Use of naltrexone in treating opioid use disorder in pregnancy.

BACKGROUND: The mainstay of the management of opioid use disorder in pregnancy is with methadone or buprenorphine medication-assisted treatment. Methadone and buprenorphine are opioid agonist drugs. Naltrexone, an opioid antagonist, is also a medication-assisted treatment option; however, to date, only a few retrospective studies have reported its use in pregnancy. OBJECTIVE: Our study objective was to evaluate prospectively obstetric and newborn outcomes and the maternal/fetal effects of the use of naltrexone as a medication-assisted treatment in pregnant patients with opioid use disorder. STUDY DESIGN: We performed a prospective cohort study collecting data on all pregnant women who were treated with naltrexone medication-assisted treatment compared with pregnant women who were treated with methadone or buprenorphine medication-assisted treatment. Based on a sample size calculation, it was determined that for a power of 90, a minimum of 160 study participants (80 in each group) was needed with an alpha of .01 and an expected 60% rate of newborn infants who were treated for neonatal abstinence syndrome in the methadone or buprenorphine medication-assisted treatment group compared with a 30% rate in the naltrexone medication-assisted treatment group. In a random subset of 20 maternal/newborn dyads, blood levels for naltrexone and 6-beta-naltrexol (an active metabolite) were analyzed at delivery. RESULTS: A total of 230 patients were studied: 121 patients with naltrexone medication-assisted treatment compared with 109 patients with methadone or buprenorphine medication-assisted treatment. No differences between groups were seen regarding demographics, the use of comedications/drugs, or obstetric outcomes. For newborn outcomes, the rate of neonatal abstinence syndrome in neonates >34 weeks gestation was significantly lower in the naltrexone medication-assisted treatment group (10/119 [8.4%] vs 79/105 [75.2%]; P<.0001). Multivariate analysis demonstrated that the only significant factor for the rate of neonatal abstinence syndrome was the form of medication-assisted treatment. Of 87 patients who received naltrexone up to delivery, no neonates experienced symptoms of neonatal abstinence syndrome. No maternal relapses occurred in the 7-day no-treatment window before the initiation of naltrexone therapy. No cases of spontaneous abortion or stillbirth occurred in either group. In 64 patients who started naltrexone therapy at ≥24 weeks gestation, no changes were seen in the fetal heart monitor tracing with drug initiation. The incidence of birth anomalies was no different between the groups. Umbilical cord blood and maternal levels for naltrexone and 6-beta-naltrexol matched; no levels were elevated, and values were undetected if naltrexone was discontinued >60 hours before delivery. CONCLUSION: These study data demonstrate that, in pregnant women who choose to completely detoxify off opioid drugs during gestation, naltrexone, as a continued form of medication-assisted treatment, is a viable option for some pregnant patients who experience opioid use disorder. Naltrexone crosses the placenta, and maternal and fetal levels are concordant. Because naltrexone clears quickly from the maternal circulation, this rapid clearance needs to be addressed with patients. This is important because maternal relapse could occur in a short time-period if the oral drug is discontinued without the knowledge of their healthcare providers. Nonetheless, the drug is well-tolerated by both mother and fetus, and newborn infants do not experience symptoms of neonatal abstinence syndrome if naltrexone medication-assisted treatment is maintained to delivery.

Fetomaternal Bleeding and Neonatal Hematocrit following Cesarean Delivery: Routine versus Transplacental Transection.

Objective To evaluate fetomaternal bleeding following routine cesarean delivery compared with cesarean delivery involving transplacental transection. Study Design A prospective cohort study evaluating cesarean delivery in which the placenta was transected (cases) versus controls (placenta not transected) from January 2016 to April 2018. A maternal Kleihauer-Betke's (KB) test and newborn hematocrit were performed shortly after delivery. Results The rate of a positive KB test was not significantly different between cases ( n = 31) and controls ( n = 61) (19 vs. 14%; odds ratio [OR]: 1.44; 95% confidence interval [CI]: 0.46-4.49; p = 0.74). Median neonatal hematocrits were not different. However, the rate of newborn hematocrits <40% at delivery was higher in cases compared with controls (23 vs. 3%; OR: 8.90; 95% CI: 1.72-45.90; p = 0.005). Conclusion A cesarean requiring transplacental transection to accomplish delivery does not significantly increase the rate of fetomaternal bleeding but is associated with a higher likelihood of newborn hematocrit <40% at delivery.

Transplacental passage of vancomycin.

OBJECTIVE: To evaluate a larger number of patients receiving a vancomycin-dosing regimen of 20 mg/kg IV every 8 h for Group B streptococcus (GBS) chemoprophylaxis and analyze maternal and neonatal cord blood levels at delivery. METHODS: We prospectively enrolled every mother that entered labor with a positive GBS culture and a high-risk penicillin allergy with resistance to clindamycin or unknown sensitivity. Maternal and cord blood vancomycin levels were obtained at delivery. Time from last dose completion to delivery, number of doses administered and body mass index were assessed. RESULTS: A total of 30 patients consented and 23 (77%) maternal levels and cord blood levels were therapeutic. There were eight patients where one or both maternal and/or cord blood values were non-therapeutic, but in six of these, there was a regimen violation regarding timing of the next dose or total dosage administered. Of the 24 patients where the regimen was correctly followed, 22 (92%) had therapeutic maternal and cord blood levels. CONCLUSIONS: Using a vancomycin-dosing regimen of 20 mg/kg IV every 8 h (maximum individual dose of 2 g) produces therapeutic levels in more than 75% of mother/newborn pairs and this can exceed 90% when dosing regimens are correctly followed.

Patient reaction to Tdap vaccination in pregnancy.

BACKGROUND: The current obstetrical recommendation is to routinely administer the tetanus, diphtheria, and acellular pertussis (Tdap) vaccination during every pregnancy regardless of a patient's prior history. There are minimal data that have prospectively evaluated solicited patient response to this treatment plan. The study objective was to evaluate patient reaction following receipt of Tdap vaccination during pregnancy. METHODS: This was a prospective observational study conducted from May 2014 through March 2016. The study design involved solicited patient reaction within 1-7days after the administration of the Tdap vaccine. Data collected included pain or soreness, swelling, and/or redness at the injection site, as well as, fever and generalized body aches. Statistical analysis involved simple percentages with Poisson binomial 95% confidence intervals with Chi-square and Fisher's exact comparisons where appropriate. RESULTS: A total of 737 patients were evaluated and 496 (67%, 95% Confidence Interval [CI] 64-71%) were found to have at least 1 reaction to the vaccination and 187 (25%, 95% CI 22-29%) had 2 reactions or more. Overall, the majority of patients stated that the vaccination was tolerated. However, 24 (3%, 95% CI 2-5%) of the study population stated that they would not accept receipt of Tdap in a subsequent pregnancy because of the response that occurred in the current pregnancy. CONCLUSION: These data demonstrate that maternal reactions following receipt of Tdap are common (two-thirds of the study population). A potential concern is the finding that some patients might refuse a repeat vaccination in a subsequent pregnancy due to these reactions. If further research reveals similar findings, a pertussis only vaccine for pregnant patients might need to be evaluated.

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.

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

Transplacental passage of antimicrobial paraben preservatives.

Parabens are widely used preservatives suspected of being endocrine disruptors, with implications for human growth and development. The most common paraben found in consumer products is methylparaben. To date, no study has examined whether these substances cross the human placenta. A total of 100 study subjects (50 mother-child pairs) were enrolled at two medical institutions, serving primarily African-American and Caucasian women, respectively. A maternal blood sample was drawn on admission and a paired cord blood sample was obtained at delivery. Of the 50 mothers, 47 (94%) showed methylparaben in their blood (mean level 20.41 ng/l), and 47 in cords bloods (mean level 36.54 ng/l). There were 45 mother-child pairs where methylparaben was found in both samples. Of these, the fetal level was higher than the maternal level in 23 (51%). For butylparaben, only 4 mothers (8%) showed detectable levels (mean 40.54 ng/l), whereas 8 cord blood samples (16%) were positive (mean 32.5 ng/l). African-American mothers and infants showed higher prevalence of detectable levels (P=0.017). Methylparaben and butylparaben demonstrate transplacental passage. Additional studies are needed to examine potential differences in exposure by geography and demographics, what products are used by pregnant women that contain these preservatives, as well as any potential long-term effects in the growth and development of exposed children.

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.

Advances in preconception genetic counseling.

Preconception counseling offers couples contemplating pregnancy the opportunity to identify and reduce potential pregnancy risks, plan care for known risks, and establish early prenatal care. The goal of preconception counseling is to promote physically and emotionally healthy parents in an attempt to ensure optimal prenatal, intrapartum, and postpartum maternal and fetal health. The advantages of addressing these issues prior to conception include the opportunity of giving recurrence or occurrence risk information for informed decision regarding pregnancy, the accessibility of more reproductive options such as preimplantation genetic diagnosis, and the opportunity to make lifestyle, medical, and behavior alterations for optimal maternal and fetal outcome. This article will discuss advances and updates in preconception genetic counseling including risk assessment and potential intervention for concerns identified through evaluation of family history, ethnicity, maternal age, medical and obstetric history, and associated psychosocial and nursing implications. Significant advances have emerged in the areas of cystic fibrosis carrier screening, first trimester screening, preimplantation genetic diagnosis, and detection and treatment of maternal thrombophilia.

Antepartum, intrapartum, and neonatal significance of exercise on healthy low-risk pregnant working women.

OBJECTIVE: To evaluate the influence of exercise on maternal and perinatal outcome in a low-risk healthy obstetric population. METHODS: We conducted a prospective observational study of low-risk healthy women exercising during their pregnancy. An extensive questionnaire collected antepartum, intrapartum, and postpartum patient information on 750 women. The women were divided into four groups based on exercise level during pregnancy. RESULTS: There were no differences among groups for maternal demographic characteristics, antenatal illnesses, stress, social support, or smoking. Heavily exercising women were older (P =.042), had higher incomes (P =.001), and were exercising more at conception (P =.001). Women who did more exercise were more likely to need an induction of labor (P =.033, relative risk 1.84, 95% confidence interval 1.05, 3.20), induction or augmentation with oxytocin (P =.015, relative risk 1.53, 95% confidence interval 1.19, 1.97), and had longer first-stage labors (P =.032) resulting in longer total labors (P =.011). The difference in the length of first-stage labor was even greater if the no-exercise group was compared with the strongly exercising group (P =.009, relative risk 1.38, 95% confidence interval 0.16, 2.60). Fewer umbilical cord abnormalities (P =.034) were observed with exercise, but exercising women had more colds and flu (P =.008). Heavily exercising women had smaller infants (mean difference 86.5 g) compared with sedentary women. CONCLUSION: Exercise in working women is associated with smaller babies, increased number of inductions and augmentations of labor, and longer labors. Colds and flu are more frequent in exercising women.