Maternity Care for Pregnant Women with Opioid Use Disorder: A Review

Opioid misuse is a problem that is complex and widespread. Opioid misuse rates are rising across all US demographics, including among pregnant women. The opioid epidemic brings a unique set of challenges for maternity health care providers, ranging from ethical considerations to the complex health needs and risks for both woman and fetus. This article addresses care for pregnant women during the antepartum, intrapartum, and postpartum periods through the lens of the opioid epidemic, including screening and counseling, an interprofessional approach to prenatal care, legal considerations, and considerations for care during labor and birth and postpartum. Providers can be trained to identify at-risk women through the evidence-based process of Screening, Brief Intervention, and Referral to Treatment (SBIRT) and connect them with the appropriate care to optimize outcomes. Women at moderate risk of opioid use disorder can be engaged in a brief conversation with their provider to discuss risks and enhance motivation for healthy behaviors.  Women with risky opioid use can be given a warm referral to pharmacologic treatment programs, ideally comprehensive prenatal treatment programs where available (a warm referral is a term used when a provider, with the patient's permission, contacts another provider or another service him or herself rather than providing a phone number and referral number). Evidence regarding care for the pregnant woman with opioid use disorder and practical clinical recommendations are provided.

Complete fracture-dislocation of the lower lumbar spine with spontaneous neurologic decompression

Complete posterior fracture-dislocation of the lumbar spine at L4-L5 level occurred in an 18-year-old male patient, who remained neurologically intact. The body of L4 with the vertebral column above was totally displaced behind the body of L5. The posterior elements of L5 were fractured and displaced posteriorly with L4, and this led to marked widening of the canal with spontaneous neurologic decompression. Open reduction and internal fixation with a sacral rod and two Harrington rods restored the anatomic relationship. In spite of the good reduction immediately obtained after surgery, two months later the fracture showed some redisplacement. The implants were removed, and a bone graft was transplanted for additional support. Seven months after trauma, the patient is asymptomatic and the spine is solidly fused. In spite of the risk of neurologic deterioration involved during surgery, open reduction and internal fixation were performed because they offered the best chance of healing, producing a biomechanically sound spine, and decreasing the risk of delayed neurologic deterioration. Because of the relatively wide neural canal at the lumbar level and the absence of spinal cord from the neural elements at the level of the injury, the risk of permanent neurologic deficit being produced during surgery was considered minimal.