Hospital readmission after delivery: evidence for an increased incidence of nonurogenital infection in the immediate postpartum period

Risk factors for postpartum readmission: a prediction model in Iranian pregnant women

BACKGROUND

Postpartum readmissions (PPRs) are an important indicator of maternal postpartum complications and the quality of medical services and are important for reducing medical costs. The present study aimed to investigate the risk factors affecting readmission after delivery in Imam Ali Hospital in Amol, Iran.

METHODS

This retrospective cohort study was conducted on the mothers who were readmitted after delivery within 30 days, at Imam Ali Hospital (2019-2023). The demographic and obstetrics characteristics were identified through the registry system. Univariate and multivariate logistic regressions with odds ratios (ORs) and 95% CIs were carried out. To identify the most important variables by machine learning methods, a random forest model was used. The data were analyzed using SPSS 22 software and R (4.1.3) at a significant level of 0.05.

RESULTS

Among 13,983 deliveries 164 (1.2%) had readmission after delivery. The most prevalent cause of readmission after delivery was infection (59.7%). The chance of readmission for women who underwent elective cesarean section and women who experienced labor pain onset by induction of labor was twice and 1.5 times greater than that among women who experienced spontaneous labor pain, respectively. Women with pregnancy complications had more than 2 times the chance of readmission. Cesarean section increased the chance of readmission by 2.69 times compared to normal vaginal delivery.

CONCLUSION

The method of labor pain onset, mode of delivery, and complications during pregnancy were the most important factors related to readmission after childbirth.

Early Postpartum Hospital Encounters among Patients with Genitourinary and Wound Infections during Hospitalization for Birth

OBJECTIVES

 This study aimed to assess the associations between genitourinary and wound infections during the birth hospitalization and early postpartum hospital encounters, and to evaluate clinical risk factors for early postpartum hospital encounters among patients with genitourinary and wound infections during the birth hospitalization.

STUDY DESIGN

 We conducted a population-based cohort study of births in California during 2016 to 2018 and postpartum hospital encounters. We identified genitourinary and wound infections using diagnosis codes. Our main outcome was early postpartum hospital encounter, defined as a readmission or emergency department (ED) visit within 3 days after discharge from the birth hospitalization. We evaluated the association of genitourinary and wound infections (overall and subtypes) with early postpartum hospital encounter using logistic regression, adjusting for sociodemographic factors and comorbidities and stratified by mode of birth. We then evaluated factors associated with early postpartum hospital encounter among patients with genitourinary and wound infections.

RESULTS

 Among 1,217,803 birth hospitalizations, 5.5% were complicated by genitourinary and wound infections. Genitourinary or wound infection was associated with an early postpartum hospital encounter among patients with both vaginal births (2.2%; adjusted risk ratio [aRR[: 1.26; 95% confidence interval [CI]: 1.17-1.36) and cesarean births (3.2%; aRR: 1.23; 95% CI: 1.15-1.32). Patients with a cesarean birth and a major puerperal infection or wound infection had the highest risk of an early postpartum hospital encounter (6.4 and 4.3%, respectively). Among patients with genitourinary and wound infections during the birth hospitalization, factors associated with an early postpartum hospital encounter included severe maternal morbidity, major mental health condition, prolonged postpartum hospital stay, and, among cesarean births, postpartum hemorrhage (p-value < 0.05).

CONCLUSION

 Genitourinary and wound infections during hospitalization for birth may increase risk of a readmission or ED visit within the first few days after discharge, particularly among patients who have a cesarean birth and a major puerperal infection or wound infection.

KEY POINTS

· In all, 5.5% of patients giving birth had a genitourinary or wound infection (GWI).. · A total of 2.7% of GWI patients had a hospital encounter within 3 days of discharge after birth.. · Major puerperal infection and wound infection had the highest risk of an early hospital encounter.. · Among GWI patients, several birth complications were associated with an early hospital encounter..

Unintended uterine extension at the time of cesarean delivery - risk factors and associated adverse maternal and neonatal outcomes

OBJECTIVE

To identify risk factors, maternal and neonatal adverse outcomes related to unintended lower segment uterine extension during cesarean delivery (CD).

METHODS

A retrospective cohort analysis in a single, university-affiliated medical center between 1 January 2018 and 31 December 2019. All singleton pregnancies delivered by CD were included. Univariate and multivariate analyses were performed to identify maternal and obstetrical predictors for uterine extension during CD. For secondary outcomes, we assessed the correlation between uterine extension and any adverse maternal or neonatal outcome. Risk factors were analyzed using ROC statistics to measure their prediction performance for a uterine extension.

RESULTS

Overall, 1746 (19.3%) CDs were performed during the study period. Of them, 121 (6.9%) CDs were complicated by unintended uterine extension. There was no difference in maternal demographics and clinical data stratified by uterine extension at CD. Uterine extensions were significantly more common following induction of labor, intrapartum fever, premature rupture of membranes, a trial of labor after cesarean, advanced gestational age, emergent CD, and in particular CD during the second stage of labor (37.2% vs. 6.5%) and after failed vacuum extraction (6.6% vs. 1.1%), p < .05 for all. The incidence of postpartum hemorrhage and re-laparotomy did not differ between the groups. Most of the extensions were caudal-directed (40.4%), and were closed by a two-layer closure (92%). Mean extension size was 4.5 ± 1.7 cm. Using multivariable analysis, the only factor that remained significant was CD at the second stage of labor (adjusted odds ratio (aOR) 54.2, 95% CI 4.5-648.9, p = .002), with an area under the ROC curve 0.653 (95% CI 0.595-0.712, p < .001). Emergent CD, body mass index, birth weight, failed vacuum attempt, and trial of labor after cesarean were not significant. For secondary outcomes, an unintended uterine extension was associated with longer operation time, higher estimated blood loss, greater pre- to post-CD hemoglobin difference, increased blood products transfusion, puerperal fever, and longer hospital stay. No clinically significant neonatal adverse outcomes were observed.

CONCLUSIONS

In our cohort, second-stage CD was the strongest predictor for an unintended uterine extension. Following uterine extension, women had increased infectious and blood-loss morbidity.

Decision and economic analysis of hostile abortion laws compared with supportive abortion laws

BACKGROUND

On June 24, 2022, the US Supreme Court overturned Roe v Wade in Dobbs v Jackson Women's Health Organization. Therefore, several states banned abortion, and other states are considering more hostile abortion laws.

OBJECTIVE

This study aimed to assess the incidence of adverse maternal and neonatal outcomes in the hypothetical cohort where all states have hostile abortion laws compared with the pre-Dobbs v Jackson cohort (supportive abortion laws cohort) and examine the cost-effectiveness of these policies.

STUDY DESIGN

This study developed a decision and economic analysis model comparing the hostile abortion laws cohort with the supportive abortion laws cohort in a sample of 5.3 million pregnancies. Cost (inflated to 2022 US dollars) estimates were from a healthcare provider's perspective, including immediate and long-term costs. The time horizon was set to a lifetime. Probabilities, costs, and utilities were derived from the literature. The cost-effectiveness threshold was set to be at $100,000 per quality-adjusted life year. Probabilistic sensitivity analyses using the Monte Carlo simulation with 10,000 simulations were performed to assess the robustness of our results. The primary outcomes included maternal mortality and an incremental cost-effectiveness ratio. The secondary outcomes included hysterectomy, cesarean delivery, hospital readmission, neonatal intensive care unit admission, neonatal mortality, profound neurodevelopmental disability, and incremental cost and effectiveness.

RESULTS

In the base case analysis, the hostile abortion laws cohort had 12,911 more maternal mortalities, 7518 more hysterectomies, 234,376 more cesarean deliveries, 102,712 more hospital readmissions, 83,911 more neonatal intensive care unit admissions, 3311 more neonatal mortalities, and 904 more cases of profound neurodevelopmental disability than the supportive abortion laws cohort. The hostile abortion laws cohort was associated with more cost ($109.8 billion [hostile abortion laws cohort] vs $75.6 billion [supportive abortion laws cohort]) and 120,749,900 fewer quality-adjusted life years with an incremental cost-effectiveness ratio of negative $140,687.60 than the supportive abortion laws cohort. Probabilistic sensitivity analyses suggested that the chance of the supportive abortion laws cohort being the preferred strategy was more than 95%.

CONCLUSION

When states consider enacting hostile abortion laws, legislators should consider an increase in the incidence of adverse maternal and neonatal outcomes.

Severe Maternal Morbidity and Postpartum Readmission Through 1 Year

OBJECTIVE

To conduct a cohort study to estimate risk for readmission through 1 year postpartum and the most common readmission diagnoses for individuals with and without severe maternal morbidity (SMM) at delivery.

METHODS

Using national health care claims data from IBM MarketScan Commercial Research Databases (now known as Merative), we identified all delivery hospitalizations for continuously enrolled individuals 15-49 years of age that occurred between January 1, 2016, and December 31, 2018. Severe maternal morbidity at delivery was identified using diagnosis and procedure codes. Individuals were followed for 365 days after delivery discharge, and cumulative readmission rates were calculated for up to 42 days, up to 90 days, up to 180 days, and up to 365 days. We used multivariable generalized linear models to estimate adjusted relative risks (aRR), adjusted risk differences, and 95% CIs for the association between readmission and SMM at each of the timepoints.

RESULTS

The study population included 459,872 deliveries; 5,146 (1.1%) individuals had SMM during the delivery hospitalization, and 11,603 (2.5%) were readmitted within 365 days. The cumulative incidence of readmission was higher in individuals with SMM than those without at all timepoints (within 42 days: 3.5% vs 1.2%, aRR 1.44, 95% CI 1.23-1.68; within 90 days: 4.1% vs 1.4%, aRR 1.46, 95% CI 1.26-1.69); within 180 days: 5.0% vs 1.8%, aRR 1.48, 95% CI 1.30-1.69; within 365 days: 6.4% vs 2.5%, aRR 1.44, 95% CI 1.28-1.61). Sepsis and hypertensive disorders were the most common reason for readmission within 42 and 365 days for individuals with SMM (35.2% and 25.8%, respectively).

CONCLUSION

Severe maternal morbidity at delivery was associated with increased risk for readmission throughout the year after delivery, a finding that underscores the need for heightened awareness of risk for complications beyond the traditional 6-week postpartum period.

Patient Sociodemographics and Comorbidities and Birth Hospital Characteristics Associated With Postpartum Emergency Department Care

IMPORTANCE

Postpartum emergency department (ED) visits may indicate poor access to care and risk for maternal morbidity.

OBJECTIVES

To identify patient and hospital characteristics associated with postpartum ED visit rates.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used data from the 2014 to 2016 New York State Inpatient Database and State Emergency Department Database. All obstetric discharges from acute care hospitals in New York State from January 1, 2014, through November 15, 2016, were included. Obstetric discharges in the inpatient database were linked to subsequent ED visits by the same patient in the ED database. Data were analyzed from February 2020 to August 2022.

EXPOSURES

Patient characteristics assessed included age, race, insurance, home zip code income quartile, Charlson Comorbidity Index score, and obstetric risk factors. Hospital characteristics assessed included safety net status, teaching status, and status as a hospital disproportionally serving racial and ethnic minority populations.

MAIN OUTCOMES AND MEASURES

The primary outcome was any ED visit within 42 days of obstetric discharge. Multilevel logistic regression with 2-level nested mixed effects was used to account for patient and hospital characteristics and hospital-level clustering.

RESULTS

Of 608 559 obstetric discharges, 35 299 (5.8%) were associated with an ED visit within 42 days. The median (IQR) birth hospital postpartum ED visit rate was 6.3% (4.6%-8.7%). The mean (SD) age was 28.4 (9.1) years, 53 006 (8.7%) were Asian patients, 90 675 (14.9%) were Black patients, 101 812 (16.7%) were Hispanic patients, and 275 860 (45.3%) were White patients; 292 991 (48%) were insured by Medicaid, and 290 526 (47.7%) had private insurance. Asian patients had the lowest postpartum ED visit rates (2118 ED visits after 53 006 births by Asian patients [3.99%]), and Black patients had the highest postpartum ED visit rates (8306 ED visits after 90 675 births by Black patients [9.15%]). Odds of postpartum ED visits were greater for Black patients (odds ratio [OR], 1.31; 95% CI, 1.26-1.35; P < .001) and Hispanic patients (OR, 1.19; 95% CI, 1.15-1.24; P < .001) relative to White patients; those with Medicare (OR, 1.55; 95% CI, 1.39-1.72; P < .001), Medicaid (OR, 1.37; 95% CI, 1.34-1.41; P < .001), or self-pay insurance (OR, 1.50; 95% CI, 1.41-1.59; P < .001) relative to commercial insurance; births that occurred at safety net hospitals (OR, 1.43; 95% CI, 1.37-1.51; P < .001) and hospitals disproportionately serving racial and ethnic minority populations (OR, 1.14; 95% CI, 1.08-1.20; P < .001); and births that occurred at hospitals with fewer than 500 births per year (OR, 1.25; 95% CI, 1.14-1.39; P < .001) relative to those with more than 2000 annual births. Adjusted odds of postpartum ED visits were lower after birth at teaching hospitals (OR,  0.82; 95% CI, 0.74-0.91; P < .001) and metropolitan hospitals (OR, 0.74; 95% CI, 0.65-0.85; P < .001).

CONCLUSIONS AND RELEVANCE

This cohort study found that Black and Hispanic patients experienced higher adjusted odds of postpartum ED visits across all hospital types, particularly at safety net hospitals and those disproportionately serving racial and ethnic minority populations . These findings support the urgent need to mitigate structural racism underlying maternal health disparities.

Association of Sickle Cell Disease With Severe Maternal Morbidity

OBJECTIVE

To evaluate the association between sickle cell disease (SCD) and severe maternal morbidity (SMM) in a contemporary cohort of deliveries by non-Hispanic Black people.

METHODS

We retrospectively examined SMM by using electronic health record data on deliveries by non-Hispanic Black patients between 2011 and 2020 at a single tertiary, public institution. Sickle cell disease was identified during the delivery admission by using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes. The primary outcome, SMM at delivery hospitalization, was ascertained using ICD-9-CM and ICD-10-CM codes and excluded sickle cell crisis as an indicator of SMM. We also constructed a secondary measure of SMM that excluded deliveries in which blood transfusion was the only indication of SMM. Poisson regression models were used to estimate risk ratios (RRs) and 95% CIs for the associations between SCD and SMM (overall and for individual indicators). Multivariable models adjusted for age, parity, insurance type, chronic conditions (chronic hypertension, diabetes mellitus, obesity), and multiple gestation.

RESULTS

Among 17,493 deliveries by non-Hispanic Black patients during the study period, 132 (0.8%) had a diagnosis of SCD. Of those patients, 87 (65.9%, 95% CI 57.2-73.9) with SCD and 2,035 (11.7%), 95% CI 11.2-12.2) without SCD had SMM. Sickle cell disease was associated with increased risk of SMM (87 vs 2,035, adjusted risk ratio [aRR] 5.4, 95% CI 4.6-6.3) and nontransfusion SMM (51 vs 1,057, aRR 6.0, 95% CI 4.6-8.0). Effect estimates were highest for cardiac arrest (3 vs 14, RR 28.2, 95% CI 3.8-209.3), air and thrombotic embolism (14 vs 72, RR 25.6, 95% CI 12.0-54.6), and puerperal cerebrovascular disorders (10 vs 53, RR 24.8, 95% CI 10.2-60.5).

CONCLUSION

Sickle cell disease was associated with a more than fivefold increased risk of SMM during the delivery hospitalization. Our data suggest cardiovascular morbidity as the driving major risk. The identification and monitoring of cardiovascular pathology in patients with SCD before and during pregnancy may reduce SMM.

Postpartum Hospital Readmissions and Emergency Department Visits Among High-Risk, Medicaid-Insured Women in New York City

Objectives: To describe the incidence of and characteristics associated with postpartum emergency department (ED) visits and hospital readmissions among high-risk, low-income, predominantly Black and Latina women in New York City (NYC). Methods: We conducted a secondary analysis of detailed survey and medical chart data from an intervention to improve timely postpartum visits among Medicaid-insured, high-risk women in NYC from 2015 to 2016. Among 380 women who completed surveys at baseline (bedside postpartum) and 3 weeks after delivery, we examined the incidence of having an ED visit or readmission within 3 weeks postpartum. We used logistic regression to examine unadjusted and adjusted associations between patient demographic, clinical, and psychosocial characteristics and the odds of postpartum hospital use. Results: In total, 12.8% (n = 48) of women reported an ED visit or readmission within 3 weeks postpartum. Unadjusted odds of postpartum hospital use were higher among women who self-identified as Black versus Latina, U.S. born versus foreign born, and English versus Spanish speaking. Clinical and psychosocial characteristics associated with increased unadjusted odds of postpartum hospital use included cesarean delivery, hypertensive disorders of pregnancy, and positive depression or anxiety screen, and we found preliminary evidence of decreased hospital use among women breastfeeding at three weeks postpartum. The odds of seeking postpartum hospital care remained roughly 2.5 times higher among women with hypertension or depression/anxiety in adjusted analyses. Conclusions: We identified characteristics associated with ED visits and hospital readmissions among a high-risk subset of postpartum women in NYC. These characteristics, including depressive symptoms and hypertension, suggest women who may benefit from additional postpartum support to prevent maternal complications and reduce health disparities.

Association of Prepregnancy Body Mass Index With Risk of Severe Maternal Morbidity and Mortality Among Medicaid Beneficiaries

IMPORTANCE

The association between body mass index (BMI, which is calculated as weight in kilograms divided by height in meters squared) and severe maternal morbidity (SMM) and/or mortality is uncertain, judging from the current evidence.

OBJECTIVE

To examine the association between prepregnancy BMI and SMM and/or mortality through 1 year post partum and to identify both the direct and indirect implications of maternal obesity for SMM and/or mortality by examining hypertensive disorders and pregestational diabetes as potential mediators.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study was conducted from March to October 2021 using the vital records and linked Medicaid claims data in the state of Ohio from January 1, 2012, through December 31, 2017. The cohort comprised pregnant Medicaid beneficiaries who delivered at 20 weeks' gestation or later and had prepregnancy BMI information.

EXPOSURES

The primary exposure was maternal prepregnancy BMI, which was categorized as follows: underweight (<18.5), healthy weight (18.5-24.9), overweight (25.0-29.9), class 1 obesity (30.0-34.9), class 2 obesity (35.0-39.9), and class 3 obesity (≥40.0).

MAIN OUTCOMES AND MEASURES

The primary outcome was a composite of SMM (defined using Centers for Disease Control and Prevention criteria) and/or maternal mortality between 20 weeks' gestation and 1 year post partum. Additional periods were assessed, including 20 weeks' gestation through delivery hospitalization and 20 weeks' gestation through 42 days post partum. Generalized estimating equation models were used to estimate adjusted relative risks (aRRs) for the primary outcome according to BMI category. Maternal hypertensive diseases and pregestational diabetes were assessed as potential meditators.

RESULTS

In a cohort of 347 497 pregnancies among 276 691 Medicaid beneficiaries (median [IQR] maternal age at delivery, 25 [21-29] years; 210 470 non-Hispanic White individuals [60.6%]), the prevalence of maternal obesity was 30.5% (n = 106 031). Composite SMM and/or mortality outcome occurred in 5.3% of pregnancies (n = 18 398). Overweight (aRR, 1.07; 95% CI, 1.03-1.11) and obesity (class 1: aRR, 1.19 [95% CI, 1.14-1.24]; class 2: aRR, 1.37 [95% CI, 1.30-1.44]; class 3: aRR, 1.71 [95% CI, 1.63-1.80]) were associated with an elevated risk of SMM and/or mortality during pregnancy to 1 year post partum compared with healthy BMI. Similar findings were observed when the follow-up period was shortened to 42 days post partum or the delivery hospitalization. Hypertension mediated 65.1% (95% CI, 64.6%-65.6%) of the association between obesity and the primary outcome.

CONCLUSIONS AND RELEVANCE

Results of this study showed that maternal prepregnancy obesity was associated with an elevated risk of SMM and/or mortality. Hypertensive disorders appeared to mediate this association, suggesting that improved prevention and management of hypertensive disorders in pregnancy may reduce morbidity and mortality in individuals with obesity.

Society for Maternal-Fetal Medicine Special Statement: A critique of postpartum readmission rate as a quality metric

Hospital readmission is considered a core measure of quality in healthcare. Readmission soon after hospital discharge can result from suboptimal care during the index hospitalization or from inadequate systems for postdischarge care. For many conditions, readmission is associated with a high rate of serious morbidity and potentially avoidable costs. In obstetrics, for postpartum care specifically, hospitals and payers can easily track the rate of maternal readmission after childbirth and may seek to incentivize obstetricians, maternal-fetal medicine specialists, or provider groups to reduce the rate of readmission. However, this practice has not been shown to improve outcomes or reduce harm. There are major concerns with incentivizing providers to reduce postpartum readmissions, including the lack of a standardized metric, a baseline rate of 1% to 2% that is too low to accurately discriminate between random variation and controllable factors, the need for risk adjustment that greatly complicates rate calculations, the potential for bias depending on the duration of the follow-up interval, the potential for the "gaming" of the metric, the lack of evidence that obstetrical providers can influence the rate, and the potential for unintended harm in the vulnerable postpartum population. Until these problems are adequately addressed, maternal readmission rate after a childbirth hospitalization currently has limited utility as a metric for quality or performance improvement or as a factor to adjust provider reimbursement.

Reduced rate of postpartum readmissions among homeless compared with non-homeless women in New York: a population-based study using serial, cross-sectional data

Objective

To assess differences in rates of postpartum hospitalisations among homeless women compared with non-homeless women.

Design

Cross-sectional secondary analysis of readmissions and emergency department (ED) utilisation among postpartum women using hierarchical regression models adjusted for age, race/ethnicity, insurance type during delivery, delivery length of stay, maternal comorbidity index score, other pregnancy complications, neonatal complications, caesarean delivery, year fixed effect and a birth hospital random effect.

Setting

New York statewide inpatient and emergency department databases (2009–2014).

Participants

82 820 and 1 026 965 postpartum homeless and non-homeless women, respectively.

Main outcome measures

Postpartum readmissions (primary outcome) and postpartum ED visits (secondary outcome) within 6 weeks after discharge date from delivery hospitalisation.

Results

Homeless women had lower rates of both postpartum readmissions (risk-adjusted rates: 1.4% vs 1.6%; adjusted OR (aOR) 0.87, 95% CI 0.75 to 1.00, p=0.048) and ED visits than non-homeless women (risk-adjusted rates: 8.1% vs 9.5%; aOR 0.83, 95% CI 0.77 to 0.90, p<0.001). A sensitivity analysis stratifying the non-homeless population by income quartile revealed significantly lower hospitalisation rates of homeless women compared with housed women in the lowest income quartile. These results were surprising due to the trend of postpartum hospitalisation rates increasing as income levels decreased.

Conclusions

Two factors likely led to lower rates of hospital readmissions among homeless women. First, barriers including lack of transportation, payment or childcare could have impeded access to postpartum inpatient and emergency care. Second, given New York State’s extensive safety net, discharge planning such as respite and sober living housing may have provided access to outpatient care and quality of life, preventing adverse health events. Additional research using outpatient data and patient perspectives is needed to recognise how the factors affect postpartum health among homeless women. These findings could aid in lowering readmissions of the housed postpartum population.

Are Cesarean Section and Appendectomy in Pregnancy and Puerperium Interrelated? A Cohort Study

Introduction

It is not known whether appendectomy for acute appendicitis (AA) increases the Cesarean section (CS) rate and whether CS increases the likelihood of AA and appendectomy in the early puerperium. In this study, delivery type and delivery outcomes and appendectomy during pregnancy and puerperium were analyzed.

Methods

This cross-sectional retrospective study was performed on 11,513 women, delivered during 2015–2020. Inclusion criteria were patients undergoing appendectomy for AA during pregnancy and the first 6 weeks after delivery. Evaluating parameters were age, parity, gestational week at birth, delivery type, and babies' birth weight.

Results

Thirty-two patients underwent appendectomy: 12 during pregnancy (2 in the first trimester, 6 in the second trimester, 4 in the third trimester) and 20 women during puerperium. 58.2% of pregnant women and 65% of puerperal women were submitted to CS.

Discussion

Half of the women who underwent appendectomy for AA during pregnancy may require urgent CS. The cause of acute abdomen in the postpartum period, especially in the first week, could be AA, especially in women delivered by CS.

Reducing Disparities Using Telehealth Approaches for Postdelivery Preeclampsia Care

The management of hypertensive disease of pregnancy presents an ongoing challenge after patients are discharged from delivery hospitalizations. Preeclampsia and other forms of postpartum hypertension increase the risk for severe maternal morbidity and mortality in the postpartum period, and both hypertension and its associated adverse events disproportionately affect black women. With its ability to transcend barriers to health care access, telemedicine can facilitate high-quality postpartum care delivery for preeclampsia management and thereby reduce racial disparities in obstetric care and outcomes. Here we discuss racial disparities in preeclampsia and the challenge of providing equitable postpartum preeclampsia care. We then describe the utility of novel telemedicine platforms and their application to combat these disparities in preeclampsia care.

Evaluation of Hospital Cesarean Delivery-Related Profits and Rates in the United States

IMPORTANCE

A high cesarean delivery rate in US hospitals indicates the potential overuse of this procedure; however, underlying causes of the excessive use of cesarean procedures in the US have not been fully understood.

OBJECTIVE

To investigate the association between the probability of cesarean delivery at the patient-level and profit per procedure from cesarean deliveries.

DESIGN, SETTING, AND PARTICIPANTS

This observational, cross-sectional study used a nationally representative sample of hospital discharge data from women at low risk for cesarean birth who delivered newborns between 2010 and 2014 in the US. Data were gathered from the Nationwide Readmissions Database from the Healthcare Cost and Utilization Project, compiled by the Agency for Healthcare Research and Quality. Data cleaning and analyses were conducted between August 2019 and May 2020.

EXPOSURES

Hospital-level median value of profits from cesarean deliveries, defined as the difference between the charge and the cost for cesarean delivery calculated for each hospital.

MAIN OUTCOMES AND MEASURES

Our primary outcome was the individual-level probability of undergoing a cesarean delivery. We examined the association with the hospital-level median value of profits per procedure for cesarean delivery (defined as the difference between the charge and the cost for cesarean delivery) using hierarchical regression models adjusted for patient and hospital characteristics and year-fixed effects.

RESULTS

A total of 13 215 853 deliveries were included in our analyses (mean [SE] age, 27.4 [0] years), of which 2 202 632 (16.7%) were cesarean deliveries. After adjusting for potential confounders, pregnant women were more likely to have a cesarean birth when they delivered at hospitals with higher profits per procedure from cesarean deliveries. Women cared for at hospitals with the highest (adjusted odds ratio, 1.08; 95% CI, 1.02-1.14; P = .005) and second-highest profit quartiles (adjusted odds ratio, 1.07; 95% CI, 1.02-1.13; P = .007) had higher probabilities of a cesarean delivery compared with those cared for at hospitals in the lowest profit quartile.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of US nationally representative hospital discharge data, hospitals with higher profits per cesarean procedure were associated with an increased probability of delivering newborns through cesarean birth. These findings highlight the potential influence financial incentives play in determining a high cesarean delivery rate in the US.

A Gap in Care? Postpartum Women Presenting to the Emergency Room and Getting Readmitted

OBJECTIVE

Emergent postpartum hospital encounters in the first 42 days after birth are estimated to complicate 5 to 12% of births. Approximately 2% of these visits result in admission. Data on emergent visits and admissions are critically needed to address the current maternal morbidity crisis. Our objective is to characterize trends in emergent postpartum hospital encounters and readmissions through chief complaints and admission diagnoses over a 4.5-year period.

STUDY DESIGN

All postpartum hospital encounters within 42 days of delivery at our institution from 2015 to 2019 were included. We reviewed demographic information, antepartum, intrapartum, and postpartum care and postpartum hospital encounters. Trends in hospital presentation and admission over the study period were analyzed. Comparisons between women who were admitted to those managed outpatient were performed. Statistical analysis included Chi-square, student's t-test, and Mantel-Haenszel test for trend and ANOVA, as appropriate. A p-value <0.05 considered significant.

RESULTS

Among 8,589 deliveries, 491 (5.7%) presented emergently to the hospital within 42 days of delivery, resulting in 576 hospital encounters. From 2015 to 2019, annual rates of presentation were stable, ranging from 5.0 to 6.4% (p = 0.09). Of the 576 hospital encounters, 224 (38.9%) resulted in an admission with increasing rates from 2.0% in 2015 to 3.4% in 2019 (p = 0.005). Primiparous women with higher body mass index, cesarean delivery, and blood loss ≥1, 000 mL during delivery were significantly more likely to be admitted to the hospital. Women with psychiatric illnesses increasingly utilized the emergency room in the postpartum period (6.7-17.2%, p = 0.03). The most common presenting complaints were fever, abdominal pain, headache, vaginal bleeding, wound concerns, and high blood pressure. Admitting diagnoses were predominantly hypertensive disorder (22.9%), wound complications (12.8%), endometritis (9.6%), headache (6.9%), and delayed postpartum hemorrhage (5.6%).

CONCLUSION

The average proportion of women presenting for an emergent hospital encounter in the immediate 42-day postpartum period is 5.7%. Nearly 40% of emergent hospital encounters resulted in admission and the rate increased from to 2.0 to 3.4% over the study period. The most common reasons for presentation were fever, abdominal pain, headache, vaginal bleeding, wound concerns, and hypertension. Hypertension, wound complications, and endometritis accounted for the top three admission diagnoses.

How often do we identify fetal abnormalities during routine third-trimester ultrasound? A systematic review and meta-analysis

BACKGROUND

Routine third-trimester ultrasound is frequently offered to pregnant women to identify fetuses with abnormal growth. Infrequently, a congenital anomaly is incidentally detected.

OBJECTIVE

To establish the prevalence and type of fetal anomalies detected during routine third-trimester scans using a systematic review and meta-analysis.

SEARCH STRATEGY

Electronic databases (MEDLINE, Embase and the Cochrane library) from inception until August 2019.

SELECTION CRITERIA

Population-based studies (randomised control trials, prospective and retrospective cohorts) reporting abnormalities detected at the routine third-trimester ultrasound performed in unselected populations with prior screening. Case reports, case series, case-control studies and reviews without original data were excluded.

DATA COLLECTION AND ANALYSIS

Prevalence and type of anomalies detected in the third trimester. We calculated pooled prevalence as the number of anomalies per 1000 scans with 95% confidence intervals. Publication bias was assessed.

MAIN RESULTS

The literature search identified 9594 citations: 13 studies were eligible representing 141 717 women; 643 were diagnosed with an unexpected abnormality. The pooled prevalence of a new abnormality diagnosed was 3.68 per 1000 women scanned (95% CI 2.72-4.78). The largest groups of abnormalities were urogenital (55%), central nervous system abnormalities (18%) and cardiac abnormalities (14%).

CONCLUSION

Combining data from 13 studies and over 140 000 women, we show that during routine third-trimester ultrasound, an incidental fetal anomaly will be found in about 1 in 300 scanned women. This information should be taken into account when taking consent from women for third-trimester ultrasound and when designing and assessing cost of third-trimester ultrasound screening programmes.

TWEETABLE ABSTRACT

One in 300 women attending a third-trimester scan will have a finding of a fetal abnormality.

Convertirse en madre durante la adolescencia: transiciones en el rol materno

El artículo pretende dar a conocer la experiencia en el desarrollo de una estrategia de enfermería que promueva el cuidado integral de la madre adolescente, hijo, pareja o acompañante para la activación del rol materno durante el posparto, como parte del programa Creciendo Juntos de la ESE Hospital Regional de Duitama (Boyacá, Colombia). La estrategia de cuidado se diseñó a partir de la aplicación de la teoría “convertirse en madre”, de Ramona Mercer, desde el sistema conceptual teórico-empírico y el modelo del marco lógico, así como desde el apoyo social, desarrollado en cuatro intervenciones: una visita domiciliaria inicial, seguimiento telefónico, grupo de madres y acompañantes en posparto y una segunda visita domiciliaria. De igual forma, los resultados se presentan en indicadores empíricos del desarrollo de la estrategia de cuidado en un grupo de 25 madres, cuyas intervenciones institucionales de salud se orientaron hacia la práctica del cuidado, como parte de la visibilidad asistencial de enfermería en madres adolescentes, y hacia la promoción de la maternidad desde la activación y normalización del rol en el proceso de convertirse en madre.

Chronic hypertension in pregnancy

Chronic hypertension and associated cardiovascular disease are among the leading causes of maternal and perinatal morbidity and death in the United States. Chronic hypertension in pregnancy is associated with a host of adverse outcomes that include preeclampsia, cesarean delivery, cerebrovascular accidents, fetal growth restriction, preterm birth, and maternal and perinatal death. There are several key issues related to the diagnosis and management of chronic hypertension in pregnancy where data are limited and further research is needed. These challenges and recent guidelines for the management of chronic hypertension are reviewed. Well-timed pregnancies are of utmost importance to reduce the risks of chronic hypertension; long-acting reversible contraceptive options are preferred. Research to determine optimal blood pressure thresholds for diagnosis and treatment to optimize short- and long-term maternal and perinatal outcomes should be prioritized along with interventions to reduce extant racial and ethnic disparities.

Postpartum visits in the gynecological emergency room: How can we improve?

Background

The attendance to the gynecological-emergency-room (GER) of women only a few weeks following previous discharge after birth comprises a medical as well as social problem. The objective of the study was to characterize the postpartum women that attended the GER, and depict the leading etiologies and risk-factors that lead them to attend the GER, and to examine correlations between their medical findings at discharge and the reasons for their attendance to the hospital.

Methods

All women that attended the GER between 01/01/2016 and 30/09/2016 during 6 weeks after birth were included. The variables assessed were: medical history, mode of birth, maternal complications of birth, diagnosis at the GER, treatment received and readmission.

Results

There were 446 visits of 413 women (5.6% of all deliveries). Most were generally healthy after their first normal vaginal birth with no complications during or following birth. 38.7% had a cesarean birth (p < 0.001). The most common causes of the visits were fever (30.3%), problems in episiotomy or surgical scar (26.6%) and abdominal pain (25.7%). Women with hypertensive disorders during birth had significantly more hypertensive problems in the GER. Diabetic women suffered statistically more from hypertensive disorder in the GER. 33.2% were examined and found healthy. Seventy-two women (1% of all deliveries) were hospitalized, most of them due to infection. Only 7.5% were referred to the GER due to bleeding.

Conclusions

Postpartum women are at risk of morbidities, especially following cesarean sections and in women with hypertensive disorders of during pregnancy. Scheduled visits to high-risk women to attend outpatient clinic sooner are recommended.

Risk Factors for Maternal Readmission with Sepsis

OBJECTIVE

Our primary objective was to identify risk factors for maternal readmission with sepsis. Our secondary objectives were to (1) assess diagnoses and infecting organisms at readmission and (2) compare early (<6 weeks) and late (6 weeks to 9 months postpartum) maternal readmission with sepsis.

STUDY DESIGN

We identified our cohort using linked hospital discharge data and birth certificates for California deliveries from 2008 to 2011. Consistent with the 2016 sepsis classification, we defined sepsis as septicemia plus acute organ dysfunction. We compared women with early or late readmission with sepsis to women without readmission with sepsis.

RESULTS

Among 1,880,264 women, 494 (0.03%) were readmitted with sepsis, 61% after 6 weeks. Risk factors for readmission with sepsis included preterm birth, hemorrhage, obesity, government-provided insurance, and primary cesarean. For both early and late sepsis readmissions, the most common diagnoses were urinary tract infection and pyelonephritis, and the most frequently identified infecting organism was gram-negative bacteria. Women with early compared with late readmission with sepsis shared similar obstetric characteristics.

CONCLUSION

Maternal risk factors for both early and late readmission with sepsis included demographic characteristics, cesarean, hemorrhage, and preterm birth. Risks for sepsis after delivery persist beyond the traditional postpartum period of 6 weeks.

The relationship between severe maternal morbidity and a risk of postpartum readmission among Korean women: a nationwide population-based cohort study

Background

As the rate of cesarean section delivery has increased, the incidence of severe maternal morbidity continues to increase. Severe maternal morbidity is associated with high medical costs, extended length of hospital stay, and long-term rehabilitation. However, there is no evidence whether severe maternal morbidity affects postpartum readmission. Therefore, this study aimed to determine the relationship between severe maternal morbidity and postpartum readmission.

Methods

This nationwide population-based cohort study used the Korean National Health Insurance Service-National Sample cohort of 90,035 delivery cases between January 2003 and November 2013. The outcome variable was postpartum readmission until 6 weeks after the first date of delivery in the hospital. Another variable of interest was the occurrence of severe maternal morbidity, which was determined using the Center for Disease Control and Prevention’s algorithm. The Cox proportional hazard model was used to assess the association between postpartum readmission and severe maternal morbidity after all covariates were adjusted.

Results

The overall incidence of postpartum readmission was 2041 cases (0.95%) of delivery. Women with severe maternal morbidity had an approximately 2.4 times higher risk of postpartum readmission than those without severe maternal morbidity (hazard ratio 2.36, 95% confidence interval 1.75–3.19). In addition, compared with reference group, women who were aged 20–30 years, nulliparous, and delivered in a tertiary hospital were at high risk of postpartum readmission.

Conclusions

Severe maternal morbidity was related to the risk of postpartum readmission. Policy makers should provide a quality indicator of postpartum maternal health care and improve the quality of intrapartum care.

Rate and causes of severe maternal morbidity at readmission: California births in 2008-2012

OBJECTIVE

To determine the rate, maternal characteristics, timing, and indicators of severe maternal morbidity (SMM) that occurs at postpartum readmission.

STUDY DESIGN

Women with a birth in California during 2008-2012 were included in the analysis. Readmissions up to 42 days after delivery were investigated. SMM was defined as presence of any of the 21 indicators defined by ICD-9 codes.

RESULTS

Among 2,413,943 women with a birth, SMM at readmission occurred in 4229 women. Of all SMM, 12.1% occurred at readmission. Over half (53.5%) of the readmissions with SMM occurred within the first week after delivery hospitalization. The most common indicators of SMM were blood transfusion, sepsis, and pulmonary edema/acute heart failure.

CONCLUSION

Twelve percent of SMM was identified at readmission with the majority occurring within 1 week after discharge from delivery hospitalization. Because early readmission may reflect lack of discharge readiness, there may be opportunities to improve care.

Maternal morbidity: a longitudinal study of women's health during and up to 22 months after pregnancy in Jamaica

Our study evaluated factors associated with ill-health in a population-based longitudinal study of women who delivered a singleton live-born baby in a 3-month period across Jamaica. Socio-demographics, perception of health, chronic illnesses, frequency and reasons for hospital admission were assessed. Relationships between ill-health and maternal characteristics were estimated using log-normal regression analysis. Of 9,742 women interviewed at birth, 1,311 were assessed at four stages, 27.7% of whom reported ill-health at least once. Hospitalization rates were 20.9% during pregnancy, 6.1% up to 12 months and 0.5% up to 22 months after childbirth. Ill-health, reported by 11% of women, was less likely with better education (RR=0.62, 95%; 0.42-0.84). Hospital admission was associated with higher socio-economic status (RR=1.33, 95% 1.04-1.70) and Caesarean section [CS] (RR=1.57, 95%; 1.21-2.04). One in three (33.7%) women reported chronic illnesses, and the likelihood increased with age, parity and delivery by elective CS (RR=1.44, 95%; 1.20-1.73). In multivariable analyses, ill-health was more likely with chronic illness (RR=2.06, 95%; CI: 1.71-2.48) and hospital admission from 12 to 22 months after childbirth (RR=1.54, 95% CI: 1.12-2.12). Ill-health during pregnancy and after childbirth represent a significant burden of disease and requires a standardised comprehensive approach to measuring and addressing this disease burden.

To drain or not to drain: intraperitoneal closed-suction drainage placement during cesarean delivery

INTRODUCTION

Intraperitoneal closed suction drains are occasionally placed during cesarean delivery. This study aims to ascertain the prevalence, associated factors, outcome, and risks of intraperitoneal closed-suction drain placed during cesarean delivery.

MATERIAL AND METHODS

A retrospective cohort study of all women undergoing cesarean delivery in a single center from 2005 to 2015. We excluded cases of cesarean hysterectomy and women who had hollow viscus injury. Cesarean deliveries were categorized into two groups based on intraperitoneal drain use: drain + and drain-.The study aims were to describe: (1) drain use prevalence; (2) factors associated with drain use; (3) interval to relaparotomy due to intraperitoneal bleeding and outcome of drain use; and (4) unique drain-related adverse outcome. Statistics: univariate, multivariable, and inverse probability treatment weighting (IPTW) analysis.

RESULTS

After applying the inclusion and exclusion criteria, 16 581 (99.3%) cesareans were included. An intraperitoneal drain was used in 1264 (7.6%) cesareans, ranging from 4.4 to 18.8% in women with no and four or more cesareans, respectively. Comparing the drain + and drain- groups, multivariable analysis revealed that the factors associated with the use of a drain included (OR, 95%CI) uterine rupture (5.14, 3.15-8.38), intrapartum fever (2.65, 1.87-3.75), previous cesareans (2.29, 2.00-2.68), second-stage cesarean (2.21, 1.64-2.74), preterm delivery (1.89, 1.63-2.19), spontaneous onset of labor (1.42, 1.24-1.63), and maternal age greater than 35 years (1.35, 1.19-1.54); p < .001 for all. Of the forty-four women (0.27%) who underwent relaparotomy for intraperitoneal bleeding, there were fourteen in the intraperitoneal drain group. Inverse probability treatment weighting analysis demonstrated that median (interquartile range) times (hours) to relaparotomy were significantly shorter in the drain + group [3.5 (3.3-10.0) versus 12.5 (7.9-15.6), p < .001] and that puerperal fever incidence was higher in the drain + group (2.2 vs. 1.4%, p < .001). The incidence of relaparotomy to remove a retained drain or drain fragment was 0.48% (6/1264).

CONCLUSIONS

Drain use in our study resulted in a shorter time to relaparotomy for intraperitoneal hemorrhage. However, it was associated with a higher risk for puerperal fever and a 0.5% risk for relaparotomy for removal of the drain.KEY MESSAGEIntraperitoneal drain placed during cesarean is used more often in complicated surgeries and is associated with a shorter interval to relaparotomy.

Relationship Between Depression and/or Anxiety and Hospital Readmission Among Women After Childbirth

OBJECTIVE

To examine the relationship between depression and/or anxiety and any psychiatric diagnosis and readmission after childbirth.

DESIGN

Cross-sectional analysis of administrative data from patient discharge records.

SETTING

Urban academic medical center in the northeastern United States.

PARTICIPANTS

Women admitted for childbirth (N = 17,905).

METHODS

Differences among participants with and without depression and/or anxiety present on admission were compared using t tests and chi-square tests. Risk-adjusted logistic regression models were used to examine the effects of depression and/or anxiety and any psychiatric diagnosis on 7-, 30-, 60-, 90-, and 180-day readmissions after childbirth.

RESULTS

Significant differences were noted between participants with (n = 1,169) and without (n = 16,736) depression and/or anxiety. Participants with these diagnoses had a higher mean age and a longer mean length of stay during hospitalization for childbirth. A greater proportion of these participants were White, were single, had cesarean births, and were discharged with home health services. The presence of depression and/or anxiety was not significantly associated with readmission. The effect of having any psychiatric diagnosis was significantly associated with a greater risk of readmission at 7 (odds ratio [OR] = 1.51, p = .100), 30 (OR = 1.45, p = .030), 60 (OR = 1.45, p = .026), 90 (OR = 1.56, p = .004), and 180 days (OR =1.74, p < .001) following discharge after childbirth.

CONCLUSION

In this sample, women with a psychiatric diagnosis, but not depression and/or anxiety alone, were at increased risk for readmission after childbirth.

Patient and hospital characteristics associated with severe maternal morbidity among postpartum readmissions

OBJECTIVE

To examine the influence of socioeconomic, clinical, and hospital characteristics on the risk of severe maternal morbidity among postpartum readmissions.

STUDY DESIGN

A cross-sectional analysis was conducted using the National Inpatient Sample 2006-2012 to estimate the risk of severe maternal morbidity and identify potential risk factors. Odds ratios were calculated using multivariate logistic regression.

RESULTS

Women aged ≥35 years (ages 35-39: OR 1.12 [CI 1.06, 1.19]; ages 40+: OR 1.27 [CI 1.17, 1.39]), non-Hispanic blacks (OR 1.16 [CI 1.10, 1.22]), and women with pre-existing medical conditions (OR 1.62 [CI 1.56, 1.68]) were at greater risk of severe maternal morbidity during postpartum readmissions. Women hospitalized outside the Northeast region (Midwest: OR 1.20 [CI 1.10, 1.30]; South: OR 1.29 [CI 1.20, 1.38]; West: OR 1.33 [CI 1.22, 1.44]) were also at increased risk.

CONCLUSION

The risk of severe maternal morbidity is heightened beyond delivery hospitalization for a subset of high-risk women.

Hypertensive disorders of pregnancy and postpartum readmission in the United States: national surveillance of the revolving door

OBJECTIVES

Hypertensive disorders of pregnancy (HDP) represent the most common cause of maternal-fetal morbidity and mortality. Yet, the prevalence and cost of postpartum (42-day) readmission (PPR) among HDP-complicated pregnancies in the United States remains unknown. This study provides national prevalence and cost estimates of HDP, and examine factors associated with potentially preventable PPR following HDP-complicated pregnancies.

METHOD

The 2013 and 2014 Nationwide Readmissions Databases were used to investigate HDP and PPR among delivery hospitalizations to women aged 15-49 years. PPR rates, length of stay, and costs were stratified by four HDP subtypes based on timing and severity of their condition. Survey logistic regression was employed to generate adjusted odds ratios for the association between HDP and PPR.

RESULT

In 2013 and 2014, there were 6.3 million delivery hospitalizations; 666 506 (10.6%) were complicated by HDP. Annually, HDP was responsible for higher rates of potentially preventable PPR. Among HDP-complicated pregnancies, the 42-day all-cause PPR rate ranged from 2.5% (gestational hypertension) to 4.6% (superimposed preeclampsia/eclampsia). Compared with normotensive pregnancies, HDP resulted in an excess 404 800 hospital days and inpatient care costs of $731 million. Even after controlling for patient-level and hospital-level confounders, all hypertensive subgroups continued to have at least two-fold, statistically significant, increased odds of potentially preventable PPR.

CONCLUSION

HDP is associated with increased risk of PPR and substantial medical costs. Preventive efforts should be made to identify women at increased risk of PPR during hospitalization so that transition care intervention can be initiated.

Standardized outcome measures for pregnancy and childbirth, an ICHOM proposal

BACKGROUND

Value-based health care aims to optimize the balance of patient outcomes and health care costs. To improve value in perinatal care using this strategy, standard outcomes must first be defined. The objective of this work was to define a minimum, internationally appropriate set of outcome measures for evaluating and improving perinatal care with a focus on outcomes that matter to women and their families.

METHODS

An interdisciplinary and international Working Group was assembled. Existing literature and current measurement initiatives were reviewed. Serial guided discussions and validation surveys provided consumer input. A series of nine teleconferences, incorporating a modified Delphi process, were held to reach consensus on the proposed Standard Set.

RESULTS

The Working Group selected 24 outcome measures to evaluate care during pregnancy and up to 6 months postpartum. These include clinical outcomes such as maternal and neonatal mortality and morbidity, stillbirth, preterm birth, birth injury and patient-reported outcome measures (PROMs) that assess health-related quality of life (HRQoL), mental health, mother-infant bonding, confidence and success with breastfeeding, incontinence, and satisfaction with care and birth experience. To support analysis of these outcome measures, pertinent baseline characteristics and risk factor metrics were also defined.

CONCLUSIONS

We propose a set of outcome measures for evaluating the care that women and infants receive during pregnancy and the postpartum period. While validation and refinement via pilot implementation projects are needed, we view this as an important initial step towards value-based improvements in care.

Comparison of readmission rates between groups with early versus late discharge after vaginal or cesarean delivery: a retrospective analyzes of 14,460 cases

AIM

The aim of this retrospective analysis was to show the readmission rate of cases with and without early discharge following vaginal or cesarean delivery.

METHODS

After exclusion of cases with pregnancy, delivery and neonatal complications, a total of 14,460 cases who delivered at Zeynep Kamil Women and Children's Health Training and Research Hospital were retrospectively screened from hospital database. Subjects were divided into two groups as Group 1: early discharge (n = 6802) and Group 2: late discharge (n = 7658). Groups were compared in terms of readmission rates and indications for readmission.

RESULTS

There were 6802 cases with early discharge whereas the remaining women were discharged after 24 h for vaginal delivery and 48 h following cesarean delivery on regular bases. Among cases with early discharge, 205 (3%) cases readmitted to emergency service with variable indications, while there were 216 (2.8%) readmitted women who were discharged on regular bases. Most common indication for readmission was wound infection in both groups. Neonatal sex distributions were similar between groups (p > .05), where as there was a higher rate of cesarean deliveries in Group 2 (p < .05). Furthermore, cesarean rate was significantly higher in readmitted women with early discharge (p < .05).

CONCLUSION

Similar readmission rates were observed in groups with early and late discharges following vaginal or cesarean delivery without any mortality or permanent morbidity and cost analyses revealed 68 Turkish liras lower cost with early discharge.

The relationship between the rising cesarean delivery and postpartum readmission rates

OBJECTIVE

This study seeks to determine if the increasing rate of postpartum readmissions is related to the increasing rate of cesarean delivery.

STUDY DESIGN

Readmitted patients were identified in the State Inpatient Databases of California, Florida and New York from 2004 to 2011. Relevant maternal comorbidities, pregnancy complications and intrapartum events were collected using ICD-9 diagnosis and procedure codes. The effects of cesarean delivery were first examined via univariate logistic regression to calculate the odds of readmission by year for patients who had delivered via cesarean section. Then, we used multivariate logistic regression models to isolate the effect of mode of delivery on the odds of readmission by adjusting for the effects of patient demographics, hospital characteristics and maternal comorbidities.

RESULTS

Nearly one million deliveries were identified each year, and ~600 000 deliveries per year met inclusion criteria. During this time, the readmission rate increased from 1.72 to 2.16%, and the cesarean delivery rate increased from 30.4 to 33.9%. The odds of readmission for patients delivered via cesarean section decreased yearly, from 1.343 (95% CI: 1.295 to 1.392) in 2004 to 1.046 (95% CI: 1.012 to 1.108) in 2011. In a multivariate model, the odds based on year were 1.032 (95% CI: 1.030 to 1.035), demonstrating an increased odds of readmission over time. When cesarean delivery was added to the model, this odds estimate did not change (OR: 1.031, 95% CI: 1.028 to 1.035), suggesting it did not account for the increased odds of readmission over time, even though cesarean delivery rates increased. However, when maternal comorbidities were added to the model, the odds ratio for year became insignificant (OR: 1.001, 95% CI: 0.998 to 1.005), suggesting that they accounted for the increasing rate of readmissions.

CONCLUSIONS

The increasing cesarean delivery rate does not explain the increasing rate of postpartum readmissions. Rather, the increasing postpartum readmission rate appears to be related to maternal comorbidities.

Knowledge of blood loss at delivery among postpartum patients

Background

Postpartum hemorrhage (PPH) is a leading cause of obstetric morbidity. There is limited understanding of patients’ knowledge about blood loss at delivery, PPH, and PPH-related morbidities, including transfusion and anemia.

Methods

We surveyed 100 healthy postpartum patients who underwent vaginal or cesarean delivery about blood loss, and whether they received information about transfusion and peripartum hemoglobin (Hb) testing. Responses were compared between women undergoing vaginal delivery vs. cesarean delivery; P < 0.05 considered as statistically significant.

Results

In our cohort, 49 women underwent vaginal delivery and 51 women underwent cesarean delivery. Only 29 (29%) of women provided blood loss estimates for their delivery. Women who underwent cesarean delivery were more likely to receive clear information about transfusion therapy than those undergoing vaginal delivery (43.1% vs. 20.4% respectively; P = 0.04). Women who underwent vaginal delivery were more likely to receive results of postpartum Hb tests compared to those undergoing cesarean delivery (49% vs. 29.4%; P = 0.02).

Conclusion

Our findings suggest that women are poorly informed about the magnitude of blood loss at delivery. Hematologic information given to patients varies according to mode of delivery. Further research is needed to better understand the clinical implications of patients’ knowledge gaps about PPH, transfusion and postpartum anemia.

A multi-state analysis of postpartum readmissions in the United States

BACKGROUND

Readmission rates are used as a quality metric in medical and surgical specialties; however, little is known about obstetrics readmissions.

OBJECTIVE

Our goals for this study were to describe the trends in postpartum readmissions over time; to characterize the common indications and associated diagnoses for readmissions; and to determine maternal, delivery, and hospital characteristics that may be associated with readmission.

STUDY DESIGN

Postpartum readmissions occurring within the first 6 weeks after delivery in California, Florida, and New York were identified between 2004 and 2011 in State Inpatient Databases. Of the 5,949,739 eligible deliveries identified, 114,748 women were readmitted over the 8-year period. We calculated the rates of readmissions and their indications by state and over time. The characteristics of the readmission stay, including day readmitted, length of readmission, and charge for readmission, were compared among the diagnoses. Odds ratios were calculated using a multivariate logistic regression to determine the predictors of readmission.

RESULTS

The readmission rate increased from 1.72% in 2004 to 2.16% in 2011. Readmitted patients were more likely to be publicly insured (54.3% vs 42.0%, P < .001), to be black (18.7% vs 13.5%, P < .001), to have comorbidities such as hypertension (15.3% vs 2.4%, P < 0.001) and diabetes (13.1% vs 6.8%, P < .001), and to have had a cesarean delivery (37.2% vs 32.9%, P < .001). The most common indications for readmission were infection (15.5%), hypertension (9.3%), and psychiatric illness (7.7%). Patients were readmitted, on average, 7 days after discharge, but readmission day varied by diagnosis: day 3 for hypertension, day 5 for infection, and day 9 for psychiatric disease. Maternal comorbidities were the strongest predictors of postpartum readmissions: psychiatric disease, substance use, seizure disorder, hypertension, and tobacco use.

CONCLUSION

Postpartum readmission rates have risen over the last 8 years. Understanding the risk factors, etiologies, and cause-specific timing for postpartum readmissions may aid in the development of new quality metrics in obstetrics and targeted strategies to curb the rising rate of postpartum readmissions in the United States.

Impact of surgeon annual volume on short-term maternal outcome in cesarean delivery

BACKGROUND

The annual procedure volume is an accepted marker for quality of care and has been documented in various medical fields. Surgeon volume has been shown to correlate with morbidity and mortality rates in surgical and high-risk medical procedures. Although cesarean delivery is 1 of the most common surgical procedures in the United States, the link between a surgeon's annual cesarean delivery volume and maternal outcome has never been tested.

OBJECTIVE

The purpose of this study was to evaluate the impact of a surgeon's annual volume on short-term maternal outcome in cesarean deliveries.

STUDY DESIGN

We performed a retrospective cohort study in a single tertiary center between 2006 and 2013. Cesarean deliveries were categorized into 2 groups based on the annual volume of cesarean delivery of the attending obstetrician. The "low" group included obstetricians with a low annual volume, whose annual volume of cesarean delivery was lower than median. The "high" group comprised obstetricians with a high annual volume whose annual volume was at median and above. Further analyses were done for quartiles and for 4 clinical relevant groups according to the annual number of cesarean deliveries that were performed/supervised by the attending obstetrician (≤20, 21-60, 61-120, and >120). The primary outcome was a composite adverse maternal outcome that included ≥1 of the following outcomes: urinary or gastrointestinal tract injuries, hemoglobin drop >3 g/dL, blood transfusion, relaparotomy, puerperal fever, prolonged maternal hospitalization, and readmission. Secondary outcomes were operative times (skin incision to delivery and overall).

RESULTS

A total of 11,954 cesarean deliveries were included; the median annual number of cesarean deliveries that were performed/supervised by 1 obstetrician was 48. Unadjusted analysis suggested that the patients in the high group had fewer urinary and gastrointestinal injuries (18/9278 [0.2%] vs 16/2676 [0.6%] injuries; P < .001), less blood loss as measured by hemoglobin drop >3 g/dL (1053/9278 [11.5%] vs 366/2676 [13.8%]; P < .001), and fewer cases of prolonged maternal hospitalization (80/9278 [0.9%] vs 39/2676 [1.5%]; P = .006). The rate of blood transfusion, relaparotomy, puerperal febrile morbidity, and readmission to hospital did not differ between groups. Multivariable regression analysis showed that cesarean delivery performed/supervised by the high group resulted in a significantly lower composite adverse maternal outcome (15.8% vs 18.9%; odds ratio, 0.86; 95% confidence interval, 0.78-0.95; P = .004). This was related primarily to a decreased frequency of urinary and gastrointestinal injuries, lower likelihood of hemoglobin drop >3 g/dL, and lower incidence of prolonged maternal hospitalization. Operative times were significantly shorter for the high group. Composite adverse maternal outcome ranged from 21.8% in the lowest quartile to 17.9% in quartile 2, to 17.4% in quartile 3, and 15.6% in quartile 4. quartile 4 served as the reference; quartile 3 had an odds ratio of 1.14 (95% confidence interval, 1.01-1.29; P = .029); quartile 2 had an odds ratio of 1.18 (95% confidence interval, 1.02-1.36; P = .021, and quartile 1 had an odds ratio of 1.51 (95% confidence interval, 1.14-1.99; P = .004) for composite adverse maternal outcome. Composite adverse maternal outcome ranged from 21.5% in clinical group 1 to 17.5% in clinical group 2, to 17.9% in clinical group 3, and 15.2% in clinical group 4 (P = .001). Cesarean delivery performed/supervised by clinical groups 2, 3, and 4 in comparison with clinical group 1 were associated with a statistically significant risk reduction, (23%, 25%, and 34% respectively).

CONCLUSION

Maternal composite morbidity is decreased as the volume of cesarean deliveries that are performed or supervised by obstetricians increases.

Appendicitis in Postpartum Period: A Diagnostic Challenge

Infections that occur in the postpartum period are assumed to be related to pregnancy or delivery; however other causes should also be considered. Appendicitis is one of the most common conditions requiring laparotomy during pregnancy, but very few cases of postpartum appendicitis have been reported. We report two such cases and the challenges faced by clinicians in diagnosis of immediate postpartum appendicitis. The first case was managed on lines of puerperal sepsis and the second one as enteric fever. Appendicular pathology was detected incidentally on laparotomy. In postpartum patients with no obvious focus of sepsis, appendicitis should be kept in mind. A team approach involving sensitized obstetricians and surgeons is likely to reduce serious morbidities.

Respiratory disease in pregnancy

Many physiological and anatomical changes of pregnancy affect the respiratory system. These changes often affect the presentation and management of the various respiratory illnesses in pregnancy. This article focuses on several important respiratory issues in pregnancy. The management of asthma, one of the most common chronic illnesses in pregnancy, remains largely unchanged compared to the nonpregnant state. Infectious respiratory illness, including pneumonia and tuberculosis, are similarly managed in pregnancy with antibiotics, although special attention may be needed for antibiotic choices with more pregnancy safety data. When mechanical ventilation is necessary, consideration should be given to the maternal hemodynamics of pregnancy and fetal oxygenation. Maintaining maternal oxygen saturation above 95% is recommended to sustain optimal fetal oxygenation. Cigarette smoking has known risks in pregnancy, and current practice guidelines recommend offering cognitive and pharmacologic interventions to pregnant women to assist in smoking cessation.

Puerperal infections of the genital tract: a clinical review

Puerperal genital tract infections, although less common in the 21st century, continue to affect maternal mortality and morbidity rates in the United States. Puerperal genital tract infections include endometritis as well as abdominal and perineal wound infections. These infections interrupt postpartum restoration, increase the potential for readmission to a health care facility, and can interfere with maternal-infant bonding. In addition, unrecognized or improperly treated genital tract infection could extend to other sites via venous circulation or the lymphatic system and increase the risk of severe complications or sepsis. Midwives are leaders in education, low rates of intervention, and prompt recognition of deviation from normal. Because puerperal genital tract infection usually begins after discharge, detailed education for women will encourage preventative health care, prompt recognition, and treatment.