Torticollis in infants with neonatal abstinence syndrome.

OBJECTIVE: To report the incidence of torticollis diagnosed in infants treated for neonatal abstinence syndrome (NAS) and compare neonates with and without torticollis. STUDY DESIGN: This prospective cohort study reports on infants examined at 1-4 months of age. Numerous obstetrical/newborn factors and other drugs used during gestation were compared. RESULTS: Of 501 neonates treated for NAS, 421 (84%) were seen for follow-up. Of these, 105 (24.9%) were diagnosed with torticollis. The only significant obstetrical/newborn factor identified was a lower rate if the parents were the primary caregiver after hospital discharge. Of the 105 cases, 88 (84%) were right-sided and 17 (16%) were left-sided. CONCLUSIONS: These data demonstrate that torticollis is a common diagnosis in infants examined at 1-4 months of age after being treated for NAS with a predilection for this to be right-sided. The etiology for this is uncertain, but newborns treated for NAS need close follow-up post discharge.

Fetal Outcomes with Detoxification from Opioid Drugs during Pregnancy: A Systematic Review.

OBJECTIVE: This study aimed to perform a systematic review of all studies reporting fetal outcomes following detoxification or tapering of opioid drugs during pregnancy. STUDY DESIGN: PubMed, Scopus, Medline, and Google Scholar were searched, and only manuscripts clearly reporting pregnancy/fetal outcomes involving tapering or detoxification from opioid drugs were included. Only pregnancies managed after 1980 were included (when antenatal fetal surveillance became more routine). Collected data included study design, location, years patients were managed, number of patients who were tapered or detoxified, method of tapering, and pregnancy outcome. RESULTS: A total of 14 publications met the criteria for review after evaluating more than 2,000 abstracts and 153 published manuscripts. In 1,097 pregnancies, based on mortality rate analyses and forest plots, no increased fetal risks due to tapering or detoxification from opioid drugs were identified. No increased risk of preterm delivery was found. CONCLUSION: Pregnant women with opioid use disorder who are stable in a medication-assisted treatment program with behavioral health can be informed that tapering or full detoxification from opioid drugs does not increase the fetal risk of poor pregnancy outcome. Future research needs to answer the questions on maternal and long-term newborn consequences of tapering or detoxification versus long-term newborn consequences of continued chronic in utero opioid exposure.

Psychosocial Background History of Pregnant Women with Opioid Use Disorder: A Prospective Cohort Study.

OBJECTIVE: This study aimed to evaluate the psychosocial background history and confounding social factors in pregnant women with opioid use disorder (OUD). STUDY DESIGN: We performed a prospective observational cohort study of pregnant women from a dedicated obstetrical OUD clinic. Data collection came from extensive interview sessions regarding psychosocial background events and other social factors that might impact prenatal care. RESULTS: From February 1, 2017, through September 30, 2018, 411 pregnant women were evaluated and 294 (72%, 95% confidence interval [CI]: 67-76%) reported abuse of which 217 (53%, 95% CI: 48-58%) involved sexual abuse (prior to the age of 13 years in 54% of cases) and 209 (51%, 95% CI: 46-56%) involved cases of other physical abuse. Only 10% reported habitual opioid use for managing chronic pain. Only 9% had a valid driver's license with access to a car making transportation to office visits difficult. CONCLUSION: A history of abuse (mainly sexual and/or physical) appears to be the main precipitating event leading to OUD in our pregnant population. Transportation was the primary social factor limiting access to prenatal care. For primary prevention to be successful in our region, early identification of young women who have experienced abuse needs to occur followed by psychotherapy health care intervention before opioid drugs are used.

Sharing of Snorting Straws and Hepatitis C Virus Infection in Pregnant Women.

OBJECTIVE: To evaluate possible modes of hepatitis C virus (HCV) acquisition in pregnant women found to be HCV-infected in the prenatal period and to assess transmission risk factors. METHODS: This was a prospective cohort study conducted from March 2014 through June 2015 involving the distribution of an anonymous survey to HCV-infected pregnant women that assessed for numerous modes of potential HCV transmission involving, intravenous drug use, blood transfusion, organ transplant, sexual contact, tattoos, and snorting drugs with a straw. Participants were drawn from our institutional obstetric high-risk clinic. Statistical analysis involved simple percentages and χ comparisons where appropriate; P<.05 was considered significant. To test biologic plausibility, snorting utensils confiscated by law enforcement authorities from patients not in this study were tested for the presence of human blood. RESULTS: A total of 189 HCV-infected pregnant patients completed the survey, and no approached patients declined. Of these, 136 (72%, 95% confidence interval [CI] 65-78%) admitted to intravenous drug use, of whom 89 (65%, 95% CI 57-73%) reported sharing needles. Of the 178 (94%, 95% CI 90-97%) who admitted snorting drugs, 164 (92%, 95% CI 87-96%) reported sharing straws. The difference between the proportion reporting sharing of snorting utensils compared with the proportion sharing intravenous drug use utensils was significant (P<.001). Twenty-nine patients (15%, 95% CI 11-21%) reported snorting drugs and sharing straws but denied any other risk factor except sexual contact. Of the 54 straws confiscated by law enforcement authorities, 13 (24%, 95% CI 13-38%) tested positive for the presence of human blood. CONCLUSION: Sharing snorting utensils (straws) in noninjection drug use may be an additional risk factor for HCV and other virus transmission.

Detoxification from opiate drugs during pregnancy.

BACKGROUND: The current recommendation regarding the management of a pregnant patient with opioid dependence is not to perform detoxification during pregnancy because of a potential risk for preterm labor, fetal distress, or fetal demise. OBJECTIVE: The objective of the study was to evaluate the safety of full opiate detoxification during pregnancy in a large number of patients through 4 different methods and analyze the rate of newborn treatment of neonatal abstinence syndrome for each method. STUDY DESIGN: This was a retrospective analysis of data collected prospectively during ongoing prenatal care of opiate-addicted pregnant women. Data were analyzed for pregnancy complications including fetal demise and preterm labor of opiate-addicted pregnant women who underwent detoxification during pregnancy through 4 different methods: acute detoxification of incarcerated patients; inpatient detoxification with intense outpatient follow-up management; inpatient detoxification without intense outpatient follow-up management; and slow outpatient buprenorphine detoxification. The rates of newborns treated for neonatal abstinence syndrome were also assessed for each group. RESULTS: Over 5.5 years, 301 opiate-addicted pregnant patients were fully detoxified during pregnancy with no adverse fetal outcomes related to detoxification identified. There were 94 patients who delivered newborns treated for neonatal abstinence syndrome (31%). There was an 18.5% rate of neonatal abstinence syndrome in the 108 acutely detoxified while incarcerated, a 17.4% rate of neonatal abstinence syndrome in the 23 who had inpatient detoxification with intense outpatient follow-up management, a 17.2% rate of neonatal abstinence syndrome in the 93 who went through slow outpatient buprenorphine detoxification, but a 70.1% rate of neonatal abstinence syndrome in the 77 who had inpatient detoxification without intense outpatient follow-up management. CONCLUSION: With these data and other published studies, more than 600 patients have been reported to detoxify from opiates during pregnancy with no report of fetal harm related to the process. These data highly suggest that detoxification of opiate-addicted pregnant patients is not harmful. The rate of neonatal abstinence syndrome is high but primarily when no continued long-term follow-up occurs. Once a patient is drug free, intense behavioral health follow-up is needed for continued success.

Blood Contaminated Amniotic Fluid and the Lamellar Body Count Fetal Lung Maturity Test.

OBJECTIVE: To determine if maternal blood contamination falsely elevates the lamellar body count fetal lung maturity test. STUDY DESIGN: Fifty mothers undergoing amniocentesis for fetal lung maturity consented to participation in the study. For each participant a blood-contaminated sample using the patient's own blood was run in tandem with the noncontaminated sample used for clinical practice. RESULTS: Of the 50 study patient samples the lamellar body count decreased by ≥ 3,000/µL in 33 (66%) and remained unchanged in 16 (32%). In only 1 case did the value increase--the actual result of 37,000/µL increased to 44,000/µL, both of which exceeded the mature level in our institution. CONCLUSION: Maternal blood contamination of amniotic fluid does not falsely increase the lamellar body count in 98% of cases. The result was falsely lowered in 2 out of 3 cases. Therefore, a mature lamellar body count test result in a blood-contaminated sample is reliable

The use of prostaglandin E1 in peripartum patients with asthma.

OBJECTIVE: Prostaglandin E1 (PGE1) is commonly used in obstetric practice for labor induction and cervical ripening and in treating postpartum hemorrhage; however, its use in pregnant asthmatic patients has not been studied to date. The package insert states there is an unknown causal side effect for dyspnea and bronchospasm. Other pharmacological publications have stated that bronchoconstriction may occur with the use of PGE1. The study objective was to examine peripartum pregnant asthmatic patients who received prostaglandin E1. STUDY DESIGN: Every patient who was administered PGE1 from January 2010 through December 2013 was prospectively recorded. The charts were retrospectively reviewed. Peripartum patients with asthma were identified and further analyzed for any evidence of an asthma exacerbation following administration of the drug. RESULTS: A total of 234 of 2629 patients (8.9%) who received PGE1 were identified as having asthma. None of the patients had any evidence of an asthma exacerbation (0 of 234; 95% confidence interval, 0-0.017). Of the 234 patients, 104 (44%) had active asthma and were receiving daily medication, and the remaining 130 patients had a medical history of asthma for which they used an inhaler on an as-needed basis. A total of 98 patients (42%) received greater than 400 µg of total dose. A post hoc statistical assessment was performed, and the study was sufficiently powered to detect any clinically meaningful increase in asthma exacerbation with PGE1 usage, if such a risk existed. CONCLUSION: Based on the 95% confidence interval of these data, the maximum risk for an asthma exacerbation following the use of prostaglandin E1 is less than 2%. Although all medications administered to asthmatic patients in the peripartum period should be carefully selected, this information supports the use of prostaglandin E1 in obstetric patients with asthma, if clinically indicated.

Accuracy of the lamellar body count in amniotic fluid contaminated by meconium.

OBJECTIVE: To determine whether meconium-contaminated amniotic fluid falsely elevates the lamellar body count in fetal lung maturity testing. METHODS: Thirty mothers undergoing amniocentesis for fetal lung maturity testing were prospectively consented. A 2 mL portion of the patient's sample was mixed with a 10% meconium solution and the meconium-stained sample was then run in tandem with the patient's sample used in clinical management. Pure meconium samples without amniotic fluid were also run through the cell counter for analysis. RESULTS: Following meconium contamination, the lamellar body count value increased in 67% of the cases, decreased in 23% and remained the same in 10%. There were 13 test results that had "immature" values in the uncontaminated patient management sample group and nine of these (69%) became elevated to a "mature" level (a false elevation) following the addition of meconium. All of the 10 pure liquid meconium samples devoid of amniotic fluid processed by the cell counter identified and quantified some particle the size of platelets. CONCLUSIONS: The lamellar body count test result is not reliable in meconium-stained amniotic fluid specimens. There is some unknown particle found in meconium that is the size of platelets/lamellar bodies that can falsely elevate the test result. Currently, the only reliable fetal lung maturity test in meconium-stained amniotic fluid is the presence of phosphatidylglycerol.

Transplacental passage of vancomycin from mother to neonate.

OBJECTIVE: The objective of the study was to analyze a large number of patients receiving vancomycin chemoprophylaxis and evaluate the maternal and neonatal cord blood levels at the time of delivery. STUDY DESIGN: Every mother who entered labor with a positive group B streptococcal culture and a high-risk penicillin allergy with resistance to clindamycin or unknown sensitivity was consented to participate in the study. In the initial phase of the study, patients received the standard intravenous dose of 1 g every 12 hours. Based on the results, this was changed to a dosing of 15 mg/kg every 12 hours in the second phase and then further modified to 20 mg/kg every 8 hours in the third phase. Maternal and cord blood vancomycin levels were obtained at delivery and evaluated. RESULTS: A total of 55 patients consented to participate in the study, with 31 in phase I, 12 in phase II, and 12 in phase III. For the standard-dosing phase I group, only 32% of maternal and 9% of cord blood samples were therapeutic at delivery. For phase II, 50% of maternal and 33% of cord blood values were therapeutic; however, in phase III, 83% of mothers and neonates had therapeutic levels at the time of delivery. CONCLUSION: With standard dosing, only 9% of neonates have therapeutic vancomycin levels at delivery. By using a regimen of 20 mg/kg intravenous every 8 hours (maximum individual dose 2 g), the newborn therapeutic level increases above 80%. The pharmacological pattern shows that transplacental passage occurs with fetal levels equaling maternal levels, but transplacental transport is somewhat slow in both directions.

Vagal nerve stimulator use during pregnancy for treatment of refractory seizure disorder.

BACKGROUND: In patients with medically refractory seizures, vagal nerve stimulation is becoming an increasingly common adjunctive therapy. Although its safety and efficacy have been proven in the general population, little is known about its use during pregnancy. CASE: A 19-year-old primigravid woman presented during the first trimester for routine prenatal care. She had a past medical history significant for generalized tonic-clonic seizure disorder since childhood. Multiple medical regimens had failed, and a vagal nerve stimulator was implanted approximately 2 months before conception. The patient continued to take phenytoin, with improved seizure control. She had a term spontaneous delivery complicated by mild preeclampsia. CONCLUSION: Adjunctive treatment of medically refractory seizures with a vagal nerve stimulator is a viable option during pregnancy.