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Prescription Opioid Use in Pregnancy
On the Edge
Prescription Opioid Use in Pregnancy Summer Hunt Jennifer Hellwig
Photos © top: iStock Collection, bottom: Wavebreakmedia Ltd / both from thinkstockphotos.com
M
More than a third (39 percent) of reproductive-age women enrolled in Medicaid, and more than a quarter (28 percent) of those with private insurance, filled a prescription for an opioid pain medication each year during the 2008 to 2012 time period, according to Morbidity and Mortality Weekly Report (MMWR). Opioid use in pregnancy can cause birth defects and other serious problems for women and infants, necessitating efforts to reduce opioid prescriptions among reproductive-age women when safer alternatives are available. The report looked at women ages 15 to 44 years and found hydrocodone, codeine and oxycodone to be the most commonly prescribed opioids. Prescription rates were highest in the South and lowest in the Northeast; race/ethnicity information indicated that opioid prescriptions were nearly one and a half times higher among non-Hispanic white women of reproductive age compared to non-Hispanic black or Hispanic women. Read the full report here: www.cdc.gov/mmwr/pdf/wk/mm6402.pdf.
Mobile App for Sun Safety A smartphone mobile app that can provide personalized, real-time sun protection advice improved some sun protection behavior, according to an article published online January 28, 2015 in JAMA Dermatology. The study enrolled 604 participants; of the 305 individuals in the treatment group, 232 people downloaded the app but only 125 individuals (41 percent) used it. Complete data were available on 454 individuals (222 in the treatment group and 232 in a control group). Study participants were younger, more educated, more affluent and fewer were Hispanic whites than in the U.S. population. Results show that participants in the treatment group reported spending more time in the shade (average days staying in the shade, 41 percent vs. 33.7 percent) but less sunscreen use (average days, 28.6 percent vs. 34.5 percent) than those in the control group. There was no significant difference in the number of sunburns in the past 3 months between the groups. Users of the mobile app reported spending less time in the sun (average days keeping time in the sun to a minimum, 60.4 percent for app users vs. 49.3 percent for nonusers) and more use of all sun protection behaviors (such as sunscreen, protective clothing and shade) combined (average days, 39.4 percent vs. 33.8 percent).
http://nwh.awhonn.org
© 2015, AWHONN
123
On the Edge
Pregnancy in Kidney Transplant Recipients
DOI: 10.1111/1751-486X.12184
New Antibacterial Drug The FDA has approved Zerbaxa (ceftolozane/tazobactam), a new antibacterial drug product, to treat adults with complicated intra-abdominal infections (cIAIs) and complicated urinary tract infections (cUTIs). Zerbaxa is a combination product containing ceftolozane, a cephalosporin antibacterial drug, and tazobactam, a beta-lactamase inhibitor. Zerbaxa is used to treat cUTI, including kidney infection (pyelonephritis). It is used in combination with metronidazole to treat cIAI.
Flame Retardants and Prematurity Researchers at The University of Texas Medical Branch have determined that maternal exposure to high levels of flame retardants may be a contributing factor in preterm births. The study found that pregnant women with higher levels of flame-retardant chemicals in their bodies, namely polybrominated diphenyl ethers, were more likely to give birth early than women with lower levels. The investigators collected and analyzed blood samples from pregnant women when they were admitted to the hospital for labor and birth. The study was published in the February issue of the Journal of Reproductive Immunology. Flame-retardant chemicals have been widely used for more than 40 years in home construction, furniture, clothing and electronic appliances. They save lives and reduce injury by giving people time to extinguish or escape from a spreading fire. Unfortunately, these chemicals don’t permanently bond with the materials they are used on so they leach into the environment and become a pollutant over time.
124
Nursing for Women’s Health
Volume 19
Issue 2
Photo © Comstock Images / thinkstockphotos.com
Summer Hunt is editorial coordinator for publications; Jennifer Hellwig, MS, RDN, ELS, is managing editor of Nursing for Women’s Health; both authors are with AWHONN in Washington, DC.
Pregnancy outcomes appear to be similar for women who undergo kidney transplants as children or adults, according to an article published online February 2, 2015 in JAMA Pediatrics. The study included all women with a functioning kidney transplant included in the Australia and New Zealand dialysis
and transplant registry who had at least one pregnancy reported between 1963 and 2012. Authors identified a total of 101 pregnancies in 66 child-tx mothers and 626 pregnancies in 401 adult-tx mothers. At the time of pregnancy, the child-tx mothers were an average age of 25 years and had a functioning transplant for 10 years, while adult-tx mothers were an average age of 31 years with a functioning transplant for 6 years. Results show that live births resulted from 76 percent of pregnancies in child-tx mothers and 77 percent of pregnancies in adulttx mothers. The incidence of premature babies (<37 weeks gestation) also was similar for childtx mothers (45 percent) and adult-tx mothers (53 percent). In addition, a similar proportion of preterm babies born to both sets of mothers were small for gestational age (22 percent for child-tx mothers and 10 percent for adult-tx mothers). Term babies born to child-tx and adult-tx mothers were frequently small for gestational age (57 percent vs. 38 percent, respectively), both significantly more frequently than babies born at term in the general population.
Childbirth Positioning The traditional practice of positioning women on their side, with hips tilted at 15 degrees, during labor does not effectively reduce compression of the inferior vena cava as previously thought. In fact, not until the degree of tilt reached 30 degrees did blood flow only partially increase in patients, according to a study published in the February issue of Anesthesiology. In the study, magnetic resonance images of 10 pregnant women at full-term and 10 nonpregnant women were obtained for measurement of the abdominal aorta and the inferior vena cava. Measurements were taken while the women laid flat on their back and while tilted at 15, 30 and 45 degrees. Foam was placed under the right side of the study participants to achieve the desired amount of tilt. Abdominal aortic blood volume did not differ significantly between pregnant and nonpregnant women regardless of their position. Conversely, inferior vena cava blood volume was significantly lower in pregnant women than in nonpregnant women when the women were positioned flat on their back, indicating almost complete compression of the vein. Inferior vena cava blood volume did not increase at 15 degress, but partially increased at 30 degrees.
Photos © left: Joachim Angeltun, right: Nick Thompson / both from thinkstockphotos.com
Community-Based CVD Prevention In rural Franklin County, Maine, a sustained, community-wide program targeting cardiovascular disease (CVD) risk factors and behavior changes was associated with reductions in hospitalization and death rates over a 40-year period (1970 to 2010) compared with the rest of the state, with substantial improvements seen for hypertension and cholesterol control and smoking cessation, according to a study in the January 13 issue of JAMA. In its first 4 years, the program screened about 50 percent of county adults. Individuals with hypertension showed significant movement from detection to treatment and blood pressure control; the proportion in control increased from 18.3 percent to 43.0 percent from 1975 to 1978, an absolute increase of 24.7 percent. After introducing cholesterol screening in 1986, the program reached 40 percent of county adults within 5 years, half of whom had elevated cholesterol levels. Over subsequent decades, cholesterol control had an absolute increase of 28.5 percent, from 0.4 percent to 28.9 percent, from 1986 to 2010. Similarly, after initiation of multiple community smoking cessation projects, community-wide smoking quit rates improved significantly, from 48.5 percent to 69.5 percent, and became significantly higher than that for the rest of Maine; these differences later disappeared when Maine’s overall quit rate increased. Franklin County hospitalizations per capita were less than expected for the period 1994 to 2006. The lower overall hospitalization rates were associated with $5,450,362 reductions in total in- and out-of-area hospital charges for Franklin County residents per year. After being at or above overall Maine mortality rates in the 1960s, Franklin County rates decreased below Maine rates for almost the entire period 1970 to 2010. Cardiovascularspecific mortality rates decreased similarly.
April | May 2015
Treating Male Infertility The use intracytoplasmic sperm injection (ICSI), in which a single sperm is injected directly into an egg, doubled between 1996 and 2012, although compared with conventional in vitro fertilization (IVF), ICSI was not associated with improved reproductive outcomes, according to a study in the January 20 issue of JAMA. Researchers assessed national trends and reproductive outcomes of fresh IVF cycles (embryos transferred without being frozen) associated with the use of ICSI compared with conventional IVF. Data were from reports to the U.S. National Assisted Reproductive Technology Surveillance System during 1996 to 2012. Of the fresh IVF cycles from 1996 through 2012, 65.1 percent used ICSI and 35.8 percent reported male factor infertility. Among cycles with male factor infertility, ICSI use increased from 76.3 percent to 93.3 percent; for those without male factor infertility, ICSI use increased from 15.4 percent to 66.9 percent. During 2008 to 2012, male factor infertility was reported for 35.7 percent of fresh cycles. In the absence of male factor infertility, ICSI use was associated with small but statistically significant decreases in implantation, pregnancy, live birth, multiple live birth and low-birth-weight rates compared with conventional IVF.
Nursing for Women’s Health
125
On the Edge
When Medications and Alcohol Don’t Mix Nearly 42 percent of U.S. adults who drink also report using medications known to interact with alcohol, based on a study published in the February 2015 issue of Alcoholism: Clinical and Experimental Research. Among those over 65 years of age who drink alcohol, nearly 78 percent report using alcohol-interactive medications. The research is among the first to estimate the proportion of adult drinkers in the United States who may be mixing alcohol-interactive medications with alcohol.
The resulting health effects can range from mild (nausea, headaches, loss of coordination) to severe (internal bleeding, heart problems, difficulty breathing). Older adults are at particular risk of experiencing alcohol-medication interactions. Not only are they more likely to be taking medications in general, but certain alcohol-interactive medications, such as diazepam (Valium), are metabolized more slowly as one ages, creating a larger window for potential interactions.
Operative birth is associated with persisting pain during or after sexual intercourse, known as dyspareunia, according to a study published January 21 in BJOG: An International Journal of Obstetrics and Gynaecology. A cohort of 1,244 first-time mothers across six maternity hospitals in Australia was studied. Data were taken from baseline and postnatal questionnaires at 3, 6, 12 and 18 months. Of the women sampled, 49 percent had a spontaneous vaginal birth, two-thirds of whom sustained a sutured tear and/or episiotomy, 10.8 percent had an operative vaginal birth assisted by vacuum extraction and 10.7 percent gave birth assisted by forceps. Additionally, 9.7 percent had elective cesarean surgical birth and 19.9 percent had emergency cesarean. Results showed that 78 percent of the study population had resumed sexual intercourse by 3 months, 94 percent by 6 months, 97 percent by 12 months and 98 percent by 18 months postpartum. Most of the women (85.7 percent) who had resumed sex by 12 months postpartum experienced pain during first vaginal sex after childbirth. Dyspareunia was reported by 44.7 percent of women at 3 months postpartum, 43.4 percent at 6 months, 28.1 percent at 12 months and 23.4 percent at 18 months postpartum. Of the women who reported dyspareunia at 6 months postpartum, a third (32.7 percent) reported persisting dyspareunia at 18 months postpartum. Compared to women who had a spontaneous vaginal birth with intact perineum or unsutured tear, women who had an emergency cesarean, vacuum extraction or elective cesarean had double the risk of reporting dyspareunia at 18 months postpartum, adjusting for maternal age and other risk factors. Other factors associated with dyspareunia at 18 months postpartum include prepregnancy dyspareunia, intimate partner abuse and maternal fatigue. One in six women (16 percent) experienced abuse by an intimate partner in the first 12 months postpartum. One-third of these women (32.4 percent) reported dyspareunia at 18 months postpartum, compared with 20.7 percent of women who did not experience intimate partner abuse.
126
Nursing for Women’s Health
Volume 19
Issue 2
Photo © Wellford Tiller / thinkstockphotos.com
Operative Birth and Dyspareunia
Episiotomy Use Declines Between 2006 and 2012 in the United States, there was a decline in rates of episiotomy, according to a study in the January 13 issue of JAMA. Researchers used the Perspective database to identify women who underwent a vaginal birth from 2006 to 2012. The analysis included 2,261,070 women who were hospitalized for a vaginal birth in 510 hospitals, of whom 325,193 underwent episiotomy (14.4 percent). There was a decline in the rate of episiotomy between 2006 (17.3 percent) and 2012 (11.6 percent). Several demographic characteristics were associated with receipt of episiotomy: 15.7 percent of white women versus 7.9 percent of black women; and 17.2 percent with commercial insurance versus 11.2 percent with Medicaid insurance. Hospital factors (rural location and teaching status) were associated with less use. “These observations suggest nonmedical factors are related to use of episiotomy,” the authors write. Adjusted hospital rates of episiotomy use demonstrated significant variation. Among the 10 percent of hospitals that used the procedure most frequently, the average adjusted hospital episiotomy rate was 34.1 percent versus 2.5 percent in the 10 percent of hospitals that used the procedure least frequently.
New HPV Vaccine In December, the U.S. Food and Drug Administration (FDA) approved Gardasil 9 (Human Papillomavirus 9-valent Vaccine, Recombinant) for the prevention of certain diseases caused by nine types of human papillomavirus (HPV), five more HPV types than Gardasil (previously approved by the FDA). Gardasil 9 is approved for use in females ages 9 through 26 and males ages 9 through 15 and has the potential to prevent approximately 90 percent of cervical, vulvar, vaginal and anal cancers.
Photo © iStock Collection / thinkstockphotos.com
Secondhand Smoke Exposure One in four nonsmokers—approximately 58 million people—are regularly exposed to SHS, according to a new Vital Signs report from the Centers for Disease Control and Prevention (CDC). Data show that declines in exposure to SHS have been slower and exposure remains higher among children, blacks, those who live in poverty and those who live in rental housing. The report finds that two in every five children ages 3 to 11 years are exposed to SHS. The study
April | May 2015
assessed exposure using cotinine, a marker of SHS found in the blood. The U.S. Surgeon General has concluded that there is no safe level of exposure to SHS, which contains more than 7,000 chemicals including about 70 that can cause cancer. It is a known cause of sudden infant death syndrome, respiratory infections, ear infections and asthma attacks in infants and children, as well as heart disease, stroke and lung cancer in adult nonsmokers.
Medication for BingeEating Disorder The FDA expanded the approved uses of Vyvanse (lisdexamfetamine dimesylate) to treat binge-eating disorder in adults. The drug is the first FDAapproved medication to treat this condition. The efficacy of Vyvanse in treating binge-eating disorder was shown in two clinical studies that included 724 adults with moderate-to-severe bingeeating disorder. Participants taking Vyvanse experienced a decrease in the number of binge-eating days per week and had fewer obsessive-compulsive binge-eating behaviors compared to those on the inactive pill (placebo). The most serious risks of use include psychiatric problems and heart complications, including sudden death in people who have heart problems or heart defects, and stroke and heart attack in adults. Central nervous system stimulants, such as Vyvanse, may cause psychotic or manic symptoms, such as hallucinations, delusional thinking or mania, even in individuals without a prior history of psychotic illness. The most common side effects reported by people taking Vyvanse in the clinical trials included dry mouth, sleeplessness (insomnia), increased heart rate, jittery feelings, constipation and anxiety. Vyvanse is not approved for, or recommended for, weight loss. Its efficacy for weight loss has not been studied. Vyvanse was approved in 2007 as a once-daily medication to treat attention-deficit hyperactivity disorder in patients ages 6 and older. Vyvanse is a Schedule II controlled substance because it has high potential for abuse, with use potentially leading to dependence.
Nursing for Women’s Health
127
Prescription Opioid Use in Pregnancy Summer Hunt Jennifer Hellwig
Photos © top: iStock Collection, bottom: Wavebreakmedia Ltd / both from thinkstockphotos.com
M
More than a third (39 percent) of reproductive-age women enrolled in Medicaid, and more than a quarter (28 percent) of those with private insurance, filled a prescription for an opioid pain medication each year during the 2008 to 2012 time period, according to Morbidity and Mortality Weekly Report (MMWR). Opioid use in pregnancy can cause birth defects and other serious problems for women and infants, necessitating efforts to reduce opioid prescriptions among reproductive-age women when safer alternatives are available. The report looked at women ages 15 to 44 years and found hydrocodone, codeine and oxycodone to be the most commonly prescribed opioids. Prescription rates were highest in the South and lowest in the Northeast; race/ethnicity information indicated that opioid prescriptions were nearly one and a half times higher among non-Hispanic white women of reproductive age compared to non-Hispanic black or Hispanic women. Read the full report here: www.cdc.gov/mmwr/pdf/wk/mm6402.pdf.
Mobile App for Sun Safety A smartphone mobile app that can provide personalized, real-time sun protection advice improved some sun protection behavior, according to an article published online January 28, 2015 in JAMA Dermatology. The study enrolled 604 participants; of the 305 individuals in the treatment group, 232 people downloaded the app but only 125 individuals (41 percent) used it. Complete data were available on 454 individuals (222 in the treatment group and 232 in a control group). Study participants were younger, more educated, more affluent and fewer were Hispanic whites than in the U.S. population. Results show that participants in the treatment group reported spending more time in the shade (average days staying in the shade, 41 percent vs. 33.7 percent) but less sunscreen use (average days, 28.6 percent vs. 34.5 percent) than those in the control group. There was no significant difference in the number of sunburns in the past 3 months between the groups. Users of the mobile app reported spending less time in the sun (average days keeping time in the sun to a minimum, 60.4 percent for app users vs. 49.3 percent for nonusers) and more use of all sun protection behaviors (such as sunscreen, protective clothing and shade) combined (average days, 39.4 percent vs. 33.8 percent).
http://nwh.awhonn.org
© 2015, AWHONN
123
On the Edge
Pregnancy in Kidney Transplant Recipients
DOI: 10.1111/1751-486X.12184
New Antibacterial Drug The FDA has approved Zerbaxa (ceftolozane/tazobactam), a new antibacterial drug product, to treat adults with complicated intra-abdominal infections (cIAIs) and complicated urinary tract infections (cUTIs). Zerbaxa is a combination product containing ceftolozane, a cephalosporin antibacterial drug, and tazobactam, a beta-lactamase inhibitor. Zerbaxa is used to treat cUTI, including kidney infection (pyelonephritis). It is used in combination with metronidazole to treat cIAI.
Flame Retardants and Prematurity Researchers at The University of Texas Medical Branch have determined that maternal exposure to high levels of flame retardants may be a contributing factor in preterm births. The study found that pregnant women with higher levels of flame-retardant chemicals in their bodies, namely polybrominated diphenyl ethers, were more likely to give birth early than women with lower levels. The investigators collected and analyzed blood samples from pregnant women when they were admitted to the hospital for labor and birth. The study was published in the February issue of the Journal of Reproductive Immunology. Flame-retardant chemicals have been widely used for more than 40 years in home construction, furniture, clothing and electronic appliances. They save lives and reduce injury by giving people time to extinguish or escape from a spreading fire. Unfortunately, these chemicals don’t permanently bond with the materials they are used on so they leach into the environment and become a pollutant over time.
124
Nursing for Women’s Health
Volume 19
Issue 2
Photo © Comstock Images / thinkstockphotos.com
Summer Hunt is editorial coordinator for publications; Jennifer Hellwig, MS, RDN, ELS, is managing editor of Nursing for Women’s Health; both authors are with AWHONN in Washington, DC.
Pregnancy outcomes appear to be similar for women who undergo kidney transplants as children or adults, according to an article published online February 2, 2015 in JAMA Pediatrics. The study included all women with a functioning kidney transplant included in the Australia and New Zealand dialysis
and transplant registry who had at least one pregnancy reported between 1963 and 2012. Authors identified a total of 101 pregnancies in 66 child-tx mothers and 626 pregnancies in 401 adult-tx mothers. At the time of pregnancy, the child-tx mothers were an average age of 25 years and had a functioning transplant for 10 years, while adult-tx mothers were an average age of 31 years with a functioning transplant for 6 years. Results show that live births resulted from 76 percent of pregnancies in child-tx mothers and 77 percent of pregnancies in adulttx mothers. The incidence of premature babies (<37 weeks gestation) also was similar for childtx mothers (45 percent) and adult-tx mothers (53 percent). In addition, a similar proportion of preterm babies born to both sets of mothers were small for gestational age (22 percent for child-tx mothers and 10 percent for adult-tx mothers). Term babies born to child-tx and adult-tx mothers were frequently small for gestational age (57 percent vs. 38 percent, respectively), both significantly more frequently than babies born at term in the general population.
Childbirth Positioning The traditional practice of positioning women on their side, with hips tilted at 15 degrees, during labor does not effectively reduce compression of the inferior vena cava as previously thought. In fact, not until the degree of tilt reached 30 degrees did blood flow only partially increase in patients, according to a study published in the February issue of Anesthesiology. In the study, magnetic resonance images of 10 pregnant women at full-term and 10 nonpregnant women were obtained for measurement of the abdominal aorta and the inferior vena cava. Measurements were taken while the women laid flat on their back and while tilted at 15, 30 and 45 degrees. Foam was placed under the right side of the study participants to achieve the desired amount of tilt. Abdominal aortic blood volume did not differ significantly between pregnant and nonpregnant women regardless of their position. Conversely, inferior vena cava blood volume was significantly lower in pregnant women than in nonpregnant women when the women were positioned flat on their back, indicating almost complete compression of the vein. Inferior vena cava blood volume did not increase at 15 degress, but partially increased at 30 degrees.
Photos © left: Joachim Angeltun, right: Nick Thompson / both from thinkstockphotos.com
Community-Based CVD Prevention In rural Franklin County, Maine, a sustained, community-wide program targeting cardiovascular disease (CVD) risk factors and behavior changes was associated with reductions in hospitalization and death rates over a 40-year period (1970 to 2010) compared with the rest of the state, with substantial improvements seen for hypertension and cholesterol control and smoking cessation, according to a study in the January 13 issue of JAMA. In its first 4 years, the program screened about 50 percent of county adults. Individuals with hypertension showed significant movement from detection to treatment and blood pressure control; the proportion in control increased from 18.3 percent to 43.0 percent from 1975 to 1978, an absolute increase of 24.7 percent. After introducing cholesterol screening in 1986, the program reached 40 percent of county adults within 5 years, half of whom had elevated cholesterol levels. Over subsequent decades, cholesterol control had an absolute increase of 28.5 percent, from 0.4 percent to 28.9 percent, from 1986 to 2010. Similarly, after initiation of multiple community smoking cessation projects, community-wide smoking quit rates improved significantly, from 48.5 percent to 69.5 percent, and became significantly higher than that for the rest of Maine; these differences later disappeared when Maine’s overall quit rate increased. Franklin County hospitalizations per capita were less than expected for the period 1994 to 2006. The lower overall hospitalization rates were associated with $5,450,362 reductions in total in- and out-of-area hospital charges for Franklin County residents per year. After being at or above overall Maine mortality rates in the 1960s, Franklin County rates decreased below Maine rates for almost the entire period 1970 to 2010. Cardiovascularspecific mortality rates decreased similarly.
April | May 2015
Treating Male Infertility The use intracytoplasmic sperm injection (ICSI), in which a single sperm is injected directly into an egg, doubled between 1996 and 2012, although compared with conventional in vitro fertilization (IVF), ICSI was not associated with improved reproductive outcomes, according to a study in the January 20 issue of JAMA. Researchers assessed national trends and reproductive outcomes of fresh IVF cycles (embryos transferred without being frozen) associated with the use of ICSI compared with conventional IVF. Data were from reports to the U.S. National Assisted Reproductive Technology Surveillance System during 1996 to 2012. Of the fresh IVF cycles from 1996 through 2012, 65.1 percent used ICSI and 35.8 percent reported male factor infertility. Among cycles with male factor infertility, ICSI use increased from 76.3 percent to 93.3 percent; for those without male factor infertility, ICSI use increased from 15.4 percent to 66.9 percent. During 2008 to 2012, male factor infertility was reported for 35.7 percent of fresh cycles. In the absence of male factor infertility, ICSI use was associated with small but statistically significant decreases in implantation, pregnancy, live birth, multiple live birth and low-birth-weight rates compared with conventional IVF.
Nursing for Women’s Health
125
On the Edge
When Medications and Alcohol Don’t Mix Nearly 42 percent of U.S. adults who drink also report using medications known to interact with alcohol, based on a study published in the February 2015 issue of Alcoholism: Clinical and Experimental Research. Among those over 65 years of age who drink alcohol, nearly 78 percent report using alcohol-interactive medications. The research is among the first to estimate the proportion of adult drinkers in the United States who may be mixing alcohol-interactive medications with alcohol.
The resulting health effects can range from mild (nausea, headaches, loss of coordination) to severe (internal bleeding, heart problems, difficulty breathing). Older adults are at particular risk of experiencing alcohol-medication interactions. Not only are they more likely to be taking medications in general, but certain alcohol-interactive medications, such as diazepam (Valium), are metabolized more slowly as one ages, creating a larger window for potential interactions.
Operative birth is associated with persisting pain during or after sexual intercourse, known as dyspareunia, according to a study published January 21 in BJOG: An International Journal of Obstetrics and Gynaecology. A cohort of 1,244 first-time mothers across six maternity hospitals in Australia was studied. Data were taken from baseline and postnatal questionnaires at 3, 6, 12 and 18 months. Of the women sampled, 49 percent had a spontaneous vaginal birth, two-thirds of whom sustained a sutured tear and/or episiotomy, 10.8 percent had an operative vaginal birth assisted by vacuum extraction and 10.7 percent gave birth assisted by forceps. Additionally, 9.7 percent had elective cesarean surgical birth and 19.9 percent had emergency cesarean. Results showed that 78 percent of the study population had resumed sexual intercourse by 3 months, 94 percent by 6 months, 97 percent by 12 months and 98 percent by 18 months postpartum. Most of the women (85.7 percent) who had resumed sex by 12 months postpartum experienced pain during first vaginal sex after childbirth. Dyspareunia was reported by 44.7 percent of women at 3 months postpartum, 43.4 percent at 6 months, 28.1 percent at 12 months and 23.4 percent at 18 months postpartum. Of the women who reported dyspareunia at 6 months postpartum, a third (32.7 percent) reported persisting dyspareunia at 18 months postpartum. Compared to women who had a spontaneous vaginal birth with intact perineum or unsutured tear, women who had an emergency cesarean, vacuum extraction or elective cesarean had double the risk of reporting dyspareunia at 18 months postpartum, adjusting for maternal age and other risk factors. Other factors associated with dyspareunia at 18 months postpartum include prepregnancy dyspareunia, intimate partner abuse and maternal fatigue. One in six women (16 percent) experienced abuse by an intimate partner in the first 12 months postpartum. One-third of these women (32.4 percent) reported dyspareunia at 18 months postpartum, compared with 20.7 percent of women who did not experience intimate partner abuse.
126
Nursing for Women’s Health
Volume 19
Issue 2
Photo © Wellford Tiller / thinkstockphotos.com
Operative Birth and Dyspareunia
Episiotomy Use Declines Between 2006 and 2012 in the United States, there was a decline in rates of episiotomy, according to a study in the January 13 issue of JAMA. Researchers used the Perspective database to identify women who underwent a vaginal birth from 2006 to 2012. The analysis included 2,261,070 women who were hospitalized for a vaginal birth in 510 hospitals, of whom 325,193 underwent episiotomy (14.4 percent). There was a decline in the rate of episiotomy between 2006 (17.3 percent) and 2012 (11.6 percent). Several demographic characteristics were associated with receipt of episiotomy: 15.7 percent of white women versus 7.9 percent of black women; and 17.2 percent with commercial insurance versus 11.2 percent with Medicaid insurance. Hospital factors (rural location and teaching status) were associated with less use. “These observations suggest nonmedical factors are related to use of episiotomy,” the authors write. Adjusted hospital rates of episiotomy use demonstrated significant variation. Among the 10 percent of hospitals that used the procedure most frequently, the average adjusted hospital episiotomy rate was 34.1 percent versus 2.5 percent in the 10 percent of hospitals that used the procedure least frequently.
New HPV Vaccine In December, the U.S. Food and Drug Administration (FDA) approved Gardasil 9 (Human Papillomavirus 9-valent Vaccine, Recombinant) for the prevention of certain diseases caused by nine types of human papillomavirus (HPV), five more HPV types than Gardasil (previously approved by the FDA). Gardasil 9 is approved for use in females ages 9 through 26 and males ages 9 through 15 and has the potential to prevent approximately 90 percent of cervical, vulvar, vaginal and anal cancers.
Photo © iStock Collection / thinkstockphotos.com
Secondhand Smoke Exposure One in four nonsmokers—approximately 58 million people—are regularly exposed to SHS, according to a new Vital Signs report from the Centers for Disease Control and Prevention (CDC). Data show that declines in exposure to SHS have been slower and exposure remains higher among children, blacks, those who live in poverty and those who live in rental housing. The report finds that two in every five children ages 3 to 11 years are exposed to SHS. The study
April | May 2015
assessed exposure using cotinine, a marker of SHS found in the blood. The U.S. Surgeon General has concluded that there is no safe level of exposure to SHS, which contains more than 7,000 chemicals including about 70 that can cause cancer. It is a known cause of sudden infant death syndrome, respiratory infections, ear infections and asthma attacks in infants and children, as well as heart disease, stroke and lung cancer in adult nonsmokers.
Medication for BingeEating Disorder The FDA expanded the approved uses of Vyvanse (lisdexamfetamine dimesylate) to treat binge-eating disorder in adults. The drug is the first FDAapproved medication to treat this condition. The efficacy of Vyvanse in treating binge-eating disorder was shown in two clinical studies that included 724 adults with moderate-to-severe bingeeating disorder. Participants taking Vyvanse experienced a decrease in the number of binge-eating days per week and had fewer obsessive-compulsive binge-eating behaviors compared to those on the inactive pill (placebo). The most serious risks of use include psychiatric problems and heart complications, including sudden death in people who have heart problems or heart defects, and stroke and heart attack in adults. Central nervous system stimulants, such as Vyvanse, may cause psychotic or manic symptoms, such as hallucinations, delusional thinking or mania, even in individuals without a prior history of psychotic illness. The most common side effects reported by people taking Vyvanse in the clinical trials included dry mouth, sleeplessness (insomnia), increased heart rate, jittery feelings, constipation and anxiety. Vyvanse is not approved for, or recommended for, weight loss. Its efficacy for weight loss has not been studied. Vyvanse was approved in 2007 as a once-daily medication to treat attention-deficit hyperactivity disorder in patients ages 6 and older. Vyvanse is a Schedule II controlled substance because it has high potential for abuse, with use potentially leading to dependence.
Nursing for Women’s Health
127