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Plain ropivacaine dose linked to spinal hypotension after cesarean section

The March of Dimes 2024 report reveals a troubling D+ grade for US preterm births, with significant racial and socioeconomic disparities fueling an urgent need for better prenatal care and targeted interventions.

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While physicians face many financial and legal risks, the elephant in the room is always your professional liability and the risk of a malpractice lawsuit. We start an in-depth look at the facts about these lawsuits including where they happen, who they happen to, and what they cost.



Malpractice by the numbers

These are 3D ultrasound images of a 14-week fetus. What is your diagnosis?

occipital meningocele and umbilical hernia

Clinical

DailyDx: 3D Images of a 14-week fetus

A 27-year-old woman presents with an 18-month history of vulvar irritation. She is otherwise healthy except for episodes of depression. She has tried multiple agents for her condition including topical steroids, Vagisil, antibiotics, and fluconazole. She used oral steroids but developed knee pain. Tacrolimus has not helped. A biopsy revealed lichen simplex chronicus. Immunofluorescent studies were negative.

A 27-year-old woman presents with an 18-month history of vulvar irritation. She has tried multiple agents for her condition including topical steroids, Vagisil, antibiotics, and fluconazole without relief. What's your diagnosis?

Vulvar irritation in a 27-year-old woman

Saying "obstetrician-gynecologist" is a mouthful for most people, and it's probably the most abbreviated specialty in medicine, both spoken and written. However, there doesn't seem to be a consensus on how to pronounce OB-GYN. First, is it the two-syllable "O-B" or the monosyllabic "Ob"? Second, is it "gin" or "gyne" (like "Lyme")? I wonder if you have a preference. I know I do.

Almost nobody says "obstetrician-gynecologist" when speaking about these specialist physicians. But what's the "correct" way to pronounce OB/GYN?

Is It Ob-Gin or Ob-Gyne?

This middle-aged woman has severe dysmenorrhea and pelvic discomfort. Ultrasound images of the uterus are shown. What is your diagnosis?

Daily Dx: Dysmenorrhea and Pelvic Discomfort

Recreational cannabis legalization in California was linked to increased rates of cannabis use during 

 among women—particularly in jurisdictions in the state that allowed adult-use retailer businesses to open.

The findings from the population-based time-series study highlights a potential public health worth addressing proactively in obstetrician / gynecology clinics in states where recreational cannabis may potentially become legalized going forward.

A team of investigators from the University of California, San Francisco—led by Kelly C. Young-Wolff, PhD, MPH, from the division of research at Kaiser Permanente Northern California—sought any correlations between recreational cannabis legalization and prenatal cannabis use rates via self-report and urine toxicology testing. They additionally wanted to observe any more distinct correlations prenatal cannabis use and local policies banning or allowing cannabis retail.

Their setting was California, where cannabis was legalized in November 2016. The team observed that the prevalence of self-reported cannabis use has more than doubled in the US since 2002.

“Pregnant individuals report using cannabis to treat mental health and physical symptoms, and some view cannabis as a potentially safer option than prescription medications,” investigators wrote. “However, prenatal cannabis use is associated with an increased risk of adverse neonatal outcomes and maternal pregnancy outcomes and may also be associated with offspring neurodevelopment. National medical organizations recommend that clinicians screen for prenatal cannabis use, educate patients about potential risks, and recommend abstinence during pregnancy.”

Their time-series analysis of the real-world population used data from pregnancies to occur at Kaiser Permanente Northern California. The data included screen results from universal pregnancy cannabis use tests—both self-report and toxicology—between January 2012 – December 2019.

Young-Wolff and colleagues examined California’s legalization and the implementation of legal sales in 2018 with a 1-month lag. They additionally assessed local policies for or against medical retailers prior to recreational use legalization, and adult-use retailers, post-recreational use legalization.

Prenatal cannabis use was based on screening at entrance of prenatal care (8 – 10 weeks’ gestation) and were defined by either positive urine toxicology and self-report, lone toxicology, or lone-report.

The team’s data included 300,993 pregnancies from 236,327 individuals over the time period. Patients were primarily White (37.7%), then Hispanic (26.0%) or Asian (25.9%). Median age was 3.03 years old.

Prenatal cannabis use rose from 4.5% in January 2012 to 7.1% in January 2018. At the time of recreational cannabis use legalization in California, there was no change use rates among early-pregnancy women. In the first month after recreational cannabis implementation, the rate of prenatal cannabis use increased to 8.6% in February 2018—indicating a level change increased risk of 10% (RR, 1.10; 95% CI, 1.04 – 1.16). The team observed no difference in prenatal cannabis use based on toxicology test self-report.

Based on local policies, investigators observed that post-recreational cannabis legalization increase in use was only observed in jurisdictions that which allowed adult-use cannabis retailers (RR, 1.21; 95% CI, 1.10 – 1.33).

In prior research, another team of US investigators observed that public health interventions including warning sign policies do not seem to deter the rate of women who use cannabis during pregnancy.

In reviewing the findings, Young-Wolff and colleagues concluded that the implementation of legalized recreational cannabis in California was linked to an increase in early pregnancy cannabis use.

“Longer-term studies are needed to understand whether trends persist or change further

over time,” the team wrote. “As legalization spreads across the US, it will be important to test whether local policies that prohibit or limit adult-use retailers moderate changes in prenatal cannabis use associated with state-level legalization.”

California Courts. Proposition 64: Legalizes Marijuana. Accessed October 30, 2024. Available from: https://www.courts.ca.gov/prop64.htm#:~:text=Effective%20November%209%2C%202016%2C%20Proposition,sealing%20of%20prior%2C%20eligible%20marijuana%2D

Krewson C. Impact of warning signs on cannabis use during pregnancy. 

. Published June 21, 2023. https://www.contemporaryobgyn.net/view/impact-of-warning-signs-on-cannabis-use-during-pregnancy

A population-based time-series analysis California before, during and after legalization show a rising trend in women using cannabis while pregnancy especially when the state has legalized the drug.

Early pregnancy cannabis use high in states with recreational legalization

The study found that among privately insured families with in-network deliveries in 2019, nearly 1 in 5 potentially received a surprise bill for maternal and/or newborn care, averaging $744.

“Childbirth is the most common reason for hospitalization,” said principal investigator Kao-Ping Chua, MD, PhD, an assistant professor of pediatrics at the University of Michigan Medical School in Ann Arbor. Chua also is an assistant professor of health management and policy. “Although older studies have estimated the frequency of surprise bills for deliveries, no recent studies have estimated the frequency of surprise bills for both deliveries and newborn hospitalizations.”

The authors analyzed 2019 data from Optum’s de-identified Clinformatics Data Mart, which includes 12 million privately insured enrollees from all states.

Potential surprise bills occurred in 15.5% of newborn hospitalizations with neonatal intensive care, for a median liability of $1,282, and in 8.9% of newborn hospitalizations without neonatal intensive care, for a median liability of $262.

Neonatal intensive care accounted for 19.4% of surprise bills for newborn hospitalizations, the highest share of any service.

“We found that anesthesia for vaginal birth, such as epidural placement, was the No. 1 reason for potential surprise bills related to the maternal delivery,” Chua told 

. “We also discovered that surprise bills were more common with Cesarean section. This suggests that families may be able to decrease their risk of receiving a surprise bill by planning for a delivery with fewer interventions when possible.”

Study results are not unexpected because other studies also have found a high frequency of surprise bills related to hospitalization, according to Chua. “Nonetheless, I believe some of our findings are quite sobering,” he said. “For example, we found that potential surprise bills were common when babies need intensive care. Families are already stressed out enough in those situations, and they already will face large bills for the intensive care unit stay in the absence of surprise bills. To add surprise bills on top of all this seems particularly unfair.”

Starting January 1, 2022, the No Surprises Act will begin protecting families from most surprise bills. “For privately insured mothers who are expecting before this date, it is important to understand that there is a significant chance of receiving a surprise bill, even if the delivery and newborn hospitalization occur at an in-network facility,” Chua said. “Those surprise bills will be in addition to the roughly $3,000 that privately insured families pay out-of-pocket on average for deliveries and newborn hospitalizations.”

Hence, families need to save as much money as they can before the delivery, according to Chua, “so that they have the funds to pay both the hospital bill and any surprise bills.”

After January 1, 2022, privately insured mothers who are expecting should not receive bills from out-of-network providers after this date. “But families might still receive these bills if there are problems implementing the federal ban,” Chua said. “If this happens, families should contest these bills.”

The high frequency of potential surprise bills in the study suggests that childbirth might currently be the most common source of hospitalization-related surprise bills. “Therefore, it is particularly important for policymakers to ensure that the new ban on surprise bills is appropriately implemented in the case of childbirth,” Chua said. “Otherwise, a large number of families could still receive surprise bills in error.”

Chua reports no relevant financial disclosures.

Chua KP, Fendrick AM, Conti RM, et al. Prevalence and magnitude of potential surprise bills for childbirth. Published online July 2, 2021. 

2021;2(7):e211460. doi:10.1001/jamahealthforum.2021.1460

In addition to welcoming a newborn, parents may be unexpectedly billed for some hospitalization services, according to a research letter in JAMA Health Forum.

Ike Devji, JD

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