Opioid Prescription and Persistent Opioid Use After Ectopic Pregnancy

Readmission following methotrexate treatment for tubal pregnancy

OBJECTIVE

To identify risk factors for readmission following methotrexate treatment for tubal pregnancy.

METHODS

A retrospective study undertaken in two tertiary medical centers, including all individuals with medically treated tubal pregnancy (N = 511), between December 2009 and June 2021. Individuals with and without readmission following methotrexate treatment were compared. The primary outcome was the readmission rate. Secondary outcomes included the rate of post-discharge gynecological emergency department visits, tubal rupture rate, and the eventual need for surgical treatment.

RESULTS

Readmission following methotrexate treatment occurred in 224/511 patients (43.8%). Most readmissions were due to abdominal pain or suspicion of treatment failure. Readmitted individuals were more likely to have a history of pelvic inflammatory disease and pretreatment serum human chorionic gonadotropin (hCG) >2000 mIU/mL. Both factors remained significantly associated with higher readmission rates in a logistic regression analysis (adjusted odds ratio [OR] 6.28, 95% confidence interval [CI] 1.30-30.45, and adjusted OR 2.73, 95% CI 1.83-4.07, respectively) after adjustment for age, endometriosis, tubal pathology, abdominal pain, and presence of yolk sac or embryo at diagnosis. A dose-dependent association was observed between pretreatment serum hCG levels and readmission rate (P < 0.001). Pretreatment hCG levels were also associated with tubal rupture and the eventual need for surgical treatment (P < 0.001 for both). A prediction model using hCG was not sufficiently accurate to predict readmission risk.

CONCLUSION

Readmission following methotrexate treatment for tubal pregnancy was independently associated with previous pelvic inflammatory disease and pretreatment serum hCG levels. The latter was also associated with surgical intervention rate.

Investigating the association between asthma and opioid use disorder with interactions of anxiety and depression among a national sample of the US population

INTRODUCTION

Previous studies have not examined the association between asthma and opioid use disorder (OUD) in a comprehensive national sample of the U.S. population. This study aims to investigate such an association.

METHODS

This is a matched retrospective cohort study, with a follow-up period of two years, utilizing longitudinal electronic medical records of a comprehensive national healthcare database in the U.S.-Cerner-Real World DataTM. Patients selected for analysis were ≥12 years old with a hospital encounter between January 2000 and June 2020. Adjusted risk ratios (aRRs) of incident OUD for those with asthma compared to those without asthma were calculated using a modified Poisson regressions with robust standard errors via the Huber-White sandwich estimator, and results were stratified by comorbid mental illnesses.

RESULTS

Individuals with asthma had a greater risk of OUD compared to those without asthma (aRR = 2.12; 95% CI 2.03-2.23). When stratified by anxiety and depression status, individuals with asthma and no anxiety or depression had a greater risk of incident OUD compared to individuals with asthma and either anxiety, depression, or both. Additionally, individuals with asthma medication had 1.29 (95% CI: 1.24, 1.35) greater overall risk for incident OUD compared to those without medication. Independent of comorbid mental illnesses, individuals with asthma medication had greater risk for incident OUD compared to those without medication among individuals without severe/obstructive asthma.

CONCLUSIONS

Individuals with asthma face a higher OUD risk compared to those without asthma. Comorbid mental illnesses modulate this risk. Caution is advised in opioid prescribing for asthma patients.

The risk of opioid use disorder among women undergoing obstetric-related procedures: Results from the Cerner Real-World Database

Introduction

While the relationship between various obstetric procedures and the onset of opioid use disorder (OUD) remains ambiguous, this study aims to elucidate the immediate and prolonged risks of OUD in women who have undergone procedures such as vaginal and cesarean deliveries, induced abortions, and treatments related to miscarriages and ectopic pregnancies.

Methods

Retrospective data (n = 632,872) from the Cerner Real-World Data™ for pregnant females (age 15-44) between January 2010 and March 2020 were used. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were used to compare odds of OUD for each obstetric outcome to normal vaginal delivery using multivariable logistic regression. New opioid prescriptions and persistent opioid prescriptions were secondary outcomes for which modified Poisson regression models were used.

Results

Compared to patients with a vaginal delivery, those with an ectopic pregnancy, a cesarean delivery, miscarriage, and an induced abortion had 84%, 46%, 119%, and 131% significantly higher odds of OUD (aOR [95% CI]: 1.84 [1.36, 2.48], 1.46 [1.29, 1.65], 2.19 [1.94, 2.47], and 2.31 [1.80, 2.96]) respectively. Among opioid naïve patients, all other obstetric procedure groups (besides miscarriage) had significantly higher risk of being prescribed new opioids than those with a vaginal delivery. Among those newly prescribed opioids, patients from all other obstetric procedure groups demonstrated a significantly higher risk of persistent opioid prescription compared to those who had a vaginal delivery.

Conclusion

The association between specific obstetric outcomes, notably miscarriage and induced abortions, and opioid use patterns should inform safer and more effective pain management in a maternal population.

Transvaginal natural orifice endoscopic surgery for tubal ectopic pregnancy: A more suitable surgical approach for enhanced recovery after surgery

Objective

We aimed to determine the safety of Vaginal natural orifice transluminal endoscopic surgery (vNOTES) in terms of the Enhanced Recovery after Surgery (ERAS) concept for tubal pregnancy surgery and provide a detailed process of vNOTES for tubal pregnancy surgery, including experience and key points for surgeons performing this procedure.

Methods

The Longitudinal Vaginal Natural Orifice Transluminal Endoscopic Surgery Study (LovNOTESS), which was conducted in Chengdu, China. A total of 219 patients who underwent tubal ectopic pregnancy surgery between September 2021 and March 2022. The patients underwent salpingectomy or salpingostomy using transumbilical laparoendoscopic single-site surgery (LESS) or vNOTES, according to their preferences. This study prospectively collected perioperative and one-year follow-up data on tubal pregnancy outcomes after vNOTES and compared them with those after LESS.

Results

The vNOTES group showed a shorter surgical duration, hospitalization duration, and postoperative exhaust time and a lower analgesic medication usage rate, but it showed a higher surgical conversion rate. The vNOTES approach reduced the postoperative exhaust time by approximately 9 h (95% confidence interval [CI]: -11.93, -5.57 h, p < .001) and the risk of postoperative analgesic drug use by 77% (odds ratio, 0.23; 95% CI: 0.10, 0.61, p = .023).

Conclusion

vNOTES can shorten the exhaust time and duration of hospitalization, reduce postoperative pain, and avoid surface surgical scars in tubal pregnancy surgeries, consistent with the ERAS concept. However, more comprehensive preoperative evaluation of patients who choose vNOTES is required to reduce the occurrence of intraoperative conversion.Trial registration: ChiCTR2100053483.