Ebony Boyce Carter

/SUMMARY: Objective: Cannabis use during pregnancy is increasing; associations with neonatal growth may be confounded by nicotine. We evaluated prenatal cannabis exposure (PreCE) and neonatal outcomes in a prospective cohort with biochemical control for nicotine exposure. Methods: In the Cannabis Use During Early Life and Development (CUDDEL) study, pregnant women with a lifetime history of cannabis use were classified as PreCE if they self-reported use or had urine THC-COOH positivity at any trimester (n=297) and as unexposed if they reported no use and tested negative (n=151). Linear regression and modified Poisson models estimated associations with birthweight and small for gestational age (SGA; <10th and weekly vs <monthly) and cotinine status. Results: Participants (N=448; 18-41 years; 85.3% non-Hispanic Black) had lower birthweight with PreCE in adjusted models (Beta=-0.08; padj=0.041). High-frequency PreCE was associated with lower birthweight compared with unexposed pregnancies (Beta=-0.13; padj=0.03), whereas low-frequency PreCE was not. Cotinine-positive PreCE showed the greatest birthweight reduction versus unexposed (Beta=-0.20; padj<0.001). PreCE was also associated with higher likelihood of SGA <5th percentile; risk was highest in PreCE+Nicotine compared with both unexposed and PreCE-Nicotine groups. Conclusions: Prenatal cannabis exposure was associated with reduced birthweight and SGA in this cohort. Nicotine co-exposure intensified these associations, yet effects persisted without cotinine, supporting cannabis as an independent perinatal risk factor and emphasizing the value of cotinine assessment in populations where blunt use or secondhand exposure is common.

Shared medical appointments (SMAs) for diabetes and group prenatal care (GPC) for pregnant patients have emerged as innovative care delivery models. They have the potential to transform diabetes care by overcoming many of the time limitations of traditional one-on-one clinical visits. There is compelling evidence that SMAs improve glycemic control for nonpregnant patients with diabetes, GPC reduces Black and White health disparities in preterm birth, and diabetes GPC increases postpartum glucose tolerance test uptake among patients with gestational diabetes mellitus. GPC models stand out as one of few interventions that reduce racial health disparities, which we hypothesize occurs because their effect is inadvertently exerted on both the patient and clinician through an over 20-h meaningful shared experience. In this article I explore the evidence for SMAs and GPC in diabetes and pregnancy, theoretical underpinnings of the models, their potential to promote more equitable care, and future directions from my perspective as a physician in high-risk obstetrics and 2019 American Diabetes Association Pathway Accelerator Award recipient. This article is part of a series of perspectives that report on research funded by the American Diabetes Association Pathway to Stop Diabetes program.

OBJECTIVE: Evaluate associations between prenatal cannabis use (PCU) and perinatal outcomes. METHODS: We performed an interval analysis of a prospective cohort study of pregnant individuals with pre-pregnancy cannabis use and negative self-report of nicotine use, comparing those who continued cannabis through pregnancy with those who stopped. Patients underwent interviews and urine drug screening for cannabis and cotinine, a nicotine metabolite, in each trimester. The primary outcome was small for gestational age (SGA) at delivery. Secondary outcomes included antenatal and postpartum complications, mode of delivery, and neonatal outcomes. Secondary analyses included stratification by intensity of cannabis use and urinary cotinine positivity. RESULTS: Birthing persons with PCU differed in age (25.5 vs 27.8 years, p=0.001), body mass index (BMI; 27.4 vs 30.9, p=0.001), area deprivation index percentiles (92% PCU vs 88%, p=0.013), cotinine positivity (42.8% vs 10.8%, pth percentile, compared to PCU cases without nicotine exposure (17.4% vs 8.3%, aRR 2.7 [1.21-5.38], 35.8% vs 18.6%, aRR 2.4 [1.51-3.48]), and controls (35.8% vs 12.9%, aRR 2.75 [1.64-4.13]). Cotinine-negative PCU patients and controls did not differ. CONCLUSION: PCU was not independently associated with adverse birthing person outcomes. Many patients demonstrated nicotine exposure, either via inadvertent exposure or undisclosed use. While neonates exposed to cannabis alone did not differ from unexposed neonates, those exposed to both cannabis and nicotine were at increased risk of SGA.

Objective This study aimed to examine the association between transportation assistance and study visits, and explore differences by transportation modality. Study Design This was a secondary analysis of prospective cohort study. We identified patients requesting transportation support for research ultrasound visits and identified controls (1:2 ratio) who did not request support matched for age, race, and insurance type. Conditional logistic regression examined the association between transportation support and mode of transportation with study visit attendance. Results Transportation support was requested by 57/1,184 (4.8%) participants. Participants that requested transportation support were three times more likely to attend visits than their matched controls (adjusted odds ratio [aOR] = 3.16, 95% confidence interval [CI]: 1.76–5.68). Among visits with transportation support, those supported by a ridesharing service had five-fold higher odds of attendance than visits supported with taxi service (aOR = 5.06, 95% CI: 1.50–16.98). Conclusion Transportation support, especially a ridesharing service, is associated with improved attendance at research study visits in a sample of predominantly low-income, Black, pregnant participants. Implementing transportation support may be a promising strategy to improve engagement in research studies. Key Points

OBJECTIVE: To estimate the effect of diabetes group prenatal care on rates of preterm birth and large for gestational age (LGA) among patients with diabetes in pregnancy compared with individual diabetes prenatal care. DATA SOURCES: We searched Ovid Medline (1946–), Embase.com (1947–), Scopus (1823–), Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. METHODS OF STUDY SELECTION: We searched electronic databases for randomized controlled trials (RCTs) and observational studies comparing diabetes group prenatal care with individual care among patients with type 2 diabetes mellitus or gestational diabetes mellitus (GDM). The primary outcomes were preterm birth before 37 weeks of gestation and LGA (birth weight at or above the 90th percentile). Secondary outcomes were small for gestational age, cesarean delivery, neonatal hypoglycemia, neonatal intensive care unit admission, breastfeeding at hospital discharge, long-acting reversible contraception (LARC) uptake, and 6-week postpartum visit attendance. Secondary outcomes, limited to the subgroup of patients with GDM, included rates of GDM requiring diabetes medication (A2GDM) and completion of postpartum oral glucose tolerance testing (OGTT). Heterogeneity was assessed with the Cochran Q test and I ² statistic. Random-effects models were used to calculate pooled relative risks (RRs) and weighted mean differences. TABULATION, INTEGRATION, AND RESULTS: Eight studies met study criteria and were included in the final analysis: three RCTs and five observational studies. A total of 1,701 patients were included in the pooled studies: 770 (45.3%) in diabetes group prenatal care and 931 (54.7%) in individual care. Patients in diabetes group prenatal care had similar rates of preterm birth compared with patients in individual care (seven studies: pooled rates 9.5% diabetes group prenatal care vs 11.5% individual care, pooled RR 0.77, 95% CI, 0.59–1.01), which held for RCTs and observational studies. There was no difference between diabetes group prenatal care and individual care in rates of LGA overall (four studies: pooled rate 16.7% diabetes group prenatal care vs 20.2% individual care, pooled RR 0.93, 95% CI, 0.59–1.45) or by study type. Rates of other secondary outcomes were similar between diabetes group prenatal care and individual care, except patients in diabetes group prenatal care were more likely to receive postpartum LARC (three studies: pooled rates 46.1% diabetes group prenatal care vs 34.1% individual care, pooled RR 1.44, 95% CI, 1.09–1.91). When analysis was limited to patients with GDM, there were no differences in rates of A2GDM or postpartum visit attendance, but patients in diabetes group prenatal care were significantly more likely to complete postpartum OGTT (five studies: pooled rate 74.0% diabetes group prenatal care vs 49.4% individual care, pooled RR 1.58, 95% CI, 1.19–2.09). CONCLUSION: Patients with type 2 diabetes and GDM who participate in diabetes group prenatal care have similar rates of preterm birth, LGA, and other pregnancy outcomes compared with those who participate in individual care; however, they are significantly more likely to receive postpartum LARC, and those with GDM are more likely to return for postpartum OGTT. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021279233.

Introduction: Postpartum depression has costly consequences for the mother, baby, and society. Numerous pharmacological and non-pharmacological interventions are available for the prevention and treatment of postpartum depression. To date, no attempt has been made to synthesize the evidence from comparisons of interventions both within and across these categories. Methods: We will perform a systematic review of the literature and perform network meta-analysis of interventions to (a) prevent and (b) treat postpartum depression. This review will include studies of primiparous or multiparous women during pregnancy or within 12 months of delivery of their baby that assess either interventions initiated during pregnancy or within 1 year of childbirth. Comparators will be other eligible interventions or control conditions. The outcome of interests will be related to the antidepressant efficacy of the interventions as well as their acceptability. The published literature will be searched in Ovid MEDLINE 1946-, Embase.com 1947-, Scopus 1823-, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. The search will use a combination of standardized terms and keywords for postpartum depression, a sensitive search filter to limit for randomized controlled trials, and a librarian-created “humans” filter. The search results will be uploaded to the Covidence online systematic review platform (Veritas Health Information Ltd., Victoria, Australia) where two review team members will independently screen articles. We will extract data to include year of publication, language, country, participants (number, demographic data, eligibility criteria, psychiatric symptoms, and co-morbidities), characteristics of the intervention and control conditions, and reported outcomes. Risk of bias for each study will be assessed independently by two review authors using the RoB 2: A revised Cochrane risk of bias tool for randomized trials. Network meta-analysis will be performed using a Bayesian hierarchical model supplemented with a Markov chain Monte Carlo approach. Discussion: Postpartum depression is a devastating disease with long-lasting consequences. Given the numerous available interventions to both prevent and treat postpartum depression and the great number of studies comparing them, it is imperative that clinicians and patients are provided with an assessment of their comparative efficacy and acceptability. Systematic review registration: Prospero registration (CRD42022303247).

Background: Evidence suggests ketamine may prevent postpartum depression (PPD) after cesarean delivery (CD) although intolerability and inconvenience of administration are problematic. We assessed the feasibility of studying ketamine (0.5 mg/kg, via subcutaneous injection or 40-min intravenous infusion) to prevent PPD after CD. Methods: Twenty-three women scheduled for cesarean delivery under neuraxial anesthesia were randomized to one of three groups: subcutaneous ketamine (SC Group, n = 8), intravenous ketamine (IV Group, n = 8) or placebo (n = 7). We measured depression (Edinburgh Postpartum Depression Scale [EPDS]) scores pre-operatively and at 1, 2, 21 and 42 days postoperatively. Anxiety, adverse effects, surgical site pain and analgesic consumption were also assessed. Feasibility was assessed based on acceptability, burden of disease, ability to collect study data and, tolerability of interventions. Results: Baseline characteristics of groups were similar, however, more women in the placebo group had pre-existing anxiety disorder (p = 0.03). 20.7% (25/121) of those approached consented to participate and 34.8% (8/23), of those assessed, screened positive for depression in the postpartum (EPDS > 12). PPD screening data was complete in 78.3% (18/23). No differences were observed for any adverse effect outcomes except for fewer incidences of intraoperative shivering with ketamine (SC: 25%, IV: 0% and Placebo: 85.7%, p = 0.01). No statistically significant difference in positive screening for PPD was observed (SC: 14.3%, IV: 50% and Placebo: 42.9%, p = 0.58). Conclusion: An RCT was judged to be feasible and there was no evidence of intolerability of either route of ketamine administration. Dispensing with the need for intravenous access makes the subcutaneous route a particularly attractive option for use in the postpartum population. Further examination of these interventions to prevent, and possibly treat, postpartum depression is warranted. Trial registration: NCT04227704, January 14^th, 2020.

Postpartum fat mass (FM) and fat-free mass (FFM) may be informative predictors of future disease risk among women; hence, there is growing use of bioelectrical impedance analysis (BIA) to quantify FFM and FM among postpartum women due to the quick, non-invasive, and inexpensive nature of BIA. Despite this, very few studies have examined BIA’s performance, and it remains unclear as to whether specific BIA equations are needed for postpartum women. To explore these questions, we measured total body FFM and FM with a multi-frequency, segmental BIA, and dual-X-ray absorptiometry (DXA) in (1) women at one and four months postpartum (n = 21); and (2) height- and weight-matched non-postpartum women (controls, n = 21). BIA was compared to DXA using Deming regression models, paired t-tests, and Bland–Altman plots. Between-group comparisons were performed using an analysis of variance models. The mean difference between DXA and BIA was 1.2 ± 1.7 kg FFM (p < 0.01) and −1.0 ± 1.7 kg FM (p < 0.05) in postpartum women at both time points. The measurements of longitudinal changes in FFM and FM were not significantly different between BIA and DXA. Furthermore, there was no significant difference in BIA’s performance in postpartum vs. non-postpartum women (p = 0.29), which suggests that population-specific equations are not needed for postpartum women. The results of this study suggest that BIA is a suitable method to assess postpartum body composition among women at one and four months postpartum, using existing age-, race-, and sex-adjusted equations.

Adverse pregnancy outcomes (APOs) collectively represent the leading causes of maternal and neonatal morbidity and mortality. Beyond the potentially devastating impact of APOs during pregnancy and the puerperium, women diagnosed with APOs have a 2-fold to 4-fold increased risk of future cardiovascular disease. Fortunately, APOs occur at an opportune time, in early-adulthood to mid-adulthood, when primary and secondary prevention strategies can alter the disease trajectory and improve long-term health outcomes. This chapter takes a life-course approach to (1) the epidemiology of APOs, (2) evidence-based strategies for clinicians to manage APOs, and (3) future directions for APO research and clinical practice.