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Atluru S, Bruehlman AK, Vaughn P, Schauberger CW, Smid MC. Naltrexone Compared With Buprenorphine or Methadone in Pregnancy: A Systematic Review. Obstet Gynecol 2024; 143:403-410. [PMID: 38227945 DOI: 10.1097/aog.0000000000005510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 11/30/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE Although naltrexone is an evidence-based medication for opioid use disorder (MOUD), few data are available with use in pregnancy. Our objective was to assess outcomes of pregnant individuals with opioid use disorder (OUD) taking naltrexone compared with those taking methadone or buprenorphine. DATA SOURCES We undertook a systematic review using electronic database search (PubMed, CINAHL, EMBASE, PsycInfo), conference proceedings, and trial registries including ClinicalTrials.gov . METHODS OF STUDY SELECTION We conducted an electronic search of research articles through May 2023 for randomized controlled trials, prospective cohort, and retrospective cohort studies of naltrexone (oral, implant, or extended release) compared with methadone or buprenorphine (sublingual or extended release) among pregnant individuals with OUD. After double review of all articles, we abstracted obstetric (primary outcome: gestational age at delivery), neonatal (primary outcome: neonatal abstinence syndrome [NAS]), and substance use outcomes. TABULATION, INTEGRATION, AND RESULTS Five studies met eligibility criteria; four were retrospective cohort studies, and one was a prospective cohort study. Four studies included data on gestational age at delivery (weeks) with no difference detected between the two groups in any study (mean difference ranging -0.20, 95% CI, -1.49-1.09 to 0.8, 95% CI, -0.15 to 1.75). Three studies included data on NAS with all studies detecting a lower risk in the naltrexone group compared with methadone or buprenorphine (relative risk ranging from 0.08, 95% CI, 0.01-1.16 to 0.15, 95% CI, 0.06-0.36). Most studies (four of five) had a moderate or high potential for selection bias primarily driven by small sample size and lack of controlling for confounders. CONCLUSION Although the evidence base is limited, available data suggest that naltrexone use in pregnancy is a reasonable MOUD option with reassuring perinatal outcomes. To enhance confidence in this conclusion and to assess substance use outcomes, further comparative studies of pregnant people with OUD taking naltrexone and other MOUD types are needed. SYSTEMATIC REVIEW REGISTRATION PROSPERO, 42017074249.
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Affiliation(s)
- Sreevalli Atluru
- Department of Family Medicine and Community Health, and the Division of Hospital Medicine, Department of Medicine, University of Wisconsin Madison School of Medicine and Public Health, Madison, and Addiction Medical Services, Onalaska, Wisconsin; the Department of Pediatrics, University of Utah School of Medicine, and the Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah; and the Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Cochran G, Smid MC, Krans EE, Yu Z, Carlston K, White A, Abdulla W, Baylis J, Charron E, Okifugi A, Gordon AJ, Lundahl B, Silipigni J, Seliski N, Haaland B, Tarter R. Patient navigation for pregnant individuals with opioid use disorder: Results of a randomized multi-site pilot trial. Addiction 2024; 119:544-556. [PMID: 37859587 DOI: 10.1111/add.16364] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 09/14/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND AND AIMS Patient navigation (PN) may benefit pregnant individuals with opioid use disorder (OUD) by improving treatment adherence. We examined participant enrollment, session delivery and assessment feasibility for a PN intervention among pregnant participants and compared PN preliminary effectiveness for OUD treatment engagement with participants in usual care (UC). DESIGN This study was a pilot single-blinded multi-site randomized trial. SETTING Two academic medical centers in Pennsylvania (n = 57) and Utah (n = 45), United States participated. PARTICIPANTS One hundred and two pregnant adult participants unestablished (fewer than 6 weeks) on medication for OUD (MOUD) were randomized to PN (n = 53) or UC (n = 49). INTERVENTION PN was composed of 10 prenatal sessions (delivered after baseline but before the prenatal assessments) and four postnatal sessions (delivered before the 2- and 6-month postpartum assessments) focused upon OUD treatment and physical/mental health needs. UC involved brief case management. MEASUREMENTS Feasibility assessments included consent, session delivery and assessment rates. Mixed-effect models for intent-to-treat (ITT) and per protocol (PP, received six or more sessions) populations were estimated to compare outcomes of MOUD use, secondary outcomes of substance use disorder (SUD) treatment attendance and non-prescribed opioid use, and exploratory outcome of overdose at baseline, predelivery and 2 and 6 months postpartum. FINDINGS We consented 87% (106 of 122) of the proposed target, delivered ~60% of sessions delivered and completed ≥ 75% assessments. PN ITT and PP had better MOUD adherence, SUD treatment attendance, non-prescribed opioid use and overdose outcomes than UC. Notable changes included good evidence for greater percentage change in days for PN PP MOUD use from baseline to 2 months postpartum [PN = 28.0 versus UC = -10.9, 95% confidence interval (CI) = 9.7, 62.1] and some evidence for baseline to 6 months postpartum (PN = 45.4 versus UC = 23.4, 95% CI = -0.7, 48.2). PN PP percentage change in days for SUD treatment attendance also showed good evidence for improvements from baseline to prenatal assessment (PN = 7.4 versus UC = -21.3, 95% CI = 3.3, 53.5). PN compared to UC participants reported fewer overdoses at 2 months (PN = 11.9%/UC = 16.1%) and at 6 months postpartum (PN = 3.8%/UC = 6.2%). CONCLUSIONS Patient navigation appears to be associated with improvements in opioid use disorder treatment engagement and overdoses during pregnancy. This pilot trial shows the feasibility of the intervention and a future large-scale trial.
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Affiliation(s)
- Gerald Cochran
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Marcela C Smid
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Utah Health, Salt Lake City, UT, USA
| | - Elizabeth E Krans
- Department of Obstetrics, Gynecology and Reproductive Sciences, UPMC, Pittsburgh, PA, USA
| | - Ziji Yu
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Kristi Carlston
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Ashley White
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Walitta Abdulla
- Department of Obstetrics, Gynecology and Reproductive Sciences, UPMC, Pittsburgh, PA, USA
| | - Jacob Baylis
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Elizabeth Charron
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Akiko Okifugi
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Adam J Gordon
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Brad Lundahl
- College of Social Work, University of Utah, Salt Lake City, UT, USA
| | - John Silipigni
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Utah Health, Salt Lake City, UT, USA
| | - Natasha Seliski
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Benjamin Haaland
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Ralph Tarter
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
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Smid MC, Vaughn P, Nowicki CC, Goodman DA, Zaharatos J, Campbell KA. Consensus pregnancy-related criteria for suicide and unintentional overdoses using a Delphi process. Arch Womens Ment Health 2024; 27:109-125. [PMID: 37770631 PMCID: PMC11000257 DOI: 10.1007/s00737-023-01375-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 09/15/2023] [Indexed: 09/30/2023]
Abstract
Suicide and unintentional overdose are leading manners of preventable death during and within a year of pregnancy. Recently, the Utah Maternal Mortality Review Committee (MMRC) developed 10 criteria to guide pregnancy-related classification of these deaths. Our objective was to (1) evaluate if consensus could be reached across experts in maternal mortality review when applying criteria to the determination of pregnancy-relatedness in mock MMRC case evaluation and (2) assess how additional case information shifted participants' determination of pregnancy-relatedness in these mock cases. We used a modified Delphi process to evaluate criteria for pregnancy-related suicides and unintentional overdose. The study team developed base case scenarios to reflect the 10 proposed criteria. Base scenarios varied in timing of death (prenatal or delivery, early postpartum (<6 months), late postpartum (6-12 months)) and level of additional information available (e.g., informant interviews, social media posts). Consensus in favor of a criterion was met when ≥75% of participants identified a case as pregnancy-related in at least 1 scenario. Fifty-eight participants, representing 48 MMRCs, reviewed scenarios. Of 10 proposed criteria, 8 reached consensus. Overall, participants classified 19.4% of base case scenarios as pregnancy-related, which increased to 56.8% with additional information. Pregnancy-related classification changed across timing of death and with availability of additional information (prenatal or delivery 27.7% versus 84.6%; early postpartum 30.0% versus 58.3%; late postpartum 0.0% versus 25.0%, respectively). We identified consensus supporting the application of 8 standardized criteria in MMRC determinations of pregnancy-relatedness among suicide and unintentional overdose deaths.
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Affiliation(s)
- Marcela C Smid
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA.
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Porcia Vaughn
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | - David A Goodman
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Julie Zaharatos
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kristine A Campbell
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
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Smid MC, Allshouse AA, Metz TD, Debbink MP, Charron E, Campbell K, Cochran G. Co-occurring opioid and methamphetamine use disorder and severe maternal morbidity and mortality in Utah. Am J Obstet Gynecol MFM 2024; 6:101221. [PMID: 37949409 DOI: 10.1016/j.ajogmf.2023.101221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/16/2023] [Accepted: 10/20/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Marcela C Smid
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT.
| | - Amanda A Allshouse
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT
| | - Torri D Metz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT
| | - Michelle P Debbink
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT
| | - Elizabeth Charron
- Department of Health Promotion Sciences, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Schusterman Center, Tulsa, OK
| | - Kristine Campbell
- Department of Pediatrics, University of Utah Health, Salt Lake City, UT
| | - Gerald Cochran
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
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Kurtz T, Charles JE, Schwartz M, Smid MC. Postpartum Extended-Release Buprenorphine Tissue Necrosis. Obstet Gynecol 2023; 142:1504-1508. [PMID: 37917935 DOI: 10.1097/aog.0000000000005425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 09/14/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Extended-release buprenorphine (XRB) may improve medication for opioid use disorder continuation among postpartum individuals. However, obstetric clinicians have relatively little experience with XRB. We describe two cases of XRB-related tissue necrosis in postpartum individuals to highlight recommended injection technique and management strategies for this rare complication. CASES One patient developed tissue necrosis after her initial injection. Her wound was expectantly managed. Another patient on long-term XRB developed tissue necrosis within 1 day of injection. General surgery excised the depot. Both instances were attributed to injection of XRB intradermally rather than subcutaneously. Both patients continued monthly XRB without recurrence, suggesting that this complication is not an allergy. CONCLUSION Clinicians should be able to prevent, recognize, and manage tissue necrosis, a rare complication of XRB injection.
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Affiliation(s)
- Theresa Kurtz
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, and Family Medicine, Exodus Healthcare Network, Magna, Utah
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Herrera CA, McPherson JA, Vladutiu CJ, Smid MC. Neonatal morbidity associated with maternal Group B Streptococcal colonization in individuals undergoing planned cesarean delivery. J Matern Fetal Neonatal Med 2023; 36:2183740. [PMID: 36851857 DOI: 10.1080/14767058.2023.2183740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
OBJECTIVE To examine the association between unknown maternal Group B Streptococcal (GBS) colonization and the risk of severe neonatal morbidity among individuals undergoing planned cesarean delivery. METHODS We performed a secondary analysis of a multicenter, prospective observational study of individuals with singleton gestations and planned cesarean delivery ≥37 weeks gestation with cervical dilation ≤3 cm, intact membranes, and no evidence of labor or induction. GBS status was categorized as positive, negative, or unknown. The primary outcome was a composite of severe neonatal morbidity, including clinical or culture-proven sepsis, ventilator support in the first 24 h, respiratory distress syndrome, hypotension requiring treatment, intubation, necrotizing enterocolitis, hypoxic-ischemic encephalopathy, or death. We compared individuals with unknown GBS status to those with positive and negative GBS status. RESULTS In this cohort, 4,963 individuals met inclusion criteria; 72% had unknown GBS status, 25% were GBS negative and 3% were GBS positive. Among individuals with unknown GBS status, 208 (5.9%) had the primary composite neonatal outcome, compared with 75 (6%) of GBS negative individuals and 6 (4%) of GBS positive individuals. There was no difference in composite severe neonatal morbidity among GBS unknown, GBS negative, and GBS positive individuals (5.9% vs 6% vs 4%, p = .61). After adjusting for male sex and intrapartum antibiotic exposure, unknown GBS status was not associated with severe neonatal morbidity (adjusted risk ratio, 0.95; 95% confidence interval, 0.73-1.22). CONCLUSION GBS status at time of planned cesarean delivery does not appear to be associated with composite severe neonatal morbidity. The cost effectiveness and clinical utility of GBS screening among individuals undergoing planned cesarean delivery requires further investigation.
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Affiliation(s)
| | | | | | - Marcela C Smid
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA.,Intermountain Healthcare Division of Maternal Fetal Medicine, Salt Lake City, UT, USA
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Bowman J, Lai M, Charles JE, Gordon AJ, Smid MC. Kratom Use Among Pregnant and Lactating Individuals With Substance Use Disorder. J Addict Med 2023; 17:722-724. [PMID: 37934544 DOI: 10.1097/adm.0000000000001212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
OBJECTIVE Kratom ( Mitragyna speciosa ) use in pregnancy is associated with maternal and neonatal opioid withdrawal syndrome. However, kratom use patterns in the population of peripartum and postpartum individuals with substance use disorder (SUD) are unknown. The aim of this study was to determine the proportion of pregnant and postpartum individuals with SUD who report using kratom in pregnancy or lactation and the reasons for their use. METHODS We conducted an anonymous survey of pregnant and postpartum individuals receiving care at a single center's multidisciplinary prenatal clinic for individuals with SUD. We collected participants' demographic and pregnancy characteristics. We assessed ever use of kratom, kratom use during pregnancy or lactation, and reasons for kratom use. Descriptive statistics were used to summarize the data. RESULTS From January 2021 to May 2021, a total of 80 surveys were collected (81% response rate of 98 eligible individuals). Most respondents were pregnant (n = 50 [62.5%]). The most frequent substance(s) of use were opioids (n = 50 [62.5%]) and methamphetamine (n = 39 [48.8%]). Many (n = 26 [32.5%]) reported ever use of kratom use. Of all respondents, 4 (5%) reported use during pregnancy, and 1 (1%) reported use during lactation. Kratom was primarily used to relieve opioid withdrawal symptoms and for relaxation, pain control, and stress relief. CONCLUSION In a survey of pregnant and postpartum individuals with SUD at a single high-risk pregnancy clinic, ever use of kratom was frequent, whereas peripartum use was rare.
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Affiliation(s)
- Justin Bowman
- From the University of Utah School of Medicine, Salt Lake City, UT (JB); Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, University of Utah Health, Salt Lake City, UT (JEC, MCS); Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT (ML, AJG); Program for Addiction Research, Clinical Care, Knowledge and Advocacy, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT (JEC, MCS); and Informatics, Decision-Enhancement, and Analytic Sciences Center, Salt Lake City VA Health Care System, Salt Lake City, UT (AJG)
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Goffman D, Rood KM, Bianco A, Biggio JR, Dietz P, Drake K, Heilman E, Hopkins M, De Four Jones M, Katz T, Martin C, Prasad M, Smid MC, Wine KD, Ryan R, Yong C, Carney PI, Simhan HN. Real-World Utilization of an Intrauterine, Vacuum-Induced, Hemorrhage-Control Device. Obstet Gynecol 2023; 142:1006-1016. [PMID: 37713322 DOI: 10.1097/aog.0000000000005366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/20/2023] [Indexed: 09/17/2023]
Abstract
OBJECTIVE To assess the real-world effectiveness and safety of a U.S. Food and Drug Administration (FDA)-cleared intrauterine vacuum-induced-hemorrhage control device for postpartum hemorrhage (PPH) management. METHODS Sixteen centers in the United States participated in this observational, postmarket registry medical record review (October 2020 through March 2022). The primary effectiveness outcome was treatment success , defined as bleeding control after insertion with no treatment escalation or bleeding recurrence. Additional outcomes included blood loss, time to device insertion, indwelling time, bleeding recurrence, and time to bleeding control. Treatment success and severe maternal morbidity measures (transfusion of 4 or more units of red blood cell, intensive care unit admission, and hysterectomy) were evaluated by blood loss before insertion. To assess safety, serious adverse events (SAEs) and adverse device effects were collected. All outcomes were summarized by mode of delivery; treatment success was summarized by bleeding cause (all causes, any atony, isolated atony, nonatony). RESULTS In total, 800 individuals (530 vaginal births, 270 cesarean births) were treated with the device; 94.3% had uterine atony (alone or in combination with other causes). Median total blood loss at device insertion was 1,050 mL in vaginal births and 1,600 mL in cesarean births. Across all bleeding causes, the treatment success rate was 92.5% for vaginal births and was 83.7% for cesarean births (95.8% [n=307] and 88.2% [n=220], respectively, in isolated atony). Median indwelling time was 3.1 hours and 4.6 hours, respectively. In vaginal births, 14 SAEs were reported among 13 individuals (2.5%). In cesarean births, 22 SAEs were reported among 21 individuals (7.8%). Three (0.4%) SAEs were deemed possibly related to the device or procedure. No uterine perforations or deaths were reported. CONCLUSION For both vaginal and cesarean births in real-world settings, rapid and effective bleeding control was achieved with an FDA-cleared intrauterine vacuum-induced hemorrhage-control device. The safety profile was consistent with that observed in the registrational trial (NCT02883673), and SAEs or adverse device effects were of the nature and severity expected in the setting of PPH. This device is an important new tool for managing a life-threatening condition, and timely utilization may help to improve obstetric hemorrhage outcomes. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov , NCT04995887.
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Affiliation(s)
- Dena Goffman
- New York-Presbyterian/Columbia University Irving Medical Center and the Icahn School of Medicine at Mount Sinai, New York, and the Long Island Jewish Medical Center, New Hyde Park, New York; The Ohio State University-Wexner Medical Center and OhioHealth, Columbus, and the Women's Health Institute, Cleveland Clinic, and Case Western Reserve University, University Hospitals Cleveland, Cleveland, Ohio; Ochsner Health, New Orleans, Louisiana; the West Virginia University School of Medicine and Charleston Area Medical Center, Charleston, West Virginia; The Mother Baby Center at Abbott Northwestern Hospital, Minneapolis, Minnesota; ChristianaCare Health System, Newark, Delaware; Loma Linda University Children's Hospital, Loma Linda, and Alydia Health Inc, Menlo Park, California; the University of Utah Health, Salt Lake City, Utah; Organon & Co., Jersey City, New Jersey; and the University of Pittsburgh Medical Center-Magee Women's Hospital, Pittsburgh, Pennsylvania
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Park Y, Dang EP, Board A, Gilboa SM, Ondersma SJ, Smid MC, Shakib JH, Mitchell KT, England LJ, Broussard CS, Meaney-Delman D, Iskander J, Kim SY. Polysubstance Use in Pregnancy: Surveillance, Interventions, and Next Steps. J Womens Health (Larchmt) 2023; 32:899-904. [PMID: 37552850 PMCID: PMC10558011 DOI: 10.1089/jwh.2023.0341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023] Open
Abstract
Substance use during pregnancy increases risk for a wide range of adverse maternal and neonatal health outcomes. Polysubstance use is common among people who use substances during pregnancy; however, the risks of combined substance exposures during pregnancy are poorly understood. In this report, we provide an overview of the activities of the Centers for Disease Control and Prevention (CDC) and partners and identified gaps related to (1) surveillance, (2) routine screening, and (3) prevention of polysubstance use during pregnancy. Efforts by CDC and other partners to reduce polysubstance use during pregnancy can improve the health of pregnant people and their infants and children.
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Affiliation(s)
- Youngjoo Park
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Oak Ridge Institute for Science and Education (ORISE), Oak Ridge, Tennessee, USA
| | - Elizabeth P. Dang
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Amy Board
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Suzanne M. Gilboa
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Steven J. Ondersma
- Department of Public Health, Michigan State University, East Lansing, Michigan, USA
| | - Marcela C. Smid
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, USA
| | - Julie H. Shakib
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | | | - Lucinda J. England
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Cheryl S. Broussard
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Dana Meaney-Delman
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - John Iskander
- Office of Science, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Shin Y. Kim
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Kurtz T, Smid MC. The Fall of Roe v. Wade : The Addiction Specialist's Role in Championing Reproductive Rights. J Addict Med 2023; 17:497-499. [PMID: 37788598 DOI: 10.1097/adm.0000000000001179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Reproductive age-pregnant individuals who use substances are disproportionately impacted by the US Supreme Court reversal of Roe v. Wade . Because of historic and ongoing discrimination against pregnant individuals who use substances, this group is at high risk for inadequate pregnancy options counseling and lack of access to safe and legal abortions. Fetal rights laws set a concerning precedent that further criminalize and penalize substance use in pregnancy. As addiction specialists, we have the professional responsibility to champion the reproductive freedoms of pregnant individuals who use substances. There are several ways that addiction specialists can uphold the reproductive rights of patients on an individual, state, and federal level, including the following: incorporate reproductive healthcare into addiction practices, help those seeking abortion navigate barriers, partner with perinatal healthcare clinicians to provide evidence-based addiction treatment during pregnancy, and support decriminalization and destigmatization of substance use, especially in pregnancy.
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Affiliation(s)
- Theresa Kurtz
- From the Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT
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Kurtz T, Smid MC. Office-Based Management of Perinatal Substance Use and Substance Use Disorder for the General Obstetrician-Gynecologist. Obstet Gynecol Clin North Am 2023; 50:609-627. [PMID: 37500220 DOI: 10.1016/j.ogc.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
This is a review of substance use and substance use disorder in pregnancy, intended for the generalist obstetrician-gynecologist. Herein, the authors discuss legal considerations, outline definitions, review screening tools, introduce special considerations and harm reduction, caution the use of urinary toxicology testing, and touch on the screening, brief intervention, and referral to treatment model. Furthermore, the authors provide a brief overview of the prevalence, maternal and neonatal risks, and treatment approaches for commonly used substances.
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Affiliation(s)
- Theresa Kurtz
- Department of Obstetrics and Gynecology, University of Utah Health, 30 North 1900 East #2B200 SOM, Salt Lake City, UT 84132, USA.
| | - Marcela C Smid
- Department of Obstetrics and Gynecology, University of Utah Health, 30 North 1900 East #2B200 SOM, Salt Lake City, UT 84132, USA
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Charron E, Yu Z, Lundahl B, Silipigni J, Okifuji A, Gordon AJ, Baylis JD, White A, Carlston K, Abdullah W, Haaland B, Krans EE, Smid MC, Cochran G. Cluster analysis to identify patient profiles and substance use patterns among pregnant persons with opioid use disorder. Addict Behav Rep 2023; 17:100484. [PMID: 36844693 PMCID: PMC9950438 DOI: 10.1016/j.abrep.2023.100484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/23/2023] [Accepted: 02/14/2023] [Indexed: 02/17/2023] Open
Abstract
The study objective was to identify distinct profiles of pregnant persons with opioid use disorder (PP-OUD) using cluster analysis and examine difference in substance use patterns between profiles. We examined data from 104 PP-OUD ≤ 32 weeks of gestation who were recruited into a behavioral health clinical trial at two academic medical centers. We used Partitioning Around Medoids analysis to identify clusters and explored patterns of substance use and substance use treatment between clusters using bivariate statistical tests and regression methods. We identified two distinct clusters of participants, including 'Group A' (n = 68; 65.4 %) and 'Group B' (n = 36; 34.6 %). Group A had fewer members who were not employed (38 % vs 58 %) and incarcerated (3 % vs 8 %) compared to Group B. Group A compared with Group B included more members with: a history of overdose (72 % vs 50 %); anxiety (85 % vs 25 %); ≥moderate pain (76 % vs 22 %); ≥moderate depression (75 % vs 36 %); ≥moderate drug use severity (94 % vs 78 %); and, more days of cannabis (mean: 6.2 vs 2.3 days), stimulant (mean: 4.5 vs 1.3 days), and injection heroin (mean: 1.3 vs 0 days) use in the past 30 days (P < 0.05 for all comparisons). Clusters of PP-OUD differed with respect to sociodemographic characteristics, mental health conditions, and substance use patterns. More research is needed to confirm identified profiles and assess treatment outcomes associated with cluster membership.
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Affiliation(s)
- Elizabeth Charron
- Department of Health Promotion Sciences, Hudson College of Public Health, University of Oklahoma, Schusterman Center, Tulsa, OK, United States
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Ziji Yu
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Brad Lundahl
- College of Social Work, University of Utah, Salt Lake City, UT, United States
| | - John Silipigni
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, United States
| | - Akiko Okifuji
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Adam J. Gordon
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, United States
| | - Jacob D. Baylis
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Ashley White
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Kristi Carlston
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Walitta Abdullah
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, United States
| | - Benjamin Haaland
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Elizabeth E. Krans
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, United States
- Center for Perinatal Addiction Research, Education and Evidence-based Solutions (Magee CARES), Magee-Womens Research Institute, Pittsburgh, PA, United States
| | - Marcela C. Smid
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, United States
| | - Gerald Cochran
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
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Kropp FB, Smid MC, Lofwall MR, Wachman EM, Martin PR, Murphy SM, Wilder CM, Winhusen TJ. Collaborative care programs for pregnant and postpartum individuals with opioid use disorder: Organizational characteristics of sites participating in the NIDA CTN0080 MOMs study. Journal of Substance Use and Addiction Treatment 2023; 149:209030. [PMID: 37023858 DOI: 10.1016/j.josat.2023.209030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/17/2022] [Accepted: 03/20/2023] [Indexed: 04/07/2023]
Abstract
INTRODUCTION Pregnant individuals with substance use disorders face complex issues that may serve as barriers to treatment entry and retention. Several professional organizations have established recommendations on comprehensive, collaborative approaches to treatment to meet the needs of this population, but information on real-world application is lacking. Sites participating in the NIDA CTN0080 "Medication treatment for Opioid use disorder in expectant Mothers (MOMs)"-a randomized clinical trial of extended release compared to sublingual buprenorphine among pregnant and postpartum individuals (PPI)-were selected, in part, because they have a collaborative approach to treating PPI with opioid use disorder (OUD). However, organizational differences among sites and how they implement expert recommendations for collaborative care could impact study outcomes. METHODS Prior to study launch at each of the 13 MOMs sites, investigators used the Pregnancy and Addiction Services Assessment (PAASA) to collect information about organizational factors. Input from a team of addiction, perinatal, and economic evaluation experts guided the development of the PAASA. Investigators programmed the PAASA into a web-based data system and summarized the resultant site data using descriptive statistics. RESULTS Study sites represented four US census regions. Most sites were specialty obstetrics & gynecology (OB/GYN) programs providing OUD services (n = 9, 69.2 %), were affiliated with an academic institution (n = 11, 84.6 %), and prescribed buprenorphine in an ambulatory/outpatient setting (n = 11, 84.6 %); all sites offered access to naloxone. Sites reported that their population was primarily White, utilized public insurance, and faced numerous psychosocial barriers to treatment. Although all sites offered many services recommended by expert consensus groups, they varied in how they coordinated these services. CONCLUSIONS By providing the organizational characteristics of sites participating in the MOMs study, this report assists in filling the current gap in knowledge regarding similar programs providing services to PPI with OUD. Collaborative care programs such as those participating in MOMs are uniquely positioned to participate in research to determine the most effective models of care and to determine how research can be integrated into those clinical care settings.
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Affiliation(s)
- Frankie B Kropp
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA.
| | - Marcela C Smid
- University of Utah, 50 N. Medical Drive, Salt Lake City, UT 84132, USA.
| | - Michelle R Lofwall
- Departments of Behavioral Science and Psychiatry, University of Kentucky College of Medicine, 845 Angliana Avenue, Lexington, KY 40508, USA.
| | - Elisha M Wachman
- Boston Medical Center, 801 Albany Street, Boston, MA 02119, USA.
| | - Peter R Martin
- Vanderbilt Psychiatric Hospital, Vanderbilt University Medical Center, 1601 23rd Avenue South, Suite 3035, Nashville, TN 372124, USA.
| | - Sean M Murphy
- Department of Population Health Sciences, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA.
| | - Christine M Wilder
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA; Center for Addiction Research, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA.
| | - T John Winhusen
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA; Center for Addiction Research, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA.
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Charles JE, Baylis J, Smid MC, Cochran G. Nonfatal Overdoses Among Pregnant Individuals With Opioid Use Disorder. Obstet Gynecol 2023; 141:961-963. [PMID: 37103536 DOI: 10.1097/aog.0000000000005129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/22/2023] [Indexed: 04/28/2023]
Abstract
Little is understood about overdose history among pregnant individuals with opioid use disorder (OUD). We performed a cross-sectional secondary analysis of data from the OPTI-Mom 2.0 (Optimizing Pregnancy and Treatment Interventions for Moms 2.0) study (NCT03833245), a multi-site randomized controlled trial of patient navigation and usual care. We summarized participant demographics, overdose history, and substances involved in most recent overdose. Of the 102 participants with severe OUD included, 64.7% (95% CI 54.8-73.4%) had a reported a history of an overdose event and 41.2% (95% CI 31-52%) reported at least one overdose within the past year. In the most recent overdose, 81.8% (95% CI 70.4-89.5%) reported using opioids and 30.3% (95% CI 20.3-42.6%) reported using sedatives. These findings suggest need for heightened awareness of overdose-reduction and harm-reduction strategies in this population.
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Affiliation(s)
- Jasmin E Charles
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, and the Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City Utah
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Charron E, White A, Carlston K, Abdullah W, Baylis JD, Pierce S, Businelle MS, Gordon AJ, Krans EE, Smid MC, Cochran G. Prospective acceptability of digital phenotyping among pregnant and parenting people with opioid use disorder: A multisite qualitative study. Front Psychiatry 2023; 14:1137071. [PMID: 37139320 PMCID: PMC10149825 DOI: 10.3389/fpsyt.2023.1137071] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/27/2023] [Indexed: 05/05/2023] Open
Abstract
Background While medications for opioid use disorder (MOUD) effectively treat OUD during pregnancy and the postpartum period, poor treatment retention is common. Digital phenotyping, or passive sensing data captured from personal mobile devices, namely smartphones, provides an opportunity to understand behaviors, psychological states, and social influences contributing to perinatal MOUD non-retention. Given this novel area of investigation, we conducted a qualitative study to determine the acceptability of digital phenotyping among pregnant and parenting people with opioid use disorder (PPP-OUD). Methods This study was guided by the Theoretical Framework of Acceptability (TFA). Within a clinical trial testing a behavioral health intervention for PPP-OUD, we used purposeful criterion sampling to recruit 11 participants who delivered a child in the past 12 months and received OUD treatment during pregnancy or the postpartum period. Data were collected through phone interviews using a structured interview guide based on four TFA constructs (affective attitude, burden, ethicality, self-efficacy). We used framework analysis to code, chart, and identify key patterns within the data. Results Participants generally expressed positive attitudes about digital phenotyping and high self-efficacy and low anticipated burden to participate in studies that collect smartphone-based passive sensing data. Nonetheless, concerns were noted related to data privacy/security and sharing location information. Differences in participant assessments of burden were related to length of time required and level of remuneration to participate in a study. Interviewees voiced broad support for participating in a digital phenotyping study with known/trusted individuals but expressed concerns about third-party data sharing and government monitoring. Conclusion Digital phenotyping methods were acceptable to PPP-OUD. Enhancements in acceptability include allowing participants to maintain control over which data are shared, limiting frequency of research contacts, aligning compensation with participant burden, and outlining data privacy/security protections on study materials.
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Affiliation(s)
- Elizabeth Charron
- Department of Health Promotion Sciences, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Tulsa, OK, United States
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Ashley White
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Kristi Carlston
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Walitta Abdullah
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jacob D Baylis
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Stephanie Pierce
- Section of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Michael S Businelle
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Adam J Gordon
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, United States
| | - Elizabeth E Krans
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, United States
- Center for Perinatal Addiction Research, Education and Evidence-based Solutions (Magee CARES), Magee-Womens Research Institute, Pittsburgh, PA, United States
| | - Marcela C Smid
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, United States
| | - Gerald Cochran
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
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Smid MC. Preventing Postpartum Opioid Overdoses: Our Patients, Our Job. Obstet Gynecol 2023; 141:653-655. [PMID: 36897153 DOI: 10.1097/aog.0000000000005140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Affiliation(s)
- Marcela C Smid
- Marcela C. Smid is from the Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, and the Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah;
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Dude AM, Smid MC, Branch DW, West J, Meeks H, Yu Z, Fraser A, Smith K, Reddy D. Interpregnancy Body Mass Index Change and Offspring Mortality Risk following the Second Pregnancy. Am J Perinatol 2023; 40:387-393. [PMID: 33878768 PMCID: PMC10552797 DOI: 10.1055/s-0041-1727230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim of the study is to examine the impact of maternal interpregnancy body mass index (BMI) change on subsequent offspring mortality risk. STUDY DESIGN This is a retrospective cohort study of women who had two consecutive live singleton deliveries of at least 20 weeks' gestation from the Utah Population Database. Our exposure was defined as interpregnancy BMI change from the date of first delivery to the conception date of subsequent pregnancy. We categorized BMI change as: < - 1, -1 to 0, 0 to <1 (reference), 1 to 2, 2 to 4, ≥4 kg/m2. Our primary outcome was all-cause age-specific mortality during four time periods: neonatal (≤28 days), infant (29 days to <1 year old), childhood ((≥1 to <5 years old), and late childhood (5 to <18 years old). We also examined mortality specifically attributed to congenital anomalies. Analyses used Cox proportional hazard models stratified by full term (≥37 weeks) and preterm (<37 weeks) deliveries. All models were adjusted for relevant confounders. RESULTS Of 266,752 women, among full-term deliveries, women with a BMI increase of 4 kg/m2 or more had an increased risk of neonatal mortality in their subsequent pregnancy (hazard ratio or HR = 1.72, 95% confidence interval or CI: 1.23-2.41) Women who lost 1 kg/m2 or more between deliveries also had increased neonatal mortality (HR = 1.46, 95% CI: 1.04-2.05). There were no differences in infant, early, or late childhood mortality by interpregnancy BMI change. Maternal interpregnancy interval weight loss of 1 kg/m2 or more and weight gain of ≥4 kg/m2 also had increased risk of mortality associated with congenital anomalies or conditions arising during the neonatal period following their subsequent delivery. CONCLUSION Women with significant interpregnancy weight gain and modest weight loss have a significant increased risk of neonatal mortality following their subsequent pregnancy. KEY POINTS · Significant weight gain between deliveries increases the risk of neonatal death.. · Modest weight loss between deliveries increases the risk of neonatal death.. · This risk may be partially explained by increased risk of congenital malformations..
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Affiliation(s)
- Annie M. Dude
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Marcela C. Smid
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
- Division of Maternal Fetal Medicine, Women and Newborns Clinical Program, Intermountain Healthcare, Salt Lake City, Utah
| | - D. Ware Branch
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
- Division of Maternal Fetal Medicine, Women and Newborns Clinical Program, Intermountain Healthcare, Salt Lake City, Utah
| | - Jennifer West
- Department of Population Science, Population Science, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Huong Meeks
- Department of Population Science, Population Science, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Zhe Yu
- Department of Population Science, Population Science, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Alison Fraser
- Department of Population Science, Population Science, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Ken Smith
- Department of Population Science, Population Science, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
- Department of Family and Consumer Studies, University of Utah, Salt Lake City, Utah
| | - Deepika Reddy
- Department of Medicine, University Diabetes and Endocrinology Center, University of Utah, Salt Lake City, Utah
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Goffman D, Rood KM, Bianco A, Biggio JR, Dietz P, Drake K, Heilman E, Hopkins M, De Four Jones M, Katz T, Martin C, Prasad M, Smid MC, Wine K, Ryan R, Yong C, Carney PI, Simhan H. Real-world utilization of an intrauterine vacuum-induced hemorrhage-control device. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.1308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Metz TD, Allshouse AA, McMillin GA, Silver RM, Smid MC, Haas DM, Simhan HN, Saade GR, Grobman WA, Parry S, Chung JH, Jarlenski MP. Association of Cannabis Use With Nausea and Vomiting of Pregnancy. Obstet Gynecol 2022; 140:266-270. [PMID: 35852278 PMCID: PMC9309979 DOI: 10.1097/aog.0000000000004850] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/21/2022] [Indexed: 11/26/2022]
Abstract
Our objective was to evaluate whether cannabis use was associated with nausea and vomiting in early pregnancy. Participants from nuMoM2b (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be) enrolled from October 2010 through September 2013 with a PUQE (Pregnancy-Unique Quantification of Emesis) questionnaire and an available stored urine sample from the first study visit (median gestational age 12 weeks) were included. Cannabis exposure was ascertained by urine immunoassay for 11-nor-9-carboxy-delta-9-tetrahydrocannabinol (THC-COOH); positive results were confirmed with liquid chromatography tandem mass spectrometry. The primary outcome was moderate-to-severe nausea by the PUQE score. Overall, 9,250 participants were included, and 5.8% (95% CI 5.4-6.3%) had detectable urine THC-COOH. In adjusted analyses, higher THC-COOH levels were associated with greater odds of moderate-to-severe nausea (20.7% in the group with THC-COOH detected vs 15.5% in the group with THC-COOH not detected, adjusted odds ratio 1.6, 95% CI 1.1-2.2 for a 500 ng/mg Cr THC-COOH increment).
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Affiliation(s)
- Torri D Metz
- University of Utah Health and ARUP Laboratories, Salt Lake City, Utah; Indiana University, Indianapolis, Indiana; University of Pittsburgh, Pittsburgh, Pennsylvania; University of Texas Medical Branch, Galveston, Texas; The Ohio State University, Columbus, Ohio; University of Pennsylvania, Philadelphia, Pennsylvania; University of California Irvine, Irvine, California; and University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
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Smid MC, Allshouse AA, McMillin GA, Nunez K, Cavin T, Worden J, Buchi K, Muniyappa B, Varner MW, Cochran G, Metz TD. Umbilical Cord Collection and Drug Testing to Estimate Prenatal Substance Exposure in Utah. Obstet Gynecol 2022; 140:153-162. [PMID: 35852263 PMCID: PMC9373719 DOI: 10.1097/aog.0000000000004868] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/12/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Our primary objective was to estimate statewide prenatal substance exposure based on umbilical cord sampling. Our secondary objectives were to compare prevalence of prenatal substance exposure across urban, rural, and frontier regions, and to compare contemporary findings to those previously reported. METHODS We performed a cross-sectional prevalence study of prenatal substance exposure, as determined by umbilical cord positivity for 49 drugs and drug metabolites, through the use of qualitative liquid chromatography-tandem mass spectrometry. All labor and delivery units in Utah (N=45) were invited to participate. Based on a 2010 study using similar methodology, we calculated that a sample size of at least 1,600 cords would have 90% power to detect 33% higher rate of umbilical cords testing positive for any substance. Deidentified umbilical cords were collected from consecutive deliveries at participating hospitals. Prevalence of prenatal substance exposure was estimated statewide and by rurality using weighted analysis. RESULTS From November 2020 to November 2021, 1,748 cords (urban n=988, rural n=384, frontier n=376) were collected from 37 hospitals, representing 92% of hospitals that conduct 91% of births in the state. More than 99% of cords (n=1,739) yielded results. Statewide, 9.9% (95% CI 8.1-11.7%) were positive for at least one substance, most commonly opioids (7.0%, 95% CI 5.5-8.5%), followed by cannabinoid (11-nor-9-carboxy-delta-9-tetrahydrocannabinol [THC-COOH]) (2.5%, 95% CI 1.6-3.4%), amphetamines (0.9%, 95% CI 0.4-1.5), benzodiazepines (0.5%, 95% CI 0.1-0.9%), alcohol (0.4%, 95% CI 0.1-0.7%), and cocaine (0.1%, 95% CI 0-0.3%). Cord positivity was similar by rurality (urban=10.3%, 95% CI 8.3-12.3%, rural=7.1%, 95% CI 3.5-10.7%, frontier=9.2%, 95% CI 6.2-12.2%, P=.31) and did not differ by substance type. Compared with a previous study, prenatal exposure to any substance (6.8 vs 9.9%, P=.01), opioids (4.7 vs 7.0% vs 4.7%, P=.03), amphetamines (0.1 vs 0.9%, P=.01) and THC-COOH (0.5 vs 2.5%, P<.001) increased. CONCLUSION Prenatal substance exposure was detected in nearly 1 in 10 births statewide.
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Affiliation(s)
- Marcela C Smid
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, the Department of Pathology, and the Department of Pediatrics, University of Utah Health, the Division of Maternal Fetal Medicine, Women and Newborns Clinical Program, Intermountain Healthcare, the Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, and ARUP Laboratories, Salt Lake City, Utah
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Smid MC, Metz TD. In Reply:. Obstet Gynecol 2022; 139:939-940. [PMID: 35576360 PMCID: PMC9223443 DOI: 10.1097/aog.0000000000004780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Metz TD, Allshouse AA, Pinar H, Varner M, Smid MC, Hogue C, Dudley DJ, Bukowski R, Saade GR, Goldenberg RL, Reddy U, Silver RM. Maternal Marijuana Exposure, Feto-Placental Weight Ratio, and Placental Histology. Am J Perinatol 2022; 39:546-553. [PMID: 32971561 PMCID: PMC10506868 DOI: 10.1055/s-0040-1717092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Marijuana use is associated with placenta-mediated adverse pregnancy outcomes including fetal growth restriction, but the mechanism remains uncertain. The objective was to evaluate the association between maternal marijuana use and the feto-placental weight ratio (FPR). Secondarily, we aimed to compare placental histology of women who used marijuana to those who did not. STUDY DESIGN This was a secondary analysis of singleton pregnancies enrolled in a multicenter and case-control stillbirth study. Prior marijuana use was detected by electronic medical record abstraction or cord homogenate positive for 11-nor-delta-9-tetrahydrocannabinol-9-carboxylic acid. Prior tobacco use was detected by self-report or presence of maternal serum cotinine. Stillbirths and live births were considered separately. The primary outcome was FPR. Association of marijuana use with FPR was estimated with multivariable linear modeling adjusted for fetal sex, preterm birth, and tobacco use. Comparisons between groups for placental histology were made using Chi-square and stratified by live birth and stillbirth, term and preterm deliveries, and fetal sex. RESULTS Of 1,027 participants, 224 were stillbirths and 803 were live births. Overall, 41 (4%) women used marijuana during the pregnancy. The FPR ratio was lower among exposed offspring but reached statistical significance only for term stillbirths (mean 6.84 with marijuana use vs. mean 7.8 without use, p < 0.001). In multivariable modeling, marijuana use was not significantly associated with FPR (p = 0.09). There were no differences in histologic placental features among those with and without marijuana use overall or in stratified analyses. CONCLUSION Exposure to marijuana may not be associated with FPR. Similarly, there were no placental histologic features associated with marijuana exposure. Further study of the influence of maternal marijuana use on placental development and function is warranted to better understand the association between prenatal marijuana use and poor fetal growth. KEY POINTS · Maternal marijuana exposure was not associated with the feto-placental weight ratio.. · Marijuana exposure was not associated with differences in placental histology.. · Concerning trend toward lower feto-placental weight ratios among marijuana-exposed stillbirths..
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Affiliation(s)
| | | | | | | | | | | | - Donald J Dudley
- University of Virginia School of Medicine, Charlottesville, Virginia
| | - Radek Bukowski
- University of Texas at Austin, Dell Medical School, Austin, Texas
| | | | | | - Uma Reddy
- Yale University, New Haven, Connecticut
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Debbink MP, Metz TD, Nelson RE, Janes SE, Kroes A, Begaye LJ, Heuser CC, Smid MC, Silver RM, Varner MW, Einerson BD. Directly Measured Costs of Severe Maternal Morbidity Events during Delivery Admission Compared with Uncomplicated Deliveries. Am J Perinatol 2022; 39:567-576. [PMID: 34856617 PMCID: PMC9420545 DOI: 10.1055/s-0041-1740237] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To estimate the actual excess costs of care for delivery admissions complicated by severe maternal morbidity (SMM) compared with uncomplicated deliveries. STUDY DESIGN This is a retrospective cohort study of all deliveries between October 2015 and September 2018 at a single tertiary academic center. Pregnant individuals ≥ 20 weeks' gestation who delivered during a hospital admission (i.e., a "delivery admission") were included. The primary exposure was SMM, as defined by Centers for Disease Control and Prevention (CDC) criteria, CDC criteria excluding blood transfusion, or by validated hospital-defined criteria (intensive care unit admission or ≥ 4 units of blood products). Potential SMM events identified via administrative and blood bank data were reviewed to confirm SMM events had occurred. Primary outcome was total actual costs of delivery admission derived from time-based accounting and acquisition costs in the institutional Value Driven Outcomes database. Cost of delivery admissions with SMM events was compared with the cost of uncomplicated delivery using adjusted generalized linear models, with separate models for each of the SMM definitions. Relative cost differences are reported due to data restrictions. RESULTS Of 12,367 eligible individuals, 12,361 had complete cost data. Two hundred and eighty individuals (2.3%) had confirmed SMM events meeting CDC criteria. CDC criteria excluding transfusion alone occurred in 1.0% (n = 121) and hospital-defined SMM in 0.6% (n = 76). In adjusted models, SMM events by CDC criteria were associated with a relative cost increase of 2.45 times (95% confidence interval [CI]: 2.29-2.61) the cost of an uncomplicated delivery. SMM by CDC criteria excluding transfusion alone was associated with a relative increase of 3.26 (95% CI: 2.95-3.60) and hospital-defined SMM with a 4.19-fold (95% CI: 3.64-4.83) increase. Each additional CDC subcategory of SMM diagnoses conferred a relative cost increase of 1.60 (95% CI: 1.43-1.79). CONCLUSION SMM is associated with between 2.5- and 4-fold higher cost than uncomplicated deliveries. KEY POINTS · Severe maternal morbidity as defined by CDC criteria confers a 2.5-fold increase in delivery hospitalization costs.. · Intensive care unit admission or ≥ 4 units of blood products confer a fourfold increase in cost.. · Costs of maternal morbidity may motivate SMM review..
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Affiliation(s)
- Michelle P. Debbink
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Utah Health, Salt Lake City, Utah,Division of Maternal Fetal Medicine, Women and Newborns Clinical Program, Intermountain Healthcare, Salt Lake City, Utah
| | - Torri D. Metz
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Utah Health, Salt Lake City, Utah,Division of Maternal Fetal Medicine, Women and Newborns Clinical Program, Intermountain Healthcare, Salt Lake City, Utah
| | - Richard E. Nelson
- Department of Internal Medicine, Division of Epidemiology, University of Utah Health, Salt Lake City, Utah,Department of Pediatrics, Division of Pediatric Administration, University of Utah Health, Salt Lake City, Utah
| | - Sophie E. Janes
- University of Utah School of Medicine, University of Utah Health, Salt Lake City, Utah
| | - Alexandra Kroes
- University of Utah School of Medicine, University of Utah Health, Salt Lake City, Utah
| | - Lori J. Begaye
- Department of international Studies, University of Utah, Salt Lake City, Utah
| | - Cara C. Heuser
- Division of Maternal Fetal Medicine, Women and Newborns Clinical Program, Intermountain Healthcare, Salt Lake City, Utah
| | - Marcela C. Smid
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Utah Health, Salt Lake City, Utah,Division of Maternal Fetal Medicine, Women and Newborns Clinical Program, Intermountain Healthcare, Salt Lake City, Utah
| | - Robert M. Silver
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Utah Health, Salt Lake City, Utah
| | - Michael W. Varner
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Utah Health, Salt Lake City, Utah,Division of Maternal Fetal Medicine, Women and Newborns Clinical Program, Intermountain Healthcare, Salt Lake City, Utah
| | - Brett D. Einerson
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Utah Health, Salt Lake City, Utah,Division of Maternal Fetal Medicine, Women and Newborns Clinical Program, Intermountain Healthcare, Salt Lake City, Utah
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Baylis JD, Charron E, Archer S, Garets M, Bryan MA, Foringer J, Kelley AT, Smid MC, Cochran G. Attitudes, self-efficacy, and practices related to opioid risk assessment and mitigation: A comparison of health care professionals in rural communities. Subst Abus 2022; 43:1163-1171. [PMID: 35617634 DOI: 10.1080/08897077.2022.2074593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background: Health care professionals (HCPs) play an important role in opioid misuse and opioid use disorder (OUD) screening/identification, mitigation, and referral to treatment. This study compared attitudes, self-efficacy, and practices related to opioid risk assessment and mitigation among pregnancy and non-pregnancy HCPs in rural communities. Methods: We conducted a secondary analysis of cross-sectional, self-report survey data of HCPs in two rural counties in southern Utah. Pregnancy HCPs were identified by a question asking whether they provide care to pregnant patients. HCPs' attitudes toward their patients with opioid misuse/OUD were measured using the Survey of Attitudes and Perceptions questionnaire. Self-efficacy and practices related to opioid risk assessment and mitigation were captured with questions asking about assessment and screening of opioid use, advisement to change opioid use behavior, and referral to treatment for OUD. We used linear regression analyses to estimate associations between HCPs' attitudes toward patients with opioid misuse/OUD and their self-efficacy and use of opioid risk assessment and mitigation practices. Results: This sample included a total of 132 HCPs, including 82 pregnancy HCPs and 50 non-pregnancy HCPs. Attitudes domains were similar among pregnancy and non-pregnancy HCPs. Among pregnancy HCPs, role adequacy (β = .48, 95% CI = .16-.80), role legitimacy (β = .72, 95% CI = .21-1.22), motivation (β = .68, 95% CI = .14-1.21), and positive task-specific self-esteem (β = 1.52, 95% CI = .70-2.35) were positively associated with more frequent use of opioid risk assessment and mitigation practices, while attitudes were not associated with these practices among non-pregnancy HCPs. Conclusions: Training initiatives that lead to improved HCP attitudes could improve opioid care management among rural pregnancy HCPs. More research is needed to determine approaches to increase the use of opioid risk assessment and mitigation practices among rural non-pregnancy HCPs.
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Affiliation(s)
- Jacob D Baylis
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Elizabeth Charron
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Shayla Archer
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Mitchell Garets
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - M Aryana Bryan
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jacob Foringer
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - A Taylor Kelley
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Marcela C Smid
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Gerald Cochran
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Greater Intermountain Node (GIN), NIH NIDA Clinical Trials Network, University of Utah, Salt Lake City, UT, USA
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Smid MC, Metz TD, McMillin GA, Mele L, Casey BM, Reddy UM, Wapner RJ, Thorp JM, Saade GR, Tita ATN, Miller ES, Rouse DJ, Sibai B, Costantine MM, Mercer BM, Caritis SN. Prenatal Nicotine or Cannabis Exposure and Offspring Neurobehavioral Outcomes. Obstet Gynecol 2022; 139:21-30. [PMID: 34856574 PMCID: PMC8715943 DOI: 10.1097/aog.0000000000004632] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/07/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To study the association between nicotine or cannabis metabolite presence in maternal urine and child neurodevelopmental outcomes. METHODS We conducted a secondary analysis of two parallel multicenter randomized controlled trials of treatment for hypothyroxinemia or subclinical hypothyroidism among pregnant individuals enrolled at 8-20 weeks of gestation. All maternal-child dyads with a maternal urine sample at enrollment and child neurodevelopmental testing were included (N=1,197). Exposure was urine samples positive for nicotine (cotinine) or cannabis 11-nor-9-carboxy-delta-9-tetrahydrocannabinol [THC-COOH]) or both metabolites. Primary outcome was child IQ at 60 months. Secondary outcomes included cognitive, motor and language, attention, behavioral and social competency, and differential skills assessments at 12, 24, 36, and 48 months. Quantile regression analysis was performed with confounder adjustment. RESULTS Of 1,197 pregnant individuals, 99 (8.3%) had positive cotinine samples and 47 (3.9%) had positive THC-COOH samples; 33 (2.8%) were positive for both. Groups differed in self-reported race and ethnicity, education, marital status, insurance, and thyroid status. Median IQ was similar between cotinine-exposed and -unexposed children (90 vs 95, adjusted difference in medians -2.47, 95% CI -6.22 to 1.29) and THC-COOH-exposed and -unexposed children (89 vs 95, adjusted difference in medians -1.35, 95% CI -7.76 to 5.05). In secondary outcome analysis, children with THC-COOH exposure compared with those unexposed had higher attention scores at 48 months of age (57 vs 49, adjusted difference in medians 6.0, 95% CI 1.11-10.89). CONCLUSIONS Neither prenatal nicotine nor cannabis exposure was associated with a difference in IQ. Cannabis exposure was associated with worse attention scores in early childhood. Longitudinal studies assessing associations between child neurodevelopmental outcomes and prenatal nicotine and cannabis exposure with a focus on timing and quantity of exposure are needed. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT00388297.
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Affiliation(s)
- Marcela C Smid
- Departments of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, University of Texas-Southwestern, Dallas, Texas, Columbia University, New York, New York, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, University of Texas Medical Branch at Galveston, Galveston, Texas, University of Alabama at Birmingham, Birmingham, Alabama, Northwestern University, Chicago, Illinois, Brown University, Providence, Rhode Island, University of Texas-Houston, Houston, Texas, The Ohio State University, Columbus, Ohio, Case Western Reserve University, Cleveland, Ohio, and University of Pittsburgh, Pittsburgh, Pennsylvania; the Department of Pathology, University of Utah Health and ARUP Laboratories, Salt Lake City, Utah; the George Washington University Biostatistics Center, Washington, DC; and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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Kelley AT, Smid MC, Baylis JD, Charron E, Begaye LJ, Binns-Calvey A, Archer S, Weiner S, Pettey W, Cochran G. Treatment access for opioid use disorder in pregnancy among rural and American Indian communities. J Subst Abuse Treat 2021; 136:108685. [PMID: 34953636 DOI: 10.1016/j.jsat.2021.108685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 07/28/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Opioid use disorder (OUD) in pregnancy disproportionately impacts rural and American Indian (AI) communities. With limited data available about access to care for these populations, this study's objective was to assess clinic knowledge and new patient access for OUD treatment in three rural U.S. counties. MATERIAL AND METHODS The research team used unannounced standardized patients (USPs) to request new patient appointments by phone for white and AI pregnant individuals with OUD at primary care and OB/GYN clinics that provide prenatal care in three rural Utah counties. We assessed a) clinic familiarity with buprenorphine for OUD; b) appointment availability for buprenorphine treatment; c) appointment wait times; d) referral provision when care was unavailable; and e) availability of OUD care at referral locations. We compared outcomes for AI and white USP profiles using descriptive statistics. RESULTS The USPs made 34 calls to 17 clinics, including 4 with publicly listed buprenorphine prescribers on the Substance Abuse and Mental Health Services Administration website. Among clinical staff answering calls, 16 (47%) were unfamiliar with buprenorphine. OUD treatment was offered when requested in 6 calls (17.6%), with a median appointment wait time of 2.5 days (IQR 1-5). Among clinics with a listed buprenorphine prescriber, 2 of 4 (50%) offered OUD treatment. Most clinics (n = 24/28, 85.7%) not offering OUD treatment provided a referral; however, a buprenorphine provider was unavailable/unreachable 67% of the time. The study observed no differences in appointment availability between AI and white individuals. CONCLUSIONS Rural-dwelling AI and white pregnant individuals with OUD experience significant barriers to accessing care. Improving OUD knowledge and referral practices among rural clinics may increase access to care for this high-risk population.
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Affiliation(s)
- A Taylor Kelley
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84132, United States of America; Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, 500 Foothill Drive, Building 2, Salt Lake City, UT 84148, United States of America; Department of Internal Medicine, Division of General Internal Medicine, University of Utah School of Medicine, 30 N 1900 E 5R341, Salt Lake City, UT 84132, United States of America.
| | - Marcela C Smid
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84132, United States of America; Department of Obstetrics and Gynecology, University of Utah School of Medicine, 30 N 1900 E 2B300, Salt Lake City, UT 84132, United States of America
| | - Jacob D Baylis
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84132, United States of America
| | - Elizabeth Charron
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84132, United States of America
| | - Lori Jo Begaye
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84132, United States of America
| | - Amy Binns-Calvey
- Department of Medicine, Division of Academic Internal Medicine and Geriatrics, University of Illinois at Chicago, 840 South Wood Street, CSN 440, Chicago, IL 60612, United States of America
| | - Shayla Archer
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84132, United States of America
| | - Saul Weiner
- Jesse Brown VA Medical Center, Medical Services, 820 S Damen Ave, Chicago, IL 60612, United States of America; Department of Medicine, Division of Academic Internal Medicine and Geriatrics, University of Illinois at Chicago, 840 South Wood Street, CSN 440, Chicago, IL 60612, United States of America
| | - Warren Pettey
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84132, United States of America
| | - Gerald Cochran
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84132, United States of America
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Cleary EM, Smid MC, Bokat C, Costantine MM, Rood KM. Indicated Opioids in Pregnancy: Guidance on Providing Comprehensive Care. Am J Perinatol 2021; 40:602-611. [PMID: 34768306 DOI: 10.1055/s-0041-1739427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
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..
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Affiliation(s)
- Erin M Cleary
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
| | - Marcela C Smid
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Christina Bokat
- Department of Anesthesia, University of Utah Health, Salt Lake City, Utah
| | - Maged M Costantine
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
| | - Kara M Rood
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
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Cleary EM, Smid MC, Charles JE, Jones KM, Costantine MM, Saade G, Rood KM. Buprenorphine X-waiver exemption - beyond the basics for the obstetrical provider. Am J Obstet Gynecol MFM 2021; 3:100451. [PMID: 34320429 DOI: 10.1016/j.ajogmf.2021.100451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 07/20/2021] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Erin M Cleary
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH.
| | - Marcela C Smid
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT
| | - Jasmin E Charles
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT
| | - Kaitlyn M Jones
- College of Nursing, University of Utah Health, Salt Lake City, UT
| | - Maged M Costantine
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH
| | - George Saade
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX
| | - Kara M Rood
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH
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Smid MC, Saitz R. Postpartum Treatment of Individuals With Opioid Use Disorder: Maternal Risk and Need for Evidence Do Not End When Pregnancy Ends. J Addict Med 2021; 15:267-268. [PMID: 34397779 DOI: 10.1097/adm.0000000000000878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Marcela C Smid
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT (MCS), Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT (MCS), Department of Community Health Sciences, Boston University School of Public Health, Boston, MA (RS), Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, and the Grayken Center for Addiction, Boston Medical Center, Boston, MA (RS)
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Kelley AT, Smid MC, Baylis JD, Charron E, Binns-Calvey AE, Archer S, Weiner SJ, Begaye LJ, Cochran G. Development of an unannounced standardized patient protocol to evaluate opioid use disorder treatment in pregnancy for American Indian and rural communities. Addict Sci Clin Pract 2021; 16:40. [PMID: 34172081 PMCID: PMC8229269 DOI: 10.1186/s13722-021-00246-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 06/03/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Opioid use disorder (OUD) disproportionately impacts rural and American Indian communities and has quadrupled among pregnant individuals nationwide in the past two decades. Yet, limited data are available about access and quality of care available to pregnant individuals in rural areas, particularly among American Indians (AIs). Unannounced standardized patients (USPs), or "secret shoppers" with standardized characteristics, have been used to assess healthcare access and quality when outcomes cannot be measured by conventional methods or when differences may exist between actual versus reported care. While the USP approach has shown benefit in evaluating primary care and select specialties, its use to date for OUD and pregnancy is very limited. METHODS We used literature review, current practice guidelines for perinatal OUD management, and stakeholder engagement to design a novel USP protocol to assess healthcare access and quality for OUD in pregnancy. We developed two USP profiles-one white and one AI-to reflect our target study area consisting of three rural, predominantly white and AI US counties. We partnered with a local community health center network providing care to a large AI population to define six priority outcomes for evaluation: (1) OUD treatment knowledge among clinical staff answering telephones; (2) primary care clinic facilitation and provision of prenatal care and buprenorphine treatment; (3) appropriate completion of evidence-based screening, symptom assessment, and initial steps in management; (4) appropriate completion of risk factor screening/probing about individual circumstances that may affect care; (5) patient-directed tone, stigma, and professionalism by clinic staff; and (6) disparities in care between whites and American Indians. DISCUSSION The development of this USP protocol tailored to a specific environment and high-risk patient population establishes an innovative approach to evaluate healthcare access and quality for pregnant individuals with OUD. It is intended to serve as a roadmap for our own study and for future related work within the context of substance use disorders and pregnancy.
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Affiliation(s)
- A Taylor Kelley
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, 500 Foothill Drive, Building 2, Salt Lake City, UT, 84148, USA.
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N 1900 E 5R341, Salt Lake City, UT, 84132, USA.
| | - Marcela C Smid
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, 30 N 1900 E 2B300, Salt Lake City, UT, 84132, USA
| | - Jacob D Baylis
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N 1900 E 5R341, Salt Lake City, UT, 84132, USA
| | - Elizabeth Charron
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N 1900 E 5R341, Salt Lake City, UT, 84132, USA
| | - Amy E Binns-Calvey
- Jesse Brown VA Medical Center, Medical Services, 820 S Damen Ave, Chicago, IL, 60612, USA
- Division of Academic Internal Medicine and Geriatrics, Department of Medicine, University of Illinois At Chicago, 840 South Wood Street, CSN 440, Chicago, IL, 60612, USA
- Edward Hines VA Hospital, Center of Innovation for Complex Chronic Healthcare, 5000 5th Avenue, Hines, IL, USA
| | - Shayla Archer
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, 500 Foothill Drive, Building 2, Salt Lake City, UT, 84148, USA
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N 1900 E 5R341, Salt Lake City, UT, 84132, USA
| | - Saul J Weiner
- Jesse Brown VA Medical Center, Medical Services, 820 S Damen Ave, Chicago, IL, 60612, USA
- Division of Academic Internal Medicine and Geriatrics, Department of Medicine, University of Illinois At Chicago, 840 South Wood Street, CSN 440, Chicago, IL, 60612, USA
| | - Lori Jo Begaye
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N 1900 E 5R341, Salt Lake City, UT, 84132, USA
| | - Gerald Cochran
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N 1900 E 5R341, Salt Lake City, UT, 84132, USA
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Reese SE, Riquino MR, Molloy J, Nguyen V, Smid MC, Tenort B, Gezinski LB. Experiences of Nursing Professionals Working With Women Diagnosed With Opioid Use Disorder and Their Newborns: Burnout and the Need for Support. Adv Neonatal Care 2021; 21:32-40. [PMID: 33055519 DOI: 10.1097/anc.0000000000000816] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND As the rate of opioid use in pregnancy escalates, there are a growing number of women diagnosed with opioid use disorder (OUD) and their newborns being cared for in inpatient settings. PURPOSE In this study, we sought to better understand the experiences of nurses and nursing assistants working with women diagnosed with OUD and their newborns. By identifying the needs of nurses and nursing assistants, the findings from this study may contribute to reductions in stigma and improved patient care. METHODS Nurses and nursing assistants were recruited from a postpartum unit at a large urban hospital in Utah. Participants (n = 30) attended up to 4 semistructured focus groups. We utilized Braun and Clarke's 6-phase approach to thematic analysis to analyze transcribed interviews. FINDINGS/RESULTS Themes identified during the data analysis process included negative feelings and reactions toward patients; preferential concern for the newborn over maternal well-being; and identification of organizational and training needs to overcome these challenges. IMPLICATIONS FOR PRACTICE These findings identify strategies for addressing challenges faced by nurses and nursing assistants in caring for women diagnosed with OUD and their newborns. IMPLICATIONS FOR RESEARCH Future research should examine the effectiveness of approaches to reduce behaviors influenced by stigma among nurses and nursing assistants working with women diagnosed with OUD and their newborns, as well as employee and patient satisfaction, and long-term health outcomes.
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Affiliation(s)
- Sarah E Reese
- School of Social Work, University of Montana, Missoula (Dr. Reese); School of Social Welfare, University of Kansas, Lawrence (Dr Riquino); School of Social Work, University of Montana, Missoula (Dr Molloy); independent researcher, Salt Lake City, UT (Dr. Nguyen); Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City (Dr Smid); and Labor & Delivery and Obstetrical Emergency Services, University of Utah Hospital, Salt Lake City (Ms Tenort). Dr Gezinski is an independent researcher, Amsterdam, the Netherlands
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Cassimatis IR, Battarbee AN, Allshouse AA, Badreldin N, Vranes CM, Oler AM, Smid MC. Neonatal outcomes associated with late preterm betamethasone administration in women with pregestational diabetes. Pediatr Neonatol 2020; 61:645-646. [PMID: 32763054 DOI: 10.1016/j.pedneo.2020.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/30/2020] [Accepted: 07/01/2020] [Indexed: 10/23/2022] Open
Affiliation(s)
- Irina R Cassimatis
- University of Utah Health, Salt Lake City, UT, USA; Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | | | | | - Nevert Badreldin
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Ann M Oler
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Venkatesh KK, Pate V, Boggess KA, Jones HE, Funk MJ, Smid MC. Trends in Opioid and Psychotropic Prescription in Pregnancy in the United States From 2001 to 2015 in a Privately Insured Population : A Cross-sectional Study. Ann Intern Med 2020; 173:S19-S28. [PMID: 33253018 DOI: 10.7326/m19-3249] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Opioid and psychotropic prescriptions are common during pregnancy. Little is known about coprescriptions of both medications in this setting. OBJECTIVE To describe opioid prescription among women who are prescribed psychotropics compared with women who are not. DESIGN Cross-sectional study. SETTING U.S. commercial insurance beneficiaries from MarketScan (2001 to 2015). PARTICIPANTS Pregnant women at 22 weeks' gestation or greater who were insured continuously for 3 months or more before pregnancy through delivery. MEASUREMENTS Opioid prescription, dosage thresholds (morphine milligram equivalents [MME] of ≥50/day and ≥90/day), number of opioid agents (≥2), and duration (≥30 days) among those with and without prescription of psychotropics, from 2011 to 2015. RESULTS Among 958 980 pregnant women, 10% received opioids only, 6% psychotropics only, and 2% opioids with coprescription of psychotropics. Opioid prescription was higher among women prescribed psychotropics versus those who were not (26.5% vs. 10.7%). From 2001 to 2015, psychotropic prescription overall increased from 4.4% to 7.6%, opioid prescription without coprescription of psychotropics decreased from 11.9% to 8.4%, and opioids with coprescription decreased from 28.1% to 22.0%. Morphine milligram equivalents of 50 or greater per day decreased for women with and without coprescription (29.6% to 17.3% and 22.8% to 18.5%, respectively); MME of 90 or greater per day also decreased in both groups (15.0% to 4.7% and 11.5% to 4.2%, respectively). Women prescribed opioids only were more likely to have an antepartum hospitalization compared with those with neither prescription, as were women with coprescription versus those prescribed psychotropics only. Compared with those prescribed opioids only, women with coprescriptions were more likely to exceed MME of 90 or greater per day and to be prescribed 2 or more opioid agents and for 30 days or longer. Number and duration of opioids increased with benzodiazepine and gabapentin coprescription. LIMITATION Inability to determine appropriateness of prescribing or overdose events. CONCLUSION Opioids are frequently coprescribed with psychotropic medication during pregnancy and are associated with antepartum hospitalization. A substantial proportion of pregnant women are prescribed opioids at doses that increase overdose risk and exceed daily recommendations. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
| | - Virginia Pate
- Gillings School of Global Public Health and Center for Women's Health Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (V.P., M.J.F.)
| | - Kim A Boggess
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (K.A.B., H.E.J.)
| | - Hendrée E Jones
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (K.A.B., H.E.J.)
| | - Michele Jonsson Funk
- Gillings School of Global Public Health and Center for Women's Health Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (V.P., M.J.F.)
| | - Marcela C Smid
- University of Utah Health, Salt Lake City, Utah (M.C.S.)
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Smid MC, Schauberger CW, Terplan M, Wright TE. Early lessons from maternal mortality review committees on drug-related deaths-time for obstetrical providers to take the lead in addressing addiction. Am J Obstet Gynecol MFM 2020; 2:100177. [PMID: 33345905 PMCID: PMC7753059 DOI: 10.1016/j.ajogmf.2020.100177] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 07/01/2020] [Indexed: 12/17/2022]
Abstract
Problem: In the United States, maternal mortality review committees (MMRC) are providing compelling data that drug-related deaths are emerging as a leading cause of pregnancy-associated death (death during pregnancy or up to a year postpartum). Recommendations from the MMRC consistently highlight screening all pregnant and postpartum women for drug use and improving access to evidence-based substance use disorder and mental health treatment. Unfortunately, many providers lack the confidence, skills and necessary resources to screen for substance use, provide basic behavioral health services or facilitate referral to high-quality services in their clinical settings. Our profession’s collective lack of response to a leading cause of maternal death represents a missed opportunity for potentially life-saving interventions. A Solution: We call on our fellow obstetrician gynecologists to incorporate the lessons learned from MMRC and integrate addiction assessment and treatment into prenatal and postpartum care. Provider level integration of behavioral health services is, however, insufficient to fully address the magnitude of drug-related maternal deaths in the US. We, therefore, ask colleagues to address the structural/systemic barriers to care identified in MMRC. By doing so, we can prevent drug-related maternal deaths.
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Affiliation(s)
- Marcela C Smid
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and the Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT.
| | - Charles W Schauberger
- Department of Obstetrics and Gynecology and Behavioral Health, Gundersen Health System, La Crosse, WI
| | | | - Tricia E Wright
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
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Bryan MA, Smid MC, Cheng M, Fortenberry KT, Kenney A, Muniyappa B, Pendergrass D, Gordon AJ, Cochran G. Addressing opioid use disorder among rural pregnant and postpartum women: a study protocol. Addict Sci Clin Pract 2020; 15:33. [PMID: 33129355 PMCID: PMC7603672 DOI: 10.1186/s13722-020-00206-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/23/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Opioid use disorder (OUD) among women delivering at a hospital has increased 400% from 1999-2014 in the United States. From the years 2007 to 2016, opioid-related mortality during pregnancy increased over 200%, and drug-overdose deaths made up nearly 10% of all pregnancy-associated mortality in 2016 in the US. Disproportionately higher rates of neonatal opioid withdrawal syndrome (NOWS) have been reported in rural areas of the country, suggesting that perinatal OUD is a pressing issue among these communities. There is an urgent need for comprehensive, evidence-based treatment services for pregnant women experiencing OUD. The purpose of this article is to describe a study protocol aimed at developing and evaluating a perinatal OUD curriculum, enhancing evidence-based perinatal OUD treatment in a rural setting, and evaluating the implementation of such collaborative care for perinatal OUD. METHODS This two-year study employed a one group, repeated measures, hybrid type-1 effectiveness-implementation design. This study delivered interventions at 2 levels, both targeting improvement of care for pregnant women with OUD. The first area of focus was at the community healthcare provider-level, which aimed to evaluate the acceptability and feasibility of perinatal OUD education across time and to improve provider education by increasing knowledge specific to: MOUD provision; screening, brief intervention, and referral to treatment (SBIRT) utilization; and NOWS treatment. The second area of intervention focus was at the patient-level, which assessed the preliminary effect of perinatal OUD provider education in promoting illicit opioid abstinence and treatment engagement among pregnant women with OUD. We adopted constructs from the Consolidated Framework for Implementation Research (CFIR) to assess contextual factors that may influence implementation, and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model to comprehensively evaluate implementation outcomes. DISCUSSION This article presents the protocol of an implementation study that is employing the CFIR and RE-AIM frameworks to implement and evaluate a perinatal OUD education and service coordination program in two rural counties. This protocol could serve as a model for clinicians and researchers seeking to implement improvements in perinatal care for women with OUD in other rural communities. Trial registration NCT04448015 clinicaltrials.gov.
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Affiliation(s)
- M Aryana Bryan
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
| | - Marcela C Smid
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.,Department of Obstetrics and Gynecology, University of Utah School of Medicine, Division of Maternal Fetal Medicine, Salt Lake City, UT, 84132, USA
| | - Melissa Cheng
- Department of Family and Preventive Medicine, University of Utah School of Medicine, 375 Chipeta Way Ste. A, Salt Lake City, UT, 84108, USA
| | - Katherine T Fortenberry
- Department of Family and Preventive Medicine, University of Utah School of Medicine, 375 Chipeta Way Ste. A, Salt Lake City, UT, 84108, USA
| | - Amy Kenney
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Bhanu Muniyappa
- Department of Pediatrics, University of Utah School of Medicine, Division of General Pediatrics, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | | | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.,Greater Intermountain Node (GIN), NIH NIDA Clinical Trials Network, University of Utah, Salt Lake City, UT, USA.,Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Gerald Cochran
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.,Greater Intermountain Node (GIN), NIH NIDA Clinical Trials Network, University of Utah, Salt Lake City, UT, USA
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Cochran G, Smid MC, Krans EE, Bryan MA, Gordon AJ, Lundahl B, Silipigni J, Haaland B, Tarter R. A pilot multisite study of patient navigation for pregnant women with opioid use disorder. Contemp Clin Trials 2019; 87:105888. [PMID: 31731006 PMCID: PMC7201898 DOI: 10.1016/j.cct.2019.105888] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 11/06/2019] [Accepted: 11/09/2019] [Indexed: 11/17/2022]
Abstract
The opioid crisis continues to affect pregnant and postpartum women the United States, with the number of pregnant women diagnosed with opioid use disorder (OUD) quadrupling over the last decade. The associated increase in morbidity and mortality among mother and baby warrants prompt, targeted intervention efforts that improve engagement, linkage of care, and treatment retention. Patient navigation (PN) is a chronic care intervention that can directly address this need by helping women identify medical, behavioral, and psychosocial care goals. Moreover, PN can assist women in preparing for, engaging in, and maintaining patient participation in necessary services. Specifically, PN includes strengths-based case management, 1-1 clinical support, motivational interviewing, and addiction-relapse prevention programming. The objective of this article is to present the study protocol of a pilot multisite randomized clinical trial, entitled: Optimizing Pregnancy and Treatment Interventions for Moms 2.0 (OPTI-Mom 2.0; NCT03833245). In this study, we build upon a proof-of-concept study, employing evidence-informed frameworks for protocol and intervention expansion in order to construct a PN intervention tailored for pregnant women with OUD in central Utah and southwestern Pennsylvania. Our protocol provides an initial framework of a potentially impactful intervention and may guide development of future programs. Importantly, this study further establishes the evidence-base-with potential to ameliorate serious adverse opioid-related outcomes and improve health for women and their children.
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Affiliation(s)
- Gerald Cochran
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States; Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, United States.
| | - Marcela C Smid
- Department of Maternal Fetal Medicine, University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT, United States
| | - Elizabeth E Krans
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Magee-Womens Research Institute, 300 Halket Street, Pittsburgh, PA, United States
| | - M Aryana Bryan
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States; University of Utah College of Social Work, 395 S 1500 E #111, Salt Lake City, UT, United States
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States; Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, United States
| | - Brad Lundahl
- University of Utah College of Social Work, 395 S 1500 E #111, Salt Lake City, UT, United States
| | - John Silipigni
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Magee-Womens Research Institute, 300 Halket Street, Pittsburgh, PA, United States
| | - Benjamin Haaland
- Department of Population Health Sciences, University of Utah School of Medicine 30 N 1900 E, Salt Lake City, UT, United States
| | - Ralph Tarter
- University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA, United States
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Dotters-Katz SK, Smid MC, Tinkham S, Chuang A. Impact of Preclinical Labor and Delivery Shadowing on Student Perceptions of Obstetrics and Gynecology as a Specialty and Possible Career: A Prospective Cohort. AJP Rep 2019; 9:e361-e365. [PMID: 31754549 PMCID: PMC6864504 DOI: 10.1055/s-0039-1695747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 05/25/2019] [Indexed: 11/23/2022] Open
Abstract
Objective The purpose of this study was to determine the impact of preclinical shadowing on student interest and perceptions of obstetrics and gynecology (OBGYN). Methods We enrolled a prospective cohort of preclinical medical students who shadowed on labor and delivery (L&D). Students sent electronic surveys a week prior (presurvey), the week after (postsurvey), and three months after shadowing (far-survey). Responses compared using descriptive statistics. We analyzed common themes of free text responses. Results From July 2016 to April 2017, 41 students shadowed on L&D; 81% were female. Eighty percent responded to at least one survey, 37% completed all surveys, (presurvey: 76%, postsurvey: 51%, and far-survey: 46%). Prior to shadowing, 10% (3/31) planed a career in OBGYN compared with 24% (5/21) after shadowing ( p = 0.42). Over 50% of students described the people and procedures as altering their perceptions of OBGYN in a positive way. Common themes explaining this change included: culture ( n = 4), team interactions ( n = 4), seeing deliveries ( n = 3), and hands-on experiences ( n = 3). Three months after shadowing, 79% described the experience as very worthwhile. Eighty-nine percent would recommend the experience to a friend not interested in OBGYN and 100% stated they would shadow again. Discussion Although shadowing may not increase students' desire to pursue OBGYN, it is nearly universally felt to be worthwhile and improves perceptions of the field.
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Affiliation(s)
- Sarah K Dotters-Katz
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Marcela C Smid
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Sara Tinkham
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
| | - Alice Chuang
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
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Smid MC. Marijuana use among young pregnant women: more common and more harmful than we think. BJOG 2019; 126:1498. [PMID: 31454457 DOI: 10.1111/1471-0528.15919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- M C Smid
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, USA.,Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah, USA
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Lin B, Kaliush PR, Conradt E, Terrell S, Neff D, Allen AK, Smid MC, Monk C, Crowell SE. Intergenerational transmission of emotion dysregulation: Part I. Psychopathology, self-injury, and parasympathetic responsivity among pregnant women. Dev Psychopathol 2019; 31:817-831. [PMID: 31064587 PMCID: PMC6790982 DOI: 10.1017/s0954579419000336] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The World Health Organization recently reported that maternal mental health is a major public health concern. As many as one in four women suffer from psychiatric disorders at some point during pregnancy or the first postpartum year. Furthermore, self-injurious thoughts and behaviors (SITBs) represent one of the leading causes of death among women during this time. Thus, efforts to identify women at risk for serious forms of psychopathology and especially for SITBs are of utmost importance. Despite this urgency, current single-diagnostic approaches fail to recognize a significant subset of women who are vulnerable to perinatal stress and distress. The current study was among the first to investigate emotion dysregulation-a multilevel, transdiagnostic risk factor for psychopathology-and its associations with stress, distress, and SITBs in a sample of pregnant women (26-40 weeks gestation) recruited to reflect a range of emotion dysregulation. Both self-reported emotion dysregulation and respiratory sinus arrhythmia, a biomarker of emotion dysregulation, demonstrated expected associations with measures of mental health, including depression, anxiety, borderline personality pathology, and SITBs. In addition, self-reported emotion dysregulation was associated with blunted respiratory sinus arrhythmia responsivity to an ecologically valid infant cry task. Findings add to the literature considering transdiagnostic risk during pregnancy using a multiple-levels-of-analysis approach.
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Affiliation(s)
- Betty Lin
- Department of Psychology, University at Albany, State University of New York, Albany, NY, USA
| | - Parisa R. Kaliush
- Department of Psychology, University of Utah, Salt Lake City, UT, USA
| | - Elisabeth Conradt
- Department of Psychology, University of Utah, Salt Lake City, UT, USA
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Sarah Terrell
- Department of Psychology, University of Utah, Salt Lake City, UT, USA
| | - Dylan Neff
- Department of Psychology, University of Utah, Salt Lake City, UT, USA
| | - Ashley K. Allen
- Department of Psychology, University of Utah, Salt Lake City, UT, USA
| | - Marcela C. Smid
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Catherine Monk
- Department of Psychiatry, Columbia University, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
| | - Sheila E. Crowell
- Department of Psychology, University of Utah, Salt Lake City, UT, USA
- Department of Psychiatry, University of Utah, Salt Lake City, UT, USA
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Dotters-Katz SK, Smid MC, Grace MR, Gunatilake RP, Sykes C, Blake K, Boggess KA, Patil AS, Manuck T. The Effect of Blood Loss on Cefazolin Levels in Women Undergoing Cesarean Delivery. Am J Perinatol 2019; 36:688-694. [PMID: 30336498 DOI: 10.1055/s-0038-1673654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To quantify the effects of operative blood loss during cesarean on tissue and plasma cefazolin concentrations. STUDY DESIGN This was a prospective observational study of singleton pregnancies undergoing scheduled cesarean between 34 and 40 weeks. Cefazolin administered prior to skin incision. Maternal plasma samples were obtained (Time 1[T1]: immediately, T2: 20 minutes, T3: 40 minutes, and T4: 60 minutes after cefazolin infusion). Subcutaneous adipose tissue sampled before and after fascia. Primary outcome was subcutaneous adipose cefazolin level after fascial closure. Formal quantitative blood loss (QBL) performed. Women with higher QBL, those at/above 75% of QBL in this population, were compared with those with lower QBL (QBL below 75%). Data analyzed using bivariable statistics. RESULTS Ninety-two women were screened, 32 were eligible, and 20 enrolled. Median QBL was 630 mL (interquartile range [IQR]: 473-818) and 1,160 mL (IQR: 1,000-1,560) in the low and high QBL groups, respectively. Demographics and operative characteristics were similar. Median adipose cefazolin level after fascial closure did not differ between the groups (3.5 vs. 3.9 μg/g, p = 0.75). No differences in maternal plasma cefazolin concentrations between the groups at any time point or in pharmacokinetic parameters were seen. CONCLUSION Intraoperative maternal plasma concentrations and adipose levels of cefazolin are similar between women with high and low blood loss at the time of cesarean delivery.
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Affiliation(s)
| | - Marcela C Smid
- Division of Maternal-Fetal Medicine, University of Utah, Salt Lake City, Utah
| | | | - Ravindu P Gunatilake
- Center for Personalized Obstetric Medicine, Valley Perinatal Services, Phoenix, Arizona
| | - Craig Sykes
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kimberly Blake
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kim A Boggess
- Division of Maternal-Fetal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Avinash S Patil
- Center for Personalized Obstetric Medicine, Valley Perinatal Services, Phoenix, Arizona
| | - Tracy Manuck
- Division of Maternal-Fetal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Smid MC, Stone N, Baksh L, Debbink MP, Einerson BD, Varner MW, Gordon AJ, Clark EAS. Pregnancy-Associated Death in Utah: Contribution of Drug-Induced Deaths. Obstet Gynecol 2019; 133:1131-1140. [PMID: 31135726 PMCID: PMC6548332 DOI: 10.1097/aog.0000000000003279] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Drug-induced deaths, defined as intentional or unintentional consumption of illicit substances or diverted medications leading to death, are the leading cause of death for reproductive-age women in the United States. Our objective was to describe pregnancy-associated deaths attributed to drug-induced causes to identify opportunities for intervention. METHODS Using the Utah Perinatal Morality Review Committee database, we performed a retrospective cohort study of all pregnancy-associated deaths-death of a woman during pregnancy or within 1 year from the end of pregnancy-from 2005 to 2014. We performed a detailed descriptive analysis of women with drug-induced deaths. We compared characteristics of women with drug-induced and other pregnancy-associated deaths. RESULTS From 2005 to 2014, 136 pregnancy-associated deaths were identified. Drug-induced death was the leading cause of pregnancy-associated death (n=35, 26%) and 89% occurred in the postpartum period. More specifically, those with a drug-induced death were more likely to die in the late postpartum period, defined as death occurring within 43 days to 1 year of the end of the pregnancy, (n=28/35, 80%) compared with women whose deaths were from other pregnancy-associated causes (n=34/101, 34%) (P<.001). The majority of drug-induced deaths were attributed to opioids (n=27/35, 77%), prescription opioids (n=21/35, 60%), and polysubstance use (n=29/35, 83%). From 2005 to 2014, the pregnancy-associated mortality ratio increased 76%, from 23.3 in 2005 to 41.0 in 2014. During this same time period, the drug-induced pregnancy-associated mortality ratio increased 200%, from 3.9 in 2005 to 11.7 in 2014. CONCLUSION Drug-induced death is the leading cause of pregnancy-associated death in Utah and occurs primarily in the late postpartum period. Interventional studies focused on identifying and treating women at risk of drug-induced death are urgently needed.
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Affiliation(s)
- Marcela C. Smid
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT
- Division of Maternal Fetal Medicine, Women and Newborns Clinical Program, Intermountain Healthcare, Salt Lake City UT
- Maternal and Infant Health Program, Utah Department of Health, Salt Lake City, UT
| | - Nicole Stone
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City UT
| | - Laurie Baksh
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City UT
| | - Michelle P. Debbink
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT
- Division of Maternal Fetal Medicine, Women and Newborns Clinical Program, Intermountain Healthcare, Salt Lake City UT
| | - Brett D. Einerson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT
- Division of Maternal Fetal Medicine, Women and Newborns Clinical Program, Intermountain Healthcare, Salt Lake City UT
| | - Michael W. Varner
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT
- Division of Maternal Fetal Medicine, Women and Newborns Clinical Program, Intermountain Healthcare, Salt Lake City UT
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City UT
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, Salt Lake City VA Health Care System, Salt Lake City, UT
| | - Erin AS Clark
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT
- Division of Maternal Fetal Medicine, Women and Newborns Clinical Program, Intermountain Healthcare, Salt Lake City UT
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Abstract
Stimulant use, including cocaine, methamphetamines, ecstasy, and prescription stimulants, in pregnancy is increasingly common. In the United States, stimulants are the second most widely used and abused substances during pregnancy and pregnant women using stimulants in pregnancy are at increased risk of adverse perinatal, neonatal, and childhood outcomes. In this review, we describe the pharmacology, pathophysiology, and epidemiology of stimulants, summarize the maternal and neonatal effects of perinatal stimulant use, and outline treatment options for stimulant use disorders among pregnant women. Development of effective treatment strategies for stimulant use disorders identified among pregnant women are urgently needed.
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Affiliation(s)
- Marcela C Smid
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine
- Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS), Salt Lake City VA Health Care System, Salt Lake City, Utah
| | - Torri D Metz
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine
- Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS), Salt Lake City VA Health Care System, Salt Lake City, Utah
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Smid MC, Dotters-Katz SK, Mcelwain CA, Volckmann ET, Schulkin J, Stuebe AM. Pregnancy After Bariatric Surgery: National Survey of Obstetrician's Comfort, Knowledge, and Practice Patterns. Obes Surg 2018; 27:2354-2359. [PMID: 28361492 DOI: 10.1007/s11695-017-2661-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The objective of this study is to survey a nationally representative sample of obstetricians regarding comfort, knowledge, and practice patterns of caring for pregnant women after bariatric surgery. MATERIALS AND METHODS We conducted an online survey of US obstetricians and describe obstetrician's demographics, practice settings, and practice patterns. We assessed respondent's knowledge and recommended practices. We compared provider knowledge by years since completing residency, scope of practice (generalist or specialist), and practice setting (academic setting or other). Statistical significance was set at p < 0.05. RESULTS A total of 106 completed the survey (response rate of 54%). Respondents had a median age of 47 and median 17 years in practice. Sixty-two percent were generalists. Nearly all of the respondents (94%) had some experience with caring for pregnant women after bariatric surgery and 83% reported feeling "very comfortable" (48%) or "somewhat comfortable" (35%) providing care for this population. Most (74%) were aware of increased risk of small for gestational age after surgery. Only 13% were able to correctly identify all recommended nutritional labs and 20% reported that they "did not know" which labs are recommended. There were no differences in comfort, experience, knowledge, and practice patterns by physician characteristics and practice settings. CONCLUSION While most obstetricians are aware of perinatal risks after bariatric surgery, a substantial percentage of obstetricians are unaware of recommended practices regarding nutrition and nutritional monitoring. As bariatric surgery becomes increasingly prevalent among reproductive age women, educational interventions to increase obstetricians' knowledge of optimal care of pregnant women after bariatric surgery are urgently needed.
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Affiliation(s)
- Marcela C Smid
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA. .,Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, 50 North Medical Drive, Suite 2B200, Salt Lake City, UT, 84132, USA.
| | - Sarah K Dotters-Katz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA
| | - Cora-Ann Mcelwain
- American College of Obstetricians and Gynecologists, Washington, DC, USA
| | - Eric T Volckmann
- Division of Bariatric Surgery, Department of Surgery, University of Utah Salt Lake City, Salt Lake City, UT, USA
| | - Jay Schulkin
- American College of Obstetricians and Gynecologists, Washington, DC, USA
| | - Alison M Stuebe
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA
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Abstract
OBJECTIVE Moderate fish intake in early pregnancy is associated with decreased risk of preterm birth (PTB). Obesity during pregnancy is characterized by inflammation and insufficiency of essential fatty acids. The objective of this study was to measure the association between fish intake during pregnancy and risk of recurrent spontaneous (s) PTB among lean, overweight, and obese women. DESIGN This is secondary analysis of a randomized controlled trial of omega-3 fatty acid supplementation for recurrent PTB prevention, 2005-2006. The primary exposure was fish intake at time of enrollment (16-22.9-week gestation). The primary outcomes were sPTB <37 weeks and sPTB <35 weeks. Maternal prepregnancy body mass index was treated as an effect modifier. SUBJECTS Eight hundred and fifty-two women were included, 47% were lean, 25% overweight, and 28% obese. RESULTS In this cohort, among lean, but not overweight or obese women, ≥1 serving of fish per week was associated with decreased frequency of sPTB <37 weeks compared with <1 serving of fish per week (45.1% versus 27.5%, p = .001) and spontaneous PTB <35 (21.4% versus 11.6%, p = .01). In adjusted models, as fish intake increased, the predicted probability of sPTB decreased in lean women but increased in overweight and obese women (p for interaction < .10). CONCLUSION Fish intake was associated with lower probability of sPTB in lean women and higher probability in obese women. These findings warrant further investigation to understand the dietary or metabolic factors associated with obesity that may modulate benefit of fish intake during pregnancy.
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Affiliation(s)
- Marcela C Smid
- a Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology , University of Utah School of Medicine , Salt Lake City , UT , USA.,b Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology , University of North Carolina School of Medicine , Chapel Hill , NC , USA
| | - Alison M Stuebe
- b Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology , University of North Carolina School of Medicine , Chapel Hill , NC , USA.,c Department of Maternal and Child Health , Gillings School of Global Public Health , Chapel Hill , NC , USA
| | - Tracy A Manuck
- b Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology , University of North Carolina School of Medicine , Chapel Hill , NC , USA
| | - Sarbattama Sen
- d Department of Pediatric Newborn Medicine , Brigham and Women's Hospital , Boston , MA , USA
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Cassimatis IR, Gibbins KJ, Dudley DJ, Silver RM, Smid MC. 965: Causes and timing of stillbirth among women with pre-gestational and gestational diabetes: Stillbirth Collaborative Research Network data. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.11.452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
BACKGROUND Limited data exist regarding the neonatal and neurodevelopmental outcomes of infants exposed to marijuana (MJ) in-utero, particularly among preterm infants. We hypothesized that MJ-exposed preterm infants would have worse neonatal and childhood developmental outcomes compared to MJ-unexposed infants. METHODS Secondary analysis of multicenter randomized-controlled trial of antenatal magnesium sulfate for the prevention of cerebral palsy was conducted. Singleton nonanomalous infants delivered <35 weeks exposed to MJ in-utero were compared to MJ-unexposed. Primary neonatal outcome was death, grade 3/4 intraventricular hemorrhage, periventricular leukomalacia, bronchopulmonary dysplasia, and/or stage II/III necrotizing enterocolitis before discharge. Primary childhood outcome was death, moderate/severe cerebral palsy, or/and Bayley II Scales <70 at age 2. Backward-stepwise regression used to estimate odds of primary outcomes. RESULTS 1867 infants met inclusion criteria; 135(7.2%) were MJ-exposed. There were no differences in neonatal (20% vs. 26%, p = 0.14) or childhood (26% vs. 21%, p = 0.21) outcomes in MJ-exposed infants compared to MJ-unexposed infants. In adjusted models, MJ-exposure was not associated with adverse neonatal outcomes (aOR 0.83 95% CI 0.47,1.44) or early childhood outcomes (aOR 1.47, 95% CI 0.97,2.23). CONCLUSIONS Among infants born <35 weeks of gestation, MJ-exposure was not associated with adverse neonatal or childhood outcomes. Long-term follow-up studies are needed to assess later childhood neurodevelopmental outcomes following MJ-exposure.
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Affiliation(s)
- Sarah K Dotters-Katz
- a Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology , University of North Carolina , Chapel Hill , NC , USA
| | - Marcela C Smid
- b Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology , University of Utah , Salt Lake City , UT , USA
| | - Tracy A Manuck
- a Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology , University of North Carolina , Chapel Hill , NC , USA
| | - Torri D Metz
- c Department of Obstetrics and Gynecology , Denver Health Medical Center , Denver , CO , USA
- d Department of Obstetrics and Gynecology, University of Colorado School of Medicine , Aurora , CO , USA
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Smid MC, Dotters-Katz SK, Grace M, Wright ST, Villers MS, Hardy-Fairbanks A, Stamilio DM. Prophylactic Negative Pressure Wound Therapy for Obese Women After Cesarean Delivery. Obstet Gynecol 2017; 130:969-978. [DOI: 10.1097/aog.0000000000002259] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Smid MC, Lee JH, Grant JH, Miles G, Stoddard GJ, Chapman DA, Manuck TA. Maternal race and intergenerational preterm birth recurrence. Am J Obstet Gynecol 2017; 217:480.e1-480.e9. [PMID: 28578169 DOI: 10.1016/j.ajog.2017.05.051] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/16/2017] [Accepted: 05/22/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Preterm birth is a complex disorder with a heritable genetic component. Studies of primarily White women born preterm show that they have an increased risk of subsequently delivering preterm. This risk of intergenerational preterm birth is poorly defined among Black women. OBJECTIVE Our objective was to evaluate and compare intergenerational preterm birth risk among non-Hispanic Black and non-Hispanic White mothers. STUDY DESIGN This was a population-based retrospective cohort study, using the Virginia Intergenerational Linked Birth File. All non-Hispanic Black and non-Hispanic White mothers born in Virginia 1960 through 1996 who delivered their first live-born, nonanomalous, singleton infant ≥20 weeks from 2005 through 2009 were included. We assessed the overall gestational age distribution between non-Hispanic Black and White mothers born term and preterm (<37 weeks) and their infants born term and preterm (<37 weeks) using Cox regression and Kaplan-Meier survivor functions. Mothers were grouped by maternal gestational age at delivery (term, ≥37 completed weeks; late preterm birth, 34-36 weeks; and early preterm birth, <34 weeks). The primary outcomes were: (1) preterm birth among all eligible births; and (2) suspected spontaneous preterm birth among births to women with medical complications (eg, diabetes, hypertension, preeclampsia and thus higher risk for a medically indicated preterm birth). Multivariable logistic regression was used to estimate odds of preterm birth and spontaneous preterm birth by maternal race and maternal gestational age after adjusting for confounders including maternal education, maternal age, smoking, drug/alcohol use, and infant gender. RESULTS Of 173,822 deliveries captured in the intergenerational birth cohort, 71,676 (41.2%) women met inclusion criteria for this study. Of the entire cohort, 30.0% (n = 21,467) were non-Hispanic Black and 70.0% were non-Hispanic White mothers. Compared to non-Hispanic White mothers, non-Hispanic Black mothers were more likely to have been born late preterm (6.8% vs 3.7%) or early preterm (2.8 vs 1.0%), P < .001. Non-Hispanic White mothers who were born (early or late) preterm were not at an increased risk of early or late preterm delivery compared to non-Hispanic White mothers born term. The risk of early preterm birth was most pronounced for Black mothers who were born early preterm (adjusted odds ratio, 3.26; 95% confidence interval, 1.77-6.02) compared to non-Hispanic White mothers. CONCLUSION We found an intergenerational effect of preterm birth among non-Hispanic Black mothers but not non-Hispanic White mothers. Black mothers born <34 weeks carry the highest risk of delivering their first child very preterm. Future studies should elucidate the underlying pathways leading to this racial disparity.
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Abstract
Objective To estimate the association between severity of thrombocytopenia and postpartum hemorrhage.
Study Design We performed a secondary analysis of a prospective cohort of women delivering by cesarean or vaginal birth after cesarean conducted by the National Institute of Child Health and Human Development (NICHD) Maternal–Fetal Medicine Unit. Women delivering ≥ 20 weeks with platelets < 400,000/mL were included. Thrombocytopenia was defined as predelivery platelets of < 150,000/mL. Primary outcomes were (1) laboratory evidence of hemorrhage, defined as a decrease in hemoglobin ≥ 4 mg/dL and (2) clinical evidence of hemorrhage, a composite of atony, transfusion, coagulopathy, hysterectomy, laparotomy, or intensive care unit admission. Odds ratios were calculated for primary outcomes using thrombocytopenia as a dichotomous and ordinal variable.
Results A total of 54,597 women were included; 5,611 (10.3%) had antepartum thrombocytopenia, 1,976 (3.6%) women had laboratory evidence of hemorrhage, and 3,862 (7.1%) had clinical evidence of hemorrhage. Thrombocytopenia was associated with both laboratory evidence of hemorrhage (adjusted odds ratio [aOR]: 1.60, 95% CI: 1.38–1.86) and clinical evidence of hemorrhage (aOR: 1.68, 95% CI: 1.52–1.83). The odds of laboratory and clinical evidence of hemorrhage increased incrementally with severity of thrombocytopenia.
Conclusion Thrombocytopenia is associated with both laboratory and clinical evidence of hemorrhage; risk increases dramatically as platelet count decreases.
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Affiliation(s)
- Laura M Carlson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Sarah K Dotters-Katz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Marcela C Smid
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Tracy A Manuck
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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