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Savelli Binsted AC, Saade G, Kawakita T. External validation and comparison of four prediction scores for severe maternal morbidity. Am J Obstet Gynecol MFM 2024; 6:101471. [PMID: 39179157 DOI: 10.1016/j.ajogmf.2024.101471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 08/05/2024] [Accepted: 08/13/2024] [Indexed: 08/26/2024]
Abstract
BACKGROUND Severe maternal morbidity (SMM) is increasing in the United States. Several tools and scores exist to stratify an individual's risk of SMM. OBJECTIVE We sought to examine and compare the validity of four scoring systems for predicting SMM. STUDY DESIGN This was a retrospective cohort study of all individuals in the Consortium on Safe Labor dataset, which was conducted from 2002 to 2008. Individuals were excluded if they had missing information on risk factors. SMM was defined based on the Centers for Disease Control and Prevention excluding blood transfusion. Blood transfusion was excluded due to concerns regarding the specificity of International Classification of Diseases codes for this indicator and its variable clinical significance. Risk scores were calculated for each participant using the Assessment of Perinatal Excellence (APEX), California Maternal Quality Care Collaborative (CMQCC), Obstetric Comorbidity Index (OB-CMI), and modified OB-CMI. We calculated the probability of SMM according to the risk scores. The discriminative performance of the prediction score was examined by the areas under receiver operating characteristic curves and their 95% confidence intervals (95% CI). The area under the curve for each score was compared using the bootstrap resampling. Calibration plots were developed for each score to examine the goodness-of-fit. The concordance probability method was used to define an optimal cutoff point for the best-performing score. RESULTS Of 153, 463 individuals, 1115 (0.7%) had SMM. The CMQCC scoring system had a significantly higher area under the curve (95% CI) (0.78 [0.77-0.80]) compared to the APEX scoring system, OB-CMI, and modified OB-CMI scoring systems (0.75 [0.73-0.76], 0.67 [0.65-0.68], 0.66 [0.70-0.73]; P<.001). Calibration plots showed excellent concordance between the predicted and actual SMM for the APEX scoring system and OB-CMI (both Hosmer-Lemeshow test P values=1.00, suggesting goodness-of-fit). CONCLUSION This study validated four risk-scoring systems to predict SMM. Both CMQCC and APEX scoring systems had good discrimination to predict SMM. The APEX score and the OB-CMI had goodness-of-fit. At ideal calculated cut-off points, the APEX score had the highest sensitivity of the four scores at 71%, indicating that better scoring systems are still needed for predicting SMM.
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Affiliation(s)
| | - George Saade
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA
| | - Tetsuya Kawakita
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA
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Diaz-Rodriguez G, Braverman A, Elam GG, Norris-Stojak D, Harmon K, Hartwig J, Dunlap T, Nixon H, Rasamimari P, Buhimschi IA, Buhimschi CS. Is Faster Better? Relationships of Cesarean Acuity with Risk of Low Apgar Scores and Fetal Acidemia. Am J Perinatol 2024; 41:e1925-e1934. [PMID: 37156530 DOI: 10.1055/a-2088-5393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Timely response to obstetrical emergencies is highly desired. The recommendation for decision-to-incision (DTI) time in cesarean delivery (CD) of not more than 30 minutes was issued to prevent neonatal hypoxic-ischemic morbidities. We analyzed the efficiency with which an institutional-specific CD acuity classification system (emergent case: target DTI ≤ 15 minutes; urgent case: target DTI ≤ 30 minutes) reflected in the actual DTI time, Apgar scores, and newborn acid-base status. STUDY DESIGN Data on all 610 cesarean sections (CSs) performed over a 14-month period at a tertiary medical center were retrospectively extracted. Cases grouped by target DTI time categories were compared for proportions in low Agar scores and fetal acidosis. Multivariable regression was used to identify clinical variables associated with the need for neonatal resuscitation. RESULTS During the study period, 60 (10%) of CSs were emergent, 296 (49%) urgent, and 254 (41%) elective. The target DTI ≤ 15 minutes was achieved in 68% of emergent CSs with 93% having a DTI ≤ 30 minutes. Among urgent surgeries, the target DTI ≤ 30 minutes was reached in 48% of cases with 83% having DTI ≤ 45 minutes. Compared with both urgent and scheduled procedures the incidence of newborn acidosis and Apgar scores ≤4 and ≤7 was the highest among emergent CSs. The proportion of moderate and severe acidosis for deliveries with DTI ≤ 15 minutes was significantly higher compared with procedures with DTI 16 to 30 and >30 minutes. The need for neonatal resuscitation, including intubation, was independently associated with fetal acidosis, low gestational age, surgery acuity level, general anesthesia, but not with the actual DTI time. CONCLUSION Adherence to tight DTI time targets is pragmatically difficult. The need for neonatal resuscitation varies with the acuity of the procedure but not with the actual DTI interval, implying that within certain time limits, the indication for surgery plays a greater role in the status of the newborn than the speed of the CS. KEY POINTS · Adherence to prespecified DTI times for cesarean is pragmatically difficult.. · Emergent CS had the highest proportion of newborns with acidosis and low Apgar scores despite shorter DTI.. · The need for neonatal resuscitation associated with fetal acidemia, prematurity and general anesthesia..
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Affiliation(s)
- Gian Diaz-Rodriguez
- Department of Obstetrics Gynecology, University of Illinois at Chicago College of Medicine, Chicago, Illinois
- University of Illinois Hospital and Health Sciences (UI Health), Chicago, Illinois
| | - Alexis Braverman
- Department of Obstetrics Gynecology, University of Illinois at Chicago College of Medicine, Chicago, Illinois
- University of Illinois Hospital and Health Sciences (UI Health), Chicago, Illinois
| | - Gloria G Elam
- Department of Obstetrics Gynecology, University of Illinois at Chicago College of Medicine, Chicago, Illinois
- University of Illinois Hospital and Health Sciences (UI Health), Chicago, Illinois
| | - Doreen Norris-Stojak
- University of Illinois Hospital and Health Sciences (UI Health), Chicago, Illinois
| | - Kathleen Harmon
- Department of Obstetrics Gynecology, University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Julie Hartwig
- Department of Obstetrics Gynecology, University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Tiana Dunlap
- University of Illinois Hospital and Health Sciences (UI Health), Chicago, Illinois
| | - Heather Nixon
- Department of Anesthesiology, University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Phornphat Rasamimari
- Department of Pediatrics, University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Irina A Buhimschi
- Department of Obstetrics Gynecology, University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Catalin S Buhimschi
- Department of Obstetrics Gynecology, University of Illinois at Chicago College of Medicine, Chicago, Illinois
- University of Illinois Hospital and Health Sciences (UI Health), Chicago, Illinois
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MacDonald EJ, Lawton B, Storey F, Stevenson K, Tait JD, Stone P. Severe maternal morbidity - we need more action to prevent harm. Aust N Z J Obstet Gynaecol 2024; 64:85-87. [PMID: 38549222 DOI: 10.1111/ajo.13813] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 03/14/2024] [Indexed: 04/18/2024]
Affiliation(s)
- Evelyn Jane MacDonald
- National Centre for Women's Health Research Aotearoa, Victoria University of Wellington, Wellington, New Zealand
| | - Beverley Lawton
- National Centre for Women's Health Research Aotearoa, Victoria University of Wellington, Wellington, New Zealand
| | - Francesca Storey
- National Centre for Women's Health Research Aotearoa, Victoria University of Wellington, Wellington, New Zealand
| | - Kendall Stevenson
- National Centre for Women's Health Research Aotearoa, Victoria University of Wellington, Wellington, New Zealand
| | - John David Tait
- Women's Health Department, Wellington Hospital, Wellington, New Zealand
| | - Peter Stone
- Department of Obstetrics and Gynaecology, Auckland University, Auckland, New Zealand
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Garland CE, Geller SE, Koch AR. Adverse Delivery and Neonatal Outcomes Among Women with Severe Maternal Morbidity in Illinois, 2018-2019. J Womens Health (Larchmt) 2024; 33:163-170. [PMID: 37972060 DOI: 10.1089/jwh.2023.0248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023] Open
Abstract
Objective: To examine adverse delivery outcomes from 2018 to 2019 severe maternal morbidity (SMM) cases that were reviewed by facility-level review committees in Illinois (n = 666) and describe the burden of adverse delivery outcomes among demographic subgroups, SMM etiology, and whether the SMM event was potentially preventable. Materials and Methods: This is a descriptive analysis of the SMM review cohort. Consistent with expert recommendations to identify SMM for hospital quality review, SMM was defined as any intensive care or critical care unit admission and/or transfusion of four or more units of packed red blood cells from conception to 42 days postpartum. Adverse delivery outcomes were fetal death, low birthweight, preterm birth, neonatal intensive care unit admission, and 5-minute Apgar score <7. Chi square and Fisher's exact tests compared maternal demographic and delivery characteristics between the SMM sample and 2018-2019 deliveries in Illinois. Logistic regression modeled the associations between primary cause of morbidity, maternal race/ethnicity, adverse delivery outcomes, and opportunities to alter the outcome to assess whether the burden of adverse birth outcomes was distributed evenly across subcategories of the cohort. Results: Overall, 53.9% of women with SMM had at least one adverse delivery outcome. SMM events owing to preeclampsia/eclampsia (adjusted odds ratio [aOR] = 4.41, 95% confidence interval [CI] = 2.37-8.24) and infection/sepsis (aOR = 4.40, 95% CI = 1.79-11.04) were more likely to be accompanied by adverse delivery outcomes compared with hemorrhage-related SMM. Non-Hispanic Black women with SMM were more likely to have an adverse delivery outcome compared with non-Hispanic White women with SMM (aOR = 1.74, 95% CI = 1.01-3.02). Conclusion: A greater proportion of the SMM review cohort experienced adverse delivery outcomes compared with the overall birthing population in the state. Non-Hispanic Black women with SMM were almost twice as likely to have an adverse delivery outcome compared with non-Hispanic White women.
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Affiliation(s)
- Caitlin E Garland
- Center for Research on Women and Gender, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | - Stacie E Geller
- Center for Research on Women and Gender, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
- Departments of Obstetrics and Gynecology and Medicine, Chicago College of Medicine, University of Illinois, Chicago, Illinois, USA
| | - Abigail R Koch
- Center for Research on Women and Gender, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
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Munoz JL, Ramsey PS, Byrne JJ. Risk of Severe Maternal Morbidity in Patients with Placenta Accreta Spectrum Disorders Referred from Rural Communities to a Regional Placenta Accreta Spectrum Center. Am J Perinatol 2023; 40:1738-1744. [PMID: 37433315 DOI: 10.1055/a-2126-7337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
OBJECTIVE The primary objective of this study was to assess the risk of severe maternal morbidity (SMM) experienced by patients residing in rural communities when delivered by a multidisciplinary team within a single urban academic center for placenta accreta spectrum (PAS). Subsequently, we aimed to determine a distance-dependent relationship between PAS morbidity and distance travelled by patients in rural communities. STUDY DESIGN This was a retrospective cohort study of patients who had PAS histopathological confirmation and delivery at our institution from 2005 to 2022. Our objective was to determine the relationship between patient locations (rural vs. urban) and maternal morbidity associated with PAS delivery. Sociogeographic determination of rurality was determined using the National Center for Health Statistics and most recent national census population data. Distance travelled was calculated by patient zip code to our PAS center using global positioning system data. RESULTS During the study period, 139 patients were managed by cesarean hysterectomy with confirmed PAS histopathology. Of these, 94 (67.6%) were from our urban community and 45 (32.4%) were from surrounding rural communities. The overall SMM incidence was 85% including blood transfusion and 17% without blood transfusions. Patient from rural communities were more likely to experience SMM (28.9 vs. 12.8%, p = 0.03) and this was driven by acute renal failure (1.1 vs. 11.1%, p = 0.01) and disseminated intravascular coagulopathy (1.1 vs. 8.8%, p = 0.04). SMM did reveal a distance-dependent relationship with SMM rates of 13.2, 33.3, and 43.8% at 50, 100, and 150 miles, respectively (p = 0.005). CONCLUSION Patients with PAS experience high rates of SMM. Geographic distance to a PAS center appears to significantly impact the overall morbidity a patient experiences. Further research is warranted to address this disparity and optimize patient outcomes for patients in rural communities KEY POINTS: · Patients from rural communities experience greater SMM in the setting of PAS.. · Intraoperative outcomes and interventions were similar, regardless of patient location.. · SMM may be related to the distance travelled by patients in rural communities..
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Affiliation(s)
- Jessian L Munoz
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Balor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Patrick S Ramsey
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Texas Health Sciences Center at San Antonio and University Health System, San Antonio, Texas
| | - John J Byrne
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Texas Health Sciences Center at San Antonio and University Health System, San Antonio, Texas
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Docheva N, Woelkers D, Yao W, Jin Y, Espinoza J, Kunz L, Amegashie C, Gencay M, Harris J, Rana S. Racial differences in healthcare utilization among patients with suspected or diagnosed preeclampsia: A retrospective cohort study. Pregnancy Hypertens 2023; 33:8-16. [PMID: 37245376 DOI: 10.1016/j.preghy.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 03/21/2023] [Accepted: 05/16/2023] [Indexed: 05/30/2023]
Abstract
OBJECTIVES To analyze healthcare resource utilization and severe maternal morbidity (SMM) in Black and White patients with preeclampsia diagnosis versus signs/symptoms. STUDY DESIGN This was a retrospective cohort study analyzing data from the IBM® Explorys Database between 7/31/2012-12/31/2020. Demographic, clinical, and laboratory data were extracted. Healthcare utilization and SMM were analyzed during the antepartum period (20 weeks of gestation until delivery) among Black and White patients with signs/symptoms of preeclampsia, with a diagnosis of preeclampsia, or neither (control). MAIN OUTCOME MEASURES Healthcare utilization and SMM in those with a preeclampsia diagnosis or signs/symptoms of preeclampsia only were compared with a control group (White patients with no preeclampsia diagnosis or signs/symptoms). RESULTS Data from 38,190 Black and 248,568 White patients were analyzed. Patients with preeclampsia diagnosis or signs/symptoms were more likely to visit the emergency room compared to those without diagnosis or signs/symptoms. Black patients with signs/symptoms of preeclampsia had the highest elevated risk (odds ratio [OR] = 3.4), followed by Black patients with a preeclampsia diagnosis (OR = 3.2), White patients with signs/symptoms (OR = 2.2), and White patients with a preeclampsia diagnosis (OR = 1.8). More Black patients experienced SMM (SMM rate 6.1% [Black with preeclampsia diagnosis] and 2.6% [Black with signs/symptoms]) than White patients (5.0% [White with preeclampsia diagnosis] and 2.0% [White with signs/symptoms]). SMM rates were higher for Black preeclampsia patients with severe features than for White preeclampsia patients with severe features (8.9% vs 7.3%). CONCLUSIONS Compared with White patients, Black patients had higher rates of antepartum emergency care and antepartum SMM.
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Affiliation(s)
- N Docheva
- Department of Obstetrics and Gynecology/Division of Maternal Fetal Medicine, University of Chicago, Chicago, IL, USA
| | - D Woelkers
- Department of Reproductive Medicine, University of California, San Diego, CA, USA
| | - W Yao
- Roche Diagnostics, Indianapolis, IN, USA
| | - Y Jin
- Roche Diagnostics, Indianapolis, IN, USA
| | - J Espinoza
- The Fetal Center at Children's Memorial Hermann Hospital and McGovern Medical School at the University of Texas, Houston, TX, USA
| | - L Kunz
- Roche Diagnostics, Indianapolis, IN, USA
| | - C Amegashie
- Department of Obstetrics and Gynecology/Division of Maternal Fetal Medicine, University of Chicago, Chicago, IL, USA
| | - M Gencay
- Roche Diagnostics, Indianapolis, IN, USA
| | - J Harris
- Roche Diagnostics, Indianapolis, IN, USA
| | - S Rana
- Department of Obstetrics and Gynecology/Division of Maternal Fetal Medicine, University of Chicago, Chicago, IL, USA.
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Meadows AR, Cabral H, Liu CL, Cui X, Amutah-Onukagha N, Diop H, Declercq ER. Preconception and perinatal hospitalizations as indicators of risk for severe maternal morbidity in primiparas. Am J Obstet Gynecol MFM 2023; 5:101014. [PMID: 37178717 PMCID: PMC10367434 DOI: 10.1016/j.ajogmf.2023.101014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 05/08/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Severe maternal morbidity includes unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman's health. A statewide longitudinally linked database was used to examine hospitalization during and before pregnancy for birthing people with severe maternal morbidity at delivery. OBJECTIVE This study aimed to examine the association between hospital visits during pregnancy and 1 to 5 years before pregnancy and severe maternal morbidity at delivery. STUDY DESIGN This study was a retrospective, population-based cohort analysis of the Massachusetts Pregnancy to Early Life Longitudinal database between January 1, 2004, and December 31, 2018. Nonbirth hospital visits, including emergency department visits, observational stays, and hospital admissions during pregnancy and 5 years before pregnancy, were identified. The diagnoses for hospitalizations were categorized. We compared medical conditions leading to antecedent, nonbirth hospital visits among primiparous birthing individuals with singleton births with and without severe maternal morbidity, excluding transfusions. RESULTS Of 235,398 birthing individuals, 2120 had severe maternal morbidity, a rate of 90.1 cases per 10,000 deliveries, and 233,278 did not have severe maternal morbidity. Compared with 4.3% of patients without severe maternal morbidity, 10.4% of patients with severe maternal morbidity were hospitalized during pregnancy. In multivariable analysis, there was a 31% increased risk of hospital admission during the prenatal period, a 60% increased risk of hospital admission in the year before pregnancy, and a 41% increased risk of hospital admission in 2 to 5 years before pregnancy. Compared with 9.8% of non-Hispanic White birthing people, 14.9% of non-Hispanic Black birthing people with severe maternal morbidity experienced a hospital admission during pregnancy. For those with severe maternal morbidity, prenatal hospitalization was most common for those with endocrine (3.6%) or hematologic (3.3%) conditions, with the largest differences between those with and without severe maternal morbidity for musculoskeletal (relative risk, 9.82; 95% confidence interval, 7.06-13.64) and cardiovascular (relative risk, 9.73; 95% confidence interval, 7.26-13.03) conditions. CONCLUSION This study found a strong association between previous nonbirth hospitalizations and the likelihood of severe maternal morbidity at delivery.
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Affiliation(s)
- Audra R Meadows
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Diego, San Diego, CA (Dr Meadows)
| | - Howard Cabral
- Boston University School of Public Health, Boston, MA (Drs Cabral and Declercq)
| | | | - Xiaohui Cui
- Massachusetts Department of Public Health, Boston, MA (Drs Cui and Diop)
| | | | - Hafsatou Diop
- Massachusetts Department of Public Health, Boston, MA (Drs Cui and Diop)
| | - Eugene R Declercq
- Boston University School of Public Health, Boston, MA (Drs Cabral and Declercq).
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Docheva N, Heimberger S, Mueller A, Bisson C, Arenas G, Perdigao JL, Kordik A, Stewart K, Goodall P, Lengyel E, Rana S. A Comparison of Obstetric Interventions and Outcomes Between Black and White Patients at an Urban Tertiary Medical Center. Reprod Sci 2023; 30:2313-2323. [PMID: 36717463 DOI: 10.1007/s43032-023-01174-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 01/13/2023] [Indexed: 02/01/2023]
Abstract
The objective of the study is to evaluate whether rates of selected labor and delivery interventions and severe maternal morbidity (SMM) differ between Black and White pregnant patients. This retrospective observational cohort study included all Black or White pregnant patients who delivered at the University of Chicago Medical Center between January 2015 and December 2019. Data queried included demographic information, antepartum complications, preterm interventions, labor and delivery events, and neonatal outcomes. SMM was a composite outcome, including intensive care unit admission, blood transfusion, hysterectomy, eclampsia, cardiac arrest, or death. In total, 10,885 parturients (9001 Black and 1884 White) and 11,211 neonates (9254 born to Black and 1957 to White patients) were included in the study. Black patients were more likely to have preterm labor (3.51% vs. 1.86%, p = 0.0002) and no prenatal care (17.83% vs. 4.05%, p < 0.0001). There was no significant difference in the administration of magnesium sulfate for fetal neuroprotection (Black 44.78% vs. White 49.32%, p = 0.48) or antenatal corticosteroids (Black 67.83% vs. White 71.98%, p = 0.28) among those with preterm delivery. There was no significant difference in SMM (Black 2.24% vs. White 2.44%, p = 0.60), and SMM rates decreased over time (OR 0.79 per year, 95% CI: 0.72-0.87, p < 0.0001) for all patients. Black patients had more pregnancy complications, but their complications were addressed with similar rates of obstetrical interventions. In a high-resource setting, there was no difference in rates of SMM when compared to White patients.
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Affiliation(s)
- Nikolina Docheva
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Sarah Heimberger
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Ariel Mueller
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Courtney Bisson
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Gabriel Arenas
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Joana Lopes Perdigao
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Abbe Kordik
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Karie Stewart
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Perpetua Goodall
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Ernst Lengyel
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Sarosh Rana
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA.
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9
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Garland CE, Craemer KA, Koch AR, Locher S, Geller SE. Comparing State-Level and Facility-Based Review to Assess Quality of Severe Maternal Morbidity Reviews. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2023; 29:361-368. [PMID: 36867602 DOI: 10.1097/phh.0000000000001717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
OBJECTIVE To compare results from facility-level and state-level severe maternal morbidity (SMM) reviews in Illinois. DESIGN We report descriptive characteristics about SMM cases and compare the results of both review processes, including the primary cause, assessment of preventability, and factors that contributed to the severity of the SMM cases. SETTING All birthing hospitals in Illinois. PARTICIPANTS A total of 81 SMM cases were reviewed by a facility-level committee and the state-level review committee. SMM was defined as any intensive care or critical care unit admission and/or transfusion of 4 or more units of packed red blood cells from conception to 42 days postpartum. RESULTS Among the cases reviewed by both committees, hemorrhage was the primary cause of morbidity, with 26 (32.1%) and 38 (46.9%) hemorrhage cases identified by the facility-level and state-level committees, respectively. Both committees identified infection/sepsis (n = 12) and preeclampsia/eclampsia (n = 12) as the next most common causes of SMM. State-level review found more cases potentially preventable (n = 29, 35.8% vs n = 18, 22.2%) and more cases not preventable but improvement in care needed (n = 31, 38.3% vs n = 27, 33.3%). State-level review found more provider and system opportunities to alter the SMM outcome and fewer patient opportunities than facility-level review. CONCLUSION State-level review found more SMM cases potentially preventable and identified more opportunities to improve care than facility-level review. State-level review has the potential to strengthen facility-level reviews by identifying opportunities to improve the review process and develop recommendations and tools to aid facility-level reviews.
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Affiliation(s)
- Caitlin E Garland
- Center for Research on Women and Gender (Mss Garland and Craemer and Drs Koch and Geller), Department of Obstetrics and Gynecology (Drs Locher and Geller), and Department of Medicine (Dr Geller), College of Medicine, University of Illinois Chicago, Chicago, Illinois
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Thakkar A, Hameed AB, Makshood M, Gudenkauf B, Creanga AA, Malhamé I, Grandi SM, Thorne SA, D'Souza R, Sharma G. Assessment and Prediction of Cardiovascular Contributions to Severe Maternal Morbidity. JACC. ADVANCES 2023; 2:100275. [PMID: 37560021 PMCID: PMC10410605 DOI: 10.1016/j.jacadv.2023.100275] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 01/30/2023] [Accepted: 02/03/2023] [Indexed: 08/11/2023]
Abstract
Severe maternal morbidity (SMM) refers to any unexpected outcome directly related to pregnancy and childbirth that results in both short-term delivery complications and long-term consequences to a women's health. This affects about 60,000 women annually in the United States. Cardiovascular contributions to SMM including cardiac arrest, arrhythmia, and acute myocardial infarction are on the rise, probably driven by changing demographics of the pregnant population including more women of extreme maternal age and an increased prevalence of cardiometabolic and structural heart disease. The utilization of SMM prediction tools and risk scores specific to cardiovascular disease in pregnancy has helped with risk stratification. Furthermore, health system data monitoring and reporting to identify and assess etiologies of cardiovascular complications has led to improvement in outcomes and greater standardization of care for mothers with cardiovascular disease. Improving cardiovascular disease-related SMM relies on a multipronged approach comprised of patient-level identification of risk factors, individualized review of SMM cases, and validation of risk stratification tools and system-wide improvements in quality of care. In this article, we review the epidemiology and cardiac causes of SMM, we provide a framework of risk prediction clinical tools, and we highlight need for organization of care to improve outcomes.
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Affiliation(s)
- Aarti Thakkar
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Afshan B. Hameed
- Department of Obstetrics & Gynecology, Department of Medicine, University of California-Irvine, Irvine, California, USA
| | - Minhal Makshood
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brent Gudenkauf
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andreea A. Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Isabelle Malhamé
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Center for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Sonia M. Grandi
- Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Sara A. Thorne
- Division of Cardiology, Pregnancy & Heart Disease Program, Mount Sinai Hospital & University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rohan D'Souza
- Departments of Obstetrics & Gynaecology and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Garima Sharma
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Trends and inequities in severe maternal morbidity in Massachusetts: A closer look at the last two decades. PLoS One 2022; 17:e0279161. [PMID: 36538524 PMCID: PMC9767362 DOI: 10.1371/journal.pone.0279161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 12/01/2022] [Indexed: 01/04/2023] Open
Abstract
It is estimated that 50,000-60,000 pregnant people in the United States (US) experience severe maternal morbidity (SMM). SMM includes life-threatening conditions, such as acute myocardial infarction, acute renal failure, amniotic fluid embolism, disseminated intravascular coagulation, or sepsis. Prior research has identified both rising rates through 2014 and wide racial disparities in SMM. While reducing maternal death and SMM has been a global goal for the past several decades, limited progress has been made in the US in achieving this goal. Our objectives were to examine SMM trends from 1998-2018 to identify factors contributing to the persistent and rising rates of SMM by race/ethnicity and describe the Black non-Hispanic/White non-Hispanic rate ratio for each SMM condition. We used a population-based data system that links delivery records to their corresponding hospital discharge records to identify SMM rates (excluding transfusion) per 10, 000 deliveries and examined the trends by race/ethnicity. We then conducted stratified analyses separately for Black and White birthing people. While the rates of SMM during the same periods steadily increased for all racial/ethnic groups, Black birthing people experienced the greatest absolute increase compared to any other race/ethnic group going from 69.4 in 1998-2000 to 173.7 per 10,000 deliveries in 2016-2018. In addition, we found that Black birthing people had higher rates for every individual condition compared to White birthing people, with rate ratios ranging from a low of 1.11 for heart failure during surgery to a high of 102.4 for sickle cell anemia. Obesity was not significantly associated with SMM among Black birthing people but was associated with SMM among White birthing people [aRR 1.18 (95% CI: 1.02, 1.36)]. An unbiased understanding of how SMM has affected different race/ethnicity groups is key to improving maternal health and preventing SMM and mortality among Black birthing people. SMM needs to be addressed as both a medical and public health challenge.
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Wolfson C, Qian J, Chin P, Downey C, Mattingly KJ, Jones-Beatty K, Olaku J, Qureshi S, Rhule J, Silldorff D, Atlas R, Banfield A, Johnson CT, Neale D, Sheffield JS, Silverman D, McLaughlin K, Koru G, Creanga AA. Findings From Severe Maternal Morbidity Surveillance and Review in Maryland. JAMA Netw Open 2022; 5:e2244077. [PMID: 36445707 PMCID: PMC9709651 DOI: 10.1001/jamanetworkopen.2022.44077] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/13/2022] [Indexed: 11/30/2022] Open
Abstract
Importance In the US, more than 50 000 women experience severe maternal morbidity (SMM) each year, and the SMM rate more than doubled during the past 25 years. In response, professional organizations called for birthing facilities to routinely identify and review SMM events and identify prevention opportunities. Objective To examine SMM levels, primary causes, and factors associated with the preventability of SMM using Maryland's SMM surveillance and review program. Design, Setting, and Participants This cross-sectional study included pregnant and postpartum patients at 42 days or less after delivery who were hospitalized at 1 of 6 birthing hospitals in Maryland between August 1, 2020, and November 30, 2021. Hospital-based SMM surveillance was conducted through a detailed review of medical records. Exposures Hospitalization during pregnancy or within 42 days post partum. Main Outcomes and Measures The main outcomes were admission to an intensive care unit, having at least 4 U of red blood cells transfused, and/or having COVID-19 infection requiring inpatient hospital care. Results A total of 192 SMM events were identified and reviewed. Patients with SMM had a mean [SD] age of 31 [6.49] years; 9 [4.7%] were Asian, 27 [14.1%] were Hispanic, 83 [43.2%] were non-Hispanic Black, and 68 [35.4%] were non-Hispanic White. Obstetric hemorrhage was the leading primary cause of SMM (83 [43.2%]), followed by COVID-19 infection (57 [29.7%]) and hypertensive disorders of pregnancy (17 [8.9%]). The SMM rate was highest among Hispanic patients (154.9 per 10 000 deliveries), primarily driven by COVID-19 infection. The rate of SMM among non-Hispanic Black patients was nearly 50% higher than for non-Hispanic White patients (119.9 vs 65.7 per 10 000 deliveries). The SMM outcome assessed could have been prevented in 61 events (31.8%). Clinician-level factors and interventions in the antepartum period were most frequently cited as potentially altering the SMM outcome. Practices that were performed well most often pertained to hospitals' readiness and adequate response to managing pregnancy complications. Recommendations for care improvement focused mainly on timely recognition and rapid response to such. Conclusions and Relevance The findings of this cross-sectional study, which used hospital-based SMM surveillance and review beyond the mere exploration of administrative data, offers opportunities for identifying valuable quality improvement strategies to reduce SMM. Immediate strategies to reduce SMM in Maryland should target its most common causes and address factors associated with preventability identified at individual hospitals.
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Affiliation(s)
- Carrie Wolfson
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jiage Qian
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Cathy Downey
- Howard County General Hospital, Columbia, Maryland
| | | | - Kimberly Jones-Beatty
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Joanne Olaku
- Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sadaf Qureshi
- Luminis Health Anne Arundel Medical Center, Annapolis, Maryland
| | | | | | | | | | - Clark T. Johnson
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland
- Sinai Hospital of Baltimore, Baltimore, Maryland
- Department of Obstetrics and Gynecology, George Washington School of Medicine and Health Sciences, Washington, DC
| | - Donna Neale
- Howard County General Hospital, Columbia, Maryland
| | - Jeanne S. Sheffield
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - Kacie McLaughlin
- Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, Maryland
| | - Güneş Koru
- Department of Health Policy and Management, University of Arkansas for Medical Sciences, Fayetteville
| | - Andreea A. Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland
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13
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Suresh S, Amegashie C, Patel E, Nieman KM, Rana S. Racial Disparities in Diagnosis, Management, and Outcomes in Preeclampsia. Curr Hypertens Rep 2022; 24:87-93. [PMID: 35254590 DOI: 10.1007/s11906-022-01172-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 01/05/2023]
Abstract
PURPOSE OF THE REVIEW Racial disparities are prevalent in many aspects of obstetric care in the USA. Non-Hispanic black women have a higher prevalence of the diagnosis of hypertensive disorders of pregnancy in addition to associated morbidity and mortality. The purpose of this review is to review current data regarding racial disparities in the diagnosis and management of hypertensive disorders of pregnancy. RECENT FINDINGS Diagnosis of hypertensive disorders of pregnancy is more common among non-Hispanic black women even after adjustment for comorbidities. Furthermore, prevalence of severe morbidity among those with hypertensive disorders of pregnancy is increased in non-Hispanic black women, including cardiovascular events related. Proposed management solutions include quality improvement initiatives, telehealth, and strategies to reduce both structural racism and implicit bias. Racial disparities exist in both diagnosis and management of hypertensive disorders of pregnancy; further innovative work is needed to reduce these disparities.
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Affiliation(s)
- Sunitha Suresh
- Division of Maternal Fetal Medicine/Department of Obstetrics and Gynecology, University of Chicago Medicine, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | | | - Easha Patel
- Division of Maternal Fetal Medicine/Department of Obstetrics and Gynecology, University of Chicago Medicine, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Kristin M Nieman
- Division of Maternal Fetal Medicine/Department of Obstetrics and Gynecology, University of Chicago Medicine, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Sarosh Rana
- Division of Maternal Fetal Medicine/Department of Obstetrics and Gynecology, University of Chicago Medicine, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA.
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