OBJECTIVE: To evaluate the effects of eliminating the routine use of oral opioids for postcesarean delivery analgesia on postcesarean opioid consumption. METHODS: At a tertiary care center, we implemented a quality improvement intervention among faculty practice patients undergoing cesarean delivery, which consisted of 1) eliminating routine ordering of oral opioids after cesarean delivery, 2) implementing guidelines for ordering a short course of opioids when deemed necessary, and 3) coupling opioid prescribing at discharge to patterns of opioid use in-hospital combined with shared decision-making. All patients, both before and after the intervention, were administered neuraxial opioids and scheduled acetaminophen and nonsteroidal antiinflammatory medications in the absence of contraindications. The primary outcome was the percentage of women who used any opioids postoperatively in-hospital. Secondary outcomes included the percentage of women discharged with a prescription for opioids, the quantity of opioids used in-hospital, pain scores, satisfaction, opioid-related side effects, and opioid prescriptions ordered in the 6 weeks after delivery. The effects of this intervention were assessed based on a chart review of patient data and a survey of patients in the 12 weeks before and 12 weeks after the intervention. RESULTS: We evaluated the records of 191 postcesarean delivery patients before and 181 after the intervention. Less than half of women used oral opioids in-hospital after the intervention, 82 (45%) compared with 130 (68%) before (P<.001). However, there was no change in pain scores or overall satisfaction with pain relief. Postintervention, only 40% of patients were discharged with prescriptions for opioids compared with 91% of patients before the intervention (P<.001). CONCLUSION: Eliminating routine ordering of oral opioids after cesarean delivery is associated with a significant decrease in opioid consumption while maintaining the same levels of pain control and patient satisfaction. Oral opioids are not needed by a large proportion of women after cesarean delivery.

No abstract

No abstract

Objectives: The use of extracorporeal membrane oxygenation (ECMO) therapy has increased in the adult population. Studies from the H1N1 influenza pandemic suggest that ECMO deployment in pregnancy is associated with favorable outcomes. With increasing numbers of pregnant women affected by COVID-19 and potentially requiring this life-saving therapy, we sought to compare comorbidities, costs, and outcomes between pregnancy and non-pregnancy associated ECMO therapy among reproductive-aged female patients. Study Design: We used the 2013-2019 National Readmissions Database. Diagnosis and procedural coding were used to identify ECMO deployment, potential indications, comorbid conditions, and pregnancy outcomes. The primary outcome was in-hospital mortality during the patient’s initial ECMO stay. Secondary outcomes included length of stay and hospital charges/costs, occurrence of thromboembolic or bleeding complications during ECMO hospitalization, and mortality and readmissions up to 330 days following ECMO stay. Univariate and multivariate regression models were used to model the associations between pregnancy status and outcomes. Results: The sample included 324 pregnancy-associated hospitalizations and 3,805 non- pregnancy associated hospitalizations, corresponding to national estimates of 665 and 7,653 over the study period, respectively. Pregnancy-associated ECMO had lower incidence of in-hospital death (adjusted odds ratio (AOR): 0.56, 95% confidence interval (CI): 0.41-0.75) and bleeding complications (AOR: 0.67, 95% CI: 0.49-0.93). Length of stay was significantly shorter (adjusted rate ratio (ARR): 0.86, 95% CI: 0.77-0.96) and total hospital costs were less (ARR: 0.83, 95% CI: 0.75-0.93). Differences in the incidence of thromboembolic events (AOR: 1.04, 95% CI: 0.78-1.38) were not statistically significant. Conclusion: Pregnancy-associated ECMO therapy had lower incidence of in-hospital death, bleeding complications, total inpatient cost, and length of stay when compared to non-pregnancy associated ECMO therapy without increased thromboembolic complications. Pregnancy-associated ECMO therapy should be offered to eligible patients.

No abstract

No abstract

Introduction GNAS mutations have been reprted in both McCune-Albright Syndrome (MAS) and juvenile granulosa cell tumors (JGCT), but have never been reported simultaneously in the same patient. Case Presentation A 15-year-old girl developed secondary oligomenorrhea. Laboratory studies revealed suppressed gonadotropin levels with markedly elevated estradiol and inhibin B levels. Pelvic ultrasound showed a 12-cm heterogeneous right adnexal mass; pelvic MRI to further characterize the mass displayed heterogeneous bilateral femoral bone lesions initially concerning for metastatic disease. PET/CT showed minimal fluorodeoxyglucose (FDG) uptake in the pelvic mass, but unexpectedly revealed FDG uptake throughout the skeleton, concerning for polyostotic fibrous dysplasia in the context of McCune-Albright Syndrome (MAS). The adnexal mass was excised and pathology confirmed a juvenile granulosa cell tumor (JGCT). The patient’s affected bone and JGCT tissue revealed the same pathogenic GNAS p.R201C mutation, while her peripheral blood contained wild type arginine at codon 201. Conclusion This mutation has been previously reported in cases of MAS and JGCT, but never simultaneously in the same patient. This demonstration of a GNAS mutation underlying both JGCT and MAS in the same patient raises questions about appropriate surveillance for patients with these conditions.

No abstract