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Waqar M, Yaseen O, Chadwick A, Lee JX, Khan G, Evans DG, Horner D, Jaiswal A, Freeman S, Bhalla R, Lloyd S, Hammerbeck-Ward C, Rutherford SA, King AT, Pathmanaban ON. Venous thromboembolism chemical prophylaxis after skull base surgery. Acta Neurochir (Wien) 2024; 166:165. [PMID: 38565732 PMCID: PMC10987339 DOI: 10.1007/s00701-024-06035-9] [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: 11/16/2023] [Accepted: 03/11/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE There is no guidance surrounding postoperative venous thromboembolism (VTE) prophylaxis using pharmacological agents (chemoprophylaxis) in patients undergoing skull base surgery. The aim of this study was to compare VTE and intracranial haematoma rates after skull base surgery in patients treated with/without chemoprophylaxis. METHODS Review of prospective quaternary centre database including adults undergoing first-time skull base surgery (2009-2020). VTE was defined as deep vein thrombosis (DVT) and pulmonary embolism (PE) within 6 months of surgery. Multivariate logistic regression was used to determine factors predictive of postoperative intracranial haematoma/VTE. Propensity score matching (PSM) was used in group comparisons. RESULTS One thousand five hundred fifty-one patients were included with a median age of 52 years (range 16-89 years) and female predominance (62%). Postoperative chemoprophylaxis was used in 81% of patients at a median of 1 day postoperatively. There were 12 VTE events (1.2%), and the use of chemoprophylaxis did not negate the risk of VTE entirely (p > 0.99) and was highest on/after postoperative day 6 (9/12 VTE events). There were 18 intracranial haematomas (0.8%), and after PSM, chemoprophylaxis did not significantly increase the risk of an intracranial haematoma (p > 0.99). Patients administered chemoprophylaxis from postoperative days 1 and 2 had similar rates of intracranial haematomas (p = 0.60) and VTE (p = 0.60), affirmed in PSM. CONCLUSION Postoperative chemoprophylaxis represents a relatively safe strategy in patients undergoing skull base surgery. We advocate a personalised approach to chemoprophylaxis and recommend it on postoperative days 1 or 2 when indicated.
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Affiliation(s)
- Mueez Waqar
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Geoffrey Jefferson Brain Research Centre, Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Omar Yaseen
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Annabel Chadwick
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Geoffrey Jefferson Brain Research Centre, Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Jing Xian Lee
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Ghazn Khan
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - D Gareth Evans
- Department of Neurogenetics, Manchester Centre for Genomic Medicine, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Daniel Horner
- Geoffrey Jefferson Brain Research Centre, Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Department of Neurocritical Care, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Archana Jaiswal
- Department of Otorhinolaryngology, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Simon Freeman
- Department of Otorhinolaryngology, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Rajiv Bhalla
- Department of Otorhinolaryngology, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Simon Lloyd
- Department of Otorhinolaryngology, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Charlotte Hammerbeck-Ward
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Scott A Rutherford
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Andrew T King
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Geoffrey Jefferson Brain Research Centre, Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Omar N Pathmanaban
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK.
- Geoffrey Jefferson Brain Research Centre, Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.
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Qiao N, Zhang Q, Chen L, He W, Ma Z, Ye Z, He M, Zhang Z, Zhou X, Shen M, Shou X, Cao X, Wang Y, Zhao Y. Machine learning prediction of venous thromboembolism after surgeries of major sellar region tumors. Thromb Res 2023; 226:1-8. [PMID: 37079979 DOI: 10.1016/j.thromres.2023.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 03/12/2023] [Accepted: 04/07/2023] [Indexed: 04/22/2023]
Abstract
PURPOSE To describe and predict the risk of venous thromboembolism (VTE) after surgical resection of major sellar region tumors. METHOD Patients with sellar region tumors were identified from a database. The outcome was VTE, including deep vein thrombosis (DVT) and pulmonary embolism (PE) within 60 days after surgery. We trained regression and machine learning models to predict the outcome using baseline characteristics, surgical findings and postoperative laboratory tests. RESULTS Among 3818 patients included, 124 patients developed VTE after surgery. The total 60-day VTE incidence was 3.2 %, with incidence peak within ten days after the surgery. The risk increased in patients >65 years old (OR 2.96, p < 0.001), in patients with chordoma (OR 3.40, p = 0.006) or craniopharyngioma (OR 1.86, p = 0.036), in patients underwent craniotomy approach (OR 2.78, p = 0.017), in patients with high volume CSF leakage (OR 4.24, p < 0.001), and in patients with longer surgical duration (OR 1.78, p = 0.029). The linear discriminant analysis algorithm had the highest AUC (0.869, 95%CI, 0.840-0.898) in predicting the outcome. The specificity, accuracy, and sensitivity of the best model were 61.8 %, 93.6 %, and 92.8 %, respectively. Risk stratification using our best model suggested that 1.3 % and 24.5 % of the patient developed VTE in the low-risk group and in the high-risk group, respectively. We developed an online decision-support tool available on https://deepvep.shinyapps.io/VTEpred/. CONCLUSION The overall incidence of VTE after surgical resection of major sellar region tumors was clinically significant, especially in older patients with chordoma or craniopharyngioma.
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Affiliation(s)
- Nidan Qiao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China; National Center for Neurological Disorders, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Key Laboratory of Medical Brain Function and Restoration and Neural Regeneration, Fudan University, Shanghai, China.
| | - Qilin Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China; National Center for Neurological Disorders, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Key Laboratory of Medical Brain Function and Restoration and Neural Regeneration, Fudan University, Shanghai, China
| | - Li Chen
- Department of Ultrasound, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China
| | - Wenqiang He
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China; National Center for Neurological Disorders, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Key Laboratory of Medical Brain Function and Restoration and Neural Regeneration, Fudan University, Shanghai, China
| | - Zengyi Ma
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China; National Center for Neurological Disorders, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Key Laboratory of Medical Brain Function and Restoration and Neural Regeneration, Fudan University, Shanghai, China
| | - Zhao Ye
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China; National Center for Neurological Disorders, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Key Laboratory of Medical Brain Function and Restoration and Neural Regeneration, Fudan University, Shanghai, China
| | - Min He
- Department of Endocrinology, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China
| | - Zhaoyun Zhang
- Department of Endocrinology, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China
| | - Xiang Zhou
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China; National Center for Neurological Disorders, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Key Laboratory of Medical Brain Function and Restoration and Neural Regeneration, Fudan University, Shanghai, China
| | - Ming Shen
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China; National Center for Neurological Disorders, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Key Laboratory of Medical Brain Function and Restoration and Neural Regeneration, Fudan University, Shanghai, China
| | - Xuefei Shou
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China; National Center for Neurological Disorders, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Key Laboratory of Medical Brain Function and Restoration and Neural Regeneration, Fudan University, Shanghai, China
| | - Xiaoyun Cao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China; National Center for Neurological Disorders, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Key Laboratory of Medical Brain Function and Restoration and Neural Regeneration, Fudan University, Shanghai, China.
| | - Yongfei Wang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China; National Center for Neurological Disorders, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Key Laboratory of Medical Brain Function and Restoration and Neural Regeneration, Fudan University, Shanghai, China
| | - Yao Zhao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China; National Center for Neurological Disorders, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Key Laboratory of Medical Brain Function and Restoration and Neural Regeneration, Fudan University, Shanghai, China; State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Institutes of Brain Science, Fudan University, Shanghai, China.
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Venous thromboembolic and hemorrhagic events after meningioma surgery: A single-center retrospective cohort study of risk factors. PLoS One 2022; 17:e0273189. [PMID: 35972947 PMCID: PMC9380925 DOI: 10.1371/journal.pone.0273189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 08/04/2022] [Indexed: 11/19/2022] Open
Abstract
Microsurgical resection of meningiomas in a majority of cases leads to a favorable outcome. Therefore, severe postoperative adverse events are less acceptable. The main purpose of this study was to investigate the incidence of symptomatic venous thromboembolism (VTE) and hemorrhagic complications in patients after operative treatment of intracranial meningiomas and to identify the risk factors in this patient subgroup. Of 106 patients undergoing elective craniotomy for meningioma overall incidence of symptomatic VTE was noted in 5.7% (six patients). For the risk-factor analysis older age (57.20 ± 11.60 vs. 71.00 ± 0.90 years, p < 0.001), higher body mass index (27.60 ± 4.80 vs. 33.16 ± 0.60 kg/m2, p < 0.001), WHO grade II (3.00% vs. 33.33%, p = 0.02), lower intraoperative blood loss (466.00 ± 383.70 vs. 216.70 ± 68.30 mL, p < 0.001), bedridden status and neurologic deficit (0.00% vs. 33.33%, p = 0.003 and 38.00% vs. 100.00%, p = 0.004) were associated with greater VTE risk. No risk factors for hemorrhagic complications were identified on univariate analysis. In conclusion, the incidence of VTE in meningioma patients is not negligible. Identified risk factors should be taken into account in the decision-making process for chemoprophylaxis when the risk of bleeding decreases.
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Waqar M, Chadwick A, Kersey J, Horner D, Kearney T, Karabatsou K, Gnanalingham KK, Pathmanaban ON. Venous thromboembolism chemical prophylaxis after endoscopic trans-sphenoidal pituitary surgery. Pituitary 2022; 25:267-274. [PMID: 34843070 PMCID: PMC8894148 DOI: 10.1007/s11102-021-01195-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE There is no compelling outcome data or clear guidance surrounding postoperative venous thromboembolism (VTE) prophylaxis using low molecular weight heparin (chemoprophylaxis) in patients undergoing pituitary surgery. Here we describe our experience of early chemoprophylaxis (post-operative day 1) following trans-sphenoidal pituitary surgery. METHODS Single-centre review of a prospective surgical database and VTE records. Adults undergoing first time trans-sphenoidal pituitary surgery were included (2009-2018). VTE was defined as either deep vein thrombosis and/or pulmonary embolism within 3 months of surgery. Postoperative haematomas were those associated with a clinical deterioration together with radiological evidence. RESULTS 651 Patients included with a median age of 55 years (range 16-86 years). Most (99%) patients underwent trans-sphenoidal surgery using a standard endoscopic single nostril or bi-nostril trans-sphenoidal technique. More than three quarters had pituitary adenomas (n = 520, 80%). Postoperative chemoprophylaxis to prevent VTE was administered in 478 patients (73%). Chemoprophylaxis was initiated at a median of 1 day post-procedure (range 1-5 days postoperatively; 92% on postoperative day 1). Tinzaparin was used in 465/478 patients (97%) and enoxaparin was used in 14/478 (3%). There were no cases of VTE, even in 78 ACTH-dependent Cushing's disease patients. Six patients (1%) developed postoperative haematomas. Chemoprophylaxis was not associated with a significantly higher rate of postoperative haematoma formation (Fisher's Exact, p = 0.99) or epistaxis (Fisher's Exact, p > 0.99). CONCLUSIONS Chemoprophylaxis after trans-sphenoidal pituitary surgery on post-operative day 1 is a safe strategy to reduce the risk of VTE without significantly increasing the risk of postoperative bleeding events.
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Affiliation(s)
- Mueez Waqar
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
- Faculty of Biology, Medicine and Health, Geoffrey Jefferson Brain Research Centre, The University of Manchester, Manchester, UK
| | - Annabel Chadwick
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
- School of Medicine, Geoffrey Jefferson Brain Research Centre, The University of Manchester, Manchester, UK
| | - James Kersey
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
- Department of Neurocritical Care, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Daniel Horner
- Faculty of Biology, Medicine and Health, Geoffrey Jefferson Brain Research Centre, The University of Manchester, Manchester, UK
- Department of Neurocritical Care, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
- School of Medicine, Geoffrey Jefferson Brain Research Centre, The University of Manchester, Manchester, UK
| | - Tara Kearney
- Department of Endocrinology, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Konstantina Karabatsou
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Kanna K Gnanalingham
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Omar N Pathmanaban
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK.
- Faculty of Biology, Medicine and Health, Geoffrey Jefferson Brain Research Centre, The University of Manchester, Manchester, UK.
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Antibiotic Use Without Indication During Delivery Hospitalizations in the United States. Obstet Gynecol 2020; 134:718-725. [PMID: 31503161 DOI: 10.1097/aog.0000000000003485] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To analyze trends in unindicated antibiotic use during vaginal delivery hospitalization. METHODS This study used an administrative database to analyze antibiotic use during delivery hospitalizations from January 2006 to March 2015. Women were classified by mode of delivery and whether they had an evidence-based indication for antibiotics. Indications for antibiotics included preterm prelabor rupture of membranes (PROM), cesarean delivery, group B streptococcus (GBS) colonization, chorioamnionitis, endometritis, urinary tract infections, and other infections. The Cochran-Armitage test was used to assess trends of antibiotic administration. Unadjusted and adjusted analyses for antibiotic receipt including demographic, hospital, and obstetric and medical factors were performed with unadjusted and adjusted risk ratios (RRs) with 95% CIs as measures of association. RESULTS A total of 5,536,756 delivery hospitalizations, including 2,872,286 vaginal deliveries without an indication for antibiotics, were analyzed. The most common indication for antibiotics was cesarean delivery (33.6% of the entire cohort), followed by GBS colonization (15.8%), chorioamnionitis (1.7%), preterm PROM (1.6%), endometritis (1.2%), urinary tract infections (0.6%), and other infections (total less than 0.5%). The proportion of women receiving unindicated antibiotics decreased 44.4%, from 38.1% in 2006 to 21.2% in 2015. Adjusted risk for receipt of unindicated antibiotics was lower in 2015 vs 2006 (adjusted RR 0.56, 95% CI 0.55-0.57). CONCLUSION Use of antibiotics during vaginal delivery hospitalizations without an indication for antibiotic use declined significantly based on an analysis of a large administrative data set.
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Trends and Outcomes Associated With Using Long-Acting Opioids During Delivery Hospitalizations. Obstet Gynecol 2019; 132:937-947. [PMID: 30204694 DOI: 10.1097/aog.0000000000002861] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess trends in use of long-acting opioids during delivery hospitalizations. METHODS The Perspective database, an administrative inpatient database that includes medication receipt, was analyzed to evaluate patterns of long-acting opioid use during delivery hospitalizations from January 2006 through March 2015. Medications evaluated included methadone, formulations including buprenorphine and extended-release formulations of oxycodone, morphine, fentanyl, and other opioids. Temporal trends in use of these medications were determined. Unadjusted and adjusted models evaluating the role of demographic and hospital factors were created evaluating both use of these medications and risk for severe morbidity. Risk for severe morbidity was determined based on Centers for Disease Control and Prevention criteria. RESULTS Our analysis included 2,994,630 delivery hospitalizations meeting study criteria. Over the entire study period, use of long-acting opioids increased significantly from 457 to 844 per 100,000 deliveries. Although buprenorphine and methadone use increased, use of other long-acting opioids decreased. In 2006, methadone and buprenorphine accounted for less than one third of all long-acting opioids used during delivery hospitalizations. By 2015, buprenorphine and methadone represented 73.5% of long-acting opioids used. In adjusted and unadjusted models, risk for severe morbidity was significantly lower with buprenorphine or methadone compared with other long-acting opioids. Restricting the cohort to only women with drug abuse or dependence, risk for severe morbidity was lower with methadone and buprenorphine than without any long-acting opioids. CONCLUSION Increased use of methadone and buprenorphine in this study supports the feasibility of use of these medications during pregnancy and uptake of clinical recommendations for women with opioid use disorder. Use of methadone and buprenorphine is associated with decreased maternal morbidity, although causation cannot be presumed from this study model.
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Use of Antihypertensive Medications During Delivery Hospitalizations Complicated by Preeclampsia. Obstet Gynecol 2019; 131:441-450. [PMID: 29420396 DOI: 10.1097/aog.0000000000002479] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate temporal trends in use of antihypertensive medications during delivery hospitalizations complicated by preeclampsia and risk of maternal stroke over the same time period. METHODS The Perspective database was used to perform a retrospective cohort study evaluating antihypertensive drugs dispensed during delivery hospitalizations complicated by preeclampsia from 2006 to the first quarter of 2015. Medications evaluated included nifedipine, hydralazine, and oral and intravenous labetalol. Adjusted models for receipt of antihypertensive agents accounting for demographic and hospital factors were created. Hospital-level rates of antihypertensive administration for women with severe preeclampsia were analyzed. Risk of stroke during delivery hospitalization was evaluated. RESULTS A total of 239,454 patients with preeclampsia were included in the analysis including 126,595 women with mild, 31,628 with superimposed, and 81,231 with severe preeclampsia. Overall, 105,409 women received a hypertensive agent. From 2006 to 2014, for all patients with preeclampsia, receipt of oral labetalol increased from 20.3% to 31.4%, intravenous labetalol from 13.3% to 21.4%, hydralazine from 12.8% to 16.9%, nifedipine from 15.0% to 18.2%, and more than one medication from 16.5% to 25.8%. The proportion of patients with preeclampsia receiving any antihypertensive medication rose from 37.8% in 2006 to 49.4% in 2015. In adjusted models, temporal trends retained significance. Rates of antihypertensive administration for severe preeclampsia varied significantly by hospital. For severe preeclampsia, the risk for stroke decreased from 13.5 per 10,000 deliveries in 2006-2008 (n=27) to 9.7 in 2009-2011 (n=25) to 6.0 in 2012-2014 (n=20) (P=.02). CONCLUSION Use of multiple antihypertensive agents to treat preeclamptic women increased over the study period for women with mild, superimposed, and severe preeclampsia. There was substantial hospital variation in use of antihypertensive agents. This trend was associated with decreased risk of maternal stroke.
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Booker WA, Ananth CV, Wright JD, Siddiq Z, D'Alton ME, Cleary KL, Goffman D, Friedman AM. Trends in comorbidity, acuity, and maternal risk associated with preeclampsia across obstetric volume settings. J Matern Fetal Neonatal Med 2018; 32:2680-2687. [PMID: 29478359 DOI: 10.1080/14767058.2018.1446077] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The objective of this study was to characterize morbidity, acuity, and maternal risks associated with preeclampsia across hospitals with varying obstetric volumes. METHODS This retrospective cohort analysis used a large administrative data source, the Perspective database, to characterize the risk for preeclampsia from 2006 to 2015. Hospitals were classified as having either low (≤1000), moderate (1001-2000), or high (≥2000) delivery volume. The primary outcomes included preeclampsia, antihypertensive administration, comorbidity, and related severe maternal morbidity. Severe maternal morbidity was estimated using criteria from the Centers for Disease Control and Prevention. Comorbidity was estimated using an obstetric comorbidity index. Univariable comparisons were made with Chi-squared test. Adjusted log linear regression models were fit to assess factors associated with severe morbidity with risk ratios with 95% confidence intervals as the measures of effect. Population weights were applied to create national estimates. RESULTS Of 36,985,729 deliveries included, 1,414,484 (3.8%) had a diagnosis of preeclampsia. Of these, 779,511 (2.1%) had mild, 171,109 (0.5%) superimposed, and 463,864 (1.3%) severe preeclampsia. The prevalence of mild, superimposed, and severe preeclampsia each increased over the study period with severe and superimposed preeclampsia as opposed to mild preeclampsia increasing the most proportionately (53.2 and 102.5 versus 10.8%, respectively). The use of antihypertensives used to treat severe range hypertension increased with use of intravenous labetalol increasing 31.5%, 43.2%, and 36.1% at low-, medium-, and high-volume hospitals. Comorbid risk also increased across hospital volume settings as did risk for severe maternal morbidity. CONCLUSIONS Preeclampsia is increasing across obstetric care settings with preeclamptic patients demonstrating increasing comorbid risk, increased risk for severe morbidity, and more frequent need for treatment of acute hypertension.
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Affiliation(s)
- Whitney A Booker
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
| | - Cande V Ananth
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA.,b Department of Epidemiology , Joseph L. Mailman School of Public Health, Columbia University , New York , NY , USA
| | - Jason D Wright
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
| | - Zainab Siddiq
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
| | - Mary E D'Alton
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
| | - Kirstin L Cleary
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
| | - Dena Goffman
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
| | - Alexander M Friedman
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
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Venous Thromboembolism Prophylaxis During Antepartum Admissions and Postpartum Readmissions. Obstet Gynecol 2017; 130:270-278. [PMID: 28697100 DOI: 10.1097/aog.0000000000002099] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To characterize the use of venous thromboembolism prophylaxis during antepartum and postpartum hospitalizations in the United States. METHODS A retrospective cohort study using the Perspective database was performed to analyze temporal trends of mechanical and pharmacologic venous thromboembolism prophylaxis for patients hospitalized for antepartum and postpartum indications between 2006 and 2015. Delivery hospitalizations were excluded. The association between use of prophylaxis and medical and obstetric risk factors as well as patient demographic and hospital characteristics was evaluated with unadjusted and adjusted models accounting for demographic, hospital and medical, and obstetric risk factors. RESULTS A total of 622,740 antepartum and 105,361 postpartum readmissions were identified and included in the analysis. Between 2006 and 2015, use of venous thromboembolism prophylaxis increased from 18.5% to 38.7% for antepartum admissions (adjusted risk ratio [RR] 1.94, 95% CI 1.88-2.01) and from 22.5% to 30.6% for postpartum readmissions (adjusted RR 1.31, 95% CI 1.21-1.43). Among women readmitted postpartum, 56.4% of prophylaxis was pharmacologic and 43.6% was mechanical. For antepartum admissions, 87.2% of prophylaxis was mechanical and 12.8% was pharmacologic. Significant regional and hospital-level variation was noted with prophylaxis most common in the South. In both unadjusted and unadjusted analyses, use of venous thromboembolism prophylaxis was more common for women with thrombophilia, ovarian hyperstimulation syndrome, a history of venous thromboembolism, and prolonged hospitalization. Factors associated with decreased rates of prophylaxis included hyperemesis and postpartum endometritis. CONCLUSION Although antepartum and postpartum venous thromboembolism prophylaxis is becoming increasingly common, particularly in the setting of medical or obstetric risk factors, use of prophylaxis varies regionally and on a hospital level. Some risk factors for venous thromboembolism were associated with lower rates of prophylaxis. The heterogeneity of clinical approaches to venous thromboembolism prophylaxis for these patient populations may represent an opportunity to perform outcomes research to further clarify best practices.
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