Doug Brunk

SAN DIEGO – Meconium-stained amniotic fluid may increased risk of surgical site infections following a cesarean delivery, results from a large analysis showed.

Surgical site infection (SSI) occurs in 3%-9% of patients who have a cesarean delivery, and many require hospitalization or further surgery, lead study author Andrea Snyder, MD, PhD, said at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. Risk factors for SSI included chorioamnionitis, obesity, preeclampsia, preterm premature rupture of membranes, nulliparity, or emergency cesarean. Current management for avoiding SSIs includes prophylactic antibiotics, antiseptic skin, and vaginal prep.

Doug Brunk/Frontline Medical News

Meconium-stained amniotic fluid (MSAF) occurs in 12%-15% of all deliveries, Dr. Snyder, of the department of obstetrics and gynecology at Ohio State University, Columbus, noted. “It is known to be associated with maternal infections including chorioamnionitis and endometriosis,” she said. “It is suspected that MSAF could be associated with SSI; however, few studies have been done.” One study from 1984 showed that MSAF was significantly associated with SSI (Am J Infect Control. 1984 Feb;12[1]:19-25). “However, this study was done prior to the routine administration of preoperative antibiotics for cesarean deliveries,” Dr. Snyder said. “Other studies since that time have either not shown an association between MSAF and SSI or have not separated SSI from postpartum endometriosis.”

In an effort to test the hypothesis that meconium-stained fluid is an independent risk factor associated with an increased risk of postcesarean SSI, she and her associates evaluated a subset of 25,220 women from the Maternal-Fetal Medicine Units Network cesarean registry who were treated at 19 different institutions. Their mean age was 27 years, they were all attempting labor or induction of labor, were all singleton pregnancies, and all had cesarean deliveries.

Of the 25,220 patients studied, 5,883 (23%) had MSAF. The researchers found that the incidence of SSI was 11.9% among patients who had MSAF, compared with an incidence of 8.9% among patients who did not, a difference that reached statistical significance (P less than .001). After using a multivariable logistic regression model to control for confounders including chorioamnionitis, diabetes, intrauterine pressure catheter placement, tobacco use, length of labor, length of rupture, preeclampsia, and obesity, the association between MSAF and SSI persisted (odds ratio, 1.25; confidence interval, 1.12-1.39; P less than .001).

Advantages of the study, she said, include the fact that it was a large population of patients treated at multiple institutions, “so it should be very generalizable to most practices. We also controlled for many known factors associated with SSI.” Dr. Snyder acknowledged certain limitations of the study, including the fact that the data do not show causation and that there is no further information about the SSIs. “Were those associated with meconium less or more severe SSIs?” she asked. “Does the increase in risk confer an increased risk of severe infectious morbidity? Where do we go from here and what do we do with this information? At this point we don’t have any way of preventing meconium.”

A 2014 Cochrane review found that, while prophylactic antibiotics for patients with MSAF did not decrease the risk of postpartum endometriosis, it did decrease the risk of chorioamnionitis. “But would it help decrease the risk of SSIs? We have no idea,” Dr. Snyder asked. “Would continuing antibiotics after delivery help reduce wound infections? We don’t do that routinely in a C-section, but maybe that would make sense for patients that are higher risk.” She reported having no financial disclosures.

[email protected]

SAN DIEGO – Meconium-stained amniotic fluid may increased risk of surgical site infections following a cesarean delivery, results from a large analysis showed.

Surgical site infection (SSI) occurs in 3%-9% of patients who have a cesarean delivery, and many require hospitalization or further surgery, lead study author Andrea Snyder, MD, PhD, said at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. Risk factors for SSI included chorioamnionitis, obesity, preeclampsia, preterm premature rupture of membranes, nulliparity, or emergency cesarean. Current management for avoiding SSIs includes prophylactic antibiotics, antiseptic skin, and vaginal prep.

Doug Brunk/Frontline Medical News

Meconium-stained amniotic fluid (MSAF) occurs in 12%-15% of all deliveries, Dr. Snyder, of the department of obstetrics and gynecology at Ohio State University, Columbus, noted. “It is known to be associated with maternal infections including chorioamnionitis and endometriosis,” she said. “It is suspected that MSAF could be associated with SSI; however, few studies have been done.” One study from 1984 showed that MSAF was significantly associated with SSI (Am J Infect Control. 1984 Feb;12[1]:19-25). “However, this study was done prior to the routine administration of preoperative antibiotics for cesarean deliveries,” Dr. Snyder said. “Other studies since that time have either not shown an association between MSAF and SSI or have not separated SSI from postpartum endometriosis.”

In an effort to test the hypothesis that meconium-stained fluid is an independent risk factor associated with an increased risk of postcesarean SSI, she and her associates evaluated a subset of 25,220 women from the Maternal-Fetal Medicine Units Network cesarean registry who were treated at 19 different institutions. Their mean age was 27 years, they were all attempting labor or induction of labor, were all singleton pregnancies, and all had cesarean deliveries.

Of the 25,220 patients studied, 5,883 (23%) had MSAF. The researchers found that the incidence of SSI was 11.9% among patients who had MSAF, compared with an incidence of 8.9% among patients who did not, a difference that reached statistical significance (P less than .001). After using a multivariable logistic regression model to control for confounders including chorioamnionitis, diabetes, intrauterine pressure catheter placement, tobacco use, length of labor, length of rupture, preeclampsia, and obesity, the association between MSAF and SSI persisted (odds ratio, 1.25; confidence interval, 1.12-1.39; P less than .001).

Advantages of the study, she said, include the fact that it was a large population of patients treated at multiple institutions, “so it should be very generalizable to most practices. We also controlled for many known factors associated with SSI.” Dr. Snyder acknowledged certain limitations of the study, including the fact that the data do not show causation and that there is no further information about the SSIs. “Were those associated with meconium less or more severe SSIs?” she asked. “Does the increase in risk confer an increased risk of severe infectious morbidity? Where do we go from here and what do we do with this information? At this point we don’t have any way of preventing meconium.”

A 2014 Cochrane review found that, while prophylactic antibiotics for patients with MSAF did not decrease the risk of postpartum endometriosis, it did decrease the risk of chorioamnionitis. “But would it help decrease the risk of SSIs? We have no idea,” Dr. Snyder asked. “Would continuing antibiotics after delivery help reduce wound infections? We don’t do that routinely in a C-section, but maybe that would make sense for patients that are higher risk.” She reported having no financial disclosures.

[email protected]

SAN DIEGO – Meconium-stained amniotic fluid may increased risk of surgical site infections following a cesarean delivery, results from a large analysis showed.

Surgical site infection (SSI) occurs in 3%-9% of patients who have a cesarean delivery, and many require hospitalization or further surgery, lead study author Andrea Snyder, MD, PhD, said at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. Risk factors for SSI included chorioamnionitis, obesity, preeclampsia, preterm premature rupture of membranes, nulliparity, or emergency cesarean. Current management for avoiding SSIs includes prophylactic antibiotics, antiseptic skin, and vaginal prep.

Doug Brunk/Frontline Medical News

Meconium-stained amniotic fluid (MSAF) occurs in 12%-15% of all deliveries, Dr. Snyder, of the department of obstetrics and gynecology at Ohio State University, Columbus, noted. “It is known to be associated with maternal infections including chorioamnionitis and endometriosis,” she said. “It is suspected that MSAF could be associated with SSI; however, few studies have been done.” One study from 1984 showed that MSAF was significantly associated with SSI (Am J Infect Control. 1984 Feb;12[1]:19-25). “However, this study was done prior to the routine administration of preoperative antibiotics for cesarean deliveries,” Dr. Snyder said. “Other studies since that time have either not shown an association between MSAF and SSI or have not separated SSI from postpartum endometriosis.”

In an effort to test the hypothesis that meconium-stained fluid is an independent risk factor associated with an increased risk of postcesarean SSI, she and her associates evaluated a subset of 25,220 women from the Maternal-Fetal Medicine Units Network cesarean registry who were treated at 19 different institutions. Their mean age was 27 years, they were all attempting labor or induction of labor, were all singleton pregnancies, and all had cesarean deliveries.

Of the 25,220 patients studied, 5,883 (23%) had MSAF. The researchers found that the incidence of SSI was 11.9% among patients who had MSAF, compared with an incidence of 8.9% among patients who did not, a difference that reached statistical significance (P less than .001). After using a multivariable logistic regression model to control for confounders including chorioamnionitis, diabetes, intrauterine pressure catheter placement, tobacco use, length of labor, length of rupture, preeclampsia, and obesity, the association between MSAF and SSI persisted (odds ratio, 1.25; confidence interval, 1.12-1.39; P less than .001).

Advantages of the study, she said, include the fact that it was a large population of patients treated at multiple institutions, “so it should be very generalizable to most practices. We also controlled for many known factors associated with SSI.” Dr. Snyder acknowledged certain limitations of the study, including the fact that the data do not show causation and that there is no further information about the SSIs. “Were those associated with meconium less or more severe SSIs?” she asked. “Does the increase in risk confer an increased risk of severe infectious morbidity? Where do we go from here and what do we do with this information? At this point we don’t have any way of preventing meconium.”

A 2014 Cochrane review found that, while prophylactic antibiotics for patients with MSAF did not decrease the risk of postpartum endometriosis, it did decrease the risk of chorioamnionitis. “But would it help decrease the risk of SSIs? We have no idea,” Dr. Snyder asked. “Would continuing antibiotics after delivery help reduce wound infections? We don’t do that routinely in a C-section, but maybe that would make sense for patients that are higher risk.” She reported having no financial disclosures.

[email protected]

 

SAN DIEGO – Young women who received group prenatal visits under the CenteringPregnancy model were significantly more likely than were women receiving traditional prenatal care to elect long-acting reversible contraceptives postpartum, results from a small study show.

CenteringPregnancy (CP) – a group prenatal care model for women with due dates around the same time – has been touted as a way to decrease the incidence of preterm deliveries, but little is known about potential additional benefits for other birth-related outcomes, lead study author

Dikea Roussos-Ross, MD, said at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

CP sessions “follow the regular prenatal visit structure but the care itself is in a group setting,” said Dr. Roussos-Ross, an ob.gyn. at the University of Florida, Gainesville. “Each session lasts an hour and a half to 2 hours. In that group session, patients receive routine prenatal care and increased knowledge of various topics in pregnancy.”

Dr. Roussos-Ross and her associates set out to compare pregnancy-related outcomes in 20 patients aged 18-21 years who received care through the CP model, with a random sample of 20 patients who received care via the traditional care model in women’s health clinics at the University of Florida Health from January to December of 2014. They found that a significantly higher proportion of women in the CP group were African American, compared with those in the control group (85% vs. 55%, respectively; P = .024). In addition, uptake of long-acting reversible contraceptives was significantly higher among the CP group, compared with the control group (32% vs. 0%; P = .0292).

“One of the centering sessions is revolved around the education of different contraceptive uses, so they get information on the different options that they have,” Dr. Roussos-Ross said.

Differences did not reach statistical significance in other birth-related outcomes, but trends favored the CP group in most of the variables studied, including higher rates of flu vaccination (50% vs. 30%; P = .196), Tdap vaccination (60% vs. 35%; P = .11), breastfeeding initiation (95% vs. 90%; P = .579), and breastfeeding at 6 weeks postpartum (42% vs. 20%; P = .2427). Some adverse outcomes were lower in the CP group, such as low birth weight (0% vs. 10%; P = .1468), and the proportion of patients who failed to appear for their postpartum visit (21% vs. 35%; P = .333).

“The CP program was not able to demonstrate an improved preterm delivery outcome in adolescent mothers,” Dr. Roussos-Ross said. “However, this small study was able to demonstrate complementary benefits of CP in adolescent mothers, including improved breastfeeding rates, immunization rates, and [long-acting reversible contraception] usage rates. Offering adolescent mothers group care allows for greater time with their provider, which in turn may lead to increased knowledge and understanding of health and pregnancy-related outcomes.”

The researchers received grant funding from the March of Dimes for start-up costs.

[email protected]

 

SAN DIEGO – Young women who received group prenatal visits under the CenteringPregnancy model were significantly more likely than were women receiving traditional prenatal care to elect long-acting reversible contraceptives postpartum, results from a small study show.

CenteringPregnancy (CP) – a group prenatal care model for women with due dates around the same time – has been touted as a way to decrease the incidence of preterm deliveries, but little is known about potential additional benefits for other birth-related outcomes, lead study author

Dikea Roussos-Ross, MD, said at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

CP sessions “follow the regular prenatal visit structure but the care itself is in a group setting,” said Dr. Roussos-Ross, an ob.gyn. at the University of Florida, Gainesville. “Each session lasts an hour and a half to 2 hours. In that group session, patients receive routine prenatal care and increased knowledge of various topics in pregnancy.”

Dr. Roussos-Ross and her associates set out to compare pregnancy-related outcomes in 20 patients aged 18-21 years who received care through the CP model, with a random sample of 20 patients who received care via the traditional care model in women’s health clinics at the University of Florida Health from January to December of 2014. They found that a significantly higher proportion of women in the CP group were African American, compared with those in the control group (85% vs. 55%, respectively; P = .024). In addition, uptake of long-acting reversible contraceptives was significantly higher among the CP group, compared with the control group (32% vs. 0%; P = .0292).

“One of the centering sessions is revolved around the education of different contraceptive uses, so they get information on the different options that they have,” Dr. Roussos-Ross said.

Differences did not reach statistical significance in other birth-related outcomes, but trends favored the CP group in most of the variables studied, including higher rates of flu vaccination (50% vs. 30%; P = .196), Tdap vaccination (60% vs. 35%; P = .11), breastfeeding initiation (95% vs. 90%; P = .579), and breastfeeding at 6 weeks postpartum (42% vs. 20%; P = .2427). Some adverse outcomes were lower in the CP group, such as low birth weight (0% vs. 10%; P = .1468), and the proportion of patients who failed to appear for their postpartum visit (21% vs. 35%; P = .333).

“The CP program was not able to demonstrate an improved preterm delivery outcome in adolescent mothers,” Dr. Roussos-Ross said. “However, this small study was able to demonstrate complementary benefits of CP in adolescent mothers, including improved breastfeeding rates, immunization rates, and [long-acting reversible contraception] usage rates. Offering adolescent mothers group care allows for greater time with their provider, which in turn may lead to increased knowledge and understanding of health and pregnancy-related outcomes.”

The researchers received grant funding from the March of Dimes for start-up costs.

[email protected]

 

SAN DIEGO – Young women who received group prenatal visits under the CenteringPregnancy model were significantly more likely than were women receiving traditional prenatal care to elect long-acting reversible contraceptives postpartum, results from a small study show.

CenteringPregnancy (CP) – a group prenatal care model for women with due dates around the same time – has been touted as a way to decrease the incidence of preterm deliveries, but little is known about potential additional benefits for other birth-related outcomes, lead study author

Dikea Roussos-Ross, MD, said at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

CP sessions “follow the regular prenatal visit structure but the care itself is in a group setting,” said Dr. Roussos-Ross, an ob.gyn. at the University of Florida, Gainesville. “Each session lasts an hour and a half to 2 hours. In that group session, patients receive routine prenatal care and increased knowledge of various topics in pregnancy.”

Dr. Roussos-Ross and her associates set out to compare pregnancy-related outcomes in 20 patients aged 18-21 years who received care through the CP model, with a random sample of 20 patients who received care via the traditional care model in women’s health clinics at the University of Florida Health from January to December of 2014. They found that a significantly higher proportion of women in the CP group were African American, compared with those in the control group (85% vs. 55%, respectively; P = .024). In addition, uptake of long-acting reversible contraceptives was significantly higher among the CP group, compared with the control group (32% vs. 0%; P = .0292).

“One of the centering sessions is revolved around the education of different contraceptive uses, so they get information on the different options that they have,” Dr. Roussos-Ross said.

Differences did not reach statistical significance in other birth-related outcomes, but trends favored the CP group in most of the variables studied, including higher rates of flu vaccination (50% vs. 30%; P = .196), Tdap vaccination (60% vs. 35%; P = .11), breastfeeding initiation (95% vs. 90%; P = .579), and breastfeeding at 6 weeks postpartum (42% vs. 20%; P = .2427). Some adverse outcomes were lower in the CP group, such as low birth weight (0% vs. 10%; P = .1468), and the proportion of patients who failed to appear for their postpartum visit (21% vs. 35%; P = .333).

“The CP program was not able to demonstrate an improved preterm delivery outcome in adolescent mothers,” Dr. Roussos-Ross said. “However, this small study was able to demonstrate complementary benefits of CP in adolescent mothers, including improved breastfeeding rates, immunization rates, and [long-acting reversible contraception] usage rates. Offering adolescent mothers group care allows for greater time with their provider, which in turn may lead to increased knowledge and understanding of health and pregnancy-related outcomes.”

The researchers received grant funding from the March of Dimes for start-up costs.

[email protected]

 

SAN DIEGO – Most transgender men have visited a gynecologist’s office at least once, but just 37% attend annual visits, results from a small survey showed.

“We’re seeing a large need and lack of access to gynecologic care,” Adriana J. Wong, the study author, said in an interview at the annual meeting of the American College of Obstetricians and Gynecologists. “Some barriers that we’ve identified are fear of mistreatment, a perceived lack of informed providers, and gender dysphoria.”

A 2011 opinion from ACOG’s Committee on Health Care for Underserved Women urges clinicians to provide quality health care to transgender patients, yet a 2015 survey published in the Journal of Woman’s Health found that just 29% of ob.gyns. report feeling comfortable caring for transgender men (2015 Feb;24[2]:114-8).

In an effort to assess transgender men’s experiences with, ability to access, and understanding of gynecologic care, Ms. Wong and her associates distributed an anonymous Web-based and paper-based survey to a convenience sample of transgender men in the Miami area. The mean age of the 41 respondents was 28 years, 56% were white, 41% had a high school diploma, 27% had a college degree, and 17% had a graduate degree.

The majority of survey participants (78%) reported having been to a gynecologist, 37% attended annual visits, 78% had health insurance, 56% delayed care because of gender identity concerns, and 20% experienced mistreatment at a gynecologist’s office.

Respondents reported delaying or avoiding care because they “felt uncomfortable with the extremely gendered experience of [gynecologic] care,” “fear of mistreatment,” and “my dysphoria prevented me. Plus, I wasn’t sure if there were friendly ob.gyns. around.”

“One of the most distinctive things to me is that we had a pretty well-insured population in our sample, and they were mostly Caucasian,” said Ms. Wong, a second-year medical student at the University of Miami. “Even though almost 80% were insured, [fewer] than 40% were receiving annual visits. This is the population that would potentially have the best possibility of receiving care, but they’re not seeking it out.”

The researchers reported having no relevant financial disclosures.

[email protected]

 

SAN DIEGO – Most transgender men have visited a gynecologist’s office at least once, but just 37% attend annual visits, results from a small survey showed.

“We’re seeing a large need and lack of access to gynecologic care,” Adriana J. Wong, the study author, said in an interview at the annual meeting of the American College of Obstetricians and Gynecologists. “Some barriers that we’ve identified are fear of mistreatment, a perceived lack of informed providers, and gender dysphoria.”

A 2011 opinion from ACOG’s Committee on Health Care for Underserved Women urges clinicians to provide quality health care to transgender patients, yet a 2015 survey published in the Journal of Woman’s Health found that just 29% of ob.gyns. report feeling comfortable caring for transgender men (2015 Feb;24[2]:114-8).

In an effort to assess transgender men’s experiences with, ability to access, and understanding of gynecologic care, Ms. Wong and her associates distributed an anonymous Web-based and paper-based survey to a convenience sample of transgender men in the Miami area. The mean age of the 41 respondents was 28 years, 56% were white, 41% had a high school diploma, 27% had a college degree, and 17% had a graduate degree.

The majority of survey participants (78%) reported having been to a gynecologist, 37% attended annual visits, 78% had health insurance, 56% delayed care because of gender identity concerns, and 20% experienced mistreatment at a gynecologist’s office.

Respondents reported delaying or avoiding care because they “felt uncomfortable with the extremely gendered experience of [gynecologic] care,” “fear of mistreatment,” and “my dysphoria prevented me. Plus, I wasn’t sure if there were friendly ob.gyns. around.”

“One of the most distinctive things to me is that we had a pretty well-insured population in our sample, and they were mostly Caucasian,” said Ms. Wong, a second-year medical student at the University of Miami. “Even though almost 80% were insured, [fewer] than 40% were receiving annual visits. This is the population that would potentially have the best possibility of receiving care, but they’re not seeking it out.”

The researchers reported having no relevant financial disclosures.

[email protected]

 

SAN DIEGO – Most transgender men have visited a gynecologist’s office at least once, but just 37% attend annual visits, results from a small survey showed.

“We’re seeing a large need and lack of access to gynecologic care,” Adriana J. Wong, the study author, said in an interview at the annual meeting of the American College of Obstetricians and Gynecologists. “Some barriers that we’ve identified are fear of mistreatment, a perceived lack of informed providers, and gender dysphoria.”

A 2011 opinion from ACOG’s Committee on Health Care for Underserved Women urges clinicians to provide quality health care to transgender patients, yet a 2015 survey published in the Journal of Woman’s Health found that just 29% of ob.gyns. report feeling comfortable caring for transgender men (2015 Feb;24[2]:114-8).

In an effort to assess transgender men’s experiences with, ability to access, and understanding of gynecologic care, Ms. Wong and her associates distributed an anonymous Web-based and paper-based survey to a convenience sample of transgender men in the Miami area. The mean age of the 41 respondents was 28 years, 56% were white, 41% had a high school diploma, 27% had a college degree, and 17% had a graduate degree.

The majority of survey participants (78%) reported having been to a gynecologist, 37% attended annual visits, 78% had health insurance, 56% delayed care because of gender identity concerns, and 20% experienced mistreatment at a gynecologist’s office.

Respondents reported delaying or avoiding care because they “felt uncomfortable with the extremely gendered experience of [gynecologic] care,” “fear of mistreatment,” and “my dysphoria prevented me. Plus, I wasn’t sure if there were friendly ob.gyns. around.”

“One of the most distinctive things to me is that we had a pretty well-insured population in our sample, and they were mostly Caucasian,” said Ms. Wong, a second-year medical student at the University of Miami. “Even though almost 80% were insured, [fewer] than 40% were receiving annual visits. This is the population that would potentially have the best possibility of receiving care, but they’re not seeking it out.”

The researchers reported having no relevant financial disclosures.

[email protected]

 

SAN DIEGO – Utah hospitals reported improved implementation of an obstetrics hemorrhage bundle following a series of teleconferencing sessions.

“There is an increasing body of evidence to support the use of protocols and bundles in obstetrics to improve outcomes for pregnant women and their babies,” Brett D. Einerson, MD, MPH, lead study author, said in an interview. “In Utah and throughout the Mountain West, we face the unique challenge of disseminating information and education on the latest evidence-based treatments to smaller rural hospitals that still need to be prepared for events like severe postpartum hemorrhage but do not have the volume, or sometime the resources, to be adequately prepared.”

Telehealth, or the use of audio-visual technology in medicine, has been used to connect health care providers to patients in need of specialized medical care in the United States – particularly in states like Utah with low population density, said Dr. Einerson, a clinical fellow in the division of maternal-fetal medicine at the University of Utah Health Sciences Center, Salt Lake City. He and his associates set out to use telehealth for another purpose: to train health care providers in the use of obstetric bundles with twice-monthly telehealth trainings. He presented their findings at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

“Telehealth allowed us to reach providers who otherwise could not travel the distance to attend frequent training sessions and gave the whole state access to expertise at the region’s large tertiary care hospitals,” Dr. Einerson said. “As far as we know, this is one of the first uses of telehealth as a tool for disseminating patient safety and quality improvement education for health care providers on a statewide scale.”

Dr. Einerson and his associates invited all Utah hospitals to participate in the Obstetric Hemorrhage Collaborative, an evidence-based educational program aimed at facilitating implementation of the obstetric hemorrhage bundle. The program involved two in-person training meetings and twice-monthly teleconferencing with expert mentorship over 6 months. In-person sessions consisted of hands-on training and strategy building, while telehealth sessions were led by regional and national leaders in the field of obstetric hemorrhage.

A statewide self-assessment survey of 38 bundle elements was administered before initiation of the project and after completion. The researchers used modified Likert scales to describe participant responses. Means and proportions were compared before and after the training.

Of Utah’s obstetric hospitals, representing every hospital system in the state, 27 (61%) completed the needs-assessment survey, and 15 (34%) participated in the Obstetric Hemorrhage Collaborative, which included four bundle domains:

• Recognition and Prevention: Conducting a risk assessment and active management of the Third Stage of labor.
• Response: Creating a checklist and a rapid response team.
• Readiness: Establishing a blood bank, hemorrhage cart, and conducting simulation/team drills.
• Reporting and Learning: Fostering a culture of debriefing, conducting a multidisciplinary review, and measuring outcomes and processes.

Hospitals reported implementation, or progress toward implementation, of significantly more elements of the bundle after the educational program, compared with before the collaborative (a mean of 33.3 vs. 19 bundle elements; P less than 0.001). Hospitals reported increased implementation of elements in all four bundle domains. All participants (100%) reported that teleconferencing sessions were “very helpful,” and 14 (93%) said that they were “very satisfied” with the collaborative.

“Hospitals in the state of Utah generally had the right tools to treat and prevent obstetric hemorrhage but did not have the systems in place to be sure that the tools were used correctly,” Dr. Einerson said. “For instance, 80% of hospitals had access to a cart with supplies for treating bleeding, but less than 15% were systematically measuring blood loss after delivery. What surprised me most, however, was that most hospitals did not track their rates of postpartum bleeding. In my mind, you can’t set goals for treatment until you know how good – or bad – you are doing. Knowing your baseline rate of outcomes can help set goals and measure progress toward achieving them. Before training, less than 50% of Utah hospitals knew their own rate of hemorrhage, but all participating hospitals reported tracking their rates after the intervention.”

He acknowledged certain limitations of the study, including the fact that it did not measure obstetric outcomes. “We are in the process of measuring the effectiveness of our telehealth intervention by monitoring hemorrhage rates and complications over time,” Dr. Einerson said. “This survey of participants in the statewide telehealth bundle program is the first step.”

Dr. Einerson reported having no financial disclosures.

 

[email protected]

 

SAN DIEGO – Utah hospitals reported improved implementation of an obstetrics hemorrhage bundle following a series of teleconferencing sessions.

“There is an increasing body of evidence to support the use of protocols and bundles in obstetrics to improve outcomes for pregnant women and their babies,” Brett D. Einerson, MD, MPH, lead study author, said in an interview. “In Utah and throughout the Mountain West, we face the unique challenge of disseminating information and education on the latest evidence-based treatments to smaller rural hospitals that still need to be prepared for events like severe postpartum hemorrhage but do not have the volume, or sometime the resources, to be adequately prepared.”

Telehealth, or the use of audio-visual technology in medicine, has been used to connect health care providers to patients in need of specialized medical care in the United States – particularly in states like Utah with low population density, said Dr. Einerson, a clinical fellow in the division of maternal-fetal medicine at the University of Utah Health Sciences Center, Salt Lake City. He and his associates set out to use telehealth for another purpose: to train health care providers in the use of obstetric bundles with twice-monthly telehealth trainings. He presented their findings at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

“Telehealth allowed us to reach providers who otherwise could not travel the distance to attend frequent training sessions and gave the whole state access to expertise at the region’s large tertiary care hospitals,” Dr. Einerson said. “As far as we know, this is one of the first uses of telehealth as a tool for disseminating patient safety and quality improvement education for health care providers on a statewide scale.”

Dr. Einerson and his associates invited all Utah hospitals to participate in the Obstetric Hemorrhage Collaborative, an evidence-based educational program aimed at facilitating implementation of the obstetric hemorrhage bundle. The program involved two in-person training meetings and twice-monthly teleconferencing with expert mentorship over 6 months. In-person sessions consisted of hands-on training and strategy building, while telehealth sessions were led by regional and national leaders in the field of obstetric hemorrhage.

A statewide self-assessment survey of 38 bundle elements was administered before initiation of the project and after completion. The researchers used modified Likert scales to describe participant responses. Means and proportions were compared before and after the training.

Of Utah’s obstetric hospitals, representing every hospital system in the state, 27 (61%) completed the needs-assessment survey, and 15 (34%) participated in the Obstetric Hemorrhage Collaborative, which included four bundle domains:

• Recognition and Prevention: Conducting a risk assessment and active management of the Third Stage of labor.
• Response: Creating a checklist and a rapid response team.
• Readiness: Establishing a blood bank, hemorrhage cart, and conducting simulation/team drills.
• Reporting and Learning: Fostering a culture of debriefing, conducting a multidisciplinary review, and measuring outcomes and processes.

Hospitals reported implementation, or progress toward implementation, of significantly more elements of the bundle after the educational program, compared with before the collaborative (a mean of 33.3 vs. 19 bundle elements; P less than 0.001). Hospitals reported increased implementation of elements in all four bundle domains. All participants (100%) reported that teleconferencing sessions were “very helpful,” and 14 (93%) said that they were “very satisfied” with the collaborative.

“Hospitals in the state of Utah generally had the right tools to treat and prevent obstetric hemorrhage but did not have the systems in place to be sure that the tools were used correctly,” Dr. Einerson said. “For instance, 80% of hospitals had access to a cart with supplies for treating bleeding, but less than 15% were systematically measuring blood loss after delivery. What surprised me most, however, was that most hospitals did not track their rates of postpartum bleeding. In my mind, you can’t set goals for treatment until you know how good – or bad – you are doing. Knowing your baseline rate of outcomes can help set goals and measure progress toward achieving them. Before training, less than 50% of Utah hospitals knew their own rate of hemorrhage, but all participating hospitals reported tracking their rates after the intervention.”

He acknowledged certain limitations of the study, including the fact that it did not measure obstetric outcomes. “We are in the process of measuring the effectiveness of our telehealth intervention by monitoring hemorrhage rates and complications over time,” Dr. Einerson said. “This survey of participants in the statewide telehealth bundle program is the first step.”

Dr. Einerson reported having no financial disclosures.

 

[email protected]

 

SAN DIEGO – Utah hospitals reported improved implementation of an obstetrics hemorrhage bundle following a series of teleconferencing sessions.

“There is an increasing body of evidence to support the use of protocols and bundles in obstetrics to improve outcomes for pregnant women and their babies,” Brett D. Einerson, MD, MPH, lead study author, said in an interview. “In Utah and throughout the Mountain West, we face the unique challenge of disseminating information and education on the latest evidence-based treatments to smaller rural hospitals that still need to be prepared for events like severe postpartum hemorrhage but do not have the volume, or sometime the resources, to be adequately prepared.”

Telehealth, or the use of audio-visual technology in medicine, has been used to connect health care providers to patients in need of specialized medical care in the United States – particularly in states like Utah with low population density, said Dr. Einerson, a clinical fellow in the division of maternal-fetal medicine at the University of Utah Health Sciences Center, Salt Lake City. He and his associates set out to use telehealth for another purpose: to train health care providers in the use of obstetric bundles with twice-monthly telehealth trainings. He presented their findings at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

“Telehealth allowed us to reach providers who otherwise could not travel the distance to attend frequent training sessions and gave the whole state access to expertise at the region’s large tertiary care hospitals,” Dr. Einerson said. “As far as we know, this is one of the first uses of telehealth as a tool for disseminating patient safety and quality improvement education for health care providers on a statewide scale.”

Dr. Einerson and his associates invited all Utah hospitals to participate in the Obstetric Hemorrhage Collaborative, an evidence-based educational program aimed at facilitating implementation of the obstetric hemorrhage bundle. The program involved two in-person training meetings and twice-monthly teleconferencing with expert mentorship over 6 months. In-person sessions consisted of hands-on training and strategy building, while telehealth sessions were led by regional and national leaders in the field of obstetric hemorrhage.

A statewide self-assessment survey of 38 bundle elements was administered before initiation of the project and after completion. The researchers used modified Likert scales to describe participant responses. Means and proportions were compared before and after the training.

Of Utah’s obstetric hospitals, representing every hospital system in the state, 27 (61%) completed the needs-assessment survey, and 15 (34%) participated in the Obstetric Hemorrhage Collaborative, which included four bundle domains:

• Recognition and Prevention: Conducting a risk assessment and active management of the Third Stage of labor.
• Response: Creating a checklist and a rapid response team.
• Readiness: Establishing a blood bank, hemorrhage cart, and conducting simulation/team drills.
• Reporting and Learning: Fostering a culture of debriefing, conducting a multidisciplinary review, and measuring outcomes and processes.

Hospitals reported implementation, or progress toward implementation, of significantly more elements of the bundle after the educational program, compared with before the collaborative (a mean of 33.3 vs. 19 bundle elements; P less than 0.001). Hospitals reported increased implementation of elements in all four bundle domains. All participants (100%) reported that teleconferencing sessions were “very helpful,” and 14 (93%) said that they were “very satisfied” with the collaborative.

“Hospitals in the state of Utah generally had the right tools to treat and prevent obstetric hemorrhage but did not have the systems in place to be sure that the tools were used correctly,” Dr. Einerson said. “For instance, 80% of hospitals had access to a cart with supplies for treating bleeding, but less than 15% were systematically measuring blood loss after delivery. What surprised me most, however, was that most hospitals did not track their rates of postpartum bleeding. In my mind, you can’t set goals for treatment until you know how good – or bad – you are doing. Knowing your baseline rate of outcomes can help set goals and measure progress toward achieving them. Before training, less than 50% of Utah hospitals knew their own rate of hemorrhage, but all participating hospitals reported tracking their rates after the intervention.”

He acknowledged certain limitations of the study, including the fact that it did not measure obstetric outcomes. “We are in the process of measuring the effectiveness of our telehealth intervention by monitoring hemorrhage rates and complications over time,” Dr. Einerson said. “This survey of participants in the statewide telehealth bundle program is the first step.”

Dr. Einerson reported having no financial disclosures.

 

[email protected]

 

SAN DIEGO – A review of genetic tests ordered during a 3-month period found that more than one-third were misordered, leading to more than $20,000 in unnecessary health care costs, results from a single-center quality improvement project showed.

“We know there is an ever-expanding number of genetic tests available for clinicians to order, and there is more direct marketing to the patient,” Kathleen Ruzzo, MD, the lead study author, said in an interview prior to the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. “It can be difficult to stay on top of that as we have so many different clinical responsibilities.”

Courtesy Naval Medical Center San Diego

Over a period of 3 months, Dr. Ruzzo, an ob.gyn. resident at Naval Medical Center San Diego, and her associates identified 114 charts associated with genetic test billing codes for common tests sent through LabCorp: cystic fibrosis, BRCA, factor V Leiden, prothrombin, alpha-thalassemia, hemochromatosis, and cell-free DNA. They retrospectively reviewed the charts to assess for compliance with published clinical practice guidelines identified on GeneReviews and classified the tests as appropriate, misordered/not indicated, misordered/false reassurance, or misordered/inadequate. Researchers also performed a cost analysis.

Of genetic tests ordered for the 114 patients, 44 (39%) were deemed to be misordered based on published clinical practice guidelines. Of the rest, 24 tests were misordered/not indicated, 8 tests were misordered/false reassurance, and 12 tests were misordered/inadequate.

The costs of ordered genetic testing totaled approximately $75,000, while the cost of recommended testing following the chart review was approximately $54,000, a difference of more than $20,000.

When Dr. Ruzzo shared results of the study with her colleagues at Naval Medical Center San Diego, “I think it opened a lot of people’s eyes … to be more meticulous about [genetic] testing and to ask for help when you need help,” she said. “Having trained individuals, reviewing genetic tests could save money in the health care system more broadly. We could also approve the appropriate testing for the patient.”

She acknowledged certain limitations of the study, including the fact that it “reviewed a very narrow scope of [genetic] tests for a short amount of time, so we think we underestimated the appropriate health care expenditures. Additionally, we didn’t focus on the clinical ramifications of the misordering for patients.”

Study coauthor Monica A. Lutgendorf, MD, a maternal-fetal medicine physician at the medical center, characterized the study findings as “a call to action in general for ob.gyns. to get additional training and resources to handle the ever-expanding number of [genetic] tests,” she said. “I don’t think that this is unique to any specific institution. I think this is part of the new environment of practice that we’re in.”

Physicians can learn more about genetic testing from ACOG and from the Perinatal Quality Foundation, Dr. Lutgendorf said. The study won first prize among oral abstracts presented at the ACOG meeting. The researchers reported having no financial disclosures.

[email protected]

 

SAN DIEGO – A review of genetic tests ordered during a 3-month period found that more than one-third were misordered, leading to more than $20,000 in unnecessary health care costs, results from a single-center quality improvement project showed.

“We know there is an ever-expanding number of genetic tests available for clinicians to order, and there is more direct marketing to the patient,” Kathleen Ruzzo, MD, the lead study author, said in an interview prior to the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. “It can be difficult to stay on top of that as we have so many different clinical responsibilities.”

Courtesy Naval Medical Center San Diego

Over a period of 3 months, Dr. Ruzzo, an ob.gyn. resident at Naval Medical Center San Diego, and her associates identified 114 charts associated with genetic test billing codes for common tests sent through LabCorp: cystic fibrosis, BRCA, factor V Leiden, prothrombin, alpha-thalassemia, hemochromatosis, and cell-free DNA. They retrospectively reviewed the charts to assess for compliance with published clinical practice guidelines identified on GeneReviews and classified the tests as appropriate, misordered/not indicated, misordered/false reassurance, or misordered/inadequate. Researchers also performed a cost analysis.

Of genetic tests ordered for the 114 patients, 44 (39%) were deemed to be misordered based on published clinical practice guidelines. Of the rest, 24 tests were misordered/not indicated, 8 tests were misordered/false reassurance, and 12 tests were misordered/inadequate.

The costs of ordered genetic testing totaled approximately $75,000, while the cost of recommended testing following the chart review was approximately $54,000, a difference of more than $20,000.

When Dr. Ruzzo shared results of the study with her colleagues at Naval Medical Center San Diego, “I think it opened a lot of people’s eyes … to be more meticulous about [genetic] testing and to ask for help when you need help,” she said. “Having trained individuals, reviewing genetic tests could save money in the health care system more broadly. We could also approve the appropriate testing for the patient.”

She acknowledged certain limitations of the study, including the fact that it “reviewed a very narrow scope of [genetic] tests for a short amount of time, so we think we underestimated the appropriate health care expenditures. Additionally, we didn’t focus on the clinical ramifications of the misordering for patients.”

Study coauthor Monica A. Lutgendorf, MD, a maternal-fetal medicine physician at the medical center, characterized the study findings as “a call to action in general for ob.gyns. to get additional training and resources to handle the ever-expanding number of [genetic] tests,” she said. “I don’t think that this is unique to any specific institution. I think this is part of the new environment of practice that we’re in.”

Physicians can learn more about genetic testing from ACOG and from the Perinatal Quality Foundation, Dr. Lutgendorf said. The study won first prize among oral abstracts presented at the ACOG meeting. The researchers reported having no financial disclosures.

[email protected]

 

SAN DIEGO – A review of genetic tests ordered during a 3-month period found that more than one-third were misordered, leading to more than $20,000 in unnecessary health care costs, results from a single-center quality improvement project showed.

“We know there is an ever-expanding number of genetic tests available for clinicians to order, and there is more direct marketing to the patient,” Kathleen Ruzzo, MD, the lead study author, said in an interview prior to the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. “It can be difficult to stay on top of that as we have so many different clinical responsibilities.”

Courtesy Naval Medical Center San Diego

Over a period of 3 months, Dr. Ruzzo, an ob.gyn. resident at Naval Medical Center San Diego, and her associates identified 114 charts associated with genetic test billing codes for common tests sent through LabCorp: cystic fibrosis, BRCA, factor V Leiden, prothrombin, alpha-thalassemia, hemochromatosis, and cell-free DNA. They retrospectively reviewed the charts to assess for compliance with published clinical practice guidelines identified on GeneReviews and classified the tests as appropriate, misordered/not indicated, misordered/false reassurance, or misordered/inadequate. Researchers also performed a cost analysis.

Of genetic tests ordered for the 114 patients, 44 (39%) were deemed to be misordered based on published clinical practice guidelines. Of the rest, 24 tests were misordered/not indicated, 8 tests were misordered/false reassurance, and 12 tests were misordered/inadequate.

The costs of ordered genetic testing totaled approximately $75,000, while the cost of recommended testing following the chart review was approximately $54,000, a difference of more than $20,000.

When Dr. Ruzzo shared results of the study with her colleagues at Naval Medical Center San Diego, “I think it opened a lot of people’s eyes … to be more meticulous about [genetic] testing and to ask for help when you need help,” she said. “Having trained individuals, reviewing genetic tests could save money in the health care system more broadly. We could also approve the appropriate testing for the patient.”

She acknowledged certain limitations of the study, including the fact that it “reviewed a very narrow scope of [genetic] tests for a short amount of time, so we think we underestimated the appropriate health care expenditures. Additionally, we didn’t focus on the clinical ramifications of the misordering for patients.”

Study coauthor Monica A. Lutgendorf, MD, a maternal-fetal medicine physician at the medical center, characterized the study findings as “a call to action in general for ob.gyns. to get additional training and resources to handle the ever-expanding number of [genetic] tests,” she said. “I don’t think that this is unique to any specific institution. I think this is part of the new environment of practice that we’re in.”

Physicians can learn more about genetic testing from ACOG and from the Perinatal Quality Foundation, Dr. Lutgendorf said. The study won first prize among oral abstracts presented at the ACOG meeting. The researchers reported having no financial disclosures.

[email protected]

 

SAN DIEGO – Endometrial cancer (EC) rates increased after 2002, coinciding with the release of results from the Women’s Health Initiative and including a 10% spike between 2006 and 2014, according to a large analysis of national data.

“Be aware of an increase of endometrial cancer and, whenever possible, look to minimize possible inciting causes,” Ginger Constantine, MD, lead study author, said in an interview prior to the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. “Be certain that the hormonal products that patients are taking are delivering adequate progesterone to the endometrium in those patients at an increased risk of endometrial cancer, such as those with unopposed estrogen.”

Dr. Constantine, of Malvern, Pennsylvania–based EndoRheum Consultants, noted that EC rates were stable prior to 2002.

“We sought to look at possible causes for the increase of the known risk factors for EC,” she said. “What has changed in the years leading up to 2006?” To find out, she and her associates obtained EC incidence from the Surveillance, Epidemiology, and End Result Program database from 1975 through 2014. They evaluated the incidence of risk factors thought to be associated with EC, including age, obesity, race, number of menstrual cycles, gravidity and parity, metabolic syndromes, diet and exercise, and medications, including various types of hormone therapy, tamoxifen, and hormonal contraceptives.

Shelli Graham, PhD, vice president of medical affairs for Boca Raton, Florida–based TherapeuticsMD, presented the study findings on behalf of Dr. Constantine, who was unable to attend the meeting. The rates of EC were relatively constant from 1992 to 2002 (at about 76/100,000 cases per year) but have increased 2.5% annually, with a 10% increase from 2006 to 2014, especially in women aged 55-64 years.

Use of estrogen and progestin combinations have decreased while risk factors remained constant or decreased during the same time period. However, the researchers observed a “huge increase (of 1-2.5 million U.S. women) using non-FDA approved compounded estrogen and estrogen and progesterone, which may not provide adequate endometrial protection from estrogen, a known cause of EC,” Dr. Constantine said. “Additionally, there is less progestin use subsequent to the [Women’s Health Initiative] and it is known that progestin is protective on the endometrium.”

The researchers also examined the incidence of obesity – another known risk factor for EC – and found that, although obesity has continued to increase in incidence, “it does not appear to be increasing at the same rate as EC, so [it] does not appear to be enough to explain the increase in EC from 2006,” Dr. Constantine said. “I was surprised at the rate of increase of EC from 2006 to 2014 and have also been surprised by the amount of non-FDA compounded hormone use.”

Dr. Graham characterized the increase in EC incidence as “a public health concern that is most likely multifactorial in etiology.” Contributors, she said, include the combination of an increase in obesity with an inherent increase in endogenous estrogen, decreasing progesterone use from a decrease in the use of FDA-approved hormone therapy products, and an increase in compounded hormone therapy that may not deliver adequate endometrial protection.

Dr. Constantine acknowledged certain limitations of the study, including the fact that it is “an ecological analysis, not a randomized clinical trial. It is hypothesis-generating.”

Dr. Constantine reported that she is a consultant/advisory member for TherapeuticsMD and other pharmaceutical companies. She owns stock in TherapeuticsMD. Coauthor Steven R. Goldstein, MD, reported having numerous financial relationships with pharmaceutical companies including TherapeuticsMD. Dr. Graham is an employee of TherapeuticsMD.

[email protected]

 

SAN DIEGO – Endometrial cancer (EC) rates increased after 2002, coinciding with the release of results from the Women’s Health Initiative and including a 10% spike between 2006 and 2014, according to a large analysis of national data.

“Be aware of an increase of endometrial cancer and, whenever possible, look to minimize possible inciting causes,” Ginger Constantine, MD, lead study author, said in an interview prior to the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. “Be certain that the hormonal products that patients are taking are delivering adequate progesterone to the endometrium in those patients at an increased risk of endometrial cancer, such as those with unopposed estrogen.”

Dr. Constantine, of Malvern, Pennsylvania–based EndoRheum Consultants, noted that EC rates were stable prior to 2002.

“We sought to look at possible causes for the increase of the known risk factors for EC,” she said. “What has changed in the years leading up to 2006?” To find out, she and her associates obtained EC incidence from the Surveillance, Epidemiology, and End Result Program database from 1975 through 2014. They evaluated the incidence of risk factors thought to be associated with EC, including age, obesity, race, number of menstrual cycles, gravidity and parity, metabolic syndromes, diet and exercise, and medications, including various types of hormone therapy, tamoxifen, and hormonal contraceptives.

Shelli Graham, PhD, vice president of medical affairs for Boca Raton, Florida–based TherapeuticsMD, presented the study findings on behalf of Dr. Constantine, who was unable to attend the meeting. The rates of EC were relatively constant from 1992 to 2002 (at about 76/100,000 cases per year) but have increased 2.5% annually, with a 10% increase from 2006 to 2014, especially in women aged 55-64 years.

Use of estrogen and progestin combinations have decreased while risk factors remained constant or decreased during the same time period. However, the researchers observed a “huge increase (of 1-2.5 million U.S. women) using non-FDA approved compounded estrogen and estrogen and progesterone, which may not provide adequate endometrial protection from estrogen, a known cause of EC,” Dr. Constantine said. “Additionally, there is less progestin use subsequent to the [Women’s Health Initiative] and it is known that progestin is protective on the endometrium.”

The researchers also examined the incidence of obesity – another known risk factor for EC – and found that, although obesity has continued to increase in incidence, “it does not appear to be increasing at the same rate as EC, so [it] does not appear to be enough to explain the increase in EC from 2006,” Dr. Constantine said. “I was surprised at the rate of increase of EC from 2006 to 2014 and have also been surprised by the amount of non-FDA compounded hormone use.”

Dr. Graham characterized the increase in EC incidence as “a public health concern that is most likely multifactorial in etiology.” Contributors, she said, include the combination of an increase in obesity with an inherent increase in endogenous estrogen, decreasing progesterone use from a decrease in the use of FDA-approved hormone therapy products, and an increase in compounded hormone therapy that may not deliver adequate endometrial protection.

Dr. Constantine acknowledged certain limitations of the study, including the fact that it is “an ecological analysis, not a randomized clinical trial. It is hypothesis-generating.”

Dr. Constantine reported that she is a consultant/advisory member for TherapeuticsMD and other pharmaceutical companies. She owns stock in TherapeuticsMD. Coauthor Steven R. Goldstein, MD, reported having numerous financial relationships with pharmaceutical companies including TherapeuticsMD. Dr. Graham is an employee of TherapeuticsMD.

[email protected]

 

SAN DIEGO – Endometrial cancer (EC) rates increased after 2002, coinciding with the release of results from the Women’s Health Initiative and including a 10% spike between 2006 and 2014, according to a large analysis of national data.

“Be aware of an increase of endometrial cancer and, whenever possible, look to minimize possible inciting causes,” Ginger Constantine, MD, lead study author, said in an interview prior to the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. “Be certain that the hormonal products that patients are taking are delivering adequate progesterone to the endometrium in those patients at an increased risk of endometrial cancer, such as those with unopposed estrogen.”

Dr. Constantine, of Malvern, Pennsylvania–based EndoRheum Consultants, noted that EC rates were stable prior to 2002.

“We sought to look at possible causes for the increase of the known risk factors for EC,” she said. “What has changed in the years leading up to 2006?” To find out, she and her associates obtained EC incidence from the Surveillance, Epidemiology, and End Result Program database from 1975 through 2014. They evaluated the incidence of risk factors thought to be associated with EC, including age, obesity, race, number of menstrual cycles, gravidity and parity, metabolic syndromes, diet and exercise, and medications, including various types of hormone therapy, tamoxifen, and hormonal contraceptives.

Shelli Graham, PhD, vice president of medical affairs for Boca Raton, Florida–based TherapeuticsMD, presented the study findings on behalf of Dr. Constantine, who was unable to attend the meeting. The rates of EC were relatively constant from 1992 to 2002 (at about 76/100,000 cases per year) but have increased 2.5% annually, with a 10% increase from 2006 to 2014, especially in women aged 55-64 years.

Use of estrogen and progestin combinations have decreased while risk factors remained constant or decreased during the same time period. However, the researchers observed a “huge increase (of 1-2.5 million U.S. women) using non-FDA approved compounded estrogen and estrogen and progesterone, which may not provide adequate endometrial protection from estrogen, a known cause of EC,” Dr. Constantine said. “Additionally, there is less progestin use subsequent to the [Women’s Health Initiative] and it is known that progestin is protective on the endometrium.”

The researchers also examined the incidence of obesity – another known risk factor for EC – and found that, although obesity has continued to increase in incidence, “it does not appear to be increasing at the same rate as EC, so [it] does not appear to be enough to explain the increase in EC from 2006,” Dr. Constantine said. “I was surprised at the rate of increase of EC from 2006 to 2014 and have also been surprised by the amount of non-FDA compounded hormone use.”

Dr. Graham characterized the increase in EC incidence as “a public health concern that is most likely multifactorial in etiology.” Contributors, she said, include the combination of an increase in obesity with an inherent increase in endogenous estrogen, decreasing progesterone use from a decrease in the use of FDA-approved hormone therapy products, and an increase in compounded hormone therapy that may not deliver adequate endometrial protection.

Dr. Constantine acknowledged certain limitations of the study, including the fact that it is “an ecological analysis, not a randomized clinical trial. It is hypothesis-generating.”

Dr. Constantine reported that she is a consultant/advisory member for TherapeuticsMD and other pharmaceutical companies. She owns stock in TherapeuticsMD. Coauthor Steven R. Goldstein, MD, reported having numerous financial relationships with pharmaceutical companies including TherapeuticsMD. Dr. Graham is an employee of TherapeuticsMD.

[email protected]

 

The grip that opioid addiction has on adolescents often resembles that on addicted adults. Both groups crave the next high at all costs.

“Basically, they’re living to find their next heroin or opioids because their ‘feeling good’ completely depends on it,” Steven C. Matson, MD, , chief of the division of adolescent medicine at Nationwide Children’s Hospital, Columbus, Ohio, said in an interview. “They’re up in the morning, out trying to hustle money constantly, and then using and rebounding, and doing it over and over again. It gets to be a pretty dismal way of life.”

courtesy Lindsey Pulfer, RN

After losing several friends to opioid overdoses, a 17-year-old patient of Leslie Hulvershorn, MD, became so emotionally hardened that she thought little of her own young life. “She suffers from depression and PTSD and has talked from time to time about how she doesn’t really care if she lives or dies,” said Dr. Hulvershorn, a child and adolescent psychiatrist who runs an adolescent addiction treatment outpatient program at Riley Hospital for Children, Indianapolis.

Parents often have no clue that their child is addicted to opioids, whether prescription forms like oxycodone or synthetic forms like heroin. “It usually only becomes clear when it comes to the attention of a probation officer or a school that insists on treatment,” said Dr. Hulvershorn, who is also medical director for the State of Indiana’s Division of Mental Health and Addiction, which licenses and certifies all of the opioid treatment programs in the state. “It’s not uncommon to see adolescents who get out of the house at night and go out and use or sell or do something that’s really dangerous. The situations are usually very high risk, very concerning.”

The scope of the problem

The 2015 National Survey on Drug Use and Health (NSDUH) found that 6.5 million Americans over the age of 12 years used controlled prescription medicines nonmedically during the past month, second only to marijuana and more than past-month users of cocaine, heroin, and hallucinogens combined. According to the Centers for Disease Control and Prevention, 91 Americans die every day from an overdose of opioids. In fact, opioid overdoses in the United States increased four times since 1999 and were highest among persons 25-54 years of age. In 2015, the five states with the highest rates of death resulting from drug overdose were West Virginia (41.5 per 100,000), New Hampshire (34.3 per 100,000), Kentucky (29.9 per 100,000), Ohio (29.9 per 100,000), and Rhode Island (28.2 per 100,000).

The CDC also found that, between 2013 and 2014, the number of children aged 0-14 years who died from a drug overdose increased slightly from 105 to 109. The number of children aged 15-24 years who died from a drug overdose rose from 3,664 to 3,798, an increase of 3.6%. While the precise path to opioid addiction differs from patient to patient, experts interviewed for this story noted that adolescents who currently smoke marijuana or drink alcohol on a regular basis face an increased risk of progressing to opioid use, compared with peers who lack substance abuse problems. In such cases, “go ahead and refer for substance abuse treatment at that point, rather than waiting for them to get into something much more dangerous,” Dr. Hulvershorn advised. “Neither of those drugs is good for adolescents either, but you could easily be preventing a worse outcome later. Sometimes physicians will ask, ‘You really want me to refer kids who are smoking pot?’ The answer is, ‘Absolutely.’ That’s probably our best shot at providing them with skills early on, before they get into heavier stuff.”

In October 2016, as part of the Comprehensive Addiction and Recovery Act, the Drug Enforcement Agency announced plans to reduce the amount of almost every Schedule II opiate and opioid medication that may be manufactured in the United States in 2017 by 25% or more. That – coupled with increased media attention in recent years to the perils of opioid addiction in adults, mandatory prescriber education on the use of opioids pain management, and other national efforts to promote safe prescribing practices – has helped to stymie the supply of opioids for illicit use. However, addicts young and old are turning to dangerous alternatives, like heroin, which may be tainted with fentanyl.

“There are even stronger agents like carfentanil, or carfentanyl, a strong veterinary opioid, which is used to put elephants to sleep,” Dr. Matson said. “Suddenly, you read that 18 people die because they got a hold of that. It’s hard to understand. It doesn’t make a lot of sense why somebody trying to make money off of selling drugs would sell you something that would kill you, but most people develop tolerance after long enough use of heroin. People are always trying to reach that new level of high.”

The implication of developing an opioid addiction at such a young age rarely registers with users, yet it can interfere with development “in substantial ways,” said Marc N. Potenza, MD, PhD, professor of psychiatry in the Child Study Center at Yale School of Medicine, New Haven, Conn. “If one is addicted, a lot of time, effort, energy, and attention is focused on the addiction, rather than on things like school, family, and friends.”

 

How to spot a troubled teen

Pediatricians can do their part to detect addiction by regularly asking about drug use during office visits. One quick screen Dr. Matson recommends is the HEADSS (Home, Education/employment, peer group Activities, Drugs, Sexuality, and Suicide/depression).

But, simply being attuned to how patients are performing in general domains can help you spot a troubled teen. “If a kid is still playing football and getting straight A’s, there’s probably a pretty low chance he’s having a serious problem,” he said. “A big part of addiction is secret, so I think when parents start to see their kids be more secretive, hiding their phone,” that’s a red flag. Or maybe their child has a new set of friends that “don’t seem as ‘good’ as the previous set of friends.” Other signs might be “losing a job that they were doing well at before, grades starting to go down, [or] loss of interest in the things they normally like to do. In general, I think kids work their way up to opioid addiction. If parents know their kids smoke cigarettes and think they might be doing some weed, those are the kids that are at risk for moving on to a bigger high.”

Many kids start with pills that they find or take from someone. “They may not think of them as a drug, so you would need to specifically ask, ‘Have you ever used a pill like a pain medication that you may have found or gotten from a family member or a friend for recreational use or for something other than how it was prescribed?’ ” Dr. Hulvershorn said.

The amount of parental supervision also factors in. “There’s been a lot of research showing that, if parents don’t have any idea where their kids are after school or what they’re up do, those kids are much more likely to be using,” she said. “So, you want to ask parents, ‘Are there times when your adolescent is unsupervised?’ ”

If you suspect that one of your adolescent patients is using opioids, but he or she won’t open up about it, consider intermittent urine screening, Dr. Hulvershorn said. If a screen comes back positive, be familiar with patient privacy regulations in your state, because special federal protections apply to adolescents and adults with respect to substance abuse disorder assessment and treatment. For example, in Indiana there is no age limit. Anyone under the age of 18 has the same protection as an adult. “I cannot legally release that information to the parent without the adolescent’s consent, which is really unusual,” she said. “Each state determines the age where that might apply. The best approach is to try to get the adolescent on board, and say, ‘Here’s what we found. We really need to get this out in the open and get you some treatment. I’d really like to have a conversation with your parents.’ Sometimes you can get them to agree, and sometimes you can’t. Nonetheless, you would try to proceed with treatment. You don’t need parental consent for treatment.”

Once Dr. Matson establishes confidentiality with patients, he spends time helping them understand where they fall in the “continuum of use.” He asks for permission to share information with them about the negative aspects of drug use instead of force-feeding it.

“A lot of these kids are hanging around the same kinds of kids and somehow, in their minds, think that what they’re doing is normal,” he said. “To me, somebody smoking weed twice a day every day is a problem, and they probably are addicted. It’s hard to know whether you’d be ready to pull a parent [into the room] at that point or at least give the kid a chance to think if they ... could cut down. If they would, maybe see them back with a warning that, if it’s not going to get much better, you might have to inform parents.

“Weed is always a big issue, especially in kids with ADHD. Those kids are at high risk for substance abuse, especially if they aren’t maintained on their [ADHD] drugs later on,” Dr. Matson said.

Adolescents on opioids “usually are going to present in a more dramatic fashion because they’re starting to get into trouble. They might have gotten arrested or might have been driving under the influence with both alcohol and opioids. To support their habit, a lot of kids have to steal things, so a kid who gets caught shoplifting is someone to be concerned about,” he said.

 

Treatment options

In 2016, the American Academy of Pediatrics issued a new policy statement, “Medication-Assisted Treatment for Adolescents with Opioid Disorders,” which recommends that pediatricians consider offering medication-assisted treatments to their adolescent and young adult patients with opioid use disorders or refer them to other providers who can. Ideally, pediatricians should refer patients to clinicians who have expertise in treating substance abuse disorders in adolescents, typically psychiatrists.

Psychiatrists “tend to have quite a bit of experience with addiction, but they can be very hard to find,” Dr. Hulvershorn said. “Sometimes, it’s a mental health center provider who treats adults with addiction. Addiction is a different beast in kids, but that might be the next best thing.”

Three medicines indicated for treating severe opioid disorder include buprenorphine (the “gold standard,” Dr. Matson said), methadone, and naltrexone, which is Dr. Hulvershorn’s typical drug of choice, “because it’s not a drug of abuse. It’s an opioid antagonist, so it blocks the euphoria that you might get when you are using a drug of abuse such as an opioid.”

Even though pediatricians have access to an American Academy of Pediatrics–endorsed buprenorphine waiver course, not all clinicians feel comfortable adding medication-assisted treatment to patients.

“It might mean that you partner with a substance use provider who can do more comprehensive services but not the prescribing,” Dr. Hulvershorn said. “You certainly don’t want to treat these kids in a vacuum by yourself, because it’s very complicated to treat them.”

Still, the office-based practice of prescribing opioid withdrawal medication “is a very successful approach and a reasonable alternative to other approaches that have been used historically, like methadone maintenance programs,” noted Dr. Potenza, emphasizing that physicians have to understand how to help patients with addiction.

Physicians interviewed for this story underscored the importance of a comprehensive approach that includes behavioral treatment, medication, and support from family and friends.

“A lot of kids who get into these problems come from families that don’t have many resources,” Dr. Matson said, noting that, often, it is a generational problem, in which grandparents and parents are drug users. “But, for kids who take a wrong path, encouraging words really can come true. It’s really a matter of how many people you have cheerleading for you and keeping an eye on you.”

When Dr. Matson’s clinic began treating patients with opioid use disorders 8 years ago, only about 25% of adolescents returned for a second visit, and the rate of abstinence at 1 year was only 9%. The clinic has undertake a large quality improvement project to improve that percentage. “We learned to not scare people right away with a bunch of assignments they have to get done but to just welcome them in, get them started on the medication, and give them positive messages. For short-term remission at 3 months, we’re at 50%-60%, which is pretty good. It’s probably as good as any adult program. I think we’re at 35%-40% remission at 1 year for people first time in recovery,” he said.

Where to go from here

Reflecting on what he’d like opioid use disorder treatment to look like 5 or 10 years down the road, Dr. Matson emphasized the prominent role that pediatricians can play.

“We’re really the ones that could make a difference if we can try to intervene,” he said. “I’m not sure I can prove it, but my pipe dream is, the earlier that we catch people and the less time they’ve been using drugs, it’s got to be easier to stop it then, than if they’ve been using for 5 or 10 years.”

That’s the kind of hope Dr. Hulvershorn holds for the17-year-old patient she’s treating who suffers from depression and PTSD.

“She has decided that it’s important for her to come clean,” said Dr. Hulvershorn, who added that the patient has received mental health and trauma counseling. “Part of our treatment program involves helping patients reorganize their life so that activities they’re involved with are not drug-related. That involves finding new friends and new activities, which can take some time. She is really committed to graduating from high school now that she’s clean. She’s really made a 180.”

Dr. Potenza disclosed having been a consultant to Jazz Pharmaceuticals and Opiant Pharmaceuticals. Dr. Matson and Dr. Hulvershorn reported having no relevant financial disclosures.

Role of a pediatrician’s support is vital

The way Deepa R. Camenga, MD, sees it, pediatricians play a vital role in not only counseling adolescents struggling with opioid use disorders but in helping to prevent it in the first place.

 

Prevention starts with advising parents or caregivers to manage any prescription medication that adolescents may receive for medical indications such as wisdom tooth extractions or sports injuries. “There is some risk for misuse or using it inappropriately or recreationally,” said Dr. Camenga, a pediatrician at Yale School of Medicine, New Haven, Conn., who is also board certified in addiction medicine. “The parents should be highly involved in the administration of these medications to teenagers.”

Other risk factors for opioid use disorders include alcohol, marijuana, or other recreational drugs use or the presence of undiagnosed or undertreated mental health conditions such as ADHD, anxiety, and depression.

“In the primary care setting, I’ve seen a real increase in marijuana use over the last 10 years,” she said. “Some teens are moving on to opiates, but, luckily, it’s still a rarer thing than using marijuana or alcohol. Identifying these conditions is important because, in the act of screening and helping parents and kids link to treatment, pediatricians are preventing drug use.”

Other red flags include poor academic performance and a lack of connectedness in the community. “When we are doing the well-child exams, we often ask about the home and school environment,” Dr. Camenga said. “Looking for positive healthy activities and attachment is essential. If a kid doesn’t have these protective factors, it puts them at higher risk for drug initiation.”

Any time an adolescent’s drug use is escalating in frequency, leading to parental concern or a decrease in function or problems, consider referring the child to a higher level of treatment with a specialist. “Even among teens with low levels of drug use, there are teens who have many risk factors for escalating to a higher level of use,” said Dr. Camenga, who has treated approximately 50 adolescents with opioid use disorders over the past 2 years. “In this case, you may consider referring them earlier rather than later.”

Broaching the conversation about referral to a specialist in substance abuse treatment can be tricky. She recommends saying something like, “ ‘They [the substance use treatment providers] are not going to force you to do anything you don’t want to do,’ because that’s a concern for the teens. ‘They’re going to discuss different options to help you over time, because, physically, it’s very difficult to stop on your own.’ ”

One young patient with several chronic medical conditions was referred to Dr. Camenga after being hospitalized in a psychiatric facility because she was using heroin and stimulants, which triggered a seizure.

“She came into treatment, and it took about 6 months for stabilization, but now she’s doing well,” the pediatrician said. “She’s been in recovery for 2 years and is not using opioids. She’s working, and she’s trying to obtain a higher education certificate.”

Although the American Academy of Pediatrics published a policy statement recommending that pediatricians consider offering buprenorphine and other medication-assisted treatment options for adolescents coping with opioid use disorder (Pediatrics. 2016 Aug. doi: 10.1542/peds.2016-1893). Dr. Camenga said that some physicians are reluctant to do so “because there are concerns about exposing the developing brain to another opiate over time, and there are generally few studies that examine the efficacy of buprenorphine in adolescents specifically. However, the adolescents I’ve had on it do well. I’ve had several adolescents go through an entire treatment course and into recovery on buprenorphine.”

Training options for pediatricians looking to become certified in prescribing buprenorphine for adolescents include an American Academy of Pediatrics–endorsed buprenorphine waiver course.

“At first it may seem overwhelming, but you can make a huge impact by treating two or three people,” she said. “When you do the training through Substance Abuse and Mental Health Services Administration–supported programs (including one at www.asam.org), they provide lots of resources for mentorship or support from providers across the nation who work with special populations, including adolescents. Reach out to them. When I was learning, I talked a lot with my colleagues in different states because there are very few people who treat adolescents and who have the comfort in treating children. We’re all very supportive of each other and reach out to discuss cases.”

Dr. Camenga emphasized that pediatricians play a role in supporting parents and families of adolescents impacted by addiction to opioids.

“It’s a rampant disease and we all know someone affected by it,” she said. “Even if we feel powerless, perhaps, with this epidemic, we have a unique skill in supporting families. More awareness and less stigmatization, and support of families who are going through this, is important.

“We as a society have stigmatized this disease. I think that inhibits some young people getting treatment earlier rather than later. We also need to focus on prevention,” Dr. Camenga emphasized.

She reported having no relevant financial disclosures.
 

 

[email protected]

*This article was updated May 17, 2017.

 

The grip that opioid addiction has on adolescents often resembles that on addicted adults. Both groups crave the next high at all costs.

“Basically, they’re living to find their next heroin or opioids because their ‘feeling good’ completely depends on it,” Steven C. Matson, MD, , chief of the division of adolescent medicine at Nationwide Children’s Hospital, Columbus, Ohio, said in an interview. “They’re up in the morning, out trying to hustle money constantly, and then using and rebounding, and doing it over and over again. It gets to be a pretty dismal way of life.”

courtesy Lindsey Pulfer, RN

After losing several friends to opioid overdoses, a 17-year-old patient of Leslie Hulvershorn, MD, became so emotionally hardened that she thought little of her own young life. “She suffers from depression and PTSD and has talked from time to time about how she doesn’t really care if she lives or dies,” said Dr. Hulvershorn, a child and adolescent psychiatrist who runs an adolescent addiction treatment outpatient program at Riley Hospital for Children, Indianapolis.

Parents often have no clue that their child is addicted to opioids, whether prescription forms like oxycodone or synthetic forms like heroin. “It usually only becomes clear when it comes to the attention of a probation officer or a school that insists on treatment,” said Dr. Hulvershorn, who is also medical director for the State of Indiana’s Division of Mental Health and Addiction, which licenses and certifies all of the opioid treatment programs in the state. “It’s not uncommon to see adolescents who get out of the house at night and go out and use or sell or do something that’s really dangerous. The situations are usually very high risk, very concerning.”

The scope of the problem

The 2015 National Survey on Drug Use and Health (NSDUH) found that 6.5 million Americans over the age of 12 years used controlled prescription medicines nonmedically during the past month, second only to marijuana and more than past-month users of cocaine, heroin, and hallucinogens combined. According to the Centers for Disease Control and Prevention, 91 Americans die every day from an overdose of opioids. In fact, opioid overdoses in the United States increased four times since 1999 and were highest among persons 25-54 years of age. In 2015, the five states with the highest rates of death resulting from drug overdose were West Virginia (41.5 per 100,000), New Hampshire (34.3 per 100,000), Kentucky (29.9 per 100,000), Ohio (29.9 per 100,000), and Rhode Island (28.2 per 100,000).

The CDC also found that, between 2013 and 2014, the number of children aged 0-14 years who died from a drug overdose increased slightly from 105 to 109. The number of children aged 15-24 years who died from a drug overdose rose from 3,664 to 3,798, an increase of 3.6%. While the precise path to opioid addiction differs from patient to patient, experts interviewed for this story noted that adolescents who currently smoke marijuana or drink alcohol on a regular basis face an increased risk of progressing to opioid use, compared with peers who lack substance abuse problems. In such cases, “go ahead and refer for substance abuse treatment at that point, rather than waiting for them to get into something much more dangerous,” Dr. Hulvershorn advised. “Neither of those drugs is good for adolescents either, but you could easily be preventing a worse outcome later. Sometimes physicians will ask, ‘You really want me to refer kids who are smoking pot?’ The answer is, ‘Absolutely.’ That’s probably our best shot at providing them with skills early on, before they get into heavier stuff.”

In October 2016, as part of the Comprehensive Addiction and Recovery Act, the Drug Enforcement Agency announced plans to reduce the amount of almost every Schedule II opiate and opioid medication that may be manufactured in the United States in 2017 by 25% or more. That – coupled with increased media attention in recent years to the perils of opioid addiction in adults, mandatory prescriber education on the use of opioids pain management, and other national efforts to promote safe prescribing practices – has helped to stymie the supply of opioids for illicit use. However, addicts young and old are turning to dangerous alternatives, like heroin, which may be tainted with fentanyl.

“There are even stronger agents like carfentanil, or carfentanyl, a strong veterinary opioid, which is used to put elephants to sleep,” Dr. Matson said. “Suddenly, you read that 18 people die because they got a hold of that. It’s hard to understand. It doesn’t make a lot of sense why somebody trying to make money off of selling drugs would sell you something that would kill you, but most people develop tolerance after long enough use of heroin. People are always trying to reach that new level of high.”

The implication of developing an opioid addiction at such a young age rarely registers with users, yet it can interfere with development “in substantial ways,” said Marc N. Potenza, MD, PhD, professor of psychiatry in the Child Study Center at Yale School of Medicine, New Haven, Conn. “If one is addicted, a lot of time, effort, energy, and attention is focused on the addiction, rather than on things like school, family, and friends.”

 

How to spot a troubled teen

Pediatricians can do their part to detect addiction by regularly asking about drug use during office visits. One quick screen Dr. Matson recommends is the HEADSS (Home, Education/employment, peer group Activities, Drugs, Sexuality, and Suicide/depression).

But, simply being attuned to how patients are performing in general domains can help you spot a troubled teen. “If a kid is still playing football and getting straight A’s, there’s probably a pretty low chance he’s having a serious problem,” he said. “A big part of addiction is secret, so I think when parents start to see their kids be more secretive, hiding their phone,” that’s a red flag. Or maybe their child has a new set of friends that “don’t seem as ‘good’ as the previous set of friends.” Other signs might be “losing a job that they were doing well at before, grades starting to go down, [or] loss of interest in the things they normally like to do. In general, I think kids work their way up to opioid addiction. If parents know their kids smoke cigarettes and think they might be doing some weed, those are the kids that are at risk for moving on to a bigger high.”

Many kids start with pills that they find or take from someone. “They may not think of them as a drug, so you would need to specifically ask, ‘Have you ever used a pill like a pain medication that you may have found or gotten from a family member or a friend for recreational use or for something other than how it was prescribed?’ ” Dr. Hulvershorn said.

The amount of parental supervision also factors in. “There’s been a lot of research showing that, if parents don’t have any idea where their kids are after school or what they’re up do, those kids are much more likely to be using,” she said. “So, you want to ask parents, ‘Are there times when your adolescent is unsupervised?’ ”

If you suspect that one of your adolescent patients is using opioids, but he or she won’t open up about it, consider intermittent urine screening, Dr. Hulvershorn said. If a screen comes back positive, be familiar with patient privacy regulations in your state, because special federal protections apply to adolescents and adults with respect to substance abuse disorder assessment and treatment. For example, in Indiana there is no age limit. Anyone under the age of 18 has the same protection as an adult. “I cannot legally release that information to the parent without the adolescent’s consent, which is really unusual,” she said. “Each state determines the age where that might apply. The best approach is to try to get the adolescent on board, and say, ‘Here’s what we found. We really need to get this out in the open and get you some treatment. I’d really like to have a conversation with your parents.’ Sometimes you can get them to agree, and sometimes you can’t. Nonetheless, you would try to proceed with treatment. You don’t need parental consent for treatment.”

Once Dr. Matson establishes confidentiality with patients, he spends time helping them understand where they fall in the “continuum of use.” He asks for permission to share information with them about the negative aspects of drug use instead of force-feeding it.

“A lot of these kids are hanging around the same kinds of kids and somehow, in their minds, think that what they’re doing is normal,” he said. “To me, somebody smoking weed twice a day every day is a problem, and they probably are addicted. It’s hard to know whether you’d be ready to pull a parent [into the room] at that point or at least give the kid a chance to think if they ... could cut down. If they would, maybe see them back with a warning that, if it’s not going to get much better, you might have to inform parents.

“Weed is always a big issue, especially in kids with ADHD. Those kids are at high risk for substance abuse, especially if they aren’t maintained on their [ADHD] drugs later on,” Dr. Matson said.

Adolescents on opioids “usually are going to present in a more dramatic fashion because they’re starting to get into trouble. They might have gotten arrested or might have been driving under the influence with both alcohol and opioids. To support their habit, a lot of kids have to steal things, so a kid who gets caught shoplifting is someone to be concerned about,” he said.

 

Treatment options

In 2016, the American Academy of Pediatrics issued a new policy statement, “Medication-Assisted Treatment for Adolescents with Opioid Disorders,” which recommends that pediatricians consider offering medication-assisted treatments to their adolescent and young adult patients with opioid use disorders or refer them to other providers who can. Ideally, pediatricians should refer patients to clinicians who have expertise in treating substance abuse disorders in adolescents, typically psychiatrists.

Psychiatrists “tend to have quite a bit of experience with addiction, but they can be very hard to find,” Dr. Hulvershorn said. “Sometimes, it’s a mental health center provider who treats adults with addiction. Addiction is a different beast in kids, but that might be the next best thing.”

Three medicines indicated for treating severe opioid disorder include buprenorphine (the “gold standard,” Dr. Matson said), methadone, and naltrexone, which is Dr. Hulvershorn’s typical drug of choice, “because it’s not a drug of abuse. It’s an opioid antagonist, so it blocks the euphoria that you might get when you are using a drug of abuse such as an opioid.”

Even though pediatricians have access to an American Academy of Pediatrics–endorsed buprenorphine waiver course, not all clinicians feel comfortable adding medication-assisted treatment to patients.

“It might mean that you partner with a substance use provider who can do more comprehensive services but not the prescribing,” Dr. Hulvershorn said. “You certainly don’t want to treat these kids in a vacuum by yourself, because it’s very complicated to treat them.”

Still, the office-based practice of prescribing opioid withdrawal medication “is a very successful approach and a reasonable alternative to other approaches that have been used historically, like methadone maintenance programs,” noted Dr. Potenza, emphasizing that physicians have to understand how to help patients with addiction.

Physicians interviewed for this story underscored the importance of a comprehensive approach that includes behavioral treatment, medication, and support from family and friends.

“A lot of kids who get into these problems come from families that don’t have many resources,” Dr. Matson said, noting that, often, it is a generational problem, in which grandparents and parents are drug users. “But, for kids who take a wrong path, encouraging words really can come true. It’s really a matter of how many people you have cheerleading for you and keeping an eye on you.”

When Dr. Matson’s clinic began treating patients with opioid use disorders 8 years ago, only about 25% of adolescents returned for a second visit, and the rate of abstinence at 1 year was only 9%. The clinic has undertake a large quality improvement project to improve that percentage. “We learned to not scare people right away with a bunch of assignments they have to get done but to just welcome them in, get them started on the medication, and give them positive messages. For short-term remission at 3 months, we’re at 50%-60%, which is pretty good. It’s probably as good as any adult program. I think we’re at 35%-40% remission at 1 year for people first time in recovery,” he said.

Where to go from here

Reflecting on what he’d like opioid use disorder treatment to look like 5 or 10 years down the road, Dr. Matson emphasized the prominent role that pediatricians can play.

“We’re really the ones that could make a difference if we can try to intervene,” he said. “I’m not sure I can prove it, but my pipe dream is, the earlier that we catch people and the less time they’ve been using drugs, it’s got to be easier to stop it then, than if they’ve been using for 5 or 10 years.”

That’s the kind of hope Dr. Hulvershorn holds for the17-year-old patient she’s treating who suffers from depression and PTSD.

“She has decided that it’s important for her to come clean,” said Dr. Hulvershorn, who added that the patient has received mental health and trauma counseling. “Part of our treatment program involves helping patients reorganize their life so that activities they’re involved with are not drug-related. That involves finding new friends and new activities, which can take some time. She is really committed to graduating from high school now that she’s clean. She’s really made a 180.”

Dr. Potenza disclosed having been a consultant to Jazz Pharmaceuticals and Opiant Pharmaceuticals. Dr. Matson and Dr. Hulvershorn reported having no relevant financial disclosures.

Role of a pediatrician’s support is vital

The way Deepa R. Camenga, MD, sees it, pediatricians play a vital role in not only counseling adolescents struggling with opioid use disorders but in helping to prevent it in the first place.

 

Prevention starts with advising parents or caregivers to manage any prescription medication that adolescents may receive for medical indications such as wisdom tooth extractions or sports injuries. “There is some risk for misuse or using it inappropriately or recreationally,” said Dr. Camenga, a pediatrician at Yale School of Medicine, New Haven, Conn., who is also board certified in addiction medicine. “The parents should be highly involved in the administration of these medications to teenagers.”

Other risk factors for opioid use disorders include alcohol, marijuana, or other recreational drugs use or the presence of undiagnosed or undertreated mental health conditions such as ADHD, anxiety, and depression.

“In the primary care setting, I’ve seen a real increase in marijuana use over the last 10 years,” she said. “Some teens are moving on to opiates, but, luckily, it’s still a rarer thing than using marijuana or alcohol. Identifying these conditions is important because, in the act of screening and helping parents and kids link to treatment, pediatricians are preventing drug use.”

Other red flags include poor academic performance and a lack of connectedness in the community. “When we are doing the well-child exams, we often ask about the home and school environment,” Dr. Camenga said. “Looking for positive healthy activities and attachment is essential. If a kid doesn’t have these protective factors, it puts them at higher risk for drug initiation.”

Any time an adolescent’s drug use is escalating in frequency, leading to parental concern or a decrease in function or problems, consider referring the child to a higher level of treatment with a specialist. “Even among teens with low levels of drug use, there are teens who have many risk factors for escalating to a higher level of use,” said Dr. Camenga, who has treated approximately 50 adolescents with opioid use disorders over the past 2 years. “In this case, you may consider referring them earlier rather than later.”

Broaching the conversation about referral to a specialist in substance abuse treatment can be tricky. She recommends saying something like, “ ‘They [the substance use treatment providers] are not going to force you to do anything you don’t want to do,’ because that’s a concern for the teens. ‘They’re going to discuss different options to help you over time, because, physically, it’s very difficult to stop on your own.’ ”

One young patient with several chronic medical conditions was referred to Dr. Camenga after being hospitalized in a psychiatric facility because she was using heroin and stimulants, which triggered a seizure.

“She came into treatment, and it took about 6 months for stabilization, but now she’s doing well,” the pediatrician said. “She’s been in recovery for 2 years and is not using opioids. She’s working, and she’s trying to obtain a higher education certificate.”

Although the American Academy of Pediatrics published a policy statement recommending that pediatricians consider offering buprenorphine and other medication-assisted treatment options for adolescents coping with opioid use disorder (Pediatrics. 2016 Aug. doi: 10.1542/peds.2016-1893). Dr. Camenga said that some physicians are reluctant to do so “because there are concerns about exposing the developing brain to another opiate over time, and there are generally few studies that examine the efficacy of buprenorphine in adolescents specifically. However, the adolescents I’ve had on it do well. I’ve had several adolescents go through an entire treatment course and into recovery on buprenorphine.”

Training options for pediatricians looking to become certified in prescribing buprenorphine for adolescents include an American Academy of Pediatrics–endorsed buprenorphine waiver course.

“At first it may seem overwhelming, but you can make a huge impact by treating two or three people,” she said. “When you do the training through Substance Abuse and Mental Health Services Administration–supported programs (including one at www.asam.org), they provide lots of resources for mentorship or support from providers across the nation who work with special populations, including adolescents. Reach out to them. When I was learning, I talked a lot with my colleagues in different states because there are very few people who treat adolescents and who have the comfort in treating children. We’re all very supportive of each other and reach out to discuss cases.”

Dr. Camenga emphasized that pediatricians play a role in supporting parents and families of adolescents impacted by addiction to opioids.

“It’s a rampant disease and we all know someone affected by it,” she said. “Even if we feel powerless, perhaps, with this epidemic, we have a unique skill in supporting families. More awareness and less stigmatization, and support of families who are going through this, is important.

“We as a society have stigmatized this disease. I think that inhibits some young people getting treatment earlier rather than later. We also need to focus on prevention,” Dr. Camenga emphasized.

She reported having no relevant financial disclosures.
 

 

[email protected]

*This article was updated May 17, 2017.

 

The grip that opioid addiction has on adolescents often resembles that on addicted adults. Both groups crave the next high at all costs.

“Basically, they’re living to find their next heroin or opioids because their ‘feeling good’ completely depends on it,” Steven C. Matson, MD, , chief of the division of adolescent medicine at Nationwide Children’s Hospital, Columbus, Ohio, said in an interview. “They’re up in the morning, out trying to hustle money constantly, and then using and rebounding, and doing it over and over again. It gets to be a pretty dismal way of life.”

courtesy Lindsey Pulfer, RN

After losing several friends to opioid overdoses, a 17-year-old patient of Leslie Hulvershorn, MD, became so emotionally hardened that she thought little of her own young life. “She suffers from depression and PTSD and has talked from time to time about how she doesn’t really care if she lives or dies,” said Dr. Hulvershorn, a child and adolescent psychiatrist who runs an adolescent addiction treatment outpatient program at Riley Hospital for Children, Indianapolis.

Parents often have no clue that their child is addicted to opioids, whether prescription forms like oxycodone or synthetic forms like heroin. “It usually only becomes clear when it comes to the attention of a probation officer or a school that insists on treatment,” said Dr. Hulvershorn, who is also medical director for the State of Indiana’s Division of Mental Health and Addiction, which licenses and certifies all of the opioid treatment programs in the state. “It’s not uncommon to see adolescents who get out of the house at night and go out and use or sell or do something that’s really dangerous. The situations are usually very high risk, very concerning.”

The scope of the problem

The 2015 National Survey on Drug Use and Health (NSDUH) found that 6.5 million Americans over the age of 12 years used controlled prescription medicines nonmedically during the past month, second only to marijuana and more than past-month users of cocaine, heroin, and hallucinogens combined. According to the Centers for Disease Control and Prevention, 91 Americans die every day from an overdose of opioids. In fact, opioid overdoses in the United States increased four times since 1999 and were highest among persons 25-54 years of age. In 2015, the five states with the highest rates of death resulting from drug overdose were West Virginia (41.5 per 100,000), New Hampshire (34.3 per 100,000), Kentucky (29.9 per 100,000), Ohio (29.9 per 100,000), and Rhode Island (28.2 per 100,000).

The CDC also found that, between 2013 and 2014, the number of children aged 0-14 years who died from a drug overdose increased slightly from 105 to 109. The number of children aged 15-24 years who died from a drug overdose rose from 3,664 to 3,798, an increase of 3.6%. While the precise path to opioid addiction differs from patient to patient, experts interviewed for this story noted that adolescents who currently smoke marijuana or drink alcohol on a regular basis face an increased risk of progressing to opioid use, compared with peers who lack substance abuse problems. In such cases, “go ahead and refer for substance abuse treatment at that point, rather than waiting for them to get into something much more dangerous,” Dr. Hulvershorn advised. “Neither of those drugs is good for adolescents either, but you could easily be preventing a worse outcome later. Sometimes physicians will ask, ‘You really want me to refer kids who are smoking pot?’ The answer is, ‘Absolutely.’ That’s probably our best shot at providing them with skills early on, before they get into heavier stuff.”

In October 2016, as part of the Comprehensive Addiction and Recovery Act, the Drug Enforcement Agency announced plans to reduce the amount of almost every Schedule II opiate and opioid medication that may be manufactured in the United States in 2017 by 25% or more. That – coupled with increased media attention in recent years to the perils of opioid addiction in adults, mandatory prescriber education on the use of opioids pain management, and other national efforts to promote safe prescribing practices – has helped to stymie the supply of opioids for illicit use. However, addicts young and old are turning to dangerous alternatives, like heroin, which may be tainted with fentanyl.

“There are even stronger agents like carfentanil, or carfentanyl, a strong veterinary opioid, which is used to put elephants to sleep,” Dr. Matson said. “Suddenly, you read that 18 people die because they got a hold of that. It’s hard to understand. It doesn’t make a lot of sense why somebody trying to make money off of selling drugs would sell you something that would kill you, but most people develop tolerance after long enough use of heroin. People are always trying to reach that new level of high.”

The implication of developing an opioid addiction at such a young age rarely registers with users, yet it can interfere with development “in substantial ways,” said Marc N. Potenza, MD, PhD, professor of psychiatry in the Child Study Center at Yale School of Medicine, New Haven, Conn. “If one is addicted, a lot of time, effort, energy, and attention is focused on the addiction, rather than on things like school, family, and friends.”

 

How to spot a troubled teen

Pediatricians can do their part to detect addiction by regularly asking about drug use during office visits. One quick screen Dr. Matson recommends is the HEADSS (Home, Education/employment, peer group Activities, Drugs, Sexuality, and Suicide/depression).

But, simply being attuned to how patients are performing in general domains can help you spot a troubled teen. “If a kid is still playing football and getting straight A’s, there’s probably a pretty low chance he’s having a serious problem,” he said. “A big part of addiction is secret, so I think when parents start to see their kids be more secretive, hiding their phone,” that’s a red flag. Or maybe their child has a new set of friends that “don’t seem as ‘good’ as the previous set of friends.” Other signs might be “losing a job that they were doing well at before, grades starting to go down, [or] loss of interest in the things they normally like to do. In general, I think kids work their way up to opioid addiction. If parents know their kids smoke cigarettes and think they might be doing some weed, those are the kids that are at risk for moving on to a bigger high.”

Many kids start with pills that they find or take from someone. “They may not think of them as a drug, so you would need to specifically ask, ‘Have you ever used a pill like a pain medication that you may have found or gotten from a family member or a friend for recreational use or for something other than how it was prescribed?’ ” Dr. Hulvershorn said.

The amount of parental supervision also factors in. “There’s been a lot of research showing that, if parents don’t have any idea where their kids are after school or what they’re up do, those kids are much more likely to be using,” she said. “So, you want to ask parents, ‘Are there times when your adolescent is unsupervised?’ ”

If you suspect that one of your adolescent patients is using opioids, but he or she won’t open up about it, consider intermittent urine screening, Dr. Hulvershorn said. If a screen comes back positive, be familiar with patient privacy regulations in your state, because special federal protections apply to adolescents and adults with respect to substance abuse disorder assessment and treatment. For example, in Indiana there is no age limit. Anyone under the age of 18 has the same protection as an adult. “I cannot legally release that information to the parent without the adolescent’s consent, which is really unusual,” she said. “Each state determines the age where that might apply. The best approach is to try to get the adolescent on board, and say, ‘Here’s what we found. We really need to get this out in the open and get you some treatment. I’d really like to have a conversation with your parents.’ Sometimes you can get them to agree, and sometimes you can’t. Nonetheless, you would try to proceed with treatment. You don’t need parental consent for treatment.”

Once Dr. Matson establishes confidentiality with patients, he spends time helping them understand where they fall in the “continuum of use.” He asks for permission to share information with them about the negative aspects of drug use instead of force-feeding it.

“A lot of these kids are hanging around the same kinds of kids and somehow, in their minds, think that what they’re doing is normal,” he said. “To me, somebody smoking weed twice a day every day is a problem, and they probably are addicted. It’s hard to know whether you’d be ready to pull a parent [into the room] at that point or at least give the kid a chance to think if they ... could cut down. If they would, maybe see them back with a warning that, if it’s not going to get much better, you might have to inform parents.

“Weed is always a big issue, especially in kids with ADHD. Those kids are at high risk for substance abuse, especially if they aren’t maintained on their [ADHD] drugs later on,” Dr. Matson said.

Adolescents on opioids “usually are going to present in a more dramatic fashion because they’re starting to get into trouble. They might have gotten arrested or might have been driving under the influence with both alcohol and opioids. To support their habit, a lot of kids have to steal things, so a kid who gets caught shoplifting is someone to be concerned about,” he said.

 

Treatment options

In 2016, the American Academy of Pediatrics issued a new policy statement, “Medication-Assisted Treatment for Adolescents with Opioid Disorders,” which recommends that pediatricians consider offering medication-assisted treatments to their adolescent and young adult patients with opioid use disorders or refer them to other providers who can. Ideally, pediatricians should refer patients to clinicians who have expertise in treating substance abuse disorders in adolescents, typically psychiatrists.

Psychiatrists “tend to have quite a bit of experience with addiction, but they can be very hard to find,” Dr. Hulvershorn said. “Sometimes, it’s a mental health center provider who treats adults with addiction. Addiction is a different beast in kids, but that might be the next best thing.”

Three medicines indicated for treating severe opioid disorder include buprenorphine (the “gold standard,” Dr. Matson said), methadone, and naltrexone, which is Dr. Hulvershorn’s typical drug of choice, “because it’s not a drug of abuse. It’s an opioid antagonist, so it blocks the euphoria that you might get when you are using a drug of abuse such as an opioid.”

Even though pediatricians have access to an American Academy of Pediatrics–endorsed buprenorphine waiver course, not all clinicians feel comfortable adding medication-assisted treatment to patients.

“It might mean that you partner with a substance use provider who can do more comprehensive services but not the prescribing,” Dr. Hulvershorn said. “You certainly don’t want to treat these kids in a vacuum by yourself, because it’s very complicated to treat them.”

Still, the office-based practice of prescribing opioid withdrawal medication “is a very successful approach and a reasonable alternative to other approaches that have been used historically, like methadone maintenance programs,” noted Dr. Potenza, emphasizing that physicians have to understand how to help patients with addiction.

Physicians interviewed for this story underscored the importance of a comprehensive approach that includes behavioral treatment, medication, and support from family and friends.

“A lot of kids who get into these problems come from families that don’t have many resources,” Dr. Matson said, noting that, often, it is a generational problem, in which grandparents and parents are drug users. “But, for kids who take a wrong path, encouraging words really can come true. It’s really a matter of how many people you have cheerleading for you and keeping an eye on you.”

When Dr. Matson’s clinic began treating patients with opioid use disorders 8 years ago, only about 25% of adolescents returned for a second visit, and the rate of abstinence at 1 year was only 9%. The clinic has undertake a large quality improvement project to improve that percentage. “We learned to not scare people right away with a bunch of assignments they have to get done but to just welcome them in, get them started on the medication, and give them positive messages. For short-term remission at 3 months, we’re at 50%-60%, which is pretty good. It’s probably as good as any adult program. I think we’re at 35%-40% remission at 1 year for people first time in recovery,” he said.

Where to go from here

Reflecting on what he’d like opioid use disorder treatment to look like 5 or 10 years down the road, Dr. Matson emphasized the prominent role that pediatricians can play.

“We’re really the ones that could make a difference if we can try to intervene,” he said. “I’m not sure I can prove it, but my pipe dream is, the earlier that we catch people and the less time they’ve been using drugs, it’s got to be easier to stop it then, than if they’ve been using for 5 or 10 years.”

That’s the kind of hope Dr. Hulvershorn holds for the17-year-old patient she’s treating who suffers from depression and PTSD.

“She has decided that it’s important for her to come clean,” said Dr. Hulvershorn, who added that the patient has received mental health and trauma counseling. “Part of our treatment program involves helping patients reorganize their life so that activities they’re involved with are not drug-related. That involves finding new friends and new activities, which can take some time. She is really committed to graduating from high school now that she’s clean. She’s really made a 180.”

Dr. Potenza disclosed having been a consultant to Jazz Pharmaceuticals and Opiant Pharmaceuticals. Dr. Matson and Dr. Hulvershorn reported having no relevant financial disclosures.

Role of a pediatrician’s support is vital

The way Deepa R. Camenga, MD, sees it, pediatricians play a vital role in not only counseling adolescents struggling with opioid use disorders but in helping to prevent it in the first place.

 

Prevention starts with advising parents or caregivers to manage any prescription medication that adolescents may receive for medical indications such as wisdom tooth extractions or sports injuries. “There is some risk for misuse or using it inappropriately or recreationally,” said Dr. Camenga, a pediatrician at Yale School of Medicine, New Haven, Conn., who is also board certified in addiction medicine. “The parents should be highly involved in the administration of these medications to teenagers.”

Other risk factors for opioid use disorders include alcohol, marijuana, or other recreational drugs use or the presence of undiagnosed or undertreated mental health conditions such as ADHD, anxiety, and depression.

“In the primary care setting, I’ve seen a real increase in marijuana use over the last 10 years,” she said. “Some teens are moving on to opiates, but, luckily, it’s still a rarer thing than using marijuana or alcohol. Identifying these conditions is important because, in the act of screening and helping parents and kids link to treatment, pediatricians are preventing drug use.”

Other red flags include poor academic performance and a lack of connectedness in the community. “When we are doing the well-child exams, we often ask about the home and school environment,” Dr. Camenga said. “Looking for positive healthy activities and attachment is essential. If a kid doesn’t have these protective factors, it puts them at higher risk for drug initiation.”

Any time an adolescent’s drug use is escalating in frequency, leading to parental concern or a decrease in function or problems, consider referring the child to a higher level of treatment with a specialist. “Even among teens with low levels of drug use, there are teens who have many risk factors for escalating to a higher level of use,” said Dr. Camenga, who has treated approximately 50 adolescents with opioid use disorders over the past 2 years. “In this case, you may consider referring them earlier rather than later.”

Broaching the conversation about referral to a specialist in substance abuse treatment can be tricky. She recommends saying something like, “ ‘They [the substance use treatment providers] are not going to force you to do anything you don’t want to do,’ because that’s a concern for the teens. ‘They’re going to discuss different options to help you over time, because, physically, it’s very difficult to stop on your own.’ ”

One young patient with several chronic medical conditions was referred to Dr. Camenga after being hospitalized in a psychiatric facility because she was using heroin and stimulants, which triggered a seizure.

“She came into treatment, and it took about 6 months for stabilization, but now she’s doing well,” the pediatrician said. “She’s been in recovery for 2 years and is not using opioids. She’s working, and she’s trying to obtain a higher education certificate.”

Although the American Academy of Pediatrics published a policy statement recommending that pediatricians consider offering buprenorphine and other medication-assisted treatment options for adolescents coping with opioid use disorder (Pediatrics. 2016 Aug. doi: 10.1542/peds.2016-1893). Dr. Camenga said that some physicians are reluctant to do so “because there are concerns about exposing the developing brain to another opiate over time, and there are generally few studies that examine the efficacy of buprenorphine in adolescents specifically. However, the adolescents I’ve had on it do well. I’ve had several adolescents go through an entire treatment course and into recovery on buprenorphine.”

Training options for pediatricians looking to become certified in prescribing buprenorphine for adolescents include an American Academy of Pediatrics–endorsed buprenorphine waiver course.

“At first it may seem overwhelming, but you can make a huge impact by treating two or three people,” she said. “When you do the training through Substance Abuse and Mental Health Services Administration–supported programs (including one at www.asam.org), they provide lots of resources for mentorship or support from providers across the nation who work with special populations, including adolescents. Reach out to them. When I was learning, I talked a lot with my colleagues in different states because there are very few people who treat adolescents and who have the comfort in treating children. We’re all very supportive of each other and reach out to discuss cases.”

Dr. Camenga emphasized that pediatricians play a role in supporting parents and families of adolescents impacted by addiction to opioids.

“It’s a rampant disease and we all know someone affected by it,” she said. “Even if we feel powerless, perhaps, with this epidemic, we have a unique skill in supporting families. More awareness and less stigmatization, and support of families who are going through this, is important.

“We as a society have stigmatized this disease. I think that inhibits some young people getting treatment earlier rather than later. We also need to focus on prevention,” Dr. Camenga emphasized.

She reported having no relevant financial disclosures.
 

 

[email protected]

*This article was updated May 17, 2017.

 

SAN DIEGO – Among obese women, weight loss, stable weight, or weight gain below Institute of Medicine guidelines may result in more favorable or similar perinatal outcomes, compared with weight gain within IOM guidelines, but not for small for gestational age, results from a retrospective cohort study showed.

“This study adds to the limited body of evidence regarding associations of low weight gain and perinatal outcomes among obese women,” Emilia G. Wilkins, MD, the lead study author, said in an interview prior to the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. “This is the first study that uses data collected after the 2009 IOM guidelines were published. Although there have been some studies published after that time, they used older cohorts. We have a large, diverse cohort and had access to robust electronic health records, which allowed for inclusion of multiple relevant covariates.”

In an effort to contribute data to support more specific IOM guidelines for obesity classes I-III, Dr. Wilkins and her associates conducted a retrospective cohort study of 19,810 obese women who delivered singleton, live births greater than 35 weeks at Kaiser Permanente Northern California hospitals between 2009 and 2012. The researchers divided weight gain into three categories below the IOM guidelines of 5 kg-9 kg in an attempt to determine an optimal “low” weight gain category: below –2 kg, –2 kg-2 kg, and 2 kg-5 kg. They used logistic regression to estimate the odds ratios of newborn (size for gestational age, neonatal intensive care unit [NICU] admission, length of hospital stay) and maternal (mode of delivery, preeclampsia, gestational hypertension) outcomes associated with gestational weight gain below IOM guidelines.

Dr. Wilkins, a fourth-year ob.gyn. resident at Kaiser Permanente in Oakland, Calif., reported that 59% of obese women gained weight above the IOM guidelines and that gestational weight gain above the IOM guidelines was consistently associated with worse perinatal outcomes.

Among class III obese women (BMI of 40 or greater), gestational weight gain below –2 kg, compared with gestational weight gain within IOM guidelines, was associated with lower odds of large-for-gestational-age infants (OR, 0.4; 95% CI, 0.3–0.7), preeclampsia/eclampsia (OR, 0.5; 95% CI, 0.3–0.9), cesarean section (OR, 0.5; 95% CI, 0.4–0.7), NICU admission (OR, 0.7; 95% CI, 0.5–1.1), and length of stay greater than 3 days (OR, 0.5; 95% CI, 0.4–0.8), but higher odds of small for gestational age (OR, 2.61; 95% CI, 1.11–6.20). Findings were similar for other obesity classes.

“It is surprising that the protective associations for weight loss were so strong,” Dr. Wilkins said. “At least 50% lower odds of adverse outcomes [were seen], including large for gestational age, cesarean delivery, preeclampsia/eclampsia, and extended neonatal hospital stay – all of which are clinically significant and could have a major implications for maternal and child health. The degree of increased odds (2- to 2.7-fold higher) of small for gestational age was also a surprising finding and indicates the need to further assess whether the health of the small-for-gestational-age babies differed across the gestational weight gain categories.”

One surprise was that, although the weight loss group had higher odds of delivering a small for gestational age infant, there was no association with increased NICU admission or increased neonatal hospital stay,” Dr. Wilkins added.

She acknowledged certain limitations of the study, including the fact that approximately 10% of the prepregnancy weights were self-measured. Additionally, there was low statistical power to evaluate NICU and length of stay data, and maternal conditions associated with prior weight loss such as bariatric surgery were not evaluated.

Dr. Wilkins reported having no financial disclosures.

[email protected]

 

SAN DIEGO – Among obese women, weight loss, stable weight, or weight gain below Institute of Medicine guidelines may result in more favorable or similar perinatal outcomes, compared with weight gain within IOM guidelines, but not for small for gestational age, results from a retrospective cohort study showed.

“This study adds to the limited body of evidence regarding associations of low weight gain and perinatal outcomes among obese women,” Emilia G. Wilkins, MD, the lead study author, said in an interview prior to the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. “This is the first study that uses data collected after the 2009 IOM guidelines were published. Although there have been some studies published after that time, they used older cohorts. We have a large, diverse cohort and had access to robust electronic health records, which allowed for inclusion of multiple relevant covariates.”

In an effort to contribute data to support more specific IOM guidelines for obesity classes I-III, Dr. Wilkins and her associates conducted a retrospective cohort study of 19,810 obese women who delivered singleton, live births greater than 35 weeks at Kaiser Permanente Northern California hospitals between 2009 and 2012. The researchers divided weight gain into three categories below the IOM guidelines of 5 kg-9 kg in an attempt to determine an optimal “low” weight gain category: below –2 kg, –2 kg-2 kg, and 2 kg-5 kg. They used logistic regression to estimate the odds ratios of newborn (size for gestational age, neonatal intensive care unit [NICU] admission, length of hospital stay) and maternal (mode of delivery, preeclampsia, gestational hypertension) outcomes associated with gestational weight gain below IOM guidelines.

Dr. Wilkins, a fourth-year ob.gyn. resident at Kaiser Permanente in Oakland, Calif., reported that 59% of obese women gained weight above the IOM guidelines and that gestational weight gain above the IOM guidelines was consistently associated with worse perinatal outcomes.

Among class III obese women (BMI of 40 or greater), gestational weight gain below –2 kg, compared with gestational weight gain within IOM guidelines, was associated with lower odds of large-for-gestational-age infants (OR, 0.4; 95% CI, 0.3–0.7), preeclampsia/eclampsia (OR, 0.5; 95% CI, 0.3–0.9), cesarean section (OR, 0.5; 95% CI, 0.4–0.7), NICU admission (OR, 0.7; 95% CI, 0.5–1.1), and length of stay greater than 3 days (OR, 0.5; 95% CI, 0.4–0.8), but higher odds of small for gestational age (OR, 2.61; 95% CI, 1.11–6.20). Findings were similar for other obesity classes.

“It is surprising that the protective associations for weight loss were so strong,” Dr. Wilkins said. “At least 50% lower odds of adverse outcomes [were seen], including large for gestational age, cesarean delivery, preeclampsia/eclampsia, and extended neonatal hospital stay – all of which are clinically significant and could have a major implications for maternal and child health. The degree of increased odds (2- to 2.7-fold higher) of small for gestational age was also a surprising finding and indicates the need to further assess whether the health of the small-for-gestational-age babies differed across the gestational weight gain categories.”

One surprise was that, although the weight loss group had higher odds of delivering a small for gestational age infant, there was no association with increased NICU admission or increased neonatal hospital stay,” Dr. Wilkins added.

She acknowledged certain limitations of the study, including the fact that approximately 10% of the prepregnancy weights were self-measured. Additionally, there was low statistical power to evaluate NICU and length of stay data, and maternal conditions associated with prior weight loss such as bariatric surgery were not evaluated.

Dr. Wilkins reported having no financial disclosures.

[email protected]

 

SAN DIEGO – Among obese women, weight loss, stable weight, or weight gain below Institute of Medicine guidelines may result in more favorable or similar perinatal outcomes, compared with weight gain within IOM guidelines, but not for small for gestational age, results from a retrospective cohort study showed.

“This study adds to the limited body of evidence regarding associations of low weight gain and perinatal outcomes among obese women,” Emilia G. Wilkins, MD, the lead study author, said in an interview prior to the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. “This is the first study that uses data collected after the 2009 IOM guidelines were published. Although there have been some studies published after that time, they used older cohorts. We have a large, diverse cohort and had access to robust electronic health records, which allowed for inclusion of multiple relevant covariates.”

In an effort to contribute data to support more specific IOM guidelines for obesity classes I-III, Dr. Wilkins and her associates conducted a retrospective cohort study of 19,810 obese women who delivered singleton, live births greater than 35 weeks at Kaiser Permanente Northern California hospitals between 2009 and 2012. The researchers divided weight gain into three categories below the IOM guidelines of 5 kg-9 kg in an attempt to determine an optimal “low” weight gain category: below –2 kg, –2 kg-2 kg, and 2 kg-5 kg. They used logistic regression to estimate the odds ratios of newborn (size for gestational age, neonatal intensive care unit [NICU] admission, length of hospital stay) and maternal (mode of delivery, preeclampsia, gestational hypertension) outcomes associated with gestational weight gain below IOM guidelines.

Dr. Wilkins, a fourth-year ob.gyn. resident at Kaiser Permanente in Oakland, Calif., reported that 59% of obese women gained weight above the IOM guidelines and that gestational weight gain above the IOM guidelines was consistently associated with worse perinatal outcomes.

Among class III obese women (BMI of 40 or greater), gestational weight gain below –2 kg, compared with gestational weight gain within IOM guidelines, was associated with lower odds of large-for-gestational-age infants (OR, 0.4; 95% CI, 0.3–0.7), preeclampsia/eclampsia (OR, 0.5; 95% CI, 0.3–0.9), cesarean section (OR, 0.5; 95% CI, 0.4–0.7), NICU admission (OR, 0.7; 95% CI, 0.5–1.1), and length of stay greater than 3 days (OR, 0.5; 95% CI, 0.4–0.8), but higher odds of small for gestational age (OR, 2.61; 95% CI, 1.11–6.20). Findings were similar for other obesity classes.

“It is surprising that the protective associations for weight loss were so strong,” Dr. Wilkins said. “At least 50% lower odds of adverse outcomes [were seen], including large for gestational age, cesarean delivery, preeclampsia/eclampsia, and extended neonatal hospital stay – all of which are clinically significant and could have a major implications for maternal and child health. The degree of increased odds (2- to 2.7-fold higher) of small for gestational age was also a surprising finding and indicates the need to further assess whether the health of the small-for-gestational-age babies differed across the gestational weight gain categories.”

One surprise was that, although the weight loss group had higher odds of delivering a small for gestational age infant, there was no association with increased NICU admission or increased neonatal hospital stay,” Dr. Wilkins added.

She acknowledged certain limitations of the study, including the fact that approximately 10% of the prepregnancy weights were self-measured. Additionally, there was low statistical power to evaluate NICU and length of stay data, and maternal conditions associated with prior weight loss such as bariatric surgery were not evaluated.

Dr. Wilkins reported having no financial disclosures.

[email protected]

SAN DIEGO – Vulnerable patients experienced higher 30-day postpartum readmission rates, regardless of site of care, results from a large national analysis demonstrated.

“Although childbirth is the most common indication for inpatient admission in the United States – accounting for up to 4 million inpatient stays per year – national 30-day postpartum readmission rates, reasons for readmissions, and variation in readmission rates according to patient clinical and demographic characteristics on a national scale remain unknown,” Anju Ranjit, MD, said in an interview prior to the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

In an effort to determine 30-day readmission rates following delivery in the United States, assess for access-based differences in readmission rates, and determine if differences vary by site of care, the researchers used the Nationwide Readmissions Database to identify deliveries during January 2013-October 2013. They defined “vulnerable patients” as those on Medicaid or uninsured patients or patients with income of less than $25,000 per year. They defined “nonvulnerable patients” as those with private and other types of insurance or patients with an income of more than $25,000 per year. Finally, they ranked hospitals by the proportion of vulnerable patients served.

Dr. Ranjit, a postdoctoral research fellow at Brigham and Women’s Hospital, Boston, and her associates used multivariable logistic regression to compare differences in 30-day readmissions among 499,578 patients treated at hospitals serving a higher proportion of vulnerable patients (safety net hospitals) with the 30-day readmissions among 877,325 patients treated at hospitals serving a higher proportion of nonvulnerable patients (non–safety net hospitals). Models were adjusted for differences in patient demographics, comorbidities, pregnancy risk-status, type of deliveries, and hospital characteristics.

The researchers included 1,374,903 deliveries in the analysis, which were weighted to represent 3,113,047 deliveries nationwide. The national 30-day postpartum readmission rate was 1.4/100 deliveries. The top three reasons for readmission were wound infection (20.8%), infection (7.7%), and hypertension-related complications (6.2%).

Dr. Ranjit reported that in 2013, a total of 724,833 (53.3%) deliveries were to vulnerable patients and the remaining 652,070 (47.4%) to nonvulnerable patients. The rate of 30-day postpartum readmissions were higher among vulnerable patients, compared with their nonvulnerable counterparts (1.52% vs. 1.18%, respectively; adjusted odds ratio, 1.31; confidence interval, 1.26-1.37) and among patients who were treated at hospitals managing a higher proportion of vulnerable patients (1.51% vs. 1.27%; adjusted OR 1.19; CI, 1.12-1.27).*

“Higher readmission rates seen among vulnerable patients across institutions speak to the need to address disparities in perinatal care,” Dr. Ranjit said. “Quality improvement interventions targeted at safety net hospitals, where the majority of vulnerable patients seek care, could be helpful in reducing readmission rates among vulnerable populations.”

She acknowledged certain limitations of study, including the use of administrative data that is subject to coding error and that lacks clinical granularity.

“We were unable to control for patient’s race and region of residence due of lack of information,” she added. “Classification of hospitals into ‘safety net’ and ‘non–safety net’ hospitals was done – based on the proportion of vulnerable patients served, as identified in the national readmissions database – for the purpose of this study only.”

Dr. Ranjit reported having no financial disclosures.

* Correction, 05/08/17: An earlier version of this article incorrectly described the patient populations.

[email protected]

SAN DIEGO – Vulnerable patients experienced higher 30-day postpartum readmission rates, regardless of site of care, results from a large national analysis demonstrated.

“Although childbirth is the most common indication for inpatient admission in the United States – accounting for up to 4 million inpatient stays per year – national 30-day postpartum readmission rates, reasons for readmissions, and variation in readmission rates according to patient clinical and demographic characteristics on a national scale remain unknown,” Anju Ranjit, MD, said in an interview prior to the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

In an effort to determine 30-day readmission rates following delivery in the United States, assess for access-based differences in readmission rates, and determine if differences vary by site of care, the researchers used the Nationwide Readmissions Database to identify deliveries during January 2013-October 2013. They defined “vulnerable patients” as those on Medicaid or uninsured patients or patients with income of less than $25,000 per year. They defined “nonvulnerable patients” as those with private and other types of insurance or patients with an income of more than $25,000 per year. Finally, they ranked hospitals by the proportion of vulnerable patients served.

Dr. Ranjit, a postdoctoral research fellow at Brigham and Women’s Hospital, Boston, and her associates used multivariable logistic regression to compare differences in 30-day readmissions among 499,578 patients treated at hospitals serving a higher proportion of vulnerable patients (safety net hospitals) with the 30-day readmissions among 877,325 patients treated at hospitals serving a higher proportion of nonvulnerable patients (non–safety net hospitals). Models were adjusted for differences in patient demographics, comorbidities, pregnancy risk-status, type of deliveries, and hospital characteristics.

The researchers included 1,374,903 deliveries in the analysis, which were weighted to represent 3,113,047 deliveries nationwide. The national 30-day postpartum readmission rate was 1.4/100 deliveries. The top three reasons for readmission were wound infection (20.8%), infection (7.7%), and hypertension-related complications (6.2%).

Dr. Ranjit reported that in 2013, a total of 724,833 (53.3%) deliveries were to vulnerable patients and the remaining 652,070 (47.4%) to nonvulnerable patients. The rate of 30-day postpartum readmissions were higher among vulnerable patients, compared with their nonvulnerable counterparts (1.52% vs. 1.18%, respectively; adjusted odds ratio, 1.31; confidence interval, 1.26-1.37) and among patients who were treated at hospitals managing a higher proportion of vulnerable patients (1.51% vs. 1.27%; adjusted OR 1.19; CI, 1.12-1.27).*

“Higher readmission rates seen among vulnerable patients across institutions speak to the need to address disparities in perinatal care,” Dr. Ranjit said. “Quality improvement interventions targeted at safety net hospitals, where the majority of vulnerable patients seek care, could be helpful in reducing readmission rates among vulnerable populations.”

She acknowledged certain limitations of study, including the use of administrative data that is subject to coding error and that lacks clinical granularity.

“We were unable to control for patient’s race and region of residence due of lack of information,” she added. “Classification of hospitals into ‘safety net’ and ‘non–safety net’ hospitals was done – based on the proportion of vulnerable patients served, as identified in the national readmissions database – for the purpose of this study only.”

Dr. Ranjit reported having no financial disclosures.

* Correction, 05/08/17: An earlier version of this article incorrectly described the patient populations.

[email protected]

SAN DIEGO – Vulnerable patients experienced higher 30-day postpartum readmission rates, regardless of site of care, results from a large national analysis demonstrated.

“Although childbirth is the most common indication for inpatient admission in the United States – accounting for up to 4 million inpatient stays per year – national 30-day postpartum readmission rates, reasons for readmissions, and variation in readmission rates according to patient clinical and demographic characteristics on a national scale remain unknown,” Anju Ranjit, MD, said in an interview prior to the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

In an effort to determine 30-day readmission rates following delivery in the United States, assess for access-based differences in readmission rates, and determine if differences vary by site of care, the researchers used the Nationwide Readmissions Database to identify deliveries during January 2013-October 2013. They defined “vulnerable patients” as those on Medicaid or uninsured patients or patients with income of less than $25,000 per year. They defined “nonvulnerable patients” as those with private and other types of insurance or patients with an income of more than $25,000 per year. Finally, they ranked hospitals by the proportion of vulnerable patients served.

Dr. Ranjit, a postdoctoral research fellow at Brigham and Women’s Hospital, Boston, and her associates used multivariable logistic regression to compare differences in 30-day readmissions among 499,578 patients treated at hospitals serving a higher proportion of vulnerable patients (safety net hospitals) with the 30-day readmissions among 877,325 patients treated at hospitals serving a higher proportion of nonvulnerable patients (non–safety net hospitals). Models were adjusted for differences in patient demographics, comorbidities, pregnancy risk-status, type of deliveries, and hospital characteristics.

The researchers included 1,374,903 deliveries in the analysis, which were weighted to represent 3,113,047 deliveries nationwide. The national 30-day postpartum readmission rate was 1.4/100 deliveries. The top three reasons for readmission were wound infection (20.8%), infection (7.7%), and hypertension-related complications (6.2%).

Dr. Ranjit reported that in 2013, a total of 724,833 (53.3%) deliveries were to vulnerable patients and the remaining 652,070 (47.4%) to nonvulnerable patients. The rate of 30-day postpartum readmissions were higher among vulnerable patients, compared with their nonvulnerable counterparts (1.52% vs. 1.18%, respectively; adjusted odds ratio, 1.31; confidence interval, 1.26-1.37) and among patients who were treated at hospitals managing a higher proportion of vulnerable patients (1.51% vs. 1.27%; adjusted OR 1.19; CI, 1.12-1.27).*

“Higher readmission rates seen among vulnerable patients across institutions speak to the need to address disparities in perinatal care,” Dr. Ranjit said. “Quality improvement interventions targeted at safety net hospitals, where the majority of vulnerable patients seek care, could be helpful in reducing readmission rates among vulnerable populations.”

She acknowledged certain limitations of study, including the use of administrative data that is subject to coding error and that lacks clinical granularity.

“We were unable to control for patient’s race and region of residence due of lack of information,” she added. “Classification of hospitals into ‘safety net’ and ‘non–safety net’ hospitals was done – based on the proportion of vulnerable patients served, as identified in the national readmissions database – for the purpose of this study only.”

Dr. Ranjit reported having no financial disclosures.

* Correction, 05/08/17: An earlier version of this article incorrectly described the patient populations.

[email protected]

 

SAN DIEGO – Smoking during the period of fetal organogenesis, during the first trimester of pregnancy, is associated with increased risk of some birth defects, results from a large retrospective analysis demonstrated.

“Significant amounts of research have looked into the effects of smoking on pregnancy,” lead study author Madeline Perry said in an interview prior to the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. “From this we’ve learned a lot, such as how smoking contributes to adverse fetal outcomes like intrauterine growth restriction. However, less research has evaluated how smoking influences congenital birth defects. There are studies that suggest this connection. However, this study is unique in that in order to better understand this relationship, it looks at smoking in the months leading up to pregnancy as well as during the first trimester. While it’s understood that smoking during pregnancy can have negative effects on both the mother and the fetus, I was especially interested in how smoking even before conception can affect fetal development.”

Ms. Perry, a second-year medical student at the University of Cincinnati and her associates conducted a population-based retrospective cohort analysis of 1,436,036 live births in Ohio during 2006-2015. They compared the rates of major defects between births to nonsmoking mothers and those who smoked only during the 3-month preconception period and not in the first trimester; and in the preconception period plus throughout the first trimester. They used multivariate logistic regression to quantify the relationship between smoking and birth defects after adjustment for maternal race, age, pregestational diabetes, and socioeconomic factors.

The researchers observed that 23.3% of women smoked during pregnancy; 6.0% during preconception only and 17.3% smoked through the first trimester, as well. Smoking during the preconception period only, even without first trimester exposure, was associated with a 40% increased risk of gastroschisis (adjusted risk ratio, 1.4), but no other individual birth defects. However, smoking through the first trimester was associated with a modest but significantly increased risk of several defects, including gastroschisis (adjusted RR, 1.9), limb reduction (adjusted RR, 1.6), congenital diaphragmatic hernia (adjusted RR, 1.4), and cleft palate (adjusted RR, 1.2), even after adjustment for coexisting factors.

“It was surprising to see that, even when women stop smoking when they find out they are pregnant, and therefore are not smoking during the period of fetal organogenesis, there is still an increased risk of some congenital birth defects to the fetus,” Ms. Perry said. “My hope is that this study serves as a launching point for future research and public health efforts. It’s important to encourage smoking cessation in women of reproductive age, whether pregnant or not. Furthermore, it’s valuable to be able to explain to patients that along with adverse effects to their own health, smoking even before conception poses a risk to the fetus.”

She acknowledged certain limitations of the study, including its observational design. “There could exist unmeasurable influences that we were unable to adjust for,” Ms. Perry said. She reported having no financial disclosures.

[email protected]

 

SAN DIEGO – Smoking during the period of fetal organogenesis, during the first trimester of pregnancy, is associated with increased risk of some birth defects, results from a large retrospective analysis demonstrated.

“Significant amounts of research have looked into the effects of smoking on pregnancy,” lead study author Madeline Perry said in an interview prior to the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. “From this we’ve learned a lot, such as how smoking contributes to adverse fetal outcomes like intrauterine growth restriction. However, less research has evaluated how smoking influences congenital birth defects. There are studies that suggest this connection. However, this study is unique in that in order to better understand this relationship, it looks at smoking in the months leading up to pregnancy as well as during the first trimester. While it’s understood that smoking during pregnancy can have negative effects on both the mother and the fetus, I was especially interested in how smoking even before conception can affect fetal development.”

Ms. Perry, a second-year medical student at the University of Cincinnati and her associates conducted a population-based retrospective cohort analysis of 1,436,036 live births in Ohio during 2006-2015. They compared the rates of major defects between births to nonsmoking mothers and those who smoked only during the 3-month preconception period and not in the first trimester; and in the preconception period plus throughout the first trimester. They used multivariate logistic regression to quantify the relationship between smoking and birth defects after adjustment for maternal race, age, pregestational diabetes, and socioeconomic factors.

The researchers observed that 23.3% of women smoked during pregnancy; 6.0% during preconception only and 17.3% smoked through the first trimester, as well. Smoking during the preconception period only, even without first trimester exposure, was associated with a 40% increased risk of gastroschisis (adjusted risk ratio, 1.4), but no other individual birth defects. However, smoking through the first trimester was associated with a modest but significantly increased risk of several defects, including gastroschisis (adjusted RR, 1.9), limb reduction (adjusted RR, 1.6), congenital diaphragmatic hernia (adjusted RR, 1.4), and cleft palate (adjusted RR, 1.2), even after adjustment for coexisting factors.

“It was surprising to see that, even when women stop smoking when they find out they are pregnant, and therefore are not smoking during the period of fetal organogenesis, there is still an increased risk of some congenital birth defects to the fetus,” Ms. Perry said. “My hope is that this study serves as a launching point for future research and public health efforts. It’s important to encourage smoking cessation in women of reproductive age, whether pregnant or not. Furthermore, it’s valuable to be able to explain to patients that along with adverse effects to their own health, smoking even before conception poses a risk to the fetus.”

She acknowledged certain limitations of the study, including its observational design. “There could exist unmeasurable influences that we were unable to adjust for,” Ms. Perry said. She reported having no financial disclosures.

[email protected]

 

SAN DIEGO – Smoking during the period of fetal organogenesis, during the first trimester of pregnancy, is associated with increased risk of some birth defects, results from a large retrospective analysis demonstrated.

“Significant amounts of research have looked into the effects of smoking on pregnancy,” lead study author Madeline Perry said in an interview prior to the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. “From this we’ve learned a lot, such as how smoking contributes to adverse fetal outcomes like intrauterine growth restriction. However, less research has evaluated how smoking influences congenital birth defects. There are studies that suggest this connection. However, this study is unique in that in order to better understand this relationship, it looks at smoking in the months leading up to pregnancy as well as during the first trimester. While it’s understood that smoking during pregnancy can have negative effects on both the mother and the fetus, I was especially interested in how smoking even before conception can affect fetal development.”

Ms. Perry, a second-year medical student at the University of Cincinnati and her associates conducted a population-based retrospective cohort analysis of 1,436,036 live births in Ohio during 2006-2015. They compared the rates of major defects between births to nonsmoking mothers and those who smoked only during the 3-month preconception period and not in the first trimester; and in the preconception period plus throughout the first trimester. They used multivariate logistic regression to quantify the relationship between smoking and birth defects after adjustment for maternal race, age, pregestational diabetes, and socioeconomic factors.

The researchers observed that 23.3% of women smoked during pregnancy; 6.0% during preconception only and 17.3% smoked through the first trimester, as well. Smoking during the preconception period only, even without first trimester exposure, was associated with a 40% increased risk of gastroschisis (adjusted risk ratio, 1.4), but no other individual birth defects. However, smoking through the first trimester was associated with a modest but significantly increased risk of several defects, including gastroschisis (adjusted RR, 1.9), limb reduction (adjusted RR, 1.6), congenital diaphragmatic hernia (adjusted RR, 1.4), and cleft palate (adjusted RR, 1.2), even after adjustment for coexisting factors.

“It was surprising to see that, even when women stop smoking when they find out they are pregnant, and therefore are not smoking during the period of fetal organogenesis, there is still an increased risk of some congenital birth defects to the fetus,” Ms. Perry said. “My hope is that this study serves as a launching point for future research and public health efforts. It’s important to encourage smoking cessation in women of reproductive age, whether pregnant or not. Furthermore, it’s valuable to be able to explain to patients that along with adverse effects to their own health, smoking even before conception poses a risk to the fetus.”

She acknowledged certain limitations of the study, including its observational design. “There could exist unmeasurable influences that we were unable to adjust for,” Ms. Perry said. She reported having no financial disclosures.

[email protected]