Publications by authors named "Adina R Kern-Goldberger"

15 Publications

  • Page 1 of 1

Examining Ultrasound Diagnostic Performance Improvement with Utilization of Maternal-Fetal Medicine Tele-Interpretation.

Am J Obstet Gynecol MFM 2021 May 3:100389. Epub 2021 May 3.

Maternal and Child Health Research Center, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.

Background: Telemedicine can extend essential health services to under-resourced settings and improve level and quality of obstetric care. Specifically, evaluation and management of fetal anomalies often requires perinatal subspecialists, rendering prenatal diagnosis essential, and may benefit from telemedicine platforms to improve access to care.

Objective: This study examines the impact of a maternal-fetal medicine (MFM) tele-ultrasound program on diagnostic accuracy of fetal anomalies when deployed within practices where ultrasounds are otherwise interpreted by general obstetricians or family medicine physicians.

Study Design: This is a cross-sectional study of all patients receiving care at eleven private obstetric practices and imaging centers who had an obstetric ultrasound performed from January 1, 2020 - July 6, 2020. All ultrasounds were performed by sonographers remotely trained under a standardized protocol and interpreted by MFM physicians via telemedicine. Ultrasound characteristics and interpretation were extracted from ultrasound reports. Prior to introduction of tele-MFM, all ultrasounds were reviewed by general obstetricians and family medicine physicians with reliance predominantly on the sonographer's impression. The primary outcome was potential missed diagnosis of a fetal anomaly, defined as an ultrasound designated as normal by the sonographer but diagnosed with an anomaly via tele-MFM. These serve as a proxy measure of anomaly diagnoses that would likely be missed without MFM supervision. Characteristics of potential missed diagnoses were compared by type of scan and fetal organ system in univariable analysis. A survey was also conducted of sonographers and in-person obstetric providers to assess perceptions of MFM ultrasound interpretation via telemedicine.

Results: In total, 6,403 ultrasounds were evaluated, 310 of which had a diagnosis of a fetal anomaly by an MFM physician (4.8%). 43 of the anomalies were diagnosed on anatomic survey (13.9%) and 89 were cardiac anomalies (28.7%). The overall rate of potential missed diagnoses was 34.5% and varied significantly by type of ultrasound [anatomy scans versus other first, second, and third trimester ultrasounds] (p < 0.01). There were significant differences in the rate of potential missed diagnoses by organ system, with the highest rate for cardiac anomalies (p< 0.01).

Conclusions: MFM expertise refines diagnostic performance of antenatal ultrasound throughout pregnancy. This has implications for improving quality of antenatal care by ensuring appropriate referrals and site of delivery, particularly for cardiac anomalies.
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http://dx.doi.org/10.1016/j.ajogmf.2021.100389DOI Listing
May 2021

Risk for and disparities in critical care during delivery hospitalizations.

Am J Obstet Gynecol MFM 2021 Mar 22;3(4):100354. Epub 2021 Mar 22.

Departments of Obstetrics and Gynecology (Drs Arditi, Wen, Gyamfi-Bannerman, D'Alton, and Friedman). Electronic address:

Background: Need for critical care during delivery hospitalizations may be an important maternal outcome measure, but it is not well characterized.

Objective: This study aimed to characterize the risks and disparities in critical care diagnoses and interventions during delivery hospitalizations.

Study Design: This serial cross-sectional study used the 2000-2014 National Inpatient Sample. Here, the primary outcome was a composite of critical care interventions and diagnoses, including mechanical ventilation and intubation, central monitoring, septicemia, coma, acute cerebrovascular disease, extracorporeal membrane oxygenation, Swan-Ganz catheter monitoring, cardiac rhythm conversion, and respiratory failure. Temporal trends, risk of death, and the proportion of deaths with a critical care composite diagnosis were determined. Unadjusted and adjusted log-linear regression models were fit with a critical care composite as the outcome, adjusting for demographic, clinical, and hospital factors. To evaluate the role of critical care interventions in disparities, analyses were stratified by maternal race and ethnicity.

Results: Of 45.8 million deliveries identified, 0.21% had a critical care procedure or diagnosis during the delivery hospitalization. Overall, 75.8% of maternal deaths had an associated diagnosis from a critical care composite. The critical composite increased from 17.9 to 30.3 per 10,000 deliveries from 2000 to 2014 with an average annual percentage change of 3.4% (95% confidence interval, 1.3-5.5). Mechanical ventilation and intubation (21.5% of cases) and respiratory failure (54.8% of cases) were the most common diagnoses present in the composite. Although non-Hispanic black women were at 32.4% higher risk than non-Hispanic white women to die in the setting of a critical care diagnosis (2.2% vs 1.7%; P<.01), they were 162% more likely to have a critical care diagnosis (risk ratio, 2.62; 95% confidence interval, 2.58-2.66). Of clinical factors, primary cesarean delivery (adjusted relative risk, 7.54; 95% confidence interval, 7.43-7.65), postpartum hemorrhage (adjusted relative risk, 5.11; 95% confidence interval, 5.02-5.19), and chronic kidney disease (adjusted relative risk, 4.06; 95% confidence interval, 3.89-4.23) were associated with the highest adjusted risk of a critical care composite.

Conclusion: Here, three-quarters of maternal deaths were associated with a critical care diagnosis or procedure. The rate of critical care during delivery hospitalizations increased over the study period. Maternal mortality disparities may result from risks of conditions that require critical care rather than the care received once a critical care condition has developed.
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http://dx.doi.org/10.1016/j.ajogmf.2021.100354DOI Listing
March 2021

Racial Disparities in Maternal Critical Care: Are There Racial Differences in Level of Care?

J Racial Ethn Health Disparities 2021 Mar 8. Epub 2021 Mar 8.

Columbia University Medical Center, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, NY, New York, USA.

Background: Obstetric care in the US is complicated by marked racial and ethnic disparities in maternal obstetric outcomes, including severe morbidity and mortality, which are not explained by underlying differences in patient characteristics. Understanding differences in care delivery related to clinical acuity across different racial groups may help elucidate the source of these disparities.

Objective: This study examined the association of maternal race with utilization of critical care interventions.

Study Design: This is a retrospective cohort study conducted as a secondary analysis of a large, multicenter observational study of women undergoing cesarean delivery. All women with a known delivery date were included. The primary outcome measure, a composite of critical care interventions (CCI) at delivery or postpartum that included mechanical ventilation, central and arterial line placement, and intensive care unit (ICU) admission were compared by racial/ethnic group-non-Hispanic white, non-Hispanic black, Hispanic, Asian, and Native American. We evaluated differences in utilization of critical care with a multivariable regression model accounting for selected characteristics present at admission for delivery, including maternal age, BMI, co-morbidities, parity, and plurality. Maternal mortality was also evaluated as a secondary outcome and the frequency of CCI by significant maternal co-morbidity, specifically heart disease, renal disease, and chronic hypertension was assessed to ascertain the level of care provided to women of different race/ethnicity with specific baseline co-morbidities.

Results: 73,096 of 73,257 women in the parent trial met inclusion criteria, of whom 505 (0.7%) received a CCI and 3337 (4.6%) had a significant medical co-morbidity (1.2% heart disease, 0.8% renal disease, 2.5% chronic hypertension). The mortality rate was significantly higher among non-Hispanic black women, compared to non-Hispanic white and Hispanic women. In the adjusted model, there was no significant association between CCI and race/ethnicity.

Conclusion: This study suggests that differences in maternal morbidity by race may be accounted for by differential escalation to higher intensity care. Further investigation into processes for care intensification may continue to clarify sources of racial and ethnic disparities in maternal morbidity and potential for improvement.
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http://dx.doi.org/10.1007/s40615-021-01000-zDOI Listing
March 2021

Methodologic Concerns With Concluding a Link Between Epidural and Autism Spectrum Disorder.

JAMA Pediatr 2021 May;175(5):536-537

Maternal and Child Health Research Center, Perelman School of Medicine, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia.

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http://dx.doi.org/10.1001/jamapediatrics.2020.6692DOI Listing
May 2021

Disparities in obstetric morbidity by maternal level of education.

J Matern Fetal Neonatal Med 2020 Dec 14:1-5. Epub 2020 Dec 14.

Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA.

Background: Maternal race and socioeconomic status are predictors of obstetric morbidity and mortality in the U.S. A better understanding of the role that maternal education plays in these disparities could enable and target better interventions to improve obstetric outcomes.

Objective: This study aims to assess the impact of the level of education on morbidity.

Study Design: We conducted a retrospective nested cohort study from a multicenter observational cohort of women undergoing cesarean delivery. Nulliparous women with live, non-anomalous singleton gestations who underwent primary cesarean section and had education status recorded were included. Education level was categorized as none, elementary, high school, some college, and a college degree. The primary outcome was a composite of maternal cesarean complications including hysterectomy, uterine atony, blood transfusion, surgical injury, arterial ligation, infection, wound complication, and ileus. A composite of neonatal morbidity was evaluated as a secondary outcome. We then created a multivariable logistic regression model adjusting for selected demographic and obstetric variables that may influence the likelihood of the primary outcome.

Results: 10,344 women met inclusion criteria with a 20.3% incidence of the primary outcome. After adjusting for potential confounding variables including race and medical co-morbidities, the incidence of maternal cesarean complications was found to be higher for women with only elementary (OR 1.34, 95% CI 1.01-1.78) and high school (OR 1.24, 95% CI 1.03-1.48) education, compared to women with a college degree. There was also higher neonatal morbidity among women with high school (OR 1.39, 95% CI 1.20-1.62) and some college (OR 1.23, 95% CI 1.04-1.46) education, compared to women with a college degree.

Conclusion: These findings suggest that efforts to alleviate adverse outcomes in obstetrics should target patient counseling and health literacy as differences in educational background are closely associated with disparities in maternal and neonatal morbidity.
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http://dx.doi.org/10.1080/14767058.2020.1860935DOI Listing
December 2020

Telemedicine in Obstetrics.

Clin Perinatol 2020 12;47(4):743-757

Department of Obstetrics & Gynecology, Maternal Child Health Research Center, University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2nd Floor Silverstein Building, Philadelphia, PA 19146, USA. Electronic address:

Telemedicine is an important modality of care delivery in the twenty-first century and has many applications for the obstetric population. Existing research has shown the clinical efficacy and improved patient satisfaction of many telemedicine platforms in obstetrics. Telemedicine has the potential to reduce racial and geographic disparities in pregnancy care, but more research is necessary to inform best practices. Developing cost-effective telemedicine programs and establishing health care policy that standardizes insurance reimbursement are some of the most important steps toward scaling up telemedicine offerings for obstetric patients in the United States.
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http://dx.doi.org/10.1016/j.clp.2020.08.007DOI Listing
December 2020

An assessment of baseline risk factors for peripartum maternal critical care interventions.

J Matern Fetal Neonatal Med 2020 Aug 10:1-6. Epub 2020 Aug 10.

Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA.

Background: Maternal morbidity presents a growing challenge to the American healthcare system and increasing numbers of patients are requiring higher levels of care in pregnancy. Identifying patients at high risk for critical care interventions, including intensive care unit admission, during delivery hospitalizations may facilitate appropriate multidisciplinary planning and lead to improved maternal safety. Baseline risk factors for critical care in pregnancy have not been well-described previously.

Objective: This study assesses baseline factors associated with critical care interventions that were present at admission for delivery.

Study Design: This is a secondary analysis of a multicenter observational registry of pregnancy after prior uterine surgery and primary cesarean delivery. All women with known gestational age were included. The primary outcome measure was a composite of critical care interventions that included postpartum intensive care unit admission, mechanical ventilation, central intravenous access, and arterial line placement. Risk for this critical care outcome measure was compared by selected baseline and obstetric characteristics known at the time of hospital admission, including maternal age, pre-pregnancy BMI, race, maternal co-morbidities, parity, and plurality. We evaluated these potential predictors and fit a multivariable logistic regression model to ascertain the most significant risk factors for critical care during a delivery hospitalization.

Results: 73,096 of 73,257 women in the parent trial met inclusion criteria, of whom 505 underwent a critical care intervention (0.7%). In the adjusted model, heart disease [aOR = 10.05, CI = 6.97 - 14.49], renal disease [aOR = 2.78, CI = 1.49 - 5.18], and connective tissue disease [aOR = 3.27, CI = 1.52 - 6.99], as well as hypertensive disorders of pregnancy [aOR = 2.04, CI = 1.31 - 3.17] were associated with the greatest odds of critical care intervention [ < .01] (Table 2). Other predictors associated with increased risk included maternal age, African American race, smoking, diabetes, asthma, anemia, nulliparity, and twin pregnancy.

Conclusion: In this cohort, women with cardiac disease, renal disease, connective tissue disease and preeclampsia spectrum disorders were at increased risk for critical care interventions. Obstetric providers should assess patient risk routinely, ensure appropriate maternal level of care, and create multidisciplinary plans to improve maternal safety and reduce risk.
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http://dx.doi.org/10.1080/14767058.2020.1803258DOI Listing
August 2020

Wrong-Patient Ordering Errors in Peripartum Mother-Newborn Pairs: A Unique Patient-Safety Challenge in Obstetrics.

Obstet Gynecol 2020 07;136(1):161-166

Department of Obstetrics & Gynecology and the Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, and the Department of Quality and Patient Safety, NewYork-Presbyterian Hospital, New York, New York.

Because maternal morbidity and mortality remain persistent challenges to the U.S. health care system, efforts to improve inpatient patient safety are critical. One important aspect of ensuring patient safety is reducing medical errors. However, obstetrics presents a uniquely challenging environment for safe ordering practices. When mother-newborn pairs are admitted in the postpartum setting with nearly identical names in the medical record (for example, Jane Doe and Janegirl Doe), there is a potential for wrong-patient medication ordering errors. This can lead to harm from the wrong patient receiving a medication or diagnostic test, especially a newborn receiving an adult dose of medication, as well as delaying treatment for the appropriate patient. We describe two clinical scenarios of wrong-patient ordering errors between mother-newborn pairs. The first involves an intravenous labetalol order that was placed for a postpartum patient but was released from the automated dispensing cabinet under the newborn's name. The medication was administered correctly, but an automatic order for labetalol was generated in the neonate's chart. Another scenario involves a woman presenting in labor with acute psychotic symptoms. The psychiatry service placed a note and orders for antipsychotic medications in the neonate's chart. These orders were cancelled shortly thereafter and replaced for the mother. These scenarios illustrate this specific patient-safety concern inherent in the treatment of mother-newborn pairs and highlight that perinatal units should evaluate threats to patient safety embedded in the unique mother-newborn relationship and develop strategies to reduce risk.
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http://dx.doi.org/10.1097/AOG.0000000000003872DOI Listing
July 2020

Clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnancies: a United States cohort study.

Am J Obstet Gynecol MFM 2020 08 8;2(3):100134. Epub 2020 May 8.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.

Background: The coronavirus disease 2019 pandemic has had an impact on healthcare systems around the world with 3 million people contracting the disease and 208,000 cases resulting in death as of this writing. Information regarding coronavirus infection in pregnancy is still limited.

Objective: This study aimed to describe the clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnant women with positive laboratory testing for severe acute respiratory syndrome coronavirus 2.

Study Design: This is a cohort study of pregnant women with severe or critical coronavirus disease 2019 hospitalized at 12 US institutions between March 5, 2020, and April 20, 2020. Severe disease was defined according to published criteria as patient-reported dyspnea, respiratory rate >30 per minute, blood oxygen saturation ≤93% on room air, ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen <300 mm Hg, or lung infiltrates >50% within 24-48 hours on chest imaging. Critical disease was defined as respiratory failure, septic shock, or multiple organ dysfunction or failure. Women were excluded from the study if they had presumed coronavirus disease 2019, but laboratory testing was negative. The primary outcome was median duration from hospital admission to discharge. Secondary outcomes included need for supplemental oxygen, intubation, cardiomyopathy, cardiac arrest, death, and timing of delivery. The clinical courses are described by the median disease day on which these outcomes occurred after the onset of symptoms. Treatment and neonatal outcomes are also reported.

Results: Of 64 hospitalized pregnant women with coronavirus disease 2019, 44 (69%) had severe disease, and 20 (31%) had critical disease. The following preexisting comorbidities were observed: 25% had a pulmonary condition, 17% had cardiac disease, and the mean body mass index was 34 kg/m. Gestational age was at a mean of 29±6 weeks at symptom onset and a mean of 30±6 weeks at hospital admission, with a median disease day 7 since first symptoms. Most women (81%) were treated with hydroxychloroquine; 7% of women with severe disease and 65% of women with critical disease received remdesivir. All women with critical disease received either prophylactic or therapeutic anticoagulation during their admission. The median duration of hospital stay was 6 days (6 days [severe group] and 10.5 days [critical group]; =.01). Intubation was usually performed around day 9 on patients who required it, and peak respiratory support for women with severe disease was performed on day 8. In women with critical disease, prone positioning was required in 20% of cases, the rate of acute respiratory distress syndrome was 70%, and reintubation was necessary in 20%. There was 1 case of maternal cardiac arrest, but there were no cases of cardiomyopathy or maternal death. Thirty-two of 64 (50%) women with coronavirus disease 2019 in this cohort delivered during their hospitalization (34% [severe group] and 85% [critical group]). Furthermore, 15 of 17 (88%) pregnant women with critical coronavirus disease 2019 delivered preterm during their disease course, with 16 of 17 (94%) pregnant women giving birth through cesarean delivery; overall, 15 of 20 (75%) women with critical disease delivered preterm. There were no stillbirths or neonatal deaths or cases of vertical transmission.

Conclusion: In pregnant women with severe or critical coronavirus disease 2019, admission into the hospital typically occurred about 7 days after symptom onset, and the duration of hospitalization was 6 days (6 [severe group] vs 12 [critical group]). Women with critical disease had a high rate of acute respiratory distress syndrome, and there was 1 case of cardiac arrest, but there were no cases of cardiomyopathy or maternal mortality. Hospitalization of pregnant women with severe or critical coronavirus disease 2019 resulted in delivery during the clinical course of the disease in 50% of this cohort, usually in the third trimester. There were no perinatal deaths in this cohort.
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http://dx.doi.org/10.1016/j.ajogmf.2020.100134DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7205698PMC
August 2020

Care of critically ill pregnant patients with coronavirus disease 2019: a case series.

Am J Obstet Gynecol 2020 08 1;223(2):286-290. Epub 2020 May 1.

Department of Obstetrics & Gynecology, Maternal Child Health Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

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http://dx.doi.org/10.1016/j.ajog.2020.04.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7252050PMC
August 2020

Searching for a biochemical correlate of critical illness in obstetrics: a descriptive study of maternal lactate in patients presenting for acute care in pregnancy.

J Matern Fetal Neonatal Med 2020 Mar 23:1-3. Epub 2020 Mar 23.

Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA.

Obstetric physiology may alter lactate metabolism and affect the ability to use lactate as a discriminator of critical illness in pregnancy. This prospective, cross-sectional study describes venous lactate levels in women presenting for acute care during pregnancy as well as characteristics associated with elevated lactate. Obstetric patients >20-week gestation presenting for acute evaluation were included and a venous lactate sample was drawn for each patient. Elevated lactate was defined as ≥2 mmol/L. One hundred two women were enrolled and venous lactate samples were obtained for 100 participants. Median lactate level was 1.22 (IQR 0.95-1.49) and 86% of patients had normal lactate. Six patients presented with infectious complaints, none of whom had sepsis or elevated lactate. Of the 14 patients with elevated lactate, all presented with labor complaints and 10 (71.4%) were admitted in labor. Elevated lactate level was significantly associated with labor complaints and admission in labor ( < .01). Thus, lactate may not be able to discriminate severe infection consistently in pregnancy as it is confounded by labor. Further research is necessary to clarify how lactate may be used more effectively in pregnant patients and to identify alternate strategies for sepsis screening.
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http://dx.doi.org/10.1080/14767058.2020.1743667DOI Listing
March 2020

Opioid Use Disorder during Antepartum and Postpartum Hospitalizations.

Am J Perinatol 2020 12 17;37(14):1467-1475. Epub 2019 Aug 17.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Columbia University, New York.

Objective: This study aimed to evaluate temporal trends in opioid use disorder (OUD) during antepartum and postpartum hospitalizations.

Study Design: This repeated cross-sectional analysis analyzed data from the National (Nationwide) Inpatient Sample. Women aged 15 to 54 years admitted antepartum or postpartum were identified. The presence of OUD was determined based on a diagnosis of opioid abuse, opioid dependence, or opioid overdose. Temporal trends in OUD were evaluated using the Rao-Scott chi-square test. Temporal trends in opioid overdose were additionally evaluated.

Results: An estimated 7,336,562 antepartum hospitalizations and 1,063,845 postpartum readmissions were included in this analysis. The presence of an OUD diagnosis during antepartum hospitalizations increased from 0.7% of patients in 1998 to 1999 to 2.9% in 2014 ( < 0.01) and during postpartum hospitalizations increased from 0.8% of patients in 1998 to 1999 to 2.1% of patients in 2014 ( < 0.01). Risk of overdose diagnoses increased significantly for both antepartum hospitalizations, from 22.7 per 100,000 hospitalizations in 1998 to 2000 to 70.3 per 100,000 hospitalizations in 2013 to 2014 ( < 0.001), and postpartum hospitalizations, from 18.8 per 100,000 hospitalizations in 1998 to 2000 to 65.2 per 100,000 hospitalizations in 2013 to 2014 ( = 0.02).

Discussion: Risk of OUD diagnoses and overdoses increased over the study period for both antepartum and postpartum hospitalizations.
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http://dx.doi.org/10.1055/s-0039-1694725DOI Listing
December 2020

Oral Opioid Use during Vaginal Delivery Hospitalizations.

Am J Perinatol 2020 03 12;37(4):390-397. Epub 2019 Feb 12.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York.

Objective: This study aimed to determine the receipt of short-acting opioid medications during vaginal delivery hospitalizations.

Study Design: The Perspective database was analyzed to evaluate patterns of short-acting oral opioid use during vaginal delivery hospitalizations from January 2006 to March 2015. Unadjusted and adjusted models evaluating the role of demographic and hospital factors were created evaluating use of opioids. Hospital-level rates of opioid use were evaluated. Opioid receipt among women with opioid abuse or dependence was evaluated based on overall hospital rates of opioid use.

Results: Of 3,785,396 vaginal delivery hospitalizations from 2006 to 2015, 1,720,899 (45.5%) women received an oral opioid for pain relief. Opioid use varied significantly among the 458 hospitals included in the analysis, with one-third of hospitals providing opioids to <38% of patients, one-third to 38 to <59% of patients, and one-third to ≥59% of patients. When hospitals were stratified by overall opioid administration rates, women with opioid abuse or dependence were less likely to be given opioids in hospitals with low overall opioid rates.

Discussion: The use of opioid pain medications during vaginal delivery hospitalizations varied significantly among hospitals, suggesting that standardization of pain management practices could reduce opioid use.
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http://dx.doi.org/10.1055/s-0039-1678566DOI Listing
March 2020

Trends and Outcomes Associated With Using Long-Acting Opioids During Delivery Hospitalizations.

Obstet Gynecol 2018 10;132(4):937-947

Departments of Obstetrics and Gynecology and Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, New York.

Objective: To assess trends in use of long-acting opioids during delivery hospitalizations.

Methods: The Perspective database, an administrative inpatient database that includes medication receipt, was analyzed to evaluate patterns of long-acting opioid use during delivery hospitalizations from January 2006 through March 2015. Medications evaluated included methadone, formulations including buprenorphine and extended-release formulations of oxycodone, morphine, fentanyl, and other opioids. Temporal trends in use of these medications were determined. Unadjusted and adjusted models evaluating the role of demographic and hospital factors were created evaluating both use of these medications and risk for severe morbidity. Risk for severe morbidity was determined based on Centers for Disease Control and Prevention criteria.

Results: Our analysis included 2,994,630 delivery hospitalizations meeting study criteria. Over the entire study period, use of long-acting opioids increased significantly from 457 to 844 per 100,000 deliveries. Although buprenorphine and methadone use increased, use of other long-acting opioids decreased. In 2006, methadone and buprenorphine accounted for less than one third of all long-acting opioids used during delivery hospitalizations. By 2015, buprenorphine and methadone represented 73.5% of long-acting opioids used. In adjusted and unadjusted models, risk for severe morbidity was significantly lower with buprenorphine or methadone compared with other long-acting opioids. Restricting the cohort to only women with drug abuse or dependence, risk for severe morbidity was lower with methadone and buprenorphine than without any long-acting opioids.

Conclusion: Increased use of methadone and buprenorphine in this study supports the feasibility of use of these medications during pregnancy and uptake of clinical recommendations for women with opioid use disorder. Use of methadone and buprenorphine is associated with decreased maternal morbidity, although causation cannot be presumed from this study model.
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http://dx.doi.org/10.1097/AOG.0000000000002861DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6153065PMC
October 2018

Maternal age and risk for adverse outcomes.

Am J Obstet Gynecol 2018 10 25;219(4):390.e1-390.e15. Epub 2018 Aug 25.

Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY. Electronic address:

Objective: The objective of this study was to characterize the risk for severe maternal morbidity and other pregnancy complications by maternal age during delivery hospitalizations.

Study Design: This retrospective cohort analysis used the Perspective database to characterize the risk for adverse maternal outcomes from 2006 to 2015 based on maternal age. Women were divided into 7 categories based on maternal age: 15-17, 18-24, 25-29, 30-34, 35-39, 40-44, and 45-54 years of age. The primary outcome of this study was severe maternal morbidity as defined by the Centers for Disease Control and Prevention. Secondary outcomes included (1) overall comorbid risk; (2) risk for pregnancy complications such as postpartum hemorrhage, gestational diabetes, preeclampsia, and cesarean delivery; and (3) risk for individual severe morbidity diagnoses such as stroke, embolism, eclampsia, and hysterectomy. Adjusted models were fitted to assess factors associated with severe morbidity with adjusted risk ratios (aRRs) and 95% confidence intervals (CI) as measures of effect. Population weights were applied to create national estimates.

Results: Of 36,944,292 deliveries included, 2.5% occurred among women aged 15-17 years (n = 921,236), 29.1% to women aged 18-24 years (n = 10,732,715), 28.6% to women aged 25-29 years (n = 10,564,850), 24.9% to women aged 30-34 years (n = 9,213,227), 12.1% to women aged 35-39 years (n = 4,479,236), 2.6% to women aged 40-44 years (n = 974,289), and 0.2% to women aged 45-54 years (n = 58,739). In unadjusted analyses, severe morbidity was more than 3 times higher (risk ratio [RR], 3.33, 95% confidence interval [CI], 3.03-3.66) for women 45-54 years compared with women 25-29 years. Women aged 40-44, 35-39, and 15-17 years were also at increased risk (RR, 1.83, 95% CI, 1.77-1.89; RR, 1.36, 95% CI, 1.33-1.39; RR, 1.39, 95% CI, 1.34-1.45, respectively). In the adjusted model, the 45-54 year old group was associated with the highest relative risk (aRR, 3.46, 95% CI, 3.15-3.80) followed by the 40-44 year old group (aRR 1.90, 95% CI, 1.84-1.97), the 35-39 year old group (aRR, 1.43, 95% CI, 1.40-1.47), and the 15-17 year old group (aRR, 1.20, 95% CI, 1.15-1.24). Cesarean delivery, preeclampsia, postpartum hemorrhage, and gestational diabetes were most common among women aged 45-54 years, as were thrombosis and hysterectomy.

Conclusion: While differential risk was noted across maternal age categories, women aged 45 years old and older were at highest risk for a broad range of adverse outcomes during delivery hospitalizations.
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http://dx.doi.org/10.1016/j.ajog.2018.08.034DOI Listing
October 2018