Edward Hayes

Predicting length of treatment for neonatal abstinence syndrome in methadone-exposed neonates.

OBJECTIVE The objective of the study was to identify maternal variables predicting length of treatment for neonatal abstinence syndrome (NAS). STUDY DESIGN This was a retrospective cohort study of infants treated for NAS during 2000-2006 whose mothers were on methadone maintenance at delivery. Mixed-effects linear regression was used to examine the interaction of maternal and neonatal variables with length of treatment. RESULTS Of 204 neonates born to methadone exposed mothers, the average dose at delivery was 127 mg daily (25-340 mg) with median length of treatment 32 days (1-122 days). Trimester of initial exposure (P = .33), methadone dose at delivery (P = .198), body mass index (P = .31), antidepressant use (P = .40), cigarette use (P = .76), race (P = .78), and maternal age (P = .84) did not predict length of treatment. In the multivariate analysis, gestational age at delivery and benzodiazepine use were significant predictors of length of treatment. CONCLUSION Later gestational age and concomitant benzodiazepine use were associated with longer treatment.

Improving patient safety and uniformity of care by a standardized regimen for the use of oxytocin

Oxytocin is 1 of the most commonly used drugs in labor and has been associated with adverse maternal and fetal outcomes. In an attempt to improve patient safety, we constructed a standardized protocol for labor induction with oxytocin. We reviewed the numerous publications regarding oxytocin use for either induction or augmentation of labor in order to determine if there was a protocol available that would maximize success of delivery and minimize the adverse maternal and fetal effects of the drug. Using the literature review and the specific pharmacokinetics of oxytocin, we developed a standardized approach for the dilution and administration of oxytocin in order to improve patient safety, develop uniformity of the drug use, maximize its benefits, and minimize its side effects. We suggest that a standardized approach to oxytocin use be adopted that uses an oxytocin dilution of 10 mU/mL, initial dose of 2 mU/min (12 mL/hr), incremental increase of 2 mU (12 mL) every 45 minutes until adequate labor with the maximum dose being 16 mU/min (96 mL/hr).

Effect of antenatal corticosteroids on survival for neonates born at 23 weeks of gestation.

OBJECTIVE: To estimate if exposure to antenatal corticosteroids was associated with decreased rate of death in neonates born at 23 weeks of gestation. METHODS: This is a retrospective cohort study performed at three tertiary centers of neonates born at 23 weeks of gestation between 1998 and 2007. Stillbirths, voluntary terminations, or parental elected nonresuscitations were excluded. Clinical and demographic variables were examined to determine possible confounding variables. A multivariable logistic regression model was used to assess the effect of steroids on the odds of death after adjustment for these confounders. RESULTS: The sample included 181 neonates. Of the multiple variables examined (institution, race, diagnosis, illicit drug use, antibiotics, assisted reproduction, birth weight, gender, and route of delivery), only multiple gestations were significantly associated (P≤.15) with steroid use and increased odds of death (odds ratio [OR] 3.66, 95% confidence interval [CI] 1.05–12.73) and controlled for in the final model. The multivariable model revealed those exposed to antenatal corticosteroids had decreased odds of death (OR 0.32, 95% CI 0.12–0.84), with no significant differences in the occurrence of necrotizing enterocolitis among survivors (15.4% compared with 28.6%, P=.59) or severe intraventricular hemorrhage (23.1% compared with 57.1%, P=.17). In analyzing the effect of steroid dose, only a complete course of corticosteroids was associated with a decreased odds of death (OR 0.18, 95% CI 0.06–0.54). CONCLUSION: Neonates at 23 weeks of gestation whose mothers completed a course of antenatal corticosteroids had an associated 82% reduction in odds of death. LEVEL OF EVIDENCE: II

Relationship between maternal methadone dose at delivery and neonatal abstinence syndrome.

OBJECTIVE To estimate the relationship between maternal methadone dose and the incidence of neonatal abstinence syndrome (NAS). STUDY DESIGN We performed a retrospective cohort study of pregnant women treated with methadone for opiate addiction who delivered live-born neonates between 1996 and 2006. Four dose groups, on the basis of total daily methadone dose, were compared (<or=80 mg/d, 81-120 mg/d, 121-160 mg/d, and >160 mg/d). The primary outcome was treatment for NAS. Symptoms of NAS were objectively measured with the Finnegan scoring system, and treatment was initiated for a score>24 during the prior 24 hours. RESULTS A total of 330 women treated with methadone and their 388 offspring were included. Average methadone dose at delivery was 117+/-50 mg/d (range, 20-340 mg/d). Overall, 68% of infants were treated for NAS. Of infants exposed to methadone doses<or=80 mg/d, 81-120 mg/d, 121-160 mg/d, and >160 mg/d, treatment for NAS was initiated for 68%, 63%, 70%, and 73% of neonates, respectively (P=.48). The rate of maternal illicit opiate abuse at delivery was 26%, 28%, 19%, and 11%, respectively (P=.04). CONCLUSION No correlation was found between maternal methadone dose and rate of NAS. However, higher doses of methadone were associated with decreased illicit opiate abuse at delivery.

Review of "Multiple Pregnancy: Epidemiology, Gestation & Perinatal Outcome. Second Edition"

Over the past two decades, an epidemic of multiple pregnancies has taken place in the developed world due to the widespread use of assisted reproductive technology. The general public has come to accept the phenomenon of higher order multiple as being a normal occurrence, expecting a good outcome for both the fetuses and the mother. However, physicians caring for these patients appreciate that these pregnancies have an increased number of complications both for the mother and fetus. The mother suffers substantial morbidity not just due to the risk and interventions of prematurity but also the increased incidence in medical complications. The fetuses are at jeopardy not just due to premature delivery, but also the increased rates of anomalies in multiples, and those complications uniquely associated with multiples, such as twin to twin transfusion syndrome. Clinicians involved in management of these high-risk pregnancies regrettably have had to rely on protocols based on expert opinion with unproven efficacy. These protocols may unintentionally place a mother and her unborn children at significant risk without achieving the desired benefit.