Evaluating the Association between Prenatal Care Visits and Adverse Perinatal Outcome in Pregnancies Complicated by Opioid Use Disorder.

OBJECTIVE: This study aimed to evaluate the association between number of prenatal care visits and adverse perinatal outcome among pregnant individuals with opioid use disorder (OUD). STUDY DESIGN: This is a retrospective cohort of singleton, nonanomalous pregnancies complicated by OUD that delivered from January 2015 to July 2020 at our academic medical center. Primary outcome was the presence of composite adverse perinatal outcome, defined as one or more of the following: stillbirth, placental abruption, perinatal death, neonatal respiratory distress syndrome, need for morphine treatment, and hyperbilirubinemia. Logistic and linear regression estimated the association between the number of prenatal care visits and the presence of adverse perinatal outcome. A Mann-Whitney U test evaluated the association between number of prenatal care visits and length of hospital stay for the neonate. RESULTS: A total of 185 patients were identified, of which 35 neonates required morphine treatment for neonatal opioid withdrawal syndrome. During pregnancy, most individuals were treated with buprenorphine 107 (57.8%), whereas 64 (34.6%) received methadone, 13 (7.0%) received no treatment, and 1 (0.5%) received naltrexone. The median number of prenatal care visits was 8 (interquartile range: 4-10). With each additional visit per 10 weeks of gestational age, the risk of adverse perinatal outcome decreased by 38% (95% confidence interval [CI]: 0.451-0.854). The need for neonatal intensive care and hyperbilirubinemia also significantly decreased with additional prenatal visits. Neonatal hospital stay decreased by a median of 2 days (95% CI: 1-4) for individuals who received more than the median of eight prenatal care visits. CONCLUSION: Pregnant individuals with OUD who attend fewer prenatal care visits experience more adverse perinatal outcome. Future research should focus on barriers to prenatal care and interventions to improve access in this high-risk population. KEY POINTS: · Use of prenatal care affects newborn outcomes.. · More prenatal care shortens neonatal hospital stay.. · Prenatal care reduces certain adverse outcomes..

Implementing American College of Obstetricians and Gynecologists Outpatient Antepartum Testing Recommendations: Can Your Clinic Handle It?

OBJECTIVE: This study was conducted to determine the difference in the number of pregnancies that would qualify for outpatient fetal testing between our current academic practice and that of the 2021 American College of Obstetricians and Gynecologists (ACOG) antepartum recommendations. STUDY DESIGN: We performed a retrospective study of all pregnancies that delivered and received prenatal care at our institution between January 1, 2019, and May 31, 2021. The timing and amount of outpatient antepartum testing was determined for each patient. Our current antepartum testing guidelines (clinic protocol) were compared with the 2021 ACOG recommendations (ACOG protocol). Statistical analysis was performed with descriptive statistics and z scoring to compare the total amount of antepartum testing utilized with each protocol. RESULTS: A total of 1,335 pregnancies were included in the study. With the ACOG protocol, an additional 310 (23.2%) of pregnancies would qualify for antepartum testing (57.8% with ACOG protocol vs. 34.6% with clinic protocol). Most of the increased testing was due to maternal age with additional risk factors, hypertensive disorders, diabetes, prepregnancy body mass index ≥ 35, and complex fetal anomalies or aneuploidies. Overall, the ACOG protocol would require an additional 570 antepartum tests (z-score = 4.04, p = 0.000005) over the study period, which is equivalent to 19 additional tests per month and 5 per week. Only nine stillbirths occurred during this time, of which two would have had antepartum testing with both protocols, one would have only had testing per ACOG, and two would have had testing individualized per ACOG. CONCLUSION: More pregnancies would require outpatient antenatal testing with adoption of the ACOG protocol. A 23% increase in testing would equate to five additional antepartum tests per week. Although this study cannot assess the clinical impact of additional testing, minimal scheduling resources are needed to accommodate this increase. KEY POINTS: · Most pregnancies have risk factors for stillbirth.. · Most pregnancies qualify for fetal testing per ACOG.. · More resources are needed for this increased testing..

Use of gestation adjusted projection method for predicting fetal head circumference.

OBJECTIVES: The aim of this study is to determine if the gestation adjusted projection (GAP) method applied to a fetal head circumference (FHC) measured on ultrasound between 32 and 36 weeks and 6 days gestation can predict birth head circumference, specifically ≥ 35 cm, which is a known risk factor for Cesarean. METHODS: This is a retrospective chart review of 60 pregnancies from January to December 2019. Eligible patients delivered a singleton term neonate and received two ultrasounds, one at 32-36 weeks and 6 days gestation (period 1) and a second within 7 days of a term birth (period 2). Fetal head circumference was predicted two ways, by applying (1) the GAP method to the period 1 ultrasound and (2) by direct measurement with a period 2 ultrasound. These estimates were compared to the birth head circumference (HCBIRTH) by measures of error and with paired t-tests. McNemar's test compared the ability to predict head circumference (HC) ≥ 35 cm. RESULTS: None of the measures of error were significantly different between the GAP and the period 2 ultrasound, including the ability to predict HC ≥ 35 cm. In patients who delivered at ≥ 39 weeks, the period 2 ultrasound performed poorly while the GAP's performance remained good. CONCLUSION: The GAP method applied to an early third trimester ultrasound predicts HCBIRTH with accuracy similar to an ultrasound performed seven days from delivery and may be superior for deliveries ≥ 39 weeks. The ability to predict HCBIRTH could improve clinical management of affected pregnancies.

Impact of obesity on blood pressures measured at alternative locations during pregnancy.

BACKGROUND: In patients with obesity, the distribution of subcutaneous tissue can make blood pressure measurement on the standard location of the upper arm difficult. In these cases, alternative locations, such as the lower arm or wrist, are commonly used. It is unknown whether there is a discrepancy in these measurements for pregnant patients at extremes of body mass index. OBJECTIVE: We hypothesized that noninvasive blood pressure measurements on the lower arm and wrist will differ from blood pressure measurements on the upper arm and that this difference will be greater with increasing body mass index. STUDY DESIGN: We conducted a prospective observational study of pregnant patients from July 2020 to August 2020. We collected study subjects' biometric measurements and took 3 blood pressure measurements (systolic and diastolic blood pressures) from the upper arm, lower arm, and wrist. Measurements on the lower arm and wrist were considered alternative locations and compared with measurements on the upper arm. We stratified patients by body mass index. Agreement between locations was assessed using the Bland-Altman analysis. We used linear regression to assess the blood pressure discrepancy dependence on body mass index. RESULTS: We included 100 patients with 20 patients from each body mass index class. Blood pressure measurements at each site correlated but were discrepant. For the lower arm, there was an upward bias of 11.5 mm Hg (limit of agreement, +30.7 to -7.8) for systolic blood pressure and 11.2 mm Hg (limit of agreement, +25.9 to -2.9) for diastolic blood pressure compared with the upper arm. For the wrist, there was an upward bias of 7.1 mm Hg (limit of agreement, +35.1 to -20.9) for systolic blood pressure and 7.3 mm Hg (limit of agreement, +26.2 to -11.7) for diastolic blood pressure compared with the upper arm. Overall, there was a greater discrepancy in blood pressure measurements between the lower and upper arms with increasing body mass index. When comparing blood pressure measurements between the lower and upper arms, the discrepancy increased by 0.43 mm Hg (P<.001) for systolic blood pressure and 0.18 mm Hg (P=.02) for diastolic blood pressure with each increasing body mass index unit. There was no statistically significant change in the discrepancy of systolic (P=.45) or diastolic (P=.86) blood pressure in the upper arm vs the wrist based on body mass index. CONCLUSION: This study highlighted that blood pressure measurements are higher when taken at alternative locations, such as the lower arm and wrist, and that lower arm blood pressure measurements are increasingly discrepant from upper arm blood pressure measurements with increasing body mass index.

Inhibiting ERα expression in the medial amygdala increases prosocial behavior in male meadow voles (Microtus pennsylvanicus).

This study tested the hypothesis that site-specific estrogen receptor alpha (ERα) expression is a critical factor in the expression of male prosocial behavior and aggression. Previous studies have shown that in the socially monogamous prairie vole (Microtus ochrogaster) low levels of ERα expression, in the medial amygdala (MeA), play an essential role in the expression of high levels of male prosocial behavior and that increasing ERα expression reduced male prosocial behavior. We used an shRNA adeno-associated viral vector to knock down/inhibit ERα in the MeA of the polygynous male meadow vole (M. pennsylvanicus), which displays significantly higher levels of ERα in the MeA than its monogamous relative. Control males were transfected with a luciferase expressing AAV vector. After treatment males participated in three social behavior tests, a same-sex dyadic encounter, an opposite-sex social preference test and an alloparental test. We predicted that decreasing MeA ERα would increase male meadow vole's prosocial behavior and reduce aggression. The results generally supported the hypothesis. Specifically, MeA knockdown males displayed lower levels of defensive aggression during dyadic encounters and increased levels of overall side-x-side physical contact with females during the social preference test, eliminating the partner preference observed in controls. There was no effect on pup interactions, with both treatments expressing low levels of alloparental behavior. Behaviors affected were similar to those in male prairie voles with increased ERα in the BST rather than the MeA, suggesting that relative changes of expression within these nuclei may play a critical role in regulating prosocial behavior.