February 2025
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3 Reads
Drug and Alcohol Dependence
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February 2025
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3 Reads
Drug and Alcohol Dependence
January 2025
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7 Reads
Addiction Science & Clinical Practice
Background The postpartum period provides an opportunity for birthing people with opioid use disorder (OUD) to consider their future reproductive health goals. However, the relationship between the use of medication for opioid use disorder (MOUD) and contraception utilization is not well understood. We used multistate administrative claims data to compare contraception utilization rates among postpartum people with OUD initiating buprenorphine (BUP) versus no medication (psychosocial services receipt without MOUD (PSY)) in the United States (US). Methods In this retrospective cohort study, we analyzed data from the Merative™ MarketScan ® Multi-State Medicaid Databases 2016–2021 among postpartum women with OUD who did and did not initiate BUP during pregnancy. Our primary outcome was the receipt of prescribed highly-effective or effective contraception by 90 days postpartum. Highly-effective contraception was defined as female sterilization and long-acting reversible contraception [LARC]). Effective contraception was defined as oral contraceptive pills [OCPs], the contraceptive patch, ring, or injection. We used multivariable Poisson regression models, adjusting for sociodemographic and clinical characteristics, to measure the association of BUP (vs. PSY) on postpartum contraception utilization. Results Our sample consisted of 11,118 postpartum people with OUD. Among those, 3,443 initiated BUP and 7,675 received PSY. By 90 days postpartum, 22.4% ( n = 2,487) of the cohort were prescribed contraception (21.5% PSY vs. 24.3% BUP). Among these participants, most received LARC (41.0%), followed by female sterilization (27.3%), the contraceptive injection (17.3%), pills (8.6%), ring (4.7%), and patch (1.0%), Compared to people engaged in PSY, BUP receipt was associated with a greater use of prescribed contraceptive use by 90 days postpartum (adjusted relative risk [aRR] = 1.17[1.07–1.28]), including a modestly greater use of the patch, ring, and pills, (aRR = 1.13[1.08–1.18]), but a modestly lesser use of injection contraception (aRR = 0.95[0.91–0.99]). There was no relationship observed between BUP and LARC use (aRR = 1.00[0.95–1.04]) and female sterilization (aRR = 1.01[0.98–1.06]). Conclusions Only 22% of pregnant people with OUD in our cohort used effective or highly-effective postpartum contraception. BUP receipt during pregnancy, relative to PSY, was associated with modestly greater use of prescribed effective contraceptive methods but was not associated with greater use of provider-administered contraceptive methods, such as the contraceptive injection, LARC and female sterilization.
December 2024
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2 Reads
American Journal of Obstetrics & Gynecology MFM
November 2024
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3 Reads
Journal of Addiction Medicine
Objective Untreated opioid use disorder (OUD) is associated with significant morbidity in pregnancy. Recent reports have highlighted the rise of xylazine in the nonprescribed fentanyl supply. The frequency with which pregnant people with OUD are exposed to xylazine has not been characterized. We sought to describe the rate of xylazine detection in urine drug screens (UDS) from pregnant people admitted to a labor unit. Methods We performed a cross sectional study of all UDS results from an inpatient obstetric unit at an urban tertiary care center from December 2022, when xylazine was added to the detection panel, through July 2023. We perform universal verbal drug screening, with subsequent urine drug screening only performed after a positive verbal screen and consent. The trend of opioid-positive urine drug screens also positive for xylazine from December to July was measured with the Cochran-Armitage test. Results Of 5662 people admitted to Labor and Delivery during the study period, 138 UDS were sent for 123 unique individuals. Ninety-eight (71%) of UDS were positive for nonprescribed substances. Of positive UDS, 36 (37%) were positive for nonprescribed opioids, and of these, 17 (47.2%) were positive for xylazine among 14 pregnant people. The trend of UDS positive for opioids that were also positive for xylazine increased significantly over time ( P = 0.030), from 0% in December 2022 to 100% in July 2023. Conclusions Over 8 months, xylazine positivity significantly increased in UDSs positive for nonprescribed opioids in an urban Midwestern hospital. These results underscore the critical need to study the impact of xylazine on obstetric outcomes.
October 2024
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1 Read
American Journal of Clinical Pathology
Black patients on labor and delivery (L&D) units are more likely to undergo urine drug screening (UDS) and subsequent mandated reporting to child protective services (CPS), which can result in increased separation of the parent and infant, contributes to systemic inequities, and erodes the patient/provider relationship. These disparities are driven by a testing indication of isolated cannabis use (ICU), which based on previous data from our institution, disproportionately selects Black patients for testing. In October 2022, the Barnes-Jewish Hospital (St. Louis, MO) L&D unit removed ICU as a UDS indication; concurrently, we implemented an electronic health record (EHR)-based order question requiring providers to select an indication for testing. The objective of this study was to analyze the impact of this intervention on racial equity in UDS testing and CPS reporting. Data on deliveries, UDS testing, and CPS reports were obtained from the EHR, and data for deliveries occurring during the pre- (1/1/2020-9/30/2022; 33 months) vs. post-implementation (10/1/2022-2/1/2024; 16 months) periods was compared. There were a total of 9,187 and 4,757 deliveries during the pre- and post-implementation periods, respectively. At baseline, there were more deliveries by Black patients in the pre-implementation (47.8%) vs. post-implementation (44.0%) period (p<0.001); there was no difference in age, multiparity, or neonatal outcomes between the two periods. In the pre-intervention period, 29.2% of Black and 13.8% of White patients had UDS testing (p<0.001), and 7.6% of Black and 4.1% of White patients underwent reporting to CPS (p<0.001); in the post-intervention period, 4.5% of Black and 3.6% of White patients had UDS testing (p=0.52), and 4.2% of Black and 3.5% of White patients underwent reporting to CPS (p=0.52). 34.6% vs. 67.8% of UDSs in the pre- and post-implementation were positive for any non-cannabis compound, respectively (p<0.001). In conclusion, removing ICU as an order indication dramatically improves racial equity in UDS testing and CPS reporting on a L&D floor, and improves the pre-test probability of UDS testing for non-cannabis compounds.
October 2024
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15 Reads
American Journal of Perinatology
Objective The American College of Obstetricians and Gynecologists recommends speculum exams, rather than digital exams, for evaluation of the cervix after preterm prelabor rupture of membranes (PPROM). However, in clinical practice, digital exams may be necessary. We examined whether increasing numbers of digital exams were associated with adverse outcomes in PPROM. Study Design This was a single-center retrospective cohort study of patients admitted between 2019 and 2021 with PPROM at 24 to 34 weeks of gestation. The primary outcome was intra-amniotic infection and inflammation (triple I), compared between patients who had ≤1 or ≥2 digital exams during expectant management of PPROM. Secondary outcomes included latency, antepartum events, and other maternal and neonatal morbidities. Groups were compared using univariate analysis and Cox proportional hazards model to account for time between admission and delivery and potential confounders. Results Of 125 patients included in the analysis, 46 (36.8%) had ≤ 1 and 79 (63.2%) had ≥2 digital exams. There was no significant difference in triple I between groups (adjusted hazard ratio [aHR]: 1.03, 95% confidence interval [CI]: 0.47, 2.26). There were no significant differences in composite maternal or neonatal morbidities or latency from admission to delivery between groups (8 days [interquartile range (IQR): 3, 14] vs. 6 days [IQR: 3, 12]). There was a higher rate of spontaneous labor as the indication for delivery in the group with ≥2 exams (aHR: 2.07, 95% CI: 1.04, 4.11). Conclusion In this retrospective cohort study, ≥2 digital exams during expectant management of PPROM was not associated with change in infectious morbidity or pregnancy latency. There was an increase in spontaneous labor in the group with more digital exams; this may be due to confounding by indication, as patients who are in prodromal labor are more likely to receive digital exams. These results suggest equipoise in exam type in the management of PPROM. Key Points
October 2024
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6 Reads
American Journal of Obstetrics & Gynecology MFM
September 2024
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31 Reads
SARS-CoV-2 infection poses a significant risk to placental physiology, but its impact on placental homeostasis is not well understood. We and others have previously shown that SARS-CoV-2 can colonize maternal and fetal placental cells, yet the specific mechanisms remain unclear. In this study, we investigate ORF3a, a key accessory protein of SARS-CoV-2 that exhibits continuous mutations. Our findings reveal that ORF3a is present in placental tissue from pregnant women infected with SARS-CoV-2 and disrupts autophagic flux in placental cell lines and 3D stem-cell-derived trophoblast organoids (SCTOs), impairing syncytiotrophoblast differentiation and trophoblast invasion. This disruption leads to protein aggregation in cytotrophoblasts (CTB) and activates secretory autophagy, increasing CD63+ extracellular vesicle secretion, along with ORF3a itself. ORF3a also compromises CTB barrier integrity by disrupting tight junctions via interaction with ZO-1, mediated by its PDZ-binding motif, SVPL. Colocalization of ORF3a and ZO-1 in SARS-CoV-2-infected human placental tissue supports our in vitro findings. Deleting the PDZ binding motif in the ORF3a protein (ORF3a-noPBM mutant) restored proper ZO-1 localization at the cell junctions in an autophagy-independent manner. Lastly, we demonstrate that constitutive ORF3a expression induces SC-TOs to transition towards a secretory autophagy pathway likely via the PBM motif, as the ORF3a-NoPBM mutants showed a significant lack of CD63 expression. This study demonstrates the functional impact of ORF3a on placental autophagy and reveals a new mechanism for the activation of secretory autophagy, which may lead to increased extracellular vesicle secretion. These findings provide a foundation for exploring therapeutic approaches targeting ORF3a, specifically focusing on its PBM region to block its interactions with host cellular proteins and limiting placental impact.
September 2024
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11 Reads
American Journal of Perinatology
Objective We sought to assess the impact of a prolonged latent phase (PLP) on maternal and neonatal morbidity. Study Design This is a secondary analysis of a prospective cohort study conducted 2010 to 2015 that included all term gravidas who reached active labor (6 cm). Primary outcomes were composite maternal morbidity (maternal fever, postpartum hemorrhage, transfusion, endometritis, and severe perineal lacerations) and composite neonatal morbidity (respiratory distress syndrome, mechanical ventilation, birth injury, seizures, hypoxic ischemic encephalopathy, therapeutic hypothermia, or umbilical artery pH ≤ 7.1). Outcomes were compared between patients with and without PLP, defined as ≥90th percentile of labor duration between admission and active phase. Results were stratified by induction of labor (IOL) versus spontaneous labor. A stratified analysis was performed by mode of delivery. Multivariable logistic regression was used to adjust for confounders. Results In this cohort of 6,509 patients, 51% underwent IOL. A total of 650 patients had a PLP with a median length of 8.5 hours in spontaneous labor and 18.8 hours in IOL. Among patients with PLP, there was a significant increase in composite maternal morbidity with both IOL (adjusted odds ratio [aOR]: 1.36, 95% confidence interval [CI]: 1.01, 1.84) and spontaneous labor (aOR: 1.49, 95% CI: 1.09, 2.04) and an increase in composite neonatal morbidity with spontaneous labor only (aOR: 1.57, 95% CI: 1.01, 2.45). Cesarean delivery occurred more often in PLP group (14.0 vs. 25.1%). Among patients who underwent cesarean delivery, PLP remained associated with increased odds of maternal morbidity compared with those with normal latent phase. Conclusion PLP at or above the 90th percentile in patients who reach active labor is associated with increased risk of maternal morbidity that is not mediated by cesarean delivery. PLP in spontaneous labor is associated with increased neonatal morbidity. These data suggest that further research is needed to establish latent phase cutoffs that may be incorporated into labor management guidelines. Key Points
September 2024
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9 Reads
American Journal of Obstetrics & Gynecology MFM
... Few birthing people with opioid use disorder (OUD) receive postpartum contraception in the United States (U.S.) [1][2][3]. An analysis of postpartum Medicaid enrollees with OUD in Pennsylvania (2008)(2009)(2010)(2011)(2012)(2013) found that only 25% received effective or highly-effective contraception, suggesting an unmet need for contraception access among birthing people with OUD [2]. ...
June 2024
Drug and Alcohol Dependence Reports
... For instance, retrospective evidence suggests that ADHD treatment intersects favorably with SUD outcomes. Several reports also highlight that ADHD pharmacotherapy may improve retention in SUD treatments, [17][18][19][20] which represents a major predictor of successful outcome for SUD. Previously, it had been thought that abstinence should be established for an undetermined amount of time prior to initiating medication therapy. ...
June 2024
Nature Mental Health
... In the study by Lynch et al. (48), for example, the RSFC of the SN differed when individuals were depressed versus not depressed. Furthermore, our group recently measured PFM in an individual woman with postpartum depression before and after treatment with brexanolone, a rapid-acting antidepressant (49). We detected widespread patterns of RSFC across individually defined functional brain areas that correlated with symptom severity over the course of treatment. ...
March 2024
Journal of Clinical Psychopharmacology
... Telehealth technology can be categorized into four main groups: (i) telemedicine services, which utilize videoconferencing or audio-only communication for consultations, diagnostics, and treatment; (ii) the transfer of medical information, such as digital images, through store-and-forward imaging systems; (iii) the electronic gathering and transmission of health and medical data for remote patient monitoring; and (iv) the support of healthcare and medical operations [43][44][45]. Telehealth technology has the capability to provide a diverse range of services pertaining to pregnancy [46][47][48][49][50]. Continued telehealth application aims to provide equitable access to perinatal care [51]. ...
November 2023
American Journal of Obstetrics & Gynecology MFM
... Currently, there is a research gap in evaluating the Centering Pregnancy group care model specifically for diabetes due to limited studies conducted in this area [18,19]. Most of the existing studies have relied on observational designs [20][21][22], which may be susceptible to confounding factors. ...
November 2023
Obstetrics and Gynecology
... CHM occurs in approximately 1 to 3 per 1000 pregnancies. 1 3 In rarer cases, a viable fetus can develop with a coexisting complete mole (CHMCF), occurring in every 1/20 000 to 1/100 000 pregnancies. [2][3][4][5][6][7][8] Its incidence is increasing due to the rise of artificial fertilisation. 4 5 GTD is prone to maternal and fetal complications, such as preeclampsia, vaginal bleeding, hyperthyroidism and fetal malformations. 3 4 8 Due to the risk of malignancy, pregnancy interruption might be recommended. 2-4 9 10 The coexistence of a viable fetus with a mole distinguishes it into three types. ...
September 2023
... Large, multi-state, administrative datasets can be particularly helpful for studying reproductive health outcomes during pregnancy due to their ability to provide a real-world, population level assessment of contraceptive utilization patterns. As a result, we used a large, multistate Medicaid dataset to compare postpartum contraceptive utilization patterns among people initiating buprenorphine (BUP) versus those receiving psychosocial services without any MOUD use during pregnancy (PSY), which constitutes at least half of pregnant people with OUD [12,13]. We specifically hypothesized that BUP receipt during pregnancy, as a proxy for greater engagement in substance use disorder (SUD) care, may be associated with greater contraception uptake postpartum in people with OUD compared to the receipt of PSY. ...
July 2023
Journal of General Internal Medicine
... First, most IR studies consider such interventions as a response to "fetal distress", another term lacking a uniform definition, although it is often associated with FHR changes warranting at least an ACOG Category II (CAT II) classification. CAT II encompasses the majority of all pregnancies, rendering it a very poor statistic for discrimination of fetal status [5][6][7][8][9][10]. Second, the benefits and potential risks of several of the IR components, particularly maternal oxygen administration, have been seriously questioned and are hard to quantitate [8,[10][11][12]. ...
May 2023
American Journal of Obstetrics & Gynecology MFM
... A video explaining prenatal genetic tests resulted in increased knowledge scores, decreased testing uptake, and decreased decisional regret [17]. Another study evaluated a coaching video for pushing provided at the initiation of the second stage of labor, which improved patient comfort during birth and positive feelings toward their physician team [18]. However, current studies available on this topic are randomized in which participants watch videos during hospitalizations or clinic visits immediately prior to the relevant procedure. ...
March 2023
American Journal of Obstetrics and Gynecology
... It can mitigate the elevated risk for overdose during pregnancy and postpartum [6][7][8][9][10][11][12], the latter of which may be increased by prolonged abstinence during pregnancy [13,14]. Despite established best practices from the American College of Obstetrics and Gynecology, the Substance Abuse Mental Health Services Administration and the American Society for Addiction Medicine, the majority of pregnant people in the United States (US) do not receive medication for OUD [3][4][5]15]. ...
March 2023
Obstetrics and Gynecology