A personalized protocol for prescribing opioids after cesarean delivery: leveraging the electronic medical record to reduce outpatient opioid prescriptions.

BACKGROUND: Although cesarean delivery is the most common surgery performed in the United States, prescribing practices for analgesia vary. Strategies to manage postpartum pain have mostly focused on the immediate postpartum period when patients are still admitted to the hospital. At discharge, most providers prescribe a fixed number of opioid tablets. Most patients do not use all the opioids that they are prescribed at hospital discharge. This leads to an excess of opioids in the community, which can ultimately lead to misuse and diversion. OBJECTIVE: This study aimed to determine whether a transition from universal opioid prescribing to a personalized, patient-specific protocol decreases morphine milligram equivalents prescribed at hospital discharge after cesarean delivery while adequately controlling pain. STUDY DESIGN: This was a prospective cohort study of patients undergoing cesarean delivery before and after the implementation of a personalized opioid-prescribing practice at the time of hospital discharge. Each patient was prescribed scheduled ibuprofen and acetaminophen, with a prescription for oxycodone tablets equal to 5 times the morphine milligram equivalents used in the 24 hours before discharge, calculated via an electronic order set. The previous traditional cohorts were routinely prescribed 30 tablets of acetaminophen-codeine 300/30 mg. The primary outcome was morphine milligram equivalents prescribed at discharge. A hotline to address pain control issues after discharge was established, and calls, emergency department visits, and readmissions were examined. Statistical analyses was performed using chi-square and Wilcoxon rank-sum test, with a P value of <.05 considered statistically significant. RESULTS: Overall, 412 patients underwent cesarean delivery in the 6 weeks after initiation of the personalized prescribing protocol and were compared with 367 patients before the change. The median morphine milligram equivalents prescribed at discharge was lower with personalized prescribing (37.5 [interquartile range, 0-75] vs 135 [interquartile range, 135-135]; P<.001). Moreover, 176 patients (43%) were not prescribed opioids at discharge, which was a substantial change as all 367 patients in the traditional cohort received opioids at discharge (P<.001). Of note, 9 hotline phone calls were received; none required additional opioids after a 24-hour trial of scheduled ibuprofen, which none had taken before the call. In addition, 11 patients (2.7%) presented to the emergency department for pain evaluation, of which none required readmission or an outpatient prescription of opioids. CONCLUSION: A personalized protocol for opioid prescriptions after cesarean delivery decreased the total morphine milligram equivalents and the number of opioid tablets at discharge, without hospital readmissions or need for rescue opioid prescriptions after discharge. Opioids released into our community will be reduced by more than 90,000 tablets per year, without demonstrable adverse effect.

Examining the impact of trimester of diagnosis on COVID-19 disease progression in pregnancy.

BACKGROUND: COVID-19 infection is associated with increased morbidity in pregnancy and adverse maternal and neonatal outcomes. Little is currently known about how the timing of infection during pregnancy affects these outcomes. OBJECTIVE: This study aimed to evaluate the effect of trimester of COVID-19 infection on disease progression and severity in pregnant patients. STUDY DESIGN: This was a prospective cohort study of pregnant patients diagnosed with COVID-19 infection who delivered at a single urban hospital. Universal testing for SARS-CoV-2 was performed at hospital admission and for symptomatic patients in inpatient, emergency department, and outpatient settings. Disease severity was defined as asymptomatic, mild, moderate, severe, or critical on the basis of National Institutes of Health criteria. We evaluated disease progression from asymptomatic to symptomatic infection and from asymptomatic or mild infection to moderate, severe, or critical illness, and stratified by trimester of COVID-19 diagnosis. Primary outcomes included progression of COVID-19 disease severity and a composite obstetrical outcome, which included delivery at <37 weeks, preeclampsia with severe features, abruption, excess blood loss at delivery (>500 mL for vaginal or >1000 mL for cesarean delivery), and stillbirth. RESULTS: From March 18, 2020 to September 30, 2021, 1326 pregnant patients were diagnosed with COVID-19 and delivered at our institution, including 103 (8%) first-, 355 (27%) second-, and 868 (65%) third-trimester patients. First-trimester patients were older and had more medical comorbidities; 86% of patients in all trimesters were Hispanic. Among patients admitted within 14 days of a positive test, 3 of 18 (17%) first-trimester, 20 of 47 (43%) second-trimester, and 34 of 574 (6%) third-trimester patients were admitted for the indication of COVID-19 illness. Across all trimesters, 1195 (90%) of 1326 COVID-19 infections were asymptomatic or mild, and 45 (10%) of 436 initially asymptomatic patients developed symptoms. Of patients with asymptomatic or mild symptoms at diagnosis, 4 (4%) of 93 first-, 18 (5%) of 337 second-, and 49 (6%) of 836 third-trimester patients developed moderate, severe, or critical illness (P=.80). There was no significant difference in composite obstetrical outcome with respect to trimester of COVID-19 diagnosis (24% first-trimester, 28% second-trimester, 28% third-trimester patients; P=.69). CONCLUSION: Moderate, severe, or critical illness develops in almost 10% of pregnant patients. The frequency of COVID-19 disease progression in pregnancy does not differ by trimester of diagnosis.

Multimodal opioid-sparing pain management for emergent cesarean delivery under general anesthesia: a quality improvement project.

BACKGROUND: Opioid-sparing multimodal analgesic approach has been shown to provide effective postoperative pain relief and reduce postoperative opioid consumption and opioid-associated adverse effects. While many studies have evaluated analgesic strategies for elective cesarean delivery, few studies have investigated analgesic approaches in emergent cesarean deliveries under general anesthesia. The primary aim of this quality improvement project is to evaluate opioid consumption with the use of a multimodal opioid-sparing pain management pathway in patients undergoing emergent cesarean delivery under general anesthesia. METHODS: Seventy-two women (age > 16 years) undergoing emergent cesarean delivery under general anesthesia before (n = 36) and after (n = 36) implementation of a multimodal opioid-sparing pain management pathway were included. All patients received a standardized general anesthetic. Prior to implementation of the pathway, postoperative pain management was primarily limited to intravenous patient-controlled opioid administration. The new multimodal pathway included scheduled acetaminophen and non-steroidal anti-inflammatory medications and ultrasound-guided classic lateral transversus abdominis plane blocks with postoperative opioids reserved only for rescue analgesia. Data obtained from electronic records included demographics, intraoperative opioid use, and pain scores and opioid consumption upon arrival to the recovery room, at 2, 6, 12, 24, 48, and 72 h postoperatively. RESULTS: Patients receiving multimodal opioid sparing analgesia (AFTER group) had lower opioid use for 72 h, postoperatively. Only 2 of the 36 patients (5.6%) in the AFTER group required intravenous opioids through patient-controlled analgesia while 30 out of 36 patients (83.3%) in the BEFORE group required intravenous opioids. CONCLUSIONS: Multimodal opioid-sparing analgesia is associated with reduced postoperative opioid consumption after emergent cesarean delivery.

A comparison of acute pain management strategies after cesarean delivery.

BACKGROUND: There are approximately 1.2 million cesarean deliveries performed each year in the United States alone. While traditional postoperative pain management strategies previously relied heavily on opioids, practitioners are now moving toward opioid-sparing protocols using multiple classes of nonnarcotic analgesics. Multimodal pain management systems have been adopted by other surgical specialties including gynecology, although the data regarding their use for postoperative cesarean delivery pain management remain limited. OBJECTIVE: To determine if a multimodal pain management regimen after cesarean delivery reduces the required number of morphine milligram equivalents (a unit of measurement for opioids) compared with traditional morphine patient-controlled analgesia 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. It was conducted during a transition from a traditional morphine patient-controlled analgesia regimen to a multimodal regimen that included scheduled nonsteroidal anti-inflammatory drugs and acetaminophen, with opioids used as needed. The data were collected for a 6-week period before and after the transition. The primary outcome was postoperative opioid use defined as morphine milligram equivalents in the first 48 hours. The secondary outcomes included serial pain scores, time to discharge, and exclusive breastfeeding rates. Women who required general anesthesia or had a history of substance abuse disorder were excluded. The statistical analyses included the Student t test, Wilcoxon rank-sum, and Hodges-Lehman shift, with a P value <.05 being considered significant. RESULTS: During the study period, 877 women underwent cesarean delivery and 778 met the inclusion criteria-378 received the traditional morphine patient-controlled analgesia and 400 received the multimodal regimen. The implementation of a multimodal regimen resulted in a significant reduction in the morphine milligram equivalent use in the first 48 hours (28 [14-41] morphine milligram equivalents vs 128 [86-174] morphine milligram equivalents; P<.001). Compared with the traditional group, more women in the multimodal group reported a pain score ≤4 by 48 hours (88% vs 77%; P<.001). There was no difference in the time to discharge (P=.32). Of the women who exclusively planned to breastfeed, fewer used formula before discharge in the multimodal group than in the traditional group (9% vs 12%; P<.001). CONCLUSION: Transition to a multimodal pain management regimen for women undergoing cesarean delivery resulted in a decrease in opioid use while adequately controlling postoperative pain. A multimodal regimen was associated with early successful exclusive breastfeeding.

Timing of Emergency Postpartum Hospital Visits in the Fourth Trimester.

OBJECTIVE: The concept of the "fourth trimester" emphasizes the importance of individualized postpartum follow-up. Women seek care for urgent issues during this critical time period. Our objective was to evaluate trends in presenting complaints and admissions in an emergency setting over the first 42 days following delivery. STUDY DESIGN: Postpartum hospital encounters within 42 days of delivery at our institution from 2015 to 2019 were studied. Demographic information, delivery route, and emergent hospital encounter details were obtained from the electronic medical record. The postpartum encounters were analyzed by week of presentation. Statistical analysis included Student's t-test and Mantel-Haenszel test with p <0.05 considered significant. RESULTS: Of the 8,589 deliveries, 491 (5.7%) were complicated by an emergent hospital presentation within 42 days of delivery resulting in 576 hospital encounters. 35.9% of these visits occurred in the first week and 75.5% occurred within the first 3 weeks. Women presenting to the hospital were more commonly African American, higher body mass index, and delivered via cesarean. The most common chief complaints were fever, headache, abdominal pain, vaginal bleeding, hypertension, and wound concerns with temporal trends noted. 72% of admissions occur within 14 days of delivery and drop dramatically thereafter (p = 0.001). The most common diagnoses were hypertension/preeclampsia with severe features, vaginal bleeding/delayed postpartum hemorrhage, and wound infection. CONCLUSION: We observed important trends in presenting complaints and admission diagnoses of emergency postpartum visits in the first 42 days. The majority of hospital visits and admissions occur within the first 2 weeks postpartum. Understanding maternal conditions and reasons for accessing care through an emergency setting allows for tailoring of routine postpartum follow-up. KEY POINTS: · Women presenting in the postpartum period most commonly seek care within 3 weeks of delivery.. · Postpartum presentations requiring admission most frequently occur within 2 weeks of delivery.. · The most common diagnoses on presentation were hypentension, vaginal bleeding, and wound infections..

The impact of baseline proteinuria in pregnant women with pregestational diabetes mellitus.

BACKGROUND: The incidence of diabetes in pregnancy has increased dramatically with the rising rates of obesity. Because there are a number of recognized adverse maternal and fetal outcomes associated with diabetes, there have been several attempts to classify this disorder for perinatal risk stratification. One of the first classification systems for pregnancy was developed by White nearly 70 years ago. More recently, efforts to stratify diabetic disease severity according to vasculopathy have been adopted. Regardless of classification system, vasculopathy-associated effects have been associated with worsening pregnancy outcomes. Defining vasculopathy within an organ system, however, has not been consistent. For example, definitions of diabetic kidney disease differ from the previously used threshold of ≥500 mg/d by White for pregnancy to varying thresholds of albuminuria by the American Diabetes Association. OBJECTIVE: To evaluate a proteinuria threshold that was a relevant determinant of perinatal risk in a cohort of women with type 2 diabetes. MATERIALS AND METHODS: This was a retrospective cohort study of women with pregestational diabetes delivered of nonanomalous, singleton, liveborn infants. All women were assessed for baseline maternal disease burden with a 24-hour proteinuria quantification performed before 20 weeks' gestation. Women with <500 mg/d on 24-hour urine collections were included. Perinatal outcomes were analyzed according to the following protein excretion values: 50-100, 101-200, 201-300, and 301-499 mg/d. Based on trends noted in these results and using the prior definition of the American Diabetes Association of 300 mg/d of albumin for diabetic kidney disease, women were then analyzed according to 24-hour urine collections of ≤300 or >300 mg/d. RESULTS: Between 2009 and 2016, a total of 594 women with pregestational diabetes were found to meet study criteria. When analyzed according to protein excretion values 50-100, 101-200, 201-300, and 301-499 mg/d, there were no differences in maternal demographics. The rate of preeclampsia with severe features (P for trend = .02), preterm birth at <37 weeks (P for trend <.001), and birthweight <10th percentile (P for trend = .02) were significantly associated with increasing proteinuria excretion, with the highest rates in the >300 mg/d group. Perinatal outcomes were then examined in the context of 24-hour urine protein excretion values of ≤300 or >300 mg/d, with no differences in maternal demographics. Protein excretion values >300 mg/d were significantly associated with preterm birth <37 weeks (P = .003), preeclampsia with severe features (P = .002), and birthweight <10th percentile (P = .048). CONCLUSION: White's classification in 1949 was developed to stratify perinatal risks based on maternal disease burden, and it was found that urinary protein excretion of >500 mg/d was associated with adverse pregnancy outcomes. In a contemporary cohort of pregnant women, proteinuria >300 mg/d was associated with preterm birth, preeclampsia with severe features, and birthweight <10th percentile.

A Gap in Care? Postpartum Women Presenting to the Emergency Room and Getting Readmitted.

OBJECTIVE: Emergent postpartum hospital encounters in the first 42 days after birth are estimated to complicate 5 to 12% of births. Approximately 2% of these visits result in admission. Data on emergent visits and admissions are critically needed to address the current maternal morbidity crisis. Our objective is to characterize trends in emergent postpartum hospital encounters and readmissions through chief complaints and admission diagnoses over a 4.5-year period. STUDY DESIGN: All postpartum hospital encounters within 42 days of delivery at our institution from 2015 to 2019 were included. We reviewed demographic information, antepartum, intrapartum, and postpartum care and postpartum hospital encounters. Trends in hospital presentation and admission over the study period were analyzed. Comparisons between women who were admitted to those managed outpatient were performed. Statistical analysis included Chi-square, student's t-test, and Mantel-Haenszel test for trend and ANOVA, as appropriate. A p-value <0.05 considered significant. RESULTS: Among 8,589 deliveries, 491 (5.7%) presented emergently to the hospital within 42 days of delivery, resulting in 576 hospital encounters. From 2015 to 2019, annual rates of presentation were stable, ranging from 5.0 to 6.4% (p = 0.09). Of the 576 hospital encounters, 224 (38.9%) resulted in an admission with increasing rates from 2.0% in 2015 to 3.4% in 2019 (p = 0.005). Primiparous women with higher body mass index, cesarean delivery, and blood loss ≥1, 000 mL during delivery were significantly more likely to be admitted to the hospital. Women with psychiatric illnesses increasingly utilized the emergency room in the postpartum period (6.7-17.2%, p = 0.03). The most common presenting complaints were fever, abdominal pain, headache, vaginal bleeding, wound concerns, and high blood pressure. Admitting diagnoses were predominantly hypertensive disorder (22.9%), wound complications (12.8%), endometritis (9.6%), headache (6.9%), and delayed postpartum hemorrhage (5.6%). CONCLUSION: The average proportion of women presenting for an emergent hospital encounter in the immediate 42-day postpartum period is 5.7%. Nearly 40% of emergent hospital encounters resulted in admission and the rate increased from to 2.0 to 3.4% over the study period. The most common reasons for presentation were fever, abdominal pain, headache, vaginal bleeding, wound concerns, and hypertension. Hypertension, wound complications, and endometritis accounted for the top three admission diagnoses.

Diagnostic accuracy of fourth-generation ARCHITECT HIV Ag/Ab Combo assay and utility of signal-to-cutoff ratio to predict false-positive HIV tests in pregnancy.

BACKGROUND: False-positive HIV screening tests in pregnancy may lead to unnecessary interventions in labor. In 2014, the Centers for Disease Control and Prevention released a new algorithm for HIV diagnosis using a fourth-generation screening test, which detects antibodies to HIV as well as p24 antigen and has a shorter window period compared with prior generations. A reactive screen requires a differentiation assay, and supplemental qualitative RNA testing is necessary for nonreactive differentiation assay. One screening test, the ARCHITECT Ag/Ab Combo assay, is described to have 100% sensitivity and >99% specificity in nonpregnant populations; however, its clinical performance in pregnancy has not been well described. OBJECTIVE: The objective of the study was to determine the performance of the ARCHITECT assay among pregnant women at a large county hospital and to assess whether the relative signal-to-cutoff ratio can be used to differentiate between false-positive vs confirmed HIV infections in women with a nonreactive differentiation assay. STUDY DESIGN: This is a retrospective review of fourth-generation HIV testing in pregnant women at Parkland Hospital between June 1, 2015, and Jan. 31, 2017. We identified gravidas screened using the ARCHITECT Ag/Ab Combo assay (index test), with reflex to differentiation assay. Women with reactive ARCHITECT and nonreactive differentiation assay were evaluated with a qualitative RNA assay (reference standard). We calculated sensitivity, specificity, predictive value, and false-positive rate of the ARCHITECT screening assay in our population and described characteristics of women with false-positive HIV testing vs confirmed infection. Among women with a nonreactive differentiation assay, we compared interventions among women with and without a qualitative RNA assay result available at delivery and examined relative signal-to-cutoff ratios of the ARCHITECT assay in women with false-positive vs confirmed HIV infection. RESULTS: A total of 21,163 pregnant women were screened using the ARCHITECT assay, and 190 tested positive. Of these, 33 of 190 (17%) women had false-positive HIV screening tests (28 deliveries available for analysis), and 157 of 190 (83%) had confirmed HIV-1 infection (140 available for analysis). Diagnostic accuracy of the ARCHITECT HIV Ag/Ab Combo assay in our prenatal population (with 95% confidence interval) was as follows: sensitivity, 100% (97.7-100%); specificity, 99.8% (99.8-99.9%); positive likelihood ratio, 636 (453-895); negative likelihood ratio, 0.0 (NA); positive predictive value, 83% (77-88%); and false positive rate, 0.16% (0.11-0.22%), with a prevalence of 7 per 1000. Women with false-positive HIV testing were younger and more likely of Hispanic ethnicity. A qualitative RNA assay (reference standard) was performed prenatally in 24 (86%) and quantitative viral load in 22 (92%). Interventions occurred more frequently in women without a qualitative RNA assay result available at delivery, including intrapartum zidovudine (75% vs 4%, P = .002), breastfeeding delay (75% vs 8%, P = .001), and neonatal zidovudine initiation (75% vs 4%, P = .002). The ARCHITECT signal-to-cutoff ratio was significantly lower for women with false-positive HIV tests compared with those with established HIV infection (1.89 [1.27, 2.73] vs 533.65 [391.12, 737.22], respectively, P < .001). CONCLUSION: While the performance of the fourth-generation ARCHITECT HIV Ag/Ab Combo assay among pregnant women is comparable with that reported in nonpregnant populations, clinical implications of using a screening test with a positive predictive value of 83% in pregnancy are significant. When the qualitative RNA assay result is unavailable, absence of risk factors in combination with an ARCHITECT HIV Ag/Ab assay S/Co ratio <5 and nonreactive differentiation assay provide sufficient evidence to support deferral of unnecessary intrapartum interventions while awaiting qualitative RNA results.