Late Pregnancy and Postpartum Emergencies

Randomized control trial of postpartum visits at 2 and 6 weeks

BACKGROUND

The postpartum period is critical, and women are at highest risk of perinatal complications; however, patient attendance at postpartum clinic visits is low.

OBJECTIVE

This study aimed to determine whether decreasing the time to an initial postpartum visit from 6 weeks to 2 weeks can increase the attendance rates of patients in routine postpartum visits.

STUDY DESIGN

We conducted a parallel, randomized, nonblinded trial at a publicly insured clinic comparing a single 6-week postpartum visit (control) with 2 visits at 2 and 6 weeks after delivery (intervention). The primary outcome was attendance at 1 or more routine postpartum visits. Secondary outcomes were emergency department visits within 30 days after delivery and nonroutine clinic visits. Multivariable regression was performed to identify predictors of clinic nonattendance. To demonstrate a significant increase from the baseline clinic attendance rate of 70% to 85%, 250 participants were needed.

RESULTS

Between November 2018 and March 2020, 250 patients were randomized and analyzed. The patient population had multiple comorbidities, notably obesity (53%), diabetes mellitus (30%), mental health disorders (22%), and hypertensive disorders (21%). The attendance at 1 or more postpartum visits was not significantly different among the control and intervention arms (58% vs 70%; P=.065). The 2-week visit had an attendance rate of 41% (51 of 125), and the 6-week visit had an attendance rate of 60% (151 of 250). After adjusting for confounders, significant predictors of postpartum visit nonattendance included younger age, multiparity, and being a patient from the high-risk obstetrical clinic. The rate of emergency department visits was similar between the control and intervention arms (8% vs 6%; P=.635). However, more patients in the control arm come to the clinic for nonroutine visits (30% vs 16%; P=.010). In response to a patient satisfaction survey on the optimal timing of the postpartum visit, most respondents (59%) would have preferred both the 2- and 6-week visits.

CONCLUSION

The addition of a 2-week postpartum visit to the 6-week postpartum visit did not increase the likelihood of attendance of patients in a routine visit but did decrease the number of urgent clinic visits.

Emergency department use among postpartum women with mental health disorders

Background

Mental health disorders are becoming more recognized in pregnancy. Whether mental health disorders are associated with health services utilization after child birth is not completely understood.

Objective

This study aimed to investigate postpartum emergency department use within 30 days of delivery among women with preexisting mental health disorders during pregnancy.

Study Design

This was a retrospective cohort study evaluating emergency department use among postpartum women with or without mental health disorders who delivered at an academic center between January 2014 and June 2018. Demographic and outcome data were medical record abstracted and analyzed. Multivariate regression was performed to adjust for covariates.

Results

During the study period, 13,605 women delivered at the institution, 2355 of whom (17.3%) had an underlying mental health disorder. The primary diagnoses of mental health disorder were anxiety (48.8%), depression (34.8%), substance use disorder (11.4%), bipolar disorder (3.4%), psychosis (0.7%), and other (0.8%). There were a total of 565 emergency department visits within 30 days of delivery. Women who presented to the emergency department after delivery were more likely to have public insurance, identify as black or Asian, and have an underlying mental health disorder. Among women with mental health disorders, 155 (6.6%) used the emergency department within 30 days of their delivery compared with 410 (3.6%) of patients without mental health disorder (adjusted odds ratio, 1.74; 95% confidence interval, 1.42–2.13; P<.001). When assessing the risk of emergency department usage per the type of mental health disorder, anxiety (adjusted odds ratio, 1.73; 95% confidence interval, 1.31–2.27) and depression (adjusted odds ratio, 2.13; 95% confidence interval, 1.59–2.86) carried the highest risk. Compared with women without mental health disorders, women with underlying mental health disorders had more presentations for hypertension (15.5% vs 11.2%) and psychiatric evaluations (4.5% vs 0.2%; both P<.001).

Conclusion

Women with mental health disorders use the emergency department during the postpartum period for psychiatric and obstetrical reasons more frequently than women without mental health disorders. Increased surveillance, treatment, and follow-up during pregnancy and the early postpartum period may be warranted for this high-risk population.