The Association between Prenatal Nicotine Exposure and Offspring's Hearing Impairment

OBJECTIVES

 The objective of this study is to evaluate whether there is an association between in-utero exposure to nicotine and subsequent hearing dysfunction.

MATERIALS AND METHODS

 Secondary analysis of a multicenter randomized trial to prevent congenital cytomegalovirus (CMV) infection among gravidas with primary CMV infection was conducted. Monthly intravenous immunoglobulin hyperimmune globulin therapy did not influence the rate of congenital CMV. Dyads with missing urine, fetal or neonatal demise, infants diagnosed with a major congenital anomaly, congenital CMV infection, or with evidence of middle ear dysfunction were excluded. The primary outcome was neonatal hearing impairment in one or more ears defined as abnormal distortion product otoacoustic emissions (DPOAEs; 1 to 8 kHz) that were measured within 42 days of birth. DPOAEs were interpreted using optimized frequency-specific level criteria. Cotinine was measured via enzyme-linked immunosorbent assay kits in maternal urine collected at enrollment and in the third trimester (mean gestational age 16.0 and 36.7 weeks, respectively). Blinded personnel ran samples in duplicates. Maternal urine cotinine >5 ng/mL at either time point was defined as in-utero exposure to nicotine. Multivariable logistic regression included variables associated with the primary outcome and with the exposure (p < 0.05) in univariate analysis.

RESULTS

 Of 399 enrolled patients in the original trial, 150 were included in this analysis, of whom 46 (31%) were exposed to nicotine. The primary outcome occurred in 18 (12%) newborns and was higher in nicotine-exposed infants compared with those nonexposed (15.2 vs. 10.6%, odds ratio [OR] 1.52, 95% confidence interval [CI] 0.55-4.20), but the difference was not significantly different (adjusted odds ratio [aOR] = 1.0, 95% CI 0.30-3.31). This association was similar when exposure was stratified as heavy (>100 ng/mL, aOR 0.72, 95% CI 0.15-3.51) or mild (5-100 ng/mL, aOR 1.28, 95% CI 0.33-4.95). There was no association between nicotine exposure and frequency-specific DPOAE amplitude.

CONCLUSION

 In a cohort of parturients with primary CMV infection, nicotine exposure was not associated with offspring hearing dysfunction assessed with DPOAEs.

KEY POINTS

· Nicotine exposure was quantified from maternal urine.. · Nicotine exposure was identified in 30% of the cohort.. · Exposure was not associated with offspring hearing dysfunction..

Trial of Intrapartum Extended-Release Nifedipine to Prevent Severe Hypertension Among Pregnant Individuals With Preeclampsia With Severe Features

BACKGROUND

Preeclampsia is associated with maternal and perinatal morbidity. Besides acute therapy for severe hypertension, best practices are lacking for intrapartum hypertension management. Our objective was to test the hypothesis that intrapartum initiation of extended-release nifedipine in individuals with preeclampsia with severe features prevents severe hypertension.

METHODS

Randomized, triple-blind, placebo-controlled trial of individuals with preeclampsia with severe features undergoing labor induction between 22^0/7 and 41^6/7 weeks gestation. Participants were randomized to oral extended-release nifedipine 30 mg or identical placebo every 24 hours. Primary outcome is defined as receipt of ≥1 dose of acute hypertension therapy for severe blood pressure (≥160/110 mm Hg) sustained ≥10 minutes. Secondary outcomes included route of delivery, neonatal intensive care unit admission, and a composite of adverse neonatal outcomes.

RESULTS

Of 365 individuals screened, 55 were randomized to nifedipine and 55 to placebo. Primary outcome was observed in 34.0% of individuals in nifedipine group versus 55.1% in placebo group (relative risk [RR] 0.62 [95% CI, 0.39-0.97]); number needed to treat to prevent receipt of acute treatment was 4.7 (95% CI, 2.5-44.3). Fewer individuals in nifedipine group required cesarean delivery compared with placebo group (20.8% versus 34.7%, RR, 0.60 [95% CI, 0.31-1.15]). Neonatal intensive care unit admission rate was lower in nifedipine group compared with placebo (29.1% versus 47.1%; RR 0.62 [95% CI, 0.37-1.02]). Neonatal composite was similar between groups (35.8% versus 41.2%, RR, 0.83 [95% CI, 0.51-1.37]).

CONCLUSIONS

Initiation of extended-release nifedipine is effective in reducing intrapartum acute hypertensive therapy among individuals with preeclampsia with severe features.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT04392375.

Risk factors for preterm birth among gravid individuals receiving buprenorphine for opioid use disorder

OBJECTIVE

Pregnancies complicated by opioid use disorder (OUD) are at an increased risk for preterm birth (PTB), defined as delivery <37 weeks gestation. Limited literature is available on prevalence and risk factors for PTB in pregnancies complicated by OUD maintained on buprenorphine Therefore, we sought to determine rate of PTB and risk factors for PTB in this population.

STUDY DESIGN

We performed a retrospective cohort study of pregnant individuals with singleton gestation receiving buprenorphine for OUD, who delivered at a tertiary academic medical center between 7/1/2013 and 6/30/2018. Individuals who had at least three visits in our co-located clinic were included in analysis. Patients were divided into 2 groups, those delivered <37 weeks gestation were included in preterm group, while patient delivered ≥ 37 weeks were included in term group. We defined "supplements to buprenorphine" to include any illicit drugs found on antepartum urine toxicology. Variables evaluated as potential risk factors for PTB included medical and infectious comorbidities as well as illicit polysubstance use.

RESULTS

The overall PTB rate in this cohort was 22.7% (115/507). There was a non-significant trend towards decrease in overall PTB and provider-initiated PTB rate over study period. No differences found in spontaneous PTB or PTB< 34 weeks. There were no differences in use of tobacco, alcohol, number of prenatal visits or gestational age when prenatal care started between those who delivered preterm compared to term. Individuals with PTB in the index pregnancy were more likely to have history of PTB compared to those with term delivery (73% vs 16%; P<.01). No medical or infectious comorbidity nor any specific supplement increased risk of PTB. Among individuals using 0, 1, 2, or 3 or more illicit supplements in addition to confirmed buprenorphine for OUD, the PTB rate was 27.4% (reference), 18.0% (P=0.09), 18.1% (P=0.44), and 15.8% (P=0.77), respectively.

CONCLUSION

The PTB rate among individuals using buprenorphine for OUD (22.7%) is higher than national average but lower than the reported PTB rate in individuals using methadone for MOUD.. No medical or infectious comorbidity or use of additional illicit substances increased the risk of PTB.

Indicated Opioids in Pregnancy: Guidance on Providing Comprehensive Care

In modern obstetric practice, providers will encounter patients for whom opioid use in pregnancy is reasonable or even necessary. A "one-size-fits-all" approach to the counseling and management of such patients is misguided. Understanding indications for ongoing opioid use in pregnancy is essential to patient-centered care. Specifically, recognition of the nuanced differences between opioid dependence and opioid use disorder is crucial for appropriate diagnosis, screening for common concurrent conditions, adequately counseling about individualized maternal and perinatal risks, and accurate documentation of diagnoses and medical decision-making. In this paper, we explore the current typical scenarios in which opioid use in pregnancy may be encountered, ongoing opioid prescribing should be considered, and provide a guide for the obstetric provider to navigate the antepartum, intrapartum, and postpartum periods. KEY POINTS: · Opioid use in pregnant and postpartum individuals is not rare.. · Obstetric providers may elect to assume opioid prescribing.. · Obstetric providers are positioned to optimize outcomes for the mother-infant dyad..

Buprenorphine X-waiver exemption - beyond the basics for the obstetrical provider

Buprenorphine is 1 of 3 medications approved by the US Food and Drug Administration for the treatment of opioid use disorder, and practitioners must obtain a federal waiver to prescribe buprenorphine. Until recently, physicians and advanced practice clinicians were required to complete 8 and 24 hours of training, respectively, before applying for this waiver and to provide psychosocial services when prescribing buprenorphine to ≤30 patients. The US Department of Health and Human Services announced in April 2021 that eligible providers would be exempt from the educational requirement for certification, making the waiver more accessible for those intending to prescribe to ≤30 patients. Here, we reviewed the historic background to the exemption and provided practical guidelines to practitioners caring for obstetrical patients with opioid use disorder who are considering applying for the waiver for the first time. Because the educational requirements will no longer be required for X-waiver application, we reviewed fundamental topics and challenging scenarios that are often reviewed in certification courses.