Cardiovascular and cerebrovascular health after pre-eclampsia: the Motherhealth prospective cohort study protocol

INTRODUCTION

Cardiovascular and cerebrovascular diseases (CCVDs) are the leading cause of maternal mortality in the first year after delivery. Women whose pregnancies were complicated by pre-eclampsia are at particularly high risk for adverse events. In addition, women with a history of pre-eclampsia have higher risk of CCVD later in life. The physiological mechanisms that contribute to increased CCVD risk in these women are not well understood, and the optimal clinical pathways for postpartum CCVD risk reduction are not yet defined.

METHODS AND ANALYSIS

The Motherhealth Study (MHS) is a prospective cohort study at Columbia University Irving Medical Center (CUIMC), a quaternary care academic medical centre serving a multiethnic population in New York City. MHS began recruitment on 28 September 2018 and will enrol 60 women diagnosed with pre-eclampsia with severe features in the antepartum or postpartum period, and 40 normotensive pregnant women as a comparison cohort. Clinical data, biospecimens and measures of vascular function will be collected from all participants at the time of enrolment. Women in the pre-eclampsia group will complete an additional three postpartum study visits over 12-24 months. Visits will include additional detailed cardiovascular and cerebrovascular phenotyping. As this is an exploratory, observational pilot study, only descriptive statistics are planned. Data will be used to inform power calculations for future planned interventional studies.

ETHICS AND DISSEMINATION

The CUIMC Institutional Review Board approved this study prior to initiation of recruitment. All participants signed informed consent prior to enrolment. Results will be disseminated to the clinical and research community, along with the public, on completion of analyses. Data will be shared on reasonable request.

Postpartum Psychiatric Admissions in the United States

OBJECTIVE

This study aimed to assess risk for postpartum psychiatric admissions in the United States.

STUDY DESIGN

This study used the 2010 to 2014 Nationwide Readmissions Database to identify psychiatric admissions during the first 60 days after delivery hospitalization. Timing of admission after delivery discharge was determined. We fit multivariable log-linear regression models to assess the impact of psychiatric comorbidity on admission risk, adjusting for patient, obstetrical, and hospital factors.

RESULTS

Of 15.7 million deliveries from 2010 to 2014, 11,497 women (0.07%) were readmitted for a primary psychiatric diagnosis within 60 days postpartum. Psychiatric admissions occurred relatively consistently across 10-day periods after delivery hospitalization discharge. Psychiatric diagnoses were present among 5% of women at delivery but 40% of women who were readmitted postpartum for a psychiatric indication. In the adjusted model, women with psychiatric diagnoses at delivery hospitalization were 9.7 times more likely to be readmitted compared with those without psychiatric comorbidity. Women at highest risk for psychiatric admission were those with Medicare and Medicaid, in lower income quartiles, and of younger age.

CONCLUSION

While a large proportion of psychiatric admissions occurred among a relatively small proportion of at-risk women, admissions occurred over a broad temporal period relative to other indications for postpartum admission.

Postpartum hemorrhage and risk for postpartum readmission

Objective: This study had two objectives: (i) to evaluate risk factors for postpartum readmission for a primary diagnosis of postpartum hemorrhage (PPH) among all women, and (ii) to determine risk for postpartum readmission specifically among women with PPH during their delivery hospitalization.Methods: The Healthcare Cost and Utilization Project's Nationwide Readmissions Database for 2010 to 2014 was used to evaluate risk for postpartum readmission for PPH within 60 days of discharge from a delivery hospitalization. Obstetric, medical, demographic, and hospital factors including PPH during the index delivery were analyzed. Sixty-day postpartum readmission for PPH was the primary outcome. Both unadjusted and adjusted analyses were performed. In adjusted models, the risk was characterized as adjusted risk ratios (aRR) with 95% confidence intervals (CI). As a secondary outcome to further characterize how PPH at delivery was associated with readmission likelihood, the risk for all-cause readmission was evaluated among women with this diagnosis during their delivery.Results: Of the 15,701,150 delivery hospitalizations, 10,618 women were readmitted postpartum for a primary indication of postpartum hemorrhage. Eighty-two percent of readmissions occurred ≤20 days after discharge. In the adjusted model for readmission for PPH, PPH during the delivery hospitalization was associated with aRR of 5.26 (95% CI 4.94, 5.59) for hemorrhage alone, aRR of 14.28 (95% CI 13.06, 15.60) for hemorrhage requiring transfusion, and aRR of 12.40 for PPH with disseminated intravascular coagulation (DIC) requiring transfusion (95% CI 9.56-16.08) compared to no PPH. For the secondary analysis evaluating all-cause readmission, PPH during delivery was associated with aRR of 1.47 for PPH alone (95% CI 1.44-1.51), aRR of 2.43 for PPH requiring transfusion (95% CI 2.34-2.52), and aRR of 2.77 for PPH with DIC requiring transfusion (95% CI 2.54-3.03) compared to no PPH.Conclusion: PPH at delivery is a significant risk factor for subsequent readmission both for PPH and for all causes. For women who undergo large hemorrhage during delivery, shorter interval postpartum follow-up may be indicated.

Nutrition during Pregnancy: Findings from the National Institute of Child Health and Human Development (NICHD) Fetal Growth Studies-Singleton Cohort

BACKGROUND

Accumulating evidence indicates that maternal diets are important for optimizing maternal and offspring health. Existing research lacks comprehensive profiles of maternal diets throughout pregnancy, especially in a racially/ethnically diverse obstetrical population.

OBJECTIVE

The aim was to characterize diets in a longitudinal US pregnancy cohort by trimester, race/ethnicity, and prepregnancy BMI.

METHODS

Data were obtained from pregnant women in the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Fetal Growth Studies-Singleton cohort (2009-2013). A food-frequency questionnaire (FFQ) at 8-13 wk of gestation assessed periconception and first-trimester diet (n = 1615). Automated, self-administered, 24-h dietary recalls targeted at 16-22, 24-29, 30-33, and 34-37 wk of gestation assessed second- and third-trimester diets (n = 1817 women/6791 recalls). The Healthy Eating Index-2010 (HEI-2010) assessed diet quality (i.e., adherence to US Dietary Guidelines). Variations in weighted energy-adjusted means for foods and nutrients were examined by trimester, self-identified race/ethnicity, and self-reported prepregnancy BMI.

RESULTS

Mean (95% CI) HEI-2010 was 65.9 (64.9, 67.0) during periconception to the first trimester assessed with an FFQ and 51.6 (50.8, 52.4) and 51.5 (50.7, 52.3) during the second trimester and third trimester, respectively, assessed using 24-h recalls. No significant differences were observed between the second and third trimester in macronutrients, micronutrients, foods, or HEI-2010 components (P ≥ 0.05). Periconception to first-trimester HEI-2010 was highest among Asian/Pacific Islander [67.2 (65.9, 68.6)] and lowest among non-Hispanic Black [58.7 (57.5, 60.0)] women and highest among women with normal weight [67.2 (66.1, 68.4)] and lowest among women with obesity [63.5 (62.1, 64.9)]. Similar rankings were observed in the second/third trimesters.

CONCLUSIONS

Most pregnant women in this cohort reported dietary intakes that, on average, did not meet US Dietary Guidelines for nonpregnant individuals. Also, diet differed across race/ethnic groups and by prepregnancy BMI, with the lowest overall dietary quality in all trimesters among non-Hispanic Black women and women with obesity. No meaningful changes in dietary intake were observed between the second and third trimesters.

Postpartum cardiac readmissions among women without a cardiac diagnosis at delivery

OBJECTIVE

To determine risk for cardiac readmissions among women without cardiac diagnoses present at delivery up to 9 months after delivery hospitalization discharge.

METHODS

Delivery hospitalizations without cardiac diagnoses were identified from the 2010-2014 Nationwide Readmissions Database and linked with subsequent cardiac hospitalizations over the following 9 months. The temporality of new-onset cardiac hospitalizations was calculated for each 30-day interval from delivery discharge up to 9 months postpartum. Multivariable log-linear regression models were fit to identify risk factors for cardiac readmissions adjusting for patient, medical, and obstetrical factors with adjusted risk ratios as measures of effect (aRR).

RESULTS

Among 4.4 million delivery hospitalizations without a cardiac diagnosis, readmission for a cardiac condition within 9 months occurred in 26.8 per 10,000 women. Almost half of readmissions (45.9%) occurred within the first 30 days after delivery discharge with subsequent hospitalizations broadly distributed over the remaining 8 months. Factors such as hypertensive diseases of pregnancy (aRR 2.19, 95% CI 2.09, 2.30), severe maternal morbidity at delivery (aRR 2.06, 95% CI 1.79, 2.37), chronic hypertension (aRR 2.52, 95% CI 2.31, 2.74), lupus (aRR 4.62, 95% CI 3.82, 5.60), and venous thromboembolism during delivery (aRR 3.72, 95% CI 2.75, 5.02) were all associated with increased risk for 9-month postpartum cardiac admissions as were Medicaid (aRR 1.57, 95% CI 1.51, 1.64) and Medicare insurance (aRR 3.06, 95% CI 2.70, 3.46) compared to commercial insurance and maternal ages 35-39 and 40-54 years (aRR 1.24, 95% CI 1.17, 1.32, aRR 1.74, 95% CI 1.60, 1.90, respectively) compared to maternal age 25-29 years.

CONCLUSIONS

Among women without a cardiac diagnosis at delivery, multiple medical factors and obstetrical complications are associated with development of new cardiac disease requiring readmission in the postpartum period. Given that pregnancy complications and comorbidities may be associated with intermediate-term health outcomes, these findings support the importance of continued health care access after six weeks postpartum.

Opioid Use Disorder during Antepartum and Postpartum Hospitalizations

OBJECTIVE

This study aimed to evaluate temporal trends in opioid use disorder (OUD) during antepartum and postpartum hospitalizations.

STUDY DESIGN

This repeated cross-sectional analysis analyzed data from the National (Nationwide) Inpatient Sample. Women aged 15 to 54 years admitted antepartum or postpartum were identified. The presence of OUD was determined based on a diagnosis of opioid abuse, opioid dependence, or opioid overdose. Temporal trends in OUD were evaluated using the Rao-Scott chi-square test. Temporal trends in opioid overdose were additionally evaluated.

RESULTS

An estimated 7,336,562 antepartum hospitalizations and 1,063,845 postpartum readmissions were included in this analysis. The presence of an OUD diagnosis during antepartum hospitalizations increased from 0.7% of patients in 1998 to 1999 to 2.9% in 2014 (p < 0.01) and during postpartum hospitalizations increased from 0.8% of patients in 1998 to 1999 to 2.1% of patients in 2014 (p < 0.01). Risk of overdose diagnoses increased significantly for both antepartum hospitalizations, from 22.7 per 100,000 hospitalizations in 1998 to 2000 to 70.3 per 100,000 hospitalizations in 2013 to 2014 (p < 0.001), and postpartum hospitalizations, from 18.8 per 100,000 hospitalizations in 1998 to 2000 to 65.2 per 100,000 hospitalizations in 2013 to 2014 (p = 0.02).

DISCUSSION

Risk of OUD diagnoses and overdoses increased over the study period for both antepartum and postpartum hospitalizations.

Building an obstetric intensive care unit during the COVID-19 pandemic at a tertiary hospital and selected maternal-fetal and delivery considerations

During the novel Coronavirus Disease 2019 pandemic, New York City became an international epicenter for this highly infectious respiratory virus. In anticipation of the unfortunate reality of community spread and high disease burden, the Anesthesia and Obstetrics and Gynecology departments at NewYork-Presbyterian / Columbia University Irving Medical Center, an academic hospital system in Manhattan, created an Obstetric Intensive Care Unit on Labor and Delivery to defray volume from the hospital's preexisting intensive care units. Its purpose was threefold: (1) to accommodate the anticipated influx of critically ill pregnant and postpartum patients due to novel coronavirus, (2) to care for critically ill obstetric patients who would previously have been transferred to a non-obstetric intensive care unit, and (3) to continue caring for our usual census of pregnant and postpartum patients, who are novel Coronavirus negative and require a higher level of care. In this chapter, we share key operational details for the conversion of a non-intensive care space into an obstetric intensive care unit, with an emphasis on the infrastructure, personnel and workflow, as well as the goals for maternal and fetal monitoring.

The Response to a Pandemic at Columbia University Irving Medical Center's Department of Obstetrics and Gynecology

The rapid evolution of the COVID-19 pandemic in New York City during the spring of 2020 challenged the Department of Obstetrics and Gynecology at Columbia University Irving Medical Center to rely on its core values to respond effectively. In particular, five core values, "5 C's," were engaged: Communication; Collaboration; Continuity; Community; and Culture. Beginning on March 11, 2020, the Department of Ob/Gyn used these values to navigate an unprecedented public health crisis, continuing to deliver care to the women and families of New York City, to protecting and supporting its team, and to sharing its lessons learned with the national and international women's health community.

Placenta accreta spectrum: biomarker discovery using plasma proteomics

BACKGROUND

Many cases of placenta accreta spectrum are not diagnosed antenatally, despite identified risk factors and improved imaging methods. Identification of plasma protein biomarkers could further improve the antenatal diagnosis of placenta accreta spectrum .

OBJECTIVE

The purpose of this study was to determine if women with placenta accreta spectrum have a distinct plasma protein profile compared with control subjects.

STUDY DESIGN

We obtained plasma samples before delivery from 16 participants with placenta accreta spectrum and 10 control subjects with similar gestational ages (35.1 vs 35.5 weeks gestation, respectively). We analyzed plasma samples with an aptamer-based proteomics platform for alterations in 1305 unique proteins. Heat maps of the most differentially expressed proteins (T test, P<.01) were generated with matrix visualization and analysis software. Principal component analysis was performed with the use of all 1305 proteins and the top 21 dysregulated proteins. We then confirmed dysregulated proteins using enzyme-linked immunosorbent assay and report significant differences between placenta accreta spectrum and control cases (Wilcoxon-rank sum test, P<.05).

RESULTS

Many of the top 50 proteins that significantly dysregulated in participants with placenta accreta spectrum were inflammatory cytokines, factors that regulate vascular remodeling, and extracellular matrix proteins that regulate invasion. Placenta accreta spectrum, with the use of the top 21 proteins, distinctly separated the placenta accreta spectrum cases from control cases (P<.01). Using enzyme-linked immunosorbent assay, we confirmed 4 proteins that were dysregulated in placenta accreta spectrum compared with control cases: median antithrombin III concentrations (240.4 vs 150.3 mg/mL; P=.002), median plasminogen activator inhibitor 1 concentrations (4.1 vs 7.1 ng/mL; P<.001), soluble Tie2 (13.5 vs 10.4 ng/mL; P=.02), soluble vascular endothelial growth factor receptor 2 (9.0 vs 5.9 ng/mL; P=.003).

CONCLUSION

Participants with placenta accreta spectrum had a unique and distinct plasma protein signature.

Telehealth Uptake into Prenatal Care and Provider Attitudes during the COVID-19 Pandemic in New York City: A Quantitative and Qualitative Analysis

OBJECTIVE

This study aimed to (1) determine to what degree prenatal care was able to be transitioned to telehealth at prenatal practices associated with two affiliated hospitals in New York City during the novel coronavirus disease 2019 (COVID-19) pandemic and (2) describe providers' experience with this transition.

STUDY DESIGN

Trends in whether prenatal care visits were conducted in-person or via telehealth were analyzed by week for a 5-week period from March 9 to April 12 at Columbia University Irving Medical Center (CUIMC)-affiliated prenatal practices in New York City during the COVID-19 pandemic. Visits were analyzed for maternal-fetal medicine (MFM) and general obstetrical faculty practices, as well as a clinic system serving patients with public insurance. The proportion of visits that were telehealth was analyzed by visit type by week. A survey and semistructured interviews of providers were conducted evaluating resources and obstacles in the uptake of telehealth.

RESULTS

During the study period, there were 4,248 visits, of which approximately one-third were performed by telehealth (n = 1,352, 31.8%). By the fifth week, 56.1% of generalist visits, 61.5% of MFM visits, and 41.5% of clinic visits were performed via telehealth. A total of 36 providers completed the survey and 11 were interviewed. Accessing technology and performing visits, documentation, and follow-up using the telehealth electronic medical record were all viewed favorably by providers. In transitioning to telehealth, operational challenges were more significant for health clinics than for MFM and generalist faculty practices with patients receiving public insurance experiencing greater difficulties and barriers to care. Additional resources on the patient and operational level were required to optimize attendance at in-person and video visits for clinic patients.

CONCLUSION

Telehealth was rapidly implemented in the setting of the COVID-19 pandemic and was viewed favorably by providers. Limited barriers to care were observed for practices serving patients with commercial insurance. However, to optimize access for patients with Medicaid, additional patient-level and operational supports were required.

KEY POINTS

· Telehealth uptake differed based on insurance.. · Medicaid patients may require increased assistance for telehealth.. · Quick adoption of telehealth is feasible..

Fragmentation of postpartum readmissions in the United States

BACKGROUND

Fragmentation of care, wherein a patient is readmitted to a hospital different from the initial point of care, has been shown to be associated with worse patient outcomes in other medical specialties. However, postpartum fragmentation of care has not been well characterized in obstetrics.

OBJECTIVE

To characterize risk for and outcomes associated with fragmentation of postpartum readmissions wherein the readmitting hospital is different than the delivery hospital.

METHODS

The 2010 to 2014 Nationwide Readmissions Database was used for this retrospective cohort study. Postpartum readmissions within 60 days of delivery hospitalization discharge for women aged 15-54 years were identified. The primary outcome, fragmentation, was defined as readmission to a different hospital than the delivery hospital. Hospital, demographic, medical, and obstetric factors associated with fragmented readmission were analyzed. Adjusted log-linear models were performed to analyze risk for readmission with adjusted risk ratios and 95% confidence intervals as the measures of effect. The associations between fragmentation and secondary outcomes including (1) length of stay >90th percentile, (2) hospitalization costs >90th percentile, and (3) severe maternal morbidity were determined. Whether specific indications for readmission such as hypertensive diseases of pregnancy, wound complications, and other conditions were associated with higher or lower risk for fragmentation was analyzed.

RESULTS

From 2010 to 2014, 141,276 60-day postpartum readmissions were identified, of which 15% of readmissions (n = 21,789) occurred at a hospital different from where the delivery occurred. Evaluating individual readmission indications, fragmentation was less likely for hypertension (11.1%), wound complications (10.7%), and uterine infections (11.0%), and more likely for heart failure (28.6%), thromboembolism (28.4%), and upper respiratory infections (33.9%) (P < .01 for all). In the adjusted analysis, factors associated with fragmentation included public insurance compared to private insurance (Medicare: adjusted risk ratio, 1.68; 95% confidence interval, 1.52, 1.86; Medicaid: adjusted risk ratio, 1.28; 95% confidence interval, 1.24, 1.32). Fragmentation was associated with increased risk for severe maternal morbidity during readmissions in both unadjusted (relative risk, 1.84; 95% confidence interval, 1.79, 1.89) and adjusted (adjusted risk ratio, 1.81; 95% confidence interval, 1.76, 1.86) analyses. In adjusted analyses, fragmentation was also associated with increased risk for length of stay >90th percentile (relative risk, 1.48; 95% confidence interval, 1.42-1.54) and hospitalization costs >90th percentile (adjusted risk ratio, 1.74; 95% confidence interval, 1.67, 1.81).

CONCLUSION

This study of nationwide estimates of postpartum fragmentation found discontinuity of postpartum care was associated with increased risk for severe morbidity, high costs, and long length of stay. Reduction of fragmentation may represent an important goal in overall efforts to improve postpartum care.

Measurement of hemorrhage-related severe maternal morbidity with billing versus electronic medical record data

Objective: Measurement of obstetric hemorrhage-related morbidity is important for quality assurance purposes but presents logistical challenges in large populations. Billing codes are typically used to track severe maternal morbidity but may be of suboptimal validity. The objective of this study was to evaluate the validity of billing code diagnoses for hemorrhage-related morbidity compared to data obtained from the electronic medical record.Study design: Deliveries occurring between July 2014 and July 2017 from three hospitals within a single system were analyzed. Three outcomes related to obstetric hemorrhage that are part of the Centers for Disease Control and Prevention definition of severe maternal morbidity (SMM) were evaluated: (i) transfusion, (ii) disseminated intravascular coagulation (DIC), and (iii) acute renal failure (ARF). ICD-9-CM and ICD-10-CM for these conditions were ascertained and compared to blood bank records and laboratory values. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) with 95% confidence intervals (CI) were calculated. Ancillary analyses were performed comparing codes and outcomes between hospitals and comparing ICD-9-CM to ICD-10-CM codes. Comparisons of categorical variables were performed with the chi-squared test. T-tests were used to compare continuous outcomes.Results: 35,518 deliveries were analyzed. 786 women underwent transfusion, 168 had serum creatinine ≥1.2 mg/dL, and 99, 40, and 16 had fibrinogen ≤200, ≤150, and ≤100 mg/dL, respectively. Transfusion codes were 65% sensitive (95% CI 62-69%) with a 91% PPV (89-94%) for blood bank records of transfusion. DIC codes were 22% sensitive (95% CI 15-32%) for a fibrinogen cutoff of ≤200 mg/dL with 15% PPV (95% CI 10-22%). Sensitivity for ARF was 33% (95% CI 26-41%) for a creatinine of 1.2 mg/dL with a PPV of 63% (95% CI 52-73%). Sensitivity of ICD-9-CM for transfusion was significantly higher than ICD-10-CM (81%, 95% CI 76-86% versus 56%, 95% CI 51-60%, p < .01). Evaluating sensitivity of codes by individual hospitals, sensitivity of diagnosis codes for transfusion varied significantly (Hospital A 47%, 95% CI 36-58% versus Hospital B 63%, 95% CI 58-67% versus Hospital C 80%, 95% CI 74-86%, p < .01).Conclusion: Use of administrative billing codes for postpartum hemorrhage complications may be appropriate for measuring trends related to disease burden and resource utilization, particularly in the case of transfusion, but may be suboptimal for measuring clinical outcomes within and between hospitals.

Telehealth for High-Risk Pregnancies in the Setting of the COVID-19 Pandemic

As New York City became an international epicenter of the novel coronavirus disease 2019 (COVID-19) pandemic, telehealth was rapidly integrated into prenatal care at Columbia University Irving Medical Center, an academic hospital system in Manhattan. Goals of implementation were to consolidate in-person prenatal screening, surveillance, and examinations into fewer in-person visits while maintaining patient access to ongoing antenatal care and subspecialty consultations via telehealth virtual visits. The rationale for this change was to minimize patient travel and thus risk for COVID-19 exposure. Because a large portion of obstetric patients had underlying medical or fetal conditions placing them at increased risk for adverse outcomes, prenatal care telehealth regimens were tailored for increased surveillance and/or counseling. Based on the incorporation of telehealth into prenatal care for high-risk patients, specific recommendations are made for the following conditions, clinical scenarios, and services: (1) hypertensive disorders of pregnancy including preeclampsia, gestational hypertension, and chronic hypertension; (2) pregestational and gestational diabetes mellitus; (3) maternal cardiovascular disease; (4) maternal neurologic conditions; (5) history of preterm birth and poor obstetrical history including prior stillbirth; (6) fetal conditions such as intrauterine growth restriction, congenital anomalies, and multiple gestations including monochorionic placentation; (7) genetic counseling; (8) mental health services; (9) obstetric anesthesia consultations; and (10) postpartum care. While telehealth virtual visits do not fully replace in-person encounters during prenatal care, they do offer a means of reducing potential patient and provider exposure to COVID-19 while providing consolidated in-person testing and services. KEY POINTS: · Telehealth for prenatal care is feasible.. · Telehealth may reduce coronavirus exposure during prenatal care.. · Telehealth should be tailored for high risk prenatal patients..

Postpartum Readmissions Among Women With Diabetes

OBJECTIVE

To estimate whether women with diabetes are at risk for 60-day postpartum readmissions and associated complications.

METHODS

The Nationwide Readmissions Database from 2010 to 2014 was analyzed to determine risk for 60-day postpartum readmissions among women with type 1 diabetes mellitus (DM), type 2 DM, gestational diabetes mellitus (GDM), and unspecified DM compared with women with no diabetes. Secondary outcomes included evaluating risk for overall severe maternal morbidity during readmissions, as well as wound complications, acute diabetic complications such as diabetic ketoacidosis, venous thromboembolism, and hypertensive diseases of pregnancy. Billing data were used to ascertain both exposures and outcomes. Adjusted log-linear regression models including demographic, hospital, medical and obstetric, and hospital factors were performed with adjusted risk ratios (aRRs) and with 95% Cis as measures of association.

RESULTS

Of an estimated 15.7 million delivery hospitalizations, 1.1 million occurred among women with diabetes, of whom 3.2% had type 1 DM, 9.1% type 2 DM, 86.6% GDM, and 1.1% unspecified diabetes. Compared with women without diabetes (1.5% risk for readmission), risk for readmission was significantly higher for women with type 1 DM (4.4%), unspecified diabetes (4.0%), type 2 DM (3.9%), and GDM (2.0%) (P<.01). After adjusting for hospital, demographic, medical, and obstetric risk factors, type 1 DM (aRR 1.77, 95% CI 1.69-1.87), type 2 DM (aRR 1.46, 95% CI 1.42-1.51), unspecified (aRR 1.73, 95% CI 1.59-1.89) and gestational diabetes (aRR 1.16, 95% CI 1.14-1.17) retained increased risk. Among women with diabetes public insurance, lower ZIP code income quartiles, and hospitals with high safety net burdens were associated with higher risk for readmission. In both unadjusted and adjusted analyses, all diabetes diagnoses were associated with readmissions for wound complications, hypertensive diseases of pregnancy, and severe maternal morbidity.

CONCLUSION

Although overall risk for readmission is low, pregnancies complicated by pregestational diabetes in particular are at increased risk. Women in this high-risk group should receive coordinated care and be monitored closely in the postpartum period.

A principled framework for phenotyping postpartum hemorrhage across multiple levels of severity

Maternal morbidity and mortality have gained major attention recently, spurred on by rising domestic rates even as maternal mortality decreases in Europe. A major driver of morbidity and mortality among delivering women is postpartum hemorrhage (PPH). PPH is currently phenotyped using the subjective measure of 'Estimated blood loss' (EBL), which has been shown to be unreliable for tracking quality. Here we present a framework for phenotyping PPH into multiple severity levels, using a combination of data-driven techniques and expert-derived clinical indicators. We validate the framework by predicting large drops in hematocrit and quantitative blood loss, finding that the framework performs better in predicting coded PPH than a hematocrit-based predictor or predictors based on other metrics such as blood transfusions, and does better in predicting quantitative blood loss, a gold standard metric for blood loss that we have for a subset of patients, than any predictor we could build using hematocrit drops alone. In all, we present a principled framework that can be used to phenotype PPH in hospitals using readily available EHR data, and that will perform with more granularity and accuracy than existing methods.

Oral Opioid Use during Vaginal Delivery Hospitalizations

OBJECTIVE

This study aimed to determine the receipt of short-acting opioid medications during vaginal delivery hospitalizations.

STUDY DESIGN

The Perspective database was analyzed to evaluate patterns of short-acting oral opioid use during vaginal delivery hospitalizations from January 2006 to March 2015. Unadjusted and adjusted models evaluating the role of demographic and hospital factors were created evaluating use of opioids. Hospital-level rates of opioid use were evaluated. Opioid receipt among women with opioid abuse or dependence was evaluated based on overall hospital rates of opioid use.

RESULTS

Of 3,785,396 vaginal delivery hospitalizations from 2006 to 2015, 1,720,899 (45.5%) women received an oral opioid for pain relief. Opioid use varied significantly among the 458 hospitals included in the analysis, with one-third of hospitals providing opioids to <38% of patients, one-third to 38 to <59% of patients, and one-third to ≥59% of patients. When hospitals were stratified by overall opioid administration rates, women with opioid abuse or dependence were less likely to be given opioids in hospitals with low overall opioid rates.

DISCUSSION

The use of opioid pain medications during vaginal delivery hospitalizations varied significantly among hospitals, suggesting that standardization of pain management practices could reduce opioid use.

Use of Uterine Tamponade and Interventional Radiology Procedures During Delivery Hospitalizations

OBJECTIVE

To characterize use of uterine tamponade and interventional radiology procedures.

METHODS

This retrospective study analyzed uterine tamponade and interventional radiology procedures in a large administrative database. The primary outcomes were temporal trends in these procedures 1) during deliveries, 2) by hospital volume, and 3) before hysterectomy for uterine atony or delayed postpartum hemorrhage. Three 3-year periods were analyzed: 2006-2008, 2009-2011, and 2012-2014. Risk of morbidity in the setting of hysterectomy with uterine tamponade and interventional radiology procedures as the primary exposures was additionally analyzed in adjusted models.

RESULTS

The study included 5,383,486 deliveries, which involved 6,675 uterine tamponade procedures, 1,199 interventional radiology procedures, and 1,937 hysterectomies. Interventional radiology procedures increased from 16.4 to 25.7 per 100,000 delivery hospitalizations from 2006-2008 to 2012-2014 (P<.01), and uterine tamponade increased from 86.3 to 158.1 (P<.01). Interventional radiology procedures use was highest (45.0/100,000 deliveries, 95% CI 41.0-48.9) in the highest and lowest (8.9/100,000, 95% CI 7.1-10.7) in the lowest volume quintile. Uterine tamponade procedures were most common in the fourth (209.8/100,000, 95% CI 201.1-218.5) and lowest in the third quintile (59.8/100,000, 95% CI 55.1-64.4). Interventional radiology procedures occurred before 3.3% of hysterectomies from 2006 to 2008 compared with 6.3% from 2012 to 2014 (P<.05), and uterine tamponade procedures increased from 3.6% to 20.1% (P<.01). Adjusted risks for morbidity in the setting of uterine tamponade and interventional radiology before hysterectomy were significantly higher (adjusted risk ratio [aRR] 1.63, 95% CI 1.47-1.81 and aRR 1.75 95% CI 1.51-2.03, respectively) compared with when these procedures were not performed.

CONCLUSION

This analysis found that uterine tamponade and interventional radiology procedures became increasingly common over the study period, are used across obstetric volume settings, and in the setting of hysterectomy may be associated with increased risk of morbidity, although this relationship is not necessarily causal.

Maternal Race/Ethnicity, Hypertension, and Risk for Stroke During Delivery Admission

Background

Racial disparities contribute to maternal morbidity in the United States. Hypertension is associated with poor maternal outcomes, including stroke. Disparities in hypertension might contribute to maternal strokes.

Methods and Results

Using billing data from the Healthcare Cost and Utilization Project's National Inpatient Sample, we analyzed the effect of race/ethnicity on stroke during delivery admission in women aged 18 to 54 years delivering in US hospitals from January 1, 1998, through December 31, 2014. We categorized hypertension as normotensive, chronic hypertension, or pregnancy‐induced hypertension. Adjusted risk ratios (aRRs) and 95% CIs were calculated using log‐linear Poisson regression models, testing for interactions between race/ethnicity and hypertensive status. A total of 65 286 425 women were admitted for delivery during the study period, of whom 7764 were diagnosed with a stroke (11.9 per 100 000 deliveries). Hypertension modified the effect of race/ethnicity (P<0.0001 for interaction). Among women with pregnancy‐induced hypertension, black and Hispanic women had higher stroke risk compared with non‐Hispanic whites (blacks: aRR, 2.07; 95% CI, 1.86–2.30; Hispanics: aRR, 2.19; 95% CI, 1.98–2.43). Among women with chronic hypertension, all minority women had higher stroke risk (blacks: aRR, 1.71; 95% CI, 1.30–2.26; Hispanics: aRR, 1.75; 95% CI, 2.32–5.63; Asian/Pacific Islanders: aRR, 3.62; 95% CI, 2.32–5.63). Among normotensive women, only blacks had increased stroke risk (aRR, 1.17; 95% CI, 1.07–1.28).

Conclusions

Pregnant US women from minority groups had higher stroke risk during delivery admissions, compared with non‐Hispanic whites. The effect of race/ethnicity was larger in women with chronic hypertension or pregnancy‐induced hypertension. Targeting blood pressure management in pregnancy may help reduce maternal stroke risk in minority populations.