Reducing Opioid Prescribing after Cesarean Delivery by Utilizing a Tailored Opioid Prescribing Algorithm.

OBJECTIVE: There are increasing efforts among health care systems to promote safe opioid prescribing; however, best practice for minimizing overprescription is not established. Our study aimed to evaluate the effect of a tailored opioid prescribing algorithm on opioid prescription quantities. STUDY DESIGN: A tailored opioid prescribing algorithm was developed to provide a recommended prescription quantity based on inpatient opioid use. A retrospective analysis of opioid prescribing 3 months before and after implementation was performed. Our primary outcome was the number of oxycodone 5-mg tablets prescribed. Subgroup analysis by oxycodone consumption in the 24 hour prior to discharge was performed. Patient satisfaction and unused opioid tablets were assessed by text message survey 2 weeks' postpartum. RESULTS: We included 627 (n = 313 preimplementation; n = 314 postimplementation) patients who underwent cesarean delivery. Clinical characteristics were similar between groups. The median number of oxycodone 5-mg tablets prescribed in the baseline group was 20 (interquartile range [IQR]: 20-30), compared with 5 (IQR: 0-10) in the tailored prescribing group (p < 0.0001). For patients with no opioid use in the 24 hours prior to discharge, the median number of tablets prescribed decreased from 20 (IQR: 10-20) to 0 (IQR: 0-5) following the intervention (p < 0.0001). The proportion of patients discharged without an opioid prescription increased from 7% (23/313) in the baseline group to 35% (111/314) in the tailored prescribing group (odds ratio: 6.9, 95% confidence interval [4.3, 11.1]). CONCLUSION: Tailored opioid prescribing reduced the number of opioid tablets prescribed and increased the proportion of patients who were discharged without an opioid prescription. KEY POINTS: · Opioid prescribing should be tailored by inpatient use.. · Tailored prescribing reduced opioid prescription amounts.. · Many patients do not require an opioid prescription..

Physical activity and pregnancy outcomes: an expert review.

This expert review aimed to assess current literature on the effect and tracking of physical activity during pregnancy and associated outcomes. Self-reported physical activity may be inaccurate given the subjective nature of the questionnaires. The accelerometer ActiGraph is considered the "gold standard" to objectively measure physical activity. However, other more user-friendly wearable devices are now widely available and may accurately track physical activity. Conclusive data from both validated activity questionnaires and accelerometers indicate that physical activity is safe during pregnancy. In addition, studies of physical activity during pregnancy that evaluate pregnancy outcomes have found reduced risks of preterm birth, preeclampsia, and gestational diabetes mellitus and improved mental health among individuals who regularly engage in physical activity. In the United States, approximately 48% of pregnant individuals gain more than the recommended amount of weight during pregnancy; excessive gestational weight gain is associated with an increased risk of maternal and fetal complications, including preterm birth, preeclampsia, and gestational diabetes mellitus, and corresponding higher adverse short- and long-term maternal and offspring health outcomes. Although physical activity is safe during pregnancy and may reduce excessive gestational weight gain and resultant pregnancy complications, further research is needed to determine the frequency and duration of specific types of physical activity during pregnancy. Providers should encourage physical activity before and during pregnancy and educate patients regarding the benefits and safety of physical activity.

A Quality Improvement Effort to Reduce Inpatient Opioid Consumption following Cesarean Delivery.

OBJECTIVE: The amount of opioid prescribed following cesarean delivery (CD) is commonly in excess of patients' needs. An additional concern in a breastfeeding mother is neonatal opioid exposure. A maximum daily dose of 30 mg of oxycodone is recommended in breastfeeding women. Inadequate pain control can inhibit breastfeeding, as well as other negative consequences. We aimed to evaluate the effect of reducing the as-needed opioid ordered following CD on inpatient opioid consumption and analgesia. STUDY DESIGN: At our tertiary-care institution, our standard as-needed opioid order was reduced from oxycodone 5 to 10 mg every 4 hours to oxycodone 5 mg every 6 hours, in May 2019. Orders for scheduled acetaminophen and nonsteroidal anti-inflammatory drugs were unchanged. We compared opioid use and pain scores before (February 2019-April 2019) and after (May 2019-July 2019) the order modification. Our primary outcome was the proportion of patients using >30 mg of oxycodone in the 24 hours prior to hospital discharge. We further assessed 48-hour opioid consumption and patient-reported verbal pain scores. RESULTS: There were 559 patients who met inclusion criteria; 241 preintervention patients and 318 postintervention patients. In the preintervention group, 14.5% (35/241) used >30-mg oxycodone in the 24 hours before discharge, compared with 5.0% (16/318) after the order set change (relative risk [RR] = 0.34, 95% confidence interval [CI]: 0.19, 0.61; number needed to treat [NNT] = 10.5). There was no change in the proportion of women with one or more pain score >7 (preintervention: 44.4% [107/241], postintervention: 43.1% [137/318], p = 0.756) or >4 and ≤7 (preintervention: 36.9% [89/241], postintervention: 36.9% [125/318], p = 0.567), nor was there a change in mean pain score (mean ± standard deviation [SD]: preintervention = 2.8 ± 1.6 and postintervention = 2.7 ± 1.4, p = 0.464). CONCLUSION: Reducing the amount of opioid ordered after CD reduced the proportion of post-CD patients exceeding the maximum recommended daily oxycodone dose for breastfeeding women. KEY POINTS: · Inpatient opioid prescribing influences usage.. · Opioid orders influence consumption.. · Reducing opioids may not increase pain..

Seroreduction of syphilis non-treponemal titers during pregnancy for women with and without HIV co-infection.

OBJECTIVE: To evaluate the effect of HIV co-infection on non-treponemal titers during pregnancy in women with syphilis. METHODS: This is a secondary analysis of pregnant women with syphilis in the prospective, observational Zambian Preterm Birth Prevention Study (ZAPPS). Treponemal (Treponema pallidum particle agglutination) and non-treponemal (rapid plasma reagin; RPR) testing were performed on serum biospecimens, resulting in 47 participants with serologically confirmed syphilis (27 HIV-positive, 20 HIV-negative). The primary outcome, achievement of RPR titer seroreduction during pregnancy, was analyzed by logistic regression. Secondary outcomes included overall titer reduction, seroreduction rate, serologic cure, and adverse pregnancy outcomes. RESULTS: Seroreduction of RPR titer occurred in 78% (21/27) of women with HIV versus 45% (9/20) of women without (adjusted odds ratio 4.66; 95% confidence interval [CI] 1.14 - 19.08). Overall RPR titer reduction, rate of seroreduction per week, and the proportion achieving serologic cure each trended higher among women with HIV compared with those without HIV. There was a trend toward decreased stillbirth incidence in participants achieving seroreduction (odds ratio 0.15, 95% CI 0.01-1.58). CONCLUSION: HIV co-infection in this cohort of Zambian women with syphilis was associated with greater odds of RPR titer seroreduction during pregnancy. Pregnant women with syphilis and HIV may not be at increased risk for a delayed syphilis treatment response compared with women without HIV.

Extracorporeal membrane oxygenation in pregnant and postpartum women: a ten-year case series.

Objective: tExtracorporeal membrane oxygenation (ECMO) is a life-saving therapy for severe, reversible cardiopulmonary failure, but data regarding its use in pregnancy and the postpartum period are limited. We sought to quantify survival of pregnant and postpartum women necessitating ECMO in a contemporary cohort at a single tertiary institution. Study Design: All women of reproductive age (14-44 years), who underwent ECMO at our institution between January 1, 2008, and December 31, 2017, were identified using a query of hospital encounters for ECMO-related CPT codes. We manually reviewed all charts of women of reproductive age; women who were pregnant or <6 weeks postpartum at the time of ECMO initiation were included. Clinical characteristics and maternal and fetal outcomes are described. Results: In this study, 54 women of reproductive age underwent ECMO for cardiopulmonary failure. Of those, 9 (17%) were pregnant or <6 weeks postpartum at the time of ECMO initiation: 4 antepartum, 1 intraoperative at the time of cesarean delivery, and 4 postpartum (including 2 in whom ECMO was initiated on postpartum day 0 or 1). Overall, maternal survival was 33%. The median maternal age was 24 years (range 19-39 years); most women were nonsmokers without underlying medical comorbidities. The most common indication for ECMO use in pregnant and postpartum women was acute respiratory distress syndrome, which was present in 7 cases (78%), including 5 cases that were due to infectious etiologies and 2 cases that were attributed to preeclampsia. The median number of days on ECMO was 6 (range 1-14). There were no cases of obstetric hemorrhage. Venovenous ECMO was utilized in all but 1 case, in which emergent attempted venoarterial ECMO was unsuccessful in resuscitating a postpartum patient with cardiac arrest and a massive pulmonary embolism. A total of 4 women were initiated on ECMO during pregnancy: their gestational ages at ECMO initiation were 21, 22, 29, and 30 weeks; maternal survival was 50%, and fetal mortality was 50%. A case of ECMO initiated during cesarean section at 29 weeks' gestation resulted in both maternal and fetal survival. Among 4 mothers with ECMO initiation after childbirth, none survived. Finally, we found a tendency toward survival in those patients for whom ECMO was initiated soon after mechanical ventilation, earlier in the disease process. In contrast, in this study, 23 of 45 women of reproductive age (51%) who were not pregnant but underwent ECMO survived. Conclusion: When ECMO was initiated during pregnancy or during childbirth, 60% of mothers and fetuses survived, supporting current use of ECMO as a salvage therapy in pregnant and intrapartum women. In this generally young and healthy population, ECMO has the potential to increase the survival rates of both mother and fetus and should be considered a salvage therapy for peripartum women with reversible forms of cardiorespiratory failure.

Capnocytophaga bacteremia precipitating severe thrombocytopenia and preterm labor in an asplenic host.

Capnocytophaga species are gram-negative bacilli that inhabit mammalian oral surfaces and can cause opportunistic infection, especially in asplenic patients. The species Capnocytophaga canimorsus is particularly associated with dog bites and is known to cause endocarditis, meningitis, and sepsis in the general population. In pregnant patients, infections tied to Capnocytophaga species from human flora have been associated with preterm labor, chorioamnionitis, and neonatal septicemia. There is little known about the effects of zoonotically-acquired Capnocytophaga infection in pregnant patients. In this case report, we present a patient with Capnocytophaga bacteremia acquired after a dog bite associated with profound thrombocytopenia and preterm labor. Dog bites are common in the United States, and we present basic recommendations for management of dog bites in pregnant patients in order to avoid morbidity associated with delay in time to antibiotic treatment of infection as described in this case.

Prenatal genetic considerations of congenital anomalies of the kidney and urinary tract (CAKUT).

Congenital anomalies of the kidney and urinary tract (CAKUT) constitute 20% of all congenital malformations occurring in one in 500 live births. Worldwide, CAKUT are responsible for 40% to 50% of pediatric and 7% of adult end-stage renal disease. Pathogenic variants in genes causing CAKUT include monogenic diseases such as polycystic kidney disease and ciliopathies, as well as syndromes that include isolated kidney disease in conjunction with other abnormalities. Prenatal diagnosis most often occurs using ultrasonography; however, further genetic diagnosis may be made using a variety of testing strategies. Family history and pathologic examination can also provide information to improve the ability to make a prenatal diagnosis of CAKUT. Here, we provide a comprehensive overview of genetic considerations in the prenatal diagnosis of CAKUT disorders. Specifically, we discuss monogenic causes of CAKUT, associated ultrasound characteristics, and considerations for genetic diagnosis, antenatal care, and postnatal care.