Trends in opioid and psychotropic prescription in pregnancy in the united states from 2001 to 2015 in a privately insured population: A cross-sectional study

Background: Opioid and psychotropic prescriptions are common during pregnancy. Little is known about coprescriptions of both medications in this setting. Objective: To describe opioid prescription among women who are prescribed psychotropics compared with women who are not. Design: Cross-sectional study. Setting: U.S. commercial insurance beneficiaries from Market- Scan (2001 to 2015). Participants: Pregnant women at 22 weeks' gestation or greater who were insured continuously for 3 months or more before pregnancy through delivery. Measurements: Opioid prescription, dosage thresholds (morphine milligram equivalents [MME] of ≥50/day and ≥90/day), number of opioid agents (≥2), and duration (≥30 days) among those with and without prescription of psychotropics, from 2011 to 2015. Results: Among 958 980 pregnant women, 10% received opioids only, 6% psychotropics only, and 2% opioids with coprescription of psychotropics. Opioid prescription was higher among women prescribed psychotropics versus those who were not (26.5% vs. 10.7%). From 2001 to 2015, psychotropic prescription overall increased from 4.4% to 7.6%, opioid prescription without coprescription of psychotropics decreased from 11.9% to 8.4%, and opioids with coprescription decreased from 28.1% to 22.0%. Morphine milligram equivalents of 50 or greater per day decreased for women with and without coprescription (29.6% to 17.3% and 22.8% to 18.5%, respectively); MME of 90 or greater per day also decreased in both groups (15.0% to 4.7% and 11.5% to 4.2%, respectively). Women prescribed opioids only were more likely to have an antepartum hospitalization compared with those with neither prescription, as were women with coprescription versus those prescribed psychotropics only. Compared with those prescribed opioids only, women with coprescriptions were more likely to exceed MME of 90 or greater per day and to be prescribed 2 or more opioid agents and for 30 days or longer. Number and duration of opioids increased with benzodiazepine and gabapentin coprescription. Limitation: Inability to determine appropriateness of prescribing or overdose events. Conclusion: Opioids are frequently coprescribed with psychotropic medication during pregnancy and are associated with antepartum hospitalization. A substantial proportion of pregnant women are prescribed opioids at doses that increase overdose risk and exceed daily recommendations

Maternal obesity and major intraoperative complications during cesarean delivery

Background Multiple studies have demonstrated an association between maternal obesity and postoperative complications, but there is a dearth of information about the impact of obesity on intraoperative complications. Objective To estimate the association between maternal obesity at delivery and major intraoperative complications during cesarean delivery (CD). Methods This is a secondary analysis of the deidentified Maternal-Fetal Medicine Unit Cesarean Registry of women with singleton pregnancies. Maternal body mass index (BMI) at delivery was categorized as BMI 18.5 to 29.9 kg/m2, BMI 30 to 39.9 kg/m2, BMI 40 to 49.9 kg/m2, and BMI ≥ 50 kg/m2. The primary outcome, any intraoperative complication, was defined as having at least 1 major intraoperative complication, including perioperative blood transfusion, intraoperative injury (bowel, bladder, ureteral injury; broad ligament hematoma), atony requiring surgical intervention, repeat laparotomy, and hysterectomy. Log-binomial models were used to estimate risk ratios of intraoperative complication in 2 models: model 1 adjusting for maternal race, and preterm delivery <37 weeks; and model 2 adjusting for confounders in Model 1 as well as emergency CD, and type of skin incision. Results A total of 51,218 women underwent CD; 38% had BMI 18.5 to 29.9 kg/m2, 47% BMI 30 to 39.9 kg/m2, 12% BMI 40 to 49.9 kg/m2 and 3% BMI ≥ 50 kg/m2. Having at least 1 intraoperative complication was uncommon (3.4%): 3.8% for BMI 18.5 to 29.9 kg/m2, 3.2% BMI 30 to 39.9 kg/m2, 2.6% BMI 40 to 49.9 kg/m2 and 4.3% BMI ≥ 50 kg/m2 (P < .001). In the fully adjusted model 2, women with BMI 40 to 49.9 kg/m2 had a lower risk of any intraoperative complication (adjusted risk ratio [ARR], 0.76; 95% confidence interval [CI], 0.64 to 0.89) compared with women with BMI 18.5 to 29.9 kg/m2. Women with BMI 30 to 39.9 kg/m2 (ARR, 0.93; 95% CI, 0.84 to 1.03) had a similar risk of any intraoperative complication compared with nonobese women. Among super obese women, there was evidence of effect modification by emergency CD. Compared with nonobese women, neither super obese women undergoing nonemergency CD (ARR, 1.13; 95% CI, 0.84 to 1.52) nor those undergoing emergency CD (ARR, 0.59; 95% CI, 0.32 to 1.10) had an increased risk of intraoperative complication. Conclusion In contrast to the risk for postcesarean complications, the risk of intraoperative complication does not appear to be increased in obese women, even among those with super obesity

Maternal super obesity and neonatal morbidity after term cesarean delivery

Objective To estimate the association between maternal super obesity (body mass index [BMI] ≥ 50 kg/m2) and neonatal morbidity among neonates born via cesarean delivery (CD). Methods Retrospective cohort of singleton neonates delivered via CD ≥ 37 weeks in the Maternal-Fetal Medicine Unit Cesarean Registry. Maternal BMI at delivery was stratified as 18.5 to 29.9 kg/m2, 30 to 39.9 kg/m2, 40 to 49.9 kg/m2, and ≥ 50 kg/m2. Primary outcomes included acute (5-minute Apgar score < 5, cardiopulmonary resuscitation and ventilator support < 24 hours, neonatal injury, and/or transient tachypnea of the newborn) and severe (grade 3 or 4 intraventricular hemorrhage, necrotizing enterocolitis, seizure, respiratory distress syndrome, hypoxic ischemic encephalopathy, meconium aspiration, ventilator support ≥ 2 days, sepsis and/or neonatal death) neonatal morbidity. Odds of neonatal morbidity were estimated for each BMI category adjusting for clinical and operative characteristics. Results Of 41,262 maternal-neonatal dyads, 36% of women were nonobese, 49% had BMI of 30 to 39.9 kg/m2, 12% had BMI of 40 to 49.9 kg/m2, and 3% were super obese. Compared with nonobese women, super obese women had twofold odds of acute (5 vs. 10%; adjusted odds ratio [aOR]: 1.81, 95% confidence interval [CI]: 1.59-2.73) and severe (3 vs. 6%; aOR: 2.08; 95% CI: 1.59-2.73) neonatal morbidity. Conclusion Among term infants delivered via CD, maternal super obesity is associated with increased risk of neonatal morbidity

Prenatal Tdap immunization and risk of maternal and newborn adverse events

Many countries recommend combined tetanus toxoid, reduced diphtheria toxoid and acellular pertussis immunization (Tdap) during pregnancy to stimulate transplacental transmission of pertussis antibodies to newborns. The immune system can be altered during pregnancy, potentially resulting in differing immunization risks in pregnant women. The safety of widespread Tdap immunization during pregnancy needs to be established. Our objective was to assess whether prenatal Tdap immunization was associated with adverse birth outcomes, and to evaluate the effect of timing of Tdap administration on these outcomes. We identified pregnancies at delivery in a large insurance claims database (2010–2014). Tdap immunization was categorized as optimal prenatal (27 + weeks), early prenatal (<27 weeks), postpartum (≤7 days post-delivery), or none. Medical claims were searched to identify maternal adverse immunization reactions (e.g. anaphylaxis, fever, Guillian-Barre syndrome [GBS]), adverse birth outcomes (e.g. preeclampsia/eclampsia, premature rupture or membranes, chorioamnionitis) and newborn outcomes (e.g. respiratory distress, pulmonary hypertension, neonatal jaundice). Women with optimal or early prenatal Tdap were compared to those not immunized in pregnancy, using propensity score-weighted log-binomial regression and Cox proportional hazards models to estimate risk ratios (RR) and hazard ratios (HR). We identified 1,079,034 deliveries and 677,075 linked newborns; 11.5% were immunized optimally and 2.3% immunized early. There were 1 case of post-immunization anaphylaxis, and 12 cases of maternal encephalopathy (all post- delivery); there were no cases of GBS. Optimally-timed immunization was associated with small increased relative risks of: chorioamnionitis [RR = 1.11, (95% CI: 1.07–1.15), overall risk = 2.8%], and postpartum hemorrhage [RR = 1.23 (95% DI: 1.18–1.28), overall risk = 2.4%]; however, these relative increases corresponded to low absolute risk increases. Tdap was not associated with increased risk of any adverse newborn outcome. Overall, prenatal Tdap immunization was not associated with newborn adverse events, but potential associations with chorioamnionitis consistent with one previous study and postpartum hemorrhage require further investigation

Maternal Morbidity after Previable Prelabor Rupture of Membranes

OBJECTIVE: To identify risk factors for maternal morbidity after previable prelabor rupture of membranes (PROM). METHODS: We conducted a case-control study of singleton and twin pregnancies complicated by previable PROM (14.0-22.9 weeks of gestation) at a single tertiary care referral institution, 2000-2015. Pregnancies complicated by fetal anomalies, previable PROM within 2 weeks of chorionic villus sampling or amniocentesis, and those with contraindications to expectant management (eg, chorioamnionitis) were excluded. Cases were women with the primary outcome of composite maternal morbidity (defined as having at one or more of the following: sepsis, intensive care unit admission, acute renal insufficiency, uterine curettage, hysterectomy, deep vein thrombosis, pulmonary embolus, blood transfusion, readmission, or maternal death). Controls were women without the primary composite morbidity. Bivariate analysis compared demographic, clinical, and management characteristics of women in the case group and those in the control group. Multivariable logistic regression models were developed to quantify the association between maternal characteristics and composite severe maternal morbidity. RESULTS: During the study period, 174 women presented with by previable PROM and were candidates for expectant management. Sixty-five (37%) women opted for immediate delivery; 109 (63%) elected expectant management. Twenty-five of 174 (14%) experienced one or more components of the composite maternal morbidity (cases) and were compared with 149 (86%) women in the control group. Women in the case group were more not more likely to elect expectant management (68% compared with 59%, P=.40), but were more likely to be aged 35 years or older (40% compared with 14%, P=.002) or to be carrying twins (52% compared with 16%, P<.01). In the regression model, twin gestation and age 35 years or older were both significantly associated with increased odds of composite maternal morbidity (odds ratio [OR] 5.62, 95% confidence interval [CI] 2.21-14.3 and OR 4.00, 95% CI 1.48-10.8, respectively). CONCLUSION: Antenatal counseling of women with previable PROM should include that one in seven women experience significant morbidity. Although expectant management was not associated with increased risk in this cohort, women with twins or those aged 35 years or older were at substantially increased risk

Effectiveness of Prenatal Tetanus, Diphtheria, Acellular Pertussis Vaccination in the Prevention of Infant Pertussis in the U.S.

Introduction: It is recommended that all pregnant women in the U.S. receive tetanus, diphtheria, acellular pertussis (Tdap) immunization to prevent infant pertussis. This study's objective was to examine the clinical effectiveness of prenatal Tdap, and whether effectiveness varies by gestational age at immunization. Methods: A nationwide cohort study of pregnant women with deliveries in 2010–2014 and their infants was performed. Commercial insurance claims data were analyzed in 2016–2017 to identify Tdap receipt by the pregnant women, and hospitalizations and outpatient visits for pertussis in their infants until the infants reached 18 months of age. Pertussis occurrence was compared between infants of mothers who received prenatal Tdap (overall and stratified by gestational age at administration) and infants of unvaccinated mothers. Results: There were 675,167 mother–infant pairs in the cohort. Among infants whose mothers received prenatal Tdap, the rate of pertussis was 43% lower (hazard ratio=0.57, 95% CI=0.35, 0.92) than infants whose mothers did not receive prenatal or postpartum Tdap; this reduction was consistent across pertussis definitions (hazard ratio for inpatient-only pertussis=0.32, 95% CI=0.11, 0.91). Pertussis rates were also lower for infants whose mothers received Tdap during the third trimester. Infants whose mothers received Tdap at <27 weeks of gestation did not experience reductions in pertussis rates (hazard ratio for pertussis=1.10, 95% CI=0.54, 2.25). Conclusions: Infants of mothers who received prenatal Tdap experienced half the rate of pertussis as compared with infants of unimmunized mothers. These results do not provide evidence to support changing the currently recommended timing of Tdap administration in pregnancy

Predictors of low uptake of prenatal tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis immunization in privately insured women in the United States

OBJECTIVE: To examine the uptake of prenatal tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) immunization among pregnant women in the United States. METHODS: Using MarketScan data, we conducted a historical cohort study among pregnant women with employer-based commercial insurance in the United States who delivered between January 1, 2010, and December 31, 2014. We examined temporal trends of uptake, predictors of uptake, and timing of Tdap immunization. RESULTS: Among 1,222,384 eligible pregnancies in 1,147,711 women, receipt of prenatal Tdap immunization increased from 0.0% of women who delivered in January 2010 to 9.8% who delivered in October 2012 (the date of the recommendation by the Advisory Committee on Immunization Practices for Tdap during every pregnancy) to 44.4% who delivered in December 2014. Among women who received Tdap during pregnancy, the majority were immunized between 27 weeks and 36 6/7 weeks of gestation per the Advisory Committee on Immunization Practices recommendation. In multivariable analyses among women who delivered between November 2012 and December 2014, rates of prenatal Tdap immunization were lower for women younger than 25 years of age (eg, 20-24 compared with 30-34 years rate ratio [RR] 0.83, 95% confidence interval [CI] 0.85-0.88), with other children (eg, three compared with zero children: RR 0.86, 95% CI 0.84-0.88), residing in the South compared with the Midwest (RR 0.81, 95% CI 0.80-0.82), or with emergency department visits in early pregnancy (RR 0.93, 95% CI 0.92-0.95). The proportion of pregnant women who received prenatal Tdap increased with increasing gestational age at birth. CONCLUSION: By the end of 2014, fewer than half of pregnant women in the United States were receiving prenatal Tdap immunization. Implementation and dissemination strategies are needed to increase Tdap coverage among pregnant women, especially those who are young, have other children, or reside in the South

Association between Features of Spontaneous Late Preterm Labor and Late Preterm Birth

Objective This study aimed to evaluate the association between clinical and examination features at admission and late preterm birth. Study Design The present study is a secondary analysis of a randomized trial of singleton pregnancies at 34 0/7 to 36 5/7 weeks' gestation. We included women in spontaneous preterm labor with intact membranes and compared them by gestational age at delivery (preterm vs. term). We calculated a statistical cut-point optimizing the sensitivity and specificity of initial cervical dilation and effacement at predicting preterm birth and used multivariable regression to identify factors associated with late preterm delivery. Results A total of 431 out of 732 (59%) women delivered preterm. Cervical dilation ≥ 4 cm was 60% sensitive and 68% specific for late preterm birth. Cervical effacement ≥ 75% was 59% sensitive and 65% specific for late preterm birth. Earlier gestational age at randomization, nulliparity, and fetal malpresentation were associated with late preterm birth. The final regression model including clinical and examination features significantly improved late preterm birth prediction (81% sensitivity, 48% specificity, area under the curve = 0.72, 95% confidence interval [CI]: 0.68-0.75, and p -value &lt; 0.01). Conclusion Four in 10 women in late-preterm labor subsequently delivered at term. Combination of examination and clinical features (including parity and gestational age) improved late-preterm birth prediction

Simulating Inbred-Maize Yields with CERES-IM

CERES-Maize, which was designed for simulation of hybrid maize (Zea mays L.), cannot be applied directly to seed-producing inbred maize because of specific field operations and physiological traits of inbred maize plants. We developed CERES-IM, a modified version of CERES-Maize 3.0 that accommodates these inbred-specific operations and traits, using a set of phenological measurements conducted in Nebraska (NE), and further tested this model with a set of field data from Michigan (MI). Detasseling (i.e., removal of the tassels from the female plants) was conducted prior to silking. Male rows were removed approximately 10 d following 75% silking. The thermal time from emergence to the end of the juvenile phase (P1) and the potential number of kernels per plant (G2) were assessed from field data, and were the only two coefficients allowed to vary according to the inbred line. Rate of leaf appearance of the inbreds was accurately simulated using a measured phyllochron interval of 54 degree-days (°Cd). Simulation of detasseling and male-row removal improved grain yield simulation for inbreds. For a set of 35 inbred-site-year simulations, the model simulated grain yield with satisfactory accuracy (RMSE 5 429 kg ha-1). Average grain yields were 4556 and 4721 kg ha-1 for the measured and simulated values, respectively. CERES- IM simulations suggest that the effect of male-row removal on grain yield is extremely sensitive to the precise date at which this operation is conducted. This would explain the inconsistent effect of male-row removal on female grain yields reported in the literature