Don D. McIntire’s research while affiliated with University of Texas Southwestern Medical Center and other places

Background: There are approximately 1.2 million cesarean deliveries performed each year, and while traditional postoperative pain management strategies previously relied heavily on opioids, practitioners are now moving toward opioid-sparing protocols using multiple classes of non-narcotic analgesics. Multimodal pain management systems have been adopted by other surgical specialties, including gynecology, though data regarding use for postoperative cesarean delivery pain management remains limited. Objective: To determine if a multimodal pain management regimen after cesarean delivery reduces the number of morphine milligram equivalents (MME, a unit of measurement for opioids) compared to traditional patient controlled opioid analgesia (PCA) while adequately controlling postoperative pain. Study design: This was a prospective cohort study of postoperative pain management for women undergoing cesarean delivery at a large county hospital during a transition from a traditional morphine PCA to a multimodal regimen that included scheduled nonsteroidal anti-inflammatory drugs and acetaminophen, with opioids as needed. Data was collected for a 6-week period before and after the transition. The primary outcome was postoperative opioid, use defined as MME, in the first 48 hours. Secondary outcomes included serial pain scores, time to discharge, and exclusive breastfeeding rates. Women who required general anesthesia or who had a history of substance abuse disorder were excluded. Statistical analysis included Student's t test, Wilcoxon rank sum and Hodges-Lehman shift, with p-value <0.05 considered significant. Results: During the study period 877 women underwent cesarean delivery and 778 met inclusion criteria: 378 received the traditional PCA and 400 received the multimodal regimen. Implementation of a multimodal regimen resulted in a significant reduction in MME use in the first 48 hours (28 [14,41] MME vs 128 [86,174] MME, p<0.001). Compared to the traditional group, more women in the multimodal group reported a pain score ≤4 by 48 hours (88% vs 77%, p<0.001). There was no difference in time to discharge (p = 0.32). Of women who planned to exclusively breastfeed, fewer used formula prior to discharge in the multimodal group as compared to the traditional group (9% vs 12%, p<0.001). Conclusions: Transition to a multimodal pain management regimen for women undergoing cesarean delivery resulted in decreased opioid use while adequately controlling postoperative pain. A multimodal regimen was associated with early successful exclusive breastfeeding.

Background Perinatal mood disorders have both short and long term negative consequences for mothers and babies. National organizations recommend universal screening for postpartum depression. Little is known, however, about screening and referral among women living in underserved areas with limited access to care. Objectives The objective of this report was to evaluate the utilization of mental health services in an urban inner-city hospital following implementation of co-located counseling services across ten county-sponsored clinics serving a medically underserved population. We further explored antecedents to a positive postpartum depression screen, factors associated with successful referral, and rate of perinatal mood disorder diagnosis following universal screening. We hypothesized that integrated mental health services would improve referral rates following positive postpartum depression screening compared to historically separated services. Study Design This was a retrospective cohort study of women undergoing universal postpartum depression screening with deliveries from January 2017 to December 2019 compared to a historical cohort from the same population from June 2008 to March 2010. The Edinburgh Postnatal Depression Scale was administered to women at their postpartum visit and a mental health service referral was offered for a score of ≥ 13. The primary outcome was a comparison of completed referrals between cohorts with and without co-located mental health services following a positive postpartum depression screen. Statistical analysis included chi-square with p < 0.05 considered significant and adjusted multivariate analysis for perinatal outcomes associated with a positive postpartum screen. Results Between January 2017 to December 2019, 25,425 women completed postpartum depression screening with 978 (4%) recording a positive screen. After implementation of co-located mental health counselors, completed perinatal mental health referrals significantly increased compared to a historical cohort without co-located services (57% [N = 560/978] versus 22% [N = 238/1106], p < 0.001). Adverse neonatal outcomes, such as stillbirth (aRR 9.5; 95% CI 6.35 to 14.26) and neonatal demise (aRR 14.3; 95% CI 6.67 to 30.46), were most strongly associated with a positive depression screen. There were 122 (21%) women with a positive screen diagnosed with a depressive disorder in the peripartum period. There were no specific features of those who did, and did not, complete referral. One-fifth of women were referred for psychiatric evaluation following an initial evaluation and the need for referral was associated with higher scores on the depression screen (p < 0.001). Conclusions Utilization of mental health services following a positive depression screen more than doubled following implementation of co-located services.