidences, and tested age-adjusted Poisson models to compare the incidence risk ratio of acute coronary syndrome between pregnant and nonpregnant women, with 95% confidence intervals. RESULTS Among 6,298,967 deliveries in France, we observed 225 first-time acute coronary syndrome diagnoses during overall pregnancy (overall pregnancy-related acute coronary syndrome incidence, 4.34/100,000 person-years; 1 case/23,000 pregnancies). In multivariate analysis, independent factors associated with acute coronary syndrome were age, social deprivation, obesity, tobacco use, chronic hypertension, and hypertensive disorders of pregnancy (all P<.05). Among the nonpregnant women aged 15 to 49 years in the general French population, 18,247 cases of acute coronary syndrome (incidence, 16.5/100,000 person-years) occurred throughout the whole study period (>100 million person-years). Compared with the acute coronary syndrome incidence in nonpregnant women, age-adjusted overall pregnancy-related acute coronary syndrome incidence was lower (incidence rate ratio, 0.76; 95% confidence interval, 0.57-0.98; P<.05). Although compared with nonpregnant women, age-adjusted incidence rates were lower during pregnancy, risk was increased during peripartum and postpartum periods. CONCLUSION With an incidence of 4.34 per 100,000 person-years, acute coronary syndrome still accounts for a significant proportion of maternal mortality. The peripartum and postpartum periods remain high-risk periods, and greater efforts should be made in terms of acute coronary syndrome prevention, especially because several cardiovascular risk factors are treatable, such as tobacco use and hypertensive disorders of pregnancy.
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Jeffers NK, Berger BO, Marea CX, Gemmill A. Investigating the impact of structural racism on black birthing people - associations between racialized economic segregation, incarceration inequality, and severe maternal morbidity. Soc Sci Med 2023; 317:115622. [PMID: 36542927 PMCID: PMC9910389 DOI: 10.1016/j.socscimed.2022.115622] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022]
Abstract
Black birthing people are twice as likely to experience severe maternal morbidity (SMM) as their white counterparts. Structural racism provides a framework for understanding root causes of perinatal health disparities. Our objective was to investigate associations between measures of structural racism and severe maternal morbidity (SMM) among Black birthing people in the US. We linked delivery hospitalizations for Black birthing people in the National Inpatient Sample (2008-2011) with data from the American Community Survey 5-year estimates and the Vera Institute of Justice Incarceration Trends datasets (2008-2011). Structural racism measures included the Index of Concentration at the Extremes for race and income (i.e., racialized economic segregation) and Black-white incarceration inequality, assessed as quintiles by hospital county. Multilevel logistic regression assessed the relationship between these county-level indicators of structural racism and SMM. Black birthing people delivering in quintiles 5 (concentrated deprivation; OR = 1.45, 95% CI = 1.16-1.81) and 3 (OR = 1.27, 95% CI = 1.04-1.56) experienced increased odds of SMM compared to those in quintile 1 (concentrated privilege). After adjusting for individual characteristics, obstetric comorbidities, and hospital characteristics the odds of SMM remained elevated for Black birthing people delivering in quintiles 5 (aOR = 1.32, 95% CI = 1.02-1.71) and 3 (aOR = 1.24, 95% CI = 1.02-1.51). Delivering in the quintile with the highest incarceration inequality (Q5) was not significantly associated with SMM (aOR = 0.95, 95% CI = 0.72-1.25) compared to those delivering in counties with the lowest incarceration inequality (Q1). In this national-level study, racialized economic segregation was associated with SMM among Black birthing people. Our findings highlight the need to promote maternal and perinatal health equity through actionable policies that prioritize investment in communities experiencing deprivation.
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Affiliation(s)
- Noelene K Jeffers
- Johns Hopkins Bloomberg School of Public Health, Department of Population Family, And Reproductive Health, 615 N. Wolfe Street, Baltimore, MD, 21205, United States.
| | - Blair O Berger
- Johns Hopkins Bloomberg School of Public Health, Department of Population Family, And Reproductive Health, 615 N. Wolfe Street, Baltimore, MD, 21205, United States.
| | - Christina X Marea
- Georgetown University School of Nursing & Health Studies, Department of Advanced Nursing Practice, St. Mary's Hall 3700 Reservoir Road, N.W., Washington D.C, 20057-1107, United States.
| | - Alison Gemmill
- Johns Hopkins Bloomberg School of Public Health, Department of Population Family, And Reproductive Health, 615 N. Wolfe Street, Baltimore, MD, 21205, United States.
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117
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Endres K, Razavi N, Tian Z, Zhou S, Krawiec C, Jasani S. A retrospective analysis of complications associated with postpartum hemorrhage up to 1 year postpartum in mothers with and without a pre-existing mental health diagnosis. WOMEN'S HEALTH (LONDON, ENGLAND) 2023; 19:17455057231211094. [PMID: 37966026 PMCID: PMC10652806 DOI: 10.1177/17455057231211094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 10/03/2023] [Accepted: 10/12/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND/OBJECTIVES There is limited research on the associated immediate and long-term outcomes of postpartum hemorrhage. Mothers with a pre-existing psychiatric disease prior to delivery may be especially vulnerable to postpartum hemorrhage outcomes but little is known on this topic. Barriers to studying this population exist and add to knowledge gaps. The goal of this study is to determine the clinical characteristics and frequency of complications within 1 year of a postpartum hemorrhage diagnosis and the psychiatric sequelae within 7 days of a postpartum hemorrhage diagnosis in mothers with a pre-existing mental health diagnosis prior to delivery versus those without. METHODS/DESIGN This is a multicenter retrospective observational cohort study using TriNetX, a de-identified electronic health record database. The following electronic health record data were collected and evaluated in postpartum females who were billed for either a vaginal or cesarean delivery: age, race, ethnicity, diagnostic codes, medication codes, and number of deaths. RESULTS We included 10,649 subjects (6994 (65.7%) no mental health diagnosis and 3655 (34.3%) pre-existing mental health diagnosis). Haloperidol administration (118 (3.2%) versus 129 (1.8%), p < 0.001) was more prevalent in subjects with a pre-existing mental health diagnosis. Adjusting for demographics, pre-existing mental health diagnoses were associated with complications within 1 year after postpartum hemorrhage diagnosis (OR = 1.39, 95% CI: 1.26-1.52, p < 0.001). CONCLUSION Having a mental health disorder history is associated with a higher odds of developing subsequent complications within 1 year of postpartum hemorrhage diagnosis. Mothers with a pre-existing mental health disorder have a significantly higher frequency of certain severe postpartum hemorrhage sequelae, including acute respiratory distress syndrome, retained placenta, sickle cell crisis, and need for mechanical ventilation/tracheostomy up to 1 year after delivery. Medications such as haloperidol were ordered more frequently within 7 days of a postpartum hemorrhage diagnosis in these mothers as well. Further research is needed to understand and manage the unique consequences of postpartum hemorrhage in this vulnerable maternal population.
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Affiliation(s)
- Kodi Endres
- Penn State College of Medicine, Pennsylvania State University, Hershey, PA, USA
| | - Nina Razavi
- Penn State College of Medicine, Pennsylvania State University, Hershey, PA, USA
| | - Zizhong Tian
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Penn State College of Medicine, Pennsylvania State University, Hershey, PA, USA
| | - Shouhao Zhou
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Penn State College of Medicine, Pennsylvania State University, Hershey, PA, USA
| | - Conrad Krawiec
- Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Hershey Children’s Hospital, Hershey, PA, USA
| | - Sona Jasani
- Division of Obstetric Specialties and Midwifery, Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
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118
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Development and Validation of Algorithms to Estimate Live Birth Gestational Age in Medicaid Analytic eXtract Data. Epidemiology 2023; 34:69-79. [PMID: 36455247 DOI: 10.1097/ede.0000000000001559] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND While healthcare utilization data are useful for postmarketing surveillance of drug safety in pregnancy, the start of pregnancy and gestational age at birth are often incompletely recorded or missing. Our objective was to develop and validate a claims-based live birth gestational age algorithm. METHODS Using the Medicaid Analytic eXtract (MAX) linked to birth certificates in three states, we developed four candidate algorithms based on: preterm codes; preterm or postterm codes; timing of prenatal care; and prediction models - using conventional regression and machine-learning approaches with a broad range of prespecified and empirically selected predictors. We assessed algorithm performance based on mean squared error (MSE) and proportion of pregnancies with estimated gestational age within 1 and 2 weeks of the gold standard, defined as the clinical or obstetric estimate of gestation on the birth certificate. We validated the best-performing algorithms against medical records in a nationwide sample. We quantified misclassification of select drug exposure scenarios due to estimated gestational age as positive predictive value (PPV), sensitivity, and specificity. RESULTS Among 114,117 eligible pregnancies, the random forest model with all predictors emerged as the best performing algorithm: MSE 1.5; 84.8% within 1 week and 96.3% within 2 weeks, with similar performance in the nationwide validation cohort. For all exposure scenarios, PPVs were >93.8%, sensitivities >94.3%, and specificities >99.4%. CONCLUSIONS We developed a highly accurate algorithm for estimating gestational age among live births in the nationwide MAX data, further supporting the value of these data for drug safety surveillance in pregnancy. See video abstract at, http://links.lww.com/EDE/B989 .
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Trinh NTH, Nordeng HME, Bandoli G, Palmsten K, Eberhard-Gran M, Lupattelli A. Antidepressant Fill and Dose Trajectories in Pregnant Women with Depression and/or Anxiety: A Norwegian Registry Linkage Study. Clin Epidemiol 2022; 14:1439-1451. [PMID: 36506004 PMCID: PMC9733444 DOI: 10.2147/clep.s379370] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/18/2022] [Indexed: 12/08/2022] Open
Abstract
Background Few studies investigated longitudinal antidepressant exposure during pregnancy and included dosage in the assessment. Methods We conducted a nationwide, registry-linkage study in Norway using data on antidepressant prescription fills in pregnancies lasting ≥32 weeks in women with a delivery between 2009 and 2018 who had a depression/anxiety diagnosis and antidepressant fills prior to pregnancy. Information on antidepressant exposure by week (measured by filled prescriptions) and prescribed average daily dose was used in longitudinal k-means trajectory modelling for a 108-week time window from six months prior to pregnancy to one year after delivery. Factors associated with trajectory group membership were examined using multinomial logistic regression models. Results We included 8,460 pregnancies in 8,092 women. Four antidepressant fill trajectories were identified based on filled antidepressant prescriptions: two distinct discontinuing patterns, one at around the start of pregnancy (30.4%) and one around the end of pregnancy (33.8%); one continuing pattern (20.6%); and one interrupting pattern (15.2%). Using average usual daily dose, we identified low dose discontinuing (60.3%), medium dose reducing (20.6%) and high dose continuing (15.2%) patterns. The multinomial logistic regressions showed that the fill trajectory group membership was strongly associated with: antidepressant type and dose prior to pregnancy and co-medication prior to pregnancy, maternal age, marital status, parity, previous pregnancy loss, and pregnancy planning. Conclusion Longitudinal trajectory modelling revealed distinct antidepressant fill and dosage patterns in the period around pregnancy. Knowledge about factors associated with utilization trajectories might be useful for health-care personnel counselling women about antidepressant use in pregnancy.
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Affiliation(s)
- Nhung T H Trinh
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway,Correspondence: Nhung TH Trinh, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Post box 1068 Blindern, Oslo, 0316, Norway, Email
| | - Hedvig M E Nordeng
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway,Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
| | - Gretchen Bandoli
- Department of Pediatrics, University of California San Diego, La Jolla, CA, USA,Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA, USA
| | | | - Malin Eberhard-Gran
- Norwegian Research Centre for Women’s Health, Women’s and Children’s Division, Oslo University Hospital, Rikshospitalet, Oslo, Norway,Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Angela Lupattelli
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
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Logue TC, Wen T, Friedman AM. Demographic trends associated with substance use disorder and risk for adverse obstetric outcomes with cannabis and opioid use disorders. J Matern Fetal Neonatal Med 2022; 35:2128658. [PMID: 36617462 DOI: 10.1080/14767058.2022.2128658] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Substance use disorders (SUDs) are increasing in the obstetric population, vary with demographic characteristics, and are associated with adverse pregnancy outcomes. Cannabis use disorder and opioid use disorder are two of the most common SUDs during pregnancy. OBJECTIVE This study had two objectives. The first objective was to assess trends in any SUD diagnosis during delivery hospitalizations from 2000 to 2018 by maternal age, ZIP code income quartile, and hospital location and teaching status. The second objective was to determine risk for adverse pregnancy outcomes during delivery hospitalizations specifically in the presence of cannabis and opioid use disorder diagnoses. STUDY DESIGN We conducted a serial cross-sectional analysis of the 2000-2018 National Inpatient Sample. Delivery hospitalizations to women aged 15-54 years with substance use disorder diagnoses were identified. SUD included (i) cannabis use disorder; (ii) opioid use disorder; (iii) alcohol use disorder; and (iv) other drug use disorder. We used joinpoint regression to estimate the average annual percent change (AAPC) in any substance use disorder diagnoses with 95% confidence intervals (CIs) by (i) ZIP code income quartile, (ii) hospital location and teaching status, and (iii) maternal age. We used unadjusted and adjusted log-linear regression to evaluate the relationship between cannabis use disorder and opioid use disorder several adverse maternal outcomes. We report unadjusted and adjusted risk ratios (aRRs) as measures of effect. RESULTS From 2000 to 2018, trends analyses broadly demonstrated increasing risk for SUD across demographic categories. In trends analyses stratified by ZIP code-income quartile, the proportion of deliveries with any SUD diagnosis increased across each income quartile with significant increases in the lowest income quartile (AAPC 4.6%, 95% CI 0.4%, 8.9%), second lowest quartile (AAPC 6.3%, 95% CI 5.3%, 7.4%), second highest quartile (AAPC 5.4%, 95% CI 4.1%, 6.8%), and highest quartile (AAPC 4.4%, 95% CI 2.1%, 6.8%). A larger increasing AAPC for SUD was present for deliveries in rural hospitals (AAPC 12.3%, 95% CI 9.8%, 14.9%) as compared to teaching (AAPC 5.7%, 95% CI 5.2%, 6.3%) and non-teaching urban hospitals (AAPC 7.0%, 95% CI 5.9%, 8.1%). By maternal age group, there was a significant larger AAPC for SUD for women aged 15-19 years (AAPC 8.5%, 95% CI 6.6%, 10.4%), 20-24 years (AAPC 9.0%, 95% CI 6.9%, 11.1%) and 25-29 years (AAPC 9.8%, 95% CI 9.1%, 10.6%) than women ≥30 years of age. Cannabis use disorder was associated with increased adjusted risk for preterm delivery (aRR 1.44, 95% CI 1.43, 1.45) and abruption and antepartum hemorrhage (aRR 1.77, 95% CI 1.75, 1.80). Opioid use disorder was associated with risk for non-transfusion severe maternal morbidity (aRR 1.73, 95% CI 1.67, 1.79), preterm delivery (aRR 1.75, 95% CI 1.74, 1.77), and abruption and antepartum hemorrhage (aRR 2.15, 95% CI 2.11, 2.19). CONCLUSION While substance use disorders are increasing in pregnancy across rural and urban settings, age groups, and income quartiles, several populations are associated with higher increased risks and trends. These findings support that SUDs are likely to continue to be of public health significance in diverse geographic and demographic settings.
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Affiliation(s)
- Teresa C Logue
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Timothy Wen
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, USA
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
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Craig A, Federspiel J, Wein L, Thompson J, Dotters-Katz S. Maternal and obstetric outcomes of listeria pregnancy: insights from a national cohort. J Matern Fetal Neonatal Med 2022; 35:10010-10016. [PMID: 35686719 PMCID: PMC9846892 DOI: 10.1080/14767058.2022.2083494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 05/09/2022] [Accepted: 05/20/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVE We sought to evaluate and describe the maternal and obstetric morbidity associated with Listeria infection in pregnancy. METHODS Retrospective cohort of pregnant women using the 2007-2018 National Inpatient Sample. Pregnant women with discharge diagnosis codes consistent with Listeria infection were identified. Outcomes of deliveries complicated by Listeria infection were compared to those of delivery without this infection. The primary outcome was a composite of severe maternal morbidity. Secondary outcomes included components of the composite, maternal length of stay, mode of delivery, stillbirth, and preterm delivery. RESULTS We identified 134 maternity associated hospitalizations for Listeria (weighted national estimate 666), of which 72 (weighted national estimate of 358) were delivery admissions. Delivery admissions complicated by Listeria resulted in higher rates of severe maternal morbidity than those without, (30.9% vs. 1.6%, p<.001). In adjusted analyses, women with Listeria had 21.2-fold higher risk of severe maternal morbidity (95% CI: 14.0, 31.9) when compared to those without Listeria. Specifically, Listeria delivery admissions had higher rates of acute respiratory distress syndrome (2.8% vs. 0.1%, p<.001), mechanical ventilation (1.4% vs. 0.0%, p<.001), sepsis (28.1% vs. 0.1%, p<.001), and shock (1.4% vs. 0.0%, p<.001). Listeria delivery admissions also had higher rates of preterm birth (61.3% vs. 7.7%, p < 0.001) and stillbirth (13.5% vs. 0.7%, p<.001). Women hospitalized or delivered with Listeria infection were also more likely to have a cesarean delivery (57.9% vs. 32.9, p<.001) and the average length of stay for women with Listeria was also longer (4.0 days vs. 2.3 days, p<.001). CONCLUSIONS Women with Listeria infection in pregnancy have higher rates of severe maternal morbidity, specifically increased risk of sepsis, septic shock, and acute respiratory distress syndrome. Among delivery hospitalizations, these women also have higher rates of preterm birth and stillbirth.
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Affiliation(s)
- Amanda Craig
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Jerome Federspiel
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
- Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lauren Wein
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Jennifer Thompson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sarah Dotters-Katz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
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Sundbakk LM, Gran JM, Wood ME, Handal M, Skurtveit S, Nordeng H. Association of Prenatal Exposure to Benzodiazepines and Z-Hypnotics With Risk of Attention-Deficit/Hyperactivity Disorder in Childhood. JAMA Netw Open 2022; 5:e2246889. [PMID: 36520439 PMCID: PMC9856385 DOI: 10.1001/jamanetworkopen.2022.46889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Evidence is limited regarding the safety of prenatal benzodiazepine and z-hypnotic exposure and its association with long-term neurodevelopment in childhood. OBJECTIVE To quantify the associations of the timing and number of intervals of prenatal exposure to benzodiazepines and/or z-hypnotics with the risk of attention-deficit/hyperactivity disorder (ADHD) in childhood. DESIGN, SETTING, AND PARTICIPANTS This cohort study used data from the 1999 to 2008 population-based Norwegian Mother, Father and Child Cohort Study, which are linked to the Medical Birth Registry of Norway, Norwegian Patient Registry, and Norwegian Prescription Database. Two populations of participants were created: a full sample and a mental health sample. The full sample included mothers and their live-born singletons, whereas the mental health sample was restricted to offspring of mothers who reported anxiety, depression, or sleeping problems during pregnancy or 6 months before pregnancy. Data were analyzed from September 2021 to February 2022. EXPOSURES Maternal self-report of benzodiazepine and/or z-hypnotic use during pregnancy was grouped into early pregnancy exposure and middle and/or late pregnancy exposure for analysis of the association with timing of exposure, and number of 4-week intervals of exposure was classified (single [1] vs multiple [≥2]) for analysis of the association with number of exposed intervals. MAIN OUTCOME AND MEASURES The outcome was ADHD, defined as time to ADHD diagnosis or filled prescription for ADHD medication. To control for confounding, inverse probability of treatment-weighted Cox proportional hazards regression models were used. Hazard ratios and 95% CIs were estimated. The weights were derived from propensity score modeling of the probability of benzodiazepine and/or z-hypnotic exposure as a function of potential confounders between the exposure and the outcome, including maternal symptoms of depression and anxiety. RESULTS The full sample comprised 82 201 pregnancies, and the mental health sample included 19 585 pregnancies. In total, 681 offspring (0.8%) in the full sample and 468 offspring (2.4%) in the mental health sample were prenatally exposed to benzodiazepines and/or z-hypnotics. After weighting, exposure in early (hazard ratio, 0.74; 95% CI, 0.39-1.94) and middle and/or late (hazard ratio, 0.76; 95% CI, 0.35-1.61) pregnancy was not associated with increased risk of childhood ADHD. There was no evidence of substantial association between the number of exposed intervals during pregnancy and childhood ADHD. CONCLUSIONS AND RELEVANCE Results of this study suggest that there may be no increased risk of childhood ADHD associated with prenatal exposure to benzodiazepines and/or z-hypnotics, regardless of timing of exposure and number of exposed intervals. However, these findings should be interpreted with caution due to low study power.
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Affiliation(s)
- Lene Maria Sundbakk
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, and PharmaTox Strategic Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Jon Michael Gran
- Oslo Centre for Biostatistics and Epidemiology, Department of Biostatistics, University of Oslo, Oslo, Norway
| | - Mollie E. Wood
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, and PharmaTox Strategic Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill
| | - Marte Handal
- Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway
| | - Svetlana Skurtveit
- Department of Mental Disorders, Norwegian Institute of Public Health, Oslo, Norway
| | - Hedvig Nordeng
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, and PharmaTox Strategic Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
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Trend in neuraxial morphine use and postoperative analgesia after cesarean delivery in Japan from 2005 to 2020. Sci Rep 2022; 12:17234. [PMID: 36241762 PMCID: PMC9568599 DOI: 10.1038/s41598-022-22165-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 10/11/2022] [Indexed: 01/06/2023] Open
Abstract
The increasing rate of cesarean deliveries warrants obstetric anesthesiologists to deliver high-quality post-cesarean delivery analgesia. The aim of this study was to evaluate the temporal trends in the use of neuraxial morphine for cesarean deliveries and to describe the current postoperative analgesia practices. A retrospective cohort study using nationwide health insurance claims databases was conducted from 2005 to 2020 in Japan. Pregnant women who had undergone cesarean deliveries were included. The annual rate of neuraxial morphine use was extracted and analyzed. Additionally, we explored the patient- and facility-level factors associated with neuraxial morphine use through a multilevel logistic regression analysis. The cohort included 65,208 cesarean delivery cases from 2275 institutions. The prevalence of neuraxial morphine use was 16.0% (95% confidence interval [CI], 15.8-16.3) in the overall cohort. Intrathecal morphine was used in 20.6% (95% CI, 20.2-21.0) of spinal anesthesia cases. The trend in neuraxial morphine use steadily increased from 2005 to 2020. The significant predictors of neuraxial morphine use included spinal anesthesia, recent surgery, large medical facilities, and academic hospitals. Variations in the utilization of postoperative analgesia were observed. Our study described the current trend of neuraxial morphine use and the variation in postoperative analgesia practice in Japan.
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Kendle AM, Salemi JL, Jackson CL, Buysse DJ, Louis JM. Insomnia during pregnancy and severe maternal morbidity in the united states: nationally representative data from 2006 to 2017. Sleep 2022; 45:zsac175. [PMID: 35901516 PMCID: PMC9548669 DOI: 10.1093/sleep/zsac175] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 06/08/2022] [Indexed: 07/30/2023] Open
Abstract
STUDY OBJECTIVES Using a large, nationally representative database, we aimed to estimate the prevalence and trends of insomnia among pregnant women over a 12-year period. In addition, we aimed to examine the interplay among insomnia, maternal comorbidities, and severe maternal morbidity (SMM). METHODS We conducted a serial cross-sectional analysis of pregnancy-related hospitalizations in the United States from the 2006 to 2017 National Inpatient Sample (NIS). ICD-9 and ICD-10 codes were used to capture diagnoses of insomnia and obstetric comorbidities during delivery and non-delivery hospitalizations. The primary outcome was the diagnosis of SMM at delivery. We used logistic regression to assess the association between insomnia and SMM. Joinpoint regression was used to estimate trends in insomnia and SMM. RESULTS Of nearly 47 million delivery hospitalizations, 24 625 women had a diagnosis of insomnia, or 5.2 per 10 000 deliveries. The annual incidence increased from 1.8 to 8.6 per 10 000 over the study period. The crude rate of insomnia was 6.3 times higher for non-delivery hospitalizations. Patients with insomnia had more comorbidities, particularly neuromuscular disease, mental health disorders, asthma, and substance use disorder. Prevalence of non-blood transfusion SMM was 3.6 times higher for patients with insomnia (2.4% vs. 0.7%). SMM increased annually by 11% (95% CI = 3.0% to 19.7%) in patients with insomnia. After adjusting for comorbidities, there remained a 24% increased likelihood of SMM for patients with insomnia. CONCLUSIONS Coded diagnosis of insomnia during pregnancy has increased over time, and this burden disparately affects women of low socioeconomic status. Diagnosis of insomnia is an independent predictor of SMM.
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Affiliation(s)
- Anthony M Kendle
- Corresponding author: Anthony M. Kendle, 2 Tampa General Circle, Tampa, FL 33606, USA.
| | - Jason L Salemi
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa FL, USA
- College of Public Health, University of South Florida, Tampa FL, USA
| | - Chandra L Jackson
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, NC, USA
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Department of Health and Human Services, Bethesda, MD,USA
| | - Daniel J Buysse
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA,USA
| | - Judette M Louis
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa FL, USA
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Suarez EA, Bateman BT, Hernández-Díaz S, Straub L, Wisner KL, Gray KJ, Pennell PB, Lester B, McDougle CJ, Zhu Y, Mogun H, Huybrechts KF. Association of Antidepressant Use During Pregnancy With Risk of Neurodevelopmental Disorders in Children. JAMA Intern Med 2022; 182:2797101. [PMID: 36190722 PMCID: PMC9531086 DOI: 10.1001/jamainternmed.2022.4268] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/01/2022] [Indexed: 12/18/2022]
Abstract
Importance Antidepressant use during pregnancy has been associated with neurodevelopmental disorders in children in some studies. However, results may be explained by uncontrolled confounding by parental mental health status, genetics, and environmental factors. Objective To evaluate the association between antidepressant use in pregnancy and neurodevelopmental outcomes in children. Design, Setting, and Participants This cohort study of health care utilization data was separated into cohorts of publicly and privately insured pregnant individuals and their children nested in the Medicaid Analytic eXtract (MAX; 2000-2014) and the IBM MarketScan Research Database (MarketScan; 2003-2015). A total of 1.93 million pregnancies in MAX and 1.25 million pregnancies in MarketScan were recorded. Children were followed from birth until outcome diagnosis, disenrollment, death, or end of study (maximum 14 years). Analyses were conducted between August 2020 and July 2021. Exposures Dispensing of antidepressant medication from gestational week 19 until delivery, the period of synaptogenesis. Main Outcomes and Measures Neurodevelopmental disorders in children defined using validated algorithms. Early pregnancy exposure was considered in sensitivity analyses, and approaches to confounding adjustment included propensity score fine stratification, discontinuers comparison, and sibling analyses. Results Among the individuals included in the analysis, there were 145 702 antidepressant-exposed and 3 032 745 unexposed pregnancies; the mean (SD) age among the antidepressant exposed and unexposed was 26.2 (5.7) and 24.3 (5.8) years in MAX and 32.7 (4.6) and 31.9 (4.6) years in MarketScan, respectively; and in MAX, which collected information on race and ethnicity, 72.4% of the antidepressant-exposed and 37.1% of the unexposed individuals were White. Crude results suggested up to a doubling in risk of neurodevelopmental outcomes associated with antidepressant exposure; however, no association was observed in the most fully adjusted analyses. When comparing antidepressant-exposed and unexposed siblings, hazard ratios were 0.97 (95% CI, 0.88-1.06) for any neurodevelopmental disorder, 0.86 (95% CI, 0.60-1.23) for autism spectrum disorder, 0.94 (95% CI, 0.81-1.08) for attention-deficit/hyperactivity disorder, 0.77 (95% CI, 0.42-1.39) for specific learning disorders, 1.01 (95% CI, 0.88-1.16) for developmental speech/language disorder, 0.79 (95% CI, 0.54-1.17) for developmental coordination disorder, 1.00 (95% CI, 0.45-2.22) for intellectual disability, and 0.95 (95% CI, 0.80-1.12) for behavioral disorders. Results were generally consistent for antidepressant classes and drugs and across exposure windows. Conclusions and Relevance The results of this cohort study suggest that antidepressant use in pregnancy itself does not increase the risk of neurodevelopmental disorders in children. However, given strong crude associations, antidepressant exposure in pregnancy may be an important marker for the need of early screening and intervention.
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Affiliation(s)
- Elizabeth A. Suarez
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brian T. Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Sonia Hernández-Díaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Loreen Straub
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Katherine L. Wisner
- Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Kathryn J. Gray
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Page B. Pennell
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Barry Lester
- Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, Rhode Island
| | - Christopher J. McDougle
- Lurie Center for Autism, Massachusetts General Hospital, Lexington
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Yanmin Zhu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Krista F. Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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Clapp MA, Kim E, James KE, Perlis RH, Kaimal AJ, McCoy TH, Easter SR. Comparison of Natural Language Processing of Clinical Notes With a Validated Risk-Stratification Tool to Predict Severe Maternal Morbidity. JAMA Netw Open 2022; 5:e2234924. [PMID: 36197662 PMCID: PMC9535539 DOI: 10.1001/jamanetworkopen.2022.34924] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
IMPORTANCE Risk-stratification tools are routinely used in obstetrics to assist care teams in assessing and communicating risk associated with delivery. Electronic health record data and machine learning methods may offer a novel opportunity to improve and automate risk assessment. OBJECTIVE To compare the predictive performance of natural language processing (NLP) of clinician documentation with that of a previously validated tool to identify individuals at high risk for maternal morbidity. DESIGN, SETTING, AND PARTICIPANTS This retrospective diagnostic study was conducted at Brigham and Women's Hospital and Massachusetts General Hospital, Boston, Massachusetts, and included individuals admitted for delivery at the former institution from July 1, 2016, to February 29, 2020. A subset of these encounters (admissions from February to December 2018) was part of a previous prospective validation study of the Obstetric Comorbidity Index (OB-CMI), a comorbidity-weighted score to stratify risk of severe maternal morbidity (SMM). EXPOSURES Natural language processing of clinician documentation and OB-CMI scores. MAIN OUTCOMES AND MEASURES Natural language processing of clinician-authored admission notes was used to predict SMM in individuals delivering at the same institution but not included in the prospective OB-CMI study. The NLP model was then compared with the OB-CMI in the subset with a known OB-CMI score. Model discrimination between the 2 approaches was compared using the DeLong test. Sensitivity and positive predictive value for the identification of individuals at highest risk were prioritized as the characteristics of interest. RESULTS This study included 19 794 individuals; 4034 (20.4%) were included in the original prospective validation study of the OB-CMI (testing set), and the remaining 15 760 (79.6%) composed the training set. Mean (SD) age was 32.3 (5.2) years in the testing cohort and 32.2 (5.2) years in the training cohort. A total of 115 individuals in the testing cohort (2.9%) and 468 in the training cohort (3.0%) experienced SMM. The NLP model was built from a pruned vocabulary of 2783 unique words that occurred within the 15 760 admission notes from individuals in the training set. The area under the receiver operating characteristic curve of the NLP-based model for the prediction of SMM was 0.76 (95% CI, 0.72-0.81) and was comparable with that of the OB-CMI model (0.74; 95% CI, 0.70-0.79) in the testing set (P = .53). Sensitivity (NLP, 28.7%; OB-CMI, 24.4%) and positive predictive value (NLP, 19.4%; OB-CMI, 17.6%) were comparable between the NLP and OB-CMI high-risk designations for the prediction of SMM. CONCLUSIONS AND RELEVANCE In this study, the NLP method and a validated risk-stratification tool had a similar ability to identify patients at high risk of SMM. Future prospective research is needed to validate the NLP approach in clinical practice and determine whether it could augment or replace tools requiring manual user input.
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Affiliation(s)
- Mark A. Clapp
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston
| | - Ellen Kim
- Department of Radiation Oncology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Kaitlyn E. James
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston
| | - Roy H. Perlis
- Center for Quantitative Health, Massachusetts General Hospital, Boston
- Department of Psychiatry, Massachusetts General Hospital, Boston
| | - Anjali J. Kaimal
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston
- Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
| | - Thomas H. McCoy
- Center for Quantitative Health, Massachusetts General Hospital, Boston
- Department of Psychiatry, Massachusetts General Hospital, Boston
| | - Sarah Rae Easter
- Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, Massachusetts
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Masterson JA, Adamestam I, Beatty M, Boardman JP, Johnston P, Joss J, Lawrence H, Litchfield K, Walsh TS, Wise A, Wood R, Weir CJ, Denison FC, Lone NI. Severe maternal morbidity in Scotland. Anaesthesia 2022; 77:971-980. [PMID: 35820195 PMCID: PMC9544155 DOI: 10.1111/anae.15798] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2022] [Indexed: 11/26/2022]
Abstract
Using a cohort study design, we analysed 17 diagnoses and 9 interventions (including critical care admission) as a composite measure of severe maternal morbidity for pregnancies recorded over 14 years in Scotland. There were 762,918 pregnancies, of which 7947 (10 in 1000 pregnancies) recorded 9345 severe maternal morbidity events, 2802 episodes of puerperal sepsis being the most common (30%). Severe maternal morbidity incidence increased from 9 in 1000 pregnancies in 2012 to 17 in 1000 pregnancies in 2018, due in part to puerperal sepsis recording. The odds ratio (95%CI) for severe maternal morbidity was higher for: older women, for instance 1.22 (1.13-1.33) for women aged 35-39 years and 1.44 (1.27-1.63) for women aged > 40 years compared with those aged 25-29 years; obese women, for instance 1.13 (1.06-1.21) for BMI 30-40 kg.m-2 and 1.32 (1.15-1.51) for BMI > 40 kg.m-2 compared with BMI 18.5-24.9 kg.m-2 ; multiple pregnancy, 2.39 (2.09-2.74); and previous caesarean delivery, 1.52 (1.40-1.65). The median (IQR [range]) hospital stay was 3 (2-5 [1-8]) days with severe maternal morbidity and 2 (1-3 [1-5]) days without. Forty-one women died during pregnancy or up to 42 days after delivery, representing mortality rates per 100,000 pregnancies of about 365 with severe maternal morbidity and 1.6 without. There were 1449 women admitted to critical care, 807 (58%) for mechanical ventilation or support of at least two organs. We recorded an incidence of severe maternal morbidity higher than previously published, possibly because sepsis was coded inaccurately in our databases. Further research may determine the value of this composite measure of severe maternal morbidity.
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Affiliation(s)
- J. A. Masterson
- Department of Anaesthesia, Critical Care and Pain MedicineUniversity of EdinburghUK
| | | | - M. Beatty
- Department of Anaesthesia, Critical Care and Pain MedicineRoyal Infirmary of EdinburghUK
| | - J. P. Boardman
- MRC Centre for Reproductive HealthQueen's Medical Research Institute, University of EdinburghUK
| | - P. Johnston
- Department of Anaesthesia, Critical Care and Pain MedicineNinewells HospitalDundeeUK
| | - J. Joss
- Department of Anaesthesia, Critical Care and Pain MedicineNinewells HospitalDundeeUK
| | | | - K. Litchfield
- Department of Anaesthesia, Critical Care and Pain MedicineGlasgow Royal InfirmaryGlasgowUK
| | - T. S. Walsh
- Department of Anaesthesia, Critical Care and Pain MedicineRoyal Infirmary of EdinburghUK
- Usher InstituteUniversity of EdinburghUK
| | - A. Wise
- Department of Anaesthesia, Critical Care and Pain MedicineRoyal Infirmary of EdinburghUK
| | - R. Wood
- Usher InstituteUniversity of EdinburghUK
- Public Health ScotlandGlasgowUK
| | - C. J. Weir
- Usher InstituteUniversity of EdinburghUK
| | - F. C. Denison
- MRC Centre for Reproductive HealthQueen's Medical Research Institute, University of EdinburghUK
| | - N. I. Lone
- Department of Anaesthesia, Critical Care and Pain MedicineRoyal Infirmary of EdinburghUK
- Usher InstituteUniversity of EdinburghUK
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Chao GF, Yang J, Peahl AF, Thumma JR, Dimick JB, Arterburn DE, Telem DA. Comparative effectiveness of sleeve gastrectomy vs Roux-en-Y gastric bypass in patients giving birth after bariatric surgery: reinterventions and obstetric outcomes. Surg Endosc 2022; 36:6954-6968. [PMID: 35099628 DOI: 10.1007/s00464-022-09063-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 01/17/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Women of childbearing age comprise approximately 65% of all patients who undergo bariatric surgery in the USA. Despite this, data on maternal reintervention and obstetric outcomes after surgery are limited especially with regard to comparative effectiveness between sleeve gastrectomy and Roux-en-Y gastric bypass, the most common procedures today. METHODS Using IBM MarketScan claims data, we performed a retrospective cohort study of women ages 18-52 who gave birth after undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass with 2-year continuous follow-up. We balanced the cohort on observable characteristics using inverse probability weighting. We utilized multivariable logistic regression to examine the association between procedure selection and outcomes, including risk of reinterventions (revisions, enteral access, vascular access, reoperations, other) or adverse obstetric outcomes (pregnancy complications, severe maternal morbidity, and delivery complications). In all analyses, we controlled for age, U.S. state, and Elixhauser or Bateman comorbidities. RESULTS From 2011 to 2016, 1,079 women gave birth within the first two years after undergoing bariatric surgery. Among these women, we found no significant difference in reintervention rates among those who had gastric bypass compared to sleeve gastrectomy (OR 1.41, 95% CI 0.91-2.21, P = 0.13). We then examined obstetric outcomes in the patients who gave birth after bariatric surgery. Compared to patients who underwent sleeve gastrectomy, those who had Roux-en-Y gastric bypass were not significantly more likely to experience any adverse obstetric outcomes. CONCLUSION In this first national cohort of females giving birth following bariatric surgery, no significant difference was observed in persons who underwent Roux-en-Y gastric bypass versus sleeve gastrectomy with respect to either reinterventions or obstetric outcomes. This suggests possible equipoise between these two procedures with regards to safety within the first two years following a bariatric procedure among women who may become pregnant, but more research is needed to confirm these findings in larger samples.
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Affiliation(s)
- Grace F Chao
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
- Veterans Affairs Ann Arbor, Ann Arbor, MI, USA.
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
| | - Jie Yang
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Alex F Peahl
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Jyothi R Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - David E Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Dana A Telem
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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Current Epidemiology of the General Anesthesia Practice for Cesarean Delivery Using a Nationwide Claims Database in Japan: A Descriptive Study. J Clin Med 2022; 11:jcm11164808. [PMID: 36013045 PMCID: PMC9409718 DOI: 10.3390/jcm11164808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/01/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
The current status of general anesthesia practice for cesarean delivery in Japan remains unknown. Therefore, using a nationwide claims database, we aimed to investigate general anesthesia use for cesarean delivery over a period of 15 years, and to analyze the general anesthesia practice in Japan. Patients who claimed the Japanese general anesthesia claim code (L008) for cesarean delivery between 1 January 2005, and 31 March 2020, were analyzed. Primary endpoint was the prevalence of general anesthesia use. We used two definitions of general anesthesia: L008 code only (insurance definition) and combination of the L008 code with muscle relaxant use (clinical definition). The general anesthesia claim cohort (L008) included 10,972 cesarean deliveries at 1111 institutions from 2005 to 2020. Muscle relaxants were used in 27.3% of L008 claims cases. The rate of general anesthesia use for cesarean delivery ranged from 3.9% in clinical definition to 14.4% in insurance definition of all cesarean deliveries. We observed a temporal trend of gradual decrease in general anesthesia use, regardless of its definition (p for trend < 0.001). We recommend the clinical definition of general anesthesia as the combination of L008 code and muscle relaxant use in a claims-based approach.
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Potnuru PP, Ganduglia C, Schaefer CM, Suresh M, Eltzschig HK, Jiang Y. Impact of cesarean versus vaginal delivery on the risk of postpartum acute kidney injury: A retrospective database controlled study in 116,876 parturients. J Clin Anesth 2022; 82:110915. [PMID: 35969987 DOI: 10.1016/j.jclinane.2022.110915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/14/2022] [Accepted: 06/15/2022] [Indexed: 10/31/2022]
Abstract
STUDY OBJECTIVE The rate of cesarean delivery is increasing globally but the risk of perioperative organ injury associated with cesarean delivery is not well defined. The objective of this study was to determine the risk of postpartum acute kidney injury, a peripartum complication defined by an acute decrease in kidney function, associated with cesarean delivery compared to vaginal delivery. SETTING Population-based discharge database. PATIENTS The Optum Clinformatics® Data Mart was queried for parturients that underwent cesarean or vaginal delivery between January 2016 to January 2018. Using a propensity score model based on 27 antepartum characteristics, we generated a final matched cohort of 116,876 parturients. INTERVENTION/EXPOSURE Cesarean delivery as the mode of delivery. MEASUREMENTS The risk of acute kidney injury associated with each delivery mode and the effect of acute kidney injury on the length of hospital stay for parturients. MAIN RESULTS The matched cohort consisted of 116,876 deliveries, with 58,438 cases in each group. In the cesarean delivery group, the incidence of postpartum acute kidney injury was 24.5 vs. 7.9 per 10,000 deliveries in the vaginal delivery group (adjusted odds ratio = 3; 95% CI, 2.13-4.22; P < .001). The median of the length of hospital stay [interquartile range] was longer by 50% in parturients who developed postpartum acute kidney injury after vaginal delivery (3 [2-4] days vs. those who did not, 2 [2, 3] days; P < .001) and by 67% after cesarean delivery (5 [4-7] days vs. 3 [3, 4] days; P < .001). CONCLUSIONS Cesarean delivery is associated with a significantly increased risk of postpartum acute kidney injury as compared to vaginal delivery. The development of postpartum acute kidney injury is associated with prolonged length of hospital stay.
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Affiliation(s)
- Paul P Potnuru
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth), Houston, TX 77030, USA
| | - Cecilia Ganduglia
- School of Public Health, University of Texas Health Science Center at Houston (UTHealth), Houston, TX 77030, USA
| | - Caroline M Schaefer
- School of Public Health, University of Texas Health Science Center at Houston (UTHealth), Houston, TX 77030, USA
| | - Maya Suresh
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth), Houston, TX 77030, USA
| | - Holger K Eltzschig
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth), Houston, TX 77030, USA
| | - Yandong Jiang
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth), Houston, TX 77030, USA.
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Esposito DB, Huybrechts KF, Werler MM, Straub L, Hernández-Díaz S, Mogun H, Bateman BT. Characteristics of Prescription Opioid Analgesics in Pregnancy and Risk of Neonatal Opioid Withdrawal Syndrome in Newborns. JAMA Netw Open 2022; 5:e2228588. [PMID: 36001312 PMCID: PMC9403776 DOI: 10.1001/jamanetworkopen.2022.28588] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
IMPORTANCE Prescription opioids are often used during pregnancy even though they are associated with neonatal opioid withdrawal syndrome (NOWS). Most studies of adverse outcomes of opioid use for pain have assessed only the class-wide outcome despite the pharmacodynamic and pharmacokinetic heterogeneity across opioid medications. OBJECTIVE To compare the risk of NOWS across common types of opioids when prescribed as monotherapy during the last 3 months of pregnancy. DESIGN, SETTING, AND PARTICIPANTS This cohort study analyzed administrative claims data of Medicaid-insured mothers and newborns in 46 states and Washington DC from January 1, 2000, through December 31, 2014. Participants were mothers with 2 or more dispensed opioid prescriptions within 90 days before delivery and their eligible live-born neonates. Data were analyzed from February 2020 to March 2021. EXPOSURE Different types of opioid medications were compared by agonist strength (strong vs weak) and half-life (medium vs short and long vs short) of the opioid active ingredient. MAIN OUTCOMES AND MEASURES The primary outcome was NOWS, which was identified using an International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic code in the 30 days after delivery. Relative risks (RRs) were adjusted for an exposure propensity score, including demographic characteristics, comorbidities, other medication use, and opioid treatment characteristics (including morphine milligram equivalents), using fine stratification. RESULTS The cohort comprised 48 202 opioid-exposed pregnancies with live newborns. A total of 1069 neonates (2.2%) had NOWS and 559 (1.2%) had severe NOWS. Opioid exposure during pregnancy included 16 202 pregnancies exposed to codeine, 4540 to oxycodone, 1244 to tramadol, 260 to methadone (dispensed for pain), 90 to hydromorphone, and 63 to morphine compared with 25 710 exposed to hydrocodone. Demographic characteristics varied across opioids, with tramadol, oxycodone, methadone, hydromorphone, and morphine being more commonly dispensed at older maternal age (≥35 years). Compared with hydrocodone, codeine had a lower adjusted RR of NOWS (0.57; 95% CI, 0.46-0.70), with a similar adjusted RR for tramadol (RR, 1.06; 95% CI, 0.73-1.56), and 2- to 3-fold higher adjusted RRs for oxycodone (1.87; 95% CI, 1.66-2.11), morphine (2.84; 95% CI, 1.30-6.22), methadone (3.02; 95% CI, 2.45-3.73), and hydromorphone (2.03; 95% CI, 1.09-3.78). Strong agonists were associated with a higher risk of NOWS than weak agonists (RR, 1.97; 95% CI, 1.78-2.17), and long half-life opioids were associated with an increased risk compared with short half-life products (RR, 1.33; 95% CI, 1.12-1.56). Findings were consistent across sensitivity and subgroup analyses. CONCLUSIONS AND RELEVANCE Results of this study show higher risk of NOWS and severe NOWS among neonates with in utero exposure to strong agonists and long half-life prescription opioids. Information on the opioid-specific risk of NOWS may help prescribers select opioids for pain management in late stages of pregnancy.
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Affiliation(s)
- Daina B. Esposito
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Krista F. Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Martha M. Werler
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Loreen Straub
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Sonia Hernández-Díaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Brian T. Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Anesthesia, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
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Al-Huda F, Shapiro GD, Davenport MH, Bertagnolli M, Dayan N. Association between Cardiorespiratory Fitness and Hypertensive Disorders of Pregnancy: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:4364. [PMID: 35955988 PMCID: PMC9369055 DOI: 10.3390/jcm11154364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/15/2022] [Accepted: 07/21/2022] [Indexed: 02/01/2023] Open
Abstract
Hypertensive disorders of pregnancy (HDP) are associated with future cardiovascular disease (CVD), which may be mediated by diminished cardiorespiratory fitness (CRF). In this systematic review and meta-analysis, we summarize evidence linking CRF with HDP before, during, and after pregnancy. We searched relevant databases to identify observational or randomized studies that measured CRF (VO2 max or peak, VO2 at anaerobic threshold, or work rate at peak VO2) in women with and without HDP. We pooled results using random effects models. Fourteen studies (n = 2406 women) reporting on CRF before, during, and after pregnancy were included. Before pregnancy, women who developed HDP had lower CRF (e.g., VO2max < 37 vs. ≥37 mL O2/min) than those without HDP (two studies, 811 women). VO2max at 14−18 weeks of pregnancy was marginally lower among women who developed preeclampsia vs. normotensive women (three studies, 275 women; mean difference 0.43 mL/kg/min [95% CI 0.97, 0.10]). Postpartum, there was a trend towards lower VO2peak in women with previous preeclampsia (three studies, 208 women; 0.26 mL/kg/min [−0.54, 0.02]). While exploratory, our findings raise the possibility that CRF can identify women at risk for HDP, and furthermore, that HDP confers a hit to a woman’s cardiorespiratory reserve.
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Affiliation(s)
- Farah Al-Huda
- Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University Health Centre, Montreal, QC H4A 3J1, Canada;
| | - Gabriel D. Shapiro
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3A 1G1, Canada;
| | - Margie H. Davenport
- Program for Pregnancy and Postpartum Health, Faculty of Kinesiology, Sport and Recreation, University of Alberta, Edmonton, AB T6G 2H9, Canada;
| | - Mariane Bertagnolli
- School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3G 1Y5, Canada;
| | - Natalie Dayan
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3A 1G1, Canada;
- Research Institute, McGill University Health Centre, Montreal, QC H4A 3S5, Canada
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Stanhope KK, Worrell N, Jamieson DJ, Geary FH, Boulet SL. Double, Triple, and Quadruple Jeopardy: Entering Pregnancy With Two or More Multimorbid Diagnoses and Increased Risk of Severe Maternal Morbidity and Postpartum Readmission. Womens Health Issues 2022; 32:607-614. [PMID: 35835642 DOI: 10.1016/j.whi.2022.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 05/30/2022] [Accepted: 06/10/2022] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Multimorbidity, the presence of two or more chronic disease diagnoses, is associated with an increased risk of mortality and high health care costs in the general population and older adults. However, little evidence is available about the prevalence and impact of multimorbidity in obstetric populations. The goal of this analysis was to estimate the association between multimorbidity and severe maternal morbidity (SMM) and 90-day postpartum readmission in an obstetric cohort in Atlanta, Georgia. STUDY DESIGN We conducted a retrospective cohort study of livebirths and stillbirths at Grady Memorial Hospital, from October 2015 to April 2021. To determine preexisting chronic conditions, we linked information on births to inpatient diagnoses within the prior year. Multimorbidity was defined as the presence of two or more chronic disease diagnoses at birth or within the prior year. We conducted multivariable log binomial regression to estimate risk ratios and 95% confidence intervals for the crude and adjusted (for age, race/ethnicity, parity, and insurance) association between multimorbidity (two or more chronic conditions vs. zero or one) and SMM (at or within 42 days after birth) or 90-day postpartum readmission for any reason. RESULTS Of 14,225 included births, 10.1% were to patients with multimorbidity. Overall, SMM complicated 7.5% of births, and the 90-day readmission rate was 2.4%. Both SMM and readmission were more common among women with multimorbidity (SMM, 18.6% among women with multimorbidity compared with 6.3% without; 90-day readmission, 5.4% compared with 2.1%). Adjusting for potential confounders, multimorbidity was associated with increased risk of SMM (adjusted risk ratio, 2.9; 95% confidence interval, 2.5-3.0) and readmission (adjusted risk ratio, 2.2; 95% confidence interval, 1.7-2.9). CONCLUSIONS Individuals entering pregnancy with two or more chronic diseases were at an increased risk of SMM and postpartum readmission compared with individuals with one or zero chronic disease diagnoses.
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Affiliation(s)
- Kaitlyn K Stanhope
- Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, Georgia.
| | | | - Denise J Jamieson
- Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, Georgia
| | - Franklyn H Geary
- Morehouse School of Medicine, Department of Obstetrics and Gynecology, Atlanta, Georgia
| | - Sheree L Boulet
- Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, Georgia
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Parikh AN, Triplett RL, Wu TJ, Arora J, Lukas K, Smyser TA, Miller JP, Luby JL, Rogers CE, Barch DM, Warner BB, Smyser CD. Neonatal Intensive Care Unit Network Neurobehavioral Scale Profiles in Full-Term Infants: Associations with Maternal Adversity, Medical Risk, and Neonatal Outcomes. J Pediatr 2022; 246:71-79.e3. [PMID: 35430247 PMCID: PMC10030163 DOI: 10.1016/j.jpeds.2022.04.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 03/01/2022] [Accepted: 04/08/2022] [Indexed: 01/30/2023]
Abstract
OBJECTIVES To examine healthy, full-term neonatal behavior using the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS) in relation to measures of maternal adversity, maternal medical risk, and infant brain volumes. STUDY DESIGN This was a prospective, longitudinal, observational cohort study of pregnant mothers followed from the first trimester and their healthy, full-term infants. Infants underwent an NNNS assessment and high-quality magnetic resonance imaging 2-5 weeks after birth. A latent profile analysis of NNNS scores categorized infants into neurobehavioral profiles. Univariate and multivariate analyses compared differences in maternal factors (social advantage, psychosocial stress, and medical risk) and neonatal characteristics between profiles. RESULTS The latent profile analysis of NNNS summary scales of 296 infants generated 3 profiles: regulated (46.6%), hypotonic (16.6%), and fussy (36.8%). Infants with a hypotonic profile were more likely to be male (χ2 = 8.601; P = .014). Fussy infants had smaller head circumferences (F = 3.871; P = .022) and smaller total brain (F = 3.522; P = .031) and cerebral white matter (F = 3.986; P = .020) volumes compared with infants with a hypotonic profile. There were no differences between profiles in prenatal maternal health, social advantage, or psychosocial stress. CONCLUSIONS Three distinct neurobehavioral profiles were identified in healthy, full-term infants with hypotonic and fussy neurobehavioral features related to neonatal brain volumes and head circumference, but not prenatal exposure to socioeconomic or psychosocial adversity. Follow-up beyond the neonatal period will determine if identified profiles at birth are associated with subsequent clinical or developmental outcomes.
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Affiliation(s)
- Amisha N Parikh
- School of Medicine, Washington University in St. Louis, St. Louis, MO
| | - Regina L Triplett
- Department of Neurology, Washington University in St. Louis, St. Louis, MO.
| | - Tiffany J Wu
- School of Medicine, Washington University in St. Louis, St. Louis, MO
| | - Jyoti Arora
- Division of Biostatistics, Washington University in St. Louis, St. Louis, MO
| | - Karen Lukas
- Department of Neurology, Washington University in St. Louis, St. Louis, MO
| | - Tara A Smyser
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO
| | - J Philip Miller
- Division of Biostatistics, Washington University in St. Louis, St. Louis, MO
| | - Joan L Luby
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO
| | - Cynthia E Rogers
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO; Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Deanna M Barch
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO; Department of Psychological and Brain Sciences, Washington University in St. Louis, St. Louis, MO; Department of Radiology, Washington University in St. Louis, St. Louis, MO
| | - Barbara B Warner
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Christopher D Smyser
- Department of Neurology, Washington University in St. Louis, St. Louis, MO; Department of Pediatrics, Washington University in St. Louis, St. Louis, MO; Department of Radiology, Washington University in St. Louis, St. Louis, MO
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Rosa AC, Pacchiarotti A, Addis A, Ciardulli A, Belleudi V, Davoli M, Kirchmayer U. Effectiveness and safety of gonadotropins used in female infertility: a population-based study in the Lazio region, Italy. Eur J Clin Pharmacol 2022; 78:1185-1196. [PMID: 35507074 PMCID: PMC9184418 DOI: 10.1007/s00228-022-03330-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 04/25/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Infertility is a topic of growing interest, and female infertility is often treated with gonadotropins. Evidence regarding comparative safety and efficacy of different gonadotropin formulations is available from clinical studies, while real-world data are missing. The present study aims to investigate effectiveness and safety of treatment with different gonadotropin formulations in women undergoing medically assisted procreation treatments in Latium, a region in central Italy, through a real-world data approach. METHODS A retrospective population-based cohort study in women between the ages of 18 and 45 years who were prescribed with at least one gonadotropin between 2007 and 2019 was conducted. Women were enrolled from the regional drug dispense registry, and data on their clinical history, exposure to therapeutic cycles (based on recombinant "REC" or extractives "EXT" gonadotropin, or combined protocol "CMD" (REC + EXT)), and maternal/infantile outcomes were linked from the regional healthcare administrative databases. Multivariate logistic regression models were applied to estimate the association between exposure and outcomes. RESULTS Overall, 90,292 therapeutic cycles prescribed to 35,899 women were linked to pregnancies. Overall, 15.8% of cycles successfully led to pregnancy. Compared to extractives, recombinant and combined treatments showed a stronger association with conception rate (RRREC adj = 1.06, 95% CI: 1.01-1.12; RRCBD adj = 1.17, 95% CI: 1.11-1.24). Maternal outcomes occurred in less than 5% of deliveries, and no significant differences between treatments were observed (REC vs EXT, pre-eclampsia: RR adj = 1.24, 95% CI: 0.86-1.79, ovarian hyperstimulation syndrome: RR adj = 1.25, 95% CI: 0.59-2.65, gestational diabetes: RR adj = 1.06, 95% CI: 0.84-1.35). Regarding infantile outcomes, similar results were obtained for different gonadotropin formulations (REC vs EXT: low birth weight: RR adj = 0.98, 95% CI: 0.83-1.26, multiple births: RR adj = 1.06, 95% CI: 0.92-1.23, preterm birth: RR adj = 1.03, 95% CI: 0.92-1.26). CONCLUSIONS Efficacy and safety profiles of REC proved to be similar to those of EXT. Regarding the efficacy in terms of conception rate and birth rate, protocols using the combined approach performed slightly better. Outcomes related to maternal and infantile safety were generally very rare, and safety features were overlapping between gonadotropin formulations.
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Affiliation(s)
| | | | - Antonio Addis
- Department of Epidemiology, Regional Health Service, ASL Roma 1, Rome, Lazio, Italy
| | - Andrea Ciardulli
- Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, Ospedale Cristo Re, Rome, Italy
| | - Valeria Belleudi
- Department of Epidemiology, Regional Health Service, ASL Roma 1, Rome, Lazio, Italy
| | - Marina Davoli
- Department of Epidemiology, Regional Health Service, ASL Roma 1, Rome, Lazio, Italy
| | - Ursula Kirchmayer
- Department of Epidemiology, Regional Health Service, ASL Roma 1, Rome, Lazio, Italy
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Interrante JD, Tuttle MS, Admon LK, Kozhimannil KB. Severe Maternal Morbidity and Mortality Risk at the Intersection of Rurality, Race and Ethnicity, and Medicaid. Womens Health Issues 2022; 32:540-549. [PMID: 35760662 DOI: 10.1016/j.whi.2022.05.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 05/19/2022] [Accepted: 05/31/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE We examined differences in rates of severe maternal morbidity and mortality (SMMM) among Medicaid-funded compared with privately insured hospital births through specific additive and intersectional risk by rural or urban geography, race and ethnicity, and clinical factors. METHODS We used maternal discharge records from childbirth hospitalizations in the Health care Cost and Utilization Project's National Inpatient Sample from 2007 to 2015. We calculated predicted probabilities using weighted multivariable logistic regressions to estimate adjusted rates of SMMM, examining differences in rates by payer, rurality, race and ethnicity, and clinical factors. To assess the presence and extent of additive risk by payer, with other risk factors, on rates of SMMM, we estimated the proportion of the combined effect that was due to the interaction. RESULTS In this analysis of 6,357,796 hospitalizations for childbirth, 2,932,234 were Medicaid funded and 3,425,562 were privately insured. Controlling for sociodemographic and clinical factors, the highest rate of SMMM (224.9 per 10,000 births) occurred among rural Indigenous Medicaid-funded births. Medicaid-funded births among Black rural and urban residents, and among Hispanic urban residents, also experienced elevated rates and significant additive interaction. Thirty-two percent (Bonferroni-adjusted 95% confidence interval, 19%-45%) of SMMM cases among patients with chronic heart disease were due to payer interaction, and 19% (Bonferroni-adjusted 95% confidence interval, 17%-22%) among those with cesarean birth were due to the interaction. CONCLUSIONS Heightened rates of SMMM among Medicaid-funded births indicate an opportunity for tailored state and federal policy responses to address the particular maternal health challenges faced by Medicaid beneficiaries, including Black, Indigenous, and rural residents.
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Affiliation(s)
- Julia D Interrante
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota.
| | - Mariana S Tuttle
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - Lindsay K Admon
- Department of Obstetrics and Gynecology and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Katy B Kozhimannil
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota
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Shen JJ, Mojtahedi Z, Vanderlaan J, Rathi S. Disparities in Adverse Maternal Outcomes Among Five Race and Ethnicity Groups. J Womens Health (Larchmt) 2022; 31:1432-1439. [PMID: 35675682 DOI: 10.1089/jwh.2021.0495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Racial/ethnic disparities are evident in adverse maternal health outcomes, but they are shifting due to interventions, initiatives, changing demographics, and the prevalence of preexisting conditions. This study examined the current racial/ethnic disparities in adverse maternal outcomes. Materials and Methods: In a cross-sectional study, the International Classification of Diseases-10 codes for the principal diagnosis and secondary diagnoses were retrieved from the National Inpatient Sample database (2016-2018). A weighted multiple logistic regression model assessed disparities in seven adverse maternal outcomes, including preterm labor, gestational hypertension (GHTN) and diabetes, premature rupture of membranes (PRM), infection of the amniotic cavity (INFAC), placental abruption, and postpartum hemorrhage (PPH). A weighted linear regression model assessed disparities in a composite variable of maternal outcomes. A maternal-specific comorbidity index assessed risk adjustment, and other clinical, sociodemographic, and hospital factors were considered. Results: A total of 2,211,345 pregnancies were included. Preterm labor, GHTN, and placental abruption had the highest raw rate among Black women compared to all races. After adjusting for control variables in the regression analysis, these adverse outcomes also showed the highest odds ratio (OR) among Black women compared to White women (the reference group). Gestational diabetes, PRM, and INFAC had the highest raw rate among Asians/Pacific Islanders (PIs). After adjusting for control variables, these adverse outcomes also showed the highest OR among Asians/PIs compared to White women. The OR for PPH was the highest for Native Americans compared to White women. Furthermore, results of the composite outcome variable indicated that all minority groups experienced the overall poorer maternal outcome than White women. Conclusions: Overall, all four minority women had higher raw rates and also odds of experiencing the studied adverse outcomes than White women. Existing efforts should be strengthened to continue reducing racial/ethnic disparities in adverse maternal outcomes.
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Affiliation(s)
- Jay J Shen
- Department of Healthcare Administration and Policy, School of Public Health, University of Nevada, Las Vegas, Nevada, USA
| | - Zahra Mojtahedi
- Department of Healthcare Administration and Policy, School of Public Health, University of Nevada, Las Vegas, Nevada, USA
| | | | - Sfurti Rathi
- Department of Healthcare Administration and Policy, School of Public Health, University of Nevada, Las Vegas, Nevada, USA
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138
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Shen HS, Chang WC, Chen YL, Wu DL, Wen SH, Wu HC. Chinese Herbal Medicines Have Potentially Beneficial Effects on the Perinatal Outcomes of Pregnant Women. Front Pharmacol 2022; 13:831690. [PMID: 35734397 PMCID: PMC9207412 DOI: 10.3389/fphar.2022.831690] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction: Tocolytic treatment is beneficial to pregnant women with a risk of premature labor or miscarriage. However, previous reports have shown that progestogen might not be effective and ritodrine may increase the risk of maternal vascular-related diseases. Chinese herbal products (CHP) are used as alternative therapies for pregnant women. The goal was to evaluate the efficacy of combined tocolytic therapy and CHP therapy in pregnancy outcomes for pregnant women in Taiwan.Materials and Methods: We conducted a retrospective cohort study based on the National Health Insurance Research Database. A total of 47,153 pregnant women treated with tocolytics aged 18–50 years from 2001 to 2015 were selected from two million random samples. According to the medical use of tocolytics and CHP, we divided the users into two groups: western medicine (WM) only (n = 40,961) and WM/CHP (n = 6,192) groups. A propensity score (PS)-matched cohort (6,192 pairs) was established based on baseline confounders. All participants were followed up to perinatal outcomes. Conditional logistic regression analysis was used to examine the effects of CHP use on the odds of miscarriage and preterm birth.Results: The adjusted odds ratio (OR) for premature birth in the WM/CHP group (n = 411, 6.64%) was significantly lower than in the WM group (n = 471, 7,61%) (0,86, 95% confidence interval [CI], 0.74–0.99). Further subgroup analysis based on the usage of formulae that activate blood and remove stasis or purgative formulae, the adjusted OR of preterm birth of those using these formulae was significantly lower in the WM/CHP group (n = 215, 6.32%) than that in the WM group (n = 265, 7.77%) (OR: 0.79, 95% CI: 0.65–0.96).Conclusion: We found that the combination of CHP and tocolytics can be beneficial to pregnant women in the prevention of premature birth. Further research is required to investigate causal relationships.
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Affiliation(s)
- Hsuan-Shu Shen
- Department of Chinese Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- School of Post-baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan
- Sports Medicine Center, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Wei-Chuan Chang
- Department of Medical Research, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - Yi-Lin Chen
- Department of Obstetrics and Gynecology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Dai-Lun Wu
- Department of Public Health, College of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Shu-Hui Wen
- Department of Public Health, College of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Hsien-Chang Wu
- School of Post-baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan
- Department of Chinese Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
- *Correspondence: Hsien-Chang Wu,
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139
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Cairncross ZF, Couloigner I, Ryan MC, McMorris C, Muehlenbachs L, Nikolaou N, Wong RCK, Hawkins SM, Bertazzon S, Cabaj J, Metcalfe A. Association Between Residential Proximity to Hydraulic Fracturing Sites and Adverse Birth Outcomes. JAMA Pediatr 2022; 176:585-592. [PMID: 35377398 PMCID: PMC8981068 DOI: 10.1001/jamapediatrics.2022.0306] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The association between hydraulic fracturing and human development is not well understood. Several studies have identified significant associations between unconventional natural gas development and adverse birth outcomes; however, geology and legislation vary between regions. OBJECTIVE To examine the overall association between residential proximity to hydraulic fracturing sites and adverse birth outcomes, and investigate whether well density influenced this association. DESIGN, SETTING, AND PARTICIPANTS This population-based retrospective cohort study of pregnant individuals in rural Alberta, Canada, took place from 2013 to 2018. Participants included reproductive-aged individuals (18-50 years) who had a pregnancy from January 1, 2013, to December 31, 2018, and lived in rural areas. Individuals were excluded if they lived in an urban setting, were outside of the age range, or were missing data on infant sex, postal code, or area-level socioeconomic status. EXPOSURES Oil and gas wells that underwent hydraulic fracturing between 2013 to 2018 were identified through the Alberta Energy Regulator (n = 4871). Individuals were considered exposed if their postal delivery point was located within 10 km of 1 or more wells that was hydraulically fractured during 1 year preconception or during pregnancy. MAIN OUTCOMES AND MEASURES Outcomes investigated were spontaneous and indicated preterm birth, small for gestational age, major congenital anomalies, and severe neonatal morbidity or mortality. RESULTS After exclusions, the sample included 26 193 individuals with 34 873 unique pregnancies, and a mean (SD) parental age of 28.2 (5.2) years. Small for gestational age and major congenital anomalies were significantly higher for individuals who lived within 10 km of at least 1 hydraulically fractured well after adjusting for parental age at delivery, multiple births, fetal sex, obstetric comorbidities, and area-level socioeconomic status. Risk of spontaneous preterm birth and small for gestational age were significantly increased in those with 100 or more wells within 10 km. CONCLUSIONS AND RELEVANCE Results suggest that individuals who were exposed to hydraulic fracturing within pregnancy may be at higher risk of several adverse birth outcomes. These results may be relevant to health policy regarding legislation of unconventional oil and gas development in Canada and internationally.
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Affiliation(s)
- Zoe F. Cairncross
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Isabelle Couloigner
- Department of Geography, University of Calgary, Calgary, Alberta, Canada,Department of Ecosystem and Public Health, University of Calgary, Calgary, Alberta, Canada
| | - M. Cathryn Ryan
- Department of Geoscience, University of Calgary, Calgary, Alberta, Canada
| | - Carly McMorris
- Werklund School of Education, University of Calgary, Calgary, Alberta, Canada
| | | | - Nickie Nikolaou
- Faculty of Law, University of Calgary, Calgary, Alberta, Canada
| | - Ron Chik-Kwong Wong
- Department of Civil Engineering, University of Calgary, Calgary, Alberta, Canada
| | | | - Stefania Bertazzon
- Department of Geography, University of Calgary, Calgary, Alberta, Canada
| | - Jason Cabaj
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Amy Metcalfe
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada,Department of Medicine, University of Calgary, Calgary, Canada
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140
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Wen T, Schmidt CN, Sobhani NC, Guglielminotti J, Miller EC, Sutton D, Lahtermaher Y, D'Alton ME, Friedman AM. Trends and outcomes for deliveries with hypertensive disorders of pregnancy from 2000 to 2018: A repeated cross-sectional study. BJOG 2022; 129:1050-1060. [PMID: 34865302 PMCID: PMC10028501 DOI: 10.1111/1471-0528.17038] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 11/10/2021] [Accepted: 11/24/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To analyse trends, risk factors, and outcomes related to hypertensive disorders of pregnancy (HDP). DESIGN Repeated cross-sectional. SETTING US delivery hospitalisations. POPULATION Delivery hospitalisations in the 2000-2018 National Inpatient Sample. METHODS US hospital delivery hospitalisations with HDP were analysed. Several trends were analysed: (i) the proportion of deliveries by year with HDP, (ii) the proportion of deliveries with HDP risk factors and (iii) adverse outcomes associated with HDP including maternal stroke, acute renal failure and acute liver injury. Risk ratios were determined using regression models with HDP as the exposure of interest. MAIN OUTCOME MEASURES Prevalence of HDP, risk factors for HDP and associated adverse outcomes. RESULTS Of 73.1 million delivery hospitalisations, 7.7% had an associated diagnosis of HDP. Over the study period, HDP doubled from 6.0% of deliveries in 2000 to 12.0% in 2018. The proportion of deliveries with risk factors for HDP increased from 9.6% in 2000 to 24.6% in 2018. In adjusted models, HDP were associated with increased stroke (aRR [adjusted risk ratio] 15.9, 95% CI 14.8-17.1), acute renal failure (aRR 13.8, 95% CI 13.5-14.2) and acute liver injury (aRR 1.2, 95% CI 1.2-1.3). Among deliveries with HDP, acute renal failure and acute liver injury increased; in comparison, stroke decreased. CONCLUSION Hypertensive disorders of pregnancy increased in the setting of risk factors for HDP becoming more common, whereas stroke decreased. TWEETABLE ABSTRACT While hypertensive disorders of pregnancy increased from 2000 to 2018, stroke appears to be decreasing.
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Affiliation(s)
- Timothy Wen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Christina N Schmidt
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Nasim C Sobhani
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Jean Guglielminotti
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Eliza C Miller
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Desmond Sutton
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York, USA
| | - Yael Lahtermaher
- Escola de Medicina Souza Marques (EMSM), Fundação Tecnico Educação Souza Marques, Rio De Janeiro, Brazil
| | - Mary E D'Alton
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York, USA
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York, USA
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141
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Yu K, Faye AS, Wen T, Guglielminotti JR, Huang Y, Wright JD, D'Alton ME, Friedman AM. Outcomes during delivery hospitalisations with inflammatory bowel disease. BJOG 2022; 129:1073-1083. [PMID: 35152548 DOI: 10.1111/1471-0528.17039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/22/2021] [Accepted: 11/05/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To characterise inflammatory bowel disease (IBD) trends and associated risk during delivery hospitalisations. DESIGN Cross-sectional. SETTING US delivery hospitalisations. POPULATION Delivery hospitalisations in the 2000-2018 National Inpatient Sample. METHODS This study analysed a nationally representative hospital discharge database based on the presence of IBD. Temporal trends in IBD were analysed using joinpoint regression to estimate the average annual percent change (AAPC). IBD severity was characterised by the presence of diagnoses such as penetrating and stricturing disease and history of bowel resection. Risks for adverse outcomes were analysed based on presence of IBD. Poisson regression models were performed with unadjusted and adjusted risk ratios (aRR) as measures of effect. MAIN OUTCOME MEASURE Prevalence of IBD and associated adverse outcomes. RESULTS Of 73 109 790 delivery hospitalisations, 89 965 had a diagnosis of IBD. IBD rose from 0.06% in 2000 to 0.21% in 2018 (AAPC 7.3%, 95% CI 6.7-7.9%). Among deliveries with IBD, IBD severity diagnoses increased from 4.1% to 8.1% from 2000 to 2018. In adjusted analysis, IBD was associated with increased risk for preterm delivery (aRR 1.50, 95% CI 1.47-1.53), severe maternal morbidity (aRR 1.93, 95% CI 1.83-2.04), venous thrombo-embolism (aRR 2.76, 95% CI 2.39-3.18) and surgical injury during caesarean delivery hospitalisation (aRR 5.03, 95% CI 4.76-5.31). In the presence of a severe IBD diagnosis, risk was further increased for all adverse outcomes. CONCLUSION IBD is increasing in the obstetric population and is associated with adverse outcomes. Risk is increased in the presence of a severe IBD diagnosis. TWEETABLE ABSTRACT Deliveries among women with inflammatory bowel disease are increasing. Disease severity is associated with adverse outcomes.
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Affiliation(s)
- K Yu
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - A S Faye
- Department of Medicine, Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
| | - T Wen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California-San Francisco, San Francisco, CA, USA
| | | | - Y Huang
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - J D Wright
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - M E D'Alton
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - A M Friedman
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
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142
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Yehuda R. Performance of obstetric comorbidity indices within race/ethnicity categories. Int J Obstet Anesth 2022; 51:103569. [DOI: 10.1016/j.ijoa.2022.103569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/19/2022] [Accepted: 06/15/2022] [Indexed: 10/18/2022]
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143
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Symum H, Zayas-Castro J. Impact of Statewide Mandatory Medicaid Managed Care (SMMC) Programs on Hospital Obstetric Outcomes. Healthcare (Basel) 2022; 10:healthcare10050874. [PMID: 35628011 PMCID: PMC9141169 DOI: 10.3390/healthcare10050874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/24/2022] [Accepted: 05/01/2022] [Indexed: 11/16/2022] Open
Abstract
The state of Florida implemented mandatory managed care for Medicaid enrollees via the Statewide Medicaid Managed Care (SMMC) program in April of 2014. The objective of this study was to examine the impact of the implementation of the SMMC program on the access to care and quality of maternal care for Medicaid enrollees, as measured by several hospital obstetric outcomes. The primary data source for this retrospective observational study was the Hospital Cost and Utilization Project (HCUP) all-payer State ED (SED) visit and State Inpatient Databases (SIDs) from 2010 to 2017. The primary health outcomes for obstetric care were primary cesarean, preterm birth, postpartum preventable ED visits, postpartum preventable readmissions, and vaginal delivery after cesarean (VBAC) rates. Using difference-in-differences (DID) estimation, selected health outcomes were examined for Florida residents with Medicaid beneficiaries (treatment) and the commercially insured population (comparison), before and after the implementation of SMMC. Improvement in disparities for racial/ethnic minority Medicaid enrollees was estimated relative to whites, compared to the relative change among commercially insured patients. From the DID estimation, the findings showed that SMMC is statistically significantly associated with a higher reduction in primary cesarean rates, preterm births, preventable postpartum ED visits, and readmissions among Medicaid beneficiaries relative to their commercially insured counterparts. However, this study did not find any significant reduction in racial/ethnic disparities in obstetric outcomes. In general, this study highlights the impact of SMMC implementation on obstetric outcomes in Florida and provides important insights and potential scope for improvement in obstetric care quality and associated racial/ethnic disparities.
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144
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Travel time to delivery, antenatal care, and birth outcomes: a population-based cohort of uncomplicated pregnancies in British Columbia, 2012-2019. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:886-894. [PMID: 35525429 DOI: 10.1016/j.jogc.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Health policy and system leaders need to know whether long travel time to a delivery facility adversely affects birth outcomes. In this study, we estimated associations between travel time to delivery and outcomes in low-risk pregnancies. METHODS This population-based cohort included all singleton births without obstetric comorbidities or intrapartum facility transfers in British Columbia, Canada, from 2012 to 2019. Travel time was measured from maternal residential postal code to delivery facility using road network analysis. We estimated associations between travel time and severe maternal morbidity, stillbirth, preterm birth, and small-for-gestational age (SGA) and large-for-gestational age (LGA) status using logistic regression, adjusted for confounders (adjusted odds ratios [aORs]). To examine variations in associations between travel time and outcomes by antenatal care utilization, we stratified models by antenatal care categories. RESULTS Of 232 698 births, 3.8% occurred at a facility ≥60 minutes from the maternal residence. Obesity, adolescent age, substance use, inadequate prenatal care, and low socioeconomic status were more frequent among those traveling farther for delivery. Travel time ≥120 minutes was associated with increased risk of stillbirth (aOR 1.8; 95% CI 1.2-2.8), preterm birth (aOR 2.3; 95% CI 2 1-2.5), LGA (aOR 1.5; 95% CI 1.4-1.6), and severe maternal morbidity (aOR 1.5; 95% CI 1.2-1.8), but not SGA (aOR 1.0; 95% CI 0.8-1.1), when compared with a travel time of 1-29 minutes. Risk of stillbirth was greatest with inadequate and intensive (adequate plus) antenatal care but persisted for severe maternal morbidity, preterm birth, and LGA across categories. CONCLUSION Longer travel time to delivery was associated with increased risk of adverse outcomes in low-risk pregnancies after adjusting for confounding factors. Associations were stronger among those with inadequate antenatal care.
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145
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Straub L, Hernández-Díaz S, Bateman BT, Wisner KL, Gray KJ, Pennell PB, Lester B, McDougle CJ, Suarez EA, Zhu Y, Zakoul H, Mogun H, Huybrechts KF. Association of Antipsychotic Drug Exposure in Pregnancy With Risk of Neurodevelopmental Disorders: A National Birth Cohort Study. JAMA Intern Med 2022; 182:522-533. [PMID: 35343998 PMCID: PMC8961398 DOI: 10.1001/jamainternmed.2022.0375] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Although antipsychotic drugs cross the placenta and animal data suggest potential neurotoxic effects, information regarding human neurodevelopmental teratogenicity is limited. OBJECTIVE To evaluate whether children prenatally exposed to antipsychotic medication are at an increased risk of neurodevelopmental disorders (NDD). DESIGN, SETTINGS, AND PARTICIPANTS This birth cohort study used data from the Medicaid Analytic eXtract (MAX, 2000-2014) and the IBM Health MarketScan Research Database (MarketScan, 2003-2015) for a nationwide sample of publicly (MAX) and privately (MarketScan) insured mother-child dyads with up to 14 years of follow-up. The MAX cohort consisted of 2 034 883 children who were not prenatally exposed and 9551 who were prenatally exposed to antipsychotic medications; the MarketScan consisted of 1 306 408 and 1221 children, respectively. Hazard ratios were estimated through Cox proportional hazards regression, using propensity score overlap weights for confounding control. Estimates from both cohorts were combined through meta-analysis. EXPOSURES At least 1 dispensing of a medication during the second half of pregnancy (period of synaptogenesis), assessed for any antipsychotic drug, at the class level (atypical and typical), and for the most commonly used drugs (aripiprazole, olanzapine, quetiapine, risperidone, and haloperidol). MAIN OUTCOMES AND MEASURES Autism spectrum disorder, attention-deficit/hyperactivity disorder, learning disability, speech or language disorder, developmental coordination disorder, intellectual disability, and behavioral disorder, identified using validated algorithms, and the composite outcome of any NDD. Data were analyzed from April 2020 to January 2022. RESULTS The MAX cohort consisted of 2 034 883 unexposed pregnancies and 9551 pregnancies with 1 or more antipsychotic drug dispensings among women with a mean (SD) age of 26.8 (6.1) years, 204 (2.1%) of whom identified as Asian/Pacific Islander, 2720 (28.5%) as Black, 500 (5.2%) as Hispanic/Latino, and 5356 (56.1%) as White. The MarketScan cohort consisted of 1 306 408 unexposed and 1221 exposed pregnancies among women with a mean (SD) age of 33.1 (5.0) years; race and ethnicity data were not available. Although the unadjusted results were consistent with an approximate 2-fold increased risk for most exposure-outcome contrasts, risks were no longer meaningfully increased after adjustment (eg, pooled unadjusted vs adjusted hazard ratios [95% CI] for any NDD after any antipsychotic exposure: 1.91 [1.79-2.03] vs 1.08 [1.01-1.17]), with the possible exception of aripiprazole (1.36 [1.14-1.63]). Results were consistent across sensitivity analyses. CONCLUSIONS AND RELEVANCE The findings of this birth cohort study suggest that the increased risk of NDD seen in children born to women who took antipsychotic drugs late in pregnancy seems to be explained by maternal characteristics and is not causally related with prenatal antipsychotic exposure. This finding highlights the importance of closely monitoring the neurodevelopment of the offspring of women with mental illness to ensure early intervention and support. The potential signal for aripiprazole requires replication in other data before causality can be assumed.
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Affiliation(s)
- Loreen Straub
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sonia Hernández-Díaz
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Katherine L Wisner
- The Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Kathryn J Gray
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Page B Pennell
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Barry Lester
- Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Alpert Medical School of Brown University, and Women and Infants Hospital, Providence, Rhode Island
| | - Christopher J McDougle
- Lurie Center for Autism, Massachusetts General Hospital, Lexington.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth A Suarez
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Yanmin Zhu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Heidi Zakoul
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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146
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Sociodemographic and Geographic Disparities in Obstetrical Ultrasound Imaging Utilization: A Population-based Study. Acad Radiol 2022; 29:650-662. [PMID: 34452819 DOI: 10.1016/j.acra.2021.07.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/30/2021] [Accepted: 07/10/2021] [Indexed: 11/23/2022]
Abstract
RATIONALE AND OBJECTIVES Obstetrical ultrasound imaging is an important part of prenatal care, though not all patients have readily available access to ultrasound services. This study aimed to assess the association between sociodemographic and geographic factors and (1) having a second trimester complete obstetrical ultrasound and (2) overall obstetrical ultrasound utilization. METHODS All pregnancies and obstetrical ultrasound exams billed from 2014-2018 in Saskatchewan, Canada were identified from province-wide databases. Generalized estimating equation (GEE) models with binomial and Poisson distributions were used to identify factors associated with having a second trimester ultrasound and overall obstetrical ultrasound utilization, respectively. RESULTS 80,536 pregnancies from 57,881 individuals were included. Of 57,186 pregnancies carried to ≥23 weeks, a second trimester ultrasound was performed in 50,180 (87.7%). Patients living in rural areas (adjusted odds ratio [aOR], 0.70; 95% confidence interval [CI], 0.63-0.77; p <0.0001), remote areas (aOR, 0.35 for greatest vs. least remoteness level; 95% CI, 0.32-0.39; p <0.0001), and status First Nations individuals (aOR, 0.50; 95% CI, 0.46-0.53; p <0.0001) were less likely to have a second trimester ultrasound. Patients living in higher income neighbourhoods (aOR, 1.86 for highest vs. lowest quintile; 95% CI, 1.62-2.13; p <0.0001) were more likely to have a second trimester ultrasound. GEE Poisson regression analysis demonstrated these same factors, except rural residence, were associated with overall obstetrical ultrasound utilization. CONCLUSION Substantial disparities in obstetrical ultrasound utilization exist among patients in remote geographic areas, Indigenous peoples, and patients in low income neighbourhoods. Addressing barriers which these demographic groups face in accessing ultrasound imaging is critical to ensure health equity.
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147
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The effect of severe maternal morbidity on infant costs and lengths of stay. J Perinatol 2022; 42:611-616. [PMID: 35184145 PMCID: PMC9098672 DOI: 10.1038/s41372-022-01343-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 01/05/2022] [Accepted: 02/03/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To examine the association between severe maternal morbidity (SMM) and infant health using the additional infant costs and length of stay (LOS) as markers of added clinical complexity. STUDY DESIGN Secondary data analysis using California linked birth certificate-patient discharge data for 2009-2011 (N = 1,260,457). Regression models were used to estimate the association between SMM and infant costs and LOS. RESULTS The 16,687 SMM-exposed infants experienced a $6550 (33%) increase in costs and a 0.7 (18%) day increase in LOS. Preterm infants had ($11,258 (18%) added costs and 1.3 days (8.1%) longer LOS) than term infants ($2539 (38%) added costs and 0.5 days (22%) longer LOS). CONCLUSIONS SMM was associated with increased infant costs and LOS, suggesting that SMM may have adverse health effects for infants, including term infants. The relatively larger effect on costs indicates an increase in treatment intensity (clinical severity) greater than additional LOS.
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148
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Natural language processing of admission notes to predict severe maternal morbidity during the delivery encounter. Am J Obstet Gynecol 2022; 227:511.e1-511.e8. [PMID: 35430230 DOI: 10.1016/j.ajog.2022.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/31/2022] [Accepted: 04/09/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Severe maternal morbidity and mortality remain public health priorities in the United States, given their high rates relative to other high-income countries and the notable racial and ethnic disparities that exist. In general, accurate risk stratification methods are needed to help patients, providers, hospitals, and health systems plan for and potentially avert adverse outcomes. OBJECTIVE Our objective was to understand if machine learning methods with natural language processing of history and physical notes could identify a group of patients at high risk of maternal morbidity on admission for delivery without relying on any additional patient information (eg, demographics and diagnosis codes). STUDY DESIGN This was a retrospective study of people admitted for delivery at 2 hospitals (hospitals A and B) in a single healthcare system between July 1, 2016, and June 30, 2020. The primary outcome was severe maternal morbidity, as defined by the Centers for Disease Control and Prevention; furthermore, we examined nontransfusion severe maternal morbidity. Clinician documents designated as history and physical notes were extracted from the electronic health record for processing and analysis. A bag-of-words approach was used for this natural language processing analysis (ie, each history or physical note was converted into a matrix of counts of individual words (or phrases) that occurred within the document). The least absolute shrinkage and selection operator models were used to generate prediction probabilities for severe maternal morbidity and nontransfusion severe maternal morbidity for each note. Model discrimination was assessed via the area under the receiver operating curve. Discrimination was compared between models using the DeLong test. Calibration plots were generated to assess model calibration. Moreover, the natural language processing models with history and physical note texts were compared with validated obstetrical comorbidity risk scores based on diagnosis codes. RESULTS There were 13,572 delivery encounters with history and physical notes from hospital A, split between training (Atrain, n=10,250) and testing (Atest, n=3,322) datasets for model derivation and internal validation. There were 23,397 delivery encounters with history and physical notes from hospital B (Bvalid) used for external validation. For the outcome of severe maternal morbidity, the natural language processing model had an area under the receiver operating curve of 0.67 (95% confidence interval, 0.63-0.72) and 0.72 (95% confidence interval, 0.70-0.74) in the Atest and Bvalid datasets, respectively. For the outcome of nontransfusion severe maternal morbidity, the area under the receiver operating curve was 0.72 (95% confidence interval, 0.65-0.80) and 0.76 (95% confidence interval, 0.73-0.79) in the Atest and Bvalid datasets, respectively. The calibration plots demonstrated the bag-of-words model's ability to distinguish a group of individuals at a substantially higher risk of severe maternal morbidity and nontransfusion severe maternal morbidity, notably those in the top deciles of predicted risk. Areas under the receiver operating curve in the natural language processing-based models were similar to those generated using a validated, retrospectively derived, diagnosis code-based comorbidity score. CONCLUSION In this practical application of machine learning, we demonstrated the capabilities of natural language processing for the prediction of severe maternal morbidity based on provider documentation inherently generated at the time of admission. This work should serve as a catalyst for providers, hospitals, and electronic health record systems to explore ways that artificial intelligence can be incorporated into clinical practice and evaluated rigorously for their ability to improve health.
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Triplett RL, Lean RE, Parikh A, Miller JP, Alexopoulos D, Kaplan S, Meyer D, Adamson C, Smyser TA, Rogers CE, Barch DM, Warner B, Luby JL, Smyser CD. Association of Prenatal Exposure to Early-Life Adversity With Neonatal Brain Volumes at Birth. JAMA Netw Open 2022; 5:e227045. [PMID: 35412624 PMCID: PMC9006107 DOI: 10.1001/jamanetworkopen.2022.7045] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 02/24/2022] [Indexed: 12/21/2022] Open
Abstract
Importance Exposure to early-life adversity alters the structural development of key brain regions underlying neurodevelopmental impairments. The association between prenatal exposure to adversity and brain structure at birth remains poorly understood. Objective To examine whether prenatal exposure to maternal social disadvantage and psychosocial stress is associated with neonatal global and regional brain volumes and cortical folding. Design, Setting, and Participants This prospective, longitudinal cohort study included 399 mother-infant dyads of sociodemographically diverse mothers recruited in the first or early second trimester of pregnancy and their infants, who underwent brain magnetic resonance imaging in the first weeks of life. Mothers were recruited from local obstetric clinics in St Louis, Missouri from September 1, 2017, to February 28, 2020. Exposures Maternal social disadvantage and psychosocial stress in pregnancy. Main Outcomes and Measures Confirmatory factor analyses were used to create latent constructs of maternal social disadvantage (income-to-needs ratio, Area Deprivation Index, Healthy Eating Index, educational level, and insurance status) and psychosocial stress (Perceived Stress Scale, Edinburgh Postnatal Depression Scale, Everyday Discrimination Scale, and Stress and Adversity Inventory). Neonatal cortical and subcortical gray matter, white matter, cerebellum, hippocampus, and amygdala volumes were generated using semiautomated, age-specific, segmentation pipelines. Results A total of 280 mothers (mean [SD] age, 29.1 [5.3] years; 170 [60.7%] Black or African American, 100 [35.7%] White, and 10 [3.6%] other race or ethnicity) and their healthy, term-born infants (149 [53.2%] male; mean [SD] infant gestational age, 38.6 [1.0] weeks) were included in the analysis. After covariate adjustment and multiple comparisons correction, greater social disadvantage was associated with reduced cortical gray matter (unstandardized β = -2.0; 95% CI, -3.5 to -0.5; P = .01), subcortical gray matter (unstandardized β = -0.4; 95% CI, -0.7 to -0.2; P = .003), and white matter (unstandardized β = -5.5; 95% CI, -7.8 to -3.3; P < .001) volumes and cortical folding (unstandardized β = -0.03; 95% CI, -0.04 to -0.01; P < .001). Psychosocial stress showed no association with brain metrics. Although social disadvantage accounted for an additional 2.3% of the variance of the left hippocampus (unstandardized β = -0.03; 95% CI, -0.05 to -0.01), 2.3% of the right hippocampus (unstandardized β = -0.03; 95% CI, -0.05 to -0.01), 3.1% of the left amygdala (unstandardized β = -0.02; 95% CI, -0.03 to -0.01), and 2.9% of the right amygdala (unstandardized β = -0.02; 95% CI, -0.03 to -0.01), no regional effects were found after accounting for total brain volume. Conclusions and Relevance In this baseline assessment of an ongoing cohort study, prenatal social disadvantage was associated with global reductions in brain volumes and cortical folding at birth. No regional specificity for the hippocampus or amygdala was detected. Results highlight that associations between poverty and brain development begin in utero and are evident early in life. These findings emphasize that preventive interventions that support fetal brain development should address parental socioeconomic hardships.
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Affiliation(s)
- Regina L. Triplett
- Department of Neurology, Washington University in St Louis, St Louis, Missouri
| | - Rachel E. Lean
- Department of Psychiatry, Washington University in St Louis, St Louis, Missouri
| | - Amisha Parikh
- School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - J. Philip Miller
- Department of Biostatistics, Washington University in St Louis, St Louis, Missouri
| | | | - Sydney Kaplan
- Department of Neurology, Washington University in St Louis, St Louis, Missouri
| | - Dominique Meyer
- Department of Neurology, Washington University in St Louis, St Louis, Missouri
| | - Christopher Adamson
- Developmental Imaging, Murdoch Children’s Institute, Melbourne, Australia
- Electrical and Electronic Engineering, University of Melbourne, Melbourne, Australia
| | - Tara A. Smyser
- Department of Psychiatry, Washington University in St Louis, St Louis, Missouri
| | - Cynthia E. Rogers
- Department of Psychiatry, Washington University in St Louis, St Louis, Missouri
- Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Deanna M. Barch
- Department of Psychiatry, Washington University in St Louis, St Louis, Missouri
- Department of Psychological and Brain Sciences, Washington University in St Louis, St Louis, Missouri
- Department of Radiology, Washington University in St Louis, St Louis, Missouri
| | - Barbara Warner
- Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Joan L. Luby
- Department of Psychiatry, Washington University in St Louis, St Louis, Missouri
| | - Christopher D. Smyser
- Department of Neurology, Washington University in St Louis, St Louis, Missouri
- Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
- Department of Radiology, Washington University in St Louis, St Louis, Missouri
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Catastrophic Health Expenditures With Pregnancy and Delivery in the United States. Obstet Gynecol 2022; 139:509-520. [PMID: 35271537 PMCID: PMC9124691 DOI: 10.1097/aog.0000000000004704] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 12/30/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe prevalence, trends, and risk factors for catastrophic health expenditures in the year of delivery among birth parents (delivering people). METHODS We conducted a retrospective, cross-sectional study of the Medical Expenditure Panel Survey from 2008-2016. We identified newborn birth parents and a 2:1 nearest-neighbor propensity-matched control cohort of nonpregnant reproductive-aged individuals, then assessed for catastrophic health expenditures (spending greater than 10% of family income) in the delivery year. We applied survey weights to extrapolate to the noninstitutionalized U.S. population and used the adjusted Wald test for significance testing. We compared risk of catastrophic health expenditures between birth parents and the control cohort and described time trends and risk factors for catastrophic spending with subgroup comparisons. RESULTS We analyzed 4,056 birth parents and 7,996 reproductive-aged females without pregnancy in a given year. Birth parents reported higher rates of unemployment (52.6% vs 46.6%, P<.001), and high rates of gaining (22.4%) and losing (25.6%) Medicaid in the delivery year. Birth parents were at higher risk of catastrophic health expenditures (excluding premiums: 9.2% vs 6.8%, odds ratio [OR] 1.95, 95% CI 1.61-2.34; including premiums: 21.3% vs 18.4%, OR 1.53, 95% CI 1.32-1.82). Birth parents living on low incomes had the highest risk of catastrophic health expenditures (18.8% vs 0.7% excluding premiums for 138% or less vs greater than 400% of the federal poverty level, relative risk [RR] 26.9; 29.8% vs 5.9% including premiums, RR 5.1). For birth parents living at low incomes, public insurance was associated with lower risks of catastrophic health expenditures than private insurance, particularly when including premium spending (incomes 138% of the federal poverty level or lower: 18.8% public vs 67.9% private, RR 0.28; incomes 139-250% of the federal poverty level: 6.5% public vs 41.1% private, RR 0.16). The risk of catastrophic spending for birth parents did not change significantly over time from before to after Affordable Care Act implementation. CONCLUSION Pregnancy and delivery are associated with increased risk of catastrophic health expenditures in the delivery year. Medicaid and public coverage were more protective from high out-of-pocket costs than private insurance, particularly among low-income families.
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