Objective To quantify physician prescribing patterns and patient opioid use in the two weeks after hysterectomy at an academic institution, and determine whether patient factors predict postsurgical opioid use and pain recovery. Methods We conducted a prospective quality initiative study by recruiting all English-speaking patients undergoing hysterectomy for benign, non-obstetric indications at a university hospital between August and December 2015, excluding those with major medical morbidities or substance abuse. Before hysterectomy, patients completed the Fibromyalgia Survey, a validated measure of centralized pain. Following hysterectomy, opioid use (converted to oral morphine equivalents) and pain scores (0–10 numeric rating scale) were collected by a daily diary and a structured telephone interview 14 days after surgery. Primary outcomes were total opioid prescribed and consumed in the 2 weeks after hysterectomy. Secondary outcomes included daily opioid use and daily pain severity for 14 days after hysterectomy. Results Of 103 eligible patients, 102 (99%) agreed to participate, including 44 (43.1%) laparoscopic, 42 (41.2%) vaginal, and 16 (15.7%) abdominal hysterectomies. Telephone surveys were completed on 89 (87%) participants, diaries were returned from 60 (59%) participants. Diary non-responders had different baseline characteristics than non-responders. Median amount of opioid prescribed was 200 oral morphine equivalents (interquartile range (IQR) 150–250). Patients reported using approximately half of the opioids prescribed, with a median excess of 110 morphine equivalents (IQR 40–150). The best fit model of total opioid consumption identified preoperative Fibromyalgia Score, overall body pain, preoperative opioid use, prior endometriosis, abdominal hysterectomy (compared to laparoscopic), and uterine weight as significant predictors. Highest tertile of Fibromyalgia Score was associated with greater daily opioid consumption (13.9 [95% CI 3.0 – 24.8] greater OME at baseline, p=0.02). Conclusion Gynecologists at a large academic medical center prescribe twice the amount of opioids than the average patient uses after hysterectomy. A personalized approach to prescribing opioids for postoperative pain should be considered.
Objective To examine the relationship between sleep disordered breathing (SDB) and adverse pregnancy outcomes in a high-risk cohort Study Design This was a planned analysis of a prospective cohort designed to estimate the prevalence and trends of SDB in a high-risk pregnant women. We recruited women with a BMI ≥ 30 kg/m2, chronic hypertension, pre-gestational diabetes, prior preeclampsia, and/or a twin gestation. Objective assessment of SDB was completed between 6–20 weeks and again in the third trimester. SDB was defined as an apnea hypopnea index ≥5, and further grouped into severity categories: mild SDB (5–14.9), moderate SDB (15–29.9) and severe SDB (≥30). Pregnancy outcomes (preeclampsia, gestational diabetes, preterm birth, infant weight) were abstracted by physicians blinded to the SDB results. Results Of the 188 women with a valid early pregnancy sleep study, 182 had complete delivery records. There was no relationship demonstrated between SDB exposure in early or late pregnancy and preeclampsia, preterm birth < 34 weeks, and small for gestational age (<5%) or large for gestational age (>95%) neonates. Conversely, SDB severity in early pregnancy was associated with the risk of developing gestational diabetes (no SDB 25%, mild SDB 43%, moderate/severe SDB 63%, p=.03). The adjusted OR for developing gestational diabetes for moderate/severe SDB was 3.6 (0.6, 21.8). Conclusions This study suggests a dose-dependent relationship between SDB in early pregnancy and the subsequent development of gestational diabetes. In contrast, no relationships between SDB during pregnancy and preeclampsia, preterm birth, and extremes of birthweight were demonstrated.
Fewer than 25% of women undergoing laparoscopic or abdominal hysterectomy for chronic pelvic pain have endometriosis at the time of surgery.
This analysis demonstrates that conversion to laparotomy is associated with increased odds of postoperative morbidity, and robotic assistance and surgeon volume are strongly associated with decreased odds of conversion.
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