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Tivnan P, Setty BN, Howard E, Agarwal J, Farris CW, Wachman EM, Castro-Aragon I. Ultrasound evaluation of brain parenchyma in preterm infants with prenatal opioid exposure. J Perinatol 2024; 44:1119-1124. [PMID: 37863985 DOI: 10.1038/s41372-023-01804-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 09/30/2023] [Accepted: 10/09/2023] [Indexed: 10/22/2023]
Abstract
OBJECTIVE To evaluate whether preterm infants with prenatal opioid exposure had differences in brain size on head ultrasounds (HUS) in comparison to non-exposed infants. STUDY DESIGN Preterm infants ≤34 weeks with prenatal opioid exposure (n = 47) and matched non-exposed infants (n = 62) with early HUSs were examined. Fifteen brain measurements were made and linear regression models performed to evaluate differences. RESULTS Brain measurements were smaller in the right ventricular index [β = -0.18 mm (95% CI -0.32, -0.03]), left ventricular index [β = -0.04 mm (95% CI -0.08, -0.003)], left basal ganglia insula [β = -0.10 mm (95% CI -0.15, -0.04)], right basal ganglia insula [β = -0.08 mm (95% CI -0.14, -0.03)], corpus callosum fastigium length [β = -0.16 mm (95% CI -0.25, -0.06)], intracranial height index [β = -0.31 mm (95% CI -0.44, -0.18)], and transcerebellar measurements [β = -0.13 (95% CI -0.25, -0.02)] in the opioid-exposed group. CONCLUSIONS Preterm infants with prenatal opioid exposure have smaller brain sizes compared to non-exposed infants, potentially increasing their risk for neurodevelopmental abnormalities.
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Affiliation(s)
- Patrick Tivnan
- Department of Radiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
- Department of Radiology, Johns Hopkins University, 4940 Eastern Avenue, Baltimore, MD, 21224, USA.
| | - Bindu N Setty
- Department of Pediatric Radiology, Boston University Chobanian & Avedisian School of Medicine, 715 Albany Street, Boston, MA, 02118, USA
| | - Eileen Howard
- Boston University Chobanian & Avedisian School of Medicine, 715 Albany Street, Boston, MA, 02118, USA
| | - Joel Agarwal
- Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA
| | - Chad W Farris
- Department of Pediatric Radiology, Boston University Chobanian & Avedisian School of Medicine, 715 Albany Street, Boston, MA, 02118, USA
| | - Elisha M Wachman
- Department of Pediatrics, Boston University Chobanian & Avedisian School of Medicine, 715 Albany Street, Boston, MA, 02118, USA
| | - Ilse Castro-Aragon
- Department of Pediatric Radiology, Boston University Chobanian & Avedisian School of Medicine, 715 Albany Street, Boston, MA, 02118, USA
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Milos RI, Schmidbauer V, Watzenboeck ML, Stuhr F, Gruber GM, Mitter C, Dovjak GO, Milković-Periša M, Kostovic I, Jovanov-Milošević N, Kasprian G, Prayer D. T1-weighted fast fluid-attenuated inversion-recovery sequence (T1-FFLAIR) enables the visualization and quantification of fetal brain myelination in utero. Eur Radiol 2024; 34:4573-4584. [PMID: 38019312 PMCID: PMC11213743 DOI: 10.1007/s00330-023-10401-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 09/03/2023] [Accepted: 09/16/2023] [Indexed: 11/30/2023]
Abstract
OBJECTIVES To investigate the advantage of T1-weighted fast fluid-attenuated inversion-recovery MRI sequence without (T1-FFLAIR) and with compressed sensing technology (T1-FFLAIR-CS), which shows improved T1-weighted contrast, over standard used T1-weighted fast field echo (T1-FFE) sequence for the assessment of fetal myelination. MATERIALS AND METHODS This retrospective single-center study included 115 consecutive fetal brain MRI examinations (63 axial and 76 coronal, mean gestational age (GA) 28.56 ± 5.23 weeks, range 19-39 weeks). Two raters, blinded to GA, qualitatively assessed a fetal myelin total score (MTS) on each T1-weighted sequence at five brain regions (medulla oblongata, pons, mesencephalon, thalamus, central region). One rater performed region-of-interest quantitative analysis (n = 61) at the same five brain regions. Pearson correlation analysis was applied for correlation of MTS and of the signal intensity ratios (relative to muscle) with GA on each T1-weighted sequence. Fetal MRI-based results were compared with myelination patterns of postmortem fetal human brains (n = 46; GA 18 to 42), processed by histological and immunohistochemical analysis. RESULTS MTS positively correlated with GA on all three sequences (all r between 0.802 and 0.908). The signal intensity ratios measured at the five brain regions correlated best with GA on T1-FFLAIR (r between 0.583 and 0.785). T1-FFLAIR demonstrated significantly better correlations with GA than T1-FFE for both qualitative and quantitative analysis (all p < 0.05). Furthermore, T1-FFLAIR enabled the best visualization of myelinated brain structures when compared to histology. CONCLUSION T1-FFLAIR outperforms the standard T1-FFE sequence in the visualization of fetal brain myelination, as demonstrated by qualitative and quantitative methods. CLINICAL RELEVANCE STATEMENT T1-weighted fast fluid-attenuated inversion-recovery sequence (T1-FFLAIR) provided best visualization and quantification of myelination in utero that, in addition to the relatively short acquisition time, makes feasible its routine application in fetal MRI for the assessment of brain myelination. KEY POINTS • So far, the assessment of fetal myelination in utero was limited due to the insufficient contrast. • T1-weighted fast fluid-attenuated inversion-recovery sequence allows a qualitative and quantitative assessment of fetal brain myelination. • T1-weighted fast fluid-attenuated inversion-recovery sequence outperforms the standard used T1-weighted sequence for visualization and quantification of myelination in utero.
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Affiliation(s)
- Ruxandra-Iulia Milos
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Victor Schmidbauer
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Martin L Watzenboeck
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Friedrich Stuhr
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Gerlinde Maria Gruber
- Department of Anatomy and Biomechanics, Karl Landsteiner University of Health Sciences, 3500, Krems, Austria
| | - Christian Mitter
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Gregor O Dovjak
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Marija Milković-Periša
- Department of Pathology and Cytology, University Hospital Centre Zagreb, Petrova 13, 10000, Zagreb, Croatia
| | - Ivica Kostovic
- Croatian Institute for Brain Research, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Nataša Jovanov-Milošević
- Croatian Institute for Brain Research, School of Medicine, University of Zagreb, Zagreb, Croatia
- Department of Biology, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Gregor Kasprian
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Daniela Prayer
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Flores A, Nguyen NM, Devanaboyina M, Sanketh S, Athota P, Jagadesan S, Guda C, Yelamanchili SV, Pendyala G. Neurobehavioral Characterization of Perinatal Oxycodone-Exposed Offspring in Early Adolescence. J Neuroimmune Pharmacol 2024; 19:29. [PMID: 38874861 DOI: 10.1007/s11481-024-10129-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 05/25/2024] [Indexed: 06/15/2024]
Abstract
The opioid epidemic has received considerable attention, but the impact on perinatal opioid-exposed (POE) offspring remains underexplored. This study addresses the emerging public health challenge of understanding and treating POE children. We examined two scenarios using preclinical models: offspring exposed to oxycodone (OXY) in utero (IUO) and acute postnatal OXY (PNO). We hypothesized exposure to OXY during pregnancy primes offspring for neurodevelopmental deficits and severity of deficits is dependent on timing of exposure. Notable findings include reduced head size and brain weight in offspring. Molecular analyses revealed significantly lower levels of inflammasome-specific genes in the prefrontal cortex (PFC). Gene Set Enrichment Analysis (GSEA) and Ingenuity Pathway Analysis (IPA) highlighted the enrichment of genes associated with mitochondrial and synapse dysfunction in POE offspring. Western blot analysis validated IPA predictions of mitochondrial dysfunction in PFC-derived synaptosomes. Behavioral studies identified significant social deficits in POE offspring. This study presents the first comparative analysis of acute PNO- and IUO-offspring during early adolescence finding acute PNO-offspring have considerably greater deficits. The striking difference in deficit severity in acute PNO-offspring suggests that exposure to opioids in late pregnancy pose the greatest risk for offspring well-being.
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Affiliation(s)
- Adrian Flores
- Department of Anesthesiology, University of Nebraska Medical Center (UNMC), Omaha, NE, 68198, USA
- Department of Cellular and Integrative Physiology, UNMC, Omaha, NE, 68198, USA
| | - Nghi M Nguyen
- Department of Anesthesiology, University of Nebraska Medical Center (UNMC), Omaha, NE, 68198, USA
- Department of Genetics, Cell Biology and Anatomy, UNMC, Omaha, NE, 68198, USA
- Child Health Research Institute, Omaha, NE, 68198, USA
| | - Murali Devanaboyina
- Department of Anesthesiology, University of Nebraska Medical Center (UNMC), Omaha, NE, 68198, USA
| | - Samarth Sanketh
- Department of Anesthesiology, University of Nebraska Medical Center (UNMC), Omaha, NE, 68198, USA
| | - Pranavi Athota
- Department of Anesthesiology, University of Nebraska Medical Center (UNMC), Omaha, NE, 68198, USA
| | | | - Chittibabu Guda
- Department of Genetics, Cell Biology and Anatomy, UNMC, Omaha, NE, 68198, USA
| | - Sowmya V Yelamanchili
- Department of Anesthesiology, University of Nebraska Medical Center (UNMC), Omaha, NE, 68198, USA
- Department of Genetics, Cell Biology and Anatomy, UNMC, Omaha, NE, 68198, USA
- National Strategic Research Institute, UNMC, Omaha, NE, USA
| | - Gurudutt Pendyala
- Department of Anesthesiology, University of Nebraska Medical Center (UNMC), Omaha, NE, 68198, USA.
- Department of Genetics, Cell Biology and Anatomy, UNMC, Omaha, NE, 68198, USA.
- Child Health Research Institute, Omaha, NE, 68198, USA.
- National Strategic Research Institute, UNMC, Omaha, NE, USA.
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Kanervo M, Tupola S, Nikkola E, Rantakari K, Kahila H. Extended-release versus oral buprenorphine as opioid maintenance treatment during pregnancy-maternal and neonatal outcomes. Eur J Obstet Gynecol Reprod Biol 2024; 297:106-110. [PMID: 38608352 DOI: 10.1016/j.ejogrb.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 04/02/2024] [Accepted: 04/05/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVE To get information on subcutaneous extended-release buprenorphine as opioid maintenance treatment during pregnancy, we compared it to orally administered buprenorphine and buprenorphine-naloxone treatments. We hypothesized that maternal and neonatal outcomes do not differ between the treatment groups. Study design In this population-based cohort study, 60 pregnant individuals receiving non-changed opioid maintenance treatment for opioid use disorder with a buprenorphine product from the time before conception to the time after delivery and their newborns were included. They were divided into three groups based on the pharmacotherapy with subcutaneous extended-release buprenorphine, sublingual buprenorphine, or buprenorphine-naloxone. Statistical analyses were conducted using Fischer's exact tests, ANOVA tests, and Kruskal-Wallis tests. All the statistical tests were two-tailed. RESULTS The frequency of pregnancy or delivery complications did not significantly differ between the group receiving extended-release buprenorphine and the other groups. During pregnancy, 38 % of the women used illicit drugs concomitantly, with equal frequency in the extended-release buprenorphine group and the other groups. Of the neonates, 93 % were born full-term and 90 % got at least eight Apgar points in one minute age, without significant differences between the groups (p = 0.57). The need for pharmacotherapy for neonatal opioid withdrawal syndrome was the lowest in the extended-release buprenorphine group (25 %) and highest in the sublingual buprenorphine group (67 %). Still, the difference between the treatment groups did not reach statistical significance (p = 0.17). Among all neonates, the breastfed infants were less likely to receive pharmacotherapy for withdrawal symptoms than the formula-fed ones (p = 0.048). CONCLUSIONS Extended-release buprenorphine with steady drug concentration seems to be a promising pharmacotherapy option during pregnancy for mothers. Maternal health during pregnancy may contribute to the well-being of newborns. Larger trials are urgently needed to confirm these results..
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Affiliation(s)
- Minna Kanervo
- University of Helsinki Doctoral School, P.O. box 4, FI-00014 Helsinki, Finland; Children's Hospital, Pediatric Research Center, HUS Helsinki University Hospital and University of Helsinki, P.O. box 347, FI-00029 HUS, Helsinki, Finland.
| | - Sarimari Tupola
- Children's Hospital, Pediatric Research Center, HUS Helsinki University Hospital and University of Helsinki, P.O. box 347, FI-00029 HUS, Helsinki, Finland
| | - Eeva Nikkola
- Children's Hospital, Pediatric Research Center, HUS Helsinki University Hospital and University of Helsinki, P.O. box 347, FI-00029 HUS, Helsinki, Finland
| | - Krista Rantakari
- Children's Hospital, Pediatric Research Center, HUS Helsinki University Hospital and University of Helsinki, P.O. box 347, FI-00029 HUS, Helsinki, Finland
| | - Hanna Kahila
- Gynecology and Obstetrics, HUS Helsinki University Hospital and University of Helsinki, P.O. box 140, FI-00029 HUS, Helsinki, Finland
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Warner NS, Hanson AC, Schulte PJ, Kara F, Reid RI, Schwarz CG, Benarroch EE, Graff-Radford J, Vemuri P, Jack CR, Petersen RC, Warner DO, Mielke MM, Kantarci K. Prescription Opioids and Brain Structure in Community-Dwelling Older Adults. Mayo Clin Proc 2024; 99:716-726. [PMID: 38702125 PMCID: PMC11081533 DOI: 10.1016/j.mayocp.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 12/22/2023] [Accepted: 01/30/2024] [Indexed: 05/06/2024]
Abstract
OBJECTIVE To evaluate the associations between prescription opioid exposures in community-dwelling older adults and gray and white matter structure by magnetic resonance imaging. METHODS Secondary analysis was conducted of a prospective, longitudinal population-based cohort study employing cross-sectional imaging of older adult (≥65 years) enrollees between November 1, 2004, and December 31, 2017. Gray matter outcomes included cortical thickness in 41 structures and subcortical volumes in 6 structures. White matter outcomes included fractional anisotropy in 40 tracts and global white matter hyperintensity volumes. The primary exposure was prescription opioid availability expressed as the per-year rate of opioid days preceding magnetic resonance imaging, with a secondary exposure of per-year total morphine milligram equivalents (MME). Multivariable models assessed associations between opioid exposures and brain structures. RESULTS The study included 2185 participants; median (interquartile range) age was 80 (75 to 85) years, 47% were women, and 1246 (57%) received opioids. No significant associations were found between opioids and gray matter. Increased opioid days and MME were associated with decreased white matter fractional anisotropy in 15 (38%) and 16 (40%) regions, respectively, including the corpus callosum, posterior thalamic radiation, and anterior limb of the internal capsule, among others. Opioid days and MME were also associated with greater white matter hyperintensity volume (1.02 [95% CI, 1.002 to 1.036; P=.029] and 1.01 [1.001 to 1.024; P=.032] increase in the geometric mean, respectively). CONCLUSION The duration and dose of prescription opioids were associated with decreased white matter integrity but not with gray matter structure. Future studies with longitudinal imaging and clinical correlation are warranted to further evaluate these relationships.
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Affiliation(s)
- Nafisseh S Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
| | - Andrew C Hanson
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | - Firat Kara
- Department of Radiology, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | | | | - David O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Michelle M Mielke
- Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, NC
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Shore S, Lewis N, Olsen M. Rise in Neonatal Abstinence Syndrome Rate Is Associated with Increase in Buprenorphine Prescription Numbers. South Med J 2023; 116:930-937. [PMID: 38051165 DOI: 10.14423/smj.0000000000001634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
OBJECTIVES Southern Appalachia is a region of the United States that is disproportionately affected by the opioid epidemic and by increasing rates of neonatal abstinence syndrome (NAS). NAS rates increased approximately 400% between 1999 and 2012. Buprenorphine prescriptions written to treat opioid use disorder also increased dramatically. The present study was undertaken to ascertain any relationship between the number of buprenorphine prescriptions compared with NAS rates in southern Appalachia. METHODS A total of 250 southern Appalachian counties across seven states, including all of West Virginia and portions of Virginia, Kentucky, Maryland, North Carolina, Ohio, and Tennessee were identified. A retrospective cohort analysis of these counties was conducted for the years 2005-2018. All of the data were obtained from publicly accessible sources or direct communication with government offices. Measures from each county in southern Appalachia included annual NAS rates, buprenorphine prescription rates, drug-induced death rates, and opioid prescribing rates. Associations among these variables were examined using a generalized linear regression. RESULTS Significant linear associations exist between the rising rate of NAS diagnoses and the rising rate of buprenorphine prescriptions (r = 0.977, R2 = 95.53%, P < 0.001) and between the rising rate of buprenorphine prescriptions and the increase in drug-induced deaths (r = 0.712, R2 = 50.82%, P = 0.031). CONCLUSIONS This is the first report that documents an association between rising NAS rates and increasing buprenorphine prescribing. Between the years 2010 and 2018, the NAS rate in southern Appalachia rose by 335%, and the number of buprenorphine prescriptions rose by 413%. Discussions regarding the current policies for buprenorphine management during pregnancy are warranted. We suggest a reevaluation of buprenorphine prescribing recommendations during pregnancy and further research on establishing the lowest effective buprenorphine dose for each pregnant patient.
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Affiliation(s)
| | - Nicole Lewis
- Department of Medical Education, James H. Quillen College of Medicine
| | - Martin Olsen
- Department of Obstetrics/Gynecology, James H. Quillen College of Medicine, East Tennessee State University, Johnson City
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Turner S, Allen VM, Carson G, Graves L, Tanguay R, Green CR, Cook JL. Guideline No. 443b: Opioid Use Throughout Women's Lifespan: Opioid Use in Pregnancy and Breastfeeding. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102144. [PMID: 37977721 DOI: 10.1016/j.jogc.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
OBJECTIVE To provide health care providers the best evidence on opioid use and women's health. Areas of focus include pregnancy and postpartum care. TARGET POPULATION The target population includes all women currently using or contemplating using opioids. OUTCOMES Open, evidence-informed dialogue about opioid use will improve patient care. BENEFITS, HARMS, AND COSTS Exploring opioid use through a trauma-informed approach provides the health care provider and patient with an opportunity to build a strong, collaborative, and therapeutic alliance. This alliance empowers women to make informed choices about their own care. It also allows for the diagnosis and possible treatment of opioid use disorders. Opioid use should not be stigmatized, as stigma leads to poor "partnered care" (i.e., the partnership between the patient and care provider). Health care providers need to understand the effect opioids can have on pregnant women and support them to make knowledgeable decisions about their health. EVIDENCE A literature search was designed and carried out in PubMed and the Cochrane Library databases from August 2018 until March 2023 using following MeSH terms and keywords (and variants): opioids, opioid agonist therapy, illicit drugs, fertility, pregnancy, fetal development, neonatal abstinence syndrome, and breastfeeding. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE All health care providers who care for pregnant and/or post-partum women and their newborns. TWEETABLE ABSTRACT Opioid use during pregnancy often co-occurs with mental health issues and is associated with adverse maternal, fetal, and neonatal outcomes; treatment of opioid use disorder with agonist therapy for pregnant women can be safe during pregnancy where the risks outnumber the benefits. SUMMARY STATEMENTS RECOMMENDATIONS.
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Turner S, Allen VM, Carson G, Graves L, Tanguay R, Green CR, Cook JL. Directive clinique n o 443b : Opioïdes aux différentes étapes de la vie des femmes : Grossesse et allaitement. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102146. [PMID: 37977719 DOI: 10.1016/j.jogc.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
OBJECTIF Présenter aux professionnels de la santé les données probantes concernant l'utilisation des opioïdes et la santé des femmes. Les domaines d'intérêt sont la grossesse et les soins post-partum. POPULATION CIBLE Toutes les femmes qui utilisent des opioïdes. RéSULTATS: Un dialogue ouvert et éclairé sur l'utilisation des opioïdes améliorera les soins aux patientes. BéNéFICES, RISQUES ET COûTS: L'exploration de l'utilisation d'opioïdes par une approche tenant compte des traumatismes antérieurs donne au professionnel de la santé et à la patiente l'occasion de bâtir une alliance solide, collaborative et thérapeutique. Cette alliance permet aux femmes de faire des choix éclairés. Elle favorise le diagnostic et le traitement possible du trouble lié à l'utilisation d'opioïdes. L'utilisation ne doit pas être stigmatisée, puisque la stigmatisation affaiblit le partenariat (le partenariat entre patiente et professionnel de la santé). Les professionnels de la santé ceus-ci doivent comprendre l'effet potentiel des opioïdes sur la santé les femmes enceintes et les aider à prendre des décisions éclairées sur leur santé. DONNéES PROBANTES: Une recherche a été conçue puis effectuée dans les bases de données PubMed et Cochrane Library pour la période d'août 2018 à mars 2023 des termes MeSH et mots clés suivants (et variantes) : opioids, opioid agonist therapy, illicit drugs, fertility, pregnancy, fetal development, neonatal abstinence syndrome et breastfeeding. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Tous les professionnels de la santé qui prodiguent des soins aux femmes et aux nouveaux-nés. RéSUMé POUR TWITTER: La consommation d'opioïdes pendant la grossesse coïncide souvent avec des problèmes de santé mentale et est associée à des conséquences néfastes pour la mère, le fœtus et le nouveau-né ; le traitement des troubles liés à la consommation d'opioïdes par agonistes peut être sûr pendant la grossesse lorsque les risques sont plus nombreux que les avantages. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.
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Bloch-Salisbury E, Wilson JD, Rodriguez N, Bruch T, McKenna L, Derbin M, Glidden B, Ayturk D, Aurora S, Yanowitz T, Barton B, Vining M, Beers SR, Bogen DL. Efficacy of a Vibrating Crib Mattress to Reduce Pharmacologic Treatment in Opioid-Exposed Newborns: A Randomized Clinical Trial. JAMA Pediatr 2023; 177:665-674. [PMID: 37184872 PMCID: PMC10186209 DOI: 10.1001/jamapediatrics.2023.1077] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 03/09/2023] [Indexed: 05/16/2023]
Abstract
Importance Pharmacologic agents are often used to treat newborns with prenatal opioid exposure (POE) despite known adverse effects on neurodevelopment. Alternative nonpharmacological interventions are needed. Objective To examine efficacy of a vibrating crib mattress for treating newborns with POE. Design, Setting, and Participants In this dual-site randomized clinical trial, 208 term newborns with POE, enrolled from March 9, 2017, to March 10, 2020, were studied at their bedside throughout hospitalization. Interventions Half the cohort received treatment as usual (TAU) and half received standard care plus low-level stochastic (random) vibrotactile stimulation (SVS) using a uniquely constructed crib mattress with a 3-hour on-off cycle. Study initiated in the newborn unit where newborns were randomized to TAU or SVS within 48 hours of birth. All infants whose symptoms met clinical criteria for pharmacologic treatment received morphine in the neonatal intensive care unit per standard care. Main Outcomes and Measures The a priori primary outcomes analyzed were pharmacotherapy (administration of morphine treatment [AMT], first-line medication at both study sites [number of infants treated], and cumulative morphine dose) and hospital length of stay. Intention-to-treat analysis was conducted. Results Analyses were performed on 181 newborns who completed hospitalization at the study sites (mean [SD] gestational age, 39.0 [1.2] weeks; mean [SD] birth weight, 3076 (489) g; 100 [55.2%] were female). Of the 181 analyzed infants, 121 (66.9%) were discharged without medication and 60 (33.1%) were transferred to the NICU for morphine treatment (31 [51.7%] TAU and 29 [48.3%] SVS). Treatment rate was not significantly different in the 2 groups: 35.6% (31 of 87 infants who received TAU) and 30.9% (29 of 94 infants who received SVS) (P = .60). Adjusting for site, sex, birth weight, opioid exposure, and feed type, infant duration on the vibrating mattress in the newborn unit was associated with reduction in AMT (adjusted odds ratio, 0.88 hours per day; 95% CI, 0.81-0.93 hours per day). This translated to a 50% relative reduction in AMT for infants who received SVS on average 6 hours per day. Among 32 infants transferred to the neonatal intensive care unit for morphine treatment who completed treatment within 3 weeks, those assigned to SVS finished treatment nearly twice as fast (hazard ratio, 1.96; 95% CI, 1.01-3.81), resulting in 3.18 fewer treatment days (95% CI, -0.47 to -0.04 days) and receiving a mean 1.76 mg/kg less morphine (95% CI, -3.02 to -0.50 mg/kg) than the TAU cohort. No effects of condition were observed among infants treated for more than 3 weeks (n = 28). Conclusions and Relevance The findings of this clinical trial suggest that SVS may serve as a complementary nonpharmacologic intervention for newborns with POE. Reducing pharmacotherapy with SVS has implications for reduced hospitalization stays and costs, and possibly improved infant outcomes given the known adverse effects of morphine on neurodevelopment. Trial Registration ClinicalTrials.gov Identifier: NCT02801331.
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Affiliation(s)
- Elisabeth Bloch-Salisbury
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Pediatrics, University of Massachusetts Chan School of Medicine, Worcester
| | - James D. Wilson
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Nicolas Rodriguez
- Department of Pediatrics, University of Massachusetts Chan School of Medicine, Worcester
| | - Tory Bruch
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Lauren McKenna
- Department of Pediatrics, University of Massachusetts Chan School of Medicine, Worcester
| | - Matthew Derbin
- Department of Pediatrics, University of Massachusetts Chan School of Medicine, Worcester
| | - Barbara Glidden
- Department of Pediatrics, University of Massachusetts Chan School of Medicine, Worcester
| | - Didem Ayturk
- Department of Quantitative and Health Sciences, University of Massachusetts Chan School of Medicine, Worcester
| | - Sanjay Aurora
- Department of Pediatrics, University of Massachusetts Chan School of Medicine, Worcester
| | - Toby Yanowitz
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Bruce Barton
- Department of Quantitative and Health Sciences, University of Massachusetts Chan School of Medicine, Worcester
| | - Mark Vining
- Department of Pediatrics, University of Massachusetts Chan School of Medicine, Worcester
| | - Sue R. Beers
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Debra L. Bogen
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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10
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Sanjanwala AR, Lim G, Krans EE. Opioids and Opioid Use Disorder in Pregnancy. Obstet Gynecol Clin North Am 2023; 50:229-240. [PMID: 36822706 DOI: 10.1016/j.ogc.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
Overdose is a leading cause of pregnancy-associated morbidity and mortality in the United States. As such, all obstetric providers have a responsibility to provide evidence-based care for patients with opioid use disorder to mitigate adverse outcomes associated with substance use during pregnancy.
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Affiliation(s)
- Aalok R Sanjanwala
- Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Maternal-Fetal Medicine, University of Pittsburgh School of Medicine, 300 Halket Street Pittsburgh, PA 15213, USA
| | - Grace Lim
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, 300 Halket Street, Pittsburgh, PA 15213, USA; Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh School of Medicine, 300 Halket Street, Pittsburgh, PA 15213, USA
| | - Elizabeth E Krans
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh School of Medicine, Magee-Womens Research Institute, 300 Halket Street, Pittsburgh, PA 15213, USA.
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11
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Chin EM, Kitase Y, Madurai NK, Robinson S, Jantzie LL. In utero methadone exposure permanently alters anatomical and functional connectivity: A preclinical evaluation. Front Pediatr 2023; 11:1139378. [PMID: 36911026 PMCID: PMC9995894 DOI: 10.3389/fped.2023.1139378] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 02/03/2023] [Indexed: 02/25/2023] Open
Abstract
The opioid epidemic is an ongoing public health crisis, and children born following prenatal opioid exposure (POE) have increased risk of long-term cognitive and behavioral sequelae. Clinical studies have identified reduced gray matter volume and abnormal white matter microstructure in children with POE but impacts on whole-brain functional brain connectivity (FC) have not been reported. To define effects of POE on whole brain FC and white matter injury in adult animals, we performed quantitative whole-brain structural and functional MRI. We used an established rat model of POE in which we have previously reported impaired executive function in adult rats analogous to persistent neurocognitive symptoms described in humans with POE. Pregnant Sprague-Dawley rat dams received continuous methadone (12 mg/kg/day) vs. saline infusion for 28 days via osmotic mini-pumps, exposing rats to pre- and postnatal opioid until weaning. At young adult age (P60), POE and saline exposed offspring underwent in vivo MRI included diffusion tensor imaging and functional MRI (fMRI). Results indicate that fractional anisotropy (FA) was decreased in adult animals with POE [n = 11] compared to animals that received saline [n = 9] in major white matter tracts, including the corpus callosum (p < 0.001) and external capsule (p < 0.01). This change in FA was concomitant with reduced axial diffusivity in the external capsule (p < 0.01) and increased radial diffusivity in the corpus callosum (p < 0.01). fMRI analyses reveal brainwide FC was diffusely lower in POE (p < 10-6; 10% of variance explained by group). Decreased connectivity in cortical-cortical and cortico-basal ganglia circuitry was particularly prominent with large effect sizes (Glass's Δ > 1). Taken together, these data confirm POE reduces brainwide functional connectivity as well as microstructural integrity of major white matter tracts. Altered neural circuitry, dysregulated network refinement, and diffuse network dysfunction have been implicated in executive function deficits that are common in children with POE. FC may serve as a translatable biomarker in children with POE.
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Affiliation(s)
- Eric M. Chin
- Department of Neurodevelopmental Medicine, Phelps Center for Cerebral Palsy and Neurodevelopmental Medicine, Kennedy Krieger Institute, Baltimore, MD, United States
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Yuma Kitase
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Nethra K. Madurai
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Shenandoah Robinson
- Department of Neurodevelopmental Medicine, Phelps Center for Cerebral Palsy and Neurodevelopmental Medicine, Kennedy Krieger Institute, Baltimore, MD, United States
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Lauren L. Jantzie
- Department of Neurodevelopmental Medicine, Phelps Center for Cerebral Palsy and Neurodevelopmental Medicine, Kennedy Krieger Institute, Baltimore, MD, United States
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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12
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Miller FA, Sacco A, David AL, Boyle AK. Interventions for Infection and Inflammation-Induced Preterm Birth: a Preclinical Systematic Review. Reprod Sci 2023; 30:361-379. [PMID: 35426035 PMCID: PMC9988807 DOI: 10.1007/s43032-022-00934-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 04/02/2022] [Indexed: 12/09/2022]
Abstract
Spontaneous preterm births (< 37 weeks gestation) are frequently associated with infection. Current treatment options are limited but new therapeutic interventions are being developed in animal models. In this PROSPERO-registered preclinical systematic review, we aimed to summarise promising interventions for infection/inflammation-induced preterm birth. Following PRISMA guidance, we searched PubMed, EMBASE, and Web of Science using the themes: "animal models", "preterm birth", "inflammation", and "therapeutics". We included original quantitative, peer-reviewed, and controlled studies applying prenatal interventions to prevent infection/inflammation-induced preterm birth in animal models. We employed two risk of bias tools. Of 4020 identified studies, 23 studies (24 interventions) met our inclusion criteria. All studies used mouse models. Preterm birth was most commonly induced by lipopolysaccharide (18 studies) or Escherichia coli (4 studies). Models varied according to infectious agent serotype, dose, and route of delivery. Gestational length was significantly prolonged in 20/24 interventions (83%) and markers of maternal inflammation were reduced in 20/23 interventions (87%). Interventions targeting interleukin-1, interleukin-6, and toll-like receptors show particular therapeutic potential. However, due to the heterogeneity of the methodology of the included studies, meta-analysis was impossible. All studies were assigned an unclear risk of bias using the SYRCLE risk of bias tool. Interventions targeting inflammation demonstrate therapeutic potential for the prevention of preterm birth. However, better standardisation of preterm birth models, including the dose, serotype, timing of administration and pathogenicity of infectious agent, and outcome reporting is urgently required to improve the reproducibility of preclinical studies, allow meaningful comparison of intervention efficacy, and aid clinical translation.
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Affiliation(s)
- Faith A Miller
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, 86-96 Chenies Mews, London, WC1E 6HX, UK
| | - Adalina Sacco
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, 86-96 Chenies Mews, London, WC1E 6HX, UK
| | - Anna L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, 86-96 Chenies Mews, London, WC1E 6HX, UK
- National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, UK
| | - Ashley K Boyle
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, 86-96 Chenies Mews, London, WC1E 6HX, UK.
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13
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Zamani N, Osgoei LT, Aliaghaei A, Zamani N, Hassanian-Moghaddam H. Chronic exposure to methadone induces activated microglia and astrocyte and cell death in the cerebellum of adult male rats. Metab Brain Dis 2023; 38:323-338. [PMID: 36287354 DOI: 10.1007/s11011-022-01108-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/13/2022] [Indexed: 02/03/2023]
Abstract
Methadone is a centrally-acting synthetic opioid analgesic widely used in the methadone maintenance therapy (MMT) programs throughout the world. Considering its neurotoxic effects particularly on the cerebellum, this study aims to address the behavioral and histological alterations in the cerebellar cortex associated with methadone administration. Twenty-four adult male albino rats were randomized into two groups of control and methadone treatment. Methadone was subcutaneously administered (2.5-10 mg/kg) once a day for two consecutive weeks. The functional and structural changes in the cerebellum were compared to the control group. Our data revealed that treating rats with methadone not only induced cerebellar atrophy, but also prompted the actuation of microgliosis, astrogliosis, and apoptotic biomarkers. We further demonstrated that treating rats with methadone increased complexity of astrocyte processes and decreased complexity of microglia processes. Our result showed that methadone impaired motor coordination and locomotor performance and neuromuscular activity. Additionally, relative gene expression of TNF-α, caspase-3 and RIPK3 increased significantly due to methadone. Our findings suggest that methadone administration has a neurodegenerative effect on the cerebellar cortex via dysregulation of microgliosis, astrogliosis, apoptosis, and neuro-inflammation.
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Affiliation(s)
- Naghmeh Zamani
- Department of Biology, Faculty of Biological Science, North Tehran Branch, Islamic Azad University, Tehran, Iran
| | - Laya Takbiri Osgoei
- Department of Microbiology, Faculty of Biological Science, North Tehran Branch, Islamic Azad University, Tehran, Iran.
| | - Abbas Aliaghaei
- Hearing Disorders Research Center, Loghman-Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
- Department of Biology and Anatomical Sciences, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Nasim Zamani
- Department of Clinical Toxicology, Loghman-Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hossein Hassanian-Moghaddam
- Department of Clinical Toxicology, Loghman-Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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14
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Benninger KL, Richard C, Conroy S, Newton J, Taylor HG, Sayed A, Pietruszewski L, Nelin MA, Batterson N, Maitre NL. One-Year Neurodevelopmental Outcomes After Neonatal Opioid Withdrawal Syndrome: A Prospective Cohort Study. PERSPECTIVES OF THE ASHA SPECIAL INTEREST GROUPS 2022; 7:1019-1032. [PMID: 36211832 PMCID: PMC9539823 DOI: 10.1044/2022_persp-21-00270] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Purpose The aims of this study were, in a cohort of children with neonatal opioid withdrawal syndrome (NOWS), (a) to report 1-year neurodevelopmental outcomes and specifically characterize speech, language, and hearing outcomes and (b) to report the prevalence of cleft lip and/or cleft palate. Method This prospective observational cohort study includes newborns with confirmed in utero opioid exposure who received pharmacological treatment for NOWS. During 1-year-old developmental visits, we administered standardized assessments (Bayley Scales of Infant and Toddler Development-Third Edition [Bayley-III] or Developmental Assessment of Young Children-Second Edition [DAYC-2]-due to COVID-19 restrictions). We compared Bayley-III scores to standardized population means using one-sample z tests. We report estimates, 95% confidence intervals, and two-sided p values. Results We enrolled 202 infants (October 2018 to March 2020). Follow-up at 1-year was 80%. Infants with NOWS had lower Bayley-III scores at 1 year compared to published norms for cognitive, language, and motor domains. One infant with NOWS was diagnosed with isolated cleft palate and Pierre Robin sequence. All infants passed the newborn hearing screen, and 7.5% had a formal hearing evaluation after neonatal intensive care unit discharge, with 40% having abnormal or inconclusive results; middle ear effusion was the leading cause of abnormal hearing (66.7%). Ten percent of children received a speech-language pathology referral prior to 2 years of age. Infants born to mothers with mental health conditions were more likely to have Bayley-III or DAYC-2 scores below 95 in language or motor domains. Conclusions Infants with pharmacologically treated NOWS have significantly lower cognitive, language, and motor scores on standardized developmental testing compared to population means at 1 year of age. Early speech-language pathology referral is frequently necessary to promote optimal development in this population. Supplemental Material https://doi.org/10.23641/asha.20044403.
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Affiliation(s)
- Kristen L. Benninger
- Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University Wexner Medical Center, Columbus
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH
| | - Celine Richard
- Department of Otolaryngology, The University of Tennessee Health Science Center College of Medicine, Memphis
- Department of Otolaryngology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Sara Conroy
- Biostatistics Core, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus
| | - Julia Newton
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH
| | - H. Gerry Taylor
- Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University Wexner Medical Center, Columbus
- Center for Biobehavioral Health, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH
| | - Alaisha Sayed
- Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University Wexner Medical Center, Columbus
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH
| | - Lindsay Pietruszewski
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH
| | - Mary Ann Nelin
- Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University Wexner Medical Center, Columbus
| | - Nancy Batterson
- Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University Wexner Medical Center, Columbus
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH
| | - Nathalie L. Maitre
- Department of Pediatrics, Emory University and Children’s Healthcare of Atlanta, GA
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15
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Benninger KL, Peng J, Ho ML, Newton J, Wang DJJ, Hu HH, Stark AR, Rusin JA, Maitre NL. Cerebral perfusion and neurological examination characterise neonatal opioid withdrawal syndrome: a prospective cohort study. Arch Dis Child Fetal Neonatal Ed 2022; 107:414-420. [PMID: 34725106 DOI: 10.1136/archdischild-2021-322192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 10/15/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To test the hypothesis that cerebral blood flow (CBF) assessed with arterial spin labelling (ASL) MRI is increased and standardised neurological examination is altered in infants with neonatal opioid withdrawal syndrome (NOWS) compared with those without. DESIGN Prospective cohort study. SETTING Level IV neonatal intensive care unit and outpatient primary care centre. PARTICIPANTS Infants with NOWS receiving pharmacological treatment and unexposed controls matched for gestational age at birth and post-menstrual age at MRI. MAIN OUTCOMES CBF assessed by ASL on non-sedated 3-Tesla MRI and standardised Hammersmith Neonatal Neurological Examination (HNNE) within 14 days of birth. RESULTS Thirty infants with NOWS and 31 control infants were enrolled and included in the final analysis. Global CBF across the brain was higher in the NOWS group compared with controls (14.2 mL/100 g/min±5.5 vs 10.7 mL/100 g/min±4.3, mean±SD, Cohen's d=0.72). HNNE total optimality score was lower in the NOWS group compared with controls (25.9±3.6 vs 28.4±2.4, mean±SD, Cohen's d=0.81). A penalised logistic regression model including both CBF and HNNE items discriminated best between the two groups. CONCLUSIONS Increased cerebral perfusion and neurological examination abnormalities characterise infants with NOWS compared with those without intrauterine drug exposure and suggest prenatal substance exposure affects fetal brain development. Identifying neurological and neuroimaging characteristics of infants with NOWS can contribute to understanding mechanisms underlying later outcomes and to designing potential new treatments.
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Affiliation(s)
- Kristen L Benninger
- Department of Pediatrics and Neonatology, Nationwide Children's Hospital, Columbus, Ohio, USA .,Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jin Peng
- Research Information Solutions and Innovation Research & Development, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Mai-Lan Ho
- Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Julia Newton
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Danny J J Wang
- Stevens Neuroimaging and Informatics Institute, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Houchun H Hu
- Department of Radiology, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Ann R Stark
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jerome A Rusin
- Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio, USA
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16
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English F, Greyson D. "You still have that fear": Policy constraints on informed decision making about legalized cannabis use during pregnancy and lactation. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 106:103774. [PMID: 35772267 DOI: 10.1016/j.drugpo.2022.103774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 06/14/2022] [Accepted: 06/20/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Cannabis is the most commonly used drug during pregnancy, excluding alcohol and tobacco, in the United States. Cannabis consumption during pregnancy is increasing along with greater legal and social acceptance. METHODS We conducted a qualitative content analysis of 23 in-depth interviews with pregnant and lactating people in Massachusetts, a state that legalized cannabis for adult use in 2016. Our aim was to explore how policy constrains or facilitates people's ability to make informed decisions about cannabis use during pregnancy and lactation. Our analysis was conducted using an ecosocial approach, recognizing that the implementation and interpretation of cannabis policy can be understood at multiple levels, which interact with each other and shape the health and experiences of individuals. Additionally, this analysis was informed by a harm reduction approach in which we acknowledge the complexity surrounding cannabis use during pregnancy and lactation, while attempting to identify ways to reduce potentially harmful consequences. RESULTS Findings revealed that, despite the legal status of cannabis, there continues to be a lack of clarity for pregnant and lactating people regarding the legal implications of cannabis use. Inconsistent state and institutional policies about drug testing of mothers and newborns leave a cloud of fear hanging over the experiences of people who use cannabis and inhibit their ability to obtain expert advice from healthcare providers. CONCLUSION Decision makers in public and institutional policy should work to clarify and update policies regarding substance use during pregnancy following legalization of a new substance, and ensure that pregnant and lactating people are afforded the same legal protections as the general population.
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Affiliation(s)
- Faith English
- Department of Health Promotion and Policy 325 Arnold House, School of Public Health & Health Sciences, University of Massachusetts Amherst, 715 North Pleasant St. Amherst, MA, 01003, USA.
| | - Devon Greyson
- Department of Communication N308 Integrative Learning Center 650 N. Pleasant St. University of Massachusetts Amherst, Amherst, MA, 01003, USA.
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17
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BENNINGER KRISTENL, PURNELL JESSICA, CONROY SARA, JACKSON KENNETH, BATTERSON NANCY, NEEL MARYLAUREN, HESTER MARKE, MAITRE NATHALIEL. Intrauterine drug exposure as a risk factor for cerebral palsy. Dev Med Child Neurol 2022; 64:453-461. [PMID: 34528707 PMCID: PMC8897226 DOI: 10.1111/dmcn.15050] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 07/28/2021] [Accepted: 08/02/2021] [Indexed: 11/30/2022]
Abstract
AIM To determine whether infants with intrauterine drug exposure (IUDE) are similarly at risk for cerebral palsy (CP) as other high-risk populations, whether CP classification differs based on IUDE status, and describe the association of CP with specific substances among exposed infants. METHOD This was a retrospective analysis of infants in a high-risk follow-up program (n=5578) between January 2014 and February 2018 with a history of IUDE or who received a CP diagnosis. CP rates were compared using two-sample z-tests. CP classification was assessed using Fisher's exact, Cochran-Armitage, and Wilcoxon rank-sum tests. Models for CP risk were assessed using multivariable logistic regression. RESULTS Among all infants with IUDE (n=1086), 53.8% were male with a mean (SD) birth gestational age of 36.8 (3.6) weeks. Among unexposed infants with CP (n=259), 54.4% were male with a mean (SD) birth gestational age of 29.9 (5.7) weeks. Opioids were the most common exposure (93.7%) of all infants with IUDE. The CP rate in the IUDE (5.2%) and unexposed (5.7%) high-risk populations were not significantly different (p=0.168), nor were there differences in CP typology, topography, or severity between exposed (n=57) and unexposed (n=259) infants (all p>0.05). In patients with IUDE and after controlling for established CP risk factors, the observed odds of CP varied among substances. INTERPRETATION We suggest that IUDE should be considered a 'newborn-detectable risk' in the guidelines for the early detection of CP.
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Affiliation(s)
- KRISTEN L BENNINGER
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH,Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University Wexner Medical Center, Columbus, OH
| | - JESSICA PURNELL
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH
| | - SARA CONROY
- Biostatistics Core, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH,Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - KENNETH JACKSON
- Biostatistics Core, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH,Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - NANCY BATTERSON
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH,Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University Wexner Medical Center, Columbus, OH
| | - MARY LAUREN NEEL
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH,Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University Wexner Medical Center, Columbus, OH
| | - MARK E HESTER
- Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University Wexner Medical Center, Columbus, OH,The Steve and Cindy Rasmussen Institute for Genomic Medicine, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH
| | - NATHALIE L MAITRE
- Department of Pediatrics, Emory University and Children’s Healthcare of Atlanta, Atlanta, GA, USA
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18
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Etemadi-Aleagha A, Akhgari M. Psychotropic drug abuse in pregnancy and its impact on child neurodevelopment: A review. World J Clin Pediatr 2022; 11:1-13. [PMID: 35096542 PMCID: PMC8771314 DOI: 10.5409/wjcp.v11.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/21/2021] [Accepted: 11/29/2021] [Indexed: 02/06/2023] Open
Abstract
Substance abuse by women of child-bearing age and fetal in utero drug exposure has increased in the number of infants born with health issues. Prenatal exposure to psychoactive substances can lead to neurological and neurodevelopmental deficits later in life. Useful data concerning the effects of psychoactive drugs on fetal neurodevelopmental status are sparse. Understanding the neurodevelopmental consequences of prenatally drug-exposed children has become a pressing global concern. The aim of this review is to gather current evidence and information on neurodevelopmental outcomes of in utero drug exposure. A literature search was performed on the PubMed, Scopus, and Google Scholar databases using the terms “psychotropic drugs”, “neurodevelopmental consequences”, “prenatal drug exposure”, and “pregnancy”. Available studies on in utero drug exposure were reviewed and found to support the idea that some degree of health issues are present in fetuses and children. Different psychoactive substances have profound neurodevelopmental consequences, such as structural brain changes, poor attention span, Down syndrome, attention deficit hyperactivity disorder, autism spectrum disorder, imbalances in neurotransmitter levels, and many structural deficits. The pervasive use of psychoactive drugs in women of child-bearing age is an important health concern. Further scientific efforts are needed to investigate the effect of prenatal exposure to psychoactive drugs on children.
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Affiliation(s)
- Afshar Etemadi-Aleagha
- Department of Anesthesiology and Intensive Care, Tehran University of Medical Sciences, Tehran 1145765111, Iran
| | - Maryam Akhgari
- Legal Medicine Research Center, Legal Medicine Organization, Tehran 1114795113, Iran
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19
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Krans EE, Kim JY, Chen Q, Rothenberger SD, James AE, Kelley D, Jarlenski MP. Outcomes associated with the use of medications for opioid use disorder during pregnancy. Addiction 2021; 116:3504-3514. [PMID: 34033170 PMCID: PMC8578145 DOI: 10.1111/add.15582] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 01/28/2021] [Accepted: 05/12/2021] [Indexed: 12/18/2022]
Abstract
AIM To test the effect of the duration of medication for opioid use disorder (MOUD) use during pregnancy on maternal, perinatal and neonatal outcomes. DESIGN Retrospective cohort analysis of claims, encounter and pharmacy data. SETTING Pennsylvania, USA. PARTICIPANTS We analyzed 13 320 pregnancies among 10 741 women with opioid use disorder aged 15-44 years enrolled in Pennsylvania Medicaid between 2009 and 2017. MEASUREMENTS We examined five outcomes during pregnancy and for 12 weeks postpartum: (1) overdose, (2) postpartum MOUD continuation, (3) preterm birth (< 37 weeks gestation), (4) term low birth weight (< 2500 g at ≥ 37 weeks) and (5) neonatal abstinence syndrome (NAS). Our primary exposure was the duration (count of weeks) of any MOUD use, including methadone or buprenorphine, during pregnancy. FINDINGS Among 13 320 pregnancies, 306 (2.3%) were complicated by an overdose, 1753 (13.2%) resulted in a preterm birth and 6787 (50.9%) continued MOUD postpartum. Among infants, 874 (7.6%) were low birth weight at term and 7706 (57.9%) were diagnosed with NAS. As the duration of MOUD use increased, we found a statistically significant decrease in the rate of overdose and preterm birth, a statistically significant increase in the rate of postpartum MOUD continuation and NAS and a decline in term low birth weight. Specifically, for each additional week of MOUD, the adjusted odds of overdose decreased by 2% [adjusted odds ratio (aOR) = 0.98; 95% confidence interval (CI) = 0.97, 0.99], preterm birth decreased by 1% (aOR = 0.99; 95% CI = 0.99, 1.00), postpartum MOUD continuation increased by 95% (aOR = 1.95; 95% CI = 1.87, 2.04) and NAS increased by 41% (aOR = 1.41; 95% CI = 1.35, 1.47). The odds of term low birth weight did not change (aOR = 1.00; 95% CI = 0.99, 1.00), although the rate declined with a longer duration of MOUD use during pregnancy. CONCLUSIONS Longer duration of medication for opioid use disorder use during pregnancy appears to be associated with improved maternal and perinatal outcomes.
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Affiliation(s)
- Elizabeth E. Krans
- Department of Obstetrics, Gynecology & Reproductive Sciences, Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joo Yeon Kim
- Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Qingwen Chen
- Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Scott D. Rothenberger
- Center for Research on Health Care Data Center, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alton Everette James
- Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David Kelley
- Pennsylvania Department of Human Services, Harrisburg, Pennsylvania
| | - Marian P. Jarlenski
- Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, Pennsylvania
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Trønnes JN, Lupattelli A, Handal M, Skurtveit S, Ystrom E, Nordeng H. Association of Timing and Duration of Prenatal Analgesic Opioid Exposure With Attention-Deficit/Hyperactivity Disorder in Children. JAMA Netw Open 2021; 4:e2124324. [PMID: 34524436 PMCID: PMC8444023 DOI: 10.1001/jamanetworkopen.2021.24324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Prior studies have reported that the use of illicit opioids during pregnancy is associated with increased risk of attention-deficit/hyperactivity disorder (ADHD) in offspring; however, evidence regarding the association of analgesic opioids is limited. OBJECTIVE To examine the association of timing and duration of prenatal analgesic opioid exposure with ADHD in children. DESIGN, SETTING, AND PARTICIPANTS This cohort study uses data from the Norwegian Mother, Father and Child Cohort study (1999-2008), a nationwide birth cohort study linked to national health registries, with a mean (SD) follow-up of 10.8 (2.2) years. A total of 73 784 live-born singleton children born to 62 013 mothers who reported a pain-related condition before and/or during pregnancy were included, with 2 comparator groups: (1) mothers who did not use any opioids and (2) mothers who used opioids before pregnancy only. Data were analyzed from June to December 2020. EXPOSURES Maternal self-report of analgesic opioid use during pregnancy, by timing (early and middle and/or late) and duration (≥5 weeks vs ≤4 weeks). MAIN OUTCOMES AND MEASURES Diagnosis of ADHD or filled prescription for ADHD medication in children and symptoms of ADHD at child age 5 years, measured by Conners' Parent Rating Scale-Revised. Inverse probability of treatment weights were used to control for measured confounding. Cox regression was used to estimate hazard ratios (HRs) and 95% CIs. RESULTS The analyses of ADHD diagnosis and ADHD symptoms included 73 480 children (35 996 [49.0%] girls; mean [SD] maternal age, 30.0 [4.6] years) and 31 270 children (15 377 [49.2%] girls; mean [SD] maternal age, 30.5 [4.4] years), respectively. Overall, 1726 children in the ADHD diagnosis sample (2.3%) and 667 children in the ADHD symptom sample (2.1%) were exposed to an analgesic opioid at least once during gestation. No associations between timing of prenatal analgesic opioid exposure and ADHD diagnosis or symptoms was found. Exposure for 5 or more weeks was associated with an increased risk of ADHD diagnosis (HR, 1.60, 95% CI, 1.04-2.47) compared with exposure for 4 weeks or less; however, there was no such association for the risk of ADHD symptoms. CONCLUSIONS AND RELEVANCE In this cohort study, a slightly elevated risk of ADHD diagnosis after prenatal analgesic opioid exposure for 5 or more weeks was found compared with exposure for 4 weeks or less. This result may be driven by longer duration of use; however, the role of residual or unmeasured confounding cannot be excluded. This finding needs to be replicated in other studies.
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Affiliation(s)
- Johanne Naper Trønnes
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Angela Lupattelli
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Marte Handal
- Department of Mental Disorders, Norwegian Institute of Public Health, Oslo, Norway
| | - Svetlana Skurtveit
- Department of Mental Disorders, Norwegian Institute of Public Health, Oslo, Norway
| | - Eivind Ystrom
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Mental Disorders, Norwegian Institute of Public Health, Oslo, Norway
- PROMENTA Research Center, Department of Psychology, University of Oslo, Oslo, Norway
| | - Hedvig Nordeng
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
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21
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Caritis SN, Venkataramanan R. Obstetrical, fetal, and lactation pharmacology-a crisis that can no longer be ignored. Am J Obstet Gynecol 2021; 225:10-20. [PMID: 34215351 DOI: 10.1016/j.ajog.2021.02.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/01/2021] [Indexed: 02/01/2023]
Abstract
The data available to inform pregnant and lactating women about drug safety and efficacy are woefully inadequate. This lack of information encompasses every aspect of pharmaceutics, including limited human data about the embryonic risk, limited pharmacokinetic and pharmacodynamic information during and after pregnancy to ensure proper dosing, and a dearth of new medications to treat obstetrical and lactation disorders. This state of affairs has been longstanding and can be attributed to several realities, most of which have withstood any efforts to modify them. The first reality is the disinterest of the pharmaceutical industry to undertake pregnancy and lactation studies because of the considerable disincentives to undertake such studies. The medicolegal risks and the limited opportunity for financial gain are significant barriers to their participation. The US Food and Drug Administration has not mandated that new drugs or drugs "on patent" must include studies in pregnant women. Regulatory constrains that have defined pregnant women as a vulnerable class have greatly limited pharmacologic studies. Another contributing factor to this lack of information is the lack of researchers skilled in pharmacology with an interest in the pregnant woman. In addition, although difficult to measure, there is the hesitancy of pregnant and lactating women to participate in pharmacology research either for fear of fetal risk or an inability to commit the time required for such studies. Research in obstetrical and lactation pharmacology lags far behind that of pediatric pharmacology. Through the efforts of many, research in that field is highly funded and very productive in providing new information on medications used in children who, like pregnant women, have differing pharmacologic needs based on age (chronology for children and gestational age for pregnant women). Recently, the deficiencies and possible remedies for this embarrassing state of affairs in obstetrical and lactation pharmacology have been addressed by the federal government, which led to 15 recommendations from the Task Force on Research Specific to Pregnant Women and Lactating Women. In this article, we address the challenges in providing meaningful information about specific medications used by the mother and how these problems have evolved. We also suggest specific strategies to start the process of remediation.
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Affiliation(s)
- Steve N Caritis
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, UPMC Magee-Women's Hospital, University of Pittsburgh, Pittsburgh, PA; Department of Pharmaceutical Science, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA; Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Raman Venkataramanan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, UPMC Magee-Women's Hospital, University of Pittsburgh, Pittsburgh, PA; Department of Pharmaceutical Science, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA; Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA
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22
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Anesthetic management of the parturient with opioid addiction. Int Anesthesiol Clin 2021; 59:28-39. [PMID: 34100798 DOI: 10.1097/aia.0000000000000323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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van der Veeken L, Inversetti A, Galgano A, Bleeser T, Papastefanou I, van de Merwe J, Rex S, Deprest J. Fetally-injected drugs for immobilization and analgesia do not modify fetal brain development in a rabbit model. Prenat Diagn 2021; 41:1164-1170. [PMID: 33892522 DOI: 10.1002/pd.5954] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 03/29/2021] [Accepted: 04/05/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE During fetal surgery, fetuses receive medication (atropine-fentanyl-curare) to prevent fetal pain, movement and bradycardia. Although essential there has been no detailed review of potential side effects. Herein we aimed to assess the effects of this medication cocktail on fetal brain development in a rabbit model. METHODS Pregnant does underwent laparotomy at 28 days of gestation. Two pups of each horn were randomized to an ultrasound guided injection with medication (atropine-cisatracurium-fentanyl, as clinically used) or saline (sham). The third pup was used as control. At term, does were delivered by cesarean. Outcome measures were neonatal biometry, neuromotoric functioning and neuro-histology (neuron density, synaptic density and proliferation). RESULTS Maternal vital parameters remained stable during surgery. Fetal heart rates did not differ before and after injection, and were comparable for the three groups. At birth, neonatal body weights and brain-to-body weight ratios were also comparable. Both motor and sensory neurobehavioral scores were comparable. There were no differences in neuron density or proliferation. Sham pups, had a lower synaptic density in the hippocampus as compared to the medication group, however there was no difference in the other brain areas. CONCLUSION In the rabbit model, fetal medication does not appear to lead to short-term neurocognitive effects.
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Affiliation(s)
- Lennart van der Veeken
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Belgium
- Clinical Department Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Annalisa Inversetti
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Belgium
| | - Angela Galgano
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Belgium
| | - Tom Bleeser
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, Group Biomedical Sciences, KU Leuven, Belgium
| | | | - Johannes van de Merwe
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Belgium
- Clinical Department Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, Group Biomedical Sciences, KU Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Belgium
- Clinical Department Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Institute for Women's Health, University College London, London, UK
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24
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Olsen M. Prevention of Neonatal Abstinence Syndrome in an Outpatient Prenatal Buprenorphine Tapering Program. South Med J 2021; 113:553-558. [PMID: 33140108 DOI: 10.14423/smj.0000000000001164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Many addicted pregnant patients receiving buprenorphine medication-assisted therapy (MAT) wish to discontinue this medication while pregnant. This study was undertaken to determine whether outpatient detoxification from buprenorphine during pregnancy is safe and effective when confirmed with postdetoxification urine drug screens (UDSs). METHODS This case series reports the maternal and neonatal outcomes for 21 patients who ended MAT with buprenorphine while pregnant. A retrospective chart review of both maternal and newborn electronic medical records was performed to obtain results. Newborn neonatal abstinence syndrome (NAS) diagnosis, need for morphine, maternal safety and fetal/newborn complications were assessed. Maternal sobriety was documented with UDSs at the time of admission for delivery. Umbilical cord blood also was assessed for substances of abuse. An additional 182 pregnant women who lowered their buprenorphine doses but did not decide to end MAT were assessed via routine quality assurance methods. RESULTS None of the women who stopped buprenorphine during their pregnancy as confirmed by UDSs and umbilical cord sampling delivered neonates who had NAS. Eleven patients ended MAT with medical assistance and 10 ended MAT without medical assistance. No overdoses were reported for the 182 additional pregnant patients who indicated an intention to taper buprenorphine dosage while pregnant but who did not decide to end MAT; the neonatal benefits were obtained without any identified maternal harm. CONCLUSIONS The neonates of pregnant women enrolled in an outpatient buprenorphine MAT tapering program who are able to completely stop taking buprenorphine (as documented by negative urinary drug screen) are very unlikely to have NAS. Further research will be important.
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Affiliation(s)
- Martin Olsen
- From the Department of Obstetrics and Gynecology, Quillen College of Medicine, East Tennessee State University, Johnson City
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25
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Macfie J, Towers CV, Fortner KB, Stuart GL, Zvara BJ, Kurdziel-Adams G, Kors SB, Noose SK, Gorrondona AM, Cohen CT. Medication-assisted treatment vs. detoxification for women who misuse opioids in pregnancy: Associations with dropout, relapse, neonatal opioid withdrawal syndrome (NOWS), and childhood sexual abuse. Addict Behav Rep 2020; 12:100315. [PMID: 33364323 PMCID: PMC7752716 DOI: 10.1016/j.abrep.2020.100315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/10/2020] [Accepted: 11/09/2020] [Indexed: 11/25/2022] Open
Abstract
A professional organization does not recommend opioid detoxification in pregnancy. Medically-assisted treatment (MAT) is recommended to reduce relapse and dropout. We sampled 55 pregnant women who misused opioids who chose detoxification or MAT. There was no dropout in either group and more relapse with MAT than detoxification. Replication and follow-up are needed to assess relative rates of relapse postpartum.
The American College of Obstetricians and Gynecologists recommends medication-assisted treatment (MAT) for pregnant women who misuse opioids rather than detoxification because of possible relapse and dropout from treatment (ACOG, 2017). In a prospective study, fifty-five pregnant women with an opioid use disorder were offered a choice of MAT or detoxification. Ethical concerns precluded random assignment. We assessed dropout, treatment outcome, relapse, other illicit drug use, infant neonatal opioid withdrawal syndrome (NOWS), and childhood sexual abuse. Of 55 women, 13 initially chose MAT and 42 women chose detoxification. All women received behavioral support. No one dropped out of treatment prior to delivery. All women who chose MAT initially remained on MAT. Of women who chose detoxification, 23% switched to MAT, 30% tapered below initial MAT doses, and 45% fully detoxified by delivery. There was a significant difference in opioid relapse between women on MAT (26%) and those who detoxified (0%), but no differences for other illicit drug use. Infants of women on MAT were more likely to have neonatal NOWS (91%) than infants of women who tapered below initial MAT doses but did not fully detoxify (62%). Infants of mothers who tapered (62%) were more likely to have NOWS than infants of women who fully detoxified (0%). Women on MAT reported significantly lower sexual abuse severity than did women who tapered or detoxified. It is critical to replicate the current findings and to follow up with mothers and their infants postpartum to ascertain the long-term impact of tapering or detoxification during pregnancy.
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Affiliation(s)
- Jenny Macfie
- Psychology Department, University of Tennessee Knoxville, Knoxville, TN 37996-0900, United States
| | - Craig V Towers
- High Risk Obstetrical Consultants, Knoxville, TN, United States
| | - Kimberly B Fortner
- Department of Obstetrics and Gynecology, University of Tennessee Medical Center, Knoxville, TN, United States
| | - Gregory L Stuart
- Psychology Department, University of Tennessee Knoxville, Knoxville, TN 37996-0900, United States
| | - Bharathi J Zvara
- Gillings School of Global Public Health, University of North Carolina, United States
| | | | - Stephanie B Kors
- Psychology Department, University of Tennessee Knoxville, Knoxville, TN 37996-0900, United States
| | - Samantha K Noose
- Psychology Department, University of Tennessee Knoxville, Knoxville, TN 37996-0900, United States
| | - Andrea M Gorrondona
- Psychology Department, University of Tennessee Knoxville, Knoxville, TN 37996-0900, United States
| | - Chloe T Cohen
- Psychology Department, University of Tennessee Knoxville, Knoxville, TN 37996-0900, United States
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Porter AC, Behrendt NJ, Zaretsky MV, Liechty KW, Wood C, Chow F, Galan HL. Continuous local bupivacaine wound infusion reduces oral opioid use for acute postoperative pain control following myelomeningocele repair. Am J Obstet Gynecol MFM 2020; 3:100296. [PMID: 33485023 DOI: 10.1016/j.ajogmf.2020.100296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/05/2020] [Accepted: 12/11/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND For pregnancies complicated by fetal myelomeningocele who meet the established criteria, prenatal closure is a viable management option. Prenatal closure is an open procedure, with some techniques requiring greater dissection of maternal tissue than cesarean delivery; pain control is an important postoperative goal. Given the rising rates of opioid dependence and concerns regarding the fetal and neonatal effects of opioid use, our practice has turned to nonopioid pain management techniques. OBJECTIVE This study aimed to compare postoperative opioid use and pain scores in women undergoing open fetal myelomeningocele repair with and without continuous local bupivacaine wound infusion. STUDY DESIGN This was a retrospective, single-center chart review of all consecutive patients who underwent open myelomeningocele repair from March 2013 to December 2019. Women were enrolled at the time of referral and locally followed for 2 weeks postoperatively. The control group received patient-controlled epidural analgesia for 48 hours with acetaminophen and oral and intravenous opioids as needed. The treatment group received patient-controlled epidural analgesia for 24 hours with acetaminophen, oral and intravenous opioids, and continuous local bupivacaine infusion. Pain scores, medication use, and postoperative milestones and complications through discharge were abstracted from the chart and compared. RESULTS Of 72 subjects, 51 were in the control group and 21 in the treatment group. Total opioid use, including intravenous doses (165 vs 52.5 mg; P=.001) and daily average oral opioid use (30 vs 10.5 mg; P=.002) were lower in the treatment group. In addition, 24% of women in the treatment group used no opioid postoperatively, compared with 4% in the control group. There was no difference in postoperative day 1 to 4 pain scores, antiemetic use, or bowel function; the treatment group was discharged significantly earlier. CONCLUSION Postoperative opioid use was reduced in women who received continuous local wound infusion of bupivacaine for incisional pain control after prenatal myelomeningocele repair. Pain control is paramount following open myelomeningocele repair; local bupivacaine wound infusion is an important adjunct to reduce opioid use postoperatively.
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Affiliation(s)
- Anne C Porter
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO.
| | - Nicholas J Behrendt
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | - Michael V Zaretsky
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | - Kenneth W Liechty
- Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO; Division of Pediatric Surgery; Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Cristina Wood
- Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | - Franklin Chow
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | - Henry L Galan
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO; Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO
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Environmental and Nutritional "Stressors" and Oligodendrocyte Dysfunction: Role of Mitochondrial and Endoplasmatic Reticulum Impairment. Biomedicines 2020; 8:biomedicines8120553. [PMID: 33265917 PMCID: PMC7760976 DOI: 10.3390/biomedicines8120553] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 11/25/2020] [Accepted: 11/27/2020] [Indexed: 12/13/2022] Open
Abstract
Oligodendrocytes are myelinating cells of the central nervous system which are generated by progenitor oligodendrocytes as a result of maturation processes. The main function of mature oligodendrocytes is to produce myelin, a lipid-rich multi-lamellar membrane that wraps tightly around neuronal axons, insulating them and facilitating nerve conduction through saltatory propagation. The myelination process requires the consumption a large amount of energy and a high metabolic turnover. Mitochondria are essential organelles which regulate many cellular functions, including energy production through oxidative phosphorylation. Any mitochondrial dysfunction impacts cellular metabolism and negatively affects the health of the organism. If the functioning of the mitochondria is unbalanced, the myelination process is impaired. When myelination has finished, oligodendrocyte will have synthesized about 40% of the total lipids present in the brain. Since lipid synthesis occurs in the cellular endoplasmic reticulum, the dysfunction of this organelle can lead to partial or deficient myelination, triggering numerous neurodegenerative diseases. In this review, the induced malfunction of oligodendrocytes by harmful exogenous stimuli has been outlined. In particular, the effects of alcohol consumption and heavy metal intake are discussed. Furthermore, the response of the oligodendrocyte to excessive mitochondrial oxidative stress and to the altered regulation of the functioning of the endoplasmic reticulum will be explored.
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28
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Jobe AH. Other causes of fetal brain injury. Am J Obstet Gynecol 2020; 223:301. [PMID: 32184152 DOI: 10.1016/j.ajog.2020.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/10/2020] [Indexed: 10/24/2022]
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Goldstein RZ, Barrot M, Everitt BJ, Foxe JJ. Addiction in focus: molecular mechanisms, model systems, circuit maps, risk prediction and the quest for effective interventions. Eur J Neurosci 2020; 50:2007-2013. [PMID: 31502353 DOI: 10.1111/ejn.14544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Rita Z Goldstein
- Department of Psychiatry and Neuroscience, Icahn School of Medicine at Mount Sinai, The Leon and Norma Hess Center for Science and Medicine, New York, NY, USA
| | - Michel Barrot
- Centre National de la Recherche Scientifique, Institut des Neurosciences Cellulaires et Intégratives, Université de Strasbourg, Strasbourg, France
| | - Barry J Everitt
- Behavioural and Clinical Neuroscience Institute and Department of Psychology, University of Cambridge, Cambridge, UK
| | - John J Foxe
- The Cognitive Neurophysiology Laboratory, Department of Neuroscience, The Ernest J. Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Caritis SN, Venkataramanan R. Naltrexone use in pregnancy: a time for change. Am J Obstet Gynecol 2020; 222:1-2. [PMID: 31883574 DOI: 10.1016/j.ajog.2019.08.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 08/22/2019] [Indexed: 10/25/2022]
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