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Hensel D, Helou NE, Zhang F, Stout MJ, Raghuraman N, Friedman H, Carter E, Odibo AO, Kelly JC. The Impact of a Multidisciplinary Opioid Use Disorder Prenatal Clinic on Breastfeeding Rates and Postpartum Care. Am J Perinatol 2024; 41:884-890. [PMID: 35668653 DOI: 10.1055/s-0042-1748526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To evaluate the hypothesis that patients with opioid use disorder (OUD), who receive prenatal care in a multidisciplinary, prenatal OUD clinic, have comparable postpartum breastfeeding rates, prenatal and postpartum visit compliance, and postpartum contraceptive use when compared with matched controls without a diagnosis of OUD. STUDY DESIGN This was a retrospective, matched, cohort study that included all patients who received prenatal care in a multidisciplinary, prenatal OUD clinic-Clinic for Acceptance Recovery and Empowerment (CARE)-between September 2018 and August 2020. These patients were maintained on opioid agonist therapy (OAT) throughout their pregnancy. CARE patients were matched to controls without OUD in a 1:4 ratio for mode of delivery, race, gestational age ± 1 week, and delivery date ± 6 months. The primary outcome was rate of exclusive breastfeeding at maternal discharge. Secondary outcomes included adherence with prenatal care (≥4 prenatal visits), adherence with postpartum care (≥1 postpartum visit), postpartum contraception plan prior to delivery, and type of postpartum contraceptive use. Conditional multivariate logistic regression was used to account for possible confounders in adjusted calculations. RESULTS A total of 210 patients were included (42 CARE and 168 matched controls). Despite having lower rates of adequate prenatal care, 40 CARE patients (95%) were exclusively breastfeeding at discharge resulting in CARE patients being significantly more likely to be breastfeeding at discharge (adjusted relative risk (aRR): 1.28, 95% confidence interval [CI]: 1.05-1.55). CARE patients and controls demonstrated no difference in postpartum visit compliance (86 vs. 81%, aRR: 1.03, 95% CI: 0.76-1.40) or effective, long-term contraception use (48 vs. 48%; aRR: 0.81, 95% CI: 0.36-1.84). CONCLUSION In the setting of multidisciplinary OUD prenatal care during pregnancy, patients with OUD were more likely to be breastfeeding at the time of discharge than matched controls, with no difference in postpartum visit compliance or effective, long-term contraception. KEY POINTS · Women with OUD are more likely to breastfeed when engaged in a multidisciplinary prenatal clinic.. · Women with OUD had no difference in LARC use when engaged in a multidisciplinary prenatal clinic.. · Women with OUD had no difference in postpartum visit rate in a multidisciplinary prenatal clinic..
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Affiliation(s)
- Drew Hensel
- Division of Maternal Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Nicole El Helou
- Division of Maternal Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Fan Zhang
- Division of Maternal Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Molly J Stout
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Nandini Raghuraman
- Division of Maternal Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Hayley Friedman
- Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Ebony Carter
- Division of Maternal Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Anthony O Odibo
- Division of Maternal Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Jeannie C Kelly
- Division of Maternal Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
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Trammel CJ, Whitley J, Kelly JC. Pharmacotherapy for opioid use disorder in pregnancy. Curr Opin Obstet Gynecol 2024; 36:74-80. [PMID: 38193300 DOI: 10.1097/gco.0000000000000932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
PURPOSE OF REVIEW Opioid use disorder (OUD) in pregnancy has significantly increased in the last decade, impacting 8.2 per 1000 deliveries. OUD carries significant risk of morbidity and mortality for both the birthing person and neonate, but outcomes for both are improved with opioid agonist treatment (OAT). Here, we describe the recommended forms of OAT in pregnancy, updates to the literature, and alternate OAT strategies, and share practical peripartum considerations for patients on OAT. RECENT FINDINGS Recent studies comparing buprenorphine and methadone have reaffirmed previous findings that buprenorphine is associated with superior outcomes for the neonate, without clear differences in morbidity or mortality for the birthing person. Optimal initiation and dosing of OAT remains unclear, with several recent studies evaluating methods of initiation, as well as a potential role for higher and more rapid dosing in the fentanyl era. Alternative products such as buprenorphine-naloxone and extended-release buprenorphine are of significant research interest, though randomized prospective data are not yet available. SUMMARY Buprenorphine and methadone are standard of care for treatment of OUD during pregnancy, and multiple patient factors impact the optimal choice. Insufficient data exist to recommend alternative agents as a primary strategy currently. All patients with OUD in pregnancy should be counseled regarding OAT. VIDEO http://links.lww.com/COOG/A94.
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Affiliation(s)
- Cassandra J Trammel
- Washington University in Saint Louis, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Ultrasound, St. Louis, Missouri, USA
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Guard M, Labonte AK, Mendoza M, Myers MJ, Duncan M, Drysdale AT, Mukherji E, Rahman T, Tandon M, Kelly JC, Cooke E, Rogers CE, Lenze S, Sylvester CM. Brexanolone Treatment in a Real-World Patient Population: A Case Series and Pilot Feasibility Study of Precision Neuroimaging. J Clin Psychopharmacol 2024:00004714-990000000-00228. [PMID: 38551454 DOI: 10.1097/jcp.0000000000001859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
PURPOSE/BACKGROUND Brexanolone is approved for postpartum depression (PPD) by the United States Food and Drug Administration. Brexanolone has outperformed placebo in clinical trials, but less is known about the efficacy in real-world patients with complex social and medical histories. Furthermore, the impact of brexanolone on large-scale brain systems such as changes in functional connectivity (FC) is unknown. METHODS/PROCEDURES We tracked changes in depressive symptoms across a diverse group of patients who received brexanolone at a large medical center. Edinburgh Postnatal Depression Scale (EPDS) scores were collected through chart review for 17 patients immediately prior to infusion through approximately 1 year postinfusion. In 2 participants, we performed precision functional neuroimaging (pfMRI), including before and after treatment in 1 patient. pfMRI collects many hours of data in individuals for precision medicine applications and was performed to assess the feasibility of investigating changes in FC with brexanolone. FINDINGS/RESULTS The mean EPDS score immediately postinfusion was significantly lower than the mean preinfusion score (mean change [95% CI]: 10.76 [7.11-14.40], t(15) = 6.29, P < 0.0001). The mean EPDS score stayed significantly lower at 1 week (mean difference [95% CI]: 9.50 [5.23-13.76], t(11) = 4.90, P = 0.0005) and 3 months (mean difference [95% CI]: 9.99 [4.71-15.27], t(6) = 4.63, P = 0.0036) postinfusion. Widespread changes in FC followed infusion, which correlated with EPDS scores. IMPLICATIONS/CONCLUSIONS Brexanolone is a successful treatment for PPD in the clinical setting. In conjunction with routine clinical care, brexanolone was linked to a reduction in symptoms lasting at least 3 months. pfMRI is feasible in postpartum patients receiving brexanolone and has the potential to elucidate individual-specific mechanisms of action.
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Affiliation(s)
| | - Alyssa K Labonte
- From the Department of Psychiatry, Washington University in St Louis, St Louis, MO
| | - Molly Mendoza
- From the Department of Psychiatry, Washington University in St Louis, St Louis, MO
| | - Michael J Myers
- From the Department of Psychiatry, Washington University in St Louis, St Louis, MO
| | - Maida Duncan
- From the Department of Psychiatry, Washington University in St Louis, St Louis, MO
| | - Andrew T Drysdale
- New York State Psychiatric Institute and the Department of Psychiatry, Columbia University Irving Medical Center, New York, NY
| | - Emily Mukherji
- From the Department of Psychiatry, Washington University in St Louis, St Louis, MO
| | - Tahir Rahman
- From the Department of Psychiatry, Washington University in St Louis, St Louis, MO
| | - Mini Tandon
- From the Department of Psychiatry, Washington University in St Louis, St Louis, MO
| | - Jeannie C Kelly
- Department of Obstetrics and Gynecology, Washington University in St Louis, St Louis, MO
| | - Emily Cooke
- Department of Pharmacy, Barnes-Jewish Hospital, St Louis, MO
| | | | - Shannon Lenze
- From the Department of Psychiatry, Washington University in St Louis, St Louis, MO
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O'Nan SL, Huang R, Zhao P, Garr Barry V, Lawlor M, Carter EB, Kelly JC, Frolova AI, England SK, Raghuraman N. Dietary risk factors for hypertensive disorders of pregnancy. Pregnancy Hypertens 2024; 36:101120. [PMID: 38508015 DOI: 10.1016/j.preghy.2024.101120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 03/12/2024] [Accepted: 03/14/2024] [Indexed: 03/22/2024]
Abstract
OBJECTIVE To assess whether diet quality and specific dietary components are associated with hypertensive disorders of pregnancy (HDP). STUDY DESIGN Nested case control study in a prospectively collected cohort of 450 participants with singleton pregnancies who completed the National Institutes of Health Diet Health Questionnaire II (DHQ-II) in the third trimester or within 3 months of delivery. Patients with fetal anomalies, conception by in-vitro fertilization, and deliveries at outside hospitals were excluded from the original prospective cohort study. Cases were patients diagnosed with HDP and controls were patients without HDP. Cases and controls were matched by BMI class in a 1:2 ratio. Exposures of interest were HEI-2015 score components and other DHQ-II dietary components including minerals, caffeine, and water. These dietary components were compared between cohorts using univariate analyses. MAIN OUTCOME MEASURES HEI-2015 total scores representing diet quality, component scores, and objective background data between patients with HDP and patients without HDP. RESULTS 150 patients with HDP were matched to 300 controls without HDP. Baseline demographics were similar between groups, including BMI. Patients with HDP were less likely to have high quality diets (HEI ≥ 70) than controls (7.3 % v 15.7 %, P = 0.02). HDP were associated with significantly higher dairy, saturated fat, and sodium intake compared to controls. Other components were similar between groups. CONCLUSION Patients with HDP are more likely to have lower diet quality and higher consumption of sodium, dairy, and saturated fats. These results can be used to study antenatal diet modification in patients at high risk of HDP.
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Affiliation(s)
- Suzanne L O'Nan
- Washington University School of Medicine in Saint Louis, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Saint Louis, MO, USA.
| | - Ruizhi Huang
- Washington University School of Medicine in Saint Louis, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Saint Louis, MO, USA
| | - Peinan Zhao
- Washington University School of Medicine in Saint Louis, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Saint Louis, MO, USA
| | - Valene Garr Barry
- Washington University School of Medicine in Saint Louis, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Saint Louis, MO, USA
| | - Megan Lawlor
- Washington University School of Medicine in Saint Louis, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Saint Louis, MO, USA
| | - Ebony B Carter
- Washington University School of Medicine in Saint Louis, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Saint Louis, MO, USA
| | - Jeannie C Kelly
- Washington University School of Medicine in Saint Louis, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Saint Louis, MO, USA
| | - Antonina I Frolova
- Washington University School of Medicine in Saint Louis, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Saint Louis, MO, USA
| | - Sarah K England
- Washington University School of Medicine in Saint Louis, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Saint Louis, MO, USA
| | - Nandini Raghuraman
- Washington University School of Medicine in Saint Louis, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Saint Louis, MO, USA
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Bedrick BS, Cary C, O'Donnell C, Marx C, Friedman H, Carter EB, Raghuraman N, Stout MJ, Ku BS, Xu KY, Kelly JC. County-level neonatal opioid withdrawal syndrome rates and real-world access to buprenorphine during pregnancy: An audit ("secret shopper") study in Missouri. Drug Alcohol Depend Rep 2024; 10:100218. [PMID: 38380272 PMCID: PMC10877162 DOI: 10.1016/j.dadr.2024.100218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/22/2024]
Abstract
Background Amid rising rates of neonatal opioid withdrawal syndrome (NOWS) worldwide and in many regions of the USA, we conducted an audit study ("secret shopper study") to evaluate the influence of county-level buprenorphine capacity and rurality on county-level NOWS rates. Methods In 2019, up to three phone calls were made to buprenorphine prescribers in the state of Missouri (USA). County-level buprenorphine capacity was defined as the number of clinicians (across all specialties) accepting pregnant people divided by the number of births. Multivariable negative binomial regression models estimated associations between buprenorphine capacity, rurality, and county-level NOWS rates, controlling for potential confounders (i.e., poverty, unemployment, and physician shortages) that may correspond to higher rates of NOWS and lower rates of buprenorphine prescribing. Analyses were stratified using tertiles of county-level overdose rates (top, middle, and lowest 1/3 of overdose rates). Results Of 115 Missouri counties, 81(70 %) had no buprenorphine capacity, 17(15 %) were low-capacity (<0.5-clinicians/1,000 births), and 17(15 %) were high-capacity (≥0.5/1,000 births). The mean NOWS rate was 6.5/1,000 births. In Missouri counties with both the highest and lowest opioid overdose rates, higher buprenorphine capacity did not correspond to decreases in NOWS rates (incidence rate ratio[IRR]=1.23[95 %-confidence-interval[CI]=0.65-2.32] and IRR=1.57[1.21-2.03] respectively). Rurality did not correspond to greater NOWS burden in both Missouri counties with highest and lowest opioid overdose rates. Conclusions The vast majority of counties in Missouri have no capacity for buprenorphine prescribing during pregnancy. Rurality and lower buprenorphine capacity did not significantly predict elevated rates of NOWS.
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Affiliation(s)
- Bronwyn S. Bedrick
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caroline Cary
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO
| | - Carly O'Donnell
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Christine Marx
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Hayley Friedman
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Ebony B. Carter
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Nandini Raghuraman
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO
| | - Molly J. Stout
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI
| | - Benson S. Ku
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Kevin Y Xu
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Jeannie C. Kelly
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO
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Kau NS, Kelly JC, Kim H, Smith R, Fraum TJ, Byrnes K, Trikalinos NA, Aranha O, Li KZ, Liu SA, Suresh R. Treatment of metastatic rectal squamous cell carcinoma in a pregnant patient. BMJ Case Rep 2024; 17:e257984. [PMID: 38378585 PMCID: PMC10882350 DOI: 10.1136/bcr-2023-257984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024] Open
Abstract
Rectal squamous cell carcinoma is an exceedingly rare form of rectal cancer, with limited data available regarding its presentation and effective treatment. Rectal cancer occurring during pregnancy is uncommon as well. This is a case of metastatic rectal squamous cell carcinoma presenting in a 22-week pregnant, female patient in her early 30s. The patient was treated with 5-fluorouracil and cisplatin and delivered a healthy male child born via uncomplicated vaginal delivery at 35 weeks. This article demonstrates that despite the rare nature of this cancer, in the already rare context of pregnancy, effective and safe treatment is possible with a multidisciplinary team.
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Affiliation(s)
- Nathan S Kau
- Department of Medicine, Division of Medical Oncology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Jeannie C Kelly
- Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Hyun Kim
- Department of Radiation Oncology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Radhika Smith
- Department of Surgery, Division of Colon and Rectal Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Tyler J Fraum
- Department of Radiology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Kathleen Byrnes
- Department of Pathology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Nikolaos A Trikalinos
- Department of Medicine, Division of Medical Oncology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Olivia Aranha
- Department of Medicine, Division of Medical Oncology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Kevin Z Li
- Department of Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Shiyuan Anabeth Liu
- Department of Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Rama Suresh
- Department of Medicine, Division of Medical Oncology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
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Trammel CJ, Beermann S, Goodman B, Marks L, Mills M, Durkin M, Raghuraman N, Carter EB, Odibo AO, Zofkie AC, Kelly JC. Hepatitis C and obstetrical morbidity in a substance use disorder clinic: a role for telemedicine? Am J Obstet Gynecol MFM 2024; 6:101219. [PMID: 37951578 DOI: 10.1016/j.ajogmf.2023.101219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/26/2023] [Accepted: 11/04/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Hepatitis C infection often co-occurs with substance use disorders in pregnancy. Accessing hepatitis C treatment is challenging because of loss to follow-up in the postpartum period, attributable to social and financial barriers to care. Telemedicine has been explored as a means of increasing routine postpartum care, but the potential impact on retention in and completion of care for postpartum hepatitis C has not been assessed. OBJECTIVE This study aimed to evaluate the impact of hepatitis C on obstetrical morbidity in a substance use disorder-specific prenatal clinic, and the effect of Infectious Disease telemedicine consultation on subsequent treatment delivery. STUDY DESIGN We performed a retrospective cohort study of all patients in our substance use disorder prenatal clinic from June 2018 to February 2023. Telemedicine consults for hepatitis C diagnoses began in March 2020 and included electronic chart review by Infectious Disease when patients were unable to be seen. Our primary outcome was composite obstetrical morbidity (preterm birth, preeclampsia, fetal growth restriction, fetal anomaly, abruption, postpartum hemorrhage, or chorioamnionitis) compared between patients with and without active hepatitis C. We additionally evaluated rates of completed referral and initiation of hepatitis C treatment before and after implementation of telemedicine consult. RESULTS A total of 224 patients were included. Of the 222 patients who underwent screening, 71 (32%) were positive for active hepatitis C. Compared with patients without hepatitis C, a higher proportion of patients with hepatitis C were White (80% vs 58%; P=.02), had a history of amphetamine use (61% vs 32%; P<.01), injection drug use (72% vs 38%; P<.01), or overdose (56% vs 29%; P<.01), and were on methadone (37% vs 18%; P<.01). There was no difference in the primary outcome of composite obstetrical morbidity. The rate of hepatitis C diagnosis was not statistically significantly different between the pre- and posttelemedicine cohorts (N=29 [41%], N=42 [27%]), and demographics of hepatitis C virus-positive patients were similar, with most being unemployed, single, and publicly insured. A lower proportion of patients in the posttelemedicine group reported heroin use compared with the pretelemedicine cohort (62% vs 90%; P=.013). After implementation of telemedicine, patients were more likely to attend the visit (19% vs 44%; P=.03), and positive patients were much more likely to receive treatment (14% vs 57%; P<.01); 100% of visits in the posttelemedicine group occurred via telemedicine. There were 7 patients who were prescribed treatment by their obstetrician after chart review by Infectious Disease. CONCLUSION Patients with and without hepatitis C had similar maternal and neonatal outcomes, with multiple indicators of social and financial vulnerability. Telemedicine Infectious Disease consult was associated with increased follow-up and hepatitis C treatment, and obstetricians were able to directly prescribe. Because patients with substance use disorders and hepatitis C may have increased barriers to care, telemedicine may represent an opportunity for intervention.
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Affiliation(s)
- Cassandra J Trammel
- Division of Maternal-Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Drs Trammel, Beerman, and Goodman, Ms Mills, and Drs Raghuraman, Carter, Odibo, Zofkie, and Kelly).
| | - Shannon Beermann
- Division of Maternal-Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Drs Trammel, Beerman, and Goodman, Ms Mills, and Drs Raghuraman, Carter, Odibo, Zofkie, and Kelly)
| | - Bree Goodman
- Division of Maternal-Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Drs Trammel, Beerman, and Goodman, Ms Mills, and Drs Raghuraman, Carter, Odibo, Zofkie, and Kelly)
| | - Laura Marks
- Division of Infectious Disease, Department of Internal Medicine, Washington University in St. Louis, St. Louis, MO (Drs Marks and Durkin)
| | - Melissa Mills
- Division of Maternal-Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Drs Trammel, Beerman, and Goodman, Ms Mills, and Drs Raghuraman, Carter, Odibo, Zofkie, and Kelly)
| | - Michael Durkin
- Division of Infectious Disease, Department of Internal Medicine, Washington University in St. Louis, St. Louis, MO (Drs Marks and Durkin)
| | - Nandini Raghuraman
- Division of Maternal-Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Drs Trammel, Beerman, and Goodman, Ms Mills, and Drs Raghuraman, Carter, Odibo, Zofkie, and Kelly)
| | - Ebony B Carter
- Division of Maternal-Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Drs Trammel, Beerman, and Goodman, Ms Mills, and Drs Raghuraman, Carter, Odibo, Zofkie, and Kelly)
| | - Anthony O Odibo
- Division of Maternal-Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Drs Trammel, Beerman, and Goodman, Ms Mills, and Drs Raghuraman, Carter, Odibo, Zofkie, and Kelly)
| | - Amanda C Zofkie
- Division of Maternal-Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Drs Trammel, Beerman, and Goodman, Ms Mills, and Drs Raghuraman, Carter, Odibo, Zofkie, and Kelly)
| | - Jeannie C Kelly
- Division of Maternal-Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Drs Trammel, Beerman, and Goodman, Ms Mills, and Drs Raghuraman, Carter, Odibo, Zofkie, and Kelly)
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Vinson A, Paul R, Chubiz J, Raghuraman N, Kelly JC, England SK, Carter EB. The Association between Mode of Transportation Support and Research Study Visit Attendance among Pregnant Patients. Am J Perinatol 2023. [PMID: 38101443 DOI: 10.1055/s-0043-1777441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
OBJECTIVE This study aimed to examine the association between transportation assistance and study visits, and explore differences by transportation modality. STUDY DESIGN This was a secondary analysis of prospective cohort study. We identified patients requesting transportation support for research ultrasound visits and identified controls (1:2 ratio) who did not request support matched for age, race, and insurance type. Conditional logistic regression examined the association between transportation support and mode of transportation with study visit attendance. RESULTS Transportation support was requested by 57/1,184 (4.8%) participants. Participants that requested transportation support were three times more likely to attend visits than their matched controls (adjusted odds ratio [aOR] 3.16, 95% confidence interval [CI]: 1.76-5.68). Among visits with transportation support, those supported by a ridesharing service had five-fold higher odds of attendance than visits supported with taxi service (aOR 5.06, 95% CI: 1.50-16.98). CONCLUSION Transportation support, especially a ridesharing service, is associated with improved attendance at research study visits in a sample of predominantly low-income, Black, pregnant participants. Implementing transportation support may be a promising strategy to improve engagement in research studies. KEY POINTS · Participants utilizing transportation assistance were more likely to attend study appointments.. · Participants using ridesharing had higher likelihood of attendance than those using taxi service.. · Transportation assistance may improve research engagement for historically marginalized people..
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Affiliation(s)
- Ariel Vinson
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, Missouri
- Meharry Medical College, Nashville, Tennessee
| | - Rachel Paul
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, Missouri
| | - Jessica Chubiz
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, Missouri
| | - Nandini Raghuraman
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, Missouri
| | - Jeannie C Kelly
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, Missouri
| | - Sarah K England
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, Missouri
| | - Ebony B Carter
- Department of Obstetrics and Gynecology , University of North at Chapel Hill
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Xu KY, Schiff DM, Jones HE, Martin CE, Kelly JC, Bierut LJ, Carter EB, Grucza RA. Racial and Ethnic Inequities in Buprenorphine and Methadone Utilization Among Reproductive-Age Women with Opioid Use Disorder: an Analysis of Multi-state Medicaid Claims in the USA. J Gen Intern Med 2023; 38:3499-3508. [PMID: 37436568 PMCID: PMC10713957 DOI: 10.1007/s11606-023-08306-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 06/27/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Associations between race/ethnicity and medications to treat OUD (MOUD), buprenorphine and methadone, in reproductive-age women have not been thoroughly studied in multi-state samples. OBJECTIVE To evaluate racial/ethnic variation in buprenorphine and methadone receipt and retention in a multi-state U.S. sample of Medicaid-enrolled, reproductive-age women with opioid use disorder (OUD) at the beginning of OUD treatment. DESIGN Retrospective cohort study. SUBJECTS Reproductive-age (18-45 years) women with OUD, in the Merative™ MarketScan® Multi-State Medicaid Database (2011-2016). MAIN MEASURES Differences by race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, "other" race/ethnicity) in the likelihood of receiving buprenorphine and methadone during the start of OUD treatment (yes/no) were estimated using multivariable logistic regression. Differences in time to medication discontinuation (days) by race/ethnicity were evaluated using multivariable Cox regression. RESULTS Of 66,550 reproductive-age Medicaid enrollees with OUD (84.1% non-Hispanic White, 5.9% non-Hispanic Black, 1.0% Hispanic, 5.3% "other"), 15,313 (23.0%) received buprenorphine and 6290 (9.5%) methadone. Non-Hispanic Black enrollees were less likely to receive buprenorphine (adjusted odds ratio, aOR = 0.76 [0.68-0.84]) and more likely to be referred to methadone clinics (aOR = 1.78 [1.60-2.00]) compared to non-Hispanic White participants. Across both buprenorphine and methadone in unadjusted analyses, the median discontinuation time for non-Hispanic Black enrollees was 123 days compared to 132 days and 141 days for non-Hispanic White and Hispanic enrollees respectively (χ2 = 10.6; P = .01). In adjusted analyses, non-Hispanic Black enrollees experienced greater discontinuation for buprenorphine and methadone (adjusted hazard ratio, aHR = 1.16 [1.08-1.24] and aHR = 1.16 [1.07-1.30] respectively) compared to non-Hispanic White peers. We did not observe differences in buprenorphine or methadone receipt or retention for Hispanic enrollees compared to the non-Hispanic White enrollees. CONCLUSIONS Our data illustrate inequities between non-Hispanic Black and non-Hispanic White Medicaid enrollees with regard to buprenorphine and methadone utilization in the USA, consistent with literature on the racialized origins of methadone and buprenorphine treatment.
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Affiliation(s)
- Kevin Y Xu
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA.
| | - Davida M Schiff
- Division of General Academic Pediatrics, Mass General Hospital for Children, Boston, MA, USA
| | - Hendrée E Jones
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Caitlin E Martin
- Department of Obstetrics and Gynecology and VCU Institute for Drug and Alcohol Studies, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Jeannie C Kelly
- Division of Maternal-Fetal Medicine and the Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, USA
| | - Laura J Bierut
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
- Alvin J Siteman Cancer Center, Barnes Jewish Hospital, St. Louis, MO, USA
| | - Ebony B Carter
- Division of Maternal-Fetal Medicine and the Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, USA
| | - Richard A Grucza
- Departments of Family and Community Medicine and Health and Outcomes Research, St. Louis University, St. Louis, MO, USA
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Zhong L, Xie E, Iyer V, Ruan J, Bell L, Chery J, Wang V, Sun C, Zhang F, Raghuraman N, Carter EB, Kelly JC. Comparing Asian and White maternal and obstetrical outcomes at 2 hospitals. Am J Obstet Gynecol MFM 2023; 5:101195. [PMID: 37844686 DOI: 10.1016/j.ajogmf.2023.101195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 10/11/2023] [Indexed: 10/18/2023]
Affiliation(s)
- Lydia Zhong
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO 63110.
| | - Evaline Xie
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO 63110
| | - Vidya Iyer
- Department of Obstetrics and Gynecology, Tufts University School of Medicine, Boston, MA
| | - Jenny Ruan
- Department of Obstetrics and Gynecology, Tufts University School of Medicine, Boston, MA
| | - Lindsey Bell
- Department of Obstetrics and Gynecology, Tufts University School of Medicine, Boston, MA
| | - Joronia Chery
- Department of Obstetrics and Gynecology, Tufts University School of Medicine, Boston, MA
| | - Victoria Wang
- Department of Obstetrics and Gynecology, Tufts University School of Medicine, Boston, MA
| | - Chenchen Sun
- Department of Obstetrics and Gynecology, Tufts University School of Medicine, Boston, MA
| | - Fan Zhang
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Washington University School of Medicine, St. Louis, MO
| | - Nandini Raghuraman
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Washington University School of Medicine, St. Louis, MO
| | - Ebony B Carter
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Washington University School of Medicine, St. Louis, MO
| | - Jeannie C Kelly
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Washington University School of Medicine, St. Louis, MO
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Carter EB, Thayer SM, Paul R, Barry VG, Iqbal SN, Ehrenberg S, Doering M, Mazzoni SE, Frolova AI, Kelly JC, Raghuraman N, Debbink MP. Diabetes Group Prenatal Care: A Systematic Review and Meta-analysis. Obstet Gynecol 2023:00006250-990000000-00958. [PMID: 37944148 DOI: 10.1097/aog.0000000000005442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/05/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE To estimate the effect of diabetes group prenatal care on rates of preterm birth and large for gestational age (LGA) among patients with diabetes in pregnancy compared with individual diabetes prenatal care. DATA SOURCES We searched Ovid Medline (1946-), Embase.com (1947-), Scopus (1823-), Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. METHODS OF STUDY SELECTION We searched electronic databases for randomized controlled trials (RCTs) and observational studies comparing diabetes group prenatal care with individual care among patients with type 2 diabetes mellitus or gestational diabetes mellitus (GDM). The primary outcomes were preterm birth before 37 weeks of gestation and LGA (birth weight at or above the 90th percentile). Secondary outcomes were small for gestational age, cesarean delivery, neonatal hypoglycemia, neonatal intensive care unit admission, breastfeeding at hospital discharge, long-acting reversible contraception (LARC) uptake, and 6-week postpartum visit attendance. Secondary outcomes, limited to the subgroup of patients with GDM, included rates of GDM requiring diabetes medication (A2GDM) and completion of postpartum oral glucose tolerance testing (OGTT). Heterogeneity was assessed with the Cochran Q test and I2 statistic. Random-effects models were used to calculate pooled relative risks (RRs) and weighted mean differences. TABULATION, INTEGRATION, AND RESULTS Eight studies met study criteria and were included in the final analysis: three RCTs and five observational studies. A total of 1,701 patients were included in the pooled studies: 770 (45.3%) in diabetes group prenatal care and 931 (54.7%) in individual care. Patients in diabetes group prenatal care had similar rates of preterm birth compared with patients in individual care (seven studies: pooled rates 9.5% diabetes group prenatal care vs 11.5% individual care, pooled RR 0.77, 95% CI, 0.59-1.01), which held for RCTs and observational studies. There was no difference between diabetes group prenatal care and individual care in rates of LGA overall (four studies: pooled rate 16.7% diabetes group prenatal care vs 20.2% individual care, pooled RR 0.93, 95% CI, 0.59-1.45) or by study type. Rates of other secondary outcomes were similar between diabetes group prenatal care and individual care, except patients in diabetes group prenatal care were more likely to receive postpartum LARC (three studies: pooled rates 46.1% diabetes group prenatal care vs 34.1% individual care, pooled RR 1.44, 95% CI, 1.09-1.91). When analysis was limited to patients with GDM, there were no differences in rates of A2GDM or postpartum visit attendance, but patients in diabetes group prenatal care were significantly more likely to complete postpartum OGTT (five studies: pooled rate 74.0% diabetes group prenatal care vs 49.4% individual care, pooled RR 1.58, 95% CI, 1.19-2.09). CONCLUSION Patients with type 2 diabetes and GDM who participate in diabetes group prenatal care have similar rates of preterm birth, LGA, and other pregnancy outcomes compared with those who participate in individual care; however, they are significantly more likely to receive postpartum LARC, and those with GDM are more likely to return for postpartum OGTT. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021279233.
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Affiliation(s)
- Ebony B Carter
- Division of Maternal Fetal Medicine and the Division of Clinical Research, Department of Obstetrics and Gynecology, and the Becker Library, Washington University School of Medicine in St. Louis, St. Louis, Missouri; the Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Columbia, Maryland; the Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland Ohio; Harborview OB/GYN Generalists, Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington; and the Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
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Galati BM, Wenzinger M, Rogers CE, Cooke E, Kelly JC. Buprenorphine Extended-Release Treatment for Opioid Use Disorder in the Postpartum Period. Obstet Gynecol 2023; 142:1148-1152. [PMID: 37856853 DOI: 10.1097/aog.0000000000005319] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 06/15/2023] [Indexed: 10/21/2023]
Abstract
Buprenorphine extended-release (XR) is an extended-release monthly injection to treat opioid use disorder (OUD). This retrospective case series includes 15 postpartum patients who were treated with buprenorphine-XR at a single center and reports on their outcomes. The average total daily sublingual buprenorphine dose before initiation of buprenorphine-XR was 16.25 mg (SD±7.76, range 2-32 mg). Overall, 137 total doses of buprenorphine-XR were administered between May 17, 2021, and April 11, 2023. Urine toxicology test results were negative for opioids other than buprenorphine in the majority (80.0%) of patients once appropriate maintenance doses were achieved. Euphoria and intoxication were not reported. A minority of patients (20.0%) discontinued buprenorphine-XR. Although more extensive research is needed before widespread use, buprenorphine-XR may be a favorable treatment for OUD in this high-risk population.
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Affiliation(s)
- Bridget M Galati
- Department of Psychiatry and the Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, and the Department of Pharmacy, Barnes Jewish Hospital, St. Louis, Missouri
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13
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Rimsza RR, Frolova AI, Kelly JC, Carter EB, Cahill AG, Raghuraman N. Intrapartum electronic fetal monitoring features associated with a clinical diagnosis of nonreassuring fetal status. Am J Obstet Gynecol MFM 2023; 5:101068. [PMID: 37380056 DOI: 10.1016/j.ajogmf.2023.101068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/20/2023] [Accepted: 06/22/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Nonreassuring fetal status detected by continuous electronic fetal monitoring accounts for almost 1 in 4 primary cesarean deliveries. However, given the subjective nature of the diagnosis, there is a need to identify the electronic fetal monitoring patterns that are clinically considered nonreassuring. OBJECTIVE This study aimed to describe which electronic fetal monitoring features are most commonly associated with first-stage cesarean delivery for nonreassuring fetal status, and to evaluate the risk of neonatal acidemia following cesarean delivery for nonreassuring fetal status. STUDY DESIGN This was a nested case-control study in a prospectively collected cohort of patients with singleton pregnancies at ≥37 weeks' gestation, admitted in spontaneous labor or for induction of labor from 2010 to 2014 at a single tertiary care center. Patients with preterm pregnancies, multiple gestations, planned cesarean delivery, or nonreassuring fetal status in the second stage of labor were excluded. Cases were identified as having nonreassuring fetal status on the basis of what was documented in the operative note by the delivering physician. Controls were patients without nonreassuring fetal status within 1 hour of delivery. Cases were matched to controls in a 1:2 ratio by parity, obesity, and history of cesarean delivery. Electronic fetal monitoring data were abstracted by credentialed obstetrical research nurses for the 60 minutes before delivery. The primary exposure of interest was the incidence of high-risk category II electronic fetal monitoring features in the 60 minutes before delivery; in particular, the incidence of minimal variability, recurrent late decelerations, recurrent variable decelerations, tachycardia, and >1 prolonged deceleration were compared between groups. We also compared neonatal outcomes between cases and controls, including fetal acidemia (umbilical artery pH <7.1), other umbilical artery gas analytes, and neonatal and maternal outcomes. RESULTS Of the 8580 patients in the parent study, 714 (8.3%) underwent cesarean delivery for nonreassuring fetal status in the first stage of labor. Patients diagnosed with nonreassuring fetal status requiring cesarean delivery were more likely to have recurrent late decelerations, >1 prolonged deceleration, and recurrent variable decelerations compared with controls. More than 1 prolonged deceleration was associated with 6 times increased rate of nonreassuring fetal status diagnosis resulting in cesarean delivery (adjusted odds ratio, 6.73 [95% confidence interval, 2.47-8.33]). Rates of fetal tachycardia were similar between groups. Minimal variability was less common in the nonreassuring fetal status group compared with controls (adjusted odds ratio, 0.36 [95% confidence interval, 0.25-0.54]). Compared with control deliveries, cesarean delivery for nonreassuring fetal status was associated with nearly 7 times higher risk of neonatal acidemia (7.2% vs 1.1%; adjusted odds ratio, 6.93 [95% confidence interval, 3.83-12.54]). Composite neonatal morbidity and composite maternal morbidity were more likely among patients delivered for nonreassuring fetal status in the first stage (3.9% vs 1.1%; adjusted odds ratio, 5.70 [2.60-12.49]; and 13.3% vs 8.0%; adjusted odds ratio, 1.99 [1.41-2.80]). CONCLUSION Although multiple category II electronic fetal monitoring features have been traditionally linked to acidemia, the presence of recurrent late decelerations, recurrent variable decelerations, and prolonged decelerations seemed to concern obstetricians enough to surgically intervene for nonreassuring fetal status. A clinical intrapartum diagnosis of nonreassuring fetal status in the setting of these electronic fetal monitoring features is also associated with increased risk of acidemia, suggesting clinical validity to the diagnosis of nonreassuring fetal status.
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Affiliation(s)
- Rebecca R Rimsza
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Drs Rimsza, Frolova, Kelly, Carter, and Raghuraman).
| | - Antonina I Frolova
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Drs Rimsza, Frolova, Kelly, Carter, and Raghuraman)
| | - Jeannie C Kelly
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Drs Rimsza, Frolova, Kelly, Carter, and Raghuraman)
| | - Ebony B Carter
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Drs Rimsza, Frolova, Kelly, Carter, and Raghuraman)
| | - Alison G Cahill
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Dell Medical School, The University of Texas at Austin, Austin, TX (Dr Cahill)
| | - Nandini Raghuraman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Drs Rimsza, Frolova, Kelly, Carter, and Raghuraman)
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14
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Szlyk HS, Constantino-Pettit A, Li X, Kasson E, Maranets E, Worku Y, Montayne M, Banks DE, Kelly JC, Cavazos-Rehg PA. Self-Identified Stage in Recovery and Substance-Use Behaviors among Pregnant and Postpartum Women and People with Opioid Use Disorder. Healthcare (Basel) 2023; 11:2392. [PMID: 37685426 PMCID: PMC10486579 DOI: 10.3390/healthcare11172392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/09/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
Opioid use among pregnant and postpartum women and people (PPWP) has significant health repercussions. This study explores how substance-use behaviors may vary by stage in recovery among PPWP with opioid use disorder (OUD). We recruited 29 PPWP with OUD. "High-risk" participants self-identified as "not being engaged in treatment" or "new or early in their recovery" (n = 11); "low-risk" participants self-identified as being "well-established" or "in long-term recovery" (n = 18). Participants were queried regarding sociodemographic, mental health, and drug-misuse factors; urine drug screens were collected at baseline. Univariate group comparisons between high-risk and low-risk PPWP were conducted. High-risk PPWP were more likely to self-identify as non-Hispanic African American and more likely to report current opioid use, other illicit drugs, and tobacco. High-risk PPWP had higher opioid cravings versus low-risk PPWP. High-risk PPWP were more likely to screen positive on urine tests for non-opioid drugs and on concurrent use of both non-opioid drugs and opioids versus low-risk participants. PPWP earlier in recovery are at higher-risk for opioid and other illicit drug misuse but are willing to disclose aspects of their recent use. PPWP early in recovery are an ideal population for interventions that can help facilitate recovery during the perinatal period and beyond.
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Affiliation(s)
- Hannah S. Szlyk
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
| | - Anna Constantino-Pettit
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
- Brown School, Washington University in St. Louis, 1 Brookings Dr., St. Louis, MO 63130, USA
| | - Xiao Li
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
| | - Erin Kasson
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
| | - Emily Maranets
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
| | - Yoseph Worku
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
| | - Mandy Montayne
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
| | - Devin E. Banks
- Department of Psychological Sciences, University of Missouri–St. Louis, One University Blvd., 325 Stadler Hall, St. Louis, MO 63121, USA;
| | - Jeannie C. Kelly
- Department of Obstetrics & Gynecology, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO 63110, USA;
| | - Patricia A. Cavazos-Rehg
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
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15
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Thayer SM, Faramarzi P, Krauss MJ, Snider E, Kelly JC, Carter EB, Frolova AI, Odibo AO, Raghuraman N. Heterogeneity in management of category II fetal tracings: data from a multihospital healthcare system. Am J Obstet Gynecol MFM 2023; 5:101001. [PMID: 37146688 DOI: 10.1016/j.ajogmf.2023.101001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/28/2023] [Accepted: 04/30/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Electronic fetal monitoring is widely used to identify and intervene in suspected fetal hypoxia and/or acidemia. Category II fetal heart rate tracings are the most common class of fetal monitoring in labor, and intrauterine resuscitation is recommended given the association of category II fetal heart rate tracings with fetal acidemia. However, limited published data are available to guide intrauterine resuscitation technique selection, leading to heterogeneity in the response to category II fetal heart rate tracings. OBJECTIVE This study aimed to characterize approaches to intrauterine resuscitation in response to category II fetal heart rate tracings. STUDY DESIGN This was a survey study administered to labor unit nurses and delivering clinicians (physicians and midwives) across 7 hospitals in a Midwestern healthcare system spanning 2 states. The survey posed 3 category II fetal heart rate tracing scenarios (recurrent late decelerations, minimal variability, and recurrent variable decelerations) and asked participants to select first- and second-line intrauterine resuscitation management strategies. The participants were asked to quantify the level of influence certain factors have on their choice using a scale from 1 to 5. Intrauterine resuscitation strategy selection was compared by clinical role and hospital type (nurses vs delivering clinicians and university-affiliated hospital vs non-university-affiliated hospital). RESULTS Of 610 providers invited to take the survey, 163 participated (response rate of 27%): 37% of participants from university-affiliated hospitals, 62% of nurses, and 37% of physicians. Maternal repositioning was the most selected first-line strategy, regardless of the type of category II fetal heart rate tracing. First-line management varied by clinical role and hospital affiliation for each fetal heart rate tracing scenario, particularly for minimal variability, which was associated with the most heterogeneity in the first-line approach. Previous experience and recommendations from professional societies were the most influential factors in intrauterine resuscitation selection overall. Of note, 16.5% of participants reported that published evidence did not influence their choice at all. Participants from a university-affiliated hospital were more likely than participants from a non-university-affiliated hospital to consider patient preference when selecting an intrauterine resuscitation technique. Nurses and delivering clinicians differed significantly in the rationale for management choices: nurses were more often influenced by advice from other healthcare providers on the team (P<.001), whereas delivering clinicians were more influenced by literature (P=.02) and ease of technique (P=.02). CONCLUSION There was significant heterogeneity in the management of category II fetal heart rate tracing. In addition, motivations for choice in intrauterine resuscitation technique varied by hospital type and clinical role. These factors should be considered when creating fetal monitoring and intrauterine resuscitation protocols.
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Affiliation(s)
- Sydney M Thayer
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Dr Thayer, Ms Faramarzi, and Drs Kelly, Carter, Frolova, Odibo, and Raghuraman).
| | - Parisa Faramarzi
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Dr Thayer, Ms Faramarzi, and Drs Kelly, Carter, Frolova, Odibo, and Raghuraman)
| | - Melissa J Krauss
- Brown School at Washington University in St. Louis, St. Louis, MO (Mses Krauss and Snider)
| | - Elsa Snider
- Brown School at Washington University in St. Louis, St. Louis, MO (Mses Krauss and Snider)
| | - Jeannie C Kelly
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Dr Thayer, Ms Faramarzi, and Drs Kelly, Carter, Frolova, Odibo, and Raghuraman)
| | - Ebony B Carter
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Dr Thayer, Ms Faramarzi, and Drs Kelly, Carter, Frolova, Odibo, and Raghuraman)
| | - Antonina I Frolova
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Dr Thayer, Ms Faramarzi, and Drs Kelly, Carter, Frolova, Odibo, and Raghuraman)
| | - Anthony O Odibo
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Dr Thayer, Ms Faramarzi, and Drs Kelly, Carter, Frolova, Odibo, and Raghuraman)
| | - Nandini Raghuraman
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Dr Thayer, Ms Faramarzi, and Drs Kelly, Carter, Frolova, Odibo, and Raghuraman)
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Kelly JC, Ayala NK, Holroyd L, Raghuraman N, Carter EB, Williams SA, Mills MM, Friedman H, Zhang F, Townsel C. Number of buprenorphine induction attempts impacts maternal and neonatal outcomes: a multicenter cohort study. Am J Obstet Gynecol MFM 2023; 5:100998. [PMID: 38236700 DOI: 10.1016/j.ajogmf.2023.100998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/14/2023] [Accepted: 04/27/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Buprenorphine can be used to treat maternal opioid use disorder effectively and decrease obstetrical risks. Compared with the use of other medications to treat opioid use disorder, the use of buprenorphine results in improved neonatal outcomes; however, its use is associated with higher rates of treatment attrition. Initiation of buprenorphine, termed "induction," is a high-risk time for treatment dropout and can require repeated attempts. OBJECTIVE This study aimed to evaluate the effect of multiple buprenorphine induction attempts on maternal and neonatal outcomes. STUDY DESIGN This was a retrospective cohort study of all pregnant patients who underwent sublingual buprenorphine induction for the treatment of opioid use disorder from June 18, 2018, to January 1, 2021, at 3 tertiary care centers. Patients who required only 1 attempt for successful buprenorphine induction were compared with those who required multiple attempts but ultimately were successful in the treatment initiation during pregnancy, confirmed by urine drug screening. The primary outcome was nonprescribed opioid use at the time of delivery. The secondary outcomes included obstetrical and neonatal outcomes associated with opioid use disorder. Background characteristics were compared using Fisher exact, chi-square, Mann-Whitney U, and Student t tests. The outcomes were compared using multivariable logistic regression, and time to delivery after initiation of prenatal care was compared between groups using Kaplan-Meier curves and a Cox proportional-hazards model. RESULTS Overall, 63 patients undergoing buprenorphine induction during pregnancy were included, with 38 (60.3%) patients with 1 attempt and 25 patients (39.7%) with multiple attempts. There was no statistical difference between the 2 groups in terms of background characteristics. Compared with a single successful attempt, multiple attempts at buprenorphine induction were associated with a significantly increased odds of nonprescribed opioid use at the time of delivery (76.0% vs 15.8%; adjusted odds ratio, 30.00; 95% confidence interval, 5.50-163.90), increased risk of preterm birth (48.0% vs 15.8%; adjusted hazard ratio, 3.24; 95% confidence interval, 1.17-8.95), and decreased rate of breastfeeding at both maternal discharge (24.0% vs 78.9%; adjusted odds ratio, 0.06; 95% confidence interval, 0.00-0.30) and infant discharge (24.0% vs 55.3%; adjusted odds ratio, 0.23; 95% confidence interval, 0.10-0.80). CONCLUSION Requiring multiple attempts for buprenorphine induction significantly increases the odds of nonprescribed opioid use at the time of delivery and preterm birth and decreases the odds of breastfeeding. As the buprenorphine induction process may affect obstetrical outcomes for patients induced during pregnancy, investigating the techniques that increase the likelihood of successful induction is crucially needed to improve outcomes in patients with maternal opioid use disorder.
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Affiliation(s)
- Jeannie C Kelly
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (Drs Kelly, Holroyd, Raghuraman, and Carter); Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (Drs Kelly, Raghuraman, and Carter, Mses Williams and Mills, and Dr Zhang); Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI (Dr Townsel).
| | - Nina K Ayala
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, RI (Dr Ayala)
| | - Lauren Holroyd
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (Drs Kelly, Holroyd, Raghuraman, and Carter)
| | - Nandini Raghuraman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (Drs Kelly, Holroyd, Raghuraman, and Carter); Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (Drs Kelly, Raghuraman, and Carter, Mses Williams and Mills, and Dr Zhang)
| | - Ebony B Carter
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (Drs Kelly, Holroyd, Raghuraman, and Carter); Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (Drs Kelly, Raghuraman, and Carter, Mses Williams and Mills, and Dr Zhang)
| | - Samantha A Williams
- Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (Drs Kelly, Raghuraman, and Carter, Mses Williams and Mills, and Dr Zhang)
| | - Melissa M Mills
- Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (Drs Kelly, Raghuraman, and Carter, Mses Williams and Mills, and Dr Zhang)
| | - Hayley Friedman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, RI (Dr Ayala)
| | - Fan Zhang
- Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (Drs Kelly, Raghuraman, and Carter, Mses Williams and Mills, and Dr Zhang)
| | - Courtney Townsel
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO (Dr Friedman)
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Rimsza RR, Kelly JC, Frolova A, Odibo A, Carter E, Cahill AG, Raghuraman N. The impact of cervical effacement at time of amniotomy in patients undergoing induction of labor. Am J Perinatol 2023. [PMID: 37207677 DOI: 10.1055/a-2096-2277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
OBJECTIVE There is evidence to suggest that early amniotomy during induction of labor is advantageous. However, following cervical ripening balloon removal the cervix remains less effaced and the utility of amniotomy in this setting is less clear. We investigated whether cervical effacement at the time of amniotomy impacts outcomes among nulliparas undergoing induction of labor. STUDY DESIGN This was a secondary analysis of a prospective cohort of singleton, term, nulliparous patients at a tertiary care center undergoing induction of labor and amniotomy. The primary outcome was completion of the first stage of labor. Secondary outcomes were vaginal delivery and postpartum hemorrhage. Outcomes were compared between patients with cervical effacement ≤50% (low effacement) and >50% (high effacement) at time of amniotomy. Multivariable logistic regression was used to adjust for confounders including cervical dilation. Stratified analysis was performed in patients with cervical ripening balloon use. A post-hoc sensitivity analysis was performed to further control for cervical dilation. RESULTS Of 1256 patients, 365 (29%) underwent amniotomy at low effacement. Amniotomy at low effacement was associated with reduced likelihood of completing the first stage (aRR 0.87 [95% CI 0.78-0.95]) and vaginal delivery (aRR 0.87 [95% CI 0.77-0.96]). Although amniotomy at low effacement was associated with lower likelihood of completing the first stage in all-comers, those who had amniotomy performed at low effacement following cervical ripening balloon expulsion were at highest risk (aRR 0.84 [95% CI 0.69-0.98] P for interaction= 0.04) In the post-hoc sensitivity analysis, including patients who underwent amniotomy at 3 or 4 centimeters dilation, low cervical effacement remained associated with a lower likelihood of completing the first stage of labor. CONCLUSION Low cervical effacement at time of amniotomy, particularly following cervical ripening balloon expulsion, is associated with a lower likelihood of successful induction.
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Affiliation(s)
- Rebecca R Rimsza
- Obstetrics and Gynecology, Washington University in St Louis, St Louis, United States
| | - Jeannie C Kelly
- Obstetrics and Gynecology, Washington University in St Louis, St Louis, United States
| | - Antonina Frolova
- Obstetrics and Gynecology, Washington University in Saint Louis School of Medicine, Saint Louis, United States
| | - Anthony Odibo
- Obstetrics and Gynecology, Washington University in St Louis, St Louis, United States
| | - Ebony Carter
- OB/GYN, Washington University in St Louis, St Louis, United States
| | - Alison G Cahill
- Women's Health, University of Texas at Austin Dell Medical School, Austin, United States
| | - Nandini Raghuraman
- OB GYN, Maternal-Fetal Medicine, Washington University in St Louis, St. Louis, United States
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Xu KY, Jones HE, Schiff DM, Martin CE, Kelly JC, Carter EB, Bierut LJ, Grucza RA. Initiation and Treatment Discontinuation of Medications for Opioid Use Disorder in Pregnant People Compared With Nonpregnant People. Obstet Gynecol 2023; 141:845-853. [PMID: 36897142 PMCID: PMC10201921 DOI: 10.1097/aog.0000000000005117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/12/2023] [Indexed: 03/11/2023]
Abstract
OBJECTIVE To examine the association between pregnancy and medications for opioid use disorder (MOUD) initiation and discontinuation among reproductive-aged people receiving treatment for opioid use disorder (OUD) in the United States. METHODS We conducted a retrospective cohort study of people with gender recorded as female, aged 18-45 years, in the Merative TM MarketScan ® Commercial and Multi-State Medicaid Databases (2006-2016). Opioid use disorder and pregnancy status were identified based on inpatient or outpatient claims for established International Classification of Diseases, Ninth and Tenth Revision diagnosis and procedure codes. The main outcomes were buprenorphine and methadone initiation and discontinuation, determined by using pharmacy and outpatient procedure claims. Analyses were conducted at the treatment episode level. Adjusting for insurance status, age, and co-occurring psychiatric and substance use disorders, we used logistic regression to estimate MOUD initiation and used Cox regression to estimate MOUD discontinuation. RESULTS Our sample included 101,772 reproductive-aged people with OUD, encompassing 155,771 treatment episodes (mean age 30.8 years, 64.4% Medicaid insurance, 84.1% White), of whom 2,687 (3.2%, encompassing 3,325 episodes) were pregnant. In the pregnant group, 51.2% of treatment episodes (1,703/3,325) involved psychosocial treatment without MOUD, in comparison with 61.1% (93,156/152,446) in the nonpregnant comparator group. In adjusted analyses assessing likelihood of initiation for individual MOUD, pregnancy status was associated with an increase in buprenorphine (adjusted odds ratio [aOR] 1.57, 95% CI 1.44-1.70) and methadone initiation (aOR 2.04, 95% CI 1.82-2.27). Discontinuation rates of MOUD at 270 days were high for both buprenorphine (72.4% for nonpregnant episodes vs 59.9% for pregnant episodes) and methadone (65.7% for nonpregnant episodes vs 54.1% for pregnant episodes). Pregnancy was associated with a decreased likelihood of discontinuation at 270 days for both buprenorphine (adjusted hazard ratio [aHR] 0.71, 95% CI 0.67-0.76) and methadone (aHR 0.68, 95% CI 0.61-0.75), in comparison with nonpregnant status. CONCLUSION Although a minority of reproductive-aged people with OUD in the United States are initiated on MOUD, pregnancy is associated with a significant increase in treatment initiation and a reduced risk of medication discontinuation.
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Affiliation(s)
- Kevin Y Xu
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Hendrée E Jones
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Davida M Schiff
- Division of General Academic Pediatrics, Mass General Hospital for Children, Boston, MA, USA
| | - Caitlin E Martin
- Department of Obstetrics and Gynecology and VCU Institute for Drug and Alcohol Studies, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Jeannie C Kelly
- Division of Maternal-Fetal Medicine and the Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ebony B Carter
- Division of Maternal-Fetal Medicine and the Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, USA
| | - Laura J Bierut
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
- Alvin J Siteman Cancer Center, Barnes Jewish Hospital, St. Louis, MO, USA
| | - Richard A Grucza
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
- Departments of Family and Community Medicine and Health and Outcomes Research, St. Louis University, St. Louis, MO, USA
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Rimsza RR, Perez M, Woolfolk C, Kelly JC, Carter EB, Frolova AI, Odibo AO, Raghuraman N. Video Instruction for Pushing in the Second Stage (VIPss): A randomized controlled trial. Am J Obstet Gynecol 2023:S0002-9378(23)00170-9. [PMID: 36940771 DOI: 10.1016/j.ajog.2023.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/16/2023] [Accepted: 03/12/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND The second stage of labor requires active patient engagement. Prior studies suggest that coaching can influence second stage duration. However, a standardized education tool has not been established and patients face many barriers to accessing childbirth education before delivery OBJECTIVE: We investigated the effect of an intrapartum video pushing education tool on second stage duration. STUDY DESIGN This was a randomized controlled trial of nulliparous patients with singleton pregnancies ≥37 weeks admitted for induction or spontaneous labor with neuraxial anesthesia. Patients were consented on admission and block randomized in active labor to one of two arms in a 1:1 ratio. The study arm viewed a 4-minute video prior to the second stage on what to anticipate in second stage and pushing techniques. The control arm received the standard of care: bedside coaching at 10cm dilation from a nurse or physician. The primary outcome was second stage duration. Secondary outcomes were birth satisfaction (using Modified Mackey Childbirth Satisfaction Rating Scale), mode of delivery, postpartum hemorrhage, clinical chorioamnionitis, neonatal intensive care unit admission, and umbilical artery gases. 156 patients were needed to detect a 20% decrease in second stage duration with 80% power, 2-sided alpha 0.05, and 10% loss after randomization RESULTS: Of 161 patients, 81 were randomized to standard of care and 80 to intrapartum video education. Among these, 149 progressed to the second stage and were included in the intention-to-treat analysis: 69 video and 78 control. Maternal demographics and labor characteristics were similar between groups. Second stage duration was statistically similar between the video arm (61min [IQR 20-140]) and the control arm (49min [IQR 27-131]), P=0.77. There were no differences in mode of delivery, postpartum hemorrhage, clinical chorioamnionitis, neonatal intensive care unit admission, or umbilical artery gases between groups. Although the overall birth satisfaction score on the Modified Mackey Childbirth Satisfaction Rating Scale was similar between groups, patients in the video group rated their "level of comfort during birth" and "attitude of the doctors in birth" significantly higher/more positively than control patients. CONCLUSION Intrapartum video education was not associated with a shorter second stage. However, patients who received video education reported higher level of comfort and a more favorable perception of their physician, suggesting that video education may be a helpful tool to improve the birth experience.
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Affiliation(s)
- Rebecca R Rimsza
- Washington University in Saint Louis, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Ultrasound, Saint Louis, MO
| | - Marta Perez
- University of Texas at Austin, Dell School of Medicine, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Austin, TX
| | - Candice Woolfolk
- Washington University in Saint Louis, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Ultrasound, Saint Louis, MO
| | - Jeannie C Kelly
- Washington University in Saint Louis, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Ultrasound, Saint Louis, MO
| | - Ebony B Carter
- Washington University in Saint Louis, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Ultrasound, Saint Louis, MO
| | - Antonina I Frolova
- Washington University in Saint Louis, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Ultrasound, Saint Louis, MO
| | - Anthony O Odibo
- Washington University in Saint Louis, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Ultrasound, Saint Louis, MO
| | - Nandini Raghuraman
- Washington University in Saint Louis, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Ultrasound, Saint Louis, MO
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Rimsza RR, Raghuraman N, Carter EB, Kelly JC, Cahill AG, Frolova AI. Association between Elevated Intrauterine Resting Tone during Labor and Neonatal Morbidity. Am J Perinatol 2023. [PMID: 36720261 DOI: 10.1055/a-2022-9588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Internal contraction monitoring provides a quantitative assessment of intrauterine resting tone. During the course of labor, elevated intrauterine resting tone may be identified. We hypothesized that elevated intrauterine resting tone could lead to compression of the spiral arteries, thus limiting uterine blood flow and resulting in neonatal compromise. Therefore, our objective was to assess the association between elevated resting tone during labor and neonatal morbidity. STUDY DESIGN This was a secondary analysis of a prospective cohort study of singleton deliveries at ≥37 weeks of gestation. Patients with ruptured membranes and an intrauterine pressure catheter in place for at least 30 minutes prior to delivery were included. Intrauterine resting tone was calculated as the average baseline pressure between contractions during the 30 minutes prior to delivery. The study group had elevated intrauterine resting tone, defined as intrauterine resting tone ≥75th percentile (≥12.3 mm Hg). Primary outcome was composite neonatal morbidity: hypoxic-ischemic encephalopathy, hypothermia treatment, intubation, seizures, umbilical arterial pH ≤7.1, oxygen requirement, or death. Secondary outcomes included umbilical artery pH <7.2, lactate ≥4 mmol/L, and rates of neonatal intensive care unit admission. RESULTS Of the 8,580 patients in the cohort, 2,210 (25.8%) met the inclusion criteria. The median intrauterine resting tone was 9.7 mm Hg (interquartile range: 7.3-12.3 mm Hg). Elevated resting tone was associated with a shorter median duration of the first stage of labor (10.0 vs. 11.0 hours, p < 0.01) and lower rates of labor induction and oxytocin augmentation (p < 0.01). Neonatal composite morbidity was higher among patients with elevated intrauterine resting tone (5.1 vs. 2.9%, p = 0.01). After adjusting for chorioamnionitis and amnioinfusion, elevated intrauterine resting tone was associated with increased risk of neonatal morbidity (adjusted odds ratio: 1.70, 95% confidence interval: 1.06-2.74). CONCLUSION Our findings suggest that elevated intrauterine resting tone is associated with increased risk of neonatal composite morbidity. KEY POINTS · Higher intrauterine resting tone is associated with increased risk of neonatal morbidity.. · Elevated intrauterine tone can negatively impact umbilical artery pH and lactate levels.. · If elevated intrauterine pressure is noted, we recommend close monitoring of fetal status..
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Affiliation(s)
- Rebecca R Rimsza
- Division of Maternal-Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University in Saint Louis, St. Louis, Missouri
| | - Nandini Raghuraman
- Division of Maternal-Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University in Saint Louis, St. Louis, Missouri
| | - Ebony B Carter
- Division of Maternal-Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University in Saint Louis, St. Louis, Missouri
| | - Jeannie C Kelly
- Division of Maternal-Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University in Saint Louis, St. Louis, Missouri
| | - Alison G Cahill
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Dell School of Medicine, University of Texas at Austin, Austin, Texas
| | - Antonina I Frolova
- Division of Maternal-Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University in Saint Louis, St. Louis, Missouri
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Rimsza RR, Perez M, Kelly JC, Carter EB, Frolova AI, Hardy C, Odibo AO, Raghuraman N. Video instruction for pushing in the second stage (VIPss): a randomized controlled trial. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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O'Nan S, Huang R, peinan Zhao, Barry VG, Lawlor ML, Carter EB, Kelly JC, Frolova AI, England SK, Raghuraman N. Dietary risk factors for hypertensive disorders of pregnancy. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Rimsza RR, Goyal S, Barry VG, Oakes MC, Turnbull D, Sabol B, Kelly JC, Raghuraman N, Carter EB, Rampersad RM. Factors affecting engagement in a postpartum remote blood pressure monitoring program: Identifying opportunities for improvement. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.1216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Trammel C, Lawlor ML, Jacobsen H, Mills M, Krauss M, Galati B, Raghuraman N, Carter EB, Odibo AO, Kelly JC. Patient satisfaction with buprenorphine or methadone for treatment of opioid use disorder during obstetric care. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Rimsza RR, Kelly JC, Carter EB, Massa K, Frolova AI, Odibo AO, Raghuraman N. Do antenatal childbirth education classes improve birth satisfaction? Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.1214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Trammel C, Marks LR, Beermann SE, Mills M, Raghuraman N, Carter EB, Odibo AO, Zofkie AC, Kelly JC. Treating hepatitis C in a substance use disorder prenatal clinic: can telemedicine make us better? Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Burd J, Woolfolk C, Dombrowski M, Carter EB, Kelly JC, Frolova AI, Odibo AO, Cahill AG, Raghuraman N. How long is too long? Assessing risks of prolonged latent phase of labor. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Burd J, Woolfolk C, Frolova AI, Zofkie AC, Odibo AO, Carter EB, Kelly JC, Cahill AG, Raghuraman N. Interpregnancy interval in multiparas: does it impact the labor curve? Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Huysman BC, Thayer SM, Kernberg A, Frolova AI, Zofkie AC, Odibo AO, Raghuraman N, Carter EB, Kelly JC. Rupture before 34 weeks: does offering expectant management beyond 34 weeks make a difference? Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Huysman BC, Thayer SM, Kernberg A, Frolova AI, Rampersad RM, Odibo AO, Raghuraman N, Carter EB, Kelly JC. Shared decision-making aid to increase equity in the management of PPROM. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Paul R, Raghuraman N, Carter EB, Odibo AO, Kelly JC, Foeller ME, Perez MJ. COVID Vaccine Information Sources Utilized by Female Healthcare Workers. Am J Obstet Gynecol MFM 2022; 4:100704. [PMID: 35931368 PMCID: PMC9345656 DOI: 10.1016/j.ajogmf.2022.100704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/13/2022] [Accepted: 07/28/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Clinical trials of the messenger RNA COVID-19 vaccines excluded individuals with active reproductive needs (attempting to conceive, currently pregnant, and/or lactating). Women comprise three-quarters of healthcare workers in the United States-an occupational field among the first to receive the vaccine. Professional medical and government organizations have encouraged shared decision-making and access to vaccination among those with active reproductive needs. OBJECTIVE This study aimed to characterize the information sources used by pregnancy-capable healthcare workers for information about the COVID-19 vaccines and to compare the self-reported "most important" source by the respondents' active reproductive needs, if any. STUDY DESIGN This was a web-based national survey of female, US-based healthcare workers in January 2021. Recruitment was done using social media and subsequent sharing via word of mouth. We classified the respondents into 6 groups on the basis of self-reported reproductive needs as follows: (1) preventing pregnancy, (2) attempting pregnancy, (3) currently pregnant, (4) lactating, (5) attempting pregnancy and lactating, and (6) currently pregnant and lactating. We provided respondents with a list of information sources (friends, family, obstetrician-gynecologists, pediatrician, news, social media, government organizations, their employer, and "other") and asked respondents which source(s) they used when looking for information about the vaccine and their most important source. We used descriptive statistics to characterize the information sources and compared the endorsement of government organizations and obstetrician-gynecologists, which were the most important information source between reproductive groups, using the chi-square test. The effect size was calculated using Cramér V. RESULTS Our survey had 11,405 unique respondents: 5846 (51.3%) were preventing pregnancy, 955 (8.4%) were attempting pregnancy, 2196 (19.3%) were currently pregnant, 2250 (19.7%) were lactating, 67 (0.6%) were attempting pregnancy and lactating, and 91 (0.8%) were currently pregnant and lactating. The most endorsed information sources were government organizations (88.7%), employers (48.5%), obstetrician-gynecologists (44.9%), and social media (39.6%). Considering the most important information source, the distribution of respondents endorsing government organizations was different between reproductive groups (P<.001); it was most common among respondents preventing pregnancy (62.6%) and least common among those currently pregnant (31.5%). We observed an inverse pattern among the respondents endorsing an obstetrician-gynecologist as the most important source; the source was most common among currently pregnant respondents (51.4%) and least common among those preventing pregnancy (5.8%), P<.001. The differences in the endorsement of social media as an information source between groups were significant but had a small effect size. CONCLUSION Healthcare workers use government and professional medical organizations for information. Respondents attempting pregnancy and those pregnant and/or lactating are more likely to use social media and an obstetrician-gynecologist as information sources for vaccine decision-making. These data can inform public health messaging and counseling for clinicians.
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Affiliation(s)
- Rachel Paul
- Divisions of Maternal-Fetal Medicine & Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (R. Paul and Drs Raghuraman, Carter, Odibo, Kelly, and Perez)
| | - Nandini Raghuraman
- Divisions of Maternal-Fetal Medicine & Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (R. Paul and Drs Raghuraman, Carter, Odibo, Kelly, and Perez)
| | - Ebony B Carter
- Divisions of Maternal-Fetal Medicine & Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (R. Paul and Drs Raghuraman, Carter, Odibo, Kelly, and Perez)
| | - Anthony O Odibo
- Divisions of Maternal-Fetal Medicine & Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (R. Paul and Drs Raghuraman, Carter, Odibo, Kelly, and Perez)
| | - Jeannie C Kelly
- Divisions of Maternal-Fetal Medicine & Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (R. Paul and Drs Raghuraman, Carter, Odibo, Kelly, and Perez)
| | - Megan E Foeller
- Maternal-Fetal Medicine, Saint Alphonsus Medical Center, Boise, ID (Dr Foeller)
| | - Marta J Perez
- Divisions of Maternal-Fetal Medicine & Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (R. Paul and Drs Raghuraman, Carter, Odibo, Kelly, and Perez).
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El Helou N, Paul R, Valentine MC, Raghuraman N, Carter EB, Kelly JC, Friedman H, Stout MJ. Reframing maternal opioid use disorder as an opportunity for delivering dyad-centered care: a call for action. Am J Obstet Gynecol MFM 2022; 4:100646. [PMID: 35439635 DOI: 10.1016/j.ajogmf.2022.100646] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 04/05/2022] [Accepted: 04/11/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Nicole El Helou
- Department of Obstetrics and Gynecology, Washington University School of Medicine, 22 N Euclid Ave., Ste. 233, St. Louis, MO 63108.
| | - Rachel Paul
- Department of Obstetrics and Gynecology, Washington University School of Medicine, 22 N Euclid Ave., Ste. 233, St. Louis, MO 63108
| | - Mark C Valentine
- Department of Obstetrics and Gynecology, Washington University School of Medicine, 22 N Euclid Ave., Ste. 233, St. Louis, MO 63108
| | - Nandini Raghuraman
- Department of Obstetrics and Gynecology, Washington University School of Medicine, 22 N Euclid Ave., Ste. 233, St. Louis, MO 63108
| | - Ebony B Carter
- Department of Obstetrics and Gynecology, Washington University School of Medicine, 22 N Euclid Ave., Ste. 233, St. Louis, MO 63108
| | - Jeannie C Kelly
- Department of Obstetrics and Gynecology, Washington University School of Medicine, 22 N Euclid Ave., Ste. 233, St. Louis, MO 63108
| | - Hayley Friedman
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO
| | - Molly J Stout
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
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Oakes MC, Hensel DM, Kelly JC, Rampersad R, Carter EB, Cahill AG, Raghuraman N. Simplifying the prediction of vaginal birth after cesarean delivery: role of the cervical exam. J Matern Fetal Neonatal Med 2022; 35:10030-10035. [PMID: 35723653 DOI: 10.1080/14767058.2022.2086795] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Predicting likelihood of vaginal birth after cesarean (VBAC) is a cornerstone in counseling patients considering a trial of labor after cesarean (TOLAC). Yet, the simplified Bishop score (SBS), a score comprised cervical dilation, station, and effacement assessment used to predict successful vaginal delivery, has not been applied to the TOLAC population. We evaluated the relationship between admission SBS and likelihood of successful VBAC. We also determined the predictive characteristics of SBS, compared to cervical dilation alone, for successful VBAC. METHODS This is a secondary analysis of a prospective cohort study of patients with a singleton gestation, ≥37 0/7 weeks gestation, and prior cesarean admitted to Labor & Delivery between 2010 and 2014. The primary outcome of successful VBAC was compared between those with a favorable (score >5) and unfavorable (score ≤5) admission SBS. Secondary outcomes were select maternal and neonatal outcomes. Adjusted risk ratios were estimated using multivariable logistic regression analyses. Receiver-operating characteristic curves compared predictive capabilities of cervical dilation alone to SBS for successful VBAC. RESULTS Of the 656 patients who underwent a TOLAC during the study period, 421 (64%) had a successful VBAC. 203 (31%) and 453 (69%) had a favorable and an unfavorable admission SBS, respectively. After adjusting for body mass index and prior vaginal delivery, patients with a favorable admission SBS had a 30% greater likelihood of successful VBAC compared to those with an unfavorable SBS (aRR 1.30, 95% CI 1.16-1.40). Admission cervical dilation alone performed similarly to SBS as a predictor of successful VBAC, with a receiver-operator characteristic curve area under the curve (AUC) of 0.68 (95% CI 0.64-0.72) versus an AUC 0.66 (95% CI 0.62-0.70), respectively (p = .07). There were no differences in adverse maternal or neonatal outcomes between those with an unfavorable and favorable SBS. CONCLUSIONS A favorable admission SBS is associated with an increased likelihood of VBAC. Although both admission SBS and cervical dilation alone are only modest predictors of VBAC, admission cervical dilation performs overall similarly to current models for VBAC prediction and is an objective, reproducible, and generalizable measure. Our study highlights the value of waiting until end of pregnancy (rather than the first prenatal visit) to conclude patient counseling on the decision to TOLAC in order to consider admission cervical assessment, particularly cervical dilation.
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Affiliation(s)
- Megan C Oakes
- Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Drew M Hensel
- Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Jeannie C Kelly
- Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Roxane Rampersad
- Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Ebony B Carter
- Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Alison G Cahill
- Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Nandini Raghuraman
- Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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Oakes MC, Zhang F, Stevenson L, Porcelli B, Carter EB, Raghuraman N, Kelly JC. Changes in the Antenatal Utilization of High-Risk Obstetric Services and Stillbirth Rate during the COVID-19 Pandemic. Am J Perinatol 2022; 39:830-835. [PMID: 34856612 PMCID: PMC9757080 DOI: 10.1055/s-0041-1740212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The primary objective of this study was to evaluate coronavirus 2019 (COVID-19) pandemic-related changes in the antenatal utilization of high-risk obstetric services. Our secondary objective was to characterize change in stillbirth rate during the pandemic. STUDY DESIGN This is a retrospective, observational study performed at a single, tertiary care center. Maternal-Fetal Medicine (MFM) visits, ultrasounds, and antenatal tests of fetal well-being during the pandemic epoch (2020), which spans the first 12 weeks of the year to include pandemic onset and implementation of mitigation efforts, were compared with the same epoch of the three preceding years visually and using general linear models to account for week and year effect. An analysis of stillbirth rate comparing the pandemic time period to prepandemic was also performed. RESULTS While there were decreased MFM visits and antenatal tests of fetal well-being during the pandemic epoch compared with prepandemic epochs, only the decrease in MFM visits by year was statistically significant (p < 0.001). The stillbirth rate during the pandemic epoch was not significantly different when compared with the prepandemic period and accounting for both week (p = 0.286) and year (p = 0.643) effect. CONCLUSION The COVID-19 pandemic resulted in a significant decrease in MFM visits, whereas obstetric ultrasounds and antenatal tests of fetal well-being remained unchanged. While we observed no change in the stillbirth rate compared with the prepandemic epoch, our study design and sample size preclude us from making assumptions of association. Our findings may support future work investigating how changes in prenatal care for high-risk obstetric patients influence perinatal outcomes. KEY POINTS · MFM visits significantly decreased during the COVID-19 pandemic epoch.. · The overall stillbirth rate during the COVID-19 pandemic epoch was not significantly changed.. · Larger studies are needed to capitalize on these changes to evaluate rare outcomes such as stillbirth..
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Affiliation(s)
- Megan C. Oakes
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University, in St. Louis School of Medicine, St. Louis, Missouri
| | - Fan Zhang
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University, in St. Louis School of Medicine, St. Louis, Missouri
| | - Lori Stevenson
- Women & Infants Center, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Bree Porcelli
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University, in St. Louis School of Medicine, St. Louis, Missouri
| | - Ebony B. Carter
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University, in St. Louis School of Medicine, St. Louis, Missouri
| | - Nandini Raghuraman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University, in St. Louis School of Medicine, St. Louis, Missouri
| | - Jeannie C. Kelly
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University, in St. Louis School of Medicine, St. Louis, Missouri
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Hensel D, Zhang F, Carter EB, Frolova AI, Odibo AO, Kelly JC, Cahill AG, Raghuraman N. Severity of intrapartum fever and neonatal outcomes. Am J Obstet Gynecol 2022; 227:513.e1-513.e8. [PMID: 35598690 DOI: 10.1016/j.ajog.2022.05.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/06/2022] [Accepted: 05/12/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND The few studies that have addressed the relationship between severity of intrapartum fever and neonatal and maternal morbidity have had mixed results. The impact of the duration between reaching maximum intrapartum temperature and delivery on neonatal outcomes remains unknown. OBJECTIVE To test the association of severity of intrapartum fever and duration from reaching maximum temperature to delivery with neonatal and maternal morbidity. STUDY DESIGN This was a secondary analysis of a prospective cohort of term, singleton patients admitted for induction of labor or spontaneous labor who had intrapartum fever (≥38°C). Patients were divided into 3 groups according to maximum temperature during labor: afebrile (<38°C), mild fever (38°C-39°C), and severe fever (>39°C). The primary outcome was composite neonatal morbidity (umbilical artery pH <7.1, mechanical ventilation, respiratory distress, meconium aspiration with pulmonary hypertension, hypoglycemia, neonatal intensive care unit admission, and Apgar <7 at 5 minutes). Secondary outcomes were composite neonatal neurologic morbidity (hypoxic-ischemic encephalopathy, hypothermia treatment, and seizures) and composite maternal morbidity (postpartum hemorrhage, endometritis, and maternal packed red blood cell transfusion). Outcomes were compared between the maximum temperature groups using multivariable logistic regression. Cox proportional-hazards regression modeling accounted for the duration between reaching maximum intrapartum temperature and delivery. RESULTS Of the 8132 patients included, 278 (3.4%) had a mild fever and 74 (0.9%) had a severe fever. The incidence of composite neonatal morbidity increased with intrapartum fever severity (afebrile 5.4% vs mild 18.0% vs severe 29.7%; P<.01). After adjusting for confounders, there were increased odds of composite neonatal morbidity with severe fever compared with mild fever (adjusted odds ratio, 1.93 [95% confidence interval, 1.07-3.48]). Severe fevers remained associated with composite neonatal morbidity compared with mild fevers after accounting for the duration between reaching maximum intrapartum temperature and delivery (adjusted hazard ratio, 2.05 [95% confidence interval, 1.23-3.43]). Composite neonatal neurologic morbidity and composite maternal morbidity were not different between patients with mild and patients with severe fevers. CONCLUSION Composite neonatal morbidity correlated with intrapartum fever severity in a potentially dose-dependent fashion. This correlation was independent of the duration from reaching maximum intrapartum temperature to delivery, suggesting that clinical management of intrapartum fever, in terms of timing or mode of delivery, should not be affected by this duration.
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Koch SK, Paul R, Addante AN, Brubaker A, Kelly JC, Raghuraman N, Madden T, Tepe M, Carter EB. Medicaid Reimbursement Program for Immediate Postpartum Long-Acting Reversible Contraception Improves Uptake Regardless of Insurance Status. Contraception 2022; 113:57-61. [PMID: 35588793 DOI: 10.1016/j.contraception.2022.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 05/10/2022] [Accepted: 05/11/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate whether a Medicaid reimbursement program for immediate postpartum long-acting reversible contraception (LARC) is associated with an increased rate of LARC uptake. STUDY DESIGN We conducted a retrospective cohort study comparing patients who delivered at a large, urban, tertiary medical center one year before and after Missouri Medicaid coverage changed to reimburse immediate postpartum LARC in October 2016. Patients were identified through the electronic medical record and excluded if they delivered prior to 24 weeks gestation or had a contraindication to immediate postpartum LARC. The primary outcome was placement of immediate postpartum LARC, which we examined overall and stratified by insurance type. We used multivariable logistic regression to determine the impact of the policy change while adjusting for appropriate confounders. RESULTS A total of 6,233 eligible patients delivered during the study period: 3,105 before and 3,128 after the change in reimbursement for immediate postpartum LARC. Patients delivering after the policy change were more likely to be Hispanic, have commercial insurance or be uninsured, and have a BMI >30. Placement of immediate postpartum LARC increased from 0.7% pre- to 9.7% post-policy change (aOR 15.6; 95% CI 10.1-24.2). In our stratified analysis, immediate postpartum LARC uptake increased for patients with Medicaid (aOR 15.8; 95% CI 9.9-25.4) and commercial insurance (aOR 9.7; 95% CI 3.0-31.8). CONCLUSION The change in Missouri Medicaid reimbursement for placement of immediate postpartum LARC had systemic impact with an increase in postpartum LARC uptake in all patients, regardless of insurance provider. IMPLICATIONS Insurance reimbursement has the power to influence hospital policy and patient care. Overall, changes to Medicaid reimbursement increased access to postpartum LARC for all patients at a large academic institution, regardless of insurance status.
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Affiliation(s)
- Susannah K Koch
- Washington University in St. Louis School of Medicine, Department of Obstetrics and Gynecology, St. Louis, MO.
| | - Rachel Paul
- Washington University in St. Louis School of Medicine, Department of Obstetrics and Gynecology, Division of Family Planning, St. Louis, MO; Washington University in St. Louis School of Medicine, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, St. Louis, MO
| | - Amy N Addante
- Washington University in St. Louis School of Medicine, Department of Obstetrics and Gynecology, Division of Family Planning, St. Louis, MO; Advocate Medical Group, Park Ridge, IL
| | - Allison Brubaker
- Washington University in St. Louis School of Medicine, Department of Obstetrics and Gynecology, St. Louis, MO; Women's Care of Wisconsin, S.C. Neenah, WI
| | - Jeannie C Kelly
- Washington University in St. Louis School of Medicine, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, St. Louis, MO
| | - Nandini Raghuraman
- Washington University in St. Louis School of Medicine, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, St. Louis, MO
| | - Tessa Madden
- Washington University in St. Louis School of Medicine, Department of Obstetrics and Gynecology, Division of Family Planning, St. Louis, MO
| | | | - Ebony B Carter
- Washington University in St. Louis School of Medicine, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, St. Louis, MO
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Perez MJ, Paul R, Raghuraman N, Kelly JC, Carter EB, Foeller M. COVID-19 vaccine information sources utilized by female healthcare workers. Am J Obstet Gynecol 2022. [PMCID: PMC8696709 DOI: 10.1016/j.ajog.2021.11.1099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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El Helou N, Cook CR, Katherine N, Carter EB, Odibo AO, Stout MJ, Kelly JC, Raghuraman N. Impact of the COVID-19 pandemic on outpatient postpartum care utilization. Am J Obstet Gynecol 2022. [PMCID: PMC8696582 DOI: 10.1016/j.ajog.2021.11.526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Thayer SM, Faramarzi P, Krauss M, Snider E, Kelly JC, Carter EB, Frolova AI, Odibo AO, Raghuraman N. A standardized protocol for management of Category II tracings: provider perceptions of benefits and barriers. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hensel DM, Zhang F, Carter EB, Frolova AI, Odibo AO, Kelly JC, Cahill AG, Raghuraman N. Severity of Intrapartum Fever and Neonatal Outcomes: What Temperature is Too High? Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.1182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Holroyd L, El Helou N, Raghuraman N, Carter EB, Odibo AO, Kelly JC. The impact of multiple buprenorphine induction attempts on maternal and neonatal outcomes. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Brady M, Paul R, Frolova AI, Dombrowski M, Raghuraman N, Kelly JC, Carter EB. Clinical characteristics associated with need for intrapartum insulin infusion. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Brady M, Paul R, Frolova AI, Odibo AO, Raghuraman N, Kelly JC, Carter EB. Neonatal outcomes associated with insulin infusion during labor. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kernberg A, Raghuraman N, Carter EB, Odibo AO, Perez MJ, Russell S, Holroyd L, Kelly JC. Shared Decision Making: Women Undergoing Expectant Management with Prelabor Rupture of Membranes. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Watkins VY, peinan Zhao, Frolova AI, Carter EB, Kelly JC, Odibo AO, England SK, Raghuraman N. How does physical activity change throughout pregnancy? Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Watkins VY, peinan Zhao, Frolova AI, Carter EB, Kelly JC, Odibo AO, England SK, Raghuraman N. The impact of physical activity during pregnancy on fetal growth. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Beermann SE, Porcelli BA, Durkin MJ, Marks LR, Raghuraman N, Carter EB, Odibo AO, Kelly JC. The impact of hepatitis C on obstetric outcomes in an opioid use disorder-specific prenatal clinic. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Zhong L, Ruan J, Bell L, Chery J, Iyer V, Wang V, Sun C, Craigo S, Mhatre M, House M, Peterson A, Mauban E, Wang XY, Hensel DM, Min C, Oakes MC, Raghuraman N, Carter EB, Odibo AO, Kelly JC. Differences in obstetric complications between Asian and White patients at two tertiary care centers. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Thayer SM, Faramarzi P, Krauss M, Snider E, Kelly JC, Carter EB, Frolova AI, Odibo AO, Raghuraman N. Heterogeneity in management of Category II fetal tracings: data from a multi-hospital healthcare system. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.1026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Huysman BC, Odibo AO, Carter EB, Kelly JC, Frolova AI, Cahill AG, Raghuraman N. Making the diagnosis of non-reassuring fetal status: Potential for implicit bias. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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