Remotely delivered cognitive behavior therapy for disturbed grief during the COVID-19 crisis: challenges and opportunities

Cognitive behavior therapy (CBT) interventions are effective in alleviating disturbed grief. CBT is typically delivered face-to-face. Government policy during the coronavirus (COVID-19) pandemic (quarantine and social distancing) may impede access to face-to-face therapy. Psychotherapy is now widely delivered remotely. In this article, various points of attention related to the application of CBT for disturbed grief using telephone or videoconferencing (or video calling) services are discussed. Additionally, we explore possible ways in which individual risk factors and stressors connected with COVID-19 can be addressed in treatment. Remote treatment brings challenges but also opportunities to help people in shifting from unhealthy to healthy grieving

Maternal obesity, fish intake, and recurrent spontaneous preterm birth

Objective: Moderate fish intake in early pregnancy is associated with decreased risk of preterm birth (PTB). Obesity during pregnancy is characterized by inflammation and insufficiency of essential fatty acids. The objective of this study was to measure the association between fish intake during pregnancy and risk of recurrent spontaneous (s) PTB among lean, overweight, and obese women. Design: This is secondary analysis of a randomized controlled trial of omega-3 fatty acid supplementation for recurrent PTB prevention, 2005–2006. The primary exposure was fish intake at time of enrollment (16–22.9-week gestation). The primary outcomes were sPTB <37 weeks and sPTB <35 weeks. Maternal prepregnancy body mass index was treated as an effect modifier. Subjects: Eight hundred and fifty-two women were included, 47% were lean, 25% overweight, and 28% obese. Results: In this cohort, among lean, but not overweight or obese women, ≥1 serving of fish per week was associated with decreased frequency of sPTB <37 weeks compared with <1 serving of fish per week (45.1% versus 27.5%, p =.001) and spontaneous PTB <35 (21.4% versus 11.6%, p =.01). In adjusted models, as fish intake increased, the predicted probability of sPTB decreased in lean women but increased in overweight and obese women (p for interaction <.10). Conclusion: Fish intake was associated with lower probability of sPTB in lean women and higher probability in obese women. These findings warrant further investigation to understand the dietary or metabolic factors associated with obesity that may modulate benefit of fish intake during pregnancy

Risk of neonatal and childhood morbidity among preterm infants exposed to marijuana

Background: Limited data exist regarding the neonatal and neurodevelopmental outcomes of infants exposed to marijuana (MJ) in-utero, particularly among preterm infants. We hypothesized that MJ-exposed preterm infants would have worse neonatal and childhood developmental outcomes compared to MJ-unexposed infants. Methods: Secondary analysis of multicenter randomized-controlled trial of antenatal magnesium sulfate for the prevention of cerebral palsy was conducted. Singleton nonanomalous infants delivered <35 weeks exposed to MJ in-utero were compared to MJ-unexposed. Primary neonatal outcome was death, grade 3/4 intraventricular hemorrhage, periventricular leukomalacia, bronchopulmonary dysplasia, and/or stage II/III necrotizing enterocolitis before discharge. Primary childhood outcome was death, moderate/severe cerebral palsy, or/and Bayley II Scales <70 at age 2. Backward-stepwise regression used to estimate odds of primary outcomes. Results: 1867 infants met inclusion criteria; 135(7.2%) were MJ-exposed. There were no differences in neonatal (20% vs. 26%, p = 0.14) or childhood (26% vs. 21%, p = 0.21) outcomes in MJ-exposed infants compared to MJ-unexposed infants. In adjusted models, MJ-exposure was not associated with adverse neonatal outcomes (aOR 0.83 95% CI 0.47,1.44) or early childhood outcomes (aOR 1.47, 95% CI 0.97,2.23). Conclusions: Among infants born <35 weeks of gestation, MJ-exposure was not associated with adverse neonatal or childhood outcomes. Long-term follow-up studies are needed to assess later childhood neurodevelopmental outcomes following MJ-exposure

How Low Is Too Low? Postpartum Hemorrhage Risk among Women with Thrombocytopenia

Objective To estimate the association between severity of thrombocytopenia and postpartum hemorrhage. Study Design We performed a secondary analysis of a prospective cohort of women delivering by cesarean or vaginal birth after cesarean conducted by the National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Unit. Women delivering ≥ 20 weeks with platelets < 400,000/mL were included. Thrombocytopenia was defined as predelivery platelets of < 150,000/mL. Primary outcomes were (1) laboratory evidence of hemorrhage, defined as a decrease in hemoglobin ≥ 4 mg/dL and (2) clinical evidence of hemorrhage, a composite of atony, transfusion, coagulopathy, hysterectomy, laparotomy, or intensive care unit admission. Odds ratios were calculated for primary outcomes using thrombocytopenia as a dichotomous and ordinal variable. Results A total of 54,597 women were included; 5,611 (10.3%) had antepartum thrombocytopenia, 1,976 (3.6%) women had laboratory evidence of hemorrhage, and 3,862 (7.1%) had clinical evidence of hemorrhage. Thrombocytopenia was associated with both laboratory evidence of hemorrhage (adjusted odds ratio [aOR]: 1.60, 95% CI: 1.38-1.86) and clinical evidence of hemorrhage (aOR: 1.68, 95% CI: 1.52-1.83). The odds of laboratory and clinical evidence of hemorrhage increased incrementally with severity of thrombocytopenia. Conclusion Thrombocytopenia is associated with both laboratory and clinical evidence of hemorrhage; risk increases dramatically as platelet count decreases

“Only One Way Out”-Partners' Experiences and Grief Related to the Death of Their Loved One by Suicide or Physician-Assisted Dying Due to a Mental Disorder

Background: Previous research has provided insight into the grief of suicide survivors, but little is known about grief following physician-assisted dying (PAD), and no prior study specifically focused on grief following PAD due to a mental disorder. The current study aims to increase insight into experiences preceding PAD or suicide of a loved one due to a mental disorder and their impact on mental health symptoms. Methods: We performed a survey study and in-depth interviews with 27 bereaved life partners. The deceased had been in treatment for mental disorders and had died by PAD (n = 12) or suicide (n = 15). Interviews explored grief experiences and experiences with mental health care. In the survey, we assessed self-reported symptoms of grief, post-traumatic stress, anxiety, depression, quality of life, and impairments in social, and occupational functioning. Results: All participants reported generally low levels of mental health symptoms. Longer time since death and death by PAD were associated with lower grief intensity. Interviews showed various degrees of expectedness of the partners' death, and a varying impact of being present at the death on bereaved partners. Conclusion: Expectedness of the death of the partner, absence of suffering of the partner at the time of dying, and presence of physician support may in part explain the protective effects of PAD against severe grief reactions. Physicians considering their position regarding their personal involvement in PAD due to a mental disorder could take grief reactions of the bereaved partner into account

“Only One Way Out”-Partners' Experiences and Grief Related to the Death of Their Loved One by Suicide or Physician-Assisted Dying Due to a Mental Disorder

Background: Previous research has provided insight into the grief of suicide survivors, but little is known about grief following physician-assisted dying (PAD), and no prior study specifically focused on grief following PAD due to a mental disorder. The current study aims to increase insight into experiences preceding PAD or suicide of a loved one due to a mental disorder and their impact on mental health symptoms. Methods: We performed a survey study and in-depth interviews with 27 bereaved life partners. The deceased had been in treatment for mental disorders and had died by PAD (n = 12) or suicide (n = 15). Interviews explored grief experiences and experiences with mental health care. In the survey, we assessed self-reported symptoms of grief, post-traumatic stress, anxiety, depression, quality of life, and impairments in social, and occupational functioning. Results: All participants reported generally low levels of mental health symptoms. Longer time since death and death by PAD were associated with lower grief intensity. Interviews showed various degrees of expectedness of the partners' death, and a varying impact of being present at the death on bereaved partners. Conclusion: Expectedness of the death of the partner, absence of suffering of the partner at the time of dying, and presence of physician support may in part explain the protective effects of PAD against severe grief reactions. Physicians considering their position regarding their personal involvement in PAD due to a mental disorder could take grief reactions of the bereaved partner into account

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 &lt;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 &lt; .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

Risk Factors for Postpartum Septic Pelvic Thrombophlebitis: A Multicenter Cohort

Objective The objective of this study was to identify risk factors associated with the development of septic pelvic thrombophlebitis (SPT). Study Design This is a secondary case-control study of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Unit Network Cesarean Registry. SPT was defined as suspected infectious thrombosis of the pelvic veins, often persistent febrile illness in the setting of antibiotic therapy for endometritis. Women with SPT were compared with those without SPT using descriptive statistics. Logistic regression models estimated the association between selected risk factors and SPT. Results Of 73,087 women in the cohort, 89 (0.1%) developed SPT. Women with SPT were more likely to be < 20 years old (33.7 vs. 10.6%, p < 0.001), black race (58.4 vs. 29.1%, p < 0.001), and nulliparous (51.1 vs. 23.3%, p < 0.001). Hypertensive disorders of pregnancy (32.6 vs. 11.8%, p < 0.001) and multiple gestation (12.5 vs. 7.4%, p = 0.03) were also more common in women with SPT. In the multivariable regression model, maternal age < 20, black race, multiple gestation, and preeclampsia were all significantly associated with increased odds of SPT (adjusted odds ratio [aOR]: 1.96, 95% confidence interval [CI]: 1.22, 3.14; aOR: 2.6, 95% CI: 1.68, 4.02; aOR: 2.10, 95% CI: 1.13, 3.88; aOR: 2.91, 95% CI: 1.86, 4.57). Conclusion SPT is a rare pregnancy complication. Our analysis confirmed known risk factors (e.g., infections, cesarean delivery), and identified novel ones, including black race, young age, preeclampsia, and multiple gestation