Caitlin Clancy

Opioid abuse and dependence during pregnancy: temporal trends and obstetrical outcomes.

Background:The authors investigated nationwide trends in opioid abuse or dependence during pregnancy and assessed the impact on maternal and obstetrical outcomes in the United States. Methods:Hospitalizations for delivery were extracted from the Nationwide Inpatient Sample from 1998 to 2011. Temporal trends were assessed and logistic regression was used to examine the associations between maternal opioid abuse or dependence and obstetrical outcomes adjusting for relevant confounders. Results:The prevalence of opioid abuse or dependence during pregnancy increased from 0.17% (1998) to 0.39% (2011) for an increase of 127%. Deliveries associated with maternal opioid abuse or dependence compared with those without opioid abuse or dependence were associated with an increased odds of maternal death during hospitalization (adjusted odds ratio [aOR], 4.6; 95% CI, 1.8 to 12.1, crude incidence 0.03 vs. 0.006%), cardiac arrest (aOR, 3.6; 95% CI, 1.4 to 9.1; 0.04 vs. 0.01%), intrauterine growth restriction (aOR, 2.7; 95% CI, 2.4 to 2.9; 6.8 vs. 2.1%), placental abruption (aOR, 2.4; 95% CI, 2.1 to 2.6; 3.8 vs. 1.1%), length of stay more than 7 days (aOR, 2.2; 95% CI, 2.0 to 2.5; 3.0 vs. 1.2%), preterm labor (aOR, 2.1; 95% CI, 2.0 to 2.3; 17.3 vs. 7.4%), oligohydramnios (aOR, 1.7; 95% CI, 1.6 to 1.9; 4.5 vs. 2.8%), transfusion (aOR, 1.7; 95% CI, 1.5 to 1.9; 2.0 vs. 1.0%), stillbirth (aOR, 1.5; 95% CI, 1.3 to 1.8; 1.2 vs. 0.6%), premature rupture of membranes (aOR, 1.4; 95% CI, 1.3 to 1.6; 5.7 vs. 3.8%), and cesarean delivery (aOR, 1.2; 95% CI, 1.1 to 1.3; 36.3 vs. 33.1%). Conclusions:Opioid abuse or dependence during pregnancy is associated with considerable obstetrical morbidity and mortality, and its prevalence is dramatically increasing in the United States. Identifying preventive strategies and therapeutic interventions in pregnant women who abuse drugs are important priorities for clinicians and scientists.

Hypertensive disorders and pregnancy-related stroke: frequency, trends, risk factors, and outcomes.

OBJECTIVE: To evaluate trends and associations of hypertensive disorders of pregnancy with stroke risk and test the hypothesis that hypertensive disorders of pregnancy-associated stroke results in higher rates of stroke-related complications than pregnancy-associated stroke without hypertensive disorders. METHODS: A cross-sectional study was performed using 81,983,216 pregnancy hospitalizations from the 1994–2011 Nationwide Inpatient Sample. Rates of stroke hospitalizations with and without these hypertensive disorders were reported per 10,000 pregnancy hospitalizations. Using logistic regression, adjusted odds ratios (OR) with 95% confidence intervals were obtained. RESULTS: Between 1994–1995 and 2010–2011, the nationwide rate of stroke with hypertensive disorders of pregnancy increased from 0.8 to 1.6 per 10,000 pregnancy hospitalizations (103%), whereas the rate without these disorders increased from 2.2 to 3.2 per 10,000 pregnancy hospitalizations (47%). Women with hypertensive disorders of pregnancy were 5.2 times more likely to have a stroke than those without. Having traditional stroke risk factors (eg, congenital heart disease, atrial fibrillation, sickle cell anemia, congenital coagulation defects) substantially increased the stroke risk among hypertensive disorders of pregnancy hospitalizations: from adjusted OR 2.68 for congenital coagulation defects to adjusted OR 13.1 for congenital heart disease. Stroke-related complications were increased in stroke with hypertensive disorders of pregnancy compared with without (from adjusted OR 1.23 for nonroutine discharge to adjusted OR 1.93 for mechanical ventilation). CONCLUSION: Having traditional stroke risk factors substantially increased the stroke risk among hypertensive disorders of pregnancy hospitalizations. Stroke with hypertensive disorders in pregnancy had two distinctive characteristics: a greater increase in frequency since the mid-1990s and significantly higher stroke-related complication rates. LEVEL OF EVIDENCE: III

Patterns of Opioid Prescription and Use After Cesarean Delivery

OBJECTIVE To define the amount of opioid analgesics prescribed and consumed after discharge after cesarean delivery. METHODS We conducted a survey at six academic medical centers in the United States from September 2014 to March 2016. Women who had undergone a cesarean delivery were contacted by phone 2 weeks after discharge and participated in a structured interview about the opioid prescription they received on discharge and their oral opioid intake while at home. RESULTS A total of 720 women were enrolled; of these, 615 (85.4%) filled an opioid prescription. The median number of dispensed opioid tablets was 40 (interquartile range 30-40), the median number consumed was 20 (interquartile range 8-30), and leftover was 15 (interquartile range 3-26). Of those with leftover opioids, 95.3% had not disposed of the excess medication at the time of the interview. There was an association between a larger number of tablets dispensed and the number consumed independent of patient characteristics. The amount of opioids dispensed did not correlate with patient satisfaction, pain control, or the need to refill the opioid prescription. CONCLUSION The amount of opioid prescribed after cesarean delivery generally exceeds the amount consumed by a significant margin, leading to substantial amounts of leftover opioid medication. Lower opioid prescription correlates with lower consumption without a concomitant increase in pain scores or satisfaction.

Patient Characteristics and Outcomes After Hemorrhagic Stroke in Pregnancy

Background—Hospitalizations for pregnancy-related stroke are rare but increasing. Hemorrhagic stroke (HS), ie, subarachnoid hemorrhage and intracerebral hemorrhage, is more common than ischemic stroke in pregnant versus nonpregnant women, reflecting different phenotypes or risk factors. We compared stroke risk factors and outcomes in pregnant versus nonpregnant HS in the Get With The Guidelines-Stroke Registry. Methods and Results—Using medical history or International Classification of Diseases-Ninth Revision codes, we identified 330 pregnant and 10 562 nonpregnant female patients aged 18 to 44 years with HS in Get With The Guidelines-Stroke (2008–2014). Differences in patient and care characteristics were compared by &khgr;2 or Fisher exact test (categorical variables) or Wilcoxon rank-sum (continuous variables) tests. Conditional logistic regression assessed the association of pregnancy with outcomes conditional on categorical age and further adjusted for patient and hospital characteristics. Pregnant versus nonpregnant HS patients were younger with fewer pre-existing stroke risk factors and medications. Pregnant versus nonpregnant subarachnoid hemorrhage patients were less impaired at arrival, and less than half met blood pressure criteria for severe preeclampsia. In-hospital mortality was lower in pregnant versus nonpregnant HS patients: adjusted odds ratios (95% CI) for subarachnoid hemorrhage 0.17 (0.06–0.45) and intracerebral hemorrhage 0.57 (0.34–0.94). Pregnant subarachnoid hemorrhage patients also had a higher likelihood of home discharge (2.60 [1.67–4.06]) and independent ambulation at discharge (2.40 [1.56–3.70]). Conclusions—Pregnant HS patients are younger and have fewer risk factors than their nonpregnant counterparts, and risk-adjusted in-hospital mortality is lower. Our findings suggest possible differences in underlying disease pathophysiology and challenges to identifying at-risk patients.